On August 19, 2024, the US Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report indicating that certain for-profit nursing homes may have failed to comply with federal infection preventionist (IP) requirements. According to the report, the audit results suggest that approximately 25 percent of for-profit nursing homes nationwide may not have adhered to federal standards for IPs.
The Centers for Medicare & Medicaid Services (CMS) introduced new regulations in 2016 requiring nursing homes to implement and maintain an infection prevention and control program (IPCP) to ensure a safe, sanitary, and comfortable environment for residents.
As of July 2022, there were 15,178 Medicare- and Medicaid-certified nursing homes across the United States, including the 50 states, the District of Columbia, Guam, and Puerto Rico. Of these, 10,702 were for-profit nursing homes. The OIG conducted a simple random sample audit of 100 of these for-profit facilities to assess compliance with federal IP regulations during the period from July 1, 2021, to June 30, 2022.
For each selected nursing home, the OIG requested information from officials, including details about the IP(s) during the audit period, their qualifications, the job description for the IP role, and policies and procedures for IPC coverage when the IP was unavailable. They also sought details on any changes in nursing home administrators and ownership. This documentation was reviewed to determine whether the facilities met federal IP requirements.
Based on the sample results, the OIG estimated that 2,568 for-profit nursing homes nationwide (approximately 1 in 4 for-profit nursing homes) may not have complied with federal requirements for IPs to have completed specialized training prior to designation or to designate an IP. As a result, there may be increased health and safety risks for the residents and staff of these nursing homes.
The full report can be found here.
Compliance Perspective
Issue
According to F882, nursing homes are required to designate at least one individual as the IP who is responsible for the facility’s IPCP. Per the regulations, the IP(s) must: (1) have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; (2) be qualified by education, training, experience, or certification; (3) work at least part-time at the facility; and (4) have completed specialized training in infection prevention and control.
Discussion Points
- Review policies and procedures for the facility’s IPCP and IP, to ensure they align with federal requirements, including those stipulated in F881. Ensure that policies are up to date with the most recent CDC and CMS infection control guidelines.
- Ensure that all staff members are trained to follow the facility’s IPCP. Training should cover the importance of infection control, specific protocols to be followed, and the role of the IP in maintaining these standards.
- Periodically audit to verify that the designated IP meets all regulatory qualifications. Also audit to ensure that staff members are following infection control policies and procedures correctly, and that the IPCP is reviewed annually.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
