United States Government Accountability Office Testimony Before the Committee on Finance, U.S. Senate COVID-19 IN NURSING For Release on Delivery Expected at 10:00 a.m. ET Wednesday, March 17, 2021 HOMES HHS Has Taken Steps in Response to Pandemic, but Several GAO Recommendations Have Not Been Implemented Statement of John E. Dicken, Director, Health Care GAO-21-402T March 2021 COVID-19 IN NURSING HOMES HHS Has Taken Steps in Response to Pandemic, but Several GAO Recommendations Have Not Been Highlights of GAO-21-402T, a testimony Implemented before the Committee on Finance, U.S. Senate. Why GAO Did This Study What GAO Found The COVID-19 pandemic has had a GAO’s review of data from the Centers for Disease Control and Prevention disproportionate impact on the 1.4 (CDC) found that winter 2020 was marked by a significant surge in the number of million elderly or disabled residents in COVID-19 cases and deaths in nursing homes. However, CDC data as of the nation’s more than 15,000 February 2021, show that both cases and deaths have declined by more than 80 Medicare- and Medicaid-certified percent since their peaks in December 2020. With the introduction of vaccines, nursing homes, who are often in frail observers are hopeful that nursing homes may be beginning to see a reprieve. health and living in close proximity to Nevertheless, the emergence of more highly transmissible virus variants one another. HHS, primarily through warrants the need for continued vigilance, according to public health officials. CMS and CDC, has led the pandemic response in nursing homes. GAO’s prior work has found that nursing homes have faced many difficult challenges battling COVID-19. While challenges related to staffing shortages The CARES Act includes a provision have persisted through the pandemic, challenges related to obtaining Personal for GAO to conduct monitoring and Protective Equipment (PPE) and conducting COVID-19 tests—although still oversight of the federal government’s notable—have generally shown signs of improvement since summer 2020. efforts to prepare for, respond to, and Further, with the decline in nursing homes cases, the Centers for Medicare and recover from the COVID-19 pandemic. Medicaid Services (CMS) updated its guidance in March 2021 to expand resident GAO has examined the government’s visitation, an issue that has been an ongoing challenge during the pandemic. response to COVID-19 in nursing Some new challenges have also emerged as vaccinations began in nursing homes through its CARES Act homes, such as reluctance among some staff to receive a COVID-19 vaccine. reporting (GAO-21-265, GAO-21-191, GAO-20-701, and GAO-20-625). The Department of Health and Human Services (HHS), primarily through CMS This testimony will summarize the and the CDC, has taken steps to address COVID-19 in nursing homes. However, findings from these reports. HHS has not implemented several relevant GAO recommendations, including: Specifically, it describes COVID-19 trends in nursing homes and their • HHS has not implemented GAO’s recommendation related to the Nursing experiences responding to the Home Commission report, which assessed the response to COVID-19 in pandemic, and HHS’s response to the nursing homes. CMS released the Nursing Home Commission’s report and pandemic in nursing homes. recommendations in September 2020. When the report was released, CMS broadly outlined the actions the agency had taken, but the agency did not To conduct this previously reported provide a plan that would allow it to track its progress. GAO recommended in work, GAO reviewed CDC data, November 2020 that HHS develop an implementation plan. As of February agency guidance, and other relevant 2021, this recommendation had not been implemented. information on HHS’s response to the COVID-19 pandemic. GAO interviewed • HHS has not implemented GAO’s recommendation to fill COVID-19 data agency officials and other voids. CMS required nursing homes to begin reporting the number of cases knowledgeable stakeholders. In and deaths to the agency effective May 8, 2020. However, CMS made the addition, GAO supplemented this information with updated data from reporting of the data prior to this date optional. GAO recommended in CDC on COVID-19 cases and deaths September 2020 that HHS develop a strategy to capture more complete reported by nursing homes as of COVID-19 data in nursing homes retroactively back to January 1, 2020. As of February 2021. February 2021, this recommendation had not been implemented. Implementing GAO’s recommendations could help address some of the challenges nursing homes continue to face and fill important gaps in the federal government’s understanding of, and transparency around, data on COVID-19 in nursing homes. In addition to monitoring HHS’s implementation of past View GAO-21-402T. For more information, contact John E. Dicken at (202) 512-7114 or recommendations, GAO has ongoing work