CMS Issues Updates to Survey Documents

The Centers for Medicare & Medicaid Services (CMS) has released updates to several survey resource documents, including the Entrance Conference form and the Infection Prevention, Control, and Immunization Critical Element (CE) pathway. This was done to align with updated regulations and guidance related to the end of the public health emergency (PHE), and as noted with the expiration of COVID-19 Testing requirements (QSO-20-38-NH) and the updates made to Visitation (QSO-20-39-NH).

Changes to the Entrance Conference Worksheet include:

  1. The removal of the following items:
    • ​​​​A list of residents who are confirmed or are suspected cases of COVID-19.
    • Name of facility staff responsible for overseeing the COVID-19 vaccination effort.
    • The facility’s mechanism(s) to inform residents, their representatives, and families of confirmed or suspected COVID-19.
    • Documentation related to COVID-19 testing.
    • List of residents and their COVID-19 vaccination status.
    • The staff responsible for notifying all residents, representatives, and families of confirmed or suspected COVID-19 cases in the facility. This is consistent with QSO-23-13-ALL where CMS stated they will use enforcement discretion and not expecting providers to meet the requirement at F885.

​2. The facility now must provide surveyors with the Medical Director’s phone number within one hour of entrance.

Changes to the Infection Prevention, Control, and Immunization CE pathway include:

  1. ​​Requirements to review employee COVID-19 vaccination information was significantly reduced.
  2. Requirements to review source control were changed to only require surveyors to ensure source control is in accordance with national standards.
  3. Surveyors are only required to ensure COVID-19 testing is in accordance with national standards.
  4. Surveyors must ensure facility residents and staff were offered and educated on any potential risks of receiving the COVID-19 vaccination.
  5. Surveyors must ensure visitors were educated of the potential risk, before visiting residents on Transmission Based Precautions.
An additional update was made to the language regarding review of residents who have entered into arbitration agreements was made to the Entrance Conference worksheet. The surveyor will now request to see a list of only residents who currently reside in the facility and have entered into a binding arbitration agreement. Previously, a list was requested for all residents who had entered into a binding arbitration agreement, regardless of if they were a current resident
Posted in Regulatory