In a January 4, 2021 revision to a June 1, 2020 Quality, Safety and Oversight memorandum, the Centers for Medicare and Medicaid Services (CMS) revised the criteria for focused infection control (FIC) surveys in nursing facilities and released Frequently Asked Questions (FAQ) pertaining to health, life safety code (LSC), and emergency preparedness surveys during the Public Health Emergency (PHE).

FIC Survey Triggering Criteria

The original memorandum simply stated that on-site FIC surveys are to be performed within three (3) to five (5) days after a nursing home is identified as having three (3) or more new confirmed cases of COVID-19 (based on National Healthcare Safety Network reporting), or one (1) new confirmed case among residents in a facility that was previously COVID-free.  While these criteria remain, the January 4 revised memorandum adds consideration of “other factors that may place residents’ health and safety at risk” to the trigger for an FIC survey.  CMS states that such factors include the following:

• Multiple weeks with new COVID-19 cases;
• Low staffing;
• Designation of the facility as a Special Focus Facility per Section 1819(f)(8)(B) of the Social Security Act;
• Concerns related to conducting outbreak testing per CMS requirements; or
• Allegations or complaints which pose a risk for harm or Immediate Jeopardy to the health or safety of residents which are related to certain areas, such as abuse or quality of care (e.g., pressure ulcers, weight loss, depression, decline in functioning).

The revised memorandum states that a facility meeting the criteria does not need to be resurveyed if it has received a FIC survey (either stand-alone or as part of a recertification survey) within the previous three (3) weeks.

Importantly, the revised memorandum also states that beginning October 1, 2020, states must perform annual stand-alone FIC surveys for at least twenty percent (20%) of nursing homes.  Facilities that meet the triggering criteria will count toward the 20% requirement.  The state may use its discretion or additional data regarding facility or community risks to identify other facilities for such surveys.

FAQs

The FAQs cover a variety of topics of relevance to conducting standard recertification health surveys as well as emergency preparedness and LSC surveys. Highlights of the FAQs include the following:

• When conducting surveys in a facility that is cohorting COVID-positive residents and residents whose COVID status is unknown (i.e., suspected cases, new admissions, etc.), only one surveyor should be assigned in each such area of the facility. Further, surveyors assigned to these areas should meet virtually with the rest of the survey team while on site.  If there is only one surveyor on the premises, the surveyor should begin the survey activity with COVID-negative residents, then move on to those whose COVID status is unknown, and finish with COVID-positive residents.

• Surveyors should not expect a facility to provide personal protective equipment (PPE), though facilities are not prohibited from providing surveyors with PPE.

• While facilities must grant access to surveyors, including fire marshals performing LSC and emergency preparedness inspections, the surveyors and inspectors should not enter a facility if they are experiencing signs or symptoms consistent with COVID-19 and should adhere to the facility’s health-related screening protocols. They should also wear appropriate PPE and practice social distancing, hand hygiene, etc.

• The survey team should include residents with confirmed or suspected COVID-19 in sample selection.

• For the most part, standard recertification surveys should be conducted on-site, with modifications to account for cohorting and other infection control measures. Some survey activities, such as team meetings, review of policy and procedures, and the exit conference, can be conducted off-site.

• If the facility is experiencing a COVID-19 outbreak, some facility tasks during the survey may be modified to prevent the further spread of COVID-19. This would include modifications to the resident council interview and observation of dining task.

• There are also specific modifications to the LSC and emergency preparedness survey that do not apply to standard health surveys, including not entering rooms or wings with residents confirmed or suspected of having COVID-19 if the rest of the facility constitutes a representative sample of rooms, and limited smoke and fire barrier inspections, among others. Also, certain Section 1135 blanket waivers modify the circumstances under which facilities can be cited for LSC violations involving some missed Inspection, Testing and Maintenance timeframes, placement of alcohol-based hand rub dispensers, fire drills (though a documented orientation training program on the fire plan must be implemented), or walls and barriers deficiencies.

The memorandum also includes a K-tag crosswalk for Section 1135 blanket waivers relating to LSC issues.

While the revised memorandum is clearly intended to guide State Survey Agencies and surveyors in how they approach health, LSC, and emergency preparedness surveys, it nevertheless provides valuable insight for providers in terms of knowing what to expect for each type of survey when a survey team arrives at the premises.  It also provides some degree of predictability with respect to FIC surveys going forward given anecdotal reports of individual facilities in several states receiving multiple FIC surveys in a short period of time, though the language of the revised memorandum regarding resurveys appears to be less certain in nature than it is advisory.