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COVID-19 Focused Survey Entrance Conference Worksheet & Materials

Please be advised that as part of the Centers for Medicare & Medicaid Services (CMS) Infection Control Focused Survey process, updated surveyor resources have been published. There is a different Entrance Conference Worksheet that will be used for the focused surveys.

The Entrance Conference Worksheet for the COVID-19 Survey now requests the following information, and asks that surveyors be flexible in receiving information within these timeframes based on what is occurring in the facility. Surveyors are instructed to not require these materials to be provided within the specific timeframes if there are critical activities underway to prevent COVID-19 transmission in the facility.

  • Immediately Upon Entrance to the Facility:
    • Census #
    • Alphabetized list of all residents and their room numbers. Any resident who is out of the facility should be noted
    • List of residents who are confirmed OR presumed positive for COVID-19
    • Name of staff member responsible for Infection Prevention and Control Program
  • Within 1 Hour of Entrance:
    • Actual working schedules for licensed and registered nursing staff for the survey timeframe
    • List of key personnel, locations and phone numbers. Any contract staff should be noted.
    • Access to all electronic health records
      • Surveyors are supposed to ensure that as much offsite record review as possible can be completed to limit potential exposure or transmission. This includes EHR if it can be reviewed remotely. If remote access is not available, surveyors will request photocopies. If photocopies need to be made, the Entrance Conference Worksheet states that surveyors can make the copies instead of facility staff. Per the COVID-19 Focused Survey Protocol, surveyors are limited to making copies only of records necessary to confirm noncompliance or to support findings of a deficient practice.
    • Facility Policies and Procedures:
      • Infection Prevention and Control Program P&P, including the facility’s Surveillance Plan
      • Emergency Preparedness P&P, including Emergency Staffing Strategies

Electronic Health Record Information

The Entrance Conference Worksheet requests that surveyors are provided with EHR access and have the ability to view the following information:

  • Infections
  • Hospitalizations
  • Change in Condition
  • Medications
  • Diagnoses

Review the COVID-19 Focused Survey Materials here (.zip file).

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