Updated Guidelines for Initiating the HHCAHPS Survey More Than 21 Days After the Close of the Sample Month
folder_openChanges to Protocols and Guidelines, Information for Home Health Agenciescalendar_todayPosted October 21, 2011

Please note that the information in the box below is additional clarification of the protocol for fielding the survey more than 26 days after the sample month ends, which was originally described in an announcement posted on the HHCAHPS Web site on October 13, 2011.

Home Health Care CAHPS (HHCAHPS) Survey protocols require that HHCAHPS Survey vendors initiate the survey—that is, begin data collection activities—within 21 days after the close of a sample month. The rationale for this protocol is that sample patients will be better able to recall and accurately report their experiences with home health care if the survey is administered as soon as possible after the care is received.

The Centers for Medicare & Medicaid Services (CMS) is issuing the following guidance to HHCAHPS Survey vendors and home health agencies (HHAs) regarding initiating the HHCAHPS Survey more than 21 days after the sample month ends.

Effective immediately, if the survey cannot be fielded within 21 days after the sample month ends, HHCAHPS Survey vendors will be permitted to field the survey by the 26th day after the sample month ends. Survey vendors, however, should still make a concerted effort to initiate the survey within 21 days after the sample month ends. HHAs and vendors do not need approval to initiate the HHCAHPS Survey between the 22nd and 26th day after the sample month ends; however, survey vendors must continue to submit a Discrepancy Notification Report (DNR) to document the fact that the survey was not initiated within 21 days after the sample month ended.

CMS recognizes that occasionally HHAs may experience a situation that may make it difficult to provide a monthly patient information file in time for the vendor to initiate the survey within 21 days after the sample month ends. If the survey cannot be initiated within 26 days after the sample month ends, the HHA’s approved vendor must request approval from CMS to field the survey for the specific sample month. To request this approval, the survey vendor should send an e-mail message to the HHCAHPS Coordination Team, copying its HHA client, indicating the reason(s) the survey cannot be initiated as scheduled, and the expected date by which the survey will be initiated. CMS will review each request; the Coordination Team will notify the HHA and its vendor as to whether the request is approved.

CMS will only consider requests for approval to field the survey more than 26 days after the sample month ends for HHAs that cannot submit a monthly patient information file because of a natural disaster (tornadoes, floods, earthquakes), weather-related emergencies, fires, computer crashes, extreme personnel issues, or similar situations. Approval for fielding the survey more than 26 days after a sample month ends will not be granted to HHAs just beginning their participation in HHCAHPS, nor will it be granted to HHAs that do not submit a monthly patient information file in time for the vendor to initiate the survey within 26 days after the sample month ends for any reason other than those stated above or similar reasons.

If CMS approves the request for the HHA to initiate the HHCAHPS Survey more than 26 days after the sample month ends, the vendor will not need to submit a DNR. The e-mail message that the vendor submitted requesting approval to field the survey will be retained as documentation of the late data collection start.

HHCAHPS Survey vendors and HHAs should contact the HHCAHPS Coordination Team at hhcahps@rti.org or by calling the HHCAHPS toll-free number at 1-866-354-0985 if they have any questions or need further information about this protocol.