CMS Issues New QSO Memo on Enhanced Enforcement for Infection Control Deficiencies
On March 30, the Centers for Medicare and Medicaid Services (CMS) rescinded previous guidance and released QSO Memo QSO-23-10-NH, which updates the enhanced enforcement policy for infection control deficiencies, which was implemented early in the pandemic. This update is related to changes that have occurred throughout the pandemic, including an interim final rule that established long term care facility vaccine immunization requirements, CMS noted the need to continue to evaluate guidance.
Upon release of the new QSO memo, CMS also rescinded the previous memo, QSO-20-31-ALL, which was originally issued in 2020 and amended in early 2021. The previous QSO memo was scheduled to expire upon the termination of the federal PHE, which is set to terminate on May 11. For survey cycles that began prior to the effective date of QSO-23-10-NH (March 30, 2023), facilities should continue to reference the previous memo.
The biggest change in enforcement, is that a CMP would no longer apply for all infection control citations. Instead, a CMP would only apply if the scope and severity was cited at a G or higher. Furthermore, enhanced enforcement (Directed POC (plan of correction) and DDPNA), would only be enforced at Level 2 (D, E, & F) when BOTH F880-Infection Prevention & Control- and F887-COVID-19 Immunizations were cited. Note, F887 can be cited at any level. However, CMS did reduce the times to achieve substantial compliance. Compliance must be achieved in 30 days for a Level 2 (D, E, & F) deficiency and 15 days for a Level 3 (G, H, & I) or 4 (J, K, & L) deficiency.
| Non-compliance with BOTH F880 and F887 (S/S Level 2- D, E, F) **On the same survey** | Non-compliance for F880 (S/S Level 3- G, H, I) | Non-compliance for F880 (S/S Level 4- J, K, L) |
| Directed POC with the QIO (Quality Improvement Organizations) or another qualified consultant | Directed POC with the QIO or hiring an IC Consultant | Directed POC with the QIO or hiring an IC Consultant |
| DDPNA with 30-days to achieve substantial compliance | DDPNA with 15-days to achieve substantial compliance | DDPNA with 15-days to achieve substantial compliance |
| CMP according to the CMP Analytical Tool with a 10% increase adjustment | CMP according to the CMP Analytical Tool with a 20% increase adjustment |
Finally, the QIOs have been directed to focus their attention on assisting facilities with technical assistance to nursing homes with a history of infection control challenges.
QIO Update:
CMS Rescinds Memorandum QSO-20-31-ALL
As mentioned in the closing of QSO-23-10-NH, CMS had realigned Quality Improvement Organizations (QIOs) strategic approach to assist in combating commutable disease infections within nursing homes. Superior Health Quality Alliance (Superior Health) is the QIO for the states of Michigan, Minnesota and Wisconsin.
Superior Health has a long-standing history assisting nursing homes in quality improvement initiatives including technical assistance, education and resources in infection prevention and control. Our team of specialized quality improvement advisors are here to provide:
- Data-driven one on one technical assistance.
- Expert Infection Preventionist support including virtual or onsite visits to assess facility infection prevention and control practices and programs.
- Quality improvement assistance with enhancing facility Quality Assurance and Performance Improvement (QAPI) program including root cause analysis and implementing corrective action plans.
- Improvement in vaccination rates including help with National Healthcare Safety Network (NHSN) reporting and referral to free mobile vaccination clinics.
- A library of education, tools and resources on infection prevention and control and other quality improvement topics.
- Bi-monthly and on-demand training on a variety of pertinent quality improvement topics.
- Focused attention on reducing rehospitalizations due to Clostridioides difficile (C. difficile), urinary tract infections (UTI), sepsis, pneumonia and COVID-19.
For more information visit our website or to receive additional support reach out to program director, Aimee Rasmussen, arasmuss@metastar.com.
Updated Quality, Safety Education Portal (QSEP) Targeted COVID -19 Training for Staff and Management
Source: CMS
The Targeted COVID-19 Training for Staff and Management has recently been updated. The training consists of five modules for staff and 10 for management. The training can be accessed 24/7 and each module has a pre- and post-test. Use Superior Health’s tutorial to access the QSEP Training.
Use Data Analytics to Improve Care
Join the Superior Health Real Time Medical Systems Collaborative
There is still time to join the Superior Health Quality Alliance (Superior Health)-Real Time Medical Systems collaborative at no cost through October 2024. Real Time uses data analytics to improve resident quality and safety, improve efficiency and focuses on early identification, intervention and prevention. Please review the documents and reach out to Toni Kettner, tkettner@metastar.com for more details.
- Superior Health Quality Alliance and Real-Time Information flyer
- Infection Control and Antibiotic Stewardship Surveillance
- Unlock the Power of Your Electronic Health Record (EHR) and Turn Data into Actionable Insights
