The Centers for Disease Control and Prevention (CDC) continues to update the National Healthcare Safety Network (NHSN) system to which nursing homes and other healthcare providers report COVID-19 and other infection control data. Highlights of the latest updates include changes to the Event-Level COVID-19 Vaccination Data form, changes to the surveillance definition of “up to date”, and updates on data transfers to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).

Event-Level COVID-19 Vaccination Data Form

Since May 2022, nursing homes have had the option of utilizing an event-level reporting form for staff and resident COVID-19 vaccination data. This optional form requires SAMS Level 3 access, as staff are reporting individual staff and resident data at the “person level”, rather than reporting aggregate numbers as rules require. Changes were made recently to how this form is accessed in order to provide increased data security.

To access the event-level reporting form for reporting staff COVID-19 vaccination data, users must now be granted additional user rights by the individual designated as the Facility Administrator in NHSN. For access to this form, the Facility Administrator must allow “Staff/Visitor – Add, Edit, Delete” and “Staff/Visitor – View”. NHSN users who have not been conferred these rights will not be able to access the event-level form for staff, even if they have previously been granted “All Rights” or “Administrator Rights”. Information on how the Facility Administrator can add user rights is available here. To re-assign the Facility Administrator, follow the instructions here.

“Up to Date” for NHSN

CDC updated the operational definition of “up to date” in early September, but this change did not impact NHSN reporting. When reporting “up to date” status in NHSN, providers utilize a surveillance definition, which cannot change in the middle of a reporting period. With the current reporting period ending September 25, CDC has announced that the new definition of “up to date” will be incorporated into NHSN reporting with reporting week starting September 26. Beginning on September 26, the surveillance definition will be updated to be consistent with the operational definition that includes the updated bivalent booster.

CDC plans to host a webinar on September 21 to review the new definition of “up to date” and how this will impact NHSN reporting. Register for the webinar here. The event-level vaccination reporting forms will be updated for the new definition and CDC states that any vaccinations reported in September using the event-level form will be assumed to be the bivalent booster, since the monovalent booster is no longer authorized, and will be counted accordingly.

SNF QRP and the Monthly Reporting Plan

When CMS adopted the COVID-19 Vaccination Coverage Among Healthcare Personnel measure for the SNF QRP in the Fiscal Year (FY) 2022 SNF Prospective Payment System (PPS) final rule, this simultaneously introduced the requirement of the Monthly Reporting Plan. The Monthly Reporting Plan is a report completed in NHSN each month by providers to authorize transfer of reported data from NHSN to the respective Quality Reporting Program. The Monthly Reporting Plan has previously been in use for other CMS-certified providers that utilize NHSN data in Quality Reporting Programs. LeadingAge advocated against the Monthly Reporting Plan, pointing out that nursing homes are already overwhelmed by the amount of required reporting and should not be taxed with additional reporting simply for paperwork compliance. CDC agreed and created an alternative process to ensure nursing home data was transferred to the SNF QRP without additional burden to providers.

LeadingAge has confirmed that the alternative process created in 2021 and extended in 2022 has now been accepted indefinitely and nursing homes will not be required to submit Monthly Reporting Plans in order for COVID-19 staff vaccination data to be transferred to the SNF QRP. Additionally, CDC reported that the alternative process has been updated to include nursing home data on flu vaccinations, which will be required reporting for the SNF QRP program beginning with the 2022/2023 flu season (October 2022 – March 2023) due to the FY 2023 SNF PPS final rule adoption of the Influenza Vaccination Coverage Among Healthcare Personnel measure into the SNF QRP for FY 2024.