related to COVID-19 outbreaks in dickenj@gao.gov. nursing homes and CMS’s oversight of infection control and emergency preparedness. United States Government Accountability Office Letter Letter Chairman Wyden, Ranking Member Crapo, and Members of the Committee: I am pleased to be here today to discuss our work on Coronavirus Disease 2019 (COVID-19) in nursing homes. Just over a year ago, a Washington State nursing home was battling one of the first major COVID-19 outbreaks in the United States. Today, the COVID-19 pandemic has reached nearly all of the more than 15,000 Medicare- and Medicaid-certified nursing homes in the country, resulting in a disproportionately high number of COVID-19 deaths among residents. While the nation’s 1.4 million nursing home residents are a small share of the total U.S. population (less than 1 percent), they comprise nearly 30 percent of COVID-19 deaths reported by the Centers for Disease Control and Prevention (CDC). Nursing home residents are at a high risk for COVID-19 infection and death because the virus has a high mortality rate among elderly adults and those with underlying health conditions. In addition, the congregate nature of nursing homes, with staff caring for multiple residents and shared communal spaces, as well as high incidence rates in the surrounding community, can increase the risk that COVID-19 will enter the home and easily spread. Further, efforts to reduce the spread of COVID-19 in nursing homes have required changes in typical nursing home practices—such as restricting visitors and isolating residents exposed to COVID-19—raising concerns for vulnerable residents, who may have less social interaction and third party oversight of their care. The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), is responsible for ensuring that nursing homes meet federal quality standards to participate in the Medicare and Medicaid programs. 1 In response to the pandemic, HHS, primarily through CMS and CDC, has taken a series of actions with nursing homes, such as providing guidance, developing targeted inspections to improve infection control practices, and distributing testing 1To monitor compliance with these standards, CMS enters into agreements with state survey agencies in each state government to conduct inspections, including recurring comprehensive standard surveys and as-needed investigations. CMS’s Center for Clinical Standards and Quality has responsibility for overseeing state survey agencies’ survey and certification activities, among others. Page 1 GAO-21-402T devices to homes. 2 In addition, in May 2020, CDC began collecting weekly COVID-19 data from nursing homes through its National Healthcare Safety Network system. The CARES Act includes a provision for us to conduct monitoring and oversight of the federal government’s efforts to prepare for, respond to, and recover from the COVID-19 pandemic. 3 In response to the CARES Act, we have examined the response to COVID-19 in nursing homes in four reports since June 2020. To help inform today’s discussion, my testimony will summarize our findings on nursing home issues from these reports. 4 In particular, my statement will address: 1. COVID-19 trends in nursing homes and their experiences responding to the COVID-19 pandemic, and 2. HHS’s response to the COVID-19 pandemic in nursing homes. In addition, I will highlight key actions that we recommended HHS take and the current status of those recommendations. While my comments today focus on the findings of our CARES Act reports, they are also informed by our longer-term body of work examining nursing home oversight and quality prior to the pandemic. To conduct the work for the previously issued reports on which my comments are based, we reviewed CDC data, agency guidance, and other relevant information on HHS’s response to the COVID-19 pandemic. We interviewed agency officials, as well as researchers with experience in infection control, advocates for individuals residing in nursing homes and their families, national associations representing nursing homes, and representatives from associations representing state and local officials. More detailed information on our methodology can be 2In our May 2020 report, we found that infection control deficiencies were widespread and persistent in nursing homes in the years prior to the COVID-19 pandemic. See GAO, Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic, GAO-20-576R, (Washington, D.C.: May 20, 2020). 3Pub. L. No. 116-139, § 19010(b), 134 Stat. 281, 579 (2020). 4See GAO, COVID-19: Critical Vaccine Distribution, Supply Chain, Program Integrity, and Other Challenges Require Focused Federal Attention, GAO-21-265, (Washington, D.C.: Jan. 28, 2021); COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal Response, GAO-21-191, (Washington, D.C.: Nov. 30, 2020);COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted Actions, GAO-20-701, (Washington, D.C.: Sept. 21, 2020); and COVID-19: Opportunities to Improve Federal Response and Recovery Efforts, GAO-20-625, (Washington, D.C.: June 25, 2020). Page 2 GAO-21-402T found in the issued reports. 