Department of Health and Human Services 
OFFICE  OF 
INSPECTOR  GENERAL 
STATE PROGRESS  IN CARRYING  OUT 
THE  NURSING  HOME  SURVEY  REFORMS 
MAY  1993  -1 
_  OFFICE OF INSPE~OR  GENERAL 
The  mission of the  Office of Inspector  General  (OIG),  as mandated  by Public  Law 95-452, as 
amended,  is to protect  the  integrity  of the  Department  of Health  and Human  Services (HHS) 
programs  as well as the  health  and welfare  of beneficiaries  served by those  programs.  This 
statutory  mission  is carried  out  through  a nationwide  network  of audits,  investigations,  and 
inspections  conducted  by three  OIG  operating  components:  the  Office of Audit  Services,  the 
Office of Investigations,  and the  Office of Evaluation  and Inspections.  The  OIG also informs 
the  Secretary  of HHS  of program  and management  problems  and recommends  courses  to 
correct  them. 
OFFICE OF AUDIT  SERVICES 
The  OIGS  Office of Audit  Services  (OAS)  provides  all auditing  services for HHS,  either  by 
conducting  audits with its own audit resources  or by overseeing  audit work  done  by others. 
Audits  examine  the  performance  of HHS  programs  and/or  its grantees  and contractors  in 
carrying out  their  respective  responsibilities  and are intended  to provide  independent 
assessments  of HHS  programs  and operations  in order  to reduce  waste,  abuse,  and 
mismanagement  and to promote  economy  and efficiency throughout  the  Department. 
OFFICE OF INVESTIGATIONS 
The  OIGS  Office of Investigations  (01)  conducts  criminal,  civil, and administrative 
investigations  of allegations  of wrongdoing  in HHS  programs  or to HHS  beneficiaries  and of 
unjust  enrichment  by providers.  The  investigative  efforts  of 01  lead to criminal  convictions, 
administrative  sanctions,  or civil money  penalties.  The  01  also oversees  State  Medicaid  fraud 
control  units which investigate  and prosecute  fraud  and patient  abuse  in the  Medicaid  program. 
OFFICE OF EVALUATION  AND  INSPECHONS 
The  OIGS Office of Evaluation  and Inspections  (OEI)  conducts  short-term  management  and 
program  evaluations  (called inspections)  that  focus on issues of concern  to the Department, 
the  Congress,  and the  public.  The  findings and recommendations  contained  in these  inspection 
reports  generate  rapid,  accurate,  and up-to-date  information  on the efficiency, vulnerability, 
and effectiveness  of departmental  programs. 
This report  was prepared  under  the direction  of Mark  R. Yessian,  Ph.D.,  Regional  Inspector 
General,  and Martha  B. Kvaal, Deputy  Regional  Inspector  General,  Boston  Region,  Office of 
Evaluation  and Inspections.  Participating  in this project  were  the following  people: 
Boston  Headquarters 
Russell  W. Hereford,  Ph.D.,  Project Leader  Cathaleen  A. Ahern 
Joyce M. Greenleaf,  Lead AnaZyst  Linda  M. Moscoe  Depatiment  of Health and Human Setices 
OFFICE  OF 
INSPECTOR  GENERAL 
STATE PROGRESS  IN CARRYING  OUT 
THE  NURSING  HOME  SURVEY REFORMS 
my  1993  OEI-01-91415W   EXECUTIVE  SUMMARY 
PURPOSE 
To  assess  States  progress  in  carrying  out  their  Medicare/Medicaid  nursing  home 
survey responsibilities  under  the  1987 Nursing  Home  Reform  Law. 
BACKGROUND 
The  1987 nursing  home  reforms  marked  a major  shift in how States  monitor  nursing 
home  quality.  Prior  to implementing  those  reforms  in October  1990, State  surveys  of 
homes  receiving  Medicare  or Medicaid  stressed  reviewing  processes  and  records  to 
document  compliance  with Federal  standards.  Now the  process-focussed  record 
review  has taken  a back  seat  to observing  how well the  staff  meet  individual  resident 
needs  and  how well the  homes  structure  supports  resident  well-being.  This  shift 
reflects  the  recommendations  called  for in the  Institute  of Medicines  1986 study, 
Improving the Quality ofCare in Nuning Homes. 
In this report,  we examine  the  States  progress  in carrying  out  their  survey 
responsibilities.  By survey responsibilities,  we mean  conducting  the  certification 
surveys, responding  to  complaints,  and  carrying  out  the  follow-up  activities  these  two 
entail,  such  as extended  surveys.  We  sought  information  from  the  top  20 States 
ranked  by number  of nursing  home  beds  and  draw  on interviews  with  18 State  survey 
agency  officials  and  data  from  19 of those  top  20 States.  The  19 States  contain  73 
percent  of the  nursing  home  beds  in the  country;  the  18, 70 percent.  We  interviewed 
nursing  home  surveyors  and  supefisors  in two States.  We  also draw  on information 
from  the  Health  Care  Financing  Administrations  (HCFA)  central  and  regional  office 
staff and  discussions  with national  groups  representing  nursing  homes  and  residents. 
FINDINGS 
The 19 SkZes are mukikgpmgress  h  canyikg out t.heii new numikg home swvey 
responsibilitks  cakki  fw  in the 1987 N&g  Home  Rejonn  Law. 
Resources  for nursing  home  survey and  certification  increased  from  FY  1990 to 

1992.  The  budgets  increased  in each  of the  19 States;  staff increased  in  16 of 
the  19 States  and  decreased  in 3.  The  average  budget  increase  was 59 percent, 
and  the  average  staff increase,  37 percent. 
State  survey  agencies  are  overseeing  nursing  homes  with  the  new, outcome-

focussed  survey process.  They  are  also taking  steps  to implement  a new, more 
flexible  survey  cycle, which  allows them  to concentrate  on problem  homes. 
Seventeen  of the  19 States  are  conducting  the  standard  certification  surveys on 

time. 
i  Despite  their pmgrq  the 19 States are facing hpkmmta  tion problem  that couki 
jeoe    theintentofthe  nlushghome  refoms. 
State  survey  staff  are  experiencing  problems  adjusting  to the  new outcome-
 
focussed  survey.  While  sumeyor  training  has helped,  both  HCFA  regional  staff 
and  State  officials  expressed  concerns  about  that  training. 
State  survey agencies  contend  with  staff turnover  and  recruitment  problems  that 
 
are  compounded  by their  own State  fiscal pressures.  At the  time  they 
responded  to our  survey, the  19 States  reported  over  700 vacancies  among 
about  3,800 survey and  support  staff in FY  1992. 
State  survey agencies  relationships  with nursing  homes  are  increasingly 
 
