CMS Guidance Tackles Survey Backlog, Lifts Nursing Home Visitation Limitations

November 12, 2021, Amy Stulick, Skilled Nursing News - The Centers for Medicare and Medicaid Services (CMS) on Friday issued two updates regarding survey and visitation guidance — steps to address the backlog of complaint and recertification surveys, and revising visitation to include “all residents at all times.”

CMS said it will assist state survey agencies (SAs) with resuming surveys that took a backseat during the pandemic, when agencies prioritized infection prevention and control.  Timeframes will be determined on a state-by-state basis, CMS said in a memo.

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) said the survey backlog was something it had been “concerned about,” and praised CMS for its decision to lift visitation restrictions in an emailed statement to Skilled Nursing News. 

“This appears to be great news – a near return to normal,” a spokesperson for fellow senior care advocacy group LeadingAge said regarding the updates.  “But, the pandemic is still not over, so cooperation and collaboration are required to be sure that everyone follows core infection control principles.  Nursing home staff, residents, their families and friends all have to work together to ensure everyone’s well being.”

Revised criteria for COVID-19 Focused Infection Control (FIC) surveys was also part of the update — instead of conducting such surveys within three to five days of a facility having three-plus confirmed cases of COVID (or one confirmed case from a resident that was previously COVID-free), CMS is allowing FIC investigations to occur when COVID-19 management or infection control practice concerns arise.

The move is a bit ironic for Holly Harmon, vice president of quality, regulatory and clinical services for AHCA/NCAL and registered nurse; such surveys would produce new risks for exposure to COVID-19. 

“Surveyors are not required to be vaccinated against COVID-19.  This is counterintuitive when the federal agency is directing these same surveyors to soon penalize providers with less than perfect staff vaccination rates,” said Harmon.  “We should be a united front in protecting our vulnerable residents, and that means government officials who must enter our facilities for days on end should be fully vaccinated as well.”

SAs still need to conduct standalone FIC surveys — not associated with recertification — for 20% of total nursing homes in a state.  States that don’t meet the benchmark may lose up to 5% of their CARES Act funding annually.

Recertification surveys, which are normally conducted between 12-15 months apart for each facility, will resume within that pre-pandemic timeframe, CMS said.

Certain “protocol tasks” taken during a survey can be triggered based on ongoing investigations or concerns brought up during the onsite observations or interviews.  Resident council meetings, involving an interview with the surveyor and up to 40 residents, or dining observation, counts as a protocol task, CMS said in its memo.

“If the SA had scheduled a LTC recertification survey for a facility in April 2020, and was unable to conduct it because of the [public health emergency, PHE], but now conducts that survey in August 2021, the next annual recertification survey would be due by the end of October 2022,” CMS explained.

No additional recertification surveys will be needed to make up for those that couldn’t be completed during the PHE; SAs will instead be allowed to resume a “normal survey schedule,” CMS said in its update.

During the height of the pandemic, CMS had limited onsite surveys and activities to FIC investigations; complaints and facility-reported incidents alleging immediate jeopardy; revisits to verify removal of immediate jeopardy; and infection-related complaints.

Special Focus Facility (SFF) recertification surveys will resume every six months.

“Minor flexibilities” will be granted for complaint investigations, CMS added in its statement.  Just like with recertification surveys, SAs will be able to prioritize complaint surveys when more serious allegations arise.

Surveyors, with oversight from CMS, will focus more on resident quality-of-life and quality-of-care concerns while conducting investigations too.

Nursing staff competency will be more closely monitored within each facility, including inappropriate use of antipsychotic drugs, and if residents are experiencing unplanned weight loss, mobility loss, depression, abuse/neglect, or pressure ulcers.

“One of our major reform proposals includes improving the oversight process to be more resident-driven, so that surveyors are not simply looking for ways to penalize providers but recognizing good faith efforts and helping them find ways to improve,” Harmon said, referring to the organization’s Care For Our Seniors Act and noting similarities in efforts to improve resident quality of care via government oversight.

Added Harmon: “Now more than ever, we need to be lending caregivers a helping hand.  It is important that CMS and surveyors acknowledge the crises nursing home providers have faced and continue to experience with the unprecedented workforce and financial challenges, all while still battling COVID.”

Another memo specific to visitations states that while visitors should be made aware of COVID-19 risks in a nursing home, PHE limitations to resident visits will be lifted.  That includes nursing homes undergoing an outbreak investigation.

Facilities can no longer curb the number of visitors, frequency or length of the visit, which were all previously acceptable under the PHE.  Visits should still adhere to infection prevention protocols, CMS was quick to add — physical distancing should still be maintained during peak gathering hours, like mealtimes.

“This update represents our most comprehensive action to bring residents and loved ones closer together,” CMS said in its statement.

“We support and promote the need to allow visitors at all times,” added Harmon.  “They are crucial to our residents’ health and wellbeing, and loved ones are valued partners in delivering high quality care to residents.  It is key that visitors adhere to good infection prevention and control practices to protect their loved ones and other residents.”