Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

Full text

U.S Department of Health and Human Service Of
fice of Inspector General
Onsite Surveys of Nursing
Homes During the COVID-19
Pandemic:
March 23–May 30, 2020
Christi A. Grimm

Principal Deputy Inspector General

December 2020, OEI-01-20-00430

U.S Department of Health and Human Services O
ffice of Inspector General R
eports in Brief

December 2020, OEI-01-20-00430
Why OIG Did This Review
We did this review to determine
the number and results of onsite
surveys of nursing homes during
the COVID-19 pandemic.  Nursing
home residents are particularly
vulnerable to infectious diseases
such as COVID-19, and infection
control has been a persistent
problem for most nursing homes.
As of November 8, 2020, more than
67,000 nursing home residents
have died of COVID-19, which
represented almost 30 percent of
all COVID-19 deaths in the United
States at that time.  Onsite State
surveys, conducted on behalf of the
Centers for Medicare & Medicaid
Services (CMS), assess the quality
of services in nursing homes, a
critical function for protecting
residents.  CMS changed survey
practices in response to the
pandemic.  These changes—
together with nursing home
residents’ high-risk status and the
importance of the State surveys—
warrant close examination to assess
the sufficiency of this oversight.
How OIG Did This Review
We analyzed CMS administrative
data to determine the number of
focused infection control and
complaint surveys conducted from
March 23 through May 30, 2020.
We also identified the number and
types of deficiencies cited as a
result of these surveys.  We
interviewed officials in CMS and 10
States to learn more about their
approaches to oversight,
challenges to conducting onsite
surveys, and experiences during the
COVID-19 pandemic.
Onsite Surveys of Nursing Homes During the
COVID-19 Pandemic: March 23–May 30, 2020
CMS and States share responsibility for oversight of the Nation’s nearly
16,000 nursing homes.  Following
Key Takeaway
CMS protocols, States conduct
onsite surveys to assess compliance
States conducted onsite surveys at
with Federal requirements and to
31 percent of nursing homes from
investigate complaints.  In response
March 23 through May 30, 2020,
to the COVID-19 pandemic, CMS
fewer than during the same time
suspended annual “standard”
period in 2019 when States and
surveys in March 2020 and
CMS were under normal operations
introduced a new focused infection
and conducting standard and other
control survey.  On June 1, 2020,
surveys.  These surveys resulted in
CMS directed States to conduct
few deficiencies but allowed States
these focused surveys for all nursing
to provide nursing homes with
homes and to continue surveys for
guidance and other support.  States
the most serious complaints.
had challenges in securing personal
protective equipment and sufficient
What OIG Found
staff to conduct onsite surveys.
Overall, States conducted onsite
surveys at 31 percent of nursing
homes from March 23 through May 30, 2020; however, States varied
significantly.  During the same time period in 2019—when States and CMS
were under normal operations—53 percent of nursing homes received an
onsite survey.  The infection control surveys conducted during this timeframe
in 2020 resulted in few deficiencies, in part because of their limited scope and
less surveyor time onsite.  State officials reported ongoing challenges to
securing personal protective equipment (PPE) and surveyors.  States provided
guidance and other support—such as training—to nursing homes outside of
the survey process.  State officials reported concerns about mounting
backlogs of standard and complaint surveys, as the pandemic continues.
What OIG Recommends
We recommend that CMS assess the results of the infection control survey
and revise the survey as appropriate. We also recommend that CMS work
with States to overcome challenges with PPE and staffing, and that it clarify
expectations for States to complete backlogs.  CMS did not explicitly concur
with our recommendations to assess and revise the infection control survey
or to clarify expectations for States to complete backlogs but stated that it
has taken steps to implement those recommendations.  CMS did not concur
with our recommendation to work with States to overcome challenges with
PPE and staffing, citing its lack of authority to address issues of allocating PPE
and staff.  OIG continues to recommend that CMS identify opportunities
within its authority to support States facing challenges with PPE and staffing.

Table of Contents
BACKGROUND
1
Abbreviated Methodology
5
FINDINGS
7
Overall, States conducted onsite surveys at 31 percent of nursing homes from March 23
7
through May 30, 2020; however, States varied significantly
From March 23 through May 30, 2020, limited-scope surveys resulted in few cited
13
deficiencies but provided opportunities for surveyors to support nursing homes
States reported ongoing challenges to conducting safe onsite surveys of nursing homes
15
during the COVID-19 pandemic
As COVID-19 hindered onsite surveys, States made efforts to support nursing homes outside
20
of the survey process
CONCLUSION and RECOMMENDATIONS
22
Assess the results of infection control surveys and revise the survey as appropriate
23
Work with States to help overcome challenges with PPE and staffing
23
Clarify expectations for States to complete backlogs of standard surveys and high-priority
24
complaint surveys
AGENCY COMMENTS AND OIG RESPONSE
25
DETAILED METHODOLOGY
26
APPENDICES
29
A. CMS guidance to States pertaining to nursing homes from February through August 2020
29
B. Percentage of nursing homes with onsite survey, by State
31
C. Percentage of nursing homes surveyed in each State, March 23–May 30, 2020
33
D. Summaries of instances of noncompliance identified for 68 infection control deficiencies
34
E. Agency Comments

39
ACKNOWLEDGMENTS AND CONTACT
44
ABOUT THE OFFICE OF INSPECTOR GENERAL
45
ENDNOTES
46

BACKGROUND
Objectives
1. To determine the number and results of surveys of nursing homes
conducted by the Centers for Medicare & Medicaid Services (CMS) and
State survey agencies (States) from March 23 through May 30, 2020.
2. To describe challenges that CMS and States experienced in conducting
nursing home oversight during the COVID-19 pandemic and their insights
into their experiences.
Background
Nursing home residents are particularly vulnerable to infectious diseases such as
COVID-19 because of their age and underlying medical conditions.1  The early
COVID-19 outbreak at the Life Care Center in Kirkland, Washington, killed at least
37 people and demonstrated just how quickly infections can spread through a nursing
home.2  As of November 8, 2020, more than 67,000 nursing home residents have died
of COVID-19, which represents almost 30 percent of all U.S. COVID-19 deaths.3, 4
Infection control has been a persistent problem for nursing homes.5  From 2013
through 2017, CMS and State surveyors cited 82 percent of nursing homes with
infection control deficiencies, and half of those homes were cited across multiple
years.6  During the COVID-19 pandemic, these longstanding problems may be
exacerbated by numerous challenges, including ensuring adequate staffing,
equipment, and supplies, especially testing supplies and personal protective
equipment (PPE).7,8
CMS plays a pivotal role in the oversight of nursing homes to ensure quality care and
safety for residents.  During the COVID-19 pandemic, CMS suspended some of its
usual oversight activities and introduced a new oversight tool focused on infection
control.  In addition, CMS is providing COVID-19-related guidance and other supports
to help meet the emerging and evolving needs of residents and the staff in nursing
homes during the pandemic.
Nursing Home Oversight Prior to the COVID-19 Pandemic
Onsite nursing home surveys are a fundamental safeguard to ensure that nursing
home residents are safe and receive quality care.  CMS, in conjunction with States,
oversees nearly 16,000 Medicare and Medicaid nursing homes to ensure that they
meet Federal requirements.9, 10, 11  States conduct standard certification surveys
(standard surveys) on behalf of CMS for nursing homes on average every 12 months
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Background | 1

but at least every 15 months.12, 13  These surveys evaluate the safety and quality of
care that nursing homes provide.14, 15  In addition, between standard surveys, States
conduct complaint surveys as needed in response to allegations of noncompliance
with Federal requirements from residents, their families, and nursing home staff,
among others.16
Surveyors from CMS regional offices may also conduct surveys.  CMS surveyors
conduct Validation Surveys and Federal Oversight Support Surveys to observe and
assess State surveyor performance.  CMS surveyors also conducted infection control
and complaint surveys during the COVID-19 pandemic.  In this report, we include
surveys conducted by CMS when we reference State surveys.  Together, standard and
complaint surveys ensure that nursing homes meet minimum Federal requirements,
provide quality of care to all their residents, identify problems, and correct those
problems.
Standard Surveys.  To monitor nursing home compliance with requirements for
participation in Medicare and Medicaid, CMS enters into agreements with each State
survey agency.  State survey agencies conduct standard surveys of the State’s nursing
homes and investigate nursing home complaints on behalf of CMS.17, 18  Standard
surveys assess nursing home compliance with the CMS requirements for participation
and evaluate the safety and quality of nursing home care.19,
Multidisciplinary teams of surveyors, including at least one registered nurse, complete
a set of both offsite and onsite tasks to assess the nursing home.20  Offsite tasks
include, but are not limited to, a review of the nursing home quality measures,
statements of deficiencies, and complaints.21  While onsite, surveyors follow a
protocol that includes a tour of the facility for observation, reviews of medical records,
and interviews with residents, family, and staff, among other activities.22
Surveyors cite deficiencies when they observe a nursing home in violation of Federal
requirement.  Surveyors also determine the scope and severity of each deficiency.
The scope of a deficiency refers to the number of residents affected.  The severity of a
deficiency refers to its impact and is categorized using four levels of harm, with the
two highest levels of harm defined as actual harm that is not immediate jeopardy and
immediate jeopardy to resident health or safety.23, 24
Complaint Surveys.  In addition to conducting standard surveys, State survey
agencies conduct onsite surveys to investigate complaints from residents, their
families, nursing home staff, and others.25  CMS provides States with procedural
guidelines for how to intake, prioritize, and investigate complaints for
Medicare/Medicaid-certified nursing homes.26  To determine whether a complaint
warrants an onsite survey, CMS requires that a qualified professional with knowledge
of clinical standards and Federal requirements triage each complaint by assigning it a
priority level.27
A complaint’s priority level determines the State’s required timeframe for
investigation.  The two most serious priority levels are immediate jeopardy (IJ) and
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Background | 2

non-immediate jeopardy–high (high priority).  These complaints allege serious injury
or that there may be harm and require a rapid response to address the complaint and
ensure residents’ safety.28  States must initiate investigations of IJ complaints within
2 business days of receipt and high-priority complaints within 10 business days of
prioritization.  From 2011 through 2018, the largest source of complaints overall—and
of IJ complaints specifically—has consistently been family members of nursing home
residents (about 40 percent).29, 30
States also conduct onsite surveys in response to nursing home incidents.31  Incidents
are self-reported by the nursing home, and nursing homes must report incidents that
involve allegations of abuse, neglect, exploitation, or mistreatment.32  As with
complaints, States must conduct onsite surveys for IJ incidents.33
Oversight of State Survey Agency Performance.  CMS oversees State survey agencies
and evaluates their performance in conducting surveys.34  The State Performance
Standards System is an annual assessment that establishes performance measures
and thresholds for acceptable performance.  Acceptable performance is determined
by three survey “dimensions”: frequency, quality, and enforcement and remedy.35  The
performance measures include expectations that States begin complaint surveys
within required timeframes for 95 percent of complaint allegations and that all
nursing homes are surveyed at least once every 15.9 months.36
The Emergence of COVID-19
COVID-19 is a disease caused by a highly contagious coronavirus with symptoms that
can include fever, fatigue, dry cough, and shortness of breath.  It can be fatal in some
cases.37, 38  The first reported case of COVID-19 in the United States was on January
20, 2020.39  On February 26, the nursing home Life Care Center of Kirkland,
Washington, notified State officials of an outbreak of respiratory illness that was later
determined to be COVID-19.40
On March 11, 2020, the World Health Organization characterized COVID-19 as a
pandemic, which refers to an epidemic that has spread over several countries or
continents, usually affecting a large number of people.41, 42, 43  On March 13, 2020,
President Trump declared the COVID-19 outbreak to be a national emergency.44  The
national emergency declaration triggered the Department of Health and Human
Services (HHS) Secretary’s authority, under section 1135 of the Social Security Act, to
temporarily waive certain requirements, including requirements for oversight surveys
of nursing homes.45  Under this waiver authority, beginning in March 2020, CMS
prioritized certain Federal and State surveys and suspended others to focus State and
nursing home resources on limiting the spread of COVID-19.46, 47
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Background | 3