contentious  as the  reforms  provide  new incentives  for nursing  homes  to refute 
deficiencies.  This  can  result  in surveyors  citing fewer  or less serious 
deficiencies. 
The  State  survey  and  HCFA  regional  officials  expressed  concerns  over  long 
 
waits  for HCFA  regulations  and,  to a lesser  extent,  over  unclear  and 
inconsistent  guidance  from  HCFA.  This  can  result  in confusion  and 
inconsistent  implementation. 
VhherabiMies  in both musing honws and other State-surveyed health fadiies  could be 
kxming  as States fixus  on the impkmen@tion  chalknges  of the refoms. 
Complaints  about  nursing  homes  increased  for  15 and  decreased  for  3 of the  18 
b 
responding  States  from  FY  1990 to  1992.  The  average  increase  was 74 percent. 
Some  State  survey officials  are  concerned  about  their  ability  to respond  to 
complaints  quickly  and  effectively. 
Some  State  survey  officials report  curtailing,  delaying,  and/or  omitting  surveys 
 
for facilities  such  as home  health  agencies,  hospices,  and  hospitals. 
CONCLUSION 
Nursing  home  and  resident  advocates  alike welcomed  the  nursing  home  reforms  of 
1987 as a positive  step  in improving  the  lives of nursing  home  residents.  And  the 
intent  of the  reforms  is beginning  to be  realized.  The  HCFA  has  an important  role  to 
play in fostering  continued  progress  in the  implementation  of these  reforms.  Toward 
this end,  it has  opportunities  in three  areas.  First,  it could  invigorate  its surveyor 
training  program  to  enhance  surveyor  skills.  Second,  it could  use  its annual  evaluation 
of each  State  agencys contract  compliance  to identify  areas  of weak  performance,  and 
then  take  action  to prevent  problems  before  they  present  any danger  to users  of State-
surveyed  health  facilities.  Finally,  HCFA  has  opportunities  to improve  its guidance  to 
States  by quickly issuing final regulations  and  ensuring  the  State  Operations  Manual 
reflects  current  HCFA  policy. 
ii  TABLE  OF  CONTENTS 
EXECUTIW  SUMMARY 
mODU~ON  . . . . . . . . . . . . . . . . . . . . ..=.  ~. . . . . ..  ooococsoooooo  1 
mugs  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  O. . . ..  OOOOOO0000000  3 
 
Implementation  Progress  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3 
 
Implementation  Problems  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 
 
Looming  Vulnerabilities  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8 
b 
mN~USION  . . . . . . . . . . . . . . . ...=  . . ..=.  .=~.  .*  O*OOOOOOOOOOOO1OO1O 
APPENDICES 
k  Methodology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  ==soooooooooo  D A-1 
B:Notes  . . . . . . . . . . . . . . . . . .=.......  . . . ..=  OOOOOS=SOOOOOOO  B-1 
 
... 
111   INTRODUCTION 
PURPOSE 
To  assess  States  progress  in carrying  out  their  Medicare/Medicaid  nursing  home 
survey responsibilities  under  the  1987 Nursing  Home  Reform  Law. 
BACKGROUND 
The  1987 nursing  home  reformsl  marked  a major  shift in how States  monitor  nursing 
home  quality.  Prior  to implementing  those  reforms  in October  1990, State  surveys  of 
homes  receiving  Medicare  or Medicaid  funds  stressed  reviewing  processes  and  records 
to document  compliance  with  Federal  standards.  Now the  process-focussed  record 
review  has  taken  a back  seat  to outcomes, observing  how well the  staff meet  individual 
resident  needs  and  how well the  homes  structure  supports  resident  well-being.  This 
shift reflects  the  recommendations  called  for in the  Institute  of Medicines  (IOM)  1986 
study, Improving the Quality of Care in Nuning Homes. 
The  1987 reforms  addressed  the  problems  the  IOM  identified  with the  previous 
nursing  home  inspection  process.  That  process  included  an annual  survey,  an  annual 
inspection  of the  care  provided  to each  Medicaid  recipient  (both  utilization  review  and 
quality  of care),  and  the  ad hoc  investigation  of complaints.  Among  the  problems 
IOM  identified  with that  process  were  its predictability,  insensitivity  to resident  needs, 
focus  on paper  compliance,  and  the  ease  with which  substandard  homes  could  avoid 
termination  by maintaining  compliance  only long enough  to become  recertified. 
The  reforms  addressed  the  surveys predictability  by eliminating  nursing  homes  time-
limited  agreements  (TLAs)2,  so that  the  survey schedule  could  be more  flexible.  Now 
surveys must  occur  at least  every  15 months,  with  a statewide  average  of 12 months. 
The  reforms  also called  for surveyors  to focus  on outcomes,  by determining  how well 
nursing  home  residents  are  achieving  their  highest  practicable  physical,  mental  and 
psychosocial  well-being.3  That  new focus  addresses  IOMS concerns  not  only about 
insensitivity  to resident  needs  but  also paper  compliance  because  surveyors  are  now 
required  to observe  residents,  not  simply ensure  the  proper  documentation  of their 
records.  And  the  reforms  called  for a range  of intermediate  sanctions  to deter 
violations  and  support  sustained  compliance. 
About  90 percent  of all nursing  homes  participate  in Medicare  and  Medicaid.4  To 
participate  in those  programs,  the  homes  must  meet  new Federal  standards  called  for 
in the  reforms.  The  Health  Care  Financing  Administration  (HCFA)  contracts  with 
State  governments  (i.e., survey agencies)  to inspect  the  quality  of care  each  home 
provides  and  ensure  those  standards  are  met.  These  State  sumey  agencies  not  only 
conduct  certification  surveys but  also investigate  complaints  and  license  nursing 
homes.5  And  they  oversee  other  health  care  facilities,  such as laboratories,  hospices, 
home  health  agencies,  and  hospitals. 
1  The  HCFA  details  the  procedures  for each  of the  seven  standard  survey  tasks  in its 
State  Operations  Manual.  The  tasks  are:  (l)off-site  preparation,  (2) entrance 
conference  and  on-site  preparation,  (3) orientation  tour,  (4) resident  sampling, 
(5) information  gathering,  (6) information  analysis  and  decision  making,  and  (7) exit 
conference. 
If the  survey team  finds the  home  meets  the  standards,  then  the  State  certifies  that 
home  to participate  in Medicare  and/or  Medicaid.  If certain  standards  are  not  met, 
the  home  can  still be  certified  but  has to correct  its deficiencies  through  a written  plan 
of correction.  Based  on deficiencies,  the  teams  can  also  conduct  extended  surveys to 
focus  on the  homes  underlying  policies  and  procedures  that  allow the  deficiencies  to 
exist.h 
The  survey  agencies  must  take  more  drastic  actions  if deficiencies  threaten  the  health 
or safety  of residents.  The  1987 reforms  require  a range  of enforcement  remedies 
including  payment  denial,  civil monetary  penalties,  temporary  management,  and 
termination  from  Medicare  and  Medicaid.  They  require  criteria  for  enforcement  that 
specify how and  when  the  remedies  be  applied  based  on a deficiencys  scope  and 
severity,  speci&  the  amount  of fines, minimize  the  time  between  the  deficiency  and 
remedy,  and  provide  for more  severe  remedies  for repeat  deficiencies. 
Thus,  these  nursing  home  reforms  mandated  major  changes  in how States  will ensure 
that  the  nursing  homes  where  thousands  of Americans  live meet  Federal  standards.  In 
addition,  the  Clinical  Laboratory  Improvement  Act  (CLIA)  of 19907 also placed  new 
burdens  on State  survey agencies.  Given  these  changes  plus the  fiscal stress  many 
States  are  operating  under,  State  survey  agencies  are  facing  many  challenges  in 
implementing  the  reforms. 
More  than  two years  have  passed  since  the  implementation  of the  reforms.  The 
reduced  use  of physical  and  chemical  restraints  on nursing  home  residents  is often 
cited  as one  positive  and  tangible  outcome  of the  reforms  to date.  In this report,  we 
examine  the  State  survey agencies  progress  in carrying  out  the  reforms  in their  survey 
responsibilities.  By survey responsibilities,  we mean  conducting  the  certification 
surveys,  responding  to complaints,  and  carrying  out  the  follow-up  activities  these  two 
entail,  such  as extended  surveys.  We  sought  information  from  the  top  20 States 
ranked  by number  of nursing  home  beds  and  draw  on interviews  with  18 State  survey 
agency  officials  and  data  from  19 of those  top  20 States.  The  19 States  contain  73 
percent  of the  nursing  home  beds  in the  country,  the  18, 70 percent.  We  interviewed 
nursing  home  sumeyors  and  supervisors  in two States.  We  also draw  on information 
from  the  Health  Care  Financing  Administrations  central  and  regional  office  staff and 
discussions  with  national  groups  representing  nursing  homes  and  residents.  (Refer  to 
appendix  A for more  detail  on our  methodology.) 
We  conducted  our  review  in accordance  with the  Quality Standards for Inspections 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
2  FINDINGS 
Tke 19 Staiks are makhgpmgress  in c*g  out theih new raunhg  how  -q 
ruponsibiliiies  called for h  the 1987 N&g  Home  Refimn  LAW. 
Resources  for nursing  home  survey  and  certification  increased  from  FY  1990 to 
 
