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Declining, Reinforces Importance of Enhanced Oversight' which was 
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Report to Congressional Requesters:

United States General Accounting Office:

GAO:

July 2003:

Nursing Home Quality:

Prevalence of Serious Problems, While Declining, Reinforces Importance 
of Enhanced Oversight:

GAO-03-561:

GAO Highlights: 

Highlights of GAO-03-561, a report to congressional requesters 

Why GAO Did This Study:

Since July 1998, GAO has reported numerous times on nursing home 
quality-of-care issues and identified significant weaknesses in 
federal and state oversight. GAO was asked to assess the extent of 
the progress made in improving the quality of care provided by nursing 
homes to vulnerable elderly and disabled individuals, including 
(1) trends in measured nursing home quality, (2) state responses to 
previously identified weaknesses in their survey, complaint, and 
enforcement activities, and (3) the status of oversight and quality 
improvement efforts by the Centers for Medicare & Medicaid Services 
(CMS). 

what GAO Found:

The proportion of nursing homes with serious quality problems remains 
unacceptably high, despite a decline in the incidence of such reported 
problems. Actual harm or more serious deficiencies were cited for 20 
percent or about 3,500 nursing homes during an 18-month period ending 
January 2002, compared to 29 percent for an earlier period. Fewer 
discrepancies between federal and state surveys of the same homes 
suggests that state surveyors are doing a better job of documenting 
serious deficiencies and that the decline in serious quality problems 
is potentially real. Despite these improvements, the continuing 
prevalence of and state surveyor understatement of actual harm 
deficiencies is disturbing. For example, 39 percent of 76 state 
surveys from homes with a history of quality-of-care problemsbut 
whose current survey found no actual harm deficiencieshad documented 
problems that should have been classified as actual harm or higher, 
such as serious, avoidable pressure sores.

Weaknesses persist in state survey, complaint, and enforcement 
activities. According to CMS and states, several factors contribute to 
the understatement of serious quality problems, including poor 
investigation and documentation of deficiencies, limited quality 
assurance systems, and a large number of inexperienced surveyors in 
some states. In addition, GAO found that about one-third of the most 
recent state surveys nationwide remained predictable in their timing, 
allowing homes to conceal problems if they chose to do so. 
Considerable state variation remains regarding the ease of filing a 
complaint, the appropriateness of the investigation priorities, and 
the timeliness of investigations. Some states attributed timeliness 
problems to inadequate staff and an increase in the number of 
complaints. Although the agency strengthened enforcement policy by 
requiring states to refer for immediate sanction homes that had 
repeatedly harmed residents, GAO found that states failed to refer a 
substantial number of such homes, significantly undermining the 
policys intended deterrent effect. 

CMS oversight of state survey activities has improved but requires 
continued attention to help ensure compliance with federal 
requirements. While CMS strengthened oversight by initiating annual 
state performance reviews, officials acknowledged that the reviews 
effectiveness could be improved. 

For the initial fiscal year 2001 review, officials said they lacked 
the capability to systematically distinguish between minor lapses and 
more serious problems that required intervention. CMS oversight is 
also hampered by continuing database limitations, the inability of 
some CMS regions to use available data to monitor state activities, 
and inadequate oversight in areas such as survey predictability and 
state referral of homes for enforcement. Three key CMS initiatives 
have been significantly delayedstrengthening the survey methodology, 
improving surveyor guidance for determining the scope and severity of 
deficiencies, and producing greater standardization in state complaint 
processes. These initiatives are critical to reducing the subjectivity 
evident in current state survey and complaint activities. 

What GAO Recommends: 

GAO is making several recommendations to the Administrator of CMS to 
(1) strengthen the nursing home survey process, (2) ensure that state 
survey and complaint activities adequately assess quality-of-care 
problems, and (3) improve CMS oversight of state survey activities. 
CMS concurred with the reports recommendations, but its comments on 
intended actions were not fully responsive to all of the 
recommendations. Eleven states provided comments that most often 
focused on the resource constraints states face in meeting federal 
standards for oversight of nursing homes.

www.gao.gov/cgi-bin/getrpt?GAO-03-561.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Kathryn G. Allen at 
(202) 512-7118.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

Magnitude of Problems Remains Cause for Concern Even Though Fewer 
Serious Nursing Home Quality Problems Reported:

Weaknesses Persist in State Survey, Complaint, and Enforcement 
Activities:

CMS Oversight of State Survey Activities Requires Further 
Strengthening:

Conclusions:

Recommendations for Executive Action:

Agency and State Comments and Our Evaluation:

Appendix I: Scope and Methodology:

Appendix II: Trends in The Proportion of Nursing Homes Cited for Actual 
Harm or Immediate Jeopardy Deficiencies, 1997-2002:

Appendix III: Abstracts of Nursing Home Survey Reports That Understated 
Quality-of-Care Problems:

Appendix IV: Information on State Nursing Home Surveyor Staffing:

Appendix V: Predictability of Standard Nursing Home Surveys:

Appendix VI: Immediate Sanctions Implemented Under CMS's Expanded 
Immediate Sanctions Policy:

Appendix VII: Cases States Did Not Refer to CMS for Immediate Sanction:

Appendix VIII: HCFA State Performance Standards for Fiscal Year 2001:

Appendix IX: Highlights of State Compliance with CMS Performance 
Standards:

Appendix X: Comments from the Centers for Medicare & Medcaid Services:

Appendix XI: GAO Contact and Staff Acknowledgements:

GAO Contact:

Acknowledgements:

Related GAO Products:

Tables:

Table 1: Scope and Severity of Deficiencies Identified During Nursing 
Home Surveys:

Table 2: Change in the Percentage of Nursing Homes Cited for Actual 
Harm or Immediate Jeopardy during State Standard Surveys between the 
periods January 1, 1999, through July 10, 2000, and July 11, 2000, 
through January 31, 2002, by State:

Table 3: Incidence of Underreported Actual Harm Deficiencies in Surveys 
GAO Reviewed:

Table 4: Predictability of Nursing Home Surveys:

Table 5: Key Findings of Report to CMS on State Complaint Investigation 
Processes:

Table 6: Quality of Care Requirements Reviewed in a Sample of State 
Survey Reports:

Table 7: Trends in the Percentage of Nursing Homes Cited for Actual 
Harm or Immediate Jeopardy during State Standard Surveys, by State:

Table 8: Abstracts of the 39 Nursing Home Deficiencies that Understated 
Actual Harm from a Sample of 76 Nursing Home Survey Reports:

Table 9: State Survey Agency Responses to Questions about Surveyor 
Experience, Vacancies, Hiring Freezes, Competitiveness of Salaries, and 
Minimum Required Experience:

Table 10: Predictability of Current Nursing Home Surveys, by State:

Table 11: Federal Sanctions Implemented against Nursing Homes Referred 
for Immediate Sanction, January 14, 2000, through March 28, 2002:

Table 12: Federal CMPs Implemented under CMS's Immediate Sanctions 
Policy, January 2000 through March 2002:

Table 13: Number of Cases States Did Not Refer for Sanction, as 
Required, and the Number States Appropriately Referred, January 2000 
through March 2002:

Table 14: Overview of HCFA's Seven State Performance Standards for 
Nursing Home Survey Activities for Fiscal Year 2001:

Table 15: State Compliance with Selected CMS Performance Standards, 
Fiscal Year 2001:

Figure:

Figure 1: Four States with the Greatest Number of Cases that Should 
Have Been Referred for Immediate Sanctions, January 14, 2000, through 
March 28, 2002:

Abbreviations:

ACTS: ASPEN Complaint Tracking System: 

CMS: Centers for Medicare & Medicaid Services: 

CMP: civil money penalties:  

HCFA: Health Care Financing Administration: 

MDS: minimum data set:  

OSCAR: On-Line Survey, Certification, and Reporting system:  

RN: registered nurse:

United States General Accounting Office:

Washington, DC 20548:

July 15, 2003:

The Honorable Charles E. Grassley 
Chairman 
Committee on Finance 
United States Senate:

The Honorable Christopher S. Bond 
United States Senate:

A number of congressional hearings since July 1998 have focused 
considerable attention on the need to improve the quality of care for 
the nation's 1.7 million nursing home residents, a highly vulnerable 
population of elderly and disabled individuals. As we previously 
reported, poor quality of care at about 15 percent of the nation's 
approximately 17,000 nursing homes--an unacceptably high proportion--
had repeatedly caused actual harm to residents, such as worsening 
pressure sores or untreated weight loss, or had placed them at risk of 
death or serious injury.[Footnote 1] Significant weaknesses in federal 
and state nursing home oversight that we identified in a series of 
reports and testimonies since 1998 included (1) periodic state 
inspections, known as surveys, that understated the extent of serious 
care problems due to procedural weaknesses, (2) considerable state 
delays in investigating public complaints alleging harm to residents, 
(3) federal enforcement policies that did not ensure deficiencies were 
addressed and remained corrected, and (4) federal oversight of state 
survey activities that was limited in scope and effectiveness.[Footnote 
2]

In July 1998, the Health Care Financing Administration (HCFA)--the 
federal agency with responsibility for managing Medicare and Medicaid 
and overseeing compliance with federal nursing home quality standards-
-launched a series of actions intended to address many of the 
weaknesses we identified.[Footnote 3] Since 1998, the agency has worked 
to strengthen surveyors' ability to detect quality-of-care 
deficiencies; required states to investigate complaints alleging 
resident harm within 10 days; mandated immediate sanctions for nursing 
homes with a pattern of harming residents;[Footnote 4] and begun 
measuring state compliance with federal survey requirements and 
reviewing data on the results of state surveys to help pinpoint 
shortcomings in state survey activities.

To evaluate the extent of the progress made in improving the quality of 
nursing home care since we last addressed this issue in September 2000, 
you asked us to assess:

* trends in measured nursing home quality;

* state responses to previously identified weaknesses in their survey, 
complaint, and enforcement activities; and:

* the status of key federal efforts to oversee state survey agency 
performance and improve quality.

To assess recent trends in measured nursing home quality, we analyzed 
survey results for the period July 11, 2000, through January 31, 2002, 
and compared them to survey results for two earlier 18-month periods: 
(1) January 1, 1997, through June 30, 1998, and (2) January 1, 1999, 
through July 10, 2000. Our analysis relied on data from the Centers for 
Medicare & Medicaid Services' (CMS) On-Line Survey, Certification, and 
Reporting (OSCAR) system, which compiles the results of all state 
nursing home surveys nationwide. To better understand the trends 
identified through our OSCAR analysis, we analyzed the results of 
federal comparative surveys, conducted at recently surveyed nursing 
homes to assess the adequacy of the state surveys, for two time 
periods--October 1998 through May 2000 and June 2000 through February 
2002. We also reviewed 76 survey reports from homes with a history of 
actual harm deficiencies but whose most recent survey found no such 
deficiencies in states where the percentage of homes cited for actual 
harm had declined to below the national average since mid-2000. Our 
review of deficiencies from these survey reports focused on the types 
of quality-of-care deficiencies most frequently cited nationwide.

To assess state survey activities as well as federal oversight, we 
analyzed the conduct and results of fiscal year 2001 state survey 
agency performance reviews during which CMS regional offices determined 
state compliance with seven federal standards; we focused on the five 
standards related to statutory survey intervals, survey documentation, 
complaint activities, enforcement requirements, and OSCAR data entry. 
We conducted structured interviews with officials from CMS, CMS's 10 
regional offices, and 16 state survey agencies to discuss trends in 
survey deficiencies, the underlying causes of problems identified 
during the performance reviews, and state and federal efforts to 
address these problems.[Footnote 5] We also discussed these issues with 
officials from 10 additional states during a governing board meeting of 
the Association of Health Facility Survey Agencies. We selected the 16 
states with the goal of including states that (1) were from diverse 
geographic areas, (2) had shown either increases or decreases in the 
percentage of homes cited for actual harm, (3) had been contacted in 
our prior work, and (4) represented a mixture of strong and weak 
performance based on the results of federal performance reviews of 
state survey activities. We also obtained data from most state survey 
agencies on staffing issues such as nursing home surveyor experience 
and vacancies. To assess enforcement actions, we analyzed data in CMS's 
enforcement database and compared homes identified in OSCAR as 
requiring immediate sanctions with those actually referred to CMS for 
sanctions by state survey agencies. See appendix I for a more detailed 
description of our scope and methodology. Our work was performed from 
January 2002 through June 2003 in accordance with generally accepted 
government auditing standards.

Results in Brief:

State survey data indicate that the proportion of nursing homes with 
serious quality problems remains unacceptably high, despite a decline 
in such reported problems since mid-2000. Compared to the prior 18-
month period, the percentage of nursing homes cited for actual harm or 
immediate jeopardy from July 2000 through January 2002 declined by 
about one-third--from 29 percent (about 5,000 homes) to 20 percent 
(about 3,500 homes). Consistent with this reported improvement in 
quality, federal comparative surveys completed during a recent 20-month 
period found actual harm or higher-level deficiencies in 22 percent of 
homes where state surveyors found no such deficiencies, compared to 34 
percent in an earlier period. Fewer discrepancies between federal and 
state surveys suggest that state surveyors' performance in documenting 
serious deficiencies has improved and that the decline in serious 
quality problems nationwide is potentially real. Despite this 
improvement, however, the magnitude of understatement of actual harm 
deficiencies remains a cause for concern. Federal surveyors found 
examples of actual harm deficiencies in about one-fifth of homes that 
states had judged to be deficiency free. Moreover, 39 percent of 76 
surveys we reviewed from homes with a history of quality-of-care 
problems--but whose current survey indicated no actual harm 
deficiencies--had documented problems that should have been classified 
as actual harm: serious, avoidable pressure sores; severe weight loss; 
and multiple falls resulting in broken bones and other injuries.

Weaknesses persist in state survey, complaint investigation, and 
enforcement activities. Several factors at the state level contribute 
to the understatement of serious quality-of-care problems. Poor 
investigation and documentation of deficiencies identified during 
nursing home surveys preclude a determination of the seriousness of 
some deficiencies. According to some state officials, the large number 
of inexperienced surveyors due to high attrition and hiring limitations 
has also had a negative impact on the quality of surveys. While most of 
the 16 states we contacted had a quality assurance process in place to 
review deficiencies cited at the actual harm level and higher, half did 
not have such a process to help ensure that the scope and severity of 
less serious deficiencies were not understated. The continued 
predictability of the occurrence of standard surveys also likely 
contributes to the understatement of deficiencies. Our analysis of 
OSCAR data indicated that about one-third of the most recent state 
surveys nationwide occurred on a predictable schedule, allowing homes 
to conceal problems if they chose to do so. In addition, many states' 
complaint investigation policies and procedures were still inadequate 
to provide intended protections. For example, 15 states did not provide 
toll-free hotlines to facilitate the filing of complaints, the majority 
of states lacked adequate systems for managing complaints, and one or 
more states in most of CMS's 10 regions did not correctly determine the 
investigation priority for complaints. Moreover, most states did not 
investigate all complaints involving actual harm within 10 days, as 
required. Some states attributed the timeliness problem to insufficient 
staff and an increase in the number of complaints. Although HCFA 
strengthened its enforcement policy by requiring state survey agencies, 
beginning in January 2000, to refer for immediate sanction homes that 
had a pattern of harming residents, we found that states failed to 
refer a substantial number of such homes, significantly undermining the 
intended deterrent effect of this policy.

While CMS has increased its oversight of state survey and complaint 
activities, continued attention is required to help ensure compliance 
with federal requirements. In October 2000, HCFA implemented new annual 
performance reviews to measure state performance in seven areas, 
including the timeliness of survey and complaint investigations and the 
proper documentation of survey findings. The first round of results, 
however, did not produce information enabling the agency to identify 
and initiate needed improvements. For example, some regional office 
summary reports provided too little information to determine if a state 
did not meet a particular standard by a wide or a narrow margin--
information that could help CMS to judge the seriousness of problems 
identified. We also found inconsistencies in how CMS regions conducted 
their reviews, raising questions about the validity and fairness of the 
results. Rather than relying on its regional offices, CMS plans to more 
centrally manage future state performance reviews to improve 
consistency and to help ensure that the results of those reviews could 
be used to more readily identify serious problems. Implementation has 
been significantly delayed for three other federal initiatives that are 
critical to reducing the subjectivity evident in the state survey 
process for identifying deficiencies and investigating complaints. 
These delayed initiatives were intended to strengthen the methodology 
for conducting surveys, improve surveyor guidance for determining the 
scope and severity of deficiencies, and increase standardization in 
state complaint investigation processes.

We are recommending that the Administrator of CMS strengthen survey, 
complaint, enforcement, and oversight processes by (1) finishing the 
development of a more rigorous survey methodology, (2) requiring states 
to implement a quality assurance process to test the validity of cited 
deficiencies for surveys that include deficiencies below the actual 
harm level, (3) developing guidance for states that addresses key 
weaknesses in their complaint investigation processes, and (4) 
improving the ability of federal oversight of state survey activities 
to distinguish between systemic and less serious state survey 
performance problems. Although CMS concurred with our recommendations, 
its comments did not fully address our concerns about the status of the 
initiative intended to improve the effectiveness of the survey process 
or the recommendation regarding state quality assurance systems. Eleven 
states provided comments that most often focused on the resource 
constraints states face in meeting federal standards for oversight of 
nursing homes.

Background:

Combined Medicare and Medicaid payments to nursing homes for care 
provided to vulnerable elderly and disabled beneficiaries were expected 
to total about $63 billion in 2002, with a federal share of 
approximately $42 billion. Oversight of nursing homes is a shared 
federal-state responsibility. Based on statutory requirements, CMS 
defines standards that nursing homes must meet to participate in the 
Medicare and Medicaid programs and contracts with states to assess 
whether homes meet these standards through annual surveys and complaint 
investigations. A range of statutorily defined sanctions is available 
to help ensure that homes maintain compliance with federal quality 
requirements. CMS is also responsible for monitoring the adequacy of 
state survey activities.

Standard Surveys:

Every nursing home receiving Medicare or Medicaid payment must undergo 
a standard survey not less than once every 15 months, and the statewide 
average interval for these surveys must not exceed 12 months.[Footnote 
6] A standard survey entails a team of state surveyors, including 
registered nurses (RN), spending several days in the nursing home to 
assess compliance with federal long-term care facility requirements, 
particularly whether care and services provided meet the assessed needs 
of the residents and whether the home is providing adequate quality 
care, such as preventing avoidable pressure sores, weight loss, or 
accidents. Based on our earlier work indicating that facilities could 
mask certain deficiencies, such as routinely having too few staff to 
care for residents, if they could predict the survey timing, HCFA 
directed states in 1999 to (1) avoid scheduling a home's survey for the 
same month of the year as the home's previous standard survey and (2) 
begin at least 10 percent of standard surveys outside the normal 
workday (either on weekends, early in the morning, or late in the 
evening).

State surveyors' assessment of the quality of care provided to a sample 
of residents during the standard survey serves as the basis for 
evaluating nursing homes' compliance with federal requirements. CMS 
establishes specific investigative protocols for state surveyors to use 
in conducting these comprehensive surveys. These procedural 
instructions are intended to make the on-site surveys thorough and 
consistent across states. In response to our earlier recommendations 
concerning the need to better ensure that surveyors do not miss 
significant care problems, HCFA planned a two-phase revision of the 
survey process. In phase one, HCFA instructed states in 1999 to (1) 
begin using a series of new investigative protocols covering pressure 
sores, weight loss, dehydration, and other key quality areas, (2) 
increase the sample of residents reviewed with conditions related to 
these areas, and (3) review "quality indicator" information on the care 
provided to a home's residents, before actually visiting the home, to 
help guide survey activities. Quality indicators are essentially 
numeric warning signs of the prevalence of care problems such as 
greater-than-expected instances of weight loss, dehydration, or 
pressures sores.[Footnote 7] They are derived from nursing homes' 
assessments of residents and rank a facility in 24 areas compared with 
other nursing homes in the state.[Footnote 8] By using the quality 
indicators to select a preliminary sample of residents before the on-
site review, surveyors are better prepared to identify potential care 
problems. Surveyors augment this preliminary sample with additional 
resident cases once they arrive in the home. To address remaining 
problems with sampling and the investigative protocols, CMS is planning 
a second set of revisions to its survey methodology. The focus of phase 
two is (1) improving the on-site augmentation of the preliminary sample 
selected off-site using the quality indicators and (2) strengthening 
the protocols used by surveyors to ensure more rigor in their on-site 
investigations.

Complaint Investigations:

Complaint investigations provide an opportunity for state surveyors to 
intervene promptly if quality-of-care problems arise between standard 
surveys. Within certain federal guidelines and time frames, surveyors 
generally follow state procedures when investigating complaints filed 
against a home by a resident, the resident's family, or nursing home 
employees, and typically target a single area in response to the 
complaint. Historically, HCFA had played a minimal role in providing 
states with guidance and oversight of complaint investigations. Until 
1999, federal guidelines were limited to requiring the investigation of 
complaints alleging immediate jeopardy conditions within 2 workdays. In 
March 1999, HCFA acted to strengthen state complaint procedures by 
instructing states to investigate any complaint alleging harm to a 
nursing home resident within 10 workdays. Additional guidance provided 
to states in late 1999 specified that, as with immediate jeopardy 
complaints, investigations should generally be conducted on-site at the 
nursing home. This guidance also identified techniques to help states 
identify complaints having a higher level of actual harm. As part of a 
complaint improvement project, also initiated in late 1999, HCFA plans 
to issue more detailed guidance to states, such as identifying model 
programs or practices to increase the effectiveness of complaint 
investigations.

Deficiency Reporting:

Quality-of-care deficiencies identified during either standard surveys 
or complaint investigations are classified in 1of 12 categories 
according to their scope (i.e., the number of residents potentially or 
actually affected) and their severity. An A-level deficiency is the 
least serious and is isolated in scope, while an L-level deficiency is 
the most serious and is considered to be widespread in the nursing home 
(see table 1). States are required to enter information about surveys 
and complaint investigations, including the scope and severity of 
deficiencies identified, in CMS's OSCAR database.

Table 1: Scope and Severity of Deficiencies Identified During Nursing 
Home Surveys:

Severity: Immediate jeopardy[A]; Scope: Isolated: J; Scope: Pattern: K; 
Scope: Widespread: L.

Severity: Actual harm; Scope: Isolated: G; Scope: Pattern: H; Scope: 
Widespread: I.

Severity: Potential for more than minimal harm; Scope: Isolated: D; 
Scope: Pattern: E; Scope: Widespread: F.

Severity: Potential for minimal harm[B]; Scope: Isolated: A; Scope: 
Pattern: B; Scope: Widespread: C.

Source: CMS.

[A] Actual or potential for death/serious injury.

[B] Nursing home is considered to be in "substantial compliance.":

[End of table]

The importance of accurate and timely reporting of nursing home 
deficiency data has increased with the public reporting of survey 
deficiencies, which HCFA initiated in 1998 on its Nursing Home Compare 
Web site.[Footnote 9] The public reporting of deficiency data is 
intended to assist individuals in differentiating among nursing homes. 
In November 2002, CMS augmented the deficiency data available on its 
Web site with 10 clinical indicators of quality, such as the percentage 
of residents with pressure sores, in nursing homes nationwide. While 
the intent of this new initiative is worthwhile, CMS had not resolved 
several important issues that we raised prior to moving from a six-
state pilot to nationwide implementation.[Footnote 10] These issues 
included: (1) the ability of the new information to accurately identify 
differences in nursing home quality, (2) the accuracy of the underlying 
data used to calculate the quality indicators, and (3) the potential 
for public confusion over the available data.

Enforcement Policy:

Ensuring that documented deficiencies are corrected is a shared 
federal-state responsibility. CMS imposes sanctions on homes with 
Medicare or dual Medicare and Medicaid certification on the basis of 
state referrals.[Footnote 11] CMS normally accepts a state's 
recommendation for sanctions but can modify it. The scope and severity 
of a deficiency determine the applicable sanctions that can involve, 
among other things, requiring training for staff providing care to 
residents, imposing monetary fines, denying the home Medicare and 
Medicaid payments for new admissions, and terminating the home from 
participation in these programs. Before a sanction is imposed, federal 
policy generally gives nursing homes a grace period of 30 to 60 days to 
correct the deficiency. We earlier reported, however, that the threat 
of federal sanctions did not prevent nursing homes from cycling in and 
out of compliance because they were able to avoid sanctions by 
returning to compliance within the grace period, even when they had 
been cited for actual harm on successive surveys.[Footnote 12] In 1998, 
HCFA began a two-stage phase-in of a new enforcement policy. In the 
first stage, effective September 1998, HCFA required states to refer 
for immediate sanction homes found to have a pattern of harming 
residents or exposing them to actual or potential death or serious 
injury (H-level deficiencies and above on CMS's scope and severity 
grid). Effective January 14, 2000, HCFA expanded this policy to also 
require referral of homes found to have harmed one or a small number of 
residents (G-level deficiencies) on successive standard 
surveys.[Footnote 13]

CMS Oversight:

CMS is responsible for overseeing each state survey agency's 
performance in ensuring quality of care in state nursing homes. Its 
primary oversight tools are statutorily required federal monitoring 
surveys conducted annually in 5 percent of the nation's certified 
Medicare and Medicaid nursing homes, on-site annual state performance 
reviews instituted during fiscal year 2001, and analysis of periodic 
oversight reports that have been produced since 2000. Federal 
monitoring surveys can be either comparative or observational. A 
comparative survey involves a federal survey team conducting a 
complete, independent survey of a home within 2 months of the 
completion of a state's survey in order to compare and contrast the 
findings. In an observational survey, one or more federal surveyors 
accompany a state survey team to a nursing home to observe the team's 
performance. Roughly 85 percent of federal surveys are observational. 
State performance reviews, implemented in October 2000, measure state 
performance against seven standards, including statutory requirements 
regarding survey frequency, requirements for documenting deficiencies, 
timeliness of complaint investigations, and timely and accurate entry 
of deficiencies into OSCAR. These reviews replaced state self-reporting 
of their compliance with federal requirements. In October 2000, HCFA 
also began to produce 19 periodic reports to monitor both state and 
regional office performance. The reports are based on OSCAR and other 
CMS databases. Examples of reports that track state activities include 
pending nursing home terminations (weekly), data entry timeliness 
(quarterly), tallies of state surveys that find homes deficiency free 
(semiannually), and analyses of the most frequently cited deficiencies 
by states (annually). These reports, in a standard format, enable 
comparisons within and across states and regions and are intended to 
help identify problems and the need for intervention. Certain reports-
-such as the timeliness of state survey activities--are used to monitor 
compliance with state performance standards.

Magnitude of Problems Remains Cause for Concern Even Though Fewer 
Serious Nursing Home Quality Problems Reported:

The magnitude of the problems uncovered during standard nursing home 
surveys remains a cause for concern even though OSCAR deficiency data 
indicate that state surveyors are finding fewer serious quality 
problems. Compared to an earlier period, the percentage of homes 
nationwide cited since mid-2000 for actual harm or immediate jeopardy 
has decreased in over three-quarters of states--with seven states 
reporting a drop of 20 percentage points or more. State surveys 
conducted since about mid-2000 showed less variance from federal 
comparative surveys, suggesting that (1) state surveyors' performance 
in documenting serious deficiencies has improved and (2) the decline in 
serious nursing home quality problems is potentially real. However, 
federal comparative surveys, as well as our review of a sample of 
survey reports from homes with a history of quality-of-care problems, 
continued to find understatement of actual harm deficiencies.

Proportion of Nursing Homes with Documented Actual Harm or Immediate 
Jeopardy Care Problems Has Declined since 2000:

Compared to the preceding 18-month period, the proportion of nursing 
homes cited for actual harm or immediate jeopardy has declined 
nationally from 29 percent to 20 percent since mid-2000.[Footnote 14] 
In contrast, from early 1997 through mid-2000, the percentage of homes 
cited for such serious deficiencies was either relatively stable or 
increased in 31 states.[Footnote 15] From July 2000 through January 
2002, 40 states cited a smaller percentage of homes with such serious 
deficiencies, while only 9 states and the District of Columbia cited a 
larger proportion of homes with such deficiencies.[Footnote 16] Despite 
these changes, there is still considerable variation in the proportion 
of homes cited for serious deficiencies, ranging from about 7 percent 
in Wisconsin to about 50 percent in Connecticut. Appendix II provides 
trend data on the percentage of nursing homes cited for serious 
deficiencies for all 50 states and the District of Columbia.

Table 2 shows the recent change in actual harm and immediate jeopardy 
deficiencies for states that surveyed at least 100 nursing 
homes.[Footnote 17] Specifically:

* Twenty-five states had a 5 percentage point or greater decrease in 
the proportion of homes identified with actual harm or immediate 
jeopardy. For over two-thirds of these states, the decrease in serious 
deficiencies was greater than 10 percentage points. Seven states--
Arizona, Alabama, California, Michigan, Indiana, Pennsylvania, and 
Washington--experienced declines of 15 percentage points or more.

* Two states, South Dakota and Colorado, experienced an increase of 5 
percentage points or greater in the proportion of homes with actual 
harm or immediate jeopardy deficiencies (6.6 and 10.8, respectively).

* The remaining 11 states were relatively stable--experiencing 
approximately a 4 percentage point change or less.

Table 2: Change in the Percentage of Nursing Homes Cited for Actual 
Harm or Immediate Jeopardy during State Standard Surveys between the 
periods January 1, 1999, through July 10, 2000, and July 11, 2000, 
through January 31, 2002, by State:

Decrease of 5 percentage points or greater:

State[A]: Arizona; Number of homes surveyed (7/00-1/02): 147; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 33.8; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 8.8; Percentage point 
difference[B]: -25.0.

