What Nursing Homes Need to Know as CMS Cracks Down on Infection Control

With the federal government cracking down on nursing home infection control policies based on the initial coronavirus outbreak at a Washington state facility, the Centers for Medicare & Medicaid Services (CMS) rolled out a self-assessment tool for nursing home leadership to proactively monitor safety in place.

“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?” CMS administrator Seema Verma said on a Monday afternoon call with reporters.

With all of the other strains placed on nursing homes amid the spread of the novel coronavirus, the new focus on infection-control surveys represents another area of concern for nursing home operators and their ground-level leaders.


To get an idea of the issues that skilled nursing facilities should prioritize during this time, SNN spoke to Ron Orth, a senior analyst on skilled nursing regulations and reimbursement for the North Carolina-based Relias, a learning and services firm for health care providers.

Relias recently released a new toolkit for providers looking to shore up their infection control standards as a supplement to official guidance from CMS and the Centers for Disease Control and Prevention (CDC), which have been evolving rapidly.

As the anticipated number of COVID-19 infected patients at nursing homes continues to increase, Orth recommended the following infection control strategies:

  • Monitor staff, visitors, and residents for any sign/symptoms of the virus
  • Restrict or limit visitors for special circumstances only. Visitors allowed in should be restricted to limited areas
  • Follow social distancing by means of eliminating communal dining, activities, and other group events
  • Monitor and continually assess supply of personal protective equipment (PPE).
  • Develop a plan for optimizing PPE (See CDC strategies)
  • Monitor CDC and state and local websites for updates on best practices
  • Perform routine observations of staff use of proper infection control measures, including hygiene and use of PPE.
  • Consolidate those with suspected or confirmed COVID-19 infection to a specific area, if possible.
  • Minimize the number of staff entering a resident or patient’s room. Instead, have one person complete multiple tasks in the room such as vitals, toileting, assessment, meal delivery, etc.
  • Communicate frequently with staff on any new developments or change in infection control practices.

Though it may be difficult, there’s another important consideration that caregivers should consider outside of their facility’s walls: health care workers who may be in daily contact with suspected or confirmed COVID-19 patients should consider limiting their personal contact with those individuals in their families that may be at higher risk, Orth said, including the elderly, those with chronic illness, and the immunocompromised.

What are some of your recently updated infection control policies, and are you using the latest CMS guidelines to implement your education practices? Do you have any anecdotes you’d like to share or feedback you have recently received?

This is all unprecedented, what’s happening right now in the industry. You have your baseline infection control practices that are well established, but we are not really facing a normal outbreak of, let’s say, the flu. This is a pandemic of really an unknown virus. They’re finding more and more out about it every day since the World Health Organization … officially designated the virus as a pandemic.

Since the incident in — I hate to say incident — but the nursing home in Washington, CMS has issued actually three different memos, survey and certification memos, basically to state survey agencies and to nursing home providers on their recommended guidance under these very unusual circumstances — or unprecedented, as the word of the day.

Well, actually, let me step back there. There was a memo on March 13. That was an updated memo with guidance to nursing facilities on steps that they need to take to minimize the spread of this disease, this virus within their nursing facility.

Since then, based on information that they have learned from investigating the nursing facility in Washington, CMS has now come out and provided sort of a COVID-19 survey infection assessment that they’re going to be using; it’s sort of like a pathway. So CMS has pathways that they use for their survey process, and basically it gives direction to state surveyors on what they should be looking for when they go into a nursing facility. And this is actually concentrating specifically on COVID-19, and what steps have the nursing facilities taken to identify and then prevent any spread of the COVID-19 virus.

In their efforts to try to contain this — and also probably while they want to focus surveyors or the capacity of the whole health care system, whether you are a health care provider or even a state agency, [you’re] being stretched — CMS has to take steps to use their resources in the best manner that they feel can help manage this crisis that the health care industry is currently focusing on.

So CMS is basically suspending all survey activities, for the most part — except they are going to be identifying key geographic areas based on data that they have, and perform these infection control surveys.

Do you have any specific recommendations for nursing facilities to better implement infection control?

This is where this pathway comes into place. I would highly recommend that the infection preventionist in the facility — the administrator, the DON, [director of nursing] somebody within that organization who is sort of leading the charge in the organization for each nursing facility — take this pathway, this assessment and use this tool to do our own self-assessment of what infection control practices have they implemented, to help identify individuals who may be infected with the coronavirus. And then those who are symptomatic — so that would not only be their resident population, but also visitors and staff.

Have you heard any feedback from facilities about their main pain points, and how they’re trying to remedy those?

I think one of the things is: A lot of the courses that are included in our toolkit really are practices that facilities should have been doing all along [as] their standards, like the transmission-based precautions and hand-washing. 

So you have your foundation of infection-control practices, and hand-washing, and hand-hygiene practices — and then you have this additional information that needs to be disseminated to the staff quickly. So that information, since it’s changing almost every other day, depending on new findings, is just information that we try to disseminate either through blogs, and then they can incorporate that into the blended learning approach at the facility level.

So it sounds like the strategies are mostly just updates of existing practices, rather than a full new way of thinking.

Right. There’s new interim guidance, so that has changed some of the ways that we’ve always done things — just on a temporary basis because of the crisis situation. And a lot of it has to do with the personal protective equipment that health care professionals wear to prevent the transmission from one patient to another.

Do you have any specific guidance for nursing and rehab companies struggling with the personal protective equipment shortages?

Because of the shortage, and the crisis related to shortages of PPE, the CDC, along with CMS, have issued interim guidance on strategies that they may be able to take, in cases where they can’t follow the standard guidance.

So for instance, we normally don’t reuse personal protective equipment. But that is a strategy that is being recommended. If an organization or a facility has identified that they’re going to run out of personal protective equipment, one of the things that you’re seeing now is people making their own masks — and I know several people who are sitting at home because of working from home or unable to work, who are actually sewing masks and donating [to] health care providers because there’s a shortage.

These are not standard measures that we would normally do. But in some organizations and in some parts of the country, we’re in dire measures. And so, having homemade personal protective equipment is better than no personal protective equipment.

How do you update the advice you’re giving clients as we learn more about the virus?

This is all unprecedented. And so going back to the courses, we basically have just added some information like a pop-up saying: Hey there is some interim guidance that was provided by the CDC in light of the pandemic currently going on. It doesn’t really change the foundation of best infection control practices, but they’ve had to lighten the standards a little bit because of the shortage.

Are there any educational misconceptions that you’ve been working to clear up?

I don’t want to say there’s anything that we’ve had to clear up. I think there have been opinions, or people’s interpretations of things — that I think over the last three to four weeks, their opinions have changed.

A lot of people thought that this was no big deal, that this is no different than just the normal flu. And I think now, the events over the last three weeks — seeing the numbers of individuals who have been impacted, the number of deaths that are occurring at a fairly alarming rate — have made it so that people who had these misconceptions before or these beliefs or whatever have started to change their mind

I just have to mention, too, that as we are trying to prevent the transmission from one patient to another, we can’t forget that health care workers are putting their lives on the line daily — and many health care workers are becoming infected. And so this is critical that, given the crisis situation that we’re in, whatever steps health care providers can take to minimize that transmission to themselves or to others needs to be taken.

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