1992.  The  budgets  increased  in each  of the  19 States;  staff increased  in 16 of 
the  19 States  and  staff decreased  in 3.  The  average  budget  increase  was 59 
percent,  and  the  average  staff increase,  37 percent. 
State  survey  agencies  are  overseeing  nursing  homes  with the  new, outcome-
 
focussed  survey process.  They  are  also taking  steps  to implement  a new, more 
flexible  survey  cycle, which  allows them  to concentrate  on problem  homes. 
Seventeen  of the  19 States  have  conducted  the  standard  certification  surveys on 
 
time. 
The  Medicare  and  Medicaid  nursing  home  survey and  certification  budgets  for the  19 
States  and  increased  from  $96,737,360  in FY  1990 to $152,823,544  in FY  1992.8  The 
increases  ranged  from  a low of 10 percent  to a high of 128 percent.  The  median  was 
55 percent.  In most  States,  both  the  Medicare  and  Medicaid  budgets  increased:  in 16 
States  Medicare  budgets  increased  62 percent  on average,  and  in  17 States  Medicaid 
budgets  increased  99 percent  on average. 9  The  overall  nursing  home  survey  and 
certification  budgets  increased  even  in those  States  that  experienced  a decrease  in 
either  Medicare  (three  States)  or Medicaid  (two States)  from  FY  1990 to  1992. 
The  19 States  that  responded  to our  survey reported  having  1,923 full-time  equivalent 
(FTE)  surveyors  conducting  nursing  home  surveys in FY  1990, most  of them  registered 
nurses.  By FY  1992, that  number  increased  35 percent  to 2,587, still mostly  registered 
nurses.  Likewise,  the  number  of support  staff, such as supervisors  and  clerks, 
increased  23 percent  between  FY  1990 and  1992.  Overall,  the  staff  (survey  and 
support  staff)  increases  ranged  from  a low of 2 percent  to a high of 128 percent  for 
the  16 States  that  had  an increase;  the  median  was 31 percent. 
These  increases  reflect  the  survey agencies  increased  workload  under  the  nursing 
home  reforms.  The  majority  of the  State  survey officials  responding  to our  inquiry 
reported  that  each  of survey tasks we asked  about  took  longer  than  before  the 
reforms;  no one  said they  took  less.  The  tasks we asked  about  are:  conducting  the 
surveys  on-site,  preparing  the  survey paperwork  before the  survey, preparing  the  survey 
paperwork  after the  survey, conducting  enforcement  activities,  and  responding  to 
complaints.  Extended  and  partial  extended  surveys, begun  since  the  reforms,  also add 
to the  workload.  Prior  to implementing  them,  HCFA  estimated  that  the  reforms 
would  increase  survey workload  by a minimum  of 40 percent  for  a standard  survey to 
as much  as 64 percent  when  an extended  survey is needed.*O 
3  In our  discussions  with  them,  the  State  survey officials indicated  they were 
implementing  the  new flexible  survey cycle as called  for in the  reforms.ll  Some 
reported  they will rely on a homes  compliance  history,  complaints,  and/or  turnover 
among  key staff to select  homes  for more  frequent  surveys.  Some  also reported 
expecting  this change  to reduce  some  of the  paperwork  burden  of the  survey  process. 
Before  States  began  implementing  this new survey cycle, HCFA  required  them  to 
complete  the  standard  recertification  surveys before  the  12-month  agreements  expired. 
With  few exceptions,  the  States  reported  meeting  those  deadlines.12  And  HCFAS 
evaluation  of the  States  timely  conduct  of the  surveys also shows that,  for the  most 
part,  States  were  up-to-date  in completing  those  surveys.13 
Despite  thdpqgr~  the 19 StaUX are facing impkmen@tim  pmbkms  that COW 
jeopadzze9  theiilk?ntofth  e?umhghomer~m. 
State  sumey  staff  are  experiencing  problems  adjusting  to the  new outcome-
	
