Full text
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
CDC PROVIDED OVERSIGHT AND
ASSISTANCE; HOWEVER, ELC
RECIPIENTS STILL FACED
CHALLENGES IN IMPLEMENTING
COVID-19 SCREENING
TESTING PROGRAMS
Amy J. Frontz
Deputy Inspector General
for Audit Services
September 2023
A-05-22-00010
Inquiries about this report may be addressed to the Office of Public Affairs at
Public.Affairs@oig.hhs.gov.
Office of Inspector General
https://oig.hhs.gov
The mission of the Office of Inspector General (OIG) is to provide objective oversight to promote the
economy, efficiency, effectiveness, and integrity of the Department of Health and Human Services (HHS)
programs, as well as the health and welfare of the people they serve. Established by Public Law
No. 95-452, as amended, OIG carries out its mission through audits, investigations, and evaluations
conducted by the following operating components:
Office of Audit Services. OAS provides auditing services for HHS, either by conducting audits
with its own audit resources or by overseeing audit work done by others. The audits examine the
performance of HHS programs, funding recipients, and contractors in carrying out their respective
responsibilities and provide independent assessments of HHS programs and operations to reduce waste,
abuse, and mismanagement.
Office of Evaluation and Inspections. OEI’s national evaluations provide HHS, Congress,
and the public with timely, useful, and reliable information on significant issues. To promote impact,
OEI reports also provide practical recommendations for improving program operations.
Office of Investigations. OI’s criminal, civil, and administrative investigations of fraud and
misconduct related to HHS programs and operations often lead to criminal convictions, administrative
sanctions, and civil monetary penalties. OI’s nationwide network of investigators collaborates with the
Department of Justice and other Federal, State, and local law enforcement authorities. OI works with
public health entities to minimize adverse patient impacts following enforcement operations. OI also
provides security and protection for the Secretary and other senior HHS officials.
Office of Counsel to the Inspector General. OCIG provides legal advice to OIG on HHS
programs and OIG’s internal operations. The law office also imposes exclusions and civil monetary
penalties, monitors Corporate Integrity Agreements, and represents HHS’s interests in False Claims Act
cases. In addition, OCIG publishes advisory opinions, compliance program guidance documents, fraud
alerts, and other resources regarding compliance considerations, the anti-kickback statute, and other
OIG enforcement authorities.
Notices
THIS REPORT IS AVAILABLE TO THE PUBLIC
at https://oig.hhs.gov
Section 8M of the Inspector General Act, 5 U.S.C. App., requires
that OIG post its publicly available reports on the OIG website.
OFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS
The designation of financial or management practices as
questionable, a recommendation for the disallowance of costs
incurred or claimed, and any other conclusions and
recommendations in this report represent the findings and
opinions of OAS. Authorized officials of the HHS operating
divisions will make final determination on these matters.
Report in Brief
Date: September 2023
Report No. A-05-22-00010
Why OIG Did This Audit
The Centers for Disease Control and
Prevention’s (CDC’s) Epidemiology
and Laboratory Capacity for
Prevention and Control of Emerging
Infectious Diseases (ELC) program
provides strategic investments
through its cooperative agreement
with health departments aimed at
reducing domestic infectious disease-
related illnesses and death.
The American Rescue Plan (ARP)
provided relief to address the
continued impact of COVID-19 on the
economy, public health, State and
local governments, individuals, and
businesses. CDC provided $10 billion
in ARP funding to 64 ELC recipients to
support COVID-19 screening testing
for teachers, staff, and students in
K-12 school settings.
Our objective was to determine what
oversight and assistance CDC
provided to assist ELC recipients in
implementing COVID-19 screening
testing programs.
How OIG Did This Audit
We reviewed information the ELC
recipients were required to report
during the project period of April
2021 through July 2023 and
determined the programmatic and
financial oversight CDC provided to
support the ELC Reopening Schools
project. In addition, we reviewed the
technical assistance, implementation
tools, and resources CDC provided to
ELC recipients in implementing the
COVID-19 screening testing
programs.
The full report can be found at https://oig.hhs.gov/oas/reports/region5/A052200010.asp.
CDC Provided Oversight and Assistance; However,
ELC Recipients Still Faced Challenges in
Implementing COVID-19 Screening Testing Programs
What OIG Found
We found that CDC provided oversight and assistance to the ELC recipients in
implementing the COVID-19 screening testing programs, by utilizing recipient
data and conducting periodic outreach through webinars and technical
assistance calls, among other things. However, based on the ELC recipients’
responses to the OIG survey, we identified challenges the ELC recipients
encountered in implementing the ELC screening testing programs within their
jurisdictions. Some of the ELC recipients encountered challenges expending
the ELC Reopening Schools funding, such as barriers from schools in
implementing the screening testing programs in their districts, while others
used alternative sources of government funding in the implementation of the
screening testing programs. In addition, some of the ELC recipients
encountered challenges implementing the ELC screening testing programs,
including: (1) lack of interest from the schools and communities, (2) limitations
on the costs that were allowable under the terms and conditions of the
awards, (3) insufficient school staffing and resources, and (4) issues with
vendors or contractors. The challenges that were identified in implementing
the screening testing programs from the survey of ELC recipients provide CDC
with areas to focus on when implementing future ELC programs.
