U.S. Department of Health and Human Services 
Office of Inspector General 
Home Health Agencies Used 
Multiple Strategies To 
Respond to the COVID-19 
Pandemic, Although Some 
Challenges Persist 
Ann Maxwell 
Deputy Inspector General for Evaluation and Inspections 
October 2022, OEI-01-21-00110  U.S. Department of Health and Human Services 
Office of Inspector General 
Report in Brief 
October 2022, OEI-01-21-00110 
Why OIG Did This Review  Home Health Agencies Used Multiple 
The COVID-19 pandemic required 
Strategies To Respond to the COVID-19 
home health agencies (HHAs) to 
adapt their care to respond to  Pandemic, Although Some Challenges 
COVID-19s infectious nature, as 
Persist 
well as other circumstances from 
the pandemic. HHAs play an 
What OIG Found 
important role in caring for 
Key Takeaway 
Medicare beneficiaries: in 2020, the  Like all health care providers, HHAs 
first year of the COVID-19  Home health agencies (HHAs)  have experienced multiple 
pandemic, HHAs cared for over  developed strategies to  challenges to providing care during 
3 million beneficiaries. The Centers  respond to challenges during  the COVID-19 pandemic. HHAs 
for Medicare & Medicaid Services  the COVID 19 pandemic,  have continued to experience 
(CMS) requires HHAs to prepare for  including providing new  longstanding staffing challenges as 
and respond to emergencies and,  incentives to maintain staff and  well as new ones resulting from the 
during those emergencies, CMS can  seeking alternative sources of  pandemic, such as maintaining 
offer regulatory flexibilities and  personal protective equipment.  staffing despite quarantine and 
supports (which we refer to  HHAs have also benefited from  isolation protocols. These staffing 
collectively as regulatory  CMS support, such as  challenges persist for many HHAs 
flexibilities) for various  regulatory flexibilities and  despite efforts to address them. In 
requirements. This report provides  expanded telehealth  addition, HHAs faced numerous and 
insights into HHAs experiences that  allowances, but staffing  widespread infection control 
will help stakeholders continue  challenges persist. In light of  challenges, including accessing 
managing the response to COVID- the expanded use of telehealth,  personal protective equipment 
19 and prepare for future  more information is needed to  (PPE) to limit exposure and spread, 
emergencies.  determine its future use across  but these have mostly eased since 
different home health services.  early in the pandemic. 
How OIG Did This Review 
HHAs own strategies to respond to 
We surveyed a nationally 
the pandemic included offering paid leave to retain staff and finding PPE 
representative sample of 400 HHAs, 
from nontraditional sources. HHAs have also benefited from government 
396 of which participated in 
supportincluding regulatory flexibilities instituted in response to the 
Medicare, in fall 2021 to ask about 
declaration of a public health emergencyand this support has 
their experiences early in the 
mitigated some staffing challenges. For example, by the Federal 
pandemic and at the time we 
governments allowing new types of providers to certify and order home 
administered the survey. We 
health services and complete certain patient assessments, HHAs could 
projected our results to the 72 
more efficiently provide care. Telehealth flexibilities under the public 
percent of Medicare-participating 
health emergency have also helped HHAs provide care while reducing 
HHAs represented by our sample. 
COVID-19 exposure and dealing with staffing shortages. However, HHAs 
In addition, we interviewed 12 
challenges with telehealth raise questions about its future role in home 
HHAs about notable challenges, 
health care, andbecause of limited reporting requirementsCMS has 
strategies, or other experiences 
limited insight into HHAs telehealth use. Finally, the emergency 
they identified in their surveys. We 
preparedness plans required by CMS guided HHAs responses to the 
also interviewed staff at CMS about 
pandemic but fell short of fully addressing a global emergency such as 
its support ofand perspectives 
COVID-19. 
onHHAs provision of care during 
the pandemic.  What OIG Recommends and How the Agency Responded 
CMS has an opportunity to assess how to best help HHAs prepare for 
and respond to future emergencies, as well as to evaluate how changes 
to the home health landscape can better serve patients. To that end, we 
recommend that CMS evaluate how HHAs are using telehealth 
specifically, the types of services provided via telehealth and the 
characteristics of patients who benefit from these services. We also 
recommend that CMSto inform decision-makingevaluate how the 
regulatory flexibilities it has offered in response to the COVID-19 public 
health emergency affect the quality of home health care. Finally, we 
recommend that CMSin collaboration with the Administration for 
Strategic Preparedness and Responses (ASPRs) Technical Resources, 
Assistance Center, and Information Exchange (TRACIE)apply lessons 
learned from the COVID-19 pandemic to update and/or develop 
emergency preparedness trainings and materials for HHAs on 
responding to infectious disease outbreaks. CMS concurred with all 
three recommendations.  TABLE OF CONTENTS 
BACKGROUND................................................................................................................................................ 1 
FINDINGS.........................................................................................................................................................9 
Staffing challenges persist despite HHAs efforts to address them....................................................................... 9 
HHAs infection control challenges were numerous and widespread early in the pandemic, but these 
challenges lessened by fall 2021.......................................................................................................................................14 
Although most HHAs used telehealth during the pandemic, challenges that HHAs experienced raise 
questions about telehealths future role in home health ........................................................................................17 
Emergency preparedness (EP) plans guided HHAs response to the pandemic, but the plans fell short 
of fully addressing a global emergency such as COVID-19....................................................................................21 
CONCLUSION AND RECOMMENDATIONS.......................................................................................... 25 
Evaluate how HHAs are using telehealthspecifically, the types of services provided via telehealth 
and the characteristics of patients who benefit from these services ..................................................................25 
To inform decision-making, evaluate how the regulatory flexibilities it has offered in response to the 
COVID-19 public health emergency affect the quality of home health care...................................................26 
In collaboration with ASPR TRACIE, apply lessons learned from the COVID-19 pandemic to update 
and/or develop emergency preparedness trainings and materials for HHAs on responding to 
infectious disease outbreaks ..............................................................................................................................................27 
AGENCY COMMENTS AND OIG RESPONSE ........................................................................................ 28 
DETAILED METHODOLOGY...................................................................................................................... 29 
APPENDICES.................................................................................................................................................. 31 
Appendix A: CMS Conditions of Participation (CoPs): Infection Prevention and Control ...........................31 
Appendix B: Regulatory Flexibilities and Supports for Home Health Agencies During the COVID-19 
Public Health Emergency (PHE).........................................................................................................................................32 
Appendix C: Analysis of Nonresponse Bias...................................................................................................................36 
Appendix D: Home Health Agencies Responses to OIGs Survey.......................................................................37 
Appendix E: Agency Comments........................................................................................................................................44 
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 49 
Acknowledgments ..................................................................................................................................................................49 
Contact........................................................................................................................................................................................49 
ABOUT THE OFFICE OF INSPECTOR GENERAL.................................................................................... 50  ENDNOTES .................................................................................................................................................... 51  BACKGROUND 
OBJECTIVES 
1.  To identify HHAs key challenges to providing patient care during the 
COVID-19 pandemic.  
2.  To identify key strategies HHAs used to address the challenges presented by 
COVID-19. 
The emergence of the COVID-19 pandemic in early 2020 affected health care 
organizations across the United States.  Hospitals reported decreases in elective 
surgeries, and nursing homes experienced devastating outbreaks among residents.  
Home health agencies (HHAs) were likewise affected and have reported challenges 
ranging from procuring personal protective equipment (PPE) to staffing shortages.1, 2, 
3  To continue to serve the millions of Americans who rely on home-based care during 
the pandemic, both HHAs and the Federal government, including Congress and CMS, 
took action to address COVID-19-related challenges.4, 5, 6 
CMS plays a pivotal role in supporting HHA preparations and responses to 
emergencies, including emerging infectious disease outbreaks such as COVID-19.  For 
example, CMS has supported HHAs during the COVID-19 public health emergency by 
offering regulatory relief for various requirements that HHAs must meet.  CMS also 
requires HHAs to incorporate internal processes and procedures to prepare for future 
emergencies.  
This study provides insights into HHAs perspectives on the challenges they 
experienced during the first months of the COVID-19 pandemic up until the end of 
2021, as well as the strategies they used to address these challenges.  These strategies 
include HHAs developing their own approaches to address specific challenges, using 
emergency preparedness plans required by CMS, and using the flexibilities that the 
government has offered during the COVID-19 public health emergency.  These 
insights will help CMS, HHAs, and other stakeholders continue managing the 
response to COVID-19 and prepare for future emergencies to ensure that 
beneficiaries receive needed care.  
Home Health Agencies 
HHAs provide skilled nursing and therapeutic services to patients in a home-based 
setting.  HHAs are a critical component of our health care system.  They can provide 
an alternative to inpatient health care settings, when appropriate and feasible.  
Services that HHAs can provide include post-operative care, occupational therapy, 
and chronic disease management.7  Many home health services require hands-on 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Background | 1  contact between staff and patients.  For example, a physical therapist may test a 
patients strength, balance, and coordination to assess rehabilitation needs.  In 
addition, a nurse may change a patients wound dressing and monitor for signs of 
infection following an operation.8  Home health may also include services that do not 
necessarily require hands-on contact and may be completed remotely, such as 
behavioral therapy or social services.9 
Beneficiaries must meet certain conditions to qualify for home health care coverage 
under Medicarefor example, they must be homebound, which means that they have 
trouble leaving home without assistance because of injury or illness or have a 
condition such that leaving their home is medically contraindicated.10  Prior to 
receiving home health care, beneficiaries must also meet face to face with a doctor (or 
other allowed health care provider) related to the primary reason for the home health 
care.11  Although beneficiaries must be homebound to be eligible for home health 
services covered by Medicare, they do not need to be hospitalized prior to receiving 
care.12  In 2020, three-fourths of Medicare home health episodes were not preceded 
by a stay at a hospital or post-acute care institution, and more than 11,400 HHAs 
provided care to 3.1 million Medicare fee-for-service beneficiaries.13 
To qualify as an HHA and participate in Medicare, an HHA must demonstrate that it 
meets regulatory health and safety requirements, or the Conditions of Participation 
(CoPs).  Each CoP covers a broad topic (e.g., emergency preparedness) and then is 
further defined by a set of specific standards that HHAs must meet.14, 15  To assess 
compliance with CoPs, State survey and certification agencies and Accrediting 
Organizations (as applicable) typically conduct onsite inspections, including observing 
home visits, on behalf of CMS.16, 17 
Rural HHAs may experience different challenges to providing home health care 
compared to HHAs in more populated settings.  For example, rural HHAs patients 
may be spaced farther apart, requiring more travel time between visits.  Some 
evidence also suggests that, early in the pandemic, rural HHAs experienced different 
challenges responding to COVID-19 compared to HHAs located in urban settings.  
This includes potential differences in access to PPE and proportion of patients with 
COVID-19.18 
The COVID-19 Pandemic 
The virus that causes the disease known as COVID-19 is highly contagious and can 
cause symptoms including fever, cough, and shortness of breath.19  COVID-19 can 
sometimes result in severe illness leading to hospitalization or death.20  The Centers 
for Disease Control and Prevention (CDC) identified the first U.S. laboratory-confirmed 
case of COVID-19 in the United States in Washington State on January 20, 2020, and 
the disease has since spread nationwide.21  On January 31, 2020, the Secretary of 
Health and Human Services declared a public health emergency.22  On March 11, 
2020, the World Health Organization characterized COVID-19 as a pandemic, 
indicating that COVID-19 had spread to several countries or continents, potentially 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Background | 2  affecting a large number of people.23, 24  On March 13, 2020, the President declared a 
national emergency.25 
As of September 23, 2022, CDC had reported over 95 million cases in the United 
States and over one million deaths.26  Since COVID-19s emergence within the United 
States, rates of infection and death have varied over time and within different 
geographic locations.  Factors that can affect COVID-19 infection rates include 
vaccination rates, population density, and the presence of more contagious variants 
of the COVID-19 virus.27, 28 
HHA Care During the COVID-19 Pandemic 
As the COVID-19 pandemic evolved, HHAs had to adapt their care to respond to 
COVID-19s infectious nature as well as other circumstances caused by the pandemic, 
such as decreased staff availability.  During the public health emergency, CMS has 
offered HHAs regulatory relief for various CMS requirements to support HHAs 
response to the pandemic.  Furthermore, CMS provided guidance to support HHAs in 
meeting infection control and emergency preparedness requirements. 
CMS Guidance on Infection Control.  To protect patients and staff, CMS requires 
HHAs to meet the CoP for infection prevention and control (hereinafter referred to as 
infection control).  This includes following widely accepted guidelines (e.g., hand 
hygiene) to prevent transmitting infectious diseases as well as educating staff, 
patients, and caregivers on preventing infections (see Appendix A).29  During the 
pandemic, CMS provided HHAs with additional suggestions to address COVID-19.  In 
March 2020, it issued guidance that outlined further infection control 
recommendations, such as how to screen patients for COVID-19 and use PPE 
appropriately.  CMS also directed HHAs to CDCwith which CMS engaged 
regularlyfor further guidance on infection control for COVID-19.  For example, to 
help address emerging supply shortages due to global disruptions, CMS suggested 
that HHAs contact local authorities and follow CDC guidelines for optimizing 
supplies.30 
HHA Flexibilities During the Public Health Emergency.  After declaring a national 
emergency on March 13, 2020, the President directed the Secretary of Health and 
Human Services to temporarily waive or modify certain Medicare requirements during 
the public health emergency.31, 32  (The Secretary had declared a public health 
emergency on January 31, 2020.)  Beginning in March 2020, CMS issued a series of 
regulatory waivers and new rules to support HHAs during the public health 
emergency. 33, 34 (In this report, we refer to regulatory flexibilities, waivers, and new 
rules as flexibilities.)  For example, CMS allowed HHAs additional time to submit 
patient assessment information.  CMS has continued to modify and add to these 
flexibilities.  These flexibilities are available to HHAs nationwide for the duration of the 
public health emergency and target different aspects of home health care.35, 36  See 
Appendix B for a full list of the flexibilities. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Background | 3  The Coronavirus Aid, Relief, and Economic Security (CARES) Act (enacted on March 27, 
2020) also included statutory changes to help HHAs provide care during the public 
health emergency.  Specifically, the CARES Act allowed additional types of providers 
(nurse practitioners, clinical nurse specialists, and physician assistants) to certify 
eligibility for home health care and order home health services.37 
Telehealth Flexibilities During the Public Health Emergency. Medicare telehealth 
services refer to services that are provided remotely using technology between a 
provider and a beneficiary.38, 39  (Telehealth may also be referred to as telemedicine or 
telecommunications technology.)  Telehealth may include videoconferencing 
(hereinafter, video) to conduct speech therapy visits; using a blood pressure cuff that 
automatically sends information to a provider; or a phone call between a nurse and a 
patient to discuss whether a patients worsening symptoms warrant an extra home 
visit.40, 41  For these technologies to qualify as telehealth, providers must use them to 
improve a patients health care.42  On the basis of this definition, CMS would not 
consider administrative tasks, such as calling a patient to schedule an in-person 
appointment, as telehealth.  CMS specifies which services it considers telehealth as 
covered under the Medicare home health benefit (i.e., Medicare does not cover all 
uses of telehealth).43, 44 
The CARES Act directed the Department of Health and Human Services (HHS) to 
encourage HHAs to use telehealth technology for services provided during the public 
health emergency.45  In response, CMS issued flexibilities that expanded HHAs ability 
to use telehealth and thereby reduced infection risk.  For example, CMS allowed HHAs 
to perform certain Medicare-covered assessments and determine patients 
homebound status via telehealth or record review.46  CMS also allowed the required 
face-to-face encounter between a patient and authorized health care provider, who 
certifies the patient as eligible for home care, to take place remotely.47 
In addition, effective on March 31, 2020, CMS permitted HHAs to use telehealth 
technology services within the patients plan of care if these services are related to the 
patients needs and do not replace needed in-person visits.48, 49  CMS made this 
regulatory change permanent effective January 1, 2021.  (See Exhibit 1 for examples of 
how HHAs can use telehealthinitially, limited to the duration of the public health 
emergency, but now permanently.)50  Although HHAs may choose to provide 
telehealth services, HHAs cannot bill Medicare for telehealth services as equivalent to 
an in-person visitwithout a statutory change, CMS cannot directly reimburse HHAs 
for telehealth services.51  However, HHAs can report the costs of providing telehealth 
services, such as the cost incurred to set up technology, as allowable administrative 
and general costs within cost reports.52, 53  HHAs submit cost reports to CMS each 
year.  CMS factors information reported within cost reports, including costs to provide 
telehealth, into future Medicare payments to HHAs.54 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Background | 4  Exhibit 1. Examples of how HHAs have been allowed to use telehealth under 
the Medicare home health benefit, beginning with the COVID-19 public 
health emergency* 
Live video or audio visits between a  Electronically transmitting health 
patient and HHA provider  information for a provider to access 
later 
Examples include: 
Examples include: 
  Assessing over video whether a 
  A heart rate monitor that 
patient can move properly after a hip 
automatically sends data to the HHA 
surgery 
every 30 minutes 
  Calling to make sure that a patient 
  An HHA nurse who sends a visit 
continues to take medication as 
report to the patient's doctor via 
prescribed 
health application software for the 
  Calling to determine whether a 
doctor to evaluate at a later time 
patient needs to visit their primary 
care physician 
* HHAs are also now able to provide these services under the Medicare home health benefit beyond the COVID-19 
public health emergency. 