focussed  survey.  While  surveyor  training  has  helped,  both  HCFA  regional  staff 
and  State  officials  expressed  concerns  about  that  training. 
The  new survey process  represents  a major  culture  change  for many  surveyors.14 
They  now look  to see if the  care  provided  by nursing  homes  allows the  residents  to 
achieve  their  highest  practicable  level  of physical,  mental,  and  psychosocial  well-
being.  This  attention  to resident  outcomes  is a long way from  the  prior  focus  on a 
homes  capacity  to meet  Federal  standards.  Indeed,  the  focus  on outcomes  calls for 
developing  new investigatory  skills and  enhancing  skills many  surveyors  already  have, 
such as interviewing  and  observation. 
A recent  study  involved  the  review  of a random  sample  of 359 deficiency  statements 
from  21 States.15  Deficiency  statements  are  the  paperwork,  using specific  HCFA 
forms,  that  surveyors  prepare  to document  deficiencies  they  find during  the  survey. 
That  study raises  questions  about  the  extent  to which  surveyors  writing  those 
statements  have  adjusted  to the  new outcome  focus:  45 percent  of the  deficiency 
statements  failed  to consider  either  actual  or potential  negative  outcomes.  When 
those  deficiencies  related  more  to a homes  structure  than  to a residents  outcome 
were  excluded,  43 percent  still failed  to consider  actual  or potential  outcome.lG 
Teaching  hundreds  of surveyors  not  only to shift their  focus  to outcomes  and  learn 
new skills but  also become  familiar  with a barrage  of new  survey forms  and  processes 
is a daunting  task.  The  HCFA  undertook  this task  through  training  manuals  and 
courses  in Baltimore  and  the  regions.  In some  respects,  this training  has been  helpful 
and  well-regarded;  however,  many with whom  we spoke  expressed  some  serious 
concerns  about  the  content  and  availability  of the  training. 
Most  of the  State  survey  officials rated  HCFAS training  highly:  14 of the  18 who 
answered  the  question  said the  training  was moderately  or significantly  helpful.  They 
cited  a range  of activities  for which  the  surveyors  had  received  training,  from 
conducting  the  standard  and  extended  surveys, to completing  the  forms  and  using 
4  computers.  Many  praised  the Principles  of Documentation  manual  and  course,  which 
provide  guidance  on the  proper  documentation  for deficiencies.  That  course 
addresses  the  types  of concerns  raised  in the  above-noted  study on deficiency 
statements. 
Officials  from  HCFA  regional  offices, State  survey agencies,  and  national  groups 
representing  nursing  homes  and  residents  expressed  concerns  about  the  content  of the 
training.  Both  HCFA  and  State  officials mentioned  the  lack  of training  in 
investigatory  skills; one  also mentioned  the  lack  of training  aimed  at the  needs  of 
more  experienced  surveyors  who  account  for as much  as 75 percent  of all 
surveyors.*7  Some  questioned  whether  the  focus of the  training  adequately  reflected 
the  focus  of the  reforms.  For  example,  the  basic  surveyor  training  course18 includes 
a mock  hearing,  which  few surveyors  will likely ever  attend.  Some  also expressed 
concerns  about  how most  of the  training  was provided:  structured  lectures  to large 
groups  rather  than  a more  interactive  approach  with smaller  groups.  Typical  of the 
concerns  of the  national  groups  was this comment  from  one  such  official who,  in 
questioning  how well surveyors  are  coping  with the  new outcome  focus,  also 
questioned  whether  the  training  has taught  the spirit  of OB~  not just  the  letter. 
We  also heard  concerns  about  the  amount  of training  available  for  surveyors.  For 
example,  many  State  officials noted  inadequate  space  in the  training  courses,  and 
HCFA  regional  officials  echoed  this concern. 19 In fact,  as of October  1, 1990, when 
the  new survey  system was to begin,  924 State  and  Federal  surveyors  had  attended 
HCFAS 3-day course  on the  new survey process.  At best,  that  represented  about  one-
fifth of all State  surveyors. n  Since  then,  of course,  more  sumeyors  have  attended 
that  and  other  courses,  such as the  basic  health  facility course,  designed  for new 
surveyors.  According  to HCFAS train  the  trainer  approach,  those  who  attend  each 
course  are  expected  to share  their  knowledge  with those  unable  to  attend.  But based 
on HCFAS own data,  as many  as one-third  of State  surveyors  had  not  been  trained  by 
the  end  of FY  1992.21 
State  survey  agencies,  of course,  also have  orientation  and  training  programs  for  their 
surveyors.  They  often  assign new surveyors  to shadow  more  experienced  surveyors 
until  they know  the  ropes.  But  HCFA  officials and  others  we spoke  with expressed 
concerns  that,  because  the  more  experienced  surveyors  may be  the  ones  having  the 
hardest  time  adjusting  to the  new focus  on outcomes,  this approach  to training  maybe 
counterproductive. 
To  the  extent  that  the  new outcome  focus of the  survey process  is not being 
implemented,  the  intent  of the  reforms  is left unrealized.  For  example,  the  survey in 
one  home  we know  about  illustrates  this threat.  Surveyors  cited  this home  for 
deficiencies  that  posed  an immediate  and  serious  threat  to the  health  and  safety  of its 
residents.  The  survey agency  gave the  home  23 days to correct  its problems  or be 
terminated  from  the  Medicare  and  Medicaid  programs.  At the  end  of the  23 days, the 
home  had  not  only failed  to correct  its deficiencies,  but  the  State  survey  agency  had 
also  determined  that  the  conditions  in the  home  constituted  an emergency  that  directly 
5  jeopardized  many  residents.  The  State  survey agency  therefore  issued  an emergency 
order  for the  relocation  of these  residents.  When  challenged  by the  homes  attorney, 
however,  the  State  survey agency  decided  the  residents  could  remain  if the  attending 
physician  of each  resident  or the  homes  medical  director  simply documented  that 
each  resident  would  not  be  at jeopardy  in the  home.  And  the  physicians  did just  that. 
Thus  the  survey  agency  essentially  erased  the  emergency  relocation  order  based  on 
documentation  rather  than  actual  improvement  or correction  of deficiencies. 
State  sumey  agencies  contend  with staff turnover  and  recruitment  problems  that 
 
