CMS memo QSO-22-02-ALL includes new guidance on survey activity. Focused infection control surveys will no longer be required based on outbreak. State survey agencies are still required to conduct focused infection control surveys at 20% of the nursing homes in the state during a given fiscal year and may conduct additional FIC surveys when a concern arises, such as outbreak in a nursing home with low vaccination rates.

Recertification surveys should continue but surveys are not required to make up those missed during survey reprioritization periods. For example, if a recert was due in April 2020 but was not conducted until August 2021, the next recert would be due no later than October 2022 (15 months after the completion of the August 2021 survey). Recertification surveys can be prioritized based on potential risk to residents (factors such as past noncompliance, allegations of noncompliance, or complaints regarding abuse, infection control, insufficient staff or staff competency, violation of transfer/discharge rights, quality of care issues, etc.). Some surveyor tasks will temporarily be discretionary (resident council observation, dining observation, medication storage).

The memo outlines levels of triage to assist surveyors in addressing back-log of complaints and facility-reported incidents. Surveyors are directed to pay special attention to certain areas such as nurse competency including assessing for change in status, inappropriate use of antipsychotics, and risks to health and safety such as unplanned weight loss, loss of function/mobility, pressure ulcers, abuse/neglect, and depression.

Questions?

Contact:

Laura Hofmann, MSN, RN – Director of Clinical and Nursing Facility Regulatory Services
c: 425-231-4804