Now that we’ve covered F880, let’s take a look at the F-tag with the most citations in 2021.
Since May 8, 2020, nursing homes have been required to report information related to COVID-19 directly to the CDC. The following information is required:
- Suspected and confirmed COVID-19 infections among residents and staff
- Total deaths and deaths related to COVID-19 infection, including both resident and staff deaths
- PPE and hand hygiene supplies
- Ventilator capacity and supplies
- Resident beds and census
- Resident access to testing
- Staffing shortages
Noncompliant nursing homes receive a per day civil money penalty (CMP) for one day assessed at $1,000. For each additional week the nursing home fails to comply with this requirement, the rate of the per day CMP increases by an additional $500.12
The citations most commonly issued are:
- Not all seven modules completed
- Not all data elements in module completed
- Waiting to submit on Sunday and then something goes wrong
- Having only one person registered for submissions
You can avoid CMPs by following the critical element pathways (CEPs). Surveyors follow a process that is specific and known. Guidance for infection prevention-related CEPs is available on the CMS site.13
Don’t forget OSHA inspections
Citations from other entities are possible as well. On June 10, 2021, the Occupational Safety and Health Administration (OSHA) issued the COVID-19 Healthcare Emergency Temporary Standard (ETS), which requires healthcare employers to follow safety and infection prevention requirements related to COVID-19. The ETS addresses policies and procedures, PPE, administrative controls and engineering controls to reduce the risk of infection.
OSHA has announced plans to target onsite inspections in hospitals, assisted living complexes, nursing homes and other facilities treating patients with COVID-19. The inspection will include a program and document review, as well as a facility walkthrough. Citations may be issued if a facility lacks a COVID-19 plan and if other requirements of the standard have not been implemented. Each component failing compliance can be cited as a separate violation.
Your facility should perform an internal audit of your current IPCP to determine if it complies. Some requirements of the regulation are specific to COVID-19 and will need to be addressed, such as the mini-respiratory protection program, paid leave requirements, and additional training, recordkeeping and reporting obligations.14
Everyone in your facility plays a role in keeping people safe from infection—from staff to residents to visitors. We know it’s tough to meet increasing regulations when you already have competing priorities, limited resources and a high labor shortage. That’s why it’s so important that your facility’s leaders provide best practice guidance and ensure access to the right education, training and products.