CMS Announcement on NHSN Data and Guidance on COVID-19-Related Survey Activity – June 2, 2020
The Centers for Medicare and Medicaid Services (CMS) has released a memorandum (QSO-20-31-ALL) addressing NHSN data, COVID-19 survey activities, enhanced enforcement, and engagement of Quality Improvement Organizations (QIOs). This guidance is effective immediately and will cease to be in effect when the Secretary determines there is no longer a Public Health Emergency due to COVID-19. At that time, CMS will send public notice that this guidance has ceased to be effective via its website.
NHSN Data Initial Release: CMS released a state-by-state report on COVID-19 cases for residents and staff along with numbers of infection control focused surveys completed. CMS will post the underlying CDC-collected data on a link on Nursing Home Compare later this week. The data will be broken down by state, number of residents and number of staff. The data will be searchable by facility name and will be downloadable so researchers and other stakeholders can perform their own in-depth analysis. CMS will update the data weekly. Ensure systems and processes are in place to report at least weekly to NHSN per CMS requirements. If you have difficulty reporting or accessing NHSN, keep documentation of all efforts made to be in compliance.
Focused Infection Control Nursing Home Surveys and CARES Act Supplemental Funding
Based on the COVID-19 nursing home data being reported to the CDC, CMS believes further direction is needed to prioritize completion of focused infection control surveys in nursing homes.
- States that have not completed focused infection control surveys in 100% of their state’s nursing homes by July 31, 2020, will be required to submit a corrective action plan to their CMS location outlining the strategy for completion of these surveys within 30 days.
- If, after the 30-day period, states have still not conducted surveys in 100% of their nursing homes, their CARES Act FY2021 allocation may be reduced by up to 10%.
- Subsequent 30-day extensions could result in an additional reduction up to 5%. These funds would then be redistributed to those states that completed 100% of their focused infection control surveys by July 31.
- Access to FY 2020 CARES Act allocations will be impacted by state performance on completing the nursing home infection control focused surveys.
COVID-19 Survey Activities
CMS is also requiring states to implement the following COVID-19 survey activities. States that fail to perform these survey activities timely and completely could forfeit up to 5% of their CARES Act Allocation, annually.
- Perform on-site surveys (within 30 days of this memo) of nursing homes with previous COVID-19 outbreaks, defined as:
- Cumulative confirmed cases/bed capacity at 10% or greater; or
- Cumulative confirmed plus suspected cases/bed capacity at 20% or greater; or
- Ten or more deaths reported
- Perform on-site surveys (within three to five days of identification) of any nursing home with 3 or more new COVID-19 suspected and confirmed cases in the since the last NHSN COVID-19 report, or 1 confirmed resident case in a facility that was previously COVID-free.
- State survey agencies are encouraged to communicate with their state health care associated infection coordinators prior to initiating these surveys.
- Starting in 2021, perform annual focused infection control surveys of 20 percent of nursing homes based on state discretion or additional data that identifies facility and community risks.
Enhanced Enforcement for Infection Control Deficiencies
CMS is expanding enforcement for infection control deficiencies. Specifically, CMS announced it will impose remedies for infection control deficiencies based on the scope and severity of the current deficiency as well as findings of prior infection control deficiencies. For all infection control deficiencies at a scope and severity of D or above, CMS will impose a directed plan of correction that will include the use of root cause analysis.
The use of remedies will increase as the scope and severity of the survey findings increase and based on the scope and severity of prior infection control deficiencies and will include discretionary denials of payment for new admissions (DPNA) and per instance civil money penalties (CMPs). Nursing homes cited for noncompliance with infection control regulations at the immediate jeopardy level will face mandatory statutory remedies as well as a discretionary DPNA with 15 days to demonstrate compliance and the highest CMP amount as indicated in the CMP analytic tool.
For further details, review the memo. Use the self-assessment tool (.zip) provided by CMS to evaluate your infection prevention & control program in advance of focused infection control surveys.
