Nonprofit and Government-Owned Nursing Homes Generally Complied With Federal Requirements (OIG A-01-24-00002)

Summary

An HHS Office of Inspector General audit report, A-01-24-00002, dated December 2024, titled Nonprofit and Government-Owned Nursing Homes Generally Complied With Federal Requirements Regarding the Infection Preventionist Position. It states that three nonprofit and two Government-owned nursing homes may not have complied with the requirement that infection preventionists complete specialized infection prevention and control training prior to assuming the role. On the basis of sample results, it estimates that 117 nursing homes nationwide (99 of 3,294 nonprofit and 18 of 922 Government-owned) may not have complied. It recommends that the Centers for Medicare & Medicaid Services instruct the State survey agencies to follow up with the five nursing homes, and states that CMS concurred.

Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used

Full text

OIG.HHS.GOV
December 2024 | A-01-24-00002
Nonprofit and Government-Owned
Nursing Homes Generally Complied
With Federal Requirements
Regarding the Infection
Preventionist Position

OIG.HHS.GOV

December 2024 | A-01-24-00002
Nonprofit and Government-Owned Nursing Homes Generally Complied
With Federal Requirements Regarding the Infection Preventionist
Position
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.
What OIG Found
Three nonprofit and two Government-owned nursing homes may not have complied with the requirement
that the IPs complete specialized infection prevention and control training prior to assuming the IP role.
On the basis of our sample results, we estimated that 117 nursing homes nationwide (99 of 3,294 nonprofit
and 18 of 922 Government-owned) may not have complied with Federal regulations 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 instruct the State survey agencies to
follow up with the five nursing homes (three nonprofit and two Government-owned) that may not have
complied with Federal requirements to verify that they have taken corrective actions.
CMS concurred with our recommendation.

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)

TABLE OF CONTENTS

INTRODUCTION ............................................................................................................................... 1

Why We Did This Audit ....................................................................................................... 1

Objective ............................................................................................................................. 1

Background ......................................................................................................................... 1
Medicare and Medicaid Coverage of Nursing Homes ............................................ 1
Requirements for Infection Prevention and Control .............................................. 1
Responsibilities for Infection Prevention and Control ............................................ 2

How We Conducted This Audit ........................................................................................... 3

FINDINGS ......................................................................................................................................... 5

Some Nursing Homes May Not Have Complied With the Infection Preventionist
   Training Requirement ...................................................................................................... 6
Nonprofit Nursing Homes ....................................................................................... 6
Government-Owned Nursing Homes ..................................................................... 7

Why Nursing Homes May Not Have Complied With IP Requirements .............................. 8

Nonprofit And Government-Owned Nursing Homes Nationwide Generally Complied
   With IP Requirements ...................................................................................................... 8

RECOMMENDATION ....................................................................................................................... 8

CMS COMMENTS ............................................................................................................................ 9

APPENDICES

A: Audit Scope and Methodology ..................................................................................... 10

B: Related Office of Inspector General Reports ................................................................ 12

C: Statistical Sampling Methodology ................................................................................ 13

D: Sample Results and Estimates ...................................................................................... 15

E: Area of Infection Preventionist Possible Noncompliance ............................................ 16

F: CMS Comments ............................................................................................................. 17

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
1
INTRODUCTION

WHY WE DID THIS AUDIT

More than 1.3 million people reside in the approximately 15,000 Medicare and Medicaid
certified nursing homes nationwide.  Approximately two-thirds of those nursing homes are
for-profit nursing homes, and the remaining one-third of nursing homes is comprised of
nonprofit and Government-owned nursing homes.  In October 2016, the Centers for Medicare
& Medicaid Services (CMS) issued a final rule that stated infection prevention and control is a
critical issue for nursing homes because of the high number of health care-associated
infections, the residents’ increased susceptibility to infections, and the significant exposure to
health care-associated infections residents face.1  To minimize exposure to, and transmission
of, infections and contagious diseases, it is critical that nursing homes strictly adhere to Federal
requirements for proper infection prevention and control practices.  Prior Office of Inspector
General (OIG) audits found that nursing homes did not always comply with infection prevention
and control (IPC) Federal regulations regarding designating an infection preventionist (IP) who
met Federal requirements for that position.2

OBJECTIVE

Our objective was to determine whether nonprofit and Government-owned nursing homes
nationwide complied with Federal requirements pertaining to IPs.

