NSHN and OSHA Reporting: Prepared to Meet the Deadline?

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It is that time of year again. At least for acute care hospitals, long-term acute care (LTAC) hospitals and inpatient rehabilitation facilities (IRF) who report to The National Healthcare Safety Network (NHSN). If annual surveys are not reported by March 1st, then your organization will not be permitted to enter monthly reporting plans until the annual survey has been completed. Although there are just a few weeks to go, early planning is the key.


It is important to consider that responses to the Annual Survey questions are a collaborative effort. Planning a meeting in advance with key stakeholders will help to ease the stress of completing what some may consider to be a daunting task. Be sure to coordinate with Facilities Managers, Pharmacists, Laboratory, Nursing, Infection Prevention and Quality leaders on annual survey responses. Although individuals who are responsible for report submission may find that some of the data has not changed significantly from the previous year, we have identified that some questions have been removed while additional questions have been added.


If you are new to NHSN reporting and have not yet completed an annual survey, you will find an alert reminding you on your dashboard upon logging in. Keep in mind that the survey you are completing requires data from the previous calendar year. You will be submitting data for 2024 due March 1st, 2025. There are a variety of questions that will require information about metrics, facility type, infection prevention practices, laboratory testing methods, water quality management, and antimicrobial stewardship practices for example.


Instructions on completing your organization’s annual survey click on the link below that corresponds with your facility type:

Instructions for Completing Annual Hospital Survey

Instructions for Completing LTAC Annual Survey

Instructions for Completing IRF Annual Survey


OSHA requires the following facilities to complete an annual occupational injury and Illness Report:

  • Ambulatory Health Care Servies
  • General Medical and Surgical Hospitals
  • Psychiatric and Substance Abuse Hospitals
  • Specialty Hospitals
  • Skilled Nursing Facilities


For a complete list of facilities required to report annually via electronic submission and for additional information on Standard 1904 Subpart E Appendix B click on the following link: OSHA Injury and Illness Reporting Requirements.


Much like NHSN annual surveys, this reporting is also for the prior calendar year. Your deadline for submission is March 2, 2025. If your organization has not previously been reporting, please note that you will need to set up an Injury Tracking Application (ITA) account. For complete instructions, click on the following link User Guide.


Individuals who are responsible for report completion and submission should have a clear understanding of criteria that constitutes a work-related injury. They will also need to know if the employee missed days of work because of injury or illness. If an employee was restricted from usual work activities or reassigned to a new role as a result of the injury or illness this information must be documented. If an employee required care beyond basic first aid, this will also need to be reported.


Reporters should not include Protected Health Information (PHI). For a brief tutorial on OSHA annual reporting requirements, click on the following link OSHA Injury and Illness Reporting.

 

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References:

https://www.cdc.gov/nhsn/forms/instr/57_103-toi.pd

https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904SubpartEAppB

https://www.osha.gov/sites/default/files/ita_user_guide.pdf

https://www.osha.gov/sites/default/files/osha_rktutorial.pdf

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February 28, 2026
February may be the shortest month of the year, but in the world of healthcare facilities and regulatory oversight, it often feels like the longest. Between the launch of the Joint Commission’s Accreditation 360 and the sudden shifting of federal staffing mandates, your compliance "To-Do" list likely looks more like a "To-Don't-Panic" list. Below is your breakdown of the critical updates, deadlines, and strategic shifts defining February 2026. Regulatory Roundup: The "Great Repeal" of 2026 The most significant news hitting desks this month is the formal pivot in Long-Term Care (LTC) staffing. CMS Staffing Mandate Repealed : Effective February 2, 2026 , CMS officially rescinded the 2024 minimum staffing requirements (the 3.48 HPRD mandate). The Fine Print : While the "one-size-fits-all" numbers are gone, the Enhanced Facility Assessment requirements are still very much alive. Regulators are moving away from rigid ratios toward a "competency-based" model. You must still prove your staffing levels match your specific resident acuity. What it means for you : It’s time to double-check your assessment documentation. Auditors aren't counting heads as strictly, but they are scrutinizing the logic behind your staffing decisions. HIPAA & Privacy: The February 16th Pivot If you haven't updated your Notice of Privacy Practices (NPP) yet, you are officially behind. February 16, 2026, marked the deadline for compliance with the final rule aligning 42 CFR Part 2 (Substance Use Disorder records) with HIPAA. Lawful Holder Doctrine : Any practice receiving SUD records is now a "lawful holder," triggering new obligations for how those records are handled in legal proceedings. Reproductive Health Privacy : New prohibitions are in place regarding the disclosure of PHI for investigations into lawful reproductive healthcare. Security Rule Modernization : Th e HHS Office for Civil Rights (OCR) is phasing out the "addressable" vs. "required" distinction. By late 2026, every safeguard will be mandatory. Tech & Sustainability: Do Less with Less The 2026 facility mantra has shifted from "do more with less" to "do less with less"—meaning we are using data to eliminate wasted effort. Unified Platforms : The era of separate spreadsheets for maintenance, energy, and compliance is over. Integrated CAFM (Computer-Aided Facility Management) tools are now the standard for audit-ready reporting. The "Heart" of the Facility : Since it’s American Heart Month, it’s the perfect time to run a Life Safety check on AEDs and Cardiac Crash Carts. Ensure your battery replacement logs are digitized—paper tags are so 2024. A Note on Candor : Let’s be real—the repeal of the staffing mandate might feel like a relief, but it’s actually a trap for the unprepared. Without a fixed ratio to hide behind, your clinical judgment is the only thing standing between you and a "Statement of Deficiencies." Don't let the lack of a mandate lead to a lack of a plan.
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January 2, 2026
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