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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

	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

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

IC Title	Form No.	Form Name
Long Term Care Data Set	CMS-10409, CMS-10409, CMS-10409, CMS-10409	, , ,

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	102,590	136,650	-34,060
Annual Time Burden (Hours)	184,588	185,101	-513
Annual Cost Burden (Dollars)	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

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

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