Round-Up: National Healthcare Safety Network Reporting

Posted on June 17, 2020 by Jonathan Lips

As we enter the fifth week of nursing homes reporting to the CDC’s National Healthcare Safety Network (NHSN), we thought it would be worthwhile to highlight some of the information we’ve shared with members through our daily updates over the past couple of weeks.  

Have facilities been cited for not reporting – even if they are stuck in the enrollment process?

Yes, some LeadingAge MN members have received a deficiency citation (F884, scope and severity level F) and notice of civil money penalty (CMP) for failure to submit data. CMS is providing the deficiency notifications, not MDH, because only federal survey staff have access to the information needed to determine compliance. 

We are hearing of citations/CMPs both for facilities that submitted data and those that did not, including facilities that have not been able to submit data because CDC has not completed their enrollment.

On a national teleconference, CMS officials noted that facilities that feel they should not have received the CMP – including those that submitted data but still received a fine and those that have not yet accessed NHSN due to enrollment bottlenecks – may pursue Independent Informal Dispute Resolution (IIDR), following instructions in the notice of enforcement.

Evan Shulman, Director of the Division of Nursing Homes, stated that CMS intends to be fair and acknowledged that circumstances outside a facility’s control may justify overturning a deficiency. He cautioned that a facility would need to submit adequate documentation (email history, screen shots, other) to support any IIDR request.

Review your notice of enforcement carefully, including noting any key deadlines, and consult with your legal counsel if you have questions about whether to proceed with an appeal and how best to support your case.

How can I check the CMS data about my facility(ies) and how often is it updated?

There are two ways to review and verify the CMS data: You can visit this CMS webpage (scroll down to find the data set) and use the filters to search for a particular nursing home. If you want to review data for multiple facilities, you can also access the dataset directly for additional analysis options and to download the dataset for Minnesota, or multiple states, in an Excel format. If you click on the Filter tab, you filter the data to specify the State for which you want to review data, then click the Export tab.

This FAQ explains that COVID-19 data reported to NHSN are captured from the system shortly after midnight EST every Monday morning and subsequently sent to CMS. CMS will process these data in preparation for the weekly update of their nursing home COVID-19 webpage. Therefore, there will be a delay (approximately 11 days) in viewing this week’s data on CMS webpages.

NOTE:  Instructions on how to export your NHSN data for comparison to the CMS data can be found in this FAQ document.

I have evidence that I submitted data, but the CMS database doesn’t show it.  What gives?

If CMS is saying your nursing home didn’t report data to NHSN, even though you believe you submitted the information correctly, here are four possible explanations for what might have happened:

• Your CMS Certification Number (CCN) is missing or incorrect. When NHSN sends the data to CMS, CMS uses the CCN to check for compliance with reporting requirements. If you are entering data but the CCN is missing or incorrect, CMS is unable to confirm you have submitted. In other words, NHSN will let you submit the data, but CMS will view this as a not-reporting situation.  The same problem happens with an incorrect facility type (see below). To add or edit your CCN, follow the instructions here.
• Your facility type is wrong. When NHSN sends the data to CMS, they are sending data for skilled nursing facilities. If your facility type is not skilled nursing facility, your data may not be received by CMS. To change your facility type, follow the instructions here.
• Your facility has multiple enrollments. CMS uses the CCN to check for compliance with reporting requirements. The CCN is unique to your facility. If you have multiple enrollments, you may be accidentally reporting under an enrollment that has a missing or incorrect CCN and therefore, CMS is unable to confirm you have submitted. To add or edit your CCN, follow the instructions here.
• You’re missing the weekly deadline. CMS requires nursing homes to submit data at least once per week. Reporting deadlines for each week are Sundays at 11:59pm. If you choose to enter data on a weekly basis, be sure data is entered prior to 11:59pm on Sundays to be counted for that week.

What are some common data submission errors?

NSHN offered a webinar on data quality on June 10 (repeated June 16).  The webinar describes commonly observed reporting errors in COVID-19 counts data, provide examples of best practices in reporting counts to improve data accuracy, and describe how to correct reporting errors. Here are a few of the tips CDC offered, based on common errors they are seeing in the data:

• If you report weekly, do not report data on any additional day for that week, or you will have an overcount. 
• COVID-19 deaths should never be larger than total deaths, because total deaths is a measure of all deaths from all causes.  The numbers could be the same for a given week (e.g. 2 deaths total, 2 deaths from COVID) but COVID-deaths can never be larger.
• Some providers are submitting data in some but not all of the pathways.  If data is missing in one or more pathways, the report will be considered incomplete.

• CDS is noticing some provider reports have missing data for a given field or given collection day.  If data is missing, the report will be considered incomplete.  TIP:  If you have no count(s) for a given day or data field, be sure to enter 0, do not leave it blank.  If you do not have counts to report, enter 0.
• Some overcounting is occurring because some providers are duplicating data they have already submitted.  When reporting on a given date, include/submit only data that represents new counts, and do not carry over counts from the last time you reported.