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CDC Has Improved the
Nursing Home Reporting
Process for COVID-19 Data in
NHSN, but Challenges Remain
Ann Maxwell
Deputy Inspector General
for Evaluation and Inspections
January 2024, OEI-06-22-00030
U.S. Department of Health and Human Services
Office of Inspector General
CDC Has Improved the Nursing Home Reporting
Process for COVID-19 Data in NHSN, but
Challenges Remain
What OIG Found
Despite CDC efforts, both CDC and
nursing homes experienced difficulties
during a mass enrollment of more than
12,000 facilities into NHSN to begin
reporting COVID-19 data in May 2020.
As the pandemic continued, CDC added
data variables to NHSN, including fields
with personally identifiable information,
in response to emerging data needs and
new Federal reporting requirements.
Nursing homes had to upgrade their
security access levels to report the
sensitive data. At this time, CDC
experienced a significant backlog of
support requests, which also inhibited
some facilities from accessing NHSN.
CDC improved the process of nursing home reporting to NHSN throughout
the pandemic. Facilities acknowledged this effort and reported that CDC
support improved, but some continued to experience difficulty getting
assistance. Additionally, a quarter of nursing homes reported lacking
confidence in the quality of NHSN data, despite the quality assurance checks
CDC conducts on key variables.
After December 2024, CMS reporting requirements for some key variables
will expire, but the mandate for reporting vaccination-related data will
remain. CDC stated that it will continue to support voluntary reporting of
COVID-19 data and other infection and quality measures, and modernize
NHSN reporting processes. Stakeholders and CDC expressed that having
nursing home participation in NHSN is valuable for public health surveillance,
and the agency is exploring opportunities to leverage the current national
enrollment for reporting on other health outcomes.
What OIG Recommends and How the Agency Responded
To continue improvements, we recommend that CDC (1) improve the user
support the NHSN Help Desk provides to nursing homes, (2) take further
steps to ensure the quality of nursing home reporting of COVID-19 data to
NHSN, and (3) consider how quality assurance checks can be enhanced to
ensure data accuracy, as appropriate. CDC partially concurred with our first
recommendation and concurred with our second and third
recommendations.
Why OIG Did This Review
The National Healthcare Safety
Network (NHSN) has served as a
critical source for monitoring the
effects of the COVID-19 pandemic,
and informing the Federal, State,
and local pandemic response. In
May 2020, the Centers for
Medicare & Medicaid Services
(CMS) issued a requirement for
nursing homes to report COVID-19
data to NHSN. The Centers for
Disease Control and Prevention
(CDC) has operated NHSN since
2005, but nursing home reporting
had been voluntary, with
participation from only a small
proportion of facilities. The
reporting requirement resulted in
the influx of thousands of nursing
homes enrolling in and reporting
to NHSN in 2020, while they, and
CDC, also responded to the
pandemic.
This evaluation provides insights
into nursing home experiences
enrolling in and reporting to
NHSN, and CDC efforts to facilitate
reporting such as user support for
facilities facing difficulties. These
insights can help CDC address
ongoing challenges, and mitigate
potential issues in future updates
or expansions.
How OIG Did This Review
We administered an electronic
survey to a simple random sample
of 197 nursing homes from a
population of 15,324 facilities that
have reported COVID-19 data to
NHSN, and interviewed a subset of
facilities. We also interviewed CDC
and CMS officials to understand
CDC efforts to facilitate nursing
home enrollment and reporting to
NHSN. We based our findings on
analysis of survey and interview
responses.
Key Takeaway
CDC struggled to support
nursing homes during mass
enrollment into NHSN in 2020
and as COVID-19 reporting
requirements changed
throughout the pandemic.
CDC has improved the nursing
home reporting process and
guidance, but some
challenges remain. Continued
improvements to NHSN user
support and data quality will
be important for continued
reporting on vaccinations and
for future public health
surveillance.
U.S. Department of Health and Human Services
Office of Inspector General
Report in Brief
January 2024, OEI-06-22-00030
TABLE OF CONTENTS
BACKGROUND ................................................................................................................................................ 4
FINDINGS ....................................................................................................................................................... 14
Despite CDC efforts, both the agency and nursing homes experienced difficulties during mass
enrollment in NHSN: May–June 2020 ............................................................................................................................. 14
CDC changes to NHSN data fields and security resulted in new challenges for the agency and nursing
homes: August–December 2020 ....................................................................................................................................... 18
CDC has improved nursing home experiences reporting to the COVID-19 Module throughout the
pandemic.................................................................................................................................................................................... 21
Nursing home experiences with reporting have improved since May 2020, though issues remain for
both facilities and CDC ......................................................................................................................................................... 23
CDC has made efforts to ensure data quality, but nursing homes reporting to the COVID-19 Module
expressed concerns ................................................................................................................................................................ 28
CDC plans to continue improving NHSN for nursing home reporting and is considering how to
leverage national enrollment for voluntary reporting on other health events ............................................... 30
CONCLUSION AND RECOMMENDATIONS .......................................................................................... 33
Improve the user support the NHSN Help Desk provides to nursing homes ................................................. 33
Take further steps to ensure the quality of nursing home reporting of COVID-19 data to NHSN ......... 34
Consider how quality assurance checks can be enhanced to ensure data accuracy, as appropriate ..... 34
AGENCY COMMENTS AND OIG RESPONSE ........................................................................................ 35
APPENDICES................................................................................................................................................. 36
Appendix A: Estimates, Confidence Intervals, and Key Statistics for Nursing Home Survey Results ...... 36
Appendix B: Changes to the LTCF COVID-19 Module .............................................................................................. 43
Appendix C: Step-by-Step Enrollment Process for NHSN Users .......................................................................... 44
Appendix D: SAMS Registration and Identity Verification ...................................................................................... 47
Appendix E: Agency Comments ........................................................................................................................................ 48
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 53
ABOUT THE OFFICE OF INSPECTOR GENERAL .................................................................................... 54
ENDNOTES ................................................................................................................................................... 55
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Background | 4
BACKGROUND
OBJECTIVES
1. To examine nursing home experiences enrolling in and reporting required
data to the National Healthcare Safety Network (NHSN) COVID-19 Module.
2. To assess Centers for Disease Control and Prevention (CDC) efforts to
facilitate nursing home reporting to NHSN.
The COVID-19 pandemic has had a devastating impact on nursing homes and their
residents. Nursing homes have experienced widespread challenges during the
pandemic, such as inadequate access to personal protective equipment (PPE) and
staffing shortages.1, 2 As of January 1, 2023, more than 1.4 million nursing home
residents in the United States had confirmed cases of COVID-19, with approximately
160,000 deaths.3
To monitor the effects of the pandemic and inform public health policies, the Centers
for Medicare & Medicaid Services (CMS) issued a requirement for nursing homes to
report COVID-19 data to CDC’s NHSN.4, a The reporting requirement resulted in an
influx of thousands of nursing homes submitting data to NHSN. While the data have
been critical for informing the pandemic response, nursing homes have experienced
challenges enrolling in and reporting COVID-19 data to NHSN.
The National Healthcare Safety Network
CDC launched NHSN, a web-based surveillance system, in 2005 to collect data on
health care-associated infections (HAIs) in health care facilities.5 The Surveillance
Branch, within CDC’s Division of Healthcare Quality Promotion, manages NHSN.6
NHSN’s designated operating budget was $21 million in fiscal year 2022.7
NHSN Long-term Care Facility Component
CDC launched the NHSN Long-term Care Facility (LTCF) Component in 2012 for
voluntary reporting of HAI and prevention data.8 The LTCF Component allows
facilities to monitor HAIs and infection control to identify problems, improve care, and
determine progress towards national HAI goals.9 Several types of LTCFs report to the
component, including nursing homes and assisted living facilities.10, b The LTCF
_____________________________________________________________________________________________________________________________
a In this report, the term “nursing homes” refers to both Medicare-certified skilled nursing facilities and
Medicaid-certified nursing facilities. See SSA § 1819, “Requirements for, and assuring quality of care in,
skilled nursing facilities,” and SSA § 1919, “Requirements for nursing facilities.”
b Nursing homes, assisted living, and Intermediate/Chronic Care Facilities for individuals with intellectual
disability report to the NHSN LTCF Component.
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Background | 5
Component consists of four modules: (1) the HAI Module, (2) the
Laboratory-identified Event Module, (3) the Prevention Process Measures Module, and
(4) the COVID-19 Module.11, 12
CDC released the LTCF COVID-19 Module in April 2020 to support pandemic
response activities.13, 14 Initially, the COVID-19 Module only collected data on the
impact of the pandemic on residents and staff, facility supplies, and the facility
response.15, 16 CDC has since made changes to the module to collect data on various
pandemic-related developments.17, 18, 19, 20 (See Exhibit 1 for the structure of the
COVID-19 Module, as of June 2023, and Appendix B for a timeline of major changes
to the module.)
Exhibit 1: Structure of the LTCF COVID-19 Module
Source: CDC, LTCF COVID-19 Module. Accessed at https://www.cdc.gov/nhsn/ltc/covid19/index.html on
February 6, 2023. CDC, HCP & Resident COVID-19 Vaccination. Accessed at
https://www.cdc.gov/nhsn/ltc/weekly-covid-vac/index.html on December 3, 2021.
Note: The bottom three boxes under the Surveillance Reporting Pathways (Supplies and PPE, Ventilator Capacity and
Supplies, and Therapeutics) indicate pathways CDC later removed from the COVID-19 Module.
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COVID-19 Module Enrollment
LTCFs must enroll in NHSN to use the COVID-19 Module.21 Facilities that were
already enrolled in the LTCF Component had immediate access to the module.
Facilities newly enrolling in NHSN have followed a multi-step enrollment process to
gain access.
Each LTCF must designate an NHSN Facility Administrator (NHSN Administrator) for
enrollment.22 The NHSN Administrator serves as the facility’s point of contact for
receiving information from and reporting data to NHSN.23 The NHSN Administrator
submits all required information in the NHSN registration page.24 Following
registration with NHSN, the applicant receives an email invitation to register with the
Secure Access Management Service (SAMS) with steps to submit facility contact
information.25 The NHSN Administrator then enters all required information in SAMS
to complete enrollment.26 (See Appendix C for the step-by-step enrollment process
published by CDC.)
SAMS Registration
SAMS is an online portal that provides authentication, login, and secure access to
authorized personnel to more than 300 CDC technology applications, including
NHSN.27 The Digital Services Office (Digital Services), within the CDC Office of Chief
Information Officer, manages SAMS.28
NHSN applicants undergo an identity verification process in SAMS, due to the
sensitivity of the data they will be submitting. SAMS grants users one of
three distinct access levels following registration. Each tier requires increasing levels
of user authentication during enrollment and login.
•
Level 1: Users are not authorized to report personally identifiable information.29
This access level does not require identity verification or any additional security
measure during the enrollment or login process.30
•
Level 2: Applicants must complete identity verification during enrollment.31 Users
may log in to the application with only the username and password.32
•
Level 3: Users are authorized to report personally identifiable information.33 Users
must complete identity verification during enrollment.34 To log in, users must
complete second-factor authorization using a soft token, which is a mobile
authentication application, or a hard token, which is a physical card mailed to the
user’s home address.35, 36
According to CDC, reporting to NHSN requires SAMS Level 3 access if the user reports
data that includes personally identifiable information.c
_____________________________________________________________________________________________________________________________
c Initially, nursing homes newly enrolling in the COVID-19 Module only needed SAMS Level 1 access, as
reporting to the module did not involve submitting data with personally identifiable information. (See
“Simplified enrollment process” on page 15.)
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Background | 7
NHSN Technical Support
CDC provides support to NHSN users through the NHSN User Support Help Desk
(NHSN Help Desk).37 Users submit support requests exclusively via email, given that
the NHSN Help Desk does not have a user support telephone line. The staff
operating the Help Desk triage tickets manually. After submitting an email request,
users receive an automated response, which includes a ticket number and the
expected wait time. Prior to the pandemic, user support requests to the Help Desk
had an expected wait time of 2 to 5 business days, with a 7-day wait time if the
inquiry required subject-matter expertise.38
CMS Nursing Home Reporting Requirements
CMS sets and enforces health and safety standards, and oversees nursing home
compliance with Medicare and Medicaid standards to ensure resident health and
safety.39 On May 8, 2020, as a part of its pandemic response, CMS issued an interim
final rule that required nursing homes to report COVID-19 data to NHSN.40 Nursing
homes had until May 17, 2020, to enroll in NHSN to begin reporting COVID-19 data.