What OIG Recommends
The report includes no recommendations. However, we expect that CDC will
use the suggestions and feedback from the ELC recipients’ responses to the
OIG survey to improve development of ELC programs that are in response to
future public health emergencies. CDC elected not to provide formal written
comments on our draft report but did provide technical comments, which we
addressed as appropriate.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
TABLE OF CONTENTS
INTRODUCTION ............................................................................................................................... 1
Why We Did This Audit ....................................................................................................... 1
Objective ............................................................................................................................. 1
Background ......................................................................................................................... 2
American Rescue Plan Funding for COVID-19 Screening Testing
at Schools ............................................................................................................. 2
CDC’s COVID-19 Screening Testing Program .......................................................... 2
ELC Reopening School Guidance............................................................................. 3
Requirements for CDC’s Monitoring and Oversight of the
ELC Recipients ...................................................................................................... 3
Recipients’ Use of ELC Reopening School Funding During the ELC
Reopening School Project Period ......................................................................... 4
How We Conducted This Audit ........................................................................................... 5
FINDINGS ......................................................................................................................................... 6
CDC Provided Oversight and Assistance to the ELC Recipients in Implementing the
COVID-19 Screening Testing Programs ......................................................................... 6
CDC Used Recipient Data To Oversee Implementation of the ELC COVID-19
Screening Testing Program .................................................................................. 6
CDC Provided Several Types of Technical Assistance During Implementation of
the School Screening Testing Program ................................................................ 8
ELC Recipient Responses Related to the Oversight and Assistance Provided by CDC, the
Challenges Expending Award Funds, and Implementing the COVID-19 Screening
Testing Programs ........................................................................................................ 11
Most ELC Recipients Responded That Assistance CDC Provided in Implementing
the ELC Screening Testing Programs Met or Exceeded Expectations ................ 11
ELC Recipient Comments on the Oversight CDC Provided in Implementing the
ELC Screening Testing Programs ........................................................................ 13
Challenges the ELC Recipients Faced Expending the ELC Reopening
Schools Funding.................................................................................................. 13
Challenges the ELC Recipients Encountered in Implementing the ELC
Screening Testing Programs ............................................................................... 15
APPENDICES
A: Audit Scope and Methodology ..................................................................................... 17
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
B: ELC Reopening Schools Funding and Expenditures by ELC Recipient .......................... 19
C: OIG Survey to ELC Recipients ........................................................................................ 21
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
1
INTRODUCTION
WHY WE DID THIS AUDIT
The Centers for Disease Control and Prevention’s (CDC’s) Epidemiology and Laboratory Capacity
for Prevention and Control of Emerging Infectious Diseases (ELC) program provides strategic
investments through its cooperative agreement with health departments aimed at reducing
domestic infectious disease-related illnesses and death. Since 1995, CDC’s ELC program has
been providing support to health departments throughout the United States. Currently, CDC
provides financial resources and technical assistance each year to 64 ELC recipients to support
activities related to surveillance, detection, response, and prevention of infectious diseases.1
The American Rescue Plan (ARP) Act of 2021 (P.L. No. 117-2) provided relief to address the
continued impact of COVID-19 on the economy, public health, State and local governments,
individuals, and businesses. CDC provided $10 billion in ARP funding to the 64 ELC recipients to
support COVID-19 screening testing for teachers, staff, and students in K-12 school settings.2, 3
CDC used an existing ELC cooperative agreement (CK19-1904) and recipients to ensure that the
funding was deployed quickly to help schools reopen and remain open for in-person
instruction. Recognizing that establishing a testing program was new for many schools, CDC
and State and local health departments provided support and technical assistance to assist
States and schools with implementing these programs.
COVID-19 has created extraordinary challenges for the delivery of health care and human
services to the American people. As the oversight agency for the Department of Health and
Human Services (HHS), the Office of Inspector General (OIG) oversees HHS’s COVID-19 response
and recovery efforts. This audit is part of OIG’s COVID-19 response strategic plan.4
OBJECTIVE
Our objective was to determine what oversight and assistance CDC provided to assist ELC
recipients in implementing COVID-19 screening testing programs.
1 The 64 ELC recipients include all 50 States, large local governments, and United States territories and affiliate
health departments.
2 Three of the sixty-four ELC recipients did not accept or use the funds, and one recipient accepted part of the
funding, resulting in $1 billion of ARP funding that was de-obligated. As a result, of the $10 billion in ARP funding
awarded to the ELC recipients, the final obligation amount was $9 billion.
3 “Screening testing” is intended to identify people with COVID-19 who are asymptomatic or do not have any
known, suspected, or reported exposure to someone with COVID-19.
4 OIG’s COVID-19 response strategic plan and oversight activities can be accessed at HHS-OIG's Oversight of
COVID-19 Response and Recovery | HHS-OIG.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
2
BACKGROUND
American Rescue Plan Funding for COVID-19 Screening Testing at Schools
The ARP Act, enacted March 11, 2021, appropriated $47.8 billion to HHS to carry out activities
to detect, diagnose, trace, and monitor SARS-CoV-2 and COVID-19 infections and related
strategies to mitigate the spread of COVID-19 (§ 2401 of the ARP Act [or] 42 USC § 247d). CDC,
through the ELC program, provided $10 billion to States to support COVID-19 screening testing
for teachers, staff, and students to assist schools in reopening safely for in-person instruction.
The objectives and goals of the funding were focused on providing the resources to implement
screening testing programs in schools. ELC recipients were encouraged to align their approach
to testing with CDC recommendations for K-12 schools whenever possible.
From April 7−8, 2021, the $10 billion was awarded to the 64 ELC recipients according to a
population-based formula. The funding was awarded for a 16-month project period ending
July 31, 2022. On March 30, 2022, CDC notified the ELC recipients that it would be extending
the use of the ELC Reopening Schools funding through July 31, 2023.
CDC’s COVID-19 Screening Testing Program
According to CDC, screening testing was a tool that schools could utilize to help safely reopen as
part of a comprehensive COVID-19 mitigation approach. CDC awarded the funds to existing
cooperative agreement recipients to ensure the funding was deployed quickly to help schools
reopen and remain open. In addition to providing diagnostic testing of symptomatic and
exposed individuals, screening testing would help schools identify infected individuals without
symptoms who may be contagious so that prompt action could be taken to prevent further
transmission. With the ARP funding, ELC recipients could support implementing critical
screening testing programs that were needed in schools. Recognizing that establishing a testing
program was new for many schools, CDC and State and local health departments provided
support and technical assistance to assist States and schools with implementing these
programs.
