Reform of Requirements for Long-Term Care Facilities (CMS-10573)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10573 Supporting Statement 6-13-2019.docx	Supporting Statement A	Uploaded 2019-06-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
236471	483.95(g)		New
236470	483.95(f)		New
236469	483.95(a) through 483.95(e)		New
236468	483.90(i)(5)		New
236467	483.85(e)		New
236464	483.85(d)(1)		New
236463	483.80		New
236462	483.70		New
236461	483.460(i)(3)		New
236460	483.60(c)(4)		New
236459	483.55		New
236458	483.25(n)(2)		New
236457	483.21(c)		New
236456	483.21(b)(2)(ii)		New
236455	483.21(a)		New
236454	483.15(c)(4)		New
236452	483.10(j)		New
236451	485.10(g)(17)		New
236450	483.10(f)(4)(v) through 483.10(f)(4)(vi)		New
236448	483.10(c)(2)		New
236417	483.85(c)		New
236416	483.85(b)		New
236414	483.75(b)(2)		New
236412	483.75(a)		New

ICR Details

OMB Control No: 0938-1363	ICR Reference No: 201901-0938-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Reform of Requirements for Long-Term Care Facilities (CMS-10573)
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/17/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/14/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	36 Months From Approved
Responses	8,860,061	0	0
Time Burden (Hours)	4,095,643	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Long term care facilities are required to maintain certain documentation within their own agency records that demonstrates compliance with specific requirements for participation in the Medicare and Medicaid programs. This documentation is maintained on-site for use in the long term care facility survey process.

---

Authorizing Statute(s): US Code: 42 USC 1396r Name of Law: Social Security Act
   US Code: 42 USC 1395i-3 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AR61	Final or interim final rulemaking	81 FR 68688	10/04/2016

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 42167	07/16/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 68688	10/04/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 24

table that charts list of burden

IC Title	Form No.	Form Name
483.10(c)(2)
483.10(f)(4)(v) through 483.10(f)(4)(vi)
483.10(j)
483.15(c)(4)
483.21(a)
483.21(b)(2)(ii)
483.21(c)
483.25(n)(2)
483.460(i)(3)
483.55
483.60(c)(4)
483.70
483.75(a)
483.75(b)(2)
483.80
483.85(b)
483.85(c)
483.85(d)(1)
483.85(e)
483.90(i)(5)
483.95(a) through 483.95(e)
483.95(f)
483.95(g)
485.10(g)(17)

---

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	8,860,061	0	0	0	0	8,860,061
Annual Time Burden (Hours)	4,095,643	0	0	0	0	4,095,643
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: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $20,000

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: 06/14/2019

---