CMS Updates Surveyor Guidance – 5 New Factors Could Trigger a Focused Infection Control Survey

On January 4, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a revised QSO Memo, “Revised COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality Improvement Activities in Nursing Homes.” The QSO Memo was originally issued on June 1, 2020 and now includes updates to the COVID-19 Survey Activities section of the document.

The Memo includes clear instances that will trigger a Focused Infection Control Survey (FICS) along with timeframes for when the survey should begin. These include:

Performing an on-site Focused Infection Control Survey:

  • When cumulative confirmed cases/bed capacity at 10% or greater
  • When cumulative confirmed cases/bed capacity at 20% or greater
  • Ten or more deaths reported due to COVID-19

This information is consistent with the prior version of the QSO Memo, although adds in “within 30 days of June 1, 2020,” to the information.

Additionally, an on-site Focused Infection Control Survey must occur within 3-5 days of identification of any nursing home:

  • With 3 or more new COVID-19 confirmed cases since the last NHSN COVID-19 Report
  • 1 confirmed resident case in a facility that was previously COVID-free

Additional Triggers

CMS has identified five additional factors that may potentially place a nursing home’s residents’ health and safety at risk and these factors have been added as triggers that may require an on-site Focused Infection Control Survey within 3-5 days of identification. The QSO Memo notes that CMS will work with State Agencies to identify facilities that meet these criteria and to ensure the survey is started quickly. The added factors include:

  1. Low staffing levels
  2. Multiple weeks with new COVID-19 cases
  3. Concerns related to conducting outbreak testing in accordance with CMS requirements
  4. Allegations or complaints that pose a risk for harm or Immediate Jeopardy, such as with abuse or a quality of care concern, including weight loss, decline in function, depression and/or pressure ulcers)
  5. Designation as a Special Focus Facility (SFF)

As CMS collects more and more data from providers, it gets easier for them to flag a facility that meets these criteria, so it is not surprising that the Agency is taking a data-driven approach to survey & certification.

Exception to the Triggers

The QSO Memo also outlines one instance where facilities that have met the criteria to trigger a focused survey may not need one. This includes:

  • If a Focused Infection Control Survey was conducted within the previous three weeks. The Focused Survey may have been conducted as a stand-alone survey or as part of a recertification survey.

What to Expect for 2021

The QSO Memo also states that beginning in FY 2021, State Survey Agencies are expected to perform annual Focused Infection Control Surveys of 20 percent of facilities in the State. The facilities selected can be based on the State’s discretion or through additional data that identifies facilities and community risks. Surveys that have been triggered by the above-mentioned criteria may count as part of a State’s twenty percent. These surveys must be conducted as stand-alone surveys in order to fulfill the 20 percent requirement, so providers should anticipate the continued likelihood that they may receive a Focused Infection Control Survey either separately or combined with a recertification survey since State Agencies are expected to conduct both. If a State does not perform these surveys in a timely manner, it could forfeit up to 5% of its CARES Act allocation annually.

So, will these surveys just be “focused” on Infection Control issues? No, of course not. When conducting a Focused Survey, surveyors continue to be instructed to investigate any concerns related to residents who have experienced a significant decline in their condition during the PHE.

Frequently Asked Questions

In the Memo, CMS references the Frequently Asked Questions (FAQ) document that it added into the Survey Resources file on January 4, 2021. If you missed the updated information, you can find the link here.

Read the revised CMS QSO Memo (Ref: QSO-20-31-ALL) here.


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