5 In addition, we supplemented this information with updated data from CDC on COVID-19 reported by nursing homes for the week ending February 7, 2021. 6 We analyzed the CDC data as they were reported by nursing homes to CDC and publicly posted by CMS. We did not otherwise independently verify the accuracy of the information with these nursing homes. We assessed the reliability of the data sets used in our analyses by checking for missing values and obvious errors and reviewing relevant CMS and CDC documents. We determined the data were sufficiently reliable for the purposes of our reporting objective. We conducted the work on which this statement is based in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. 5For example, see GAO-21-265. 6We analyzed the most recent data available on February 18, 2021. The CDC data on COVID-19 in nursing homes were accessed on February 18, 2021, for the week ending February 7, 2021, from https://data.cms.gov/Covid19-nursing-home-data. For the data on COVID-19 in nursing homes, we analyzed and reported data that had been determined by CDC and CMS to pass quality assurance checks for data entry errors. According to CDC, data used in this analysis are part of a live data set, meaning that facilities can make corrections to the data at any time. Page 3 GAO-21-402T Nursing Home COVID-19 Cases and Deaths Are Declining after Winter Surge; Persistent Challenges Remain in Pandemic Response After a Winter Surge, CDC Our analysis of CDC data shows that winter 2020 was marked by a Data Show a Decline in significant surge in the number of COVID-19 cases and deaths for nursing home residents and staff. Specifically, during mid-December COVID-19 Cases and 2020, there were more than 33,600 new resident cases and 28,600 new Deaths among Nursing staff cases, which was more than twice as high as the prior case number Home Residents and Staff peaks in summer 2020. CDC data show that cases and deaths in nursing to Levels Closer to Those homes are on the decline. Specifically, as of the week ending February 7, of Fall 2020 2021, resident and staff cases have both declined by more than 80 percent since their peaks in December 2020. The changing weekly COVID-19 death counts in nursing homes generally moved in the same direction as changes in the country as a whole. With the introduction of vaccines, observers are hopeful that nursing homes may be beginning to see a reprieve; however, the emergence of more highly transmissible virus variants warrants the need for continued vigilance, according to public health officials. 7 (See fig. 1). 7These numbers are likely underreported because they do not include data for the 998 nursing homes (6.5 percent) that did not report COVID-19 data to CDC for the week ending February 7, 2021, or that submitted data that failed data quality assurance checks. The week ending May 31, 2020, is the first single week of data reported to CDC. The week ending May 24 is the only earlier week of data, and could potentially include cases and deaths for multiple weeks dating back to January 1, 2020, for those homes which voluntarily reported such data. It is therefore not comparable with data for other weeks, and we excluded it. According to CDC, data used in this analysis are part of a live data set, meaning that facilities can make corrections to the data at any time. Page 4 GAO-21-402T Figure 1: New Weekly Confirmed COVID-19 Cases and Deaths among U.S. Nursing Home Residents and Staff, as Reported by Medicare- and Medicaid-Certified Nursing Homes, May 31, 2020, through Feb 7, 2021 Notes: Dates refer to the end of a week (e.g., May 31 refers to the entire week from May 25 through May 31). Page 5 GAO-21-402T According to CDC, data used in this analysis are part of a live data set, meaning that facilities can make corrections to the data at any time. Data presented reflect the data downloaded as of February 18, 2021, which includes data through the week ending February 7, 2021. We excluded data for the week ending May 24, 2020, because it is the first week for which data are available from the CDC and could include cases and deaths from multiple weeks dating back to January 1, 2020. Weekly and cumulative case and death counts are likely underreported because they do not include data for the nursing homes that did not report COVID-19 data to CDC for that week or from nursing homes that submitted data that failed data quality assurance checks. Additionally, as we previously reported, the Centers for Medicare & Medicaid Services (CMS) does not require nursing homes to report data prior to May 2020, although nursing homes may do so voluntarily. We recommended that the Secretary of Health and Human Services—in consultation with CMS and CDC—develop a strategy to capture more complete data on confirmed COVID-19 cases and deaths in nursing homes retroactively to January 1, 2020. See GAO, COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted Actions, GAO-20-701, (Washington, D.C.: Sept. 21, 2020). Weekly staff deaths reported for the weeks ending May 31 through February 7 ranged from 13 (week ending September 20, 2020) to 61 (week ending May 31, 2020). Some Challenges Nursing In our prior CARES Act reports, we found that nursing homes have faced Homes Faced Persisted many difficult challenges battling COVID-19. 