F884: Reporting-National Healthcare Safety Network (NHSN)
The facility must—
(1) Electronically report information about COVID-19 in a standardized format specified by the Secretary. This report must include but is not limited to--
(i) Suspected and confirmed COVID-19 infections among residents and staff, including residents previously treated for COVID-19;
(ii) Total deaths and COVID-19 deaths among residents and staff;
(iii) Personal protective equipment and hand hygiene supplies in the facility;
(iv) Ventilator capacity and supplies in the facility;
(v) Resident beds and census;
(vi) Access to COVID-19 testing while the resident is in the facility;
(vii) Staffing shortages; and
(viii) Other information specified by the Secretary.
(2) Provide the information specified in paragraph (g)(1) of this section at a frequency specified by the Secretary, but no less than weekly to the Centers for Disease Control and Prevention’s National Healthcare Safety Network. This information will be posted publicly by CMS to support protecting the health and safety of residents, personnel, and the general public.
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.
LTC facility administrators and clinical leadership are encouraged to track vaccination coverage in their facility, which can help them target efforts to improve vaccination coverage. Facilities may use the COVID-19 Vaccination module in NHSN to track aggregate vaccination coverage.
Refer to CMS memorandum QSO-20-29-NH for additional NHSN reporting requirements under F884 as well as instructions on registering, enrolling, and reporting to NHSN. For NHSN questions, please email: NHSN@cdc.gov and add “Weekly COVID-19 Vaccination” in the subject header.
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.
Enforcement for F884
Compliance with F884 requires facilities to continue to report COVID-19 data through NHSN’s LTCF COVID-19 Module, and now, with finalization of the new reporting requirements at §483.80(g)(viii) and (ix), they must begin reporting vaccination data for residents and staff and the use of therapeutics for residents. 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.
NHSN Resources for Providers
• LTCF COVID19 Module webpage (https://www.cdc.gov/nhsn/ltc/covid19/index.html): Visit this website before submitting questions to the NHSN help desk.
• Enrollment help: https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-enrollment508.pdf or https://www.cdc.gov/nhsn/ltc/covid19/enroll.html. If you still need help with enrollment/data submission, contact NHSN@cdc.gov “LTCF” in the subject line.
• To correct facility type: https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/change-ltcf-508.pdf.
• To change/update your NHSN facility administrator: https://www.cdc.gov/nhsn/facadmin/index.html
• For enforcement-related questions, please email: DNH_Enforcement@cms.hhs.gov
Contact: For questions or concerns regarding this memo, please contact DNH_TriageTeam@cms.hhs.gov.
Effective Date: This policy should be communicated with all survey and certification staff, their managers and the State/CMS Location training coordinators immediately. The effective dates of the specific actions are specified above.
We understand that state and local health departments may currently require nursing homes to report certain COVID-19 related information to them. A key difference between the state/local reporting and this new national reporting requirement is that reporting to state/local health departments allows them to understand the status of their local environment and intervene (e.g., direct staffing and supplies), whereas this national requirement provides standardized information to assist with national surveillance on the status of COVID-19 in all nursing homes. State and local health departments are also able to submit the required data on behalf of a nursing homes, although this does not relieve facilities of their accountability to report in accordance with the regulation.
