On March 23, 2020, the Centers for Medicare and Medicaid Services (CMS) issued QSO-20-20-All (PDF) to announce the prioritization and suspension of certain surveys in response to the COVID-19 pandemic. On June 1, 2020, CMS issued QSO-20-31-All (PDF), authorizing additional survey activities for all provider types if States have entered CMS Phase 3 of the Nursing Homes Reopening Recommendations (PDF), or earlier at the State's discretion. CMS then issued QSO-20-35-All (PDF), which revises guidance on the expansion of survey activities to authorize onsite revisits and other survey types. CDPH is committed to maintaining its presence in health facilities to protect patient safety. CDPH is implementing an alternative approach to monitoring facilities during the pandemic using predictive analytics and conducting surveys in locations identified as being high risk.
CDPH Survey Priorities
California is currently in CMS Phase 2 of the Nursing Home Reopening Recommendations (PDF). Until further notice, CDPH will prioritize the following survey activities:
- Focused infection control surveys
- Complaint and facility reported incident (FRI) investigations
- Revisits associated with immediate jeopardy (IJ)
- Licensing surveys
- Skilled nursing facility (SNF) COVID-19 mitigation plan visits
- SNF high risk visits
- Hospital surge monitoring visits
I. All Facilities
Focused Infection Control Surveys
CDPH recommends facilities use the CMS Infection Control Checklist to conduct a voluntary self-assessment of their infection control plans and protections. Acute care providers should refer to the checklist available in QSO-20-20-All (PDF), and SNFs should refer to the checklist available in QSO-20-38-NH (PDF).
Complaint and FRI Investigations
CDPH will prioritize and conduct all complaint and FRI investigations due to the backlog and increased volume in California. CDPH is committed to addressing complaints and FRIs as timely as possible for patient safety.
For all complaints and FRI investigations triaged at the IJ level, CDPH will also conduct an infection control review with the CMS Infection Control Checklist, regardless of the IJ allegation.
Revisits Associated with IJs
If an IJ is cited during an onsite survey or investigation, CDPH will conduct a federal revisit survey to verify removal of the IJ.
CDPH will conduct limited state licensing survey activities. These may entail initial licensing surveys (and state revisit surveys as necessary) for selected new facilities/agencies and/or change of service or change of location surveys.
COVID-19 Mitigation Plan Visits
Each SNF will receive a visit from CDPH to validate its mitigation plan at least every six to eight weeks. If CDPH determines that the SNF is not implementing its approved mitigation plan and identifies unsafe practices that have or are likely to cause harm to patients, CDPH may take enforcement action.
High Risk Visits
CDPH uses daily SNF COVID-19 reporting data to track and respond to urgent needs and integrates this data with high-risk priority level indicators to project the spread and severity of COVID-19 in SNFs across California. This allows CDPH staff to contact SNFs regarding resource requests, send a team onsite, or make a referral to the CDPH Healthcare-Associated Infections (HAI) strike team. Being listed on these reports does not imply wrongdoing on the part of the facility. CDPH is using predictive analytics to daily identify and monitor SNFs at high risk of outbreaks and increased infection spread by a list of indicators that flag facilities for immediate attention. These key indicators include:
- Staff absenteeism
- Changes in administrative staff
- Noncompliance with COVID-19 mitigation plans
- Receiving active intervention from the HAI Program
- Historical infection control deficiencies
- A facility with new outbreak of COVID-19
- Reported personal protective equipment shortages
- Inability to meet minimum staffing requirements
- Proximity to other SNFs with identified outbreaks
III. General Acute Care Hospitals (GACHs)
Surge Monitoring Visits
CDPH is using daily reported COVID-19 data to identify and monitor GACHs at risk for surge capacity. Key indicators include:
- Intensive care unit (ICU) bed occupancy
- Medical/surgical bed occupancy
- Staff absenteeism
- Ventilator shortages
- PPE shortages
If CDPH determines a hospital's surge capacity is at risk, hospitals will receive a check-in phone call from CDPH regarding their surge plan, any urgent needs, and whether they need assistance from CDPH.
If a hospital is considered at high-risk, CDPH may conduct a surge monitoring visit to evaluate the hospital's surge preparedness and infection control practices. Hospitals may refer to the CDPH Hospital Surge Monitoring Checklist (PDF) for a self-assessment of their surge preparedness and state infection control requirements. CDPH recommends hospitals have their surge plan and emergency policies and procedures readily available and together (e.g. in a surge binder) for review during the onsite visits.
CDPH is also developing a dashboard to monitor surge capacity in GACHs. The dashboard will be available on the CDPH Health Care Facilities webpage once it is completed.
If you have any questions about this AFL, please contact your local district office.
Original signed by Heidi W. Steinecker
Heidi W. Steinecker