CMS Guidance to States on Oversight of Nursing Homes During
the COVID-19 Pandemic
Starting in February, CMS issued a series of guidance documents adjusting its
approach to nursing home oversight to focus on addressing and preventing the
spread of COVID-19.  See Exhibit 1 below for a timeline of key CMS guidance to
States early in the COVID-19 pandemic.  See Appendix A for the complete list of CMS
memos to States from February 2020 through June 2020.
Exhibit 1: Timeline of key CMS guidance to States early in the COVID-19 pandemic.
 Source: OIG analysis of CMS guidance, 2020.
COVID-19-Focused Survey for Nursing Homes
As part of its March 23 guidance, CMS provided the COVID-19-focused survey tool
for nursing homes to assess compliance with infection control.48  The survey tool
includes a focused framework of several infection control categories that are
associated with the transmission of COVID-19 and other communicable diseases and
infections, including hand hygiene, PPE, and infection surveillance, among other areas.
CMS also provided a brief training and protocol to help surveyors prioritize survey
activities while onsite and identify activities that they could complete offsite to
decrease the transmission of COVID-19.49, 50  The protocol also instructs States to
ensure surveyors are trained in the proper use of PPE and to refrain from conducting
onsite surveys if surveyors are unable to meet the PPE expectations outlined by
Centers for Disease Control and Prevention (CDC).51
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Background | 4

Related OIG Work
This study is part of a larger body of forthcoming work from the Office of the
Inspector General (OIG) examining the impact of COVID-19 on nursing homes.  For
instance, OIG has work underway that will describe the characteristics of the nursing
homes that were hit hardest by COVID-19 (i.e., homes with high numbers of residents
who had COVID-19 or had died).  This work will also describe the strategies nursing
homes have used to mitigate the effects of COVID-19 on their residents and staff in
the face of these unique circumstances.52  Other forthcoming OIG work will determine
whether selected nursing homes have programs for infection prevention and control
and emergency preparedness in accordance with Federal requirements.53  OIG also
has work underway that will assess nursing homes’ reporting of CMS-required
information related to the COVID-19 pandemic.54
In addition, OIG has several evaluations and audits of nursing home oversight and
quality of care that began prior to the COVID-19 pandemic.  Two are particularly
relevant to this evaluation.  One is a report examining complaint trends in nursing
homes.  This report updates OIG’s 2017 data brief and finds that States continued to
fall short in meeting required timeframes for investigating nursing home complaints.55
To complement this report, OIG has published an updated interactive map that
illustrates State-by-State trends in nursing home complaints for 2016 through 2018.
The interactive map is available at https://oig.hhs.gov/oei/maps/2019-nursing-
home/index.asp.  The other is a forthcoming OIG report that examines CMS oversight
of State survey agency performance specific to nursing homes and may identify
additional opportunities or recommendations for CMS to improve performance.56  A
complete listing of OIG’s ongoing evaluations and audits is available in our online
Work Plan at https://www.oig.hhs.gov/.
Abbreviated Methodology
Data Sources and Analysis
CMS Complaint and Incident Data. We analyzed Automated Survey Processing
Environment (ASPEN) Complaints/Incidents Tracking System (ACTS) data on nursing
home complaints and incidents that State survey agencies received during the same
2019 and 2020 time periods.  We analyzed these data to determine the number of
overall complaints and incidents States received, the number of complaints and
incidents that States prioritized as IJ, and the sources of complaints (e.g., residents’
family members) from March 23 through May 30, 2019, and from March 23 through
May 30, 2020.  We used a longer time span of data in the calculation to identify the
backlog of high-priority complaints (March 23 through June 28, 2020).  This longer
timespan was only available for this measure.
CMS Survey and Deficiency Data. We used CMS’s publicly available data on Nursing
Home Compare to examine onsite surveys (infection control surveys and IJ complaint
surveys) and resulting deficiencies from March 23 through May 30, 2020.  We used
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Background | 5

ASPEN and Certification and Survey Provider Enhanced Reports (CASPER) data from
CMS to analyze trends in nursing home surveys and deficiencies in the same 2019
time period to provide historical context.  Specifically, we assessed trends in standard
surveys, surveys related to complaints/incidents, and resulting deficiencies from
March 23 through May 30, 2019.
Review of CMS-2567 Forms.  We conducted a limited review of CMS-2567
(statements of deficiencies) forms from onsite surveys during the pandemic.  Using
the CMS-2567 forms that CMS made available on Nursing Home Compare on June
24, 2020, we identified and reviewed all 68 CMS-2567 forms that included the F-880
infection prevention and control deficiency from March 23 through May 30, 2020.
The CMS-2567 forms included the specific instances of noncompliance that resulted
in the deficiency citation.  Deficiencies may be based on more than one instance of
noncompliance.
We reviewed the narrative of each CMS-2567 form and categorized the instances of
noncompliance into one or more category to determine the most common reasons
for noncompliance with infection control practices (e.g., hand hygiene).
Interviews with CMS and State Survey Agencies.  Finally, we interviewed leadership
in CMS’s Survey and Operations Group and the Quality, Safety, and Oversight Group
regarding their approach to oversight during the pandemic.  We also interviewed a
purposive sample of 10 States regarding their experiences and challenges conducting
surveys during the pandemic.  We selected the sample of 10 States to ensure that we
included States with a range of impact from COVID-19 and to represent each of the
10 CMS locations.  We conducted these interviews from June 9 through June 18, 2020.
See the Detailed Methodology section on page 26 for additional information about
our data collection and analysis.
Limitations
We did not assess the extent to which the data in ACTS, ASPEN/CASPER, and Nursing
Home Compare are complete.  We also did not assess the appropriateness and
quality of State responses to complaints and incidents or survey results.  In addition,
the complaint survey data from ASPEN/CASPER includes the four most recent
complaint surveys in each nursing home, rather than all complaint surveys conducted
in 2019.  Our analysis includes self-reported data from States that we did not
independently verify.
Standards
We conducted this study in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Background | 6

FINDINGS

Overall, States conducted onsite surveys at 31 percent of
nursing homes from March 23 through May 30, 2020; however,
States varied significantly
Prior to the COVID-19 pandemic, States regularly conducted standard surveys to
assess whether nursing homes met minimum Federal requirements, including
evaluating nursing homes’ safety and quality of care.  In addition, States conducted
complaint surveys as needed in response to allegations from residents, their families,
and nursing home staff.  The COVID-19 pandemic prompted CMS to issue policy that
changed the State survey process.  On March 23, 2020, CMS directed States to
suspend standard surveys and conduct COVID-19-focused infection control survey for
nursing homes (infection control surveys) and surveys for the most serious (IJ)
complaints/incidents.  CMS stated that the change in survey activities was to focus
State and nursing home resources on limiting the spread of COVID-19.  In June, CMS
updated its direction to States to require that they conduct infection control surveys
for all nursing homes by July 31, 2020.
During this time period, States conducted onsite infection control
and complaint surveys.
States conducted infection control surveys and/or IJ
complaint/incident surveys for 31 percent of nursing
homes from March 23 through May 30, 2020.  For
reference, 53 percent of nursing homes received an
31%
onsite survey during the same time period in
of nursing homes had
2019, when States and CMS were conducting standard
an onsite survey from
surveys and surveys for all complaints that required one.
March 23 through
Overall, during this time in 2020, States conducted
May 30, 2020
7,193 onsite surveys in 4,805 nursing homes.57  States
surveyed 1,169 nursing homes more than once during
this time period.
States reached most of these nursing homes for an onsite survey in the first month of
this time period.  From March 23 through April 23, States surveyed 19 percent of
nursing homes onsite.  By May 30, States and CMS had surveyed an additional
12 percent of nursing homes onsite.  Although outside the scope of our analysis, CMS
reported that more than 99 percent of nursing homes had some type of onsite survey
from March 1 through August 21, 2020.58
States we spoke with used their own criteria to prioritize nursing homes for infection
control surveys.  Most States used nursing homes’ prior deficiency citations or chose
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 7

homes with high numbers of COVID-19 infections and deaths to target these surveys.
For example, one State gave top priority to nursing homes with a history of multiple
infection control deficiencies.  Some States used other criteria, such as complaints
received against a nursing home or the number of COVID-19 cases in the local
community.
Over two-thirds of States surveyed fewer than 10 percent of their
nursing homes in the first month following CMS’s directive to
conduct only infection control surveys and immediate jeopardy
complaint surveys.
In the first month after CMS suspended
certain surveys (from March 23 through
April 23, 2020), 36 States surveyed fewer
than 10 percent of their nursing homes
onsite, and 8 States did not survey any
nursing homes onsite: Arizona, Idaho,
Maryland, Montana, Nebraska,
New Mexico, Virginia, and West Virginia
(see Exhibit 2 on the next page).  Overall,
States surveyed 13 percent of their
nursing homes on average in this first
month.  For reference, in 2019, States
surveyed 23 percent of their nursing
homes per month on average.  CMS’s
suspension of certain surveys—as well as
States’ challenges with getting
equipment and staff needed to survey
nursing homes onsite—contributed to
the difference in onsite survey activity
between 2019 and this first month after
CMS’s directive.  See Appendix B for
details on the percentage of nursing
homes that received a survey from
March 23 through April 23 and the
average per month during 2019, by State.
The 10 States we interviewed in
mid-June expected to meet CMS’s
July 31 deadline to survey all nursing
homes, but some with substantial
difficulty.
Some State officials were surprised by CMS’s
July 31 deadline requiring States to survey all
nursing homes. One State pointed out that
the timeframe was tight for the States that
had a slow start on their surveys.  Officials
from another State reported that given the
high threat of COVID-19 for nursing home
residents, they had always planned to survey
all nursing homes.
Although outside the scope of OIG’s analysis
of surveys, CMS reported to the Nursing
Home Compare website that these 10 States
had surveyed at least 98 percent of their
nursing homes as of August 21, 2020.  These
results are based on data beginning March 1
and include some surveys conducted prior to
the directive to suspend certain survey
activities.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 8

Exhibit 2: Most States surveyed fewer than 10 percent of their nursing homes
in the month following CMS’s directive to conduct only infection control
surveys and surveys in response to immediate jeopardy complaints.
Source: OIG analysis of Nursing Home Compare data, 2020.
A couple of States reached far more nursing homes for onsite surveys than others in
the first month following CMS’s directive.  California and Washington conducted
onsite surveys for about 85 percent of nursing homes in their States during this
month-long period.  In addition, both States surveyed some of their nursing homes
more than once.  California required nursing homes to submit their daily numbers of
staff and COVID-19-positive cases (prior to this being required by CMS), and the State
developed a dashboard to identify high-risk facilities for onsite surveys.  As California
further developed the dashboard and metrics, officials formed a “strike team” to
survey nursing homes with urgent problems and used predictive analytics to create a
list of high-risk facilities, calculating risk by using deficiencies cited, proximity to hot
spots, and other factors.  Washington obtained PPE for surveyors early and was
therefore able to get its surveyors onsite early to conduct surveys.  Washington also
surveyed some nursing homes multiple times in response to outbreaks.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 9

