The Centers for Medicare and Medicaid Services (CMS) retired its Focused Infection Control (FIC) Survey and tool last winter, but it still wants to know whether agencies are doing all they should to prevent the spread of COVID-19.
From handwashing procedures to nursing bag technique, infection control measures continue to top the areas of interest for surveyors, according to Sheila Salisbury-Sizemore, SimiTree Senior Manager, Compliance, Regulatory and Quality.
Surveyors are also evaluating agency compliance with the COVID-19 vaccine mandate CMS made effective Feb. 28.
“Even though CMS stopped using the FIC Survey in February, it expects agencies to incorporate COVID-19 management strategies into their infrastructure and operations on an ongoing basis,” Sizemore said.
“This means surveyors will continue to evaluate an agency’s infection prevention and control by using the existing survey process,” she said. “Any time there’s a survey -- whether it’s a routine 36-month survey, a complaint survey, a survey due to the addition of a branch or a survey for any other reason -- surveyors are going to look at how well the agency is meeting infection control regulations.”
Why is it so confusing?
Sizemore, who works with agencies across the country to assess survey readiness and make compliance improvements, often encounters questions and misunderstandings regarding infection control compliance.
Part of the problem, she said, is that the same answers don’t apply to all providers. Agencies are subject to state mandates as well as CMS requirements.
“There’s still a great deal of confusion in the industry about the vaccine mandate and what the regulations actually mean for agencies,” Sizemore said. “For example, what does the phrase ‘fully vaccinated’ actually mean? Does it mean the employee must have a booster as well as the full course of the vaccine? If an additional booster is made available, will employees need it to be considered fully vaccinated?
“A booster is not required under the CMS mandate, but some states do require it – so it’s impossible to be compliant without knowing exactly what is required in your state.”
Whenever there is a difference between state and federal regulations, Sizemore said, it’s a good rule of thumb to follow all.
“Remember, when regulations differ, agencies are always going to be held to the most stringent regulations,” Sizemore said.
Some helpful guidelines
How can agencies sift through the confusion and control their compliance risk?
“Infection control is one of those subjects that we could write an entire thesis on, but some general principles do apply,” Sizemore said.
She offers these helpful suggestions:
- Research all requirements that apply to your agency.
Work with your state Department of Health, State Agency, and/or Accrediting Organization (AO) to make certain your agency is following all applicable state rules and regulations in addition to CMS requirements. In most cases, the state Department of Health will have this information available on its web site.
In addition, make certain to follow the latest Centers for Communicable Disease (CDC) guidelines.
- Develop agency policies and procedures based on all applicable requirements.
CMS requires organizations to address infection control in two primary ways. A specific and robust Infection Control Program must be maintained and well documented, per regulations set out under the Conditions of Participation at §484.70. Infectious diseases must also be addressed under the agency’s Emergency Preparedness Program, per regulations set out at §484.102.
Both programs will require detailed policies and procedures. CMS, state and AO requirements should serve as the foundation for those policies and procedures, Sizemore said.
- Train your staff – and spot-check for compliance.
“Surveyors are going to hold you accountable for following your own policies and procedures. They’re going to look at how familiar your staff is with your policies and at how well they are following each procedure,” Sizemore said.
“Make sure your staff knows your policies and procedures inside out. You want them to be able to follow those policies and procedures blindfolded,” Sizemore said.
It's important to spot-check to make certain staff is following protocol, Sizemore said. She uses the example of handwashing. “Everyone knows you’re supposed to wash your hands for a full 20 seconds. But is a busy clinician in the field cutting that by a few seconds? Those are the small things you’ll want to make certain your staff is doing right.”
- Review and update your policies.
If your organization isn’t regularly reviewing CDC guidance, state and federal regulations and updating policies accordingly, you’re courting compliance risk, Sizemore said.
“We’re learning that a lot of agencies never updated Appendix Z when it changed early last year, outlining how they should be operating under emergent infectious diseases,” Sizemore said. “Surveyors are going to make certain what you have is current.”
- Make certain your documentation is in order.
Documentation of current vaccinations and approved exemptions should be reviewed and updated regularly, Sizemore said, as well as documentation of exposure and tracking.
“These are essential elements of your Infection Control Program, and they need to be current when surveyors arrive,” she said.
Need help with survey readiness?
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