U.S. Department of Health and Human Services 
Office of Inspector General 
+ 
 
 
CDC Has Improved the 
Nursing Home Reporting 
Process for COVID-19 Data in 
NHSN, but Challenges Remain 
Ann Maxwell 
Deputy Inspector General 
   for Evaluation and Inspections 
January 2024, OEI-06-22-00030  U.S. Department of Health and Human Services 
 
Office of Inspector General 
Report in Brief 
January 2024, OEI-06-22-00030 
 
CDC Has Improved the Nursing Home Reporting 
Why OIG Did This Review 
The National Healthcare Safety  Process for COVID-19 Data in NHSN, but 
Network (NHSN) has served as a 
Challenges Remain 
critical source for monitoring the 
effects of the COVID-19 pandemic, 
What OIG Found 
and informing the Federal, State,  Key Takeaway 
Despite CDC efforts, both CDC and 
and local pandemic response.  In 
CDC struggled to support 
nursing homes experienced difficulties 
May 2020, the Centers for 
nursing homes during mass 
during a mass enrollment of more than 
Medicare & Medicaid Services   enrollment into NHSN in 2020 
12,000 facilities into NHSN to begin 
(CMS) issued a requirement for 
and as COVID-19 reporting 
reporting COVID-19 data in May 2020.  
nursing homes to report COVID-19 
requirements changed 
data to NHSN.  The Centers for  throughout the pandemic.   As the pandemic continued, CDC added 
Disease Control and Prevention  CDC has improved the nursing  data variables to NHSN, including fields 
(CDC) has operated NHSN since 
home reporting process and  with personally identifiable information, 
2005, but nursing home reporting 
guidance, but some  in response to emerging data needs and 
had been voluntary, with  challenges remain.  Continued  new Federal reporting requirements.  
participation from only a small 
improvements to NHSN user  Nursing homes had to upgrade their 
proportion of facilities.  The 
support and data quality will  security access levels to report the 
reporting requirement resulted in  be important for continued  sensitive data.  At this time, CDC 
the influx of thousands of nursing 
reporting on vaccinations and  experienced a significant backlog of 
homes enrolling in and reporting 
for future public health  support requests, which also inhibited 
to NHSN in 2020, while they, and  surveillance.     some facilities from accessing NHSN.  
CDC, also responded to the 
pandemic.    CDC improved the process of nursing home reporting to NHSN throughout 
the pandemic.  Facilities acknowledged this effort and reported that CDC 
This evaluation provides insights 
support improved, but some continued to experience difficulty getting 
into nursing home experiences 
assistance.  Additionally, a quarter of nursing homes reported lacking 
enrolling in and reporting to 
confidence in the quality of NHSN data, despite the quality assurance checks 
NHSN, and CDC efforts to facilitate 
CDC conducts on key variables.  
reporting such as user support for 
facilities facing difficulties.  These  After December 2024, CMS reporting requirements for some key variables 
insights can help CDC address  will expire, but the mandate for reporting vaccination-related data will 
ongoing challenges, and mitigate  remain.  CDC stated that it will continue to support voluntary reporting of 
potential issues in future updates  COVID-19 data and other infection and quality measures, and modernize 
or expansions.   NHSN reporting processes.  Stakeholders and CDC expressed that having 
nursing home participation in NHSN is valuable for public health surveillance, 
How OIG Did This Review 
and the agency is exploring opportunities to leverage the current national 
We administered an electronic  enrollment for reporting on other health outcomes.   
survey to a simple random sample 
of 197 nursing homes from a  What OIG Recommends and How the Agency Responded 
population of 15,324 facilities that  To continue improvements, we recommend that CDC (1) improve the user 
have reported COVID-19 data to  support the NHSN Help Desk provides to nursing homes, (2) take further 
NHSN, and interviewed a subset of  steps to ensure the quality of nursing home reporting of COVID-19 data to 
facilities.  We also interviewed CDC  NHSN, and (3) consider how quality assurance checks can be enhanced to 
and CMS officials to understand  ensure data accuracy, as appropriate.  CDC partially concurred with our first 
CDC efforts to facilitate nursing  recommendation and concurred with our second and third 
home enrollment and reporting to  recommendations. 
NHSN.  We based our findings on 
a nalysis of survey and interview 
responses.   
TABLE OF CONTENTS 
 
 
BACKGROUND ................................................................................................................................................ 4 
FINDINGS ....................................................................................................................................................... 14 
Despite CDC efforts, both the agency and nursing homes experienced difficulties during mass 
enrollment in NHSN: MayJune 2020 ............................................................................................................................. 14 
CDC changes to NHSN data fields and security resulted in new challenges for the agency and nursing 
homes: AugustDecember 2020 ....................................................................................................................................... 18 
CDC has improved nursing home experiences reporting to the COVID-19 Module throughout the 
pandemic.................................................................................................................................................................................... 21 
Nursing home experiences with reporting have improved since May 2020, though issues remain for 
both facilities and CDC ......................................................................................................................................................... 23 
CDC has made efforts to ensure data quality, but nursing homes reporting to the COVID-19 Module 
expressed concerns ................................................................................................................................................................ 28 
CDC plans to continue improving NHSN for nursing home reporting and is considering how to 
leverage national enrollment for voluntary reporting on other health events ............................................... 30 
CONCLUSION AND RECOMMENDATIONS .......................................................................................... 33 
Improve the user support the NHSN Help Desk provides to nursing homes ................................................. 33 
Take further steps to ensure the quality of nursing home reporting of COVID-19 data to NHSN ......... 34 
Consider how quality assurance checks can be enhanced to ensure data accuracy, as appropriate ..... 34 
AGENCY COMMENTS AND OIG RESPONSE ........................................................................................ 35 
APPENDICES................................................................................................................................................. 36 
Appendix A: Estimates, Confidence Intervals, and Key Statistics for Nursing Home Survey Results ...... 36 
Appendix B: Changes to the LTCF COVID-19 Module .............................................................................................. 43 
Appendix C: Step-by-Step Enrollment Process for NHSN Users .......................................................................... 44 
Appendix D: SAMS Registration and Identity Verification ...................................................................................... 47 
Appendix E: Agency Comments ........................................................................................................................................ 48 
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 53 
ABOUT THE OFFICE OF INSPECTOR GENERAL .................................................................................... 54 
ENDNOTES ................................................................................................................................................... 55 
 
   
BACKGROUND 
OBJECTIVES 
1.  To examine nursing home experiences enrolling in and reporting required 
data to the National Healthcare Safety Network (NHSN) COVID-19 Module. 
2.  To assess Centers for Disease Control and Prevention (CDC) efforts to 
facilitate nursing home reporting to NHSN. 
 
The COVID-19 pandemic has had a devastating impact on nursing homes and their 
residents.  Nursing homes have experienced widespread challenges during the 
pandemic, such as inadequate access to personal protective equipment (PPE) and 
staffing shortages.1, 2  As of January 1, 2023, more than 1.4 million nursing home 
residents in the United States had confirmed cases of COVID-19, with approximately 
160,000 deaths.3 
To monitor the effects of the pandemic and inform public health policies, the Centers 
for Medicare & Medicaid Services (CMS) issued a requirement for nursing homes to 
report COVID-19 data to CDCs NHSN.4, a  The reporting requirement resulted in an 
influx of thousands of nursing homes submitting data to NHSN.  While the data have 
been critical for informing the pandemic response, nursing homes have experienced 
challenges enrolling in and reporting COVID-19 data to NHSN. 
The National Healthcare Safety Network 
CDC launched NHSN, a web-based surveillance system, in 2005 to collect data on 
health care-associated infections (HAIs) in health care facilities.5  The Surveillance 
Branch, within CDCs Division of Healthcare Quality Promotion, manages NHSN.6  
NHSNs designated operating budget was $21 million in fiscal year 2022.7   
NHSN Long-term Care Facility Component 
CDC launched the NHSN Long-term Care Facility (LTCF) Component in 2012 for 
voluntary reporting of HAI and prevention data.8  The LTCF Component allows 
facilities to monitor HAIs and infection control to identify problems, improve care, and 
determine progress towards national HAI goals.9  Several types of LTCFs report to the 
component, including nursing homes and assisted living facilities.10, b  The LTCF 
_____________________________________________________________________________________________________________________________ 
a In this report, the term nursing homes refers to both Medicare-certified skilled nursing facilities and 
Medicaid-certified nursing facilities.  See SSA  1819, Requirements for, and assuring quality of care in, 
skilled nursing facilities, and SSA  1919, Requirements for nursing facilities. 
b Nursing homes, assisted living, and Intermediate/Chronic Care Facilities for individuals with intellectual 
disability report to the NHSN LTCF Component.   
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030   Background | 4    
Component consists of four modules: (1) the HAI Module, (2) the  
Laboratory-identified Event Module, (3) the Prevention Process Measures Module, and 
(4) the COVID-19 Module.11, 12  
CDC released the LTCF COVID-19 Module in April 2020 to support pandemic 
response activities.13, 14  Initially, the COVID-19 Module only collected data on the 
impact of the pandemic on residents and staff, facility supplies, and the facility 
response.15, 16  CDC has since made changes to the module to collect data on various 
pandemic-related developments.17, 18, 19, 20  (See Exhibit 1 for the structure of the 
COVID-19 Module, as of June 2023, and Appendix B for a timeline of major changes 
to the module.) 
Exhibit 1: Structure of the LTCF COVID-19 Module  
 
Source: CDC, LTCF COVID-19 Module.  Accessed at https://www.cdc.gov/nhsn/ltc/covid19/index.html on  
February 6, 2023.  CDC, HCP & Resident COVID-19 Vaccination.  Accessed at  
https://www.cdc.gov/nhsn/ltc/weekly-covid-vac/index.html on December 3, 2021. 
Note: The bottom three boxes under the Surveillance Reporting Pathways (Supplies and PPE, Ventilator Capacity and 
Supplies, and Therapeutics) indicate pathways CDC later removed from the COVID-19 Module. 
 
 
 