State[A]: Alabama; Number of homes surveyed (7/00-1/02): 228; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 42.2; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 18.4; Percentage point 
difference[B]: -23.8.

State[A]: Pennsylvania; Number of homes surveyed (7/00-1/02): 764; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 32.2; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 11.6; Percentage point 
difference[B]: -20.6.

State[A]: California; Number of homes surveyed (7/00-1/02): 1,348; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 29.1; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 9.3; Percentage point 
difference[B]: -19.9.

State[A]: Indiana; Number of homes surveyed (7/00-1/02): 573; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 45.3; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 26.2; Percentage point 
difference[B]: -19.1.

State[A]: Michigan; Number of homes surveyed (7/00-1/02): 441; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 42.1; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 24.7; Percentage point 
difference[B]: -17.4.

State[A]: Washington; Number of homes surveyed (7/00-1/02): 275; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 54.1; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 38.5; Percentage point 
difference[B]: -15.6.

State[A]: Oregon; Number of homes surveyed (7/00-1/02): 152; Percentage 
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 47.5; Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 7/00-1/02: 33.6; Percentage point difference[B]: -13.9.

State[A]: Illinois; Number of homes surveyed (7/00-1/02): 881; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 29.3; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 15.4; Percentage point 
difference[B]: -13.9.

State[A]: Mississippi; Number of homes surveyed (7/00-1/02): 219; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 33.2; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 19.6; Percentage point 
difference[B]: -13.5.

State[A]: Minnesota; Number of homes surveyed (7/00-1/02): 431; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 31.7; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 18.8; Percentage point 
difference[B]: -12.9.

State[A]: Montana; Number of homes surveyed (7/00-1/02): 103; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 37.5; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 25.2; Percentage point 
difference[B]: -12.3.

State[A]: Missouri; Number of homes surveyed (7/00-1/02): 569; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 22.3; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 10.2; Percentage point 
difference[B]: -12.1.

State[A]: South Carolina; Number of homes surveyed (7/00-1/02): 180; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 28.7; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 17.8; Percentage point 
difference[B]: -10.9.

State[A]: North Carolina; Number of homes surveyed (7/00-1/02): 419; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 40.8; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 30.1; Percentage point 
difference[B]: -10.7.

State[A]: Arkansas; Number of homes surveyed (7/00-1/02): 267; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 37.7; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 27.3; Percentage point 
difference[B]: -10.4.

State[A]: Massachusetts; Number of homes surveyed (7/00-1/02): 512; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 33.0; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 22.9; Percentage point 
difference[B]: -10.2.

State[A]: Iowa; Number of homes surveyed (7/00-1/02): 494; Percentage 
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 19.3; Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 7/00-1/02: 9.9; Percentage point difference[B]: -9.4.

State[A]: Tennessee; Number of homes surveyed (7/00-1/02): 377; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 26.0; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 16.7; Percentage point 
difference[B]: -9.3.

Nation: Number of homes surveyed (7/00-1/02): 17,149; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 29.3; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 20.5; Percentage point 
difference[B]: -8.8.

State[A]: Virginia; Number of homes surveyed (7/00-1/02): 285; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 19.9; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 11.6; Percentage point 
difference[B]: -8.3.

State[A]: Kansas; Number of homes surveyed (7/00-1/02): 400; Percentage 
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 37.1; Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 7/00-1/02: 29.0; Percentage point difference[B]: -8.1.

State[A]: Nebraska; Number of homes surveyed (7/00-1/02): 243; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 26.0; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 18.9; Percentage point 
difference[B]: -7.1.

State[A]: Wisconsin; Number of homes surveyed (7/00-1/02): 421; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 14.0; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 7.1; Percentage point 
difference[B]: -6.9.

State[A]: Maryland; Number of homes surveyed (7/00-1/02): 248; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 25.6; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 20.2; Percentage point 
difference[B]: -5.5.

State[A]: Ohio; Number of homes surveyed (7/00-1/02): 1,029; Percentage 
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 29.0; Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 7/00-1/02: 23.7; Percentage point difference[B]: -5.3.

Change of less than 5 percentage points:

State[A]: Kentucky; Number of homes surveyed (7/00-1/02): 306; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 28.8; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 25.2; Percentage point 
difference[B]: -3.7.

State[A]: New Jersey; Number of homes surveyed (7/00-1/02): 366; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 24.5; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 22.4; Percentage point 
difference[B]: -2.1.

State[A]: Georgia; Number of homes surveyed (7/00-1/02): 370; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 22.6; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 20.5; Percentage point 
difference[B]: -2.0.

State[A]: West Virginia; Number of homes surveyed (7/00-1/02): 143; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 15.6; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 14.0; Percentage point 
difference[B]: -1.7.

State[A]: Texas; Number of homes surveyed (7/00-1/02): 1,275; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 26.9; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 25.5; Percentage point 
difference[B]: -1.5.

State[A]: Florida; Number of homes surveyed (7/00-1/02): 742; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 20.8; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 20.1; Percentage point 
difference[B]: -0.8.

State[A]: Maine; Number of homes surveyed (7/00-1/02): 124; Percentage 
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 10.3; Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 7/00-1/02: 9.7; Percentage point difference[B]: -0.6.

State[A]: New York; Number of homes surveyed (7/00-1/02): 671; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 32.2; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 32.3; Percentage point 
difference[B]: 0.2.

State[A]: Connecticut; Number of homes surveyed (7/00-1/02): 259; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 48.5; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 49.4; Percentage point 
difference[B]: 0.9.

State[A]: Louisiana; Number of homes surveyed (7/00-1/02): 367; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 19.9; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 23.4; Percentage point 
difference[B]: 3.5.

State[A]: Oklahoma; Number of homes surveyed (7/00-1/02): 394; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 16.7; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 20.6; Percentage point 
difference[B]: 3.9.

Increase of 5 percentage points or greater:

State[A]: South Dakota; Number of homes surveyed (7/00-1/02): 114; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 24.1; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 30.7; Percentage point 
difference[B]: 6.6.

State[A]: Colorado; Number of homes surveyed (7/00-1/02): 225; 
Percentage of homes with actual harm or immediate jeopardy 
deficiencies: 1/99-7/00: 15.4; Percentage of homes with actual harm or 
immediate jeopardy deficiencies: 7/00-1/02: 26.2; Percentage point 
difference[B]: 10.8.

Source: GAO analysis of OSCAR data as of June 24, 2002.

[A] Includes only those states in which 100 or more homes were surveyed 
since July 2000.

[B] Differences are based on numbers before rounding.

[End of table]

States offered several explanations for the declines in actual harm and 
immediate jeopardy deficiencies, including (1) changing guidance from 
CMS regional offices as to what constitutes actual harm, (2) hiring 
additional staff, and (3) surveyors failing to properly identify actual 
harm deficiencies.

Federal Comparative Surveys Show Decreased Variance with State Survey 
Findings, but Understatement of Actual Harm Deficiencies Continued:

Our analysis of federal comparative surveys conducted nationwide prior 
to and since June 2000 showed a decreased variance between federal and 
state survey findings (see app. I for a description of our scope and 
methodology). For comparative surveys completed from October 1998 
through May 2000, federal surveyors found actual harm or higher-level 
deficiencies in 34 percent of homes where state surveyors had found no 
such deficiencies, compared to 22 percent for comparative surveys 
completed from June 2000 through February 2002. In addition, while 
federal surveyors found more serious care problems than state surveyors 
on 70 percent of the earlier comparative surveys, this percentage 
declined to 60 percent for the more recent surveys.

Despite the decline in understatement of actual harm deficiencies from 
34 percent to 22 percent, the magnitude of the state surveyors' 
understatement of quality problems remains an issue. For example, from 
June 2000 through February 2002, federal surveyors found at least one 
actual harm or immediate jeopardy quality-of-care deficiency in 16 of 
the 85 homes (19 percent) that the states had found to be free of 
deficiencies. For example, federal surveyors found that 1 of the 16 
homes failed to prevent pressure sores, failed to consistently monitor 
pressure sores when they did develop, and failed to notify the 
physician promptly so that proper treatment could be started. The 
federal surveyors who conducted the comparative survey of this nursing 
home noted in the file that a lack of consistent monitoring of pressure 
sores existed at the home during the time of the state's survey and 
that the state surveyors should have found the deficiency.

Several states that reviewed a draft of this report questioned the 
value of federal comparative surveys because of their timing. Arizona 
noted that comparative surveys do not have to begin until up to 2 
months after the state's survey, and Iowa and Virginia officials said 
they might occur so long after the state's survey that conditions in 
the home may have significantly changed. Although legislation requires 
comparative surveys to begin within 2 months of the state's survey, CMS 
is continuing to make progress in reducing the timeframe between the 
state and the comparative survey. Based on our earlier recommendation 
that comparative surveys begin as soon after the state's survey as 
possible, CMS instructed the regions to begin these surveys no later 
than one month following the state's survey, and the average time 
between surveys nationally has decreased from 33 calendar days in 1999 
to about 26 calendar days for surveys conducted from June 2000 through 
February 2002.[Footnote 18]

Quality-of-Care Problems Were Understated in Homes with a History of 
Problems:

Even with the reported decline in serious deficiencies, an unacceptably 
high number of nursing homes--one in five nationwide--still had actual 
harm or immediate jeopardy deficiencies. Moreover, we found widespread 
understatement of actual harm deficiencies in a sample of surveys we 
reviewed that were conducted since July 2000 at homes with a history of 
harming residents (see app. I for a description of our methodology in 
selecting this sample). In 39 percent of the 76 survey reports we 
reviewed, we found sufficient evidence to conclude that deficiencies 
cited at a lower level (generally, potential for more than minimal 
harm, D or E) should have been cited at the level of actual harm or 
higher (G level or higher on CMS's scope and severity grid). We were 
unable to assess whether the scope and severity of other deficiencies 
in our sample of surveys were also understated because of weaknesses in 
the investigations conducted by surveyors and in the adequacy with 
which they documented those deficiencies.

Of the surveys we reviewed, 30 (39 percent) contained sufficient 
evidence for us to conclude that deficiencies cited at the D and E 
level should have been cited as at least actual harm because a 
deficient practice was identified and linked to documented actual harm 
involving at least one resident (see table 3). These 30 survey reports 
depicted examples of actual harm, including serious, avoidable pressure 
sores; severe weight loss; and multiple falls resulting in broken bones 
and other injuries (see app. III for abstracts of these 30 survey 
reports). The following example illustrates understated actual harm 
involving the failure to provide necessary care and services. A nurse 
at one facility noted a large area of bruising and swelling on an 89-
year-old resident's chest. Nothing further was done to explore this 
injury until 11 days later when the resident began to experience 
shortness of breath and diminished breath sounds. Then a chest x ray 
was taken, revealing that the resident had sustained two fractured ribs 
and fluid had accumulated in the resident's left lung. A facility 
investigation determined that the resident had been injured by a lift 
used to transfer the resident to and from the bed. It was clear from 
the surveyor's information that the facility failed to take appropriate 
action to assess and provide the necessary care until the resident 
developed serious symptoms of chest trauma. Nevertheless, the surveyor 
concluded that there was no actual harm and cited a D-level deficiency-
-potential for more than minimal harm.

Table 3: Incidence of Underreported Actual Harm Deficiencies in Surveys 
GAO Reviewed:

State: Alabama; Number of surveys from state: 6; Number of surveys in 
which GAO identified G-level deficiencies: 2; Number of G-level 
deficiencies GAO identified: 2.

State: Arizona; Number of surveys from state: 3; Number of surveys in 
which GAO identified G-level deficiencies: 1; Number of G-level 
deficiencies GAO identified: 2.

State: California; Number of surveys from state: 22; Number of surveys 
in which GAO identified G-level deficiencies: 13; Number of G-level 
deficiencies GAO identified: 17.

State: Iowa; Number of surveys from state: 7; Number of surveys in 
which GAO identified G-level deficiencies: 5; Number of G-level 
deficiencies GAO identified: 7.

State: Maryland; Number of surveys from state: 3; Number of surveys in 
which GAO identified G-level deficiencies: 1; Number of G-level 
deficiencies GAO identified: 1.

State: Minnesota; Number of surveys from state: 5; Number of surveys in 
which GAO identified G-level deficiencies: 0; Number of G-level 
deficiencies GAO identified: 0.

State: Mississippi; Number of surveys from state: 1; Number of surveys 
in which GAO identified G-level deficiencies: 0; Number of G-level 
deficiencies GAO identified: 0.

State: Missouri; Number of surveys from state: 4; Number of surveys in 
which GAO identified G-level deficiencies: 1; Number of G-level 
deficiencies GAO identified: 1.

State: Nebraska; Number of surveys from state: 4; Number of surveys in 
which GAO identified G-level deficiencies: 2; Number of G-level 
deficiencies GAO identified: 2.

State: Pennsylvania; Number of surveys from state: 11; Number of 
surveys in which GAO identified G-level deficiencies: 2; Number of G-
level deficiencies GAO identified: 3.

State: South Carolina; Number of surveys from state: 1; Number of 
surveys in which GAO identified G-level deficiencies: 0; Number of G-
level deficiencies GAO identified: 0.

State: Virginia; Number of surveys from state: 7; Number of surveys in 
which GAO identified G-level deficiencies: 3; Number of G-level 
deficiencies GAO identified: 4.

State: West Virginia; Number of surveys from state: 1; Number of 
surveys in which GAO identified G-level deficiencies: 0; Number of G-
level deficiencies GAO identified: 0.

State: Wisconsin; Number of surveys from state: 1; Number of surveys in 
which GAO identified G-level deficiencies: 0; Number of G-level 
deficiencies GAO identified: 0.

State: Total; Number of surveys from state: 76; Number of surveys in 
which GAO identified G-level deficiencies: 30; Number of G-level 
deficiencies GAO identified: 39.

Source: GAO analysis of state surveys.

Note: We reviewed surveys where state surveyors had cited deficiencies 
at the D or E level (potential for more than minimal harm) in one or 
more of four quality-of-care areas (see app. I, table 6). We reviewed 
all such deficiencies to determine if, in our judgment, the 
deficiencies should have been cited at the G level or higher (actual 
harm).

[End of table]

State survey agency officials in Alabama, California, Iowa, and 
Nebraska told us that surveyors had originally cited G-level 
deficiencies in 10 of the surveys we reviewed, but that the 
deficiencies had been reduced to the D level during the states' reviews 
because of inadequate surveyor documentation. We concluded that 5 of 
the 10 surveys did contain adequate documentation to support actual 
harm because there was a clear link between the deficient facility 
practice and the documented harm to a resident. For example, the survey 
managers in one state changed a G-to a D-level deficiency because the 
surveyor only cited one source of evidence to support the deficiency--
nurses' notes in the residents' medical records.[Footnote 19] According 
to the surveyor, a resident with dementia, experiencing long-and short-
term memory problems, fell 11 times and sustained a fractured wrist, 
three fractured ribs, and numerous bruises, abrasions, and skin tears. 
According to the notes of facility nurses, a personal alarm unit was in 
place as a safety device to prevent falls. The surveyor found that the 
facility had (1) failed to provide adequate interventions to prevent 
accidents and (2) continued to use the alarm unit even though it did 
not prevent any of the falls. The medical record documentation of these 
events was extensive and, in our judgment, was sufficient evidence of a 
deficiency that resulted in actual harm to the resident.

In many of the 76 surveys we reviewed, including surveys in which we 
found no D-or E-level deficiencies that would appear to meet the 
criteria for actual harm deficiencies, we identified serious 
investigation or documentation weaknesses that could further contribute 
to the understatement of serious deficiencies in nursing homes. In some 
cases, the survey did not clearly describe the elements of the 
deficient practice, such as whether the resident developed a pressure 
sore in the facility or what the facility did to prevent the 
development of a facility-acquired pressure sore. In other cases, the 
survey omitted critical facts, such as whether a pressure sore had 
worsened or the size of the pressure sore.

Weaknesses Persist in State Survey, Complaint, and Enforcement 
Activities:

Widespread weaknesses persist in state survey, complaint investigation, 
and enforcement activities despite increased attention to these issues 
in recent years. Several factors at the state level contribute to the 
understatement of serious quality-of-care problems, including poor 
investigation and documentation of deficiencies, the absence of 
adequate quality assurance processes, and a large number of 
inexperienced surveyors in some states due to high attrition or hiring 
limitations. In addition, our analysis of OSCAR data indicated that the 
timing of a significant proportion of state surveys remained 
predictable, allowing homes to conceal problems if they choose to do 
so. Many states' complaint investigation policies and procedures were 
still inadequate to provide intended protections. For example, many 
states do not investigate all complaints identified as alleging actual 
harm in a timely manner, a problem some states attributed to 
insufficient staff and an increase in the number of complaints. 
Although HCFA strengthened its enforcement policy by requiring state 
survey agencies, beginning in January 2000, to refer for immediate 
sanction homes that had a pattern of harming residents, we found that 
many states did not fully comply with this new requirement. States 
failed to refer a substantial number of homes for sanction, 
significantly undermining the policy's intended deterrent effect.

Investigation Weaknesses and Other Factors Contribute to Underreporting 
of Care Problems:

CMS and state officials identified several factors that they believe 
contribute to state surveys continuing to miss significant care 
problems. These weaknesses persist, in part, because many states lack 
adequate quality assurance processes to ensure that deficiencies 
identified by surveyors are appropriately classified. According to 
officials we interviewed, the large number of inexperienced surveyors 
in some states due to high attrition has also had a negative impact on 
the quality of state surveys and investigations. Our analysis of OSCAR 
data also indicated that nursing homes could conceal problems if they 
choose to do so because a significant proportion of current state 
surveys remain predictable.

Investigation and Documentation Weaknesses:

Consistent with the investigation and documentation weaknesses we found 
in our review of a sample of survey reports from homes with a history 
of actual harm deficiencies, CMS officials told us that their own 
activities had identified similar problems that could contribute to an 
understatement of serious deficiencies at nursing homes.

* CMS reviews of state survey reports during fiscal year 2001 
demonstrated weaknesses in a majority of states, including: (1) 
inadequate investigation and documentation of a poor outcome, such as 
reviewing available records to help identify when a pressure sore was 
first observed and how it changed over time, (2) failure to 
specifically identify the deficient practice that contributed to a poor 
outcome, or (3) understatement of the seriousness of a deficiency, such 
as citing a deficiency at the D level (potential for actual harm) when 
there was sufficient evidence in the survey report to cite the 
deficiency at the G level (actual harm).

* State survey agency officials expressed confusion about the 
definition of "actual harm" and "immediate jeopardy," suggesting that 
such confusion contributes to the variability in state deficiency 
trends. For example, officials in one state told us that, in their 
view, residents must experience functional impairment for state 
surveyors to cite an actual harm deficiency, an interpretation that CMS 
officials told us was incorrect. Under such a definition, repeated 
falls that resulted in bruises, cuts, and painful skin tears would not 
be cited as actual harm, even if the facility failed to assess the 
resident for measures to prevent falls.

* CMS officials also told us that, contrary to federal guidance, state 
surveyors in at least one state did not cite all identified 
deficiencies but rather brought them to the homes' attention with the 
expectation that the deficiencies would be corrected. CMS officials 
told us that they identified the problem by asking state officials 
about the unusually high number of homes with no deficiencies on their 
standard surveys.

Inadequate Quality Assurance Processes:

Some state officials told us that considerable staff resources are 
devoted to scrutinizing the support for actual harm and higher-level 
deficiencies that could lead to the imposition of a sanction. While 
most of the 16 states we contacted had quality assurance processes to 
review deficiencies cited at the actual harm level and higher, half did 
not have such processes to help ensure that the scope and severity of 
less serious deficiencies were not understated.[Footnote 20] State 
officials generally told us that they lacked the staff and time to 
review deficiencies that did not involve actual harm or immediate 
jeopardy, but some states have established such programs. For example, 
Maryland established a technical assistance unit in early 2001 to 
review a sample of survey reports; the review looks at all 
deficiencies--not just those involving actual harm or immediate 
jeopardy. A Maryland official told us that she had the resources to do 
so because the state legislature authorized a substantial increase in 
the number of surveyors in 1999. However, staff cutbacks in late 2002 
due to the state's budget crisis have resulted in the reviews being 
less systematic than originally planned. In Colorado, two long-term-
care supervisors reviewed all 1,351 deficiencies cited in fiscal year 
2001. Maryland and Colorado officials told us that the reviews have 
identified shortcomings in the investigation and documentation of 
deficiencies, such as the failure to interview residents or the 
classification of deficiencies as process issues when they actually 
involved quality of care. The reviews, we were told, provide an 
opportunity for surveyor feedback or training that improves the quality 
and consistency of future surveys.

Inexperienced State Surveyors:

State officials cited the limited experience level of state surveyors 
as a factor contributing to the variability in citing actual harm or 
higher-level deficiencies and the understatement of such deficiencies. 
Data we obtained from 42 state survey agencies in July 2002 revealed 
the magnitude of the problem: in 11 states, 50 percent or more of 
surveyors had 2-years' experience or less; in another 13 states, from 
30 percent to 48 percent of surveyors had similarly limited experience 
(see app. IV). For example, Alabama's and Louisiana's recent annual 
attrition rates were 29 percent and 18 percent, respectively, and, as a 
result, almost half of the surveyors in both states had been on the job 
for 2 years or less. In California and Maryland--states that hired a 
significant number of new surveyors since 2000--52 percent and 70 
percent of surveyors, respectively, had less than 2 years of on-the-job 
experience.[Footnote 21] According to CMS regional office and state 
officials, the first year for a new surveyor is essentially a period of 
training and low productivity, and it takes as long as 3 years for a 
surveyor to gain sufficient knowledge, experience, and confidence to 
perform the job well. High staff turnover was attributed, in part, to 
low salaries for RN surveyors--salaries that may not be competitive 
with other employment opportunities for nurses. Overall, 29 of the 42 
states that responded to our inquiry indicated that they believed nurse 
surveyor salaries were not competitive (see app. IV). Officials in 
several states also told us that the combination of low starting 
salaries and a highly competitive market forced them to hire less 
qualified candidates with less breadth of experience.

Predictable Surveys:

Even though HCFA directed states, beginning January 1, 1999, to avoid 
scheduling a nursing home's survey for the same month of the year as 
its previous survey, over one-third of state surveys remain 
predictable. Our analysis demonstrated little change in the proportion 
of predictable nursing home surveys. Predictable surveys can allow 
quality-of-care problems to go undetected because homes, if they choose 
to do so, may conceal problems.[Footnote 22] We recommended in 1998 
that HCFA segment the standard survey into more than one review 
throughout the year, simultaneously increasing state surveyor presence 
in nursing homes and decreasing survey predictability. Although HCFA 
disagreed with segmenting the survey, it did recognize the need to 
reduce predictability.

Our analysis of OSCAR data demonstrated that, on average, the timing of 
34 percent of current surveys nationwide could have been predicted by 
nursing homes, a slight reduction from the prior surveys when about 38 
percent of all surveys were predictable. The predictability of current 
surveys ranged from 83 percent in Alabama to 10 percent in Michigan 
(see app. V for data on all 50 states and the District of Columbia). In 
34 states, 25 percent to 50 percent of current surveys were 
predictable, as shown in table 4. In 9 states, more than 50 percent of 
current surveys were predictable.[Footnote 23]

Table 4: Predictability of Nursing Home Surveys:

Percentage of predictable surveys[A]: More than 50 percent; Number of 
states[B]: 9.

Percentage of predictable surveys[A]: 25 percent to 50 percent; Number 
of states[B]: 34.

Percentage of predictable surveys[A]: Less than 25 percent; Number of 
states[B]: 8.

Source: GAO analysis of OSCAR data as of April 9, 2002.

[A] We considered surveys to be predictable if (1) homes were surveyed 
within 15 days of the 1-year anniversary of their prior surveys, or (2) 
homes were surveyed within 1 month of the maximum 15-month interval 
between standard surveys.

[B] Includes the District of Columbia.

[End of table]

Many State Complaint Investigation Systems Still Have Timeliness 
Problems and Other Weaknesses:

Most state agencies did not investigate serious complaints filed 
against nursing homes within required time frames, and practices for 
investigating complaints in many states may not be as effective as they 
could be. A CMS review of states' timeliness in investigating 
complaints alleging harm to residents revealed that most states did not 
investigate all such complaints within 10 days, as CMS requires. 
Additionally, a CMS-sponsored study of complaint practices in 47 states 
raised concerns about state approaches to accepting and investigating 
complaints.

Until March 1999, states could set their own complaint investigation 
time frames, except that they were required to investigate within 2 
workdays all complaints alleging immediate jeopardy conditions. In 
March 1999, we reported that inadequate complaint intake and 
investigation practices in states we reviewed had too often resulted in 
extensive delays in investigating serious complaints.[Footnote 24] As a 
result of our findings, HCFA began requiring states to investigate 
complaints that allege actual harm, but do not rise to the level of 
immediate jeopardy, within 10 workdays.[Footnote 25] CMS's 2001 review 
of a sample of complaints in all states demonstrated that many states 
were not complying with these requirements. Specifically, 12 states 
were not investigating all immediate jeopardy complaints within the 
required 2 workdays, and 42 states were not complying with the 
requirement to investigate actual harm complaints within 10 
days.[Footnote 26] The agency also found that the triaging of 
complaints to determine how quickly each complaint should be 
investigated was inadequate in many states.

The extent to which states did not meet the 2-day and 10-day 
investigation requirements varied considerably. Officials from 12 of 
the 16 states we contacted indicated that they were unable to 
investigate complaints on time because of staff shortages. Oklahoma 
investigated only 3 of the 21 immediate jeopardy complaints that CMS 
sampled within the required 2-day period and none of 14 sampled actual 
harm complaints in 10 days. Oklahoma officials attributed this 
timeliness problem to staff shortages and a surge in the number of 
complaints received in 2000, from about 5 per day to about 35. The 
rising volume of complaints is a particular problem for California, 
which receives about 10,000 complaints annually, and had a 20 percent 
increase in complaints from January 2001 through July 2002. State 
officials told us that California law requires all complaints alleging 
immediate jeopardy to a resident to be investigated within 24 hours and 
all others to be investigated within 10 days, and that the increase in 
the number of complaints requires an additional 32 surveyor 
positions.[Footnote 27] CMS regional officials told us that the vast 
majority of California complaints were investigated within 10 days. 
However, the 2001 review also showed that about 9 percent of the 
state's standard surveys were conducted late.[Footnote 28] Both CMS and 
California officials indicated that the priority the state attaches to 
investigating complaints affected survey timeliness. Officials from 
Washington told us that their practice of investigating facility self-
reported incidents led to their not meeting the 10-day requirement on 
all complaints that CMS reviewed. Washington investigated 18 of 20 
sampled actual harm complaints on time--missing the 10-day requirement 
for the other two by 2 days and 4 days, respectively. Washington 
officials pointed out that the two complaints not investigated within 
10 days were facility self-reported incidents and commented that many 
other states do not even require investigation of such incidents. Thus, 
in these other states, such incidents would not even have been included 
in CMS's review.

In its review of state complaint files, CMS also evaluated whether 
states had appropriately triaged complaints--that is, determined how 
quickly each complaint should be investigated. Most of the regions told 
us that one or more of their states had difficulty determining the 
investigation priority for complaints. In an extreme case, a regional 
office discovered that one of its states was prioritizing its 
complaints on the basis of staff availability rather than on the 
seriousness of the complaints. Several regions indicated that some 
states improperly assigned complaints to categories that permitted 
longer investigation time frames, and one region indicated that 
triaging difficulties involved state personnel not collecting enough 
information from the complainant to make a proper decision. Officials 
from some of the 16 state survey agencies we contacted indicated that 
HCFA's 1999 guidance to states on what constitutes an actual harm 
complaint was unclear and confusing.

In an effort to improve state responsiveness to complaints, HCFA hired 
a contractor in 1999 to assess and recommend improvements to state 
complaint practices. The study identified significant problems with 
states' complaint processes, including complaint intake activities, 
investigation procedures, and complaint substantiation 
practices.[Footnote 29] For example, the report noted that 15 states 
did not have toll-free hotlines for the public to file complaints. In 
our earlier reports, we noted that the process of filing a complaint 
should not place an unnecessary burden on a complainant and that an 
easy-to-use complaint process should include a toll-free number that 
permits the complainant to leave a recorded message when state staff 
are unavailable.[Footnote 30] Table 5 summarizes major findings from 
the contractor's report to CMS.

Table 5: Key Findings of Report to CMS on State Complaint Investigation 
Processes:

Finding: States vary in the ease with which the public can file a 
complaint; Description: Thirty-four states indicated that they provide 
toll-free hotlines for the public to file complaints. Twenty-nine of 
the 34 states indicated that they operate their hotlines 24 hours a 
day, 7 days a week, and 5 said their hotlines were answered during 
business hours. Nineteen states had no provisions or plans to handle 
non-English speaking complainants.

Finding: States need to improve their complaint intake and triaging 
systems; Description: States need to better triage their complaints 
and decide which complaints should be referred to other agencies for 
investigation. They should also improve procedures for merging 
complaints with ongoing survey activities at a nursing home. More 
consistency is needed in handling facility self-reported incidents.

Finding: State survey staffs that conduct complaint intake and 
investigation often have additional duties; Description: States should 
use staff dedicated to investigating complaints to improve the quality 
of investigations. This might include assigning responsibility for a 
state's total complaint system to a single complaint supervisor or 
coordinator and also may require more careful hiring standards with 
specific job qualifications.

