Survey Tips & Common Issues
The CMS re-certification process can be a stressful event. It is the facilities opportunity to demonstrate compliance with CMS federal conditions of participation. It is your opportunity to show off your facility Infection Prevention Program and the work that you do. Be proud!
Surveys are unannounced and can take around one week with multiple surveyors, depending on the size of the facility. It is expected to take place annually - every 9 to 15 months, though the COVID-19 pandemic disrupted this schedule. Upon entrance into the facility a space will be requested, and an entrance conference will take place with the facility leadership. During this time a request for documents will be presented. It is best to maintain these documents in an up to date and readily accessible format.
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The re-certification surveyors can be from your local CDPH Licensing and Certification office or from another contracted entity. The surveyors are guided by the CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities. Infection Prevention is covered in F tags 880 – 883 on pages 770 – 882. Infection Prevention education is covered under F tag 945 on pages 861 – 863. CMS provides “Critical Element Pathways” for the surveyors to use to guide their process. Many of those have recently been updated to include elements of Enhanced Barrier Precautions These resources can be downloaded from the CMS website under “Survey Resources”.
In addition to the CMS (Federal) conditions of participation the facility must follow the State (California Code of Regulations (CCR)) and other local regulations when applicable. Examples include the Aerosol Transmissible Disease Standard - Title 8 CCR; Section 5199, Bloodborne Pathogen Standard including exposure control plan - Title 8 CCR; Section 5193 and general license requirements found in Title 22 CCR; Division 5, Chapter 3.
Potential issues:
Issues and questions sometimes come up during surveys, especially when the facility practices are not in line with the surveyor’s expectations. This may be due to surveyor bias or even lack of knowledge of current evidence-based practices. If these questions arise it is important to be able to base the facility policy and procedure and observed practice on current evidence-based guidelines from a reliable source such as CMS, CDPH or CDC. Additionally, questions and potential deficiencies come up because your policy and procedure may not be up to date or reflect the observed practices, even if the practice is correct.
Some issues and questions that have been reported from surveys:
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Q. Do we have to include all antimicrobials (including antifungals and antivirals and not just antibiotics) in our infection surveillance log?
A. The CMS guidelines are specific for “antibiotic stewardship”, (not antimicrobial) and define antibiotics: “Antibiotic” refers to a medication used to treat bacterial infections. They are not effective for infections caused by viruses (e.g., influenza or most cases of bronchitis)” (see page 805 of the CMS Manual). Further, the generally accepted Loeb’s criteria does not cover viral or fungal indications. It would be incorrect to issue an F-tag for this. (F-483)
Q. Should we also include any signs and symptoms of infection even if not being treated or being prescribed with antimicrobials?
A. Yes, As part of HAI surveillance, any resident with S&S of infection (suspected or confirmed) should be listed on the infection event log irrespective of receipt of antibiotic. (Page 780 – Outcome surveillance)
Q. Are antifungals and antivirals, antiparasitics, etc. required by CMS to be included in our antibiotic stewardship program?
A. No. Buried in the CMS State Operations Manual that is based on the Code of Federal Regulations and guides the surveyors during a CMS re-certification survey is the definition of antibiotic and it specifically refers to agents that treat bacterial infections, not antivirals or antifungals. The link is the advanced copy for 2025 that will be used by surveyors later in April 2025. On page 788 you will find the definition below:
• “Antibiotic” refers to a medication used to treat bacterial infections. They are not effective for infections caused by viruses (e.g., influenza or most cases of bronchitis).
• “Antibiotic Stewardship” refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration.
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Q. Should we have a policy and procedure or utilize Reverse isolation or Neutropenic Precautions?
A. In the "old days" the CDC had "reverse isolation" or Neutropenic Precautions" and it still shows up in some older textbooks. Now the CDC describes a Protective Environment for allogeneic hematopoietic stem cell transplant (HSCT) patients only. Most nursing homes would not have the capacity to provide this level of protection.