Sources: HHS, What is telehealth?, June 29, 2022 (updated September 14, 2022);55 CMS, COVID-19 Frequently Asked 
Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, updated January 7, 2021;56 42 CFR  409.46. 
Since the start of the pandemic, CMS and other sources have reported a dramatic 
increase in the use of telehealth by Medicare beneficiaries, including HHAs, from that 
of prior years.57, 58, 59  A previous OIG study found that Medicare beneficiaries used 88 
times as many telehealth services during the first year of the pandemic (March 2020 
through February 2021) as they used in the prior year.60  However, in a recent report 
to Congress, the Medicare Payment Advisory Commission noted that Medicare 
beneficiaries and providers had some concerns about whether telehealth offered the 
same quality of care as did in-person services.61 
CMS-Required Emergency Preparedness Plans. As of November 2017, CMS requires 
HHAs, along with other types of providers, to meet the CoP for emergency 
preparedness.62  CMS includes four core elements in its emergency preparedness 
requirements (see Exhibit 2).  HHAs must review these elements and update them 
every 2 years.63, 64 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Background | 5  Exhibit 2. CMS requires emergency preparedness plans to include four core 
elements. 
m 
Risk assessment  HHAs must perform risk assessments using an all-hazards 
and planning  approach, which considers those emergencies or disasters 
that are most likely to occur. Individual HHA emergency 
preparedness plans may therefore vary due to differences in 
location (e.g., if an HHA is in a tornado-prone area). 
II 
Policies and  HHAs must develop policies and procedures based on 
procedures  components of the emergency preparedness plan and risk 
assessment, such as how to track patients and staff during 
an emergency. 
B 
Communication  HHAs must develop emergency communication plans that 
plan  comply with Federal and State laws. These plans must 
include important contact information as well as methods 
for sharing patient information during emergencies. 
($] 
Training and  HHAs must train staff and test their emergency plans via 
testing program  drills. 
Sources: CMS, Emergency Preparedness Rule: Whats New based on the Medicare and Medicaid Programs; Regulatory 
Provisions to Promote Program Efficiency, Transparency, and Burden Reduction Final Rule; CMS, Frequently Asked 
Questions (FAQs): Emergency Preparedness Regulation, January 2017.65 
As of 2019, CMS guidance on emergency planning instructs providers to include 
emerging infectious diseases as part of their risk assessments all-hazards planning.66 
In March 2021, CMS updated that guidance to include additional information on 
incorporating emerging infectious diseases into providers all-hazards planning.  For 
example, CMS added guidance on assessing PPE needs and screening patients, 
among other considerations, during an infectious disease emergency.  CMS also 
suggested that providers develop policies to update their emergency preparedness 
plans during emergencies that last longer than expected.67 
CMS directs HHAs to various resources to support emergency preparedness.  For 
example, CMS provides online training to health care providers on emergency 
preparedness.68, 69  CMS may also refer HHAs to the Administration for Strategic 
Preparedness and Responses (ASPRs) Technical Resources, Assistance Center, and 
Information Exchange (TRACIE), which periodically updates EP resources on its 
website.70 
Related OIG Work 
This study contributes to the Office of Inspector Generals (OIGs) work on home 
health care and on providers experiences during the COVID-19 pandemic.  A 2021 
OIG audit assessed infection control practices at eight HHAs and found that six HHAs 
infection control policies and procedures complied with CMS requirements and 
COVID-19 guidance.71  Another audit is underway to examine HHAs compliance with 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Background | 6  CMSs regulations for telehealth servicesi.e., the regulations that were initially 
limited to the duration of the public health emergency, but subsequently made 
permanent.72 
Prior OIG home health work focused on unverified patient lists used in home health 
surveys and common characteristics of HHAs and physicians found in OIG-
investigated cases of home health fraud.73, 74  OIG has also conducted a series of 
compliance audits of home health care providers.  A complete listing of OIGs 
ongoing evaluations and audits is available in our online Work Plan at 
https://www.oig.hhs.gov/. 
Methodology 
This study used the following data sources: (1) a survey of a random sample of HHAs; 
(2) interviews with a purposive sample of 12 HHAs; and (3) an interview with CMS 
staff. 
Scope 
This study focuses on Medicare-participating HHA experiences from early in the 
pandemic to the point that OIG surveyed or interviewed HHAs in September through 
December 2021.  As part of the survey and interviews, we asked HHAs about 
challenges experienced early in the pandemic and in fall 2021.  We defined early in 
the pandemic to mean when the respondent HHAs geographic area experienced its 
first wave of COVID-19 infection. 
Data Sources and Analysis 
Survey of HHAs.  We administered a survey between September and November 2021 
to a random sample of 400 HHAs asking about their experiences during the COVID-
19 pandemic.  Of the 377 eligible Medicare-participating HHAs we surveyed, we 
received responses from 271, a 72-percent response rate.75  We analyzed the survey 
data to determine challenges HHAs experienced during the pandemic; strategies they 
used to address those challenges; and HHAs experiences with telehealth, emergency 
preparedness plans, and regulatory flexibilities.  We produce estimates from these 
data to speak to the experiences of Medicare-participating HHAs represented by our 
respondents.  See Appendix C for a description of our nonresponse bias analysis. 
To identify HHAs as rural, we used 2019 Medicare claims data to determine whether 
HHAs provided services to Medicare beneficiaries in mostly rural counties.  We 
identified 41 HHA survey respondents as rural.  We analyzed rural HHAs survey 
responses to describe the experiences of rural HHAs in our sample and do not 
generalize these responses to all rural HHAs.  
Interviews with HHAs.  We interviewed staff from a purposive sample of 12 HHAs in 
November and December 2021.  We asked HHAs about their experiences during the 
COVID-19 pandemic on the basis of their responses to our survey.  We selected HHAs 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Background | 7  that indicated notable challenges, strategies, or other experiences during the 
pandemic in their survey responses. 
Interview with CMS.  We conducted one interview with staff in CMSs Center for 
Clinical Standards and Quality and Center for Medicare regarding their perspectives 
on HHAs experiences during the pandemic and the support provided to HHAs by 
CMS.  We conducted this interview on January 21, 2022. 
See the Detailed Methodology on page 29 for additional information about our data 
collection and analysis. 
Limitations 
We based our findings regarding HHAs on the information reported by HHAs in our 
survey and during interviews.  We did not independently verify the information HHAs 
provided.  We did not evaluate the effectiveness of the strategies HHAs reported 
using to address challenges during the COVID-19 pandemic.  Our results pertaining to 
HHAs apply only to the population represented by the respondents and cannot be 
generalized to all HHAs.  
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. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Background | 8  FINDINGS 
Staffing challenges persist despite HHAs efforts to address 
them 
HHA staffing levels are important to ensuring that patients receive needed and high-
quality care.  Understaffed HHAs may be not able to send health care providers to 
patients homes to the extent required in each patients plan of care.  HHAs without 
enough staff may also struggle to accept new patient referrals, which could affect 
beneficiaries access to home health care.  
The pandemic exacerbated longstanding staffing challenges for 
HHAs and added new ones 
The COVID-19 pandemic further strained HHAs ability to hire and keep staff (see 
Exhibit 3).  HHAs described longstanding (i.e., pre-pandemic) challenges retaining and 
recruiting staff, including positions that 
remain vacant because candidates either do 
not apply or do not qualify for the position. 
We have [an] already tight market and a 
These challenges extended into the 
limited number of nursing professionals living 
pandemic.  According to many HHAs, 
in this area, staffing is always an issue.  In the 
challenges early in the pandemic included 
light of the pandemic, [it has] made the nurse 
difficulty recruiting new clinical staff due to 
shortage even more noticeable and  increased competition from other health care 
challenging.  Senior HHA staff  facilities or contract agencies (71 percent) 
and staff leaving to work for these facilities 
and contract agencies (51 percent). Two 
HHAs noted difficulty in recruiting and 
retaining staff because other companies offered higher wages. 
In addition to longstanding staffing challenges that were exacerbated by the 
pandemic, many HHAs faced challenges that emerged as a result of the COVID-19 
pandemic (see Exhibit 3).  Most HHAs (85 percent) had early challenges with limited 
staff due to personal circumstances related to the pandemic, such as school closures, 
or because of self-quarantine/isolation requirements.  About half of HHAs struggled 
early in the pandemic to pay contracted clinical staff due to higher contracting costs.  
Finally, three HHAs that we interviewed also noted challenges with staff uneasiness 
with caring for COVID-19 patients, which may have resulted in these patients not 
receiving care or overburdening the staff willing to care for COVID-19 patients.  Rural 
HHAs that responded to our survey also experienced several of these same 
longstanding and COVID-19-specific challenges.  For example, 39 of 41 rural HHAs 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 9  reported challenges with limited staff availability to work because of a COVID-19 
exposure. 
HHAs told us that staffing challenges made it difficult to complete patient visits and 
accept new patients: 
We could not accept some referrals due to staffing challenges.  Senior HHA staff 
When schools closed [we] had to discharge clients.  Senior HHA staff 
We had the potential to see a lot of patients, but we didnt always have the staff.  Senior 
HHA staff 
According to many HHAs, both longstanding and new staffing challenges persist, 
despite some improvement over the period of our review (see Exhibit 3).  For example, 
in fall 2021, 62 percent of HHAs still experienced challenges with recruiting new staff 
due to competition from other facilities or health care contract agencies, and 40 
percent still struggled with staff leaving to work for other health care facilities.  
Moreover, many HHAs continued to struggle with challenges that emerged due to the 
pandemic.  Despite some improvement, about half of HHAs still experienced 
challenges with limited staff availability due to personal circumstances related to the 
pandemic or because of self-quarantine/isolation requirements.  In addition, HHAs 
found that the challenge of paying contracted clinical staffa challenge stemming 
from higher contracting costs during the pandemicdecreased only slightly from 
early in the pandemic; 44 percent of HHAs struggled with this in fall 2021. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 10  Exhibit 3. Many HHAs continued to experience staffing challenges well into the pandemic.* 
Early in the pandemic  Fall 2021 
When an HHA 's area experienced  September 21 to November 22, 
its first wave of COV/O-19  2021 
Recruiting new clinical staff due to 
increased competition from other 
71%  62% 
health care providers**  . .  
Clinical staff leaving this HHA to 
work for other health care 
51% 
providers** 
-
Paying contracted clinical staff 
due to higher contracting costs 
during the pandemic 
Limited staff availability to work 
because of self-quarantine/ 
55% 
isolation due to COVID-19 
exposure 
Limited staff availability to work 
due to personal circumstances  55% 
related to the pandemic 
 Longstanding staffing challenges   COVID-19 specific staffing challenges 
* All differences between the two time points are significant at the 0.05 level (n=271). See Appendix D for more details. 
** These providers may include health care contract agencies or other health care facilities, such as hospitals. 
Source: OIG analysis of survey data, 2022. 
Although none of the challenges were fully resolved by fall 2021, 
HHA-developed strategies and CMS flexibilities helped HHAs to 
mitigate some staffing challenges 
HHAs developed their own strategies to ensure that patients received care despite 
staffing challenges (see Exhibit 4).  Many HHAs found it useful to assist staff with 
addressing COVID-19-related concerns, including by providing paid or unpaid leaves 
of absence (65 percent) or benefits, such as flexible schedules (59 percent).  Nearly as 
many (58 percent) also benefited from training staff to perform tasks outside of their 
usual duties, such as administrative work or duties in a different clinical area.  In 
addition, 40 percent of HHAs created and found it helpful to have specialized care 
teams of clinical staff who only treat COVID-19 patients.  For example, one HHA that 
we interviewed created COVID-19 care teams composed of staff who volunteered to 
see those patients.  Furthermore, HHAs reported using COVID-19 relief funds, such as 
the Provider Relief Fund, to recruit and maintain staff.76  Two HHAs that we 
interviewed used these funds to pay staff who were unable to work because of the 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 11  pandemic, and two HHAs used the funds to offer hazard pay.  However, another two 
HHAs that we interviewed noted that using financial support to recruit new staff, such 
as with signing bonuses, had limited effectiveness because of the lack of candidates 
applying for open positions. 
Exhibit 4. HHAs used and found helpful various strategies that they developed to respond to 
- - - 
staffing challenges during the pandemic.* 
Provided paid and/or unpaid leaves of absence to 
retain staff that are unable to work 
- - - 
Provided staff benefits to address COVI D-19-
related concerns  - - - 
Trained staff to perform tasks outside of their usual 
duties 
- - 
Created specialized care teams of clinical staff who 
treat only COVID-19 patients 
Developed new partnerships or used existing 
partnerships with other HHAs or health care ----- . 
facilities to share staff to fill staffing gaps 
* Surveyed HHAs also had the option to indicate if they used a strategy and did not find it helpful or if they did not use the strategy (see 
Appendix D). 
