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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10409 LCDS version 5.3 Unplanned Discharge	Form and Instruction	Modified	Available
Form CMS-10409 LCDS version 5.3 Planned Discharge	Form and Instruction	Modified	Available
Form CMS-10409 LCDS version 5.3 Expired	Form and Instruction	Modified	Available
Form CMS-10409 LCDS version 5.3 Admission	Form and Instruction	Modified	Available
CMS_10409_Supporting_Statement_LCDS_v5.3_4-30-26.docx	Supporting Statement A	Uploaded 2026-05-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201171	Long Term Care Data Set	Form and Instruction	Modified	LCDS version 5.3 Unplanned Discharge
201171	Long Term Care Data Set	Form and Instruction	Modified	LCDS version 5.3 Planned Discharge
201171	Long Term Care Data Set	Form and Instruction	Modified	LCDS version 5.3 Expired
201171	Long Term Care Data Set	Form and Instruction	Modified	LCDS version 5.3 Admission

ICR Details

OMB Control No: 0938-1163	ICR Reference No: 202604-0938-025
Status: Received in OIRA	Previous ICR Reference No: 202508-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Long Term Care Hospital (LTCH) Quality Reporting Program (CMS-10409)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/05/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2027
Responses	102,590	136,650
Time Burden (Hours)	184,588	185,101
Cost Burden (Dollars)	0	0

---

Abstract: The Centers for Medicare & Medicaid Services (CMS) is requesting approval of revisions to the Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) Version 5.3 that will be effective October 1, 2026.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 3004 Name of Law: Quality reporting for LTCHs, inpatient rehabilitation hospitals, and hospice programs
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3004 Name of Law: Quality reporting for LTCHs, inpatient rehabilitation hospitals, and hospice programs

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV79	Proposed rulemaking	91 FR 19312	04/14/2026

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Long Term Care Data Set	CMS-10409, CMS-10409, CMS-10409, CMS-10409	LCDS version 5.3 Admission ,   LCDS version 5.3 Expired ,   LCDS version 5.3 Planned Discharge ,   LCDS version 5.3 Unplanned Discharge

---

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	102,590	136,650	0	-34,060	0	0
Annual Time Burden (Hours)	184,588	185,101	0	-513	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Since the approval of the LCDS V5.3, the number of LTCHs submitting assessments has changed to 318. LTCHs are submitting approximately 102,590 planned and unplanned discharge assessments. As a result of these changes, we estimate an overall decrease in burden hours for LTCHs. Specifically, the burden hours will decrease by 513 hours [185,101 hours – 184,588].

---

Annual Cost to Federal Government: $3,384,268

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? Yes

---

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: 05/05/2026

---