 
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COVID-19 Module Enrollment 
LTCFs must enroll in NHSN to use the COVID-19 Module.21  Facilities that were 
already enrolled in the LTCF Component had immediate access to the module.  
Facilities newly enrolling in NHSN have followed a multi-step enrollment process to 
gain access.   
Each LTCF must designate an NHSN Facility Administrator (NHSN Administrator) for 
enrollment.22  The NHSN Administrator serves as the facilitys point of contact for 
receiving information from and reporting data to NHSN.23  The NHSN Administrator 
submits all required information in the NHSN registration page.24  Following 
registration with NHSN, the applicant receives an email invitation to register with the 
Secure Access Management Service (SAMS) with steps to submit facility contact 
information.25  The NHSN Administrator then enters all required information in SAMS 
to complete enrollment.26  (See Appendix C for the step-by-step enrollment process 
published by CDC.)     
SAMS Registration 
SAMS is an online portal that provides authentication, login, and secure access to 
authorized personnel to more than 300 CDC technology applications, including 
NHSN.27  The Digital Services Office (Digital Services), within the CDC Office of Chief 
Information Officer, manages SAMS.28   
NHSN applicants undergo an identity verification process in SAMS, due to the 
sensitivity of the data they will be submitting.  SAMS grants users one of  
three distinct access levels following registration.  Each tier requires increasing levels 
of user authentication during enrollment and login.   
  Level 1: Users are not authorized to report personally identifiable information.29   
This access level does not require identity verification or any additional security 
measure during the enrollment or login process.30 
  Level 2: Applicants must complete identity verification during enrollment.31  Users 
may log in to the application with only the username and password.32 
  Level 3: Users are authorized to report personally identifiable information.33  Users 
must complete identity verification during enrollment.34  To log in, users must 
complete second-factor authorization using a soft token, which is a mobile 
authentication application, or a hard token, which is a physical card mailed to the 
users home address.35, 36  
According to CDC, reporting to NHSN requires SAMS Level 3 access if the user reports 
data that includes personally identifiable information.c 
_____________________________________________________________________________________________________________________________ 
c Initially, nursing homes newly enrolling in the COVID-19 Module only needed SAMS Level 1 access, as 
reporting to the module did not involve submitting data with personally identifiable information.  (See 
Simplified enrollment process on page 15.) 
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NHSN Technical Support 
CDC provides support to NHSN users through the NHSN User Support Help Desk 
(NHSN Help Desk).37  Users submit support requests exclusively via email, given that 
the NHSN Help Desk does not have a user support telephone line.  The staff 
operating the Help Desk triage tickets manually.  After submitting an email request, 
users receive an automated response, which includes a ticket number and the 
expected wait time.  Prior to the pandemic, user support requests to the Help Desk 
had an expected wait time of 2 to 5 business days, with a 7-day wait time if the 
inquiry required subject-matter expertise.38   
CMS Nursing Home Reporting Requirements 
CMS sets and enforces health and safety standards, and oversees nursing home 
compliance with Medicare and Medicaid standards to ensure resident health and 
safety.39  On May 8, 2020, as a part of its pandemic response, CMS issued an interim 
final rule that required nursing homes to report COVID-19 data to NHSN.40  Nursing 
homes had until May 17, 2020, to enroll in NHSN to begin reporting COVID-19 data. 
Nursing homes fulfill the reporting requirements via the LTCF COVID-19 Modules 
Surveillance Reporting Pathways (referenced in Exhibit 1 on page 5).  The interim final 
rule required facilities to electronically report the following data on a weekly basis: 
  Suspected and confirmed COVID-19 infections among residents and staff, 
including residents previously treated for COVID-19; 
  Total deaths and COVID-19 deaths among residents and staff; 
  PPE and hand hygiene supplies in the facility; 
  Ventilator capacity and supplies in the facility; 
  Resident beds and census; 
  Access to COVID-19 testing while the resident is in the facility; and 
  Staffing shortages.41 
CDC experienced a substantial rise in NHSN enrollment by nursing homes as a result 
of the CMS reporting requirements.  Prior to the pandemic, nursing home reporting 
to NHSN was largely voluntary and not Federally required.  Between March and  
June 2020, the total number of LTCFs enrolled in NHSN increased by more than  
450 percent, from 3,086 to 17,248 facilities.42, 43, d    
_____________________________________________________________________________________________________________________________ 
d The number of LTCFs enrolled in NHSN increased by 14,162 between March and June 2020.  According 
to CDC, the majority of the increase in NHSN enrollment is attributable to the addition of more than 
12,000 nursing homes.  During the week of June 7, 2020, a total of 15,365 nursing homes reported 
COVID-19 data to NHSN. 
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CMS expanded its reporting requirements in a second interim final rule issued on  
May 13, 2021.  Nursing homes fulfilled the additional requirements via the COVID-19 
Vaccinations Module and the Therapeutics Pathway (referenced in Exhibit 1 on  
page 5).  CMS added the following data variables, some of which include personally 
identifiable information: 
  COVID-19 vaccine status of residents and staff, including total numbers of 
residents and staff; numbers of vaccinated residents and staff; numbers of each 
dose of the COVID-19 vaccine received; and COVID-19 vaccination-related 
adverse events; and 
  Therapeutics administered to residents for treatment of COVID-19.44 
Enforcement Actions 
CMS has the authority to penalize nursing homes that do not meet the weekly 
reporting requirements.  On September 2, 2020, CMS issued an interim final rule that 
established civil money penalties for facilities that fail to submit required data for a 
given reporting week.45  CMS finds that a nursing home meets requirements if the 
facility reports any data related to the effects of COVID-19 on residents and staff.46 
Nursing Home Reporting 
The number of data points nursing homes are required to submit to NHSN has 
changed over time.  In November 2021, facilities were required to submit up to  
132 data points, including 100 data points that were conditionally required on the 
basis of facility responses.47  For example, if a nursing home reported that it had any 
residents stay at the facility at least 1 day (24 hours) of a reporting week, the nursing 
home needed to submit up to six additional data points about resident vaccination 
status.  Over time, CDC has substantially reduced the number of questions a nursing 
home may need to submit.  As of August 2023, nursing homes only have to submit up 
to 37 data points, 3 of which are conditionally required.  Of the 34 required data 
points, 5 are related to infections and deaths, and 29 are related to vaccinations.48, 49, 
50, 51   
CMS requirements to report data related to COVID-19 infections, deaths, and staffing 
will expire after December 2024, but requirements for nursing homes to report 
vaccination-related data will continue.52  According to CDC, this means that, 
beginning in 2025, facilities will only report data for the 29 vaccination-related 
variables. 
Nursing homes report data to the COVID-19 Module by entering data directly into 
the module or uploading data files based on templates provided by CDC.53  The 
module visually shows when a submission is complete or is missing data points.54  
Authorized group users, such as State and local health departments, may also report 
to NHSN on behalf of nursing homes, but facilities are still responsible for data 
submission.55   
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Quality Assurance Checks 
CDC conducts quality assurance (QA) checks on the data for facility admissions, 
COVID-19 cases, and COVID-19 deaths in the COVID-19 Module.56  If a nursing 
homes data fail to meet the QA criteria, CDC flags the data to allow for correction by 
the facility. 
For resident and staff variables, the data must: 
  Represent a weekly count of a given variable and not a cumulative total, and   
  Not exceed a subset of cutoff values established by CDC to identify outliers that 
appear invalid. 
Following its QA checks, CDC shares nursing home COVID-19 data from NHSN with 
CMS on a weekly basis.  Prior to sharing the file, CDC nullifies data that failed its QA 
checks, and flags the facility in the dataset for CMS.   
CDC also conducts QA checks on two vaccination variables: the percentage of current 
residents, and the percentage of health care personnel, with no medical 
contraindications who received a completed or partial COVID-19 vaccination at any 
time.  For the given reporting week, the data values for the two vaccination variables 
cannot be less than or equal to 10 percent.57 
Use of NHSN COVID-19 Data 
Nursing home COVID-19 data from NHSN have informed efforts within the U.S. 
Department of Health and Human Services (HHS) and the broader stakeholder 
community.  According to CDC, other stakeholders that used COVID-19 data from 
NHSN include the following:   
  The White House COVID-19 Task Force, to inform its emergency response 
actions;  
  The Assistant Secretary of Preparedness and Response, with efforts to 
distribute PPE and other medical supplies, as well as to address health care 
personnel shortages;  
  The Federal Emergency Management Agency, to also address health care 
personnel shortages;  
  Long-term care trade or membership organizations, to support outreach and 
educational efforts;  
  State and local health departments, to inform prevention activities and 
pandemic outbreak investigations; and 
  CMS, to support efforts by its Quality Improvement Organizations, among 
other uses. 
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CMS referenced NHSN data on staff COVID-19 vaccination coverage in its  
November 2021 interim final rule regarding vaccination requirements for health care 
personnel.58  CDC also posts data specific to COVID-19 cases and deaths among 
nursing home residents and staff on a publicly available dashboard that is updated 
weekly.59   
Since May 31, 2020, CMS has maintained a public dataset of weekly nursing home 
COVID-19 data to support efforts to protect the health and safety of residents and 
other consumers.60, 61  CMS conducts separate QA checks on the NHSN data it 
receives from CDC to review compliance with certain requirements, such as reporting 
data on total resident and staff COVID-19 deaths.62  If a nursing homes data fail to 
meet CMSs QA criteria, CMS does not include any of the facilitys data in the publicly 
posted dataset, and notes that the facility did not pass the QA check. 
CMS has since added to the ways it presents NHSN data to consumers and other 
stakeholders.  In September 2021, CMS began displaying COVID-19 vaccination data 
on its Care Compare tool, which provides quality metrics for nursing homes and other 
health care facilities to help consumers make more informed choices.63  
Related Work 
In September 2021, OIG released a report that found that COVID-19 data submitted 
to NHSN by a small portion of nursing homes in the early months of the CMS interim 
final rule were inaccurate or incomplete.  Specifically, OIG found that about 5 percent 
of reported nursing home data between June 22 and July 19, 2020, did not include all 
required data and were not complete or accurate following CMS QA checks.64 
OIG has other work related to the pandemics effects on nursing homes and Federal 
and State programs.  OIG found that overall mortality in nursing homes increased in 
2020, and that States conducted fewer onsite surveys to assess compliance with 
Federal requirements during the pandemic.65, 66  OIG also found that 1,358 nursing 
homes had extremely high infection rates75 percent or moreduring surges of 
COVID-19 cases in the spring and fall of 2020, and experienced an average overall 
mortality rate approaching 20 percent.67  An ongoing study is examining nursing 
home strategies to address challenges during the pandemic and in future public 
emergencies.68  
Methodology 
Scope of Inspection 
We examined the experience of nursing homes enrolling in and reporting required 
data to the LTCF COVID-19 Module, including any challenges facilities faced, and 
strategies used to overcome the difficulties.  We did not assess the completeness or 
accuracy of the data.  We also evaluated CDC efforts to facilitate nursing home 
enrollment in and reporting to the COVID-19 Module.  These efforts included CDC 
instructions and correspondence about NHSN, and its actions to address nursing 
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OEI-06-22-00030   Background | 10    
home challenges.  Although we describe CMS involvement with the module, we did 
not evaluate CMS actions regarding NHSN as part of this evaluation.  The timeframe 
for our review was February 2020 through June 2023. 
We used the following data sources for our evaluation: (1) an electronic survey of a 
sample of LTCFs reporting to the COVID-19 Module; (2) interviews with a smaller 
subset of nursing home administrators and staff, selected from the survey sample;  
(3) interviews with CDC officials involved with NHSN; (4) interviews with CMS officials 
involved in collaborating with CDC regarding nursing home COVID-19 data in NHSN; 
and (5) documentation provided by CDC regarding nursing home enrollment and 
reporting to the COVID-19 Module. 
Data Collection 
Survey.  We administered an electronic survey to a simple random sample of  
200 LTCFs and received responses from 171 facilities, for an 86-percent rate of 
contact.e, f  Our sample population consisted of 15,324 facilities that reported data at 
least once to the LTCF COVID-19 Module between May 24 and December 26, 2021.  
(Our sample of 200 LTCFs represented 1.3 percent of the total population.)  Of the 
171 respondents, 167 were nursing homes and the remaining 4 were LTCFs of other 
types.g  Our sampling method and response rate allowed us to project the results of 
our survey to the total population of LTCFs reporting to the COVID-19 Module during 
this timeframe. 
The survey consisted of both closed- and open-ended questions.  The closed-ended 
questions focused on nursing home experiences enrolling in and reporting data to 
the COVID-19 Module.  The open-ended questions asked nursing homes to provide 
additional details on any identified challenges and improvements to enrollment and 
reporting, as well as perceptions of related CDC efforts. 
Interviews.  We conducted semi-structured virtual interviews with stakeholders 
involved in nursing homes enrolling in and reporting to the COVID-19 Module as 
follows:   
  Individual interviews with 12 CDC officialsincluding Division of Healthcare 
Quality Promotion leadership involved with NHSN, the COVID-19 Module, and the 
NHSN Help Desk, and Digital Services leadership involved with SAMSto identify 
and understand CDC efforts to facilitate nursing home enrollment in and 
_____________________________________________________________________________________________________________________________ 
e We randomly selected a sample of 200 facilities from the population of 15,324 that reported to the 
LTCF COVID-19 Module at least once between May 16 and December 26, 2021.  We did not distribute a 
survey to three nursing homes, as two were involved in ongoing work by OIGs Office of Investigations, 
and the remaining one had permanently closed.  
f We made a minimum of three follow-up attempts to contact respondents who did not submit a 
completed survey. 
g We refer to the survey respondents as nursing homes for the remainder of our report. 
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reporting to NHSN.  We also inquired about related challenges CDC experienced, 
as well as factors that may negatively affect reporting. 
  Group interview with eight CDC officials as a follow-up discussion to clarify CDCs 
most recent NHSN efforts and future uses of NHSN in collaboration with 
stakeholders.  We also discussed ongoing reporting requirements and how they 
would affect nursing home engagement with NHSN.  
  Individual interviews with representatives from 10 facilities involved with enrolling 
in and reporting to the COVID-19 Module, representing a subset of survey 
respondents, to gain further insight on nursing home experiences with NHSN.  
Using facility survey responses, we selected facilities that (1) reported, and 
provided detail about, common themes that we identified in our analysis of the 
overall survey results; and (2) reported challenges and navigated those challenges 
in ways we found informative.  We conducted interviews with 12 respondents 
representing the 10 facilities. 
  Group interview with 12 CMS officials involved with nursing home reporting to the 
COVID-19 Module, to identify inter-agency collaboration efforts.  
Documentation.  We reviewed documents related to nursing home reporting to the 
COVID-19 Module, including (1) CDC manuals, memos, presentations, and other 
guidance about enrolling in and reporting to the module; (2) records of user support 
requests submitted to and resolved by the NHSN Help Desk, and templates for 
related email communication; and (3) CDC guidance that explains or relates to QA 
checks performed on the data.  
Data Analysis 
Survey.  We analyzed survey results to gain insight into nursing home experiences 
reporting to the COVID-19 Module and perceptions of CDC user support.    
We used closed-ended question responses to identify the proportion of nursing 
homes with certain experiences enrolling in and reporting COVID-19 data to NHSN.  
Using SAS statistical software, we projected the closed-ended question responses 
from our nursing home respondents to the population of facilities enrolled in the 
COVID-19 Module at the time of data collection. 
The open-ended question responses provided additional context and anecdotal 
examples that illustrated our findings.   We also used the open-ended responses to 
select a sample of nursing homes to interview.  
Interviews.  Interviews with CDC and CMS officials, as well as with nursing home 
representatives, added important context and examples of NHSN-related challenges 
and CDC efforts to address them.  We used interviews with CDC to detail support 
efforts, including how the agency formulated and distributed guidance, and how it 
responded to difficulties experienced by nursing homes.  We used the interview with 
CMS to identify how CDC addressed updates to the COVID-19 Module, as well as how 
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
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it accommodated CMS use of NHSN data.  We used interviews with facility 
representatives to gain further insight into the frequency and severity of challenges 
the facilities have experienced with NHSN.  The scope of our evaluation focused on 
CDC efforts and did not include the assessment of CMS actions related to NHSN.  
Documentation.  We reviewed documents to identify gaps in CDC guidance that may 
have contributed to or helped resolve nursing home difficulties, and related 
correspondence.  Our analysis of documents evaluated how CDC approached the 
challenges and relayed information related to the reporting process. 
Limitations 
We did not independently verify information self-reported by CDC and nursing 
homes, including data submitted by nursing homes to NHSN.  We also did not 
determine a causal relationship between CDC actions and improved nursing home 
reporting.  
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.   
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FINDINGS 
Despite CDC efforts, both the agency and nursing homes 
experienced difficulties during mass enrollment in NHSN: May
June 2020 
CDC described the mass enrollment of nursing homes following the CMS reporting 
requirements as difficult and labor-intensive.  It described experiencing pressure and 
challenges preparing for and managing the influx of newly enrolling facilities.  Starting 
in May 2020, immediately following the CMS interim final rule, CDC onboarded 
thousands of nursing homes in NHSN under a compressed timeline.   
Nursing homes enrolling in the COVID-19 Module also faced challenges.  Among 
newly enrolled facilities in our sample, 101 of 117 reported experiencing difficulties 
during the enrollment process, such as issues with accessing CDC guidance and 
resources.h 
CDC made efforts to mitigate enrollment-related challenges, 
including streamlining the process and reallocating staff 
CDC prepared for the mass onboarding of nursing homes internally, and by 
collaborating with external partners such as CMS.  CDC frequently communicated with 
partners; added and relocated staff; and distributed guidance and resources to NHSN 
users.  One CDC official explained that joint efforts with external partners were 
particularly important in successfully enrolling facilities in the COVID-19 Module.  
CDC decided to use NHSN for collecting nursing home COVID-19 data in 
collaboration with CMS.  CDC and CMS reported that, starting in late  
February 2020, the two Federal agencies routinely met to discuss COVID-19-related 
items, particularly in regard to nursing homes.  They identified the need to obtain 
data from nursing homes during the pandemic, and decided to use NHSN as the data 
collection system.  CDC regularly sought CMS feedback on the language and 
important topics of interest for data collection.  CMS concurrently developed the 
interim final rule, and involved CDC in writing the reporting requirements, rules, 
guidance, and memos.  This collaboration was critical, because the development of 
the COVID-19 Module, and related guidance, depended on the CMS interim final rule 
to dictate what data nursing homes would be required to report. 
Both agencies reported that they were able to accomplish the module development 
due to collaborative efforts with external partners.  On April 19, 2020, CMS alerted 
_____________________________________________________________________________________________________________________________ 
h Of the sample nursing homes, one-third (54 of 171) voluntarily enrolled in NHSN prior to the CMS 
interim final rule, and two-thirds (117 of 171) newly enrolled after CMS issued the reporting 
requirements. 
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nursing homes to the upcoming reporting requirements.  Following the issuance of 
the CMS interim final rule on May 8, nursing homes had until May 17, 2020, to enroll 
in NHSN to report COVID-19 data.  CDC and CMS held national stakeholder calls with 
trade organizations, which contacted their members about enrollment and directed 
nursing homes to guidance and resources such as the NHSN Help Desk.  One CMS 
official stated that a combination of outreach and CMS authority to require facility 
participation helped enrollment.  A CDC official agreed, explaining that voluntary 
reporting had not been as effective as CMS requiring nursing homes to report to 
NHSN. 
CDC rapidly developed and launched the LTCF COVID-19 Module in  
April 2020.  CDC built the reporting platform, and its subject-matter experts 
developed questions to inform pandemic response and prevention.  The agency 
stated that discussions about creating a module in NHSN for COVID-19 reporting 
began in March 2020.  One CDC official reported that developing and launching the 
COVID-19 Module itself occurred over 10 days, from April 16 to April 25.  Agency 
officials noted that the development of new NHSN modules prior to February 2020 
normally took multiple years.  Another official explained that existing system 
infrastructure and field expertise, in addition to the allocation of additional resources, 
allowed for an expedited module development process. 
CDC anticipated and made preparations to address the enrollment surge, 
including simplifying the onboarding process, allocating additional staff, 
and hosting support calls.  Following the development of the COVID-19 Module, 
CDC identified potential challenges associated with enrolling a large volume of new 
users who are unfamiliar with NHSN and electronic reporting.  According to 
Surveillance Branch officials, CDC used several strategies to alleviate strain during the 
enrollment surge, such as the following: 
  Simplified enrollment process.  Nursing homes initially submitted data to the 
COVID-19 Module that consisted of aggregate, facility-level information, but not 
personally identifiable information.  CDC created an enrollment process with 
SAMS Level 1 access for nursing homes newly enrolling in NHSN to report  
COVID-19 data.  The simpler process reduced the length of enrollment from 
several weeks to a maximum of 2 days. 
  Click squad.  CDC established a task force called the click squad to manually 
review and approve invitations, and to respond to facilities.  The click squad 
consisted of Surveillance Branch staff and other agency staff not normally involved 
with NHSN, including detailees and contractors.  
  Conference calls.  The Surveillance Branch also hosted conference calls to ease 
the burden on the NHSN Help Desk.  CDC staff held the calls two to three times 
per week during the mass enrollment period to provide direct support to nursing 
homes.  CDC officials reported that the conference calls were well-attended, 
sometimes with hundreds of facilities on the call. 
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The NHSN Help Desk and other systems experienced difficulties 
providing support to newly enrolling facilities 
Mass enrollment of nursing homes caused significant strain on the NHSN Help Desk.  
The rapid increase in total NHSN users included thousands of facilities that had not 
previously interacted with NHSN and now needed 
additional help.  The Help Desk had no phone support, so  [User volume] 
user support specialists often had to walk new users  almost doubled 
through their questions via email, in addition to facilitating  overnight, while we 
all other inquiries and enrollment activities, which resulted 
didnt double our 
in a bottleneck.  According to CDC, Surveillance Branch 
staff overnight to 
staff worked 60 to 80 hours a week to manage the 
deal with it. 
increased onboarding and Help Desk tickets during the 
initial 6 to 8 weeks of nursing homes enrolling in the 
 CDC official 
COVID-19 Module.  
CDC assigned additional staff to the NHSN Help Desk in anticipation of enrollment-
related challenges, but the Help Desk continued to experience difficulties.  CDC 
reported that the agency increased work hours of existing user support specialists, 
reallocated other CDC contractors, detailed staff from various task forces, and pulled 
members from other teams to help respond to users.  Still, according to one official, 
the NHSN Help Desk had delayed responses and a growing backlog of unresolved 
tickets.  CDC explained that user support requests related to COVID-19 data 
submission had an expected wait time of 1 to 3 weeks, depending on the subject 
matter, as compared to a typical 2 to 5 days prior to the pandemic. 
The enrollment surge also impacted other CDC user support systems.  The SAMS Help 
Desk, operated by Digital Services to provide SAMS-related support to users via email 
and telephone, faced difficulties as a result of NHSN users needing assistance.  CDC 
reported that Digital Services frequently coordinated with the Surveillance Branch to 
address problems and to proactively mitigate challenges during influxes in 
enrollment.  Collaboration between both teams also included discussions about 
NHSN-related inquiries that came to the SAMS Help Desk.  The SAMS Help Desk 
often received NHSN-related telephone calls through its phone line.  One nursing 
home representative recalled contacting the SAMS Help Desk with NHSN-related 
inquiries because it had a phone line, but being told that the facility could only 
receive the help it needed from the NHSN Help Desk.  One Digital Services official 
reported that the SAMS Help Desk felt the brunt of escalations related to urgency in 
interactions with frustrated users.  The official further stated that users wanting to 
speak with someone, but not being able to, was a pinch point. 
 
