Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
Please see corrected information below and disregard previous version of this message:
+ **Attention Acute Care Hospitals, Cancer Hospitals, Inpatient Rehabilitation Facilities, Long-term Acute Care Facilities (Long-term Care Hospitals) **
This email contains reporting deadline reminders for the CMS Quality Reporting Programs. The National Healthcare Safety Network (NHSN) encourages facilities to enter data in timely manner ahead of the prescribed deadlines in order to ensure data completion and accuracy. Make sure to allow ample time before the deadline to review, and if necessary, correct your HAI data. Data that are entered in NHSN after the submission deadline are not sent to CMS and will not be used in CMS pay-for-reporting or pay-for-performance programs. Data can be reviewed by using the Analysis reports within NHSN. For questions about how to access or interpret the analysis reports, please email nhsn@cdc.gov.
If you are unable to enter data into NHSN, it is possible that your Facility Administrator or Patient Safety Primary Contact has not accepted the updated NHSN Agreement to Participate and Consent. For questions or assistance with the updated Consent form and/or reassignment of the Facility Administrator or Primary Contact, please contact nhsn@cdc.gov as soon as possible.
The following data must be entered into NHSN by February 15, 2022, for facilities that participate in certain CMS quality reporting programs.
Acute Care Hospitals that participate in the Hospital Value-Based Purchasing (VBP) and Hospital-Acquired Conditions (HAC) Reduction Programs:
2021 Quarter 3 (July 1 – September 30) CLABSI and CAUTI data
- All ICU locations
- Adult and pediatric medical, surgical, and medical/surgical wards
- Includes Veterans Affairs and Department of Defense (DoD) acute care hospitals
2021 Quarter 3 (July 1 – September 30) Inpatient COLO and HYST SSI data
2021 Quarter 3 (July 1 – September 30) MRSA Bacteremia and C. difficile LabID Events (all healthcare-onset and community-onset)
- FacWideIN
- ED and 24-hour observation locations
- Includes DoD acute care hospitals
Cancer Hospitals that participate in the PPS-Exempt Cancer Hospital Quality Reporting Program:
2021 Quarter 3 (July 1 – September 30) CLABSI and CAUTI data (all bedded inpatient care locations)
2021 Quarter 3 (July 1 – September 30) Inpatient COLO and HYST SSI data
2021 Quarter 3 (July 1 – September 30) MRSA Bacteremia and C. difficile LabID Events (all healthcare-onset and community-onset)
Inpatient Rehabilitation Facilities (IRFs) that participate in the Inpatient Rehabilitation Facility Quality Reporting Program:
2021 Quarter 3 (July 1 – September 30) CAUTI data (all bedded inpatient locations)
2021 Quarter 3 (July 1 – September 30) C. difficile LabID Events (all healthcare-onset and community-onset)
- Freestanding IRFs: Reporting by FacWideIN
- IRF units within acute care or critical access hospitals: Reporting by each CMS IRF unit
Long-Term Acute Care Facilities (LTACs/LTCHs) that participate in the Long-Term Care Hospital Quality Reporting Program:
2021 Quarter 3 (July 1 – September 30) CLABSI and CAUTI data (all bedded inpatient locations)
2021 Quarter 3 (July 1 – September 30) C. difficile LabID Events (FacWideIN, all healthcare-onset, and community-onset)
Please ensure that at least one individual at your facility can access NHSN via their Secure Access Management Services (SAMS) account and has been assigned appropriate user rights in NHSN to enter and view your facility’s data. To guarantee that your data is accurately entered into NHSN, verify that; 1) your monthly reporting plans are complete; 2) you’ve entered appropriate summary and event data or checked the appropriate no events boxes; and 3) you’ve cleared all alerts from your NHSN facility homepage. For additional guidance on ensuring your data are accurately sent to CMS for Quality Reporting purposes, please visit our website and navigate to the appropriate section(s) for your facility type: https://www.cdc.gov/nhsn/cms/index.html.
If you have any questions, please contact the NHSN Helpdesk: NHSN@cdc.gov. The NHSN Helpdesk is staffed Mondays thru Fridays, 7 am ET – 5 pm ET, excluding Federal Holidays.
+ [NOTE: this does NOT apply to NHSN reporting for SNF/LTC facilities.]
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