GAO-23-105613, COVID 19 IN NURSING HOMES: Experts Identified Actions Aimed at Improving Infection Prevention and Control

Issuer: Government Accountability Office
Document type: Order
Date: 2023-03-20

Summary

A report to congressional addressees by the U.S. Government Accountability Office, GAO-23-105613, dated March 20, 2023, on infection prevention and control in nursing homes. It describes actions that a roundtable of 13 experts, convened in April 2022 with help from the National Academies of Sciences, Engineering, and Medicine, identified for HHS: six actions to continue, seven to enhance and one to discontinue. The report also compares those actions with prior recommendations from GAO, CMS's Coronavirus Commission on Safety and Quality in Nursing Homes and the National Academies' Committee on the Quality of Care in Nursing Homes. It cites the CARES Act provision, Pub. L. No. 116-136, § 19010(b), for GAO's pandemic monitoring and states the audit ran from December 2021 to March 2023. The contents list a background section, agency comments, two appendices and four figures.

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Full text

United States Government Accountability Office
Report to Congressional Addressees

COVID-19 IN
March 2023

NURSING HOMES

Experts Identified
Actions Aimed at
Improving Infection
Prevention and
Control

GAO-23-105613
March 2023

COVID-19 IN NURSING HOMES
Experts Identified Actions Aimed at Improving
Infection Prevention and Control
Highlights of GAO-23-105613, a report to
congressional addressees

Why GAO Did This Study What GAO Found
Before the COVID-19 pandemic led to The Department of Health and Human Services (HHS), primarily through the
devastating consequences in nursing Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease
homes, infections were a leading Control and Prevention, has led the federal response to the COVID-19 pandemic
cause of hospitalization and death in nursing homes.
among nursing home residents. As the
nation moves forward, COVID-19 and The expert roundtable GAO convened identified actions aimed at improving
other infectious diseases will continue infection prevention and control in nursing homes, including six actions HHS
to present a threat to these individuals. should continue, seven it should enhance, and one it should discontinue.
Proper infection prevention and control
procedures, such as hand hygiene, will
remain critical to ensuring resident
safety.
The CARES Act includes a provision
for GAO to monitor and report on the
federal pandemic response. GAO was
also asked to review federal oversight
of nursing homes in light of the
pandemic. This report: (1) describes
actions experts identified that HHS
should continue, enhance, or
discontinue to improve infection
prevention and control practices in
nursing homes and (2) compares
actions identified by experts with prior
recommendations from GAO and
others.
GAO convened a roundtable of 13
experts to discuss actions to improve
infection prevention and control in
nursing homes. GAO contracted with Note: The actions in this report are not listed in any specific rank or order, and their inclusion should
the National Academies of Sciences, not be interpreted as GAO endorsing any of them. Implementing any one action or a combination of
actions listed in this report might require additional efforts to address program design or legal issues.
Engineering, and Medicine to help Except in those areas directly related to GAO’s prior recommendations, GAO did not assess how
identify experts representing a range of effective the actions listed in this report may be or the extent to which legislative changes and federal
perspectives on nursing homes and financial support would be needed to implement them.
infection prevention and control, Many of the actions identified by GAO’s expert roundtable are consistent with
including researchers and infectious prior recommendations made to HHS to improve infection prevention and control.
disease specialists, nursing home staff, Specifically, reports from CMS’s Coronavirus Commission on Safety and Quality
individuals with nursing home oversight
in Nursing Homes, and the National Academies’ Committee on the Quality of
and regulatory experience, as well as
Care in Nursing Homes, as well as prior GAO reports, have examined infection
representatives for residents and their
families. GAO also interviewed officials prevention and control challenges in nursing homes and made similar
from CMS and the Centers for Disease recommendations.
Control and Prevention. HHS’s continued leadership in prioritizing infection prevention and control—in
coordination with other federal, state, and private entities—is critical to better
protect nursing home residents from the enduring risks of declining health and
View GAO-23-105613. For more information, premature death posed by infections. The actions identified by GAO’s expert
contact John E. Dicken at (202) 512-7114 or
dickenj@gao.gov. roundtable may, for example, assist HHS in addressing prior recommendations
from GAO and others, presenting new solutions, or expanding on current efforts.
United States Government Accountability Office
Contents

Letter 1
Background 4
Experts Identified Actions HHS Should Continue, Enhance, or
Discontinue to Improve Infection Prevention and Control 8
Many Actions Experts Identified Are Consistent with Prior
Recommendations Made to Improve Infection Prevention and
Control 28
Agency Comments 32

Appendix I Expert Roundtable on Infection Prevention and Control in Nursing
Homes 36

Appendix II GAO Contact and Staff Acknowledgments 39

Related GAO Products 40

Table
Table 1: List of Expert Participants in GAO’s Roundtable on
Infection Prevention and Control in Nursing Homes, Held
April 27 and 28, 2022 37

Figures
Figure 1: Actions Experts Said the Department of Health and
Human Services (HHS) Should Continue 9
Figure 2: Actions Experts Said the Department of Health and
Human Services (HHS) Should Enhance 16
Figure 3: Action Experts Said the Department of Health and
Human Services (HHS) Should Discontinue 26
Figure 4: Comparison of GAO Expert Roundtable Actions on
Infection Prevention and Control with Prior
Recommendations by GAO and Others 29

Page i GAO-23-105613 Nursing Home Expert Roundtable
Abbreviations

CDC Centers for Disease Control and Prevention
CMS Centers for Medicare & Medicaid Services
HHS Department of Health and Human Services

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Page ii GAO-23-105613 Nursing Home Expert Roundtable
Letter

441 G St. N.W.
Washington, DC 20548

March 20, 2023

Congressional Addressees

Long before COVID-19 emerged as a new and highly contagious
respiratory disease with devastating consequences in nursing homes,
infections—such as pneumonia—were a leading cause of hospitalization
and death among nursing home residents. 1 Nursing homes and state and
federal agencies have made progress in responding to the
unprecedented challenges presented by the COVID-19 pandemic.
However, as the nation moves forward, the ongoing risk of both COVID-
19 and other infectious diseases will continue to present a threat to
nursing home residents. 2 Proper infection prevention and control
procedures, such as hand hygiene and using masks and other personal
protective equipment to control the spread of infections, will remain critical
to ensuring the safety of the nation’s more than one million nursing home
residents and ensuring high quality of care. 3

The Department of Health and Human Services (HHS), primarily through
the Centers for Medicare & Medicaid Services (CMS) and the Centers for
Disease Control and Prevention (CDC), has led the federal response to
the COVID-19 pandemic in the nation’s more than 15,000 Medicare- and
Medicaid-certified nursing homes. CMS is responsible for ensuring that
nursing homes meet federal quality standards to be eligible to participate
in the Medicare and Medicaid programs. These standards require, for
example, that nursing homes establish and maintain an infection
prevention and control program. To monitor compliance with these
standards, CMS enters into agreements with state survey agencies in
each state government and oversees the work the state survey agencies

1Estimates are that up to 380,000 residents died from infections each year prior to
COVID-19. Department of Health and Human Services, The National Action Plan to
Prevent Health Care-Associated Infections: Road Map to Elimination (Washington, D.C.:
2013).
2For example, the spread of drug-resistant infections and deaths increased by 15 percent
in 2020, the first year of the pandemic. Prior to this, in 2017, deaths from drug-resistant
infections decreased by 18 percent. See Centers for Disease Control and Prevention,
COVID-19: U.S. Impact on Antimicrobial Resistance, Special Report (Atlanta, Georgia:
2022).
3According to the Centers for Disease Control and Prevention, infection prevention and
control protects patients, residents, healthcare personnel and visitors by preventing
healthcare-associated infections and limiting the spread of pathogens through the
implementation of evidence-based interventions.

Page 1 GAO-23-105613 Nursing Home Expert Roundtable
do. CDC issues guidance with recommendations for preventing and
managing infectious diseases, operates infectious disease surveillance
systems, and provides technical assistance through programs aimed at
supporting and assessing infection prevention and control in nursing
homes. According to agency officials, CMS and CDC coordinate infection
prevention and control efforts through nursing home task force meetings,
which took place daily earlier in the COVID-19 pandemic and currently
take place about once a week, but more or less often as needed.

Since 2020, we have examined infection prevention and control and the
federal response to COVID-19 in nursing homes in multiple studies. For a
complete list of our previous work in this area, see the Related GAO
Products page at the end of this report. In addition, others have also
reported on nursing home challenges with infection prevention and
control. 4 The CARES Act includes a provision for us to monitor and report
on the federal response to the COVID-19 pandemic. 5 Further, you also
asked us to examine federal oversight of infection prevention and control
protocols and the adequacy of emergency preparedness standards for
emerging infectious diseases in nursing homes, as well as CMS’s
response to the pandemic.

In this report, we

1. describe actions experts identified that HHS should continue,
enhance, or discontinue to improve infection prevention and control
practices in nursing homes, and
2. compare actions identified by experts with prior recommendations by
GAO and others.

4See National Academies of Sciences, Engineering, and Medicine, Committee on the
Quality of Care in Nursing Homes, The National Imperative to Improve Nursing Home
Quality: Honoring Our Commitment to Residents, Families, and Staff (Washington, D.C.:
The National Academies Press, 2022) and MITRE, Coronavirus Commission on Safety
and Quality in Nursing Homes, Commission Final Report (McLean, Va.: The MITRE
Corporation, 2020). This report was written for CMS under a government contract.
5Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020). The American Rescue Plan
Act of 2021 also includes a provision for us to conduct oversight of the COVID-19
response. Pub. L. No. 117-2, § 4002, 135 Stat. 4, 78. Throughout the pandemic, we
regularly issued government-wide reports on the federal response to COVID-19. All
government-wide reports are available on GAO’s website at
https://www.gao.gov/coronavirus.

Page 2 GAO-23-105613 Nursing Home Expert Roundtable
To address our first objective, in April 2022, we convened a roundtable of
13 experts to discuss actions that HHS should continue, enhance, or
discontinue to improve infection prevention and control practices in
nursing homes. 6 Specifically, we contracted with the National Academies
of Sciences, Engineering, and Medicine (National Academies) to help us
identify individuals with expertise in this topic area. The experts we
selected represented a broad spectrum of views and a variety of
professional and academic fields—such as researchers and infectious
disease specialists, nursing home management and staff, individuals with
nursing home oversight and regulatory experience at the federal and
state levels, as well as representatives for nursing home residents and
families. 7 The 13 experts who participated in the roundtable, their
professional disciplines, and their institutional affiliations at the time of our
roundtable are listed in appendix I.

