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ASC-20 Reporting Deadline Approaching Quickly

Changes in guidance that ASCs need to be on top of to avoid penalty

BY KARA NEWBURY | JULY 2022

The Centers for Disease Control and Prevention (CDC) recently updated its reporting guidance for ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel (HCP), including the definition of what it means for an individual to be “up to date” with vaccinations. This change became effective with reporting beginning the week of June 27.

For people under 50 years of age, “up to date” means those who 1) received at least one booster dose or 2) recently received all recommended doses in the primary vaccine series but are not yet eligible for a booster dose. For individuals 50 years and older, “up to date” means those who 1) received a second booster dose (or received a first booster dose less than four months ago and are not yet eligible for a second booster dose) or 2) recently received all recommended doses in the primary vaccine series but are not yet eligible for a booster dose. This is the second time the definition of “up to date” has been revised in the past two months.

As ASCA reported a few weeks ago regarding the May updates to these definitions, ASCA has confirmed with the Centers for Medicare & Medicaid Services (CMS) that although the definition of “up to date” includes at least one booster, only data on an initial series, which was considered a complete vaccination course when the rule was published, will be made publicly available. Meaning, although it is a mandatory field to report, booster data will not count against your vaccinated healthcare personnel totals. The CDC is currently updating the Excel Data Tracking Worksheet for HCP to reflect recent changes to the definition of “up to date,” but it should be available in the portal when you report.

ASC-20 reporting for compliance with the ASC Quality Reporting Program is separate from 42 CFR §416.51(c) Conditions for coverage - Infection control, Standard: COVID-19 Vaccination of Staff. The standard states that “staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19.” While the guidance on this mandate requires facilities to develop “a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC,” ASCs will not be penalized if their staff are not “up to date.”

ASCs need to enter data only once per month to fulfill the CMS reporting requirement, but the CDC sends emails to centers stating they have incomplete reporting if facilities do not enter data each week. This email is separate from CMS requirements and, according to the CDC, there is not a way to turn off these alerts; however, they do not interfere with data reporting. The CDC put together a blast email that facilities should have received on July 6. The email provides clarification on the missing data alerts and CMS reporting requirements.

While vendors are a mandatory field—and it is often difficult to obtain vaccination information on all vendors—the "other personnel" category is not included in the numbers that CMS will publicly report. Only the core categories are included in public reporting: 1) employees (staff on facility payroll), 2) licensed independent practitioners (physicians, advanced practice nurses, and physician assistants) and 3) adult students/trainees and volunteers.

Upcoming Deadlines

If you have not already started the National Healthcare Safety Network (NHSN) enrollment process, now is the time to start. ASCs must collect the number of HCP who have received a completed COVID-19 vaccination course (numerator) and the total number of HCP eligible to work in the ASC for at least one day during the reporting period (denominator) and submit to the NHSN Healthcare Personnel Safety Component for at least one, self-selected week each month. Each month in a quarter should be reported according to the deadlines below.

How to Report ASC-20 Accurately provides more information on NHSN enrollment and data submission. In addition, the CDC has made available the following resources:

1. NHSN enrollment webpage
2. Enrollment checklist
3. Change NHSN Facility Administrator form
4. Data collection resources

Write Kara Newbury with questions.