8 While challenges related to While Other New staffing shortages have persisted through the pandemic, challenges related to obtaining Personal Protective Equipment (PPE) and conducting Challenges Have COVID-19 tests—although still notable—have generally shown signs of Emerged improvement since summer 2020. Further, with the decline in nursing home cases, CMS updated its guidance in March 2021 to expand resident visitation, an issue that has been an ongoing and persistent challenge during the pandemic. Some new challenges have also emerged as vaccinations started for nursing home residents and staff. (See table 1). Some of these challenges, such as staffing shortages, obtaining PPE, and conducting testing, are critically important for infection control. Table 1: Key Pandemic Challenges Experienced by Nursing Homes Challenge Description Status Visitation Through interviews with researchers, advocacy organizations, and national Challenge has persisted association officials from July 2020 to February 2021, we consistently heard throughout pandemic that nursing homes have faced an ongoing tension between providing residents with important visitation and minimizing the potential for a COVID-19 outbreak: • The restriction of visitors has negatively affected residents’ mental and physical health. Researchers and advocacy organizations have noted that the isolation resulting from decreased visitation can cause loneliness, anxiety, and depression among residents. • The restriction of visitors has created limited oversight of facilities through the exclusion of resident advocates, such as family members and ombudsmen. 8See GAO-20-701; GAO-21-265; GAO-21-191; and GAO-20-625. Page 6 GAO-21-402T Challenge Description Status Staffing In our reviews of data from the Centers for Disease Control and Prevention Challenge has persisted (CDC) and interviews with advocacy organization and national association throughout pandemic officials from July 2020 through January 2021, we consistently found that nursing home staffing challenges were difficult and ongoing throughout the pandemic: • CDC data from July through December 2020 consistently show that about one in five nursing homes were reporting to CDC that they had a shortage of nurse aides or other support staff.a • From nursing home associations we interviewed, we heard that many alternative staffing sources have been used to fill critical gaps, such as seeking help from staffing agencies, sharing staff between other local providers, and using emergency waivers to hire nurse aides who had yet to complete their certification. As of January 2021, we continued to hear that staff are exhausted, face burn-out from emotional trauma, need to quarantine due to exposure to or illness from the virus, or stay home to take care of family members—all of which further strains staffing resources. Personal Protective According to our reviews of data from the CDC and interviews with advocacy Challenge has generally Equipment (PPE) organization and national association officials from July 2020 to January shown improvement 2021, shortages of PPE in nursing homes have improved since the beginning of the COVID-19 pandemic but remain an issue: • CDC data show that, as recently as December 2020, about 10 percent of nursing homes did not have a one-week supply of at least one of the following: N95 respirators, surgical masks, gloves, eye protection, or gowns (a decrease from about 22 percent of nursing homes in July 2020). • In interviews with advocacy organizations and national association officials from July 2020 to January 2021, we heard that, while challenges maintaining PPE supplies in reserve is an ongoing concern, supply shortages have become less severe over time. Testing According to our reviews of CDC data and interviews with a researcher and Challenge has generally with nursing home association officials in November 2020 and January 2021, shown improvement nursing homes’ ability to use testing to identify infected residents and staff through testing protocols has improved over the course of the pandemic, but at a high cost to nursing homes: • Nursing homes have reported to CDC improved testing capacity. Specifically, the number of nursing homes testing for COVID-19 in both staff and residents has increased by 48 percentage points—from 35 to 83 percent—between August 16, 2020, and