Certain For-Profit Nursing Homes May Not Have Complied With Federal Requirements Regarding the Infection Preventionist Position

Report Materials

• Full Report (PDF, 2.4 MB)
• Report In Brief (PDF, 314.5 KB)

Why OIG Did This Audit

• More than 1.3 million people live in nursing homes nationwide. These individuals are susceptible to a high number of health care-associated infections.
• Prior OIG audits found that nursing homes did not always comply with Federal regulations regarding designating an infection preventionist (IP) who met Federal requirements for that position.
• This audit examined whether for-profit nursing homes nationwide complied with Federal requirements pertaining to IPs.

What OIG Found

Not all for-profit nursing homes that we reviewed met Federal requirements. Seventy-six of the 100 for-profit nursing homes in our sample complied with Federal requirements pertaining to IPs. However:

• 17 potentially did not comply with the requirement that the IP complete specialized infection prevention and control training prior to assuming the role and
• 7 potentially did not comply with the requirement to designate an IP.

On the basis of our sample results, we estimated that 2,568 for-profit nursing homes nationwide (approximately 1 in 4) may not have complied with Federal requirements pertaining to IPs during our audit period. As a result, there may be increased health and safety risks for the residents and staff of these nursing homes.

What OIG Recommends

We recommend that the Centers for Medicare & Medicaid Services:

1. instruct the State survey agencies to follow up with the 24 nursing homes that may not have complied with Federal requirements to verify that they have taken corrective actions, and
2. share the results of this audit with the State survey agencies and encourage them to focus their oversight on verifying that nursing homes designate an IP and that the IPs complete specialized training prior to filling that position.

CMS concurred with both recommendations and indicated that it would implement them.