New Targeted Facility Inspection Plan for Healthcare Facilities Announced by CMS
The Centers for Medicare & Medicaid services (CMS) announced March 23 results from a recent inspection of the Washington nursing home that is considered the epicenter for the COVID-19 outbreak in that state. The inspection provided CMS with information to improve and enhance its national strategy for keeping residents in nursing homes and other healthcare facilities safe using a focused inspection process.
CMS Administrator Seema Verma stressed that, “Patient safety starts with the front line healthcare provider, so we’ve developed a self-assessment tool in coordination with the CDC. Today, we’re issuing a call to action to nursing homes, hospitals, and the entire healthcare system: Don’t wait to be inspected.
Starting today, you can – and should – use CMS’s self-assessment tool to ensure you’re prepared to prevent the spread of Coronavirus.” (https://qsep.cms.gov/data/252/A._NursingHome_InfectionControl_Worksheet11-8-19508.pdf)
This targeting will be in full effect beginning immediately. Under CMS’ focused survey process, only the following types of federal inspections will be prioritized and conducted over the next few weeks:
- Complaint inspections: State survey agencies will continue to conduct inspections related to complaints and facility-reported incidents that are triaged at the Immediate Jeopardy level. Inspectors will use a streamlined Infection Control review tool, regardless of the Immediate Jeopardy allegation.
- Targeted Infection Control inspections: Federal and state inspectors will conduct targeted infection control inspections of providers identified through CMS collaboration with the Centers for Disease Control and Prevention (CDC). These inspectors will use a streamlined targeted review checklist to minimize the impact on provider activities, while ensuring providers are implementing actions to protect health and safety. This will consist of both onsite and offsite inspections.
- Self-Assessments: The Infection Control checklist referenced above will also be shared with providers and suppliers, to allow for self-assessment of their Infection Control plans. This may be the best solution in some cases when there is a lack of personal protective equipment or state surveyors available.
Compliance Perspective
Failing to perform self-assessments to ensure that a facility is prepared to prevent the spread of COVID-19 may result in placing residents in immediate jeopardy and be considered provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding self-assessment of the facility’s Infection Control Plan using the CMS Infection Control checklist.
- Train staff regarding the facility’s Infection Control Plan and performing self-assessment of that plan, using CMS’s Infection Control checklist.
- Periodically audit to determine if the facility is continuing to self-assess its Infection Control Plan using the CMS Infection Control checklist.
