CMS-10668 MRSA Validation Template

---

Overview

Definitions
Template
NHSN Location
FY2022 Submission Instructions

---

Sheet 1: Definitions

Methicillin-Resistant Staphylococcus Aureus (MRSA) Validation Template
In support of Centers for Medicare and Medicaid Services (CMS) inpatient data validation for the Fiscal Year (FY) 2022 Payment Determination:
• Each hospital selected for MRSA validation is to produce a list of all final results for blood cultures that are positive for MRSA during an inpatient episode
of care.
• The list may include cultures collected in the ED and/or 24-hour observation locations collected prior to an inpatient admission; however, if the patient was
only seen in the ED and/or 24-hour observation and never admitted as an inpatient status, do not include these on the Validation Template. These are
scenarios where CMS and the National Healthcare Safety Network (NHSN) reporting differ.
	FY 2022 - MRSA Validation Template
	(Use this template for 3Q19 & 4Q19 blood cultures positive for MRSA - all quarters must be submitted on separate templates)
FIELD (* indicates required field)	DESCRIPTION	SECTION
NHSN Facility ID*	The National Healthcare Safety Network (NHSN)-assigned facility ID under which your hospital submits NHSN data.
Provider ID/CCN*	Hospital's 6-digit CMS Certification Number (CCN). Do not include any hyphens.
Hospital Name*	Hospital Name associated with CCN.
State*	Enter the 2 character abbreviation for the state in which the hospital is located.
Calendar Quarter*	Select from the drop-down list the calendar quarter to which the MRSA Validation Template pertains.
Hospital Contact Name*	Hospital contact name for CMS to contact with questions.
Contact Phone*	Phone number for hospital contact listed.
Contact Email*	Email address for hospital contact listed.
Blood cultures positive for MRSA (Y/N)*	Select Yes or No from the drop-down list. Does the hospital have any final results for blood cultures positive for MRSA for patients in the calendar quarter referenced?
Patient Identifier*	The patient identifier assigned by the hospital. Use the same patient identifier that would be submitted to NHSN if the episode of care (EOC) would be reported as a laboratory-identified MRSA bacteremia event.
Birthdate*	The patient date of birth using MM/DD/YYYY format.
Sex*	Select Female, Male or unknown from the drop-down list to indicate the sex of the patient.
Admit Date*	Enter date patient was admitted to hospital in MM/DD/YYYY format.
Discharge Date*	Enter date patient was discharged from the hospital in MM/DD/YYYY format. If a patient has not been discharged from the hospital enter "Not Discharged" for the Discharge Date field. Discharge dates that fall within the reporting quarter will be eligible for validation.
First Name	First name of patient.
Last Name	Last name of patient.
NHSN Location*	Select from the drop-down list, the NHSN location to which the patient was assigned when the blood culture positive for MRSA was collected. Only locations from the drop-down will be accepted; do not use a hospital-assigned location.
Lab ID*	Lab ID, accession number or specimen number corresponding to positive blood culture.
Blood Culture Date*	Provide the date the blood culture was collected in MM/DD/YYYY format.
Blood Culture Time	Provide the time the blood was collected if easily available.
Blank cell
For additional information, view the appropriate MRSA Abstraction Manual posted on the Inpatient Chart-Abstracted Data Validation Resources
page of QualityNet (direct link):	https://www.qualitynet.org/inpatient/data-management/chart-abstracted-data-validation/resources
For the purposes of CMS inpatient chart-abstracted data validation, please note the differences between NHSN data submission
and validation template/medical record submission, as described below:
End of Spreadsheet
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 02/28/2022). The time required to complete this information collection is estimated to average 10 hours 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 Validation Support Contractor at [email protected].

