CMS to Enforce Tougher Survey Guidelines in Wake of COVID-19 Deaths at Kirkland Nursing Home

The federal government on Monday announced the release of an updated survey tool for nursing home inspectors, with an even stricter focus on infection-control policies — derived directly from lessons learned at a facility in Washington state that served as the epicenter of the first COVID-19 outbreak in the United States.

The Centers for Medicare & Medicaid Services (CMS) doubled down on efforts to reorganize the nation’s nursing home survey apparatus around infection control amid the ongoing pandemic, stating its intention to more proactively target areas believed to be at the greatest risk for future outbreaks — as well as rolling out a self-assessment tool that administrator Seema Verma encouraged families to use as a quick pulse check on a given building’s safety.

“Nursing home residents and their families who want to be sure a nursing home is safe should not hesitate to ask staff directly: What are the results of your CMS self-assessment?” Verma said on a Monday afternoon call with reporters.


As part of the new guidance, for the next three weeks, surveyors will only be focusing on three kinds of surveys: immediate-jeopardy level complaints and incidents, targeted infection control surveys, and the self-assessments.

“We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations,” the government wrote in its most recent memo to State Survey Agencies (SSAs). “We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. This document may be requested by surveyors, if an onsite investigation takes place.”

The government will explicitly not authorize standard surveys for nursing homes, home health agencies, and other care sites. The suspended surveys also include life safety code and emergency preparedness inspections, as well as any revisits not associated with an immediate jeopardy claim.


The moves are all so the limited number of surveyors — many of whom can be recalled by state governors to perform other tasks, and are also facing the same shortages of personal protective equipment (PPE) as other frontline providers — can focus exclusively on coronavirus safety.

“They will use a streamlined review checklist to minimize the impact on provider activities, while ensuring providers are implementing actions to protect the health and safety of individuals to respond to the COVID-19 pandemic,” CMS noted of the targeted infection control inspections.

In one of the earliest federal actions aimed at fighting the coronavirus, CMS on March 4 suspended all non-emergency survey work at nursing homes, reserving inspections solely for infection-control compliance and outright cases of abuse and neglect.

At the time, the general public was largely aware of COVID-19’s deadly potential because of an outbreak at a nursing home in Kirkland, Wash. operated by Life Care Centers of America.

The Centers for Disease Control and Prevention (CDC) had previously determined that less than three weeks after the first resident showed symptoms consistent with COVID-19 infection, more than a quarter of the building’s census was dead.

The CDC blamed the rapidly moving situation in Kirkland on a variety of factors, including staff members continuing to work while sick — and employees working at multiple nursing homes, helping to hasten the spread of the disease.

Verma on Monday announced that CMS had concluded its own emergency survey of the Kirkland property, which resulted in an immediate jeopardy citation. The property now faces the termination of its Medicare and Medicaid licenses unless an upcoming surprise inspection reveals that it has rectified the problems CMS surveyors identified.

“Specifically, the facility failed to identify and manage sick residents,” Verma said. “They failed to notify the state health department, and the state about sickness amongst the residents. And they failed to have a backup plan for when their staff doctor became sick.”

Those factors had a direct impact on Monday’s updated survey guidelines.

“We used our experiences in Kirkland to develop a new inspection approach, and we’re also learning from the newest data about the virus and relying on longstanding principles of infection control,” Verma said.

Cheryl Strange, secretary of the Washington Department of Social & Health Services, said that state regulators plan to visit all of the nursing homes in the state to ensure infection-control compliance.

“We have learned valuable lessons,” Strange said in a statement. “We are applying these lessons daily in our efforts to prepare long term care facilities throughout the state for the potential of COVID-19.”

A spokesperson for Life Care Centers told the Wall Street Journal that the company was “disappointed” that CMS didn’t consider the unprecedented nature of the coronavirus outbreak when meting out its potential punishments, and also noted that the facility was unable to receive COVID-19 testing kits until March 5 — weeks after the first symptoms appeared.

“It’s unrealistic to expect any nursing home to be able to manage this on our own within the framework of a normal disaster response plan,” spokesman Tom Killian told the publication, adding that the property has already rectified the problems identified in the survey.

While CMS had also previously announced that its infection-control efforts would be concentrated in areas with significant numbers of COVID-19 cases — including California, New York, and the Seattle metropolitan area — Verma on Monday said its new strategies will take things a step further.

Using the CDC’s database of reported COVID-19 cases and modeling tools, CMS will attempt to deploy its surveyors to potential COVID-19 hotspots before massive building-level outbreaks can occur.

“Beginning today, we will be working with the CDC to focus and identify areas the virus is projected to strike next, and target our inspections accordingly,” Verma said. “This will allow us to focus inspections on the most urgent situations — so we’re getting the information that we need to ensure safety while not getting in the way of patient care.”

As of Monday, the CDC has identified 146 nursing homes across 27 states with confirmed COVID-19 cases. Because the virus is particularly deadly for frail nursing home residents, many of whom have a host of underlying medical conditions, Verma reiterated the importance of obeying a federal ban on all non-essential visits to skilled nursing facilities.

“Unless you must absolutely go into a nursing home, don’t,” she said.

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