Minimum Data Set 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) for the Collection of Data Related to the Patient Driven Payment Model and the Skilled Nursing Facility QRP (CMS-10387)

Forms and Documents

Document Name	Status
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
CMS-10387 - Supporting Statement A (2019 final rule version 2)_OMB CLEAN.docx Supporting Statement A	2019-11-21
Comment-Response for OMB 0938-1140 (CMS 10387) clean.docx Supplementary Document	2019-09-25

IC Document Collections

IC ID	Document Title	Status
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: 201909-0938-013
Status: Historical Active	Previous ICR Reference No: 201905-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Minimum Data Set 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) for the Collection of Data Related to the Patient Driven Payment Model and the Skilled Nursing Facility QRP (CMS-10387)
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: 11/22/2019
	Date Received in OIRA: 09/26/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved	02/28/2022
Responses	4,905,042	0	4,905,042
Time Burden (Hours)	4,169,286	0	4,169,286
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-AT75	Final or interim final rulemaking	84 FR 38728	08/07/2019

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 17620	04/25/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 38728	08/07/2019
Did the Agency receive public comments on this ICR? Yes

---

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

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 and Swing Bed OMRA (NO/SO) Item Set ,   Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (Cover Only) ,   Nursing Home Part A PPS Discharge (NPE) Item Set ,   Interim Payment Assessment (IPA) Item Set ,   Final SNF QRP New and Modified Items

---

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	4,905,042	4,905,042	0	0	0	0
Annual Time Burden (Hours)	4,169,286	4,169,286	0	0	0	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: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $3,164,707

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: 09/26/2019

---