Report (2021-03-17)
- Issuer
- Government Accountability Office
- Document type
- Report
- Date
- 2021-03-17
Summary
GAO-21-402T is testimony of the U.S. Government Accountability Office before the Committee on Finance, U.S. Senate, for release on March 17, 2021, delivered by John E. Dicken, Director, Health Care. The statement on COVID-19 in nursing homes summarizes findings from GAO's CARES Act reports GAO-21-265, GAO-21-191, GAO-20-701 and GAO-20-625. The testimony reports that CDC data show a winter 2020 surge in nursing home cases and deaths, followed by declines of more than 80 percent since their December 2020 peaks. It describes persistent staffing shortages and newer challenges such as reluctance among some staff to receive a COVID-19 vaccine. It states that HHS has not implemented GAO recommendations to develop an implementation plan for the Nursing Home Commission report and to capture more complete COVID-19 data back to January 1, 2020.
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United States Government Accountability Office
Testimony
Before the Committee on Finance,
U.S. Senate
COVID-19 IN NURSING
For Release on Delivery
Expected at 10:00 a.m. ET
Wednesday, March 17, 2021
HOMES
HHS Has Taken Steps in
Response to Pandemic,
but Several GAO
Recommendations Have
Not Been Implemented
Statement of John E. Dicken, Director, Health Care
GAO-21-402T
March 2021
COVID-19 IN NURSING HOMES
HHS Has Taken Steps in Response to Pandemic, but
Several GAO Recommendations Have Not Been
Highlights of GAO-21-402T, a testimony Implemented
before the Committee on Finance, U.S.
Senate.
Why GAO Did This Study What GAO Found
The COVID-19 pandemic has had a GAO’s review of data from the Centers for Disease Control and Prevention
disproportionate impact on the 1.4 (CDC) found that winter 2020 was marked by a significant surge in the number of
million elderly or disabled residents in COVID-19 cases and deaths in nursing homes. However, CDC data as of
the nation’s more than 15,000 February 2021, show that both cases and deaths have declined by more than 80
Medicare- and Medicaid-certified percent since their peaks in December 2020. With the introduction of vaccines,
nursing homes, who are often in frail observers are hopeful that nursing homes may be beginning to see a reprieve.
health and living in close proximity to Nevertheless, the emergence of more highly transmissible virus variants
one another. HHS, primarily through warrants the need for continued vigilance, according to public health officials.
CMS and CDC, has led the pandemic
response in nursing homes. GAO’s prior work has found that nursing homes have faced many difficult
challenges battling COVID-19. While challenges related to staffing shortages
The CARES Act includes a provision have persisted through the pandemic, challenges related to obtaining Personal
for GAO to conduct monitoring and Protective Equipment (PPE) and conducting COVID-19 tests—although still
oversight of the federal government’s notable—have generally shown signs of improvement since summer 2020.
efforts to prepare for, respond to, and Further, with the decline in nursing homes cases, the Centers for Medicare and
recover from the COVID-19 pandemic. Medicaid Services (CMS) updated its guidance in March 2021 to expand resident
GAO has examined the government’s visitation, an issue that has been an ongoing challenge during the pandemic.
response to COVID-19 in nursing Some new challenges have also emerged as vaccinations began in nursing
homes through its CARES Act
homes, such as reluctance among some staff to receive a COVID-19 vaccine.
reporting (GAO-21-265, GAO-21-191,
GAO-20-701, and GAO-20-625).
The Department of Health and Human Services (HHS), primarily through CMS
This testimony will summarize the and the CDC, has taken steps to address COVID-19 in nursing homes. However,
findings from these reports. HHS has not implemented several relevant GAO recommendations, including:
Specifically, it describes COVID-19
trends in nursing homes and their • HHS has not implemented GAO’s recommendation related to the Nursing
experiences responding to the Home Commission report, which assessed the response to COVID-19 in
pandemic, and HHS’s response to the nursing homes. CMS released the Nursing Home Commission’s report and
pandemic in nursing homes. recommendations in September 2020. When the report was released, CMS
broadly outlined the actions the agency had taken, but the agency did not
To conduct this previously reported provide a plan that would allow it to track its progress. GAO recommended in
work, GAO reviewed CDC data, November 2020 that HHS develop an implementation plan. As of February
agency guidance, and other relevant 2021, this recommendation had not been implemented.
