Objective

To determine the extent of implementation of the five recommendations included in our initial audit report, Use, Collection, and Reporting of Infection Control Data (2020-S-55). The five recommendations included four recommendations to the Department of Health (Department) and one to the Governor.

About the Program

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. Within weeks after the first case was identified, COVID-19 infection and death rates among New York State nursing home residents soared.

Infection control is an essential component of any health care delivery and 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. 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. The COVID-19 pandemic elevated the importance of establishing and adhering to strong infection control practices.

The Department is responsible for overseeing nursing homes, long-term care facilities, and hospitals (hereafter collectively referred to as facilities), and ensuring they comply with federal and State regulations, including infectious control requirements. 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.

The objective of our initial audit, issued on March 15, 2022 and covering the period January 2017 through November 2021, was to determine whether the Department was 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, was accurate and reliable. The audit found that, while the Department’s duty is to act solely to promote public health, instead of providing accurate and reliable information during a public health emergency, the Department conformed its presentation to the previous Executive's¹ narrative, often presenting data in a manner that misled the public. As a result, the Department was not transparent in its reporting of COVID-19 deaths at nursing homes and at one point understated the number of deaths at nursing homes by as much as 50%. 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.

The audit also found that 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. Better data and information systems and an established system of proactive infection control reviews for facilities prior to the pandemic would have provided the Department with more accurate and complete information early on to assist it in its work and would have helped facilities be better prepared. However, despite the substantial amount of different but related data the Department does collect, it did not cooperatively use the various data sources at its disposal to promote strong infection control practices. Further, it did 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.

Key Findings

Department officials and the Executive Chamber have made limited progress in addressing the issues we identified in the initial audit report. Of the initial report’s four audit recommendations to the Department, one was implemented, one was partially implemented, and two were not implemented. The one recommendation to the Governor was partially implemented.

Key Recommendations

Officials are given 30 days after the issuance of this report to provide information on any actions planned to address the unresolved issues discussed in this follow-up.