Full text
COVID-19 IN
NURSING HOMES
Most Homes Had
Multiple Outbreaks
and Weeks of
Sustained
Transmission from
May 2020 through
January 2021
Report to Congressional Addressees
May 2021
GAO-21-367
United States Government Accountability Office
United States Government Accountability Office
Highlights of GAO-21-367, a report to
congressional addressees
May 2021
COVID-19 IN NURSING HOMES
Most Homes Had Multiple Outbreaks and Weeks of Sustained
Transmission from May 2020 through January 2021
What GAO Found
GAO analysis of data from the Centers for Disease Control and Prevention
(CDC) shows that, from May 2020 through January 2021, nursing homes
commonly experienced multiple COVID-19 outbreaks. According to CDC, an
outbreak starts the week a nursing home reports a new resident or staff COVID-
19 case and ends when there are 2 weeks with no new cases. GAO found that
nursing homes had an average of about three outbreaks during the review
period, with most of the nursing homes (94 percent, or 12,555 of the 13,380
nursing homes) experiencing more than one COVID-19 outbreak.
Note: Percentages may not add to 100 due to rounding. Data are from the weeks ending May 31, 2020, through
January 31, 2021. An outbreak begins when a nursing home reports a new case of COVID-19 in residents or staff.
For each nursing home’s longest-lasting COVID-19 outbreak, GAO found that
about 85 percent (11,311 nursing homes) had outbreaks lasting 5 or more
weeks. Conversely, for about 15 percent of nursing homes (2,005 homes), the
longest outbreak was shorter in duration, lasting between 1 and 4 weeks, with
267 of those homes able to control their outbreaks after the initial week.
•
The average number of COVID-19 cases per outbreak for nursing
homes with a long-duration outbreak was 56, while the average for
nursing homes with a short-duration outbreak was 13.
•
For both long- and short-duration outbreaks, over half of the nursing
homes (66 percent, or 8,720 homes) reported that these outbreaks
began with a staff member who tested positive the first week.
Note: Of 13,380 nursing homes reviewed, 13,316 nursing homes had COVID-19 outbreaks and 64 nursing homes
did not. Data are from the weeks ending May 31, 2020, through January 31, 2021.
View GAO-21-367. For more information,
contact John E. Dicken at (202) 512-7114 or
dickenj@gao.gov.
Why GAO Did This Study
The COVID-19 pandemic has had a
disproportionate impact on the 1.4
million elderly or disabled residents in
the nation’s more than 15,000
Medicare- and Medicaid-certified
nursing homes. The Centers for
Medicare & Medicaid Services (CMS)
is responsible for ensuring that nursing
homes nationwide meet federal quality
standards.
The CARES Act includes a provision
directing GAO to monitor the federal
pandemic response. GAO was also
asked to review CMS oversight of
nursing homes in light of the pandemic.
This report describes the frequency
and duration of COVID-19 outbreaks in
nursing homes. Future GAO reports
will further examine nursing homes’
experiences with COVID-19 outbreaks.
To conduct this work, GAO analyzed
CDC data on COVID-19 reported by
nursing homes each week of the
review period from May 2020 through
January 2021, the most recent data
available at the time GAO conducted
its review. Using CDC’s definition of an
outbreak, GAO determined the number
and duration of outbreaks each nursing
home experienced during the review
period. GAO included data from the
13,380 Medicare- and Medicaid-
certified homes (88 percent of
Medicare- and Medicaid-certified
homes) that passed CDC and CMS
quality checks each week of the review
period—the most reliable data for
calculating the number and duration of
outbreaks. GAO also categorized the
nursing homes into two groups based
on the duration of their longest
outbreak: 1) those nursing homes with
outbreaks lasting less than 5 weeks
and 2) those nursing homes with
outbreaks lasting at least 5 weeks.
