Full text
The Provider Relief Fund
Helped Select Nursing Homes
Maintain Services During
the COVID-19 Pandemic,
but Some Found Guidance
Difficult to Use
U.S. Department of Health and Human Services
Office of Inspector General
Christi A. Grimm
Inspector General
December 2023, OEI-06-22-00040
The Provider Relief Fund Helped Select
Nursing Homes Maintain Services During
the COVID-19 Pandemic, but Some Found
Guidance Difficult to Use
What OIG Found
After receiving congressional
appropriations in March 2020, HHS quickly
worked with HRSA and other stakeholders
to develop PRF and began distributing
general relief payments to health care
providers the following month. HHS began
the first targeted distribution payments to
nursing homes in May. Although leaders
for the nursing homes in our sample
appreciated how quickly the payments
were disbursed, they sometimes faced
challenges with PRF distribution and
attestation processes.
HRSA distributed nearly $15 million in PRF payments to the 11 nursing
homes in our sample in 2020 and 2021, including more than $5 million from
targeted distributions to nursing homes and SNFs. Nursing home leaders
reported that HRSA’s broad guidance on allowable uses was initially unclear
and difficult to use. As a result, some were hesitant to use the funds for fear
they would use the money incorrectly and be forced to pay it back later.
Regardless of the challenges, the nursing homes had used and reported
about $12 million of the $15 million when we began our site visits in
May 2022. Nursing home leaders reported using the funds for expenses and
lost revenue, and reported that PRF payments were integral to maintaining
services during the pandemic.
HRSA required nursing homes to submit reports about PRF use. The nursing
homes in this review generally complied with the reporting requirements, but
some appeared to misreport data or had to resubmit information. Nursing
home leaders reported that it was difficult to find time to review lengthy
reporting guidance, and that completing the reports was a burden. Although
HRSA reported plans to assess nursing home use of PRF, the agency had not
yet begun conducting audits at the time we conducted our review.
What OIG Recommends and How the Agency Responded
We recommend that HRSA: (1) create a document to record lessons learned
from managing PRF and submit the document to HHS leadership and
(2) expedite audits of provider use of PRF payments. HRSA did not concur
with the first recommendation and concurred with the second.
Why OIG Did This Review
Nursing homes and their residents
have been among the hardest hit
by the COVID-19 pandemic, partly
because of longstanding
challenges with staffing and
infection control. To help nursing
homes and other health care
providers respond to the
pandemic, Congress appropriated
$178 billion and designated HHS
to oversee Provider Relief Fund
(PRF) and related distributions to
providers. HHS made
approximately $9.4 billion in
targeted PRF distributions to
nursing homes and skilled nursing
facilities (SNFs).
How OIG Did This Review
We conducted this evaluation in
conjunction with a series of
Pandemic Response Accountability
Committee (PRAC) studies
examining COVID-19 funding in
six select locations. We examined
how 11 nursing homes in those
locations used PRF payments
during 2020 and 2021 to improve
their responses to the COVID-19
pandemic. We also examined
Health Resources and Services
Administration (HRSA) oversight of
the funds. We based our findings
on document reviews, an analysis
of PRF payment data, and
33 interviews with leadership, staff,
residents, and residents’ family
members from the selected
nursing homes. We also
conducted two group interviews
with HRSA officials. We collected
the documents and data in early
2022 to prepare for conducting
interviews from May through
December concurrently with the
PRAC’s site visits.
Key Takeaway
HHS and HRSA quickly
distributed PRF payments
to nursing homes. Nursing
homes reported that
payments were integral to
maintaining services during
the COVID-19 pandemic,
but that guidance from
HRSA about the payments
and reporting requirements
was often difficult to use.
U.S. Department of Health and Human Services
Office of Inspector General
Report in Brief
December 2023, OEI-06-22-00040
TABLE OF CONTENTS
BACKGROUND ................................................................................................................................................ 1
FINDINGS ....................................................................................................................................................... 13
After receiving congressional appropriations, HHS quickly developed PRF and began distributing
payments to nursing homes ............................................................................................................................................... 13
Nursing homes in our sample used $12 million in PRF payments to address COVID-19-related
expenses and lost revenue, and said that the funds were integral to maintaining services during
the pandemic ............................................................................................................................................................................ 15
Nursing homes in our sample generally complied with PRF reporting requirements but reported
that HRSA guidance was difficult to use ........................................................................................................................ 21
HRSA developed plans to assess nursing home use of PRF but had not yet begun auditing nursing
homes at the time we conducted our review ............................................................................................................... 23
CONCLUSION AND RECOMMENDATIONS .......................................................................................... 25
Create a document to record lessons learned from managing PRF and submit the document to HHS
leadership ................................................................................................................................................................................... 25
Expedite audits of provider use of PRF payments ...................................................................................................... 26
AGENCY COMMENTS AND OIG RESPONSE ......................................................................................... 27
APPENDIX ..................................................................................................................................................... 28
Agency Comments ................................................................................................................................................................. 28
ACKNOWLEDGMENTS AND CONTACT ................................................................................................. 31
ABOUT THE OFFICE OF INSPECTOR GENERAL .................................................................................... 32
ENDNOTES ................................................................................................................................................... 33
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BACKGROUND
OBJECTIVES
1. To assess how select nursing homes used Provider Relief Fund (PRF)
payments during calendar years (CYs) 2020 and 2021 to improve their
responses to the COVID-19 pandemic.
2. To evaluate the Health Resources and Services Administration’s (HRSA’s)
management and oversight of PRF payments distributed to nursing homes.
Background
The COVID-19 pandemic has had a devastating effect on nursing homes and their
residents, partly because of longstanding challenges related to infection control and
staffing.1, 2, 3 To reimburse nursing homes and other health care providers for health
care-related expenses and lost revenues attributable to COVID-19, Congress
appropriated $178 billion to the Department of Health and Human Services (HHS)
during 2020 and 2021.4 HHS administered the funds through PRF and related
programs.5 This review includes only funding administered through PRF distributions,
of which there were two types: general distributions and targeted distributions to
categories of health care providers that had added COVID-19 challenges.6 HHS made
approximately $9.4 billion in targeted PRF distributions to skilled nursing facilities
(SNFs) and nursing homes, and obligated approximately $54.7 billion in total to SNFs
and nursing homes across all PRF distributions.7 HHS stopped making PRF payments
in June 2023 following passage of the Fiscal Responsibility Act of 2023.8
COVID-19 and Nursing Homes
The nation’s nursing home residents have been hard hit by the COVID-19 pandemic.
Residents’ advanced ages, underlying medical conditions, and close living quarters
have made residents especially vulnerable.9 As of January 1, 2023, more than
1.4 million nursing home residents in the United States had already had a confirmed
case of COVID-19, with approximately 160,000 deaths.10 Previous HHS Office of
Inspector General (OIG) work found that almost 1,000 more nursing home residents
enrolled in Medicare died per day in April 2020 than in April the previous year.11
Nursing homes have faced longstanding infection control and other challenges that
continued during the pandemic. From 2013 through 2017, the Centers for Medicare
& Medicaid Services (CMS) and State surveyors cited 82 percent of nursing homes
with infection control deficiencies, and cited half of those homes in consecutive
years.12 During COVID-19 surges in the spring and fall of 2020, more than
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1,300 nursing homes had infection rates of 75 percent or more among residents
enrolled in Medicare.13 Nursing homes also experienced inadequate access to
personal protective equipment (PPE) and staffing shortages, which may have further
contributed to infection control problems.14, 15 In July 2021, the American Health Care
Association and National Center for Assisted Living released survey results that found
94 percent of nursing homes reported recently experiencing staffing shortages.16
According to media reports, nursing homes also faced ongoing financial hardships
throughout the pandemic.17, 18
PRF Overview
During CYs 2020 and 2021, Congress appropriated $178 billion to HHS’s Public Health
and Social Services Emergency Fund to reimburse eligible health care providers for
health care-related expenses or lost revenues attributable to COVID-19.a, b HHS
administered $136.6 billion of that funding through PRF. HHS administered further
funding through related programs.19, c
PRF included two funding distribution types: general and targeted. General
distributions were broadly available to health care providers, while targeted
distributions were for health care providers with added COVID-19 challenges, such as
providers highly impacted by COVID-19 or serving high-need and vulnerable
populations (e.g., nursing homes).20, 21 HHS disbursed the general distributions—
totaling $81.4 billion—in four phases.22, 23 Targeted distributions were made to
specific provider types, including providers in COVID-19 high-impact areas, rural
providers, Indian Health Service and Tribal providers, safety net hospitals, children’s
hospitals, SNFs, and nursing homes. Targeted distributions made to these provider
types varied in amount, with totals ranging from $494 million to $20.7 billion.24 (See
Exhibit 1 for PRF distribution type summaries.) Allocation levels differ from the
amounts HHS originally planned and announced due to the number of applicants for
some general distributions, returned funds, and other factors.d HHS stopped making
PRF payments in June 2023.25
a HHS uses the Public Health and Social Services Emergency Fund to improve preparedness against
naturally occurring and man-made health threats, as well as threats that interfere with HHS’s function.
