On 01/04/2021 CMS issued revised QSO-20-31-All. In this memo, CMS has revised the criteria requiring states to conduct focused infection control surveys due to the increased availability of resources for the testing of residents and staff and factors related to the quality of care and CMS provided Frequently Asked Questions related to health, emergency preparedness and life safety code surveys.

Revisions include:

  • States are required to perform on-site Focused Infection Control (FIC) surveys (start survey within three to five days of identification) of any nursing home with 3 or more new COVID-19 confirmed cases since the last National Healthcare Safety Network (NHSN) COVID-19 report, or 1 confirmed resident case in a facility that was previously COVID-free, and other factors that may place residents’ health and safety at risk. These factors include:
    • Multiple weeks with new COVID-19 cases;
    • Low staffing;
    • Selection 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).
  • CMS will work with State Survey Agencies to identify facilities that meet the criteria to have a FIC survey performed, and the survey must start within 3-5 days of identification.
  • Facilities that meet the criteria to trigger a FIC survey will not need to be resurveyed if a FIC survey was conducted within the previous 3 weeks. If a facility meets the criteria for a survey in the fourth week after a FIC survey was conducted, an additional FIC survey must be conducted within 3-5 days.
  • CMS clarified that to count toward the required 20% of nursing homes on which a FIC survey must be performed starting in FY2021, these FIC surveys must be stand-alone surveys not associated with a recertification survey; FIC surveys conducted in FY2021 that were triggered by meeting the criteria for a FIC survey, may count toward meeting the State’s 20% requirement.
  • The memo also alerted surveyors that when conducting FIC surveys, they should be alert to and investigate any concerns related to residents who have had a significant decline in their condition (e.g., weight loss, mobility) during the PHE.
  • The memo includes FAQs addressing questions on LTC surveys, Emergency Preparedness surveys, and Life Safety Code surveys, along with a guide to waived F-tags and K-tags for clarification.


Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, Proactive Medical Review

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