CMS released an Interim Final Rule May 1, 2020, which will require all Medicare and/or Medicaid-certified nursing homes to report information about COVID-19 at least weekly to the CDC Long-Term Care Facility Module in the National Healthcare Safety Network (NHSN). The requirement will be effective once published in the Federal Register. The new rule is expected to go into effect May 8, 2020 with a 2 week grace period provided to get registered and data uploaded.  Data older than May 8th is not required to be reported. Facilities must submit their first set of data by 11:59 p.m. Sunday, May 17, 2020.

As part of CDC’s ongoing COVID-19 response, the COVID-19 Module for Long Term Care Facilities (LTCF) has been created in NHSN to help LTCFs track and monitor the number of residents with suspected and laboratory positive COVID-19, staff and facility personnel impact, and supply availability. LTCFs eligible to report data into the module include skilled nursing facilities (SNF) / nursing homes (NH), long-term care for the developmentally disabled, and assisted living facilities. LTCFs that are not currently enrolled in NHSN will need to complete an expedited enrollment before reporting into the module will be available.

 

Electronically Report to CDC’s National Healthcare Safety Network (NHSN)

Enrollment:

If the facility is already enrolled in the National Healthcare Safety Network (NHSN), please do NOT re-enroll. LTCF’s that are currently enrolled in NHSN’s LTCF Component have immediate access to the new module and may begin reporting.  NOTE: in many cases registration is taking longer than expected and facilities are encouraged to start enrolling now to avoid further delays that may impact your compliance.

If your facility is enrolled and you need to change your NHSN Facility Administrator, submit the change here: https://www.cdc.gov/nhsn/facadmin/index.html

If your facility previously enrolled, but you are unable to access NHSN, please submit an e-mail to [email protected] for assistance. As part of enrollment, a NHSN Facility or Group Administrator must be identified.  This designated person will be the point of contact for receiving information from NHSN and other functions in the application including setting up rights within the app. Rights that may be granted include: Administrative, View data, Data entry, or Data analysis.  Administrative rights allows the user to also add locations, and other users. One person may hold multiple roles. *Only the NHSN Facility Administrator can reassign their role to another user. It is STRONGLY encouraged that facilities have at least one back-up person trained on the NHSN enrollment/data submission process.

A NHSN LTCF Contact Person must be provided to serve as the main point of contact between the CDC and the facility –note, this is often the same person as the NHSN Facility Administrator NHSN User.  Again, NHSN enrollment is required:

      • Actively enrolled NHSN facilities have access through NHSN home page
      • Non-NHSN LTCFs must complete online enrollment specifically for the LTC COVID-19 Module

 

Items Needed for Online Enrollment

LTCF COVID-19 Module Enrollment Steps

      • Step 1 –    Prepare your computer to interact with NHSN
      • Step 2A – Register Facility with NHSN
      • Step 2B – Register with SAMS (Security Access Management System)
      • Step 3 –   Complete the NHSN LTC Enrollment
      • Step 4 –   Electronically Accept the NHSN Agreement to Participate and Consent

After successfully completing enrollment, the NHSN Facility Administrator and Component Primary Contact (if different) will receive an NHSN email with instructions on how to electronically accept the NHSN Agreement to Participate and Consent. The consent form must be accepted by either the NHSN Facility Administer or the NHSN Primary Contact immediately to expedite access to NHSN for LTC reporting. Now you can begin LTC reporting in the COVID-19 Module.

 

Provider Reporting:

Electronically report information about COVID-19 on the CDC NHSN portal. The report to CDC must include, but is not limited to:

      • Suspected and confirmed COVID-19 infections among staff and residents including residents previously treated for COVID-19;
      • Total deaths and COVID-19 deaths among residents and staff;
      • PPE and hand hygiene supplies in the facility;
      • Ventilator capacity and supplies;
      • Resident beds and census;
      • Access to COVID-19 testing while the resident is in the facility;
      • Staffing shortages; and
      • Other information specified by the secretary

Provide all information specified.  Facilities must report on the portal at least weekly, but can report daily. This information will be posted publicly by CMS to support protecting the health and safety of residents, personnel, and the general public. In addition, providers must continue to comply with state and local reporting requirements for COVID-19.

