Surveyors are increasingly focused on infection control. Read more to learn how you can prepare your facility.
The Centers for Medicare and Medicaid Services (CMS) has taken note of the vulnerability of older adults to infectious diseases like COVID-19 and the flu, and they are taking steps to address the spread of infections among residents. As part of President Biden's "Protecting Seniors by Improving Safety and Quality of Care in the Nation's Nursing Homes" initiative, CMS now requires every nursing home to have an on-site infection preventionist (IP) at least part-time.
Infection control has been a long-standing challenge for nursing homes, even preceding the COVID-19 pandemic. Shockingly, between 2013 and 2017, 82% of facilities were cited for infection control and prevention deficiencies, and unfortunately, not much has changed since then.
Currently, one of the most cited deficiencies is F880: Infection Prevention and Control. While F880 was most cited at an E scope and severity in 2022, Polaris Consultants are seeing the scope and severity rise to an F level with 10% of F880 tags cited at a G level in 1st Quarter 2023.
Tips to ensure compliance with F880:
- Monitor use of gowns, changing of gloves and proper posting of isolation signs during your daily rounds.
- Question any employee wearing gloves in the hallways. This is an opportunity for a real-time teaching moment.
- Know that surveyors are watching non-clinical staff too. Monitor environmental staff transporting trash and soiled linens throughout your facility. Watch for hand hygiene and removal of gloves.
- Educate all staff during meetings about F880 basics, including proper food handling, hand hygiene, linen handling, and proper sanitizing of shared equipment.
You may want to review your written standards, policies, and procedures for your Infection Control and Prevention program to ensure the following as well:
- The presence of a surveillance system that identifies all communicable diseases.
- Updated contact information for reporting of incidents of communicable disease or infections.
- When and how isolation for a resident is communicated.
- Annual updates to IPCP and ensuring a review has occurred since the end of Public Health Emergency on May 11, 2023.
Other strategies to improve compliance
To improve deficiencies and avoid citations to F880, nursing homes can benefit from mock surveys conducted by Polaris Group. Mock surveys follow the protocols, tasks, and quality indicators used by official surveyors and provide a detailed report with potential infection control deficiency findings and recommendations for corrective action. This process helps nursing homes identify risk areas, achieve compliance, and avoid monetary penalties that can range from $5,000 to $10,000 per instance.
Polaris Group consultants can further assist nursing homes in reviewing documentation processes, as proper charting is essential for compliance with infection control and preventing F-tag citation. Consultants can also lead facility in-services and staff training to ensure that staff can proficiently demonstrate infection control procedures to surveyors. Topics such as hand hygiene, proper donning and doffing of personal protective equipment (PPE), and infection monitoring practices are of utmost importance.
The time to improve infection control is now. CMS mandates it, and more importantly, our residents deserve it. Nursing homes seeking guidance on building robust infection control and prevention plans can reach out to Polaris Group consultants for expert assistance.
