CMS-10432 Data Accuracy and Completeness Acknowledgement (DACA)

Inpatient Psychiatric Facility Quality Reporting Program

Data Accuracy and Completeness Acknowledgement (DACA)

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.

The DACA is an annual requirement for providers participating in the Hospital IQR, IPFQR, and PCHQR Programs to electronically acknowledge that the data submitted to these programs by or on behalf of the providers are accurate and complete to the best of their knowledge.

Data Accuracy and Completeness Acknowledgement (DACA)

I acknowledge that to the best of my ability all of the information reported for the Inpatient Psychiatric Facility (IPF) Quality Reporting (IPFQR) Program, as required for the Fiscal Year 2028 IPFQR Program requirements is accurate and complete. This information includes the following:

• Aggregate data for all required measures

• Non-measure data

• Current Notice of Participation

I understand that the acknowledgement covers all IPFQR information reported by this inpatient psychiatric hospital or psychiatric unit (and any data vendor(s) acting as agents on behalf of this IPF) to CMS and its contractors for the FY 2028 payment determination year. To the best of my knowledge, 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.

I understand that this acknowledgement is required for purposes of meeting any Fiscal Year 2028 IPFQR Program requirements.

Position

Ex. Administrator, Director, etc.

I confirm that the information I have submitted is accurate and complete, to the best of my knowledge.

Cancel

Sign

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 0938-1171 (Expires XX/XX/XXXX). 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, MD 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 Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor at (844) 472-4477.