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CMS Continues to Make Updates to COVID-19-Focus Survey Tool for Long-Term Care Facilities

April 1, 2021
April 1, 2021

When CMS revised its survey process in March 2020 to focus on facilities with a history of infection control issues or those that had suffered an outbreak of COVID-19, the goal was simple—a shorter, more limited survey that would reduce the number of staff needed to be onsite, as well as their time there, while also freeing up caregivers to handle the increased complexity of patient care.

In an April webinar hosted by HealthStream, Robin Harper, RN, a former surveyor and survey trainer who worked at CMS in its division for nursing homes as well as the division for chronic and post-acute care, and Tracy Cooley, RN, also a former surveyor and survey trainer who also has served as Director of Nursing in a skilled-nursing setting, shared some of the new survey’s goals and challenges that could come up. Now, in an update to that information, they have followed up with a second webinar appearance to talk about changes and what that means to providers and their facilities.

As before, the revised tool provides a focused review of seven critical elements that are associated with the transmission of COVID-19:

  • standard and transmission-based precautions
  • resident care
  • infection prevention and control program
  • infection
  • surveillance
  • education monitoring
  • screening of staff, visitor entry, and emergency preparedness

and now there are two new critical elements:

  • reporting to residents, representatives and families
  • reporting to the CDC

As they did in their previous presentation, Cooley and Harper reiterated the importance of pre-survey planning, such as coordinating with CMS and local and/or state health authorities in the case of an active COVID-19 case. In that instance, the survey team may be asked to wait before their visit. And as before, the visit will likely be a mix of on- and off-site surveyors.

“This is going to vary,” Cooley says. “We're hearing how surveys are being conducted is varying based on some of them being completely 100 percent offsite, while some are going to have that offsite-onsite component, the onsite component being anything from one to two surveyors for one to two days, or one surveyor for as little as 30 minutes a day for multiple days in a row. This is going to vary and it's going to vary based on what's going on in your facility and what's going on in your state.”

The planned offsite activities may include:

  • medical record reviews
  • phone interviews
  • facility policy and procedure reviews for the infection prevention and control program, including:
  • the surveillance plan
  • emergency preparedness pertaining to emergency staffing strategy

Onsite activities may include:

  • prioritized observations to key areas
  • activities related to infection control, onsite interviews
  • ·onsite record reviews

All this should be factored into pre-survey planning, Cooley says, so that the facility team is ready for whatever actually happens.

“If they decide there's going to be that onsite component when the survey team shows up at your door, they're going to notify the administrator of the limited nature of the COVID-19 focused survey,” she explains. “They'll conduct an entrance conference using the COVID-19 entrance conference form that was developed for this type of survey. If you haven't already taken a look at that, please do so and be prepared to follow that entrance conference form.”

Also, she adds, “Be prepared when asked by a surveyor to present your self-assessment using the COVID-19 focused survey tool. This tool walks you through a thorough review of your current processes. We encourage you as part of your QAPI program, as part of your infection control program, to use this tool along with the CDC coronavirus disease 2019 preparedness checklist for nursing homes and other long-term care settings. Together, these tools will help you determine gaps in care and services related to COVID-19.”

In this rapidly evolving environment, both of terms of facility operations and simply life in general, it will be essential to stay on top of ordinary workflow policies and procedures, especially those around hygiene and general infection prevention, Harper noted.

“Your staff want to do the right thing. They want to provide the best care possible to your residents,” she points out. “But right now, they're tired. They're scared. They may need those gentle reminders and guidance from you all to ensure that ongoing compliance in these areas. It's everyone's responsibility from the administrator, the director of nursing or even that peer to peer observations to ensure all staff have the continual guidance and education that they need.”

HealthStream works with organizations throughout non-acute care to address their challenges, from keeping pace with regulatory requirements to engaging and developing competent staff who can satisfy the demands of increased patient complexity. By partnering with HealthStream, organizations are equipped to seamlessly manage the pressures of surveyor visits, while remaining focused on high-quality patient and resident care. Learn more about HealthStream solutions for non-acute care organizations.