CMS Updates Entrance Conference Document for Survey

Multiple COVID-19-related updates have been made to the Entrance Conference Worksheet that is provided to the administrator upon the survey team entering the nursing home for survey. The changes are broken down by section below:

Immediately Upon Entrance:

#5 – List of residents positive for or suspected of having COVID-19

#7 – Name of facility staff responsible for overseeing COVID-19 vaccination effort

At Entrance Conference:

#12 – A copy of the facility's updated floor plan, if changes have been made, including COVID-19 observation and COVID-19 units

Within One Hour of Entrance:

#19 – List of key personnel, location, and phone number of who is responsible for COVID-19 notification to residents, families, and representatives for confirmed or suspected cases in the facility

#21 – What mechanism is used to inform residents, families, and representatives of confirmed or suspected cases of COVID-19 in the facility, and what mitigating actions are being taken to reduce the risk of transmission, including if normal operations in the nursing home will be altered (e.g., supply the newsletter, email, website). If the system is dependent on the resident or representative to obtain the information themselves (e.g., website), provide the notification/information given to the residents, their representatives, and families informing them of how to obtain the updates.

#22 – Documentation related to COVID-19 testing, which may include the facility's testing plan, logs of county positivity rates (before Sept. 10, 2021) and the level of community transmission (after Sept. 10, 2021), testing schedules, list of staff who are confirmed or suspected of being COVID-19-positive, and if there were testing issues, contact with state and local health departments

Within Four Hours of Entrance:

#23 – Completed Matrix (CMS-802) *This form now contains COVID-19 as an infection in column 20 – Infections*

#31 – COVID-19 Immunization Policy and Procedures

#32 – Lists of residents and staff with their COVID-19 vaccination status

Before End of First Day:

On the Electronic Health Record (EHR) Information Form, which is provided to surveyors showing them how to access certain pieces of information in the facility's EHR, there is now a spot for COVID-19 testing. Facilities should make sure, if their lab results are integrated with their EHR, that they document how to access the COVID-19 test results for the residents on this form before providing to the survey team.

Contact: Mark Kepner-Clough, mkepner-clough@leadingageny.org, 518-728-2365