Page i
GAO-21-367 Covid-19 In Nursing Homes
Letter
1
Background
4
Most Nursing Homes Had Multiple COVID-19 Outbreaks and 5 or
More Weeks of Sustained Transmission
6
Agency Comments
12
Appendix I
State Analysis
16
Appendix II
Related GAO Products on COVID-19 in Nursing Homes
18
Appendix III
GAO Contact and Staff Acknowledgments
19
Figures
Figure 1: Number and Duration of COVID-19 Outbreaks in
Nursing Homes, May 31, 2020, through January 31, 2021
8
Figure 2: Number of Nursing Homes by Duration of Longest
COVID-19 Outbreak, May 31, 2020, through January 31,
2021
10
Figure 3: Percentage of Nursing Homes with No COVID-19
Outbreaks, COVID-19 Outbreaks Lasting 1 through 4
Weeks, and COVID-19 Outbreaks Lasting for 5 or More
Weeks, by State, May 31, 2020, through January 31,
2021
16
Contents
Page ii
GAO-21-367 Covid-19 In Nursing Homes
Abbreviations
CDC
Centers for Disease Control and Prevention
CMS
Centers for Medicare & Medicaid Services
COVID-19
Coronavirus Disease 2019
HHS
Department of Health and Human Services
This is a work of the U.S. government and is not subject to copyright protection in the
United States. The published product may be reproduced and distributed in its entirety
without further permission from GAO. However, because this work may contain
copyrighted images or other material, permission from the copyright holder may be
necessary if you wish to reproduce this material separately.
Page 1
GAO-21-367 Nursing Home COVID-19 Outbreaks
441 G St. N.W.
Washington, DC 20548
May 19, 2021
Congressional Addressees
The Coronavirus Disease 2019 (COVID-19) pandemic has had a
disproportionate impact on the 1.4 million elderly or disabled residents in
the nation’s more than 15,000 Medicare- and Medicaid-certified nursing
homes, who are often in frail health and living in close proximity to one
another. One of the first major COVID-19 outbreaks was reported in a
Washington State nursing home in February 2020, where there were
reports that infection transmission continued among residents, staff, and
visitors for several weeks before the outbreak was contained. One year
later, the COVID-19 pandemic had reached nearly all Medicare- and
Medicaid-certified nursing homes, according to data from the Centers for
Disease Control and Prevention (CDC). While the introduction of vaccines
and the sharp decline in nursing home cases and deaths since their
peaks in December 2020 may indicate that nursing homes are seeing a
reprieve, little is still known about the frequency and duration of COVID-
19 outbreaks in nursing homes at critical points during the pandemic.
The CARES Act includes a provision directing us to monitor the federal
response to the COVID-19 pandemic.1 In response to the CARES Act, we
have examined the response to COVID-19 in nursing homes in five
reports since June 2020.2 Also, you asked us to examine the Centers for
Medicare & Medicaid Services’ (CMS) oversight of infection prevention
and control protocols and the adequacy of emergency preparedness
standards for emerging infectious diseases in nursing homes, as well as
CMS’s response to the pandemic.
This report describes the frequency and duration of COVID-19 outbreaks
in nursing homes from May 2020 through January 2021. Future GAO
reports will examine more broadly infection prevention and control and
emergency preparedness in nursing homes and CMS’s response to the
COVID-19 pandemic.
1Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 579 (2020).
2We regularly issue government-wide reports on the federal response to COVID-19. For
the latest report, see GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic
Enters Its Second Year, GAO-21-387 (Washington, D.C.: Mar. 31, 2021). Our next
government-wide report will be issued in July 2021 and will be available on GAO’s website
at https://www.gao.gov/coronavirus.
Letter
Page 2
GAO-21-367 Nursing Home COVID-19 Outbreaks
To conduct this work, we analyzed CMS and CDC data; reviewed agency
guidance and documents; spoke to representatives from three national
organizations that we selected because they represent nursing homes,
residents, and their families; and spoke to five researchers with published
research on nursing home infection control. Specifically, in our data
review, we analyzed CDC data on COVID-19 reported by nursing homes
from the week ending May 31, 2020, through the week ending January
31, 2021, the most recent data available at the time we conducted our
review.3 We analyzed data from 13,380 Medicare- and Medicaid-certified
nursing homes that had COVID-19 data that passed CDC’s and CMS’s
quality assurance checks in all weeks of our review period.4 This
represents approximately 88 percent of all Medicare- and Medicaid-
certified nursing homes that submitted data at any point during our review
period.5
Our analysis included multiple steps. First, we identified the nursing
homes that reported at least one new COVID-19 case in a resident or
staff member in any week of our review period.6 According to CDC, a
COVID-19 outbreak starts the week a nursing home reports a new
3The CDC data on COVID-19 in nursing homes were accessed on February 25, 2021, for
the week ending January 31, 2021, from https://data.cms.gov/Covid19-nursing-home-
data. Nursing homes report aggregate data to CDC on a weekly basis. According to CDC,
data used in this analysis are part of a live data set, meaning that facilities can make
corrections to the data at any time.
