Infection control deficiencies were widespread throughout nursing homes even before the COVID-19 pandemic, according to a new report by the Government Accountability Office. 

The report found that 82% of all surveyed nursing homes were cited for having an infection prevention and control deficiency in one or more years between 2013 and 2017.

“This is an indicator of persistent problems at these nursing homes,” the agency wrote.

Sen. Ron Wyden (D) requested that the GAO conduct the study to analyze the Centers for Medicare & Medicaid Services’ oversight of infection prevention and control protocols and its emergency preparedness standards for emerging infectious diseases in nursing homes.

Carolyn Hicks, an Environmental Services employee at Levindale Hebrew Geriatric Center
Carolyn Hicks, an Environmental Services employee at Levindale Hebrew Geriatric Center, cleans a cleans a sink bathroom.

Nearly 50% of facilities were cited in consecutive years in that same time period; 35% had deficiencies cited in three for four consecutive years; and 6% had deficiencies in all five years. About 40% of facilities were cited for infection control and prevention issues in each year through 2019. 

Of the deficiencies, nearly all of them (99%) were classified by surveyors as not severe each year, meaning the surveyor found that residents were not harmed. 

Sixty-seven percent classified as not severe did not have any enforcement actions imposed or implemented, while 31% had enforcement actions imposed but not implemented — meaning the nursing home likely had an opportunity to correct the deficiency before an enforcement action was imposed, according to the report. 

“Our review of CMS data shows that implemented enforcement actions for these deficiencies were typically rare: from 2013 through 2017, CMS implemented enforcement actions for 1 percent of these infection prevention and control deficiencies classified as not severe,” the GAO wrote. 

The GAO did not make any recommendations. It did, however, provide a report to the Department of Health and Human Services for review. It also plans to release reports on broad infection prevention and control and emergency preparedness in nursing homes, and CMS’s response to the pandemic.