Support from Quality Improvement Organizations (QIOs)
CMS states that nursing homes can take advantage of weekly National Infection Control Training that focuses on infection control, prevention and management to help prevent the transmission of COVID-19. The memo adds that QIOs are being deployed to provide technical assistance to nursing homes, which includes a targeted focus on nursing homes with a history of infection control challenges. Additionally, States may request QIO technical assistance for a specific nursing home(s) that have experienced an outbreak.
NHSN Update and FAQs – May 27, 2020
Nursing facilities were required to submit their first set of data to NHSN by 11:59 pm on May 17, 2020 to be compliant with the new requirements. Facilities may choose to report more frequently, but at minimum must report at least once every seven days. The initial two-week grace period ends at 11:59 pm on May 24, 2020. Facilities that fail to begin reporting after the third week, ending at 11:59 pm on May 31, will receive a warning letter reminding them to begin reporting the required information to CDC/NHSN. Facilities who have not started reporting in the NHSN system by 11:59 pm 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. Each subsequent week that the facility fails to report will result in an additional one-day PD CMP imposed at an amount increased by $500.
NHSN updated the instructions for the pathway forms on May 12. When completing the data collection and upload, be sure that you are using the most current instructions. You can find the new instructions on the NHSN website. During one of the NHSN data reporting webinars, the NHSN team identified that each item question must have an answer entered or it will be counted as missing data and it will be counted as not being reported. When you enter count data, even if the answer is nothing or zero, you must enter 0 in the data field. If you leave it empty, it will be flagged as “no answer.”
According to the CDC, “to maintain consistency in reporting, if a facility is using crisis level strategies” the facility is experiencing a shortage. “In other words, PPE strategies that do not commensurate with U.S. standards of care are considered as a shortage. For information in relation to CDC’s optimization strategies for PPE (standard, conventional, and crisis), we encourage facilities to refer to Optimize PPE Supply website.
A center can easily identify if they are missing data in the NSHN module by reviewing the calendar view page. Any pathway that is incomplete will be highlighted as a tan color. Pathways highlighted as green indicated all questions were answered. Missing pathway means the pathway has not been started. As of right now, NHSN does not send notices for incomplete data. Centers are encouraged to review the calendar view to ensure all four pathways are highlighted in green to ensure compliance with reporting to NHSN.
Centers are continuing to report a delay in being able to register and upload data to NHSN. There are also centers who are reporting significant delays in having their questions answered via NHSN help desk. Centers who are experiencing delays are encouraged to keep documentation of all attempts of contacting NHSN and any communications you have with them.
Some centers are reporting that they are not receiving the Agreement to Participate and Consent email. If this is happening to your center and you do not receive the Agreement to Participate and Consent in your inbox for whatever reason, you should follow these instructions:
- Log-in to SAMS.
- Select Long-term Care Facility Component and your facility/group name.
- Click “Submit” to review the “Agreement to Participate and Consent”.
- Click ‘Accept’ next to the appropriate contact name.
- Click “Submit”. A pop-up notification will appear confirming this action.
- Click “ok” to acknowledge the notification.
- If you log in to SAMS and see the “Annual Survey” alert on your facility homepage, you should follow these steps to remove the alert:
- On the facility homepage, click “Survey Required 2020” alert on the facility homepage to be directed to the online survey
- Complete the “Facility Characteristics” section and scroll to the bottom to click “save” to submit your survey.
- CDC Posts NHSN Training Recording and Offers Webinar for Groups
The COVID-19 Module Overview for Long-term Care Facilities recorded video presentation and slides are now available on the COVID-19 LTCF Module webpage, as well as COVID-19 Module Enrollment Guidance for LTCF under Training.
Reporting Accurately to NHSN COVID-19 – May 15, 2020
The American Health Care Association previously provided guidelines on accurately reporting staffing and PPE shortages to NHSN COVID-19 LTC module. As stated in the update, it is important the data reported to NHSN gives an accurate picture as this data will be used by state, federal governments and other stakeholders. The AHCA received questions about the staffing guidance and have revised as shown below based on review of the latest CDC instruction for NHSN reporting.
