In a press release issued March 23, 2020, “CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Healthcare Facility Inspections in light of COVID-19,” The Centers for Medicare & Medicaid Services (CMS) announced its findings from its inspection of the Kirkland, Washington nursing home where the first COVID-19 outbreak in the country occurred. The findings of federal and state surveyors – which include three Immediate Jeopardy-level citations – provided the foundation for a new Infection Control survey process. The findings included:
- Lack of identification and management of ill residents
- Prompt notification to the Washington Department of Health about an increasing rate of respiratory infection among residents
- Not having a plan in place that was sufficient to have access to a physician after the facility’s primary clinician became ill.
A March 20, 2020 QSO Memo released at the same time supersedes the information provided in the March 4, 2020 QSO Memo, “Suspension of Survey Activities.”
Prioritized Survey Types
Types of surveys that will prioritized and conducted:
- Complaint/ Facility-Reported Incident (FRI)bn
Surveys that are triaged at an Immediate Jeopardy Level. Regardless of the
IJ allegation, surveyors will conduct a streamlined Infection Control review as
- If a complaint/FRI is triaged at the IJ level,
State Survey Agencies (SSAs) are instructed to follow their normal P&P for
surveying that provider.
- If a survey was conducted under these circumstances but cited for non-compliance at a scope/severity other than IJ, a revisit survey will not be conducted. Providers can choose to delay submission of their Plan of Correction until the prioritization period is over.
- Non-IJ level complaints/FRIs will be entered into ASPEN and onsite surveys will not be conducted during the 3-week period. CMS will be providing guidance about the survey procedure related to these incidents in another memo.
- If a complaint/FRI is triaged at the IJ level, State Survey Agencies (SSAs) are instructed to follow their normal P&P for surveying that provider.
- Targeted Infection Control Surveys. Providers that have been identified through CMS’s collaboration with CDC and ASPR will have targeted Infection Control surveys conducted in their facilities. Surveyors will use a streamlined review checklist to minimize their impact on the provider’s activities, but will be ensuring that providers are actively protecting the health and safety of residents as it relates to COVID-19.
- Self–Assessments. Providers have been given the Infection Control Self-Assessment tool and this forms the basis of the Infection Control checklist that that surveyors will be using for Targeted Infection Control Surveys. While the QSO memo states that this tool is for “voluntary” self-assessment, the memo later states that the self-assessment may be requested by surveyors if an on-site investigation takes place.
What’s Not Authorized Currently
Survey types that are not authorized for the 3 week period:
- Standard surveys for:
- Nursing homes
- Home health agencies
- Intermediate care facilities for individuals with intellectual disabilities
- Revisits that are not associated with an IJ.
Enforcement Actions Suspended
Since revisits that are not associated with an IJ are currently not authorized, CMS has also suspended some enforcement actions. These include:
- Nursing Homes:
- Denial of Payment for New Admissions (DPNAs) is suspended currently
- This includes situations where facilities are not in substantial compliance at 3 months. This will allow for new admissions during this time period.
- Home Health Agencies:
- Suspension of Payments for New Admissions (SPNAs) following the last day of survey when termination has been imposed will be lifted to allow for new admissions during this time.
- Nursing Homes and Home Health Agencies:
- Per day Civil Money Penalty (CMP) accumulation is suspended
- Imposition of termination for facilities not in substantial compliance at 6 months is suspended
What Else to Know
- If an active case of COVID-19 is identified
in the facility while a surveyor is investigating an IJ complaint/FRI:
Surveyors will report the case to the SSA, the state health department and the
CMS Regional Office. These groups will decide what action to take.
- The Infection Control Survey Process can be used to investigate non-compliance and ensure that the provider is taking the necessary steps to minimize transmission of COVID-19 in the facility.
- Facilities that have been cited with IJ-level
deficiencies and surveyors have not verified that the IJ has been
removed will still have a revisit survey completed under normal processes to
verify that the IJ has been removed will occur.
- If the revisit shows continuing non-compliance, but at a scope/severity lower than an IJ, another on-site revisit survey will not occur. These providers may submit a Plan of Correction (POC) or delay submission of the POC until the prioritization period is over.
- Onsite surveys that were started before the prioritization period that do not meet the guidance provided will be ended. Surveyors are instructed to exit the facility.
Infection Control Information for Nursing Homes
CMS states in the QSO memo that it is including the Infection Control Survey that was developed by the CDC and CMS so that facilities know what the expectations are and what the latest practices that should be in place are. The Agency notes that it expects providers to use the process – as well as the latest guidance from the CDC – to perform a voluntary self-assessment of their organization’s ability to prevent the transmission of COVID-19.
Additionally, CMS provided the following reminders:
- Facilities must have a surveillance system in place that is designed to identify possible communicable diseases or infections before they can spread to other residents in a facility, and when and to whom these possible incidents should be reported.
- CDC recommends that nursing homes notify their
health department about:
- Residents with severe respiratory infection
- A cluster of respiratory illness (e.g. > or = 3 residents or health care practitioners with new on-set respiratory symptoms within 72 hours.
Healthcare Staff Access
CMS states in the memo that it is aware that nursing homes, assisted living facilities and other providers have put into place significant entry restrictions for staff from other providers who are providing direct care to their residents. CMS states that if staff members are appropriately wearing PPE and do not meet the criteria for restricted access, they should be allowed to enter the facility and provide services.
Length of Survey Prioritization
CMS states that it will continue to evaluate its prioritization of survey activities in areas with large numbers of COVID-19 cases to determine if this limited survey activity needs to continue past the current 3-week period. For instance, in the press release about the findings at the Kirkland facility, the Washington Health Department noted that their surveyors are focused on visiting all nursing homes in Washington state to ensure they are practicing proper infection control practices. Additionally, CMS notes that the CDC has provided them with information that 27 states have confirmed COVID-19 cases in nearly 150 nursing homes.
For More Information
- CMS Fact Sheet: Kirkland, Washington Update and Survey Prioritization Fact Sheet (3/23/2020)
- CMS Press Release: CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Healthcare Facility Inspections in light of COVID-19 (3/23/2020)
- CMS Administrator Seema Verma’s Remarks (as prepared for delivery): Updates on Healthcare Facility Inspections in light of COVID-19 (3/23/2020)
- CMS QSO Memo: “Prioritization of Survey Activities” (Ref: QSO-20-20-ALL) (3/23/2020) – This memo includes the Infection Control Survey Tool that will be used by surveyors.