Long Term Care Facilities Final Report

A Study of the COVID-19 Outbreak and Response in
Connecticut Long-Term Care Facilities

FINAL REPORT
September 30, 2020

DPH #2021-0041
Submitted to: Submitted by:

Connecticut Department of Public Health Mathematica, Inc.
Donna C. Maselli, R.N., M.P.H., Project Lead 600 Alexander Park, Suite 100
410 Capital Ave., MS #13, GCT Princeton, NJ 08540
Hartford, CT 06134
A Study of the COVID-19 Outbreak and Response in Connecticut Long-Term Care Facilities
Acknowledgements
Mathematica developed this report under contract to the Connecticut Department of Public Health
(Contract Log #2021-0041). The work to complete this project was a team effort and we acknowledge the
contributions of the entire team.
Report authors
Patricia Rowan, M.P.P., PMP (project director)
Reena Gupta, M.Sc.
Rebecca Lester, B.A.
Michael Levere, Ph.D.
Kristie Liao, M.P.P.
Jenna Libersky, M.P.H
Debra Lipson, M.H.S.A.
Andrea Wysocki, Ph.D.
Julie Robison, Ph.D. (UConn Health, Center on Aging)
Patricia A. Bowen, J.D., L.M.S.W., L.N.H.A (UConn Health MPH Student)
Research analytics support

Dayna Gallagher, Burke Hays, Addison Larson, Ash Levine, Huihua Lu, Cherise Mangal, Télyse
Masaoay, Joseph Mastrianni, Margaret Raskob, Grace Reinders, Shauna Robinson, Britta Seifert,
Christina Sintek, and Annu van Bodegom
Communications support
Amy Berridge, Sheryl Friedlander, Donovan Griffin, Margaret Hallisey, John Kennedy, Gwyneth
Olson, Anuja Pandit, Allison Pinckney, Jennifer de Vallance, and Sarah Westbrook
Mathematica would also like to express our gratitude to everyone who supported this work by
participating in interviews—particularly residents of long-term care facilities and their family members—
and sharing their experiences.
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Contents
Acknowledgements ..................................................................................................................... ii
List of Acronyms ....................................................................................................................... vii
Executive Summary ................................................................................................................. viii
I. Introduction ..........................................................................................................................1
A. About this report ............................................................................................................1
B. Similar assessments done by other states ....................................................................3
C. Organization of this report .............................................................................................3
II. Recommendations to Help Connecticut Prevent and Prepare for Future Infectious
Disease Outbreaks in LTC Facilities ....................................................................................4
A. Person-centered care ....................................................................................................4
B. Surveillance and outbreak response .............................................................................5
C. Emergency response ....................................................................................................6
D. Screening and testing ...................................................................................................7
E. Infection control .............................................................................................................8
F. LTC staffing and workforce availability ..........................................................................9
G. State agency roles, expertise, and skills ......................................................................10
H. Communication and coordination across state agencies, facilities, and support
organizations...............................................................................................................10
I. Care transitions ...........................................................................................................11
J. Reimbursement mechanisms to support increased LTC system costs ........................ 12
III. Assessment of the COVID-19 Outbreak in Connecticut on Residents in the State’s
LTC Facilities .....................................................................................................................13
A. Connecticut as a whole ...............................................................................................13
B. Residents of Connecticut nursing homes ....................................................................16
C. Connecticut assisted living facilities.............................................................................33
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IV. Assessment of the State’s Preparedness and Response to COVID-19 in LTC

Facilities .............................................................................................................................35
A. Surveillance and outbreak response ...........................................................................35
B. Infection control, including PPE ...................................................................................39
C. Emergency response structure and communications ..................................................47
D. State agency roles, expertise, and skills ......................................................................51
E. Screening and testing of residents and staff ................................................................52
F. Reimbursement mechanisms to support increasing LTC system costs ....................... 54
G. Communications with LTC industry stakeholders and other key stakeholders ............. 55
V. Assessment of the LTC Industry’s Preparedness and Response to COVID-19 .................. 58
A. Surveillance and outbreak response ...........................................................................58
B. Infection control within and outside of facilities, including PPE .................................... 59
C. LTC facility staffing and workforce availability .............................................................62
D. Screening and testing of residents and staff ................................................................66
E. Care transitions ...........................................................................................................67
F. Communication between LTC facilities and the state, and between facilities and
residents and family members.....................................................................................69
VI. Conclusion .........................................................................................................................73
References ...............................................................................................................................74
Appendix A. Methods .............................................................................................................. A.1
Appendix B. Supplemental Tables and Figures ....................................................................... B.1
Appendix C. Timelines ............................................................................................................ C.1
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Exhibits
ES.1. Count of recommendations by topic ............................................................................... viii
1. New COVID-19 cases and deaths in Connecticut, neighboring states, and the United
States ............................................................................................................................14
2. Total COVID-19 deaths per 100,000 residents, by age group, in Connecticut,
neighboring states, and the United States .....................................................................15
3. Ratio of the share of total COVID-19 cases and deaths, by race and ethnicity, to share
of population in Connecticut and neighboring states ......................................................16
4. Total COVID-19 cases and deaths per licensed bed in Connecticut nursing homes..............17
5. New COVID-19 cases and deaths in Connecticut nursing homes .........................................18
6. Summary of findings from analyses of relationship between nursing home
characteristics and COVID-19 outcome .........................................................................21
7. COVID-19 cases and deaths in an example nursing home, by room location........................24
8. Summary of findings from analyses of relationship between resident characteristics
and COVID-19 outcome ................................................................................................26
9. Data availability for individual nursing home COVID-19 outcomes by state ...........................28
10. Total nursing home COVID-19 cases and deaths per licensed bed in Connecticut
and nearby states, adjusted for nursing home characteristics........................................29
11. Changes in any depressive symptoms among Connecticut nursing home residents,
March through July ........................................................................................................31
12. Changes in unplanned substantial weight loss among Connecticut nursing home
residents, March through July ........................................................................................32
13. Total COVID-19 cases and deaths per bed in Connecticut assisted living facilities .............34
14. Calls to DPH infection control staff related to COVID-19, March through June 2020 ...........42
15. DPH count of PPE distribution by setting, as of July 16, 2020 .............................................44
16. Daily CRF admissions, April 15 through June 30, 2020 .......................................................50
17. Pre-COVID staffing levels reported by nursing homes in Connecticut, the United
States, and nearby states ..............................................................................................63
A.1. Interview topics, by stakeholder ....................................................................................... A.2
B.1. Characteristics of Connecticut nursing homes ................................................................. B.2
B.2. Characteristics of Connecticut assisted living facilities ..................................................... B.4
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B.3. Rates of COVID-19 transmission in Connecticut and neighboring states ......................... B.4
B.4. Rates of COVID-19 transmission in Connecticut by county.............................................. B.5
B.5. Characteristics of Connecticut nursing home residents .................................................... B.6
B.6. Characteristics included in feature selection model.......................................................... B.7
B.7. COVID-19 cases and deaths in Connecticut nursing homes compared to cases in
the surrounding town ................................................................................................... B.9
B.8. Facility-level multivariate regression model .................................................................... B.10
B.9. Bivariate analyses of the relationship between nursing home characteristics and
COVID-19 cases and deaths per licensed bed in Connecticut ................................... B.11
B.10. Bivariate regression coefficients from analyses of the relationship between nursing
home characteristics and COVID-19 cases and deaths per licensed bed in
Connecticut ............................................................................................................... B.13
B.11. Concentration of COVID-19 cases in wings within nursing homes ............................... B.14
B.12. Individual-level multivariate regression model .............................................................. B.15
B.13. Wing-level multivariate regression model ..................................................................... B.16
B.14. Total COVID-19 cases and deaths in long-term care facilities per 100,000 total
population in Northeast states ................................................................................... B.17
B.15. Total nursing home COVID-19 cases and deaths per licensed bed in Connecticut
and nearby states and nearby nursing homes ........................................................... B.18
B.16. Unplanned substantial weight loss, by COVID-19 status.............................................. B.19
B.17. Changes in severe pressure ulcers among Connecticut nursing home residents,
March through July .................................................................................................... B.20
B.18. Changes in cognitive functioning scale among Connecticut nursing home
residents, March through July .................................................................................... B.21
B.19. Changes in activities of daily living score among Connecticut nursing home
residents, March through July .................................................................................... B.22
B.20. Changes in episodes of incontinence among Connecticut nursing home residents,
March through July .................................................................................................... B.23
B.21. Total COVID-19 cases and deaths in Connecticut assisted living facilities
compared to cases in the surrounding town .............................................................. B.24
B.22. Total COVID-19 cases and deaths in Connecticut assisted living facilities by size
of facility .................................................................................................................... B.24
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List of Acronyms
List of Acronyms
CDC Centers for Disease Control and Prevention

CMS Centers for Medicare & Medicaid Services
COVID-19 SARS-Co-V-2
CRF COVID-19 recovery facility
CT DSS Connecticut Department of Social Services
DHHS U.S. Department of Health and Human Services
DPH Connecticut Department of Public Health
FEMA Federal Emergency Management Agency
FLIS Facility Licensing and Inspection Section
HAI health care-acquired infection
HCBS home and community-based services
ICAR Infection Control Assessment and Response
LPN licensed practical nurse
LTC long-term care
LTSS long-term services and supports
LR long-term recommendation
MAP Mutual Aid Plan
MDS Minimum Data Set
NF nursing facility
NHSN National Healthcare Safety Network
OPM Connecticut Office of Policy and Management
PPE personal protective equipment
PPS point prevalence survey
POD point of distribution
RN registered nurse
SEIU Service Employees International Union
SR short-term recommendation
WHO World Health Organization
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Executive Summary
Executive Summary
In Connecticut, SARS-CoV-2 (COVID-19) has had a disproportionate impact on long-term care (LTC)
facilities, with cumulative deaths among long-term care residents representing nearly three-quarters of all
COVID-19-related deaths in the state (72 percent of 4,432 deaths as of July 30, 2020). In response,
Connecticut hired Mathematica and its partner at the UConn Center on Aging to conduct an independent
assessment of the impact of COVID-19 on the state’s nursing homes and assisted living facilities.
Mathematica has released its findings in two parts: an interim and a final report. The interim report, which
the Connecticut Department of Public Health (DPH) released on August 18, 2020, contained a
preliminary analysis of the impact of COVID-19 in the state and in LTC facilities, and a preliminary
assessment of the state and LTC industry’s preparedness and response to the COVID-19 outbreak.
This document comprises the final report, which presents Mathematica’s updated assessment of the state
and industry’s preparedness and response to the COVID-19 outbreak, along with its analysis of both
facility- and resident-level data in the state to determine predictive factors of greater incidence of
COVID-19 cases in LTC facilities. The final report relies on data collected and analyzed from July 13 to
September 15, 2020, which includes publicly reported information, data and documentation provided by
the state, and interviews with key stakeholders. Specifically, Mathematica received and reviewed 190
documents from the state’s agencies and extracted relevant information. Mathematica conducted 52
interviews with more than 130 stakeholders and analyzed them for themes and congruence with other
documentation. Mathematica also analyzed facility- and resident-level data using descriptive statistics and
multivariate regression models.
Exhibit ES.1. Count of recommendations by topic
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Executive Summary
The final report presents 23 short-term immediate and achievable steps the state and LTC industry can
take to prepare for a second wave of COVID-19 and 22 long-term recommendations to prepare for future
disease outbreaks in LTC facilities (Section II). The report organizes the recommendations into 10 themes
as presented in Exhibit ES1: (1) person-centered care; (2) surveillance and outbreak response; (3)
emergency response; (4) screening and testing; (5) infection control; (6) long-term care staffing and
workforce availability; (7) state agency roles, expertise, and skills; (8) communication and coordination
across state agencies, facilities, and support organizations; (9) care transitions; and (10) reimbursement
mechanisms. Section II provides a full list of recommendations. The report also presents an assessment of
the preparedness for and response to COVID-19 at state agencies, including DPH (Section IV) and for the
LTC industry (Section V). The findings and recommendations rely on data on the extent of the outbreak
in Connecticut compared to neighboring states and its impact on LTC residents (Section III).
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Section I. Introduction
I. Introduction
Older adults living in long-term care (LTC) facilities are at greater risk of complications and death from
SARS-CoV-2 (COVID-19) than older adults living in the community. The increased risk comes from the
higher prevalence of underlying clinical conditions among older adults in these facilities, the highly
transmissible nature of the virus, and the frequent interactions common in congregate care settings
(Centers for Disease Control and Prevention [CDC] 2020a). Although individuals living in LTC facilities
represent about 1 percent of the total U.S. population, this group accounts for more than 40 percent of all
U.S. COVID-19 deaths through the middle of September 2020 (COVID Tracking Project 2020). The
percentage is even higher in Connecticut; deaths in LTC facilities represented 72 percent of the state’s
4,432 total deaths from COVID-19 as of July 30.
At the time of this report, the COVID-19 pandemic in Connecticut has subsided and community spread
remains relatively low, with the test positivity rate below 2 percent as of September 17, 2020. The
window of opportunity to change the state’s public policies and approach to response to the outbreak
might be limited as the season changes and more activities move indoors, increasing the risk of an
increase in cases and deaths. The recommendations contained in this report aim to ensure Connecticut is
well positioned to respond to both a potential second wave of COVID-19 and outbreaks of any future
infectious diseases.
A. About this report

On June 8, 2020, Connecticut Governor Ned Lamont ordered an independent assessment of the impact of
COVID-19 on the state’s nursing homes and assisted living facilities (Office of Governor Ned Lamont
2020a). The goals of the assessment are to (1) describe the impact of COVID-19 in Connecticut as a
whole and in LTC facilities compared to other states in the region and the country, (2) assess the state and
LTC industry’s preparedness and response to the COVID-19 outbreak, and (3) identify immediate and
achievable steps the state and LTC industry can take to prepare for a potential second wave of COVID-19
and long-term recommendations (LRs)to prevent future infectious disease outbreaks in LTC facilities.
The Connecticut Department of Public Health (DPH) selected Mathematica—a nonpartisan, independent
public policy research firm—along with consultants at the UConn Center on Aging to conduct this
assessment after a competitive procurement process. On August 18, DPH released Mathematica’s interim
report, which contained an analysis of the impact of COVID-19 in the state and in LTC facilities, along
with a preliminary assessment of the state and LTC industry’s preparedness and response to the COVID-
19 outbreak (Rowan et al. 2020). The interim report also identified immediate and achievable steps the
state and LTC industry could take to prepare for a potential second wave of COVID-19.
This final report contains an updated assessment of the state and industry’s preparedness and response to
the COVID-19 outbreak. This report also contains a detailed analysis of both facility- and resident-level
data for nursing home residents in Connecticut to determine factors that predicted greater incidence of
COVID-19 cases in LTC facilities. The information contained within this final report includes the
information contained in the interim report, some of which has been supplemented with more complete
data and makes recommendations for both short and long-term actions to prevent and respond to future
infectious disease outbreaks.
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1. Sources
Mathematica’s review of information provided by DPH and other relevant state agencies informs this
report. These data included information reported to the state by LTC facilities directly to DPH, as well as
resident-level data from Minimum Data Set (MDS) assessments of nursing home residents’ health and
functional status conducted in the state from 2012 to August 2020. Mathematica also requested written
documentation from state agencies for review related to emergency preparedness and planning,
regulations governing LTC facilities in the state, all relevant guidance and communication from DPH to
LTC facilities, organizational charts and other information related to state agency staffing, and
documentation related to facility reporting requirements.
In addition, Mathematica conducted 52 interviews with 132 people from July 27 to September 10, 2020.
We interviewed a sample of state agency staff, facility administrators, trade association representatives,
labor representatives, legislators, direct care staff working in nursing homes, LTC advocacy groups,
nursing home residents, and family members of residents living in LTC facilities.
For a full explanation of the sources and methods used in this report, including a list of the organizational
affiliations of the individuals interviewed, please see Appendix A.
2. Limitations of this report

Mathematica completed the data collection and analysis for this report over a 13-week period from July to
September 2020. Although Mathematica has done everything in its power to ensure all information
contained in this report is up to date and accurate as of September 15, 2020, Mathematica recognizes the
policy response at both the state and federal levels continues to evolve rapidly. As a result, it is possible
some information related to the state’s response could be outdated or inaccurate by the time this report is
released to the public.
Because of the accelerated timeline for this project, Mathematica relied on in-depth interviews with key
stakeholders in the state and LTC industry to provide information related to the state’s preparedness and
response. In most cases, Mathematica could verify the information stakeholders provided by reviewing
written documentation from the state. But in some cases, verification was not possible either because the
documentation was not available or there was insufficient time to locate the source. In those cases,
Mathematica relied on the views and experiences of the stakeholders interviewed, and the report includes
such perspectives if two or more stakeholders reported them during interviews. 1
Mathematica worked with DPH to ensure we interviewed a wide variety of stakeholders with a range of
perspectives to inform the assessment contained in this report. However, a few individuals that
Mathematica contacted for an interview—including at DPH and the Governor’s office—did not respond
to our requests after repeated attempts.
This report does not analyze COVID-19 cases and deaths among staff working in LTC facilities due to a
lack of sufficient data available. Section V.C.2.d discusses the data that are available and presents the
available information on the toll of COVID-19 on direct care staff.
1
Throughout this report, we use the terms some or several to refer to perspectives shared by two or three
stakeholders, whereas the term many refers to information shared by four or more individuals. In some instances, we
have included information not reported by two or more stakeholders to ensure we captured the range of experiences
and perspectives.
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Finally, due to travel restrictions and visitation lock downs at LTC facilities that were in place during the
period of performance, Mathematica did not conduct any in-person visits to LTC facilities in the state.
Instead, Mathematica conducted all stakeholder interviews by telephone and video conferences.
B. Similar assessments done by other states

Since the beginning of the pandemic, states across the country have monitored and assessed the impact of
COVID-19, taking a variety of actions to mitigate the spread of COVID-19 in LTC facilities and protect
the health and well-being of LTC facility residents and staff. These actions include issuing executive
orders, releasing regulatory guidance and policies, and enacting state legislation that address many issues,
including LTC facility visitation, testing of residents and staff, availability of and funding for personal
protective equipment (PPE) and other resources, staff compensation and workforce capacity, hospital
discharges, facility oversight and monitoring, emergency preparedness, health disparities and residents’
quality of life.
Like Connecticut, many other states also have undertaken an assessment of the COVID-19 outbreak in
LTC. Reports similar to this one have been undertaken in Arizona, Colorado, Michigan, New York, New
Jersey, and Virginia (Arizona Department of Health Services 2020; Colorado Department of Public
Health & Environment 2020; Michigan Nursing Home COVID-19 Task Force 2020; New York State
Department of Health 2020a; Manatt Health 2020; Virginia Department of Health 2020). In addition, the
federal Centers for Medicare & Medicaid Services (CMS) released a report on September 17, 2020, from
its independent Coronavirus Commission on Safety and Quality in Nursing Homes (MITRE 2020).
Where relevant, this report highlights findings and recommendations from these other assessments that
are relevant to Connecticut.
C. Organization of this report

Section II of this report presents short- and long-term recommendations for Connecticut and the LTC
industry. Section III assesses facility- and resident-level data to quantify the impact of COVID-19 on
residents in LTC facilities. Section IV assesses the state’s preparedness and response to the COVID-19
outbreak in LTC facilities. Section V assesses the industry’s preparedness and response to the COVID-19
outbreak. Section VI presents conclusions.
Appendix A describes in detail the methods used in this study and Appendix B contains supplementary
tables and figures from the data analysis. Appendix C contains timelines of select federal and state policy
and guidance in response to the COVID-19 outbreak from March through September 15, 2020.
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Section II. Recommendations to Help Connecticut Prevent and Prepare for Future Outbreaks in LTC Facilities
II. Recommendations to Help Connecticut Prevent and Prepare for

Future Infectious Disease Outbreaks in LTC Facilities
This report presents 45 recommendations: 23 short-term recommendations (SRs) for immediate and
achievable steps the state and LTC industry can take to prepare for a potential second wave of COVID-19
and 22 LRs to prepare for future disease outbreaks in LTC facilities. The report organizes the
recommendations into 10 themes: person-centered care; surveillance and outbreak response; emergency
response; screening and testing; infection control; LTC staffing and workforce availability; state agency
roles, expertise, and skills; communication and coordination across state agencies, facilities, and support
organizations; care transitions; and reimbursement mechanisms.
The report numbers the recommendations for easy reference to them; the numbering approach does not
indicate any rank ordering of recommendations. Many of these recommendations are complementary and
would have to be implemented concurrently to have the greatest impact.
Mathematica acknowledges that the state has already begun implementing some of these
recommendations. In those instances, we recommend that the work continue.
A. Person-centered care
1. Short-term recommendations to mitigate a second wave of COVID-19

• SR1: LTC facilities and their state regulators must balance strict measures designed to limit the
spread of the virus with the need to support the physical, emotional, and psychosocial needs of LTC
residents.
− The state and LTC industry must continue to prioritize person-centered care, which is care that
meets residents’ physical, emotional, and psychosocial needs and gives them choices and control
over their daily lives.
• SR2: Facilities should ensure resident care plans reflect COVID-19-specific impacts on individual
residents.
− Resident care plans should address social supports, a plan to prevent isolation and loneliness, any
risk factors for depression, and how nursing homes meet residents’ needs when family members
are not allowed in the building.
• SR3: Facilities should continuously assess the appropriateness of any policy that restricts the
movement of residents within their facility.
− The state should support facilities with appropriate guidance on resident restrictions based on the
prevalence of COVID-19 in each facility and with input from representatives of the LTC
industry, residents and resident councils, family members, the LTC ombudsman, and state
regulators.
• SR4: Recognizing that visitation is an important resident right, the state should develop a framework
to guide policies on the reopening of LTC facilities to visitors based on a set of criteria. The
framework could be modeled on those developed by other states and would allow facilities to reopen
based on meeting specified criteria at the facility and community levels, rather than a one-size-fits-all
statewide policy that does not consider facility and local indicators (Minnesota Department of Health
2020a; Arizona Department of Health Services 2020).
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− Criteria included in the visitor reopening framework should include availability and frequency of
testing, community prevalence of COVID-19, and the facility-level PPE stockpile, among others.
• SR5: The state should work with facilities that meet certain criteria to designate essential caregivers
(family members and private duty aides hired by the family) who would have increased access to
LTC facilities to fill a defined role for specific residents.
− This would be similar to an approach taken in Michigan that allows these individuals to be in the
facility for two to three hours per day to provide care and assistance to residents, and one in
Minnesota, which recommends allowing essential caregivers access to the facility for up to three
hours per day (Robert 2020; Minnesota Department of Health 2020b).
− DPH should issue guidance to facilities for designating these caregivers. For example, the
Department should require essential caregivers to comply with facility policies for screening,
regular COVID-19 testing, and training in appropriate donning and doffing of PPE. DPH should
also specify criteria that facilities need to meet in order to implement this policy.
− The state should consider granting limited immunity to facilities for any adverse events that arise
as a result of allowing essential caregivers access to the facility if all other requirements for
screening, training, and testing are met.
B. Surveillance and outbreak response

• SR6: DPH should continue infection control focused surveys, targeting more frequent surveys in
nursing homes with ongoing or increasing infections.
− Surveyors should continue to provide technical assistance and real-time remedial instruction to
facilities during these surveys to ensure compliance with state regulations.
• SR7: DPH should ensure all temporary survey staff, including National Guard personnel, complete
basic and ongoing training to conduct surveys consistently and thoroughly, including training on
infection control and prevention.
− Industry stakeholders reported survey teams can be an important source of communication and
guidance. To this end, it is critical that all personnel conducting infection control focused surveys
receive basic and ongoing training on how to conduct surveys and issue citations consistent with
CMS guidelines.
− Opportunities for ongoing communication and guidance to surveyors are also important. DPH
should continue to assess the frequency of meetings with surveyors and provide written
summaries for those who cannot attend.
• SR8: All Facility Licensing and Investigations Section (FLIS) staff or other personnel conducting in-
person surveys in nursing homes should be regularly tested for COVID-19 to ensure that surveyors do
not become a source of possible infection among residents or staff.
2. Longer-term recommendations to prevent future outbreaks

• LR1: The state should explore ways to reduce duplicate case reporting to minimize burden on
facilities and the state and reduce the risk of data errors.
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− For example, the state could map which data elements and metrics related to census, cases, PPE,
and so on are reported by facilities to multiple reporting streams and eliminate overlap. The state
should explore integrating reporting systems or automating uploads from one system to another.
− Streamlining reporting requirements might help free LTC facility, DPH, and contractor personnel
from ensuring data accuracy and timeliness toward efforts to strengthen infection control
procedures.
• LR2: The state should make participation in the Mutual Aid Plan (MAP) mandatory for assisted
living communities.
− The requirement that assisted living facilities report to MAP under Executive Order Number 7EE
(Lamont 2020a) should be made permanent to ensure the state has immediate access to data from
these facilities anytime there is a future activation of the state’s Mutual Aid Plan (Lamont 2020a).
− The state should ensure membership fees in the MAP are equal for all participants to eliminate
potential barriers to entry for MAP participation or consider a sliding fee scale based on facility
revenue.
• LR3: The state should make infection control training mandatory for the designated on-call nurses at
assisted living service agencies that provide services to adults living in assisted living facilities. 2
− Before the pandemic, Connecticut was one of only nine states (as of 2019) without any specific
regulations that addressed infection control policies in assisted living communities (Bucy et al.
2020).
C. Emergency response

• SR9: The state should develop plans for a potential second wave in consultation with representatives
from the state legislature, LTC industry and home and community-based services (HCBS) providers,
residents, and family members.
− Early planning and response efforts focused on hospital capacity, with nursing homes viewed
primarily as a backstop to alleviate high demand for acute care beds. Ongoing emergency
planning and response efforts should include representatives of the LTC industry, including
HCBS providers, and LTC residents and family members to address their unique needs.
• SR10: The state should continue its planning efforts to scale up COVID-19 recovery facility (CRF)
capacity as needed and deploy it quickly in response to the scope and severity of a second wave.
− LTC facilities should continue to have the option to transfer COVID-19-positive residents
directly to a CRF without first transferring them to the hospital.
− DPH has developed three CRF models; Mathematica recommends DPH use Models 2 and 3 for
ongoing CRF capacity to avoid the trauma of moving residents out of the facilities where they
live. Section IV.C.2.B provides more information.
2
According to state regulations “Connecticut does not license assisted living facilities; instead it licenses and
regulates the ‘assisted living service agencies’ that provide assisted living services” within the facilities considered
managed residential communities in the state’s regulations. See https://www.cga.ct.gov/2012/rpt/2012-R-
0244.htm#:~:text=Connecticut%20does%20not%20license%20assisted,that%20provide%20assisted%20living%20s
ervices.&text=An%20MRC%20can%20become%20a,existing%20ALSA%20to%20provide%20services.
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• SR11: The state should explore executing per diem contracts for staff extenders now to ensure
resources are available for a timely response to a potential second wave.
− State agency staff reported using outside contractors for subject matter expertise and general staff
extension in the first wave of the COVID-19 response. Contracts for similar resources could be
put in place now (for example, with testing lab Care Partners, housing contractors to house staff
that need to quarantine, and per diem staff) to quickly scale up the state’s response to future
waves.

• LR4: The state should revise its emergency response plans to explicitly include LTC facilities and
HCBS providers.
− The revised plans should recognize these settings and providers as critical health care assets and
detail a specific response that addresses the unique risks and needs of residents and staff in those
settings, drawing on the lessons learned from the COVID-19 response.
• LR5: Planning for and responding to future infectious disease outbreaks should include
representatives of the LTC industry and HCBS providers.
− The earliest response to COVID-19 in Connecticut did not include these perspectives and, as a
result, those settings were somewhat neglected due to the focus on hospitals.
• LR6: The state should explore creating a mechanism to redeploy furloughed licensed health care
personnel from other settings to LTC facilities and HCBS providers during future outbreaks.
− For example, if outpatient clinics are closed or health care staff are furloughed as a result of
decreased demand, those staff could be redeployed to LTC facilities or HCBS providers to make
up for staffing shortages in those settings.
− One approach could be similar to the Massachusetts COVID-19 LTC Facility Staffing Portal,
which matches demand for staffing needs with potential staff. As of May 2020, 1,900 individuals
had applied to meet the demand for jobs posted on the portal (MassHealth 2020).
D. Screening and testing

• SR12: DPH should continuously revisit its guidance on testing LTC facility residents and staff as
new information becomes available or testing guidance from the CDC evolves.
− For example, the state recently changed its resident and staff testing guidance to align with the
CDC recommendations to base testing on community prevalence.
• SR13: DPH should continue to assess the Care Partners testing program to ensure it meets its
intended goals.
− The Care Partners program aims to provide a dedicated testing partner to each nursing home in
the state to process tests of residents and staff. DPH should examine how well these matches
work, ensure assignments consider geographical distance between facilities and Care Partner
contractors, and ensure that they allow for some flexibility for facilities to continue using their
existing lab relationships as appropriate.
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• LR7: As new testing technology receives Food and Drug Administration approval the state should
continue to review its Medicaid reimbursement to ensure they incentivize efficient use of resources.
− For example, if a combined COVID-19 and influenza test becomes available, Medicaid
reimbursement policy should ensure facilities are not incentivized to test separately, which could
create undue pressure on laboratory capacity.
• LR8: Facilities should consider increasing the testing frequency of some residents at higher risk,
beyond current requirements.
− Our analysis found increased risk of contracting COVID-19 among residents who frequently
leave the facility for dialysis or other outpatient treatment.
• LR9: The state should issue guidance on recommended screening and testing strategies for visitors to
LTC facilities as visitation policies expand and the change in seasons limits the ability to conduct
outdoor visits (see also SR4).
− For example, the guidance could require that visitors get tested and self-isolate while waiting for
the results before visiting a facility. The state could look to policies instituted by health systems
for elective surgeries that require testing 48 hours in advance as an example of a potential best
practice.
E. Infection control

• SR14: Due to the role of community prevalence in driving COVID-19 outbreaks in facilities,
everyone living in or visiting Connecticut should continue to heed guidance from the state and
national authorities to ensure community spread remains low.
− This includes continuing to maintain social distancing, wearing a mask while in public, practicing
good hygiene, staying home when feeling sick, and getting a flu shot to protect yourself and
others from infection.
• SR15: Facilities should consider the rooming assignments of high-risk residents on units in such a
way that reduces exposure of others on the unit.
− For example, facilities could assign residents who frequently leave the facility for dialysis or
other outpatient treatment a room at the end of a hallway near an exit to allow for easier transfers.
• SR16: Facilities should ensure they have an adequate stockpile of PPE that is available and accessible
to staff on every shift.
− Facility management should ensure someone on every shift has access to the PPE supply if the
supplies are stored in locked containers.

• LR10: Connecticut should broaden qualifications for an infection preventionist and expand the role to
full-time in all nursing homes. Medicaid payment rates should be adjusted to cover the extra cost of
full-time positions.
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− The state could broaden the training for infection preventionists to align with the federal rules of
participation for nursing homes, which state this position can have training in nursing, medical
technology, microbiology, epidemiology, or other related fields (§42 CFR 483.80.b.1).
− The state and LTC industry should work with community colleges and other training programs to
meet the increased demand for infection control and prevention training and certifications.
• LR11: The state should continue to maintain a stockpile of PPE that is available to LTC facilities in
case of future increases in COVID-19 or other infectious diseases that are accompanied by
breakdowns in the supply chain and lack of availability from the Strategic National Stockpile.
• LR12: As evidence emerges regarding the role of building design and ventilation, LTC facilities
should consider changing their physical environments to better limit the spread of an airborne virus
similar to COVID-19. The state could support these building renovations by guaranteeing loans for
facilities.
• LR13: When vaccines to provide protection from COVID-19 become available and are proven safe
and effective for vulnerable populations, state distribution plans should designate LTC residents and
staff as having priority to receive them.
− On September 21, Governor Ned Lamont announced the creation of a special commission that
would establish priorities for distribution of an eventual vaccine. This group should consider the
unique risks of LTC facility residents and staff in prioritizing receipt of a vaccine.
F. LTC staffing and workforce availability

• SR17: Facilities should adopt staffing policies that can help limit potential exposure for staff and
residents, such as the following:
− Facilities can use two 12-hour shifts instead of three 8-hour shifts to limit entry and exit of staff to
the building while maintaining staffing levels.
− Facilities should also explore strategies, such as increasing full-time staff positions, to limit the
number of staff working in multiple facilities (for example, fewer moonlighting staff).
− Facilities should consistently assign staff to work on the same unit and with the same residents.
• SR18: The state should extend the temporary suspension of in-state licensure requirements for as
long as the public health emergency is in effect.
− Before the pandemic, Connecticut was 1 of only 10 states without a nurse licensing compact in
place to allow licensed staff from out of state to work in its health care facilities (National
Council of State Boards of Nursing 2020). The temporary lifting of licensing requirements has
given the LTC industry needed flexibility to bring in staff from out of state.

• LR14: Connecticut should increase the minimum required staffing ratios in nursing homes and may
need to consider financing mechanisms to raise the Medicaid reimbursement rate to support greater
increases in direct care workers’ pay and benefits.
− At a minimum, the state could increase staffing ratios in all nursing homes to match the ratios
required in CRFs. The state could also consider increasing the minimum staffing ratios to match
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the staffing levels required for a 4- or 5-star staffing rating. CMS identified these staffing
thresholds in its staffing study, which set thresholds based on clinical evidence on the relationship
between staffing and quality (CMS 2020a).
• LR15: The state should ensure all LTC facility staff and HCBS providers have access to guaranteed
paid sick time under the state’s existing paid sick leave regulations.
• LR16: If any nursing homes close due to declining occupancy rates as a result of COVID-19, the
state should work with local colleges and universities to facilitate opportunities for staff retraining in
HCBS jobs.
G. State agency roles, expertise, and skills

• SR19: The state should designate qualified staff or contractors that can provide technical assistance to
LTC facilities regarding infection control guidelines.
− DPH employees in the Infectious Disease section reported providing significant assistance to
facilities during regular provider calls, which industry stakeholders described as helpful.
− To the extent possible, the state should explore whether additional resources can provide further
technical assistance given the demands on the time of infectious disease staff. Staff providing
technical assistance should have education and experience in infection control and prevention,
epidemiology, and knowledge of the regulatory requirements of LTC facilities.
− The state should set up a single point of entry for facilities to access this expertise.

• LR17: The state should conduct a comprehensive assessment of DPH staffing needs, including
number of staff, skills required for topics including infection control and emergency response, and
interaction with other groups within and outside of DPH.
− The state should look to the staffing approaches used in other similar states as a model. The
assessment should consider lessons learned related to the state agency resources needed to
respond to COVID-19.
H. Communication and coordination across state agencies, facilities, and support

organizations

• SR20: DPH should supplement its weekly calls with LTC facilities by providing written summaries
following each call and archiving guidance in a central place (for example, via Blast Faxes or the
MAP website).
− At the end of August, DPH began adding written summaries and recordings of weekly webinars
to the MAP website to address this recommendation.
− DPH should organize blast fax records by date, provide a brief summary of the content in each
document, and list the newest documents first. DPH currently posts blast faxes on two websites
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(the FLIS website and the LTC MAP); the state should ensure information is consistent across
these sites.
• SR21: Facilities should ensure family members can obtain accurate and timely information on
residents’ health and well-being.
− Family members reported challenges obtaining information about their loved ones from facilities.
Facilities should provide weekly written updates on the situation in each facility and designate a
single point of contact for family members to request updates on individual residents.
− The Ombudsman program should facilitate communication between families and facilities when
families do not receive timely information about residents.

• LR18: The state’s LTC Planning Committee, comprising elected officials and state agency
representatives, should increase the frequency of meetings and add agenda topics related to the
COVID-19 response moving forward.
− This committee currently meets quarterly but recent meeting agendas have not discussed the
effects of COVID-19 (Connecticut Office of Policy and Management 2020a).
− The committee should invite state associations for nursing homes, assisted living communities,
and HCBS providers to participate on this committee to formalize a venue for communication
with the industry.
I. Care transitions

• SR22: The Connecticut Department of Social Services (CT DSS) and contracted access agencies
should work with hospitals to facilitate discharge of older adults and people with disabilities with
COVID-19 to home and community-based settings, rather than nursing homes, with appropriate home
health and other supports and care coordination.

• LR19: The state should ensure all LTC residents receive counseling on their options to receive
services in the community and support those who want return to the community
− The state should ensure continued support to state Medicaid programs (Money Follows the
Person, My Community Options, and MyPlaceCT.org) that help people who need long-term
services and supports (LTSS) return to or remain in the community, if that is their preference.
− CT DSS should ensure sufficient resources to deliver adequate HCBS and PPE, including grocery
and medical supplies, to beneficiaries’ homes and prioritize COVID-19 cases.
• LR20: The state should support nursing homes that want to develop business plans to repurpose their
facilities to provide community-based care.
− For example, Connecticut’s right-sizing plan provides grants to nursing facilities to develop new
business plans that repurpose their physical space for community-based care such as adult day
programs, with funds supporting architectural and site development plans, and potentially for
construction costs.
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J. Reimbursement mechanisms to support increased LTC system costs

• SR23: The state should continue to assess how it supports facilities with the cost of widespread
resident and staff testing.
− The state announced on August 5 that it would continue to cover the cost of testing LTC facility
residents and staff through October 31.