Nursing homes fulfill the reporting requirements via the LTCF COVID-19 Module’s
Surveillance Reporting Pathways (referenced in Exhibit 1 on page 5). The interim final
rule required facilities to electronically report the following data on a weekly basis:
•
Suspected and confirmed COVID-19 infections among residents and staff,
including residents previously treated for COVID-19;
•
Total deaths and COVID-19 deaths among residents and staff;
•
PPE and hand hygiene supplies in the facility;
•
Ventilator capacity and supplies in the facility;
•
Resident beds and census;
•
Access to COVID-19 testing while the resident is in the facility; and
•
Staffing shortages.41
CDC experienced a substantial rise in NHSN enrollment by nursing homes as a result
of the CMS reporting requirements. Prior to the pandemic, nursing home reporting
to NHSN was largely voluntary and not Federally required. Between March and
June 2020, the total number of LTCFs enrolled in NHSN increased by more than
450 percent, from 3,086 to 17,248 facilities.42, 43, d
_____________________________________________________________________________________________________________________________
d The number of LTCFs enrolled in NHSN increased by 14,162 between March and June 2020. According
to CDC, the majority of the increase in NHSN enrollment is attributable to the addition of more than
12,000 nursing homes. During the week of June 7, 2020, a total of 15,365 nursing homes reported
COVID-19 data to NHSN.
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Background | 8
CMS expanded its reporting requirements in a second interim final rule issued on
May 13, 2021. Nursing homes fulfilled the additional requirements via the COVID-19
Vaccinations Module and the Therapeutics Pathway (referenced in Exhibit 1 on
page 5). CMS added the following data variables, some of which include personally
identifiable information:
•
COVID-19 vaccine status of residents and staff, including total numbers of
residents and staff; numbers of vaccinated residents and staff; numbers of each
dose of the COVID-19 vaccine received; and COVID-19 vaccination-related
adverse events; and
•
Therapeutics administered to residents for treatment of COVID-19.44
Enforcement Actions
CMS has the authority to penalize nursing homes that do not meet the weekly
reporting requirements. On September 2, 2020, CMS issued an interim final rule that
established civil money penalties for facilities that fail to submit required data for a
given reporting week.45 CMS finds that a nursing home meets requirements if the
facility reports any data related to the effects of COVID-19 on residents and staff.46
Nursing Home Reporting
The number of data points nursing homes are required to submit to NHSN has
changed over time. In November 2021, facilities were required to submit up to
132 data points, including 100 data points that were conditionally required on the
basis of facility responses.47 For example, if a nursing home reported that it had any
residents stay at the facility at least 1 day (24 hours) of a reporting week, the nursing
home needed to submit up to six additional data points about resident vaccination
status. Over time, CDC has substantially reduced the number of questions a nursing
home may need to submit. As of August 2023, nursing homes only have to submit up
to 37 data points, 3 of which are conditionally required. Of the 34 required data
points, 5 are related to infections and deaths, and 29 are related to vaccinations.48, 49,
50, 51
CMS requirements to report data related to COVID-19 infections, deaths, and staffing
will expire after December 2024, but requirements for nursing homes to report
vaccination-related data will continue.52 According to CDC, this means that,
beginning in 2025, facilities will only report data for the 29 vaccination-related
variables.
Nursing homes report data to the COVID-19 Module by entering data directly into
the module or uploading data files based on templates provided by CDC.53 The
module visually shows when a submission is complete or is missing data points.54
Authorized group users, such as State and local health departments, may also report
to NHSN on behalf of nursing homes, but facilities are still responsible for data
submission.55
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Quality Assurance Checks
CDC conducts quality assurance (QA) checks on the data for facility admissions,
COVID-19 cases, and COVID-19 deaths in the COVID-19 Module.56 If a nursing
home’s data fail to meet the QA criteria, CDC flags the data to allow for correction by
the facility.
For resident and staff variables, the data must:
•
Represent a weekly count of a given variable and not a cumulative total, and
•
Not exceed a subset of cutoff values established by CDC to identify outliers that
appear invalid.
Following its QA checks, CDC shares nursing home COVID-19 data from NHSN with
CMS on a weekly basis. Prior to sharing the file, CDC nullifies data that failed its QA
checks, and flags the facility in the dataset for CMS.
CDC also conducts QA checks on two vaccination variables: the percentage of current
residents, and the percentage of health care personnel, with no medical
contraindications who received a completed or partial COVID-19 vaccination at any
time. For the given reporting week, the data values for the two vaccination variables
cannot be less than or equal to 10 percent.57
Use of NHSN COVID-19 Data
Nursing home COVID-19 data from NHSN have informed efforts within the U.S.
Department of Health and Human Services (HHS) and the broader stakeholder
community. According to CDC, other stakeholders that used COVID-19 data from
NHSN include the following:
•
The White House COVID-19 Task Force, to inform its emergency response
actions;
•
The Assistant Secretary of Preparedness and Response, with efforts to
distribute PPE and other medical supplies, as well as to address health care
personnel shortages;
•
The Federal Emergency Management Agency, to also address health care
personnel shortages;
•
Long-term care trade or membership organizations, to support outreach and
educational efforts;
•
State and local health departments, to inform prevention activities and
pandemic outbreak investigations; and
•
CMS, to support efforts by its Quality Improvement Organizations, among
other uses.
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CMS referenced NHSN data on staff COVID-19 vaccination coverage in its
November 2021 interim final rule regarding vaccination requirements for health care
personnel.58 CDC also posts data specific to COVID-19 cases and deaths among
nursing home residents and staff on a publicly available dashboard that is updated
weekly.59
Since May 31, 2020, CMS has maintained a public dataset of weekly nursing home
COVID-19 data to support efforts to protect the health and safety of residents and
other consumers.60, 61 CMS conducts separate QA checks on the NHSN data it
receives from CDC to review compliance with certain requirements, such as reporting
data on total resident and staff COVID-19 deaths.62 If a nursing home’s data fail to
meet CMS’s QA criteria, CMS does not include any of the facility’s data in the publicly
posted dataset, and notes that the facility did not pass the QA check.
CMS has since added to the ways it presents NHSN data to consumers and other
stakeholders. In September 2021, CMS began displaying COVID-19 vaccination data
on its Care Compare tool, which provides quality metrics for nursing homes and other
health care facilities to help consumers make more informed choices.63
Related Work
In September 2021, OIG released a report that found that COVID-19 data submitted
to NHSN by a small portion of nursing homes in the early months of the CMS interim
final rule were inaccurate or incomplete. Specifically, OIG found that about 5 percent
of reported nursing home data between June 22 and July 19, 2020, did not include all
required data and were not complete or accurate following CMS QA checks.64
OIG has other work related to the pandemic’s effects on nursing homes and Federal
and State programs. OIG found that overall mortality in nursing homes increased in
2020, and that States conducted fewer onsite surveys to assess compliance with
Federal requirements during the pandemic.65, 66 OIG also found that 1,358 nursing
homes had extremely high infection rates—75 percent or more—during surges of
COVID-19 cases in the spring and fall of 2020, and experienced an average overall
mortality rate approaching 20 percent.67 An ongoing study is examining nursing
home strategies to address challenges during the pandemic and in future public
emergencies.68
Methodology
Scope of Inspection
We examined the experience of nursing homes enrolling in and reporting required
data to the LTCF COVID-19 Module, including any challenges facilities faced, and
strategies used to overcome the difficulties. We did not assess the completeness or
accuracy of the data. We also evaluated CDC efforts to facilitate nursing home
enrollment in and reporting to the COVID-19 Module. These efforts included CDC
instructions and correspondence about NHSN, and its actions to address nursing
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Background | 11
home challenges. Although we describe CMS involvement with the module, we did
not evaluate CMS actions regarding NHSN as part of this evaluation. The timeframe
for our review was February 2020 through June 2023.
We used the following data sources for our evaluation: (1) an electronic survey of a
sample of LTCFs reporting to the COVID-19 Module; (2) interviews with a smaller
subset of nursing home administrators and staff, selected from the survey sample;
(3) interviews with CDC officials involved with NHSN; (4) interviews with CMS officials
involved in collaborating with CDC regarding nursing home COVID-19 data in NHSN;
and (5) documentation provided by CDC regarding nursing home enrollment and
reporting to the COVID-19 Module.
Data Collection
Survey. We administered an electronic survey to a simple random sample of
200 LTCFs and received responses from 171 facilities, for an 86-percent rate of
contact.e, f Our sample population consisted of 15,324 facilities that reported data at
least once to the LTCF COVID-19 Module between May 24 and December 26, 2021.
(Our sample of 200 LTCFs represented 1.3 percent of the total population.) Of the
171 respondents, 167 were nursing homes and the remaining 4 were LTCFs of other
types.g Our sampling method and response rate allowed us to project the results of
our survey to the total population of LTCFs reporting to the COVID-19 Module during
this timeframe.
The survey consisted of both closed- and open-ended questions. The closed-ended
questions focused on nursing home experiences enrolling in and reporting data to
the COVID-19 Module. The open-ended questions asked nursing homes to provide
additional details on any identified challenges and improvements to enrollment and
reporting, as well as perceptions of related CDC efforts.
Interviews. We conducted semi-structured virtual interviews with stakeholders
involved in nursing homes enrolling in and reporting to the COVID-19 Module as
follows:
•
Individual interviews with 12 CDC officials—including Division of Healthcare
Quality Promotion leadership involved with NHSN, the COVID-19 Module, and the
NHSN Help Desk, and Digital Services leadership involved with SAMS—to identify
and understand CDC efforts to facilitate nursing home enrollment in and
_____________________________________________________________________________________________________________________________
e We randomly selected a sample of 200 facilities from the population of 15,324 that reported to the
LTCF COVID-19 Module at least once between May 16 and December 26, 2021. We did not distribute a
survey to three nursing homes, as two were involved in ongoing work by OIG’s Office of Investigations,
and the remaining one had permanently closed.
f We made a minimum of three follow-up attempts to contact respondents who did not submit a
completed survey.
g We refer to the survey respondents as nursing homes for the remainder of our report.
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reporting to NHSN. We also inquired about related challenges CDC experienced,
as well as factors that may negatively affect reporting.
•
Group interview with eight CDC officials as a follow-up discussion to clarify CDC’s
most recent NHSN efforts and future uses of NHSN in collaboration with
stakeholders. We also discussed ongoing reporting requirements and how they
would affect nursing home engagement with NHSN.
•
Individual interviews with representatives from 10 facilities involved with enrolling
in and reporting to the COVID-19 Module, representing a subset of survey
respondents, to gain further insight on nursing home experiences with NHSN.
Using facility survey responses, we selected facilities that (1) reported, and
provided detail about, common themes that we identified in our analysis of the
overall survey results; and (2) reported challenges and navigated those challenges
in ways we found informative. We conducted interviews with 12 respondents
representing the 10 facilities.
•
Group interview with 12 CMS officials involved with nursing home reporting to the
COVID-19 Module, to identify inter-agency collaboration efforts.
Documentation. We reviewed documents related to nursing home reporting to the
COVID-19 Module, including (1) CDC manuals, memos, presentations, and other
guidance about enrolling in and reporting to the module; (2) records of user support
requests submitted to and resolved by the NHSN Help Desk, and templates for
related email communication; and (3) CDC guidance that explains or relates to QA
checks performed on the data.
Data Analysis
Survey. We analyzed survey results to gain insight into nursing home experiences
reporting to the COVID-19 Module and perceptions of CDC user support.
We used closed-ended question responses to identify the proportion of nursing
homes with certain experiences enrolling in and reporting COVID-19 data to NHSN.
Using SAS statistical software, we projected the closed-ended question responses
from our nursing home respondents to the population of facilities enrolled in the
COVID-19 Module at the time of data collection.
The open-ended question responses provided additional context and anecdotal
examples that illustrated our findings. We also used the open-ended responses to
select a sample of nursing homes to interview.
Interviews. Interviews with CDC and CMS officials, as well as with nursing home
representatives, added important context and examples of NHSN-related challenges
and CDC efforts to address them. We used interviews with CDC to detail support
efforts, including how the agency formulated and distributed guidance, and how it
responded to difficulties experienced by nursing homes. We used the interview with
CMS to identify how CDC addressed updates to the COVID-19 Module, as well as how
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it accommodated CMS use of NHSN data. We used interviews with facility
representatives to gain further insight into the frequency and severity of challenges
the facilities have experienced with NHSN. The scope of our evaluation focused on
CDC efforts and did not include the assessment of CMS actions related to NHSN.