CDC stated that reopening school resources were critical in ensuring that students and staff
safely continued in-person learning. As of April 2023, over 156 million tests have been
conducted as a result of ELC Reopening Schools funding. ELC Reopening Schools funding
provided financial support for over 5,600 positions. The main category of funded positions was
school nurses, representing over 3,200 positions.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
3
ELC Reopening School Guidance
CDC published the initial ELC Reopening Schools: Support for Screening Testing To Reopen
& Keep Schools Operating Safely (ELC Reopening Schools) guidance document in March 2021.
As the response to the pandemic changed throughout the COVID-19 public health emergency
(PHE), the ELC program issued revised ELC Reopening Schools guidance documents to align with
CDC recommendations and the current needs of the ELC recipients to address the PHE.
In accordance with the ELC Reopening Schools guidance, a minimum of 85 percent of the funds
must be directly used to support prevention efforts in school districts. This support can include
directly providing funds to schools or indirectly providing support to increase screening testing
and support for related prevention strategies in all K-12 schools within the ELC recipient’s
jurisdiction. ELC recipients may use a combination of approaches to successfully provide the
necessary support to schools. Up to 15 percent of the funds may be used by ELC recipients for
coordination, management, technical assistance, monitoring, data collection, and reporting
activities.
The funds could not be applied to expenditures that were incurred before the date of award.
However, ELC recipients could use previously awarded COVID-19 funding for any school
screening testing activities that are consistent with those awards.5
Requirements for CDC’s Monitoring and Oversight of the ELC Recipients
CDC is required to conduct post-award monitoring for all cooperative agreements on a regular
basis.6 Post-award monitoring is intended to ensure the ELC recipients make progress to
achieve the objectives of the Federal award, consistent with performance goals included in the
Federal award, and specific project activities.7 The objectives and goals of the ELC Reopening
Schools funding focused on providing needed resources to implement screening testing
programs in schools aligned with the CDC recommendations for K-12 schools. As an awarding
agency, CDC is required to ensure that program objectives and goals are accomplished by the
ELC recipients.
The ELC program operates within the CDC’s Division of Preparedness and Emerging Infections,
Scientific Program and Development Branch (DPEI branch). The ELC project officers and
program advisors provide oversight to the ELC recipients on the financial reporting
requirements under the cooperative agreement. In addition, the ELC project officer team and
5 The previously awarded COVID-19 funding was the ELC Enhancing Detection funding of $10.25 billion awarded
under the Paycheck Protection Program and Health Care Enhancement Act of 2020 (P.L. No. 116-139, April 24,
2020) and the ELC Enhancing Detection Expansion funding of $19.11 billion awarded under the Coronavirus
Response and Relief Supplemental Appropriations Act of 2021 (P.L. No. 116-260, Dec. 27, 2020).
6 Post-award monitoring extends through the period of performance and closeout.
7 HHS Grants Policy Administration Manual, part H, chapter 2.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
4
other units within the DPEI branch provided guidance, technical assistance, and resources to
ELC recipients in implementing the ELC screening testing programs. The project officers are
listed on the Notice of Award and have the responsibility for overseeing the project. Program
advisers are subject matter experts who provide technical information to help recipients move
their projects forward.
CDC stated that it continuously and closely monitored the ELC recipients’ performance,
activities, and progress through regular engagement, including routine and ongoing
communication between CDC and ELC recipients.
Recipients’ Use of ELC Reopening School Funding During the
ELC Reopening School Project Period
The $10 billion in ELC Reopening Schools funding was awarded to the ELC recipients from April
7-8, 2021, under the current ELC cooperative agreement (CK19-1904). The funding was
awarded for a 16-month funding period ending July 31, 2022. On March 30, 2022, CDC notified
ELC recipients that it would be extending the use of the ELC Reopening Schools funding through
July 31, 2023. Recipients were encouraged to continue using the funding to meet current K-12
COVID-19 testing needs. According to CDC, the extension of the ELC Reopening Schools funding
budget period allowed ELC recipients to avoid interrupting current school testing activities and
maintain critical testing capacity to quickly ramp up school testing when COVID-19 community
levels increase.
As of July 2023, the ELC recipients had expended approximately $4.9 billion of the $10 billion in
ELC Reopening Schools funding. Of the 64 ELC recipients that were awarded ELC Reopening
Schools funding, 61 expended funds. The remaining three recipients did not accept or use ELC
Reopening Schools funding. The three recipients explained they would be utilizing other
sources of government funding for school-related COVID-19 testing.
For the ELC Reopening Schools funding and expenditures for each ELC recipient, see Appendix
B. In addition, Figure 1 on the next page shows the monthly and cumulative drawdown
amounts for all ELC recipients during the ELC Reopening Schools funding project period.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
5
Figure 1: American Rescue Plan ELC Spending During the Project Period
(April 2021 through July 2023)
Source: HHS Payment Management System, OIG analysis of ELC recipient data, July 2023.
CDC explained that any unexpended ELC Reopening Schools funding will be de-obligated from
the ELC recipients and returned to CDC following normal grant procedures. CDC will return the
funding to HHS after the funding is de-obligated from ELC recipients.
HOW WE CONDUCTED THIS AUDIT
Our audit covered the oversight and assistance CDC provided to 64 ELC recipients that were
awarded $10 billion in ELC Reopening Schools funding to implement screening testing programs
at schools within their jurisdictions during the project period (April 2021 through July 2023). To
accomplish our objective, we obtained and reviewed the Grants Policy Administration Manual,
ELC Policy & Procedure Manual, terms and conditions of the supplemental awards, and
guidance related to the ELC Reopening Schools funding. We also reviewed the information the
ELC recipients were required to report during the project period and determined the
programmatic and financial oversight CDC provided to support the ELC Reopening Schools
project. In addition, we reviewed the technical assistance, implementation tools, and resources
CDC provided to ELC recipients in implementing the COVID-19 screening testing programs.
