Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic (GAO-20-576R)
Summary
A GAO report, GAO-20-576R, dated May 20, 2020, to Senator Ron Wyden, Ranking Member of the Senate Committee on Finance, on infection control in nursing homes before the COVID-19 pandemic. It notes the nation's 1.4 million nursing home residents and estimates of more than 25,000 COVID-19 deaths in nursing homes as of May 2020. It explains that the Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring that approximately 15,500 nursing homes meet federal quality standards and works through state survey agencies that cite deficiencies. The report describes the prevalence of infection prevention and control deficiencies in nursing homes before the pandemic.
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441 G St. N.W.
Washington, DC 20548
May 20, 2020
The Honorable Ron Wyden
Ranking Member
Committee on Finance
United States Senate
Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior
to COVID-19 Pandemic
Dear Senator Wyden:
The Coronavirus Disease 2019 (COVID-19) originated in late 2019 as a new and highly
contagious respiratory disease causing severe illness and death, particularly among the
elderly. 1 Because of this, the health and safety of the nation’s 1.4 million nursing home
residents—who are often in frail health and living in close proximity to one another—has been a
particular concern. One of the first major outbreaks reported in the U.S. occurred in a
Washington State nursing home in February 2020. Since then, there has been a rapid increase
in the number of COVID-19 cases in U.S. nursing homes, with estimates of more than 25,000
deaths as of May 2020. 2
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of
Health and Human Services (HHS), is responsible for ensuring approximately 15,500 nursing
homes nationwide meet federal quality standards to participate in the Medicare and Medicaid
programs. These standards require, for example, that nursing homes establish and maintain an
infection prevention and control program. 3 To monitor compliance with these standards, CMS
enters into agreements with agencies in each state government—known as state survey
agencies—and oversees the work the state survey agencies do.
In general, CMS requires that state survey agencies conduct standard surveys, or evaluations,
approximately once each year of the state’s nursing homes and investigate both complaints
1Patel, A., Jernigan, D.B. “Initial Public Health Response and Interim Clinical Guidance for the 2019 Novel
Coronavirus Outbreak—United States, December 31, 2019–February 4, 2020.” CDC Morbidity and Mortality Weekly
Report. vol. 69: 140–146 (2020).
2For examples, see Kaiser Family Foundation, “State Reports of Long-Term Care Facility Cases and Deaths Related
to COVID-19 (as of May 7, 2020),” May 7, 2020. Also, see K. Yourish, K.K.R. Lai, D. Ivory, and M. Smith, “One-Third
of All U.S. Coronavirus Deaths are Nursing Home Residents or Workers,” New York Times, May 11, 2020.
3At a minimum, nursing homes must (1) have a system to prevent, identify, report, investigate, and control infections
and communicable diseases for all residents, staff, volunteers, visitors, and others providing services in the home; (2)
have written standards, policies, and procedures for their infection prevention and control program; (3) have antibiotic
use protocols and a system to monitor antibiotic use; and (4) have a system for recording incidents identified under
the home’s infection prevention and control program and any corrective actions taken. 42 C.F.R. § 483.80(a)(1)-(4)
(2019).
Page 1 GAO-20-576R Nursing Home Infection Control
from the public and facility-reported incidents regarding resident care or safety. 4 If a surveyor
from a state survey agency determines that a nursing home violated a federal standard during a
survey or investigation, a nursing home receives a deficiency code specific to that standard,
known as a deficiency. Surveyors then classify cited deficiencies into categories according to
scope (the number of residents potentially affected) and severity (the potential for or occurrence
of harm to residents). 5
When nursing homes are cited with deficiencies, federal enforcement actions can be imposed to
encourage homes to make corrections. 6 In general, for deficiencies with a higher scope and
severity, CMS may impose certain enforcement actions so that the enforcement actions are
implemented—that is, put into effect—immediately. 7 For other deficiencies with a lower scope
and severity, the nursing home may be given an opportunity to correct the deficiencies, which, if
corrected before the scheduled effective date, can result in the imposed enforcement action not
being implemented. Nursing homes are required to submit a plan of correction that addresses
how the home would correct the noncompliance and implement systemic change to ensure the
deficient practice would not recur. 8
In light of the COVID-19 pandemic, you asked us to examine CMS’s oversight of infection
prevention and control protocols and the adequacy of emergency preparedness standards for
emerging infectious diseases in nursing homes, as well as CMS’s response to the pandemic.
