Clinical Surveillance Resources

When it comes to resident care, your role is to see the bigger picture and to put systems in place that not only protect your residents but also promote their best possible function. Preventing and identifying medical errors and adverse events is imperative for facility leaders. Using the latest technologies to synthesize resident care outcome data -- in complement with implementing proper bedside and clinical decision-making protocols -- are part of a strong clinical surveillance system that bolsters quality assurance. Find out what you need to know and how your facility can take evidence-based steps to improve care. 

  • COVID-19: CMS QSO Memo Details Nursing Home Reopening Recommendations for State and Local Officials (5/20)

    By CMS - May 19, 2020

    • Recommendations for State and Local Officials: CMS is providing recommendations to help determine the level of mitigation needed to prevent the transmission of COVID19 in nursing homes. The recommendations cover the following items:

    o Criteria for relaxing certain restrictions and mitigating the risk of resurgence: Factors to inform decisions for relaxing nursing home restrictions through a phased approach.

    o Visitation and Service Considerations: Considerations allowing visitation and services in each phase.

    o Restoration of Survey Activities: Recommendations for restarting certain surveys in each phase.

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  • CMS COVID-19 Stakeholder Engagement Calls – Week of 5/18/20

    By CMS - May 18, 2020

    CMS hosts varied recurring stakeholder engagement sessions to share information related to the agency’s response to COVID-19. These sessions are open to members of the healthcare community and are intended to provide updates, share best practices among peers, and offer attendees an opportunity to ask questions of CMS and other subject matter experts.

    Call details are below. Conference lines are limited so we highly encourage you to join via audio webcast, either on your computer or smartphone web browser. You are welcome to share this invitation with your colleagues and professional networks. 

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  • OSHA Alert: COVID-19 Guidance for Nursing Home and LTC Facility Workers (5/20)

    By MX - May 18, 2020

    The Occupational Safety and Health Administration (OSHA) is committed to protecting the health and safety of America’s workers and workplaces during these unprecedented times. The agency will be issuing a series of alerts designed to keep workers safe. In a nursing home or long-term care facility, the following tips can help reduce the risk of exposure to the coronavirus.

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  • CDC Long-term Care COVID-19 Resources Updated (5/20)

    By CDC - May 14, 2020

    Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes

     

    Summary of Changes to the Guidance:

    Updated guidance to recommend that nursing homes:

    • Act now to implement ALL COVID-19 preparedness recommendations, even before cases are identified in their community
    • Address asymptomatic and pre-symptomatic transmission, implement source control for everyone entering a healthcare facility (e.g., healthcare personnel, patients, visitors), regardless of symptoms.
    • Dedicate an area of the facility to care for residents with suspected or confirmed COVID-19; consider creating a staffing plan for that specific location


    COVID-19 Preparedness Checklist for Nursing Homes and other Long-Term Care Settings

    Nursing homes and other long-term care facilities can take steps to assess and improve their preparedness for responding to coronavirus disease 2019 (COVID-19). This checklist should be used as one tool to develop a comprehensive COVID-19 response plan, including plans for:

    • Rapid identification and management of ill residents
    • Considerations for visitors
    • Supplies and resources
    • Sick leave policies and other occupational health considerations
    • Education and training
    • Surge capacity for staffing, equipment and supplies, and postmortem care

    The checklist identifies key areas that long-term care facilities should consider in their COVID-19 planning. Long-term care facilities can use this tool to self-assess the strengths and weaknesses of current preparedness efforts. This checklist does not describe mandatory requirements or standards; rather, it highlights important areas to review to prepare for the possibility of residents with COVID-19.

     

    Additional pages: 


     


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  • CMS COVID-19 Nursing Homes Best Practices Toolkit and New QIN-QIO Virtual Assistance (5/20)

    By CMS - May 13, 2020

    New tool provides innovative solutions for states and facilities to protect our nation’s vulnerable nursing home residents during emergency

    CMS has released a new toolkit developed to aid nursing homes, Governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. The toolkit builds upon previous actions taken by the Centers for Medicare & Medicaid Services (CMS), which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency. The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalogue of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

    “The coronavirus presents a unique challenge for nursing homes. CMS is using every tool at our disposal to protect our nation’s most vulnerable citizens and aid the facilities that care for them. This toolkit will support state, local leaders and nursing homes in identifying best practices to protect our vulnerable elderly in nursing homes” said CMS Administrator Seema Verma.  

    The toolkit provides detailed resources and direction for quality improvement assistance and can help in the creation and implementation of strategies and interventions intended to manage and prevent the spread of COVID-19 within nursing homes. The toolkit outlines best practices for a variety of subjects ranging from infection control to workforce and staffing. It also provides contact information for organizations who stand ready to assist with the unique challenges posed by caring for individuals in long-term care settings. Each state was involved in the creation of this toolkit, resulting in a robust resource that may be leveraged by a variety of entities serving this vulnerable population.

    Additionally, CMS has contracted with 12 Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) to work with providers, community partners, beneficiaries and caregivers on data-driven quality improvement initiatives designed to improve the quality of care for beneficiaries across the United States. The QIN-QIOs are reaching out to nursing homes across the country to provide virtual technical assistance for homes that have an opportunity for improvement based on an analysis of previous citations for infection control deficiencies using publicly available data found on Nursing Home Compare.

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  • Coronavirus Commission for Safety and Quality in Nursing Homes to Focus on Identifying Best Practices, Strengthening Regulations and Enforcement (4/20)

    By CMS - April 30, 2020

    On April 30, the Centers for Medicare & Medicaid Services (CMS) announced that an independent Commission will conduct a comprehensive assessment of the nursing home response to the 2019 Novel Coronavirus (COVID-19) pandemic. The Commission will be convened and lead by a CMS contractor and will provide independent recommendations to the contractor to review and report to CMS to help inform immediate and future responses to COVID-19 in nursing homes. 

    The convening of the Commission is the next step in improving quality and safety within nursing homes. The Commission will help inform efforts to safeguard the health and quality of life of vulnerable Americans as CMS continues to battle COVID-19. The Commission will include residents, families, resident/patient advocates, leading industry experts, clinicians, medical ethicists, administrators, academicians, infection control and prevention professionals, state and local authorities, and other experts selected through a nomination process.

    It is expected to convene in May and develop recommendations on three key tasks: 

    • Putting nursing home residents first by ensuring they are protected from COVID-19 and improving the responsiveness of care delivery to meet the needs of all residents to maximize quality of life for residents.

    • Strengthen regulations to enable rapid and effective identification and mitigation of COVID-19 transmission in nursing homes; and 

    • Enhance federal and state enforcement strategies to improve compliance with infection control policies in response to COVID-19. 

    Additionally, the Commission will focus on identifying potentially innovative approaches for using existing and newly available nursing home (and other) data to enable better coordination between federal surveyors and state and local entities to address the current spread of COVID-19 within nursing homes as well as to analyze the impact of efforts to stop or contain the virus within these facilities. 

    Participants will help to identify best practices to address COVID-19, which CMS or states may incorporate into a larger regulatory framework for effective oversight to better inform federal and state officials as well as nursing homes across the country, to better achieve compliance through improved enforcement solutions, and to improve the quality of life and overall health status of nursing home residents during the pandemic. 

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  • COVID-19 Infection Prevention and Wandering: Can the Two Co-Exist?

    By Caralyn Davis, Staff Writer - April 28, 2020

    In the March 13 revised Quality, Safety, and Oversight (QSO) memo QSO-20-14-NH, the Centers for Medicare & Medicaid Services (CMS) advised nursing homes to restrict all visitors except for compassionate-care situations and to “cancel communal dining and all group activities, such as internal and external group activities.” Adjusting to these changes has been difficult for every nursing home resident, but social distancing is especially hard for residents with dementia who wander and are eased by group activities.

     

    “That’s not who these people are,” acknowledges Teepa Snow, MS, OTR/L, FAOTA, founder and CEO of Positive Approach to Care, a global dementia care services and products company based in Efland, NC. “Nurses are being asked to do the impossible with the inadequate.”

     

    While physicians and physician extenders may be willing to prescribe an antipsychotic medication as an emergency measure in an acute or emergency situation as allowed under F758 (Free From Unnecessary Psychotropic Meds/PRN Use) in Appendix PP of the State Operations Manual, giving residents with dementia antipsychotics to make them immobile not only increases their risk of adverse events, such as cerebrovascular accidents (CVA) and even death, it also increases their risk of respiratory symptoms, including shortness of breath—one of the primary symptoms of COVID-19, points out Snow. “Providers may also consider taking away wheelchairs and other mobility aids. However, doing that puts residents with dementia at greater risk for falls and fall-related injuries, potentially resulting in a trip to the emergency department where they may be exposed to SARS-CoV-2, the virus that causes COVID-19.”

     

    Instead, the goal should be to come up with strategies that make sense, balancing safety and resident needs, says Snow. “Keeping these residents in a small room is highly improbable, so you want to be ready to move forward with some element of safety. You will put residents at risk if you aren’t prepared for the reality that they will come out of their rooms.”

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  • AHRQ COVID-19 Articles: Peer Support/Crisis Communications and Helping LTC Settings Deal With the Pandemic (4/20)

    By AHRQ - April 28, 2020

    COVID-19: Peer support and crisis communication strategies to promote institutional resilience.

    Wu AW, Connors C, Everly Jr GS. Ann Intern Med. 2020

    To address the negative psychological impacts faced by healthcare workers during the COVID-19 crisis, the authors of this commentary recommend three strategic principles for healthcare institutions responding to the pandemic:

    ·  Encourage leadership to focus on resilience

    ·  Ensure that crisis communication provides both information and empowerment

    ·  Create a continuum of staff support within the organization to address a surge in mental health concerns among healthcare workers.

     

    Unprecedented solutions for extraordinary times: helping long-term care settings deal with the COVID-19 pandemic.

    Gaur S, Dumyati G, Nace DA, et al.  Infect Control Hosp Epidemiol. 2020

    This commentary discusses the provision of safe care in long-term care settings during the COVID-19 pandemic. The authors propose the following measures to ensure the safety of long-term care patients:

    ·  facilities should only accept patients with COVID-19 infections if they can provide effective airborne isolation;

    ·  patients recovering from COVID-19 need to have 2 negative tests on 2 consecutive days, as well as remain fever-free without mediation for at least 48 hours and not require ventilatory support that generates aerosols;

    ·  facilities should screen potential admissions for typical and atypical signs and symptoms of COVID-19, and;

    ·  facilities that are currently COVID-19 naïve should not accept any new admissions for whom there may be a concern for COVID-19.

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  • Infection Prevention and Control: Biphasic Outbreak of Invasive Group A Streptococcus Disease in Eldercare Facility, New Zealand (4/20)

    By CDC - April 28, 2020

    Emerging Infectious Diseases

    Volume 26, Number 5—May 2020

    Biphasic Outbreak of Invasive Group A Streptococcus Disease in Eldercare Facility, New Zealand

    Abstract

    A 3-month outbreak of invasive group A Streptococcus disease at an eldercare facility, in which 5 persons died, was biphasic. Although targeted chemoprophylaxis contained the initial outbreak, a second phase of the outbreak occurred after infection control processes ended. To retrospectively investigate the genomic epidemiology of the biphasic outbreak, we used whole-genome sequencing and multiple bioinformatics approaches. Analysis of isolates from the outbreak and isolates prospectively collected during the outbreak response indicated a single S. pyogenes emm81 clone among residents and staff members. Outbreak isolates differed from nonoutbreak emm81 isolates by harboring an integrative conjugative genomic element that contained the macrolide resistance determinant erm(TR). This study shows how retrospective high-resolution genomic investigations identified rapid spread of a closed-facilty clonal outbreak that was controlled, but not readily cleared, by infection control management procedures.

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  • COVID-19 Notification/Reporting Requirements Addressed in CMS QSO Memo (4/20)

    By CMS - April 19, 2020

    DATE: April 19, 2020

    TO: State Survey Agency Directors

    FROM: Director Quality, Safety & Oversight Group

    SUBJECT: Upcoming Requirements for Notification of Confirmed COVID-19 (or COVID19 Persons under Investigation) Among Residents and Staff in Nursing Homes

    Memorandum Summary

    • CMS is committed to taking critical steps to ensure America’s health care facilities are prepared to respond to the 2019 Novel Coronavirus (COVID-19) Public Health Emergency (PHE).

    • Communicable Disease Reporting Requirements: To ensure appropriate tracking, response, and mitigation of COVID-19 in nursing homes, CMS is reinforcing an existing requirement that nursing homes must report communicable diseases, healthcare-associated infections, and potential outbreaks to State and Local health departments. In rulemaking that will follow, CMS is requiring facilities to report this data to the Centers for Disease Control and Prevention (CDC) in a standardized format and frequency defined by CMS and CDC. Failure to report cases of residents or staff who have confirmed COVID -19 and Persons under Investigation (PUI) could result in an enforcement action. This memorandum summarizes new requirements which will be put in place very soon.

    • Transparency: CMS will also be previewing a new requirement for facilities to notify residents’ and their representatives to keep them up to date on the conditions inside the facility, such as when new cases of COVID-19 occur.

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  • Opioid Treatments for Chronic Pain (4/20)

    By AHRQ - April 17, 2020

    AHRQ systematic review

    Purpose of Review

    To assess the effectiveness and harms of opioid therapy for chronic noncancer pain, alternative opioid dosing strategies, and risk mitigation strategies. 

    Key Messages

    • Opioids are associated with small improvements versus placebo in pain and function, and increased risk of harms at short-term (1 to <6 months) followup; evidence on long-term effectiveness is very limited, and there is evidence of increased risk of serious harms that appear to be dose dependent.
    • At short-term followup, evidence showed no differences between opioids versus nonopioid medications in improvement in pain, function, mental health status, sleep, or depression.
    • Evidence on the effectiveness and harms of alternative opioid dosing strategies and the effects of risk mitigation strategies is lacking, although provision of naloxone to patients might reduce the likelihood of opioid-related emergency department visits, a taper support intervention might improve functional outcomes compared to no taper support, and co-prescription of benzodiazepines and gabapentinoids might increase risk of overdose.
    • No instrument has been shown to be associated with high accuracy for predicting opioid overdose, addiction, abuse, or misuse.
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  • Nonopioid Pharmacologic Treatments and Noninvasive Nonpharmacological Treatments for Chronic Pain (4/20)

    By AHRQ - April 17, 2020

    1. Nonopioid Pharmacologic Treatments for Chronic Pain

    AHRQ systematic review  

    Purpose of Review

    Evaluate the benefits and harms of nonopioid drugs in randomized controlled trials of patients with specific types of chronic pain, considering the effects on pain, function, quality of life, and adverse events.

    Key Messages

    • In the short term, improvement in pain and function was small with specific anticonvulsants, moderate with specific antidepressants in diabetic peripheral neuropathy/post-herpetic neuralgia and fibromyalgia, and small with nonsteroidal anti-inflammatory drugs (NSAIDs) in osteoarthritis and inflammatory arthritis.
    • In the intermediate term, evidence was limited, with evidence of benefit for memantine in fibromyalgia and for serotonin norepinephrine reuptake inhibitor (SNRI) antidepressants in low back pain and fibromyalgia.
    • In the long term, evidence was too limited to draw conclusions. In general, evidence on quality of life was limited and no treatment achieved a large improvement in pain or function.
    • Small to moderate, dose-dependent increases in withdrawal due to adverse events were found with SNRIs duloxetine and milnacipran, anticonvulsants pregabalin and gabapentin, and NSAIDs. Large increases were seen with oxcarbazepine. NSAIDs have increased risk of serious gastrointestinal, liver dysfunction, and cardiovascular adverse events.

    2. Noninvasive Nonpharmacological Treatment for Chronic Pain

    A Systematic Review Update

    Purpose of Review

    To assess noninvasive nonpharmacological treatments for common chronic pain conditions.

    Key Messages

    • Interventions that improved function and/or pain for ≥1 month:
    • Some interventions did not improve function or pain.
    • Serious harms were not observed with the interventions.

     

     

     


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  • CMS QSO Memo: 2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios (4/20)

    By CMS - April 13, 2020
    Memo # QSO-20-25-NH

    Posting Date 2020-04-13

    Fiscal Year 2020

     

    Summary

    • CMS is providing supplemental information for transferring or discharging residents between facilities for the purpose of cohorting residents based on COVID-19 status (i.e., positive, negative, unknown/under observation).

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  • April 8 CMS Call: COVID-19 in Nursing Homes

    By CMS - April 07, 2020

    Please join the Centers for Medicare and Medicaid Services (CMS) for a call on COVID-19 with Nursing Homes tomorrow, Wednesday, April 8th at 4:30 PM EST. CMS leadership will provide updates on the agency’s latest guidance and we will be joined by leaders in the field interested in sharing best practices with their peers. The call will be recorded if you are unable to join us.

    Conference lines are limited, so we highly encourage you to join via audio webcast, either on your computer or smartphone web browser. You are welcome to share this invitation with your colleagues and membership.

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  • COVID-19 Prevention / Management in Long-Term Care: CMS Issues New CDC-Based Recommendations (4-2-20)

    By CMS - April 02, 2020

    The new recommendations include:

    ·  Nursing homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control.

    ·  As nursing homes are a critical part of the healthcare system, and because of the ease of spread in long term care facilities and the severity of illness that occurs in residents with COVID-19, CMS/CDC urges State and local leaders to consider the needs of long term care facilities with respect to supplies of PPE and COVID-19 tests.

    ·  Nursing homes should immediately implement symptom screening for all staff, residents, and visitors – including temperature checks.

    ·  Nursing homes should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE.

    ·  To avoid transmission within nursing homes, facilities should use separate staffing teams for residents to the best of their ability, and, as President Trump announced at the White House today, the administration urges nursing homes to work with State and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status.

    “The Trump Administration is calling on the nursing home industry and state and local leaders to join us by taking action now to ensure the safety of their residents, who are among our most vulnerable citizens. The Administration urges them to carefully review our recommendations, and implement them immediately,” said CMS Administrator Seema Verma.

    Today’s recommendations will help State and local governments, and nursing homes, as they consider creative ways to stop the spread of the virus, such as designating units within facilities – or entire facilities – solely for residents with confirmed COVID-19. An example of such an arrangement is in Wilmington, Massachusetts, in which a 142-bed facility has been designated as a solely COVID-19-positive facility. Residents across the region who are infected with COVID-19 can be moved to this facility to receive appropriate care and avoid transmitting the virus within their facilities. This approach also eases the challenges of preventing transmission, like extensive PPE usage and isolation practices, for individual facilities. The Massachusetts arrangement, developed in coordination with the state’s government, is a prime example of the arrangements envisioned in the recommendations announced today.

    The recommendations also speak to enhanced screening and transmission prevention practices. Previous CMS guidance, developed with CDC and issued in mid-March, advised nursing homes to restrict all but the most urgent visitors and staff. Today’s guidance builds on this by recommending temperature screenings for all visitors and that all staff utilize adequate PPE when interacting with patients, to the extent PPE is available.

    Nursing homes are unique in the healthcare system because, unlike other healthcare facilities, they are full-time homes as well as settings of care. Importantly, nursing home residents, given their advanced age and corresponding health issues, are at particular risk of complications arising from COVID-19. Because they are large concentrations of particularly vulnerable individuals, nursing homes have been a major focus for the Trump Administration in its aggressive efforts to combat the virus.

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