Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Public Access to Nursing Home 
Survey and Certification Results 
JUNE GIBBS BROWN 
Inspector General 
MARCH 1999 
OEI-06-98-00280  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
This report was prepared in the Dallas Regional Office under the guidance of Chester Slaughter, 
Regional Inspector General, and Judith V.  Tyler, Deputy Regional Inspector General.  Project 
staff included: 
Dallas  Headquarters 
Leah K. Bostick  Susan Burbach 
Nancy Juhn  Mary Beth Clarke 
Nancy Watts  Barbara R. Tedesco 
Felicia White 
Additional assistance was provided by OEI staff in the remaining seven OEI regional offices. 
Without their valuable aid, this study would not have been possible. 
To obtain copies of this report, please call the Dallas Regional Office at 1-800-848-8960. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  EXECUTIVE SUMMARY

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PURPOSE 
To assess the availability and usefulness to the public of the results of survey and certification 
reviews of nursing homes. 
BACKGROUND 
Recent reports by the Health Care Financing Administration (HCFA), the General Accounting 
Office, and the Office of Inspector General (OIG) have raised serious concerns about nursing 
home patients care and well-being.  The Senate Special Committee on Aging held two 
hearings in the summer of 1998 on these results. 
Survey and Certification 
The most important Congressional response to prior concerns for nursing home patients was 
the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987).  The Act served to strengthen 
the standards and HCFAs survey and enforcement processes for nursing homes.  These 
reforms require that onsite surveys be conducted in nursing homes once every 12 to 15 months 
for continued certification of all nursing homes.  These annual surveys of nursing homes are 
critical because they represent the only current report card of a nursing homes quality of 
medical care. 
Availability of Survey Results 
Nursing home residents and their families need accurate information about the quality of care 
in nursing homes in order to make informed choices about which nursing home will provide the 
necessary care.  Selecting a nursing home depends, in part, on the most complete, timely 
information available.  The nursing homes most recent annual survey results are, theoretically, 
ideally suited for this purpose.  Various laws and regulations are intended to make them 
publicly available. 
In order to assess that availability and usefulness of the nursing home survey results, we tried 
to simulate a family members experience in obtaining copies of the survey and certification 
results of nursing homes being considered for a potential patient.  To find out what families 
and others might experience, we made onsite visits to nursing homes, conducted telephone 
requests to State and HCFA offices for survey results, and accessed HCFAs new Internet site 
for obtaining summary survey results for nursing homes.  We also talked to a sample of 
families and others to find out their actual experiences and reviewed pertinent State and 
Federal rules and procedures regarding access to nursing home survey results.  We conducted 
our study in eight cities. 
FINDINGS 
General Family Awareness - Two-thirds of the 155 families and others we interviewed did 
not know that the results of the Federal and State nursing home inspections are available on 
request.  Fifty-two percent were also unaware that such inspections are required.  Only 15 
individuals had requested a copy of the survey results.  Eleven of these obtained the results; 
i  however, 6 of the 11 said the results were not based on a recent survey conducted in the 
previous 15 months. 
Onsite Visits to Nursing Homes - Most of the 32 sampled nursing homes visited by OIG 
staff did not fully meet the requirements for making survey results available.  In 17 of the 
nursing homes, the notice identifying the location of the survey results was not posted; the 
OIG staff had to ask for the survey results in 24 of them; and for 17 of the nursing homes, the 
survey results were in locations directly observed by staff, contrary to regulations.  Twenty-
seven of the 32 nursing homes visited did, ultimately, make available the nursing homes survey 
results.  However, the OIG staff had an advantage over other members of the public in that 
they were aware of the type and form of the material they were seeking and knew, specifically, 
what information to request. 