• LR21: The state should ensure the ongoing cost of nursing facility resident and staff COVID-19
testing, as well as PPE, are adequately covered by the state’s Medicaid reimbursement rates.
• LR22: The state should consider tying a component of Medicaid reimbursement for LTSS in nursing
facilities and in home and community-based settings, to provider performance on quality metrics such
as those used to calculate the CMS star ratings.
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Section III. Assessment of the COVID-19 Outbreak in Connecticut on Residents in the State’s LTC Facilities
III. Assessment of the COVID-19 Outbreak in Connecticut on

Residents in the State’s LTC Facilities
Residents of Connecticut’s LTC facilities were devastated by the pandemic. As of the end of July, nursing
homes reported 2,849 residents had died because of COVID-19 3 and assisted living facilities reported an
additional 349 deaths for a total of 3,198 deaths in Connecticut LTC facilities. In total, deaths in LTC
facilities represented 72 percent of the state’s 4,432 total deaths from COVID-19.
Key factors explaining variation in the extent of the spread of the virus across nursing homes included
community prevalence and staffing ratings. However, even within nursing homes, cases and deaths varied
substantially across residents, often reflecting the demographic characteristics and health conditions
associated with COVID-19 risk, as well as the frequency of interaction with staff and providers outside
the facility. Moreover, COVID-19 cases and deaths alone do not capture the full impact of the pandemic
on residents’ well-being; nursing home residents also experienced substantial deterioration in health and
functioning because of the indirect effects of the pandemic, such as reduced visitation and changes in the
provision of care.
Connecticut has 216 licensed nursing homes; the 212 that report data on the number of COVID-19 cases
and deaths in the state’s regular reports were the focus of our analysis. Appendix Exhibit B.1 contains
descriptive statistics of these 212 nursing homes. Connecticut also reports data on COVID-19 in 133
assisted living facilities in the state’s regular reports. Appendix Exhibit B.2 contains descriptive statistics
of these assisted living facilities.
In this section, we first summarize the extent of the outbreak in Connecticut as a whole. This summary
provides important context to understand what was happening outside the walls of LTC facilities, but
where staff returned to each day. We next discuss the impact of the pandemic on residents of
Connecticut’s nursing homes relying on a broad range of data sources. We examine the characteristics
associated with the spread of COVID-19 across nursing homes and the characteristics associated with the
spread within individual residents of nursing homes. We also compare the extent of the outbreak among
nursing home residents in Connecticut to those in nearby states. In addition, we examine how the
pandemic affected residents’ well-being. Finally, we examine the impact of the pandemic on residents in
assisted living facilities.
A. Connecticut as a whole
Connecticut was among the states most adversely affected by the pandemic. In total, by the end of July
2020, nearly 50,000 residents had contracted COVID-19 and more than 4,400 had died. The number of
new cases and deaths peaked in Connecticut in late April 2020, with new cases reaching 30.9 per 100,000
residents on April 22 and deaths reaching 3.2 per 100,000 residents on April 26 (Exhibit 1). The COVID-
3
We focus our analysis through the end of July because of concerns about a change in reporting. However, as of
September 10, the state reported only 58 new cases and 28 new deaths since July 22, so all findings would be
essentially unchanged if we considered a broader time horizon. As described in the DPH weekly reports on COVID-
19 cases in nursing homes, DPH and CMS require Connecticut nursing homes to report on the impact of COVID-19
on their residents and staff through the CDC National Healthcare Safety Network (NHSN). Connecticut DPH began
reporting NHSN data from June 17, 2020. Cumulative data for residents was rebaselined on July 15 and on July 21
to account for false positives detected that week. Due to the different data collection and processing methods for
NHSN and data sources used before this source to report on COVID-19 cases and deaths, DPH does not sum the
data before and after the rebaselining on July 21, 2020, due to possible duplication of cases and deaths between prior
and current data reported.
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19 outbreak was more severe in Connecticut than the United States as a whole early in the pandemic, but
new cases and deaths nationally have remained higher than new cases and deaths in Connecticut since
mid-to-late June (Exhibit 1). Connecticut also had more new cases and deaths than the Northeast region,
but fewer cases and deaths than counties within 50 miles of Connecticut in neighboring states. 4
Exhibit 1. New COVID-19 cases and deaths in Connecticut, neighboring states, and the United
States
Source: Mathematica’s analysis of data collected from Johns Hopkins University, the New York Times, and the U.S.
Census Bureau.
Note: The figures depict the seven-day moving average of new COVID-19 cases and deaths. The Northeast
region includes Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York,
Pennsylvania, Rhode Island, Vermont, and Washington, DC. Analyses are based on cases and deaths
reported through the end of July 2020.
4
We also analyzed rates of transmission for Connecticut and states in the northeast region, which were mostly
comparable from April to July (Appendix Exhibit B.3). We also analyzed rates of transmission for each of
Connecticut’s counties, with some variation over time by geography (Appendix Exhibit B.4).
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Adults ages 85 and older were most severely affected by the pandemic (Exhibit 2). In Connecticut, the
death rate among adults ages 85 and older was 1,991 per 100,000 residents, more than 3 times the rate of
those ages 75 to 84, and 10 times the rate of those ages 65 to 74. The death rate in Connecticut for adults
ages 85 and older was most similar to those in neighboring states, where deaths per 100,000 residents
exceeded 2,000. In all regions, death rates increased with age.
Exhibit 2. Total COVID-19 deaths per 100,000 residents, by age group, in Connecticut, neighboring
states, and the United States
Source: Mathematica’s analysis of data collected from the Centers for Disease Control and Prevention and the
Census Bureau.
Note: Neighboring states include Massachusetts, New Jersey, New York, and Rhode Island. The Northeast
region includes these four states plus Delaware, Maine, Maryland, New Hampshire, Pennsylvania,
Vermont, and Washington, DC. Analyses are based on deaths reported through the end of July 2020.
COVID-19 cases in Connecticut were disproportionately higher among Hispanic and Black residents than
White residents, but deaths attributable to COVID-19 were higher for Black residents and lower for
Hispanic residents relative to White residents (Exhibit 3). The higher relative death rate for White
residents is due largely to differences in the age distribution for people of different race and ethnicity; in
Connecticut, 88 percent of residents older than 85 are White, whereas only 4 percent are Hispanic.
Among Connecticut residents of all ages, however, 66 percent are White and 17 percent are Hispanic.
Patterns for COVID-19 cases and deaths by race and ethnicity were similar in Massachusetts and Rhode
Island, which also have comparable age and racial distributions to Connecticut. In New York, deaths
attributable to COVID-19 were disproportionately higher among Hispanic residents than White residents,
which might be because a much larger share of the population older than 85 in New York are Hispanic
(10 percent).
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Exhibit 3. Ratio of the share of total COVID-19 cases and deaths, by race and ethnicity, to share of
population in Connecticut and neighboring states
Source: Mathematica’s analysis of data collected from the COVID-19 racial data dashboard as compiled by the
COVID Tracking Project and the Census Bureau.
Note: Each bar represents the ratio of the share of COVID-19 cases or deaths for that racial or ethnic group
(among those for which race or ethnicity is known) divided by the group’s share of the general population.
The ratio of cases excludes New York because it does not report the racial composition of cases. Analyses
are based on cases and deaths reported through the end of July 2020.
B. Residents of Connecticut nursing homes

The pandemic severely affected residents of Connecticut’s nursing homes, with facilities across the state
reporting nearly 3,000 residents who died from COVID-19 5 and almost 9,000 residents who contracted
the disease through the end of July. However, COVID-19 cases and deaths were concentrated in certain
nursing homes in Connecticut. About 26 percent of nursing homes reported more than 0.5 cases per
licensed bed, and 15 percent had more than 0.2 deaths per licensed bed (Exhibit 4). While COVID-19 had
a large impact on residents in a subset of nursing homes, 16 percent of nursing homes had no cases and 26
percent had no deaths among their residents. 6
5
Throughout this report, we refer to deaths from COVID-19 as those for which COVID-19 is listed on someone’s
death certificate. This does not necessarily mean that COVID-19 is the primary cause of death.
6
The histogram in Exhibit 4 does not show the share of nursing homes with zero cases or deaths. The first bar in
Exhibit 4 corresponds to zero or a low amount cases or deaths. Because histograms show a continuous distribution,
not the distribution at a single value, it does not indicate the percentage of nursing homes with zero cases or deaths.
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Exhibit 4. Total COVID-19 cases and deaths per licensed bed in Connecticut nursing homes
Source: Mathematica’s analysis of nursing home reported data included in Connecticut’s FLIS system.
Note: Deaths include both confirmed and probable deaths attributable to COVID-19. The data reflect total cases
and deaths in nursing homes reported by July 22, 2020.
FLIS = Facility Licensing and Investigations Section.
Similar to the patterns for the state as a whole, the COVID-19 outbreak among residents in Connecticut
nursing homes peaked in mid-April, when an average of nearly 200 new cases and 70 new deaths were
reported daily (Exhibit 5). New cases and deaths dropped to close to zero by mid-July and remained low
through mid-September.
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Exhibit 5. New COVID-19 cases and deaths in Connecticut nursing homes
Source: Mathematica’s analysis of Connecticut DPH FLIS portal on individual resident data, as reported by nursing
homes, by July 22, 2020; Connecticut’s Vital Records death data; and MDS data.
Note: Cases include only those with a confirmed positive test with a nonmissing date. Deaths include those who
died from COVID-19 where the person was in a nursing home. We confirmed this either by matching to the
list of residents in each nursing home or by using the address for the place of death or place of residence.
DPH = Department of Public Health; FLIS = Facility Licensing and Investigations Section; MDS = Minimum Data Set.
Across the state, 2,849 people in nursing homes died from COVID-19 through the end of July, of whom
we could identify characteristics in nursing home resident assessment data for 2,612 of them (more than
90 percent). About 36 percent of those who died were short-stay residents, meaning they had been in the
nursing home for fewer than 100 days at the time of their death (Appendix Exhibit B.5). Most people who
died were women (56 percent). More than 80 percent of those who died in nursing homes were White, 13
percent were Black and 5 percent were Hispanic. The average age of those who died from COVID-19 in
nursing homes was 83 and ranged from 33 to 108. Three-quarters of those who died in nursing homes
were older than 75.
In this section, we present results from a variety of analyses designed to understand the effects of
COVID-19 in Connecticut’s nursing homes. These analyses identify characteristics of facilities and
characteristics of residents that predicted the spread of COVID-19, which help to understand why the
disease spread and in turn suggest important ways to prevent the disease from spreading in the event of a
second wave.
First, we look at characteristics at the nursing home level, characteristics of both the facility and its
residents, to understand the spread across all nursing homes. Second, we analyze patterns within nursing
homes to assess how the disease spread across individual residents and across wings within a nursing
home. Third, we compare outcomes between Connecticut and other nearby states; if outcomes differed, it
might indicate state policies were important to explaining the variation in cases and deaths. Finally, we
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analyze the impact of the pandemic on residents’ well-being and quality of life, which must be considered
in assessing the need for policies designed to mitigate the spread of COVID-19.
1. Spread of COVID-19 across Connecticut nursing homes
a. Summary of findings
Both nursing home and residents’ characteristics were
important in predicting where and how much COVID-19 Recommendation SR4
spread:
Recognizing that visitation is an
• Nursing homes with high staffing ratings had important resident right, the state
significantly fewer cases and deaths per licensed bed. should develop a framework to
• Nursing homes in towns that had more cases guide policies on the reopening of
experienced more cases and deaths. LTC facilities to visitors based on
• Nursing homes with more residents that received a set of criteria.
dialysis and cancer treatments, which tend to be
delivered off site, had more cases per licensed bed.
Taken together, these findings suggest mitigating future risk depends on both reducing the likelihood that
COVID-19 can enter the nursing home and limiting the spread if it is introduced.
In total, the multivariate regression model can explain about one-third of the variation in cases per
licensed bed (R2 = 0.34) and deaths per licensed bed (R2 = 0.33). Thus, other factors not included in the
model that we cannot measure are also important in understanding why some nursing homes experienced
more severe outbreaks. These factors include the potential impact of asymptomatic spread by staff early
in the outbreak, availability of PPE within each nursing home as well as appropriate use by staff, and
random chance.
b. Methodology
To understand the spread of COVID-19 across nursing homes, we analyzed whether certain facility- and
resident-level characteristics were correlated with the number of cases and deaths per licensed bed in
nursing homes. This analysis identifies where COVID-19 was more pervasive and which types of nursing
homes were more susceptible. We considered several nursing home characteristics, such as geographic
location, size, profit and chain status, and Nursing Home Compare star ratings. We also considered
characteristics of residents in nursing homes, such as residents’ demographic and health characteristics.
The findings from these analyses can help the state and individual facilities better target their resources
and response in the event of a potential second wave of COVID-19.
We first present results from a multivariate regression model, which takes into account that many of the
characteristics are correlated. For example, Mathematica’s interim report found significant relationships
between COVID-19 cases and deaths and facility profit status and staffing ratings, but the two are
correlated: for-profit nursing homes are substantially less likely to have high staffing ratings. The
multivariate regression model teases out which of the characteristics matters more, holding all others
constant. In the example, staffing ratings are more predictive than for-profit status. We used a feature
selection model to identify characteristics that were important to understanding the variation in cases and
Mathematica 19
deaths per licensed bed; 7 we included this set of important characteristics in the multivariate regression
model to subsequently assess their statistical significance. We also present the bivariate (unadjusted)
relationship between each nursing home characteristic and COVID-19 outcomes. For a more detailed
discussion of the methodology, see Appendix A.
c. Results
Effect of community incidence. Nursing homes that had greater incidence of COVID-19 in the
surrounding community were more likely to experience higher numbers of cases and deaths. In particular,
as the number of cases increased in the town where the nursing home was located (excluding cases in
either nursing homes or assisted living facilities in that town), the number of cases per licensed bed
increased significantly (Exhibit 6). For each additional case per 1,000 residents in the town, the number of
cases in nursing homes per licensed bed increased by 0.006 and the number of deaths in nursing homes
per licensed bed increased by 0.003. 8
Effect of residents receiving treatment in the community. In nursing homes where a larger share of
residents had dialysis or cancer treatments, the cases and deaths per bed were higher (Exhibit 6). In
combination with the previous finding, this speaks to the importance of spread from the community into
the nursing home, likely as a result of staff entering the nursing home or residents leaving the facility for
offsite treatment. Reducing the spread of COVID-19 in a second wave will require limiting the extent to
which external cases ultimately lead to cases in the nursing home.
Effect of staffing ratios. Staffing rating was highly
predictive of the ability to limit the spread of COVID-19 Recommendation LR14
in nursing homes (Exhibit 6). Nursing homes with a high
staffing rating (4 or 5 stars) had 0.06 fewer cases and 0.03 Connecticut should increase the
fewer deaths per licensed bed than nursing homes with a minimum required staffing ratios in
lower staffing rating (1, 2, or 3 stars); both results were nursing homes.
statistically significant. Relative to the average for nursing
homes with lower ratings, this represented a reduction of
more than 20 percent in both cases and deaths for nursing homes with higher staffing ratios. These
findings are consistent with long-standing, and recent, evidence showing that higher staffing ratios are
associated with better quality (Gorges and Konetzka 2020). In nursing homes with high staffing ratios,
residents receive more staff care in terms of hours per resident than residents in nursing homes with low
staffing ratios. Nursing homes with more staff also might be able to take more time to implement best
practices with regard to PPE, thereby limiting the spread of disease.
Effect of size and occupancy rate. The total number of residents and the share of the licensed beds that
were filled also significantly predicted greater spread. Nursing homes with more residents at the
beginning of the pandemic and with a greater share of beds filled had significantly more cases and deaths
per licensed bed than facilities operating at lower capacity. This finding speaks to the importance of
density and intrafacility spread; residents in a nursing home with more residents and more beds filled
likely have greater physical interaction because there is less open space available.
7
We describe this approach in more detail in Appendix A and list all characteristics included in the feature selection
model in Appendix Exhibit B.6. The approach relies on Tibshirani (1996).
8
Appendix Exhibit B.7 shows a map of the cases and deaths per licensed bed in each nursing home plotted over the
cases per 100,000 residents to help visually establish this relationship. However, note that this simply depicts the
bivariate relationship and does not adjust for other factors.
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Effect of other nursing home characteristics. Nursing homes that had a larger percentage of residents
living in the facility as of March 9 who had a recent pressure ulcer also had more cases and deaths per
licensed bed. 9 Though not statistically significant, other characteristics of nursing homes were also
important in explaining variation in the spread of COVID-19 across nursing homes. Characteristics such
as whether the nursing home was for profit, was part of a chain, the share of male residents, and the share
with a recent fall or any depressive symptoms were important in predicting the number of cases and
deaths, though were not statistically significantly related to the number of cases and deaths. However,
nursing homes that were part of a chain were significantly more likely to have any cases (compared to no
cases; Appendix Exhibit B.8). 10
In addition to the multivariate analyses discussed above, we conducted bivariate analyses, which revealed
that many more characteristics appeared to be significantly related to cases and deaths when considered
independently. For example, for-profit nursing homes and nursing homes with more non-White residents
had more cases and deaths per licensed bed (Appendix Exhibits B.9 and B.10). However, these findings
should be interpreted with caution because they can ultimately be explained by other related factors, as
evidenced by either a lack of significance or not being included in the multivariate regression model. 11
The bivariate analyses are generally consistent with findings from Li et al. (2020) that also analyzes
characteristics associated with nursing home outcomes in Connecticut using a different modeling
approach.
Exhibit 6. Summary of findings from analyses of relationship between nursing home

characteristics and COVID-19 outcome
Multivariate analyses Bivariate analyses
Cases per Deaths per Cases per Deaths per
licensed bed licensed bed licensed bed licensed bed
Characteristic Important Stat. sig. Important Stat. sig. Stat. sig. Stat. sig.
Nursing homes’ characteristics
Town cases per 100,000 residentsa Y + Y + + +
Town median household income Y + Y + +
Number of licensed beds N N + +
Profit status Y Y + +
Chain affiliation Y Y + +
Memory care unit N N
High overall rating N N – –
High health inspection rating Y Y –
9
The item only captures whether the resident has an unhealed pressure ulcer, but does not indicate if it was acquired
at the facility or in the community.
10
A recent paper by Dean et al. (2020) found nursing homes in New York that were in a union had fewer deaths per
licensed bed than those that were not in a facility. However, in Connecticut, union status was unrelated to nursing
home COVID-19 cases and deaths after controlling for other characteristics. We added an indicator variable for part
of a union to our multivariate regression model, but this characteristic was not statistically significant and did not
add to the predictive power of the model.
11
The multivariate regression model did not include characteristics not flagged as important in Exhibit 6. However,
for any characteristics that were significantly predictive of cases or deaths in a bivariate model that were also not
considered important from the feature selection model, we confirmed that if they were added to the multivariate
model they were not significantly related to cases or deaths.
Mathematica 21
Multivariate analyses Bivariate analyses

Cases per Deaths per Cases per Deaths per
licensed bed licensed bed licensed bed licensed bed
Characteristic Important Stat. sig. Important Stat. sig. Stat. sig. Stat. sig.
High staffing rating Y – Y – – –
High quality measure rating Y N
Had a recent complaint N N – –
Total residents as of 3/9/20 Y + Y + + +
Share of licensed beds filled as of Y + Y + + +
3/9/20
Residents’ characteristics
Male Y Y + +
Age in years N N –
Non-White N N + +
Needs more help with activities of N Y
daily living
Higher cognitive functioning score N N
(more cognitively impaired)
Getting dialysis or cancer treatments Y + Y + + +
Had a recent fall Y Y
Had a recent pressure ulcer Y + Y + + +
Had any depressive symptoms Y Y – – –
Lost control of bladder Y N –
Source: Mathematica’s analysis of nursing home reported data included in Connecticut’s FLIS system, Nursing
Home Compare, LTCFocus, MDS data, and Connecticut DPH data on COVID-19.
Note: Deaths include both confirmed and probable deaths attributable to COVID-19. A characteristic is important
if a feature selection model indicated the characteristic had substantial predictive power in understanding
the variation in cases and deaths across nursing homes. The multivariate regression model then
incorporated these important characteristics. Blank cells indicate the relationship was not important to
understanding variation in COVID-19 cases or deaths, and was thus excluded from the multivariate model
or was not statistically significant. Plus or minus signs indicate the characteristic was associated with more
(or fewer) cases or deaths and was statistically significant at the 10 percent level. For the detailed
regression results, including magnitudes, see Appendix Exhibit B.8.
a Town cases exclude those reported for all nursing homes and assisted living facilities located in that town.
2. Spread of COVID-19 within Connecticut nursing homes
COVID-19 cases often were clustered within individual nursing homes, with characteristics of residents
correlating somewhat with the likelihood of becoming infected and dying. In this section, we first present
a case study showing how, in one large nursing home, specific wings experienced substantially different
rates of residents getting sick. This suggests the likely importance of both staff and physical proximity in
the role of spread of COVID-19. Next, we report on both wing- and individual-level predictive models to
further explain how the disease was transmitted within each nursing home. The individual-level predictive
model uses the full sample of more than 17,000 residents who lived in nursing homes as of March 9,
2020. The wing-level predictive model aggregates characteristics and COVID-19 outcomes for residents
Mathematica 22
in 69 nursing homes for which we had a sufficiently clear floor plan to assign people to a wing based on
their room numbers. Important predictors include risk for COVID-19 based on health factors and having
greater potential exposure to others either inside or outside the nursing home, consistent with findings
about the spread across facilities.
b. Spread within a facility: case study results
In one nursing home, the share of residents in the facility Recommendation SR15
at the beginning of the pandemic that became infected
varied by wing, ranging from as few as 10 percent to as Facilities should consider the
high as 82 percent (Exhibit 7). This analysis considers only rooming assignments of high-risk
people in the nursing home as of March 9, 2020 and residents on units in such a way
assigns them to a wing based on their room number as of that reduces exposure of others on
that date. This ensures these results do not reflect people the unit.
with COVID-19 being moved to different units as a result
of facility cohorting. We identified 56 residents with
confirmed positive tests among those in the facility as of March 9, 2020, which represents about 90
percent of the total cases this nursing home reported to the state. The three wings with the highest share of
residents with COVID-19 (second floor, wing 2 and third floor, wings 1 and 2) accounted for 57 percent
of the total COVID-19 confirmed cases but only 32 percent of the total residents.
The results underscore the possibility to limit the extent of an outbreak within a facility. Though some
wings had nearly all residents become infected, other wings had only one or two infections. In a nursing
home that had more than 0.4 cases per licensed bed, the fact that few residents in some wings became
infected indicates policies and procedures can be put in place to control the spread of the virus even in the
presence of an outbreak. Yet, several rooms had two people living in the nursing home at the outset, but
only one of them became infected despite both remaining in the nursing home for the entire duration of
the pandemic and sharing the same space and being exposed to each other for extended periods of time.
This suggests an element of random chance must also play a role.
Mathematica 23
Exhibit 7. COVID-19 cases and deaths in an example nursing home, by room location
Source: Mathematica’s analysis of Connecticut DPH FLIS portal on individual residents’ data, as reported by
nursing homes, by July 22; Connecticut’s Vital Records death data; and MDS data.
Mathematica 24
Note: Each circle indicates a room occupied as of March 9, 2020, per MDS data. Cases and deaths depend on
whether the person who lived in that room as March 9, 2020 subsequently tested positive for the disease or
died and had COVID-19 listed as a cause of death by July 31, 2020. DPH provided floor plans for
Connecticut nursing homes to Mathematica. Although this case study reflects actual data, we chose the
facility to be illustrative of patterns of within-facility spread of COVID-19 that were broadly observed in our
sample; the case study is not representative of all facilities.
Many other nursing homes experienced similar clustering of cases, suggesting staff and physical
proximity play an important role in spread (Appendix Exhibit B.11). Many nursing homes consistently
assigned staff to work on a given wing. If one of the staff working in that wing became infected, he or she
would be expected to consistently interact with and potentially expose the assigned residents on that wing,
but not others. In addition, physical proximity to others who became infected could play an important role
given the airborne nature of the virus and the potential role that ventilation may play in patterns of
COVID-19 spread (Lu et al. 2020).
c. Factors associated with cases and deaths at the individual-level and wing-level
Characteristics of residents associated with higher risk for COVID-19 increase the likelihood of becoming
infected within a nursing home. People who weigh more, are older, and those with a heart or circulation
diagnosis were significantly more likely to both become infected with COVID-19 and to die from it
(Exhibit 8). This finding is consistent with other research on the greatest risk factors for COVID-19 (CDC
2020b).
Factors that increase potential exposure to others either
within or outside the nursing home also put residents at Recommendation LR8
risk. For example, dialysis treatment is an important
predictor of cases, both at the individual and the wing Facilities should consider
levels. People who receive dialysis treatment can be more increasing the testing frequency of
exposed either to community dialysis patients or to more some residents at higher risk,
staff, which puts them at greater risk of becoming infected beyond current requirements.
(Bigelow et al. 2020). People who have a history of
wandering are also more likely to become infected, perhaps
because they were exposed to more people inside the nursing home. Conditions that might lead people to
require greater staff attention, such as having a recent fall, having a cognitive impairment, having a
psychiatric or mood disorder, or losing control of one’s bladder, also led to greater likelihood of
becoming infected, presumably through closer and more frequent contact with staff who may have been
infected.
Short-stay residents were less likely to become infected and to die. Other characteristics typically
associated with those who are only temporarily in the nursing home for some sort of rehabilitation, such
as getting physical therapy and having the stay covered by Medicare, are also similarly associated with
lower risk of infection and death. Because these analyses focus on people who were in the nursing home
as of March 9, such residents might have been especially likely to exit the facility before the peak of the
pandemic. Thus, this could simply reflect a reduction in the likelihood such residents were ever exposed.
Consistent with this, in conducting a similar analysis based on those in the facility as of April 15, the
relationship between short-stay characteristics and deaths was not significant, and the reduced likelihood
that short-stay residents had of getting infected drops by about two-thirds.
Mathematica 25
Exhibit 8. Summary of findings from analyses of relationship between resident characteristics and
COVID-19 outcome
Individual level Wing level
Characteristic Cases Deaths Cases Deaths
Greater weight + +
Recent unplanned weight loss + +
Had a recent fall + +
Had a recent pressure ulcer
Has catheter
Takes anti-psychotic medication +
Takes anti-anxiety medication
Lost control of bladder + + +
Has any depressive symptoms
Higher cognitive functioning score (more cognitively +
impaired)
Needs more help with activities of daily living – +
Short-stay (fewer than 100 days in nursing home) – – +
Months in the nursing home (as of 3/9/20) + +
Gets dialysis treatment + +
Gets cancer treatment
History of wandering +
Gets physical therapy – – –
Currently has Medicare stay – –
Age in years + +
Male + +
Race is non-White (versus White)
Cancer diagnosis
Heart or circulation diagnosis + +
Gastrointestinal diagnosis –
Genitourinary diagnosis
Infections + +
Metabolic diagnosis (e.g., diabetes or thyroid +
disorder)
Musculoskeletal diagnosis
Neurological diagnosis +
Nutritional diagnosis (malnutrition or at risk of
malnutrition)
Psychiatric or mood disorder + + +
Pulmonary diagnosis +
Vision diagnosis –
homes, by July 22; Connecticut’s Vital Records death data; and MDS data.
Mathematica 26
Note: Includes only people who lived in a nursing home as of March 9, 2020. Individual-level data indicate if the
person tested positive for the disease or died and had COVID-19 listed as a cause of death by July 31,
2020. The wing-level data aggregate the individual-level data for 69 nursing homes with a usable floor plan.
The wing-level outcomes are the share of residents who tested positive or who died from COVID-19,
whereas the wing-level characteristics are the averages for residents who lived in that wing as of March 9,
2020. Plus or minus signs indicate the characteristic was associated with a higher (or lower) likelihood of
the COVID-19 outcome and was statistically significant at the 10 percent level. Blank cells indicate the
relationship was not statistically significant. All regressions include a nursing home fixed effect. For the
detailed regression results, including magnitudes, see Appendix Exhibits B.12 (individual level) and B.13
(wing level).
FLIS = Facility Licensing and Investigations Section; MDS = Minimum Data Set.
3. Cases and deaths in Connecticut nursing homes compared to neighboring states

Our ability to compare outcomes in Connecticut to other states is somewhat limited by the data each state
makes available. Exhibit 9 compares how states in the Northeast region collect and report their data on
COVID-19 outcomes in LTC facilities. We assessed cases and deaths in nursing homes across all states in
the region, ultimately making rigorous comparisons between those in Connecticut and those in
neighboring states.
Based on aggregate statistics for cases and deaths in LTC settings, Connecticut is most similar to
Massachusetts, New Jersey, and Rhode Island (Appendix Exhibit B.14); each of these states had more
than 70 deaths in LTC facilities per 100,000 residents, whereas all other states in the region had fewer
than 40. We included New York as a comparison even though its reported deaths per 100,000 residents
was substantially lower. New York reports only deaths (not cases) among nursing home residents, and
counts only deaths that physically occurred in a nursing home. In contrast, Connecticut (and other states)
report deaths among residents whether they died in the facility or elsewhere. Based on deaths of nursing
home residents in Connecticut, we estimate that the number of deaths in nursing homes in New York
would be at least 68 to 76 percent higher if New York used a similar approach to counting deaths as the
method used in Connecticut and other states. Through this extrapolation, the number of deaths in nursing
homes in New York per state resident are comparable to the other neighboring states. 12
12
To generate this estimate, we linked data on all nursing home residents to Connecticut’s Vital Records death data
to identify people who died of COVID-19 who were recently in a nursing home. The death data indicate both
whether someone died from COVID-19 and where they died. Using this approach, we identified 2,729 deaths from
nursing homes (which represents 96 percent of the total of 2,849 nursing home deaths reported by the state). Of
these nursing home deaths, only 1,618 physically occurred in the nursing home. Therefore, if Connecticut had
reported deaths only that physically occurred in nursing homes, it would have reported 1,111 to 1,231 fewer deaths
(depending on how we treat the 120 deaths we were not able to match). Relative to the 1,618 deaths in nursing
homes, this represents from 68 to 76 percent. Assuming nursing homes in New York followed similar patterns as
those in Connecticut, the number of deaths in New York would therefore be 68 to 76 percent higher. If nursing
homes sought to limit the death count by discharging residents to hospitals (Sexton and Sapien 2020), then New
York’s undercount would be even larger.
Mathematica 27
Exhibit 9. Data availability for individual nursing home COVID-19 outcomes by state
Connecticut and
comparison states Other Northeastern states
CT MA NJ RI NY DE DC ME MD NH PA VT
Cases by nursing home Yes Yes* Yes Yes* No No Yes No Yes No Yes No
Deaths by nursing home Yes Yes Yes Yes* Yes* No Yes No Yes No Yes No
Staff cases and deaths by Yes Yes Yes No No No Yes No Yes No Yes No
nursing home (after
6/17)
Note: Cases in Massachusetts are reported only in ranges of 0, 1 to 10, 11 to 30, and greater than 30, combining
staff and resident cases. Rhode Island reports cases and deaths only in discrete ranges of 5 cases (for
example, 41 to 45). New York death data include only deaths that occurred in the nursing home. See
Appendix A for more details about data across states.
* Indicates limitations with data on the precise number of cases or deaths. See note for the description of the issues.
We found generally similar patterns in cases and deaths for Connecticut and each neighboring state,
adjusting for nursing home characteristics. To make the most robust comparison to each state, we
included only nursing homes in Connecticut that were in counties close to the neighboring state and
included only nursing homes in the neighboring state that were within 50 miles of Connecticut. We also
adjusted for nursing home characteristics, 13 such as staffing ratings and COVID-19 cases in the nearby
community, that were important predictors of nursing home-level outcomes. 14 To compare to New York,
we counted only deaths in each nursing home in Connecticut where the death physically occurred in the
nursing home. 15
Cases and deaths did not significantly differ between Connecticut and each neighboring state, with two
exceptions that may be related to data limitations. The first exception is New York. Nursing homes in
New York reported fewer deaths than those in Connecticut, though this may reflect New York’s approach
to reporting deaths within nursing homes (and not reporting deaths of nursing home residents that
occurred outside the facility), so these results should be interpreted with caution. This finding is
somewhat unexpected for two reasons: (1) deaths per licensed bed in nursing homes are similar in
Connecticut, Massachusetts, New Jersey, and Rhode Island; and (2) total deaths per capita from COVID-
19 in counties within fifty miles of Connecticut, which is heavily influenced by patterns in the New York
City area, peaked at a level more than twice as high as deaths in Connecticut (Exhibit 1). To compare
Connecticut to New York, we restricted our sample to deaths in Connecticut that occurred within the
nursing home to approximate New York’s approach to counting nursing home deaths. The second
exception is Massachusetts, which reported more cases in nursing homes than Connecticut. Because
Massachusetts reports cases in each nursing home only in a range, we had to impute total cases, which
might not be reliable.
13
The analysis controlled for the number of licensed beds in the nursing home, the share of beds typically filled, the
overall quality rating, the staffing rating, whether the nursing home was for profit, whether it was part of a chain,
whether it had a memory care unit, and the number of COVID-19 cases per capita in the county it was located in
(excluding all cases in nursing homes).
14
The findings are mostly similar if we do not make assorted adjustments, as can be seen in an unadjusted
comparison of outcomes across states presented in Appendix Exhibit B.15.
15
For more details on this approach, see footnote 12.
Mathematica 28
Exhibit 10. Total nursing home COVID-19 cases and deaths per licensed bed in Connecticut and
nearby states, adjusted for nursing home characteristics
Source: Mathematica’s analysis of state-reported data by individual nursing home, Nursing Home Compare data,
LTCFocus data, Johns Hopkins University data, and Connecticut Vital Records death data.
Note: Analyses are based on total cases and deaths in nursing homes through the end of July 2020. We shade
the bars to be more transparent for cases in Massachusetts and deaths in New York because of data
limitations surrounding these estimates that suggest the results should be interpreted with caution.
Massachusetts reported cases in nursing homes in ranges; we used the number of deaths to impute the
number of cases, resulting in total cases that approximately matched the total nursing home cases reported
across the state. See Appendix A for details. Because New York does not report cases, no information on
cases is presented in the bottom right panel for the comparison to New York. Additionally, New York reports
deaths only that occurred in the nursing home. For Connecticut, we therefore included only deaths that
physically occurred in the nursing home (using Vital Records death data). See footnote 12 for more details.
Rhode Island and New Jersey do not report information on nursing homes that had zero cases or deaths;
the licensed nursing homes not included in the state’s data are assumed to have zero cases and zero
deaths. For comparisons with other states, we included only nursing homes that were within 50 miles of the
Mathematica 29
Connecticut border. In addition, we included Connecticut nursing homes only in counties that were
sufficiently close to the comparison state, which explains the difference in outcomes for Connecticut. The
exhibit lists counties included for each comparison.
* = statistically significant difference from Connecticut at the 5 percent level.
4. Individual-level changes in well-being
Residents’ well-being declined as a result of the pandemic, affecting nursing home residents in ways
beyond the direct effects of COVID-19. Though policies put in place to limit the spread of the virus might
have been successful in doing so, they also imposed a cost in terms of declines in residents’ well-being.
The results of this analysis demonstrate the tradeoffs associated with public health measures implemented
to limit the spread of the virus.
• On several measures—such as rates of depression,

incidence of substantial unplanned weight loss, and the Recommendation SR1
presence of severe pressure ulcers—nursing home LTC facilities and their state
resident outcomes worsened. The timing of these regulators must balance strict
changes corresponded to the timing of the evolution of measures designed to limit the
the pandemic. spread of the virus with the need
• Indirect changes in well-being might have stemmed to support the physical, emotional,
from a variety of causes. These include fears and psychosocial needs of LTC
associated with the virus; changes in care practices residents.
such as declines in the provision of therapy; and
policies put in place to limit the spread of the virus,
such as restricting residents to their room and limiting
visitation, which increased isolation of nursing home
residents.
b. Methodology
The analysis compares outcomes observed in every week from March 17, 2020 to July 31, 2020 to those
observed the week of March 10, 2020 among residents present in a nursing home as of March 9, 2020.
Because many of the findings related to well-being could reflect changes in the composition of remaining
residents in nursing homes, our analyses controlled for this to the extent possible. We also controlled for
patterns in the period from 2017 to 2019 that indicate how these outcomes generally evolved over time
for residents remaining in nursing homes. 16 Such patterns could reflect seasonality, as well as selection
bias in who remains in a nursing home. 17 We also reweight residents in each week to ensure the average
16
We also considered simple descriptive trends that showed the average outcomes observed in each week for all
residents or all long-stay residents with a regular follow-up observation. We compared patterns for those in 2019 to
2020, considering all observations from January 1 to July 31. The results were generally similar to the more careful,
regression-adjusted analyses. The results of these descriptive analyses are available upon request.
17
We also estimated all results using only long-stay residents (those who had been in the nursing home for at least
100 days as of March 9, 2020) because they are likely to stay in the nursing home for a long time. Results are
essentially the same, with findings available upon request. Though understanding well-being among short-stay
residents is important, the fact that they are likely to leave the facility more quickly, and might have done so
differentially because of the pandemic, could have influenced the analysis. However, because results are similar, it
provides suggestive evidence that selection bias does not play an outsize influence in the findings.
Mathematica 30
characteristics of observed residents are constant over all time periods, as well as directly control for
characteristics. For further details on the ways our analysis controls for possible selection bias, as well as
limitations of this analysis, see Appendix A. Finally, a substantial reason for differing samples over time
is that more than 10 percent of nursing home residents living in a nursing home as of March 9, 2020 died
from COVID-19. However, those who died likely would have experienced decreases in physical and
mental well-being before their death, but these are not observed in the data. Thus, if anything, these
analyses underestimate the total impact of the pandemic on residents’ well-being.
c. Results
Shortly after the peak of the pandemic in April, the percentage of nursing home residents with any
depressive symptoms increased by about 7 percentage points relative to the percentage before the
epidemic in mid-March (Exhibit 11). Before the outbreak, about 46 percent of residents experienced any
depressive symptoms. The increase of 7 percentage points in mid-April to mid-May therefore represents a
relative increase of more than 15 percent. The percentage of residents with depressive symptoms started
to decline slightly in mid-May, both after the peak of the pandemic and when Connecticut started to allow
visitors again in an outdoor setting. Toward the end of July, depression levels were no longer significantly
higher than before the pandemic.
Exhibit 11. Changes in any depressive symptoms among Connecticut nursing home residents,
March through July
Source: Mathematica’s analysis of nursing home assessment data from Minimum Data Set assessments of
Connecticut nursing home residents.
Note: We defined any depressive symptoms as having the presence of any of the symptoms listed in the
residents’ mood interview or staff assessment of a resident’s mood (Personal Health Questionnaire-9). This
is based on items D0300 and D0600 from the Minimum Data Set Version 3.0 resident assessment form.
Each point represents the difference in average outcomes for that week relative to outcomes observed in
the week of March 10, 2020. The sample includes people who lived in the nursing home as of March 9,
Mathematica 31
2020, and includes all subsequent observations. It also controls for patterns from 2017 to 2019 using the
same approach, and reweights the sample to ensure observable characteristics are similar for all time
periods. Bars represent the 95 percent confidence interval accounting for standard errors clustered at the
nursing home level. For more details, see Appendix A.
Nursing home residents also experienced faster physical deterioration, as the results indicate large
increases in unplanned substantial weight loss (Exhibit 12). The share of residents who lost more than 5
percent of their weight in the past month (or more than 10 percent in the past six months) started to
slowly increase in mid-April—the height of the pandemic. Each week in June and July, the share
experiencing substantial weight loss doubled relative to the beginning of March (an increase of about 6
percentage points). 18 This likely reflects both the direct effects of COVID-19 among those who contracted
it and indirect effects on those who did not become infected. For residents who contracted COVID-19,
about 12 percent of residents observed each week experienced unplanned substantial weight loss from the
last week of May to the end of July (Appendix Exhibit B.16). Though the percentage of residents with
unplanned weight loss was lower for those who did not become infected—about 9 percent each week over
the same period—it still meaningfully increased relative to the 6 percent baseline in early March.
Exhibit 12. Changes in unplanned substantial weight loss among Connecticut nursing home
residents, March through July
Note: We defined unplanned substantial weight loss as someone having lost 5 percent or more in the last month
or 10 percent or more in the past six months. This is based on item K0300 from the Minimum Data Set
Version 3.0 resident assessment form. Each point represents the difference in average outcomes for that
week relative to outcomes observed in the week of March 10, 2020. The sample includes people who lived
in the nursing home as of March 9, 2020, and includes all subsequent observations. It also controls for
18
Note that the timing of observations means the weight loss likely occurred earlier than the date the person is
observed.
Mathematica 32
patterns from 2017 to 2019 using the same approach, and reweights the sample to ensure observable
characteristics are similar for all time periods. Bars represent the 95 percent confidence interval accounting
for standard errors clustered at the nursing home level. For more details, see Appendix A.
Other measures of residents’ well-being also indicated people were affected beyond the direct effects of
COVID-19. For example, in early May, residents were 2 to 3 percentage points more likely to have a
severe pressure ulcer (Appendix Exhibit B.17). This represents an increase of more than 50 percent
relative to the 4.7 percent with a severe pressure ulcer in early March. Cognitive function scores and
scores of activities of daily living also indicated temporary but meaningful deterioration of functioning
(Thomas et al. 2017; Appendix Exhibits B.18 and B.19) Residents also experienced a significant increase
in episodes of incontinence (Appendix Exhibit B.20).
Taken together, these findings suggest that the pandemic
Recommendation SR2
substantially reduced well-being of nursing home
residents. The nature of the pandemic required immediate Facilities should ensure residents’
and substantial policy actions to limit the number of care plans reflect COVID-19-
fatalities, such as restricting visitors and limiting resident specific impacts on individual
movement outside of one’s room. Though these policies residents.
may have successfully prevented more deaths among
nursing home residents, they came at a cost. Both nursing
home staff and family members play an important role in resident care, through providing homemade
food, helping residents eat, conducting other activities of daily living, and giving them opportunities for
social interaction. During interviews with residents and family members, we heard that nursing home
staffing was often not sufficient to provide the same level of care and attention that family members or
other unpaid caregivers normally provide to nursing home residents, and as a result, residents fared worse.
Future policy changes to limit the spread of COVID-19 or other infectious disease outbreaks should
consider these additional costs beyond the direct effects of morbidity and mortality due to COVID-19.
C. Connecticut assisted living facilities

