AFL 20-31.3 From the California Department of Public Health
TO: General Acute Care Hospitals (GACHs)
SUBJECT: GACH Coronavirus Disease 2019 (COVID-19) Daily Reporting (This AFL supersedes AFL 20-31.2)
AUTHORITY: Proclamation of Emergency (PDF)
All Facilities Letter (AFL) Summary
- This AFL requires GACHs to report COVID-19 data daily to the California Department of Public Health (CDPH). This reporting is to ensure California has the information necessary to respond to the COVID-19 pandemic.
- CDPH will submit data on behalf of hospitals through the Department of Health and Human Services (DHHS) TeleTracking. Hospitals will continue to report to CDPH daily via the COVID-19 Tracking Tool. The National Health Safety Network (NHSN) system is no longer used for COVID-19 hospital reporting.
- This revision updates the data dictionary and notifies GACHs of the new regulatory requirements in Title 42 CFR section 482.42(e). Failure to report specified COVID-19 data may lead to federal remedies, including termination of their Medicare provider agreement.
On July 10, 2020, DHHS updated the COVID-19 Guidance for Hospital Reporting and FAQs (PDF) to reflect new reporting methods and data metrics. Beginning July 15, 2020, hospitals were required to submit COVID-19 data to DHHS using one of several methods, including the TeleTracking portal, HHS Protect, or through the state. CDPH then issued AFL 20-31.2 to notify hospitals that the NHSN system is no longer used for COVID-19 reporting and CDPH will submit data on behalf of hospitals through TeleTracking, beginning July 22, 2020. Hospitals will continue to report to CDPH via the COVID-19 Tracking Tool no later than 12:00 P.M. Pacific Time daily.
On September 2, 2020, the Federal Register published interim final rule CMS-3401-IFC, requiring hospitals and critical access hospitals to report data in accordance with Title 42 Code of Federal Regulations (CFR) sections 482.42(e) and 485.640(d), respectively. AFL 20-31.3 notifies GACHs of the new regulatory requirement and enforcement process for reporting COVID-19 data.
In accordance with Title 42 CFR section 482.42(e) and DHHS’s COVID-19 Guidance for Hospital Reporting and FAQs (PDF), GACHs must continue to report to CDPH via the COVID-19 Tracking Tool no later than 12:00 P.M. Pacific Time daily. The COVID-19 Tracking Tool ensures GACHs report the necessary patient and resource data to support the local, state, and federal public health response to the COVID-19 pandemic.
CDPH will then submit data on behalf of hospitals through TeleTracking.
To facilitate the data transfer to TeleTracking, the California Hospital Association (CHA) worked with CDPH to update the COVID-19 Tracking Tool. This update incorporates data elements requested by DHHS, including information on COVID-19 confirmed and suspected patients, availability of personal protective equipment, medication shortages, remdesivir data and staffing shortages. To ensure consistent reporting across the state, CDPH is providing a data dictionary (PDF) that incorporates the DHHS definitions. GACHs are encouraged to review the data dictionary (PDF) in its entirety before inputting data into the COVID-19 Tracking Tool.
Use of the COVID-19 Tracking Tool will take the place of daily reporting to CDPH district offices, related to the information specified above. Use of this tool will also replace hospital reporting COVID-19 Patient Impact/Hospital Capacity and Healthcare Supply data to DHSS. All other reporting requirements to CDPH district offices will continue using the standard reporting process. CDPH may revise the types of information collected by issuing subsequent AFLs.
Failure to Report
Pursuant to CMS QSO 21-03-Hospitals/CAHs (PDF), hospitals that fail to report the specified data elements on a daily basis will receive notification from their CMS Location of their noncompliance with the reporting requirements and any further
noncompliance with reporting requirements may result in future enforcement actions.
The following process will occur for failure to report:
- Hospitals that do not meet the reporting requirements completely on a daily basis will receive an initial notification from CMS. This notification of noncompliance will also serve as a reminder of the reporting requirements.
- Three weeks after receiving an initial notification of noncompliance with reporting requirements, those providers that continue not submitting the specified information daily and completely will receive a second reminder notification of their failure to meet the reporting requirements and that future enforcement actions will be taken for continued noncompliance, which may result in termination of the Medicare provider agreement.
- Those providers that have continually failed to meet the reporting requirements for a period of six weeks after receiving an initial notification from CMS will receive the first in a series of enforcement notification letters. At this point, the enforcement actions are now in process and providers will have one calendar week to demonstrate compliance.
- Providers failing to meet the reporting requirements within one calendar week following the first enforcement notification letter will receive a second enforcement notification letter and third enforcement letter, if non-compliant the following week. The third letter will indicate that the provider will have one calendar week to demonstrate compliance with the reporting requirements otherwise the provider will receive a fourth and final enforcement notification letter, as noted in step 5.
- Providers that have failed to meet the reporting requirements within 1 week following the third enforcement notification letter will receive a fourth and final enforcement notification letter. This notification will include a notice of termination to become effective within 30 days from the date of the notification. Failure to meet the reporting requirements within this 30-day timeframe may result in termination of the Medicare provider agreement.
Note: Steps 1-2 of the above enforcement process are only applicable from October 7 – November 18, 2020. After November 18th, the noncompliance notification process described in Steps 3-5 above applies.
If a hospital receives a notification of noncompliance, the hospital will have an opportunity to provide evidence of compliance. The hospital may submit evidence to CMS within 72 hours of receiving notification of noncompliance. If the hospital is found to be in compliance with the reporting requirements, enforcement remedies will be rescinded. If the enforcement action for failure to report is rescinded and the provider subsequently demonstrates noncompliance with the requirements in the future, a new enforcement action will begin.
If you have any questions about the COVID-19 Tracking Tool, please email COVIDTracker@calhospital.org. If you have any other questions about this AFL, please contact the CDPH Duty Officer at CHCQDutyOfficer@cdph.ca.gov.
Original signed by Heidi W. Steinecker
Heidi W. Steinecker