Inpatient Rehabilitation Facilities – October 2012

The CMS PPS FY2012 rule includes a provision that inpatient rehabilitation facilities (IRFs) are to report CAUTIs from all inpatient locations.

To meet the specifications within this ruling, some changes have been made to NHSN to accurately collect the required data and allow for correct risk-adjustment for comparison purposes. These changes include development of a new annual facility survey that is specific to IRFs, identification and enrollment of new facilities that are currently defined as single locations within an acute care facility type, creation of new locations that are unique to IRFs, and removal of all acute care facility inpatient location choices from the IRF facility types.

Licensed IRFs who are free-standing facilities or have a CCN (CMS Certification Number) with the last four digits being between 3025-3099, should enroll in NHSN as a separate facility (i.e., have a unique NHSN orgID). During enrollment they should identify themselves as a “HOSP-REHAB” facility type, complete their annual facility survey, and accurately enter their CMS certification number (CCN) when it is requested during enrollment or by entering it on the Facility Information screen after enrollment.

Each CMS IRF unit within a hospital (3rd digit of the Medicare CCN provider number either a “T” or an “R”) will need to be set up as an Inpatient Rehabilitation Ward location within an enrolled acute care or critical access facility type. Set up of this location and reporting of CAUTIs can begin at any time. In mid-April 2012, NHSN will be modified to include additional questions required for licensed IRF units within hospitals to be identified appropriately for CMS reporting purposes. On the Location set-up screen, Inpatient Rehabilitation Ward locations will be asked to appropriately identify as a CMS IRF unit within a hospital, and provide a valid IRF CCN. After a location is identified as a CMS IRF unit within a hospital, additional patient population demographic information will be required (subset of questions on the IRF Annual Survey), so that reported data can be accurately risk adjusted.

The NHSN team will be reviewing rehabilitation locations that are currently defined in the system in acute care and critical access facilities, and will be contacting those facilities to assist where possible, with the switch from being defined as a single location to becoming enrolled as a separate facility if applicable.

Updated IRF Locations in NHSN [PDF - 2.79 MB] May 2012

Operational Guidance for Inpatient Rehabilitation Facilities

• Operational Guidance for Inpatient Rehabilitation Facilities to Report Catheter-Associated Urinary Tract Infection (CAUTI) Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s Quality Reporting Requirements [PDF - 108 KB] August 2012