Finding: Investigation procedures vary across states; Description: 
States do not use all available data when preparing for a complaint 
investigation. There is little agreement among states regarding how 
many resident records should be sampled during a complaint 
investigation.[A].

Finding: Complaint investigation training is needed; Description: 
Specialized complaint training and periodic refresher training on 
complaint intake, triaging, and investigation techniques are needed to 
improve the quality of complaint investigations.

Finding: Resolution of complaints is inconsistent across states; 
Description: States have developed varying criteria for determining 
what constitutes a substantiated complaint and varying practices for 
communicating the results of investigations to complainants. Twenty-two 
states could not indicate how long it takes them to provide the results 
of an investigation to the complainant, and at least four states do not 
inform the complainant of the results.

Finding: Not all states have comprehensive complaint tracking systems, 
and CMS tracking systems are not up-to-date or user friendly.[B]; 
Description: Twenty states indicated that they could track the status 
of complaints and produce summary reports.

Source: CMS.

Note: GAO analysis of information from Center for Health Systems 
Research and Analysis at the University of Wisconsin, Madison, Final 
Report: Complaint Improvement Project, prepared for CMS, June 3, 2002.

[A] In 1999, we reported that HCFA had not provided states with 
guidance on when to expand a complaint review beyond the residents who 
were the subject of the original complaint. See GAO/HEHS-99-80.

[B] CMS is planning to implement a new complaint tracking system 
nationwide that should address this shortcoming.

[End of table]

States Did Not Refer a Substantial Number of Nursing Homes to CMS for 
Immediate Sanctions:

State survey agencies did not refer 711 cases in which nursing homes 
were found to have a pattern of harming residents to CMS for immediate 
sanction as required by CMS policy.[Footnote 31] Our earlier work found 
that nursing homes tended to "yo-yo" in and out of compliance, in part 
because HCFA rarely imposed sanctions on homes with a pattern of 
deficiencies that harmed residents.[Footnote 32] In response, the 
agency required that homes found to have harmed residents on successive 
standard surveys be referred to it for immediate sanction.[Footnote 33] 
Most states did not refer at least some cases that should have been 
referred under this policy.[Footnote 34] Figure 1 shows the results of 
our analysis for the four states--Massachusetts, New York, 
Pennsylvania, and Texas--with the greatest numbers of cases that should 
have been referred and for the nation (see app. VII for information on 
all states). These four states accounted for 55 percent of the 711 
cases.

Figure 1: Four States with the Greatest Number of Cases that Should 
Have Been Referred for Immediate Sanctions, January 14, 2000, through 
March 28, 2002:

[See PDF for image]

Note: Analysis includes cases entered in CMS's enforcement database by 
March 28, 2002.

[A] According to a Dallas regional office official, Texas referred most 
of the 423 cases because the nursing homes had a "poor enforcement 
history," not because of repeat harm level deficiencies. However, based 
on other information, the region coded these cases as requiring 
immediate sanction.

[End of figure]

State and CMS officials identified several reasons why state agencies 
failed to forward cases to CMS for immediate sanction, including (1) an 
initial misunderstanding of the policy on the part of some states and 
regions, (2) poor state systems for monitoring the survey history of 
homes to identify those meeting the criteria for referral for immediate 
sanction, and (3) actions, by two states, that were at variance with 
CMS policy. First, officials from some states--and some CMS regional 
officials as well--told us that they did not initially fully understand 
the criteria for referring homes for immediate sanction.[Footnote 35] 
For example, several states and CMS regional offices reported that they 
did not understand that CMS required states to look back before the 
January 2000 policy implementation date to determine if there was an 
earlier survey with an actual-harm-level deficiency. The look-back 
requirement was specifically addressed in a February 10, 2000, CMS 
policy clarification specifying that state agencies were to consider 
the home's survey history before the January 14, 2000, implementation 
date in determining if a home met the criteria for immediate referral 
for sanction. However, officials in one region told us that they had 
instructed three of four states not to look back before the January 
2000 implementation date of the policy. Two other regional offices told 
us that CMS policy did not require the state to look back before 
January 2000 for earlier surveys. Officials at another regional office 
did not recall the look-back policy at the time we talked to them in 
mid-2002, and were not sure what advice they had given their states 
when the policy was first implemented.

Second, some state survey agencies told us that their managers 
responsible for enforcement did not have an adequate methodology for 
checking the survey history of homes to identify those meeting the 
criteria. Some states said that their managers relied on manual 
systems, which are less accurate and sometimes failed to identify cases 
that should have been referred. Officials in one state told us that its 
district offices had no consistent procedure for checking the survey 
history of homes. An official in another state told us that some cases 
were not referred because time lags in reporting some surveys meant 
that an earlier survey--such as a complaint survey--with an actual harm 
deficiency might not have been entered in the state's tracking system 
until after a later survey that also found harm-level deficiencies.

Third, two states did not implement CMS's expanded policy on immediate 
sanctions. New York was in direct conflict with CMS policy. Although 
CMS policy calls for state referrals to CMS regardless of the type of 
deficiency, a state agency official told us that the state only 
referred a home to CMS for immediate sanction if both actual harm 
citations were for the exact same deficiency.[Footnote 36] A CMS 
official indicated that New York began complying with the policy in 
September 2002.[Footnote 37] Texas, the second state, did not implement 
the CMS policy statewide until July 2002, when it received our inquiry 
about the cases not referred for immediate sanction. In the interim 
from January 2000 through July 2002, three of Texas's 11 district 
offices specifically requested from state survey agency officials, and 
were granted, permission to implement the policy.

CMS Oversight of State Survey Activities Requires Further 
Strengthening:

While CMS has increased its oversight of state survey and complaint 
activities and instituted a more systematic oversight process by 
initiating annual state performance reviews, CMS officials acknowledged 
that the effectiveness of the reviews could be improved. In particular, 
CMS officials told us that for the initial state performance review in 
fiscal year 2001, they lacked the capability to systematically 
distinguish between minor lapses identified during the reviews and more 
serious problems that require intervention. CMS oversight is also 
hampered by continuing limitations in OSCAR data, the inability or 
reluctance of some CMS regions to use such data to monitor state 
activities, and inadequate oversight of certain areas, such as survey 
predictability and state referral of homes for immediate enforcement 
actions. CMS has restructured regional office responsibilities to 
improve the consistency of federal oversight and plans to further 
strengthen oversight by increasing the number of federal comparative 
surveys. However, three federal initiatives critical to reducing the 
subjectivity evident in the current survey process and the 
investigation of complaints have been delayed.

CMS Reviews of State Performance Have Identified Areas for Improvement:

In the first of what is planned as an annual process, CMS's 10 regional 
offices reviewed states' fiscal year 2001 performance for seven 
standards to determine how well states met their nursing home survey 
responsibilities (see app. VIII for a description of the seven 
standards).[Footnote 38] This enhanced oversight of state survey agency 
performance responds to our prior recommendations. In 1999, we reported 
that HCFA's oversight of state efforts had limitations preventing it 
from developing accurate and reliable assessments of state 
performance.[Footnote 39] HCFA regional office policies, practices, and 
oversight had been inconsistent, a reflection of coordination problems 
between HCFA's central office and its regional staffs. In important 
areas, such as the adequacy of surveyors' findings and complaint 
investigations, HCFA relied on states to evaluate their own performance 
and report their findings to HCFA. Although OSCAR data were available 
to HCFA for monitoring state performance, they were infrequently used, 
and neither the states nor HCFA's regional offices were held 
accountable for failing to meet or enforce established performance 
standards.

To promote consistent application of the standards across the 10 
regions, the agency developed detailed guidance for measuring each 
standard, including the method of evaluation, the data sources to be 
used, and the criteria for determining whether a state met a standard. 
Only two states met each of the five standards we reviewed and many did 
not meet several standards. Appendix IX identifies the standards we 
analyzed and the results of CMS's review of these standards. During the 
2001 review, CMS elected not to impose the most serious sanctions 
available for inadequate state performance, including reducing federal 
payments to the state or initiating action to terminate the state's 
agreement, but advised the states that annual reviews in subsequent 
years will serve as the basis for such actions. While imposing no 
sanctions during the 2001 review, CMS did require several states to 
prepare corrective action plans. Each year, CMS plans to update and 
improve the standards based on experience gained in prior years.

CMS's State Performance Standards and Review Had Shortcomings:

Characterizing its fiscal year 2001 state performance review as a 
"shakeout cruise," CMS is working to address several weaknesses 
identified during the reviews, including difficulty in determining if 
identified problems were isolated incidents or systemic problems, 
flawed criteria for evaluating a critical standard, and inconsistencies 
in how regional offices conducted the reviews. In our discussions of 
the results of the performance reviews with officials of CMS's regional 
offices, it was evident that some regions had a much better 
appreciation of the strengths and weaknesses of survey activities in 
their respective states than was reflected in the state performance 
reports. However, this information was not readily available to CMS's 
central office. In addition, CMS has not released a summary of the 
review to permit easy comparison of the results. For subsequent 
reviews, CMS plans to more centrally manage the process to improve 
consistency and help ensure that future reviews distinguish serious 
from minor problems.

Distinctions in State Performance Were Hard to Identify:

CMS officials acknowledged that the first performance review did not 
provide adequate information regarding the seriousness of identified 
problems. The agency indicated that it had since revised the 
performance standards to enable it to determine the seriousness of the 
problems identified. Some regional office summary reports provided 
insufficient information to determine whether a state did not meet a 
particular standard by a wide or a narrow margin. For example, although 
California did not meet the standard to investigate all complaints 
alleging actual harm within 10 days, the regional office summary 
provided no details about the results. Regional officials told us that 
they found very few California complaints that were not investigated 
within the 10-day deadline and those that were not were generally 
investigated by the 13th day.[Footnote 40] Conversely, although the 
report for Oregon shows that the state met the 10-day requirement, our 
discussions with regional officials revealed that serious shortcomings 
nevertheless existed in the state's complaint investigation practices. 
[Footnote 41] Officials in the Seattle region told us that for many 
years Oregon had contracted out investigations of complaints to local 
government entities not under the control of the state agency and, as a 
result, exercised little control over the roughly 2,000 complaints the 
state receives against nursing homes each year. For instance, under 
this arrangement, information about complaint investigations, 
including deficiencies identified, was not entered into CMS's database. 
Regional officials told us that the Oregon state agency recently 
assumed responsibility for investigating complaints filed by the 
public, but that the local government entities continue to investigate 
facility self-reported incidents.

CMS's Standard for Measuring States' Documentation of Deficiencies Was 
Flawed:

CMS's standard for measuring how well states document deficiencies 
identified during standard surveys was flawed because it mixed major 
and minor issues, blurring the significance of findings. CMS's protocol 
required assessment of 33 items, ranging from the important issue of 
whether state surveyors cited deficiencies at the correct scope and 
severity level to the less significant issue of whether they used 
active voice when writing deficiencies. Because of the complexity of 
the criteria and concerns about the consistency of regional office 
reviews of states' documentation practices, CMS decided not to report 
the results for this standard for 2001. For the 2002 review, CMS 
reduced the number of criteria to be assessed from 33 to 7.[Footnote 
42] Based on the available evidence of the understatement of actual 
harm deficiencies, we believe that successful implementation of the 
documentation standard in 2002 and future years is critical to help 
ensure that deficiencies are cited at the appropriate scope and 
severity level.

CMS Regions' Reviews Were Inconsistent:

CMS's regional offices were sometimes inconsistent in how they 
conducted their reviews, raising questions about the validity and 
fairness of the results. For example:

* Although the guidelines for the review indicated that the regional 
offices were to assess the timeliness of complaint investigations based 
on the state's prioritization of the complaint, officials from one 
region told us that they judged timeliness based on their opinion of 
how the complaint should have been prioritized.

* Two regional offices acknowledged that they did not use clinicians to 
review complaint triaging. Officials from two states questioned the 
credibility of reviews not conducted by clinicians.

* Although one objective of the reviews was to review some immediate 
jeopardy complaints in every state, the random samples selected in some 
states did not yield such complaints. In such cases, one region 
indicated that it specifically selected a few immediate jeopardy 
complaints outside the sample while another region did not. To 
eliminate this inconsistency in future years, CMS has instructed the 
regions to expand their sample to ensure that at least two immediate 
jeopardy complaints are reviewed in each state.

* While some regions examined more than the required number of 
complaints to assess overall timeliness, one region felt that 
additional reviews were unnecessary. For instance, surveyors reviewing 
California, which receives thousands of complaints per year, expanded 
the number of complaints reviewed beyond the minimum number required 
because they felt that the required random sample of 40 complaints did 
not provide sufficient information about overall timeliness in the 
state. To assess overall timeliness, they visited all but 1 of the 
state's 17 district offices to review complaints. However, surveyors 
from another CMS region reviewed only 3 or 4 of the roughly 18 
complaints a state received and told us that additional reviews were 
unnecessary because the state had already failed the timeliness 
criterion based on the few complaints reviewed. Although the review of 
3 or 4 complaints technically met CMS's sampling requirement, we 
believe examination of most or all of the relatively few remaining 
complaints would have provided a more complete picture of the state's 
overall timeliness.

Performance Standards Excluded Some Important Areas:

While CMS has addressed some of the weaknesses in its 2001 state 
performance review by revising the standards and guidance for the 2002 
review, including simplifying the criteria for assessing documentation 
and requiring regions to assess states' complaint prioritization 
efforts separately from the timeliness issue, the performance standards 
do not yet address certain issues that are important for assessing 
state performance and that would further strengthen CMS oversight of 
state survey activities. These issues include:

* Assessing the predictability of state surveys. Although CMS monitored 
compliance with its requirement for state survey agencies to initiate 
at least 10 percent of their standard surveys outside normal working 
hours to reduce predictability, it did not examine compliance with its 
1999 instructions for states to avoid scheduling a home's survey during 
the same month each year. As shown in app. V, our analysis of CMS data 
found that from 10 percent to 31 percent of surveys in 31 states were 
predictable because they were initiated within 15 days of the 1-year 
anniversary of the prior survey.

* Evaluating states' compliance with the requirement to refer nursing 
homes that have a pattern of harming residents for immediate sanctions. 
CMS officials confirmed that there was no consistent oversight of state 
agencies' implementation of this policy. Several CMS regional offices 
generally did not know, for example, how their states were monitoring 
homes' survey history to detect cases that should be referred for 
immediate sanction. CMS could have used the enforcement database to 
determine that New York was not adhering to the agency's immediate 
sanctions policy. During calendar years 2000 and 2001, New York cited 
actual harm at a relatively high proportion of its nursing homes but 
only referred 19 cases for immediate sanction. Over a comparable 
period, New Jersey, a state with far fewer homes and citations, 
referred almost three times as many cases.[Footnote 43]

* Developing better measures of the quality of state performance, in 
addition to process measures. Several CMS regional officials believed 
that the scope of the state performance standards should address 
additional areas of performance, including assessing the adequacy of 
nursing homes' plans of correction submitted in response to 
deficiencies and the appropriateness of states' recommended enforcement 
remedies. In particular, several regions noted that rather than 
focusing only on the timeliness of complaint investigations, regions 
should also assess the adequacy of the investigation itself, including 
whether the complaint should have been substantiated. The introduction 
of a new CMS complaint tracking database, discussed below, should 
enable regions to automate the review of complaint timeliness, thereby 
allowing them to focus more attention on such issues.

Data Limitations and Inconsistent Use of Periodic Reports Hamper 
Oversight:

CMS's oversight of state survey activities is further hampered by 
limitations in the data used to develop the 19 periodic reports 
intended to assist the regions in monitoring state performance and by 
the regions' inconsistent use of the reports.[Footnote 44] For 
instance, CMS's current complaint database does not provide key 
information about the number of complaints each state receives 
(including facility self-reported incidents) or the time frame in which 
each complaint is investigated.[Footnote 45] In addition, officials 
from one region emphasized to us that information about complaints 
provided in the reports did not correspond with CMS's required 
complaint investigation time frames. The reports identify the number of 
state on-site complaint investigations that took place in three 
different time periods--3 days, from 4 to 14 days, and 15 days or more; 
however, required time frames for complaint investigations are 2 days 
for complaints alleging immediate jeopardy and 10 days for those 
alleging harm. Additionally, a regional official pointed out that 
investigations shown in one of the reports as taking place within 3 
days do not necessarily represent complaints that the state prioritized 
as immediate jeopardy. Despite the problems with these data, however, 
several regional offices indicated that the reports could at least 
serve as a starting point for discussions with states about their 
complaint programs and often lead to a better understanding of state 
complaint activities. CMS indicated that the deficiencies in complaint 
data should be addressed by the new automated complaint tracking system 
that it is developing for use by all states as part of the redesign of 
OSCAR.[Footnote 46]

Officials from several regions also told us that the value of some of 
the 19 periodic reports was unclear, and officials in three regions 
said they either lacked the staff expertise or the time to use the 
reports routinely to oversee state activities. For example, officials 
in one region told us that they used one of the reports about 
complaints to ask states questions about their prioritization 
practices. But a different region appeared unaware that the reports 
showed that two of its states might be outliers in terms of the 
percentage of complaints they prioritized as actual harm or immediate 
jeopardy. Additionally, because the periodic reports do not include 
trend data, many regional offices were unaware of the trends in the 
percentage of homes cited in their states for actual harm or immediate 
jeopardy. We believe that such data could be useful to CMS's regions in 
identifying significant trends in their states.

CMS indicated that it is continuing to make progress in redesigning the 
OSCAR reporting system. In 1999, we recommended that the agency develop 
an improved management information system that would help it track the 
status and history of deficiencies, integrate the results of complaint 
investigations, and monitor enforcement actions.[Footnote 47] Another 
objective of the OSCAR redesign is to make it easier to analyze the 
data it contains, addressing the problem that generating analytical 
reports from OSCAR was difficult and most regions lacked the expertise 
to do so. The redesigned system, called the Quality Improvement and 
Evaluation System, would also eliminate the need for duplicate data 
entry, which should reduce the potential for data entry errors to which 
OSCAR is susceptible.[Footnote 48] CMS has faced some problems in the 
implementation of the new system, such as inadvertent modifications of 
survey data results when data are transferred from the old OSCAR 
database into the new system, but the agency indicated that its target 
date for completing the redesign is 2005.

CMS Is Making Progress but Also Encountering Delays in Several Key 
Efforts:

CMS has taken, or is undertaking, several other efforts to improve 
federal oversight and survey procedures, including making structural 
changes to the regional offices to improve coordination, expanding the 
number of comparative surveys conducted each year, improving the survey 
methodology, developing clearer guidance for surveyors, and developing 
additional guidance to states for investigating complaints. As of April 
2003, only the effort to restructure the regional offices had been 
completed. The other efforts critical to reducing the subjectivity 
evident in the current survey process and the investigation of 
complaints have been delayed.

CMS Is Taking Additional Steps to Address Inconsistencies in Regional 
Office Performance and Improve Federal Oversight:

In December 2002, CMS reduced the number of regional managers in charge 
of survey activities from 10 (1 per region) to 5, a change intended to 
provide more management attention to survey matters and to improve 
accountability, direction, and leadership. Our prior and current work 
found that regional offices' policies, practices, and oversight were 
often inconsistent. For example, in 1999 we reported that regional 
offices used different criteria for selecting and conducting 
comparative surveys. The 5 regional managers will be responsible only 
for survey and certification activities, while in the past many of the 
10 were also responsible for managing their regions' Medicaid programs.

In response to our prior recommendations, CMS plans to more than double 
the number of federal comparative surveys in which federal surveyors 
resurvey a nursing home within 2 months of the state survey to assess 
state performance. We noted in 1999 that, although insufficient in 
number, comparative surveys were the most effective technique for 
assessing state agencies' abilities to identify serious deficiencies in 
nursing homes because they constitute an independent evaluation of the 
state survey. CMS plans to hire a contractor to perform approximately 
170 additional comparative surveys per year, bringing the annual total 
of comparative surveys performed by both CMS surveyors and the 
contractor to about 330. Although CMS had intended to award a contract 
and begin surveys by spring 2003, as of July 2003, it was still in the 
process of identifying qualified contractors. CMS officials stated that 
using a contractor would provide CMS flexibility because if it suspects 
that a state or region is having problems with surveys, it can quickly 
have the contractor conduct several comparative surveys there. Being 
able to direct the contractor to quickly focus on states or regions 
where state surveys may be problematic could represent a significant 
improvement in CMS's oversight of state survey agencies.

Key Initiatives to Improve Survey Consistency and Complaint 
Investigations Have Been Delayed:

CMS's implementation schedules have slipped for three critical 
initiatives intended to enhance the consistency and accuracy of state 
surveys and complaint investigations, delaying the introduction of 
improved methodologies or guidance until 2003 or 2004. Because 
surveyors often missed significant care problems due to weaknesses in 
the survey process, HCFA took some initial steps to strengthen the 
survey methodology, with the goal of introducing an improved survey 
process in 2000. In July 1999, the agency introduced quality indicators 
to help surveyors do a better job of selecting a resident sample, 
instructed states to increase the sample size in areas of particular 
concern, and required the use of investigative protocols in certain 
areas, such as pressures sores and nutrition, to help make the survey 
process more systematic.[Footnote 49] However, HCFA recognized that 
additional steps were required to ensure that surveyors thoroughly and 
systematically identify and assess care problems.

To address remaining problems with sampling and the investigative 
protocols, CMS contracted for the development of a revised survey 
methodology. The contractor has proposed a two-phase survey 
process.[Footnote 50] In the first phase, surveyors would initially 
identify potential care problems using quality indicators generated 
off-site prior to the start of the survey and additional, standardized 
information collected on-site, from a sample of as many as 70 
residents. During the second phase, surveyors would conduct an 
investigation to confirm and document the care deficiencies initially 
identified.[Footnote 51] According to CMS officials, this process 
differs from the current methodology because it would more 
systematically target potential problems at a home and give surveyors 
new tools to more adequately document care outcomes and conduct on-site 
investigations. Use of the new methodology could result in survey 
findings that more accurately identify the quality of care provided by 
a nursing home to all of its residents.[Footnote 52] Initial testing to 
evaluate the proposed methodology focused primarily on the first phase 
and was completed in three states during 2002. As of April 2003, a CMS 
official told us that the agency lacked adequate funding to conduct 
further testing that more fully incorporates phase two. As a result, it 
is not clear when changes to survey methodology will be implemented. We 
continue to believe that redesign of the survey methodology, under way 
since 1998, is necessary for CMS to fully respond to our past 
recommendation to improve the ability of surveys to effectively 
identify the existence and extent of deficiencies. While CMS's goal of 
not adding additional time to surveys is an important consideration, it 
should not take priority over the goal of ensuring that surveys are as 
effective as possible in identifying the quality of care provided to 
residents.

Recognizing inconsistencies in how the scope and severity of 
deficiencies are cited across states, in October 2000, HCFA began 
developing more structured guidance for surveyors, including survey 
investigative protocols for assessing specific deficiencies. The intent 
of this initiative is to enable surveyors to better (1) identify 
specific deficiencies, (2) investigate whether a deficiency is the 
result of poor care, and (3) document the level of harm resulting from 
a home's identified deficient care practices. The areas originally 
targeted for this initiative included deficiencies related to pressure 
sores, urinary catheters and incontinence, activities programming, safe 
food handling, and nutrition. Delays have occurred because CMS is 
committed to incorporating the work of multiple expert panels and two 
rounds of public comments for each deficiency. The project has been 
further delayed because the approach used to identify resident harm 
shifted during the course of work. The process should proceed more 
quickly, however, now that CMS has developed its approach. CMS expected 
to release the first new guidance, addressing pressure sores, in early 
2003, but officials were unable to tell us how many of the 190 federal 
nursing home requirements will ultimately receive new guidance or a 
specific time line for when this initiative will be completed.[Footnote 
53] As discussed earlier, CMS's state performance reviews include an 
assessment of state surveyors' documentation of the scope and severity 
of a sample of deficiencies cited, which should provide CMS with an 
opportunity to assess the effectiveness of the new guidance.

Finally, despite initiation of a complaint improvement project in 1999, 
CMS has not yet developed detailed guidance for states to help improve 
their complaint systems. Effective complaint procedures are critical 
because complaints offer an opportunity to assess nursing home care 
between standard surveys, which can be as long as 15 months apart. In 
1999, HCFA commissioned a contractor to assess and recommend 
improvements to state complaint practices. CMS received the 
contractor's final report in June 2002, and indicated agreement with 
the contractor that reforming the complaint system is urgently needed 
to achieve a more standardized, consistent, and effective process. The 
study identified serious weaknesses in state complaint processes (see 
table 5) and made numerous recommendations to CMS for strengthening 
them. Key recommendations were that CMS increase direction and 
oversight of states' complaint processes and establish mechanisms to 
monitor states' performance. CMS indicated that it has already taken 
steps to address these recommendations by initiating annual performance 
reviews that include evaluating the timeliness of state complaint 
investigations and the accuracy of states' complaint triaging 
decisions, and by developing the new ASPEN complaint tracking system, 
which should provide more complete data about complaint activities than 
the current system. The contractor also recommended that CMS (1) expand 
outreach for the initiation of complaints, such as use of billboards or 
media advertising, (2) enhance complaint intake processes by using 
professional intake staff, (3) improve investigation and resolution 
processes by using available data about the home being investigated and 
establishing uniform definitions and criteria for substantiating 
complaints, (4) make the process more responsive by conducting timely 
investigations and allowing the complainant to track the progress of 
the investigation, and (5) establish a higher priority for complaint 
investigations in the state survey agency. CMS noted that some of these 
recommendations are beyond the agency's purview and will require the 
support of all stakeholders to accomplish. CMS told us that it plans to 
issue new guidance to the states in late fiscal year 2003--about 4 
years after the complaint improvement project initiative was launched.

Conclusions:

As we reported in September 2000, continued federal and state attention 
is required to ensure necessary improvements in the quality of care 
provided to the nation's vulnerable nursing home residents. The 
reported decline in the percentage of homes cited for serious 
deficiencies that harm residents is consistent with the concerted 
congressional, federal, and state attention focused on addressing 
quality-of-care problems. More active and data-driven oversight is 
increasing CMS's understanding of the nature and extent of weaknesses 
in state survey activities. Despite these efforts, however, the 
proportion of homes reported to have harmed residents is still 
unacceptably high. It is therefore essential that CMS fully implement 
key initiatives to improve the rigor and consistency of state survey, 
complaint investigation, and enforcement processes.

The seriousness of the challenge confronting CMS in ensuring 
consistency in state survey activities is also becoming more apparent. 
Our work, as well as that of CMS, demonstrates the persistence of 
several long-standing problems and also provides insights on factors 
that may be contributing to these shortcomings:

* state surveyors continue to understate serious deficiencies that 
caused actual harm or placed residents in immediate jeopardy;

* deficiencies are often poorly investigated and documented, making it 
difficult to determine the appropriate severity category;

* states focus considerable effort on reviewing proposed actual harm 
deficiencies, but many have no quality assurance processes in place to 
determine if less serious deficiencies are understated or have 
investigation and documentation problems;

* the timing of too many surveys remains predictable, allowing problems 
to go undetected if a home chooses to conceal deficiencies;

* numerous weaknesses persist in many states' complaint processes, 
including the lack of consumer toll-free hotlines in many states, 
confusion over prioritization of complaints, inconsistent complaint 
investigation procedures, and the failure of most states to investigate 
all complaints alleging actual harm within 10 days, as required; and:

* states did not refer a substantial number of homes that had a pattern 
of harming residents to CMS for immediate sanctions.

Over the past several years, CMS has taken numerous steps to improve 
its oversight of state survey agencies, but needs to continue its 
efforts to help better ensure consistent compliance with federal 
requirements. Several areas that require CMS's ongoing attention 
include (1) the newly established standard performance reviews to 
ensure that critical elements of the review, such as assessing states' 
ability to properly document deficiencies, are successfully 
implemented, (2) the successful modernization of CMS's data system by 
2005 to support the survey process and provide key information for 
monitoring state survey activities, (3) the planned expansion of 
comparative surveys to improve federal oversight of the state survey 
process, (4) the survey methodology redesign intended to make the 
survey process more systematic, (5) the development of more structured 
guidance for surveyors to address inconsistencies in how the scope and 
severity of deficiencies are cited across states, and (6) the provision 
of detailed guidance to states to ensure thorough and consistent 
complaint investigations. Some of these efforts have been under way for 
several years, and CMS has consistently extended their estimated 
completion and implementation dates. We believe that effective 
implementation of planned improvements in each of these six areas is 
critical to ensuring better quality care for the nation's 1.7 million 
nursing home residents.

Recommendations for Executive Action:

To strengthen the ability of the nursing home survey process to 
identify and address problems that affect the quality of care, we 
recommend that the Administrator of CMS:

* finalize the development, testing, and implementation of a more 
rigorous survey methodology, including guidance for surveyors in 
documenting deficiencies at the appropriate level of scope and 
severity.

To better ensure that state survey and complaint activities adequately 
address quality-of-care problems, we recommend that the Administrator:

* require states to have a quality assurance process that includes, at 
a minimum, a review of a sample of survey reports below the level of 
actual harm (less than G level) to assess the appropriateness of the 
scope and severity cited and to help reduce instances of understated 
quality-of-care problems.

* finalize the development of guidance to states for their complaint 
investigation processes and ensure that it addresses key weaknesses, 
including the prioritization of complaints for investigation, 
particularly those alleging harm to residents; the handling of facility 
self-reported incidents; and the use of appropriate complaint 
investigation practices.

