CMS Form 1572, officially the Home Health Agency Survey and Deficiencies Report, is the standardized report that state survey agency staff complete after inspecting a Medicare-certified home health agency. It captures identifying information about the agency, the type of survey conducted, and any deficiencies found against the federal conditions of participation in 42 CFR Part 484.1Federal Register. Agency Information Collection Activities: Submission for OMB Review; Comment Request2eCFR. 42 CFR 484.1 – Basis and Scope The home health agency itself does not fill it out. Surveyors do.3Centers for Medicare & Medicaid Services. Home Health Agency Survey Report (CMS-1572)
For agency administrators, that distinction matters. Form 1572 is the surveyor’s internal record. What you receive as a provider is a different document, Form 2567, generated from the findings recorded on 1572.
What the Form Records
The form has two parts. Part 1 collects background information about the agency and the survey itself: the official name of the agency, the six-digit CMS Certification Number, and the dates of the survey. Part 2 is completed by the surveyor and documents the inspection findings, coded to the specific federal requirement that was not met.3Centers for Medicare & Medicaid Services. Home Health Agency Survey Report (CMS-1572)
The current version is a fillable PDF, revised from the earlier static form to include interactive text fields and check blocks.1Federal Register. Agency Information Collection Activities: Submission for OMB Review; Comment Request Every finding documented on it must trace back to observations made during the physical inspection and the review of patient records.
Survey Types Checked on the Form
One of the first things a surveyor marks is the type of survey being conducted. The options are more specific than a general “annual inspection” label suggests. They include the initial certification survey, done when an agency first seeks entry into Medicare, and several recertification categories:3Centers for Medicare & Medicaid Services. Home Health Agency Survey Report (CMS-1572)
- Standard (1): the baseline recertification survey evaluating compliance across the conditions of participation.
- Partial Extended (2): a deeper review triggered when the standard survey uncovers problems suggesting broader noncompliance.
- Extended (3): the most comprehensive recertification survey, examining regulatory areas beyond those in a partial extended.
- Combinations (4, 5, 6): checkboxes indicating a visit combined a standard survey with a partial extended, an extended, or all three.
Home health agencies are surveyed at least once every 36 months, and surveys are unannounced. CMS can authorize more frequent visits to confirm that previously cited deficiencies have been corrected or to respond to complaints about care.4eCFR. 42 CFR 488.730 – Survey Frequency and Content
How Deficiencies Are Recorded
When a surveyor identifies a violation, the finding is recorded using a G-tag, a shorthand code that ties the deficiency to a specific section of 42 CFR Part 484. Tags in the G100–G116 range, for example, correspond to patient rights requirements under § 484.10, while tags in the G156–G166 range cover care planning and medical supervision under § 484.18.5Centers for Medicare & Medicaid Services. Home Health G Tags and Abbreviated Identifiers G-tags are prioritized. Level 1 tags are reviewed during every standard survey; Level 2 tags come into play during partial extended surveys.
Scope and Severity
Each cited deficiency is evaluated on two axes. Scope measures how many patients were affected: isolated (one or a very limited number), pattern (more than a few), or widespread (a large portion of the agency’s patients). Severity measures the harm caused or risked, from no more than a minor negative impact up to immediate jeopardy to patient health or safety.6Centers for Medicare & Medicaid Services. SFF Scoring Methodology The combination determines where a deficiency sits on the enforcement matrix.
Immediate Jeopardy
The most serious finding is immediate jeopardy. It requires three elements: the agency failed to meet a federal requirement, that failure caused or is likely to cause serious injury, harm, or death to one or more patients, and the situation demands corrective action right away.7Centers for Medicare & Medicaid Services. State Operations Manual Appendix Q – Core Guidelines for Determining Immediate Jeopardy An immediate jeopardy citation accelerates the enforcement timeline sharply.
What Happens After the Surveyor Completes the Form
After the on-site inspection, the lead surveyor enters the findings from Form 1572 into the electronic system used by the state survey agency. Once uploaded, the data becomes part of the agency’s permanent compliance record and is available to federal regulators for enforcement decisions.
The submission timeline depends on what was found. When immediate jeopardy exists, the state survey agency must submit all certification materials to the CMS Regional Office within two working days of completing the survey. For standard surveys, that window is 30 calendar days.8Centers for Medicare & Medicaid Services. State Operations Manual – Chapter 3 – Additional Program Activities
The Form the Agency Actually Receives: Form 2567
Findings from Form 1572 feed into a separate document, CMS Form 2567, the Statement of Deficiencies and Plan of Correction. Form 2567 is the formal notice sent to the provider listing every cited deficiency and requiring a written response.9Centers for Medicare & Medicaid Services. Quality, Safety and Oversight – Enforcement – Section: Statement of Deficiencies It becomes publicly releasable within 14 days after the provider receives it.10Centers for Medicare & Medicaid Services. Release of CMS-2567 Statement of Deficiencies and Plan of Correction
Once Form 2567 arrives, the agency has 10 calendar days to submit a Plan of Correction back to the surveying body, whether that is the state agency, an accrediting organization, or the CMS Regional Office.11Centers for Medicare & Medicaid Services. CMS-2567 – Statement of Deficiencies and Plan of Correction The plan must address each cited deficiency individually, explaining the corrective steps taken or planned and the date each correction will be completed. A vague or incomplete plan will be returned, which eats into the correction window.
Informal Dispute Resolution
An agency that disagrees with a condition-level finding can request informal dispute resolution (IDR). The right to request IDR begins upon receipt of the official Statement of Deficiencies.12eCFR. 42 CFR 488.745 – Informal Dispute Resolution (IDR) IDR is not an appeal that halts enforcement; it is an informal process for presenting evidence that a deficiency was incorrectly identified. Filing does not extend the 10-day Plan of Correction deadline, so many compliance officers prepare both in parallel.
Getting a Copy of the Form
The current fillable PDF of Form 1572 is on the CMS forms library page.13Centers for Medicare & Medicaid Services. CMS 1572 Agency administrators do not complete it, but reading a blank copy is one of the most practical ways to prepare for a survey. Walking through the fields shows exactly what surveyors document and which regulatory areas they evaluate. The CMS website carries the most current version.