---

Sheet 2: Template

NHSN Facility ID*

Provider ID/CCN*

Hospital Name*

State*

Calendar Quarter*

Hospital Contact Name*

Contact Phone*

Contact Email*

Blood cultures positive for MRSA (Y/N) *

Patient Identifier*

Birthdate*

Sex*

Admit Date*

Discharge Date*

First Name

Last Name

NHSN Location*

Lab ID*

Blood Culture Date*

Blood Culture Time

---

Sheet 3: NHSN Location

	NHSN Locations Included inpatient MRSA Reporting
CDC LOCATION LABEL	CDC LOCATION CODE	LOCATION DESCRIPTION
	Inpatient Adult Critical Care Units
Burn Critical Care	IN:ACUTE:CC:B	Critical care area for the care of patients with significant/major burns.
Medical Cardiac Critical Care	IN:ACUTE:CC:C	Critical care area for the care of patients with serious heart problems that do not require heart surgery.
Medical Critical Care	IN:ACUTE:CC:M	Critical care area for the care of patients who are being treated for nonsurgical conditions.
Medical-Surgical Critical Care	IN:ACUTE:CC:MS	Critical care area for the care of patients with medical and/or surgical conditions.
Neurologic Critical Care	IN:ACUTE:CC:N	Critical care area for the care of patients with life- threatening neurologic diseases.
Neurosurgical Critical Care	IN:ACUTE:CC:NS	Critical care area for the surgical management of patients with severe neurologic diseases or those at risk for neurologic injury as a result of surgery.
ONC Medical Critical Care	IN:ACUTE:CC:ONC_M	Critical care area for the care of oncology patients who are being treated for nonsurgical conditions related to their malignancy.
ONC Surgical Critical Care	IN:ACUTE:CC:ONC_S	Critical care area for the evaluation and management of oncology patients with serious illness before and/or after cancer-related surgery.
ONC Medical-Surgical Critical Care	IN:ACUTE:CC:ONC_MS	Critical care area for the care of oncology patients with medical and/or surgical conditions related to their malignancy.
Prenatal Critical Care	IN:ACUTE:CC:PNATL	Critical care area for the care of pregnant patients with complex medical or obstetric problems requiring a high level of care to prevent the loss of the fetus and to protect the life of the mother.
Respiratory Critical Care	IN:ACUTE:CC:R	Critical care area for the evaluation and treatment of patients with severe respiratory conditions.
Surgical Cardiothoracic Critical Care	IN:ACUTE:CC:CT	Critical care area for the care of patients following cardiac and/or thoracic surgery.
Surgical Critical Care	IN:ACUTE:CC:S	Critical care area for the evaluation and management of patients with serious illness before and/or after surgery.
Trauma Critical Care	IN:ACUTE:CC:T	Critical care area for the care of patients who require a high level of monitoring and/or intervention following trauma or during critical illness related to trauma.
	Inpatient Pediatric Critical Care Units
ONC Pediatric Critical Care	IN:ACUTE:CC:ONC_PED	Critical care area for the care of oncology patients ≤18 years old who are being treated for surgical or nonsurgical conditions related to their malignancy.
Pediatric Burn Critical Care	IN:ACUTE:CC:B_PED	Critical care area for the care of patients ≤18 years old with significant/major burns.
Pediatric Surgical Cardiothoracic Critical Care	IN:ACUTE:CC:CT_PED	Critical care area for the care of patients ≤18 years old following cardiac and thoracic surgery.
Pediatric Medical Critical Care	IN:ACUTE:CC:M_PED	Critical care area for the care of patients ≤18 years old who are being treated for nonsurgical conditions.
Pediatric Medical-Surgical Critical Care	IN:ACUTE:CC:MS_PED	Critical care area for the care of patients ≤18 years old with medical and/or surgical conditions.
Pediatric Neurosurgical Critical Care	IN:ACUTE:CC:NS_PED	Critical care area for the surgical management of patients ≤18 years old with severe neurologic diseases or those at risk for neurologic injury as a result of surgery.
Pediatric Respiratory Critical Care	IN:ACUTE:CC:R_PED	Critical care area for the evaluation and treatment of patients ≤18 years old with severe respiratory conditions.
