GAO-22-104425, COVID-19: Selected States Modified Meal Provision and Other Older Americans Act Services to Prioritize Safety
- Issuer
- Government Accountability Office
- Document type
- Report
- Date
- 2021-12-15
Summary
A U.S. Government Accountability Office report to congressional addressees, GAO-22-104425, dated December 15, 2021, on how states used Older Americans Act of 1965 (OAA) COVID-19 funds. Prepared under GAO's CARES Act oversight responsibilities, it examines states' use of the funds and related flexibilities, strategies used by selected states and localities, and the Administration for Community Living's oversight. GAO reports that states spent most supplemental funds on meals and provided about 24 million more meals in fiscal year 2020 than in 2019. Officials from Georgia, New Mexico, New York and South Dakota and eight localities described modifying meal services and suspending some in-person services for safety. The report also describes ACL's new reporting template for fiscal year 2021.
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Full text
United States Government Accountability Office
Report to Congressional Addressees
COVID-19
December 2021
Selected States
Modified Meal
Provision and Other
Older Americans Act
Services to Prioritize
Safety
GAO-22-104425
December 2021
COVID-19
Selected States Modified Meal Provision and Other
Older Americans Act Services to Prioritize Safety
Highlights of GAO-22-104425, a report to
congressional addressees
Why GAO Did This Study What GAO Found
COVID-19 relief funding in 2020 and States spent most of their supplemental COVID-19 funding from the Older
2021 totaled over $2.7 billion to Americans Act of 1965 (OAA) to provide meals, and reported using certain
support OAA services during the pandemic-related flexibilities to waive some related requirements. In fiscal year
pandemic. OAA provides services, 2020, states overall provided about 24 million more meals—using COVID-19 and
such as home-delivered meals, in- other funds—compared to 2019, according to national data from the Department
home personal care, and caregiver of Health and Human Services’ Administration for Community Living (ACL).
support services, to help older adults Compared to meals, states spent much less of the supplemental funding on other
age in place in their homes and OAA services, such as providing in-home care. In addition, officials from four
communities.
selected states reported using CARES Act flexibilities to help address pandemic-
As part of GAO’s CARES Act oversight related challenges. For example, officials from most of the selected localities in
responsibilities, this report examines these states said waiving nutrition requirements for OAA-provided meals helped
(1) states’ use of OAA COVID-19 funds them meet demand by providing frozen meals, shelf-stable meals, or groceries.
and related flexibilities, (2) strategies
selected states and localities used to Officials GAO interviewed from the four selected states and eight localities
serve older adults during the reported adapting to safety concerns during the pandemic by modifying meal
pandemic, and (3) ACL’s efforts to services or temporarily suspending other OAA services, although in-person
oversee COVID-19 funds and support services in most localities resumed by September 2021. For example, some
states. localities reported converting from meals served in group settings to meals that
could be taken home (see photos). In addition, most localities reported holding
GAO reviewed national data from ACL wellness classes or other activities online. Some localities reported reducing or
on OAA service expenditures from
temporarily suspending in-home care services due to safety concerns. Officials
fiscal years 2019 and 2020 (the most
from most of the localities reported leveraging new or existing partnerships with
recent available), related ACL
guidance, and relevant federal laws public health and emergency agencies, and most localities reported assisting
and regulations. Additionally, GAO with COVID-19 vaccinations.
interviewed officials from four state
Selected Localities Found Alternative Methods for Providing Meals to Older Adults during the
units on aging (Georgia, New Mexico, Pandemic
New York, and South Dakota),
selected based on their percentages of
older adults, and demographic and
geographic diversity. In these states,
GAO interviewed officials from eight
localities that deliver OAA services in
both rural and urban areas. GAO also
interviewed ACL headquarters and
regional officials and representatives
from six national aging organizations.
ACL modified state reporting processes to oversee COVID-19 spending and
supported states by providing guidance and information. For fiscal year 2020,
ACL asked states to report their use of COVID-19 supplemental funds in
narrative form. Due to the flexible format, ACL received varying levels of detail
that ACL said required considerable follow-up with states. For fiscal year 2021,
ACL developed a template for state reporting, which officials said will help them
efficiently collect more consistent information on the use of COVID-19 funds.
View GAO-22-104425. For more information, ACL supported states by providing frequent guidance, sharing information on the
contact Kathryn A. Larin, (202) 512-7215 or use of funds, and suggesting ways to modify services.
larink@gao.gov
United States Government Accountability Office
Contents
Letter 1
Background 4
States Spent Most COVID-19 OAA Funds on Meals for Older
Adults and Used COVID-19 Flexibilities to Address Changing
Demand 9
Selected States Focused on Safety and Meeting Increased
Demand When Modifying Nutrition and Other Services 17
ACL Responded to Emergency by Modifying State Reporting
Processes and Sharing Information with States 31
Agency Comments 37
Appendix I: GAO Contact and Staff Acknowledgments 41
Tables
Table 1: Fiscal Year 2021 and COVID-19 Relief Appropriations for
Older Americans Act of 1965 (OAA) Programs 6
Table 2: Key COVID-19 Flexibilities for Older Americans Act of
1965 (OAA) Programs Provided by the CARES Act and
OAA 8
Figures
Figure 1: COVID-19 Supplemental Funds Spent on Older
Americans Act of 1965 (OAA) Title III Services, Fiscal
Year 2020, in Millions 10
Figure 2: Number of Meals Provided in Older Americans Act of
1965 (OAA) Title III Nutrition Programs, Fiscal Years
2019 and 2020, in Millions 11
Figure 3: Percentage Change in Total Expenditures for Selected
Older Americans Act of 1965 (OAA) Title III Services
between Fiscal Years 2019 and 2020 13
Figure 4: Meals on Wheels of Central Maryland Prepared Home-
Delivered Meals for Older Adults during the Pandemic 18
Figure 5: Grab-and-Go Meal Pick Up at a Congregate Meal Site in
Boston 21
Figure 6: Older Adult Participating in a Virtual Exercise Activity 23
Figure 7: Older Adults Socialize with Masks in a Partially Re-
opened Congregate Meal Dining Hall 25
Page i GAO-22-104425 COVID-19 Services for Older Adults
Abbreviations
AAA area agency on aging
ACL Administration for Community Living
APS Adult Protective Services
ADRC Aging and Disability Resource Centers
ARPA American Rescue Plan Act of 2021
CAA-21 Consolidated Appropriations Act, 2021
CDC Centers for Disease Control and Prevention
COVID-19 Coronavirus Disease 2019
FFCRA Families First Coronavirus Response Act
HHS Department of Health and Human Services
OAA Older Americans Act of 1965
SNAP Supplemental Nutrition Assistance Program
USDA United States Department of Agriculture
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Page ii GAO-22-104425 COVID-19 Services for Older Adults
Letter
441 G St. N.W.
Washington, DC 20548
December 15, 2021
Congressional Addressees
The ongoing Coronavirus Disease 2019 (COVID-19) pandemic has put
older adults at increased risk for COVID-19 complications or death. 1
Before the availability of vaccines, many older adults were advised to stay
in their homes to avoid contracting the virus. 2 As a result, services
provided under Title III of the Older Americans Act of 1965 (OAA), such
as home-delivered meals or in-home personal care, became increasingly
important during the pandemic to ensure that older adults could meet
basic nutrition needs, maintain daily routines, and live safely in their
homes and communities. 3 OAA is administered by the Administration for
Community Living (ACL) within the Department of Health and Human
Services (HHS). ACL distributes funds and provides oversight to an
“aging network” that includes state units on aging, area agencies on aging
(AAA), and local service providers.
As of October 2021, OAA Title III services have received nearly $2.6
billion in supplemental appropriations in response to the COVID-19
pandemic. 4 In January 2021, we reported on the way ACL had initially
provided guidance and support to help states and AAAs meet the
increased demand for nutrition assistance and provide other services for
1Though all populations are at risk of COVID-19, data indicate that throughout the
pandemic, adults over age 65 were more likely to be hospitalized and to die from the virus.
In fact, according to the Centers for Disease Control and Prevention (CDC), adults aged
65-74 who contracted COVID-19 were 90 times more likely to die than those aged 18-29,
and the risk was even greater for those over age 74. See CDC, Risk for COVID-19
Infection, Hospitalizations, and Death by Age Group (Updated Sept. 9, 2021).
2CDC guidance from March 2020 recommended that older adults stay home, among other
precautions. Some state and local officials issued more stringent guidance that older
adults self-isolate at home or stay-at-home orders for the general public.
3OAA Title III services for older adults are designed to maintain the health and well-being
of older persons, with the majority of funds being allocated to the provision of nutrition and
nutrition-related services.
4Consolidated Appropriations Act, 2021 (CAA-21), Pub. L. No. 116-260, div. N, tit. VII, §
731, 134 Stat. 1182, 2104 (2020) and American Rescue Plan Act of 2021 (ARPA) Pub. L.
No. 117-2 tit. II, § 2921, 135 Stat. 4, 52. Of the $2.7 billion in supplemental appropriations
provided for OAA programs in response to the COVID-19 pandemic, nearly $2.6 billion
were for OAA Title III services.
Page 1 GAO-22-104425 COVID-19 Services for Older Adults
older adults who were homebound early in the pandemic. 5 This report
builds on that work by examining: (1) how states have used OAA COVID-
19 funds and how these funds and related flexibilities have helped
selected states address challenges serving older adults during COVID-
19, (2) what strategies selected states and localities have used to meet
the nutrition and other needs of older adults during the COVID-19
pandemic, and (3) what efforts ACL has made to oversee COVID-19
funds and support states. 6 We conducted this work as part of GAO’s
monitoring and oversight responsibilities under the CARES Act. 7
To address all three of our objectives, we conducted interviews with and
gathered documents from four states (Georgia, New Mexico, New York,
and South Dakota). We selected these states for their higher percentages
of adults 60 and older below the poverty level and higher COVID-19
infection and death rates, as well as to reflect demographic and
geographic diversity. In each of the selected states, we interviewed
officials from the state unit on aging as well as from two localities within
the state—either AAAs or, in the case of South Dakota, service providers
that subcontract directly with the state. 8 We selected one urban- and one
rural-serving locality in each state based on their higher concentrations of
older adults, and selected at least one locality in each state with a higher
percentage of minority older adults living in the service area. We also
asked for input on our choice of selected localities from officials in each
state.
