Covid-19 In Nursing Homes: HHS Has Taken Steps in Response to Pandemic, but Several GAO Recommendations Have Not Been Implemented

What GAO Found

GAO’s review of data from the Centers for Disease Control and Prevention (CDC) found that winter 2020 was marked by a significant surge in the number of COVID-19 cases and deaths in nursing homes. However, CDC data as of February 2021, show that both cases and deaths have declined by more than 80 percent since their peaks in December 2020. With the introduction of vaccines, observers are hopeful that nursing homes may be beginning to see a reprieve. Nevertheless, the emergence of more highly transmissible virus variants warrants the need for continued vigilance, according to public health officials.

GAO’s prior work has found that nursing homes have faced many difficult challenges battling COVID-19. While challenges related to staffing shortages have persisted through the pandemic, challenges related to obtaining Personal Protective Equipment (PPE) and conducting COVID-19 tests—although still notable—have generally shown signs of improvement since summer 2020. Further, with the decline in nursing homes cases, the Centers for Medicare and Medicaid Services (CMS) updated its guidance in March 2021 to expand resident visitation, an issue that has been an ongoing challenge during the pandemic. Some new challenges have also emerged as vaccinations began in nursing homes, such as reluctance among some staff to receive a COVID-19 vaccine.

The Department of Health and Human Services (HHS), primarily through CMS and the CDC, has taken steps to address COVID-19 in nursing homes. However, HHS has not implemented several relevant GAO recommendations, including:

  • HHS has not implemented GAO’s recommendation related to the Nursing Home Commission report, which assessed the response to COVID-19 in nursing homes. CMS released the Nursing Home Commission’s report and recommendations in September 2020. When the report was released, CMS broadly outlined the actions the agency had taken, but the agency did not provide a plan that would allow it to track its progress. GAO recommended in November 2020 that HHS develop an implementation plan. As of February 2021, this recommendation had not been implemented.
  • HHS has not implemented GAO’s recommendation to fill COVID-19 data voids. CMS required nursing homes to begin reporting the number of cases and deaths to the agency effective May 8, 2020. However, CMS made the reporting of the data prior to this date optional. GAO recommended in September 2020 that HHS develop a strategy to capture more complete COVID-19 data in nursing homes retroactively back to January 1, 2020. As of 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 recommendations, GAO has ongoing work related to COVID-19 outbreaks in nursing homes and CMS’s oversight of infection control and emergency preparedness.

Why GAO Did This Study

The COVID-19 pandemic has had a disproportionate impact on the 1.4 million elderly or disabled residents in the nation’s more than 15,000 Medicare- and Medicaid-certified nursing homes, who are often in frail health and living in close proximity to one another. HHS, primarily through CMS and CDC, has led the pandemic response in nursing homes.

The CARES Act includes a provision for GAO to conduct monitoring and oversight of the federal government’s efforts to prepare for, respond to, and recover from the COVID-19 pandemic. GAO has examined the government’s response to COVID-19 in nursing homes through its CARES Act reporting (GAO-21-265, GAO-21-191, GAO-20-701, and GAO-20-625).

This testimony will summarize the findings from these reports. Specifically, it describes COVID-19 trends in nursing homes and their experiences responding to the pandemic, and HHS’s response to the pandemic in nursing homes.

To conduct this previously reported work, GAO reviewed CDC data, agency guidance, and other relevant information on HHS’s response to the COVID-19 pandemic. GAO interviewed agency officials and other knowledgeable stakeholders. In addition, GAO supplemented this information with updated data from CDC on COVID-19 cases and deaths reported by nursing homes as of February 2021.

For more information, contact John E. Dicken at (202) 512-7114 or dickenj@gao.gov.

