Due to the COVID-19 pandemic, we have seen multiple changes. One change is the survey process. If you recall, on March 4, 2020, The Centers for Medicare and Medicaid Services (CM)S required states to focus surveys on infection control and then on March 23, 2020, CMS provided a tool to help with these efforts. In a June 1, 2020 memo, CMS announced an expansion plan and added measures to improve provider accountability and ongoing compliance of infection control practices. The memo reports that those states that have not completed 100% of the focused infection control nursing home surveys by July 31, 2020 will be required to submit a corrective action plan strategy to CMS for completion of the survey within 30 days. If after the 30 day period has expired, and if any subsequent 30 days extensions are needed to complete the 100% infection control surveys, there will be a reduction in their 2021 CARES Act allocation.
In addition to completing the focused infection control surveys of nursing homes, CMS is also requiring states to implement the following COVID-19 survey activities:
- “Perform on-site surveys (within 30 days of the June 1, 2020 memo) of nursing homes with previous COVID-19 outbreaks, defined as:
- Cumulative confirmed cases/bed capacity at 10% or greater; or
- Cumulative confirmed plus suspected cases/bed capacity at 20% or greater; or
- Ten or more deaths reported due to COVID-19.
- Perform on-site surveys (within three to five days of identification) of any nursing home with 3 or more new COVID-19 suspected and confirmed cases since the last National Healthcare Safety Network (NHSN) COVID-19 report, or 1 confirmed resident case in a facility that was previously COVID-free. State Survey Agencies are encouraged to communicate with their State Healthcare Associated Infection coordinators prior to initiating these surveys.
- Starting in FY 2021, perform annual focused infection control surveys of 20 percent of nursing homes based on state discretion or additional data that identifies facility and community risks.
States that fail to perform these survey activities timely and completely could forfeit up to 5% of their CARES Act Allocation, annually.”
For facilities who consistently perform poorly on infection control measures could face fines ranging from $5,000 up to $20,000 depending on how poorly they perform.
CMS followed up with another memo on June 4, 2020 informing facilities that the health inspection results conducted on or after March 4, 2020 were now being reported on Nursing Home Compare. These results are from “inspections related to complaints and facility-reported incidents that were triaged at the Immediate Jeopardy (IJ) level, and the streamlined infection control inspection process”.
What can you do for a successful infection control survey? Here are some considerations:
- Implement and following CDC recommendations;
- Ensure staff follow your facility infection prevention practices;
- Consider designating an Infection Preventionist at your facility.
Functional Pathways is here to support you! Our RN Clinical Reimbursement Specialist, Verona Bair is a Nursing Home Infection Preventionist through the CDC. If you would like to consult with Verona Bair on Infection Control, please contact firstname.lastname@example.org for more information.
Gina Elkins, Director of Compliance and Regulatory Strategy