This report describes the prevalence of infection prevention and control deficiencies in nursing
homes prior to the COVID-19 pandemic. Future GAO reports will examine more broadly
infection prevention and control and emergency preparedness in nursing homes and CMS’s
response to the COVID-19 pandemic, including recent actions CMS has announced. 9
To describe the prevalence of infection prevention and control deficiencies in nursing homes
prior to the COVID-19 pandemic, we reviewed CMS guidance and analyzed data on nursing
4By law, every nursing home receiving Medicare or Medicaid payment must undergo a standard survey during which
teams of state surveyors conduct a comprehensive on-site evaluation of compliance with federal quality standards.
These surveys must occur at least once every 15 months, with a statewide average interval for surveys not to exceed
12 months.
5CMS categorizes deficiencies into one of three scope categories based on whether the incident was: (1) an isolated
occurrence; (2) a part of a pattern of behavior; or (3) a widespread behavior. CMS categorizes deficiencies into one
of four severity categories based on whether the deficiency constitutes: (1) no actual harm with a potential for minimal
harm; (2) no actual harm with a potential for more than minimal harm, but not immediate jeopardy; (3) actual harm
that is not immediate jeopardy; or (4) immediate jeopardy to resident health or safety.
6CMS guidance does not require enforcement actions be imposed for all deficiencies. Enforcement actions include,
but are not limited to, directed in-service training, fines known as civil money penalties, denial of payment, and
termination from the Medicare and Medicaid programs.
7The scope and severity of a deficiency is one of the factors that CMS may take into account when imposing
enforcement actions. CMS may also consider a nursing home’s prior compliance history, desired corrective action
and long-term compliance, and the number and severity of all the nursing home’s deficiencies.
8The plan of correction serves as the nursing home’s allegation of compliance. Depending on the severity of the
deficiency cited, surveyors revisit the nursing home to ensure that the home actually implemented its plan and
corrected the deficiency.
9See, for example, CMS, Center for Clinical Standards and Quality/Quality Safety & Oversight Group, Upcoming
Requirements for Notification of Confirmed COVID-19 (or COVID-19 Persons under Investigation) among Residents
and Staff in Nursing Homes, QSO-20-26-NH (April 19, 2020).
Page 2 GAO-20-576R Nursing Home Infection Control
home deficiencies cited by surveyors in all 50 states and Washington, D.C., from 2013 through
2017 provided by CMS for a prior GAO report, with a particular focus on deficiencies related to
infection prevention and control. 10 Using these data, we analyzed the deficiency code used by
state surveyors when a nursing home fails to meet CMS’s requirements for infection prevention
and control. 11 Also using CMS’s data, we determined the most common type of deficiency
among nursing homes, the number of nursing homes that had infection prevention and control
deficiencies, as well as the number of homes with repeated infection prevention and control
deficiencies over the 5-year period from 2013 through 2017 and the characteristics of those
homes.
We also used CMS’s data to identify the enforcement actions associated with these
deficiencies. CMS’s data also included narratives written by state surveyors describing the
deficiencies they identified. We reviewed examples of these narratives written by state
surveyors to illustrate infection prevention and control deficiencies with varying severity levels.
In addition to the 2013 through 2017 data we obtained from CMS for a prior report, we also
examined the number of nursing homes that had infection prevention and control deficiencies in
2018 and 2019 by analyzing publicly available data from CMS’s Nursing Home Compare
website. 12 We assessed the reliability of each of the datasets used in our analyses by checking
for missing values and obvious errors and reviewing relevant CMS documents and other
documentation from our prior report that used these data. We determined the data were
sufficiently reliable for the purposes of this reporting objective.