We then convened a roundtable where we asked experts to identify
actions that HHS should continue, enhance, or discontinue to improve
infection prevention and control practices in nursing homes and examples
of each. The actions in this report are not listed in any specific rank or
order, and their inclusion should not be interpreted as GAO endorsing any
of them. Implementing any one action or a combination of actions listed in
this report might require additional efforts to address program design or
legal issues. Except in those areas directly related to GAO’s prior
recommendations, we did not assess how effective the actions listed in
this report may be or the extent to which legislative changes and federal
financial support would be needed to implement them. Following the
roundtable, we sent the experts the actions and examples for review and
comment and incorporated those comments into this report as
appropriate.

In addition, we reviewed CMS regulations and policies and CDC guidance
related to infection prevention and control in nursing homes, and
interviewed CMS and CDC officials. We also reviewed selected research

6This roundtable was planned and convened with the assistance of the National
Academies of Sciences, Engineering, and Medicine to help ensure that a breadth of
expertise was brought to bear in its preparation; however, all final decisions regarding
meeting substance and expert participation are the responsibility of GAO.
7The comments provided by the experts reflected their own views and not those of the
organizations with which they are affiliated. Further, the experts’ views may not
correspond with those of others with similar backgrounds and expertise.

Page 3 GAO-23-105613 Nursing Home Expert Roundtable
related to infection prevention and control in nursing homes to provide
additional context.

To compare actions identified by experts with prior recommendations by
GAO and others, we reviewed prior reports by GAO, CMS’s Coronavirus
Commission on Safety and Quality in Nursing Homes, and the National
Academies’ Committee on the Quality of Care in Nursing Homes. 8

We conducted this performance audit from December 2021 to March
2023 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.

Federal law requires Medicare- and Medicaid-certified nursing homes to
Background establish and maintain an infection prevention and control program
designed to help prevent the development and transmission of
communicable diseases and infections. 9

Infections in Nursing Even before COVID-19, nursing home residents were at a high risk for
Homes several different types of infections, including respiratory infections,
gastroenteritis, skin and soft tissue infections, and urinary tract infections.
Nursing home residents can be particularly susceptible to infections
because of their advanced age and higher risk of comorbidities. 10 Further,
nursing home residents are increasingly requiring more medically
complex care and are therefore more susceptible to infection. Residents
discharged from the hospital back to the nursing home can bring
infections into the home. In addition, while nursing homes create
important social opportunities for residents through communal dining and

8The prior work we reviewed was: National Academies, The National Imperative to
Improve Nursing Home Quality; MITRE, Commission Final Report; GAO, COVID-19 in
Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention
and Control, GAO-22-105133 (Sep. 14, 2022); COVID-19: Sustained Federal Action is
Crucial as Pandemic Enters Its Second Year, GAO-21-387 (Mar. 31, 2021); and COVID-
19: Federal Efforts Could Be Strengthened by Timely and Concerted Actions,
GAO-20-701 (Sept. 21, 2020). Some of the experts in our roundtable also participated in
the CMS and National Academies’ efforts.
942 U.S.C. §§ 1395i-3(d)(3)(A), 1396r(d)(3)(A); 42 C.F.R. § 483.80 (2021).

10Comorbidity refers to the presence of more than one distinct disease in a person at the
same time.

Page 4 GAO-23-105613 Nursing Home Expert Roundtable
recreational spaces, these shared spaces can increase the transmission
risk for infectious diseases, especially viruses causing respiratory or
gastrointestinal outbreaks.

The COVID-19 Pandemic COVID-19 originated in late 2019 as a new and highly contagious
respiratory disease that quickly spread across the country and has led to
high rates of infection and death in U.S. nursing home residents and staff.
One of the first major COVID-19 outbreaks was reported in a Washington
State nursing home in February 2020. In the weeks that followed, the
Secretary of HHS declared a public health emergency for the U.S. and
the World Health Organization characterized COVID-19 as a pandemic.
Within 1 year, COVID-19 had reached nearly all of the nation’s nursing
homes. 11

The introduction of COVID-19 vaccines in December 2020 was a key
turning point in the pandemic, with cases and deaths in nursing homes
declining through the first part of 2021. However, cases and deaths
began to increase again with the emergence of more transmissible virus
variants that could infect and spread among people regardless of
vaccination status—first, during the summer of 2021, coinciding with the
emergence of the Delta variant, and again in the winter of 2022,
coinciding with the emergence of the Omicron variant. 12 According to
CDC, nursing home residents continue to be at a high risk for severe
illness and death due to COVID-19; however, getting vaccinated and
staying up-to-date with booster doses will help to prevent severe illness,
hospitalization, and death. Further, public health officials continue to
emphasize the need for nursing homes to remain vigilant in maintaining
proper infection prevention and control practices.

11GAO, COVID-19 in Nursing Homes: Most Homes Had Multiple Outbreaks and Weeks of
Sustained Transmission from May 2020 through January 2021, GAO-21-367
(Washington, D.C.: May 19, 2021).
12See GAO, COVID-19 in Nursing Homes: Outbreak Duration Averaged 4 Weeks and
Was Strongly Associated with Community Spread, GAO-23-104291 (Washington, D.C.:
Dec. 15, 2022).

Page 5 GAO-23-105613 Nursing Home Expert Roundtable
Federal Oversight of Federal laws establish minimum requirements nursing homes must meet
Nursing Homes to participate in the Medicare and Medicaid programs, including
standards for the quality of care. 13 One such standard is that nursing
The Infection Preventionist Role homes establish and maintain an infection prevention and control
The infection preventionist must work at least program. 14 In 2016, CMS finalized a comprehensive update to its nursing
part time at the nursing home and have home standards. 15 For example, CMS updated infection prevention and
training in infection prevention and control.
This individual is responsible for the home’s control requirements to include the requirement that nursing homes
program for preventing, identifying, reporting, designate at least one infection preventionist to oversee the facility’s
investigating, and controlling infections and
communicable diseases.
infection prevention and control program, effective beginning November
Source: 42 C.F.R. § 483.80(b) (2021). | GAO-23-105613 2019.

To monitor compliance with federal quality standards, CMS enters into
agreements with state survey agencies in each state to assess whether
nursing homes meet CMS’s standards through both recurring
comprehensive standard surveys and as-needed investigations for
complaints from the public and facility-reported incidents. For a number of
months during the first year of the pandemic, regular standard surveys of
nursing homes and low priority investigations were temporarily
suspended, replaced by focused infection control surveys. These focused
infection control surveys evaluated compliance with CMS infection

1342 U.S.C. §§ 1395i-3, 1396r; 42 C.F.R. §§ 483.1—483.95 (2021). Federal statutes and
their implementing regulations use the terms “skilled nursing facility” (Medicare) and
“nursing facility” (Medicaid). For the purposes of this report, we use the term “nursing
home” to refer to both skilled nursing facilities and nursing facilities.
14At a minimum, nursing homes must (1) have a system to prevent, identify, report,
investigate, and control infections and communicable diseases for all residents, staff,
volunteers, visitors, and others providing services in the home; (2) have written standards,
policies, and procedures for their infection prevention and control program; (3) have
antibiotic use protocols and a system to monitor antibiotic use; and (4) have a system for
recording incidents identified under the home’s infection prevention and control program
and any corrective actions taken. 42 C.F.R. § 483.80(a)(1)-(4) (2021).
15Medicare and Medicaid Programs, Reform of Requirements for Long-Term Care
Facilities, 81 Fed. Reg. 68,688 (Oct. 4, 2016). Phase 1 (effective November 28, 2016)
implemented mostly minor modifications to the existing nursing home regulations; phase 2
(effective November 28, 2017) implemented new regulations and re-structured CMS’s
deficiency code system; and phase 3 (effective November 28, 2019) implemented the
remaining requirements.

Page 6 GAO-23-105613 Nursing Home Expert Roundtable
prevention and control policies. 16 If a surveyor from a state survey agency
determines that a nursing home violated a federal standard during a
survey or investigation, the nursing home is cited for the deficiency.

For most cited deficiencies, nursing homes are required to submit a plan
of correction that addresses how the home plans to correct the
noncompliance and implement systemic change to ensure the deficient
practice will not recur. 17 In addition, when nursing homes are cited with
deficiencies, federal enforcement actions can be implemented to compel
homes to make corrections. 18 In general, for deficiencies with a higher
scope and severity, CMS may implement the enforcement action
immediately. 19 For other deficiencies with a lower scope and severity, the
nursing home may be given an opportunity to correct the deficiencies,
which, if corrected before the scheduled effective date, can result in the
planned enforcement action not being implemented. We previously
reported that in each year from 2013 through 2017, nearly all infection
prevention and control deficiencies were classified by surveyors as not
severe, meaning the surveyor determined that residents were not harmed
and that implemented enforcement actions for these deficiencies were
typically rare. 20

16Beginning in March 2020, CMS required state survey agencies to conduct focused
infection control surveys, a new type of survey in response to the pandemic with a
narrower scope than a standard survey. Beginning in August 2020, CMS indicated state
survey agencies should resume standard surveys as soon as they have the resources to
conduct the surveys but also required them to continue conducting focused infection
control surveys. In November 2021, CMS required state survey agencies to perform
focused infection control surveys for 20 percent of nursing homes in their state annually,
prioritizing those facilities that report new COVID-19 cases and low vaccination rates, in
addition to continuing to conduct standard surveys and investigations.
17The plan of correction serves as the nursing home’s allegation of compliance.
Depending on the severity of the deficiency cited, surveyors revisit the nursing home to
ensure that the home actually implemented its plan and corrected the deficiency.
18CMS does not require enforcement actions be implemented for all deficiencies.
Enforcement actions include, but are not limited to, directed in-service training, fines
known as civil money penalties, denial of payment, and termination from the Medicare and
Medicaid programs.
19The scope and severity of a deficiency is one of the factors that CMS may take into
account when implementing enforcement actions. CMS may also consider a nursing
home’s prior compliance history, desired corrective action and long-term compliance, and
the number and severity of all the nursing home’s deficiencies.
20See GAO, Infection Control Deficiencies Were Widespread and Persistent in Nursing
Homes Prior to the COVID-19 Pandemic, GAO-20-576R (Washington, D.C.: May 20,
2020).