BACKGROUND

Medicare and Medicaid Coverage of Nursing Homes

The Medicare and Medicaid programs cover care in nursing homes for eligible residents.
Sections 1819 and 1919 of the Social Security Act (the Act) establish requirements for CMS and
States to perform surveys of nursing homes to determine whether they meet Federal
participation requirements.3

Requirements for Infection Prevention and Control

Nursing homes are required to operate and provide services in compliance with all Federal,
State, and local laws, regulations, codes, and accepted professional standards and principles
(42 CFR § 483.70).  CMS implemented new regulations in 2016 requiring that nursing homes

1 81 Fed. Reg. 68688, 68808 (Oct. 4, 2016).

2 See Appendix B for related Office of Inspector General reports.

3 For Medicare and Medicaid, these statutory participation and survey requirements are implemented at 42 CFR,
part 483, subpart B, and 42 CFR, part 488, subpart E, respectively.

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
2
establish and maintain an infection prevention and control program (IPCP) designed to provide
a safe, sanitary, and comfortable environment.  The IPCP must include:

• a system for preventing, identifying, reporting, investigating, and controlling infections
and communicable diseases for residents and staff (including volunteers, visitors, and
other individuals providing services under a contractual arrangement);

• written standards, policies, and procedures for the program that must include: (1) a
system of surveillance designed to identify possible communicable diseases or infections
before they can spread to other persons in the nursing home, (2) when and to whom
possible incidents of communicable diseases or infections should be reported,
(3) standard and transmission-based precautions to be followed to prevent the spread
of infections, (4) when and how isolation should be used for a resident, (5) the
circumstances under which the facility must prohibit employees with a communicable
disease or infected skin lesions from direct contact with residents or their food, and
(6) the hand hygiene procedures to be followed by staff involved in direct resident
contact;

• an antibiotic stewardship program that includes a system to monitor antibiotic use; and

• a system for recording incidents identified under the IPCP and the corrective actions
taken by the nursing home (42 CFR § 483.80(a)(1-4)).

Under these regulations, nursing homes are required to designate at least one individual as the
IP who is responsible for the facility’s IPCP.  Per the regulations, IP(s) must: (1) have primary
professional training in nursing, medical technology, microbiology, epidemiology, or other
related field; (2) be qualified by education, training, experience, or certification; (3) work at
least part-time at the facility; and (4) have completed specialized training in infection
prevention and control (42 CFR § 483.80(b)(1-4)).

Responsibilities for Infection Prevention and Control

The Act mandates the establishment of minimum health and safety standards that must be met
by providers participating in the Medicare and Medicaid programs.  CMS established these
standards and incorporated them in Title 42 of the Code of Federal Regulations.  CMS is
responsible for overseeing health care provider compliance with Medicare and Medicaid health
and safety standards.  CMS delegates a variety of tasks related to this oversight to State survey
agencies (SSAs) (the Act § 1864).  One of these tasks is to conduct investigations and
fact-finding surveys to determine whether health care providers, including nursing homes,
comply with their applicable conditions of participation (CoPs).  Standard surveys of nursing

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
3
homes must occur no later than 15 months after the previous survey.4, 5  SSAs are also
responsible for conducting a complaint survey if a review of the complaint allegation concludes
that noncompliance with CoPs may have occurred.  Such a survey can happen at any time,
regardless of standard survey intervals.  SSAs cite nursing homes with deficiencies when they
do not meet the CoPs, including when they do not follow infection prevention and control
requirements.

Management and staff at a nursing home are ultimately responsible for ensuring the safety and
well-being of residents and staff and for complying with Federal, State, and local regulations.
They are responsible for ensuring that the nursing home develops, maintains, and implements
an IPCP.