To assess the oversight and assistance provided by CDC, and to determine the challenges in
implementing the COVID-19 screening testing programs, we administered an online survey to
the 64 ELC recipients that were awarded the ARP supplemental funding. We received
responses from 61 of these recipients, for a response rate of 95 percent. Our analysis of the
survey results relied only on self-reported data from ELC recipients. We did not independently
verify information received from the ELC recipients.
Prior to administering the survey to the ELC recipients, we met with CDC to discuss the survey.
After administering the survey to the ELC recipients, we provided CDC with a summary of the
survey responses. In addition, we obtained CDC’s feedback on the survey results. CDC
explained how it intended to utilize the survey results. CDC indicated that it would share the
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
6
ELC recipient suggestions and feedback with those CDC officials who develop plans for future
PHE responses. Appendix C contains the survey that was sent to the ELC recipients.
We conducted this performance audit 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.
Appendix A contains the details of our audit scope and methodology.
FINDINGS
We found that CDC provided oversight and assistance to the ELC recipients in implementing the
COVID-19 screening testing programs by utilizing recipient data and conducting periodic
outreach through webinars and technical assistance calls, among other things. However, based
on the ELC recipients’ responses to the OIG survey, we identified challenges the ELC recipients
encountered in implementing the ELC screening testing programs within their jurisdictions.
Some of the ELC recipients encountered challenges expending the ELC Reopening Schools
funding, such as barriers from schools in implementing the screening testing programs in their
districts (e.g., lack of interest in establishing screening testing programs), while others used
alternative sources of government funding in the implementation of the screening testing
programs. In addition, some of the ELC recipients encountered challenges implementing the
ELC screening testing programs, including: (1) lack of interest from the schools and
communities, (2) limitations on the costs that were allowable under the terms and conditions of
the awards, (3) insufficient school staffing and resources, and (4) issues with vendors or
contractors. The challenges that were identified in implementing the screening testing
programs from the survey of ELC recipients provide CDC with areas to focus on when
implementing future ELC programs.
CDC PROVIDED OVERSIGHT AND ASSISTANCE TO THE ELC RECIPIENTS IN IMPLEMENTING THE
COVID-19 SCREENING TESTING PROGRAMS
CDC Used Recipient Data To Oversee Implementation of the ELC COVID-19
Screening Testing Program
CDC used the data ELC recipients were required to report to oversee the ELC program. The
data included: (1) budget documentation, (2) K-12 screening testing implementation plans,
(3) COVID-19 screening testing reporting, and (4) financial reports. The following details the
data reported by the ELC recipients and the oversight provided by CDC to the ELC recipients
during the project period.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
7
ELC Screening Testing Supplemental Award Budget
CDC used ELC recipient budgets to monitor recipients’ implementation of their screening
testing programs. CDC’s oversight of the ELC recipients’ budgets included reviewing workplans
to determine whether they were feasible based on the budgets and consistent with the intent
of the award. In addition, CDC stated that it closely monitored the budgets for each award by
tracking expenditures in the HHS Payment Management System throughout the project period.
ELC Recipient K-12 Screening Testing Implementation Plans
CDC utilized the ELC recipients’ comprehensive screening testing implementation plans to
understand how they planned to implement the activities under the ELC Reopening Schools
project. In addition, the plans provided CDC with an understanding of the ELC recipients’ roles,
as health departments, to ensure success of the screening testing programs.
According to CDC, the ELC program also used the plans to help ensure that awarded funds were
being used in a manner consistent with the legislative language and intent of the funding. CDC
indicated it quickly identified recipients that did not include the required activities as described
in the funding announcement. CDC followed up with those ELC recipients to provide technical
assistance and ensure that activities followed the guidance. CDC also used information
provided in the plans to understand general themes or trends for how ELC recipients were
planning to implement screening testing, prioritize outreach to ELC recipients whose submitted
plans indicated a need for follow-up, and facilitate sharing of information with peers in other
jurisdictions.
COVID-19 Screening Testing Reporting by ELC Recipients
CDC utilized the ELC recipients’ test volume data to understand breadth of screening testing
across districts at a high level.8 The test volume data were reported from schools that
implemented screening testing programs. Weekly and monthly test volume data reports
included the number of tests conducted by school district, test type, and cases identified. For
the quarterly reports, the test volume data only contained the total number of tests conducted
within the jurisdiction. In addition, the information provided CDC with insight on the demand
for testing as well as spikes in that demand (e.g., testing associated with return to school from
the holidays).
8 Weekly reports of test volume data were required to be reported from April through June 2021. From July 2021
through September 2022, the test volume data was reported monthly, and beginning October 2022, the test
volume data was reported quarterly.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
8
Financial Reporting for ELC COVID-19 Funded Projects
CDC used monthly reports of expenditures and unliquidated obligations to monitor progress
and assess expenditures.9 According to CDC, reviewing spending in the context of the approved
budgets and testing plans allowed CDC to gauge progress at a very high level and provide
support to the ELC recipients. In addition, during quarterly calls, CDC project officers and
program advisors reviewed the financial reporting with ELC recipients and discussed spending
and barriers they were facing in implementing the screening testing programs.
CDC Provided Several Types of Technical Assistance During Implementation of the
School Screening Testing Program
During implementation of the School Screening Testing Program, CDC provided assistance to
State, local, and territorial health departments for testing efforts, including those in K-12 school
settings. In addition, CDC offered technical assistance to help keep ELC recipients on track with
expending funds by end of the ELC Reopening Schools funding project period. In accordance
with CDC guidance, the ELC recipients were required to participate in technical assistance
during the ELC Reopening Schools funding project period.
