Sens. Casey, Wyden Issue Report: 'Update on the Trump Administration's Response to COVID-19 in Nursing Homes'

WASHINGTON, Sept. 30 -- The Senate Special Aging Committee minority issued the following report entitled "The Cost of Inaction: 11 Deaths An Hour - An Update on the Trump Administration's Response to COVID-19 in Nursing Homes" by Sen. Bob Casey, D-Pennsylvania, ranking member of the Aging Committee, and Sen. Ron Wyden, D-Oregon, ranking member of the Senate Finance Committee:

EXECUTIVE SUMMARY

In February 2020, the novel coronavirus (COVID-19) took hold in the first nursing home in the United States, ultimately claiming 35 lives./1 While these residents and workers of the Life Care Center of Kirkland (Wash.) suffered and died, President Trump intentionally downplayed the deadly threat of COVID-19./2 It was clear early on that the virus would lead to deaths and severe illness among the Nation's nursing home residents and workers, a fact that was well established by the country's very first and very deadly outbreak in Kirkland. Now, months later, the crisis in nursing homes nationwide has worsened. To date, more than 78,000 residents and workers in nursing homes and other long-term care facilities have died of COVID-19./3

This report provides an update to "COVID-19 in Nursing Homes: How the Trump Administration Failed Residents and Workers," a comprehensive report released on July 1, 2020 by Senate Democrats./4 It provides new information on the pandemic's deadly toll on nursing home residents and workers, based on a minority staff analysis of data submitted by nursing homes to the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS)./5

Despite early warning signs and continued calls from States, local communities, industry, and advocates for additional funding, enhanced coordination, and federal leadership, the Trump Administration and Republicans in Congress continue to fail to deliver needed aid to nursing homes, their residents, and their workers./6 As a result, week by week, the death toll in nursing homes continues to climb. Tens of thousands of nursing home residents and workers' lives have been lost, not only to a terrible virus, but to a pandemic response marred by missteps and delays./7 This report underscores these realities, highlighting unmet workforce needs, ongoing personal protective equipment (PPE) shortages, and a woefully deficient testing strategy at nursing homes nationwide. It also outlines the overdue solutions required to overcome these challenges and save lives in nursing homes. Among the report's findings:

* Growing Death Toll: More than 16,800 nursing home residents and workers died of COVID-19 in July 2020 and August 2020. During those months, on average, more than one nursing home resident was infected every minute, and 11 residents died every hour.

* Severe PPE Shortages Remain: The number of nursing homes reporting PPE shortages tripled from July 5, 2020 to August 30, 2020, as inadequate supplies of basic safety equipment like N95 masks persisted.

* Inadequate COVID-19 Testing: Nursing homes still lack adequate testing capacity. As of August 30, 2020, more than 700 nursing homes--nearly five percent of the Nation's total--reported having no ability to test all residents or workers within the next seven days.

* Critical Workforce Shortages Continue: Nursing homes continue to be severely short-staffed, with roughly one in five nursing homes nationwide reporting shortages of aides and one in seven reporting shortages of nurses.

* Poor Data Collection: The Trump Administration is still not tracking nursing home COVID-19 cases and deaths prior to May 1, 2020, and it is still not collecting vital demographic data, including on race and ethnicity, on COVID-19 outbreaks in nursing homes.

BACKGROUND

More than 1.3 million Americans receive health care services and supports in nursing homes across the country./8 And while residents in long-term care facilities, like nursing homes, represent a fraction of the country's population, they account for more than 40 percent of all deaths due to COVID-19./9 To date, according to the latest media reports, more than 78,000 residents and workers in nursing homes and other long-term care settings have died from COVID-19./10 Further, it is well-documented that Black and Hispanic/Latinx nursing home residents have borne the brunt of the pandemic, becoming sick and dying at disproportionately higher rates compared to their white counterparts./11

Tens of thousands of grandparents, parents, veterans, neighbors, friends and essential workers might still be alive today had it not been for the President's flippant disregard for medical science, the Trump Administration's anemic response to the pandemic, and the fecklessness of Republicans in Congress. Yet, the complete toll of COVID-19 in nursing homes may never be known. More than eight months into the pandemic, the Trump Administration still does not require data collection on nursing home deaths and cases that took place prior to May 1, 2020, nor is data being collected on critical demographic indicators, like age, race, ethnicity, gender, and disability status of nursing home residents and workers affected by the virus./12 The Trump Administration has also failed to equip nursing homes with the personal protective equipment (PPE) they need or present the public with a coherent national testing strategy.

