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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
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We did not receive any public comments on this proposal.
We are finalizing our proposal to replace the term Quality Net system administrator with QualityNet security official as proposed.
Additionally, we proposed to no longer require IPFs to maintain an active QualityNet security official account to qualify for payment. As we reviewed the requirements for the security official role and the basic user 165 role to identify the most appropriate language to describe the distinguishing authority invested in the security official role, we recognized that the QualityNet security official is not required for submitting dataa basic user can serve in this rolebut remains necessary to set up QualityNet basic user accounts and for security purposes. Therefore, consistent with adopting the security official term to differentiate the unique security authority and responsibilities of the role from the data submission responsibilities of the basic user role, we would continue to require a QualityNet basic user account to meet IPFQR Program requirements, including data submission and administrative requirements, while recommending, but not requiring, that hospitals maintain an active QualityNet security official account.
We welcomed public comments on our proposal to no longer require facilities to maintain an active QualityNet security official account to qualify for payment.
We received the following comments in response to our proposal.
Comment: Many commenters supported removal of the requirement to have an active QualityNet Security Official for the complete year to meet IPFQR Program requirements and therefore be eligible to receive a full payment update.
Response: We thank these commenters for their support. We note that IPFs that do not meet all IPFQR
Program requirements must receive a 2
percent reduction to their annual payment update.
After review of the public comments received, we are finalizing our proposal to no longer require facilities to maintain an active QualityNet security 165 We also noted that a basic user is a QualityNet user who 1 does not have the registration access described for security officials, 2 has the appropriate data entry roles and permissions for program participation, 3 can submit and review measures and non-measure data, 4 signs and submits the Data Accuracy Completeness Acknowledgement DACA form, and 5 refreshes their QualityNet account password every 180 days to ensure that the facilitys IPFQR Program Notice of Participation status is Participating.

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official account to qualify for payment as proposed.
b. Updated Reference to QualityNet Administrator in Code of Federal Regulations We proposed to revise our regulation at 412.434b3 by replacing QualityNet system administrator with QualityNet security official. The term QualityNet security official refers to the individuals who have responsibilities for security and account management requirements for a hospitals QualityNet account. To clarify, this update in terminology would not change the individuals responsibilities or add burden. The revised paragraph b3 reads: Contact information for the inpatient psychiatric facilitys chief executive officer and QualityNet security official, including each individuals name, email address, telephone number, and physical mailing address.
We invited public comment on our proposal to replace the term QualityNet system administrator with QualityNet security official at 412.434b3.
We did not receive any public comments in response to our proposal.
We are finalizing our proposal to no longer require facilities to replace the term QualityNet system administrator with QualityNet security official at 412.434b3 as proposed.
2. Data Submission Requirements We refer readers to the FY 2013 IPPS/
LTCH PPS final rule 77 FR 53655
through 53657, the FY 2014 IPPS/LTCH
PPS final rule 78 FR 50899 through 50900, and the FY 2018 IPPS/LTCH
PPS final rule 82 FR 38472 through 38473 for our previously finalized data submission requirements. In this final rule, we are finalizing our proposal to adopt one measure for the FY 2023
payment determination and subsequent years and one measure for the FY 2024
payment determination and subsequent years. Data submission requirements for each of these measures are described in the following subsections. Additionally, we are finalizing our proposal to adopt patient level data submission for certain chart abstracted measures beginning with data submitted for the FY 2023
payment determination and subsequent years; details of this proposal are in subsection c. of this section.
a. Data Submission Requirements for FY
2023 Payment Determination and Subsequent Years The measure we are finalizing for FY
2023 payment determination and subsequent years the COVID19

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Vaccination Coverage Among HCP
measure requires facilities to report data on the number of HCP who have received completed vaccination course of a COVID19 vaccine through the CDCs National Healthcare Safety Network NHSN. Specific details on data submission for this measure can be found in the CDCs Overview of the Healthcare Safety Component, available at https www.cdc.gov/nhsn/PDFs/
slides/NHSN-Overview-HPS_
Aug2012.pdf. For each CMS
Certification Number CCN, a percentage of the HCP who received a completed vaccine course of the COVID19 vaccination would be calculated and publicly reported, so that the public would know what percentage of the HCP have been vaccinated in each IPF.
For the COVID19 HCP Vaccination measure, we proposed that facilities would report the numerator and denominator for the COVID19 HCP
vaccination measure to the NHSN for at least one week each month, beginning in October 2021 for the October 1, 2021
through December 31, 2021 reporting period affecting the FY 2023 payment determination. If facilities report more than one week of data in a month, the most recent weeks data would be used to calculate the measure. Each quarter, the CDC would calculate a single quarterly result of COVID19
vaccination coverage which would summarize the data submitted by IPFs for each of the three weeks of data submitted over the three-month period.
CMS will publicly report the CDCs quarterly summary of COVID19
vaccination coverage for IPFs.
We invited public comment on our proposal to require facilities to report the COVID19 HCP vaccination measure.
We did not receive any comments in response to our proposal.
We are finalizing our proposal to require facilities to report the COVID19
HCP vaccination measure as proposed.
b. Data Submission Requirements for FY
2024 Payment Determination and Subsequent Years Because the Follow-Up After Psychiatric Hospitalization FAPH
measure would be calculated by CMS
using Medicare Fee-for-Service claims, there will be no additional data submission requirements for the FY
2024 payment determination and subsequent years. Therefore, we did not propose any changes to our data submission policies associated with the proposal to adopt this measure.

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