5See 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).
6In this report, we use the term “COVID-19 funds” to refer to supplemental funds from the
Families First Coronavirus Response Act (FFCRA) and CARES Act, which states received
in fiscal year 2020. This report does not include analysis of how states and localities spent
the OAA funds appropriated by the Consolidated Appropriations Act, 2021 (CAA-21) and
American Rescue Plan Act of 2021 (ARPA), neither of which had been distributed to
states at the time we initiated this work.
7Pub. L. No. 116-136, § 19010, 134 Stat. 281, 579-81 (2020). We regularly issue
government-wide reports on the federal response to COVID-19. For the latest report, see
GAO, COVID-19: Additional Actions Needed to Improve Accountability and Program
Effectiveness of Federal Response, GAO-22-105051 (Washington, D.C.: Oct. 27, 2021).
Our next government-wide report will be issued in January 2022 and will be available on
GAO’s website at https://www.gao.gov/coronavirus.
8A handful of states, many of which are small or sparsely populated, do not have AAAs
and provide services directly or through contracts with providers.
Page 2 GAO-22-104425 COVID-19 Services for Older Adults
In our interviews, we asked state and local officials about several topics,
including the service needs of older adults during the pandemic, how their
state or locality used the supplemental COVID-19 funds, and how they
modified their services and responded to challenges during the pandemic.
We also reviewed relevant documents about services and programs from
the selected states and localities. Our findings cannot be generalized to
all states and localities, but they provide insights into the types of
challenges faced and responses to serving older adults during the
COVID-19 pandemic. 9
For all three objectives, we also reviewed relevant federal laws and
regulations, and relevant ACL documents, such as guidance on allowable
activities and reporting requirements, information on ACL’s oversight and
monitoring processes, and informational resources provided to help
states and localities modify their programs and address challenges during
the pandemic. We interviewed ACL headquarters officials and ACL
regional administrators responsible for each of the four selected states
about the agency’s various efforts. 10 We also interviewed officials from six
national associations that represent older adults and the aging network. 11
To address our first objective, we also reviewed national ACL data on
OAA Title III service expenditures and meals served from fiscal years
2019 and 2020, the most recent data available. Our review focused on
how states spent their supplemental COVID-19 funds in fiscal year 2020,
although states have until the end of fiscal year 2022 to spend funds from
the Families First Coronavirus Response Act (FFCRA) and the CARES
9In this report, we use the term “states” to collectively refer to the 50 states, the District of
Columbia, and U.S. territories. We use the term “localities” to encompass both AAAs and
service providers that sub-contract with a state unit on aging to provide services in certain
geographic areas. Where relevant, we specify whether we are referring to a state unit on
aging, an AAA, or a service provider. To characterize the views of the localities throughout
this report, we defined modifiers (e.g., “most”) to quantify the opinions presented by our
interviewees as follows: “all” represents all eight localities; “most” represents six or seven
localities; and “some” represents three, four, or five localities. When referring to fewer than
three localities, we specified the exact number.
10ACL has 10 regional offices which serve as the focal points for the development,
coordination, and administration of ACL programs and activities within their regions.
11These national aging associations included ADvancing States (representing state units
on aging), AARP, Meals on Wheels of America, the National Association of Nutrition and
Aging Services Programs, the National Council on Aging, and USAging (formerly the
National Association of Area Agencies on Aging).
Page 3 GAO-22-104425 COVID-19 Services for Older Adults
Act. 12 We focused on OAA Title III—Grants for State and Community
Programs on Aging—because Title III is the largest OAA expenditure and
received the majority of the OAA COVID-19 supplemental funds.
To assess the reliability of these data, we examined the data for missing
or inconsistent information, reviewed ACL documents, interviewed ACL
officials, and requested written responses to questions from ACL regional
administrators responsible for working directly with states on their annual
state program reports. We included in our analysis only those service and
program expenditures data that we found to be sufficiently reliable for the
purposes of demonstrating how states used the supplemental COVID-19
funds. Specifically, we included data on expenditures and the number of
meals provided with all funding sources. 13 We excluded data on Title III
client demographics, as well as data on service units and clients served
specifically with the supplemental COVID-19 funds, due to the amount of
missing data and based on our data reliability discussions with ACL
officials.
We conducted this performance audit from January 2021 to December
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.
Background
OAA Services The OAA, first enacted in 1965 and reauthorized most recently in 2020,
provides support for programs that help older adults live independently in
12Initially, funds from FFCRA and the CARES Act were available to states through the end
of fiscal year 2021. In April 2021, ACL provided automatic no-cost extensions for these
funds, so funds are now available to states until the end of fiscal year 2022.
13States used several funding sources to provide services: annual OAA funds,
supplemental COVID-19 funds provided under FFCRA and the CARES Act, state
(including state and local match) funds, and program revenue (e.g., contributions from
older adults).
Page 4 GAO-22-104425 COVID-19 Services for Older Adults
their homes and communities to the extent possible. 14 OAA Title III grants
provided to states—collectively the largest expenditure under the OAA—
are a key source of federal funds for state and community programs on
aging and fund a broad range of services. OAA Title III services for older
adults are designed to maintain the health and well-being of older
persons, with the majority of funds being allocated to the provision of
nutrition and nutrition-related services. Examples of services supported
by OAA funds are:
• supportive services, such as in-home personal care, transportation,
and information and assistance;
• nutrition programs, such as providing congregate (meals served in
group settings, such as at senior centers) and home-delivered
meals; 15
• evidence-based health promotion activities, such as group exercise
programs and programs to help prevent falls; and
• caregiver support services, such as assisting family caregivers with
information and resources, and providing respite care.
Other OAA programs not part of Title III provide additional services to
help support older adults. For example, other services include information
and referrals provided through Aging and Disability Resource Centers
(ADRC), and long-term care ombudsmen services. OAA services are
generally for adults age 60 and older, and are targeted to certain
populations of older adults, such as those living in poverty or rural areas.
Within these federal parameters, however, the states have a great deal of
discretion to determine how OAA funds will be used and how to prioritize
who receives services.
COVID-19 Funding and The OAA is funded through the annual discretionary appropriations
Flexibilities process and an additional $2.7 billion in supplemental appropriations was
14See Pub. L. No. 89-73, 79 Stat. 218 as amended by the Supporting Older Americans
Act of 2020, Pub. L. No. 116-131, 134 Stat. 240. Other federal programs, such as
Medicaid, also fund home and community-based services and supports to help older
adults continue living independently. See GAO, Older Adults: Federal Strategy Needed to
Help Ensure Efficient and Effective Delivery of Home and Community-Based Services and
Supports, GAO-15-190 (Washington, D.C.: May 20, 2015).
15Congregate and home-delivered nutrition services include the provision of meals, as
well as other nutrition services, such as nutrition education and counseling.
Page 5 GAO-22-104425 COVID-19 Services for Older Adults
provided for OAA programs in response to the COVID-19 pandemic. 16
Nearly $2.6 billion of these supplemental funds were for OAA Title III
services, with the remainder going to other OAA programs (see table 1).
States receive separate allotments of OAA Title III funds for different
types of services based on statutory funding formulas, and states typically
distribute funds to AAAs using specific intrastate funding formulas. 17
Table 1: Fiscal Year 2021 and COVID-19 Relief Appropriations for Older Americans Act of 1965 (OAA) Programs
OAA program Fiscal year 2021 appropriated COVID-19 relief funding (in
funds (in millions) millions)
OAA Title III programs $1,572 $2,587
Supportive services (Title III-B): transportation, in-home $393 $200 (CARES Act)
personal care, chore, homemaker, outreach, information $460 (ARPA)
and assistance
Nutrition programs (Title III-C): congregate meals, home- $240 (FFCRA)
delivered meals $952 $480 (CARES Act)
$168 (CAA-21)
$750 (ARPA)
Evidence-based health promotion (Title III-D): nutrition $38 $44 (ARPA)
education, disease prevention, wellness activities
Caregiver support services (Title III-E): respite care, $189 $100 (CARES Act)
training, information on caregiving $145 (ARPA)
Other OAA programs $62 $142
Aging and Disability Resource Centers (ADRC) (Title II): $8 $50 (CARES Act)
information and referrals to services for older adults,
people with disabilities, families and caregivers
Nutrition and related services for Native American $35 $10 (FFCRA)
Programs (Title VI) $20 (CARES Act)
$7 (CAA-21)
$25 (ARPA)
Long-term Care Ombudsman Program (Title VII): $19 $20 (CARES Act)
investigate and resolve complaints related to health and $10 (ARPA)
safety of individuals living in long-term care facilities
Total for All OAA programs $1,634 $2,729
Source: GAO analysis of COVID-19 relief funding from the Families First Coronavirus Response Act (FFCRA), the CARES Act, the Consolidated Appropriations Act, 2021 (CAA-21), and the American
Rescue Plan Act of 2021 (ARPA), and agency documents. | GAO-22-104425.
Note: Total funding amounts may not add exactly due to rounding.
16State and local funds also support OAA Title III services.
17State units on aging distribute Title III grant funds to AAAs, and AAAs may provide
services directly or contract with local providers.
Page 6 GAO-22-104425 COVID-19 Services for Older Adults
Provisions in the CARES Act and the Consolidated Appropriations Act,
2021 (CAA-21) allowed HHS to temporarily waive some OAA
requirements; these provisions as well as other existing authorities
provided ACL and states with additional flexibilities. 18 For example, meals
provided using OAA funds are typically subject to certain dietary
requirements, but such requirements could be waived during the
pandemic. Specifically, ACL waived requirements for meals to comply
with two sets of federal guidelines—the Dietary Guidelines for Americans
and the Dietary Reference Intakes, but ACL maintained requirements for
meals to meet minimum calorie levels and encouraged providers to
continue meeting nutritional guidelines. 19
In addition, to promote socialization, the majority of OAA nutrition funds
are intended for congregate meals—where older adults dine together—
rather than home-delivered meals. While states are normally allowed to
transfer some Title III funds between programs to meet local needs, they
are limited in how much funding they can transfer without being granted a
waiver from ACL. 20 During the COVID-19 public health emergency, states
have been able to transfer up to 100 percent of funds between the
congregate and home-delivered meal programs. Further, states were also
provided flexibility under the OAA’s disaster relief provisions to use any
amount of their Title III funds for disaster relief for older adults once the
18In general, some services provided under Title III are required, such as congregate and
home-delivered meals, while some supportive services, such as in-home care and
transportation services, are optional and can be adjusted depending on the needs of the
state.
