OIG: Pandemic Data Shows Major Changes Needed in Nursing Home Staffing, Surveys, Infection Control

A federal watchdog agency is calling for “significant changes” to nursing home operations and oversight in light of new data on Covid-19 infection rates.

The Department of Health and Human Services Office of Inspector General (OIG) calls on the Centers for Medicare & Medicaid Services (CMS) to take action in a report issued Thursday. More than 1,300 nursing homes had Covid-19 infection rates of 75% or more during surges in 2020, even though most of them had no infection control issues as identified by surveys, as well as nursing hours that met or exceeded Medicare minimums, the OIG analysis found.

Recommendations made by the HHS Office of the Inspector General (OIG) build on previous probes into the skilled nursing industry and include re-examining and revising nursing staff requirements.


“Meeting these requirements did not prevent these nursing homes from reaching the highest COVID-19 infection rates in the country,” OIG said in its report, also pointing out that the nursing hour requirements were established in 1987.

For nursing homes, the fall 2020 surge in infections was even greater than the initial surge in the spring, “well after they were known to be vulnerable,” according to the report. These homes had an average overall mortality rate of 20%, more than double that of other facilities.

For-profit nursing homes made up a “disproportionate” percentage of these homes, according to OIG.


Another finding: high Covid transmission in a county didn’t always lead to nursing homes in that county reaching high infection rates. As a result of these findings, each of OIG’s recommendations involve infection prevention and control in some way.

Start from scratch with staffing

Further evidence is needed to determine the level and type of nursing staff necessary for today’s nursing home resident, with a focus on how the infection preventionist fits in, the OIG report stated.

The recommendation acknowledges an initiative already underway with the Centers for Medicare & Medicaid Services (CMS), namely, a staffing mandate proposal and supporting study due to be published this year.

While encouraging CMS to use data in the report released today, OIG also cautioned the agency to recognize staffing challenges and consider what role it could play in strengthening the nursing home workforce amid looming mandates.

Part two of this first recommendation – re-evaluating staffing data collection – should better align with staffing requirements outlined in the mandate proposal, OIG added.

“For example, amending staffing data to include a timestamp would better allow CMS to determine whether nursing homes have provided around-the-clock nursing services,” OIG said in its report. “This would assist CMS in monitoring compliance with staffing requirements, as well as ensure quality data for future analyses.”

Surveys, infection prevention and special interventions

Other recommendations included identifying infection control risks via surveys, strengthening guidance on assessing the scope and severity of such risks.

“The survey process is a critical oversight tool for CMS and, as such, must be meaningful,” OIG said in its report. “These homes passed Medicare’s infection control test, yet COVID-19 was able to engulf them in a matter of weeks.”

OIG refers to surveys conducted in 2020 between March and May, which found few deficiencies despite extremely high infection rates. These findings “call into question” how effective current surveys are at finding and preventing infection control issues in nursing homes, according to the report.

The first step for CMS is to seek input from a broad range of experts in infection control and prevention as part of its Technical Expert Panels, OIG suggested.

Consulting with other knowledgeable sources in infection control could help too, OIG said, naming the Association for Professionals in Infection Control and Epidemiology, the Agency for Healthcare Research and Quality, and The Joint Commission as potential contacts.

The third recommendation was to target facilities most in need of infection control intervention, providing enhanced oversight and technical assistance to these operators.

As a supplement to surveys, OIG said, there should be further analysis of care and intervention at certain nursing homes.

“These may be nursing homes with dramatic increases in mortality, a high percentage of residents with infectious diseases, or nursing homes with other characteristics that raise concern,” OIG researchers said. “This analysis could help CMS’s efforts to effectively target its resources toward nursing homes most in need of intervention.”

CMS “concurred with the intent” of the recommendations to reexamine nursing staff requirements and potentially revise them, and to target nursing homes most in need of infection control intervention and provide assistance and oversight as appropriate. CMS “neither concurred nor nonconcurred” with the recommendation to improve how surveys identify infection control risks to residents and strengthen guidance on assessing scope and severity of such risks.

This isn’t the first time OIG has focused on the nursing home sector – the agency in August and October launched probes into Medicare payments to related parties, and potentially preventable hospitalizations of skilled nursing residents, respectively.

A month later, another OIG report focused on the “high and unchanged” use of psychotropic drugs in the sector. Then,; in December, OIG Chief Christi Grimm said nursing home oversight and quality would be the office’s top priority, in tandem with the Biden administration’s reform initiatives announced in February 2022.

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