Documentation. We reviewed documents to identify gaps in CDC guidance that may
have contributed to or helped resolve nursing home difficulties, and related
correspondence. Our analysis of documents evaluated how CDC approached the
challenges and relayed information related to the reporting process.
Limitations
We did not independently verify information self-reported by CDC and nursing
homes, including data submitted by nursing homes to NHSN. We also did not
determine a causal relationship between CDC actions and improved nursing home
reporting.
Standards
We conducted this study in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.
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Findings | 14
FINDINGS
Despite CDC efforts, both the agency and nursing homes
experienced difficulties during mass enrollment in NHSN: May–
June 2020
CDC described the mass enrollment of nursing homes following the CMS reporting
requirements as difficult and labor-intensive. It described experiencing pressure and
challenges preparing for and managing the influx of newly enrolling facilities. Starting
in May 2020, immediately following the CMS interim final rule, CDC onboarded
thousands of nursing homes in NHSN under a compressed timeline.
Nursing homes enrolling in the COVID-19 Module also faced challenges. Among
newly enrolled facilities in our sample, 101 of 117 reported experiencing difficulties
during the enrollment process, such as issues with accessing CDC guidance and
resources.h
CDC made efforts to mitigate enrollment-related challenges,
including streamlining the process and reallocating staff
CDC prepared for the mass onboarding of nursing homes internally, and by
collaborating with external partners such as CMS. CDC frequently communicated with
partners; added and relocated staff; and distributed guidance and resources to NHSN
users. One CDC official explained that joint efforts with external partners were
particularly important in successfully enrolling facilities in the COVID-19 Module.
CDC decided to use NHSN for collecting nursing home COVID-19 data in
collaboration with CMS. CDC and CMS reported that, starting in late
February 2020, the two Federal agencies routinely met to discuss COVID-19-related
items, particularly in regard to nursing homes. They identified the need to obtain
data from nursing homes during the pandemic, and decided to use NHSN as the data
collection system. CDC regularly sought CMS feedback on the language and
important topics of interest for data collection. CMS concurrently developed the
interim final rule, and involved CDC in writing the reporting requirements, rules,
guidance, and memos. This collaboration was critical, because the development of
the COVID-19 Module, and related guidance, depended on the CMS interim final rule
to dictate what data nursing homes would be required to report.
Both agencies reported that they were able to accomplish the module development
due to collaborative efforts with external partners. On April 19, 2020, CMS alerted
_____________________________________________________________________________________________________________________________
h Of the sample nursing homes, one-third (54 of 171) voluntarily enrolled in NHSN prior to the CMS
interim final rule, and two-thirds (117 of 171) newly enrolled after CMS issued the reporting
requirements.
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Findings | 15
nursing homes to the upcoming reporting requirements. Following the issuance of
the CMS interim final rule on May 8, nursing homes had until May 17, 2020, to enroll
in NHSN to report COVID-19 data. CDC and CMS held national stakeholder calls with
trade organizations, which contacted their members about enrollment and directed
nursing homes to guidance and resources such as the NHSN Help Desk. One CMS
official stated that a combination of outreach and CMS authority to require facility
participation helped enrollment. A CDC official agreed, explaining that voluntary
reporting had not been as effective as CMS requiring nursing homes to report to
NHSN.
CDC rapidly developed and launched the LTCF COVID-19 Module in
April 2020. CDC built the reporting platform, and its subject-matter experts
developed questions to inform pandemic response and prevention. The agency
stated that discussions about creating a module in NHSN for COVID-19 reporting
began in March 2020. One CDC official reported that developing and launching the
COVID-19 Module itself occurred over 10 days, from April 16 to April 25. Agency
officials noted that the development of new NHSN modules prior to February 2020
“normally took multiple years.” Another official explained that existing system
infrastructure and field expertise, in addition to the allocation of additional resources,
allowed for an expedited module development process.
CDC anticipated and made preparations to address the enrollment surge,
including simplifying the onboarding process, allocating additional staff,
and hosting support calls. Following the development of the COVID-19 Module,
CDC identified potential challenges associated with enrolling a large volume of new
users who are unfamiliar with NHSN and electronic reporting. According to
Surveillance Branch officials, CDC used several strategies to alleviate strain during the
enrollment surge, such as the following:
•
Simplified enrollment process. Nursing homes initially submitted data to the
COVID-19 Module that consisted of aggregate, facility-level information, but not
personally identifiable information. CDC created an enrollment process with
SAMS Level 1 access for nursing homes newly enrolling in NHSN to report
COVID-19 data. The simpler process reduced the length of enrollment from
several weeks to a maximum of 2 days.
•
Click squad. CDC established a task force called the “click squad” to manually
review and approve invitations, and to respond to facilities. The click squad
consisted of Surveillance Branch staff and other agency staff not normally involved
with NHSN, including detailees and contractors.
•
Conference calls. The Surveillance Branch also hosted conference calls to ease
the burden on the NHSN Help Desk. CDC staff held the calls two to three times
per week during the mass enrollment period to provide direct support to nursing
homes. CDC officials reported that the conference calls were well-attended,
sometimes with “hundreds of facilities” on the call.
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The NHSN Help Desk and other systems experienced difficulties
providing support to newly enrolling facilities
Mass enrollment of nursing homes caused significant strain on the NHSN Help Desk.
The rapid increase in total NHSN users included thousands of facilities that had not
previously interacted with NHSN and now needed
additional help. The Help Desk had no phone support, so
user support specialists often had to walk new users
through their questions via email, in addition to facilitating
all other inquiries and enrollment activities, which resulted
in a bottleneck. According to CDC, Surveillance Branch
staff worked 60 to 80 hours a week to manage the
increased onboarding and Help Desk tickets during the
initial 6 to 8 weeks of nursing homes enrolling in the
COVID-19 Module.
CDC assigned additional staff to the NHSN Help Desk in anticipation of enrollment-
related challenges, but the Help Desk continued to experience difficulties. CDC
reported that the agency increased work hours of existing user support specialists,
reallocated other CDC contractors, detailed staff from various task forces, and pulled
members from other teams to help respond to users. Still, according to one official,
the NHSN Help Desk had delayed responses and a growing backlog of unresolved
tickets. CDC explained that user support requests related to COVID-19 data
submission had an expected wait time of 1 to 3 weeks, depending on the subject
matter, as compared to a typical 2 to 5 days prior to the pandemic.
The enrollment surge also impacted other CDC user support systems. The SAMS Help
Desk, operated by Digital Services to provide SAMS-related support to users via email
and telephone, faced difficulties as a result of NHSN users needing assistance. CDC
reported that Digital Services frequently coordinated with the Surveillance Branch to
address problems and to proactively mitigate challenges during influxes in
enrollment. Collaboration between both teams also included discussions about
NHSN-related inquiries that came to the SAMS Help Desk. The SAMS Help Desk
often received NHSN-related telephone calls through its phone line. One nursing
home representative recalled contacting the SAMS Help Desk with NHSN-related
inquiries because it had a phone line, but being told that the facility could only
receive the help it needed from the NHSN Help Desk. One Digital Services official
reported that the SAMS Help Desk “felt the brunt of escalations related to urgency” in
interactions with frustrated users. The official further stated that users wanting to
speak with someone, but not being able to, was a “pinch point.”
“[User volume]
almost doubled
overnight, while we
didn’t double our
staff overnight to
deal with it.”
– CDC official
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Nursing homes experienced difficulties enrolling in NHSN, such
as with registering staff to report data
Most newly enrolling nursing homes (86 percent) had challenges with various aspects
of NHSN enrollment.i, j These facilities reported a range of difficulties, including
challenges registering staff to input data (67 percent) and receiving technical
assistance from CDC (56 percent). (See Exhibit 2.)
Exhibit 2: Newly enrolled nursing homes reported difficulties enrolling in
NHSN during the COVID-19 pandemic (n=117).
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.
Nursing homes made efforts to address the enrollment difficulties, most often
proactively seeking assistance from CDC and others. Nearly half of the newly
enrolling facilities (49 percent) reached out to the CDC NHSN Help Desk for
assistance, and 30 percent reached out to CMS. Nursing homes also sought
assistance from other sources. For example, 38 percent reached out to their
corporate or facility chain, and 20 percent contacted nongovernment organizations,
such as trade and membership groups, to seek assistance navigating the process.
_____________________________________________________________________________________________________________________________
i Survey respondents indicated whether they enrolled in NHSN prior to the CMS reporting requirements
in May 2020. Upon indicating that they newly enrolled in the system, respondents were prompted by the
survey to answer several questions about enrollment. This created a sample subset of 117 facilities.
j OIG analysis of survey responses concluded that 101 of 117 newly enrolling facilities reported having
difficulty with at least one of the listed enrollment aspects.
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CDC changes to NHSN data fields and security resulted in new
challenges for the agency and nursing homes:
August–December 2020
Following nursing homes enrolling in and beginning to report data to NHSN, CDC
made several changes to the system to incorporate more information that HHS and
stakeholders requested to inform pandemic response efforts. The newly requested
data, such as point-of-care (POC) testing information, included personally identifiable
information, which resulted in many nursing homes needing to upgrade their SAMS
security access from Level 1 to Level 3. The transition to a higher level of security
access required a more difficult and complex process (referenced in SAMS
Registration on page 6). This resulted in an additional backlog of Help Desk requests.
CDC worked with stakeholders to add new data fields to NHSN
following pandemic-related developments
CDC reported that changes in the COVID-19 response, environment, and knowledge
resulted in new data needs, and that the agency expanded data elements as
countermeasures became available. The development of new pandemic response
efforts resulted in the immediate need for data and rapid additions to the COVID-19
Module. For example, CDC added therapeutics-related variables to determine which
nursing homes obtained and used, and how successful they were in obtaining,
antiviral and antibody therapies. CDC also included fields about the types of
COVID-19 vaccines being administered to identify any distinctions.
CDC subject-matter experts, such as doctors, nurses, and infection preventionists,
developed NHSN questions as the pandemic continued. In developing the
vaccine-related variables, they determined the level of detail and flexibility to build
into the system for future accommodations, such as new manufacturers. CDC also
collaborated with external stakeholders throughout the pandemic to update NHSN
modules and data fields.
CDC collaborated with CMS and other partners to add data fields to
NHSN, and considered the burden to nursing homes. One CDC official
reported that collaboration with stakeholders—including trade organizations and
Federal, State, and local agencies—that wanted certain data was critical in adjusting to
different phases of the pandemic. For example, another CDC official explained that
the agency added questions related to POC tests and testing supplies after receiving
requests from Federal stakeholders involved in the pandemic response. CDC also
presented proposed changes to external partners to solicit feedback when unsure
about potential alterations to NHSN.
CMS provided input as CDC was developing additions to the COVID-19 Module. CMS
reported that it provided feedback before and after CDC deployed certain changes,
and about any changes CDC suggested. One CMS official stated that leadership and
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technical teams from both agencies regularly met and discussed strategic needs
during the development of the Vaccinations Module. After launching the new
module for voluntary data submission, CDC and CMS discussed expanding the
reporting requirements to mandate vaccine-related reporting. One CDC official
characterized the collaboration as involving constant communication about user
feedback, submitted data, and additional information that may be necessary.
CDC reported taking the nursing home burden into account when implementing
changes to the COVID-19 Module. The agency said that, although NHSN data
collection is valuable to CDC and other stakeholders, adding reporting obligations
required caution. One official noted that the “same people” submitting data are the
ones “taking care of the patients.” A CMS official reported that, while discussing
changes to the COVID-19 Module to meet data collection needs, both agencies
recognized the need to consider the burden on facilities. Another CDC official
explained that making sudden changes to questions in NHSN does not promote
standardized surveillance practices, because it is a significant undertaking for
thousands of nursing homes to quickly alter their reporting.
Changes to the COVID-19 Module resulted in additional
difficulties, such as an increased backlog of requests for
assistance
The growing interest in patient-level COVID-19 data led CDC to prepare nursing
homes to upgrade their security access levels to submit personally identifiable
information to NHSN. CDC began conducting outreach to facilities about
transitioning their security access level during August and September 2020. CDC
explained that it used a phased approach for facility outreach, with a goal of
contacting 2,500 nursing homes per week. One official said that it was difficult to
persuade facilities to voluntarily convert their SAMS access level status immediately.