The technical assistance CDC provided included: (1) community-of-practice webinars,
(2) technical assistance calls, (3) weekly office hours, (4) peer learning calls, (5) implementation
tools and resources, and (6) collaboration with partners. The following details the technical
assistance provided by CDC.
Community-of-Practice Webinars
The CDC ELC program hosted a kickoff webinar on April 1, 2021, to discuss the Reopening
Schools guidance with all ELC recipients. Following the webinar, CDC hosted seven community-
of-practice webinars from July 2021 through February 2022 to provide the ELC recipients and
local partners timely updates and opportunities for peer learning that focused on COVID-19
testing and school readiness. The community-of-practice webinars were attended by hundreds
of individuals from the ELC recipients and local partners. The topics of the webinars included
prevention strategies in schools, school testing, test-to-stay in K-12 settings, strategies and
challenges, testing updates, and requirements.10
9 Unliquidated obligations refer to financial obligations incurred by the ELC recipients that have not been paid or
that have not been recorded.
10 Test-to-stay strategy enabled unvaccinated students, exposed in school to a person infected with COVID-19, to
remain in school while under quarantine if both the infected person and the exposed person wore masks correctly
and consistently throughout the exposure.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010)
9
Technical Assistance Calls
CDC conducted technical assistance calls for the School Screening Testing Program with all of
the ELC recipients during the following three timeframes in 2021: (1) May to June, (2) July to
August, and (3) October to November.11
• May to June: CDC and the ELC recipients discussed the K-12 school screening testing
plans including COVID-19 testing models, test reporting, type of tests, staffing, next
steps, and available resources.
• July to August: CDC and the ELC recipients discussed the testing program
implementation, including overview of testing programs, school participation,
evaluation of testing programs, items for follow-up, and available resources.
• October to November: CDC and the ELC recipients discussed the testing program,
including staffing, school participation and outreach, contact tracing and case
investigation, evaluation of testing program, successes, challenges, items for follow-up,
and available resources.
Weekly Office Hours
Beginning in August 2021 through December 2022, CDC hosted weekly office hours for ELC
school testing programs. Beginning in January 2023, office hours were hosted on a biweekly
basis. During the office hours, ELC recipients had direct access to communicate with CDC ELC
program officials and other subject matter experts for technical assistance. In addition, ELC
recipients were able to share information and practices among peers.
Peer Learning Calls
To support peer-to-peer learning, CDC organized and facilitated small group discussions where
ELC recipients were able to discuss specific COVID-19 testing issues faced by schools and share
creative solutions to those challenges. CDC hosted 14 peer learning calls from June through
December 2021. The peer learning calls were organized by topic and geographic location. The
topics of the calls included creative approaches to school testing, testing strategies, incentives,
and benchmarks.
Implementation Resources and Tools
The CDC ELC program provided resources and tools for ELC recipients and schools to implement
the School Screening Testing Program. CDC provided resources and tools on the ELC Reopening
Schools webpage. In addition, CDC launched a communications toolkit. The toolkit provided
11 In addition to the scheduled technical assistance calls in 2021, CDC provided one-on-one technical assistance
calls as requested or needed. In 2022, CDC provided one-on-one technical assistance calls with 12 ELC recipients.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 10
flyers and digital media aimed at encouraging parents to opt into school COVID-19 screening
testing. Other resources and key information were shared with ELC recipients. For example,
CDC developed resources to support the implementation of test-to-stay and shared the
resources with the ELC recipients. Additionally, CDC developed frequently asked questions
based on guidance and common questions from recipients and distributed weekly school
testing announcements with relevant updates and resources.
Collaboration With Partners
CDC collaborated with the Rockefeller Foundation, which hosted a weekly forum for public
health and school partners across the country.12 The forum’s goal was to connect and resolve
issues through collective thinking and best practice sharing around K-12 reopening efforts
through the State and Territory Alliance for Testing K-12 Action Network and the COVID-19
Learning Network for schools. CDC routinely joined weekly forum calls to provide updates, hear
feedback from ELC recipients, and address questions. In addition, CDC collaborated with the
Shah Family Foundation13 to provide input on the creation of the Open & Safe Schools
website.14 The website provided a variety of school testing resources, including information on
how to get started with COVID-19 testing, checklists, sample documents, and other items for
both schools and health departments.
12 The Rockefeller Foundation and its partners focused on supporting schools in their efforts to reopen safely
amidst the COVID-19 PHE. Available online at https://www.rockefellerfoundation.org/covid-19-response/k-12-
schools-testing-resources (accessed on August 9, 2023).
13 The Shah Family Foundation works with local, State, and Federal government partners to test ideas and rethink
how budgets are spent, especially in the areas of food access, health and wellness, and education. Available online
at https://www.shahfoundation.org/how-we-work (accessed on August 9, 2023).
14 The Open and Safe Schools toolkit was designed to support State public health leaders and school leaders in
leveraging Federal Government programs and resources to implement school COVID-19 testing programs as a part
of their school reopening strategies. Available online at https://www.openandsafeschools.org (accessed on
August 9, 2023).
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 11
ELC RECIPIENT RESPONSES RELATED TO THE OVERSIGHT AND ASSISTANCE PROVIDED BY CDC,
THE CHALLENGES EXPENDING AWARD FUNDS, AND IMPLEMENTING THE COVID-19
SCREENING TESTING PROGRAMS
Most ELC Recipients Responded That Assistance CDC Provided in Implementing the ELC
Screening Testing Programs Met or Exceeded Expectations
We asked the ELC recipients to rate the types of assistance provided by CDC in implementing
the ELC screening testing programs. The types of assistance included: (1) communication,
(2) technical support, (3) resources, (4) CDC K-12 and early care and education programs
guidance, and (5) ELC reopening school guidance. Most of the respondents reported that the
assistance provided by CDC in implementing the ELC screening testing programs exceeded or
met expectations.
