Use these checklists to stay ahead of promised COVID-19 focus during surveys

Download checklists provided by CMS and the CDC to review your infectious disease preparedness plans as CMS signals again that it expects hospitals and nursing homes, as well as other healthcare providers, to be prepared for the spread of the latest virus, COVID-19.

In a Quality, Safety & Oversight Group memo to state and regional CMS offices, the agency ordered its surveyors to suspend “non-emergency inspections across the country” to allow “inspectors to turn their focus on the most serious health and safety threats like infectious diseases and abuse. This shift in approach will also allow inspectors to focus on addressing the spread of the coronavirus disease 2019 (COVID-19).” This change takes effect immediately and until further notice.

Two other memos outline infection control, physical environment and other expectations for hospitals and nursing homes, which will be the initial key targets for CMS surveyors.

“The memos together provide good advice for the quality department and leadership on what to expect from CMS in the near future,” says Kurt Patton, MS, RPh, founder of Patton Healthcare Consulting and a former director of accreditation services for The Joint Commission (TJC).

He points to the memo for hospitals on infection control and the triage of potential COVID-19 patients as the most significant because it also has a Hospital Preparedness Assessment Tool for surveyors to use. “It requires implementation activities in all areas of the hospital including rechecking of airborne isolation rooms,” he notes. The memo also has “good guidance on visitor restrictions and how to implement these in a compliant fashion.”

Download checklists

Download that checklist as well as the hospital preparedness tool by the CDC, advises Jennifer Cowel, RN, MHS, a former TJC executive and CEO of Patton Healthcare Consulting.

Both checklists should be printed and distributed to leadership to conduct a self-assessment on the readiness of your facilities.

The CMS preparedness tool “speaks to the obvious, like proper hand hygiene and PPE [personal protective equipment]. Internal staff auditors should do observational audits to really assess staff compliance,” Cowel recommends.

Use the checklist to help beef up staff compliance “as we prepare for a potential spread of COVID-19 in our country.  When we do audits in hospitals, we routinely see non-compliance with PPE or improper use of PPE.  The staff take off PPE in a manner that exposes both healthcare workers and patients.  If non-compliance is observed, infection preventionists can conduct just-in-time training to staff,” she says.

The second checklist from the CDC “outlines the steps that hospitals should have in place as we prepare for potential Coronavirus.  This checklist highlights important areas that hospitals should consider as they prepare,” says Cowel.

Pay attention to EOC guidance

That includes several items within the physical environment of care.

“Some common-sense suggestions are directing individuals with symptoms of infection to put on a mask, signage for waiting rooms is discussed, patient placement is highlighted. The group at a hospital responsible for preparedness should review the recommendations and assign groups to review compliance,” says Cowel.

“Some recommendations will go back to facilities managers to document whether you have sufficient air exchanges for example in your negative pressure rooms. Out of the self-assessment, hospitals should take action on beefing up compliance with those recommendations the hospital chooses to implement at this time. Everyone from EVS to laundry services plays a role in preventing infection.”

The memo to hospitals also highlights guidance from CMS on protecting patients and healthcare workers.

 “This memo appears to be more directive on the need to screen visitors and patients for signs of infection and actions to take,” says Cowel.

Even if you think you are prepared, review the checklists and guidance in the memos to ensure you can meet CMS expectations.

“My sense is that folks are generally in pretty good shape preparedness-wise than back in the days of Ebola (which, in recollection, was a much scarier immediate reality),” notes Steve MacArthur, safety consultant for The Greeley Company.

Although potentially deadly, there has already been a lot of information about COVID-19 released so that many facilities are staying prepared, he says.

That said, the existence of COVID-19 will push infection control and preparedness to handle any patient surge for all surveyors, he notes, particularly in terms of staff practices and behaviors concerning hand hygiene, the use of PPE, and other IC measures. “Which is pretty much where the survey process has been moving over the last couple of years (with the exception of the diversion into ligature risks),” he says.

While his clients “routinely have been spending a lot of time and resources making sure that they are prepared for COVID-19’s arrival,” the memos do offer a warning, he says. “It does sound like those facilities with a previous finding of an IJ under infection control are potentially going to undergo more intense scrutiny.”

According to the overall memo, “Effective immediately, survey activity is limited to the following (in Priority Order):

  • All immediate jeopardy complaints (cases that represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death or harm) and allegations of abuse and neglect;
  • Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses;
  • Statutorily required recertification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities);
  • Any re-visits necessary to resolve current enforcement actions;
  • Initial certifications;
  • Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years;
  • Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy.”

“Today’s actions, taken together, represent a call to action across the health care system,” said CMS Administrator Seema Verma. “All health care providers must immediately review their procedures to ensure compliance with CMS’ infection control requirements, as well as the guidelines from the Centers for Disease Control and Prevention (CDC). We sincerely appreciate the proactive efforts of the nursing home and hospital associations that have already galvanized to provide up-to-the-minute information to their members. We must continue working together to keep American patients and residents safe and healthy and prevent the spread of COVID-19.”

Keep up with the latest news on COVID-19 compliance expectations on Simplify Compliance’s Accreditation & Quality Compliance, Hospital Safety Center, and at Patient Safety & Quality Healthcare sites.