To better ensure that states comply with statutory, regulatory, and 
other CMS nursing home requirements designed to protect resident health 
and safety, we recommend that the Administrator:

* further refine annual state performance reviews so that they (1) 
consistently distinguish between systemic problems and less serious 
issues regarding state performance, (2) analyze trends in the 
proportion of homes that harm residents, (3) assess state compliance 
with the immediate sanctions policy for homes with a pattern of harming 
residents, and (4) analyze the predictability of state surveys.

Agency and State Comments and Our Evaluation:

We provided a draft of this report to CMS and the 22 states we 
contacted during the course of our review. (CMS's comments are 
reproduced in app. X.) CMS concurred with our findings and 
recommendations, stating that it already had initiatives under way to 
improve the effectiveness of the survey process, address the 
understatement of serious deficiencies, provide better data on state 
complaint activities, and improve the annual federal performance 
reviews of state survey activities. Although CMS concurred with our 
recommendations, its comments on intended actions did not fully address 
our concerns about the status of the initiative to improve the 
effectiveness of the survey process or the recommendation regarding 
state quality assurance systems. Eleven of the 22 states also commented 
on our draft report.[Footnote 54] CMS and state comments generally 
covered five areas: survey methodology, state quality assurance 
systems, definition of actual harm, survey predictability, and resource 
constraints.

Survey Methodology Redesign:

In response to our recommendation that the agency finalize the 
development, testing, and implementation of a more rigorous nursing 
home survey methodology, under way since 1998, CMS commented that it 
had already taken steps to improve the effectiveness of the survey 
process, such as the development of surveyor guidance on a series of 
clinical issues.[Footnote 55] However, the agency did not specifically 
comment on any actions it would take to finalize and implement its new 
survey methodology, which is broader than the actions CMS described. 
Our draft report noted that, earlier this year, CMS said it lacked 
adequate funding for the additional field testing needed to implement 
the new survey methodology. Through September 2003, CMS will have 
committed $4.7 million to this effort. While CMS did not address the 
lack of adequate funding in its comments on our draft report, a CMS 
official subsequently told us that about $508,000 has now been slated 
for additional field testing. This amount, however, has not yet been 
approved. Not funding additional field testing could jeopardize the 
entire initiative, in which a substantial investment has already been 
made. We continue to believe that CMS should implement a revised survey 
methodology to address our 1998 finding that state surveyors often 
missed significant care problems due to weaknesses in the survey 
process.

State Quality Assurance Systems:

We recommended that CMS require states to have a quality assurance 
process that includes, at a minimum, a review of a sample of survey 
reports below the level of actual harm to help reduce instances of 
understated quality-of-care problems. CMS commented on the importance 
of this concept and noted it had already incorporated such reviews into 
CMS regional offices' reviews of the state performance standards. 
However, the agency did not indicate whether it would require states to 
initiate an ongoing process that would evaluate the appropriateness of 
the scope and severity of documented deficiencies, as we recommended. 
While federal oversight is critical, the annual performance reviews 
conducted by federal surveyors examine only a small, random sample of 
state survey reports and should not be considered a substitute for 
appropriate and ongoing state quality assurance mechanisms. In its 
comments, New York stated that, in April 2003, it had implemented a 
process consistent with our recommendation and it had already realized 
positive results. New York is using the results of these reviews to 
provide surveyor feedback and expects that instances where deficiencies 
may be understated will decrease. California also commented that it 
fully supports this recommendation but indicated that a new requirement 
could not be implemented without additional resources.

State Resource Constraints:

Officials from five states indicated that resource shortages are a 
challenge in meeting federal standards for oversight of nursing homes. 
Alabama commented that there is a relationship among (1) the scheduling 
of nursing home standard surveys, (2) the number and timing of 
complaint surveys, (3) the tasks that must be accomplished during each 
survey, and (4) the resources that are available to state agencies. 
According to Alabama, the funding provided by CMS is insufficient to 
meet all of the CMS workload demands, and many of the serious problems 
identified in our draft report were attributable to insufficient 
funding for state agencies to hire and retain the staff necessary to do 
the required surveys. For example, Alabama indicated that the inability 
of some states to meet survey time frames--maintaining a 12-month 
average between standard surveys and investigating complaints alleging 
actual harm within 10 days--is almost always the result of states not 
having enough surveyors to accomplish the required workload.

Comments from other states echoed Alabama's concerns about the adequacy 
of funding provided by CMS. Arizona said that, in order to hire and 
retain qualified surveyors, it increased surveyor salaries in 2001. 
Because CMS did not increase the state's survey and certification 
budget to accommodate these increases, the state left surveyor 
positions unfilled and curtailed training to make up for the funding 
shortfall. Arizona also observed that CMS's priorities sometimes 
conflict, further complicating effective resource use. CMS's 
performance standards require states to investigate all complaints 
alleging immediate jeopardy or actual harm in 2 and 10 days, 
respectively. For budgeting purposes, however, CMS ranks complaint 
investigations as a lower priority than annual surveys and instructs 
states to ensure that annual surveys will be completed before beginning 
work on complaints. California and Connecticut officials said that the 
growing volume of complaints in their states, combined with limited 
resources, is a concern. California officials observed that the growth 
in the number of complaints, coupled with the lack of significant 
funding increase from CMS, has made it impossible to meet all federal 
and state standards. They added that they received a 3-percent increase 
in survey funding from fiscal years 2000 through 2003, but documented 
the need for a 24-percent increase over this period. As noted in our 
draft report, the higher priority California attaches to investigating 
complaints affected survey timeliness--about 12 percent of the state's 
homes were not surveyed within the required 15 months. Connecticut 
indicated that 90 percent of the complaints it receives allege actual 
harm and require investigation within 10 days, but that with fairly 
stagnant budget allocations from CMS, its ability to initiate 
investigations of so many complaints within 10 days was limited. CMS's 
fiscal year 2001 state performance review found that Connecticut did 
not investigate about 30 percent of the sampled actual harm complaints 
in a timely manner. Although not specifically mentioning resources, New 
York noted that the increasing volume of complaints was a concern and 
indicated that any assistance CMS could provide would be welcome.

Definition of Actual Harm:

Comments from four states on our analysis of a sample of survey 
deficiencies from homes with a history of harming residents revealed 
state confusion about CMS's definition of actual harm and immediate 
jeopardy, a situation that contributes to the variability in state 
deficiency trends shown in table 2. CMS's written comments did not 
address our review of these deficiencies; however, during an interview 
to follow up on state comments, CMS officials told us that they agreed 
with our determinations of actual harm as detailed in appendix III.

Arizona and California agreed that some of the deficiencies we reviewed 
for nursing homes in their states should have been cited at the level 
of actual harm. However, their disagreement regarding others stemmed 
from differing interpretations of CMS guidance, particularly the 
language on the extent of the consequences to a resident resulting from 
a deficiency.[Footnote 56] For example, Arizona stated that one of the 
two deficiencies we reviewed could not be supported at the actual harm 
level because the injuries from multiple falls--including skin tears 
and lacerations of the extremities and head requiring suturing--did not 
compromise the residents' ability to function at their highest optimal 
level (table 8, Arizona 3). In these cases, it was documented that 
nursing home staff had failed to implement plans of care intended to 
prevent such falls. In contrast, California agreed with us that state 
surveyors should have cited actual harm for similar injuries resulting 
from falls--head lacerations and a minimal impaction fracture of the 
hip--due to the inappropriate use of bed side rails (table 8, 
California 9). CMS officials noted that the definition of actual harm 
uses the term "well-being" rather than function because harm can be 
psychological as well as physical. Moreover, they indicated that 
whether the consequence was small or large was irrelevant to 
determining harm. CMS central office officials acknowledged that the 
language linking actual harm to practices that have "limited 
consequences" for a resident has created confusion for state surveyors 
and that this reference will be eliminated in an upcoming revision of 
the guidance.

Regarding preventable stage II pressure sores, California stated that 
guidance received from CMS's San Francisco regional office in November 
2000 precluded citing actual harm unless the pressure sores had an 
impact on residents' ability to function.[Footnote 57] According to a 
California official, this and similar guidance on weight loss was the 
CMS regional office's reaction to the growing volume of appeals by 
nursing homes of actual harm citations as well as a reaction to 
administrative law hearing decisions.[Footnote 58] Prior to this 
written guidance, which California received in late 2000, it routinely 
cited preventable stage II pressure sores as actual harm. The guidance 
noted that small stage II pressure sores seldom cause actual harm 
because they have the potential to heal relatively quickly and are 
usually of limited consequence to the resident's ability to function. 
We discussed the San Francisco regional office guidance with another 
regional office as well as with CMS central office officials, who 
agreed that the San Francisco region's pressure sore guidance was 
inconsistent with CMS's definition of harm, which judges the impact of 
a deficiency on a resident's "well-being" rather than functioning. 
Moreover, central office officials indicated that the regional office's 
guidance should have been submitted to CMS's Policy Clearinghouse for 
approval. This entity was created in June 2000 to ensure that regional 
directives to states are consistent with national policy. San Francisco 
regional office officials indicated that the individual responsible for 
the guidance provided to California had since left the agency.

California also disagreed with our assessment that state surveyors 
should have cited immediate jeopardy for a resident who repeatedly 
wandered (eloped) outside the facility near a busy intersection. 
According to state officials, California's policy on immediate jeopardy 
requires the surveyor to witness the incident. A San Francisco regional 
office official told us that surveyors did not have to witness an 
elopement to cite immediate jeopardy. An official from a different 
regional office agreed and noted that repeated elopements suggested the 
existence of a systemic problem that warranted citation of immediate 
jeopardy.

Although Iowa and Nebraska did not comment specifically on the 
deficiencies in their surveys that we determined to be actual harm, 
they did address the definition of harm and the role of surveyor 
judgment in classifying deficiencies. Iowa officials indicated that a 
more precise definition of harm is needed because of varying emphasis 
over the last several years on the degree of harm--harm that has a 
small consequence for the resident or serious harm. Nebraska commented 
that we may have based our conclusion that two deficiencies in its 
surveys should have been cited at the actual harm level on insufficient 
information because citing actual harm is a judgment call that varies 
among state and federal surveyors based on experience and expertise. As 
noted in our draft report, we found sufficient evidence in the surveys 
we reviewed to conclude that some deficiencies should have been cited 
as actual harm because a deficient practice was identified and linked 
to documented actual harm.

Survey Predictability:

CMS, Arizona, and Iowa commented that nursing home surveys, as 
currently structured, are inherently predictable because of the 
statutory requirement to survey nursing homes on average every 12 
months with a maximum interval of 15 months between each home's survey. 
We agree but believe that survey predictability could be further 
mitigated by segmenting the surveys into more than one visit, a 
recommendation we made in 1998 but that CMS has not 
implemented.[Footnote 59] Currently, surveys are comprehensive reviews 
that can last several days and entail examining not only a home's 
compliance with resident care standards but also with administrative 
and housekeeping standards. Dividing the survey into segments performed 
over several visits, particularly for those homes with a history of 
serious deficiencies, would increase the presence of surveyors in these 
homes and provide an opportunity for surveyors to initiate broader 
reviews when warranted. With a segmented set of inspections, homes 
would be less able to predict their next scheduled visit and adjust the 
care they provide in anticipation of such visits.

CMS also commented that our report captures only the number of days 
since the prior survey and does not take into account other predictors, 
for example the time of day or day of the week. Rather than segmenting 
standard surveys as we earlier recommended, the agency instructed 
states to reduce survey predictability by starting at least 10 percent 
of surveys outside the normal workday--either on weekends, in the early 
morning, or in the evening. It also instructed states to avoid, if 
possible, scheduling a home's survey for the same month as its previous 
standard survey. Though varying the starting time of surveys may be 
beneficial, this initiative is too limited in reducing survey 
predictability, as evidenced by our finding that 34 percent of current 
surveys were predictable. Arizona commented that it was unaware of any 
CMS guidance to avoid scheduling a home's survey for the same month of 
the year as the home's previous standard survey and indicated the state 
will now incorporate the requirement into its scheduling process.

Comments from CMS and Arizona stated that the window of time for a 
survey to be unpredictable was limited and, as a result, little could 
be done to reduce predictability. CMS's technical comments noted that 
many states have annual state licensing inspection requirements that 
would limit the window available to conduct surveys to 9 to 12 months 
after the prior survey, particularly since most inspections are done in 
conjunction with the federal survey to maximize available resources. 
CMS, however, was unable to provide a list of such states. None of the 
10 states we subsequently contacted had state licensure inspection 
requirements that would explain their high levels of survey 
predictability.[Footnote 60] Arizona commented that the state's 
licensing inspections are triggered by facilities applying to renew 
their licenses 60-120 days before their annual license expires. Due to 
budgetary constraints, Arizona conducts both this state and the federal 
survey at the same time. While not a requirement, the state strives to 
complete surveys during this 60-120 day period of time. Thus, nursing 
homes in Arizona may have some level of control over when federal 
surveys are conducted, particularly when the state begins complying 
with CMS guidance to avoid scheduling a home's survey for the same 
month as its previous survey. As we reported in September 2000, 
Tennessee also had an annual licensing inspection requirement that 
contributed to survey predictability, but the state modified its law to 
permit homes to be surveyed at a maximum interval of 15 
months.[Footnote 61] Since then, the proportion of predictable surveys 
in Tennessee decreased from about 56 percent to 29 percent. Arizona 
also stated that surveys had to be conducted within a 45-day window 
after the 1-year anniversary of the prior survey to be considered 
unpredictable.[Footnote 62] Arizona's comments erroneously assume that 
a survey cannot take place before the 1-year anniversary of the prior 
survey. There is no prohibition on resurveying a home prior to the 1-
year anniversary of its last survey, and many states do so. In fact, 
from October 1, 2000 through September 30, 2001, Arizona conducted 23 
percent of its surveys before the 1-year anniversary.

CMS provided several technical comments that we incorporated as 
appropriate.

As arranged with your offices, unless you publicly announce its 
contents earlier, we plan no further distribution of this report until 
30 days after its issue date. At that time, we will send copies of this 
report to the Administrator of the Centers for Medicare & Medicaid 
Services and appropriate congressional committees. We also will make 
copies available to others upon request. In addition, the report will 
be available at no charge on the GAO Web site at http://www.gao.gov.

Please contact me at (202) 512-7118 or Walter Ochinko, Assistant 
Director at (202) 512-7157 if you or your staffs have any questions. 
GAO staff acknowledgments are listed in appendix XI.

Kathryn G. Allen 
Director, Health Care--Medicaid and Private Health Insurance Issues:

Signed by Kathryn G. Allen: 

[End of section]

Appendix I: Scope and Methodology:

This appendix describes our scope and methodology following the order 
that findings appear in the report.

Nursing home deficiency trends. To identify trends in the proportion of 
nursing homes cited for actual harm or immediate jeopardy, we analyzed 
data from CMS's OSCAR system. We compared standard survey results for 
three approximately 18-month periods: (1) January 1, 1997, through June 
30, 1998, (2) January 1, 1999, through July 10, 2000, and (3) July 11, 
2000, through January 31, 2002. Because surveys are to be conducted at 
least once every 15 months (with a required 12-month state average), it 
is possible that a facility was surveyed more than once in a time 
period. To avoid double counting of facilities, we included only the 
most recent survey of a facility from each of the time periods. The 
data from the two earliest time periods were included in our September 
2000 report.[Footnote 63] We updated our earlier analysis of surveys 
conducted from January 1, 1999, through July 10, 2000, because it 
excluded approximately 300 surveys that had been conducted but not 
entered into OSCAR at the time we conducted our analysis in July 2000.

Sample of state survey reports. To assess the trends in actual harm and 
immediate jeopardy deficiencies discussed above, we (1) identified 14 
states in which the percentage of homes cited for actual harm had 
declined to below the national average since mid-2000 or was 
consistently below that average and (2) reviewed 76 survey reports from 
homes that had G-level or higher quality-of-care deficiencies on prior 
surveys but whose current survey had quality-of-care deficiencies at 
the D or E level, suggesting that the homes had improved.[Footnote 64] 
All the surveys we reviewed were conducted from July 2000 through April 
2002. Our review focused on four quality-of-care requirements that are 
the most frequently cited nursing home deficiencies nationwide (see 
table 6). According to OSCAR data, 99 surveys in the 14 states 
conducted on or after July 2000 documented a D-or E-level deficiency in 
at least one of these four quality-of-care requirements. We reviewed 
all such deficiencies in surveys from 13 states but randomly selected 
22 surveys from California, which cited the majority (45) of these 
deficiencies. In reviewing the surveys, we looked for a description of 
the resident's diagnoses, any assessment of special problems, and a 
description of the care plan and physician orders connected with the 
deficiency identified. We also looked for a clear statement of the 
home's deficient practice and the relationship between the deficiency 
and the care outcome.

Table 6: Quality of Care Requirements Reviewed in a Sample of State 
Survey Reports:

Nursing home quality of care requirements: Necessary care and services; 
Description: Facility must provide the necessary care and services for 
each resident to attain or maintain the highest practicable well-
being.

Nursing home quality of care requirements: Pressure sores; Description: 
Facility must ensure residents entering facility without pressure sores 
do not develop sores, unless the individual's clinical condition 
indicates the pressure sores were unavoidable, and that residents with 
sores receive necessary treatment to promote healing, prevent 
infection, and prevent new sores.

Nursing home quality of care requirements: Prevention of accidents; 
Description: Facility must ensure each resident receives adequate 
supervision and assistance devices to prevent accidents.

Nursing home quality of care requirements: Maintenance of nutrition; 
Description: Facility must ensure each resident maintains acceptable 
parameters of nutritional status, such as body weight.

Source: CMS's Medicare State Operations Manual.

[End of table]

Federal comparative surveys. In September 2000, we reported on the 
results of 157 comparative surveys completed from October 1998 through 
May 2000.[Footnote 65] To update our analysis, we asked each CMS region 
to provide the results of more recent comparative surveys, including 
data on the corresponding state survey. The regions identified and 
provided information on the deficiencies identified in 277 comparative 
surveys that were completed from June 2000 through February 
2002.[Footnote 66]

Survey predictability. In order to determine the predictability of 
nursing home surveys, we analyzed data from CMS's OSCAR database. We 
considered surveys to be predictable if (1) homes were surveyed within 
15 days of the 1-year anniversary of their prior survey or (2) homes 
were surveyed within 1 month of the maximum 15-month interval between 
standard surveys. Consistent with CMS's interpretation, we used 15.9 
months as the maximum allowable interval between surveys. Because homes 
know the maximum allowable interval between surveys, those whose prior 
surveys were conducted 14 or 15 months earlier are aware that they are 
likely to be surveyed soon.

Complaints. We analyzed the results of CMS's state performance review 
for fiscal year 2001 to determine states' success in investigating both 
immediate jeopardy complaints and actual harm complaints within time 
frames required either by statute or by CMS instructions. To better 
understand the results of state performance as determined by CMS's 
review, we interviewed officials from CMS's 10 regional offices and 16 
state survey agencies (see state performance standards below for a 
description of how these states were chosen).[Footnote 67] We also 
reviewed the report submitted to CMS by its contractor, which was 
intended to assess and recommend ways to strengthen state complaint 
practices.[Footnote 68] Finally, to assess the implementation of CMS's 
new automated system for tracking information about complaints, we 
reviewed CMS guidance materials and interviewed CMS officials and state 
survey agency officials from our 16 sample states.

Enforcement. To determine if states had consistently applied the 
expanded immediate sanction policy, we analyzed state surveys in OSCAR 
that were conducted before April 9, 2002, and identified homes that met 
the criteria for referral for immediate sanction. We included surveys 
conducted prior to the implementation of the expanded immediate 
sanction policy because actual harm deficiencies identified in such 
surveys were to be considered by states in recommending a home for 
immediate sanction beginning in January 2000. To be affected by CMS's 
expanded policy, a home with actual harm on two surveys must have an 
intervening period of compliance between the two surveys. Because OSCAR 
is not structured to consistently record the date a home with 
deficiencies returned to compliance, we had to estimate compliance 
dates using revisit dates as a proxy. We compared the results of our 
analysis to CMS's enforcement database to determine if CMS had opened 
enforcement cases for the homes we identified. Our analysis compared 
the survey date in OSCAR to the survey date in CMS's enforcement 
database. We considered any survey date in the enforcement database 
within 30 days of the OSCAR survey date to be a match. CMS officials 
reviewed and concurred with our methodology. We then asked CMS to 
analyze the resulting 1,334 unmatched cases to determine if a referral 
should have been made.[Footnote 69]

State performance standards. To assess state survey activities as well 
as federal oversight of state performance, we analyzed the conduct and 
results of fiscal year 2001 state survey agency performance reviews 
during which the CMS regional offices determined compliance with seven 
federal standards; we focused on the five standards related to 
statutory survey intervals, deficiency documentation, complaint 
activities, enforcement requirements, and OSCAR data entry. Because 
some regional office summary reports on the results of their reviews 
for each state did not provide detailed information about the results, 
we also obtained and reviewed regions' worksheets on which the summary 
reports were based. In addition, we conducted structured interviews 
with officials from CMS, CMS's 10 regional offices, and 16 state survey 
agencies to discuss nursing home deficiency trends, the underlying 
causes of problems identified during the performance reviews, and state 
and federal efforts to address these problems. We also discussed these 
issues with officials from 10 additional states during a governing 
board meeting of the Association of Health Facility Survey Agencies. We 
selected the 16 states with the goal of including states that (1) were 
from diverse geographic areas, (2) had shown either an increase or a 
decrease in the percentage of homes cited for actual harm, (3) had been 
contacted in our prior work, and (4) represented a mixture of results 
from federal performance reviews of state survey activities. We also 
obtained data from 42 state survey agencies on surveyor experience, 
vacancies, and related staffing issues.

[End of section]

Appendix II: Trends in The Proportion of Nursing Homes Cited for Actual 
Harm or Immediate Jeopardy Deficiencies, 1997-2002:

Nationwide, the proportion of nursing homes cited for actual harm or 
immediate jeopardy during state standard surveys declined from 29 
percent in mid-2000 to 20 percent in January 2002. From July 2000 
through January 2002, 40 states cited a smaller percentage of homes 
with such serious deficiencies while only 9 states and the District of 
Columbia cited a larger proportion of homes with such 
deficiencies.[Footnote 70] In contrast, from early 1997 through mid-
2000, the percentage of homes cited for such serious deficiencies was 
either relatively stable or increased in 31 states.

To identify these trends, we analyzed data from CMS's OSCAR system. We 
compared results for three approximately 18-month periods: (1) January 
1, 1997, through June 30, 1998, (2) January 1, 1999, through July 10, 
2000, and (3) July 11, 2000, through January 31, 2002 (see table 7). 
Because surveys are to be conducted at least once every 15 months (with 
a required 12-month state average), it is possible that a facility was 
surveyed more than once in a time period. To avoid double counting of 
facilities, we included only the most recent survey from each of the 
time periods. Some of the data in table 7 were included in our 
September 2000 report.[Footnote 71] However, we updated our analysis of 
surveys conducted from January 1, 1999, through July 10, 2000, because 
it excluded approximately 300 surveys that had been conducted but not 
entered into OSCAR at the time we conducted our analysis in July 2000.

Table 7: Trends in the Percentage of Nursing Homes Cited for Actual 
Harm or Immediate Jeopardy during State Standard Surveys, by State:

State: Alabama; Number of homes surveyed: 1/97-6/98: 227; 
Number of homes surveyed: 1/99-7/00: 225; Number of homes surveyed: 7/
00-1/02: 228; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 51.1; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 42.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -8.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -23.8.

State: Alaska; Number of homes surveyed: 1/97-6/98: 16; Number 
of homes surveyed: 1/99-7/00: 15; Number of homes surveyed: 7/00-1/02: 
15; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 37.5; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 20.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 33.3; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: -17.5; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: 13.3.

State: Arizona; Number of homes surveyed: 1/97-6/98: 163; 
Number of homes surveyed: 1/99-7/00: 142; Number of homes surveyed: 7/
00-1/02: 147; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 17.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 33.8; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 8.8; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 16.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -25.0.

State: Arkansas; Number of homes surveyed: 1/97-6/98: 285; 
Number of homes surveyed: 1/99-7/00: 273; Number of homes surveyed: 7/
00-1/02: 267; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 14.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 37.7; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 27.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 23.0; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.4.

State: California; Number of homes surveyed: 1/97-6/98: 1,435; 
Number of homes surveyed: 1/99-7/00: 1,400; Number of homes surveyed: 
7/00-1/02: 1,348; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 28.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 29.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 9.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -19.9.

State: Colorado; Number of homes surveyed: 1/97-6/98: 234; 
Number of homes surveyed: 1/99-7/00: 227; Number of homes surveyed: 7/
00-1/02: 225; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 11.1; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 15.4; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 26.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 10.8.

State: Connecticut; Number of homes surveyed: 1/97-6/98: 263; 
Number of homes surveyed: 1/99-7/00: 262; Number of homes surveyed: 7/
00-1/02: 259; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 52.9; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 48.5; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 49.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.4; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 0.9.

State: Delaware; Number of homes surveyed: 1/97-6/98: 44; 
Number of homes surveyed: 1/99-7/00: 42; Number of homes surveyed: 7/
00-1/02: 42; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 45.5; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 52.4; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 14.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 6.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -38.1.

State: District of Columbia; Number of homes surveyed: 1/97-6/
98: 24; Number of homes surveyed: 1/99-7/00: 20; Number of homes 
surveyed: 7/00-1/02: 21; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 12.5; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 10.0; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 33.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -2.5; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 23.3.

State: Florida; Number of homes surveyed: 1/97-6/98: 730; 
Number of homes surveyed: 1/99-7/00: 753; Number of homes surveyed: 7/
00-1/02: 742; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 36.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 20.8; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -15.5; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -0.8.

State: Georgia; Number of homes surveyed: 1/97-6/98: 371; 
Number of homes surveyed: 1/99-7/00: 368; Number of homes surveyed: 7/
00-1/02: 370; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 17.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 22.6; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.0.

State: Hawaii; Number of homes surveyed: 1/97-6/98: 45; Number 
of homes surveyed: 1/99-7/00: 47; Number of homes surveyed: 7/00-1/02: 
46; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 24.4; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 25.5; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 15.2; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: 1.1; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -10.3.

State: Idaho; Number of homes surveyed: 1/97-6/98: 86; Number 
of homes surveyed: 1/99-7/00: 83; Number of homes surveyed: 7/00-1/02: 
84; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 55.8; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 54.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 31.0; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: -1.6; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -23.3.

State: Illinois; Number of homes surveyed: 1/97-6/98: 899; 
Number of homes surveyed: 1/99-7/00: 900; Number of homes surveyed: 7/
00-1/02: 881; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 29.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 29.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 15.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -0.5; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.9.

State: Indiana; Number of homes surveyed: 1/97-6/98: 602; 
Number of homes surveyed: 1/99-7/00: 590; Number of homes surveyed: 7/
00-1/02: 573; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 40.5; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 45.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 26.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -19.1.

State: Iowa; Number of homes surveyed: 1/97-6/98: 525; Number 
of homes surveyed: 1/99-7/00: 492; Number of homes surveyed: 7/00-1/02: 
494; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 39.2; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 19.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 9.9; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: -19.9; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -9.4.

State: Kansas; Number of homes surveyed: 1/97-6/98: 445; 
Number of homes surveyed: 1/99-7/00: 410; Number of homes surveyed: 7/
00-1/02: 400; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 47.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 37.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 29.0; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -9.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.1.

State: Kentucky; Number of homes surveyed: 1/97-6/98: 318; 
Number of homes surveyed: 1/99-7/00: 312; Number of homes surveyed: 7/
00-1/02: 306; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 28.6; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 28.8; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -3.7.

State: Louisiana; Number of homes surveyed: 1/97-6/98: 433; 
Number of homes surveyed: 1/99-7/00: 387; Number of homes surveyed: 7/
00-1/02: 367; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 12.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 19.9; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 23.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 7.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 3.5.

State: Maine; Number of homes surveyed: 1/97-6/98: 135; Number 
of homes surveyed: 1/99-7/00: 126; Number of homes surveyed: 7/00-1/02: 
124; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 7.4; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 10.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 9.7; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: 2.9; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -0.6.

State: Maryland; Number of homes surveyed: 1/97-6/98: 258; 
Number of homes surveyed: 1/99-7/00: 242; Number of homes surveyed: 7/
00-1/02: 248; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 19.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 25.6; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 6.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -5.5.

State: Massachusetts; Number of homes surveyed: 1/97-6/98: 
576; Number of homes surveyed: 1/99-7/00: 542; Number of homes 
surveyed: 7/00-1/02: 512; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 24.0; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 33.0; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 22.9; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 9.0; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.2.

State: Michigan; Number of homes surveyed: 1/97-6/98: 451; 
Number of homes surveyed: 1/99-7/00: 449; Number of homes surveyed: 7/
00-1/02: 441; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 43.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 42.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 24.7; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -1.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -17.4.

State: Minnesota; Number of homes surveyed: 1/97-6/98: 446; 
Number of homes surveyed: 1/99-7/00: 439; Number of homes surveyed: 7/
00-1/02: 431; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 29.6; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 31.7; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.8; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 2.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.9.

State: Mississippi; Number of homes surveyed: 1/97-6/98: 218; 
Number of homes surveyed: 1/99-7/00: 202; Number of homes surveyed: 7/
00-1/02: 219; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 24.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 33.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 19.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 8.4; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.5.

