State Surveys During Covid-19: What You Need to Know

From February to August this year, CMS issued 18 sets of guidelines for long-term care facilities (LTCFs) to help combat the global COVID-19 pandemic crisis. Everywhere I go, I hear the same message. LTCFs struggling to keep up with the changes and then the expectation to perform at 100% compliance. To top it off, they are hit with record fines due to noncompliance of the new guidance. The importance of passing state and federal surveys has never been higher, and this already resource-strapped healthcare environment is harmed by monetary fines during a pandemic. The U.S. PIRG, a public interest advocacy group, examined data voluntarily submitted to federal health officials by nursing homes in May through August. Almost 3,000 nursing homes said they had less than a week’s worth of PPE on hand. More than one in five nursing homes reported “severe” shortfalls of both personal protective equipment (PPE) and staffing, a new study published in the journal Health Affairs found.

Who can argue that the MOST important work within this healthcare setting is to keep the vulnerable residents and healthcare personnel safe? Yet, this is not the attitude of the surveyors. It’s as if they are determined to find something, anything wrong. I had one facility cited for crumbs on a Hoyer-Lift.  Don’t you think our needs to be more on helping these facilities? Most important, rather than checking a box on a clipboard, is keeping healthcare workers and residents protected and safe. If he goal of state surveys, which has been around since the 1970s is to help protect nursing home residents, fines in a time of shortages is not the answer.

Facilities can be better prepared with utilizing the new CMS COVID-19 specific survey.

Visiting the CMS assessment on CMS.gov is an important first step, and because of changing guidelines it is vital to check this site often. (HOW OFTEN?) This assessment will give us the specifics of what the surveyor will be looking for. (Survey specific guidelines begin on page 13.)

This is an excellent first step in preparedness for a survey. Knowing exactly what the surveyor will be looking give facilities an opportunity to be prepared, and it’s a great guideline for staff and resident safety. One key to these guidelines for staff is understanding. The surveyors want to make sure staff understands the guidelines, as to be able to communicate things such as visitor entry guidelines to families of residents.

Heavily focused on infection control, the survey hits on standard precautions, transmission-based precautions, testing, data collection, and more. For a quick video walkthrough of the assessment, check out this video.

A report from AARP found that 39% of homes in the state reported they had less than one week’s supply of PPE in the Sept. 21-Oct. 18 period.

The U.S. PIRG examined data voluntarily submitted to federal health officials by nursing homes in May through August. Almost 3,000 nursing homes said they had less than a week’s worth of PPE on hand, according to the data.

Here is some information that comes from the book that I am writing. This may help.

We cannot turn the clock back nor can we undo the harm caused, but we have the power to determine the future and to ensure that what has happened never happens again. Paul Kagame

Within the United States, there are approximately 16,000 CMS-certified Long-term Care facilities, aka nursing homes that provide healthcare services to an estimated 4 million individuals annually (Hunter, Mu, Dumyati, & Farley; Burden of Nursing Home-Onset Clostridium difficile Infection in the United States: Estimates of Incidence and Patient Outcomes, 2016).  These healthcare services are estimated to cost $143 billion every year (The Henry J Kaiser Family Foundation, 2013). In 1987 Congress passed the Nursing Home Reform Act requiring nursing homes to implement new practices that would improve the quality and care for the residents. This did not complete the job, however as a decade later, the Government Accountability Office (GAO) continued to receive documented reports identifying significant issues within nursing homes that resulted serious harms, along with the lack of enforcement by federal agencies. In 2008, CMS adopted the five-star quality rating system which provides nursing homes with an individual report as well as a composite ranking of other nursing homes based on their health inspections, nurse staffing hours, and selected quality measures. Quality Measures, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures

For short-stay residents, which stay less than 100 days, there are no outcome infection related measures, for long-stay residents out of the 16 quality measures, the only infection related measure is if the resident had a urinary tract infection. For both categories, there are process measures which support preventing an infection including the administration of the flu and pneumonia vaccination. The purpose of the five-star quality rating was to provide consumers with a snap shot of the quality of a nursing homes. If a nursing home was a 5 star that is suppose to mean that they are the best of the best, similar to a hotel rating. A 1 star, well, let’s just say I’m going to avoid placing my loved one there…if I can help it and if I have the financial means to do so. (question, do Medicaid only facility have lower star ratings?)

In 2009, the Patient Protection and Affordable Care Act adopted new policies requiring nursing homes to increase transparency and accountability regarding ownership, finances, staffing, and quality measures such as: pressure sores, physical restraints, pain, loss of mobility, and other conditions associated with care.  This meant that nursing homes were required to report specific outcomes for the public and government entities to view.

Up until 2017, infection control policies and practices were not a targeted focus for regulation and as a result, it has been estimated that 3.8 million healthcare associated infections (HAI) occur every year, however, the true burden is not actually known because HAI surveillance is not a standard requirement, meaning some states require more reporting than others(Palms, MugaI, Eure, & Anttila, 2018). In addition, 38% of all nursing homes are cited for infection control violations every year (Herzig, Stone, Castle, & Pogorzelska-Maziarz, 2016).

CMS recognizing a problem, they issued an updated order, hadn’t been updated since 1992, To combat this, as of October 2017, all CMS certified LTCFs were required by the federal government to have an infection control program that includes surveillance for HAIs and, by November 2019, to have a part-time infection control officer (HSS, 2016). Even though each LTCF must conduct their own in-house surveillance, reporting HAIs at the federal level still is not required. Experts agree that standardized surveillance is needed to understand the burden of HAIs, establish a baseline for benchmarking, monitor trends, and develop national data-driven quality improvement projects aimed to reduce HAIs (Dick, Bell, & Stone, 2018).

On October 4, 2016, the Department of Health and Human Services (HHS) published the final rule for Medicare and Medicaid participating LTCFs. This was the first time the regulations had been updated since February 5, 1992 (HHS, 2016). In these guidelines, LTCFs were now required to have an infection prevention and control program (IC), an antibiotic stewardship program, and an infection preventionist (IP) at least part-time (HHS, 2016). Within the IC program, the final rule stated that each facility must have “A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases…” (HHS, 2016).

Scroll to Top