See HHS, Fiscal Year 2020 Public Health and Social Services Emergency Fund, Justification of Estimates for
Appropriations Committee, p. 11. Accessed at https://www.hhs.gov/sites/default/files/fy-2020-cj-phssef-
final-print.pdf on Jan. 30, 2023.
b The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated $100 billion; the Paycheck
Protection Program and Health Care Enhancement (PPPHCE) Act appropriated $75 billion; and the
Consolidated Appropriations Act, 2021, appropriated $3 billion. See CARES Act, P.L. No. 116-136,
Division B, Title VIII, (Mar. 27, 2020); PPPHCE Act, P.L. No. 116-139, Division B, Title I (Apr. 24, 2020); and
Consolidated Appropriations Act, 2021, P.L. No. 116-260, Division M, Title III (Dec. 27, 2020).
c For more information about related programs funded using these and other appropriations, see
footnotes e and f on page 4 of this report.
d For example, HHS initially announced $18 billion for Phase 2 of the General Distribution but only
allocated $4.5 billion. See HRSA, Past General Distributions, November 2022. Accessed at
https://www.hrsa.gov/provider-relief/past-payments/general-distribution on Dec. 16, 2022.
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Exhibit 1: PRF Distribution Types
Sources: HRSA, Past General Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-
relief/payments-and-data/past-payments/general-distribution on Dec. 16, 2022. HRSA, Phase 4 and ARP Rural
Distributions, September 2023. Accessed https://www.hrsa.gov/provider-relief/payments-and-data/phase4-arp on
Sept. 18, 2023. HRSA, Past Targeted Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-
relief/payments-and-data/past-payments/targeted-distribution on Dec. 16, 2022.
Note: Purple boxes indicate targeted distributions for nursing homes and SNFs. HRSA does not publicly report total
amounts from other PRF distributions that may have gone to nursing homes or SNFs.
HRSA Management of PRF
HRSA is the HHS agency responsible for administering the PRF program. HRSA
operates programs that provide health care to people who are geographically isolated
or economically or medically vulnerable. Its mission is to improve health outcomes
and achieve health equity through access to quality services; a skilled health
workforce; and innovative, high-value programs.26 The agency has served several
critical functions during the pandemic, including investing in the public health
workforce using National Health Service Corps programs; expanding vaccine access in
health centers, rural health clinics, and community-based organizations; operating the
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COVID-19 Coverage Assistance Fund, which covers costs associated with
administering COVID-19 vaccines to patients whose health insurance would not fully
cover those costs; and administering claims reimbursement to health care providers
for COVID-19 testing, treatment, and vaccinations for uninsured patients through the
COVID-19 Uninsured Program.27, 28, 29, e, f
HRSA manages the PRF program through its Provider Relief Bureau by overseeing
provider application reviews and operating the PRF Reporting Portal, among other
efforts.30, 31, 32 HRSA has contracted with external organizations to assist with some
functions, such as collecting information through the application portal, facilitating
the distribution of PRF payments, and auditing provider use of PRF.33, 34, 35
Targeted PRF Distributions to Nursing Homes and SNFs
HRSA distributed approximately $9.4 billion in targeted PRF payments directly to SNFs
and nursing homes.36, g HRSA distributed $4.8 billion of this amount to 12,806 SNFs
which provide complex nursing and therapy care that can only be safely and
effectively performed by, or under the supervision of, skilled nursing and therapy
professionals.37 HRSA used a fixed-payment approach for this SNF distribution; SNFs
with at least six CMS-certified beds qualified for $50,000 plus $2,500 per bed.38 The
terms and conditions required that recipients use the payments to prevent, prepare
for, and respond to COVID-19, and only for health care-related expenses or lost
revenues attributable to COVID-19.39
e Within PRF, HHS and HRSA used a portion of the funding Congress appropriated to support health
care-related expenses attributable to the COVID-19 pandemic in order to support the Coverage
Assistance Fund and the COVID-19 Uninsured Program. See Centers for Disease Control and Prevention
(CDC), Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine
Administration of the Uninsured, updated Mar. 3, 2022. Accessed at https://data.cdc.gov/Administrative/
Claims-Reimbursement-to-Health-Care-Providers-and-/rksx-33p3 on Jan. 30, 2023; and CDC, COVID-19
Coverage Assistance Fund: Claims Reimbursement to Health Care Providers and Facilities for Services to the
Underinsured, updated Nov. 16, 2022. Accessed at https://data.cdc.gov/Administrative/COVID-19-
Coverage-Assistance-Fund-Claims-Reimburse/xgy8-wnft on Jan. 30, 2023.
f HRSA administered funds for other programs alongside PRF. HHS used $8.5 billion that Congress
appropriated through the American Rescue Plan (ARP) Act of 2021 to establish the ARP Rural Distribution
to administer payments to providers and suppliers who serve rural enrollees in Medicaid, the Children’s
Health Insurance Program, and Medicare. The Rural Health Clinic COVID-19 Testing (RHCCT) and Rural
Health Clinic COVID-19 Testing and Mitigation (RHCCTM) programs supported Rural Health Clinics in
maintaining and increasing COVID-19 testing and mitigation efforts. See HHS press release, “Biden-
Harris Administration Begins Distributing American Rescue Plan Rural Funding to Support Providers
Impacted by Pandemic,” Nov. 23, 2021. Accessed at https://public3.pagefreezer.com/browse/HHS.gov/
30-12-2021T15:27/https:/www.hhs.gov/about/news/2021/11/23/biden-admin-begins-distributing-arp-
prf-support-to-providers-impacted-by-pandemic.html on Aug. 10, 2023; and HRSA, Rural Health Clinic
COVID-19 Testing and Mitigation (RHCCTM) Program, August 2022. Accessed at
https://www.hrsa.gov/coronavirus/rural-health-clinics/testing on Oct. 27, 2022.
g In addition to the targeted distributions, some nursing homes also qualified for additional funding
through general and other PRF distributions. In June 2023, HRSA reported to OIG that HHS had
obligated approximately $54.7 billion total to SNFs and nursing homes across all PRF distributions.
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HHS distributed the remaining $4.6 billion to nursing homes through the Nursing
Home Infection Control (NHIC) distribution. The NHIC distribution included two types
of allocations: infection control payments and the Quality Incentive Payment (QIP)
program. HRSA distributed infection control payments to 12,787 nursing homes
using a per-facility formula: $10,000 per home plus $1,450 per certified bed. HRSA
distributed QIP to 11,819 nursing homes in amounts that varied by facility and month.
HHS developed a complex formula using COVID-19 infection and mortality rates to
determine whether nursing homes qualified for QIP. HRSA distributed QIP four times
following monthly assessments between September and December 2020.40, h (See
Exhibit 2 for information about SNF and NHIC payment calculations.) The terms and
conditions for the NHIC distribution required that recipients spend the funds on
infection control-related expenses, such as COVID-19 testing and hiring staff.41
Exhibit 2: Targeted PRF Distributions to SNFs and Nursing Homes
Source: HRSA, Past Targeted Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-
relief/payments-and-data/past-payments/targeted-distribution on Dec. 16, 2022.
HRSA automatically distributed SNF and NHIC payments directly to eligible nursing
homes electronically or by check.42 HRSA directed providers to attest to accepting
the associated terms and conditions upon receiving the funds.i The terms and
conditions required nursing homes to allow public disclosure of the payments and to
fully cooperate with audits, in addition to other requirements.43, 44 HRSA requires
h HHS and HRSA calculated the infection and mortality measures using data from sources such as CDC’s
National Healthcare Safety Network and COVID-19 community profile reports. See HRSA, Nursing Home
Quality Incentive Program Methodology, Dec. 7, 2020. Accessed at https://www.hrsa.gov/sites/default/
files/hrsa/provider-relief/nursing-home-qip-methodology.pdf on Jan. 31, 2023.
i HRSA deemed providers that did not attest to the terms and conditions as having attested if they
retained a payment for 90 days. Providers use the CARES Act PRF Payment Attestation Portal or the PRF
Application and Attestation Portal to attest to the terms and conditions. See HRSA, PRB Provider Relief
Fund General Information FAQ. Accessed at https://www.hrsa.gov/provider-relief/faq/general on
Jan. 31, 2023.
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providers with unused funds at the end of a relevant period of availability to return
the funds.j
Timelines and Reporting Requirements
HHS began issuing PRF payments in April 2020 and, for reporting purposes,
established periods during which PRF recipients must use and report on the funds.45
HRSA required all recipients that received PRF payment(s) exceeding $10,000 in the
aggregate during any given payment-received period (i.e., a time period in which a
health care provider received one or more PRF payments) to report use of the funds
during the applicable reporting period. Those recipients reported use in broad
categories, by lost revenue, or by general or health care-related expense.46, k
In general, PRF recipients must use the funds within 1 year after the payment-received
period ends and report on use during a subsequent 3-month period. HRSA has
revised the periods since developing its initial timelines. In May 2023, HRSA added
Periods 8 and 9 that extend reporting through fiscal year 2025.47 (See Exhibit 3 for a
list of the payment-received, use, and reporting periods.)
j Providers return unused PRF payment amounts to HRSA through the Return Unused PRF Funds Portal.