In July 2020, Senate Democrats issued a report chronicling the Trump Administration's deadly delays in responding to COVID-19,/13 including its:

* Failure to track and count basic public health data including COVID-19 cases and deaths in nursing homes until months into the pandemic;/14

* Failure to ship adequate volumes of emergency PPE, much of which ultimately proved to be faulty and unusable, as nursing homes struggled to acquire supplies in a market environment exacerbated by the Trump Administration's scattershot response;/15 and

* Failure to distribute emergency funding, for both vital oversight and accountability and relief to nursing homes operators and workers on the front lines of the pandemic./16

Non-partisan experts have repeatedly sounded the alarm. In July 2020 a 25-member commission, convened by CMS, directly warned the agency that nursing homes faced ongoing shortages of PPE and testing supplies, writing that without "additional federal action" in these areas, "the virus will continue to spread."/17 The commission's final report, issued in September 2020, stated that PPE, testing, and staffing shortages continue plaguing nursing homes./18 Additionally, in September 2020, the Government Accountability Office (GAO) concluded that "COVID-19 challenges for nursing homes remain, including challenges related to PPE, testing, and staffing shortages."/19 GAO recommended that CMS and CDC collect "more complete data on COVID-19 cases and deaths in nursing homes retroactively back to January 1, 2020,"stating that as they stand, the data "do not provide...a complete picture of the extent of the pandemic and its effect on nursing homes."/20 The commission, convened by CMS, similarly called on the agency to collect nursing home data from the "beginning of the pandemic."/21

The consequence of the Trump Administration's errors and delays has been a devastating loss of life, especially in nursing homes. The following findings in this updated report show the degree to which nursing home residents and workers are still under siege from COVID-19.

FINDINGS

* Growing Death Toll: More than 16,800 nursing home residents and workers died of COVID-19 in July 2020 and August 2020. During those months, on average, more than one nursing home resident was infected every minute, and 11 residents died every hour.

The data reported to CDC and CMS by nursing homes paint a grim picture of the cost of inaction. During the months of July 2020 and August 2020, 16,487 nursing home residents died, along with 331 workers./22 During this same period, nursing homes nationwide reported 137,859 confirmed and suspected cases of COVID-19 among residents./23

* Severe PPE Shortages Remain: The number of nursing homes reporting PPE shortages tripled from July 5, 2020 to August 30, 2020, as inadequate supplies of basic safety equipment like N95 masks persisted.

Nursing homes across the country face challenges obtaining adequate supplies of PPE./24 Emblematic of this struggle is the shortage of N95 masks, which provide the best protection against the transmission of COVID-19./25 This shortage, while not unique to nursing homes, is likely contributing to dire outcomes. Between July 5, 2020 and August 30, 2020, the number of nursing homes reporting that they had no current supply of N95 masks more than tripled, with over 1,100 facilities reporting that they did not have any supplies of N95 masks on August 30, 2020./26 Additionally, at the end of August 2020, over 16 percent (2,600) of nursing homes reported not having a week's supply of N95 masks,/27 a 38 percent increase over that nine-week period (July 5, 2020 to August 30, 2020)./28

? Inadequate COVID-19 Testing: Nursing homes still lack adequate testing capacity. As of August 30, 2020, more than 700 nursing homes--nearly five percent of the Nation's total--reported having no ability to test all residents or workers within the next seven days.

