New Survey/Enforcement Plan Outlined in QSO-20-31-All

On June 1, CMS released this memo and laid out a new survey plan for state survey agencies, including requiring states to perform on-site surveys of nursing facilities with previous higher instances of COVID-19 outbreaks and requiring states to perform on-site surveys (within three to five days of identification) of any nursing home with new COVID-19 suspected and confirmed cases. A full breakdown of the new survey plan and future survey activity timelines is available here:

COVID-19 Survey Activities

In addition to completing the Focused Infection Control surveys of nursing homes by July 31, CMS is also requiring States to implement the following COVID-19 survey activities:

  1. Perform on-site surveys (within 30 days of this memo) of nursing homes with
    previous COVID-19 outbreaks, defined as:

    1. Cumulative confirmed cases/bed capacity at 10% or greater; or
    2. Cumulative confirmed plus suspected cases/bed capacity at 20% or greater;
      or
    3. Ten or more deaths reported due to COVID-19.
  2. Perform on-site surveys (within three to five days of identification) of any nursing
    home with 3 or more new COVID-19 suspected and confirmed cases in the since the
    last National Healthcare Safety Network (NHSN) COVID-19 report, or 1 confirmed
    resident case in a facility that was previously COVID-free. State Survey Agencies
    are encouraged to communicate with their State Healthcare Associated Infection
    coordinators prior to initiating these surveys.
  3. Starting in FY 2021, perform annual Focused Infection Control surveys of 20 percent
    of nursing homes based on State discretion or additional data that identifies facility
    and community risks. Note: WHCA will be reaching out to DQA to determine what this will look like in Wisconsin.

Note: States that fail to perform these survey activities timely and completely could forfeit up to 5% of
their CARES Act Allocation, annually.


Expanded Survey Activities

Finally, to transition States to more routine oversight and survey activities, once a state has entered
Phase 3 of the Nursing Homes Re-opening guidance or earlier, at the state’s discretion, States are authorized to expand beyond the current survey prioritization (Immediate Jeopardy,
Focused Infection Control, and Initial Certification surveys) to perform (for all provider and
supplier types):

  • Complaint investigations that are triaged as Non-Immediate Jeopardy-High
  • Revisit surveys of any facility with removed Immediate Jeopardy (but still out of
    compliance),
  • Special Focus Facility and Special Focus Facility Candidate recertification surveys,
    and
  • Nursing home and Intermediate Care Facility for individuals with Intellectual
    Disability (ICF/IID) recertification surveys that are greater than 15 months.

When determining the order in which to schedule more routine surveys, States should prioritize
providers based on those with a history of noncompliance, or allegations of noncompliance, with the below items:

  • Abuse or neglect;
  • Infection control;
  • Violations of transfer or discharge requirements;
  • Insufficient staffing or competency; or
  • Other quality of care issues (e.g., falls, pressure ulcers, etc.).

Enhanced Enforcement for Infection Control Deficiencies

Substantial non-compliance (D or above) with any deficiency associated with Infection Control requirements will lead to the following enforcement remedies:

  • Non-compliance for an Infection Control deficiency when none have been cited in
    the last year (or on the last standard survey):

    • Nursing homes cited for current non-compliance that is not widespread
      (Level D & E) – Directed Plan of Correction
    • Nursing homes cited for current non-compliance with infection control
      requirements that is widespread (Level F) – Directed Plan of Correction,
      Discretionary Denial of Payment for New Admissions with 45-days to
      demonstrate compliance with Infection Control deficiencies.
  • Non-compliance for Infection Control Deficiencies cited once in the last year (or last
    standard survey):

    • Nursing Homes cited for current non-compliance with infection control requirements that is not widespread (Level D & E) -Directed Plan of Correction, Discretionary Denial of Payment for New Admissions with 45-days to demonstrate compliance with Infection Control deficiencies, Per Instance Civil Monetary Penalty (CMP) up to $5000 (at State/CMS discretion)
    • Nursing Homes cited for current non-compliance with infection control requirements that is widespread (Level F) -Directed Plan of Correction, Discretionary Denial of Payment for New Admissions with 45-days to demonstrate compliance with Infection Control deficiencies, $10,000 Per Instance CMP
  • Non-compliance that has been cited for Infection Control Deficiencies twice or more in the last two years (or twice since second to last standard survey)
    • Nursing homes cited for current non-compliance with Infection Control requirements that is not widespread (Level D & E) -Directed Plan of Correction, Discretionary Denial of Payment for New Admissions, 30-days to demonstrate compliance with Infection Control deficiencies, $15,000 Per Instance CMP (or per day CMP may be imposed, as long as the total amount
      exceeds $15,000)
    • Nursing homes cited for current non-compliance with Infection Control requirements that is widespread (Level F) -Directed Plan of Correction, Discretionary Denial of Payment for New Admissions, 30-days to demonstrate compliance with Infection Control deficiencies, $20,000 Per Instance CMP (or per day CMP may be imposed, as long as the total amount exceeds $20,000)
  • Nursing Homes cited for current non-compliance with Infection Control Deficiencies
    at the Harm Level (Level G, H, I), regardless of past history

    • Directed Plan of Correction, Discretionary Denial of Payment for New Admissions with 30 days to demonstrate compliance with Infection Control deficiencies. Enforcement imposed
      by CMS Location per current policy, but CMP imposed at highest amount option within the appropriate (non-Immediate Jeopardy) range in the CMP analytic tool.
  • Nursing Homes cited for current non-compliance with Infection Control Deficiencies
    at the Immediate Jeopardy Level (Level J, K, L) regardless of past history

    • In addition to the mandatory remedies of Temporary Manager or Termination, imposition of Directed Plan of Correction, Discretionary Denial of Payment for New Admissions, 15-days to demonstrate compliance with Infection Control deficiencies. Enforcement imposed by CMS Location per current policy, but CMP imposed at highest amount option within the appropriate (IJ) range in the CMP analytic tool.