On May 6, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum on the interim final rule (published May 9, 2020) updating requirements for notification of confirmed and suspected COVID-19 cases among residents and staff in nursing homes.
The interim final rule contains updates to the COVID-19 Focused Survey for Nursing Homes, including an updated assessment of the new requirements for nursing facilities to report to the National Healthcare Safety Network (NHSN) and to the resident, their representative, and family. The updated forms can be found on the CMS’ website by clicking on Medicare > Quality, Safety & Oversight-Guidance to Laws & Regulations > Nursing Homes and locating the Survey Resources link under the Downloads section. The documents include two new deficiency tags, F884 and F885, for citing noncompliance with the new requirements.
F884 COVID-19 Reporting to CDC
Review for F884 will be conducted offsite by CMS Federal surveyors. Following an initial reporting grace period granted to facilities, CMS will receive the CDC NHSN COVID-19 reported data and review for timely and complete reporting of all data elements. Facilities identified as not reporting will receive a deficiency citation for F884 on Form CMS-2567 with a scope and severity level of an F (no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy [IJ] and that is widespread; this is a systemic failure with the potential to affect a large portion or all of the residents or employees), and be subject to an enforcement remedy imposed as described below.
F885 COVID-19 Reporting to Residents, their Representatives, and Families
Review for F885 is included in the COVID-19 Focused Survey Protocol and will occur onsite by State and/or Federal surveyors. If the survey finds noncompliance with this requirement, a deficiency citation for this tag will be recorded on Form CMS-2567 and enforcement actions will follow per the memo QSO-20-20-All. In the memo, CMS noted that there are a variety of ways that facilities can meet this requirement, such as informing families and representatives through email listservs, website postings, paper notification, and/or recorded telephone messages. CMS does 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, CMS expects facilities to take reasonable efforts to make it easy for residents, their representatives, and families to obtain the information facilities are required to provide.
The interim final rule requires skilled nursing facilities (SNF) to submit data to the Centers for Disease Control and Prevention (CDC) through the NHSN portal starting June 1, 2020. Any SNF that does not submit the required data will be issued a citation at F884 and a $1,000 civil monetary penalty (CMP) per instance. If the facility in subsequent weeks fails to submit data, the CMP escalates.
Form CMS-2567 with F-level citations for F884 with a $1,000 CMP per instance are being issued to all SNFs identified by CMS from data transmitted by the CDC as not having submitted data, or submitting incomplete or otherwise erroneous data for the week of June 1 to June 7, 2020. The notifications of deficiency and CMPs are being sent via the CASPER/QIES system and are automatically generated for these facilities. CMS will continue to review if data was submitted weekly and issue citations and CMP enforcement for facilities that are not compliant.
What Nursing Facilities Should Do
To ensure compliance, nursing facilities should:
- Check the CAPER/QIES system for claims.
- Begin using the revised COVID-19 Focused Survey for Nursing Homes to perform a self-assessment. The updated forms can be found on the CMS website by clicking on Medicare > Quality, Safety & Oversight-Guidance to Laws & Regulations > Nursing Homes and locating the Survey Resources link under the Downloads section.
For more information, contact Rod Farley at 717-213-3123 or email RFarley@LW-Consult.com.