Despite assurances from the Trump Administration that nursing homes would have sufficient testing supplies, nursing homes continue to have trouble accessing adequate, timely testing for workers and residents. Analysis of CMS data reveals that, as of August 30, 2020, 745 facilities reported being unable to test or obtain materials to test all of their residents within the next seven days. During the same time frame, 780 facilities were unable to test or obtain resources to test all staff within the next seven days./29 As such, as of August 30, 2020, none of these facilities had the testing capability necessary to comply with new CMS guidelines requiring nursing homes to test all residents and all workers in the event of a COVID-19 outbreak./30

While the Trump Administration announced an initiative to provide testing devices to nursing homes in early July 2020, many nursing homes may not see the federally provided testing devices until the end of September 2020./31 Additionally, these supplies will include only enough testing kits to test residents and staff once, meaning that once those supplies are exhausted, facilities will have testing devices but no supplies to use them./32 Finally, while the importance of testing residents and workers in nursing homes is paramount, so too is ensuring that those tests are reliable. The testing devices supplied to nursing homes are for antigen testing, which is less reliable than molecular testing methods and, according to reports, may not be well suited for screening asymptomatic residents or workers./33 While antigen tests can accurately determine that a patient is positive for COVID-19, they are more likely to produce false negatives because, compared to other tests, they are less sensitive to the proteins needed to identify the presence of COVID-19./34 For the devices the Trump Administration sent to nursing homes, the rate of false negatives can be as high as 15 percent./35 As such, nursing homes may not be able to rely entirely on the results provided by these tests to administer treatment, separate residents that have the virus from those who do not, or screen workers who may bring the virus into the nursing home./36

* Critical Workforce Shortages Continue: Nursing homes continue to be severely short-staffed, with roughly one in five nursing homes nationwide reporting shortages of aides and one in seven reporting shortages of nurses.

From the beginning of the pandemic, nursing homes have struggled to maintain an adequate workforce./37 On the front lines--without access to adequate PPE, paid sick and family medical leave, and testing--nursing home workers have borne an immeasurable burden and made the highest sacrifice in helping others. Indeed, in the past two months alone, COVID-19 has cost 331 nursing home workers their lives./38 As the pandemic spread, some nursing homes were not able to retain an adequate workforce to care for residents, as workers were exposed to COVID-19 and could not come into work or were forced to stay home to care for family members and children./39 Further, according to one analysis, workforce shortages were most severe among lower-quality nursing homes and those more reliant on Medicaid funding, meaning those facilities were more likely to be without essential workers amid deadly COVID-19 outbreaks./40 More than eight months into the pandemic, these workforce issues persist. In July and August 2020, 15 percent or more of nursing homes reported shortages in nursing staff every week./41 As of August 30, 2020, more than 15 percent of nursing homes reported that they were experiencing shortages of nurses, and almost 20 percent of facilities reported shortages of aides./42 These shortages are even more alarming given preliminary studies suggesting that adequate staffing, particularly among nurses, may help limit the severity of facility outbreaks./43

* Poor Data Collection: The Trump Administration is still not tracking nursing home COVID-19 cases and deaths prior to May 1, 2020, and it is still not collecting vital demographic data, including on race and ethnicity, on COVID-19 outbreaks in nursing homes.

More than eight months into the pandemic, the Trump Administration's data on nursing homes still fails to fully capture the devastating toll of COVID-19 in nursing homes, as there is no required data collection whatsoever on case counts and deaths that occurred prior to May 1, 2020. Further, alarmingly, the Trump Administration is still not collecting information that would shed light on the disparate impact of the pandemic on Black and Hispanic/Latinx individuals and other people of color in nursing homes./44 According to the Washington Post, "[H]omes where at least 7 in 10 residents are Black saw a death rate about 40 percent higher than homes with majority-white populations."/45 Researchers have also found that people of color working in health care are twice as likely to contract COVID-19 and 50 percent more likely to receive inadequate or reused PPE supplies./46

These findings are in line with a recent study showing that in the general population, COVID-19 infection rates are more than three times higher among Hispanic/Latinx patients than white patients, more than two times higher among Black patients than white patients, and 65 percent higher among Asian patients than white patients./47 Despite calls from Congress and growing evidence that COVID-19 is infecting and killing residents and workers who live and work in nursing homes that have a majority of Black and Hispanic/Latinx residents at higher rates, the Trump Administration is still not collecting the necessary demographic information./48