19The OAA requires states to ensure that meals provided comply with the most recent
Dietary Guidelines for Americans. These guidelines recommend components—such as
fruits, vegetables, grains and protein—and portion sizes. The OAA also requires each
meal include a minimum of 33.3 percent of the Dietary Reference Intakes, which provide
intake recommendations of a wide range of nutrients, including vitamins, such as vitamins
A and C; minerals, such as sodium and iron; and macronutrients, such as fiber and fat.
20Specifically, the OAA typically allows states to transfer up to 40 percent of funds
between the congregate and home-delivered meal programs and 30 percent of funds
between the supportive services and nutrition programs. States may transfer an additional
10 percent of Title III-C funds between parts 1 and 2 (i.e., the congregate and home-
delivered meal programs) if they are granted a waiver from ACL.
Page 7 GAO-22-104425 COVID-19 Services for Older Adults
President approved a major disaster declaration. 21 Table 2 provides
examples of the flexibilities.
Table 2: Key COVID-19 Flexibilities for Older Americans Act of 1965 (OAA) Programs Provided by the CARES Act and OAA
Source of Type of Description of flexibility
flexibility flexibility
CARES Act Nutrition Nutrition requirements wavier: Allows the Secretary of Health and Human Services to waive nutrition
program requirements for congregate and home-delivered meal programs.
flexibility
Nutrition Eligibility expansion: Permits states to establish new guidelines that broaden home-delivered meal
program eligibility criteria to include individuals unable to obtain nutrition services because of social distancing.a
flexibility
Nutrition Funding transfer flexibility: Allows state agencies and area agencies on aging (AAA) to transfer up to 100
program percent of funds received for congregate and home-delivered meal programs between the two programs
flexibility without prior approval.
OAA General Disaster relief provisions: Allows states to use any portion of the funds made available under any and all
funding sections of the OAA to provide disaster relief for older individuals, once the President approves a major
flexibility disaster declaration for the state.b For example, under the disaster relief provisions, funds made
available under OAA Titles III-B (supportive services), and III-E (caregiver services) could be used to
provide more services under III-C (nutrition).
Source: GAO analysis of the CARES Act, the Consolidated Appropriations Act, 2021 (CAA-21), OAA, and Administration for Community Living (ACL) documents. | GAO-22-104425
Notes: These flexibilities established under the CARES Act apply to OAA Titles III, VI, and VII and
were also extended to funds made available under the Families First Coronavirus Response Act
(FFCRA) and the American Rescue Plan Act of 2021 (ARPA). The OAA also provides for other
administrative flexibilities, such as flexibility in the deadlines for state plans, which states generally
submit to ACL every 4 years.
a
Under the OAA, services are generally for adults age 60 and older, but the OAA permits states to
establish specific eligibility criteria beyond the age requirement. Therefore, states will continue to
have this flexibility after the pandemic.
b
In accordance with the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford
Act), as amended, the President of the United States may declare that a major disaster or emergency
exists in response to a governor’s or tribal chief executive’s request if the disaster is of such severity
and magnitude that effective response is beyond the capabilities of a state, tribe, or local government
and federal assistance is necessary. See 42 U.S.C. § 5170. On March 13, 2020, the President
declared COVID-19 a national emergency under the National Emergencies Act and a nationwide
21In accordance with the Robert T. Stafford Disaster Relief and Emergency Assistance Act
(Stafford Act), as amended, the President of the United States may declare that a major
disaster or emergency exists in response to a governor’s or tribal chief executive’s request
if the disaster is of such severity and magnitude that effective response is beyond the
capabilities of a state, tribe, or local government and federal assistance is necessary. See
42 U.S.C. § 5170. On March 13, 2020, the President declared COVID-19 a national
emergency under the National Emergencies Act and a nationwide emergency under
section 501(b) of the Stafford Act. The President also approved major disaster
declarations under the Stafford Act for all 50 states, the District of Columbia, and five
territories. Once a state has an approved major disaster declaration under the Stafford
Act, under the disaster relief provisions of the OAA, states are allowed to use any portion
of the funds made available under any and all sections of the OAA to provide disaster
relief for older individuals, without the need for a separate transfer request or waiver. See
42 U.S.C. § 3030(c).
Page 8 GAO-22-104425 COVID-19 Services for Older Adults
emergency under section 501(b) of the Stafford Act. The President also approved major disaster
declarations under the Stafford Act for all 50 states, the District of Columbia, and five territories. Once
a state has an approved major disaster declaration under the Stafford Act, under the disaster relief
provisions of the OAA, states are allowed to use any portion of the funds made available under any
and all sections of the OAA to provide disaster relief for older individuals, without the need for a
separate transfer request or waiver. See 42 U.S.C. § 3030(c).
States Spent Most
COVID-19 OAA
Funds on Meals for
Older Adults and
Used COVID-19
Flexibilities to
Address Changing
Demand
As Spending Shifted from In fiscal year 2020, states spent over $475 million of funds received for
In-Person Services to Title III services from FFCRA and the CARES Act, with most of it used to
provide meals, according to the most recent data from ACL (see fig.1). 22
Meal Delivery,
This is about 47 percent of the $1.02 billion received, which states have
Supplemental Funds until the end of fiscal year 2022 to spend. 23 In fiscal year 2020, states
Helped States Respond to spent over $280 million of these funds on home-delivered meals and over
Increased Demand $35 million on congregate meals, including meals that older adults could
eat at home while socializing virtually.
22In their fiscal year 2020 program reports, 50 of the 56 states and territories reported on
how they spent $380 million of the FFCRA and CARES Act funds. According to ACL,
states had spent over $475 million of the FFCRA and CARES Act funds as of the end of
fiscal year 2020. ACL was unable to provide us with information about the remaining $95
million, in part because of issues with reporting and data collection, as discussed later in
this report.
23In April 2021, ACL provided automatic no-cost extensions to states for annual OAA Title
III awards and supplemental COVID-19 awards provided under FFCRA and the CARES
Act. As a result, these funds are now available until the end of fiscal year 2022.
Page 9 GAO-22-104425 COVID-19 Services for Older Adults
Figure 1: COVID-19 Supplemental Funds Spent on Older Americans Act of 1965
(OAA) Title III Services, Fiscal Year 2020, in Millions
Notes: “Meals” includes both home-delivered and congregate meals.
States received $1.02 billion in FFCRA and CARES Act funds and spent $475 million of these funds
in fiscal year 2020, according to ACL. In their annual program reports, 50 of the 56 states and
territories reported on how they spent $380 million of these funds. ACL was unable to provide us with
information about the remaining $95 million, in part because of issues with reporting and data
collection, as discussed later in this report.
Initially, Title III funds from FFCRA and the CARES Act were available for
states until the end of fiscal year 2021, and the pace of spending varied
across states and localities. According to ACL officials, some states spent
funds quickly as they attempted to meet the increased demand, while
other states conserved funds because of uncertainty about how long the
pandemic would last and whether states would receive additional federal
funds. Further, officials we interviewed from one selected locality said
they conserved federal funds because they had other funds with earlier
expiration dates, which they spent first. In September 2021, some of the
selected localities reported that they had spent all of the supplemental
COVID-19 funds, but officials from two localities said they had conserved
funds to ensure they could meet demand through the summer and into
the next fiscal year. For example, officials from one locality in Georgia
said they were conserving CARES Act funds to bridge the gap until they
receive funds from the American Rescue Plan Act of 2021 (ARPA). 24
24The OAA includes a requirement for states to match 15 percent of the funds they
receive from annual appropriations. While FFCRA, the CARES Act, and CAA-21 waived
this matching requirement, ARPA did not, so localities will not receive funds from ARPA
until their state appropriates matching funds.
Page 10 GAO-22-104425 COVID-19 Services for Older Adults
Most of the localities reported that the current level of supplemental
funding, including additional funds from the Consolidated Appropriations
Act, 2021 (CAA-21) and ARPA, will help them continue to address
increased demand for services or higher food costs into 2022.
Meals States provided more meals to older adults overall in fiscal year 2020
compared to fiscal year 2019, although the number of congregate meals
decreased as home-delivered meals increased. 25 When comparing the
total number of meals provided (including meals provided with other types
of funding such as annual Title III funds and state funds), states provided
about 24 million more meals overall and about 32 percent more home-
delivered meals in fiscal year 2020, compared to fiscal year 2019 (see fig.
2). 26 According to ACL officials, most states replaced congregate meals
with home-delivered meals during the pandemic. While the number of
congregate meals dropped, some states continued to provide congregate
meals during the pandemic and some providers replaced meals in
traditional congregate settings with grab-and-go meals paired with in-
person or virtual socialization, according to ACL officials.
Figure 2: Number of Meals Provided in Older Americans Act of 1965 (OAA) Title III
Nutrition Programs, Fiscal Years 2019 and 2020, in Millions
25ACL’s data could not be used to determine exactly how many meals were provided with
the supplemental COVID-19 funds because some states do not capture information on the
supplemental funds separately, as we describe later in the report.
26These numbers include meals that states purchased with several funding sources:
annual OAA Title III funds, supplemental COVID-19 funds provided under FFCRA and the
CARES Act, state (including state and local match) funds, and program revenue (e.g.,
contributions from older adults).
Page 11 GAO-22-104425 COVID-19 Services for Older Adults
Note: These numbers include meals that states purchased with several funding sources: annual OAA
Title III funds, supplemental COVID-19 funds provided under the Families First Coronavirus
Response Act and the CARES Act, state (including state and local match) funds, and program
revenue (e.g., contributions from older adults). States received $1.32 billion in fiscal year 2019 and
$1.36 billion in fiscal year 2020 in annual Title III funds. In addition, states received $1.02 billion in
supplemental COVID-19 funds that were available through fiscal year 2021 and spent $475 million of
these funds in fiscal year 2020, according to ACL.