HOW WE CONDUCTED THIS AUDIT

As of October 1, 2023, there were 14,944 Medicare- and Medicaid-certified nursing homes
nationwide, of which 3,294 were nonprofit nursing homes (located in 50 States, the District of
Columbia, and Puerto Rico) and 922 were Government-owned nursing homes (located in 49
States (there were no Government-owned nursing homes in Rhode Island) and Guam).6  We
selected a stratified random sample of 200 nursing homes consisting of 100 nonprofit nursing
homes and 100 Government-owned nursing homes to determine whether they complied with
Federal requirements pertaining to IPs during the audit period October 1, 2022, through
September 30, 2023. 7, 8, 9  See the map in Figure 1 (on the next page) and Figure 2 (on page 5)
for the States where the selected nonprofit and Government-owned nursing homes,
respectively, were located and the number of nursing homes selected from those States.  For

4 The Act §§ 1819(g)(2)(A)(iii)(l), 1919(g)(2)(A)(iii)(I) and 42 CFR § 488.308.

5 A standard survey is a periodic, resident-centered inspection that gathers information about the quality of service
furnished in a facility to determine compliance with requirements of participation (42 CFR § 488.301).

6 CMS provider information is available at https://data.cms.gov/provider-data/dataset/4pq5-n9py.  Accessed on
Oct. 1, 2023.

7 We did not contact one of the selected nonprofit nursing homes due to ongoing OIG work related to that nursing
home.  As a result, we did not determine whether the nursing home complied with Federal requirements.  To be
conservative, we considered this sample item a non-error.

8 Three of the selected Government-owned nursing homes closed operations after we selected our sample.
Therefore, we were unable to contact the nursing homes to request documentation to determine compliance with
Federal requirements.  To be conservative, we considered these three sample items as non-errors.

9 On the Medicare.gov website, four of the selected nonprofit nursing homes were incorrectly identified as
nonprofit nursing homes instead of a for-profit (one nursing home) and Government-owned (three nursing
homes), and five of the selected Government-owned nursing homes were incorrectly identified as Government-
owned nursing homes instead of for-profit nursing homes.  Since these nursing homes should not have been in our
nonprofit or Government-owned sampling frames, we did not determine compliance with Federal requirements
for these sample items.  To be conservative, we considered these sample items non-errors.

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
4
each of the sampled items, we contacted the nursing homes and sent a questionnaire
requesting information regarding the IP position (including the IP job description).  Specifically,
we requested that nursing home officials provide the name(s) of each IP(s) during the audit
period, the date(s) that each individual served as the IP, and the IP(s) qualifications for the
position.  We also requested information regarding changes in nursing home administrators
and ownership.  We reviewed the documentation to determine whether the nursing homes
complied with Federal regulations pertaining to IPs.

We conducted this performance audit 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.

Appendix A describes our audit scope and methodology, Appendix C describes our statistical
sampling methodology, and Appendix D contains our sample results and estimates.

Figure 1: The Locations of the 100 Sampled Nonprofit Nursing Homes

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
5
Figure 2: The Locations of the 100 Sampled Government-Owned Nursing Homes

FINDINGS

Ninety-two of the 100 nonprofit nursing homes and 90 of the 100 Government-owned nursing
homes in our nationwide samples complied with Federal requirements pertaining to IPs;
however, 3 nonprofit nursing homes and 2 Government-owned nursing homes may not have
complied with the requirement that the IPs complete specialized IPC training prior to assuming
the IP role.10, 11

Nursing home officials attributed the potential noncompliance to difficulties hiring and
retaining experienced and qualified IPs.

On the basis of our sample results, we estimated that 117 nonprofit and Government-owned
nursing homes nationwide (99 nonprofit and 18 Government-owned nursing homes) may not

10 We could not obtain records to determine compliance with Federal requirements for an additional 13 nursing
homes.  As a result, we considered five nonprofit and eight Government-owned sample items as non-errors.  See
footnotes 7, 8, and 9 for further details on why we could not determine compliance for these sampled items.

11 CMS officials informed us that actual deficiencies are cited onsite following a thorough investigation by trained
Federal, State, and contractual surveyors to determine compliance with the Federal requirements for participation
(i.e., the minimum health and safety standards).  Therefore, we will defer to the trained surveyors who may
conduct a followup review at the selected nursing homes to determine whether a deficiency exists for each
condition identified in this report.

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
6
have complied with Federal requirements pertaining to IPs during our audit period.12  As a
result, there may be increased health and safety risks for the residents and staff of these
nursing homes.

Appendix E summarizes the types of potential noncompliance that we identified at each
nonprofit and Government-owned nursing home.

SOME NURSING HOMES MAY NOT HAVE COMPLIED WITH THE INFECTION PREVENTIONIST
TRAINING REQUIREMENTS

The individual that a nursing home designates as its IP must meet the following Federal
requirements: (1) have primary professional training in nursing, medical technology,
microbiology, epidemiology, or other related field; (2) be qualified by education, training,
experience, or certification; (3) work at least part time at the facility; and (4) have completed
specialized training in infection prevention and control (42 CFR § 483.80(b)(1-4)).

