CAHPS® Hospice Survey

What's New
     

Quick Links: UPDATED: CAHPS Hospice Survey State Scores Posted | UPDATED: CAHPS Hospice Survey National Percentiles Posted | CAHPS Hospice Survey Data Submission Deadline Has Passed | Extraordinary Circumstances Extension / Exception (ECE) due to Hurricane MichaelApplicability of Quality Reporting Requirements for Hospices Affected by Hurricane FlorenceCAHPS Hospice Survey Attestation Statement Submission Deadline and Quality Assurance Plan Update CAHPS Hospice Survey Quality Assurance Guidelines V5.0 is Now Available | UPDATED: CAHPS Hospice Survey Response RateUPDATED: Case-Mix Adjustment Methods for CAHPS Hospice Survey Measures Document Posted Fiscal Year 2019 Hospice Final Rule Released | CAHPS Hospice Survey Results Available on Hospice Compare | Fiscal Year 2019 Hospice Proposed Rule Released UPDATED: Minimum Business Requirements to Administer the CAHPS Hospice SurveyREMINDER: CY 2018 Participation Exemption for Size Form Available | ADDED: New Informational Podcast Now AvailableStep-by-Step Guide for Calculating CAHPS Hospice Survey Top-, Middle-, and Bottom-Box Scores Document Posted | UPDATE: Applicability of Reporting Requirements for Hospices (California Wildfires) 

 UPDATED: CAHPS Hospice Survey State Scores Posted (11/15/2018)

The CAHPS Hospice Survey State Score document for the upcoming public reporting period (first quarter of 2016 through the fourth quarter of 2017) is available here.


 UPDATED: CAHPS Hospice Survey National Percentiles Posted (11/15/2018)

The CAHPS Hospice Survey National Percentiles document for the upcoming public reporting period (first quarter of 2016 through the fourth quarter of 2017) is available here.

CAHPS Hospice Survey Data Submission Deadline Has Passed (11/15/2018)

The data submission deadline for patients that passed away in April, May and June 2018 (Quarter 2 2018) has passed. No further data submission will be accepted. 


 Extraordinary Circumstances Extension / Exception (ECE) due to Hurricane Michael (11/2/2018)

The purpose of this communication is to notify Post-Acute Care providers of the Centers for Medicare & Medicaid Services (CMS) intent to grant quality reporting data submission and validation exceptions to Medicare providers in several care settings adversely affected by the devastating impact of Hurricane Michael, including Long-Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Hospices, Home Health Agencies, and Skilled Nursing Facilities (SNFs). CMS is issuing exceptions for several quality reporting data submission requirements because of possible damage to facilities and/or systems resulting in their inability to gather or submit data, as well as the need to prioritize immediate resources for direct patient care.

Specifically, for the specified reporting quarter(s), as indicated in this communication, affected providers will not be required to submit quality measure data to meet submission requirements.

CMS is exercising its authority to grant exceptions for data submission requirements for the above quality reporting programs for providers located within the Federal Emergency Management Agency (FEMA)-designated “major disaster” counties of Florida, and Georgia listed below:

Florida Counties

Georgia Counties

  • Bay
  • Calhoun
  • Franklin
  • Gadsden
  • Gulf
  • Hamilton
  • Holmes
  • Jefferson
  • Jackson
  • Leon
  • Liberty
  • Madison
  • Suwannee
  • Taylor
  • Wakulla 
  • Washington
  • Baker 
  • Bleckley 
  • Calhoun
  • Colquitt
  • Crisp
  • Decatur
  • Dodge
  • Dooly
  • Dougherty
  • Early
  • Emmanuel
  • Grady
  • Houston
  • Jefferson
  • Jefferson
  • Lee
  • Macon
  • Miller
  • Mitchell
  • Pulaski
  • Seminole
  • Sumter
  • Terrell
  • Thomas
  • Treutlen
  • Turner
  • Wilcox
  • Worth


The healthcare providers located outside of the counties listed above are not covered by this communication, but may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing programs it participates in using the applicable extraordinary circumstances exception procedure for the respective program(s). CMS will assess and decide upon each extraordinary circumstances exception request on a case-by-case basis.

CMS recommends visiting the FEMA website at https://www.fema.gov for the most up to date list of counties affected by Hurricane Michael. Please note that Medicare providers located outside of the counties covered under this memo, and in need of an extension or exception from program requirements are required to follow the submission process described at the bottom of this memo.

Hospice Quality Reporting Program (QRP)

For the following Hospice QRP requirements and discharged quarters listed below, CMS grants a blanket exception for all Hospices in the above-designated counties.

Hospices participating in the CMS Hospice QRP are granted an exception from the data reporting requirements of the Hospice QRP, specifically the data submitted via the Hospice Item Set (HIS) and the Hospice Consumer Assessment of Healthcare Providers and Systems (Hospice CAHPS®) survey. The CAHPS Hospice Survey exception will apply to “Q3 2018 and Q4 2018 decedents,” or hospice patients who died between July-December 2018

Hospices located in covered counties are granted an exception from reporting quality data to CMS, as described above, for the following reporting quarters:

  • July 1, 2018 – September 30, 2018 (3rd Quarter 2018)
  • October 1, 2018 – December 31, 2018 (4th Quarter 2018)

We would like to note that this exception from quality reporting requirements for the above-listed CMS QRPs may impact the minimum case threshold counts for calculation of quality metrics. While you can continue to submit data to CMS, any data submissions for the above-listed exempt CY 2018 quarters will not be considered when determining compliance related to the FY 2020 reporting requirements for your hospital or facility. That is, you will not be held accountable for quality data collected and submitted during the 2018 quarters identified above. Please also note that this may affect the minimum amount of data needed to calculate specific quality measures for public reporting purposes, in which case CMS would suppress the applicable data on the respective Compare sites, when quality measure data are calculated and posted.

Exception and Extension Request Process

Hospitals and Facilities in other counties and states may submit ECE Requests for data submission based on individual circumstances by one of the following processes:


 Applicability of Quality Reporting Requirements for Hospices Affected by Hurricane Florence (10/19/2018)

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions under certain Medicare quality reporting and value-based purchasing programs to hospitals, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, renal dialysis facilities, long-term care hospitals, and ambulatory surgical centers, as well as Merit-Based Incentive Payment System (MIPS)eligible clinicians, located in areas affected by Hurricane Florence due to the devastating impact of the storm. These healthcare providers and suppliers will be granted exceptions if they are located in one of the North Carolina or South Carolina counties listed below, all of which have been designated by the Federal Emergency Management Agency (FEMA) as a major disaster county.

The scope and duration of the exception under each Medicare quality reporting program and value-based purchasing program is described below.  CMS is granting exceptions to assist these providers while they direct their resources toward caring for their patients and repairing structural damages to facilities.

CMS is closely monitoring the situation for future potential widespread catastrophic events, and will update exception lists soon after any events occur in the future.

The affected counties designated by FEMA under the North Carolina Hurricane Florence (DR-4393) and the South Carolina Hurricane Florence (DR-4394) Major Disaster Declarations, as of the date of this communication, are as follows:  

North Carolina Counties

South Carolina Counties

  • Beaufort
  • Bladen
  • Brunswick
  • Carteret
  • Columbus
  • Craven
  • Cumberland
  • Duplin
  • Greene
  • Harnett
  • Hoke
  • Hyde
  • Johnston
  • Jones
  • Lee 
  • Lenoir
  • Moore
  • New Hanover
  • Onslow
  • Pamlico
  • Pender
  • Pitt
  • Richmond
  • Robeson
  • Sampson
  • Scotland
  • Wayne
  • Wilson
  • Berkeley 
  • Charleston
  • Chesterfield
  • Darlington
  • Dillon
  • Dorchester
  • Florence
  • Georgetown
  • Horry
  • Marion
  • Marlboro
  • Orangeburg
  • Sumter
  • Williamsburg


The healthcare providers located outside of the counties listed above are not covered by this communication, but may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing programs it participates in using the applicable extraordinary circumstances exception procedure for the respective program(s). CMS will assess and decide upon each extraordinary circumstances exception request on a case-by-case basis.

If FEMA expands the current disaster declaration for Hurricane Florence to include additional counties, CMS will update this communication to reflect the expanded list of applicable counties for which healthcare providers would be eligible to receive an exception without submitting a request. In addition, CMS will continue to monitor the situation and adjust exempted reporting periods and submission deadlines accordingly.

