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NHSN Reporting Changes

The Centers for Disease Control and Prevention (CDC) is implementing changes to the way that nursing homes report COVID-19 vaccination status data for staff and residents on the National Healthcare Safety Network (NHSN). The CDC presented a webinar on Thurs., Sept. 23rd that highlighted the upcoming changes. The same presentation will be replayed on Wed., Sept. 29th at 1 p.m. Registration is available here. The slides used during the webinars are available here.

While much of the presentation reviews the reporting that nursing homes have been doing for a number of months, there are some changes that may increase the stakes and add to the burden of reporting. For example, the categories of staff have been reorganized, requiring reporting facilities to become familiar with the new categories and report accordingly. Changes in reporting requirements are indicated by green stars in the presentation. The changes, which only impact the COVID-19 module, are effective Oct. 1st.

Although the need to complete a monthly reporting plan (MRP) was initially required along with other Oct. 1st changes, the CDC communicated with members that no action is currently required. Providers do not need to complete the MRP to report COVID-19 vaccination data for residents and health care personnel for reporting weeks ending Oct. 3, 2021 through March 27, 2022. For now, NHSN will auto-populate the MRP for the vaccination coverage module. When required, the MRP will consist of simply checking off boxes indicating that the facility intends to report weekly data for the given month. Note that accessing the MRP functionality requires Level 3 Secure Access Management Services (SAMS) access, and weekly data (after March 27, 2022) cannot be submitted until the MRP is complete. We have reached out to members who we believe do not have Level 3 security access, but we invite any organization that faces challenges due to that requirement to let us know. When applicable, completion of the MRP is expected to be included in the Quality Reporting Program (QRP), which could result in penalties for providers who do not meet set thresholds of compliance.

To initiate the process of upgrading data security from Level 1 (general NHSN user) to Level 3, NHSN users should email nhsn@cdc.gov with “Enhancing SAMS Data Security” in the subject line, then follow the instructions here.

Members may want to review the updated data collection forms and instructions posted under the heading Data Collection Forms and Instructions on the NHSN page here, which also contains a number of reporting resources. A beneficial vaccination tracking tool is available on the Agency for Healthcare Research and Quality (AHRQ) website here.

Contact: Ken Allison, kallison@leadingageny.org, 518-867-8820