The week ending May 31, 2020, is the first single week of data reported to CDC. The
week ending May 24 is the only earlier week of data and could potentially include cases
and deaths for multiple weeks dating back to January 1, 2020, for those homes that
voluntarily reported such data. It is therefore not comparable with data for other weeks,
and we excluded it.
4Data quality checks are performed by CDC and CMS to identify instances where facilities
may have entered incorrect data, such as entering cumulative counts over time instead of
new cases and other data entry errors. One thousand, eight hundred fifty-one Medicare-
or Medicaid-certified nursing homes were excluded because they did not pass one or
more weeks of these data quality checks during the 36 weeks of the period analyzed.
These excluded homes were located in all states but one. Further, while there was
variation in the percentage of homes in each state that did not pass data quality checks,
no states were extreme outliers.
5We compared our findings to an analysis of Medicare- and Medicaid-certified nursing
homes with CDC data that passed quality assurance checks in any week during our
review period—rather than every week—and had similar findings.
6According to CDC, nursing home staff include anyone working or volunteering in the
home, which includes, but is not limited to, contractors, temporary staff, or resident
caregivers.
Page 3
GAO-21-367 Nursing Home COVID-19 Outbreaks
COVID-19 case in a resident or staff member and ends when the nursing
home has 2 consecutive weeks where they report no new staff or resident
cases.7 Using this definition of an outbreak, we determined the number
and duration of outbreaks each nursing home experienced during the
review period.
Next, we categorized the nursing homes with COVID-19 outbreaks into
two groups based on the duration of their outbreak. So that each nursing
home was represented once, we used the longest-lasting outbreak for
nursing homes with more than one outbreak. We defined the groups as
nursing homes with
•
short-duration outbreaks—nursing homes with an outbreak lasting
less than 5 weeks—and
•
long-duration outbreaks—that is, nursing homes with an outbreak
lasting 5 or more weeks.8
Finally, we used CMS data to examine a selection of characteristics for
nursing homes with no outbreaks, short-duration outbreaks, and long-
duration outbreaks. Specifically, we examined nursing home ownership
and nursing home bed size using data publicly available on CMS’s
website, as well as infection prevention and control deficiencies cited prior
to the pandemic.9 We used these data to describe the distribution of
these characteristics and the duration of the COVID-19 outbreaks. In
addition, we examined the variation among states by outbreak duration.
We analyzed the CDC data as they were reported by nursing homes to
CDC and publicly posted by CMS. We did not otherwise independently
verify the accuracy of the information with these nursing homes. We
7See Centers for Disease Control and Prevention, Testing Guidelines for Nursing Homes,
accessed January 13, 2021, from
https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html#nursing-hom
e.
8The cut-off point between 4 and 5 weeks for the two groups was based on the incubation
period for COVID-19—which, according to CDC, is thought to extend to 2 weeks from
exposure—and additional time to receive test results.
9Infection prevention and control deficiencies are the deficiency code used by state
surveyors when a nursing home fails to meet CMS’s requirements for infection prevention
and control. We examined the publicly available infection prevention and control
deficiencies cited in 2018 and 2019. We also analyzed data on infection prevention and
control deficiencies cited from 2013 through 2017 and provided by CMS for a prior GAO
report. See GAO, Infection Control Deficiencies Were Widespread and Persistent in
Nursing Homes Prior to COVID-19 Pandemic. GAO-20-576R (Washington, D.C.: May 20,
2020).
Page 4
GAO-21-367 Nursing Home COVID-19 Outbreaks
assessed the reliability of the CDC and CMS data sets used in our
analyses by checking for missing values and obvious errors and
reviewing relevant CDC and CMS documents. We determined the data
were sufficiently reliable for the purposes of our reporting objective.