Figure 2: Survey Responses on the Overall Assistance Provided by CDC in Implementing the
ELC Screening Testing Programs15
15 Figure 2 excludes the responses for the three ELC recipients that did not utilize the ELC Reopening Schools
funding.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 12
For the ELC recipients that responded that the assistance CDC provided was inadequate, we
asked the ELC recipients to describe why the assistance was inadequate. Respondents provided
several reasons for rating CDC’s assistance as inadequate, including the timeliness of the initial
guidance, communication, and technical support at the beginning of the ELC screening testing
program implementation. For example, one respondent stated, “at the beginning of this
program, while it was clear that funding was made available, initial communication and
technical support was inadequate.” Another respondent explained that “the guidance was
inadequate because it was delayed, and changes/updates were not communicated in an
effective or timely manner.”
In another survey question, we asked the ELC recipients to rate the types of technical assistance
provided by CDC in implementing the ELC screening testing programs. The types of technical
assistance included in the survey were: (1) technical assistance calls, (2) weekly office hours,
(3) peer learning calls, and (4) community of practice webinars. Most of the respondents
reported that all types of technical assistance provided by CDC in implementing the ELC
screening testing programs were effective.
Figure 3: Survey Responses on Types of Technical Assistance Provided by CDC in
Implementing the ELC Screening Testing Programs16
16 Figure 3 excludes the responses for the three ELC recipients that did not utilize the ELC Reopening Schools
funding.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 13
For the ELC recipient that responded that the peer learning calls CDC provided were not
effective, we asked the ELC recipient to describe why the calls were not effective. The
respondent stated, “while the peer learning calls were informative, there was very little
information that would be applicable to our response needs.”
ELC Recipient Comments on the Oversight CDC Provided in Implementing the ELC
Screening Testing Programs
We also provided the ELC recipients an opportunity to provide additional comments on the
oversight provided by CDC during the ELC Reopening Schools funding project period. We
received many comments from the ELC recipients on the oversight that CDC provided during
the implementation of the ELC screening testing programs. For example, one respondent
stated that “CDC has always been responsive in answering questions we have posed.
Additionally, they have been generous with their time. One opportunity for improvement is
that we would have benefited from peer learning calls with jurisdictions similar to ours.”
Another respondent stated that “CDC has provided an effective oversight with implementing
screening testing programs for the schools. This program has been of great assistance for the
schools, especially the students, faculty, and staff.”
In response to the survey results, CDC officials indicated that the ELC recipients’ feedback was
useful in understanding the technical assistance that was most effective. CDC will consider the
ELC recipients’ responses to the survey to highlight things to avoid for future situations where
rapid development of funding guidance and deployment of resources is necessary.
Challenges the ELC Recipients Faced Expending the ELC Reopening Schools Funding
As of July 2023, the ELC recipients had expended $4.9 billion.
Figure 4 shows the range of spending by the ELC recipients during the ELC Reopening Schools
funding project period as of July 2023.
Figure 4: Range of Spending by the ELC Recipients During the Project Period
Source: HHS Payment Management System, OIG analysis of ELC recipient data, July 2023.
In one of the survey questions, we asked the ELC recipients to indicate the reasons they had
expended less than 50 percent of the ELC Reopening Schools funding at the time of the survey.
The ELC recipients were able to select multiple reasons, which included: (1) barriers from
schools with implementing screening testing programs in their districts, (2) utilizing other
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 14
sources of government funding,17 (3) administrative issues, (4) low COVID-19 transmission
rates, (5) lack of testing supplies, and (6) other.
Figure 5 shows the reasons the ELC recipients gave for expending less than 50 percent of the
ELC Reopening Schools funding at the time of the survey.
Figure 5: ELC Recipient Reasons for Spending Less Than 50 Percent of the Funding
For the 14 ELC recipients that selected “other” as a response, the respondents were able to
enter the reason for expending less than 50 percent of the ELC Reopening Schools funding at
the time of our survey. The reasons included limitations on the allowability of costs for certain
activities and contract procurement difficulties.
In another survey question, we asked the ELC recipients if they anticipated expending all the
ELC Reopening Schools funding by the end of the project period, July 31, 2023. Of the ELC
recipients that responded, 44 percent indicated that they anticipated expending all the ELC
Reopening Schools funding by the end of the project period.
17 Other sources of government funding that supported COVID-19 testing included the Governor’s Emergency
Education Relief funding awarded under the Coronavirus Aid, Relief, and Economic Security Act (P. L. No. 116-136,
Mar. 27, 2020), ELC Enhancing Detection funding awarded under the Paycheck Protection Program and Health
Care Enhancement Act of 2020 (P. L. No. 116-139, April 24, 2020), ELC Enhancing Detection Expansion funding
awarded under the Coronavirus Response and Relief Supplemental Appropriations Act of 2021 (P. L. No. 116-260,
Dec. 27, 2020), and Elementary and Secondary School Emergency Relief funding awarded under the ARP.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 15
More than $5.1 billion of the ELC Reopening Schools funding remained unspent as of July
2023.18 The ELC Reopening Schools funds were awarded to the ELC recipients at the end of the
2020−2021 school year. According to CDC, the majority of the ELC recipients were not able to
begin using the funds to directly support in-person education until the fall of the 2021−2022
school year, several months after the funds were awarded. CDC indicated that it would
continue to work with ELC recipients to ensure appropriate use of the ELC Reopening Schools
funding before the project end date of July 31, 2023. In addition, CDC explained that any
unexpended ELC Reopening Schools funding will be de-obligated from the ELC recipients and
returned to CDC following normal grant procedures. CDC will return the funding to HHS after
the funding is de-obligated from ELC recipients.