Page 7 GAO-23-105613 Nursing Home Expert Roundtable
The expert roundtable we convened identified actions aimed at improving
Experts Identified infection prevention and control in nursing homes, including six actions
Actions HHS Should HHS should continue, seven it should enhance, and one it should
discontinue.
Continue, Enhance,
or Discontinue to
Improve Infection
Prevention and
Control
Experts Identified Six The expert roundtable we convened identified six infection prevention and
Actions HHS Should control actions that HHS should continue, focusing in particular on the
actions taken by HHS during the COVID-19 pandemic. Experts said that,
Continue
by carrying forward the HHS actions that worked well during the
pandemic, nursing homes would be in a better position to prepare for the
next infectious disease emergency. (See fig. 1 for each action and
examples of how the action could be continued.)

Page 8 GAO-23-105613 Nursing Home Expert Roundtable
Figure 1: Actions Experts Said the Department of Health and Human Services (HHS)
Should Continue

Note: The actions in this report are not listed in any specific rank or order, and their inclusion should
not be interpreted as GAO endorsing any of them. Implementing any one action or a combination of
actions listed in this report might require additional efforts to address program design or legal issues.
Except in those areas directly related to GAO’s prior recommendations, we did not assess how
effective the actions listed in this report may be or the extent to which legislative changes and federal
financial support would be needed to implement them.
a
CDC’s National Healthcare Safety Network is a national infection surveillance system that collects
data on a range of different healthcare-associated infections from different types of health care
facilities, including nursing homes. In May 2020, CMS began requiring nursing homes to report data
at least weekly through the National Healthcare Safety Network on the number of COVID-19 cases
and deaths among residents and staff, access to personal protective equipment and testing supplies,
and staff shortages, among other things.

Page 9 GAO-23-105613 Nursing Home Expert Roundtable
b
Experts generally agreed that HHS could consider ways to leverage the surveillance data
opportunities in the National Healthcare Safety Network while balancing the time commitment
required by nursing home staff if additional reporting were required.
c
Strike teams are teams of infection prevention and public health professionals.
d
During the pandemic, CMS implemented regulatory flexibilities through its authority under section
1135 of the Social Security Act to temporarily waive or modify certain program requirements in certain
emergencies. One expert noted that these flexibilities were too flexible and should be rolled back.
Another expert noted that some of these waivers should be made permanent.

Continue required data reporting to the National Healthcare Safety
Network. Experts said that HHS could consider continuing to require
nursing homes to report data on COVID-19 to CDC’s National Healthcare
Safety Network, noting it is helpful for understanding the effect of the
pandemic and for providing information to consumers. 21 Prior to the
pandemic, nursing homes could report infections, like C. difficile, to the
National Healthcare Safety Network, but reporting was voluntary. The
reporting of infectious disease data to the National Healthcare Safety
Network is consistent with reporting by other types of facilities, like
hospitals, which must report data to qualify for reimbursement. Reporting
these types of data has also been a national priority since the release of
HHS’s National Action Plan to Prevent Health Care-Associated Infections
in 2013. 22 While experts generally agreed that required COVID-19 data
reporting to the National Healthcare Safety Network should continue, with
some experts saying it should be expanded to include other infectious
diseases, the experts noted that HHS should balance the reporting
requirements with the time commitment required by nursing home staff. 23

21The National Healthcare Safety Network is a national infection surveillance system
administered by CDC that collects data on a range of different healthcare-associated
infections from different types of health care facilities, including nursing homes. In May
2020, CMS began requiring nursing homes to report data at least weekly through the
National Healthcare Safety Network on the number of COVID-19 cases and deaths
among residents and staff, access to personal protective equipment and testing supplies,
and staff shortages, among other things. Medicare and Medicaid Programs; Additional
Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency,
85 Fed. Reg. 27,550, 27,627 (May 8, 2020) (codified at 42 C.F.R. § 483.80(g)).
22This plan is intended to coordinate and maximize the efficiency of healthcare-associated
infection prevention efforts across the federal government. See Department of Health and
Human Services, The National Action Plan to Prevent Health Care-Associated Infections:
Road Map to Elimination (Washington, D.C.: 2013).
23CMS officials noted that any changes to what nursing homes report to the National
Healthcare Safety Network must occur through the notice and comment rulemaking
process.

Page 10 GAO-23-105613 Nursing Home Expert Roundtable
We discussed this action with HHS officials. Specifically, CMS officials
said that they are continuing to evaluate the amount of data nursing
homes are required to report to the National Healthcare Safety Network.
CDC officials said the requirements evolved during the pandemic to
include more data fields and told us the benefits of reporting this critical
information outweighed the reporting burden it put on nursing homes.
CMS and CDC have both taken steps to ease this burden. For example,
according to CDC officials, early in 2022, CMS and CDC removed some
required fields that were no longer pertinent. CMS also extended the
requirement that nursing homes report data to the National Healthcare
Safety Network through 2024, beyond the anticipated end of the public
health emergency, in order to maintain this reporting. 24

Continue to emphasize and prioritize infection prevention and
control. Experts said that HHS could consider continuing to work with
federal and state partners to promote successful infection prevention and
control practices in nursing homes, as well as learning from and
correcting infection prevention and control weaknesses identified during
and prior to the pandemic. With the onset of the COVID-19 pandemic,
one expert said that people now pay more attention to infection
prevention and control in nursing homes, and this expert would like to see
this emphasis continued in the long-term. Another expert noted that the
pandemic brought infection prevention and control to the forefront in
nursing homes because “everybody’s talking about it.”

We discussed this action with HHS officials. Specifically, CDC officials
said they are supportive of continuing to improve infection prevention and
control efforts in nursing homes, noting that CDC has learned a lot during
the pandemic about weaknesses in infection prevention and control in
nursing homes and ways that nursing homes can improve.

24Medicare and Medicaid Programs; COVID-19 Reporting Requirements for Long-Term
Care Facilities, 86 Fed. Reg. 62,240. (Nov. 9, 2021).

Page 11 GAO-23-105613 Nursing Home Expert Roundtable
Continue to prioritize nursing homes for resources. Experts said that
Expert Perspectives on Prioritizing
HHS could consider continuing to coordinate with federal partners to
Nursing Homes for Resources designate nursing homes as high priority health care providers for access
“Early on in the pandemic, nursing homes to personal protective equipment, testing, and vaccines during future
weren’t prioritized. They were getting supplies infectious disease emergencies. 25
to hospitals, and they were not considering
nursing homes. That did not come until later in
the pandemic. And I believe from the very At the start of the pandemic, experts said that nursing homes faced
beginning that nursing homes systemically
need to be prioritized.” challenges with shortages of personal protective equipment and testing
“Somewhere during the pandemic, we did supplies. 26 Beginning in the summer of 2020, the federal government
prioritize nursing homes for vaccines, testing, began prioritizing nursing homes for these resources. 27 However, experts
personal protective equipment, and other
resources. I would like to see that prioritization said it would have been helpful if nursing homes were prioritized at the
maintained.” outset of the pandemic. This was the case for the COVID-19 vaccines. As
Source: Statements from GAO’s roundtable of 13 experts. |
GAO-23-105613 the initial vaccines received emergency use approval in December 2020,
nursing home residents and staff were prioritized for receiving
vaccinations, which experts said was very helpful to responding to the
pandemic. 28

25One article we reviewed said that nursing homes have residents that are among the
most vulnerable to infection and related adverse events and should be a priority for federal
and state governments in providing adequate resources, particularly in underserved
areas, where health disparities make residents more susceptible. See J. Ouslander and D.
Grabowski, “COVID-19 in Nursing Homes: Calming the Perfect Storm,” Journal of the
American Geriatrics Society, vol. 68, no. 10 (2020), 2153-2162.
26We and others have reported on challenges with lack of supplies during the pandemic
needed to perform proper infection prevention and control. See GAO-20-701 and B.
McGarry et al., “Severe Staffing and Personal Protective Equipment Shortages Faced by
Nursing Homes During the COVID-19 Pandemic,” Health Affairs, vol. 39, no. 10 (2020),
1812-1821.
27From May through August 2020, the Federal Emergency Management Agency
coordinated a two-shipment initiative to send a 14-day supply of personal protective
equipment to all Medicare- and Medicaid-certified nursing homes. Federal Emergency
Management Agency officials acknowledged some issues with the initial round of supplies
sent to nursing homes and said that adjustments were made in subsequent rounds.

Beginning in July 2020, HHS began distributing antigen diagnostic tests and associated
point-of-care testing instruments to nursing homes in COVID-19 hotspots across the
country to help identify and prevent the spread of COVID-19 through rapid, on-site testing.
28CDC’s Advisory Committee on Immunization Practices recommended prioritizing
nursing home residents for vaccinations, in addition to health care personnel and other
residents of long-term care facilities. The CDC Director then accepted the advisory
committee’s recommendation for priority groups for the initial phase of the COVID-19
vaccination program.

Page 12 GAO-23-105613 Nursing Home Expert Roundtable
We discussed this action with HHS officials. They did not have any
comments.

Continue to use strike teams. Experts said that HHS could consider
continuing to work with federal and state partners to make strike teams
available to help nursing homes during future infectious disease
emergencies. 29 Specifically, beginning in July 2020, HHS deployed
federal strike teams of infection prevention and public health
professionals from CDC, CMS, and other organizations to nursing homes
facing challenges with infection control. 30 When describing a strike team,
one expert said it was the first time they had seen an active
multidisciplinary collaboration between the acute care health system and
nursing homes. The involvement of acute care professionals was
important, the expert told us, because they gave strike teams the
expertise to help determine the needs of nursing homes experiencing
outbreaks and the ability to connect them with those resources.

We discussed this action with HHS officials. Specifically, CDC officials
said they are continuing to fund state-based strike teams in collaboration
with CMS but noted that the funding for these teams will end 12 months
after the conclusion of the public health emergency. CDC officials said
that Congress would need to take action to extend the program for it to
continue.

