On May 6, 2020, CMS announced that nursing homes are required to report COVID-19 data through the CDC’s National Health Safety Network (NHSN) reporting system to ensure appropriate tracking, response, and mitigation of COVID-19 in nursing homes. To be compliant with the new requirement, facilities must submit the data through the NHSN system at least once every seven days. Daily is preferred if possible but you must submit at least every seven 7 days at a minimum.
How to check if you’re compliant in SimpleLTC
CMS will notify you via the QIES mailbox if your facility is out of compliance. SimpleLTC customers, please check your CASPER reports on a daily basis by going to MDS > CMS Reports > CMS Automated. No letter means you’re currently in compliance but continue to check your mailbox at least every seven days.
If you see a report called, “Impose Letter”, your facility or a facility at your organization has not yet submitted that week’s COVID-19 reporting data. In order to avoid accruing additional fines, please start submitting your COVID-19 data immediately. We recommend you submit your COVID-19 data on a daily basis.
Submitting your data in NHSN
If you have not done so already, your facility should immediately gain access to the NHSN reporting system. Please visit NHSN for important info including how to register:
The following provides an overview of the registration process:
- Prepare your computer to interact with NHSN · You may need to change your email and internet security settings to receive communications from NHSN during the enrollment process.
- Register Facility with NHSN · The person who will serve as the NHSN Facility Administrator must access and read the NHSN Facility/Group Administrator Rules of Behavior from https://nhsn.cdc.gov/RegistrationForm/index.
- Register with SAMS (Security Access Management System) · After CDC receives your completed registration, you will receive an Invitation to Register with SAMS via email.
- Complete NHSN Enrollment · On the SAMS homepage, click the link to the National Healthcare Safety Network labeled NHSN Enrollment and Complete Facility Contact Information.
- Electronically Accept the NHSN Agreement to Participate and Consent ·
After successfully completing enrollment, the NHSN Facility Administrator and Component Primary Contact (which may be the same person) will receive an NHSN email with instructions on how to electronically accept the NHSN Agreement to Participate and Consent. For NHSN questions, please email NHSN@cdc.gov.
Penalties for failing to submit your COVID-19 data
Enforcement for F884
A determination that a facility failed to comply with the requirement to report COVID-19 related 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.
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.
Please note the “teeth” in F884 non-compliance! That’s a significant amount of money, to be sure and that CMP will hurt.
The SimpleLTC support team is available to assist at firstname.lastname@example.org or 469.916.2803.
- NHSN Reporting of LTC COVID-19 Infections training
- Infection Prevention/Control on-demand training
- Enhanced enforcement actions based on nursing home COVID-19 data and inspection results
- Imposition notices of civil monetary penalty for failure to report COVID-19 data to NHSN
- CMS posted QSO-20-29-NH: Interim Final Rule updating requirements for notification of COVID-19 cases
- COVID-19 reporting requires NHSN enrollment now