Officials in each of the four selected states attributed the increase in
home-delivered meals during the pandemic to the movement of
congregate meal clients to home delivery and new clients who were
staying at home. For example, officials from a locality in New York said
their existing congregate meal clients switched to home-delivered meals
when the locality closed congregate meal sites. Regarding new clients,
officials from each of the four states said one reason they gained new
clients was that additional older adults became aware of meal services
during the pandemic. For example, officials from one locality said they
increased outreach to older adults during the pandemic and officials from
another locality said older adults learned about the services from their
friends. The increased funding may have also allowed some programs to
serve clients who had been waitlisted prior to the pandemic. For example,
officials from a locality in Georgia said the supplemental funds allowed
them to serve all older adults who requested meals including those that
had been on a waitlist.
States also spent more on meals because the cost of providing home-
delivered meals increased, according to officials from selected localities.
Local officials from South Dakota and New Mexico said providers needed
to purchase additional supplies, such as personal protective equipment
and food delivery containers that increased the cost of providing meals.
Local officials in South Dakota said food costs increased during
shortages.
Other Services Compared with meals, states spent much less of their supplemental
COVID-19 funds on all other services combined (see fig. 1). After meals,
states reported spending the most funds on providing information and
assistance, including connecting older adults to services. Other services
that states reported spending the highest amounts of supplemental funds
on included case management, homemaker (e.g., meal preparation or
light housework), and socialization (e.g., wellness phone calls).
Similarly, regarding both annual and supplemental expenditures
combined, states spent much less on other services than on meals in
fiscal year 2020, compared to fiscal year 2019 (see fig. 3). However, the
Page 12 GAO-22-104425 COVID-19 Services for Older Adults
extent that this was due to the pandemic is unclear. Although total
expenditures on some in-person services, such as homemaker services,
remained steady, states’ spending on adult day care and transportation
decreased by over 20 percent. Officials from three national aging
associations said that demand for in-home services decreased early in
the pandemic, in part, because some older adults were hesitant to have
other people in their homes. Additionally, public health orders led to the
suspension of many in-person services, such adult day care centers,
according to state and local officials in New Mexico. However, ACL
officials noted that prior to the pandemic, states’ spending by service
could vary significantly from year to year, making it hard to attribute
changes between 2019 and 2020 entirely to the pandemic.
Figure 3: Percentage Change in Total Expenditures for Selected Older Americans Act of 1965 (OAA) Title III Services between
Fiscal Years 2019 and 2020
Note: These numbers include meals that states purchased with several funding sources: annual OAA
Title III funds, supplemental COVID-19 funds provided under the Families First Coronavirus
Response Act and the CARES Act, state (including state and local match) funds, and program
revenue (e.g., contributions from older adults). States received $1.32 billion in fiscal year 2019 and
$1.36 billion in fiscal year 2020 in annual Title III funds. In addition, states received $1.02 billion in
supplemental COVID-19 funds that were available through fiscal year 2021 and spent $475 million of
these funds in fiscal year 2020, according to ACL. It is unclear to what extent the changes shown
above were due to the pandemic, as year to year fluctuation in service expenditures are common,
according to ACL officials.
Page 13 GAO-22-104425 COVID-19 Services for Older Adults
Selected States Reported Officials in the four selected states said several COVID-19 flexibilities
That COVID-19 allowed them to quickly shift to home-delivered meals, expand provider
networks, enroll new clients, and adapt to food shortages.
Flexibilities Helped Them
Quickly Shift Resources to • Funding flexibilities. All of the selected localities across the four
Meet Changing Demands states used at least one of the funding flexibilities to redirect funds to
address changing client needs, according to state and local officials.
For example, they said all localities used the COVID-19 nutrition
program funding flexibility, which allowed states to transfer 100
percent of funds between the congregate and home-delivered meal
programs, enabling them to address the increased demand for home-
delivered meals. In addition, officials from some localities said the
OAA disaster relief flexibility allowed them to redistribute funds across
all OAA services based on local needs during the pandemic. For
example, state and local officials in New Mexico said this flexibility
helped them redistribute funds and staff from the in-home services
program, which the state suspended, to address increased demand
and staffing shortages in the nutrition program.
• Nutrition requirements waiver. Officials from most localities across
the four states reported that the nutrition requirements waiver helped
them address challenges during the pandemic. Specifically, officials
from some localities said the waiver helped them work around food
and provider shortages during the pandemic, which made it difficult to
ensure meals met the two sets of requirements—Dietary Guidelines
for Americans and the Dietary Reference Intakes. According to one
state official, the nutrition requirements waiver allowed localities in the
state to provide uninterrupted meal service despite food shortages.
The waiver allowed two localities to leverage local resources to meet
the demand for meals. For example, a locality in Georgia reported
partnering with restaurants to provide meals early in the pandemic
because their existing meal providers could not serve the increased
number of clients. Initially, the restaurants were not always able to
meet the nutrition requirements, but have since coordinated with a
dietitian to create special meals for older adults that meet
requirements, according to a local official. Other state and local
officials said they were able to return to meeting the nutrition
requirements when food shortages eased later in the pandemic.
Additionally, officials from some localities across three states reported
that the nutrition requirements waiver allowed them to address the
increased demand for food with frozen meals, shelf-stable meals, or
groceries, which did not always meet nutrition requirements. For
Page 14 GAO-22-104425 COVID-19 Services for Older Adults
example, officials from a locality in New Mexico said their providers
prepared new recipes that they could freeze easily, and the providers
distributed them to older adults quickly to meet demand without fully
reviewing the nutritional value. State officials in New Mexico added
that their first priority was on meeting older adults’ immediate needs—
which sometimes necessitated providing available shelf-stable foods.
• Eligibility expansion for home-delivered meals. Officials from
some localities we spoke with said the ability to expand eligibility for
home-delivered meals helped them enroll new clients quickly as
demand for these increased. According to ACL, the OAA already
provides states flexibility to determine their own eligibility
requirements for home-delivered meals beyond the age requirement.
However, the additional flexibility in the COVID-19 relief laws helped
some states broaden eligibility requirements quickly, according to ACL
officials. For example, officials from a locality in New York said they
waived eligibility assessments and provided home-delivered meals to
all older adults who requested them early in the pandemic. By
October 2020, the locality returned to assessing eligibility based on
the need for meals to be provided in the home (e.g., the extent that
older adults were homebound or could not shop for or prepare meals
themselves). In contrast, officials from two large urban localities in the
selected states said they could not serve all older adults who wanted
these services, so they maintained systems to assess older adults
and prioritize services to those with the greatest need.
ACL officials do not believe that states will continue to need the
flexibilities after the pandemic eases due to the inherent flexibilities within
the OAA, but state, local, and national aging association officials had
mixed views on whether the flexibilities would remain helpful in the future.
Regarding the nutrition requirements, officials from some localities said
they tried to adhere to the requirements as much as possible during the
pandemic, and ACL officials said the nutrition requirements help keep
older adults healthy and prevent malnutrition and food insecurity. 27
However, officials from two state offices said changes to the nutrition
27In 2019, we found that the nutrition requirements provide broad guidance on nutrition for
healthy populations, but do not address the varying nutrition needs of older adults. We
recommended that HHS develop a plan to include specific nutrition guidelines for older
adults in its guidance, and as of September 2021, ACL reported related efforts underway
but had not fully implemented our recommendation. See GAO, Nutrition Assistance
Programs: Agencies Could Do More to Help Address the Nutritional Needs of Older
Adults, GAO-20-18 (Washington, D.C.: Nov. 21, 2019).
Page 15 GAO-22-104425 COVID-19 Services for Older Adults
requirements would help them continue to serve older adults after the
pandemic. For example, officials from a locality in one of these states said
the waiver would help providers serve more culturally diverse meals.
Officials from two national aging associations also reported that the
nutrition requirements are not always culturally appropriate. For example,
according to one of these associations, the nutrition requirements call for
the inclusion of dairy, but adults from some cultures typically do not
consume dairy products. According to ACL, dairy is not an OAA
requirement, but many state policies require that OAA meals include milk.
The OAA requires states to ensure that that meals provided comply with
the most recent Dietary Guidelines for Americans, and the 2020-2025
guidelines recommend that older adults consume 3 cups of dairy or
fortified soy alternatives per day. 28
Regarding the funding flexibilities, officials from three states and some
localities said some amount of continued flexibility would help them
allocate resources based on local needs and changing demand.
However, officials from one state also noted that all of the OAA programs
are important and that large transfers could leave some programs with
insufficient funds.
ACL has requested that Congress allow states to transfer 100 percent of
their funds between Title III programs in fiscal year 2022, but ACL officials
said states would not need this flexibility after the pandemic because the
OAA allows sufficient flexibility to meet states’ needs. For example, prior
to the pandemic, states rarely requested waivers from ACL to transfer
funds beyond the statutory limits in the OAA, according to ACL officials.
ACL data show that in fiscal year 2019, no state requested a waiver to
transfer above the limit, and six states transferred amounts within 5
percentage points of the limit. Moving forward, ACL officials said they will
continue to assess whether to request that Congress continue any
pandemic-instituted flexibilities after fiscal year 2022.
28The OAA also requires that meals include a minimum of 33.3 percent of the Dietary
Reference Intakes, which provide intake recommendations of a wide range of nutrients,
such as calcium. According to ACL, one of the most common sources of calcium is milk,
and many state nutrition policies require that OAA meals include milk since it is often
cheaper and easier to offer than alternative sources. ACL has provided information to
states about alternative sources of calcium that can be provided instead of milk. See ACL,
The Older Americans Act Nutrition Program: Did You Know…? (May 2015), accessed on
December 3, 2021, https://acl.gov/sites/default/files/programs/2016-11/OAA-Nutrition-
Program-FAQ.pdf.
Page 16 GAO-22-104425 COVID-19 Services for Older Adults
Selected States
Focused on Safety
and Meeting
Increased Demand
When Modifying
Nutrition and Other
Services
Selected States and Home-delivered meals. Officials from selected localities said they
Localities Expanded Meal adjusted their methods of preparing and delivering home-delivered meals
to meet the increased demand and keep people safe. For instance, some
Delivery Methods and
localities made single deliveries with multiple days’ worth of meals, and
Adjusted or Paused Other provided frozen meals instead of hot meals to limit the number of times
Services they needed to make contact with the client (see fig. 4). To increase
safety for clients, volunteers, and employees, some localities reported
implementing new delivery protocols such as leaving meals on the porch
or entryway and observing the client’s receipt of the meals at a distance.
