How Would Your Facility Fare on an Unannounced OIG Compliance Inspection?

If you’re reading this post and wondering what on earth is CMSCG talking about, you may not be aware that almost two dozen New Jersey nursing homes were the target of unannounced inspections by the Office of the Inspector General (OIG) in 2022. OIG issued a report in July 2022 which assessed nursing homes’ compliance with Federal requirements for Life Safety and Emergency Preparedness. The New Jersey audit not only looked at these requirements, but also compliance with Federal Infection Control requirements. OIG states in the new report that this audit is part of a series of audits related to nursing home compliance regarding CMS Infection Control regulations – how would you fare if the OIG showed up at your building?

The report, “New Jersey Could Better Ensure That Nursing Homes Comply with Federal Requirements for Life Safety, Emergency Preparedness, and Infection Control” dings the New Jersey Department of Health for not identifying all the issues identified by the OIG during its audit. New Jersey responded by noting that many observational deficiencies are a snapshot in time that may not have been observed when DOH was onsite to conduct its own surveys. This is one of providers’ biggest gripes with the survey process – the facility’s “snapshot” during survey sticks with it, including impacting its Five-Star Quality Rating. As you are likely aware, the facility’s Health Inspection rating comprises 60% of its Overall Five-Star Rating, so it’s essential to have good survey outcomes.

It’s also worth noting that the OIG recommended that New Jersey survey its facilities more frequently, which DOH responded by indicating it has 15.9-month intervals to survey providers in. Per CASPER data from 10/1/2023, 41.7% (145) New Jersey nursing homes are at 16-month months or more from their last survey, indicating the State is not keeping within these timeframes. That’s an issue across the country, as State Agencies struggle to find staff to conduct surveys.

According to current CASPER data, more than a quarter of nursing homes in the United States are beyond that 15.9-month mark – nearly 4,000 facilities haven’t had their “annual” survey.

Recap of OIG Audit Findings for New Jersey Nursing Homes

NJDOH took issue with many of OIG’s audit findings related to Life Safety and Emergency Preparedness requirements, with much pushback around semantics and interpretations of guidance. The State Agency also commented that high turnover and inconsistent management knowledge at the facilities in its state contributed to the identification of these issues. So, taking all that into account, here are some of the key issues observed during OIG’s visits to twenty New Jersey nursing homes:

Life Safety

OIG identified 148 deficiencies (K-tags) related to Life Safety during its unannounced visits, many of which are issues commonly identified on Life Safety Surveys:

  • Means of egress blocked
  • Self-closing doors propped open
  • Missing/damaged smoke and fire barriers
  • Blocked/ obstructed sprinkler heads
  • Sprinkler systems not tested and maintained
  • Carbon monoxide detectors not installed where required
  • Storage of hazardous chemicals
  • Insufficient fire drills
  • Insufficient records and logs for multiple areas – elevators, patient equipment, electrical receptacles
Emergency Preparedness

OIG identified 152 deficiencies (E-tags) at the twenty facilities, all of which are issues that CMSCG sees when reviewing client Emergency Preparedness Plans. Depending on the State, facilities may have minimal review of their EPP during survey, resulting in limited numbers of citations in the State, which may change going forward due to the OIG’s persistent focus on this area. Issues cited during these inspections included:

  • EPPs not reviewed annually, in keeping with regulatory requirements
  • Insufficient food and/or water supplies
  • Generator testing/maintenance
  • Issues with plans for evacuation, sheltering in place and emergency communications
Infection Control

Unlike the push-back given towards the Life Safety and Emergency Preparedness part of the audit, the New Jersey Department of Health generally concurred that the issues identified by OIG on its inspections would have been cited by New Jersey survey teams. OIG identified 63 issues related to infection control requirements, including related to immunization requirements (COVID-19, influenza and pneumococcal), antibiotic stewardship, having an Infection Preventionist – and one who actively participates in QAPI – and some COVID-19 specific requirements.

Read the October 2023 OIG Report here for full details.


CMS Compliance Group, Inc. is a regulatory compliance and quality improvement consulting firm. Our interdisciplinary team of consultants includes Life Safety and Environmental Consultants, as well as Clinical Consultants/Infection Preventionists. If your organization has concerns about these or other areas, please contact CMSCG to learn more about how we can work with your organization to improve its quality.  To learn more about our nursing home consulting services, click here.


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