Although many assisted living facilities had COVID-19 outbreaks, they were typically less severe than in
nursing homes (Exhibit 13). In total, assisted living facilities in Connecticut had 1,073 cases and 379
deaths by the end of July 2020. About 37 percent of assisted living facilities had no COVID-19 cases or
deaths. Only three percent of assisted living facilities had more than 50 percent of residents who
contracted COVID-19, and only 3 percent had more than 20 percent of residents who died. In nursing
homes, about 26 percent of nursing homes had at least 50 percent of residents who contracted COVID-19,
and 15 percent had at least 20 percent of residents who died. 19
19
Similar to Exhibit 4, the histogram in Exhibit 13 does not show the share of assisted living facilities with zero
cases or deaths. The first bar in Exhibit 13 corresponds to zero or a low amount cases or deaths. Because histograms
show a continuous distribution, not the distribution at a single value, the exhibit does not indicate the percentage of
assisted living facilities with zero cases or deaths.
Mathematica 33
Exhibit 13. Total COVID-19 cases and deaths per bed in Connecticut assisted living facilities
Source: Mathematica’s analysis of assisted-living facility reported data included in Connecticut’s FLIS system.
Note: Deaths include both confirmed and probable deaths attributable to COVID-19. Analyses are based on
cases and deaths in assisted living facilities by July 22, 2020.
FLIS = Facility Licensing and Investigation Section.
Similar to the findings for nursing homes, the prevalence of COVID-19 in the surrounding community
was an important predictor of assisted living facility cases and deaths, and larger facilities had more cases
and deaths per licensed bed (Appendix Exhibits B.21 and B.22).
Because of limited data availability for assisted living
facilities, we cannot conduct the same level of Recommendation LR2
comprehensive analyses of assisted living facilities as we
can for nursing homes. In particular, due to the challenges in The state should make
reliably comparing outcomes in assisted living facilities participation in the MAP mandatory
across states, we were unable to compare outcomes in for assisted living communities to
Connecticut assisted living facilities with neighboring states. ensure access to data in future
See Appendix A for more details. outbreaks.
Mathematica 34
Section IV. Assessment of the State’s Preparedness and Response to COVID-19 in LTC Facilities
IV. Assessment of the State’s Preparedness and Response to

COVID-19 in LTC Facilities
In responding to COVID-19 in LTC facilities, Connecticut faced an unprecedented challenge. Gaps in
scientific knowledge about how the virus spreads, the range and severity of symptoms (especially in older
adults), and underlying factors that might place an individual at greater risk undermined its early
responses to the outbreak. State officials made policy decisions and issued guidance based on the
available knowledge at the time from federal and state epidemiologists and public health experts.
Although scientific knowledge and understanding of the virus has evolved over time, much remains
unknown.
This section describes the state government’s preparedness for and response to COVID-19 in LTC
facilities. It largely focuses on the role of DPH but acknowledges additional resources from other state
agencies and units brought in to support the response, including the Connecticut National Guard.
It is important to note the state’s role in responding to the COVID-19 pandemic was significantly greater
than for previous disease outbreaks such as H1N1 or Ebola because the federal government delegated
many decisions about how to respond to COVID-19 to states. In addition, the federal government did not
provide resources from the Strategic National Stockpile, as state officials had expected under the Federal
Emergency Management Agency’s (FEMA) National Preparedness System, nor did it provide clear,
timely, and unbiased scientific guidance on the evolving understanding of the disease and or expected
response. Assessing the federal response is beyond the scope of our work here and is well documented
elsewhere, we have included information on how the federal response affected the state’s actions in our
report (Government Accountability Office 2020; New York Times 2020; Sanger et al. 2020; Drew 2020;
Ed 2020). Appendix C provides a timeline of federal response actions.
A. Surveillance and outbreak response

Though Connecticut had several systems in place to collect information from LTC facilities on cases,
deaths, and resource needs, the state modified and enhanced these systems throughout the spring and
summer of 2020 to better manage the outbreak. The state also retooled its routine surveys of LTC
facilities to focus on infection control in accordance with guidance from CMS. Despite these changes,
data users at both the state and LTC facilities have identified the need for additional system
modifications. State and facility staff have also identified resources and requirements to strengthen the
utility of surveys. This section details the state’s preparedness and response regarding surveillance and
outbreak response and identifies related SRs and LRs.
1. Preparedness
a. Data availability and reporting by LTC facilities

Before the COVID-19 outbreak, state officials report that DPH, including FLIS staff, relied on data
collection systems in which facilities reported information to the department via paper or fax. The design
of such systems supported existing reportable outbreaks from facilities, including seasonal influenza,
salmonella, and other diseases. The state also collected electronic data on bed capacity, staffing,
transportation, and supply need and availability via the MAP website (Mutual Aid Plan 2020). The state
had activated the MAP for previous natural disasters, and state staff involved in those activities report that
Mathematica 35
LTC facilities were “used to daily reporting” to this platform whenever the reporting requirement was
activated in response to an emergency. However, the information MAP collected was designed to support
potential evacuation of a facility, not long-term shelter in place or incidents affecting a large number of
facilities at one time.
The state’s existing reporting systems could not fully support its needs in response to COVID-19. Before
modifying the FLIS system in mid-April, the reportable disease data DPH received did not specifically
identify cases among residents in nursing homes and assisted living facilities separate from those reported
by hospitals or among people who lived in the community.
b. Licensing and inspection of LTC facilities, and investigation of complaints

A federal and state partnership regulates nursing homes certified by Medicare or Medicaid: CMS sets the
conditions of participation for certification and oversees state compliance with inspection requirements.
The state’s DPH FLIS conducts regular inspections (known as surveys) of licensed nursing homes to
ensure compliance with federal and state requirements and reports the results to CMS. The state LTC
ombudsman’s office ensures residents and families are aware of their rights and assists in resolving
concerns.
2. Response
a. Suspension of civil liability

The Governor’s Executive Order 7U (Lamont 2020b) on April 5 granted nursing homes immunity from
civil liability for any injury or death sustained in support of the state’s COVID-19 response. The order
covered “acts or omissions undertaken because of a lack of resources that renders the facility unable to
provide the level or manner of care that otherwise
would be required in the absence of the COVID-19
“Liability holds people accountable
pandemic.” In the interviews conducted for this
and ensures best practices are
assessment, consumer advocates and family members,
followed.… At the same time you’ve
taken resident’s eyes and ears away” as well as several elected officials, expressed
[by restricting visitation]. concerns with this removal of an important
—Senator Kevin Kelly mechanism for holding facilities accountable for their
actions.
b. Modifications to data systems and reporting requirements

Because the existing data systems did not sufficiently capture cases in nursing homes and assisted living
facilities, the state had to develop new systems and refine existing systems to monitor COVID-19 by
facility type. At the beginning of the pandemic, there were no national data standards in place regarding
how to report cases among LTC residents, so DPH developed its own methodology. It overhauled its
reporting systems in real time, including the MAP website it used to share needs and availability of
resources across LTC facilities. This evolution resulted in differences in reporting requirements over the
course of the pandemic.
At the time of this study (July to September 2020), Connecticut collected and used COVID-19 related
data from LTC facilities through three systems:
Mathematica 36
1. The Connecticut DPH FLIS portal. Data reported to this portal include the number of positive and
pending tests, deaths, transfers of nursing home residents to the hospital, and nursing home bed
availability; assisted living facilities are not required to report to the system or the National
Healthcare Safety Network (NHSN), discussed below (Lamont 2020a). Health care-acquired
infection (HAI) staff and FLIS nurse consultants review this information daily. Daily electronic
reporting from facilities to the state began on May 8, 2020.
2. LTC MAP portal. This website collects daily counts of bed availability, new COVID-19 cases, and
PPE resource availability and needs categorized according to their urgency. The site updates each
minute and FLIS uses it to make decisions about which facilities to inspect, among other things.
Before COVID-19, all nursing homes and about 25 percent of assisted living facilities reported to
MAP. The MAP system activated on April 3 for daily reporting on COVID-19 from nursing homes;
Executive Order Number 7EE extended the daily reporting requirement to assisted living facilities on
April 23, 2020.
3. NHSN. This national website, maintained by the CDC, collects information on nursing home resident
impact and facility capacity, staff and personnel impact, supplies and PPE, and ventilator capacity and
supplies. On May 8, CMS issued guidance requiring weekly reporting to NHSN by nursing homes
beginning on May 17. DPH staff report using this site primarily to determine whether nursing homes
comply with the Department’s requirements regarding resident and staff testing, which allow a
facility to pause testing if it meets certain criteria outlined by the state.
Data for all three of these reporting streams remain largely
self-reported by facilities, and stakeholders reported that
Recommendation LR1
FLIS staff (or students at the Yale School of Public Health
under contract with DPH) verify the data primarily through The state should explore ways to
direct calls to facilities. Some lawmakers have raised reduce duplicate case reporting to
concerns about data accuracy because facilities might be minimize burden on facilities and
motivated to keep case counts low. However, our study the state and reduce the risk of
found a high degree of validity in the data; 96 percent of data errors.
the deaths self-reported to DPH through the FLIS portal
could be matched in the state’s vital records. Our study also
found Connecticut reported its data in a similar format to most neighboring states, except New York
(Exhibit 9 provides more information).
Despite significant improvements in the state’s ability to collect data, there are still challenges related to
duplication of data reporting and specificity. DPH has acknowledged that some of the information
reported across systems is duplicative, particularly that regarding PPE availability and testing. At the
same time, DPH needs to obtain more detail from the data than it currently can—for example, by tracking
new cases by facility and location, and disaggregating cases among residents and staff. State leadership
and the media also increasingly demand new and more frequent data, even though the staff available to
implement system changes and provide information has not increased. Improving data systems and
honing reporting will require further work.
c. Infection control focused surveys

In accordance with federal requirements issued March 20, 2020, Connecticut stopped normal survey
operations at the start of the outbreak and focused its resources on COVID-19-related tasks, such as
conducting inspections of infection control practices and investigating complaints about issues that
Mathematica 37
endangered the life of a resident (CMS 2020b). During this time, DPH surveyed most facilities every two
weeks but prioritized surveys based on the teams’ assessment of (1) the ombudsman reports of resident
and family concerns; (2) data on new outbreaks (that is, facilities with at least one new case within three
days); and (3) concerns raised through meetings with the labor union representing LTC employees (1199
Service Employees International Union [SEIU] 1199). The state conducted virtual surveys from March 20
to April 6, 2020; during this time residents and families could report complaints over the phone to the
ombudsman related to abuse and neglect, rather than in person. In-person surveys resumed April 7, 2020,
but were modified to limit the number of staff entering a building. One person we interviewed reported
the first wave of surveyors entering buildings did not have proper PPE and were not tested for COVID-19
before entering.
Beginning in May, DPH assigned staff to survey facilities by region to enhance relationships and ensure
continuity. Under the model, inspection nurses oversaw 10 nursing homes and consistently visited those
homes; each supervisor oversaw 20 nursing homes.
From March 1 to August 13, FLIS conducted 1,658 focused infection control surveys and issued 205
citations for deficient practice related to infection control.20 Mathematica’s interim report included a
reference to CMS data indicating the state had not issued any infection control citations; afterward, DPH
identified a problem in the process of uploading data to CMS reporting systems. DPH has resolved this
issue and DPH staff have received training on reporting requirements according to leadership at FLIS.
d. Use of National Guard members to augment facility inspection

On April 27, the state began using National Guard members to help conduct focused surveys alongside
per diem nurse consultants hired to augment existing FLIS survey staff (Carlesso 2020). Two National
Guard members and one FLIS nurse consultant staffed the visits to facilities. DPH protocols specified that
survey observations, interviews, and reviews should focus on hand hygiene, PPE, PPE supplies on the
units and secured areas, transmission-based precautions, resident care, infection surveillance, visitor
entry, education, monitoring, screening of staff, and staff schedules (CMS 2020c). Inspection teams
observed the environment and checked on the cleaning and disinfecting of supplies. DPH reported
National Guard members enforced staff screening requirements upon entering the building, distributed
PPE, and monitored cleaning and disinfection practices and supplies. Industry stakeholders reported
National Guard staff also helped count facilities’ inventory of PPE; facilities used the Guard’s hand
counts of PPE to verify facility reporting of PPE availability to the MAP website.
e. Impact of changes to the survey process

Catalyst for changes in infection control. Overall, most stakeholders reported focused infection control
surveys were an important tool for ensuring compliance with infection control requirements and in
communicating needed changes directly to facilities, particularly as state guidance on appropriate use of
PPE and infection control evolved over the course of the pandemic. Advocates, however, felt conducting
surveys while facilities were immune from civil liability meant the results could not be used as evidence
in potential lawsuits thus “removing a level of accountability” that resulted in a lower standard of care
(Lamont 2020b). A representative of one facility we spoke with identified a need for additional support
implementing changes identified through surveys, requesting either a dedicated monitoring partner or
hotline that facilities could call for technical assistance.
20
Documentation provided by DPH to Mathematica.
Mathematica 38
Recommendations related to surveillance and outbreak response

• SR6. DPH should continue infection control focused surveys, targeting more
frequent surveys in nursing homes with ongoing or increasing infections.
• SR7. DPH should ensure all temporary survey staff, including National Guard
personnel, complete basic and ongoing training to conduct surveys consistently and
thoroughly, including training on infection control and prevention.
• SR8. All FLIS staff or other personnel conducting in-person surveys in nursing
homes should be regularly tested for COVID-19 to ensure surveyors do not become
a possible source of infection for residents or staff.
Uneven application of guidance. Stakeholders reported mixed experiences with surveyors over time.
Frequent changes in the process for deploying survey teams felt “confusing” and “inconsistent” to FLIS
staff, and the nurse consultants who participated in the surveys felt especially “out of the loop” in
receiving timely guidance to use for the inspections. Although DPH felt using the National Guard to
augment survey teams enabled direct care staff to focus on the care-related issues and made the entire
team more efficient, industry representatives suggested the mix of surveyors (which included National
Guard members) interpreted the survey guidelines differently, resulting in uneven inspections. Issues
related to consistent enforcement of nursing home
“Calling in FLIS forced corporations to regulations across survey teams has long been a
respond to concerns about faulty challenge, but the COVID-19 outbreak might have
infection control practices … and exacerbated these inconsistencies across surveyors
improved the situation in their when facilities needed real-time information in the
facilities.” face of evolving guidance from the state (Kramer et
—Industry stakeholder al. 2020).
Emphasis on PPE. Some staff also reported National Guard members inspecting facilities were primarily
concerned with counting PPE, a focus that might have stemmed from the Guard’s role in coordinating the
distribution of PPE through the point of distribution (POD) system set up by the state (Section IV.B.2.c
provides more information). In addition, many facility staff interviewed reported administrators would
prepare for scheduled visits by filling PPE stocks or making PPE more widely available to direct care
staff, only to restrict PPE immediately following the visit.
B. Infection control, including PPE

Infection control practices and personal protective equipment are frontline tools in preventing the spread
of COVID-19. When COVID-19 arrived in Connecticut, however, the state found itself short of staff with
infection control expertise and PPE to supplement supplies at facilities. Despite intense efforts from DPH
staff and the National Guard, over 19 percent of Connecticut nursing homes did not have a one-week
Mathematica 39
supply of at least type of PPE reported to NHSN the week of September 6, 2020. 21 The state needs a long-
term strategy regarding state staff and supplies.
1. Preparedness
a. Staff dedicated to infection prevention

Facility-based infection preventionists. Federal requirements (42 CFR §483.80b) and the State Public
Health Code (§19-13-D8t) require nursing facilities to dedicate staff to infection control by employing a
dedicated infection preventionist and convening an infection control committee at least quarterly. The
infection preventionist must have specialized training, work at least part time, and be employed directly
by the facility. However, due in part to high turnover among staff filling this role, 10 of the 70 nursing
facilities in the state whose staff are represented by 1199 SEIU did not have an infection preventionist on
staff when the COVID-19 outbreak began, according to an 1199 SEIU representative. In addition, there is
some concern that having the infection preventionists report to the facility, not the state, influences
“whether they will stand up to bad practices.”
Assisted living service agencies (which provide services to
individuals living in assisted living facilities) must be Recommendation LR10
licensed by DPH but are not subject to the same infection
control requirements that govern nursing homes and, Connecticut should broaden
therefore, are not required to dedicate staff to infection qualifications for an infection
control. According to a 2019 review of assisted living preventionist and expand the role
regulations across the United States, Connecticut was one to full-time in all nursing homes.
of only nine states that does not have regulations related to
infection control policy or staff training requirements for
staff in assisted living services agencies (Bucy et al. 2020).
State infection control staff. Various waves of federal grant funding, including the Infection Control
Assessment and Response (ICAR) program prompted by the 2015 Ebola outbreak, supported state agency
staff extenders and training activities on infection control. Specifically, ICAR supported hiring five
infection control nurse consultants and an administrative assistant who, together with contractors,
conducted numerous in-person and webinar trainings during 2017 and 2018. 22 However, when ICAR
funding ended in 2019, the state team dedicated to infection control shrunk.
b. Availability and use of PPE

Like the reported experience in other states, Connecticut LTC facilities had insufficient PPE at the start of
the outbreak. Facilities were expected to procure and stockpile their own PPE, and the state expected to
receive emergency PPE from the Strategic National Stockpile, so the state did not have its own cache
21
Similar to our multivariate regression model presented in Section III, we also used these data to try to predict
recent nursing home outcomes across the entire country as well as in areas with substantial spread of COVID-19
throughout the summer. Because there were so many fewer cases and deaths in nursing homes during the summer
than in Connecticut during the early stages of the pandemic, the predictive power of this model was substantially
weaker than the multivariate regression model for Connecticut only. Yet one key finding was the importance of
PPE, with nursing homes that had a PPE shortage in June having more cases per licensed bed in July. Therefore,
ensuring PPE is widely available is likely important to mitigating the effects of a potential second wave.
22
Ebola-Associated Supplement Healthcare Infection Control Assessment and Response. Documentation provided
to Mathematica by DPH on September 8, 2020.
Mathematica 40
(Hay 2020; Connecticut DPH 2020a). According to state officials, they had received training to rely on
and use the Strategic National Stockpile.
During two waves of visits and trainings supported by
ICAR and conducted from 2014 to 2016, the state
“Every [emergency preparedness] identified LTC facilities as having high staff turnover
plan focused on the Strategic National and low resources that suggested a strong need and
Stockpile to provide resources that demand for infection prevention training, particularly
would be needed by a state in an donning and doffing of PPE (Connecticut DPH 2020a).
incident.” In 2019, DPH sponsored PPE training programs for
—Unified Command Leadership
high-consequence pathogens, but trainings occurred in
the state’s two designated Ebola treatment hospitals,
not LTC facilities (Connecticut DPH 2020a).
2. Response
a. Infection control guidelines for staff and residents

Connecticut developed its infection control guidelines for LTC facilities in March and April 2020; the
guidelines covered visitation, PPE, screening and testing, and movement in and out of the facility. On
March 9, 2020, DPH restricted visitors entering nursing and convalescent homes to only those visiting
someone residing at one of these facilities in hospice or end-of-life care, and the visitors had to wear
proper PPE. DPH issued nursing home-specific guidance, recommending assessing symptoms and
temperatures for all staff at the beginning of each shift, limiting staff movement within the facility,
reinforcing social distancing guidelines, and assessing residents for symptoms at least once daily (Office
of Governor Ned Lamont 2020b). It also included guidance on appropriate transfers of residents with
confirmed or suspected COVID-19 to and from hospitals. On April 4, 2020, DPH issued guidance
requiring all health care personnel in all settings to be universally masked while working. Fewer than two
weeks later, on April 16, 2020, Connecticut’s first COVID-19 recovery facility opened for hospital
discharges.
From the beginning of the COVID-19 outbreak,
“The evolving nature of CDC guidance state officials worked around the clock to provide
resulted in DHHS continuously shifting accurate and timely guidance to facilities on
their messaging; confusion came from infection control requirements, but given the rapidly
unclear shifting federal guidance.” changing understanding of the virus, many
—DPH official stakeholders felt the guidance was inadequate. First,
some stakeholders said state guidance on infection
control tended to follow federal guidelines, which was less restrictive in its recommendations than
guidance in neighboring states experiencing a peak outbreak. For example, Connecticut issued a universal
masking order for personnel in all health care facilities on April 4, 2020, one day after the U.S.
Coronavirus Task Force called for universal masking for the general public. In contrast, New York
implemented a masking order for personnel in all health care facilities on March 13, 2020 (New York
State Department of Health 2020b). Second, CDC guidance also differed from that issued by the World
Health Organization (WHO), leading to confusion about differences in the guidance. For example,
infection control staff reported the WHO recommended using an N95 mask in LTC settings, but the CDC
guidance did not. “Staff in nursing homes would say they won’t work without an N95,” which was
consistent with WHO guidance, but not CDC guidance. Third, the state provided guidance entirely in
Mathematica 41
English, and at least one facility noted it would have been helpful to also have guidance in Spanish to
better reach its many Spanish-speaking staff.
b. Direct assistance to facilities on how to implement infection control guidance

DPH’s Infectious Disease section and local public health nurses provided direct assistance to LTC
facilities on how to implement guidance on infection control. Such support was critical to nursing
facilities that needed more help than their infection preventionist could provide, and to assisted living
facilities that did not have infection control personnel on staff. Call logs obtained for this study showed
DPH staff fielded an average of nearly 12 calls per day from health care and LTC facility staff, media,
and the general public with questions related to COVID-19 (for example, how to interpret infection
control guidance, where to obtain PPE, requests for test kits, and so on), with up to 46 on a single day in
late March (Exhibit 14).
Exhibit 14. Calls to DPH infection control staff related to COVID-19, March through June 2020
Source: Mathematica’s analysis of call logs provided by DPH.

Note: This analysis includes all telephone calls fielded by the HAI and infection control staff at DPH. Callers
included representatives of LTC facilities, other health care providers, media, and general public callers
with questions related to COVID-19.
DPH = Department of Public Health; LTC = long-term care; HAI = health care acquired infection.
Facilities found this assistance helpful, but DPH staff reported being challenged by the need to directly
help facilities while balancing their surveillance duties. Local public health nurses were stretched thin
because neighboring towns that did not employ their own nurses would look to their neighbors for
support. Local public health nurses also reported DPH often released information to the public before
sharing it with local public health authorities; as one public health nurse reported, “when we don’t learn
about changes being made [before facilities ask questions about them], we lose our credibility.” FLIS
nurse consultants also provided infection control guidance to facilities; however, they felt they could not
fully address the needs of facilities for technical assistance. One person we spoke with reported several
open nurse consultant and supervisor positions. DPH hired per diem FLIS nurse consultants to perform
Mathematica 42
enhanced monitoring, but officials we spoke with reported

these staff did not get as much training as the permanent Recommendation SR19
nurse consultant staff.
The state should designate
c. Procuring and distributing PPE qualified staff or contractors that
can provide technical assistance to
Ad hoc distribution. When the COVID-19 outbreak first
LTC facilities regarding infection
began, state staff did their best to obtain and distribute PPE
control guidelines.
from whatever sources were available. When the federal
government failed to play a role in centralized
procurement and distribution of PPE to the states, leaving
the responsibilities to procure PPE to states and facilities, competition among many small purchasers
created price spikes and uneven allocation. Nevertheless, early in its response, DPH coordinated donation
and distribution of PPE supplies to medical settings, including to LTC facilities. DPH staff and local
public health nurses also made emergency deliveries to LTC facilities whose management was not
delivering PPE as quickly as needed. United Way’s 211 service coordinated donations from the public
and distributed them to facilities. The state also received supplies from FEMA; however, supplies did not
show up as timely as expected and Connecticut prioritized distribution to hospitals (though there were
two shipments to nursing homes23). State officials also reported FEMA did not communicate the amount
of PPE it provided to health care providers, so Connecticut had a hard time understanding how to
prioritize additional PPE to hospitals, LTC facilities, and other recipients. As one facility lamented, “It
was the wild west.”
Coordinated, regional distribution. From mid-April to mid-August, the state distributed PPE to health
care settings, including LTC facilities, through five regional PODs (Connecticut DPH 2020b). The
National Guard staffed these PODs. The state procured materials through existing contracts, with the
National Guard supporting logistics. The state considered a regional approach to purchasing PPE that
would have pooled purchasing power across Connecticut, Delaware, Massachusetts, New Jersey, New
York, Pennsylvania, and Rhode Island, but it never came to fruition (Office of Governor Ned Lamont
2020c).
Facilities did not place orders or request specific supplies but they received equipment based on their size
and the extent of the outbreak in each facility; this resulted in some confusion among facilities: they
reported receiving what was available, not what they needed or requested via the MAP website. In
deciding how to allocate PPE across various recipients (including health care settings and the
community), Connecticut officials placed the highest priority on nursing homes, which received 40
percent of all supplies; home health and hospice, assisted living, and residential care homes received 15,
10, and 10 percent of the allocation, respectively. The state determined the allocation to each facility
based on reported need via the MAP site, and adjusted the need based on burn rates, bed counts, and other
factors.
Facility representatives reported that although the state-provided PPE comprised a small share of their
total PPE, the state played a useful role as supplier of last resort. In total, according to DPH data, by mid-
July, Connecticut had distributed nearly 600,000 N95 filtering face-piece respirators, more than 3.7
23
On April 30, 2020, FEMA announced (Release No. HQ-20-126) it was coordinating two shipments totaling a 14-
day supply of PPE to nearly 15,000 nursing homes across the United States (a number of PPE to be included in the
two shipments was not listed in FEMA announcement). See https://www.fema.gov/news-
release/20200727/personal-protective-equipment-medicare-and-medicaid-nursing-homes.
Mathematica 43
million surgical masks, nearly 170,000 face shields, more than 200,000 surgical gowns, and over 3.2
million gloves to LTC facilities (Exhibit 15).
Exhibit 15. DPH count of PPE distribution by setting, as of July 16, 2020
Source: DPH documentation provided to Mathematica.

ACH = acute care hospitals, ALSA-RCH = assisted living service agencies and residential care homes, EMS =
emergency medical services, FQHCS = federally qualified health centers, LDH = local departments of health, LTC =
long-term care.
Mathematica 44
However, despite the state’s best efforts to support PPE

procurement and distribution, many LTC facility staff
reported PPE availability in March through May was not
Recommendation LR11
adequate, though availability had improved by the time of The state should maintain a
our interviews in August and September. Uncertainty stockpile of PPE that is available
remains as to whether facilities have stockpiled enough to LTC facilities in case of future
PPE to address a potential second wave. State officials are increases in COVID-19 or other
concerned counts of PPE remain inaccurate, and one infectious disease outbreaks that
facility administrator confirmed this possibility: they are are accompanied by breakdowns
fearful that if they accumulate too much PPE, the state will in the supply chain and lack of
take it away. As a result, they feel they have to hide their availability from the Strategic
PPE supply and are more inclined to inaccurately report National Stockpile.
existing supplies. Questions remain regarding who should
pay for future distribution and stockpiles. Though DPH
expected to only provide PPE “where truly needed,”
stakeholders on all sides recognize the critical importance
of adequate PPE to protect staff and residents.
d. Visitor restrictions and visitation policies

Policies restricting visitation. When the COVID-19 outbreak appeared in Connecticut in mid-March, the
Governor issued a series of executive orders prohibiting visitors, including nonessential workers, from
entering nursing facilities (Office of Governor Ned Lamont 2020d; Lamont 2020c). These restrictions
barred most family members and other caregivers from entering nursing homes except when residents
were near the end of life. During this time, communications between residents and families were limited
to phone, video conference, and window visits (where possible). DPH guidance issued on May 9
emphasized that facilities should adopt “reasonable and practicable alternative means of communication
between residents and family members,” which included at least weekly window visits, virtual visitation,
social media communications, and phone calls that should occur on at least a weekly basis (Connecticut
DPH 2020c). However, some of the stakeholders we interviewed reported facilities varied in how they
chose to comply with this guidance, resulting in vastly different experiences across the state. Despite
differences in methods and frequency of visitations, nearly all family members reported the physical and
emotional health of residents declined significantly without frequent, in-person interactions with the
family members and caregivers who had provided critical support for activities of daily living. This
concern is consistent with our analysis that found significant declines in physical and emotional well-
being (Section III.B.4 provides more information).
Virtual support from the ombudsman. During this time, the state LTC ombudsman supported families
and residents by hosting daily Facebook Live video conferences to provide information to families; DPH
staff attended on occasion. These events enabled “residents and family members to sign on, hear updates
on the outbreak, and ask questions directly or message the Ombudsman office privately.” Many family
members reported these events were helpful; some even felt they were more effective than in-person
visits, letters, and phone calls the ombudsman’s office used to communicate with families before COVID-
19.
Compassionate care visits and the need for expanded visitation. The deterioration of the health and
well-being of residents when visitor restrictions were in place points to the critical role family members
play in caring for residents. Before the pandemic, many family members made frequent visits to their
Mathematica 45
loved ones to ensure they received an adequate level of care. When the pandemic hit, residents were
locked in the facilities away from their families and many did not receive the same level of care. For this
reason, on August 27 DPH (1) clarified the obligation for LTC facilities to facilitate visitations; and (2)
expanded visitations for purposes of “compassionate care” beyond end-of-life to include visits for
residents who undergo significant change in physical, mental, or psychosocial condition (Connecticut
DPH 2020d). Compassionate visits can take place indoors with appropriate PPE, as long as the facility is
not experiencing an active outbreak.
While allowing compassionate care visits is a step
“"Why are we separating mental health forward, it does not address the daily support needs
from medical health? ... [Existing residents have that facility staff do not fully meet, nor
policies are] not speaking to the long- does it offer a longer-term plan that would allow
term effects of this isolation on more in-person, indoor visitation to resume when
everybody, but especially for the most appropriate. Other states have taken steps to address
fragile people who have no one but both issues. In June and July, respectively, Indiana
their family to sit by their side daily. To and Minnesota allowed residents in LTC facilities to
cut that off at a moment’s notice at designate essential caregivers for each resident
this stage of their life is harmful, and (Indiana State Department of Health 2020; Minnesota
it’s avoidable. " Department of Health 2020b). Caregivers who
—Family member of an NF resident comply with PPE and infection control requirements
may enter the facility for two to three hours a day.
Michigan is working on a similar but expanded concept for visitation volunteers, which it would
implement in areas with low community spread (Michigan Nursing Homes COVID-19 Task Force 2020).
Michigan’s recommendation states nursing homes that follow all visitation guidance be assured they will
not be cited by the state for an adverse event as a result of visitation (University of Michigan 2020).
CMS guidance on June 23, 2020, identified steps nursing homes should take before reopening to visitors,
and stakeholders in several states have adapted this guidance to create frameworks for facilities to use to
decide how to move toward reopening (CMS 2020d).
Decision-making frameworks from LeadingAge
Minnesota and American Medical Facilities Management Recommendation SR5
in West Virginia provide examples (LeadingAge
Minnesota 2020; American Medical Facilities The state should work with
Management 2020). In these examples, changes to facilities to designate essential
visitation depend on facility factors—including active caregivers who would have
cases, access to PPE, current staffing, and access to increased access to LTC facilities
testing—as well as community prevalence. As shown in to fill a defined role for specific
these two states, DPH can work with its LTC facility residents.
associations and other stakeholder groups to create a
practical framework that provides a pathway to reopening
facilities for visitation.
e. Cohorting
DPH guidance on May 11 and June 22 recommended cohorting residents into three separate units or
areas: Positive, Negative, Exposed (Connecticut DPH 2020e, f). However, one elected official reported
providing the first guidance on cohorting two months into the pandemic was too late. And like guidance
on PPE use, guidance on cohorting changed over time. Specifically, the state changed its plans to
Mathematica 46
physically separate every symptomatic and asymptomatic nursing home resident after the CDC
announced individuals can be asymptomatic and still transmit the virus. Until DPH issued very strict
cohorting guidance for residents who tested positive (versus negative and unknown), it was not clear
which cohort the nursing home should put the asymptomatic patient in. Perhaps as a result of the
changing guidance, stakeholders we spoke with provided conflicting reports on whether facilities
performed cohorting as directed, which might be due to referring to different time periods (Section
V.B.2.c provides more information). In addition to containing viral spread, accurate and appropriate
cohorting is needed to prevent moving residents unnecessarily, because transferring people increases the
risk of failure to thrive, mobility issues, maladaptive behaviors, limited time out of bed, and lack of
interaction among residents.
f. Physical changes to facilities, including ventilation

To our knowledge, the DPH did not provide guidance to facilities on changes to the physical
environment, other than through cohorting. Therefore, facilities were on their own to identify needed
changes to ventilation or other systems. One facility reported it found research developed by the
Minnesota Department of Health that identified how to develop temporary negative pressure isolation
rooms in response to deadly airborne diseases (Minnesota Department of Health 2019). According to this
facility, the state did not support the negative pressure isolation rooms because “they were skeptical of
their efficacy.”
C. Emergency response structure and communications

Connecticut activated its response to the COVID-19 emergency in January 2020, well before the first
outbreak in the state; however, the state’s previous experience and existing emergency response plans did
not fully prepare the state to respond to an event of this scope and duration. Over time, Connecticut
adjusted its operations by improving communications with LTC facilities and opening COVID-19
recovery facilities, among other things. Stakeholders we spoke with urged the state to continue these
successful practices throughout the remainder of its response.
1. Preparedness
Connecticut’s DPH had a robust emergency response Recommendation LR4

continuity of operations plan that outlined roles and
responsibilities, the structure of the joint incident The state should revise its
command, and communication expectations, but the plan emergency response plans to
did not sufficiently address LTC facilities. First, the Public explicitly include LTC facilities
Health and Medical Services component of the state’s and HCBS providers as health
disaster and emergency operations plan focused care assets.
exclusively on hospitals and did not mention LTC
Recommendation LR5
facilities in the list of health care assets of the state
(Connecticut DPH 2019). The FEMA Pandemic Flu Planning for and responding to
planning guidance document also did not mention LTC future infectious disease
facilities (FEMA n.d.). Perhaps as a result of the existing outbreaks should include
plans, during the initial outbreak of COVID-19, hospitals representatives of the LTC and
were the priority for emergency planning and response. HCBS industries.
Mathematica 47
Second, the state’s plan focused on responding to disasters that needed evacuations, but did not
sufficiently consider how to respond to long-term sheltering in place in residential care settings. State
officials confirmed previous emergency preparedness exercises and data collection through the mutual aid
plan were designed to support evacuation. Nursing facilities have planned and participated in these
exercises since 2017, though assisted living facilities are not required to do so (only 25 percent
voluntarily participated in the mutual aid plan before 2020; initiation and membership fees might have
deterred the others from participating) (81 FR 63860).
Third, the state designed its plan to respond to an
“Facilities couldn't help each other event that might affect only a handful of facilities, but
because they were all worried that COVID-19 affected every facility at the same time.
they were going to be next.” This limited the state’s ability to respond and help
—Connecticut state official facilities share resources. Officials familiar with the
MAP reported that in previous emergencies, facilities
willingly shared resources. However, when the COVID-19 outbreak began, facilities stockpiled PPE and
were reluctant to share. This hamstrung the ability for the MAP to share resources because all groups
were perceived as challenged at the same time.
Fourth, the plan assumed a sufficient supply of PPE and that only noninfected staff would work in health
care facilities. The plan also assumed the Strategic National Stockpile would provide resources, including
PPE, that a state would need in a widespread incident. However, as discussed in Section IV.B.1.b, receipt
of PPE from the Strategic National Stockpile was not timely or adequate, and Connecticut was left to
procure and distribute PPE without support from federal resources.
State emergency preparedness staff were also spread thin before the COVID-19 outbreak. As of January
2020, six of nine positions in the Office of Public Health Preparedness and Response were vacant. The
state filled these positions by July 2020, but the vacant positions in January indicate insufficient capacity
to monitor and manage an emergency of this magnitude at the start of the pandemic.
2. Response
a. Emergency response and decision making

