The Center for Medicaid & Medicare Services (CMS) continues to survey hospitals and long-term care facilities for infection control measures to prevent the novel coronavirus, COVID-19. The inspections assess the basics of hand hygiene, personal protective equipment (PPE), and staff education — things most facilities should be doing months into a pandemic.
The CMS can do a novel coronavirus inspection if the agency receives a complaint on something completely unrelated, warns Ann Marie Pettis, RN, BSN, CIC, FAPIC, director of infection control at the University of Rochester, NY.
“We were surveyed by CMS. They came in on a routine complaint, but once they are in, they can determine what their focus will be,” she says. “Once they realized the complaint was not legitimate, they decided to turn it into COVID survey. We did very well.”
In large part, that is because of the pandemic response, because infection control is being emphasized across the entire healthcare delivery system, she adds. “Some of our nursing homes were also surveyed recently by CMS, and they have done well,” Pettis says. “In terms of how to prepare for these surveys, basically what we have been doing all along [for novel coronavirus] is really preparation for any survey, including by CMS.”
Indeed, there is so much emphasis on infection prevention during delivery of care, that in some cases, healthcare workers may be safer at work than in the community.
“We are seeing very little transmission,” says Pettis, president-elect of the Association for Professionals in Infection Control and Epidemiology (APIC). “Our healthcare workers are wearing the appropriate PPE, so our positivity rate is actually lower than in the community. That tells you that appropriate PPE is protective for healthcare workers.”
The CMS surveys were announced in a March 23, 2020, memo to inspectors.1 Originally, the action was set to expire in three weeks, but CMS is expected to continue surveys at least until the pandemic emergency order is lifted. As this report was filed, there was an effort by APIC and other medical groups to extend the emergency order beyond the original July 25 deadline.2
The CMS survey includes a checklist of measures, summarized as follows. For the complete requirements see the aforementioned CMS memo.
CMS recommends taking the following actions to reduce COVID-19 transmission:
- Are staff performing hand hygiene when indicated?
- If alcohol-based hand rub (ABHR) is available, is it readily accessible and preferentially used by staff for hand hygiene?
- Staff should wash hands with soap and water when their hands are visibly soiled (e.g., blood, body fluids). Interview appropriate staff to determine if hand hygiene supplies are readily available and who they contact for replacement supplies. If there are shortages of ABHR, hand hygiene should be done with soap and water.
Staff should perform hand hygiene — even if gloves are used — in the following situations:
- Before and after contact with patients
- After contact with blood, body fluids, or visibly contaminated surfaces or other objects and surfaces in the care environment
- After removing PPE (e.g., gloves, gown, facemask)
- Before performing a procedure, such as an aseptic task (e.g., insertion of an invasive device, such as a urinary catheter, manipulation of a central venous catheter, medication preparation, and/or dressing care).
Determine if staff appropriately use PPE, including, but not limited to, the following:
- Gloves are worn if potential contact with blood or body fluid, mucous membranes, or non-intact skin
- Gloves are removed after contact with blood or body fluids, mucous membranes, or non-intact skin
- Gloves are changed and hand hygiene is performed before moving from a contaminated site to a clean site during care (body, equipment, etc.)
- An isolation gown is worn for direct patient contact if the patient has uncontained secretions or excretions
- A facemask, gloves, isolation gown, and eye protection are worn when caring for a patient with new acute cough or symptoms of an undiagnosed respiratory infection unless the suspected diagnosis requires airborne precautions (e.g., tuberculosis)
- If PPE use is extended/reused, is it done according to national and/or local guidelines? If it is reused, is it cleaned/decontaminated/maintained after and/or between uses?
Interview appropriate staff to determine if PPE is available, accessible, and used by staff.
- Are there sufficient PPE supplies available to follow infection prevention and control guidelines? In the event of PPE shortages, what procedures is the facility taking to address this issue?
- Do staff know how to obtain PPE supplies before providing care?
- Do they know who to contact for replacement supplies?
Education and Screening
CMS also recommends making sure the following questions have satisfactory answers:
- Is there evidence the provider has educated staff on COVID-19 (e.g., symptoms, how it is transmitted, screening criteria, work exclusions)?
- How does the provider convey updates on COVID-19 to all staff?
- Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness?
- Is the facility actively taking their temperature and documenting absence of illness (or signs/symptoms of COVID-19 as more information becomes available)?
If staff develop symptoms at work, does the facility:
- have a process for staff to report their illness or developing symptoms;
- place them in a facemask and have them return home for appropriate medical evaluation;
- inform the facility’s infection preventionist and include information on individuals, equipment, and locations the person came in contact with.
- Centers for Medicare & Medicaid Services. Prioritization of Survey Activities. March 23, 2020. https://www.cms.gov/files/document/qso-20-20-all.pdf
- American Public Health Association. Letter to U.S. Department of Health & Human Services. June 23, 2020. https://www.apha.org/-/media/files/pdf/advocacy/letters/2020/200623_azar_covid19_ph_emergency.ashx?la=en&hash=FB3B1D3CF27CF7BE77431F79A4043AEB91BEA7B1