 

Reporting Frequency for Facilities:

      • Daily reporting – Selected calendar date must reflect the date in which the responses and counts are collected and reported
      • Non-daily reporting – Selected calendar date must reflect the date in which data are being reported. Unless otherwise indicated, counts must include only new counts for the specific data element since the last time counts were entered in the NHSN LTCF COVID-19 module
      • Weekly reporting – Report on the same day of the week every week, if possible (but not required). Selected calendar date must reflect the date in which responses are being reported.  Unless otherwise indicated, counts must be reported as the total number of new counts since the last time counts were entered in the NHSN LTCF COVID-19 module
      • While daily reporting will provide the timeliest data to assist with COVID-19 emergency response efforts, retrospective reporting of counts for prior day(s) is encouraged if daily reporting is not feasible. At a minimum, facilities should enter data at least once a week.

The reporting module is made up of 4 separate reporting pathways:

      • Resident Impact and Facility Capacity
      • Staff and Personnel Impact
      • Supplies and Personal Protective Equipment
      • Ventilator Capacity and Supplies

Module questions include a combination of aggregate counts and check box responses. Users can opt to navigate to each pathway during one session or in different sessions. The module is designed to allow users the ability to SAVE incomplete data in one or all pathways, which means users do not have to complete data entry in one session, unless otherwise stated in the instructions. Resident and staff level information is not collected. Data may be entered on weekdays and weekends and at any time.

For each reporting pathway, an accompanying form and form instructions is available. It is Important for users to apply the accompanying instructions when entering responses in the COVID-19 module to ensure accuracy in the application of case definitions and criteria.

Each Monday, CMS will review the data submitted to assess if each facility submitted data at  least once in the previous seven days. The data pulled each Monday will also be used to update the data that is publicly reported.  CMS anticipates publicly posting CDC’s NHSN data (including facility names, number of COVID-19 suspected and confirmed cases, deaths, and other data as determined appropriate) weekly on Monday’s at https://data.cms.gov/ by the end of May.

 

Failure to Report:

This forthcoming rulemaking will provide further clarification, but failure to timely report resident or staff incidences of infection could result in enforcement actions being taken by CMS against the nursing home.

Surveyors will cite facilities for not submitting complete data through the NHSN system in accordance with the new reporting requirements.

Updates to the COVID-19 Focused Survey for Nursing Homes include 2 new deficiency tags:

      • F884: COVID-19 Reporting to CDC – Review for F884 will be conducted offsite by CMS Federal surveyors (state surveyors should not cite this F-tag). Following an initial reporting grace period granted to facilities, CMS will receive the CDC NHSN COVID-19 reported data and review for timely and complete reporting of all data elements. Facilities identified as not reporting will receive a deficiency citation at F884 on the CMS-2567 with a scope and severity level at an F (no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy [IJ] and that is widespread; this is a systemic failure with the potential to affect a large portion or all of the residents or employees), and be subject to an enforcement remedy imposed as described below.
      • F885: COVID-19 Reporting to Residents, their Representatives, and Families – Review for F885 is included in the “COVID-19 Focused Survey Protocol” and will occur onsite by State and/or Federal surveyors. If the survey finds noncompliance with this requirement, a deficiency citation at this tag will be recorded on the CMS-2567 and enforcement actions will follow the memo QSO-20-20-All. There are a variety of ways that facilities can meet this requirement, such as informing families and representatives through email listservs, website postings, paper notification, and/or recorded telephone messages. We do not expect facilities to make individual telephone calls to each resident’s family or responsible party to inform them that a resident in the facility has laboratory-confirmed COVID-19. However, it is expected that facilities take reasonable efforts to make it easy for residents, their representatives, and families to obtain the information facilities are required to provide. In addition, when the State Survey Agency is planning to conduct these surveys, the COVID-19 Focused Survey should be coded in the Automated Survey Process Environment (ASPEN) under “Survey Type” as U=COVID-19. If the survey is taking place with an IJ complaint investigation, the survey should be coded in ASPEN under “Survey Type” as A=complaint and U=COVID-19. This will help ensure consistent, accurate reporting.

