Colorado Could Better Ensure That Nursing Homes Comply With Federal Requirements For Life Safety, Emergency Preparedness, And Infection Control
Learn how the AI-generated research projects were createdOverall Conclusion
Colorado could better ensure that nursing homes participating in Medicare and Medicaid comply with Federal life safety, emergency preparedness, and infection control requirements. Deficiencies were observed across all 20 nursing homes audited, indicating ongoing oversight challenges and the need for stronger follow-up actions and staff training.
Source Document
Audit Scope
As of July 2022, 219 nursing homes in Colorado participated in the Medicare or Medicaid programs. A nonstatistical sample of 20 nursing homes was selected for audit based on location and risk factors; unannounced site visits were conducted September–November 2022 to assess compliance with life safety, emergency preparedness, and infection control requirements per CMS survey checklists.
Key Findings Summary
Colorado could better ensure that nursing homes participating in Medicare or Medicaid comply with Federal requirements for life safety, emergency preparedness, and infection control.
Deficiencies were identified at all 20 nursing homes audited, totaling 556 deficiencies (165 life safety; 210 emergency preparedness; 181 infection control).
Deficiencies occurred due to inadequate oversight by the State agency and nursing home management, frequent turnover, and limited survey resources, contributing to a backlog.
View the Findings tab to see all 7 findings
AI-Assisted
AI Scope Summary
Future audits should assess whether the state agency maintains an effective, risk-based survey program to ensure CMS life safety, emergency preparedness, and infection control requirements are met, focusing on survey cadence, backlog reduction, corrective action follow-up, and staff training improvements across nursing homes with a history of high-risk deficiencies or turnover.
AI-Generated Insight
The audit highlights continued gaps in oversight and resources for state survey agencies, resulting in widespread deficiencies across life safety, emergency preparedness, and infection control in Colorado nursing homes. The findings support prioritizing risk-based surveys and standardized staff training to improve resident safety.
Audit Objectives
Determine whether the Colorado Department of Health Care Policy and Financing (State agency) ensured that selected nursing homes in Colorado that participated in the Medicare or Medicaid programs complied with Federal requirements for life safety, emergency preparedness, and infection control.
Audit Findings (7)
Colorado could better ensure that nursing homes participating in Medicare or Medicaid comply with Federal requirements for life safety, emergency preparedness, and infection control.
Deficiencies were identified at all 20 nursing homes audited, totaling 556 deficiencies (165 life safety; 210 emergency preparedness; 181 infection control).
Deficiencies occurred due to inadequate oversight by the State agency and nursing home management, frequent turnover, and limited survey resources, contributing to a backlog.
CDPHE had a backlog of standard surveys; 38 of 219 Medicare- and Medicaid-certified nursing homes in Colorado had not had a standard survey conducted since the resumption of these surveys, as of the draft report.
Lack of standardized life safety training for nursing home staff, despite CMS providing online training resources.
The deficiencies spanned three domains with counts: life safety (165), emergency preparedness (210), infection control (181).
CDPHE's backlog and resource challenges were acknowledged, with goals to reduce backlog by 50% in 2022 and 2023, and progress described as on track.
Recommendations (3)
Follow up with the 20 nursing homes reviewed to ensure corrective actions have been taken regarding the life safety, emergency preparedness, and infection control deficiencies identified.
Work with CMS to develop a risk-based approach to identify nursing homes at which surveys would be conducted more frequently, such as facilities with a history of multiple high-risk deficiencies or frequent management turnover.
Work with CMS to develop standardized life safety training for nursing home staff.