CMS Issues Revised Guidance for More Stringent Infection Control Enforcement Actions

The Centers for Medicare and Medicaid Services (CMS) has issued QSO-23-10-NH and rescinds QSO-20-31-All.

CMS rescinded memorandum QSO-20-31-ALL, the Enhanced Enforcement for Infection Control Deficiencies, and replaced it with memorandum QSO-23-10-NH, revised guidance for Strengthened Enhanced Enforcement for Infection Control Deficiencies.

The strengthened enhanced enforcement actions are more severe for infection control deficiencies that result in actual harm or immediate jeopardy to residents. In addition, the criteria for strengthened enhanced enforcement on infection control deficiencies that result in no resident harm has been expanded to include enforcement on noncompliance with Infection Prevention and Control (F880) combined with COVID-19 Vaccine Immunization Requirements for Residents and Staff (F887).

Enforcement cases with a survey cycle start date before March 30, 2023, with deficiencies associated with Infection Prevention and Control requirements at F880 are subject to the enforcement remedies as previously outlined in QSO-20-31-All. In addition, enforcement cases with a survey cycle start date before March 30, 2023, with pending enforcement actions because of enhanced enforcement at F880 are still subject to the enforcement remedies previously outlined in QSO-20-31-All.

Noncompliance with deficiencies associated with Strengthened Revised Enhanced Enforcement for Infection Control Deficiencies will lead to the following enforcement remedies:

  • Noncompliance with both Infection Prevention and Control (F880) concurrent with COVID-19 Vaccine Immunization Requirements for Residents and Staff (F887) requirements cited at Scope and Severity (S/S) Level 2 – i.e., D, E, F (No Actual Harm with Potential for More Than Minimal Harm):
    • Directed Plan of Correction that includes Root Cause Analyses and working with a Quality Improvement Organization or another qualified consultant.
    • Discretionary Denial of Payment for New Admissions with a 30-day notice period to achieve substantial compliance.
    • Enhanced Enforcement of F880 at S/S Level 2 is applicable when F887 is also cited at any level. Additional remedies may apply if F887 is cited at S/S Level 3 or 4, as per normal enforcement policy outlined in Chapter 7 of the State Operations Manual.
  • Noncompliance for Infection Prevention and Control (F880) cited at S/S Level 3 – i.e., G, H, I (Actual Harm):
    • Directed Plan of Correction that includes Root Cause Analyses and working with a Quality Improvement Organization or hiring an Infection Control Consultant to develop and implement a corrective action plan.
    • Discretionary Denial of Payment for New Admissions with a 15-day notice period to achieve substantial compliance.
    • Civil Money Penalty imposed according to the CMP Analytic Tool with a 10% increase adjustment.
  • Noncompliance for Infection Prevention and Control (F880) at S/S Level 4 – i.e., J, K, L (Immediate Jeopardy):
    • Directed Plan of Correction that includes Root Cause Analyses and working with a Quality Improvement Organization or hiring an Infection Control Consultant to develop and implement a corrective action plan.
    • Discretionary Denial of Payment for New Admissions with a 15-day notice period to achieve substantial compliance.
    • Civil Money Penalty imposed according to the CMP Analytic Tool with a 20% increase adjustment.

Email the TMF Quality Innovation Network at nhnetwork@tmf.org for quality improvement assistance with the establishment of strong infection control and surveillance programs.

Read the QSO-23-10-NH details.