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Series: Audits of Emergency Preparedness, Infection Prevention and Control, and Life Safety at Intermediate Care Facilities for Individuals With Intellectual Disabilities

Announced on  | Last Modified on  | Series Number: SRS-A-25-026
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

An Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) is an institution that provides health and/or rehabilitation services to individuals with intellectual disabilities under the Medicaid program. ICF/IID services are covered by Medicaid when they are provided in a residential facility licensed and certified by a State survey agency as an ICF/IID. Medicaid covers ICF/IID services for more than 100,000 individuals with intellectual disabilities and other related conditions. ICF/IIDs face significant challenges in the event of emergencies such as fires, emerging infectious disease outbreaks, and natural disasters. Previous OIG audits on infection prevention and control, emergency preparedness, and life safety at nursing homes identified multiple issues that put Medicaid enrollees at increased risk. Our objective is to determine whether selected States' ICF/IIDs complied with Federal requirements for infection prevention and control, emergency preparedness, and life safety.

There are 7 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (1)

Project OAS-25-09-113 • Announced on May 21, 2025

COMPLETED PROJECTS IN THIS SERIES (6)

Arkansas

Project OAS-25-06-029 • Completed on December 9, 2025

Connecticut

Project OAS-25-01-040 • Completed on October 21, 2025

North Carolina

Project A-04-24-02504 • Completed on July 23, 2025

Oklahoma

Project A-06-24-09002 • Completed on July 15, 2025

Maine

Project A-01-24-00004 • Completed on June 12, 2025

Massachusetts

Project A-01-24-00001 • Completed on October 23, 2024

TIMELINE

6 REPORT PUBLISHED

Massachusetts Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety and Emergency Preparedness (A-01-24-00001)

We identified 44 deficiencies related to life safety and emergency preparedness at the 2 ICF/IIDs operated by Massachusetts. The State agency generally ensured that the ICF/IIDs complied with Federal requirements for infection control. These deficiencies put the health and safety of residents, staff, and visitors at an increased risk of injury or death during a fire or other emergency.

25-A-01-004.01 to CMS - Closed Implemented
Closed on 01/16/2025
We recommend that the Massachusetts Department of Public Health follow up with the two ICF/IIDs to verify that they have taken corrective actions on the life safety and emergency preparedness deficiencies identified during the audit.

25-A-01-004.02 to CMS - Closed Implemented
Closed on 01/16/2025
We recommend that the Massachusetts Department of Public Health work with CMS to develop standardized life safety training for ICF/IID staff.

View in Recommendation Tracker

Maine Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control (A-01-24-00004)

We identified 121 deficiencies related to life safety, emergency preparedness, and infection control at the 16 ICF/IIDs in Maine. These deficiencies put the health and safety of residents, staff, and visitors at an increased risk of injury or death during a fire or other emergency or in the event of an infectious disease outbreak.

25-A-01-072.01 to CMS - Closed Implemented
Closed on 10/22/2025
We recommend that the Maine Department of Health and Human Services follow up with the 16 ICF/IIDs to verify that they have taken corrective actions on the life safety, emergency preparedness, and infection control deficiencies identified during the audit.

25-A-01-072.02 to CMS - Closed Implemented
Closed on 10/22/2025
We recommend that the Maine Department of Health and Human Services conduct surveys at ICF/IIDs at least every 15 months as required by CMS.

25-A-01-072.03 to CMS - Open Unimplemented
Update expected on 10/17/2026
We recommend that the Maine Department of Health and Human Services work with CMS to develop standardized life safety training for ICF/IID staff.

View in Recommendation Tracker

North Carolina Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety and Infection Control (A-04-24-02504)

We identified 14 deficiencies related to life safety and infection control at the 3 ICF/IIDs operated by North Carolina. We did not identify any deficiencies related to emergency preparedness.

25-A-04-085.01 to CMS - Closed Implemented
Closed on 11/10/2025
We recommend that the North Carolina Department of Health and Human Services verify that the three ICF/IIDs we inspected have taken corrective actions on the life safety and infection contol deficiencies identified during the audit.

25-A-04-085.02 to CMS - Closed Implemented
Closed on 11/10/2025
We recommend that the North Carolina Department of Health and Human Services work with the applicable ICF/IID to determine whether mold exists.

25-A-04-085.03 to CMS - Closed Implemented
Closed on 11/10/2025
We recommend that the North Carolina Department of Health and Human Services work with CMS to develop standardized life safety training for staff and ICF/IIDs.

View in Recommendation Tracker

Oklahoma Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control (A-06-24-09002)

We identified 426 deficiencies related to life safety, emergency preparedness, and infection control at the 42 ICF/IIDs operated in Oklahoma that we reviewed. These deficiencies put residents, staff, and visitors at an increased risk of injury or death during a fire or other emergency.

25-A-06-080.01 to CMS - Closed Implemented
Closed on 04/07/2026
We recommended that the Oklahoma State Department of Health follow up with the 42 ICF/IIDs to verify that they have taken corrective actions on the life safety, emergency preparedness, and infection control deficiencies identified during the audit.

25-A-06-080.02 to CMS - Closed Implemented
Closed on 04/07/2026
We recommended that the Oklahoma State Department of Health conduct surveys at ICF/IIDs at least every 15 months as required by CMS.

25-A-06-080.03 to CMS - Open Unimplemented
Update expected on 10/07/2026
We recommended that the Oklahoma State Department of Health work with CMS to develop standardized life safety training for ICF/IID staff.

View in Recommendation Tracker

Connecticut Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control (OAS-25-01-040)

We identified 80 deficiencies related to life safety, emergency preparedness, and infection control at the 15 ICF/IIDs that we reviewed in Connecticut. These deficiencies put the health and safety of residents, staff, and visitors at an increased risk of injury or death during a fire or other emergency, or in the event of an infectious disease outbreak.

26-A-01-004.01 to CMS - Closed Implemented
Closed on 02/23/2026
We recommend that the Connecticut Department of Public Health follow up with the 15 ICF/IIDs reviewed to verify that they have taken corrective actions on the life safety, emergency preparedness, and infection control deficiencies identified during the audit.

26-A-01-004.02 to CMS - Open Unimplemented
Update expected on 08/23/2026
We recommend that the Connecticut Department of Public Health work with CMS to develop standardized life safety training for ICF/IID staff.

View in Recommendation Tracker

Arkansas Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control (OAS-25-06-029)

We identified 93 deficiencies related to life safety, emergency preparedness, and infection control at the 10 ICF/IIDs in Arkansas that we reviewed. These deficiencies put residents, staff, and visitors at an increased risk of injury or death during a fire or other emergency.

26-A-06-021.01 to CMS - Closed Implemented
Closed on 02/27/2026
We recommend that the Arkansas Department of Human Services follow up with the 10 ICF/IIDs to verify that they have taken corrective actions on the life safety, emergency preparedness, and infection control deficiencies identified during the audit.

26-A-06-021.02 to CMS - Closed Implemented
Closed on 02/27/2026
We recommend that the Arkansas Department of Human Services work with State surveyors to include all areas of life safety, emergency preparedness, and infection control when conducting their reviews at ICF/IIDs as required by CMS.

26-A-06-021.03 to CMS - Closed Implemented
Closed on 02/27/2026
We recommend that the Arkansas Department of Human Services work with CMS to develop standardized life safety, emergency preparedness, and infection control training for ICF/IID staff.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Quality of Care Public Health Issues Emergency Preparedness and Response
Target Groups
-
Financial Groups
Medicaid