Long Term Care Hospital (LTCH) Quality Reporting Program (CMS-10409)

Forms and Documents

Document Name	Status
Form CMS-10409 Long Term Care Data Set Form and Instruction	Modified
CMS-10409 Supporting Statement Part A (8-30-19).docx Supporting Statement A	2019-10-16

IC Document Collections

IC ID	Document Title	Status
201171	Long Term Care Data Set Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1163	ICR Reference No: 201910-0938-002
Status: Historical Active	Previous ICR Reference No: 201905-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Long Term Care Hospital (LTCH) Quality Reporting Program (CMS-10409)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/23/2019
	Date Received in OIRA: 10/22/2019
Terms of Clearance: Previous terms continue: OMB notes that CMS states it plans to display the expiration date associated with this collection on all of its manuals, instructions, and collections. The expiration date and OMB control number must be displayed on all paper and electronic versions of the collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved	12/31/2021
Responses	204,936	0	272,952
Time Burden (Hours)	145,831	0	121,674
Cost Burden (Dollars)	0	0	0

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Abstract: We are requesting approval for revisions to the LTCH CARE Data Set in the FY 2020 IPPS/LTCH PPS rule. The LTCH CARE Data Set is used to collect, submit, and report quality data to CMS for compliance with the Long-Term Care Hospital Quality Reporting Program (LTCH QRP). We are proposing the following revisions to the LTCH CARE Data Set V5.00 (effective October 1, 2020): a) Proposed data elements for the two Transfer of Health Information Measures: Transfer of Health Information to Provider–Post-Acute Care (PAC) and Transfer of Health Information to Patient–Post-Acute Care (PAC) b) Proposed Standardized Patient Assessment Data Elements

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3004 Name of Law: Quality reporting for LTCHs, inpatient rehabilitation hospitals, and hospice programs
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3004 Name of Law: Quality reporting for LTCHs, inpatient rehabilitation hospitals, and hospice programs

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT73	Final or interim final rulemaking	84 FR 42044	08/16/2019

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Federal Register Notices & Comments

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
Long Term Care Data Set	CMS-10409	Proposed LTCH QRP New and Modified Items

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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	204,936	272,952	0	-68,016	0	0
Annual Time Burden (Hours)	145,831	121,674	0	24,157	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: The total annual burden hours increased from 145,665 to 145,831 between the proposed and final rules this year. We have decreased our time estimate from 39.2 to 39.15 minutes for completing the admission assessment and increased our time estimate from 36.1 to 36.25 minutes for completing the discharge assessment. Overall, the combined time estimate increased from 75.3 to 75.4 minutes for the revised LTCH CARE Data Set.

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Annual Cost to Federal Government: $3,155,500

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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: 10/22/2019

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