Telephone Requests - Four of the eight nursing homes from whom we requested survey 
results by telephone refused the request and did not provide a referral for the caller.  Of the ten 
HCFA regional offices we called, five agreed to provide the survey results; three of the ten 
made inappropriate referrals to the Social Security Administration.  In contrast, seven of eight 
State offices we called agreed to provide the requested information. 
Mail Requests - Processing and delivery procedures may delay timely response to requests 
made by mail to States and HCFA regional offices.  Also, both the States and HCFA charge 
for processing and providing requested survey results.  The amount of these charges may be 
unclear to the requester at the time the request is made and are potentially expensive. 
Internet Requests - The HCFAs Internet site, Nursing Home Compare, was somewhat 
difficult to locate, but once located, was easy to use.  We found survey and certification 
reports for 56 of the 64 nursing homes in our study sample.  Sixty-five percent of the families 
and others we interviewed said the Internet could be very helpful in providing useful nursing 
home information. 
Legibility of Reports - The summary survey and certification reports on HCFAs new 
Internet site are more readable and understandable than the standard system-generated HCFA 
survey results. 
RECOMMENDATIONS 
We conclude that the existing system for providing public access to nursing home survey 
information does not work as intended.  The HCFAs new Internet initiative will prove very 
helpful to those having access to the Internet.  However, it is equally important to strengthen 
all existing avenues for receiving information and to identify new avenues.  To accomplish this, 
we believe HCFA should: 
<	  Continue to promote public awareness of the required quality of care standards for nursing 
homes. 
<	  Work with States and patient advocacy associations to promote public awareness that 
nursing home survey results are available for review by any member of the public. 
<	  Include, in HCFAs Guide to Choosing a Nursing Home, language that explains simply 
what constitutes a nursing home survey and the availability and location of survey results. 
ii  <	  Work with interested public and private entities to promote public knowledge about how 
and where to access HCFA survey reports on nursing homes. 
<	  Work with the States, patient advocacy associations, and nursing home industry 
associations to develop acceptable laymens language for HCFA nursing home reports 
provided in response to public requests for such information.  Some improvements can be 
made by modeling a summary report after the one that appears on HCFAs new Internet 
page. 
<	  Consider the feasibility of requiring nursing homes to provide a HCFA-prepared summary 
survey report as part of the admission process in each nursing home. 
<	  Promote awareness of the new HCFA Internet site providing summary nursing home 
survey report information. 
<	  Create a direct link to the summary nursing home information on HCFAs Internet home 
page. 
<	  Require the posting of available nursing home survey information in a standard, readily 
visible location in each nursing home. 
<	  Enforce the requirement to post survey results in locations not readily observable by 
nursing home staff. 
<	  Explore other avenues of providing nursing home information to the public.  For example, 
determine the feasibility of providing hospital discharge planners with nursing home survey 
reports to facilitate the choice of a nursing home when patients are transferred from the 
hospital to a nursing home. 
<	  Work with States and advocacy associations to explore additional means of providing 
nursing home profile information (e.g., advertised telephone number in each State and 
HCFA regional office for consumers to call). 
AGENCY COMMENTS 
We solicited comments from agencies within the Department of Health and Human Services 
which have responsibilities for policies related to Medicare and Medicaid, as well as for long 
term care.  We received comments from HCFA concurring with our recommendations.  The 
HCFA further emphasized their continued support of providing sufficient information to the 
public for their use in making informed decisions regarding long term care.  They further 
indicated their additional interest in exploring the development of a national 1-800 number to 
provide public access information and reports regarding nursing homes. 
iii  TABLE OF CONTENTS

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EXECUTIVE SUMMARY 
INTRODUCTION  1
 
