Evidence record
Colorado Could Better Ensure That Nursing Homes Comply With Federal Requirements For Life Safety, Emergency Preparedness, And Infection Control
- Jurisdiction
- Colorado
- Publication date
- February 2024
- Source record
- Original document linked
Findings
7
Recommendations
3
Overall 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.
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.
Findings (7)
Each finding has a stable link.
- F-833
Colorado could better ensure that nursing homes participating in Medicare or Medicaid comply with Federal requirements for life safety, emergency preparedness, and infection control.
- F-834
Deficiencies were identified at all 20 nursing homes audited, totaling 556 deficiencies (165 life safety; 210 emergency preparedness; 181 infection control).
- F-835
Deficiencies occurred due to inadequate oversight by the State agency and nursing home management, frequent turnover, and limited survey resources, contributing to a backlog.
- F-836
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.
- F-837
Lack of standardized life safety training for nursing home staff, despite CMS providing online training resources.
- F-838
The deficiencies spanned three domains with counts: life safety (165), emergency preparedness (210), infection control (181).
- F-839
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)
- R-730
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.
Related finding F-834 - R-731
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.
Related finding F-835 - R-732
Work with CMS to develop standardized life safety training for nursing home staff.
Related finding F-837