Lessons Learned During the Pandemic Can Help Improve Care in Nursing Homes (OEI-02-20-00492, February 2024)

Summary

The Office of Inspector General of the Department of Health and Human Services issued report OEI-02-20-00492 in February 2024, the third and final report in a three-part series about the effects of the COVID-19 pandemic on nursing homes. It is based on firsthand accounts from 25 nursing home administrators about challenges with staffing and infection control practices. It found that nursing homes faced monumental and ongoing staffing challenges and that many used outside staffing agencies to fill gaps, which had significant downsides. OIG recommends that the Centers for Medicare & Medicaid Services (CMS) strengthen the nursing home workforce, reassess nurse aide training and certification requirements, and update infection control requirements. CMS did not explicitly state its concurrence or nonconcurrence for the five recommendations.

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Full text

Lessons Learned
During the Pandemic
Can Help Improve Care
in Nursing Homes
U.S. Department of Health and Human Services
Office of Inspector General
Christi A. Grimm
Inspector General
February 2024, OEI-02-20-00492

OIG.HHS.GOV
February 2024 | OEI-02-20-00492
Lessons Learned During the Pandemic Can Help Improve Care
in Nursing Homes
Why OIG Did This Review
•
Nursing home residents and staff have been especially impacted by the COVID-19 pandemic.  Now, it is
critical to learn from what happened in nursing homes and take steps to better protect residents and
staff during future infectious disease outbreaks, emergencies, or other disruptions to the health care
system.
•
This is the third and final report in a three-part series about the effects of the COVID-19 pandemic on
nursing homes.  The previous reports found that COVID-19 had a devastating impact on Medicare
beneficiaries in nursing homes during 2020, as 2 in 5 residents had or likely had COVID-19 in 2020.
Also, more than 1,300 nursing homes had infection rates of 75 percent or higher during surge periods.
What OIG Found
Nursing homes faced monumental and ongoing staffing challenges, including a significant loss of
staff and substantial difficulties in hiring, training, and retaining new staff.  Many nursing homes
used outside staffing agencies to fill gaps, which had significant downsides.
Nursing homes continued to struggle with costs, testing protocols, personal protective equipment
(PPE) compliance, and vaccination rates after initial challenges were resolved.
Nursing homes identified challenges with implementing effective infection control practices and
opportunities for improvement.
What OIG Recommends
OIG recommends that the Centers for Medicare & Medicaid Services (CMS):
1.
Implement and expand upon its policies and programs to strengthen the nursing home workforce.
2.
Reassess nurse aide training and certification requirements.
3.
Update the nursing home requirements for infection control to incorporate lessons learned from the
pandemic.
4.
Provide effective guidance and assistance to nursing homes on how to comply with updated infection
control requirements.
5.
Facilitate sharing of strategies and information to help nursing homes overcome challenges and
improve care.
CMS did not explicitly state its concurrence or nonconcurrence for the five recommendations.

Issue Brief: Lessons Learned During the Pandemic Can Help Improve Care in Nursing Homes
OEI-02-20-00492

Background | i

This report is the third in a series about the effects of the COVID-19 pandemic on nursing homes,
their residents, and residents’ families and visitors.  For more information about the first two
reports in this series, see below or click the title of the report to be directed to the OIG website.

COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes
During 2020, OEI-02-20-00490

We found that:
•
Two in five Medicare beneficiaries in nursing homes were diagnosed with either
COVID-19 or likely COVID-19 in 2020 alone.
•
Almost 1,000 more beneficiaries died per day in April 2020 than in April 2019.
•
Overall mortality in nursing homes increased to 22 percent in 2020 from 17 percent
in 2019.
•
About half of Black, Hispanic, and Asian beneficiaries in nursing homes had or likely had
COVID-19 in 2020, and 41 percent of White beneficiaries did.

More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More
in the First Year of the COVID-19 Pandemic; Better Protections Are Needed for Future
Emergencies, OEI-02-20-00491

We found that:
•
Nursing homes had a surge of COVID-19 cases during the spring of 2020 and a greater
surge during the fall, well after nursing homes were known to be vulnerable.
•
More than 1,300 nursing homes had extremely high infection rates—75 percent or
more—during these surges.  For-profit nursing homes made up a disproportionate
percentage of these homes.
•
Nursing homes with extremely high infection rates had an average overall mortality rate
approaching 20 percent during the surges—roughly double that of other nursing
homes.
•
High COVID-19 transmission in a county did not always lead to nursing homes in that
county reaching extremely high infection rates.

We recommended that CMS:
•
Re-examine current nursing staff requirements and revise them as necessary.
•
Improve how surveys identify infection control risks to nursing home residents and
strengthen guidance on assessing the scope and severity of those risks.
•
Target nursing homes in most need of infection control intervention, and provide
enhanced oversight and technical assistance to these facilities as appropriate.

Issue Brief: Lessons Learned During the Pandemic Can Help Improve Care in Nursing Homes
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Findings | 1
FINDINGS
OIG completed a three-part series of evaluations to learn more about the pandemic’s impact on
nursing homes.  This work is crucial to understanding the experiences of residents, staff, and
facilities so that improvements can be made to prevent any repeat of the widespread pain and
suffering nursing home residents and staff experienced during the COVID-19 public health
emergency.
The first part in the series focused on residents while the second focused on nursing homes
themselves.  This third part provides a more indepth look at the experiences of nursing homes: It
is based on firsthand accounts from 25 nursing home administrators about challenges with
staffing and infection control practices that include supplies, testing, and vaccines.  It also
includes recommendations to better protect the health and safety of nursing home residents
and staff.
Nursing homes cited monumental and ongoing staffing
challenges, including a significant loss of staff and substantial
difficulties in hiring, training, and retaining new staff
Every nursing home interviewed confronted staffing challenges, with most describing
these challenges as significant and ongoing.  Specifically, nursing homes reported
difficulties with high rates of turnover, finding and hiring new staff, and training.
Nursing homes explained that at the start of the
pandemic the fear of contracting COVID-19 drove
some staff to retire early or leave for other jobs.  Some
staff went to other health care jobs at hospitals or
clinics for better benefits, a better work-life balance, or
a more prestigious position.  These losses continued
throughout the pandemic.
Nursing homes particularly struggled to find and retain staff for lower-wage positions
such as certified nurse aides (CNAs), dietary services staff, and housekeeping staff.
Nursing homes noted that individuals could find work in the fast-food industry, at big
box stores, or with delivery services for more money and fewer physical and
emotional demands than for working as a nurse aide.  As one administrator explained,
a nurse aide’s work includes heavy lifting and caring for residents who have cognitive
decline yet is compensated at only $14 per hour at their facility.  According to nursing
homes, an entry-level nurse aide position no longer has a competitive advantage as
wages in other industries increased even prior to the pandemic.
STAFFING
“Not enough staff even exists.  Even if I
paid all the money in the world and
were fully staffed, it would only leave
other nursing homes in dire straits.”
—An administrator

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Findings | 2
Nursing homes repeatedly mentioned
burnout as contributing to high rates
of turnover.  They noted that staff felt
overworked and underappreciated,
adding to a sense that their work was
undervalued compared to work in
other health care settings.
Nursing homes also stressed that
hiring was very difficult, as candidates
frequently dropped out of the hiring process.  Problems included candidates not
coming to scheduled interviews, failing to attend orientation after being hired, or not
showing up for their first day of work after completing orientation.  One administrator
described the experience as getting “ghosted.”
Nursing homes spoke of ensuing problems in managing
performance even when they could hire.  They feared being
too strict and driving away the workers they had worked
hard to onboard.
Nursing homes also faced challenges training staff because
much of the training shifted to online during the pandemic.
Some nursing homes reported that new staff, in particular,
lacked hands-on training.  They also reported that
COVID-19 protocols and procedures were so demanding that other routine training
had to take a back seat.  Nursing homes said that they fulfilled basic training
requirements, but any additional training time had to be spent updating staff on ever-
changing COVID-19 guidance.
Many nursing homes used outside staffing agencies to fill gaps,
which had significant downsides
Most nursing homes turned to outside staffing agencies to fill immediate needs and
meet minimum staffing requirements during the pandemic.  However, using agency
staff brought significant challenges.
Many nursing homes characterized the rates for agency staff as exorbitant, especially
during the most intense periods of the pandemic.  They explained that pandemic
relief funds helped but financial strains have
been considerable.  One administrator said
some agency costs increased by 40 percent,
which was an amount the nursing home
could not maintain in the long term.
Another administrator noted that high
agency rates put a lot of nursing facilities
out of business.
Downsides of using agency staff
• High costs

• Unreliability

• Unfamiliarity with systems
and residents
“Long-term care isn’t sought out.
When people hear you work in a
nursing home, people look at you as
less of a nurse than someone who
works in an emergency room . . . like
you have less knowledge, less skill.”
—An administrator
“[Y]our staff has the market.  They
could leave your place at any point
and go get a new job whenever they
want . . . .  They know they can
call off and what are you going to
do, fire them?”  —An administrator

