CMS Required Reporting to CDC via NHSN

CMS Required Reporting to CDC via NHSN

CMS has issued QSO Memo 20-29 NH, which outlines reporting requirements and provides an initial two-week grace period to begin reporting cases in the NHSN system. The start date for reporting has been pushed out to May 17 with the two week grace period to May 24.  The memo details two new F-tags related to the reporting requirements, and includes 22 FAQs related to COVID-19. (Prior to the new requirement, CMS reported that 3,000 nursing homes were already enrolled; since the new requirement (in COVID time) was announced, 600 additional providers have made it through the enrollment process. This is probably the reason for the grace period.)  

This reporting requirement is only for CMS certified Medicare/Medicaid licensed skilled nursing facilities.  If you do not have a Medicare or Medicaid contract, or you are an assisted living facility, you are not required to report into the NHSN/CDC system.  You must still report outbreaks to DSHS CRU and your local health jurisdiction, and you are asked to submit your PPE, testing and COVID cases to RCS, using their survey tool, twice weekly.

Summary of Memo

  • On May 8, 2020, CMS will publish an interim final rule with comment period. 
  • COVID-19 Reporting Requirements: CMS is requiring nursing homes to report COVID-19 facility data to the Centers for Disease Control and Prevention (CDC) and to residents, their representatives, and families of residents in facilities. This requirement is in effect May 8th, 2020. There is not a grace period for this section of the reporting rule.
  • Enforcement: Failure to report in accordance with 42 CFR §483.80(g) can result in an enforcement action.
  • Updated Survey Tools: CMS has updated the 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 to reflect COVID-19 reporting requirements.
  • COVID-19 Tags: F884 and F885.
  • Transparency: CMS will begin posting data from the CDC National Healthcare Safety Network (NHSN) for viewing by facilities, stakeholders, or the general public. The COVID-19 public use file will be available on

Facilities must submit their first set of data to the NHSN system by 11:59 p.m. Sunday, May 17, 2020. To be compliant with the new requirement, facilities must submit the data through the NHSN reporting system at least once every seven days. 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). Each Monday, CMS will review the data submitted to assess if each facility submitted data at least once in the previous seven days. The data pulled each Monday will also be used to update the data that is publicly reported. On page 4 in discussion of survey F-tag F884 it outlines the grace period where facilities have until 11:59 pm Sunday May 24 to submit data. Facilities that fail to begin reporting after the third week (by 11:59 p.m. on May 31st) will receive a warning letter reminding them to begin reporting the required information to CDC. Data older than May 8th is not required to be reported.

F884: COVID-19 Reporting to CDC as required at §483.80(g)(1)-(2) Review for F884 will be conducted offsite by CMS Federal surveyors (state surveyors should not cite this F-tag). 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 at F884 on the CMS-2567 with a scope and severity level at 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 as required at §483.80(g)(3)(i)-(iii) 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 at this tag will be recorded on the CMS-2567 and enforcement actions will follow the memo QSO-20-20-All. We note 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. 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.

Remember, this reporting requirement states you must Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. This information must—

  • Not include personally identifiable information;
  • Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and
  • Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other

The grace period for reporting to NHSN does not include this reporting requirement.  You need to start reporting to residents, designated representatives and families as of May 8th.  In the FAQ section of the memo it states the regulation does not require facilities to report to residents, their representatives, and families every suspected case of COVID-19 in residents and staff of the facility. However, it does require facilities to report suspected cases when three or more occur within 72 hours of each other. 




Laura Hofmann, MSN, RN – Director of Clinical and Nursing Facility Regulatory Services
c: 324-231-4804