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    Eighty-two Children's Savings Account (CSA) programs operated and had collectively enrolled about 700,000 children in 2019, according to survey data from the nonprofit organization Prosperity Now. These programs—operated by states, cities, and other organizations—use a variety of strategies to enroll families, especially those with lower incomes, and help them save and prepare for college. For example, CSA programs enroll families by partnering with trusted organizations (e.g., schools) or through automatic enrollment, according to the Consumer Financial Protection Bureau (CFPB) and CSA experts. In addition, these programs help families build savings once children are enrolled by, for example, providing initial deposits or financial education. While experts GAO interviewed said savings may be modest given lower-income families' and programs' limited resources, CSA programs also aim to help lower-income families prepare for college, such as by increasing financial knowledge. There is evidence that CSA program strategies have positive short-term effects on families, including those with lower incomes. These effects include increased CSA program enrollment and participation, amounts saved, and educational expectations, based on research GAO reviewed (see figure). For example, strategies such as automatically enrolling families and providing financial contributions (e.g., initial deposits) may help CSA programs reach more families and encourage saving. Several studies of a CSA program that used both these strategies found increases in the number of children enrolled and the amount saved by enrolled families. One study found that families who were enrolled for 7 years saved over four times more of their own money, on average, than families who were not enrolled—$261 compared to $59. When including financial contributions from the CSA program, enrolled families had about six times more total savings ($1,851) compared to other families ($323). Enrollment and participation in CSA programs may also increase families' educational expectations for their children. For example, a study found that parents with children enrolled in one CSA program were nearly twice as likely to expect their children to attend college. However, information on college enrollment and other long-term effects on families participating in CSA programs is limited because most of the children have not yet reached college age. Effects of CSA Program Strategies in Three Commonly Assessed Areas Rising college costs have outpaced federal grant aid and placed more of the financial burden on students and their families. CSA programs help families, especially lower-income families, save for college—and other postsecondary education—by providing financial contributions and possibly other supports. A Senate Appropriations Committee report included provisions for GAO to examine various aspects of college savings account programs and their effectiveness. This report examines (1) the number of CSA programs and how they use strategies to help families, especially lower-income families, save and prepare for college; and (2) what is known about the effects of these strategies on families, including lower-income families. GAO reviewed 2016–2019 annual CSA program survey data collected by the nonprofit Prosperity Now. GAO also analyzed CFPB documents and the findings of 33 peer-reviewed studies from 2010 through 2019—and one working paper from 2017—that met GAO's criteria for inclusion, for example, used data from the United States. In addition, GAO interviewed officials from CFPB, the Department of Education, and four organizations that have expertise on these programs. For more information, contact Melissa Emrey-Arras at (617) 788-0534 or emreyarrasm@gao.gov.
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  • Department of Justice Begins Third Distribution of Forfeited Funds to Compensate Victims of Fraud Scheme Facilitated by Western Union
    In Crime News
    The Department of Justice announced today that the Western Union Remission Fund began its third distribution of approximately $66 million in funds forfeited to the United States from the Western Union Company (Western Union) to approximately 6,000 victims located in the United States and abroad. These victims, many of whom were elderly victims of consumer fraud, will be recovering the full amount of their losses.
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    In Crime Control and Security News
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  • Texas Entrepreneur Charged with Spending COVID Relief Funds on Improper Expenses Including Lamborghini and Strip Club
    In Crime News
    A Houston, Texas man has been taken into custody on allegations he fraudulently obtained more than $1.6 million in Paycheck Protection Program (PPP) loans, announced Acting Assistant Attorney General Brian C. Rabbitt of the Justice Department’s Criminal Division and U.S. Attorney Ryan K. Patrick of the Southern District of Texas.
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    In Crime Control and Security News
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  • Virginia Return Preparer Indicted for Evading her Own Taxes and Not Filing Her Returns
    In Crime News
