CMS-10210 Data Accuracy and Completeness Form

Hospital Reporting Initiative--Hospital Quality Measures (CMS-10210)

2. Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA)_vFINAL(508)ff

OMB: 0938-1022

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Hospital Quality Reporting
Data Accuracy and Completeness Acknowledgement (DACA) Text
Please Note: A data collection tool available within the Hospital Quality Reporting system via
the Hospital Quality Reporting 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 to the Centers for Medicare & Medicaid Services (CMS) is accurate and complete. This
information includes the following:
• Clinical chart-abstracted measure
• 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
• COVID-19 Vaccination Coverage for Healthcare Providers (HCP COVID-19) reported
using NHSN
• Web-based measure
• Structural measures
• Electronic clinical quality measures (eCQMs)
• Electronic health record core clinical data elements for hybrid measures
• Current Notice of Participation
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, for annual
payment updates under the Hospital Inpatient Quality Reporting Program, and for value-based
payment adjustments under the Hospital-Acquired Condition Reduction Program and the
Hospital Value-Based Purchasing Program.
I understand this acknowledgement covers all inpatient hospital information reported by this
hospital (and any data or survey information reported by any vendors acting as agents on behalf
of this hospital) to CMS and its contractors.

[ ] Yes, I Acknowledge.
Name __________________________________________
Position ________________________________________
Date ___________________________________________
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Baltimore, MD 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or
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January 2023

Hospital Quality Reporting
Data Accuracy and Completeness Acknowledgement (DACA) Text
submit your documents, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education
Support Contractor at (844) 472-4477.

January 2023


File Typeapplication/pdf
File TitleData Accuracy and Completeness Acknowledgement
Subject2023, Data Accuracy and Completeness Acknowledgement
AuthorCMS
File Modified2023-06-12
File Created2023-06-12

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