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.)
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
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.
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 firstname.lastname@example.org.
This page was last modified on (1/10/20)