Additionally, officials from some localities said they met the increased
demand for meals by implementing new approaches to manage the
preparation and distribution of meals. For example, in order to store the
increased number of prepared meals, a New York locality reported using
freezer spaces at 10 local restaurants. As an alternative to preparing
meals in-house, officials from two other localities told us they contracted
with businesses that sell prepared meals, such as shelf-stable meals and
frozen meals to ship directly to some of their clients.
Page 17 GAO-22-104425 COVID-19 Services for Older Adults
Figure 4: Meals on Wheels of Central Maryland Prepared Home-Delivered Meals for Older Adults during the Pandemic
Additionally, officials from some of the selected localities reported facing
shortages of staff and volunteers to deliver meals and found alternative
solutions. For instance, some local officials reported that many of their
traditional volunteers, often older adults themselves, no longer felt
comfortable serving during the pandemic or were directed by state or
Page 18 GAO-22-104425 COVID-19 Services for Older Adults
local orders to stay at home. 29 Officials from one South Dakota locality
reported some of their volunteers who became infected with COVID-19
were unable to return due to the long-term effects of the disease. As a
result, localities reported finding alternative solutions to fill these gaps.
For example, one local official told us that county employees from other
departments were able to help at the meal distribution sites. Additionally,
an official at a rural locality in South Dakota said they used COVID-19
funding to retain existing drivers and hire additional delivery drivers for
their home-delivered meals, while a New Mexico locality reported using
their transportation services’ vans to deliver meals to their clients.
Grocery deliveries. Some localities provided groceries to their clients,
either as a supplement or an alternative to home-delivered meals.
Officials from one locality in New York told us they provided clients with
supplemental care packages including shelf-stable foods and household
items such as toilet paper, along with puzzles and games to provide their
clients with activities during the stay-at-home order. Some local officials
we spoke with said they provided grocery boxes instead of or in addition
to home-delivered meals to some of their older adult clients who were
able to cook meals for themselves. Officials from one locality said that
providing groceries to some of their clients instead of prepared meals
helped preserve their clients’ independence, which is a core goal of their
agency and the OAA. 30 See text box for more information on use of the
Supplemental Nutrition Assistance Program (SNAP) online purchasing
pilot to provide older adult SNAP recipients access to grocery deliveries.
29For instance, in March 2020, the governor of New York announced an initiative (referred
to as “Matilda’s Law”), which was intended to protect individuals 70 and older, by requiring
them to stay home, wear a mask in the company of others, and limit their in-home
visitation.
30ACL, working with the National Resource Center on Nutrition and Aging, suggested
providing groceries to clients during the pandemic as one method to increase food access
and assist with feeding older adults facing food insecurity, according to officials. See ACL,
COVID-19 Response: FAQ – Groceries and OAA Programs (last updated on May 20,
2020), accessed on October 5, 2021,
https://acl.gov/sites/default/files/common/Posted%20-%20AoA%20-
%20FAQ%20Addendum%20-%20Groceries_05-20-2020-FINAL%20AWR.docx, and
Using Groceries and other Nutrition Services to Meet Senior Needs (last updated on Oct.
27, 2020), accessed on October 14, 2021.
https://acl.gov/sites/default/files/SN/GroceryTipSheet.docx.
Page 19 GAO-22-104425 COVID-19 Services for Older Adults
Use of SNAP Online Purchasing among Older Adults
The Supplemental Nutrition Assistance Program (SNAP) provides monthly nutrition assistance benefits to low-income
households, including those with older adults, who meet the eligibility criteria. The Department of Agriculture’s Food and
Nutrition Service (FNS) oversees SNAP, and state SNAP agencies administer the program. The Agricultural Act of 2014
established the SNAP online purchasing pilot, which allows recipients in participating states to use their SNAP benefits
online at participating retailers.a The pilot began in New York in 2019 and, as of August 2021, includes 47 states and the
District of Columbia, according to FNS officials.b
The extent to which older adult SNAP recipients took advantage of this program during the COVID-19 pandemic is unknown,
according to FNS. Specifically, FNS does not track data specific to SNAP online purchasing for older adults, including their
use of online purchasing since the start of the pandemic. Officials from two FNS regional offices reported hearing anecdotally
that the pilot has been helpful to SNAP recipients (including older adults) during the pandemic, as a way to help them use
their benefits safely, and that some of the participating retailers offered recipients curbside pick-up options as another way to
keep people safe.
Although the online purchasing pilot could be a useful option for older adult SNAP recipients to reduce their exposure to
COVID-19 by having groceries delivered, certain factors may limit its use, according to officials we interviewed. For instance,
officials from one national aging association said they believe not all older adults are aware of the program. Officials from the
four state units on aging said that Aging and Disability Resource Centers—which serve as a central source of information for
older adults and people with disabilities—may be providing information and assistance to older adults who are eligible for
SNAP benefits, but not all eligible adults seek services from these centers.
Further, officials in New Mexico and South Dakota said older adults in rural areas may not have access to online retailers
because only a few retailers in urban and suburban areas participate at this time. For example, at the time of our interview,
an official in South Dakota told us there were three retailers in the state that participate in the pilot and one of those retailers
only operates in Sioux Falls, the largest city in the state.
In addition, officials from some of the eight localities we spoke with noted that some older adults may not be comfortable with
or have access to the technology required to place online grocery orders. Officials from one national aging association said
that delivery fees cannot be paid for with SNAP benefits, which may further deter older adults from using this pilot program.c
Source: Information from FNS’s website and interviews with state units on aging and area agencies on aging in four states (Georgia, New Mexico, New York, and South Dakota), FNS officials, and
national aging associations. | GAO-22-104425
a
See Pub. L. No. 113-79 §4011 128 Stat. 649, 790-93.
b
According to FNS officials, the agency plans to continue the pilot program moving forward.
c
Some participating retailers waived some delivery fees for SNAP recipients using their benefits
online.
Congregate meals. Officials from most localities said that social
distancing requirements and stay-at-home advisories meant that older
adults could no longer have traditional congregate meals at sites, such as
senior centers, although some localities told us they adjusted their
operations to continue to provide meals in other ways. Officials from most
of the localities we spoke with reported that they initially shut down their
congregate meal sites. As the pandemic continued, according to officials,
some localities converted their congregate sites to centers for “grab-and-
go” meal pickup, but other localities continued to provide all their
congregate meal clients with home-delivered meals (see fig. 5). To retain
some of the social aspects of the congregate meal community
experience, local officials in Georgia and New Mexico told us their
organizations hosted socially distanced phone and video conferences so
Page 20 GAO-22-104425 COVID-19 Services for Older Adults
their older adult clients could socialize with each other. According to ACL,
other localities maintained some social activities for their congregate meal
clients who had participated in the congregate meal program prior to the
pandemic. For example, one locality hosted activities such as live
entertainment and small group outdoor picnics when clients picked up
their grab-and-go meals, while another locality held online social dining
events for their clients.
Figure 5: Grab-and-Go Meal Pick Up at a Congregate Meal Site in Boston
Transportation. Officials in three states and some localities told us they
suspended or significantly reduced their transportation services early in
the pandemic due to safety concerns, but as the pandemic continued,
some localities modified transportation services to comply with social
distancing measures and ensure older adults were able to get to their
medical appointments. Local officials in New Mexico told us their state
implemented additional safety precautions, such as limiting the number of
clients in a vehicle, which officials said made operating costs higher and
limited the transportation service schedule. Once COVID-19 vaccines
were available for older adults, officials with two of the selected localities
Page 21 GAO-22-104425 COVID-19 Services for Older Adults
told us they began providing transportation services for older adults going
to and from their vaccine appointments.
In-home supportive services. Officials in some localities stated that in-
home supportive services for their clients were reduced or temporarily
stopped at the beginning of the pandemic, and officials from two localities
mentioned that some clients were reluctant or scared to have others in
their homes. In-home services may also have been reduced due to
workers’ own concerns about their safety, according to officials from a
national aging association we interviewed. Most selected localities
reported conducting well-being checks via telephone instead of going into
clients’ homes. These calls allowed them to assess the needs of their
clients and make sure clients had the support they needed during stay-at-
home orders.
Caregiver support services. Early on when the pandemic began, some
of the selected states and localities reported shutting down caregiver
support groups and respite care services, which can give caregivers a
break. As the pandemic continued, most local officials we spoke with said
they shifted to providing virtual support groups for caregivers, and two
localities resumed offering limited respite care services to caregivers. For
example, in the spring of 2021, officials from one locality in Georgia said
they began to offer respite care vouchers that caregivers could use to
bring their older adult relative to an adult day care center. Officials from
one of the selected states and some localities expressed concern about
the well-being of caregivers during the pandemic, with one state official
acknowledging that caregivers experienced greater stress during the
pandemic because they did not have opportunities to take breaks from
their caregiving responsibilities.
Health and wellness. Selected states and most localities reported using
technology—such as social media, video chats, or other platforms—to
either provide virtual exercise or other wellness classes and increase
social opportunities for their clients (see fig. 6). For example, a Georgia
locality hosted live-streamed classes such as chair aerobics on their
Facebook page, also enabling these videos to be available for later on-
demand viewing. This locality also reported hosting activities by
telephone—such as a call-in lunchtime social hour and phone bingo—for
clients who may be unfamiliar with or have limited access to the internet
or other technology.
Page 22 GAO-22-104425 COVID-19 Services for Older Adults
Figure 6: Older Adult Participating in a Virtual Exercise Activity
Some states and localities also reported providing electronic devices and
assistance with using technology to their clients, in an effort to support
their overall wellness. For example, officials in three of the selected states
reported distributing tablets to some of their clients to allow them to
participate in videoconference calls for socialization purposes.
Additionally, officials in New Mexico said they provided wireless data
subscriptions for tablets to some older adults, while Georgia state officials
said they had clients use their tablets for telehealth evaluations and
addressing social isolation. As localities began hosting online activities,
one New York locality reported partnering with community volunteers to
train and assist clients in accessing virtual senior center programs from
home.