information on HHS’s response to the
COVID-19 pandemic. GAO interviewed • HHS has not implemented GAO’s recommendation to fill COVID-19 data
agency officials and other
voids. CMS required nursing homes to begin reporting the number of cases
knowledgeable stakeholders. In
and deaths to the agency effective May 8, 2020. However, CMS made the
addition, GAO supplemented this
information with updated data from
reporting of the data prior to this date optional. GAO recommended in
CDC on COVID-19 cases and deaths September 2020 that HHS develop a strategy to capture more complete
reported by nursing homes as of COVID-19 data in nursing homes retroactively back to January 1, 2020. As of
February 2021. February 2021, this recommendation had not been implemented.
Implementing GAO’s recommendations could help address some of the
challenges nursing homes continue to face and fill important gaps in the federal
government’s understanding of, and transparency around, data on COVID-19 in
nursing homes. In addition to monitoring HHS’s implementation of past
View GAO-21-402T. For more information,
contact John E. Dicken at (202) 512-7114 or recommendations, GAO has ongoing work related to COVID-19 outbreaks in
dickenj@gao.gov. nursing homes and CMS’s oversight of infection control and emergency
preparedness.
United States Government Accountability Office
Letter Letter
Chairman Wyden, Ranking Member Crapo, and Members of the
Committee:
I am pleased to be here today to discuss our work on Coronavirus
Disease 2019 (COVID-19) in nursing homes. Just over a year ago, a
Washington State nursing home was battling one of the first major
COVID-19 outbreaks in the United States. Today, the COVID-19
pandemic has reached nearly all of the more than 15,000 Medicare- and
Medicaid-certified nursing homes in the country, resulting in a
disproportionately high number of COVID-19 deaths among residents.
While the nation’s 1.4 million nursing home residents are a small share of
the total U.S. population (less than 1 percent), they comprise nearly 30
percent of COVID-19 deaths reported by the Centers for Disease Control
and Prevention (CDC). 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. In
addition, the congregate nature of nursing homes, with staff caring for
multiple residents and shared communal spaces, as well as high
incidence rates in the surrounding community, can increase the risk that
COVID-19 will enter the home and easily spread. Further, efforts to
reduce the spread of COVID-19 in nursing homes have required changes
in typical nursing home practices—such as restricting visitors and
isolating residents exposed to COVID-19—raising concerns for vulnerable
residents, who may have less social interaction and third party oversight
of their care.
The Centers for Medicare & Medicaid Services (CMS), an agency within
the Department of Health and Human Services (HHS), is responsible for
ensuring that nursing homes meet federal quality standards to participate
in the Medicare and Medicaid programs. 1 In response to the pandemic,
HHS, primarily through CMS and CDC, has taken a series of actions with
nursing homes, such as providing guidance, developing targeted
inspections to improve infection control practices, and distributing testing
1To 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. CMS’s Center for Clinical
Standards and Quality has responsibility for overseeing state survey agencies’ survey and
certification activities, among others.
Page 1 GAO-21-402T
devices to homes. 2 In addition, in May 2020, CDC began collecting
weekly COVID-19 data from nursing homes through its National
Healthcare Safety Network system.
The CARES Act includes a provision for us to conduct monitoring and
oversight of the federal government’s efforts to prepare for, respond to,
and recover from the COVID-19 pandemic. 3 In response to the CARES
Act, we have examined the response to COVID-19 in nursing homes in
four reports since June 2020. To help inform today’s discussion, my
testimony will summarize our findings on nursing home issues from these
reports. 4 In particular, my statement will address:
1. COVID-19 trends in nursing homes and their experiences responding
to the COVID-19 pandemic, and
2. HHS’s response to the COVID-19 pandemic in nursing homes.
In addition, I will highlight key actions that we recommended HHS take
and the current status of those recommendations. While my comments
today focus on the findings of our CARES Act reports, they are also
informed by our longer-term body of work examining nursing home
oversight and quality prior to the pandemic.
To conduct the work for the previously issued reports on which my
comments are based, we reviewed CDC data, agency guidance, and
other relevant information on HHS’s response to the COVID-19
pandemic. We interviewed agency officials, as well as researchers with
experience in infection control, advocates for individuals residing in
nursing homes and their families, national associations representing
nursing homes, and representatives from associations representing state
and local officials. More detailed information on our methodology can be
2In our May 2020 report, we found that infection control deficiencies were widespread and
persistent in nursing homes in the years prior to the COVID-19 pandemic. 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).
