In this Issue:

New EQRS User Trainings

Recent EQRS Updates

Social Drivers of Health (SDOH) Patient Screening

ESRD Data Submission Deadlines

Check out the education page on MyCROWNWeb.org for the following updated video trainings:

• Manage Access
• Facility Dashboard Overview
• Set Default Preferences
• Medical Personnel
• Facility Contacts
• Admit a Patient
• View and Edit Patient Details

The Centers for Medicare & Medicaid Services (CMS) adopted the FCHE reporting measure as part of the payment year (PY) 2026 ESRD QIP measure set. As of January 1, 2024, facilities can attest to their commitment to advancing health equity across five domains. These domains include Equity is a Strategic Priority, Data Collection, Data Analysis, Quality Improvement, and Leadership Engagement. The elements within each of the five domains require an affirmative attestation for the facility to receive points for each domain. The attestations are due on March 3, 2025, at 11:59 p.m. PT for the calendar year (CY) 2024 period of assessment. For more information on the ESRD QIP FCHE reporting measure, please see the ESRD Measures Manual v9.1.

The 2023 versions of the Forms CMS-2728 and CMS-2746 were released in EQRS on October 1, 2024. Training was provided at the September EQRS Monthly Stakeholder Webinar on September 17, 2024. Additional information, including Slides and a recording of the webinar are now available at Educational Resources | My CROWN Web.

The CMS released the final ESRD QIP PSRs, PSCs, and Patient List Reports (PLRs) on November 6, 2024.  Authorized facility staff can log in to view and download these documents.  Facilities are required to display both the English and Spanish version of their PSC in a prominent patient location within the facility by November 27, 2024, which is 15 business days after they are available.  PSCs must remain posted throughout CY 2024, until next year’s PSCs are available.

Each facility should save an electronic copy of their Final PSR and PSC for reference, reprinting, and reposting throughout the year, if needed.  Final reports can be accessed via the ESRD QIP user interface (UI) in EQRS.  For instructions on how to access the ESRD QIP UI, refer to the PY 2025 ESRD QIP UI Quick Start Guide.  For additional information about the PSR, refer to the PY 2025 Guide to the ESRD QIP Performance Score Report.  Both resources are available for download from the QualityNet website: https://qualitynet.cms.gov/esrd/esrdqip/reports.

The Medical Personnel Module has replaced the previous Personnel module on the Facility page in EQRS.  The new module will only contain medical professional with valid National Provider Identifier (NPI) numbers.  Please see EQRS News Flash: Medical Personnel & Addition of Facility Contacts | My CROWN Web for more information.

The facility contacts section of the Facility page in EQRS now requires the entry of key dialysis facility staff.  In this section, CMS requires facilities to provide contact information for three specific positions including: Primary Facility Contact, Disaster Contact and Disaster Contact back-up.  For more information, please see EQRS News Flash: Medical Personnel & Addition of Facility Contacts | My CROWN Web.

Please visit the Events page to remain informed about developments related to EQRS and topics that will be covered in our Monthly EQRS Stakeholder Webinars. These monthly webinars will provide EQRS users with the latest updates as well as offer EQRS users the opportunity to engage in live Q&A sessions with EQRS experts.

Coming Soon in EQRS

January 1, 2025

To submit your patient’s SDOH screening:

1.     Log in to EQRS

2.     Click Social Drivers of Health (SDOH) Patient Screening

3.     Select the Assessment Period

4.    Click Enter Screening Data for each patient that has a Not Submitted screening status

5.     Answer whether the patient has been screened for the SDOH factors during the assessment period

6.     If the patient has not been screened, select the reason that the patient was not screened during the assessment period

7.   If the patient was screened during the assessment period, indicate Yes or No for each SDOH Factor

8.     Submit Screening

Remaining EQRS & NHSN Data Submission Deadlines for CY 2024

Dialysis facilities must submit ESRD data by the deadlines listed below. Failure to submit the required data by these deadlines puts your facility at risk for an ESRD QIP payment reduction. Please note that if the last day of the month falls on a Friday, Saturday, Sunday, or federal holiday, the deadline will occur on the next federal business day. The data submission deadlines apply to all collection types (Hemodialysis and Peritoneal Dialysis) and to all submission methods. CMS strongly recommends that facilities complete large data submissions and audit batch submitted data prior to data submission deadlines.

EQRS Clinical Data

Clinical Depression Screening, Follow-up Assessments, ICH CAHPS Facility Attestation, & Commitment to Health Equity Attestation

NHSN Deadlines for 2024 ESRD Data

(BSI in Hemodialysis Patients, Dialysis Event Reporting, & COVID-19 Vaccination Coverage Among Healthcare Personnel)

For assistance with EQRS technical issues, please contact the Center for Clinical Standards and Quality (CCSQ) Service Center. The CCSQ Service Center is open Monday-Friday 8 AM to 8 PM Eastern Time and can be reached via phone at 866-288-8912, email at qnetsupport-esrd@cms.hhs.gov or online at the CCSQ Support Center.

For assistance with general EQRS and ESRD QIP questions, please contact the ESRD QIP Team via the QualityNet Q&A Tool.

Thank you,

The ESRD Quality Program Support (QPS)Team

Website: https://www.MyCROWNWeb.org