Continue to consider granting federal flexibilities in future
emergencies. Experts said HHS could consider evaluating the
effectiveness of the flexibilities it provided to providers and state survey
agencies during the COVID-19 pandemic and could consider whether to
continue these during future infectious disease emergencies. For
example, CMS issued several temporary emergency blanket waivers to
provide nursing homes with flexibility to respond to the COVID-19

29Strike teams are teams of infection prevention and public health professionals. The
American Rescue Plan Act of 2021 appropriated funds for strike teams to be deployed to
nursing facilities to assist with clinical care, infection control, or staffing during, and for up
to 1 year following, the COVID-19 emergency. Pub. L. No. 117-2, §§ 9402, 9818, 135
Stat. 4, 127, 218.
30The strike teams identified challenges related to staffing, personal protective equipment
supplies, COVID-19 testing, and infection prevention and control measure implementation.
See L. Anderson et al., “Protecting Nursing Home Residents from COVID-19: Federal
Strike Team Findings and Lessons Learned,” New England Journal of Medicine Catalyst
(June 28, 2021).

Page 13 GAO-23-105613 Nursing Home Expert Roundtable
pandemic. 31 Experts said that the waiver of certain training and
certification requirements for certified nurse assistants, the waiver of the
Medicare requirement for a 3-day prior hospitalization before coverage of
a nursing home stay, and the waiver allowing for provider visits to be
conducted via telehealth, were particularly helpful. One expert said that
some of the waivers should be considered for future permanent
regulatory change; however, we did not assess the extent to which
additional legislative authority would be necessary for such permanent
regulatory changes. 32 Conversely, one expert noted that these waivers
were too lenient and should be rolled back. CMS officials have reported
the agency has continued to assess the need for the emergency blanket
waivers throughout the pandemic and have ended some waivers as
appropriate. 33

We discussed this action with HHS officials. Specifically, CMS officials
said that the agency is developing a “playbook” of the types of flexibilities
the agency would use again in a future pandemic. CMS has used
emergency blanket waivers in the past for natural disasters like floods
and fires but had not used these before in the context of a pandemic
emergency and with such a long duration.

31Under section 1135 of the Social Security Act, HHS may temporarily waive or modify
certain federal health care requirements when both a public health emergency and a
disaster or emergency have been declared. 42 U.S.C. § 1320b-5. The President
authorized HHS to issue waivers under section 1135 beginning in March 2020.

Blanket waivers apply automatically to all applicable providers and suppliers in the
emergency area, which encompassed the entire United States in the case of the COVID-
19 pandemic. Providers and suppliers do not need to apply individually or notify CMS that
they are acting upon the waiver.
32See Centers for Medicare & Medicaid Services, COVID-19 Emergency Declaration
Blanket Waivers for Health Care Providers (Baltimore, Md.: March 13, 2020) and Centers
for Medicare & Medicaid Services, Update to COVID-19 Emergency Declaration Blanket
Waivers for Specific Providers, QSO-22-15-NH (Baltimore, Md.: April 7, 2022).
33CMS’s Pandemic Plan outlining its policies for responding to a pandemic establishes
that the agency will monitor the efficacy of the waivers CMS implements. We have
previously reported that CMS officials said it would not be possible to measure the unique
effects of waivers and flexibilities, given other changes affecting nursing home residents.
However, the agency stated that certain waivers and flexibilities—among other factors—
might have contributed to declines in patient safety metrics for long-term care residents.
See GAO, Medicare: CMS Needs to Address Risks Posed by Provider Enrollment
Waivers and Flexibilities, GAO-23-105494 (Washington, D.C.: Dec. 19, 2022) and
Department of Health and Human Services, Centers for Medicare & Medicaid Services,
Pandemic Plan, V. 3.1. Public Release (updated Jan. 11, 2021).

Page 14 GAO-23-105613 Nursing Home Expert Roundtable
Continue stakeholder communication and briefings. Experts said that
HHS could consider creating standardized communication practices for
future infectious disease emergencies based on lessons learned from the
COVID-19 pandemic. One expert said that the regular outreach and
communication during the pandemic was an important opportunity for
nursing homes to, for example, receive updated COVID-19 case counts
and understand changing guidance. Experts added that the question and
answer period of these routine calls were helpful for nursing homes.

We discussed this action with HHS officials. Specifically, CMS officials
noted that it was helpful to share information during the pandemic
between CMS and nursing homes, and that these briefings are
continuing. CMS officials also noted the importance of nursing homes
sharing best practices and lessons learned with one another.

Experts Identified Seven The expert roundtable we convened identified seven actions HHS should
Actions HHS Should enhance that could improve infection prevention and control in nursing
homes. Experts said that enhancing these actions through new agency
Enhance
investments or policies could improve routine and emergency infection
prevention and control practices. (See fig. 2 for each action and examples
of how the action could be enhanced.)

Page 15 GAO-23-105613 Nursing Home Expert Roundtable
Figure 2: Actions Experts Said the Department of Health and Human Services (HHS) Should Enhance

Note: The actions in this report are not listed in any specific rank or order, and their inclusion should
not be interpreted as GAO endorsing any of them. Implementing any one action or a combination of
actions listed in this report might require additional efforts to address program design or legal issues.
Except in those areas directly related to GAO’s prior recommendations, we did not assess how
effective the actions listed in this report may be or the extent to which legislative changes and federal
financial support would be needed to implement them. For the examples of how the action can be
enhanced, experts said that specific details on the implementation approach are important and input
from relevant stakeholders should be considered.
According to HHS officials, two of the actions—increasing infection prevention and control technical
assistance and ensuring consistent guidance—were already underway and therefore should be
considered actions HHS should continue.
a
One expert noted that more state collaboration is needed when determining mandatory infection
prevention and control training requirements.

Page 16 GAO-23-105613 Nursing Home Expert Roundtable
b
One expert said that there is a need to strengthen and encourage state-based assistance programs
to increase infection prevention and control technical assistance. Another expert said that infection
prevention and control technical assistance should be evaluated for its effectiveness.

Develop staffing solutions. Experts told us that HHS could consider
Expert Perspective on Staffing in Nursing developing solutions to ensure adequate staffing to perform proper
Homes
infection prevention and control in nursing homes, including increasing
“I don’t think I’m in a single conversation
where people don’t prioritize staffing as the minimum staffing standards for the infection preventionist and other
probably the number one issue.” nursing home staff.
Source: Statement from GAO’s roundtable of 13 experts. |
GAO-23-105613
Experts consistently described the need to improve staffing as the highest
priority issue in nursing homes, noting several long-term and ongoing
staffing challenges including shortages and high turnover. Experts said
that inadequate staffing can make it difficult for nursing homes to adhere
to proper infection prevention and control practices and can have effects
beyond infection prevention and control to other aspects of quality of
care. 34 For example, numerous studies have demonstrated a relationship
between nursing home staffing and quality, as shown through a 2001
CMS study that identified minimum nurse-to-resident staffing levels
required to ensure quality care and avoid poor outcomes. 35 Nursing
homes are required to employ an infection preventionist, who must work
at the nursing home at least part-time, and generally must employ a
registered nurse at least 8 consecutive hours a day, 7 days a week. 36 In
February 2022, the Administration announced that CMS will conduct a
new research study to determine the level and type of staffing needed to
ensure safe and quality care. Experts were supportive of CMS’s efforts to
examine minimum staffing requirements.

However, the experts emphasized that additional staffing solutions are
needed in the nursing home sector to ensure there are enough staff
available for nursing homes to meet any new federal standards. For
example, experts told us that nursing homes need to create more
incentives for improving staff recruitment, retention, and compensation,

34For example, a 2021 study found that staff turnover was positively associated with the
probability of a nursing home receiving an infection control citation. See L. Loomer et al.,
“Association between Nursing Home Staff Turnover and Infection Control Citation,” Health
Services Research (2021).
35See Centers for Medicare & Medicaid Services, Report to Congress: Appropriateness of
Minimum Nurse Staffing Ratios in Nursing Homes Phase II Final Report (Baltimore, Md.:
2001).
3642 C.F.R. § 483.80(b) (2021). See also 42 U.S.C. §§ 1395i-3(b)(4)(C)(i),
1396r(b)(4)(C)(i).

Page 17 GAO-23-105613 Nursing Home Expert Roundtable
noting that low wages and few benefits mean that nursing home staff
sometimes struggle to make ends meet and have to work multiple jobs.

For the role of the infection preventionist, experts said that they often do
not have adequate time to perform their responsibilities because the role
is often shared with the Director of Nursing. Experts specified that it
should be a dedicated position with enough time to perform needed
duties. Some experts said that the position should be full-time while
others said that full-time equivalence should depend on the number of
beds in the nursing home.

We discussed this action with HHS officials. Specifically, CMS officials
said that they have taken action where they can, such as publicly posting
data on staffing measures and staff turnover to encourage nursing homes
to retain staff and evaluating the minimum standards for nursing home
staffing. CMS officials said they plan to issue a proposal based on this
evaluation in the spring of 2023. CDC officials were supportive of this
action and noted that increased resources and funding would need to be
allocated by facilities and agencies in this area. CMS officials said that,
for the role of the infection preventionist, their regulations already indicate
that infection preventionists must work in this role at least part-time to
implement an effective infection prevention and control program, but
noted that the infection preventionist could work more than that according
to the needs of the home. CMS officials said they expect nursing homes
to know how much time an infection preventionist needs to work in order
to implement an effective infection prevention and control program. 37

Expert Perspective on Infection Prevention
Strengthen mandatory infection prevention and control training.
and Control Training in Nursing Homes Experts said that HHS could consider strengthening mandatory infection
“Certified nurse assistants [those trained to prevention and control training requirements in its federal regulations for
help nurses by providing non-medical care] all nursing home staff positions and for surveyors conducting nursing
are the largest employee group, by far, in
skilled nursing…[and] they’re only regulated in home inspections. Experts also said that HHS could consider developing
long-term care to have one hour of infection additional infection prevention and control training resources for nursing
control [training] annually.”
Source: Statement from GAO’s roundtable of 13 experts. |
home staff and surveyors. Experts described challenges with nursing
GAO-23-105613 home staff and surveyors lacking adequate infection prevention and

37Specifically, CMS officials noted that nursing homes are required to conduct at least an
annual facility assessment, which considers resident needs and staff ability to provide
care. See 42 C.F.R. § 483.70(e) (2021).

