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.
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.
|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)|
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.
|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|
|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.
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.
|Questions about Chapter 270||NHSN User Support|
Maine Health Data Organization
|CDC-NHSN is available to answer your questions about the surveillance protocols and to help navigate the NHSN web application via e-mail at email@example.com. Type “LTCF” in the subject line for quickest routing to the LTCF Team.|
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.