April 6, 2023

QSO Updates Enforcement for Infection Control Citations

On April 6, 2023 by Kari Everson

On March 30, the Centers for Medicare and Medicaid Services (CMS) released QSO-23-10-NH, which rescinds QSO-20-31-NH and provides updated guidance on enforcement for infection control non-compliance. As a result, enforcement actions are more severe than before when cited under F880 and/or F887.

Enhanced remedies based upon scope and severity

The scope and severity of an F880 or F887 deficiency determine enforcement remedies. Directed plans of correction, discretionary denial of payment, and civil money penalties are imposed depending upon scope and severity.

Deficiencies at D, E, F

• Directed plan of correction (DPOC), including Root Cause Analysis (RCA) and working with a Quality Improvement Organization (QIO) or another qualified consultant
• Discretionary denial of payment for new admissions with a 30-day notice period to achieve substantial compliance.
• Additional remedies may apply if F887 is cited at a higher-level severity.

Deficiencies at G, H, I

• DPOC, including RCA and working with a QIO or hiring an Infection control consultant to develop and implement a plan of correction.
• Discretionary denial of payment for new admissions with a 15-day notice period to achieve substantial compliance.
• Civil Money Penalty (CMP) imposed according to the CMP Analytic Tool with a 10% increase adjustment.

Deficiencies at J, K, L

• DPOC with RCA and working with QIO or other Infection control consultant
• Discretionary denial of payment for new admissions with a 15-day notice period to achieve substantial compliance.
• Civil Money Penalty (CMP) imposed according to the CMP Analytic Tool with a 20% increase adjustment.

QIO available for support

Superior Health Alliance is the QIO for Minnesota and has quality improvement advisors available to assist. In addition, they have infection preventionist support, QAPI program and RCA assistance, an education library, and more. You can visit their website or contact their program director for more information.

If you have additional questions, please contact Kari Everson.