Update on the CDC’s National Healthcare Safety Network (NHSN): CMS Citing SNF

Nancy Leveille and Jackie Pappalardi in Clinical & Quality

CMS began to cite facilities at the F-tag level for facilities who have not submitted required data via the NHSN. NYSHFA has been in close contact with American Health Care Association (AHCA) to assist with resolutions especially for facilities that have been actively trying to enroll within the normal timeframe; where data submission had a major problem; or the facility user accounts have not been working. AHCA shared the following concerns with their recommendations for follow up actions to be taken:

Concerns from Providers

  • I submitted my data, why am I getting a citation?
  • I have been trying to register but CDC/NHSN is not getting back to me or the answers they provide don’t work.
  • I finally got registered but can’t submit data and CDC/NHSN either will not get back to me or the answers don’t solve the problem.
  • Why is this citation at an F-level?

AHCA’s Actions:

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

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

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

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

  • AHCA requested CMS change the level of the deficiency to a C-level citation.

CMS response is pending. 

  • AHCA requested CMS to address the language in the 2567 citation to give the provider sufficient information on what the error is that led to the citation, making it difficult or impossible for the provider to counter the citation in their IIDR request.

CMS response is pending. 

  • AHCA shared examples of screen shots with CMS where the facility submitted data correctly per CDC/NHSN, showing that the citations are in error.

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

AHCA and NYSHFA Recommendations

  1. Providers check CASPER to see if they have a citation
  2. If you have a citation that they believe is in error, they should assemble the information needed to submit an IIDR. We would recommend putting together at least the following:
    • A summary table of dates they started the registration process and all dates of communications with CDC/NHSN: NHSN user support at nhsn@cdc.gov
    • Screen shots if they have documented their data submission
    • Copies of emails sent and received from CDC/NHSN
    • Any other documentation of efforts they did to register and submit data such as communications with the QIO or state. 

Key points from NHSN’s previous webinars

  • If you are a multi-owned facility and need to connect your facilities to the corporation, there is a special process for that. Each SNF still must enroll, the corporate entity must enroll and then invite the enrolled SNF into the group.
  • If you used a temporary user identification and now that one is invalid, you must connect with them to correct:
  • When entering data, within that process, you must review your data for accuracy and the after that step you submit your data. If you miss that step, your data will not upload.



Nancy Leveille, RN, MS
Director, Special Projects and Educational Development
518-462-4800 x20

Jackie Pappalardi, RN, BSN
Executive Director
518-462-4800 x16