OIG Audit Finds 97 Percent of Nursing Homes Non-compliant for Safety Requirements

20 Jul, 2022 F.J. Thomas


Sarasota, FL (WorkersCompensation.com) – The Centers for Medicare and Medicaid Services (CMS) updated the life safety and emergency preparedness regulations for nursing homes in 2016, with the required implementation date of November 15th, 2017. An OIG audit performed between January 2018 and November 2019 found that 97 percent of the nursing homes they visited were non-compliant, posing risks to not only residents, but visitors and staff as well.

The new regulations addressed requirements for sprinkler systems and smoke detector coverage, as well as protocols for sheltering in place and evacuations. Included in the updates were requirements for facilities to annually update and test their emergency plans, as well as train staff on those plans.

Starting in 2018, the OIG conducted audits across 8 states, covering 154 nursing homes with unannounced site visits. According to the findings of the audit, 150 nursing homes were found to be non-compliant, with a total of 2,233 deficits. There were 1,094 areas of non-compliance related to life safety requirements, and 1,139 areas of non-compliance for emergency preparedness.

Overall, there were 416 deficiencies found for building exits, fire barriers, and smoke partitions. Inspectors found issues such as blocked exits, fire exit doors that did not properly open, improperly marked exit doors, damaged smoke and fire barriers, self-closing fire doors that were either propped open or removed, and un-illuminated exit signs. Additionally, inspectors found patient doors that would not latch and fully seal to protect occupants in the event of a fire.

For fire detection and suppression systems, there were 268 deficiencies found. Some of the issues inspectors noted included blocked sprinkler heads, inadequate power back up for fire alarms, inadequate sprinkler coverage and testing, missing and improperly stored pressurized fire extinguishers, and missing batteries in batter-operated smoke detectors. One specific example given was a nursing home in Iowa where the sprinkler system had not been routinely tested and maintained due to a leak, which made doing so impossible. The CMS surveyor issued a fire watch in that specific case.

Four deficiencies were noted for resident call systems, which included cases of unlocked restrooms without call systems, and a resident sleeping room with a call system that needed repair.

There were 12 cases noted for carbon monoxide detectors. Inspectors found cases where detectors had been improperly installed, and also noted cases where the facilities either had inadequate coverage or no detectors at all. 

Inspectors found 124 cases related to hazardous storage. Incidents included improperly stored gasoline, storage areas with high fire loads, improperly labeled and stored oxygen containers, gas and vacuum pipe systems that were not labeled or had been inspected. Additionally, the inspectors found issues with the doors on storage areas, such as improper door type, doors that were propped open, and damage to prevent closing.


For elevator and electrical maintenance and testing, there were 163 deficiencies noted. The inspectors not only noted inadequate testing and maintenance of elevators, but also noted unsafe use of extension cords and power strips, as well as portable space heaters.

The inspectors also found 107 cases of smoking policies that were not enforced, and fire drills that were either inadequately conducted or not at all.

Inspectors found 194 incidents in which there were deficiencies for tracking residents and staff in the event of an evacuation. Some of the issues noted related to emergency preparedness included emergency plans that did not address evacuations or sheltering in place, nor did they address issues such as transferring medical records, or obtaining waivers.

There were 331 deficiencies related to emergency communication plans. In some cases, the nursing homes did not have an emergency communication plan with names and contact information for required parties. Inspectors noted cases where facilities did not have procedures for recording resident condition and location information, and did not have procedures in place for sharing emergency plan information with residents and their families.

For emergency plan training and testing, inspectors noted 245 cases of non-compliance. Noted incidents included nursing homes that did not conduct training on their emergency plans, failure to update emergency plans annually, and failure to review their training exercises.

The inspectors felt that the insufficiencies were the result of inadequate facility management oversight, high staff turnover, lack of State oversight by survey agencies, as well as a lack of mandatory standardized life safety training programs.

The OIG made four recommendations based on the findings of the audit –

  • Implement regulations requiring nursing homes and inspector contractors to notify the State when there are issues with fire alarms not working properly
  • Implement regulations requiring carbon monoxide detectors for all nursing homes that have fuel-burning appliances or have an attached garage
  • Implement mandatory standardized life safety training for nursing home staff
  • Implement a plan with States to address foundational issues to address nursing homes with a with a history of multiple high-risk deficiencies 

In Boulder, Colorado late last year, at least 18 nursing facilities were suddenly evacuated due to wild fire, according to a report from 9News.  Initially, staff stepped up and took turns with the fire extinguisher attempting to put out the fires, but were shortly notified of the evacuation orders and commenced with moving residents. Unexpected cases such as this incident clearly shows why evacuation preparedness is essential for not only clients but staff as well.

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    About The Author

    • F.J. Thomas

      F.J. Thomas has worked in healthcare business for more than fifteen years in Tennessee. Her experience as a contract appeals analyst has given her an intimate grasp of the inner workings of both the provider and insurance world. Knowing first hand that the industry is constantly changing, she strives to find resources and information you can use.

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