Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
In 2016, the Centers for Medicare & Medicaid Services (CMS) updated its life safety and emergency preparedness regulations for health care facilities to improve protections for individuals enrolled in Medicare and Medicaid, including those residing in long-term care facilities (nursing homes). The updates expanded requirements related to sprinkler systems, smoke detector coverage, and emergency preparedness plans. In addition, facilities were required to implement an infection control program.
(OIG’s) objective was to determine whether Georgia ensured that selected nursing homes in Georgia that participated in the Medicare or Medicaid programs complied with Federal requirements for life safety, emergency preparedness, and infection control.
Of the 358 nursing homes in Georgia that participated in Medicare and Medicaid, we selected a nonstatistical sample of 20 nursing homes for this audit (38 pages) based on certain risk factors, including multiple high-risk deficiencies Georgia reported to CMS.
(OIG) conducted unannounced site visits at the 20 nursing homes from June through September 2022. During the site visits, we checked for life safety, emergency preparedness, and infection control deficiencies.
Findings:
The State agency could better ensure that nursing homes in Georgia that participate in the Medicare or Medicaid programs comply with Federal requirements for life safety, emergency preparedness, and infection control if additional resources were available. During our site visits, we identified deficiencies related to life safety, emergency preparedness, or infection control at 19 of the 20 nursing homes that we audited, totaling 155 deficiencies. Specifically:
- We found 71 deficiencies with life safety requirements related to building exits, fire barriers, and smoke partitions (29); fire detection and suppression systems (23); hazardous storage areas (5); smoking policies and fire drills (4); and electrical equipment (10).
- We found 66 deficiencies with emergency preparedness requirements related to emergency preparedness plans (10); emergency supplies and power (5); plans for evacuations, sheltering in place, and tracking residents and staff during an emergency (5); emergency communications plans (23); and emergency preparedness plan training and testing (23).
- We found 18 deficiencies with infection control requirements or guidance related to IPCPs (8), influenza and pneumococcal immunizations (4), COVID-19 immunizations (5), and COVID-19 testing (1).
The identified deficiencies occurred because of frequent management and staff turnover at the nursing homes, which contributed to a lack of awareness of, or failure to address, Federal requirements. In addition, the State agency had limited resources to conduct surveys of all nursing homes, including those with a history of multiple high-risk deficiencies, more frequently than required by CMS (i.e., every 15 months). Finally, although not required by CMS, the State agency 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.
As a result, the health and safety of residents, staff, and visitors at the 19 nursing homes are at an increased risk of injury or death during a fire or other emergency, or in the event of an infectious disease outbreak.
Appendix C summarizes the deficiencies that we identified at each nursing home.
This OIG report contains photographs of many of the deficiencies found.
The complete report can be viewed here.
The report in brief is found here.
This report merits review by all LTC facilities. What would your facility look like under such scrutiny?
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