In general, Standard precautions are indicated and may consider avoiding dried and fresh flowers and carpet and perform dusting using wet dusting procedures to minimize dust. Also note that when dealing with a viral infection, a longer period of isolation may be necessary as immune compromised individuals may take longer to clear a viral load. If you have a P&P for neutropenic precautions or reverse isolation you may consider updating or retiring as these are no longer included in the recommendations and have shown to be in-effective and not necessary. Despite this, if a physician or other prescriber writes an order for Neutropenic Precautions or Reverse Isolation (in the absence of a facility policy that would be obsolete anyway), they should be requested to specify what they would like to have implemented beyond Standard Precautions.
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Q. What are the current CDC guidelines for hand hygiene and C diff.
A. The most recent hand hygiene guidelines that include methods to promote and monitor can be found here: SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 Update (cambridge.org). These guidelines are summarized by the CDC Note that the guidance has been updated for hand washing for the care of patients with suspected or confirmed infection of C diff and norovirus – only during outbreaks or when hands are visibly soiled, otherwise ABHS is preferred. Remember that your practice must be consistent with your policy and procedure and your procedure should be evidence-based and reflect current best practices.
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Q. Should active infections be placed in transmission-based precautions (Contact, Droplet, etc.) or Enhanced Barrier Precautions (EBP)?
A. “Acute” or “active” infections are not listed in EBP; however, some may be Transmission Based Precautions (Contact, Droplet) if indicated on the Transmission Based Precautions Appendix A such as C diff, Scabies, Influenza, etc. Guidance on when and how long to use transmission based precautions (contact, droplet, etc.) can be found at the CDC’s appendix A. UTI with or without urinary catheter is standard precautions. MRSA and ESBL organisms do not require any special treatment in the nursing home setting unless there is evidence of ongoing transmission. For wounds it would be EBP unless exudate cannot be contained by dressings
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Q. Are AV shunts and fistulas for dialysis a risk factor that needs Enhanced Barrier Precautions?
A. No. Though AV shunts (Dialysis Ports) are not specifically mentioned in the CDC EBP FAQs, (see question #22), note that AV shunts and AV Fistulas are not catheters but are grafts or anastomosis and are normally completely under the skin. We quired the CDC and received this response to confirm.
What is the definition of "indwelling medical device"?
...Devices that are fully embedded in the body, without components that communicate with the outside, such as pacemakers, would not be considered an indication for Enhanced Barrier Precautions.
So, if the dialysis port does not have a component that communicates externally, the resident would not have a recommendation for EBP to be used unless they have another indwelling device, wound, or MDRO that would have them meet criteria.
Q. Is it still OK to use reusable gowns?
A. Yes, there is often a misperception that re-usable gowns should not be used since re-usable gowns were recommended when disposables where not available during early COVID-19. However, there is no guidance or references that indicate that disposable gowns are superior to re-usable gowns or that re-usable gowns should no longer be used. In fact studies have shown that for several reasons re-usable may be better and certainly better for the environment: Disposable versus reusable medical gowns: A performance comparison - American Journal of Infection Control (ajicjournal.org)
This was also confirmed by the AHCA via an email communication wit the CDC and addressed in their FAQ document: AHCA EBP FAQ.pdf
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Q. Is monitoring or testing for legionella required for our water management program?
A. The goal of the water management program is to ensure that water, from the point of entry in the facility to the point of use, meets all applicable quality standards. This includes other areas where water may be used as a component such as decorative fountains, swamp coolers, ice machines and hot water storage tanks
CMS Specifically states that testing for Legionella is not a requirement: “At this time, CMS does not require water cultures for Legionella or other opportunistic waterborne pathogens as part of routine program validation, although there may be instances when it is needed. This is generally done or directed by the local health jurisdiction. (e.g., a case of healthcare-associated legionellosis or a potential outbreak of legionellosis in the facility). Note that when CMS states that a facility “specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained” they mean testing water temperature in any water storage tanks such as hot water tanks, testing for disinfectant residual in stored water, decorative fountains or other water systems as needed etc.