CMS made updates to the Long-Term Care Survey Process Procedure Guide effective January 27, 2022. These updates include:
- Mandatory facility task assignment and review of NHSN data related to the QSO Memo-QSO-22-07-ALL
- Entrance Conference Worksheet updates to include COVID-19 Vaccine review and COVID-19 Staff Vaccination Matrix (located under Survey Resources January 2022).
- Closed record review - surveyors may select a resident with confirmed case of COVID-19 in last four weeks who was hospitalized or died.
- Infection Control surveyor will review the infection prevention and control program policy and procedures for staff COVID-19 vaccination, antibiotic stewardship program, and the influenza, pneumococcal, and COVID-19 for residents and staff.
- Facilities will have 4 hours to complete the COVID-19 Staff Vaccination Matrix.
- Once the matrix is received, the assigned surveyor will select eight staff to review for COVID-19 vaccinations according to the guidelines below:
- 2 vaccinated staff (at least one CNA and one contractor who provides services, such as hospice and dialysis staff, occupational therapists, mental health professionals, licensed practitioners).
- If they identify any staff that weren’t vaccinated and weren’t granted an exemption or temporary delay (and weren’t listed on the staff matrix), that individual(s) will be added to the staff sample.
- F888 will be cited according to Attachment A in the QSO-22-07-ALL memo.
- Dining task: Temporarily allowing the dining task to be discretionary and completed only if a resident is investigated for nutrition, weight loss, or facility incidents related to dialysis.
- Medication Storage: CMS is temporarily allowing the medication storage task to be discretionary and only completed if there is an outstanding complaint, or concerns from the ombudsman or concerns identified when completing the medication administration observation task.
- Resident Council: CMS is temporarily allowing the resident council task to be discretionary and only completed if there’s an outstanding complaint, or concerns from the ombudsman or during the initial pool (e.g., with visitation or grievances).