Background

On September 2, 2020, the Federal Register published interim final rule CMS-3401-IFC, requiring hospitals and critical access hospitals to report data to DHHS in accordance with Title 42 CFR sections 482.42(e) and 485.640(d), respectively. During the COVID-19 public health emergency, CDPH reported daily COVID-19 and influenza data to DHHS on behalf of hospitals via the COVID-19 Tracking Tool.

COVID-19 and Influenza Reporting

On February 9, 2023, DHHS announced that the federal COVID-19 Public Health Emergency will end on May 11, 2023. This AFL announces that effective May 12, 2023, GACHs must report COVID-19 and influenza data directly to the CDC's NHSN system, in lieu of reporting COVID-19 and influenza data daily to CDPH via the COVID-19 Tracking Tool; these data are still required in accordance with Title 42 CFR section 482.42(e) and (f) until April 30, 2024, unless DHHS specifies an earlier date.

Data previously submitted through the COVID-19 Tracking tool have been critical for the pandemic response to inform hospital capacity and projections for staffing, beds, level loading, and general situational awareness. CDPH is glad to resume direct reporting to NHSN to greatly reduce the reporting burden from the current data elements on the COVID-19 tracking tool, while still maintaining hospital capacity data for California.  NHSN has issued communications regarding additional changes to reporting cadence and the smaller number of required data elements anticipated in the coming weeks. 

COVID-19 case counts are becoming less representative of disease burden and less available due to home-testing. Other seasonal illnesses such as influenza and RSV have seen significant increases, straining hospitals. In this context, general and disease-specific hospital data tracking will assume an even more important role for maintaining timely understanding of strain on individual hospitals and the health care system as well as overall infectious respiratory disease surveillance. To that end, in addition to the 44 data elements required by CMS for submission to NHSN, CDPH will direct that hospitals continue to submit high-quality data on two of the federal “optional data elements," that are determined at the state level: the number of ED visits due to COVID and the number of total ED visits. These data continue to be important to California's ongoing COVID-19 surveillance and response to hospital strain due to COVID-19 and more generally, and are not currently available through other reporting systems.

Please refer to DHHS's COVID-19 Guidance for Hospital Reporting and FAQs (PDF) and NHSN's COVID-19 Hospital Data Reporting for further guidance.

Failure to Report COVID-19 Requirements

Pursuant to CMS QSO 21-03-Hospitals/CAHs (PDF), hospitals that fail to report the specified COVID-19 data elements on a daily basis will receive notification from their CMS Location of their noncompliance with the reporting requirements and any further

noncompliance with reporting requirements may result in future enforcement actions.

The following process will occur for failure to report:

1. Those providers that have continually failed to meet the reporting requirements for a period of six weeks after receiving an initial notification from CMS will receive the first in a series of enforcement notification letters. At this point, the enforcement actions are now in process and providers will have one calendar week to demonstrate compliance.
2. Providers failing to meet the reporting requirements within one calendar week following the first enforcement notification letter will receive a second enforcement notification letter and third enforcement letter, if non-compliant the following week. The third letter will indicate that the provider will have one calendar week to demonstrate compliance with the reporting requirements otherwise the provider will receive a fourth and final enforcement notification letter, as noted in step 3.
3. Providers that have failed to meet the reporting requirements within 1 week following the third enforcement notification letter will receive a fourth and final enforcement notification letter. This notification will include a notice of termination to become effective within 30 days from the date of the notification. Failure to meet the reporting requirements within this 30-day timeframe may result in termination of the Medicare provider agreement.
   
   If a hospital receives a notification of noncompliance, the hospital will have an opportunity to provide evidence of compliance. The hospital may submit evidence to CMS within 72 hours of receiving notification of noncompliance. If the hospital is found to be in compliance with the reporting requirements, enforcement remedies will be rescinded. If the enforcement action for failure to report is rescinded and the provider subsequently demonstrates noncompliance with the requirements in the future, a new enforcement action will begin.
   

Questions

If you have any questions about this AFL, please contact the CDPH GACH Data Support at COVID-19-CHCQData@cdph.ca.gov.

Sincerely,

Original signed by Cassie Dunham​

Cassie Dunham

Deputy Director

Resources:

• Federal Register Interim Final Rule CMS-3401-IFC
• CMS QSO 21-03-Hospitals/CAHs (PDF)
• DHHS COVID-19 Guidance for Hospital Reporting and FAQs (PDF)
• NHSN COVID-19 Hospital Data Reporting
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