National CMS/CDC Nursing Home COVID-19 Training FAQs

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Training Questions

How do I access the training presentations later?

The presentation slides and recordings are available on the QIO Program website: https://qioprogram.org/nursing-home-trainings.

Cohorting Questions

For new admissions with unknown COVID-19 status, is a closed door adequate or is a barrier also recommended?

Defer to CDC. If there is only one room as part of their COVID-19 suspect area, closing the door may be sufficient, but if there are additional residents then a barrier with separate entrance/break room may be necessary. It depends on the functional layout of the building and the number of COVID-19-suspected residents being cared for at the time.

Should doors be closed in the nursing home setting?

Defer to CDC. It depends on the functional layout of the space and if it is a COVID-19-positive unit. Generally, if a high-risk procedure is being performed, closing the door would minimize any aerosol from exiting the room. However, this may represent a resident safety issue and should be assessed on a case-by-case basis.

National Healthcare Safety Network (NHSN) Questions

Data Entry Questions

How many people in a facility are able to report to NHSN?
NHSN does not limit the number of users a facility can have. It is recommended that at least two people have NHSN access per facility. Both invididuals are able to report, but will need to have a process to avoid reporting duplicate counts. Duplicate reporting can result in falsely inflated counts.

How do I grant NHSN access to a new user?
If you are already an active user, then you can add the user to NHSN by:

On left-side navigation pane, select Users > Add
Complete the required fields and click Save
You will then be prompted to assign the new user rights
Click Save
Please check to ensure that you have designated the added user as an Active User. The user will then receive e-mail instructions to complete the process. These enrollment training slides may offer additional detail if needed.

We received an email to confer NHSN rights. What does this mean? Each facility has access and an administrator. Are they not able to confer rights for each facliity?
This email means that the user wants the long term care facility (LTCF) to share data with another entity. This needs to be done through the conferral of rights by the LTCF.

Do we report daily counts to NHSN?
NHSN does not require daily reporting. However, new daily counts must be included in the counts reported for the week. For CMS-certified facilities, weekly reporting is required. Regardless of how often reporting occurs during the week, only new counts must be entered since the last date the specific counts were collected for entering in NHSN. If entering once per week, data must include new counts for the previous seven calendar days.

Do we submit data to NHSN once a week to represent a week time span?
Yes. Regardless of how often reporting occurs during the week, only new counts must be entered since the last date the specific counts were collected for entering in NHSN. If entering once per week, data must include new counts for the previous seven calendar days.

My regional manager mandates that we report twice a week instead of every seven days. Is this a problem or will it cause penalties?
Twice a week reporting is just fine. Be sure to only include new counts each time you report. For example, if your surveillance week is Monday - Friday and you report on Monday and Wednesday, only include new counts from the previous Friday through Sunday in your Monday submission and then new counts from Monday through Thursday in your Friday count. This methods allows you to report for a full seven calendar days, just twice a week instead of once.

Recently I have been getting a pop up message in reporting that says information has been reported within the last seven days and to make sure that I am only reporting new information since the last report. I am only reporting at seven days.
This message was recently added to questions requiring counts. The purpose was to assist with data quality by reminding the user to only enter new cases since the last date counts were entered, as many users continue to enter cumulative/rolling data. This does not mean that there is an issue with your data. NHSN will be removing the alerts in the near future.

Is there anything else we should be doing if our data is uploaded to NHSN automatically?
All users are encouraged to perform at least weekly validation (before Sunday each week). By logging in and viewing the calendar page, you will be able to see which days information was submitted (i.e., entered manually and/or uploaded via CSV). You will also have the option to click into each pathway to verify/edit the accuracy of the data that was submitted. If you have a vendor reporting on your behalf, please remind them about the pop-up message confirming the record was successfully uploaded/received. Uploaded and manually entered data are immediately available after successful submission.

When is our cutoff date to make corrections in NHSN?
NHSN does not specify a cut-off date. Data are submitted to CMS every Sunday, after 11:59 pm. Data entered after that date will be included in the next weeks' CMS submission.

Resident Impact & Facility Capacity Questions

Is the New Admissions column in place to indicate any new admission, or only new admissions of COVID-19-positive residents?
This column includes new admissions who were previously diagnosed with COVID-19 and continue to require transmission-based isolation precautions due to ongoing illness/symptoms. These admissions only get counted in the Admissions count; not the Suspected or Confirmed count.

