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

GAO-21-402T Published: Mar 17, 2021. Publicly Released: Mar 17, 2021.
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Fast Facts

We testified on findings from our CARES Act reports related to the pandemic's disproportionate impact on nursing home residents.

We discussed challenges that have persisted throughout the pandemic, such as staff shortages. Nursing home staff also report exhaustion and burnout.

Some challenges have shown signs of improving over time, such as the availability of personal protective equipment (PPE).

Recently, new challenges for nursing homes have also emerged—such as vaccinating staff.

While the Department of Health and Human Services has taken steps to address COVID-19 in nursing homes, several of our recommendations haven't been implemented.

An illustration of the coronavirus depicting its round shape and red spikes.

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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

Full Report

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Compliance oversightDeathsDisease controlElderly personsFederal assistance programsHealth careHealth care standardsInfection controlMedicaid servicesMedicareNursing homespandemicsPublic health emergenciesVaccinations