 
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Nursing homes experienced difficulties enrolling in NHSN, such 
as with registering staff to report data 
Most newly enrolling nursing homes (86 percent) had challenges with various aspects 
of NHSN enrollment.i, j  These facilities reported a range of difficulties, including 
challenges registering staff to input data (67 percent) and receiving technical 
assistance from CDC (56 percent).  (See Exhibit 2.)     
Exhibit 2: Newly enrolled nursing homes reported difficulties enrolling in 
NHSN during the COVID-19 pandemic (n=117).  
 
Source: OIG analysis of survey responses from 171 nursing homes, November 2022. 
Nursing homes made efforts to address the enrollment difficulties, most often 
proactively seeking assistance from CDC and others.  Nearly half of the newly 
enrolling facilities (49 percent) reached out to the CDC NHSN Help Desk for 
assistance, and 30 percent reached out to CMS.  Nursing homes also sought 
assistance from other sources.  For example, 38 percent reached out to their 
corporate or facility chain, and 20 percent contacted nongovernment organizations, 
such as trade and membership groups, to seek assistance navigating the process. 
 
_____________________________________________________________________________________________________________________________ 
i Survey respondents indicated whether they enrolled in NHSN prior to the CMS reporting requirements 
in May 2020.  Upon indicating that they newly enrolled in the system, respondents were prompted by the 
survey to answer several questions about enrollment.  This created a sample subset of 117 facilities. 
j OIG analysis of survey responses concluded that 101 of 117 newly enrolling facilities reported having 
difficulty with at least one of the listed enrollment aspects.  
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CDC changes to NHSN data fields and security resulted in new 
challenges for the agency and nursing homes: 
AugustDecember 2020 
Following nursing homes enrolling in and beginning to report data to NHSN, CDC 
made several changes to the system to incorporate more information that HHS and 
stakeholders requested to inform pandemic response efforts.  The newly requested 
data, such as point-of-care (POC) testing information, included personally identifiable 
information, which resulted in many nursing homes needing to upgrade their SAMS 
security access from Level 1 to Level 3.  The transition to a higher level of security 
access required a more difficult and complex process (referenced in SAMS 
Registration on page 6).  This resulted in an additional backlog of Help Desk requests.  
CDC worked with stakeholders to add new data fields to NHSN 
following pandemic-related developments 
CDC reported that changes in the COVID-19 response, environment, and knowledge 
resulted in new data needs, and that the agency expanded data elements as 
countermeasures became available.  The development of new pandemic response 
efforts resulted in the immediate need for data and rapid additions to the COVID-19 
Module.  For example, CDC added therapeutics-related variables to determine which 
nursing homes obtained and used, and how successful they were in obtaining, 
antiviral and antibody therapies.  CDC also included fields about the types of  
COVID-19 vaccines being administered to identify any distinctions. 
CDC subject-matter experts, such as doctors, nurses, and infection preventionists, 
developed NHSN questions as the pandemic continued.  In developing the  
vaccine-related variables, they determined the level of detail and flexibility to build 
into the system for future accommodations, such as new manufacturers.  CDC also 
collaborated with external stakeholders throughout the pandemic to update NHSN 
modules and data fields. 
CDC collaborated with CMS and other partners to add data fields to 
NHSN, and considered the burden to nursing homes.  One CDC official 
reported that collaboration with stakeholdersincluding trade organizations and 
Federal, State, and local agenciesthat wanted certain data was critical in adjusting to 
different phases of the pandemic.  For example, another CDC official explained that 
the agency added questions related to POC tests and testing supplies after receiving 
requests from Federal stakeholders involved in the pandemic response.  CDC also 
presented proposed changes to external partners to solicit feedback when unsure 
about potential alterations to NHSN. 
CMS provided input as CDC was developing additions to the COVID-19 Module.  CMS 
reported that it provided feedback before and after CDC deployed certain changes, 
and about any changes CDC suggested.  One CMS official stated that leadership and 
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technical teams from both agencies regularly met and discussed strategic needs 
during the development of the Vaccinations Module.  After launching the new 
module for voluntary data submission, CDC and CMS discussed expanding the 
reporting requirements to mandate vaccine-related reporting.  One CDC official 
characterized the collaboration as involving constant communication about user 
feedback, submitted data, and additional information that may be necessary. 
CDC reported taking the nursing home burden into account when implementing 
changes to the COVID-19 Module.  The agency said that, although NHSN data 
collection is valuable to CDC and other stakeholders, adding reporting obligations 
required caution.  One official noted that the same people submitting data are the 
ones taking care of the patients.  A CMS official reported that, while discussing 
changes to the COVID-19 Module to meet data collection needs, both agencies 
recognized the need to consider the burden on facilities.  Another CDC official 
explained that making sudden changes to questions in NHSN does not promote 
standardized surveillance practices, because it is a significant undertaking for 
thousands of nursing homes to quickly alter their reporting. 
Changes to the COVID-19 Module resulted in additional 
difficulties, such as an increasedbacklog of requests for 
 
assistance  
The growing interest in patient-level COVID-19 data led CDC to prepare nursing 
homes to upgrade their security access levels to submit personally identifiable 
information to NHSN.  CDC began conducting outreach to facilities about 
transitioning their security access level during August and September 2020.  CDC 
explained that it used a phased approach for facility outreach, with a goal of 
contacting 2,500 nursing homes per week.  One official said that it was difficult to 
persuade facilities to voluntarily convert their SAMS access level status immediately. 
CDC continued its outreach efforts, but nursing homes did not upgrade their security 
access levels evenly over time.  On October 19, 2020, HHS issued a requirement for 
facilities to report POC COVID-19 test results through existing channels, including 
NHSN.69, 70, k  CDC said that the majority of nursing homes using NHSN to fulfill this 
requirement started the process to upgrade their security access levels near the 
November 2020 deadline. 
The reporting requirement resulted in an influx of nursing homes upgrading their 
security access level, with problems exacerbated by the combination of a compressed 
_____________________________________________________________________________________________________________________________ 
k Nursing homes were able to fulfill this HHS requirement by reporting data (1) directly to their State, 
Territorial, local, and Tribal public health departments; (2) to a State or regional information exchange; (3) 
to NHSN; or (4) to a centralized platform other than NHSN.  Reporting POC COVID-19 test results via 
NHSN was the CDC- and CMS-preferred method.  See CDC, COVID-19 Pandemic Response, Laboratory 
Data Reporting: CARES Act Section 18115, March 8, 2022, p. 5.  Accessed at 
https://www.cdc.gov/coronavirus/2019-ncov/downloads/lab/HHS-Laboratory-Reporting-Guidance-
508.pdf on February 2, 2023. 
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timeline and the weeks-long process involved in the upgrade.  According to one CDC 
official, the transition to higher-level security access presented more difficulties than 
the initial mass enrollment in NHSN.  The volume of upgrades strained the SAMS 
infrastructure due to a bottleneck with the identity verification process.  (See 
Appendix C for the step-by-step enrollment process published by CDC.)  Many 
nursing homes had to restart their upgrade processes, because SAMS had workflow 
timers that automatically removed applicants for lack of activity after not completing 
identity verifications over a set period of time.  According to one Digital Services 
official, SAMS experienced the most significant backlog of facilities during the 
upgrades at the end of 2020. 
 
