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Survey Changes on the Way

On Nov. 12, 2021, the Centers for Medicare and Medicaid Services (CMS) issued memorandum QSO-22-02-ALL outlining a number of changes to both the Focused Infection Control (FIC) survey and recertification survey process. The QSO also highlights some areas that surveyors have been directed to focus on as recertification surveys resume.

FIC Surveys

CMS will no longer require FIC surveys to be conducted within three to five days of a nursing home having three or more new COVID-19 confirmed cases, or one confirmed resident case in a facility that was previously COVID-19-free. However, each survey agency (SA) must continue to perform annual FIC surveys of 20 percent of nursing homes. To count toward the required 20 percent, these FIC surveys must be stand-alone surveys not associated with a recertification survey; the FIC survey may be combined with a complaint survey.

Recertification Surveys

SAs conduct unannounced standard recertification surveys, which provide a comprehensive review of the quality of care furnished in a facility. For long term care facilities, these recertification surveys must be conducted no later than 15 months after the previous recertification survey, with a statewide average interval of 12 months or less. At this time, CMS believes that SAs should be able to resume recertification surveys on a regular basis and should do so by establishing new intervals based on each facility’s next survey, not based on the last survey that was conducted prior to the COVID-19 Public Health Emergency (PHE). Prioritization of nursing home surveys should be based on the following considerations:

  • Abuse or neglect;
  • Infection control;
  • Violations of transfer or discharge requirements;
  • Insufficient staffing or competency;
  • Special Focus Facilities (SFFs) and SFF candidates; and/or
  • Other quality-of-care issues (e.g., falls, pressure ulcers).

In addition, some mandatory survey tasks are being made discretionary (on a temporary basis) unless offsite or onsite information or observation warrant that they be completed. Those tasks are as follows:

  • Resident Council Meeting: Surveyors interview up to 40 residents in the initial pool depending on facility census (see Attachment A of the Long Term Care Survey Process (LTCSP) Procedure Guide). If concerns are identified through these interviews (e.g., concerns with visitation or grievances), the survey team should proceed with conducting this task.
  • Dining Observation Task: This task may be discretionary except it must be completed if a resident is being investigated for nutrition, weight loss, or concerns identified related to dialysis.
  • Medication Storage: This task may be discretionary except it must be completed if the surveyor identified concerns with medication storage when completing the mandatory task of medication administration observation.

The guidance outlines that backlogged complaints depending on certain circumstances may be investigated as part of a recertification survey or may be investigated as a complaint survey. Adding additional individuals to the recertification survey may require additional surveyors or more time to complete the survey. Batching a number of complaints to be looked at in a separate complaint survey may be helpful in situations where there is a high volume of open complaints.

Lastly, CMS plans to increase oversight in certain care-related areas. According to CMS, throughout the COVID-19 PHE, CMS and SAs have been unable to have the traditional level of visibility inside nursing homes to assess residents’ health and safety and survey for facilities’ compliance. Due to the limitations of oversight during the PHE and changes in how some nursing homes may have operated, CMS is very concerned about how residents’ health and safety has been impacted, such as increased weight loss, pressure ulcers, abuse or neglect, and other quality-of-care and quality-of-life issues. Surveyors should be aware that these may be potential areas for further investigation during the survey, such as the following:

  • Surveying for Nurse Competency (licensed nursing staff and certified nursing assistants (CNAs)): CMS is concerned that the lack of competency may have resulted in the failure to identify potential issues early, so interventions can be applied to prevent a condition from worsening or becoming acute. Without these competencies, residents may experience a decline in health status, function, or need to be transferred to a hospital.
  • Inappropriate Use of Antipsychotic Medication: SAs should continue to focus their efforts on identifying the inappropriate use of antipsychotic medications and emphasize non-pharmacologic approaches and person-centered care practices.
  • Identifying Areas of Concern: Surveyors should assess other care areas where residents’ health and safety may be at increased risk, such as unplanned weight loss, loss of function/mobility, depression, abuse/neglect, or pressure ulcers. SAs should use the appropriate critical element pathways to thoroughly investigate these areas to ensure that any noncompliance is identified and subsequently corrected.

The guidance is effective immediately.

Contact: Elliott Frost, efrost@leadingageny.org, 518-441-8761