As the COVID-19 pandemic progressed, some States notably increased their surveys,
while others did not.  By May 30, three additional States had surveyed over 80 percent
of their nursing homes onsite since March 23: Connecticut, Oregon, and Wyoming.  In
addition, 13 States surveyed 50 percent or more of their nursing homes by May 30,
compared to the 2 States that had done so in the first month.  Several of these States
greatly increased their onsite survey activity in May.  For example, Oregon surveyed 5
percent of its nursing homes onsite in the first month, but this increased to 92 percent
by May 30.  (See Exhibit 3 on the following page for the 13 States that surveyed 50
percent or more of their nursing homes.)  However, 16 States still surveyed less than
10 percent of their nursing homes through May.  (See Appendix C for the percentage
of nursing homes surveyed in each State during the period of March 23 through
May 30.)
Between March 23 and May 30, States experienced different degrees of COVID-19
outbreaks, likely affecting the extent to which States could survey nursing homes and
when they could conduct those surveys.  For example, New York and New Jersey
experienced severe COVID-19 outbreaks in March and April and they surveyed
3 percent and 8 percent, respectively, of their nursing homes in the first month
following CMS’s directive.  By May 30, these two States had surveyed about
20 percent of their nursing homes.  Other States, such as Florida and Texas, did not
experience severe COVID-19 outbreaks during this time and surveyed 50 percent of
their nursing homes onsite by the end of May.  As outbreaks continue to affect
different States at different times, States’ ability to survey nursing homes onsite will
likely change.  For example, States may need to redirect surveyors or prioritize PPE if
they experience an outbreak.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 10

Exhibit 3: Thirteen States surveyed 50 percent or more of their nursing
homes by May 30, 2020.
Source: OIG analysis of Nursing Home Compare data, 2020.
States prioritized more nursing home complaints as immediate
jeopardy from March 23 through May 30, 2020, than during the
same months in 2019 but received half as many complaints
overall.
In addition to conducting infection control surveys, States conducted surveys for
IJ complaints and incidents.  During the COVID-19 pandemic, States have prioritized a
much higher proportion of complaints as IJ.  From March 23 through May 30, States
prioritized 31 percent of complaints as IJ, compared to about 7 percent in the same
time period in 2019.  (See Exhibit 4 on the next page.)  States and CMS reported that
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 11

 Exhibit 4: States prioritized a higher percentage of complaints as immediate jeopardy during the COVID-19 pandemic, but they received half as many complaints as in 2019.

because COVID-19 increases the likelihood of serious harm or death for residents,
some States prioritized more complaints related to infection control as IJ.  Not
surprisingly, States also received proportionally more complaints regarding infection
control during the pandemic.  From March 23 through May 30, the data showed that
23 percent of complaint allegations were related to infection control.  During this
same time period in 2019, 1 percent of complaint allegations were related to infection
control.
Source: OIG analysis of ACTS data, 2020.
Although States prioritized a high proportion of complaints as IJ, they received far
fewer complaints overall.  From March 23 through May 30, States received about half
the number of nursing home complaints as compared to the same time period in
2019: from 14,592 in 2019 to 6,911 in 2020.  (See Exhibit 4.)  Starting on March 13,
CMS issued guidance to nursing homes to restrict all visitors and non-essential health
care personnel to limit the spread of COVID-19 and to protect residents.  This change
resulted in fewer people in nursing homes to observe conditions and likely
contributed to fewer complaints in the following months.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 12

Historically, the most common source of complaints has been nursing home
residents’ family members, who in 2019 submitted about 6,000 complaints from
March 23 through May 30.  That number fell to about 2,000 for the same time period
in 2020.  Trends in total incidents self-reported by nursing homes and those incidents
that States prioritized as IJ were similar to trends in complaints.59
From March 23 through May 30, limited-scope surveys resulted
in few cited deficiencies but provided opportunities for
surveyors to support nursing homes
While onsite, surveyors observe conditions for compliance with the Federal
requirements.  Infection control and complaint surveys focus on a narrower set of
compliance concerns than standard surveys, which assess the overall quality of
services provided in nursing homes.60  However, surveyors may observe and cite
noncompliance with other Federal requirements during these limited-scope surveys.
Surveyors can cite over 200 deficiencies, which cover topics including administration,
resident rights, training, infection control, and quality of care, among others.
Furthermore, while onsite, surveyors also have opportunities to share information with
and provide support to nursing home staff.
States cited a deficiency in 3 percent of nursing home surveys,
with infection control deficiencies cited most often
States and CMS conducted 7,193 onsite surveys from March 23 through May 30, and
3 percent (193 surveys) resulted in a cited deficiency.  This represents a decrease from
the 40 percent of onsite surveys resulting in a cited deficiency during the same time
period in 2019 when States and CMS were conducting standard surveys and surveys
for all complaints that required one.  Changes in State survey activities, the limited
scope of the infection control surveys, and nursing facility use of CMS’s self-
assessment tool may all have contributed to the decrease in deficiencies cited.  During
this timeframe in both 2019 and 2020, infection control problems were the most
commonly cited deficiencies on nursing home surveys.  Surveyors cited an infection
control deficiency in 1 percent of onsite surveys from March 23 through May 30, 2020
(68 surveys), and 10 percent of surveys during the same time period in 2019.
Officials from CMS and some States reported that the limited scope of the infection
control surveys and an increased focus on infection control at nursing homes
contributed to the low number of deficiencies cited.  Given the risk of COVID-19 to
residents and staff, CMS designed the focused surveys to review aspects of care that
could undermine infection control—a much narrower and more specific scope than
standard surveys.  According to State officials we interviewed, a more limited scope
led to less time onsite by fewer surveyors.  State officials told us that infection control
surveys typically included one to two surveyors who were onsite for less than 2 days,
and one State official explained that surveyors were onsite for about 2 hours.  In
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 13

contrast, State and CMS officials told us that a standard survey includes two to
five surveyors who are onsite for 3 to 5 days.  State officials told us that this limited
time onsite may have provided fewer opportunities for surveyors to observe
noncompliance leading to fewer deficiencies being cited.  CMS also provided the
focused infection control survey tool to nursing homes and encouraged them to
conduct self-assessments to learn about the latest practices for preventing the spread
of COVID-19.61  Some officials also reported that they believed nursing homes had
increased their vigilance around infection control protocols because of the risk of
COVID-19, which may have also contributed to fewer citations of infection control
deficiencies.
The most common types of noncompliance cited in infection
control deficiencies were improper use of PPE, contaminants on
surfaces, and lapses in hand hygiene
Infection control deficiencies included noncompliance with both preventive measures
to avoid the spread of disease, and noncompliance with resident care.  Among the
68 infection control deficiencies cited by surveyors for all States between March 23
and May 30, the most common instances of noncompliance were improper use of PPE
(43 of 68 deficiencies), contaminants on environmental surfaces (32 of 68) and lapses
in hand hygiene (31 of 68).  Other instances included failing to isolate infected
residents and failing to provide staff education about COVID-19.  For example, during
an onsite survey conducted in April 2020, staff from one nursing home told surveyors
that they were “unaware of a policy or procedure” specific to COVID-19.
Most of the infection control deficiencies included more than one instance of
noncompliance, including practices throughout the facility such as food service,
laundry, and visitor entry.  Analysis of the deficiencies revealed blatantly poor
practices in some instances, such as one nursing home being cited for allowing staff
to continue working despite showing signs of COVID-19.  Surveyors found that
another nursing home failed to enforce staff PPE use and handwashing despite having
54 confirmed cases among its residents.  See Appendix D for summaries of the
instances of noncompliance identified for the 68 infection control deficiencies.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 14

States reported benefits of their onsite surveys beyond assessing
compliance
Even though they spent limited time onsite, States reported value in their surveys.
One State official suggested that the surveys “balanced” oversight with support to
nursing homes during this time.  Another State
official said that the State was able to support
“There is no replacement
and train the nursing homes to “set them up for
for being physically present.
success” against COVID-19.  Another State
Even if we’re not citing,
official said that these surveys provided an
we’re ensuring that they
opportunity for nursing homes to openly discuss
have all the tools they need.
concerns with surveyors.  Some States reported
The presence that sends the
that CMS’s self-assessment tool was a good
message: you're not alone,
resource and encouraged its use among nursing
you're not isolated, we're in
homes to reinforce infection control practices, to
this with you.”
target issues of concern, and to potentially limit
–State official
surveyor time onsite.  In addition, State officials
reported benefit from the shorter time required
onsite during the abbreviated surveys.  One State said that the abbreviated survey
allowed surveyors to access more nursing homes more often than when the State
conducted standard surveys.  Another State mentioned the increased time in offsite
activities associated with these surveys gave surveyors opportunities to review and
follow up with nursing homes in greater depth.
States reported ongoing challenges to conducting safe onsite
surveys of nursing homes during the COVID-19 pandemic
The health care community continues to grapple with COVID-19.  The pandemic
disrupted daily routines, and for many, the ability to continue working.  No single
roadmap existed to guide CMS’s and States’ oversight in this environment.  State
officials reported challenges to overseeing nursing homes under these conditions,
and they voiced concern about mounting survey backlogs in this time of uncertainty.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 15

States reported difficulties in conducting onsite surveys because
of challenges in acquiring and fitting PPE
All of the States we interviewed reported difficulty obtaining PPE for surveyors to
enter nursing homes.  State officials reported that they were aware of the great need
Personal Protective Equipment (PPE)
for PPE among providers and wanted
to prioritize the limited amount of
PPE is protective clothing, helmets, goggles, or
PPE for nursing and other medical
other garments or equipment designed to
staff.  In some States—including one
protect the wearer from injury or infection.
considered an early hot spot for its
PPE also includes a variety of types of
large number of COVID-19 cases—
respirators and face masks.  A common mask
the lack of PPE delayed onsite
type used for treatment of individuals with
surveys for weeks.  States had
known or suspected cases of COVID-19 is the
particular difficulty in obtaining
N95 respirator mask, a respiratory protective
N95 face masks.  CMS guidance
device designed to achieve a close facial fit and
efficient filtration of airborne particles.  Certain
stated from the outset of the
respirator masks require fit testing, during
pandemic that surveyors should not
which the seal between the respirator and the
go onsite without protective
face is tested for proper fit; fit testing can take
equipment, and States reported their
15 to 20 minutes to complete and results in a
concerns about compromising the
properly fitting mask of a certain make, model,
safety of their staff as well as that of
and size.
nursing home residents.
States also reported difficulty in training surveyors in proper use of PPE, including
putting on and taking off (donning and doffing) protective gear, and in conducting fit
testing for N95 masks.62  These difficulties were caused in part because State survey
agencies did not routinely acquire or use PPE prior to the COVID-19 pandemic; rather,
they received PPE from the facilities as needed when they went onsite.  As another
example, one State reported that some staff require medical clearance for fit testing
N95 masks and that staff sometimes do not pass fit testing.
In some cases when States were unable to secure
“We did not want to be a
PPE, CMS stepped in to conduct surveys, surveying
transmission source since
hundreds of facilities in the early months of the
we knew that most cases
pandemic.63   For example, officials from one State
were brought into nursing
reported that when they received IJ complaints
homes from the outside.”
before they could secure PPE, they requested that
–State official   CMS conduct those surveys given the need for
timeliness.  States also sought equipment and fit
testing from other sources such as the National
Guard, who also visited and provided equipment and training to nursing homes.  In
one State, the National Guard visited every nursing home in the early weeks of the
pandemic, and also joined State surveyors onsite to monitor the surveyors’ donning
and doffing practices.  Some States also received assistance from State COVID-19 task
forces—groups that included entities across State government to coordinate supplies
and training.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 16