are  compounded  by their  own State  fiscal pressures.  At the  time  they 
responded  to our  survey, the  19 States  reported  over  700 vacancies  among 
about  3,800 survey and  support  staff in FY  1992. 
All but  one  of the  State  survey  officials who responded  to our  sumey  said  they  had 
turnover  and/or  recruitment  problems.  Several  mentioned  chronic  vacancy  rates  of 15 
percent  and  1 as high as 27 percent.  Each  of the  19 States  for which we have  data 
reported  vacancies  among  their  nurse  surveyors--often  long-term  vacancies.  In one 
State,  only two of seven  survey  teams  were  fully staffed;  in another,  survey  teams  in 
one  urban  area  have  never  been  fully staffed.  And  in another  large  State,  some  of the 
district  offices  lack experienced  surveyors. 
In explaining  the  problems,  many  survey agency  officials  cited  the  onerous  travel 
required  of the  surveyors  and  lack  of competitive  salaries,  especially  for registered 
nurse  surveyors  and  registered  dietitians.  22 They  also cited  State  salary  and  hiring
freezes,  early  retirement  programs,  and  cumbersome  hiring  procedures  as exacerbating 
these  problems. 
These  problems  can have  serious  implications  for the  State  survey  agencies.  Twelve  of 
the  18 survey  agencies  that  responded  to our  survey reported  having  inadequate 
capacity  to conduct  either  their  standard  surveys, extended  surveys,  and/or  complaint 
investigations.  Officials  from  11 States  reported  cutting  back  on survey  activities  in 
some  ways, most  often  by not  conducting  all the  follow-up  required  to monitor  a 
homes  progress  in correcting  deficiencies.  The  surveyors  we spoke  with  in two States 
reported  needing  more  time  for some  of the  survey tasks,  particularly  observing 
residents  and  reviewing  medical  records  for the  quality  of care  assessment.  And  in 
another  State,  the  survey  agency  officials have  cut HCFAS required  survey  samples  in 
half because  of staffing  shortages. 
State  survey agencies  relationships  with nursing  homes  are  increasingly 
b 
contentious  as the  reforms  provide  new incentives  for nursing  homes  to refute 
deficiencies.  This  can result  in surveyors  citing fewer  or less serious 
deficiencies. 
We  heard  about  the  increasingly  contentious  relationship  from  both  HCFA  and  State 
officials,  as well as officials from  groups  representing  residents  and  nursing  homes. 
For  example,  they  reported  a trend  of more  and  more  homes  refuting  deficiencies  and 
6  appealing  sanctions--although  neither  HCFA  nor  any of the  nursing  home  or resident 
associations  we asked  track  how many  deficiencies  are  refuted  or how many  sanctions 
are  appealed. 
That  trend  may be  in response,  at least  in part,  to two stimuli:  increasing  numbers  of 
malpractice  suits against  nursing  homes~  and  HCFAS proposed  enforcement 
regulations.  Survey  reports  and  deficiencies  can become  evidence  in malpractice  suits, 
and  recent  cases  have  resulted  in significant  awards  against  homes.x  And  the 
proposed  enforcement  regulations  call for sanctions  when  homes  are  found  to have 
provided  substandard  care n  for three  consecutive  sumeys.  This  means  the  stakes  are 
higher  for homes  having  even  one  deficiency  in any one  survey. 
We  also heard  about  a related  trend  that  speaks  to the  increasingly  contentious 
relationship:  homes  submitting  plans  of correction  that  more  and  more  often  contain 
a disclaimer  stating  that  preparing  and  executing  such  a plan  does  not  indicate  the 
home  agrees  to the  facts  alleged  in the  deficiency.  For  example,  the  disclaimer  in one 
plan  of correction  we reviewed  read  as follows:  Preparation  and/or  execution  of this 
plan  of correction  does  not  constitute  admission  or agreement  by the  provider  of the 
truth  of the  facts  alleged  or conclusions  set forth  in the  statement  of deficiencies.  The 
plan  of correction  is prepared  and/or  executed  solely because  it is required  by the 
provisions  of federal  and  state  law.  The  homes  may view such  a disclaimer  as 
valuable  if they were  to appeal  a sanction  or if they were  to defend  themselves  against 
a malpractice  suit. 
of  course,  that  the  relationship  can be  contentious  is not  always problematic,  nor  is it 
a surprise--after  all, the  relationship  between  the  home  and  the  surveyor  is one  of the 
regulated  and  the  regulator.  Indeed,  to the  extent  that  a contentious  relationship 
causes  the  surveyors  to improve  by being  more  careful  and  precise  in documenting 
deficiencies,  it is welcome.  But  the  trends  we describe  also have  other  implications 
that  can  threaten  the  intent  of the  reforms.  For  example,  surveyors,  seeking  to avoid 
a lengthy  battle  or appeals  process,  may cite fewer  or less serious  deficiencies.  or 
they  may become  involved  in long appeals  or malpractice  cases,  meaning  they  have 
less time  for their  routine  survey, follow-up,  and  enforcement  activities. 
The  State  survey and  HCFA  regional  officials  expressed  concerns  over  long 
 
waits  for HCFA  regulations  and,  to a lesser  extent,  over  unclear  and 
inconsistent  guidance  from  HCFA.  This  can result  in confusion  and 
inconsistent  implementation. 
The  nursing  home  reform  legislation  provided  statutory  deadlines  for implementing 
major  parts  of the  reforms.  The  HCFA  failed  to issue proposed  or final  regulations 
timely  for both  of the  two major  sets of regulations  upon  which  State  survey  agencies 
rely.  One  is related  to survey and  certification,  which  had  a statutory  deadline  of 
January  1990; the  other,  enforcement,  had  a statutory  deadline  of October  1988.  The 
proposed  regulations  for both  were  published  August  28, 1992; final  regulations  have 
yet  to be  issued. 
7  Both  State  and  HCFA  regional  officials with whom  we spoke  called  the  delays 
unacceptable  and  expressed  deep  frustration  with them.  They  are  concerned  that  the 
lack  of final  regulations  leaves  inadequate  guidance  for the  States  and  invites  provider 
challenges,  such  as refuting  deficiencies  or appealing  sanctions.  With  such challenges, 
HCFA  faces  the  threat  that  proposed  regulations  will be  interpreted  through  the 
courts. 
Both  State  officials  and  HCFA  regional  staff with whom  we spoke  also  cited 
inconsistent  and  unclear  guidance  from  HCFA  as presenting  implementation  problems 
for the  States.  Confusion  over what  constitutes  HCFA  policy is part  of the  problem. 
For  example,  HCFA  regional  offices routinely  submit  questions  to the  central  office, 
which  responds  in a memorandum.  Each  regional  office receives  a copy.  Whether 
these  memoranda  apply  only to the  specific  question  posed  or constitute  policy is 
interpreted  differently  among  the  HCFA  regional  offices.  And  since  the  regional 
offices  interpret  these  memoranda  differently,  guidance  to the  States  may  also differ. 
In another  example,  reported  in an industry  newsletter  and  referred  to by several 
people  with whom  we spoke,  a HCFA  regional  office responded  in September  1992 to 
a consumer  groups  question  about  what  nursing  homes  are  allowed  to ask of 
prospective  residents  finances.  Shortly  thereafter,  HCFA  central  office  issued  another 
response.  With  HCFA  and  consumers  sparring  not  only over  the  consistency  but  also 
the  correctness  of the  two HCFA  responses,  State  survey  agencies  are  left unsure 
about  how to  enforce  the  policy in question. 
Virilities  in both musing homes and other Statk-surveyed health fadities  could be 
kmning  as Saks  f-on  the impkmentation  challenges of the refioms. 
Complaints  about  nursing  homes  increased  for  15 and  decreased  for  3 of the  18 
	
