Resident Therapeutics Form - Instructions

January 2021

Instructions for Completion of the COVID-19 Long-term Care Facility (LTCF) Resident Therapeutics Form (CDC 57.XXX)

Data Field	Instructions for Form Completion
NHSN Facility ID #	The NHSN-assigned facility ID will be auto generated by the system.
CMS Certification Number (CCN)-may be referred to as participation number	Auto generated by the computer, if applicable, based on the CCN entered during NHSN registration or last updated, if previously edited. Please see NHSN CCN Guidance document for instructions on how to add a new CCN or edit an existing CCN.
Facility Name	Auto generated by the system based on the facility name previously entered during NHSN registration.
Date for which counts are reported	Required. Select the date on the calendar in which the aggregate counts are being reported.
Facility Type	Auto generated based on the facility type selected during NHSN enrollment. Selections include: LTC-ASSIST – Assisted Living Residence LTC-DEVDIS – Long-term Care Facility for the Developmentally Disabled (referred to by CMS as “Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID”). LTC-SKILLNURS – Skilled Nursing Facility + +Includes both skilled nursing facilities and nursing homes Please see NHSN Guidance document for instructions on How to Correct Your Facility Type if the autogenerated information is incorrect.
Date Created	Auto generated based on the first calendar date and time that a user manually enters and saves data or the date the facility first submits a CSV file for a specific pathway. Note: The date and time will automatically generate after the “Save” button is selected and cannot be modified.

Important:

Report total counts for the below questions only one calendar day during the reporting week and include only new counts since the previously reported counts. If the count is zero, a “0” must be entered as the response. A blank response is equivalent to missing data.

Data Field

Instructions for Form Completion

THERAPEUTIC For each therapeutic listed, enter number of residents who received the therapeutic at this facility or elsewhere during the reporting week.

Therapeutic is defined as a treatment, therapy, or drug. Monoclonal antibodies are examples of anti-SARS-CoV-2 antibody-based therapeutics used to help the immune system recognize and respond more effectively to the COVID-19 virus. For this reporting week, indicate the number of residents who were treated by one or more of the listed therapeutic, based on: In-house stock that was stored at your facility (specifically, either administered by your LTCF or by an outside entity using stock provided by your LTCF). Stock that was stored at another facility, such as an infusion center or hospital. Important: The reported counts must include only the number of newly administered therapeutics since the last date in which therapeutic counts were reported to NHSN. If no residents received one or more of the listed therapeutics, a zero “0” should be reported. A blank field is equivalent to missing data. Counts include resident(s) who received the listed therapeutic during the reporting week regardless if the therapeutic was administered to the resident while in the LTCF or while in another facility. Example: During this reporting week, a total of 4 residents were treated with monoclonal antibodies. Resident A was transferred to the emergency department where he received an infusion with Bamlanivimab (Lilly). Residents B and C were treated in their LTCF with Regeneron’s Casirivimab plus Imdevimab by an infusion nurse who administered the infusions from stock available at the LTCF. Resident D was treated with Bamlanivimab by an infusion nurse who brought the therapeutic from an outside pharmacy. The below data were reported to NHSN for the reporting week.

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