CMS Requirements
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CMS Resources for NHSN Users
Operational Guidance for Acute Care Hospitals
- Operational Guidance for Acute Care Hospitals to Report Central Line-Associated Bloodstream Infection (CLABSI) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Hospital Inpatient Quality Reporting (IQR) Requirements November 2014 [PDF – 99K]
- Operational Guidance for Acute Care Hospitals to Report Catheter-Associated Urinary Tract Infection (CAUTI) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Hospital Inpatient Quality Reporting (IQR) Requirements November 2014 [PDF – 113K]
- Operational Guidance for Reporting Surgical Site Infection Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Hospital Inpatient Quality Reporting (IQR) Program Requirements November 2014 [PDF – 103K]
- Operational Guidance for Acute Care Hospitals to Report Healthcare Personnel (HCP) Influenza Vaccination Data to CDC’s National Healthcare Safety Network (NHSN) for the Purpose of Fulfilling CMS’s Hospital Inpatient Quality Reporting (IQR) Program Requirements and CMS’s Hospital Outpatient Quality Reporting (OQR) Program Requirements. September 2015 [PDF – 86K]
- Operational Guidance for Acute Care Hospitals to Report Facility-Wide Inpatient (FacWideIN) Methicillin-Resistant Staphylococcus aureus (MRSA) Blood Specimen (Bacteremia) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Hospital Inpatient Quality Reporting (IQR) Requirements Nov. 2014 [PDF – 356K]
- Operational Guidance for Acute Care Hospitals to Report Facility-Wide Inpatient (FacWideIN) Clostridium difficile Infection (CDI) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Hospital Inpatient Quality Reporting (IQR) Requirements Nov. 2014 [PDF – 354K]
Operational Guidance for Ambulatory Surgery Centers
Operational Guidance for PPS-Exempt Cancer Hospitals
- Operational Guidance for Applicable Cancer Hospitals to Report Facility-Wide Inpatient (FacWideIN) Clostridium difficile Infection (CDI) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Requirements, December 2015 [PDF – 136K]
- Operational Guidance for Applicable Cancer Hospitals to Report Facility-Wide Inpatient (FacWideIN) Methicillin-Resistant Staphylococcus aureus (MRSA) Blood Specimen (Bacteremia) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Requirements, December 2015 [PDF – 138K]
- Operational Guidance for Applicable Cancer Hospitals to Report Central Line-Associated Bloodstream Infection (CLABSI) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s PPS-Exempt Cancer Hospital Quality Reporting Program Requirements November 2014 [PDF – 111K]
- Operational Guidance for Applicable Cancer Hospitals to Report Catheter-Associated Urinary Tract Infection (CAUTI) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s PPS-Exempt Cancer Hospital Quality Reporting Program Requirements November 2014 [PDF – 111K]
- Operational Guidance for PPS-Exempt Cancer Hospitals to Report Surgical Site Infection (SSI) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Requirements November 2014 [PDF – 121K]
- Operational Guidance for Prospective Payment System (PPS)-Exempt Cancer Hospitals to Report Healthcare Personnel (HCP) Influenza Vaccination Data to CDC’s National Healthcare Safety Network (NHSN) for the Purpose of Fulfilling CMS’s PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Requirements. February 2017 [PDF – 391K]
Operational Guidance for Long-term Acute Care Facilities
- Operational Guidance for Long Term Care Hospitals* to Report Central Line-Associated Bloodstream Infection (CLABSI) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Quality Reporting Requirements September 2016 [PDF – 114K]
- Operational Guidance for Long-term Acute Care Hospitals to Report Catheter-Associated Urinary Tract Infection (CAUTI) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Hospital Inpatient Quality Reporting (IQR) Requirements September 2016 [PDF – 111K]
- Operational Guidance for Long Term Care Hospitals to Report Facility-Wide Inpatient (FacWideIN) Methicillin-Resistant Staphylococcus aureus (MRSA) Blood Specimen (Bacteremia) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Long Term Care Hospital Quality Reporting Requirements January 2017 [PDF – 152K]
- Operational Guidance for Long Term Care Hospitals to Report Facility-Wide Inpatient (FacWideIN) Clostridium difficile Infection (CDI) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Long Term Care Hospital Quality Reporting Requirements January 2017 [PDF – 151K]