November 22, 2020, the last week complete data for overall testing were available. • Although data reported in December 2020 by nursing homes found that less than 2 percent of nursing homes would be unable to test all staff or residents within the week if needed, nursing home association officials note that the high cost of continuous testing is not sustainable indefinitely. Page 7 GAO-21-402T Challenge Description Status Vaccinations According to our reviews of a CDC analysis of vaccination data and interviews Emerging challenge with nursing home and state and local government officials, nursing homes face some emerging challenges related to vaccinations: • A February 2021 CDC study estimated low rates of vaccine uptake among nursing home staff (38 percent) compared to nursing home residents (78 percent) participating in the Pharmacy Partnership for Long- Term Care Program.b • In interviews with nursing home and state and local government association officials since the vaccines were first administered in December 2020, we heard about reluctance among some nursing home staff to receive the COVID-19 vaccine, in addition to hearing about uncertainty around certain aspects of vaccination distribution and requirements earlier in the year. Source: GAO review of CDC data and interviews. | GAO-21-402T a According to CDC’s data documentation, other support staff may include certified nursing assistants, medication aides, and medication technicians as reported to CDC by the provider. b R. Gharpure, et al., “Early COVID-19 First-Dose Vaccination Coverage Among Residents and Staff Members of Skilled Nursing Facilities Participating in the Pharmacy Partnership for Long-Term Care Program—United States, December 2020-January 2021,” Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, vol. 70, no. 5 (2021): 178-182. Our prior CARES Act reports have described how HHS, primarily through HHS Has Taken CMS and CDC, has taken a series of actions to address COVID-19 in Steps in Response to nursing homes, such as providing guidance to nursing homes on infection control practices and issuing waivers and regulatory flexibilities. 9 COVID-19, but Examples of other actions include: Several Relevant Temporarily suspending state survey agencies’ standard surveys and GAO • many complaint investigations, instead shifting to targeted infection Recommendations Have Not Been Implemented 9For example, in March 2020 CMS waived the requirement that a nursing home not employ nurse aides for more than 4 months unless they meet certain training and certification requirements. This was done to address potential staffing shortages in nursing homes due to the COVID-19 pandemic. Page 8 GAO-21-402T prevention and control surveys and high-priority complaint investigations. 10 • Creating a new reporting requirement for nursing homes to report weekly COVID-19 cases and deaths for residents and staff as of May 8, 2020. • Distributing antigen diagnostic tests and associated point-of-care testing instruments to nursing homes. • Distributing billions of dollars in payments from the Provider Relief Fund, established with funds provided under the CARES Act and other COVID-19 relief laws, as direct payments to assist nursing homes with responding to COVID-19. 11 • Convening the Coronavirus Commission on Safety and Quality in Nursing Homes (the Nursing Home Commission) in June 2020, which was tasked with assessing the response to the COVID-19 pandemic in nursing homes and made recommendations for additional actions CMS could take. • Establishing the Pharmacy Partnership for Long-Term Care Program in October 2020, an agreement with CVS, Walgreens, and Managed Health Care Associates Inc. to provide and administer COVID-19 vaccines to residents of long-term care facilities, including nursing homes. • Directing nursing homes to expand resident visitation beginning in March 2021, after previously restricting visitors and non-essential health care personnel in nursing homes, except in certain 10On June 1, CMS issued survey re-prioritization guidance as part of its nursing home reopening strategy. Specifically, once a state enters phase 3—a threshold based on factors including case status in the community and the nursing home, as well as access to testing, PPE, and adequate staffing—state survey agencies were authorized to expand beyond conducting targeted infection control surveys and high-priority complaint investigations to include lower-priority complaint investigations. See Centers for Medicare & Medicaid Services, “COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control Deficiencies, and Quality Improvement Activities in Nursing Homes,” QSO-20-31-ALL, (Baltimore, Md.: June 1, 2020). On August 17, CMS revised this guidance to authorize traditional, comprehensive, standard surveys and lower- priority complaint investigations as soon as state survey agencies have the resources, such as staff and PPE. See Centers for Medicare & Medicaid Services, “Enforcement Cases Held During the Prioritization Period and Revised Survey Prioritization,” QSO-20- 35-ALL, (Baltimore, Md.: Aug. 17, 2020). 