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Colorado Could Better Ensure That Nursing Homes Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control

Why OIG Did This Audit

In 2016, the Centers for Medicare & Medicaid Services (CMS) updated its life safety and emergency preparedness regulations related to health care facilities to improve protections for all 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. Additionally, facilities were required to implement an infection control program.

Our objective was to determine whether Colorado ensured that selected nursing homes in Colorado that participated in the Medicare or Medicaid programs complied with Federal requirements for life safety, emergency preparedness, and infection control.

How OIG Did This Audit

Of the 219 nursing homes in Colorado that participated in the Medicare or Medicaid programs, we selected a nonstatistical sample of 20 nursing homes for our audit based on location and certain risk factors, including multiple high-risk deficiencies that Colorado reported to CMS.

We conducted unannounced site visits at the 20 nursing homes from September through November 2022. During the site visits, we checked for life safety, emergency preparedness, and infection control deficiencies.

What OIG Found

Colorado could better ensure that nursing homes in Colorado that participated in the Medicare or Medicaid programs comply with Federal requirements for life safety, emergency preparedness, and infection control. During our onsite visits, we identified deficiencies related to life safety, emergency preparedness, or infection control at all 20 nursing homes that we audited, totaling 556 deficiencies. Specifically, we identified 165 deficiencies related to life safety requirements, 210 deficiencies related to emergency preparedness requirements, and 181 deficiencies related to infection control requirements. As a result, 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.

The identified deficiencies occurred because of inadequate oversight by Colorado and by nursing home management, frequent management and staff turnover at the nursing homes, inadequate oversight by the State survey agency, and frequent State survey agency staff turnover. In addition, the State survey agency had limited resources to conduct surveys of all nursing homes, including those with a history of multiple high-risk deficiencies, more frequently than was required by CMS. Finally, although not required by CMS, Colorado 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.

What OIG Recommends and Colorado Comments

We recommend that Colorado follow up with the 20 nursing homes reviewed in this audit to ensure that corrective actions have been taken regarding the life safety, emergency preparedness, and infection control deficiencies we identified; work with CMS to develop a risk-based approach to identify nursing homes at which surveys would be conducted more frequently, such as those with a history of multiple high-risk deficiencies or frequent management turnover; and work with CMS to develop standardized life safety training for nursing home staff.

Colorado concurred with our first recommendation and described corrective actions it would take. Colorado did not concur with our second recommendation and neither concurred nor nonconcurred with our third recommendation. We maintain that our findings and recommendations are valid.

Filed under: Centers for Medicare and Medicaid Services