Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
“Selected nursing homes may not have complied with Federal requirements for infection prevention and control and emergency preparedness. Specifically, 28 of the 39 nursing homes had possible deficiencies. We found 48 instances at 25 nursing homes of possible noncompliance with infection prevention and control requirements and 18 instances at 18 nursing homes of possible noncompliance with emergency preparedness requirements related to all-hazards risk assessments and strategies to address emerging infectious diseases. The nursing homes attributed the possible noncompliance to: (1) nursing home inadequate internal controls, (2) nursing home inadequate management oversight, (3) nursing home administrative and leadership changes, (4) inadequate communication and training from the Centers for Medicare & Medicaid Services (CMS), and (5) inconsistent and confusing regulations.”
This is the opening statement for brief of the OIG Report published July 26, 2022.
“(OIG) recommends that CMS: (1) instruct SSAs (State Survey Agencies) to follow up with the 28 nursing homes that we have identified with potential infection prevention and control and emergency preparedness deficiencies to ensure that they have taken corrective actions; (2) issue updated phase 3 interpretive guidance as soon as feasible; (3) provide training to SSAs on the updated phase 3 interpretive guidance as soon as feasible; and (4) consider updating the regulation to make clear that nursing homes must include emerging infectious diseases as a risk on their facility- and community-based all-hazards risk assessments.
CMS concurred with our first three recommendations and described corrective actions it had taken or planned to take, such as ensuring that SSAs follow up with the nursing homes, issuing phase 3 interpretive guidance, and providing training related to the phase 3 interpretive guidance. CMS stated that it had intended to release the phase 3 interpretive guidance during the second quarter of 2020. However, prior to issuing the guidance, the COVID-19 public health emergency (PHE) was declared, and CMS immediately redirected resources to address patient safety needs related to the PHE. Regarding (OIG) fourth recommendation, CMS stated that it would consider this recommendation in future rulemaking and that it has taken considerable steps to make clear that nursing homes should include emerging infectious diseases as an identified risk on their facility- and community-based all-hazards risk assessments.”
The full 34-page report is found here.
Be sure to review the noncompliance findings of the OIG report, starting on page 13. The findings include:
- the designation of a qualified infection preventionist,
- the occurrence of QAAC meetings,
- infection preventionist attendance at QAAC meetings,
- policies and procedures regarding reporting possible incidents of communicable diseases and infections,
- the nursing homes’ annual reviews of their IPCPs, and
“(OIG) found that 18 of the 39 nursing homes each had 1 possible deficiency related to emergency preparedness. Appendix D summarizes the areas of emergency preparedness possible noncompliance. These possible deficiencies related to completing a facility-based and community-based risk assessment and strategies to address emerging infectious diseases.
As a result of the potential infection prevention and control and emergency preparedness deficiencies, selected nursing homes may have an increased risk for health and safety issues, including emerging infectious disease threats for residents and staff.”
I also recommend you share and review Other Matters, starting on page 22. Eye-opening, to be sure.