Skilled Nursing Facilities: Compliance Lessons from Kirkland, Washington

On March 23, 2020, Centers for Medicare & Medicaid Services (“CMS”) announced the preliminary results of a recent survey of a nursing home in Kirkland, Washington, the epicenter of the COVID-19 outbreak in Washington. According to a Centers for Disease Control and Prevention (“CDC”) report, 81 residents, 34 staff and 14 visitors also became ill at the facility. Tragically, 26 people have lost their lives. As of March 23, 2020, according to CDC data, 147 nursing homes across 27 states have at least one resident with COVID-19.

The CDC’s report identified that health care personnel with confirmed COVID-19 included the following occupations at the facility: physical therapist, occupational therapist assistant, environmental care worker, nurse, certified nursing assistant, health information officer, physician and case manager.

Kirkland, Washington Inspection

On March 16, 2020, CMS and the Washington Department of Social & Health Services (“WDH”), as the designated State Survey Agency concluded a survey of the facility at the center of the COVID-19 situation in Washington. Two federal surveyors conducted the onsite survey, including observations of patient care, while WDH staff assisted offsite by reviewing documents. The surveyors found three immediate jeopardy situations, which are situations in which a resident’s safety is placed in imminent danger:

The facility failed to rapidly identify and manage ill residents.
The facility failed to notify the Washington Department of Health about the increasing rate of respiratory infection among residents.
The facility failed to possess a sufficient backup plan following the absence of the facility’s primary clinician, who fell ill.

Information received from the survey visits identified factors that likely contributed to the vulnerability of the facility, including:

Staff members who worked while symptomatic;
Staff members who worked in more than one facility;
Inadequate familiarity and adherence to standard, droplet and contact precautions and eye protection recommendations;
Challenges to implementing infection control practices including inadequate supplies of personal protective equipment and other items (e.g., alcohol-based hand sanitizer); and
Delayed recognition of cases because of low index of suspicion, limited testing availability and difficulty identifying persons with COVID-19 based on signs and symptoms alone.

Based on the deficiencies found in Kirkland, on March 18, 2020, CMS notified the facility of its intent to terminate its participation in federal health programs within 23 days unless it remedies the immediate danger to residents. CMS required the facility to provide CMS with a plan to remove those urgent problems. CMS will also perform an unannounced survey soon to verify residents are no longer at immediate risk.

1) Failure to rapidly identify and manage ill residents.

The surveyors found that the facility failed to rapidly identify and manage ill residents.

It is likely that this survey resulted in facilities being urged by CMS in a recent memo to promptly detect, triage and isolate potentially infectious residents are essential to prevent unnecessary exposures among residents, health care personnel and visitors at the facility. Accordingly, facilities should continue to be vigilant in identifying any possible infected individuals. Facilities should consider frequent monitoring for potential symptoms of respiratory infection as needed throughout the day. Furthermore, we encourage facilities to take advantage of resources that have been made available by the CDC and CMS to train and prepare staff to improve infection control and prevention practices. Lastly, facilities should maintain a person-centered approach to care. This includes communicating effectively with residents, resident representatives and/or their family, and understanding their individual needs and goals of care.

2) Failure to notify the Washington Department of Health about the increasing rate of respiratory infection among residents.

CMS has recommended that facilities with residents suspected of having COVID-19 infection should contact their local health department. Residents infected with COVID-19 may vary in severity from lack of symptoms to mild or severe symptoms or fatality. Initially, symptoms may be mild and not require transfer to a hospital as long as the facility can follow the infection prevention and control practices recommended by the CDC.

3) Failure to notify state Department of Health about the increasing rate of respiratory infection among residents.

CMS has also urged facilities experiencing an increased number of respiratory illnesses (regardless of suspected etiology) among patients/residents or health care personnel should immediately contact their local or state health department for further guidance.

Resolution in Kirkland, Washington

In Washington, local and state authorities implemented comprehensive prevention measures for long-term care facilities that included:

Implementation of symptom screening and restriction policies for visitors and nonessential personnel; active screening of health care personnel, including measurement and documentation of body temperature and ascertainment of respiratory symptoms to identify and exclude symptomatic workers;
Symptom monitoring of residents;
Social distancing, including restricting resident movement and group activities;
Staff training on infection control and PPE use; and
Establishment of plans to address local PPE shortages, including county and state coordination of supply chains and stockpile releases to meet needs.

CMS Focused Inspection Process

CMS also announced its enhanced, focused inspection process, using the lessons learned at Kirkland, Washington, and to be used across the country and will focus on:

Complaint inspections that are triaged at the Immediate Jeopardy level.
Targeted Infection Control inspections of providers identified through CMS collaboration with the CDC.
The Infection Control checklist referenced above will also be shared with providers and suppliers, to allow for self-assessment of their Infection Control plans.

This new focused inspection process includes existing components of CMS’s infection control inspection process but adds actions based on the latest guidance from the CDC and CMS.

COVID-19 Focused Survey for Nursing Homes – Facility Self-Assessment Tool

The CMS focused inspection process includes a self-assessment tool for providers to employ. CMS also encourages residents and families to join CMS in being proactive about facility safety. Residents and families should ask facility staff how the facility performed on its self-assessment. The tool covers:

Infection Prevention and Control Programs
Standard and Transmission Based Precautions
Resident Care
Infection Surveillance Plan
Visitor Screening and Entry
Education, Monitoring and Screening of Staff
Staffing During Emergencies

Next Actions: Policy and Practice Reviews Needed

SNFs should carefully review and revise their symptom screening and restriction policies for visitors and nonessential personnel; active screening of health care personnel to incorporate these recommendations.
SNFs should implement the use of the CMS COVID-19 self-screening tool.
SNFs should watch for additional updates from CMS and/or the CDC as the COVID-19 situation unfolds.

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