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CMS Releases QSO Memo Requiring Enhanced Barrier Precautions

On March 20, the Centers for Medicare and Medicaid Services (CMS) released QSO-24-08-NH on Enhanced Barrier Precautions (EBP) in Nursing Homes. In July 2022, the Centers for Disease Control and Prevention (CDC) released updated EBP recommendations for Implementation of PPE Use in Nursing Homes to Prevent Spread of MDROs which encouraged nursing homes to establish EBP, however, it has not been required. Effective April 1, 2024, CMS will include processes for surveying nursing home compliance with CDC’s recommendations for EBP.

The interpretative guidance in Appendix PP within the State Operations Manual for F880 will be updated to include the following information on EBP.

Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities.

EBP must be used in conjunction with standard precautions to expand the use of PPE to donning gowns and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug Resistant Organisms (MDROs) to staff hands and clothing. EBP are indicated for residents with the following:

  • Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or
  • Wounds (generally include chronic wounds, not shorter lasting wounds) and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.
    • Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic food ulcers, unhealed surgical wounds, and venous stasis ulcers.
    • Examples of indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a PICC) is not considered an indwelling device for the purpose of EBP.
  • Nursing homes have discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC.
    • MDROs Targeted by CDC include Pan-resistant organisms; Carbapenemase-producing carbapenem-resistant Enterbacterales; carbapenem-resistant Pseudomonas; carbapenem-resistant Acinetobacter baumannii (CRAB) and Candida auris.

The QSO memo includes a table which outlines the resident’s status and when contact precautions or EBP should be used. For example, in cases where the resident is infected or colonized with any MDRO and has secretions or excretions that are unable to be covered the nursing home would use contact precautions instead of EBP.

High-contact resident care activities include:

  • Dressing
  • Bathing/showering
  • Transferring
  • Providing hygiene
  • Changing linens
  • Changing incontinent briefs or assisting with toileting
  • Device care or use
  • Wound care
  • CMS notes that in general, gowns and gloves would not be recommended when performing transfers in common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration.
  • Outside the resident’s room, EBP should be followed when performing transfers or assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.

Residents are not restricted to their rooms or limited from participation in group activities when in EBP. Discontinuation of EBP can occur when the wound is resolved/healed or upon removal of the indwelling medical device that placed them at higher risk.

Nursing homes can choose how to communicate to staff which residents require the use of EBP. CMS encouraged nursing homes to consider creative or subtle ways to alert staff when EBP use is necessary to help maintain a home-like environment, as long as staff are aware which residents require the use of EBP during high-contact care activities.

PPE and alcohol-based hand rub (ABHR) must be readily accessible to staff with discretion in the placement of supplies such as near or outside the resident’s room. The PPE may not need to be donned prior to entering the resident’s room. For example, when staff are answering the resident’s call light, staff are able to answer the call light and converse with the resident without donning PPE.

Surveyors are expected to evaluate the use of EBP when reviewing sampled residents for whom EBP are indicated and focus their evaluations of EBP use as it relates to CDC-targeted MDROs.

CMS notes that surveyor resources will be uploaded to the CMS Nursing Home website and downloaded into survey systems when available. As of March 20, these resources have not been updated. LeadingAge is also developing a policy template which will be included on the LAI website when available for members to use.

CDC also has resources available which may be helpful while training staff on the use of EBP: