CAHPS® Hospice Survey

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

Submission Date: 11/24/2017
Name of Survey Vendor Submitting the Exception Request: *

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

First Name, Last Name: *
  Title: *
Mailing Address: *
Mail Address 2:
City: *    State: *    Zip Code: *
(Area Code) Telephone Number: * (Area Code) Fax Number:
Contact Email: *

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

1. Exception Request for (please select one): *
1a. New Exception
Appeal of Exception Denial
1b. Exception (specify): *
2. List of hospices applicable to this Exception Request
2a. Total number of Affected Hospices: *

2b. Add the information for the affected hospices by populating the following 2 fields.
Name of Hospice: *      CCN: *


Number Affected Hospice Name CCN
{{plan.grpNumber}} {{plan.grpPracticeName}} {{plan.grpPracticeID}}
3. Description of Exception Request
3a. Purpose of Proposed Exception Requested (e.g., sampling, other): *


3b. Rationale for Proposed Exception Request: *


3c. Explanation of Implementation of Proposed Exception Request: *


3d. Evidence that Exception will not Affect Survey Results: *


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