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Findings | 3
Nursing homes also noted that agencies pay higher wages than nursing homes, thus
creating an attractive alternative for staff.  One nursing home reported losing staff to
higher-paying agencies.  Morale also suffered: As one nursing home recounted,
agency staff would talk openly about how much money they were making, upsetting
permanent staff who felt agency staff were not working as hard as they were.
Problems with using agency staff were not just about costs.  Nursing homes found
agency staff to be unreliable and felt they had little recourse when agency staff failed
to show up, arrived late, or failed to perform duties.  One nursing home worried that
complaining might prompt agencies to stop sending workers and leave the facility
short-staffed.
Moreover, nursing homes reported that the
agency staff that showed up were less familiar
than nursing home staff with the facility and
residents.  One administrator noted that the
quality of care might be affected if, for example,
agency staff did not understand a facility’s
electronic health records and narcotics systems.
Some nursing homes suggested ways to address agency difficulties.  A few
administrators noted that hiring agency staff under long-term contracts helps deepen
the connection between agency staff and a nursing home.  Many nursing homes
called for improved regulation of staffing agencies in hopes of keeping prices down
and improving the quality of care.
To retain and hire staff, nursing homes tried changing the work
environment and using incentives, but success was mixed
Nursing homes tried a number of strategies to retain and hire staff.  Specifically,
nursing homes bolstered workforce “culture,” took steps to reduce workloads while
maintaining the quality of care, and introduced a variety of incentives.  Some
strategies worked for some but not all nursing homes.  Other strategies were
minimally successful, and some strategies were not feasible for some nursing homes
that lacked the necessary means.  (See the box on the next page for a list of strategies
that nursing homes tried.)
Facing significant staff losses, nursing homes found that fostering an “all-hands-on-
deck” approach was necessary to meet staffing needs.  For example, nonclinical staff
distributed residents’ meals and helped submit testing and vaccination reports to
authorities.  Administrators filled in wherever needed, and directors of nursing were
known to cover floor shifts in addition to their regular responsibilities.  However,
nursing homes noted that this all-hands-on-deck approach came with costs: It
contributed to turnover and feelings of burnout among staff.
“Agency staff comes in and talks about
how much money they’re making and
our own staff gets upset because
[agency staff] aren’t working as hard.”
—An administrator

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Findings | 4
To maintain morale and
improve retention,
nursing homes leveraged
workplace culture.  To
show appreciation to
staff, nursing homes
offered perks such as free
meals and massages.
Nursing homes stressed
the importance of
keeping lines of
communication open,
being receptive to new
ideas and feedback from
staff, and trying to help
staff with more personal
matters such as car
troubles.  Some nursing
homes offered bonuses to staff who picked up additional shifts, had perfect
attendance, or worked in a facility’s COVID-19 unit.
Nursing homes also described efforts to lessen workloads and provide good care.
Some kept a lower census so they could ensure adequate staffing.  Others tried
inventive ways to maintain the quality of care when new and unfamiliar staff worked
in their facilities.  For example, one nursing home created an individualized, one-page
care guide for each resident.  Another nursing home posted icons outside each
resident’s door—such as a leaf icon for someone at risk of falling—so staff had
pertinent information at a glance.
To bring in new staff, many nursing homes took
advantage of a temporary waiver of formal testing
and certification requirements for nurse aides.  One
facility even used this program to train existing
department heads as nurse aides so that they could
assist on the floor when needed.  Nursing homes
said that the waiver allowed them to obtain staff
more quickly, but when the end of the waiver
program was announced they felt rushed to have
their new nurse aides tested and certified.  Some
nursing homes reported concerns about temporary
nurse aides, such as concerns about the quality of
their work and their ability to succeed on a
certification exam.
Nursing homes employed a variety of other strategies to tackle hiring challenges.  For
example, they advertised positions across job sites and social media, and many
Strategies for addressing staffing challenges
• Fostering an ‘all-hands-on-deck’ approach

• Showing staff appreciation

• Maintaining a lower census

• Making pertinent resident information
readily available

• Taking advantage of the temporary waiver
of nurse aide certification requirements

• Posting social media ads

• Offering bonuses and/or increasing wages
and benefits

• Partnering with local schools or nurse aide
programs
CMS provided the nurse aide waiver
to allow nurse aides to train on the
job in nursing homes without
completing the standard certification
requirements until the waiver period
ended.  This waiver permitted nurse
aides to work longer than 4 months
without completing training and
certification provided the nurse aides
demonstrated competency in the
skills needed for resident care.

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Findings | 5
offered sign-on bonuses.  One nursing home paid additional bonuses for new hires
who stayed through a trial period.  Another offered bonuses to employees who
referred a new employee.  Aside from incentive-based strategies, nursing homes also
mentioned increasing wages and enhancing benefits, such as 401(k) plans and tuition
reimbursement programs, to improve hiring.
The success of these strategies was
inconsistent across nursing homes.
While some found giving bonuses
and using social media helpful,
others did not.  Furthermore, not all
nursing homes could afford to try
these strategies.
Nursing homes near colleges and CNA programs reported successes with recruitment.
These facilities benefited from better access to new graduates.  One nursing home
found that some CNA students were able to learn on the job and complete clinical
requirements at the same time.
Two nursing homes created their own internal “staffing agency” to fulfill staffing
needs rather than retain outside agencies.  These homes offered higher wages but no
benefits as an option for workers.  One noted that workers could make an additional
$10 to $20 per hour by working through an internal agency, while the other noted
that an internal agency allowed the home to retain staff and manage performance
more directly than possible for outside agency staff.
While considerable difficulties related to testing and PPE were
generally resolved, nursing homes still struggled with costs,
testing protocols, and PPE compliance
Nursing homes reported that testing turnaround times and PPE supply issues caused
significant difficulties at the beginning of the COVID-19 pandemic.  While these
challenges were generally resolved, difficulties with costs and compliance with testing
protocols and PPE requirements remained.
Long waits for test results early in the pandemic created a host of
problems for nursing homes that were alleviated with access to
rapid tests
Nursing homes reported challenges with obtaining timely COVID-19 test results at the
beginning of the pandemic.  Only polymerase chain reaction (PCR) tests—which must
“We’ve done ads, Facebook, social
media, referral programs, sign-on
bonuses.  We spend thousands of dollars
a month, but we’re not hiring anybody.”
—An administrator
TESTING AND PPE

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Findings | 6
be sent to a lab for analysis—were available.  As a result, there were long turnaround
times for testing in the early months.  One administrator recalled that the local lab
could take only five tests at a time.  Another administrator recalled waiting up to 18
days for results from a State lab.  While waiting for results, nursing homes had to
choose between exacerbating staffing shortages by keeping staff at home or having
staff work and potentially spread COVID-19.  One administrator noted that long
turnaround times for testing extended isolation periods for residents.
Some nursing homes also mentioned that there was confusion over how labs would
communicate positive test results and whether a nursing home was required to pay
for testing.
Many of these difficulties were resolved when rapid
tests became available and the Federal Government
supplied nursing homes with rapid antigen test kits
on a weekly basis.  Nursing homes noted their
appreciation for and reliance on these regular
deliveries to meet testing needs.
Testing protocols continued to burden nursing homes
Nursing homes said testing protocols can be time-consuming and pull staff from
regular duties.  At the time of our interviews, facilities had to conduct routine testing
on schedules that varied based on local positivity rates and outbreaks.1  One
administrator of a large facility noted that 220 staff and about 160 residents had to be
tested twice a week during outbreaks.  The administrator said testing takes so much
time and so many resources that other activities, such as floor supervision and routine
surveillance of new nurses and nurse aides, became secondary.  Some nursing homes
said that they trained nonclinical office staff to conduct tests to take the burden off
clinical staff.
Testing also presented logistical challenges.  In particular, nursing homes reported
difficulties coordinating routine testing for part-time staff, agency staff, and student
workers.
Although PPE supplies stabilized, nursing homes reported that
PPE costs remained high and staff experienced ‘PPE fatigue’
Nursing homes described extremely difficult experiences with obtaining PPE at the
beginning of the pandemic.  Staff spent a lot of time searching for PPE and resorted
to using alternative, unregulated items instead of PPE, such as rain ponchos and
painters’ clothes.  One administrator described the beginning of the pandemic as
“absolutely chaos” and recalled driving hours to pick up a couple of cases of gowns,
which provided enough gowns for only one day.
“I am looking at 23 boxes of
COVID [rapid] tests in my office
right now.  The government has
been great at providing us with
those tests.”  —An administrator

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Findings | 7
As the pandemic continued, nursing homes struggled to acquire sufficient PPE, at
times competing with other health care facilities.  Some nursing homes said vendors
shipped to them a fixed PPE allotment based on previous orders, which was a smaller
allotment than necessary for a pandemic.  In addition, nursing homes recalled that
hospitals received priority treatment for PPE supplies.  One administrator lamented
that at the start of the pandemic nursing homes were at “the back of the line” and
unable to get PPE.
Based on these experiences, many nursing homes reported they have created PPE
stockpiles for their facilities and generally have a dependable supply of PPE.  However,
at the time of our interviews some nursing homes said PPE costs remained high.  One
administrator reported that a case of gloves cost more than $600, up from $95 pre-
pandemic.
Nursing homes reported that, after many months of the pandemic, staff grew tired of
the nearly constant use of PPE.  As a result, nursing homes started seeing problems
with compliance.  Administrators felt torn between enforcing PPE requirements and
maintaining adequate staffing levels.  They feared losing staff who were disciplined
over PPE issues.  Administrators also said that they tried to boost compliance with
reminders and training but found that these steps did not overcome what they called
“PPE fatigue.”  In addition, administrators noted that residents, especially those with
dementia, struggled with wearing masks.  They further noted that masks created
communication challenges for hard-of-hearing residents as they could no longer read
lips.
Nursing homes reported success with the initial vaccine rollout,
but challenges remained with subsequent vaccine doses
for staff
Most nursing homes reported ready access to COVID-19 vaccines.  Many were able to
partner with a local pharmacy to administer the vaccines to residents and staff, usually
at the nursing home.  In addition to pharmacies, nursing homes said
that government entities and corporations played a crucial role in
accessing vaccines.  One administrator was particularly impressed
with the nursing home’s State health department that helped with
rapid response teams and all documentation associated with
vaccinations.  One nursing home said it received vaccines from its
parent corporation that had made long-term care staff a priority.
VACCINES
“We had all doses for
residents and staff when
rollout began . . . .
Rollout has been great.”
—An administrator