Well before the governor declared a public health emergency, Connecticut activated its emergency plan
and filled many of its critical roles creatively—for example, by using the National Guard to help establish
COVID-19 recovery facilities and inspecting nursing homes, and by working with United Way’s 211
center to provide information to and from the public.
“When DPH finally paid attention to Though the earliest planning conversations did not
nursing homes, it didn’t feel as include legislators, by April they received invitations,
collaborative as it could’ve been.” though several lawmakers expressed a desire to be
—Facility representative more fully included in future planning and response
efforts. Connecticut also collaborated with other
“Better communication happened in states, which one official reported has been helpful in
the second half of the ballgame.” both “brainstorming strategies and knowing that
—Facility representative Connecticut isn’t facing these challenges alone.”
Many stakeholders, however, report the state’s decision making early in the pandemic was “slow and
insular,” particularly regarding the response in nursing facilities. Connecticut officials reported they
expected the federal government to provide decision-making support and supplies to assist its response to
Mathematica 48
COVID-19; however, the federal government did not meet the state’s needs and expectations, resulting in
a delayed and siloed response.
Another reason for the delay and disconnect is that the state’s early decision making did not involve LTC
industry representatives. State officials acknowledged LTC facilities became a focus later in the
pandemic, but coordination with these facilities improved over time (for example, mid-way through the
state’s response to the COVID-19 outbreak, it began coordinating weekly calls with LTC facilities). One
facility reported communications largely improved due to the encouragement and involvement of Leading
Age and Connecticut Association of Health Care Facilities [the two trade associations], which pushed the
state to communicate more openly and frequently with providers. DPH acknowledged its shortcomings in
communications, and DPH officials report they are currently thinking about additional congregate care
settings they need to include in planning conversations going forward, such as residential care homes and
the settings that care for people with intellectual and developmental disabilities.
b. COVID-19 recovery facilities (CRFs)

Connecticut DPH partnered with the nursing home industry to open CRFs across the state. These facilities
sought to be part of the state’s medical surge plan to expand the state’s capacity and alleviate burden on
hospitals. On April 11, the Governor’s Executive Order 7Y authorized the designation and operation of
two CRFs, one in Sharon and one in Bridgeport (Lamont 2020d). Consent orders were issued to an
additional five facilities from April 15 to May 8 in Torrington, Meriden, East Hartford, Wallingford, and
New Canaan. 24 Among these seven facilities, 634 CRF beds were available across the state. Initially
CRFs could accept only individuals being discharged from the hospital; this was later changed to allow
CRFs to accept admissions directly from other nursing homes or the community.
Nearly all stakeholders from the state, elected
“Everyone was panicked about dealing officials, and industry officials expressed support for
with a surge on the hospitals, but the creating CRFs as an alternative to nursing homes
surge came from within the long-term caring for COVID-19 residents in place. In addition,
care industry” several nursing home operators we spoke with, as
—Athena Health Care System well as representatives from assisted living
Representatives communities, valued CRFs because their own
facility was not equipped to provide adequate care
for COVID-19 residents and preferred to transfer
them to the hospital or another location like a CRF.
Planning for CRFs. Planning for CRFs began on March 13, within days of the first confirmed COVID-
19 case in the state. The state’s Unified Command emergency response structure provided the emergency
support functions necessary for the state to lease buildings and procure supplies to get CRFs up and
running as quickly as possible. The first CRF admissions took place on April 15.
On March 22, DPH finalized a nursing home surge plan that identified three models for CRFs: Model 1
referred to nursing homes already in operation that operate as CRFs after discharging their current
residents to other locations; Model 2 referred to vacant nursing homes or other empty buildings that could
be operational relatively quickly after receiving authority to operate from the state; Model 3 referred to
distinct units in existing nursing homes with enough empty beds and separate entrances. State officials
24
Consent orders provided by DPH to Mathematica.
Mathematica 49
identified up to 11 possible sites for CRFs. They identified those locations across the state and opened
them in areas with the greatest need depending on prevalence in the community.
State officials expressed concerns with Model 1 from the beginning given the potential trauma of having
to discharge and move residents who lived in those facilities. Athena Health Care Systems, which
operated the CRF in Bridgeport and had existing residents in needed of transfer, agreed this process was
difficult on both residents and staff. For this reason, Mathematica recommends the state continue to use
Models 2 and 3 in the future if the state has to expand CRF capacity to deal with future waves of COVID-
19 or other infectious disease outbreaks. Michigan, which set up distinct units within nursing facilities
similar to Connecticut’s Model 3, found no significant evidence of COVID-19 transmission between
residents in the COVID-dedicated units and those in non-COVID units, suggesting that dedicating
separate wings as CRFs in existing nursing homes can operate safely with adequate PPE, testing, and
dedicated staff who do not work across these units (University of Michigan 2020).
CRF reimbursement and use. The state agreed to reimburse CRFs at $600 per bed per day for the care
of COVID-19 positive residents and to review monthly cost and expense reports for consideration of
expenses that exceeded the per diem of $600. Athena shared with Mathematica in August that it was still
in the process of having the state audit its cost reports but felt its actual costs were much higher than $600
per resident per day because it only ever filled about 45 percent of its beds. Had use been higher, Athena
felt the $600 per resident per day reimbursement would have been appropriate to cover costs.
Five of the seven CRFs ever accepted residents according to documentation provided by the state; 386
admissions across these five facilities took place from April 15 to July 15. 25 Exhibit 16 presents a graph
of the number of daily admissions to CRFs. Daily admissions quickly declined, consistent with the
decline in total COVID-19 cases in the state, which peaked in mid-April.
Exhibit 16. Daily CRF admissions, April 15 through June 30, 2020
Source: Mathematica’s analysis of MDS data for five CRFs that had non-zero admissions.
Notes: State data based on documentation provided by DPH to Mathematica. The state data rely on daily reporting
by CRFs to DPH, which differs slightly from the MDS assessments we observe in our data set, though the
patterns are consistent in both sources.
25
Documentation provided by DPH to Mathematica.
Mathematica 50
CRF = COVID-19 recovery facility; DPH = Department of Public Health; MDS = Minimum Data Set.
State officials felt CRFs provided a higher standard of COVID-19-related care than other nursing homes
could offer. The CRF consent orders required higher staffing levels than other nursing homes, with a
nurse aide-to-patient ratio of 1:10 during the first and second shifts and 1:15 during the third shift and a
licensed nurse ratio of 1:15 during first and second shifts, and 1:30 during the third shift.
During an interview with Athena Health Care Systems, which operated four of the facilities that received
the majority of all CRF admissions, representatives shared that they saw a higher proportion of COVID-
positive residents recover successfully compared to Athena’s non-CRF facilities in the state. In CRFs, the
recovery ratio was 10:1 (10 recoveries of COVID-positive residents for every 1 death); in Athena’s non-
CRFs the recovery ratio was 2.5:1. This finding is consistent with the experience in Michigan; the
COVID-19 death rate in Michigan dedicated COVID facilities was 17 percent compared to 26 percent in
other nursing homes (University of Michigan 2020).
Future planning for CRFs. As of mid-August, only two Recommendation SR10
CRFs were operational with a total of 270 beds between
them. These facilities also accepted non-COVID residents The state should continue its
at the time of our interview with Athena. Planning to planning efforts to scale up CRF
quickly scale up CRF capacity could be critical to capacity and deploy it quickly in
mitigating a potential second wave of COVID-19 in response to the scope and severity
Connecticut. According to Athena, it takes about 30 days of a second wave.
of planning before a CRF can begin admitting patients to
procure the appropriate equipment, hire and train staff, and
receive all necessary building inspections and operating permits. If additional CRFs open in the future,
the state should continue to allow these facilities to admit patients from any setting, including hospitals,
other nursing homes, and assisted living and general community settings. The state is continuing to lease
the facilities with the CRF consent orders to enable these facilities to quickly become operational again
should the added capacity be needed to deal with future waves of COVID-19 or other similar outbreaks.
D. State agency roles, expertise, and skills

Recognizing the COVID-19 outbreak is greater in scale and severity than any disease outbreak in recent
memory, it is not surprising that Connecticut, like most other states, found itself without sufficient staff to
respond to the pandemic. It is difficult to assess the adequacy of state agency roles, expertise, and skills
without objective criteria for the ideal composition of backgrounds, training, and skill set for a given
position to use as a point of reference. Based on our assessment, Connecticut generally had staff with the
appropriate skills and training to address the pandemic in LTC facilities, but many stakeholders suggested
there were not enough staff to ensure an efficient and quick response. Where the state was missing skill
sets, it reached out to contractors to fill the gap, such as those from Yale School of Medicine Department
of Infectious Diseases. However, stakeholder interviews suggested the right people were not always at the
table during relevant conversations. For example, weekly DPH leadership calls did not include infection
control staff at the beginning of the outbreak.
Mathematica 51
Connecticut DPH was the lead agency under the Unified

Command structure for the COVID-19 response in LTC
Recommendation LR17
facilities. Although many offices within DPH engaged in
the response, the primary offices according to state agency The state should conduct a
stakeholders were FLIS, the Infectious Disease Section comprehensive assessment of
and the Healthcare Associated Infections and Antibiotic DPH staffing needs, including
Resistance program within that section, and the Public number of staff, skills required for
Health Preparedness and Local Health Section. All of topics including infection control
these sections had some vacant positions before the and emergency response, and
outbreak according to organizational charts provided by interaction with groups within and
DPH to Mathematica. FLIS had 6 vacancies in its survey outside of DPH.
and certification unit (of 62 total positions) and 9
vacancies (of 37 total positions) in its licensure and
enforcement unit as of February 3, 2020. The Infectious Disease Section had 6 vacancies (of 66 total
positions) on January 13, 2020. The Public Health Preparedness and Local Health Section had 6 of 17
total positions vacant on January 13, 2020. (At the time, new hires were pending for 3 of these positions.)
DPH also experienced a change in leadership in May when the former commissioner, Renée Coleman-
Mitchell, left her post. The Commissioner of the DSS, Dr. Deidre Gifford, was appointed as the acting
DPH commissioner on May 12. Stakeholders we spoke with believed following this change in leadership
the DPH issued more timely guidance than it had previously. It is impossible to disentangle how much of
this improvement might be due to the change in leadership, reduction in the number of cases and deaths
being reported by May, or the experience gained by the Department over the previous two months.
E. Screening and testing of residents and staff

Connecticut’s approach to developing guidance for screening and testing of LTC facility residents and
staff reflected changing federal guidance as the scientific understanding of the virus evolved. Insufficient
testing supplies also drove the response, particularly during the early stages of the outbreak.
1. Screening and testing of residents and staff

In March, COVID-19 testing was generally limited to hospital patients, so LTC residents suspected of
having COVID-19 had to be transferred to hospitals for testing and care. At that time, DPH guidance to
health care facilities reflected federal guidance to focus screening and testing on individuals with
respiratory symptoms, those with international travel within the past 14 days to restricted countries, or
contact with someone with or suspected of having COVID-19 (CMS 2020e). The first nursing home-
specific guidance from the DPH, released on March 26, 2020, recommended assessing symptoms and
temperatures for all staff at the beginning of the shift, assessing residents for symptoms at least once
daily, and guidance on testing for symptomatic residents only (Connecticut DPH 2020a).
2. Testing capacity
Like other states at the beginning of the pandemic, Connecticut had insufficient testing capacity, and
prioritized available test kits for use in hospitals. The state public health laboratory was the first lab in the
state to receive approval from the CDC to begin testing samples itself rather than sending samples to
CDC testing sites in Atlanta. After receiving this approval on February 28, the state lab started with four
individuals who could conduct testing. Within a week it more than doubled the staff to nine people, but
Mathematica 52
social distancing requirements and material shortages limited the lab’s capacity. State laboratory staff
reached out to encourage partner labs to ramp up to prepare for increased testing and to leverage other
labs’ purchasing power (especially the national lab chains) to mitigate shortages of testing supplies. A
March 9 press release indicated the state lab at that time could conduct 15 to 20 tests per day, that a
second lab had become operational, and a third was preparing to come online. At that time, the state
required a physician’s order for testing by these facilities (Office of Governor Ned Lamont 2020b).
3. Point prevalence survey and increased testing requirements

Connecticut conducted a state-funded point prevalence survey (PPS) over the course of three weeks in
early May, with a goal of testing all nursing home residents for COVID-19 (Connecticut DPH 2020e).
The DPH Infectious Disease Section and FLIS worked to coordinate the survey and the National Guard
delivered and collected test kits from facilities. DPH strongly encouraged but did not require facilities to
participate in the survey. Most did, which enabled individual facilities to assess their residents’ COVID-
19 status and implement appropriate cohorting accordingly. DPH processed results in 24 to 48 hours and
instructed facilities to cohort residents based on test results. The PPS provided the state with an
understanding of details such as the percentage of residents who were positive but asymptomatic and the
percentage who were negative and had a positive roommate, statewide and within individual facilities.
The PPS excluded residents who had previously tested positive for COVID-19 and facility staff. During
interviews, stakeholders shared that although they thought it would be best to test staff as well during this
survey, testing capacity was limited and the state felt it should prioritize testing of residents.
On May 6, DPH issued an order removing the requirement for a licensed practitioner order for COVID-19
testing (Connecticut DPH 2020g). On June 1, the Governor issued Executive Order UU, which required
weekly testing of LTC staff for the duration of the pandemic (Lamont 2020e). A June 5 DPH memo
recommended weekly retesting of previously negative residents and staff until no new cases are identified
for 14 days (Connecticut DPH 2020h). The administration expanded this weekly testing requirement to
include assisted living facilities on June 17, 2020 (Lamont 2020f).
4. Care Partners program

Shortly after the Governor’s June 1 order mandating
weekly testing of facility staff and DPH’s June 5 memo Recommendation SR13
recommending weekly testing of residents, the state
notified facilities that it would cover the costs of testing for DPH should continue to assess the
anyone not covered under Medicare Part B or Medicare Care Partners testing program to
Advantage. The state also paired facilities with area testing ensure it meets its intended goals.
contractors, referred to as Care Partners. The state funded
these testing Care Partners to order, conduct, and report
testing results to the state. Care Partners were also responsible for providing physicians orders for tests,
collecting the insurance information for non-Medicaid qualified residents, and billing the relevant insurers
directly (Connecticut DPH 2020i). The state initially committed to funding the testing contractors
program through August 31, and, on August 6, extended the policy through at least October 31 (Office of
Governor Ned Lamont 2020e). The number of Care Partners has expanded since its implementation and
the state continues to revisit the assignments as new testing contractors join the program.
Mathematica 53
5. Current screening and testing policies and capacity

DPH’s current testing policy reflects CMS guidance,
updated August 26, that includes guidance on routine tests
of nursing facility staff (CMS 2020f). The guidance
Recommendation SR12
suggests symptomatic staff have access to rapid testing and DPH should continuously revisit its
weekly testing of asymptomatic nursing home residents guidance on testing LTC facility
and staff who have not previously tested positive until residents and staff as new
there are no new positive test results for 14 days among information becomes available or
residents or staff. After these criteria are met, facilities testing guidance from the CDC
with 100 or more staff are recommended to test 25 percent evolves.
of staff weekly, and facilities with fewer than 100 staff to
test 50 percent of the staff every other week. The policy
notes testing strategy can be adjusted based on trends in community spread. Weekly testing of all
residents and staff resumes if a single new confirmed or suspected case is identified (Connecticut DPH
2020j).
Stakeholders shared mixed opinions about the state’s current and ongoing capacity to conduct needed
COVID-19 testing. One state official expressed confidence in the state’s testing supplies and its capacity
to continue to meet testing demand, noting the state has “figured out the supply chains.” However, facility
staff note sometimes even Care Partners do not process and report the results of all tests in a timely way.
And when asked if there is sufficient testing capacity now, state lab staff also noted “turnaround time can
still be a challenge. There can be shortages of collection kits, and there are concerns about testing
doubling once flu season begins.”
F. Reimbursement mechanisms to support increasing LTC system costs
1. Preparedness
Connecticut Medicaid is the funding source for more than 70 percent of nursing home care provided in
the state. For state fiscal year 2020, the average Medicaid nursing facility rate in the state was $243.46 a
day (Connecticut Department of Social Services 2019). In June 2020, the reported national average
Medicaid reimbursement in the United States was $230 per day, although this did not adjust for state
differences in wages and cost of living (National
Investment Center for Seniors Housing & Care 2020).
Connecticut is part of a multiyear project to revise its Recommendation LR21
nursing facility payment rates from a cost-based to an
The state should ensure that
acuity-based system. The goals of these changes are to
ongoing cost of nursing home
move to a more data-driven and transparent methodology,
resident and staff COVID-19
lay the groundwork for developing value-based payment
testing, as well as PPE, are
approaches, and use payment policy to drive right-sizing
adequately covered by the state’s
of the supply of nursing home beds and rebalancing of the
Medicaid rates.
LTSS system (Connecticut Department of Social Services
2020a).
Nursing homes faced higher costs as a result of COVID-19 combined with decreased revenues due to loss
of higher-paying short-stay skilled nursing patients, whose admissions are usually covered by Medicare,
as well as further decreased census in the long-stay population due to some residents choosing to move to
Mathematica 54
or remain in the community. This trend is consistent with patterns observed across the country (National
Investment Center for Seniors Housing & Care 2020).
2. Response
a. State financial support for LTC facilities in response to the COVID-19 pandemic
Connecticut provided a variety of financial supports to nursing homes in response to the COVID
pandemic. The state provided a 10 percent Medicaid rate increase effective March 1 through April 30. It
also used part of its $1.4 billion in federal CARES Act Coronavirus Relief Funds to make payments to
each skilled nursing facility, except CRFs. This funding approximated the value of an additional 10
percent increase in April and 20 percent for May and June. Facilities could use both the Medicaid rate
increases and the Coronavirus Relief Funds for employee wages, new costs related to visitor screening,
PPE, and cleaning and housekeeping supplies, and other COVID-related costs (Connecticut Office of
Policy and Management 2020b). In addition, facilities could submit hardship payment requests for
consideration of expenses that exceeded those covered by these additional funds for the period of March
through June (Connecticut Department of Social Services 2020b). Hardship payments also came out of
the state’s Coronavirus Relief Funds and it granted them in some cases to “avoid substantial deterioration
of the nursing facility’s financial condition that might adversely affect resident care and the continued
operation of the facility” (Connecticut Office of Policy and Management 2020c).The state paid a cost-
adjusted rate of $600 per bed per day to CRFs (Connecticut Department of Social Services 2020c).
Section IV.C.2.b provides more information on these facilities.
Connecticut set aside about $123 million of the federal CARES Act Coronavirus Relief Funds to support
nursing homes, which represents about 9 percent of the state’s overall allocation from the federal
government. Funding includes $14 million for designated CRFs, $52 million in grants to support
nondesignated CRFs, and $57 million for hardship grants for facilities. However, the state reports a
significant portion of the funding allocated for hardship grants will remain unexpended due to the low
number of requests received that represented allowable uses for grant funding (Connecticut Office of
Policy and Management 2020b, d).
b. State methods to determine financial supports

Beginning in March, the CT DSS partnered with the Office of Policy and Management (OPM) to analyze
short-term cost reports to understand nursing home revenue loss and costs associated with response to the
pandemic and determine allocation of the federal Coronavirus Relief Funds (the primary vehicle for
funding Medicaid providers) to assist these facilities. State staff noted it was challenging to understand
the full picture of funding coming to each facility through the various streams of funding (CARES Act,
Paycheck Protection Program, and State Medicaid funding), and they are currently conducting an analysis
to understand nursing home costs and funds received since the COVID-19 outbreak.
G. Communications with LTC industry stakeholders and other key stakeholders
1. Preparedness
State and facility stakeholders described the LTC MAP website as an important source of information and
guidance from the state for use in emergency preparedness situations. The MAP establishes a
commitment and agreed-upon procedures for facilities to assist one another during a disaster. In addition
Mathematica 55
to the MAP, the state provided updated guidance to LTC industry and other key stakeholders through two
other main communication channels: (1) the DPH’s Blast Fax page and (2) its COVID-19 Healthcare
Guidance page (Connecticut DPH 2020k, l). Both of these sites served as repositories of the state
guidance for health care facilities and providers.
The Connecticut LTC Ombudsman Program provides a mechanism for communication between the state
and residents and family members. The ombudsman’s role is to work on behalf of residents and family
members to investigate residents’ complaints and assist them in resolving problems. Before the outbreak,
the LTC Ombudsman Program investigated cases in person (Connecticut Long-Term Care Ombudsman
Program, n.d.a).
2. Response
Several stakeholders reported the state’s response to the outbreak in LTC facilities was not quick enough,
particularly early on. For example, although the first confirmed positive case in the state was identified on
March 8, the Department of Public Health’s first nursing-home specific COVID-19 guidance was not
issued until March 26 (Connecticut DPH 2020a). Like other states that had COVID cases early on,
Connecticut’s response prioritized managing the outbreak in hospitals first, and focused on long-term care
facilities later on. One stakeholder noted that, given the outbreaks observed in nursing facilities in
Washington State, Connecticut should have anticipated and prepared for the possibility the virus would
hit nursing homes hard.
a. Pace of communications
Multiple interview respondents reported the state was slow to provide guidance to facilities, which often
left facilities unsure how to implement practices suggested by other sources such as the CDC or national
associations, for example regarding cohorting or testing practices. Respondents from one facility reported
written guidance sometimes came out weeks after calls with DPH. In the meantime, facilities, in some
cases, were unsure how to implement policies discussed in these calls. The state has improved the speed
and accessibility of communications since the beginning of the pandemic, but some stakeholders
indicated a need for further improvements. For example, the state released guidance on expanded
visitation policies for nursing homes on August 27, 2020. A state official said during an interview on
September 10, 2020 that the state was still working on writing a frequently asked questions document for
that guidance. At the time of this report in September 2020, state respondents report they have hired
additional contract staff to help make guidance available more quickly going forward.
b. Modes of communication
FLIS and staff from HAI teams held a weekly call with
Recommendation SR20
LTC facilities to provide guidance and answer questions DPH should supplement its weekly
on infection control and other topics. This is a main calls with LTC facilities by
channel for facilities to obtain more information about how providing written summaries
DPH would like them to implement guidance. Facility following each call and archiving
staff shared it can be difficult to attend these calls due to guidance in a central place.
scheduling conflicts. They requested that the state post
summaries after each call, along with a transcript to make
it easier for those who cannot attend live to review the
Mathematica 56
information quickly. As of the end of August, DPH has begun posting written summaries of these calls on
the MAP website.
c. Including key stakeholders

Several respondents requested that DPH be more transparent about the issues and policies under
consideration by consulting with key stakeholders and requesting their input into policy decisions.
Several stakeholders suggested developing state plans for a potential second wave in consultation with
legislative representatives, representatives from the LTC industry, HCBS providers, residents, and family
members.
Mathematica 57
Section V. Assessment of the LTC Industry’s Preparedness and Response to COVID-19
V. Assessment of the LTC Industry’s Preparedness and Response to

COVID-19
Nursing homes are subject to numerous federal and state laws and regulations in a broad range of areas,
including comprehensive resident assessments; minimal licensed nursing staff requirements; and the
protection and promotion of residents’ rights such as freedom from restraints, accommodation of needs,
grievances, and refusal of certain transfers. Federal and state rules also govern the use of certain drugs,
advance directives, access and visitation, sanitary and infection control, and physical environment
standards (Muscumeci and Chidambaram 2020).
Consequently, LTC industry stakeholders interviewed in Connecticut believed they had to wait for
guidance and direction from DPH on actions that were allowable for nursing home providers at the
beginning of the COVID-19 outbreak. Many of these stakeholders indicated DPH delayed providing
guidance on what proactive measures nursing homes could or should implement to prevent the spread of
the coronavirus, and avoid the COVID-19 outbreak at Life Care Center of Kirkland, a nursing facility in
Washington State in February 2020.
This section contains an overview of the LTC industry’s preparedness and response to the COVID-19
outbreak in Connecticut. The information in this section relies primarily on interviews with industry
stakeholders, residents and family members, and direct care staff working in nursing homes around the
state. It also includes secondary reporting on the number of COVID-19 cases and deaths among LTC
staff.
A. Surveillance and outbreak response

Before the COVID-19 outbreak, DPH required nursing homes to report infectious disease outbreaks to the
state when there were three or more cases of a lab-confirmed infection for most health care-associated
infections, such as influenza, viral gastroenteritis, or chickenpox. DPH rules required reporting Category
1 diseases—defined as those that require an immediate public health response—to the state via telephone
the same day (Connecticut DPH 2015). On February 5, 2020, the commissioner of DPH added COVID-
19 as a Category 1 disease, which required immediate reporting by health care facilities to DPH and the
local department of health in their town (Connecticut DPH 2020m). Nursing homes were generally well
practiced in responding to infectious disease outbreaks based on their experiences with seasonal flu or
bacterial infections.
Some industry stakeholders who spoke with Mathematica shared that when they began to see the impact
of COVID-19 at Life Care Center of Kirkland, they met with their leadership teams to prepare their
response. Many of these facilities based their earliest plans on their experiences with flu and other
outbreaks, without realizing that COVID-19 would be very different from other infectious disease
outbreaks.
Some of the earliest surveillance mechanisms that facilities put in place included displaying posters to
raise awareness about the symptoms of COVID-19 to watch for and reinforce good hand hygiene. That
quickly evolved into a surveillance approach that included regular temperature checks for staff and
screening questionnaires asking about symptom or travel history. Direct care staff interviewed reported
that, in February and March, they received very little training or communication from their facility
management on how they should prepare to respond if COVID-19 arrived in Connecticut.
Mathematica 58
B. Infection control within and outside of facilities, including PPE
1. Preparedness
Before the outbreak, LTC facilities had established PPE supply chains and relationships with medical
suppliers and generally did not have problems acquiring sufficient PPE. One industry stakeholder
remarked that due to tight financial margins, many “nursing homes operated on a three- to five-day
supply of PPE.” Another nursing home operator said nursing homes do not traditionally use N95 masks,
“so it was harder for them to obtain those than hospitals” as the need for N95 masks rose during the
outbreak. Industry stakeholders also reported the state’s initial focus on addressing the impact of the
outbreak in hospitals led to a delayed response in developing infection control guidance related to
COVID-19 specific to nursing homes.
2. Response
Efforts to respond to the COVID-19 outbreak focused on infection control and the availability of PPE,
according to most stakeholders. This section describes the experience of the LTC industry as it relates to
infection control and PPE and describes the variation in facilities’ approaches to prevent or limit the
spread of COVID-19 in LTC facilities. Industry stakeholders reported substantial variation in approaches
to limit the spread of COVID-19, but struggled with frequently changing guidance from DPH.
a. Within-facility source control

On April 4, DPH ordered universal masking for personnel in all health care facilities in response to
emerging evidence on presymptomatic shedding of the virus and transmission. Based on interviews with
industry stakeholders, before the state’s universal masking order for direct care staff, nursing home
operators took different approaches to implementing source control measures. Some nursing homes
adopted universal masking policies for their own staff before the state’s requirement, whereas others did
not, citing lack of guidance on what they needed for protection or the inability to secure surgical or N95
masks. In some cases, direct care staff workers and industry stakeholders observed nursing homes did not
require masking for all personnel who were
susceptible to COVID-19. For example, staff in
“The most frustrating part was to housekeeping, laundry, and dietary services did not
stand back and watch because as a receive PPE from the facility or their employer if the
family member, my hands have been facility contracted these services. Others shared that
tied since March.”
requiring masks for residents, especially those with
—Family member
dementia or other cognitive issues, was difficult to
enforce.
In accordance with the March 9 DPH order restricting visitation in nursing homes, facilities limited entry
of nonessential personnel, including family members, vendors, and food or mail delivery. Facilities
transitioned nonessential medical services to virtual appointments or telemedicine. Facilities also took
different approaches to changes to staff and residents’ movements that included confining residents to
rooms, restricting residents from congregating and sitting in hallways, and limiting residents’ social and
recreational activities to those in their immediate cohort or unit to limit exposure. Finally, some facilities
implemented a 14-day quarantine of residents who returned after a hospital stay.
Mathematica 59
b. PPE
Procuring PPE. On March 5, 2020, DPH issued recommendations to nursing homes to “inventory their
PPE supplies, evaluate current usage, and ensure staff are using PPE properly” noting that PPE,
particularly N95 masks were limited or unavailable through the supply chain by that point (Ortelle 2020).
Based on PPE shortage requests from April to July 2020, DPH most frequently received reports of urgent
needs for isolation gowns and N95 masks reports from facilities through the LTC MAP portal.
With no single approach to procurement, the widespread lack of PPE from traditional suppliers
challenged facilities. As nursing homes had always been responsible for procuring their own PPE,
operators of nursing homes shared that it felt like the “wild, wild West” and they were “largely left to
compete against each other” to procure PPE in the face of a nationwide shortage. Smaller nursing homes
felt constrained, with some sharing that they lacked the collective buying power of the larger chains,
which generally centralized PPE procurement efforts for all facilities in their chain by leveraging their
size to increase purchasing power. The typical medical supply chains were largely out of stock of PPE at
the beginning of the outbreak, so LTC facilities had to quickly diversify their supply chains. Some turned
to nontraditional suppliers, such as eBay or Amazon, to procure the necessary equipment.
In the face of a nationwide PPE shortage and compounded by the lack of a centralized approach to
procurement for the LTC industry, industry stakeholders reported the cost of PPE increased drastically
from prepandemic levels. One nursing home shared that a “a six-cent mask cost $1.00 to $1.20; a 60-cent
gown cost $6.00 to $12.00; and gloves went up in price but not as dramatically.” In other cases, nursing
home operators reported adopting cost-saving
measures, finding it too costly to continue to purchase
“At the beginning, we were confused disposable PPE. For example, one nursing home
about the PPE, what to wear and how chain reported investing in reusable gowns, which
to wear it.” represented a more significant investment of $40.00
—Nursing home CNA per gown, but felt this was more reasonable, with
potential for hundreds of uses with appropriate
laundering.
Regional distribution of PPE from the state. On April 11, 2020, the state set up five PODs staffed by
the National Guard (Connecticut DPH 2020b). The National Guard distributed bundles of PPE on a
routine schedule, and facility operators picked up the packs at regional dispensing sites. (Section IV.B.2.c
provides more information on the state’s role in distributing PPE.) Although the state expected its
distribution formula to take into account the supply of PPE that facilities reported through the MAP, and
the status of the outbreak in their facilities, industry stakeholders reported the information National Guard
staff had at the POD was often inaccurate. Industry stakeholders had mixed perspectives on the value of
the PPE received from the state, claiming they received whatever was available at the time and the PPE
they received was not specific to the needs or requests of operators. For example, one operator “received
body wash that week but they really needed gloves and gowns.” Another operator said that “while
distribution has been somewhat sporadic in terms of the items and quantities that were available, it really
helped many providers accomplish [procurement of PPE], get through shortages, as well as create
stockpiles.” This sentiment was consistent across industry stakeholders; although the PPE they received
from the state represented only a fraction of the total need, the state was an important “supplier of last
resort,” especially for facilities that found their PPE supply approaching a critical shortage.
Mathematica 60
Availability of PPE within facilities. At the outset of the COVID-19 outbreak, many direct care staff
reported varying experiences with obtaining adequate PPE needed to provide direct care to COVID-19
patients. In some instances, staff reported receiving masks with differing filtering standards (that is, N95
and KN95 masks) and felt guidance was unclear on appropriateness of use of KN95 masks for direct care.
Many staff also shared that they were never fitted for N95 masks or that fit tests were performed late in
the summer. A few nursing home operators shared that they lacked the appropriate equipment for fit tests
and, in some cases, nursing home operators reached out to and partnered with the local fire department to
fit their staff for N95 masks.
Nursing home direct care staff reported varying guidance from administrators on appropriate use of PPE
and having to reuse PPE for longer periods than before the outbreak. Most direct care staff reported
experiences with multiple uses of respirators and gowns. Some staff said they received a single surgical
mask for up to a week or longer before receiving another mask, and frequently masks became damaged or
visibly contaminated. 26 In other cases, staff reported they received paper bags to keep masks in after their
shift, but that at times these bags became mixed up, and use of others’ PPE became an issue.
Some staff felt the gowns provided by facilities were not
adequate to protect against splashes or sprays of infectious Recommendation SR16
materials. Staff reported receiving cloth gowns or gowns
that did not overlap in the back or provide protection or Facilities should ensure they have
were not fluid-resistant or impermeable materials. Staff an adequate stockpile of PPE that
also felt reuse of gowns exposed residents and staff to is available and accessible to staff
cross-contamination. In one case, a staff member said the on every shift.
same gown for the resident was hung in the room, and
each worker who entered the resident’s room had to wear
the same gown, at one point. During focus groups with direct care staff, several reported some staff chose
to wear plastic trash bags on top of the PPE provided by the facility to add an extra layer of protection if
they felt that they did not have sufficient PPE.
LTC industry representatives and staff at nursing homes reported using different approaches to providing
PPE to staff and residents. Some said their facility immediately posted hand sanitizer stations at the
entrance of residents’ rooms, but others reported hand sanitizers were “locked up” and removed from
walls. Nursing home direct care staff frequently observed that administrators locked PPE and it was not
readily accessible when needed for direct patient care. At some points, direct care staff reported facilities
ran out of PPE, such as masks and gowns, and staff received inadequate PPE. In one case, staff said
second and third shift workers could not reach the administrator after hours to access PPE locked in
storage or, in some cases, staff reported calling the facility administrator to get PPE from the locked
supplies during the weekend. During industry stakeholder interviews, we observed a tension between the
experience of direct care staff and the perspective of nursing home leadership. Most facility managers we
spoke with acknowledged keeping PPE supplies locked in closets or offices, but did so to protect the
supply that was available. Guidance from the CDC on PPE optimization strategies evolved over the
course of the COVID-19 outbreak (CDC 2020c). Nursing home management frequently changed their
approach to distributing PPE to staff based on evolving guidance and the availability of PPE in the
building. Staff perceived this as management hoarding supplies or not being willing to provide what staff
26
CDC guidance on PPE optimization strategies evolved over the course of the pandemic. The guidance includes
acceptable standards of PPE used based on the available supply of PPE (conventional capacity, contingency
capacity, or crisis capacity).
Mathematica 61
felt was necessary to protect themselves. Management also felt staff at times had “unreasonable”
expectations of what PPE they should have based on media coverage showing hospital staff in full PPE
suits.
c. Cohorting
DPH issued guidance related to cohorting of LTC residents on May 11, 2020 based on the results of the
point prevalence survey conducted in the first three weeks of May (Connecticut DPH 20202e). Some
industry representatives reported adopting cohorting practices earlier to separate residents based on
COVID-19 status. Other nursing home operators and staff began to cohort residents as a result of the PPS
effort. Some facility managers and staff reported struggling at times to implement the cohorting guidance
due to lack of timely test results and insufficient training. For example, one staff member said they
received no guidance for cohorting residents based on test results that became available over the weekend.
In interviews with nursing home direct care staff, staff reported a lack of training from management on
the facility’s changing policies in response to COVID-19, including clearly communicating which
residents had tested positive for COVID-19, how to
effectively cohort residents, appropriate use and reuse of
PPE, and changes to other rules and procedures. Recommendation LR12
d. Changes to physical environment As evidence emerges regarding

the role of building design and
Industry stakeholders reported taking different approaches ventilation, LTC facilities should
to changes in the physical environment in response to the consider changing their physical
COVID-19 outbreak. Some of the strategies included the environments to better limit the
increased use of high-efficiency particulate air (HEPA) spread of an airborne virus similar
filters in ventilation and air conditioning systems, to COVID-19.
equipping rooms with negative air pressure machines for
isolating COVID-19 positive patients, and designating
single staff entrances. DPH issued guidance for routine
cleaning and disinfection procedures on May 11, 2020 (Connecticut DPH 2020n). Some nursing home
staff and industry stakeholders observed that housekeeping staff were not provided adequate PPE initially,
potentially exposing them to the virus.
C. LTC facility staffing and workforce availability

There is a well-documented relationship between the level of staffing in nursing homes and the quality of
care outcomes among residents (Schnelle et al. 2004). Industry stakeholders said they had challenges
related to recruiting and retaining staff before COVID-19, and these challenges increased during the
outbreak.
1. Preparedness
a. Make-up of the LTC workforce

In the first quarter of 2020, unemployment in Connecticut was less than 4 percent (Connecticut
Department of Labor 2020). A tight labor market exacerbates existing challenges hiring staff for low-
wage jobs in LTC facilities. In 2018, Black and Hispanic individuals made up 47 percent of the total LTC
workforce and 57 percent of aides and personal care workers, who have the closest and most frequent
Mathematica 62
interaction with residents in these settings (Kaiser Family Foundation 2020). With minorities
overrepresented in the LTC workforce, this group was at increased risk of becoming infected given their
frequent contact with patients, which might explain some of the patterns observed in the distribution of
COVID-19 cases across racial groups (Exhibit 3).
b. Connecticut LTC staffing requirements

