Interim Final Rule (IFC), CMS-3401-IFC; Requirements and Enforcement Process for Reporting COVID-19 Data Elements for Hospitals and CAHs

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

On October 6, 2020, CMS issued this QSO-21-03-Hospitals/CAHs memorandum.  This is a 12-page memorandum. 

 Also included with this QSO is a Hospital Mandatory COVID-19 Reporting Enforcement Workflow document:

Facilities to Report

The following hospitals should report the data elements specified in the table below on a daily basis, except Psychiatric and Rehabilitation hospitals will report weekly:

• Short term
• Long term
• Critical access hospital
• Children’s
• Distinct part psychiatric hospital
• Medicaid only short term
• Medicaid only children’s
• Medicaid only long-term hospitals

Reporting Timing

Reporting should be completed within one business day of the reporting period. If a hospital does not have the ability to report on weekends or holidays, the data can be submitted on the next business day.

There are 38 data elements in this reporting.  The QSO memorandum identifies each in detail.

Enforcement Process for Non-compliance

CMS has established a multi-step approach to enforcement for non-compliance with the hospital and CAH reporting requirements implemented in the September 2, 2020 IFC. Hospitals or CAHs that fail to report the specified data elements on a daily basis will receive a notification from their CMS Location of their noncompliance with the reporting requirements and any further noncompliance with reporting requirements may result in future enforcement actions. Compliance with these reporting requirements will be determined independently from health and safety surveys for all other CoPs performed by state survey agencies or accreditation organizations processes under 42 CFR Part 488.

As with all Interim Final Rules, the effective date of this QSO is immediately.

Be sure to review and share this information with your colleagues!