Norris Cunningham

With the roll out of vaccines and slowing rates of COVID-19 infections, the Centers for Medicare & Medicaid Services has not shifted its survey focus away from infection control. Instead, the agency released new guidance to surveyors continuing focus on infection control during annual and complaint surveys, including additional F-tags.

This focus, while timely, will most likely extend the survey process and result in additional tags and possible civil monetary penalties. Of concern is the attention to interviewing staff members who might use the time to air grievances instead of looking at the facility as a whole.

Surveyors have been instructed to confirm that staff are performing proper general standard precautions, including respiratory hygiene/cough etiquette, environmental cleaning and disinfection, reprocessing of reusable resident medical equipment, mask wearing and hand hygiene.

Staff will be interviewed to determine if hand hygiene supplies (e.g., alcohol-based hand rub, soap, paper towels) are readily available and who they contact for replacement supplies. While this information would be expected to be known by all staff, it is possible that facilities could be found not in compliance if one staff member does not provide all the information upon questioning.  

As broadcast nightly throughout the midst of the pandemic, personal protective equipment is a hot point for healthcare providers and now, surveyors. While PPE is now more available, staff will still be interviewed to determine if PPE supplies are readily available, accessible and used by staff, and who they contact for replacement supplies.

Kathryn Cordell

While in-servicing staff, confirm they are not only following appropriate infection protocols but also are knowledgeable about the location of supplies and how to request additional supplies.  Simply put, facilities must make certain that supplies are readily available to staff. If PPE supplies are low, the facility needs to be able to show the steps taken to address the issue. Therefore, documentation of any and all orders for PPE as well as contacts in obtaining the same are imperative to demonstrate compliance.  

Finally, surveyors are also being instructed to focus on the presence of a facility infection preventionist, who is responsible for the facility’s infection prevention and control program. The only requirements set forth by CMS are that the infection preventionist(s) must work at least part-time and must complete specialized training in infection prevention and control.

Documentation of this training must be maintained and presented to surveyors upon request.  It is concerning that the guidelines to the surveyors do not address how or when a facility can be cited if its IP wears multiple hats and infection prevention is one of their duties.  

The impact of COVID-19 has propelled infection control into the forefront and will undoubtedly be a major area of inspection during any and all surveys conducted by the state agencies. 

Facilities must continue to navigate the increased attention to infection control and must ensure that they remain up to date on CMS’s ever-changing policies.

The impact of the intense focus on infection control considering the COVID pandemic has resulted in significant citations and civil monetary penalties. It is unfortunate that a not insignificant number of citations and penalties will be issued based solely upon the misinformed statements of a small number of staff.  

Norris Cunningham is a founding shareholder and leads the Health Care Practice Group at Katz Korin Cunningham PC (KKC) in Indianapolis. Contact him at [email protected]. Kathryn Cordell is a partner and a member of Katz Korin Cunningham PC’s Health Care Practice Group. She concentrates her practice in the defense of healthcare providers in civil and regulatory actions, including Medicaid, Medicare and professional licensing boards. Contact her at [email protected].