3% of Emergency Nursing Home Surveys Result in Citations, Backlog Could Take Years to Clear

Despite a spike in the number of “immediate jeopardy” complaints at nursing homes, the initial wave of emergency inspections during the COVID-19 crisis resulted in a significantly lower rate of violations, a new federal report determined — while states across the country face a growing backlog of overdue routine surveys.

Between March 23 and May 30, onsite inspections of 7,193 nursing homes resulted in cited deficiencies at 193 facilities, for a rate of 3%, the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) determined in a report released in late December.

That’s a significant drop from the 40% deficiency rate logged during the same period in 2019, though the 2020 data comes with a host of caveats.


March 23 was the day that the Centers for Medicare & Medicaid Services (CMS) suspended all routine nursing home inspections, directing State Survey Agencies (SSAs) to focus solely on targeted infection control checks and investigations of the highest-priority immediate jeopardy (IJ) complaints.

The overall number of complaints tumbled in the early days of the COVID-19 crisis, dropping from more than 14,000 between March 23 and May 30, 2019 to just under 7,000 during that same span last year.

At the same time, both the number and proportion of IJ complaints spiked, representing 31% of all reports received over the course of those nine weeks last year; in 2019, the 992 IJ complaints accounted for just 7% of the total.

Source: HHS OIG

Infection control violations led the way during that initial COVID enforcement push, appearing in 68 of the 193 surveys with any citations; the most common problems involved the improper use of PPE, “lapses in hand hygiene,” and unclean surfaces.

“Most of the infection control deficiencies included more than one instance of noncompliance, including practices throughout the facility such as food service, laundry, and visitor entry,” the OIG observed. “Analysis of the deficiencies revealed blatantly poor practices in some instances, such as one nursing home being cited for allowing staff to continue working despite showing signs of COVID-19. Surveyors found that another nursing home failed to enforce staff PPE use and hand-washing despite having 54 confirmed cases among its residents.”

The OIG, HHS’s primary watchdog arm, acknowledged that the story behind the numbers is complex.

With access to nursing homes restricted to all but the most essential personnel starting in mid-March, residents’ family members — the primary source of complaints — were not around to observe conditions in facilities. The limited scope of the survey directives, as well as shorter periods of time spent within the nursing homes, also contributed to the trends, the OIG observed.

In addition, state survey teams faced the same challenges as nursing home operators around securing appropriate quantities of personal protective equipment (PPE) and maintaining workforce strength amid rising infection rates.

“We did not want to be a transmission source, since we knew that most cases were brought into nursing homes from the outside,” one state official told the OIG.

The 3% rate tracks with similar data released directly by CMS as early as the first week of June.

The federal government has faced scrutiny from resident advocates and lawmakers over the seeming disconnect between the high infection and death rates in nursing homes and the lack of a corresponding uptick in safety violations; the Center for Medicare Advocacy, for instance, in June called the survey data “not credible.”

“It is simply not plausible, during the pandemic, when at least 32,000 residents have died of COVID-19 and large proportions of deaths from COVID-19 nationwide are residents and staff, that facilities have no problems in their infection prevention and control practices,” the Washington, D.C.-based advocacy group said at the time. “Problems cannot be fixed going forward if they aren’t even identified and acknowledged.”

The number of confirmed COVID-19 deaths in nursing homes stood at 92,373 in CMS’s most recent count as of December 20, though the true number is almost certainly higher due to reporting limitations during the earliest days of the crisis.

CMS in August directed states to resume normal survey work, but clearing out the pile of inspections that were shoved to the back burner in March 2020 may take some time to achieve.

By the end of June, about 8% of facilities had gone longer than the required 15-month timeframe without receiving a standard survey, according to the OIG; the chart below shows the projected compounding of the problem over the course of last year.

A further 14%, or more than 2,000 facilities, were still awaiting inspections stemming from high-priority complaints, and relief is likely far off: One state reported that it would take two years to tackle the backlog and return to a typical survey schedule, while another state indicated that the task was impossible without additional help.

“These backlogs — and the possibility that it could take years for states to return to normal survey timeframes — raise concerns for nursing home residents’ safety and quality of care,” the OIG concluded. “Standard surveys are critically important for protecting nursing home residents.”

Multiple state officials told the OIG that despite the lower rate of violations, the inspections still helped nursing homes by providing an opportunity for building staff to express their top concerns and issues — as well as hands-on training for workers.

“There is no replacement for being physically present,” one official said. “Even if we’re not citing, we’re ensuring that they have all the tools they need. The presence sends the message: You’re not alone, you’re not isolated, we’re in this with you.”