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CMS Revises Guidance about Infection Control Surveys

January 06, 2021

Summary of CMS Memo on COVID-19 Survey Activities


On January 4, 2021, the Centers for Medicare & Medicaid Services (CMS) revised a June 1, 2020 memo to State Survey Agency Directors regarding survey activities and issued a set of Frequently Asked Questions (FAQs) about the resumption of survey activities (QSO-20-31-ALL). There are two major changes in the memo. The first is revision of the criteria triggering Focused Infection Control (FIC) surveys. The second is that during any FIC survey, surveyors must look into situations where residents have experienced a significant decline.

Find Consumer Voice’s previous summary of the original June 1, 2020 guidance here:  https://theconsumervoice.org/uploads/files/issues/CMS_June_1_memo_-_COVID_state_data-_governors_letter.pdf.  

Revised Criteria for Focused Infection Control Surveys  

The memo modifies when FIC surveys must be conducted.  Specifically, surveyors are to perform an onsite FIC survey within 3-5 days of identifying a facility with the following conditions:

  • Three or more new confirmed COVID-19 cases since the last National Healthcare Safety Network (NHSN) COVID-19 report, OR  
  • One confirmed resident case in a facility that was previously COVID free; AND
  • The presence of additional factors that may place residents’ health and safety at risk, including:
    • Multiple weeks with new COVID-19 cases;
    • Low staffing;
    • Selection as a Special Focus Facility;
    • Concerns related to conducting outbreak testing per CMS requirements; or
    • Allegations or complaints which pose a risk for harm or Immediate Jeopardy to the health or safety of residents related to certain areas such as abuse or quality of care.

CMS will work with State Survey Agencies to identify facilities that meet the above criteria.  

If a FIC survey was conducted in a facility within the previous three weeks, then the facility does not need to be resurveyed, even when the facility meets the above criteria.  However, if the facility meets this criteria more than three weeks after a FIC survey was conducted, a new FIC survey must be conducted within 3-5 days.

Concerns about Residents’ Condition

Importantly, in the course of any FIC survey, CMS is now directing surveyors to be alert to and investigate concerns related to residents who have experienced a significant decline in their condition during the pandemic.

FAQs About Resumption of Survey Activities

Below are key highlights from these FAQs, which cover a range of topics:

  • Survey agencies should supply surveyors with proper PPE.
  • Medicare and Medicaid certified facilities must allow surveyors to enter.
  • Surveyors must wear appropriate PPE and adhere to both COVID infection prevention practices and facility screening protocols.
  • Surveyors are not required to be tested.
  • COVID suspected or confirmed residents should be included in sample selection.
  • One surveyor should be assigned to work with COVID-19 positive residents only, when possible.
  • Surveyors should not move between COVID positive, suspected positive, and non-COVID areas within the facility.
  • Entrance activities and observations/interviews/record reviews should be done onsite and not by phone.
  • Tasks related to the resident council interview and dining may be modified if the facility is experiencing an outbreak in order to limit the spread of the virus.
  • The exit conference may be conducted by phone if all parties agree (facility, ombudsman, officer of the resident council).

Blanket Waivers

The memo provides a list of regulations/tags that have been waived or partially waived since 3/1/20.  The only waiver that has been rescinded since that date is the one exempting facilities from submitting staffing data.  This requirement was fully restored on 6/25/20.  All other waivers are still in effect.

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