On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) announced steps to address a backlog of complaint and recertification surveys. Additionally, CMS announced that they will be increasing oversight in nursing homes, which will permit a more focused review of quality of life and quality of care concerns. Both changes are effective immediately.
During the Public Health Emergency (PHE), CMS had a more targeted approach for assessing compliance with CMS infection prevention and control requirements. The following steps will now be taken by CMS to allow the State Survey Agencies (SAs) to focus their efforts on identifying concerns for all aspects of quality of care and quality of life, ensuring resident health and safety:
- Focused Infection Control (FIC) surveys: CMS is rescinding the requirement per QSO 20-31-All to conduct COVID-19 FIC surveys within 3-5 days of an outbreak of COVID-19. SAs may still conduct these surveys when concerns related to managing COVID-19 or infection control practices arise.
- Resuming standard recertification surveys: SAs will continue to conduct recertification surveys, but do not need to conduct additional recertification surveys to make up for any that could not be completed during the COVID-19 PHE. In other words, SAs will resume the normal survey schedule moving forward.
- Nursing Home complaints/facility-reported incidents: CMS is providing SAs with flexibilities to focus on allegations that are more serious.
- Timeframe for clearing backlogs: CMS will collaborate with each State to determine appropriate timeframes for clearing the survey backlog.
- Temporary guidance and flexibilities: CMS is providing temporary guidance and minor flexibilities for SAs to work through the current backlog of complaint and recertification surveys that are a direct result of the suspension of certain onsite survey activities in an effort to control the spread of COVID-19.
NOTE: While CMS is changing its policy regarding FIC surveys, there are other policies in QSO 20-31-All that are still in place.
FIC Surveys
CMS will no longer require FIC surveys to be conducted within 3-5 days of a nursing home having 3 or more new COVID-19 confirmed cases, or 1 confirmed resident case in a facility that was previously COVID-19-free. However, each survey agency must continue to perform annual FIC surveys of 20% of nursing homes. States will prioritize these surveys for facilities that are reporting new cases and have low vaccination rates. To count toward the required 20%, these FIC surveys must be stand-alone surveys not associated with a recertification survey. The FIC survey may be combined with a complaint survey. States may also conduct these surveys when concerns related to COVID-19 infection control arise. States that fail to perform these survey activities timely and completely could forfeit up to 5% of their Coronavirus Aid, Relief, and Economic Security (CARES) Act allocation annually.
Recertification Surveys
At this time, SAs will resume recertification surveys on a regular basis, and will establish new intervals based on each facility’s next survey, not based on the last survey that was conducted prior to the COVID-19 PHE. CMS recommends that SAs prioritize recertification surveys according to the potential risk to residents, such as facilities with a history of noncompliance, or allegations of noncompliance, with any of the following:
- Abuse or neglect;
- Infection control;
- Violations of transfer or discharge requirements;
- Insufficient staffing or competency;
- Special Focus Facilities (SFFs) and SFF candidates; and/or
- Other quality-of-care issues (e.g., falls, pressure ulcers, etc.)
CMS is temporarily allowing certain mandatory survey protocol tasks to be discretionary or triggered based on concerns identified during offsite preparation activities. The mandatory survey tasks eligible for temporary discretion are the following:
- Resident Council Meeting: If concerns are identified through interviews (e.g., concerns with visitation or grievances), the survey team will conduct this task.
- Dining Observation Task: Must be completed if a resident is being investigated for nutrition, weight loss, or concerns identified related to dialysis.
- Medication Storage: Must be completed if the surveyor identified concerns with medication storage when completing the mandatory task of medication administration observation.
Complaints/Facility-Reported Incidents (FRIs)
Throughout the COVID-19 PHE, CMS directed SAs to prioritize complaints/FRIs triaged as IJ for investigation. CMS is now issuing guidance for SAs to investigate the backlog of complaints/FRIs according to the level of triage. This guidance remains in effect only for as long as it takes a State to clear any backlog and resume routine operations. Complaints/FRIs triaged as IJ and Non-IJ-High are required to be investigated within two and ten working days. CMS will work with SAs to establish reasonable expectations for when these requirements should be met based on the size of the backlog and each SA’s plan to address it.
Increasing Oversight in Nursing Homes
CMS is very concerned about how residents’ health and safety have been impacted by changes in survey frequency, such as increased weight loss, pressure ulcers, abuse or neglect, and other quality-of-care and quality-of-life issues. The following are potential areas for further investigation during surveys:
Surveying for Nurse Competency: CMS waived the requirements that a facility may not employ a nurse aide for longer than four months if they did not meet certain training and certification requirements (42 C.F.R § 483.35(d)). CMS did not waive § 483.35(c), which requires facilities to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. A key component of competency is the ability to identify and address a resident’s change in condition. This expectation applies to licensed and registered nurses, as well as nurse aides.
Inappropriate Use of Antipsychotic Medications: Inappropriate use of antipsychotic medications continues to be an area of concern related to quality of care. SAs will continue to focus their efforts on identifying the inappropriate use of antipsychotic medications and emphasize non-pharmacologic approaches and person-centered care practices.
Identifying Other Areas of Concern: Surveyors will assess other care areas where residents’ health and safety may be at increased risk, such as unplanned weight loss, loss of function/mobility, depression, abuse/neglect, or pressure ulcers.
The entire CMS memo QSO-22-02-All can be accessed here.
Compliance Perspective
Issue
As healthcare facilities remain vigilant against the spread of COVID-19 and other infections, it is also critical to ensure that quality of care and quality of life standards are met. Therefore, it is imperative that all facilities review policies and procedures for provision of quality care and quality of life. The Quality Assurance and Performance Improvement (QAPI) committee can be an asset in this effort. Failure to meet these standards may result in monetary fines, other sanctions, and increased monitoring by state inspectors.
Discussion Points
- Review your policies and procedures on Quality Assurance and Performance Improvement Committee oversight of resident care. Update as needed.
- Train all staff on what the QAPI Committee does, and how they can help the facility achieve high quality of care and meet quality of life standards for all residents.
- Periodically audit to ensure that the QAPI Committee is monitoring care and providing recommendations to your healthcare team, and that the recommendations are being followed within the facility.