This report focuses on the prevalence of infection prevention and control deficiencies in nursing
homes in the years prior to the COVID-19 pandemic. It does not examine CMS’s actions to
10GAO, Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse, GAO-19-433,
(Washington, D.C.: June 13, 2019). This report is our most recent analysis of CMS nursing home deficiency data,
part of a broader GAO body of work examining weaknesses in CMS oversight of nursing homes. For brief summaries
of GAO reports on the health and welfare of the elderly in nursing homes and other settings since 2015, including any
recommendations, see Nursing Homes: Better Oversight Needed to Protect Residents from Abuse, GAO-20-259T,
(Washington, D.C.: Nov. 14, 2019).
For the purposes of this report, we include Washington, D.C., when we refer to data for states.
11CMS’s State Operations Manual provides guidance to state surveyors of nursing homes to determine compliance
with federal quality standards, including those related to federal infection prevention and control program
requirements. We reviewed Appendix PP of the State Operations Manual because it is the section that provides
guidance to state surveyors about determining compliance with federal quality standards and their associated
deficiency codes. We used the March 8, 2017, version of the Appendix PP—the most recent version during our
period of review—when determining which deficiency codes to analyze for this report. CMS, State Operations
Manual, Appendix PP—Guidance to Surveyors for Long Term Care Facilities. (March 8, 2017). We also reviewed the
multiple revisions to Appendix PP in the State Operations Manual during the period of our review (January 1, 2013,
through November 27, 2017). Specifically, there were eight updates to the appendix during the 5-year period. The
November 26, 2014, revision to Appendix PP added new guidance and investigative criteria relating to single-use
disposable equipment, single-dose medication, and insulin pens, as well as additional guidance on procedures for
handling linens to prevent and control infection transmission. Otherwise, none of the other revisions significantly
changed the infection prevention and control deficiency citation code used by state surveyors.
CMS restructured its deficiency code system beginning on November 28, 2017, and, due to these coding changes,
we did not analyze CMS deficiency data cited by surveyors from November 28, 2017, through December 31, 2017.
12To perform this 2018-2019 analysis, we examined nursing homes cited with the current infection prevention and
control deficiency code that went into effect as part of CMS’s restructured deficiency coding system on November 28,
2017. The CMS Nursing Home Compare Provider Information files were accessed on April 23, 2020, from
https://data.medicare.gov/data/archives/nursing-home-compare.
Page 3 GAO-20-576R Nursing Home Infection Control
address these issues, including actions announced beginning in March 2020 in light of the
COVID-19 pandemic. We will examine CMS’s actions in a future report.
We conducted this performance audit from April 2020 to May 2020 in accordance with generally
accepted government auditing standards. Those standards require that we plan and perform the
audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings
and conclusions based on our audit objectives. We believe that the evidence obtained provides
a reasonable basis for our findings and conclusions based on our audit objectives.
Most Nursing Homes Had Infection Control Deficiencies Prior to the COVID-19 Pandemic;
Half of These Homes Had Persistent Problems
Our 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). 13 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 and using
masks and other personal protective equipment to control the spread of infection. 14 Many of
these practices can be critical to preventing the spread of infectious diseases, including COVID-
19.
In each individual year from 2013 through 2017, the percent of surveyed nursing homes with an
infection prevention and control deficiency ranged from 39 percent to 41 percent. In 2018 and
2019, we found that this continued with about 40 percent of surveyed nursing homes having an
infection prevention and control deficiency cited each year. 15
About half—6,427 of 13,299 (48 percent)—of the nursing homes with an infection prevention
and control deficiency cited in one or more years of the period we reviewed had this type of
deficiency cited in multiple consecutive years from 2013 through 2017. This is an indicator of
persistent problems. An additional 19 percent of the nursing homes (2,563 out of 13,299) had
an infection prevention and control deficiency cited in multiple nonconsecutive years. (See fig.
1.) Furthermore, of the 6,427 nursing homes with an infection prevention and control deficiency
13The next most common deficiencies cited in nursing homes from 2013 through 2017 were related to ensuring the
environment is free from accidents (about 37 percent of surveyed nursing homes in each year) and food safety (about
36 percent of surveyed nursing homes in each year).
