Expanded surveys will focus on staffing, MDS coding

The Centers for Medicare & Medicaid Services has revised the criteria that require states to conduct the specific surveys, the agency noted in a memo to state survey agencies Jan. 4.

Since June, CMS has required states to perform on-site infection control-focused surveys by the end of July at nursing homes with previous COVID-19 outbreaks, or within three to five days of any nursing home with three or more new confirmed cases since their last report to the National Health Care Safety Network.

The agency added five other factors that would trigger a survey. In addition to the presence of multiple new cases and consistently low staffing, new factors are: facilities selected for Special Focus Facility designation; facilities causing concerns related to conducting outbreak testing; and facilities that have had “Immediate Jeopardy” allegations or complaints lodged against them.

CMS said it will work with state surveyors to identify facilities meeting the new criteria.  

“Facilities that meet the criteria above to trigger a FIC (focused infection control) survey do not need to be resurveyed if a FIC survey was conducted (as a stand-alone FIC survey or as part of a recertification survey) within the previous three weeks,” the agency explained.  

“For example, if a facility is surveyed with a FIC survey within three to five days after meeting the criteria, and the same facility meets the criteria for being surveyed within three to five days in any of the next three weeks, the survey team does not need to conduct another survey within those three weeks. However, if the facility meets the criteria for a survey in the fourth week after a FIC survey was conducted, an additional FIC survey must be conducted within three to five days.”