U.S. Department of Health and Human Services 
Office of Inspector General 
The Provider Relief Fund 
Helped Select Nursing Homes 
Maintain Services During 
the COVID-19 Pandemic, 
but Some Found Guidance 
Difficult to Use
 
 
Christi A. Grimm  
Inspector General  
December 2023, OEI-06-22-00040  U.S. Department of Health and Human Services 
 
Office of Inspector General 
Report in Brief 
December 2023, OEI-06-22-00040 
Why OIG Did This Review  The Provider Relief Fund Helped Select 
Nursing homes and their residents 
Nursing Homes Maintain Services During 
have been among the hardest hit 
by the COVID-19 pandemic, partly  the COVID-19 Pandemic, but Some Found 
because of longstanding 
challenges with staffing and  Guidance Difficult to Use 
infection control.  To help nursing 
homes and other health care  What OIG Found 
Key Takeaway 
providers respond to the  After receiving congressional 
pandemic, Congress appropriated  HHS and HRSA quickly  appropriations in March 2020, HHS quickly 
$178 billion and designated HHS  distributed PRF payments  worked with HRSA and other stakeholders 
to oversee Provider Relief Fund  to nursing homes.  Nursing  to develop PRF and began distributing 
(PRF) and related distributions to  homes reported that  general relief payments to health care 
providers.  HHS made  payments were integral to  providers the following month.  HHS began 
approximately $9.4 billion in  maintaining services during  the first targeted distribution payments to 
targeted PRF distributions to  the COVID-19 pandemic,  nursing homes in May.  Although leaders 
nursing homes and skilled nursing  but that guidance from  for the nursing homes in our sample 
facilities (SNFs).    HRSA about the payments  appreciated how quickly the payments 
and reporting requirements  were disbursed, they sometimes faced 
How OIG Did This Review 
was often difficult to use.  challenges with PRF distribution and 
We conducted this evaluation in 
attestation processes. 
conjunction with a series of 
Pandemic Response Accountability  HRSA distributed nearly $15 million in PRF payments to the 11 nursing 
Committee (PRAC) studies  homes in our sample in 2020 and 2021, including more than $5 million from 
examining COVID-19 funding in  targeted distributions to nursing homes and SNFs.  Nursing home leaders 
six select locations.  We examined  reported that HRSAs broad guidance on allowable uses was initially unclear 
how 11 nursing homes in those  and difficult to use.  As a result, some were hesitant to use the funds for fear 
locations used PRF payments  they would use the money incorrectly and be forced to pay it back later.  
during 2020 and 2021 to improve  Regardless of the challenges, the nursing homes had used and reported 
their responses to the COVID-19  about $12 million of the $15 million when we began our site visits in 
pandemic.  We also examined  May 2022.  Nursing home leaders reported using the funds for expenses and 
Health Resources and Services  lost revenue, and reported that PRF payments were integral to maintaining 
Administration (HRSA) oversight of  services during the pandemic. 
the funds.  We based our findings 
HRSA required nursing homes to submit reports about PRF use.  The nursing 
on document reviews, an analysis 
homes in this review generally complied with the reporting requirements, but 
of PRF payment data, and 
some appeared to misreport data or had to resubmit information.  Nursing 
33 interviews with leadership, staff, 
home leaders reported that it was difficult to find time to review lengthy 
residents, and residents family 
reporting guidance, and that completing the reports was a burden.  Although 
members from the selected 
HRSA reported plans to assess nursing home use of PRF, the agency had not 
nursing homes.  We also 
yet begun conducting audits at the time we conducted our review. 
conducted two group interviews 
with HRSA officials.  We collected 
What OIG Recommends and How the Agency Responded 
the documents and data in early 
We recommend that HRSA: (1) create a document to record lessons learned 
2022 to prepare for conducting 
from managing PRF and submit the document to HHS leadership and 
interviews from May through 
(2) expedite audits of provider use of PRF payments.  HRSA did not concur 
December concurrently with the 
with the first recommendation and concurred with the second.
PRACs site visits. 
   
TABLE OF CONTENTS 
 
 
BACKGROUND ................................................................................................................................................ 1 
FINDINGS ....................................................................................................................................................... 13 
After receiving congressional appropriations, HHS quickly developed PRF and began distributing 
payments to nursing homes ............................................................................................................................................... 13 
Nursing homes in our sample used $12 million in PRF payments to address COVID-19-related 
expenses and lost revenue, and said that the funds were integral to maintaining services during 
the pandemic ............................................................................................................................................................................ 15 
Nursing homes in our sample generally complied with PRF reporting requirements but reported 
that HRSA guidance was difficult to use ........................................................................................................................ 21 
HRSA developed plans to assess nursing home use of PRF but had not yet begun auditing nursing 
homes at the time we conducted our review ............................................................................................................... 23 
CONCLUSION AND RECOMMENDATIONS .......................................................................................... 25 
Create a document to record lessons learned from managing PRF and submit the document to HHS 
leadership ................................................................................................................................................................................... 25 
Expedite audits of provider use of PRF payments ...................................................................................................... 26 
AGENCY COMMENTS AND OIG RESPONSE ......................................................................................... 27 
APPENDIX ..................................................................................................................................................... 28 
Agency Comments ................................................................................................................................................................. 28 
ACKNOWLEDGMENTS AND CONTACT ................................................................................................. 31 
ABOUT THE OFFICE OF INSPECTOR GENERAL .................................................................................... 32 
ENDNOTES ................................................................................................................................................... 33 
 
 
 
   
BACKGROUND 
OBJECTIVES 
1.  To assess how select nursing homes used Provider Relief Fund (PRF) 
payments during calendar years (CYs) 2020 and 2021 to improve their 
responses to the COVID-19 pandemic. 
2.  To evaluate the Health Resources and Services Administrations (HRSAs) 
management and oversight of PRF payments distributed to nursing homes. 
 
Background  
The COVID-19 pandemic has had a devastating effect on nursing homes and their 
residents, partly because of longstanding challenges related to infection control and 
staffing.1, 2, 3  To reimburse nursing homes and other health care providers for health 
care-related expenses and lost revenues attributable to COVID-19, Congress 
appropriated $178 billion to the Department of Health and Human Services (HHS) 
during 2020 and 2021.4  HHS administered the funds through PRF and related 
programs.5  This review includes only funding administered through PRF distributions, 
of which there were two types: general distributions and targeted distributions to 
categories of health care providers that had added COVID-19 challenges.6  HHS made 
approximately $9.4 billion in targeted PRF distributions to skilled nursing facilities 
(SNFs) and nursing homes, and obligated approximately $54.7 billion in total to SNFs 
and nursing homes across all PRF distributions.7  HHS stopped making PRF payments 
in June 2023 following passage of the Fiscal Responsibility Act of 2023.8 
COVID-19 and Nursing Homes 
The nations nursing home residents have been hard hit by the COVID-19 pandemic.  
Residents advanced ages, underlying medical conditions, and close living quarters 
have made residents especially vulnerable.9  As of January 1, 2023, more than 
1.4 million nursing home residents in the United States had already had a confirmed 
case of COVID-19, with approximately 160,000 deaths.10  Previous HHS Office of 
Inspector General (OIG) work found that almost 1,000 more nursing home residents 
enrolled in Medicare died per day in April 2020 than in April the previous year.11   
Nursing homes have faced longstanding infection control and other challenges that 
continued during the pandemic.  From 2013 through 2017, the Centers for Medicare 
& Medicaid Services (CMS) and State surveyors cited 82 percent of nursing homes 
with infection control deficiencies, and cited half of those homes in consecutive 
years.12  During COVID-19 surges in the spring and fall of 2020, more than 
The PRF Helped Select Nursing Homes Maintain Services During the COVID-19 Pandemic, but Some Found Guidance  
Difficult to Use   
OEI-06-22-00040   Background | 1    
1,300 nursing homes had infection rates of 75 percent or more among residents 
enrolled in Medicare.13  Nursing homes also experienced inadequate access to 
personal protective equipment (PPE) and staffing shortages, which may have further 
contributed to infection control problems.14, 15  In July 2021, the American Health Care 
Association and National Center for Assisted Living released survey results that found 
94 percent of nursing homes reported recently experiencing staffing shortages.16  
According to media reports, nursing homes also faced ongoing financial hardships 
throughout the pandemic.17, 18 
PRF Overview 
During CYs 2020 and 2021, Congress appropriated $178 billion to HHSs Public Health 
and Social Services Emergency Fund to reimburse eligible health care providers for 
health care-related expenses or lost revenues attributable to COVID-19.a, b  HHS 
administered $136.6 billion of that funding through PRF.  HHS administered further 
funding through related programs.19, c 
PRF included two funding distribution types: general and targeted.  General 
distributions were broadly available to health care providers, while targeted 
distributions were for health care providers with added COVID-19 challenges, such as 
providers highly impacted by COVID-19 or serving high-need and vulnerable 
populations (e.g., nursing homes).20, 21  HHS disbursed the general distributions
totaling $81.4 billionin four phases.22, 23  Targeted distributions were made to 
specific provider types, including providers in COVID-19 high-impact areas, rural 
providers, Indian Health Service and Tribal providers, safety net hospitals, childrens 
hospitals, SNFs, and nursing homes.  Targeted distributions made to these provider 
types varied in amount, with totals ranging from $494 million to $20.7 billion.24  (See 
Exhibit 1 for PRF distribution type summaries.)  Allocation levels differ from the 
amounts HHS originally planned and announced due to the number of applicants for 
some general distributions, returned funds, and other factors.d  HHS stopped making 
PRF payments in June 2023.25
 
