The Centers for Medicare & Medicaid Services (CMS) released guidance on nursing home reporting of COVID-19 data ahead of implementation of the interim final rule that goes into effect May 8. This rule requires nursing homes to report data directly to the Centers for Disease Control & Prevention (CDC) and to notify residents, resident representatives, and families of COVID-19 status and related operations within the facility. Nursing homes will have a short grace period to comply with reporting requirements prior to the implementation of enforcement actions for non-compliance. CMS anticipates publicly reporting data at data.cms.gov on a weekly basis beginning at the end of May.

Reporting Requirements: Reporting to CDC

Effective May 8, nursing homes will be required to report information related to COVID-19 directly to CDC through the National Healthcare Safety Network (NHSN) system.

Nursing homes will be required to report the following information:

• Suspected and confirmed COVID-19 infections among residents and staff.
• Total deaths and deaths related to COVID-19 infection, including both resident and staff deaths.
• Personal Protective Equipment (PPE) and hand hygiene supplies.
• Ventilator capacity and supplies.
• Resident beds and census.
• Resident access to testing.
• Staffing shortages.
• Any additional information as required (none identified at this time).

In order to report data into the NHSN system, nursing homes will need to enroll. An expedited enrollment process has been developed and information on enrollment is available on the NHSN system site, including training slides and information on live Q&A sessions. Nursing homes will need their CMS Certification Number (CCN) to enroll and it is imperative that the CCN is entered accurately into the NHSN system, as this will be the way by which CMS can confirm compliance with reporting requirements.

Nursing homes are required to make their first submission to the NHSN system by 11:59pm on May 17, 2020. Nursing homes will need to submit data on a weekly basis (at least once every 7 days) thereafter to remain compliant with requirements. While CMS does not require submission on a certain day, submissions should be made on the same day each week and each submission should cover the same data collection period (e.g. Monday – Sunday). CMS will pull and inspect data on Monday of each week.

Nursing homes will have a 2-week initial grace period for complying with requirements for reporting to through the NHSN system. Nursing homes must be in compliance by 11:59pm on May 24. Nursing homes that fail to report data by 11:59pm on May 31 will receive a warning letter from CMS. Failure to report by 11:59pm on June 7 will result in enforcement actions, outlined below (“Survey and Enforcement”).

Reporting Requirements: Notifying Residents, Resident Representatives, and Families

Effective May 8, nursing homes will be required to notify residents, resident representatives, and families of COVID-19 status within the nursing home. By 5pm of the next calendar day following the occurrence of either:

• A single, confirmed COVID-19 infection among residents or staff or,
• 3 or more residents or staff with new-onset of respiratory symptoms consistent with COVID-19 infection in a 72-hour period.

Nursing homes will also be required to provide weekly cumulative updates to residents, resident representatives, and families. If new cases or symptom clusters are identified more frequently than weekly, nursing homes will not be required to make additional “cumulative weekly updates” notification, as each notification related to new cases and clusters must include cumulative updates, as outlined below. If a week has passed since identification of the last new case or symptom cluster and notification, nursing homes must provide a weekly update to residents, resident representatives, and families.

When notifying residents, resident representatives, and families, nursing homes must follow these guidelines:

• Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered,
• Include cumulative updates on COVID-19 cases and clusters of respiratory symptoms,
• Not include any personally identifiable information.

When surveying for compliance with this requirement, surveyors will interview residents and resident representatives to determine timely notifications. Nursing homes are expected to make reasonable efforts to make it easy for residents, resident representatives, and families to obtain the information nursing homes are required to provide.

Nursing homes are not required to distinguish in these notifications between numbers of new cases vs. numbers of total cases, or numbers of cases among staff vs. numbers of cases among residents. For information on what respiratory symptoms should be monitored and reported, CMS refers to CDC guidance Symptoms of Coronavirus and Preparing for COVID-19: Long-Term Care Facilities and Nursing Homes.

Survey and Enforcement

As noted above, nursing homes will receive enforcement actions for failure to comply with requirements for reporting to CDC through the NHSN system and notifications to residents, resident representatives, and families. CMS has created 2 new F-tags to address these requirements:

• F884 COVID-19 Reporting to CDC: This F-tag will be reviewed off-site and cited at the federal level. It will be cited at scope and severity level F and will be subject to enforcement remedy as outlined below.
• F885 COVID-19 Reporting to Residents, their Representatives, and Families: This F-tag will be reviewed on-site and may be cited by either state or federal surveyors. Enforcement actions for this F-tag will follow the guidelines outlined in CMS memo QSO-20-20-ALL.

As noted above, nursing homes will have a grace period for compliance with F884 COVID-19 Reporting to CDC prior to the implementation of enforcement actions. If a nursing home fails to comply with requirements for reporting to CDC after the end of the grace period, the nursing home will receive a warning letter (failure to report by May 31). If a nursing home continues to be noncompliant with reporting requirements, the nursing home will receive a per day Civil Money Penalty (CMP) for one day assessed at $1,000. For each additional week the nursing home fails to comply with this requirement, the rate of the per day CMP will increase by an additional $500.

For example, if a facility fails to report by the end of Week 4 (June 7), they will receive a CMP of $1,000. If the facility still has not reported by the end of Week 5 (June 14), they will receive an additional CMP of $1,500 for a total of $2,500 in CMPs. If the facility reports by the end of Week 6 (June 21), then fails to subsequently report by the end of Week 7 (June 28), they will receive a CMP of $2,000 for a total of $4,500 in CMPs.

CMS has also updated several survey resources for surveyors. These resources can be accessed through the link in CMS memo QSO-20-29-NH or by accessing the Survey Resources folder in the Downloads section on the CMS Nursing Homes site. The following documents have been updated:

• COVID-19 Focused Survey for Nursing Homes
• Entrance Conference Worksheet
• COVID-19 Focused Survey Protocol
• Summary of the COVID-19 Focused Survey for Nursing Homes

CMS notes that nursing homes should use the updated COVID-19 Focused Survey for Nursing Homes tool to complete self-assessments.

What This Means for Providers

Nursing homes should take immediate steps to enroll in the NHSN system if not already enrolled in order to begin reporting to CDC by May 17. Develop a process for reporting, including designating a specific individual or individuals who will ensure compliance.

Nursing homes must begin notifying residents, resident representatives, and families of new confirmed cases or symptom clusters on May 8. Develop a process for this notification, including required weekly cumulative updates, and ensure that reasonable accommodations have been made so that residents, resident representatives, and families can access information.

Nursing homes will face enforcement remedies for failure to comply with either requirement, including steep CMPs for failure to comply with requirements for reporting to CDC. Nursing homes should also review their infection control self-assessments using the newly updated survey tool.

What LeadingAge is Doing

LeadingAge continues to advocate with both Congress and CMS for one universal reporting process, rather than duplicative reporting to CDC and according to state requirements. We will also be submitting comments on the interim final rule to address, among other issues, concerns over enforcement actions. In particular, LeadingAge will oppose the imposition of Civil Money Penalties for failure to report to CDC. LeadingAge will update tools, templates, and resources to assist nursing homes with compliance. These resources can be accessed on the LeadingAge COVID-19 page