SOLUTIONS

Democrats in the Senate and House of Representatives proposed a series of policy solutions and necessary funding to address these and other issues that persist in nursing homes. Experts and advocates alike maintain that these sensible proposals, while long overdue, are critical to addressing the ongoing crisis in nursing homes./49 However, Republicans in Congress and the Trump Administration continue to defy reason and logic, prioritizing corporate interests and judicial gains, while residents and workers in nursing homes die and Americans look through windowpanes at their loved ones in horror. The following solutions continue to be critical to address the ongoing crisis in nursing homes:

* Ensure adequate data collection. One of the earliest missteps in the response to COVID-19 in nursing homes was the Trump Administration's failure to collect and disclose nursing home data. Comprehensive nursing home data on all COVID-19 cases and deaths as well as supplies (including PPE, testing, staffing, and more) is essential to the promotion of a targeted response and the dissemination of vital resources. CMS and CDC should collect data on COVID-19 cases and deaths in nursing homes dating back to the beginning of the pandemic, as well as demographic data including on gender, race, ethnicity, age, and disability status.

* Support States and nursing homes and implement best practices. States, communities, and nursing homes were unprepared for a pandemic of this scale, lacking emergency resources to acquire testing supplies, compete in the market for overpriced PPE, provide premium pay to workers, cover the unexpected cost of childcare, and retrofit specialized wings or entire nursing homes to care for people with COVID-19. Congress should provide adequate funding to States and nursing homes to combat the virus. That funding must be paired with a national action plan, drawing on best practices in infection control and prevention, including cohorting and surge teams.

* Provide urgently needed PPE and testing. Nursing homes cannot accomplish effective implementation of promising strategies, including cohorting and the use of surge teams, without sufficient access to essential supplies, including PPE and testing. Nursing home workers require PPE to keep themselves and residents safe, and nursing homes need to be able to consistently test residents and workers to track and monitor the virus.

* Invest in home and community-based services. Over 2.5 million seniors and people with disabilities currently receive home and community-based services, and 800,000 are on waiting lists for those services./50 A thoughtful strategy to protect nursing home residents and workers must include a meaningful investment to promote access to home and community-based services provided under Medicaid. Individuals in nursing homes and other congregate settings are particularly vulnerable to deadly COVID-19 outbreaks, making access to long-term services and supports in the home critical. An essential component of keeping seniors and people with disabilities safe from the virus is helping them avoid care delivery in congregate settings when home and community-based care is desired and appropriate.

* Elevate the workforce. Seniors and people with disabilities living in nursing homes will never be safe from COVID-19 if the nursing home workforce is not provided the supplies and support they need to provide care under difficult conditions. Providing workers with adequate pay and ensuring they receive essential benefits is fundamental to preventing the continued spread of COVID-19 in nursing homes. These heroes on the front lines should receive premium pay, paid sick leave, paid family and medical leave, access to child care, and temporary housing as the need for quarantining arises. Further, in the spirit of the G.I. Bill passed after World War II, the Nation owes health care workers and first responders meaningful payment towards education and training, loan forgiveness, or other needs in acknowledgement of their service to vulnerable citizens.

* Uphold resident rights and resume visitation safely. Any strategy to save lives in nursing homes amid the pandemic must aim to preserve residents' rights and quality of life. Alongside the receipt of resources, nursing homes must be subject to continued oversight and held to the highest standards of care through adequate enforcement. CMS should prohibit nursing homes from involuntarily discharging or evicting residents amid the pandemic, and penalize those that do. Funding should be provided for technology to support "virtual visitation," and "essential caregiver" or "compassionate caregiver" policies should be implemented to allow families to safely resume visiting their loved ones in person.

There will be a time for a reckoning, to reflect on this pandemic and ask what more could have been done. Until that time to comes, Congress must act to save lives in nursing homes. Inaction on these key proposals is an abdication of the highest degree by Republicans in Congress and the Trump Administration. It demands a course correction, as the lives of nursing home residents and workers hang in the balance.

