Pressure Ulcer Submissions

(CMS-10409) Long Term Care Hospital (LCTH) Quality Reporting Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1163 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10409 Pressure Ulcer Submissions Form and Instruction
CMS-10409 LTCH Care Data Set Admissions LTCH CARE Data Set_Admission_V3 00_FINAL_508C.pdf Form and Instruction
CMS-10409 LTCH Care Data Set Expired LTCH CARE Data Set_Expired_V3 00_FINAL_508C.pdf Form and Instruction
CMS-10409 LTCH Care Data Set Planned Discharge LTCH CARE Data Set_Planned Discharge_V3 00_FINAL_508C.pdf Form and Instruction
CMS-10409 LTCH Care Data Set Unplanned Discharge LTCH CARE Data Set_Unplanned Discharge_V3 00_FINAL_508C.pdf Form and Instruction
Appendix A_Master List of LTCH CARE Data Set Version 3.00 Items_508C.pdf Appendix A LTCH Item Matrix V3.00 IC Document
Appendix B - LTCH CARE Data Set Change Table V2.01 to Final V3.00.pdf Appendix B LTCH Change Table V 2.01 to V 3.00 IC Document

Information Collection (IC) Details

IC Title:	Pressure Ulcer Submissions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10409	LTCH Care Data Set Admissions	LTCH CARE Data Set_Admission_V3 00_FINAL_508C.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Expired	LTCH CARE Data Set_Expired_V3 00_FINAL_508C.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Planned Discharge	LTCH CARE Data Set_Planned Discharge_V3 00_FINAL_508C.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Unplanned Discharge	LTCH CARE Data Set_Unplanned Discharge_V3 00_FINAL_508C.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 432	Number of Respondents for Small Entity: 112

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	405,270	1,282	403,988
Annual IC Time Burden (Hours)	392,861	180,701	212,160
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix A LTCH Item Matrix V3.00	Appendix A_Master List of LTCH CARE Data Set Version 3.00 Items_508C.pdf	05/31/2016
Appendix B LTCH Change Table V 2.01 to V 3.00	Appendix B - LTCH CARE Data Set Change Table V2.01 to Final V3.00.pdf	05/31/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.