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Massachusetts Could Better Ensure That Nursing Homes Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control

Issued on  | Posted on  | Report number: A-01-23-00003

Report Materials

Why OIG Did This Audit

  • Nursing homes that participate in Medicare and Medicaid are required by CMS to comply with requirements intended to protect residents, including requirements related to sprinkler systems, smoke detector coverage, and emergency preparedness plans. Facilities are also required to develop infection control programs.
  • In Massachusetts, the State’s Department of Public Health conducts surveys of nursing homes to ensure compliance with Federal requirements.
  • This audit is one in a series of audits that assesses compliance with Federal requirements for life safety, emergency preparedness, and infection control.

What OIG Found

We identified 236 deficiencies related to life safety, emergency preparedness, or infection control at the 20 nursing homes in Massachusetts that we reviewed.

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These deficiencies put the health and safety of residents, staff, and visitors at an increased risk of injury or death during a fire or other emergency, or in the event of an infectious disease outbreak.

What OIG Recommends

We made four recommendations to Massachusetts to improve the health and safety of residents, staff, and visitors at nursing homes, including that it follow up with the 20 nursing homes where we identified deficiencies to ensure that they have taken corrective actions. We also recommended that Massachusetts work with CMS to identify nursing homes requiring frequent inspections. The full recommendations are in the report.

In written comments on our draft report, Massachusetts concurred with our recommendations and described the actions that it had taken or planned to take to address them.

25-A-01-002.01 to CMS - Open Unimplemented
Update expected on 04/03/2025
We recommend that the Massachusetts Department of Public Health follow up with the 20 nursing homes reviewed in this audit that demonstrated life safety, emergency preparedness, and infection control deficiencies to ensure that they have taken corrective actions.

25-A-01-002.02 to CMS - Open Unimplemented
Update expected on 04/03/2025
We recommend that the Massachusetts Department of Public Health work with CMS to develop a risk-based approach to identify nursing homes at which surveys should be conducted more frequently than once every 15 months, such as those with a history of multiple high-risk deficiencies or frequent management turnover.

25-A-01-002.03 to CMS - Open Unimplemented
Update expected on 04/03/2025
We recommend that the Massachusetts Department of Public Health work with CMS to develop a plan to address the foundational issues preventing more frequent surveys at nursing homes with a history of multiple high-risk deficiencies.

25-A-01-002.04 to CMS - Open Unimplemented
Update expected on 04/03/2025
We recommend that the Massachusetts Department of Public health work with CMS to develop standardized life safety training for nursing home staff.

View in Recommendation Tracker
Report Type
Audit
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Emergency Preparedness and Response Nursing Homes, Nursing Facilities, and Assisted Living Facilities
Target Groups
-
Financial Groups
Medicaid

Notice

This report may be subject to section 5274 of the National Defense Authorization Act Fiscal Year 2023, 117 Pub. L. 263.