Nonprofit Nursing Homes

The nonprofit nursing homes in our sample complied with the first three requirements.
However, the IPs at three of the nonprofit nursing homes did not complete specialized IPC
training prior to assuming their role as the designated IP.13

For the nonprofit nursing homes that complied with this requirement, Federal and State
agencies provided approximately 69 percent of the specialized training classes.  Private entities
provided the remaining training classes.  See Figure 3 on the next page for the breakout of the
different training sources.

12 Specifically, we estimated that 117 nursing homes (99 nonprofit and 18 Government-owned nursing homes) may
not have complied with Federal requirements pertaining to the IP during the audit period.  In addition, the 90-
percent confidence interval for potential noncompliance with Federal regulations in the sampling frame was 24 to
211 (nonprofit and Government-owned nursing homes), 28 to 247 (nonprofit nursing homes), and 4 to 54
(Government-owned nursing homes).

13 CMS and the U.S. Centers for Disease Control and Prevention collaborated to develop and offer a specialized
online class called “Nursing Home Infection Preventionist Training Course.”  Available online at
https://www.train.org/cdctrain/training_plan/3814.  (Accessed Aug. 28, 2024.)

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
7

Government-Owned Nursing Homes

The Government-owned nursing homes in our sample complied with the first three
requirements.  However, the IPs at two of the Government-owned nursing homes did not
complete specialized IPC training prior to assuming their role as the designated IP.

For the nursing homes that complied with this requirement, Federal and State agencies
provided approximately 77 percent of the specialized training classes.  Private entities provided
the remaining training classes.  See Figure 4 on the next page for the breakout of the different
training sources.

Private
31%
State
1%
Federal
68%
Figure 3: Specialized Training Sources Nonprofit Samples
Private
State
Federal

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
8

WHY NURSING HOMES MAY NOT HAVE COMPLIED WITH IP REQUIREMENTS

Officials from the five nursing homes attributed the potential noncompliance to difficulties
hiring and retaining experienced and qualified IPs.

NONPROFIT AND GOVERNMENT-OWNED NURSING HOMES NATIONWIDE GENERALLY
COMPLIED WITH IP REQUIREMENTS

On the basis of our sample results, we estimated that 117 nonprofit and Government-owned
nursing homes nationwide (99 nonprofit and 18 Government-owned nursing homes) 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.

RECOMMENDATION

We recommend that the Centers for Medicare & Medicaid Services instruct the SSAs to follow
up with the five nursing homes (three nonprofit and two Government-owned) that may not
have complied with Federal requirements to verify that they have taken corrective actions.14

14 SSAs should prioritize followup activities: (1) based upon the level of risk to beneficiaries and (2) in accordance
with CMS policies for triaging nursing home complaints and incidents.

Federal
71%
State
6%
Private
23%
Figure 4: Specialized Training Sources Grovenment-Owned Sample
Federal
State
Private

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
9
CMS COMMENTS

In written comments on our draft report, CMS concurred with our recommendation and stated
that it had already contacted the appropriate SSAs to ensure that the five nursing homes we
identified with possible infection preventionist deficiencies are in compliance with Federal
requirements.  CMS’s comments are included as Appendix F.

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
10
APPENDIX A: AUDIT SCOPE AND METHODOLOGY

SCOPE

As of October 2023, there were 4,216 Medicare- and Medicaid-certified nonprofit (3,294) and
Government-owned (922) nursing homes in operation during the audit period with valid
six-digit Federal provider numbers.15  We selected 100 nursing homes from each category for
review.

We did not assess CMS’s or the nursing homes’ overall internal control structures.  Rather, we
limited our review of internal controls to the nursing homes’ policies and procedures related to
the IP.

We performed our audit from April 2024 through October 2024.

METHODOLOGY

To accomplish our objective, we:

• reviewed applicable Federal requirements,

• corresponded with CMS program officials to gain an understanding of the infection
preventionist requirements,

• obtained a list of all Medicare- and Medicaid-certified nonprofit and Government-
owned nursing homes,

• selected a stratified random sample of 100 nonprofit nursing homes and 100
Government-owned nursing homes,

• contacted selected nursing homes and requested documentation related to the IP,

• reviewed documentation from nursing homes to determine whether they complied with
Federal regulations pertaining to the IP,

• estimated the number of nursing homes that potentially did not comply with Federal
regulations pertaining to IPs, and

• discussed the results of our audit with CMS officials.