They were sitting on a queue of 10,000 [upgrade requests] and can 
  only get through 100 or so per day.  Thats where the big issue 
happened.  Digital Services official 
 
     
The majority of newly enrolled nursing homes reported that 
upgrading their SAMS access levels was a difficult process 
Among the sample nursing homes, many reported experiencing challenges upgrading 
their security access level.  Of the 117 newly enrolled facilities, 72 percent found 
upgrading their access level to be difficulteither very difficult (39 percent) or 
somewhat difficult (33 percent).  (See Exhibit 3.)       
Exhibit 3: Newly enrolled nursing homes reported difficulties upgrading 
from SAMS Level 1 to Level 3 access (n=117).  
 
Source: OIG analysis of survey responses from 171 nursing homes, November 2022. 
Note: The total sum of the percentages above does not equal 100 percent because of rounding.     
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Multiple nursing homes reported that it took a significant amount of time for their 
NHSN Administrators to upgrade their security access levels, with one facility 
reporting that it did not receive access until a year later.  A representative from 
another nursing home described how not receiving timely assistance from the Help 
Desk inhibited the facility from fulfilling that weeks reporting requirements.    
CDC has improved nursing home experiences reporting to the 
COVID-19 Module throughout the pandemic 
Following the initial implementation and early additions to the COVID-19 Module, 
CDC has continued to communicate with nursing homes; make changes to reduce the 
reporting burden; and collaborate with CMS and other stakeholders.  CDC reported 
that improvements to the system have been necessary to alleviate challenges for both 
the agency and NHSN users, such as nursing homes.  CDC addressed enrollment 
difficulties by streamlining the process using quicker and more accessible identity 
verification tools.  To reduce any unnecessary reporting burden, CDC also worked 
with CMS to determine what data are no longer critical to collect.   
CDC has continued to communicate with and provide guidance 
and resources to nursing homes 
Following the launch of the COVID-19 Module in April 2020, CDC has continued to 
produce and regularly update online webpages, interactive webinars, virtual trainings, 
and various guidance documents related to nursing home reporting.  CDC recorded 
and uploaded training resources online, and collaborated with external partners to 
provide and disseminate additional resources, such as responses to frequently asked 
questions.  
CDC reported using multiple channels of outreach to share information about the 
COVID-19 Module.  The agency has maintained a list of active email addresses, 
collected during the enrollment process, for every NHSN Administrator submitting 
data to the system.  Throughout the pandemic, the agency sent emails to notify 
facilities of new guidance and resources, such as details for upcoming trainings, and 
changes or updates to the COVID-19 Module. 
CDC conducted additional outreach through collaboration with external partners.  
CMS frequently invited CDC representatives to share new NHSN-related guidance and 
changes, and to answer questions during webinars and weekly stakeholder calls with 
nursing home administrators, directors of nursing, and others.  CDC explained that it 
also worked with nursing home chains, trade organizations, and State health 
departments to disseminate information to facilities.  For example, the Surveillance 
Branch worked with internal and external partners to publish guidance that addressed 
frequently asked questions.  One CDC official said the comprehensive approach to 
getting the information out is the key to [NHSNs] success.   
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Ongoing nursing home challenges have led to additional 
enrollment-related improvements  
To address the significant delay in the identity verification process, CDCs Digital 
Services implemented two new system improvements in October 2021 to upgrade 
users security access levels.  One Digital Services official reported that CDC 
contracted with a financial credit company to expedite identity verification.  The 
streamlined process involves SAMS directing applicant information, such as date of 
birth, telephone number, and Social Security number, to the contracted system for 
verification.  The user then answers five credit history-related questions to complete 
the process.  Users who choose not to participate in the contracted process may still 
use the original method.  
CDC further improved the enrollment process by providing a more direct way of 
receiving a second form of authentication.  According to the Digital Services official, 
an individual would previously receive a physical token by mail, which allowed the 
user to log in to NHSN.  Digital Services then introduced a self-service portal and a 
corresponding mobile authenticator application that provides immediate access to 
the system.  The official reported that, after the deployment of the instant 
authenticator, CDC saw a significant shift from the use of physical cards to use of the 
mobile authenticator. 
CDC has collaborated with CMS and other stakeholders to reduce 
data variables no longer deemed necessary and further ease the 
reporting burden on facilities   
While nursing homes may benefit from reduced reporting, the potential removal of 
data variables posed challenges to CDC.  A CDC official explained that it was more 
difficult to remove than to add pandemic-related fields because removing certain 
elements could conflict with CMS reporting requirements.   
CDC involved input from CMS and trade organizations in decisions about removing 
data variables throughout the pandemic.  CDC reported that, toward the end of 2021, 
it began receiving and reviewing feedback from stakeholders that confirmed that 
certain data elements were no longer necessary.  One official stated that as COVID-19 
cases decreased, CDC received more feedback from nursing homes requesting that it 
reduce the number of questions.  Facilities were more receptive about the need for 
data collection during increases in COVID-19 case counts, but were in crisis mode 
with providing care.   
CDC has continued to collaborate with CMS and stakeholders to determine what data 
fields to change or remove in NHSN, while still fulfilling CMS reporting requirements.  
For example, CDC removed the Ventilator Capacity and Supplies Pathway in July 2021.  
According to one official, CDC began the process of eliminating variables related to 
ventilators after facilities and other stakeholders communicated that the information 
was no longer necessary to make resource decisions.  CDC reviewed data to find that 
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nursing home use of ventilators had decreased, and removed the pathway after CMS 
did not contest its elimination.   
CDC has continued to reduce the amount of data nursing homes must report to the 
COVID-19 Module.  As described on page 8, in November 2021, nursing homes were 
required to report up to 132 data points to NHSN (including questions to elaborate 
on selected response options).  By August 2023, that number dropped to 37 data 
points. 
Nursing home experiences with reporting have improved since 
May 2020, though issues remain for both facilities and CDC 
As of June 2022, nursing homes noted that the process for reporting COVID-19 data 
has improved.  However, some facilities still reported experiencing issues with 
reporting and difficulties receiving timely support from the NHSN Help Desk. 
Facilities reported that CDC improvements have helped nursing 
homes reporting COVID-19 data to NHSN 
Survey results indicated that CDC actions have led to improvements in the ability of 
nursing homes to submit data to the COVID-19 Module.  Most facilities (84 percent) 
noted that CDCs communication regarding updates made to NHSN has improved.  
Facilities also recognized that guidance has improved, with 83 percent reporting that 
guidance on how to report data to NHSN had improved, and 80 percent reporting 
that guidance on what to report had improved.  (See Exhibit 4 on the next page.)  One 
facility said that miscommunication has become less of a concern because CDC 
guidance has become more clear.   
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Exhibit 4: Nursing homes reported that aspects of the NHSN reporting 
process have improved, as of June 2022 (n=171). 
 
Source: OIG analysis of survey responses from 171 nursing homes, November 2022. 
Many nursing homes no longer experience challenges with the NHSN 
reporting process that existed earlier in the pandemic.  A number of nursing 
homes identified several previous issues with reporting that they no longer 
experienced as of June 2022.  Challenges that nursing homes reported previously 
experiencing at a higher rate included confusion about how to report  
(37 percent) and technical difficulties with reporting (35 percent).  Further, some 
facilities (16 percent) reported having past challenges with limited time or staff 
available to report.  (See Exhibit 5 on the next page.)  A corporate representative for 
one facility explained that clinical staff manage multiple tasks, such as conducting 
COVID-19 tests and maintaining supplies, and data submission added to these 
existing time commitments.   
 
 
 
 
 
 
 
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Exhibit 5: Nursing homes reported past and current challenges with 
reporting to NHSN, as of June 2022 (n=171). 
 
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.  
Note: The total percentages for some of the challenges above do not sum to 100 pecent because of rounding.     
CDC reported that nursing homes had initial concerns about how to interpret certain 
data elements, such as which fields were requesting incident or cumulative 
information, and what to do with data for former residents no longer at the facilities.  
The agency noted a continued need to facilitate nursing home reporting to NHSN.                                               
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Despite CDC actions, ongoing nursing home challenges suggest a 
need for further improvements to the NHSN system and 
processes 
Some nursing homes identified multiple challenges with reporting to NHSN, which 
were ongoing as of June 2022.  For example, 36 percent of facilities reported that 
having limited time or staff available made it difficult to submit data, while 13 percent 
reported being uncertain about what data they were required to submit to NHSN.  
(See Exhibit 5 on the preceding page.) 
Some nursing homes have had worsening experiences reporting to NHSN 
over the course of the pandemic.  For example, 22 percent of facilities reported 
that receiving error messages when attempting to submit data had worsened, and  
9 percent reported that CDC communication regarding updates to NHSN had 
worsened.  (See Exhibit 6.)  A corporate representative for one nursing home 
described how the time commitment for reporting was a burden that increased over 
time, causing the organization to dedicate three full-time employees to handling 
COVID-19 reporting across their facilities.  The representative also noted that the 
organizations internal processes for collecting and submitting required data were 
hampered by updates to NHSN because there was a lack of information in advance 
about the changes.   
Exhibit 6: Nursing homes reported that aspects of the NHSN reporting 
process have worsened, as of June 2022 (n=171).   
 
 
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.
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Nursing homes faced difficulties receiving timely and useful 
assistance from the NHSN Help Desk, which did not keep up with 
user support requests and communicated only via email     
Nursing homes reported that NHSN Help Desk responses were often not 
prompt or useful.  Facilities reported reaching out to the NHSN Help Desk for 
support during the pandemic.  As of June 2022, 85 percent of facilities had sought 
help from the Help Desk.  The majority of these nursing homes (63 percent) reported 
having issues with the responses to their inquiries.  Nursing homes reported that 
assistance was delayed (33 percent); not useful (8 percent); or both delayed and not 
useful (19 percent).  A small number of nursing homes (3 percent) reported not 
receiving a response from the Help Desk.  (See Exhibit 7.)  
Exhibit 7: Nursing homes reported difficulties receiving timely and useful 
assistance from the NHSN Help Desk, as of June 2022 (n=145).  
 