* * *

Footnotes:

1 Jack Healy and Serge F. Kovaleski, "The Coronavirus's Rampage Through a Suburban Nursing Home," New York Times, March. 21, 2020, https://www.nytimes.com/2020/03/21/us/coronavirus-nursing-home-kirkland-life-care.html.

2 Jamie Gangel and Elizabeth Stuart, "'Pretty cool. Right?' Unfiltered moments from Trump's 18 interviews with Bob Woodward," CNN, Sept. 9, 2020 https://www.cnn.com/2020/09/09/politics/trump-bob-woodward-interviews/index.html.

3 The COVID Tracking Project, "The Long-Term Care COVID Tracker," https://covidtracking.com/data/longtermcare (last accessed Sept. 22, 2020).

4 "COVID-19 in Nursing Homes: How the Trump Administration Failed Residents and Works," U.S. Senators Casey, Peters, and Wyden, July 1, 2020, https://www.aging.senate.gov/download/covid-19-in-nursing-homes.

5 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020).

6 Alex Spanko, "Skilled Nursing Distress Looms as CARES Funding Ebbs: 'Bills Are Starting to Come Due," Skilled Nursing News, Sept. 1, 2020, https://skillednursingnews.com/2020/09/skilled-nursing-distress-looms-as-cares-funding-ebbs-bills-are-starting-to-come-due/.

7 The COVID Tracking Project, "The Long-Term Care COVID Tracker," https://covidtracking.com/data/longtermcare (last accessed Sept. 22, 2020).

8 "Total Number of Residents in Certified Nursing Facilities," Kaiser Family Foundation, 2019, https://www.kff.org/other/state-indicator/number-of-nursing-facilityresidents/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (last accessed Sept. 18, 2020).

9 Ricardo Alonso-Zaldivar, "Nursing home cases up nearly 80% in COVID-19 rebound," Associated Press, Aug. 17, 2020, https://apnews.com/ae2b6d71bdc3a9391ae02910d8f0491f.

10 Anna Wilde Mathews, "'I Want to Be With Her.' When Covid Closed Nursing Homes, One Husband Moved In," Wall Street Journal, Aug. 21, 2020, https://www.wsj.com/articles/i-want-to-be-with-her-when-covid-closed-nursing-homes-one-husband-moved-in-11598024821; The COVID Tracking Project, "The Long-Term Care COVID Tracker," https://covidtracking.com/data/longtermcare (last accessed Sept. 22, 2020).

11 Robert Gebeloff, et al., "The Striking Racial Divide in How Covid-19 Has Hit Nursing Homes," New York Times, Sept. 10, 2020, https://www.nytimes.com/article/coronavirus-nursing-homes-racial-disparity.html; Sidnee King and Joel Jacobs, "Near birthplace of Martin Luther King Jr., a predominantly Black nursing home tries to heal after outbreak," Washington Post, Sept. 9, 2020, https://www.washingtonpost.com/business/2020/09/09/black-nursing-homes-coronavirus/.

12 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020); Laura Strickler, "Trump admin won't require nursing homes to count COVID-19 deaths that occurred before May 6," NBC News, May 22, 2020, https://www.nbcnews.com/health/health-care/trump-admin-won-t-require-nursing-homes-count-covid-19-n1213141.

13 "COVID-19 in Nursing Homes: How the Trump Administration Failed Residents and Works," U.S. Senators Casey, Peters, and Wyden, July 1, 2020, https://www.aging.senate.gov/imo/media/doc/COVID-19%20in%20Nursing%20Homes%20Final%20Report.pdf.

14 Centers for Medicare and Medicaid Services, "Trump Administration Announces New Nursing Homes COVID-19 Transparency Effort," Apr. 19, 2020, https://www.cms.gov/newsroom/press-releases/trump-administration-announces-new-nursing-homes-covid-19-transparency-effort; Laura Strickler and Suzy Khimm, "The government still doesn't know how many nursing homes have coronavirus outbreaks," NBC News, May 8, 2020, https://www.nbcnews.com/health/health-news/government-still-doesn-t-know-how-many-nursing-homes-have-n1202281.

