What to Expect During a CMS COVID-19 Infection Control Focused Survey

06/25/2020
By Michelle McDonald, RN, MPH, CJCP, Executive Director, Government Regulations & Advisory Services

Prior to arriving onsite for a survey, the CMS surveyors will be performing offsite work so they can limit the interruptions to staff. They will conduct offsite planning based on available information from:

  • Facility-reported information;
  • Center for Disease Control (CDC), state/local public health information if available (in some cases CDC or public health will have gone onsite prior to the state agency (SA)/CMS);
  • Available hospital information regarding patients transferred to the hospital; and/or
  • Complaint allegations.

If the CMS survey team, which will be limited to 1-2 surveyors, plans to enter a facility with an active COVID-19 case, or identifies an active COVID-19 case after entering a facility, the survey team will contact their State Survey Agency (SSA), the state health department, and CMS Regional Location to coordinate activities for these facilities.

Those agencies may ask the survey team to delay the survey until the health department or CDC has assessed the situation or they may proceed. As CMS surveyors may enter a facility with confirmed or suspected COVID cases, or a facility requiring certain PPE in order to enter, SSAs should ensure surveyors have needed personal protective equipment (PPE) that could be required onsite. If they do not have the proper PPE, they will not enter the site. Surveyors will follow the latest CDC guidance on use of Personal Protective Equipment.

Once onsite, CMS surveyors will perform the entrance conference with the new COVID-19 Entrance Conference Worksheet. Be sure you are familiar with this worksheet before the surveyors arrive. This form will also be used to request information throughout the survey. During this entrance conference, they will notify the administrator of the limited focus survey activity. They will also outline that prioritized observations will be on day one and the remaining observation and interviews will be completed on day 2.

CMS expects facilities to use the new Infection Control survey tool, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. CMS also encourages nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. It is important to perform this self-assessment, because you may be asked to present your self-assessment during this time. They will also make sure you used the self-assessment tool in conjunction with the CDC Preparedness Checklist. Hopefully, if you used both of these tools, you will have identified any gaps that needed to go to QAPI for F880 and Etag0024 compliance.

During the survey, CMS surveyor(s) will review for these topics:

  • The overall effectiveness of the Infection Prevention and Control Program (IPCP) including IPCP policies and procedures;
  • Standard and Transmission-Based Precautions;
  • Quality of resident care practices, including those with COVID-19 (laboratory-positive case), if applicable;
  • The surveillance plan;
  • Visitor entry and facility screening practices;
  • Education, monitoring, and screening practices of staff; and
  • Facility policies and procedures to address staffing issues during emergencies, such as transmission of COVID-19.

In addition to the 1-2 onsite CMS surveyors, additional surveyors will be offsite to receive information from the surveyors or facility staff while onsite. These offsite surveyors will be performing:

  • Medical record reviews;
  • Telephonic interviews; and
  • Facility Policy/Procedure Reviews (e.g., Infection Control and Prevention Program, Emergency Preparedness Plan).

Keep in mind, while the focus of this CMS survey is infection prevention, surveyors will also investigate any areas of potential non-compliance where there is a likelihood of an Immediate Jeopardy (IJ). If they find noncompliance which has caused or is likely to cause serious injury, harm, impairment, or death to a resident, they will use guidance in Appendix Q and complete an IJ Template.

CMS surveyors will conduct any survey exit discussion with the facility by telephone, unless requested in person by facility. The CMS-2567 will also be drafted offsite. Include the term, “COVID-19” in the 2567 citation, ideally in the Deficient Practice Statement so it can be identified as a specific survey for IPC.

Michelle McDonald oversees the CMS practice area and government advisory services as well as provides guidance, education and technical assistance in the provision of CMS content, federal laws, regulations, guidelines, federal surveillance protocols and standards governing the operation of health care facilities. Prior to joining the JCR team, Michelle held numerous operational and educational leadership positions at Arden Hill Hospital, Good Samaritan Home Care and the Orange County Department of Health, involved in the development and implementation of Care Management Programs in the acute, post-acute and community settings. She directed the Tuberculosis Control Program, Sexually Transmitted Disease and Immunization Clinics and led the community health education as the Community Health Educator.


The use of Joint Commission Resources (JCR) advisory services is not necessary to obtain a Joint Commission Accreditation award, nor does it influence the granting of such awards. JCR products and services are based on U.S. standards and regulations.

This is informational material and does not constitute legal advice regarding any specific situation.

Source: https://www.cms.gov/files/document/qso-20-20-allpdf.pdf