a HHS uses the Public Health and Social Services Emergency Fund to improve preparedness against 
naturally occurring and man-made health threats, as well as threats that interfere with HHSs function.  
See HHS, Fiscal Year 2020 Public Health and Social Services Emergency Fund, Justification of Estimates for 
Appropriations Committee, p. 11.  Accessed at https://www.hhs.gov/sites/default/files/fy-2020-cj-phssef-
final-print.pdf on Jan. 30, 2023.  
b The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated $100 billion; the Paycheck 
Protection Program and Health Care Enhancement (PPPHCE) Act appropriated $75 billion; and the 
Consolidated Appropriations Act, 2021, appropriated $3 billion.  See CARES Act, P.L. No. 116-136, 
Division B, Title VIII, (Mar. 27, 2020); PPPHCE Act, P.L. No. 116-139, Division B, Title I (Apr. 24, 2020); and 
Consolidated Appropriations Act, 2021, P.L. No. 116-260, Division M, Title III (Dec. 27, 2020). 
c For more information about related programs funded using these and other appropriations, see 
footnotes e and f on page 4 of this report. 
d For example, HHS initially announced $18 billion for Phase 2 of the General Distribution but only 
allocated $4.5 billion.  See HRSA, Past General Distributions, November 2022.  Accessed at 
https://www.hrsa.gov/provider-relief/past-payments/general-distribution on Dec. 16, 2022. 
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OEI-06-22-00040   Background | 2    
Exhibit 1: PRF Distribution Types 
 
Sources: HRSA, Past General Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-
relief/payments-and-data/past-payments/general-distribution on Dec. 16, 2022.  HRSA, Phase 4 and ARP Rural 
Distributions, September 2023.  Accessed https://www.hrsa.gov/provider-relief/payments-and-data/phase4-arp on 
Sept. 18, 2023.  HRSA, Past Targeted Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-
relief/payments-and-data/past-payments/targeted-distribution on Dec. 16, 2022. 
Note: Purple boxes indicate targeted distributions for nursing homes and SNFs.  HRSA does not publicly report total 
amounts from other PRF distributions that may have gone to nursing homes or SNFs. 
HRSA Management of PRF 
HRSA is the HHS agency responsible for administering the PRF program.  HRSA 
operates programs that provide health care to people who are geographically isolated 
or economically or medically vulnerable.  Its mission is to improve health outcomes 
and achieve health equity through access to quality services; a skilled health 
workforce; and innovative, high-value programs.26  The agency has served several 
critical functions during the pandemic, including investing in the public health 
workforce using National Health Service Corps programs; expanding vaccine access in 
health centers, rural health clinics, and community-based organizations; operating the 
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COVID-19 Coverage Assistance Fund, which covers costs associated with 
administering COVID-19 vaccines to patients whose health insurance would not fully 
cover those costs; and administering claims reimbursement to health care providers 
for COVID-19 testing, treatment, and vaccinations for uninsured patients through the 
COVID-19 Uninsured Program.27, 28, 29, e, f   
HRSA manages the PRF program through its Provider Relief Bureau by overseeing 
provider application reviews and operating the PRF Reporting Portal, among other 
efforts.30, 31, 32  HRSA has contracted with external organizations to assist with some 
functions, such as collecting information through the application portal, facilitating 
the distribution of PRF payments, and auditing provider use of PRF.33, 34, 35   
Targeted PRF Distributions to Nursing Homes and SNFs 
HRSA distributed approximately $9.4 billion in targeted PRF payments directly to SNFs 
and nursing homes.36, g  HRSA distributed $4.8 billion of this amount to 12,806 SNFs 
which provide complex nursing and therapy care that can only be safely and 
effectively performed by, or under the supervision of, skilled nursing and therapy 
professionals.37  HRSA used a fixed-payment approach for this SNF distribution; SNFs 
with at least six CMS-certified beds qualified for $50,000 plus $2,500 per bed.38  The 
terms and conditions required that recipients use the payments to prevent, prepare 
for, and respond to COVID-19, and only for health care-related expenses or lost 
revenues attributable to COVID-19.39 
 
e Within PRF, HHS and HRSA used a portion of the funding Congress appropriated to support health 
care-related expenses attributable to the COVID-19 pandemic in order to support the Coverage 
Assistance Fund and the COVID-19 Uninsured Program.  See Centers for Disease Control and Prevention 
(CDC), Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine 
Administration of the Uninsured, updated Mar. 3, 2022.  Accessed at https://data.cdc.gov/Administrative/ 
Claims-Reimbursement-to-Health-Care-Providers-and-/rksx-33p3 on Jan. 30, 2023; and CDC, COVID-19 
Coverage Assistance Fund: Claims Reimbursement to Health Care Providers and Facilities for Services to the 
Underinsured, updated Nov. 16, 2022.  Accessed at https://data.cdc.gov/Administrative/COVID-19-
Coverage-Assistance-Fund-Claims-Reimburse/xgy8-wnft on Jan. 30, 2023. 
f HRSA administered funds for other programs alongside PRF.  HHS used $8.5 billion that Congress 
appropriated through the American Rescue Plan (ARP) Act of 2021 to establish the ARP Rural Distribution 
to administer payments to providers and suppliers who serve rural enrollees in Medicaid, the Childrens 
Health Insurance Program, and Medicare.  The Rural Health Clinic COVID-19 Testing (RHCCT) and Rural 
Health Clinic COVID-19 Testing and Mitigation (RHCCTM) programs supported Rural Health Clinics in 
maintaining and increasing COVID-19 testing and mitigation efforts.  See HHS press release, Biden-
Harris Administration Begins Distributing American Rescue Plan Rural Funding to Support Providers 
Impacted by Pandemic, Nov. 23, 2021.  Accessed at https://public3.pagefreezer.com/browse/HHS.gov/
30-12-2021T15:27/https:/www.hhs.gov/about/news/2021/11/23/biden-admin-begins-distributing-arp-
prf-support-to-providers-impacted-by-pandemic.html on Aug. 10, 2023; and HRSA, Rural Health Clinic 
COVID-19 Testing and Mitigation (RHCCTM) Program, August 2022.  Accessed at 
https://www.hrsa.gov/coronavirus/rural-health-clinics/testing on Oct. 27, 2022. 
g In addition to the targeted distributions, some nursing homes also qualified for additional funding 
through general and other PRF distributions.  In June 2023, HRSA reported to OIG that HHS had 
obligated approximately $54.7 billion total to SNFs and nursing homes across all PRF distributions. 
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OEI-06-22-00040   Background | 4    
HHS distributed the remaining $4.6 billion to nursing homes through the Nursing 
Home Infection Control (NHIC) distribution.  The NHIC distribution included two types 
of allocations: infection control payments and the Quality Incentive Payment (QIP) 
program.  HRSA distributed infection control payments to 12,787 nursing homes 
using a per-facility formula: $10,000 per home plus $1,450 per certified bed.  HRSA 
distributed QIP to 11,819 nursing homes in amounts that varied by facility and month.  
HHS developed a complex formula using COVID-19 infection and mortality rates to 
determine whether nursing homes qualified for QIP.  HRSA distributed QIP four times 
following monthly assessments between September and December 2020.40, h  (See 
Exhibit 2 for information about SNF and NHIC payment calculations.)  The terms and 
conditions for the NHIC distribution required that recipients spend the funds on 
infection control-related expenses, such as COVID-19 testing and hiring staff.41   
Exhibit 2: Targeted PRF Distributions to SNFs and Nursing Homes 
 
Source: HRSA, Past Targeted Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-
relief/payments-and-data/past-payments/targeted-distribution on Dec. 16, 2022. 
HRSA automatically distributed SNF and NHIC payments directly to eligible nursing 
homes electronically or by check.42  HRSA directed providers to attest to accepting 
the associated terms and conditions upon receiving the funds.i  The terms and 
conditions required nursing homes to allow public disclosure of the payments and to 
fully cooperate with audits, in addition to other requirements.43, 44  HRSA requires 
 
h HHS and HRSA calculated the infection and mortality measures using data from sources such as CDCs 
National Healthcare Safety Network and COVID-19 community profile reports.  See HRSA, Nursing Home 
Quality Incentive Program Methodology, Dec. 7, 2020.  Accessed at https://www.hrsa.gov/sites/default/
files/hrsa/provider-relief/nursing-home-qip-methodology.pdf on Jan. 31, 2023. 
i HRSA deemed providers that did not attest to the terms and conditions as having attested if they 
retained a payment for 90 days.  Providers use the CARES Act PRF Payment Attestation Portal or the PRF 
Application and Attestation Portal to attest to the terms and conditions.  See HRSA, PRB Provider Relief 
Fund General Information FAQ.  Accessed at https://www.hrsa.gov/provider-relief/faq/general on 
Jan. 31, 2023.   
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providers with unused funds at the end of a relevant period of availability to return 
the funds.j   
Timelines and Reporting Requirements   
HHS began issuing PRF payments in April 2020 and, for reporting purposes, 
established periods during which PRF recipients must use and report on the funds.45  
HRSA required all recipients that received PRF payment(s) exceeding $10,000 in the 
aggregate during any given payment-received period (i.e., a time period in which a 
health care provider received one or more PRF payments) to report use of the funds 
during the applicable reporting period.  Those recipients reported use in broad 
categories, by lost revenue, or by general or health care-related expense.46, k  
In general, PRF recipients must use the funds within 1 year after the payment-received 
period ends and report on use during a subsequent 3-month period.  HRSA has 
revised the periods since developing its initial timelines.  In May 2023, HRSA added 
Periods 8 and 9 that extend reporting through fiscal year 2025.47  (See Exhibit 3 for a 
list of the payment-received, use, and reporting periods.) 
 
