New CMS QSO Outlines Enhanced Enforcement for Infection Control Deficiencies in Nursing Homes
On March 30, 2023, the Centers for Medicare and Medicaid Services (CMS) rescinded memorandum QSO-20-31-ALL and issued QSO-23-10-NH strengthening enforcement efforts for infection control deficiencies in nursing homes.
Per the new QSO:
- The enhanced enforcement actions are more stringent for infection control deficiencies that result in actual harm or immediate jeopardy to residents. In addition, the criteria for enhanced enforcement on infection control deficiencies that result in no resident harm has been expanded to include enforcement on noncompliance with Infection Prevention and Control (F880) combined with COVID-19 Vaccine Immunization Requirements for Residents and Staff (F887).
- CMS is providing guidance to the State Survey Agencies and CMS locations on handling enforcement cases before and after the revisions of Enhanced Enforcement for Infection Control Deficiencies.
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Revised Enhanced Enforcement for Infection Control Deficiencies
Non-compliance with deficiencies associated with Infection Control requirements will lead to the following enforcement remedies:
Non-compliance with both Infection Prevention and Control (F880) concurrent with COVID-19 Vaccine Immunization Requirements for Residents Staff (F887) requirements cited at Scope and Severity (S/S) Level 2 – i.e., D, E, F (No Actual Harm with Potential for More Than Minimal Harm):
- Directed Plan of Correction that includes Root Cause Analyses and working with a Quality Improvement Organization or another qualified consultant; and
- Discretionary Denial of Payment for New Admissions with a 30-day notice period to achieve substantial compliance.
- Enhanced Enforcement of F880 at S/S Level 2 is applicable when F887 is also cited at any level. Additional remedies may apply if F887 is cited at S/S Level 3 or 4, as per normal enforcement policy outlined in Chapter 7 of the State Operations Manual.
Non-compliance for Infection Prevention and Control (F880) cited at S/S Level 3 – i.e., G, H, I (Actual Harm):
- Directed Plan of Correction that includes Root Cause Analyses and working with a Quality Improvement Organization or hiring an Infection Control Consultant to develop and implement a corrective action plan; and
- Discretionary Denial of Payment for New Admissions with a 15-day notice period to achieve substantial compliance; and
- Civil Money Penalty imposed according to the CMP Analytic Tool with a ten percent increase adjustment.
Non-compliance for Infection Prevention and Control (F880) at S/S Level 4 – i.e., J, K, L (Immediate Jeopardy):
- Directed Plan of Correction that includes Root Cause Analyses and working with a Quality Improvement Organization or hiring an Infection Control Consultant to develop and implement a corrective action plan; and
- Discretionary Denial of Payment for New Admissions with a 15-day notice period to achieve substantial compliance; and
- Civil Money Penalty imposed according to the CMP Analytic Tool with a twenty percent increase adjustment.
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The strengthened Enhanced Enforcement for Infection Control deficiencies guidance outlined above will apply to any enforcement cases with a survey cycle start date on or after [March 30, 2023].
LeadingAge NY encourages nursing home members to read the new QSO in its entirety and reach out to any member of the Policy staff with any questions.
Contact: Amy Nelson, anelson@leadingageny.org, 518-867-8383 ext. 146