Page 23 GAO-22-104425 COVID-19 Services for Older Adults
Information, assistance, and referrals to services. Officials from one
of the localities reported a large increase in calls for information,
assistance, and referrals to services during the pandemic. According to
state and local officials we interviewed, information requests included
vaccine availability and scheduling, assistance with transportation, and
help obtaining items such as groceries or prescription drugs. One locality
reported assisting some clients with support for paying utility bills or
temporary housing. At most localities, officials reported conducting
outreach to their clients by telephone to assess their needs and identify
appropriate assistance, and others reported disseminating information in
other ways such as by sending emails, posting information on their
websites, and distributing flyers with home-delivered meals.
ACL officials stated that Aging and Disability Resource Centers (ADRC)—
which are sometimes operated by AAAs—have also played a critical role
in providing older adults with information and referrals to other federal
programs, such as SNAP and Medicaid, as well as local community
resources. 31 Since the pandemic began, ACL officials reported that
overall, the volume of calls to ADRCs from people requesting assistance
increased substantially. Officials from two national aging associations
said that AAAs had hired additional staff to field information and referral
calls, and two localities in Georgia reported using some supplemental
COVID-19 funds to hire additional ADRC staff to assist their older adult
clients during the pandemic.
The selected states and localities told us about the strategies and service
modifications described above in the spring of 2021. As of September
2021, most of the eight localities reported that some in-person services
had resumed, though services continued to be affected by the pandemic.
Most localities reported resuming congregate meals with new safety
precautions, such as encouraging social distancing and mask wearing
when not eating, and implementing capacity limits (see fig. 7). In-home
supportive services had largely resumed, according to officials from some
localities; however, most noted that they were experiencing staffing
shortages for in-home services, which some said has limited the number
of clients who can receive these services. As of September 2021, most of
31ADRC programs received a total of $50 million under the CARES Act. These funds were
targeted to connect people at greatest risk of COVID-19 to community-based services to
avoid unnecessary institutionalization, as well as to mitigate the negative psychosocial
impact of social isolation, according to ACL. As of 2019, 65 percent of AAAs in the United
States also perform ADRC functions according to the national aging association USAging.
Of the eight selected localities in this review, four were also serving as ADRCs.
Page 24 GAO-22-104425 COVID-19 Services for Older Adults
the selected localities reported the current volume of calls for information,
assistance, and referrals had either remained steady or increased,
compared to the beginning of the pandemic.
Figure 7: Older Adults Socialize with Masks in a Partially Re-opened Congregate Meal Dining Hall
Virtual Service Delivery Virtual service delivery. Officials from two selected states and some
and Expanded localities, as well as from ACL, said they anticipated that some services
will continue to be delivered virtually moving forward, with some officials
Partnerships with Public
noting that this helps them serve more clients. Officials from some
Health and Others May localities we met with noted that virtual programming benefits older adults
Continue Post-Pandemic by giving them more options to engage with local organizations. For
example, an official from a New Mexico locality envisioned continuing to
use a hybrid service model to help them meet the increased demand
resulting from the pandemic in both their adult day care (in-person care)
and recreation programs (virtual). Officials from a New York locality also
said that increasing their virtual service offerings after the pandemic will
help them continue to engage with older adults who they believe may
continue to be reluctant to leave their homes and gather in-person.
Officials from a rural locality in Georgia reported that offering virtual
services and decentralizing their service delivery methods allows more
Page 25 GAO-22-104425 COVID-19 Services for Older Adults
clients to receive services in their large service area, with the added
benefit of keeping older adults integrated into their local communities.
Using Animatronic Pets To Address Social In addition, officials from selected states, ACL, and national aging
Isolation in New York associations described using technology to mitigate the pandemic’s
New York reported using a method to help effects of increased isolation by continuing to engage older adults
combat social isolation and loneliness among
older adults by piloting a program that, as of
socially, strategies which may continue after the pandemic. As noted
November 2021, had distributed 3,500 earlier, most of the selected localities conducted virtual social events,
animatronic pets to some of their older adult telephone wellness checks, or other virtual activities to keep older adults
clients across the state. The animatronic pet
devices mimic the movements and sounds of engaged and connected to one another while isolated at home.
pets and interact with their users. A New York Additionally, according to officials in Georgia, some ADRCs trained their
official said they found these pets to be
successful in reducing feelings of isolation staff to assess social isolation risk virtually during telephone screenings
and pain. during the pandemic, and officials said that an older adult determined to
be at risk may subsequently receive an intervention strategy, such as a
tablet to connect with family or friends. In New York, an official reported
distributing animatronic pets during the pandemic to help some older
adults with aspects of social isolation (see sidebar). 32
However, most state and local officials we spoke with said that not all
older adults are comfortable using or have access to technology to
connect to virtual services, and some officials described efforts to try to
help address this. For instance, various officials described older adults’
lack of familiarity with technology as a barrier to their use of virtual
services. To help address this, localities in two states reported leveraging
non-traditional volunteers to help older adults with technology. For
example, state officials from Georgia described their “device advice”
program, which was in place before the pandemic, where high school
student volunteers taught older adults how to use technology. In New
York, a state official told us that their partnerships, such as with
technology companies, to provide technology support to older adults
Source: GAO interview with New York State Office for the
Aging and photographs provided by an official in New York. | expanded significantly during the pandemic, and this official confirmed
GAO-22-104425
that these new partnerships will continue.
Additionally, limited broadband can create challenges for older adults to
connect to virtual services, and officials from all four selected states
32According to ACL, while this type of intervention may show promise for select
populations of older adults, OAA Title III socialization activities typically involve person-to-
person interaction.
Page 26 GAO-22-104425 COVID-19 Services for Older Adults
reported this as an issue for their clients living in rural areas. 33 An official
in New York noted that efforts to increase broadband access during the
pandemic, such as for remote schooling, have benefited their older adult
clients as well. ACL officials acknowledged that the implications of the
pandemic will continue to affect the older adult population for some time,
and said that it was important to direct some of the supplemental COVID-
19 funds towards improving older adults’ access to technology to connect
to virtual services.
While greater access to virtual services could be helpful for older adults,
officials from one locality and a national aging association representing
state units on aging also cautioned that virtual service offerings and
telephone wellness checks are not adequate substitutes for in-person
services, socialization, or check-ins. Officials from one national aging
association and three of the four states noted that going into a person’s
home provides valuable information about the older adult’s health and
well-being. 34 (See text box for additional information about supplemental
COVID-19 funds for state Adult Protective Services programs.) Another
official from a national aging association noted that more research is
needed to determine the extent to which virtual services help to address
social isolation and loneliness. 35 Congress included language related to
the $460 million in ARPA supplemental OAA Title III-B funding, which
33We reported on technology-related challenges, including those related to broadband
availability, for rural older adults. See GAO-19-330, Older Americans Act: HHS Could Help
Rural Service Providers by Centralizing Information on Promising Practices (Washington,
D.C.: May 23, 2019).
34In September 2021, the contractor that manages the National Adult Maltreatment
Reporting System on behalf of ACL noted that stakeholders in the Adult Protective
Services (APS) community have identified a need to collect better data on the social
isolation of APS clients and victims. The contractor asked for input from stakeholders on
how this system could be modified to collect data on social isolation in the future. For
more information on ACL’s efforts to work with state APS agencies to collect national data
on adult maltreatment through the National Adult Maltreatment Reporting System, see
GAO-21-90, Elder Justice: HHS Could Do More to Encourage State Reporting on the
Costs of Financial Exploitation (Washington, D.C.: Dec. 18, 2020).
35According to a national survey of AAAs conducted by the national aging association
USAging in April 2021, over 75 percent of respondents cited social isolation of older adults
as a top concern as the pandemic continues. Other research has described the negative
effects of social isolation on older adults’ health and mortality. See National Academies of
Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults:
Opportunities for the Health Care System. Washington, DC: The National Academies
Press, 2020.
Page 27 GAO-22-104425 COVID-19 Services for Older Adults
indicated that states and AAAs could use these funds toward addressing
social isolation among older adults. 36
Supplemental COVID-19 Funding for Adult Protective Services’ (APS) Response to the Pandemic
APS officials in the four selected states shared concerns that the COVID-19 pandemic has increased the risk that abuse or
neglect of older adults will go unnoticed and unreported, as all of the selected states’ APS agencies reporting reducing in-
person visits by APS caseworkers during the pandemic as a way to keep staff and clients safe.a
In December 2020, the Administration for Community Living (ACL) received $100 million in funding from the Consolidated
Appropriations Act, 2021 (CAA-21) for elder justice programs including APS, the first time federal funds have been provided
directly to support APS programs.b ACL announced that these funds would be allocated through formula grant awards to all
states and territories, and should be used by states to enhance, improve, and expand the ability of APS to investigate
allegations of abuse, neglect, and exploitation in the context of COVID-19. States could use the funds for purposes such as
expanding training, purchasing personal protective equipment for caseworkers, and acquiring equipment to improve remote
worksites for APS workers.
To obtain this supplemental COVID-19 funding, states were required to submit a spending plan to ACL to describe how they
planned to use it. Our four selected states’ APS agencies reported they would use these funds for a variety of purposes:
• Georgia reported that it planned to spend its funds on items such as rent and utility assistance, and minor home repairs
for the purpose of keeping APS clients in their homes and avoiding long-term care facilities.
• New Mexico planned to spend some of its funds upgrading its information technology systems to support its staff who
are now working remotely.
• New York reported plans to spend some of these APS funds to establish new or improve existing processes to respond
to alleged COVID-19 related scams and frauds, particularly concerning vaccine or cure scams.
• South Dakota planned to spend its funds to purchase personal protective equipment for its staff and on a public
awareness outreach campaign, among other things.
APS officials in all of the selected states said these supplemental funds were extremely beneficial to their efforts to keep
older adults safe during this unprecedented crisis. Three of them expressed concern that once the federal funding ends, they
would have to reevaluate their ability to continue these APS services moving forward.c
Source: Information from ACL and written responses from selected states and information from selected states’ APS agency spend plans. | GAO-22-104425
a
APS programs are state and locally run and respond to reports of suspected abuse and neglect of
older adults (60 and older) and in many states, of adults with disabilities who are 18 and older. APS
caseworkers are social service professionals who investigate and substantiate reports of abuse and
take steps to stop the abuse and assist the victim with appropriate services, when necessary.
b
Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, 134 Stat. 1182, 1916 (2020). Elder
justice programs, including APS, are authorized through the Elder Justice Act of 2009, and
administered by ACL.
c
The American Rescue Plan Act of 2021 (ARPA) authorized and appropriated additional funding for
formula grants to APS programs. In September 2021, ACL announced that more than $85 million in
ARPA funds had been awarded to states and territories.