responding  States  from  FY  1990 to  1992.  The  average  increase  was 74 percent. 
Some  State  survey officials  are  concerned  about  their  ability  to respond  to 
complaints  quickly and  effectively. 
Some  State  survey  officials report  curtailing,  delaying,  and/or  omitting  surveys 
b 
for facilities  such as home  health  agencies,  hospices,  and  hospitals. 
Officials  from  11 States  expressed  concerns  about  their  ongoing  ability  to respond  to

complaints--more  so than  other  areas  of their  survey responsibilities  that  we asked

about.  The  dramatic  increase  in complaints  ranged  from  4 percent  to  as high as 438

percent  in those  15 States.  The  median  was 23 percent.  The  increase,  coupled  with

the  sumeyors  limited  investigatory  skills, have  taxed  States  ability  to respond.

Officials  for those  11 States  reported  having  inadequate  capacity  to investigate  those

complaints  appropriately.  Even  among  the  States  that  reported  having  adequate

capacity  to investigate  their  complaints,  some  officials mentioned  cutting  back  in other

areas,  such  as follow-up  visits to veri&  plans  of correction,  in order  to investigate

complaints.

8  Investigating  complaints  requires  many  skills and  even  contacts  within  the  nursing 
homes  community,  particularly  complaints  alleging  resident  abuse  or misappropriation 
of resident  property.  And  while no State  official  reported  having  studied  their 
increased  complaints,  7 of the  17 State  officials who responded  to our  question 
thought  that  the  nature  of the  complaints  might  be  changing.  They  mentioned  more 
complaints  of resident  abuse,  neglect,  and  misappropriation  of resident  property  most 
often.  In those  types  of cases,  the  complainant  may wish to press  criminal  charges,  so 
that  preserving  evidence,  identif@g  witnesses,  and  contacting  proper  authorities  (such 
as the  police  and/or  State  Medicaid  Fraud  Control  Units)  are  vital  to the  proper 
investigation  of the  complaint. 
Areas  other  than  complaints  may also become  vulnerable  as States  continue  to focus 
on the  nursing  home  reforms.  Indeed,  officials from  10 of the  19 States  we heard 
from  reported  cutting  back  their  State  licensure  or survey  activities  for facilities  other 
than  nursing  homes.  For  example,  one  State  official reported  deferring  hospice  and 
home  health  agency  surveys in order  to devote  more  staff to nursing  home  surveys. 
Officials  from  HCFA  regional  offices also expressed  concern  about  the  lack  of 
attention  to these  other  facilities.  While  recognizing  nursing  homes  as the  largest 
portion  of survey  agencies  workload,  they  also warned  that  other  areas  not  be 
neglected. 
In  13 of the  19 responding  States,  the  same  surveyors  that  are  responsible  for nursing 
home  surveys  also conduct  surveys of other  health  facilities,  such as hospitals,  home 
health  agencies,  hospices,  and  end-stage  renal  disease  (ESRD)  facilities,  among  others. 
Each  of these  surveys requires  some  specialized  knowledge.  One  State  official 
elaborated  on these  concerns  about  surveyors  abilities  to keep  up with  each  field  and 
noted  particularly  infection  control  techniques  for facilities  relying  on high or quickly 
changing  technologies,  such  as ESRD  and  hospitals. 
9   CONCLUSION 
Nursing  home  and  resident  advocates  alike  welcomed  the  nursing  home  reforms  of 
1987 as a positive  step  toward  improving  the  lives of nursing  home  residents.  And  the 
intent  of those  reforms  is beginning  to be  realized.  In this report,  we addressed  both 
the  progress  State  survey agencies  have  made  in implementing  the  reforms  and  the 
implementation  problems  they face.  We  also reported  on some  dangers:  survey 
agencies  continued  focus  on nursing  home  reforms  could  be  at the  expense  of both 
adequately  responding  to complaints  and  attending  to other  State-surveyed  health 
facilities. 
Clearly,  State  sumey  agencies  operate  in a complex  environment  of myriad  State  fiscal 
pressures  and  responsibilities,  Federal  oversight,  and  an array  of State  and  Federal 
regulations.  And  while  implementation  of the  nursing  home  reforms  is underway, 
State  survey agencies  also face  the  implementation  of the  Clinical  Laboratory 
Improvement  Act  of 1988, which  calls for unannounced  inspections  of all laboratories 
testing  human  specimens--an  enormous  undertaking. 
The  HCFAS role  is crucial  in helping  the  States  maintain  progress  in realizing  the 
nursing  home  reforms.  The  HCFA  has  opportunities  to foster  the  momentum  through 
its surveyor  training  initiatives,  its evaluation  of State  survey  agencies,  and  its guidance 
to the  States.  Renewed  efforts  to be responsive  to State  and  HCFA  regional  office 
concerns  in each  of the  these  areas  could  enhance  the  partnership  between  HCFA 
and  the  States,  and  promote  further  progress  in realizing  the  full intent  of the  nursing 
home  reforms. 
Surveyor Training 
 
The  HCFA  has  an opportunity  to invigorate  its surveyor  training  program  and  ensure 
its focus  reflects  the  goals  of the  reforms  and  the  needs  of the  surveyors.  The  HCFA 
has many  resources  from  which  to draw  to do that.  For  example,  HCFA  recently 
completed  a provider  survey that  offered  insights  on the  providers  views of the  survey 
process  and  how well surveyors  convey their  findings.  Likewise,  HCFA  will soon  have 
a report  for which  it contracted  on surveyor  decision-making  and  consistency  as well as 
quality-of-life  and  quality-of-care  measurement.27  The  HCFA  will also have  the 
results  of its Surveyor  Minimum  Qualifications  Test  (SMQT).%  Each  of these 
resources,  plus  this report,  should  provide  HCFA  with ample  information  to draw  on 
in assessing  ways to improve  its training  programs,  for example,  to enhance  surveyor 
skills for assessing  resident  outcome  and  address  other  training  needs  that  are 
identified. 
Evaluation 
 
