CMS Updates LTC Surveyor Guidance – LeadingAge NY Analysis: Segment 3: Infection Control

(Dec. 17, 2024) LeadingAge NY continues to analyze the Centers for Medicare and Medicaid Services' (CMS) new updates to the guidelines for surveyors recently announced in memorandum QSO-25-07-NH. With the effective date of Feb. 24, 2025 fast approaching, it is imperative to fully understand the implications for nursing home providers. This article will review the infection control modifications and major updates.

While significant sections have been added to the State Operations Manual (SOM) under Infection Control tags in the last few years, the guidance is not new. These updates include new guidance on the implementation of Enhanced Barrier Precautions (EBP), described in CMS memorandum QSO-24-08-NH; the requirements for educating staff and residents on COVID-19 vaccination, which includes offering or assisting with access to vaccine, as described in CMS memorandum QSO-21-19-NH; scope and severity consideration updates under F880; and the new F887 tag.

Providers should be aware that in the updates to F880 regarding EBP, a cross-reference is made creating a possibility for multiple tag citations with the new tag F628 Discharge Process, information provided to the receiving provider. Nursing homes should be sure that their EBP policies and procedures include notification of such status in all discharges to avoid this. More detailed information on the EBP requirements for nursing homes can be found here and here.

New guidance has been added in the SOM for surveyors to use when assessing the scope and severity of a citation at F880. This includes the following scenarios:

The facility failed to initiate an outbreak investigation and implement preventative measures to address transmission of COVID-19 among residents in one unit of the facility. Subsequently, one or more residents in an adjoining unit became seriously ill with contracted COVID-19, resulting in hospitalization for some residents.
The facility failed to prevent the transmission of COVID-19 between residents. Resident #1, who had COVID-19 symptoms, was not tested for COVID-19 prior to being placed in a room with a resident (Resident #2) who was not known to have COVID-19 and who did not have COVID-19 symptoms. This failure resulted in Resident #2 contracting COVID-19 and developing moderate illness.
During the survey, staff were observed entering a COVID-19 unit housing cognitively impaired residents through a stairwell entrance without donning necessary personal protective equipment (PPE). PPE was necessary when entering the unit because the cognitively impaired residents with COVID-19 could not be restricted to their room. Staff indicated that they were unaware of the need for donning PPE prior to entering this unit. Signs were not in place at all entrances to the designated COVID-19 unit indicating the need for PPE prior to entering. The lack of signage at the stairwell entrance of the COVID-19 unit resulted in staff not donning appropriate PPE prior to entering, which caused staff to not be properly protected and increased the risk of COVID-19 transmission.

Providers should also take note of the addition of F887, which covers COVID-19 immunizations. This describes in detail what the facility policies and procedures must contain, which include:

When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident or staff member has already been immunized.
Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine.
Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine.
In situations where COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine.
Before requesting consent for administration of any additional doses:
- The resident or resident representative has the opportunity to accept or refuse a COVID-19 vaccine and change their decision; and
- The resident's medical record includes documentation that indicates, at a minimum, the following:
  - That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and
  - Each dose of COVID-19 vaccine administered to the resident; or
  - If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.
The facility maintains documentation related to staff COVID-19 vaccination that includes, at a minimum, the following:
- That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine;
- Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
- The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN).

The guidance at F887 goes on to describe acceptable ways the vaccine may be offered, which include both directly by the facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity. The SOM also states instances where the facility is not required to educate and offer COVID-19 vaccinations, such as to individuals who enter the facility for specific purposes and for a limited amount of time, such as delivery and repair personnel or volunteers who may enter the facility infrequently (meaning less than once weekly).

Finally, CMS provides the updated critical element pathway for respiratory care under F880. Facilities should familiarize their staff with this updated surveyor tool as a great way to help prepare. More information on CMS's updated surveyor guidelines can be found here.

Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147