If we admit a COVID-19-positive resident, do we enter a "1" in the New Admission column, and "1" in the New Confirmed Column, since the resident is new to the population?
If new admit was confirmed positive do you add them to both new admit and new confirmed?
If a new admission comes in COVID-19-positive, do they count as a new confirmed case?
No. New residents admissions or readmissions who were previously diagnosed with COVID-19 and continue to require transmission-based isolation precautions are included in the Admissions Count only. These residents are not also included in the Suspected or Confirmed Counts. Additionally, recovered admissions (symptoms resolved and do not require transmission-based precautions) are not to be included in the Admissions count. The purpose of Admissions is to assess burden of COVID-19 coming into a long term care facility.

What if we admit a new resident who had COVID-19, but had two negative tests before admission, should he or she be included in the Admission Count?
It depends. If the resident has a diagnosis of COVID-19 and will be placed on transmission-based precautions due to the diagnosis, the resident should be included in the Admission Count.

What are the criteria for suspected COVID-19 status?
To be included in the Suspected COVID-19 count, staff and/or residents without a COVID-19-positive test result must be managed as though they have COVID-19 due to signs and/or symptoms compatible with COVID-19.

How is a new resident with a negative COVID-19 test counted?
A new admission/readmission should only be included in the Admissions Count if the resident was previously diagnosed with confirmed or suspected COVID-19 and still requires transmission-based isolation precautions upon admission to the long term care facility (LTCF). The purpose of the Admissions Count is to assess burden of COVID-19 coming into a LTCF. A recovered resident or preemptive isolation are excluded from the count.

If we have admitted a resident with history of COVID-19 who no longer requires isolation (i.e., no more symptoms and more than two weeks from initial diagnosis), do I count him as a new admission proviously diagosed with COVID-19?
No. Admission/readmission of residents with resolved infections are excluded from the Admissions count.

If we have a new patient with suspected COVID-19 symptoms and count them on one day, then two days later the patient's COVID-19 test results are positive, do I include that patient in the New Confirmed category?
If a person is "Suspected" on Monday, and a COVID-19-positive test result is received on Thursday, do yo still count them in the "Suspected" number since they will be ultimately in the New Confirmed number?

Yes. The resident will be included in both counts since the signs/symptoms and subsequent isolation occurred on a different calendar day from the positive test result.

We have been testing residents and staff, and have not have any signs or symptoms among residents since May 2020, though they have tested positive. Can you address those who test positive and are asymptomatic?
Residents and/or staff with a new positive COVID-19 test result must be reported in the Confirmed COVID-19 Count for that day/surveillance week, even if asymptomatic. Repeat positive results on these same individuals are not to be reported in the Confirmed COVID-19 Count unless there is evidence of an active infection that resolves and returns at a later time.

If you have residents exposed from a COVID-19-positive health care work, but have tested negative, are they to be listed in the resident data as Suspected COVID-19, or is this category only for residents who actually show signs or symptoms of COVID-19?
On the reporting if we have a new admission that is COVID-19-negative and we place them in isolation pending a second COVID test do we count that as suspected?
If a person is being quarantined due to exposure to a COVID-19-positive person, but is asymptomatic, are they considered as a suspected case?

No. Only residents who develop signs and symptoms suggestive of COVID-19 in the absence of a positive test are included in the Suspected COVID-19 Count. Exposure alone does not quality. Admitted or readmitted residents preemptively placed on observation, but who do not have a previous diagnosis of COVID-19, should not be included in the Admissions Count. Do not include in Suspected COVID-19 Count either.

Our facility has been COVID-19-free for two months, but our reporting is still showing high total suspected cases.
Only newly suspected residents or staff should be included in the count for the reporting period. The count is not a rolling or cumulative count. The purpose is to capture incidence only. Consider validating the reported data using the calendar page to see if someone else is entering or uploading data on your behalf, which could result in duplicate or falsely inflated counts.

Due to symptoms, a resident was placed on droplet and contact precautions and tested for COVID-19; however, we did not move the resident to a private room or use an N95 mask for care. The resident tested negative for COVID-19. Do we still consider that resident "Suspected?"
Yes. Any resident newly suspected of COVID-19 due to signs and symptoms suggestive of COVID-19 in accordance with CDC’s guidance for evaluating and testing person for COVID-19 but does not have a positive COVID-19 test result are to be counted in the Suspected Count. This includes those who have not been tested, pending test results, as well as those with a negative test result in the presence of COVID-19 signs/symptoms.

Is it the intent to reset the "Suspected" column to 0 each week or when a resident tests negative from testing?
For any data element required counts, users are to report the new counts only - since the last date counts were entered. So essentially, after each data entry, the count returns to blank and only new cases are entered. For Suspected Counts, only record the number of residents who are newly suspected of having COVID-19 each day. In other words, a resident is newly suspected of having COVID-19 and is placed on transmission-based precautions. Once a resident is counted in the Suspected Count, he or she is not removed from the count. If the test result returns as positive, the resident will also be counted in the newly COVID-19 Positive Count.