15 To determine whether a nursing home was in operation during the audit period, we used the CMS Quality,
Certification & Oversight Reports website, available at https://qcor.cms.gov/main.jsp.  Accessed on Jan. 31, 2023.

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
11
See Appendix C for our statistical sampling methodology and Appendix D for our sample results
and estimates.

We conducted this performance audit 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.

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
12
APPENDIX B: RELATED OFFICE OF INSPECTOR GENERAL REPORTS

Report Title
Report
Number
Date Issued
Certain For-Profit Nursing Homes May Not Have
Complied with Federal Requirements Regarding the
Infection Preventionist Position
A-01-22-00001
08/19/2024
Certain Life Care Nursing Homes May Not Have
Complied With Federal Requirements for Infection
Prevention and Control and Emergency Preparedness
A-01-20-00004
9/15/2022
Certain Nursing Homes May Not Have Complied With
Federal Requirements for Infection Prevention and
Control and Emergency Preparedness
A-01-20-00005
7/26/2022

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
13
APPENDIX C: STATISTICAL SAMPLING METHODOLOGY

SAMPLING FRAME

The sampling frame included 4,216 active nonprofit and Government-owned nursing homes
that have valid 6-digit Federal provider numbers.16, 17

SAMPLE UNIT

The sample unit was a nursing home.

SAMPLE DESIGN AND SAMPLE SIZE

We used a stratified random sample with strata and sample sizes defined in Table 1.

Table 1: Strata and Sample Sizes

Stratum

Nursing Home Type

Number of Frame Units

Sample Size
1
Nonprofit
3,294
100
2
Government‐Owned
922
100

Total
4,216
200

SOURCE OF RANDOM NUMBERS

We generated the random numbers using the OIG, Office of Audit Services (OAS), statistical
software.

METHOD FOR SELECTING SAMPLE UNITS

We sorted the items in each stratum by the Federal provider number in ascending order and
consecutively numbered the items in each stratum in the sampling frame.  After generating the
random numbers for each of these strata according to our sample design, we selected the
corresponding frame items for review.

16 We determined whether a nursing home was still active using the Quality, Certification & Oversight Reports
website, available at https://qcor.cms.gov/main.jsp.

17 The Federal provider numbers of less than one percent of the nursing homes in the provider data catalog were in
scientific notation.

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
14
ESTIMATION METHODOLOGY

We used the OIG/OAS, statistical software to estimate the number of nonprofit and
Government-owned nursing homes in the sampling frame that potentially did not comply with
Federal regulations regarding IPs.  Using this software, we calculated a point estimate and a
two-sided 90-percent confidence interval (Appendix D).

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
15
APPENDIX D: SAMPLE RESULTS AND ESTIMATES

Table 2: Sample Detail and Results

Stratum

Nursing Home Type
Number of Nursing
Homes in Frame
Sample
Size
Number of Potential
Deficiencies
1
Nonprofit Nursing Homes
3,294
100
3
2
Government-Owned Nursing Homes
922
100
2

Totals
4,216
200
5

Table 3: Estimated Number of Nursing Homes in the Sampling Frame That
Were Potentially Not in Compliance
(Limits Calculated for a 90-Percent Confidence Interval)

Total
Nonprofit
Nursing Homes
Government-Owned
Nursing Homes
Point estimate
117
99
18
Lower limit
24
28
4
Upper limit
211
247
54

Table 4: Estimated Percentage of Nursing Homes in the Sampling Frame That
Were Potentially Not in Compliance
(Limits Calculated for a 90-Percent Confidence Interval)

Total
Nonprofit
Nursing Homes
Government-Owned
Nursing Homes
Point estimate 2.222%
3.000%
2.000%
Lower limit
0.560%
0.850%
0.434%
Upper limit
5.003%
7.498%
5.857%

Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
16
APPENDIX E: AREA OF INFECTION PREVENTIONIST
POSSIBLE NONCOMPLIANCE

Table 5: NONPROFIT NURSING HOMES

Nursing
Home
IP Did Not
Complete
Specialized
Training Prior
To Designation
N-019
1
N-034
1
N-087
1
Total
3

