The Centers for Medicare & Medicaid Services (CMS) announced this week (QSO-20-31-All) that it will expand survey activity and increase enforcement remedies relating to nursing home infection control requirements, effective immediately.  Several story lines arise from this memo.   

THE DATA AND WHAT IT MEANS

According to the CMS press release, the enhanced and targeted measures are a necessary, swift response to early trends in the CDC National Healthcare Safety Network data regarding incidence of COVID-19 in and related deaths in nursing homes.

It’s become a well-publicized data point: Long-term care residents represent 12% of the state’s total COVID-19 positive cases and nearly 82% of the deaths. What has been lacking in the media coverage and lawmakers’ perspective on this point is something we have broadly shared: it is not possible to do a state-by-state comparison when there has been no nationwide standard or benchmark for reporting positive cases and deaths in long-term care settings. And we are now seeing validation that Minnesota may not be an outlier – a preliminary sort and assessment of the data released Monday by CMS shows Minnesota’s cases and deaths per 1,000 long-term care residents is below the national average.

CMS is expected to post the underlying CDC-collected data on a link on Nursing Home Compare on Thursday, June 4. The data will be broken down by state, number of residents and number of staff.  The data will be searchable by facility name and will be downloadable to facilitate analysis.  CMS will also post a link to the data on the home page of the Nursing Home Compare website so patients, residents, and families can easily find it. CMS will update the data weekly.

Note of Caution: Please know the CMS data is incomplete and subject to change. That, combined with no standardized requirement for reporting positive cases and deaths in assisted living across states, means our work to provide context and perspective based on real experience continues.

Our message focus: 1) We need PPE, testing and more staff to combat this virus; 2) We have implemented robust infection control and social engagement measures; and 3) We are capable of containing the virus once it is in our settings.

Our message: “We are focused on reducing the chances of this virus entering nursing homes and assisted living and being transmitted to our residents and staff. Even as testing increases, we still need more PPE, better staffing support and improvements in treatments. Without those steps, this data collection is useful but not enough to improve protection for seniors. We have supported the steps MDH has taken toward transparency and will continue to support MDH and CMS efforts to share public health data in ways that better inform prevention and treatment.”

INFECTION CONTROL SURVEYS: THE NEW NORMAL

State survey agencies across the country must complete infection control surveys in 100% of nursing homes by August 31, or they will suffer a 10% reduction in federal CARES Act funds to the state survey agency.  The June 1 CMS data shows the MN Department of Health (MN) has completed surveys for 67% of our care centers.  However, MDH has reported a 100% completion rate, and we will reach out for clarification.

Important: Those baseline surveys are not the end of the story for us.  Targeted infection control survey activity will continue into the future:

• By July 1 MDH must perform on-site surveys of nursing homes with previous COVID-19 outbreaks, defined as: (1) cumulative confirmed cases at 10% of bed capacity; and (2) cumulative confirmed and suspected cases at 20% of bed capacity OR 10 or more deaths reported due to COVID-19.  NOTE: CMS does not define suspected cases and does not indicate whether cases includes residents-only or residents and staff. We will work with LeadingAge national to get more information.
• MDH will perform on-site surveys (within three to five days of identification) of any nursing home with 3 or more new COVID-19 suspected and confirmed cases in the since the last National Healthcare Safety Network (NHSN) COVID-19 report, or 1 confirmed resident case in a facility that was previously COVID-free.
• Starting next fiscal year, MDH will conduct annual Focused Infection Control surveys of 20 percent of nursing homes, to be determined by the State based on its discretion using data that identifies facility and community risks.

This survey program makes clear that CMS will be utilizing data from the NHSN reporting system to identify nursing homes for survey, which further emphasizes the need to report that data accurately.

Finally, to transition to more routine oversight and survey activities, CMS notes that once a state has entered Phase 3 of the Nursing Homes Re-opening guidance, or earlier at the state’s discretion, surveyors are authorized to expand beyond the current survey prioritization (Immediate Jeopardy, Focused Infection Control, and Initial Certification surveys) to perform:

• Complaint investigations that are triaged as high importance but non-immediate jeopardy
• Revisit surveys of any facility with removed Immediate Jeopardy (but still out of compliance)
• Special Focus Facility and Special Focus Facility Candidate recertification surveys, and
• Nursing home recertification surveys that are greater than 15 months.

ENHANCED ENFORCEMENT

“Due to the heightened threat to resident health and safety for even low-level, isolated infection control citations (such as proper hand-washing and use of personal protective equipment (PPE),” CMS explains, it is expanding enforcement to improve accountability and sustained compliance with these crucial practices.

CMS will impose remedies for any deficiency associated with infection control requirements at scope and severity level D and above.  The harshness of the remedy will be based on two factors:

• The facility’s compliance history, escalating from a facility with no infection control citations in the last year (or on the last standard survey), to once in the last year (or last standard survey), to twice or more in the last two years (or twice since second to last standard survey); and
• Scope and severity, escalating from levels D&E, to Level F, to Harm (G-I), to Immediate Jeopardy.

Remedies will include Directed Plans of Correction, including use of Root Cause Analysis, discretionary denial of nonpayment (with some, but limited opportunity to demonstrate compliance), and civil money penalties, which escalate according to the factors above, with fines reaching $20,000 or higher in the most serious cases.

WHAT THIS MEANS FOR PROVIDERS

Infection control surveys and enforcement is our new normal.  Regulatory attention to this issue will continue indefinitely, even after we emerge from the current emergency, and all care centers should expect and prepare for infection control surveys.  

Here are a sampling of resources available to members:

• Please join our weekly Clinical Coaching Room with Kari Everson, which run every Tuesday at 3:00 (except for next week, due to District Meetings).  The registration links appear in our daily COVID-19 Updates.
• Our COVID-19 webpage includes a Focus Survey preparation brief, a checklist for preparation of your survey binder, and a resource for improving hand hygiene and PPE compliance, among other tools.

• CMS has launched a weekly training series focused on infection prevention in the nursing home setting. Sign-up here to receive information about this webinar series, including additional resources and tools.
• CMS and CDC have developed an Infection Preventionist training course for nursing homes, and LeadingAge Minnesota plans to offer our Infection Prevention Certificate Program again this fall.
• In response to our request for data, MDH yesterday provided dozens of 2567s from their recent Infection Control Focus Surveys, and we will analyze those and report the common issues and findings to members as soon as we call.

LeadingAge Minnesota will do all that we can in the days and weeks ahead to support you in this work.  Please contact me or Kari Everson to let us know how we can help.