QSO-23-10-NH - CMS Issues Enhanced Enforcement for Infection Control Deficiencies and Quality Improvement Activities in Nursing Homes
CMS rescinds previous QSO-20-31-ALL, from 2020, and issues updated guidance for Enhanced Enforcement for Infection Control Deficiencies.
Today, the Centers for Medicare and Medicaid Services (CMS) released QSO Memo QSO-23-10-NH, which updates the enhanced enforcement policy, which was implemented early in the pandemic. This update is related to changes that have occurred throughout the pandemic, including an interim final rule that established long term care facility vaccine immunization requirements, CMS noted the need to continue to evaluate guidance.
The biggest change, in enforcement, is that a CMP (Civil Money Penalty) would no longer apply for all infection control citations. Instead, a CMP would only apply if the scope and severity was cited at a G or higher. Furthermore, enhanced enforcement (Directed POC (plan of correction) and DDPNA), would only be enforced at Level 2 (D, E, & F) when BOTH F880-Infection Prevention & Control- and F887-COVID-19 Immunizations were cited. Note, F887 can be
cited at any level. However, CMS did reduce the times to achieve substantial compliance. Compliance must be achieved in 30 days for a Level 2 (D, E, & F) deficiency and 15 days for a Level 3 (G, H, & I) or 4 (J, K, & L) deficiency.
| Non-compliance with BOTH F880 and F887 (S/S Level 2- D, E, F) **On the same
survey** | Non-compliance for F880 (S/S Level 3- G, H, I) | Non-compliance for F880 (S/S Level 4- J, K, L) |
| Directed POC with the QIO (Quality Improvement Organizations) or another qualified consultant | Directed POC with the QIO or hiring an IC Consultant | Directed POC with the QIO or hiring an IC Consultant |
| DDPNA with 30-days to achieve substantial compliance | DDPNA with 15-days to achieve substantial compliance | DDPNA with 15-days to achieve substantial compliance |
| | CMP according to the CMP Analytical Tool with a 10% increase adjustment | CMP according to the CMP Analytical Tool with a 20% increase adjustment |
For survey cycles that began prior to the effective date of QSO-23-10-NH (March 30, 2023), facilities should continue to reference the previous memo.
Finally, the QIOs have been directed to focus their attention on assisting facilities with technical assistance to nursing homes with a history of infection control challenges.
For questions, please contact regulatory@ahca.org.