CDC continued its outreach efforts, but nursing homes did not upgrade their security
access levels evenly over time. On October 19, 2020, HHS issued a requirement for
facilities to report POC COVID-19 test results through existing channels, including
NHSN.69, 70, k CDC said that the majority of nursing homes using NHSN to fulfill this
requirement started the process to upgrade their security access levels near the
November 2020 deadline.
The reporting requirement resulted in an influx of nursing homes upgrading their
security access level, with problems exacerbated by the combination of a compressed
_____________________________________________________________________________________________________________________________
k Nursing homes were able to fulfill this HHS requirement by reporting data (1) directly to their State,
Territorial, local, and Tribal public health departments; (2) to a State or regional information exchange; (3)
to NHSN; or (4) to a centralized platform other than NHSN. Reporting POC COVID-19 test results via
NHSN was the CDC- and CMS-preferred method. See CDC, COVID-19 Pandemic Response, Laboratory
Data Reporting: CARES Act Section 18115, March 8, 2022, p. 5. Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/downloads/lab/HHS-Laboratory-Reporting-Guidance-
508.pdf on February 2, 2023.
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timeline and the weeks-long process involved in the upgrade. According to one CDC
official, the transition to higher-level security access presented more difficulties than
the initial mass enrollment in NHSN. The volume of upgrades strained the SAMS
infrastructure due to a bottleneck with the identity verification process. (See
Appendix C for the step-by-step enrollment process published by CDC.) Many
nursing homes had to restart their upgrade processes, because SAMS had workflow
timers that automatically removed applicants for lack of activity after not completing
identity verifications over a set period of time. According to one Digital Services
official, SAMS experienced the most significant backlog of facilities during the
upgrades at the end of 2020.
The majority of newly enrolled nursing homes reported that
upgrading their SAMS access levels was a difficult process
Among the sample nursing homes, many reported experiencing challenges upgrading
their security access level. Of the 117 newly enrolled facilities, 72 percent found
upgrading their access level to be difficult—either very difficult (39 percent) or
somewhat difficult (33 percent). (See Exhibit 3.)
Exhibit 3: Newly enrolled nursing homes reported difficulties upgrading
from SAMS Level 1 to Level 3 access (n=117).
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.
Note: The total sum of the percentages above does not equal 100 percent because of rounding.
“They were sitting on a queue of 10,000 [upgrade requests] and can
only get through 100 or so per day. That’s where the big issue
happened.“ – Digital Services official
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Multiple nursing homes reported that it took a significant amount of time for their
NHSN Administrators to upgrade their security access levels, with one facility
reporting that it did not receive access until a year later. A representative from
another nursing home described how not receiving timely assistance from the Help
Desk inhibited the facility from fulfilling that week’s reporting requirements.
CDC has improved nursing home experiences reporting to the
COVID-19 Module throughout the pandemic
Following the initial implementation and early additions to the COVID-19 Module,
CDC has continued to communicate with nursing homes; make changes to reduce the
reporting burden; and collaborate with CMS and other stakeholders. CDC reported
that improvements to the system have been necessary to alleviate challenges for both
the agency and NHSN users, such as nursing homes. CDC addressed enrollment
difficulties by streamlining the process using quicker and more accessible identity
verification tools. To reduce any unnecessary reporting burden, CDC also worked
with CMS to determine what data are no longer critical to collect.
CDC has continued to communicate with and provide guidance
and resources to nursing homes
Following the launch of the COVID-19 Module in April 2020, CDC has continued to
produce and regularly update online webpages, interactive webinars, virtual trainings,
and various guidance documents related to nursing home reporting. CDC recorded
and uploaded training resources online, and collaborated with external partners to
provide and disseminate additional resources, such as responses to frequently asked
questions.
CDC reported using multiple channels of outreach to share information about the
COVID-19 Module. The agency has maintained a list of active email addresses,
collected during the enrollment process, for every NHSN Administrator submitting
data to the system. Throughout the pandemic, the agency sent emails to notify
facilities of new guidance and resources, such as details for upcoming trainings, and
changes or updates to the COVID-19 Module.
CDC conducted additional outreach through collaboration with external partners.
CMS frequently invited CDC representatives to share new NHSN-related guidance and
changes, and to answer questions during webinars and weekly stakeholder calls with
nursing home administrators, directors of nursing, and others. CDC explained that it
also worked with nursing home chains, trade organizations, and State health
departments to disseminate information to facilities. For example, the Surveillance
Branch worked with internal and external partners to publish guidance that addressed
frequently asked questions. One CDC official said the “comprehensive approach to
getting the information out is the key to [NHSN’s] success.”
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Ongoing nursing home challenges have led to additional
enrollment-related improvements
To address the significant delay in the identity verification process, CDC’s Digital
Services implemented two new system improvements in October 2021 to upgrade
users’ security access levels. One Digital Services official reported that CDC
contracted with a financial credit company to expedite identity verification. The
streamlined process involves SAMS directing applicant information, such as date of
birth, telephone number, and Social Security number, to the contracted system for
verification. The user then answers five credit history-related questions to complete
the process. Users who choose not to participate in the contracted process may still
use the original method.
CDC further improved the enrollment process by providing a more direct way of
receiving a second form of authentication. According to the Digital Services official,
an individual would previously receive a physical token by mail, which allowed the
user to log in to NHSN. Digital Services then introduced a self-service portal and a
corresponding mobile authenticator application that provides immediate access to
the system. The official reported that, after the deployment of the instant
authenticator, CDC saw a significant shift from the use of physical cards to use of the
mobile authenticator.
CDC has collaborated with CMS and other stakeholders to reduce
data variables no longer deemed necessary and further ease the
reporting burden on facilities
While nursing homes may benefit from reduced reporting, the potential removal of
data variables posed challenges to CDC. A CDC official explained that it was more
difficult to remove than to add pandemic-related fields because removing certain
elements could conflict with CMS reporting requirements.
CDC involved input from CMS and trade organizations in decisions about removing
data variables throughout the pandemic. CDC reported that, toward the end of 2021,
it began receiving and reviewing feedback from stakeholders that confirmed that
certain data elements were no longer necessary. One official stated that as COVID-19
cases decreased, CDC received more feedback from nursing homes requesting that it
reduce the number of questions. Facilities were more receptive about the need for
data collection during increases in COVID-19 case counts, but were in “crisis mode
with providing care.”
CDC has continued to collaborate with CMS and stakeholders to determine what data
fields to change or remove in NHSN, while still fulfilling CMS reporting requirements.
For example, CDC removed the Ventilator Capacity and Supplies Pathway in July 2021.
According to one official, CDC began the process of eliminating variables related to
ventilators after facilities and other stakeholders communicated that the information
was no longer necessary to make resource decisions. CDC reviewed data to find that
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nursing home use of ventilators had decreased, and removed the pathway after CMS
did not contest its elimination.
CDC has continued to reduce the amount of data nursing homes must report to the
COVID-19 Module. As described on page 8, in November 2021, nursing homes were
required to report up to 132 data points to NHSN (including questions to elaborate
on selected response options). By August 2023, that number dropped to 37 data
points.
Nursing home experiences with reporting have improved since
May 2020, though issues remain for both facilities and CDC
As of June 2022, nursing homes noted that the process for reporting COVID-19 data
has improved. However, some facilities still reported experiencing issues with
reporting and difficulties receiving timely support from the NHSN Help Desk.
Facilities reported that CDC improvements have helped nursing
homes reporting COVID-19 data to NHSN
Survey results indicated that CDC actions have led to improvements in the ability of
nursing homes to submit data to the COVID-19 Module. Most facilities (84 percent)
noted that CDC’s communication regarding updates made to NHSN has improved.
Facilities also recognized that guidance has improved, with 83 percent reporting that
guidance on how to report data to NHSN had improved, and 80 percent reporting
that guidance on what to report had improved. (See Exhibit 4 on the next page.) One
facility said that miscommunication has become less of a concern because CDC
guidance has become more clear.
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Exhibit 4: Nursing homes reported that aspects of the NHSN reporting
process have improved, as of June 2022 (n=171).
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.
Many nursing homes no longer experience challenges with the NHSN
reporting process that existed earlier in the pandemic. A number of nursing
homes identified several previous issues with reporting that they no longer
experienced as of June 2022. Challenges that nursing homes reported previously
experiencing at a higher rate included confusion about how to report
(37 percent) and technical difficulties with reporting (35 percent). Further, some
facilities (16 percent) reported having past challenges with limited time or staff
available to report. (See Exhibit 5 on the next page.) A corporate representative for
one facility explained that clinical staff manage multiple tasks, such as conducting
COVID-19 tests and maintaining supplies, and data submission added to these
existing time commitments.
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Exhibit 5: Nursing homes reported past and current challenges with
reporting to NHSN, as of June 2022 (n=171).
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.
Note: The total percentages for some of the challenges above do not sum to 100 pecent because of rounding.
CDC reported that nursing homes had initial concerns about how to interpret certain
data elements, such as which fields were requesting incident or cumulative
information, and what to do with data for former residents no longer at the facilities.
The agency noted a continued need to facilitate nursing home reporting to NHSN.
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Despite CDC actions, ongoing nursing home challenges suggest a
need for further improvements to the NHSN system and
processes
Some nursing homes identified multiple challenges with reporting to NHSN, which
were ongoing as of June 2022. For example, 36 percent of facilities reported that
having limited time or staff available made it difficult to submit data, while 13 percent
reported being uncertain about what data they were required to submit to NHSN.
(See Exhibit 5 on the preceding page.)
Some nursing homes have had worsening experiences reporting to NHSN
over the course of the pandemic. For example, 22 percent of facilities reported
that receiving error messages when attempting to submit data had worsened, and
9 percent reported that CDC communication regarding updates to NHSN had
worsened. (See Exhibit 6.) A corporate representative for one nursing home
described how the time commitment for reporting was a burden that increased over
time, causing the organization to dedicate three full-time employees to handling
COVID-19 reporting across their facilities. The representative also noted that the
organization’s internal processes for collecting and submitting required data were
hampered by updates to NHSN because there was a lack of information in advance
about the changes.
Exhibit 6: Nursing homes reported that aspects of the NHSN reporting
process have worsened, as of June 2022 (n=171).
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.
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Nursing homes faced difficulties receiving timely and useful
assistance from the NHSN Help Desk, which did not keep up with
user support requests and communicated only via email
Nursing homes reported that NHSN Help Desk responses were often not
prompt or useful. Facilities reported reaching out to the NHSN Help Desk for
support during the pandemic. As of June 2022, 85 percent of facilities had sought
help from the Help Desk. The majority of these nursing homes (63 percent) reported
having issues with the responses to their inquiries. Nursing homes reported that
assistance was delayed (33 percent); not useful (8 percent); or both delayed and not
useful (19 percent). A small number of nursing homes (3 percent) reported not
receiving a response from the Help Desk. (See Exhibit 7.)
Exhibit 7: Nursing homes reported difficulties receiving timely and useful
assistance from the NHSN Help Desk, as of June 2022 (n=145).
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.
The NHSN Help Desk only supported users via email, without alternatives such as a
phone line or live chat support. Several nursing home representatives noted that this
made interactions particularly cumbersome and frustrating. One facility
representative said they submitted multiple questions to the Help Desk, but never
received responses that specifically addressed their concerns. Rather, they always
received generic responses that referenced the NHSN webpage for frequently asked
questions. An administrator from another nursing home reported receiving delayed
assistance from the NHSN Help Desk, which resulted in the facility missing a reporting
deadline and being fined. A corporate representative for one nursing home noted
reaching out to a Quality Improvement Organization for assistance instead of
continuing to contact the Help Desk.71 The representative explained that Help Desk
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responses did not address the facility’s questions, and reaching out to the Help Desk
was confusing in general.
The NHSN Help Desk had ongoing difficulty addressing its backlog of
user requests, despite using strategies to streamline processes. Despite
CDC efforts, the NHSN Help Desk continues to experience a backlog of user support
requests. CDC reported that it detailed additional staff and pulled members from
other teams to help respond to user inquiries. Still, the Help Desk experienced
challenges in offsetting the continuous influx of tickets brought about by the
substantial increase in total users. One official explained that the NHSN Help Desk
received 300 to 500 new tickets daily, which were “physically impossible” to
individually triage on the same day.
