CMS nears completion of infection control survey

Adds quality, discharge planning to inspections

Already finalizing an infection control survey for hospitals, the Centers for Medicare and Medicaid Services (CMS) has expanded the scope of the program to assess compliance with quality improvement and discharge planning during the same visit. The original plan was to conduct the three surveys — which are all in a “pilot” testing phase — during separate inspections, but linking them brings the CMS more in line with the broader patient safety goals of its Partnership for Patients program.

Ruth Carrico

It also reflects awareness that infection prevention and other patient safety issues must be addressed across multiple departments and indeed the entire care continuum to be effective, says Ruth Carrico, PhD, RN, CIC, an associate professor at the School of Public Health and Information Sciences at the University of Louisville, KY.

“I think all infection preventionists realize that infection control is part of patient safety,” she says. “So the fact that they have pulled these surveys together is not surprising, nor to me is it particularly problematic. It really demonstrates that CMS recognizes — as should we — that patient safety is a ‘systems’ issue. We have spent a lot of time in infection prevention saying don’t focus on correcting a single problem or a single issue — look at the root cause, look at how your systems activities and your system structure either enables this error or prevents it. The fact that CMS is pulling all of these together and taking more of a systems approach — to me this is really the way to go.”

According to a CMS official who spoke on a condition of anonymity, there have been “slight changes” in the infection control survey based on feedback from CMS surveyors and from the infection control community. The finalization process is continuing with the CMS working in collaboration with the Centers for Disease Control and Prevention, but no major changes are anticipated as the CMS completes the process in coming months. Earlier versions of the CMS pilot infection control survey have generally received favorable reviews for its design and attention to detail by infection preventionists. Indeed, some see the survey program as a potential game-changer for infection prevention, particularly if CMS strengthens its ties to conditions of participation and ultimately links survey results directly to reimbursements.

“[Our] surveyors were extremely positive and liked that fact that they knew exactly what to look for, they liked the questions, they liked the way that it was organized, so from the surveyor side it was extremely positive,” the CMS official said. “The pushback we got from the professional organizations and the infection control organizations was based primarily on the wording of the questions and whether they were in alignment with CDC guidelines. We actually did make a few [wording] changes.”

The CMS survey tool is a broad assessment of infection prevention, using a “patient tracer” approach in some areas to focus on key issues and connections through the care process. The survey includes such areas as infection control program and resources, multidrug resistant organisms, antibiotic stewardship, employee health, hand hygiene, needle use, environmental services, and cleaning and reprocessing equipment. Some have questioned the inclusion of areas like antibiotic stewardship, which cannot be cited under current CMS regulations. However, that provision remains in intact in the most recently revised version, which still runs 42 pages. (See editor’s note below for a link to the surveys.)

Finalization nears, will citations follow?

No citations are being issued during the ongoing pilot testing of the CMS surveys. Though CMS officials estimate the infection control survey will be finalized in the next few months, it is not clear when surveyors will begin using the final version. The final version will be released publically, with plans calling for it to be added to the formal survey process sometime thereafter.

“Our intention — and don’t ask me when — is that once this tool is finalized, it will be used as part of the survey process,” the CMS official said. “When we use a final version and we put it out there with instructions to the surveyors that they must use the survey tool on all of their surveys then yes, they will cite deficiencies.”

However, the CMS continues to weigh its options and evaluate the surveys, seeming somewhat noncommittal about whether they will be ultimately used to inspect and cite hospitals in formal CMS surveys.

“My guess is as we get closer to the end of the fiscal year we will put together our priorities for the coming year and then decide where we go from there,” the CMS official said. “I hesitate to tell you because we have been changing this on the fly for two years. I think we have made it better and made it in a way that really supports some of the other [patient safety] activities. The real question I think in the future is when are we going to include this as part of the [formal CMS] survey process — that I can’t tell you.”

Regardless, to the extent the survey reflects and codifies CDC guidelines, it could prove to be a highly useful risk assessment tool for infection prevention in hospitals.

