Testing Experience and Functional Tools: Functional Assessment Standardized Items (FASI) Based on the CARE Tool (CMS-10243)

Forms and Documents

Document Name	Status
Form CMS-10243 Functional Assessment Standardized Items (FASI): Round 2 Form and Instruction	Removed
CMS-10243 - Supporting Statement A (2019 version 3).docx Supporting Statement A	2019-12-18
CMS-10243 - Supporting Statement B_Clean.docx Supporting Statement B	2019-12-18

IC Document Collections

IC ID	Document Title	Status
222998	Functional Assessment Standardized Items (FASI): Round 2 Form and Instruction	Removed
222991	Functional Assessment Standardized Items (FASI): Round 1 Instruction	Modified

ICR Details

OMB Control No: 0938-1037	ICR Reference No: 201912-0938-009
Status: Active	Previous ICR Reference No: 201608-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Testing Experience and Functional Tools: Functional Assessment Standardized Items (FASI) Based on the CARE Tool (CMS-10243)
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: 04/29/2020
	Date Received in OIRA: 12/18/2019
Terms of Clearance: *

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2023	36 Months From Approved	04/30/2020
Responses	1,570	0	5,650
Time Burden (Hours)	785	0	2,825
Cost Burden (Dollars)	0	0	0

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Abstract: In 2012, the Disabled & Elderly Health Programs Group (DEHPG), within the Center for Medicaid and Children’s Health Insurance Program Services (CMCS) of the Centers for Medicare & Medicaid Services (CMS), funded a project entitled, Technical Assistance to States for Testing Experience and Functional Tools (TEFT) Grants. One component of this demonstration is to amend and test the reliability of a setting-agnostic, interoperable set of data elements, called “items,” that can support standardized assessment of individuals across the continuum of care. Items that were created for use in post-acute care settings using the Continuity Assessment Record and Evaluation (CARE) tool have been adopted, modified, or supplemented for use in community-based long-term services and supports (CB-LTSS) programs. This project will test the reliability and validity of the function-related assessment items, now referred to as Functional Assessment Standardized Items (FASI), when applied in community settings, and in various populations: elders (65 years and older); younger adults (18-64) with physical disabilities; and adults of any age with intellectual or developmental disabilities, with severe mental illness, or with traumatic brain injury. Data will be collected through interviews with individuals, conducted in their homes or another setting of their choosing. Assessment interviews will be conducted by trained assessors who already work with these clients to conduct assessments for the Medicaid Home and Community-Based Services (HCBS) coverage. Data will be collected using a modification of their current form in an electronic PDF format and uploaded to Truven Health Analytics through a secure electronic transfer file (ETF) application.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2701 Name of Law: Patient Protection and Affordable Care Act
  

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:
	84 FR 55966	10/18/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 69380	12/18/2019
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
Functional Assessment Standardized Items (FASI): Round 2	CMS-10243	Functional Assessment Standardized Items (FASI)
Functional Assessment Standardized Items (FASI): Round 1	CMS-10243, CMS-10243	Consent Form ,   Functional Assessment Standardized Items (FASI)

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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	1,570	5,650	0	-4,080	0	0
Annual Time Burden (Hours)	785	2,825	0	-2,040	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Based on a TEP’s review of the Round 1 Testing results changes to the FASI Item Set including clarifying instructions to assessors for completing personal priorities sections, enhancing examples of simple financial management, revising the list of assistive devices, and removing two duplicative items from the caregiver assistance section. The Round 1 burden was updated with more recent wage data while Round 2 will not be conducted.

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Annual Cost to Federal Government: $89,250

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

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.     Yes

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: 12/18/2019

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