On Nov. 12, 2021, CMS issued a memo regarding changes to COVID-19 Survey Activities and Increased Oversight in Nursing Homes.

Key changes to the survey process announced in this memo include:

      • CMS is rescinding the requirement to conduct focused infection control (FIC) surveys within 3-5 days of a COVID-19 outbreak, but survey agencies (SA) may still conduct FIC when concerns related to managing COVID-19 or infection control practices arise.
      • Each state must continue to perform annual stand-alone FIC surveys (not associated with a recertification survey) of 20% of nursing homes and should prioritize these surveys for facilities that are reporting new cases and have low vaccination rates. These FIC surveys may be combined with a complaint survey.
      • Additional recertification surveys do not need to be conducted to make up for any surveys that could not be completed during the COVID-19 PHE. Surveyors will resume the normal survey schedule moving forward. CMS directed SAs to establish new intervals for scheduling recertification surveys based on each facility’s next survey, not based on the last survey that was conducted prior to the COVID-19 PHE.
      • CMS is providing SAs with flexibilities to focus complaint surveys on those allegations which are more serious.
      • CMS will collaborate with each state to determine appropriate timeframes for clearing the survey backlog.
      • CMS is temporarily allowing certain mandatory survey tasks to be discretionary or triggered based on concerns identified during offsite preparation activities, those raided by ombudsman, previous patterns of citations, or based on concerns identified during the onsite survey. The tasks that are eligible for temporary discretion include:
        • Resident council meeting
        • Dining observation
        • Medication storage
      • Guidance for investigating backlogged complaints include:
        • Complaints/FRIs triaged as IJ or Non-IJ High are to be investigated as soon as possible
        • Those triggered as Non-IJ Medium may be investigated at the next scheduled standard survey if the complaint/FRI was received within one year of the scheduled survey date or if the allegation involves staff to resident abuse, neglect, or misappropriation of resident property, regardless of the date the complaint was received.
        • SAs are not required to investigate backlogged complaints/FRI triages as Non-IJ Low

In this memo, CMS pointed out that they are very concerned about how residents’ health and safety have been impacted, due to the limitations of oversight during the public health emergency and changes in how some nursing homes have operated and they alerted surveyors to pay additional attention to compliance with requirements for sufficient and competent staff, which states:

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e).”

CMS specifically instructed surveyors to review the guidance in Appendix PP of the State Operations Manual for tag F-726, which guides surveyors to assess compliance with the requirement for nursing staff to have appropriate competencies. In the memo, they reference that a key component of competency is the ability of both licensed nurses and nurse aides to identify and address a resident’s change in condition. Surveyors will refer to the Sufficient and Competent Staffing Critical Element Pathway for determining compliance with the requirements related to sufficient and competent staff. You can download a copy of this Critical Element Pathway from the “LTC Survey Pathways” folder at: https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes

Key areas that surveyors will review that should be considered when developing your education and training plan for the upcoming year include:

      • Does the facility assessment appropriately consider facility census and resident’s acuity to determine competency of staff required to meet each resident’s needs?
      • Evaluate hospitalizations that have occurred over the past year to determine if staff possess the required competencies to care for each resident and to appropriately identify and address changes in condition
      • If you use agency staff, how do you ensure they possess the required competencies to care for each resident?
      • How do you assess if staff retain the information provided by training to maintain the required competencies to meet each resident’s needs?


Contact Proactive to learn more about regulatory support and survey preparedness services.


Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC
Director of Regulatory Services

Learn more about the rest of the Proactive team.