CMS-10210 Data Accuracy and Completeness Form

Hospital Quality Reporting
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, as required for determining the annual payment update for Fiscal Year (FY) 2020
under the Hospital Inpatient Quality Reporting (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
• 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)
• Electronic Clinical Quality Measures (eCQMs)
• Current Notice of Participation
• QualityNet Security Administrator
I understand this acknowledgement covers all inpatient hospital information reported by this
hospital (and any data or survey information reported by any vendor[s] acting as agents on
behalf of this hospital) to the Centers for Medicare & Medicaid Services (CMS) and its
contractors for the FY 2020 annual payment update under the Hospital IQR Program.
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 and for
value-based payment adjustments under the Hospital-Acquired Condition Reduction Program
and the Hospital Value-Based Purchasing Program.
I understand that this acknowledgement is required for the purpose of meeting any FY 2020
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 (Expires xx-xxxxxx). 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 estimate(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, Maryland 21244-1850. ****CMS
Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded,
or retained. If you have questions or concerns regarding where to submit your documents, please contact the Hospital
Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor at (844) 472-4477.

April 2018