Form CMS-10409 LCDS version 4.00 Admission

Patient

Identifier

Date

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1163 (Expiration Date: XX/XX/XXXX). The time required to complete this information collection is estimated to
average 24 minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. *****CMS Disclaimer*****Please do not
send applications, claims, payments, medical records, or any documents containing sensitive information to the
PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded,
or retained. If you have questions or concerns regarding where to submit your documents, please contact Lorraine
Wickiser at Lorraine.Wickiser@cms.hhs.gov.

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Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 4.00
PATIENT ASSESSMENT FORM - ADMISSION

Section A

Administrative Information

A0050. Type of Record.
Enter Code

1. Add new assessment/record
2. Modify existing record
3. Inactivate existing record

A0100. Facility Provider Numbers. Enter Code in boxes provided..
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

C. State Medicaid Provider Number:

A0200. Type of Provider.
Enter Code

3. Long-Term Care Hospital

A0210. Assessment Reference Date.
Observation end date:

_

_
Month

Day

Year

A0220. Admission Date
_

_
Month

Day

Year

A0250. Reason for Assessment .
Enter Code

01.
10.
11.
12.

Admission
Planned discharge
Unplanned discharge .
Expired

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Patient

Identifier

Section A

Date

Administrative Information

Patient Demographic Information .
A0500. Legal Name of Patient.
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers.
A. Social Security Number:

_

_

B. Medicare number (or comparable railroad insurance number):

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.

A0800. Gender.
Enter Code

1. Male.
2. Female.

A0900. Birth Date.
_

_
Month

Day

Year

A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.

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Patient

Identifier

Section A

Date

Administrative Information

A1100. Language.
Enter Code

A. Does the patient need or want an interpreter to communicate with a doctor or health care staff?
0. No... Skip to A1200, Marital Status.
1. Yes
Specify in A1100B, Preferred language.
9. Unable to determine... Skip to A1200, Marital Status.
B. Preferred language:

A1200. Marital Status.
Enter Code

1.
2.
3.
4.
5.

Never married.
Married.
Widowed.
Separated.
Divorced.

A1400. Payer Information.
Check all that apply
A. Medicare (traditional fee-for-service)
B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-service)
D. Medicaid (managed care).
E. Workers' compensation
F. Title programs (e.g., Title III, V, or XX).
G. Other government (e.g., TRICARE, VA, etc.)
H. Private insurance/Medigap.
I. Private managed care
J. Self-pay.
K. No payer source
X. Unknown
Y. Other .

Pre-Admission Service Use .
A1802. Admitted From. Immediately preceding this admission, where was the patient?.
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
99.

Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)
Long-term care facility
Skilled nursing facility (SNF)
Hospital emergency department
Short-stay acute hospital (IPPS)
Long-term care hospital (LTCH)
Inpatient rehabilitation facility or unit (IRF)
Psychiatric hospital or unit
Intellectually Disabled/Developmentally Disabled (ID/DD) facility
Hospice
None of the above

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Patient

Identifier

Section B

Date

Hearing, Speech, and Vision

B0100. Comatose.
Enter Code

Persistent vegetative state/no discernible consciousness .
0. No
Continue to B0700, Expression of Ideas and Wants
Skip to GG0100, Prior Functioning: Everyday Activities
1. Yes

BB0700. Expression of Ideas and Wants (3-day assessment period)
Enter Code

Expression of ideas and wants (consider both verbal and non-verbal expression and excluding language barriers)
4. Expresses complex messages without difficulty and with speech that is clear and easy to understand
3. Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear
2. Frequently exhibits difficulty with expressing needs and ideas
1. Rarely/Never expresses self or speech is very difficult to understand.

BB0800. Understanding Verbal and Non-Verbal Content (3-day assessment period)
Enter Code

Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)
4. Understands: Clear comprehension without cues or repetitions
3. Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand
2. Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand
1. Rarely/Never Understands

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Patient

Section C

Identifier

Date

Cognitive Patterns

C1610. Signs and Symptoms of Delirium (from CAM©)
Confusion Assessment Method (CAM©) Shortened Version Worksheet (3-day assessment period)
CODING:
0. No
1. Yes

Enter Code in Boxes.
Acute Onset and Fluctuating Course
A. Is there evidence of an acute change in mental status from the patient's baseline?
B. Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go or increase and
decrease in severity?
Inattention
C. Did the patient have difficulty focusing attention, for example, being easily distractible or having
difficulty keeping track of what was being said?
Disorganized Thinking
D. Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation,
unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
Altered Level of Consciousness
E. Overall, how would you rate the patient's level of consciousness?
E1. Alert (Normal)
E2. Vigilant (hyperalert) or Lethargic (drowsy, easily aroused) or Stupor (difficult to arouse) or Coma
(unarousable)

Adapted with permission from: Inouye SK et al, Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine.
1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide, Copyright 2003, Hospital Elder Life Program, LLC. Not to be reproduced without
permission.