See HRSA, PRB Provider Relief Fund General Information FAQ. Accessed at
https://www.hrsa.gov/provider-relief/faq/general on Jan. 31, 2023.
k HRSA required providers to report use of NHIC payments and all other payments separately.
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Exhibit 3: Timelines for Provider Receipt, Use, and Reports of PRF Payments
Payment-Received
Period*
Deadline for
Using Funds
Reporting Time
Period
Period 1
From Apr. 10 to
June 30, 2020
June 30, 2021
July 1 to
Sept. 30, 2021**
Period 2
From July 1 to
Dec. 31, 2020
Dec. 31, 2021
Jan. 1 to
Mar. 31, 2022
Period 3
From Jan. 1 to
June 30, 2021
June 30, 2022
July 1 to
Sept. 30, 2022
Period 4
From July 1 to
Dec. 31, 2021
Dec. 31, 2022
Jan. 1 to
Mar. 31, 2023
Period 5
From Jan. 1 to
June 30, 2022
June 30, 2023
July 1 to
Sept. 30, 2023
Period 6
July 1 to
Dec. 31, 2022
Dec. 31, 2023***
Jan. 1 to
Mar. 31, 2024
Period 7
Jan. 1 to
June 30, 2023
June 30, 2024***
July 1 to
Sept. 30, 2024
Period 8
July 1 to
Dec. 31, 2023
Dec. 31, 2024***
Jan. 1 to
Mar. 31, 2025
Period 9
Jan. 1 to
June 30, 2024
June 30, 2025***
July 1 to
Sept. 30, 2025
Source: HRSA, Important Dates for Reporting, May 2023. Accessed at https://www.hrsa.gov/provider-relief/reporting-
auditing/important-dates on May 11, 2023.
* These periods are not the same as the general distribution phases. HHS used the general distribution phases to
distribute funding as the Department received and allocated it; these periods were established for reporting purposes.
** HRSA allowed a grace period for this reporting time period, which ended on Nov. 30, 2021.
*** PRF payments not fully expended on expenses attributable to COVID-19 may only be applied to lost revenue up to
the end of the quarter in which the Public Health Emergency ended (i.e., June 30, 2023). See HRSA, How to Calculate
Lost Revenues for PRF and ARP Rural Reporting, February 2023. Accessed at https://www.hrsa.gov/provider-
relief/reporting-auditing/lost-revenues on Mar. 20, 2023.
Related Work
This study expands on OIG’s body of work focused on the health and well-being of
nursing home residents, as well as OIG’s oversight of HHS’s COVID-19 response and
recovery. Prior evaluations found that nursing home residents enrolled in Medicare
were hard-hit by COVID-19, with 2 in 5 diagnosed with either COVID-19 or likely
COVID-19 in 2020, and that more than 1,000 nursing homes experienced “extremely
high” infection rates and an average overall mortality rate approaching 20 percent
during COVID-19 surges in 2020.48, 49 A July 2023 evaluation found some differences
in targeted PRF funds allocated to hospitals with respect to the race and ethnicity of
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the populations the hospitals served.50 OIG has an ongoing evaluation examining
nursing home strategies to mitigate pandemic-related challenges.51
OIG has an ongoing, three-part approach to auditing PRF. In the first part, OIG found
that HHS’s oversight of automatic general distribution Phase 1 PRF payments was
generally effective but improvements could be made.52 In the second, OIG is
conducting several additional audits of PRF general distributions, including audits of
controls for provider submission of information, provider eligibility, and other items.53
In one of these audits, OIG found that HHS’s and HRSA’s controls related to selected
PRF program requirements could be improved.54 In the third part of its audit strategy,
OIG is auditing provider expenditures of PRF funding and compliance with program
requirements.55, 56 One of those audits will include a larger sample of SNFs to
determine whether PRF recipients complied with certain terms, conditions, and
Federal requirements for spending and reporting on PRF payments.
See the OIG COVID-19 Portal for more information about OIG’s oversight work
related to COVID-19 and the OIG nursing home site for more information about OIG’s
efforts to protect nursing home residents, strengthen oversight, and promote
emergency preparedness.
Joint Work With the PRAC
We conducted this evaluation in conjunction with a series of studies led by the
Pandemic Response Accountability Committee (PRAC)—a committee of 20 Inspectors
General created by Congress to oversee pandemic relief spending—that examined
Federal COVID-19 funding. The PRAC released the first report in July 2023 and plans
to release the remaining reports in 2024.57
The PRAC divided its project into two phases:
1) Phase 1 provides an overview of Federal COVID-19 funding to 6 geographic
locations, which was distributed by programs overseen by 10 participating Federal
OIGs.
2) Phase 2 will detail funding distributed to each location for specific programs
chosen by each OIG. The PRAC and participating OIGs visited each selected
location, virtually or in person, and conducted interviews with community officials
and others to examine the use and effect of pandemic relief funding in the
selected programs.
Methodology
Scope of Inspection
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We examined the use of PRF payments to 11 nursing homes during CYs 2020 and
2021, and HRSA management and oversight of those funds.l We conducted our data
collection concurrently with the PRAC’s Phase 2 site visits to its selected locations
from May through December 2022. We used virtual interviews, documents, and
payment data to identify how the nursing homes used PRF payments and whether
they experienced any challenges using these funds. To assess HRSA management
and oversight of PRF payments, we interviewed HRSA officials and nursing home
leaders about PRF distribution processes and the agency’s efforts to collect and
review related data and documentation.
As noted, we conducted this evaluation in conjunction with a series of studies led by
the PRAC that examined Federal COVID-19 funding. The PRAC selected
six geographic locations as the subject of its studies. The PRAC chose the 6 by
randomly selecting 10 locations within each of 3 area types: small to-mid-sized cities,
rural communities, and Tribal reservations. From each group of 10, the PRAC then
selected 2 locations based on the highest total number of COVID-19 cases. The PRAC
also considered additional factors, such as total funding provided to each location
and geographic distribution across the United States.
The 11 sample nursing homes include all nursing homes located in the PRAC’s
6 selected geographic locations that received PRF payments through the SNF and
NHIC distributions.m (See Exhibit 4 for a list of the geographic locations selected by
the PRAC and the number and size of nursing homes within each location.) One of
the six PRAC-selected locations did not include any nursing homes that directly
received PRF funds and was not included as part of this evaluation. Because of data
constraints, we did not include 2 nursing homes that did not receive direct PRF
payments in our sample of 11 nursing homes, although they may have received PRF
funds as subrecipients of distributions to their owners. We also excluded a
third nursing home. That nursing home’s Taxpayer Identification Number (TIN) was
associated with an outdated location in the PRF payment data, which was located
within study boundaries. However, a representative for the company identified by the
TIN reported that the company no longer operated a facility within those boundaries.
l For purposes of our review, we used the term “nursing homes” to refer to all facilities in our sample
regardless of technical status (i.e., nursing facility and/or SNF) according to common use. We use the
term “SNF” throughout only when referring to HRSA’s targeted distribution allocated to SNFs.
m To determine the sample of nursing homes, we filtered data about PRF payments to nursing homes
using ZIP Codes for each location provided by the PRAC. We also verified the sample by using mapping
tools to identify any additional nursing homes located within the ZIP Codes but included in the PRF data
under another location, such as the location of facility owners.
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Exhibit 4: Number and Size of Sample Nursing Homes in Each Location
Location Selected by the PRAC
Number of
Nursing Homes
Average Number
of Beds per
Nursing Home*
Springfield, MA
1**
120
Coeur d’Alene, ID
5
86
Sheridan County, NE
3
56
Marion County, GA
1
70
White Earth Nation Indian
Reservation (MN)
1
32
Jicarilla Apache Nation
Reservation (NM)
-
-
All Locations
11
75
Source: OIG analysis of PRF data and OIG analysis of supplemental National Healthcare Safety Network COVID-19
nursing home data from August 2022.
* Numbers rounded to the nearest whole number.
** The three nursing homes that we did not include in our sample were located in Springfield.
Although we determined our sample by selecting the nursing homes in each location
that received PRF payments through the SNF and NHIC distributions, our findings
include a discussion about the nursing homes’ use of all types of PRF payments
received. In addition to SNF and NHIC payments, the nursing homes in our sample
received payments from other PRF distributions, including general distributions and
targeted distributions to other types of health care providers.n, o We chose to include
the nursing homes’ broader PRF payments because interview respondents often did
not distinguish SNF and NHIC payments from other payments. In addition, use of
SNF payments is reported together with the use of other payment types to HRSA.
Data Collection
n Some of the nursing homes in our sample are part of facilities that also serve as hospitals, health
centers, or other facility types.
o We refer to all non-NHIC or SNF payments the nursing homes in our sample received as “other”
throughout this report.