Pediatric Surgical Critical Care	IN:ACUTE:CC:S_PED	Critical care area for the evaluation and management of patients ≤18 years old with serious illness before and/or after surgery.
Pediatric Trauma Critical Care	IN:ACUTE:CC:T_PED	Critical care area for the care of patients ≤18 years old who require a high level of monitoring and/or intervention following trauma or during critical illness related to trauma.
	Inpatient Neonatal Units
Well Baby Nursery (Level I)	IN:ACUTE:WARD:NURS	Hospital area for evaluation and postnatal care of healthy newborns. May include neonatal resuscitation and stabilization of ill newborns until transfer to a facility at which specialty neonatal care is provided.
Step down Neonatal Nursery (Level II)	IN:ACUTE:STEP:NURS	The capabilities of Level II, listed below, are from the American Academy of Pediatrics definitions of levels of neonatal care.1 Level II special care nursery Level I capabilities plus: • Provide care for infants born ≥32 wks. gestation and weighing ≥1500 g who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis • Provide care for infants convalescing after intensive care • Provide mechanical ventilation for brief duration (<24 h) or continuous positive airway pressure or both • Stabilize infants born before 32 wks. gestation and weighing less than 1500 g until transfer to a neonatal intensive care facility
Neonatal Critical Care (Level II/III)	IN:ACUTE:CC_STEP:NURS	Combined nursery housing both Level II and III newborns and infants, as per the NHSN level definitions above and below. This is analogous to a mixed acuity unit specifically for Neonatal Critical Care patients.
Neonatal Critical Care (Level III)	IN:ACUTE:CC:NURS	A hospital neonatal intensive care unit (NICU) organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness. The capabilities of Level III and Level IV, listed below, are from the American Academy of Pediatrics definitions of levels of neonatal care.1 NOTE: These classifications are all considered Level III NICUs in NHSN. Level III NICU Level II capabilities plus: • Provide sustained life support • Provide comprehensive care for infants born < 32 wks. gestation and weighing <1500 g and infants born at all gestational ages and birth weights with critical illness • Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists • Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide • Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI, and echocardiography Level IV Regional NICU Level III capabilities plus: • Located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions • Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric subspecialists at the site • Facilitate transport and provide outreach education
	Inpatient Specialty Care Areas (SCA)
Dialysis Specialty Care Area	IN:ACUTE:SCA:DIAL	Specialty care area for the care of patients who require acute dialysis as a temporary measure.
Pediatric Dialysis Specialty Care Area	IN:ACUTE:SCA:DIAL_PED	Specialty care area for the care of patients ≤18 years old who require acute dialysis as a temporary measure.
Pediatric Solid Organ Transplant Specialty Care Area	IN:ACUTE:SCA:SOTP_PED	Hospital specialty area for the postoperative care of patients ≤18 years old who have had a solid organ transplant (e.g., heart/lung, kidney, liver, pancreas).
Solid Organ Transplant Specialty Care Area	IN:ACUTE:SCA:SOTP	Specialty care area for the postoperative care of patients ≤18 years old who have had a solid organ transplant (e.g., heart/lung, kidney, liver, pancreas).
	Inpatient Adult Wards
Antenatal Care Ward	IN:ACUTE:WARD:ANTENAT	Hospital area for observation, evaluation, treatment or surgery of high risk pregnancy patients.
Behavioral Health/Psych Ward	IN:ACUTE:WARD:BHV	Area for the evaluation and treatment of patients with acute psychiatric or behavioral disorders.
Burn Ward	IN:ACUTE:WARD:B	Area for the evaluation and treatment of patients who have burns.
Ear, Nose, Throat Ward	IN:ACUTE:WARD:ENT	Area for the evaluation, treatment, or surgery of patients with ear, nose, or throat disorders.
Gastrointestinal Ward	IN:ACUTE:WARD:GI	Area for the evaluation, treatment, or surgery of patients with disorders of the gastrointestinal tract.