15 Federal Emergency Management Agency, "Coronavirus Pandemic Response: PPE Packages for Nursing Homes," May 1, 2020, https://www.fema.gov/fact-sheet/coronavirus-pandemic-response-ppe-packages-nursing-homes; Jordan Rau, "Federal Help Falters As Nursing Homes Run Short Of Protective Equipment," Kaiser Health News, June 11, 2020, https://khn.org/news/federal-help-falters-as-nursing-homes-run-short-of-protective-equipment/; Alex Spanko, "As Stories of 'Useless' PPE Sent to Nursing Homes Pile Up, Providers Demand Investigation into FEMA Response," Skilled Nursing News, June 11, 2020, https://skillednursingnews.com/2020/06/as-stories-of-useless-ppe-sent-to-nursing-homes-pile-up-providers-demand-investigation-into-fema/.

16 Department of Health and Human Services, "Trump Administration Announces the Distribution of $2.5 Billion to Nursing Homes for COVID-19 Relief Funding," Aug. 27, 2020, https://www.hhs.gov/about/news/2020/08/27/trump-administration-announces-2-5-billion-to-nursing-homes-for-covid-19-relief-funding.html.

17 Coronavirus Commission on Safety and Quality in Nursing Homes, "Commission Memorandum of Short-Term Recommendations," July 17, 2020, https://www.cms.gov/files/document/covid-final-nh-commission-report.pdf.

18 Coronavirus Commission on Safety and Quality in Nursing Homes, "Commission Final Report," Sept. 2020, https://edit.cms.gov/files/document/covid-final-nh-commission-report.pdf; Coronavirus Commission on Safety and Quality in Nursing Homes, "Commission Memorandum of Short-Term Recommendations," July 17, 2020, https://www.cms.gov/files/document/covid-final-nh-commission-report.pdf.

19 Government Accountability Office "Federal Efforts Could Be Strengthened by Timely and Concerted Actions" (GAO-20-701), Sept. 21, 2020, https://www.gao.gov/reports/GAO-20-701/.

20 Government Accountability Office "Federal Efforts Could Be Strengthened by Timely and Concerted Actions" (GAO-20-701), Sept. 21, 2020, https://www.gao.gov/reports/GAO-20-701/.

21 Coronavirus Commission on Safety and Quality in Nursing Homes, "Commission Final Report," Sept. 2020, https://edit.cms.gov/files/document/covid-final-nh-commission-report.pdf.

22 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020).

23 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020).

24 "Wyden, Casey Sound Alarm on Growing PPE Shortages in Nursing Home," U.S. Senate Committee on Finance, Office of the Ranking Member, Aug. 26, 2020, https://www.finance.senate.gov/ranking-members-news/wyden-casey-sound-alarm-on-growing-ppe-shortages-in-nursing-homes; American Nurses Association, "New Survey Findings from 21K US Nurses: PPE Shortages Persist, Re-Use Practices on the Rise Amid COVID-19 Pandemic," Sept. 1, 2020, https://www.nursingworld.org/news/news-releases/2020/new-survey-findings-from-21k-us-nurses--ppe-shortages-persist-re-use-practices-on-the-rise-amid-covid-19-pandemic/.

25 "Wyden, Casey Sound Alarm on Growing PPE Shortages in Nursing Home," U.S. Senate Committee on Finance, Office of the Ranking Member, Aug. 26, 2020, https://www.finance.senate.gov/ranking-members-news/wyden-casey-sound-alarm-on-growing-ppe-shortages-in-nursing-homes.

26 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020).

27 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020).

28 https://data.cms.gov/stories/s/bkwz-xpvg; https://www.finance.senate.gov/imo/media/doc/082620%20Wyden-Casey%20to%20Vice%20President%20Pence%20re%20Nursing%20Home%20PPE%20Shortages%20Final.pdf

29 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020).