NHSN asks, “Does your organization have a shortage of staff and/or personnel?” Any of the following situations support a YES response:
- Staffing less than your facility needs or internal policies for staffing ratios (despite efforts made by the facility to secure staff)
- Employing crisis strategies for staffing shortage
- Using any temporary positions per waiver allowances (such as temporary nurse aide or temporary feeding assistant) or agency staff, yet staffing ratios for facility needs and internal policies are still not met
As a reminder, keep documentation of efforts to secure more PPE as well as staffing. Report to your local and state health departments if employing contingency and crisis strategies to conserve PPE and staffing.
NHSH resources for nursing homes – May 14, 2020
From the Alabama Department of Public Health: As we get closer to the official NHSN COVD-19 report date (May 17), we (ADPH) wanted to share the following resources with you regarding facility enrollment, data collection and data entry into the NHSN system. If you have any questions, please contact Melanie Chervony, HAI Coordinator at Melanie.Chervony@adph.state.al.us.
In addition, please send the contact information for your primary NHSN user to HAI@adph.state.al.us.
- Please include the following elements:
- NHSN Org ID:
- Facility Name:
- NHSN Facility Contact:
- Phone Number:
- Email address:
NHSN COVID-19 LTC Module Resources
NHSN COVID-19 Reporting: Accurately Reporting Staffing & PPE Shortages – May 12, 2020
NHSN COVID-19 mandated reporting for nursing homes has begun. The American Health Care Association recommends accurately reporting the staffing and PPE situation at nursing homes based on normal standards and guidance for PPE and staffing, not conservation guidance. Federal and state governments will use this data to hold nursing homes accountable for care and services provided and to identify who needs additional resources. It is important that the data reported to NHSN gives an accurate picture of staffing and PPE as well as the other areas collected in NHSN. Given the instructions on NHSN, reporting that you have what you need, tells CMS that you have enough PPE and staff to follow conventional and normal practices, which will likely be used by surveyors when comparing what they find during their surveys. Please use the below guidelines.
Staffing: NHSN asks “Does your organization have a shortage of staff and/or personnel?” Answer YES if any of the following are occurring during the time period of reporting:
- Staffing less than your facility needs or internal policies for staffing ratios prior to COVID or based on increased needs since COVID
- Employing contingency or crisis strategies for staffing shortage
- Using more agency staff than you used before the pandemic
- Using volunteers for staffing needs more than what you may have used prior to the pandemic
- Using any temporary positions per waiver allowances (such as temporary nurse aide or temporary feeding assistant)
PPE: NHSN asks “Do you have enough for one week?” each for N95 masks, surgical masks, eye protection, gowns, gloves, alcohol-based hand sanitizer. Answer NO if any of the following are occurring during the time period of reporting:
- Employing any conservation strategies for PPE use; if you are not able to use PPE per conventional transmission-based precautions in place before the pandemic you should answer NO
- Using alternative PPE such as cloth masks or other types of face coverings, clothing or other types of coverings instead of surgical gowns, or glasses for eye protection
- Reusing any single use supply item such as gown or masks
- If additional residents in the next week will need to be placed on precautions, it will compromise your PPE supply
- If additional staff in the next week will need to use PPE when returning to work, it will compromise your PPE supply
- If visitors or contractors in the next week need to visit, it will compromise your PPE supply
As a reminder, nursing homes should keep documentation of their efforts to secure more PPE as well as staffing. You should report to your local and state health departments that you are employing contingency and crisis strategies to conserve PPE and staffing.
NHSN Enrollment Delays & Tips – May 11, 2020
It is taking longer than anticipated for nursing homes to enroll in CDC’s National Healthcare Safety Network (NHSN) due to high demand from the new CMS reporting requirements. The NHSN have recruited additional staff to reduce the processing time of enrollment requests. Access detailed registration instructions for new facilities. Facilities are encouraged to review the Enrollment Guidance document for a more in-depth explanation of the enrollment process. Nursing homes should keep documentation of efforts made to enroll in NHSN.