We conducted this performance audit from December 2020 to May 2021
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Nursing home residents are at a high risk for COVID-19 infection and
death because the virus has a high mortality rate among elderly adults
and those with underlying health conditions, according to CDC.10 The
congregate nature of nursing homes, with staff caring for multiple
residents and residents sharing rooms and other communal spaces, as
well as high incidence rates in the surrounding community, can increase
the risk that COVID-19 will enter the home (for example, through staff)
and easily spread.11 Asymptomatic transmission can further complicate a
nursing home’s efforts to prevent and control the spread, as it allows the
virus to continue to transmit in the home undetected. A growing body of
evidence shows that asymptomatic transmission may be a contributing
10Centers for Disease Control and Prevention, COVID-19: People Who Live in a Nursing
Home or Long-Term Care Facility, accessed on January 5, 2021, from
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-in-nursing-
homes.html.
11A recent study found that trends in reported COVID-19 cases among nursing home
residents and staff were similar to trends in incidence of COVID-19 in surrounding
communities. See S. Bagchi et al, “Rates of COVID-19 among Residents and Staff
Members in Nursing Homes—United States, May 25-November 22, 2020,” Centers for
Disease Control and Prevention Morbidity and Mortality Weekly Report, January 15, 2021,
vol. 70, no. 2 (2021): 52-55.
From March through September 2020, CMS directed nursing homes to restrict visitors and
non-essential health care personnel in nursing homes, except in certain compassionate
care situations, to reduce the transmission of COVID-19.
Background
Page 5
GAO-21-367 Nursing Home COVID-19 Outbreaks
factor to nursing home COVID-19 outbreaks.12 However, studies have
shown that testing of residents and staff is a key strategy that can allow
for the timely identification and control of infections and, when paired with
strict adherence to infection prevention and control practices, can be
critical for containing outbreaks and protecting both residents and staff.13
CMS is responsible for ensuring that nursing homes meet federal quality
standards to participate in the Medicare and Medicaid programs. These
standards require, for example, that nursing homes establish and
maintain an infection control program. To monitor compliance with these
standards, CMS enters into agreements with state survey agencies in
each state government to conduct inspections, including recurring
comprehensive standard surveys and as-needed investigations. If a
surveyor from a state survey agency determines that a nursing home
violated a federal standard during a survey or investigation, the nursing
home is cited for the deficiency.
We have issued several reports examining COVID-19 in nursing homes,
part of our larger bodies of work on nursing home oversight and on the
federal response to the COVID-19 pandemic. (See app. II for a list of
related GAO products.) In May 2020, we analyzed CMS nursing home
infection prevention and control deficiency data, finding that these
deficiencies were widespread and persistent in nursing homes in the
years prior to the COVID-19 pandemic.14 In response to the CARES Act,
12Studies have shown that approximately half of nursing home residents diagnosed with
COVID-19 were asymptomatic at the time of testing. For example, see A. Kimball et al.,
“Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term
Care Skilled Nursing Facility—King County, Washington, March 2020,” Centers for
Disease Control and Prevention Morbidity and Mortality Weekly Report, vol. 69, no. 13
(2020): 377-381; M. Arons et al., “Presymptomatic SARS-CoV-2 Infections and
Transmission in a Skilled Nursing Facility,” New England Journal of Medicine, vol. 382,
no.22 (2020): 2081-2090; and S. Shi et al., “Risk Factors, Presentation, and Course of
Coronavirus Disease 2019 in a Large, Academic, Long-Term Care Facility,” JAMDA, vol.
21, no. 10 (2020): 1378-1383.
13See C. Telford et al., “Preventing COVID-19 Outbreaks in Long-Term Care Facilities
through Preemptive Testing of Residents and Staff Members—Fulton County, Georgia,
March-May 2020,” Centers for Disease Control and Prevention Morbidity and Mortality
Weekly Report, vol. 69, no. 37 (2020) 1296-1299, and J. Taylor, “Serial Testing for SARS-
CoV-2 and Virus Whole Genome Sequencing Inform Infection Risk at Two Skilled Nursing
Facilities with COVID-19 Outbreaks—Minnesota, April-June 2020,” Centers for Disease
Control and Prevention Morbidity and Mortality Weekly Report, vol. 69, no. 37 (2020):
1288-1295.