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Interviews: To evaluate nursing home use of PRF payments, we held interviews
virtually with leadership, staff, and a small number of residents and family members
from the selected nursing homes concurrently with the PRAC’s onsite visits.p We also
conducted two virtual group interviews with relevant HRSA officials. We employed
adaptable interview protocols that allowed us to modify questions, as needed, and
follow up on additional issues as we identified key issues.
Nursing Home Interviews: We conducted 33 individual or group interviews with
131 leaders, staff, residents, and family members at the selected nursing homes.
Leaders included nursing home administrators and directors of nursing; corporate
executives; representatives from contracted management and audit groups; health
care system leaders; and others. Staff interviews included clinical and nonclinical staff.
During interviews, we discussed nursing home experiences in using the funds and
reporting the information to HRSA, including any challenges and interactions with
HRSA. We conducted interviews with residents and/or family members at some of
the nursing homes to gather supplementary insights about nursing home care during
COVID-19. We used these insights for the PRAC’s corresponding location-specific
reports described on page 8 of this report.
HRSA Interviews: We conducted two group interviews with representatives from
HRSA‘s Provider Relief Bureau and Office of Planning, Analysis, and Evaluation.
Interviewees included 13 officials who responded during one or both interviews, as
well as 6 other attendees. During the interviews, we discussed HRSA’s efforts to
manage and oversee PRF, including the agency’s efforts related to PRF payment
distribution, provider reporting processes, audits, and recovery of improper or
unintended payments. We also asked about any coordination regarding nursing
homes with CMS and other Federal or State agencies. We discussed any challenges
that HRSA experienced with oversight, and any actions it took to assist nursing homes
in overcoming challenges.
Document Review: We collected available funding receipt attestations and reports
to HRSA about how the sample nursing homes used PRF payments. OIG extracted
the documents during April and June 2022 in preparation for the PRAC’s series of
location site visits. At that time, only two of four required reporting periods had
passed, so the nursing homes had not yet reported on their use of all PRF payments.
They had, however, reported on most of the payments they received through the SNF
and NHIC distributions.q We also requested and reviewed summary documentation
from the nursing homes supporting expenses and lost revenue outlined in those
p In addition to conducting our own interviews, we attended 13 PRAC interviews with leadership and
health or related departments in the 5 locations containing nursing homes that received PRF payments
directly. We did not include information from those interviews in our findings. We did, however, confirm
that the local departments did not have any role in helping nursing homes determine how to use PRF.
q During the first two reporting periods, the nursing homes in our sample were required to report about
their use of 61 of 80 PRF payments received during 2020 and 2021, including 43 of 57 SNF and NHIC
payments.
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reports. Additionally, we requested any correspondence between HRSA officials and
the nursing homes about PRF money and the reports, as well as any documentation
of HRSA’s oversight actions related to the use of the funds. As of June 8, 2022, HRSA
had no documentation of oversight actions related to the nursing homes.
PRF Payment Data: To summarize PRF payments the nursing homes received and
kept, we reviewed PRF payment data from HRSA for the 11 selected nursing homes.
We collected PRF payment data in preparation for the PRAC’s series of location site
visits; the data were extracted on February 28, 2022, and, depending on whether the
payments were made electronically or by check, were current through the beginning
of January or February 2022. The data therefore included all payments made during
our timeframe, which included CYs 2020 and 2021.
Data Analysis
We conducted a qualitative analysis of interview data and documentation from the
nursing homes and HRSA. We used our analysis to gain a deeper understanding of
PRF program strengths and weaknesses from the perspective of HRSA and the
11 nursing homes. This analysis also helped us to determine how the selected
nursing homes used targeted payments to improve infection control and address
health care expenses and lost revenue related to the pandemic. We identified themes
and challenges related to the disbursement and use of the funds, and PRF oversight
processes.
We conducted a quantitative review of PRF payment data and of the nursing homes’
reports and supporting financial documentation. We used our analysis of the data to
briefly summarize the types and amounts of PRF payments each nursing home
received and how the funds were used.
Limitations
We focused only on the experiences of the 11 selected nursing homes. Our findings
cannot be generalized to all nursing homes that received PRF payments.
Although HHS-OIG compared the nursing home reports to HRSA against supporting
documentation and PRF terms and conditions to assess appropriateness, we did not
conduct an audit of the nursing homes’ financial documentation to verify their reports
and supporting material.
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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FINDINGS
After receiving congressional appropriations, HHS quickly
developed PRF and began distributing payments
to nursing homes
HRSA officials described PRF development as an urgent and difficult endeavor.
Officials said that it was an “extraordinary” challenge to balance the urgency to
distribute the payments with the large amount of information, guidance, and requests
the agency received from stakeholders. One official explained that HHS and HRSA’s
goal in developing PRF was to invest in entities that would have the highest
pandemic-related lost revenues and increased expenses, such as hard-hit nursing
homes. Another official added that HHS and HRSA sought to use QIP distributions to
reward nursing homes that created and maintained safe environments for residents.
HHS and HRSA quickly developed PRF policies and processes and began distributing
general distribution Phase 1 payments to health care providers on April 10, 2020,
within 1 month after the enactment of the CARES Act on March 27. HRSA began the
SNF and NHIC distributions shortly thereafter. (See Exhibit 5 for a timeline of PRF
development and initial distribution to nursing homes.) As OIG has recognized,
distributing PRF quickly during unprecedented circumstances was a substantial
challenge.58
Exhibit 5: PRF Development and Distribution Timeline
Sources: CARES Act, P.L. No. 116-136, (Mar. 27, 2020); and data from HRSA officials, June 2022.
HHS worked with HRSA, other HHS agencies, and contractors
to rapidly develop PRF policies and processes
HHS collaborated with HRSA and a wide range of other stakeholders to develop and
manage PRF. According to HRSA officials, the HHS Office of the Secretary led
program and policy development including the development of payment
methodologies, terms and conditions, oversight processes, and determining eligibility
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standards. HHS sought feedback from HRSA and other agencies about the
distributions. For example, one official reported that HHS convened agencies
including CMS, CDC, and others to coordinate HHS infection control activities,
including NHIC QIP. HHS and HRSA also sought feedback from two nursing home
associations about QIP.
Following PRF development, HRSA became responsible for program management
and worked with HHS on provider communication. HHS and HRSA worked with
contractors to develop payment methodologies, portals for applications and
attestations, and other efforts.
One official reported that HHS and HRSA developed broad PRF terms and conditions
so that providers could “use [the] money in any way they saw fit” to address health
care-related expenses and lost revenue attributable to COVID-19 in accordance with
the PRF appropriations statutes. The official further confirmed that, according to the
NHIC terms and conditions, NHIC payments could be used for COVID-19-related
infection control expenses but could not be used for lost revenue.
HRSA used a variety of methods to distribute payments
to providers, but had some difficulty issuing automatic payments
to nursing homes because of data lags
To quickly distribute PRF payments, HRSA relied on various payment techniques.
HRSA officials reported that the agency used automatic push payments during the
first phase of the general distribution and for targeted distributions. To distribute
automatic payments, HRSA used data such as bank account information and provider
addresses from other HHS agencies, including CMS and the Indian Health Service.
For example, HRSA was able to distribute many of the targeted payments to nursing
homes using banking information CMS had for Medicare- and Medicaid-participating
facilities. HRSA used application processes to gather information about providers for
which it did not already have necessary data. HRSA distributed general distribution
Phase 2, 3, and 4 and some Phase 1 payments using information providers submitted
through those applications.
Officials reported that the timing of data on changes in nursing home ownership
affected payment distribution. Specifically for general distribution Phase 1 and SNF
targeted distribution payments, officials said that lags in ownership data that HRSA
received from other HHS agencies resulted in a small number of payments distributed
to prior owners. To remedy this, HRSA allowed providers that did not receive correct
general distribution Phase 1 payments to apply for funds during Phase 2 and required
incorrect recipients to return the funds. HRSA also reissued targeted distribution
payments to the correct providers.
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Nursing homes in our sample sometimes faced challenges
with PRF distribution and attestation processes
Nursing home leaders appreciated the efficiency of payment disbursement but were
sometimes unsure of or disagreed with PRF distribution processes. Some said they
had little or no notice regarding when they would receive the funds, and sometimes
they had to retroactively determine which distributions the payments came from after
receiving them. Some leaders were unsure of, or disagreed with, the methods HRSA
used to determine the payment amounts. For example, one nursing home
administrator disagreed with the use of QIP to incentivize quality. The administrator
stated that most nursing homes continually strive for quality, but that it is harder for
facilities with less funding to meet quality benchmarks, which results in ineligibility for
payments determined by quality measures and can lead to a cycle of underfunding.
