The Centers for Medicare and Medicaid Services (CMS) issued a memorandum to State Survey Agency Directors that provides further guidance regarding survey priorities for health care facilities, providers, and clinical laboratories due to COVID-19 and other respiratory illnesses.

The Centers for Medicare and Medicaid Services (CMS) issued a memorandum on March 20, 2020, to State Survey Agency Directors that provides further guidance regarding survey priorities for health care facilities, providers, and clinical laboratories due to COVID-19 and other respiratory illnesses.

This memorandum supersedes CMS’ March 4, 2020 announcement regarding its temporary suspension of non-emergency inspections, and applies to “all certified provider and supplier types” for three weeks, beginning March 20, 2020. The memorandum details CMS’s prioritization and suspension of certain inspections, the delaying of certain revisit surveys, and discretion with enforcement.

Inspections and Surveys Limited

For the three-week time period, only the following types of inspections and surveys will be conducted:

• State Survey Agencies (SSAs) will conduct surveys and revisits for complaints and Facility-Reported Incidents (FRIs) at the Immediate Jeopardy (IJ) level.
• Federal CMS surveyors and SSAs will conduct Infection Control surveys and revisits of facilities in areas that most need oversight, which will be identified collaboratively with the Centers for Disease Control and Prevention (CDC) and the Department of Health and Human Services Assistant Secretary for Preparedness and Response (ASPR).

Surveyors Will Wear Personal Protective Equipment; Survey Tools Designed to Target Critical Elements Linked to COVID-19 Transmission And Limit Disruption

Surveyors are required to conduct surveys wearing the CDC-recommended personal protective equipment and will be utilizing the Focused Infection Control Survey tools attached to the memorandum. The COVID-19 Focused Infection Control Survey: Acute and Continuing Care generally applies to any healthcare setting, and the COVID-19 Focused Survey for Nursing Homes applies to nursing homes specifically. The survey tools were designed to target critical elements linked to COVID-19 transmission in order to protect the health and safety of providers, patients, and staff, while minimizing the effect on providers to avoid disrupting their COVID-19 treatment and prevention efforts.

Nursing Homes Must Perform Self-Assessments; Surveyors May Investigate Additional Concerns

Significantly, nursing home providers are expected to perform self-assessments using the COVID-19 Focused Survey for Nursing Homes tool, which surveyors may request from nursing homes in the case of an onsite inspection. Additionally, surveyors may investigate concerns related to other requirements according to existing guidance in the State Operations Manual (SOM) and related survey instructions, including Emergency Preparedness concerns under Appendix Z of the SOM.

Other Providers May Perform Voluntary Self-Assessments Utilizing a Streamlined Infection Control Checklist

A streamlined Infection Control checklist for surveyors will be utilized during this time period. This checklist is included in the memorandum and is available to providers and suppliers who may choose to conduct voluntary infection control self-assessments.

Most Survey Types and Enforcement Actions Suspended; Immediate Jeopardy Surveys and Enforcement Actions Will Proceed

During the three-week period, CMS has indicated that the following types of surveys will not be conducted by CMS or state survey agencies:

• Standard surveys for long term care facilities, hospitals, home health agencies, intermediate care facilities for individuals with intellectual disabilities, and hospices. This includes life safety code and Emergency Preparedness elements of standard surveys.
• Revisit surveys without IJ-level deficiencies.

Further, other than for unremoved IJ-level deficiencies, CMS will suspend the following enforcement actions:

• For nursing homes – Denial of Payment for New Admissions will be lifted for facilities that are not in substantial compliance at 3 months, and new admissions will be permitted during this time.
• For home health agencies (HHA) – The suspension of payments for new admissions following the last day of survey when a termination is imposed will be lifted and new admissions will be permitted during this time.
• For both nursing homes and HHAs, per day civil monetary penalties, as well as terminations that would have otherwise been imposed for lack of substantial compliance at 6 months.

For facilities with IJ-level deficiencies where there has not been confirmation by surveyors that the IJ-level deficiency has been removed, the surveyors will proceed as usual and will conduct a revisit survey to verify that the IJ-level deficiency is removed. Additionally, for facilities with IJ-level deficiencies that are not cleared on survey exit, enforcement actions and penalties will continue as usual.

For facilities that had an IJ-level deficiency and then undergo a re-visit survey and still have deficiencies, but not at an IJ level, further actions required to be taken by providers and surveyors, as well as the timing of those actions, will depend on the results of the resurvey. However, if there are no IJ-level deficiencies on resurvey, further revisit surveys will not be conducted during this time.

For entities with Clinical Laboratory Improvement Amendment (CLIA) certificates, CMS will prioritize IJ situations over recertification surveys, and will use discretion in enforcement when there is no IJ situation.

CMS will continue to authorize initial certification surveys according to current guidance and prioritization, including for new providers in order to increase the healthcare capacity.

CMS Provides Additional Guidance And Forecasts Additional Guidance To Come

The memorandum offers additional guidance for nursing homes, including direction on when to share self-assessments and information on when to report potential disease or infections. It also includes guidance for other non-long term care providers regarding items including education and signage, visitors, and access to outside healthcare staff, including organ procurement coordinators for hospitals and healthcare providers providing services to residents in nursing homes and assisted living facilities.

CMS urges other surveyors, such as accrediting organizations, to take a similar approach to surveys. CMS advised that it will continue to monitor the situation to determine if these measures need to be extended beyond the three-week period. In the next few weeks, CMS expects to issue additional guidance related to non-IJ complaints or FRIs and enforcement actions.

What Can Providers and Suppliers Do Now?

All providers and suppliers should follow the CMS, CDC, and other relevant agency infection control guidance, and must monitor for updates to the guidance. Nursing homes should immediately conduct a self-assessment of their infection prevention and control practices using the COVID-19 Focused Survey for Nursing Homes document. Other providers and suppliers should conduct self-assessments utilizing the COVID-19 Focused Infection Control Survey: Acute and Continuing Care document. All providers and suppliers should implement corrective actions for any deficiencies identified on the self-assessment surveys.