Source: OIG analysis of survey data, 2022. 
In addition to developing their own strategies, HHAs relied on flexibilities that CMS 
offered to help address staffing challenges (see Exhibit 5).  CMS told us that it offered 
flexibilities that increased time for staff to complete certain assessments and relaxed 
training requirements to help with staffing constraints.  About half of HHAs found 
each of these helpful (54 percent and 41 percent, respectively).  As required by 
provisions in the CARES Act, CMS permanently amended regulations to authorize 
nurse practitioners and physician assistants to certify and order home health services 
in addition to physicians.  HHAs told us that it made it easier and faster to admit new 
patients.  One HHA that we interviewed said that this flexibility was huge in getting 
orders for home health services signed and implemented.  CMS also expanded the 
types of HHA staff who may perform initial and comprehensive patient assessments 
to include occupational therapists (OTs), in addition to registered nurses, physical 
therapists (PTs), and speech language pathologists (SLPs).77  Three HHAs that we 
interviewed told us that this flexibility helped them admit and assess patients more 
quickly when staffing resources were stretched thin.  (See Appendix B for a summary 
of CMS flexibilities, including their status as of summer 2022.) 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 12  Although CMS has taken actions to ease HHAs staffing challenges, it has limited 
information on how these flexibilities have affected HHAs care.  In March 2021, CMS 
issued an update to the State Operation Manuals Appendix ZEmergency 
Preparedness Interpretive Guidelinesto provide additional guidance for the 
requirement that HHAs have policies and procedures that address emergency staffing 
strategies.  However, HHAs have discretion on which staffing strategies they use 
during an emergency.  
CMS receives feedback on the flexibilities via regular and ad hoc engagements with 
HHA stakeholders.  For example, stakeholders have told CMS that the flexibilities are 
helpful and needed until the end of the COVID-19 public health emergency.  CMS 
told us that it used feedback from stakeholder engagements to inform decision-
making on which flexibilities to make permanent.  However, CMS is not systematically 
collecting data to capture how HHAs are using or benefiting from flexibilities that 
aimed to help with staffing challenges or how flexibilities have affected the quality of 
patient care.  
Exhibit 5. HHAs used and found helpful the various flexibilities that CMS provided for them 
to respond to staffing challenges during the COVID-19 public health emergency.* 
- - - 
Authorizing additional practitioners to certify 
beneficiaries for eligibility, order home health 
services, and establish and review the care plan 
- - 
Allowing OTs, PTs, and SLPs to perform certain 
assessments for all patients receiving therapy 
services  - - 
Extending the 5-day completion requirement for the 
comprehension assessment to 30 days 
- - 
Waiving the requirement for onsite visits by a nurse 
every 2 weeks 
-  
Postponing the deadline for certain training 
requirements for home health aides 
* Surveyed HHAs also had the option to indicate if they used a flexibility and did not find it helpful or if they did not use the flexibility (see 
Appendix D). 
Source: OIG analysis of survey data, 2022. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 13  HHAs infection control challenges were numerous and 
widespread early in the pandemic, but these challenges 
lessened by fall 2021 
Because of COVID-19s infectious nature, HHAs had to quickly pivot to continue to 
provide needed care while also protecting patients and staff.  Limiting the spread of 
disease requires an understanding of how to prevent transmission and how to 
appropriately care for infected patients.  Enhanced infection control also requires 
adequate levels of supplies, particularly PPE.  However, limited knowledge of COVID-
19 as well as disrupted supply chains impeded HHAs ability to carry out these 
important tasks early in the pandemic. 
Early on, HHAs struggled to understand and navigate infection 
control for COVID-19; they relied on government guidance, 
trainings, and new protocols to help address this 
According to HHAs, it was a challenge to mitigate transmission and care for COVID-19 
patients at the beginning of the pandemic (see Exhibit 6).  Because COVID-19 was a 
novel disease, information regarding how to care for patients was limited and evolved 
as understanding of the virus grew.  Indeed, early in the pandemic, most HHAs (87 
percent) experienced challenges with navigating evolving guidance about how to 
treat COVID-19 patients.  Four HHAs that we interviewed also described struggling to 
interpret changing guidance to inform their infection 
control protocols (e.g., changes in appropriate PPE 
Having to research and determine 
use and post-exposure quarantine requirements).  In 
what information to base [p]olicies on 
addition, 88 percent of HHAs experienced challenges 
has been very time consuming.  with unclear and conflicting Federal and/or State 
 Senior HHA staff  government guidance about COVID-19 infection 
prevention and control.  Likewise, most rural HHAs 
that responded to our survey (34 of 41) reported 
experiencing this challenge.  HHAs described having 
to devote sometimes substantial resources to researching government websites to 
develop infection control protocols.  These challenges with guidance affected patient 
care: 56 percent of HHAs postponed caring for patients with positive COVID-19 
diagnoses until they had adequate infection control procedures in place. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 14  Exhibit 6. Most HHAs experienced challenges with understanding and navigating infection 
control information early on, although these challenges have decreased.* 
Early in the pandemic  Fall 2021 
When an HHA's area experienced  September 27 to November 22, 
its first wave of COV/0-79  2027 
Unclear State/Federal guidance about 
how to treat COVI D-19 patients  89% 
Unclear or conflicting State/Federal 
guidelines about COVID-19 infection  88% 
prevention and control 
Navigating evolving guidance about  i!fi 
87% 
how to treat COVI D-19 patients 
* All differences between the two time points are significant at the 0.05 level (n=271). See Appendix D for more details. 
Source: OIG analysis of survey data, 2022. 
HHAs attempted to mitigate challenges with infection control while their 
understanding of COVID-19 increased.  In addition to continuing to comply with the 
CoPs for infection prevention and control (see Appendix A), the COVID-19 pandemic 
required HHAs to take further action to address COVID-19 infection challenges.  From 
the perspective of HHAs, nearly all (97 percent) found it helpful to use available 
information to develop internal COVID-19 protocols, which can include information 
on how to respond to an exposure.  Moreover, nearly all HHAs found it helpful to 
increase or improve trainings for staff on COVID-19 treatment (95 percent) and 
provide staff with PPE training (96 percent). Although HHAs struggled with infection 
control information early in the pandemic, HHAs still accessed and relied on 
government sources, including CDC guidance, to inform protocols for minimizing 
transmission.  
Nearly all HHAs faced challenges with accessing PPE and other 
critical supplies to control the spread of COVID-19 early in the 
pandemic, but these challenges eased over time 
PPE and sanitizing products are essential for infection control.  Their widespread 
shortages early in the pandemic posed 
challenges to safely caring for patients (see 
[We] [n]ever thought that we 
Exhibit 7).  According to HHAs, over 90 
percent faced early challenges with accessing  would not be able to obtain PPE. 
supplies such as masks, other types of PPE,   Senior HHA staff 
and sanitizing products (e.g., sanitizing wipes, 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 15  hand sanitizer).  Nearly all rural HHAs that responded to our survey also experienced 
these challenges early in the pandemic: 37 with accessing masks, 37 with accessing 
other types of PPE, and 38 with accessing sanitizing products (of the 41 rural HHAs 
that responded to our survey).  These challenges with accessing supplies came at a 
time when HHAs needed to use more supplies than ever to protect patients and staff 
from COVID-19 infection.  One HHA that we interviewed described its limited access 
to supplies early in the pandemic as absolutely horrific. 
Exhibit 7. Almost all HHAs struggled with accessing supplies early on, but these challenges 
lessened over time.* 
Early in the pandemic  Fall 2021 
When an HHA's area experienced its  September 21 to November 22, 
first wave of COV/D-19  2021 
Access to masks 
93% 
Access to other types of PPE  91% 
Access to sanitizing products  94% 
High cost of PPE during the 
89%  42% 
pandemic 
* All differences between the two time points are significant at the 0.05 level (n=271). See Appendix D for more details. 
Source: OIG analysis of survey data, 2022. 
Until supply chains stabilized, HHAs had to take unprecedented steps to address 
limited supply access.  Over half (57 percent) found it helpful to conserve PPE, such as 
by re-using PPE normally meant for single use or by prioritizing PPE for the highest-
risk activities.  In addition, almost half (42 percent) of HHAs found it helpful to 
develop new, or use existing, partnerships with other HHAs or providers to obtain or 
pool supplies.  Finally, some 
HHAs (31 percent) found it 
helpful to access PPE through  Some of my staff and myself [sic] went to stores to try 
nontraditional sources, such  and find 90% alcohol to clean our equipment.  We 
as nail salons.  One HHA that  made [a]lcohol wipes out of industrial paper towels, we 
we interviewed characterized 
went to hardware stores to get N95 masks. 
its activities to access scarce 
 Senior HHA staff 
supplies as follows: we 
[HHAs] were just doing what 
we all could to survive. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 16  Although most HHAs used telehealth during the pandemic, 
challenges that HHAs experienced raise questions about 
telehealths future role in home health 
CMS implemented telehealth flexibilities for many types of providers during the 
COVID-19 public health emergency, including flexibilities for HHAs.  Indeed, as HHAs 
struggled with shortages of staff and supplies due to COVID-19, telehealth provided 
an opportunity to safely care for patients while reducing risk of infection.  CMS 
updated regulations in November 2020 to permanently allow HHAs to use telehealth 
as part of their patients plans of care, even after the public health emergency ends.78 
This regulatory change makes it vital to understand how HHAs use telehealth and its 
potential effects on patient care. 
HHAs used telehealth to provide a variety of services to patients 
during the pandemic, including phone calls for status checks and 
video visits for therapy services 
Most HHAs (73 percent) used telehealth during the pandemic and used 
it to conduct visits, share information, and facilitate interactions with 
outside providers. Of the HHAs that used telehealth, just over three-
73% 
quarters (78 percent) provided live video or audio visits during the 
pandemic (see Exhibit 8).79 Three HHAs that we interviewed noted that 
remote visits were particularly useful because of COVID-19s infectious 
of HHAs used telehealth 
during the pandemic  nature.  For example, HHAs were able to provide services to patients 
who did not want providers in their homes, especially early in the 
pandemic.  HHAs also described using telehealth to supplement care, 
such as through status checks for 
patients with chronic illnesses or COVID-
19. One HHA told us that it made daily 
[Telehealth] helped us keep patients 
phone calls to active COVID patients who 
seen when they needed visits and keep 
were under quarantine to assess the 
them home and healthy. 
need for an in-person visit. Notably, 
 Senior HHA staff 
two HHAs that we interviewed told us 
that telehealth was useful for continuing 
to provide patient care despite staffing 
challenges. 
Although Medicare does not cover this use of telehealth under the home health 
benefit, nearly two-thirds of HHAs (63 percent) helped patients set up or participate in 
telehealth services with a non-HHA provider such as a physician.  HHAs described 
using telehealth to facilitate remote communication with physicians and to meet 
certain requirements for home health care.  For example, one HHA that we surveyed 
wrote that it assisted patient[s] with telehealth visits with their physicians by setting 
up appointments and having a clinician with them to report specific vital signs and 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 17  other symptoms. Furthermore, half of the HHAs we interviewed reported that they 
would facilitate video calls between patients and physicians that, prior to the public 
health emergency, were required to be conducted in person. 
Just under half of HHAs (44 percent) electronically transmitted health information to 
health care providers within and/or outside of the HHA.  This may include 
electronically sending information for a health care provider to later assess.  HHAs 
also reported using telehealth for remote patient monitoring, which involves leaving 
equipment such as heart rate monitors with patients so that the HHA can continue to 
monitor vital signs.  One HHA that we surveyed told us that it used this for vital sign 
assessments for heart failure or other chronic conditions. 
Exhibit 8. HHAs used telehealth for different purposes during the 
pandemic.* 
Live, real-time services between a patient and a provider (in the HHA) 
HHA providers helping patients set up or participate in telehealth services with 
a provider outside of the HHA 
Electronically transmitting patient health information to a provider for their 
assessment at a different time 
* Among HHAs that used telehealth during the pandemic. 
Source: OIG analysis of survey data, 2022. 
Challenges using telehealth in home health care may limit its 
future use 
From the perspective of many HHAs that used telehealth during the pandemic, 
providing telehealth services often came with challenges (see Exhibit 9).  Some 
challenges were due to limitations with delivering telehealth services.  For example, 
home-based telehealth requires the patients home to have access to phone service, 
internet, and equipment (such as a smartphone).  About two-thirds of HHAs found 
that insufficient internet access in patients homes was a challenge, and five HHAs that 
we interviewed told us that patients struggled with accessing phone service and 
equipment.  In addition, almost two-thirds of HHAs found that most home care 
services require physical contact with patients, such as providing wound care, which 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 18  may affect the quality of care provided using telehealth.  Three HHAs that we 
interviewed noted that assessing patients, for example to evaluate mobility when a 
patient is walking, is difficult to do over video.  Other HHAs said that patients may be 
less capable of taking their own vital signs, such as blood pressure or heart rates, than 
are health care professionals.  As a result, one HHA that we interviewed told us that 
self-reported health information, whereby patients assess their own vital signs and 
symptoms and communicate them to the HHA, doesnt reflect the real situation or 
condition of the patient... [W]e cant get an accurate picture of our patient because of 
those limitations. 
According to HHAs, they also experienced financial challenges with using telehealth 
(see Exhibit 9).  Almost half of HHAs (44 percent) struggled with the high cost of 
telehealth.  HHAs cannot bill Medicare for telehealth services as equivalent to an in-
person visit, and two-thirds of HHAs found that this lack of direct reimbursement was 
a challenge.  HHAs that we interviewed told us that lack of direct reimbursement 
meant they could not afford to use telehealth more frequently.  For example, three 
HHAs that we interviewed noted that setting up and using telehealth, including 
purchasing the required equipment, is costly. 
Exhibit 9. HHAs that used telehealth during the pandemic experienced challenges in 
providing telehealth services. 
Lack of direct reimbursement for   
telehealth services -----------------------:    
Insufficient internet access in patients' 
- - - - 
homes 
Requirement for physical contact with 
- - 
patient for most care 
High cost of providing telehealth 
services 
 Challenges due to limitations   Challenges due to financial 
delivering telehealth services  concerns 
Source: OIG analysis of survey data, 2022. 
Rural HHAs may experience greater challenges providing telehealth services 
compared to HHAs in other settings.  Of the 31 rural HHAs that responded to our 
survey and used telehealth during the pandemic, 25 identified insufficient internet 
access as a challenge.  HHAs serving patients in rural settings reported that their 
patients often live in locations with limited or no cellular service or internet access and 
have limited access to equipment necessary to facilitate telehealth services.  One rural 
HHA that we surveyed told us: We can't provide [t]elemedicine to patients unless 
there is adequate equipment in the home.  In rural eastern Washington state, there is 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 19  often not.  There is also often not internet or cell phone service in the home, making 
[t]elemedicine impossible. 