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Findings | 8
Vaccine challenges mainly involved staff vaccination, especially booster doses.  At the
time of our interviews, nursing home staff were required to have received the primary
vaccination series or an exemption.  Subsequent booster doses were encouraged but
optional.2  Other OIG work published in June 2022 estimated that 91 percent of
nursing home staff nationwide received the required primary vaccination series and
56 percent received a booster dose.3  The nursing homes we interviewed confirmed
that the percentage of staff who received the primary vaccination series was high, but
that the percentage of staff who were “up to date”
with all boosters was lower.4  Some administrators
talked about “vaccine fatigue” concerning booster
doses, which were more of a challenge than
primary doses.  Administrators said that false
information on social media made some staff more
hesitant to get vaccinated.  Nursing homes also
described confusion regarding changing guidance
as contributing to hesitancy.  For example, administrators found it difficult to convey
the evolving requirements, such as those related to the definition of “up to date” and
the need for booster doses.
Nursing homes that reported few challenges with vaccine hesitancy attributed this
lack of hesitancy to culture and trust.  One nursing home noted that its director of
nursing was well-respected in the nursing home, which made residents and families
more comfortable with the vaccines.  Other nursing homes reported using education
and financial incentives to encourage vaccination among staff.  Some administrators
reported bringing in cultural leaders and medical professionals from the community
to answer questions, emphasize vaccine safety, and address concerns.  Administrators
also held town hall meetings and one-on-one discussions to discuss hesitations and
reaffirm facts about the vaccine.  Other nursing homes offered financial incentives and
raffles to encourage vaccination.  One facility offered a $100 bonus to each staff
member who got vaccinated.
Despite these efforts, some nursing homes found that some staff simply refused
vaccinations.  One administrator concluded that staff who were already leaning
toward getting vaccinated could be persuaded by incentives, but staff who were “hard
no’s” were unmoved.  This administrator was convinced that even an incentive of
$1,000 would not have made a difference.
In addition, administrators pointed out that unvaccinated visitors could pose an
infection control risk to residents.  They noted that nursing homes could not hire
unvaccinated staff but had to allow unvaccinated visitors into the facilities.

“[S]ome people do not
believe the vaccine is safe.
That’s one hurdle . . . .
They get information from
wrong sources.”
—An administrator

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Findings | 9
Nursing homes identified challenges with implementing
effective infection control practices and opportunities
for improvement
The COVID-19 pandemic created substantial challenges for infection control in
nursing homes.  Preventing and controlling infections was a monumental task due to
the novelty of the virus and the characteristics of the nursing home setting.
Administrators described instances when COVID-19 spread through their facilities.
Two administrators said it spread like “wildfire.”  Reflecting on the rapid spread, some
administrators questioned the efficacy of certain infection control measures they
implemented.
Nursing homes had trouble identifying and implementing the most effective
infection control practices.  For instance, nursing homes had difficulty developing
designated COVID-19 units.5  Administrators noted that they lacked private rooms or
space for designated units.  They also said that residents, especially those with
dementia, had trouble adjusting to unfamiliar surroundings.  Some administrators
even questioned whether moving residents to COVID-19 units inadvertently spread
the disease.  Moreover, nursing homes felt as if these practices had been developed
without feedback or input from nursing homes themselves.  Specifically, some
administrators were concerned that the guidance did not sufficiently consider what
practices were feasible in the nursing home setting.
As the pandemic continued, CMS worked with the Centers for Disease Control and
Prevention (CDC) to update infection control guidance.6  However, nursing homes
recounted the significant challenges of interpreting this changing guidance and
disseminating the guidance to staff.  While revisions to guidance are necessary when
more is learned about a novel virus, the pace of changes—occurring as often as
several times a day at the beginning of the pandemic—created practical challenges
for nursing homes.  For several administrators, simply reading guidance became a
full-time job.  They said incoming guidance was often unclear, which made effective
implementation difficult.
Administrators said they wanted concise and explicit
guidance on effective infection control measures.  They
emphasized the importance of consistency in guidance from
Federal, State, and local entities.  In their view, guidance was
sometimes conflicting.  Particularly conflicting, in their view,
was guidance from CMS, CDC, and State and local
departments of health.  This left nursing homes unsure about
which actions to take to remain in compliance with Federal
requirements.
OTHER INFECTION CONTROL
“Put things in simple terms.  It
should say ‘this replaces memo X’
and highlight the changes . . . .
Make it simple, quick, and easy
to read.”
—A director of nursing

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Findings | 10
Nursing homes noted the importance of having access to resources that answered
their questions about infection control.  For example, some nursing homes found
State and local health departments or corporate offices helpful with interpreting and
implementing new requirements.  They described regular calls or webinars with State
and local health departments and industry associations.  Some administrators found
in-person assistance beneficial.  One recounted a team of State epidemiologists
walking through the nursing home and explaining where to put hand sanitizer and
plexiglass as well as additional infection control information staff should know, such
as “how quickly certain chemicals could clean.”
While some nursing homes had such resources, others did not know where to turn
for assistance or were unable to get clear answers.  One administrator explained that
the health department only shared website links for fear of incorrectly interpreting
guidance.  Another administrator said the health department “left us to fend for
ourselves.”
Throughout the pandemic, CMS hosted recurring stakeholder calls for nursing homes
during which CMS explained relevant guidance and Quality Improvement
Organizations (QIOs) provided technical assistance to nursing homes.7  However,
none of the nursing homes we interviewed mentioned turning to QIOs as a resource.

Nursing homes conveyed the dire physical, mental, and
emotional toll the COVID-19 pandemic took on residents
and staff
As nursing homes reflected on their challenges and struggles, a common theme
emerged: The pandemic took a tremendous toll on residents and staff.  Nursing
homes described isolation, loneliness, and a decrease in quality of life among
residents during the pandemic.  They also described the extreme emotional burden
carried by staff, who were often the residents’ only human interaction.
Nursing homes recounted how residents
were isolated from their spouses, family
members, and other loved ones, some of
whom had visited daily prior to the
pandemic.  They said residents’ daily
routines were upended due to short staffing
and the absence of loved ones.  And for long
periods during the pandemic, residents were restricted to their rooms, unable to eat
together in common rooms or participate in social activities.  Nursing homes
described the loneliness felt by the residents whose only source of human interaction
TOLL ON RESIDENTS AND STAFF
“[I]t was heartbreaking seeing
residents die alone . . . without
someone to hold their hand.”
—An acting administrator

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Findings | 11
was with staff hidden behind masks, goggles, gowns, and gloves.  Some
administrators recalled trying to comfort family members who were upset about
being unable to visit residents in what would likely be their final months.
Some nursing homes said that the loneliness and isolation contributed
to depression and premature death.  Several administrators described
their facilities as prisons during the pandemic—not the homes
residents deserved.  They pointed to an increase in depression among
residents, as well as in the use of medication to treat depression.
Some told heartbreaking stories of residents deprived of physical
touch, smiles, and comfort from loved ones and caretakers, and tragic
stories of residents who died alone.
Administrators lamented that while they took necessary and required actions to stem
exposure to the potentially deadly virus, these actions had dire consequences for
residents and staff.  Administrators described how serving as a sole source of comfort
to residents weighed heavily on staff.  One spoke of the unprecedented amount of
death that staff witnessed, and another described staff as experiencing post-traumatic
stress disorder after functioning as the residents’ substitute family during the peak of
the pandemic.
“I think depression took
over and we lost a lot of
people because they gave
up hope.”  —An acting
administrator

