MDS Alert

Avoid citations for COVID-19-related issues.

Depending on your facility’s location, you may have been required to report COVID-19 infection information to your local or state health department. With the Centers for Disease Control and Prevention (CDC) now requiring national reporting, the Centers for Medicare & Medicaid Services (CMS) is putting out new survey guidance specific to COVID-19.

With the new reporting requirements come new enforcement tactics. Federal surveyors will be on the lookout, and they’re now equipped with new Ftags to cite facilities that don’t comply. And the grace period is ending, with the monetary penalties rising steeply.

“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,” says Linda Elizaitis, RN, RAC-CT, BS, president and founder of CMS Compliance Group in Melville, New York.

Understand This Context

“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,” says David R. Wright, director quality safety & oversight at CMS in Baltimore.

Even if your local or state health department is submitting data for your facility, your facility must still submit data per CMS’ instructions, on the specified modules. “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,” Wright says.

Work Out all Kinks in CDC Reporting

This new COVID-19-related Ftag can be cited by federal surveyors alone. “Review for F884 will be conducted offsite by CMS Federal surveyors (state surveyors should not cite this F-tag),” Wright notes.

By this point, you should have a few weeks’ of data submission under your belt, but just in case, make sure you’re submitting at least weekly. “Facilities may choose to submit multiple times a week. CMS is not prescribing which day of the week the data must be submitted, although reporting should remain consistent with data being submitted on the same day(s) each week. The collection period should also remain consistent (e.g., Monday through Sunday),” Wright says.

You can find the specific instructions for reporting your facility’s data to the CDC’s National Healthcare Safety Network (NHSN) via the Long-Term Care Facility COVID-19 Module here: www.cms.gov/files/document/qso-20-29-nh.pdf.

Report COVID Status to Residents, Families, Representatives

Know your responsibility for keeping residents and their families or representatives informed — or risk a citation. You have options for the manner in which you meet this requirement, including email listservs, website postings, paper notification, or recorded telephone messages.

“We do not expect facilities to make individual telephone calls to each resident’s family or responsible party to inform them that a resident in the facility has laboratory-confirmed COVID-19. However, we expect facilities to take reasonable efforts to make it easy for residents, their representatives, and families to obtain the information facilities are required to provide,” Wright says.

The quality, safety & oversight (QSO) memo does not mention HIPAA nor other resident privacy concerns.

Facilities that are found by state or federal surveyors to not be meeting the requirements listed for F885 in reporting infection status to residents, families, and representatives will be cited, but CMS does not specify any penalties.

Beware These F884 Penalties

Federal surveyors are serious about collecting this data, knowing that understanding where outbreaks are occurring is paramount in keeping nursing facility residents safe. Therefore, CMS warns that any facility not submitting data in an appropriate or timely fashion will receive a deficiency citation and be subjected to a civil money penalty (CMP).

With over a month of reporting under your facility’s belt now, you shouldn’t be in for any surprises that you haven’t already encountered. However, the failure to report is steep: The CMP rises an additional $500 as the weeks progress.

One example Wright provides is especially pertinent to this point in time: “… if the facility complies with the reporting requirements and submits the required report in week six, but then subsequently fails to report as required in week seven, a one-day PD CMP amount of $2,000 will be imposed (which is $500 more than the last imposed PD CMP amount) for a total of $4,500 imposed CMPs,” Wright says.

Even though these new Ftags are specific to the COVID-19 pandemic, brace yourselves for increased scrutiny to be the new normal.

“Expect increasing scrutiny of your facility’s infection prevention and control practices. In a post-COVID world (whenever that is), the focus on infection control is not going away,” Elizaitis says.