The US Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a report on October 4, 2024, which says Massachusetts could better ensure that nursing homes comply with federal requirements for life safety, emergency preparedness, and infection control.
From the 347 nursing homes in Massachusetts that participate in Medicare and Medicaid, the OIG selected a nonstatistical sample of 20 nursing homes based on certain risk factors, including multiple high-risk deficiencies reported to the Centers for Medicare & Medicaid Services (CMS). Unannounced site visits were conducted at each facility during October and November 2023.
During these visits, the OIG checked for life safety violations, reviewed the nursing home’s emergency preparedness plan, and reviewed the nursing home’s policies and procedures for infection control and prevention. Noncompliance with any federal requirement was classified as a deficiency, regardless of the number of instances observed. For example, if three fire extinguishers were found noncompliant with the monthly testing requirement, it was recorded as a single deficiency.
The OIG identified deficiencies related to life safety, emergency preparedness, or infection control at all 20 nursing homes that they audited, totaling 236 deficiencies. Specifically, they found:
- Life Safety Requirements: 128 deficiencies related to building exits, fire barriers, smoke partitions (41); fire detection and suppression systems (35); hazardous storage areas (36); smoking policies and fire drills (5); elevator and electrical equipment testing and maintenance (3); and resident call systems (8).
- Emergency Preparedness Requirements: 57 deficiencies related to emergency preparedness plans (7); emergency supplies and power (6); plans for sheltering in place and tracking residents and staff during an emergency (3); emergency communications plans (20); and emergency preparedness plan training and testing (21).
- Infection Control Requirements: 51 deficiencies related to infection control programs and antibiotic stewardship (29); infection preventionists (3); and influenza and pneumococcal immunizations (19).
The report states that these deficiencies increase the health and safety risks for residents, staff, and visitors during fires, emergencies, or infectious disease outbreaks.
The OIG identified frequent management and staff turnover as a key factor contributing to a lack of awareness or failure to address federal requirements. Additionally, Massachusetts has limited resources to conduct more frequent surveys of nursing homes, especially those with a history of high-risk deficiencies. Finally, although not required by CMS, Massachusetts does not require relevant nursing home staff to participate in standardized life safety training programs despite CMS having a publicly accessible online learning portal with appropriate content on life safety requirements.
The complete OIG report can be accessed here.
Compliance Perspective
Issue
Many residents of nursing homes have limited or no mobility and are particularly vulnerable in emergencies. As communal living environments, nursing homes also pose a heightened risk for the spread of infectious diseases. Federal law mandates nursing homes to protect the health, safety, welfare, and rights of residents, including compliance with Medicare and Medicaid requirements established by CMS, which cover emergency preparedness plans, sprinkler systems, smoke detector coverage, and infection control programs.
Discussion Points
- Review your emergency preparedness plan and update it as necessary. Ensure compliance with current life safety codes and make the plan easily accessible to staff. Also, review your infection prevention and control plan and vaccination policies to incorporate the latest information from CMS.
- Train all staff on the emergency preparedness plan and conduct drills for various disaster response scenarios to ensure competency. Ensure the facility maintenance director is familiar with current life safety codes and receives necessary training. An educational program titled Emergency Preparedness Requirements for Nursing Homes is available in the Safety Category of Med-Net Academy. Additionally, train staff on current infection prevention protocols, including vaccination policies. Document all training and drills and keep signed records in each employee’s education file.
- Periodically conduct environmental audits to ensure compliance with life safety codes. Assess staff understanding of their roles in each category of emergency as outlined in your emergency preparedness plan. Ensure thorough documentation of each drill is on file for surveyor access, including participation in an annual area-wide drill with local emergency response teams. Regularly audit adherence to the infection prevention and control plan and provide additional training where needed.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
