Digital Debut

Trend Emerges in CMS Citations

Infection control tags dominate top 10 cited areas

BY KARA NEWBURY | JUNE 2022

The Centers for Medicare & Medicaid Services’ (CMS) Quality, Certification and Oversight Reports (QCOR) page allows the public to pull citation frequency reports for both health surveys and Life Safety Code surveys. While you can drill down on specific facilities to see which tags they were cited for, unfortunately, information on the specific cause of the citation within each tag is not available.

Infection control has always been a focus of CMS surveyors, and it is not surprising that this remained the case during 2021, as the country and healthcare providers continued to deal with issues related to the COVID-19 pandemic. Review the revised ASC Infection Control Surveyor Worksheet to help avoid these citations.

CMS Health Surveys

From a total of 1,307 health surveys in 2021, the report returned infection control as a top area in which ASCs were cited (Q0241 Sanitary Environment and Q0242 Infection Control Program are number 1 and number 3, respectively).

Tags are listed from most frequently to least frequently cited, with the number of citations in parentheses.

Q0241 Sanitary Environment (238)

Q0181 Administration of Drugs (210)

Q0242 Infection Control Program (203)

Q0162 Medical Records: Form and Content of Record (108)

Q0104 Safety from Fire (92)

Q0101 Physical Environment (91)

Q0240 Infection Control (83)

Q0100 Environment (69)

Q0141 Organization and Staffing (69)

Q0266 Discharge – Order (57)

Infection control has remained a focus in 2022. In 2021, three tags appeared in the top 10 citations, while in 2022, so far, four tags have appeared in the top 10 (number of citations in parentheses): Q0241 (48), Q0242 (37), Q0240 (10) and Q0243 (10). Surveyors have completed 239 health surveys so far in 2022.

As a reminder, CMS also is now surveying for compliance with 42 CFR §416.51(c) Conditions for coverage - Infection control; Standard: COVID-19 Vaccination of Staff (Q0246). CMS has already cited eight facilities for this tag in 2022, including two complaint surveys and six standard surveys.

For additional detail of the regulatory requirements associated with each tag, consult Appendix L of the State Operations Manual, also referred to as the Interpretive Guidelines. ASCA has recently heard from its contacts at CMS that they expect revisions to Appendix L to be released this summer. Please stay tuned to ASCA communications for more information.

Life Safety Code Surveys

From a total of 635 Life Safety Code surveys in 2021, the following areas were cited most often, in order of volume of citations:

K0918 Electrical Systems – Essential Electric System (123)

K0353 Sprinkler System – Maintenance and Testing (113)

K0345 Fire Alarm System – Testing and Maintenance (92)

K0761 Maintenance, Inspection and Testing – Doors (84)

K0291 Emergency Lighting (80)

K0712 Fire Drills (72)

K0914 Electrical Systems – Maintenance and Testing (63)

K0293 Exit Signage (52)

K0321 Hazardous Areas – Enclosure (52)

For more information on Life Safety Code surveys, please consult Appendix I of the State Operations Manual.