Please Note: On January 5, 2021, this article was updated based on CMS’s recent revisions to QSO 20-31. Under the original QSO, onsite focused infection control surveys are required to start within three to five days of identifying a nursing facility with three or more new COVID-19 confirmed cases since a facility’s last NHSN report, or one confirmed resident case in a facility that was previously COVID-free. The updated QSO requires a nursing facility to also indicate other factors that may place residents’ health and safety at risk to be subject to a focused infection control survey, such as:
- Multiple weeks with new COVID-19 cases;
- Low staffing;
- Selection as a Special Focus Facility;
- Concern related to conducting outbreak testing; or
- Allegations or complaints which pose a risk for harm or Immediate Jeopardy (i.e., abuse or quality of care issues such as pressure ulcers, weight loss, depression, or decline in functioning).
The updated QSO specifies that the required focused infection control surveys cannot be associated with a recertification survey to count toward the required 20% (as of October 1, 2020, state survey agencies are required perform focused infection control surveys of 20% of all nursing facilities). The updated QSO also states that when conducting focused infection control surveys, surveyors should be alert to and investigate any concerns related to residents who have had a significant decline in their condition during the public health emergency (i.e., weight loss, mobility).
Finally, the updated QSO includes K-tag and F-tag Waiver Guides and a FAQ document that provides guidance to state survey agencies when conducting LTC standard recertification health surveys and emergency preparedness and life safety code surveys, which we encourage nursing facilities to review.
On June 1, 2020, the federal Centers for Medicare and Medicaid Services (CMS) issued QSO 20-31 on COVID-19 survey activities, CARES Act funding, and enhanced enforcement for infection control deficiencies. The memorandum was accompanied by the release of the nursing facility COVID-19 data collected through the NHSN LTCF Module to date. Highlights from the memorandum are as follows:
Infection Control Surveys and Funding
State survey agencies were required to complete 100% of their focused infection control surveys for nursing facilities by July 31, 2020, or to submit a corrective action plan for completion within 30 days.
New Survey Activities
State survey agencies must also conduct the following, or risk the loss of their CARES Act allocation by up to 5% annually:
- Survey within the month of June any nursing facility with a COVID-19 outbreak, which is defined as cumulative cases/bed capacity greater than 10%; cumulative confirmed cases plus suspected cases/bed capacity greater than 20%; or 10 or more COVID-19 deaths.
- Perform a focused infection control survey within three to five days of identification of any nursing facility with three or more new COVID-19 confirmed cases since thefacility’s last NHSN data report, or one confirmed case in a facility that was previously COVID-free. As of January 4, 2021, nursing facilities will also have to indicate other factors that may place residents’ health and safety at risk to be subject to a focused infection control survey, such as multiple weeks with new COVID-19 cases, low staffing, selection as a Special Focus Facility, concern related to conducting outbreak testing, or allegation or complaints which post a risk for harm or Immediate Jeopardy (i.e., abuse or quality of care issues such as pressure ulcers, weight loss, depression, decline in functioning). CMS will work with state survey agencies to identify facilities that meet this criteria. Facilities that meet this criteria do not need to re-surveyed if a focused infection control survey was conducted within the previous three weeks as a stand-alone focused infection control survey or as a part of a recertification survey.
- Starting October 1, 2020, perform focused infection control surveys of 20% of all nursing facilities based on state survey agency discretion or additional data that identifies facility or community risk. These surveys cannot be associated with a recertification survey to count toward the required 20%, although the focused infection control surveys conducted under the criteria outlined in the second bullet point above may count toward the required 20%.
The updated QSO also states that when conducting focused infection control surveys, surveyors should be alert to and investigate any concerns related to residents who have had a significant decline in their condition during the public health emergency (i.e., weight loss, mobility)
Phase 3 Surveys
Once a nursing facility has entered Phase 3 of CMS’s Nursing Home Reopening Recommendations, meaning no new facility-onset COVID-19 cases in the past 28 days, state survey agencies are authorized to expand survey activities beyond the current prioritization, such as complaint investigations that are triaged as Non-Immediate Jeopardy-High. These survey activities will apply to all provider and supplier types, and a state may begin these survey activities earlier at its discretion. Prioritization is to be based on the history or allegations of noncompliance with regard to abuse or neglect, infection control, violations of transfer or discharge requirements, insufficient staffing or competency, and other quality of care issues (i.e., falls, pressure ulcers).
Enhanced Enforcement for Infection Control Deficiencies
Finally, CMS expanded enforcement of infection control deficiencies, and any substantial non-compliance, meaning D or above, associated with infection control requirements at F880 will lead to the following enforcement remedies:
- Non-compliance for an infection control deficiency when none have been cited in the last year or on the last standard survey:
- Current non-compliance that is not widespread (Level D & E) – Directed Plan of Correction (POC)
- Current non-compliance that is widespread (Level F) – Directed POC, Discretionary Denial of Payment for New Admissions with 45 days to demonstrate compliance
- Non-compliance for infection control deficiencies cited once in the last year or on the last standard survey:
- Current non-compliance that is not widespread (Level D & E) – Directed POC, Discretionary Denial of Payment for New Admissions with 45 days to demonstrate compliance, Per Instance Civil Monetary Penalty (CMP) of up to $5,000
- Current non-compliance that is widespread (Level F) – Directed POC, Discretionary Denial of Payment for New Admissions with 45 days to demonstrate compliance, $10,000 Per Instance CMP
- Non-compliance that has been cited for infection control deficiencies twice or more in the last two years or twice since the second to last standard survey:
- Current non-compliance that is not widespread (Level D & E) – Directed POC, Discretionary Denial of Payment for New Admissions with 30 days to demonstrate compliance, $15,000 Per Instance CMP
- Current non-compliance that is widespread (Level F) – Directed POC, Discretionary Denial of Payment for New Admissions with 30 days to demonstrate compliance, $20,000 Per Instance CMP
- Current non-compliance at the Harm Level (Level G, H, I) regardless of past history – Directed POC, Discretionary Denial of Payment for New Admissions with 30 days to demonstrate compliance, CMP imposed at highest amount option within the appropriate range in the CMP analytic tool
- Current non-compliance at the Immediate Jeopardy Level (Level J, K, L) regardless of past history – In addition to the mandatory remedies of Temporary Manager or Termination, imposition of Directed POC, Discretionary Denial of Payment for New Admissions with 15 days to demonstrate compliance, CMP imposed at highest amount option within the appropriate range in the CMP analytic tool
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