On March 20, 2020, the Centers for Medicare and Medicaid Services (CMS) issued an order suspending standard healthcare facility surveys for a period of three weeks (“the prioritization period”). The only surveys that will be conducted during the prioritization period are surveys related to complaints and facility-reported incidents (FRIs) that are triaged at the immediate jeopardy level or targeted COVID-19 infection control surveys. With respect to laboratories regulated under the Clinical Laboratory Improvement Amendments (CLIA), CMS intends to prioritize immediate jeopardy situations over recertification surveys. New laboratory certification surveys will continue in order to increase health care capacity.
CMS considers immediate jeopardy-level complaints and incidents to involve situations where entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. State survey agencies are to follow standard protocols for triaging immediate jeopardy complaints. All non-immediate jeopardy complaints will be tracked, but no onsite surveys will be conducted during the prioritization period. CMS will issue further guidance regarding how non-immediate jeopardy complaints will be addressed in the future.
Targeted surveys designed to assess COVID-19 infection control include two different targeted surveys, one for nursing homes and one for all other acute and continuing care centers. In nursing homes, surveyors will review for: (1) overall effectiveness of the Infection Prevention and Control Program (IPCP), including IPCP policies and procedures; (2) standard and transmission-based precautions; (3) quality of resident care practices, including those with COVID-19 laboratory-positive case, if applicable; (4) the surveillance plan; (5) visitor entry and facility screening practices; (6) education, monitoring and screening practices of staff; and (7) facility policies and procedures to address staffing issues during emergencies, such as transmission of COVID-19. The targeted survey for all other facilities is similar with additional requirements for patient care and hospital-specific risks.
Facility administrators should review the applicable targeted infection surveys and ensure that they are in compliance with the requirements. Even if formal infection surveys are not scheduled, CMS expects facilities to perform voluntary self-assessments of their ability to prevent the transmission of COVID-19. Administrators should consider performing self-assessments consistent with the published targeted survey criteria.
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