CMS-10409 LCDS version 5.1 Unplanned Discharge

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 Ariel Cress at Ariel.Cress@cms.hhs.gov and Lorraine Wickiser at Lorraine.Wickser@cms.hhs.gov.

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT RECORD & EVALUATION (CARE) DATA SET - Version 5.1 PATIENT ASSESSMENT FORM - UNPLANNED DISCHARGE

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.

1. National Provider Identifier (NPI):

2. CMS Certification Number (CCN):

3. 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. Admission

10. Planned discharge

11. Unplanned discharge

12. Expired

A0270. Discharge Date.

–

–

Month Day Year

Section A

Administrative Information

Patient Demographic Information

A0500. Legal Name of Patient

1. First name:

2. Middle initial:

3. Last name:

4. Suffix:

A0600. Social Security and Medicare Numbers

1. Social Security Number:

–

–

2. 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

Section A		Administrative Information
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
A1990. Patient Discharged Against Medical Advice?
Enter Code	No Yes
A2105. Discharge Location
Enter Code	Home/Community (e.g., private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements) Nursing Home (long-term care facility) Skilled Nursing Facility (SNF, swing bed) Short-Term General Hospital (acute hospital, IPPS) Long-Term Care Hospital (LTCH) Inpatient Rehabilitation Facility (IRF, free standing facility or unit) Inpatient Psychiatric Facility (psychiatric hospital or unit) Intermediate Care Facility (ID/DD facility) Hospice (home/non-institutional) Hospice (institutional facility) Critical Access Hospital (CAH) Home under care of organized home health service organization 99. Not Listed

Section A		Administrative Information
A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge At the time of discharge to another provider, did your facility provide the patient’s current reconciled medication list to the subsequent provider?
Enter Code	No – Current reconciled medication list not provided to the subsequent provider Skip to A2123, Provision of Current Reconciled Medication List to Patient at Discharge Yes – Current reconciled medication list provided to the subsequent provider
A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Route of Transmission			Check all that apply
A. Electronic Health Record
B. Health Information Exchange
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E. Other Methods (e.g., texting, email, CDs)
A2123. Provision of Current Reconciled Medication List to Patient at Discharge At the time of discharge, did your facility provide the patient’s current reconciled medication list to the patient, family and/or caregiver?
Enter Code	No – Current reconciled medication list not provided to the patient, family and/or caregiver Skip to C1310, Signs and Symptoms of Delirium (from CAM©) Yes – Current reconciled medication list provided to the patient, family and/or caregiver
A2124. Route of Current Reconciled Medication List Transmission to Patient Indicate the route(s) of transmission of the current reconciled medication list to the patient/family/caregiver.
Route of Transmission			Check all that apply
A. Electronic Health Record (e.g., electronic access to patient portal)
B. Health Information Exchange
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E. Other Methods (e.g., texting, email, CDs)

Section C		Cognitive Patterns
C1310. Signs and Symptoms of Delirium (from CAM©)
Code after reviewing medical record.
A. Acute Onset Mental Status Change
Enter Code	Is there evidence of an acute change in mental status from the patient’s baseline? No Yes
Coding: Behavior not present Behavior continuously present, does not fluctuate Behavior present, fluctuates (comes and goes, changes in severity)			Enter Code in Boxes
				B. Inattention - Did the patient have difficulty focusing attention, for example being easily distractible or having difficulty keeping track of what was being said?
				C. Disorganized thinking - Was the patient’s thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?
				Altered level of consciousness - Did the patient have altered level of consciousness as indicated by any of the following criteria? vigilant - startled easily to any sound or touch lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch stuporous - very difficult to arouse and keep aroused for the interview comatose - could not be aroused
Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to be reproduced without permission.

J1800. Any Falls Since Admission
Enter Code	Has the patient had any falls since admission? No Skip to K0520, Nutritional Approaches Yes Continue to J1900, Number of Falls Since Admission
J1900. Number of Falls Since Admission
Coding: None One Two or more		Enter Codes in Boxes
			A. No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall.
			B. Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain.
			C. Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.

Section K	Swallowing/Nutritional Status
K0520. Nutritional Approaches
Last 7 Days Check all of the nutritional approaches that were received in the last 7 days At Discharge Check all of the nutritional approaches that were being received at discharge		4. Last 7 Days	5. At Discharge
		Check all that apply	Check all that apply
A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

Section M		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? No Skip to N0415, High-Risk Drug Classes: Use and Indication 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	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. Number of Stage 1 pressure injuries
Enter Number Enter Number	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. Number of Stage 2 pressure ulcers - If 0 Skip to M0300C, Stage 3 Number of these Stage 2 pressure ulcers that were present upon admission - enter how many were noted at the time of admission
Enter Number Enter Number	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. Number of Stage 3 pressure ulcers - If 0 Skip to M0300D, Stage 4 Number of these Stage 3 pressure ulcers that were present upon admission - enter how many were noted at the time of admission
Enter Number Enter Number	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. Number of Stage 4 pressure ulcers - If 0 Skip to M0300E, Unstageable - Non-removable dressing/device Number of these Stage 4 pressure ulcers that were present upon admission - enter how many were noted at the time of admission
Enter Number Enter Number	Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 Skip to M0300F, Unstageable - Slough and/or eschar Number of these unstageable pressure ulcers/injuries that were present upon admission - enter how many were noted at the time of admission
Enter Number Enter Number	Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0 Skip to M0300G, Unstageable - Deep tissue injury. Number of these unstageable pressure ulcers that were present upon admission - enter how many were noted at the time of admission
Enter Number Enter Number	Unstageable - Deep tissue injury Number of unstageable pressure injuries presenting as deep tissue injury - If 0 Skip to N0415, High-Risk Drug Classes: Use and Indication Number of these unstageable pressure injuries that were present upon admission - enter how many were noted at the time of admission

Section N		Medications
N0415. High-Risk Drug Classes: Use and Indication
Is taking Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes Indication noted If column 1 is checked, check if there is an indication noted for all medications in the drug class			1. Is taking	2. Indication noted
			Check all that apply	Check all that apply
A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the above
N2005. Medication Intervention
Enter Code	Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the admission? No Yes 9. Not applicable - There were no potential clinically significant medication issues identified since admission or patient is not taking any medications

O0110. Special Treatments, Procedures, and Programs Check all of the following treatments, procedures, and programs that apply at discharge.
	c. At Discharge
	Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-Invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

	O0200. Ventilator Liberation Rate (Note: 2 calendar days prior to discharge = 2 calendar days + day of discharge)
	Enter Code		Invasive Mechanical Ventilator: Liberation Status at Discharge Not fully liberated at discharge (i.e., patient required partial or full invasive mechanical ventilation support within 2 calendar days prior to discharge) Fully liberated at discharge (i.e., patient did not require any invasive mechanical ventilation support for at least 2 consecutive calendar days immediately prior to discharge) 9. Not applicable (code only if the patient was not on invasive mechanical ventilator support upon admission [O0150A = 0] or the patient was determined to be non-weaning upon admission [O0150A2 = 0])
O0350. Patient’s COVID-19 vaccination is up to date.
Enter Code		0. No, patient is not up to date 1. Yes, patient is up to date

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.
	Signature	Title.	Sections	Date Section Completed
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Z0500. Signature of Person Verifying Assessment Completion
	A. Signature: B. LTCH CARE Data Set Completion Date: _ _ Month Day Year

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Final LTCH CARE Data Set Version 5.1, Unplanned Discharge - Effective October 1, 2024