Source: OIG analysis of survey responses from 171 nursing homes, November 2022.    
The NHSN Help Desk only supported users via email, without alternatives such as a 
phone line or live chat support.  Several nursing home representatives noted that this 
made interactions particularly cumbersome and frustrating.  One facility 
representative said they submitted multiple questions to the Help Desk, but never 
received responses that specifically addressed their concerns.  Rather, they always 
received generic responses that referenced the NHSN webpage for frequently asked 
questions.  An administrator from another nursing home reported receiving delayed 
assistance from the NHSN Help Desk, which resulted in the facility missing a reporting 
deadline and being fined.  A corporate representative for one nursing home noted 
reaching out to a Quality Improvement Organization for assistance instead of 
continuing to contact the Help Desk.71  The representative explained that Help Desk 
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responses did not address the facilitys questions, and reaching out to the Help Desk 
was confusing in general.     
The NHSN Help Desk had ongoing difficulty addressing its backlog of 
user requests, despite using strategies to streamline processes.  Despite 
CDC efforts, the NHSN Help Desk continues to experience a backlog of user support 
requests.  CDC reported that it detailed additional staff and pulled members from 
other teams to help respond to user inquiries.  Still, the Help Desk experienced 
challenges in offsetting the continuous influx of tickets brought about by the 
substantial increase in total users.  One official explained that the NHSN Help Desk 
received 300 to 500 new tickets daily, which were physically impossible to 
individually triage on the same day. 
In addition, the NHSN Help Desk often needed more information than what users 
provided in their email inquiries to deliver thorough responses.  The need for  
back-and-forth correspondence, in addition to the large quantity of tickets, 
contributed to delay of responses.  One CDC official added that staff turnover in 
nursing homes, which resulted in new users, was another cause of the continuing flow 
of Help Desk tickets.  The official also reported that the Surveillance Branch ultimately 
did not have the necessary resources to fully respond to facilities requesting 
assistance at this scale.  A different official said that, as of May 2022, the NHSN Help 
Desk still had a backlog of unanswered and untriaged tickets, but that the backlog 
was not as significant as it was in 2020. 
According to CDC, the NHSN Help Desk used various strategies to improve efficiency.  
The agency reported that the Help Desk added internal training for user support 
specialists.  In addition, Help Desk staff developed a bank of canned responses, or 
copied and pasted template responses, to common inquiries.  The NHSN Help Desk 
also created a new email address specifically for enrollment-related questions, and 
encouraged users to include specific subject lines in their emails to expedite the triage 
of inquiries to specific NHSN subject-matter experts. 
CDC has made efforts to ensure data quality, but nursing homes 
reporting to the COVID-19 Module expressed concerns  
CDC established QA criteria to address data issues identified during the early stage of 
the required COVID-19 nursing home reporting.  The agency conducted outreach to 
some facilities with notable data concerns and built visual alerts for QA flags into the 
system.  Despite CDC efforts, some facilities reported not feeling confident about the 
completeness or accuracy of the nursing home COVID-19 data in NHSN. 
The agency identified data quality issues and built QA checks into 
its processes 
CDC flagged potential data quality problems early in its data collection.  According to 
agency officials, initial reviews of COVID-19 data revealed that many nursing homes 
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reported cumulative data instead of incident-level data.  CDC analyzed data from the 
COVID-19 Module in May and June 2020 to identify patterns that may suggest data 
entry errors, such as repeated or cumulative values, in certain variables related to 
COVID-19 cases and deaths.  CDC then established QA criteria to identify outliers that 
indicate potential data quality issues.  
CDC began contacting nursing homes in June 2020 in response to the initial data 
quality issues.  The agency stated that the Surveillance Branch produced monthly 
reports with an emphasis on information related to COVID-19 cases, deaths, and 
other key fields.  If a facilitys data exceeded the outlier threshold, Surveillance Branch 
staff emailed or called the nursing home, or notified the relevant State health 
department.l  Once in contact with the facility, the agency staff members verified the 
information or helped the nursing home user correct it.  According to one CDC 
official, the frequency of outreach to nursing homes has declined over time.   
CDC also built visual QA flags into the COVID-19 Module to identify and reduce data 
errors.  If submitted data activate the QA flags, system alerts visually notify the user of 
possible data entry issues.  The user can then click on the alert to navigate to the issue 
and fix the problem.  CDC reported that the Surveillance Branch now takes a two-
pronged approach to improve data quality: visual alerts in NHSN and direct outreach, 
when necessary. 
CMSs QA checks provide another opportunity to identify problems with data 
reported to the COVID-19 Module.  CDC reported that NHSN shares nursing home 
COVID-19 data with CMS at the end of each reporting week, after which CMS 
conducts its own QA check on the data.  CMS removes a nursing homes data from its 
publicly available nursing home datasets if the data failed its QA checks.  CMS is able 
to take enforcement actions, including fines, if it identifies that a facility has not met 
its weekly reporting obligations.   
Nursing home challenges with reporting may result in inaccurate 
COVID-19 data reported to NHSN   
More than one in four facilities reported not being confident that the data nursing 
homes have submitted to NHSN are complete and accurate.  One administrator 
stated that data may be omitted in instances of facility staff turnover, after which the 
new NHSN Administrator does not have access to previous records used to submit 
data to the COVID-19 Module.   
 
I can almost guarantee you, as complicated as this data is, there 
  are facilities that are not reporting correctly.  
 Nursing home corporate representative 
 
 
_____________________________________________________________________________________________________________________________ 
l CDC does not have the authority to take punitive action against a nursing home that does not meet its 
weekly reporting obligation. 
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A corporate representative for another facility expressed having no confidence that 
the data are accurate, because the definitions for the data variables are unclear and 
leave room for varying interpretations.  Regarding COVID-19 vaccinations, one 
nursing home representative said it was difficult to have complete confidence with 
staff vaccination counts and rates when turnover leads to complicated week-to-week 
changes in data.  
CDC plans to continue improving NHSN for nursing home 
reporting and is considering how to leverage national 
enrollment for voluntary reporting on other health events 
As noted, CMS will continue to require nursing homes to report a full range of 
COVID-19 data through December 2024, while the vaccination-related data mandate 
will be ongoing.  This means that required weekly reporting by nursing homes to 
NHSN will continue.  CDC officials reported considering how the agency might 
leverage this national enrollment and reporting to track other health events.    
In May 2023, CDC reported that it has been focused on current reporting and related 
changes to the system, and has not yet planned an approach for encouraging 
voluntary reporting after some requirements expire.  One official noted that CDC 
intends to keep all portions of the COVID-19 Module accessible to nursing homes 
after requirements expire.  Additionally, the agency intends to encourage voluntary 
reporting to NHSN.    
There is precedent for voluntary reporting by nursing homes to NHSN.  Prior to the 
COVID-19 pandemic, more than 3,000 nursing homes were enrolled in NHSN to 
voluntarily report data on HAIs and infection prevention measures.  One CDC official 
noted that during the pandemic, a third of nursing homes (about 5,000) reported data 
on individual COVID-19 tests for optional data fields.  Another official said that it is 
difficult to accurately predict how many nursing homes will voluntarily report  
COVID-19 data after the requirements expire.   
CDC plans to continue modernization of NHSN data collection, 
such as automating data input 
CDC reported that it is investing significant resources to modernize NHSN as part of a 
larger data initiative within the agency.m  One official stated that it is essential to 
continue the modernization of the [information technology] structure within NHSN, 
with the goal of making the system more automated and less of a burden on facilities.  
For example, according to CDC officials, the agency has considered the possibility of 
_____________________________________________________________________________________________________________________________ 
m In July 2023, CDC clarified to OIG that continued modernization and enhancement of NHSN were 
contingent on the agency receiving funds detailed in its 2024 budget request to Congress.  See HHS, 
CDC, Fiscal Year 2024 Justification of Estimates for Appropriations.  Accessed at 
https://www.cdc.gov/budget/documents/fy2024/FY-2024-CDC-congressional-justification.pdf on  
August 15, 2023.  
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OEI-06-22-00030   Findings | 30    
developing an interaction between NHSN and facility electronic health records that 
would input certain information directly into NHSN.   
As a part of pursuing its modernization objectives, CDC is looking at ways to improve 
data collection efforts in the future, in part by reflecting on its experience using NHSN 
during its pandemic response.  One official noted that automated improvements to 
SAMS, such as streamlined identity verification during enrollment, have saved time 
and effort granting facilities access to the system.  CDC reported that its teams have 
continued to rethink the best ways to be more proactive and ready to help nursing 
homes interacting with NHSN for ongoing required and voluntary reporting. 
Facilities suggested several ways CDC could better facilitate nursing home 
reporting to NHSN.  Nursing homes noted that CDC should be more responsive 
and easier to reach for assistance.  More than one-third of facilities (58 of 171) 
reported that CDC being more responsive to support tickets would be the most 
significant way to improve NHSN support.  (See Exhibit 8.)  One nursing home said 
that a phone line for the NHSN Help Desk is necessary for providing more immediate 
assistance.  Another facility agreed that telephone support should be offered and 
added that it would be particularly helpful with the enrollment process.   
Exhibit 8: Nursing homes reported actions CDC could take to better facilitate 
nursing home reporting to NHSN (n=171).    
 
Source: OIG analysis of survey responses from 171 nursing homes, November 2022. 
 
 
 
 
 
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OEI-06-22-00030   Findings | 31    
CDC reported that it is considering how to leverage national 
nursing home enrollment in NHSN to encourage participation in 
reporting for other health care outcomes 
One agency official reported that multiple stakeholders have expressed the desire to 
maintain national nursing home reporting after the public health emergency.  The 
agency has communicated with CMS about the value of nursing home reporting and 
the use of NHSN for other public health surveillance.  CDC reported that it continues 
to collaborate with CMS about COVID-19 data requirements and how NHSN data 
could be used to inform other public health and nursing home quality and safety 
efforts, such as CMS quality measures for nursing homes.  A CDC official said that 
NHSN has clearly demonstrated it is the platform to be used for these data 
collection efforts, and that nursing home reporting to the COVID-19 Module could 
serve as a foundation for collecting data related to various health care issues.  
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OEI-06-22-00030   Findings | 32    
CONCLUSION AND RECOMMENDATIONS 
NHSN has been a critical data collection tool for the national COVID-19 pandemic 
response in nursing homes.  Following initial challenges with the influx of nursing 
home enrollment, CDC made improvements to the enrollment and reporting 
processes.  CDC collaborated with external partners, such as CMS, and other 
stakeholders to disseminate guidance, communicate with nursing homes, and 
implement important changes to the COVID-19 Module.  Facilities reported that some 
challenges were resolved, but that other difficulties are ongoing.  Over time, CDC has 
reduced the number of variables needed to meet requirements.  Beginning in January 
2025, required variables related to infections, deaths, and staffing will expire.  Nursing 
homes will continue to be required to report COVID-19 vaccination data to NHSN, 
and may voluntarily report other variables.  
CDC efforts have resulted in a better reporting experience, but more improvements 
are needed to facilitate nursing home reporting and ensure data quality.  These 
improvements will also facilitate CDC efforts to leverage national nursing home 
enrollment for potential ongoing and future use of NHSN.   
We recommend that CDC: 
Improve the user support the NHSN Help Desk provides to 
nursing homes  
CDC officials recognized that the NHSN Help Desk faced challenges due to the influx 
of facilities requesting extensive support.  The Help Desk, which is only accessible via 
email, was quickly overwhelmed with user support requests, but did not see a 
proportional increase in staff to meet the higher demand.  Despite agencywide 
efforts, such as the deployment of the click squad, the NHSN Help Desk has 
struggled to meet the needs of nursing homes reporting to the system.   
CDC should add communication channels to provide direct assistance to NHSN users.  
This should include adding telephone or live chat support functions so nursing homes 
can have questions answered in real time and provide feedback about their 
experiences enrolling in and reporting to the system.  Providing an option for NHSN 
users to directly communicate with a user support specialist may promote more 
accurate, timely, and complete reporting, and build on the relationship between the 
agency and NHSN users.  CDC should also improve its ability to increase its Help Desk 
staffing during periodic influxes of requests, such as when reporting needs or 
guidance changes.   
 