On the Resident page, the question regarding COVID-19 deaths and all other deaths are listed, but the pop up that reminds you that the counts are new. Have the questions switched (i.e. the COVID-19 death pop up asks about deaths that happened at the facility and all other facilities and the Other Death pop up asks about actual COVID-19 deaths)?
The COVID-19 Death Count includes new COVID-19 related deaths for the surveillance week. The count includes residents who died within the facility or another location (if known).

Can you clarify New Total Deaths?
New Total Death Count includes all resident deaths that occur for any reason, including COVID-19, during the surveillance week. The count includes residents who died within the facility or another location (if known).

If a resident tested positive for COVID-19 in May, and expired in July, would that be considered a COVID-19-related death?
Only if the autopsy or other results indicate the resident died from COVID-19-related complications. If you are not sure, only include the resident in the Total Death Count. You can always go back and add him/her to the COVID-19 Death Count for that day if the autopsy later returns as COVID-19.

If a resident is COVID-19-positive but the cause of death is not COVID-19-related according to the medical examiner, how is this reported?
This is a tricky question. In attempts to maintain some consistency with reporting, if the resident has a positive COVID-19 test result at the time of death, include in both the Total Death Count and the COVID-19 Death Count. If the resident recovered from COVID-19 and no longer had a positive test result, only include in the Total Death Count.

We need to know how to count deaths related to COVID-19. Do we go by the death certificate? Or if the residents were positive or negative for COVID-19?
You can use both. So for example, if the resident was COVID-19-positive at the time of death, include in the Total Deaths Count and the COVID-19 Deaths Count. If, at any point, you receive an autopsy report indicating COVID-19 as the cause of death or a resident was positive for COVID-19, and this resident was not previously included in the COVID-19 death count, then you would need to add the resident to the COVID-19 Death Count on the date he or she was reported in the Total Deaths Count.

Do you have any instructions on COVID-related death? Do we need to see COVID-19 as a complication on the death certificate? Or are we simply looking for a positive test and a death?
Let's say a resident passes away. You are unlikely to know the cause of death until a coroner's report or autopsy is performed. So, how can you (at the time of the death), know and document in NHSN within the seven-day reporting day time frame, whether the death was COVID-19 related, or from something else?

Use the resources you have available to you. For example, if the resident was COVID-19-positive at the time of death or had signs and symptoms suggestive of COVID-19, include in the Total Death Count and the COVID-19 Death Count. If, at any point, you receive an autopsy report indicating COVID-19 as the cause of death or a resident was positive for COVID-19, and this resident was not previously included in the COVID-19 Death Count, then you would need to add the resident to the COVID-19 Death Count on the date he/she was reported in the Total Deaths Count. The updated counts will be included in the next CMS data submission.

We have a resident who was reported as expired, then we received notice that the resident tested positive for COVID-19. Should we count him as a COVID-19 death even though he was already reported as a facility death?
Yes. If, at any point, you receive an autopsy report indicating COVID-19-positive on a resident that was not previously included in the COVID-19 Death Count, then you would need to add the resident to the COVID-19 Death Count on the date he or she was reported in the Total Deaths Count.

Do we count a death that occurred after a COVID-19-positive covid resident was transferred to hospital?
Let's say that you did not enter a death for a specific week because the patient died elsewhere; is it okay to go back and edit that previous week's death after submission?

Yes. It is preferred that users edit the applicable pathway and add the count to the date that the resident died. The updates will be sent in the next CMS submission.

If a patient is admitted with COVID-19 and in the building less than 72 hours, then passes away at the hospital, do we count that death in our facility reporting?
Yes. The resident will be included in both the Admissions Count on the date of admission to your facility and then in your Total Deaths Count and COVID-19 Counts on the date of death.

If NHSN is counting a death that occurred after a COVID-19-positive resident was transferred to the hospital, how do we know that the resident death has not been counted by the hospital as well - therefore counted twice?
It is a possibility, but it is also possible the patient/resident will not be reported by the hospital. These are the scenerios and details that are still being worked out as we learn more and become more sophisticated across reporting systems.

How is the Current Census calculated?
Current Census is entered based on the number of residents occupying a bed on the date that data are reported.

Staff and Personnel Impact Questions

An employee is off work due to failing screening upon entry to the facility with vague symptoms. The employee likely has allergies, but is being tested out of an overabundance of caution and is awaiting results before returning to work. Would this be considered a "Suspected COVID-19" case among facility employees?
This subject can be tricky. To be included in the Suspected COVID-19 Count, staff and/or residents without a COVID-19-positive test result must be managed as though they have COVID-19 due to signs and/or symptoms compatible with COVID-19 per the CDC’s Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19). Examples include, but are not limited to, fever, acute respiratory illness (cough, shortness of breath, difficulty breathing), chills, repeated shaking with chills, muscle pain, new loss of taste or smell, diarrhea, vomiting, headache or sore throat. Preemptive testing to rule out COVID-19 in the absence of signs or symptoms does not meet the NHSN definition for Suspected COVID-19 Count.

