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Important CMS Updates for Skilled Nursing Facilities

Article / COVID-19

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Two Important Links for Today:

Nursing Home Visitation – COVID-19 (Revised) Memo

Changes to COVID-19 Survey Activities and Increased Oversight in Nursing Homes Memo

Important CMS Updates for Skilled Nursing Facilities:

On Friday Nov. 12, 2021, the Centers for Medicare & Medicaid Services (CMS) released two Quality, Safety & Oversight memos—one regarding visitation and another regarding survey oversight for nursing homes. AAPACN recommends reading both memos for full details. A summary of the highlights is provided below.

Nursing Home Visitation

CMS revised its September 2020 memo, allowing visitation for residents at all times for both indoor and outdoor visitation. Facilities are not permitted to limit the frequency, length, number of visitors, or require advanced scheduling of visits. All visits should adhere to the core principles of COVID-19 infection prevention, which include:

  • Visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine, should not enter the facility. Facilities should screen all who enter for these visitation exclusions.
  • Hand hygiene principles  (use of alcohol-based hand rub is preferred)
  • Face covering or mask (covering mouth and nose) and physical distancing at least six feet between people, in accordance with CDC guidance
  • Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits, and routes to designated areas)
  • Frequent cleaning and disinfecting of high-touch surfaces, and designated visitation areas after each visit
  • Appropriate staff use of Personal Protective Equipment (PPE)
  • Effective cohorting of residents (e.g., separate areas dedicated to COVID-19 care)
  • Resident and staff testing conducted as required at 42 CFR § 483.80(h) (see QSO-20- 38-NH)

Physical distancing should be maintained during peak times of visitation, such as meal times and evenings. Large gatherings within the facility should be avoided if physical distancing cannot be maintained. All visitors should wear face coverings or masks when around other residents or healthcare personnel, regardless of vaccination status. Additional guidance directs:

  • If the nursing home’s county COVID-19 community level of transmission is substantial to high, all residents and visitors regardless of vaccination status, should wear face coverings or masks and physically distance, at all times.
  • If a resident and all their visitor(s) are fully vaccinated and the resident is not moderately or severely immunocompromised, they may choose not to wear face coverings or masks and to have physical contact.
  • If a resident’s roommate is unvaccinated or immunocompromised (regardless of vaccination status), visits should not take place in the resident’s room, if possible.

The new revision also allows, but does not recommend, that residents who are on transmission-based precautions or quarantine may receive visitors. These visits should occur in the resident’s room and the resident should wear a well-fitting facemask (if tolerated). Before visiting these residents, visitors should be educated on the potential risks of the visitation and precautions that should be taken. Facilities may offer well-fitting facemasks or other appropriate PPE to visitors, but it is not required.

Unvaccinated residents may also choose to have physical contact with their visitors. Prior to the visit, the resident making this choice and their visitor should be educated regarding the potential risks of this physical contact. 

Visits during a facility outbreak investigation are now allowed as well. Visitors must be educated regarding the potential risk of entering the facility and should wear face coverings or masks during the visit regardless of vaccination status and adhere to the core principles of infection prevention.

Visitor Testing and Vaccination

Although it is not required, CMS encourages facilities in counties with substantial or high levels of community transmission to offer testing to visitors, if feasible. If they do not offer testing, they should encourage visitors to get a test on their own prior to coming to the facility for a visit. 

Facilities should educate and encourage visitors to become vaccinated. They may ask visitors about their vaccination status; however, they cannot limit entry to only vaccinated visitors. All visitors that are either unvaccinated or decline to discuss their vaccination status should wear a face covering at all times.

Access to Long-Term Care Ombudsman and Federal Disability Rights Laws and Protection & Advocacy (P&A) Programs

The ombudsman and any representative of the protection and advocacy systems must have immediate access to any resident. If an ombudsman or P&A representative is planning to visit a resident on transmission-based precautions or quarantine, or an unvaccinated resident in a county with substantial or high level of transmission in the past 7 days, both the resident and the ombudsman or P&A representative should be educated of the potential risk of the visit and the visit should take place in the resident’s room. If either the resident or the ombudsman or P&A representative requests alternative communication instead of an in-person meeting, the facility must provide such by phone or other means of technology.

Resident Outings

CMS states, “The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while in communal areas of the facility. For more information, see the Implement Source Control section of the CDC guidance “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.”

Residents must be allowed to leave the facility as they choose. When a resident leaves the facility, both the resident and the individual accompanying them should be educated to follow all recommended infection prevention practices while out of the facility including wearing a mask, hand hygiene, and physical distancing. 

Upon the resident’s return, nursing homes should take the following actions:

  • Screen residents upon return for signs or symptoms of COVID-19.
    • If the resident or family member reports possible close contact to an individual with COVID-19 while outside of the nursing home, test the resident for COVID-19, regardless of vaccination status. Place the resident on quarantine if the resident has not been fully vaccinated.
    • If the resident develops signs or symptoms of COVID-19 after the outing, test the resident for COVID-19 and place the resident on Transmission-Based Precautions, regardless of vaccination status.
  • A nursing home may also opt to test unvaccinated residents without signs or symptoms if they leave the nursing home frequently or for a prolonged length of time, such as over 24 hours.
  • Facilities might consider quarantining unvaccinated residents who leave the facility if, based on an assessment of risk, uncertainty exists about their adherence or the adherence of those around them to recommended infection prevention measures.
  • Monitor residents for signs and symptoms of COVID-19 daily.

Any resident out of the facility for 24 hours or longer should be considered as a new admission or readmission.