Challenges the ELC Recipients Encountered in Implementing the ELC
Screening Testing Programs
We asked the ELC recipients to describe any other issues or barriers the agency faced with the
implementation of the ELC screening testing programs. We received various narrative
responses from the ELC recipients on issues and barriers that they faced in implementing the
ELC screening testing programs. The following are the main categories of responses and
examples we received from the ELC recipients.19
• School and community lack of interest in implementing the screening testing program
(25 ELC recipients). For example, one respondent explained that there was “lack of
interest from schools, especially in the rural areas of the state.” Another respondent
stated that “schools have not been receptive to implementing testing programs. We
have supported all who are interested. We have utilized CDC testing resources so
haven't needed to purchase as many testing supplies. Testing uptake was low overall
due to community.”
• Limitations on the costs that were allowable under the terms and conditions of the
awards (seven ELC recipients). For example, one respondent indicated that restrictions
with the cooperative agreement did “…not allow for flexibility in how funds could be
utilized.” Another respondent stated that “funding was initially restricted to K-12
schools. It would have been helpful to permit use of the funding for Early Care and
Education Programs from the beginning.”
18 Of the $5.1 billion in unspent funds, $1 billion has been de-obligated for the four ELC recipients that did not
accept, did not use, or accepted part of the funds.
19 An ELC recipient response could have included more than one issue or barrier the agency faced with
implementing the ELC screening testing program. These are the main categories of responses we received from
the ELC recipients.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 16
• Insufficient school staffing and resources (five ELC recipients). For example, one
respondent explained that “many schools reported difficulty hiring staff needed to
support implementation of screening testing programs.” Another respondent stated
that the “lack of school nursing support was also a barrier.”
• Issues with vendors or contractors (three ELC recipients). For example, one respondent
explained that “as the Reopening Schools program has evolved over time, we have had
some difficulties executing contracts for changing timelines. Because we thought the
program would end in July 2022, we didn’t have flexibility in those testing contracts, and
we had to put out new bids for third party testing vendors.” Another respondent stated
that “there was an issue with a vendor, and it was resolved by not renewing their
contract.”
This report includes no recommendations. However, we expect that CDC will use the
suggestions and feedback from the ELC recipients’ responses to the OIG survey to improve
development of ELC programs that are in response to future public health emergencies. CDC
elected not to provide formal written comments on our draft report but did provide technical
comments, which we addressed as appropriate.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 17
APPENDIX A: AUDIT SCOPE AND METHODOLOGY
SCOPE
Our audit covered the oversight and assistance CDC provided to 64 ELC recipients that were
awarded $10 billion in ELC Reopening Schools funding to implement screening testing programs
at schools within their jurisdictions during the project period (April 2021 through July 2023).
We obtained and reviewed the Grants Policy Administration Manual, ELC Policy & Procedure
Manual, terms and conditions of the supplemental awards, and guidance related to the ELC
Reopening Schools funding. We also reviewed the documentation the ELC recipients were
required to report during the project period and determined the programmatic and financial
oversight CDC provided to support the ELC Reopening Schools project. In addition, we
reviewed the technical assistance, implementation tools, and resources CDC provided to ELC
recipients in implementing the COVID-19 screening testing programs. Furthermore, we
administered an online survey to the ELC recipients that were awarded the ARP supplemental
funding.
We did not perform an overall assessment of CDC’s internal control structure. Rather, we
limited our review of internal controls to those that were significant to our objective.
Specifically, we reviewed CDC's monitoring of ELC recipients.
We conducted our audit work from February 2022 to August 2023.
METHODOLOGY
To accomplish our objective, we:
• reviewed applicable Federal requirements, HHS Grants Policy Administration Manual,
terms and conditions of the awards, CDC policies and procedures, and CDC ELC
guidance;
• reviewed the budget documentation, K-12 screening testing implementation plans,
COVID-19 screening testing reporting, and financial reports submitted by the ELC
recipients;
• reviewed the technical assistance CDC provided to the ELC recipients;
• met with CDC ELC officials to gain an understanding of the oversight and assistance CDC
provided to the ELC recipients in implementing the COVID-19 screening testing
programs;
• administered an online survey to all ELC recipients;
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 18
• analyzed and summarized the ELC recipient survey responses;
• obtained the ELC recipient supplemental award and expenditure data from the HHS
Payment Management System; and
• discussed the results of our audit with CDC officials.
We provided CDC with a draft report on August 31, 2023, for review. CDC elected not to
provide formal comments; however, it provided technical comments, which we addressed as
appropriate.
We conducted this performance audit 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.
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 19
APPENDIX B: ELC REOPENING SCHOOLS FUNDING AND EXPENDITURES BY ELC RECIPIENT
ELC Recipient
Award
Expenditure
Percent
Expended
Alabama
$147,681,528
$115,318,872
78%
Alaska
22,033,777
16,102,241
73%
American Samoa
1,487,904
600,069
40%
Arizona
219,231,387 106,149,520
48%
Arkansas
90,894,777
14,755,405
16%
California
887,715,802 797,712,762
90%
Chicago, IL
81,141,237
53,823,245
66%
Colorado
173,450,305
67,866,620
39%
Connecticut
107,384,696
37,088,805
35%
Delaware
29,329,294
27,177,394
93%
District of Columbia
21,256,814
16,358,604
77%
Florida
646,898,907 -
0%
Georgia
319,791,575 119,619,665
37%
Guam
5,075,137
3,429,249
68%
Hawaii
42,645,370
37,463,873
88%
Houston, TX
69,885,366
16,382,097
23%
Idaho
53,825,522 -
0%
Illinois
300,527,799 152,820,352
51%
Indiana
202,771,135
30,215,264
15%
Iowa
95,029,161 -
0%
Kansas
87,747,589
49,729,208
57%
Kentucky
134,564,120 134,189,692
99%
Los Angeles County, CA
302,372,981 234,066,059
77%
Louisiana
140,019,396 124,947,363
89%
Maine
40,487,006
40,487,006
100%
Marshall Islands
2,346,310 860,610
37%
Maryland
182,092,917 124,225,113
68%
Massachusetts
207,598,811 201,235,492
97%
Michigan
300,799,236
54,187,836
18%
Micronesia
3,084,238
1,643,185
53%
Minnesota
169,862,951 129,285,226
76%
Mississippi
89,640,149
9,366,636
10%
Missouri
184,856,322
43,706,065
24%
Montana
32,191,069
20,849,558
65%
Nebraska
58,263,420
13,342,370
23%
Nevada
92,772,788
86,277,016
93%
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 20
20 The expenditures are the total drawdowns, as of July 2023, that were obtained from the HHS Payment
Management System for the ELC Reopening Schools funding.
