NHSN Reporting Made Easy

The University Place Nursing Center is a skilled nursing facility in Houston specializing in short-term, post-acute care for seniors, as well as long-term care for seniors who need around-the-clock care and other medical services. The problems faced by this 60-bed facility were not uncommon among nursing homes. In September 2023, University Place was notified by the Centers for Medicare & Medicaid Services (CMS) of a missing week of reporting in the National Healthcare Safety Network (NHSN), and that reporting data did not match required NHSN guidelines, so their reports were flagged with alerts.

The University Place partnered with the TMF Quality Innovation Network-Quality Improvement Organization (QIN-QIO) to identify and resolve two issues:

  1. Root cause analysis of the NHSN alerts
  2. Education and technical assistance to complete the appropriate NHSN reporting requirements

“The following week, using the knowledge provided by our TMF QIN-QIO quality improvement specialist (QIS), we were able to correctly update our NHSN reporting for the Health Care Personnel (HCP) and Residents Pathway, as well as COVID-19 vaccine reporting in a timely manner,” said infection preventionist Augusta Opara-Aku, MPH, BSN, RN, CPN. “As a result of the education and assistance provided, our facility has achieved 100% reporting compliance and we continue reporting correctly,” she said.

NHSN reporting has the potential to impact all staff and residents. With collaborative discovery among the University Place’s quality team, infection control and the TMF QIN-QIO QIS, Opara-Aku identified that they were not reporting the HCP COVID-19 status or reporting on the HCP and Residents COVID-19 Pathway accurately.

“We learned that there are two different reports required for NHSN reporting compliance: the HCP and Residents Pathway weekly reporting, and the COVID-19 weekly reporting,” Opara-Aku said. “Our TMF QIN-QIO QIS provided the support we needed to report appropriately by offering assistance, sharing useful links to webinars and information about NHSN, as well as one-on-one education and orientation to multiple NHSN user modules.”

Today University Place keeps up with NHSN reporting and updates by joining webinars and other training provided by the TMF QIN-QIO and the Centers for Disease Control and Prevention, which administers NHSN.

“We continue to complete appropriate and accurate NHSN reporting, thanks to the TMF QIN-QIO team providing NHSN support. Our TMF QIN-QIO QIS will also touch base twice monthly to review any additional needs we may have,” said Opara-Aku. “We encourage others to reach out to the TMF QIN-QIO regarding challenges they may have.”

The TMF QIN-QIO is contracted by CMS to assist nursing homes free of charge. To find out how the TMF QIN-QIO can help your facility with challenges related to COVID-19 and vaccinations, email NHconnect@tmf.org.