Inspector General Provides Recommendations for Nursing Home Infection Prevention

By Jasmyne Ray

Findings in a recent data brief from the Office of Inspector General looking at nursing homes with high infection rates during the first year of the pandemic show the need for a new approach to infection prevention.

The brief, the second in a series of three, comes as a result of the devastating impact of COVID-19 on nursing homes and their residents. According to the brief, understanding the effects of the pandemic will help the Centers for Medicare and Medicaid Services (CMS), policymakers, and stakeholders make informed decisions as they try to improve care and protect residents.

Using Medicare claims data, the OIG looked at 15,086 nursing homes nationwide that had “extremely high” infection rates between spring and fall of 2020. Particularly, they looked at each facility’s characteristics, whether they’d been cited with infection control deficiencies, as well as if their reported nursing hours met Medicare’s minimum requirement.


More than 1,300 nursing homes stood out as having “extremely high” infection rates. For-profit facilities made up a disproportionate percentage of this group during the first and second surge of COVID-19. While 71% percent of nursing homes are for-profit, they made up 77% of the homes with extremely high infection rates.

Nonprofit nursing homes, which make up 23% of all nursing homes, made up 19% of facilities with extremely high infection rates during the first surge and 18% during the second surge. The 6% of nursing homes owned by government entities made up 4% and 5% of facilities with extremely high infection rates during the first and second surges, respectively.

In surveying the nursing homes, the OIG didn’t identify any deficiencies in infection control for majority of homes with extremely high infection rates. In fact, 83% of nursing homes with the highest rates of infection didn’t have any serious infection control deficiencies.

The same group of facilities also reported nursing hours at or above Medicare’s minimum requirement of eight consecutive hours of registered nursing services per day and 24 hours of licensed nursing services per day.

“These findings raise questions as to whether the current number of nursing hours that Medicare specifies is sufficient to keep residents safe from infectious disease,” the brief stated.


The brief affirmed what many in healthcare have come to believe, and that is that we were unprepared for a health emergency like COVID-19. Now as the disease is becoming endemic, the need for improvement is crucial.

The OIG suggested the following recommendations to CMS:

  1. Re-examine current nursing staff requirements and revise them as necessary—Nursing homes with extremely high infection rates reported nursing hours that either met or exceeded Medicare’s minimum requirement. OIG suggests the CMS revise these requirements, which were initially established in 1987, including assessing the level of nursing needed to adequately prevent and manage infection.
  2. Improve how surveys identify infection control risks and strengthen guidance on assessing the those risks—Survey practices used to detect infection control issues should be reexamined in a broader capacity. CMS should also engage a broad range of infection control experts to develop more effective methods to identify risk factors in nursing homes.
  3. Target nursing homes needing infection control intervention, providing enhanced oversight and technical assistance as needed—Further data analysis should supplement the survey process to identify facilities in need of intervention. CMS should review data from sources like the Medicare Enrollment Database and Certification and Survey Provider Enhanced Reporting System, among others, for example.

CMS responds

The OIG shared its recommendations with CMS, which indicated it will continue to work to protect the safety and health of nursing home residents.CMS agreed with the recommendations to reexamine and possibly revise staffing requirements, as they coincide with similar efforts by the Biden administration. The organization also agreed with targeting and providing assistance to facilities needing infection control intervention.However, regarding the use of surveys to identify infection control risks and guidance on assessing them, CMS “did not concur or nonconcur.” According to the brief, CMS explained it prioritized similar efforts at the beginning of the pandemic, sharing tools with nursing homes so they could review their own compliance.

Since the control surveys conducted in 2020 found no deficiencies in the majority of nursing homes with extremely high infection rates, the brief’s findings raise the question of the effectiveness of the survey process. One suggestion the OIG offered was to convene a Technical Expert Panel to seek input from a broad range of experts in infection control.