Genitourinary Ward	IN:ACUTE:WARD:GU	Area for the evaluation, treatment, or surgery of patients with disorders of the genitourinary system.
Gerontology Ward	IN:ACUTE:WARD:GNT	Area for the evaluation, treatment, or surgery of patients with age-related diseases.
Gynecology Ward	IN:ACUTE:WARD:GYN	Area for the evaluation, treatment, or surgery of female patients with reproductive tract disorders.
Jail Unit	IN:ACUTE:WARD:JAL	Overnight stay patient care area of a hospital or correctional facility used only for those who are in custody of law enforcement during their treatment.
Labor and Delivery Ward	IN:ACUTE:WARD:LD	Area where women labor and give birth.
Labor, Delivery, Recovery, Postpartum Suite	IN:ACUTE:WARD:LD_PP	Suite used for labor, delivery, recovery and postpartum care -- all within the same suite.
Medical Ward	IN:ACUTE:WARD:M	Area for the evaluation and treatment of patients with medical conditions or disorders.
Medical-Surgical Ward	IN:ACUTE:WARD:MS	Area for the evaluation of patients with medical and/or surgical conditions.
Neurology Ward	IN:ACUTE:WARD:N	Area for the evaluation and treatment of patients with neurologic disorders.
Neurosurgical Ward	IN:ACUTE:WARD:NS	Area for the care of patients whose primary reason for admission is to have neurosurgery or to be cared for by a neurosurgeon after head or spinal trauma.
ONC Leukemia Ward	IN:ACUTE:WARD:ONC_LEUK	Area for the evaluation and treatment of patients with leukemia.
ONC Lymphoma Ward	IN:ACUTE:WARD:ONC_LYMPH	Area for the evaluation and treatment of patients with lymphoma.
ONC Leukemia/Lymphoma Ward	IN:ACUTE:WARD:ONC_LL	Area for the evaluation and treatment of patients with leukemia and/or lymphoma.
ONC Solid Tumor Ward	IN:ACUTE:WARD:ONC_ST	Area for the evaluation and treatment of oncology patients with solid tumors.
ONC Hematopoietic Stem Cell Transplant Ward	IN:ACUTE:WARD:ONC_HSCT	Area for the care of patients who undergo stem cell transplant for the treatment of cancers and/or blood or immune system disorders.
ONC General Hematology/Oncology Ward	IN:ACUTE:WARD:ONC_HONC	Area for the evaluation and treatment of patients with cancer and/or blood disorders.
Ophthalmology Ward	IN:ACUTE:WARD:OPH	Area for the care of patients whose primary reason for admission is to have eye surgery or to be cared for by an ophthalmologist after eye trauma.
Orthopedic Ward	IN:ACUTE:WARD:ORT	Area for the evaluation, treatment, or surgery on bones, joints, and associated structures by an orthopedist.
Orthopedic Trauma Ward	IN:ACUTE:WARD:T_ORT	Area for the evaluation and treatment of patients with orthopedic injuries or disorders.
Plastic Surgery Ward	IN:ACUTE:WARD:PLS	Area for the care of patients who have reconstructive surgery performed by a plastic surgeon.
Postpartum Ward	IN:ACUTE:WARD:PP	Area for the care of patients recovering from childbirth.
Pulmonary Ward	IN:ACUTE:WARD:PULM	Area for the evaluation and treatment of patients with respiratory system conditions or disorders.
Rehabilitation Ward (within Acute Care Hospital)	IN:ACUTE:WARD:REHAB	Area for the evaluation and restoration of function to patients who have lost function due to acute or chronic pain, musculoskeletal problems, stroke, or catastrophic events resulting in complete or partial paralysis.
School Infirmary	IN:ACUTE:WARD:IFM	Overnight stay patient care area of a school infirmary or health center (e.g., private residential school or college campus).
Stroke (Acute) Ward	IN:ACUTE:WARD:STRK	Area for the evaluation, stabilization, and treatment of patients who have experienced an acute stroke.
Surgical Ward	IN:ACUTE:WARD:S	Area for the evaluation and treatment of patients who have undergone a surgical procedure.
Telemetry Ward	IN:ACUTE:WARD:TEL	Hospital area dedicated to providing evaluation and treatment of patients requiring continuous cardiac monitoring
Vascular Surgery Ward	IN:ACUTE:WARD:VS	Area for the evaluation and treatment of patients who have undergone vascular surgery.
	Inpatient Pediatric Wards
Adolescent Behavioral Health Ward	IN:ACUTE:WARD:BHV_ADOL	Area for the evaluation and treatment of patients 13-18 years old with acute psychiatric or behavioral disorders.
