Friday, June 12, 2020

Update on NHSN Reporting and Related Citations & Fines

AHCA received communication from the Centers for Medicare and Medicaid Services (CMS) late last night (June 11) regarding NHSN reporting. CMS is researching the issues resulting in providers being marked as noncompliant. 

CMS reports that there are a few common issues they have discovered so far, including:
  • facilities not entering the right CCN 
  • facilities not selecting the right facility type
  • facilities entering data after the Sunday deadline, but for the reporting week, and
  • facilities entering data during the week but for previous week’s data 
CMS is seeking the center’s help to get these corrected and straightened out. The Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) is looking into some actions that they can take to make it easier for these issues to be identified on the facility side of the platform.

Steps that your center can take now to ensure your data is being uploaded correctly include: 
  • Check to make sure that your CCN number is correct 
  • Check to ensure that your facility type is correct 
  • Ensure that you are submitting data prior to 11:59pm each Sunday 
  • Data submitted should be new data since previous submission. Do not enter cumulative data in NHSN.
  • Enter zero (0) if the answer is zero for questions requiring counts. Blank data elements equal missing data. All pathways must be completed. 

CMS has stated that they intend to be fair on reviewing IDRs for citations and CMPs issued as part of this regulation as long as providers can show that they did submit the data or have been trying to register or submit the data but had delays in resolving challenges because of CDC’s help line being overwhelmed with requests.

According to the CDC/NHSN, some centers are being identified as “duplicates” because they have registered more than once with the same CCN. Duplicate facilities can lead to problematic scenarios, including: 
  • User reporting data for both NHSN facility accounts 
  • User intermittently reporting into both NHSN facility accounts during the same time period 
  • User reports into one account for a period of time, then switches to the other account for a period of time 
Unfortunately, the CDC/NHSN system cannot delete either account due to not knowing which account is the accurate account. CDC/NHSN has provided the following guidance for centers to correct this issue:

Correct the Facility CCN
If you are unsure of your facility’s CCN, please refer to the look-up tool and follow the instructions below:
  1. Using the left navigation pane, select "Basic Search" under "Tool".
  2. On the next page, enter your facility information and click the “Search” button.
  3. Select your facility on the basic search results report screen to view results and the CCN.
  4. Compare your CCN generated by the look-up tool to the CCN recorded in NHSN. If these differ, please enter the correct CCN for your facility in NHSN. To change the CCN listed in NHSN, please refer to this guidance document.  
Remove Multiple Enrollments 
A facility should not enroll in NHSN more than once and create more than one NHSN OrgID. Each NHSN Org ID should only have one CCN affiliated with that Org ID. Facilities enrolled more than once and share the same CCN will not have accurate data recorded and submitted to CMS.

Please follow these steps to withdraw any duplicate facilities:
  1. Choose one NHSN facility OrgID to submit data and ensure the CCN is correct.
  2. Merged from any duplicate facilities into the one designated facility from step #1.
  3. Withdraw duplicate facilities from NHSN by doing the following:
    1. Log into the duplicate enrolled facility in NHSN.
    2. On the left navigation pane, select facility->facility info.
    3. Scroll down to the component itemization and deselect the component that is a duplicate.
    4. Accept the alert indicating that you’ve deselected the facility.
    5. Select update to reflect changes.
  4. Add users to the one NHSN facility chosen in step #1, if needed.
Add a NHSN User 
  1. Log into SAMS and selecting NHSN reporting. 
  2. Go to the left navigation pane and click on Users>ADD.
  3. Complete the required fields marked with an asterisk (*) and click SAVE at the bottom of the page.
  4. Assign user rights and click on SAVE at the bottom of page.
  5. Ensure that you have made all users an “Active User.”
If a newly added user does not have SAMS access, they should receive an email confirmation following this process. The email will also ask the new user to click on the corresponding link to agree to the NHSN Rules of Behavior. Once they agree to the Rules of Behavior, NHSN will automatically submit an invite to the user for SAMS authentication.

Correct Erroneous Data
Centers can correct errors in data by logging into the NHSN system and navigate to the calendar view.
  1. Click on the data that data needs correcting.
  2. Click on the pathway that needs correcting
  3. Correct the erroneous data
  4. Click SAVE
NHSN Help Desk contact info: nhsn@cdc.gov

SAMS Help Desk contact info: SAMSHelp@cdc.gov or (877) 681-2901

CMS Help Desk contact info: NH_COVID_Data@cms.hhs.gov

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