14Another deficiency code related to preventing the spread of infections can be cited by surveyors when a nursing
home fails to develop policies and procedures to ensure that residents are offered influenza and pneumococcal
vaccinations. Nursing homes must educate each resident on the benefits and potential side effects when offering
each vaccine and document this interaction, as well as each resident’s decision to receive or refuse each vaccine. In
2017, 4 percent of surveyed nursing homes (539 homes) had at least one influenza and pneumococcal vaccination
deficiency.
15In our review of publicly available data from 2018 and 2019, infection prevention and control deficiencies were the
most common type of deficiency cited in surveyed nursing homes, with deficiencies related to ensuring that the
environment is free from accidents and deficiencies related to food safety as the next most common.
Also see: D. Cenziper, J. Jacobs, and S. Mulcahy, “Hundreds of Nursing Homes with Cases of Coronavirus Have
Violated Federal Infection-Control Rules in Recent Years,” The Washington Post, April 17, 2020; and Jordan Rau,
“Coronavirus Stress Test: Many 5-Star Nursing Homes Have Infection-Control Lapses,” Kaiser Health News, March
4, 2020.
Page 4 GAO-20-576R Nursing Home Infection Control
cited in multiple consecutive years, 35 percent (2,225 nursing homes) had these deficiencies
cited in 3 or 4 consecutive years, and 6 percent (411 nursing homes) had these deficiencies
cited across all 5 years. At the state level, all states had nursing homes with infection prevention
and control deficiencies cited in multiple consecutive years. For additional state-level
information, see enclosure I.
Figure 1: Nursing Homes with Infection Prevention and Control Deficiencies Cited in Multiple Years, 2013
through 2017
Note: CMS restructured its deficiency code system beginning on November 28, 2017, and, due to these coding changes, we did not
analyze CMS data cited by surveyors from November 28, 2017, through December 31, 2017.
Percentages may not add to 100 due to rounding.
We also found that 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. 16 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
16For the purposes of this report, a classification of “not severe” means that surveyors determined that the deficiency
posed either 1) no actual harm with a potential for minimal harm or (2) no actual harm with a potential for more than
minimal harm, but not immediate jeopardy. Infection prevention and control deficiencies were also categorized by
scope—whether the incident was an isolated occurrence, a part of a pattern of behavior, or a widespread behavior—
with about 47 percent of infection prevention and control deficiencies cited categorized as isolated, about 38 percent
categorized as a pattern, and about 14 percent categorized as widespread each year from 2013 through 2017.
Percentages do not add to 100 due to rounding.
Page 5 GAO-20-576R Nursing Home Infection Control
prevention and control deficiencies classified as not severe. Furthermore, 67 percent of these
infection prevention and control deficiencies classified as not severe did not have any
enforcement actions imposed or implemented, and 31 percent had enforcement actions
imposed but not implemented—meaning the nursing home likely had an opportunity to correct
the deficiency before an enforcement action was imposed. 17 For examples of the types of
infection prevention and control deficiencies cited in nursing homes and summaries of their
resulting enforcement actions, see table 1. 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.
Table 1: Illustrative Examples of Narratives from Infection Prevention and Control Deficiencies Cited in
Nursing Homes
Classification of Scope
Narrative details and resulting CMS enforcement action and Severity
A certified nursing assistant in a California nursing home was observed by surveyors Scope: A pattern of
coughing and looking unwell. The certified nursing assistant said she had been sick behavior
for at least 2 days and had experienced fever, diarrhea, cough, and a runny nose.
Surveyors also observed improper hand hygiene by a different certified nurse Severity: No actual harm
assistant during incontinent care, which created the potential to spread disease and with a potential for more
infection. In addition, seven employees had not been screened for tuberculosis prior than minimal harm, but not
to employment. Also, surveyors observed employees who had not been vaccinated immediate jeopardy
for influenza and were not wearing face masks.
No enforcement actions were implemented against this nursing home.
