Nursing Facility Submitters - State Reporting Requirement effective July 1, 2023

The information below provides information on the new reporting requirement specific to nursing facilities effective July 1, 2023. A nursing facility is defined in 22 MRS §1812-A. You will find information on what to report, timelines, and the steps the facility must take in NHSN to allow MHDO access to their CDI data in NHSN. This page will be updated as needed with information to assist nursing facilities with complying with this requirement.

Requirement

90-590 CMR Chapter 270 defines health care quality data sets and the provisions for filing these data sets by health care providers to the MHDO. Section 2(E) of Chapter 270 requires Maine nursing facilities to report Clostridioides difficile (CDI) LabID Event data for all facility-wide residents in accordance with the CDC’s National Healthcare Safety Network (NHSN) specifications. In addition, Section 2(H) of Chapter 270 requires facilities to authorize the MHDO to have access to their healthcare associated infections data submitted to NHSN under a state or federal mandate.

What to Report

Measure	C. difficile (CDI) LabID Event
Description	Clostridioides difficile (CDI) Lab ID Event data, for all facility-wide residents (FacWideIN) in accordance with NHSN specifications
Reporting	Data must be submitted through NHSN (National Healthcare Safety Network)
Specifications	National Healthcare Safety Network (NHSN) 2020 LTCF Component Manual Section 8, titled: Clostridioides difficile Infection (CDI) Surveillance using LabID Event Methodology (see document pages 54 – 62)

Fact Sheet: Please check out this CDI LabID Event Reporting Fact Sheet. You should find this helpful.

Implementation of New Reporting Requirement and Suggested Reporting Timelines

April 2023	Informational webinar hosted by the Maine Health Care Association
June 2023	Educational materials (including a copy of the webinar) will be available online at the Maine Infection Prevention Forum Website (https://maineinfectionpreventionforum.org).
July 2023	CDI LabID event surveillance begins

April 2023 - Webinar Recording and Deck are Available - You may access the recording from the Maine Health Care Association and the PowerPoint Presentation Deck via this link.

Recommended Reporting Timelines

Surveillance Month & Data	Report Data to NHSN
July 2023	August 2023
August 2023	September 2023
September 2023	October 2023
October 2023	November 2023
November 2023	December 2023
December 2023	January 2024

Note: Chapter 270 requires data to be submitted no later than the 15th of the 5th month following the end of each calendar quarter. Although facilities are required to make quarterly data submissions, separated out by month, facilities are urged to submit their data to NHSN each month.

National Healthcare Safety Network Data Access

The National Healthcare Safety Network (NHSN) is the US CDC’s secure internet-based data collection system managed by the Division of Healthcare Quality Promotion. Chapter 270, Section 2(H) states, “Each health care facility shall also authorize the MHDO to have access to the NHSN for facility-specific reports of data submitted for any healthcare associated infection measure under a state or federal mandate, for the purpose of public reporting.” Below are the steps nursing facilities must take in order to grant MHDO access to their NHSN CDI data.

• To access the NHSN reports of data, MHDO has created an NHSN group named: “MHDOnursingfacilityqualitydata.”
• To join the Group, NHSN facility administrator (or user with administrative rights in your facility) will enter a 5-digit ID number and joining password the MHDO provided.
• From the NHSN home page, select Group and Join. Then, enter the ID number, joining password, and click “Join Group.”
• Follow the prompts in NHSN to finish joining the Group.
• Immediately after joining the Group, the user will be taken to the Define Rights Template to agree to confer rights.
  • When you agree to confer rights, you are authorizing the MHDO access to the data as specified in the define rights template. Only MHDO has NHSN access to group members’ data.
• Review and click “Accept” at the bottom of the screen to accept the new define rights agreement.
• For detailed instructions on how to join the Group and to agree to confer rights, you can access the NHSN document titled, “Data Sharing in NHSN: Joining a Group and Accepting the Confer Rights Template” here: http://www.cdc.gov/nhsn/pdfs/groups-startup/joingroup-current.pdf .
• This YouTube video walks through the process of joining a group and conferring rights in NHSN: https://www.youtube.com/watch?v=nCmh6oRJhoE .

NHSN Resources

• Long-term Care Facility (LTCF) Component Training
• Guide for Long-term Care Facilities (LTCFs) Enrolling in NHSN
• Long-Term Care Facility (LTCF) Component Roadmap
• Protocols, Data Collection Forms and Instructions
• FAQs: Clostridioides difficile Infection

Questions about Chapter 270	NHSN User Support
Kimberly Bonsant Maine Health Data Organization 207.287.2296 Kimberly.Bonsant@maine.gov	CDC-NHSN is available to answer your questions about the surveillance protocols and to help navigate the NHSN web application via e-mail at nhsn@cdc.gov. Type “LTCF” in the subject line for quickest routing to the LTCF Team.

Compliance

Failure to comply with the provisions in 90-590 Chapter 270, may result in financial penalties as described in 90-590 CMR Chapter 100, Enforcement Procedures.