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
Do you have any training for upcoming MDS changes in October 2020?
Hi Ramona—yes, we do! We had a live webinar on Tue, Aug 25 over upcoming MDS changes. Once you fill out the form on this page, you can access the on-demand webinar recording and handouts.
Can I see the webinar and handouts for the upcoming changes in MDS?
Hi Jennifer, once you fill out the form on this page, you can access the upcoming MDS changes on-demand webinar and handouts.
I just want to clarify regarding the cms regulation for baseline care plan
Hi Jennifer. F655 says: The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must— (i) Be developed within 48 hours of a resident’s admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to— (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan— (i) Is developed within 48 hours of the resident’s admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).
§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident’s medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.
INTENT §483.21(a) Completion and implementation of the baseline care plan within 48 hours of a resident’s admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan.