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In November 2024, the Centers for Medicare and Medicaid Services (CMS) released Revised Long-Term Care (LTC) Surveyor Guidance. The memo included significant changes to guidance in Appendix PP. The memo was updated January 16, 2025, to include additional changes to the guidance. The changes will be effective, and surveyors will begin surveying based on the revised guidance, on March 24, 2025. Note: The effective date was delayed from the original memo.
CMS is incorporating the guidance regarding Enhanced Barrier Precautions (EBP) and COVID-19 immunizations in Appendix PP previously released in the CMS memos QSO-24-08-NH on March 20, 2024, and QSO-21 19-NH on May 11, 2021, respectively. CMS did not make any changes to the guidance from the memos but included new deficiency examples.
Additional takeaways include the following:
- Year after year, F880 remains one of the top citations for nursing homes nationwide.
- Surveyors will evaluate the use of EBP when reviewing sampled residents for whom EBP are indicated and focus their evaluation of EBP use as it relates to Centers for Disease Control and Prevention (CDC)-targeted multi-drug resistant organisms (MDROs). Since the implementation of EBP on April 1, 2024, F880 citations that included “Enhanced Barrier Precautions” in the 2567 have ranged from 27.3 to 43.2%, making EBP-related citations one in three.
- Most EBP-related citations note the following:
- Staff not donning/doffing gloves/gowns as required for residents on EBP during high-contact resident care activities.
- Lack of identifications for which residents are on EBP (whether signage or another method).
- Staff being unaware of which residents are on EBP.
- Staff not following facility policies/procedures related to EBP
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The definition for “up to date” for the COVID-19 vaccine may change over time as new or updated vaccines are developed, so it will be important to keep informed of any changes. Refer to the CDC’s Staying Up to Date with COVID-19 Vaccines | COVID-19 | CDC. It is important to note that up to date definitions for National Healthcare Safety Network (NHSN) reporting may not align with clinical practice or minimum data set (MDS) reporting. When the definition changes in clinical practice (and MDS), it does not change in NHSN until the next calendar quarter.
For additional information AHCA’s F-Tag Action Tool-Infection Prevention & Control contains actions items and a check list related to EBP and COVID-19 Immunizations which can assist your facility with regulatory compliance.
AHCA has also developed an on-demand webinar that walks learners through each of the changes to guidance, the updates to the Critical Element Pathways (CEP), and provides some tips/action items to be compliant ahead of the effective date. As a result of the updated CMS memo, additions and extending the effective date for the Appendix PP changes have been made to AHCA’s webinar, AHCA Education: Preparing for Upcoming CMS Guidance Changes: Key Updates and Action Items for Compliance. This training is available free to AHCA/NCAL members and $65 non-members. Please send questions to regulatory@ahca.org, and email educate@ahca.org if you need assistance with registering.
Thank you to AHCA for the development of the information contained within this communication and the associated tools. If you have questions, please contact Elena Madrid, Executive Vice President of Education and Regulatory Affairs.
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