14See GAO-20-576R.
Page 6
GAO-21-367 Nursing Home COVID-19 Outbreaks
we have examined the federal response to COVID-19 in nursing homes in
five subsequent reports, where we reported on nursing home-related
actions the Department of Health and Human Services (HHS) had taken
in response to the pandemic, primarily through CMS and CDC, as well as
challenges nursing homes faced responding to COVID-19. For example,
in our September 2020 report we described how HHS, through CMS,
implemented a COVID-19 reporting requirement for nursing homes
effective May 8, 2020, and made reporting prior to May 8, 2020,
optional.15 Also in September 2020, HHS began requiring nursing homes
to routinely test staff for COVID-19 based on the degree of community
spread and to test staff and residents with symptoms. If a nursing home
identifies a new COVID-19 case in staff or residents, all staff and
residents must be tested.
Our analysis of CDC data shows that, from May 2020 through January
2021, nursing homes commonly experienced multiple COVID-19
outbreaks that often lasted 5 or more weeks and were first reported in
staff. This analysis highlights the challenges most nursing homes faced
when responding to the COVID-19 pandemic—responding to repeated
outbreaks, many with weeks of continued spread and marked by high
numbers of cases and deaths. Specifically, we found that nursing homes
had an average of about three outbreaks from May 2020 through January
2021, with most nursing homes (94 percent or 12,555 of the 13,380
nursing homes with CDC data that passed quality assurance checks in all
weeks) experiencing more than one outbreak during our period of
review.16
15GAO has made four recommendations to HHS related to nursing homes in our CARES
Act reports, including to develop a strategy to capture more complete data on confirmed
COVID-19 cases and deaths in nursing homes retroactively back to January 1, 2020. We
will continue to monitor HHS’s progress towards implementing these four
recommendations. For the GAO CARES Act reports with nursing home-related
recommendations, see GAO, COVID-19: Federal Efforts Could Be Strengthened by Timely
and Concerted Actions, GAO-20-701, (Washington, D.C.: Sept. 21, 2020); COVID-19:
Urgent Actions Needed to Better Ensure an Effective Federal Response, GAO-21-191,
(Washington, D.C.: Nov. 30, 2020); and COVID-19: Sustained Federal Action is Crucial as
Pandemic Enters its Second Year, GAO-21-387, (Washington, D.C.: March 31, 2021).
16Most of the remaining 6 percent of nursing homes (761 homes) had one COVID-19
outbreak while less than 1 percent (64 homes) had no outbreaks.
Most Nursing Homes
Had Multiple COVID-
19 Outbreaks and 5
or More Weeks of
Sustained
Transmission
Page 7
GAO-21-367 Nursing Home COVID-19 Outbreaks
For each nursing home’s longest-lasting COVID-19 outbreak, about 85
percent (11,311 nursing homes) had outbreaks lasting 5 or more weeks.17
Conversely, for about 15 percent of nursing homes (2,005 homes), the
longest outbreak was shorter in duration, lasting between 1 and 4 weeks,
and 267 of those homes were able to control their outbreaks after the
initial week.18 (See fig. 1.) Further:
•
Nursing homes with a long-duration outbreak also had a higher
average number of resident and staff cases during the outbreak
compared to nursing homes with a short-duration outbreak.
Specifically, the average number of COVID-19 cases per outbreak for
nursing homes with a long-duration outbreak was 56, while the
average for nursing homes with a short-duration outbreak was 13.19
•
For both long- and short-duration outbreaks, over half of the nursing
homes (66 percent or 8,720 nursing homes) reported that these
outbreaks began with a staff case the first week of the outbreak.20
17Since many nursing homes experienced repeated COVID-19 outbreaks, we used the
outbreak with the longest duration for this analysis.
18We also examined this for Medicare- and Medicaid-certified nursing homes with CDC
data that passed quality assurance checks in any week during our review period—rather
than every week—and found similar percentages. Specifically, for each home’s longest-
lasting outbreak, 12,706 of 15,231 nursing homes (83 percent) had a long-duration
outbreak and 2,409 (16 percent) had a short-duration outbreak.