Home Health Agencies (HHAs), Hospices, Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs)

CMS is granting an exception to all Quality Reporting Program (QRP) reporting requirements, including the reporting of data on measures and any other data requested by CMS for the post-acute care (PAC) quality reporting programs for calendar year 2018 quarters 3 and 4 (July 1 to December 31, 2018):

  • Hospices – Hospice QRP

For further information about exceptions, view the program-specific web page:


CAHPS Hospice Survey Attestation Statement Submission Deadline and Quality Assurance Plan Update (10/01/2018)

CAHPS Hospice Survey vendors approved to administer the CAHPS Hospice Survey must submit an updated CAHPS Hospice Survey Attestation Statement. Please click here to view and print the CAHPS Hospice Survey Attestation Statement form. The executed form must be submitted to the CAHPS Hospice Survey Project Team via hospicecahpssurvey@HCQIS.org by December 13, 2018.

CAHPS Hospice Survey vendors approved to administer the CAHPS Hospice Survey must update their Quality Assurance Plan (QAP) to be complete, comprehensive and accurate in reflecting updates made to the CAHPS Hospice Survey Quality Assurance Guidelines V5.0, as well as any changes in key personnel, resources and processes. QAPs will be requested by the CAHPS Hospice Survey Project Team prior to site visits. 


CAHPS Hospice Survey Quality Assurance Guidelines Version 5.0 is Now Available (09/19/2018)

The CAHPS Hospice Survey administration protocols are contained in the CAHPS Hospice Survey Quality Assurance Guidelines Version 5.0 (QAG V5.0). To view or download the QAG V5.0, please click on the left hand Quality Assurance Guidelines navigation button.

(Return to top)


UPDATED: CAHPS Hospice Survey Response Rate (09/05/2018)

The CAHPS Hospice Survey response rate for the upcoming public reporting period (first quarter of 2016 through the fourth quarter of 2017) is available here.

(Return to top)


 UPDATED: Case-Mix Adjustment Methods for CAHPS Hospice Survey Measures Document Posted (09/05/2018)

Updates to the Case-Mix Adjustment (CMA) Methods document which describes refinements to the CMA model, updated coefficients and means from Quarter 4 2017 for CAHPS Hospice Survey has been posted on the Scoring and Analysis page. To view or download these documents, please click on the left hand Survey and Analysis navigation button. 

(Return to top)


Fiscal Year 2019 Hospice Final Rule Released (08/23/2018)

CMS released the final rule for the fiscal year (FY) 2019 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements on August 6, 2018. The FY 2019 hospice final rule can be accessed by clicking here: https://www.federalregister.gov/documents/2018/08/06/2018-16539/medicare-program-fy-2019-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting.  

(Return to top)


CAHPS Hospice Survey Results Available on Hospice Compare (08/21/2018)

The August 2018 quarterly Hospice Compare refresh of quality data is now available. The current reporting period covers hospice care experiences from the fourth quarter of 2015 through the third quarter of 2017 (10/1/2015 through 9/30/2017). Downloadable data sets are available at https://data.medicare.gov/data/hospice-compare.

More details about Hospice Quality Public Reporting are available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Public-Reporting.html.

(Return to top)


 Fiscal Year 2019 Hospice Proposed Rule Released (05/16/2018)

CMS issued a proposed rule to update the Medicare hospice wage index, Medicare hospice payment rates and cap amount for Fiscal Year (FY) 2019 on May 8, 2018. For more information, please visit: https://www.federalregister.gov/documents/2018/05/08/2018-08773/medicare-program-fy-2019-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting.

(Return to top)


UPDATED: Minimum Business Requirements to Administer the CAHPS Hospice Survey (04/30/2018)

To administer the CAHPS Hospice Survey, organizations must meet all of the CAHPS Hospice Survey Minimum Business Requirements. In addition, subcontractors and any other organizations performing major CAHPS Hospice Survey administration functions (e.g., mail/telephone operations) must also meet all of the CAHPS Hospice Survey Minimum Business Requirements that pertain to that role. Organizations requesting consideration for approval to administer the CAHPS Hospice Survey must meet all of the posted CAHPS Hospice Survey Minimum Business Requirements at the time the CAHPS Hospice Survey Participation Form is received (a subcontractor’s or other organization’s survey administration experience does not substitute for a survey vendor’s).

We anticipate that the CAHPS Hospice Survey Participation Form will become available in the next month. Please note, survey vendors that are currently approved to administer the CAHPS Hospice Survey are not required to submit a CAHPS Hospice Survey Participation Form (unless the survey vendor is requesting to be approved for additional modes of survey administration or the survey vendor does not have any contracted hospice clients and it has been two years since the survey vendor received approval to administer the CAHPS Hospice Survey).

