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CMS Issues QSO-22-02-ALL Related to Survey Activity

On Nov. 12, CMS issued QSO-22-02-ALL providing guidance to state survey agencies (SA) on survey activity.  Included in the QSO are directives on how to address the backlog of complaints and recertification surveys including revising the criteria for Focused Infection Control (FIC) surveys, resuming recertification surveys and temporary guidance, and minor flexibility on conducting compliant surveys.  Also included in the QSO are directives for SSAs to focus on particular quality-of-life standards that CMS expressed an increased concern with during the PHE. 

CMS expressed in the QSO that infection prevention and control remain a priority in nursing homes, however, vaccination rates have led to decreased cases and deaths among residents and staff in the nursing home setting.  CMS addressed that the vaccine mandate interim final rule was developed because staff vaccination rates were approximately 20% lower than resident vaccination rates as of August 2021.

Focused Infection Control Surveys:

  • CMS is rescinding the guidance in QSO-20-31-All directing SA to conduct FIC surveys within 3-5 days of an outbreak of COVID-19, unless the SA has concerns related to the providers ability to manage COVID-19 infections or concerns with infection control practices.  CMS notes that the other remaining practices in QSO-20-31-ALL remain in effect.  The remaining practices in QSO-20-31-ALL included enhanced enforcement for infection control deficiencies, Quality Improvement Activities in Nursing homes, and CARES Act Funding.
  • The SAs are still required to complete 20% annually of FIC surveys in nursing homes, which should be prioritized based on providers that are reporting new cases of COVID-19 and have low vaccination rates.  The 20% FIC surveys must continue to be stand-alone surveys (not conducted in conjunction with recertification surveys) but are able to be completed with complaint surveys.  If SA fail to conduct these FIC surveys or fail to complete surveys timely, they could forfeit up to 5% of their CARES act, annually. 

Recertification Surveys:

  • Recertification surveys that were missed during the PHE do not need to be “made up”.  In other words, SA’s should resume the normal survey schedule moving forward as described. 
  • CMS is indicating that all SA’s should be able to resume recertification surveys on a regular basis and should do so by establishing new intervals based on each nursing home’s next survey, not based on the last survey that was conducted prior to the COVID-19 PHE.  The QSO lists the following example:
    • If the SA scheduled a LTC Recertification in April 2020, and was unable to conduct it because of the PHE, but now conducts that survey in August 2021, the next annual recertification survey would be due by the end of the October 2022 (15 months from completion of the August 2021 survey).
    • If the nursing home is considered a special focus facility (SFF) and is scheduled for recertifications every 6 months, the next recertification would be due by the end of February 2022. 
  • CMS is recommending that SA’s prioritize recertification surveys according to the potential risk to residents, such as nursing homes 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 competencies
    • SFF and SFF candidates
    • Other quality-of-care issues such as falls or pressure ulcers.
  • In addition, CMS is temporarily allowing certain mandatory survey tasks to be completed at the discretion of the surveyor or when triggered based on concerns identified during offsite survey preparation, concerns identified by the ombudsman, and previous patterns of citations. These tasks include:
    • Resident Council Meetings.  Since the surveyors complete approximately 40 resident interviews based on the census, they may skip the resident council meeting task.  If there are concerns expressed during interviews such as with visitation or grievances, the survey team should proceed with the task.
    • Dining Observation.  This task may be skipped unless the surveyor has concerns with nutrition, weight loss, or concerns identified related to dialysis.
    • Medication Storage.  This task may be skipped unless the surveyor identified concerns with medication storage when completing the mandatory task of medication administration observation. 

Complaint/Facility Reported Incidents:

  • CMS is providing flexibility in completing Complaint and Facility Reported Incident (FRI) Investigations.
  • CMS stated that if a complaint/FRI is added to the recertification survey and the maximum number of residents is exceeded, CMS expects that the survey team will either add additional surveyors to the survey or extend the survey length.
  • In an effort to work through the backlog of complaints/FRI, CMS is instructing the SA to prioritize complaints/FRI and reviewing the time frames that complaints/FRI must be completed in. 
    • Complaints/FRI triaged as an IJ and Non-IJ-High are required to be investigated within two to ten working days, respectively.  If they cannot meet that deadline, the complaints/FRI should be investigated as soon as possible. 
    • Complaints/FRI triaged as a Non-IJ-Medium may be completed with the next scheduled standard survey. 
      • If the complaint/FRI was received within one year of the scheduled standard survey date or the allegation involved staff to resident abuse, neglect, or misappropriation of resident property, regardless of the date that the complaint/FRI was received.  
      •  If the SA chooses to not investigate during the next standard survey, they may initiate a complaint survey. 
      • If conducted during the standard survey, the resident must be linked to the survey and included in the initial pool and final resident sample.  For example, if a standard survey was scheduled for Aug. 1, 2021, then the SA must investigate all non-IJ-Medium complaints/FRI that were received since Aug. 1, 2020 that were not already investigated.
      • If the complaint/FRI was received more than one year ahead of the scheduled survey, the SA should review the allegation for patterns of poor care.  If there is an indication of a pattern of poor care, the SA should include the complaint/FRI in the next standard survey.  If there is no pattern of poor care the SA may close the complaint without investigation. 
    • Complaints/FRI triaged as Non-IJ-Low are not required to be investigated and may be closed. The SA may use discretion and include the complaint in the next standard survey.
    • CMS has acknowledged that conducting complaint/FRI with recertification surveys could lengthen the time to complete the surveys and will work with SAs to establish reasonable expectations on plans to address the backlog.

Increased Oversight in Nursing Homes:

CMS expressed they are very concerned about how residents’ health and safety has been impacted during the PHE in areas such as weight loss, pressure ulcers, abuse or neglect and other quality-of-care and quality-of-life issues and wants surveyors to be aware of these areas for potential further investigation during the survey.  These areas include:

  • Surveying for nurse competencies.  Since CMS has waived requirements surrounding the nurse aide training/testing, they are alerting SA to pay additional attention to compliance with the requirements for sufficient staffing and competencies.  CMS notes that surveyors should pay particular attention to the nursing staff's ability to identify and address a resident’s change in condition. Note that DIA indicated on our call Monday that they are issuing increased deficiencies in this area.
  • Inappropriate Use of Antipsychotic Medications. Surveys are instructed to focus their efforts on identifying the inappropriate use of antipsychotic medications and emphasize non-pharmacological approaches and person-centered care practices.
  • Identifying Other Areas of Concern such as unplanned weight loss, loss of function/mobility, depression, abuse/neglect, or pressure ulcers. 

CMS is encouraging SA to utilize the Sufficient and Competent Staffing Critical Element Pathway and the appropriate critical element pathways noted in the other areas of concern. Critical element pathways can be found on CMS’ nursing home website.