Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
On May 27, 2020, CMS announced the following:
The purpose of this communication is to inform you that CMS will utilize the QIES mailbox to communicate important information related to your nursing home’s compliance with the requirement to report COVID-19 data to the Centers for Disease Control and Prevention (CDC) through the National Healthcare Safety Network (NHSN). This includes the CMS 2567 and Enforcement Notices for noncompliance. You will not receive a notice if you are found in compliance with the reporting requirement.
If you have any questions concerning this information, please contact the DNH Triage email box at: DNH_TriageTeam@cms.hhs.gov.
Here are those requirements:
You should always check your QIES mailbox for any notification and this is no exception. If you do not receive a notification, you’re good…you’re in compliance with the NHSN reporting requirement.
Here’s what can happen if you are in non-compliance with the COVID-19 reporting requirements (note the bolding within the verbiage below). This verbiage is also found in QSO-20-29-NH … May 6, 2020.
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.
Please note the “teeth” in F884 non-compliance! That’s a significant amount of money, to be sure and that CMP will hurt.
Posting Facility-Level COVID-19 Data
Reporting COVID-19 data supports CMS’s responsibility to protect and ensure the health and safety of residents and is necessary to ensure the appropriate tracking, response, and mitigation of the spread and impact of COVID-19 on our most vulnerable citizens, personnel who care for them, and the general public. The information provided may be used to inform residents, families, and communities of the status of COVID-19 infections in their area. We believe that this action strengthens CMS’s response to the COVID-19 pandemic and reaffirms our commitment to transparency and protecting the health and safety of nursing home residents. 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 https://data.cms.gov/ by the end of May.