State: Missouri; Number of homes surveyed: 1/97-6/98: 595; 
Number of homes surveyed: 1/99-7/00: 584; Number of homes surveyed: 7/
00-1/02: 569; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 21.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 22.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 10.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 1.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.1.

State: Montana; Number of homes surveyed: 1/97-6/98: 106; 
Number of homes surveyed: 1/99-7/00: 104; Number of homes surveyed: 7/
00-1/02: 103; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 38.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 37.5; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -1.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.3.

State: Nebraska; Number of homes surveyed: 1/97-6/98: 263; 
Number of homes surveyed: 1/99-7/00: 242; Number of homes surveyed: 7/
00-1/02: 243; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 32.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 26.0; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.9; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -6.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -7.1.

State: Nevada; Number of homes surveyed: 1/97-6/98: 49; Number 
of homes surveyed: 1/99-7/00: 52; Number of homes surveyed: 7/00-1/02: 
51; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 40.8; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 32.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 9.8; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: -8.1; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -22.9.

State: New Hampshire; Number of homes surveyed: 1/97-6/98: 86; 
Number of homes surveyed: 1/99-7/00: 83; Number of homes surveyed: 7/
00-1/02: 79; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 30.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 37.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 21.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 7.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -15.8.

State: New Jersey; Number of homes surveyed: 1/97-6/98: 377; 
Number of homes surveyed: 1/99-7/00: 359; Number of homes surveyed: 7/
00-1/02: 366; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 13.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 24.5; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 22.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 11.5; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.1.

State: New Mexico; Number of homes surveyed: 1/97-6/98: 88; 
Number of homes surveyed: 1/99-7/00: 82; Number of homes surveyed: 7/
00-1/02: 82; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 11.4; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 31.7; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 17.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 20.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -14.6.

State: New York; Number of homes surveyed: 1/97-6/98: 662; 
Number of homes surveyed: 1/99-7/00: 668; Number of homes surveyed: 7/
00-1/02: 671; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 13.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 32.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 32.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 18.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 0.2.

State: North Carolina; Number of homes surveyed: 1/97-6/98: 
407; Number of homes surveyed: 1/99-7/00: 414; Number of homes 
surveyed: 7/00-1/02: 419; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 31.0; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 40.8; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 30.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 9.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.7.

State: North Dakota; Number of homes surveyed: 1/97-6/98: 88; 
Number of homes surveyed: 1/99-7/00: 89; Number of homes surveyed: 7/
00-1/02: 88; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 55.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 21.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 28.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -34.4; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 7.1.

State: Ohio; Number of homes surveyed: 1/97-6/98: 1,043; 
Number of homes surveyed: 1/99-7/00: 1,047; Number of homes surveyed: 
7/00-1/02: 1,029; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 31.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 29.0; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 23.7; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -2.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -5.3.

State: Oklahoma; Number of homes surveyed: 1/97-6/98: 463; 
Number of homes surveyed: 1/99-7/00: 432; Number of homes surveyed: 7/
00-1/02: 394; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 8.4; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 16.7; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 8.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 3.9.

State: Oregon; Number of homes surveyed: 1/97-6/98: 171; 
Number of homes surveyed: 1/99-7/00: 158; Number of homes surveyed: 7/
00-1/02: 152; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 43.9; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 47.5; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 33.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 3.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.9.

State: Pennsylvania; Number of homes surveyed: 1/97-6/98: 811; 
Number of homes surveyed: 1/99-7/00: 788; Number of homes surveyed: 7/
00-1/02: 764; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 29.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 32.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 11.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 2.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -20.6.

State: Rhode Island; Number of homes surveyed: 1/97-6/98: 102; 
Number of homes surveyed: 1/99-7/00: 99; Number of homes surveyed: 7/
00-1/02: 99; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 11.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 12.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 10.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.0.

State: South Carolina; Number of homes surveyed: 1/97-6/98: 
175; Number of homes surveyed: 1/99-7/00: 178; Number of homes 
surveyed: 7/00-1/02: 180; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 28.6; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 28.7; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 17.8; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.9.

State: South Dakota; Number of homes surveyed: 1/97-6/98: 124; 
Number of homes surveyed: 1/99-7/00: 112; Number of homes surveyed: 7/
00-1/02: 114; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 40.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 24.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 30.7; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -16.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 6.6.

State: Tennessee; Number of homes surveyed: 1/97-6/98: 361; 
Number of homes surveyed: 1/99-7/00: 354; Number of homes surveyed: 7/
00-1/02: 377; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 11.1; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 26.0; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 16.7; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 14.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -9.3.

State: Texas; Number of homes surveyed: 1/97-6/98: 1,381; 
Number of homes surveyed: 1/99-7/00: 1,336; Number of homes surveyed: 
7/00-1/02: 1,275; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 22.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 26.9; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.7; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -1.5.

State: Utah; Number of homes surveyed: 1/97-6/98: 98; Number 
of homes surveyed: 1/99-7/00: 95; Number of homes surveyed: 7/00-1/02: 
95; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 15.3; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 15.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 15.8; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: 0.5; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: 0.0.

State: Vermont; Number of homes surveyed: 1/97-6/98: 45; 
Number of homes surveyed: 1/99-7/00: 46; Number of homes surveyed: 7/
00-1/02: 45; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 20.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 15.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 17.8; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 2.6.

State: Virginia; Number of homes surveyed: 1/97-6/98: 279; 
Number of homes surveyed: 1/99-7/00: 287; Number of homes surveyed: 7/
00-1/02: 285; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 24.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 19.9; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 11.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.3.

State: Washington; Number of homes surveyed: 1/97-6/98: 288; 
Number of homes surveyed: 1/99-7/00: 279; Number of homes surveyed: 7/
00-1/02: 275; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 63.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 54.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 38.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -9.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -15.6.

State: West Virginia; Number of homes surveyed: 1/97-6/98: 
130; Number of homes surveyed: 1/99-7/00: 147; Number of homes 
surveyed: 7/00-1/02: 143; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 12.3; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 15.6; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 14.0; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 3.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -1.7.

State: Wisconsin; Number of homes surveyed: 1/97-6/98: 438; 
Number of homes surveyed: 1/99-7/00: 428; Number of homes surveyed: 7/
00-1/02: 421; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 17.1; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 14.0; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 7.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -3.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -6.9.

State: Wyoming; Number of homes surveyed: 1/97-6/98: 38; 
Number of homes surveyed: 1/99-7/00: 41; Number of homes surveyed: 7/
00-1/02: 40; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 28.9; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 43.9; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 22.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 15.0; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -21.4.

State: Nation; Number of homes surveyed: 1/97-6/98: 17,897; 
Number of homes surveyed: 1/99-7/00: 17,452; Number of homes surveyed: 
7/00-1/02: 17,149; Percentage of homes cited for actual harm 
or immediate jeopardy: 1/97-6/98: 27.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 29.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 1.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.8.

Source: GAO analysis of OSCAR data as of June 24, 2002.

[A] Differences are based on numbers before rounding.

[End of table]

[End of section]

Appendix III: Abstracts of Nursing Home Survey Reports That Understated 
Quality-of-Care Problems:

Our analysis of a sample of 76 nursing home survey reports demonstrated 
a substantial understatement of quality-of-care problems. Our sample 
was selected from 14 states in which the percentage of homes cited for 
actual harm had declined to below the national average since mid-2000 
or was consistently below that average. We identified survey reports in 
these states from homes that had G-level or higher quality-of-care 
deficiencies (see table 1) on prior surveys but whose current survey 
had quality-of-care deficiencies at the D or E level, suggesting that 
the homes had improved. All the surveys we reviewed were conducted from 
July 2000 through April 2002. Our review focused on four quality-of-
care requirements that are the most frequently cited nursing home 
deficiencies nationwide (see table 6).[Footnote 72]

In our judgment, 30 of the 76 surveys (39 percent) from 9 of the 14 
states had one or more deficiencies that documented actual harm to 
residents--G-level deficiencies--and 1 survey contained a deficiency 
that could have been cited at the immediate jeopardy level. While state 
surveyors classified these deficiencies as less severe, we believe that 
the survey reports document that poor care provided to and injuries 
sustained by these residents constituted at least actual harm. Table 8 
provides abstracts of the 39 deficiencies that understated quality 
problems.

Table 8: Abstracts of the 39 Nursing Home Deficiencies that Understated 
Actual Harm from a Sample of 76 Nursing Home Survey Reports:

State and date of survey[A]: Alabama-1 November 2001; Requirement and 
scope and severity cited: Provide necessary care and services: D; 
Resident description and relevant diagnoses[B]: Resident admitted to 
facility 5/15/01 with a fractured hip; a gastrostomy tube was inserted 
through the abdomen into the stomach to maintain feeding. On 10/9/01, 
resident was hospitalized for abdominal pain and signs of infection 
related to the gastrostomy tube. On return to facility, physician 
orders state, "clean G tube site with soap and water, apply a drain 
sponge."; Actual harm to resident documented by surveyor: Site of 
gastrostomy tube insertion became reddened with thick yellow-green 
drainage, and had an odor, indicating signs of infection, on 11/7/01; 
Deficiencies in care cited by surveyor: Facility failed to provide 
proper care and services: daily cleaning and application of a drain 
sponge around the gastrostomy tube; Family indicated no one changed 
the dressing. There is no documentation to show resident's gastrostomy 
tube site was cleansed as ordered 12 out of 16 opportunities.

State and date of survey[A]: Alabama-5 March 2001; Requirement and 
scope and severity cited: Provide supervision and devices to prevent 
accidents: D; Resident description and relevant diagnoses[B]: Resident 
1 admitted to facility 11/6/00 with diagnoses of stroke, pressure 
sores, and kidney failure. On 11/16/00, resident was noted to have 
abrasions and bruises; Actual harm to resident documented by surveyor: 
Resident 1 sustained four skin tears on right arm and leg and multiple 
bruises to both legs from 1/16/01 to 3/21/01; Deficiencies in care 
cited by surveyor: The facility failed to consistently reassess for 
preventive measures to address the problem of skin tears and bruises 
for both residents. Staff were unable to provide documentation of 
preventive interventions.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]Arizona-3 July 2000: Resident 2 was admitted to the facility 
11/23/98 with anemia, depression, urinary incontinence, and a history 
of falls. She was identified as having a problem with skin tears and 
bruising.[C]; Actual harm to resident documented by surveyor: State and 
date of survey[A]Arizona-3 July 2000: Resident 2 sustained seven skin 
tears and bruises to legs from 12/29/99 to 10/9/00; Deficiencies in 
care cited by surveyor: State and date of survey[A]Arizona-3 July 2000: 
[Empty].

State and date of survey[A]: Arizona-3 July 2000; Requirement and scope 
and severity cited: Ensure prevention and healing of pressure sores: D; 
Resident description and relevant diagnoses[B]: Resident admitted to 
facility 08/24/99 with heart failure, high blood pressure, paraplegia, 
and a stage II pressure sore on lower back.[D] Pressure sore remained a 
stage II until May 2000, when wound was documented to be a stage III; 
Actual harm to resident documented by surveyor: On 7/5/00, it was noted 
that the resident had developed a stage IV pressure sore; Deficiencies 
in care cited by surveyor: The necessary services and care to promote 
healing and prevent worsening of existing pressure sore were not 
provided. Even after the pressure sore progressed to stage IV and a 
physician ordered that the resident be turned every hour, the staff 
failed to turn the resident as directed. Surveyor observed resident 
lying on her back for 2 or more hours. Resident stated that frequently 
she was turned only twice in 8 hours. Charge nurse did not know 
physician had ordered resident to be turned every hour.

State and date of survey[A]: Arizona-3 July 2000; Requirement and scope 
and severity cited: Ensure adequate supervision to prevent accidents: 
D; Resident description and relevant diagnoses[B]: Resident 1 admitted 
to the facility 4/7/00 with diabetes, partial paralysis of left side, 
and inability to speak. Resident also had a history of spinal 
fractures, and a fall prevention plan was developed on 4/15/00; Actual 
harm to resident documented by surveyor: Resident 1 fell four times and 
sustained skin tears, abrasions, and lacerations; Deficiencies in care 
cited by surveyor: Facility staff failed to implement a plan of care 
that called for identifying resident as a fall risk by placing a star 
on his door by his name. No other preventive measures were identified, 
and surveyor observed no star next to resident's name outside his 
door.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]California-2 September 2000: Resident 2 admitted to the 
facility 12/10/97 with dementia, painful joints, and visual problems. A 
7/13/00 assessment indicated resident was cognitively impaired and had 
a mental function that varied throughout the day. She was also 
identified as a wanderer; Actual harm to resident documented by 
surveyor: State and date of survey[A]California-2 September 2000: 
Resident sustained 12 falls from 2/18 to 7/8/00 with lacerations of 
extremities and head requiring suturing and with other cuts and 
bruises; Deficiencies in care cited by surveyor: State and date of 
survey[A]California-2 September 2000: Although resident was identified 
as at risk for falls in a care plan of 4/22/00, the facility staff 
failed to develop approaches to prevent falls even though the resident 
continued to fall and injure herself.

State and date of survey[A]: California-2 September 2000; Requirement 
and scope and severity cited: Ensure prevention and healing of pressure 
sores: D; Resident description and relevant diagnoses[B]: Resident 1 
with leg contractures (permanent tightening of muscle, tendons, 
ligaments, or skin that prevents normal movement) was noted to have a 
small reddened area on left lower back on 9/20/00; Actual harm to 
resident documented by surveyor: Resident 1 developed a reddened open 
area .3 cm. in diameter, (stage II pressure sore) on left lower back by 
9/23/00; Deficiencies in care cited by surveyor: The surveyor found 
that the facility did not identify, document, or provide intervention 
to prevent this facility-acquired pressure sore. The reddened area 
noted was not documented in the medical record 9/20-9/22/00.

Resident description and relevant diagnoses[B]: Requirement and scope 
and severity citedState and date of survey[A]: Maintain nutritional 
status: D: Resident 2 was admitted to facility on 2/2/00. Family 
identified resident as having a "skin problem" on 9/17/00; Actual harm 
to resident documented by surveyor: Requirement and scope and severity 
citedState and date of survey[A]: Maintain nutritional status: D: 
Resident 2 developed a stage II pressure sore; Deficiencies in care 
cited by surveyor: Requirement and scope and severity citedState and 
date of survey[A]: Maintain nutritional status: D: The facility 
developed a nursing care plan for prevention of pressure sores and 
turning the resident every 2 hours on 9/8/00. The family identified a 
stage II pressure sore on 9/17/00. The surveyor found no evidence that 
the care plan was implemented at time of survey.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]California-2 September 2000: Resident 3 admitted to facility 
9/20/00 with diagnoses of multiple sclerosis, bilateral fractures of 
the femur, and obesity. Resident was unable to turn herself in bed; 
physician documented resident had no areas of skin breakdown and 
ordered resident to be up in a wheel chair two to three times a day; 
Actual harm to resident documented by surveyor: State and date of 
survey[A]California-2 September 2000: Seven days after admission, 
resident 3 was noted to have four stage II pressure sores on right and 
left shoulder blades and right buttock and three stage I pressure sores 
on the left buttock; Deficiencies in care cited by surveyor: State and 
date of survey[A]California-2 September 2000: The facility failed to 
prevent a rapid decline in resident's condition and occurrence of 
facility-acquired pressure sores. Staff said they were unable to turn 
resident (a larger bed and mattress were not provided, which would have 
facilitated turning). No pressure-relieving devices and staff 
assistance in getting out of bed were provided. In the 7 days after 
admission, the resident was out of bed only once, at which time the 
pressure sores were discovered.

State and date of survey[A]: California-2 September 2000; Requirement 
and scope and severity cited: Maintain nutritional status: D; Resident 
description and relevant diagnoses[B]: Resident admitted to facility 7/
7/00 with a diagnosis of failure to thrive and a recorded weight of 89 
pounds; Actual harm to resident documented by surveyor: Resident's 
weight was recorded as 77 pounds 1 month after admission. Resident 
sustained a severe loss of 12 pounds (13 percent) between July and 
August; Deficiencies in care cited by surveyor: Facility failed to 
provide a comprehensive nutritional assessment to meet resident's 
nutritional needs in order to maintain body weight.

State and date of survey[A]: California-5 February 2001; Requirement 
and scope and severity cited: Provide supervision and devices to 
prevent accidents: D; Resident description and relevant diagnoses[B]: 
Resident was identified as at high risk for falls in 5/00; Actual harm 
to resident documented by surveyor: Resident fell while walking 
unassisted on 6/21/00 and again on 2/22/01, fracturing his right hip 
each time; Deficiencies in care cited by surveyor: Facility failed to 
develop and implement a fall prevention plan when resident was 
identified as being a high risk for falls and after the first hip 
fracture.

State and date of survey[A]: California-6 May 2001; Requirement and 
scope and severity cited: Provide supervision and devices to prevent 
accidents: D; Resident description and relevant diagnoses[B]: Resident 
admitted to facility on 2/12/01with dizziness, fainting, poor vision, 
and cognitive impairment. Care plan of 2/20/01 identified resident as a 
wanderer and at risk for falls. Interventions suggested were visual 
checks every 2 hours and involvement of resident in facility 
activities. On 2/20/01 at 9:30 pm resident was found wandering outside 
on the patio and had fallen and sustained abrasions; Actual harm to 
resident documented by surveyor: Resident wandered to an area 100 yards 
from facility near two busy intersections on 3/26/01 and again on 5/19/
01; ; According to CMS, the failure of a facility to provide 
supervision of a cognitively impaired individual with known risk for 
wandering is considered failure to prevent neglect and places the 
resident in immediate jeopardy for death or serious injury during such 
an incident; Deficiencies in care cited by surveyor: Facility failed 
to provide supervision and devices to prevent accidents even after 
resident was found wandering outside the facility on 2/20/01. The 
facility did not immediately implement procedures cited in the care 
plan to supervise the resident and prevent accidents and wandering, nor 
did the facility implement existing facility policies to prevent 
wandering and injury.

State and date of survey[A]: California-8; June 2001; Requirement and 
scope and severity cited: Ensure prevention and healing of pressure 
sores: D; Resident description and relevant diagnoses[B]: Resident 
admitted to facility in 1996 with stroke, paralysis of lower right 
side, and senile dementia. Physician orders of 4/5/01 called for an air 
mattress. Assessment of 4/24/01 noted resident had a stage IV pressure 
sore on the right outer ankle. On 5/17/01, physician ordered cleansing 
of the wound with saline and an anti-infective solution, dressing it 
with soft protective gauze; Actual harm to resident documented by 
surveyor: Resident sustained a facility-acquired stage IV pressure sore 
of the right ankle measuring 7 cm. by 5 cm; Deficiencies in care cited 
by surveyor: Facility failed to ensure necessary treatment and service 
to promote healing and prevent infection of the pressure sore. Surveyor 
observed on 6/20 and 6/21/01 that there was no air mattress on 
resident's bed and on 6/20/01 that inappropriate technique was used in 
changing the dressing on the resident's ankle.

State and date of survey[A]: California-8 June 2001; Requirement and 
scope and severity cited: Ensure maintenance of nutritional status: D; 
Resident description and relevant diagnoses[B]: Resident admitted to 
facility in 1990 with a diagnosis of stroke and inability to speak. A 
3/7/01 assessment noted erosive gastritis, anemia, and weight of 111 
lbs. The county was the conservator and requested maximum treatment. 
Resident was placed on an enriched pureed diet with supplemental 
feedings three times daily; Actual harm to resident documented by 
surveyor: Resident weighed 98.4 lbs and experienced a severe weight 
loss of 13 pounds (12 percent) in 3 months; Deficiencies in care cited 
by surveyor: Facility failed to ensure that the resident maintained 
adequate nutrition. It did not monitor the amount of nutritional 
supplements consumed by the resident and inconsistently recorded 
weights, often without associated dates. It did not notify the 
physician of the resident's weight loss.

State and date of survey[A]: California-9; December 2000; Requirement 
and scope and severity cited: Provide supervision and devices to 
prevent accidents: B[E,F]; Resident description and relevant 
diagnoses[B]: Resident 1, 48 years old, admitted to facility after a 
stroke with incontinence, inability to speak, right-side paralysis, and 
functional use of his left side. Resident communicated by signs and 
sounds; Actual harm to resident documented by surveyor: Resident fell 
when trying to climb over side rails, sustaining a laceration to his 
head; Deficiencies in care cited by surveyor: The facility failed to 
supervise the resident and prevent accidents from occurring: staff 
failed to accurately assess resident's safety needs and inappropriately 
assumed resident needed full side rails on the bed.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]California-9: Resident 2 had a history of a right hip 
fracture, chronic weakness in both legs, and dementia. Resident had a 
physician's order (9/16/99) for soft belt restraints when in wheelchair 
to prevent resident from getting up from wheelchair without 
assistance; Actual harm to resident documented by surveyor: State and 
date of survey[A]California-9: On 3/29/00, resident climbed over the 
bed side rails and was found on the floor at the foot of his bed with 
both side rails in the up position. Seven hours later, an x ray was 
taken and found that resident had a "minimal impaction fracture" of the 
left hip; ; Because restraints, including side rails, can pose a 
serious health and safety risk to nursing home residents if used 
improperly, CMS requires that restraints should only be used when 
other, less severe alternatives fail to address a resident's medical 
needs, and the benefits outweigh the potential risks. In such cases, 
the nursing home must ensure that any restraints are used safely and 
properly; Deficiencies in care cited by surveyor: State and date of 
survey[A]California-9: The facility failed to provide supervision and 
appropriate interventions to prevent this resident's fall. According to 
the surveyor, there were no orders for restraints in bed and no 
indication that all reasonable efforts had been made to safeguard the 
resident from additional injuries.

State and date of survey[A]: California-9; December 2000; Requirement 
and scope and severity cited: Ensure maintenance of nutritional status: 
D; Resident description and relevant diagnoses[B]: Resident was 
readmitted (6/11/00) to facility following the removal of a hip 
prosthesis and a surgical incision that became infected with a fungus, 
resulting in a large gaping wound. Resident was unable to swallow 
following a stroke and was fed via a nasogastric tube; Actual harm to 
resident documented by surveyor: A stage IV pressure sore on right heel 
was noted on 7/27/00; Deficiencies in care cited by surveyor: Facility 
was slow to implement the dietician's recommendations of 6/15/00 for 
caloric, protein, and water intake necessary for wound healing. Diet 
ordered on 6/20/00. On 6/24/00 resident was admitted to the hospital 
for care of gastrointestinal bleeding and found to need nutritional 
supplements to address gastrointestinal bleeding and promote wound 
healing. Resident was readmitted to facility on 6/29/00. Following 
readmission, the facility also failed to implement both the hospital's 
and its own dietician's recommendations for increased protein, 
calories, and water to encourage wound healing.

State and date of survey[A]: California-10 May 2001; Requirement and 
scope and severity cited: Provide supervision and devices to prevent 
accidents: D; Resident description and relevant diagnoses[B]: Resident 
admitted to facility with diagnoses of dementia and Alzheimer's disease 
and a history of falls, confusion, and unsteady gait. Resident 
identified as high risk for falls and had a physician's order for a 
restraining belt when in bed; Actual harm to resident documented by 
surveyor: Resident fell while attempting to get out of bed and 
lacerated left elbow; Deficiencies in care cited by surveyor: Facility 
failed to provide supervision and devices to prevent accidents. 
Specifically, resident was put to bed without a restraining belt.

State and date of survey[A]: California-11; May 2001; Requirement and 
scope and severity cited: Provide necessary care and services: D; 
Resident description and relevant diagnoses[B]: Resident admitted to 
the facility in 1999 with dementia and neurological disorders. Resident 
was receiving an antipsychotic medication that has a side effect of 
constipation. Care plan of 1/04/01 called for (1) providing liquids, 
roughage, and exercise, (2) monitoring for abdominal distention, pain, 
cramps, nausea, and vomiting, and (3) checking for impaction every 3 
days; Actual harm to resident documented by surveyor: Resident 
admitted to hospital for "several days" to relieve a fecal impaction; 
Deficiencies in care cited by surveyor: Staff failed to implement the 
care plan. On 5/23/01 the surveyor noted the resident crying out, 
moaning, grimacing, and moving her arms and legs about. Last bowel 
movement recorded was on 5/19/01. The charge nurse administered Tylenol 
with codeine for what she believed was an earache at 10 a.m. Resident 
continued to cry out and the charge nurse called the physician who had 
the resident transferred to a hospital emergency room.

State and date of survey[A]: California-11; Requirement and scope and 
severity cited: Provide supervision and devices to prevent accidents: 
E; Resident description and relevant diagnoses[B]: Resident was 
admitted 4/25/01 with acute kidney failure and emphysema and was one of 
five residents identified as being at risk for skin tears; all five 
developed skin tears. A care plan for potential for skin breakdown and 
treatment of the skin tears was developed; Actual harm to resident 
documented by surveyor: Resident sustained a 9 cm. skin tear to the 
lower left leg on 4/28/01 and two 3 cm. skin tears below the left knee 
on 5/3/01. Four other residents also sustained multiple skin tears to 
their extremities and hip; Deficiencies in care cited by surveyor: 
Facility failed to develop skin tear prevention plans. Staff did not 
fully investigate causes of the tears and did not know how to prevent 
skin tears. The staff development director stated that she had never 
provided instruction for the certified nurse aides on prevention of 
skin tears.

State and date of survey[A]: California-14; March 2001; Requirement and 
scope and severity cited: Ensure prevention and healing of pressure 
sores: D; Resident description and relevant diagnoses[B]: Resident 
admitted to facility 1/26/01 following a stroke, with inability to 
swallow, a gastric tube in place for feedings, and a stage I pressure 
sore on right hip; Actual harm to resident documented by surveyor: 
Resident's pressure sore progressed to a stage II by 2/28/01 and a 
stage III on 3/7/01; Deficiencies in care cited by surveyor: Facility 
staff failed to promote healing or prevent worsening of pressure sore 
by failing to employ the appropriate sheets that are used in 
conjunction with the low-air-loss, pressure sore mattress, thereby 
negating the pressure-relieving benefits of the mattress.

State and date of survey[A]: California-16; April 2001; Requirement and 
scope and severity cited: Ensure prevention and healing of pressure 
sores: D; Resident description and relevant diagnoses[B]: Resident 
admitted to facility 11/16/98 with dementia, anemia, irregular 
heartbeat, diabetes, high blood pressure, and difficulty in 
swallowing; Actual harm to resident documented by surveyor: Resident 
developed a new stage II pressure sore on 4/26/01; Deficiencies in 
care cited by surveyor: Facility staff did not prevent the development 
of a facility-acquired pressure sore. Specifically, the surveyor 
observed on 4/24/01 that the staff did not turn resident every 2 hours 
as directed by the care plan, and left her in the same position for as 
long as 8 hours.

State and date of survey[A]: California-18; April 2001; Requirement and 
scope and severity cited: Provide necessary care and services: E; 
Resident description and relevant diagnoses[B]: Resident admitted to 
the facility with a steel plate implanted in her back following a 
fracture. Nursing care plan called for comfort measures for back pain, 
such as heat/cold application, therapeutic touch, and staying with 
resident when she was in distress. Resident also had an order for 
Methadone 20 mg. that had been reduced to 2.5 mg; Actual harm to 
resident documented by surveyor: Resident was observed screaming and 
writhing in unrelieved pain for greater than an hour; Deficiencies in 
care cited by surveyor: Facility staff failed to assess the resident's 
pain levels after decreasing her Methadone. They did not do an in-depth 
pain assessment at any time after admission. The surveyor observed the 
staff ignoring the resident's cries for help and relief, which 
continued until the surveyor intervened.

State and date of survey[A]: California-19; June 2001; Requirement and 
scope and severity cited: Provide necessary care and services: D; 
Resident description and relevant diagnoses[B]: Resident admitted to 
facility on 3/97 with stroke, one-sided paralysis, and moderate 
contractures of upper and lower extremities. Resident took Tylenol four 
times a day since 2/98 for pain. As his pain worsened, he began to 
refuse the splinting of his contracted extremities because it was too 
painful; Actual harm to resident documented by surveyor: As a result 
of the facility's failure to address the resident's pain, the resident 
refused the splints used to control the contractures and the 
contractures worsened, leading to greater pain; Deficiencies in care 
cited by surveyor: Facility staff did not reassess this resident's pain 
level and need for stronger pain relief.

State and date of survey[A]: California-20 January 2001; Requirement 
and scope and severity cited: Provide supervision and devices to 
prevent accidents: D; Resident description and relevant diagnoses[B]: 
Resident was admitted to facility on 3/6/00 and identified as a high 
risk for falls on 12/6/00 because of resident's failure to remember 
warnings about personal safety and poor safety awareness; Actual harm 
to resident documented by surveyor: Resident fell and sustained 
abrasions to her right flank and hip on 12/24/00 and again on 1/7/01, 
sustaining a scalp laceration on the back of her head; Deficiencies in 
care cited by surveyor: Facility failed to implement care plan of 12/
19/00 that called for safety assessment and rehabilitation screening 
related to falls. In addition, facility failed to reassess resident's 
safety needs and alternative preventive measures after the two falls, 
as called for by facility policy and the care plan. Physical therapy 
staff did not assess resident for safety needs either. There was no 
documented evidence that a plan was implemented to prevent future 
falls.