METHODOLOGY  2
 
FINDINGS  5
 
General Family Awareness  5
 
Accessing Survey Results at Nursing Homes  5
 
Telephone Requests for Survey Results  6
 
Mail Requests  7
 
Accessing Survey Results from the Internet  9
 
Legibility of Reports  10
 
RECOMMENDATIONS  11
 
AGENCY COMMENTS  12
 
ENDNOTES  13
 
APPENDICES 
A - Sample HCFA Internet Nursing Home Report  A-1
 
B - Sample HCFA Form 2567L  B-1
 
C - Sample OSCAR Report 3  C-1
 
D - Sample OSCAR Report 4  D-1
 
E - Sample OSCAR Report 40  E-1
 
F - HCFA Comments on Draft Report  F-1
  INTRODUCTION

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PURPOSE 
To assess the availability to the public of the results of survey and certification reviews of 
nursing homes. 
BACKGROUND 
Recent reports of the Health Care Financing Administration (HCFA) on nursing home 
responsibilities and processes, and General Accounting Office reviews of patient care in 
California nursing homes raised serious concerns for patients care and well-being. The Senate 
Special Committee on Aging held hearings in the summer of 1998 on these results.  At the 
same time, the Office of Inspector General (OIG) undertook additional studies aimed at 
assessing the quality of care in nursing homes.  We recently issued reports on the inadequacy 
of criminal background checks on nursing homes employees and raised questions about States 
responses to reports of patient abuse.  Additional OIG reports will examine the extent and 
nature of reported abuse of nursing home patients, the nursing home survey and certification 
process, and the Ombudsmans role. 
The most important Congressional response to prior concerns for nursing home patients was 
the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987).  The Act served to strengthen 
quality standards and HCFAs survey and enforcement processes for nursing homes.  These 
reforms require that onsite surveys be conducted in nursing homes once every 12 to 15 months 
for continued certification of all nursing homes.1  These annual surveys of nursing homes are 
critical because they represent the only current report card of a nursing homes quality of 
medical care. 
Nursing home residents and their families need accurate information about the quality of care 
in nursing homes in order to make informed choices about which nursing home will provide the 
necessary care.  Selecting a nursing home depends, in part, on the most complete, timely 
information available.  The nursing homes most recent annual survey results are, theoretically, 
ideally suited for this purpose.  Various laws and regulations are intended to make them 
publicly available. 
Health Care Financing Administration Nursing Home Reports  - The State and HCFA do 
not routinely notify the public of nursing home survey results or of any subsequent plans of 
correction for identified deficiencies.  However, HCFA must disclose them to the public upon 
request under the Freedom of Information Act (FOIA).2,3  Requests can either be by telephone 
or in writing to each HCFA regional office, in addition to the central office located in 
Baltimore, Maryland.  The HCFA defines and categorizes requesters for billing purposes,4 
using the guidance provided by the FOIA and the Department of Health and Human Services 
FOIA policy.5,6 
1
  Requests for nursing home information can be provided by HCFA on the most recent survey 
conducted on a nursing home.  There are generally four computer-generated reports which can 
provide this information: 
<	  The HCFA 2567L (see Appendix B), Statement of Deficiencies and Statement of Isolated 
Deficiencies, is the form generated by the most recent standard survey and any subsequent 
extended surveys.  This survey report provides a picture of any deficiencies noted in the 
nursing home during the State or Federal survey and is the form available in the nursing 
home. 
<	  OSCAR Report 3 (see Appendix C), Facility History Profile, contains provider 
identification data and deficiencies from the most recent four surveys. 
<	  OSCAR Report 4 (see Appendix D), Facility Full Profile, contains a comprehensive 
summary of the most recently completed survey. 
<	  OSCAR Report 40 (see Appendix E), Complaint Facility History Profile, provides a 
summary complaint history of the nursing home. 
Reports 3 and 4, which provide summaries of the HCFA 2567L, are most often requested or 
provided in response to a request.  In addition to these reports, HCFA has an Internet multi-
purpose site.  This site provides information about Medicare and Medicaid, as well as about 
the OSCAR system and processes for requesting nursing home survey information. 
Nursing Homes - The HCFA requires each certified nursing home to post a notice giving the 
location and availability of the survey results.  The nursing home must also make the results 
available for examination in a place readily accessible to residents7 and frequented by most 
residents, such as in the facility lobby or dining area.  The definition of patient has been 
informally extended to also include individuals having responsibility for the patient, family 
members, and prospective future patients. 
HCFA Internet Initiative - The HCFA recently initiated a new Internet site, Nursing Home 
Compare,8 for public access to summary information on nursing home survey results.  This 
site, an addition to the multi-purpose site already existing, provides consumers access to 
simplified nursing home survey results. 
METHODOLOGY 
We limited our study to a purposive sample of eight States (California, Georgia, Illinois, 