States we interviewed reported that challenges to acquiring PPE have continued
beyond the first weeks of the pandemic.  Although lack of PPE was the most
significant limiting factor early on, States continue to prioritize PPE for frontline
workers and sometimes struggle to provide it for surveyors.  As one official reported
in June 2020, “Every day is a conversation about PPE.”  CMS officials explained that
many of the challenges to acquiring PPE reflected scarcity of equipment, and not
necessarily a lack of financial resources.  To assist State surveyors in acquiring PPE,
CMS sent a letter to governors in May 2020 encouraging them to allocate PPE
resources to State surveyors.64
CMS also experienced challenges with surveyor availability
CMS also had difficulty in reaching some nursing homes to conduct surveys.  In addition
to having only 70 Federal surveyors nationwide (compared to about 8,400 State
surveyors), travel restrictions limited access to some locations.  CMS officials explained
that in the early days of the pandemic, travel restrictions were changing, and they
feared sending surveyors to hot spots when they may not be able to get
home. Therefore, CMS planned survey assignments based on where surveyors could
drive.
States explained that the COVID-19 pandemic exacerbated a
longstanding challenge of maintaining sufficient staff levels
Securing an adequate number of surveyors is a longstanding problem for many
States,65 and State survey agencies reported that the COVID-19 pandemic led to
additional shortages.  Surveyors were unable to perform survey work during the
pandemic for several reasons.  Some surveyors had personal risk factors for
contracting COVID-19, such as underlying medical conditions and older age.  One
State assigned these staff to tasks other than onsite surveys, including reviewing
licensures and managing contact tracing.66  One State with nurse surveyors at higher
risk lent the nurses to the State’s social services department to conduct clinical
assistance video calls with providers.  CMS officials reported that in some States,
surveyors were also diverted to other urgent tasks, such as to staff testing centers and
hotlines, or direct care.
Further limiting available surveyors, one State reported that individual surveyors
sometimes requested to go onsite with another surveyor, even when one surveyor
might technically be sufficient.  The State official explained that these surveyors were
accustomed to having a full team onsite (typically two to five surveyors for a standard
survey) and felt uncomfortable conducting the work alone, particularly considering
the added stress of having only recently learned PPE protocols, and fearing the risk of
infection.
Officials from one State voiced concern that as the pandemic continues, surveyor
shortages may deepen.  State officials worried that the growing number of nursing
home infections and deaths could make it harder to recruit and retain surveyors.  To
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 17

compensate for shortages of State surveyors, States reported hiring contracted
surveyors through vendors with Surveyor Minimum Qualification Test certifications.67
States also assigned surveyors who were typically assigned to hospitals and other
facility types to nursing homework.
States expressed concern about the mounting backlogs of
standard surveys and high-priority complaint surveys
accumulating during the COVID-19 pandemic
As of June 2020, States had delayed standard surveys and surveys in response to
high-priority complaints at about one-fifth (21 percent) of nursing homes as a result
of COVID-19.  CMS’s suspension of surveys allowed providers time to implement the
most recent infection control guidance from both CMS and CDC but also created
backlogs for when States resume these required surveys.68, 69, 70  As of June 28, 2020,
8 percent of nursing homes (1,281 of 15,416) had gone more than 15 months without
a standard survey and 14 percent of nursing homes (2,127) had not received surveys
for high-priority complaints.71  The backlogs could continue to grow until States
resume survey activities and they may compound pre-existing problems that some
States had in completing surveys within required timeframes (see Exhibit 5). Exhibit 5: The number of nursing homes without a standard survey for more than 15 months could continue to grow.

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 18

CMS authorized States to gradually expand survey activities.72, 73, 74  As of June 1, 2020,
CMS authorized States to expand certain survey activities, including standard surveys
and high-priority complaint surveys, at the State’s discretion.75  CMS revised this
guidance on August 17, 2020, indicating that States should resume survey activities if
States have the resources to conduct the surveys. 76  Still, some States expressed
concerns about completing their respective backlogs as they resume normal survey
activities.  Addressing the backlogs could take substantial time and make it difficult to
meet the timeliness requirements for new surveys that will be due in the coming
months.
Completing the backlogs of surveys as well as the upcoming surveys will add
additional pressure to already tight resources and limited staff.  One State estimated
that it would take at least 2 years to eliminate its backlog of surveys and return to
normal timeframes for completing surveys, and another reported that it would be
unable to complete its backlog without external assistance.  Two States also reported
seeking additional funding to address their respective backlogs.  (Two States made
requests to CMS and one of these States also requested supplemental funding under
the Coronavirus Aid, Relief, and Economic Security (CARES) Act).77
These backlogs—and the possibility that it could take years for States to return to
normal survey timeframes—raise concerns for nursing home residents’ safety and
quality of care.  Standard surveys are critically important for protecting nursing home
residents.78  In 2019, standard surveys identified 98,242 deficiencies at nursing homes,
some involving actual harm or IJ deficiencies.79, 80  Outside of the COVID-19 pandemic,
Congress has determined that nursing homes should not exceed 15 months without a
standard survey to certify compliance with Federal requirements, yet more and more
nursing homes will, in fact, exceed 15 months.81, 82  The Federal requirements include
those related to resident rights and quality of care, among many others.
The backlogs in high-priority complaint surveys—which CMS also suspended—raise
further concerns for resident safety and quality of care.  High-priority complaints
allege situations in which a nursing home’s noncompliance with Federal requirements
may have caused patient harm that negatively impacts residents’ mental, physical,
and/or psychological status.  In 2019, high-priority complaints resulted in surveyors
citing 21,120 deficiencies.  Those complaint allegations commonly related to quality
of care/treatment, resident rights, and resident neglect.
These backlogs may compound preexisting challenges that States faced in meeting
required survey timeframes.  According to CMS, 32 States failed to meet CMS
performance standards for investigating high-priority complaints within 10 days
during fiscal years 2016 through 2018 and 17 of these 32 failed to meet the
performance standard in all 3 years.83  Furthermore, 23 States did not meet CMS
performance standards for conducting standard surveys within the 15-month
period.84  These past performance problems raise further concern that States may face
significant difficulty in completing both their current survey activities and their
backlogs.  One State said that it spent 2 years overcoming performance problems
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 19

regarding survey timeliness, only to relapse during the pandemic.  Officials from this
State identified this relapse as their “biggest concern.”
Another issue that State officials raised was their ability to manage additional surges
of COVID-19 in the coming months or years.  State officials expressed a desire for
CMS to further finalize protocols and guidance in the future, creating even more
“definitive and concrete protocols” based on lessons learned from the initial months
of the pandemic.  They also expressed fear of cases continuing long into the future.
As one official said, “We hope that prior to [a new surge,] any additional changes that
are forthcoming could come at a time where there may be a lull, so we aren’t
managing crises and following new protocols all at the same time.”
As COVID-19 hindered onsite surveys, States made efforts to
support nursing homes outside of the survey process
CMS and State officials acknowledged the enormous toll of the presence or threat of
COVID-19 in nursing homes, and that much work remained to improve practices and
prevent infection.  State officials reported generally that they supported CMS’s
decision to suspend standard surveys to limit the spread of COVID-19.  With the
smaller number of surveys, States made efforts to increase support of nursing homes
outside of the normal survey process.
In addition to their role as regulators, CMS
“I hope that as a Nation, we let this
and States placed a new emphasis on assisting
be an opportunity to see how we
nursing homes.  One State survey agency
can look at quality and safety
reported working with State and university
infectious-disease specialists to help train
oversight in a new light, that all
nursing home staff.  These specialists also
States are looking at creative
helped relay information about COVID-19 to
new ways to go forward.”
nursing home providers.  Another State hired
–State official
social workers to communicate to resident
families since nursing homes had difficulty
responding to family members’ concerns, such as those about new COVID-19
visitation policies.
In addition, States have communicated more with nursing homes, including
conducting webinars and discussion forums, and have coordinated closely with State
nursing home associations.  One official said, “We have spent a lot of time telling
[facilities] that they still need to communicate with residents’ families.  Families are
champing at the bit, and if the administrator does not communicate with the families,
the families call us.”  Another official, from a State that appeared to have recovered
from a significant outbreak, explained that collaboration with nursing homes and
provider associations, including guidance and webinars, resulted in improved
operations.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 20

State officials also reported assisting nursing homes with managing specific resident
cases, such as by coordinating with the State Medicaid offices to transfer sick
residents to facilities dedicated to COVID-19 patients.  Assisting with other specific
cases potentially reduced the survey workload; for example, some States worked with
nursing homes and families to resolve less serious complaint issues.
CMS supported States in these expanded efforts.  CMS helped States acquire supplies
and support from State leadership; consulted with States on issues of guidance and
regulation; and posted a toolkit of State best practices that had been compiled by
Quality Improvement Organizations.  States we interviewed were positive about CMS
support, particularly from CMS’s regional offices, citing examples of assistance and
close collaboration in managing facility and resident needs.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Findings | 21

CONCLUSION AND RECOMMENDATIONS
Conclusion
CMS has an essential, ongoing responsibility to oversee nursing homes to ensure that
their residents are safe and receiving high-quality care.  In March 2020, CMS adjusted
its oversight approach to suspend standard surveys, prioritize the most serious
complaints, elevate attention on infection control, and develop a new survey tool to
ensure that nursing homes are implementing actions to prevent the spread of
COVID-19.
Suspending standard surveys and surveys in response to high-priority complaints may
have been the appropriate actions at that time to allow nursing homes and States to
focus on responding to the COVID-19 pandemic and to reduce risks to nursing home
residents, staff, and surveyors.  However, the limited scope of the surveys, combined
with other factors, such as a lack of PPE and limiting visitors, have resulted in less
comprehensive oversight of nursing homes and residents.  Onsite surveys have been
fewer and shorter, and—with families often restricted from visiting—complaints have
decreased.  State survey agencies have shifted some of their time to providing more
support to nursing homes—for example, helping homes communicate with residents’
family members.  Meanwhile, nursing home residents remain among those at the
highest risk of COVID-19 infection and death, as evidenced by the more than 67,000
nursing home residents who have died as of November 8, 2020.
Although no system of oversight is foolproof, the spread of COVID-19 and resulting
deaths in nursing homes raise questions about how well the oversight identified and
addressed shortfalls in infection control.85  As CMS continues to work with States to
ensure the safety of vulnerable nursing home residents, it has an opportunity to
enhance its approach to oversight and adapt this oversight to take advantage of
lessons learned.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Recommendations | 22