State and date of survey[A]: California-22; October 2000; Requirement 
and scope and severity cited: Provide supervision and devices to 
prevent accidents: D; Resident description and relevant diagnoses[B]: 
Resident had diagnoses of diabetes, bipolar disease, and high blood 
pressure. Resident was assessed as at risk for falls; Actual harm to 
resident documented by surveyor: Resident fell 17 documented times from 
4/21 to 10/14/00, when she sustained a bruising of the right eye, and a 
bruise and an abrasion to her forehead; Deficiencies in care cited by 
surveyor: Facility failed to provide supervision and prevent accidents. 
Specifically, facility staff did not provide a self-releasing seat belt 
or pressure sensitive alarm on resident's wheelchair as recommended by 
the facility's fall/risk committee. Although the MDS assessment of 9/4/
00 indicated that the resident had no falls for 180 days, the 
resident's medical record indicated that the resident fell at least six 
times in this period.

State and date of survey[A]: Iowa-1; June 2001; Requirement and scope 
and severity cited: Ensure prevention and healing of pressure sores: D; 
Resident description and relevant diagnoses[B]: Resident 1 had 
diagnoses that included renal failure, diabetes, and dementia. 
Resident's record noted the presence of two pressure sores, one on 1/9/
01 and the second on 4/1/01, between the buttocks and on the lower 
right back, respectively; Actual harm to resident documented by 
surveyor: Resident's stage II pressure sores healed and then reopened 
repeatedly from 1/9/01 to 6/20/01; Deficiencies in care cited by 
surveyor: Facility staff failed to provide appropriate treatment to 
prevent reoccurrence of pressure sores, resulting in the reappearance 
of pressure sores after they had resolved. Specifically, the facility 
did not reassess the current plan of treatment and did not modify the 
care plan to meet the needs of the resident.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]Iowa-2: Resident 2 had a history of stroke and dementia. A 4/
20/01 assessment note indicated that the resident had no ulcers, skin 
problems, or lesions. On 4/22/01, the resident fell, was admitted to 
the hospital for treatment of a fracture of the right wrist, and was 
readmitted to nursing home on 4/27/01 with a cast on the right arm, 
including the lower half of the hand and thumb; Actual harm to 
resident documented by surveyor: State and date of survey[A]Iowa-2: 
Resident developed an infected stage II pressure ulcer at the base of 
the right thumb; Deficiencies in care cited by surveyor: State and 
date of survey[A]Iowa-2: Facility staff failed to prevent an avoidable 
pressure sore. After the resident was readmitted with the cast on his 
arm, the staff did not assess whether the skin around the cast was 
intact for 18 days (4/27-5/14/01), at which time the nurse noted a foul 
odor and a reddened thumb.

State and date of survey[A]: Iowa-2; March 2002; Requirement and scope 
and severity cited: (1) Ensure prevention and healing of pressure 
sores: D; Resident description and relevant diagnoses[B]: On 2/25/02, 
surveyor observed resident being transferred using a mechanical lift 
and noted an open stage II pressure sore on the lower back. A record 
review revealed a history of healing and reoccurrence of a lower-back 
pressure sore on several occasions from 7/8/01 through 2/26/02; Actual 
harm to resident documented by surveyor: Resident developed a stage II 
pressure sore that persisted and reopened after resolving; 
Deficiencies in care cited by surveyor: Facility staff failed to ensure 
that a resident with a pressure sore received necessary treatment to 
promote healing and to prevent new sores from developing. Specifically, 
the record lacked evidence of assessment of potential causal factors 
and interventions to prevent the reoccurring pressure sore.

Requirement and scope and severity cited: State and date of 
survey[A]Iowa-4: (2) Provide supervision and devices to prevent 
accidents: D; Resident description and relevant diagnoses[B]: State and 
date of survey[A]Iowa-4: During the above cited observation of the same 
resident on the mechanical lift, the surveyor also noted bilateral 
purple bruises on the resident's lower legs and later checked the 
resident more fully and noted a total of five bruises and a scrape to 
the legs. A review of the resident's record revealed multiple bruises, 
abrasions, and skin tears going back 1 year. The surveyor observed that 
there was no padding on the mechanical lift; Actual harm to resident 
documented by surveyor: State and date of survey[A]Iowa-4: Resident 
sustained multiple bruises, skin tears, and scrapes; Deficiencies in 
care cited by surveyor: State and date of survey[A]Iowa-4: Facility 
failed to prevent bruises and skin tear injuries. The staff did not 
assess the cause of the injuries or implement protective devices, such 
as padding of the lift and wheelchair. On 2/26/02, a staff member 
stated that the probable cause of the bruises was the resident's 
hitting the mechanical Hoyer lift during transfers and that the lift 
should be padded.

State and date of survey[A]: Iowa-4; February 2001; Requirement and 
scope and severity cited: Provide necessary care and; services: E; 
Resident description and relevant diagnoses[B]: Resident with a 
diagnosis of multiple sclerosis required extensive assistance with 
transfers, walking, and other activities of daily living. Care plan of 
1/19/01 directed staff to monitor and record all skin changes. Surveyor 
noted multiple bruises on resident's legs; Actual harm to resident 
documented by surveyor: Surveyor noted bruises on resident's legs and 
saw how resident's legs and feet were twisted between the wheelchair 
pedals and dragged and bumped against the wheelchair on 1/30 and 1/31/
01. Resident sustained multiple bruises on both lower legs; 
Deficiencies in care cited by surveyor: Facility staff failed to 
provide the necessary care and services in accordance with the plan of 
care. Staff failed to assess for risk of skin injury from wheelchair 
transfers and to protect resident from harm during transfers. Staff 
also failed to document resident's bruises.

State and date of survey[A]: Iowa-5; March 2001; Requirement and scope 
and severity cited: Provide necessary care and; services: D; Resident 
description and relevant diagnoses[B]: Resident admitted to facility on 
7/6/99 with Alzheimer's disease, high blood pressure, and anemia. 
Resident was receiving a diuretic to reduce blood pressure and an 
antihistamine for itching. Both drugs can reduce blood pressure below 
normal levels, causing dizziness or a drop in blood pressure when 
rising to stand (orthostatic hypotension). Resident's plan of care 
called for staff to monitor blood pressure on a weekly basis; Actual 
harm to resident documented by surveyor: Resident fell five documented 
times, sustaining abrasions to the forehead, a bloody nose and mouth, a 
bump to the forehead, a broken tooth, a carpet burn of the knees, and a 
broken nose; Deficiencies in care cited by surveyor: Facility failed 
to properly assess and monitor after the resident fell, striking her 
head on all five occasions. There was no documentation of weekly 
monitoring of blood pressure or for neurological status after resident 
struck her head.

State and date of survey[A]: Iowa-7; August 2001; Requirement and scope 
and severity cited: Provide necessary care and services: D; Resident 
description and relevant diagnoses[B]: Resident 1 admitted to facility 
on 3/2/01 with history of stroke, heart failure, and poor circulation, 
with related rash of the legs and feet. Assessment revealed a small 
scab on the left ankle that healed by 5/01. Resident developed a 
scabbed area on right foot. The physician ordered skin and heel 
protectors to be worn at night on 5/29/01; Actual harm to resident 
documented by surveyor: Resident developed two stage II ulcers of the 
foot and ankle, one on 6/18/01 and the other on 6/26/01, which were 
still present, unhealed, on 8/7/01; Deficiencies in care cited by 
surveyor: Facility staff did not consistently follow the orders and 
provide the necessary care for the resident. According to the surveyor, 
the skin and heel protectors were left off and the wheelchair was not 
padded and was causing additional erosion of the ankle lesions.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]Iowa-7: Resident 2 was admitted with lung cancer, degenerative 
arthritis, osteoporosis, and anxiety. Physician's note of 5/16/01 
indicated that resident was dying and would need to be assessed for 
pain relief as the disease progressed and that stronger, more effective 
pain relievers would be considered. As the resident began to experience 
increasing pain, he was given Tylenol even when pain appeared severe 
and unrelieved; Actual harm to resident documented by surveyor: State 
and date of survey[A]Iowa-7: Resident 2 experienced severe unrelieved 
pain; Deficiencies in care cited by surveyor: State and date of 
survey[A]Iowa-7: Facility staff failed to provide the necessary care 
for this resident to maintain comfort measures and avoid pain. The care 
plan of 5/21 and 6/13/01 did not include pain management. The staff did 
not assess the resident's complaints of pain and need for effective 
pain relief.

State and date of survey[A]: Iowa-7; August 2001; Requirement and scope 
and severity cited: Provide supervision and devices to prevent 
accidents: D; Resident description and relevant diagnoses[B]: Resident 
1 has diagnoses of dementia and depression with long-and short-term 
memory deficits. Surveyor noted resident had fallen frequently from 2/
23/01 through 7/23/01 and sustained serious injuries. Personal safety 
alarms selected for resident were ineffective in preventing falls; 
Actual harm to resident documented by surveyor: Resident 1 fell 11 
times and sustained a fractured wrist, three fractured ribs, bruises, 
abrasions, and a skin tear, plus pain associated with all these falls 
and injuries; Deficiencies in care cited by surveyor: The facility 
failed to provide adequate interventions to prevent accidents. The 
personal alarm system was the only safety device employed, and there is 
no evidence that the staff evaluated its effectiveness and selected 
other measures.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]Maryland-1: Resident 2 was admitted to facility on 8/8/00 with 
renal failure and impaired mobility. On 4/3/01, he was assessed as 
being mentally confused at times. Surveyor noted the resident's record 
stated that resident fell frequently. The care plan and monthly summary 
for April identify the personal alarm unit as the safety device in use 
during this time (initiated 3/25/01). The resident frequently removed 
the unit or put it in his pocket; Actual harm to resident documented 
by surveyor: State and date of survey[A]Maryland-1: Resident 2 fell 21 
times from 1/6/01 to 6/26/01 and sustained multiple skin tears, two 
lacerations to the head and elbow requiring emergency room or clinic 
visits for sutures, multiple bruises and abrasions, and head injuries; 
Deficiencies in care cited by surveyor: State and date of 
survey[A]Maryland-1: The facility failed to provide adequate 
interventions to prevent accidents. The personal alarm unit in use for 
this resident did not prevent his falls from occurring and there is no 
indication that other safety options were considered.

State and date of survey[A]: Maryland-1; August 2001; Requirement and 
scope and severity cited: Provide supervision and devices to prevent 
accidents: D; Resident description and relevant diagnoses[B]: Resident 
admitted to facility with multiple diagnoses including congestive heart 
failure, high blood pressure, and obesity. Resident suffered from 
shortness of breath and required oxygen at 3 liters per minute. She 
also had a history of falls and was considered a high risk for falls. 
Resident had a physician order for a quick-release belt while in 
wheelchair for safety; Actual harm to resident documented by surveyor: 
Resident fell out of the wheelchair, was bleeding from nose and mouth, 
and was in acute respiratory distress. Staff did not intervene to 
address respiratory distress until resident stopped breathing and her 
pulse stopped. At this time the staff began to administer 
cardiopulmonary resuscitation (CPR); Deficiencies in care cited by 
surveyor: The facility failed to provide supervision and devices to 
prevent accidents by not placing safety belt around resident while she 
was in the wheelchair. Staff also did not provide the resident with 
oxygen as ordered while she was in the wheelchair. Staff did not 
respond in a timely and appropriate manner to resident's onset of 
respiratory distress following the fall from the wheelchair. Staff did 
not initiate CPR until resident was no longer breathing and her pulse 
stopped.

State and date of survey[A]: Missouri-3; May 2001; Requirement and 
scope and severity cited: Ensure adequate nutritional status: D; 
Resident description and relevant diagnoses[B]: Resident had diagnoses 
of peptic ulcer disease, aspiration pneumonia, and a penicillin-
resistant infection requiring long-term antibiotic treatment. From 11/
00 through 2/01, resident sustained a severe weight loss of 10 to 12 
percent; Actual harm to resident documented by surveyor: Resident 
experienced another severe weight loss, dropping from 126 lbs in 3/01 
to 116.9 lbs in 4/01, a loss of 7.2 percent in 1 month; Deficiencies 
in care cited by surveyor: The facility failed to ensure adequate 
nutritional status. After noting resident's weight loss in 2/01, no 
care plan was developed to address the weight loss. In March, the 
dietician recommended a dietary supplement, which did not begin for a 
month.

State and date of survey[A]: Nebraska-1; September 2000; Requirement 
and scope and severity cited: Provide necessary care and services: D; 
Resident description and relevant diagnoses[B]: Resident 1 readmitted 
to facility from hospital with a diagnosis of insulin-dependent 
diabetes. Physician orders stated that the physician was to be called 
when resident's blood sugar fell below 40 or rose above 350 (normal 
range is 70 to 110). Resident received insulin on a sliding scale 
(insulin dose based on most recent blood sugar), and a variety of 
dietary interventions; Actual harm to resident documented by surveyor: 
Over a period of 9 months, resident's blood sugar fluctuated, including 
frequent episodes of symptomatic hypoglycemia (low blood sugar between 
48 and 60) and loss of consciousness; Deficiencies in care cited by 
surveyor: Facility failed to provide the necessary care and services 
required to manage resident's diabetes. Specifically, (1) the staff 
infrequently called the physician about blood sugars below 40, the 
frequent blood sugar fluctuations, or the resident's episodes of 
symptomatic hypoglycemia, (2) fluctuating blood sugars were not 
identified as a problem in the care plan, and (3) there was no 
assessment of the resident's diabetes, appropriate diet, treatment 
effectiveness of hypoglycemic episodes, and administration of insulin 
on a sliding scale.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]Nebraska-3 September 2001: Resident 2 with diagnoses of 
emphysema, Parkinson's disease, and osteoarthritis was receiving 
hospice services. Resident experienced increasing pain on a daily 
basis, unrelieved by regular Tylenol, a tranquilizer, and an 
antipsychotic drug specific for schizophrenia and mania. Resident 
obtained short-term (2.5 hours) relief from Tylox (Tylenol and 
oxycodone for pain relief and sedation); Actual harm to resident 
documented by surveyor: State and date of survey[A]Nebraska-3 September 
2001: This terminally ill resident suffered with unrelieved pain for at 
least 4 months; Deficiencies in care cited by surveyor: State and date 
of survey[A]Nebraska-3 September 2001: Facility staff did not provide 
the necessary care and services to this resident. The staff did not 
assess or respond to the resident's continuing complaints of pain and 
noted in the record that the resident was demanding and manipulative. 
Nor did they monitor the effectiveness of the medications administered, 
resulting (according to the surveyor) in the resident's voicing 
thoughts of suicide.

State and date of survey[A]: Nebraska-3 September 2001; Requirement and 
scope and severity cited: Ensure prevention and healing of pressure 
sores: D; Resident description and relevant diagnoses[B]: Resident was 
readmitted to facility 5/24/01 with diagnoses of stroke, diabetes, and 
one stage II pressure sore of the lower back and one stage I pressure 
sore between the buttocks. Resident was totally dependent on staff for 
bed mobility because of a right-sided paralysis and developed pressure 
sores of both heels that were noted on 6/3/01 and identified as stage 
II on 7/24/01. A pressure-reducing mattress was added to the care plan 
on 9/4/01; Actual harm to resident documented by surveyor: Resident 
developed a stage III pressure sore on the right heel with thick green 
drainage and foul odor; Deficiencies in care cited by surveyor: 
Facility failed to ensure that a resident did not develop a pressure 
sore in the facility. Specifically, the facility staff failed to 
recognize the challenge the resident had in moving in bed because of 
the right-sided paralysis. In addition, they were slow to use a 
pressure-reducing mattress. When the mattress was placed on the bed the 
staff did not discontinue use of the fleece-lined protection booties 
and continued use for 3 weeks, which negated the pressure-reducing 
effects of the mattress.

State and date of survey[A]: Pennsylvania-3; May 2001; Requirement and 
scope and severity cited: Ensure prevention and healing of pressure 
sores: D; Resident description and relevant diagnoses[B]: Resident had 
a left hip fracture and was identified as high risk for skin breakdown 
on 12/18/00. A stage I pressure sore of the left heel was noted on 3/7/
01 and by 3/14/01 it had progressed to stage II. A special boot to keep 
left heel elevated was not applied until 3/21/01 and was then left on 
continuously. A second stage II pressure sore was noted on the left 
outer foot 4/10/01. The boot was discontinued on 4/11/01. A nutrition 
assessment on 3/27/01 indicated resident's skin was intact and 
recommended no increase in protein in the diet; Actual harm to 
resident documented by surveyor: In addition to the stage II pressure 
sore of the foot, resident developed a second stage II facility-
acquired pressure sore on 4/10/01; Deficiencies in care cited by 
surveyor: Facility failed to prevent the development of pressure sores. 
Specifically, the boot, which was left on continuously, contributed to 
the development of the pressure sore identified on 4/10/01. In 
addition, the dietician did not note the existing original pressure 
sore and wrongly assumed the resident had no extra need for protein. 
The need for additional protein in the diet was confirmed by laboratory 
tests indicating the resident's protein levels were below the normal 
range.

State and date of survey[A]: Pennsylvania-3; May 2001; Requirement and 
scope and severity cited: Provide supervision and devices to prevent 
accidents: E; Resident description and relevant diagnoses[B]: Resident 
had piriformis syndrome (compression of the sciatic nerve by the 
piriformis muscle) with a physician's order for physical therapy using 
stretching exercises and heat application. Physical therapy used a 
hydrocollator pack to provide moist heat treatments.[G]; Actual harm to 
resident documented by surveyor: Resident developed a second-degree 
burn of the right buttock, which blistered and was still healing after 
a month; Deficiencies in care cited by surveyor: Facility staff failed 
to provide supervision and prevent injury; During a routine check on 
1/9/01, the facility found that the temperature on the hydrocollator 
pack was 11 degrees above the manufacturer's recommended temperature. 
On 4/16/01 the hydrocollator pack was applied to the resident's right 
buttock. Resident said that he told the therapy staff that the pack was 
getting too hot and the pack was removed. Facility staff did not check 
the water temperature after the incident.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]Pennsylvania-9: Resident 2 had diagnoses that included 
dementia, poor vision, and Parkinson's disease and was assessed as a 
moderate risk for falls on 12/29/00. The MDS significant change 
assessment of 1/24/01 and the 4/9/01 quarterly review noted a history 
of falls, impaired decision making, and the need for assistance for 
transferring and walking. The records noted interventions found to be 
ineffective continued to be used; Actual harm to resident documented 
by surveyor: State and date of survey[A]Pennsylvania-9: Resident 2 fell 
nine documented times and, as a result of these falls, sustained a skin 
tear, a laceration requiring transfer to the hospital for treatment, 
and a dislocated hip requiring another hospital visit; Deficiencies in 
care cited by surveyor: State and date of survey[A]Pennsylvania-9: The 
facility failed to ensure adequate supervision and assistance devices 
to prevent accidents. According to the surveyor, there was no evidence 
that the facility had implemented effective interventions to avoid the 
risk of such accidents for the resident. The surveyor noted that this 
at-risk resident's room was too far from the nurses' station, making 
observation difficult.

State and date of survey[A]: Pennsylvania-9; May 2001; Requirement and 
scope and severity cited: Provide supervision and devices to prevent 
accidents: D; Resident description and relevant diagnoses[B]: A 
dependent resident with cognitive impairment was assessed as at risk 
for falls and skin tears. Interventions to prevent falls listed in the 
care plan included use of personal alarms, protective sleeves, and 
padded side rails; Actual harm to resident documented by surveyor: 
Resident sustained eight skin tears on 6/27/00, 7/24/00, 7/31/00, 8/16/
00, 9/20/00, 10/24/00, 1/8/01, and 1/27/01; Deficiencies in care cited 
by surveyor: Surveyor stated that the facility failed to ensure that 
the necessary safety measures and/or devices were implemented and 
failed to adequately assess the ongoing use of these devices given 
their ineffectiveness in preventing falls and skin tears.

State and date of survey[A]: Virginia-1; August 2000; Requirement and 
scope and severity cited: Provide necessary care and; services: D; 
Resident description and relevant diagnoses[B]: Resident admitted to 
facility for pain management associated with spread of cancer to the 
spine. Resident had physician orders for Oxycontin every 12 hours for 
long-term pain relief, as needed, and Percocet every 4 hours for any 
additional pain, as needed. Staff noted resident lay very still in bed 
and seldom asked for pain medication but that it was obvious he was in 
a lot of pain whenever he was turned or touched. Resident's daughter 
said her father was in constant pain and was depressed; Actual harm to 
resident documented by surveyor: This resident suffered with severe 
pain that was incompletely relieved by the use of Percocet. The longer 
acting Oxycontin was never used; Deficiencies in care cited by 
surveyor: The facility did not provide necessary care and services to 
manage this resident's pain. Resident did not receive any of the 
longer-acting Oxycontin and received only 10 doses of the Percocet 
during the 6 days he was in the facility. He was not offered pain 
relief in the morning when he was being turned and bathed. Monitoring 
of medication effectiveness was incomplete. Percocet was given, on 
average, once a day.

State and date of survey[A]: Virginia-2; March 2001; Requirement and 
scope and severity cited: Provide necessary care and; services: D; 
Resident description and relevant diagnoses[B]: Resident was admitted 
to facility 11/4/97, with diagnoses of stroke, depression, and 
delusions. An MDS of 11/9/00 indicated the resident was cognitively 
impaired and required lift transfer. On 12/27/00 the nurse noted a 
large area of bruising on the left chest and left underarm with 
swelling around the rib cage. On 1/6/01 resident began to experience 
shallow breathing. Physician ordered a chest x ray if resident's 
breathing difficulties continued; Actual harm to resident documented 
by surveyor: Resident sustained fractures of the eighth and ninth ribs 
with fluid in the left lower lobe of the lung demonstrated by x ray; 
Deficiencies in care cited by surveyor: The facility failed to provide 
the necessary care and services to provide prompt treatment of the 
resident's chest injury. Specifically, the facility failed to take 
appropriate action to assess and provide the necessary care for this 
resident's injury for 11 days. The results of an investigation 
implicated the lift used to transfer the resident to and from the bed.

State and date of survey[A]: Virginia-2; March 2001; Requirement and 
scope and severity cited: Ensure prevention and healing of pressure 
sores: D; Resident description and relevant diagnoses[B]: Resident 1 
admitted to the facility with diagnoses of Alzheimer's disease, anemia, 
depression, and joint pain. No pressure sores were noted on the 
admission assessment form. The care plan on 2/22/00 noted the resident 
was incontinent of bowel and bladder and at risk for pressure sores. 
Resident's blood protein was low. The most recent MDS (2/23/01) 
indicated no pressure sores but noted the resident was losing weight, 5 
percent or more in the past 30 days (1/24/01-2/23/01); Actual harm to 
resident documented by surveyor: Resident developed three open pressure 
sores of the buttocks, evident 2 days after the MDS assessment. One of 
the pressure sores was a stage III; Deficiencies in care cited by 
surveyor: The facility failed to prevent the development of facility-
acquired pressure sores. The staff did not obtain timely alternative 
treatments and interventions to promote healing of early pressure 
sores.

Resident description and relevant diagnoses[B]: State and date of 
survey[A]Virginia-4: Resident 2 admitted to facility on 12/24/00 with 
diabetes, stroke, prostate cancer, requiring limited assistance for 
activities of daily living, and incontinent of bowel and bladder. As of 
12/31/00 resident had an unhealed surgical wound of the back, two stage 
IV pressure sores of the right and left heels, and an excoriated (stage 
I) buttock. After a brief hospitalization, resident was readmitted to 
facility and the clinical record on 2/26/00 described the buttock sore 
as a stage II pressure sore. Treatment with a sealed dressing 
continued; Actual harm to resident documented by surveyor: State and 
date of survey[A]Virginia-4: Resident developed an open stage III 
pressure sore with yellow drainage; Deficiencies in care cited by 
surveyor: State and date of survey[A]Virginia-4: Staff failed to obtain 
timely alternative treatments and interventions to promote healing upon 
worsening of these sores from1/18/01 through 3/1/01. Specifically, the 
staff continued to treat the pressure sores without evaluating the 
effectiveness of the treatment.

State and date of survey[A]: Virginia-4; March 2001; Requirement and 
scope and severity cited: Provide necessary care and services: D; 
Resident description and relevant diagnoses[B]: Resident was an 81-
year-old admitted to the facility on 8/17/90 with psychoses and 
hypothyroidism. Recent assessment (1/22/01) indicated long-and short-
term memory loss and moderate dependency for activities of daily 
living. Care plan identified resident as at risk for falls. A list of 
preventive measures was provided. On 9/14/00 at 7:30 p.m., resident 
fell and complained of pain all over; Actual harm to resident 
documented by surveyor: Resident sustained a nondisplaced fracture of 
the left wrist and suffered unnecessary pain; Deficiencies in care 
cited by surveyor: Facility failed to provide necessary care and 
services. The facility failed to assess and investigate the source of 
the resident's pain. Nurses' notes indicate no apparent injury after 
fall. On 9/15/00 at 6:30 p.m., resident complained of pain in left arm. 
There was bruising on wrist and thumb, and the arm was swollen and 
tender to touch. According to the surveyor, there was a delay in 
seeking more aggressive treatment or service, as evidenced by the fact 
that an x-ray was not obtained until 37 hours after the resident's 
fall.

Source: State nursing home survey reports.

[A] To more easily distinguish among multiple surveys from the same 
state, we assigned consecutive numbers to each state's surveys.

[B] The resident description and relevant diagnoses are limited to the 
information provided by the surveyor. In some of the surveys, no 
background or diagnostic information was provided.

[C] Skin tears and multiple bruises are serious and painful injuries 
for older individuals and should not be considered in the same context 
as cuts and bruises sustained by healthy and younger adults. A skin 
tear is a traumatic wound occurring principally on the extremities of 
older adults as a result of friction alone or shearing and friction 
forces that separate the top layer of skin from the underlying layer or 
both layers from the underlying structures. A skin tear is a painful 
but preventable injury. Individuals most at risk for skin tears are 
those with (1) fragile skin, (2) advanced age, (3) assistance devices 
(wheelchairs, lifts, walkers), (4) cognitive and sensory impairment, 
(5) history of skin tears, and (6) total dependence for care. In 
addition, treatment of bruises and skin tears for elderly residents of 
a nursing home is frequently complicated by diabetes, poor circulation, 
poor nutrition, and medications with blood thinning effects. See Sharon 
Baranoski, "Skin Tears: Staying on Guard Against the Enemy of Frail 
Skin," Nursing 2000, vol. 30, no. 9, 2000.

[D] Stages of pressure sore formation are I--skin of involved area is 
reddened, II--upper layer of skin is involved and blistered or abraded, 
III--skin has an open sore and involves all layers of skin down to 
underlying connective tissue, and IV--tissue surrounding the sore has 
died and may extend to muscle and bone and involve infection.

[E] The following two resident incidents were cited at the B level for 
scope and severity, which means the surveyor found that both injuries 
were unavoidable and that the nursing home was in substantial 
compliance with the requirements.

[F] These two citations involve two residents, one cognitively 
competent and the other with dementia, who were injured because side 
rails were in place on their beds. Numerous reports have cited the 
danger of side rails. Residents trying to get out of bed over the rails 
have injured themselves by falling. Other individuals have been caught 
between the bed rails and the mattress or have caught their heads in 
the rails. Some of these injuries resulted in death.

[G] A hydrocollator pack is a canvas bag containing a silicone gel 
paste that absorbs an amount of water 10 times its weight. The pack is 
placed in a heated water container, set at a temperature above 150 F. 
When ready, it is placed in a protective dry terrycloth wrap and 
applied on top of the area where the individual is experiencing pain. 
Lying or sitting on the pack negates the insulating effect of the 
terrycloth and the individual may be burned.

[End of table]

[End of section]

Appendix IV: Information on State Nursing Home Surveyor Staffing:

Table 9 summarizes state survey agencies' responses to our July 2002 
questions about nursing home surveyor experience, vacancies, hiring 
freezes, competitiveness of salaries, and minimum required experience.

Table 9: State Survey Agency Responses to Questions about Surveyor 
Experience, Vacancies, Hiring Freezes, Competitiveness of Salaries, and 
Minimum Required Experience:

State[A]: Maryland; Surveyors with: 2 years or less experience: 
(percent): 70; Surveyor positions vacant (percent): 9; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
0 to 2.

State[A]: Oklahoma; Surveyors with: 2 years or less experience: 
(percent): 67; Surveyor positions vacant (percent): 4; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
0 to1.

State[A]: New Hampshire; Surveyors with: 2 years or less experience: 
(percent): 60; Surveyor positions vacant (percent): 12; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
2.

State[A]: Florida; Surveyors with: 2 years or less experience: 
(percent): 55; Surveyor positions vacant (percent): 8; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
0.

State[A]: Idaho; Surveyors with: 2 years or less experience: (percent): 
54; Surveyor positions vacant (percent): 0; Surveyor hiring freeze in 
effect as of mid-2002: Yes; RN surveyor salaries are competitive: No; 
Minimum required experience for RN surveyors (years): 1.

State[A]: Washington; Surveyors with: 2 years or less experience: 
(percent): 54; Surveyor positions vacant (percent): 0; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
2.

State[A]: California; Surveyors with: 2 years or less experience: 
(percent): 52; Surveyor positions vacant (percent): 6; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
1.

State[A]: Georgia; Surveyors with: 2 years or less experience: 
(percent): 51; Surveyor positions vacant (percent): 14; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
3.

State[A]: Kentucky; Surveyors with: 2 years or less experience: 
(percent): 51; Surveyor positions vacant (percent): 17; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
4.

State[A]: District of Columbia; Surveyors with: 2 years or less 
experience: (percent): 50; Surveyor positions vacant (percent): 9; 
Surveyor hiring freeze in effect as of mid-2002: Yes; RN surveyor 
salaries are competitive: Yes; Minimum required experience for RN 
surveyors (years): 3.