Page 18 GAO-23-105613 Nursing Home Expert Roundtable
control training and variable training requirements for certain nursing
home staff. 38

Experts said that all types of nursing home staff—including those not
providing direct care such as housekeeping staff—lacked proficiency in
infection prevention and control practices. These practices include proper
hand hygiene and the consistent and appropriate use of personal
protective equipment. 39 For example, one expert noted that, prior to the
pandemic, consistent hand hygiene compliance in long-term care settings
was generally low. 40 Experts noted that the federal regulations that
describe required nursing home staff training, including for the infection
preventionist, need to be enhanced. Experts also discussed the need to
increase training for nursing home surveyors, noting that some surveyors
do not know the basics of infection prevention.

We discussed this action with HHS officials. Specifically, CMS officials
noted that federal regulations require nursing homes to train all new and

38For example, experts said that the infection preventionist has responsibilities that are
distinct from a physician or nurse and require specialized training. One expert said that
CDC’s free, online infection preventionist training course was a good starting point, but
that additional training is needed. One study found that nursing homes that received
infection prevention and control deficiencies were more likely to have infection
preventionists with less experience and training and were less likely to provide financial
resources for continuing education in infection control. See C. Herzig et al., “Infection
Prevention and Control Programs in United States Nursing Homes: Results of a National
Survey,” Journal of the American Medical Directors Association, vol. 17, no. 1, (2016), 85-
88.

CMS requirements specify that nursing homes must develop, implement, and maintain an
effective training program for all new and existing staff, including contract staff and
volunteers. Nursing homes must determine the amount and types of training necessary for
their staff based on individual home needs. Training topics are required to include
infection control, among other things. See 42 C.F.R. § 483.95 (2021).
39We and others have also found that nursing homes have faced persistent challenges
with infection prevention and control. See, for example GAO-20-576R and
GAO-22-105133.
40One study found that compliance with hand washing by nurse aides was likely less than
optimal, citing barriers to hand washing such as time constraints and lack of materials.
This study found that about 57 percent of nurse aides comply with hand washing when
caring for residents most of the time, and about 22 percent of nurse aides always
comply. See N. Castle et al., “Hand Hygiene Practices Reported By Nurse Aides in
Nursing Homes,” Journal of Applied Gerontology, vol. 35, no. 3, 267-85 (2016).
One expert noted that more state collaboration is needed when determining mandatory
infection prevention and control training requirements.

Page 19 GAO-23-105613 Nursing Home Expert Roundtable
existing nursing home staff—including temporary contract staff—on
infection prevention and control practices. CMS officials said that state
surveyors are also required to be trained in infection prevention and
control practices. 41 However, CMS officials also said that infection
prevention and control deficiencies are the most commonly cited
deficiency in nursing homes, indicating that nursing homes may not be
correctly implementing infection prevention and control practices learned
during trainings.

CMS officials described training and resources they have made available
to nursing homes, noting that they collaborated with CDC to provide a
publicly available 19-hour course that meets federal training
requirements. 42 CDC officials said the agency is working with public
health, clinical, academic and federal partners, including nursing home
organizations and CMS, to develop and disseminate innovative and
quality infection control training and education for frontline healthcare
workers. 43 CMS and CDC officials said they would like to continue to
collaborate on additional nursing home training resources; however, CMS
officials noted the development of additional resources would require
additional funding.

41CMS officials noted that all facilities are required to include as part of their infection
prevention and control program mandatory training that includes the written standards,
policies, and procedures for the program. See 42 C.F.R. § 483.95(e) (2021). CMS officials
also pointed to a requirement that each facility develop, implement, and maintain an
effective training program for all new and existing staff; individuals providing services
under a contractual arrangement; and volunteers, consistent with their expected roles.
Each facility must determine the amount and types of training necessary based on a
facility assessment that occurs as necessary, but at least annually. See 42 C.F.R. §
483.70(e) (2021).
42CMS officials stated the agency has also published a training on antibiotic stewardship
to support compliance with requirements for an effective antibiotic stewardship program.
CMS officials also noted the agency provides additional resources for nursing homes,
such as the nursing home Infection Control Worksheet, developed in collaboration with
CDC, and other resources for nursing homes on antibiotic stewardship.
43According to CDC officials, this work is being conducted under the name Project
Firstline. Agency officials described Project Firstline as a collaboration of health care,
academic, and public health partners focused on stopping the spread of infectious
diseases in healthcare, including COVID-19, respiratory syncytial virus, and infections
caused by resistant bacteria.

Page 20 GAO-23-105613 Nursing Home Expert Roundtable
Increase infection prevention and control technical assistance.
Experts said that HHS could consider strengthening and broadening the
Expert Perspectives on Technical
Assistance in Nursing Homes quality improvement organization program—organizations that help
“[Nursing homes] need…onsite supports in a nursing homes and other types of providers improve quality of care.
meaningful way that work with facilities one- Experts said that HHS could also consider assisting states with
on-one to improve systems, correct deficient
practices, and connect to hard-to-find conducting more in-person Infection Control Assessment and Response
services.” assessments—a tool developed by CDC to direct infection prevention and
“The Infection Control Assessment and control technical assistance efforts in nursing homes—and offering other
Response assessment...was actually very
helpful [and it would make] a difference in types of technical assistance through state-based Healthcare Associated
oversight…because there would be fewer Infection programs. 44
deficiencies cited…”
Source: Statements from GAO’s roundtable of 13 experts. |
GAO-23-105613 Specifically, experts said that HHS could consider strengthening and
broadening the quality improvement organization program by ensuring
consistency between the organizations and ensuring that quality
improvement organization program staff have adequate infection
prevention and control expertise. 45 As part of its pandemic response, in
June 2020, CMS deployed a network of these organizations to provide
technical assistance, such as training staff on proper personal protective
equipment usage and cohorting (grouping) residents, to approximately
3,000 low performing nursing homes with a history of infection control
challenges. 46 However, experts said that these organizations were active
in some states and not others, and that their level of effectiveness varied.
For example, one expert said that a nursing home reached out to their

44Since 2002, CMS has required quality improvement organizations to work with nursing
homes to improve quality of care. CMS contracts with a quality improvement organization
for each state. We have previously reported that CMS needs to improve targeting and
evaluation of assistance to quality improvement organizations. See GAO, Nursing Homes:
Federal Actions Needed to Improve Targeting and Evaluation of Assistance by Quality
Improvement Organizations, GAO-07-373 (Washington, D.C.: May 29, 2007).
CDC funds state-level programs to detect, prevent, contain, and respond to healthcare
associated infections in health care facilities, including nursing homes. CDC developed a
nursing home-specific Infection Control Assessment and Response tool to systematically
assess a nursing home’s infection prevention and control practices and guide quality
improvement by addressing identified gaps.
45One expert said that there is a need to strengthen and encourage state-based
assistance programs to increase infection prevention and control technical assistance.
Another expert said that infection prevention and control technical assistance should be
evaluated for its effectiveness.
46Centers for Medicare & Medicaid Services, COVID-19 Survey Activities, CARES Act
Funding, Enhanced Enforcement for Infection Control Deficiencies, and Quality
Improvement Activities in Nursing Homes, QSO-20-31-ALL (Baltimore, Md.: June 1, 2020)
(revised January 4, 2021).

Page 21 GAO-23-105613 Nursing Home Expert Roundtable
state’s quality improvement organization in the middle of its first outbreak
but was unable to obtain onsite assistance. Another expert noted that
some quality improvement organizations do not have staff with
appropriate expertise and background to work with nursing homes while
others do.

Experts praised the use of HHS’s Infection Control Assessment and
Response tool during the pandemic, which assisted health departments
and nursing homes to assess infection prevention and control programs
and practices. This tool was developed by CDC in 2016 to guide quality
improvement activities in nursing homes and was later adapted to include
COVID-19-specific practices. 47 Experts said this tool could be more
widely used on-site in nursing homes. For example, one expert described
the assessment as incredibly helpful, noting that the assessor spent the
entire day with the nursing home staff, identified gaps in their infection
control program, and showed staff where time and attention needed to be
prioritized.

We discussed this action with HHS officials. Specifically, CDC officials
described the agency’s investment in state-based Healthcare Associated
Infection prevention programs. Specifically, from January 2020 to July
2021, these CDC-funded infection prevention programs conducted over
8,000 online Infection Control Assessment and Response tool
assessments and over 13,000 remote assessments, a majority of which
were conducted in nursing homes and other long-term care facilities. The
state programs also provided over 58,000 consultations by email, phone,
or in the field. CMS officials said that this action should be categorized as
continued rather than enhanced, citing the infection prevention and
control resources it already provides to nursing home staff. They noted
that CMS evaluations show that quality improvement organizations are
beneficial to nursing homes. However, any expansion of the program
would require additional funding.

Strengthen the use of non-monetary enforcement actions. Experts
told us that non-monetary enforcement actions, like directed plans of
correction, are an underused tool in HHS’s enforcement toolbox, and that
HHS could consider strengthening their use to help nursing homes
improve infection prevention and control practices.

47The Infection Control Assessment and Response tool was adapted and used by health
departments and other partners to perform remote video-assisted or onsite assessment of
COVID-19-specific infection prevention and control practices.