A leader for two nursing homes in our sample said the nursing homes were initially
unable to access some PRF funds. The nursing homes were in a chain and had
difficulty accessing NHIC payments because the chain was going through bankruptcy
and therefore had been deemed ineligible for PRF funds.r
HHS and HRSA required nursing homes and other providers to attest to the
associated terms and conditions upon receiving payments, but the nursing homes in
our sample often did not complete attestations.s One leader reported that the
attestation process was tedious, required “a lot of clicks,” and that sometimes
information did not save correctly. The leader added that every payment required
separate attestations, which meant completing the same process repeatedly. As
noted in footnote i (on page 5), HRSA deemed providers that did not attest to the
terms and conditions as having attested if they retained a payment for 90 days.
Nursing homes in our sample used $12 million in PRF payments
to address COVID-19-related expenses and lost revenue, and
said that the funds were integral to maintaining services during
the pandemic
At the time of our review, the sample nursing homes had been required to report to
HRSA about the use of approximately $12 million of nearly $15 million in total PRF
payments they had received. Nursing home leaders reported gathering input from
personnel about facility and staff needs, and using the funds to cover lost revenue,
general and administrative expenses, and health care-related expenses. Specific costs
r HRSA told us that it later changed its policy so that bankruptcy was no longer a consideration when
determining eligibility and paid these facilities during subsequent payment waves.
s During CYs 2020 and 2021, the 11 nursing homes in our sample had attested to receiving 49 of 80 PRF
payments. The nursing homes had either taken no action or had not yet been required to respond about
the remaining payments.
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included health care-related equipment and supplies, such as PPE, and staffing.
Nursing home leaders reported that use of the funds allowed them to maintain
operations, infection control, and resident care during the pandemic.
The 11 nursing homes in our sample received nearly $15 million
in total PRF payments
As of December 2021, the 11 nursing homes in our sample had received a total of
$14.8 million from general and targeted PRF distributions.t Targeted payments
included $2.6 million from the SNF distribution and $2.5 million from the NHIC
distribution (see Exhibit 6). The nursing homes also received payments from general
and other types of distributions.
Exhibit 6: PRF Payments to Nursing Homes*
Distribution
Total Payments Distributed
to Nursing Homes Nationally
Total Payments Distributed
to Sample Nursing Homes
SNF
$4.8 billion
$2,625,000
NHIC
$4.6 billion
$2,498,150
Other**
$45.3 billion
$9,666,953
Total
$54.7 billion
$14,790,103
Sources: HRSA, Past Targeted Distributions, November 2022, accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022; and OIG analysis of PRF payment data.
* HRSA last reviewed the web page that lists the targeted distribution totals in November 2022 and stated that the
totals were current through September 2022. PRF payment data for our sample nursing homes are current through
December 2021.
** “Other” includes all other payments to nursing homes (i.e., PRF payments made through distributions that are not
SNF and NHIC distributions). HRSA reported to OIG in June 2023 the total amount paid to nursing homes, but does
not publicly report total amounts distributed to specific provider types for general distributions. HRSA also does not
publicly report total amounts from other PRF distributions—other than the SNF and NHIC distributions—that may
have gone to those facilities.
HRSA’s methods for determining payment amounts, which were sometimes based on
the number of beds in a facility, meant that each nursing home received different
general and targeted distribution payment amounts. Additionally, some nursing
homes were part of small health centers or health systems that included hospitals and
other provider types that were also eligible for other types of targeted distributions.
(See Exhibit 7 for the number of nursing homes within each location and associated
PRF payments.)
t The nursing homes also received an additional $893,300 from the ARP Rural Distribution and the RHCCT
and RHCCTM programs. These programs are separate from PRF but are related in that HRSA
administered them and included their data alongside PRF.
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Exhibit 7: The 11 sample nursing homes in locations selected by the PRAC
received nearly $15 million in total PRF payments, including more than
$5 million from the SNF and NHIC distributions.
Location Selected
by the PRAC
Number of
Nursing Homes
Total PRF
Payments
Total PRF Payments
from SNF and NHIC
Distributions
Springfield, MA
1
$919,454
$698,532
Coeur d’Alene, ID
5
$4,572,004
$2,615,091
Sheridan County, NE
3
$4,961,682
$1,099,614
Marion County, GA
1
$504,617
$411,958
White Earth Nation
Reservation (MN)
1
$3,832,346
$297,955
Jicarilla Apache Nation
Reservation (NM)
-
-
-
Total
11
$14,790,103
$5,123,150
Source: OIG analysis of PRF data.
Sample nursing homes reported that guidance on allowable
PRF uses was initially unclear and difficult to use
Nursing home leaders reported that they used HRSA’s terms and conditions, emails,
and FAQ resources for guidance about what was allowable, but said the guidance was
broad and unclear. Although intended by HRSA to be helpful, the broad guidance
and allowable uses of funding (i.e., for expenses and lost revenue attributable to
COVID-19) made some leaders hesitant to make decisions about how to use funds for
fear that they would use the money incorrectly and be forced to pay it back later.
One administrator stated, “There wasn’t a lot of clear-cut, black and white writing
about ‘This is what you can spend it on.’” The administrator explained that the
nursing home had to purchase things such as extra dumpsters due to increased
waste, but worried that such use would “backfire” and that funds would need to be
returned. The CEO for a health center that included one of the nursing homes said
that sometimes it was even unclear whether payments were for the nursing home or
for the hospital. A few leaders reported that guidance about allowable uses improved
over time, with one saying allowable uses were not clear until reporting guidance
came out in summer 2021, prior to the first reporting deadline.
“It would have been nice to have more knowledge upfront in the terms and conditions
to know exactly what we could use it for, instead of the overhanging fear of, ‘Are we
doing this correctly?’” – Corporate Accountant
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Leaders also reported that the large amount of guidance and information, including
frequent updates, was difficult to keep up with, leading to additional uncertainty.
One leader said, “It seemed like the guidance changed so often. You weren’t really
sure. Maybe you could use it for wages, maybe not. Maybe you could only use it for
infection prevention, maybe you couldn’t. That’s where it got really difficult for us.”
Although some nursing homes found supplemental information such as FAQs useful,
one leader said that the FAQs were difficult to monitor: “Some FAQs would be there,
then they would disappear, including questions on costs. It was hard to keep up.”
Leaders sought additional information to clarify guidance but had difficulty obtaining
guidance. Some leaders said they used the helpline to seek supplemental guidance
but that it was sometimes difficult to reach a helpline operator and that some
operators knew little more about PRF than the leaders did. Leaders reported
sometimes relying on outside sources such as nursing home or health care
associations, consultants, or other experts for clarification about guidance. One
corporate leader reported gathering information from multiple sources that was then
“cobble[d] together” to determine what was allowable.
Nursing homes reported using PRF payments to address
COVID-19-related expenses and lost revenue
Leaders reported that nursing homes used or returned all funds received during the
first two periods.u, v Specifically, the 11 nursing homes reported about $12.2 million in
total PRF payments, including $4.3 million in payments targeted for nursing homes
($2.6 million in SNF payments and $1.7 million in NHIC payments) and $10,969 in
interest earned on PRF payments.
How the 11 nursing homes used funds to respond to the pandemic varied.
Four nursing homes used payments they had reported on for lost revenue and for
general or health care-related expenses, four used payments only for expenses, and
three used payments only for lost revenue. As required, the nursing homes reported
use of NHIC payments and all other payments separately. (See Exhibit 8 for a
summary of how nursing homes reported using funds.)
u At the time we began the virtual site visits, the nursing homes were only required to have used and
reported on PRF payments received during the first two periods. For that reason, we included only those
two reporting periods in this review.
v The nursing homes were required to use and report about the funds within the timeframes defined in
Exhibit 3. If the nursing homes had not met the deadlines, they would have been considered out of
compliance with PRF terms and conditions, and funds may have been recouped. See HRSA, Important
Dates for Reporting, May 2023. Accessed at https://www.hrsa.gov/provider-relief/reporting-
auditing/important-dates on May 11, 2023.
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Exhibit 8: Nursing homes used most of the PRF payments reported on,
including NHIC payments, for pandemic-related health care and
administrative expenses.
Source: OIG analysis of nursing home reports to HRSA about PRF use.
Notes: “Other Payments” includes reported use of all non-NHIC payments. HRSA required nursing homes to report
the use of NHIC payments and all other payments (including SNF payments) separately. The total of all payments in
this exhibit does not equal $12.2 million because one nursing home returned an NHIC payment.
Despite initial hesitation over broad guidance, nursing home leaders
reported the guidance allowed for discretion in using the funds to meet
facility needs. Nursing home leaders said they were conservative in using the
funds, especially early on, partly due to fear that they might have been required to
return the funds if used incorrectly. One nursing home returned a $97,000 NHIC
payment because its leaders did not feel they could use the money appropriately
during the given time period. Leaders for other nursing homes described using funds
for items that were clearly pandemic-related, such as lost revenue, staffing, PPE, or
tests. Some leaders said they later became more comfortable using the funds for
broader purposes to address specific needs. For example, one nursing home used
PRF to replace facility flooring with flooring material that was easier to disinfect as an
infection control measure. Another nursing home reported using PRF to replace its
heating, ventilation, and air conditioning system for the same reason.