36Further, the 2020 OAA reauthorization included several requirements for ACL to report
on efforts to reduce social isolation, including to “develop priorities, objectives, and a long-
term plan to support state and local efforts involving education about, prevention of,
detection of, and response to negative health effects of social isolation among older
adults.” In May 2021, ACL reported to Congress on its efforts, which included providing
the aging network with technical assistance and training and continuing its “Commit to
Connect” campaign—a collaborative effort involving federal agencies and national and
state aging organizations to help address social isolation.
Page 28 GAO-22-104425 COVID-19 Services for Older Adults
New and expanded partnerships for nutrition services. Officials from
a number of the selected states and localities told us that the pandemic
forced them to look to other non-traditional partnerships to continue to
serve older adults, particularly in terms of providing meals or groceries.
For instance, partnerships that we heard about among the selected states
and localities, as well as national aging associations, included those with:
• private companies to obtain packaged meals;
Community Partnerships in Other States
AAAs around the country leveraged • restaurant partnerships to serve congregate and home-delivered meal
community partnerships to expand the clients;
services they provided to older adults during
the pandemic. For example, an AAA in • faith-based organizations or food banks to provide groceries to older
Pennsylvania reported partnering with a local
youth organization to help pack and deliver adults—for instance, state officials in New Mexico said their
shelf-stable food and hygiene products to community partnerships included churches and assistance from
older adults. An AAA in Florida leveraged volunteers, which enabled them to distribute tens of thousands of food
community partnerships to secure donations
of hygiene products, which it delivered to boxes at senior centers, helping older adults in need; 37
older adults along with their meals and at
grab-and-go sites. • local farmers to provide fresh produce; and
Community partnerships also helped AAAs
reach older adults for vaccinations. An AAA in • schools to prepare and deliver meals (e.g., via school buses), and the
Minnesota reported coordinating with coordination of such efforts with providing meals for school-aged
community organizations to hold vaccine children.
clinics targeted to underserved populations,
such as immigrant communities. For example, Although some of these partnerships were established to provide meals
the AAA partnered with a local religious
organization to vaccinate around 6,000 older during this emergency situation and amid food and staff shortages, ACL
adults, according to an AAA official. The officials believe that the aging network will maintain its partnership with
official said this partnership was successful
because religious leaders helped build trust USDA’s Food and Nutrition Service to provide older adults with increased
among individuals in the community who were food access. State and local officials in one state also reported that they
hesitant to receive the vaccine.
planned to maintain some of these practices, such as partnerships with
Source: GAO review of documents from USAging and written
responses from AAA officials. | GAO-22-104425 local restaurants, to continue to provide meals to older adults after the
pandemic.
Collaboration with public health and emergency management.
Expanded partnerships or collaborative efforts established with public
health and emergency management during the pandemic may continue,
according to officials from ACL and most localities we spoke with across
the four states. For instance, state officials from New Mexico told us that
they have partnered with emergency management to deliver meals, and
local law enforcement to conduct wellness checks on older adults.
Additionally, ACL officials stated that the new partnerships the aging
37ACL has posted information on its website regarding how aging offices and providers
can partner with food banks and other nutrition programs administered by the USDA. See
National Resource Center on Nutrition and Aging, “Partnerships with Foodbanks and
Other United States Department of Agriculture (USDA) Programs.”
Page 29 GAO-22-104425 COVID-19 Services for Older Adults
network made with federal, state, and local public health and emergency
management agencies were critical in providing information and services
to older adults during the pandemic, and that maintaining such
partnerships would be useful in responding to future emergencies.
As an example of this collaboration, most of the selected localities were
involved in efforts to help older adults get vaccinated when vaccines
became available in early 2021—ranging from conducting outreach to
facilitating in-home vaccines—and sometimes collaborated with public
health or emergency management departments or other entities in these
efforts. One national aging association noted that state aging offices and
local providers were well positioned to help facilitate the vaccine rollout
among older adults given their existing client relationships and experience
providing age-friendly support, and could be called upon to assist with
future vaccination efforts. 38
• Outreach and information efforts included working with public health
departments to disseminate vaccine information to older adults.
Examples included placing flyers about vaccines in meal deliveries;
posting information on social media sites, in emails, or in newsletters;
and conducting targeted outreach to homebound clients. At the
request of their public health departments, two localities made vaccine
outreach calls to older adult clients on their client lists.
• Scheduling and coordination efforts included helping older adults
register for the vaccine or scheduling vaccine appointments, such as
by navigating sometimes challenging websites. For instance, state
officials from New Mexico told us that their aging providers had direct
access to the public health department’s portal to help older adults get
registered.
38In March 2021, HHS announced a partnership between ACL and the Centers for
Disease Control and Prevention (CDC) to help increase vaccinations among older adults
and people with disabilities. Specifically, this partnership allowed ACL to distribute $93
million of CDC funding to aging and disability offices (including ADRCs) in all states to
help provide assistance with scheduling vaccine appointments, transportation to vaccine
sites, in-home vaccinations, and education and outreach, among other efforts. An
additional $5 million was to help fund national hotlines to connect older adults and people
with disabilities with local disability and aging agencies to help with vaccine registration
and related supports and services. As of September 2021, virtually all of this funding had
been obligated, according to ACL. Additionally, ACL has posted information on its website
on strategies states, localities, and other organizations can use to help older adults and
people with disabilities access the COVID-19 vaccine. (See ACL, “Strategies for Helping
Older Adults and People with Disabilities Access COVID-19 Vaccines,” (Washington,
D.C.: April 2021), accessed August 5, 2021, https://acl.gov/sites/default/files/2021-
04/ACLStrategiesVaccineAccess_Final.pdf.)
Page 30 GAO-22-104425 COVID-19 Services for Older Adults
• Vaccination assistance efforts included helping older adults with
transportation to vaccine sites and escorting them to their
appointments, if needed, as well as providing older adults with
vaccines at home or in smaller sites. For instance, officials from an
urban AAA in New York said that they helped thousands of
homebound older adults and their caregivers get vaccinated in their
homes. Officials in several localities also told us they worked with
public health departments or pharmacies to arrange smaller vaccine
sites, such as at senior centers, which may be more familiar locations
to their older adult clients.
As of September 2021, officials at most localities reported that they will
continue to work with their local emergency management or public health
departments going forward, with some localities specifically mentioning
their plans to continue to coordinate to deliver additional COVID-19
vaccines and annual flu shots for their clients.
ACL Responded to
Emergency by
Modifying State
Reporting Processes
and Sharing
Information with
States
States Provided ACL with States began receiving supplemental COVID-19 funds midway through
Varying Levels of Detail on the 2020 federal fiscal year, which required ACL to quickly update its
existing State Program Report guidance to include reporting requirements
How COVID-19 Funds
for states’ use of the supplemental funds. Typically, ACL requires states
Were Spent and ACL to report OAA data annually using an ACL template that includes specific
Plans to Collect More data fields. These fields include, among others, number of clients served,
Consistent Information service units provided (e.g., meals or service hours), and expenditures by
services within Title III programs (e.g., case management or homemaker
expenditures, which fall under Title III-B supportive services). For fiscal
year 2020, ACL maintained these reporting requirements, but also asked
states to report on their use of COVID-19 funds by including an open-
Page 31 GAO-22-104425 COVID-19 Services for Older Adults
response “narrative” with their annual State Program Reports. 39
Specifically, for fiscal year 2020 State Program Reports, ACL required
states to provide information in their COVID-19 narrative on FFCRA and
CARES Act expenditures by Title III program (e.g., Title III-B supportive
services, Title III-E caregiver support services), as well as any funds
expended when using the OAA disaster relief flexibility.
ACL officials said they chose this reporting method to facilitate simple and
flexible reporting for states, AAAs, and local providers during the
pandemic. Typically, states receive these data from AAAs, who receive
data on clients and service units from their providers. Therefore,
implementing a new template with new data elements halfway through
the fiscal year would add to states, AAAs, and providers’ reporting
burden, which ACL officials said they wanted to minimize given the need
to focus on getting meals to older adults. Rather than requiring states to
report specific data, ACL repurposed a narrative section within the
existing template to capture general information on COVID-19 spending.
Using this narrative approach rather than prescribing specific data
elements also gave states more flexibility in reporting, which ACL officials
indicated was useful for states.
To assist states in completing their COVID-19 narratives, ACL provided
guidance and example narratives with the information states should
report. ACL officials said they also held virtual sessions for states in which
they walked through this information. In addition to the training and
guidance on reporting that ACL provided before states submitted their
fiscal year 2020 reports, ACL officials said its regional administrators or
other ACL staff provided individualized assistance to states regarding
their fiscal year 2020 reports when needed. For example, one regional
administrator said they held trainings on reporting requirements with three
states. Another regional administrator said they emailed each state to
clarify the information ACL wanted in the narratives.
Despite these efforts, ACL received varying levels of detail from states’
COVID-19 narratives, due in part to the flexibility of ACL’s reporting
format. For instance, in our review of these reports from the four selected
states, three did not include all of the required information, and all four
states provided inconsistent levels of detail, making it difficult for ACL to
compare spending across states. For example, one of the selected states
39The COVID-19 relief laws did not require ACL to collect any additional information on
how states used the funds.
Page 32 GAO-22-104425 COVID-19 Services for Older Adults
combined FFCRA and CARES Act expenditures in its report, while
another state reported separate expenditures for each funding source. In
our review of the information all states provided ACL, we identified four
states that did not include any information on their use of the COVID-19
funds in the narrative section of their fiscal year 2020 State Program
Reports. ACL officials said, overall, states’ information on expenditures by
funding source and service type were valid and reliable.
ACL took several steps after receiving these initial reports to obtain more
consistent and reliable data for fiscal year 2020 from states, which
officials said gave them overall confidence on how states used
supplemental funds by service. After receiving the initial 2020 reports, all
regional administrators said they followed up with all of the states to
clarify and confirm expenditures reported in the narratives. In addition,
ACL officials said they and their contractor, who reviewed the information
from the narratives, reached out to clarify issues with the majority of
states, such as disaggregating information that states reported in
aggregate (e.g., reporting a combined total for home-delivered and
congregate meals).