19Similarly, for the entire period of our review, total reported COVID-19 deaths for homes
with long-duration outbreaks ranged from zero to 102, with an average of seven deaths
per nursing home; for homes with short-duration outbreaks, deaths ranged from zero to
54, with an average of two deaths per nursing home. We analyzed deaths over the entire
period of review, rather than just for the longest duration outbreak, because we cannot
determine to which outbreak a death is attributed.
20Sixteen percent (2,095 homes) of nursing homes reported cases in residents first, and
19 percent of nursing homes (2,501 homes) reported that both residents and staff were
identified with cases in the first week of the outbreak.
Page 8
GAO-21-367 Nursing Home COVID-19 Outbreaks
Figure 1: Number and Duration of COVID-19 Outbreaks in Nursing Homes, May 31,
2020, through January 31, 2021
Note: The universe of 13,380 nursing homes includes Medicare- and Medicaid-certified homes with
COVID-19 data that passed CDC quality assurance checks in all weeks from May 31, 2020, through
January 31, 2021. An outbreak begins when a nursing home reports a new case of COVID-19 in a
resident or staff member, and an outbreak ends when the nursing home has 2 consecutive weeks
without a new COVID-19 case. Percentages may not add to 100 due to rounding.
A closer examination of the 11,311 nursing homes in the CDC data with
long-duration COVID-19 outbreaks (5 or more weeks) shows the
following:
•
Over half of the nursing homes (61 percent or 6,858 nursing homes)
had outbreaks lasting between 5 and 10 weeks. The remaining 39
Page 9
GAO-21-367 Nursing Home COVID-19 Outbreaks
percent of these homes with long-duration outbreaks (4,453 nursing
homes) had outbreaks lasting more than 10 weeks. (See fig. 2.)
•
About one-third (36 percent or 4,045 nursing homes) had more than
one long-duration outbreak during the period of our review, and 88
percent (9,921 nursing homes) also had one or more short-duration
outbreaks.
•
The majority of these long-duration outbreaks started between
October and December 2020—generally consistent with a period of
time where weekly case and death counts in nursing homes increased
to their highest points since the start of the pandemic.
Page 10
GAO-21-367 Nursing Home COVID-19 Outbreaks
Figure 2: Number of Nursing Homes by Duration of Longest COVID-19 Outbreak, May 31, 2020, through January 31, 2021
Note: The universe of 13,316 nursing homes includes Medicare- and Medicaid-certified homes with
COVID-19 outbreaks and data that passed CDC quality assurance checks in all weeks from May 31,
2020, through January 31, 2021. Since many nursing homes experienced repeated COVID-19
outbreaks, we used the outbreak with the longest duration for this analysis. An outbreak begins when
a nursing home reports a new case of COVID-19 in a resident or staff member, and an outbreak ends
when the nursing home has 2 consecutive weeks without a new COVID-19 case.
Page 11
GAO-21-367 Nursing Home COVID-19 Outbreaks
Further, using the CDC data and CMS nursing home data, we describe
the distribution of a selection of nursing home characteristics and the
duration of COVID-19 outbreaks—long-duration, short-duration, and
none.
•
Number of beds. We found that nursing homes with long-duration
outbreaks were more likely to have a larger number of beds than
homes with short-duration outbreaks. Specifically, nursing homes with
less than 50 beds comprised 12 percent of all nursing homes in our
review, but made up a greater share of homes with short-duration
outbreaks (28 percent) and a smaller share of homes with long-
duration outbreaks (9 percent). The inverse was the case for nursing
homes with 100 to 199 beds, as they made up 44 percent of homes in
our review overall but made up 27 percent of homes with short-
duration outbreaks and 47 percent of homes with long-duration
outbreaks.21 In part, this reflects the fact that larger homes will
inherently incur a higher risk of having at least one case, given that
they have more residents and staff, each of whom could become that
case. In addition, studies have shown that larger nursing homes with
more beds and, subsequently, more residents and staff, may have a
higher risk of exposure to COVID-19—particularly in areas of high
community spread—and thus greater potential for more people in the
facility to become infected.22
•
Ownership. We did not see differences between the homes with
long- and short-duration outbreaks and their ownership profit status
(i.e., for-profit, non-profit, or government). For example, nursing
homes owned by for-profit organizations, which comprised 70 percent
of all nursing homes in our review, also accounted for about 70
percent of nursing homes in each of these outbreak duration groups.
