On March 30, the Centers for Medicare & Medicaid Services (CMS) announced that it had rescinded its “Enhanced Enforcement for Infection Control Deficiencies” guidance and replaced it with revised guidance for “Strengthened Enhanced Enforcement for Infection Control Deficiencies,” effective immediately. According to CMS, the revised guidance strengthens enforcement efforts for noncompliance with infection control deficiencies. The enhanced enforcement actions are more stringent for infection control deficiencies that result in actual harm or immediate jeopardy to residents.
In addition, the criteria for enhanced enforcement on infection control deficiencies that result in no resident harm was expanded to include enforcement on noncompliance with Infection Prevention and Control (F880) combined with COVID-19 Vaccine Immunization Requirements for Residents and Staff (F887).
According to the guidance, Quality Improvement Organizations (QIO) will be deployed to provide technical assistance to nursing homes, including a targeted focus on approximately 3,000 low-performing nursing homes with a history of infection control challenges. States may request QIO technical assistance specifically targeted to nursing homes that have experienced an outbreak.
The QIOs will help nursing homes identify their greatest infection control challenges, create action plans, and implement specific steps to establish a strong infection control and surveillance program in the nursing home. For instance, they will train staff on the proper use of personal protective equipment (PPE), cohorting residents appropriately, and transferring residents safely. They will monitor compliance with infection control standards and practices in the nursing home.
The revised guidance can be accessed here. Nursing homes can locate the QIO responsible for their state here.
Compliance Perspective
Issue
CMS is strengthening the enhanced enforcement for infection control policy to target facilities with or at risk for the most significant negative resident health outcomes by taking more aggressive enforcement actions. These changes include increased civil money penalties, a shortened time period for facilities to demonstrate compliance prior to the effectuation of discretionary denial of payment for new admissions remedy, and stronger directed plans of correction. Enhanced enforcement will be applied to higher-level infection control deficiencies that cause harm, serious harm, or the likelihood of serious harm. Additionally, enforcement actions will be imposed on facilities when they are concurrently cited for noncompliance with F880 and F887 at a level that causes no actual harm, but with the potential for more than minimal harm to residents.
Discussion Points
- Review your infection prevention and control plan and vaccination policies and procedures to ensure they include the most up-to-date information from CMS.
- Train staff on the most current infection prevention and control protocols, including vaccination policies and best practices. Document that the trainings occurred and keep a signed copy in each employee’s education file. Provide resident- and family member-related education through presentations at Resident or Family Council Meetings and document within those meetings’ minutes.
- Periodically audit to ensure that all staff are following your infection prevention and control plan. Provide additional training where needs are identified. Audit vaccine consent and administration rates and provide additional education where needed.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
