DEPARTMENT OF HEALTH AND HUMAN SERVICES Form ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0379 Hospice Survey and Deficiencies Report Page ____ of ____Provider Number Name of Facility Survey Date 1. Was this hospice surveyed for compliance with 42 CFR 418.100? L50 Yes No 2. If this hospice provides inpatient care directly, is the inpatient care provided on the premises? L51 Yes No 3. Has a waiver of core nursing services been granted? 4. If "Yes" indicate date L52 L53 Yes No 5. Indicate type of setting(s) in which the hospice provides routine home care. L54 Private residenceSNF  NF Other (specify) 6. Number of hospice patients residing in a SNF, NF or other residential facility who receive routine home care L55 from the hospice. 7. Number of hospice patients admitted during recent 12 month period. L568. Number of records reviewed during survey. L579. Number of home visits conducted to patients in a private residence. L5810. Number of home visits conducted to patients in residential facilities. L5911. Does this hospice operate under the same provider number at 12. If "Yes" enter L60 L61 more than one location? number of locations. Yes No 13. Does this hospice operate as part of another entity that participates14. If "Yes" enter the Medicare provider L62 L63 in the Medicare program? number of the entity. Yes No Surveyor Signature Title Date According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0938-0379. The time required to complete this information collection is estimated to average 2.5hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the informationcollection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Mailstop N2-14-26,7500 Security Boulevard, Baltimore, Maryland 21244-1850. CMS-643 (11-94) >>>> 2 Hospice Survey and Deficiencies Report Page ____ of ____Deficiencies Data Tag Number CoP/Stnd. No. Comments I certify that I have reviewed each hospice Condition of Participation and related standards and except as indicated on thisform the facility was found to be in compliance with the standards and/or the Conditions of Participation. Surveyor Signature Title DateSurveyor Signature Title DateCMS-643 (11-94)