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NHSN Reporting Compliance Tips – Avoid CMPs and Nursing Home Compare Points

Posted Jun 11, 20206 min Read

Regulatory & Clinical

As required by the Centers for Medicare & Medicaid Services (CMS), outlined in QSO-20-29-NH, SNFs/NFs must report certain COVID-19 data to the National Healthcare Safety Network (NHSN) at least once every seven (7) days.  Facilities that did not report into the NHSN system by 11:59 p.m. on June 7, 2020 were subject to a per day Civil Money Penalty (CMP) for failure to report that week (the week of June 7), and for each subsequent week that data is not reported the CMP will increase by $500.  The facility will also be cited for F884 at scope and severity level F, though no plan of correction is required.

Even with the issues that facilities have had registering for and reporting to NHSN, CMS has begun sending CMP letters to nursing facilities that do not have data in the NHSN system. IHCA/INCAL and AHCA have pushed back on CMS (see later in this article for CMS responses).

CMP letters are being reported through the CASPER/QIES system.  You should check your CASPER/QIES portal to check for a letter as the fines and appeal rights are stated within that letter.  Federal Independent Informal Dispute Resolution to question cited deficiencies is available as is a formal challenge and appeal of the CMS through the HHS Departmental Appeals Board.  Appeals must be filed 60 days from date of the CMS letter.

Recommendations to Comply

To assist facilities with compliance and to avoid CMPs and points on the nursing home compare rating, we recommend the following:

  1. Ensure that you have designated more than one user to the NHSN system for reporting. Having a solid back-up plan is important to timely reporting.
  2. Pick a day each week and consistently report your data to NHSN on that same day each week. Each provider must report every 7 days.  This is not optional.
  3. If you change the day of data reporting, it is important to know that you will need to report two times the week that you change your reporting day in order to avoid a penalty for not reporting.
  4. Do not misunderstand the requirement to report every 7 days with reporting 7 days of data.
  5. Submit your data and always go back to the calendar on the NSHN reporting system to double check for a green bar for each of the four components required for reporting. If you see a tan bar you have not successfully met the reporting requirements and something needs to be corrected to avoid a fine.
  6. Understand that the Indiana State Department of Health EMResources system is not currently submitting your data currently. It is a goal of ISDH to use EMResources for NHSN reporting, but it is not yet active.  Continue to report directly to NHSN until further notice from ISDH and IHCA/INCAL.
  7. Notification of CMP fines are reported by CMS through the CMS CASPER/QIES system. Each provider should check the CASPER/QIES system for communications weekly.
  8. If you are having difficulty and/or need to trouble shoot and issue related to the NHSN system, Kara Dawson, Quality Improvement Advisor with QSource can assist you.

Contact information for Kara Dawson:


Cell:  317-628-1145

Feel free to also contact Lori Davenport at

Responses from CMS

IHCA and AHCA have reported these difficulties to CMS and have engaged CMS to reverse these decisions given the system difficulties.  AHCA has head back today from CMS on several issues and a few more are pending.

  • We have told CMS that they need to stop issuing citations since there are apparent issues in how CMS is receiving data that providers have proof of reporting to CDC as well as ongoing unresolved issues for some providers with the registration and submission process to NHSN

 CMS Response: CMS has said providers should follow the IIDR process specified in the enforcement letter and that CMS will consider adequate evidence of providers trying to register and submit data when reviewing IIDR submissions as long as facilities have documentation that shows they did not wait to the last minute to register and that CDC/NHSN has been slow to respond or their recommendations were ineffective, or that the required data was submitted timely. CMS has said they are looking into a more “streamlined” IIDR process for reviewing these citations.

  • We have been telling CMS the notification should be sent through the normal process for issuing 2567s and enforcement letters, not CASPER, in order to ensure the 2567s are received timely by the appropriate people in the facility such as the administrator.

 CMS response: They are using the CASPER system because this allows them to automate the process for issuing these 2567s and enforcement letters on a weekly basis. They are looking at additional options to alert the facility when the notice has been uploaded into CASPER.

  • We have asked that they change the level of the deficiency to a C-level citation.

 CMS response is pending.

  • We told CMS that because the language in the 2567 citation is so generic, it does not give the provider sufficient information on what the error is that led to the citation, making it difficult or impossible for the provider to counter the citation in their IIDR request.

 CMS response is pending.

  • We have shown CMS examples where the facility submitted data correctly per CDC/NHSN but they still received a citation. We have sent them screen shots showing that the citations are in error.

 CMS response: Facilities need to follow the IIDR instructions and that will be taken into consideration during the IIDR review.

About the Author

Zach Cattell, President, Indiana Health Care Association