3Pub. L. No. 116-139, § 19010(b), 134 Stat. 281, 579 (2020).
4See GAO, COVID-19: Critical Vaccine Distribution, Supply Chain, Program Integrity, and
Other Challenges Require Focused Federal Attention, GAO-21-265, (Washington, D.C.:
Jan. 28, 2021); COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal
Response, GAO-21-191, (Washington, D.C.: Nov. 30, 2020);COVID-19: Federal Efforts
Could Be Strengthened by Timely and Concerted Actions, GAO-20-701, (Washington,
D.C.: Sept. 21, 2020); and COVID-19: Opportunities to Improve Federal Response and
Recovery Efforts, GAO-20-625, (Washington, D.C.: June 25, 2020).
Page 2 GAO-21-402T
found in the issued reports. 5 In addition, we supplemented this
information with updated data from CDC on COVID-19 reported by
nursing homes for the week ending February 7, 2021. 6 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 assessed the reliability
of the data sets used in our analyses by checking for missing values and
obvious errors and reviewing relevant CMS and CDC documents. We
determined the data were sufficiently reliable for the purposes of our
reporting objective.
We conducted the work on which this statement is based 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.
5For example, see GAO-21-265.
6We analyzed the most recent data available on February 18, 2021. The CDC data on
COVID-19 in nursing homes were accessed on February 18, 2021, for the week ending
February 7, 2021, from https://data.cms.gov/Covid19-nursing-home-data. For the data on
COVID-19 in nursing homes, we analyzed and reported data that had been determined by
CDC and CMS to pass quality assurance checks for data entry errors. 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.
Page 3 GAO-21-402T
Nursing Home
COVID-19 Cases and
Deaths Are Declining
after Winter Surge;
Persistent Challenges
Remain in Pandemic
Response
After a Winter Surge, CDC Our analysis of CDC data shows that winter 2020 was marked by a
Data Show a Decline in significant surge in the number of COVID-19 cases and deaths for
nursing home residents and staff. Specifically, during mid-December
COVID-19 Cases and
2020, there were more than 33,600 new resident cases and 28,600 new
Deaths among Nursing staff cases, which was more than twice as high as the prior case number
Home Residents and Staff peaks in summer 2020. CDC data show that cases and deaths in nursing
to Levels Closer to Those homes are on the decline. Specifically, as of the week ending February 7,
of Fall 2020 2021, resident and staff cases have both declined by more than 80
percent since their peaks in December 2020. The changing weekly
COVID-19 death counts in nursing homes generally moved in the same
direction as changes in the country as a whole. With the introduction of
vaccines, observers are hopeful that nursing homes may be beginning to
see a reprieve; however, the emergence of more highly transmissible
virus variants warrants the need for continued vigilance, according to
public health officials. 7 (See fig. 1).
7These numbers are likely underreported because they do not include data for the 998
nursing homes (6.5 percent) that did not report COVID-19 data to CDC for the week
ending February 7, 2021, or that submitted data that failed data quality assurance checks.
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 which
voluntarily reported such data. It is therefore not comparable with data for other weeks,
and we excluded it. 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.
Page 4 GAO-21-402T
Figure 1: New Weekly Confirmed COVID-19 Cases and Deaths among U.S. Nursing Home Residents and Staff, as Reported by
Medicare- and Medicaid-Certified Nursing Homes, May 31, 2020, through Feb 7, 2021
Notes: Dates refer to the end of a week (e.g., May 31 refers to the entire week from May 25 through
May 31).
Page 5 GAO-21-402T
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. Data presented reflect the data downloaded as of February
18, 2021, which includes data through the week ending February 7, 2021. We excluded data for the
week ending May 24, 2020, because it is the first week for which data are available from the CDC
and could include cases and deaths from multiple weeks dating back to January 1, 2020.
Weekly and cumulative case and death counts are likely underreported because they do not include
data for the nursing homes that did not report COVID-19 data to CDC for that week or from nursing
homes that submitted data that failed data quality assurance checks. Additionally, as we previously
reported, the Centers for Medicare & Medicaid Services (CMS) does not require nursing homes to
report data prior to May 2020, although nursing homes may do so voluntarily. We recommended that
the Secretary of Health and Human Services—in consultation with CMS and CDC—develop a
strategy to capture more complete data on confirmed COVID-19 cases and deaths in nursing homes
retroactively to January 1, 2020. See GAO, COVID-19: Federal Efforts Could Be Strengthened by
Timely and Concerted Actions, GAO-20-701, (Washington, D.C.: Sept. 21, 2020).
