Discrepancy Report Process:

From time to time a hospital/survey vendor may identify inadvertent and temporary discrepancies from HCAHPS protocols that require corrections to procedures and/or electronic processing to realign the activity to HCAHPS protocols. Hospitals/Survey vendors are required to notify CMS of these discrepancies. (Examples of temporary discrepancies may include, but are not limited to, missing eligible discharges from a particular date, or computer programming that caused an otherwise eligible MS-DRG to be excluded from the sample frame.)

• Hospitals/Survey vendors must notify the HCAHPS  Project Team within 24 hours of discovery of the discrepancy, regardless of whether the root cause, scope of issue or a resolution has been identified. If all the information is not immediately available, survey vendors must submit an initial Discrepancy Report alerting CMS of the issue and subsequently update the Discrepancy Report with the remaining required information within two weeks of the original submission.
       
• See the current HCAHPS Quality Assurance Guidelines for the form that must be submitted online (www.hcahpsonline.org), or to access the Discrepancy Report Form online see below. This report notifies the HCAHPS Project Team of the nature, timing, cause, and extent of the discrepancy, as well as the proposed correction and timeline to correct the discrepancy, to the extent this information is immediately available.
  
  
• Survey Vendors must complete and submit all Discrepancy  Reports on behalf of their client hospitals
  
  
• For information not immediately available, complete required form fields with "To be updated"
  
  

Review Process

The Discrepancy Report will be reviewed by the HCAHPS Project Team, who will assess the actual or potential impact of the discrepancy on publicly reported HCAHPS results.

Depending on the nature and extent of the discrepancy, a formal review of the hospital's/survey vendor's procedures, and/or conference call or on-site visit, may be undertaken. The HCAHPS Project Team will notify hospitals/survey vendors whether additional information is required to document and correct the issue.

Directions for Completing the Discrepancy Report Form

General Instructions

NOTE: This form does not accept any special characters or symbols in the text boxes. Use only alphanumeric characters when completing this form.

Please be sure to complete the Discrepancy Report in its entirety, to the extent this information is immediately available.

• If all the information is not immediately available, survey vendors must submit an initial Discrepancy Report alerting CMS of the issue and subsequently update the Discrepancy Report with the remaining required information within two weeks of the original submission      
       
• All form fields must be completed to the extent this information is available
       
• For information not immediately available, complete required form fields with "To be updated"

Section 1: Must contain information for the organization submitting the Discrepancy Report.

Section 2: Must contain the name of the individual to contact regarding the Discrepancy Report.

Section 3: Provide information about the discrepancy, including: a detailed description of the discrepancy; how it was identified; the corrective actions taken to prevent the identified issue from reoccurring; and any other information that might assist the HCAHPS team to determine an outcome.

Section 4: Submit information for each hospital that was affected by the discrepancy. All fields are required and at least one hospital must be listed in order to submit the online Discrepancy Report.

To enter data for a minimum of one hospital: Complete all items in Section 4 and select the “Add Affected Hospital Information” button. Select the “Submit Form” button and the Discrepancy Request will be submitted to the HCAHPS team for review.

To enter data for multiple hospitals: After entering the data for one hospital, select the “Add Affected Hospital Information” button. A notice will appear at the top of the page indicating that the “Affected hospital information has been added successfully.” This action will result in listing the previously entered information in the “onscreen” table and blank out the data fields so that information regarding an additional hospital may be entered. Repeat this process until all hospitals have been entered. Next step is to select the “Submit Form” button and the Discrepancy Request will be submitted to the HCAHPS team for review. A notice will appear at the top of the page indicating that “You have successfully submitted your completed Discrepancy Report Form.”

If the Discrepancy Report affects more than 20 hospitals, download the Discrepancy Report Hospital Information Form, input the information regarding each hospital, and email the completed spreadsheet via HCAHPS Technical Assistance at hcahps@hsag.com.

This page was last modified on (1/10/20)

Indicate whether this report is an Initial Discrepancy Report or an Updated Discrepancy Report.

InitialReport Initial Discrepancy Report * (Must be submitted within 24 hours after the discrepancy has been discovered.)

UpdateReport Updated Discrepancy Report * (If needed, must be submitted within two weeks of initial Discrepancy Report.)

Date of initial Discrepancy Report submission * Date of initial Discrepancy Report submission is required.

Initial Discrepancy Report ID * The Initial Discrepancy Report ID is required.

Section 1 is to be completed by the organization submitting this form.  The requested information regarding the affected hospitals must be provided in Section 4 in order to complete the HCAHPS Discrepancy Report.  THIS FORM MUST BE SUBMITTED ONLINE (www.hcahpsonline.org).  All required fields are indicated with an asterisk (*).

1. General Information

Unique Report ID 120169

Submission Date 03/26/2023

1a. Name of Organization submitting the Discrepancy Report * The Name of the Organization is required.

1b. Type of Organization * Choose One {{option.name}} The Type of the Organization is required.

Survey Vendor The Name of the Vendor is required.

Other The Type of the Organization is required.

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2. Contact Person for this Discrepancy Report (Confirmation email will be sent to the Contact Person.)

2a. First Name * First Name is required.

2b. Last Name * Last Name is required.

2c. Mailing Address 1 * Mailing Address 1 is required.

2d. Mailing Address 2

2e. City * City is required.

2f. State * State is required.

2g. Zip Code * Zip Code is required.

2h. Telephone * Telephone is required.

Extension

2i. Fax Number

2j. Email * Email is required.

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3. Information about the Discrepancy

3a. Description of the discrepancy * Description of the discrepancy is required. {{2000 - model.DiscrepancyDescription.length}} characters remaining

3b. Description of how the discrepancy was identified * Description of how the discrepancy was identified is required. {{2000 - model.DiscrepancyIdentified.length}} characters remaining

3c. Description of the Corrective Action to fix the discrepancy, including estimated time for implementation * Description of the Corrective Action is required. {{2000 - model.CorrectiveAction.length}} characters remaining

3d. Additional information that would be helpful that has not been included above * Additional Info is required. {{2000 - model.AdditionalInfo.length}} characters remaining

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4. List of Hospitals Applicable to this Discrepancy

4a. Total number of Affected Hospitals * The Number of Affected Hospitals is required.

4b. Add the information for the affected hospitals by populating the following 10 fields. A hospital may be added more than once if there are multiple time frames for the hospital. It is important that the affects of the Discrepancy Report are quantified, however "unknown" will be accepted as a valid response.

Name of Hospital * Name of Hospital is required.

CCN * CCN is required.

Hospital Contact Name * Hospital Contact Name is required.

Email Address for the Hospital Contact * A valid Email Address is required.

Number of Eligible Discharges Affected * Number of Eligible Discharges Affected is required.

Average number of Eligible Discharges per month * Average number of Eligible Discharges per month is required.

Count of Sampled Patients affected * Count of Sampled Patients affected is required.

Average number of surveys administered per month (sampled patients) * Average number of surveys administered is required.

Date Discovered * Date Discovered * Date Discovered * Time frame affected: Begin Date * Begin Date is required.

Time frame affected: End Date * End Date is required. End Date must be on or after Begin Date.

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