ACL officials told us, however, that they could not determine how many
clients were served and service units were provided by each
supplemental funding source (e.g., FFCRA and CARES Act) due to
challenges with reporting and data collection. ACL encouraged states to
provide such information in the narrative section, but did not require it.
According to ACL, some states and localities do not track clients and
service units for the supplemental funds separately, and overall, ACL
officials told us that the reported information was too inconsistent to use
reliably.
We heard similar data reporting challenges from two of our selected
localities, given the change in how services were provided during the
pandemic. For example, officials from one locality said they delivered
grocery boxes to older adults and recorded each box as one meal,
although older adults could prepare multiple meals with the food from
each box. Although ACL issued guidance for reporting on COVID-19
services such as grocery delivery and wellness calls in May 2020, states
Page 33 GAO-22-104425 COVID-19 Services for Older Adults
or localities may have recorded these services inconsistently at the
beginning of the pandemic. 40
To collect more consistent and complete data from states on how they
used the supplemental COVID-19 funds in fiscal year 2021 with less need
for follow-up, ACL developed a template that officials said will be
available for states to use in their fiscal year 2021 State Program
Reports. 41 Our review of this template found that it lists services that
states are required to report on by funding source, which could help
address some of the inconsistent reporting from states in fiscal year 2020.
For example, the template lists home-delivered and congregate meals
separately, which could encourage states that aggregated these numbers
in fiscal year 2020 to report on them separately in fiscal year 2021. ACL
anticipates that the template will help it efficiently gather more consistent
data on states’ supplemental COVID-19 spending, which could ultimately
improve oversight of these funds.
In addition to the annual State Program Reports, ACL is relying on its
other existing oversight processes—Federal Financial Reports and single
audits—to oversee the use of COVID-19 funds, according to ACL
officials. 42 In their semi-annual Federal Financial Reports, states are
required to report high-level expenditures for each grant they receive from
40In May 2020, ACL also issued guidance on providing groceries through OAA programs
which stated that groceries should not be counted as meals. See ACL, “COVID-19
Response: FAQ – Groceries and OAA Programs.”
41ACL officials said the template would be available for use but would not be required
because ACL would need to obtain Office of Management and Budget (OMB) approval
before requiring states to use the template. Because the OMB approval process takes
time, ACL made the template optional.
42Federal agencies have oversight responsibilities under the Single Audit Act of 1984, as
amended, for the funds they award to nonfederal entities. Federal award recipients that
expend $750,000 or more in federal awards in a fiscal year are required to undergo a
single audit, which is an audit of an entity’s financial statements and federal awards, or a
program-specific audit, for the fiscal year. Single audits are generally conducted by state
auditors or independent public accounting firms, and federal agencies are responsible for
following up on audit findings to provide reasonable assurance that award recipients take
timely and appropriate action to correct deficiencies identified through the single audit
process. See, generally, 31 U.S.C. §§ 7501-7507, 2 C.F.R. §§ 200.500-21.
Page 34 GAO-22-104425 COVID-19 Services for Older Adults
ACL, including FFCRA and CARES Act grants. 43 ACL officials said they
review states’ reported expenditures and compare expenditures to
budgeted amounts for each grant.
In addition, ACL officials said the single audit process could provide
another level of oversight. For grantees where OAA is a major program,
ACL officials said they review single audits of states annually, and that
states review single audits of AAAs. 44 While single audits are not specific
to the COVID-19 funds, these audits could help identify deficiencies in the
award recipient’s compliance with applicable provisions of laws,
regulations, contracts, or grant agreements and in its financial
management and internal control systems. 45
ACL Supported States by To support states thus far in the pandemic, ACL provided guidance,
Providing Guidance, information, and technical assistance to states on use of the COVID-19
funds and approaches to modify services, according to our review and
Technical Assistance, and
ACL officials. ACL officials said they have held regular calls with states
Forums for Information (initially on a weekly basis) on how to use and report on the COVID-19
Sharing funds. Officials also said they responded to common questions from
states during these calls and posted summaries of the calls online. In
addition to the national calls, ACL’s regional administrators said they
served as an additional resource by providing technical assistance to
states and offering individualized assistance and support upon request.
ACL continued to provide various forms of guidance and information
online as the pandemic evolved and the COVID-19 relief laws provided
additional funding. For example, ACL used its website to answer
43For example, states report expenditures on each OAA Title III program, such as
supportive services, but do not provide information on the specific types of service
expenditures within each program (e.g., case management or homemaker), clients, or
service units, as this detail should be reported through the State Program Reports
described above.
44Auditors are required to use a risk-based approach to determine which federal programs
are major programs in the context of that particular audited entity. 45 C.F.R. § 75.518(a). If
the independent auditors responsible for the single audit identify Title III as a “major
program” for the recipient, these auditors are required to determine whether the recipient
used Title III funds for allowable purposes and met requirements for monitoring any sub-
recipients.
45As we reported in July 2021, OMB directed agencies, including ACL, to provide single
audit submission extensions for award recipients and sub-recipients in 2020 and 2021.
See GAO-21-551, COVID-19: Continued Attention Needed to Enhance Federal
Preparedness, Response, Services Deliver, and Program Integrity (Washington, D.C.:
July 29, 2021).
Page 35 GAO-22-104425 COVID-19 Services for Older Adults
frequently asked questions and post other guidance or information. Our
review of the website found information on topics including:
• Using COVID-19 funds and flexibilities (e.g., allowable expenses)
• Using an existing OAA flexibility to update eligibility requirements for
home-delivered meals
• Reporting on COVID-19 funds (e.g., requirements for State Program
Reports and Federal Financial Reports)
• Modifying services (e.g., ideas for virtual social and fitness activities)
• Reopening congregate meal sites (e.g., programming ideas and
safety considerations for sites that are closed, partially open, and fully
open)
ACL officials said they also worked with the National Resource Center on
Nutrition and Aging to share information on nutrition programs during the
pandemic. 46 For example, the resource center provided recommendations
for how to provide nutritious meals and meet minimum calorie
requirements during the pandemic, and shared best practices and
provided technical assistance for implementing grab-and-go meals.
In addition, ACL served as a forum for information sharing among other
entities in the aging network. For instance, the frequent calls with states
allowed the states an opportunity to share best practices with each other,
according to ACL officials. Additionally, on its website, ACL has posted
links to other online resources from national organizations, such as
strategies to modify programs and reduce social isolation. ACL also
hosted webinars with outside speakers to share examples of promising
practices for providing Title III services during the pandemic, vaccinating
older adults, and addressing COVID-19 vaccine hesitancy.
Officials in the four selected states said they were mostly satisfied with
ACL’s support during the pandemic and found the conference calls and
other guidance helpful. For example, these officials said ACL provided
clear and sufficient guidance on the use of the COVID-19 funds and
flexibilities. Officials in all four states also said they reached out to their
regional administrators with specific questions and received responses.
46ACL supports several national resource centers that publish information on promising
practices for delivering services to older adults. The information disseminated through the
resource centers has broad reach, as it is aimed at the larger aging network, including
state aging directors, AAAs, providers, and in some cases older adults and their families.
Page 36 GAO-22-104425 COVID-19 Services for Older Adults
However, officials from one state said ACL’s guidance and responses
from regional administrators were sometimes high-level and not specific
enough for their particular situation.
ACL has also made longer-term efforts to support information sharing on
OAA services and emergency preparation. For instance, ACL is
sponsoring two categories of fiscal year 2021 grants for the aging network
to identify innovative practices in nutrition services for potential replication
nationwide. 47 In particular, ACL is seeking innovative practices that have
been implemented during the pandemic to transition back to and sustain
congregate meal programs, such as new types of congregate meal sites
and hybrid models that offer some virtual social and educational
programming. To help states prepare for future emergencies, HHS also
announced in May 2021 its plans to establish a National Advisory
Committee on Seniors and Disasters. According to HHS, the committee
will advise the Secretary of HHS on how to support and enhance
response strategies to meet the unique needs of older adults in future
emergencies. 48
We provided a draft of this report to HHS for review and comment. HHS
Agency Comments provided technical comments, which we incorporated as appropriate.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, and other
interested parties. The report is also available at no charge on the GAO
website at http://www.gao.gov.
47According to ACL, it awarded nearly $1.2 million to four community research entities for
the Innovations in Nutrition Programs and Services grant in September 2021.
4886 Fed. Reg. 26,149, 26,228 (May 13, 2021).
Page 37 GAO-22-104425 COVID-19 Services for Older Adults
If you or your staff have any questions about this report, please contact
me at (202) 512-7215 or larink@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 I.
Kathryn A. Larin
Director, Education, Workforce, and Income Security Issues
Page 38 GAO-22-104425 COVID-19 Services for Older Adults
List of Committees
The Honorable Robert P. Casey, Jr.
Chairman
Special Committee on Aging
United States Senate
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
Chair
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
Chair
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
Page 39 GAO-22-104425 COVID-19 Services for Older Adults
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
The Honorable Robert C. “Bobby” Scott
Chairman
The Honorable Virginia Foxx
Republican Leader
Committee on Education and Labor
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 Suzanne Bonamici
Chair
Subcommittee on Civil Rights and Human Services
Committee on Education and Labor
House of Representatives
Page 40 GAO-22-104425 COVID-19 Services for Older Adults
Appendix I: GAO Contact and Staff
Appendix I: GAO Contact and Staff
Acknowledgments
Acknowledgments
Kathryn A. Larin, (202) 512-7215 or larink@gao.gov
GAO Contact:
In addition to the contact named above, Theresa Lo (Assistant Director),
Staff Nora Boretti (Analyst in Charge), Caroline DeCelles, and Daniel Setlow
Acknowledgments: made significant contributions to this report. Also contributing to this
report were Andrew Bellis, Daniel Concepcion, Allison Gunn, Monica
Savoy, Joy Solmonson, Curtia Taylor, Ben Theuma, Matthew Valenta,
David Watsula and Adam Wendel.
(104425)
Page 41 GAO-22-104425 COVID-19 Services for Older Adults
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