We recommend that CMS:
Assess the results of infection control surveys and revise the
survey as appropriate
CMS deployed a limited-scope survey focused on infection control to ensure that
nursing homes focused on preventing the spread of COVID-19 and other
communicable diseases and infections.  CMS should determine whether these
infection control surveys are effective in determining whether nursing homes
implement proper infection prevention and control practices.  Because CMS
mandated that States complete infection control surveys for 100 percent of nursing
homes nationwide, CMS should have data from more than 15,000 nursing homes to
assess the impact of this survey tool.
In considering any revisions to the infection control survey, CMS should also consider
whether to add elements beyond infection control.  CMS designed the infection
control survey to be limited in scope so that surveyors could focus on what CMS
deemed most important during the COVID-19 pandemic.  However, as the pandemic
continues, this interim survey protocol may not provide sufficient oversight if used in
the longer term.  If States are unable to resume standard surveys as the COVID-19
pandemic continues, CMS should determine whether to expand the limited scope of
the infection control surveys.  CMS could include assessments of additional quality of
care requirements, creating a broader interim survey to be used as long as States
continue to struggle obtaining PPE and staffing and may be months from
reestablishing normal operations.
Work with States to help overcome challenges with PPE and
staffing
CMS relies on States to ensure that nursing homes meet Federal requirements,
including by conducting onsite surveys.  The COVID-19 pandemic exacerbated
existing staffing challenges in States as well as introduced new challenges in
obtaining and appropriately using PPE.  These challenges hampered some States in
conducting surveys.  Although CMS does not typically provide direct assistance, it
responded by having Federal surveyors conduct some surveys and wrote a letter to
encourage State Governors to prioritize testing in nursing homes.
States indicated that staffing and PPE shortages remain, and may be an ongoing
problem.  As CMS oversees States during the remainder of the pandemic, it has an
opportunity to consider longer-term policies and strategies for assisting States during
this pandemic and in future crises.  To that end, CMS could pursue a number of
avenues to assist States with staffing and PPE challenges, including:
(1) Developing plans for CMS and States to ensure sufficient capacity for conducting
onsite surveys that are based on lessons learned during the early months of the
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Recommendations | 23

COVID-19 pandemic.  The plans could include technical assistance, such as best
practices for States in acquiring PPE, and sources for training and N95 fitting.  The
plans could also make clear the circumstances under which CMS might send its
limited number of Federal surveyors to supplement State surveys and other types of
direct assistance.  For example, it could describe the criteria that it might use to
determine how, when, and where to send Federal surveyors to assist States.
(2) Requiring States to establish their own clear action plan for reducing barriers to
conducting onsite surveys, including practical information about sources for PPE and
supplemental staffing, and other support as needed to assist State surveyors in
conducting onsite surveys.
(3) Assisting States in other ways, such as serving as a liaison and advocate for States
in interacting with Federal agencies for PPE acquisition (Federal Emergency
Management Agency) or PPE training (CDC).
Clarify expectations for States to complete backlogs of standard
surveys and high-priority complaint surveys
Onsite nursing home surveys, including those that respond to serious complaints, are
critical safeguards to protect nursing home residents.  CMS’s suspension of standard
surveys and high-priority complaint surveys resulted in substantial backlogs of
required surveys.  On August 17, CMS authorized States to resume these surveys
when the States have the resources to do so.  Although this will reduce the growth of
the backlogs, States expressed concerns that additional resources and time are
needed to address the backlogs that already exist.  In addition, past performance
problems—prior to COVID-19—indicate that many States were already struggling to
meet required survey timeframes.  CMS should provide clear expectations for
addressing the backlogs of standard and complaint surveys, including guidance on
how States are to prioritize survey activities and required timeframes for eliminating
backlogs, as well as information about how delayed surveys will be evaluated with
respect to required timeframes.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Recommendations | 24

AGENCY COMMENTS AND OIG RESPONSE
We received comments on the draft report from CMS.
In its comments, CMS did not explicitly concur with our recommendation that it
assess results of the infection control survey and revise as appropriate, but CMS
described actions it has taken that address the recommendation.  For example, in
August 2020, CMS revised the infection control survey to incorporate new COVID-19
requirements regarding testing and designating a facility infection preventionist.
CMS also stated that it will continue to assess and revise the survey as appropriate,
and reiterated that it did not intend for the infection control survey to replace
standard surveys.  We encourage CMS to continue assessing and revising the
infection control survey as needed, including expanding its scope if States are unable
to resume standard surveys as the pandemic continues.  We ask that CMS detail any
additional and planned steps toward implementing this recommendation in its Final
Management Decision.
CMS also did not explicitly concur with our recommendation that it clarify
expectations for States to complete survey backlogs, but CMS described actions it has
taken that address the recommendation.  For example, CMS issued guidance
regarding how States are to resume onsite surveys when they have the resources to
do so.  CMS also stated that it will continue working with States regarding how to
address backlogs of standard and complaint surveys.  As CMS continues to work with
States on this, we encourage CMS to more specifically detail any required timeframes
for eliminating backlogs, as well as provide information about how it will evaluate any
delayed surveys with respect to required timeframes.  This is especially important
given the importance of surveys to resident safety and ongoing difficulties with States
meeting survey timeframes.  We ask that CMS detail any additional and planned steps
toward implementing this recommendation in its Final Management Decision.
CMS did not concur with our recommendation that it work with States to help
overcome challenges with PPE and staffing, citing its lack of authority to address
issues of allocating these resources to States.  CMS noted that it has taken steps to
support States in these areas where feasible.  OIG is not recommending CMS exceed
its authority; rather, we continue to recommend that CMS identify opportunities
within its authority to support States facing challenges securing PPE and staffing.
CMS could do this by providing additional guidance and leadership, as articulated in
this recommendation.  We ask that CMS detail any additional and planned steps
toward implementing this recommendation in its Final Management Decision.
For the full text of CMS’s comments, see Appendix E.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Agency Comments and OIG Response | 25

DETAILED METHODOLOGY
Data Sources
This study used the following data sources: (1) complaint, incident, and associated
survey information entered into ACTS; (2) survey and deficiency data from CMS’s
ASPEN and CASPER systems; (3) survey and deficiency data from Nursing Home
Compare; (4) statements of deficiencies (CMS-2567 forms) from onsite surveys in
2020; (5) an interview with CMS; and (6) brief interviews with 10 State survey agencies.
Data Analysis
CMS Complaint and Incident Data.  OIG’s Division of Data Analytics (DDA)
obtained ACTS data from CMS on nursing home complaints and incidents that States
received in comparable 2019 and 2020 time periods. CMS extracted the data on
June 29, 2020.  We removed records in which the State entered a start date for the
onsite survey that was prior to the complaint receipt date.  Our final dataset included
observations from all 50 States and the District of Columbia.  We analyzed these data
to determine the number of complaints and incidents that States prioritized as IJ in
Medicare and Medicaid-certified nursing homes from March 23 through May 30,
2019, and from March 23 through May 30, 2020.  We also determined the sources of
complaints during these time periods (e.g., nursing home residents, their family
members, and nursing home staff).  In addition, we analyzed the types of allegations
for complaints received.  Finally, we determined the number of nursing homes that
received a high-priority complaint from March 23 through June 28, 2020.
CMS Survey and Deficiency Data.  We used CMS’s publicly available data on
the Nursing Home Compare website to assess surveys and deficiencies during the
COVID-19 pandemic in 2020.  On June 24, 2020, CMS posted data on surveys
completed between March 4 and May 30, 2020. We assessed trends in onsite surveys
and the deficiencies cited in these surveys from March 23 through May 30, 2020, in all
50 States and the District of Columbia.  To determine the percentage of nursing
homes that received an onsite survey nationally, we used the number of nursing
homes by State for 2020, available on Nursing Home Compare.
OIG’s DDA provided ASPEN data from CMS on nursing home surveys and deficiencies
from January 1, 2018, through June 28, 2020.  The data were extracted on June 29,
2020.  We used these data to assess trends in surveys and deficiencies during the
same time period in 2019 in all 50 States and the District of Columbia.  When
determining the number of nursing homes that CMS and States surveyed onsite, we
counted nursing homes that had at least one standard survey or complaint survey.
We excluded those complaint surveys with zero onsite hours.  We calculated the
average percentage of nursing homes with an onsite survey by month in 2019.  For
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Detailed Methodology | 26

this calculation, we used the number of nursing homes by State in 2019 available on
Nursing Home Compare.  For our comparison to deficiencies cited in 2019, we
included any deficiency cited from standard surveys and complaint surveys between
March 23 through May 30, 2019.  In addition, we determined the number of nursing
homes that did not have a standard survey during the 16 months prior to March 23
through June 28, 2020, to estimate the backlog of surveys for each State.  To
determine the number of deficiencies associated with a high-priority complaint in
2019, OIG’s DDA matched complaint data from ACTS to complaint survey data in
ASPEN with an algorithm provided by CMS.
Finally, we determined the number of infection control deficiencies by counting
instances of CMS’ F-880 infection prevention and control deficiency during both the
comparable 2019 time period and the COVID-19 pandemic.
Review of CMS-2567 Forms.  We conducted a limited review of CMS-2567
forms (statements of deficiencies) from onsite surveys during the pandemic.  A
completed CMS-2567 form includes detailed descriptions about deficiencies cited
during a survey and the plan of correction for each deficiency.
Using the CMS-2567 forms that CMS made available on Nursing Home Compare on
June 24, 2020, we identified and reviewed all 68 CMS-2567 forms that included the
F-880 infection prevention and control deficiency from March 23 through May 30,
2020.  The CMS-2567 forms included the specific instances of noncompliance that
resulted in the deficiency citation.  Deficiencies may be based on more than one
instance of noncompliance.
We developed 11 categories to describe specific instances of noncompliance for the
68 infection control deficiencies.  We based the categories on critical elements
associated with the transmission of COVID-19 as described in the CMS
COVID-19-focused survey.  We reviewed the narrative of each CMS-2567 form and
categorized the instances of noncompliance into 1 or more of the 11 categories to
determine the most common reasons for noncompliance with infection control
practices (e.g., hand hygiene).
Interview with CMS.  We conducted an interview with leadership in the Survey
and Operations Group and the Quality, Safety, and Oversight Group on June 18, 2020.
We asked about CMS’s approach to nursing home oversight during COVID-19,
including: (1) the process for selecting and prioritizing nursing homes for focused
infection control surveys, (2) the number of focused infection control surveys that
CMS conducted as well as future plans to conduct surveys, (3) plans for reopening
and addressing backlogs resulting from the suspension of surveys, and (4) how CMS
has collaborated with States and other groups across HHS.
Interviews with State Survey Agencies.  To provide additional insight
about nursing home oversight during the COVID-19 pandemic, we selected a
purposive sample of 10 States for brief telephone interviews: California, Illinois,
Louisiana, Massachusetts, Nebraska, New Jersey, Tennessee, Utah, Washington, and
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Detailed Methodology | 27

West Virginia.  We conducted these interviews from June 9 through June 18, 2020.
The interviews covered five topics: (1) experiences conducting complaint surveys,
(2) experiences selecting and conducting focused infection control surveys, (3) any
barriers to conducting surveys during the pandemic, (4) any strategies to overcome
those barriers, and (5) experiences with other oversight activities conducted during
the pandemic.
We selected the sample of 10 States to ensure that we captured States with a range of
impact from COVID-19 and represented each of the 10 CMS regional offices.  We
categorized States as having a high, medium, or low impact from COVID-19 based on
cumulative cases, density of the disease within the population, and percentage of
deaths within the State occurring in long-term care facilities.  We selected about half
of the sample from States with a high impact from COVID-19 and about half from
States with a moderate or low impact.  See Exhibit 6 for statistics associated with the
selected States.
Exhibit 6: Statistics for 10 sample States as of May 14, 2020.
Percentage of State
COVID-19 Cases
COVID-19
COVID-19 Deaths in
State
Per 1,000,000
Cumulative Cases
Long-Term Care
Population
Facilities
California
73,218
2,160
39
Illinois
84,874
7,925
48
Louisiana
32,662
7,597
39
Massachusetts
80,497
12,908
63
Nebraska
9,075
5,609
71
New Jersey
141,560
16,975
52
Tennessee
16,261
2,696
32
Utah
6,624
2,405
40
Washington
18,604
2,470
53
West Virginia
1,404
862
55
Source: Kaiser Family Foundation.86
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Detailed Methodology | 28