The  HCFA  also  has an opportunity  to address  whether  it is getting  enough  meaningful 
information  from  its State  Agency  Evaluation  Program  (SAEP).  Its existing  SAEP 
10  workgroup  could  consider  new areas  for data  collection,  such  as the  number  and  types 
of deficiencies  refuted  by providers  and  the  number  and  outcome  of appealed 
sanctions.  Workgroup  members  could  assess the  extent  to which  SAEP  data  could  be 
used  to monitor  not  only each  States  contract  compliance,  but  also patterns  of weak 
performance.  They  could  also consider  a shift in the  SAEPS focus  from  process  to 
outcomes--thereby  reflecting  the  shift in the  surveys focus.  Such  careful  data 
collection  and  monitoring  through  the  SAEP  could  enable  HCFA  to take  action  and 
to avert  potential  problems  before  they  present  any danger  to nursing  home  residents, 
hospital  patients,  and  others  relying  on State-surveyed  health  facilities  for services. 
Improved Guidance 
 
Finally,  HCFA  has  opportunities  to improve  its guidance  to the  States.  It could  move 
quickly to issue final  regulations.  It could  ensure  the  State  Operations  Manual  that 
survey agencies  rely upon  is up-to-date  and  consistent  with proposed  and/or  final 
regulations.  It could  also ensure  that  other  sources  of policy information,  such  as 
memoranda,  are  clearly  labeled  as such and  incorporated  into  that  manual  as 
appropriate.  This  could  reduce  the  confusion  we heard  about  from  both  State  survey 
agency  officials  and  HCFA  regional  office  staff. 
11  APPENDIX  A 
Methodology 
Our  methodology  for this study included  collecting  information  from  and  about  the  top 
20 States  ranked  by the  number  of nursing  home  beds.  These  20 States  account  for 
about  75 percent  of all the  nursing  home  beds  in the  country.  Beginning  with those 
having  the  most  nursing  home  beds,  they  are:  California,  Texas,  New York,  Illinois, 
Ohio,  Pennsylvania,  Florida,  Indiana,  Missouri,  Michigan,  Wisconsin,  Massachusetts, 
Minnesota,  New Jersey,  Louisiana,  Georgia,  Iowa, Tennessee,  Oklahoma,  and  Kansas. 
We  received  budget  and  evaluation  data  from  the  HCFA  regional  and  central  offices 
for the  20 States  for FYs  1990, 1991, and  1992.  The  evaluation  data  is based  on 
HCFAS annual,  formal  review  of the  State  agencies  performance.  We  also wrote  to 
the  survey  directors  in each  State  and  requested  both  data  on their  nursing  home 
suxvey staff  and  activities  and  answers  to open-ended  questions  on the  implementation 
of the  reforms.  We  received  data  from  19 of the  20 States  (all except  Minnesota)  and 
responses  to our  open-ended  questions  from  18 of the  20 States  (all except  Minnesota 
and  Louisiana).  The  19 States  contain  73 percent  of the  nursing  home  beds  in the 
country;  the  18, 70 percent.  We  also held  telephone  interviews  with  a total  of nine 
surveyors  and  surveyor  supervisors  in two States. 
We  talked  to HCFA  regional  office  staff in each  of the  eight  regions  responsible  for 
States  in our  sample.  We  asked  them  how well they thought  the  reforms  were  being 
implemented  and  what  constraints  they  thought  the  States  face  in implementing  the 
reforms,  among  other  things. 
We  also  talked  to several  officials  of national  groups  representing  nursing  homes  and 
nursing  home  residents  and  researchers  and  consultants  involved  in this field.  These 
intemiews  included  officials from  the  American  Health  Care  Association,  American 
Association  of Homes  for the  Aged,  National  Citizens  Coalition  for Nursing  Home 
Reform,  National  Association  of State  Long  Term  Care  Ombudsmen,  Abt  Associates, 
and  a former  staff member  of the  Institute  of Medicine  who was involved  in 
researching  and writing  the  1986 report,  Improving the Quality of Care in Nursing 
Homes. 
Finally,  we reviewed  relevant  materials  such as legislation,  articles,  and  the  above-
noted  Institute  of Medicine  book. 
A -1   APPENDIX  B 
Notes 
1.  The  reforms  are  contained  in the  Omnibus  Budget  Reconciliation  Act  of 1987 
(Public  Law 100-203), which was enacted  on December  22, 1987. 
2.  The  agreement  requiring  that  nursing  homes  be  sumeyed  and  recertified  every 
12 months. 
3.  47 FR  5365. 
4.  National  Citizens  Coalition  for Nursing  Home  Reform,  Nursing Home Reform Law: 
Z%eBasics (Washington,  DC)  1991. 
5.  All nursing  homes  are  subject  to State  licensure,  even  if they  do not  receive  funds 
from  Medicare  and  Medicaid. 
6.  Surveyors  must  conduct  extended  surveys if they  find  any Level  A deficiency  in the 
following  requirements:  Resident  Rights,  Resident  Behavior  and  Facility  Practices, 
Quality  of Life,  or Quality  of Care. 
7.  The  CLIA  (Public  Law  100-578) set standards  for improving  the  quality  of testing 
in all clinical  laboratories  that  test  human  specimens.  It calls for State  survey  agencies 
to assess  compliance  with the  new standards  through  unannounced  laboratory 
inspections,  among  other  things. 
8.  These  budget  data  from  HCFA  reflect  Medicare  budgets  requested  and  approved 
by HCFA.  They  also include  Intermediate  Care  Facilities  and  Medicaid  nursing 
homes  because  HCFA  cannot  separate  them  from  other  nursing  home  survey  and 
certification  data.  The  national  nursing  home  survey  and  certification  budgets 
(Medicare  and  Medicaid)  increased  from  $120.2 million  in FY  1990 to $213.3 million 
in FY  1992. 
9.  Medicare  increases  ranged  from  a low of 9 percent  to a high of 276 percent  with  a 
median  of 79 percent.  Medicaid  increases  ranged  from  a low of 7 percent  to a high of 
135 percent  with a median  of 49 percent. 
10.  Based  on the  HCFA  survey time  parameters  used  for Medicare  surveys  in nursing 
homes  before  and  after  OBRA  1987.  These  show that  a survey before  OBRA  would 
take  about  148 hours  on average,  nationally,  and  207 after  OBRA.  An  extended 
survey would  require  an  additional  36 hours. 
B-1  11.  Our  contact  with State  survey agencies  began  shortly  after  HCFA  issued  its 