Page 22 GAO-23-105613 Nursing Home Expert Roundtable
Specifically, experts discussed how the enforcement actions most often
used for infection prevention and control deficiencies, such as civil money
penalties, are intended to encourage homes to swiftly fix deficient
practices and are not intended to assist nursing homes with finding and
correcting the root cause. Experts acknowledged that the surveyor’s role
is to enforce regulation and ensure a minimum level of quality and not to
provide technical assistance and feedback when deficient practices are
identified. 48 However, experts noted that this can be challenging because,
after a surveyor cites a deficiency, a nursing home may not know how to
correct the deficient infection prevention and control practice without
assistance. One expert said that surveyors come in and say “this is
wrong…but they can’t give any feedback.” Experts said that surveyors
could more frequently use directed plans of correction—a non-monetary
type of enforcement action that describes the actions the nursing home is
required to take to correct the deficient practices. 49

We discussed this action with HHS officials. Specifically, CMS officials
said that, in June 2020, they launched an enforcement program for
infection prevention and control noncompliance, which included imposing
directed plans of correction. 50

Ensure consistent guidance. Experts said that HHS could consider
working with federal and state partners to ensure the release of online
guidance that is consistent across levels of government and updated to
reflect the most current information. Especially during the beginning of the
pandemic, nursing homes struggled to implement conflicting and rapidly
changing infection prevention and control requirements and guidance
issued by different levels of government. One expert said that the federal
government would release guidance, then the state department of health

48According to the procedural guidelines for nursing home surveys, the role of the
surveyor is to identify care and services that are not consistent with the regulatory
requirements and not to ascertain the root causes of deficient practices. See 42 C.F.R. §
488.110 (2021).
49A directed plan of correction is a plan developed by CMS or the state survey agency that
describes the actions the nursing homes are required to take in order to correct the
deficiencies and specifies the date by which the deficiencies must be corrected.
50This guidance states that, due to the heightened threat to resident health and safety for
even low-level isolated infection prevention and control citations, CMS is expanding
enforcement to improve accountability and sustained compliance with these crucial
practices. In addition, CMS is also providing directed plans of correction, including root
cause analysis, to facilitate lasting systemic changes within facilities to drive sustained
compliance. Centers for Medicare & Medicaid Services, QSO-20-31-ALL (Baltimore, Md.:
June 1, 2020).

Page 23 GAO-23-105613 Nursing Home Expert Roundtable
and the local board of health would release different guidance, which
made compliance difficult. Another expert also noted the importance of
having guidance align across federal partners. In another example,
nursing homes and surveyors would sometimes be following old guidance
that was no longer up-to-date, since guidance was rapidly changing in the
face of the novel virus. One expert said that state surveyors were
sometimes confused about whether to survey nursing homes against the
older guidance or the newer guidance.

We discussed this action with HHS officials. Specifically, CDC and CMS
officials said they worked closely to align their guidance, and they felt
their guidance was aligned during the pandemic. However, CDC officials
acknowledged that the agencies fulfill different roles, which may have
contributed to some disconnect. 51 They also noted that CDC works with
state-level stakeholders to align recommendations, but that they cannot
control what rules states choose to enact. CMS officials said this action
should be categorized as continued rather than enhanced, noting that
CMS currently meets with CDC weekly. CMS officials noted that, earlier in
the pandemic, they met daily to ensure federal coordination on the
COVID-19 pandemic.

Incentivize infection prevention and control research. Experts said
that HHS could consider incentivizing infection prevention and control
research in nursing homes, such as demonstration projects to evaluate
and test effective interventions to improve infection prevention and control
in the nursing home setting. Experts also said that HHS could consider
working with academic groups and public health colleagues to conduct
infection prevention and control research in nursing homes.

Experts described a lack of research specific to nursing homes and
identified infection prevention and control topic areas where more
research is needed, such as research on hand hygiene compliance and
evaluating the quality improvement organization program. One expert
said that nursing home infection prevention and control policies are
largely based on research from the acute care setting. Another expert
said that the acute care setting is different from the nursing home setting
in terms of resources, the population served, and staffing, which makes
applying infection prevention and control guidance from acute care

51CMS is the federal oversight agency responsible for setting requirements and monitoring
nursing homes’ compliance with these requirements. CDC provides guidance,
recommendations, and technical assistance to support infection prevention and control in
nursing homes.

Page 24 GAO-23-105613 Nursing Home Expert Roundtable
settings to the nursing home setting difficult. For example, nursing homes
not only provide health care but also serve as a person’s living space and
home. This can create infection prevention and control challenges not
faced in acute care settings when cleaning and disinfecting resident
rooms.

We discussed this action with HHS officials. Specifically, CDC officials
were supportive of the experts’ identified action and noted that increased
funding and resources would need to be allocated by facilities and
agencies in these areas.

Strengthen emergency preparedness. Experts said that HHS could
Expert Perspective on Emergency
Preparedness Plans in Nursing Homes consider better ensuring that nursing homes adhere to requirements that
“You can go into any of the 15,000 nursing they develop and refine their emergency preparedness plans to include
homes in the country…and some of them will the potential for an infectious disease emergency and ensure they are
be able to show you their emergency plan and
some of them won’t…they won’t know where regularly updated. Experts also said that HHS could consider better
it is, or what’s in it.” ensuring that nursing homes adhere to requirements that they coordinate
Source: Statement from GAO’s roundtable of 13 experts. |
GAO-23-105613
with local, state, and regional partners to plan for assistance during
emergencies.

Experts said that some nursing homes lack emergency preparedness
plans, which CMS requires nursing homes to develop, maintain, and
regularly update. 52 One expert highlighted the usefulness of a specific
nursing home’s emergency preparedness plan during the pandemic. For
instance, this nursing home used a communication system—which they
had never used before the pandemic—to call staff, families, and residents
daily to provide updates on the number of COVID-19 cases in the home,
and the planned meals and activities for the day. The expert described
this emergency plan as “very effective” and noted that the nursing home
likely would not have had this plan in place without the CMS requirement
to do so.

Experts also said that nursing homes should better engage with local,
state, and regional partners to plan for assistance during emergencies, as

52According to CMS’s State Operation Manual, Appendix Z, nursing homes are required to
develop and maintain an emergency preparedness plan that includes planning for
emerging infectious disease outbreaks, and that must be reviewed and updated at least
annually. See Centers for Medicare & Medicaid Services, State Operations Manual,
Appendix Z – Emergency Preparedness for All Provider and Certified Supplier Types
Interpretive Guidance (Baltimore, Md., April 16, 2021).

Page 25 GAO-23-105613 Nursing Home Expert Roundtable
required by CMS. 53 One expert said that nursing homes should partner
with these agencies to better allocate and distribute personal protective
equipment and testing supplies. This expert also said that nursing homes
should leverage these partnerships for emergency medical services to
provide transportation for residents between nursing homes and
hospitals. Another expert said that nursing homes should connect with
regional partners, such as public health departments and academic
centers, to leverage research and support.

We discussed this action with HHS officials. Specifically, CMS officials
said their guidance in the State Operations Manual outlines requirements
for developing emergency preparedness plans and coordinating with local
and regional partners. 54

Experts Identified One The expert roundtable we convened identified one action—the extended
Action HHS Should use of limitations on visitation and group activities—that HHS should
discontinue. (See fig. 3 for the action and examples of how the action
Discontinue
could be discontinued.)

Figure 3: Action Experts Said the Department of Health and Human Services (HHS)
Should Discontinue

53According to CMS’s State Operation Manual, Appendix Z, nursing homes are required to
include a process to coordinate with federal, state, tribal, regional, and local emergency
preparedness systems. See Centers for Medicare & Medicaid Services, State Operations
Manual, Appendix Z – Emergency Preparedness for All Provider and Certified Supplier
Types Interpretive Guidance (Baltimore, Md.: April 16, 2021).
54See Centers for Medicare & Medicaid Services, State Operations Manual, Appendix Z –
Emergency Preparedness for All Provider and Certified Supplier Types Interpretive
Guidance.

Page 26 GAO-23-105613 Nursing Home Expert Roundtable
actions listed in this report might require additional efforts to address program design or legal issues.
Except in those areas directly related to GAO’s prior recommendations, we did not assess how
effective the actions listed in this report may be or the extent to which legislative changes and federal
financial support would be needed to implement them.

In March 2020, to limit the transmission of COVID-19 in nursing homes,
CMS temporarily restricted visitation from all visitors and non-essential
health care personnel (except for certain compassionate care situations)
and suspended group activities. 55 In November 2021, CMS lifted these
restrictions. 56 Prior to the COVID-19 pandemic, nursing homes would
occasionally place temporary limitations on visitation and group activities
during an infectious disease outbreak as a tool to help stop transmission.
According to CDC officials, until the pandemic, these restrictions had not
been universally used across all nursing homes and for such an extended
period of time.

Experts said that the extended period during which there were limitations
on visitation and group activities was detrimental to the physical and
mental health of residents. 57 They also said it was ineffective at keeping
COVID-19 from entering the nursing homes. 58 Experts said that HHS
could consider developing evidence-based standards for when, if at all, to
implement any limitations on visitation and group activities in future
infectious disease emergencies and for how long. HHS could also
consider issuing guidance that outlines tools nursing homes can use to
enable visitation during an outbreak. One expert said there are several

55These restrictions included ombudsmen, which are advocates for nursing home
residents. These restrictions were later clarified to allow certain conditions for visitation,
such as to allow residents access to long-term care ombudsmen. See Centers for
Medicare & Medicaid Services, Guidance for Infection Control and Prevention of
Coronavirus Disease 2019 (COVID-19) in Nursing Homes, QSO-20-14-NH (Baltimore,
Md.: Mar. 13, 2020 revision) and Centers for Medicare & Medicaid Services, Nursing
Home Five Star Quality Rating System Updates, Nursing Home Staff Counts, Frequently
Asked Questions, and Access to Ombudsman, QSO-20-28-NH (Baltimore, Md.: April 24,
2020 and Jul. 9, 2020 revision). After the initial restrictions, CMS made changes to its
visitation guidance multiple times during the pandemic to allow increased visitation and
group activities. See Centers for Medicare & Medicaid Services, Nursing Home Visitation
– COVID-19, QSO-20-39-NH (Sept. 17, 2020), revised March 10, 2021, April 27, 2021,
and Nov. 12, 2021.
56Centers for Medicare & Medicaid Services, QSO-20-39-NH (Nov. 12, 2021 revision).

57This is consistent with our prior work, which found resident mental and physical health
declined during the pandemic. GAO-22-105133.
58This is consistent with our prior work, which found that nursing homes reported that
most COVID-19 outbreaks began with a staff case, indicating that staff are likely to bring
the virus into the nursing home especially during times of high transmission in the
community. GAO-23-104291.

Page 27 GAO-23-105613 Nursing Home Expert Roundtable
tools available that can help enable visitation and group activities,
including personal protective equipment and testing. Another expert noted
that designating one family caregiver per resident who can be allowed to
enter the facility to provide essential care during a period of visitation
restrictions is one approach that worked well in their state.

