Developing a thorough understanding of key F-tags and emergency preparedness requirements are key strategies nursing homes should adopt to ensure they avoid steep fines following infection-control focused surveys. 

Having an in-depth knowledge of F880, F884, F885 and emergency preparedness requirements noted in Appendix Z E0042 is critical for providers hoping to comply with infection control requirements during the coronavirus pandemic, according to Alexis Roam, MSN, RN-BC, DNS-CT, QCP, curriculum development specialist with the American Association of Post-Acute Care Nursing. 

“Knowledge of the regulations allows providers to conduct a self-assessment to determine if there is a gap between expectations for compliance and the facility policies and daily operations,” Roam told McKnight’s

The Centers for Medicare & Medicaid Services announced Monday that providers struggling to comply with infection control requirements could be hit with fines of up to $20,000 under increased enforcement efforts.

CMS revises survey guidelines for some long-term care providers with Immediate Jeopardy citations

Operators who haven’t undergone an infection control-focused survey lately can expect one before July 31. CMS announced Monday that states that have not specially surveyed 100% of their long-term care facilities by the end of July will face financial penalties. About 20% of nursing homes hadn’t been surveyed as of earlier this week, federal officials said Monday.

“Long story short, if you have not received one yet, expect one,” said Jodi Eyigor, LeadingAge Director, Nursing Home Quality and Policy, during the group’s daily COVID-19 conference call Monday afternoon.

“In addition, by the end of June, CMS is expecting that state survey agencies will conduct on-site surveys for facilities that have had previous outbreaks with a cumulative of confirmed cases that are greater than or equal to 10 percent of their bed capacity; confirmed and suspected cases that are greater than or equal to 20 percent; or 10 or more deaths related to COVID-19,” she said. “Then within three to five days of identification of three or more new, suspected and confirmed cases since the last NHSN report or one confirmed case in a facility that was previously COVID-free.”

Danger warnings

Eyigor said “the nature of this beast [virus]” is that it will come back around at a later date. So she advised to “make sure — make absolutely sure — that you have that done your CMS self-assessment.”

She noted that LeadingAge has posted a self-assessment tool on its website that “goes right along with the CMS tool.” Eyigor added that providers should “make sure you are paying attention to all the resources that CMS is putting out there. If CMS mentions it, that means that it is important.”

She stressed that, above all, providers must adhere strictly to hand hygiene and personal protective equipment standards because that’s what federal regulators are most closely watching and citing. Constant training and monitoring of staff are also critical, she added.

AAPACN’s Roam also stressed the importance of being prepared for surveys and maintaining a survey book that’s current and contains required documentation. She noted that the COVID-19 Focused Survey for Nursing Home can be used to conduct a mock survey and test preparedness. Providers can debrief findings and develop an action plan that addresses any findings of non-compliance.

Offering education to staff that’s engaging and relative to their work is also a key tactic for providers, she explained. She added that resident change of status is important, in addition to general infection control and prevention practices. 

Other tips included: conducting routine process surveillance that includes observations at the bedside of compliance for hand hygiene, donning and doffing PPE, and utilizing the appropriate PPE that “aligns with the transmission-based precautions that are in place.” She also emphasized documenting decisions and actions that are made that impact facility operations and care delivery. 

“A daily debrief or other method for the leadership team to capture this information will be imperative to present to a survey team when questioned,” Roam said.