The Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services found that most skilled nursing facilities (“nursing homes”) in Massachusetts that it surveyed are not correctly complying with life safety requirements or emergency preparedness requirements. OIG recently issued a report on its audits of life safety requirements or emergency preparedness requirements for Massachusetts (“Massachusetts Report“). The Massachusetts Report sheds light on critical issues facing nursing homes in Massachusetts and calls for enhanced measures to ensure the safety and well-being of nursing home residents.
Detailed Analysis
In 2016, the Centers for Medicare & Medicaid Services (“CMS”) updated its life safety and emergency preparedness regulations in 42 CFR § 483.73 to improve protections for all Medicare and Medicaid beneficiaries, including those residing in nursing homes.
Federal regulations on life safety (42 CFR § 483.90) require nursing homes to comply with standards set forth in the National Fire Protection Association’s Life Safety Code (NFPA 101) and Health Care Facilities Code (NFPA 99).
Federal regulations for infection control (42 CFR § 483.80) require nursing homes to comply with specific requirements for infection prevention and control programs and with policies and procedures for certain immunizations.
OIG Review – Massachusetts
As of June 2023, 347 nursing homes in Massachusetts participated in Medicare or Medicaid programs. In October and November 2023, OIG reviewed a nonstatistical sample of 20 Massachusetts nursing homes based on certain risk factors, including multiple high-risk deficiencies Massachusetts reported to CMS. OIG then conducted unannounced site visits to check for life safety, emergency preparedness and infection control deficiencies. During each site visit, OIG checked for life safety violations, reviewed the nursing home’s emergency preparedness plan and reviewed the nursing home’s policies and procedures for infection control and prevention.
The Massachusetts Report identified deficiencies in life safety or emergency preparedness areas at all of the 20 facilities. OIG found 236 deficiencies. Specifically, OIG found 128 deficiencies related to life safety, 57 to emergency preparedness and 51 to infection control. As a result, the OIG concluded that the health and safety of residents, staff and visitors at all of the 20 nursing homes are at an increased risk during a fire or other emergency or in the event of an infectious disease outbreak.
OIG found instances of noncompliance with life safety requirements related to building exits, fire barriers and smoke partitions; fire detection and suppression systems; hazardous storage areas; smoking policies and fire drills; and elevator and electrical system equipment. The Massachusetts Report also found deficiencies with emergency preparedness requirements related to emergency preparedness plans; emergency supplies and power; plans for evacuations, sheltering in place, and tracking residents and staff during an emergency; emergency communications plans; and emergency preparedness plan training and testing. In addition, OIG found deficiencies with infection control requirements or guidance related to infection prevention and control protocols, infection preventionists, and influenza and pneumococcal immunizations.
The Massachusetts Report concluded that these deficiencies occurred because of frequent management and staff turnover, which contributed to a lack of awareness of, or failure to address Federal requirements. In addition, Massachusetts had limited resources to conduct surveys of all nursing homes more frequently than CMS required.
Next Actions: Policy, Practices and Training Reviews Needed
- Nursing homes should expect that state survey agencies will pay increased attention and take action to confirm that life safety, infection prevention and control practices and emergency preparedness practices exist and are followed.
- Nursing homes should carefully review accordingly and revise their life safety, infection prevention and control practices and emergency preparedness practices.
- Nursing homes should review and update training for staff on how to implement life safety, infection prevention and control practices and emergency preparedness areas.
Should you have any questions about this or how to update your policies, practices and staff training, please contact:
- Sean Fahey at (317) 977-1472 or sfahey@hallrender.com;
- Brian Jent at (317) 977-1402 or bjent@hallrender.com;
- Todd Selby at (317) 977-1440 or tselby@hallrender.com; or
- Your regular Hall Render attorney.
Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot—outside of an attorney-client relationship—answer specific questions that would be legal advice.
