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COVID-19 Focused Survey Updated to Include Reporting Requirements

In a May 6, 2020 QSO Memo, the Centers for Medicare & Medicaid Services (CMS) announced that it has updated the COVID-19 Focused Survey for Nursing Homes. The updated materials include the following changes:

Entrance Conference Worksheet

  • #9 – Updated to include list of staff responsible for notifying all residents, representatives and families of confirmed or suspected COVID-19 cases in the facility.
  • #13 (new) – Asks for facility’s mechanism(s) used to inform these parties of confirmed/suspected COVID-19 activity in the facility and what mitigating actions the facility has taken to prevent or reduce the risk of transmission, including if normal facility operations will be altered.
    • If the resident or representative has to obtain the information themselves, such as via the facility website or a phone number with a recorded message, the information that the facility has provided to these individuals on how to access the information should be included in this section of the worksheet.

COVID-19 Focused Survey Protocol

  • Information has been added to state that data used to determine compliance at F884 is only available for use by CMS Federal Surveyors.
  • As part of the On-Site Survey Activities, surveyors are now also expected to conduct interviews with relevant staff who are responsible for providing information on COVID-19 activity in the facility to residents/representatives and family members. Surveyors are able to identify interviews that can be conducted via phone offsite and complete those interviews that way.

COVID-19 Focused Survey for Nursing Homes

  • Critical Element #7 Reporting to Residents, Representatives and Families has been added to identify potential non-compliance with new Ftag F885.
  • Critical Element #8 Reporting to the Centers for Disease Control and Prevention (CDC) has been added. This CE will only be used during office reviews by CMS Federal Surveyors. If noncompliance with reporting requirements is identified, facilities can be cited with a new Ftag, F884.

Summary of the COVID-19 Focused Survey for Nursing Homes

The summary document outlines all of the changes listed above.

All of these materials can be found as a folder within the Survey Resources – Updated 05/07/2020 .zip file on the CM Nursing Homes webpage.


Does your nursing home need COVID-19 support services from CMS Compliance Group? Please view the following information to see our on-site and off-site consulting services for compliance and quality concerns.

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