11As of January 15, 2021, $5 billion in Provider Relief Funds had been allocated for nursing homes and $4.764 billion had been disbursed. Page 9 GAO-21-402T compassionate care situations, to reduce the transmission of COVID- 19. 12 However, HHS has not implemented several of our recommendations that could help the agency address some of the challenges nursing homes have faced and fill important voids in the federal government’s understanding of, and transparency around, data on COVID-19 in nursing homes. (See app. I for a description of related GAO reports and the status of their recommendations.) • HHS has not implemented our recommendation related to the Nursing Home Commission report. CMS released the Nursing Home Commission’s final report in September 2020, which includes 27 recommendations organized under 10 themes—such as Testing and Screening, Equipment and PPE, Workforce (staffing), and Visitation—that are paired with over 100 specific action steps for CMS. 13 CMS released a response to the report broadly outlining the actions the agency has taken to date as part of its response to the COVID-19 pandemic, but the agency did not provide an implementation plan that would allow it to track and report progress toward the Commission’s recommendations. We recommended in November 2020 that the Administrator of CMS quickly develop a plan that further details how the agency intends to respond to and implement, as appropriate, the 27 recommendations in the final report of the Coronavirus Commission on Safety and Quality in Nursing Homes. HHS neither agreed nor disagreed with our recommendation; instead, it highlighted actions CMS has taken related to Commission recommendations and indicated that it would refer to and act upon the Nursing Home Commission’s recommendations as appropriate. CMS reiterated this position in February 2021. • HHS has not implemented our recommendation to fill COVID-19 data voids. HHS, through CMS, implemented a COVID-19 reporting requirement for nursing homes effective May 8, 2020 (noted briefly 12CMS restricted visitors and non-essential health care personnel in nursing homes from March through September 2020. In September 2020, CMS issued guidance that allowed for nursing homes to resume visitations depending on certain factors. 13MITRE, Coronavirus Commission on Safety and Quality in Nursing Homes: Commission Final Report, PRS Release Number 20-2382, September 2020. Page 10 GAO-21-402T above). 14 CMS made the reporting of the data prior to May 8, 2020, optional. As a result, CMS’s data do not capture the early months of the pandemic. 15 We recommended in September 2020 that the Secretary of HHS, in consultation with CMS and CDC, develop a strategy to capture more complete data on confirmed COVID-19 cases and deaths in nursing homes retroactively back to January 1, 2020, and clarify the extent to which nursing homes had reported data before May 8, 2020. 16 Although HHS partially agreed with this recommendation and indicated that it continues to consider how to implement this recommendation, the agency had taken no specific actions, as of February 2021. We maintain the importance of our recommendations. Specifically, we maintain that developing a plan for whether CMS will proceed with the Nursing Home Commission’s recommendations and, if so, how it will do so would improve the agency’s ability to systematically consider the Nursing Home Commission’s recommendations going forward. We also maintain that collecting data on COVID-19 cases and deaths from nursing homes retroactively would better inform the government’s continued response to, and recovery from, the COVID-19 pandemic, and we maintain that HHS could ease the burden by incorporating data previously reported to CDC or to state or local public health offices. We also have recommendations from work completed prior to the pandemic that have yet to be fully implemented by CMS. Implementation of these recommendations could improve HHS’s oversight of nursing homes both generally and during a pandemic. For example, in our 2019 report on abuse in nursing homes, we made six recommendations, including recommending that CMS require state survey agencies to 1485 Fed. Reg. 27,550, 27,627 (May 8, 2020) (to be codified at 42 C.F.R. § 483.80(g)). CMS is responsible for ensuring that nursing homes meet federal quality standards to participate in the Medicare and Medicaid programs. 15Nursing homes are required to self-report data regarding COVID-19 cases and deaths among residents and staff, PPE supplies, and staffing shortages, among other things, at least weekly through CDC’s National Healthcare Safety Network. 