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

GG0100. Prior Functioning: Everyday Activities. Indicate the patient's usual ability with everyday activities prior to the current
illness, exacerbation, or injury.
Coding:
3. Independent - Patient completed the activities by him/herself, with or
without an assistive device, with no assistance from a helper.
2. Needed Some Help - Patient needed partial assistance from another
person to complete activities.
1. Dependent - A helper completed the activities for the patient.
8. Unknown
9. Not Applicable

Enter Codes in Boxes.
B. Indoor Mobility (Ambulation): Code the patient's
need for assistance with walking from room to room
(with or without a device such as cane, crutch, or
walker) prior to the current illness, exacerbation, or
injury.

GG0110. Prior Device Use. Indicate devices and aids used by the patient prior to the current illness, exacerbation, or injury.
Check all that apply.
A. Manual wheelchair.
B. Motorized wheelchair and/or scooter.
C. Mechanical lift.
Z. None of the above.

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

GG0130. Self-Care (3-day assessment period)
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at
admission, code the reason. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is
permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half
the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or
liquid once the meal is placed before the patient.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and
remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a
bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.
D. Wash upper body: The ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or
bed.

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period)
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at
admission, code the reason. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is
permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half
the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on
the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed
with feet flat on the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the
bed.
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If admission
performance is coded 07, 09, 10, or 88
Skip to GG0170Q1, Does the patient use a wheelchair and/or scooter?

J. Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period) - Continued
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at
admission, code the reason. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is
permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half
the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
Q1. Does the patient use a wheelchair and/or scooter?
0. No
Skip to H0350, Bladder Continence
1. Yes
Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and
make two turns.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar
space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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Patient

Identifier

Section H

Date

Bladder and Bowel

H0350. Bladder Continence (3-day assessment period)
Enter Code

Bladder continence - Select the one category that best describes the patient..
0. Always continent (no documented incontinence)
1. Stress incontinence only
2. Incontinent less than daily (e.g., once or twice during the 3-day assessment period)
3. Incontinent daily (at least once a day)
4. Always incontinent
5. No urine output (e.g., renal failure)
9. Not applicable (e.g., indwelling catheter)

H0400. Bowel Continence (3-day assessment period)
Enter Code

Bowel continence - Select the one category that best describes the patient..
0. Always continent
1. Occasionally incontinent (one episode of bowel incontinence)
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)
3. Always incontinent (no episodes of continent bowel movements)
9. Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days.

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Patient

Identifier

Section I

Date

Active Diagnoses

I0050. Indicate the patient's primary medical condition category.
Enter Code

Indicate the patient's primary medical condition category.
1. Acute Onset Respiratory Condition (e.g., aspiration and specified bacterial pneumonias)
2. Chronic Respiratory Condition (e.g., chronic obstructive pulmonary disease)
3. Acute Onset and Chronic Respiratory Conditions
4. Chronic Cardiac Condition (e.g., heart failure)
5. Other Medical Condition If “Other Medical Condition,” enter the ICD code in the boxes.
I0050A.

Comorbidities and Co-existing Conditions
Check all that apply.
Cancers.
I0103. Metastatic Cancer
I0104. Severe Cancer
Heart/Circulation.
I0605. Severe Left Systolic/Ventricular Dysfunction (known ejection fraction < 30%).
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
Genitourinary
I1501. Chronic Kidney Disease, Stage 5
I1502. Acute Renal Failure
Infections
I2101. Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock
I2600. Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis
Metabolic
I2900. Diabetes Mellitus (DM)
Musculoskeletal
I4100. Major Lower Limb Amputation (e.g., above knee, below knee)
Neurological
I4501. Stroke
I4801. Dementia
I4900. Hemiplegia or Hemiparesis
I5000. Paraplegia
I5101. Complete Tetraplegia
I5102. Incomplete Tetraplegia
I5110. Other Spinal Cord Disorder/Injury (e.g., myelitis, cauda equina syndrome)
I5200. Multiple Sclerosis (MS)
I5250. Huntington's Disease
I5300. Parkinson's Disease
I5450. Amyotrophic Lateral Sclerosis
I5455. Other Progressive Neuromuscular Disease
I5460. Locked-In State
I5470. Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain
I5480. Other Severe Neurological Injury, Disease, or Dysfunction

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Patient

Identifier

Section I

Date

Active Diagnoses

Nutritional
I5601. Malnutrition (protein or calorie)
I5602. At Risk for Malnutrition
Post-Transplant
I7100. Lung Transplant
I7101. Heart Transplant
I7102. Liver Transplant
I7103. Kidney Transplant
I7104. Bone Marrow Transplant
None of the Above
I7900. None of the above

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Patient

Section K

Identifier

Date

Swallowing/Nutritional Status

K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.
A. Height (in inches). Record most recent height measure since admission..
inches

pounds

B. Weight (in pounds). Base weight on most recent measure in last 3 days; measure weight consistently, according to standard
facility practice (e.g., in a.m. after voiding, before meal, with shoes off)..