Surveyors observed a certified nursing assistant in an Arkansas nursing home Scope: A pattern of
providing incontinent care to a resident after a bowel movement and then, without behavior
removing her soiled gloves or washing her hands, the certified nursing assistant
proceeded to assist the resident in repositioning in bed, adjusting the pillows, and Severity: No actual harm
replacing supplies in the resident’s bedside table drawer. Surveyors also noted that a with a potential for more
glucose meter was not properly disinfected before use on multiple residents. than minimal harm, but not
immediate jeopardy
No enforcement actions were implemented against this nursing home.
A New York nursing home experienced a respiratory infection outbreak that sickened Scope: A pattern of
38 residents. The nursing home did not maintain a complete and accurate list of behavior
those who were sick, did not isolate residents with symptoms from residents who
were symptom-free—nor did it isolate staff members helping sick patients—and Severity: Immediate
continued to allow residents to eat in the community dining room. jeopardy
CMS implemented enforcement actions requiring the nursing home to provide
directed, in-service training for its staff and submit a directed plan of correction to the
state survey agency.
A New Mexico nursing home allowed two residents diagnosed with methicillin- Scope: A pattern of
resistant Staphylococcus aureus, a highly contagious type of infection, to share a behavior
bathroom with two other residents, therefore putting the two other residents at risk of
exposure. There were also two biohazard bins in the bathroom containing Severity: Immediate
contaminated wound dressings from the infected residents. jeopardy
CMS implemented an enforcement action by assessing a civil money penalty against
the nursing home.
Source: GAO summary of Centers for Medicare & Medicaid Services’ (CMS) data. | GAO-20-576R
17Percentages do not add to 100 due to rounding. CMS may not implement imposed enforcement actions because
the nursing home came into compliance prior to the implementation date of the enforcement action, among other
reasons.
Page 6 GAO-20-576R Nursing Home Infection Control
Notes: GAO reviewed for illustrative purposes narratives written by nursing home surveyors describing the infection prevention and
control deficiencies cited. CMS categorizes deficiencies into one of three scope categories based on whether the incident was: (1)
an isolated occurrence; (2) a part of a pattern of behavior; or (3) a widespread behavior. CMS categorizes deficiencies into one of
four severity categories based on whether the deficiency constitutes: (1) no actual harm with a potential for minimal harm; (2) no
actual harm with a potential for more than minimal harm, but not immediate jeopardy; (3) actual harm that is not immediate jeopardy;
or (4) immediate jeopardy to resident health or safety.
Finally, using CMS data, we also analyzed a selection of characteristics over the 5-year period
for the nursing homes that had infection prevention and control deficiencies cited in multiple
years and found differences for some of the characteristics when we compared these nursing
homes to (a) homes that had no infection prevention and control deficiencies cited, (b) homes
with infection prevention and control deficiencies cited in a single year, or (c) all surveyed
nursing homes. For example, nursing homes owned by for-profit organizations, which
comprised about 68 percent of all surveyed nursing homes, accounted for about 72 percent of
nursing homes that had infection prevention and control deficiencies cited in multiple years, but
nursing homes owned by for-profit organizations comprised only about 61 percent of nursing
homes with no infection prevention and control deficiencies cited. In contrast, nursing homes
with an average overall five-star rating accounted for about 17 percent of all surveyed nursing
homes but comprised about 33 percent of nursing homes with no infection prevention and
control deficiencies cited and only about 10 percent of nursing homes that had infection
prevention and control deficiencies cited in multiple years. 18 For additional information, see
enclosure II.
Agency Comments
We provided a draft of this report to HHS for review and comment. HHS provided technical
comments on the report, which we incorporated as appropriate.
-----
We are sending copies of this report to the appropriate congressional committees, the Secretary
of HHS, and other interested parties. In addition, the report is available at no charge on the
GAO Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me at (202) 512-7114 or
at dickenj@gao.gov. Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. Major contributors to this report were Karin
Wallestad (Assistant Director), Sarah-Lynn McGrath (Analyst-in-Charge), Kathryn Richter, and
Julianne Flowers. Also contributing were Isabella Guyott, Laurie Pachter, Vikki Porter, Anna
Beth Smith, and Jennifer Whitworth.