For more information regarding the CAHPS Hospice Survey Minimum Business Requirements, please click here or on the left hand Minimum Business Requirements navigation button.

(Return to top) 


CY 2018 Participation Exemption for Size Form Now Available (04/16/18)

The Participation Exemption for Size Form for the calendar year (CY) 2018 CAHPS Hospice Survey data collection and reporting requirements is available to complete and submit on the CAHPS Hospice Survey Web site. Hospices that served fewer than 50 survey-eligible decedents/caregivers in CY 2017 (January 1, 2017 through December 31, 2017 [or from assignment of CCN]) can apply for an exemption from participation in the CAHPS Hospice Survey for CY 2018.

To view or complete the 2018 Participation Exemption for Size Form, please click on the left hand Participation Exemption for Size navigation button. The Participation Exemption for Size Form will be available to complete and submit online until December 31, 2018.

Please note, exemptions on the basis of size are active for one year only. If a hospice continues to meet the eligibility requirements for this exemption in subsequent years, the organization will need to again request the exemption.

If a hospice has questions regarding the Participation Exemption for Size process or how to complete the Participation Exemption for Size Form, please contact the CAHPS Hospice Survey Project Team: hospicecahpssurvey@HCQIS.org or 1-844-472-4621.

(Return to top)


ADDED: New Informational Podcast Now Available (03/12/2018)

The CAHPS Hospice Survey Project Team has added an additional podcast, Public Reporting of CAHPS Hospice Survey Scores, related to understanding public reporting of CAHPS Hospice Survey Scores including an overview of the process, how to interpret scores and how to request CMS review of scores.Currently, there are ten podcasts available containing helpful information relating to understanding various components of CAHPS Hospice Survey protocols.

To view the CAHPS Hospice Survey: Podcasts for Hospices series, click on the left hand Information for Hospices navigation button and then select the Podcasts for Hospices navigation button at the top of the page.

 (Return to top)


Step-by-Step Guide for Calculating CAHPS Hospice Survey Top-, Middle-, and Bottom-Box Scores Document Posted (03/01/2018)

Updates to the document for calculating CAHPS Hospice Survey Top-, Middle-, and Bottom-Box Scores has been posted on the Scoring and Analysis page. To view or download this document, please click on the left hand Scoring and Analysis navigation button.

(Return to top)


UPDATE: Applicability of Reporting Requirements for Hospices (California Wildfires) (11/08/2017)

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions under certain Medicare quality reporting and value-based purchasing programs to acute care hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, long-term care hospitals, renal dialysis facilities, and ambulatory surgical centers located in areas affected by the devastating impacts of the Northern California wildfires since October 8, 2017, in and around counties in Northern California. These providers will be granted exceptions without having to submit an extraordinary circumstances exception request if they are located in one of the California counties listed below, all of which have been designated by the Federal Emergency Management Agency (FEMA) as a major disaster county. The scope and duration of the exception under each Medicare quality reporting program is described below; however, all of the exceptions are being granted to assist these providers while they direct their resources toward caring for their patients and repairing structural damages to facilities.

CMS is closely monitoring the situation for future potential widespread catastrophic events, and will update exception lists soon after any events occur in the future.

The affected counties by FEMA as of the date of this communication are as follows:

Northern California Counties

  • Butte
  • Lake
  • Mendocino
  • Napa
  • Nevada
  • Orange
  • Sonoma
  • Yuba

The following providers located outside of the counties listed above are not covered by this communication, but may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing programs using the applicable extraordinary circumstances exception procedure: acute care hospitals, Prospective Payment System (PPS)-exempt cancer hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, long-term care hospitals, renal dialysis facilities, and ambulatory surgical centers.

If FEMA expands the current disaster declaration for the Northern California wildfires to include additional counties, CMS will update this communication to expand the list of providers eligible to receive an exception without submitting a request. In addition, CMS will continue to monitor the situation and adjust exempted reporting periods and submission deadlines accordingly.

Hospices

CMS is granting an exception to all Quality Reporting Program (QRP) reporting requirements, including the reporting of data on measures and any other data requested by CMS for the post-acute care (PAC) quality reporting programs for calendar year 2017 quarters 2 and 3:

  • Hospices – Hospice QRP

CMS will provide additional information about the extension and exceptions related to the PAC QRP submission requirements in subsequent announcements.

For further information about extensions and exemptions, view the program-specific webpages:

(Return to top)


This page was last modified on 11/15/2018