Patient Safety Survey Under the 9th SOW: Nursing Home In Need (NHIN)

Forms and Documents

Document Name	Status
Form CMS-10315 Burden for year 3 Form and Instruction	New
Form CMS-10315 Burden for years 1 and 2 Form and Instruction	New
CMS-10315.Supporting Statement Part A, B, and Instrument.doc Supporting Statement B	2010-07-01
CMS-10315[1].REVISED Supporting Statement Part A 11-9-10.pdf Supporting Statement A	2010-11-22

IC Document Collections

IC ID	Document Title	Status
193886	Burden for year 3 Form and Instruction	New
193885	Burden for years 1 and 2 Form and Instruction	New

ICR Details

OMB Control No: 0938-1116	ICR Reference No: 201007-0938-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Patient Safety Survey Under the 9th SOW: Nursing Home In Need (NHIN)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/05/2010
	Date Received in OIRA: 07/22/2010
Terms of Clearance: *

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2013	36 Months From Approved
Responses	212	0	0
Time Burden (Hours)	70	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (DHHS) are requesting OMB clearance for the Nursing Homes in Need (NHIN) Survey. The NHIN is a component of the Patient Safety Theme of the Quality Improvement Organization (QIO) Program's 9th Scope of Work (SOW). The statutory authority for this scope of work is found in Part B of Title XI of the Social Security Act (the Act) as amended by the Peer Review Improvement Act of 1982. The Act established the Utilization and Quality Control Peer Review Organization Program, now known as the Quality Improvement Organization (QIO) Program. The legal basis for this data collection is contained in Section 1862(g) of the Act. The CMS designee, QualMed Surveys, LLC, (QMS) of Rockville, MD, will administer the NHIN Survey to nursing homes to evaluate nursing home satisfaction with the technical assistance process (NHIN Survey data) and their perception of effectiveness of QIO technical assistance. The NHIN Survey is being used as a tool for obtaining feedback for performance improvement activities. The goal is to collect information from the nursing homes participating in the QIO program to help CMS and the QIOs improve the interventions. The NHIN Survey will be a census of 53 nursing homes (one respondent at each nursing home) working with their respective QIOs. The survey will be conducted one time for each of the nursing homes assisted in the first two years under the 9th SOW and it will be conducted twice with nursing homes assisted in the third year. The survey will elicit satisfaction data only and will not involve sampling. Nursing home contact information will be provided by the QIOs.

---

Authorizing Statute(s): US Code: 42 USC 1395y Name of Law: EXCLUSIONS FROM COVERAGE AND MEDICARE AS SECONDARY PAYER
   US Code: 42 USC 1320c-3 Name of Law: FUNCTIONS OF PEER REVIEW ORGANIZATIONS
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 13543	03/22/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 34742	06/18/2010
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Burden for years 1 and 2	CMS-10315	Nursing Home In Need (NHIN) Survey
Burden for year 3	CMS-10315	Nursing Home In Need (NHIN) Survey

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	212	0	0	212	0	0
Annual Time Burden (Hours)	70	0	0	70	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

---

Annual Cost to Federal Government: $90,598

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/22/2010

---