APPENDIX A
CMS guidance to States pertaining to nursing homes from February
through August 2020

Date
Title & Number
Key Provisions
February 6, 2020
Information for Healthcare Facilities
Strongly urges the review of CDC guidance and
Concerning 2019 Novel Coronavirus
encourages facilities to review their own infection
Illness (2012-nCoV), QSO-20-09-ALL87
prevention and control policies and practices to
prevent the spread of infection
March 4, 2020
Suspension of Survey Activities, QSO-
Limits survey activity to t he following (in Priority
20-12-All88
Order):

surveys in response to all immediate
jeopardy complaints and allegations of
abuse and neglect;

surveys in response to complaints alleging
concerns about infection control,
including facilities with potential COVID-
19 or other respiratory illnesses;

statutorily required recertification surveys;

any re-visits necessary to resolve current
enforcement actions;

initial certifications surveys;

surveys of facilities that have a history of
infection control deficiencies at the
immediate jeopardy level in the past 3
years; and

surveys of facilities centers that have a
history of infection control deficiencies at
lower levels than immediate jeopardy.
March 13, 2020
Guidance for Infection Control and
Updates the March 4, 2020, memo with guidance
Prevention of Coronavirus Disease
to restrict all visitors and non-essential health care
2019 (COVID-19) in Nursing Homes
personnel with exceptions for health care workers
(Revised), QSO-20-14-NH89
and surveyors
March 23, 2020
Prioritization of Survey Activities,
Limits surveys to:

Admin Info: QSO-20-20-All90

surveys prompted by complaint/facility-
reported incident surveys,

targeted Infection Control surveys, and

self-assessments.
Instructs State or Federal surveyors to refrain from
performing an onsite survey if they are unable to
meet the PPE expectations outlined by CDC
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix A | 29

Date
Title & Number
Key Provisions
April 19, 2020
Upcoming Requirements for
Requires that facilities notify residents and their

Notification of Confirmed COVID-19
representatives to keep them informed of the

(or COVID-19 Persons Under
conditions inside the facility.

Investigation) Among Residents and

Staff in Nursing Homes, QSO-20-26-
All91
April 24, 2020
Nursing Home Five Star Quality Rating
Waives the timeframe requirement for submitting
System Updates, Nursing Home Staff
resident assessment data and staff data.
Counts and Frequently Asked
Announced that the results of health inspections
Questions, QSO-20-28-NH92
conducted on or after March 4, 2020, will be
posted publicly but not used to calculate
inspection star ratings.
May 6, 2020
Interim Final Rule Updating
Requires nursing homes to report COVID-19
Requirements of Confirmed and
facility data to the CDC and to residents, their
Suspected COVID-19 Cases Among
representatives, and families of residents in
Residents and Staff in Nursing Homes,
facilities.
QSO-20-29-NH93
May 18, 2020
Nursing Home Reopening
Provides recommendations to determine the level
Recommendations for State and Local
of mitigation needed for their communities to
Officials, QSO-20-30-NH94
allow for relaxing restrictions in nursing homes.
June 1, 2020
COVID-19 Survey Activities, CARES Act
Requires States to complete 100 percent of
Funding, Enhanced Enforcement for
infection control surveys for all nursing homes.
Infection Control deficiencies and
Authorized States to expand certain survey
Quality Improvement Activities in
activities, including standard surveys and high-
Nursing Homes, QSO-20-31-NH95
priority complaint surveys.
June 4, 2020
Posting of Nursing Home Inspections,
Announces posting of health inspection (i.e.,
QSO-20-33-NH96
surveys) results that were conducted on or after
March 4, 2020, which is the first date that CMS
altered the way inspections are scheduled and
conducted.
June 4, 2020
Release of COVID-19 Nursing Home
Announces posting of COVID-19 data submitted
Data, QSO-20-32-NH97
by facilities via the CDC National Healthcare Safety
Network.
June 25, 2020
Changes to Staffing Information and
Ends the waiver requirement for nursing homes to
Quality Measures Posted on the
submit staffing data through the Payroll-Based
Nursing Home Compare Website and
Journal System.
Five Star Quality Rating System due to
the COVID-19 Public Health
Emergency, QSO-20-34-NH98
August 17, 2020
Enforcement Cases Held During the
Authorizes the expansion of survey activities and
Prioritization Period and Revised
provides guidance to States about resolving
Survey Prioritization, QSO-20-35-ALL
suspended enforcement cases.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix A | 30

APPENDIX B

Percentage of Nursing Homes With Onsite Survey, by State
State
March 23–April 23, 2020
Average per Month in 2019
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
2%
5%
0%
23%
88%
8%
48%
7%
6%
35%
3%
7%
0%
1%
11%
1%
10%
38%
6%
2%
0%
9%
26%
38%
1%
3%
0%
0%
47%
4%
8%
0%
3%
4%
3%
10%
11%
10%
31%
56%
21%
13%
19%
21%
33%
18%
10%
9%
43%
33%
16%
27%
24%
21%
30%
21%
21%
35%
21%
21%
49%
13%
16%
27%
12%
18%
18%
22%
23%
9%
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix B | 31

Percen
tage of Nursing Homes Wi
th Onsite Survey, by State
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix B | 32

APPENDIX C
Percentage of Nursing Homes Surveyed in Each State,
March 23–May 30, 2020
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix C | 33

Code

Category
Examples

A

Improper PPE Usage
Staff not wearing or changing PPE, staff unaware of PPE practices
B
Environmenta  l
Contamination
Staff contaminating and/or not properly disinfecting facility equi

pment
and resident surroundings

C

Improper Hand Hygiene
Staff not washi

ng hands or washi

ng i

nadequately
D
 E
F
G

Transmission Concerns

Resident Care Concerns
Screening, Monitoring,
and Education of Staff

IPCP Standards
Lack of PPE, handwashing, and/or signage within or outside of

transmission-based precaution rooms
Lack of resident isolation or social distancing, not communicating with

hospitals about transfers
Not screening and monitoring staff for infectious disease; lack of staff
education; lack of appropriate return-to-work policies
Facility’s Infection Preventi

on and Control Program (IPCP) not meeting

standards
H
Infection Surveillance
Facility not tracking, monitoring, and/or testing for reported infectious
disease
I

Visitor Entry
Facility not screening, monitoring, or properly restricting visitors
J
Laundry

Staff not handling contaminated laundry appropriately
K
Other
Additional problems not listed above, such as staff not storing
equipment and supplies or handling food correctly, and the facility’s

water not reaching correct temperatures

APPENDIX D

Summaries of Instances of Noncompliance Identified for
68 Infection Control Deficiencies
Exhibit D-1: Categories of Noncompliance with Infection Control.
Source: OIG Analysis of nursing home infection control surveys nationally, March 23–May 30, 2020.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix D | 34

Exhibit D-2: Instances of Noncompliance by Category for 68 Infection Control Deficiencies,
(March 23–May 30, 2020).
Instance of Noncompliance
Number
Percentage (n = 68)
Improper PPE Usage
43
63%
Environmental Contamination
32
47%
Improper Hand Hygiene
31
46%
Transmission-based Precautions
18
26%
Resident Care
13
19%
Screening, Monitoring, and Education of Staff
13
19%
IPCP Standards
7
10%
Infection Surveillance
7
10%
Visitor Entry
6
9%
Laundry
4
6%
Other
6
9%
Source: OIG Analysis of nursing home infection control surveys nationally, March 23–May 30, 2020.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix D | 35

Exhibit D-3: Summary of 68 Infection Control Deficiencies with Categories of
Noncompliance (March 23–May 30, 2020).
Summary of Deficiency
Categories of Noncompliance
A
B
C
D
E
F
G H
I
J
K
Staff did not place resident on transmission precautions.  Facility did not
isolate resident; did not report infectious disease.

X
X

X
Staff had no documentation of tuberculosis screening.

X
Staff did not disinfect scissors between uses.

X
Facility did not implement social distancing.
X

Staff entered isolation room without PPE; did not wash hands; did not
know which residents had infectious disease.  Facility did not isolate
residents; did not educate staff; did not require visitors to wear PPE.
X

X
X
X
X

X
X

Staff did not change soiled gloves.
X

Staff left a catheter bag on the floor.
X
Staff did not wear PPE when treating resident on isolation; did not
sanitize thermometer; entered resident’s room without washing hands.
X
X
X
X
Staff fed resident with bare hands; placed supplies on surface with no
barrier; did not wash hands.  Facility did not educate staff; had no
protocols regarding handling PICC [peripherally inserted central catheter
lines].
X
X
X

X
X

X
Staff wore masks improperly; did not wash hands; entered room marked
for droplet isolation without protective eyewear.
X

X
X
Staff did not disinfect a blood pressure cuff.

X
Facility held event without social distancing; did not prohibit visitors.
X

X

Facility did not monitor staff temperatures.

X
Staff did not wash hands between glove changes; did not sanitize
shower chair between uses; cross-contaminated linens.
X
X
X

X
Staff touched a soiled mop pad with bare hands, then touched cleaning
supply cart; did not wash hands after taking out trash.
X
X
X

Staff changed gloves without washing hands.
X

X

Staff placed personal items on isolation cart; did not wash hands.  Facility
did not ask visitors to wash hands; dishwasher did not reach 120°F.

X
X
X
X

X
Staff did not disinfect a blood pressure cuff.

X
Staff changed gloves without washing hands.
X

X

Staff stored clean laundry and open box of PPE alongside dirty laundry.

X

X
X
Staff did not use PPE when caring for resident on transmission
precautions; cleaned a thermometer with a contaminated sponge.
X
X

X
Staff did not wash hands before donning PPE or touching environment.
Facility did not monitor staff compliance with COVID-19 protocols.
X
X
X

X
Staff did not don PPE or wash hands before entering isolation room.
X

X
X
Staff did not sanitize an emergency eyewash station.

X
Staff brought dirty linen into clean linen area.

X
Staff did not doff contaminated PPE. Facility did not report COVID-19.
X

X

X
Staff did not remove gloves or wash hands before leaving resident’s
room.  Facility had vent filled with gray substance.
X
X
X

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix D | 36

Summary of Deficiency
Categories of Noncompliance
A
B
C
D
E
F
G H
I
J
K
Facility did not monitor its staff for COVID-19; did not document or
report instances of COVID-19; did not implement entry procedures for
staff or visitors in accordance with CDC guidelines.

X
X
X
Staff did not require residents to wear masks over mouths; did not
disinfect a mechanical lift; did not wash hands after handling laundry; left
dirty laundry on the floor. Facility did not implement social distancing.
X
X
X

X

X
Staff did not provide a visitor with mask.  Facility did not implement
social distancing; did not screen visitors for COVID-19.
X

X

X

Staff wore masks improperly; exited rooms and handled food without
washing hands.  Facility did not require visitors to wash hands.
X

X

X

X

X
Staff did not disinfect a blood pressure cuff.

