Resources to Navigate LTC Survey Process

February 2, 2022
On January 25, the Centers for Medicare & Medicaid Services (CMS) posted updates to the LTC Survey Process (LTCSP), specifically survey resources, including:
The LTCSP is updated in the Survey Resources folders and carries an effective date of January 27, 2022. Two (2) of the Critical Element Pathways have been updated recently: CMS-20054 was updated in late January with CMS-20062 carrying a November 2021 date. Also, the updated CMS-20054 contains detailed verbiage/information in relation to F888 compliance with HC staff vaccination.
NEW: F888 Staff Vaccination Requirement Matrix & Formula
CMS released two documents to help state surveyors survey for compliance with F888—a staff matrix that will need to be completed during a survey and formulas to determine percentage of staff vaccinated.
The matrix provides definitions and a form that includes designation of three levels of vaccinations for vaccinated staff and four levels of designation for unvaccinated staff.
  • The matrix also expects staff names, whether the staff are facility or contracted staff, titles, positions, and work areas.
  • The nursing facility will be asked to complete the form. An alternative document can be provided IF it includes all the fields on the matrix form.
  • The matrix form also provides a worksheet for surveyors to use to determine the accuracy of NHSN reporting by the facility.
  • It is recommended that staff practice filling out this form to avoid confusion (or panic) during a complaint investigation or survey.
With the new enforcement sanctions, your ability to prepare and respond quickly is more important than ever. Pathway Health experts are ready to support your COVID-19 and Infection Control survey readiness and success. Contact us to learn more.

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COVID-19 Resurgence Assessment
Conducted both on-site and off-site, and includes:
  • Observation of staff performing IP activities (e.g., screening, hand hygiene, PPE use, cleaning and disinfection, and more!)
  • Interview and interaction with leadership, Infection Preventionist, staff related to COVID-19 and infection control guidance and requirements.
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Infection Prevention & Control Resource Manual

Infection Prevention

Updated with the new vaccination section and COVID-19 tools.
Pathway Health’s Infection Prevention and Control Manual provides a multitude of resources for the Infection Preventionist to be able to customize their Infection Prevention and Control Program for quality and strategies for compliance!
This highly informative manual includes Enhanced Precautions, TB and comprehensive COVID-19 information.

 

Other COVID Resources

INFECTION PREVENTIONIST BASIC BOOTCAMP
This fast-paced VIRTUAL classroom will provide the basics of learning key aspects of the following:
  • The role necessary for the job of Infection Preventionist
  • Address regulatory requirements
  • Key best practices
  • Implementation strategies
This course is intended for nurses new to the position of Infection Preventionist or as a refresher for experienced Infection Preventionists!
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