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Recommendations | 12
RECOMMENDATIONS
COVID-19 was devastating for nursing home residents.  It also highlighted
longstanding issues with staffing and infection control that negatively impact nursing
home safety and quality of care.  To learn from what happened and better prepare for
future public health emergencies, OIG completed a three-part series of reports
assessing the pandemic’s impacts on nursing homes.  This report is the third and final
part in that series.  Our combined findings illuminate the outsized toll the pandemic
exacted on nursing home residents and staff and identify the urgent need for
improvement.  We found that nursing homes were not prepared for this scale of
infectious disease, nor could they adapt effectively.  Cases surged in spring 2020, and
there was a greater surge in the fall.  We determined that 2 in 5 Medicare
beneficiaries in nursing homes were diagnosed with either COVID-19 or likely
COVID-19 during the year.  Residents were not impacted equally, however, as
COVID-19 rates were higher among Black, Hispanic, and Asian beneficiaries than
among White beneficiaries.
More than 1,300 nursing homes had extremely high infection rates during these
surges, with at least 3 out of every 4 of their Medicare beneficiaries diagnosed with
COVID-19 or likely COVID-19 in a matter of weeks.  We found that just because a
nursing home was located in a county with a high transmission level, it was not
inevitable that the nursing home would have an extremely high infection rate.  The
effects of these high rates reached beyond those residents diagnosed with COVID-19.
Nursing homes with extremely high infection rates experienced dramatic increases in
overall mortality.
This OIG work has raised pivotal questions about existing oversight, such as whether
current staffing requirements are sufficient to protect residents from infectious
disease and how effective the survey process is in preventing and mitigating its
spread in nursing homes.  We found that even though nearly all nursing homes had
multiple surveys during 2020, the majority of those with extremely high infection rates
were not cited with any deficiencies in infection control, and few were cited with
serious deficiencies.  OIG has made important recommendations for CMS to re-
examine and revise current nursing staff requirements, improve the survey process,
and provide enhanced oversight and technical assistance to nursing homes most in
need.  The findings in this final report reinforce the urgency of these prior
recommendations.
This final report examines the challenges that nursing homes faced during the
pandemic and the strategies they used to address those challenges through the lens
of the nursing homes themselves.  The need for improvement is clear.  The
recommendations in this report, combined with recommendations from the prior
reports, offer a path for CMS to help improve nursing home performance both overall
and during crises.

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Recommendations | 13
The COVID-19 pandemic was a call to action not just for CMS but for all nursing home
stakeholders.  Significant change is needed to better protect the health and safety of
residents, and this change will require broad collaboration with partners and
stakeholders across Government, the nursing home sector, and the broader health
care industry.  The findings in this report can inform stakeholder collaborations and
improvement efforts.
Part of that change has begun, as the administration has made improving safety and
quality of care in nursing homes a priority.  Both the Department of Health and
Human Services (HHS) and CMS are playing key roles in developing and executing
initiatives aimed at this goal.  The administration outlined steps to address staffing
shortages by, for example, investing more than $75 million in scholarships and tuition
reimbursements for nursing workers through a partnership between CMS and the
Health Resources and Services Administration (HRSA), and by streamlining entry to
career opportunities in nursing homes.8  In addition, after conducting an extensive
study, CMS has proposed new minimum staffing standards for nursing homes.9
Still, our findings in this report and other OIG work demonstrate that nursing homes
face challenging and entrenched problems across multiple dimensions, including
workforce and infection control.  Beyond the initial steps CMS is taking, more must be
done to strengthen the nursing home workforce and enhance infection control
practices.  OIG offers several recommendations to do so.
These issues are complex and cannot be resolved by CMS alone.  However, as the
primary payer of nursing home care and the agency that sets quality and safety
standards for nursing homes, CMS plays a critical role.  CMS can use existing methods
and search for new ones in its efforts to protect the health and safety of nursing
home residents.  For instance, CMS can partner with other agencies and nursing
homes working to expand the nursing home workforce.  Collaboration and creative
problem-solving involving CMS, other Federal agencies, States, and the industry are
essential to improving nursing homes’ ongoing quality and safety efforts as well as
their preparedness to handle public health crises.  Moreover, although CMS does not
regulate staffing agencies, it can help identify potential strategies for nursing homes
facing challenges with staffing agencies.
To strengthen staffing in nursing homes, CMS should:
Implement and expand upon its policies and programs to strengthen
the nursing home workforce
Qualified staff are essential to ensuring that nursing homes provide safe and quality
care.  During the pandemic, however, nursing homes described substantial,
multifaceted staffing challenges.  One of the biggest and most difficult challenges was
the shortage of qualified staff.  Staffing shortages can also have negative
consequences for existing staff, such as burnout, which can affect retention.  Nursing

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Recommendations | 14
home staffing challenges are massive, complex, and have continued past the end of
the public health emergency.
CMS is an integral part of the administration’s nursing home priority and initiatives to
support, strengthen, and grow the health workforce.  CMS recently announced that it
will partner with HRSA to lead nursing home workforce development by investing
more than $75 million in financial incentives, such as scholarships and tuition
reimbursements, for individuals entering nursing home careers.10  This planned
initiative has the potential to meaningfully build a pipeline for qualified nursing home
staff.  Achieving these goals will require sustained attention from CMS and sustained
partnerships with HRSA and potentially other Federal agencies such as the Labor and
Education Departments.  Given its vast experience overseeing nursing homes, CMS is
uniquely positioned to both lead major initiatives like the one it recently announced
and to support other agencies in their related efforts to strengthen the nursing home
workforce.
Furthermore, CMS should explore which additional tools it can bring to help alleviate
nursing home staffing shortages and related challenges.  For example, CMS could
explore demonstration workforce development programs through the Center for
Medicare and Medicaid Innovation (CMMI).  CMMI is ideally suited to exploring
innovative strategies to strengthen the nursing home workforce and address staffing
challenges, and has previously run demonstration programs recognizing the impact of
staffing on outcomes, such as quality of care and cost savings for Medicare.11  CMS
should seek statutory authority if needed to run such programs.
Reassess nurse aide training and certification requirements
CMS should reassess existing nurse aide training and certification requirements in
light of nursing homes’ experiences during the COVID-19 public health emergency,
including experiences with the temporary nurse aide waiver.  The waiver allowed
nurse aides to train on the job in nursing homes without completing the standard
certification requirements until the waiver period ended.  It provided enhanced
flexibilities at a time when increased staffing was essential but opened a door to
potential nurse aide qualification concerns.  It is important that CMS take advantage
of the rich learning opportunity presented by the waiver and engage with nursing
homes about their experiences.
Effective training and certification requirements for nurse aides are critical to ensuring
the health and safety of residents while expanding and supporting the nurse aide
workforce.  As CMS considers new minimum staffing requirements for nursing homes
that emphasize the essential role of nurse aides, it is more important than ever to
update training and certification requirements when appropriate to promote a strong
and qualified workforce.  CMS should seek statutory authority if needed to make
these changes.

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Recommendations | 15
To enhance infection control practices and better protect nursing home residents,
CMS should:
Update the nursing home requirements for infection control
to incorporate lessons learned from the pandemic
The spread of COVID-19 among nursing home residents reflects failures to control
and prevent infection.  Since the beginning of the pandemic, much has been learned
about mitigating the spread of COVID-19, and this information must now be used to
protect nursing home residents.  Specifically, CMS should update the nursing home
requirements for infection control using what was learned during the pandemic about
the most effective infection control practices.
CMS conducted this type of update before the pandemic.  A periodic update is an
important step to take as knowledge evolves.  Given all that has been learned, we
recommend that CMS undertake this work again.  In doing so, CMS should
collaborate with experts including Federal partners such as the CDC, infectious
disease experts, industry groups, and resident advocacy groups.  CMS also should
take into account nursing homes’ insights by, for example, conducting “listening
sessions,” soliciting written comments, or convening a panel or council that includes
nursing home practitioners, among others.
The findings in this series of reports and the devastating toll that the pandemic took
on nursing homes demonstrate the need for updated infection control requirements.
Nursing homes were not prepared for the sweeping health emergency that COVID-19
created.  Now that the public health emergency has ended, it is time to assess the
information learned and improve infection control practices.
Once the requirements are updated, they should be incorporated into the survey
process.  Surveys are periodic, onsite inspections of nursing homes to determine
compliance with Federal requirements.  In the second part of this series, we
recommended that CMS improve the survey process.  Updating the requirements for
infection control can be a part of that improvement.
To the extent possible, infection control requirements should reflect the latest
knowledge about infection prevention for COVID-19 and other dangerous, infectious
diseases.  We encourage CMS to explore ways in which it can continuously and
quickly update requirements as needed.  These updates may be needed to respond to
novel infectious diseases or to incorporate new information about existing infectious
diseases.
Provide effective guidance and assistance to nursing homes
on how to comply with updated infection control requirements
After the nursing home requirements are updated, CMS should provide guidance and
assistance to nursing homes to implement the new requirements.  As part of this

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Recommendations | 16
recommendation, CMS should solicit and consider feedback from nursing homes
about the types of guidance, assistance, or other resources—such as webinars or
written materials—that may be most useful.  We note that some nursing homes we
interviewed did not know where to turn for assistance or were unable to get clear
answers to questions during the pandemic.
CMS should also offer individualized assistance with implementation, such as on-site
technical assistance with infection control experts or QIOs.  Nursing homes we
interviewed noted that on-site technical assistance from State and local organizations,
when available, was invaluable for implementing changing guidance, but not all of the
nursing homes had access to such assistance.  By first identifying the most effective
practices, CMS can best use resources such as QIOs.
To further support nursing homes in addressing current and future challenges,
CMS should:
Facilitate sharing of strategies and information to help nursing homes
overcome challenges and improve care
Facing unprecedented challenges posed by the COVID-19 pandemic, nursing homes
developed a number of strategies to strengthen their workforces, address testing
delays and PPE shortages, and reduce vaccine hesitancy.  They also struggled with
challenges that came with relying on staffing agencies, such as high costs and
unreliability.  While some nursing homes expressed that they developed networks to
learn from, other nursing homes—particularly those without corporate support—were
more isolated and struggled to identify the most effective strategies.
To facilitate information sharing on these and other topics and further support
nursing homes in addressing current and future challenges, CMS should develop
methods for CMS and nursing homes to exchange strategies and ideas.  These
methods could include an online platform, open forums, roundtables, or other
approaches that CMS deems appropriate.  CMS currently has some nursing home
websites and resources available that largely function in only one direction—from
CMS to nursing homes.12  There are limited mechanisms for nursing homes to give
feedback to CMS or to ask CMS questions, or for nursing homes to assist each other.
The methods that CMS develops should be easy for nursing homes to access and use.
Having methods for sharing information will help nursing homes address challenges
based on effective, on-the-ground strategies used by other facilities rather than
having to “reinvent the wheel.”  CMS should also include resources and information
that nursing homes might find helpful and connect nursing homes with contacts, such
as QIOs, that can provide additional insight into effective practices.  CMS could work
with the nursing home industry or other stakeholders to develop these methods to
facilitate this information sharing.  Furthermore, CMS should use these forums or
other methods it develops to not only share information but also to learn more about

