The Office of Inspector General (OIG) analyzed State survey agency (SSA) data on Medicare.gov for the most recent standard surveys and the previous 12 months of complaint surveys. They identified that 6,622 nursing homes had been cited for infection prevention and control program deficiencies as of February 26, 2020, and Medicare.gov indicated that 24 nursing homes were part of a nursing home chain. The OIG contacted that chain’s corporate office regarding the 24 nursing homes, and requested that they provide documentation related to infection prevention and control and emergency preparedness program policies and procedures that were in effect from January 2019 through May 2020.
The OIG’s audit found that 23 of the 24 nursing homes had possible deficiencies. At 22 nursing homes, the OIG found 35 instances of possible noncompliance with infection prevention and control requirements related to annual reviews of the Infection Prevention and Control Program (IPCP), training, designation of a qualified infection preventionist, and Quality Assessment and Assurance Committee (QAA) meetings. They also found at 16 nursing homes 20 instances of possible noncompliance with emergency preparedness requirements related to the annual review of emergency preparedness plans and annual emergency preparedness risk assessments.
The nursing home chain’s officials attributed the possible noncompliance to: (1) leadership turnover, (2) staff turnover, (3) documentation issues (i.e., information was not documented or documentation was either lost or misplaced), (4) staff members who were unfamiliar with requirements (i.e., requirements stipulating that there is no grace period for infection preventionists to complete specialized training and that emergency preparedness plans needed to be reviewed annually), (5) qualified personnel shortage, and (6) challenges related to the COVID-19 public health emergency.
The OIG said that many of the conditions noted in their report may have occurred because the Centers for Medicare and Medicaid Services (CMS) did not provide nursing homes with communication and training related to complying with the new, phase 3 infection control requirements, or clarification about the essential components to be integrated in the nursing homes’ emergency plans.
The OIG recommended that CMS instruct SSAs to follow up with the 23 nursing homes that they identified with possible infection prevention and control and emergency preparedness deficiencies to verify that they have taken corrective actions. CMS agreed with the OIG’s recommendation and stated that it had contacted the appropriate SSAs to ensure that the 23 nursing homes with possible infection prevention and control and emergency preparedness deficiencies have taken corrective actions in accordance with Federal requirements. Read the full report here: https://oig.hhs.gov/oas/reports/region1/12000004.pdf.
Issue:
Infection prevention and control is a critical issue for nursing home residents because of the high number of healthcare-associated infections, residents’ increased susceptibility to infections, and the significant exposure to healthcare-associated infections residents face. Federal regulations on infection control require nursing homes to establish and maintain an IPCP designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. In addition, Federal regulations on emergency preparedness include specific requirements for nursing homes’ emergency preparedness plans, such as requirements that facilities complete a facility-based and community-based, all-hazards (including emerging infectious diseases) risk assessment and develop strategies to address the risks identified. A nursing home’s QAA Committee must meet at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program.
Discussion Points:
- Review policies and procedures for your IPCP, infection preventionist requirements, and QAA meetings. Ensure that policies are up-to-date with the most recent CDC and CMS infection control guidelines. Review your emergency preparedness plan and update as necessary. Make sure the plan is available to staff so they can easily access the guidelines for the various components should an emergency occur.
- Train all staff to follow the facility’s policies and procedures for infection prevention and control. Train all staff on your emergency preparedness plan. Conduct drills for the various disaster response plans to ensure staff competency with each. Document that these trainings and drills occurred, and file the signed documents in each employee’s education file.
- Periodically audit to ensure that all staff members are following infection control policies and procedures correctly, and that the IPCP is reviewed annually. Provide additional education if necessary. Audit staff to ensure that they are aware of their roles during an emergency per your emergency preparedness plan. Audit to ensure that quarterly QAA meetings are conducted with all key members.