Sincerely yours,
John E. Dicken
Director, Health Care
Enclosures – 2
18The Five-Star Quality Rating System assigns nursing homes with an overall “star” rating, ranging from one to five.
Nursing homes with five stars are considered to have quality that is much above average, while nursing homes with
one star are considered to have quality that is much below average. For this comparison of nursing home
characteristics from 2013 through 2017, we calculated each nursing home’s average overall rating in each year
during the 5-year period, and then we calculated the average overall rating across all 5 years and rounded to the
nearest whole number. According to CMS, some changes to its methodology for calculating the five-star rating were
made during the time period of our review.
Page 7 GAO-20-576R Nursing Home Infection Control
Enclosure I: State Information on Infection Prevention and Control Deficiencies
We reviewed guidance from the Centers for Medicare & Medicaid Services (CMS) and analyzed
data on nursing home deficiencies cited by surveyors in all 50 states and Washington, D.C.,
from 2013 through 2017 provided by CMS for a prior GAO report, with a particular focus on
deficiencies related to infection prevention and control. 19 Using these data, we determined the
number of nursing homes that had infection prevention and control deficiencies cited as well as
the number of homes with repeated infection prevention and control deficiencies over the 5-year
period from 2013 through 2017. Table 2 provides state-level data on the nursing homes that had
infection prevention and control deficiencies cited in 2017. Table 3 provides state-level data on
the nursing homes with infection prevention and control deficiencies cited by state surveyors
from 2013 through 2017, including across multiple years.
Table 2: Infection Prevention and Control Deficiencies Cited, by State, 2017
Percentage of surveyed nursing
Number of surveyed nursing homes homes with an infection
Number of surveyed with an infection prevention and prevention and control deficiency
State nursing homes control deficiency cited cited
AK 16 5 31.3
AL 201 101 50.2
AR 217 86 39.6
AZ 131 30 22.9
CA 1,174 712 60.6
CO 187 87 46.5
CT 213 66 31.0
DC 18 6 33.3
DE 40 22 55.0
FL 646 278 43.0
GA 325 64 19.7
HI 37 17 45.9
IA 400 88 22.0
ID 61 34 55.7
IL 728 394 54.1
IN 535 187 35.0
KS 269 90 33.5
KY 264 95 36.0
LA 267 79 29.6
MA 380 111 29.2
MD 219 88 40.2
ME 100 13 13.0
MI 430 251 58.4
MN 333 138 41.4
MO 480 256 53.3
MS 191 103 53.9
MT 61 28 45.9
NC 407 64 15.7
ND 69 24 34.8
NE 193 64 33.2
NH 69 16 23.2
NJ 334 105 31.4
NM 75 27 36.0
NV 59 22 37.3
19GAO, Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse, GAO-19-433,
(Washington, D.C.: June 13, 2019).
Page 8 GAO-20-576R Nursing Home Infection Control
Percentage of surveyed nursing
Number of surveyed nursing homes homes with an infection
Number of surveyed with an infection prevention and prevention and control deficiency
State nursing homes control deficiency cited cited
NY 533 113 21.2
OH 901 255 28.3
OK 283 90 31.8
OR 129 42 32.6
PA 680 312 45.9
RI 79 3 3.8
SC 168 40 23.8
SD 96 43 44.8
TN 296 98 33.1
TX 1,166 562 48.2
UT 80 41 51.3
VA 263 102 38.8
VT 36 4 11.1
WA 219 89 40.6
WI 351 141 40.2
WV 104 51 49.0
WY 37 18 48.6
Total 14,550 5,755 39.6
Source: GAO analysis of Centers for Medicare & Medicaid Services’ (CMS) data. | GAO-20-576R
Note: CMS restructured its deficiency code system beginning on November 28, 2017, and, due to these coding changes, we did
not analyze CMS data cited by surveyors from November 28, 2017, through December 31, 2017.