In addition, the NHSN Help Desk often needed more information than what users
provided in their email inquiries to deliver thorough responses. The need for
back-and-forth correspondence, in addition to the large quantity of tickets,
contributed to delay of responses. One CDC official added that staff turnover in
nursing homes, which resulted in new users, was another cause of the continuing flow
of Help Desk tickets. The official also reported that the Surveillance Branch ultimately
did not have the necessary resources to fully respond to facilities requesting
assistance at this scale. A different official said that, as of May 2022, the NHSN Help
Desk still had a backlog of unanswered and untriaged tickets, but that the backlog
was not as significant as it was in 2020.
According to CDC, the NHSN Help Desk used various strategies to improve efficiency.
The agency reported that the Help Desk added internal training for user support
specialists. In addition, Help Desk staff developed a bank of “canned responses,” or
copied and pasted template responses, to common inquiries. The NHSN Help Desk
also created a new email address specifically for enrollment-related questions, and
encouraged users to include specific subject lines in their emails to expedite the triage
of inquiries to specific NHSN subject-matter experts.
CDC has made efforts to ensure data quality, but nursing homes
reporting to the COVID-19 Module expressed concerns
CDC established QA criteria to address data issues identified during the early stage of
the required COVID-19 nursing home reporting. The agency conducted outreach to
some facilities with notable data concerns and built visual alerts for QA flags into the
system. Despite CDC efforts, some facilities reported not feeling confident about the
completeness or accuracy of the nursing home COVID-19 data in NHSN.
The agency identified data quality issues and built QA checks into
its processes
CDC flagged potential data quality problems early in its data collection. According to
agency officials, initial reviews of COVID-19 data revealed that many nursing homes
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reported cumulative data instead of incident-level data. CDC analyzed data from the
COVID-19 Module in May and June 2020 to identify patterns that may suggest data
entry errors, such as repeated or cumulative values, in certain variables related to
COVID-19 cases and deaths. CDC then established QA criteria to identify outliers that
indicate potential data quality issues.
CDC began contacting nursing homes in June 2020 in response to the initial data
quality issues. The agency stated that the Surveillance Branch produced monthly
reports with an emphasis on information related to COVID-19 cases, deaths, and
other key fields. If a facility’s data exceeded the outlier threshold, Surveillance Branch
staff emailed or called the nursing home, or notified the relevant State health
department.l Once in contact with the facility, the agency staff members verified the
information or helped the nursing home user correct it. According to one CDC
official, the frequency of outreach to nursing homes has declined over time.
CDC also built visual QA flags into the COVID-19 Module to identify and reduce data
errors. If submitted data activate the QA flags, system alerts visually notify the user of
possible data entry issues. The user can then click on the alert to navigate to the issue
and fix the problem. CDC reported that the Surveillance Branch now takes a two-
pronged approach to improve data quality: visual alerts in NHSN and direct outreach,
when necessary.
CMS’s QA checks provide another opportunity to identify problems with data
reported to the COVID-19 Module. CDC reported that NHSN shares nursing home
COVID-19 data with CMS at the end of each reporting week, after which CMS
conducts its own QA check on the data. CMS removes a nursing home’s data from its
publicly available nursing home datasets if the data failed its QA checks. CMS is able
to take enforcement actions, including fines, if it identifies that a facility has not met
its weekly reporting obligations.
Nursing home challenges with reporting may result in inaccurate
COVID-19 data reported to NHSN
More than one in four facilities reported not being confident that the data nursing
homes have submitted to NHSN are complete and accurate. One administrator
stated that data may be omitted in instances of facility staff turnover, after which the
new NHSN Administrator does not have access to previous records used to submit
data to the COVID-19 Module.
_____________________________________________________________________________________________________________________________
l CDC does not have the authority to take punitive action against a nursing home that does not meet its
weekly reporting obligation.
“I can almost guarantee you, as complicated as this data is, there
are facilities that are not reporting correctly.”
– Nursing home corporate representative
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A corporate representative for another facility expressed having no confidence that
the data are accurate, because the definitions for the data variables are unclear and
leave room for varying interpretations. Regarding COVID-19 vaccinations, one
nursing home representative said it was difficult to have complete confidence with
staff vaccination counts and rates when turnover leads to complicated week-to-week
changes in data.
CDC plans to continue improving NHSN for nursing home
reporting and is considering how to leverage national
enrollment for voluntary reporting on other health events
As noted, CMS will continue to require nursing homes to report a full range of
COVID-19 data through December 2024, while the vaccination-related data mandate
will be ongoing. This means that required weekly reporting by nursing homes to
NHSN will continue. CDC officials reported considering how the agency might
leverage this national enrollment and reporting to track other health events.
In May 2023, CDC reported that it has been focused on current reporting and related
changes to the system, and has not yet planned an approach for encouraging
voluntary reporting after some requirements expire. One official noted that CDC
intends to keep all portions of the COVID-19 Module accessible to nursing homes
after requirements expire. Additionally, the agency intends to encourage voluntary
reporting to NHSN.
There is precedent for voluntary reporting by nursing homes to NHSN. Prior to the
COVID-19 pandemic, more than 3,000 nursing homes were enrolled in NHSN to
voluntarily report data on HAIs and infection prevention measures. One CDC official
noted that during the pandemic, a third of nursing homes (about 5,000) reported data
on individual COVID-19 tests for optional data fields. Another official said that it is
difficult to accurately predict how many nursing homes will voluntarily report
COVID-19 data after the requirements expire.
CDC plans to continue modernization of NHSN data collection,
such as automating data input
CDC reported that it is investing significant resources to modernize NHSN as part of a
larger data initiative within the agency.m One official stated that it is essential to
continue the “modernization of the [information technology] structure” within NHSN,
with the goal of making the system more automated and less of a burden on facilities.
For example, according to CDC officials, the agency has considered the possibility of
_____________________________________________________________________________________________________________________________
m In July 2023, CDC clarified to OIG that continued modernization and enhancement of NHSN were
contingent on the agency receiving funds detailed in its 2024 budget request to Congress. See HHS,
CDC, Fiscal Year 2024 Justification of Estimates for Appropriations. Accessed at
https://www.cdc.gov/budget/documents/fy2024/FY-2024-CDC-congressional-justification.pdf on
August 15, 2023.
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Findings | 31
developing an interaction between NHSN and facility electronic health records that
would input certain information directly into NHSN.
As a part of pursuing its modernization objectives, CDC is looking at ways to improve
data collection efforts in the future, in part by reflecting on its experience using NHSN
during its pandemic response. One official noted that automated improvements to
SAMS, such as streamlined identity verification during enrollment, have saved time
and effort granting facilities access to the system. CDC reported that its teams have
continued to rethink the best ways to be “more proactive and ready to help” nursing
homes interacting with NHSN for ongoing required and voluntary reporting.
Facilities suggested several ways CDC could better facilitate nursing home
reporting to NHSN. Nursing homes noted that CDC should be more responsive
and easier to reach for assistance. More than one-third of facilities (58 of 171)
reported that CDC being more responsive to support tickets would be the most
significant way to improve NHSN support. (See Exhibit 8.) One nursing home said
that a phone line for the NHSN Help Desk is necessary for providing more immediate
assistance. Another facility agreed that telephone support should be offered and
added that it would be particularly helpful with the enrollment process.
Exhibit 8: Nursing homes reported actions CDC could take to better facilitate
nursing home reporting to NHSN (n=171).
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.
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Findings | 32
CDC reported that it is considering how to leverage national
nursing home enrollment in NHSN to encourage participation in
reporting for other health care outcomes
One agency official reported that multiple stakeholders have expressed the desire to
maintain national nursing home reporting after the public health emergency. The
agency has communicated with CMS about the value of nursing home reporting and
the use of NHSN for other public health surveillance. CDC reported that it continues
to collaborate with CMS about COVID-19 data requirements and how NHSN data
could be used to inform other public health and nursing home quality and safety
efforts, such as CMS quality measures for nursing homes. A CDC official said that
NHSN has “clearly demonstrated it is the platform” to be used for these data
collection efforts, and that nursing home reporting to the COVID-19 Module could
serve as a foundation for collecting data related to various health care issues.
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Conclusion and Recommendations | 33
CONCLUSION AND RECOMMENDATIONS
NHSN has been a critical data collection tool for the national COVID-19 pandemic
response in nursing homes. Following initial challenges with the influx of nursing
home enrollment, CDC made improvements to the enrollment and reporting
processes. CDC collaborated with external partners, such as CMS, and other
stakeholders to disseminate guidance, communicate with nursing homes, and
implement important changes to the COVID-19 Module. Facilities reported that some
challenges were resolved, but that other difficulties are ongoing. Over time, CDC has
reduced the number of variables needed to meet requirements. Beginning in January
2025, required variables related to infections, deaths, and staffing will expire. Nursing
homes will continue to be required to report COVID-19 vaccination data to NHSN,
and may voluntarily report other variables.
CDC efforts have resulted in a better reporting experience, but more improvements
are needed to facilitate nursing home reporting and ensure data quality. These
improvements will also facilitate CDC efforts to leverage national nursing home
enrollment for potential ongoing and future use of NHSN.
We recommend that CDC:
Improve the user support the NHSN Help Desk provides to
nursing homes
CDC officials recognized that the NHSN Help Desk faced challenges due to the influx
of facilities requesting extensive support. The Help Desk, which is only accessible via
email, was quickly overwhelmed with user support requests, but did not see a
proportional increase in staff to meet the higher demand. Despite agencywide
efforts, such as the deployment of the “click squad,” the NHSN Help Desk has
struggled to meet the needs of nursing homes reporting to the system.
CDC should add communication channels to provide direct assistance to NHSN users.
This should include adding telephone or live chat support functions so nursing homes
can have questions answered in real time and provide feedback about their
experiences enrolling in and reporting to the system. Providing an option for NHSN
users to directly communicate with a user support specialist may promote more
accurate, timely, and complete reporting, and build on the relationship between the
agency and NHSN users. CDC should also improve its ability to increase its Help Desk
staffing during periodic influxes of requests, such as when reporting needs or
guidance changes.
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Conclusion and Recommendations | 34
Take further steps to ensure the quality of nursing home
reporting of COVID-19 data to NHSN
To address nursing home concerns about the accuracy of COVID-19 data reported to
NHSN, CDC should take further steps to provide guidance and technical assistance to
facilities, and to ensure appropriate QA processes. The agency should work toward
addressing the root causes of data quality issues by reviewing its overall approach to
guidance and support, to best determine what efforts have been beneficial to fostering
quality data reporting. For example, CDC could issue more explicit guidance on data
definitions to reduce variations in nursing homes’ interpretations, and offer technical
assistance related to maintaining data reporting during times of staff turnover. For its
participation in webinars and trainings, CDC should ensure that it provides detailed and
practical responses to the array of nursing home questions it may encounter.
Consider how quality assurance checks can be enhanced to
ensure data accuracy, as appropriate
To support quality data collection efforts ongoing and in the future, CDC should assess
how it can enhance its QA checks for the full range of COVID-19 data it will collect from
nursing homes. Data that nursing homes enter into NHSN is self-reported. It is possible
that facilities submit inaccurate information that is not detected by automated review
processes currently built into the system. Therefore, CDC should consider how it can
improve existing QA checks, as well as determining what additional QA processes it can
use to better ensure that NHSN has accurate data from facilities. CDC could also apply
these ideas to promote data accuracy and quality in any future expansions of its data
collection from nursing homes through NHSN.
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Agency Comments and OIG Response | 35
AGENCY COMMENTS AND OIG RESPONSE
CDC partially concurred with the first recommendation and concurred with the
second and third recommendations, and reported its planned actions to implement
the recommendations.
CDC partially concurred with the first recommendation to improve the user support
the NHSN Help Desk provides to nursing homes. CDC reported that it has made
improvements to the Help Desk and now offers more ways for facilities to receive
support through a new customer service portal. CDC stated that in the new portal,
inquiries from NHSN users are sent directly to the appropriate support specialist or
subject-matter expert, resulting in faster responses. CDC also noted that it has
increased staffing and relevant trainings for the Help Desk, and that there is no longer
a backlog of support requests from nursing homes. OIG appreciates CDC’s efforts to
improve the NHSN Help Desk support for its users, and acknowledges CDC’s
increased staffing for the Help Desk. However, OIG continues to recommend that
CDC also prioritize implementing telephone or live chat functionality for its Help Desk,
when resources are available, to ensure that facilities have the option to obtain real-
time assistance. Providing direct user communication with the Help Desk can help
promote accurate, timely, and complete reporting. OIG also continues to recommend
that CDC ensure its ability to dedicate or reallocate staff, as necessary, in case an
influx of requests occurs again.
