Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic
The safety of the nation’s 1.4 million nursing home residents—who are often in frail health and living in close proximity to one another—has been a particular concern during the COVID-19 pandemic. The Centers for Medicare & Medicaid Services contracts with state agencies that can cite nursing homes for failing to establish and maintain an infection prevention and control program.
Prior to the COVID-19 pandemic, we found that most nursing homes were cited for infection prevention and control deficiencies (82% of those surveyed from 2013-2017). About half of these homes had persistent problems and were cited across multiple years.
Pie chart showing 82% of nursing homes had an infection prevention and control deficiency cited in 1 or more years
What GAO Found
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), is responsible for ensuring that approximately 15,500 nursing homes nationwide meet federal quality standards. These standards require, for example, that nursing homes establish and maintain an infection prevention and control program. CMS enters into agreements with state survey agencies to conduct surveys and investigations of the state's nursing homes and to cite nursing homes with deficiency citations if the home is not in compliance with federal standards. Infection prevention and control deficiencies cited by surveyors can include situations where nursing home staff did not regularly use proper hand hygiene or failed to implement preventive measures during an infectious disease outbreak, such as isolating sick residents. Many of these practices can be critical to preventing the spread of infectious diseases, including COVID-19.
GAO analysis of CMS data shows that infection prevention and control deficiencies were the most common type of deficiency cited in surveyed nursing homes, with most nursing homes having an infection prevention and control deficiency cited in one or more years from 2013 through 2017 (13,299 nursing homes, or 82 percent of all surveyed homes). In each individual year, we found that about 40 percent of surveyed nursing homes had infection prevention and control deficiencies, and this continued in 2018 and 2019. About half—6,427 of 13,299 (48 percent)—of the nursing homes with an infection prevention and control deficiency had this deficiency cited in multiple consecutive years from 2013 through 2017. This is an indicator of persistent problems at these nursing homes.
In each year from 2013 through 2017, nearly all infection prevention and control deficiencies (about 99 percent in each year) were classified by surveyors as not severe, meaning the surveyor determined that residents were not harmed. Our review of CMS data shows that implemented enforcement actions for these deficiencies were typically rare: from 2013 through 2017, CMS implemented enforcement actions for 1 percent of these infection prevention and control deficiencies classified as not severe. We plan to examine CMS guidance and oversight of infection prevention and control in a future GAO report, including the classification of infection prevention and control deficiencies.
Why GAO Did This Study
COVID-19 originated in late 2019 as a new and highly contagious respiratory disease causing severe illness and death, particularly among the elderly. Because of this, the health and safety of the nation's 1.4 million nursing home residents—who are often in frail health and living in close proximity to one another—has been a particular concern. In light of the COVID-19 pandemic, GAO was asked to examine CMS's oversight of infection prevention and control protocols and the adequacy of emergency preparedness standards for emerging infectious diseases in nursing homes, as well as CMS's response to the pandemic. In this report, GAO describes the prevalence of infection prevention and control deficiencies in nursing homes prior to the COVID-19 pandemic. Future GAO reports will examine more broadly infection prevention and control and emergency preparedness in nursing homes, and CMS's response to the COVID-19 pandemic.
GAO reviewed CMS guidance and analyzed data on nursing home deficiencies. Specifically, GAO analyzed deficiencies cited by surveyors in all 50 states and Washington, D.C., from 2013 through 2017 provided by CMS for a prior GAO report, with a particular focus on deficiencies related to infection prevention and control. Using these data, GAO determined the most common type of deficiency among nursing homes, and the number of nursing homes that had infection prevention and control deficiencies—as well as the nursing homes with repeated infection prevention and control deficiencies over the 5-year period from 2013 through 2017, the characteristics of those homes, and the enforcement actions associated with the infection prevention and control deficiencies. In addition to the 2013 through 2017 data GAO obtained from CMS for a prior report, GAO also examined the number of nursing homes that had infection prevention and control deficiencies in 2018 and 2019 by analyzing publicly available data from CMS's Nursing Home Compare website.
GAO is not making any recommendations. GAO provided a draft copy of this report to HHS for comment. GAO received technical comments and incorporated them as appropriate.