Page 9 GAO-20-576R Nursing Home Infection Control
Table 3: Nursing Homes with Infection Prevention and Control Deficiencies Cited, by State, 2013 through
2017
Nursing homes
with infection Nursing homes
Nursing homes prevention and with infection
Nursing homes with infection control prevention and
with no infection prevention and deficiencies cited control
Total surveyed prevention and control in multiple deficiencies cited
nursing homes, control deficiencies cited nonconsecutive in multiple
State 2013-2017 deficiencies cited in only 1 year years consecutive years
AK 18 1 1 5 11
AL 232 10 48 46 128
AR 243 18 72 50 103
AZ 149 23 49 32 45
CA 1,258 76 176 204 802
CO 228 16 55 47 110
CT 231 45 71 38 77
DC 20 1 4 2 13
DE 47 4 10 13 20
FL 699 91 181 144 283
GA 365 169 136 30 30
HI 48 1 13 7 27
IA 460 134 158 41 127
ID 79 7 17 23 32
IL 791 50 129 127 485
IN 567 123 152 76 216
KS 369 41 100 77 151
KY 293 36 68 70 119
LA 280 60 86 47 87
MA 427 155 169 37 66
MD 234 51 75 49 59
ME 108 57 42 5 4
MI 456 24 74 78 280
MN 392 53 108 75 156
MO 531 52 116 94 269
MS 214 23 58 52 81
MT 84 2 15 17 50
NC 433 217 149 28 39
ND 82 5 24 21 32
NE 233 43 68 46 76
NH 77 32 28 6 11
NJ 374 95 133 55 91
NM 80 27 18 10 25
NV 60 4 9 9 38
NY 637 220 206 57 154
OH 995 308 357 113 217
OK 333 50 81 41 161
OR 144 43 50 26 25
PA 716 85 194 141 296
RI 84 52 25 3 4
SC 192 81 67 22 22
SD 113 2 17 17 77
TN 337 55 93 60 129
TX 1,303 161 280 205 657
UT 105 17 28 15 45
VA 298 44 89 51 114
VT 38 14 6 6 12
WA 230 32 70 37 91
WI 409 37 102 73 197
Page 10 GAO-20-576R Nursing Home Infection Control
Nursing homes
with infection Nursing homes
Nursing homes prevention and with infection
Nursing homes with infection control prevention and
with no infection prevention and deficiencies cited control
Total surveyed prevention and control in multiple deficiencies cited
nursing homes, control deficiencies cited nonconsecutive in multiple
State 2013-2017 deficiencies cited in only 1 year years consecutive years
WV 129 19 20 28 62
WY 41 1 12 7 21
Total 16,266 2,967 4,309 2,563 6,427
Source: GAO analysis of Centers for Medicare & Medicaid Services’ (CMS) data. | GAO-20-576R
Note: CMS restructured its deficiency code system beginning on November 28, 2017, and, due to these coding changes, we did
not analyze CMS data cited by surveyors from November 28, 2017, through December 31, 2017.
Page 11 GAO-20-576R Nursing Home Infection Control
Enclosure II: Comparison of the Percentage of Nursing Homes with and without Infection
Prevention and Control Deficiencies Cited, by Characteristic, 2013 through 2017
We reviewed guidance from the Centers for Medicare & Medicaid Services (CMS) and analyzed
data on nursing home deficiencies cited by surveyors in all 50 states and Washington, D.C.,
from 2013 through 2017 provided by CMS for a prior GAO report, with a particular focus on
deficiencies related to infection prevention and control. 20 Using these data, we determined the
characteristics of all surveyed nursing homes, nursing homes that had no infection prevention
and control deficiencies cited, a single year of these deficiencies, or multiple years of these
deficiencies from 2013 through 2017. For example, nursing homes owned by for-profit
organizations, which comprised about 68 percent of all surveyed nursing homes, accounted for
about 72 percent of nursing homes that had infection prevention and control deficiencies cited in
multiple years, but nursing homes owned by for-profit organizations comprised only about 61
percent of nursing homes with no infection prevention and control deficiencies cited. (See table
4.)
