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Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23-May 30, 2020

2021 Addendum: States' Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic


We did this review to determine the number and results of onsite State surveys of nursing homes during the COVID-19 pandemic. Nursing home residents are particularly vulnerable to infectious diseases such as COVID-19, and infection control has been a persistent problem for most nursing homes. As of November 8, 2020, more than 67,000 nursing home residents had died of COVID-19-related illnesses, which represented almost 30 percent of all COVID 19 deaths in the United States at that time. Onsite State surveys assess the quality of services in nursing homes, a critical function for protecting residents. CMS changed survey practices in response to the pandemic. These changes—together with nursing home residents' high-risk status and the importance of the State surveys—warrant close examination to assess the sufficiency of this oversight.


We analyzed CMS administrative data to determine the number of focused infection control and complaint surveys conducted during March 23-May 30, 2020. We also identified the number and types of deficiencies cited as a result of these surveys. We interviewed officials in CMS and 10 States to learn more about their approaches to oversight, challenges to conducting onsite surveys, and experiences during the COVID-19 pandemic.


States conducted onsite surveys at 31 percent of nursing homes during March 23-May 30, 2020; however, States varied significantly. During the same time period in 2019—when States and CMS were under normal operations and conducting standard and other surveys—53 percent of nursing homes received an onsite survey. The infection control surveys conducted during this timeframe in 2020 resulted in few deficiencies, in part because of their limited scope and less surveyor time onsite. State officials reported ongoing challenges to securing adequate personal protective equipment (PPE) and surveyors to complete onsite surveys. States provided guidance and other support—such as training—to nursing homes outside of the survey process. State officials reported concerns about mounting backlogs of standard and complaint surveys, as the pandemic continues.


We recommend that CMS assess the results of the focused infection control survey and revise the survey as appropriate. We also recommend that CMS work with States to help overcome challenges with PPE and staffing, and that it clarify expectations for States to complete backlogs of surveys. CMS did not explicitly concur with our recommendations to assess and revise the infection control survey or to clarify expectations for States to complete backlogs, but stated it has taken steps to implement those recommendations. CMS did not concur with our recommendation to work with States to overcome challenges with PPE and staffing, citing its lack of authority to address issues of allocating PPE and staff. OIG continues to recommend that CMS identify opportunities within its authority to support States facing challenges with PPE and staffing.