HHAs that used telehealth during the pandemic 
were divided on whether they plan to continue 
using it after the pandemic, although government  43% 
support to overcome challenges may influence 
this.  Of the HHAs that used telehealth during the 
of HHAs that used telehealth 
pandemic, 43 percent anticipated that they will 
during the pandemic will not 
not use it afterwards.  HHAs said that they 
use it afterwards 
temporarily relied on telehealth to help address 
pandemic-specific challenges, such as monitoring 
high-risk COVID-19 patients or delivering services to patients who do not want 
providers in their homes.  Almost half of the HHAs we interviewed told us that there is 
limited incentive to provide telehealth services, including after the pandemic, but that 
they might reconsider if they received direct reimbursement for these services. 
On the other hand, over half (57 percent) of HHAs that used telehealth during the 
pandemic anticipated that they will continue to use telehealth after the pandemic, 
including in ways that incorporate lessons learned.  For example, one HHA that we 
interviewed created a more detailed telehealth-based virtual assessment for patients 
it considered at higher risk for rehospitalization, including COVID-19 patients.  HHAs 
also acknowledged that although telehealth is not appropriate for all HHA-based 
care, telehealth may be better suited to certain home health services.  One HHA that 
we surveyed told us that it thought CMS should reimburse HHAs for telehealth 
services that supplement in-person care: provide reimbursement for virtual skilled 
nursing visits with patients as an adjunct to in-person visits (not as a replacement).  
This could minimize rehospitalizations. 
CMS lacks full insight into HHAs use of telehealth due to limited 
reporting requirements 
HHAs report limited information about their telehealth use to CMS.  CMS requires 
HHAs to report the direct costs of providing telehealth on their cost reports, but these 
do not include further detail on the types of services for which HHAs use telehealth.80 
HHAs cannot bill Medicare for telehealth visits as comparable to in-person visits and 
are currently not required to report telehealth use on their claims.  Therefore, CMS is 
unable to capture specific details on the extent and nature of how HHAs use 
telehealth.  CMS told us that these limitations affect the extent to which CMS can 
evaluate and review HHAs telehealth use.  For example, CMS cannot track the 
frequency with which HHAs use telehealth over time or the types of services they 
provide with telehealth. 
CMS plans to assess available information on HHAs telehealth use and to explore 
options to gather additional information.  For example, in a calendar year (CY) 2021 
final rule, CMS allowed HHAs to include remote patient monitoring and other 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 20  telehealth technology within cost reports as allowable administrative and general 
costs.  CMS plans to assess these data when it receives those cost reports.81  In June 
2022, CMS issued a CY 2023 proposed rule allowing HHAs to voluntarily report 
telehealth use on claims starting January 2023.82  The proposed rule, if enacted, will 
require this information by July 2023.  However, Medicare could not directly 
reimburse these services without a change in statute.  CMS is also soliciting 
comments on how it intends to capture telehealth use on claims as well as on the 
appropriateness of telehealth in the home health context.  Currently, CMS also 
engages with HHAs and other stakeholders on both a regular and as-needed basis 
and may receive feedback on telehealth through these engagements.  CMS 
acknowledges the importance of gaining a more complete picture of HHAs telehealth 
use to inform future decision-making. 
Emergency preparedness (EP) plans guided HHAs response to 
the pandemic, but the plans fell short of fully addressing a 
global emergency such as COVID-19 
CMS requires that HHAs conduct risk assessments to inform their EP plans.  Risk 
assessments must use an all-hazards approach to consider a broad range of 
emergencies that may affect the HHA and its patient population.  HHAs have wide 
latitude to determine the contents and structure of their EP plans.  Because each risk 
assessment is specific to the HHA, EP plans vary on the basis of emergency scenarios 
HHAs identify and how HHAs plan to address these emergencies.  This includes 
determining how to include emerging infectious diseases as part of their all-hazards 
risk assessment, as required by CMS in 2019. 
Almost all HHAs with EP plans found them helpful with 
responding to the challenges of the COVID-19 pandemic 
Nearly all HHAs (98 percent) that had an EP plan during the pandemic benefited from 
these plans, including with challenges related to infection control guidelines and 
accessing supplies (see Exhibit 10).  Notably, 91 percent of HHAs with an EP plan 
during the pandemic found the plan to be helpful with addressing infection control 
challenges. One HHA that we interviewed told us that, prior to the pandemic, its EP 
plan included infection control guidelines based on other infectious diseases such as 
influenza and severe acute respiratory syndrome.  Although these guidelines were not 
specific to COVID-19, they were helpful for reducing its transmission.  In addition, 81 
percent of HHAs that had an EP plan found them to be helpful with addressing supply 
challenges. For example, one HHA we spoke with explained that its local health and 
emergency departments became important resources for help with supplies when it 
was faced with pandemic-related shortages.  That HHA developed relationships with 
those entities prior to the pandemic through emergency drills required by CMS. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 21  Exhibit 10. HHAs that had EP plans during the pandemic found these EP plans helpful. 
Helpful overall  98% 
Helpful responding to challenges with infection 
91% 
control 
Helpful responding to challenges with supplies  81% 
Helpful responding to challenges maintaining 
74% 
appropriate staffing 
Source: OIG analysis of survey data, 2022. 
About three-quarters (74 percent) of HHAs also found their EP plans to be helpful 
with addressing staffing challenges.  A couple of HHAs that we interviewed described 
how their plans supported their responses by outlining each staff members 
responsibilities during an emergency. According to one HHA, if we didnt have an 
emergency management infrastructure in place I dont know if we would have had as 
effective of a response. Everyone knew their roles. 
Because HHAs EP plans generally focused on local, temporary 
emergencies, many fell short in a sustained, global emergency 
Although EP plans provided a useful framework 
for responding to the pandemic, about half of 
HHAs that had an EP plan found it challenging  51% 
that their EP plans were more suitable to a local 
of HHAs with an EP plan found it 
Its not like a fire, or earthquake, that hits a  challenging that their plan was 
certain area or population and you use your  more suitable to a local emergency 
than to a national or global 
EP to get through it, clean up the aftermath 
emergency such as COVID-19
and move on.  This pandemic is a disaster like 
emergency than to a national or global 
no other, that has infiltrated every aspect of 
emergency such as COVID-19.  CMS 
society...  Senior HHA staff 
instructed HHAs to include emerging 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 22  infectious diseases in its 2019 EP plan guidance, and 93 percent of HHAs did so 
before the pandemic.  However, nearly half of the HHAs we interviewed told us that 
their plans focused on emergencies that were more likely to affect their geographic 
area, such as weather events.  One HHA described how its plan included information 
on responding to hurricanes, including contacting patients to determine plans for 
evacuation, but noted that this did not prepare it for COVID-19.  Another HHA said 
that its EP plan did not originally cover situations in which staff could not enter 
patients homes, as was the case during the COVID-19 pandemic.  This HHA said that 
prior to the pandemic, it had not considered emergency preparedness on a global 
platform. 
HHAs adjusted their emergency planning to respond to COVID-19 
and identified how CMS could further help them with this 
planning 
To support their COVID-19 response, HHAs developed new, separate response plans 
as well as adjusting their existing EP plans.  In fact, 85 percent of HHAs developed a 
separate response plan specific to COVID-19.  These plans, which CMS does not 
require, included information on testing staff and patients for COVID-19, treating 
patients with COVID-19, and work-from-home policies, among other information.  
One HHA that we interviewed described a flow chart included in its COVID-19 plan 
that guides staff through determining whether an employee should isolate or 
quarantine after an exposure.  In addition, as of fall 2021, almost all HHAs (97 percent) 
modified or planned to modify their existing EP plans to apply lessons learned during 
the pandemic.  For example, one HHA that we interviewed updated its EP plan to 
include screening questions about whether patients had been exposed to any 
infectious disease, such as influenza.  Another updated the supply policy in its EP plan 
to maintain a 90-day reserve of new supplies. 
HHAs expressed that they would benefit from more support from CMS on developing 
and using their EP plans to meet the challenges of an infectious disease emergency.  
Of the HHAs that responded to our question, 
two-thirds (67 percent) said that CMS could 
better support HHAs by providing more 
One senior HHA staff member 
information on the content and 
recommended that CMS provide 
implementation of these EP plans during an 
designated training for HHAs to follow as 
infectious disease emergency.  For example, 
guides for infectious disease emergencies  one HHA suggested that CMS provide 
that are at a national or global level.  examples of guidelines that other HHAs used 
and found helpful when responding to an 
emerging infectious disease.  Another HHA 
we surveyed requested that CMS provide 
more training on using EP plans to respond to an emerging infectious disease 
emergency.  
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 23  Amidst the COVID-19 public health emergency, CMS has taken steps to help HHAs 
with their EP plans.  In March 2021, CMS issued updated guidance for EP plans and 
prompted HHAs to include more information on emerging infectious diseases.  CMS 
also told us that it plans to solicit and use feedback from providers, including HHAs, 
about their experiences during the public health emergency to make future changes 
to this guidance.  Finally, CMS told us that it coordinates with ASPR TRACIE to offer 
HHAs additional guidance on emerging infectious diseases, including COVID-19. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Findings | 24  CONCLUSION AND RECOMMENDATIONS 
The COVID-19 pandemic presented substantial challenges for HHAs and their 
capacity to care for patients.  The challenges included the novel nature of the 
virus, as well as challenges with staffing, infection control, supply shortages, 
and emergency planning, among others. 
HHAs and CMS took steps to address these challenges as knowledge 
regarding the pandemic evolved.  The regulatory flexibilities that CMS offered 
helped HHAs as they grappled with how to respond to the COVID-19 
pandemic.  HHAs used telehealth to fill gaps in their capacity to provide 
services and adjusted their emergency plans, in addition to other 
actions.  Indeed, as knowledge about the virus increased, supply chains 
stabilized, and HHAs took steps to continue caring for patients, some of the 
earliest challenges abated. 
However, HHAs experiences responding to the pandemic point to continued 
challenges. With HHAs using telehealth in new ways, questions have emerged 
about whether and how it can best serve beneficiaries in the home health 
realm. In addition, staffing challengeswhich were also present prior to the 
pandemicpersist, despite HHAs use of regulatory flexibilities and their own 
efforts to address staffing. 
As the immediacy of the pandemic lessens, CMS has an opportunity to assess 
how to best help HHAs prepare for and respond to current and future 
infectious disease outbreaks. Furthermore, changes to the home health care 
landscape, including expanded telehealth allowances, merit further study to 
understand how these changes best serve patients. 
To that end, we recommend that CMS: 
Evaluate how HHAs are using telehealthspecifically, the 
types of services provided via telehealth and the 
characteristics of patients who benefit from these services 
CMS could use such an evaluation to refine its approach to telehealth in the 
home health environment.  With CMS permanently allowing HHAs to use 
telehealth as part of a patients plan of care, understanding the strengths and 
limitations of telehealth in home health is important to ensuring that patients 
receive beneficial and high-quality care.  For example, home health patients 
may benefit from certain telehealth services, such as remote patient 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Conclusion and Recommendations | 25  monitoring or status checks, but may benefit less from other services through 
telehealth, such as physical therapy visits or wound care.  Examining HHAs 
telehealth use and its effects on access, equity, quality of care, and program 
integrity will provide vital insights into whether and how telehealth can best 
serve home health patients. 
To better determine the types of services provided by telehealth and 
characteristics of patients who benefit from these services, CMS should collect 
and analyze data on HHAs telehealth use.  CMS is planning to examine 
telehealth information included on HHAs cost reports once HHAs submit 
these data.  CMSs CY 2023 proposed rule for home health allows HHAs to 
voluntarily report telehealth use on claims starting in January 2023.  The 
proposed rule, if enacted, will require this information by July 23, 2023.  CMS is 
also soliciting comments on how CMS intends to capture telehealth use on 
claims as well as the appropriateness of home health care via telehealth given 
the hands-on nature of many home health services.  We encourage CMS to 
analyze claims data, as well as other relevant data it collects or identifies, if 
any, to evaluate HHAs use of telehealth. 
To inform decision-making, evaluate how the regulatory 
flexibilities it has offered in response to the COVID-19 
public health emergency affect the quality of home health 
care 
CMS has limited information on how flexibilities affected patient care during 
the public health emergency.  CMS obtained feedback on the flexibilities 
through structured and ad hoc engagements with stakeholders during the 
public health emergency and used this feedback to inform decisions about 
which flexibilities to make permanent.  However, CMS has not systematically 
evaluated these flexibilities, including the impact of these flexibilities on the 
quality of patient care. 
CMS should conduct a systematic review to gain insights into how the 
flexibilities offered during the public health emergencywhether as a whole 
or individually, and including those that are now permanentaffect the 
quality of patient care.  CMS could collect data from HHAs or analyze claims, 
assessment data, and/or patient feedback to examine changes in quality of 
care during the public health emergency that may relate to the flexibilities.  
CMS could use this review to inform decision-making regarding which 
flexibilities to use during future emergencies. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Conclusion and Recommendations | 26  In collaboration with ASPR TRACIE, apply lessons learned 
from the COVID-19 pandemic to update and/or develop 
emergency preparedness trainings and materials for HHAs 
on responding to infectious disease outbreaks 
CMS has an opportunity to provide additional support to HHAs responding to 
infectious disease emergencies, including those that are sustained and 
widespread.  Indeed, HHAs told us that they desire and would benefit from 
more guidance.  CMS already provides online trainings on emergency 
preparedness for health care providers and also collaborates with ASPR 
TRACIE to support HHAs emergency preparedness, including by conducting 
technical reviews of ASPR TRACIE materials for HHAs.  
CMS has solicited feedback from providers, including hospitals and nursing 
homes, on their experiences using their EP plans during COVID-19.  CMS 
should also directly engage with HHAs on their experiences using their EP 
plans.  CMS should share feedback with ASPR TRACIE, and, in collaboration 
with ASPR TRACIE, use this feedback as well as the findings of this study to 
inform emergency preparedness trainings and materials (whether as updates 
to existing resources or to develop new resources).  These trainings and 
materials should reflect lessons learned from the COVID-19 pandemic.  To 
guide these efforts, CMS could review existing CMS and ASPR TRACIE 
emergency preparedness resources, including those that are currently under 
development, to identify opportunities to incorporate lessons learned.  For 
identified opportunities, CMS could collaborate with ASPR TRACIE to develop 
new, or modify existing, resources. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Conclusion and Recommendations | 27  AGENCY COMMENTS AND OIG RESPONSE 
CMS concurred with all three of our recommendations, as detailed below. 
First, CMS concurred with our recommendation to evaluate how HHAs are using 
telehealthspecifically, the types of services provided via telehealth and the 
characteristics of patients who benefit from these services. In the CY 2023 Home 
Health Prospective Payment System proposed rule, CMS stated its plans to require 
that HHAs report the use of telehealth on home health claims beginning July 2023.  
Collecting this information is vital to understanding the strengths and limitations of 
telehealth in the home health environment, as well as the characteristics of patients 
who benefit from telehealth services.  We look forward to updates in CMSs Final 
Management Decision on both its evaluation of HHAs use of telehealth as well as 
how patients have benefited from these services. 
