In response to the public health emergency, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) recently announced that it will conduct audits of nursing facilities to determine whether facilities have programs for infection prevention and control and emergency preparedness in place in accordance with federal requirements.
The audits will cover the period of January 1, 2019, through May 31, 2020, and will include nursing facilities previously cited for deficiencies.
These audits request the following information as a preliminary matter:
- Written copies of the nursing facility’s infection prevention and control program, including written standards, policies, and procedures for the program. All versions in chronological order, including any updates, in effect during the audit period are requested.
- A record of any corrective actions taken in response to identified infection control deficiencies or other incidents identified under the facility’s infection prevention and control program during the audit period.
- Written copies of the nursing facility’s complete emergency preparedness program, including any risk assessments, emergency plans, policies and procedures, communication plans, training, and testing. All versions in chronological order, including any updates, in effect during the audit period are requested.
- Nursing facilities audited will be provided an individualized link to upload these documents to the OIG’s delivery server.
In announcing these audits, the OIG stated that to reduce the likelihood of contracting and spreading COVID-19 in nursing facilities, effective internal controls must be in place.
Best practices indicate that a nursing facility’s infection prevention and control program and emergency preparedness program should reflect the facility’s updated procedures related to COVID-19. Nursing facilities that have not yet updated their infection prevention and control program and/or emergency preparedness program in light of the public health emergency are encouraged to do so immediately.
Also, as a general reminder, these programs must be reviewed at least one year; a time-stamp must be included upon review for appropriate documentation. The Indiana State Department of Health’s LTC COVID-19 toolkit can be utilized to update programs with policies that facilities have revised related to COVID-19. It is also important to note the requirement that a nursing facility maintain a Quality Assessment and Assurance Committee has not otherwise been waived during the public health emergency, which can be utilized to focus on infection control and prevention as related to COVID-19. Finally, if a focused infection control survey results in a tag, any policy revisions would be appropriate to include in in a facility’s infection control and prevention program as well.
The OIG also recently announced it will be monitoring psychotropic drug use in nursing facilities by determining the extent to which there are inconsistencies, if any, between:
- Medicare claims data for residents prescribed psychotropic drugs compared to nursing facility self-reported data on residents who received psychotropic drugs; and
- Medicare claims data as it relates to the diagnoses that exclude residents from monitoring in the antipsychotic quality measure compared to nursing facility self-reported data on resident diagnoses.
If you have any questions, please contact Lori Davenport at Ldavenport@ihca.org.