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It has been estimated that roughly 1/3rd of all of the COVID-19 deaths in the country have occurred among the 1.4 million residents of U.S. Nursing homes. While their demographics (advanced age) and comorbidities are undoubtedly major factors, so too are their communal living conditions and quality of health care and infection control, which can vary widely by location and management.
Minimum standards for staffing (both numbers and training) vary from state to state, and many nursing home employees are relatively poorly paid.Because Medicare and Medicaid provide much of the funding for these facilities, the Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring that roughly 15,500 nursing homes meet federal quality standards.
Since the burden of HAIs (Hospital Acquired Infections), infection control is a big part of those standards. CMS requires that state agencies conduct yearly nursing home inspections, and investigate complaints, and report their findings.
Facilities found deficient are subject to federal enforcement actions.In view of the disproportionate impact of COVID-19 on nursing home residents, the GAO (Government Accountability Office) was asked to review their collective infection control inspection and investigation records submitted from all 50 states and Washington, D.C., from 2013 through 2017.
On Wednesday of this week they released a 15-page PDF report, a short (7 minute) audio podcast, and a summary report (below).
Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic
GAO-20-576R: Published: May 20, 2020. Publicly Released: May 20, 2020.
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.
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Typical infection control deficiencies described by state regulators included inadequate hand hygiene (see Assessment Of Hand Hygiene Strategies In US Healthcare Facilities), employees working while sick (see A Hospital Is No Place For A Sick Person), and a failure to immediately separate sick (or infected) residents from others.
In normal times, many of these lapses - while concerning - are unlikely to constitute an immediate or direct threat to the residents.
But during an outbreak, whether it be severe influenza, adenovirus (see DOH: 2nd NJ Facility Reporting Adenovirus Outbreak & 10th Fatality At Wanaque Center) or COVID-19 (see MMWR: Asymptomatic & Presymptomatic SARS-CoV-2 Infections in Residents of a LTCF), they can lead to tragic results.
Nursing homes, even if perfectly run, are a target rich environment for severe respiratory viruses.But as this GAO report shows, nursing homes have a longstanding record of falling short in infection control, which has likely signficantly exacerbated COVID-19's impact.