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Patient

Identifier

Section M

Date

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage.
M0210. Unhealed Pressure Ulcers/Injuries.
Enter Code

Does this patient have one or more unhealed pressure ulcers/injuries?
0. No
Skip to N2001, Drug Regimen Review.
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
Enter
Number

A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not
have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
1. Number of Stage 1 pressure injuries

Enter
Number

B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers

Enter
Number

C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers

Enter
Number

D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers

Enter
Number

E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.
1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device

Enter
Number

F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.
1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar

Enter
Number

G. Unstageable - Deep tissue injury.
1. Number of unstageable pressure injuries presenting as deep tissue injury

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Patient

Identifier

Section N

Date

Medications

N2001. Drug Regimen Review
Enter Code

Did a complete drug regimen review identify potential clinically significant medication issues?
0. No - No issues found during review
Skip to O0100, Special Treatments, Procedures, and Programs
1. Yes - Issues found during review
Continue to N2003, Medication Follow-up
9. NA - Patient is not taking any medications
Skip to O0100, Special Treatments, Procedures, and Programs

N2003. Medication Follow-up
Enter Code

Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/
recommended actions in response to the identified potential clinically significant medication issues?
0. No
1. Yes

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Patient

Identifier

Section O

Date

Special Treatments, Procedures, and Programs

O0100. Special Treatments, Procedures, and Programs
Check all the treatments at admission. For dialysis, check if it is part of the patient's treatment plan.
Check all that apply.
Respiratory Treatments
G. Non-invasive Ventilator (BiPAP, CPAP)
Other Treatments
H. IV Medications (if checked, please specify below)
H2a. Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)
J. Dialysis
N. Total Parenteral Nutrition
None of the Above
Z. None of the above

O0150. Spontaneous Breathing Trial (SBT) (including Tracheostomy Collar or Continuous Positive Airway Pressure (CPAP) Breathing
Trial) by Day 2 of the LTCH Stay
Enter Code

A. Invasive Mechanical Ventilation Support upon Admission to the LTCH
0. No, not on invasive mechanical ventilation support
Skip to O0250, Influenza Vaccine
1. Yes, weaning
Continue to O0150B, Assessed for readiness for SBT by day 2 of the LTCH stay
2. Yes, non-weaning
Skip to O0250, Influenza Vaccine

Enter Code

B. Assessed for readiness for SBT by day 2 of the LTCH stay (Note: Day 2 = Date of Admission to the LTCH (Day 1) + 1 calendar day)
0. No
Skip to O0250, Influenza Vaccine
1. Yes
Continue to O0150C, Deemed medically ready for SBT by day 2 of the LTCH stay

Enter Code

C. Deemed medically ready for SBT by day 2 of the LTCH stay
0. No

Continue to O0150D, Is there documentation of reason(s) in the patient's medical record that the patient was deemed
medically unready for SBT by day 2 of the LTCH stay?
Continue to O0150E, SBT performed by day 2 of the LTCH stay

1. Yes
Enter Code

D. Is there documentation of reason(s) in the patient's medical record that the patient was deemed medically unready for
SBT by day 2 of the LTCH stay?
0. No
1. Yes

Enter Code

Skip to O0250, Influenza Vaccine
Skip to O0250, Influenza Vaccine

E. SBT performed by day 2 of the LTCH stay
0. No
1. Yes

O0250. Influenza Vaccine - Refer to current version of LTCH Quality Reporting Program Manual for current influenza season and

reporting period..
Enter Code

A. Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No... Skip to O0250C, If influenza vaccine not received, state reason.
1. Yes
Continue to O0250B, Date influenza vaccine received.
B. Date influenza vaccine received

_

_
Month
Enter Code

Complete date and skip to Z0400, Signature of Persons Completing the Assessment

Day

Year

C. If influenza vaccine not received, state reason:
1. Patient not in this facility during this year's influenza vaccination season
2. Received outside of this facility
3. Not eligible - medical contraindication
4. Offered and declined
5. Not offered.
6. Inability to obtain influenza vaccine due to a declared shortage
9. None of the above

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Patient

Section Z

Identifier

Date

Assessment Administration

Z0400. Signature of Persons Completing the Assessment
I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected or
coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with
applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for payment from federal funds. I further
understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on
the accuracy and truthfulness of this information, and that submitting false information may subject my organization to a 2% reduction in the
Fiscal Year payment determination. I also certify that I am authorized to submit this information by this facility on its behalf.
Date Section
Signature
Title.
Sections.
Completed.

A.
B.
C.

D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of Person Verifying Assessment Completion.
A. Signature:

B. LTCH CARE Data Set Completion Date:

_

_
Month

Final LTCH CARE Data Set Version 4.00, Admission - Effective July 1, 2018

Day

Year

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