implementation  instruction  for eliminating  time-limited  agreements.  The  HCFA  issued 
that  instruction  on September  15, 1992.  We  mailed  our  surveys to the  States  on 
September  24, 1992 and  began  calling them  shortly  thereafter. 
12.  The  major  exceptions  are  Michigan  and  California.  The  Michigan  survey  agency 
recently  caught  up  on a large  backlog  of nursing  home  surveys.  In California,  the 
survey  agency  refused  to implement  the  reforms  because  it believed  its State  law 
exceeded  the  new Federal  standards.  On  October  1, 1990, the  National  Senior 
Citizens  Law Center  took  California  to court  to force  implementation.  Meanwhile, 
over  one  hundred  Federal  surveyors  flew to California  to  enforce  the  law.  In March 
of 1991, California,  HCF~  and  the  administration  negotiated  an agreement  allowing 
the  State  to make  changes  in the  surveyor  instructions,  and  California  resumed  its 
survey activities. 
13.  According  to the  State  Agency  Evaluation  Program  Reports  we reviewed  for 
FY  1992, HCFA  required  3 of the  19 States  in our  sample  to submit  corrective  action 
plans  based  on poor  performance  in completing  the  surveys on time.  In addition  to 
Michigan  and  California,  HCFA  also identified  Massachusetts.  Massachusetts  officials 
we spoke  with  indicated  no backlog,  nor  did data  from  that  State  which we reviewed. 
The  HCFAS concerns  in its review  of the  States  performance  appear  to relate  more 
to paperwork  problems. 
14.  For  a discussion  of social systems active  resistance  to change,  referred  to  as 
dynamic  conservatism,  see Donald  A. Schon,  Bevond  the  Stable  State,  New York: 
W. W. Norton  & Company,  Inc.  1971. 
15.  The  sample  included  statements  from  the  period  April  1, 1991 to March  30, 1992. 
Jean  Johnson-Pawlson,  Study of SurveyorPerformance, The  George  Washington 
University,  October  26, 1992.  This study was funded  by the  American  Health  Care 
Association. 
16.  Letter  from  the  American  Health  Care  Association  to HCF~  April  28, 1993. 
17.  Personal  communication  with  a representative  of Abt  Associates.  Under  contract 
with HCF~  Abt  is undertaking  an  evaluation  of the  surveyors  decision-making.  One 
part  of that  evaluation  involved  a mail  survey to 750 State  surveyors.  Preliminary 
results  of that  mailing  indicate  that  75 percent  of the  surveyors  were  surveying  nursing 
homes  prior  to October  1990, when  the  new survey process  was implemented. 
18.  The  HCFA  requires  all surveyors  to attend  its basic  health  facility training  course 
within  their  first year  of employment  to participate  fully as a survey team  member. 
19.  Many  State  officials said they would  like to see  more  training  opportunities  in the 
regions  rather  than  Baltimore,  and  the  HCFA  regional  staff also noted  wanting  to 
offer  more.  The  HCFA  regional  officials noted  that  their  training  budgets  for such 
projects  were  limited,  especially  because  funds  for training  compete  with funds 
B-2  required  for the  Federal  sumeyors  to conduct  their  monitoring  sumeys  at the 
mandated  5 percent  of the  homes  in each  State. 
20.  Based  on HCFAS estimated  4,111 State  nursing  home  surveyors  in FY  1990 and 
its training  records  indicating  that  924 State  and  Federal  sumeyors  attended  that 
course  by October  1, 1990.  These  data  include  all States. 
21.  Based  on HCFAS estimated  numbers  of State  nursing  home  surveyors  (5,255)  in 
FY  1992 and  actual  number  of State  and  Federal  surveyors  (3,568)  completing  the 
long-term  care  specialty  training,  the  basic  training,  or a course  on resident  assessment 
from  FY  1990 through-FY  1992 as tracked  by the-training  branch  in HCFA.  These 
data  include  all States. 
22.  We  asked  some  State  officials  about  recent  pay raises  to address  recruitment  and 
retention  problems.  Eleven  States  official reported  raises,  mostly  for the  registered 
nurses  and  often  based  on union  negotiations,  although  the  raises  were  generally  small 
cost-of-living  increases. 
23.  Malcolm  J. Harkins  and  Bradley  L. Kelly.  7he Impact of iVuning Home Survey 
Repotis in Tort and Criminal Cases.  Washington,  DC:  Cassons  and  Harkins. 
April  1992. 
24. For  example,  a jury  in Texas  awarded  $39.4 million  to the  family of a woman 
strangled  in a restraint  and  a jury  in Alabama  awarded  $2 million  in punitive  damages 
for a homes  alleged  mismanagement  of a residents  bedsores.  See  David  T. Marks. 
Nuning Home Litigation Exchange Repoti.  Houston,  TX:  Association  of Trial  Lawyers 
of America.  July 28, 1992, and  l?ze Impact of Nursing Home Survey Reports in Tort and 
Criminal Cases, op. cit. 
25.  Substandard  care  means  care  furnished  in a facility that  has  one  or more 
deficiencies  in any area  with a severity  level  of 3 (potential  physical  harm)  or 4 (actual 
physical  harm),  regardless  of scope;  or a level 2 (negative  outcome  or resident  rights 
violation,  or in the  survey  teams judgement,  the  ability  of the  individual  to achieve  the 
highest  practicable  physical,  mental  or psychosocial  well-being  has been  compromised, 
or both)  in severity  with  a level  3 (pattern)  or 4 (widespread)  in scope  in the  quality  of 
care  requirements  for long term  care  facilities. 
26.  See Long  Term  Care  Management.  HCFA BansHomes From Asking Financial 
Questions.  October  15, 1993:3.  and  Consumen, HCFA Dkpute LTC Financial 
Screening Ruling.  March  10, 1993:1. 
27.  The  HCFAS contract  is with Abt  Associates. 
28.  The  reforms  mandated  a surveyor  training  and  testing  program,  and  the  SMQT  is 
HCFAS response  to that  mandate.  It is a standardized  test  that  all sumeyors  will have 
to pass  to participate  fully as team  members.  Those  who fail can  participate  as 
trainees,  will receive  feedback  on their  test  results,  and  must  undertake  remedial 
B-3  training.  The  pretest  was held  December  7, 1992, and  HCFA  has  modified  the  test 
and  its administration  of the  test  based  on those  results.  The  operational  test  will be 
held  in the  late  summer,  1993. 
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