(CMS–10551) Nursing Home NationalProvider Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10551 Nursing Home National Provider Survey	Form and Instruction	New	Available
NH Attachment I Development of Two National Provider Surverys 2015 11 10.docx	Supplementary Document	Uploaded 2015-11-17	Available
CMS-10551 NH Supporting Statement B 2015 11 10.docx	Supporting Statement B	Uploaded 2015-11-16	Available
CMS-10551 NH Supporting Statement A 2015 11 10.docx	Supporting Statement A	Uploaded 2015-11-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217141	Nursing Home National Provider Survey	Form and Instruction	New

ICR Details

OMB Control No: 0938-1291	ICR Reference No: 201506-0938-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: (CMS–10551) Nursing Home NationalProvider Survey
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: 11/19/2015
	Date Received in OIRA: 06/22/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2018	36 Months From Approved
Responses	940	0	0
Time Burden (Hours)	639	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Section 3014 of the Patient Protection and Affordable Care Act (ACA, 2010) (P.L. 111-148) (ACA) requires that the Secretary of the Department of Health and Human Services (HHS) conduct an assessment of the quality and efficiency impact of the use of endorsed measures in specific Medicare quality reporting and incentive programs. The ACA further specifies that the initial assessment must occur no later than March 1, 2012, and once every 3 years thereafter. This planned data collection activity was developed and tested as part of the 2015 Impact Report and data collection will be conducted for reporting in the 2018 Impact Report. The implementation of quality measures by CMS has led to positive gains in the use of evidence-based standards of care by providers. To ensure the nation continues to build on these gains, and to fulfill the requirements of Section 3014 of the Patient Protection and Affordable Care Act of 2010 (ACA) for the assessment of the quality and efficiency impact of the use of endorsed measures in specific Medicare quality reporting and incentive programs, CMS has conducted two national assessments (first 1 reported in 2012 and the second to be reported in 2015.)

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3014 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3014 Name of Law: Affordable Care Act

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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:
	80 FR 15014	03/20/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 32133	06/15/2015
Did the Agency receive public comments on this ICR? No

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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
Nursing Home National Provider Survey	CMS-10551, CMS-10551, CMS-10551, CMS-10551, CMS-10551, CMS-10551	Qualitative Interview Guide ,   Structured Research Guide ,   Summary of Interview ,   List of Quality and Efficiency Measures ,   Interview Topic Guide for Semi-Structured Interview ,   Standardized Hospital National Provider Survey

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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	940	0	0	940	0	0
Annual Time Burden (Hours)	639	0	0	639	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 is a new information collection.

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Annual Cost to Federal Government: $964,943

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: 06/22/2015

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