Long Term Care Data Set

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

⚠️ Notice: This information collection may be referencing outdated material.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 Long Term Care Data Set Form and Instruction
CMS-10409 LTCH Care Data Set Admissions LTCH CARE Data Set Version 4.00 - Admission.pdf Form and Instruction
CMS-10409 LTCH Care Data Set Expired LTCH CARE Data Set Version 4.00 - Expired.pdf Form and Instruction
CMS-10409 LTCH Care Data Set Planned Discharge LTCH CARE Data Set Version 4.00 - Planned Discharge.pdf Form and Instruction
CMS-10409 LTCH Care Data Set Unplanned Discharge LTCH CARE Data Set Version 4.00 - Unplanned Discharge.pdf Form and Instruction
Final LTCH CARE Data Set Version 4.00 Change Table-Effective July 1 2018.pdf Appendix A: Change Table IC Document

Information Collection (IC) Details

IC Title:	Long Term Care Data Set	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 Version 4.00 - Admission.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Expired	LTCH CARE Data Set Version 4.00 - Expired.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Planned Discharge	LTCH CARE Data Set Version 4.00 - Planned Discharge.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Unplanned Discharge	LTCH CARE Data Set Version 4.00 - Unplanned Discharge.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 420	Number of Respondents for Small Entity: 112

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	272,952	-20,232	293,184
Annual IC Time Burden (Hours)	121,674	-13,454	135,128
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix A: Change Table	Final LTCH CARE Data Set Version 4.00 Change Table-Effective July 1 2018.pdf	08/16/2017

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