 

Enforcement for F884 – A determination that a facility failed to comply with the requirement to report COVID-19 related information to the CDC pursuant to §483.80(g)(1)-(2) (tag F884) will result in an enforcement action. These regulations require a minimum of weekly reporting, and noncompliance with this requirement will receive a deficiency citation and result in a civil money penalty (CMP) imposition. CMS will provide facilities with an initial two-week grace period to begin reporting cases in the NHSN system (which ends at 11:59 p.m. on May 24, 2020). Facilities that fail to begin reporting after the third week (by 11:59 p.m. on May 31st) will receive a warning letter reminding them to begin reporting the required information to CDC. For facilities that have not started reporting in the NHSN system by 11:59 p.m. on June 7th, ending the fourth week of reporting, CMS will impose a per day (PD) CMP of $1,000 for one day for the failure to report that week. For each subsequent week that the facility fails to submit the required report, the noncompliance will result in an additional one day PD CMP imposed at an amount increased by $500. For example, if a facility fails to report in week four (following the two week grace period and receipt of the warning letter), it will be imposed a $1,000 one-day PD CMP for that week. If it fails to report again in week five, the noncompliance will lead to the imposition of another one-day PD CMP in the amount of $1,500 for that failure to report (for a CMP total of $2,500). In this example, if the facility complies with the reporting requirements and submits the required report in week six, but then subsequently fails to report as required in week seven, a one-day PD CMP amount of $2,000 will be imposed (which is $500 more than the last imposed PD CMP amount) for a total of $4,500 imposed CMPs. For enforcement-related questions, please email: [email protected]

 

Survey Tools

Updated survey tools are posted including COVID-19 Focused Survey for Nursing Homes, Entrance Conference Worksheet, COVID-19 Focused Survey Protocol, and Summary of the COVID-19 Focused Survey for Nursing Homes. These updated forms are posted to the Survey Resources folder in the COVID-19 Focused Survey sub-folder on the CMS Nursing Homes website.  Facilities should begin using the revised “COVID-19 Focused Survey for Nursing Homes” to perform their self-assessment.  Surveyors will begin using these revised documents immediately.

 

New Reporting Requirement for Reporting Facility COVID-19 Status to Residents, Families & Staff :

The Interim Final Rule also adds a new provision, which requires facilities to inform residents, their representatives and families of residents of confirmed or suspected COVID-19 cases among residents and staff in the facility.

 

Triggering a report to residents, families & staff

New reporting is triggered either by 1) a single confirmed infection of COVID-19 or 2) three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Facilities must report such occurrences at least weekly by 5 p.m. the next calendar day.  Cumulative updates must be given at least weekly by 5 p.m. the next calendar day following a subsequent occurrence of a confirmed infection of COVID-19 or whenever new-onset respiratory symptoms occur within 72 hours of each other for three or more residents or staff.

 

Facility Requirements for Reporting:

      • Facilities need to exclude Personally Identifiable Information (PII) from these communications.
      • These reports must follow existing privacy regulations and statute.
      • Facility updates must include information about mitigating actions that the facility has implemented to prevent or reduce the risk of transmission. (e.g.) The facility’s mitigation efforts would include altering normal operations or restricting visitation or group activities.

Facilities are not expected to make individual calls in order to satisfy this reporting requirement. Facilities may send paper notifications or use listservs, website postings and/or recorded telephone messages to deliver these updates.

 

Resources:

 

Blog by Sherry Roberts, RN, Nationally Certified COVID-Ready Caregiver, Proactive Medical Review

Learn more about Sherry and the rest of the Proactive team.