Regulatory Update

Changes for nursing home surveyors are going into effect this October and one area facilities need to be focused on is infection control.

Polaris Group Profile
Polaris Group
July 25, 2022
September 14, 2022
Polaris Group Profile
Polaris Group
September 14, 2022
Summary

Read our blog on the latest CMS surveyor guidance on infection control deficiencies and how to ensure your facility prevents citations.

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Changes for nursing home surveyors are going into effect this October and one area facilities need to be focused on is infection control.

As infectious diseases like COVID-19 or the flu can cause serious illness in vulnerable older adults residing in nursing homes, the Centers for Medicare and Medicaid Services (CMS) is increasingly focused on how to mitigate the spread of infections among residents. In accordance with President Biden’s initiative “Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes“, there is now a CMS requirement that each nursing home has an infection preventionist (IP) who is on-site at least part-time.  

Nursing homes have always struggled with adequate infection control  

Having a focus on infection prevention is long over-due in nursing homes as lax infection control was a problem before the pandemic. From 2013-2017, 82% of facilities were cited for infection control and prevention deficiencies. And little has changed. Currently, the  most commonly cited Ftag deficiency is F880: Infection Prevention and Control.  

Another component of an infection prevention and control program is immunizations. Facilities must offer vaccines and vaccine education to residents. This is another area where facilities are falling short. The 7th most commonly cited deficiency is F883: Influenza and Pneumococcal Immunizations.  

As announced in the CMS memo on revised surveyor guidance, COVID-19 requirements are now linked to surveyor software for several deficiencies. Going forward, reporting COVID-19 data to residents, their representatives, and their families is associated with F-tag 885 and COVID-19 testing and vaccine administration is associated with F-tag 887. With these COVID-19 requirements now at the forefront of surveyor documentation, facilities must incorporate these components in their infection control plans.  

Strategies to reduce deficiencies and avoid citations: the role of mock surveys  

A mock survey from Polaris Group applies the same protocols, tasks, and quality indicators used by surveyors. Mock surveys also include an exit interview and detailed report with potential infection control deficiency findings and recommendations to assist in taking corrective action. This process can be very beneficial, as it helps nursing homes identify risk areas, achieve compliance, and avoid monetary penalties which can cost between $5,000 and $10,000 per instance.  

Polaris Group consultants can also assist facilities in reviewing processes for documentation as charting is key for compliance with the infection control and prevention F-tags. For example, vaccines must be offered to all residents, yet residents have the right to refuse. Importantly, refusal must be documented in the resident record to avoid citation.

Consultants can also review facility in-services and staff training to ensure that staff are able to demonstrate infection control procedures and state to a surveyor how the organization is following practices for hand hygiene and donning and doffing of PPE. And if there is an infection, Polaris Group consultants can review monitoring activities and practices to help facilities ensure that infections do not spread throughout the facility.  

The time is now for better infection control. CMS dictates it and our residents deserve it. Reach out to Polaris Group consultants for assistance in building your facility’s infection control and prevention plan.

For more information, visit: polaris-group.com

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