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Recommendations | 17
the challenges nursing homes are facing and identify potential strategies for
addressing these challenges.
One priority issue that CMS should focus on is sharing strategies and information
about nursing homes’ challenges related to staffing agencies.  CMS could use the
forums or other methods it develops to learn more about these challenges and to
help identify potential strategies for addressing these challenges.  For example,
nursing homes may be able to share strategies they found effective such as using
longer-term contracts, navigating State regulations, and holding agency staff
accountable.  CMS could also use forums to share information about staffing agency
challenges learned from its recent engagement with nursing homes as part of its
staffing study.13

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Agency Comments and OIG Response | 18
AGENCY COMMENTS AND OIG RESPONSE
CMS did not explicitly state its concurrence or nonconcurrence for the five
recommendations.  For two of the five recommendations, CMS's response generally
conveyed agreement.  CMS agreed with the intent of the remaining three
recommendations and indicated that it has implemented them, suggesting that they
be removed from the report.  OIG is aware of and has considered all of the actions
that CMS has taken, proposed, or planned.  While these are positive and necessary
actions, we stand by our recommendations, as we continue to see both the need and
the opportunity for CMS to do more.
The magnitude of the issues we identified makes clear that additional work must be
done to improve care for nursing home residents.  The findings from this series
demonstrate that COVID-19 was devastating for nursing home residents.  We found
that 2 in 5 Medicare beneficiaries in nursing homes had or likely had COVID-19 in
2020.  More than 1,300 nursing homes had extremely high infection rates during
surge periods in spring 2020 and fall 2020, and these nursing homes had dramatic
increases in mortality.  In this third report, we examined the challenges that nursing
homes faced as described by the nursing homes themselves.  The recommendations
in this report are based on the combined findings of this series.
Regarding the first recommendation to implement and expand upon its policies and
programs to strengthen the nursing home workforce, CMS noted that it issued a
proposed rule for minimum staffing requirements and will invest $75 million in
financial incentives for individuals to enter careers in nursing homes.  CMS suggested
that OIG remove this recommendation; however, we maintain its merit.  While we
appreciate the importance of these two actions and support them, neither has taken
effect yet.  Furthermore, as stated in the recommendation, we are looking for CMS to
implement a process that allows for sustained attention to the crucial issue of the
nursing home workforce and for CMS to explore additional tools it can bring to
alleviate nursing home staffing shortages and related challenges.
Regarding the second recommendation to reassess nurse aide training and
certification requirements, CMS stated that it monitored and evaluated all emergency
waivers through the course of the public health emergency, making updates as
appropriate.  CMS suggested that OIG remove this recommendation; however, we
maintain its merit.  This recommendation is for CMS to reevaluate the requirements
based on the experiences of facilities during the pandemic and consider what changes
may be appropriate in the future.  As CMS considers new minimum staffing
requirements for nursing homes that emphasize the essential role of nurse aides, it is
more important than ever to ensure that training and certification requirements
promote a strong and qualified workforce.

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Agency Comments and OIG Response | 19
Regarding the third recommendation to update the nursing home requirements for
infection control to incorporate lessons learned from the pandemic, CMS stated that it
engages with other agencies that have expertise in emergency preparedness and
infection control, such as the Administration for Strategic Preparedness and Response
and the CDC.  CMS is considering the lessons learned from the COVID-19 public
health emergency, which includes infection prevention and control during emergency
periods, as a part of an expected emergency preparedness proposed rule that will
revise and update national emergency preparedness requirements for Medicare- and
Medicaid-participating providers and suppliers.  We look forward to hearing more
about these updated requirements.  We note two potential concerns with this
approach.  First, this recommendation is for updated infection control requirements
generally—and not limited to during emergency periods—given the devastating
spread of COVID-19 among nursing home residents.  Second, requirements for all
participating providers may not sufficiently address the circumstances of the nursing
home setting and the ways in which nursing home residents are uniquely vulnerable
to infection.
Regarding the fourth recommendation to provide effective guidance and assistance
to nursing homes on how to comply with updated infection control requirements,
CMS cited infection control guidance it issued prior to the pandemic and the work of
QIOs to support facilities during the pandemic.  CMS suggested that OIG remove this
recommendation; however, we maintain its merit.  We believe it is worth a
retrospective look at all that happened and was learned during the pandemic to
determine what is needed in the future with respect to guidance and assistance.
Accordingly, we recommend that CMS solicit and consider feedback from nursing
homes about the types of guidance, assistance, and/or other resources that may be
most useful.  Furthermore, implementation of this recommendation necessarily
follows the implementation of the previous recommendation to update nursing home
requirements for infection control.
Regarding the fifth recommendation to facilitate sharing of strategies and information
to help nursing homes overcome challenges and improve care, CMS described actions
it has taken to share information with nursing homes.  These actions include regular
stakeholder listening sessions and publishing all memorandums and guidance
publicly online.  While CMS makes information available to nursing homes, there are
limited mechanisms for nursing homes to give feedback to CMS or to ask CMS
questions, or for nursing homes to assist each other.  Our recommendation is for CMS
to develop methods for CMS and nursing homes to exchange strategies and ideas.
OIG is committed to protecting the health and safety of nursing home residents and
staff and will continue to work with CMS to promote additional actions to achieve
that outcome.
For the full text of CMS’s comments, see Appendix.

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Methodology | 20
METHODOLOGY
This study is based on 25 indepth, structured interviews that we conducted with
nursing home administrators.  We asked them about their experiences during the
pandemic, specifically their challenges and strategies related to staffing and infection
control, including COVID-19 testing and PPE, COVID-19 vaccines, and other infection
control practices.
Sample Selection
We used data collected and analyzed for the second evaluation in this series to select
30 nursing homes for the sample.  We selected these nursing homes to represent a
diversity of characteristics, including geographic location, size, profit status, and the
prevalence of COVID-19 in a facility, among others.  We then contacted each of the
30 nursing homes by telephone and email to explain the study, answer questions, and
schedule interviews.  Ultimately, we interviewed 25 of the nursing homes, while
4 chose not to participate and 1 was excluded based on the short tenure of its
administrator.
Data Collection and Analysis
We conducted interviews with the 25 nursing homes by telephone from December
2021 through July 2022.  We interviewed the administrator at each nursing home, and
some interviews also included additional staff (e.g., a director of nursing or infection
preventionist) at the administrator’s discretion.  We developed a structured interview
guide that was organized by five main topic areas: staffing, testing, PPE, vaccines, and
other infection control practices.  Within each topic area, we asked about nursing
homes’ challenges and strategies used to address those challenges.
We analyzed the interview data using NVivo qualitative analysis software.  We
organized interview responses and categorized the themes that emerged related to
each of the five topic areas.  We examined results to identify significant challenges
faced by nursing homes and strategies they employed to address the challenges.
We reviewed CMS’s applicable policies, procedures, and guidance, as well as other
related documents and studies, for background and context.
Limitations
Our analysis is limited to challenges and strategies as reported by the 25 nursing
homes at the time of the interviews.  The information reported in this study does not
represent the views and experiences of all nursing homes.  In addition, we identified
and reported the most significant themes; the report does not reflect every challenge
or strategy mentioned during interviews.

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Methodology | 21
Standards
We conducted this study in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.

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Appendix | 22
APPENDIX
Agency Comments
Following this page are the official comments from CMS.