   
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OEI-06-22-00030  Conclusion and Recommendations | 33    
Take further steps to ensure the quality of nursing home 
reporting of COVID-19 data to NHSN 
To address nursing home concerns about the accuracy of COVID-19 data reported to 
NHSN, CDC should take further steps to provide guidance and technical assistance to 
facilities, and to ensure appropriate QA processes.  The agency should work toward 
addressing the root causes of data quality issues by reviewing its overall approach to 
guidance and support, to best determine what efforts have been beneficial to fostering 
quality data reporting.  For example, CDC could issue more explicit guidance on data 
definitions to reduce variations in nursing homes interpretations, and offer technical 
assistance related to maintaining data reporting during times of staff turnover.  For its 
participation in webinars and trainings, CDC should ensure that it provides detailed and 
practical responses to the array of nursing home questions it may encounter.   
Consider how quality assurance checks can be enhanced to 
ensure data accuracy, as appropriate  
To support quality data collection efforts ongoing and in the future, CDC should assess 
how it can enhance its QA checks for the full range of COVID-19 data it will collect from 
nursing homes.  Data that nursing homes enter into NHSN is self-reported.  It is possible 
that facilities submit inaccurate information that is not detected by automated review 
processes currently built into the system.  Therefore, CDC should consider how it can 
improve existing QA checks, as well as determining what additional QA processes it can 
use to better ensure that NHSN has accurate data from facilities.  CDC could also apply 
these ideas to promote data accuracy and quality in any future expansions of its data 
collection from nursing homes through NHSN.  
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OEI-06-22-00030  Conclusion and Recommendations | 34    
AGENCY COMMENTS AND OIG RESPONSE  
CDC partially concurred with the first recommendation and concurred with the 
second and third recommendations, and reported its planned actions to implement 
the recommendations.   
CDC partially concurred with the first recommendation to improve the user support 
the NHSN Help Desk provides to nursing homes.  CDC reported that it has made 
improvements to the Help Desk and now offers more ways for facilities to receive 
support through a new customer service portal.  CDC stated that in the new portal, 
inquiries from NHSN users are sent directly to the appropriate support specialist or 
subject-matter expert, resulting in faster responses.  CDC also noted that it has 
increased staffing and relevant trainings for the Help Desk, and that there is no longer 
a backlog of support requests from nursing homes.  OIG appreciates CDCs efforts to 
improve the NHSN Help Desk support for its users, and acknowledges CDCs 
increased staffing for the Help Desk.  However, OIG continues to recommend that 
CDC also prioritize implementing telephone or live chat functionality for its Help Desk, 
when resources are available, to ensure that facilities have the option to obtain real-
time assistance.  Providing direct user communication with the Help Desk can help 
promote accurate, timely, and complete reporting.  OIG also continues to recommend 
that CDC ensure its ability to dedicate or reallocate staff, as necessary, in case an 
influx of requests occurs again.   
CDC concurred with our second recommendation to take further steps to ensure the 
quality of nursing home reporting of COVID-19 data to NHSN.  CDC stated that it will 
expand its efforts to provide training materials and tools to NHSN users and health 
care facilities.  CDC reported that it has taken a multi-pronged approach to ensure 
accurate vaccination status data reporting, including providing training on NHSN for 
LTCFs and conducting real-time outlier analysis that has led to the agency contacting 
more than 8,000 facilities about their data.  OIG appreciates CDCs efforts to improve 
the quality of nursing home reporting to NHSN.  We believe that CDCs planned 
actions, when completed, will fulfill this recommendation.   
CDC also concurred with our third recommendation to consider how quality 
assurance checks can be enhanced to ensure data accuracy, as appropriate.  CDC 
stated that it will review its processes to identify opportunities to improve its data 
quality checks, user education, and outreach.  CDC also noted that incorporating 
active quality checks, such as data validation, would require additional resources and 
staff.  OIG appreciates CDCs commitment to identify opportunities for improvement.  
We look forward to the results of CDCs review and learning more about CDCs 
improvement plans in its final management decision.   
For the full text of CDCs comments, see Appendix E.
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OEI-06-22-00030  Agency Comments and OIG Response | 35    
APPENDICES 
Appendix A: Estimates, Confidence Intervals, and Key Statistics 
for Nursing Home Survey Results 
The exhibits listed below provide key statistics to support our projected results for 
each nursing home survey question used in the findings of this report.  The estimates 
are based on a sample of 171 nursing homes that reported required COVID-19 data 
to the NHSN LTCF COVID-19 Module at least once between May 24 and December 
26, 2021.  Exhibits A-1 through A-3 (n=117) and Exhibit A-7 (n=145) use subsets of 
nursing homes resulting from respondents selecting specific answers that filtered 
survey questions.   
Exhibit A-1: Nursing homes that reported difficulty with at least one aspect 
of enrollment in their responses to How easy or difficult were the following 
aspects of enrolling your facility in NHSN? (n=117) 
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Any enrollment difficulty   101  86.32%  78.74%  91.98% 
Exhibit A-2: Nursing home responses to How easy or difficult were the 
following aspects of enrolling your facility in NHSN? (n=117) 
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Finding guidance and resources 
Very easy  14  11.97%  6.70%  19.26% 
Somewhat easy  48  41.03%  32.02%  50.50% 
Somewhat difficult  33  28.21%  20.28%  37.27% 
Very difficult  13  11.11%  6.05%  18.25% 
I dont know  9  7.69%  3.58%  14.10% 
Registering users 
Very easy  12  10.26%  5.41%  17.23% 
Somewhat easy  26  22.22%  15.06%  30.84% 
Somewhat difficult  52  44.44%  35.26%  53.92% 
Very difficult  26  22.22%  15.06%  30.84% 
I dont know  1  0.85%  0.02%  4.67% 
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Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Upgrading SAMS from Level 1 to Level 3 
Very easy  6  5.13%  1.90%  10.83% 
Somewhat easy  19  16.24%  10.07%  24.19% 
Somewhat difficult  38  32.48%  24.11%  41.76% 
Very difficult  46  39.32%  30.41%  48.77% 
I dont know  8  6.84%  3.00%  13.03% 
Receiving electronic communication 
Very easy  33  28.21%  20.28%  37.27% 
Somewhat easy  46  39.32%  30.41%  48.77% 
Somewhat difficult  24  20.51%  13.61%  28.97% 
Very difficult  13  11.11%  6.05%  18.25% 
I dont know  1  0.85%  0.02%  4.67% 
Receiving technical assistance 
Very easy  14  11.97%  6.70%  19.26% 
Somewhat easy  31  26.50%  18.77%  35.45% 
Somewhat difficult  30  25.64%  18.02%  34.54% 
Very difficult  36  30.77%  22.57%  39.97% 
I dont know  6  5.13%  1.90%  10.83% 
Exhibit A-3: Nursing home responses to What actions did your facility take 
to address difficulties enrolling in NHSN? (n=117) 
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Held staff training on  14  11.97%  6.70%  19.26% 
enrolling in NHSN 
Acquired additional  2  1.71%  0.21%  6.04% 
technology 
Requested assistance  57  48.72%  39.37%  58.13% 
from CDC 
Requested assistance  35  29.91%  21.80%  39.07% 
from CMS 
Requested assistance         
from nongovernment  23  19.66%  12.89%  28.02% 
organization 
Requested assistance         
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Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
from your facility chain or  45  38.46%  29.62%  47.91% 
corporate ownership 
I do not know  2  1.71%  0.21%  6.04% 
Our facility did not take  9  7.69%  3.58%  14.10% 
any action 
Receiving technical  3  2.56%  0.53%  7.31% 
assistance 
Exhibit A-4: Nursing home responses to To what extent have the following 
aspects of reporting to NHSN become better or worse since your facility 
began using the system? (n=171) 
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Guidance on how to report 
Better  142  83.04%  76.56%  88.34% 
Somewhat better  97  56.73%  48.94%  64.27% 
Much better  45  26.32%  19.89%  33.58% 
Worse  13  7.60%  4.11%  12.65% 
Somewhat worse  11  6.43%  3.25%  11.22% 
Much worse  2  1.17%  0.14%  4.16% 
I dont know  16  9.36%  5.44%  14.75% 
Guidance on what to report 
Better  137  80.12%  73.34%  85.82% 
Somewhat better  93  54.39%  46.61%  62.01% 
Much better  44  25.73%  19.36%  32.96% 
Worse  20  11.70%  7.29%  17.48% 
Somewhat worse  17  9.94%  5.90%  15.44% 
Much worse  3  1.75%  0.36%  5.04% 
I dont know  14  8.19%  4.55%  13.36% 
CDC communication of updates 
Better  143  83.63%  77.21%  88.84% 
Somewhat better  87  50.88%  43.13%  58.59% 
Much better  56  32.75%  25.78%  40.33% 
Worse  16  9.36%  5.44%  14.75% 
Somewhat worse  11  6.43%  3.25%  11.22% 
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OEI-06-22-00030  Appendix A | 38    
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Much worse  5  2.92%  0.96%  6.69% 
I dont know  12  7.02%  3.68%  11.94% 
Adding or changing users to report data 
Better  101  59.06%  51.30%  66.51% 
Somewhat better  74  43.27%  35.73%  51.06% 
Much better  27  15.79%  10.67%  22.14% 
Worse  32  18.71%  13.17%  25.38% 
Somewhat worse  23  13.45%  8.72%  19.50% 
Much worse  9  5.26%  2.43%  9.76% 
I dont know  38  22.22%  16.23%  29.20% 
Submitting data without error messages 
Better  121  70.76%  63.33%  77.45% 
Somewhat better  81  47.37%  39.70%  55.13% 
Much better  40  23.39%  17.27%  30.46% 
Worse  37  21.64%  15.72%  28.57% 
Somewhat worse  25  14.62%  9.69%  20.82% 
Much worse  12  7.02%  3.68%  11.94% 
I dont know  13  7.60%  4.11%  12.65% 
Ability to view and edit data 
Better  138  80.70%  73.98%  86.33% 
Somewhat better  79  46.20%  38.56%  53.97% 
Much better  59  34.50%  27.41%  42.14% 
Worse  12  7.02%  3.68%  11.94% 
Somewhat worse  11  6.43%  3.25%  11.22% 
Much worse  1  0.58%  0.01%  3.22% 
I dont know  21  12.28%  7.77%  18.16% 
CDC communication on errors and issues 
Better  120  70.18%  62.72%  76.92% 
Somewhat better  80  46.78%  39.13%  54.55% 
Much better  40  23.39%  17.27%  30.46% 
Worse  24  14.04%  9.20%  20.16% 
Somewhat worse  17  9.94%  5.90%  15.44% 
Much worse  7  4.09%  1.66%  8.25% 
I dont know  27  15.79%  10.67%  22.14% 
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OEI-06-22-00030  Appendix A | 39    
Exhibit A-5: Nursing home responses to Has your facility experienced any 
of the following challenges with reporting data to NHSN? (n=171) 
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Confusion about how to report 
Previous challenge  64  37.43%  30.16%  45.14% 
Current challenge  19  11.11%  6.82%  16.81% 
No challenge  87  50.88%  43.13%  58.59% 
I dont know  1  0.58%  0.01%  3.22% 
Technical issues 
Previous challenge  60  35.09%  27.96%  42.74% 
Current challenge  45  26.32%  19.89%  33.58% 
No challenge  64  37.43%  30.16%  45.14% 
I dont know  2  1.17%  0.14%  4.16% 
System not accepting data entries 
Previous challenge  58  33.92%  26.87%  41.54% 
Current challenge  38  22.22%  16.23%  29.20% 
No challenge  73  42.69%  35.17%  50.47% 
I dont know  2  1.17%  0.14%  4.16% 
Difficulty receiving assistance 
Previous challenge  53  30.99%  24.16%  38.51% 
Current challenge  34  19.88%  14.18%  26.66% 
No challenge  80  46.78%  39.13%  54.55% 
I dont know  4  2.34%  0.64%  5.88% 
Unclear or complex data fields 
Previous challenge  52  30.41%  23.62%  37.89% 
Current challenge  40  23.39%  17.27%  30.46% 
No challenge  78  45.61%  37.99%  53.39% 
I dont know  1  0.58%  0.01%  3.22% 
Uncertainty on required data 
Previous challenge  52  30.41%  23.62%  37.89% 
Current challenge  23  13.45%  8.72%  19.50% 
No challenge  94  54.97%  47.19%  62.58% 
I dont know  2  1.17%  0.14%  4.16% 
Staff turnover         
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OEI-06-22-00030  Appendix A | 40    
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Previous challenge  44  25.73%  19.36%  32.96% 
Current challenge  27  15.79%  10.67%  22.14% 
No challenge  96  56.14%  48.36%  63.70% 
I dont know  4  2.34%  0.64%  5.88% 
Lack of communication from CDC about how to fix data errors 
Previous challenge  39  22.81%  16.75%  29.83% 
Current challenge  26  15.20%  10.18%  21.48% 
No challenge  92  53.80%  46.03%  61.44% 
I dont know  14  8.19%  4.55%  13.36% 
Difficulty collecting data 
Previous challenge  36  21.05%  15.20%  27.93% 
Current challenge  42  24.56%  18.31%  31.72% 
No challenge  91  53.22%  45.45%  60.87% 
I dont know  2  1.17%  0.14%  4.16% 
Limited time or staff availability 
Previous challenge  28  16.37%  11.16%  22.79% 
Current challenge  62  36.26%  29.06%  43.94% 
No challenge  79  46.20%  38.56%  53.97% 
I dont know  2  1.17%  0.14%  4.16% 
Exhibit A-6: Nursing home responses to CDC has an NHSN User Support 
Help Desk (NHSN Help Desk) to assist facilities that use the system.  Has 
your facility reached out to the NHSN Help Desk? (n=171) 
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Yes, reached out to  
145  84.80%  78.52%  89.82% 
Help Desk  
Exhibit A-7: Nursing home responses to Overall, how responsive was the 
NHSN Help Desk to your facilitys request(s) for assistance? (n=145) 
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Prompt and useful  50  34.48%  26.79%  42.82% 
Not helpful  91  62.76%  54.35%  70.64% 
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OEI-06-22-00030  Appendix A | 41    
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
   Prompt, but not useful  11  7.59%  3.85%  13.17% 
   Delayed, but still useful  48  33.10%  25.52%  41.40% 
   Delayed and not useful  28  19.31%  13.23%  26.69% 
   Facility did not receive  
4  2.76%  0.76%  6.91% 
   a response 
I dont know  4  2.76%  0.76%  6.91% 
Exhibit A-8: Nursing home responses to In your opinion, are you confident 
that nursing homes have submitted complete and accurate data to NHSN? 
(n=171) 
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
No  49  28.65%  22.01%  36.06% 
Yes  100  58.48%  50.71%  65.95% 
I dont know  22  12.87%  8.24%  18.83% 
Exhibit A-9: Nursing home responses to How can CDC better support your 
facilitys ability to report COVID-19 data to NHSN? (n=171) 
Number  Percentage  95-Percent Confidence Interval 
Response Description 
in Sample  Estimate  Lower Bound  Upper Bound 
Be more responsive to 
58  33.92%  26.87%  41.54% 
requests for assistance 
Provide better written 
56  32.75%  25.78%  40.33% 
instructions 
Provide more hands-on 
49  28.65%  22.01%  36.06% 
or interactive training 
Improve communication 
42  24.56%  18.31%  31.72% 
of NHSN updates 
Request more direct 
29  16.96%  11.66%  23.44% 
feedback from facilities 
 
 
 
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OEI-06-22-00030  Appendix A | 42    
Appendix B: Changes to the LTCF COVID-19 Module 
In April 2020, the LTCF COVID-19 Module consisted only of the Surveillance Reporting 
Pathways.72  Later, the module expanded to include the Point-of-Care (POC) Test 
Reporting Tool, in October 2020; the COVID-19 Vaccinations Module, in December 
2020; and the Therapeutics Pathway, in February 2021.73, 74, 75  CDC removed three 
pathways from the Surveillance Reporting Pathways: Ventilator Capacity and Supplies 
in July 2021, Supplies and PPE in May 2022, and Therapeutics in June 2023.76, 77, 78  
(See Exhibit B-1.) 
Exhibit B-1: Timeline of major CDC updates to the LTCF COVID-19 Module 
 
Sources: CDC, COVID-19 Module Enrollment Guidance for LTCFs, May 2020.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/ltcf-covid19-module-508.pdf on March 7, 2023.  CDC, COVID-19 Point of 
Care (POC) Test Result Reporting Tool Frequently Asked Questions, March 2022.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/ltcf-poc-faq-508.pdf on March 7, 2023.  CDC, HCP & Resident COVID-19 
Vaccinations.  Accessed at https://www.cdc.gov/nhsn/ltc/weekly-covid-vac/index.html on March 7, 2023. 
   