Recommendation LR14
DPH regulations set minimum staffing ratios in licensed
nursing homes and staffing expectations for assisted living Connecticut should increase the
services agencies. Nursing homes must have a registered minimum required staffing ratios
nurse in the building 24 hours a day, seven days a week in nursing homes and consider
(§19-13-D8t.M.4). In addition, these regulations require financing mechanisms to raise the
nursing homes to maintain minimum staffing ratios: one Medicaid reimbursement rate to
licensed nurse (a licensed practical nurse [LPN] or support greater increases in direct
registered nurse [RN]) per 30 residents between 7 am and care workers’ pay and benefits.
9 pm and one licensed nurse per 60 residents between 9
pm and 7 am; and one aide per 10 residents between 7 am
and 9 pm, and 20 residents between 9 pm and 7 am.
Nursing homes also must have a dedicated infection
preventionist. This individual does not have to be full-time at the facility.
Assisted living services agencies must have a registered nurse on call 24 hours a day, seven days a week,
who is reachable by telephone and available to make an on-site visit if necessary. They must also have an
RN supervisor on site part or full time depending on the size of the community and the number of staff
working there (§19-13-D105(j)).
Nursing homes must report staffing levels to CMS as part of the payroll-based journal initiative, which
requires nursing homes to report staffing data that is auditable to the facility’s payroll records (CMS
2020g). In the final quarter of 2019, Connecticut nursing homes reported staffing levels largely in line
with the national average and those in neighboring states, but with slightly lower registered nurse hours
per resident than New Jersey and Rhode Island, and slightly higher nurse aide hours per resident than
Massachusetts and New Jersey (Exhibit 17).
Exhibit 17. Pre-COVID staffing levels reported by nursing homes in Connecticut, the United States,
and nearby states
All U.S. CT MA NJ NY RI
Nurse aide staffing hours per resident per day 2.30 2.23 2.13 2.06 2.22 2.41
LPN staffing hours per resident per day 0.87 0.78 0.89 0.87 0.80 0.38
RN staffing hours per resident per day 0.69 0.71 0.70 0.83 0.69 0.83
Source: Mathematica’s analysis of Nursing Home Compare data.
Note: Staffing levels cover the time period October through December 2019.
LPN = licensed practical nurse; RN = registered nurse
Mathematica 63
2. Response
a. State strategies to address workforce availability shortages

As part of its response, Connecticut implemented a variety of strategies to address LTC workforce
availability shortages. First, the state authorized creating a temporary nurse aide position to address LTC
facility staffing shortages, which enabled people who completed eight hours of online training to work
under the supervision of nursing staff with residents who were COVID negative. Through the end of
August 2020, 116 individuals had completed this training in Connecticut. 27 DPH does not track whether
those individuals work within nursing homes in the state.
In addition, the state temporarily allowed staff licensed in other states to work in Connecticut health care
facilities. Before the outbreak, Connecticut was 1 of only 10 states without a nurse licensing compact in
place to allow licensed staff from out of state to work in its health care facilities (National Council of
State Boards of Nursing 2020). Industry stakeholders reported the temporary lifting of licensing
requirements gave them needed flexibility to hire additional staff. This was especially critical for large
chains of nursing homes that could move staff from facilities in other states that were relatively
unaffected by COVID-19 at the time Connecticut was at the peak of the first wave.
b. Staff absences and shortages

Facilities reported increased staff absences as a result of
Recommendation SR18
difficulties related to child care, preexisting conditions that
placed them at greater risk, and fear of catching the virus The state should extend the
or bringing it home to their families. Facilities also had to temporary suspension of in-state
compete for direct care staff throughout the region, licensure requirements for as long
including New York City, where hospitals and other as the public health emergency is
settings offered very competitive financial incentives. in effect.
The Families First Coronavirus Response Act excluded
nursing homes, like other health care providers; the act
extended paid sick leave and expanded family and medical leave to individuals at companies with fewer
than 500 employees (U.S. Department of Labor 2020). 28 Some nursing homes we interviewed chose to
offer paid sick leave to discourage staff from coming to work while sick, but many staff members
interviewed said they did not have access to paid sick leave. Although Connecticut does guarantee some
paid sick leave to service workers, the lack of universal paid sick leave creates a potential incentive for
employees to downplay their own symptoms or exposure risk, and possibly come to work when they
should stay home (Connecticut Department of Labor 2015).
c. Industry strategies to address workforce shortages

Bonuses and hazard pay. Facilities used both financial and nonfinancial incentives to attract and keep
staff, such as bonuses, hazard pay, and providing meals during shifts. In focus groups with direct care
staff, we heard that nursing homes tied many of the financial incentives to on-time arrival. Staff expressed
frustrations with these requirements because public transportation was limited at the height of the
outbreak, and many staff had caregiving responsibilities at home that might have occasionally made them
27
Documentation provided by DPH to Mathematica on August 26, 2020.
28
In order to access funds from the Coronavirus Relief Funds, Connecticut required that facilities elect to provide
paid sick leave through the Families First Coronavirus Response Act or the equivalent.
Mathematica 64
a few minutes late to work. Staff also reported bonuses or hazard pay were available only during a short
period (even though the pandemic has lasted for months), or that agency staff or other temporary staff
from out of state received higher pay or financial incentives than did those staff who had longer tenure at
the facility.
Staff working in multiple locations. One potential source of COVID-19 spread is staff who work in
multiple locations. Although they often decide to do so based on economic considerations, understanding
the overlap of staff across multiple facilities might be important for limiting future spread of COVID-19.
Recent research that used geolocation data from more than 30 million smartphones found 7 percent of
smartphones used in a nursing home appeared in at least one other facility (Chen et al. 2020). This
analysis estimated that, on average, each facility’s workers have connections to 15 other facilities and
eliminating staff linkages between nursing homes could reduce COVID-19 infections in nursing homes
by more than 40 percent (Chen et al. 2020).
Facility management reported although they could not
require staff who worked in multiple locations to quit one Recommendation SR17
of their jobs, many did try to limit the number of staff who
worked in multiple locations. Strategies to address this Facilities should adopt staffing
included limiting the use of per diem staff, offering policies that can help limit potential
additional shifts or hours to staff who worked in multiple exposure for staff and residents.
facilities to encourage them to work in one building, and
limiting staff from working in different units within a
campus that had both a nursing home and assisted or independent living. One nursing home operator
reported several nursing homes initially wanted to work together to identify staff working in multiple
locations so that facilities could alert one another if they had an outbreak; that effort quickly fell apart as
the outbreak spread rapidly through almost all facilities in town at nearly the same time.
d. Staff infections and deaths

Data on the number of staff infections and deaths are limited. Connecticut DPH began requiring daily
reporting of staff known to have COVID-19 beginning on May 8, 2020. Nursing homes then also had to
report data on staff infections and deaths to the NHSN beginning on June 17, 2020. Both of these
reporting requirements began weeks after the peak of COVID-19 cases in April. Given the lack of data—
combined with the limited availability of testing for nursing home staff early in the outbreak—it is nearly
impossible to verify the true number of staff who have contracted the virus.
According to an analysis done by the Connecticut Mirror on data reported by facilities to CMS, 2,234
Connecticut nursing home employees have tested positive and another 1,166 are presumed to have
contracted COVID-19; 14 deaths among LTC staff have also been reported (Carlesso and Pananjady
2020). Representatives from 1199 SEIU shared during an interview that they have had up to 4,000 of their
7,000 members who work in various health care settings either test positive or have symptoms that
required self-quarantine or time off from work; they also reported 9 of their members have died and more
than 40 family members of staff members have reported contracting COVID-19 from their family
members who work in nursing homes.
Mathematica 65
D. Screening and testing of residents and staff

The LTC industry’s approach to screening and testing of residents and staff was largely driven by
changing guidance from the state and federal agencies as the scientific understanding of the virus evolved.
However, the response was constrained by limited testing availability, particularly in the early stages of
the outbreak.
a. Screening and testing residents

In March and early April, screening and testing of
residents was limited to individuals exhibiting
“Initially in March, the only way
COVID-related symptoms or those being transferred
individuals could be tested was if
to the hospital for a higher level of care. At that point,
residents were transferred to
hospitals. Then, per guidance from
residents also needed to have other potential causes
DPH, there was a focus on care in for their symptoms ruled out (flu, urinary tract
place to avoid overburdening the infections, or gastrointestinal issues) to be eligible for
hospitals, but then some of the COVID-19 testing. This delayed a confirmed
nursing homes became diagnosis, which facilities need to cohort residents
overwhelmed.” appropriately. Family members interviewed expressed
—Industry stakeholder frustration with this approach when they wanted
quick action in response to the symptoms their loved
ones had developed.
The state provided nursing homes with a limited number of testing swabs for their residents in March and
April. Staff had to pick up testing swabs at the state lab in Rocky Hill and drop them back off there
(which was difficult for facilities not located nearby).
In June, the state assigned Care Partner labs to each nursing home to process all their resident and staff
tests. During interviews, many facility stakeholders reported that even with the Care Partners, it still took
several days to receive results of residents’ tests. Results are needed almost immediately to implement
appropriate cohorting of residents. Some facilities reported continuing to do resident testing with their
previously negotiated testing vendors (at their own cost) if their assigned Care Partner could not provide
results in a timely manner. Direct care staff reported facility management frequently told them which
residents had tested positive or that this information spread only by word of mouth, which increased staff
anxiety at the beginning of the outbreak.
b. Screening and testing staff
Early screening of staff focused on symptoms and travel outside the region but evolved to include
temperature checks and more specific screening questions about behavior outside of work. Facilities
differed in their approach to the screening, with some asking staff to self-report symptoms and
temperatures, and others dedicating staff to physically conduct this screening of all staff every day. Many
facilities reported designating a person at the front door who was responsible for screening staff and
taking temperatures at the beginning of each shift. In some cases, this was a licensed nurse with training
in infection control, which proved to be burdensome for facilities to maintain while meeting the needs of
residents. Facility leadership also reported different approaches to handling staff who screened positive
for certain symptoms, particularly at the beginning of the outbreak when testing capacity was constrained.
Some reported they would ask staff to go home and stay home for at least 24 hours, and others asked staff
Mathematica 66
to stay out of work for up to two weeks. Return-to-work guidance from the CDC also evolved. At the
time of interviews in July and August, most facilities reported they followed current CDC guidance
and/or used a testing-based strategy to allow staff to return to work only after receiving a negative test.
Direct care staff reported varying experiences with screening; those who worked the night shift reported
less consistency in staff screening. Staff also reported that as facilities changed their approach to
screening staff, the process became confusing as management frequently did not clearly communicate
changes to staff. Finally, staff said the time it took to complete the screening could sometimes delay them
from clocking in for their shift; in many cases, this caused them to lose hazard pay that depended on on-
time arrival.
For the first several months of the outbreak when testing capacity was limited, industry stakeholders
reported only symptomatic staff could get tested. Before the Care Partners program, staff had to secure
access to testing themselves through their primary care doctor or other testing sites in the state; the
facilities did not initially coordinate testing. The PPS conducted by the state in May did not include staff.
Industry stakeholders, including representatives from 1199 SEIU, and family members criticized the state
for not including staff in the PPS because these stakeholders believed staff were primarily responsible for
bringing the virus into the facility (because few residents were leaving the building then).
Beginning in June with the Governor’s executive order to test staff regularly, nursing homes were
assigned a Care Partner lab to process all their resident and staff tests. Some nursing homes reported the
Care Partner assignments interrupted previously negotiated testing contracts they had arranged with labs,
and others reported having a dedicated testing partner alleviated challenges with test processing times at
the national labs such as Quest. Representatives from assisted living facilities reported challenges
complying with this requirement because they have to “test any regular caregivers.” Because residents of
assisted living communities can hire their own private caregivers directly, the management of the assisted
living service agency finds it difficult to keep track of everyone and ensure they are being regularly
tested.
Direct care staff interviewed generally said they have been tested regularly in accordance with the
Governor’s order. Staff reported inconsistent experiences with testing if they worked nights or weekends.
Sometimes testing is done on certain days or shifts, so if they are not scheduled to work that day, they are
not tested appropriately. Staff also reported different approaches to how their facility administered tests.
In some cases, nursing home staff would administer tests and in other cases staff from a lab would
administer tests. Several LPNs reported they conduct tests on themselves. Given the discomfort
associated with a nasal swab, some staff who have administered their own tests suggested self-
administration can be inconsistent and might affect the quality of the results. Supervised self-collection of
testing specimens is allowable according to CDC and DPH guidance, particularly because staff testing
administered by Care Partners only occurs during the day shift. 29
E. Care transitions
Care transitions refer to the transfer of a resident from an LTC facility to another setting, such as the
hospital or to a community home. Research has demonstrated that transfers between a nursing home and a
hospital can have potentially negative impacts on residents, including disorientation, failure to thrive, and
29
Documentation provided by DPH to Mathematica, which cited the CDC guidance on specimen collection that is
incorporated into the Care Partner testing contracts. See https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-
clinical-specimens.html.
Mathematica 67
other negative outcomes (Levine et al. 2020). Before COVID-19, regulations outlined in Section 19a-
533(h) of the Connecticut General Statutes governed residents’ discharges and transfers. Executive Order
Number 7L on March 24 granted additional flexibilities for resident transfers and discharges based on
their COVID-19 status (Lamont 2020g). Unlike New York, Connecticut DPH did not require LTC
facilities to admit residents with COVID-19; it left that decision to individual facilities to assess their
ability to care for these residents (Connecticut DPH 2020a). Executive Order Number 7XX on June 5,
2020 suspended involuntary discharges of nursing home residents to homeless shelters, except during
emergency situations or with respect to COVID-19-recovered discharges (Lamont 2020h).
1. Transfers to and from hospitals
Industry stakeholders in many locations reported they did their own assessment of their ability to care for
COVID-19 residents in place and concluded it was in their best interest—and that of the resident—to
have a policy of transferring out any residents with symptoms. Early in the outbreak, the only option was
to transfer residents to a hospital; later, facilities could transfer directly to a CRF if needed.
Care transitions during COVID-19 introduced an added element of uncertainty for residents and family
members. Some nursing homes would accept residents back to the facility only after two negative tests if
they had been treated for COVID-19 in the hospital; others required residents to convalesce at CRFs
before returning to their home of origin.
Some involuntary transfers of residents did occur among those residents residing at Northbridge Health
Care Center in Bridgeport when that facility transitioned to a CRF. The LTC Ombudsman Office said
those involuntary transfers were due to the resident’s physician attesting that the resident would be at high
risk of death if he or she stayed in the facility when its status changed to a CRF.
Family members reported they were frequently informed afterward their loved one changed rooms as a
result of cohorting efforts or was transferred to a hospital
for treatment for COVID-19 or any other ailment requiring
hospital care. Family members and residents also reported Recommendation LR19
inconsistent experiences with whether they had to The state should ensure all LTC
quarantine when returning to the nursing home after resident receive counseling on
leaving the facility to go to the hospital or for other their options to receive services in
outpatient appointments. Residents and family members the community and support those
reported if people leave for the hospital overnight, they who want to return to the
must be isolated after coming back. If people only leave
community.
for an outpatient visit, they are not isolated upon return but
precautions are taken during transport to limit exposure,
such as sanitizing the resident’s room while the resident is
gone, using separate entrances and exits for residents going to outpatient visits, and using masks and other
PPE while out of the facility.
Nursing home operators interviewed reported different approaches to whether their facilities currently
accepted new admissions. Some facilities accept new admissions from the hospital only with a negative
test first. Others accept new admissions from hospitals or the community and isolating new admissions
for up to two weeks before new residents can join the rest of the facility population.
Mathematica 68
2. Transitions to home and community-based settings

Home and community-based settings are safe alternatives to nursing home care for people who choose
them. Connecticut’s LTSS Rebalancing Plan, an initiative of the Governor and General Assembly, aims
to increase choice in where people receive LTSS (Connecticut Department of Social Services 2020d).
Aligning with the 1999 Olmstead vs L.C. Supreme Court decision requiring states to provide community
choices for people with disabilities, the plan provides a strategy for increasing access to HCBS and
providing Connecticut residents with informed choices about their LTSS options. More than 30,000
Connecticut residents who meet Medicaid financial and functional eligibility criteria for nursing home
level of care receive that care in community settings every year, representing 64 percent of all LTSS
Medicaid clients (Connecticut Long-Term Care Planning Committee 2020). This percentage has climbed
consistently for two decades, demonstrating the ongoing trend toward rebalancing the LTSS system,
responding to people’s preferences to live and receive care in community settings while simultaneously
reducing per client Medicaid costs.
Although individuals and families might prefer nursing home care under a variety of circumstances, the
state has several programs to provide information and counseling about LTSS options, whether they live
in community or institutional settings, to consider their preferences and optimize choices for care. People
already residing in a nursing home or other congregate setting might wish to move out to a community
setting, particularly during a pandemic, to avoid heightened risk of exposure.
However, nursing home residents who wanted to transition back to the community during COVID-19
encountered difficulties related to accessing the appropriate supports to transition home or to the
community, according to the LTC Ombudsman Office and the Cross Disability Lifespan Alliance. In
addition, during the pandemic, people who received LTSS in community settings and the workforce that
supports them also needed assurances of available PPE and robust emergency back-up plans in case they
contract the disease or their workers cannot come to work. Many of them also need grocery and
medication delivery, to minimize their exposure outside of home. As part of the response to COVID-19,
the Connecticut Department of Aging and Disability Services provided meals to older adults in a drive-
through setting or arranged for home-delivered meals when senior centers could no longer offer meal
services. Social isolation due to extended separation from family and friends were also concerns for the
HCBS population.
In response to pandemic related-declines in nursing home occupancy rates, which could lead facilities to
close, it becomes even more important to maintain and potentially strengthen Connecticut’s Rebalancing
Plan strategies, including increasing transitions of institutional residents to community settings through
the Money Follows the Person program, Medicaid waiver programs, workforce development, connecting
people to information about care options through MyPlaceCT.org, improving housing and transportation
supports, and assisting the nursing home industry with aligning its business model with rebalancing trends
while delicensing excess skilled nursing beds. Workforce retraining could also help nursing home staff
shift to HCBS jobs.
F. Communication between LTC facilities and the state, and between facilities and
residents and family members
COVID-19 highlighted the need for strong channels of communication, both between the state and LTC
facilities and between facilities and their residents and family members. This section details the
Mathematica 69
preparedness and response surrounding communications between LTC facilities and the state, and
between facilities and residents and family members.
1. Preparedness
Section IV.G.2.b presents the primary venues for communication between the state and LTC industry
before the outbreak. Resident and Family Councils are also a conduit of communication between nursing
homes and residents and families. With the support of the Connecticut Long-Term Care Ombudsman
Program, the Executive Board of Resident Council Presidents, a 40-member council made up of the
presidents of resident councils from around the state, encourages residents to be informed about
legislative issues to encourage greater self-advocacy (Connecticut Long Term Care Ombudsman Program
n.d.b).
2. Response
a. Communication between LTC facilities and state

Blast faxes and webinars. DPH communicated guidance and orders to nursing homes and assisted living
facilities through blast fax notifications distributed to facility leadership and archived on the MAP
website. LTC facility leadership reported delayed communication about key provisions, such as universal
mask wearing and cohorting, contributed to spread in facilities. Communications between the state and
facilities improved as DPH began to hold weekly webinars for facilities at the beginning of April (MAP
2020). Some nursing home operators observed that although webinars conveyed policy updates, some
found the format less useful because guidance was communicated orally and written guidance did not
accompany the webinars. (At the end of August, DPH began adding written summaries and webinar
recordings to the MAP website.)
Many nursing home operators reported they struggled to consolidate rapidly changing guidance when
developing their own policies and disseminating information to staff. In some cases, nursing home
operators who wanted to disseminate information to their staff struggled to centralize and, at times, to
reconcile differences in guidance from various sources, including the DPH, CDC, and CMS. In addition,
nursing home operators reported DPH offered guidance in accordance with CDC recommendations, but
operators felt DPH did so without additional interpretation or direction. Without adequate support,
operators said the information felt “vague and left too much to discretion” to facilities that needed to
translate guidance into updated policies and procedures for their staff. Nursing home leadership suggested
a range of potential improvements, including providing facilities with templates for policies, creating a
“monitoring partner” within DPH or another agency who can get to know the facility and help answer its
questions, or establishing a hotline dedicated to facilities questions.
The LTC trade associations—LeadingAge Connecticut, Connecticut Association of Healthcare Facilities,
and the Connecticut Assisted Living Association—served an important role as a communication liaison
between the LTC industry and DPH. In response to the outbreak, nursing home and assisted living trade
associations began to hold weekly calls for their members. These calls served several purposes, including
disseminating information from the state and federal agencies, receiving and fielding questions from
members about policies, and allowing members to ask questions and share useful information with one
another. Leadership of one trade association reported timely information sharing was key, as some
regions with earlier outbreaks could share their experiences with other parts of the state experiencing
outbreaks as time went on.
Mathematica 70
b. Communications between facilities and residents/family members

In response to restricted visitation in LTC facilities,
facility leadership used different approaches to ensuring Recommendation SR21
adequate communication between the facility and residents
or family members. (Section IV.B.2.d provides more Facilities should ensure family
information on the state’s policy response.) members can obtain accurate and
timely information on residents’
Alternatives to in-person visitation. Family members health and well-being.
and residents said facilities took different approaches to
implementing alternatives to in-person visits, such as
outdoor and window visits. To comply with the state’s May 9 guidance, facilities implemented outdoor
visitation several days of the week for residents to visit with family and friends. Typically, facilities
would have at least some outdoor visitation appointments available on weekends or evenings. Visitors
had to make appointments and were subject to screening measures such as temperature checks; visits took
place with appropriate PPE and social distancing in place. Family members reported several challenges
related to outdoor visits, including ensuring privacy of conversations with loved ones as staff oversaw
visits, variability of weather conditions that could
“It is key to keep the communication affect visits, and difficulty scheduling outdoor visits
open and just pay the staff more within the limited appointments available. Window
money and reward people for keeping visits were feasible only for residents whose rooms
the virus outside of the building.” had windows that were safely accessible to family
—Nursing home resident members (that is, on the first floor, windows not
obscured by heating or cooling systems). Some
facilities also restricted window visits given security concerns with having family members or others
lurking in the parking lot.
In May—before Mother’s Day weekend—Connecticut DPH used resources from its civil monetary
penalty funds to purchase 800 iPads, which it distributed to nursing homes to facilitate virtual visitation
between residents and their families (Massaro 2020). Industry stakeholders and family members reported
these devices were useful for expanding virtual visitation, but some family members also expressed
concerns related to privacy during FaceTime calls, the devices not being charged and available for
scheduled calls, and limited staff availability to facilitate calls. A few stakeholders and family members
noted that virtual visitation and use of iPads posed challenges for residents, particularly those with
physical dexterity or cognitive issues or with hearing loss. On August 27, DPH expanded its visitation
policy and clarified that outdoor visits could take place more than once a week and extended the visitation
minimum duration from 20 to 30 minutes (Connecticut DPH 2020d).
Person-centered care plans. DPH also required facilities to assess the psychosocial needs of residents to
develop individualized visitation plans and enable compassionate care visits in additional cases. Before
the changes, family members and industry stakeholders relayed concerns for person-centered care
planning during the outbreak, in the absence of family members being physically present with residents.
Family members were concerned that in changes to care plans precipitated by the outbreak in facilities,
facilities did not appropriately consider the social and emotional needs of residents. One individual gave
an example of cases of weight loss and decline in loved ones, as family members could no longer enter
facilities to help with feeding loved ones during meals. Family members frequently shared stories of
observing deterioration and decline in the physical and emotional or mental well-being of loved ones in
facilities, including an increase in aggressive behaviors, delirium, and mental deterioration, in addition to
Mathematica 71
weight loss. One stakeholder recommended reviewing

each resident’s care plan for how the outbreak has affected
the resident in terms of physical, social, and emotional Best practices for facility
well-being. communication with family
members
Information about facility outbreaks and residents. • Hosting drop-in Zoom calls
Facilities took different approaches to inform residents and for family members when an
family of the status of the outbreak in the facility, as well outbreak occurred
as specific updates on individual residents’ status and care.
Based on experiences reported by family members, some • Designating a point of
facilities were very responsive but others provided limited contact at the facility to field
information during the outbreak. Families and stakeholders questions and calls from
also reported facilities adopted a range of approaches to family members
informing residents and families, with some facilities
• Bringing in management’s
proactively hosting drop-in Zoom calls for family
regional ombudsman staff to
members when an outbreak occurred or involving
support family members and
management’s regional ombudsman on calls; others
residents
reported facilities rarely provided details in
communications such as daily and total COVID-19
positive case counts. A few family members recommended
that facilities designate a single point of contact, after experiencing delays in reaching administrators or
nursing staff, or calls were unreturned. For example, one individual learned the facility routed all calls to
the facility through a single person at the front desk, and there was a shortage of staff to field calls.
Mathematica 72
Section VI. Conclusion
VI. Conclusion
The COVID-19 pandemic represents a public health emergency unlike any the world has faced in the past
century. Residents who remain in LTC facilities have experienced the trauma of losing friends and loved
ones, all while undergoing significant declines in their physical, emotional, and psychosocial well-being.
Family members lost loved ones without the opportunity to say a proper goodbye or hold a funeral in the
face of state restrictions on the size of gatherings.
Connecticut state officials made policy decisions and issued guidance based on the available knowledge
at the time from national and state epidemiologists and public health experts. However, early efforts that
focused on addressing the surge in demand for hospital resources hampered Connecticut’s preparedness
and response to the COVID-19 outbreak in LTC facilities. LTC facilities were not recognized as critical
health care assets in the state’s emergency preparedness plans, nor were LTC representatives at the table
at the beginning of the outbreak. In an industry that is subject to extensive federal and state regulation,
neither federal nor state governments provided clear guidance to nursing homes and assisted living
facilities soon enough to prevent the tragic loss of life. Compounded by a lack of knowledge about how
the virus spreads, LTC facilities did not take prompt and immediate action to limit entry to their
buildings, enforce staff screening measures, and implement universal mask wearing. Facilities also lacked
the PPE necessary to protect their staff and residents, and some failed to make the equipment readily
accessible to staff. Some family members were left without information about their loved ones, often
going days without a returned phone call from a facility. Despite these issues, the state granted the LTC
industry immunity from liability, which removed a critical mechanism for holding facilities accountable
for negligence.
State efforts to designate CRFs and distribute PPE to LTC facilities are commendable even if they were
too late to make a large impact (in the case of CRFs) or have recently been discontinued by the state (in
the case of PPE distribution). Further, FLIS staff should be recognized for making concerted efforts to
respond to the industry’s request for more information and technical assistance. The relationship between
nursing homes and surveyors is not typically a collaborative one, but FLIS staff pivoted to meet the needs
of the industry during a quickly evolving situation to ensure facilities were aware of, and prepared to
implement, the latest guidelines and requirements.
This report contains dozens of recommendations, both short and long term, that the state and LTC
industry can implement to mitigate a potential second wave of COVID-19 and to prevent future infectious
disease outbreaks. Implementing all of these recommendations will require political will; financial
resources; and a strong, sustained, and unwavering commitment to protect the health and well-being of
some of the state’s most vulnerable residents.
Mathematica 73
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Mathematica 82
APPENDIX A
Methods
Appendix A. Methods
A. Document review
Upon contract award, Mathematica requested a list of relevant documents from state agencies for review:
• Continuity of operation plans for relevant state agencies

• Documentation related to the state’s emergency response plan and structure, including the uses of
National Guard resources and allocation of personal protective equipment (PPE) to long-term care
(LTC) facilities
• Regulations governing nursing homes and assisted living facilities
• Documentation of nursing home inspections and outcomes
• All relevant guidance and communication from the Department of Public Health (DPH) to LTC
facilities
• Organizational charts, head counts, and other information related to state agency staffing
• Prior planning for infectious disease outbreaks in long-term care facilities
• Allocation of federal CARES Act funding to nursing homes
• Documentation related to facility reporting requirements
As we learned about the existence of additional relevant information, Mathematica requested additional
documentation from various state agencies.
In total, Mathematica received and reviewed 190 documents from Connecticut state agencies, including
DPH, the Department of Social Services (DSS), Office of Policy and Management (OPM), and others. At
least two members of the Mathematica team reviewed each document and we extracted and coded
relevant information according to category and themes (PPE, testing, communications, regulatory
framework, reimbursement, facility staffing, COVID-19 recovery centers, infection control, and other).
B. Interviews
Mathematica conducted 52 interviews with 132 people from July 27 to September 10. We used
semistructured discussion guides to obtain comparable information about the major topics from each
interview, while allowing respondents to offer their observations, experiences, and recommendations on
other issues.
We recorded interviews with permission, and generated summary notes from each interview. At least two
members of the Mathematica team who extracted and coded key points related to the interview topics
listed in Exhibit A.1 also systematically analyzed each interview transcript.
Exhibit A.1. Interview topics, by stakeholder

Executive Resident, LTC
Elected branch LTC industry family, advocacy
officials officials stakeholders and staff groups
1. Assessment of the state’s capacity to X X
detect and respond to infectious disease
outbreaks
2. PPE and testing of residents and staff X X X X X
Mathematica A.2
Appendix A. Methods
Executive Resident, LTC

Elected branch LTC industry family, advocacy
officials officials stakeholders and staff groups
3. LTC regulations and survey certification X X X
processes
4. State agency structure, emergency X X X
response systems, and communication
systems and practices
5. Reimbursement mechanisms to support X X X X
increasing LTC system costs, including
uses of funding increases
6. Cohorting of COVID-19 suspected or X X
confirmed positive individuals
7. Establishment of COVID-19 recovery X X X
facilities
8. Facility response, including changes to X X X
the physical environment, experiences
with procuring PPE, screening and testing
of residents and staff
9. Staffing challenges and LTC workforce X X X
availability
10. Infection control X X X X
11. Care transitions and communication with X X X X
other parts of the health care system
12. Communication with residents/families, X X X
other facilities, and state health
authorities
LTC = long-term care; PPE = personal protective equipment.
1. Organizational affiliation of stakeholder interviews

Mathematica did not conduct any in-person visits to nursing homes or assisted living communities
because of state requirements restricting visitation in these settings. Instead, Mathematica conducted all
stakeholder interviews by telephone and video conference. We interviewed a sample of state agency staff,
facility administrators, nursing home and assisted living trade association representatives, labor
representatives, legislators, direct care staff working in nursing homes, LTC advocacy groups, nursing
home residents, and family members of residents living in LTC facilities. We interviewed the following
list of individuals and groups from each of these entities.
a. Elected officials
• Representative Cathy Abercrombie
• Senator Cathy Osten
• Representative Toni Walker
• Senator Paul Formica
• Representative Gail Lavielle
• Representatives for Senator Len Fasano
• Representatives for Representative Joe Aresimowicz
Mathematica A.3
Appendix A. Methods
• Senator Mary Abrams

• Representative William Petit
• Senator Saud Anwar
• Senator Kevin Kelly
• Senator Heather Somers
• Representative Johnathan Steinberg
• Senator Marilyn Moore
b. Executive branch officials

• Deidre Gifford, Acting Commissioner of the Department of Public Health and Commissioner of the
Department of Social Services
• Adelita Orefice, Senior Advisor to the Commissioner
• Amy Porter, Commissioner of the Department of Aging and Disability Services
• Josh Geballe, Commissioner of the Department of Administrative Services
• Melissa McCaw, Secretary of the Office of Policy and Management
• Michelle Gilman, Deputy Incident Commander for COVID-19 and Deputy Chief Operations Officer
• Leadership from CT Unified Command, including leadership of Connecticut National Guard and the
Division of Emergency Management and Homeland Security
• Facility Licensing and Investigations Section (FLIS) at the Department of Public Health, including
nurse consultant surveyors
• Healthcare Associated Infections and Antimicrobial Resistance Section at the Department of Public
Health
• Infectious Diseases Section at the Department of Public Health
• Representatives from the Connecticut 211 Hotline
• Representatives from the Connecticut Medicaid program within the Department of Social Services
• Representatives from the Department of Public Health’s Public Health Laboratory
• Representatives from the Long-Term Care Ombudsman Program
• Representatives from the Long-Term Care Mutual Aid Plan vendor
• Representatives from Yale School of Public Health involved in supporting DPH’s COVID-19
response
c. LTC industry stakeholders

• Representatives from LeadingAge and the Connecticut Association of Health Care Facilities
• Representatives from the Connecticut Assisted Living Association
• Leadership from Athena Health Care
• Leadership from iCare Health Network
• Leadership from Genesis Health Care
Mathematica A.4
Appendix A. Methods
• Leadership from Arbors of Hop Brook Limited Partnership

• Leadership from Greenwich Woods
• Leadership from Brookdale Assisted Living
• Leadership from Mansfield Center for Nursing and Rehabilitation
• Leadership from LiveWell
d. Resident, family, and staff stakeholders

• 10 residents and family members of residents in LTC facilities
• Representatives from the New England Health Care Employees Union, District 1199
• 21 direct care staff members working in nursing homes
e. LTC resident advocates

• Representatives from the Connecticut Cross Disability Lifespan Alliance
• Representatives from Connecticut Legal Services
C. Data analysis
1. Data sources
Our data analysis drew upon a wide range of data sources, relying on both publicly available and
proprietary data. For publicly available data, we include a link to the data source. In this section, we
provide information on data sources corresponding to each of the three primary subsections of Section III.
a. Assessment of the COVID-19 outbreak in Connecticut as a whole

Johns Hopkins University and the New York Times. The Johns Hopkins University Coronavirus
Resource Center publishes daily data about new and cumulative cases and new and cumulative deaths for
each county in the U.S. 30 The New York Times publishes similar data, but for states and nationally. 31 We
used these data to construct seven-day moving averages of new cases and deaths in the relevant states and
counties through the end of July 2020. We then scaled these counts by the total state or county
population.
Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS).
The CDC NCHS is producing the most recent data available on deaths, mental health, and access to
health care, loss of work due to illness, and telemedicine due to the COVID-19 pandemic. 32 The death
counts are produced weekly for the U.S. overall and by state, and by certain demographic characteristics,
such as age group. We used data reported through the end of July 2020 for the number of deaths by age
group. We then scaled these counts by the total state population by age.
COVID Tracking Project and Census Bureau. The COVID Tracking Project at The Atlantic
consolidates race and ethnicity data for COVID-19 cases and deaths from every state and territory that
reports it. 33 We used data on cases and deaths reported through the end of July 2020. Each state only
30
https://coronavirus.jhu.edu/data
31
https://github.com/nytimes/covid-19-data
32
https://www.cdc.gov/nchs/covid19/index.htm
33
https://covidtracking.com/race/dashboard
Mathematica A.5
Appendix A. Methods
reports race and ethnicity data on a subset of all cases, and the share with race and ethnicity data differs
by state). Therefore, for each race and ethnicity group, we calculated the share of cases (deaths) for that
group out of the total number of cases (deaths) with known race or ethnicity.
rt.live. rt.live produces up-to-date values for Rt, which is a key measure of the speed of transmission of
COVID-19. 34 We used state-level data reported through the end of July 2020. Additionally, we used their
model code (provided on the website) to create county level estimates for Rt using daily data on total
positive tests and total tests by county.
Census Bureau. To capture a variety of population estimates, we used data from the Census Bureau. At
the state level, we used the data on age, sex, race, and Hispanic origin. 35 We also used total county
population. 36
b. Assessment of the COVID-19 outbreak in Connecticut’s nursing homes
Connecticut DPH weekly data on COVID-19 cases and deaths included in Connecticut’s FLIS
system. Connecticut provides weekly updates on COVID-19 cases and deaths in individual nursing
homes, as reported directly by the facilities. 37 In this report, we used data on the total cases and deaths in
each nursing home through July 22, 2020. Information is reported for 212 nursing homes in Connecticut.
Cumulative data for residents was re-baselined on July 15 and on July 21 to account for false positives
detected that week. Due to the different data collection and processing methods that went into effect in
mid-June to report on COVID-19 cases and deaths, DPH does not sum the data before and after the re-
baselining on July 21, 2020 due to possible duplication of cases and deaths between prior and current data
reported. Therefore, we also focused only on the period through the end of July. However, as of
September 10, the state reported only 58 new cases and 28 new deaths since July 22, so all findings would
be essentially unchanged if we considered a broader time horizon.
Minimum Data Set. The Long-Term Care Minimum Data Set (MDS) is an assessment tool used for all
residents (regardless of payer) of nursing homes certified to participate in Medicare or Medicaid.
Mathematica was added as an authorized user of this data under a data use agreement between the state of
Connecticut and CMS which gave Mathematica access to all MDS assessments for nursing homes in
Connecticut between 2012 and the end of July 2020. Assessments are conducted on admission or
discharge, as well as every three months or when there is a substantial change in someone’s status. The
assessment captures numerous characteristics of health and well-being. 38 We requested historical data to
be able to look back in the data and discern seasonal patterns during previous years to compare to the time
period of this study.
Connecticut DPH FLIS portal on individual resident data. Starting on May 8, 2020, Connecticut
required each nursing home to report data on individual residents in nursing homes who tested positive or
died from COVID-19. The data capture whether the resident is presumed positive or had a positive test, as
well as the date of the positive test. In this report, we only consider people who had a positive test. We
merged these data with MDS data to identify nursing home residents that got COVID-19 using a
34
https://rt.live/
35
https://www2.census.gov/programs-surveys/popest/tables/2010-2019/state/asrh/sc-est2019-alldata6.csv
36
https://www2.census.gov/programs-surveys/popest/tables/2010-2019/counties/totals/co-est2019-annres.xlsx
37
https://portal.ct.gov/Coronavirus/Nursing-Homes-and-Assisted-Living-Facilities
38
The assessment form is available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Downloads/Archive-Draft-of-the-MDS-30-Nursing-Home-Comprehensive-
NC-Version-1140.pdf.
Mathematica A.6
Appendix A. Methods
combination of name and date of birth. Of the 8,799 residents that are listed as testing positive and were
not transferred into the facility, we identified 8,168 of them in MDS data (93 percent). For any residents
in the MDS who did not match, we assumed that they did not test positive for COVID-19.
DPH Vital Records. The Connecticut DPH maintains statewide registries for births, deaths, marriages,
and fetal deaths for all vital events occurring in Connecticut. DPH provided vital records on deaths
through the end of July 2020. The vital records data capture whether one of the causes of death is
COVID-19. It also indicates whether someone died in a nursing home. We merged these data with MDS
data using a combination of name, date of birth, and address to identify nursing home residents who died
from COVID-19. Based on this merge, we identified 2,612 people in nursing homes who died from
COVID-19. We also used the information from the vital records themselves (address of residence and
address of place of death) to identify an additional 115 people who had been in a nursing home and who
subsequently died from COVID-19. In total, we therefore identified 96 percent of the total of 2,849
nursing home deaths reported in aggregate from the aggregate DPH data on deaths reported in
Connecticut’s FLIS system.
Nursing Home Compare. Nursing Home Compare is a website maintained by CMS that allows people
to find and compare nursing homes certified by Medicare and Medicaid. 39 The website contains general
information about nursing homes (such as name and address), quality of resident care, and staffing for
more than 15,000 nursing homes nationwide. Nursing Home Compare includes a five-star rating system
for each facility that provides a rating between one and five stars for health inspections, staffing, and
quality of resident care outcomes, as well as an overall rating calculated from the three individual ratings.
We used the provider info dataset to capture various characteristics of the nursing home as of June 1,
2020. 40
LTCFocus. LTCFocus.org is a website that contains data on nursing homes across the United States
produced through the Shaping Long-Term Care in America Project conducted by the Brown University
Center for Gerontology and Healthcare Research and supported in part by the National Institute on
Aging. 41 The website combines data from a variety of sources, including MDS, Online Survey
Certification and Reporting (OSCAR), and a variety of other sources. The data reports numerous
measures about the health and functional status of nursing home residents, characteristics of nursing
homes, state policies relevant to nursing home financing and care, and local market conditions. We used
data summarizing the nursing home from 2017, the most recently available information.
39
https://www.medicare.gov/nursinghomecompare/search.html
40
https://data.medicare.gov/Nursing-Home-Compare/Provider-Info/4pq5-n9py
41
http://ltcfocus.org/
Mathematica A.7
Appendix A. Methods
Nursing home COVID-19 cases and deaths from northeast states. We used publicly reported data
from Massachusetts, 42 New Jersey, 43 New York, 44 and Rhode Island 45 on COVID-19 cases and deaths
that occurred in individual nursing homes reported through the end of July 2020.
Google Maps API. We used Google Maps API to calculate distances from Connecticut for counties and
for individual long-term care facilities in nearby states. The distance captured the number of miles (along
roads) to the border of Connecticut for 56 border crossing points, and then selected the minimum
distance. For counties in nearby states, this measured the distance from the geographic center of the
county. Based on distance, we identified both relevant counties to include in our comparison of aggregate
patterns in COVD-19 and relevant nursing homes to include in our comparison of nursing home outcomes
across states.
c. Assessment of the COVID-19 outbreak in Connecticut’s assisted living facilities

