The National Healthcare Safety Network (NHSN) is the nation’s most widely used healthcare-acquired infection (HAI) tracking system. The system provides data needed to identify problem areas and a means to measure the progress of prevention efforts.
There is no cost to users with the BIG exception that if a nursing home facility does not submit the federally mandated required weekly information on certain COVID-19 data; the nursing home can and will incur financial fines, called civil money penalties (CMPs), as outlined in the Centers for Medicare & Medicaid Services (CMS) QSO-20-29-NH.
Over the last several years, the COVID-19 data that was initially required to be reported has been revised and shortened but nonetheless, reporting is STILL required for every nursing home in the nation every 7 days. The required modules for reporting Long Term Care Facility (LTCF) COVID-19 data are the COVID-19/Respiratory Pathogens Module and the COVID-19/Respiratory Pathogens Vaccination Module.
What are the Requirements and Potential Fines?
- Facility must report at least once every 7 days
- CMS will impose a per day (PD) CMP of $1000.00 for one day for the failure to report that week; reporting deadline is Sunday at 11:59 pm ET
- For each subsequent week the facility fails to submit the required report, the noncompliance will result in additional one-day PD CMP imposed at amount increased by $500.00 and for every subsequent week that data is not reported, the CMP will increase by $500.00
- The fines stack upon each other up to a maximum of $10,000 per incident
Example:
- Miss first reporting week – $1000 CMP
- Miss the 2nd week – $1000 + $500 = $1500 CMP
- Miss the 3rd week – $1500 + $500 = $2000 CMP
- Miss the 4th week – $2000 + $500 = $2500 CMP
Using this example; the total in CMP fines over the course of missing 4 weeks would total $7,000!
Using the example above: facility got back on track for timely reporting, but misses another reporting week three months later; the one-day PD CMP to be imposed now would be $3000! (which is $500.00 more than the last imposed PD CMP amount of $2500)
- Facility is cited for F884 at scope and severity level F; however, no plan of correction is required
- Facility has an opportunity to dispute the CMP imposed through the Independent Informal Dispute Resolution (IIDR) process and appeals must be filed 60 days from the date of the CMS letter
How is Facility Notified of a CMP Enforcement?
The facility is notified from CMS via the iQies system. Look under the “facility folder” for any notifications/ enforcement imposition letters. Make a habit to check the “facility folder” at least weekly and especially if you know you are outside of the 7-day reporting window. There has been some incidences that notification came via an email or in the mail, but typically, the enforcement notices are found in the iQies system in your “facility folder”. The enforcement letter will provide instructions for payment of fine and the IIDR process should you wish to dispute.
Common Reasons for NHSN Reporting Noncompliance and Best Practices to Prevent CMP
| Noncompliance Reasons | Prevention Actions |
|
Inconsistent and incomplete data collection |
Ensure all areas in the calendar of each required module show a green bar. This confirms report submitted for that reporting week (it does not necessarily indicate the exact date the report was submitted). If you see a tan colored bar – report has not been successfully submitted for that reporting week.
Double check data entered to ensure it meets data field requirements. If a data field requires a number, even if the number is zero, then “0” must be entered in the system or it will flag as missed data. |
|
Not reporting data at least once every 7 days |
Consider reporting at least twice a week. Some facilities are reporting every day.
If you do change the day of when you report; understand you may have to report twice in the same reporting period to stay within that 7 day reporting window. The COVID19 Pathogen Pathway module is the module that requires the every 7 day reporting; the Weekly COVID Vaccination module goes by weekly reporting period. |
| Current NHSN data submitter unexpectantly does not submit (i.e. illness, vacation, no longer at facility) | Ensure that a minimum of 2 staff members have access to your facility’s NHSN account at all times and that they understand how to submit a report.
Document who in facility has NHSN access and who is the designated NHSN Facility Administrator (only the NHSN Fac Adm can add new facility users) |
|
NHSN access issues – technical issues and can not get logged in |
If you have 3 unsuccessful log in attempts – the system will lock you out for 2 hours. Either wait the 2 hours and attempt again or email samshelp@cdc.gov or call SAMS at 1-877-681-2901 and request to unlock facility account.
Reboot your computer If you have exhausted the above tips and still unsuccessful in access, contact the Service Now Help Desk: The helpdesk portal is called ServiceNow; however, you can only use this if you can get past the first sign in page when you initially log into SAMS. If you can access the ServiceNow link – then use this route and it seems the responses are quicker. ServiceNow instructions here: NHSN SN Customer FAQs (cdc.gov). If you can not access the ServiceNow link; then email both samshelp@cdc.gov and nhsn@cdc.gov. SAMS and NHSN can determine what side the problem is arising from. SAMS also has a phone number 1-877-681-2901. Do not hesitate to use the phone number. Provide any screen shots of what you are seeing and attach to your email help request. Explain the issue, the date and steps taken to resolve along with your full contact information and facility you are associated with. Then SAVE ALL CORRESPONDENCE! This supporting documentation could be used if you need to dispute a CMP that may be imposed for reporting noncompliance – it verifies that you reached out for assistance. |
The Long-term Care Facilities (LTCF) Component | NHSN | CDC resource webpage was recently redesigned to make navigation to all the individual NHSN modules for long-term care
easier with just a click including how to add a new facility user and much, much, more.
“Ftag 884 for NHSN noncompliance reporting citations is the top Ftag that is cited throughout the nation. The fines imposed can significantly affect a facility’s financial bottom line. Having a consistent workflow and embedded processes in your facility can greatly decrease the chances of incurring a CMP for Ftag 884,” added Lori Hintz, RN, BSN: Quality Improvement Advisor with Great Plains QIN.
For assistance or questions, please contact Lori Hintz at lori.hintz@greatplainsqin.org.