Objective

To determine whether the Department of Health (Department) is collecting necessary data to make informed decisions and promote strong infection prevention and control policies, and whether the data collected by the Department, including data reported to the public, is accurate and reliable. The audit covered the period from January 2017 through November 2021.

About the Program

On February 28, 2020, a case of coronavirus disease 2019 (COVID-19) was identified in a resident of a long-term care skilled nursing facility in King County, Washington. The patient died on March 2. In the aftermath, 81 residents, 34 staff members, and 14 visitors would ultimately test positive, and at least 37 people would die. A March 18, 2020 report published by the Centers for Disease Control and Prevention (CDC) concluded:  

"Once COVID-19 has been introduced into a long-term care facility, it has the potential to result in high attack rates among residents, staff members, and visitors. In the context of rapidly escalating COVID-19 outbreaks in much of the United States, it is critical that long-term care facilities implement active measures to prevent introduction of COVID-19. … Substantial morbidity and mortality might be averted if all long-term care facilities take steps now to prevent exposure of their residents to COVID-19. The underlying health conditions and advanced age of many long-term care facility residents and the shared location of patients in one facility places these persons at risk for severe morbidity and death. Rapid and sustained public health interventions focusing on surveillance, infection control, and mitigation efforts are resource-intensive but are critical to curtailing COVID-19 transmission and decreasing the impact on vulnerable populations, such as residents of long-term care facilities, and the community at large." (Morbidity and Mortality Weekly Report 60:339-242)

Infection control is an essential component of any health care delivery. Infection control measures can be as simple as thorough handwashing and as sophisticated as high-level disinfection of surgical instruments or the use of personal protective equipment. Implementing these measures can prevent transmission of disease in health care settings and the community. Infection control is a key concept in achieving the Department’s mission to protect and promote the health of New Yorkers through prevention, science, and the assurance of quality health care delivery. Although infection control practices were always essential, the COVID-19 pandemic elevated the importance of establishing and adhering to strong practices. Older people are at a disproportionately greater risk of developing severe and life-threatening symptoms due to physiological changes that come with aging and potential underlying health conditions. Due to the highly contagious nature of COVID-19, the pandemic has had devastating consequences for older populations residing in congregate settings, such as nursing homes. The Department is responsible for overseeing health care facilities (nursing homes, hospitals, and long-term care facilities – hereafter collectively referred to as facilities), and ensuring they comply with federal and State regulations.

Under State regulations, facilities are required to establish and maintain an infection control program, with written policies and procedures designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection.

The Department uses three systems for collecting and reporting infection control data: the Nosocomial Outbreak Reporting Application (NORA); Health Electronic Response Data System (HERDS); and nursing home surveys. Most health care-associated infection outbreaks are reported to the Department via NORA, which receives over 1,000 reports from facilities per year. The Department uses HERDS to collect data from facilities via surveys, which are specific to an issue or public health emergency on a given day. The COVID-19 pandemic-related HERDS survey is the only one the Department has continuously issued daily since March 9, 2020 and was still issuing as of November 18, 2021. HERDS surveys are also used to collect information on COVID-19 nursing home deaths. The Department also collects data through various surveys (e.g., quality of care, fire/safety, complaints, and most recently infection control).

Key Findings

• Providing access to government data engenders transparency and promotes public trust. While the Department’s duty is to act solely to promote public health, we determined that, instead of providing accurate and reliable information during a public health emergency, the Department conformed its presentation to the Executive’s¹ narrative, often presenting data in a manner that misled the public.
• The Department, as a result, was not transparent in its reporting of COVID-19 deaths at nursing homes. Whether due to the poor-quality data that it was collecting initially or, later, a deliberate decision, for certain periods during the pandemic, the Department understated the number of deaths at nursing homes by as much as 50%.
  • From April 12, 2020 to February 3, 2021, the Department frequently changed its basis for the public reporting of COVID-19 deaths in nursing homes (e.g., reporting only resident deaths that occurred at the nursing home vs. reporting all deaths regardless of where they occurred, such as at a hospital), with virtually no explanation publicly as to why it changed.
  • All told, for the nearly 10-month period from April 2020 to February 2021, the Department failed to account for approximately 4,100 lives lost due to COVID-19.
• Persistent underinvestment in public health over the last decade may have limited the Department’s ability to prepare and respond in the most effective way. Department staff, by all accounts, worked tirelessly throughout the pandemic. However, better data and information systems and an established system of proactive infection control reviews for facilities prior to the pandemic would have provided them with more accurate and complete information early on to assist them in their work and would have helped facilities be better prepared. Moreover, once the pandemic began, rapid and sustained public health interventions, including surveillance, infection control, and mitigation efforts, were critical to curtailing COVID-19 transmission to decrease the impact on vulnerable populations, such as residents of nursing home facilities, and the community at large. However, such efforts are resource-intensive, and it is clear that the Department was not adequately equipped in this regard.
• Especially given staffing limitations, it is incumbent on the Department to maximize the effective use of all its other available resources, including data. However, the Department does not cooperatively use the various data sources at its disposal to promote strong infection control practices through policy recommendations and oversight in response to this – or any other – infectious disease event. The Department collects a substantial amount of different but related data from NORA, HERDS, and its nursing home surveys – data that, analyzed collectively, can provide far more valuable information than merely the sum of their parts. However, the Department does not routinely analyze the data broadly to detect interfacility outbreaks, geographic trends, and emerging infectious diseases or to shape its infection control practices and policies and its oversight of facilities.
• We experienced delays during the audit, with requests for information languishing at times for months. Further, Department officials frequently would not answer our questions posed during scheduled meetings, and instead asked us to submit our questions in writing afterward, to be answered at a later date.

¹The Executive is defined to mean the former Governor, members of his staff within the Executive Chamber, and members of the New York State Interagency Task Force, including former health commissioner Howard Zucker).

Key Recommendations

To the Department:

• Develop and implement policies, procedures, or processes to:
  • Expand use of infection control data, including but not limited to NORA, HERDS, and nursing home survey data, to identify patterns, trends, areas of concerns, or non-compliance, and use this information as the basis for policy recommendations for infection control practices and for executing nursing home surveys, as necessary;
  • Improve quality of publicly reported data;
  • Strengthen communication and coordination with localities on collection, reporting, and use of infection control-related data; and
  • Collect supplemental data through additional sources, such as the CDC’s Infection Control Assessment and Response tool, and incorporate its use with current data sets.
• Evaluate and request resources as necessary to establish a foundation to adequately address public health emergencies in furtherance of the Department’s mission.

To the Governor:

• Assess and document the adequacy of the internal control environment at the Department and Executive Chamber, and take necessary steps to ensure the control environment is adequate, including cooperation with authorized State oversight inquiries, communication with localities, and external reporting.