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

Forms and Documents

Document	Type	Status	Availability
Form CMS-10668 CMS Hospital-Acquired Condition (HAC) Reduction Program Validation Review for Reconsideration Request	Form and Instruction	Modified	Repair queued
Form CMS-10668 Measure Exception Form for Healthcare-Associated Infection (HAI) Data	Form and Instruction	Modified	Available
Form CMS-10668 MRSA Validation Template	Form and Instruction	Modified	Available
Form CMS-10668 CLABSI Validation Template	Form and Instruction	Modified	Available
Form CMS-10668 CDI Validation Template	Form and Instruction	Modified	Available
Form CMS-10668 Cauti Validation Template	Form and Instruction	Modified	Available
Form CMS-10668 Hospital-Acquired Condition Reduction Program-NHSN HAI Measures Validation	Form and Instruction	Modified	Available
CMS-10668 HACRP-FY2026-Supporting Stmt-B_5-9-25.docx	Supporting Statement B	Uploaded 2025-06-16	Repair queued
CMS-10668 HACRP-FY2026-Supporting Stmt-B_5-9-25.docx	Supporting Statement B	Uploaded 2025-06-16	Repair queued
CMS-10668 HACRP-FY2026-Supporting Statement Stmt-A_5-9-25.docx	Supporting Statement A	Uploaded 2025-06-16	Repair queued
CMS-10668 HACRP-FY2026-Supporting Statement Stmt-A_5-9-25.docx	Supporting Statement A	Uploaded 2025-06-16	Available

IC Document Collections

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

ICR Details

OMB Control No: 0938-1352	ICR Reference No: 202506-0938-002
Status: Historical Inactive	Previous ICR Reference No: 202408-0938-031
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: Comment filed on proposed rule and continue	Conclusion Date: 07/18/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/17/2025
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

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

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Abstract: The HAC Reduction Program is established by section 1886(p) of the Social Security Act 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 2026 IPPS/LTCH PPS proposed rule, we are not proposing to adopt or remove any measures for the FY 2026 program year or subsequent years, we propose updates to the ECE policy.

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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-AV45	Proposed rulemaking	90 FR 18002	04/30/2025

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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

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $7,766,483

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: 06/17/2025

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