Second, CMS concurred with our recommendation to evaluate how regulatory 
flexibilities offered during the COVID-19 public health emergency affect the quality of 
home health care. CMS stated that it is holding listening sessions seeking feedback 
from providers, including HHAs, on what flexibilities have been the most or least 
helpful during the public health emergency.  In its Final Management Decision, CMS 
should detail its efforts to systematically review how the flexibilities offered during the 
COVID-19 public health emergency, either individually or as a whole, affected the 
quality of patient care.  
Third, CMS concurred with our recommendation to collaborate with ASPR TRACIE to 
apply lessons learned from the COVID-19 pandemic to update and/or develop 
emergency preparedness trainings and materials for HHAs on responding to 
infectious disease outbreaks. CMS stated that it recently published case studies of 
how 30 nursing homes and hospitals responded to challenges during the onset of the 
COVID-19 pandemic.  In this report, we recommend that CMS engage directly with 
HHAs on their experiences using EP plans during the pandemic.  In its Final 
Management Decision, CMS should describe its direct engagement with HHAs, as well 
as its steps to collaborate with ASPR TRACIE, to update and/or develop emergency 
preparedness trainings and materials for the home health environment. 
For the full text of CMSs comments, see the appendix at the end of this report. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Agency Comments and OIG Response | 28  DETAILED METHODOLOGY 
This study used the following data sources: (1) a survey of a random sample of HHAs; 
(2) interviews with a purposive sample of 12 HHAs; and (3) an interview with CMS 
staff. 
Scope 
This study focuses on Medicare-participating HHA experiences from early in the 
pandemic to the point that OIG surveyed or interviewed HHAs in September through 
December 2021.  As part of the survey and interviews, we asked HHAs about 
challenges experienced early in the pandemic and in fall 2021.  We defined early in 
the pandemic to mean when the respondent HHAs geographic area experienced its 
first wave of COVID-19 infection.  
Sample 
We selected a nationally representative, simple random sample of 400 
Medicare/Medicaid-participating HHAs to ask about their experiences during the 
COVID-19 pandemic. We selected the random sample from among the 11,418 HHAs 
listed in CMSs Certification and Survey Provider Enhanced Reporting (CASPER) 
system as of June 2021.83  Of the 400 sampled HHAs, we removed 19 closed HHAs 
and 4 HHAs that participated only in Medicaid, bringing the total to 377 HHAs 
included in our sample.84 
Survey 
We sent an electronic survey to the sampled HHAs between September 21, 2021, and 
November 22, 2021; 271 HHAs responded, for a 72-percent response rate.  We 
contacted each HHA with at least two letters and a phone call before determining that 
an HHA was a nonrespondent.85  We project our sample to the 72 percent of the 
11,265 Medicare-participating HHAs represented by our respondents.  We conducted 
a nonresponse analysis to assess whether nonresponding and responding HHAs in 
our sample differed with regard to certain variables.  See Appendix C for a description 
of our nonresponse bias analysis. 
The survey included questions about HHAs challenges during the COVID-19 
pandemic; strategies to address these challenges; and the use of telehealth, 
regulatory flexibilities, and emergency preparedness plans during the pandemic.  It 
also collected background information about the HHA.  We produced estimates from 
these survey data to describe the experiences of Medicare-participating HHAs 
represented by our respondents during the pandemic.  We performed t-tests to 
determine statistically significant differences in the proportions of HHAs experiencing 
challenges early in the pandemic compared to at the time of the survey.  Significant 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Detailed Methodology | 29  differences were determined at the 0.05 level.  See Appendix D for estimates and p-
values, where appropriate.  
We analyzed open-ended survey responses by categorizing these responses by 
theme.  We used open-ended survey responses to add context to our survey 
estimates and provide insight into HHAs experiences during the COVID-19 pandemic, 
including challenges and strategies used to address challenges.  We counted the 
number of responses that directly answered the survey question to produce estimates 
from these data. 
Rural HHA Analysis 
To identify HHAs as rural, we obtained 2019 Medicare claims data for the HHAs in our 
sample and determined the percentage of care episodes HHAs provided to Medicare 
beneficiaries in rural Core Based Statistical Areas (CBSAs).  We used 2019 Medicare 
claims data because 2019 is the most recent year for which claims are complete.86  We 
defined rural HHAs as HHAs that provided 50 percent or more of their care episodes 
in rural CBSAs.87  We identified 41 rural HHAs that responded to our survey (18 
percent of respondents with 2019 Medicare claims).88 
We analyzed rural HHAs survey responses to describe the experiences of rural HHAs 
in our sample during the COVID-19 pandemic.  We do not generalize these responses 
to all rural HHAs.  
Stakeholder Interviews 
We interviewed staff from a purposive sample of 12 HHAs in November and 
December 2021.  We selected these HHAs on the basis of survey responses that 
indicated notable challenges, strategies, or other experiences that may be useful to 
CMS, the HHA industry, and other stakeholders.  We use data from these interviews to 
add context to our survey data and provide insight into HHAs experiences during the 
COVID-19 pandemic.  We do not use these interviews to generalize to all HHAs.  Of 
the 12 HHAs we interviewed, we identified 4 as rural on the basis of their 2019 
Medicare claims. 
We also interviewed CMS staff in the Center for Clinical Standards and Quality and 
Center for Medicare on January 21, 2022.  We asked about CMSs support of, and 
perspectives on, HHAs providing care during the pandemic, including (1) guidance 
that CMS provided to HHAs; (2) HHAs use of regulatory flexibilities provided by CMS; 
(3) HHAs challenges with staffing and PPE; (4) HHAs use of telehealth; and (5) HHAs 
use of emergency preparedness plans and development of COVID-19-specific 
response plans. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Detailed Methodology | 30  APPENDICES 
Appendix A: CMS Conditions of Participation (CoPs): Infection 
Prevention and Control 
CMS requires HHAs to maintain and document an infection control program to 
prevent and control infections and communicable diseases.89  To achieve compliance 
with the CoP for infection prevention and control, HHAs must meet four standards: 
   Prevention: HHAs must follow accepted standards of practice, including the 
use of standard precautions, to prevent the transmission of infections and 
communicable diseases. 
   Control: HHAs must maintain a coordinated agency-wide program for the 
surveillance, identification, prevention, control, and investigation of infectious 
and communicable diseases. 
   Education: HHAs must provide infection control education to staff, patients, 
and caregivers. 
   COVID-19 vaccination of home health agency staff: As of December 6, 2021, 
CMS requires COVID-19 vaccinations for HHA staff.  HHAs must develop and 
implement policies and procedures to ensure that all staff receive required 
vaccinations for COVID-19.90 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix A | 31  Appendix B: Regulatory Flexibilities and Supports for Home 
Health Agencies During the COVID-19 Public Health Emergency 
(PHE) 
Regulatory flexibility or  Relevant regulation  Status as of summer 2022 
support  (if applicable) 
Extend the 5-day completion  42 CFR  484.55(b)(1)  Waiver in effect for the 
requirement for the  duration of the PHE for 
comprehensive assessment to 30  COVID-19.91 
days 
Waive the 30-day Outcome and  42 CFR  484.45(a)  Waiver in effect for the 
Assessment Information Set  duration of the PHE for 
(OASIS) submission requirement.  COVID-19.92 
HHAs must submit OASIS data 
prior to submitting their final 
claim in order to receive 
Medicare payment. 
Allow HHAs to perform  42 CFR  484.55(a)  Waiver in effect for the 
Medicare-covered initial  duration of the PHE for 
assessments and determine  COVID-19.93 
patients homebound status 
remotely or by record review 
Allow the required face-to-face  42 CFR   Waiver in effect for the 
encounter for home health  424.22(a)(1)(v)(B)  duration of the PHE for 
services to be conducted via  COVID-19.94 
two-way audio-visual 
telecommunications technology 
from the patients home 
Waive requirement for an onsite  42 CFR  484.80(h)  Waiver in effect for the 
visit by a nurse every two weeks  duration of the PHE for 
COVID-19.95 
Waive requirement for a nurse  42 CFR  484.80(h)(1)  Waiver in effect for the 
supervisory assessment of home  duration of the PHE for 
health aide services every two  COVID-19.96 
weeks 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix B | 32  Authorize allowed  42 CFR  484.55(a)(2)  Flexibility made permanent in 
practitioners, in addition to  and  484.55(b)(3)  the Coronavirus Aid, Relief, 
physicians, to certify  and Economic Security Act.97 
beneficiaries for eligibility, order 
home health services, and 
establish and review the care 
plan. (Allowed practitioners are 
defined at 42  CFR 484.2 as 
physician assistants, nurse 
practitioners, or clinical nurse 
specialists.) 
Postpone deadline to  42 CFR  484.80(d)  Waiver in effect for the 
completing requirement that  duration of the PHE for 
each home health aide receive  COVID-19.98 
12 hours of in-service training in 
a 12-month period 
Allow occupational therapists,  42 CFR  484.55(a)(2)  Occupational therapist 
physical therapists, and speech  and  484.55(b)(3)  flexibility made permanent in 
language pathologists to  the Consolidated 
perform initial and  Appropriations Act, 2021.99 
comprehensive assessment for 
all patients receiving therapy  Specifically, the rule made 
services  permanent the flexibility 
allowing occupational 
therapists to complete the 
initial and comprehensive 
assessments for patients when 
occupational therapy is on the 
home health plan of care, with 
either physical therapy or 
speech therapy, and when 
skilled nursing services are not 
initially in the plan of care. 
Allow HHAs to use telehealth for  42 CFR  409.43(a)  Flexibility made permanent in 
visits and services within the  Calendar Year 2021 Home 
patients plan of care, as long as  Health Prospective Payment 
the telehealth services do not  System Final Rule.100 
replace needed in-person visits 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix B | 33  Waive requirements to provide  42 CFR  484.58(a)  Waiver in effect for the 
detailed information regarding  duration of the PHE for 
discharge planning to patients  COVID-19.101 
and their caregivers, or the 
patients representative in 
selecting a post-acute care 
provider, by using and sharing 
data that includes, but is not 
limited to, (another) HHA, skilled 
nursing facility, inpatient 
rehabilitation facility, and long-
term care hospital quality 
measures and resource use 
measures 
Extend deadline to provide a  42 CFR  484.110(e)  Waiver in effect for the 
patient with a copy of their  duration of the PHE for 
clinical record from 4 days to 10  COVID-19.102 
days 
Postpone requirement for nurse  42 CFR   Waiver in effect for the 
to make an annual onsite  484.80(h)(1)(iv)  duration of the PHE for 
supervisory visit (direct  COVID-19.103 
observation) of home health 
aide services 
Narrow scope of Quality  42 CFR  484.65(a)  Waiver in effect for the 
Assurance and Performance  (d)  duration of the PHE for 
Improvement (QAPI) to  COVID-19.104 
concentrate on infection control 
issues 
Exempt HHAs from the Home  42 CFR  484.245  Waiver no longer in effect. 
Health Quality Reporting  HHAs were required to resume 
Program (QRP) reporting  quality reporting data 
requirements. The time period  submission on July 1, 2020.105 
covered by this exemption is 
October 1, 2019, through June 
30, 2020. 
Implement a policy to align  42 CFR  484.315(b)  Waiver in effect for the 
Home Health Value-Based  duration of the PHE.106 
Purchasing (HHVBP) Model data 
submission requirements with 
any exceptions or extensions 
granted for purposes of the 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix B | 34  Home Health QRP during the 
PHE for the COVID-19 pandemic, 
as well as a policy for granting 
exceptions to the New Measures 
data reporting requirements 
under the HHVBP Model during 
the PHE for the COVID-19 
pandemic 
Allow Medicare Administrative  42 CFR   Waiver in effect for the 
Contractors to extend the auto- 484.205(h)(2)(iv)  duration of the PHE for 
cancellation date of Requests for  COVID-19.107 
Anticipated Payments during 
emergencies 
Allow HHAs that participate in  Waiver no longer in effect. 
the Review Choice  CMS resumed RCD operations 
Demonstration (RCD) for Home  on August 3, 2020.108 
Health Services to pause their 
participation for the duration of 
the PHE 
Delay cost report filing deadlines  42 CFR   Waiver no longer in effect. 
for cost reporting periods  413.24(f)(2)(i)  CMS resumed regular cost 
ending between October 1,  report deadlines.109 
2019, and December 31, 2020 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix B | 35  Appendix C: Analysis of Nonresponse Bias 
To examine the extent of potential nonresponse bias, we compared whether our 271 
respondent HHAs differed from the nonrespondents and the population of 11,265 
Medicare-participating HHAs (as of June 2021) on certain characteristics.  Specifically, 
we examined the number of branches operated by HHAs, the location of HHAs in 
rural or urban Core Based Statistical Areas, and the number of staff employed by 
HHAs.  These characteristics did not significantly differ between our respondent 
HHAs, nonrespondent HHAs, and all HHAs within our scope.  Although these 
comparisons do not preclude the possibility of nonresponse bias, they suggest that 
our respondent HHAs are similar to the nonrespondents and the population of 
Medicare-participating HHAs. 
We also examined how our survey results would have changed if all nonrespondent 
HHAs in our sample had responded differently from our respondent HHAs (e.g., the 
worst-case scenario).  For, example, our projection pertaining to telehealth usage (73 
percent) would have changed from 73 percent to 52 percent, which is still a majority.  