ONC Pediatric Hematopoietic Stem Cell Transplant Ward	IN:ACUTE:WARD:ONC_HSCT_PED	Area for the care of patients ≤18 years old who undergo stem cell transplant for the treatment of cancers and/or blood or immune system disorders.
ONC Pediatric General Hematology/Oncology Ward	IN:ACUTE:WARD:ONC_HONC_PED	Area for the evaluation and treatment of patients ≤18 years old with cancer and/or blood disorders.
Pediatric Behavioral Health Ward	IN:ACUTE:WARD:BHV_PED	Area for the evaluation and treatment of patients ≤18 years old with acute psychiatric or behavioral disorders.
Pediatric Burn Ward	IN:ACUTE:WARD:B_PED	Area for the evaluation and treatment of patients ≤18 years old who have tissue injury caused by burns.
Pediatric Ear, Nose, Throat Ward	IN:ACUTE:WARD:ENT_PED	Area for the evaluation and treatment of patients ≤18 years old with disorders of the ear, nose, and/or throat.
Pediatric Genitourinary Ward	IN:ACUTE:WARD:GU_PED	Area for the evaluation and treatment of patients ≤18 years old with disorders of the genitourinary system.
Pediatric Medical Ward	IN:ACUTE:WARD:M_PED	Area for the evaluation and treatment of patients ≤18 years old with medical conditions or disorders.
Pediatric Medical-Surgical Ward	IN:ACUTE:WARD:MS_PED	Area for the evaluation and treatment of patients ≤18 years old with medical and/or surgical conditions.
Pediatric Neurology Ward	IN:ACUTE:WARD:N_PED	Area for the evaluation and treatment of patients ≤18 years old with neurologic disorders.
Pediatric Neurosurgical Ward	IN:ACUTE:WARD:NS_PED	Area for care of patients ≤18 years old whose primary reason for admission is to have neurosurgery or to be cared for by a neurosurgeon after head or spinal trauma.
Pediatric Orthopedic Ward	IN:ACUTE:WARD:ORT_PED	Area for the evaluation and treatment of patients ≤18 years old with orthopedic injuries or disorders.
Pediatric Rehabilitation Ward (within Acute Care Hospital)	IN:ACUTE:WARD:REHAB_PED	Area for the evaluation and restoration of function to patients ≤18 years old who have lost function due to acute or chronic pain, musculoskeletal problems, stroke, or catastrophic events resulting in complete or partial paralysis.
Pediatric Surgical Ward	IN:ACUTE:WARD:S_PED	Area for the evaluation and treatment of patients ≤18 years old who have undergone a surgical procedure.
	Inpatient Step Down Units
Adult Step Down Unit	IN:ACUTE:STEP	Area for adult patients who are hemodynamically stable and can benefit from close supervision and monitoring, such as frequent pulmonary toilet, vital signs, and/or neurologic and neurovascular checks.
ONC Step Down Unit (all ages) (e.g., post-critical care)	IN:ACUTE:STEP:ONC	Area for oncology patients who are hemodynamically stable and can benefit from close supervision and monitoring, such as frequent pulmonary toilet, vital signs, and/or neurologic and neurovascular checks.
Pediatric Step Down Unit	IN:ACUTE:STEP:PED	Area for patients ≤18 years old who are hemodynamically stable and can benefit from close supervision and monitoring, such as frequent pulmonary toilet, vital signs, and/or neurologic and neurovascular checks.
	Inpatient Mixed Acuity Units
Adult Mixed Acuity Unit	IN:ACUTE:MIXED:ALL_ADULT	Hospital area for the evaluation and treatment of adult patients whose conditions are of varying levels of acuity (e.g., critical care, ward-level care, step-down type care, etc.). Such a care area may be comprised of patients followed by different hospital services(e.g., coronary, medical, surgical, etc.). This care area may or may not include ''acuity adaptable'' or ''universal'' beds (i.e., this model of patient care allows a patient to stay in same bed during all phases of his care, from critical care through lower levels of care).
Pediatric Mixed Acuity Unit	IN:ACUTE:MIXED:ALL_PEDS	Area for the evaluation and treatment of a mixture of adult and pediatric oncology patients whose conditions are of varying levels of acuity (e.g., critical care, ward- level care, step-down type care, etc.). This care area may or may not include "acuity adaptable" or universal beds (i.e. this model of patient care allows a patient to stay in the same bed during all phases of care, from critical care through lower levels of care.
