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Series: Audits of Emergency Preparedness, Infection Prevention and Control, and Life Safety at Intermediate Care Facilities for Individuals With Intellectual Disabilities

Announced on  | Last Modified on  | Series Number: SRS-A-25-026
Status
Completed
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

An Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) is an institution that provides health and/or rehabilitation services to individuals with intellectual disabilities under the Medicaid program. ICF/IID services are covered by Medicaid when they are provided in a residential facility licensed and certified by a State survey agency as an ICF/IID. Medicaid covers ICF/IID services for more than 100,000 individuals with intellectual disabilities and other related conditions. ICF/IIDs face significant challenges in the event of emergencies such as fires, emerging infectious disease outbreaks, and natural disasters. Previous OIG audits on infection prevention and control, emergency preparedness, and life safety at nursing homes identified multiple issues that put Medicaid enrollees at increased risk. Our objective is to determine whether selected States' ICF/IIDs complied with Federal requirements for infection prevention and control, emergency preparedness, and life safety.

There are 5 projects in this series.

COMPLETED PROJECTS IN THIS SERIES (5)

Connecticut

Project OAS-25-01-040 • Completed on October 21, 2025

North Carolina

Project A-04-24-02504 • Completed on July 23, 2025

Oklahoma

Project A-06-24-09002 • Completed on July 15, 2025

Maine

Project A-01-24-00004 • Completed on June 12, 2025

Massachusetts

Project A-01-24-00001 • Completed on October 23, 2024

TIMELINE

  • November 15, 2023
    Series Number SRS-A-25-026 Assigned
  • November 15, 2023
    Projects Announced

    Maine - A-01-24-00004

  • North Carolina - A-04-24-02504

  • Oklahoma - A-06-24-09002

  • November 16, 2023
    Projects Announced

    Massachusetts - A-01-24-00001

  • Connecticut - OAS-25-01-040

  • October 23, 2024
    Project Complete - A-01-24-00001

    Massachusetts has been marked as complete. This audit resulted in 2 recommendations.

  • June 12, 2025
    Project Complete - A-01-24-00004

    Maine has been marked as complete. This audit resulted in 3 recommendations.

  • July 15, 2025
    Project Complete - A-06-24-09002

    Oklahoma has been marked as complete. This audit resulted in 3 recommendations.

  • July 23, 2025
    Project Complete - A-04-24-02504

    North Carolina has been marked as complete. This audit resulted in 3 recommendations.

  • October 21, 2025
    Project Complete - OAS-25-01-040

    Connecticut has been marked as complete. This audit resulted in 2 recommendations.

  • October 21, 2025
    Series Complete

    Audits of Emergency Preparedness, Infection Prevention and Control, and Life Safety at Intermediate Care Facilities for Individuals With Intellectual Disabilities has been marked as complete.

5 REPORT PUBLISHED

Massachusetts Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety and Emergency Preparedness (A-01-24-00001)

25-A-01-004.01 to CMS - Closed Implemented
Closed on 01/16/2025
We recommend that the Massachusetts Department of Public Health follow up with the two ICF/IIDs to verify that they have taken corrective actions on the life safety and emergency preparedness deficiencies identified during the audit.

25-A-01-004.02 to CMS - Closed Implemented
Closed on 01/16/2025
We recommend that the Massachusetts Department of Public Health work with CMS to develop standardized life safety training for ICF/IID staff.

View in Recommendation Tracker

Maine Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control (A-01-24-00004)

25-A-01-072.01 to CMS - Closed Implemented
Closed on 10/22/2025
We recommend that the Maine Department of Health and Human Services follow up with the 16 ICF/IIDs to verify that they have taken corrective actions on the life safety, emergency preparedness, and infection control deficiencies identified during the audit.

25-A-01-072.02 to CMS - Closed Implemented
Closed on 10/22/2025
We recommend that the Maine Department of Health and Human Services conduct surveys at ICF/IIDs at least every 15 months as required by CMS.

25-A-01-072.03 to CMS - Open Unimplemented
Update expected on 04/22/2026
We recommend that the Maine Department of Health and Human Services work with CMS to develop standardized life safety training for ICF/IID staff.

View in Recommendation Tracker

North Carolina Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety and Infection Control (A-04-24-02504)

We identified 14 deficiencies related to life safety and infection control at the 3 ICF/IIDs operated by North Carolina. We did not identify any deficiencies related to emergency preparedness.

25-A-04-085.01 to CMS - Closed Implemented
Closed on 11/10/2025
We recommend that the North Carolina Department of Health and Human Services verify that the three ICF/IIDs we inspected have taken corrective actions on the life safety and infection contol deficiencies identified during the audit.

25-A-04-085.02 to CMS - Closed Implemented
Closed on 11/10/2025
We recommend that the North Carolina Department of Health and Human Services work with the applicable ICF/IID to determine whether mold exists.

25-A-04-085.03 to CMS - Closed Implemented
Closed on 11/10/2025
We recommend that the North Carolina Department of Health and Human Services work with CMS to develop standardized life safety training for staff and ICF/IIDs.

View in Recommendation Tracker

Oklahoma Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control (A-06-24-09002)

We identified 426 deficiencies related to life safety, emergency preparedness, and infection control at the 42 ICF/IIDs operated in Oklahoma that we reviewed. These deficiencies put residents, staff, and visitors at an increased risk of injury or death during a fire or other emergency.

25-A-06-080.01 to CMS - Open Unimplemented
Update expected on 01/14/2026
We recommended that the Oklahoma State Department of Health follow up with the 42 ICF/IIDs to verify that they have taken corrective actions on the life safety, emergency preparedness, and infection control deficiencies identified during the audit.

25-A-06-080.02 to CMS - Open Unimplemented
Update expected on 01/14/2026
We recommended that the Oklahoma State Department of Health conduct surveys at ICF/IIDs at least every 15 months as required by CMS.

25-A-06-080.03 to CMS - Open Unimplemented
Update expected on 01/14/2026
We recommended that the Oklahoma State Department of Health work with CMS to develop standardized life safety training for ICF/IID staff.

View in Recommendation Tracker

Connecticut Could Better Ensure That Intermediate Care Facilities for Individuals With Intellectual Disabilities Comply With Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control (OAS-25-01-040)

We identified 80 deficiencies related to life safety, emergency preparedness, and infection control at the 15 ICF/IIDs that we reviewed in Connecticut.

26-A-01-004.01 to CMS - Open Unimplemented
Update expected on 04/20/2026
We recommend that the Connecticut Department of Public Health follow up with the 15 ICF/IIDs reviewed to verify that they have taken corrective actions on the life safety, emergency preparedness, and infection control deficiencies identified during the audit.

26-A-01-004.02 to CMS - Open Unimplemented
Update expected on 04/20/2026
We recommend that the Connecticut Department of Public Health work with CMS to develop standardized life safety training for ICF/IID staff.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Emergency Preparedness and Response Public Health Issues Quality of Care
Target Groups
-
Financial Groups
Medicaid