Weekly staff deaths reported for the weeks ending May 31 through February 7 ranged from 13 (week
ending September 20, 2020) to 61 (week ending May 31, 2020).
Some Challenges Nursing In our prior CARES Act reports, we found that nursing homes have faced
Homes Faced Persisted many difficult challenges battling COVID-19. 8 While challenges related to
While Other New staffing shortages have persisted through the pandemic, challenges
related to obtaining Personal Protective Equipment (PPE) and conducting
Challenges Have COVID-19 tests—although still notable—have generally shown signs of
Emerged improvement since summer 2020. Further, with the decline in nursing
home cases, CMS updated its guidance in March 2021 to expand
resident visitation, an issue that has been an ongoing and persistent
challenge during the pandemic. Some new challenges have also
emerged as vaccinations started for nursing home residents and staff.
(See table 1). Some of these challenges, such as staffing shortages,
obtaining PPE, and conducting testing, are critically important for infection
control.
Table 1: Key Pandemic Challenges Experienced by Nursing Homes
Challenge Description Status
Visitation Through interviews with researchers, advocacy organizations, and national Challenge has persisted
association officials from July 2020 to February 2021, we consistently heard throughout pandemic
that nursing homes have faced an ongoing tension between providing
residents with important visitation and minimizing the potential for a COVID-19
outbreak:
• The restriction of visitors has negatively affected residents’ mental and
physical health. Researchers and advocacy organizations have noted
that the isolation resulting from decreased visitation can cause loneliness,
anxiety, and depression among residents.
• The restriction of visitors has created limited oversight of facilities through
the exclusion of resident advocates, such as family members and
ombudsmen.
8See GAO-20-701; GAO-21-265; GAO-21-191; and GAO-20-625.
Page 6 GAO-21-402T
Challenge Description Status
Staffing In our reviews of data from the Centers for Disease Control and Prevention Challenge has persisted
(CDC) and interviews with advocacy organization and national association throughout pandemic
officials from July 2020 through January 2021, we consistently found that
nursing home staffing challenges were difficult and ongoing throughout the
pandemic:
• CDC data from July through December 2020 consistently show that
about one in five nursing homes were reporting to CDC that they had a
shortage of nurse aides or other support staff.a
• From nursing home associations we interviewed, we heard that many
alternative staffing sources have been used to fill critical gaps, such as
seeking help from staffing agencies, sharing staff between other local
providers, and using emergency waivers to hire nurse aides who had yet
to complete their certification. As of January 2021, we continued to hear
that staff are exhausted, face burn-out from emotional trauma, need to
quarantine due to exposure to or illness from the virus, or stay home to
take care of family members—all of which further strains staffing
resources.
Personal Protective According to our reviews of data from the CDC and interviews with advocacy Challenge has generally
Equipment (PPE) organization and national association officials from July 2020 to January shown improvement
2021, shortages of PPE in nursing homes have improved since the beginning
of the COVID-19 pandemic but remain an issue:
• CDC data show that, as recently as December 2020, about 10 percent of
nursing homes did not have a one-week supply of at least one of the
following: N95 respirators, surgical masks, gloves, eye protection, or
gowns (a decrease from about 22 percent of nursing homes in July
2020).
• In interviews with advocacy organizations and national association
officials from July 2020 to January 2021, we heard that, while challenges
maintaining PPE supplies in reserve is an ongoing concern, supply
shortages have become less severe over time.
Testing According to our reviews of CDC data and interviews with a researcher and Challenge has generally
with nursing home association officials in November 2020 and January 2021, shown improvement
nursing homes’ ability to use testing to identify infected residents and staff
through testing protocols has improved over the course of the pandemic, but
at a high cost to nursing homes:
• Nursing homes have reported to CDC improved testing capacity.
Specifically, the number of nursing homes testing for COVID-19 in both
staff and residents has increased by 48 percentage points—from 35 to 83
percent—between August 16, 2020, and November 22, 2020, the last
week complete data for overall testing were available.