DATE:
 December 15, 2023
TO:
Juliet T. Hodgkins
Principal Deputy Inspector General
FROM:
Chiquita Brooks-LaSure
Administrator
SUBJECT:
Office of Inspector General Draft Issue Brief: Lessons Learned During the
Pandemic Can Help Improve Care in Nursing Homes (OEI-02-20-00492)
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and
comment on the Office of Inspector General’s (OIG) draft report.
CMS thanks the OIG for their review in this area and is similarly committed to transparency,
which we have used to highlight the disproportionate impact of COVID-19 on patient
populations, including individuals residing in nursing homes.1 In the first year of the COVID-19
pandemic, nursing homes were severely impacted by COVID-19, with outbreaks causing high
rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home
population combined with the inherent risks of living in a congregate health care setting have
required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19
within nursing homes. Given the continued high incidence of COVID-19 and the likelihood that
new variants and other infectious agents may cause future outbreaks, CMS sought to understand
the relationship between nursing homes and the COVID-19 public health emergency and
published data and several analyses. This includes an in-depth look at the impact of COVID-19
on Medicare beneficiaries residing in nursing homes during 20202 and a CMS-funded study to
analyze the relationship between quality ratings and COVID-19 infections, published in May
2021.3
Even before the COVID-19 pandemic began, CMS had acted to strengthen infection prevention
and control practices in nursing homes. CMS took pivotal actions in the 2016 final rule,
“Medicare and Medicaid Programs: Emergency Preparedness Requirements for Medicare and
Medicaid Participating Providers and Suppliers,” which noted the need for nursing homes to
prepare for infectious disease threats.4 CMS also outlined specific reform requirements for Long-
Term Care (LTC) facilities in the 2016 final rule, “Medicare and Medicaid Programs: Reform of
Requirements for Long-Term Care Facilities (LTC),” which was the impetus for the requirement
1 CMS, CMS COVID-19 Data Products, Updated on November 05, 2021
2 CMS, The Impact of COVID-19 on Medicare Beneficiaries, 2021
3 Williams, C., Zheng, Q., White, A., Bengtsson, A., Shulman, E., Herzer, K., Lee F., The Association of Nursing
Home Quality Ratings and Spread of COVID-19, Vol. 6, Is. 8, Journal of the American Geriatrics Society, May 31,
2021
4 Medicare and Medicaid Programs; Emergency Preparedness Requirements, 81 Fed. Reg. 63860, 63862 (Sept. 16,
2016)
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Agency Comments | 23

that nursing homes develop an infection prevention and control program that includes an
antibiotic stewardship program.5
Since the COVID-19 public health emergency declaration in early 2020, CMS has taken a
number of actions to further strengthen infection prevention and control within nursing homes.
CMS began by issuing guidance to nursing homes, encouraging them to take appropriate action
to address potential and confirmed COVID-19 cases and mitigate transmission.6 CMS reiterated
the importance of longstanding infection control guidelines and guidelines on screening
processes and the use of personal protective equipment (PPE). CMS has held regular calls with
stakeholders, nursing home associations, and State Survey Agencies (SSAs) to keep them up to
date on the latest information to respond to COVID-19 and listened to the challenges faced by
nursing homes, such as access to PPE, continuing staffing issues, and a lack of availability of
testing and vaccinations during the first year of the public health emergency.
In an effort to support surveillance of COVID-19 cases and increase transparency, CMS in
collaboration with the Centers for Disease Control and Prevention (CDC) developed a system to
conduct COVID-19 surveillance and collect COVID-19 data within the CDC’s National
Healthcare Safety Network (NHSN) system for response activities. These data were used to
strengthen surveillance locally and nationally, monitor trends in infection rates, and help local,
state, and federal authorities get help to nursing homes faster.
Furthermore, in an effort to focus on controlling the spread of COVID-19, CMS provided SSAs,
who conduct onsite surveys to assess compliance with federal requirements and investigate
facility complaints, with a streamlined review tool to conduct focused infection control surveys
of providers identified through collaboration with the CDC and the Administration for Strategic
Preparedness & Response (ASPR). This tool was shared with providers who were encouraged by
CMS to use it to self-assess their own ability to prevent the development and transmission of
COVID-19 and other communicable diseases and infections. By July 2020, over 99 percent of
Medicare and Medicaid certified nursing homes had a focused infection control survey
conducted onsite. As the public health emergency continued, the focused infection control survey
was revised to incorporate new infection control requirements to address the spread of COVID-
19 as appropriate. CMS also published a toolkit comprised of recommendations and best
practices from a variety of frontline health care providers, state governors’ COVID-19 task
forces, associations, and other experts that is intended to serve as a catalog of resources
dedicated to addressing the specific challenges facing nursing homes as they combat COVID-
19.7 CMS continues to review and revise guidance as needed.
Throughout the pandemic, CMS used data from the CDC’s NHSN, in part, to identify which
nursing homes may need targeted help through the Quality Improvement Organizations (QIOs)
to strengthen infection control practices to reduce and prevent transmission of COVID-19.
Throughout the course of the public health emergency, QIOs have helped facilities address many
COVID-19 challenges related to staffing, PPE, infection prevention and control activities,
COVID-19 testing, and vaccine uptake. The QIOs connect nursing homes with local resources,
provide educational activities, and train nursing home staff and management. Currently, QIOs
continue to focus on vaccination and infection prevention and control practices to reduce the
spread of infection and manage outbreaks effectively, as well as provide individualized training
5 Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities, 81 Fed. Reg. 68688
(October 4, 2016). Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities, 81
Fed. Reg. 68688 (Nov. 28, 2016) Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care
Facilities, 81 Fed. Reg. 68688 (Nov. 28, 2016)
6 QSO 20-09-ALL Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness (2019-nCoV)
7 QSO-21-08-NLTC: COVID-19 Focused Infection Control Survey Tool for Acute and Continuing Care Providers
and Suppliers (Revised)
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resources based on the nursing home’s specific needs through toolkits, resource materials,
guides, webinars, and clinician office hours to provide expert consultation on the particular
challenges nursing homes face. CMS collects best practices and lessons learned from each of the
QIOs and coordinates the sharing of that information across QIOs nationally for rapid
deployment. Additionally, CMS partners with federal agencies such as the CDC and ASPR,
which are the agencies tasked with national leadership of disease prevention and control and
public health emergency response, to ensure coordination of services and alignment of guidance
for nursing homes.
As nursing homes continue to deal with COVID-19, ensuring that residents receive safe, high-
quality care is a high priority for the agency. CMS is continuing the work it started before the
COVID-19 pandemic to strengthen its health and safety requirements that protect residents’
rights and improve the quality of care they receive. Based on lessons learned from the pandemic,
CMS released guidance related to the requirement for nursing homes to have an Infection
Preventionist (IP) who has specialized training to effectively oversee the facility’s infection
prevention and control program. With emerging infectious diseases such as COVID-19, CMS
believes the role of the IP is critical in nursing homes’ efforts to mitigate the onset and spread of
infections. CMS recently revised guidance to clarify its expectations for infection control and
prevention.8 For example, CMS is urging providers to consider making changes to their physical
environment to allow for a maximum of double occupancy in each room to improve infection
control and prevention by reducing the risk associated with multiple residents in the room and
making it easier to isolate or quarantine residents who are infectious.
Ensuring that nursing homes maintain sufficient staffing to allow for safe, reliable, and high-
quality nursing home care is a critical function of the Medicare and Medicaid programs and a top
priority of CMS. In September 2023, CMS issued the “Minimum Staffing Standards for Long
Term Care Facilities and Medicaid Institutional Payment Transparency Reporting” proposed rule
(88 FR 61352),9 which seeks to establish comprehensive nurse staffing requirements to hold
nursing homes accountable for providing safe and high-quality care for the over 1.2 million
residents receiving care in Medicare and Medicaid certified LTC facilities each day. The
proposed rule results from a multi-faceted approach aimed at determining the minimum level and
type of staffing needed to enable safe and quality care in LTC facilities. This effort included
issuing a Request for Information in the FY 2023 Skilled Nurse Facility Prospective Payment
System Proposed Rule (87 FR 22720),10 hosting listening sessions, and extensive engagement
with various interested parties, conducting a 2022 Nurse Home Staffing Study, which builds on
existing evidence and research studies using multiple data sources, and reviewing recent years of
Payroll-Based Journal Systems staffing data. CMS also considered how the proposed minimum
staffing requirements would align or interact with ongoing CMS initiatives and programs that
impact the LTC community. Information gathered from each of these facets was used by CMS in
the development of the proposed requirements that aim to ensure all nursing home residents are
provided safe, high-quality care.11
8 QSO-22-19-NH Revised Long-Term Care Surveyor Guidance: Revisions to Surveyor Guidance for Phase 2 & 3,
Arbitration Agreement Requirements, Investigating Complaints & Facility Reported Incidents, and the Psychosocial
Outcome Severity Guide
9 Medicare and Medicaid Programs; Minimum Staffing Standards for Long-Term Care Facilities and Medicaid
Institutional Payment Transparency Reporting, 88 Fed. Reg. 61352 (Sept. 6, 2023)
10 Medicare Program; Prospective Payment Consolidated Billing for Skilled Nursing Facilities; Fed. Reg. 22720,
Updates to the Quality Reporting Program and Value Program for Federal Fiscal Year 2023; Request for
Information Requirements for Long-Term Care Facilities Mandatory Minimum Staffing Levels, April 15, 2022
11 CMS Fact Sheet, Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities
and Medicaid Institutional Payment Transparency Reporting (CMS 3442-P), September 1, 2023
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Agency Comments | 25

