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GAO Report Details Infection Control Failures During Pandemic and Makes Recommendations for Reform

September 21, 2022

On September 14, 2022, the U.S. Government Accountability Office (GAO) released a report detailing the catastrophic failure of nursing homes to protect residents from COVID-19. The report focused on infection control practices and how years of poor practices, by nursing homes and government agencies, in the years preceding the pandemic resulted in the devastating impact on nursing home residents.

Importantly, the GAO report addressed not only the harm caused by the COVID-19 virus itself, but how many residents suffered as a result of policies implemented by the federal government and nursing homes, including bans on visitation and allowing nursing homes to use untrained nursing staff.

The report made several findings and recommendations to the Center for Medicare & Medicaid Services (CMS) to help protect residents from infections in the future.

What the Report Found:

  • CMS’s current infection control preventionist (ICP) standards are too vague.
  • CMS is not collecting staffing data on infection control preventionists.
  • CMS’s ICP guidance to state survey agencies is inadequate.
  • 2020 data from nursing homes showed a worsening in seven of eight key indicators of nursing home resident mental and physical health.
  • Stakeholders reported bans on visitation during the first year of the pandemic contributed to declines in resident health.
  • Only 1% of infection control violations were classified at the highest severity in 2018 and 2019.
  • CMS’s policy of allowing untrained workers to provide care in nursing homes contributed to poor infection control practices.

What the Report Recommended:

  • CMS establish minimum infection preventionist training standards.
  • Collect and use infection preventionist staffing data.
  • Strengthen ICP enforcement guidance to states.

Consumer Voice recommends that CMS:

  • Require all infection preventionists to be an RN, advanced RN, or physician.
  • Establish clear national training standards that all infection preventionists must meet.
  • Increase penalties for infection control deficiencies.

Read our full summary and analysis of the report.

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