    A federal grand jury in Richmond, Virginia, returned an indictment charging a return preparer with tax evasion and failure to file individual income tax returns, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Justice Department’s Tax Division and U.S. Attorney G. Zachary Terwilliger for the Eastern District of Virginia.
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    In Crime News
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    In Crime Control and Security News
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  • Couple Pleads Guilty to $1.1 Million COVID-Relief Fraud After Falsely Claiming to Be Farmers
    In Crime News
    A Florida couple pleaded guilty for their participation in a scheme to file four fraudulent loan applications seeking more than $1.1 million in forgivable Paycheck Protection Program (PPP) and Economic Injury Disaster Loans (EIDL) loans guaranteed by the Small Business Administration (SBA) under the Coronavirus Aid, Relief, and Economic Security (CARES) Act.
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  • Automated Technologies: DOT Should Take Steps to Ensure Its Workforce Has Skills Needed to Oversee Safety
    In U.S GAO News
    Stakeholders GAO interviewed said that federal oversight of automated technologies—such as those that control a function or task of a plane, train, or vehicle without human intervention—requires regulatory expertise as well as engineering, data analysis, and cybersecurity skills. Stakeholders also stated that as automated systems become more common across transportation modes, overseeing them will require understanding vehicle operating systems, software code, and the vast amounts of data produced by these systems to ensure their safety. Skills Needed to Oversee the Safety of Automated Technologies, according to Stakeholders The U.S. Department of Transportation's (DOT) Departmental Office of Human Resources Management has identified most skills DOT needs to oversee automated technologies, but it has not fully assessed whether its workforce has these skills. Through its workforce planning efforts, DOT identified many of the skills cited by stakeholders as important for overseeing automated technologies—regulatory expertise, engineering, and data analysis. In 2016 and 2020, DOT surveyed staff in related positions and identified gaps in some of these skills, including regulatory expertise. However, DOT did not survey staff or assess skill gaps in data analysis or cybersecurity positions important to automated technology oversight. As a result, DOT lacks critical information needed to identify skill gaps and ensure key relevant staff are equipped to oversee the safety of these technologies now and in the future. DOT developed strategies to address some but not all gaps in skills needed to oversee automated technologies. For example, DOT implemented some recruiting strategies and established hiring goals as a means of closing gaps identified in the 2016 survey and plans to continue these efforts in light of the 2020 survey. However, DOT has not tracked the progress of strategies implemented to close skill gaps since the 2016 survey, nor has it implemented training strategies. Accordingly, some skill gaps related to overseeing the safety of automated technologies will likely persist in DOT's workforce. Automated technologies in planes, trains, and passenger vehicles are in use today and likely to become increasingly widespread. While these technologies hold promise, accidents involving them demonstrate potential safety challenges. DOT is responsible for overseeing the safety of all modes of transportation. This report addresses: (1) stakeholders' perspectives on the skills required to oversee automated technologies; (2) the extent to which DOT has identified and assessed the skills it needs to oversee these technologies; and (3) the extent to which DOT has developed strategies to address any gaps in skills. GAO reviewed relevant literature and DOT workforce planning documents, and interviewed DOT human capital officials, selected modal administrations, and stakeholders, including transportation associations and technology developers. GAO selected modal administrations based in part on the prevalence of automated technologies. GAO is making four recommendations, including that DOT: (1) assess skill gaps in key occupations involved in overseeing automated technologies and (2) regularly measure the progress of strategies implemented to close skill gaps. DOT concurred with three recommendations and partially concurred with one on measuring progress. GAO clarified this recommendation and believes its implementation is warranted. For more information, contact Heather Krause at (202) 512-2834 or krauseh@gao.gov.
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  • Justice Department Reaches Agreement with Newton County, Arkansas and its Board of Election Commissioners to Ensure Polling Place Accessibility for Voters with Disabilities
    In Crime News
    The Justice Department yesterday reached a settlement under Title II of the Americans with Disabilities Act (ADA) with Newton County, Arkansas, and its Board of Election Commissioners to ensure that the County provides an accessible voting program, including accessible polling places, to voters with disabilities.
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    In Crime Control and Security News
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