IMPORTANT NOTE: For the best experience and quicker access to the system, please be sure you are replying to a registration/enrollment email. Emailing the NHSN user support help desk will result in longer wait times for a reply.
Additionally, NHSN is providing two live Zoom sessions to address enrollment specific questions. After registering, you will receive a confirmation email containing information about joining the meeting.
LTCFs COVID-19 Live Q&A Session for Module and Enrollment Specific Questions
Tuesday, May 12, 2020, 12:00 p.m. CT
Thursday, May 14, 2020, 1:00 p.m. CT
Still Waiting for NHSN to Complete Your Registration? Start Data Collection Now – May 6, 2020
Is your nursing center still waiting access to the National Healthcare Safety Network (NHSN) COVID-19 reporting module? There is a lag time between initiating registration to NHSN and completion of the registration process due to the number of long-term care facilities that are trying to gain access. NHSN is reporting a 24-48 hour, and in some instances longer, lag time between initial registration to actual completion of registration and the ability to use the COVID-19 reporting module.
While waiting for the registration process to complete, you should download now the four data collection pathway forms and accompanying instructions to start collecting the data that you will be uploading to NHSN once registration process is complete. It is extremely important to download, and refer to, the instructions page for each of the four data collection pathways. Refer to the definitions of each term prior to completing the data collection form.
The four data collection pathway forms are:
New Reporting Requirements for Nursing Homes Effective May 1 – May 4, 2020
The Centers for Medicare and Medicaid (CMS) release of an interim final rule with comment period which revises § 483.80, establishing explicit reporting requirements for long-term care (LTC) facilities to report information related to COVID-19 cases among facility residents and staff. These reporting requirements are applicable on the effective date of this interim final rule, which is the date of the publication at the Office of the Federal Register. CMS stated that the new requirements for nursing homes in this rule was effective as of May 1. CMS’s intention is that the first of the weekly reporting’s to CDC in the NHSN COVID-19 module are submitted by May 8. We are advocating that there be a grace period for enforcement of this rule given the lack of clarity on the notifications to residents, their representatives and families, as well as the technical complexities and quantity of information that must be submitted to CDC for NHSN COVID-19 reporting.
The American Health Care Association (AHCA) is developing resources to help members with these new requirements, including a template communication for notifications to residents, their representatives and families. AHCA is also working with CDC NHSN team to get resources to members on using NHSN. See article below for further developments on that front.
More Materials Available from CDC NHSN on New COVID-19 Module for Nursing Homes – May 4, 2020
CDC NHSN has released more materials for nursing homes to prepare for this new reporting requirement, including a guide to using the COVID-19 module. Visit the CDC website to sign up for updates. There are two upcoming webinar trainings for the new LTCF COVID-19 Module. The training webinars will be recorded and posted to the LTCF COVID-19 Module webpage with a PDF of the slide presentation.
COVID-19 Module for Long-term Care Facilities Enrollment Guidance
Monday, May 4, 2020
1:00 – 2:30 PM
COVID-19 Module Overview for Long-term Care Facilities
Tuesday May 5, 2020
2:00 – 3:30 PM
Learn how to join these webinars on the CDC NHSN website. If you have any questions, please email CDC at NHSN@cdc.gov and include LTCF COVID-19 in the subject line.
CMS Issues Interim Final Rule with New Requirements for COVID-19 Reporting for Nursing Homes – May 1, 2020
The Centers for Medicare and Medicaid Services late Thursday night issued an interim final rule with comment period which revises § 483.80 establishing explicit reporting requirements for long-term care facilities (LTCF) to report information related to COVID-19 cases among facility residents and staff. These reporting requirements are applicable on the effective date of this interim final rule which is the date of the publication at the Office of the Federal Register. The American Health Care Association (AHCA) will notify members when it is published.
