By Sheryl Rosenfeld
As we turn our calendars to 2021, all of us are eager to leave behind a year that’s been more tumultuous than many in recent memory. Most importantly, the new year welcomes the arrival of COVID-19 vaccines for SNF residents and staff—bringing us hope and optimism for the months ahead. Yet though the vaccines promise to make things better, they won’t make your job of regulatory compliance any easier. In fact, now more than ever, staying compliant means keeping up to date with best practices and adjusting as regulations evolve.
As the public health emergency continues and we learn more about COVID-19, facilities across post-acute care settings must also enhance their knowledge of infection prevention standards and related clinical competencies to provide care and protect vulnerable residents and staff. Keeping everyone safe requires facilities to skillfully—and consistently—apply these competencies, especially as COVID-19 cases surge over the winter.
Positive and/or suspected COVID-19 patients have a range of diagnoses that impact their respiratory, nutritional, skin, psychosocial, and ADL care needs. To effectively care for these patients, facilities must rely on their QAPI reviews of admission practices, clinical assessments, and documentation practices. The timely completion of accurate MDS assessments will help clinical teams develop individualized plans of care that promote positive outcomes.
To keep patients and staff safe as teams provide this care, nursing homes must stay vigilant and keep learning. Internal surveillance and ongoing education are both vital to ensure adherence to best practices. These can’t be treated as “one and done”; they must be made part of a facility’s culture. After all, it’s what federal regulations demand—and if you’re tempted to assume the public health emergency gives you leave to slack on regulatory compliance, surveyors will be happy to remind you otherwise.
Don’t think CMS has been taking it easy for the holidays. Surveyors had no qualms showing up at facilities this past Christmas Eve and handing out citations. Moreover, the agency has issued plenty of new and updated guidance heading into the new year. As part of their ongoing response to the public health emergency, CMS has issued extensive changes to the federal Interpretive Guidance, Survey Tools, and Pathways. They’ve also announced changes to the Quality Reporting Program and calculations for the Care Compare website, including Five Star rating determinations, QMs, and other facility reporting documents. These changes are on facilities’ doorsteps—they are set to take effect January 27.
Surveyors, as well, have a very good chance of being on your doorstep. Just days ago, CMS issued brand- new additions to the criteria that can trigger an on-site infection control survey. Naturally, surveyors will show up if they catch wind of new COVID-19 cases—however, they can also perform an infection control survey if a facility has low staffing levels, has issues conducting outbreak testing, or experiences complaints about quality of care. In short, surveyors now have many more avenues to justify examining facilities. And since those surveys are required to occur just 3 to 5 days after whatever triggers them, you could be paid a visit at nearly any moment. Constant readiness is the name of the game for 2021.
Compliance is challenging, to say the least. Yet it is achievable. As staff focus on people over paper, Zimmet Healthcare Services Group can help clients with an array of solutions and support services. We offer reviews and updates of policy and procedure manuals, design of QAPI and QA programs, MDS audits, education, and monitoring for essential drivers of care, reimbursement, and compliance. Whatever your questions on staying survey-ready or maintaining care quality, Zimmet’s consultants can help.
The pandemic has put facilities, communities, and families through so much in 2020. But together, we can come through it all stronger than before, with top-notch care that satisfies regulators and keeps our residents safe—plus protects the heroic staff who care for them. Let Zimmet be your guide as you turn the promise of this new year into a reality.