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Nursing homes reported that PRF payments were integral to
maintaining services during the pandemic, but that financial
challenges were ongoing
Leaders and staff across the nursing homes reported that PRF payments
were instrumental in continuing operations and maintaining infection
control and quality of care during the pandemic. Corporate leaders noted
that the payments provided a “huge financial relief,” and had both immediate and
longer-term positive effects. Staff in one nursing home explained that their facility
was one of the last in their community to experience a COVID-19 case, and that PRF
payments played a “big part [in] keeping [COVID-19] out.” Leaders and staff also
described the long-term, positive effects of the payments, explaining that they helped
nursing homes improve infection control practices and better prepare for other
emergencies.
Nursing home leaders described how using the funds for specific expense types was
beneficial. For example, some said using the money for increased wages and pay
bonuses allowed them to retain and support staff who were working in difficult
conditions. Leaders also said they expended the money on equipment they would
not have otherwise been able to obtain, such as screening, disinfection, and air
filtration devices. Finally, leaders and staff said that using the funds for resident care
expenses, such as tablets for communicating with family members remotely, helped
nursing homes better provide services during the pandemic.
“Things were getting bad and dangerous . . . then this new money showed up that we
weren’t expecting but allowed us to address things . . . . Thank God this money came
through.” – CEO, Contracted Management Group
Sample nursing homes reported that they were unable to fully address
ongoing COVID-19-related expenses using PRF. Nursing home leaders said
that PRF payments were not sufficient to offset COVID-19-related expenses, some of
which were ongoing. One nursing home reported to HRSA that, after the first
two payment and use periods, it had hundreds of thousands of dollars remaining in
unreimbursed expenses.w We conducted interviews with that nursing home in
June 2022 after it had received hundreds of thousands of dollars of PRF more than
what had been included in the first two reports. At that point, its leaders reported
that they had used all the funds received and still had remaining COVID-19-related
w HRSA defines “unreimbursed expenses” as expenses that remain unreimbursed after considering all
assistance received by HRSA and all other sources. See HRSA, User Guide: Provider Relief Fund (PRF)
Reporting Portal—Reporting, p. 64, Dec. 30, 2022. Accessed at https://www.hrsa.gov/sites/default
/files/hrsa/provider-relief/prf-reporting-portal-user-guide.pdf on Jan. 31, 2023.
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costs that had not been reimbursed by PRF. One chief financial officer explained that
although PRF payments were adequate for addressing the nursing home’s needs at
the time received, the nursing home could not have anticipated that expenses for
contracted labor and other costs would continue to increase.
Nursing homes in our sample generally complied with PRF
reporting requirements but reported that HRSA guidance
was difficult to use
HRSA required any nursing home or other provider that received more than $10,000
in PRF payments in the aggregate during a given payment-received period to submit
reports about how the funds were used (see page 6). The form required nursing
homes to report information specific to PRF payments, including the amount
distributed to the recipient during the relevant period, any interest earned on relevant
payments, and how those PRF payments were used. Reports required information
about remaining unreimbursed expenses, and the financial and clinical care effects of
PRF payments. For example, respondents ranked the amount to which they agreed
with the statement “The PRF payment(s) had a significant impact on overall
operations,” with options ranging from “Strongly Agree” to “Strongly Disagree.” The
form also had fields for identifying the provider and for general information not
specific to PRF, such as personnel and patient metrics.
The nursing homes in our sample generally complied with
HRSA’s reporting requirements, but some misreported
or were required to resubmit information
At the time we collected our data, 9 of the 11 nursing homes in our sample had
completed reports about how they used PRF funds during the first 2 periods by the
required deadline. Two nursing homes, however, initially submitted reports
incorrectly and had to resubmit information. During the first reporting period, the
corporate office that owned the two nursing homes incorrectly reported use of the
facilities’ targeted PRF payments at the corporate level rather than at the facility level.
To resolve the error, HRSA allowed the nursing homes to resubmit the reports after
the deadline had passed.x
During our review, we observed that information the nursing homes reported to
HRSA was generally supported by underlying facility data and appeared to align with
allowable uses of the general and targeted distributions. One nursing home’s
documentation, however, appeared to show that funds it reported using for general
x The two nursing homes that incorrectly reported information during the first period were also the
facilities that had difficulty accessing the NHIC payments due to bankruptcy (see page 15). Because of
the delay in the NHIC payments, the two nursing homes received no PRF payments during the
second period and were therefore not required to submit reports for that period.
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and administrative expenses were actually used for lost revenue, which would mean
that the facility incorrectly used NHIC payments. Other nursing homes appeared to
be unable to support minor items in their reports, such as the use of small amounts of
interest earned on PRF payments or small PRF expenses. Another reported use of
funds during fiscal quarters not supported by expense-incurred dates on supporting
documentation.
Nursing home leaders found that HRSA’s reporting guidance
was difficult to use and that completing the reports was difficult
Nursing home leaders found that HRSA’s reporting guidance, like the guidance on
allowable uses, was sometimes difficult to review. An administrator at one nursing
home stated that reporting resources were not readily available and that it was
difficult to find time to review the material and complete the reports given conflicting
obligations. A chief financial officer for a chain supported that sentiment, saying that
“a 90- or 100-page manual [is] a perfect example of . . . saying, ‘Here’s your manual;
it’s here to help.’” Specific challenges included interpreting nuances about how costs
should be applied to PRF payments and classified in the reports, and difficulties
defining or calculating lost revenue.
Additionally, leaders for many of the nursing homes reported that tracking their
expenses and entering the information into the reporting portal was stressful,
time-consuming, and labor intensive. One corporate officer explained that
supplemental information, such as personnel metrics, was tedious to enter because
each statistic had to be entered manually and separately. Leaders said that the
information had to be reported by quarter, which was not explained ahead of time
and was difficult to do. An administrator at a nursing home described technical
challenges, such as the report website timing out if they stepped away for another
task. Leaders for one nursing home stated that PRF reporting amplified the burden of
what was already an “incredible” amount of other COVID-19-related data tracking and
reporting.
Some nursing homes reported having to seek supplemental guidance from the PRF
help desk or from outside organizations or accountants. A leader for one nursing
home said trying to get technical support regarding the reporting portal was difficult:
“There was not a direct line to people who actually programmed the website. We had
to run through the intermediaries assigned to make the payments, and they would
determine whether they can answer your question or not, then would transfer you to
HHS technical support . . . . It was time consuming.”
Some leaders said that reporting challenges were heightened for small or
independently owned nursing homes that did not have extra resources to devote to
PRF processes. A corporate officer for a regional nursing home chain explained,
“As what I would call a small regional operator, I can only imagine the true
mom-and-pops trying to . . . maneuver through applying for funds . . . and the
reporting . . . . We had resources to manage the process; I’m sure there’s a lot of
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people who don’t.” An administrator for a small city-owned nursing home, who was
almost solely responsible for managing PRF payments that the facility received,
stated, “I’m just dreading [submitting the next report] because it’s like a weeklong
process for me.”
HRSA developed plans to assess nursing home use of PRF
but had not yet begun auditing nursing homes at the time
we conducted our review
HRSA reported developing processes to review provider reports ongoing and
following the reporting periods, using data checks, audits, and evaluations of data.
One official reported that, as a first step of review, the PRF reporting system checks
information for inconsistencies throughout the report preparation and submittal
process. It requires a provider to address any identified errors and attest to accuracy
before submitting a report.
We collected information from HRSA about its audit plans in June and July 2022, after
the close of two reporting periods. During that time, HRSA officials reported that they
had not yet begun auditing nursing homes to assess use of PRF payments and recoup
improperly used funds. HRSA officials described the plans for conducting audits. For
each reporting period, HRSA planned to select a sample of health care facilities,
including nursing homes, to be audited according to a risk-based strategy to verify
compliance with the terms and conditions of the program and recoup any
inappropriately used funds. In summer 2022, HRSA had not yet determined the
number of providers whose reports the agency would audit or assess, but had
contracted with several entities to help with the audits and assessments.y, z
HRSA officials reported that the agency would also conduct an ongoing analysis of
providers’ reported spending, seeking to identify trends in how providers spent PRF
payments to provide services during the pandemic. One official explained that HRSA
plans to highlight the impact of the program on service provision and financial
circumstances using data pulled from report fields about the ways in which funds
allowed respondents to continue or expand operations.
Agency officials said they felt it was a weakness of the PRF program that it relied
largely on self-reported information, rather than on supporting documents or other
y In October 2023, HRSA reported to OIG that it was nearing completion of 35 audits of reporting
period 1 providers and had initiated 200 additional audits, which included 7 nursing homes, to be
completed by the end of the fiscal year 2024.
z Any nursing home that spends a total of $750,000 or more in Federal funds, including PRF payments,
during a given fiscal year is subject to Single Audit requirements in accordance with 45 CFR 75 Subpart F.
In addition to conducting its own PRF audits, HRSA is responsible for resolving single audit findings
pertaining to all HRSA programs. For more information, see HRSA, Audit Requirements, June 2023.
