Nursing Facility UTI Data Submitters - State Reporting Requirement effective July 1, 2024

The information below provides information on the new reporting requirement specific to nursing facilities effective July 1, 2024. 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 UTI data in NHSN. This page will be updated as needed with information to assist nursing facilities with complying with this requirement.

Requirements

90-590 CMR Chapter 270, Uniform Reporting System for Health Care Quality Data Sets defines health care quality data sets and the provisions for filing these data sets by health care providers to the MHDO. The requirements below are from Section 2 of Rule Chapter 270.

• Section 2(F) - Each nursing facility to submit to the US CDC’s National Healthcare Safety Network a quarterly submission of data, separated by month, for Urinary Tract Infections (UTIs) for all locations within facility scope of service in accordance with NHSN specifications beginning July 1, 2024
  
  
• Section 2(I) - In lieu of reporting data directly to MHDO, each health care facility shall authorize Maine CDC to have access to the NHSN for facility-specific reports of data, including all patient identifiers, submitted for any measure under a state or federal mandate, and shall authorize the Maine CDC to use this data for data validation, public health surveillance and performance improvement purposes. Such data accessed and used by Maine CDC is not considered MHDO data but is protected by 22 M.R.S.A. §42(5) to the extent it is individually identifiable.
  
  
• Section 2(J) - Each health care facility shall authorize the MHDO to have access to the NHSN for facility-specific reports of data, including all patient identifiers, submitted for any measure under a state or federal mandate. For public reporting, all patient identifiers will be protected by MHDO and remain confidential.

What to Report

Measure	Urinary Tract Infections (UTIs) Event
Description	UTI 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	HAI Surveillance Protocol for UTI Events for LTCF (cdc.gov) Healthcare-associated Infection Surveillance Protocol for Urinary Tract Infection (UTI) Events for Long-term Care Facilities (January 2024)

Fact Sheet and Checklist: Please check out this UTI Fact Sheet and Checklist.

June 26, 2024 - An educational webinar was held via Zoom from 2:00 - 3:00 regarding the New UTI Reporting Requirement.
Please see the slides of the webinar presentation for useful information and links.

Implementation of New Reporting Requirement and Suggested Reporting Timelines

June 26, 2024	Informational webinar hosted by the Maine Health Care Association
June 2024	Educational materials (including a copy of the webinar) will be available online at the MHDO website https://mhdo.maine.gov/nursingFacilityUTIsubmitters.htm
July 2024	UTI event surveillance begins

Recommended Reporting Timelines

Surveillance Month & Data	Report Data to NHSN
July 2024	August 2024
August 2024	September 2024
September 2024	October 2024
October 2024	November 2024
November 2024	December 2024
December 2024	January 2025

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(J) of Chapter 270 states, “Each health care facility shall authorize the MHDO to have access to the NHSN for facility-specific reports of data, including all patient identifiers, submitted for any measure under a state or federal mandate. For the purpose of public reporting, all patient identifiers will be protected by MHDO and remain confidential.”

Below are the steps nursing facilities must take in order to grant MHDO access to their NHSN UTI data.

• First, the facility must be a member of the MHDO Group “MHDOnursingfacilityqualitydata”.
• Upon logging into NHSN, there will be a notification that MHDOnursingfacilityqualitydata group’s rights template has been changed and needs to be accepted.
• Click on the Group name link which will bring you to the Rights Template to review and accept - this is conferring 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.

Note: 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 .

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

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.