Recently, the Quality, Safety & Oversight Group at the Centers for Medicare & Medicaid Services (“CMS”) issued a memorandum entitled “Revised COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality Improvement Activities in Nursing Homes” (the “Memorandum”) that details new triggers and criteria for focused infection control surveys for nursing homes.
For this article, “nursing homes” refers to skilled nursing facilities (often known as “SNFs”) for Medicare and nursing facilities (often known as “NFs”) for Medicaid.
June 2020 Memo
In June 2020, CMS originally released this Memorandum and detailed a new survey plan for state survey agencies that included a requirement that states perform on-site surveys of nursing homes with several instances of COVID-19 outbreaks. Specifically, CMS called for infection control focused surveys to be initiated within three to five days of identification for nursing homes that report three or more new COVID-19 cases in the past week or one new resident case in a nursing home that was previously without COVID‑19 cases. The June 2020 memorandum also required states to perform on-site surveys (within three to five days of identification) of any nursing home with new COVID-19 suspected and confirmed cases.
At that time, CMS also announced it was implementing more directed plans of correction and fines for substantial non-compliance with any deficiency associated with infection control requirements.
Recast of Criteria That Generate Infection Control Surveys
In the recent revision of the Memorandum, CMS added several additional health and safety risk criteria that will trigger a focused infection control survey.
As a result, to generate an infection control focused survey, nursing homes must meet one of the original case criterion: (a) three or more new COVID-19 cases; or (b) one new resident COVID‑19 case and at least one of the following new factors:
- Multiple weeks with new COVID-19 cases.
- Low staffing.
- Selection as a Special Focus Facility under Section 1819(f)(8)(B) of the Social Security Act.
- Concerns related to conducting outbreak testing per CMS requirements.
- Allegations or complaints that pose a risk of harm or immediate jeopardy to the health or safety or that are related to certain areas such as abuse or quality of care (e.g. pressure ulcers, weight loss, depression, decline in functioning).
CMS has committed to coordinate and work with State Survey Agencies to identify nursing homes that satisfy these requirements and meet the above criteria, and the infection control focused survey must start within three to five days of identification.
Some Exceptions
Nursing homes that meet the criteria above to trigger an infection control focused survey do not need to be re-surveyed if an infection control focused survey was conducted (as a stand-alone infection control focused survey or as part of a recertification survey) within the previous three weeks. For example, if a nursing home is surveyed with an infection control focused survey within three to five days after meeting the criteria, and the same nursing home meets the criteria for being surveyed within three to five days in any of the next three weeks, the survey team does not need to conduct another survey within those three weeks. However, if the nursing home meets the criteria for a survey in the fourth week after an infection control focused survey was conducted, an additional infection control focused survey must be conducted within three to five days.
Surveyors to Take Note of Declines in Weight and Mobility During the Public Health Emergency
In the Memorandum, CMS directs surveyors to be alert to and investigate any concerns related to residents who have had a significant decline in their condition (e.g., weight loss, mobility) during the public health emergency, when conducting an infection control focused survey.
Frequently Asked Questions on Resumption of Survey Activities
The updated Memorandum includes a new section with several frequently asked questions. CMS had received questions from nursing homes as well as Federal and State Surveyors related to the resumption of survey activities. CMS uses the frequently asked questions to address questions on nursing home surveys, Emergency Preparedness surveys and Life Safety Code surveys, along with a Guide to Waived F-Tags and K-Tags.
Protocols for Surveyors and Recommendations When There Are Active COVID-19 Cases in the Nursing Home
The frequently asked questions address infection control safety protocols for surveyors, including that all surveyors should wear appropriate PPE and adhere to the practices for COVID-19 infection prevention (e.g., social distancing, hand hygiene, etc.) while on‑site and adhere to any health-related screening protocols before entering a nursing home, including temperature checks and noting any potential signs or symptoms of infection.
The frequently asked questions also address that, in the event of active confirmed cases within the nursing home, one surveyor should be assigned to COVID-19 positive residents only. CMS also recommends that a different surveyor be assigned to the COVID-19 suspected residents or those residents under observation. CMS also recommends that the surveyor that is assigned to the COVID-19 unit should stay on that unit for the entire survey while completing the investigation and tasks specific to that unit.
In situations where there is only one surveyor conducting the survey (e.g., complaint), to the extent possible, the surveyor should begin the survey activity in an area with negative residents and not return to that area once positive residents have been encountered.
If a surveyor is restricted to a specific area of the building (e.g., because of cohorting), the surveyor should not physically meet with any other survey team member. The surveyor should meet virtually (on the surveyor’s own) with the team throughout the survey. In such case, the team will have to retrieve that surveyor’s data securely (e.g., through email). The purpose of this is to ensure that surveyors who have been surveying on a COVID-19 positive or suspected positive unit do not also survey or make contact with persons on a non-COVID-19 unit.
Next Actions
- Nursing homes should carefully monitor the new criteria that will generate an infection control focused survey and be ready for those to occur if the nursing home meets the triggering criteria.
- Nursing homes should keep the frequently asked questions at the ready to review with surveyors to address ways to minimize COVID-19 exposure and spread that may result from the survey activities.
- If a survey occurs, nursing homes should expect the flow of the survey to work from COVID-19 negative residents to COVID-19 positive residents or for a surveyor to be dedicated to COVID-19 negative residents.
If you have questions or would like assistance with this topic, please contact:
- Sean Fahey at (317) 977-1472 or sfahey@wp.hallrender.com;
- Todd Selby at (317) 977-1440 or tselby@wp.hallrender.com;
- Brian Jent at (317) 977-1402 or bjent@wp.hallrender.com; or
- Your primary Hall Render contact.
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