Reminder: MDH Has Resumed Standard Nursing Home Survey Activity

Posted on September 2, 2020 by Jonathan Lips

Care centers are reminded that the Minnesota Department of Health (MDH) has resumed standard recertification surveys as of mid-August, consistent with CMS memorandum QSO-20-35-ALL.  

In addition to standard surveys, MDH is also conducting some non-Immediate Jeopardy complaint investigations. These nursing home recertification surveys will include onsite State Fire Marshal staff conducting the Life Safety Code component. 

MDH will conduct revisits consistent with CMS revisit requirements, which allow for offsite revisits for surveys with deficiencies at scope and severity below Level G and with proper evidence of correction.

Despite the suspension of most non-infection control survey activity earlier this year by CMS, annual recertification surveys are to be completed within 15-months from the last recertification survey, so facilities that are in their survey window should be preparing now for a visit from MDH. All survey citations issued will require a plan of correction to be filed via the normal process.

Updated COVID-19 Focused Survey

At the same time as this return toward normalcy on the standard and complaint survey activity, MDH will continue to conduct Focused Infection Control Surveys relating to COVID-19.

In its announcement last week of the new nursing home testing requirements (QSO-20-38), CMS noted that it is revising the COVID-19 Focused Survey for Nursing Homes tool to reflect the new testing requirements, as well as other updates to help ensure an effective assessment of the facility’s compliance, such as:

• How are residents reminded to perform hand hygiene?
• PPE (eye protection, facemasks, source control)
• Source control - Are residents, visitors, and others at the facility donning a cloth face covering or facemask while in the facility or while around others outside?

As noted above, CMS has added a new F-tag relating to the Infection Preventionist requirement, and the tool directs surveyors as follows:

During interview with facility administration and Infection Preventionist(s), determine the following:

• Did the facility designate one or more individual(s) as the infection preventionist(s) who are responsible for the facility’s IPCP?
• Does the Infection Preventionist(s) work at least part-time at the facility?
• Has the Infection Preventionist(s) completed specialized training in infection prevention and control?
• Does the Infection Preventionist(s) participate in the quality assessment and assurance committee? The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

CMS has also revised the Entrance Conference Worksheet to include requests for procedures to address resident and staff who refuse testing or are unable to be tested, and documentation related to COVID-19 testing, which may include the facility’s testing plan, logs of county level positivity rates, testing schedules, list of staff who have confirmed or suspected cases of COVID-19, and if there were testing issues, contact with state and local health departments.

Click here to download the revised Focused Survey, Entrance Conference Worksheet, and Focused Survey Protocol. These resources are also available in a Survey Resources file in the Downloads section of the CMS Nursing Homes webpage.