Reporting Requirements and Deadlines in NHSN per CMS ...

1 Reporting Requirements and Deadlines in nhsn per CMS Current & proposed Rules Healthcare Settings nhsn Event CMS Reporting Deadlines Acute Care Facilities CLABSI Q1 ( ): August 15. that participate in CMS Start Q1 2011 - adult, pediatric, and neonatal ICUs Q2 (April-June): November 15. Hospital IQR Program Q3 ( ): February 15. Start Q1 2015 - adult and pediatric medical, surgical, and medical/surgical wards *Medicare beneficiary Q4 ( ): May 15. identifier is optional for all nhsn events for applicable patients* CAUTI Q1 ( ): August 15. Start Q1 2012 - adult and pediatric ICUs Q2 (April-June): November 15. Start Q1 2015 - adult and pediatric medical, surgical, Q3 ( ): February 15. and medical/surgical wards Q4 ( ): May 15. SSI (following COLO Procedures) Q1 ( ): August 15. (Start Q1 2012) Q2 (April-June): November 15.

2 Q3 ( ): February 15. Q4 ( ): May 15. SSI (following HYST Procedures) Q1 ( ): August 15. (Start Q1 2012) Q2 (April-June): November 15. Q3 ( ): February 15. Q4 ( ): May 15. MRSA Bacteremia LabID Event (FacWideIN) Q1 ( ): August 15. (Start Q1 2013) Q2 (April-June): November 15. Q3 ( ): February 15. Q4 ( ): May 15. C. difficile LabID Event (FacWideIN) Q1 ( ): August 15. (Start Q1 2013) Q2 (April-June): November 15. Q3 ( ): February 15. Q4 ( ): May 15. Healthcare Personnel Influenza Vaccination Q4 ( ) - Q1 ( ): May 15. (Start Q1 2013). Updated August 2019 Page 1 of 4. Healthcare Settings nhsn Event CMS Reporting Deadlines Acute Care Facilities Healthcare Personnel Influenza that participate in the Vaccination As of October 1, 2018, OQR no longer requires CMS Hospital (Start Q4 2014) hospital outpatient departments to submit Outpatient Quality Healthcare Personnel Influenza Vaccination event Reporting (OQR) data Program Outpatient Dialysis Dialysis Event (includes Positive Q1-Q4 2012 ( : 3 month minimum): April 30, 2013.)

3 Facilities that blood culture, antimicrobial participate in CMS ESRD start, and Signs of vascular Q1-Q4 2013 ( : 6 month minimum): April 15, 2014. QIP Program access infection). Starting Q1 2014. (Start 2012). (Jan. Dec.: 12 month minimum): Q1 ( ): June 30. Q2 (April-June): September 30. Q3 ( ): December 31. Q4 ( ): March 31. Healthcare Personnel Influenza As of October 1, 2018, ESRD QIP no longer requires Vaccination outpatient dialysis facilities to submit Healthcare (Start Q4 2015) Personnel Influenza Vaccination event data Long-term Acute Care CLABSI (all bedded inpatient Q1 2014 Q3 2015 Starting Q4 2015. Facilities (LTACs) that care locations) Q1 ( ): May 15 Q1 ( ): August 15. participate in CMS (Start Q4 2012) Q2 (April-June): August 15 Q2 (April-June): November 15. LTCHQR Program Q3 ( ): November 15 Q3 ( ): February 15.

4 *Starting with October Q4 ( ): February 15 Q4 ( ): May 15. 2015 data, Reporting deadline will be CAUTI (all bedded inpatient care Q1 2014 Q3 2015 Starting Q4 2015. months after the end of the quarter.* locations) Q1 ( ): May 15 Q1 ( ): August 15. Data from Q3 2015 are due (Start Q4 2012) Q2 (April-June): August 15 Q2 (April-June): November 15. November 15, 2015. Q3 ( ): November 15 Q3 ( ): February 15. Data from Q4 2015 are due Q4 ( ): February 15 Q4 ( ): May 15. on May 15, 2016. MRSA Bacteremia LabID Event Historical Reference (FacWideIN) As of October 1, 2018, LTCHQR no longer requires Q4 2012 Q4 2013: Data due (Start Q1 2015) LTACs to submit MRSA Bacteremia LabID event data months after the end of the quarter. Q1 2014 Q3 2015: Data due months after the end of C. difficile LabID Event Q1 2014 Q3 2015 Starting Q4 2015.