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Appendix C: Step-by-Step Enrollment Process for NHSN Users 
The following instruction is from the 5-Step Enrollment for Long-term Care Facilities 
portion of the CDC NHSN webpage on January 27, 2023.79   
Step 1: Enrollment Preparation 
1.  Review required LTCF Enrollment Guidance. 
Note: The LTCF Enrollment Training slides serve as a detailed guide through the 
enrollment process. 
2.  Check trusted websites and spam blocker settings. 
  Please use the supported browsers, Microsoft Edge or Google Chrome. 
Note: Microsoft Windows Users: Microsoft is moving away from supporting 
Internet Explorer 11 (IE) in 2021.  Do not use Internet Explorer when 
accessing NHSN. 
  Add cdc.gov and verisign.com to your list of trusted websites and permit 
pop-ups for these sites in the browser. 
  Check spam-blocker settings to allow emails from NHSN@cdc.gov, SAMS-
NO-REPLY@cdc.gov. 
  For information regarding System requirements, visit: 
FAQs About NHSN | NHSN | CDC. 
Time to complete Step 1: 40 minutes 
Step 2: Register Facility with NHSN 
Read and agree to the NHSN Rules of Behavior.  You will then be redirected to 
electronically register your facility with NHSN. 
Note: The NHSN Facility Contact form may be used to manually collect required 
registration information prior to electronically entering the data into NHSN. 
Time to complete Step 2: 10 minutes 
 
 
 
 
 
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OEI-06-22-00030  Appendix C | 44    
Step 3a: Register with SAMS Partner Portal 
You will receive an email from the U.S. Centers for Disease Control: SAMS Partner 
Portal  Invitation to Register.  It will include a web link to the SAMS registration 
page along with your assigned SAMS Partner Portal User ID (email address) and a 
temporary password.  Please click on the link and enter the SAMS Partner Portal User ID 
and temporary password when prompted.  Then follow the onscreen instructions to 
register and accept the SAMS Rules of Behavior. 
Note: After being invited to SAMS, you have 30 days to complete the registration 
process. 
Time to complete Step 3a: 15 minutes 
Step 3b: Identity Proofing Verification (if applicable) 
After successful online registration, you will receive an Identity Verification Request 
email from SAMS with instructions and a request to provide proof of your identity.  
SAMS supports two options for validating your identity using the New online preferred 
method Experian or the current secured document submission process. 
* Please follow the instructions carefully for your selected identity verification option, to 
ensure timely processing. 
Time to complete Step 3b: 35 minutes 
Step 4: Access Approval and Account Activation 
Once your information is received and approved, you will receive your approval by 
email from sams-no-reply@cdc.gov.  The subject will be U.S. Centers for Disease 
Control: SAMS Partner Portal  SAMS Activity Authorization.  This email will 
contain web links to access the SAMS Partner Portal and application. 
The NHSN application requires users to be strongly authenticated.  This means users 
must have an additional token, along with their password, to log in.  The first option is 
a soft token that requires the installation of an Entrust Authenticator application on 
your phone, tablet, or computer.  The second option is a hard token which is a physical 
Entrust grid card mailed to your home address.  SAMS will communicate this 
authentication requirement to you in this email along with instructions on how to 
complete the setup after account activation. 
Note: Your SAMS grid card should be delivered to your home address via U.S. mail 
within 2 weeks after you receive your SAMS approval email.  If you do not receive 
your SAMS grid card within two weeks, contact samshelp@cdc.gov for assistance. 
Time to complete Step 4: 40 minutes 
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OEI-06-22-00030  Appendix C | 45    
Step 5a: Complete NHSN Enrollment 
After setting up your credential device (via token or receiving your SAMS grid card), 
login to SAMS.  Under the SAMS Multi-factor Login picture, click Login.  On the 
SAMS home page, select NHSN Enrollment to complete electronic enrollment into 
the Long Term Care Facility Component. 
Note: Facility registration information may be manually collected using the NHSN 
Facility Contact and Annual Facility Survey forms prior to electronically entering the 
data into NHSN. 
Time to complete Step 5a: 40 minutes 
Shortly after successfully submitting the forms, the Facility Administrator and Primary 
Contact will receive a NHSN Facility Enrollment Submitted email. 
Step 5b: Accept NHSN Agreement to Participate and Consent 
Either the component primary contact or NHSN facility administrator must login 
to SAMS, select Long-term Care Facility Component and review the Agreement to 
Participate and Consent.  Check the box to Accept next to the appropriate contact 
name and then Submit. An email will be issued confirming this action. 
Note: The consent form must be accepted within 60 days or the facility will be 
withdrawn. 
Time to complete Step 5b: 5 minutes 
Congratulations, enrollment is complete! 
Complete NHSN Long-term Care Facility specific training if not previously completed. 
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030  Appendix C | 46    
Appendix D: SAMS Registration and Identity Verification 
Upon receiving the invitation to SAMS, applicants complete the SAMS registration 
process by validating their legal name and providing their organization and contact 
information.80  The invitation is only usable for a single registration and expires after 
30 days.  If the invitation is lost or expired, the applicant must request a replacement.  
Following registration, some applicants undergo an identity verification process.  
Applicants verify their identity through a document review, or a credit history review 
by a data analytics and financial credit company contracted by CDC.81  For the 
document review, the applicant must submit a form and identity proofing documents 
to SAMS.  The form must be reviewed by a notary or other trusted third parties prior 
to submission.  Following SAMS registration, a CDC program administrator approves 
the users access to SAMS and the application.82 
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030  Appendix D | 47    
Appendix E: Agency Comments 
 
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030  Appendix E | 48    
   
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030  Appendix E | 49    
   
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030  Appendix E | 50    
   
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030  Appendix E | 51    
   
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030  Appendix E | 52    
ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
John Van Der Schans served as the project leader for this study.  Others in the Office 
of Evaluation and Inspections Dallas Regional Office who conducted the study include 
Marshall Allen and Sarah Lee.  Office of Evaluation and Inspections headquarters staff 
who provided support include Rob Gibbons and Michael Novello.    
This report was prepared under the direction of Petra Nealy, Regional Inspector 
General for Evaluation and Inspections in the Dallas Regional Office. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
 
 
 
 
 
 
 
 
 
 
 
   
 
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain   
OEI-06-22-00030  Acknowledgments and Contact | 53    
ABOUT THE OFFICE OF INSPECTOR GENERAL 
Office of Inspector General 
https://oig.hhs.gov 
The mission of the Office of Inspector General (OIG) is to provide objective oversight 
to promote the economy, efficiency, effectiveness, and integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and welfare of the 
people they serve.  Established by Public Law No. 95-452, as amended, OIG carries out 
its mission through audits, investigations, and evaluations conducted by the following 
operating components: 
The Office of Audit Services.  OAS provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit work done 
by others.  The audits examine the performance of HHS programs, funding recipients, 
and contractors in carrying out their respective responsibilities and provide 
independent assessments of HHS programs and operations to reduce waste, abuse, 
and mismanagement. 
The Office of Evaluation and Inspections.  OEIs national evaluations 
provide HHS, Congress, and the public with timely, useful, and reliable information on 
significant issues.  To promote impact, OEI reports also provide practical 
recommendations for improving program operations. 
The Office of Investigations.  OIs criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs and operations 
often lead to criminal convictions, administrative sanctions, and civil monetary 
penalties.  OIs nationwide network of investigators collaborates with the Department 
of Justice and other Federal, State, and local law enforcement authorities.  OI works 
with public health entities to minimize adverse patient impacts following enforcement 
operations.  OI also provides security and protection for the Secretary and other 
senior HHS officials. 
The Office of Counsel to the Inspector General.  OCIG provides legal 
advice to OIG on HHS programs and OIGs internal operations.  The law office also 
imposes exclusions and civil monetary penalties, monitors Corporate Integrity 
Agreements, and represents HHSs interests in False Claims Act cases.  In addition, 
OCIG publishes advisory opinions, compliance program guidance documents, fraud 
alerts, and other resources regarding compliance considerations, the anti-kickback 
statute, and other OIG enforcement authorities.
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030   About OIG | 54    
ENDNOTES   
 
1 Lenny Bernstein and Alauna Safarpour, Mask shortage for most health-care workers extended into May, Post-Ipsos poll 
shows, The Washington Post, May 20, 2020.  Accessed at  
https://www.washingtonpost.com/health/mask-shortage-for-most-health-care-workers-extended-into-may-post-ipsos-poll-
shows/2020/05/20/1ddbe588-9a21-11ea-ac72-3841fcc9b35f_story.html on November 2, 2021.   
2 Lauren Weber, Nursing Homes Keep Losing Workers, The Wall Street Journal, August 25, 2021.  Accessed at 
https://www.wsj.com/articles/nursing-homes-keep-losing-workers-11629898200 on November 2, 2021. 
3 CMS, COVID-19 Nursing Home Data.  Accessed at https://data.cms.gov/covid-19/covid-19-nursing-home-data on  
January 13, 2023. 
4 85 Fed. Reg. 27627 (May 8, 2020); 42 CFR  483.80. 
5 CDC, National Healthcare Safety Network (NHSN) report: Data summary for 2006 through 2008, Association for Professionals 
in Infection Control and Epidemiology, December 2009, p. 1.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/datastat/2009nhsnreport.pdf on November 30, 2022. 
6 CDC, Division of Healthcare Quality Promotion (DHQP).  Accessed at https://www.cdc.gov/ncezid/dhqp/index.html on 
November 30, 2022. 
7 CDC, FY 2022 Operating Plan, February 19, 2021, p. 1.  Accessed at  
https://www.cdc.gov/budget/documents/fy2021/FY-2021-CDC-Operating-Plan.pdf on December 16, 2022. 
8 CDC, July 2020 LTCF Newsletter, July 6, 2021.  Accessed at https://www.cdc.gov/nhsn/ltc/newsletters/jul20-newsletter-ltc.html  
on November 17, 2022. 
9 CDC, Introduction to NHSNs Long Term Care Facility Components, YouTube, September 23, 2019.  Accessed at 
https://www.youtube.com/watch?v=pFGVqyE-H-4 on November 17, 2022. 
10 CDC, Long-term Care Facility Component.  Accessed at https://www.cdc.gov/nhsn/ltc/index.html on November 17, 2022. 
11 CDC, NHSN Long-term Care Facility Component, January 2020, p. 10.  Accessed at  
https://www.cdc.gov/nhsn/pdfs/ltc/ltcf-manual-508.pdf on December 16, 2022. 
12 CDC, LTCF COVID-19 Module.  Accessed at https://www.cdc.gov/nhsn/ltc/covid19/index.html on November 17, 2022. 
13 CDC, July 2020 LTCF Newsletter, July 6, 2021.  Accessed at  
https://www.cdc.gov/nhsn/ltc/newsletters/jul20-newsletter-ltc.html on November 17, 2022. 
14 CDC, LTCF COVID-19 Module Enrollment.  Accessed at https://www.cdc.gov/nhsn/ltc/covid19/enroll.html on  
November 17, 2022. 
15 CDC, July 2020 LTCF Newsletter, July 6, 2021.  Accessed at  
https://www.cdc.gov/nhsn/ltc/newsletters/jul20-newsletter-ltc.html on November 17, 2022. 
16 CDC, LTCF COVID-19 Module: Resident Impact and Facility Capacity Surveillance Reporting Pathway, YouTube,  
April 2, 2021.  Accessed at https://www.youtube.com/watch?v=mrGOM4-hgAo on December 13, 2022. 
17 CDC, LTCF COVID-19 Module: Resident Impact and Facility Capacity Surveillance Reporting Pathway, YouTube, April 2, 
2021.  Accessed at https://www.youtube.com/watch?v=mrGOM4-hgAo on December 13, 2022. 
18 CDC, LTCF COVID-19 Module: Therapeutics Surveillance Reporting Pathway, YouTube, April 19, 2021.  Accessed at 
https://www.youtube.com/watch?v=ZTzRk7-3Qak on December 15, 2022. 
19 CDC, LTCF COVID-19 Module: Updates, July 2021.  Accessed at  
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/rel955-update-508.pdf on December 15, 2022. 
 