- Operational Guidance for Long Term Care Hospitals to Report Healthcare Personnel (HCP) Influenza Vaccination Data to CDC’s National Healthcare Safety Network (NHSN) for the Purpose of Fulfilling CMS’s Long Term Care Hospital Quality Reporting (LTCHQR) Program Requirements April 2014 [PDF – 147K]
- Operational Guidance for Long Term Care Hospitals* to Report Ventilator-associated Event (VAE) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Quality Reporting Requirements, September 2016 [PDF – 118K]
Operational Guidance for Inpatient Psychiatric Facilities
Operational Guidance for Inpatient Rehabilitation Facilities
- Operational Guidance for Inpatient Rehabilitation Facilities to Report Catheter-Associated Urinary Tract Infection (CAUTI) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Quality Reporting Requirements November 2014 [PDF – 115K]
- Operational Guidance for Inpatient Rehabilitation Facilities to Report Healthcare Personnel (HCP) Influenza Vaccination Data to CDC’s National Healthcare Safety Network (NHSN) for the Purpose of Fulfilling CMS’s Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) Requirements April 2014 [PDF – 126K]
- Operational Guidance for Inpatient Rehabilitation Facilities to Report Methicillin-Resistant Staphylococcus aureus (MRSA) Blood Specimen (Bacteremia) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Quality Reporting Requirements January 2017 [PDF – 134K]
- Operational Guidance for Inpatient Rehabilitation Facilities to Report Clostridium difficile Infection (CDI) Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Quality Reporting Program Requirements January 2017 [PDF – 131K]
- Updating Inpatient Rehabilitation locations in NHSN May 2012 [PDF – 419K]
Outpatient Dialysis Facilities
- Operational Guidance for Outpatient Dialysis Facilities to Report Healthcare Personnel (HCP) Influenza Vaccination Data to CDC’s National Healthcare Safety Network (NHSN) to Fulfill CMS’s End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) Requirement. September 2015 [PDF – 118K]
- NHSN Adjusted Ranking Metric (ARM) May 2014 [PDF – 86K]
- End-Stage Renal Disease (ESRD) Quality Initiative
- How to Create and Read an NHSN Report for CMS ESRD QIP January 2017 [PDF – 272K]
- FAQs about NHSN and CMS ESRD QIP Rule
CMS Reporting
Importance of NHSN Reporting
CLABSI (Acute Care Hospitals)
CLABSI (PPS-Exempt Cancer Hospitals)
CLABSI (Long-term Acute Care Facilities)
- Monthly Checklist for the CMS Long Term Care Hospital Quality Reporting Program (April 2016) [PDF – 199K]
- Simplified Guidance for Using the “SIR – CLAB Data for CMS LTCH PPS” Output Option January 2015 [PDF – 209K]
- Detailed Guidance for Using the “SIR – CLAB Data for CMS LTCH PPS” Output Option January 2015 [PDF – 349K]
CAUTI (Acute Care Hospitals)
CAUTI (PPS-Exempt Cancer Hospitals)
CAUTI (Long-term Acute Care Facilities)
- Monthly Checklist for the CMS Long Term Care Hospital Quality Reporting Program (April 2016) [PDF – 199K]
- Simplified Guidance for Using the “SIR – CAUTI Data for CMS LTCH PPS” Output Option January 2015 [PDF – 144K]
- Detailed Guidance for Using the “SIR – CAUTI Data for CMS LTCH PPS” Output Option January 2015 [PDF – 292K]
CAUTI (Inpatient Rehabilitation Facilities)
- Monthly Checklist for Acute Care Hospital Units Designated as Inpatient Rehabilitation Facilities (IRFs) Reporting to CMS IRF IQR (July 2015) [PDF – 630K]
- Monthly Checklist for Freestanding Inpatient Rehabilitation Facilities (IRFs) Reporting to CMS IRF Quality Reporting Program (July 2015) [PDF – 647K]
- Simplified Guidance for Using the “SIR – CAUTI Data for CMS IRF PPS” Output Option January 2015 [PDF – 151K]
- Detailed Guidance for Using the “SIR – CAUTI Data for CMS IRF PPS” Output Option January 2015 [PDF – 238K]
VAE (Long-term Acute Care Facilities)
- Monthly Checklist for the CMS Long Term Care Hospital Quality Reporting Program (April 2016) [PDF – 199K]
- How to Report No VAE for the CMS Long Term Care Hospital Quality Reporting Program [PDF – 294K]
- Detailed Guidance for Using the “Rate Table – VAE Data for CMS LTCH PPS” Output Option April 2016 [PDF – 227K]
- Using the “SIR – VAE Data for LTCHQR” Report (May 2017) [PDF – 320 KB]
SSI (Acute Care Hospitals)
- NHSN Monthly Checklist for Reporting to CMS Hospital IQR for Acute Care Hospitals (July 2015) [PDF – 463K]
- How to Report No Procedure or SSI Events for the CMS Inpatient Quality Reporting Program February 2017 [PDF – 247K]
- Using the “SIR- Complex 30-Day SSI Data for CMS IPPS” Output Option January 2017 [PDF – 350K]
MRSA Bacteremia and C.difficile LabID Events (Acute Care Hospitals)
