The US Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a new report on November 8, 2023, which says Pennsylvania could better ensure that nursing homes comply with federal requirements for life safety, emergency preparedness, and infection control if additional oversight was provided.
From the 701 nursing homes in Pennsylvania 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). The OIG conducted unannounced site visits at the facilities from July through October 2022.
During their onsite inspections, the OIG identified deficiencies related to life safety, emergency preparedness, or infection control at all 20 nursing homes that they audited, totaling 586 deficiencies. Specifically, they found 220 deficiencies related to life safety, 288 deficiencies related to emergency preparedness, and 78 deficiencies related to infection control. As a result, the report states, the health and safety of residents, staff, and visitors at the 20 nursing homes are at an increased risk during a fire or other emergency, or in the event of an infectious disease outbreak.
According to the report, the identified deficiencies occurred because of frequent management and staff turnover, which contributed to a lack of awareness of, or failure to address, federal requirements. In addition, poor recordkeeping, combined with an inconsistent application of policies, also contributed to deficiencies. Finally, although not required by CMS, Pennsylvania 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 OIG’s complete report can be accessed here.
Compliance Perspective
Issue
In 2016, CMS updated its life safety and emergency preparedness regulations related to healthcare facilities to improve protections for all Medicare and Medicaid enrollees, including those residing in long-term care facilities. The updates expanded requirements related to sprinkler systems, smoke detector coverage, and emergency preparedness plans. Additionally, facilities are required to implement an infection control program.
Discussion Points
- Review your Emergency Preparedness Plan and update as necessary. Review current Life Safety codes and ensure that your building meets those requirements. Make sure the Plan is available to staff so they can easily access the guidelines for the various components should an emergency occur. Also review your infection prevention and control plan and vaccination policies and procedures to ensure they include the most up-to-date information from CMS.
- Train all staff on your Emergency Preparedness Plan. Conduct drills for the various disaster response plans to ensure staff competency with each. Ensure that the facility maintenance director is aware of current Life Safety codes and provide training as needed. An educational program titled Emergency Preparedness Requirements for Nursing Homes is available in the Safety Category of Med-Net Academy Compliance for access by all clients. Also train staff on the most current infection prevention and control protocols, including vaccination policies and best practices. Document all trainings and drills that occurred, and file the signed documents in each employee’s education file.
- Periodically conduct environmental audits to ensure that Life Safety codes are being followed. Audit staff understanding to ensure that they are aware of their roles during each category of emergency per your Emergency Preparedness Plan. Audit to ensure that thorough documentation of each drill is on file and available for surveyor access when requested, to include participation in an annual area-wide drill with your local emergency response teams. Also periodically audit to ensure that all staff are following your infection prevention and control plan. Provide additional training where needs are identified.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
