Information Collection

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)

IC 197759 under ICR 202206-0938-012 · OMB 0938-1140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1140 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
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
CMS-10387 Nursing Home PPS (NP) Item Set MDS3.0_NP_PPS_v1.17.2.pdf	Form and Instruction
CMS-10387 Nursing Home PPS (NP) Item Set MDS3.0_NP_PPS_v1.17.2.pdf	Form and Instruction
CMS-10387 Long-Term Care Facility Resident Assessment Instrument ( MDS RAI Manual v1.16 PRA cover page.pdf downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf	Form and Instruction
CMS-10387 Long-Term Care Facility Resident Assessment Instrument ( MDS RAI Manual v1.16 PRA cover page.pdf downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf	Form and Instruction
CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set MDS3.0_NPE_Part_A_PPS_Discharge_v1.17.2.pdf	Form and Instruction
CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set MDS3.0_NPE_Part_A_PPS_Discharge_v1.17.2.pdf	Form and Instruction
CMS-10387 Interim Payment Assessment (IPA) Item Set MDS3.0_IPA_v1.17.2.pdf	Form and Instruction
CMS-10387 Interim Payment Assessment (IPA) Item Set MDS3.0_IPA_v1.17.2.pdf	Form and Instruction
CMS-10387 Swing Bed Discharge (SD) Item Set MDS3.0_SD_Dschg_v1.17.2.pdf	Form and Instruction
CMS-10387 Swing Bed Discharge (SD) Item Set MDS3.0_SD_Dschg_v1.17.2.pdf	Form and Instruction
CMS-10387 Swing Bed PPS (SP) Item Set MDS3.0_SP_PPS_v1.17.2.pdf	Form and Instruction
CMS-10387 Swing Bed PPS (SP) Item Set MDS3.0_SP_PPS_v1.17.2.pdf	Form and Instruction
MDS3.0_Item_Changes_v1.17.2.pdf Crosswalk	IC Document
MDS3.0_Item_Changes_v1.17.2.pdf Crosswalk	IC Document
MDS3.0_NC_Comp_v1.17.2.pdf Nursing Home Comprehensive (NC) Item Set.	IC Document
MDS3.0_ND_Dschg_v1.17.2.pdf Nursing Home Discharge (ND) Item Set	IC Document
MDS3.0_NQ_Quarterly_v1.17.2.pdf Nursing Home Quarterly (NQ) Item Set	IC Document
MDS3.0_NT_ST_Track_v1.17.2.pdf Nursing Home and Swing Bed Tracking (NT/ST) Item Set.	IC Document
MDS3.0_OSA_v1.17.2.pdf Optional State Assessment (OSA) Item Set	IC Document
PRA Screenshot.docx Screenshot of PRA disclosure statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC 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)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.32 42 CFR 413.343 42 CFR 483.20 42 CFR 413.337

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10387	Nursing Home PPS (NP) Item Set	MDS3.0_NP_PPS_v1.17.2.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10387	Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (Cover Only)	MDS RAI Manual v1.16 PRA cover page.pdf	https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Nursing Home Part A PPS Discharge (NPE) Item Set	MDS3.0_NPE_Part_A_PPS_Discharge_v1.17.2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Interim Payment Assessment (IPA) Item Set	MDS3.0_IPA_v1.17.2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Swing Bed Discharge (SD) Item Set	MDS3.0_SD_Dschg_v1.17.2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Swing Bed PPS (SP) Item Set	MDS3.0_SP_PPS_v1.17.2.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,471

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,905,042	4,905,042
Annual IC Time Burden (Hours)	4,169,286	4,169,286
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	MDS3.0_Item_Changes_v1.17.2.pdf	06/10/2022
Screenshot of PRA disclosure statement	PRA Screenshot.docx	11/21/2022

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