This week on the CMSCG Blog, we will revisit F884 – Reporting – National Health Safety Network, which is part of the Infection Control regulatory group and is only for use by Federal surveyors. When we initially wrote our Ftag of the Week for F884 in May 2020, providers had until June 2020 to submit COVID-19 data weekly to the CDC National Health Safety Network (NHSN) or face the imposition of a Civil Monetary Penalty (CMP). Well, here we are again with additional COVID-19 data that has to be reported to the CDC NHSN by June 13, 2021 (and weekly going forward), only this time, providers will be submitting COVID-19 vaccine data to the NHSN.
The updated reporting requirements for F884 were set out in a May 11, 2021 CMS QSO Memo which included the Interim Final Rule for COVID-19 Vaccine immunization requirements for nursing homes residents and staff. It also announced a new Ftag, F887 COVID-19 Vaccinations, and updated reporting requirements for F884. (Missed CMSCG’s “Ftag of the Week” for F887? View it here).
F884 – What’s New
The intent of the updated requirements under F884 is to track that providers are offering the COVID-19 vaccine to staff and residents. Providers will have to report:
- COVID-19 vaccine status of residents and staff
- Each dose of vaccine received (including by vaccine type and dose)
- Any COVID-19 vaccination Adverse Events
- Therapeutics administered to residents to treat COVID-19
Providers are expected to report this data (in addition to the existing required COVID-19 data) on a weekly basis (no later than 11:59PM Sunday of each week), and by June 13, 2021, be submitting all required data elements for COVID-19 reporting. CMS will be reviewing the data beginning Monday, June 14, 2021 to check for reporting compliance. This means that facilities have less than a month to develop and implement a system for complying with this requirement. For full details, please view the Interim File Rule here since these regulations have not yet been included in the State Operations Manual Appendix PP.
F884 – Enforcement for Failure to Report Required Data
This will come as no surprise to providers, but if you don’t submit your data timely and on a weekly basis, you will automatically receive a Civil Monetary Penalty (CMP). The automatic imposition of CMPs for failure to report became commonplace in the last year, so expect more of the same if you don’t have a good system in place in your facility. However, here’s everything to expect:
- Failure to report all required elements to NHSN, including the vaccination data, will result in a single deficiency for that reporting week – at a Scope/Severity of F – widespread.
- If it is determined that the facility has not complied with the weekly reporting requirements, then a CMP will be imposed, starting at $1,000 for the first occurrence.
- Like the existing CMP imposition structure for F884, the enforcement actions are progressive, so each continued instance of noncompliance will stacked onto the previously imposed CMP in increments of $500.
The full enforcement methodology for F884 can be found in the May 6, 2020 QSO Memo, “Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes” (Ref: QSO-20-29-NH).
CDC NHSN Training Materials to Help Comply with F884 Reporting Requirements
CDC has revised its training documents, including the “Reporting Weekly COVID-19 Vaccination Data for Residents and Healthcare Personnel of Long-term Care Facilities Using the National Health Safety Network (NHSN)” dated May 2021. The documents provide step-by-step guidance on what needs to be reported on a weekly basis, along with screenshots for navigation assistance. Providers will note that the LTC Facility Component Home Page, there are two new sections under COVID-19 on the navigation bar, “COVID-19 Vaccination – HCW” and “COVID-19 Vaccination – Residents” to use for submitting the required data elements.
There are also data collection forms, instructions and templates on the CDC Weekly HCP and Resident COVID-19 Vaccination webpage, including:
- Weekly COVID-19 Vaccination Summary Form for Residents at LTCFs (May 2021) and form instructions
- Weekly COVID-19 Vaccination Summary Form for Healthcare Personnel at LTCFs (May 2021) and form instructions
- CSV Template for Weekly COVID-19 Vaccination for Residents of LTCFs (May 2021) and a sample to work from
- CSV Template for Weekly COVID-19 Vaccination for Healthcare Personnel of LTCFs (May 2021) and a sample to work from