We discussed discontinuing this action with HHS officials. Specifically,
CMS officials said that, when the decision to place limitations on visitation
and group dining was first implemented, it was early in the pandemic
when the nation was facing a novel virus with significant uncertainty about
how it was spreading so rapidly. CMS officials said that they could not
restrict staff from entering nursing homes because they were needed to
care for residents, but they could decrease visitation. CMS officials said
they saw the unintended consequences in terms of resident psychological
well-being and decided to ease those restrictions. They said what they
learned will serve them in future infectious disease emergencies and that,
in the future, they envision providing guidance that allows for visitation to
occur while also mitigating the risk of infectious disease transmission.

CDC officials said it is possible that short-term restrictions may be
necessary in the future to control the spread of an infectious disease, but
they will be carefully balanced with resident well-being. CDC officials
noted that isolation precautions are a valuable tool for limiting
transmission but agreed the use of limitations on visitation and group
activities for a prolonged duration can potentially cause more harm to
residents than good. CDC officials said it would be helpful to have
guidance with a limit on the duration of these restrictions during an
outbreak or guidance outlining how to ease restrictions.

Many of the actions identified by the expert roundtable we convened are
Many Actions Experts consistent with prior recommendations made to HHS to improve infection
Identified Are prevention and control practices in nursing homes. Specifically, reports
from CMS’s Coronavirus Commission on Safety and Quality in Nursing
Consistent with Prior Homes and the National Academies’ Committee on the Quality of Care in
Recommendations Nursing Homes, as well as prior GAO reports, have examined infection
prevention and control challenges in nursing homes and made many
Made to Improve similar recommendations to the actions identified by our expert
Infection Prevention roundtable. See figure 4 for a comparison of the actions identified by our
expert roundtable with prior recommendations by GAO and others.
and Control

Page 28 GAO-23-105613 Nursing Home Expert Roundtable
Figure 4: Comparison of GAO Expert Roundtable Actions on Infection Prevention and Control with Prior Recommendations
by GAO and Others

a
MITRE, Coronavirus Commission on Safety and Quality in Nursing Homes, Commission Final
Report (McLean, Va.: The MITRE Corporation, 2020). This report was written for CMS under a
government contract.
b
National Academies of Sciences, Engineering, and Medicine, Committee on the Quality of Care in
Nursing Homes, The National Imperative to Improve Nursing Home Quality: Honoring Our

Page 29 GAO-23-105613 Nursing Home Expert Roundtable
Commitment to Residents, Families, and Staff (Washington, D.C.: The National Academies Press,
2022).
GAO, COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection
c

Prevention and Control, GAO-22-105133 (Sep. 14, 2022); COVID-19: Sustained Federal Action is
Crucial as Pandemic Enters Its Second Year, GAO-21-387 (Mar. 31, 2021); and COVID-19: Federal
Efforts Could Be Strengthened by Timely and Concerted Actions, GAO-20-701 (Sept. 21, 2020).
d
The Centers for Disease Control and Prevention’s National Healthcare Safety Network is a national
infection surveillance system that collects data on a range of different healthcare-associated
infections from different types of health care facilities, including nursing homes. In May 2020, CMS
began requiring nursing homes to report data at least weekly through the National Healthcare Safety
Network on the number of COVID-19 cases and deaths among residents and staff, access to
personal protective equipment and testing supplies, and staff shortages, among other things.
e
Strike teams are teams of infection prevention and public health professionals.

Details and recommendations from CMS’s Coronavirus Commission on
Safety and Quality in Nursing Homes, the National Academies’
Committee on the Quality of Care in Nursing Homes, and prior GAO
reports are listed below. The work by CMS and the National Academies
was not specifically focused on the topic of infection prevention and
control, in contrast to some of GAO’s prior work and the work of the
expert roundtable. However, those projects did identify infection
prevention and control-related recommendations in addition to
recommendations that are broader in scope to address systemic issues. 59

• CMS’s Coronavirus Commission on Safety and Quality in
Nursing Homes. In June 2020, CMS announced the establishment of
the 25-member Coronavirus Commission on Safety and Quality in
Nursing Homes. The Commission was tasked with addressing safety
and quality in nursing homes in relation to the public health
emergency by soliciting lessons learned from the early days of the
pandemic and recommendations to improve infection prevention and
control, safety procedures, and quality of life for residents. According
to the Commission’s report, which was released by CMS in
September 2020, the spread of COVID-19 in nursing homes has
exposed and exacerbated long-standing, underlying challenges,
including a patchwork approach to infection prevention and control.
The Commission’s report included 27 recommendations organized
under 10 themes. 60

59There was also discussion of systemic issues during the expert roundtable we
convened. For example, roundtable experts raised concerns about whether nursing
homes had sufficient resources available to invest in improvements to things like the
physical plant.
60See MITRE, Commission Final Report.

Page 30 GAO-23-105613 Nursing Home Expert Roundtable
As of May 2021, CMS developed an internal tracking document that
notes the status of each of the Commission’s recommendations, the
responsible agency for each recommendation, and the planned
actions for CMS-related recommendations. This document is to be
updated quarterly. This was done in response to GAO’s November
2020 recommendation that CMS quickly develop a plan that further
details how it intends to respond to and implement, as appropriate,
the Commission’s recommendations. 61

• The National Academies’ Committee on the Quality of Care in
Nursing Homes. In April 2022, the National Academies’ 17-member
Committee on the Quality of Care in Nursing Homes published its first
comprehensive examination of nursing home quality since 1986,
noting that, while many improvements have been made since then,
the COVID-19 pandemic brought new attention to long-standing
problems, including infection prevention and control. 62 Specifically, the
report notes that the pandemic revealed a significant lack of nursing
home staff expertise in infection prevention and control practices
necessary to limit the introduction and spread of COVID-19 within
nursing homes. For example, efforts to isolate those infected or
quarantine those exposed were often delayed or inadequate and
sometimes non-existent, resulting in rapid spread of the virus. The
report identified seven broad goals related to quality of care with 35
related recommendations. CMS officials said they are tracking the
recommendations from the National Academies that they believe are
within the scope of their authority.
• GAO’s prior work. In reports issued in September 2020, March 2021,
and September 2022, GAO made recommendations related to
bolstering COVID-19 data reporting to the National Healthcare Safety
Network and to strengthening the role of the infection preventionist. 63
GAO made a total of six recommendations to HHS, and the agency
agreed or partially agreed with two recommendations and did not
state whether it agreed or disagreed with the remaining four

61As noted, this recommendation was implemented by CMS as of May 2021. GAO,
COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal Response
(Nursing Homes Enclosure), GAO-21-191 (Washington, D.C.: Nov. 30, 2020).
62National Academies, The National Imperative to Improve Nursing Home Quality.

63See GAO-22-105133, GAO-21-387, and GAO-20-701.

Page 31 GAO-23-105613 Nursing Home Expert Roundtable
recommendations. 64 As of September 2022, the agency has taken
steps to implement two of these recommendations.
The COVID-19 pandemic has had devastating consequences in nursing
homes and has drawn attention to the critical importance of robust
infection prevention and control practices to address not only the threat of
COVID-19, but other infectious diseases. A growing body of work shows
that COVID-19 exposed and worsened long-standing infection prevention
and control problems in nursing homes and indicates there are
opportunities for HHS to evaluate and prioritize efforts to bolster infection
prevention and control. HHS’s continued leadership in prioritizing infection
prevention and control—in coordination with other federal, state, and
private entities—is critical to better protect nursing home residents from
the enduring risks of declining health and premature death posed by
infections. Our roundtable experts offered several potential actions to
address these long-standing problems that are consistent with prior
recommendations made by GAO, the National Academies’ Committee on
the Quality of Care in Nursing Homes, and CMS’s Coronavirus
Commission on Safety and Quality in Nursing Homes. These actions
may, for example, assist HHS in addressing prior recommendations from
GAO and others, presenting new solutions, or expanding on current
efforts.

We provided a draft of this report to HHS for review and comment. HHS,
Agency Comments specifically CDC, provided us with technical comments, which we
incorporated as appropriate.

64In September 2020, GAO made a recommendation that HHS develop a strategy to
capture more complete data on COVID-19 cases and deaths in nursing homes
retroactively back to January 1, 2020, and clarify the extent to which nursing homes have
reported data before May 2020. HHS partially agreed with this recommendation. As of
September 2022, HHS had not implemented this recommendation. In March 2021, GAO
made two recommendations that HHS collect data specific to COVID-19 vaccination rates
in nursing homes and make these data publicly available, and that HHS require nursing
homes to offer COVID-19 vaccinations to residents and staff and design and implement
associated quality measures. HHS neither agreed or disagreed with these two
recommendations. As of September 2022, HHS had implemented the recommendation
related to collecting data and partially implemented the other recommendation. In
September 2022, GAO made three recommendations, including that HHS establish
minimum infection preventionist training standards. HHS agreed with one of these
recommendations and did not agree or disagree with the other two recommendations. As
of September 2022, HHS had not implemented these recommendations. See
GAO-20-701, GAO-21-387, and GAO-22-105133.

Page 32 GAO-23-105613 Nursing Home Expert Roundtable
We are sending copies of this report to the appropriate congressional
committees, the Secretary of HHS, and other interested parties. In
addition, the report is available at no charge on the GAO website at
http://www.gao.gov.

If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or at dickenj@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in Appendix II.