30 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020); https://www.cms.gov/files/document/covid-ifc-3-8-25-20.pdf

31 Rachana Pradhan, "Trump Is Sending Fast, Cheap COVID Tests to Nursing Homes -- But There's a Hitch," Kaiser Health News, Aug. 24, 2020, https://khn.org/news/trump-is-sending-fast-cheap-covid-tests-to-nursing-homes-but-theres-a-hitch/.

32 Ricardo Alonso-Zaldivar, "Trump nursing home plan limits supply of free COVID-19 tests," Associated Press, Aug. 4, 2020, https://apnews.com/267eb99ba143f39d9d51dee32f0512a8.

33 U.S. Food and Drug Administration, "Coronavirus Testing Basics," https://www.fda.gov/consumers/consumer-updates/coronavirus-testing-basics (last accessed Sept. 18, 2020); Rachana Pradhan, "Trump Is Sending Fast, Cheap COVID Tests to Nursing Homes -- But There's a Hitch," Kaiser Health News, Aug. 24, 2020, https://khn.org/news/trump-is-sending-fast-cheap-covid-tests-to-nursing-homes-but-theres-a-hitch/.

34 Robert Service, "Coronavirus antigen tests: quick and cheap, but too often wrong?," Science Magazine, May 22, 2020, https://www.sciencemag.org/news/2020/05/coronavirus-antigen-tests-quick-and-cheap-too-often-wrong.

35 Rachana Pradhan, "Trump Is Sending Fast, Cheap COVID Tests to Nursing Homes -- But There's a Hitch," Kaiser Health News, Aug. 24, 2020, https://khn.org/news/trump-is-sending-fast-cheap-covid-tests-to-nursing-homes-but-theres-a-hitch/.

36 Rachana Pradhan, "Trump Is Sending Fast, Cheap COVID Tests to Nursing Homes -- But There's a Hitch," Kaiser Health News, Aug. 24, 2020, https://khn.org/news/trump-is-sending-fast-cheap-covid-tests-to-nursing-homes-but-theres-a-hitch/.

37 Dan Krauth, "Nursing homes face staff, testing shortages amid COVID-19 pandemic," ABC7, Apr. 15, 2020, https://abc7ny.com/coronavirus-nursing-homes-new-york-ny-cases-in/6105617/; Jordan Bontke, "Staff shortages plague Austin nursing homes as COVID-19 spreads," CBS Austin, Apr. 21, 2020, http://cbsaustin.com/news/local/staff-shortages-plague-austin-nursing-homes-as-covid-19-spreads; Allyson Chiu, "Coronavirus-wracked nursing home evacuated after most of staff failed to show for two days," Washington Post, Apr. 9, 2020, https://www.washingtonpost.com/nation/2020/04/09/california-nursing-home-coronavirus/; Anna Wilde Mathews and Jon Kamp, "Coronavirus Hits Nursing Homes Hard, as Staff Combat Infections, Shortages," Wall Street Journal, Mar. 26, 2020, https://www.wsj.com/articles/coronavirus-hits-nursing-homes-hard-as-staff-combat-infections-shortages-11585250841; Robert Weisman, "Nursing homes fear coronavirus could aggravate severe staff shortages," Boston Globe, Mar. 10, 2020, https://www.bostonglobe.com/2020/03/10/nation/nursing-homes-fear-coronavirus-could-aggravate-severe-staff-shortages/.

38 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020).

39 Letter to Senators McConnell and Schumer from Healthcare, Workers, and Disability Organizations, July 22, 2020, https://www.aging.senate.gov/imo/media/doc/7.22.20%20Sign%20on%20Letter%20for%20the%20Senate.pdf; Brian McGarry, et al., "Severe Staffing And Personal Protective Equipment Shortages Faced By Nursing Homes During The COVID-19 Pandemic," Health Affairs, Aug. 20, 2020, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.01269.

40 Brian McGarry, et al., "Severe Staffing And Personal Protective Equipment Shortages Faced By Nursing Homes During The COVID-19 Pandemic," Health Affairs, Aug. 20, 2020, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.01269.

41 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020).

