Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
Just a few minutes ago, CMS issued/posted 2 QSO Memorandums that you need to review with your team ASAP. I’m in the process of reviewing/digesting them myself. There’s a great deal of new information.
QSO-20-39-NH is 9 pages in length. Revisions are found in red, starting on page 2 of the QSO and continues throughout the entire QSO. There’s a lot of red ink in this memorandum. CMS is serious about NHs maximizing visitation by expanding access to residents.
QSO-22-02-ALL is 7 pages in length. This is a brand-new memorandum so there’s no red to be found. Some of the key points as I begin my review are these:
CMS is taking the following steps which will allow SAs to focus their efforts on identifying concerns for all aspects of quality of care, quality of life, and ensuring health and safety:
- FIC surveys: CMS is rescinding the requirement per QSO 20-31-All to conduct FIC surveys within 3-5 days of an outbreak of COVID-19. SAs may still conduct these surveys when concerns related to managing COVID-19, or infection control practices, arise. NOTE: While CMS is changing its policy regarding FIC surveys, there are other policies in QSO 20-31-All that are still in place.
- Resuming standard recertification surveys: SAs will continue to conduct recertification surveys, but do not need to conduct additional recertification surveys to make up for any surveys that could not be completed during the COVID-19 PHE. In other words, SAs will resume the normal survey schedule moving forward, as described in more detail below.
- Nursing Home complaints/facility-reported incidents: CMS is providing SAs with flexibilities to focus on allegations that are more serious.
- Timeframe for clearing backlogs: CMS will collaborate with each State to determine appropriate timeframes for clearing the survey backlog.
- Temporary guidance and flexibilities: As described below, CMS is providing temporary guidance and minor flexibilities for SAs to work through the current backlog of complaints and recertification surveys that is a direct result of the suspension of certain onsite survey activities in an effort to control the spread of COVID-19.
CMS recommends that SAs prioritize recertification surveys according to the potential risk to residents, such as facilities with a history of noncompliance, or allegations of noncompliance, with any of the following:
- Abuse or neglect;
- Infection control;
- Violations of transfer or discharge requirements;
- Insufficient staffing or competency;
- Special Focus Facilities (SFFs) and SFF candidates and/or
- Other quality-of-care issues (e.g., falls, pressure ulcers, etc.).
In addition, CMS is temporarily allowing certain mandatory survey protocol tasks to be discretionary or triggered based on concerns identified during offsite preparation activities such as complaints to be investigated during the survey, or those raised by the ombudsman, and previous patterns of citations. These tasks can also be triggered based on concerns identified during the onsite survey through observations, interviews, and record reviews or if complaint(s) are to be investigated during the recertification survey. The mandatory survey tasks eligible for temporary discretion are the following:
- Resident Council Meeting: Surveyors interview up to 40 residents in the initial pool depending on facility census (See Attachment A of the Long Term Care Survey Process (LTCSP) Procedure Guide). If concerns are identified through these interviews (e.g., concerns with visitation or grievances), the survey team should proceed with conducting this task.
- Dining Observation Task: This task may be discretionary except it must be completed if a resident is being investigated for nutrition, weight loss, or concerns identified related to dialysis.
- Medication Storage: This task may be discretionary except it must be completed if the surveyor identified concerns with medication storage when completing the mandatory task of medication administration observation.
In order to promote efficiency in addressing the backlog of survey activities, the following describes CMS’s instructions for the investigation of backlogged complaints/FRIs:
- LTC Complaints/FRIs triaged as IJ or Non-IJ High – SAs are required to investigate backlogged complaints/FRIs triaged at this level as soon as possible.
- Continuing and Acute Care provider complaints triaged as IJ – SAs are required to investigate backlogged complaints as this level as soon as possible.
- Continuing and Acute Care provider complaints triaged as Non-IJ High – SAs are required to investigate complaints triaged at this level within an average of 90 calendar days, with no one complaint exceeding 120 calendar days.
- LTC Complaints/FRIs triaged as Non-IJ Medium – SAs may investigate backlogged complaints/FRIs triaged at this level at the next scheduled standard survey:
- If the complaint/FRI was received within one year of the scheduled standard survey date, or
- If the allegation involves staff to resident abuse, neglect, or misappropriation of resident property, regardless of the date that complaint/FRI was received.
- LTC Complaints/FRIs triaged as Non-IJ Low – SAs are not required to investigate backlogged complaints/FRIs triaged at this level and may be closed in ACTS at the next standard survey. The SA has discretion to include the resident(s), who is the subject of the allegation, in the standard survey sample. For example, the SA may choose to do this when there is a pattern of the same or similar allegations that suggest areas for focused attention. If the SA does not investigate the complaint/FRI onsite, then the SA may close the complaint/FRI in ACTS, by indicating that the complaint/FRI was “Withdrawn/Expired.”
- Continuing and Acute Care provider complaints triaged as Non-IJ Medium and Non-IJ Low – SAs are required to follow the maximum time frames outlined in State Operations Manual (SOM), Chapter 5, section 5075.9.
You’ll find the following information on pages 6 and 7 of the QSO (I’m hitting the key points – please be sure to review in detail):
Increasing Oversight in Nursing Homes: Throughout the COVID-19 PHE, CMS and SAs have been unable to have the traditional level of visibility inside nursing homes to assess residents’ health and safety, and survey for facilities’ compliance. Due to the limitations of oversight during the PHE and changes in how some nursing homes may have operated, CMS is very concerned about how residents’ health and safety has been impacted, such as increased weight loss, pressure ulcers, abuse or neglect, and other quality-of-care and quality-of-life issues. Surveyors should be aware that these may be potential areas for further investigation during the survey, such as the following:
- Surveying for Nurse Competency
- Inappropriate Use of Antipsychotic Medications
- Identifying Other Areas of Concern
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