X
Staff did not doff contaminated PPE; picked up a dead roach and then
touched water faucet; did not wash hands before donning PPE.
X
X
X

Staff doffed PPE incorrectly.  Facility did not post isolation signage; did
not maintain a list of COVID-19 cases.
X

X

X
Staff did not wear a mask while moving resident.
X

Staff did not wash hands before entering room.
X

Staff changed gloves without washing hands; placed supplies on soiled
surface with no barrier.
X
X
X

Staff wore masks improperly.  Facility policy did not address hand
washing; did not ask visitors or staff to wash hands when entering.
X

X

X

X

Staff donned gloves and prepared medicine without washing hands.
X

X

Staff did not wear masks.  Facility policy did not implement masks due to
a mandate from its corporate office.
X

X

Staff did not sanitize a pulse oximeter; did not wash hands.

X
X

Staff placed PPE in pocket; did not sanitize handrails; did not wash
hands; placed isolation room tray on cart.  Facility did not implement
social distancing.
X
X
X
X
X

Staff sanitized equipment with the same disinfectant wipe.

X
Staff did not disinfect a mechanical lift.

X
Staff did not wear PPE in kitchen. Facility had no policy requiring staff to
wear PPE in kitchen despite guidelines.
X

X

Staff entered room without removing soiled gloves; did not sanitize a
blood glucose monitor; did not wash hands.
X
X
X

Facility did not complete fit testing for masks; did not isolate residents
with COVID-19; had no policies for addressing residents with COVID-19.
Staff continued to work despite chills and fever.
X

X
X
X

Staff did not wear masks.  Facility did not train staff to ask residents to
cover their faces and mouths with masks.
X

X
Staff did not wash hands prior to taking resident’s blood pressure.
X

Staff wore masks improperly; did not wash hands; did not isolate
resident; did not cover their face while serving food.
X

X

X

X
Staff changed gloves and did not wash hands; cleaned toilet and then
touched countertop.  Facility did not post isolation signage or implement
social distancing.
X
X
X
X
X

Staff did not monitor resident’s temperature despite doctor’s orders.

X
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix D | 37

Summary of Deficiency
Categories of Noncompliance
A
B
C
D
E
F
G H
I
J
K
Staff entered transmission precautions room without PPE or washing
hands.
X

X
X
Staff did not wear masks; transferred maskless resident through facility;
did not isolate resident.
X

X
X

Staff entered a room without PPE or washing hands; touched controller
with contaminated hands.
X
X
X

Staff did not disinfect a blood pressure monitor; did not wash hands.

X
X

Staff did not disinfect equipment; did not ask residents to wear masks.
Facility did not train staff to ask residents to cover faces and mouths with
masks.
X
X

X
Staff entered transmission precautions room without PPE or washing
hands; touched wheelchair with contaminated hands.
X
X
X
X
Staff wore mask improperly; touched wheelchair with contaminated
gloves.  Facility did not post isolation signage; did not implement social
distancing; did not train staff on proper PPE practices.
X
X

X
X
X
Staff wore masks improperly.
X

Facility did not have a screening station for staff and visitor entry.

X
Staff reused PPE. Facility did not require staff to discontinue this
practice.
X

X
Staff entered room without PPE or washing hands; touched wheelchair.
X
X
X

Staff cleaned surfaces with mislabeled chemicals without knowledge of
dwell time.  Facility did not document staff temperatures.

X

X
Staff did not allow surface cleaner to sit for the appropriate dwell time.

X
Staff did not use PPE; did not sanitize equipment; did not wash hands.
Facility did not post isolation signage.
X
X
X
X
Staff did not stock isolation room carts with PPE.
X

X
Staff did not use PPE.  Facility did not educate staff on COVID-19; did not
isolate resident; did not transfer resident to emergency room despite
orders.
X

X
X
X
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix D | 38

APPENDIX E
Agency Comments
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix E | 39

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix E | 40

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix E | 41

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix E | 42

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Appendix E | 43

Acknowledgments and Contact
Acknowledgments
Ben Gaddis and Kimberly Ruppert served as the project leaders for this study, and
Shanna Weitz served as the lead analyst.  Others in the Office of Evaluation and
Inspections who conducted the study include Sarah Lee, Shweta Palakkode, Karl
Santos, and Troy Yamaguchi.  Office of Evaluation and Inspections staff who provided
support include Joseph Chiarenzelli, Kevin Farber, and Christine Moritz.
This report was prepared under the direction of Ruth Ann Dorrill, Regional Inspector
General for Evaluation and Inspections in the Dallas regional office, Joyce Greenleaf,
Regional Inspector General for Evaluation and Inspections in the Boston regional
office; and Amy Ashcraft and Danielle Fletcher, Deputy Regional Inspectors General in
the Dallas and Boston regional offices, respectively.
Contact
To obtain additional information concerning this report, contact the Office of Public
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found
on the OIG website at oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Acknowledgments and Contact | 44

About the Office of Inspector General
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95­
452, as amended, is to protect the integrity of the Department of Health and Human
Services (HHS) programs, as well as the health and welfare of beneficiaries served by
those programs.  This statutory mission is carried out through a nationwide network
of audits, investigations, and inspections conducted by the following operating
components:
The Office of Audit Services (OAS) provides auditing services for HHS,
either by conducting audits with its own audit resources or by overseeing audit work
done by others.  Audits examine the performance of HHS programs and/or its
grantees and contractors in carrying out their respective responsibilities and are
intended to provide independent assessments of HHS programs and operations.
These audits help reduce waste, abuse, and mismanagement and promote economy
and efficiency throughout HHS.
The Office of Evaluation and Inspections (OEI) conducts national
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable
information on significant issues.  These evaluations focus on preventing fraud, waste,
or abuse and promoting economy, efficiency, and effectiveness of departmental
programs.  To promote impact, OEI reports also present practical recommendations
for improving program operations.
The Office of Investigations (OI) conducts criminal, civil, and administrative
investigations of fraud and misconduct related to HHS programs, operations, and
beneficiaries.  With investigators working in all 50 States and the District of Columbia,
OI utilizes its resources by actively coordinating with the Department of Justice and
other Federal, State, and local law enforcement authorities.  The investigative efforts
of OI often lead to criminal convictions, administrative sanctions, and/or civil
monetary penalties.
The Office of Counsel to the Inspector General (OCIG) provides
general legal services to OIG, rendering advice and opinions on HHS programs and
operations and providing all legal support for OIG’s internal operations.  OCIG
represents OIG in all civil and administrative fraud and abuse cases involving HHS
programs, including False Claims Act, program exclusion, and civil monetary penalty
cases.  In connection with these cases, OCIG also negotiates and monitors corporate
integrity agreements.  OCIG renders advisory opinions, issues compliance program
guidance, publishes fraud alerts, and provides other guidance to the health care
industry concerning the anti-kickback statute and other OIG enforcement authorities.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
About the OIG | 45

Endnotes
1 CDC, Coronavirus Disease 2019 (COVID-19): Older Adults, June 25, 2020.  Accessed at https://www.cdc.gov/coronavirus/2019­
ncov/need-extra-precautions/older-adults.html on July 23, 2020.
2 New York Times, Nursing Home Linked to 37 Coronavirus Deaths Faces Fine of $600,000, April 2, 2020.  Accessed at
https://www.nytimes.com/2020/04/02/us/virus-kirkland-life-care-nursing-home.html on July 13, 2020.
3 CMS, COVID-19 Nursing Home Data, submitted data as of week ending November 8, 2020.  Accessed at
https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/ on November 24, 2020.
4 Johns Hopkins University of Medicine, Coronavirus Resource Center, COVID-19 United States by County.  Accessed at
https://coronavirus.jhu.edu/us-map on November 24, 2020.
5 Government Accountability Office, Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to
COVID-19 Pandemics, GAO-20-576R, May 20, 2020.
6 Ibid.
7 Washington Post, Mask shortage for most health-care workers extended into May, Post-Ipsos poll shows, May 20, 2020.
Accessed at https://www.washingtonpost.com/health/mask-shortage-for-most-health-care-workers-extended-into-may-post­
ipsos-poll-shows/2020/05/20/1ddbe588-9a21-11ea-ac72-3841fcc9b35f_story.html on June 24, 2020.
8 OIG, Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23–27, 2020,
OEI-06-20-00300, April 4, 2020.
9 Social Security Act § 1864(a); 42 CFR § 488.330; CMS, State Operations Manual (SOM), Pub. No. 10-07 ch. 1, Program
Background and Responsibilities, Section 1002.
10 When we refer to nursing homes, we make no distinction between Medicare Skilled Nursing Facilities and Medicaid Nursing
Facilities.  We calculated the number of nursing homes nationally by counting the number of distinct skilled nursing facilities
and Medicaid Nursing Facilities that received a standard survey in the past 4 years (Source: OIG analysis, 2020).
11 Social Security Act §§ 1819(g) and 1919(g).
12 42 CFR § 488.308.
13 Sections 1819(f)(1) and 1919(f)(1) of the Social Security Act.
14 Ibid.
15 CMS, Action Plan for Further Improvement of Nursing Home Quality.  Accessed at https://www.cms.gov/Medicare/Provider­
Enrollment-and-Certification/CertificationandComplianc/Downloads/2016-2017-Nursing-Home-Action-Plan.pdf on July 12,
2020.
16 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16).
17 Social Security Act § 1864(a); 42 CFR § 488.330; SOM, ch. 1, Section 1002.
18 Social Security Act §§ 1819(g) and 1919(g).
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Endnotes | 46

19 Sections 1819(g) and 1919(g) of the Social Security Act.
20 Social Security Act §§ 1819(g)(2)(E) and 1919(g)(2)(E); CMS, SOM, Pub. No. 100-07, ch. 7, Survey and Enforcement Process for
Skilled Nursing Facilities and Nursing Facilities (Revised 185, 11-16-18).
21 CMS, SOM, Pub. No. 100-07 Appendix P: Survey Protocol for Long Term Care Facilities—Part I.  Accessed at
https://www.cms.gov/Medicare/Provider-Enrollment-and­
Certification/GuidanceforLawsAndRegulations/Downloads/som107ap_p_ltcf.pdf on July 13, 2020.
22 Ibid.
23 CMS defines the other two levels of harm as follows: no actual harm with potential for minimal harm and no actual harm
with the potential for more than minimal harm that is not immediate jeopardy.
24 CMS, Nursing Home Enforcement.  Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationEnforcement/Nursing-Home-Enforcement on July 23, 2020.
25 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16).
26 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16).
27 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 191, 07-19-19), Section 5070.
28 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16).
29 OIG analysis of ASPEN Complaint Tracking System (ACTS) data, April 2020.
30 A complaint survey focuses on the specific issues of the complaint.  However, if surveyors observe other compliance issues
while investigating the complaint allegation then they will cite the nursing home for these deficiencies as well.
31 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16).
32 42 CFR § 483.12(c)(1).
33 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 191, 07-19-19), Section 5075.9.
34 CMS, SOM, Pub. No. 100-07, ch. 1, Program Background and Responsibilities, Section 1006.
35 CMS, FY 2016 to FY 2017 Nursing Home Action Plan, May 2016, p. 11.  Accessed at https://www.cms.gov/Medicare/Provider­
Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-26.pdf on August 20, 2019.
36 CMS, FY 2020 State Performance Standards System Guidance, Admin Info: 20-02-ALL, October 17, 2019.
37 CDC, Coronavirus Disease 2019 (COVID-19) Symptoms of Coronavirus.  Accessed at https://www.cdc.gov/coronavirus/2019­
ncov/symptoms-testing/symptoms.html on March 29, 2020.
38 National Public Radio, How COVID-19 Kills: The New Coronavirus Disease Can Take a Deadly Turn.  Accessed at
https://www.npr.org/sections/goatsandsoda/2020/02/14/805289669/how-covid-19-kills-the-new-coronavirus-disease-can-
take-a-deadly-turn on July 15, 2020.
39 NPR, 1st U.S. Case of Coronavirus Confirmed in Washington State, January 22, 2020.  Accessed at
https://www.npr.org/2020/01/22/798392221/1st-u-s-case-of-coronavirus-confirmed-in-washington-state on July 7, 2020.
40 Seattle Times, Life Care Center of Kirkland, the epicenter of Seattle-area coronavirus outbreak, faces $611,000 fine, April 2,
2020.  Accessed at https://www.seattletimes.com/seattle-news/life-care-center-of-kirkland-the-epicenter-of-seattle-area-
coronavirus-outbreak-faces-611000-fine-for-jeopardy-to-patients/ on July 27, 2020.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Endnotes | 47