- How to Set Up NHSN Reporting for Facility-Wide Inpatient MRSA Bacteremia and C. difficile LabID events for the CMS Inpatient Quality Reporting Program January 2017 [PDF – 275K]
- NHSN Guidance for Acute Care Hospital FacWideIN MRSA/CDI LabID Denominator Reporting January 2017 [PDF – 143K]
- NHSN Monthly Checklist for Reporting to CMS Hospital IQR for Acute Care Hospitals (July 2015) [PDF – 463K]
- Using the “SIR – MRSA Blood FacwideIn LabID Data for CMS IPPS” Output Option January 2017 [PDF – 150K]
- Using the “SIR – FacWideIn CDI LabID Data for CMS IPPS” Output Option January 2017 [PDF – 202K]
MRSA Bacteremia and C.difficile LabID Events (Inpatient Rehabilitation Facilities)
CMS Inpatient Rehabilitation units within Acute Care or Critical Access Hospital
- How to Set Up NHSN Reporting for MRSA Bacteremia and C.difficile LabID events for the CMS Inpatient Rehabilitation Facility (IRF) Quality Reporting Program January 2017 [PDF – 252K]
- Monthly Checklist for Acute Care Hospital Units Designated as Inpatient Rehabilitation Facilities (IRFs) Reporting to CMS IRF IQR (July 2015) [PDF – 630K]
- Using the SIR – MRSA Blood LabID Data for IRFQR January 2017 [PDF – 176K]
- Using the SIR – CDI LabID data for IRFQR January 2017 [PDF – 227K]
Freestanding Inpatient Rehabilitation Facilities
- How to Set Up NHSN Reporting for MRSA Bacteremia and C.difficile LabID events for the CMS Inpatient Rehabilitation Facility (IRF) Quality Reporting Program January 2017 [PDF – 255K]
- Monthly Checklist for Freestanding Inpatient Rehabilitation Facilities (IRFs) Reporting to CMS IRF Quality Reporting Program (July 2015) [PDF – 647K]
- Using the SIR – MRSA Blood LabID Data for IRFQR January 2017 [PDF – 146K]
- Using the SIR – CDI LabID data for IRFQR January 2017 [PDF – 154K]
MRSA Bacteremia and C. difficile LabID Events (Long Term Acute Care Facilities)
- How to Set Up NHSN Reporting for Facility-Wide Inpatient MRSA Bacteremia and C. difficile LabID events for the CMS Inpatient Quality Reporting Program January 2017 [PDF – 257K]
- Monthly Checklist for the CMS Long Term Care Hospital Quality Reporting Program (April 2016) [PDF – 199K]
- Using the SIR – MRSA Blood FacwideIN LabID data for LTCHQR January 2017 [PDF – 153K]
- Using the SIR – CDI FacwideIN LabID data for LTCHQR January 2017 [PDF – 170K]
MRSA Bacteremia and C.difficile LabID Events (PPS Exempt Cancer Hospitals)
- How to Set Up NHSN Reporting for Facility-Wide Inpatient MRSA Bacteremia and C. difficile LabID events for the CMS Inpatient Quality Reporting Program January 2017 [PDF – 275K]
- NHSN Guidance for Acute Care Hospital FacWideIN MRSA/CDI LabID Denominator Reporting January 2017 [PDF – 143K]
- NHSN Monthly Checklist for Reporting to CMS Hospital IQR for Acute Care Hospitals (July 2015) [PDF – 463K]
- Using the “Rate Table – MRSA Blood LabID Data for CMS PPS-Exempt Cancer Hospitals” Output Option January 2017 [PDF – 153K]
- Using the “Rate Table – CDI LabID Data for CMS PPS-Exempt Cancer Hospitals” Output Option January 2017 [PDF – 153K]
Healthcare Personnel Influenza Vaccination (Acute Care Hospitals)
Healthcare Personnel Influenza Vaccination (Ambulatory Surgery Center)
Healthcare Personnel Influenza Vaccination (Outpatient Dialysis Facilities)
- Helpful Tips for Healthcare Personnel (HCP) Influenza Vaccination Reporting for the Centers for Medicare and Medicaid Services’ End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP). October 2015 [PDF – 117K]
- Using the “Line Listing – HCP Flu Vaccination for QIP” Output Option. May 2017 [PDF – 158 KB]
Healthcare Personnel Influenza Vaccination (Inpatient Rehabilitation Facility)
Healthcare Personnel Influenza Vaccination (Inpatient Psychiatric Facilities)
- Helpful Tips for Healthcare Personnel (HCP) Influenza Vaccination Reporting for the Centers for Medicare and Medicaid Services’ Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program September 2016 [PDF – 115K]
- Using the “Line Listing – HCP Flu Vaccination Data for CMS IPF PPS”. May 2017 [PDF – 160 KB]
Healthcare Personnel Influenza Vaccination (Long Term Acute Care Hospital)
FAQs
Resources
- Healthcare Facility HAI Reporting Requirements to CMS via NHSN Current and Proposed Requirements September 2015 [PDF – 102K]
- Reporting Requirements and Deadlines in NHSN per CMS Current Rules September 2015 [PDF – 157K]
- Hospital Inpatient Quality Reporting Program.
- CMS’ Hospital Compare tool
- CMS Inpatient Prospective Payment System (IPPS) Rule
- Changing a CCN within NHSN (updated July 2015) [PDF – 290K]
- Page last reviewed: April 5, 2017
- Page last updated: July 7, 2017
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