CDC concurred with our second recommendation to take further steps to ensure the
quality of nursing home reporting of COVID-19 data to NHSN. CDC stated that it will
expand its efforts to provide training materials and tools to NHSN users and health
care facilities. CDC reported that it has taken a multi-pronged approach to ensure
accurate vaccination status data reporting, including providing training on NHSN for
LTCFs and conducting real-time outlier analysis that has led to the agency contacting
more than 8,000 facilities about their data. OIG appreciates CDC’s efforts to improve
the quality of nursing home reporting to NHSN. We believe that CDC’s planned
actions, when completed, will fulfill this recommendation.
CDC also concurred with our third recommendation to consider how quality
assurance checks can be enhanced to ensure data accuracy, as appropriate. CDC
stated that it will review its processes to identify opportunities to improve its data
quality checks, user education, and outreach. CDC also noted that incorporating
active quality checks, such as data validation, would require additional resources and
staff. OIG appreciates CDC’s commitment to identify opportunities for improvement.
We look forward to the results of CDC’s review and learning more about CDC’s
improvement plans in its final management decision.
For the full text of CDC’s comments, see Appendix E.
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Appendix A | 36
APPENDICES
Appendix A: Estimates, Confidence Intervals, and Key Statistics
for Nursing Home Survey Results
The exhibits listed below provide key statistics to support our projected results for
each nursing home survey question used in the findings of this report. The estimates
are based on a sample of 171 nursing homes that reported required COVID-19 data
to the NHSN LTCF COVID-19 Module at least once between May 24 and December
26, 2021. Exhibits A-1 through A-3 (n=117) and Exhibit A-7 (n=145) use subsets of
nursing homes resulting from respondents selecting specific answers that filtered
survey questions.
Exhibit A-1: Nursing homes that reported difficulty with at least one aspect
of enrollment in their responses to “How easy or difficult were the following
aspects of enrolling your facility in NHSN?” (n=117)
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Any enrollment difficulty
101
86.32%
78.74%
91.98%
Exhibit A-2: Nursing home responses to “How easy or difficult were the
following aspects of enrolling your facility in NHSN?” (n=117)
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Finding guidance and resources
Very easy
14
11.97%
6.70%
19.26%
Somewhat easy
48
41.03%
32.02%
50.50%
Somewhat difficult
33
28.21%
20.28%
37.27%
Very difficult
13
11.11%
6.05%
18.25%
I don’t know
9
7.69%
3.58%
14.10%
Registering users
Very easy
12
10.26%
5.41%
17.23%
Somewhat easy
26
22.22%
15.06%
30.84%
Somewhat difficult
52
44.44%
35.26%
53.92%
Very difficult
26
22.22%
15.06%
30.84%
I don’t know
1
0.85%
0.02%
4.67%
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Appendix A | 37
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Upgrading SAMS from Level 1 to Level 3
Very easy
6
5.13%
1.90%
10.83%
Somewhat easy
19
16.24%
10.07%
24.19%
Somewhat difficult
38
32.48%
24.11%
41.76%
Very difficult
46
39.32%
30.41%
48.77%
I don’t know
8
6.84%
3.00%
13.03%
Receiving electronic communication
Very easy
33
28.21%
20.28%
37.27%
Somewhat easy
46
39.32%
30.41%
48.77%
Somewhat difficult
24
20.51%
13.61%
28.97%
Very difficult
13
11.11%
6.05%
18.25%
I don’t know
1
0.85%
0.02%
4.67%
Receiving technical assistance
Very easy
14
11.97%
6.70%
19.26%
Somewhat easy
31
26.50%
18.77%
35.45%
Somewhat difficult
30
25.64%
18.02%
34.54%
Very difficult
36
30.77%
22.57%
39.97%
I don’t know
6
5.13%
1.90%
10.83%
Exhibit A-3: Nursing home responses to “What actions did your facility take
to address difficulties enrolling in NHSN?” (n=117)
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Held staff training on
enrolling in NHSN
14
11.97%
6.70%
19.26%
Acquired additional
technology
2
1.71%
0.21%
6.04%
Requested assistance
from CDC
57
48.72%
39.37%
58.13%
Requested assistance
from CMS
35
29.91%
21.80%
39.07%
Requested assistance
from nongovernment
organization
23
19.66%
12.89%
28.02%
Requested assistance
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Appendix A | 38
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
from your facility chain or
corporate ownership
45
38.46%
29.62%
47.91%
I do not know
2
1.71%
0.21%
6.04%
Our facility did not take
any action
9
7.69%
3.58%
14.10%
Receiving technical
assistance
3
2.56%
0.53%
7.31%
Exhibit A-4: Nursing home responses to “To what extent have the following
aspects of reporting to NHSN become better or worse since your facility
began using the system?” (n=171)
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Guidance on how to report
Better
142
83.04%
76.56%
88.34%
Somewhat better
97
56.73%
48.94%
64.27%
Much better
45
26.32%
19.89%
33.58%
Worse
13
7.60%
4.11%
12.65%
Somewhat worse
11
6.43%
3.25%
11.22%
Much worse
2
1.17%
0.14%
4.16%
I don’t know
16
9.36%
5.44%
14.75%
Guidance on what to report
Better
137
80.12%
73.34%
85.82%
Somewhat better
93
54.39%
46.61%
62.01%
Much better
44
25.73%
19.36%
32.96%
Worse
20
11.70%
7.29%
17.48%
Somewhat worse
17
9.94%
5.90%
15.44%
Much worse
3
1.75%
0.36%
5.04%
I don’t know
14
8.19%
4.55%
13.36%
CDC communication of updates
Better
143
83.63%
77.21%
88.84%
Somewhat better
87
50.88%
43.13%
58.59%
Much better
56
32.75%
25.78%
40.33%
Worse
16
9.36%
5.44%
14.75%
Somewhat worse
11
6.43%
3.25%
11.22%
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Appendix A | 39
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Much worse
5
2.92%
0.96%
6.69%
I don’t know
12
7.02%
3.68%
11.94%
Adding or changing users to report data
Better
101
59.06%
51.30%
66.51%
Somewhat better
74
43.27%
35.73%
51.06%
Much better
27
15.79%
10.67%
22.14%
Worse
32
18.71%
13.17%
25.38%
Somewhat worse
23
13.45%
8.72%
19.50%
Much worse
9
5.26%
2.43%
9.76%
I don’t know
38
22.22%
16.23%
29.20%
Submitting data without error messages
Better
121
70.76%
63.33%
77.45%
Somewhat better
81
47.37%
39.70%
55.13%
Much better
40
23.39%
17.27%
30.46%
Worse
37
21.64%
15.72%
28.57%
Somewhat worse
25
14.62%
9.69%
20.82%
Much worse
12
7.02%
3.68%
11.94%
I don’t know
13
7.60%
4.11%
12.65%
Ability to view and edit data
Better
138
80.70%
73.98%
86.33%
Somewhat better
79
46.20%
38.56%
53.97%
Much better
59
34.50%
27.41%
42.14%
Worse
12
7.02%
3.68%
11.94%
Somewhat worse
11
6.43%
3.25%
11.22%
Much worse
1
0.58%
0.01%
3.22%
I don’t know
21
12.28%
7.77%
18.16%
CDC communication on errors and issues
Better
120
70.18%
62.72%
76.92%
Somewhat better
80
46.78%
39.13%
54.55%
Much better
40
23.39%
17.27%
30.46%
Worse
24
14.04%
9.20%
20.16%
Somewhat worse
17
9.94%
5.90%
15.44%
Much worse
7
4.09%
1.66%
8.25%
I don’t know
27
15.79%
10.67%
22.14%
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Appendix A | 40
Exhibit A-5: Nursing home responses to “Has your facility experienced any
of the following challenges with reporting data to NHSN?” (n=171)
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Confusion about how to report
Previous challenge
64
37.43%
30.16%
45.14%
Current challenge
19
11.11%
6.82%
16.81%
No challenge
87
50.88%
43.13%
58.59%
I don’t know
1
0.58%
0.01%
3.22%
Technical issues
Previous challenge
60
35.09%
27.96%
42.74%
Current challenge
45
26.32%
19.89%
33.58%
No challenge
64
37.43%
30.16%
45.14%
I don’t know
2
1.17%
0.14%
4.16%
System not accepting data entries
Previous challenge
58
33.92%
26.87%
41.54%
Current challenge
38
22.22%
16.23%
29.20%
No challenge
73
42.69%
35.17%
50.47%
I don’t know
2
1.17%
0.14%
4.16%
Difficulty receiving assistance
Previous challenge
53
30.99%
24.16%
38.51%
Current challenge
34
19.88%
14.18%
26.66%
No challenge
80
46.78%
39.13%
54.55%
I don’t know
4
2.34%
0.64%
5.88%
Unclear or complex data fields
Previous challenge
52
30.41%
23.62%
37.89%
Current challenge
40
23.39%
17.27%
30.46%
No challenge
78
45.61%
37.99%
53.39%
I don’t know
1
0.58%
0.01%
3.22%
Uncertainty on required data
Previous challenge
52
30.41%
23.62%
37.89%
Current challenge
23
13.45%
8.72%
19.50%
No challenge
94
54.97%
47.19%
62.58%
I don’t know
2
1.17%
0.14%
4.16%
Staff turnover
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Appendix A | 41
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Previous challenge
44
25.73%
19.36%
32.96%
Current challenge
27
15.79%
10.67%
22.14%
No challenge
96
56.14%
48.36%
63.70%
I don’t know
4
2.34%
0.64%
5.88%
Lack of communication from CDC about how to fix data errors
Previous challenge
39
22.81%
16.75%
29.83%
Current challenge
26
15.20%
10.18%
21.48%
No challenge
92
53.80%
46.03%
61.44%
I don’t know
14
8.19%
4.55%
13.36%
Difficulty collecting data
Previous challenge
36
21.05%
15.20%
27.93%
Current challenge
42
24.56%
18.31%
31.72%
No challenge
91
53.22%
45.45%
60.87%
I don’t know
2
1.17%
0.14%
4.16%
Limited time or staff availability
Previous challenge
28
16.37%
11.16%
22.79%
Current challenge
62
36.26%
29.06%
43.94%
No challenge
79
46.20%
38.56%
53.97%
I don’t know
2
1.17%
0.14%
4.16%
Exhibit A-6: Nursing home responses to “CDC has an NHSN User Support
Help Desk (NHSN Help Desk) to assist facilities that use the system. Has
your facility reached out to the NHSN Help Desk?” (n=171)
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Yes, reached out to
Help Desk
145
84.80%
78.52%
89.82%
Exhibit A-7: Nursing home responses to “Overall, how responsive was the
NHSN Help Desk to your facility’s request(s) for assistance?” (n=145)
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Prompt and useful
50
34.48%
26.79%
42.82%
Not helpful
91
62.76%
54.35%
70.64%
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Appendix A | 42
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Prompt, but not useful
11
7.59%
3.85%
13.17%
Delayed, but still useful
48
33.10%
25.52%
41.40%
Delayed and not useful
28
19.31%
13.23%
26.69%
Facility did not receive
a response
4
2.76%
0.76%
6.91%
I don’t know
4
2.76%
0.76%
6.91%
Exhibit A-8: Nursing home responses to “In your opinion, are you confident
that nursing homes have submitted complete and accurate data to NHSN?”
(n=171)
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
No
49
28.65%
22.01%
36.06%
Yes
100
58.48%
50.71%
65.95%
I don’t know
22
12.87%
8.24%
18.83%
Exhibit A-9: Nursing home responses to “How can CDC better support your
facility’s ability to report COVID-19 data to NHSN?” (n=171)
Response Description
Number
in Sample
Percentage
Estimate
95-Percent Confidence Interval
Lower Bound
Upper Bound
Be more responsive to
requests for assistance
58
33.92%
26.87%
41.54%
Provide better written
instructions
56
32.75%
25.78%
40.33%
Provide more hands-on
or interactive training
49
28.65%
22.01%
36.06%
Improve communication
of NHSN updates
42
24.56%
18.31%
31.72%
Request more direct
feedback from facilities
29
16.96%
11.66%
23.44%
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Appendix B | 43
Appendix B: Changes to the LTCF COVID-19 Module
In April 2020, the LTCF COVID-19 Module consisted only of the Surveillance Reporting
Pathways.72 Later, the module expanded to include the Point-of-Care (POC) Test
Reporting Tool, in October 2020; the COVID-19 Vaccinations Module, in December
2020; and the Therapeutics Pathway, in February 2021.73, 74, 75 CDC removed three
pathways from the Surveillance Reporting Pathways: Ventilator Capacity and Supplies
in July 2021, Supplies and PPE in May 2022, and Therapeutics in June 2023.76, 77, 78
(See Exhibit B-1.)
