Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10387 Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction	Modified	Available
Crosswalk for Change to MDS 3_PRA_FY2014.docx	Supplementary Document	Uploaded 2013-10-30	Available
CMS-10387 -- Supporting Statement part A [rev 10-30-2013 by OSORA PRA].docx	Supporting Statement A	Uploaded 2013-10-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
197759	Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1140	ICR Reference No: 201310-0938-013
Status: Historical Active	Previous ICR Reference No: 201109-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: 20789
Title: Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)
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: 01/15/2014
	Date Received in OIRA: 10/30/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved	09/30/2014
Responses	6,396,416	0	884,492
Time Burden (Hours)	6,608,971	0	913,884
Cost Burden (Dollars)	0	0	0

---

Abstract: Skilled Nursing Facilities (SNFs) will be required to submit a Change of Therapy (COT) Other Medicare Required Assessment (OMRA) to administer the payment rate methodology. This additional assessment is subject to the Paperwork Reduction Act. The burden associated with this is the SNF staff time required to complete the COT OMRA for the Minimum Data Set (MDS), SNF staff time to encode, and SNF staff time spent in transmitting the data.

---

Authorizing Statute(s): US Code: 42 USC 1395yy(e) Name of Law: Payment to Skilled Nursing Facilities for Routine Costs
   PL: Pub.L. 105 - 33 4432(a) Name of Law: Prospective Payment for Skilled Nursing Facilities
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AR65	Final or interim final rulemaking	78 FR 47936	08/06/2013

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 26438	04/06/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 47936	08/06/2013
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
Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	CMS-10387, CMS-10387, CMS-10387, CMS-10387, CMS-10387	Nursing Home PPS (NP) Item Set ,   Nursing Home OMRA-Start of Therapy and Discharge (NSD) Item Set ,   Nursing Home and Swing Bed OMRA-Start of Therapy (NS/SS) Item Set ,   Nursing Home OMRA-Discharge (NOD) Item Set ,   Nursing Home and Swing Bed OMRA (NO/SO) Item Set

---

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	6,396,416	884,492	0	5,511,924	0	0
Annual Time Burden (Hours)	6,608,971	913,884	0	5,695,087	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: No

Burden Reduction Due to:

Short Statement: This package incorporates all PPS assessment item sets. When we presented NO/SO for PRA consideration for FY 2011, the form was used as a proxy for the NP, NS, NOD and NSD Item sets inasmuch as it included all MDS payment items which were required to be considered under the PRA. According to CASPER, there were 15,376 skilled nursing facilities certified to participate in the Medicare program during FY 2012. We had previously estimated 14,266 facilities. We are also adjusting the number of responses per respondent from 62 to 416. Additionally, we are adding Item O0420 to the MDS 3.0 form as discussed in RIN 0938-AR65 (CMS-1446-F). We do not believe this action will cause any measurable adjustments to our burden estimates. Consequently, we are not revising the associated estimates.

---

Annual Cost to Federal Government: $0

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]? No

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: 10/30/2013

---