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CMS Updates Focused Infection Control Survey

On Jan. 4th, the Centers for Medicare and Medicaid Services (CMS) revised previously issued memorandum QSO 20-31-All to reflect changes to the triggers for a Focused Infection Control (FIC) survey. In addition, CMS provided additional guidance on survey and enforcement protocols and included Frequently Asked Questions (FAQs) that addressed a number of survey-related questions. The highlights are as follows:

FIC surveys will be triggered by the following new criteria:

  • Multiple weeks with new COVID-19 cases;
  • Low staffing;
  • Selection as a Special Focus Facility;
  • Concerns related to conducting outbreak testing per CMS requirements; or
  • Allegations or complaints that pose a risk of harm or immediate jeopardy to the health or safety of residents that are related to certain areas such as abuse or quality of care (e.g., pressure ulcers, weight loss, depression, decline in functioning).

In order to trigger an FIC survey, nursing homes must meet one of the original case criteria (three or more new cases or one new resident case), plus at least one of the new criteria. CMS will assist state survey agencies (SSAs) in identifying nursing homes that meet the above criteria. SSAs must initiate survey within three to five days of identification and should coordinate with the state Healthcare Associated Infection (HAI) coordinators prior to initiating survey.

CMS had previously mandated that at least 20 percent of facilities receive an FIC survey during Fiscal Year (FY) 2021. They have clarified that these will be stand-alone surveys. While an FIC survey may be performed during a recertification survey, that survey will not count in the 20 percent requirement.

Enforcement remedies, previously outlined, when deficiencies are identified during an FIC survey remain in effect. At a minimum, any citation, regardless of scope and severity, will have a Directed Plan of Correction (DPOC) imposed. Previous infection control citations or citations at a higher scope and severity will result in imposition of a Civil Money Penalty (CMP) or Denial of Payment for New Admissions (DOPNA).

With regard to on-site surveys, including health inspections, Emergency Preparedness, and Life Safety Code inspections, CMS indicates that they will be conducted regardless of a nursing home’s outbreak status. Surveyors should arrive on site equipped with the personal protective equipment (PPE) they will need to complete survey activities.

In the event of active confirmed or suspected cases within the nursing home, one surveyor will be assigned to the COVID-positive unit. This surveyor will survey only on the COVID-positive unit and will have no in-person contact with other survey team members. Communications will be conducted through alternative means, including electronic communication or virtual conference. Activities such as dining observation or Resident Council interviews will be adjusted to prevent further COVID-19 transmission. Emergency Preparedness and Life Safety Code survey activities, such as the facility tour and smoke/fire barrier inspections, may also be adjusted to accommodate appropriate infection control practices.

The FAQs provided are extensive and cover such issues as surveyor testing and screening as well as the survey process for activities such as Resident Council interviews, entrance and exit conferences, and dining observation. Also included is guidance related to 1135 waivers.

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