 
 
 
 
 
 
 
 
 
 
 
 
j Providers return unused PRF payment amounts to HRSA through the Return Unused PRF Funds Portal.  
See HRSA, PRB Provider Relief Fund General Information FAQ.  Accessed at 
https://www.hrsa.gov/provider-relief/faq/general on Jan. 31, 2023. 
k HRSA required providers to report use of NHIC payments and all other payments separately. 
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Exhibit 3: Timelines for Provider Receipt, Use, and Reports of PRF Payments 
Payment-Received  Deadline for  Reporting Time 
 
Period*  Using Funds  Period 
From Apr. 10 to  July 1 to 
Period 1  June 30, 2021 
June 30, 2020  Sept. 30, 2021** 
From July 1 to  Jan. 1 to 
Period 2  Dec. 31, 2021 
Dec. 31, 2020  Mar. 31, 2022 
From Jan. 1 to  July 1 to 
Period 3  June 30, 2022 
June 30, 2021  Sept. 30, 2022 
From July 1 to  Jan. 1 to 
Period 4  Dec. 31, 2022 
Dec. 31, 2021  Mar. 31, 2023 
From Jan. 1 to  July 1 to 
Period 5  June 30, 2023 
June 30, 2022  Sept. 30, 2023 
July 1 to  Jan. 1 to 
Period 6  Dec. 31, 2023*** 
Dec. 31, 2022  Mar. 31, 2024 
Jan. 1 to  July 1 to 
Period 7  June 30, 2024*** 
June 30, 2023  Sept. 30, 2024 
July 1 to  Jan. 1 to 
Period 8  Dec. 31, 2024*** 
Dec. 31, 2023  Mar. 31, 2025 
Jan. 1 to  July 1 to 
Period 9  June 30, 2025*** 
June 30, 2024  Sept. 30, 2025 
Source: HRSA, Important Dates for Reporting, May 2023.  Accessed at https://www.hrsa.gov/provider-relief/reporting-
auditing/important-dates on May 11, 2023. 
* These periods are not the same as the general distribution phases.  HHS used the general distribution phases to 
distribute funding as the Department received and allocated it; these periods were established for reporting purposes. 
** HRSA allowed a grace period for this reporting time period, which ended on Nov. 30, 2021.  
*** PRF payments not fully expended on expenses attributable to COVID-19 may only be applied to lost revenue up to 
the end of the quarter in which the Public Health Emergency ended (i.e., June 30, 2023).  See HRSA, How to Calculate 
Lost Revenues for PRF and ARP Rural Reporting, February 2023.  Accessed at https://www.hrsa.gov/provider-
relief/reporting-auditing/lost-revenues on Mar. 20, 2023. 
Related Work 
This study expands on OIGs body of work focused on the health and well-being of 
nursing home residents, as well as OIGs oversight of HHSs COVID-19 response and 
recovery.  Prior evaluations found that nursing home residents enrolled in Medicare  
were hard-hit by COVID-19, with 2 in 5 diagnosed with either COVID-19 or likely 
COVID-19 in 2020, and that more than 1,000 nursing homes experienced extremely 
high infection rates and an average overall mortality rate approaching 20 percent 
during COVID-19 surges in 2020.48, 49  A July 2023 evaluation found some differences 
in targeted PRF funds allocated to hospitals with respect to the race and ethnicity of 
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the populations the hospitals served.50  OIG has an ongoing evaluation examining 
nursing home strategies to mitigate pandemic-related challenges.51 
OIG has an ongoing, three-part approach to auditing PRF.  In the first part, OIG found 
that HHSs oversight of automatic general distribution Phase 1 PRF payments was 
generally effective but improvements could be made.52  In the second, OIG is 
conducting several additional audits of PRF general distributions, including audits of 
controls for provider submission of information, provider eligibility, and other items.53  
In one of these audits, OIG found that HHSs and HRSAs controls related to selected 
PRF program requirements could be improved.54  In the third part of its audit strategy, 
OIG is auditing provider expenditures of PRF funding and compliance with program 
requirements.55, 56  One of those audits will include a larger sample of SNFs to 
determine whether PRF recipients complied with certain terms, conditions, and 
Federal requirements for spending and reporting on PRF payments. 
See the OIG COVID-19 Portal for more information about OIGs oversight work 
related to COVID-19 and the OIG nursing home site for more information about OIGs 
efforts to protect nursing home residents, strengthen oversight, and promote 
emergency preparedness. 
Joint Work With the PRAC 
We conducted this evaluation in conjunction with a series of studies led by the 
Pandemic Response Accountability Committee (PRAC)a committee of 20 Inspectors 
General created by Congress to oversee pandemic relief spendingthat examined 
Federal COVID-19 funding.  The PRAC released the first report in July 2023 and plans 
to release the remaining reports in 2024.57  
The PRAC divided its project into two phases: 
1)  Phase 1 provides an overview of Federal COVID-19 funding to 6 geographic 
locations, which was distributed by programs overseen by 10 participating Federal 
OIGs.   
2)  Phase 2 will detail funding distributed to each location for specific programs 
chosen by each OIG.  The PRAC and participating OIGs visited each selected 
location, virtually or in person, and conducted interviews with community officials 
and others to examine the use and effect of pandemic relief funding in the 
selected programs.   
Methodology 
Scope of Inspection 
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We examined the use of PRF payments to 11 nursing homes during CYs 2020 and 
2021, and HRSA management and oversight of those funds.l  We conducted our data 
collection concurrently with the PRACs Phase 2 site visits to its selected locations 
from May through December 2022.  We used virtual interviews, documents, and 
payment data to identify how the nursing homes used PRF payments and whether 
they experienced any challenges using these funds.  To assess HRSA management 
and oversight of PRF payments, we interviewed HRSA officials and nursing home 
leaders about PRF distribution processes and the agencys efforts to collect and 
review related data and documentation.  
As noted, we conducted this evaluation in conjunction with a series of studies led by 
the PRAC that examined Federal COVID-19 funding.  The PRAC selected 
six geographic locations as the subject of its studies.  The PRAC chose the 6 by 
randomly selecting 10 locations within each of 3 area types: small to-mid-sized cities, 
rural communities, and Tribal reservations.  From each group of 10, the PRAC then 
selected 2 locations based on the highest total number of COVID-19 cases.  The PRAC 
also considered additional factors, such as total funding provided to each location 
and geographic distribution across the United States. 
The 11 sample nursing homes include all nursing homes located in the PRACs 
6 selected geographic locations that received PRF payments through the SNF and 
NHIC distributions.m  (See Exhibit 4 for a list of the geographic locations selected by 
the PRAC and the number and size of nursing homes within each location.)  One of 
the six PRAC-selected locations did not include any nursing homes that directly 
received PRF funds and was not included as part of this evaluation.  Because of data 
constraints, we did not include 2 nursing homes that did not receive direct PRF 
payments in our sample of 11 nursing homes, although they may have received PRF 
funds as subrecipients of distributions to their owners.  We also excluded a 
third nursing home.  That nursing homes Taxpayer Identification Number (TIN) was 
associated with an outdated location in the PRF payment data, which was located 
within study boundaries.  However, a representative for the company identified by the 
TIN reported that the company no longer operated a facility within those boundaries.   
 
