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Participation in the Joint Commission NHSN Group is optional for CAHs. CAHs may participate in other programs for which they submit the HAI measures. For example, the HAI measures are optional in MBQIP, a CMS CAH quality improvement program. https://www.ruralcenter.org/sites/default/files/2023-02/MBQIP-Measures.pdf

CAHs are technically not required to report the IQR NHSN measures because they are not paid under the Inpatient Prospective Payment System.

No; Exempt programs as indicated on the CY2024 ORYX Performance Measurement Requirements are currently excluded from NHSN participation requirement.

Per CMS' “Hospital-Acquired Condition Reduction Program Frequently Asked Questions Fiscal Year 2024” regarding program eligibility:

INCLUDES:

• General acute care hospitals paid under the Inpatient Prospective Payment System (IPPS)

EXCLUDES:

• Critical access hospitals

• Rehabilitation hospitals and units

• Long-term care hospitals (LTCH)

• Psychiatric hospitals and units

• Children’s hospitals

• Prospective Payment System (PPS)-exempt cancer hospitals

• Veterans Affairs hospitals

• Short-term acute care hospitals in U.S. territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands)

• Religious nonmedical health care institutions