In March, CMS Compliance Group put its “Ftag of the Week” Blog series on pause until providers were being less inundated with COVID-19 and infection Control-related information. However, in a May 6, 2020 QSO Memo, the Centers for Medicare & Medicaid Services (CMS) announced the addition of two new federal regulatory tags, F884 COVID-19 Reporting to CDC and F885 COVID-19 Reporting to Residents, their Representatives and Families. These two Ftags follow the rest of the Infection Control regulatory group (F880-F883).
These two regulations are related to the April 19, 2020 CMS QSO Memo, “Upcoming Requirements for Notification of Confirmed COVID-19 (or COVID-19 Persons Under Investigations) Among Residents and Staff in Nursing Homes” (Ref: QSO-20-26-NH) and the Interim Final Rule with Comment Period that will be published in the Federal Register on May 8, 2020, “Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program.” CMS has put two new sets of reporting requirements into effect, the first of which requires nursing homes to report confirmed or suspected cases of COVID-19 to the CDC to assist with infection surveillance. The second type of reporting that must be completed relates to communication with residents, their representatives and family members of actual or suspected cases of COVID-19 in nursing homes.
These two regulations have been put into place, but are not included in Appendix PP of the State Operations Manual at this time. This means that there is no Interpretive Guidance (IG) available for these Ftags, but CMS and CDC have made information available to meet the requirements for reporting to CDC NHSN, including training. Based on the information provided in the new QSO Memo, here is what you need to know about F884 and F885. As additional information becomes available, we will update the CMSCG Blog with details.
F884 COVID-19 Reporting to CDC
- This Ftag is only for use by CMS Federal Surveyors during offsite reviews.
- This information is included in the COVID-19 Focused Survey for Nursing Homes (updated 5/8/2020, Critical Element #8. CMS Federal Surveyors are guided to review CDC data provided to CMS to determine if the facility has been reporting at least once a week and if all required data elements are being reported on. In our post about the Interim Final Rule, “CMS Interim Final Rule for Nursing Home COVID-19 Reporting,” we outline what needs to be reported, when and what the expectations are.
- Facilities that are identified as not reporting to NHSN after the reporting grace period ends will receive a deficiency citation at F884 S/S: F and will be subject to an enforcement remedy.
- Nursing homes are required to report weekly to CDC, and non-compliance will result in the imposition of a Civil Monetary Penalty (CMP).
- A warning letter will be sent to all facilities who have not submitted data by May 31, 2020 at 11:59PM.
- Facilities who have not started reporting by June 7, 2020 at 11:59PM, a per day CMP of $1,000 per day will be imposed for failure to report that week.
- Each subsequent week that a facility fails to submit the required data will result in an additional one-day CMP imposed at an amount increased by $500. This means that a facility could receive a $1,000 CMP one week, and by not reporting the next week, receive an additional $1,500 CMP.
- Nursing homes are required to report weekly to CDC, and non-compliance will result in the imposition of a Civil Monetary Penalty (CMP).
F885 COVID-19 Reporting to Residents, their Representatives and Families
- This Ftag will by used during onsite surveys by either State or Federal Surveyors.
- The review for F885 has been added to the COVID-19 Focused Survey Protocol.
- Surveyors will be looking to identify the mechanism(s) that the facility is using to inform residents/reps/families about required COVID-19 data.
- In our post about the Interim Final Rule, “CMS Interim Final Rule for Nursing Home COVID-19 Reporting,” we outline what needs to be reported, when and what the expectations are.
- If a nursing home is found to not be in compliance with the regulation, the facility will receive a citation and enforcement actions will be taken that follow the guidance issued in the CMS QSO Memo issued March 23, 2020, “Prioritization of Survey Activities” (Ref: QSO-20-20-ALL).
- This regulation requires that facilities communicate with residents, representatives and family members regarding COVID-19 in their buildings. CMS notes that facilities must make reasonable efforts to provide this information to these interested parties, but it is not necessary that individual phone calls are made to each family to inform them that a resident in the facility has laboratory-confirmed COVID-19.
The COVID-19 pandemic has been hitting nursing homes particularly hard – which many of you know since you are living through it – and thus it is extremely important to complete this reporting timely. Providing Federal agencies with COVID-19 data will help them to know where resources are needed most, and providing timely information to residents/representatives and family members will help to alleviate stress during these difficult times.
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