Federal inspection timing, not compliance, associated with nursing home post-disaster outcomes - Natalia Festa et al

Sep 30, 2026

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Retrospective cohort analysis evaluates how Life Safety Code (LSC) survey timeliness and compliance status relate to post-disaster outcomes among nursing home residents exposed to Hurricane Ian (September 2022). Medicare beneficiaries aged 65+ were identified using geocoded wind-swatch exposure intensity. Two explanatory variables were constructed from the 16 months before the hurricane: lapsed inspections and, among completed inspections, LSC noncompliance defined by assigned deficiencies. Using inverse probability of treatment weighting and Cox models, lapsed inspections increased post-disaster hospitalization risk, while compliance status showed no clear association with mortality or hospitalization.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

Introduction

Data and methods

Statistical analysis

Results

Discussion

Federal inspection timing, not compliance, associated with nursing home post-disaster outcomes Natalia Festa 1,2, *, Kelsey Alexovitz1,2, Manali Phadke2,3, John O’Leary 1,2, Kendra Davis-Plourde3, Emma Zang4, Kai Chen5, Jill Kelly5, David M. Dosa6, Andrew Cohen 1,2, Thomas M. Gill 1 1 Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, United States 2VA Connecticut Healthcare System, West Haven, CT 06516, United States 3 Department of Biostatistics, Yale School of Public Health, New Haven, CT 06510, United States 4 Department of Sociology, Yale University, New Haven, CT 06510, United States 5 Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT 06510, United States 6 Department of Medicine, Division of Geriatrics, University of Massachusetts Medical School, Worcester, MA 01655, United States *Corresponding author: Yale School of Medicine, Department of Internal Medicine, Yale University Program on Aging, 300 George Street, Suite 775, New Haven, CT 06511, United States. Email: [natalia.festa@yale.edu](natalia.festa@yale.edu) Key words: CMS; long-term care; geriatrics; regulation; compliance. Introduction In response to earlier disasters that exposed critical deficits in nursing home preparedness, the Centers for Medicare & Medicaid Services (CMS) expanded its regulatory oversight by incorporating explicit emergency preparedness standards into the existing Life Safety Code (LSC) survey in 2016.1,2 Despite federal efforts to strengthen nursing home emergency preparedness, multiple audits indicate that facilities often achieve only superficial administrative compliance, which does not translate into effective disaster response.3,4 This disconnect merits critical examination, given that the operational investments required to achieve compliance may divert resources from direct patient care.5 Moreover, the empirical basis for the current LSC framework is limited, raising fundamental uncertainties as to its effectiveness in improving post-disaster outcomes for nursing home residents. This retrospective cohort study examined the influence of LSC survey timeliness and compliance status on post-disaster outcomes among nursing home residents exposed to Hurricane Ian (September 2022) . Data and methods We identified Medicare beneficiaries aged ≥65 years residing in nursing homes exposed to Hurricane Ian (September 2022) . We classified nursing homes as exposed to Hurricane Ian if their geocoded locations fell within its wind swath, as designated by the National Hurricane Center (NHC), and differentiated exposure intensity using pre-established thresholds from the NHC.6 The outcomes of interest included all-cause 30-day mortality (primary) and hospitalization (secondary) . We operationalized two explanatory variables using LSC survey data for each nursing home in the 16-months preceding Hurricane Ian, corresponding to the maximum recommended interval between surveys.7, 8 First, we identified facilities with lapsed inspections, defined as those lacking any documented LSC survey within the 16-month window. Second, among facilities with completed inspections, we classified facilities as noncompliant if they were assigned one or more deficiencies. We provide additional details in the Appendix. Statistical analysis We employed inverse probability of treatment weighting with stabilized propensity scores to balance resident, facility, and area-level characteristics that could confound the association between regulatory oversight and post-disaster outcomes (Appendix). We estimated separate marginal Cox proportional hazards models for each explanatory variable and outcome. We report hazard ratios (HR) with 95% confidence intervals (95% CI) . Results The 920 nursing homes exposed to Hurricane Ian housed 56 825 residents with a mean age of 81.1 years [standard deviation (SD) 9. 1] (Table AS1) . Most residents were female (65.4%) and received long-term

FAQs

How were lapsed inspections and noncompliance defined in the study?

Lapsed inspections were nursing homes lacking any documented LSC survey within the 16-month window before Hurricane Ian. Among facilities with completed inspections, noncompliance meant one or more assigned LSC deficiencies.

Which post-disaster outcomes were analyzed?

The primary outcome was all-cause 30-day mortality, and the secondary outcome was hospitalization.

What main association did the study find regarding inspection timing?

Lapsed inspections were associated with a 12% higher risk of post-disaster hospitalization, with no corresponding association observed for post-disaster mortality.

Sep 30, 2026

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