CMS Revises COVID-19 Focused Infection Control Survey Tool for Acute and Continuing Care Providers and Suppliers

Mary Madison, RN, RAC-CT, CDP 
Clinical Consultant – Briggs Healthcare

CMS has revised QSO-21-08-NLTC with the date of February 4, 2022, and the same title as the title of the blog.

There’s a lot of red in the entire 4-page Memorandum beyond the Memorandum Summary (above). Note also that the Memorandum now includes Providers and Suppliers which is italicized and in the title in red ink.

Refocusing the COVID-19 FIC Survey and Tool for Acute and Continuing Care: Returning to the Existing Standard Survey Processis the theme of this revised QSO.

  • There is no longer a need to continue the required use of the FIC survey and tool on a national basis because surveyors will continue to assess infection control and prevention through the standard survey process, as applicable to the provider/supplier type. Therefore, CMS is rescinding the survey requirement per QSO-21-08 to conduct FIC surveys.
  • While the contents of the FIC survey tool are generally still applicable, if facilities wish to continue use of the tool as a template for their own self-assessment we encourage them to carefully review the Centers for Disease Control and Prevention (CDC) guidelines as there have been changes to the recommendations since the original tool and update were released (see the “Additional Resource Links” section below for more information on CDC guidelines).
  • SAs and AOs should return to the existing standard survey processes and continue to assess COVID-19 infection prevention and control elements by focusing on the regulatory requirements, while incorporating lessons learned about infection control oversight during the PHE.
  • At this time, continued federal guidance on visitation restrictions for ACC facilities are no longer necessary, which is consistent with the nursing home guidance in QSO-22-39. Facilities should continue to adhere to basic COVID-19 infection prevention principles consistent with national standards of practice.
  • In light of the uncertain impact of COVID-19 variants, there may be more prescriptive state requirements that necessitate continued visitation restrictions or additional steps such as screening of employees, visitors, patients, clients, and residents during the PHE. Facilities should continue to consult with state and local public health officials to determine if modifications to visitation and screening are appropriate on a case-by-case basis.
  • Any COVID-19 infection prevention policy that is developed by a healthcare facility to meet the Medicare conditions should be approved by the facility’s governing body, or equivalent group as defined by regulation, before implementation.

Healthcare facilities should review their own infection prevention and control policies and practices to prevent the spread of infectious disease and illness, including COVID-19. Should COVID-19 case rates increase in certain geographic locations, concerned SAs should strongly consider doing a FIC survey in consultation with the applicable CMS location.

Please review the entire QSO Memorandum with your team.

One can’t help but wonder if this is a sign that HHS may be preparing to end the PHE declaration when it expires in April? We, with LTCFs and senior living communities in particular, have a long way to go before we can take our focus off the battle at hand which is keeping COVID-19 illness and the virus out of our communities and away from residents, staff and visitors. Stay sharp and safe out there!