• Although data reported in December 2020 by nursing homes found that
less than 2 percent of nursing homes would be unable to test all staff or
residents within the week if needed, nursing home association officials
note that the high cost of continuous testing is not sustainable indefinitely.
Page 7 GAO-21-402T
Challenge Description Status
Vaccinations According to our reviews of a CDC analysis of vaccination data and interviews Emerging challenge
with nursing home and state and local government officials, nursing homes
face some emerging challenges related to vaccinations:
• A February 2021 CDC study estimated low rates of vaccine uptake
among nursing home staff (38 percent) compared to nursing home
residents (78 percent) participating in the Pharmacy Partnership for Long-
Term Care Program.b
• In interviews with nursing home and state and local government
association officials since the vaccines were first administered in
December 2020, we heard about reluctance among some nursing home
staff to receive the COVID-19 vaccine, in addition to hearing about
uncertainty around certain aspects of vaccination distribution and
requirements earlier in the year.
Source: GAO review of CDC data and interviews. | GAO-21-402T
a
According to CDC’s data documentation, other support staff may include certified nursing assistants,
medication aides, and medication technicians as reported to CDC by the provider.
b
R. Gharpure, et al., “Early COVID-19 First-Dose Vaccination Coverage Among Residents and Staff
Members of Skilled Nursing Facilities Participating in the Pharmacy Partnership for Long-Term Care
Program—United States, December 2020-January 2021,” Centers for Disease Control and
Prevention Morbidity and Mortality Weekly Report, vol. 70, no. 5 (2021): 178-182.
Our prior CARES Act reports have described how HHS, primarily through
HHS Has Taken CMS and CDC, has taken a series of actions to address COVID-19 in
Steps in Response to nursing homes, such as providing guidance to nursing homes on infection
control practices and issuing waivers and regulatory flexibilities. 9
COVID-19, but Examples of other actions include:
Several Relevant
Temporarily suspending state survey agencies’ standard surveys and
GAO •
many complaint investigations, instead shifting to targeted infection
Recommendations
Have Not Been
Implemented
9For example, in March 2020 CMS waived the requirement that a nursing home not
employ nurse aides for more than 4 months unless they meet certain training and
certification requirements. This was done to address potential staffing shortages in nursing
homes due to the COVID-19 pandemic.
Page 8 GAO-21-402T
prevention and control surveys and high-priority complaint
investigations. 10
• Creating a new reporting requirement for nursing homes to report
weekly COVID-19 cases and deaths for residents and staff as of May
8, 2020.
• Distributing antigen diagnostic tests and associated point-of-care
testing instruments to nursing homes.
• Distributing billions of dollars in payments from the Provider Relief
Fund, established with funds provided under the CARES Act and
other COVID-19 relief laws, as direct payments to assist nursing
homes with responding to COVID-19. 11
• Convening the Coronavirus Commission on Safety and Quality in
Nursing Homes (the Nursing Home Commission) in June 2020, which
was tasked with assessing the response to the COVID-19 pandemic
in nursing homes and made recommendations for additional actions
CMS could take.
• Establishing the Pharmacy Partnership for Long-Term Care Program
in October 2020, an agreement with CVS, Walgreens, and Managed
Health Care Associates Inc. to provide and administer COVID-19
vaccines to residents of long-term care facilities, including nursing
homes.
• Directing nursing homes to expand resident visitation beginning in
March 2021, after previously restricting visitors and non-essential
health care personnel in nursing homes, except in certain
10On June 1, CMS issued survey re-prioritization guidance as part of its nursing home
reopening strategy. Specifically, once a state enters phase 3—a threshold based on
factors including case status in the community and the nursing home, as well as access to
testing, PPE, and adequate staffing—state survey agencies were authorized to expand
beyond conducting targeted infection control surveys and high-priority complaint
investigations to include lower-priority complaint investigations. See Centers for Medicare
& Medicaid Services, “COVID-19 Survey Activities, CARES Act Funding, Enhanced
Enforcement for Infection Control Deficiencies, and Quality Improvement Activities in
Nursing Homes,” QSO-20-31-ALL, (Baltimore, Md.: June 1, 2020). On August 17, CMS
revised this guidance to authorize traditional, comprehensive, standard surveys and lower-
priority complaint investigations as soon as state survey agencies have the resources,
such as staff and PPE. See Centers for Medicare & Medicaid Services, “Enforcement
Cases Held During the Prioritization Period and Revised Survey Prioritization,” QSO-20-
35-ALL, (Baltimore, Md.: Aug. 17, 2020).