State[A]: Utah; Surveyors with: 2 years or less experience: (percent): 
50; Surveyor positions vacant (percent): 8; Surveyor hiring freeze in 
effect as of mid-2002: No; RN surveyor salaries are competitive: No; 
Minimum required experience for RN surveyors (years): 2.

State[A]: Louisiana; Surveyors with: 2 years or less experience: 
(percent): 48; Surveyor positions vacant (percent): 6; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
2 to 3.

State[A]: Alabama; Surveyors with: 2 years or less experience: 
(percent): 48; Surveyor positions vacant (percent): 10; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
0.

State[A]: Tennessee; Surveyors with: 2 years or less experience: 
(percent): 45; Surveyor positions vacant (percent): 18; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
3.

State[A]: Maine; Surveyors with: 2 years or less experience: (percent): 
42; Surveyor positions vacant (percent): 9; Surveyor hiring freeze in 
effect as of mid-2002: Yes; RN surveyor salaries are competitive: No; 
Minimum required experience for RN surveyors (years): 5.

State[A]: Hawaii; Surveyors with: 2 years or less experience: 
(percent): 40; Surveyor positions vacant (percent): 17; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
2-.

State[A]: New York; Surveyors with: 2 years or less experience: 
(percent): 40; Surveyor positions vacant (percent): 4; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
1 to 2.

State[A]: Missouri; Surveyors with: 2 years or less experience: 
(percent): 36; Surveyor positions vacant (percent): 11; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
2.

State[A]: Oregon; Surveyors with: 2 years or less experience: 
(percent): 34; Surveyor positions vacant (percent): 12; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
5.

State[A]: Arkansas; Surveyors with: 2 years or less experience: 
(percent): 33; Surveyor positions vacant (percent): 20; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
2.

State[A]: North Carolina; Surveyors with: 2 years or less experience: 
(percent): 33; Surveyor positions vacant (percent): 18; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
4.

State[A]: Texas; Surveyors with: 2 years or less experience: (percent): 
32; Surveyor positions vacant (percent): 20[B]; Surveyor hiring freeze 
in effect as of mid-2002: No[B]; RN surveyor salaries are competitive: 
No; Minimum required experience for RN surveyors (years): 1.

State[A]: New Mexico; Surveyors with: 2 years or less experience: 
(percent): 30; Surveyor positions vacant (percent): 34; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
3.

State[A]: New Jersey; Surveyors with: 2 years or less experience: 
(percent): 30; Surveyor positions vacant (percent): 23; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
3.

State[A]: Nebraska; Surveyors with: 2 years or less experience: 
(percent): 29; Surveyor positions vacant (percent): 6; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
1 to 2.

State[A]: Connecticut; Surveyors with: 2 years or less experience: 
(percent): 29; Surveyor positions vacant (percent): 1; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
4.

State[A]: Alaska; Surveyors with: 2 years or less experience: 
(percent): 29; Surveyor positions vacant (percent): 22; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
2.

State[A]: Wisconsin; Surveyors with: 2 years or less experience: 
(percent): 25; Surveyor positions vacant (percent): 15; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
0.

State[A]: Colorado; Surveyors with: 2 years or less experience: 
(percent): 24; Surveyor positions vacant (percent): 17; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
1.

State[A]: Virginia; Surveyors with: 2 years or less experience: 
(percent): 21; Surveyor positions vacant (percent): 5; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
0.

State[A]: Indiana; Surveyors with: 2 years or less experience: 
(percent): 20; Surveyor positions vacant (percent): 18; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
1.

State[A]: Arizona; Surveyors with: 2 years or less experience: 
(percent): 20; Surveyor positions vacant (percent): 24; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
2.

State[A]: South Dakota; Surveyors with: 2 years or less experience: 
(percent): 18; Surveyor positions vacant (percent): 0; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
2.

State[A]: Ohio; Surveyors with: 2 years or less experience: (percent): 
17; Surveyor positions vacant (percent): 5; Surveyor hiring freeze in 
effect as of mid-2002: No; RN surveyor salaries are competitive: Yes; 
Minimum required experience for RN surveyors (years): 0.

State[A]: Michigan; Surveyors with: 2 years or less experience: 
(percent): 17; Surveyor positions vacant (percent): 5; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
0.

State[A]: Kansas; Surveyors with: 2 years or less experience: 
(percent): 17; Surveyor positions vacant (percent): 4; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
[C].

State[A]: Massachusetts; Surveyors with: 2 years or less experience: 
(percent): 16; Surveyor positions vacant (percent): 14; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
1 to 3.

State[A]: Pennsylvania; Surveyors with: 2 years or less experience: 
(percent): 15; Surveyor positions vacant (percent): 7; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
1.

State[A]: Rhode Island; Surveyors with: 2 years or less experience: 
(percent): 9; Surveyor positions vacant (percent): 13; Surveyor hiring 
freeze in effect as of mid-2002: No; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
1.

State[A]: Illinois; Surveyors with: 2 years or less experience: 
(percent): 5; Surveyor positions vacant (percent): 5; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: Yes; Minimum required experience for RN surveyors (years): 
2 to 3.

State[A]: Iowa; Surveyors with: 2 years or less experience: (percent): 
4; Surveyor positions vacant (percent): 0; Surveyor hiring freeze in 
effect as of mid-2002: Yes; RN surveyor salaries are competitive: No; 
Minimum required experience for RN surveyors (years): 5.

State[A]: Minnesota; Surveyors with: 2 years or less experience: 
(percent): 0; Surveyor positions vacant (percent): 17; Surveyor hiring 
freeze in effect as of mid-2002: Yes; RN surveyor salaries are 
competitive: No; Minimum required experience for RN surveyors (years): 
3.

Source: State survey agency responses to July 2002 GAO questions.

[A] Nine states did not respond to our inquiry--Delaware, Mississippi, 
Montana, Nevada, North Dakota, South Carolina, Vermont, West Virginia, 
and Wyoming.

[B] Texas indicated that although there was no hiring freeze or 
layoffs, the survey staff was reduced by 107 positions through 
attrition from September 1, 2001, through June 1, 2002, in light of 
state funding changes and agency cuts. As of mid-2002, Texas was 
authorized 215 nurse surveyors and had 42 positions vacant.

[C] Kansas requires independent experience in professional health care, 
but does not specify a time period for that experience.

[End of table]

[End of section]

Appendix V: Predictability of Standard Nursing Home Surveys:

Our analysis found that 34 percent of current nursing home surveys were 
predictable, allowing nursing homes to conceal deficiencies if they 
choose to do so. In order to determine the predictability of nursing 
home surveys, we analyzed data from CMS's OSCAR database (see table 
10). We considered surveys to be predictable if (1) homes were surveyed 
within 15 days of the 1-year anniversary of their prior survey or (2) 
homes were surveyed within 1 month of the maximum 15-month interval 
between standard surveys. Consistent with CMS's interpretation, we used 
15.9 months as the maximum allowable interval between surveys. Because 
homes know the maximum allowable interval between surveys, those whose 
prior surveys were conducted 14 or 15 months earlier are aware that 
they are likely to be surveyed soon.

Table 10: Predictability of Current Nursing Home Surveys, by State:

State: Alabama; Number of active homes with a current and prior survey: 
225; Predictable surveys (percent): 82.7; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 5.8; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
76.9.

State: Oklahoma; Number of active homes with a current and prior 
survey: 354; Predictable surveys (percent): 71.5; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 0.6; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 70.9.

State: South Carolina; Number of active homes with a current and prior 
survey: 174; Predictable surveys (percent): 67.8; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 6.9; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 60.9.

State: Nebraska; Number of active homes with a current and prior 
survey: 226; Predictable surveys (percent): 59.7; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 3.1; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 56.6.

State: Utah; Number of active homes with a current and prior survey: 
91; Predictable surveys (percent): 52.7; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 1.1; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
51.6.

State: Montana; Number of active homes with a current and prior survey: 
103; Predictable surveys (percent): 52.4; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 8.7; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
43.7.

State: Georgia; Number of active homes with a current and prior survey: 
357; Predictable surveys (percent): 52.4; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 0.6; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
51.8.

State: Hawaii; Number of active homes with a current and prior survey: 
44; Predictable surveys (percent): 52.3; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 13.6; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
38.6.

State: New York; Number of active homes with a current and prior 
survey: 663; Predictable surveys (percent): 52.0; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 14.8; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 37.3.

State: Idaho; Number of active homes with a current and prior survey: 
84; Predictable surveys (percent): 50.0; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 4.8; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
45.2.

State: New Mexico; Number of active homes with a current and prior 
survey: 80; Predictable surveys (percent): 43.8; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 13.8; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 30.0.

State: Delaware; Number of active homes with a current and prior 
survey: 42; Predictable surveys (percent): 42.9; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 31.0; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 11.9.

State: California; Number of active homes with a current and prior 
survey: 1,324; Predictable surveys (percent): 41.2; Homes surveyed 
within 15 days of 1-year anniversary of prior survey (percent): 9.5; 
Homes surveyed within 1 month of 15-month maximum interval of prior 
survey (percent): 31.7.

State: Nevada; Number of active homes with a current and prior survey: 
45; Predictable surveys (percent): 40.0; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 24.4; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
15.6.

State: Arizona; Number of active homes with a current and prior survey: 
138; Predictable surveys (percent): 39.9; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 21.0; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
18.8.

State: New Jersey; Number of active homes with a current and prior 
survey: 359; Predictable surveys (percent): 39.0; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 18.7; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 20.3.

State: Oregon; Number of active homes with a current and prior survey: 
142; Predictable surveys (percent): 38.0; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 14.1; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
23.9.

State: Maryland; Number of active homes with a current and prior 
survey: 246; Predictable surveys (percent): 37.0; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 20.7; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 16.3.

State: Massachusetts; Number of active homes with a current and prior 
survey: 497; Predictable surveys (percent): 36.2; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 17.3; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 18.9.

State: Arkansas; Number of active homes with a current and prior 
survey: 239; Predictable surveys (percent): 35.6; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 27.6; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 7.9.

State: Virginia; Number of active homes with a current and prior 
survey: 275; Predictable surveys (percent): 35.3; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 30.5; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 4.7.

State: Iowa; Number of active homes with a current and prior survey: 
457; Predictable surveys (percent): 34.6; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 31.1; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
3.5.

State: Nation; Number of active homes with a current and prior survey: 
16,332; Predictable surveys (percent): 34.0; Homes surveyed within 15 
days of 1-year anniversary of prior survey (percent): 13.0; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 21.0.

State: Kentucky; Number of active homes with a current and prior 
survey: 303; Predictable surveys (percent): 33.7; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 10.6; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 23.1.

State: Ohio; Number of active homes with a current and prior survey: 
973; Predictable surveys (percent): 33.6; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 3.0; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
30.6.

State: North Dakota; Number of active homes with a current and prior 
survey: 85; Predictable surveys (percent): 32.9; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 28.2; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 4.7.

State: Vermont; Number of active homes with a current and prior survey: 
43; Predictable surveys (percent): 32.6; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 11.6; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
20.9.

State: New Hampshire; Number of active homes with a current and prior 
survey: 83; Predictable surveys (percent): 32.5; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 12.0; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 20.5.

State: South Dakota; Number of active homes with a current and prior 
survey: 111; Predictable surveys (percent): 32.4; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 18.9; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 13.5.

State: Wisconsin; Number of active homes with a current and prior 
survey: 404; Predictable surveys (percent): 32.4; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 19.6; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 12.9.

State: Washington; Number of active homes with a current and prior 
survey: 268; Predictable surveys (percent): 32.1; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 22.4; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 9.7.

State: Florida; Number of active homes with a current and prior survey: 
718; Predictable surveys (percent): 32.0; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 9.3; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
22.7.

State: Mississippi; Number of active homes with a current and prior 
survey: 187; Predictable surveys (percent): 31.6; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 2.1; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 29.4.

State: Rhode Island; Number of active homes with a current and prior 
survey: 96; Predictable surveys (percent): 31.3; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 12.5; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 18.8.

State: Connecticut; Number of active homes with a current and prior 
survey: 253; Predictable surveys (percent): 30.8; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 15.8; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 15.0.

State: Wyoming; Number of active homes with a current and prior survey: 
39; Predictable surveys (percent): 30.8; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 10.3; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
20.5.

State: Indiana; Number of active homes with a current and prior survey: 
550; Predictable surveys (percent): 30.7; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 14.4; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
16.4.

State: Tennessee; Number of active homes with a current and prior 
survey: 324; Predictable surveys (percent): 29.0; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 6.2; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 22.8.

State: Louisiana; Number of active homes with a current and prior 
survey: 315; Predictable surveys (percent): 28.6; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 19.0; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 9.5.

State: Texas; Number of active homes with a current and prior survey: 
1,122; Predictable surveys (percent): 27.2; Homes surveyed within 15 
days of 1-year anniversary of prior survey (percent): 15.7; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 11.5.

State: Colorado; Number of active homes with a current and prior 
survey: 222; Predictable surveys (percent): 26.1; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 9.0; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 17.1.

State: Pennsylvania; Number of active homes with a current and prior 
survey: 757; Predictable surveys (percent): 26.0; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 24.0; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 2.0.

State: Kansas; Number of active homes with a current and prior survey: 
369; Predictable surveys (percent): 25.2; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 13.6; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
11.7.

State: Missouri; Number of active homes with a current and prior 
survey: 531; Predictable surveys (percent): 25.0; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 11.9; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 13.2.

State: Maine; Number of active homes with a current and prior survey: 
121; Predictable surveys (percent): 24.8; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 8.3; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
16.5.

State: Minnesota; Number of active homes with a current and prior 
survey: 427; Predictable surveys (percent): 20.4; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 4.4; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 15.9.

State: Alaska; Number of active homes with a current and prior survey: 
15; Predictable surveys (percent): 20.0; Homes surveyed within 15 days 
of 1-year anniversary of prior survey (percent): 6.7; Homes surveyed 
within 1 month of 15-month maximum interval of prior survey (percent): 
13.3.

State: District of Columbia; Number of active homes with a current and 
prior survey: 20; Predictable surveys (percent): 20.0; Homes surveyed 
within 15 days of 1-year anniversary of prior survey (percent): 15.0; 
Homes surveyed within 1 month of 15-month maximum interval of prior 
survey (percent): 5.0.

State: North Carolina; Number of active homes with a current and prior 
survey: 411; Predictable surveys (percent): 17.3; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 13.9; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 3.4.

State: Illinois; Number of active homes with a current and prior 
survey: 849; Predictable surveys (percent): 15.2; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 9.7; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 5.5.

State: West Virginia; Number of active homes with a current and prior 
survey: 138; Predictable surveys (percent): 10.9; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 8.7; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 2.2.

State: Michigan; Number of active homes with a current and prior 
survey: 433; Predictable surveys (percent): 10.2; Homes surveyed within 
15 days of 1-year anniversary of prior survey (percent): 8.8; Homes 
surveyed within 1 month of 15-month maximum interval of prior survey 
(percent): 1.4.

Source: GAO analysis of OSCAR data as of April 9, 2002.

[End of table]

[End of section]

Appendix VI: Immediate Sanctions Implemented Under CMS's Expanded 
Immediate Sanctions Policy:

From January 2000 through March 2002, states referred 4,310 cases to 
CMS under its expanded immediate sanctions policy when nursing homes 
were found to have a pattern of harming residents.[Footnote 73] Because 
some homes had more than one sanction or may have had multiple 
referrals for sanctions, 4,860 sanctions were implemented (see table 
11). Table 12 summarizes the amounts of federal civil money penalties 
(CMP) implemented against nursing homes referred for immediate 
sanction. Although these monetary sanctions were implemented, CMS's 
enforcement database does not track collections. In addition, states 
may have imposed other sanctions under their own licensure authority, 
such as state monetary sanctions, in addition to or in lieu of federal 
sanctions. Such state sanctions are not recorded in CMS's enforcement 
database.

Table 11: Federal Sanctions Implemented against Nursing Homes Referred 
for Immediate Sanction, January 14, 2000, through March 28, 2002:

Type of sanction[A]: CMP; Number implemented: 2,933.

Type of sanction[A]: Denial of payment for new admissions; Number 
implemented: 1,232.

Type of sanction[A]: Directed in-service training; Number implemented: 
345.

Type of sanction[A]: State monitoring; Number implemented: 192.

Type of sanction[A]: Directed plan of correction; Number implemented: 
77.

Type of sanction[A]: CMS approved alternative or additional state 
sanction; Number implemented: 48.

Type of sanction[A]: Termination from the Medicare and Medicaid 
programs; Number implemented: 26.

Type of sanction[A]: Temporary management; Number implemented: 4.

Type of sanction[A]: Denial of payment for all residents; Number 
implemented: 2.

Type of sanction[A]: Transfer of residents and closure of facility; 
Number implemented: 1.

Type of sanction[A]: Total; Number implemented: 4,860.

Source: CMS enforcement database as of March 28, 2002.

[A] We excluded sanctions that were not implemented either because they 
were pending as of March 28, 2002, the date of our extract of CMS's 
enforcement database, or because CMS withdrew them after imposition.

[End of table]

Table 12: Federal CMPs Implemented under CMS's Immediate Sanctions 
Policy, January 2000 through March 2002:

State: Alabama; CMP amount: $375,627.50.

State: Alaska; CMP amount: 0.00.

State: Arizona; CMP amount: 350,652.50.

State: Arkansas; CMP amount: 1,571,654.04.

State: California; CMP amount: 1,681,813.50.

State: Colorado; CMP amount: 1,489,100.00.

State: Connecticut; CMP amount: 696,350.00.

State: Delaware; CMP amount: 214,342.50.

State: District of Columbia; CMP amount: 20,000.00.

State: Florida; CMP amount: 1,975,375.00.

State: Georgia; CMP amount: 487,050.00.

State: Hawaii; CMP amount: 20,000.00.

State: Idaho; CMP amount: 37,350.00.

State: Illinois; CMP amount: 2,801,656.50.

State: Indiana; CMP amount: 1,977,685.50.

State: Iowa; CMP amount: 175,945.00.

State: Kansas; CMP amount: 415,400.00.

State: Kentucky; CMP amount: 1,195,177.50.

State: Louisiana; CMP amount: 20,000.00.

State: Maine; CMP amount: 184,920.00.

State: Maryland; CMP amount: 290,270.00.

State: Massachusetts; CMP amount: 1,031,445.00.

State: Michigan; CMP amount: 1,035,815.00.

State: Minnesota; CMP amount: 66,307.50.

State: Mississippi; CMP amount: 186,977.50.

State: Missouri; CMP amount: 467,157.50.

State: Montana; CMP amount: 0.00.

State: Nebraska; CMP amount: 11,207.50.

State: Nevada; CMP amount: 429,500.00.

State: New Hampshire; CMP amount: 93,350.00.

State: New Jersey; CMP amount: 1,543,007.50.

State: New Mexico; CMP amount: 222,430.00.

State: New York; CMP amount: 0.00.

State: North Carolina; CMP amount: 2,171,013.75.

State: North Dakota; CMP amount: 15,730.00.

State: Ohio; CMP amount: 3,104,870.00.

State: Oklahoma; CMP amount: 1,075,036.50.

State: Oregon; CMP amount: 15,225.00.

State: Pennsylvania; CMP amount: 1,250,417.00.

State: Rhode Island; CMP amount: 9,425.00.

State: South Carolina; CMP amount: 29,250.00.

State: South Dakota; CMP amount: 0.00.

State: Tennessee; CMP amount: 381,432.50.

State: Texas; CMP amount: 7,677,219.58.

State: Utah; CMP amount: 37,157.00.

State: Vermont; CMP amount: 11,550.00.

State: Virginia; CMP amount: 934,425.00.

State: Washington; CMP amount: 0.00.

State: West Virginia; CMP amount: 112,160.00.

State: Wisconsin; CMP amount: 901,960.50.

State: Wyoming; CMP amount: 0.00.

State: Total; CMP amount: $38,794,439.37.

Source: CMS enforcement database.

[End of table]

[End of section]

Appendix VII: Cases States Did Not Refer to CMS for Immediate Sanction:

State survey agencies did not refer to CMS for immediate sanction a 
substantial number of nursing homes found to have a pattern of harming 
residents. Most states failed to refer at least some cases and a few 
states did not refer a significant number of cases.[Footnote 74] While 
seven states appropriately referred all cases, the number of cases that 
should have been but were not referred ranged from 1 to 169. Four 
states accounted for about 55 percent of cases that should have been 
referred. Table 13 shows the number of cases that states should have 
but did not refer for immediate sanction (711) as well as the number of 
cases that states appropriately referred (4,310) from January 2000 
through March 2002.

Table 13: Number of Cases States Did Not Refer for Sanction, as 
Required, and the Number States Appropriately Referred, January 2000 
through March 2002:

State: Nation; State: 711; Number of cases referred[A]: 4,310.

State: Texas; State: 169; Number of cases referred[A]: 423.

State: New York; State: 140; Number of cases referred[A]: 22.

State: Massachusetts; State: 46; Number of cases referred[A]: 81.

State: Pennsylvania; State: 38; Number of cases referred[A]: 164.

State: Connecticut; State: 26; Number of cases referred[A]: 244.

State: Washington; State: 26; Number of cases referred[A]: 227.

State: Illinois; State: 24; Number of cases referred[A]: 241.

State: Florida; State: 21; Number of cases referred[A]: 150.

State: New Jersey; State: 20; Number of cases referred[A]: 56.

State: Tennessee; State: 20; Number of cases referred[A]: 46.

State: Minnesota; State: 19; Number of cases referred[A]: 68.

State: Missouri; State: 18; Number of cases referred[A]: 108.

State: South Carolina; State: 18; Number of cases referred[A]: 3.

State: North Carolina; State: 10; Number of cases referred[A]: 242.

State: Arizona; State: 9; Number of cases referred[A]: 24.

State: Maryland; State: 9; Number of cases referred[A]: 34.

State: Wyoming; State: 9; Number of cases referred[A]: 11.

State: California; State: 7; Number of cases referred[A]: 96.

State: Michigan; State: 7; Number of cases referred[A]: 284.

State: Arkansas; State: 6; Number of cases referred[A]: 115.

State: Montana; State: 6; Number of cases referred[A]: 14.

State: Ohio; State: 6; Number of cases referred[A]: 323.

State: Idaho; State: 5; Number of cases referred[A]: 31.

State: Indiana; State: 5; Number of cases referred[A]: 270.

State: Louisiana; State: 5; Number of cases referred[A]: 82.

State: Oklahoma; State: 4; Number of cases referred[A]: 53.

State: West Virginia; State: 4; Number of cases referred[A]: 11.

State: Delaware; State: 3; Number of cases referred[A]: 14.

State: Georgia; State: 3; Number of cases referred[A]: 81.

State: Hawaii; State: 3; Number of cases referred[A]: 1.

State: Iowa; State: 3; Number of cases referred[A]: 44.

State: New Hampshire; State: 3; Number of cases referred[A]: 20.

State: Colorado; State: 2; Number of cases referred[A]: 116.

State: District of Columbia; State: 2; Number of cases referred[A]: 1.

State: Oregon; State: 2; Number of cases referred[A]: 51.

State: Rhode Island; State: 2; Number of cases referred[A]: 3.

State: South Dakota; State: 2; Number of cases referred[A]: 18.

State: Virginia; State: 2; Number of cases referred[A]: 41.

State: Wisconsin; State: 2; Number of cases referred[A]: 61.

State: Alabama; State: 1; Number of cases referred[A]: 50.

State: Kansas; State: 1; Number of cases referred[A]: 175.

State: Maine; State: 1; Number of cases referred[A]: 18.

State: New Mexico; State: 1; Number of cases referred[A]: 19.

State: Nevada; State: 1; Number of cases referred[A]: 12.

State: Alaska; State: 0; Number of cases referred[A]: 0.

State: Kentucky; State: 0; Number of cases referred[A]: 75.

State: Mississippi; State: 0; Number of cases referred[A]: 23.

State: Nebraska; State: 0; Number of cases referred[A]: 30.

State: North Dakota; State: 0; Number of cases referred[A]: 20.

State: Utah; State: 0; Number of cases referred[A]: 11.

State: Vermont; State: 0; Number of cases referred[A]: 3.

Source: CMS regional office review of cases identified through GAO's 
analysis of OSCAR data and the CMS Enforcement Database.

[A] Reflects cases entered in CMS's enforcement database by March 28, 
2002.

[End of table]

[End of section]

Appendix VIII: HCFA State Performance Standards for Fiscal Year 2001:

Table 14 summarizes HCFA's state performance standards for fiscal year 
2001, describes the source of the information CMS used to assess 
compliance with each standard, and identifies the criteria the agency 
used to determine whether states met or did not meet each standard.

Table 14: Overview of HCFA's Seven State Performance Standards for 
Nursing Home Survey Activities for Fiscal Year 2001:

Description: 1. Surveys are planned, scheduled, and conducted in a 
timely manner; 

Description: * At least 10 percent of standard surveys begin on 
weekends or "off-hours"; Source of information: Surveys are planned, 
scheduled, and conducted in a timely manner: OSCAR and state survey 
schedules; Criteria for determining compliance with standard: At least 
10 percent of standard surveys begin on weekends or off-hours.

Description: * Standard surveys are conducted within prescribed time 
limits; Source of information: Surveys are planned, scheduled, and 
conducted in a timely manner: OSCAR; Criteria for determining 
compliance with standard: 100 percent of nursing homes are surveyed 
within statutory time limits.

Description: 2. Survey findings (deficiencies) are supportable; 

Description: * State surveyors explain and properly document all 
deficiencies in survey reports following HCFA guidance known as the 
"principles of documentation"; Source of information: Surveys are 
planned, scheduled, and conducted in a timely manner: A random sample 
of 10 percent (maximum of 40, minimum of 5) of the state's survey 
results in which certain deficiencies were cited at "D" or higher 
levels of scope and severity; Criteria for determining compliance with 
standard: At least 85 percent of the deficiencies reviewed meet the 
principles of documentation.

Description: 3. Surveys are fully documented and consistent with 
applicable laws, regulations, and general instructions.

Description: * Surveys are adequately conducted by state agencies using 
the standards, protocols, forms, methods, procedures, policies, and 
systems specified by HCFA instructions; Source of information: Surveys 
are planned, scheduled, and conducted in a timely manner: Reports 
generated from HCFA's database on federal monitoring surveys; Criteria 
for determining compliance with standard: 100 percent of standard 
surveys are adequately conducted by state agencies using the standards, 
protocols, forms, methods, procedures, policies, and systems specified 
by HCFA instructions.

Description: 4. When states certify that nursing homes are not in 
compliance, they follow adverse action procedures set forth in 
regulations and general instructions.

Description: * "Immediate and Serious Threat" cases are processed in a 
timely manner; Source of information: Surveys are planned, scheduled, 
and conducted in a timely manner: OSCAR, Enforcement Tracking System 
reports, and state agency provider certification files; Criteria for 
determining compliance with standard: In 95 percent of cases in which 
there is immediate jeopardy or a serious threat to resident health and 
safety, the state agency adheres to the 23-day termination process.

Description: * Payments are not made to nursing homes that have not 
achieved substantial compliance within 6 months of their last surveys; 
Source of information: Surveys are planned, scheduled, and conducted in 
a timely manner: OSCAR, Enforcement Tracking System reports, and state 
agency provider certification files; Criteria for determining 
compliance with standard: The state provides timely notice to HCFA 
(i.e., 20 days prior to the home's termination date) on 100 percent of 
the cases in which the nursing home has not achieved timely compliance.

Description: 5. All expenditures and charges to the program are 
substantiated to the Secretary's satisfaction.

Description: * The state agency employs an acceptable process for 
charging federal programs; Source of information: Surveys are planned, 
scheduled, and conducted in a timely manner: HCFA budget expenditure 
and workload reports; Criteria for determining compliance with 
standard: More than 20 different items on the two reports submitted by 
the states are reviewed for accuracy, completeness, and timeliness and 
are scored as either on time or late, or met or not met for a reporting 
period.

Description: * The state agency has an acceptable method for monitoring 
its current rate of expenditures; Source of information: Surveys are 
planned, scheduled, and conducted in a timely manner: OSCAR reports; 
Criteria for determining compliance with standard: Numerous items 
submitted by the states, such as quarterly expenditure reports and 
supplemental budget requests, are reviewed to determine if state 
requirements for monitoring expenditures are met, not met, or not 
applicable.

Description: 6. Conduct and reporting of complaint investigations are 
timely and accurate, and comply with general instructions for handling 
complaints.

Description: * Investigate immediate jeopardy complaints within 2 
workdays; Source of information: Surveys are planned, scheduled, and 
conducted in a timely manner: Semiannual review of a 10 percent sample 
of a state's complaint files; Criteria for determining compliance with 
standard: 100 percent of immediate jeopardy complaints are investigated 
within 2 days.

Description: * Investigate actual harm complaints within 10 workdays; 
Source of information: Surveys are planned, scheduled, and conducted in 
a timely manner: (maximum of 20 cases); Criteria for determining 
compliance with standard: 100 percent of actual harm complaints are 
investigated within 10 days.

Description: * Maintain and follow guidelines for the prioritization of 
all other complaints; Source of information: Surveys are planned, 
scheduled, and conducted in a timely manner: [Empty]; Criteria for 
determining compliance with standard: The state agency has and follows 
its own written criteria governing the prioritization of complaints 
that do not allege immediate jeopardy or actual harm.