Given that the nonrespondents were similar to the respondents in the characteristics 
we examined, a more reasonable scenario is that some of the nonrespondents would 
have agreed with the respondents and the realized bias may be small. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix C | 36  Appendix D: Home Health Agencies Responses to OIGs Survey 
HHA experiences with staffing during the COVID-19 pandemic 
Sample  Point  95% confidence 
Description 
size  estimate  interval 
Challenges with HHAs staffing during the COVID 19 pandemic 
Clinical staff leaving this HHA to work for other health care facilities or health care contract agencies 
Early pandemic challenge  271  50.9%  45.1-56.8% 
Pandemic challenge as of fall 2021  271  40.2%  34.6-46.1% 
p-value <0.0001 
Recruiting new clinical staff due to increased competition from other health care facilities or health care 
contract agencies 
Early pandemic challenge  271  70.8%  65.2-75.9% 
Pandemic challenge as of fall 2021  271  62.4%  56.5-67.9% 
p-value=0.0018 
Paying contracted clinical staff due to higher contracting costs during the pandemic 
Early pandemic challenge  271  48.7%  42.9-54.6% 
Pandemic challenge as of fall 2021  271  43.5%  37.8-49.4% 
p-value=0.0475 
Limited staff availability to work due to personal circumstances related to the pandemic (e.g., lack of 
childcare due to school closures) 
Early pandemic challenge  271  84.5%  79.8-88.3% 
Pandemic challenge as of fall 2021  271  55.4%  49.5-61.1% 
p-value <0.0001 
Limited staff availability to work because of self-quarantine/isolation due to COVID-19 exposure 
Early pandemic challenge  271  85.2%  80.6-88.9% 
Pandemic challenge as of fall 2021  271  55.4%  49.5-61.1% 
p-value <0.0001 
Strategies used to address challenges with HHAs staffing during the COVID 19 pandemic 
Provided staff benefits to address COVID-19-related concerns (e.g., childcare, flex time, transportation 
assistance) 
Used and found helpful  271  59.4%  53.5-65.0% 
Used but did not find helpful  271  6.3%  4.0-9.8% 
Did not use  271  34.3%  29.0-40.1% 
Trained staff to perform tasks outside of their usual duties (e.g., administrative work or duties in a different 
clinical area) 
Used and found helpful  271  57.6%  51.7-63.2% 
Used but did not find helpful  271  4.4%  2.6-7.6% 
Did not use  271  38.0%  32.5-43.8% 
Provided paid and/or unpaid leaves of absence to retain staff that are unable to work 
Used and found helpful  271  64.6%  58.8-70.0% 
Used but did not find helpful  271  10.0%  7.0-14.1% 
Did not use  271  25.5%  20.7-30.9% 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix D | 37  Created specialized care teams of clinical staff who only treat COVID-19 patients 
Used and found helpful  271  39.9%  34.3-45.7% 
Used but did not find helpful  271  5.2%  3.1-8.5% 
Did not use  271  55.0%  49.1-60.7% 
Developed new or used existing partnerships with other HHAs or health care facilities to share staff to fill 
staffing gaps 
Used and found helpful  271  26.6%  21.7-32.1% 
Used but did not find helpful  271  6.6%  4.3-10.2% 
Did not use  271  66.8%  61.0-72.1% 
Use of CMS regulatory flexibilities and supports to help address staffing challenges 
Extend the 5-day completion requirement for the comprehensive assessment to 30 days 
Used and found helpful  271  54.2%  48.4-60.0% 
Used but did not find helpful  271  3.7%  2.0-6.7% 
Did not use  271  42.1%  36.4-47.9% 
Authorize additional practitioners to certify beneficiaries for eligibility, order home health services, and 
establish and review the care plan 
Used and found helpful  271  80.1%  75.0-84.4% 
Used but did not find helpful  271  1.5%  0.6-3.8% 
Did not use  271  18.5%  14.3-23.4% 
Waive requirement for onsite visits by a nurse every 2 weeks 
Used and found helpful  271  48.0%  42.2-53.8% 
Used but did not find helpful  271  3.3%  1.8-6.2% 
Did not use  271  48.7%  42.9-54.6% 
Allow occupational therapists, physical therapists, and speech language pathologists to perform initial and 
comprehensive assessment for all patients receiving therapy services 
Used and found helpful  271  64.2%  58.4-69.6% 
Used but did not find helpful  271  4.8%  2.8-8.0% 
Did not use  271  31.0%  25.8-36.7% 
Postpone deadline to completing requirement that each home health aide receives 12 hours of in-service 
training in a 12-month period 
Used and found helpful  271  40.6%  35.0-46.5% 
Used but did not find helpful  271  3.0%  1.5-5.7% 
Did not use  271  56.5%  50.6-62.2% 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix D | 38  HHA experiences with infection control during the COVID-19 pandemic 
95% 
Point 
Description  Sample size  confidence 
estimate 
interval 
Challenges with infection control during the COVID 19 pandemic 
Unclear State/Federal guidance about how to treat COVID-19 patients 
Early pandemic challenge  271  88.6%  84.3-91.8% 
Pandemic challenge as of fall 2021  271  19.6%  15.3-24.6% 
p-value <0.0001 
Navigating evolving guidance about how to treat COVID-19 patients 
Early pandemic challenge  271  87.1%  82.6-90.5% 
Pandemic challenge as of fall 2021  271  25.5%  20.7-30.9% 
p-value <0.0001 
Unclear or conflicting State/Federal guidelines about COVID-19 infection prevention and control 
Early pandemic challenge  271  88.2%  83.8-91.5% 
Pandemic challenge as of fall 2021  271  24.4%  19.7-29.7% 
p-value <0.0001 
Access to masks (not other types of personal protective equipment (PPE)) 
Early pandemic challenge  271  92.6%  88.9-95.2% 
Pandemic challenge as of fall 2021  271  13.7%  10.1-18.2% 
p-value <0.0001 
Access to other types of PPE (not masks) 
Early pandemic challenge  271  91.1%  87.2-94.0% 
Pandemic challenge as of fall 2021  271  15.1%  11.4-19.8% 
p-value <0.0001 
Access to sanitizing products (e.g., sanitizing wipes, hand sanitizer) 
Early pandemic challenge  271  94.5%  91.1-96.6% 
Pandemic challenge as of fall 2021  271  8.9%  6.0-12.8% 
p-value <0.0001 
High cost of PPE during the pandemic 
Early pandemic challenge  271  88.6%  84.3-91.8% 
Pandemic challenge as of fall 2021  271  42.4%  36.8-48.3% 
p-value <0.0001 
Strategies used to address infection control challenges during the COVID 19 pandemic 
Developed internal COVID-19 infection control protocols for staff 
Used and found helpful  271  96.7%  93.8-98.2% 
Used but did not find helpful  271  1.5%  0.6-3.8% 
Did not use  271  1.8%  0.8-4.3% 
Increased or improved clinical staff training on COVID-19 treatment 
Used and found helpful  271  94.8%  91.5-96.9% 
Used but did not find helpful  271  3.3%  1.8-6.2% 
Did not use  271  1.8%  0.8-4.3% 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix D | 39  Provided PPE training for clinical staff 
Used and found helpful  271  95.9%  92.9-97.7% 
Used but did not find helpful  271  1.5%  0.6-3.8% 
Did not use  271  2.6%  1.2-5.3% 
Found nontraditional sources for PPE (e.g., nail salons, tattoo parlors) 
Used and found helpful  271  31.4%  26.2-37.1% 
Used but did not find helpful  271  4.8%  2.8-8.0% 
Did not use  271  63.8%  58.0-69.3% 
Conserved PPE (e.g., re-used PPE normally meant for single use, prioritized certain types of PPE for 
highest-risk activities) 
Used and found helpful  271  57.2%  51.3-62.9% 
Used but did not find helpful  271  8.5%  5.7-12.4% 
Did not use  271  34.3%  29.0-40.1% 
Developed new or used existing partnerships with other HHAs or health care facilities to obtain or pool 
supplies 
Used and found helpful  271  42.4%  36.8-48.3% 
Used but did not find helpful  271  7.4%  4.8-11.1% 
Did not use  271  50.2%  44.3-56.0% 
Postponed accepting patients with positive COVID-19 diagnosis until HHA had adequate infection control 
protocols 
Did not use  271  44.3%  38.6-50.2% 
Used (combined)  271  55.7%  49.8-61.4% 
Telehealth use during the COVID-19 pandemic 
Point  95% confidence 
Description  Sample size 
estimate  interval 
HHA used telehealth during the pandemic  271  72.7%  67.2-77.6% 
HHA did not use telehealth during the pandemic  271  27.3%  22.4-32.8% 
HHAs that provided telehealth services during the COVID 19 pandemic 
Mode of telehealth services during the pandemic 
Live, real-time services between a patient and a health care provider (in the HHA) 
Used  197  78.2%  72.0-83.3% 
Did not use  197  21.8%  16.7-28.0% 
Patient health information is electronically transmitted to a health care provider for their assessment at a 
different time 
Used  197  44.2%  37.5-51.1% 
Did not use  197  55.8%  48.9-62.5% 
HHA providers helped patients set up or participate in telehealth services with another provider (outside of the 
HHA) 
Used  197  62.9%  56.1-69.3% 
Did not use  197  37.1%  30.7-43.9% 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix D | 40  Challenges using telehealth during the pandemic 
High cost of providing telehealth services 
Challenge  197  44.2%  37.5-51.1% 
Not a challenge  197  55.8%  48.9-62.5% 
Insufficient internet access in patients homes 
Challenge  197  66.5%  59.7-72.7% 
Not a challenge  197  33.5%  27.3-40.3% 
Lack of direct reimbursement for telehealth services (other than for administrative costs) 
Challenge  197  67.5%  60.8-73.6% 
Not a challenge  197  32.5%  26.4-39.2% 
Most care required physical contact with patient 
Challenge  197  63.5%  56.6-69.8% 
Not a challenge  197  36.5%  30.2-43.4% 
Will this HHA continue to use telehealth after the pandemic? 
Yes  197  56.9%  49.9-63.5% 
No  197  43.1%  36.5-50.1% 
Note: In the survey, we used the term telemedicine rather than telehealth. 
Emergency preparedness and response 
Point  95% confidence 
Description  Sample size 
estimate  interval 
COVID 19-specific response plans 
HHAs that had a COVID-19 response plan 
HHA had a COVID-19 response plan  271  84.9%  80.2-88.6% 
HHA did not have a COVID-19 response plan  271  15.1%  11.4-19.8% 
CMS required emergency preparedness (EP) plan 
Overall, EP plan helpfulness in responding to the pandemic (of those with an EP plan during the pandemic) 
Helpful  267  98.1%  95.6-99.2% 
Not helpful  267  1.9%  0.8-4.4% 
EP plan helpfulness in responding to infection control challenges due to the pandemic (of those with an EP 
plan during the pandemic) 
Helpful  267  90.6%  86.6-93.6% 
Not helpful  267  3.7%  2.0-6.8% 
Not applicable  267  5.6%  3.4-9.1% 
EP plan helpfulness in responding to supply challenges due to the pandemic (of those with an EP plan 
during the pandemic) 
Helpful  267  80.9%  75.8-85.1% 
Not helpful  267  12.7%  9.3-17.2% 
Not applicable  267  6.4%  4.0-9.9% 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix D | 41  EP plan helpfulness in responding to staffing challenges due to the pandemic (of those with an EP plan 
during the pandemic) 
Helpful  267  74.2%  68.7-79.0% 
Not helpful  267  14.6%  10.9-19.3% 
Not applicable  267  11.2%  8.0-15.5% 
HHAs that experienced the challenge that their EP plan was more suitable to a local emergency than a 
national or global emergency such as the pandemic (of those with an EP plan during the pandemic) 
Challenge  267  50.6%  44.7-56.4% 
Not a challenge  267  49.4%  43.6-55.3% 
HHAs that will modify or have modified their EP plan to include lessons learned from the COVID-19 
pandemic (of those with an EP plan during the pandemic) 
HHA has already modified OR will modify its EP plan to 
267  96.6%  93.7-98.2% 
include lessons learned from the pandemic 
HHA has not modified and will not modify its EP plan to 
267  3.4%  1.8-6.3% 
include lessons learned from the pandemic 
HHAs with an EP plan that included an infectious disease component prior to the pandemic. 
Note: Among HHAs that had an EP plan prior to the pandemic. 
HHA did not have an EP plan with an infectious 
254  7.1%  4.5-10.9% 
disease component 
HHA had an EP plan with an infectious disease 
254  92.9%  89.1-95.5% 
component 
How could CMS better support HHAs in using EP plans to respond to emerging infectious 
diseases? (open ended responses) 
HHA suggested information about EP plan content and/or 
88  67.0%  56.8-75.9% 
implementation in response to this question 
HHA did not suggest information about EP plan content 
88  33.0%  24.1-43.2% 
and/or implementation in response to this question 
Rural HHA experiences* 
Rural HHA experiences with staffing challenges 
Limited staff availability to work because of self-quarantine/isolation due to COVID-19 exposure 
Challenge  39 
Not a challenge  2 
Rural HHA experiences with infection control and prevention challenges 
Unclear or conflicting State/Federal guidelines about COVID-19 infection prevention and control 
Early challenge  34 
Not an early challenge  7 
Access to masks (not other types of personal protective equipment (PPE)) 
Early challenge  37 
Not an early challenge  4 
Access to other types of PPE (not masks) 
Early challenge  37 
Not an early challenge  4 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix D | 42  Access to sanitizing products (e.g., sanitizing wipes, hand sanitizer) 
Early challenge  38 
Not an early challenge  3 
Rural HHA experiences with telehealth during the pandemic 
HHA used telehealth during the pandemic  31 
HHA did not use telehealth during the pandemic  10 
Challenges with insufficient internal access in patients homes 
Challenge  25 
Not a challenge  6 
* We were unable to project due to limited sample size. 
Note: Because of rounding, not all percentages may add up to 100 percent. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix D | 43  Appendix E: Agency Comments 
Following this page are the official comments from CMS. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix E | 44  DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
Administrator 
Washington, DC  20201 
DATE:   September  22,  2022  
TO:   Suzanne Murrin  
Deputy Inspector  General  for  Evaluation  and Inspections  
Office  of  Inspector  General  
FROM:   Chiquita Brooks-LaSure  
Administrator  
Centers  for  Medicare &  Medicaid Services  
SUBJECT:   Office  of  Inspector  General  (OIG)  Draft  Report:  Home Health  Agencies  Used 
Multiple Strategies  to Respond to the COVID-19 Pandemic,  Although  Some 
Challenges  Persist  (OEI-01-21-00110)  
The Centers  for  Medicare &  Medicaid Services  (CMS)  appreciates  the opportunity to review  and 
comment  on  the Office  of  Inspector  Generals  (OIG)  draft  report.  CMS is  committed to 
supporting home health  agencies  (HHAs)  during health  emergencies  so they may care for  people 
with  Medicare in  the home setting while protecting them  from  the spread of  infectious  diseases.  
CMS is  using lessons  learned during the COVID-19 public health  emergency (PHE)  to improve 
quality of  care and  equitable access  to CMS benefits,  services,  and supports.  
Throughout  the COVID-19 PHE,  CMS  has  used a combination  of  emergency authority waivers,  
regulations,  enforcement  discretion,  survey flexibilities,  and sub-regulatory guidance  to help ensure 
access  to care,  give health  care providers  the flexibilities  needed to respond to COVID-19,  and help 
keep people safer.  Flexibilities  offered during the COVID-19 PHE  supported HHAs  in  addressing 
staffing challenges,  especially early on  in  the COVID-19 PHE.  For  example,  a statutory change 
enabled CMS to allow  additional  practitioners  to certify beneficiaries  for  eligibility,  order  home 
health  services,  and establish  and review  care plans. The use of  telehealth  to furnish  home health  
services  was  finalized on  a permanent  basis  in  the calendar  year  (CY)  2021 Home Health  
Prospective Payment  System  final  rule.1  However,  such  services  cannot  be reported as  a visit  on  
home health  claims  for  the purposes  of  eligibility or  payment.  
Many of  the waivers  and flexibilities  will  terminate at  the end of  the COVID-19 PHE  or  after  the 
151st  day after  the end of  the PHE,  as  they were intended to address  the acute and extraordinary 
circumstances  of  a rapidly evolving pandemic and not  replace existing requirements.  Some were 
made  permanent  through  the passage  of  new  laws.  For  example,  Division  CC,  section  115 of  the 
Consolidated Appropriations  Act  of  2021,  made  permanent  the flexibility that  occupational  
therapists  could conduct  initial  and comprehensive assessments  for  patients  when  certain  
requirements  relating to the plan  of  care are met.   
