In Part 1 of our post about the new actions the Centers for Medicare & Medicaid Services (CMS) will be taking to improve infection control compliance, we discussed some of the initial data findings from the new CDC mandatory reporting. We also explained how CMS has “encouraged” State Agencies to get their Focused Infection Control Surveys completed or otherwise potentially miss out on CARES Act funding. Now let’s take a look at what to expect on survey in the near-term, as well as the longer-term.
What Providers Should Expect on Survey Going Forward
First and foremost, if your facility has not had a Focused Infection Control Survey yet, expect one – and most likely before mid-summer since your State Agency will be trying to meet the compliance goal that CMS has set for surveying every facility in the country. CMS noted that States and CMS had completed Focused Infection Control Surveys of slightly more than half of nursing homes (53%), so that means there are many facilities still waiting for this survey. At the end of March, CMS released COVID-19 Focused Survey materials, including an updated Entrance Conference Worksheet. Those materials were updated on May 7, 2020 to include the reporting requirements (F884 and F885). Providers should ensure they have these materials since they differ from the LTCSP materials.
As mentioned in Part 1, facilities may also receive an on-site visit from surveyors if they meet certain criteria, either due to prior COVID cases or new cases that are identified through the data reported to CDC, so the emphasis on infection prevention and control is not going away anytime soon in nursing homes. The Government Accountability Office (GAO) recently found that infection control deficiencies were widespread in nursing homes prior to the COVID-19 epidemic, but also that surveyors rarely found any actual harm or IJ-level issues during inspections. Moving forward, infection prevention and control must remain a “high risk” area for monitoring in everyday management practices at nursing homes.
Do Those Abundant, Low-Level Infection Control Deficiencies Really Matter?
Since it is widely recognized that infection prevention and control is a broad area where providers have historically had problems with compliance, does history really matter? Well, unfortunately, with this new guidance, providers with poor infection control compliance history who are cited for infection control moving forward will be penalized more heavily than those who have a better survey history. CMS is impressing upon providers the need to improve their infection control practices across the board, stating in the QSO memo that COVID-19 “highlights the imperative that nursing home staff adhere” to basic infection control practice, and that due to lack of consistency in this area, even “low-level, isolated infection control citations” – such as proper hand washing and use of Personal Protective Equipment (PPE) – create a safety hazard for vulnerable nursing home residents.
Thus, the changes coming include enhanced enforcements and the use of Directed Plans of Correction, including the use of Root Cause Analysis, to ensure facilities can maintain systemic changes to create sustained compliance. Is this only for Immediate Jeopardy-level citations? No. Providers with prior infection control deficiencies, starting as low as Scope/Severity “D” will see remedies put into place if surveyors identify substantial non-compliance with an Infection Control regulation on surveys moving forward. All providers who are cited at a S/S of D or higher for Infection Control will be required to have a Directed Plan of Correction to address the issues identified in the citation. Providers with histories of Infection Control deficiencies, or those who receive new deficiencies cited at Actual Harm or Immediate Jeopardy levels will see increasing enforcement measures. (CMSCG Clients, please click here to request a simplified view of how these remedies could play out).
What About Survey During Phase 3 of Reopening?
When nursing homes enter Phase 3 of Reopening, that is when States will be transitioning to routine survey and certification activities. Currently, survey activities are limited to Focused Infection Control Surveys, Immediate Jeopardy investigations and Initial Certifications, as per CMS guidance. Expect complaint investigations that may have been outstanding to be conducted, surveys of Special Focus Facilities (SFFs)/SFF candidates, and recertification surveys for facilities that are greater than 15 months. The QSO memo, along with the information included in the Reopening Nursing Homes Recommendations, notes that there should be a prioritization for planning when conducting these more routine survey activities. That includes prioritizing nursing homes with a history of noncompliance or allegations of noncompliance in these areas:
- Abuse or neglect
- Infection Control
- Transfer or discharge violation requirements
- Sufficient Staffing
- Staff competency
- Other quality of care issues
For the moment, Infection Control-related surveys will be the dominant focus, but as many states move through their reopening processes relatively quickly, the return to “normal” survey & certification activities could be quicker than anticipated. Don’t take your eye off the ball when it comes to these other high-risk areas – the regulators haven’t.