ELC Recipient
Award
Expenditure
Percent
Expended
New Hampshire
$40,953,829 $29,318,966
72%
New Jersey
267,527,208 126,366,116
47%
New Mexico
63,155,461
43,759,491
69%
New York
334,830,878
91,311,974
27%
New York City, NY
251,100,841 251,100,840
100%
North Carolina
315,895,947 183,741,599
58%
North Dakota
22,952,934
16,000,798
70%
Northern Marianas
1,548,143 731,566
47%
Ohio
352,069,960
10,149,819
3%
Oklahoma
119,182,026
42,611,063
36%
Oregon
127,036,170
58,209,743
46%
Palau
653,593 14,575
2%
Pennsylvania
337,878,400
90,729,673
27%
Philadelphia, PA
47,711,231
33,525,626
70%
Puerto Rico
96,192,497
51,591,779
54%
Rhode Island
31,907,434
16,288,131
51%
South Carolina
155,076,741
33,901,834
22%
South Dakota
26,645,495
9,374,385
35%
Tennessee
205,691,372 168,240,953
82%
Texas
803,456,353 277,847,664
35%
Utah
96,561,883
37,048,865
38%
Vermont
18,794,243
2,838,258
15%
Virgin Islands
3,198,692
2,978,494
93%
Virginia
257,085,647
62,732,996
24%
Washington
229,356,843 132,707,570
58%
West Virginia
53,978,589
36,762,685
68%
Wisconsin
175,368,857 163,566,579
93%
Wyoming
17,431,937
3,714,293
21%
Total
$10,000,000,000
$4,858,448,807 20
49%
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 21
APPENDIX C: OIG SURVEY TO ELC RECIPIENTS
HHS/OIG Audit Survey:
ELC Reopening Schools Award
The Department of Health and Human Services (HHS), Office of Inspector General (OIG), is
conducting an audit of the Centers for Disease Control and Prevention (CDC) awards to
recipients for COVID-19 screening testing at schools. CDC provided $10 billion in American
Rescue Plan funding to the Epidemiology and Laboratory Capacity for Prevention and Control of
Emerging Infectious Diseases (ELC) jurisdictions to support COVID-19 screening testing for
teachers, staff, and students to assist schools in reopening safely for in-person instruction.
The objective of the audit is to determine whether CDC provided effective oversight to ELC
recipients in implementing the screening testing programs.21 As a recipient of HHS award
funds, your agency is subject to OIG audits and other reviews. As a result, HHS/OIG
is requesting your timely response to the following survey. The survey should take
approximately 15 minutes to complete. Please complete this survey by December 15, 2022.
∗
Required
1. Select the jurisdiction of your agency. *
2. Rate the types of assistance provided by CDC with implementing the ELC screening testing
programs: *
Exceeded
Expectations
Met
Expectations
Inadequate
Did Not
Use Funds
a. Communication
o
o
o
o
b. Technical Support
o
o
o
o
c. Resources
o
o
o
o
d. CDC K-12 and Early Care
and Education Programs
Guidance
o
o
o
o
21 The audit objective was revised after the online survey was administered to the ELC recipients.
Select your answer
∨
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 22
e. ELC Reopening School
Guidance
o
o
o
o
3. If you responded “Inadequate” to any of the types of assistance listed in question 2, describe why the
assistance provided by CDC was inadequate.
4. Did your assigned ELC Project Officer or other CDC staff, provide an appropriate level of assistance with
implementing the ELC screening testing programs in your jurisdiction? *
o
Yes
o
No
o
Not Applicable
5. Rate the types of technical assistance provided by CDC for the implementation of the ELC screening
testing programs: *
Very
Effective
Effective
Slightly
Effective
Not
Effective
Not
Applicable
a. Technical Assistance
Calls
o
o
o
o
o
b. Weekly Office Hours
o
o
o
o
o
c. Peer Leering Calls
o
o
o
o
o
d. Community of Practice
Webinars
o
o
o
o
o
6. If you responded “Not Effective” to any of the types of technical assistance listed in question 5, describe
why the assistance provided by CDC was not effective.
Enter your answer
Enter your answer
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 23
7. How much of the ELC Reopening School award has your agency expended to date? *
o
0-25%
o
26%-50%
o
51%-75%
o
76%-100%
8. If you answered 50% or less to question 7, indicate the reason(s) your agency has only expended 50% or
less of the ELC Reopening School award. Select all that apply: *
Utilizing other sources of government funding
Barriers from schools with implementing screening testing programs in their districts
Lack of testing supplies
Low COVID-19 transmission rates
Administrative issues
Not applicable because my agency has expended greater than 50% of the award
9. Do you anticipate expending all the ELC Reopening School award by July 31, 2023 (i.e., end of current
budget period)? *
o
Yes
o
No
o
Not Applicable
10. Describe any issues or barriers your agency faced with the implementation of the ELC screening testing
programs. *
Other
Enter your answer
CDC’s Oversight and Assistance to ELC Recipients in Implementing Screening Testing Programs (A-05-22-00010) 24
11. Provide any additional comments you may have on the oversight CDC provided with implementing
the ELC screening testing program. *
Enter your answer