Nursing Home C. difficile Initiative Three-Part Educational Webinar Series

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1 Nursing Home C. difficile Initiative Three-Part Educational Webinar Series Webinar #2 Enrollment in NHSN for LTC Facilities August 23, 2016 Webinar #2 Enrollment in NHSN for LTC Facilities Nursing Home C. difficile Initiative Three Part Educational Webinar Series 1

2 Upcoming Webinar Webinar #3 Reporting C. difficile in NHSN for LTC Facilities g.php?mtid=e0cd4cd916f70855f09fea4ba33d3c38b September 21, p.m. ET, 1 2 p.m. CT Clostridium difficile infection Prevention Project Objectives Today 1. Review steps 4 and 5 of the NHSN enrollment process 2. Learn how to add and delete users in NHSN 3. Understand how to set up NHSN for reporting 2

3 NHSN Enrollment Timeline Step 1 Complete Enrollment Training Step 2. Register with NHSN and SAMS Step 3. Submit identity proofing documents, wait for SAMS grid card Step 4. Use SAMS grid and complete required enrollment forms online Step 5. Complete Participation Agreement, wait for NHSN activation ( notification) Set up NHSN C. difficile Protocol Begin collecting data Begin Reporting Webinar 1 Webinar 2 Webinar 3 Receive Confirmation and Grid Card Welcome to SAMS and Welcome to NHSN s provide links to access NHSN reporting Approximately 3 4 weeks after you submit your identify verification forms, you will receive your confirmation and Grid Card in the mail Delivered to your home address by the US Postal Service Contact SAMS if it doesn t come or

4 Step 4: Submit Annual Facility Survey & Contact Forms Electronically Step 4: Complete Annual Survey & Contact Forms on Paper The Facility Contact Form LTCFSurv_BLANK.pdf The Annual Facility Survey LTCFSurv_BLANK.pdf All of the * are required. All required fields must be complete before submitting to NHSN. NHSN does not allow you to save partially completed forms. 4

5 Step 4: Sign into NHSN selecting SAMS Grid Card Credentials Step 4: Sign In with SAMS Username & Password Access to NHSN: Enter the SAMS Username and the temporary password SAMS ed to you in the Invitation to Register in STEP 3 5

6 Step 4: Sign In with Grid Card Access to NHSN: Enter the letter/number on your Grid Card that corresponds to the letter/number on the NHSN window. This changes every time you log in. If you enter the wrong username/password or grid card numbers three times you will be locked out for 24 hours. Step 4: Select NHSN Enrollment 6

7 Step 4: Select Enroll a Facility Forms are available here if you haven t completed them Select this link to enter your annual survey and contact information into NHSN IMPORTANT: You must complete all data submission about your facility in one session! You cannot save work in progress so be prepared before you start the enrollment process! Step 4: Enter Facility Contact Info Review the slides in the first webinar and make sure they match step 4 in the Enrollment: Getting access to NHSN for your LTCF Asterisks are required 7

8 Step 4: Enter Facility Contact Info CMS certified facilities should enter CCN Quite often your business office has this number If not check with your QIN QIO Or NHSN help desk can issue temporary number Enter only one identifier and check not applicable for the other identifiers Enter the Effective Date of the CCN at 1/01/2016 (or date prior to starting) Step 4: Facility Type, NHSN Components & NHSN Facility Administrator Select most appropriate Facility Type from: LTC ASSIST Assisted Living or Residential Care Facility LTC DEVDIS Facility Caring for individuals with Developmental Disabilities LTC SKILLNURS Skilled Nursing Facility or Nursing Home Select the NHSN Components in which your facility will participate: Choose Long Term Care Facility The NHSN Facility Administrator is person enrolling the facility in NHSN: Use same addressed as used for SAMS registration (Steps 2 & 3) 8

9 Step 4: LTCF Contact Person Person who will be most involved with LTCF surveillance. Can be the same person as the NHSN Facility Administrator Step 4: Complete Annual Facility Survey Give yourself time to complete the entire survey. Incomplete surveys cannot be saved! 9

10 Step 4: Save & Submit Forms Save and Submit If you print the completed survey, don t forget to hit Save & Submit! Step 4: Complete! After submitting the forms you have completed Step 4 The facility Administrator will immediately receive an NHSN with a link to the required consent forms If you do not receive this , contact the NHSN Helpdesk 10

11 Step 5: Sign & Send Agreement to Participate The facility Administrator will immediately receive an NHSN NHSN Facility Enrollment Submitted with a link to the required Agreement to Participate and Consent form Consent forms are facility specific, you must print the consent form provided in the link You have 30 days to open the link and print form Tip: To open the consent form, you may need to log in to SAMS using your grid card and password, and then copy and paste the link into that browser window. Step 5: Sign & Send Consent Agreement to Participate and Consent includes: NHSNPurposes Eligibility Data collection and reporting requirements Assurance of Confidentiality Must be signed by: Identified LTCF Contact Highest level administrator at facility Fax page 3, the signature page to Keep the copy. Do not mail the forms in. 11

12 Step 5 Notification of NHSN Activation Enrollment is Complete!!! 2 3 business days after NHSN receives signed consent form, NHSN will activate your facility The NHSN Facility Administrator will receive notification of facility activation from NHSN Enrollment is complete and the facility is active! NHSN Set Up 1. Adding and deleting users 2. Set up LTCF Locations 3. Complete the Monthly Reporting Plan 4. Joining Groups 12