41 World Health Organization, WHO Director-General’s opening remarks at the media briefing on COVID-19, 11, March 2020.
Accessed at https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on­
covid-19---11-march-2020 on April 3, 2020.
42 An epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that
population in that area.  CDC, Principles of Epidemiology in Public Health Practice.  Accessed at
https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html on March 27, 2020.
43 World Health Organization, The classical definition of a pandemic is not elusive, July 2011, Accessed at
https://www.who.int/bulletin/volumes/89/7/11-088815/en/ on August 20, 2020.
44 CMS, CMS Takes Action Nationwide to Aggressively Respond to Coronavirus National Emergency, March 13, 2020.  Accessed at
https://www.cms.gov/newsroom/press-releases/cms-takes-action-nationwide-aggressively-respond-coronavirus-national-
emergency on July 10, 2020.
45 CMS, Prioritization of Survey Activities, Admin Info: QSO-20-20-All, March 23, 2020.
46 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020.
47 CMS, Suspension of Survey Activities, Ref: QSO-20-12-All, March 4, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-12-all.pdf on July 7, 2020.
48 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020.
49 CMS, COVID-19 Surveyor Training.  Accessed at
https://qsep.cms.gov/pubs/VideoInformation.aspx?id=274&cid=0CMSCOVID19_LTC on July 14, 2020.
50 CMS, COVID-19-Focused Survey Protocol.  Accessed at https://qsep.cms.gov/data/274/COVID-19FocusedSurveyProtocol.pdf
on July 14, 2020.
51 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020.
52 OIG Work Plan, Meeting the Challenges Presented by COVID-19: Nursing Homes, OEI-02-20-00490.
53 OIG Work Plan, Audit of Nursing Homes’ Infection Prevention and Control Program Deficiencies, W-00-20-31545.
54 OIG Work Plan, Audit of Nursing Homes’ Reporting of COVID-19 Information Under CMS’s New Requirements, W-00-20­
31546.
55 OIG, States Continued to Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016–2018,
OEI-01-19-00421, September 2020.
56 OIG Work Plan, Nursing Homes: CMS Oversight of State Survey Agencies, OEI-06-19-00460.
57 During the COVID-19 pandemic, CMS surveyors conducted about 700 surveys, from March 19 through July 9, to assist the
States.
58 These results are based on data beginning March 1, 2020, and include some surveys conducted prior to the directive to
suspend certain survey activities.  CMS, Nursing Home Compare—Nursing Home Infection Control Survey Reports, August 24,
2020.  Accessed at https://www.cms.gov/files/zip/nursing-home-infection-control-surveys.zip on August, 26, 2020.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Endnotes | 48

59 Incidents are self-reported by nursing homes and, as with complaints, do not depend on visitors observing conditions.
There is some duplication between incidents and complaints in nursing homes.  We do not know why incidents also decreased
during the COVID-19 pandemic as compared to 2019.
60 42 CFR § 488.301.
61 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020.
62 Fit testing is an important component to a respiratory protection program to ensure users receive the expected level of
protection.  The Occupational Safety and Health Administration requires annual fit testing for any respirator, such as N95
respirators used by surveyors, before being used in the workplace.  CMS does not require N95 fit testing for health care
providers in certified facilities.
63 CMS surveyors also conducted infection control and complaint surveys during the COVID-19 pandemic.  The data in this
report include surveys conducted by both CMS and States.
64 CMS, Letter to the Governors, May 31, 2020.  Accessed at https://www.cms.gov/files/document/6120-letter-governors.pdf on
July 13, 2020.
65 OIG, Nursing Home Complaint Investigations, OEI-01-04-00340, July 2006.
66 Contact tracing is the practice of identifying and monitoring individuals who may have had contact with an infectious person
as a means of controlling the spread of a communicable disease.  Source: https://www.cdc.gov/coronavirus/2019­
ncov/php/contact-tracing/contact-tracing-plan/overview.html.
67 All nursing home surveyors are required to successfully complete the Surveyor Minimum Qualifications Test (SMQT).  The
SMQT addresses the knowledge, skills, and abilities needed to conduct surveys in nursing homes.  Section 1819(g)(2) and
19191(g)(2) of the Social Security Act requires surveyors to meet minimum qualifications.  Source:
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/SCLetter08­
14.pdf.
68 CMS, Suspension of Survey Activities, Ref: QSO-20-12-All, March 4, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-12-all.pdf on July 7, 2020.
69 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020.
70 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality
Improvement Activities in Nursing Homes, Ref: QSO-20-31-All, June 1, 2020.  Accessed at
https://theconsumervoice.org/uploads/files/issues/6.1.20-20COVID-CAREs-20Survey-20and-20Enforcement-20Memo-FINAL­
20.pdf on July 1, 2020.
71 This analysis uses a 16-month interval between surveys rather than 15.9.
72 CMS, Nursing Home Reopening Recommendations for State and Local Officials, QSO-20-30-NH, May 18, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-30-nh.pdf-0 on August 11, 2020.
73 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality
Improvement Activities in Nursing Homes, QSO-20-31-ALL, June 1, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-31-all.pdf on August 20, 2020.
74 CMS, Enforcement Cases Held during the Prioritization Period and Revised Survey Prioritization, QSO-20-35-ALL, August 17,
2020.  Accessed at https://www.cms.gov/files/document/qso-20-35-all.pdf on August 20, 2020.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Endnotes | 49

75 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality
Improvement Activities in Nursing Homes, QSO-20-31-ALL, June 1, 2020.  Accessed at
https://www.cms.gov/files/document/qso-20-31-all.pdf on August 11, 2020.
76 CMS, Enforcement Cases Held during the Prioritization Period and Revised Survey Prioritization, QSO-20-35-ALL, August 17,
2020.  Accessed at https://www.cms.gov/files/document/qso-20-35-all.pdf on August 20, 2020.
77 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality
Improvement Activities in Nursing Homes, QSO-20-31-All, June 1, 2020.  Accessed at https://www.cms.gov/files/document/qso­
20-31-all.pdf on July 7, 2020.
78 CMS, SOM, Pub. No. 100-07, ch. 4, Program Administration and Fiscal Management (Revised 188, 04-26-19), Section 4157C.
79 CMS defines Serious Injury, Harm, or Death (Actual OR Likely), as a component of Immediate Jeopardy, as follows: “Has
caused or is likely to cause serious injury, harm, impairment, or death to a resident” CMS, SOM, Pub. No. 100-07, Appendix Q:
Guidelines for Determining Immediate Jeopardy. Accessed at https://www.cms.gov/Regulations-and­
Guidance/Guidance/Manuals/downloads/som107ap_q_immedjeopardy.pdf on July 25, 2020.
80 CMS defines a deficiency cited as “actual harm but not immediate jeopardy” as follows: “Noncompliance with the
requirements that result in actual harm to residents or employees that is not immediate jeopardy.” CMS, Public Release of
Nursing Home Enforcement Information Announcement.  Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-and­
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-27.pdf on August 7, 2020.
81 42 CFR §§ 488.308.
82 Social Security Act §§ 1819(g)(2)(A)(iii) and 1919(g)(2)(A)(iii).
83 CMS, Release of Fiscal Year (FY) 2018 State Performance Standards Systems (SPSS) Results.  Accessed at
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/AdminInfo-20­
01-ALL.pdf on July 7, 2020.
84 Ibid.
85 OIG Work Plan, Meeting the Challenges Presented by COVID-19: Nursing Homes, OEI-02-20-00490.  Accessed at
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000474.asp on July 13, 2020.
86 Kaiser Family Foundation, State Data and Policy Actions to Address Coronavirus, COVID-19: Confirmed Cases, Deaths, and
Testing Data (as of May 14, 2020).  Accessed at https://www.kff.org/health-costs/issue-brief/state-data-and-policy-actions-to­
address-coronavirus/ on May 15, 2020.
87 CMS, Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness (2012-nCoV), QSO-20-09-ALL, February
06, 2020. Source: https://www.cms.gov/files/document/qso-20-09-all.pdf.
88 CMS, Suspension of Survey Activities, QSO-20-12-All, March 4, 2020.
89 CMS, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (Revised),
QSO-20-14-NH, March 13, 2020.
90 CMS, Prioritization of Survey Activities, Admin Info: QSO-20-20-All, March 23, 2020.
91 CMS, Upcoming Requirements for Notification of Conformed COVID-19 (or COVID-19 Persons Under Investigation) Among
Residents and Staff in Nursing Homes, QSO-20-26-All, April 19, 2020.
92 CMS, Nursing Home Five Star Quality Rating System updates, Nursing Home Staff Counts and Frequently Asked Questions,
QSO-20-28-NH, April 24, 2020.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Endnotes | 50

93 CMS, Interim Final Rule Updating Requirements of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in
Nursing Homes, QSO-20-29-NH, May 6, 2020.
94 CMS, Nursing Home Reopening Recommendations for State and Local Officials, QSO-20-30-NH, May 18, 2020.
95 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies and Quality
Improvement Activities in Nursing Homes, QSO-20-31-NH, June 1, 2020.
96 CMS, Posting of Nursing Home Inspections, QSO-20-33-NH, June 4, 2020.
97 CMS, Release of COVID-19 Nursing Home Data, QSO-20-32-NH, June 4, 2020.
98 CMS, Changes to Staffing Information and Quality Measures Posted on the Nursing Home Compare Website and Five Star
Quality Rating System due to the COVID-19 Public Health Emergency, QSO-20-34-NH, June 25, 2020.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
OEI-01-20-00430
Endnotes | 51

File and source

File

OEI-01-20-00430-onsite-surveys-of-nursing-homes-during-the-covid-19-pandemic-march-23-may-30-202.pdf

Size

3,015,275 bytes

SHA-256

0cfad1861524fb301ec18d5431a71b5b8251227c6416cd3387ed8933999300a8

Our copy

OEI-01-20-00430-onsite-surveys-of-nursing-homes-during-the-covid-19-pandemic-march-23-may-30-202.pdf

Original

oig.hhs.gov