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CMS643

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CMS-643 (06/08)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0379
Hospice survey and deficiencies report
Page ____ of ____
CERTIFICATION NUMBER NAME OF FACILITY SURVEY DATE
1. Was this hospice surveyed for compliance with 42 CFR 418.110?
L50
o Yes o No
L51
2. If this hospice provides inpatient care directly, is the inpatient care provided on the premises?
o oYes No
3. Has a waiver of core nursing services been granted? 4. If “Yes” indicate date
L52 L53
o Yes o No
5. Indicate type of setting(s) in which the hospice provides routine home care.
L54
o Private residence o SNF o NF o Other (specify)
6. Number of hospice patients residing in a SNF, NF or other residential facility who receive routine home care
L55
from the hospice.
L56
7. Number of hospice patients admitted during recent 12 month period.
L57
8. Number of records reviewed during survey.
L58
9. Number of home visits conducted to patients in a private residence.
L59
10. Number of home visits conducted to patients in residential facilities.
11. Does this hospice operate under the same certification
12. If “Yes” enter
number at more than one location?
number of locations.
o Yes o No
14. If “Yes” enter the Medicare
13. Does this hospice operate as part of another entity that participates
certification number of the entity.
in the Medicare program?
o Yes o No
L61
L60
L63
L62
SURVEYOR SIGNATURE TITLE DATE
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0379. The time required to complete this information collection is estimated to average 1 hour
per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance
Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Hospice survey and deficiencies report
Page ____ of ____
DEFICIENCIES
DATA TAG NUMBER COP/STND. NO. COMMENTS
I certify that I have reviewed each hospice Condition of Participation and related standards and except as indicated on this
form the facility was found to be in compliance with the standards and/or the Conditions of Participation.
SURVEYOR SIGNATURE TITLE DATE
SURVEYOR SIGNATURE TITLE DATE
CMS-643 (06/08)
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CMS643

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Completed 2 October 2019

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