Accessed at https://www.hrsa.gov/provider-relief/reporting-auditing/audit-requirements on
June 26, 2023.
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Findings | 24
evidence, about how funds were used. Officials reported that they considered
requiring providers to submit documentation (e.g., receipts) but decided against it
because they thought it would be too onerous on providers. The decision to use only
self-reported information, however, makes audits and other controls more important.
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Conclusion and Recommendations | 25
CONCLUSION AND RECOMMENDATIONS
The COVID-19 pandemic has had a devastating effect on health care providers,
including hard-hit nursing homes. To help nursing homes and other health care
providers respond to the pandemic, Congress appropriated funding to HHS for PRF.
HHS quickly worked with HRSA, other HHS agencies, and other stakeholders to
develop PRF and began distributing payments to providers in April 2020.
The nursing homes in our sample reported that the nearly $15 million PRF they
received was critical for maintaining services, but many reported challenges
throughout the attestation, use, and reporting processes. Leaders also reported that
HRSA guidance on allowable uses was unclear and that reporting how they used the
funds was difficult. HRSA officials recognized difficulties related to reporting, and had
not yet begun auditing the reports at the time we conducted our review.
To address the issues identified in this report and prepare for potential future
emergencies, we recommend that HRSA:
Create a document to record lessons learned from managing
PRF and submit the document to HHS leadership
To relieve providers from the financial effects of the pandemic, HHS and HRSA had to
act quickly to develop the PRF program and begin administering payments. Nursing
homes in our sample reported that PRF payments were critical to their operations, but
that they sometimes had difficulty interacting with the program. HRSA should record
(e.g., in an after-action report or other document) its experiences and lessons learned
from its responsibilities in managing PRF. The document will serve as an accounting
of HRSA’s actions in administering these Federal funds and as a road map for future
HHS emergency funding distributions. In developing the document, HRSA should
seek feedback from nursing homes and other stakeholder groups, as appropriate, to
gain insights about how processes could be improved.
OIG is not prescriptive about the timeframe or the content to include in the
document. However, the document should be written while staff with relevant
experience are available to contribute. HRSA should consider including lessons
learned from our findings, such as potential policy or process improvements for:
•
collecting and sharing data across HHS to ensure timely and accurate funding
to providers;
•
quickly generating, updating, and communicating clear and concise program
guidance;
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Conclusion and Recommendations | 26
•
creating user-friendly reporting portals, which HHS agencies can quickly
activate in case of emergencies; and
•
developing and enacting program integrity safeguards, such as audits, for
recovering improperly used funds.
It is likely that, similar to PRF, responsibility for any future emergency funding
distributions to health care providers will be directed by HHS leadership. Following
completion, HRSA should submit the document to the HHS Office of the Secretary.
Expedite audits of provider use of PRF payments
As of mid-2023, HRSA was nearing completion of its initial audits. However, when we
conducted our data collection in mid-2022, after two reporting periods had passed,
the agency and its contractors had not yet begun auditing provider reports to assess
use. The automatic checks for inconsistencies and other efforts to pre-emptively
address issues in PRF reports likely helped ensure that the reports were complete, but
further assessment is necessary to provide proper oversight and safeguard Federal
dollars. As such, HRSA should work with urgency to assess appropriateness of PRF
use. Moving forward, the agency should work to select its samples and conduct
audits sooner after reporting period completion. Doing so will help ensure that
improperly used funds are recovered.
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Agency Comments and OIG Response | 27
AGENCY COMMENTS AND OIG RESPONSE
HRSA provided both technical and formal comments to our draft report. We have,
where appropriate, added additional context from the technical comments to this
report. In its formal comments, HRSA concurred with one recommendation and did
not concur with the other.
HRSA did not concur with our first recommendation, which was originally for it to
create an after-action report about lessons learned from managing PRF and submit
the report to HHS leadership. HRSA stated that it is unable to produce an after-action
report due to resource constraints. OIG continues to recommend that HRSA produce
a document recording its lessons learned from managing PRF and submit the
document to HHS leadership. To note, OIG is not prescriptive about the timeframe or
the content to include in the document. We revised the recommendation to make
this clear and to no longer specify that the document be an after-action report.
HRSA concurred with our second recommendation, which was for it to expedite audits
of provider use of PRF payments. HRSA reported that the agency is prioritizing its
remaining resources to expedite those audits. HRSA stated that it has defined an
audit sample for the first five reporting periods, and will complete those audits over
the next 12 months. HRSA also stated that it will initiate additional audits as the
remaining reporting periods close.
For the full text of HRSA’s comments, see the Agency Comments appendix at the end
of the report.
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Appendix A | 28
APPENDIX
Agency Comments
Following this page are the official comments from HRSA.
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Appendix A | 29
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Appendix A | 30
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Acknowledgments and Contact | 31
ACKNOWLEDGMENTS AND CONTACT
Acknowledgments
Savanna Thielbar served as the team leader for this study. Others in the Office of
Evaluation and Inspections Dallas Regional Office who conducted the study include
Sarah Lee, Emma Steyaert, and John Van Der Schans. Office of Evaluation and
Inspections headquarters staff who provided support include Chris Galvin, Althea
Hosein, and Michael Novello.
We would also like to acknowledge the contributions of other Office of Inspector
General staff, including Mandy Brooks, Miranda Fanning, Logan Kingma, Karen Lowe,
and Jennifer Wagner.
This report was prepared under the direction of Petra Nealy, Regional Inspector
General for Evaluation and Inspections in the Dallas Regional Office, and Marshall
Allen, Assistant Regional Inspector 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
Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
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About OIG | 32
ABOUT THE OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law
95-452, as amended, is to protect the integrity of the Department of Health and
Human Services (HHS) programs, as well as the health and welfare of beneficiaries
served by those programs. This statutory mission is carried out through a nationwide
network of audits, investigations, and inspections conducted by the following
operating components:
The Office of Audit Services (OAS) provides auditing services for HHS,
either by conducting audits with its own audit resources or by overseeing audit work
done by others. Audits examine the performance of HHS programs and/or its
grantees and contractors in carrying out their respective responsibilities and are
intended to provide independent assessments of HHS programs and operations.
These audits help reduce waste, abuse, and mismanagement and promote economy
and efficiency throughout HHS.
The Office of Evaluation and Inspections (OEI) conducts national
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable
information on significant issues. These evaluations focus on preventing fraud, waste,
or abuse and promoting economy, efficiency, and effectiveness of departmental
programs. To promote impact, OEI reports also present practical recommendations
for improving program operations.
The Office of Investigations (OI) conducts criminal, civil, and administrative
investigations of fraud and misconduct related to HHS programs, operations, and
beneficiaries. With investigators working in all 50 States and the District of Columbia,
OI utilizes its resources by actively coordinating with the Department of Justice and
other Federal, State, and local law enforcement authorities. The investigative efforts
of OI often lead to criminal convictions, administrative sanctions, and/or civil
monetary penalties.
The Office of Counsel to the Inspector General (OCIG) provides
general legal services to OIG, rendering advice and opinions on HHS programs and
operations and providing all legal support for OIG’s internal operations. OCIG
represents OIG in all civil and administrative fraud and abuse cases involving HHS
programs, including False Claims Act, program exclusion, and civil monetary penalty
cases. In connection with these cases, OCIG also negotiates and monitors corporate
integrity agreements. OCIG renders advisory opinions, issues compliance program
guidance, publishes fraud alerts, and provides other guidance to the health care
industry concerning the anti-kickback statute and other OIG enforcement authorities.
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Endnotes | 33
ENDNOTES
1 Government Accountability Office (GAO), Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes
Prior to COVID-19 Pandemic, GAO-20-576R, May 20, 2020.
2 Lauren Weber, “Nursing Homes Keep Losing Workers,” The Wall Street Journal, Aug. 25, 2021. Accessed at
https://www.wsj.com/articles/nursing-homes-keep-losing-workers-11629898200 on Jan. 30, 2023.
3 COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020 (OEI-02-20-00490),
June 22, 2021.
4 The $178 billion was appropriated across multiple pieces of legislation. See Coronavirus Aid, Relief, and Economic Security
(CARES) Act, P.L. No. 116-136, Division B, Title VIII, (Mar. 27, 2020); Protection Program and Health Care Enhancement
(PPPHCE) Act, P.L. No. 116-139, Division B, Title I (Apr. 24, 2020); and Consolidated Appropriations Act, 2021, P.L. No. 116-260,
Division M, Title III (Dec. 27, 2020).
5 For more information about HRSA’s administration of PRF, see HRSA, About. Accessed at https://www.hrsa.gov/provider-
relief/about/ on Jan. 31, 2023. For more information about related programs, see footnotes e and f on page 4 of this report.
6 HRSA, Past General Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-relief/past-
payments/general-distribution on Dec. 16, 2022.