“Even without this [infection control survey] becoming a ‘formal’ CMS regulatory tool — let’s say it morphs into an implementation and assessment tool only for health care facilities to promote patient safety — with rare exception the CMS has hit the target,” says Patti Grant, RN, BSN, MS, CIC, director of Infection Prevention and Quality at Methodist Hospital for Surgery in Addison, TX, and 2013 president of the Association for Professionals in Infection Control and Epidemiology. “It is obvious CMS collaborated with content experts in the field.”

As others have noted, the fact that the CMS is clearly outlining its expectations can be used by IPs to defend and clarify the role of their programs and practices, adds Carrico, an IP for some 20 years before moving into academia. “What has happened in the past, we have surveyors look at something and then give us erroneous information or they even cited us based upon something that was not accurate,” she says. “Maybe it never was never accurate, but it had become something of an ‘urban legend’ [i.e., a ‘sacred cow’].”

Focus on patient safety, avoid turf wars

As far as bringing in the other two survey areas — quality improvement and discharge planning — IPs can avoid getting get caught up in any “turf wars” by focusing on the common goal of patient safety.

“In our paradigm the patient needs to be first,” Carrico says. “And in order for the patient to be first all of these other pieces have to come together for the benefit of the patient. If we worry too much whether infection prevention and control is ‘on top,’ we lose sight of who this is really about. This is less about us individually or as a single discipline and more about how we make sure all of these pieces come together for the best possible outcome for patients. “

Indeed, the CMS Quality Assessment & Performance Improvement (QAPI) survey clearly expects such collaborations, using wording that may actually empower infection control programs. “Is there QAPI program collaboration with infection control officer(s) to identify and track avoidable healthcare-acquired infections?,” the CMS quality survey states. “Is there evidence that problems identified by infection control officer(s) are addressed through QAPI program activities?” (See related story, this page.)

“We have looked at infection prevention and control as a linear process, but it’s a circular process,” Carrico says. “It is interrelated to all of the other aspects of care.”

Similarly, transfer of infected and colonized patients across the care continuum with insufficient information on their status has been a commonly reported problem for years. In that regard, the CMS discharge planning survey specifically asks: “For patients transferred, to a post-acute care setting other than home, was necessary medical information ready at time of transfer and sent to the receiving facility with the patient?”

If they have not already done so as part of ongoing risk assessment, IPs should reach out to these other departments and open lines of communication.

“For example, you may not have to worry about patient antibiotics at discharge — that may be the responsibility of your discharge planner,” Carrico says. “But you have to be working with your discharge planner so they know that this is one of the considerations as they are preparing discharges. We want to make sure of some simple things like the patient that is being treated for endocarditis will be able to maintain home antibiotics.”

CMS Patient Safety Initiative

The CMS is finalizing all three of the surveys under the overall program title of the CMS Survey & Certification Group (SCG) Patient Safety Initiative. According to a Nov. 9, 2012 CMS memo, the three surveys were used during the pre-test and pilot phases from September 2011 through September 2012. “The three worksheets have been further revised, both to refine some questions and to make clearer the non-punitive nature of the pilot test, which is designed not only to develop effective tools for future surveyor use in assessing compliance, but also to serve as a risk management assessment tool for hospitals,” the CMS states. “In contrast to FY 2012, in FY 2013 surveyors in all State Survey Agencies will be testing the three surveyor worksheets together in one integrated survey of one hospital campus.”

The CMS is making all three hospital surveyor worksheets publicly available and encouraging hospitals to use them for self-assessment of their practices related to infection control, quality improvement and discharge planning.

During the course of 2013, the CMS state surveyors will perform from “one to nine integrated PSI surveys in their states, based on the number of Medicare-certified hospitals in each state,” the CMS memo states. “As was the case in both the pre-test and FY 2012 pilot phases, hospitals will be selected for a pilot survey based on a combination of risk-adjusted all-cause Medicare read-missions data and/or other factors.”

