Amid the national emergency caused by COVID-19, infection control in skilled nursing facilities has come under intense scrutiny, with past violations examined under the media microscope — and surveys from the government focused solely on the issue.

That scrutiny is only likely to increase due to the challenge nursing homes face trying to contain COVID-19 — a virus that can be spread while infected people show no symptoms.

The first facility to see a major outbreak, the Life Care Center of Kirkland in Kirkland, Wash., was fined $611,000 by the Centers for Medicare & Medicaid Services (CMS) for its handling of the outbreak, which was in part accelerated by staffers working while sick.

In addition, while CMS administrator Seema Verma has praised nursing homes for an “amazing job” handling the COVID-19 crisis, early infection-control surveys have revealed lingering problems in facilities — particularly around hand-washing, proper use of personal protective equipment (PPE), and separating COVID-19 patients from those without the virus.

A flash poll conducted by the advisory firm Baker Tilly Virchow Krause, LLP suggested that more than 40% of SNFs are not confident about the adequacy of their existing infection control plans to respond to COVID-19, according to a May 21 release from the firm.

That makes it all the more paramount for SNFs to take stock of their plans, especially given the current high-stakes ramifications of infection control.

Nursing homes already are required to have an infection control and emergency preparedness plan, CLA consultant Jillian Martin noted on a Thursday webinar hosted by the advisory firm. So even though SNFs have been given a COVID-19-specific checklist for infection control surveys, the state’s operations manual and infection and control guidelines is still “the ultimate guide and authority,” she said.

“Because of the current situation, long-term care facilities are subject to infection control-focused surveys, with the possibility of hefty financial penalties,” Martin said on the webinar. “Some states have also added infection control surveys, with possible penalties or incentives depending on the outcomes of those surveys.”

With COVID-19, significant fines have already emerged; in addition to the Washington facility, the Andover Subacute and Rehab II facility in New Jersey was fined $220,000 in the wake of national media attention on its coronavirus response, CLA principal Deb Freeland noted.

“This is pretty significant, compared to what we were finding before the infection control surveys starting with COVID-19,” she said.

Even amid skyrocketing PPE costs and increases in staffing expenses, SNF leadership cannot lose focus on the vital importance of infection control, Freeland said.

There are several factors SNFs need to keep in mind for the infection control survey in the age of COVID-19, whether it is done remotely or onsite, Martin said. The infection control-focused survey will examine:

• The overall effectiveness of the infection prevention and control program policies and procedures
• Standard and transmission-based precautions
• The quality of resident care practices
• The surveillance plan
• Visitor entry and facility screening
• Staff education monitoring and screening
• Procedures to address staffing issues.

“As health care providers and personnel, we have to do our part to minimize transmission to our highly vulnerable populations,” Martin said. “And we have to prove to our state and federal agencies that we understand how illnesses are transmitted, that we have put the proper steps in place, and that we are communicating all of this in a very transparent way.”

But the scope of infection control goes beyond COVID-19, and skilled nursing providers have to make sure that they have a full program in place. The components of a comprehensive infection control and prevention program include leadership, surveillance, and antibiotic stewardship, Heather Hutson, the chief infection control officer at infection prevention specialist firm AMS Onsite, said on a webinar hosted by Skilled Nursing News and sponsored by Real Time Medical Systems on May 19.

All long-term care facilities have to have a designated infection control and prevention leader, or infection preventionist per CMS mandate, even before COVID-19, Hutson noted. The duties and responsibilities of the infection preventionist include:

• Coordinating and overseeing the infection control and prevention program
• Contributing to quality reports
• Ensuring staff immunizations are up to date
• Environmental rounds
• Dietary, maintenance, and water programs
• Audits and training

“It’s important to keep in mind that it is very typical for the facility’s infection preventionist to hold other titles and have other responsibilities outside of infection control,” she said. “I bet that as legislation evolves, the role of the IP will continue to evolve as well and become more demanding than it currently is.”

A proposed rule issued in the middle of last year would have altered the role of the infection preventionist to remove the mandate that they work part-time at a SNF or have frequent contact with the facility’s infection prevention and control program staff. Instead, under the proposed rule, facilities would have to ensure that the infection preventionist “has sufficient time at the facility to meet the objectives of its infection prevention and control program.”

When it comes to surveillance in the infection control program, it is essential to be proactive rather than reactive, Hutson said.

Process surveillance involves the infection preventionist reviewing the procedures directly related to resident care and safety, such as hand-washing and disinfecting. Outcome surveillance would include taking all data collected and analyzing it to detect trends and disease clusters. That necessitates “ongoing, continual testing,” a factor that’s particularly crucial not just for COVID-19, but for other illnesses as well.

However SNFs implement these components, they face one key challenge: a lack of structural guidance.

“With leadership, facilities face challenges involving time and resources — and there’s really been no recognized structure handed down for leadership by CMS,” Hutson said. “With surveillance, the EHR [electronic health records] data is there, but how do facilities obtain effective insight and what do we do with this data?”

Real Time Medical Systems, which sponsored the webinar, uses data from EHRs to draw out clinical insights for SNFs, and Shane Dearing, executive vice president of growth, noted that AMS and Real Time have partnered to combine their work to remotely monitor residents in real time – a key consideration in the pandemic era.

And by using a system that draws the data from the EHR, rather than making SNF workers pull it manually, it makes it easier for SNFs to set up their own internal surveillance – and to report what they find, Dearing argued.

“Ask yourself how much time you’re directing currently since May 8 from patient care to comply with reporting,” he recommended. “How many FTEs [full-time equivalents] are dedicated to that reporting? How are they pulling this data? Is it purely manual? And are you able … to identify signs and symptoms down to the patient level at each of your facilities for infectious disease?”