MDH May Soon Resume Standard Nursing Home Surveys

As we noted in last week’s newsletter, new CMS criteria for what triggers focused infection control (FIC) surveys in nursing homes will have the effect of reducing the volume and frequency of FIC surveys for many care centers. The Minnesota Department of Health (MDH) signaled this week that these changes may free up enough time for surveyors to resume standard recertification surveys. MDH did not say definitively that it plans to do this, or identify any concrete timeline, but they told us they are exploring it.

Knowing this is a possibility, we recommend that care centers revisit and refresh your survey preparation processes and materials, if needed. When recertification surveys resume, they will include onsite State Fire Marshal staff conducting the Life Safety Code component.

The CMS memo (QSO-20-31-ALL-REVISED) that outlined the new triggers for FIC surveys also includes a set of Frequently Asked Questions related to health surveys, emergency preparedness surveys and Life Safety Code surveys (for all provider types), along with a guide to F-Tags and K-Tags affected by CMS regulatory waivers issued in response to the pandemic.

Please also note that CMS in December updated several nursing home survey tools and documents:

  • Entrance Conference Worksheets: Two separate Entrance Conference Worksheets with November 2020 revision dates are now posted: (1) A COVID-19 Focused Infection (FIC) Survey Entrance Conference Worksheet, which is now labeled with that name. This document is the same as the Aug. 2020 FIC Entrance Conference Worksheet, with one exception. An instruction in the August form noted “A comprehensive review of policies should be completed offsite.” In the Nov. 2020 version “should” now reads “may,” which potentially will lengthen time on-site in some cases.  (2) A standard survey Entrance Conference Worksheet, which incorporates COVID-related elements from the FIC worksheet, such as floor plan changes, staff responsible for notification of cases, and testing.
  • Matrix (CMS-802): The matrix used to identify pertinent care categories for residents now includes suspected or confirmed COVID-19 under infections (category 20).
  • Infection Control Pathway (CMS-20054 Infection Prevention Control and Immunization): This form is now integrated with the COVID-19 Focused Survey tool previously released by CMS.
  • COVID 19 FIC Survey Protocol: This 4-page document is updated for surveyor use, with new content about training, PPE, and other issues.
  • Resident Interview, Resident Observation, Record Review, and Resident Representative Interview Care Areas and Probes: CMS has updated the probes for the respiratory infection and infections (not UTI, PU, or respiratory) areas, and added a new Transmission-Based Precautions care area.

For ease of access, we have combined all of the documents described above into this CMS Survey Tools Update. You may also access these items as individual documents through this CMS Nursing Homes webpage, in the Downloads section.

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