AHCA/NCAL: CMS Releases Updated Guidance and Resources to Surveyors

CMS made updates to the Long-Term Care Survey Process Procedure Guide effective January 27, 2022. These updates include:

• Mandatory facility task assignment and review of NHSN data related to the QSO Memo-QSO-22-07-ALL
• Entrance Conference Worksheet updates to include COVID-19 Vaccine review and COVID-19 Staff Vaccination Matrix located under Survey Resources January 2022 (1/25/22) (ZIP).
• Closed record review may select a resident with confirmed case of COVID-19 in last four weeks who was hospitalized or died to add to closed record review.
• Infection Control surveyor will review the infection prevention and control program, policy and procedures for staff COVID-19 vaccination, antibiotic stewardship program, and the influenza, pneumococcal, and COVID-19 for residents and staff.
  • Details around whether to enforce §483.80(i). If enforced, the facility will have 4 hours to complete the COVID-19 Staff Vaccination Matrix.
  • Once the matrix is received, the assigned surveyor selects eight staff to review for COVID-19 vaccinations according to the guidelines below:
    • 2 vaccinated staff (at least one CNA and one contractor who provides services, such as hospice and dialysis staff, occupational therapists, mental health professionals, licensed practitioners).
    • 6 unvaccinated staff, if available (3 unvaccinated staff (2 CNAs, if available) without exemption or reason for temporary delay, 1 non-medical exemption, 1 medical exemption (Note: If there are 2 or more staff with medical exemptions, select 50% of the staff from this category), one whose primary vaccine series has been temporarily delayed.
    • If there are no staff who meet one of the above unvaccinated criteria, no increase to the sample size is needed for another category.
    • If they identify any staff that weren’t vaccinated and weren’t granted an exemption or temporary delay (and weren’t listed on the staff matrix), that individual(s) should be added to the staff sample.
• F888 will be cited according to Attachment A in the QSO-22-07-ALL memo.
• Dining task: Temporarily allowing the dining task to be discretionary and completed only if a resident is investigated for nutrition, weight loss, or facility incidents related to dialysis.
• Med Storage: CMS is temporarily allowing the med storage task to be discretionary and only completed if there is an outstanding complaint, or concerns from the ombudsman or concerns identified when completing the med admin observation task.
• Resident Council: CMS is temporarily allowing the resident council task to be discretionary and only completed if there’s an outstanding complaint, or concerns from the ombudsman or during the initial pool (e.g., with visitation or grievances).

For more information on updates, please visit CMS’s Nursing Home website.

Reminder 

Watch for Skin Integrity Issues from Mask Use: This is a reminder that elderly who often have fragile skin, decrease sensation, or limited mobility are at increased risk for skin damage from the straps on masks. There have been some reports recently of residents developing pressure ulcers to skin around the ears. Skin damage may occur quickly, which is why repositioning of masks and skin assessment should be incorporated into the plan of care for residents who need to wear masks for extended periods of time.

NYSHFA/NYSCAL CONTACTS:

Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15

Jackie Pappalardi, RN, BSN
Executive Director
518-462-4800 x16