1  Federal Register: Medicare  and Medicaid Programs; CY 2021 Home  Health Prospective Payment System Rate  
Update, Home  Health Quality Reporting Program Requirements, and Home  Infusion Therapy Services  and Supplier  
Enrollment Requirements;  and Home  Health Value-Based Purchasing  Model Data Submission Requirements; Final  
Rule  (85 FR 70298) (November 4, 2020).  
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix E | 45  CMS continues  to support  stakeholders  and the people we serve during the  current  phase of  the 
COVID-19 PHE  while looking forward to a health  system  that  successfully emerges  from  the 
COVID-19 PHE  focused on  improving quality and safety.  CMS is  also monitoring the status  of  the 
COVID-19 PHE  and has  begun  phasing out  certain  flexibilities  that  are generally no longer  needed.  
To understand how  blanket  flexibilities  and those specific to HHAs  were used on  the front  lines  
during the  COVID-19  PHE,  CMS  received feedback from  the HHA  industry,  national  HHA  
organizations,  and from  subject  matter  experts.  This  information  helped inform  waiver  disposition  
decisions  and identify groups  of  waivers  that  may be helpful  in  future PHE  response activities.  
CMS recently released fact  sheets  to summarize  the current  status  of  Medicare blanket  waivers  and 
flexibilities  by provider  type,  including HHAs.2  
Long before the COVID-19 PHE  began,  CMS had acted to strengthen  infection  prevention  and 
control  practices  for  HHAs  and other  provider  types.  CMS took pivotal  actions  in  the 2016 final  
rule,  Medicare and Medicaid Programs;  Emergency Preparedness  Requirements  for  Medicare and 
Medicaid Participating Providers  and Suppliers,  which  outlined the need for  providers  to prepare 
for  infectious  disease threats.3  In  March  2020,  CMS issued guidance  to HHAs  encouraging them  to 
take  appropriate action  to address  potential  and confirmed COVID-19 cases  and mitigate 
transmission,  including screening,  treatment  and transfer  to higher  level  care (when  appropriate).4  
CMS also held Open  Door  Forum  calls  specific to HHAs  since  2016 and added additional  COVID-
19 calls  during the COVID-19 PHE,  which  continue to date.  CMS meets  regularly  with  
stakeholders,  such  as  the National  Association  for  Home Care and Hospice,  to discuss  issues  
affecting the HHA  community.  In  addition,  CMSs  Quality Safety and Education  Portal  provides  
current  trainings  on  various  CMS survey and certification  requirements.5  These trainings  are used 
by surveyors  but  are also free  of  charge and available to the public by choosing the public access 
link on  the portal.   
CMS thanks  OIG  for  its  efforts  on  this  important  issue and looks  forward to working with  OIG  
on  this  and other  issues  in  the future.  OIGs  recommendations  and CMS's  responses  are below.  
OIG  Recommendation  
Evaluate how  HHAs  are using telehealthspecifically,  the types  of  services  provided via 
telehealth  and the characteristics  of  patients  who benefit  from  these services.  
CMS Response  
CMS concurs  with  this  recommendation.  CMS finalized policy changes  regarding the use of  
services  furnished via telecommunications  systems  in  the CY  2021 Home Health  Prospective 
Payment  System  final  rule.6  HHAs  can  utilize  telecommunications  technologies  in  providing care to 
beneficiaries  under  the Medicare home health  benefit,  as  long as  any provision  of  remote patient  
monitoring or  other  services  furnished via a telecommunications  system  or  audio-only technology 
are included on  the plan  of  care.  The use of  such  telecommunications  technology or  audio-only 
2  CMS, Home  Health Agencies: CMS Flexibilities to Fight COVID-19. August, 18, 2022. Accessed at  
https://www.cms.gov/files/document/home-health-agencies-cms-flexibilities-fight-covid-19.pdf  
3  Medicare  and Medicaid Programs; Emergency Preparedness Requirements, 81 FR 63860, 63862 (Sept. 16, 2016).  
Accessed at  https://www.federalregister.gov/documents/2016/09/16/2016-21404/medicare-and-medicaid-programs-
emergency-preparedness-requirements-for-medicare-and-medicaid   
4  CMS, Guidance for  Infection Control  and Prevention Concerning Coronavirus  Disease 2019 (COVID-19) in Home  
Health Agencies  (HHAs). March 10, 2020. Accessed at  https://www.cms.gov/files/document/qso-20-18-hha.pdf  
5  CMS, Quality, Safety & Education Portal (QSEP). Accessed at  https://qsep.cms.gov/  
6  Federal Register:  Medicare  and Medicaid Programs; CY 2021 Home  Health Prospective Payment System Rate  
Update, Home  Health Quality Reporting Program Requirements, and Home  Infusion Therapy Services  and Supplier  
Enrollment Requirements;  and Home  Health Value-Based Purchasing  Model Data Submission Requirements; Final  
Rule  (85 FR 70298) (November 4, 2020)  
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix E | 46  technology must  be tied to patient-specific needs  as  identified in  the comprehensive assessment,  
and may not  substitute for  an  in-person  home visit  that  is  ordered on  the plan  of  care.  In  addition,  
the law  7  explicitly states  that  home health  services  furnished via telecommunications  technology 
cannot  be considered a visit  for  the purpose of  patient  eligibility or  payment.  
Currently,  the collection  of  data on  the use of  telecommunications  technology under  the home 
health  benefit  is  limited to a broad category of  telecommunications  technology costs  under  
administrative costs  on  the HHA  cost  reports  (reported at  the agency level).  The CY  2023 Home 
Health  Prospective Payment  System  proposed rule solicited  comments  on  the collection  of  data on  
the use of  such  services  furnished using telecommunications  technology on  the home health  claims  
(at  the individual  beneficiary level).8  Collecting data on  the use of  telecommunications  technology 
on  home health  claims  would allow  CMS to analyze  the characteristics  of  the beneficiaries  utilizing 
services  furnished remotely,  and could provide a broader  understanding of  the social  determinants  
that  affect  who benefits  most  from  these services,  including what  barriers  may potentially exist  for  
certain  subsets  of  beneficiaries.  CMS aims  to collect  such  data on  home health  claims  by January 1,  
2023 on  a voluntary basis  by HHAs,  and plans  begin  to requiring  this  information  to be reported on  
claims  beginning  July  2023.  CMS will  consider  OIGs  recommendation  along with  comments  
submitted on  the proposed rule when  finalizing the rule.  
OIG  Recommendation  
To inform  decision-making,  evaluate how  regulatory flexibilities  offered during the COVID-19 
pandemic affect  quality of  home health  care.  
CMS Response  
CMS concurs  with  this  recommendation  to evaluate the effects  of  waivers  to the extent  it  is  possible 
to do so.  While it  may be difficult  to make  direct  links  from  waivers  to quality and health  outcomes,  
CMS is  using lessons  learned during the COVID-19 PHE  to improve quality of  care in  home care 
settings  to ensure equitable access  to CMS benefits,  services  and supports.  CMS is  monitoring the 
status  of  the COVID-19 PHE  and has  begun  phasing out  certain  flexibilities  that  are generally no 
longer  needed.  CMS released fact  sheets  to summarize  the current  status  of  Medicare blanket  
waivers  and flexibilities  by provider  type,  including HHAs.9  
Given  the unprecedented length  and scope  of  the  COVID-19  PHE,  CMS  has  systematically 
reviewed all  the emergency measures,  regulatory flexibilities,  and related programs  enacted during 
the  COVID-19  PHE  on  an  ongoing basis  since  2020 to assess  the appropriateness  of  continuing 
those flexibilities  or  of  retaining  some  as  a permanent  part  of  CMS programs,  as  permitted under  
the law.  To  understand how  HHAs  used flexibilities  during the COVID-19 PHE,  CMS received 
feedback from  the HHA  industry,  national  HHA  organizations,  and from  subject  matter  experts.  
This  information  helped inform  waiver  disposition  decisions  and identify groups  of  waivers  that  
may be helpful  in  future PHE  response activity.  For  example,  as  part  of  the  CY  2022 Home Health  
Prospective Payment  System  final  rule,  CMS finalized the provision  for  aide supervision  for  
7  Section 1895(e)(1)(A) of the  Social Security  Act. Accessed at  
https://www.ssa.gov/OP_Home/ssact/title18/1895.htm  
8  Federal Register: Medicare Program; Calendar Year (CY)  2023 Home  Health Prospective Payment System Rate  
Update;  Home  Health Quality Reporting Program Requirements;  Home  Health Value-Based Purchasing Expanded 
Model Requirements; and Home  Infusion Therapy Services Requirements; Proposed Rule  (87 FR 37600)  (June 23, 
2022)  
9  CMS, Home  Health Agencies: CMS Flexibilities to Fight COVID-19, September 1, 2022. Accessed at  
https://www.cms.gov/files/document/home-health-agencies-cms-flexibilities-fight-covid-19.pdf  
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix E | 47   patients  receiving  skilled care every 14 days  to now  allow  for  one virtual  visit  per  60-day episode 
per  patient  and only in  rare circumstances.10   
CMS is  also in  the process  of  holding a series  of  listening sessions  seeking  feedback from  
providers,  including HHAs,  on  what  specific flexibilities,  if  any,  have been the most  or  least  
helpful.  While it  is  challenging to isolate the many compounding factors  that  affect  quality of  
care and conclude that  individual  waivers  were the sole contributor  to changes  in  patient  
outcomes,  especially given  the unique circumstances  of  the COVID-19 PHE  and data limitations  
during this  time,  CMS is  reviewing waivers  as  part  of  larger  efforts  to ensure health  care quality 
and safety.  CMS remains  steadfast  in  its  commitment  to keeping the HHA  community and public 
informed throughout  the COVID-19 PHE.  
OIG  Recommendation  
In  collaboration  with  Administration  for  Strategic Preparedness  and Response (ASPR) Technical  
Resources,  Assistance  Center,  and Information  Exchange  (TRACIE),  apply lessons  learned from  
the COVID-19 PHE  to update and/or  develop emergency preparedness  trainings  and materials  
for  HHAs  on  responding to infectious  disease outbreaks.   
CMS Response  
CMS concurs  with  this  recommendation.  ASPR  TRACIE  and CMS have a long history of  working 
together  to support  providers  in  responding to emergencies,  including emerging infectious  diseases,  
such  as  COVID-19.  CMS has  provided education  and outreach  to HHAs  on  CMS quality and safety 
standards  to support  their  infection  prevention  and control  efforts.  In  addition,  CMS has  
collaborated with  ASPR  TRACIE  on  homecare related resources,  including a resource  on  HHA  
requirements  relating to the emergency preparedness  rule.11  This  resource  was  updated in  March  
2021 to reflect  updates  from  the COVID-19 PHE.   
CMS recently published case studies  of  30  providers  (nursing homes  and hospitals)  on  their  
responses  to challenges  during the onset  of  COVID-19.12  The study focused on  understanding how  
these providers  prepared for  and responded to the COVID-19 PHE.  The discussions  and 
engagement  focused on  whether  or  not  the facilities  had risk assessments  which  included emerging 
infectious  diseases  prior  to the PHE,  their  input  on  individual  preparedness  within  their  facilities,  
and discussion  on  some of  the challenges  and burdens.  The study found that  locally developed 
emergency preparedness  plans  and staff  training were key factors  in  dealing with  the  COVID-19  
PHE.  While this  study focused on  nursing homes  and hospitals,  the information  gained from  the 
study would apply across  provider  and supplier  types.  
CMS will  continue to collaborate with  ASPR  TRACIE  and share information  based on  lessons  
learned from  the COVID-19 PHE  with  the HHA  industry.  However,  CMS does  not  provide funding 
to ASPR  TRACIE.  While our  agencies  will  continue to collaborate,  CMS does  not  have the 
authority over  ASPR  TRACIE  work  products.  
10  Federal Register: Medicare  and Medicaid Programs; CY 2022 Home  Health Prospective Payment System Rate  
Update;  Home  Health Value-Based Purchasing Model Requirements and Model Expansion;  Home  Health and Other  
Quality Reporting Program Requirements;  Home  Infusion Therapy Services Requirements; Survey  and Enforcement  
Requirements for  Hospice Programs; Medicare Provider Enrollment Requirements; and COVID-19 Reporting  
Requirements for  Long-Term Care Facilities; Final Rule  (86 FR 62240) (November 9, 2021)  
11  CMS, Home  Health Agency Requirements CMS Emergency Preparedness Final Rule, March 26, 2021. Accessed 
at  https://files.asprtracie.hhs.gov/documents/aspr-tracie-cms-ep-rule-home-health-agency-requirements.pdf  
12  Blackstock, S.C., Moody-Williams, J.D., Fleisher, L.A., Learnings Regarding Emergency Preparedness During  
the Public  Health Emergency:  A  Mixed-Methods Study of  Hospitals  and Long-Term Care Facilities, NEJM  
Catalyst, August 24, 2022. Accessed at  https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0152   
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Appendix E | 48   ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Sarah Hijaz and Shanna Weitz served as the team leaders for this study, and Caitlin 
Foster served as the lead analyst.  Office of Evaluation and Inspections headquarters 
staff who provided support include Joseph Chiarenzelli, Althea Hosein, Christine 
Moritz, and Sara Swisher. 
This report was prepared under the direction of Joyce Greenleaf, Regional Inspector 
General for Evaluation and Inspections in the Boston regional office, and Danielle 
Fletcher, Deputy 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 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Acknowledgments and Contact | 49  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. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  About the Office of Inspector General | 50  ENDNOTES 
1 National Association for Home Care and Hospice, National Study Shows How Home Care Is in a Fragile State, April 27, 2020. 
Accessed at https://www.nahc.org/wp-content/uploads/2020/03/NATIONAL-STUDY-SHOWS-HOME-HEALTH-CARE-IS-IN-A-
FRAGILE-STATE.pdf on August 17, 2022. 
2 Robert Holly, Small Home Health Agencies Fighting to Stay Afloat Amid COVID-19 Crisis, Regulatory Uncertainty, Home 
Health Care News, April 19, 2020.  Accessed at https://homehealthcarenews.com/2020/04/small-home-health-agencies-
fighting-to-stay-afloat-amid-covid-19-crisis-regulatory-uncertainty/ on March 8, 2022. 
3 Jingding Shang, Ashley M. Chastain, Uduwanage Gayani E. Perera, et al., COVID-19 Preparedness in US Home Health Care 
Agencies, Journal of the American Medical Directors Association, July 2020, Vol.  21, Issue 7, pp.  924-927, DOI: 
10.1016/j.jamda.2020.06.002. Accessed at https://pubmed.ncbi.nlm.nih.gov/32674820/ on May 2, 2022. 
4 Andrew Donlan, House Passes CARES Act, Fast Forwarding Home Health Care Innovation Beyond COVID-19, Home Health 
Care News, March 27, 2020.  Accessed at https://homehealthcarenews.com/2020/03/house-passes-cares-act-fast-forwarding-
home-health-care-innovation-beyond-covid-19/ on March 8, 2022. 
5 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, updated May 24, 2021. Accessed at 
https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf on March 8, 2022. 
