Beginning with the 2022–2023 influenza season, skilled nursing facilities (SNFs) are required to submit data for the entire influenza vaccination season (October 1 through March 31) to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). The Centers for Medicare & Medicaid Services (CMS) published a final rule in the Federal Register for the CMS SNF Quality Reporting Program (QRP) requirements on August 3, 2022, that included healthcare personnel (HCP) influenza vaccination summary data reporting from SNFs via the NHSN.
SNFs are required to submit at least one report to capture influenza vaccination coverage among all staff working in the facility at least one day during the influenza season. SNFs have 45 days after the end of influenza season to report data and must enter their summary report by May 15 for data to be shared with CMS.
NHSN guidance and definitions for reporting HCP influenza vaccination summary data can be found in the NHSN Influenza Vaccination Summary Protocol. The NHSN protocol provides guidance for facilities to report HCP influenza vaccination summary data from October 1 (or when the vaccine became available) through March 31, which includes all influenza vaccinations administered during the influenza season at the facility or elsewhere, influenza vaccine declinations, and determinations of a medical contraindication to influenza vaccination.
Users must also report associated denominator data for HCP physically working in the SNFs for at least one working day of an influenza season, regardless of clinical responsibility or patient contact. Facilities must report data separately for employees, licensed independent practitioners, and adult students/trainees and volunteers. Reporting summary data from other contract personnel and vendors is optional at this time.
Facilities must activate the HPS Component in NHSN to report annual influenza vaccination summary data. Only the NHSN Facility Administrator (FA) can activate a new component. The NHSN FA can activate the HPS Component by navigating to Facility -> Add/Edit Component. The FA can then add users including the HPS Component Primary Contact. If the NHSN FA leaves the facility but does not transfer the role of FA to another individual prior to leaving, the NHSN Facility Administrator Change Request Form should be completed.
Operational guidance provided by CDC/NHSN can be found here, and the CDC summary of key points can be accessed here.
Compliance Perspective
Issue
CMS-certified SNFs are required to report annual HCP influenza vaccination summary data through the NHSN Healthcare Personnel Safety (HPS) Component for the 2022–2023 influenza season. A single summary report covering the entire reporting period for the season is required. The deadline to report the annual HCP influenza vaccination summary data through the NHSN HPS Component is May 15, 2023. Reporting weekly influenza vaccination data through the NHSN LTC Facility Component does not fulfill this reporting requirement.
Discussion Points
- Review policies and procedures to ensure HCP influenza vaccination data is accurately recorded and reported timely per CMS and CDC requirements.
- Educate all staff on the importance of infection control and vaccinations. Educate appropriate staff on how to accurately record and report vaccination data.
- Audit to ensure the HPS Component has been activated and the specific information required for data submission has been collected. If the FA needed to be reassigned, audit to make sure it’s been done correctly.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