Connecticut DPH weekly data on COVID-19 cases and deaths included in Connecticut’s FLIS
system. Connecticut provides weekly updates on COVID-19 cases and deaths in individual assisted living
facilities, as reported directly by the facilities.46 In this report, we used data on the total cases and deaths
in each assisted living facility through July 14, 2020. Similar to the approach for nursing homes, we only
used data through July 14 because of changes in data reporting that led to re-baselining on July 14, 2020.
However, as of September 10, the state reported only 20 new cases and 0 new deaths in assisted living
facilities since July 14, so all findings would be essentially unchanged if we considered a broader time
horizon.
Connecticut DPH assisted living facility data. The Connecticut DPH provided us with a list of assisted
living facilities and their licensed size. For facilities that report a licensed bed size in the database, we
used the total number of beds in the state’s assisted living facilities weekly report from June 19, 2020.
There were still 28 facilities that neither had a licensed bed size nor were included in the June 19, 2020
report. For these facilities, we used the current census from the July 30, 2020 report as the number of beds
(the same report used to capture total cases and deaths).
2. Analytic approach
a. Connecticut as a whole
We conducted several analyses to understand the impact of COVID-19 cases and deaths in Connecticut as
a whole compared to surrounding states in the region and the United States, including an analysis of new
COVID-19 cases and deaths by date, COVID-19 deaths by age group, COVID-19 cases and deaths by
race and ethnicity, and COVID-19 transmission rates by date.
42
Cases and deaths in long-term care facilities from the report as of July 29, 2020 are available at
https://www.mass.gov/doc/weekly-covid-19-public-health-report-july-29-2020/download.
43
Only the most recent data are available online. The most recent data also only include current outbreaks, but
exclude cases and deaths for individual facilities that are no longer experiencing an outbreak.
https://www.nj.gov/health/cd/topics/covid2019_dashboard.shtml
44
Only the most recent data are available online. https://www.health.ny.gov/statistics/diseases/covid-
19/fatalities_nursing_home_acf.pdf.
45
Only the most recent data are available online.
https://docs.google.com/spreadsheets/d/1c2QrNMz8pIbYEKzMJL7Uh2dtThOJa2j1sSMwiDo5Gz4/edit#gid=50039
4186
46
https://portal.ct.gov/Coronavirus/Nursing-Homes-and-Assisted-Living-Facilities
Mathematica A.8
Appendix A. Methods
To understand new COVID-19 cases and deaths per 100,000 residents through the end of July 2020, we
examined the seven-day moving average in Connecticut, the Northeast region, and the United States using
data from Johns Hopkins University and The New York Times. We aggregated state-level data from
Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania,
Rhode Island, Vermont, and Washington, DC to capture the Northeast region. We also identified counties
that were within 50 miles of Connecticut based on geocoding analyses from Google Maps. We then
calculated the seven-day moving average of new cases and deaths in these counties to construct a
comparison to Connecticut. For each of the different groups, we scaled the number of new cases and
deaths per 100,000 residents using population data from the Census Bureau.
For COVID-19 deaths by age group, we used state-level data from the CDC for age groups 25 years and
older. We aggregated data from Massachusetts, New Jersey, New York, and Rhode Island to define
deaths in neighboring states by age group. We also aggregated data from these four states plus Delaware,
Maine, Maryland, New Hampshire, Pennsylvania, Vermont, and Washington, DC to define deaths in the
Northeast region by age group. We defined all counts per 100,000 residents using population data from
the Census Bureau.
For COVID-19 cases and deaths by race and ethnicity, we used data from the COVID Tracking Project
and Census Bureau from Connecticut, Massachusetts, New Jersey, New York, and Rhode Island. For
each race or ethnicity group, we used data from the COVID Tracking Project to calculate the percentage
of cases (deaths) with known race or ethnicity that occurred in the specific group. Race and ethnicity
information could be missing for a substantial share of cases or deaths depending on the state (for
example, for deaths, it ranged from less than 1 percent for Connecticut and Massachusetts to as high as 19
percent for Rhode Island). Calculating the case and death numbers as a percentage with known race or
ethnicity avoids attributing a smaller number of cases in a given group to less prevalence, which we
cannot be certain of when there is substantial missing data. To provide context for this percentage, we
used data from the Census Bureau to calculate each race or ethnicity groups share of the state’s total
population. We then took the ratio of the percentage of cases or deaths to the percentage of the population
for each group. Ratios greater than 1.0 for a particular racial or ethnic group indicate disproportionately
higher number of cases or deaths among the group relative to their share of the general population in the
state. We were unable to calculate the ratio of the share of cases to the share of the general population for
New York because it does not report the racial composition of cases.
We used state-level data on transmission rates from rt.live to compare Connecticut to neighboring states
and the Northeast region over time. The rate of transmission is estimated as the number of new people
each infected person gets sick. Neighboring states included Massachusetts, New Jersey, New York, and
Rhode Island. The Northeast region included these four states plus Delaware, Maine, Maryland, New
Hampshire, Pennsylvania, Vermont, and Washington, DC. We also used county-level data on the number
of positive tests and total tests from Connecticut to estimate the Connecticut county-level transmission
rates over time using the rt.live model. The model calculates each county’s rate of transmission
independently, and therefore assumes that all new infections in each county only came from prior
infections in that county. Though this assumption is likely reasonable at the state-level, it is more
questionable at the county-level. However, especially early in the pandemic, limited movement may make
the county-level estimates more reasonable.
Mathematica A.9
Appendix A. Methods
b. Connecticut nursing homes

We conducted four main sets of analyses in Connecticut’s nursing homes: (1) assessing the spread of
COVID-19 across nursing homes; (2) assessing the spread of COVID-19 within nursing homes; (3)
comparing cases and deaths in Connecticut nursing homes to cases and deaths in nursing homes in
neighboring states; and (4) reporting on individual-level changes in well-being. For the first three
analyses, our primary outcomes were measures of cases and deaths within individual nursing homes. To
make more reliable comparisons across facilities, we limited the sample of nursing homes to those
licensed by CMS and therefore in Nursing Home Compare data and we also scaled the reported number
of cases and deaths by the number of licensed beds.
Assessing the spread of COVID-19 across nursing homes. The goal of this analysis was to assess the
characteristics that were associated with greater spread of COVID-19. For the 212 nursing homes in
Connecticut with reported information on cases and deaths, we gathered measures of nursing home
characteristics reported in Nursing Home Compare and LTCFocus data and measures of resident
characteristics calculated from MDS data. The resident characteristics were based on those present in the
facility as of March 9, 2020 and used the regular assessment immediately prior to March 9, 2020 to
determine their characteristics. 47 We aggregated resident characteristics to the facility level by taking the
average for all residents present in the facility.
Our primary regression model was a linear regression model that used resident and nursing home
characteristics to predict cases and deaths per licensed bed. The regression was of the form:
α β X f +ε f
y f =+ (1)
Equation (1) takes outcome y (either cases or deaths per licensed bed) for a given facility f as a function of
various characteristics X at the facility-level. In our main specification, we conducted a multivariate
analysis by including multiple characteristics in the vector X. We report heteroskedasticity robust standard
errors. This model indicates which characteristics are positively or negative correlated with nursing home
outcomes but cannot be viewed as the causal effect of having the characteristic on an outcome. For
example, if a nursing home increased its staffing rating, it does not mean that the outcomes would
necessarily change; instead, the analysis tells us the difference in outcomes between those with higher and
lower staffing ratings.
Because we had a large number of potential characteristics both at the nursing home and resident level to
include in the regression model, we first used a feature selection model to identify which characteristics
were most important in improving the predictive power of the multivariate regression model. With only
212 nursing homes, including too many characteristics would likely reduce the number that would
ultimately be found significant due to correlations across multiple characteristics. Instead, the feature
selection model uses the lasso 48 to limit the number of characteristics and only identify those which were
important to understanding the variation in cases and deaths per licensed bed. Appendix Exhibit B.6 lists
the characteristics that were entered into the feature selection model. We consider the characteristics
47
For residents admitted to the facility in the two weeks prior to March 9, if they did not have a subsequent regular
ongoing assessment by March 9, we considered a regular ongoing assessment up to March 23 as indicating their
status as of the beginning of the outbreak.
48
For more information, see Tibshirani (1996) and Zou and Hastie (2005).
Mathematica A.10
Appendix A. Methods
identified by the feature selection model as being “important”, and subsequently include these important
characteristics in the regression. Exhibit 6 indicates the characteristics that were found to be important.
Results from the multivariate regression model that only includes important characteristics can be found
in Appendix Exhibit B.8. In addition to reporting coefficients and standard errors, the table reports
standardized coefficients, which are based on re-scaling each characteristic to have a mean of 0 and
standard deviation of 1. The standardized coefficients are helpful in understanding the relative magnitude
of the relationship between each characteristic and the number of cases and deaths and indicate which are
more highly correlated.
In addition to the multivariate regression model, we also used a bivariate regression model that compares
the patterns in outcomes by a given characteristic independent of all others. This bivariate regression,
which we used in the interim report, is simpler to understand and present, but ignores potential
correlations between characteristics. These correlations can be better controlled for in the context of a
multivariate model. To estimate this model, we used Equation (1) but only included a single characteristic
in the vector X f .
Assessing the spread of COVID-19 within nursing homes. This analysis looks at patterns in COVID-
19 among residents who were in the nursing home as of March 9, 2020. We report both resident-level and
wing-level analyses. The resident-level analyses include 21,808 residents across 211 nursing homes from
MDS resident assessments (see Appendix Exhibit B.5 for a summary of resident characteristics). For
wing-level analyses, we aggregate resident-level outcomes among the people who resided in each wing
based on their room number from the MDS. 49 The wings were defined based on floor plans that DPH
provided to Mathematica, only including floor plans where the room numbers were clearly readable and
able to differentiate the rooms that corresponded to each wing in the nursing home. In total, the wing-
level analysis includes 6,731 residents across 69 nursing homes with readable floor plans.
Restricting the sample to only include people in the nursing home as of the beginning of the pandemic is
important because of challenges around selection bias. People who entered facilities after this point may
be importantly different than those who were not already in the facility, and also may not be
representative of typical residents – given the spotlight on nursing homes and the risk they posed, people
likely tried to avoid entering a nursing home to the extent possible. From the perspective of the wing-level
analysis, this is especially important because nursing homes may have placed people into different parts
of the facility or cohorted residents who experienced symptoms, which would affect the measurement of
where the disease was located. Additionally, residents newly admitted to nursing homes after March 9
accounted for fewer than 10 percent of COVID-19 cases, though made up a larger proportion of deaths
(Appendix Exhibit B.5). Therefore, even though the analyses were limited to those in the facility as of
March 9, we capture most residents who were directly affected by COVID-19.
To estimate the relationship between characteristics and COVID-19 outcomes, we used a regression
model similar to Equation (1) but augmented with a nursing home fixed effect. Because data are either at
the resident-level or the wing-level, the nursing home fixed effect lets us control for all characteristics of
the nursing home. All differences in outcomes are entirely explained by averaging for residents or wings
within a single nursing home. Additionally, whereas the outcome for the facility-level analysis was the
number of cases or deaths per licensed bed, for the resident-level analysis, the outcome is an indicator for
whether the person got COVID-19 or died from COVID-19. We still used a linear regression, meaning
49
Room numbers are missing for less than 1 percent of observations.
Mathematica A.11
Appendix A. Methods
that for the resident-level analysis our model is a linear probability model. For the wing-level analysis, the
outcome was the share of residents who got sick or died from COVID-19. We controlled for the same
characteristics in both models, though in the resident-level analysis the characteristics are reflective of the
individual person whereas in the wing-level analysis the characteristics are the average for people who
lived in that wing. In both models, standard errors are clustered at the nursing home level.
Comparing cases and deaths in Connecticut nursing homes to neighboring states. To compare
COVID-19 outcomes in Connecticut nursing homes to those in other states, we used data from
Massachusetts, New Jersey, New York and Rhode Island about all cases and deaths in nursing homes
through the end of July 2020. For each of the states, we had to make some adjustments to ensure that the
comparison with Connecticut was as valid as possible.
• Massachusetts. We needed to impute the number of cases in each nursing home. Massachusetts
reports case counts in ranges (0; 1-10; 11-30; 31 or more). To impute the number of cases by nursing
home, we first calculated a potential number of cases by multiplying the number of deaths by 4.75.
For nursing homes with cases in the 1-10 and 11-30 range, if the number of potential cases was larger
than the midpoint of the range (i.e., 5 or 20) but smaller than the maximum value, we used the
number of potential cases. If the number of potential cases was below the midpoint, we used the
midpoint. If the number was above the maximum value, we used the maximum value. For nursing
homes with more than 30 cases, if the number of potential cases was larger than 30 but less than the
number of licensed beds, we used the number of potential cases. If the number of potential cases was
less than 30, we estimated the nursing home had 45 cases. If the number of potential cases was more
than the number of licensed beds, we used the number of licensed beds. After imputing, the total
number of cases summed across all individual facilities (24,148) nearly exactly matched the
aggregate numbers reported by the state as of July 29 (24,124).
• New York. New York does not report cases in individual nursing homes and only reports deaths in
nursing homes among residents who physically died in the facility. For the comparison with
Connecticut, we re-calculated deaths in each Connecticut nursing home only including the people
who physically died in the nursing home. We were able to capture this information by merging MDS
data to Vital Records death data in Connecticut, and only counting people as having died from
COVID-19 if a cause of death was COVID-19 and the place of death was a nursing home. As
described in footnote 12, only 1,618 COVID-19 deaths occurred in a nursing home, with many more
occurring outside of the nursing home. Though this approach is more comparable to the way New
York reports deaths, it assumes that nursing homes in New York had a similar share of residents die
inside and outside of the facility. In reality, it may be different, potentially because of New York’s
policy to only count deaths if the person died in the nursing home, which incentivizes nursing homes
to discharge people to a hospital to keep death counts lower.
• New Jersey. The New Jersey data only lists nursing homes that had non-zero cases or deaths. We
therefore needed to add back in all CMS-licensed nursing homes that were not included in the state’s
data and assume that they had zero cases and deaths.
• Rhode Island. We needed to impute the number of cases and deaths in each nursing home. Rhode
Island reports cases and death counts in ranges of five (for example, 45-49). For these data, we
imputed the number of cases or deaths to equal the midpoint of the range (for example, 47).
Additionally, the Rhode Island data only lists nursing homes that had non-zero cases or deaths. We
therefore needed to add back in all CMS-licensed nursing homes that were not included in the state’s
data and assume that they had zero cases and deaths.
Mathematica A.12
Appendix A. Methods
After these adjustments, we matched the individual nursing homes from each state dataset with Nursing
Home Compare data and excluded any nursing home from the analysis that could not be matched to the
Nursing Home Compare data. For example, Massachusetts reported data on nursing homes that do not
accept Medicare payments and are thus not regulated by CMS; these nursing homes were excluded as
outcomes might inherently differ.
We then estimated separate regression models using Equation (2) for each state that compared outcomes
at nursing homes within Connecticut but close to the neighboring state to outcomes at nursing homes in
the neighboring state that were within 50 miles of the border with Connecticut. 50 The coefficient β
indicates the difference between cases or deaths per licensed bed for the average nursing home in
Connecticut and the average nursing home in the neighboring state. For the comparison to Massachusetts,
Connecticut counties included Litchfield, Hartford, Tolland, and Windham; for the comparison to New
York and New Jersey, Connecticut counties included Fairfield, Litchfield, and New Haven; for the
comparison to Rhode Island, Connecticut counties included Tolland, Windham, New London, and
Middlesex. In the vector X f , the regression model controlled for the number of licensed beds in the
nursing home, the share of beds typically filled, the overall quality rating, the staffing rating, whether the
nursing home was for profit, whether it was part of a chain, whether it had a memory care unit, and the
number of COVID-19 cases per capita in the county it was located in (excluding all cases in nursing
homes).
α β Connecticut f + δ X f + ε f
y f =+ (2)
In addition to the regression model, we also conducted some descriptive analyses to summarize
differences in outcomes in long-term care facilities relative to the northeast region as a whole and to the
neighboring states. Appendix Exhibit B.14 shows total cases and deaths in long-term care facilities
reported as of the end of July scaled by the state’s total population. These data were reported by the New
York Times. Though informative, particularly for states in the northeast region that do not report statistics
in individual facilities, the primary drawback is that it is not clear exactly what facilities are included in
the total numbers; for example, Connecticut includes cases and deaths in nursing homes and assisted
living facilities, while others may not. Differences in what is defined as an assisted living facility in each
state may also make comparisons challenging. We therefore use this figure as motivation for the states to
include in a more careful, rigorously adjusted comparison with Connecticut. For the neighboring states
(excluding New York), we also report simple summary statistics on total nursing home cases and deaths
per licensed bed in each state as well as in facilities that are within 15, 30, and 50 miles of Connecticut
(Appendix Exhibit B.15).
Individual-level changes in well-being. We analyzed changes in well-being as measured in resident
assessments over time to measure the indirect effects of COVID-19. These well-being measures included
indicators for any depressive symptoms, unplanned substantial weight loss, presence of a severe pressure
ulcer, and any episode of incontinence. We also assessed the cognitive functioning scale and activities of
daily living score. We made several adjustments to the sample to address potential selection bias issues.
First, similar to the analysis of patterns within nursing homes, we limited individual-level data to only
include those residing in a nursing home as of March 9, 2020 to counteract selection bias. Second, for
those in a nursing home as of March 9, 2020, we then considered all subsequent assessments with
observed outcomes. We grouped these assessments by the week of the observation date. Our analysis
50
Results were approximately similar if using facilities only within 35 miles of the border.
Mathematica A.13
Appendix A. Methods
measures the average difference in outcomes for people observed in each week relative to the week of
March 10. To the extent that the pandemic is an important factor in patterns in outcomes, we would
expect to find changes grow over time, likely peaking sometime in mid-April to early May to correspond
with the peak of the pandemic.
In addition to controlling for selection bias by limiting the sample, we also took several other steps to
limit the extent to which differences in who is observed are likely to drive the results:
• We control for average patterns from 2017 to 2019 using the same approach to the data as we took for
2020 (e.g., limiting to people in the facility as of March 9 in that year and looking at all subsequent
observations for those people grouped by week up until the end of July). This controls for the way
that residents’ well-being is likely to deteriorate over time, both because of general aging as well as
from changes in the composition of the sample, such as the exit of many short-stay residents.
• For each outcome, we re-weighted residents in each week to ensure that that average characteristics
of observed residents match the average composition of residents observed in the week of March 10.
To do this, we used entropy balancing (Hainmuller 2012). This process balances covariates to ensure
two groups exactly match on a broad array of characteristics. We matched on residents’ age, gender,
race/ethnicity, active diagnoses, whether they were a short-stay resident, whether they were currently
covered under Medicare, and the value for the well-being outcome observed in the period most
recently preceding March 9, 2020.
The analysis is therefore based on a regression model of the form:
yiwy= α + Σ w β w (Year= 2020)*(Week= w) + Σ wδ w (Week= w) + γ (Year= 2020) + θ X i + ε f (3)
Outcomes y are measured for individual i in week w in year y. All people with observations in 2017 to
2020 are pooled together in the regression. The coefficients β w capture the average difference in
outcomes relative to those observed in March 10, controlling for the same difference observed in 2017 to
2019. The model is therefore similar to a difference-in-differences specification. The covariates included
in X i are the same as those that were used as matching characteristics using entropy balancing. Standard
errors are clustered at the nursing home level.
c. Connecticut assisted living facilities

To examine the impact of COVID-19 in Connecticut assisted living facilities, we used the cumulative
data on COVID-19 cases and deaths from DPH through July 14, 2020. After defining the licensed size for
each facility as described above, we produced descriptive characteristics of the assisted living facilities
and COVID-19 cases and deaths by location, size, and whether the facility had joint offerings. For our
analysis of town cases per capita and size of the facility, we used a bivariate linear regression model
similar to Equation (1) to assess whether more local cases or a larger facility were associated with more
cases or deaths.
3. Limitations
These analyses provide important insights into the effect of COVID-19 on nursing home and assisted
living facility residents, but there are several limitations that are important to consider in interpreting the
findings. We provide a list of potential limitations, though there may be others that are not listed.
Mathematica A.14
Appendix A. Methods
• In analyses that required knowing whether individual residents of nursing homes either got sick or
died from COVID-19, we relied on merging data by name, date of birth, and potentially address.
Though we were able to match over 90 percent of positive cases and deaths to resident assessment
data, we were not able to match everyone. The data therefore include a small percentage of people
who presumably tested positive or died from COVID-19, but who we were not able to identify as
such. We do not know whether the characteristics of the residents that were excluded were
significantly different than those included in our analyses. However, because such a small percentage
of people were missed, it is unlikely to affect our final results in any meaningful way.
• Our wing-level analysis was limited to a subset of nursing homes with floor plans, and thus may not
be representative of the spread within all nursing homes. We only had usable floor plans for about
one-third of nursing homes (69 out of 212). Among those with floor plans, about 20 percent had no
cases or deaths (13 nursing homes), and therefore did not contribute to the analysis; because there was
no variation in outcomes within the wings of the facility, the nursing home fixed effect essentially
excludes these facilities.
• Selection bias in the MDS data could be an important factor for individual-level outcomes, both in
terms of who got sick and in terms of well-being. Resident assessments are supposed to be done upon
admission, upon discharge, every three months, and if there is a significant change in status. The
pandemic could have influenced who is included in these resident assessments data in a variety of
ways. First, the people entering and exiting the facility could change, with (presumably) fewer people
entering and more people exiting than usual to avoid any possible exposure to COVID-19 in nursing
homes. Second, residents may be more likely to have a significant change in their status, particularly
if they got COVID-19. Third, staff may have had limited time to complete regular resident
assessments because they needed to focus all energies on controlling the outbreak to the extent
possible. Taken together, these factors make it challenging to make reliable comparisons, both
because the residents included may change and because it is not inherently obvious how the changes
in resident composition might influence their outcomes. However, particularly in our analysis of
resident outcomes, we controlled for various types of selection bias to the extent possible. We limited
the sample to only include residents who were already in the nursing home as of March 9, we
controlled for trends in previous years, and we re-weighted the samples to guarantee that they were
equal in observable characteristics. Nonetheless, it is possible that there are important unobserved
characteristics that we were unable to account for, and some selection bias could have impacted our
findings. The findings should thus be considered cautiously.
• Lastly, in order to compare Connecticut outcomes to other states, we had to make several adjustments
to other states’ data. However, we do not know exactly how each state classifies and counts cases and
deaths, nor the way that the method for counting cases and deaths could influence behavior and thus
observed outcomes. The adjustments we made therefore may not guarantee that the numbers between
states are measured in the same way, and thus they may not be directly comparable.
Additionally, because of data limitations, we were unable to conduct the same types of comprehensive
analysis of the pandemic in assisted living facilities as we could in nursing homes. Beyond the number of
cases and deaths, we have little other quantitative information about residents of assisted living facilities.
We were also unable to compare outcomes in Connecticut assisted living facilities to those in neighboring
states. Although some states report cases and deaths from COVID-19 in individual assisted living
facilities, the data structure differs substantially from the data in Connecticut. In Massachusetts assisted
living facilities, cases are reported in broad ranges, similar to the approach for nursing homes, but because
Mathematica A.15
Appendix A. Methods
they do not report deaths, we could not estimate true case counts. New Jersey includes more than 500
total long-term care facilities in its data but does not indicate the type of facility. We were able to identify
comparable nursing homes in New Jersey for our nursing home analysis by merging the data with
Nursing Home Compare, but we were unable to identify assisted living facilities to compare to those in
Connecticut. Rhode Island only reported data for 12 assisted living facilities, which did not allow us to do
a robust comparison to Connecticut outcomes. Though we could adjust deaths in nursing homes in
Connecticut to match the reporting structure used in New York, this was not possible for assisted living
facilities; we did not have access to resident-level data on who was present in assisted living facilities at
the outset of the pandemic and at subsequent time periods, similar to what we can measure with the MDS
for nursing homes.
Mathematica A.16
APPENDIX B
Supplemental Tables and Figures
Appendix B. Supplemental Tables and Figures
This appendix contains supplemental tables and figures from our assessment of facility and resident-level
data presented in Chapter III of this report.
Exhibit B.1. Characteristics of Connecticut nursing homes

Characteristic Percentage
Number of licensed beds
<25 0.5
25-49 6.1
50-74 15.1
75-99 16.0
100-124 21.7
125-149 16.0
150-174 12.3
175-199 5.2
200-249 3.3
250-299 1.9
300+ 1.9
Profit status
For profit 83.0
Non-profit 17.0
Chain affiliation
Part of a chain 52.9
Not part of a chain 47.1
Memory care unit
Has memory care unit 19.5
No memory care unit 80.5
Nursing home star rating: overall
1 star 9.5
2 stars 20.5
3 stars 13.3
4 stars 27.6
5 stars 29.1
Nursing home star rating: health inspections
1 star 17.6
2 stars 23.8
3 stars 23.3
4 stars 25.7
5 stars 9.5
Mathematica B.2
Nursing home star rating: staffing
1 star 2.9
2 stars 12.9
3 stars 40.5
4 stars 29.1
5 stars 14.8
Nursing home star rating: quality measures
1 star 1.0
2 stars 7.1
3 stars 17.6
4 stars 31.4
5 stars 42.9
Source: Mathematica’s analysis of Nursing Home Compare and LTCFocus data.
Note: The analyses included 212 licensed nursing homes in the state of Connecticut with data on COVID-19
cases and deaths that could be matched to data reported by Nursing Home Compare. Chain affiliation and
presence of a memory care unit were obtained from LTCFocus, and these characteristics were only
available for 210 of the 212 nursing homes included in these analyses.
Mathematica B.3
Exhibit B.2. Characteristics of Connecticut assisted living facilities

Number of licensed beds
<25 12.8%
25-49 12.8%
50-74 21.8%
75-99 24.8%
100-124 20.3%
125+ 7.5%
Joint offerings
Has joint offerings 26.3%
No joint offerings 73.7%
Source: Mathematica’s analysis of Connecticut DPH FLIS portal on individual resident data as reported by assisted
living facilities.
Note: This includes 133 assisted living facilities in Connecticut that reported COVID-19 cases or deaths. Joint
offerings include those that also have a nursing home, senior independent living, or residential care facility
at the same location as reported by assisted living facilities to DPH.
DPH = Department of Public Health; FLIS = Facility Licensing and Investigations Section.
Exhibit B.3. Rates of COVID-19 transmission in Connecticut and neighboring states
Source: Mathematica’s analysis of transmission data compiled by rt.live.

Note: Neighboring states include Massachusetts, New Jersey, New York, and Rhode Island. The Northeast
region includes these four states plus Delaware, Maine, Maryland, New Hampshire, Pennsylvania,
Vermont, and Washington, DC. The rate of transmission is estimated as the number of new people each
infected person gets sick. The figure is capped at a rate of transmission of 1.5, so data is not displayed for
earlier dates where the rate of transmission was higher than 1.5. Analyses are based on rates of
transmission from March 9, 2020 to August 1, 2020.
Mathematica B.4
Exhibit B.4. Rates of COVID-19 transmission in Connecticut by county
Source: Mathematica’s analysis of the number of tests and positive tests reported by DPH using the model
developed by rt.live.
Note: The rate of transmission is estimated as the number of new people each infected person gets sick. The
figure is capped at a rate of transmission of 1.5, so data is not displayed for earlier dates where the rate of
transmission was higher than 1.5. Analyses are based on rates of transmission from February 25, 2020 to
July 29, 2020.
DPH = Department of Public Health;
Mathematica B.5
Exhibit B.5. Characteristics of Connecticut nursing home residents

All residents Existing stay residents New stay residents
Tested Tested Tested
Characteristic All positive Died All positive Died All positive Died
Number of people 31,827 8,168 2,612 21,808 7,380 2,191 10,019 788 421
Age (years) 78.3 78.3 82.6 79.3 78.6 82.9 76.2 75.9 81.2
Male 38.5 38.4 43.8 36.0 37.8 42.0 44.1 44.7 53.4
Race and ethnicity
Non-Hispanic White 82.3 78.8 80.7 81.7 78.8 80.2 83.6 78.3 83.6
Non-Hispanic Black 10.8 13.1 12.9 11.0 13.1 13.6 10.3 13.4 9.2
Hispanic 6.0 7.2 5.2 6.3 7.2 5.1 5.4 7.2 5.9
Health conditions
Cancer diagnosis 10.9 9.3 11.2 9.7 9.0 10.3 13.9 12.4 16.7
Heart/circulation diagnosis 52.7 52.4 57.7 50.8 51.7 57.2 57.2 59.0 60.2
Gastrointestinal diagnosis 0.9 0.5 0.7 0.7 0.5 0.8 1.3 0.7 0.0
Genitourinary diagnosis 3.3 2.8 4.1 2.7 2.5 3.6 4.8 5.6 6.9
Infections 27.5 28.0 29.7 26.4 27.2 28.4 30.3 34.7 37.2
Metabolic diagnosis 5.2 3.2 3.8 3.7 2.7 2.9 8.8 8.4 8.6
Musculoskeletal diagnosis 25.0 31.0 32.4 29.6 32.1 34.4 14.0 20.4 20.5
Neurological diagnosis 7.2 5.1 6.3 5.8 4.5 5.5 10.5 10.6 11.2
Nutritional diagnosis 29.4 36.6 33.4 34.4 38.4 37.0 17.6 20.0 12.1
Psychiatric/mood disorder 4.4 2.9 3.9 3.4 2.6 3.4 6.7 5.7 7.2
Pulmonary diagnosis 7.0 6.5 7.8 6.2 6.1 7.5 8.7 10.3 9.8
Short-stay resident 53.0 30.4 36.2 31.4 23.0 23.9 100.0 100.0 100.0
Received physical therapy 46.6 27.6 30.3 28.3 21.6 21.6 89.9 83.6 81.8
Gets dialysis treatment 2.2 2.6 2.3 1.7 2.2 1.9 3.4 6.5 4.6
Gets cancer treatment 0.9 0.7 0.8 0.7 0.7 0.7 1.5 0.8 0.9
Has any depressive symptoms 51.0 45.3 45.8 48.3 44.4 44.5 57.4 53.9 53.8
Has cognitive impairment 37.3 43.3 54.8 43.1 44.9 57.2 23.4 28.3 40.3
Recent unplanned weight loss 2.7 3.7 4.8 3.7 4.0 5.6 0.1 0.4 0.6
Recent fall 14.6 17.8 20.2 17.4 18.7 21.7 7.7 8.9 11.2
Any pressure ulcer 7.2 4.7 6.5 4.9 3.8 4.8 12.6 13.7 17.3
Has catheter 5.6 4.2 4.4 4.4 3.8 4.2 8.2 8.3 5.8
Anti-psychotic medication 13.5 13.7 14.9 13.5 13.5 14.5 13.4 15.8 17.6
Anti-anxiety medication 16.4 17.1 14.9 16.5 17.3 15.2 16.1 15.8 13.3
Source: Mathematica’s analysis of Connecticut DPH FLIS portal on individual resident data, as reported by nursing homes, by
July 22; Connecticut’s Vital Records death data; and MDS data.
Note: All characteristics are percentages unless otherwise noted. Uses nursing home resident assessment data to identify
people who lived in a nursing home as of March 9, 2020 (existing stay residents) or were admitted to the nursing home
between March 10, 2020 and July 31, 2020 (new stay residents).
Mathematica B.6
Exhibit B.6. Characteristics included in feature selection model

Characteristic Source
Nursing home characteristics
Town cases per 100,000 residentsa Connecticut Department of Public Health
Town deaths per 100,000 residentsa Connecticut Department of Public Health
Town median household income Connecticut Department of Economic and
Community Development
Town population Connecticut Department of Public Health
Nursing home ownership type Nursing Home Compare
Number of licensed beds Nursing Home Compare
Overall rating Nursing Home Compare
Health inspection rating Nursing Home Compare
Staffing rating Nursing Home Compare
Quality measure rating Nursing Home Compare
Total health deficiencies (most recent rating cycle) Nursing Home Compare
Standard health deficiencies (most recent rating cycle) Nursing Home Compare
Complaint health deficiencies (most recent rating cycle) Nursing Home Compare
Health deficiency score (most recent rating cycle) Nursing Home Compare
Total health score (most recent rating cycle) Nursing Home Compare
Total weighted health survey score Nursing Home Compare
Number of facility reported incidents Nursing Home Compare
Number of substantiated complaints Nursing Home Compare
Number of fines Nursing Home Compare
Total amount of fines in dollars Nursing Home Compare
Number of payment denials Nursing Home Compare
Total number of penalties Nursing Home Compare
Continuing care retirement community Nursing Home Compare
Percent of residents paid with Medicaid LTCFocus
Percent of residents paid with Medicare LTCFocus
Average acuity index LTCFocus
Memory care unit LTCFocus
Chain affiliation LTCFocus
Total residents as of 3/9/20 MDS
Share of licensed beds filled as of 3/9/20 Nursing Home Compare, MDS
Resident characteristics (averaged across all residents in each nursing home as of 3/9/2020)
Male MDS
Age in years MDS
Non-white MDS
Recent unplanned weight loss MDS
Had a recent fall MDS
Had a recent pressure ulcer MDS
Has catheter MDS
Mathematica B.7
Characteristic Source
Anti-psychotic medication MDS
Anti-anxiety medication MDS
Lost control of bladder MDS
Had any depressive symptoms MDS
Cognitive functioning score MDS
Activity of daily living score MDS
Short-stay (less than 100 days in nursing home) MDS
Months in the nursing home (as of 3/9/20) MDS
Getting dialysis or cancer treatments MDS
History of wandering MDS
Gets physical therapy MDS
Currently has Medicare stay MDS
Cancer diagnosis MDS
Heart/circulation diagnosis MDS
Gastrointestinal diagnosis MDS
Genitourinary diagnosis MDS
Infections MDS
Metabolic diagnosis MDS
Musculoskeletal diagnosis MDS
Neurological diagnosis MDS
Nutritional diagnosis MDS
Psychiatric/mood disorder MDS
Pulmonary diagnosis MDS
Vision diagnosis MDS
Recently isolated or quarantined MDS
homes, by July 22; Connecticut’s Vital Records death data; and MDS data.
Note: All characteristics are percentages unless otherwise noted. Uses nursing home resident assessment data
to identify people who lived in a nursing home as of March 9, 2020 (existing stay residents) or were
admitted to the nursing home between March 10, 2020 and July 31, 2020 (new stay residents).
a Town cases exclude those reported for all nursing homes and assisted living facilities located in that town.
Mathematica B.8
Exhibit B.7. COVID-19 cases and deaths in Connecticut nursing homes compared to cases in the
surrounding town
Source: Mathematica’s analysis of nursing home reported data included in Connecticut’s FLIS system.
Note: The relationship between cases and deaths in nursing homes and cases per 100,000 residents was
statistically significant for cases (p = 0.003) and death (p = 0.004). Deaths include both confirmed and
probable deaths attributable to COVID-19. Cases in each town exclude all cases reported in nursing homes
and assisted living facilities within that town. Analyses are based on cases and deaths between March 16,
2020 and July 19, 2020.
Mathematica B.9
Exhibit B.8. Facility-level multivariate regression model

