And So It Begins: The Great Government Look Back at the Effect of COVID-19 on Nursing Homes

As 2020, thankfully, comes to a close, the Department of Health and Human Services, Office of Inspector General (OIG) has released the first of several reports on the impact of COVID-19 on nursing homes and the effectiveness of measures employed to prevent and address the disease. First up: on-site surveys.

In the report released on December 17, 2020, the OIG examined on-site surveys conducted during the period from March 23 to May 30, 2020, and compared them to surveys conducted during the same period in 2019.  The report details the number and scope of surveys, findings, challenges faced by States in conducting surveys, and implications for the future.

During the time period covered by the report, State Survey Agencies were instructed to suspend standard surveys and instead conduct focused COVID-19 infection control surveys as well as surveys in response to Immediate Jeopardy (IJ) complaints or self-reported incidents.

Findings:

• Nationwide, states conducted surveys for 31% of nursing homes compared to 53% of homes during the same period in 2019; however, there was wide variation in the numbers of surveys conducted by individual states. Thirteen (13) states surveyed 50% or more of their nursing homes, while 16 states surveyed less than 10% of their nursing homes during this period.  The report attributed the variance to such factors as outbreak status and access to personal protective equipment (PPE) in various states.

• States received approximately half the number of complaints but prioritized more as IJ during the review period as compared to 2019. Specifically, 31% of complaints were prioritized as IJ during the reference period compared to 7% during the same period in 2019.  The report attributed the reduction in complaints to restrictions that resulted in fewer families and outside caregivers on the premises to observe operations.  As for the increase in IJ, the OIG explained that infection control complaints pose a greater threat to residents due to the increased likelihood of serious harm or death from COVID-19, thereby warranting the IJ designation.

• During on-site surveys, deficiencies were cited in 3% of cases versus 40% in 2019. Infection control was cited in 1% of surveys versus 10% in 2019. The report cited changes in State survey activities, the limited scope of the infection control surveys, and the use by nursing facilities of the self-assessment tool released by the Centers for Medicare and Medicaid Services (CMS) as possible reasons for the reduction in deficiencies.
  • The report mentioned “blatantly poor practices” with respect to infection control in some facilities. The most common infection control deficiencies include improper use of PPE (63%), contaminants on environmental surfaces (47%), and lapses in hand hygiene (46%); however, facilities were also cited for failing to isolate infected residents and failing to provide staff education about COVID-19.

• State Agencies faced challenges in obtaining PPE in order to conduct on-site surveys as well as in training surveyors on the proper use of PPE. In addition, CMS surveyors sometimes conducted on-site surveys to assist State Agencies but often were hampered by travel restrictions and thus were limited to assignments that were within driving distance.  Staffing also constituted a problem for states, with many reporting that some surveyors could not perform on-site surveys because of their high risk for infection.

• Even before the pandemic, State Agencies struggled to meet regulatory requirements for surveying facilities at least every 15 months. While CMS, in August 2020, instructed State agencies to resume conducting standard and high-priority complaint surveys where sufficient resources were available, the five-month pause in such surveys exacerbated existing backlogs.  Some states worry that it will take years to eliminate the backlog, raising concerns for nursing home residents’ safety and quality of care.

• Both CMS and State Agencies emphasized the role they played in assisting nursing homes in responding to the pandemic and collaborating with provider associations through guidance and webinars.

As a result of its findings, OIG concluded that while CMS’s actions in suspending certain survey activities, limiting the scope of the surveys that were conducted, and restricting visitation by families, may have been the appropriate actions at the time, they nevertheless have resulted in “less comprehensive oversight” of nursing homes.  OIG further stated that the spread of COVID-19 and the resulting deaths of thousands of nursing home residents raise questions about how well CMS and State Agency oversight identified and addressed shortfalls in infection control.  Accordingly, OIG made some very generalized recommendations to CMS:

• Assess the results of infection control surveys and revise the survey as appropriate – CMS directed States to conduct an infection control survey of every facility by July 31, 2020, a goal which was largely achieved as of September 2020. As a result, OIG urged CMS to review the data from those surveys and assess whether they are effective in determining whether nursing homes implement appropriate infection prevention and control measures.  OIG recommended that CMS may want to consider whether to add elements beyond infection control to the interim survey, such as additional quality of care requirements, if it appears that State Agencies will continue to use that survey due to ongoing PPE and staffing challenges that prevent them from resuming standard surveys. CMS responded that it has and will continue to assess and revise the interim survey instrument as needed.

• Work with State Agencies to help overcome challenges with PPE and staffing – Because challenges with obtaining PPE and providing sufficient staffing continue to hamper State Agencies, OIG recommended that CMS consider longer-term policies and strategies for assisting State Agencies going forward, including:
  • Use lessons learned from the ongoing pandemic to develop plans to ensure sufficient capacity for conducting on-site surveys. These plans could include best practices for obtaining PPE, technical assistance and training for proper utilization of PPE, and clarification of the circumstances under which CMS will make Federal surveyors available to conduct on-site surveys.
  • Requiring states to establish their own clear action plan obtaining PPE and supplemental staffing.
  • Assisting State Agencies by serving as a liaison and advocate with respect to other Federal agencies for PPE acquisition and training.

In its response to the report, CMS stated that it lacks authority to address issues of allocating PPE and PPE training resources to states, but noted that it has taken steps to support State Agencies in these regards.

• Clarify expectations for State Agencies to eliminate survey backlogs – This recommendation calls for guidance on how State Agencies are to prioritize survey activities going forward and requirements related to specific timeframes for eliminating backlogs. CMS responded that it will continue to work with State Agencies on providing guidance for eliminating backlogs as they resume conducting standard and complaint surveys but did not commit to requiring specific timeframes for doing so.

OIG stated that it is working on a series of reports regarding the effect of COVID-19 on nursing homes.  Forthcoming reports include: characteristics of homes hardest hit by the pandemic and the strategies homes have used to mitigate the effects of the pandemic; an assessment of infection prevention and control programs as well as emergency preparedness measures; and an assessment of COVID-19 reporting mechanisms.

There can be no doubt that nursing homes, State Agencies, and CMS, to varying degrees, were unprepared for an event of the scope and magnitude presented by the COVID-19 pandemic.  As a result, it is entirely appropriate to examine the root causes of the problems that have led to so much sickness, suffering, and death, and to institute appropriate measures designed to address them.  May the lessons of 2020 bring a brighter year ahead for 2021.