11As of January 15, 2021, $5 billion in Provider Relief Funds had been allocated for
nursing homes and $4.764 billion had been disbursed.
Page 9 GAO-21-402T
compassionate care situations, to reduce the transmission of COVID-
19. 12
However, HHS has not implemented several of our recommendations that
could help the agency address some of the challenges nursing homes
have faced and fill important voids in the federal government’s
understanding of, and transparency around, data on COVID-19 in nursing
homes. (See app. I for a description of related GAO reports and the
status of their recommendations.)
• HHS has not implemented our recommendation related to the
Nursing Home Commission report. CMS released the Nursing
Home Commission’s final report in September 2020, which includes
27 recommendations organized under 10 themes—such as Testing
and Screening, Equipment and PPE, Workforce (staffing), and
Visitation—that are paired with over 100 specific action steps for
CMS. 13 CMS released a response to the report broadly outlining the
actions the agency has taken to date as part of its response to the
COVID-19 pandemic, but the agency did not provide an
implementation plan that would allow it to track and report progress
toward the Commission’s recommendations.
We recommended in November 2020 that the Administrator of CMS
quickly develop a plan that further details how the agency intends to
respond to and implement, as appropriate, the 27 recommendations
in the final report of the Coronavirus Commission on Safety and
Quality in Nursing Homes. HHS neither agreed nor disagreed with our
recommendation; instead, it highlighted actions CMS has taken
related to Commission recommendations and indicated that it would
refer to and act upon the Nursing Home Commission’s
recommendations as appropriate. CMS reiterated this position in
February 2021.
• HHS has not implemented our recommendation to fill COVID-19
data voids. HHS, through CMS, implemented a COVID-19 reporting
requirement for nursing homes effective May 8, 2020 (noted briefly
12CMS restricted visitors and non-essential health care personnel in nursing homes from
March through September 2020. In September 2020, CMS issued guidance that allowed
for nursing homes to resume visitations depending on certain factors.
13MITRE, Coronavirus Commission on Safety and Quality in Nursing Homes: Commission
Final Report, PRS Release Number 20-2382, September 2020.
Page 10 GAO-21-402T
above). 14 CMS made the reporting of the data prior to May 8, 2020,
optional. As a result, CMS’s data do not capture the early months of
the pandemic. 15
We recommended in September 2020 that the Secretary of HHS, in
consultation with CMS and CDC, develop a strategy to capture more
complete data on confirmed COVID-19 cases and deaths in nursing
homes retroactively back to January 1, 2020, and clarify the extent to
which nursing homes had reported data before May 8, 2020. 16
Although HHS partially agreed with this recommendation and
indicated that it continues to consider how to implement this
recommendation, the agency had taken no specific actions, as of
February 2021.
We maintain the importance of our recommendations. Specifically, we
maintain that developing a plan for whether CMS will proceed with the
Nursing Home Commission’s recommendations and, if so, how it will do
so would improve the agency’s ability to systematically consider the
Nursing Home Commission’s recommendations going forward. We also
maintain that collecting data on COVID-19 cases and deaths from nursing
homes retroactively would better inform the government’s continued
response to, and recovery from, the COVID-19 pandemic, and we
maintain that HHS could ease the burden by incorporating data previously
reported to CDC or to state or local public health offices.
We also have recommendations from work completed prior to the
pandemic that have yet to be fully implemented by CMS. Implementation
of these recommendations could improve HHS’s oversight of nursing
homes both generally and during a pandemic. For example, in our 2019
report on abuse in nursing homes, we made six recommendations,
including recommending that CMS require state survey agencies to
1485 Fed. Reg. 27,550, 27,627 (May 8, 2020) (to be codified at 42 C.F.R. § 483.80(g)).
CMS is responsible for ensuring that nursing homes meet federal quality standards to
participate in the Medicare and Medicaid programs.
15Nursing homes are required to self-report data regarding COVID-19 cases and deaths
among residents and staff, PPE supplies, and staffing shortages, among other things, at
least weekly through CDC’s National Healthcare Safety Network.