Description: * State enters complaint data into OSCAR appropriately and 
in a timely manner; Source of information: Surveys are planned, 
scheduled, and conducted in a timely manner: Semiannual on-site reviews 
of 20 state complaint survey reports; Criteria for determining 
compliance with standard: 100 percent of deficiencies cited in the 
sampled complaints are cited under the correct federal citation.

Source of information: Surveys are planned, scheduled, and conducted in 
a timely manner: DescriptionAccurate data on survey results are entered 
into OSCAR in a timely manner: OSCAR data are reviewed quarterly for 
timely entry; Criteria for determining compliance with standard: 
DescriptionAccurate data on survey results are entered into OSCAR in a 
timely manner: Average time to enter results of complaint 
investigations does not exceed 20 calendar days from completion of the 
case.

Description: 7. Accurate data on survey results are entered into OSCAR 
in a timely manner.

Description: * Results of standard surveys are entered into OSCAR in a 
timely manner; Source of information: Surveys are planned, scheduled, 
and conducted in a timely manner: Semiannual review of all standard 
surveys based on OSCAR data; Criteria for determining compliance with 
standard: The statewide average time between state agency sign-off of 
the certification and transmittal form and entry of the survey results 
into OSCAR does not exceed 20 calendar days.

Description: * Results of surveys are entered into OSCAR accurately; 
Source of information: Surveys are planned, scheduled, and conducted in 
a timely manner: Semiannual review of a random sample of nursing home 
survey results; Criteria for determining compliance with standard: No 
less than 85 percent of cases reviewed demonstrate that data were 
entered into OSCAR accurately.

Source: HCFA's State Performance Review Protocol Guidance for fiscal 
year 2001.

Note: HCFA did not finalize and issue the fiscal 2001 performance 
standards and guidance until April 2001.

[End of table]

[End of section]

Appendix IX: Highlights of State Compliance with CMS Performance 
Standards:

Table 15 summarizes the results of CMS's fiscal year 2001 state 
performance review for each of the five standards we analyzed. We 
focused on five of CMS's seven performance standards: statutory survey 
intervals, the supportability of survey findings, enforcement 
requirements, the adequacy of complaint activities, and OSCAR data 
entry. Because several standards included multiple requirements, the 
table shows the results of each of these specific requirements 
separately.

Table 15: State Compliance with Selected CMS Performance Standards, 
Fiscal Year 2001:

[See PDF for image]

Source: GAO analysis of results of CMS Fiscal Year 2001 State 
Performance Standard Reviews.

Note: We reviewed five of the seven CMS performance standards. See app. 
VIII, table 14, for a description of standards three and five, which we 
did not review.

[End of table]

[End of section]

Appendix X: Comments from the Centers for Medicare & Medcaid Services:

DEPARTMENT OF HEALTH & HUMAN SERVICES 

Centers for Medicare a Medicaid Services:
Administrator 
Washington, DC 20201:

DATE: JUN 20 2003:

TO: Kathryn G. Allen:

Director, Health Care-Medicaid and Private Health Insurance Issues:

FROM: Thomas A. Scully Administrator:

SUBJECT: General Accounting Office (GAO) Draft Report, NURSING HOME 
QUALITY: Prevalence of Serious Problems, While Declining, Reinforces 
Importance of Enhanced Oversight, (GAO-03-561):

Thank you for the opportunity to review your draft report to Congress 
concerning enforcement and oversight of Federal nursing home standards. 
We agree with the report's findings that the Centers for Medicare & 
Medicaid Services should continue to strengthen its ability to make 
sure that nursing homes comply with Medicare and Medicaid quality-of-
care standards.

Attached are our specific comments to the report. We look forward to 
working with GAO on this and other issues in the future.

Attachment:

The Centers for Medicare & Medicaid Comments to GAO's Draft Report, 
NURSING HOME QUALITY. Prevalence of Serious Problems, While Declining, 
Reinforces Importance of Enhanced Oversight, (GAO-03-561):

GAO Recommendation:

Finalize the development, testing, and implementation of a more 
rigorous survey methodology including guidance for surveyors in 
documenting deficiencies at the appropriate level of scope and 
severity.

CMS Response:

We agree and have already taken steps to assist states in improving the 
effectiveness of the survey process. For example, we led a contract to 
develop a series of surveyor guidance on a series of clinical issues. 
Some of the clinical areas that have been identified include pressure 
sores, hydration and nutrition, accidents, unnecessary medications, and 
psychosocial harm. Additionally, we're continuing to refine data used 
by surveyors to help focus resources more effectively during a survey. 
Lastly, we are communicating to states through the Budget Call Letter 
more specific priorities of survey workload to assure that statutorily 
mandated surveys be completed.

GAO Recommendation:

Require States to have a quality assurance process that includes, at a 
minimum, a review of a sample of survey reports below the level of 
actual harm (less than G-level) to assess the appropriateness of the 
scope and severity cited and to help reduce instances of understated 
quality of care problems.

CMS Response:

We believe this to be an important concept and have already 
incorporated this concept into Standard 2 of the State Performance 
Standards. This standard requires regions to take a sample of statement 
of deficiencies to evaluate a state's ability to document deficiencies. 
We will continue to refine this standard to better evaluate the 
sufficiency of documentation of varying harm levels. In addition to 
reviewing the appropriateness of the scope and severity of 
deficiencies, we have completed a number of data analyses to look 
nationally, and by state, at the number of deficiency free facilities 
and those with high and low numbers of deficiencies. We are working on 
a data system (Aspen Enforcement Module) so that we can more easily 
assess these trends in deficiencies.

GAO Recommendation:

Finalize the development of guidance to States for their complaint 
investigation processes and ensure that it addresses key weaknesses, 
including the prioritization of complaints for investigation, 
particularly those alleging harm to resident; the handling of facility 
self-reported incidents; and, the use of appropriate complaint 
investigation practices.

CMS Response:

We concur and are developing and implementing the Aspen Complaints/
Incident Tracking System (ACTS). The ACTS will be a national complaint 
system that will standardize state complaints and incidents so that 
analysis across states can be accomplished. Over time, we expect to 
advance complaint improvement efforts that will not only address 
complaint investigation practices toward improvement, but also the 
prioritization of complaints.

GAO Recommendation:

Further refine annual state performance reviews so that they (1) 
consistently distinguish between systemic problems and less serious 
issues regarding state performance, (2) analyze the trends in the 
proportion of homes that harm residents, (3) assess state compliance 
with the immediate sanctions policy for homes with a pattern of harming 
residents, and (4) analyze the predictability of state surveys.

CMS Response:

We have already modified our FY '03 state performance standards to take 
into account assessing state compliance in a manner that differentiates 
between statutory and non-statutory performance standards. We have 
built in the ability to distinguish between systemic problems and less 
serious issues. We will continue to look at homes with varying levels 
of harm though the work we have done with our Nursing Home Data 
Compendium that is widely available to regions, states, Congress and 
other stakeholders. We are working on a data program to ascertain when 
individual nursing homes have deficiencies that would cause an 
immediate sanction for repeated instances of actual harm.

Regarding predictability of nursing home surveys, the report shows that 
two thirds of nursing home surveys are not predictable using the 
definition established by GAO. There is "predictability" that the law 
requires in that surveys be conducted other than on average of every 
twelve months, not to exceed 15 months. Within the bounds of those 
legal constraints, we have instituted a policy of "off-hour" surveys 
where survey teams conduct surveys either before or after the regular 
starting time, on weekends, evenings, and holidays. We have encouraged 
surveyors to start at a different time of the week, i.e., Wednesday 
instead of Monday. States have changed the way they are doing business. 
The findings in the report only capture the 
number of days from the previous survey and don't take into account 
other predictors of when a survey occurs, for example the time of day 
or day of the week.

In addition to the CMS initiatives mentioned in the report, CMS is also 
working on other initiatives to help in the implementation, evaluation 
and monitoring of the nursing home program.

* Compiling a nursing home data compendium with information on nursing 
home characteristics, resident demographics and quality of care data,

* Evaluating the accuracy of the MDS through the Data Verification and 
Evaluation (DAVE) contract,

* Publishing a proposed rule on Feeding Assistants in nursing homes, 
and:

* Enhancing centralized data monitoring capabilities for use by CMS 
staff, such as the ability to determine where states should refer cases 
for immediate sanctions to states.

[End of section]

Appendix XI: GAO Contact and Staff Acknowledgements:

GAO Contact:

Walter Ochinko, (202) 512-7157:

Acknowledgements:

The following staff made important contributions to this work: Jack 
Brennan, Patricia A. Jones, Dan Lee, Dean Mohs, and Peter Schmidt.

[End of section]

Related GAO Products:

Nursing Homes: Public Reporting of Quality Indicators Has Merit, but 
National Implementation Is Premature. GAO-03-187. Washington, D.C.: 
October 31, 2002.

Nursing Homes: Quality of Care More Related to Staffing than Spending. 
GAO-02-431R. Washington, D.C.: June 13, 2002.

Nursing Homes: More Can Be Done to Protect Residents from Abuse. GAO-
02-312. Washington, D.C.: March 1, 2002.

Nursing Homes: Federal Efforts to Monitor Resident Assessment Data 
Should Complement State Activities. GAO-02-279. Washington, D.C.: 
February 15, 2002.

Nursing Homes: Success of Quality Initiatives Requires Sustained 
Federal and State Commitment. GAO/T-HEHS-00-209. Washington, D.C.: 
September 28, 2000.

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of 
the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: September 
28, 2000.

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would 
Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: November 4, 
1999.

Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies 
to Better Ensure Quality of Care. GAO/T-HEHS-00-27. Washington, D.C.: 
November 4, 1999.

Nursing Home Oversight: Industry Examples Do Not Demonstrate That 
Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington, 
D.C.: August 13, 1999.

Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will 
Require Continued Commitment. GAO/T-HEHS-99-155. Washington, D.C.: 
June 30, 1999.

Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes 
Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999.

Nursing Homes: Complaint Investigation Processes in Maryland. GAO/T-
HEHS-99-146. Washington, D.C.: June 15, 1999.

Nursing Homes: Complaint Investigation Processes Often Inadequate to 
Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.

Nursing Homes: Stronger Complaint and Enforcement Practices Needed to 
Better Ensure Adequate Care. GAO/T-HEHS-99-89. Washington, D.C.: March 
22, 1999.

Nursing Homes: Additional Steps Needed to Strengthen Enforcement of 
Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March 18, 
1999.

California Nursing Homes: Federal and State Oversight Inadequate to 
Protect Residents in Homes with Serious Care Problems. GAO/T-HEHS-98-
219. Washington, D.C.: July 28, 1998.

California Nursing Homes: Care Problems Persist Despite Federal and 
State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998.

FOOTNOTES

[1] See U.S. General Accounting Office, Nursing Homes: Proposal to 
Enhance Oversight of Poorly Performing Homes Has Merit, GAO/HEHS-99-157 
(Washington, D.C.: June 30, 1999).

[2] A list of related GAO products is at the end of this report.

[3] Effective July 1, 2001, HCFA's name changed to the Centers for 
Medicare & Medicaid Services (CMS). In this report we continue to refer 
to HCFA where our findings apply to the organizational structure and 
operations associated with that name. 

[4] The term used in the law and regulations to describe a nursing home 
penalty for noncompliance is "remedy." Throughout this report, we use a 
more common term, "sanction," to refer to such penalties. Sanctions 
include actions such as fines, denial of payment for new admissions, 
and termination from the Medicare and Medicaid programs.

[5] We contacted officials in Alabama, California, Colorado, 
Connecticut, Iowa, Louisiana, Maryland, Michigan, Missouri, Nebraska, 
New York, Oklahoma, Pennsylvania, Tennessee, Washington, and Virginia.

[6] CMS generally interprets these requirements to permit a statewide 
average interval of 12.9 months and a maximum interval of 15.9 months 
for each home.

[7] Quality indicators were the result of a HCFA-funded project at the 
University of Wisconsin. The developers based their work on nursing 
home resident assessment information, known as the minimum data set 
(MDS)--data on each resident that homes are required to report to CMS. 
See Center for Health Systems Research and Analysis, Facility Guide for 
the Nursing Home Quality Indicators (University of Wisconsin-Madison: 
Sept. 1999).

[8] Because resident assessment data are used by CMS and states to 
calculate quality indicators and to determine the level of nursing 
homes' payments for Medicare (and for Medicaid in some states), 
ensuring accuracy at the facility level is critical. We have made 
earlier recommendations to CMS on ways to improve the accuracy of these 
data. See U.S. General Accounting Office, Nursing Homes: Federal 
Efforts to Monitor Resident Assessment Data Should Complement State 
Activities, GAO-02-279 (Washington, D.C.: Feb. 15, 2002). 

[9] http://www.medicare.gov/NHCompare/home.asp. 

[10] U.S. General Accounting Office, Public Reporting of Quality 
Indicators Has Merit, but National Implementation Is Premature, 
GAO-03-187 (Washington, D.C.: Oct. 31, 2002).

[11] States are responsible for enforcing standards in homes with 
Medicaid-only certification--about 14 percent of homes. They may use 
the federal sanctions or rely on their own state licensure authority 
and nursing home sanctions. States are responsible for ensuring that 
homes that have a pattern of harming residents are immediately 
sanctioned.

[12] U. S. General Accounting Office, Nursing Homes: Additional Steps 
Needed to Strengthen Enforcement of Federal Quality Standards, GAO/
HEHS-99-46 (Washington, D.C.: Mar.18, 1999).

[13] States are now required to deny a grace period to homes that are 
assessed one or more deficiencies at the actual harm level or above (G-
L on CMS's scope and severity grid) in each of two successive surveys 
within a survey cycle. A survey cycle is two successive standard 
surveys and any intervening survey, such as a complaint investigation.

[14] We analyzed OSCAR data for surveys performed from January 1, 1999, 
through July 10, 2000, and from July 11, 2000, through January 31, 
2002, and entered into OSCAR as of June 24, 2002. See app. I for our 
complete scope and methodology. Our analysis considered only standard 
surveys. In commenting on a draft of this report, Missouri stated that 
our findings would have shown that quality had remained "fairly stable" 
had we included actual harm and immediate jeopardy deficiencies 
identified during complaint investigations in our analysis in table 2. 
However, we found that both nationally and in Missouri, the proportion 
of homes cited for actual harm or immediate jeopardy showed a similar 
decline even when complaint surveys were considered.

[15] The two earlier time periods we analyzed are for surveys conducted 
from January 1, 1997, through June 30, 1998, and from January 1, 1999, 
through July 10, 2000. See U.S. General Accounting Office, Nursing 
Homes: Sustained Efforts Are Essential to Realize Potential of the 
Quality Initiatives, GAO/HEHS-00-197 (Washington, D.C.: Sept. 28, 
2000).

[16] The proportion of nursing homes in Utah cited with serious 
deficiencies remained the same between the two time periods.

[17] We excluded Alaska, Delaware, the District of Columbia, Hawaii, 
Idaho, Nevada, New Hampshire, New Mexico, North Dakota, Rhode Island, 
Utah, Vermont, and Wyoming from this analysis because fewer than 100 
homes were surveyed and even a small increase or decrease in the number 
of homes with serious deficiencies in such states produces a relatively 
large percentage point change.

[18] U.S. General Accounting Office, Nursing Homes: Enhanced HCFA 
Oversight of State Programs Would Better Ensure Quality, GAO/HEHS-00-6 
(Washington, D.C.: Nov. 4, 1999).

[19] Instructions from the state's CMS regional office suggest, but do 
not require, the use of more than one source of information to support 
a deficiency. 

[20] Officials explained the focus on actual harm or higher-level 
deficiencies by noting that the potential for sanctions increased the 
likelihood that the deficiencies would be challenged by the nursing 
home and perhaps appealed in an administrative hearing. 

[21] As of July 2002, both states had vacant surveyor positions and a 
surveyor hiring freeze.

[22] In commenting on a draft of this report, Arizona disagreed with 
the significance we attribute to survey predictability, questioning 
whether poor homes would, or even could, hide problems if they knew a 
survey was imminent. However, advocates and family members have told us 
that a home that operates with too few staff could temporarily augment 
its staff during the expected period of a survey in order to mask an 
otherwise serious deficiency--a common practice based on advocates' own 
observations. 

[23] We considered surveys to be predictable if (1) homes were surveyed 
within 15 days of the 1-year anniversary of their prior surveys (13 
percent of homes, nationally) or (2) homes were surveyed within 1 month 
of the maximum 15-month interval between standard surveys (21 percent 
of homes, nationally). Because homes know the maximum allowable 
interval between surveys, those whose prior surveys were conducted 14 
or 15 months earlier are aware that they are likely to be surveyed 
soon. 

[24] U.S. General Accounting Office, Nursing Homes: Complaint 
Investigation Processes Often Inadequate to Protect Residents, GAO/
HEHS-99-80 (Washington, D.C.: Mar. 22, 1999).

[25] In some states, the 10-day requirement significantly compressed 
the time frame in which complaints alleging potential actual harm must 
be investigated. For instance, prior to HCFA's change, such complaints 
were supposed to be investigated within 30 days in Michigan and 60 days 
in Tennessee. 

[26] Staff from each of CMS's regional offices reviewed a 10 percent 
random sample of complaint files (maximum of 40 files) in each state. 

[27] According to a state official, a hiring freeze precluded 
increasing the number of surveyors. 

[28] Because CMS based its analysis of timeliness only on nursing homes 
that actually were surveyed during fiscal year 2001--and not on all 
homes in the state--the 9 percent figure is understated. Our analysis 
of all homes indicated that about 12 percent of the state's homes were 
not surveyed within the required time frame. 

[29] Center for Health Systems Research and Analysis at the University 
of Wisconsin, Madison, Final Report: Complaint Improvement Project, 
prepared for CMS, June 3, 2002. The report is based on a questionnaire 
sent to the 50 states, the District of Columbia, Puerto Rico, and CMS's 
10 regional offices. Three states did not respond to the questionnaire. 
The report treated the District of Columbia and Puerto Rico as states. 

[30] See GAO/HEHS-99-80 and U.S. General Accounting Office, Medicare 
Home Health Agencies: Weaknesses in Federal and State Oversight Mask 
Potential Quality Issues, GAO-02-382 (Washington, D.C.: July 19, 2002).

[31] Using CMS data, we identified 1,334 cases that appeared to meet 
the criteria for immediate sanctions but that did not appear to have 
been referred to CMS by states. (See app. I for a description of our 
methodology.) We use the term "cases" rather than "nursing homes" 
because some nursing homes had multiple referrals for immediate 
sanctions. At our request, CMS reviewed most of these cases and 
determined that 711 (62 percent of those CMS reviewed) should have 
been--but were not--referred for immediate sanction. CMS did not 
analyze 155 of the cases we asked it to examine and was unable to 
determine the status of an additional 30 cases. 

[32] See GAO/HEHS-99-46.

[33] This policy was implemented in two stages, and our analysis 
focused on implementation of the second stage in January 2000. 
Beginning in September 1998, HCFA required states to refer homes that 
had a pattern of harming a significant number of residents or placed 
residents at high risk of death or serious injury (H-level deficiencies 
and above on CMS's scope and severity grid). Effective January 14, 
2000, HCFA expanded this policy by requiring state survey agencies to 
refer for immediate sanction homes that had harmed residents--G-level 
deficiencies on the agency's scope and severity grid--on successive 
surveys. States are now required to deny a grace period to homes that 
are assessed one or more deficiencies at the actual harm level or above 
(G-L on CMS's scope and severity grid) in each of two surveys within a 
survey cycle. A survey cycle is two successive standard surveys and any 
intervening survey, such as a complaint investigation.

[34] We found that states did refer 4,310 cases over a 27-month period. 
See app. VI for a summary of all sanctions that were implemented, 
including the amount of civil money penalties (CMPs) by state.

[35] Arizona's comments on a draft of this report indicated that eight 
of the nine cases not referred for immediate sanction were during the 
period January through October 2000 when the state was struggling with 
various interpretations of CMS's new requirement. Similarly, Missouri 
officials indicated in their comments that the majority of cases they 
did not refer occurred during the initial stages of the new policy, 
which Missouri believes was "complicated, at best." Missouri officials 
added that the number of missed cases significantly declined as the 
state gained a better understanding of the policy. 

[36] This New York state official told us that the state believed it 
was in compliance with CMS's policy because it imposed one of two minor 
federal sanctions and a state civil money penalty on all consecutive G-
level cases. This state official also indicated that state fines were 
imposed in place of federal civil money penalties in all cases. (The 
maximum state fine is $2,000 per violation, lower than the federal 
maximum of $10,000 per instance or per day of noncompliance.) However, 
when we discussed this explanation with officials in the CMS central 
office, they disagreed that the state was in compliance.

[37] In commenting on a draft of our report, New York officials 
indicated that their initial failure to refer nursing homes for 
immediate sanctions was based on their misinterpretation of the new 
policy and not on a deliberate refusal to implement it. They also 
indicated that their procedures are now consistent with the federal 
policy.

[38] The CMS regions assessed each state's performance by (1) reviewing 
a set of standardized reports drawn from information contained in CMS's 
databases and (2) visiting states to review procedures and to examine a 
sample of records, such as complaint investigation files. Some reviews, 
such as assessing state complaint investigation timeliness, were 
performed semiannually, enabling regional office staff to provide 
midpoint feedback intended to correct any deficiencies identified. 

[39] GAO/HEHS-00-6.

[40] According to CMS regional officials, California state law requires 
that all complaints other than those alleging immediate jeopardy be 
investigated within 10 days, irrespective of the seriousness of the 
allegation. 

[41] CMS's database showed that Oregon conducted only 14 on-site 
complaint investigations during fiscal year 2001. Because of this low 
number, the region reviewed the entire universe of complaints (instead 
of a sample), but did not identify the number reviewed in its report.

[42] CMS's criteria for evaluating the documentation standard in 2002 
are (1) the proper regulation is cited for each deficiency, (2) 
evidence supports the cited area of noncompliance, (3) several 
components required by the relevant regulation for each deficiency, 
such as identifying the citation number, are included, (4) the 
deficient practice is identified, (5) the cited severity of each 
deficiency is accurate, (6) the cited scope of each deficiency is 
accurate, and (7) the sources and identifiers in the deficient practice 
statement match the sources and identifiers in the findings.

[43] While cases referred by states were typically recorded in CMS's 
enforcement database, a New York regional official indicated that 
because of the departure of key staff members, the region had not 
entered all cases into the database.

[44] CMS's central office and the regions have jointly produced the 
reports since they were created in 2000. As CMS's systems become more 
user-friendly, the regions will be able to produce them independently.

[45] As we reported previously, although HCFA standards require states 
to report information about complaints, the process for collecting it 
results in inaccurate and incomplete information. For example, the form 
CMS requires states to use to record the results of complaint 
investigations was created to record information about a single 
complaint, but many states investigate multiple complaints at a nursing 
home during one on-site visit. As a result, the timeliness, 
prioritization, and other important tracking information related to 
multiple complaints is reported as though it applies to one complaint. 
See GAO/HEHS-99-80.

[46] CMS planned to implement the new system, known as the ASPEN 
Complaint Tracking System, or ACTS, nationwide in October 2002. 
However, implementation was delayed because of several issues that 
surfaced during pilot testing: (1) states have different policies 
regarding the treatment of self-reported facility incidents, (2) 
complaints filed with some states may be investigated by entities other 
than the state survey agency (for instance, the Board of Nursing), and 
(3) 8 to 10 states have indicated that their current state complaint 
tracking systems have superior capability to ACTS and they do not wish 
to discontinue using their own system or maintain separate systems. CMS 
plans to evaluate this last issue during the extended pilot test. As of 
July 2003, nationwide implementation had been further delayed by the 
need to obtain approval from the Office of Management and Budget for 
publication of a notice in the Federal Register, a procedure that 
applies to establishing a system of federal records. 

[47] GAO/HEHS-99-46.

[48] Until recently, states had to manually enter data into a 
computerized system that generated survey reports and then manually 
reenter much of the same data into OSCAR. This duplicative data entry 
process increased the chances for errors in OSCAR. 

[49] Quality indicators are derived from nursing homes' assessments of 
residents and rank a facility in 24 areas compared with other nursing 
homes in a state. By using the quality indicators to select a 
preliminary sample of residents before the on-site review, surveyors 
are better prepared to identify potential care problems.

[50] The agency is committed to implementing only those portions of the 
new methodology that are proven to be significantly more effective than 
the current survey methodology. CMS officials said the new process must 
be manageable and easy to use, add no additional time to surveys, and 
require limited additional training resources. Given the high turnover 
among surveyors and state budget constraints, the agency is 
particularly concerned about imposing new training requirements that 
would interfere with the conduct of mandatory surveys.

[51] A minimum of three residents would be included in the sample for 
each of the care problems identified in phase one, which covers as many 
as 33-35 resident-care areas.

[52] The goals of the new survey methodology are to (1) ensure that all 
areas of care are addressed, (2) make the survey process more data-
driven and less reliant on surveyor judgment, thus reducing variability 
in the citation of serious deficiencies, (3) focus surveyors' attention 
more on nursing homes with poor quality and less on better performing 
homes, (4) more reliably determine the scope of deficiencies at nursing 
homes, that is, the number of residents potentially or actually 
affected, and (5) produce better documented and defensible survey 
deficiencies. 

[53] As of July 2003, the guidance had not yet been released.

[54] States that commented included Alabama, Arizona, California, 
Connecticut, Iowa, Missouri, Nebraska, New York, Pennsylvania, 
Tennessee, and Virginia.

[55] Our draft report discussed the problems CMS encountered in 
developing this guidance and pointed out that the guidance on the first 
clinical issue to be addressed, pressure sores, was expected in early 
2003. As of July 2003, the guidance had not yet been released. 

[56] CMS guidance to states in the Medicare State Operations Manual 
defines actual harm as "noncompliance that results in a negative 
outcome that has compromised the resident's ability to maintain and/or 
reach his/her highest practicable physical, mental and psychosocial 
well-being as defined by an accurate and comprehensive resident 
assessment, plan of care, and provision of services. This does not 
include a deficient practice that only could or has caused limited 
consequence to the resident." 

[57] Stages of pressure sore formation are I--skin of involved area is 
reddened; II--upper layer of skin is involved and blistered or abraded; 
III--skin has an open sore and involves all layers of skin down to 
underlying connective tissue; and IV--tissue surrounding the sore has 
died and may extend to muscle and bone and involve infection.

[58] Nursing homes can appeal civil money penalties imposed by CMS when 
they are found to have serious deficiencies. The appeals are decided by 
the Department of Health and Human Service's Departmental Appeals 
Board. 

[59] U.S. General Accounting Office, California Nursing Homes: Care 
Problems Persist Despite Federal and State Oversight, GAO/HEHS-98-202 
(Washington, D.C.: July 27, 1998).

[60] We contacted 10 states that were included in our review and that 
had a significant percentage of predictable surveys--Alabama, 
California, Connecticut, Maryland, Nebraska, New York, Oklahoma, 
Tennessee, Virginia, and Washington. As shown in table 10 (see app. V), 
the proportion of predictable surveys in these states ranged from 29 
percent to 83 percent.

[61] See GAO/HEHS-00-197.

[62] We considered surveys to be predictable if (1) homes were surveyed 
within 15 days of the 1-year anniversary of their prior surveys or (2) 
homes were surveyed within 1 month of the maximum 15-month interval 
between standard surveys. 

[63] GAO/HEHS-00-197.

[64] The 14 states are Alabama, Arizona, California, Iowa, Maryland, 
Minnesota, Mississippi, Missouri, Nebraska, Pennsylvania, South 
Carolina, Virginia, West Virginia, and Wisconsin.

[65] See GAO/HEHS-00-197.

[66] One of the comparative surveys in our updated analysis was 
completed in May 2000.

[67] We contacted officials in Alabama, California, Colorado, 
Connecticut, Iowa, Louisiana, Maryland, Michigan, Missouri, Nebraska, 
New York, Oklahoma, Pennsylvania, Tennessee, Washington, and Virginia.

[68] Center for Health Systems Research and Analysis at the University 
of Wisconsin, Madison.

[69] CMS determined that for 438 of the 1,334 cases we asked it to 
examine, the state had indeed made a referral to CMS. In some of these 
438 instances, there was no corresponding case in the enforcement 
database because OSCAR had a different survey date. The "survey date" 
variable in OSCAR is the latter of the health survey date and the life-
safety code survey, while the corresponding date in the enforcement 
database is usually the health survey date. For others, an enforcement 
case was already open for the home at the time of the referral, and CMS 
officials did not open an additional case. There was also a small 
number of cases where the state agency referred the home for immediate 
sanction, and CMS chose not to accept the state's recommendation. 
States failed to refer 711 cases that met CMS criteria for immediate 
referral. In addition, CMS did not analyze 155 other cases and was 
unable to determine the status of 30 cases.

[70] The proportion of nursing homes in Utah cited with serious 
deficiencies remained the same between the two time periods.

[71] GAO/HEHS-00-197.

[72] According to OSCAR data, 99 surveys in the 14 states conducted on 
or after July 2000 documented a D-or E-level deficiency in at least one 
of the quality-of-care requirements we selected. We reviewed all such 
deficiencies in surveys from 13 states but randomly selected 22 of the 
45 California surveys. The 14 states are Alabama, Arizona, California, 
Iowa, Maryland, Minnesota, Mississippi, Missouri, Nebraska, 
Pennsylvania, South Carolina, Virginia, West Virginia, and Wisconsin.

[73] We use the term "cases" because some homes had multiple referrals 
for immediate sanctions.

[74] We use the term "cases" because some homes had multiple referrals 
for immediate sanctions.

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