5 The quarter. (FacWideIN) Q1 ( ): May 15 Q1 ( ): August 15. Q4 2015 forward: Data due (Start Q1 2015) Q2 (April-June): August 15 Q2 (April-June): November 15. months after the end of Q3 ( ): November 15 Q3 ( ): February 15. the quarter. Q4 ( ): February 15 Q4 ( ): May 15. (LTAC Requirements continued on next page). Updated August 2019 Page 2 of 4. Healthcare Settings nhsn Event CMS Reporting Deadlines Healthcare Personnel Influenza Q4 ( ) Q1 ( ): May 15. Long-term Acute Care Vaccination Facilities (LTACs) that (Start Q4 2014). participate in CMS. LTCHQR Program VAE. (continued) (all bedded adult inpatient care locations) As of October 1, 2018, LTCHQR no longer requires (Start Q1 2016). LTACs to submit VAE data CAUTI (all bedded inpatient care Q1 ( ): August 15. Inpatient Rehabilitation locations). Facilities (IRFs) that (Start Q4 2012) Q2 (April-June): November 15.

6 Participate in CMS. Q3 ( ): February 15. IRFQR Program Q4 ( ): May 15. MRSA Bacteremia LabID Event *IRFs that are mapped as a (FacWideIN)* As of October 1, 2018, IRFQR no longer requires IRFs location within affiliated (Start Q1 2015). acute care/critical access to submit MRSA Bacteremia LabID event data hospitals should pay special attention to the specific MRSA and CDI LabID. Reporting details outlined in this document: C. difficile LabID Event Q1 ( ): August 15. (FacWideIN)*. fs/cms/irfs/settingup_reporti (Start Q1 2015) Q2 (April-June): November 15. f Q3 ( ): February 15. Q4 ( ): May 15. Healthcare Personnel Influenza Q4 ( ) Q1 ( ): May 15. Vaccination (Start Q4 2014). Ambulatory Surgical Healthcare Personnel Influenza As of October 1, 2018, ASCQR no longer requires Centers that participate Vaccination ASCs to submit Healthcare Personnel Influenza in CMS ASCQR Program (Start Q4 2014) Vaccination event data Inpatient Psychiatric Healthcare Personnel Influenza Vaccination As of October 1, 2018, IPFQR no longer requires IPFs Facilities (IPFs) that to submit Healthcare Personnel Influenza participate in CMS.

7 (Start Q4 2015) Vaccination event data IPFQR Program Updated August 2019 Page 3 of 4. Healthcare Settings nhsn Event CMS Reporting Deadlines PPS-Exempt Cancer CLABSI (all bedded inpatient care locations) Q1 ( ): August 15. Facilities that (Start Q1 2013) Q2 (April-June): November 15. participate in CMS. PCHQR Program Q3 ( ): February 15. Q4 ( ): May 15. CAUTI (all bedded inpatient care locations) Q1 ( ): August 15. (Start Q1 2013) Q2 (April-June): November 15. Q3 ( ): February 15. Q4 ( ): May 15. SSI (following COLO Procedures) Q1 ( ): August 15. (Start Q1 2014) Q2 (April-June): November 15. Q3 ( ): February 15. Q4 ( ): May 15. SSI (following HYST Procedures) Q1 ( ): August 15. (Start Q1 2014) Q2 (April-June): November 15. Q3 ( ): February 15. Q4 ( ): May 15. MRSA Bacteremia LabID Event (FacWideIN) Q1 ( ): August 15.

8 (Start Q1 2016) Q2 (April-June): November 15. Q3 ( ): February 15. Q4 ( ): May 15. C. difficile LabID Event (FacWideIN) Q1 ( ): August 15. (Start Q1 2016) Q2 (April-June): November 15. Q3 ( ): February 15. Q4 ( ): May 15. Healthcare Personnel Influenza Vaccination Q4 ( ) Q1 ( ): May 15. (Start Q4 2016). Updated August 2019 Page 4 of 4.