16Also in September 2020, GAO identified gaps in COVID-19 data for racial and ethnic
minority groups, and, among other things, recommended that CDC take steps to help
ensure its ability to comprehensively assess the long-term health outcomes of persons
with COVID-19, including by race and ethnicity. HHS agreed with the recommendation
and as of February 2021, CDC is reviewing the quality of the demographic data and
assessing potential opportunities to enhance the collection of race and ethnicity data.
Page 11 GAO-21-402T
immediately notify law enforcement of any reasonable suspicion of a
crime against a resident, and that CMS provide more guidance to state
survey agencies on the information nursing homes should include on
facility-reported incidents. CMS agreed with our recommendations. 17
These recommendations have relevance prior to, during, and after the
COVID-19 pandemic, because with reduced visitors or ombudsmen
presence in nursing homes, and with the decrease or elimination of
surveyor presence, there may be a higher risk of residents being abused
and of that abuse going unreported. 18 This risk is higher than it needs to
be because CMS has not yet implemented our relevant
recommendations.
In addition to monitoring HHS’s implementation of past recommendations,
we have ongoing work examining COVID-19 outbreaks in nursing homes,
as well as CMS’s oversight of infection prevention and control protocols
and the adequacy of emergency preparedness standards for emerging
infectious diseases in nursing homes.
In summary, the COVID-19 pandemic has underscored the importance of
issues we have previously raised about nursing home quality and
oversight while pointing to new vulnerabilities unique to the pandemic.
Effective federal oversight and support for nursing homes are especially
critical during times of widespread disease outbreak, as the pandemic
has demonstrated. As nursing homes are prioritized for vaccination, there
is hope that COVID-19 cases and deaths in these homes will continue to
decline. Going forward, our work on COVID-19 in nursing homes remains
important for informing future pandemic responses, as well as for
addressing longer-standing challenges that have put residents’ health and
safety at risk, as indicated by our prior recommendations.
Chairman Wyden, Ranking Member Crapo, and Members of the
Committee, this concludes my prepared statement. I would be pleased to
respond to any questions that you may have at this time.
17See GAO, Nursing Homes: Improved Oversight Needed to Better Protect Residents
from Abuse. GAO-19-433. (Washington, D.C.: June 13, 2019).
18State surveyors evaluate nursing homes’ compliance with federal quality standards.
Page 12 GAO-21-402T
If you or your staff have any questions about this testimony, please
GAO Contact and contact John E. Dicken, Director, Health Care at (202) 512-7114 or
Staff dickenj@gao.gov. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
Acknowledgments statement. GAO staff who made key contributions to this testimony were
Karin Wallestad (Assistant Director), Sarah-Lynn McGrath (Analyst-in-
Charge), Isabella Guyott, Erin Henderson, Julianne Flowers, Elise
Pressma, and Kathryn Richter. Also contributing were Laurie Pachter,
Vikki Porter, and Jennifer Whitworth.
Page 13 GAO-21-402T
Appendix I: Description of Selected GAO Appendix I: Description of Selected GAO
Reports on Nursing Homes with
Reports on Nursing Homes with
Recommendations
Recommendations
The following table summarizes the status of relevant recommendations
from GAO’s prior reports on nursing home oversight with the status as of
the most recent detailed update. According to the Centers for Medicare &
Medicaid Services (CMS), as of March 2021, there are no additional
updates on the status of these recommendations, as the agency’s focus
has been on responding to the pandemic.
Table 1: Description of Selected GAO Reports on Nursing Homes with Recommendations, April 2011 through November 2020
Date Title Summary of recommendations
November 2020 COVID-19: Urgent Actions Needed to Better GAO made one recommendation related to nursing homes
Ensure an Effective Federal Response that the Centers for Medicare & Medicaid Services (CMS)
(GAO-21-191) should quickly develop a plan that further details how the
agency intends to respond to and implement, as appropriate,
the 27 recommendations in the final report of the Coronavirus
Commission on Safety and Quality in Nursing Homes, which
CMS released on September 16, 2020. The Department of
Health and Human Services (HHS) neither agreed nor
disagreed with our recommendation and, as of February
2021, HHS/CMS had not implemented this recommendation.
September 2020 COVID-19: Federal Efforts Could Be GAO made one recommendation related to nursing homes
Strengthened by Timely and Concerted Actions that HHS, in consultation with CMS and the Centers for
(GAO-20-701) Disease Control and Prevention (CDC), develop a strategy to
capture more complete data on confirmed COVID-19 cases
and deaths in nursing homes retroactively to January 1, 2020,
in order to address gaps in the new reporting requirements on
COVID-19 cases and deaths in nursing homes. HHS partially
agreed with this recommendation and, as of February 2021,
HHS had not implemented this recommendation.