Mixed Age Mixed Acuity Unit	IN:ACUTE:MIXED:ALL	Hospital area for the evaluation and treatment of a mixture of adult and pediatric patients whose conditions are of varying levels of acuity (e.g., critical care, ward- level care, step-down type care, etc.). Such a care area may be comprised of patients followed by different hospital services (e.g., coronary, medical, surgical, etc.). This care area may or may not include ''acuity adaptable'' or ''universal'' beds (i.e., this model of patient care allows a patient to stay in same bed during all phases of his care, from critical care through lower levels of care).
ONC Mixed Acuity Unit (all ages)	IN:ACUTE:MIXED:ONC	Area for the evaluation and treatment of a mixture of adult and pediatric oncology patients whose conditions are of varying levels of acuity (e.g., critical care, ward-level care, step down type care, etc.). This care area may or may not include ''acuity adaptable'' or ''universal'' beds (i.e., this model of patient care allows a patient to stay in same bed during all phases of care, from critical care through lower levels of care).
	Inpatient Operating Rooms
Cardiac Catheterization Room/Suite	IN:ACUTE:OR:CATH	A room or rooms in a hospital equipped for the performance of heart catheterizations for diagnostic or therapeutic purposes. Operating Room requirements for air changes, temperature, humidity and surfaces must be met.
Cesarean Section Room/Suite	IN:ACUTE:OR:LD	A room or suite in a hospital equipped for the performance of obstetric and gynecologic surgeries and for the care of the neonate immediately after birth.
Interventional Radiology	IN:ACUTE:OR:RAD	A room where diagnostic or therapeutic radiology procedures are done on outpatients or inpatients. Operating room requirements for air changes, temperature, humidity, and surfaces must be met.
Operating Room/Suite	IN:ACUTE:OR	A room or suite in a hospital equipped for the performance of surgical operations. Requirements for air changes, temperature, humidity, and surfaces must be met.
Post Anesthesia Care Unit/Recovery Room	IN:ACUTE:OR_STEP	Area designated for monitoring patients for immediate effects of anesthesia before either going home or on to an in-patient care area.
	Inpatient Chronic Care Units
Inpatient Hospice	IN:NONACUTE:LTC:HSP	Area where palliative care is provided to the dying patient.
Chronic Alzheimer's Unit	IN:NONACUTE:LTC:ALZ	Area where care is provided to persons diagnosed with Alzheimer's syndrome for extended periods of time.
Chronic Behavioral Health/Psych Unit	IN:NONACUTE:LTC:BHV	Area where care is provided to patients with psychiatric or behavioral-disorder diagnoses for extended periods of time.
Chronic Rehabilitation Unit	IN:NONACUTE:LTC:REHAB	Area where evaluation and restoration of function is provided to patients who have lost function due to acute or chronic pain, musculoskeletal problems, stroke, or catastrophic events resulting in complete or partial paralysis.
Chronic Care Unit	IN:NONACUTE:LTC	Area where care provided for patients with chronic disease or disabilities for extended periods of time.
Ventilator Dependent Unit	IN:NONACUTE:LTC:R	Area where care is provided to patients whose respirations depend on the use of a ventilator for extended periods of time.
	Acute Care Facilities General
24-Hour Observation Area	OUT:ACUTE:WARD	Area where patients are monitored for suspected or non- life threatening conditions for 24 hours or less. More than 50% of patients in this location must be outpatients who are not expected to be admitted to an inpatient unit.
Emergency Department	OUT:ACUTE:ED	Area that provides emergency medical services; top priority is given to those with life-threatening illness or injury.
	Facility-Wide Locations
Facility-wide Inpatient (FacWideIN)	FACWIDEIN	Facility-wide Inpatient (FacWIDEIn)
Facility-wide Outpatient (FacWideOUT)	FACWIDEOUT	Facility-wide Outpatient (FacWIDEOut)

