CAHPS® Hospice Survey

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Quick Links: URGENT: CAHPS Hospice Survey Data Submission Deadline Approaching | CAHPS Hospice Survey Attestation Statement Now Available | UPDATED: Technical Corrections and Clarifications to the CAHPS Hospice Survey Quality Assurance Guidelines V6.0 (QAG V6.0) Document Posted | CAHPS Hospice Survey Quality Assurance Guidelines V6.0 is Now Available | CAHPS Hospice Survey Training Materials are Now AvailableApplicability of Quality Reporting Requirements for Hospices Affected by Tropical Storm/Hurricane Barry | UPDATED: CAHPS Hospice Survey Response Rate | UPDATED: Case-Mix Adjustment Methods for CAHPS Hospice Survey Measures Document Posted | UPDATED: CAHPS Hospice Survey State Scores Posted | UPDATED: CAHPS Hospice Survey National Percentiles Posted | Fiscal Year 2020 Hospice Final Rule ReleasedREMINDER: CY 2019 Participation Exemption for Size Form Available | UPDATED: Step-by-Step Guide for Calculating CAHPS Hospice Survey Top-, Middle-, and Bottom-Box Scores Document Posted | CAHPS Hospice Survey Results Available on Hospice Compare | Fiscal Year 2020 Hospice Proposed Rule Released |  Applicability of Quality Reporting Requirements for Hospices Affected by California Wildfires (DR-4407) | Extraordinary Circumstances Extension / Exception (ECE) due to Hurricane MichaelApplicability of Quality Reporting Requirements for Hospices Affected by Hurricane Florence 

URGENT: CAHPS Hospice Survey Data Submission Deadline Approaching (11/07/2019)

The data submission deadline for patients that passed away in April, May and June 2019 (Quarter 2 2019) is November 13, 2019. Survey vendors are responsible for successfully submitting files by 11:59 PM Eastern Time on November 13, 2019. Please make sure to allow adequate time to submit data in case resubmissions are necessary.

A series of edit checks will be applied to successfully submitted files. All files that are able to be decrypted will receive reports containing the results of these edit checks. Survey vendors and hospices will receive an email indicating CAHPS Hospice Survey Data Submission Reports are available for viewing in their respective folders in the CAHPS Hospice Survey Data Warehouse. Reports will be posted by 5:00 PM Eastern Time on the next business day after submission by the survey vendor.

Should you encounter any data submission issues, please contact the CAHPS Hospice Survey Data Coordination Team at cahpshospicetechsupport@rand.org.

In addition, hospices must have a CAHPS Hospice Survey Vendor Authorization Form on file with the RAND Corporation in order for the survey vendor to submit data on behalf of the hospice. Contact the CAHPS Hospice Survey Project Team at hospicecahpssurvey@hsag.com immediately if your organization has not already submitted the CAHPS Hospice Survey Vendor Authorization Form.

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CAHPS Hospice Survey Attestation Statement Now Available (10/10/2019)

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 email at hospicecahpssurvey@hsag.com by December 13, 2019.

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UPDATED: Technical Corrections and Clarifications to the CAHPS Hospice Survey Quality Assurance Guidelines V6.0 (QAG V6.0) Document Posted (10/10/2019)

The CAHPS Hospice Survey Technical Corrections and Clarifications to the CAHPS Hospice Survey Quality Assurance Guidelines V6.0 (QAG V6.0) document has been posted. Following the release of the CAHPS Hospice Survey Quality Assurance Guidelines V6.0 (QAG 6.0), it has been determined that specific content items require correction, addition and/or further clarification.

Revisions were made to the CAHPS Hospice Survey Spanish Telephone Script instructions.

This document may be accessed by clicking here.

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CAHPS Hospice Survey Quality Assurance Guidelines Version 6.0 is Now Available (9/20/2019)

The CAHPS Hospice Survey administration protocols are contained in the CAHPS Hospice Survey Quality Assurance Guidelines Version 6.0 (QAG V6.0). To view or download the QAG V6.0, please click on the left hand Quality Assurance Guidelines navigation button. 

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 CAHPS Hospice Survey Training Materials are Now Available (09/20/2019)

 To view or download the agenda or PowerPoint slides for the September 26, 2019 CAHPS Hospice Survey Update Training session, please click on the left hand Training Materials navigation button. 

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Applicability of Quality Reporting Requirements for Hospices Affected by Tropical Storm/Hurricane Barry (9/13/2019)

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions[1] 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 Tropical Storm/Hurricane Barry 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 Louisiana parishes listed below, all of which have been designated by the Federal Emergency Management Agency (FEMA) as an emergency disaster parish.