 
 
l For purposes of our review, we used the term nursing homes to refer to all facilities in our sample 
regardless of technical status (i.e., nursing facility and/or SNF) according to common use.  We use the 
term SNF throughout only when referring to HRSAs targeted distribution allocated to SNFs. 
m To determine the sample of nursing homes, we filtered data about PRF payments to nursing homes 
using ZIP Codes for each location provided by the PRAC.  We also verified the sample by using mapping 
tools to identify any additional nursing homes located within the ZIP Codes but included in the PRF data 
under another location, such as the location of facility owners. 
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Exhibit 4: Number and Size of Sample Nursing Homes in Each Location 
Average Number 
Number of 
Location Selected by the PRAC  of Beds per 
Nursing Homes 
Nursing Home* 
Springfield, MA  1**  120 
Coeur dAlene, ID  5  86 
Sheridan County, NE  3  56 
Marion County, GA  1  70 
White Earth Nation Indian 
1  32 
Reservation (MN) 
Jicarilla Apache Nation 
-  - 
Reservation (NM) 
All Locations  11  75 
Source: OIG analysis of PRF data and OIG analysis of supplemental National Healthcare Safety Network COVID-19 
nursing home data from August 2022. 
* Numbers rounded to the nearest whole number. 
** The three nursing homes that we did not include in our sample were located in Springfield.  
Although we determined our sample by selecting the nursing homes in each location 
that received PRF payments through the SNF and NHIC distributions, our findings 
include a discussion about the nursing homes use of all types of PRF payments 
received.  In addition to SNF and NHIC payments, the nursing homes in our sample 
received payments from other PRF distributions, including general distributions and 
targeted distributions to other types of health care providers.n, o  We chose to include 
the nursing homes broader PRF payments because interview respondents often did 
not distinguish SNF and NHIC payments from other payments.  In addition, use of 
SNF payments is reported together with the use of other payment types to HRSA. 
Data Collection 
 
n Some of the nursing homes in our sample are part of facilities that also serve as hospitals, health 
centers, or other facility types. 
o We refer to all non-NHIC or SNF payments the nursing homes in our sample received as other 
throughout this report. 
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Interviews: To evaluate nursing home use of PRF payments, we held interviews 
virtually with leadership, staff, and a small number of residents and family members 
from the selected nursing homes concurrently with the PRACs onsite visits.p  We also 
conducted two virtual group interviews with relevant HRSA officials.  We employed 
adaptable interview protocols that allowed us to modify questions, as needed, and 
follow up on additional issues as we identified key issues. 
Nursing Home Interviews: We conducted 33 individual or group interviews with 
131 leaders, staff, residents, and family members at the selected nursing homes.  
Leaders included nursing home administrators and directors of nursing; corporate 
executives; representatives from contracted management and audit groups; health 
care system leaders; and others.  Staff interviews included clinical and nonclinical staff.  
During interviews, we discussed nursing home experiences in using the funds and 
reporting the information to HRSA, including any challenges and interactions with 
HRSA.  We conducted interviews with residents and/or family members at some of 
the nursing homes to gather supplementary insights about nursing home care during 
COVID-19.  We used these insights for the PRACs corresponding location-specific 
reports described on page 8 of this report. 
HRSA Interviews: We conducted two group interviews with representatives from 
HRSAs Provider Relief Bureau and Office of Planning, Analysis, and Evaluation.  
Interviewees included 13 officials who responded during one or both interviews, as 
well as 6 other attendees.  During the interviews, we discussed HRSAs efforts to 
manage and oversee PRF, including the agencys efforts related to PRF payment 
distribution, provider reporting processes, audits, and recovery of improper or 
unintended payments.  We also asked about any coordination regarding nursing 
homes with CMS and other Federal or State agencies.  We discussed any challenges 
that HRSA experienced with oversight, and any actions it took to assist nursing homes 
in overcoming challenges.   
Document Review: We collected available funding receipt attestations and reports 
to HRSA about how the sample nursing homes used PRF payments.  OIG extracted 
the documents during April and June 2022 in preparation for the PRACs series of 
location site visits.  At that time, only two of four required reporting periods had 
passed, so the nursing homes had not yet reported on their use of all PRF payments.  
They had, however, reported on most of the payments they received through the SNF 
and NHIC distributions.q  We also requested and reviewed summary documentation 
from the nursing homes supporting expenses and lost revenue outlined in those 
 
p In addition to conducting our own interviews, we attended 13 PRAC interviews with leadership and 
health or related departments in the 5 locations containing nursing homes that received PRF payments 
directly.  We did not include information from those interviews in our findings.  We did, however, confirm 
that the local departments did not have any role in helping nursing homes determine how to use PRF. 
q During the first two reporting periods, the nursing homes in our sample were required to report about 
their use of 61 of 80 PRF payments received during 2020 and 2021, including 43 of 57 SNF and NHIC 
payments. 
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reports.  Additionally, we requested any correspondence between HRSA officials and 
the nursing homes about PRF money and the reports, as well as any documentation 
of HRSAs oversight actions related to the use of the funds.  As of June 8, 2022, HRSA 
had no documentation of oversight actions related to the nursing homes.   
PRF Payment Data: To summarize PRF payments the nursing homes received and 
kept, we reviewed PRF payment data from HRSA for the 11 selected nursing homes.  
We collected PRF payment data in preparation for the PRACs series of location site 
visits; the data were extracted on February 28, 2022, and, depending on whether the 
payments were made electronically or by check, were current through the beginning 
of January or February 2022.  The data therefore included all payments made during 
our timeframe, which included CYs 2020 and 2021. 
Data Analysis 
We conducted a qualitative analysis of interview data and documentation from the 
nursing homes and HRSA.  We used our analysis to gain a deeper understanding of 
PRF program strengths and weaknesses from the perspective of HRSA and the 
11 nursing homes.  This analysis also helped us to determine how the selected 
nursing homes used targeted payments to improve infection control and address 
health care expenses and lost revenue related to the pandemic.  We identified themes 
and challenges related to the disbursement and use of the funds, and PRF oversight 
processes.   
We conducted a quantitative review of PRF payment data and of the nursing homes 
reports and supporting financial documentation.  We used our analysis of the data to 
briefly summarize the types and amounts of PRF payments each nursing home 
received and how the funds were used.   
Limitations 
We focused only on the experiences of the 11 selected nursing homes.  Our findings 
cannot be generalized to all nursing homes that received PRF payments. 
Although HHS-OIG compared the nursing home reports to HRSA against supporting 
documentation and PRF terms and conditions to assess appropriateness, we did not 
conduct an audit of the nursing homes financial documentation to verify their reports 
and supporting material. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
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FINDINGS 
After receiving congressional appropriations, HHS quickly 
developed PRF and began distributing payments 
to nursing homes 
HRSA officials described PRF development as an urgent and difficult endeavor.  
Officials said that it was an extraordinary challenge to balance the urgency to 
distribute the payments with the large amount of information, guidance, and requests 
the agency received from stakeholders.  One official explained that HHS and HRSAs 
goal in developing PRF was to invest in entities that would have the highest 
pandemic-related lost revenues and increased expenses, such as hard-hit nursing 
homes.  Another official added that HHS and HRSA sought to use QIP distributions to 
reward nursing homes that created and maintained safe environments for residents. 
HHS and HRSA quickly developed PRF policies and processes and began distributing 
general distribution Phase 1 payments to health care providers on April 10, 2020, 
within 1 month after the enactment of the CARES Act on March 27.  HRSA began the 
SNF and NHIC distributions shortly thereafter.  (See Exhibit 5 for a timeline of PRF 
development and initial distribution to nursing homes.)  As OIG has recognized, 
distributing PRF quickly during unprecedented circumstances was a substantial 
challenge.58   
Exhibit 5: PRF Development and Distribution Timeline 
 
Sources: CARES Act, P.L. No. 116-136, (Mar. 27, 2020); and data from HRSA officials, June 2022.  
HHS worked with HRSA, other HHS agencies, and contractors 
to rapidly develop PRF policies and processes 
HHS collaborated with HRSA and a wide range of other stakeholders to develop and 
manage PRF.  According to HRSA officials, the HHS Office of the Secretary led 
program and policy development including the development of payment 
methodologies, terms and conditions, oversight processes, and determining eligibility 
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standards.  HHS sought feedback from HRSA and other agencies about the 
distributions.  For example, one official reported that HHS convened agencies 
including CMS, CDC, and others to coordinate HHS infection control activities, 
including NHIC QIP.  HHS and HRSA also sought feedback from two nursing home 
associations about QIP.   
Following PRF development, HRSA became responsible for program management 
and worked with HHS on provider communication.  HHS and HRSA worked with 
contractors to develop payment methodologies, portals for applications and 
attestations, and other efforts. 
One official reported that HHS and HRSA developed broad PRF terms and conditions 
so that providers could use [the] money in any way they saw fit to address health 
care-related expenses and lost revenue attributable to COVID-19 in accordance with 
the PRF appropriations statutes.  The official further confirmed that, according to the 
NHIC terms and conditions, NHIC payments could be used for COVID-19-related 
infection control expenses but could not be used for lost revenue.   
HRSA used a variety of methods to distribute payments 
to providers, but had some difficulty issuing automatic payments 
to nursing homes because of data lags 
To quickly distribute PRF payments, HRSA relied on various payment techniques.  
HRSA officials reported that the agency used automatic push payments during the 
first phase of the general distribution and for targeted distributions.  To distribute 
automatic payments, HRSA used data such as bank account information and provider 
addresses from other HHS agencies, including CMS and the Indian Health Service.  
For example, HRSA was able to distribute many of the targeted payments to nursing 
homes using banking information CMS had for Medicare- and Medicaid-participating 
facilities.  HRSA used application processes to gather information about providers for 
which it did not already have necessary data.  HRSA distributed general distribution 
Phase 2, 3, and 4 and some Phase 1 payments using information providers submitted 
through those applications. 
Officials reported that the timing of data on changes in nursing home ownership 
affected payment distribution.  Specifically for general distribution Phase 1 and SNF 
targeted distribution payments, officials said that lags in ownership data that HRSA 
received from other HHS agencies resulted in a small number of payments distributed 
to prior owners.  To remedy this, HRSA allowed providers that did not receive correct 
general distribution Phase 1 payments to apply for funds during Phase 2 and required 
incorrect recipients to return the funds.  HRSA also reissued targeted distribution 
payments to the correct providers. 
 