Additionally, CMS announced it is developing a national campaign to support staffing in nursing
homes.12 CMS will work with the Health Resources and Services Administration (HRSA) and
other partners to make it easier for individuals to enter careers in nursing homes. For example,
CMS is investing over $75 million in financial incentives such as scholarships and tuition
reimbursement, using money collected from monetary fines against nursing homes for non-
compliance with federal regulations. This staffing campaign builds on other actions through the
HHS Health Workforce Initiative. For example, separate from CMS, in August 2023 HRSA
awarded more than $100 million to five HRSA nursing workforce programs to train more nurses
and grow the workforce.13
Although CMS appreciates OIG's review, it is important to note that OIG’s findings are based on
25 interviews with administrators that took place almost two years ago (beginning in December
2021). Since then, CMS has taken numerous actions to further strengthen infection prevention
and control within nursing homes. CMS acknowledges that administrators can provide valuable
insight. However, there are many other stakeholders whose views are not represented, such as
residents, resident advocates, and federal and state oversight entities. OIG’s recommendations
and CMS’s responses are below.
OIG Recommendation (1)
Implement and expand upon its policies and programs to strengthen the nursing home workforce.
CMS Response
CMS agrees with the need to strengthen the nursing home workforce, and in fact, has already
implemented activities prior to this report (for those actions that are within our scope and
authority). Other agencies within HHS are also leading efforts in this area. Therefore, since the
actions have been implemented within CMS’s authority, we suggest OIG remove it. As always,
CMS will continue to assess our policies for improvements in this area moving forward.
As mentioned above, CMS has issued a proposed rule that, among other things, would set a national
minimum nurse staffing standard in nursing homes, the adoption of a 24/7 RN requirements, and
enhanced facility assessment requirements.14 However, we note these proposed requirements are
subject to the comment and rule-making process. Although CMS’s scope and authority focus on a
facility’s compliance with federal requirements, staffing in nursing homes has remained a persistent
concern, especially among low-performing facilities that are at the most risk for providing unsafe
care.  In addition, CMS announced a national campaign to support staffing in nursing homes, which
will invest over $75 million in financial incentives such as scholarships and tuition
reimbursement.15 This staffing campaign builds on other actions through the HHS Health
Workforce Initiative led by HRSA, whose scope includes workforce development. CMS will
continue to partner with HHS and HRSA as appropriate as they work to strengthen the nursing
workforce.
OIG Recommendation (2)
Reassess nurse aide training and certification requirements.
CMS Response
Although CMS agrees with the intent of the recommendation, we have already implemented it
prior to the issuance of this report.  Therefore, since the actions have been implemented, CMS
12 CMS Press Release, https://www.cms.gov/newsroom/press-releases/hhs-proposes-minimum-staffing-standards-
enhance-safety-and-quality-nursing-homes
13  Id
14 Fact Sheet, Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and
Medicaid Institutional Payment Transparency Reporting (CMS 3442-P), September 2023
15 Id
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OEI-02-20-00492
Agency Comments | 26

suggests OIG remove it. As always, CMS will continue to assess our policies for improvements
in this area moving forward. CMS believes training is extremely important to ensure staff have
the appropriate skills and competencies to meet residents' needs. The existing regulations enable
this to occur, while also providing states and facilities flexibility on how to conduct the training.
Since the beginning of the COVID-19 pandemic, CMS monitored and evaluated all emergency
waivers through the course of the public health emergency, making updates as appropriate.
Additionally, CMS has participated in regular stakeholder feedback calls, including with nursing
homes, nurses, nurse aides, and advocates.
We note that existing regulations allow facilities to employ nurse aides while they are
undergoing state-approved training and competency evaluation programs.16 Additionally, federal
requirements allow states to use a variety of means for their state-approved Nurse Aide
Competency Evaluation Program training curriculum, including online, classroom, or onsite
training.17
Considering nursing homes’ experiences during the COVID-19 public health emergency, CMS
did reassess existing nurse aide training and certification requirements. We reiterate that the
current requirements allow nursing homes the flexibility to train onsite as explained above.
OIG Recommendation (3)
Update the nursing home requirements for infection control to incorporate lessons learned from
the pandemic.
CMS Response
CMS agrees with OIG that, to the extent possible, infection control requirements should reflect
the latest knowledge about infection prevention for COVID-19 and other dangerous, infectious
diseases. As such, CMS engages with other agencies that have expertise in emergency
preparedness and infection control, such as ASPR and the CDC. Additionally, CMS is
considering the lessons learned from the COVID-19 public health emergency, which includes
infection prevention and control during emergency periods, as a part of an expected emergency
preparedness proposed rule that will revise and update national emergency preparedness
requirements for Medicare and Medicaid participating providers and suppliers.18 CMS believes it
has provided extensive information to the nursing home community about infection control but
ultimately defers to colleagues at the CDC for the development of infection control and
prevention standards.
ASPR, CDC, and CMS have a long history of working together to protect Americans from
emerging infectious diseases (EID), including Ebola, and other health security threats. CDC
develops evidence-based guidelines and recommendations, along with expert interim guidance
and strategies to inform actions healthcare facilities, such as nursing homes, and healthcare
professionals should take. These guidelines and recommendations are developed based on years
of fieldwork, emergency responses and exercises, and deep clinical and scientific expertise.
CDC’s expert guidelines, interim guidance, and technical assistance to health care providers and
facilities, in conjunction with ASPR’s coordination and hospital preparedness activities and
CMS’s implementation processes drives improvements in healthcare preparedness and response
to EID threats. A year before the public health emergency, CMS and CDC collaborated on the
development of a free, online training course in infection prevention and control for nursing
16 42 CFR §483.35(d)(3)(i)
17 CMS QSO-22-15-NH & NLTC & LSC, Update to COVID-19 Emergency Declaration Blanket Waivers for
Specific Providers, August 7, 2022
18 Office of Information and Regulatory Affairs, Office of Management and Budget RIN: 0938-AV21
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OEI-02-20-00492
Agency Comments | 27

home staff in LTC settings. Originally, it comprised 23 modules and took 19 hours to complete.19
Now, the free LTC infection prevention and control training course is 24 modules and takes
approximately 20 hours to complete.
At the start of the public health emergency, CMS and CDC formed the “COVID-19 Nursing
Home Task Force” to align CMS policies and CDC guidance. During the public health
emergency, CMS, CDC, and ASPR met several times a week to discuss all providers and
suppliers impacted by COVID-19. Activities and issuances included but were not limited to a
variety of information sharing, including updated guidance by the CDC, updated data presented
by the CDC, resources presented by ASPR, as well as CMS guidance to healthcare facilities and
surveyors responsible for determining compliance. In addition, the infection control survey tool
that SSAs used to conduct focused infection control surveys at the beginning of the public health
emergency, and that CMS shared with facilities to use as a voluntary self-assessment tool, was
developed in concert with the CDC. As the public health emergency continued, the infection
control survey was revised to incorporate new infection control requirements to address the
spread of COVID-19. CMS continues to engage with other agencies and rely on its federal
partners’ expertise for emergency preparedness and infection control and prevention.
OIG Recommendation (4)
Provide effective guidance and assistance to nursing homes on how to comply with updated
infection control requirements.
CMS Response
CMS agrees with the intent of the recommendation, and in fact, implemented new guidance prior
to this report. Therefore, since the actions have been implemented, CMS suggests OIG remove it.
Additionally, as always, CMS will continue to assess our work in this area to promote effective
technical assistance to the nursing home community.
CMS agrees with the importance of effective guidance for nursing homes and in June 2022,
which CMS notes is after OIG’s audit period, CMS released the Revised LTC Surveyor
Guidance, which included new guidance for phases 2 and 3 of the 2019 “Medicare and Medicaid
Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and
Burden Reduction; Fire Safety Requirements for Certain Dialysis Facilities; Hospital and Critical
Access Hospital (CAH) Changes To Promote Innovation, Flexibility, and Improvement in
Patient Care” Final Rule (84 FR 51732)20 which in part, requires nursing homes to employ an
Infection Preventionist and implement an effective infection prevention and control program.21
The new guidance also strengthened general infection control guidance to address frequently
cited issues such as hand hygiene, transmission-based precautions, and surveillance of infectious
diseases.
Additionally, CMS uses data to target support for nursing homes most in need and deploys QIOs
to provide expedited, data-driven Quality Improvement interventions to support facilities.  In the
earliest stages of the pandemic, CMS prioritized providing QIO technical assistance to facilities
with a history of infection control deficiencies. Subsequently, and as the pandemic evolved,
CMS incorporated other criteria, such as high COVID-19 incidence among residents, or high
community spread of the virus, to direct QIOs to high-risk facilities.
19 QSO-19-10-NH, Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long Term
Care Setting is Now Available, March 2019
20 Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and
Burden Reduction; Fire Safety Requirements for Certain Dialysis Facilities; Hospital and Critical Access Hospital
(CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care
21 CMS QSO-22-19-NH, Revised Long-Term Care Surveyor Guidance, June 29, 2022
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OEI-02-20-00492
Agency Comments | 28

