CAHPS® Hospice Survey

Discrepancy Report

Discrepancy Report Process

On occasion, a survey vendor may identify discrepancies from CAHPS Hospice Survey protocols that require corrections to procedures and/or electronic processing to realign the activity to comply with CAHPS Hospice Survey protocols. Survey vendors are required to notify CMS of these discrepancies immediately upon discovery.

Review Process

The CAHPS Hospice Survey Project Team will review the Discrepancy Report to assess the actual or potential impact of the discrepancy on reported CAHPS Hospice Survey results. Notification of the outcome of the review may not be forthcoming until all the data for the affected reporting periods have been submitted and reviewed, and the impact of the discrepancy has been ascertained. Email notification will be distributed to the organization submitting the Discrepancy Report once the outcome of the review has been determined.

Discrepancy Report Form

The Discrepancy Report Form must be completed and submitted online on the CAHPS Hospice Survey Web site ( The requested information regarding the affected hospices must be provided in Section III in order to complete the CAHPS Hospice Survey Discrepancy Report. All required fields are indicated with an asterisk (*). If all of the information is not immediately available, survey vendors must submit an initial Discrepancy Report alerting CMS of the issue and subsequently update the Discrepancy Report with the remaining required information once available. When updating a Discrepancy Report, please note that the initial report is retained in its entirety; therefore, it is necessary only to provide the remaining required information pertaining to the original submission, referencing the Original Report Form ID.

NOTE: This form does not accept any special characters or symbols in the text boxes. Use only alphanumeric characters when completing this form.

NOTE: Please print completed Discrepancy Report Form before submitting to keep a copy for your records.

I. General Information

1. Survey Vendor Organization Information
Date Submitted: 3/18/2018
Indicate whether this report is an Initial Discrepancy Report or an Updated Discrepancy Report. *
Initial Report Updated Report
Organization Name: *
Date of original report submission: Original Report Form ID:
2. Date Discrepancy Was Discovered
Date: *
3. Contact Person for this Discrepancy Report (Confirmation email will be sent to the Contact Person)
First Name, Last Name: *   Title: *
  Mailing Address: *
  Mailing Address 2:
  City: *      State: *      Zip Code: *
(Area Code) Telephone Number: * (Area Code) Fax Number:
Email Address: *

II. Discrepancy Information

Please complete items 1 through 4 below in detail.
1. Description of Discrepancy: *

2. Description of How the Discrepancy was Identified: *

3. Description of the Corrective Action to Fix the Discrepancy, Including Estimated Time for Implementation: *

4. Additional Information that would be Helpful that has not been Included Above: *

III. List of Hospice(s) Applicable to this Discrepancy

A hospice may be added more than once if there are multiple time frames for the hospice. It is important that the effects of the Discrepancy Report are quantified; however, "unknown" will be accepted as a valid response.
Name of Hospice: * Name of Hospice is required. {{vm.grpPracticeNameError}}

CCN: * {{vm.grpPracticeIDError}}

Hospice Contact Person: * {{vm.hospiceContactError}}

Hospice Contact Email: * {{vm.hospiceEmailError}}

Eligible Decedents/Caregivers Affected: * {{vm.eligibleAffectedError}}      Average Eligible Decedents/Caregivers per Month: * {{vm.averageEligibleperMonthError}}

Sampled Decedents/Caregivers Affected: * {{vm.sampleAffectedError}}      Average Number of Surveys Administered per Month: * {{vm.averageSurveyPerMonthError}}

Timeframe - Begin Date: *      Timeframe - End Date: *

Hospice Name CCN Hospice Contact Name Hospice Contact Email Eligible Decedents/Caregivers Avg. Eligible Decedents/Caregivers month Sampled Decedents/Caregivers Avg. surveys month Begin Date End Date
{{plan.grpPracticeName}} {{plan.grpPracticeID}} {{plan.hospiceContact}} {{plan.hospiceEmail}} {{plan.eligibleAffected}} {{plan.averageEligibleperMonth}} {{plan.sampleAffected}} {{plan.averageSurveyperMonth}} {{plan.beginDate}} {{plan.endDate}}