Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10036 Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P (CMS-10036)	Form	Removed	Repair queued
Form CMS-10036 Inpatient Rehabilitation Facility-Patient Assessment Instrument	Form and Instruction	New	Available
Form CMS-10036 Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form	Removed	Available
Form CMS-10036 Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form	Removed	Available
Pt Influenza Measire. Burden Calculation. 03.21.13.docx	Supplementary Document	Uploaded 2013-06-04	Available
Pt Influenza Measire. Burden Calculation. 03.21.13.docx	Supplementary Document	Uploaded 2013-06-05	Available
CMS Crosswalk- IRF-PAI 2014 Discharge v2.doc	Supplementary Document	Uploaded 2013-06-04	Available
CMS Crosswalk- IRF-PAI 2014 Admission v2.doc	Supplementary Document	Uploaded 2013-06-04	Available
PU Burden Calculation. 03.26.13.docx	Supplementary Document	Uploaded 2013-06-04	Available
CMS-10036_IRF-PAI_Revisions Crosswalk.docx	Supplementary Document	Uploaded 2011-06-01	Available
CMS-10036_IRF-PAI_Revisions Crosswalk.docx	Supplementary Document	Uploaded 2011-06-01	Available
CMS-10036_IRF-PAI_Revisions Crosswalk.docx	Supplementary Document	Uploaded 2011-06-01	Available
CMS-10036 Supporting Statement A. 04.03.13.clean copy.docx	Supporting Statement A	Uploaded 2013-06-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8648	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P (CMS-10036)	Form	Removed
207222	Inpatient Rehabilitation Facility-Patient Assessment Instrument	Form and Instruction	New
187984	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form	Removed
187983	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form	Removed

ICR Details

OMB Control No: 0938-0842	ICR Reference No: 201306-0938-003
Status: Historical Inactive	Previous ICR Reference No: 201106-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: 19733
Title: Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 08/27/2013
	Date Received in OIRA: 06/06/2013
Terms of Clearance: The agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	36 Months From Approved	02/28/2015
Responses	486,550	0	486,550
Time Burden (Hours)	413,568	0	413,568
Cost Burden (Dollars)	0	0	0

---

Abstract: We are requesting approval for revisions to the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI. The burden associated with this requirement is the staff time required to complete, encode, and transmit the data from the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI). The burden associated with transmitting the IRF-PAI is not being included in this revision, since the requirement for IRFs to transmit the data is unaffected by the proposed revision to the assessment instrument. We are proposing to replace the current pressure ulcer assessment data items in the Quality Indicator section of the IRF-PAI with a new set of pressure ulcer data items. The proposed new pressure ulcer data elements are more comprehensive than in use on the current version of the IRF-PAI. The proposed new pressure ulcer items are similar to those collected through the Minimum Data Set 3.0 (MDS 3.0), which is a reporting instrument that is used in nursing homes. The current MDS 3.0 pressure ulcer items evolved as an outgrowth of CMS' work to develop a standardized patient assessment instrument, now referred to as the CARE (Continuity Assessment Records & Evaluation). We further propose to add a new measure known as the "Percent of Patients/Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine" (NQF #0680) to the IRF quality reporting program beginning on October 1, 2014. We propose to collect the data for this measure using a set of data elements that is very similar to those collected through the Minimum Data Set 3.0 (MDS 3.0). We have made several updates to the "Identification Information", "Admission Information" and the Medical Information" sections of the IRF-PAI. The number of items deleted exceeds the number of new questions added. Therefore, there has been no net increase in burden caused by these changes.

---

Authorizing Statute(s): US Code: 42 USC 1395ww(jX2)(d) Name of Law: Prospective Payment for Inpatient Rehab Services
   PL: Pub.L. 111 - 148 3004 Name of Law: Quality Reporting for Long-Term Care Hospitals, etc.
   PL: Pub.L. 105 - 1 4421 Name of Law: Prospective Payment for Inpatient Rehab Hospital Services
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AR66	Proposed rulemaking	78 FR 26880	05/08/2013

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Inpatient Rehabilitation Facility-Patient Assessment Instrument	CMS-10036, CMS-10036	Voluntary/Mandatory Items for Proposed DRAFT IRF-PAI Version 1.2 (Proposed DRAFT Effective October 1, 2014) Assessment Quality Indicator Items- Sect 3004 IRF Quality Reporting Program ,   IRF-PAI Instrument
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P (CMS-10036)	CMS-10036	IRF PAI Instrument
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	CMS-10036	IRF PAI Instrument
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	CMS-10036	IRF PAI Instrument

---

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The current pressure ulcer assessment data items in the Quality Indicator section of the IRF-PAI have been replaced with a new set of pressure ulcer data items. The new data elements are more comprehensive than in use on the current version of the IRF-PAI.

---

Annual Cost to Federal Government: $2,000,000

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

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: 06/06/2013

---