CMS-10409 LTCH Care Data Set Unplanned Discharge

Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 4.00
PATIENT ASSESSMENT FORM - UNPLANNED DISCHARGE

Section A

Administrative Information

A0050. Type of Record.
Enter Code

1. Add new assessment/record
2. Modify existing record
3. Inactivate existing record

A0100. Facility Provider Numbers. Enter Code in boxes provided..
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

C. State Medicaid Provider Number:

A0200. Type of Provider.
Enter Code

3. Long-Term Care Hospital

A0210. Assessment Reference Date.
Observation end date:

_

_
Month

Day

Year

A0220. Admission Date
_

_
Month

Day

Year

A0250. Reason for Assessment .
Enter Code

01.
10.
11.
12.

Admission
Planned discharge
Unplanned discharge .
Expired

A0270. Discharge Date.
_

_
Month

Day

Year

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

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Patient

Identifier

Section A

Date

Administrative Information

Patient Demographic Information .
A0500. Legal Name of Patient.
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers.
A. Social Security Number:

_

_

B. Medicare number (or comparable railroad insurance number):

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.

A0800. Gender.
Enter Code

1. Male.
2. Female.

A0900. Birth Date.
_

_
Month

Day

Year

A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

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Patient

Identifier

Section A

Date

Administrative Information

A1400. Payer Information.
Check all that apply
A. Medicare (traditional fee-for-service)
B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-service)
D. Medicaid (managed care).
E. Workers' compensation
F. Title programs (e.g., Title III, V, or XX).
G. Other government (e.g., TRICARE, VA, etc.)
H. Private insurance/Medigap.
I. Private managed care
J. Self-pay.
K. No payor source
X. Unknown
Y. Other .

A2110. Discharge Location
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
12.
98.

Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)
Long-term care facility
Skilled nursing facility (SNF)
Hospital emergency department
Short-stay acute hospital (IPPS)
Long-term care hospital (LTCH)
Inpatient rehabilitation facility or unit (IRF)
Psychiatric hospital or unit
ID/DD facility
Hospice
Discharged Against Medical Advice
Other

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

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Patient

Identifier

Section C

Date

Cognitive Patterns

C1310. Signs and Symptoms of Delirium (from CAM©) (within the last 7 days)
A. Acute Onset Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously
present, does not
fluctuate
2. Behavior present,
fluctuates (comes and
goes, changes in
severity)

Enter Code in Boxes.
B. Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible
or having difficulty keeping track of what was being said?
C. Disorganized Thinking - Was the patient's thinking disorganized or incoherent (rambling
or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject
to subject)?
D. Altered Level of Consciousness - Did the patient have altered level of consciousness as indicated
by any of the following criteria?
■ vigilant - startled easily to any sound or touch
■ lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch
■ stuporous - very difficult to arouse and keep aroused for the interview
■ comatose - could not be aroused

Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

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Patient

Identifier

Section J

Date

Health Conditions

J1800. Any Falls Since Admission.
Enter Code

Has the patient had any falls since admission?.
0. No
Skip to M0210, Unhealed Pressure Ulcers/Injuries
1. Yes
Continue to J1900, Number of Falls Since Admission.

J1900. Number of Falls Since Admission
Coding:
0. None
1. One
2. Two or more

Enter Codes in Boxes.
A. No injury: No evidence of any injury is noted on physical assessment by the nurse or primary
care clinician; no complaints of pain or injury by the patient; no change in the patient's
behavior is noted after the fall.
B. Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and
sprains; or any fall-related injury that causes the patient to complain of pain.
C. Major injury: Bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma.

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

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Patient

Identifier

Section M

Date

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage.
M0210. Unhealed Pressure Ulcers/Injuries.
Enter Code

Does this patient have one or more unhealed pressure ulcers/injuries?
Skip to N2005, Medication Intervention
0. No
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
Enter Number

A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not
have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
1. Number of Stage 1 pressure injuries

Enter Number

B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers.- If 0

Enter Number

Skip to M0300C, Stage 3.

2. Number of these Stage 2 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Enter Number

1. Number of Stage 3 pressure ulcers - If 0
Enter Number

Enter Number

2. Number of these Stage 3 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers - If 0

Enter Number

Skip to M0300D, Stage 4.

Skip to M0300E, Unstageable - Non-removable dressing/device.

2. Number of these Stage 4 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.

Enter Number

Enter Number

1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0
Slough and/or eschar.

Skip to M0300F, Unstageable -

2. Number of these unstageable pressure ulcers/injuries that were present upon admission - enter how many were noted at the
time of admission.
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.

Enter Number

1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0
Unstageable - Deep tissue injury.

Enter Number

2. Number of these unstageable pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.

Skip to M0300G,

M0300 continued on next page.

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

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Patient

Identifier

Section M

Date

Skin Conditions

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued.
Enter Number

G. Unstageable - Deep tissue injury
1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0

Enter Number

Skip to N2005, Medication Intervention

2. Number of these unstageable pressure injuries that were present upon admission - enter how many were noted at the time
of admission.

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

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Patient

Identifier

Section N

Date

Medications

N2005. Medication Intervention
Enter Code

Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the admission?
0. No
1. Yes
9. NA - There were no potential clinically significant medication issues identified since admission or patient is not taking
any medications

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

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Patient

Identifier

Section O

Date

Special Treatments, Procedures, and Programs

O0100. Special Treatments, Procedures, and Programs.
Check all of the following treatments, procedures, and programs that were performed during the last 14 days.
4.
Performed
during the last
14 days
Check all that apply
Respiratory Treatments.
D. Suctioning (if checked, please specify below)
D2a. Scheduled
D3a. As needed
E. Tracheostomy Care.
None of the Above
Z. None of the above

O0200. Ventilator Liberation Rate.
Enter Code

A. Invasive Mechanical Ventilator: Liberation Status at Discharge
0. Not fully liberated at discharge (i.e., patient required partial or full invasive mechanical ventilation support within 2 calendar days
prior to discharge)
1. Fully liberated at discharge (i.e., patient did not require any invasive mechanical ventilation support for at least 2 consecutive
calendar days immediately prior to discharge)
9. NA (code only if the patient was non-weaning or not ventilated on admission [O0150A=2 or 0 on Admission Assessment])

O0250. Influenza Vaccine - Refer to current version of LTCH Quality Reporting Program Manual for current influenza season and

reporting period..
Enter Code

A. Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No... Skip to O0250C, If influenza vaccine not received, state reason.
1. Yes
Continue to O0250B, Date influenza vaccine received.
B. Date influenza vaccine received

_

_
Month
Enter Code

Complete date and skip to Z0400, Signature of Persons Completing the Assessment

Day

Year

C. If influenza vaccine not received, state reason:
1. Patient not in this facility during this year's influenza vaccination season
2. Received outside of this facility
3. Not eligible - medical contraindication
4. Offered and declined
5. Not offered.
6. Inability to obtain influenza vaccine due to a declared shortage
9. None of the above

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

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Patient

Section Z

Identifier

Date

Assessment Administration

Z0400. Signature of Persons Completing the Assessment
I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected or
coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with
applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for payment from federal funds. I further
understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on
the accuracy and truthfulness of this information, and that submitting false information may subject my organization to a 2% reduction in the
Fiscal Year payment determination. I also certify that I am authorized to submit this information by this facility on its behalf.
Signature.

Title.

Date Section
Completed.

Sections.

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of Person Verifying Assessment Completion.
A. Signature:

B. LTCH CARE Data Set Completion Date:

_

_
Month

Proposed LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective April 1, 2018

Day

Year

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