20GAO, Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse, GAO-19-433,
(Washington, D.C.: June 13, 2019).
Page 12 GAO-20-576R Nursing Home Infection Control
Table 4: Comparison of the Percentage of All Surveyed Nursing Homes and Those with No, a
Single Year, or Multiple Years of Infection Prevention and Control Deficiencies Cited, by
Characteristic, 2013 through 2017
Sub-groups of all surveyed nursing homes, 2013-2017
Nursing homes
Nursing homes with infection Nursing homes with
with no infection prevention and infection prevention
All surveyed prevention and control and control
nursing homes, control deficiencies cited deficiencies cited in
Characteristic 2013-2017 deficiencies cited in a single year multiple years
Number of nursing 16,266 2,967 4,309 8,990
homes
Percentage
Type of ownershipa
For-profit 67.9 60.8 63.5 72.3
Nonprofit 23.5 29.7 27.0 19.8
Government-owned 6.0 6.0 6.2 5.9
Mixed ownershipb 1.2 1.0 1.4 1.2
Locationa
Urban 68.4 68.9 67.0 69.0
Rural 27.5 26.7 28.2 27.5
Transitioning areac 2.8 2.6 3.0 2.7
Number of Medicare and Medicaid certified bedsa, d
Small (Less than 50) 13.0 19.1 14.6 10.2
Medium (50 to 99 ) 36.5 36.2 37.4 36.2
Large (100 to 199) 43.4 37.0 40.6 46.8
Very large (200 or 7.1 7.7 7.4 6.8
more)
Special Focus Facility program designation during the time period reviewede
Participated in 2.5 1.0 1.6 3.4
program
Average of Five-Star System overall quality ratings over the time period revieweda, f
1 star 5.5 2.1 2.9 7.9
2 stars 21.2 9.2 15.7 27.8
3 stars 26.1 19.1 24.8 29.1
4 stars 28.1 33.2 31.6 24.8
5 stars 17.3 32.7 22.5 9.7
Source: GAO analysis of Centers for Medicare & Medicaid Services’ (CMS) data. | GAO-20-576R
Notes: CMS restructured its deficiency code system beginning on November 28, 2017, and, due to these coding changes, we did
not analyze CMS data cited by surveyors from November 28, 2017, through December 31, 2017.
a
Percentages do not always add to 100 due to missing data and rounding. The percentage of nursing homes with missing data was
less than 4 percent for each category.
b
For this comparison of nursing home characteristics from 2013 through 2017, “mixed ownership” refers to nursing homes that
changed their profit status at any point during the 5-year period.
c
For this comparison of nursing home characteristics from 2013 through 2017, a “transitioning area” is where the designation
changed from rural to urban or vice-versa at any point during the 5-year period.
d
For this comparison of nursing home characteristics from 2013 through 2017, if a nursing home changed bed size categories at
any point, we assigned the nursing home its largest bed size category during the 5-year period.
e
Nursing homes with chronic noncompliance with federal standards can be selected for the Special Focus Facility program, which
requires state survey agencies to conduct more frequent oversight, and the nursing homes to improve performance or risk
termination from the Medicare and Medicaid programs. The table only displays percentages for those nursing homes that
participated in the Special Focus Facility program during the 5-year period. The remaining nursing homes did not participate in the
Special Focus Facility program during the 5-year period. For this comparison of nursing home characteristics from 2013 through
2017, we considered nursing homes to have participated in the Special Focus Facility program if they participated at any point
during the 5-year period.
f
The Five-Star Quality Rating System assigns nursing homes with an overall “star” rating, ranging from one to five. Nursing homes
with five stars are considered to have quality that is much above average, while nursing homes with one star are considered to
have quality that is much below average. For this comparison of nursing home characteristics from 2013 through 2017, we
calculated each nursing home’s average overall rating in each year during the 5-year period, and then we calculated the average
overall rating across all 5 years and rounded to the nearest whole number. According to CMS, some changes to its methodology
for calculating the five-star rating were made during the time period of our review.
(104261)
Page 13 GAO-20-576R Nursing Home Infection Control
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