•
History of infection prevention and control deficiencies. An
examination of the distribution of nursing homes cited with infection
prevention and control deficiencies prior to the pandemic (2013
through 2019) and nursing homes with long- and short-duration
outbreaks did not show notable differences. This is because most
21The average number of beds in the group of nursing homes with long-duration outbreaks
was larger than the average number of beds in the group of nursing homes with short-
duration outbreaks—an average of 110 beds compared to 77 beds. We measured number
of beds using Medicare- and Medicaid-certified beds.
22See, for example, C. Harrington et al. “Nurse Staffing and Coronavirus Infections in
California Nursing Homes,” Policy, Politics, and Nursing Practice, vol. 21, no. 3 (2020):
174-186.
Page 12
GAO-21-367 Nursing Home COVID-19 Outbreaks
nursing homes in each of these groups had infection prevention and
control deficiencies cited in these years, which is consistent with our
prior reporting.23
•
Variation by state. While the precise percentage of nursing homes
that had long-duration outbreaks, short-duration outbreaks, or no
outbreaks varied by state, we found that in most states over three-
quarters of nursing homes had long-duration outbreaks. Specifically,
only eight states—Alaska, Hawaii, Maine, Massachusetts, New
Hampshire, Oregon, Vermont, and Washington—had less than three-
quarters of their homes with long-duration outbreaks and, therefore,
had a higher combined percentage of short-duration outbreaks and
homes without any outbreaks. Conversely, five states had 95 percent
or more of their nursing homes that experienced long-duration
outbreaks—Alabama, Arkansas, North Dakota, South Carolina, and
Tennessee. (See app. I.)
Researchers and representatives of national associations and
organizations we interviewed told us about several factors that can
increase the risk of COVID-19 being introduced into a nursing home and
spreading. These officials frequently highlighted the risks posed by a
failure or inability of a nursing home to implement robust infection control
practices to control the spread of the virus. For example, officials noted
that once COVID-19 enters a home—which can be more likely when
community transmission is high—the ability of the home to quickly test,
identify, and separate infected residents and staff before they infect
others is critically important to stopping the spread. In addition, officials
said that a lack of personal protective equipment in the home can
increase the risk of spread, because staff can become infected or infect
others. Further, officials noted it can be difficult for nursing homes to
adhere to infection control practices without adequate staffing. Staffing
shortages can occur if staff are out due to illness, and frequent staff
turnover makes it difficult for the home to ensure that new staff are trained
on proper infection control practices.
We requested comments on a draft of this product from HHS, including
CMS and CDC. CMS’s Director of the Division of Nursing Homes
provided us with oral technical comments, which we incorporated as
23Infection prevention and control deficiencies cited by surveyors can include situations
where nursing home staff did not regularly use proper hand hygiene or failed to implement
preventive measures during an infectious disease outbreak, such as isolating sick
residents and using masks and other personal protective equipment to control the spread
of infection. See GAO-20-576R.
Agency Comments
Page 13
GAO-21-367 Nursing Home COVID-19 Outbreaks
appropriate. HHS and CDC told us they had no comments on the draft
product.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of HHS, and other interested parties. In
addition, the report is available at no charge on the GAO website at
http://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or at dickenj@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in Appendix III.
John E. Dicken
Director, Health Care
Page 14
GAO-21-367 Nursing Home COVID-19 Outbreaks
List of Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chairman
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chairwoman
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
Page 15
GAO-21-367 Nursing Home COVID-19 Outbreaks
List of Addressees Continued
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Richard E. Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
The Honorable Michael F. Bennet
United States Senate
Appendix I: State Analysis
Page 16
GAO-21-367 Nursing Home COVID-19 Outbreaks
Figure 3: Percentage of Nursing Homes with No COVID-19 Outbreaks, COVID-19 Outbreaks Lasting 1 through 4 Weeks, and
COVID-19 Outbreaks Lasting for 5 or More Weeks, by State, May 31, 2020, through January 31, 2021
Appendix I: State Analysis
Appendix I: State Analysis
Page 17
GAO-21-367 Nursing Home COVID-19 Outbreaks
Note: The universe of 13,380 nursing homes includes Medicare- and Medicaid-certified homes with
COVID-19 data that passed CDC quality assurance checks in all weeks from May 31, 2020, through
January 31, 2021. Since many nursing homes experienced repeated COVID-19 outbreaks, we used
the outbreak with the longest duration for this analysis. An outbreak begins when a nursing home
reports a new case of COVID-19 in a resident or staff member, and an outbreak ends when the
nursing home has 2 consecutive weeks without a new COVID-19 case.
