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 (www.hospicecahpssurvey.org). 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.

 

Indicate whether this report is an Initial Discrepancy Report or an Updated Discrepancy Report.
Initial Discrepancy Report * (Must be submitted within 24 hours after the discrepancy has been discovered.)
Updated Discrepancy Report * (If needed, must be submitted within two weeks of initial Discrepancy Report.)
1. General Information
6038
11/17/2018
The Name of the Organization is required.

2. Contact Person for this Discrepancy Report (Confirmation email will be sent to the Contact Person.)
First Name is required.
Last Name is required.
Mailing Address 1 is required.
City is required.
State is required.
Zip Code is required.
Telephone is required.
Email is required.

3. Information about the Discrepancy
Description of the discrepancy is required. {{2000 - model.DiscrepancyDescription.length}} characters remaining
Description of how the discrepancy was identified is required. {{2000 - model.DiscrepancyIdentified.length}} characters remaining
Description of the Corrective Action is required. {{2000 - model.CorrectiveAction.length}} characters remaining
Additional Info is required. {{2000 - model.AdditionalInfo.length}} characters remaining

4. List of Hospices Applicable to this Discrepancy
The Number of Affected Hospices is required.
Name of Hospice is required.
CCN is required. Too few characters. Must be 6 characters Too many characters. Must be 6 characters
Hospice Contact Name is required.
A valid Email Address is required.
Number of Eligible Discharges Affected is required. Must be up to 7 characters
Average number of Eligible Discharges per month is required.
Count of Sampled Patients affected is required. Must be up to 7 characters
Average number of surveys administered is required.
Begin Date is required.
End Date is required. End Date must be on or after Begin Date.
Add
(click on a row in the grid to edit it)
Note: Please print completed Discrepancy Report form before submitting.