Massachusetts, Missouri, New York, Pennsylvania, and Texas).  These States represent 
approximately 40 percent each of  (1) the Medicaid recipients receiving services in nursing 
facilities, including skilled facilities, and (2) the total skilled, non-swing,9 nursing facility 
patients.10  Within each of the States, we selected one city, each having a regional office of the 
OIGs Office of Evaluation and Inspections (San Francisco, Atlanta, Chicago, Boston, Kansas 
City, New York City, Philadelphia, and Dallas). 
2
  We employed five parallel lines of inquiry to determine how accessible the nursing home 
survey results are to nursing home clients, their families, and other supportive persons.  In 
order to assess that availability and usefulness of the nursing home survey results, we tried to 
simulate a family members experience in obtaining copies of the survey and certification 
results of nursing homes being considered for a potential patient.  To find out what families 
and others might experience, we made onsite visits to nursing homes, conducted telephone 
requests to State and HCFA offices for survey results, and accessed HCFAs new Internet site 
for obtaining summary survey results for nursing homes.  We also talked to a sample of 
families and others to find out their actual experiences and reviewed pertinent State and 
Federal rules and procedures regarding access to nursing home survey results. 
OIG Simulation of Access - We simulated a family members experience in obtaining a copy 
of nursing home survey results. We randomly selected five nursing homes within each of the 
eight cities.  In four of the five nursing homes, our staff conducted onsite visits. 
In preparation for the onsite visits, OIG staff assumed the identity of a family member or 
friend helping someone review a nursing home for possible future care.  As such, they had 
advance preparation to answer questions concerning this fictitious individual and their 
relationship with that person.  After attempting to seek the requisite posted notice and the 
survey results of the sampled nursing homes, the OIG staff documented their experiences. 
However, the reader must understand that the OIG staff had an advantage over other members 
of the public attempting to obtain nursing home information in that they were aware of the type 
and form of the material they were seeking. 
OIG Telephone Requests - We used the fifth facility randomly selected in each of the eight 
cities to test the process of requesting survey results by telephone.  These calls were initially 
made to the sample nursing home, followed by calls or letters to State offices and HCFA 
regional offices.  All steps in the process of requesting the survey results were documented by 
OIG staff making the requests. 
Contact with Families or Other Responsible Individuals - We randomly selected another 
three nursing homes in each of the eight cities.  These 24 facilities provided a listing of all new 
patients admitted in the first six months of 1998, and the name and telephone number of each 
patients principal family contact or other responsible person.  From these recent admissions, 
we randomly selected nine per nursing home.  We then contacted, by telephone, 155 
individuals having responsibility for the patients (a 72 percent response rate).  All respondents 
provided their perceptions of nursing home inspection requirements; availability of nursing 
home survey results; and generally, how helpful they believed such reports might be in 
choosing a nursing home.  Two-thirds of the families and others also provided their 
perceptions of survey accessibility, difficulty of understanding, and whether the nursing home 
supplied the most recent survey during the admission process. 
State and HCFA Regional Office Processes - We obtained, from each of the eight State 
offices having responsibility for nursing home survey visits, information about their 
requirements and processes for providing nursing home survey results, the number and sources 
3
  of nursing home survey information requests, and any State charges to requesters.  We 
obtained similar information from ten HCFA regional offices. 
HCFAs Internet Site - We asked an OIG employee, one familiar with performing research 
on the Internet, to document her attempts to locate the new HCFA site providing nursing 
home survey results.  Upon locating the site, this employee then searched the site for the 
survey results of all 64 nursing homes which were included in this inspection. 
The table below summarizes the five lines of inquiry we used in this study: 
Summary of Sampling Units 
Lines of Inquiry and Sample Numbers:  Nursing Homes  Family/Other  State Offices  HCFA Offices 
OIG Onsite Nursing Home Visits to 
32  NA  NA  NA 
Assess Survey Results Availability 
OIG Telephone Requests to Sample 
Nursing Home and Applicable State and  8  NA  8  10 
HCFA Offices 
Contact with Family or Other 
24  192*  NA  NA 
Responsible Persons 
Survey State and HCFA Offices for 
Processes to Request and Receive  NA  NA  8  10 
Survey Results 
Access HCFA Internet Site for Survey 
64  NA  NA  NA 
Results 
*The response rate for the 192 was 72 percent or 155 completed interviews. 
Interpretation of Data and Survey Conduct 
Because of the sampling methods, the results of the data analysis cannot be generalized to all 
nursing homes.  However, we believe that the findings provide insight into several issues 
related to the availability of nursing home survey results. 
This inspection was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
4
  FINDINGS

