The state Department of Health (DOH) has made limited progress in addressing the widespread failures identified in a March 2022 audit of the state’s response to the COVID-19 outbreak in nursing homes, according to a follow-up report released today by New York State Comptroller Thomas P. DiNapoli.

The initial audit found the state was unprepared to respond to infectious disease outbreaks at nursing homes, even before the pandemic, under the previous administration. Also, the state’s persistent underinvestment in public health over the past decade may have limited DOH’s ability to prepare and respond in the most effective way. If DOH had better data, accurate information systems, and an established system of proactive infection control for facilities prior to the pandemic, it could have helped facilities be better prepared. Auditors also determined that DOH gave the public inaccurate COVID-19 death tallies and undercounted those deaths as the Executive took control of public updates on the pandemic.

“The COVID-19 pandemic devastated families and left many whose loved ones contracted the virus in nursing homes with unanswered questions,” said DiNapoli. “Last year, my office examined the extent to which residents in New York’s nursing homes were not adequately protected and the state’s shortfalls in managing the outbreak. Our follow-up review shows limited progress in fixing all that went wrong. Much more work must be done to address problems that still exist to this day. We have to learn from past mistakes, or we risk repeating them.”

Of the four recommendations to DOH in the initial audit, one was fully implemented, one was partially implemented, two others were unaddressed, and one recommendation to the Governor was partially implemented.

The initial audit recommended:

• DOH expand its use of infection control data to identify patterns and find ways to improve infection control practices and nursing home surveys, among other recommendations. Status: Partially implemented. Auditors found that some improvements in data quality were made. They compared DOH’s publicly reported nursing home resident deaths from COVID-19 as of May 16, 2023, to its internal documentation and determined the data sets matched, which was not the case for nearly the entire scope of the initial audit. However, due to data limitations auditors were unable to test the completeness or accuracy of the data. Moreover, DOH has yet to fully use infection control data to detect or identify emerging infectious diseases to shape policies or develop an outbreak management system. Officials said they were strengthening their collection, use and analysis of data but did not provide specifics. DOH also did not provide supporting documentation, such as meeting minutes, to show it has strengthened communication and coordination with localities and epidemiologists.
• DOH help facilities understand how to correctly submit information into the Nosocomial Outbreak Reporting Application (NORA) and maintain support for data submitted on Health Electronic Response Data System (HERDS) surveys to improve data quality, consistency and accountability. Status: Not implemented. DOH has not provided any new guidance to facilities on NORA submissions or support for data submitted on HERDS surveys. Because the initial audit found infections and outbreaks were significantly underreported in NORA, and inaccuracies in non-death COVID-19 data in HERDS, auditors urged DOH to guide facilities on submitting data. DOH’s failure to act on this recommendation means it is likely still collecting, reporting and analyzing data that is inaccurate, inconsistent, and incomplete.
• DOH should improve controls over additions and deletions from the Centers for Medicaid & Medicare (CMS) database and determine if publicly reported nursing home survey data is reliable. Status: Not implemented. Auditors tested data in the initial audit and the follow-up and found a significant number of discrepancies, which means that not all publicly reported data is reliable. The reliability of this data is critical because it is used by the public to make decisions about nursing homes.
• DOH evaluate and request resources as necessary to adequately address public health emergencies. Status: Implemented. DOH conducted a needs assessment and requested 74 new staff positions. 55 are currently filled.
• The Governor should assess and document the adequacy of the internal control environment at DOH and the Executive Chamber and take steps to fix it. Status: Partially implemented. According to the Executive Chamber, it has required state agencies to develop transparency plans and post data online. It is working with health providers to collect operational information and has encouraged DOH to improve communication with stakeholders to address concerns about public disclosure of COVID-19 information. It has appointed a new leadership team at DOH, who have restructured the flow of information. However, the Executive Chamber did not provide detailed information to support that it had assessed the internal control environment.

A separate independent review is underway at the direction of the Executive. The review, conducted by an outside contractor, is evaluating the state’s response to the COVID-19 pandemic. Once public, this review may also give families more answers and help improve accountability.

Follow-Up:
Use, Collection, and Reporting of Infection Control Data (Follow-Up)

2022 Audit: 
Use, Collection, and Reporting of Infection Control Data

Other Relevant Audits: 
Nursing Home Surveillance and Follow-Up 
Oversight of Resident Care-Related Medical Equipment in Nursing Homes and Follow-Up