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The Centers for Medicare and Medicaid Services (CMS) recently announced that due to system issues, the February submission deadline for the inpatient rehabilitation facility (IRF) quality reporting program (QRP) data submitted via the Centers for Disease Control and Prevention (CDC) National Health and Safety Network (NHSN) has been extended to May 15, 2017.

The deadline has been extended for the following IRF quality reporting programs, measures, and reporting programs:

May 15, 2017 IRF QRP for Quarter 3 2016

  • CDC NHSN Healthcare-Associated Infection (HAI) Measures for quarter 3 2016
    • Catheter-associated Urinary Tract Infection (CAUTI)
    • Methicillin-resistant Staphylococcus aureus (MRSA)
    • Clostridium difficile Infection (CDI)

CMS is granting this extension to provide facilities additional time to submit quality reporting data and run applicable reports to ensure accurate submission. For further assistance regarding the IRF & long-term care hospitals (LTCH) quality reporting programs and policy information, visit the IRF Quality Reporting Data Submission Deadlines web page.

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As noted in the Rebaseline Timeline posted in the June 2016 National Healthcare Safety Network (NHSN) Newsletter, the Centers for Disease Control and Prevention (CDC) submitted standardized infection ratios (SIRs) to the Centers for Medicare and Medicaid Services (CMS), using the new 2015 baseline starting with 2016 Quarter 1 data. The inpatient rehabilitation facility (IRF) quality reporting program (QRP) preview reports that CMS provided on September 1, 2016, contained calendar year (CY) 2015 healthcare-associated infection (HAI) SIRs in accordance with the new NHSN baselines, based on nationally collected data from 2015. However, providers were unable to use NHSN to verify the accuracy of the HAI data contained within their preview reports for the Compare sites during the 30-day preview period established for this purpose.

As a result, CMS will begin publically displaying the NHSN data on the Compare sites for IRFs in the next quarterly refresh in spring 2017 instead of in fall 2016. Providers will have the chance to appropriately review their HAI data and inquire about data they believe to be incorrect. IRFs will receive preview reports in December 2016 for the data that will be displayed in spring 2017.

This change will affect the posting of quality performance data on the quality measure: NHSN Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure.

When the IRF Compare website is launched in fall 2016, the following quality metrics will be displayed:

IRFs —

  • Percent of residents or patients with pressure ulcers that are new or worsened (short stay); and
  • All-cause unplanned readmission measure for 30 days post-discharge from inpatient rehabilitation facilities.

To assist IRFs in understanding the use of the rebaselined data, and how to monitor their data using the new baseline, a document has been posted in the downloads section of the IRF Quality Public Reporting web page.

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On August 12, the Centers for Medicare and Medicaid Services (CMS) announced they were extending the deadline for the submission of data associated with the inpatient rehabilitation facility (IRF) quality reporting program (QRP) for measures reported to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN).

 

This extension is being granted to provide IRFs additional time to submit data. Although the NHSN system is working, intermittent production problems have been experienced. The CDC has been working to resolve these issues and they are expected to be corrected soon.

 

The deadline for the Healthcare-associated Infection (HAI) data submission has been extended from August 15 to August 28 at 11:59 pm PT. Please Note: This extension only applies to the HAI data submission deadline. Data are submitted through the NHSN online.

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