Discrepancy Report

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

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

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 126222

Submission Date 04/17/2024

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

1b. Type of Organization * The Type of the Organization is required.

Survey Vendor The Name of the Vendor is required.

Other The Type of the Organization is required.

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.

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

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.

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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Note: Please print completed Discrepancy Report form before submitting.

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This site is hosted and maintained by Health Services Advisory Group.
It is sponsored by the Centers for Medicare & Medicaid Services.