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Nursing homes in our sample sometimes faced challenges 
with PRF distribution and attestation processes 
Nursing home leaders appreciated the efficiency of payment disbursement but were 
sometimes unsure of or disagreed with PRF distribution processes.  Some said they 
had little or no notice regarding when they would receive the funds, and sometimes 
they had to retroactively determine which distributions the payments came from after 
receiving them.  Some leaders were unsure of, or disagreed with, the methods HRSA 
used to determine the payment amounts.  For example, one nursing home 
administrator disagreed with the use of QIP to incentivize quality.  The administrator 
stated that most nursing homes continually strive for quality, but that it is harder for 
facilities with less funding to meet quality benchmarks, which results in ineligibility for 
payments determined by quality measures and can lead to a cycle of underfunding. 
A leader for two nursing homes in our sample said the nursing homes were initially 
unable to access some PRF funds.  The nursing homes were in a chain and had 
difficulty accessing NHIC payments because the chain was going through bankruptcy 
and therefore had been deemed ineligible for PRF funds.r 
HHS and HRSA required nursing homes and other providers to attest to the 
associated terms and conditions upon receiving payments, but the nursing homes in 
our sample often did not complete attestations.s  One leader reported that the 
attestation process was tedious, required a lot of clicks, and that sometimes 
information did not save correctly.  The leader added that every payment required 
separate attestations, which meant completing the same process repeatedly.  As 
noted in footnote i (on page 5), HRSA deemed providers that did not attest to the 
terms and conditions as having attested if they retained a payment for 90 days. 
Nursing homes in our sample used $12 million in PRF payments 
to address COVID-19-related expenses and lost revenue, and 
said that the funds were integral to maintaining services during 
the pandemic 
At the time of our review, the sample nursing homes had been required to report to 
HRSA about the use of approximately $12 million of nearly $15 million in total PRF 
payments they had received.  Nursing home leaders reported gathering input from 
personnel about facility and staff needs, and using the funds to cover lost revenue, 
general and administrative expenses, and health care-related expenses.  Specific costs 
 
r HRSA told us that it later changed its policy so that bankruptcy was no longer a consideration when 
determining eligibility and paid these facilities during subsequent payment waves. 
s During CYs 2020 and 2021, the 11 nursing homes in our sample had attested to receiving 49 of 80 PRF 
payments.  The nursing homes had either taken no action or had not yet been required to respond about 
the remaining payments. 
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included health care-related equipment and supplies, such as PPE, and staffing.  
Nursing home leaders reported that use of the funds allowed them to maintain 
operations, infection control, and resident care during the pandemic. 
The 11 nursing homes in our sample received nearly $15 million 
in total PRF payments 
As of December 2021, the 11 nursing homes in our sample had received a total of 
$14.8 million from general and targeted PRF distributions.t  Targeted payments 
included $2.6 million from the SNF distribution and $2.5 million from the NHIC 
distribution (see Exhibit 6).  The nursing homes also received payments from general 
and other types of distributions. 
Exhibit 6: PRF Payments to Nursing Homes* 
Total Payments Distributed  Total Payments Distributed 
Distribution 
to Nursing Homes Nationally  to Sample Nursing Homes 
SNF  $4.8 billion  $2,625,000 
NHIC  $4.6 billion  $2,498,150 
Other**  $45.3 billion  $9,666,953 
Total  $54.7 billion  $14,790,103 
Sources: HRSA, Past Targeted Distributions, November 2022, accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022; and OIG analysis of PRF payment data. 
* HRSA last reviewed the web page that lists the targeted distribution totals in November 2022 and stated that the 
totals were current through September 2022.  PRF payment data for our sample nursing homes are current through 
December 2021. 
** Other includes all other payments to nursing homes (i.e., PRF payments made through distributions that are not 
SNF and NHIC distributions).  HRSA reported to OIG in June 2023 the total amount paid to nursing homes, but does 
not publicly report total amounts distributed to specific provider types for general distributions.  HRSA also does not 
publicly report total amounts from other PRF distributionsother than the SNF and NHIC distributionsthat may 
have gone to those facilities.   
HRSAs methods for determining payment amounts, which were sometimes based on 
the number of beds in a facility, meant that each nursing home received different 
general and targeted distribution payment amounts.  Additionally, some nursing 
homes were part of small health centers or health systems that included hospitals and 
other provider types that were also eligible for other types of targeted distributions.  
(See Exhibit 7 for the number of nursing homes within each location and associated 
PRF payments.)   
 
t The nursing homes also received an additional $893,300 from the ARP Rural Distribution and the RHCCT 
and RHCCTM programs.  These programs are separate from PRF but are related in that HRSA 
administered them and included their data alongside PRF. 
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Exhibit 7: The 11 sample nursing homes in locations selected by the PRAC 
received nearly $15 million in total PRF payments, including more than 
$5 million from the SNF and NHIC distributions. 
Total PRF Payments 
Location Selected  Number of  Total PRF 
from SNF and NHIC 
by the PRAC  Nursing Homes  Payments 
Distributions  
Springfield, MA  1  $919,454  $698,532 
Coeur dAlene, ID  5  $4,572,004  $2,615,091 
Sheridan County, NE  3  $4,961,682  $1,099,614 
Marion County, GA  1  $504,617  $411,958 
White Earth Nation 
1  $3,832,346  $297,955 
Reservation (MN) 
Jicarilla Apache Nation 
-  -  - 
Reservation (NM) 
Total  11  $14,790,103  $5,123,150 
Source: OIG analysis of PRF data. 
Sample nursing homes reported that guidance on allowable 
PRF uses was initially unclear and difficult to use 
Nursing home leaders reported that they used HRSAs terms and conditions, emails, 
and FAQ resources for guidance about what was allowable, but said the guidance was 
broad and unclear.  Although intended by HRSA to be helpful, the broad guidance 
and allowable uses of funding (i.e., for expenses and lost revenue attributable to 
COVID-19) made some leaders hesitant to make decisions about how to use funds for 
fear that they would use the money incorrectly and be forced to pay it back later.  
One administrator stated, There wasnt a lot of clear-cut, black and white writing 
about This is what you can spend it on.  The administrator explained that the 
nursing home had to purchase things such as extra dumpsters due to increased 
waste, but worried that such use would backfire and that funds would need to be 
returned.  The CEO for a health center that included one of the nursing homes said 
that sometimes it was even unclear whether payments were for the nursing home or 
for the hospital.  A few leaders reported that guidance about allowable uses improved 
over time, with one saying allowable uses were not clear until reporting guidance 
came out in summer 2021, prior to the first reporting deadline. 
It would have been nice to have more knowledge upfront in the terms and conditions 
to know exactly what we could use it for, instead of the overhanging fear of, Are we 
doing this correctly?  Corporate Accountant 
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Leaders also reported that the large amount of guidance and information, including 
frequent updates, was difficult to keep up with, leading to additional uncertainty.  
One leader said, It seemed like the guidance changed so often.  You werent really 
sure.  Maybe you could use it for wages, maybe not.  Maybe you could only use it for 
infection prevention, maybe you couldnt.  Thats where it got really difficult for us.  
Although some nursing homes found supplemental information such as FAQs useful, 
one leader said that the FAQs were difficult to monitor: Some FAQs would be there, 
then they would disappear, including questions on costs.  It was hard to keep up.  
Leaders sought additional information to clarify guidance but had difficulty obtaining 
guidance.  Some leaders said they used the helpline to seek supplemental guidance 
but that it was sometimes difficult to reach a helpline operator and that some 
operators knew little more about PRF than the leaders did.  Leaders reported 
sometimes relying on outside sources such as nursing home or health care 
associations, consultants, or other experts for clarification about guidance.  One 
corporate leader reported gathering information from multiple sources that was then 
cobble[d] together to determine what was allowable. 
Nursing homes reported using PRF payments to address 
COVID-19-related expenses and lost revenue   
Leaders reported that nursing homes used or returned all funds received during the 
first two periods.u, v  Specifically, the 11 nursing homes reported about $12.2 million in 
total PRF payments, including $4.3 million in payments targeted for nursing homes 
($2.6 million in SNF payments and $1.7 million in NHIC payments) and $10,969 in 
interest earned on PRF payments.   
How the 11 nursing homes used funds to respond to the pandemic varied.  
Four nursing homes used payments they had reported on for lost revenue and for 
general or health care-related expenses, four used payments only for expenses, and 
three used payments only for lost revenue.  As required, the nursing homes reported 
use of NHIC payments and all other payments separately.  (See Exhibit 8 for a 
summary of how nursing homes reported using funds.)   
 
u At the time we began the virtual site visits, the nursing homes were only required to have used and 
reported on PRF payments received during the first two periods.  For that reason, we included only those 
two reporting periods in this review. 
v The nursing homes were required to use and report about the funds within the timeframes defined in 
Exhibit 3.  If the nursing homes had not met the deadlines, they would have been considered out of 
compliance with PRF terms and conditions, and funds may have been recouped.  See HRSA, Important 
Dates for Reporting, May 2023.  Accessed at https://www.hrsa.gov/provider-relief/reporting-
auditing/important-dates on May 11, 2023. 
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Exhibit 8: Nursing homes used most of the PRF payments reported on, 
including NHIC payments, for pandemic-related health care and 
administrative expenses. 
 
