February 29, 2016

CMS Infection Assessment & Prevention Improvement Surveys

Kris B. Harmony, OTR/L, LNHA, MBA

Kris B. Harmony, OTR/L, LNHA, MBA

hands-with-germs-adult_0-839476-edited.jpgWith a heightened focus on the growing issues with infection, specifically the Ebola Virus, The Centers for Medicare and Medicaid Services has teamed up with the Centers for Disease Control and Prevention (CDC) to begin a process of providing surveys and education across the healthcare continuum.  The intent of this process is to assist the industry with identifying issues with infection control practices and develop procedures to assist with prevention of cross contamination and the spread of disease. The initial primary focus of this plan will be nursing facilities and hospitals. CMS offered the following summary in a recent press release.

CMS Memorandum Summary

  • Project Overview: The Centers for Medicare & Medicaid Services (CMS) has begun a three year pilot project to improve the assessment of infection control and prevention regulations in nursing homes, hospitals, and during transitions of care.
  • Survey details: All surveys during the pilot will be educational (no citations will be issued) and will be conducted by a national contractor. New surveyor tools and processes will be developed and tested, focusing on existing regulations as well as recommended practices (such as those for antibiotic stewardship and transitions of care). Ten pilot surveys to be conducted in Fiscal Year (FY) 2016 will occur in nursing homes. Surveys in FY2017 and FY2018 will be conducted in nursing homes and hospitals.
  • Project Outcomes: New surveyor infection control tools and survey processes that can be used to optimize the assessment of new infection control regulations. 

The recent U.S. experience with Ebola highlighted the critical importance of infection prevention programs in protecting both healthcare personnel and patients. Translating lessons learned from the Ebola outbreak, including the importance of core infection prevention practices to every setting, is a significant opportunity to increase the safety of U.S. healthcare facilities. 

CMS also reviewed the critical role of nursing homes in the overall delivery of healthcare services and infection prevention. Per CMS, infections present in nursing facilities are estimated to include: 

  • 1 to 3 million serious infections occur every year in these facilities
  • Common infections include urinary tract infections, diarrheal diseases, antibiotic-resistant staphylococcal infections and other multi-drug resistant organisms

The industry has also had significant issues with re-hospitalizations and deaths due to infections, which has also become a significant area of focus. Per medical literature quoted in the recent CMS release, as many as 380,000 people die from infections in nursing homes every year. 

CMS also identified the importance of assessing the continuum of infection prevention efforts between hospitals and nursing homes in order to prevent transmission of infections in both settings. 

The focus of these pilots will not only be to evaluate facility practices, policies and procedures, but to also review infection prevention during transitions of care from one healthcare setting to another. Current CDC guidelines will be used to assess programs and make recommendations for process improvements. 

Details of specific visits are as follows: 

Scope of Work

CMS will use a national contractor to perform the surveys. While no citations will be issued, if an Immediate Jeopardy deficiency is noted, a referral to the CMS Regional Office will be made. The surveys will provide nursing homes and hospitals with guidance on improving infection prevention within their catchment area. Starting in FY2016, a pilot nursing home surveyor infection control worksheet (ICWS) and pilot survey process, in collaboration with the CDC, will better assess compliance with long term care facility infection control requirements that CMS published in 2015 in a Notice of Proposed Rule-Making. To the extent that such requirements are published in final form, CMS believes that these educational surveys will help the nursing homes become more prepared and help CMS and the CDC develop training materials for both nursing homes and surveyors. In FY2017, CMS expects the educational surveys will be conducted in both hospitals and nursing homes. 

Details of facilities selected and the dates that surveys will be complete will be distributed to each state’s regional Department of Health Survey Teams.

How To Prepare

Infection Control has long been the most cited F Tag in the industry. Facilities should review all of their infection control policies, including all of those related to OSHA guidelines, and ensure that they are detailed and contain the current standards of practice for both prevention and treatment of acute infections.

It is also important to ensure staff understand these definitions and document accordingly. For example, to code a UTI on the MDS, ensure all four required elements are documented in the medical record.

The final and most critical piece is to educate, educate, educate! All staff, from Physicians to Dietary need to understand how good prevention practice and appropriate treatment will ultimately prove successful in decreasing the vast amount of nosocomial infections we are plagued with as an industry.

Details related to the CMS memo can be found at the following link: 



If you have questions about this memorandum, please contact Kris B Harmony by clicking here or calling our office at (617) 595-6032

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