CMS Issuing F884 Citation and CMPs
for Failure to Report NHSN COVID-19 Data
This week, CMS began issuing 2567s with F level citations for F884 with a $1,000 per instance civil monetary penalty (CMP). These are being issued to all SNFs identified by CMS (from data transmitted by CDC) as not having submitted data or submitting incomplete or otherwise erroneous data for the week of June 1 to June 7. The notifications of deficiency and CMP are being sent via the CASPER/QIES system (not the traditional method for notifying a facility with a deficiency). Thus, facilities must login to CASPER to see if they have a citation or not. Your MDS coordinator will know how to access this system if you need help.
Background
The interim final rule requires SNFs to submit data to CDC through the NHSN portal starting June 1; any SNF that does not submit the required data will be issued a citation at F884 and a $1,000 per instance CMP. If the facility in subsequent weeks fails to submit data, the CMP escalates.
CMS is generating an automatic 2567 with F884 citation for facilities that have not submitted data starting with the week of June 1 to June 7. CMS will continue to review weekly if data was submitted and issue citations and CMP enforcement for facilities that it determines are not compliant.
- All facilities are cited at F884 at an F level.
- At this time, language in the 2567 is the same for all providers and does not specify what data was not submitted:
“This REQUIREMENT is not met as evidenced by: Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/01/2020 and 06/07/2020, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.”
CMS has said a facility can question the cited deficiency through the IIDR process by following the steps outlined in the notification letter and will give consideration for facilities that have evidence showing they submitted the data or have been trying to register and submit data but ran into technical issues.
We will continue to advocate that CMS make changes to have a more accurate and fairer process, and give providers due consideration when the errors are due to CDC/NHSN or CMS.
Steps to Take
- You should check CASPER to see if you have a citation.
- If you have a citation that you believe is in error, then you should assemble the information needed to submit an IIDR. We recommend putting together at least the following:
- A summary table of dates they started the registration process and all dates of communications with CDC/NHSN
- Screen shots if you have documented your data submission (and begin taking screen shots or other verification evidence of each submission)
- Copies of emails sent and received from CDC/NHSN
- Any other documentation of efforts you made to register and submit data such as communications with the QIO or state
