AHCA: COVID-19 Update #62 | CMS Releases Interim Final Rule Updating Requirements for Reporting and Notification COVID-19 Cases

Nancy Leveille and Jackie Pappalardi in Clinical & Quality

AHCA ‘s COVID-19 #62 update and CMS’s  Memorandum :QSO-20-29 NH dated 2020-05-06 both contain information related to the upcoming CMS guidance on reporting COVID-19 cases to the residents, families and representative; the NHSN data reporting process; and updates to the CMS  COVID-19 Focused surveys . These documents specifically identify timeframes that must be adhered to, methods used to communicate and report. CMS’ QSO has a FAQ document that provides additional information. We encourage you to review these documents thoroughly. Also note that the NHSN data must be submitted on a consistent basis each week to provide accurate cumulative data. NYSHFA will post new updates as they become available. 

Late today, CMS released a QSO memo addressing the Interim Final Rule requiring nursing homes to report to NHSN on COVID-19 as well as provide notifications to residents, their representatives and families.   

Some highlights from the memo are listed below. AHCA is reviewing the information and will issue additional updates with further details and tools to help members comply.  There are some important implementation dates members need to know.  

These requirements go into effect with the publication in the Federal Register of the interim final rule on May 8, 2020.  

CMS had previously communicated the effective date was May 1. However, CMS revised the effective date to be May 8, 2020.   

  • The effective date means nursing homes are required to begin notifications of residents, their representatives and families as of May 8. This means the first notification could be required to occur by May 9 at 5 pm, should the facility have any of the resident and/or staff cases on May 8 as described by CMS required to make notification. 
  • Action: Ensure system and processes for notifications are in place in your facility by May 8 to meet new requirements.   

Facilities must submit their first set of data by 11:59 pm on Sunday, May 17, 2020 to the NHSN Long-Term Care Facility COVID-19 Module.

  • Action: Register now for NHSN and begin collecting data starting May 8, 2020.  [NOTE: registration is taking more time than expected and we encourage you to start now to avoid further delays that may impact your compliance.] 
    • The memo provides an overview of the registration process.   
    • For NHSN questions, please email: NHSN@cdc.gov and add “LTCF” in the subject header. 

CMS will provide facilities with an initial two-week grace period to begin reporting cases in the NHSN system (which ends at 11:59 p.m. on May 24, 2020). Facilities that do not begin reporting after the third week (by 11:59 pm on May 31, 2020) will receive a warning letter reminding them to begin reporting the required information to the CDC.  

For facilities that have not started reporting in the NHSN system by 11:59 p.m. on June 7, ending the fourth week of reporting, CMS will impose a per day (PD) CMP of $1,000 for the failure to report that week. 

For each subsequent week that the facility fails to submit the required report, the noncompliance will result in an additional one-day PD CMP imposed at an amount increased by $500.  

For enforcement-related questions, please email: DNH_Enforcement@cms.hhs.gov

New COVID-19 F-tags & Updated Survey Tools 

CMS has established two new F-Tags - F884: COVID-19 Reporting to CDC and F885 COVID-19 Reporting to Residents, their Representatives, and Families. 

CMS has updated survey tools including COVID-19 Focused Survey for Nursing Homes, Entrance Conference Worksheet, COVID-19 Focused Survey Protocol, and Summary of the COVID-19 Focused Survey for Nursing Homes. These updated forms are posted to the Survey Resources folder in the COVID-19 Focused Survey sub-folder on the CMS Nursing Homes website.  

  • Action: Facilities should begin using the revised “COVID-19 Focused Survey for Nursing Homes” to perform their self-assessment.  Surveyors will begin using these revised documents immediately.   

Public Posting of NHSN Data Anticipated By End of May 

CMS anticipates publicly posting CDC’s NHSN data (including facility names, number of COVID-19 suspected and confirmed cases, deaths, and other data as determined appropriate) weekly on Monday’s at https://data.cms.gov/ by the end of May. 

Multiple Q&A  

CMS provides 22 Q&A in the last 7 pages of the memo. Question 10 addresses retrospective reporting and reads as below: 

  • Q: Are facilities required to report data that predates the effective date (May 8) of the interim final rule? 

A: No, there is no requirement in the rule to collect older data.  

Please email COVID19@ahca.org for additional questions, or visit ahcancal.org/coronavirus for more information.


Nancy Leveille, RN, MS
Director, Special Projects and Educational Development
518-462-4800 x20

Jackie Pappalardi, RN, BSN
Executive Director
518-462-4800 x16