GAO Report Focuses on Expert Recommendations to Improve Nursing Home Infection Prevention and Control

A roundtable of 13 experts convened by the Government Accountability Office (“GAO”) has made several recommendations for improving infection prevention and control (“IPC”) efforts in nursing homes. The recommendations are contained in a GAO report released on March 20, 2023.

In the report, the roundtable identified six actions that the U.S. Department of Health and Human Services (“HHS”) and its sub agencies — Centers for Disease Control and Prevention (“CDC”) and Centers for Medicare and Medicaid Services (“CMS”) — should continue after the COVID-19 Public Health Emergency (“PHE”) ends on May 11, 2023; seven practices it should enhance, and one pandemic response action that it should discontinue.

The roundtable, which convened in April 2022, consisted of researchers and infectious disease specialists, nursing home management and staff, individuals with nursing home oversight and regulatory experience at the federal and state levels, and representatives for nursing home residents and their families.

Actions HHS Should Continue

• Require data reporting to the National Healthcare Safety Network (“NHSN”). Roundtable experts agreed that mandatory NHSN reporting should be continued past the scheduled sunset date of December 31, 2024.
• Emphasize and prioritize IPC. CDC stated that it was supportive of this and noted that it learned a lot during the pandemic about weaknesses in IPC in nursing homes and ways that nursing homes can improve.
• Prioritize nursing homes for resources. This would be accomplished by designating nursing homes as high-priority healthcare providers for personal protective equipment, testing, and vaccines in the event of a future infectious disease emergency. HHS did not provide a response.
• Use multi-disciplinary strike teams to provide assistance to nursing homes facing challenges with IPC. State-based strike teams are currently funded for 12 months following the end of the PHE. CMS noted that Congressional action would be required to continue them beyond that 12-month period.
• Consider granting federal regulatory waivers and flexibilities in future emergencies. CMS responded that it is developing a “playbook” of the types of flexibilities the agency would use in the future.
• Standardize stakeholder communication and briefings. The experts noted the importance of CMS and CDC briefings during the PHE. CMS officials stated the briefings are continuing.

Actions HHS Should Enhance

• Develop staffing solutions to ensure adequate staffing, including making the infection preventionist a dedicated position with enough time to perform needed duties. In addition to supporting CMS’s efforts on establishing minimum staffing standards, roundtable experts said that nursing homes need to create more incentives for improving staff recruitment, retention, and compensation. CMS responded that a proposed staffing rule would be issued later this spring. As for the infection preventionist, CMS stated that it expects nursing homes to know how much time its infection preventionist needs to work in order to implement an effective IPC program.
• Strengthen mandatory IPC training for staff and surveyors. CMS responded that staff and surveyors already receive IPC training, and the high incidence of survey deficiencies may be because facilities are not correctly implementing the IPC practices covered during training.
• Increase IPC technical assistance through strengthening and broadening the Quality Improvement Organization (“QIO”) program. CMS stated that any expansion of the QIO program would require additional funding.
• Strengthen the use of non-monetary enforcement actions. Specifically, the roundtable experts referred to the use of directed plans of correction as an “underused tool” in CMS’s enforcement toolbox. CMS stated that it launched an enforcement program in June 2020 for IPC noncompliance that included imposing directed plans of correction.
• Ensure consistent guidance across all levels of government that is updated to reflect the most current information. Although CDC and CMS stated that they worked closely to align their guidance during the pandemic, CDC acknowledged that the two agencies fulfill different roles, which may have contributed to some disconnect during the height of the pandemic.
• Incentivize IPC research by launching demonstration projects to evaluate and test interventions to improve IPC in the nursing home setting. Although supportive of the recommendation, CDC stated that increased funding would be needed to implement it.
• Strengthen emergency preparedness to promote better engagement among nursing homes and their state and regional emergency planning partners. CMS said guidance in the State Operations Manual outlines requirements for developing emergency preparedness plans and coordinating with local and regional partners.

Action HHS Should Discontinue

The roundtable also urged CMS to discontinue limitations placed on visitation and group activities, and to consider developing evidence-based standards for when, if at all, to implement any limitations on visitation and group activities in future infectious disease emergencies and for how long. CMS explained its decision to restrict visitation early in the pandemic, and CDC noted that isolation precautions are a valuable tool for limiting transmission, but agreed that the use of limitations on visitation and group activities for a prolonged duration can potentially cause more harm to residents than good. CDC, therefore, concluded that it would be helpful to have guidance and a limitation on the duration of such requirements.

Conclusion

It remains to be seen which, if any, of the roundtable recommendations that are not presently being implemented will be adopted by CMS and/or CDC. What is certain, however, is that the story of IPC in nursing homes, as well as the government’s response to COVID-19 in general is still being written and will be debated for years to come.