16Also in September 2020, GAO identified gaps in COVID-19 data for racial and ethnic minority groups, and, among other things, recommended that CDC take steps to help ensure its ability to comprehensively assess the long-term health outcomes of persons with COVID-19, including by race and ethnicity. HHS agreed with the recommendation and as of February 2021, CDC is reviewing the quality of the demographic data and assessing potential opportunities to enhance the collection of race and ethnicity data. Page 11 GAO-21-402T immediately notify law enforcement of any reasonable suspicion of a crime against a resident, and that CMS provide more guidance to state survey agencies on the information nursing homes should include on facility-reported incidents. CMS agreed with our recommendations. 17 These recommendations have relevance prior to, during, and after the COVID-19 pandemic, because with reduced visitors or ombudsmen presence in nursing homes, and with the decrease or elimination of surveyor presence, there may be a higher risk of residents being abused and of that abuse going unreported. 18 This risk is higher than it needs to be because CMS has not yet implemented our relevant recommendations. In addition to monitoring HHS’s implementation of past recommendations, we have ongoing work examining COVID-19 outbreaks in nursing homes, as well as CMS’s oversight of infection prevention and control protocols and the adequacy of emergency preparedness standards for emerging infectious diseases in nursing homes. In summary, the COVID-19 pandemic has underscored the importance of issues we have previously raised about nursing home quality and oversight while pointing to new vulnerabilities unique to the pandemic. Effective federal oversight and support for nursing homes are especially critical during times of widespread disease outbreak, as the pandemic has demonstrated. As nursing homes are prioritized for vaccination, there is hope that COVID-19 cases and deaths in these homes will continue to decline. Going forward, our work on COVID-19 in nursing homes remains important for informing future pandemic responses, as well as for addressing longer-standing challenges that have put residents’ health and safety at risk, as indicated by our prior recommendations. Chairman Wyden, Ranking Member Crapo, and Members of the Committee, this concludes my prepared statement. I would be pleased to respond to any questions that you may have at this time. 17See GAO, Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse. GAO-19-433. (Washington, D.C.: June 13, 2019). 18State surveyors evaluate nursing homes’ compliance with federal quality standards. Page 12 GAO-21-402T If you or your staff have any questions about this testimony, please GAO Contact and contact John E. Dicken, Director, Health Care at (202) 512-7114 or Staff dickenj@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this Acknowledgments statement. GAO staff who made key contributions to this testimony were Karin Wallestad (Assistant Director), Sarah-Lynn McGrath (Analyst-in- Charge), Isabella Guyott, Erin Henderson, Julianne Flowers, Elise Pressma, and Kathryn Richter. Also contributing were Laurie Pachter, Vikki Porter, and Jennifer Whitworth. Page 13 GAO-21-402T Appendix I: Description of Selected GAO Appendix I: Description of Selected GAO Reports on Nursing Homes with Reports on Nursing Homes with Recommendations Recommendations The following table summarizes the status of relevant recommendations from GAO’s prior reports on nursing home oversight with the status as of the most recent detailed update. According to the Centers for Medicare & Medicaid Services (CMS), as of March 2021, there are no additional updates on the status of these recommendations, as the agency’s focus has been on responding to the pandemic. Table 1: Description of Selected GAO Reports on Nursing Homes with Recommendations, April 2011 through November 2020 Date Title Summary of recommendations November 2020 COVID-19: Urgent Actions Needed to Better GAO made one recommendation related to nursing homes Ensure an Effective Federal Response that the Centers for Medicare & Medicaid Services (CMS) (GAO-21-191) should quickly develop a plan that further details how the agency intends to respond to and implement, as appropriate, the 27 recommendations in the final report of the Coronavirus Commission on Safety and Quality in Nursing Homes, which CMS released on September 16, 2020. The Department of Health and Human Services (HHS) neither agreed nor disagreed with our recommendation and, as of February 2021, HHS/CMS had not implemented this recommendation. September 2020 COVID-19: Federal Efforts Could Be GAO made one recommendation related to nursing homes Strengthened by Timely and Concerted Actions that HHS, in consultation with CMS and the Centers for (GAO-20-701) Disease Control and Prevention (CDC), develop a strategy to capture more complete data on confirmed COVID-19 cases and deaths in nursing homes retroactively to January 1, 2020, in