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

WHY WE DID THIS STUDY

Almost every American has been affected in some way by the COVID-19 pandemic. By the end of 2020, COVID-19 had spread throughout the United States. The COVID-19 pandemic has been particularly devastating for Medicare beneficiaries in nursing homes, which is why OIG embarked on a three-part series of evaluations focusing exclusively on the nursing home experience during 2020. The first report in this series found that 2 in 5 Medicare beneficiaries in nursing homes either had or likely had COVID-19 in 2020. Some Medicare beneficiaries in nursing homes seemed to be at greater risk than others. Specifically, Black beneficiaries, Hispanic beneficiaries, and Asian beneficiaries were more likely than White beneficiaries to have or likely have COVID-19. In addition, overall mortality for Medicare beneficiaries in nursing homes increased by almost one-third in 2020 from the 2019 level.

This is the second report in the series and builds on the first OIG report by focusing on nursing homes themselves. It looks at the extent to which they had residents who were diagnosed with COVID-19 or likely COVID-19, and the characteristics of nursing homes with extremely high infection rates. The third report will feature specific challenges nursing homes faced and the strategies they used to deal with them.

For the health and safety of residents, nursing homes must be prepared to face current and future health emergencies. Understanding how the COVID-19 pandemic has affected nursing homes can help the CMS, Congress, and other stakeholders learn from what has happened and inform their decisions as they strive to improve care and better protect residents.

HOW WE DID THIS STUDY

We used Medicare claims data to determine the extent to which nursing homes had Medicare beneficiaries who were diagnosed with COVID-19 or likely COVID-19. We looked at 15,086 nursing homes nationwide and identified nursing homes with extremely high infection rates during the surges of cases during the spring and fall of 2020. These homes had three-quarters or more of their Medicare beneficiaries diagnosed with COVID-19 or likely COVID-19 during a surge period. We examined the characteristics of these nursing homes. We also examined whether these nursing homes had been cited with any infection control deficiencies and whether their reported nursing hours met minimum Medicare requirements for these hours.

WHAT WE FOUND

Nursing homes had a surge of COVID-19 cases during the spring of 2020 and a greater surge during the fall, well after they were known to be vulnerable. More than 1,300 nursing homes had extremely high infection rates—75 percent or more of their Medicare beneficiaries—during these surges. These nursing homes were more common and geographically widespread during the second surge. Nursing homes with extremely high infection rates experienced dramatic increases in overall mortality (not limited to deaths of beneficiaries who had or likely had COVID-19). Specifically, these nursing homes experienced an average overall mortality rate approaching 20 percent during these surges—roughly double the mortality rate of other nursing homes during the same time periods. For comparison, in 2019 the average mortality rate in these same nursing homes was 6 percent.

For-profit nursing homes made up a disproportionate percentage of the nursing homes with extremely high infection rates during both surges. Other characteristics varied by surge. For example, urban nursing homes were more likely to have extremely high infection rates during the first surge, but rural nursing homes were more likely to have extremely high rates during the second surge.

High COVID-19 transmission in a county did not always lead to nursing homes in that county reaching extremely high infection rates. In addition, the survey process did not identify any deficiencies in infection control for the majority of the nursing homes with extremely high infection rates, raising questions about how effective the survey process is in preventing and mitigating the spread of infectious disease in nursing homes. Also, the vast majority of nursing homes with extremely high infection rates reported nursing hours that met or exceeded Medicare's specific minimum requirements for these hours, which may indicate that these requirements are not adequate to keep residents safe from infectious disease.

WHAT WE RECOMMEND

These findings make clear that nursing homes in this country were not prepared for the sweeping health emergency that COVID-19 created, nor were they able to stem the devastation once it was evident that nursing homes were especially vulnerable. Virtually all nursing homes experienced infections, and more than 1,300 nursing homes had extreme infection rates of 75 percent or higher during a surge period and an average overall mortality rate close to 20 percent. Significant changes are needed to protect the health and safety of residents and better prepare nursing homes for current and future health emergencies.

The administration recently announced a major initiative to improve safety and quality of care in nursing homes. The findings in this report lend urgency to the administration's initiative. We recommend that CMS, as it supports the administration's initiative, take the following actions: (1) reexamine current nursing staff requirements and revise them as necessary; (2) improve how surveys identify infection control risks to nursing home residents and strengthen guidance on assessing the scope and severity of those risks; and (3) target nursing homes in most need of infection control intervention, and provide enhanced oversight and technical assistance to these facilities as appropriate. CMS concurred with the intent of the first and third recommendations and neither concurred nor nonconcurred with the second recommendation.