Survey Considerations

Facilities are not allowed to restrict access to surveyors based on vaccination status nor are they allowed to request proof of vaccination to allow entry into the facility. However, surveyors should not enter a facility if they have a positive COVID-19 test, show signs or symptoms of COVID-19, or meet criteria for quarantine. Upon entering a facility, surveyors should also follow the core principles of infection prevention and adhere to any state or federal COVID-19 infection prevention requirements.

Focused Infection Control (FIC) Surveys

CMS will no longer require the Survey Agency (SA) in each state to perform FIC surveys based on COVID-19 cases in a facility. Instead, CMS will require SAs perform annual FIC surveys of 20% of nursing homes. SAs should prioritize FIC surveys for facilities that are reporting new cases of COVID-19 and have low vaccination rates. To count toward the required 20%, these FIC surveys must be stand-alone surveys not associated with a recertification survey; the FIC survey may be combined with a complaint survey. FIC surveys may also be initiated by the SA when there is a concern about COVID-19 infection control. The Infection Prevention, Control, and Immunizations Survey Pathway and the FIC Survey protocol are available on the CMS website here.

Recertification Surveys

CMS directs survey agencies (SAs) to resume recertification surveys on a regular basis, which are required to be conducted no later than 15 months after the previous recertification survey for each facility, with a statewide average interval of 12 months or less. However, to reestablish adherence to this timeframe, CMS is providing the following direction to the SAs to establish new intervals based on each facility’s next survey, not based on the last survey that was conducted prior to the COVID-19 PHE. For example:

“If the SA had scheduled a LTC recertification survey for a facility in April 2020, and was unable to conduct it because of the PHE, but now conducts that survey in August 2021, the next annual recertification survey would be due by the end of October 2022 (i.e., 15 months from completion of the August 2021 survey). We note that Special Focus Facilities are required to be surveyed once every 6 months. In this example, if this facility were an SFF, the next recertification survey would be due by the end of February 2022.”

CMS directs SAs to prioritize recertification surveys for facilities according to the potential risks to residents. Facilities with a history of noncompliance or allegations of non-compliance in the following areas are recommend as a high priority:

  • Abuse or neglect;
  • Infection control;
  • Violations of transfer or discharge requirements;
  • Insufficient staffing or competency;
  • Special Focus Facilities (SFFs) and SFF candidates; and/or
  • Other quality-of-care issues (e.g., falls, pressure ulcers, etc.)

There are three mandatory tasks that are temporarily left to the discretion of the SA to determine if they are necessary or can be skipped. CMS clarifies this temporary practice in the following guidance:

  • Resident Council Meeting: Surveyors interview up to 40 residents in the initial pool depending on facility census (See Attachment A of the Long Term Care Survey Process (LTCSP) Procedure Guide). If concerns are identified through these interviews (e.g., concerns with visitation or grievances), the survey team should proceed with conducting this task.
  • Dining Observation Task: This task may be discretionary except it must be completed if a resident is being investigated for nutrition, weight loss, or concerns identified related to dialysis.
  • Medication Storage: This task may be discretionary except it must be completed if the surveyor identified concerns with medication storage when completing the mandatory task of medication administration observation.

Complaints/Facility-Reported Incidents (FRIs)

CMS will require SAs to address the backlog of complaints and FRIs with the following direction:

  • LTC Complaints/FRIs triaged as IJ or Non-IJ High – SAs are required to investigate backlogged complaints/FRIs triaged at this level as soon as possible.
  • Continuing and Acute Care provider complaints triaged as IJ – SAs are required to investigate backlogged complaints at this level as soon as possible.
  • Continuing and Acute Care provider complaints triaged as Non-IJ High – SAs are required to investigate complaints triaged at this level within an average of 90 calendar days, with no one complaint exceeding 120 calendar days.
  • LTC Complaints/FRIs triaged as Non-IJ Medium – SAs may investigate backlogged complaints/FRIs triaged at this level at the next scheduled standard survey:
    • If the complaint/FRI was received within one year of the scheduled standard survey date, or
    • If the allegation involves staff to resident abuse, neglect, or misappropriation of resident property, regardless of the date that complaint/FRI was received. Alternatively, if the SA does not investigate the Non-IJ Medium backlogged complaints/FRIs during the standard survey, the SA may initiate a complaint survey.
  • LTC Complaints/FRIs triaged as Non-IJ Low – SAs are not required to investigate backlogged complaints/FRIs triaged at this level and may be closed in ACTS at the next standard survey. The SA has discretion to include the resident(s), who is the subject of the allegation, in the standard survey sample. For example, the SA may choose to do this when there is a pattern of the same or similar allegations that suggest areas for focused attention. If the SA does not investigate the complaint/FRI onsite, then the SA may close the complaint/FRI in ACTS, by indicating that the complaint/FRI was “Withdrawn/Expired.”
  • Continuing and Acute Care provider complaints triaged as Non-IJ Medium and Non-IJ Low – SAs are required to follow the maximum time frames outlined in State Operations Manual (SOM), Chapter 5, section 5075.9.

Increasing Oversight in Nursing Homes

CMS is “very concerned about how residents’ health and safety has been impacted, such as increased weight loss, pressure ulcers, abuse or neglect, and other quality-of-care and quality-of-life issues” in relation to the PHE and the limitations on oversight. As such, CMS directs SAs to pay additional attention to compliance with nursing services at § 483.35, which states,

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e).

Furthermore, CMS directs SAs to focus on compliance with F-726 Competent Nursing Staff and discusses the need for all nursing staff to be competent to identify and manage changes in condition early and prevent decline. SA will use the Sufficient and Competent Staffing Critical Element Pathway found in the LTC survey pathways folder.

CMS also directs SAs to focus on the use of antipsychotic medications and other care areas of concern that pose a threat to resident health and safety. These areas include:

  • Unplanned weight loss
  • Loss of function/mobility
  • Depression
  • Abuse/neglect
  • Pressure ulcers/injuries

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