MDS Alert

Prioritize infection control measures, but consider ways for residents to interact safely, too.

As nursing homes and communities move to lessen various restrictions, state survey agencies are instructed to adjust their survey expectations again to abide by the White House guidelines on Opening Up America Again. These guidelines are delineated for employers and individuals, and focus on three phases of reopening. The guidelines include specific instructions and criteria for hospitals and “senior care facilities.”

As you know, during the height of nationwide efforts to “flatten the curve,” state survey agencies were structed to investigate only immediate jeopardy (IJ) situations or situations that harmed residents. Now, as communities, state and regional economies, and nursing facilities move to Phase 2 of reopening, surveyors will be on the look out to evaluate facilities’ care of residents and management of infection control and staffing.

Focus on Navigating Phases of Reopening

States and regions within states are at different “places” in their experience and response to the COVID-19 pandemic. Figuring out how to proceed becomes even more complicated for nursing facilities since they face additional pressure to keep residents safe.

“A nursing home may be in different phases than its surrounding community based on the status of COVID-19 inside the facility, and the availability of key elements including, but not limited to PPE, testing, and staffing. For example, if a facility identifies a new, nursing home onset COVID-19 case in the facility while in any phase, that facility goes back to the highest level of mitigation, and starts over (even if the community is in phase 3),” says David R. Wright, director of quality, safety, & oversight group at CMS in Baltimore.

Individual states have the power to mandate a longer waiting period, too, Wright says. Facilities that have had significant outbreaks of COVID-19 or history of noncompliance with infection control measures or issues staffing levels may need more oversight before restrictions are relaxed. Communicate with your local health department and state officials to know where your facility stands.

Understand Physical Distancing Protocols

Whether the country has truly escaped the crisis point of the pandemic remains to be seen, but elected officials, long-term care industry stakeholders, and public health experts are all acknowledging the vast toll some of the social distancing recommendations have taken and are still taking on mental health. With nursing facility residents particularly vulnerable to more severe complications from COVID-19, the disease caused by the virus SARS-CoV-2, the resident-isolation and staffing protocols affected a lot of the seemingly mundane, often intimate interactions that make up the bulk of nursing home life.

Unsurprisingly, visitors are prohibited during Phases 1 and 2 of reopening, according to the White House guidelines. However, other forms of face-to-face interaction may be possible.

Social distancing protocols are laid out for communal dining and group activities as part of Phase 2 recommendations. One big takeaway: Physical space matters, but numbers do, too.

For example, facilities can implement (or continue to allow) communal dining, but only for residents who are asymptomatic or have tested negative for COVID-19, but facilities must enforce social distancing by limiting the number of residents at each table and using 6-foot spacing, Wright says.

Make These Areas Priority

Once facilities enter Phase 2 of Opening Up America Again, state surveyors are instructed to widen their focus. The following five areas are priority, Wright says:

1. “Abuse or neglect,”

2. “Infection control, including lack of notifying families and their representatives of COVID-19 information (per new requirements at 42 CFR 483.80(g)(3)),”

3. “Violations of transfer or discharge requirements,”

4. “Insufficient staffing or competency,” and

5. “Other quality of care issues (e.g., falls, pressure ulcers, etc.)”

Surveyors are also instructed to prioritize evaluating facilities that have had a “significant number” of COVID-19 cases (though there’s no definition of what constitutes significant here), Special Focus Facilities (SFF) and SFF candidates, and facilities that have not received a standard survey in more than 15 months and also have a history of noncompliance at “harm” level for the five areas listed above.

Though this guidance is provided at a federal level, Wright notes that ultimately states are at the helm.

“We recognize that there are many different scenarios or combinations of timing of surveys and types of noncompliance that will exist. We defer to States for final decisions on scheduling surveys consistent with CMS survey prioritization guidelines,” he says.