HAI prevention still a top priority

While medication errors, preventable hospital readmissions and other patient safety issues are certainly important, the primary driver of the CMS survey program remains HAIs, which are increasingly seen as preventable but still cause 100,000 patient deaths a year. CMS and other agencies in the Department of Health and Human Services (HHS) were called on the carpet after a scathing 2008 Inspector General report cited a lack of HHS leadership and coordination to reduce “needless suffering and death” of HAIs.1

However, CMS is also the lead federal agency in The Partnership for Patients, which has set goals of reducing preventable hospital-acquired conditions by 40% in 2013 compared to 2010. Achieving this goal would mean approximately 1.8 million fewer injuries to patients, the CMS estimates. A complementary goal in the program is to improve care transitions and reducing hospital readmissions. The goal is that by the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010. Achieving this goal would mean more than 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge, according to the CMS.

“We are calling this a patient safety initiative now and trying to align with all of the other patient safety initiates that are going on both at CMS and around the HHS,” the CMS official said. “But we want everybody to understand that this [infection control survey] is kind of a stand-alone initiative and certainly it is aligned and in support of the work to improve infection control and decrease HAIs.”

Editor’s note: All three of the CMS surveys are available at:


  1. Government Accountability Office: Health-Care-Associated infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections. 2008; GAO-08-673T. Available at

CMS questions on quality, discharge planning

In addition to creating a hospital infection control survey, the CMS is pilot testing two other surveys on Quality Assessment & Performance Improvement (QAPI) and Discharge Planning. Plans call for using all three surveys in the same “integrated” inspection. Questions from the other two surveys include the following:


  • Can the hospital provide evidence that its improvement activities focus on areas that are high risk (severity), high volume (incidence or prevalence), or problem-prone?
  • Can the hospital provide evidence that it conducts distinct performance improvement projects
  • Is the number of projects proportional to the scope and complexity of the hospital’s services and operations? No fixed ratio is required, but smaller hospitals with a smaller number of distinct services would be expected to have fewer projects than a large hospital with many different services.
  • &Is there evidence of widespread staff training or communication to convey expectations for patient safety to all staff? (e.g. training related to steps to take in a situation that feels unsafe, how to report medical errors (including near misses/close calls) adverse events, etc.)
  • On each unit/program surveyed, can staff describe what is meant by medical errors (including near misses/close calls) and adverse events?
  • Does the hospital employ methods, in addition to staff incident reporting, to identify possible medical errors (including near misses/close calls) and adverse events? (Examples of other methods include, but are not limited to, retrospective medical record reviews, review of claims data, unplanned readmissions, or patient complaints/grievances, interview or survey of patients, etc.)
  • Is there QAPI program collaboration with infection control officer(s) to identify and track avoidable healthcare-acquired infections?
  • Is there evidence that problems identified by infection control officer(s) are addressed through QAPI program activities

Discharge planning

  • Does the hospital discharge planning policy include a process for ongoing reassessment of the discharge plan based on changes in patient condition, changes in available support, and/or changes in post-hospital care requirements?
  • Did the evaluation include an assessment of the patient’s ability to perform activities of daily living (e.g. personal hygiene and grooming, dressing and undressing, feeding, voluntary control over bowel and bladder, ambulation, etc.)?
  • Did the evaluation include an assessment of the patient’s or family/support person’s ability to provide self-care/care?
  • If any significant changes in the patient’s condition were noted in the medical record that changed post-discharge needs, was the discharge plan updated accordingly?
  • For patients transferred, to a post-acute care setting other than home, was necessary medical information ready at time of transfer and sent to the receiving facility with the patient?
  • Is there documentation in the medical record of providing the results of tests, pending at time of discharge, to the patient and/or post-hospital provider of care, if applicable?
  • Ask the hospital to check whether this inpatient admission is a readmission within 30 days of a prior admission to that hospital. Was there a prior admission?