(CMS-359/360) Comprehensive Outpatient Rehabilitation Facility (CORF) Certification and Survey Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-360 Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Information Collection Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64...	Form and Instruction	Modified	Repair queued
Supporting Statement A for CMS 359 CMS 360. 6.04.20.docx	Supporting Statement A	Uploaded 2020-09-11	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7917	Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Information Collection Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64...	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0267	ICR Reference No: 202009-0938-003
Status: Received in OIRA	Previous ICR Reference No: 201603-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: (CMS-359/360) Comprehensive Outpatient Rehabilitation Facility (CORF) Certification and Survey Forms
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/11/2020

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	18	0
Time Burden (Hours)	76	0
Cost Burden (Dollars)	0	0

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Abstract: In order to participate in the Medicare program as a CORF, providers must meet federal conditions of participation. The certification form is needed to determine if providers meet at least preliminary requirements. The survey form is used to record provider compliance with the individual conditions and report findings to CMS.

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Authorizing Statute(s): US Code: 42 USC 485.50 Name of Law: Conditions of Participation: CORF
  

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:
	85 FR 37456	06/22/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 56227	09/11/2020
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Information Collection Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64...	CMS-360, CMS-359	COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT ,   Comprehensive Outpatient Rehab Facility Request Form

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	18	0	0	0	-32	50
Annual Time Burden (Hours)	76	0	0	0	-47	123
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: In this PRA package we have recalculated the burden based on the existing number of new CORFs per year and the estimated number of CORFs that are surveyed per year. This has result in an increase in the cost burden of $2,057.14 and a decrease in burden hours of 46.5 hours. These changes in the burden is attributable to several factors. First, we determined that there are currently 49 CORFs. The CORFs are surveyed every 6 years, so on average, 8 CORFs are surveyed each year. Also, according to our statistics, there are 10 new CORFs each year. In the previous PRA package submission, it was stated that there were 40 annual responses for the form CMS-360. We believe that this estimate was too high because it would be the total number of CORFs existing at the time. The form CMS-360 is completed by a surveyor during the survey of a CORF that occurs only every 6 years. As these surveys occurs only every 6 years, the accrediting organizations (AOs) or the state survey agencies (SAs) cannot possibly survey all of the existing CORFs in the same year. Due to the limitation on their resources, they would divide the CORFs up and only do a certain number of surveys per year. We believe and assume for the sake of the burden calculations that the AO or SA would survey 1/6th of all CORFs each year. Therefore, if there are currently 49 CORFs, only 8 CORFs would be surveyed per year (49 divided by 6 = 8.18). Second, we increased the estimated time burden for the CMS-359 form from 15 minutes to 30 minutes because we did not believe that 15 minutes is an adequate amount of time to read the instructions and gather the information required to complete the form. We also added a 30 minute time burden for the time required for an administrative staff person to copy and mail this form to the SA. This burden was not accounted for in the prior burden estimate. We also increased the estimated time required to complete the CMS-360 report from 3 hours to 8 hours, because we believe that this burden was significantly underestimated in the prior burden estimate. The CMS-360 report is a survey report, and is based on the 12 survey activities performed by the surveyor. The survey for a CORF takes approximately one day to complete. It would not be possible for a surveyor to complete the CMS-360 report in only 3 hours, if it takes the surveyor 8 hours to complete the survey. We also added a 15 minute time burden for an administrative staff person to copy, or scan and email the completed CMS-360 survey report to the appropriate CMS Location. This burden was not accounted for in the prior burden estimate, yet is a burden that is associated with the completion of the CMS-360 survey report.

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Annual Cost to Federal Government: $30

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? No

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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: 09/11/2020

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