order to address gaps in the new reporting requirements on COVID-19 cases and deaths in nursing homes. HHS partially agreed with this recommendation and, as of February 2021, HHS had not implemented this recommendation. June 2019 Nursing Homes: Improved Oversight Needed to GAO made six recommendations, including that CMS require Better Protect Residents from Abuse state survey agencies to immediately notify law enforcement (GAO-19-433) of any reasonable suspicion of a crime against a resident, and that CMS provide more guidance to state survey agencies on the information nursing homes should include on facility-reported incidents. HHS agreed with the recommendations and, as of February 2020, HHS had not implemented these recommendations. April 2019 Management Report: CMS Needs to Address GAO made three recommendations, including that CMS Gaps in Federal Oversight of Nursing Home ensure all state survey agencies are meeting federal Abuse Investigations That Persisted in Oregon requirements for investigating alleged abuse, and that the for at Least 15 Years results are shared with CMS. HHS agreed with the (GAO-19-313R) recommendations and, as of November 2019, HHS had implemented one of the three recommendations. November 2016 Nursing Homes: Consumers Could Benefit from GAO made four recommendations, including that CMS Improvements to the Nursing Home Compare should add information to the Five-Star System that allows Website and Five-Star Quality Rating System consumers to compare nursing homes nationally. HHS (GAO-17-61) agreed with three of the four recommendations and, as of July 2019, HHS had implemented three of the four recommendations. Page 14 GAO-21-402T Appendix I: Description of Selected GAO Reports on Nursing Homes with Recommendations Date Title Summary of recommendations October 2015 Nursing Home Quality: CMS Should Continue to GAO made three recommendations, including that CMS Improve Data and Oversight implement a clear plan for ongoing auditing of self-reported (GAO-16-33) data and establish a process for monitoring oversight modifications to better assess their effects. HHS agreed with GAO’s recommendations. As of 2020, HHS had implemented these three recommendations. April 2011 Nursing Homes: More Reliable Data and GAO made seven recommendations aimed at ensuring Consistent Guidance Would Improve CMS CMS’s complaints database is reliable, strengthening CMS’s Oversight of State Complaint Investigations assessment of state survey agencies’ performance in (GAO-11-280) managing complaints, and increasing accountability for managing the complaints process. HHS generally agreed with our recommendations. As of October 2019, HHS had implemented two of these seven recommendations and indicated it would not be taking action on a third (GAO closed this as not implemented). Source: GAO. | GAO-21-402T Note: The hyperlinks to these reports provide additional details about the recommendations and their statuses. Page 15 GAO-21-402T Appendix II: Related GAO Reports Appendix II: Related GAO Reports CARES Act Reports COVID-19: Critical Vaccine Distribution, Supply Chain, Program Integrity, and Other Challenges Require Focused Federal Attention. GAO-21-265. Washington, D.C.: January 28, 2021. COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal Response. GAO-21-191. Washington, D.C.: November 30, 2020. COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted Actions. GAO-20-701. Washington, D.C.: September 21, 2020. COVID-19: Opportunities to Improve Federal Response and Recovery Efforts. GAO-20-625. Washington, D.C.: June 25, 2020. Other GAO Reports Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. GAO-20-576R. Washington, D.C.: May 20, 2020. Elder Abuse: Federal Requirements for Oversight in Nursing Homes and Assisted Living Facilities Differ. GAO-19-599. Washington, D.C.: August 19, 2019. Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse. GAO-19-433. Washington, D.C.: June 13, 2019. Management Report: CMS Needs to Address Gaps in Federal Oversight of Nursing Home Abuse Investigations That Persisted in Oregon for at Least 15 Years. GAO-19-313R. Washington, D.C.: April 15, 2019. Nursing Homes: Consumers Could Benefit from Improvements to the Nursing Home Compare Website and Five-Star Quality Rating System. GAO-17-61. Washington, D.C.: November 18, 2016. Nursing Home Quality: CMS Should Continue to Improve Data and Oversight. GAO-16-33. Washington, D.C.: October 30, 2015. Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older Adults in Nursing Homes, but Should Expand Efforts to Other Settings. GAO-15-211. Washington, D.C.: January 30, 2015. Nursing Homes: More Reliable Data and Consistent Guidance Would Improve CMS Oversight of State Complaint Investigations. GAO-11-280. Washington, D.C.: April 7, 2011. (105027) Page 16 GAO-21-402T This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. 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