13 NHSN Set up Select facility group from the drop down list NHSN Landing Page Select Long Term Care Facility Click SUBMIT Always use the navigation bar or NHSN buttons to move from page to page in NHSN 13

14 1. Adding Users and Assigning User Rights Facility Administrators add Users in NHSN On the NHSN navigation bar the NHSN Facility Administrator can add additional users to access NHSN It is recommended that you add at least one additional user 14

15 Enter User s Information Save User must use the same address for their SAMS registration Select the Rights Save 15

16 New NHSN Users Once a new user is added, an is automatically sent to their address with instructions Each user must register for access to SAMS and submit identity proofing documentation Each user must agree to the NHSN Rules of Behavior and complete required training covered in the first webinar before using NHSN Deactivate Users 1. To deactivate users select Find on the Blue navigation bar 2. On User Information Page: select Find 3.On the User List select user and click Deactivate 16

17 2. Location Mapping NHSN Set up: Location Mapping Most LTCFs have different physical locations where residents reside and receive care within the building. These locations might be known as units, wards, floors, neighborhoods, pod, etc. Each resident care location in your facility should be mapped to a CDC location code/description. This provides information about the type of residents or care services in that place When reporting an infection, the resident care location is used to identify where the resident was in the facility at the time the event occurred 17

18 Location Mapping Define each location within your facility with your own name that best describes how you identify units within your facility. In NHSN this is called Your Code and Your Label. Your Code: Create a code to help you to help you identify the location. For example, 2 East Your Label: This can be the same as the code or you could add additional information such as rehabilitation. Next select the NHSN location code for LTCF from the following slides. As a reminder, nursing homes/skilled nursing facility units located within a hospital that have a CCN that is different from the hospital must be enrolled as a separate NHSN Facility within the LTCF Component NHSN Location Codes LTCF 18

19 NHSN Location Codes LTCF Choosing the Right Location Resident Mix: To map the appropriate CDC location code for a unit, review the resident mix in that unit during the previous year Choose the location code that best describes the type of resident care/service delivered on that unit NHSN 80% Rule : Sometimes more than one type of resident receives care in a location, for example, both longstay and skilled resident beds are mixed together. In that situation, select the location code which best reflects the majority of residents usually cared for on that unit. Ideally this code would apply to 80% of residents on the unit. But, if there is not a clear majority, select the code that makes sense for your facility 19

20 LTCF Home Page: Locations Adding a Location in NHSN Anything with an asterisk is mandatory Codes and labels are specific to your facility. Choose a code and label which best describes how you identify your facility Once you have chosen a CDC location description to map with Your Code it cannot be changed so choose the CDC description carefully Use the drop down to choose the CDC Location description that best describes the unit 20

21 Add Location Example 3. Adding a Monthly Reporting Plan 21

22 The Monthly Reporting Plan Tells NHSN which modules and events your facility will be tracking Each month you must submit a Monthly Reporting Plan There is an option to select No Long Term Care Facility Component Followed this Month if you are not following any NHSN modules for the month. You can submit your Monthly Reporting Plan for one year in advance Surveillance Module Lab ID Event Event Reporting Option C. difficile, How Do I Add a Monthly Reporting Plan? 22

23 The Monthly Reporting Plan Window Choose CDIF C. difficile from the drop down CDIF C. difficile Save Check here for CDI Lab ID Event The Monthly Reporting Plan Window 23

24 You can View your Monthly Reporting Plan Step 1: Step 2: Step 3: Step 4: Summary: How to Add a Monthly Reporting Plan On the Blue NHSN Navigation Bar Select Reporting Plan, then Add Select month & year of surveillance Complete the reporting plan Select C. difficile as the organism type from dropdown for the LabID Event Module Scroll to bottom of page and click Save 24

25 4. Joining Groups Joining a Group in NHSN Any entity can maintain a Group in NHSN (state health departments, hospital systems, quality improvement organizations, etc.) Facilities can share data with these partners and agencies using NHSN s Group function Facilities join Groups and provide access to data requested by Group within the NHSN application A facility that joins a Group does not have access to any data from other facilities in the Group 25

26 Homework Complete steps 4 5 of the enrollment process. Step 4: Submit the NHSN Long Term Care Annual Facility Survey and the Facility Contact information Step 5: Submit consent forms that have been signed by the facility s leadership Set up NHSN for reporting Add others who will be using NHSN in your facility Set up LTCF locations in the NHSN application Set up NHSN Monthly Reporting Plans for your facility Join the two groups associated with this initiative, following the instructions provided by your state QIN contact (instructions to follow) Next Time September 21, p.m. ET, 1 2 p.m. CT g.php?mtid=e0cd4cd916f70855f09fea4ba33d3c38b Long term Care Facility Component Training Protocols Data Collection forms Reporting Clostridium difficile in NHSN 26

27 NHSN Support NHSN Helpdesk at SAMS Help desk or State Specific Contacts Michigan Kathleen Lavich Annett Simon Minnesota Sarah Brinkman Janet Lilleberg Wisconsin Diane Dohm Emily Nelson 27

28 This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW MN C

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