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Infection Control Focus SurveyOHCATammy L. Cassidy RN, BSN, BC, LNHA, RAC-CT(513) 646-1668tammycassidy.mds@gmail.com

Not All Infection Control Surveys are the Same

COVID-19 Focused Surveys

- versus -

Voluntary CDC Infection Reviews

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COVID-19 Focused Survey

• Not voluntary

• Used to determine whether the facility is implementing proper infection prevention and control practices to prevent the developmentand transmission of COVID-19 and other communicable diseases and infections

Guidance Changes Just About Everyday…

• Will investigate compliance with F880, F884, F885, and E0024

• States have different requirements.

• Survey will be based on CMS requirements, in place at the time of the survey

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Survey Process

• Survey tool/pathway available

• Surveyors will issue citations if appropriate

• If surveyors see additional deficit practices, they will investigate them and cite if appropriate

• All departments, including contractors and volunteers will be observed

Survey Process

• One to two surveyors will be present

• Some information will be reviewed offsite

• Medical record reviews

• Telephone interviews

• Policy and Procedure review

• Facility communication to residents and representatives

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Survey Process

• Entrance Conference will be conducted

• Entrance Conference worksheet available

• Exit Conference will be conducted by telephone (unless requested in person by facility)

• Any citations will be documented on a CMS 2567 which will be sent to the facility after the survey

Information Requested During Recent Surveys• Please provide the following by email :

• Access to Electronic Health Record (remote access)

• Census Number

• Alphabetic list of residents and their rooms

• Census of Residents by unit

• Person Responsible for the Infection Control Prevention/ Program

• Updated Floor Plan

• Actual working schedule for _(Date)_ Nursing and STNA (Full names please with title )

• Complete list of employees with phone numbers and titles (include contract staff)

• A direct number for around the clock communication and who that person will be

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Information Requested During Recent Surveys• Please provide the following by email (continued):

• List of family members who frequently visit residents

• New admission last month

• Note the Entrance Conference Work Sheet is 2 Pages

• Process of notifying family members

• List of anyone who is under PPE and please indicate what type of precautions you are utilizing

Information Requested During Recent Surveys• Need copies of :

• Infection Control Program and Policies and Procedures with the Surveillance plan

• Emergency Preparedness Policy and Procedure including Emergency Staffing Strategies

• List of new admissions

• Explain what you are doing when someone does come into the building

• Transfer / discharge process to the hospital / home

• Change in condition policy/procedure

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Survey Elements1. Standard and Transmission-Based Precautions• General Standard Precautions

• Hand Hygiene

• Personal Protective Equipment (PPE)

• Transmission – Based Precautions• Guidance also present for administration of

aerosol treatments and suctioning

Survey Elements2. Resident Care

• Are residents restricted to their room appropriately if COVID-19 is present?

• Has the facility cancelled group outings, activities and communal dining?

• Have known or suspected COVID-19 residents been isolated?

• Precautions for residents in need of transfer to hospital or other care settings

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Survey Elements3. IPCP Standards, Policies and Procedures

• Will determine if the community established facility-wide infection control policies and procedures, including for undiagnosed respiratory illness and COVID-19

• Do policies include when to notify local/state health departments

Survey Elements4. Infection Surveillance

• Will ask staff to identify:• How many residents/staff have COVID-19 symptoms

• How many residents/staff have been diagnosed with COVID-19

• How many residents/staff have been tested for COVID-19, and what is the protocol for determining who will be tested

• If a surveillance plan is in place, based on a facility assessment

• If the surveillance plan includes early detection and management of potentially infectious, symptomatic residents?

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Survey Elements4. Infection Surveillance

• Will ask staff to identify (continued):• If the facility has a process for communicating infection

status to other healthcare providers as needed, and to obtain infection status when transferred back to the long term care facility

• Will determine if appropriate staff can identify the communication protocol with local/state health department

• Will interview staff to determine if concerns are identified, reported and acted upon

Survey Elements5. Visitor Entry

• Will review screening processes, restriction criteria, and posted signage at facility entrances in regards to restrictions and procedures

• Are allowed visitors provided with PPE, and instructed to frequently perform hand hygiene and limit their interactions with others?

• Is education provided to allowed visitors to monitor for s/s of COVID-19, and what actions to take?

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Survey Elements6. Education, Monitoring and Screening of Staff

• Will determine if the facility has provided education to staff on COVID-19

• Will review how the facility conveys COVID updates to all staff

• Will determine if the facility is screening all staff at the beginning of the shift for s/s including fever

• What action does the facility take if staff develop symptoms at work?

Survey Elements7. Reporting to Residents, Representatives, and Families

• Surveyors will identify how the facility is informing residents, representatives, and families

• Must be informed by 5:00 PM the next calendar day following:

• The occurrence of a confirmed COVID-19 infection –OR

• Three or more residents or staff with new onset of respiratory symptoms that occurred within 72 hours of each other

- This may be different than state guidelines

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Survey Elements7. Reporting to Residents, Representatives, and Families• Did the notification include:

• Mitigating actions taken by the facility to prevent or reduce risk, and if normal operations will be altered?

• Personally identifiable information?

• Cumulative updates to residents, representatives, and families at least weekly?

• Surveyors will interview a resident and resident representative/family member to ensure they are receiving notification

• Any citations will fall under F885 – New F-Tag

Survey Elements8. Reporting to the CDC

• This will be performed offsite by CMS surveyors

• CDC data files will be reviewed to ensure the facility is reporting at least once a week

• Will review files to ensure all required data elements are present

• Any citations will fall under F884 – New F-Tag

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Survey Elements9. Emergency Preparedness – Staffing in Emergencies

• Does the facility have a policy and procedure for ensuring staffing to meet the needs of residents when needed during an emergency?

• Did the facility implement its planned strategy for ensuring staffing to meet the needs of the residents if needed.

F884 COVID-19 Reporting to CDC

• Following an initial reporting grace period granted to facilities, CMS will receive the CDC NHSN COVID-19 reported data and review for timely and complete reporting of all data elements. Facilities identified as not reporting will receive a deficiency citation at F884 on the CMS-2567 with a scope and severity level at an F (no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy [IJ] and that is widespread; this is a systemic failure with the potential to affect a large portion or all of the residents or employees), and be subject to an enforcement remedy

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F884 COVID-19 Reporting to CDC

• Enforcement:

• Facilities will receive a citation and civil money penalty

• Grace period for reporting ends at 11:59 PM on 5/24/2020

• Facilities will receive a warning letter if they do not report by 11:59 PM on 5/31/2020

• If a facility does not report by 11:59 PM on 6/7/2020, a $1000 CMP will be imposed.

• Each subsequent week that the facility fails to report will result in an additional one-day CMP at an amount increased by $500

F885 COVID-19 Reporting to Residents, their Representatives, and Families

• Outlined in survey element #7.

• CMS indicates they do not expect individual telephone calls to each resident’s family or responsible party

• Can notify in multiple ways such as (but not limited to) email, website posting, paper notification, recorded telephone messages

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Thank you so

much!