Under this new requirement nursing facilities must:
Electronically Report to CDC’s National Healthcare Safety Network (NHSN)
- Electronically report information about COVID-19 in a standardized format specified by the Secretary, which will rely on CDC NHSN portal that went live on Wednesday, April 29 with the new LTCF COVID-19 module. This report to CDC must include but is not limited to:
- Suspected and confirmed COVID-19 infections among residents and staff, including residents previously treated for COVID-19;
- Total deaths and COVID-19 deaths among residents and staff;
- Personal protective equipment and hand hygiene supplies in the facility;
- Ventilator capacity and supplies in the facility;
- 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 the information specified in the list above at a frequency specified by the Secretary, but no less than weekly to NHSN.
- 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.
Inform Residents, their Representatives, and Families
- Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of:
- Either a single confirmed infection of COVID-19, or
- Three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other.
- This information must:
- Not include personally identifiable information;
- Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and
- Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either:
- Each time a confirmed infection of COVID-19 is identified, or
- Whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.
- The preamble to the rule states that facilities are not expected to make individual calls. Providers may use general communication platforms easily available to residents, representatives and families such as listservs, website postings, and recorded telephone messages.
The AHCA will continue to advocate for CMS to issue clarifying language that makes this feasible and as least burdensome as possible.
Long-Term Care Facility COVID-19 Module
The Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) continues to support the nation’s COVID-19 response with the new Long-Term Care Facility COVID-19 Module in NHSN’s Long-Term Care Facility (LTCF) Component. LTCFs eligible to report into the new COVID-19 Module include skilled nursing facilities/nursing homes, long-term care for the developmentally disabled, and assisted living facilities. Furthermore, NHSN group users (for example, health departments, corporate entities) can bulk upload COVID-19 data to NHSN on behalf of member facilities in their NHSN groups.
The new Long-Term Care Facility COVID-19 Module enables LTCFs to report COVID-19 data elements:
- Counts of residents and facility personnel with suspected and laboratory positive COVID-19.
- Counts of suspected and laboratory positive COVID-19 related deaths among residents and facility personnel.
- Staffing shortages.
- Status of personal protective equipment (PPE) supplies such as ventilator supplies, N95 masks, and gloves.
- Ventilator capacity and supplies for facilities with ventilator dependent units.
LTCF data submission options include manual entry, CSV file submitted by individual facilities or bulk CSV file upload for multiple facilities. NHSN, in turn, will use the existing Group function to make COVID-19 data accessible to state and local health departments for LTCFs in their jurisdictions. Based on recent guidance from the Centers for Medicare and Medicaid Services (CMS), NHSN will also provide COVID-19 data reported by nursing homes to CMS. Please see recent guidance from CMS here.
Facility-level data collected through NSHN as part of the COVID-19 Module are being made available to a broader set of Federal, state, and local agency data users than data typically collected by NHSN. Specifically, COVID-19 data at the state, county, territory, and facility level submitted to NHSN will continue to be used for public health emergency response activities conducted by CDC’s Emergency Operations Center, the White House Coronavirus Task Force, and by the Office of the Assistant Secretary of Preparedness and Response as part of the National Response Coordination Center at the Federal Emergency Management Agency (FEMA), which maintains data in the U.S. Department of Health and Human Services’ (HHS’) COVID-19 tracking system.
NHSN’s new LTCF COVID-19 Module underscores the imperative for LTCFs to continue to report COVID-19 data to state and local health departments in accordance with requirements and reporting mechanisms currently in use. Data submission to the NHSN COVID-19 Module does not replace state and local public health reporting requirements. If NHSN’s COVID-19 data overlaps with a state or local health departments’ requirements, the data aggregated by NHSN can add value to current reporting by providing national level data. In some public health jurisdictions, the data that LTCFs report to the new Module may supplement the data that the LTCFs already report to public health.
Please visit https://www.cdc.gov/nhsn/ltc/covid19/index.html for more information and for upcoming trainings.
CDC Webinars on COVID-19 Reporting
The presentation slides for the Thursday, April 30 CDC webinar will be available on the CDC COVID-19 LTCF website: https://www.cdc.gov/nhsn/ltc/covid19/index.html in a few days. The video recording will be available later. The CDC will repeat the April 30 and May 1 presentations Monday, May 4 at 1:00 p.m. and & Tuesday, May 5 at 2:00 p.m. The ANHA will provide details when it receives them.