Exception Request

Exception Request Process

The Exception Request process has been created to provide survey vendors with more flexibility to meet individual organizations’ need for certain variations from protocol, while still maintaining the integrity of the data for standardized data reporting. The Exception Request Form must be completed with sufficient detail, including clearly defined timeframes, for the CAHPS Hospice Survey Project Team to make an informed decision.

Survey vendors must submit an Exception Request Form on behalf of their client hospice(s)
Survey vendors may submit one Exception Request Form on behalf of multiple hospices with the same Exception Request. Survey vendors must include a list of contracted hospices on whose behalf they are submitting the Exception Request. Please be sure to include the information in the specified section of the Exception Request Form.
A new Exception Request Form must be submitted for hospices not included in the original request

Exception Request Category

Survey vendors must request an exception for alternative strategies not identified in the CAHPS Hospice Survey Quality Assurance Guidelines

No alternative modes of survey administration will be permitted other than those prescribed for the survey (Mail Only, Telephone Only and Mixed Mode).

Review Process

The CAHPS Hospice Survey Project Team will review the Exception Request. These reviews will include an assessment of the methodological soundness of the proposed alternative and the potential for introducing bias. Depending on the type of exception, a review of procedures and/or a site visit or conference call may be required. The CAHPS Hospice Survey Project Team will notify survey vendors whether or not their exception has been approved. All approved Exceptions Requests will be limited to a two-year approval timeframe. The two-year period will begin from date of approval. If the request is not approved, the CAHPS Hospice Survey Project Team will provide an explanation. Survey vendors then have the option of appealing the decision.

Exception Request Form

The Exception Request Form must be completed and submitted online on the CAHPS Hospice Survey Web site (www.hospicecahpssurvey.org). The hospice(s) for which this Exception Request relates to must be listed in Section II along with each hospice’s CMS Certification Number (CCN). All required fields are indicated with an asterisk (*).

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

I. General Information

Unique Report ID 19107

Submission Date 12/21/2024

1a. Organization Name * The Name of the Organization is required.

II. Contact Person for this Exception Request Confirmation email will be sent to the Contact Person.

2a. First Name * First Name is required.

2a. Middle Initial

2a. Last Name * Last Name is required.

2b. Title * First Name is required.

2c. Degree (e.g. RN, MD, PhD)

2d. Mailing Address 1 * Mailing Address 1 is required.

2e. Mailing Address 2

2f. City * City is required.

2g. State * State is required.

2h. Zip Code * Zip Code is required.

2h. Telephone * Telephone is required.

2i. Fax Number

2j. Email Address * Email is required.

III. Exception Request Please complete items 1, 2, and 3 below for each requested exception.

1. Exception Request For (Check one in each box)

New Exception
Appeal of Exception Denial Please select an option above

Date of initial Exception Request submission * Date of initial Exception Request submission is required.

Initial Exception Request ID * The Initial Exception Request ID is required.

Exception (specify):* Please Provide your Exception Type {{150 - model.ExceptionType.length}} characters remaining

2. List of hospices applicable to this Exception Request

Total number of Affected Hospices * The Number of Affected Hospices is required.

Name of Hospice * Name of Hospice is required.

CCN * CCN is required. Too few characters. Must be 6 characters Too many characters. Must be 6 characters

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3. Description of Exception Request

3a. Purpose of Proposed Exception Requested (e.g. sampling, other) * Purpose of Proposed Exception is required. {{4000 - model.PurposeOfRequest.length}} characters remaining

3b. Rationale for Proposed Exception Requested * Rationale for Proposed Exception is required. {{4000 - model.RationaleOfRequest.length}} characters remaining

3c. Explanation of Implementation of Proposed Exception Requested * Explanation of Implementation is required. {{4000 - model.ExplanationofImplementation.length}} characters remaining

3d. Evidence that Exception Will Not Affect Results * Evidence that Exception Will Not Affect Results is required. {{4000 - model.EvidenceWhyWillNotAffectResults.length}} characters remaining

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Note: Please print completed Exception Report form before submitting.

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CAHPS® Hospice Survey

Exception Request

CAHPS^® Hospice Survey