---

Sheet 4: FY2022 Submission Instructions

USER GUIDE AND SUBMISSION INSTRUCTIONS

--->

The FY 2022 Validation Template User Guide and Submission Instructions, along with supporting documentation, can be found on QualityNet.

To access, select [Hospitals–Inpatient], and then [Data Management], followed by [Chart-Abstracted Data Validation], and lastly [Resources]:

https://www.qualitynet.org/inpatient/data-management/chart-abstracted-data-validation/resources

The only acceptable method of sending Validation Templates is through the QualityNet Secure Portal Secure File Transfer Mailbox.

Validation Templates contain Protected Health Information (PHI) and cannot be sent via personal email -- even if a template were sent encrypted from a secure

workplace email, it would still be considered a security violation.

It is recommended to submit Validation Templates at least a week prior to the submission deadline in case there are difficulties with

transmitting files and to allow time for revisions/corrections when necessary.

If you are unable to log in to the Secure Portal, the first person to contact is your hospital's QualityNet Security Administrator.

If your Security Administrator is unable to reestablish your access, you will need to contact the QualityNet HelpDesk at (866) 288-8912.

It is recommended hospitals have two QualityNet Security Administrators at all times to ensure the ability to upload Validation

Templates by the established submission deadlines.

TEMPLATE COMPLETION & SUBMISSION TIPS

Prior to submitting Validation Templates to CMS, it is recommended that quality assurance is performed on the data within the template.

Review the [Definitions] tab to ensure correct information is entered in each field.

ü

Do not add, delete, rename, or change the order of the tabs.

ü

Do not add, delete, or rename column headings.

ü

Do not leave the first row blank or skip rows between patient data.

ü

Make sure the Provider ID/CCN field is exactly 6 numeric characters (do not add a hyphen)

ü

Make sure the State field contains the 2 character abbreviation for your state, not the full state name.

ü

Verify the Calendar Quarter listed on each Validation Template is correct.

ü

Review all dates for accuracy and correct format as specified on the [Definitions] tab.

ü

If a patient has not been discharged from the hospital, enter ‘Not Discharged’ for the Discharge Date field.

ü

The 'Blood cultures positive for MRSA' column cannot include rows listing both "Yes" and "No"; entering "No" indicates no positive cultures for the quarter.

ü

Ensure all NHSN locations are within the approved NHSN drop down on the template. Hospital-assigned locations will not be accepted.

ü

Be sure to populate all required fields on each consecutive row if there were multiple final positive cultures collected for the same patient.

ü

Perform quality check of data entered into this template against what was entered into NHSN; stay mindful of differing CMS and NHSN deadlines.

ü

Check to ensure any cases with a separate Inpatient Rehabilitation Facility (IRF) or Inpatient Psychiatric Facility (IPF) CCN are not included on the template.

ü

Append the file name with the 6-digit CMS Certification Number (CCN)/Provider ID, followed by an underscore and the quarter.

For example: 012345_3QYY_FYXX_MRSA_ValTemp.xlsx

• When submitting templates via the [Compose Mail] button under the Mailbox section on the Secure File Transfer screen, input the subject of the message

with the 6-digit CCN/Provider ID, Submission Quarter, and Template type(s) attached.

For example: CCN 012345 3QYY MRSA & CDI Validation Templates

• When choosing recipients, do NOT select any individual person(s) from the recipient list; only select the "VALIDATION CONTRACTOR" recipient.

Individual accounts are not regularly monitored—sending to any one individual risks delay in processing.

• As soon as the Validation Support Contractor has downloaded the template(s), Secure File Transfer will deliver an automatic email letting the submitter

know the file has been downloaded. After a file has been downloaded, it will be in the queue for processing.

• It is suggested that users verify a message has been sent by clicking on the [Sent] link under the Mailbox section of the Secure File Transfer screen.

The message should be in your Sent folder with a status of "Received".

NOTE: It typically takes a couple minutes for messages to appear in the Sent folder with a "Received" status. Please, do NOT re-send messages

multiple times, as this significantly delays processing and requires version confirmation.

• You will receive email confirmation (usually within 2 business days of being downloaded) from the Validation Support Contractor letting you know the Validation

Templates were processed. If you do not receive a processing confirmation, please include your hospital's 6-digit CCN/Provider ID in an

email to

[email protected]