Quality Measures and Administrative Procedures for the Hospital-Acquired Condition Reduction Program (CMS-10668)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10668 CMS Hospital-Acquired Condition (HAC) Reduction Program Validation Review for Reconsideration Request	Form and Instruction	Unchanged	Available
Form CMS-10668 Measure Exception Form for Healthcare-Associated Infection (HAI) Data	Form and Instruction	Unchanged	Available
Form CMS-10668 MRSA Validation Template	Form and Instruction	Unchanged	Available
Form CMS-10668 CLABSI Validation Template	Form and Instruction	Unchanged	Available
Form CMS-10668 CDI Validation Template	Form and Instruction	Unchanged	Available
Form CMS-10668 Cauti Validation Template	Form and Instruction	Unchanged	Available
Form CMS-10668 Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction	Unchanged	Available
CMS-10668 HACRP FY 2025 FR Supporting Statement B 8-28-24.docx	Supporting Statement B	Uploaded 2024-08-29	Repair queued
CMS-10668 HACRP FY 2025 FR Supporting Statement B 8-28-24.docx	Supporting Statement B	Uploaded 2024-08-29	Repair queued
CMS-10668 HACRP FY 2025 Supporting Statement A 8-28-24.docx	Supporting Statement A	Uploaded 2024-08-29	Available
CMS-10668 HACRP FY 2025 Supporting Statement A 8-28-24.docx	Supporting Statement A	Uploaded 2024-08-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
231482	Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction	Unchanged	CMS Hospital-Acquired Condition (HAC) Reduction Program Validation Review for Reconsideration Request
231482	Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction	Unchanged	Measure Exception Form for Healthcare-Associated Infection (HAI) Data
231482	Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction	Unchanged	MRSA Validation Template
231482	Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction	Unchanged	CLABSI Validation Template
231482	Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction	Unchanged	CDI Validation Template
231482	Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction	Unchanged	Cauti Validation Template
231482	Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0938-1352	ICR Reference No: 202408-0938-031
Status: Historical Active	Previous ICR Reference No: 202405-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Quality Measures and Administrative Procedures for the Hospital-Acquired Condition Reduction Program (CMS-10668)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/21/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/29/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2027	36 Months From Approved	11/30/2025
Responses	640	0	400
Time Burden (Hours)	28,840	0	28,800
Cost Burden (Dollars)	0	0	0

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Abstract: The Hospital-Acquired Condition (HAC) Reduction Program is established by section 1886(p) of the Social Security Act, as added by Section 3008 of the Affordable Care Act (Pub. L. 111-148), and requires the Secretary to reduce payments to subsection (d) hospitals in the worst-performing quartile of all subsection (d) hospitals by 1 percent effective beginning on October 1, 2014 and subsequent years. In the FY 2025 IPPS/LTCH PPS final rule, we are not adopting or removing any measures for the FY 2025 program year or subsequent years. For the FY 2025 program year and subsequent years, we are accounting for the burden associated with submission of the Measure Exception Form for NHSN HAI Data Submission under this OMB control number (0938-1352) instead of OMB control number 0938-1022.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3008 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3008 Name of Law: Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV34	Final or interim final rulemaking	89 FR 68986	08/28/2024

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	CMS-10668, CMS-10668, CMS-10668, CMS-10668, CMS-10668, CMS-10668	Cauti Validation Template ,   CDI Validation Template ,   CLABSI Validation Template ,   MRSA Validation Template ,   Measure Exception Form for Healthcare-Associated Infection (HAI) Data ,   CMS Hospital-Acquired Condition (HAC) Reduction Program Validation Review for Reconsideration Request

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	640	400	0	240	0	0
Annual Time Burden (Hours)	28,840	28,800	0	40	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We previously requested and received approval for total annual burden estimates under this OMB control number for the FY 2025 program year of 28,800 hours at a total cost of $1,221,120. Accounting for updated wage rates, the total cost increases to $1,501,056 as shown in Table 2, a difference of $279,936. While we are updating wage rates, we are not finalizing any policies in the FY 2025 IPPS/LTCH PPS final rule which result in a change to our estimated burden. However, we are accounting for the burden of 40 hours at a cost of $2,085 associated with completion of the Measure Exception Form. In aggregate, we estimate a total increase of 40 hours and $282,021 ($279,936 + $2,085). The burden hours are now 28,840 (28,800 hours + 40 hours).

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Annual Cost to Federal Government: $7,760,700

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/29/2024

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