CMS: Relief from QIP Reporting

On March 22, 2020 CMS announced relief from QIP-related reporting requirements for CROWNWeb and the ESRD QIP.   Find the full CMS press release at https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting.  An excerpt follows:

“CMS will not count data from January 1, 2020 through June 30, 2020 (Q1-Q2) for performance or payment programs.  Data does not need to be submitted to CMS for this time period…  No data reflecting services provided January 1, 2020 through June 30, 2020 will be used in CMS’s calculations for the Medicare quality reporting… programs.  This is being done to reduce the data collection and reporting burden on providers responding to the COVID-19 pandemic.”

CMS published an additional bulletin on March 27, https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf, with ESRD information on pp.9-10.  This bulletin clarifies the original and includes new information on NHSN QIP relief, and information on opting out of the relief:

“Dialysis facilities should be aware of the potential subsequent impact to a facility’s total performance score (TPS) when data are excluded from score calculations.  Facilities impacted by COVID-19 may elect to opt out of the CMS granted exception by emailing the request to the ESRD QIP at esrdqip@cms.hhs.gov.  The email must be sent by the dialysis facility’s chief executive officer (CEO) or designee.  We are requesting that a dialysis facility make this request within 90 days of March 22, 2020.  For further assistance regarding the ESRD QIP information contained in this message, please contact the ESRD QIP at esrdqip@cms.hhs.gov.”

3/26 ASN Webinar on CDC COVID-19 Updates

ASN will present a March 26, 2020 webinar on COVID-19: CDC Recommendations and Policy Updates for Current Challenges in the Dialysis Setting.  Topics will include personal protective equipment, discontinuation of isolation, variation in interpretation by states and potential lack of uniform application of CDC recommendations, patient transportation challenges, telemedicine waivers, and QIP waivers.  Find more information and register at https://register.gotowebinar.com/register/6032221362410158859.

You can find a recording of ASN’s March 11, 2020 webinar on COVID-19 Information for Providers of Dialysis Services at https://www.asn-online.org/ntds/resources/Webcast_2020_03_11_COVID-19.mp4.

3/17+ CROWNWeb March Newsletter

The March CROWNWeb Newsletter has been published, with articles on the 2744 Annual Facility Survey, 2744 Errors and Reports, Guidance for Submission of CMS-2728/CMS-2746, HARP Account Needed for EQRS Users, EQRS System Deadline Updates, and Clinical Closures, plus the usual collection of very useful links and notes.  Find the Newsletter at https://mycrownweb.org/2020/02/march-2020-newsletter/.  Noteworthy dates include:

* Your Network may require earlier Closure.

3/2+ EQRS/QIP Deadline Extended to March 16

CMS is extending the March 2, 2020 deadline till March 16, 2020 (11:59 pm PST) for submission to EQRS of the following QIP and Clinical data:

  • ICH CAHPS Attestation.
  • Clinical Depression Screening and Follow-Up Plan.
  • December 2019 Clinical Data Submissions.

The extension applies only to the March 2020 data submission, and will have no effect on other due dates.  Facilities are encouraged to complete their HARP registration as soon as possible, as HARP is now the mandatory gateway to EQRS.  HARP training materials, Quick Start Guides, FAQs, and instructional videos can be found https://mycrownweb.org/harp-training/.  The QualityNet Service Desk at qnetsupport-esrd@hcqis.org or 1-866-288-8912 can provide assistance and answer questions.

2/21+ EQRS and HARP

The EQRS End-Stage Renal Disease Quality Reporting System will be unavailable due to system maintenance from 5pm PST on February 21, 2020 until 5am PST on February 24, 2020.  Effective February 24, 2020, HARP (HCQIS Access Role and Profile) credentials will be required to access EQRS.  Access EQRS at https://eqrs.cms.gov/globalapp.  HARP resources including training materials, Quick Start Guides, Frequently Asked Questions, and instructional videos can be found at https://mycrownweb.org/harp-training/.  The QualityNet Service Desk is available to provide assistance and answer questions, via email at qnetsupport-esrd@hcqis.org or telephone at 1-866-288-8912.

NHSN 2020 News and Deadlines

Current NHSN Dialysis Component BugsContrary to the software’s response, Denominator Data is not actually saved after making updates.  CMS analysis reports within NHSN are not functioning as expected.  On February 11, 2020, NHSN reported that “our technical team is working to resolve [these issues] as soon as possible.  We will provide an update shortly.”  Find the NHSN Current Defects List at https://www.cdc.gov/nhsn/releasemgt/index.html.

The 2020 Outpatient Dialysis Center Practices SurveyBeginning February 8, 2020, users with administrative rights will be able to complete and save this survey by using the ‘Save as Complete’ button.  Facilities must complete the Outpatient Dialysis Center Practices Survey by May 1, 2020 in order to be allowed to enter data into the NHSN Dialysis Component.  Completion by February 28 is recommended.  For convenience, a paper version of the 2020 annual survey can be found at https://www.cdc.gov/nhsn/forms/57.500_OutpatientDialysisSurv_BLANK.pdf.  Enter the information online after you log in to NHSN for your facility.

2020 NHSN Data Deadlines for QIP Credit:  To receive QIP credit, NHSN data for your facility must be entered and corrected by the deadlines in the following table.  For QIA purposes, your Network may require earlier due dates.
  • Data for October-December 2019 must be entered and corrected by March 31, 2020.
  • Data for January-March 2020 must be entered and corrected by June 30, 2020.
  • Data for April-June 2020 must be entered and corrected by September 30, 2020.
  • Data for July-September 2020 must be entered and corrected by December 31, 2020.

Before each QIP deadline, to insure proper credit, each facility should:

Paper versions of all NHSN forms can be found under the ‘Data Collection Forms’ section of https://www.cdc.gov/nhsn/dialysis/event/index.html.  For complete NHSN Dialysis Component specifications, see https://www.cdc.gov/nhsn/dialysis/event/index.html.

CW January New User Training, Newsletter

CROWNWeb has published their January Newsletter, at https://mycrownweb.org/2020/01/january-2020-newsletter/.  It includes articles on

  • Medication Reconciliation and its January 9 and 23, 2020 training sessions
  • PY2020 PSRs and PSCs (see also https://nwrnbulletins.wordpress.com/2019/12/03/py2020-qip-final-psr-and-psc-released/)
  • ICH CAHPS CY2019 exemption attestation (deadline March 2, 2020)
  • CY2020 Clinical Depression Screening requirements
  • January 16, 2020 training for ICH CAHPS and Depression Screening reporting requirements
  • Clinical data submission deadlines (if your Network doesn’t require earlier submission)

Plus announcement of the January 21, 2020 New User Training, and the usual lists of always-useful resources and links.

Find information and register for the January 30, 2020 CROWNWeb Town Hall on signing up for HCQIS HARP at https://mycrownweb.org/pcw_community_events/january-2020-town-hall/.