7 HRSA, Past Targeted Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 12, 2022.
8 HRSA, Provider Relief. Accessed at https://www.hrsa.gov/provider-relief on June 7, 2023.
9 CDC, People Who Live in a Nursing Home or Long-Term Care Facility. Accessed at https://stacks.cdc.gov/view/cdc/89837
on Oct. 10, 2023.
10 CMS, COVID-19 Nursing Home Data. Accessed at https://data.cms.gov/covid-19/covid-19-nursing-home-data
on Jan. 13, 2023.
11 COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020 (OEI-02-20-00490),
June 22, 2021.
12 GAO, Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic,
GAO-20-576R, May 20, 2020.
13 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), Jan. 19, 2023.
14 Lenny Bernstein and Alauna Safarpour, “Mask shortage for most health-care workers extended into May, Post-Ipsos poll
shows,” The Washington Post, May 20, 2020. Accessed at https://www.washingtonpost.com/health/mask-shortage-for-most-
health-care-workers-extended-into-may-post-ipsos-poll-shows/2020/05/20/1ddbe588-9a21-11ea-ac72-
3841fcc9b35f_story.html on Jan. 30, 2023.
15 Lauren Weber, “Nursing Homes Keep Losing Workers,” The Wall Street Journal, Aug. 25, 2021. Accessed at
https://www.wsj.com/articles/nursing-homes-keep-losing-workers-11629898200 on Jan. 30, 2023.
16 AHCA and NCAL press release, “Survey: 94 Percent of Nursing Homes Face Staffing Shortages,” June 23, 2021. Accessed at
https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Survey-94-Percent-of-Nursing-Homes-Face-
Staffing-Shortages.aspx on Jan. 30, 2023.
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17 AHCA and NCAL press release, “Nursing Homes Face Closures Due to Long-Standing Financial Challenges Exacerbated by
The Pandemic,” Mar. 11, 2021. Accessed at https://www.ahcancal.org/News-and-Communications/Press-
Releases/Pages/Nursing-Homes-Face-Closures-Due-To-Long-Standing-Financial-Challenges-Exacerbated-By-The-
Pandemic.aspx on Jan. 30, 2023.
18 Danielle Brown, “Only 25 percent of operators believe they’ll survive financially through 2021,” McKnight’s Long-Term Care
News, June 30, 2021. Accessed at https://www.mcknights.com/news/only-25-of-operators-believe-theyll-survive-financially-
through-2021/ on Jan. 30, 2023.
19 HRSA publicly reports amounts distributed through each PRF distribution, which total $136.6 billion. See HRSA, Past
General Distributions, November 2022, accessed at https://www.hrsa.gov/provider-relief/payments-and-data/past-
payments/general-distribution on Dec. 16, 2022; HRSA, Phase 4 and ARP Rural Distributions, September 2023, accessed at
https://www.hrsa.gov/provider-relief/payments-and-data/phase4-arp on Sept. 18, 2023; and HRSA, Past Targeted
Distributions, November 2022, accessed at https://www.hrsa.gov/provider-relief/payments-and-data/past-
payments/targeted-distribution on Dec. 16, 2022.
20 HRSA, Past General Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-relief/past-
payments/general-distribution on Dec. 16, 2022.
21 HRSA, Past Targeted Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022.
22 HRSA, Past General Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-relief/past-
payments/general-distribution on Dec. 16, 2022.
23 HRSA, Phase 4 and ARP Rural Distributions, September 2023. Accessed https://www.hrsa.gov/provider-relief/payments-
and-data/phase4-arp on Sept. 18, 2023.
24 HRSA, Past Targeted Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022.
25 HRSA, Provider Relief. Accessed at https://www.hrsa.gov/provider-relief on June 7, 2023.
26 HRSA, About HRSA. Accessed at https://www.hrsa.gov/about on Jan. 30, 2023.
27 HRSA, Coronavirus (COVID-19) Information. Accessed at https://www.hrsa.gov/coronavirus on Dec. 28, 2022.
28 HRSA, Mission, Work, and Impact, January 2023. Accessed at https://nhsc.hrsa.gov/about-us on June 26, 2023.
29 HRSA, Local Community-Based Workforce to Increase COVID-19 Vaccine Access. Accessed at
https://www.hrsa.gov/grants/find-funding/HRSA-21-140 on June 26, 2023.
30 HRSA, Application Review Process, October 2021. Accessed at https://www.hrsa.gov/provider-relief/future-
payments/phase-4-arp-rural/review-process on Jan. 30, 2023.
31 HRSA, User Guide—Registration, Provider Relief Fund Reporting Portal, Dec. 30, 2022. Accessed at
https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/prf-reporting-portal-registration-user-guide.pdf on Jan. 30, 2023.
32 HRSA, Bureaus & Offices. Accessed at https://www.hrsa.gov/about/organization/bureaus on Jan. 31, 2023.
33 HHS’s and HRSA’s Controls Related to Selected Provider Relief Fund Program Requirements Could Be Improved
(A-09-21-06001), Sept. 26, 2022.
34 HRSA, Provider Relief Fund Phase 4 General Distribution and American Rescue Plan Rural Payments, Sept. 30, 2021, p. 17.
Accessed at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/phase4-rural-webcast-09302021.pdf on
Jan. 31, 2023.
35 Alia Paavola, “HHS taps 4 firms to audit provider relief fund grants,” Becker’s Hospital CFO Report, Sept. 10, 2021. Accessed
at https://www.beckershospitalreview.com/finance/hhs-taps-4-firms-to-audit-provider-relief-fund-grants.html
on Jan. 31, 2023.
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36 HRSA, Past Targeted Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022.
37 CMS, Medicare Coverage of Skilled Nursing Facility Care, July 2019. Accessed at
https://www.medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf on Jan. 31, 2023.
38 HRSA, Past Targeted Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022.
39 HRSA, Acceptance of Terms and Conditions—Skilled Nursing Facility Relief Fund Payment Terms and Conditions. Accessed
at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/terms-conditions-skilled-nursing-facility-relief-fund.pdf
on Jan. 31, 2023.
40 HRSA, Past Targeted Distributions, November 2022. Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022.
41 HRSA, Acceptance of Terms and Conditions—Skilled Nursing Facility and Nursing Home Infection Control Relief Fund
Payment Terms and Conditions. Accessed at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/provider-relief-
fund-nf-infection-control-payment-terms-conditions.pdf on Jan. 31, 2023.
42 HRSA, About. Accessed at https://www.hrsa.gov/provider-relief/about/ on Jan. 31, 2023.
43 HRSA, Acceptance of Terms and Conditions—Skilled Nursing Facility Relief Fund Payment Terms and Conditions. Accessed
at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/terms-conditions-skilled-nursing-facility-relief-fund.pdf
on Jan. 31, 2023.
44 HRSA, Acceptance of Terms and Conditions—Skilled Nursing Facility and Nursing Home Infection Control Relief Fund
Payment Terms and Conditions. Accessed at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/provider-relief-
fund-nf-infection-control-payment-terms-conditions.pdf on Jan. 31, 2023.
45 HRSA, Important Dates for Reporting, May 2023. Accessed at https://www.hrsa.gov/provider-relief/reporting-
auditing/important-dates on May 11, 2023.
46 HRSA, User Guide: Provider Relief Fund (PRF) Reporting Portal—Reporting, Dec. 30, 2022. Accessed at
https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/prf-reporting-portal-user-guide.pdf on Jan. 31, 2023.
47 HRSA, Important Dates for Reporting, May 2023. Accessed at https://www.hrsa.gov/provider-relief/reporting-
auditing/important-dates on May 11, 2023.
48 COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020 (OEI-02-20-00490),
June 22, 2021.
49 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), Jan. 19, 2023.
50 Targeted Provider Relief Funds Allocated to Hospitals Had Some Differences With Respect to the Ethnicity and Race of
Populations Served (OEI-05-20-00580), July 12, 2023.
51 OIG Work Plan, Meeting the Challenges Presented by COVID-19: Nursing Homes (OEI-02-20-00492).
52 HHS's Oversight of Automatic Provider Relief Fund Payments Was Generally Effective but Improvements Could Be Made
(A-02-20-01025), Oct. 30, 2023.
53 OIG Work Plan, Audit of CARES Act Provider Relief Funds—Payments to Health Care Providers That Applied for General
Distribution Under Phases 1, 2, and 3 (W-00-21-35873).
54 HHS’s and HRSA’s Controls Related to Selected Provider Relief Fund Program Requirements Could Be Improved
(A-09-21-06001), Sept. 26, 2022.
55 OIG Work Plan, Hospital’s Compliance With the Provider Relief Fund Balance Billing Requirements for Out-of-Network
Patients (W-00-22-35878).
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56 OIG Work Plan, Audit of CARES Act Provider Relief Funds: General and Targeted Distributions to Providers (W-00-20-35855).
57 PRAC, Tracking Pandemic Relief Funds that Went to Local Communities Reveals Persistent Data Gaps and Data Reliability
Issues, July 2023.
58 HHS’s and HRSA’s Controls Related to Selected Provider Relief Fund Program Requirements Could Be Improved
(A-09-21-06001), Sept. 26, 2022.