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	Unchanged
CMS-10409_Supporting Statement Part A (January_18_2022)_CLEAN.docx Supporting Statement A	2022-04-26

IC Document Collections

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

ICR Details

OMB Control No: 0938-1163	ICR Reference No: 202204-0938-008
Status: Received in OIRA	Previous ICR Reference No: 202111-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Long Term Care Hospital (LTCH) Quality Reporting Program (CMS-10409)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/26/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2022
Responses	204,936	204,936
Time Burden (Hours)	145,831	145,831
Cost Burden (Dollars)	0	0

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Abstract: The Centers for Medicare & Medicaid Services (CMS) is requesting an extension to the Long-Term Care Hospital Continuity Assessment Record and Evaluation Data Set (LTCH CARE Data Set or LCDS) Version 5.0 that will be effective on October 1, 2022.

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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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 8016	02/11/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 24569	04/26/2022
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, CMS-10409, CMS-10409, CMS-10409	LCDS version 5.00 Admission ,   LCDS version 5.00 Expired ,   LCDS version 5.00 Planned Discharge ,   LCDS version 5.00 Unplanned Discharge

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ICR Summary of Burden

	Total Request	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	204,936	0	0	0	0
Annual Time Burden (Hours)	145,831	145,831	0	0	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: No

Burden Reduction Due to:

Short Statement:

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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? Yes

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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: 04/26/2022

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