(CMS-10455) Report of a Hospital Dealth Associated with Restraint or Seclusion

Forms and Documents

Document	Type	Status	Availability
Form CMS-10455 Hospital Restraint/Seclusion Death Report Worksheet	Form and Instruction	Modified	Available
CMS-10455 Supporting Statement final.docx	Supporting Statement A	Uploaded 2018-07-11	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
205636	Hospital Restraint/Seclusion Death Report Worksheet	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1210	ICR Reference No: 201802-0938-002
Status: Historical Active	Previous ICR Reference No: 201608-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No: 18578
Title: (CMS-10455) Report of a Hospital Dealth Associated with Restraint or Seclusion
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: 07/18/2018
	Date Received in OIRA: 02/08/2018
Terms of Clearance: The program will update the expiration date on the form within two weeks of approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2021	36 Months From Approved	02/29/2020
Responses	6,389	0	6,225
Time Burden (Hours)	2,619	0	2,054
Cost Burden (Dollars)	0	0	0

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Abstract: The CMS 10455 Report of a Hospital Death in Restraint or Seclusion form is utilized for the purpose of determining cases that warrant on-site investigation to determine the hospital’s compliance with the Medicare Condition of Participation (CoP) for patient’s rights. Based on information gathered from CMS Regional Offices (ROs), the current collection tool associated with this package did not provide the needed information to thoroughly evaluate whether the case warrants an on-site investigation. The ROs provided feedback for data needed on the CMS 10455 form to evaluate whether the case warrants an on-site investigation. The collection tool was revised based on the ROs need for additional information to assess for compliance with CoPs as well as the health and safety of patients requiring the use of restraint and/or seclusion.

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Authorizing Statute(s): US Code: 42 USC 591, 592, Name of Law: Public Health Service Act
   US Code: 42 USC 186 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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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:
	82 FR 51630	11/07/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 2784	01/19/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Hospital Restraint/Seclusion Death Report Worksheet	CMS-10455	Health Death Report Form

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ICR Summary 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	6,389	6,225	0	0	164	0
Annual Time Burden (Hours)	2,619	2,054	0	565	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: The estimated burden for reporting would be expected to increase to 2,619 hours from 2,054 hours due to the request for additional information with the revisions to the collection tool.

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Annual Cost to Federal Government: $147,708

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]? 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

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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: 02/08/2018

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