Appendix II: Related GAO Products on COVID-
19 in Nursing Homes
Page 18
GAO-21-367 Nursing Home COVID-19 Outbreaks
COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters its
Second Year. GAO-21-387. Washington, D.C.: March 31, 2021.
COVID-19: Critical Vaccine Distribution, Supply Chain, Program Integrity,
and Other Challenges Require Focused Federal Attention. GAO-21-265.
Washington, D.C.: January 28, 2021.
COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal
Response. GAO-21-191. Washington, D.C.: November 30, 2020.
COVID-19: Federal Efforts Could Be Strengthened by Timely and
Concerted Actions. GAO-20-701. Washington, D.C.: September 21, 2020.
COVID-19: Opportunities to Improve Federal Response and Recovery
Efforts. GAO-20-625. Washington, D.C.: June 25, 2020.
Infection Control Deficiencies Were Widespread and Persistent in Nursing
Homes Prior to COVID-19 Pandemic. GAO-20-576R. Washington, D.C.:
May 20, 2020.
Appendix II: Related GAO Products on
COVID-19 in Nursing Homes
Appendix III: GAO Contact and Staff
Acknowledgments
Page 19
GAO-21-367 Nursing Home COVID-19 Outbreaks
John E. Dicken at (202) 512-7114 or dickenj@gao.gov
In addition to the contact named above, Karin Wallestad (Assistant
Director), Sarah-Lynn McGrath (Analyst-in-Charge), Kathryn Richter, and
Julianne Flowers. Also contributing were Isabella Guyott, Laurie Pachter,
Vikki Porter, Anna Beth Smith, and Jennifer Whitworth.
Appendix III: GAO Contact and Staff
Acknowledgments
GAO Contact
Staff
Acknowledgments
(104693)
The Government Accountability Office, the audit, evaluation, and investigative
arm of Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability of the
federal government for the American people. GAO examines the use of public
funds; evaluates federal programs and policies; and provides analyses,
recommendations, and other assistance to help Congress make informed
oversight, policy, and funding decisions. GAO’s commitment to good government
is reflected in its core values of accountability, integrity, and reliability.
The fastest and easiest way to obtain copies of GAO documents at no cost is
through our website. Each weekday afternoon, GAO posts on its website newly
released reports, testimony, and correspondence. You can also subscribe to
GAO’s email updates to receive notification of newly posted products.
The price of each GAO publication reflects GAO’s actual cost of production and
distribution and depends on the number of pages in the publication and whether
the publication is printed in color or black and white. Pricing and ordering
information is posted on GAO’s website, https://www.gao.gov/ordering.htm.
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card, MasterCard,
Visa, check, or money order. Call for additional information.
Connect with GAO on Facebook, Flickr, Twitter, and YouTube.
Subscribe to our RSS Feeds or Email Updates. Listen to our Podcasts.
Visit GAO on the web at https://www.gao.gov.
Contact FraudNet:
Website: https://www.gao.gov/about/what-gao-does/fraudnet
Automated answering system: (800) 424-5454 or (202) 512-7700
Orice Williams Brown, Managing Director, WilliamsO@gao.gov, (202) 512-4400,
U.S. Government Accountability Office, 441 G Street NW, Room 7125,
Washington, DC 20548
Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548
Stephen J. Sanford, Acting Managing Director, spel@gao.gov, (202) 512-4707
U.S. Government Accountability Office, 441 G Street NW, Room 7814,
Washington, DC 20548
GAO’s Mission
Obtaining Copies of
GAO Reports and
Testimony
Order by Phone
Connect with GAO
To Report Fraud,
Waste, and Abuse in
Federal Programs
Congressional
Relations
Public Affairs
Strategic Planning and
External Liaison
Please Print on Recycled Paper.