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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10409 Long Term Care Data Set	Form and Instruction	Modified	Available
CMS-10409 Supporting Statement Part A - 2-28-18.docx	Supporting Statement A	Uploaded 2018-03-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201171	Long Term Care Data Set	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1163	ICR Reference No: 201708-0938-012
Status: Historical Active	Previous ICR Reference No: 201706-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: 19270
Title: Long Term Care Hospital (LTCH) Quality Reporting Program (CMS-10409)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/22/2018
	Date Received in OIRA: 08/16/2017
Terms of Clearance: OMB notes that CMS states it plans to display the expiration date associated with this collection on all of its manuals, instructions, and collections. The expiration date and OMB control number must be displayed on all paper and electronic versions of the collection.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2020
Responses	293,184	0	405,270
Time Burden (Hours)	135,128	0	392,861
Cost Burden (Dollars)	0	0	0

---

Abstract: In the FY 2018 IPPS/LTCH PPS final rule, CMS adopted three measures beginning with the FY 2020 LTCH QRP and removed two measures. The finalized measures are Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, Compliance with Spontaneous Breathing Trial (SBT) by Day 2 of the LTCH Stay, and Ventilator Liberation Rate. The measures removed from the LTCH QRP are Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) and the All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Long-Term Care Hospitals (NQF #2512). We also finalized to characterize certain data elements, as described in section IX.C.10 of the FY 2018 IPPS/LTCH PPS final rule, as standardized patient assessment data under section 1899B(b)(1)(B) of the Act, that must be reported by LTCHs under the LTCH QRP through the LTCH CARE Data Set.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 3004 Name of Law: Quality reporting for LTCHs, inpatient rehabilitation hospitals, and hospice programs
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3004 Name of Law: Quality reporting for LTCHs, inpatient rehabilitation hospitals, and hospice programs

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AS98	Final or interim final rulemaking	82 FR 37990	08/14/2017

---

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
Long Term Care Data Set	CMS-10409, CMS-10409, CMS-10409, CMS-10409	LTCH Care Data Set Admissions ,   LTCH Care Data Set Expired ,   LTCH Care Data Set Planned Discharge ,   LTCH Care Data Set Unplanned Discharge

---

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	293,184	405,270	0	0	-112,086	0
Annual Time Burden (Hours)	135,128	392,861	0	-30,756	-226,977	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: We have updated information regarding the current number of Medicare-certified LTCHs in the U.S., as well as the total number of yearly LTCH discharges. The number of Medicare-certified LTCHs has declined from 432 to 426 and discharges declined from 202,635 to 146,592. As a result, the annual burden hours decreased from 196,892 to 135,128. The number of items has changed from V3.00 to V4.00 which resulted in an overall decrease in time burden. We have increased our time estimate from 22.2 to 24.3 minutes for the admission assessment and decreased our time estimate from 26.1 to 21.0 minutes for the discharge assessment. Overall, the combined time estimate decreased from 48.3 minutes for V3.00 to 45.3 minutes for V4.00.

---

Annual Cost to Federal Government: $3,146,409

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 08/16/2017

---