Source: OIG analysis of nursing home reports to HRSA about PRF use.  
Notes: Other Payments includes reported use of all non-NHIC payments.  HRSA required nursing homes to report 
the use of NHIC payments and all other payments (including SNF payments) separately.  The total of all payments in 
this exhibit does not equal $12.2 million because one nursing home returned an NHIC payment. 
Despite initial hesitation over broad guidance, nursing home leaders 
reported the guidance allowed for discretion in using the funds to meet 
facility needs.  Nursing home leaders said they were conservative in using the 
funds, especially early on, partly due to fear that they might have been required to 
return the funds if used incorrectly.  One nursing home returned a $97,000 NHIC 
payment because its leaders did not feel they could use the money appropriately 
during the given time period.  Leaders for other nursing homes described using funds 
for items that were clearly pandemic-related, such as lost revenue, staffing, PPE, or 
tests.  Some leaders said they later became more comfortable using the funds for 
broader purposes to address specific needs.  For example, one nursing home used 
PRF to replace facility flooring with flooring material that was easier to disinfect as an 
infection control measure.  Another nursing home reported using PRF to replace its 
heating, ventilation, and air conditioning system for the same reason. 
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Nursing homes reported that PRF payments were integral to 
maintaining services during the pandemic, but that financial 
challenges were ongoing 
Leaders and staff across the nursing homes reported that PRF payments 
were instrumental in continuing operations and maintaining infection 
control and quality of care during the pandemic.  Corporate leaders noted 
that the payments provided a huge financial relief, and had both immediate and 
longer-term positive effects.  Staff in one nursing home explained that their facility 
was one of the last in their community to experience a COVID-19 case, and that PRF 
payments played a big part [in] keeping [COVID-19] out.  Leaders and staff also 
described the long-term, positive effects of the payments, explaining that they helped 
nursing homes improve infection control practices and better prepare for other 
emergencies. 
Nursing home leaders described how using the funds for specific expense types was 
beneficial.  For example, some said using the money for increased wages and pay 
bonuses allowed them to retain and support staff who were working in difficult 
conditions.  Leaders also said they expended the money on equipment they would 
not have otherwise been able to obtain, such as screening, disinfection, and air 
filtration devices.  Finally, leaders and staff said that using the funds for resident care 
expenses, such as tablets for communicating with family members remotely, helped 
nursing homes better provide services during the pandemic.  
Things were getting bad and dangerous . . . then this new money showed up that we 
werent expecting but allowed us to address things . . . .  Thank God this money came 
through.  CEO, Contracted Management Group 
Sample nursing homes reported that they were unable to fully address 
ongoing COVID-19-related expenses using PRF.  Nursing home leaders said 
that PRF payments were not sufficient to offset COVID-19-related expenses, some of 
which were ongoing.  One nursing home reported to HRSA that, after the first 
two payment and use periods, it had hundreds of thousands of dollars remaining in 
unreimbursed expenses.w  We conducted interviews with that nursing home in 
June 2022 after it had received hundreds of thousands of dollars of PRF more than 
what had been included in the first two reports.  At that point, its leaders reported 
that they had used all the funds received and still had remaining COVID-19-related 
 
w HRSA defines unreimbursed expenses as expenses that remain unreimbursed after considering all 
assistance received by HRSA and all other sources.  See HRSA, User Guide: Provider Relief Fund (PRF) 
Reporting PortalReporting, p. 64, Dec. 30, 2022.  Accessed at https://www.hrsa.gov/sites/default
/files/hrsa/provider-relief/prf-reporting-portal-user-guide.pdf on Jan. 31, 2023. 
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costs that had not been reimbursed by PRF.  One chief financial officer explained that 
although PRF payments were adequate for addressing the nursing homes needs at 
the time received, the nursing home could not have anticipated that expenses for 
contracted labor and other costs would continue to increase. 
Nursing homes in our sample generally complied with PRF 
reporting requirements but reported that HRSA guidance 
was difficult to use 
HRSA required any nursing home or other provider that received more than $10,000 
in PRF payments in the aggregate during a given payment-received period to submit 
reports about how the funds were used (see page 6).  The form required nursing 
homes to report information specific to PRF payments, including the amount 
distributed to the recipient during the relevant period, any interest earned on relevant 
payments, and how those PRF payments were used.  Reports required information 
about remaining unreimbursed expenses, and the financial and clinical care effects of 
PRF payments.  For example, respondents ranked the amount to which they agreed 
with the statement The PRF payment(s) had a significant impact on overall 
operations, with options ranging from Strongly Agree to Strongly Disagree.  The 
form also had fields for identifying the provider and for general information not 
specific to PRF, such as personnel and patient metrics. 
The nursing homes in our sample generally complied with 
HRSAs reporting requirements, but some misreported 
or were required to resubmit information 
At the time we collected our data, 9 of the 11 nursing homes in our sample had 
completed reports about how they used PRF funds during the first 2 periods by the 
required deadline.  Two nursing homes, however, initially submitted reports 
incorrectly and had to resubmit information.  During the first reporting period, the 
corporate office that owned the two nursing homes incorrectly reported use of the 
facilities targeted PRF payments at the corporate level rather than at the facility level.  
To resolve the error, HRSA allowed the nursing homes to resubmit the reports after 
the deadline had passed.x   
During our review, we observed that information the nursing homes reported to 
HRSA was generally supported by underlying facility data and appeared to align with 
allowable uses of the general and targeted distributions.  One nursing homes 
documentation, however, appeared to show that funds it reported using for general 
 
x The two nursing homes that incorrectly reported information during the first period were also the 
facilities that had difficulty accessing the NHIC payments due to bankruptcy (see page 15).  Because of 
the delay in the NHIC payments, the two nursing homes received no PRF payments during the 
second period and were therefore not required to submit reports for that period. 
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and administrative expenses were actually used for lost revenue, which would mean 
that the facility incorrectly used NHIC payments.  Other nursing homes appeared to 
be unable to support minor items in their reports, such as the use of small amounts of 
interest earned on PRF payments or small PRF expenses.  Another reported use of 
funds during fiscal quarters not supported by expense-incurred dates on supporting 
documentation.   
Nursing home leaders found that HRSAs reporting guidance 
was difficult to use and that completing the reports was difficult 
Nursing home leaders found that HRSAs reporting guidance, like the guidance on 
allowable uses, was sometimes difficult to review.  An administrator at one nursing 
home stated that reporting resources were not readily available and that it was 
difficult to find time to review the material and complete the reports given conflicting 
obligations.  A chief financial officer for a chain supported that sentiment, saying that 
a 90- or 100-page manual [is] a perfect example of . . . saying, Heres your manual; 
its here to help.  Specific challenges included interpreting nuances about how costs 
should be applied to PRF payments and classified in the reports, and difficulties 
defining or calculating lost revenue.   
Additionally, leaders for many of the nursing homes reported that tracking their 
expenses and entering the information into the reporting portal was stressful, 
time-consuming, and labor intensive.  One corporate officer explained that 
supplemental information, such as personnel metrics, was tedious to enter because 
each statistic had to be entered manually and separately.  Leaders said that the 
information had to be reported by quarter, which was not explained ahead of time 
and was difficult to do.  An administrator at a nursing home described technical 
challenges, such as the report website timing out if they stepped away for another 
task.  Leaders for one nursing home stated that PRF reporting amplified the burden of 
what was already an incredible amount of other COVID-19-related data tracking and 
reporting.   
Some nursing homes reported having to seek supplemental guidance from the PRF 
help desk or from outside organizations or accountants.  A leader for one nursing 
home said trying to get technical support regarding the reporting portal was difficult: 
There was not a direct line to people who actually programmed the website.  We had 
to run through the intermediaries assigned to make the payments, and they would 
determine whether they can answer your question or not, then would transfer you to 
HHS technical support . . . .  It was time consuming. 
Some leaders said that reporting challenges were heightened for small or 
independently owned nursing homes that did not have extra resources to devote to 
PRF processes.  A corporate officer for a regional nursing home chain explained, 
As what I would call a small regional operator, I can only imagine the true 
mom-and-pops trying to . . . maneuver through applying for funds . . . and the 
reporting . . . .  We had resources to manage the process; Im sure theres a lot of 
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people who dont.  An administrator for a small city-owned nursing home, who was 
almost solely responsible for managing PRF payments that the facility received, 
stated, Im just dreading [submitting the next report] because its like a weeklong 
process for me. 
HRSA developed plans to assess nursing home use of PRF 
but had not yet begun auditing nursing homes at the time 
we conducted our review 
HRSA reported developing processes to review provider reports ongoing and 
following the reporting periods, using data checks, audits, and evaluations of data.  
One official reported that, as a first step of review, the PRF reporting system checks 
information for inconsistencies throughout the report preparation and submittal 
process.  It requires a provider to address any identified errors and attest to accuracy 
before submitting a report. 
We collected information from HRSA about its audit plans in June and July 2022, after 
the close of two reporting periods.  During that time, HRSA officials reported that they 
had not yet begun auditing nursing homes to assess use of PRF payments and recoup 
improperly used funds.  HRSA officials described the plans for conducting audits.  For 
each reporting period, HRSA planned to select a sample of health care facilities, 
including nursing homes, to be audited according to a risk-based strategy to verify 
compliance with the terms and conditions of the program and recoup any 
inappropriately used funds.  In summer 2022, HRSA had not yet determined the 
number of providers whose reports the agency would audit or assess, but had 
contracted with several entities to help with the audits and assessments.y, z 
HRSA officials reported that the agency would also conduct an ongoing analysis of 
providers reported spending, seeking to identify trends in how providers spent PRF 
payments to provide services during the pandemic.  One official explained that HRSA 
plans to highlight the impact of the program on service provision and financial 
circumstances using data pulled from report fields about the ways in which funds 
allowed respondents to continue or expand operations. 
Agency officials said they felt it was a weakness of the PRF program that it relied 
largely on self-reported information, rather than on supporting documents or other 
 