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GENERAL FAMILY AWARENESS OF SURVEY RESULTS 
Two-thirds of the sampled families and others responsible for nursing home patients did 
not know that the results of the Federal and State nursing home inspections are 
available on request. 
While many of the family and other responsible individuals are aware that nursing homes are 
required to provide good quality care, 52 percent of them were unaware that the State is 
required to conduct an inspection of each Federally-certified nursing home.  Further, 67 
percent of the families and others did not know those results of nursing home inspections are 
available to anyone who wishes to see them. 
Only 15 of 155 families and others had requested nursing home survey results.  Of these, 11 
had obtained them.  As a general note, of these 11 individuals, six said the results were not 
based on the most recent survey conducted within 15 months of their visit. 
ACCESSING SURVEY RESULTS ONSITE IN THE NURSING HOMES 
Most sampled nursing homes visited by OIG staff did not fully meet the requirements 
for making survey results available. 
Posting the Notice - In 17 of the 32 nursing homes, OIG staff were unable to locate the 
notice providing information on the location of the survey results.  For those nursing homes 
which posted the notice (15), 13 posted the notice approximately 5 feet above the ground - a 
location difficult for viewing by patients using wheelchairs.  Five nursing homes posted the 
notice in locations moderately or very difficult to locate. 
Asking for Survey Results - The law requires that residents should not have to ask a staff 
person for the survey results.11  Yet, in 24 of the 32 nursing homes, OIG staff were required to 
ask employees for the results. 
Availability of Survey Results - As required by previously described laws and 
regulations, 27 of 32 nursing homes made available their most recent survey results; five were 
unable to provide the survey results for OIG  review.  On the surface, this finding suggests that 
most nursing homes are complying with requirements to make the survey results available to 
the public.  However, as noted earlier, the OIG staff had an advantage over other members of 
the public in that they were aware of the type and form of the material they were seeking and 
knew, specifically, what information to request. 
5
  Location of Survey Results - The law specifies that patients should be able to read the 
results alone without being monitored by nursing home staff.  Yet, 17 of the 32 nursing homes 
located their survey results in areas directly observed by staff.  The following table identifies 
the locations of the survey results identified by the OIG staff visiting the nursing homes: 
Location of Available Survey Results 
Number of 
Nursing Homes 
Near administration/business office  7 
Near or in nurse station  6  17 
In the administration/business office  4 
Beside the posted notice  1 
Other (entrance, reception, lounge)  5 
Received, location unknown  4 
ACCESSING SURVEY RESULTS BY TELEPHONE AND MAIL 
OIG staff encountered difficulties obtaining survey information by telephone and mail 
from sampled nursing homes and HCFA regional offices; generally, the State offices 
were more responsive. 
Telephone Requests 
For each of the eight sampled nursing homes, OIG staff contacted the nursing home, applicable 
State office, and HCFA regional office. 
Nursing Home - The first request to the nursing home for its survey results was conducted 
by telephone.  None of the nursing homes required subsequent submission of a written request. 
However, of the eight homes, four denied the request with no referral to another agency for 
assistance.  Three agreed to provide the requested information, while one referred the request 
to the Social Security Administration (SSA).12  Of the eight requests made to the nursing 
homes, only three were received.  According to the OIG staff, two of the received results were 
legible copies of the actual HCFA 2567L; the third was a State survey inspection summary 
report.  Two of the results were received three days from the date requested by OIG; the 
remaining survey took nine days. 
HCFA - The first survey results request to each HCFA regional office was conducted by 