Table 6: GOVERNMENT-OWNED NURSING HOMES

Nursing
Home
IP Did Not
Complete
Specialized
Training Prior
To Designation
G-034
1
G-080
1
Total
2

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Administrator
Washington, DC 20201
APPENDIX F: CMS COMMENTS
DATE:
November 21, 2024
TO:
Amy J. Frontz
Deputy Inspector General
FROM:
Chiquita Brooks-LaSure
Administrator
SUBJECT:
Office of Inspector General Draft Report: Nonprofit and Government-Owned
Nursing Homes Generally Complied with Federal Requirements Regarding the
Infection Preventionist Position (A-01-24-00002)
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and
comment on the Office of Inspector General’s (OIG) draft report.
CMS takes seriously its role in improving the safety and quality of care in our nation’s nursing
homes. Additionally, CMS continues to implement its efforts to ensure pandemic and emergency
preparedness in nursing homes, including strengthening infection prevention and control
practices.
In 2016, CMS took pivotal actions by issuing the “Medicare and Medicaid Programs: Reform of
Requirements for Long-Term Care Facilities” Final Rule.1 This rule was the impetus for the
requirement that nursing homes develop, implement, and maintain a quality assurance and
performance improvement (QAPI) program (§483.75), an infection prevention and control
program that includes an antibiotic stewardship program (ASP) (§483.80), and designation of at
least one infection preventionist (IP) (§483.80) to ensure the QAPI program’s effectiveness.
These regulations were implemented in three phases. The first phase was implemented in
November 2016, phase two in November 2017, and phase three in November 2019.
When the COVID-19 public health emergency was declared in early 2020, CMS took several
actions to strengthen infection prevention and control practices within nursing homes. CMS
began by issuing guidance to nursing homes to reiterate the importance of longstanding infection
control guidelines and the use of personal protective equipment. CMS continued to provide
updated guidance as new information was learned. CMS also partnered with the Centers for
Disease Control and Prevention (CDC) to support surveillance and collection of COVID-19 data,
which were used to strengthen surveillance locally and nationally, monitor trends in infection
rates, and help local, state, and federal authorities get help to nursing homes faster. In an effort to
allow CMS and the states to focus on infection prevention and control and slowing the spread of
COVID-19, CMS instructed the State Survey Agencies (SSAs) to conduct onsite surveys to
1 Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities, 81 Fed. Reg. 68688,
Nov. 28, 2016.
Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
17

assess compliance with federal requirements and investigate facility complaints, with a
streamlined review tool to conduct focused infection control surveys. CMS has since integrated
the focused infection control survey into the standard survey process, which is typically done on
behalf of CMS by the SSAs.
In June 2022, CMS announced the release of new survey guidance to support implementing all
phases of the Reform of Requirements for LTC facilities.2 In the updated guidance, CMS
clarified that the amount of time required to fulfill the IP role must be at least part-time and
should also be determined by the facility assessment, conducted according to facility assessment
requirements at §483.71, to determine the resources a facility needs for its infection prevention
and control program (IPCP), and ensure that those resources are provided for the IPCP.
Similarly, the IP must participate in the nursing homes’ Quality Assessment and Assurance
(QAA) Committee and report on the IPCP and incidents such as healthcare-associated infections
and communicable diseases. Additionally, ASP is a team effort with nursing homes’ staff, such
as physicians, nursing staff, leadership, etc. CMS clarified that the IP is responsible for ensuring
that the program meets the requirements. The IP should also review and approve infection
prevention and control training topics and content and ensure facility staff are trained on IPCPs.3
CMS notes that OIG found that 69 percent of nonprofit nursing homes and 77 percent of
government-owned nursing homes with a designated IP took specialized training classes offered
by federal or state agencies, such as the CDC’s free online training course, Nursing Home
Infection Preventionist Training Course,4 which was developed in collaboration with CMS.5
Further, the IP must have primary professional training in nursing, medical technology,
microbiology, epidemiology, or other related fields of training, such as physicians, pharmacists,
and physician assistants.6 CMS states that the IP must be qualified by education, training,
experience, or certification and must have the knowledge to perform the role. Additionally, the
IP should remain current with infection prevention and control issues and be aware of national
organizations’ guidelines and those from national, state, and local public health authorities (e.g.,
emerging pathogens). The facility should ensure the individual(s) selected as the IP has the
background and ability to fully carry out the requirements of the IP based on the needs of the
resident population, such as interpreting clinical and laboratory data. Examples of experience in
infection prevention and control may include but are not limited to identifying infectious disease
processes, surveillance and epidemiological investigation, and preventing and controlling the
transmission of infectious agents.7
The regulations intend to ensure that each nursing home develops and implements an ongoing,
facility-wide system for infection prevention, identification, reporting, investigating, and control
of infection and communicable diseases of residents, staff, and visitors and review and update
the program plans annually and as necessary.8 As of October 24, 2022, SSAs have been using the
2 CMS QSO-22-19-NH, Revised Long-Term Care Surveyor Guidance, June 29, 2022
3 State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, February 2023
4 CDC TRAIN, Nursing Home Infection Preventionist Training Course, Updated October 1, 2023
5 CMS, QSO-19-10-NH Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long-
Term Care Setting is Now Available, March 2019
6 Id.
7 Id.
8 Id.
Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
18