June 2019 Nursing Homes: Improved Oversight Needed to GAO made six recommendations, including that CMS require
Better Protect Residents from Abuse state survey agencies to immediately notify law enforcement
(GAO-19-433) of any reasonable suspicion of a crime against a resident,
and that CMS provide more guidance to state survey
agencies on the information nursing homes should include on
facility-reported incidents. HHS agreed with the
recommendations and, as of February 2020, HHS had not
implemented these recommendations.
April 2019 Management Report: CMS Needs to Address GAO made three recommendations, including that CMS
Gaps in Federal Oversight of Nursing Home ensure all state survey agencies are meeting federal
Abuse Investigations That Persisted in Oregon requirements for investigating alleged abuse, and that the
for at Least 15 Years results are shared with CMS. HHS agreed with the
(GAO-19-313R) recommendations and, as of November 2019, HHS had
implemented one of the three recommendations.
November 2016 Nursing Homes: Consumers Could Benefit from GAO made four recommendations, including that CMS
Improvements to the Nursing Home Compare should add information to the Five-Star System that allows
Website and Five-Star Quality Rating System consumers to compare nursing homes nationally. HHS
(GAO-17-61) agreed with three of the four recommendations and, as of
July 2019, HHS had implemented three of the four
recommendations.
Page 14 GAO-21-402T
Appendix I: Description of Selected GAO
Reports on Nursing Homes with
Recommendations
Date Title Summary of recommendations
October 2015 Nursing Home Quality: CMS Should Continue to GAO made three recommendations, including that CMS
Improve Data and Oversight implement a clear plan for ongoing auditing of self-reported
(GAO-16-33) data and establish a process for monitoring oversight
modifications to better assess their effects. HHS agreed with
GAO’s recommendations. As of 2020, HHS had implemented
these three recommendations.
April 2011 Nursing Homes: More Reliable Data and GAO made seven recommendations aimed at ensuring
Consistent Guidance Would Improve CMS CMS’s complaints database is reliable, strengthening CMS’s
Oversight of State Complaint Investigations assessment of state survey agencies’ performance in
(GAO-11-280) managing complaints, and increasing accountability for
managing the complaints process. HHS generally agreed with
our recommendations. As of October 2019, HHS had
implemented two of these seven recommendations and
indicated it would not be taking action on a third (GAO closed
this as not implemented).
Source: GAO. | GAO-21-402T
Note: The hyperlinks to these reports provide additional details about the recommendations and their
statuses.
Page 15 GAO-21-402T
Appendix II: Related GAO Reports
Appendix II: Related GAO Reports
CARES Act Reports 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.
Other GAO Reports Infection Control Deficiencies Were Widespread and Persistent in Nursing
Homes Prior to COVID-19 Pandemic. GAO-20-576R. Washington, D.C.:
May 20, 2020.
Elder Abuse: Federal Requirements for Oversight in Nursing Homes and
Assisted Living Facilities Differ. GAO-19-599. Washington, D.C.: August
19, 2019.
Nursing Homes: Improved Oversight Needed to Better Protect Residents
from Abuse. GAO-19-433. Washington, D.C.: June 13, 2019.
Management Report: CMS Needs to Address Gaps in Federal Oversight
of Nursing Home Abuse Investigations That Persisted in Oregon for at
Least 15 Years. GAO-19-313R. Washington, D.C.: April 15, 2019.
Nursing Homes: Consumers Could Benefit from Improvements to the
Nursing Home Compare Website and Five-Star Quality Rating System.
GAO-17-61. Washington, D.C.: November 18, 2016.
Nursing Home Quality: CMS Should Continue to Improve Data and
Oversight. GAO-16-33. Washington, D.C.: October 30, 2015.
Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older
Adults in Nursing Homes, but Should Expand Efforts to Other Settings.
GAO-15-211. Washington, D.C.: January 30, 2015.
Nursing Homes: More Reliable Data and Consistent Guidance Would
Improve CMS Oversight of State Complaint Investigations. GAO-11-280.
Washington, D.C.: April 7, 2011.
(105027)
Page 16 GAO-21-402T
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