Any cases Cases per licensed bed Deaths per licensed bed
Standard Standardized Standard Standardized Standard Standardized
Characteristic Estimate error coefficient Estimate error coefficient Estimate error coefficient
Nursing home characteristics
Town cases per 100,000
residentsa 0.013*** 0.005 0.214 0.005* 0.003 0.128 0.003*** 0.001 0.205
Town median household income 0.003*** 0.001 0.228 0.001** 0.001 0.163 0.001*** 0.000 0.268
Profit status -0.055 0.081 -0.054 0.027 0.043 0.040 0.014 0.018 0.056
Chain affiliation 0.099** 0.050 0.133 0.054 0.033 0.109 0.018 0.012 0.098
High health inspection rating -0.053 0.054 -0.068 -0.040 0.035 -0.076 -0.009 0.013 -0.047
High staffing rating -0.080 0.062 -0.106 -0.080** 0.039 -0.159 -0.032** 0.014 -0.172
High quality measure rating 0.045 0.061 0.053 0.042 0.037 0.073 0.018 0.015 0.084
Total residents as of 3/9/20 0.002*** 0.001 0.194 0.001*** 0.000 0.162 0.000** 0.000 0.130
Share of licensed beds filled as
of 3/9/20 0.004 0.002 0.104 0.006*** 0.001 0.260 0.002*** 0.001 0.256
Resident characteristics
Male 0.006* 0.003 0.189 0.002 0.002 0.109 0.000 0.001 0.041
Activities of daily living score 0.064*** 0.018 0.314 0.009 0.011 0.066 0.003 0.005 0.067
Getting dialysis or cancer
treatments 0.003 0.007 0.019 0.014** 0.006 0.152 0.004* 0.002 0.114
Had a recent fall 0.001 0.004 0.012 0.001 0.002 0.023 0.000 0.001 0.024
Had a recent pressure ulcer 0.004 0.006 0.041 0.011** 0.005 0.152 0.004** 0.002 0.161
Had any depressive symptoms -0.002** 0.001 -0.144 -0.001 0.001 -0.087 -0.000* 0.000 -0.108
Lost control of bladder -0.002 0.003 -0.074 -0.000 0.002 -0.000 0.000 0.001 0.053
Source: Mathematica’s analysis of nursing home reported data included in Connecticut’s FLIS system, Nursing Home Compare, LTCFocus, MDS data, and Connecticut DPH data
on COVID-19.
Note: Deaths include both confirmed and probable deaths attributable to COVID-19. Standard errors are robust to heteroskedasticity. Standardized coefficients are based on re-
scaling all variables to have a mean of zero and standard deviation of one, and therefore give a sense of the relative magnitudes of each of the characteristics. For binary
nursing home characteristics, the coefficient can be interpreted as the difference in outcomes between nursing homes with and without that characteristic. Resident
characteristics are based on the mean of all residents living in the nursing home as of March 9, 2020. Therefore, the coefficients can be interpreted as the change in
outcomes for a one percent increase in residents with that characteristic (or for activities of daily living, an increase of one in the average score of all residents).
a
Town cases exclude those reported for all nursing homes and assisted living facilities located in that town.
***/**/* indicate statistical significance at the 1/5/10 percent level.
Mathematica B.10
Exhibit B.9. Bivariate analyses of the relationship between nursing home characteristics and
COVID-19 cases and deaths per licensed bed in Connecticut
Characteristic N Cases per licensed bed Deaths per licensed bed
Licensed bed capacity *** ***
<75 46 0.18 0.06
75-99 34 0.31 0.09
100-124 46 0.34 0.11
125-149 34 0.35 0.12
150-199 37 0.44 0.13
200+ 15 0.35 0.12
Profit status *** **
For profit 176 0.34 0.11
Non-profit 36 0.21 0.07
Chain affiliation *** ***
Part of a chain 111 0.37 0.12
Not part of a chain 99 0.26 0.09
Memory care unit
Has memory care unit 41 0.37 0.12
No memory care unit 169 0.31 0.10
Nursing home star rating: *** **
overall
1 star 20 0.29 0.09
2 stars 43 0.38 0.13
3 stars 28 0.41 0.13
4 stars 58 0.29 0.10
5 stars 61 0.27 0.09
Nursing home star rating: **
health inspections
1 star 37 0.31 0.09
2 stars 50 0.40 0.14
3 stars 49 0.32 0.09
4 stars 54 0.27 0.09
5 stars 20 0.28 0.10
Nursing home star rating: *** ***
staffing
1 star 6 NR NR
2 stars 27 0.42 0.14
3 stars 85 0.39 0.13
4 stars 61 0.25 0.08
5 stars 31 0.20 0.07
Mathematica B.11
Characteristic N Cases per licensed bed Deaths per licensed bed

Nursing home star rating:
quality measures
1 star 2 NR NR
2 stars 15 0.20 0.07
3 stars 37 0.33 0.10
4 stars 66 0.32 0.11
5 stars 90 0.34 0.11
Recent complaint ** **
No recent complaints 64 0.25 0.08
Had a recent complaint 148 0.35 0.11
Source: Mathematica’s analysis of nursing home reported data included in Connecticut’s FLIS system, and Nursing
Home Compare and LTCFocus data.
Note: Deaths include both confirmed and probable deaths attributable to COVID-19. Stars in the top row for each
characteristic indicate whether there is a statistically significant difference in the outcome by characteristic.
For characteristics with two categories, the test compares the outcome between the two groups. For
nursing home star ratings, the test compares the outcome for facilities with 1, 2, or 3 stars to facilities with 4
or 5 stars. For licensed bed capacity, the test assesses whether there is a linear relationship between the
number of beds and the outcome. Outcomes for groups with fewer than 10 nursing homes are not reported
due to the unreliability associated with a small sample size.
FLIS = Facility Licensing and Investigations Section; NR = not reported.
Mathematica B.12
Exhibit B.10. Bivariate regression coefficients from analyses of the relationship between nursing
home characteristics and COVID-19 cases and deaths per licensed bed in Connecticut
Cases per licensed bed Deaths per licensed bed
Standard Standardized Standard Standardized
Characteristic Estimate error coefficient Estimate error coefficient
Town cases per 100,000
residentsa 0.007*** 0.002 0.161 0.003*** 0.001 0.165
Town median household
income 0.001 0.001 0.063 0.001*** 0.000 0.172
Total residents as of 3/9/20 0.002*** 0.000 0.323 0.001*** 0.000 0.276
Share of licensed beds filled
as of 3/9/20 0.005*** 0.001 0.230 0.002*** 0.001 0.216
Male 0.005*** 0.001 0.250 0.001* 0.000 0.123
Age -0.009*** 0.003 -0.240 -0.001 0.001 -0.075
Non-white 0.004*** 0.001 0.255 0.001** 0.000 0.170
Activities of daily living score -0.029 0.063 -0.033 0.016 0.024 0.047
Cognitive functioning score -0.008 0.010 -0.057 0.002 0.003 0.044
Getting dialysis or cancer
treatments 0.025*** 0.009 0.275 0.007** 0.003 0.196
Had a recent fall -0.003 0.003 -0.079 -0.001 0.001 -0.066
Had a recent pressure ulcer 0.010** 0.004 0.146 0.005*** 0.002 0.190
Had any depressive
symptoms -0.001* 0.001 -0.126 -0.000* 0.000 -0.126
Lost control of bladder -0.005** 0.002 -0.148 -0.001 0.001 -0.074
Source: Mathematica’s analysis of nursing home reported data included in Connecticut’s FLIS system and MDS
data.
Note: Deaths include both confirmed and probable deaths attributable to COVID-19. Resident characteristics are
based on the average for all residents in the nursing home as of March 9, 2020 using the resident
assessment observed most immediately preceding that date. The coefficients can be interpreted as the
change in outcomes for a one percent increase in residents with that characteristic (or for age, activities of
daily living, and cognitive functioning score, an increase of one in the average for of all residents).
Mathematica B.13
Exhibit B.11. Concentration of COVID-19 cases in wings within nursing homes
homes, by July 22; and MDS data.
Note: Includes 56 nursing homes with a floor plan that allowed us to identify room numbers associated with each
wing and that had non-zero COVID-19 cases (thirteen nursing homes that had a floor plan had zero cases,
so were excluded from this graph). Each circle represents a single wing of the facility. We calculated the
share of residents by dividing the number of residents living in that wing by the total number of residents
living in the facility as of March 9, 2020. DPH provided floor plans for Connecticut nursing homes to
Mathematica.
DPH = Department of Public Health; FLIS = Facility Licensing and Investigations Section; MDS = Minimum Datasets.
Mathematica B.14
Exhibit B.12. Individual-level multivariate regression model

Cases Deaths
Standard Standard
Characteristic Estimate error Estimate error
Weight 0.000*** 0.000 0.000** 0.000
Recent unplanned weight loss 0.003 0.018 0.036** 0.014
Had a recent fall 0.020** 0.009 0.024*** 0.007
Had a recent pressure ulcer -0.022 0.015 0.006 0.012
Has catheter -0.019 0.014 -0.008 0.011
Anti-psychotic medication 0.015 0.009 0.004 0.007
Anti-anxiety medication -0.002 0.008 -0.000 0.006
Lost control of bladder 0.027*** 0.009 0.013** 0.006
Has any depressive symptoms -0.005 0.008 0.004 0.005
Cognitive functioning score 0.006 0.004 0.018*** 0.003
Activity of daily living score -0.003*** 0.001 0.002** 0.001
Short-stay (less than 100 days in nursing home) -0.085*** 0.013 -0.008 0.007
Months in the nursing home (as of 3/9/20) 0.000 0.000 0.000** 0.000
Gets dialysis treatment 0.065** 0.028 0.015 0.016
Gets cancer treatment -0.020 0.032 0.015 0.027
History of wandering 0.041** 0.018 0.010 0.014
Gets physical therapy -0.045*** 0.011 -0.014** 0.006
Currently has Medicare stay -0.065*** 0.015 -0.023** 0.009
Age in years 0.001*** 0.000 0.003*** 0.000
Male 0.006 0.008 0.045*** 0.006
Race is non-white (versus white) -0.003 0.010 -0.008 0.007
Cancer diagnosis -0.002 0.011 0.009 0.008
Heart/circulation diagnosis 0.024*** 0.006 0.015*** 0.005
Gastrointestinal diagnosis 0.013 0.039 0.049 0.033
Genitourinary diagnosis -0.006 0.025 0.017 0.015
Infections 0.008 0.020 0.033** 0.015
Metabolic diagnosis 0.007 0.007 0.013*** 0.005
Musculoskeletal diagnosis -0.024 0.015 -0.009 0.012
Neurological diagnosis 0.012 0.008 -0.003 0.006
Nutritional diagnosis -0.009 0.013 -0.009 0.009
Psychiatric/mood disorder 0.022*** 0.008 0.015*** 0.005
Pulmonary diagnosis -0.024 0.017 0.025* 0.013
Vision diagnosis 0.000 0.014 0.015 0.010
Note: Only includes people who lived in a nursing home as of March 9, 2020. Characteristics are based on the resident
assessment observed immediately preceding March 9, 2020. Individual-level data indicates if the person tested positive
for the disease or died and have COVID-19 listed as a cause of death by July 31, 2020. The regression model includes a
nursing home fixed effect. For binary characteristics, the coefficient can be interpreted as the difference in the probability
of having COVID-19 or dying from COVID-19 for people who have that characteristic relative to the people who do not.
For non-binary characteristics, the coefficient can be interpreted as the increased probability of having COVID-19 or
dying from COVID-19 associated with an increase of one unit in the characteristic (e.g., a one-year increase in age or an
increased score of one in activities of daily living).
Mathematica B.15
Exhibit B.13. Wing-level multivariate regression model

Cases Deaths
Standard Standard
Characteristic Estimate error Estimate error
Weight 0.084 0.067 0.039 0.038
Recent unplanned weight loss 0.261* 0.143 0.118 0.125
Had a recent fall -0.026 0.079 -0.022 0.046
Had a recent pressure ulcer 0.122 0.155 -0.009 0.075
Has catheter 0.125 0.134 -0.002 0.093
Anti-psychotic medication 0.049 0.092 0.021 0.052
Anti-anxiety medication -0.141 0.091 0.054 0.048
Lost control of bladder 0.151* 0.090 0.053 0.047
Has any depressive symptoms -0.021 0.045 0.008 0.032
Cognitive functioning score -3.088 3.398 0.311 1.587
Activity of daily living score -1.022 0.749 0.029 0.439
Short-stay (less than 100 days in nursing home) -0.200*** 0.071 0.083** 0.037
Months in the nursing home (as of 3/9/20) 0.127 0.113 0.159** 0.075
Gets dialysis treatment 0.359* 0.188 0.096 0.155
Gets cancer treatment -0.194 0.359 0.228 0.224
History of wandering 0.241 0.199 0.075 0.091
Gets physical therapy 0.022 0.075 -0.066* 0.039
Currently has Medicare stay -0.050 0.119 -0.018 0.052
Age in years 0.008 0.318 0.397 0.238
Male -0.057 0.057 0.054** 0.024
Race is non-white (versus white) 0.034 0.085 0.052 0.036
Cancer diagnosis -0.107 0.087 0.020 0.067
Heart/circulation diagnosis -0.016 0.060 -0.038 0.036
Gastrointestinal diagnosis -0.544* 0.292 0.041 0.151
Genitourinary diagnosis 0.046 0.161 0.021 0.090
Infections 0.263* 0.150 0.018 0.065
Metabolic diagnosis -0.078 0.080 0.049 0.035
Musculoskeletal diagnosis -0.072 0.118 -0.016 0.060
Neurological diagnosis 0.171*** 0.062 0.030 0.032
Nutritional diagnosis -0.125 0.129 0.086 0.055
Psychiatric/mood disorder 0.044 0.074 0.078* 0.044
Pulmonary diagnosis -0.152 0.135 0.027 0.078
Vision diagnosis -0.086 0.155 -0.144* 0.075
Note: Only includes people who lived in a nursing home as of March 9, 2020. Characteristics are based on the resident
assessment observed immediately preceding March 9, 2020. Aggregates the individual-level data for 69 nursing homes
with a usable floor plan. Outcomes are the share of residents who tested positive or who died from COVID-19, while the
characteristics are the averages for residents who lived in that wing as of March 9, 2020. Individual-level data indicates if
the person tested positive for the disease or died and have COVID-19 listed as a cause of death by July 31, 2020. The
regression model includes a nursing home fixed effect. For binary characteristics, the coefficient can be interpreted as
the change in the percentage of residents testing positive for COVID-19 of dying from COVID-19 given an increase of
one percent of people in that wing with the characteristic. For non-binary characteristics, the coefficient can be
interpreted as the change in the percentage of residents testing positive for COVID-19 of dying from COVID-19 given an
increase of one unit in the average characteristic among all residents in that wing (e.g., a one-year increase in age or an
increased score of one in activities of daily living).
Mathematica B.16
Exhibit B.14. Total COVID-19 cases and deaths in long-term care facilities per 100,000 total
population in Northeast states
Source: Mathematica’s analysis of aggregate long-term care facility data across states reported by the New York
Times combined with Census Bureau population estimates.
Note: Analyses are based on cases and deaths in nursing homes reported through the end of July 2020.
Mathematica B.17
Exhibit B.15. Total nursing home COVID-19 cases and deaths per licensed bed in Connecticut and
nearby states and nearby nursing homes
Source: Mathematica’s analysis of state-reported data by individual nursing home matched to Nursing Home
Compare and LTCFocus data.
Note: Analyses are based on cases and deaths in nursing homes reported by July 31, 2020. Massachusetts
reported cases in nursing homes in ranges; we used the number of deaths to impute the number of cases,
resulting in total cases that approximately matched the total nursing home cases reported across the state.
Therefore, we shade the bar for Massachusetts to be more transparent to indicate the potential unreliability
of this number. Rhode Island and New Jersey do not report information on nursing homes that had zero
cases or deaths; the licensed nursing homes not included in the state’s data are assumed to have zero
cases and zero deaths. Our analysis of nearby nursing homes excludes New York because of data
reliability concerns.
Mathematica B.18
Exhibit B.16. Unplanned substantial weight loss, by COVID-19 status
Connecticut nursing home residents and Connecticut DPH FLIS portal on individual resident data, as
reported by nursing homes, by July 22.
Note: Unplanned substantial weight loss is defined as someone having lost 5 percent or more in the last month or
10 percent or more in the last six months. This is based on item K0300 from the Minimum Data Set Version
3.0 resident assessment form. Each point represents the percentage of residents observed that week with
unplanned substantial weight loss, reporting separately by their final COVID-19 status.
DPH = Department of Public Health; FLIS = Facility Licensing and Investigations Section.
Mathematica B.19
Exhibit B.17. Changes in severe pressure ulcers among Connecticut nursing home residents,
March through July
Note: This is based on item M0300 from the Minimum Data Set Version 3.0 resident assessment form. Each point
represents the difference in average outcomes for that week relative to outcomes observed in the week of
March 10, 2020. The sample includes people who lived in the nursing home as of March 9, 2020, and
includes all subsequent observations. It also controls for patterns from 2017 to 2019 using the same
approach, and reweights the sample to ensure observable characteristics are similar for all time periods.
Bars represent the 95 percent confidence interval accounting for standard errors clustered at the nursing
home level.
Mathematica B.20
Exhibit B.18. Changes in cognitive functioning scale among Connecticut nursing home residents,
March through July
Note: This is based on item C0500 from the Minimum Data Set Version 3.0 resident assessment form for those
who could complete the Brief Interview for Mental Status, and from an array of items used to create the
Cognitive Performance Scale (Morris et al. 1994) for those who could not complete the interview on their
own. Each point represents the difference in average outcomes for that week relative to outcomes
observed in the week of March 10, 2020. The sample includes people who lived in the nursing home as of
March 9, 2020, and includes all subsequent observations. It also controls for patterns from 2017 to 2019
using the same approach, and reweights the sample to ensure observable characteristics are similar for all
time periods. Bars represent the 95 percent confidence interval accounting for standard errors clustered at
the nursing home level.
Mathematica B.21
Exhibit B.19. Changes in activities of daily living score among Connecticut nursing home
residents, March through July
Note: This is based on items G0110A, G0110B, G0110H, and G0110I from the Minimum Data Set Version 3.0
resident assessment form. Each point represents the difference in average outcomes for that week relative
to outcomes observed in the week of March 10, 2020. The sample includes people who lived in the nursing
home as of March 9, 2020, and includes all subsequent observations. It also controls for patterns from 2017
to 2019 using the same approach, and reweights the sample to ensure observable characteristics are
similar for all time periods. Bars represent the 95 percent confidence interval accounting for standard errors
clustered at the nursing home level.
Mathematica B.22
Exhibit B.20. Changes in episodes of incontinence among Connecticut nursing home residents,
March through July
Note: This is based on items H0300 and H0400 from the Minimum Data Set Version 3.0 resident assessment
form. Each point represents the difference in average outcomes for that week relative to outcomes
observed in the week of March 10, 2020. The sample includes people who lived in the nursing home as of
March 9, 2020, and includes all subsequent observations. It also controls for patterns from 2017 to 2019
using the same approach, and reweights the sample to ensure observable characteristics are similar for all
time periods. Bars represent the 95 percent confidence interval accounting for standard errors clustered at
the nursing home level.
Mathematica B.23
Exhibit B.21. Total COVID-19 cases and deaths in Connecticut assisted living facilities compared
to cases in the surrounding town
Source: Mathematica’s analysis of assisted-living reported data included in Connecticut’s FLIS system.
Note: The relationship was highly statistically significant for cases (p = 0.035) and deaths (p = 0.023). Deaths
include both confirmed and probable deaths attributable to COVID-19. Cases in each town exclude all
cases reported in nursing homes and assisted living facilities within that town.
Exhibit B.22. Total COVID-19 cases and deaths in Connecticut assisted living facilities by size of
facility
Source: Mathematica’s analysis of assisted-living reported data included in Connecticut’s FLIS system.
Note: The relationship is significant for both cases per bed (p = 0.018) and deaths per bed (p = 0.049). Deaths
include both confirmed and probable deaths attributable to COVID-19. The size of the facility was missing
for 28 assisted living facilities; in these instances, we used the current census as the size. Some facilities
also might have reported their current census rather than the potential size as the size.
Mathematica B.24
APPENDIX C
Timelines
Appendix C. Timelines
Federal-Level Timeline of Policy Changes and Guidance

January 2020
January 31, 2020: The U.S. Department of Health and Human Services determines a public health
emergency exists and has existed since January 27, 2020.
March 2020
March 6, 2020: President Donald Trump signs an $8.3 billion spending package, the Coronavirus
Preparedness and Response Supplemental Appropriations Act of 2020 (CARES Act) (COVID-19
Package #1), which provides supplemental funding for the Department of Health and Human Services,
the State Department, and the Small Business Administration to respond to the coronavirus outbreak.
March 8, 2020: The Centers for Disease Control and Prevention issues guidance prioritizing testing of
symptomatic people who are hospitalized, in a high risk group, or who had close contact with a suspected
or confirmed COVID-19 case.
March 13, 2020: The president declares a national emergency.
March 13, 2020: The Centers for Medicare & Medicaid Services announces the activation of blanket
1135 waivers. Blanket waivers activate to ease certain requirements for providers to respond to COVID-
19, including providing flexibility and relief for state Medicaid agencies via 1135 waivers and temporary
suspension of non-emergency survey inspections (allowing for a focus on infectious disease and other
most serious health and safety threats).
March 13, 2020: The Centers for Medicare & Medicaid Services releases memo QSO-20-14-NH, which
directs nursing homes to restrict all visitors, including non-essential workers. The memo provides
additional guidance to help nursing homes improve infection control and prevention practices to prevent
transmission of COVID-19.
March 15, 2020: The Centers for Disease Control and Prevention issues guidance recommending that
gatherings of 50 or more people should be canceled for the next eight weeks.
March 18, 2020: The federal government enacts the Families First Coronavirus Response Act (COVID-
19 Package #2), which included paid sick leave, insurance coverage of coronavirus testing, nutrition
assistance, and unemployment benefits
March 23, 2020: The Centers for Medicare & Medicaid Services releases memo QSO-20-20-All, which
announces changes to the nursing home inspection process, including a new COVID-19 infection control
survey. This guidance establishes a three-week time period during which only complaints, targeted
infection control surveys, and self-assessments would be conducted. It stipulates that surveyors should not
enter facilities if they do not have the appropriate personal protective equipment to do so.
March 24, 2020: The Federal Emergency Management Agency announces use of Defense Production
Act to acquire 60,000 coronavirus testing kits.
March 27, 2020: The president signs the CARES Act (COVID-19 Package #3) into law, which includes
direct payments to Americans, extended unemployment benefits, and more than $140 billion to support
Mathematica C.2
the U.S. health system, including funding for personal protective equipment, testing supplies, and
workforce supports, as well as funding to states.
April 2020
April 3, 2020: The Centers for Disease Control and Prevention issues a recommendation encouraging the
use of a cloth face covering when out in public.
April 6, 2020: The Centers for Medicare & Medicaid Services publishes Interim Final Rule I, regulations
retrospectively effective March 31, 2020. The rule changes payment policy to allow Medicare-certified
providers flexibility to use remote communications technology (telehealth) to minimize COVID-19
exposure risks.
April 19, 2020: The Centers for Medicare & Medicaid Services releases memo QSO-20-26, Upcoming
Requirements for Notification of Confirmed COVID-19 (or COVID-19 Persons under Investigation)
Among Residents and Staff in Nursing Homes, summarizing new facility reporting requirements that
would soon be released through rulemaking.
April 21, 2020: The U.S. Department of Health and Human Services renews determination that a public
health emergency exists and has existed since January 27, 2020.
April 23, 2020: The U.S. Department of Health and Human Services announces funding to states through
the CARES Act; Connecticut will receive $20,252,520.70 total funding.
April 27, 2020: The Trump Administration releases a testing blueprint for “Opening Up America Again,”
outlining roles of federal government, states, and private sector.
April 30, 2020: The Centers for Medicare & Medicaid Services and President Trump announce the
formation of the Coronavirus Commission for Safety and Quality in Nursing Homes that will conduct a
comprehensive assessment to help inform immediate and future responses to COVID-19 in nursing
homes.
April 30, 2020: The Federal Emergency Management Agency announces (Release No. HQ-20-126) it is
coordinating two shipments totaling a 14-day supply of personal protective equipment to nearly 15,000
nursing homes across the U.S.
May 2020
May 6, 2020: The Centers for Medicare & Medicaid Services publishes interim final rule/QSO-20-29-
NH, Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among
Residents and Staff in Nursing Homes, which requires nursing homes to report COVID-19 facility data to
the Centers for Disease Control and Prevention, their residents, and their residents’ family members and
representatives.
May 8, 2020: The Centers for Disease Control and Prevention shares the Infection Prevention and
Control Assessment Tool (ICAR) for Nursing Homes Preparing for COVID-19, provides guidance for
nursing homes and assisted living facilities on topics including visitor restrictions; education, monitoring,
and screening of staff; education, monitoring, and screening of residents; ensuring availability of personal
protective equipment and other supplies; ensuring adherence to infection prevention and control practices;
and communicating with the health department and other health care facilities.
Mathematica C.3
May 11, 2020: The Food and Drug Administration issues guidance, effective immediately, providing
policy to accelerate COVID-19 testing for the duration of the public health emergency.
May 11, 2020: In a call with state governors, Vice President Mike Pence states that the federal
government recommends states test all nursing home staff and residents over the next two weeks.
May 12, 2020: The Centers for Disease Control and Prevention issues guidance on infection control
processes for memory care units in long-term care facilities (for example, considerations of potential risks
and benefits of moving residents out of the memory care unit to a designated COVID-19 care unit).
May 13, 2020: The Centers for Medicare & Medicaid Services publishes the first version of the Nursing
Homes Best Practices Toolkit, a resource cataloging innovative practices on a variety of topics key to
nursing home operations and infection control collected from states, provider associations, and other
stakeholders.
May 15, 2020: President Trump announces the creation of Operation Warp Speed, an administration task
force meant to help develop a coronavirus vaccine.
May 18, 2020: The Centers for Medicare & Medicaid Services issues guidance memo QSO-20-30-NH,
Nursing Home Reopening Recommendations for State and Local Officials, which establishes three phases
of reopening and included general and recommendations specific to phases one to three regarding (1) the
criteria for relaxing certain restrictions, (2) visitation and service considerations, and (3) types of surveys
conducted.
May 22, 2020: The U.S. Department of Health and Human Services announces a ~$4.9 billion
distribution to nursing facilities impacted by COVID-19. The department will distribute relief funds to
skilled nursing facilities on fixed and variable bases; each facility receives a fixed $50,000 distribution
and then an additional $2,500 per certified bed.
May 29, 2020: The Centers for Medicare & Medicaid Services updates Interim U.S. Guidance for Risk
Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19 (not
specific to long-term care or nursing homes).
June 2020
June 2020: The U.S. Department of Health and Human Services’ Office of the Inspector General rolls
out two long-term care investigations: (1) a study focused on the overall industry response to the COVID-
19 pandemic and (2) an evaluation study of the ongoing federal effort to compile comprehensive data on
COVID-19 deaths and infections in nursing facilities.
June 1, 2020: The Trump Administration announces enhanced enforcement activities based on nursing
home COVID-19 data and inspection results. It notes that states that had not completed 100 percent of
focused infection control surveys for their nursing homes by July 31, 2020, would be required to submit a
corrective action plan to the Centers for Medicare & Medicaid Services and be subject to potential
reductions to their CARE Act funding.
June 1, 2020: The Centers for Medicare & Medicaid Services and the Centers for Disease Control and
Prevention issue a joint letter to governors. The letter outlines the importance of completing infection
control surveys and reporting COVID-19 nursing facility data (including cases and deaths) to the recently
implemented nationwide COVID-19 surveillance system via the Centers for Disease Control and
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Prevention’s National Healthcare Safety Network for America’s Medicare and Medicaid-certified nursing
homes. The letter describes technical assistance to states being provided by Centers for Disease Control
and Prevention consultants and by Quality Improvement Organizations, notes that the Centers for
Medicare & Medicaid Services has tied survey funding to State Survey Agency performance and
completion of infection control surveys, and urges states to create a comprehensive testing plan and
submit the plan to the Centers for Medicare & Medicaid Services.
June 4, 2020: The Centers for Medicare & Medicaid Services posts the first set of COVID-19 nursing
home data and results from targeted inspections conducted by the agency since March 4, 2020, linked
on Nursing Home Compare.
June 19, 2020: The Centers for Medicare & Medicaid Services announces the Membership of
Independent Coronavirus Commission on Safety and Quality in Nursing Homes. Commission members
will conduct a comprehensive assessment of the overall response to the COVID-19 pandemic in nursing
homes. Commission recommendations will be included in a final report to be released in fall 2020.
June 23, 2020: The Centers for Medicare & Medicaid Services releases a set of frequently asked
questions on nursing home visitation that covers topics such as considerations before reopening and
clarification the definition of “compassion care situations.”
June 25, 2020: The Centers for Disease Control and Prevention updates its Preparing for COVID-19 in
Nursing Homes webpage. Changes to guidance include tiered recommendations to address nursing homes
in different phases of COVID-19 response, a new recommendation to assign an individual to manage the
facility’s infection control program, additional guidance about new requirements for nursing homes to
report to the National Healthcare Safety Network, and a recommendation to create a plan for testing
residents and health care personnel for COVID-19.
July 2020
July 1, 2020: The Centers for Disease Control and Prevention releases updated Testing Guidelines for
Nursing Homes.
July 9, 2020: The Centers for Medicare & Medicaid Services shares the video Five Things to Know
About Nursing Homes During COVID-19, reiterating federal actions and recommendations in response
to COVID-19.
July 10, 2020: The Centers for Medicare & Medicaid Services announces a targeted approach to provide
additional resources to nursing homes in COVID-19 hotspot areas. It plans to deploy Quality
Improvement Organizations to provide immediate assistance and implement an enhanced survey process
tailored to meet specific concerns of hotspot areas and coordination among federal, state, and local efforts
to leverage all available resources to the facilities
July 10, 2020: In an updated COVID-19 Guidance for Hospital Reporting and FAQs document, the
Trump Administration and the U.S. Department of Health and Human Services direct hospitals to report
COVID-19 data to a central departmental database in efforts to streamline real-time data gathering and
assist the White House task force in allocating resources; hospitals will no longer report data to the
Centers for Disease Control and Prevention.
July 14, 2020: The Centers for Medicare & Medicaid Services and the U.S. Department of Health and
Human Services announce COVID-19 point-of-care testing kits will be sent to nursing homes. Nursing
Mathematica C.5
homes would receive devices in an order ranked by the administrator of the Centers for Medicare &
Medicaid Services and her team. Point-of-care tests are described as rapid on the spot and can test 20
people per hour.
July 16, 2020: The Centers for Medicare & Medicaid Services and Quality Improvement Organization
Program hold a webcast called Establishing an Infection Prevention Program in a Nursing Home, With an
Emphasis on COVID-19.
July 17, 2020: The administrator of the Centers for Medicare & Medicaid Services holds a webcast called
COVID-19: Lessons from the Front Lines Call — July 17 with the commissioner of the Food and Drug
Administration and the White House Coronavirus Task Force. The webcast urges physicians and other
clinicians to share experiences, ideas, strategies, and insight related to COVID-19 response as well as to
ask questions.
July 17, 2020: The Federal Emergency Management Agency shares COVID-19 Best Practice
Information: Considerations for People with Disabilities, addressing several areas including public
assistance from the agency, technology, and COVID-19 testing. The document shares areas of
improvement and mitigation actions related to nursing homes, assisted living, and group homes:
1. The challenge of instituting infection disease prevention protocols because of limited access to
personal protective equipment and ventilators
− Mitigating action: The Centers for Disease Control and Prevention guidance documents for
nursing home to ensure safety of patients and staff
2. Resident isolation from families and support networks
− Mitigating action: Use technological solutions to interact with loved ones
3. Barriers people with disabilities might face transitioning out of nursing homes and assistance care
facilities because of limited staff and house for in-home care
− Mitigating action: Find government and local disability program and services
• The Federal Emergency Management Agency identifies a potential best practice: The state of Alaska
developed and published guidance to support people with disabilities and their caregivers and family
members. Specifically, resources on the page address assisting people with disabilities and face
coverings.
July 22, 2020: The Centers for Medicare & Medicaid Services and the Trump Administration announce
new resources to protect nursing home residents against COVID-19, including a provider relief fund to
long-term care facilities such as nursing homes.
• New funding: The U.S. Department of Health and Human Services will devote $5 billion to the
Provider Relief Fund under the CARES Act to long-term care facilities and nursing homes. To
receive funding, nursing homes must participate in Nursing Home COVID-19 Training.
• Enhanced testing: The Centers for Medicare & Medicaid Services will begin requiring, instead of
recommending, that all nursing homes in states with a 5-percent or greater positivity rate test all
nursing home staff each week. More than 15,000 testing devices will be deployed over the next few
months; 600 devices will be shipped this week.
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• Technical assistance and support: The Centers for Medicare & Medicaid Services reports deploying
technical assistance and education efforts in 18 nursing homes in Illinois, Florida, Louisiana, Ohio,
Pennsylvania, and Texas from July 18 to July 20.
• Weekly data on high-risk nursing homes: In addition to collecting data from all nursing homes
weekly, the Centers for Medicare & Medicaid Services will release a list of nursing homes with an
increase in cases that it will send to states each week.
July 23, 2020: The U.S. Department of Health and Human Services renews determination that a public
health emergency exists and has existed since January 27, 2020.
July 23, 2020: The Centers for Disease Control and Prevention updates its Considerations for Retirement
Communities and Independent Living Facilities COVID-19 webpage. The page redirects those seeking
guidance for long-term care facilities to the Preparing for COVID-19 in Nursing Homes webpages, last
updated on June 25, 2020.
July 31, 2020: The Centers for Medicare & Medicaid Services updates Medicare payment policies for
several types of health care providers, including skilled nursing facilities. The agency also shares that
aggregated payments to skilled nursing facilities will increase by $750 million (2.2 percent) for fiscal year
2021 compared with 2020. Updates include the following:
• Updates routine technical-rate setting to skilled nursing facility Prospective Payment System payment
rates
• Finalizes adoption of the most recent Office of Management and Budget statistical area delineations
• Applies a 5-percent cap on wage index decreases from fiscal year 2020 to 2021
• Updates the 30-day Phase One Review and Correction deadline for the baseline period quality
measure quarterly report for the Skilled Nursing Facility Value-Based Purchasing program; scoring
policies, payment policies, and performance measures of the program are not changing
August 2020
August 3, 2020: The Trump Administration announces it is temporarily exercising enforcement
discretion to allow issuers, when consistent with state law, to offer premium reductions for one or more
months for 2020 coverage. This announcement follows the Centers for Medicare & Medicaid Services’
adoption of several relaxed enforcement policies providing issuers the flexibility to assist their enrollees
impacted by the ongoing public health emergency.
August 3, 2020: The vice president discusses local, state and federal COVID-19 response and recovery
best practices with chief executive of about 50 states, territories, and the White House Coronavirus Task
Force. Items discussed related to COVID-19 are the following:
• The vice president encourages Americans to adhere to state and local guidelines and to wear face
coverings when social distancing cannot be maintained.
• Ambassador Deborah Birx provides an update on trends and data and discusses the need for ongoing
coordination between state and local officials.
August 7, 2020: The U.S. Department of Health and Human Services announces details of the CARES
Act Provider Relief Fund distribution:
Mathematica C.7
• The Agency for Healthcare Research and Quality will oversee the implementation of specialized
learning networks.
• A $5 billion distribution will be linked to nursing home performance. Evaluation of performance will
consider the prevalence of the virus in the nursing home’s local geography and will be based on the
nursing home’s ability within this context to minimize COVID spread and COVID-related fatalities
among its residents.
• Half of the $5 billion will support increase testing, staffing, and personal protective equipment needs.
• There will be additional funding available for those establishing COVID-19 isolation facilities.
• Project ECHO, a consortium of about 250 health system hubs located across the United States, will be
available to support nursing homes seeking help.
• An initial $2.5 billion distribution will occur in mid-August, followed by additional performance-
based distributions throughout the fall.
August 14, 2020: The Centers for Medicare & Medicaid Services issues a press release stating Trump
Administration has imposed more than $15 million in civil money penalties to nursing homes during the
COVID-19 pandemic for non-compliance with infection control requirements and failure to report
COVID-19 data. As of August 3, 2020, Centers for Medicare & Medicaid Services has also cited more
than 3,300 deficiencies and imposed more than $5.5 million in civil money penalties to nursing homes for
failing to report required COVID-19-related data to the Centers for Disease Control and Prevention. As of
August 3, 2020, more than 99 percent of facilities are reporting data. The press release includes the
following data from inspections:
• The Centers for Medicare & Medicaid Services and the state survey agencies have completed
infection control surveys in more than 15,276 of nursing homes (99.2 percent).
• Surveys have resulted in more than 180 immediate jeopardy-level findings (which represent a
situation in which a nursing home’s noncompliance with Centers for Medicare & Medicaid Services
requirements of participation has caused or is likely to cause serious injury, serious harm, serious
impairment, or death to a resident) for infection control, which is triple the rate of such deficiencies
found in 2019.
• The Centers for Medicare & Medicaid Services has imposed civil money penalties for these
violations, totaling nearly $10 million to nursing homes in 22 states.
• The average civil money penalties imposed was $55,000.
August 17, 2020: The Centers for Medicare & Medicaid Services issues memo QSO-20-35-ALL
announcing it will resume routine inspections for nursing home providers. The memo includes the
following information:
• The Centers for Medicare & Medicaid Services is revising guidance on the expansion of survey
activities to authorize on-site revisits and other survey types.
• The Centers for Medicare & Medicaid Services is providing guidance on resolving enforcement cases
that were previously directed to be held and on collecting civil money penalties.
• The Centers for Medicare & Medicaid Services is temporarily expanding the desk review policy to
include review of continuing noncompliance following removal of immediate jeopardy, which would
otherwise have required an on-site revisit from March 23, 2020, to May 31, 2020.
Mathematica C.8
• The Centers for Medicare & Medicaid Services is also issuing updated guidance for the re-
prioritization of routine Survey Agency Clinical Laboratory Improvement Amendments survey
activities, subject to the Survey Agency’s discretion, in addition to lifting the restriction on processing
Clinical Laboratory Improvement Amendments enforcement actions, and issuing the Statement of
Deficiencies and Plan of Correction (Form CMS-2567).
August 20, 2020: Quality Improvement Organizations announces it is moving to an on-demand, pre-
recorded format for nursing home trainings. Live questions and answer sessions will be available
biweekly.
August 20, 2020: Quality Improvement Organizations hosts a nursing home training, CMS-CDC
Fundamentals of COVID-19 Prevention for Nursing Home Management.
August 24, 2020: The Centers for Medicare & Medicaid Services releases a Medicaid Informational
Bulletin on Medicaid reimbursement strategies to prevent spread of COVID-19 in nursing facilities. The
bulletin does the following:
• Provides guidance to states on flexibilities that are available to increase reimbursement for nursing
facilities that implement specific infection control practices, such as designating a quarantine or
isolation wing for COVID-19 patients
• Encourages states to use the flexibilities that are available and in alignment with applicable Centers
for Disease Control and Prevention guidance and coordinated with the state agency responsible for
nursing facility compliance
August 24, 2020: The Centers for Disease Control and Prevention updates guidance on testing, no longer
recommending testing of asymptomatic people. Considerations for who should receive testing includes
symptomatic people, people who have had close contact with someone with confirmed COVID-19, and
people who have been asked or referred to testing by their health care provider or local or state health
department.
August 25, 2020: The Centers for Medicare & Medicaid Services issues a press release to announce the
Trump Administration’s national training program to strengthen nursing home infection control practices,
available immediately to all Medicare and Medicaid certified nursing homes. Quality Improvement
Organizations will include the training as part of action plans developed in collaboration with each
nursing home they assist. The training program has the following qualities:
• It is designed to equip frontline caregivers and their management with the knowledge required to stop
the spread of COVID-19 in nursing homes.
• It features a tailored course that incorporates the most recent lessons learned from nursing homes.
• It consists of 5 modules designed for nursing home staff and 10 modules for nursing home
management:
− Modules for nursing home staff
1. Module 1: Hand Hygiene and PPE
2. Module 2: Screening and Surveillance
3. Module 3: Cleaning the Nursing Home
4. Module 4: Cohorting
Mathematica C.9
5. Module 5: Caring for Residents with Dementia in a Pandemic