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 parishes designated by FEMA under the Tropical Storm Barry Emergency Declaration (EM-3416) and Hurricane Barry Major Disaster Declaration (DR-4458) for Louisiana, as of the date of this communication, are as follows:

                                                                                                                        Louisiana

• Acadia
• Allen
• Ascension
• Assumption
• Avoyelles
• Beauregard
• Calcasieu
• Cameron
• Catahoula
• East Baton Rouge
• East Feliciana
• Evangeline
• East Baton Rouge
• East Feliciana

• Evangeline
• East Baton Rouge
• East Feliciana
• Evangeline
• Iberia I
• Iberville
• Jefferson
• Jefferson Davis
• Lafayette
• Lafourche
• Livingston
• Orleans
• Ouachita

• Plaquemine
• Pointe Coupee
• Rapids
• St. Bernard
• St. Charles
• St. Helena
• St. James
• St. John the Baptist
• St Landry.
• St. Martin
• St. Mary

 

• St. Tammany
• Tangipahoa
• Terrebonne
• Vermilion
• Vernon
• Washington
• West Baton Rouge
• West Feliciana

 

The healthcare providers located outside of the parishes 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 emergency disaster declaration for Tropical Storm/Hurricane Barry to include additional parishes, CMS will update this communication to reflect the expanded list of applicable parishes 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 2019 for the following quarters specific to each program:

Hospices – Hospice QRP Q3, (July 1, 2019-September 30, 2019)

PAC QRP Extraordinary Circumstances Exception Request Information 

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

[1] The terminology “exception” is used as a general term intended for ease of reference, to collectively refer to policies established under separate programs, and may not be consistent with the specific terminology established under each individual program.

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 UPDATED: CAHPS Hospice Survey Response Rate (8/30/2019)

The CAHPS Hospice Survey response rate for the upcoming public reporting period (first quarter of 2017 through the fourth quarter of 2018) is available here.

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UPDATED: Case-Mix Adjustment Methods for CAHPS Hospice Survey Measures Document Posted (8/29/2019)

Updates to the Case-Mix Adjustment (CMA) Methods document which describes refinements to the CMA model, updated coefficients and means from Quarter 2 2017 to Quarter 4 2018 for CAHPS Hospice Survey is available here.

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UPDATED: CAHPS Hospice Survey State Scores Posted (8/29/2019)

The CAHPS Hospice Survey state score document for the upcoming public reporting period (first quarter of 2017 through the fourth quarter of 2018) is available here.

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UPDATED: CAHPS Hospice Survey National Percentiles Posted (8/29/2019)

The CAHPS Hospice Survey state score document for the upcoming public reporting period (first quarter of 2017 through the fourth quarter of 2018) is available here.

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Fiscal Year 2020 Hospice Final Rule (08/29/2019)

On August 6, 2019, CMS issued a final rule to update the Medicare hospice wage index, Medicare hospice payment rates and cap amount for Fiscal Year (FY) 2020. For more information, please visit: https://www.federalregister.gov/documents/2019/08/06/2019-16583/medicare-program-fy-2020-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting.

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REMINDER: CY 2019 Participation Exemption for Size Form Available (06/14/2019) 

The Participation Exemption for Size Form for the calendar year (CY) 2019 CAHPS Hospice Survey data collection and reporting requirements is available to complete and submit on the CAHPS Hospice Survey Web site (www.hospicecahpssurvey.org). Hospices that served fewer than 50 survey-eligible decedents/caregivers in CY 2018 (January 1, 2018 through December 31, 2018 [or from assignment of CCN]) can apply for an exemption from participation in the CAHPS Hospice Survey for CY 2019.

To view or complete the 2019 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, 2019.

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@hsag.com or 1-844-472-4621. 

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UPDATED: Step-by-Step Guide for Calculating CAHPS Hospice Survey Top-, Middle-, and Bottom-Box Scores Document Posted (5/30/2019) 

Updates to the document for calculating CAHPS Hospice Survey Top-, Middle-, and Bottom-Box Scores have 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. 

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CAHPS Hospice Survey Results Available on Hospice Compare (05/28/2019) 

The May 2019 quarterly Hospice Compare refresh of quality data is now available. The current reporting period covers hospice care experiences from the third quarter of 2016 through the second quarter of 2018 (7/1/2016 through 6/30/2018) 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.

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Fiscal Year 2020 Hospice Proposed Rule Released (05/09/2019)

CMS issued a proposed rule to update the Medicare hospice wage index, Medicare hospice payment rates and cap amount for Fiscal Year (FY) 2020 on April 25, 2019. For more information, please visit: https://www.federalregister.gov/documents/2019/04/25/2019-08143/medicare-program-fy-2020-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting

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Applicability of Quality Reporting Requirements for Hospices Affected by California Wildfires (DR-4407) (01/14/2019) 

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions [1] under certain Medicare quality reporting and value-based purchasing and payment programs to acute care hospitals, Prospective Payment System (PPS)-exempt cancer 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 the California wildfires due to the devastating impact of the fires. These healthcare providers and suppliers will be granted exceptions without submitting a 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 and value-based purchasing and payment program are described below. CMS is granting exceptions to assist these healthcare providers while they direct their resources toward caring for their patients and repairing structural damages to facilities. Facilities that are able to, and choose to do so, may submit their data and continue participation in the program.

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 California Wildfires (DR-4407) as of the date of this communication, are as follows:

California Counties
  • Butte
  • Los Angeles
  • Ventura


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 and payment programs they participate 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 the California wildfires 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) QRPs.  

  • Hospices – Hospice QRP Quarter 4 (October 1, 2018 to December 31, 2018)

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


[1] The terminology “exception” is used as a general term intended for ease of reference, to collectively refer to policies established under separate programs, and may not be consistent with the specific terminology established under each individual program.

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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:

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  This page was last modified on 11/07/2019