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OEI-06-22-00030   Endnotes | 55    
 
20 CDC, LTCF COVID-19 Module: Surveillance Pathway Updates, May 2022.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-mod-surv-path-508.pdf on December 15, 2022. 
21 CDC, COVID-19 Module Enrollment.  Accessed at https://www.cdc.gov/nhsn/ltc/covid19/enroll.html on November 17, 2022. 
22 CDC, Long-Term Care Facility (LTCF) Enrollment in LTCF COVID-19 Module, November 2021, p. 2.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-enrollment-508.pdf on September 16, 2021. 
23 CDC, Long-Term Care Facility (LTCF) Enrollment in LTCF COVID-19 Module, November 2021, p. 8.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-enrollment-508.pdf on September 16, 2021. 
24 CDC, Enrollment in LTCF COVID-19 Module, November 2021, pp. 2-3.  Accessed at  
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-enrollment-508.pdf on November 17, 2022. 
25 CDC, COVID-19 Module Enrollment.  Accessed at https://www.cdc.gov/nhsn/ltc/covid19/enroll.html on November 17, 2022. 
26 CDC, Enrollment in LTCF COVID-19 Module, November 2021.  Accessed at  
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-enrollment-508.pdf on November 17, 2022. 
27 CDC, About SAMS.  Accessed at https://www.cdc.gov/nhsn/sams/about-sams.html on November 17, 2022. 
28 CDC, Office of the Chief Information Officer Organization Chart.  Accessed at 
https://www.cdc.gov/od/ocio/docs/OCIO_org_chart_FY2020.pdf on December 16, 2022. 
29 Comagine Health and Medicare QIN-QIO for Idaho, Nevada, New Mexico, Oregon, Utah, and Washington, TIP Sheet for 
NHSN COVID-19 Enrollment: SAMS and Facility Enrollment.  Accessed at https://comagine.org/sites/default/files/resources/TIP-
Sheet-NHSN-Enrollment.pdf on November 17, 2022. 
30 Telligen and Medicare QIN-QIO, NHSN Access Level Guide.  Accessed at  
https://www.telligenqiconnect.com/wp-content/uploads/2022/02/NHSN-Access-Level-Document_Current-Process.pdf on 
November 17, 2022. 
31 CDC, Secure Access Management Services (SAMS) Frequently Asked Questions, September 15, 2021.  Accessed at 
https://auth.cdc.gov/sams/samsfaq.pdf?disp=true on November 17, 2022. 
32 CDC, New to NHSN?  Guided Steps to Enroll Your Facility, p. 21.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/training/enroll/nhsn-facility-enrollment-training.pdf on July 5, 2023. 
33 Comagine Health and Medicare QIN-QIO for Idaho, Nevada, New Mexico, Oregon, Utah, and Washington, TIP Sheet for 
NHSN COVID-19 Enrollment: SAMS and Facility Enrollment.  Accessed at https://comagine.org/sites/default/files/resources/TIP-
Sheet-NHSN-Enrollment.pdf on November 17, 2022. 
34 Telligen and Medicare QIN-QIO, NHSN Access Level Guide.  Accessed at  
https://www.telligenqiconnect.com/wp-content/uploads/2022/02/NHSN-Access-Level-Document_Current-Process.pdf on 
November 17, 2022. 
35 CDC, New to NHSN?  Guided Steps to Enroll Your Facility, p. 21.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/training/enroll/nhsn-facility-enrollment-training.pdf on July 5, 2023. 
36 CDC, About SAMS.  Accessed at https://www.cdc.gov/nhsn/sams/about-sams.html on November 17, 2022. 
37 CDC, About NHSN Help Desk.  Accessed at https://www.cdc.gov/nhsn/about-nhsn/helpdesk.html on September 16, 2021.   
38 CDC, About NHSN Help Desk.  Accessed at https://www.cdc.gov/nhsn/about-nhsn/helpdesk.html on September 16, 2021.   
39 Social Security Act  1819, 1919. 
40 85 Fed. Reg. 27550 (May 8, 2020); CMS, Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected 
COVID-19 Cases Among Residents and Staff in Nursing Homes, May 6, 2020, p. 3.  Accessed at 
https://www.cms.gov/files/document/qso-20-29-nh.pdf on November 10, 2021. 
41 85 Fed. Reg. 27627 (May 8, 2020); 42 CFR  483.80. 
 
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OEI-06-22-00030   Endnotes | 56    
 
42 CDC, NHSN E-Newsletter, March 2020, p. 13.  Accessed at  
https://www.cdc.gov/nhsn/pdfs/newsletters/nhsn-nl-mar20-508.pdf on June 4, 2021.  
43 CDC, NHSN E-Newsletter, June 2020, p. 15.  Accessed at https://www.cdc.gov/nhsn/pdfs/newsletters/nhsn-nl-jun20-508.pdf 
on June 4, 2021.   
44 86 Fed. Reg. 26336 (May 13, 2021); 42 CFR  483.80. 
45 85 Fed. Reg. 54824 (September 2, 2020); 42 CFR  488.447. 
46 OIG, CMSs COVID-19 Data Included Required Information From Most Nursing Homes, but CMS Could Take Actions To Improve 
Completeness and Accuracy of the Data (A-09-20-2005) September 1, 2021. 
47 OIG analysis of internal documents provided by CDC, June 2023. 
48 CDC, COVID-19 Module Long Term Care Facility: Resident Impact and Facility Capacity Pathway, June 2023.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/57.144-res-blank-p.pdf on August 16, 2023.   
49 CDC, COVID-19 Module Long Term Care Facility: Staff and Personnel Impact, June 2023.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/57.145-staff-blank-p.pdf on August 16, 2023.  
50 CDC, Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities, June 2023.  Accessed at 
https://www.cdc.gov/nhsn/forms/COVIDVax.LTC_.Resident.FORM_May2022-508.pdf on August 16, 2023.  
51 CDC, Healthcare Personnel COVID-19 Vaccination Cumulative Summary, June 2023.  Accessed at 
https://www.cdc.gov/nhsn/forms/COVIDVax.HCP_.FORM_May2022-508.pdf on August 16, 2023.  
52 42 CFR  483.80. 
53 CDC, National Healthcare Safety Network (NHSN)  Long-term Care Facility COVID-19 Module, May 2020, p. 22, 25-28.  
Accessed at https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/ltcf-covid19-module-508.pdf on June 22, 2021. 
54 CDC, National Healthcare Safety Network (NHSN)  Long-term Care Facility COVID-19 Module, May 2020, op. cit., p. 21.  
55 CMS, Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among 
Residents and Staff in Nursing Homes, op. cit., p. 3.   
56 CMS, CMS/CDC Nursing Home COVID-19 Data Quality Assurance Process.  Accessed at  
https://data.cms.gov/sites/default/files/2021-07/covid-19-nursing-home-data-quality-assurance-process_0.pdf on  
February 2, 2022. 
57 CMS, CMS/CDC Nursing Home COVID-19 Data Quality Assurance Process.  Accessed at 
https://data.cms.gov/sites/default/files/2021-07/covid-19-nursing-home-data-quality-assurance-process_0.pdf on  
February 2, 2022.  
58 CMS published an interim final rule on November 5, 2021, that established COVID-19 vaccination requirements for staff at 
certain Medicare- and Medicaid-certified providers and suppliers.  See 86 Fed. Reg. 61555 (November 5, 2021).   
59 CDC, Nursing Home COVID-19 Data Dashboard.  Accessed at https://www.cdc.gov/nhsn/covid19/ltc-report-overview.html on 
September 15, 2021. 
60 CMS, COVID-19 Nursing Home Data.  Accessed at https://data.cms.gov/covid-19/covid-19-nursing-home-data on  
January 3, 2022.   
61 CMS, COVID-19 Nursing Home Data.  Accessed at https://data.cms.gov/covid-19/covid-19-nursing-home-data/data on 
January 27, 2023.   
62 CMS, CMS/CDC Nursing Home COVID-19 Data Quality Assurance Process.  Accessed at 
https://data.cms.gov/sites/default/files/2021-07/covid-19-nursing-home-data-quality-assurance-process_0.pdf on  
February 2, 2022. 
 
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030   Endnotes | 57    
 
63 CMS, CMS Launches New Medicare.gov Tool to Compare Nursing Home Vaccination Rates, September 21, 2021.  Accessed at 
https://www.cms.gov/newsroom/press-releases/cms-launches-new-medicaregov-tool-compare-nursing-home-vaccination-
rates on January 25, 2023. 
64 OIG, CMSs COVID-19 Data Included Required Information From Most Nursing Homes, but CMS Could Take Actions To Improve 
Completeness and Accuracy of the Data (A-09-20-02005) September 1, 2021.    
65 OIG, COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020 (OEI-02-20-00490)  
June 22, 2021.  
66 OIG, Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23-May 30, 2020 (OEI-01-20-00430) December 
17, 2020.   
67 OIG, More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the COVID-19 
Pandemic; Better Protections Are Needed for Future Emergencies (OEI-02-20-00491) January 19, 2023. 
68 OIG, Workplan Summary: Meeting the Challenges Presented by COVID-19: Nursing Homes.  Accessed at 
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000474.asp on October 7, 2023.  
69 Minnesota Department of Health, Reporting Point of Care COVID-19 Test Results through the CDC National Healthcare Safety 
Network (NHSN), October 26, 2020.  Accessed at 
https://www.leadingagemn.org/assets/docs/10_26_20_NHSN_POC_Test_Reporting_LTC.pdf on February 2, 2023. 
70 CDC, COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115, March 8, 2022, p. 5.  Accessed at 
https://www.cdc.gov/coronavirus/2019-ncov/downloads/lab/HHS-Laboratory-Reporting-Guidance-508.pdf on  
February 2, 2023.  
71 A Quality Improvement Organization is a group of health quality experts, clinicians, and consumers organized to improve 
quality of care for people with Medicare coverage.  See CMS, Quality Improvement Organizations.  Accessed at 
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs on December 7, 
2022.   
72 CDC, July 2020 LTCF Newsletter, July 6, 2021.  Accessed at https://www.cdc.gov/nhsn/ltc/newsletters/jul20-newsletter-
ltc.html on November 17, 2022. 
73 CDC, LTCF COVID-19 Module: Resident Impact and Facility Capacity Surveillance Reporting Pathway, YouTube, April 2, 
2021.  Accessed at https://www.youtube.com/watch?v=mrGOM4-hgAo on December 13, 2022. 
74 CDC, December 2020 LTCF Newsletter, December 21, 2021.  Accessed at https://www.cdc.gov/nhsn/ltc/newsletters/dec20-
newsletter-ltc.html on December 13, 2022. 
75 CDC, LTCF COVID-19 Module: Therapeutics Surveillance Reporting Pathway, YouTube, April 19, 2021.  Accessed at 
https://www.youtube.com/watch?v=ZTzRk7-3Qak on December 15, 2022. 
76 CDC, LTCF COVID-19 Module: Updates, July 2021.  Accessed at https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/rel955-update-
508.pdf on December 15, 2022. 
77 CDC, LTCF COVID-19 Module: Surveillance Pathway Updates, May 2022.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/covid19-mod-surv-path-508.pdf on December 15, 2022. 
78 CDC, LTCF COVID-19 Module: Surveillance Pathway Updates, June 2023.  Accessed at 
https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/NHSN-COVID-19-11.4-updates-for-May-30th-recording-final.pdf on June 13, 
2023.   
79 CDC, 5-Step Enrollment for Long-term Care Facilities.  Accessed at https://www.cdc.gov/nhsn/ltc/enroll.html on February 7, 
2023.  
80 CDC, User Guide for CDCs SAMS Partner Portal.  Accessed at https://auth.cdc.gov/sams/SAMSUserGuide.pdf?disp=true on 
November 17, 2022. 
81 CDC, Overview for CDCs SAMS Identity Verification Process.  Accessed at 
https://auth.cdc.gov/sams/IdentityVerificationOverview.pdf?disp=true on November 17, 2022.  
82 CDC, User Guide for CDCs SAMS Partner Portal.  Accessed at https://auth.cdc.gov/sams/SAMSUserGuide.pdf?disp=true on 
November 17, 2022. 
CDC Has Improved the Nursing Home Reporting Process for COVID-19 Data in NHSN, but Challenges Remain 
OEI-06-22-00030   Endnotes | 58