− Modules for nursing home management
1. Module 1: Hand Hygiene and PPE
2. Module 2: Screening and Surveillance
3. Module 3: Cleaning the Nursing Home
4. Module 4: Cohorting
5. Module 5: Caring for Residents with Dementia in a Pandemic
6. Module 6: Basic Infection Control
7. Module 7: Emergency Preparedness and Surge Capacity
8. Module 8: Addressing Emotional Health of Residents and Staff
9. Module 9: Telehealth for Nursing Homes
10. Module 10: Getting Your Vaccine Delivery System Ready
August 25, 2020: The Centers for Medicare & Medicaid Services announces a requirement for nursing
homes to test staff and offer testing to residents when there is an outbreak or residents show symptoms for
COVID-19. Laboratories and nursing homes using point-of-care testing devices will have to report
diagnostic test results as required by the CARES Act. The new rules also require hospitals to provide
COVID-19 cases and related data to the U.S. Department of Health and Human Services.
• To ensure accountability with the testing requirement, the Trump Administration directs surveyors to
inspect nursing homes for adherence to the new testing requirements.
• Facilities that do not comply with the new requirements will be cited for non-compliance and might
face sanctions based on the severity of the noncompliance, such as civil money penalties in excess of
$400 per day, or more than $8,000 for an instance of noncompliance.
• Labs will have a one-time, three-week grace period to begin reporting required test data.
• The Centers for Medicare & Medicaid Services is also revising its previous policy that covered
repeated COVID-19 testing for Medicare beneficiaries without practitioner orders. The revised policy
states that each beneficiary can receive one COVID-19 test without the order of a physician or other
health practitioner, but Medicare will require an order for all further COVID-19 tests.
August 26, 2020: The Centers for Medicare & Medicaid Services posts guidance for implementing new
testing requirements in nursing homes and labs, QSO-20-37-CLIA, NH:
• Facilities must test staff and offer testing to all nursing home residents.
• Clinical Laboratory Improvement Amendments of 1988 regulations have been updated to require all
laboratories to report SARS-CoV-2 test results in a standardized format and at a frequency specified
by the Secretary of Health and Human Services.
• Failure to report SARS-CoV-2 test results will result in civil money penalties.
• Long-Term Care Enforcement requirements of 42 CFR Part 488 have been revised to include
requirements specific to the imposition of a civil money penalties for nursing homes that fail to report
requisite COVID-19 related data to the Centers for Disease Control and Prevention National
Healthcare Safety Network per §483.80(g)(1) and (2).
Mathematica C.10
August 27, 2020: The Centers for Medicare & Medicaid Services publishes QSO-20-38-NH, revising the
survey tool for surveyors to assess compliance with the new testing requirements. The agency also adds to
the survey process an assessment of compliance with the requirements for facilities to designate one or
more people as the infection preventionists who are responsible for the facility's infection prevention and
control program at 42 CFR §483.80(b).
August 27, 2020: Through the U.S. Department of Health and Human Services, the Trump
Administration announces it has distributed ~$2.5 billion of the planned $5 billion to nursing homes to
support increased testing, staffing, and personal protective equipment needs.
August 31, 2020: Under the Public Readiness and Emergency Preparedness Act, the U.S. Department of
Health & Human Services announces it is extending coverage for prescribing or administering point-of-
care COVID-19 tests. It preempts state or local provisions that restrict or prohibit the use of such tests.
September 2020
September 2, 2020: The U.S. Department of Health and Human Services announces assisted living
facilities can now apply for funding under the Provider Relief Fund Phase 2 General Distribution
allocation. Eligible assisted living facilities will receive 2 percent of their annual revenue from patient
care.
September 3, 2020: The U.S. Department of Health and Human Services announces the details of the $2
billion Provider Relief Fund performance-based incentive payment distribution to nursing homes. The
department will measure nursing home performance through required nursing home data submissions and
distributing payments based on these data. The announcement outlines the following:
• Qualifications: Facilities must have an active state certification as a nursing home or skilled nursing
facility and receive reimbursement from the Centers for Medicare & Medicaid Services. Facilities
must also report data to at least one of three data sources that will serve to establish eligibility and
collect necessary provider data to inform payment: Certification and Survey Provider Enhanced
Reports (CASPER), Nursing Home Compare (NHC), or Provider of Services (POS).
• Performance and payment cycle: The incentive payment program is scheduled to be divided into
four performance periods (September, October, November, December), lasting a month each, with
$500 million available to nursing homes in each period. Nursing homes will be assessed based on a
full month's worth of the aforementioned data submissions, which will then undergo additional U.S.
Department of Health and Human Services scrutiny and auditing before payments are issued the
following month after the prior month's performance period.
• Methodology: Performance will be measured on two outcomes: the ability to keep new COVID
infection rates low among residents and the ability to keep COVID mortality low among residents.
Mathematica C.11
State-Level Timeline of Policy Changes and Guidance

February 2020
February 5, 2020: Department of Public Health Directive
• Connecticut’s Department of Public Health adds coronavirus to list of reportable diseases, requiring
any physician in the state to report a case or possible case to the department.
February 28, 2020: Governor Lamont Press Release
• The state announces that the Department of Public Health’s laboratory in Rocky Hill received
approval from the Centers for Disease Control and Prevention to begin testing samples itself rather
than delivering all samples to Centers for Disease Control and Prevention testing sites in Atlanta.
March 2020
March 5, 2020: Department of Public Health Memo
• This department of Public Health guidance to all facilities refers to the Centers for Disease Control
and Prevention’s webpage on “Preparing for Community Transmission of COVID-19 in the United
States” and “Steps Healthcare Facilities Can Take Now to Prepare for COVID-19.”
March 8, 2020: Governor Lamont Press Release
• Governor Lamont announces that the Department of Public Health State Laboratory has confirmed
the first positive case of coronavirus involving a Connecticut resident.
• The second positive case of COVID-19 was identified in Connecticut, bringing the state’s total to
two.
• The state receives a second COVID-19 test kit, which boosted state testing capacity to about 1,200.
The lab can complete 15 to 20 tests per day, and each kit allows for 600 people to be tested.
• LabCorp becomes fully operational with COVID-19 testing. Quest Diagnostics expected to have
testing available soon. All people being tested by these facilities must receive advance physician
referral.
March 9, 2020: Department of Public Health Directive
• The Department of Public Health restricts visitors entering nursing and convalescent homes to only
those visiting someone residing at one of these facilities in hospice or end-of-life care, and the visitors
must wear proper personal protective equipment.
March 10, 2020: Declaration of Public Health and Civil Preparedness Emergency
• Governor Lamont declares civil preparedness and public health emergencies.

• The Connecticut Insurance Department notifies travel insurance companies about the emergency
declarations and begins monitoring their compliance with the terms of their policies.
Mathematica C.12
• The declarations trigger price gouging laws and make clear that municipal leaders have emergency
powers to mitigate disasters and emergencies.
• This provides the governor with the authority to take specific, swift actions determined necessary to
protect the safety and health of residents in the state, including temporarily suspending certain state
laws and regulations.
• The Department of Public Health confirms a third presumptive positive COVID-19 case in the state.
• Governor Lamont made an emergency request from the Strategic National Supply for a total of
540,000 additional N-95 protective masks.
• To make testing more widely available, the department is working on obtaining alternate sites
approved at local hospitals at locations around the state. Those hospitals will work with commercial
testing labs by Quest Diagnostics and LabCorp to complete the testing.
March 12, 2020: Executive Order No. 7
• This order prohibits gatherings of 250 people or more for social and recreational activities (excludes
churches).
• It creates a waiver of the 180-day school year requirement.
• It enables the Commissioner of Public Health to issue restrictions on the number, category, and
frequency of outside visitors and on the screening and protective measures in nursing homes,
residential care homes, or chronic disease hospitals.
March 13, 2020: Executive Order No. 7A
• This order grants the Commissioner of Public Health authority to restrict visitors at nursing homes,
residential care homes, and chronic disease hospitals. Note this order supersedes Executive Order
No. 7.
March 15, 2020: Executive Order No. 7C
• This order cancels classes in public schools for at least two weeks.
March 16, 2020: Executive Order No. 7D
• This order further limits recreational and social gatherings to 50 people. It closes gyms; sports,
fitness, and recreational facilities; and movie theaters.
• This statement regarded the first death in Connecticut because of complications from COVID-19. The
person was an elderly patient who had been a resident of an assisted living facility in Ridgefield.
March 18, 2020: News Article
• Governor Lamont reports that the state is currently able to conduct hundreds of COVID-19 tests per
day compared with 20 or 30 people per day in the prior week, at which time testing was “focused
mainly on those who are very sick in the hospitals.”
Mathematica C.13
March 18, 2020: Chief Medical Examiner Notice
• Notice from Office of Chief Medical Examiner (OCME) that all suspected and confirmed COVID-19
cases be reported to OCME
March 20, 2020: Executive Order No. 7H
• This order places "Stay Safe, Stay Home" restrictions on all workplaces for non-essential businesses.
March 23, 2020: Executive Order No. 7K
• This order temporarily suspends the requirement to submit background checks to the Department of
Public Health before extending an employment offer to long-term care service providers or
volunteers.
March 24, 2020: Executive Order No. 7L
• This order extends the time period for nursing home transfers. It grants additional flexibilities for
residents that might have to move or transfer facilities based on their COVID-19 status.
March 24, 2020: Department of Public Health Guidance
• This guidance from the state’s Department of Public Health regards personal protective equipment
stewardship and conservation.
March 26, 2020: Department of Public Health Guidance
• This is the first nursing-home specific guidance from the state’s Department of Public Health. The
recommendations include assessing symptoms and temperatures for all staff at the beginning of the
shift, limiting staff movement within the facility as much as practicable, social distancing guidelines,
cleaning and janitorial services, assessing residents for symptoms at least once daily, and guidance on
testing for symptomatic residents only.
− It also includes guidance on appropriate transfers of residents with confirmed or suspected
COVID-19 to and from hospitals.
March 27, 2020: Centers for Medicare & Medicaid Services Section 1135 Waiver Response (First
Request)
• Connecticut receives approval of its 1135 waiver, with a retroactive effective date of March 1, 2020.
The waiver included the following:
− Suspension of Medicaid fee-for-service prior authorization requirements
− Extension of existing prior authorizations through the end of the public health emergency
− Modification of timeframe for managed care entities to resolve appeals
− Temporary enrollment of providers enrolled with another state Medicaid agency (out-of-state
providers) or Medicare and may reimburse payable claims, which applies to the Children’s Health
Insurance Program as well
o For providers not already enrolled with a state Medicaid agency or Medicare, approved
waiving payment of application fee, criminal background checks, site visits, and in-state or
territory licensure requirements
Mathematica C.14
− Temporary ceasing of revalidation requests from providers located in the state

− Full reimbursement for services rendered during emergency to an unlicensed facility that meet
minimum standards (nursing facilities, intermediate care facilities for individuals with intellectual
and developmental disabilities, psychiatric residential treatment facilities, and hospital nursing
facilities)
− State plan amendment flexibilities to provide or increase beneficiary access to items and services
related to COVID-19 (for example, cost-sharing waivers, alternative benefit plans to add services
or providers)
March 27, 2020: Centers for Medicare & Medicaid Services Approval Letter and Waiver Approvals
• Nine Section 1915(c) HCBS waivers received time-limited amendment approvals (retroactive to
March 16, 2020), including the following:
− Temporary increase in cost limits for participants necessary to assist with continued safe support
in the community and to avoid institutionalization
− Temporary permission to pay for services (companion services) rendered by family caregivers
− Temporary modification to level of care evaluations or reevaluations (allowing these to be
conducted virtually) and delay of reassessment of up to one year
− Allowance of electronic method (that is, telephonic) for case management, monthly monitoring,
and counseling or day programs
− Adjust prior approval and authorization elements in waivers
− Add electronic method of signing off on person-centered service plan
April 2020
April 1, 2020: Department of Public Health Guidance
• The Department of Public Health issues return-to-work guidance for health care workers and first
responders for those who are symptomatic with suspected or confirmed COVID-19 or those who are
asymptomatic with high or medium risk exposures including, timeframes for return to work, use of
personal protective equipment, and reassignment if necessary.
April 3, 2020: Press Release
• The governor announces that the state’s 213 nursing homes are receiving a 10-percent across-the-
board increase in Medicaid payments to help meet extraordinary costs from the public health
emergency.
• The 10-percent funding increase runs from April 1 to June 30, with an initial payment of $11.6
million scheduled to be received by nursing homes on April 7. The three-month increase is expected
to total $35.3 million.
April 4, 2020: Department of Public Health Guidance
• This guidance requires all health care personnel in all settings to be universally masked while
working in facilities, including long-term care facilities.
Mathematica C.15
April 6, 2020: Section 1115 Waiver Application
• The state requested flexibility for a number of provisions for its 1915(i) state population, including
waiving face-to-face requirement for assessments, cost limit service changes, and electronic provision
of mental health and adult day health counseling via a Section 1115 demonstration application. (The
application was later withdrawn because the Centers for Medicare & Medicaid Services notified
Connecticut that the requested flexibilities were already allowed under blanket waivers that it issued.)
April 8, 2020: Governor's Press release
• The governor announces a partnership with Connecticut’s long-term care facilities to collaborate on a
medical surge plan that includes the establishment of COVID-19 recovery centers in nursing homes
to accept patients who can be discharged from acute care hospitals but are still impacted by COVID-
19 infection.
• In total, the state designated four COVID-19 recovery facilities in Torrington, Bridgeport, Meriden,
and Sharon with a total of 500 beds across them.
• The Department of Public Health is working with hospitals to ensure more people can meet the
requirement of negative tests 24 hours apart before being discharged back to a nursing home.
• The Connecticut Department of Social Services and the Office of Policy and Management determined
a payment rate of $600 per day for the COVID-19 recovery centers and additional payments of 10
percent across the board for all nursing homes in Connecticut during the pandemic.
April 11, 2020: Executive Order No. 7Y
• This order implements a nursing home surge plan for the duration of the public health and civil
preparedness emergency, allowing flexibility in transfer of residents to and from the hospital, a
COVID-19 recovery facility, or discharge from institutional setting.
April 11, 2020: Department of Public Health Memo
• This is a notice of distribution of personal protective equipment bundles of N95 respirators, surgical
masks, gowns, gloves, and face shields to nursing homes at five regional point of dispensing sites.
April 15, 2020: Executive Order No. 7AA
• This order grants the Department of Social Services the authority to approve temporary additional
nursing home beds for COVID-19 recovery.
April 16, 2020: Press Release
• The first COVID-19 recovery facility opens for hospital discharges.

April 17, 2020: Executive Order No. 7BB
• The governor issues a statewide order that cloth face coverings or higher level of protection required
in public wherever close contact is unavoidable.
Mathematica C.16
April 19, 2020: Governor's Press Release
• The governor announces that he is directing his administration to boost Medicaid payments for all of
the state’s nursing homes by an additional 5 percent above the recently announced 10-percent
increase.
• The state will provide an across-the-board rate increase of 10 percent for non-COVID beds
retroactive to March 1 (previously, the 10-percent increase was to occur April 1).
• The state will provide an additional across-the-board rate increase of 5 percent for non-COVID beds
for the period of April 1 to June 30, bringing the total increase during this period to 15 percent.
• The state will reimburse at $400 per day for COVID-positive residents in non-COVID recovery
facilities. This rate is in effect for a maximum of 30 days per bed.
• The state’s advance of $11.6 million from the initial 10-percent rate increase, which was received by
skilled nursing facilities on April 7, is now being extended back to March 1, adding $12 million in
immediate revenue.
April 22, 2020: Executive Order No. 7DD
• This order adds to existing list of out-of-state health care providers not required to pursue licensure,
certification, or registration for a period of 60 days and allows them to render services if appropriately
licensed, certified, or registered in another state or territory.
• New providers include occupational therapist, alcohol and drug counselor, radiography, and others.
April 23, 2020: Office of Policy Management Guidance and U.S. Department of Health and Human
Services Funding Announcement
• Connecticut was allocated $1.382 billion by the U.S. Department of the Treasury for the Coronavirus
Relief Fund established by the CARES Act (Public Law 116-136).
• This established allocation for $600 per diem, per bed grant to COVID-19 recovery facilities and
alternative COVID-19 recovery facilities. Note that this is the sole reimbursement for these facilities
from the state; the guidance indicates that the Department of Social Services would conduct a cost
audit for expenses in excess of the $600 per diem payment. The $600 per diem is more than double
the standard Connecticut Medicaid per diem for nursing home services. It established grant payments
of a 10-percent increase for April and 20 percent for May and June 2020 for nursing homes that are
not COVID-19 recovery facilities or alternate COVID-19 recovery facilities. These increases are
intended to be used for employee wages (including staff retention and overtime), costs related to
screening visitors for COVID-19, personal protective equipment, cleaning and housekeeping supplies,
and other COVID-related costs.
April 23, 2020: Executive Order No. 7EE
• This order mandates nursing homes and residential communities in the state to provide daily status
reports in the form and manner required by the Connecticut Hospital and Long-Term Care Mutual
Aid Plan.
• It establishes civil penalties for failure to comply with mandatory reporting.
Mathematica C.17
• It gives the Commission of Social Services (where Medicaid resides) the ability to waive certain
Medicaid prior authorization requirements as the commissioner deems necessary.
• It waives Medicaid bed reservation requirements for residents on leave from intermediate care
facilities for people with intellectual disabilities in the hospital or on home leave.
April 24, 2020: Press Coverage
• This article indicates testing capacity of the state public health lab in Rocky Hill has expanded from
15 to 20 tests per day at the start of the pandemic to 80 to 160 tests per day. In addition, reports that
“multiple commercial, university and medical laboratories around Connecticut have also since been
certified for COVID-19 testing.” The biggest factor limiting ability to test is a shortage of key
materials.
May 2020
May 3, 2020: Governor’s Press Release
• Governor Lamont, along with New York Governor Andrew M. Cuomo, New Jersey Governor Phil
Murphy, Massachusetts Governor Charlie Baker, Rhode Island Governor Gina Raimondo,
Pennsylvania Governor Tom Wolf, and Delaware Governor John Carney, announce a joint multi-state
agreement to develop a regional supply chain for personal protective equipment and other medical
equipment and testing.
May 7, 2020: Press Release and Department of Public Health Implementation Order
• The state announces expansion of testing for COVID-19, including increased screening of
asymptomatic people in nursing homes
• The state suspends regulation requiring prior referral for COVID-19 test from medical providers,
enacted through an implementation order from the Department of Public Health.
May 7, 2020: Executive Order No. 7KK
• This order modifies state statute to allow pharmacists to order and administer tests approved by the
Food and Drug Administration for COVID-19.
• It requires pharmacists to report all testing activities and any other information required by the
Department of Public Health in accordance with applicable orders, guidelines, or other directives
issued by the Commissioner of Public Health or her designees.
May 8, 2020: Department of Public Health Webinar
• Webinar led by Facility Licensing and Investigations section on donning and doffing of personal
protective equipment.
May 9, 2020: Department of Public Health Guidance
• The Department of Public Health issues guidance for ensuring that long-term care facilities take
reasonable and practicable alternative means of communication between residents and family
members. This included window visits, virtual visitation, social media communications, and phone
calls that should occur on at least a weekly basis.
Mathematica C.18
May 10, 2020: Press Coverage
• The governor issues an order implementing standards at nursing homes to ensure loved ones can
speak with their families either through windows or video conferencing.
May 11, 2020: Department of Public Health Guidance
• This interim guidance regards COVID-19 point prevalence survey testing and cohorting in nursing
homes.
May 11, 2020: Department of Public Health Memo
• This memo provides sample long-term care cleaning protocol guidance for nursing and environmental
services personnel when cleaning and auditing cleaning in areas where people with suspected or
laboratory-confirmed COVID-19 have been.
• It includes guidance from the Centers for Disease Control and Prevention on personal protective
equipment use, cleaning of high touch services, and aerosolization (increasing airflow in rooms).
May 12, 2020: Centers for Medicare & Medicaid Services Section 1135 Waiver Response (Updated First
Request)
• The Centers for Medicare & Medicaid Services temporary approves the state’s request to provide
services in settings that have not been determined to meet the home and community-based settings
criteria under the 1915(c) HCBS waiver program, 1915(i) home and community-based services state
plan benefit, and Community First Choice State plan option at 1915(k).
May 13, 2020: Executive Order No. 7NN
• This authorizes the Office of Policy and Management to direct the Department of Social Services to
provide Coronavirus Relief Fund distributions to nursing home facilities.
• It also authorizes the Office of Policy and Management to direct the Department of Social Services to
provide Coronavirus Relief Fund distributions to COVID-19 recovery facilities and alternate COVID-
19 recovery facilities
• It authorizes additional COVID-19-related hardship relief funding under the Coronavirus Relief Fund
to nursing home facilities.
• It waives certain limits on the amount that could be provided to caregiver relatives.
May 20, 2020: Press Release, State Guidance, Press Coverage
• This outlines phase one of reopening for businesses.

• Businesses reopening during phase one include outdoor dining, offices, retail and malls, museums
and zoos, university research, and outdoor recreation businesses.
• It includes restaurant-specific guidance: only outdoor dining permitted (open up to 50-percent
capacity and no bars open); retail and malls open up to 50-percent capacity; offices allowed to open
up to 50-percent capacity, but employees should work from home when possible; and museums and
zoos can open outdoor exhibits at up to 50-percent capacity.
Mathematica C.19
May 24, 2020: Press Coverage
• This article compares progression of testing for asymptomatic patients in nursing homes and staff of
nursing homes in Connecticut.
• The state announces broader testing efforts in nursing homes on May 7, but states in the New England
region such as Massachusetts expand testing of asymptomatic residents on April 13, and state
officials send testing kits to nursing homes and arranged for mobile testing at the facilities.
• The article says the state cites a lack of testing supplies as delaying widespread testing.
May 27, 2020: Executive Order No. 7SS
• This order creates a temporary nurse aide position in nursing homes. People holding this temporary
licensure must complete eight hours of online training and work under the supervision of nursing
staff, and they are ineligible to work with COVID-19 positive residents.
June 2020
June 1, 2020: Executive Order No. 7UU
• This order mandates COVID-19 testing for staff of private and municipal nursing homes, residential
communities, and assisted living agencies. It requires nursing homes and assisted living facilities to
test staff at least weekly for the duration of the public health emergency; this order specifically
includes agency staff and contractors.
• It requires testing to begin no later than June 14, per Department of Public Health guidance.
June 1, 2020: Press Coverage
• This outlines a modified phase one, which includes reopening of hair salons and barbershops.
June 5, 2020: Department of Public Health Memo
• This memo includes COVID-19 guidelines for infection control in nursing homes. Outlines additional
cohorting guidance, new admissions and readmissions, testing of staff and residents, use of AC and
fans, and recreation and visitation.
June 5, 2020: Executive Order No. 7XX
• This order suspends the involuntary discharge of nursing facility residents and residential care home
residents who could previously be discharged to homeless shelters, except during emergency
situations or with respect to COVID-19-recovered discharges.
• It modifies safety rules for drive-in religious gatherings and safety rules for drive-in graduations.
June 8, 2020: Department of Public Health Guidance
• This blast fax provides guidance on resident quarantine/isolation, cohorting, testing, visitation and
outdoor time
• Topics include new admissions and readmissions, residents leaving for medical appointments and
other visits, testing staff and residents, contact tracking within the nursing home, use of air
conditioning and fans, resident room doors, recreation and outdoor time by cohort, and visitation by
cohort.
Mathematica C.20
June 17, 2020: Executive Order No. 7AAA
• This order updates Executive Order 7UU regarding mandatory COVID-19 staff testing of nursing
facility and ALFs as follows:
− Only staff who have not previously tested positive for COVID-19 must be tested weekly. Weekly
testing should continue until the facility has no new cases of COVID-19 for at least 14 days.
Weekly testing must restart whenever there is a new positive case in the facility among residents
or staff.
June 17, 2020: Centers for Medicare & Medicaid Services Section 1135 Waiver Response (Second
Request)
• This is the Centers for Medicare & Medicaid Services response to the second Section 1135 Waiver
request from Connecticut:
− The Centers for Medicare & Medicaid Services approves the state’s request to modify the
deadline for initial and annual level of care determinations required for the Section 1915(k) state
plan benefit.
o The state does not need to complete assessment before start of care, and reassessment can be
postponed for one year.
− The Centers for Medicare & Medicaid Services approves the state’s request to modify the
timeline for initial evaluations and assessments and reevaluate and reassess the Section 1915(i)
HCBS state plan option.
o Similar to Section 1915(k) provisions.
− The Centers for Medicare & Medicaid Services approves the waiver of written consent from
beneficiaries for services delivered under Section 1915(c) waiver program, Section 1915(i) home
and community-based services state plan, and Section 1915(k) Community First Choice
programs.
June 17, 2020: Press Coverage, State Guidance, and Press Coverage
• These outlines set forth phase two of reopening businesses and recreation with capacity limits and
requirements for compliance with health and safety guidelines, including all personal services (nail
salons, tattoo parlors, and so on); movie theaters; outdoor arts, entertainment and events up to 50
people; bowling alleys; social clubs and pools; indoor restaurants; hotels (but no bars); museums;
zoos; outdoor amusement parks; public libraries; and youth sports.
• Any business seeking to reopen in phase two must complete a self-certification and receive a Reopen
CT badge. They must also comply with industry-specific health and safety guidelines; a non-
exhaustive list includes personal protective equipment for employees, provided at no cost to the
employee; a cleaning plan; training programs to ensure all workers are aware of the details of the
state’s reopening guidelines and cleaning requirements; adjustment of the physical space in the
business to encourage social distancing; avoidance of unnecessary physical contact or the use of
shared items; and increased ventilation where possible.
• It provides additional sector-specific capacity guidelines including, for example, that restaurants with
indoor dining can open at 50-percent occupancy (outdoor dining is still encouraged).
• It allows for private (in-home) gatherings of up to 25 indoors and 100 outdoors.
Mathematica C.21
June 22, 2020: Department of Public Health Memo
• This memo includes updated COVID-19 Infection Control Guidelines for Nursing Homes from the
Connecticut Department of Public Health Infectious Diseases Section supplements and updates prior
Department of Public Health guidance. It addresses common questions regarding resident quarantine
and isolation, cohorting, and testing.
• A travel advisory requires people coming from states with (1) a positive test rate higher than 10 per
100,000 residents or (2) a 10-percent or higher positivity rate over a seven-day rolling average to self-
quarantine for 14 days.
• At the time of this advisory, the requirement affected travelers visiting Connecticut from a total of 19
states.
June 25, 2020: Press Release and Executive Summary of Reopening Model
• Governor Lamont announces plans for 2020–2021 school year with an aim of allowing all students
opportunity to access in-school, full-time instruction at beginning of 2020–2021 academic year, if it is
supported by public health data.
• Summer day camps reopen (overnight camps not included).

• Puts into place guidance including health screenings, limiting group size to no more than 10 children,
requiring that employees wear cloth face masks, implementing hand and respiratory hygiene,
developing protocols for intensified cleaning and disinfection, and implementing social distancing
strategies.
July 2020
July 6, 2020: Press Coverage
• This establishes that K–12 summer school can reopen with limits on group size and requires using
face masks, employing social distancing (maintaining six feet between students), developing
protocols for sanitizing and cleaning bathrooms, and restricting sharing of materials (that is, books).
July 10, 2020: Press Coverage
• This pauses phase three of reopening, keeping the state at phase two.
July 14, 2020: Executive Order No. 7EEE
• This order authorizes continued temporary suspension of the requirements for licensure, certification,
or registration of out-of-state providers. It allows the commissioner of the Department of Public
Health to temporarily suspend the requirements for licensure, certification, or registration for certain
out-of-state health care providers in order to supplement the state's ability to respond to the pandemic.
• It supersedes Executive Order No. 7DD, which suspended requirements for licensure for a period of
60 days issued on April 22, 2020.
Mathematica C.22
July 21, 2020: Executive Order No. 7III
• This order announces mandatory self-quarantine for travelers from states with high COVID-19
infection levels. Travelers are required to complete a form upon entry into CT for submission to CT
DPH.
July 22, 2020: Press Release
• The state of Connecticut has received an additional extension from the Federal Emergency
Management Agency for approval to apply for reimbursement for statewide emergency feeding
efforts until August 19, 2020.
July 28, 2020: Press Release
• The Federal Emergency Management Agency approved a 30-day extension of the non-congregate
sheltering authorization under the Federal Emergency Management Agency Public Assistance
program until September 1, 2020, previously set to expire on August 1, 2020.
• It provides non-congregate housing to certain high-risk people, including those who have COVID-19
or have been in contact with people who have COVID-19.
August 2020
August 6, 2020: Press Release
• This press release announces that Connecticut will continue covering the costs of COVID-19 testing
at long-term care facilities for at least an additional two months.
• This press release announces that Connecticut received federal approval to extend full federal funding
for use of the National Guard in the state’s ongoing response to the COVID-19 pandemic through
September 30.
• In March, Connecticut received approval for full federal reimbursement for all costs associated with
activities with the National Guard through August 21.
August 12, 2020: Department of Public Health Guidance
• This document updates guidance for issues concerning cohorting new admissions with unknown
COVID-19 status, contact tracing and case investigation in nursing homes, when to test and screen
asymptomatic residents and staff in nursing homes, and antigen testing in nursing homes.
August 27, 2020: Department of Public Health Directive
• This directive expands visitation in Connecticut nursing homes and clarifies for all long-term care
facilities their obligations to facilitate visitations and to enable compassionate care visits.
• Key provisions for general visitation and compassionate care visits include the following:
− It clarifies that visits can occur more than once per week, requires nursing homes to develop a
facility-wide visitation policy, requires facilities to assess the psychosocial needs of each resident
and develop individualized visitation plans, extends the minimum time for perimeter visits (for
example, window visits, socially distanced outdoor visits) from 20 to 30 minutes, and requires
Mathematica C.23
facilities to designate no less than five days per week as visitation days (one of which must be a
Saturday or Sunday, from which a resident’s visitation schedule can be devised).
− It expands compassionate care visits beyond end-of-life visits to include visits for residents who
undergo significant change in physical, mental, or psychosocial conditions, including weight loss,
increased sleeping, confusion or agitation, delirium or other decline in cognition, and new onset
or increase of symptoms of mental illness.
• Governor Lamont, Governor Andrew M. Cuomo of New York, and Governor Phil Murphy of New
Jersey released joint statement on the weakening of COVID-19 testing guidelines from the Centers
for Disease Control and Prevention for asymptomatic individuals.
• The statement notes that New York, New Jersey, and Connecticut will not be changing guidance that
prioritizes testing for asymptomatic people.
September 2020
September 1, 2020: Public Health Emergency Declaration Extension
• Governor Lamont announces the extension of the Public Health and Civil Preparedness Emergencies
to February 9, 2021, originally in effect through September 9, 2020.
• The renewal also describes several risks that contribute to the renewal, including managing the
reopening and continued operation of schools, colleges, and universities as well as economic, fiscal,
and operational challenges facing residents, businesses, and government agencies.
September 8, 2020: Executive Order No. 9A
• This order reissues and extends COVID-19 executive orders and agency and municipality orders to
November 9, 2020.
September 9, 2020: Department of Public Health Order
• This order modifies training requirements for nurse’s aides to allow them to complete their training
using virtual clinical resources or through two weeks of employment as a temporary nurse aide.
• It allows facilities to use any nurse aide who has satisfactorily completed training, but not yet
satisfactorily completed the competency evaluation because of COVID-19 restrictions, to satisfy
staffing requirements as set forth in the Public Health Code for longer than 120 days as long as the
facility ensures that nurse aides can demonstrate competency in skills and techniques necessary to
care for residents’ needs. Such use of nurse aides can continue through the end of the public health
emergency or until the nurse aide can take a competency exam.
Mathematica C.24
September 15, 2020: Executive Order No. 9B
• This order amends mandatory self-quarantine for travelers from states with high COVID-19 levels. It
modifies the state’s previously issued self-quarantine and travel advisory order for people arriving to
Connecticut from impacted states, expanding the testing exemption to all travelers who test negative
for COVID-19 in the 72 hours before arrival.
• It authorizes the Commissioner of Public Health, local health departments, municipal chief elected
officers, and state and local police to issue fines for violations of certain COVID-19 protective
measures. These include the following:
− A fine of $100 for an person who fails to wear a mask or cloth face covering as required under
Executive Order No. 7NNN.
− A fine of $500 for any person or business entity who organizes, hosts, or sponsors a gathering
that violates the gathering size restrictions set forth in the Department of Economic and
Community Development Rules for Gatherings and Venues and Sector Rules for Outdoor Events.
− A fine of $250 for any person who attends a gathering that violates the gathering size restrictions
set forth in the Department of Economic and Community Development Rules for Gatherings and
Venues and Sector Rules for Outdoor Events.
Mathematica C.25
Mathematica
Princeton, NJ • Ann Arbor, MI • Cambridge, MA
Chicago, IL • Oakland, CA • Seattle, WA
Tucson, AZ • Woodlawn, MD • Washington, DC
EDI Global, a Mathematica Company mathematica.org
Bukoba, Tanzania • High Wycombe, United Kingdom

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What was the purpose of this report?

What was the purpose of this report?

What recommendations were made to help prevent future infectious disease outbreaks in long-term care facilities?

What recommendations were made to help prevent future infectious disease outbreaks in long-term care facilities?

A Study of the COVID-19 Outbreak and Response in

Connecticut Long-Term Care Facilities

September 30, 2020

Submitted to: Submitted by:

Research analytics support

IV. Assessment of the State’s Preparedness and Response to COVID-19 in LTC

CDC Centers for Disease Control and Prevention

Exhibit ES.1. Count of recommendations by topic

A. About this report

2. Limitations of this report

B. Similar assessments done by other states

C. Organization of this report

II. Recommendations to Help Connecticut Prevent and Prepare for

1. Short-term recommendations to mitigate a second wave of COVID-19

B. Surveillance and outbreak response

1. Short-term recommendations to mitigate a second wave of COVID-19

2. Longer-term recommendations to prevent future outbreaks

1. Short-term recommendations to mitigate a second wave of COVID-19

2. Longer-term recommendations to prevent future outbreaks

D. Screening and testing

1. Short-term recommendations to mitigate a second wave of COVID-19

2. Longer-term recommendations to prevent future outbreaks

1. Short-term recommendations to mitigate a second wave of COVID-19

2. Longer-term recommendations to prevent future outbreaks

F. LTC staffing and workforce availability

1. Short-term recommendations to mitigate a second wave of COVID-19

2. Longer-term recommendations to prevent future outbreaks

G. State agency roles, expertise, and skills

1. Short-term recommendations to mitigate a second wave of COVID-19

2. Longer-term recommendations to prevent future outbreaks

H. Communication and coordination across state agencies, facilities, and support

1. Short-term recommendations to mitigate a second wave of COVID-19

2. Longer-term recommendations to prevent future outbreaks

1. Short-term recommendations to mitigate a second wave of COVID-19

2. Longer-term recommendations to prevent future outbreaks

J. Reimbursement mechanisms to support increased LTC system costs

1. Short-term recommendations to mitigate a second wave of COVID-19

2. Longer-term recommendations to prevent future outbreaks

III. Assessment of the COVID-19 Outbreak in Connecticut on

B. Residents of Connecticut nursing homes

Exhibit 5. New COVID-19 cases and deaths in Connecticut nursing homes

1. Spread of COVID-19 across Connecticut nursing homes

Exhibit 6. Summary of findings from analyses of relationship between nursing home

Multivariate analyses Bivariate analyses

2. Spread of COVID-19 within Connecticut nursing homes

b. Spread within a facility: case study results

3. Cases and deaths in Connecticut nursing homes compared to neighboring states

4. Individual-level changes in well-being

• On several measures—such as rates of depression,

C. Connecticut assisted living facilities

IV. Assessment of the State’s Preparedness and Response to

A. Surveillance and outbreak response

a. Data availability and reporting by LTC facilities

b. Licensing and inspection of LTC facilities, and investigation of complaints

a. Suspension of civil liability

b. Modifications to data systems and reporting requirements