6 Adara Home Health, Inc., COVID-19 Preparedness Plan. Accessed at https://adarahomehealth.com/wp-
content/uploads/2020/07/Adara-COVID-19-Plan_6-29-20.pdf on March 8, 2022. 
7 Courtney Harold Van Houtven and Walter D. Dawson, Medicare and Home Health: Taking Stock in the COVID-19 Era, The 
Commonwealth Fund, October 21, 2020. Accessed at https://www.commonwealthfund.org/publications/issue-
briefs/2020/oct/medicare-home-health-taking-stock-covid-19-era on March 8, 2022. 
8 CMS, Chapter 7 -Home Health Services. Medicare Benefit Policy Manual.  Accessed at https://www.cms.gov/Regulations-
and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf on April 29, 2022. 
9 CMS, Chapter 7 -Home Health Services, Medicare Benefit Policy Manual. Accessed at https://www.cms.gov/Regulations-
and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf on April 29, 2022. 
10 Social Security Act (the Act)  1814(a)(2)(C) and (a)(concluding paragraph), and 1835(a)(2)(A) and (a)(concluding 
paragraph); 42 CFR  409.42(a). 
11 The Act  1814(a)(2)(C) and (a)(concluding paragraph), and 1835(a)(2)(A) and (a)(concluding paragraph); 42 CFR  
424.22(a)(1)(v). 
12 The Act  1814(a)(2)(C) and (a)(concluding paragraph), and 1835(a)(2)(A) and (a)(concluding paragraph); 42 CFR  
424.22(c)). 
13 MedPAC, Chapter 8 -Home health care services, Report to the Congress: Medicare Payment Policy, March 2022, pp. 275, 
279, 282.  Accessed at https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_SEC.pdf 
on August 17, 2022. 
14 42 CFR  484, subparts A-C. 
15 CMS, Appendix B- Guidance to Surveyors: Home Health Agencies, State Operations Manual, Rev. 200, February 21, 2020. 
Accessed at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_b_hha.pdf on March 
8, 2022. 
16 42 CFR  488, subpart I. 
17 CMS, Chapter 2 -The Certification Process, State Operations Manual, Rev. 205, March 11, 2022. Accessed at 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c02.pdf on April 11, 2022. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Endnotes | 51  18 Jingding Shang, Ashley M. Chastain, Uduwanage Gayani E. Perera, et al., COVID-19 Preparedness in US Home Health Care 
Agencies, Journal of the American Medical Directors Association, July 2020, Vol.  21, Issue 7, pp.  924-927, DOI: 
10.1016/j.jamda.2020.06.002. Accessed at https://pubmed.ncbi.nlm.nih.gov/32674820/ on May 2, 2022. 
19 CDC, Symptoms of COVID-19, updated March 22, 2022. Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/symptoms-testing/symptoms.html on July 11, 2002. 
20 CDC, Symptoms of COVID-19, updated March 22, 2022. Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/symptoms-testing/symptoms.html on July 11, 2022. 
21 CDC, CDC Museum COVID-19 Timeline. Accessed at https://www.cdc.gov/museum/timeline/covid19.html on March 8, 
2022. 
22 HHS, Determination That A Public Health Emergency Exists, January 31, 2020.  Accessed at 
https://aspr.hhs.gov/legal/PHE/Pages/2019-nCoV.aspx on September 29, 2022. 
23 World Health Organization, Timeline: WHOs COVID-19 response. Accessed at 
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline#! on March 8, 2022. 
24 CDC, Lesson 1: Introduction to Epidemiology, Section 11: Epidemic Disease Occurrence.  Accessed at 
https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html on August 18, 2022. 
25 85 Fed. Reg. 15337 (March 18, 2020). 
26 CDC, Trends in Number of COVID-19 Cases and Deaths in the US Reported to CDC, by State/Territory.  Accessed at 
https://covid.cdc.gov/covid-data-tracker/#trends_dailycases on September 23, 2022. 
27 Satyaki Roy and Preetam Ghosh, Factors affecting COVID-19 infected and death rates inform lockdown-related 
policymaking, PLOS One, October 23, 2020.  Accessed at https://doi.org/10.1371/journal.pone.0241165 on March 8, 2022. 
28 CDC, CDC COVID-19 Study Shows mRNA Vaccines Reduce Risk of Infection by 91 Percent for Fully Vaccinated People, June 7, 
2021. Accessed at https://www.cdc.gov/media/releases/2021/p0607-mrna-reduce-risks.html on March 8, 2022. 
29 42 CFR  484.70. 
30 CMS, Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health 
Agencies (HHAs) and Religious Nonmedical Healthcare Institutions (RNHCIs), March 10, 2020, revised April 23, 2020.  Accessed 
at https://www.cms.gov/files/document/qso-20-18-hha-revised.pdf on March 8, 2022. 
31 The Secretary may exercise this authority under section 1135 of the Social Security Act. 
32 85 Fed. Reg. 15337 (March 18, 2020). 
33 Seema Verma, Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19, Health Affairs Forefront, July 15, 
2020, DOI: 10.1377/forefront.20200715.454789.  Accessed at 
https://www.healthaffairs.org/do/10.1377/forefront.20200715.454789/full/ on March 8, 2022. 
34 85 Fed. Reg. 19230 (April 6, 2020). 
35 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, updated May 24, 2021.  Accessed at 
https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf on March 8, 2022. 
36 85 Fed. Reg. 19230 (April 6, 2020). 
37 P.L. No. 116-136,  3708, March 27, 2020. 
38 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, March 17, 2020. Accessed at 
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet on August 18, 2022. 
39 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic, 
OEI-02-20-00520, March 15, 2022.  Accessed at https://oig.hhs.gov/oei/reports/OEI-02-20-00520.asp on March 29, 2022. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Endnotes | 52  40 Videoconferencing involves live audiovisual communication between participants, in this case the health care provider and 
the patient.  Examples include Facetime or Zoom video calls. 
41 HHS, What is telehealth? Accessed at https://telehealth.hhs.gov/patients/understanding-telehealth/ on May 17, 2022. 
42 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, March 17, 2020.  Accessed at 
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet on March 18, 2022. 
43 42 CFR  409.43(a)(3)(i)(B); 42 CFR  409.46(e). 
44 85 Fed. Reg. 70298, 70322-70325 (November 4, 2020). 
45 P.L. No. 116-136,  3707, March 27, 2020. 
46 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, updated May 24, 2021.  Accessed at 
https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf on March 18, 2022. 
47 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, March 17, 2020.  Accessed at 
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet on March 18, 2022; 
CMS, COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing,  AA, Question 1, updated 
February 28, 2022. 
48 85 Fed. Reg. 19230, 19285 (April 6, 2020). 
49 CMS, COVID-19 Frequently Asked Questions (FAQ) on Medicare Fee-for-Service (FFS) Billing,  AA, Question 2, updated 
January 7, 2021, p. 116. Accessed at https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-
faqs-31720.pdf on March 8, 2022. 
50 85 Fed. Reg. 70298, 70354 (November 4, 2020). 
51 Social Security Act  1895(e)(1). 
52 42 CFR  409.46(e). 
53 Cost reports are reports submitted to CMS that include important statistical and financial data.  CMS uses cost reports to 
understand each HHAs financial situation, among other purposes.  CMS requires HHAs to submit cost reports annually. 
Providers must submit them no later than 5 months after the end of the year covered. 
54 85 Fed. Reg. 70298, 70312 (November 4, 2020). 
55 Accessed at https://telehealth.hhs.gov/patients/understanding-telehealth on July 25, 2022. 
56 Accessed at https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf on July 
29, 2022. 
57 Seema Verma, Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19, Health Affairs Forefront, July 15, 
2020, DOI: 10.1377/forefront.20200715.454789.  Accessed at 
https://www.healthaffairs.org/do/10.1377/forefront.20200715.454789/full/ on March 8, 2022. 
58 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic, 
OEI-02-20-00520, March 15, 2022.  Accessed at https://oig.hhs.gov/oei/reports/OEI-02-20-00520.asp on August 19, 2022. 
59 MedPAC, Chapter 8 -Home health care services, Report to the Congress: Medicare Payment Policy, March 2022, pp. 285-
286.  Accessed at https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_SEC.pdf on 
August 17, 2022. 
60 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic, 
OEI-02-20-00520, March 2022.  Accessed at https://oig.hhs.gov/oei/reports/OEI-02-20-00520.pdf on April 29, 2022. 
61 MedPAC, Chapter 4  Physician and other health professional services, Report to the Congress: Medicare Payment Policy, 
March 2022, pp. 129-130.  Accessed at https://www.medpac.gov/wp-
content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_SEC.pdf on August 17, 2022. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Endnotes | 53  62 81 Fed. Reg. 63860 (September 16, 2016). 
63 CMS, Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types, Interpretive Guidance, State 
Operations Manual, Rev. 204, April 16, 2021. Accessed at https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/som107ap_z_emergprep.pdf on April 11, 2022. 
64 42 CFR  484.102. 
65 Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertEmergPrep/Downloads/CMS-Understanding-the-EP-Final-Rule-Update-BRIII-2019.pdf and 
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/FAQ-Round-Four-
Definitions.pdf on April 29, 2022. 
66 CMS, Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types, Interpretive Guidance, State 
Operations Manual, Rev. 204, April 16, 2021. Accessed at https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/som107ap_z_emergprep.pdf on April 11, 2022. 
67 CMS, Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types, Interpretive Guidance, State 
Operations Manual, Rev. 204, April 16, 2021. Accessed at https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/som107ap_z_emergprep.pdf on April 11, 2022. 
68 CMS, Emergency Preparedness: Provider Readiness (EP_PR). Accessed at 
https://qsep.cms.gov/pubs/ClassInformation.aspx?cid=0CMSEPPR_WEB on July 27, 2022. 
69 CMS, Emergency Preparedness Basic Training. Accessed at 
https://qsep.cms.gov/pubs/CourseMenu.aspx?cid=0CMSEmPrep_ONL on July 27, 2022. 
70 ASPR was formerly known as the Office of the Assistant Secretary for Preparedness and Response. 
71 OIG, Six of Eight Home Health Agency Providers Had Infection Control Policies and Procedures That Complied With CMS 
Requirements and Followed CMS COVID-19 Guidance To Safeguard Medicare Beneficiaries, Caregivers, and Staff During the 
COVID-19 Pandemic, A-01-20-00508, September 24, 2021. Accessed at 
https://oig.hhs.gov/oas/reports/region1/12000508.asp on March 8, 2022. 
72 OIG, Audit of Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency.  Accessed at 
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000553.asp on March 8, 2022. 
73 OIG, Reliance on Unverified Patient Lists Creates a Vulnerability in Home Health Surveys, OEI-05-16-00510, March 5, 2018.  
Accessed at https://oig.hhs.gov/oei/reports/oei-05-16-00510.asp on March 8, 2022. 
74 OIG, Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases, OEI-05-16-00031, June 21, 2016. 
Accessed at https://oig.hhs.gov/oei/reports/oei-05-16-00031.asp on March 8, 2022. 
75 Of the 400 sampled HHAs, 19 were closed and 4 did not participate in Medicare at the time of our survey. 
76 The HHS Health Resources and Services Administration (HRSA) administers the Provider Relief Fund, which is funding that 
is distributed to health care providers affected by the COVID-19 pandemic.  Any HHA may apply to receive financial 
assistance.  HRSA, Provider Relief Fund.  Accessed at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/phase4-arp-
toolkit.pdf on August 18, 2022. 
77 86 Fed. Reg. 62240, 62421 (November 9, 2021). 
78 85 Fed. Reg. 70298, 70354 (November 4, 2020). 
79 All references to telehealth in this section are specific to HHAs that used telehealth during the pandemic. 
80 85 Fed. Reg. 70298, 70325 (November 4, 2020). 
81 HHAs submit their cost reports no later than 5 months after the end of the year that the cost report covers.  For example, 
an HHA may submit a cost report covering January 1, 2021, to December 31, 2021, in May 2022.  After submission, Medicare 
Administrative Contractors audit the cost reports, which regulations specify should happen within one year of receiving the 
cost report.  (42 CFR  413.24(f)(2)(i) and 42 CFR  405.1835(c)(1).) 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Endnotes | 54  82 87 Fed. Reg. 37600, 37658-37659 (June 23, 2022). 
83 We removed five HHAs from our scope because of their concurrent involvement in another OIG study. 
84 We considered an HHA closed if either (1) the HHAs corporate office told us that the HHA was closed or (2) the HHAs 
number was disconnected and mail sent to the HHA was returned to us. 
85 During our contact attempts, we noted that at least 21 nonresponding HHAs had changed their address and 13 had phone 
connection issues (e.g., disconnected phone line).  Challenges accessing these HHAs may at least partially explain our 
response rate. 
86 We identified 314 HHAs that submitted 2019 Medicare claims in our sample, 225 of which responded to the survey. 
87 We based our definition of rural HHAs on MedPACs analysis of majority rural freestanding HHAs in the March 2021 
Medicare Payment Policy report.  MedPAC calculated that 18 percent of freestanding HHAs were majority rural in 2019, the 
same percentage of rural HHAs with 2019 Medicare claims that responded to our survey. For MedPACs definition of 
majority rural HHAs: MedPAC, Chapter 8 -Home health care services, Report to the Congress: Medicare Payment Policy, 
March 2021, p. 243, table 8-7.  Accessed at https://www.medpac.gov/wp-
content/uploads/import_data/scrape_files/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf on 
August 17, 2022. 
88 Of the 314 HHAs with 2019 Medicare claims in our sample, 53 were rural (17 percent). 
89 42 CFR  484.70 and 86 Fed. Reg. 61555, 61621-61622 (November 5, 2021). 
90 42 CFR  484.70 and 86 Fed. Reg. 61555, 61621-61622 (November 5, 2021). 
91 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
92 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
93 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
94 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, March 17, 2020.  Accessed at 
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet on July 11, 2022; CMS, 
COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing,  AA, Question 1, updated February 28, 
2022. 
95 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
96 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
97 P. L No. 116-136,  3708(f), March 27, 2020. 
98 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
99 P.L. No. 116-260, division CC,  115, December 27, 2020. 
100 85 Fed. Reg. 70298, 70354 (November 4, 2020). 
101 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
102 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Endnotes | 55  103 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
104 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
105 CMS, Home Health Quality Reporting Program (HH QRP) COVID-19 Public Health Emergency (PHE) Tip Sheet.  Accessed at 
https://www.cms.gov/files/document/hhqrp-covid19phetipsheet-july2020v2.pdf on January 26, 2022. 
106 85 Fed. Reg. 27550, 27629 (May 8, 2020). 
107 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.  
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022. 
108 CMS, Review Choice Demonstration for Home Health Services: Resumption of Demonstration Activities Update: 07/07/2020. 
Accessed at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-
Programs/Review-Choice-Demonstration/Review-Choice-Demonstration-for-Home-Health-Services on January 22, 2022. 
109 CMS, COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing,  V, Question 1, updated 
February 28, 2022. 
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist 
OEI-01-21-00110  Endnotes | 56