y In October 2023, HRSA reported to OIG that it was nearing completion of 35 audits of reporting 
period 1 providers and had initiated 200 additional audits, which included 7 nursing homes, to be 
completed by the end of the fiscal year 2024. 
z Any nursing home that spends a total of $750,000 or more in Federal funds, including PRF payments, 
during a given fiscal year is subject to Single Audit requirements in accordance with 45 CFR 75 Subpart F.  
In addition to conducting its own PRF audits, HRSA is responsible for resolving single audit findings 
pertaining to all HRSA programs.  For more information, see HRSA, Audit Requirements, June 2023.  
Accessed at https://www.hrsa.gov/provider-relief/reporting-auditing/audit-requirements on 
June 26, 2023. 
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evidence, about how funds were used.  Officials reported that they considered 
requiring providers to submit documentation (e.g., receipts) but decided against it 
because they thought it would be too onerous on providers.  The decision to use only 
self-reported information, however, makes audits and other controls more important. 
 
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CONCLUSION AND RECOMMENDATIONS 
The COVID-19 pandemic has had a devastating effect on health care providers, 
including hard-hit nursing homes.  To help nursing homes and other health care 
providers respond to the pandemic, Congress appropriated funding to HHS for PRF.  
HHS quickly worked with HRSA, other HHS agencies, and other stakeholders to 
develop PRF and began distributing payments to providers in April 2020. 
The nursing homes in our sample reported that the nearly $15 million PRF they 
received was critical for maintaining services, but many reported challenges 
throughout the attestation, use, and reporting processes.  Leaders also reported that 
HRSA guidance on allowable uses was unclear and that reporting how they used the 
funds was difficult.  HRSA officials recognized difficulties related to reporting, and had 
not yet begun auditing the reports at the time we conducted our review. 
To address the issues identified in this report and prepare for potential future 
emergencies, we recommend that HRSA: 
Create a document to record lessons learned from managing 
PRF and submit the document to HHS leadership 
To relieve providers from the financial effects of the pandemic, HHS and HRSA had to 
act quickly to develop the PRF program and begin administering payments.  Nursing 
homes in our sample reported that PRF payments were critical to their operations, but 
that they sometimes had difficulty interacting with the program.  HRSA should record 
(e.g., in an after-action report or other document) its experiences and lessons learned 
from its responsibilities in managing PRF.  The document will serve as an accounting 
of HRSAs actions in administering these Federal funds and as a road map for future 
HHS emergency funding distributions.  In developing the document, HRSA should 
seek feedback from nursing homes and other stakeholder groups, as appropriate, to 
gain insights about how processes could be improved.   
OIG is not prescriptive about the timeframe or the content to include in the 
document.  However, the document should be written while staff with relevant 
experience are available to contribute.  HRSA should consider including lessons 
learned from our findings, such as potential policy or process improvements for: 
  collecting and sharing data across HHS to ensure timely and accurate funding 
to providers; 
  quickly generating, updating, and communicating clear and concise program 
guidance; 
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  creating user-friendly reporting portals, which HHS agencies can quickly 
activate in case of emergencies; and 
  developing and enacting program integrity safeguards, such as audits, for 
recovering improperly used funds. 
It is likely that, similar to PRF, responsibility for any future emergency funding 
distributions to health care providers will be directed by HHS leadership.  Following 
completion, HRSA should submit the document to the HHS Office of the Secretary. 
Expedite audits of provider use of PRF payments 
As of mid-2023, HRSA was nearing completion of its initial audits.  However, when we 
conducted our data collection in mid-2022, after two reporting periods had passed, 
the agency and its contractors had not yet begun auditing provider reports to assess 
use.  The automatic checks for inconsistencies and other efforts to pre-emptively 
address issues in PRF reports likely helped ensure that the reports were complete, but 
further assessment is necessary to provide proper oversight and safeguard Federal 
dollars.  As such, HRSA should work with urgency to assess appropriateness of PRF 
use.  Moving forward, the agency should work to select its samples and conduct 
audits sooner after reporting period completion.  Doing so will help ensure that 
improperly used funds are recovered.
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AGENCY COMMENTS AND OIG RESPONSE  
HRSA provided both technical and formal comments to our draft report.  We have, 
where appropriate, added additional context from the technical comments to this 
report.  In its formal comments, HRSA concurred with one recommendation and did 
not concur with the other. 
HRSA did not concur with our first recommendation, which was originally for it to 
create an after-action report about lessons learned from managing PRF and submit 
the report to HHS leadership.  HRSA stated that it is unable to produce an after-action 
report due to resource constraints.  OIG continues to recommend that HRSA produce 
a document recording its lessons learned from managing PRF and submit the 
document to HHS leadership.  To note, OIG is not prescriptive about the timeframe or 
the content to include in the document.  We revised the recommendation to make 
this clear and to no longer specify that the document be an after-action report. 
HRSA concurred with our second recommendation, which was for it to expedite audits 
of provider use of PRF payments.  HRSA reported that the agency is prioritizing its 
remaining resources to expedite those audits.  HRSA stated that it has defined an 
audit sample for the first five reporting periods, and will complete those audits over 
the next 12 months.  HRSA also stated that it will initiate additional audits as the 
remaining reporting periods close. 
For the full text of HRSAs comments, see the Agency Comments appendix at the end 
of the report. 
 
 
 
 
 
 
 
 
 
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OEI-06-22-00040  Agency Comments and OIG Response | 27    
APPENDIX 
Agency Comments 
Following this page are the official comments from HRSA. 
   
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OEI-06-22-00040  Appendix A | 28    
 
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OEI-06-22-00040  Appendix A | 29    
 
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ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Savanna Thielbar served as the team leader for this study.  Others in the Office of 
Evaluation and Inspections Dallas Regional Office who conducted the study include 
Sarah Lee, Emma Steyaert, and John Van Der Schans.  Office of Evaluation and 
Inspections headquarters staff who provided support include Chris Galvin, Althea 
Hosein, and Michael Novello.  
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including Mandy Brooks, Miranda Fanning, Logan Kingma, Karen Lowe, 
and Jennifer Wagner. 
This report was prepared under the direction of Petra Nealy, Regional Inspector 
General for Evaluation and Inspections in the Dallas Regional Office, and Marshall 
Allen, Assistant Regional Inspector General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
 
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ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 
95-452, as amended, is to protect the integrity of the Department of Health and 
Human Services (HHS) programs, as well as the health and welfare of beneficiaries 
served by those programs.  This statutory mission is carried out through a nationwide 
network of audits, investigations, and inspections conducted by the following 
operating components: 
The Office of Audit Services (OAS) provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work 
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI) conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs.  To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.  With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides 
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities. 
       
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ENDNOTES 
 
1 Government Accountability Office (GAO), Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes 
Prior to COVID-19 Pandemic, GAO-20-576R, May 20, 2020. 
2 Lauren Weber, Nursing Homes Keep Losing Workers, The Wall Street Journal, Aug. 25, 2021.  Accessed at 
https://www.wsj.com/articles/nursing-homes-keep-losing-workers-11629898200 on Jan. 30, 2023. 
3 COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020 (OEI-02-20-00490), 
June 22, 2021. 
4 The $178 billion was appropriated across multiple pieces of legislation.  See Coronavirus Aid, Relief, and Economic Security 
(CARES) Act, P.L. No. 116-136, Division B, Title VIII, (Mar. 27, 2020); Protection Program and Health Care Enhancement 
(PPPHCE) Act, P.L. No. 116-139, Division B, Title I (Apr. 24, 2020); and Consolidated Appropriations Act, 2021, P.L. No. 116-260, 
Division M, Title III (Dec. 27, 2020). 
5 For more information about HRSAs administration of PRF, see HRSA, About.  Accessed at https://www.hrsa.gov/provider-
relief/about/ on Jan. 31, 2023.  For more information about related programs, see footnotes e and f on page 4 of this report. 
6 HRSA, Past General Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-relief/past-
payments/general-distribution on Dec. 16, 2022. 
7 HRSA, Past Targeted Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 12, 2022. 
8 HRSA, Provider Relief.  Accessed at https://www.hrsa.gov/provider-relief on June 7, 2023. 
9 CDC, People Who Live in a Nursing Home or Long-Term Care Facility.  Accessed at https://stacks.cdc.gov/view/cdc/89837 
on Oct. 10, 2023. 
10 CMS, COVID-19 Nursing Home Data.  Accessed at https://data.cms.gov/covid-19/covid-19-nursing-home-data 
on Jan. 13, 2023. 
11 COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020 (OEI-02-20-00490), 
June 22, 2021. 
12 GAO, Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic, 
GAO-20-576R, May 20, 2020. 
13 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 (OEI-02-20-00491), Jan. 19, 2023. 
14 Lenny Bernstein and Alauna Safarpour, Mask shortage for most health-care workers extended into May, Post-Ipsos poll 
shows, The Washington Post, May 20, 2020.  Accessed at https://www.washingtonpost.com/health/mask-shortage-for-most-
health-care-workers-extended-into-may-post-ipsos-poll-shows/2020/05/20/1ddbe588-9a21-11ea-ac72-
3841fcc9b35f_story.html on Jan. 30, 2023.   
15 Lauren Weber, Nursing Homes Keep Losing Workers, The Wall Street Journal, Aug. 25, 2021.  Accessed at 
https://www.wsj.com/articles/nursing-homes-keep-losing-workers-11629898200 on Jan. 30, 2023. 
16 AHCA and NCAL press release, Survey: 94 Percent of Nursing Homes Face Staffing Shortages, June 23, 2021.  Accessed at 
https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Survey-94-Percent-of-Nursing-Homes-Face-
Staffing-Shortages.aspx on Jan. 30, 2023. 
 
