Breaking News: CMS Expanding Efforts to Grow COVID-19 Vaccine Confidence and Uptake Amongst Nation’s Most Vulnerable

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

CMS issued this Press Release this morning – May 11, 2021.  It carries the same title as this blog.

“As part of the ongoing response to address the COVID-19 pandemic, and to improve health care access and reduce the risk of severe illness and death from COVID-19, the Centers for Medicare & Medicaid Services (CMS) today issued a rule that will ensure long-term care facilities, and residential facilities serving clients with intellectual disabilities, educate and offer the COVID-19 vaccine to residents, clients, and staff.  These requirements apply to Long-Term Care (LTC) facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities, or ICFs-IID, and align with existing requirements for influenza and pneumococcal vaccines in LTC facilities.   

The rule also requires LTC facilities to report weekly COVID-19 vaccination status data for both residents and staff.  The new vaccination reporting requirement will not only assist in monitoring uptake amongst residents and staff, but will also aid in identifying facilities that may be in need of additional resources and/or assistance to respond to the COVID-19 pandemic.

  • To ensure LTC facilities receive support for COVID-19 vaccination efforts, they are now required to report weekly vaccination data of residents and staff to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN), the nation’s most widely used healthcare-associated infection tracking system.  LTC facilities are already required to report COVID-19 testing, case, and mortality data to the NHSN for residents and staff, but have not been required to report vaccination data. As data becomes available, CMS will post facility-specific vaccination status information reported to the NHSN for viewing by facilities, stakeholders, and the public on CMS’ COVID-19 Nursing Home Data website.
  • While today’s announcement is specific to LTC facilities and ICFs-IID, CMS is also seeking comment on opportunities to expand these policies to help encourage vaccine uptake and access in other congregate care settings, such as psychiatric residential treatment facilities (PRTFs), group homes and assisted living facilities. By requiring vaccine education and offering within LTC facilities and ICFs-IIDs, CMS is improving health care access and reducing the risk of severe illness and death from COVID-19.

For additional details on today’s rule, visit here: 

+ This is the link to the public inspection view of the interim rule that is scheduled to be published in the May 13, 2021 Federal Register. 

For COVID-19 Vaccine Immunization Requirements for Residents and Staff visit here: QSO-21-19-NH.  There is a lot of detail in this QSO so please review carefully with your team!

Key points of this Interim Final Rule include (bolding added by me):

  • Noncompliance related to the new requirements for educating and offering COVID-19 vaccination to residents and staff will be cited at F-tag 887, and noncompliance related to COVID-19 vaccination reporting will be cited at F-tag 884.
  • F884: Reporting – National Healthcare Safety Network (NHSN) 42 CFR 483.80(g)(1)(viii)-(ix) requires LTC facilities report, on a weekly basis, the COVID-19 vaccination status of residents and staff, total numbers of residents and staff vaccinated, each dose of vaccine received, COVID-19 vaccination adverse events, and therapeutics administered to residents for treatment of COVID-19 through NHSN’s LTCF COVID-19 Module.
  • Facilities must continue submitting their COVID-19 data to NHSN at least weekly, but no later than Sunday at 11:59 p.m., each week. Facilities must begin including vaccination and therapeutic data reporting in facility NHSN submissions by 11:59 p.m. Sunday, June 13, 2021. To be compliant with the new reporting requirements, facilities must submit the data through the NHSN reporting system at least once every seven days. Facilities may choose to submit multiple times a week.
  • CMS will begin reviewing for compliance with the new vaccination reporting requirements Monday, June 14, 2021.
  • As has been done since June 2020, CMS will continue to receive the CDC NHSN reported data and review for timely and complete reporting of all data elements. Facilities identified as not meeting the all reporting requirements under the provisions at §483.80(g)(1), including the new vaccination reporting requirements, will receive a deficiency citation at F884 on the CMS 2567, Statement of Deficiencies, at a scope and severity level of F (no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy [IJ] and that is widespread).

Failure to report the required elements to NHSN (including the new vaccination reporting requirements) will result in a single deficiency at F884 for that reporting week. In accordance with §488.447, a determination that a facility has failed to comply with the requirements to report weekly to the CDC pursuant to §483.80(g)(1)-(2) (tag F884) will result in a civil money penalty (CMP) imposition. Enforcement for F884 follows a progressive pattern, which leads to an increase of the CMP amount for each subsequent occurrence of noncompliance, not to exceed the maximum amount set forth in §488.408(d)(1)(iii), as specified in §488.447(a)(2).2 The amount of the CMP imposed is incrementally increased based on the provider’s history of noncompliance with F884 since June 2020 when providers were first required to start reporting COVID-19 related data to the CDC. 

  • Per enforcement requirements at §488.447, failure to meet reporting requirements at §483.80(g)(1) will result in a CMP starting at $1,000 for the first occurrence of a failure to report. For each subsequent week that the facility fails to submit the required report, the noncompliance will result in an additional CMP imposed at an amount increased by $500 and added to the previously imposed CMP amount for each subsequent occurrence. Please refer to QSO 20-29-NH, which detailed how CMS will enforce the new reporting requirement.
  • CMS will continue to provide notification of noncompliance and imposition of a CMP, along with the CMS 2567 to facilities via their CASPER shared folders.

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