Nursing Home Quality Improvement Questionnaire

Forms and Documents

Document	Type	Status	Availability
Supporting Statement - Part B.pdf	Supporting Statement B	Uploaded 2012-02-15	Available
CMS-10366 - Supporting Statement Part A [rev 05-21-2012].docx	Supporting Statement A	Uploaded 2012-05-25	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
201264	Nursing Home Quality Improvement Questionnaire	Other-Information Sheet	New

ICR Details

OMB Control No: 0938-1165	ICR Reference No: 201202-0938-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Nursing Home Quality Improvement Questionnaire
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: 06/01/2012
	Date Received in OIRA: 02/15/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved
Responses	2,100	0	0
Time Burden (Hours)	693	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The ACA requires CMS to issue a new regulation for QAPI programs, and to develop tools and resources to assist nursing homes in meeting the new QAPI regulation. To help ensure the technical assistance tools and resources are useful to nursing homes, CMS will collect data via the Nursing Home Quality Improvement Questionnaire on current quality improvement activities, challenges, and areas where TA will benefit nursing homes.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 6102(c) Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 6102(c) Name of Law: Patient Protection and Affordable Care Act

---

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:
	76 FR 71568	11/18/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 6125	02/07/2012
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Nursing Home Quality Improvement Questionnaire	CMS-10366, CMS-10366	Hard Copy - Nursing Home Quality Improvement Questionnaire ,   Screen Shots - Nursing Home Quality Improvement Questionnaire

---

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	2,100	0	2,100	0	0	0
Annual Time Burden (Hours)	693	0	693	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: No changes. This is a new collection.

---

Annual Cost to Federal Government: $233,340

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]? 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

---

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: 02/15/2012

---