Exhibit B-1: Timeline of major CDC updates to the LTCF COVID-19 Module
Sources: CDC, COVID-19 Module Enrollment Guidance for LTCFs, May 2020. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/ltcf-covid19-module-508.pdf on March 7, 2023. CDC, COVID-19 Point of
Care (POC) Test Result Reporting Tool Frequently Asked Questions, March 2022. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/ltcf-poc-faq-508.pdf on March 7, 2023. CDC, HCP & Resident COVID-19
Vaccinations. Accessed at https://www.cdc.gov/nhsn/ltc/weekly-covid-vac/index.html on March 7, 2023.
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Appendix C | 44
Appendix C: Step-by-Step Enrollment Process for NHSN Users
The following instruction is from the “5-Step Enrollment for Long-term Care Facilities”
portion of the CDC NHSN webpage on January 27, 2023.79
Step 1: Enrollment Preparation
1. Review required LTCF Enrollment Guidance.
Note: The LTCF Enrollment Training slides serve as a detailed guide through the
enrollment process.
2. Check trusted websites and spam blocker settings.
•
Please use the supported browsers, Microsoft Edge or Google Chrome.
Note: Microsoft Windows Users: Microsoft is moving away from supporting
Internet Explorer 11 (IE) in 2021. Do not use Internet Explorer when
accessing NHSN.
•
Add cdc.gov and verisign.com to your list of trusted websites and permit
pop-ups for these sites in the browser.
•
Check spam-blocker settings to allow emails from NHSN@cdc.gov, SAMS-
NO-REPLY@cdc.gov.
•
For information regarding System requirements, visit:
FAQs About NHSN | NHSN | CDC.
Time to complete Step 1: 40 minutes
Step 2: Register Facility with NHSN
Read and agree to the NHSN Rules of Behavior. You will then be redirected to
electronically register your facility with NHSN.
Note: The NHSN Facility Contact form may be used to manually collect required
registration information prior to electronically entering the data into NHSN.
Time to complete Step 2: 10 minutes
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Appendix C | 45
Step 3a: Register with SAMS Partner Portal
You will receive an email from the “U.S. Centers for Disease Control: SAMS Partner
Portal – Invitation to Register.” It will include a web link to the SAMS registration
page along with your assigned SAMS Partner Portal User ID (email address) and a
temporary password. Please click on the link and enter the SAMS Partner Portal User ID
and temporary password when prompted. Then follow the onscreen instructions to
register and accept the SAMS Rules of Behavior.
Note: After being invited to SAMS, you have 30 days to complete the registration
process.
Time to complete Step 3a: 15 minutes
Step 3b: Identity Proofing Verification (if applicable)
After successful online registration, you will receive an “Identity Verification Request”
email from SAMS with instructions and a request to provide proof of your identity.
SAMS supports two options for validating your identity using the New online preferred
method Experian or the current secured document submission process.
* Please follow the instructions carefully for your selected identity verification option, to
ensure timely processing.
Time to complete Step 3b: 35 minutes
Step 4: Access Approval and Account Activation
Once your information is received and approved, you will receive your approval by
email from sams-no-reply@cdc.gov. The subject will be “U.S. Centers for Disease
Control: SAMS Partner Portal – SAMS Activity Authorization.” This email will
contain web links to access the SAMS Partner Portal and application.
The NHSN application requires users to be strongly authenticated. This means users
must have an additional ‘token’, along with their password, to log in. The first option is
a soft token that requires the installation of an Entrust Authenticator application on
your phone, tablet, or computer. The second option is a hard token which is a physical
Entrust grid card mailed to your home address. SAMS will communicate this
authentication requirement to you in this email along with instructions on how to
complete the setup after account activation.
Note: Your SAMS grid card should be delivered to your home address via U.S. mail
within 2 weeks after you receive your SAMS approval email. If you do not receive
your SAMS grid card within two weeks, contact samshelp@cdc.gov for assistance.
Time to complete Step 4: 40 minutes
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Appendix C | 46
Step 5a: Complete NHSN Enrollment
After setting up your credential device (via token or receiving your SAMS grid card),
login to SAMS. Under the SAMS Multi-factor Login picture, click Login. On the
SAMS home page, select ‘NHSN Enrollment’ to complete electronic enrollment into
the Long Term Care Facility Component.
Note: Facility registration information may be manually collected using the NHSN
Facility Contact and Annual Facility Survey forms prior to electronically entering the
data into NHSN.
Time to complete Step 5a: 40 minutes
Shortly after successfully submitting the forms, the Facility Administrator and Primary
Contact will receive a “NHSN Facility Enrollment Submitted” email.
Step 5b: Accept “NHSN Agreement to Participate and Consent”
Either the component primary contact or NHSN facility administrator must login
to SAMS, select Long-term Care Facility Component and review the “Agreement to
Participate and Consent.” Check the box to ‘Accept’ next to the appropriate contact
name and then ‘Submit.’ An email will be issued confirming this action.
Note: The consent form must be accepted within 60 days or the facility will be
withdrawn.
Time to complete Step 5b: 5 minutes
Congratulations, enrollment is complete!
Complete NHSN Long-term Care Facility specific training if not previously completed.
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Appendix D | 47
Appendix D: SAMS Registration and Identity Verification
Upon receiving the invitation to SAMS, applicants complete the SAMS registration
process by validating their legal name and providing their organization and contact
information.80 The invitation is only usable for a single registration and expires after
30 days. If the invitation is lost or expired, the applicant must request a replacement.
Following registration, some applicants undergo an identity verification process.
Applicants verify their identity through a document review, or a credit history review
by a data analytics and financial credit company contracted by CDC.81 For the
document review, the applicant must submit a form and identity proofing documents
to SAMS. The form must be reviewed by a notary or other trusted third parties prior
to submission. Following SAMS registration, a CDC program administrator approves
the user’s access to SAMS and the application.82
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Appendix E | 48
Appendix E: Agency Comments
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Appendix E | 52
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Acknowledgments and Contact | 53
ACKNOWLEDGMENTS AND CONTACT
Acknowledgments
John Van Der Schans served as the project leader for this study. Others in the Office
of Evaluation and Inspections Dallas Regional Office who conducted the study include
Marshall Allen and Sarah Lee. Office of Evaluation and Inspections headquarters staff
who provided support include Rob Gibbons and Michael Novello.
This report was prepared under the direction of Petra Nealy, Regional Inspector
General for Evaluation and Inspections in the Dallas Regional Office.
Contact
To obtain additional information concerning this report, contact the Office of Public
Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found
on the OIG website at oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
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About OIG | 54
ABOUT THE OFFICE OF INSPECTOR GENERAL
Office of Inspector General
https://oig.hhs.gov
The mission of the Office of Inspector General (OIG) is to provide objective oversight
to promote the economy, efficiency, effectiveness, and integrity of the Department of
Health and Human Services (HHS) programs, as well as the health and welfare of the
people they serve. Established by Public Law No. 95-452, as amended, OIG carries out
its mission through audits, investigations, and evaluations conducted by the following
operating components:
The Office of Audit Services. OAS provides auditing services for HHS, either
by conducting audits with its own audit resources or by overseeing audit work done
by others. The audits examine the performance of HHS programs, funding recipients,
and contractors in carrying out their respective responsibilities and provide
independent assessments of HHS programs and operations to reduce waste, abuse,
and mismanagement.
The Office of Evaluation and Inspections. OEI’s national evaluations
provide HHS, Congress, and the public with timely, useful, and reliable information on
significant issues. To promote impact, OEI reports also provide practical
recommendations for improving program operations.
The Office of Investigations. OI’s criminal, civil, and administrative
investigations of fraud and misconduct related to HHS programs and operations
often lead to criminal convictions, administrative sanctions, and civil monetary
penalties. OI’s nationwide network of investigators collaborates with the Department
of Justice and other Federal, State, and local law enforcement authorities. OI works
with public health entities to minimize adverse patient impacts following enforcement
operations. OI also provides security and protection for the Secretary and other
senior HHS officials.
The Office of Counsel to the Inspector General. OCIG provides legal
advice to OIG on HHS programs and OIG’s internal operations. The law office also
imposes exclusions and civil monetary penalties, monitors Corporate Integrity
Agreements, and represents HHS’s interests in False Claims Act cases. In addition,
OCIG publishes advisory opinions, compliance program guidance documents, fraud
alerts, and other resources regarding compliance considerations, the anti-kickback
statute, and other OIG enforcement authorities.
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Endnotes | 55
ENDNOTES
1 Lenny Bernstein and Alauna Safarpour, “Mask shortage for most health-care workers extended into May, Post-Ipsos poll
shows,” The Washington Post, May 20, 2020. Accessed at
https://www.washingtonpost.com/health/mask-shortage-for-most-health-care-workers-extended-into-may-post-ipsos-poll-
shows/2020/05/20/1ddbe588-9a21-11ea-ac72-3841fcc9b35f_story.html on November 2, 2021.
2 Lauren Weber, “Nursing Homes Keep Losing Workers,” The Wall Street Journal, August 25, 2021. Accessed at
https://www.wsj.com/articles/nursing-homes-keep-losing-workers-11629898200 on November 2, 2021.
3 CMS, COVID-19 Nursing Home Data. Accessed at https://data.cms.gov/covid-19/covid-19-nursing-home-data on
January 13, 2023.
4 85 Fed. Reg. 27627 (May 8, 2020); 42 CFR § 483.80.
5 CDC, “National Healthcare Safety Network (NHSN) report: Data summary for 2006 through 2008,” Association for Professionals
in Infection Control and Epidemiology, December 2009, p. 1. Accessed at
https://www.cdc.gov/nhsn/pdfs/datastat/2009nhsnreport.pdf on November 30, 2022.
6 CDC, Division of Healthcare Quality Promotion (DHQP). Accessed at https://www.cdc.gov/ncezid/dhqp/index.html on
November 30, 2022.
7 CDC, FY 2022 Operating Plan, February 19, 2021, p. 1. Accessed at
https://www.cdc.gov/budget/documents/fy2021/FY-2021-CDC-Operating-Plan.pdf on December 16, 2022.
8 CDC, July 2020 LTCF Newsletter, July 6, 2021. Accessed at https://www.cdc.gov/nhsn/ltc/newsletters/jul20-newsletter-ltc.html
on November 17, 2022.
9 CDC, “Introduction to NHSN’s Long Term Care Facility Components,” YouTube, September 23, 2019. Accessed at
https://www.youtube.com/watch?v=pFGVqyE-H-4 on November 17, 2022.
10 CDC, Long-term Care Facility Component. Accessed at https://www.cdc.gov/nhsn/ltc/index.html on November 17, 2022.
11 CDC, NHSN Long-term Care Facility Component, January 2020, p. 10. Accessed at
https://www.cdc.gov/nhsn/pdfs/ltc/ltcf-manual-508.pdf on December 16, 2022.
12 CDC, LTCF COVID-19 Module. Accessed at https://www.cdc.gov/nhsn/ltc/covid19/index.html on November 17, 2022.
13 CDC, July 2020 LTCF Newsletter, July 6, 2021. Accessed at
https://www.cdc.gov/nhsn/ltc/newsletters/jul20-newsletter-ltc.html on November 17, 2022.
14 CDC, LTCF COVID-19 Module Enrollment. Accessed at https://www.cdc.gov/nhsn/ltc/covid19/enroll.html on
November 17, 2022.
15 CDC, July 2020 LTCF Newsletter, July 6, 2021. Accessed at
https://www.cdc.gov/nhsn/ltc/newsletters/jul20-newsletter-ltc.html on November 17, 2022.
16 CDC, “LTCF COVID-19 Module: Resident Impact and Facility Capacity Surveillance Reporting Pathway,” YouTube,
April 2, 2021. Accessed at https://www.youtube.com/watch?v=mrGOM4-hgAo on December 13, 2022.