Supplies & Personal Protective Equipment (PPE) Questions

Are KN95-approved respirators okay to report as COVID-19 personal protective equipment (PPE)?
No. A facility using KN95 masks instead of N95 masks would answer no to the question, Do you currently have any supply of N95 masks?

How do you report personal protective equipment (PPE) for "do you have any" if you have enough PPE for two to three days of conventional use, but are using a contingency strategy to conserve supplies. Would we answer yes to this question?
Facilities should select yes for each supply item in which the facility has any or enough for conventional use (also referred to as conventional capacity). CDC’s optimization strategies for PPE, such as contingency and/or crisis level strategies are not considered as having any supply, and therefore, no must be selected for each supply item in which contingency or crisis strategies are being used on the date responses are reported. An accurate assessment of resource needs is important in the provision of supplies and resources. Facilities are encouraged to refer to CDC’s Optimize PPE Supply website for specific examples.

NHSN Support Questions

How can our facility enroll in NHSN?
Please visit the LTCF COVID-19 Module webpage, under Enrollment for complete information on how to enroll and begin reporting data in NHSN. Additional questions should be sent to NHSN@cdc.gov and include in the subject line LTC-COVID Enrollment.

Where are NHSN forms housed?
All data collection forms and instructions for completing the forms are on the LTCF COVID-19 Module webpage, under data collection forms.

How can we access NHSN email support?
Please email NHSN@cdc.gov. To triage of a question submitted to NHSN, it is recommended to include in the subject line: LTC- and topic. For example LTC COVID-add new user; LTC UTI question; LTC-COVID-criteria question.

How do we request a correction to data?
Please email NHSN@cdc.gov and include in the subject line: LTCF-COVID Data Showing Incorrectly or LTCF-Need Help Correcting COVID Data.

Do you have any information on new lab questions that have been added to NHSN?
The new lab questions were added on August 10, 2020. All data collection forms and form instructions have been updated and posted, as well as the updated .csv file templates and guidance. All documents are located on the LTCF COVID-19 webpage.

Are there pre-made excel sheets created for the tracking/risk spreadsheet/etc.?
NHSN provides data collection forms and accompanying instructions with details for each data element to be reported. The instructions also include case study examples. NHSN does not currently have other tools or spreadsheets. Your local or state health department or local QIN-QIO may offer additional resources.

How can I print a readable copy of the report that I am submitting to NHSN?
Since there is not a print option on the pathway pages, you can try to right click and print. Another option is to use the Export CSV tab at the bottom of the calendar page. After clicking this tab, you will have the option to export saved information into a spreadsheet for further use and analysis.

Where can we access additional training?
Upcoming and archived NHSN trainings are available on the LTCF COVID-19 Module webpage, under the Training tab. These trainings are not related to the training requirement for nursing homes to receive the additional funding from the Provider Relief Fund (PRF) Program.

NHSN Data Release Questions

In the NHSN data that is released weekly, the week always ends on a Sunday. How is this calculated from a week ending on another day of the week?
All data entered since the previous CMS submission is included each week.

Is there a way to obtain confirmation for submitting information to the NHSN website?
A pop-up message will appear confirming the record was successfully uploaded/received. Uploaded and manually entered data are immediately available after successful submission for validation of completeness and accuracy.

Personal Protective Equipment (PPE) Questions

How should Personal Protective Equipment (PPE) be doffed (removed)?

CDC Doffing protocol:

Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).
Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle.
Health care personnel may now exit patient room.
Perform hand hygiene.
Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.
Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask.
1. Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
2. Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.
Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse.

When should production of the 3M N95 mask meet demand?

Unknown

How essential is fit testing for N95 masks during this time of shortages and crisis?

Fit testing is a crucial component of ensuring that staff are adequately protected (sealed) when wearing an N95 respirator.

COVID-19 Testing Questions

If a resident leaves the building for a scheduled physician appointment (in this case, it is for weekly skin grafts), should they be placed on 14-day quarantine status after each appointment?

Normally the quarantine is recommended following an inpatient stay, not following an outpatient procedure. This would be dependent on local and state guidelines.

When a staff member tests positive they are placed on 14-day quarantine. Does day 1 of the quarantine start on the test date, or when the results are sent to us?

Day 1 of the quarantine should start on the test date.

Virus Questions

Any thoughts about the virus being airborne?

Defer to CDC. The World Health Organization (WHO) has released information that shows that concerns remain that the virus remains airborne indoors.