Form CMS-10210 Data Accuracy and Completeness Form

Hospital Inpatient Quality Reporting (IQR) Program

Data Accuracy and Completeness Acknowledgement (DACA) Text

Please Note: A collection tool available on the QualityNet Secure Portal allows hospitals to complete and submit their DACA. This document is a representation of the text contained in the DACA and is for reference purposes only.

To the best of my knowledge, at the time of submission, all of the information reported for this hospital for the Hospital Inpatient Quality Reporting (IQR) Program, as required for the annual Payment Year (PY) 2018 Hospital IQR Program requirements, is accurate and complete. This information includes the following:

• Chart-Abstracted Measure sets

• Initial patient population and sample counts

• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey data

• Structural Measures

• Healthcare-Associated Infection (HAI) Measures reported using the National Healthcare Safety Network (NHSN)

• Influenza Vaccination Among Healthcare Personnel (HCP) Measure reported using NHSN

• Web-Based Measure (PC-01)

• Electronically specified Clinical Quality Measures (eCQMs)

• Current Notice of Participation

• QualityNet Security Administrator

I understand this acknowledgement covers all Hospital IQR information reported by this hospital (and any data or survey information reported by vendor(s) acting as agents on behalf of this hospital) to the Centers for Medicare & Medicaid Services (CMS) and its contractors for the PY 2018 payment update. 

To the best of my knowledge, at the time of submission, this information was collected in accordance with all applicable requirements. I understand that this information is used as the basis for the public reporting of quality of care and patient assessment of care data.

I understand that this acknowledgement is required for the purpose of meeting any PY 2018 Hospital IQR Program requirements.

[ ] Yes, I Acknowledge.

Name _________________________________________

Position _______________________________________

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 0938-1022.The time required to complete this information collection is estimated to average 10 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 estimates(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, MD 21244-1650.

Expiration Date: xx-xx-xxxx