17 CDC, “LTCF COVID-19 Module: Resident Impact and Facility Capacity Surveillance Reporting Pathway,” YouTube, April 2,
2021. Accessed at https://www.youtube.com/watch?v=mrGOM4-hgAo on December 13, 2022.
18 CDC, “LTCF COVID-19 Module: Therapeutics Surveillance Reporting Pathway,” YouTube, April 19, 2021. Accessed at
https://www.youtube.com/watch?v=ZTzRk7-3Qak on December 15, 2022.
19 CDC, LTCF COVID-19 Module: Updates, July 2021. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/rel955-update-508.pdf on December 15, 2022.
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Endnotes | 56
20 CDC, LTCF COVID-19 Module: Surveillance Pathway Updates, May 2022. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-mod-surv-path-508.pdf on December 15, 2022.
21 CDC, COVID-19 Module Enrollment. Accessed at https://www.cdc.gov/nhsn/ltc/covid19/enroll.html on November 17, 2022.
22 CDC, Long-Term Care Facility (LTCF) Enrollment in LTCF COVID-19 Module, November 2021, p. 2. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-enrollment-508.pdf on September 16, 2021.
23 CDC, Long-Term Care Facility (LTCF) Enrollment in LTCF COVID-19 Module, November 2021, p. 8. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-enrollment-508.pdf on September 16, 2021.
24 CDC, Enrollment in LTCF COVID-19 Module, November 2021, pp. 2-3. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-enrollment-508.pdf on November 17, 2022.
25 CDC, COVID-19 Module Enrollment. Accessed at https://www.cdc.gov/nhsn/ltc/covid19/enroll.html on November 17, 2022.
26 CDC, Enrollment in LTCF COVID-19 Module, November 2021. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-enrollment-508.pdf on November 17, 2022.
27 CDC, About SAMS. Accessed at https://www.cdc.gov/nhsn/sams/about-sams.html on November 17, 2022.
28 CDC, Office of the Chief Information Officer Organization Chart. Accessed at
https://www.cdc.gov/od/ocio/docs/OCIO_org_chart_FY2020.pdf on December 16, 2022.
29 Comagine Health and Medicare QIN-QIO for Idaho, Nevada, New Mexico, Oregon, Utah, and Washington, TIP Sheet for
NHSN COVID-19 Enrollment: SAMS and Facility Enrollment. Accessed at https://comagine.org/sites/default/files/resources/TIP-
Sheet-NHSN-Enrollment.pdf on November 17, 2022.
30 Telligen and Medicare QIN-QIO, NHSN Access Level Guide. Accessed at
https://www.telligenqiconnect.com/wp-content/uploads/2022/02/NHSN-Access-Level-Document_Current-Process.pdf on
November 17, 2022.
31 CDC, Secure Access Management Services (SAMS) Frequently Asked Questions, September 15, 2021. Accessed at
https://auth.cdc.gov/sams/samsfaq.pdf?disp=true on November 17, 2022.
32 CDC, New to NHSN? Guided Steps to Enroll Your Facility, p. 21. Accessed at
https://www.cdc.gov/nhsn/pdfs/training/enroll/nhsn-facility-enrollment-training.pdf on July 5, 2023.
33 Comagine Health and Medicare QIN-QIO for Idaho, Nevada, New Mexico, Oregon, Utah, and Washington, TIP Sheet for
NHSN COVID-19 Enrollment: SAMS and Facility Enrollment. Accessed at https://comagine.org/sites/default/files/resources/TIP-
Sheet-NHSN-Enrollment.pdf on November 17, 2022.
34 Telligen and Medicare QIN-QIO, NHSN Access Level Guide. Accessed at
https://www.telligenqiconnect.com/wp-content/uploads/2022/02/NHSN-Access-Level-Document_Current-Process.pdf on
November 17, 2022.
35 CDC, New to NHSN? Guided Steps to Enroll Your Facility, p. 21. Accessed at
https://www.cdc.gov/nhsn/pdfs/training/enroll/nhsn-facility-enrollment-training.pdf on July 5, 2023.
36 CDC, About SAMS. Accessed at https://www.cdc.gov/nhsn/sams/about-sams.html on November 17, 2022.
37 CDC, About NHSN Help Desk. Accessed at https://www.cdc.gov/nhsn/about-nhsn/helpdesk.html on September 16, 2021.
38 CDC, About NHSN Help Desk. Accessed at https://www.cdc.gov/nhsn/about-nhsn/helpdesk.html on September 16, 2021.
39 Social Security Act §§ 1819, 1919.
40 85 Fed. Reg. 27550 (May 8, 2020); CMS, Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected
COVID-19 Cases Among Residents and Staff in Nursing Homes, May 6, 2020, p. 3. Accessed at
https://www.cms.gov/files/document/qso-20-29-nh.pdf on November 10, 2021.
41 85 Fed. Reg. 27627 (May 8, 2020); 42 CFR § 483.80.
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Endnotes | 57
42 CDC, NHSN E-Newsletter, March 2020, p. 13. Accessed at
https://www.cdc.gov/nhsn/pdfs/newsletters/nhsn-nl-mar20-508.pdf on June 4, 2021.
43 CDC, NHSN E-Newsletter, June 2020, p. 15. Accessed at https://www.cdc.gov/nhsn/pdfs/newsletters/nhsn-nl-jun20-508.pdf
on June 4, 2021.
44 86 Fed. Reg. 26336 (May 13, 2021); 42 CFR § 483.80.
45 85 Fed. Reg. 54824 (September 2, 2020); 42 CFR § 488.447.
46 OIG, CMS’s COVID-19 Data Included Required Information From Most Nursing Homes, but CMS Could Take Actions To Improve
Completeness and Accuracy of the Data (A-09-20-2005) September 1, 2021.
47 OIG analysis of internal documents provided by CDC, June 2023.
48 CDC, COVID-19 Module Long Term Care Facility: Resident Impact and Facility Capacity Pathway, June 2023. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/57.144-res-blank-p.pdf on August 16, 2023.
49 CDC, COVID-19 Module Long Term Care Facility: Staff and Personnel Impact, June 2023. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/57.145-staff-blank-p.pdf on August 16, 2023.
50 CDC, Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities, June 2023. Accessed at
https://www.cdc.gov/nhsn/forms/COVIDVax.LTC_.Resident.FORM_May2022-508.pdf on August 16, 2023.
51 CDC, Healthcare Personnel COVID-19 Vaccination Cumulative Summary, June 2023. Accessed at
https://www.cdc.gov/nhsn/forms/COVIDVax.HCP_.FORM_May2022-508.pdf on August 16, 2023.
52 42 CFR § 483.80.
53 CDC, National Healthcare Safety Network (NHSN) – Long-term Care Facility COVID-19 Module, May 2020, p. 22, 25-28.
Accessed at https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/ltcf-covid19-module-508.pdf on June 22, 2021.
54 CDC, National Healthcare Safety Network (NHSN) – Long-term Care Facility COVID-19 Module, May 2020, op. cit., p. 21.
55 CMS, Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among
Residents and Staff in Nursing Homes, op. cit., p. 3.
56 CMS, CMS/CDC Nursing Home COVID-19 Data Quality Assurance Process. Accessed at
https://data.cms.gov/sites/default/files/2021-07/covid-19-nursing-home-data-quality-assurance-process_0.pdf on
February 2, 2022.
57 CMS, CMS/CDC Nursing Home COVID-19 Data Quality Assurance Process. Accessed at
https://data.cms.gov/sites/default/files/2021-07/covid-19-nursing-home-data-quality-assurance-process_0.pdf on
February 2, 2022.
58 CMS published an interim final rule on November 5, 2021, that established COVID-19 vaccination requirements for staff at
certain Medicare- and Medicaid-certified providers and suppliers. See 86 Fed. Reg. 61555 (November 5, 2021).
59 CDC, Nursing Home COVID-19 Data Dashboard. Accessed at https://www.cdc.gov/nhsn/covid19/ltc-report-overview.html on
September 15, 2021.
60 CMS, COVID-19 Nursing Home Data. Accessed at https://data.cms.gov/covid-19/covid-19-nursing-home-data on
January 3, 2022.
61 CMS, COVID-19 Nursing Home Data. Accessed at https://data.cms.gov/covid-19/covid-19-nursing-home-data/data on
January 27, 2023.
62 CMS, CMS/CDC Nursing Home COVID-19 Data Quality Assurance Process. Accessed at
https://data.cms.gov/sites/default/files/2021-07/covid-19-nursing-home-data-quality-assurance-process_0.pdf on
February 2, 2022.
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Endnotes | 58
63 CMS, CMS Launches New Medicare.gov Tool to Compare Nursing Home Vaccination Rates, September 21, 2021. Accessed at
https://www.cms.gov/newsroom/press-releases/cms-launches-new-medicaregov-tool-compare-nursing-home-vaccination-
rates on January 25, 2023.
64 OIG, CMS’s COVID-19 Data Included Required Information From Most Nursing Homes, but CMS Could Take Actions To Improve
Completeness and Accuracy of the Data (A-09-20-02005) September 1, 2021.
65 OIG, COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020 (OEI-02-20-00490)
June 22, 2021.
66 OIG, Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23-May 30, 2020 (OEI-01-20-00430) December
17, 2020.
67 OIG, More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the COVID-19
Pandemic; Better Protections Are Needed for Future Emergencies (OEI-02-20-00491) January 19, 2023.
68 OIG, Workplan Summary: Meeting the Challenges Presented by COVID-19: Nursing Homes. Accessed at
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000474.asp on October 7, 2023.
69 Minnesota Department of Health, Reporting Point of Care COVID-19 Test Results through the CDC National Healthcare Safety
Network (NHSN), October 26, 2020. Accessed at
https://www.leadingagemn.org/assets/docs/10_26_20_NHSN_POC_Test_Reporting_LTC.pdf on February 2, 2023.
70 CDC, COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115, March 8, 2022, p. 5. Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/downloads/lab/HHS-Laboratory-Reporting-Guidance-508.pdf on
February 2, 2023.
71 A Quality Improvement Organization is a group of health quality experts, clinicians, and consumers organized to improve
quality of care for people with Medicare coverage. See CMS, Quality Improvement Organizations. Accessed at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs on December 7,
2022.
72 CDC, July 2020 LTCF Newsletter, July 6, 2021. Accessed at https://www.cdc.gov/nhsn/ltc/newsletters/jul20-newsletter-
ltc.html on November 17, 2022.
73 CDC, “LTCF COVID-19 Module: Resident Impact and Facility Capacity Surveillance Reporting Pathway,” YouTube, April 2,
2021. Accessed at https://www.youtube.com/watch?v=mrGOM4-hgAo on December 13, 2022.
74 CDC, December 2020 LTCF Newsletter, December 21, 2021. Accessed at https://www.cdc.gov/nhsn/ltc/newsletters/dec20-
newsletter-ltc.html on December 13, 2022.
75 CDC, “LTCF COVID-19 Module: Therapeutics Surveillance Reporting Pathway,” YouTube, April 19, 2021. Accessed at
https://www.youtube.com/watch?v=ZTzRk7-3Qak on December 15, 2022.
76 CDC, LTCF COVID-19 Module: Updates, July 2021. Accessed at https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/rel955-update-
508.pdf on December 15, 2022.
77 CDC, LTCF COVID-19 Module: Surveillance Pathway Updates, May 2022. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-mod-surv-path-508.pdf on December 15, 2022.
78 CDC, LTCF COVID-19 Module: Surveillance Pathway Updates, June 2023. Accessed at
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/NHSN-COVID-19-11.4-updates-for-May-30th-recording-final.pdf on June 13,
2023.
79 CDC, 5-Step Enrollment for Long-term Care Facilities. Accessed at https://www.cdc.gov/nhsn/ltc/enroll.html on February 7,
2023.
80 CDC, User Guide for CDC’s SAMS Partner Portal. Accessed at https://auth.cdc.gov/sams/SAMSUserGuide.pdf?disp=true on
November 17, 2022.
81 CDC, Overview for CDC’s SAMS Identity Verification Process. Accessed at
https://auth.cdc.gov/sams/IdentityVerificationOverview.pdf?disp=true on November 17, 2022.
82 CDC, User Guide for CDC’s SAMS Partner Portal. Accessed at https://auth.cdc.gov/sams/SAMSUserGuide.pdf?disp=true on
November 17, 2022.