Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD) (CMS-10387)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10387 Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction	Modified	Available
CMS-10387 - Supporting Statement A (rev 05-10-2018 by OSORA PRA).docx	Supporting Statement A	Uploaded 2018-05-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
197759	Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1140	ICR Reference No: 201805-0938-004
Status: Historical Inactive	Previous ICR Reference No: 201703-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-FFS
Title: Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD) (CMS-10387)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 07/10/2018
	Date Received in OIRA: 05/10/2018
Terms of Clearance: OMB is withholding approval at this time. Prior to publication of the final rule, the agency should provide a summary of any comments related to the information collection and their response, including any changes made to the ICR as a result of comments. In addition, the agency must enter the correct burden estimates.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	02/29/2020
Responses	6,563,344	0	6,563,344
Time Burden (Hours)	5,580,885	0	5,580,885
Cost Burden (Dollars)	0	0	0

---

Abstract: Skilled Nursing Facilities (SNFs) will be required to submit a Change of Therapy (COT) Other Medicare Required Assessment (OMRA) to administer the payment rate methodology. This additional assessment is subject to the Paperwork Reduction Act. The burden associated with this is the SNF staff time required to complete the COT OMRA for the Minimum Data Set (MDS), SNF staff time to encode, and SNF staff time spent in transmitting the data.

---

Authorizing Statute(s): US Code: 42 USC 1395yy(e) Name of Law: Payment to Skilled Nursing Facilities for Routine Costs
   PL: Pub.L. 105 - 33 4432(a) Name of Law: Prospective Payment for Skilled Nursing Facilities
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT24	Proposed rulemaking	83 FR 21018	05/08/2018

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 21018	05/08/2018
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
Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	CMS-10387, CMS-10387, CMS-10387, CMS-10387, CMS-10387, CMS-10387	Nursing Home PPS (NP) Item Set ,   Nursing Home OMRA-Start of Therapy and Discharge (NSD) Item Set ,   Nursing Home and Swing Bed OMRA-Start of Therapy (NS/SS) Item Set ,   Nursing Home OMRA-Discharge (NOD) Item Set ,   Nursing Home and Swing Bed OMRA (NO/SO) Item Set ,   Long-Term Care Facility Resident Assessment Instrument User's Manual (Cover Only)

---

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: Changing Regulations

Short Statement: There are no changes in the burden estimate of how long it takes to prepare, code, and transmit each assessment. The total number of responses has decreased to 4,905,042 because there will be fewer required assessments under the proposed PDPM. The number of SNFs changes from year to year, therefore the number of respondents increased by +8.

---

Annual Cost to Federal Government: $0

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

---

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: 05/10/2018

---