On June 1, CMS outlined the details of the enforcement actions or penalties that can be levied against facilities for their performance on the new Targeted Infection Control Surveys.  We’ve written before about issues with past Infection Control deficiencies and about the new IC Surveys, but now, the two combined can be a significant liability for any offending facility.

We found CMS’s memo confusing, so we designed a chart that we hope simplifies things.  Let’s start with the bottom two rows.  The upshot here is that if you receive a Actual Harm (GHI) or Immediate Jeopardy (JKL) deficiency on your Targeted Infection Control survey, you can expect a cornucopia of enforcement actions.  While scary, this may not be as big a concern as expected.  As the Center for Medicare Advocacy pointed out in June, there are shockingly few Infection Control deficiencies being found.   Our own analysis of the most recent data bears this out.

Infection Control Survey Findings

CMS’s data shows that nearly 17,000 Surveys were conducted between March 4 and the most recent Survey published in the dataset, which was conducted on June 9.  Of these, most of which are Targeted Infection Control Surveys, only 6.68% turned up even a single deficiency.  Of those, only 347 turned up an Infection Control Deficiency.  That’s about 2.1% of all Surveys conducted.  Given the current crisis and the spread in homes, this seems highly unlikely.  But this is good news for operators looking to avoid the fines. 

Scope/Severity of IC Deficiencies

Of the 347 IC deficiencies, only 23 were recorded at the Immediate Jeopardy (JKL) level.  Curiously, only one deficiency was recorded at the Actual Harm Level (GHI).  The balance were mostly risk-of-harm or DEF-level.  Looking at the top two rows of the initial table, this is where the fine structure gets tricky. A facility needs to look out for their prior Infection Control deficiencies to understand their liability for enforcement.  On the far right of the table, we can see that those homes with repeat IC deficiencies over the past two years/Survey cycles receive much higher penalties than those with none. 


Since these penalties can result in serious problems for a facility, StarPRO has added a feature showing each home’s Infection Control performance, both Pre-Covid, and in the Covid era.  StarAnalyzer subscribers can use the former to see if a facility should expect any penalties, and the latter to understand either the reason for the penalty they received, or their potential risk level for a future penalty.  All these new rules are confusing, and everyone has a laundry list of competing priorities, so our goal is always to get you the information you need to keep moving.

For more insights like these, subscribe to our monthly newsletter with the form above.

Related Post