Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD) (CMS-10387)

Forms and Documents

Document Name	Status
Form CMS-10387 Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD) Form and Instruction	Modified
Justification for Nonsubstantive Change of OMB 0938-1140 V4_4-5-2017 [rev 04-19-2017 by OSORA PRA].docx Justification for No Material/Nonsubstantive Change	2017-04-19
OMB 0938-1140 Supporting Statement Revision_nonsub_V4-4-5-2017 (rev 04-07-2017 by OSORA PRA).docx Supporting Statement A	2017-04-19

IC Document Collections

IC ID	Document Title	Status
197759	Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1140	ICR Reference No: 201703-0938-018
Status: Historical Active	Previous ICR Reference No: 201603-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-FFS
Title: Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD) (CMS-10387)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/28/2017
	Date Received in OIRA: 04/19/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	02/29/2020	02/29/2020
Responses	6,563,344	0	678,524
Time Burden (Hours)	5,580,885	0	701,119
Cost Burden (Dollars)	0	0	0

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Abstract: Skilled Nursing Facilities (SNFs) will be required to submit a Change of Therapy (COT) Other Medicare Required Assessment (OMRA) to administer the payment rate methodology. This additional assessment is subject to the Paperwork Reduction Act. The burden associated with this is the SNF staff time required to complete the COT OMRA for the Minimum Data Set (MDS), SNF staff time to encode, and SNF staff time spent in transmitting the data.

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Authorizing Statute(s): PL: Pub.L. 105 - 33 4432(a) Name of Law: Prospective Payment for Skilled Nursing Facilities
   US Code: 42 USC 1395yy(e) Name of Law: Payment to Skilled Nursing Facilities for Routine Costs
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 53516	09/04/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 11569	03/04/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	CMS-10387, CMS-10387, CMS-10387, CMS-10387, CMS-10387	Nursing Home PPS (NP) Item Set ,   Nursing Home OMRA-Start of Therapy and Discharge (NSD) Item Set ,   Nursing Home and Swing Bed OMRA-Start of Therapy (NS/SS) Item Set ,   Nursing Home OMRA-Discharge (NOD) Item Set ,   Nursing Home and Swing Bed OMRA (NO/SO) Item Set

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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	6,563,344	678,524	0	0	5,884,820	0
Annual Time Burden (Hours)	5,580,885	701,119	0	0	4,879,766	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: This iteration’s nonsubstantive changes consist of two corrections and one adjustment. Correction #1 reintroduces burden that was previously approved but was inadverantly removed. Correction #2 addresses ROCIS data entry errors. The Adjustment makes a few burden changes that are based on more current data. This request does not revise any requirements, nor does it propose any program changes. Likewise, our per response burden estimate is unchanged.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

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

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Common Form ICR:  No

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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: 04/19/2017

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