When a nursing home is referred to the QIO, the QIO conducts a root cause analysis and assists
nursing home leadership with developing an improvement plan. The QIO then guides the nursing
homes to implement the plan and provides coaching where needed. The QIOs monitor the
nursing home’s progress to ensure improvement is occurring. Once CMS has made nursing home
referrals to the QIOs, and after the QIOs have begun training and offering technical assistance,
CMS regularly reviews and monitors QIO progress in the referred nursing homes, reviews the
incoming data from the QIOs on a weekly basis, and monitors the performance of the QIOs in
improving vaccine rates and managing COVID-19 outbreaks in nursing homes. As of November
2023, QIOs have assisted over 13,000 nursing homes with infection prevention and control
activities.
CMS has provided updated infection prevention and control guidance based on insights gained
during the COVID-19 pandemic and the QIOs continue to provide nursing homes individualized
assistance based on the most effective practices.
OIG Recommendation (5)
Facilitate sharing of strategies and information to help nursing homes overcome challenges and
improve care.
CMS Response
CMS agrees that the sharing of information with nursing homes is an important measure to assist
nursing homes with challenges.  As described throughout this response, CMS holds regular
stakeholder listening sessions for nursing homes and advocates and often provides updates based
on feedback received. In March 2020, CMS issued a Nursing Home Best Practices toolkit to
combat COVID-19, and regularly updated it with additional guidance as necessary. Further,
CMS notes that all quality, safety, and oversight memorandums, guidance, clarification, and
instructions are available publicly online.22 CMS contends that the agency has therefore met this
recommendation. It is important to note, however, that creating individualized communication
with over 15,000 nursing homes is not feasible with CMS’s available resources.
Additionally, CMS contracted with QIOs to work with providers, community partners,
beneficiaries, and caregivers on data-driven quality improvement initiatives designed to improve
the quality of care for nursing home residents. The QIOs have been strategically refocused to
assist nursing homes in combating COVID-19 through such efforts as education and training,
creating action plans based on infection control problem areas, and recommending steps to
establish a strong infection control surveillance program. As of November 2023, the QIOs have
assisted more than 14,000 nursing homes with staffing, emergency preparedness, PPE, infection
prevention and control activities, COVID-19 testing, and vaccine uptake through providing
targeted education, best practices, technical assistance, and identifying root causes to find long-
term solutions.
22 Nursing Homes: Policy & Memos to States and CMS Locations
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OEI-02-20-00492
Agency Comments | 29

Issue Brief: Lessons Learned During the Pandemic Can Help Improve Care in Nursing Homes
OEI-02-20-00492
Acknowledgments and Contact | 30
ACKNOWLEDGMENTS AND CONTACT
Acknowledgments
Rachel Bryan served as the team leader for this study.  Others in the Office of
Evaluation and Inspections who conducted the study include Jenell Clarke-Whyte,
Sarah Guyer, Heather Koenig, and Sophie Shepley.  Office of Evaluation and
Inspections headquarters staff who provided support include Joe Chiarenzelli and
Robert Gibbons.
This report was prepared under the direction of Jodi Nudelman, Regional Inspector
General for Evaluation and Inspections in the New York Regional Office, and Nancy
Harrison and Meridith Seife, Deputy Regional Inspectors General.

Contact
To obtain additional information concerning this report, contact the Office of Public
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found
on the OIG website at oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201

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OEI-02-20-00492
Endnotes | 31
ENDNOTES

1 Although these requirements have since changed, at the time of our interviews facilities’ routine testing schedules varied
from once per month if the county positivity rate was less than 5 percent to twice per week if the county positivity rate was
higher than 10 percent.  Outbreak testing protocols require testing all staff and residents every 3 to 7 days while there are
cases in a facility until there have been no cases for at least 14 days.  See CMS, Interim Final Rule (IFC), CMS-3401-IFC,
Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care
(LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool: QSO-20-38-NH, Apr. 27, 2021.
2 At the time of our interviews, CMS required that nursing home staff be fully vaccinated against COVID-19.  Staff are
considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19.
The regulations allow nursing homes to grant staff exemptions from the vaccination requirements based on Federal law
(e.g., for specific medical or religious reasons).  The regulations also require nursing homes to track and securely document the
vaccination status of staff and exemptions, including each type of exemption and supporting documentation.  CMS is also
urging facilities to communicate with their fully vaccinated staff members and residents about the importance of staying up to
date with COVID-19 shots to protect the nursing home population.  CMS requires that nursing homes educate their residents
and staff and offer the COVID-19 vaccine, which includes the booster, but does not currently require booster doses.  See 42
CFR § 483.80; CMS, Long-Term Care and Skilled Nursing Facility, Attachment A: QSO-22-07-ALL.  Accessed at
https://www.cms.gov/files/document/qso-22-07-all-attachment-ltc.pdf on Mar. 7, 2023.  See also CMS, CMS Makes Nursing
Home COVID-19 Booster Vaccination Data Available Online, Increasing Transparency for Consumers, Feb. 9, 2022.  Accessed at
https://www.cms.gov/newsroom/news-alert/cms-makes-nursing-home-covid-19-booster-vaccination-data-available-online-
increasing-transparency on Aug. 7, 2023.
3 As of the week ending Mar. 27, 2022, an OIG report estimated that 91 percent of nursing home staff members nationwide
had received the required vaccine doses, 56 percent of staff nationwide had received a booster dose, and 6 percent of staff
nationwide had been granted a religious exemption.  See OIG, An Estimated 91 Percent of Nursing Home Staff Nationwide
Received the Required COVID-19 Vaccine Doses, and an Estimated 56 Percent of Staff Nationwide Received a Booster Dose
(A-09-22-02003), June 2022.  Accessed at https://oig.hhs.gov/oas/reports/region9/92202003.pdf on Aug. 31, 2023.
4 We note that our interviews occurred prior to the availability of the bivalent booster or the updated COVID-19 vaccine.
5 On Apr. 2, 2020, CMS and CDC issued recommendations to nursing homes to create COVID-19-positive units to separate
residents who have COVID-19 from residents who do not have COVID-19 or have an unknown status.  CMS reiterated this
guidance to nursing homes in a subsequent memorandum (QSO-20-25-NH).  See CMS, COVID-19 Long-Term Care Facility
Guidance, Apr. 2, 2020.  Accessed at https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf
on Feb. 21, 2023.  See also CMS, 2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios:
QSO-20-25-NH, Apr. 13, 2020.  Accessed at https://www.cms.gov/files/document/qso-20-25-nh.pdf on Mar. 15, 2023.
6 For example, see CMS, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing
homes: QSO-20-14-NH, Mar. 9, 2023.  Accessed at https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf on Aug. 31,
2023.  See also CMS, Revised Long-Term Care Surveyor Guidance: Revisions to Surveyor Guidance for Phases 2 & 3, Arbitration
Agreement Requirements, Investigating Complaints & Facility Reported Incidents, and the Psychosocial Outcome Severity Guide:
QSO-22-19-NH, June 29, 2022.  Accessed at https://www.cms.gov/files/document/qso-22-19-nh-revised-long-term-care-
surveyor-guidance.pdf on Aug. 11, 2023.  See also CMS, Strengthened Enhanced Enforcement for Infection Control Deficiencies
and Quality Improvement Activities in Nursing Homes: QSO-23-10-NH, Mar. 30, 2023.  Accessed at
https://www.cms.gov/files/document/qso-23-10-nh.pdf on Aug. 11, 2023.
7 A QIO is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to
people with Medicare.

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OEI-02-20-00492
Endnotes | 32

8 The White House, FACT SHEET: Biden-⁠Harris Administration Takes Steps to Crack Down on Nursing Homes that Endanger
Resident Safety, Sept. 1, 2023.  Accessed at https://www.whitehouse.gov/briefing-room/statements-releases/2023/09/01/fact-
sheet-biden-harris-administration-takes-steps-to-crack-down-on-nursing-homes-that-endanger-resident-safety/ on Sept. 5,
2023.

9 CMS, Centers for Medicare & Medicaid Services Staffing Study to Inform Minimum Staffing Requirements for Nursing Homes,
Aug. 22, 2022.  Accessed at https://www.cms.gov/blog/centers-medicare-medicaid-services-staffing-study-inform-minimum-
staffing-requirements-nursing-homes on May 11, 2023.  See also CMS, HHS Proposes Minimum Staffing Standards to Enhance
Safety and Quality in Nursing Homes, Sept. 1, 2023.  Accessed at https://www.cms.gov/newsroom/press-releases/hhs-
proposes-minimum-staffing-standards-enhance-safety-and-quality-nursing-homes on Sept. 5, 2023.
10 CMS, HHS Proposes Minimum Staffing Standards to Enhance Safety and Quality in Nursing Homes, Sept. 1, 2023.  Accessed at
https://www.cms.gov/newsroom/press-releases/hhs-proposes-minimum-staffing-standards-enhance-safety-and-quality-
nursing-homes on Sept. 5, 2023.
11 CMMI, Graduate Nurse Education Demonstration, November 2019.  Accessed at
https://www.cms.gov/priorities/innovation/innovation-models/gne on Mar. 7, 2023.  See also CMMI, Nursing Home Value-
Based Purchasing Demonstration, July 1, 2009.  Accessed at https://www.cms.gov/priorities/innovation/innovation-
models/nursing-home-value-based-purchasing on Aug. 3, 2023.
12 For example, see QIOs, Tools and Resources.  Accessed at https://qioprogram.org/tools-and-
resources?combine=&created%5Bmin%5D=&created%5Bmax%5D=&field_tags_target_id%5B106%5D=106&page=0 on
Aug. 11, 2023.  See also CMS, Welcome to the Nursing Home Resource Center!  Accessed at https://www.cms.gov/nursing-
homes on Aug. 11, 2023.
13 CMS, Centers for Medicare & Medicaid Services Staffing Study to Inform Minimum Staffing Requirements for Nursing Homes,
Aug. 22, 2022.  Accessed at https://www.cms.gov/blog/centers-medicare-medicaid-services-staffing-study-inform-minimum-
staffing-requirements-nursing-homes on May 11, 2023.

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