John E. Dicken
Director, Health Care

Page 33 GAO-23-105613 Nursing Home Expert Roundtable
List of Addressees

The Honorable Patty Murray
Chair
The Honorable Susan Collins
Vice Chair
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 Bernard Sanders
Chair
The Honorable Bill Cassidy
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate

The Honorable Gary C. Peters
Chairman
The Honorable Rand Paul, M.D.
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate

The Honorable Kay Granger
Chair
The Honorable Rosa L. DeLauro
Ranking Member
Committee on Appropriations
House of Representatives

The Honorable Cathy McMorris Rodgers
Chair
The Honorable Frank Pallone, Jr.
Ranking Member
Committee on Energy and Commerce
House of Representatives

Page 34 GAO-23-105613 Nursing Home Expert Roundtable
The Honorable Mark E. Green, M.D.
Chairman
The Honorable Bennie G. Thompson
Ranking Member
Committee on Homeland Security
House of Representatives

The Honorable James Comer
Chairman
The Honorable Jamie Raskin
Ranking Member
Committee on Oversight and Accountability
House of Representatives

The Honorable Jason Smith
Chairman
The Honorable Richard Neal
Ranking Member
Committee on Ways and Means
House of Representatives

The Honorable Michael F. Bennet
United States Senate

Page 35 GAO-23-105613 Nursing Home Expert Roundtable
Appendix I: Expert Roundtable on Infection
Appendix I: Expert Roundtable on Infection
Prevention and Control in Nursing Homes

Prevention and Control in Nursing Homes

To address our first objective, we convened a 2-day roundtable on April
27 and 28, 2022, of 13 experts to discuss actions that the Department of
Health and Human Services (HHS) should continue, enhance, or
discontinue to improve infection prevention and control practices in
nursing homes. We contracted with the National Academies of Sciences,
Engineering, and Medicine (National Academies) to help us identify
potential experts. 1 The National Academies identified potential experts
based on the experts’ experience in the following areas:

• academic researchers and infectious disease specialists with
knowledge of nursing home infection prevention and control oversight,
• nursing home management and staff,
• individuals with oversight and regulatory experience, and
• representatives for residents and their families.
From the list of potential experts from the National Academies, we
selected the experts based on factors such as (1) type and depth of
experience, (2) recognition in the professional community, (3) published
work and its relevance to our research objectives, (4) professional
affiliations, and (5) present and past employment history. The team also
considered other factors like geographic representation and diversity,
where possible. Some experts had experience or qualifications in multiple
areas of interest.

To help identify any potential biases or conflicts of interest, before
finalizing the participation of experts, we asked each expert who
participated in the roundtable to disclose whether they had investments,
sources of earned income, organizational positions, relationships, or other
circumstances that could affect, or could be viewed to affect, an expert’s
statements during the roundtable. None of the experts reported potential
conflicts that would affect their ability to participate in the roundtable. (See
table 1).

1The expert roundtable was planned and convened with the assistance of the National
Academies to help ensure that a breadth of expertise was brought to bear in its
preparation; however, all final decisions regarding meeting substance and expert
participation are the responsibility of GAO.

Page 36 GAO-23-105613 Nursing Home Expert Roundtable
Appendix I: Expert Roundtable on Infection
Prevention and Control in Nursing Homes

Table 1: List of Expert Participants in GAO’s Roundtable on Infection Prevention and Control in Nursing Homes, Held April 27
and 28, 2022

Institutional affiliation at time of
Expert Discipline roundtable
Alice Bonner, Ph.D., R.N., FAAN Nurse Practitioner, Former CMS Director Johns Hopkins University School of
of the Division of Nursing Homes Nursing; Institute for Healthcare
Improvement
Kathy Bradley Resident and Family Advocate, Director of Our Mother’s Voice
Nonprofit Advocacy Organization serving
people across the country
Scott Brunner State Survey Agency Official Kansas Department for Aging and
Disability Services
Deb Patterson Burdsall, Ph.D., R.N.-B.C., Long-Term Care Infection Preventionist, Hektoen Institute of Medicine. Grantee,
CIC, LTC-CIP, FAPIC Registered Nurse Illinois Department of Public Health
Sumathi Devarajan, M.D. Medical Director of Geriatrics; Attending Department of Family Medicine, Oregon
Physician at a Nursing Home Health Science University; Kindred
Hospice; Friendship Holgate Center
(nursing home)
Morgan Katz, M.D., M.H.S. Physician Specializing in Infectious Johns Hopkins University
Disease, State Nursing Home Strike Team
Member
Beverley L. Laubert, M.A. Former State Ombudsman The Administration for Community Living
Nicky Martin, M.P.A., LNHA, QCP Technical Assistance Program, Clinical Quality Improvement Program for Missouri,
Instructor, Quality Improvement University of Missouri Sinclair School of
Organization Program Team Leader Nursing
Lori Porter, CNA Certified Nursing Assistant, Director of National Association of Health Care
National CNA Organization Assistants (NAHCA)
Janet Snipes, LNHA Nursing Home Administration (Executive Holly Heights Nursing Center (nursing
Director) home)
David G. Stevenson, Ph.D. Professor of Health Policy Vanderbilt University School of Medicine,
Geriatric Research, Education, and Clinical
Center (GRECC), VA Tennessee Valley
Healthcare System
Patricia W. Stone, Ph.D., R.N., FAAN, CIC, Professor of Health Policy; Nurse Scientist, Columbia University School of Nursing
FAPIC Nurse Practitioner, and Infection
Preventionist
Dallas Taylor, B.S.N., M.P.H., R.N. Nursing Home Administration (Director of The Village of St. Edward (nursing home)
Nursing); Registered Nurse
Legend: M.D. = doctor of medicine; Ph.D. = doctor of philosophy; M.A. = master of arts; B.S.N. = bachelor of science in nursing; FAAN = fellow of the
American Academy of Nursing; R.N. = registered nurse; R.N.-B.C. = registered nurse board certified; CIC = certified in infection control; LTC-CIP= long-
term care certification in infection prevention; M.H.S. = master of health science; M.P.A. = master of public administration; M.P.H. = master of public
health; LNHA = licensed nursing home administrator; QCP = quality assurance and performance improvement certified professional; CNA = certified
nursing assistant; FAPIC = Fellow of the Association for Professionals in Infection Control and Epidemiology.
Source: GAO. | GAO-23-105613

Note: The comments provided by the experts reflected their own views and not those of the
organizations with which they are affiliated. Further, the experts’ views may not correspond with those
of others with similar backgrounds and expertise. To help identify any potential biases or conflicts of
interest, before finalizing the participation of experts, we asked each expert who participated in the

Page 37 GAO-23-105613 Nursing Home Expert Roundtable
Appendix I: Expert Roundtable on Infection
Prevention and Control in Nursing Homes

roundtable to disclose whether they had investments, sources of earned income, organizational
positions, relationships, or other circumstances that could affect, or could be viewed to affect, their
statements during the roundtable. None of the experts reported potential conflicts that would affect
their ability to participate in the roundtable.

The 2-day expert roundtable discussions were recorded and transcribed
to ensure that we accurately captured experts’ statements. We then
reviewed the transcripts and identified the actions that experts said HHS
should continue, enhance, or discontinue to improve infection prevention
and control practices in nursing homes and examples of each. 2 Following
the roundtable, we sent the experts the actions and examples for review
and comment and incorporated those comments into our report as
appropriate.

2The comments provided by the experts reflected their own views and not those of the
organizations with which they are affiliated. Further, the experts’ views may not
correspond with those of others with similar backgrounds and expertise.

The actions in this report are not listed in any specific rank or order, and their inclusion
should not be interpreted as GAO endorsing any of them. Implementing any one action or
a combination of actions listed in this report might require additional efforts to address
program design or legal issues. Except in those areas directly related to GAO’s prior
recommendations, we did not assess how effective the actions listed in this report may be
or the extent to which legislative changes and federal financial support would be needed
to implement them.

Page 38 GAO-23-105613 Nursing Home Expert Roundtable
Appendix II: GAO Contact and Staff
Appendix II: GAO Contact and Staff
Acknowledgments

Acknowledgments

John E. Dicken, (202) 512-7114 or dickenj@gao.gov
GAO Contact
In addition to the contact named above, key contributors to this report
Staff were Karin Wallestad (Assistant Director), Sarah-Lynn McGrath (Analyst-
Acknowledgments in-Charge), and Elaina Stephenson. Also contributing were Elise
Pressma, Kathryn Richter, Isabella Guyott, Meghann Lewis, Laurie
Pachter, Patricia Powell, Roxanna Sun, Walter Vance, and Jennifer
Whitworth.

Page 39 GAO-23-105613 Nursing Home Expert Roundtable
Related GAO Products on COVID-19 in
Related GAO Products on COVID-19 in Nursing
Homes

Nursing Homes

COVID-19 in Nursing Homes: Outbreak Duration Averaged 4 Weeks and
Was Strongly Associated with Community Spread. GAO-23-104291.
Washington, D.C.: Dec. 15, 2022.

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen
Oversight of Infection Prevention and Control. GAO-22-105133.
Washington, D.C.: Sept. 14, 2022.

Health Care Capsule: Improving Nursing Home Quality and Information.
GAO-22-105422. Washington, D.C.: Jan. 14, 2022.

COVID-19: Continued Attention Needed to Enhance Federal
Preparedness, Response, Service Delivery, and Program Integrity
(Nursing Homes Enclosure). GAO-21-551. Washington, D.C.: July 19,
2021.

COVID-19 in Nursing Homes: Most Homes Had Multiple Outbreaks and
Weeks of Sustained Transmission from May 2020 through January 2021.
GAO-21-367. Washington, D.C.: May 19, 2021.

COVID-19: Sustained Federal Action is Crucial as Pandemic Enters its
Second Year (Nursing Homes Enclosure). GAO-21-387. Washington,
D.C.: March 31, 2021.

COVID-19 in Nursing Homes: HHS Has Taken Steps in Response to
Pandemic, but Several GAO Recommendations Have Not Been
Implemented. GAO-21-402T. Washington, D.C.: March 17, 2021.

COVID-19: Critical Vaccine Distribution, Supply Chain, Program Integrity,
and Other Challenges Require Focused Federal Attention (Nursing
Homes Enclosure). GAO-21-265. Washington, D.C.: January 28, 2021.

COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal
Response (Nursing Homes Enclosure). GAO-21-191. Washington, D.C.:
November 30, 2020.

COVID-19: Federal Efforts Could Be Strengthened by Timely and
Concerted Actions (Nursing Homes Enclosure). GAO-20-701.
Washington, D.C.: September 21, 2020.

COVID-19: Opportunities to Improve Federal Response and Recovery
Efforts (Nursing Homes Enclosure). GAO-20-625. Washington, D.C.:
June 25, 2020.

Page 40 GAO-23-105613 Nursing Home Expert Roundtable
Related GAO Products on COVID-19 in Nursing
Homes

Infection Control Deficiencies Were Widespread and Persistent in Nursing
Homes Prior to COVID-19 Pandemic. GAO-20-576R. Washington, D.C.:
May 20, 2020.

Page 41 GAO-23-105613 Nursing Home Expert Roundtable
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