Focused Infection Control Surveys and CARES Act Funding
On June 1, 2020, CMS released a memo to State Survey Agency Directors calling on states to ensure that all Medicare and Medicaid certified nursing homes receive an on-site infection control focused survey and that access to the new CARES Act funding for states will be tied to their progress on completing these surveys. To date, States and CMS have completed Focused Infection Control surveys in approximately 53% of the nation’s nursing homes. States that do not complete 100% of their focused infection control surveys in nursing homes by July 31, 2020 will be required to submit a corrective action plan to CMS outlining their strategy for completing 100% of the surveys within 30 days. If after the 30-day period, they still have not surveyed 100% of the nursing homes in the state, their CARES Act FY2021 allocation may be reduced by up to 10% and these funds would then be redistributed to the states that completed 100% of their focused infection control surveys by the July 31 deadline.
COVID-19 Survey Activities
In addition to requiring states to complete the Focused Infection Control survey in 100% of nursing homes, CMS is also requiring them to:
- Perform on-site surveys by June 30, 2020 in all nursing home with previous COVID-19 outbreaks, which they define as cumulative confirmed cases/bed capacity at 10% or greater; or cumulative confirmed plus suspected cases/bed capacity at 20% or greater; or 10 or more deaths reported due to COVID-19.
- Perform on-site surveys within 3-5 days of identification of any nursing home with 3 or more new COVID-19 suspected and confirmed cases since their last NHSN COVID-19 report or 1 confirmed resident case in a facility that was previously COVID-free.
- Beginning in Oct 2020, perform annual Focused Infection Control surveys of 20% of nursing home in the state, based on state discretion or additional data that identifies facility and community risk.
States that fail to perform these survey activities timely and completely could also forfeit up to 5% of their CARES Act allocation, annually.
Expanded Survey Activities
To transition states to more routine oversight and survey activities, once a state has entered Phase 3 of the Nursing Home Re-opening guidance, or earlier, at the state’s discretion, States are authorized to expand beyond the current survey prioritization that is in place to perform complaint investigations that are triaged as Non-Immediate Jeopardy-high; revisits for facilities with removed Immediate Jeopardy, but who are still out of compliance; Special Focus Facility and Special Focus Facility Candidate recertification surveys; and surveys that are greater than 15 months. When determining the order of scheduling more routine surveys, states are directed to prioritize providers with a history of or allegations of non-compliance with abuse/neglect, infection control, violations of transfer/discharge requirements, insufficient staffing or competency, or other quality of care issues.
Enhanced Enforcement for Infection Control Deficiencies
In the memo, CMS also announced that they are expanding enforcement for infection control citations to improve accountability and sustained compliance with infection control practices. In addition to enhanced enforcement, they will also be providing Directed Plan of Correction, including use of Root Cause Analysis, to facilitate lasting systemic changes within facilities to drive sustained compliance. Any infection control deficiency cited at a D level or above will lead to the following enforcement remedies:
- Non-compliance for an Infection Control deficiency when none have been cited in the last year (or on the last standard survey):
- Level D or E – Directed Plan of Correction
- Level F- Directed Plan of Correction and Discretionary Denial of Payment for New Admissions with 45-days to demonstrate compliance with Infection Control deficiencies, $10,000 per instance CMP
- Non-compliance that has been cited for Infection Control deficiencies 2 or more times in the last 2 years or twice since second to last standard survey:
- Level D or E- -Directed Plan of Correction, Discretionary Denial of Payment for New Admissions, 30-days to demonstrate compliance with Infection Control deficiencies, $15,000 Per Instance CMP (or per day CMP may be imposed, as long as the total amount exceeds $15,000)
- Level F- Directed Plan of Correction, Discretionary Denial of Payment for New Admissions, 30-days to demonstrate compliance with Infection Control deficiencies, $20,000 Per Instance CMP (or per day CMP may be imposed, as long as the total amount exceeds $20,000)
- Non-Compliance with Infection Control deficiencies at Harm level (Level G, H, or I), regardless of past history:
- Directed Plan of Correction, Discretionary Denial of Payment for New Admissions with 30 days to demonstrate compliance with Infection Control deficiencies. Enforcement imposed by CMS per current policy, but CMP imposed at highest amount option within the appropriate (non-Immediate Jeopardy) range in the CMP analytic tool
- Non-compliance with Infection Control Deficiencies at the Immediate Jeopardy Level (Level J, K, L) regardless of past history:
- In addition to the mandatory remedies of Temporary Manager or Termination, the imposition of Directed Plan of Correction, Discretionary Denial of Payment for New Admissions, 15-days to demonstrate compliance with Infection Control deficiencies. Enforcement imposed by CMS per the current policy, but CMP imposed at highest amount option within the appropriate (IJ) range in the CMP analytic tool.
QIO Support
CMS has refocused the approach of the Quality Improvement Organizations (QIO) to assist in combating COVID-19 in facilities. Currently, QIOs host a weekly National Infection Control Training that focuses on all aspects of infection control, prevention, and management to help nursing homes prevent the transmission of COVID-19 in facilities and keep residents safe and they provide direct assistance to around 6,000 small, rural nursing homes and those serving vulnerable populations in areas where access to care is limited to help them understand and comply with CMS and CDC reporting requirements, share best practices related to infection control, testing, and patient transfers.
The QIOs are being deployed by CMS to provide technical assistance to nursing homes, which includes a targeted focus of around 3,000 low performing nursing homes who have a history of infection control challenges. States may also request QIO assistance at nursing homes that have experienced an outbreak. In the memo, CMS states that “The QIOs help nursing homes identify what their greatest areas of infection control problems are, then create an action plan, and implement specific steps to establish a strong infection control and surveillance program in the nursing home. For instance, they train staff on the proper use of personal protective equipment (PPE), cohorting residents appropriately, and transferring residents safely. They monitor compliance with infection control standards and practices in the nursing home.”
To view the state survey memo, visit: https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/covid-19-survey-activities-cares-act-funding-enhanced-enforcement-infection-control-deficiencies-and
To view the letter to the Governors, visit: https://www.cms.gov/files/document/6120-letter-governors.pdf
To view a state breakdown of the Nursing Home COVID-19 data, visit: https://www.cms.gov/files/document/6120-nursing-home-covid-19-data.pdf
