By Maria Arellano, MS, RN, RAC-CT
CMS’s rapid fire memos on COVID-19 over the last two weeks surely leave many facility staff confused and overwhelmed. Finding time to sit, read and interpret these memos may be rare so here’s what you need to know. If you’re in your survey window right now, CMS may be giving you some much needed breathing room if you do not land in one of the priority categories.
March 4 CMS Memo Suspending Non-Emergency Surveys
On March 4th, CMS released a memo suspending non-emergency surveys across the country, allowing surveyors to focus on the most serious health and safety threats, such as infections and abuse.
Effective immediately, the survey activity was limited to the following:
- All immediate jeopardy complaints (cases that represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death or harm) and allegations of abuse and neglect;
- Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses;
- Statutorily required recertification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities);
- Any re-visits necessary to resolve current enforcement actions;
- Initial certifications;
- Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years;
- Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy.
March 23 CMS Memo Revisions
On March 23rd, CMS released another memo that revised their COVID-19 survey strategy for the next 3 weeks to focus on facilities that meet the following criteria:
- Complaint/facility-reported incident surveys triaged at IJ level, and
- Targeted Infection Control Surveys in key states, currently CA, NY, and WA, but others may be added as cases rise.
The March 23rd memo revises the March 4th memo for the next three weeks only and allows health care providers time to implement the most recent infection control guidance from both CMS and the Centers for Disease Control and Prevention (CDC). During this three-week timeframe, state survey agencies (SSAs) and CMS surveyors will prioritize and conduct surveys (including revisit surveys) related to complaints and facility reported incidents (FRIs) that are triaged at the Immediate Jeopardy (IJ) level, for all allegations, in addition to a review with a Focused Infection Control survey.
COVID-19 Focused Survey Document
The Critical Element pathway for the COVID-19 Focused Survey was also provided. This tool offers facilities full visibility into the Focused Survey to understand CMS’s expectations for an infection prevention and control program during the COVID-19 pandemic. CMS expects facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. This document may be requested by surveyors if an onsite investigation takes place. CMS also encourages nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Seema Verma, CMS administrator, suggested that nursing home residents and their families should ask about the results of this self-assessment to ensure the facility is safe.
5 Ways to Prepare for Potential Survey
- Review your survey history to assess your risk for a prioritized survey.
- Any Immediate Jeopardy deficiencies in F880, F881, F882, or F883 on a standard or complaint survey?
- Any recent complaints of abuse or facility reported incidents that could rise to an immediate jeopardy level?
- Any repeat deficiencies in the last 3 surveys for infection control at a lower scope and severity?
- Complete the Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings. Document your findings and include any action plans to resolve them.
- Review the CMS COVID-19 Focused Survey Checklist with the full department leadership team to identify weaknesses and support your survey readiness strategy.
- Monitor the CDC website daily as well as the CMS Coronavirus Updates for changes.
- Be ready for residents, families and others to request the results of your self-assessments.
If you are at risk for a survey either by survey history or geographical location, completing these checklists and developing comprehensive action plans can go a long way in demonstrating your commitment to quality of care and safety for your residents and your proactive efforts may actually save you a deficiency or two.
Maria Arellano, MS, RN, RAC-CT
Senior Healthcare Specialist, PointRight
Maria has over 35 years’ experience as a registered nurse in the post-acute industry. Maria has served in a variety of roles directly in or supporting the long-term post-acute care sector including staff development, director of nursing and corporate consultant where she demonstrated regulatory excellence and exemplary quality outcomes. Previously she was a nursing home quality specialist with a quality improvement organization (QIO) and worked to enhance the quality of care for residents. Maria participated on CMS Technical Expert Panels as well as various committees and advisory boards throughout her career. She is focused on quality improvement, which fuels her passion for transforming data into knowledge and actionable insights.