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17 AHCA and NCAL press release, Nursing Homes Face Closures Due to Long-Standing Financial Challenges Exacerbated by 
The Pandemic, Mar. 11, 2021.  Accessed at https://www.ahcancal.org/News-and-Communications/Press-
Releases/Pages/Nursing-Homes-Face-Closures-Due-To-Long-Standing-Financial-Challenges-Exacerbated-By-The-
Pandemic.aspx on Jan. 30, 2023. 
18 Danielle Brown, Only 25 percent of operators believe theyll survive financially through 2021, McKnights Long-Term Care 
News, June 30, 2021.  Accessed at https://www.mcknights.com/news/only-25-of-operators-believe-theyll-survive-financially-
through-2021/ on Jan. 30, 2023. 
19 HRSA publicly reports amounts distributed through each PRF distribution, which total $136.6 billion.  See HRSA, Past 
General Distributions, November 2022, accessed at https://www.hrsa.gov/provider-relief/payments-and-data/past-
payments/general-distribution on Dec. 16, 2022; HRSA, Phase 4 and ARP Rural Distributions, September 2023, accessed at 
https://www.hrsa.gov/provider-relief/payments-and-data/phase4-arp on Sept. 18, 2023; and HRSA, Past Targeted 
Distributions, November 2022, accessed at https://www.hrsa.gov/provider-relief/payments-and-data/past-
payments/targeted-distribution on Dec. 16, 2022. 
20 HRSA, Past General Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-relief/past-
payments/general-distribution on Dec. 16, 2022. 
21 HRSA, Past Targeted Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022. 
22 HRSA, Past General Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-relief/past-
payments/general-distribution on Dec. 16, 2022. 
23 HRSA, Phase 4 and ARP Rural Distributions, September 2023.  Accessed https://www.hrsa.gov/provider-relief/payments-
and-data/phase4-arp on Sept. 18, 2023. 
24 HRSA, Past Targeted Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022. 
25 HRSA, Provider Relief.  Accessed at https://www.hrsa.gov/provider-relief on June 7, 2023. 
26 HRSA, About HRSA.  Accessed at https://www.hrsa.gov/about on Jan. 30, 2023. 
27 HRSA, Coronavirus (COVID-19) Information.  Accessed at https://www.hrsa.gov/coronavirus on Dec. 28, 2022. 
28 HRSA, Mission, Work, and Impact, January 2023.  Accessed at https://nhsc.hrsa.gov/about-us on June 26, 2023. 
29 HRSA, Local Community-Based Workforce to Increase COVID-19 Vaccine Access.  Accessed at 
https://www.hrsa.gov/grants/find-funding/HRSA-21-140 on June 26, 2023. 
30 HRSA, Application Review Process, October 2021.  Accessed at https://www.hrsa.gov/provider-relief/future-
payments/phase-4-arp-rural/review-process on Jan. 30, 2023.  
31 HRSA, User GuideRegistration, Provider Relief Fund Reporting Portal, Dec. 30, 2022.  Accessed at 
https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/prf-reporting-portal-registration-user-guide.pdf on Jan. 30, 2023.  
32 HRSA, Bureaus & Offices.  Accessed at https://www.hrsa.gov/about/organization/bureaus on Jan. 31, 2023. 
33 HHSs and HRSAs Controls Related to Selected Provider Relief Fund Program Requirements Could Be Improved 
(A-09-21-06001), Sept. 26, 2022. 
34 HRSA, Provider Relief Fund Phase 4 General Distribution and American Rescue Plan Rural Payments, Sept. 30, 2021, p. 17.  
Accessed at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/phase4-rural-webcast-09302021.pdf on 
Jan. 31, 2023. 
35 Alia Paavola, HHS taps 4 firms to audit provider relief fund grants, Beckers Hospital CFO Report, Sept. 10, 2021.  Accessed 
at https://www.beckershospitalreview.com/finance/hhs-taps-4-firms-to-audit-provider-relief-fund-grants.html 
on Jan. 31, 2023. 
 
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36 HRSA, Past Targeted Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022. 
37 CMS, Medicare Coverage of Skilled Nursing Facility Care, July 2019.  Accessed at 
https://www.medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf on Jan. 31, 2023. 
38 HRSA, Past Targeted Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022. 
39 HRSA, Acceptance of Terms and ConditionsSkilled Nursing Facility Relief Fund Payment Terms and Conditions.  Accessed 
at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/terms-conditions-skilled-nursing-facility-relief-fund.pdf 
on Jan. 31, 2023. 
40 HRSA, Past Targeted Distributions, November 2022.  Accessed at https://www.hrsa.gov/provider-relief/past-
payments/targeted-distribution on Dec. 16, 2022. 
41 HRSA, Acceptance of Terms and ConditionsSkilled Nursing Facility and Nursing Home Infection Control Relief Fund 
Payment Terms and Conditions.  Accessed at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/provider-relief-
fund-nf-infection-control-payment-terms-conditions.pdf on Jan. 31, 2023. 
42 HRSA, About.  Accessed at https://www.hrsa.gov/provider-relief/about/ on Jan. 31, 2023. 
43 HRSA, Acceptance of Terms and ConditionsSkilled Nursing Facility Relief Fund Payment Terms and Conditions.  Accessed 
at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/terms-conditions-skilled-nursing-facility-relief-fund.pdf 
on Jan. 31, 2023. 
44 HRSA, Acceptance of Terms and ConditionsSkilled Nursing Facility and Nursing Home Infection Control Relief Fund 
Payment Terms and Conditions.  Accessed at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/provider-relief-
fund-nf-infection-control-payment-terms-conditions.pdf on Jan. 31, 2023. 
45 HRSA, Important Dates for Reporting, May 2023.  Accessed at https://www.hrsa.gov/provider-relief/reporting-
auditing/important-dates on May 11, 2023. 
46 HRSA, User Guide: Provider Relief Fund (PRF) Reporting PortalReporting, Dec. 30, 2022.  Accessed at 
https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/prf-reporting-portal-user-guide.pdf on Jan. 31, 2023. 
47 HRSA, Important Dates for Reporting, May 2023.  Accessed at https://www.hrsa.gov/provider-relief/reporting-
auditing/important-dates on May 11, 2023. 
48 COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020 (OEI-02-20-00490), 
June 22, 2021. 
49 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 (OEI-02-20-00491), Jan. 19, 2023. 
50 Targeted Provider Relief Funds Allocated to Hospitals Had Some Differences With Respect to the Ethnicity and Race of 
Populations Served (OEI-05-20-00580), July 12, 2023. 
51 OIG Work Plan, Meeting the Challenges Presented by COVID-19: Nursing Homes (OEI-02-20-00492). 
52 HHS's Oversight of Automatic Provider Relief Fund Payments Was Generally Effective but Improvements Could Be Made 
(A-02-20-01025), Oct. 30, 2023. 
53 OIG Work Plan, Audit of CARES Act Provider Relief FundsPayments to Health Care Providers That Applied for General 
Distribution Under Phases 1, 2, and 3 (W-00-21-35873). 
54 HHSs and HRSAs Controls Related to Selected Provider Relief Fund Program Requirements Could Be Improved 
(A-09-21-06001), Sept. 26, 2022. 
55 OIG Work Plan, Hospitals Compliance With the Provider Relief Fund Balance Billing Requirements for Out-of-Network 
Patients (W-00-22-35878). 
 
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56 OIG Work Plan, Audit of CARES Act Provider Relief Funds: General and Targeted Distributions to Providers (W-00-20-35855). 
57 PRAC, Tracking Pandemic Relief Funds that Went to Local Communities Reveals Persistent Data Gaps and Data Reliability 
Issues, July 2023. 
58 HHSs and HRSAs Controls Related to Selected Provider Relief Fund Program Requirements Could Be Improved 
(A-09-21-06001), Sept. 26, 2022. 
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