42 Centers for Medicare and Medicaid Services, "COVID-19 Nursing Home Data," https://data.cms.gov/stories/s/bkwz-xpvg (last accessed Sept. 17, 2020).

43 Rebecca J. Gorges and R. Tamara Konetzka, "Staffing Levels and COVID-19 Cases and Outbreaks in U.S. Nursing Homes," Journal of the American Geriatrics Society, Aug. 8, 2020, https://doi.org/10.1111/jgs.16787; Jose F. Figueroa, et al., "Association of Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse Staffing With COVID-19 Cases," JAMA, Aug. 10, 2020, https://jamanetwork.com/journals/jama/fullarticle/2769437.

44 Robert Gebeloff, et al., "The Striking Racial Divide in How Covid-19 Has Hit Nursing Homes," New York Times, Sept. 10, 2020, https://www.nytimes.com/article/coronavirus-nursing-homes-racial-disparity.html; Sidnee King and Joel Jacobs, "Near birthplace of Martin Luther King Jr., a predominantly Black nursing home tries to heal after outbreak," Washington Post, Sept. 9, 2020, https://www.washingtonpost.com/business/2020/09/09/black-nursing-homes-coronavirus/.

45 Sidnee King and Joel Jacobs, "Near birthplace of Martin Luther King Jr., a predominantly Black nursing home tries to heal after outbreak," Washington Post, Sept. 9, 2020, https://www.washingtonpost.com/business/2020/09/09/black-nursing-homes-coronavirus/.

46 Christina Jewett, "Health Care Workers of Color Nearly Twice as Likely as Whites to Get COVID-19," Kaiser Health News, Aug. 6, 2020, https://khn.org/news/health-care-workers-of-color-nearly-twice-as-likely-as-whites-to-get-covid-19/.

47 Lily Rubin-Miller, et al., "COVID-19 Racial Disparities in Testing, Infection, Hospitalization, and Death: Analysis of Epic Patient Data," Kaiser Family Foundation, Sept. 16, 2020, https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-racial-disparities-testing-infection-hospitalization-death-analysis-epic-patient-data/.

48 Sidnee King and Joel Jacobs, "Near birthplace of Martin Luther King Jr., a predominantly Black nursing home tries to heal after outbreak," Washington Post, Sept. 9, 2020, https://www.washingtonpost.com/business/2020/09/09/black-nursing-homes-coronavirus/; Robert Gebeloff, et al., "The Striking Racial Divide in How Covid-19 Has Hit Nursing Homes," New York Times, Sept. 10, 2020, https://www.nytimes.com/article/coronavirus-nursing-homes-racial-disparity.html; Testimony of R. Tamara Konetzka at "Caring for Seniors amid the COVID-19 Crisis," U.S. Senate Special Committee on Aging, May 21, 2020, https://www.aging.senate.gov/imo/media/doc/SCA_Konetzka_05_21_20.pdf; Testimony of David Grabowski at "Examining the COVID-19 Nursing Home Crisis," U.S. House of Representatives Ways and Means Health Subcommittee, June 25, 2020, https://waysandmeans.house.gov/sites/democrats.waysandmeans.house.gov/files/documents/David%20Grabowski_Testimony.pdf; Letter to Administrator Verma and Director Redfield from Senators Warren, Casey, Wyden, and Murray, July 15, 2020, https://www.warren.senate.gov/imo/media/doc/2020.07.15%20Letter%20to%20CDC+CMS%20re%20nursing%20home%20demographic%20data.pdf.

49 Letter to Senators McConnell and Schumer from Healthcare, Workers, and Disability Organizations, July 22, 2020, https://www.aging.senate.gov/imo/media/doc/7.22.20%20Sign%20on%20Letter%20for%20the%20Senate.pdf.

50 MaryBeth Musumeci and Priya Chidambaram, "COVID-19 Issues and Medicaid Policy Options for People Who Need Long-Term Services and Supports," Kaiser Family Foundation, Apr. 16, 2020, https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-issues-and-medicaid-policy-options-for-people-who-need-long-term-services-and-supports/.

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