Long Term Care Hospital (LCTH) Quality Reporting Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10409 Pressure Ulcer Submissions	Form and Instruction	Modified	Available
Supporting Statement B.12.09.11.docx	Supporting Statement B	Uploaded 2012-06-28	Available
LTCH CARE Item Matrix_V1.01.pdf	Supplementary Document	Uploaded 2012-06-28	Available
CMS-10409.Justification of Nonmaterial Changes_2012.06.08.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2012-06-28	Available
Supporting Statement A Revised 12 19 11 (2).clean copy.docx	Supporting Statement A	Uploaded 2012-06-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201171	Pressure Ulcer Submissions	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1163	ICR Reference No: 201208-0938-002
Status: Historical Active	Previous ICR Reference No: 201202-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Long Term Care Hospital (LCTH) Quality Reporting Program
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: 08/13/2012
	Date Received in OIRA: 08/07/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2013	04/30/2013	04/30/2013
Responses	263,000	0	263,000
Time Burden (Hours)	43,500	0	43,500
Cost Burden (Dollars)	0	0	0

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Abstract: Section 3004 of The Affordable Care Act authorizes the establishment of a new quality reporting program for Long Term Care Hospitals (LTCHs). Beginning in FY 2014, LTCHs that fail to submit quality measures data to CMS may be subject to a 2 percentage point reduction in their annual update to the standard Federal rate for discharges occurring during a rate year. One of the quality measures LTCHs are to collect and submit data on for this new quality reporting program is the Percent of Residents with Pressure Ulcers That Are New or Have Worsened. A new pressure ulcer data set has been developed specifically for use in LTCHs. This pressure ulcer data set incorporates data items contained in other, well know and clinically established pressure ulcer data sets, including but not limited to the Minimum Data Set 3.0 (MDS 3.0) and Continuity Assessment Record & Evaluation (CARE). Beginning on October 1, 2012, LTCHs will begin to collect a newly created set of pressure ulcer measure data elements for the LTCH quality reporting program. This data set consists of the following components: (1) pressure ulcer documentation; (2) selected covariates related to pressure ulcers; (3) patient demographic information; and; (4) a provider attestation section The use of the newly created LTCH CARE Data Set is necessary in order to allow CMS to collect LTCH quality measure data in compliance with Section 3004 of the Affordable Care Act. There are no other reasonable alternatives available to CMS for use in the collection of pressure ulcer data in LTCHs.

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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: 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

Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
Pressure Ulcer Submissions	CMS-10409, CMS-10409, CMS-10409, CMS-10409	LTCH CARE Data Set_Planned Discharge_v1.01 ,   LTCH CARE Data Set_Unplanned Discharge_v1.01 ,   LTCH CARE Data Set_Admission_v1.01 ,   LTCH CARE Data Set_Expired_v1.01

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ICR Summary of Burden

table that charts list 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	263,000	263,000	0	0	0	0
Annual Time Burden (Hours)	43,500	43,500	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: $760,500

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

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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: 08/07/2012

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