guidance to survey for compliance or non-compliance with all requirements from the 2016 Final
Rule from all three phases.9
CMS thanks OIG for its efforts on this important issue and looks forward to working with OIG
on this and other issues in the future. OIG’s recommendations and CMS’s responses are below.
OIG Recommendation
Instruct the SSAs to follow up with the five nursing homes that may not have complied with
federal requirements to verify they have taken corrective actions.
CMS Response
CMS concurs with this recommendation and has already contacted the appropriate SSAs to
ensure that the five nursing homes OIG identified with possible infection preventionist
deficiencies are in compliance with federal requirements.
9 CMS QSO-22-19-NH, Revised Long-Term Care Surveyor Guidance, June 29, 2022
Infection Preventionist Position at Nonprofit and Government-Owned Nursing Homes (A-01-24-00002)
19

1
Report Fraud, Waste,
and Abuse
OIG Hotline Operations accepts tips and complaints from all sources about
potential fraud, waste, abuse, and mismanagement in HHS programs.  Hotline
tips are incredibly valuable, and we appreciate your efforts to help us stamp
out fraud, waste, and abuse.

TIPS.HHS.GOV
Phone: 1-800-447-8477
TTY: 1-800-377-4950

Who Can Report?
Anyone who suspects fraud, waste, and abuse should report their concerns
to the OIG Hotline.  OIG addresses complaints about misconduct and
mismanagement in HHS programs, fraudulent claims submitted to Federal
health care programs such as Medicare, abuse or neglect in nursing homes,
and many more.  Learn more about complaints OIG investigates.
How Does it Help?
Every complaint helps OIG carry out its mission of overseeing HHS programs
and protecting the individuals they serve.  By reporting your concerns to the
OIG Hotline, you help us safeguard taxpayer dollars and ensure the success of
our oversight efforts.
Who Is Protected?
Anyone may request confidentiality.  The Privacy Act, the Inspector General
Act of 1978, and other applicable laws protect complainants.  The Inspector
General Act states that the Inspector General shall not disclose the identity of
an HHS employee who reports an allegation or provides information without
the employee’s consent, unless the Inspector General determines that
disclosure is unavoidable during the investigation.  By law, Federal employees
may not take or threaten to take a personnel action because of
whistleblowing or the exercise of a lawful appeal, complaint, or grievance
right.  Non-HHS employees who report allegations may also specifically
request confidentiality.

1

Stay In Touch
Follow HHS-OIG for up to date news and publications.
OIGatHHS
HHS Office of Inspector General
Subscribe To Our Newsletter
OIG.HHS.GOV
Contact Us
For specific contact information, please visit us online.
U.S. Department of Health and Human Services
Office of Inspector General
Public Affairs
330 Independence Ave., SW
Washington, DC 20201
Email: Public.Affairs@oig.hhs.gov

File and source

File

A-01-24-00002-nonprofit-and-government-owned-nursing-homes-generally-complied-with-federal-req.pdf

Size

3,278,024 bytes

SHA-256

73053aa783816eae6d0b6b2a9f282d21fb755d4e9c6c33669ebb8488404024de

Our copy

A-01-24-00002-nonprofit-and-government-owned-nursing-homes-generally-complied-with-federal-req.pdf

Original

oig.hhs.gov