telephone.  Half of the offices required subsequent submission of a written request.  Of the ten 
offices, five agreed to provide the requested information, three inappropriately referred callers 
to SSA, and two did not provide a referral.  Due to the time constraints of our study, we 
specified a date by which the OIG staff had to complete their reviews.  From the five HCFA 
offices which agreed to provide the survey results, we received only one response, 23 days 
after our request. 
6
  State Agency - The first request for survey results to each of the eight State offices 
responsible for surveys was conducted by telephone.  As with HCFA, half of the offices 
required subsequent submission of a written request.  Of the eight offices, seven agreed to 
provide the requested information; one referred the caller to another State agency.  However, 
only four of these seven offices responded.  Their response times ranged between one and 12 
days. 
Mail Requests to State and HCFA Offices 
Most requests for nursing home survey results are initiated by mail, and most of the 
requests are made to the State; patients and their families are the least frequent 
requesters using this method. 
As the following table indicates, the State offices vary greatly in the numbers of requests for 
survey results: 
State Requests for Survey Results 
(Calendar Year 1997) 
California  861 
Georgia  1,175 
Illinois  157 
Massachusetts  221 
Missouri  1,500 
New York  17 
Pennsylvania  Not maintained 
Texas  Unknown 
In contrast, most of the HCFA regional offices indicated they did not receive many requests for 
survey results.  Eight offices reported requests ranging from three to ten in calendar year 1997; 
two offices did not respond.  Regardless of whether the requests are made to the State or 
HCFA, patients and their families are the least frequent requesters of nursing home survey 
results.  The highest number of requests is received from attorneys, according to six State and 
eight HCFA offices.  The next highest category of requestor was the media according to three 
HCFA offices and advocacy groups per one State office. 
While all State offices and HCFA regional offices accept written, faxed, or electronic 
requests, States most often reported to the OIG that they would accept telephone 
requests. 
Six of the States, as compared to only two of the HCFA regional offices, reported to the OIG 
that they would accept telephone requests from the public.  This may account for one possible 
reason why individuals do not request information from the HCFA regional offices more often. 
Possible responses times may be another factor. 
7
  Processing and delivery procedures may delay timely receipt of requested survey results. 
Five of the eight State offices reported responding to a request in less than ten days (from the 
date received to mailing); one reported less than 30 days, and one reported less than 60 days. 
For the few requests HCFA regional offices reported receiving, their response times ranged 
from a low of seven days to a high of 20 days.  We did not verify the response times reported 
by the State or HCFA offices. 
Additionally, HCFAs central office indicates that delivery time may delay receipt of the survey 
reports.13  The Freedom of Information Act requires processing of requests within 20 days. 
However, HCFA suggests that the duration between request and receipt of survey results can 
be increased five to six weeks.  Also, HCFA considers mailing of the request for information as 
acceptance by the requestor of any associated costs.  To ensure the requestor understands this 
concept, a time delay may occur before shipment of the results while HCFA notifies the 
requestor of the report costs and requires the requester to confirm information (as to the 
purpose and use of the reports) presented in their request letters.14 
State and HCFA charges for processing and providing survey results may be unclear to 
the requestor and are potentially expensive. 
Each of the State offices and HCFA regional offices apply charges for services in response to 
public requests for nursing home survey information, but what charges will actually be billed is 
sometimes unclear at the time the request is initiated.  For example, four of the eight State 
offices indicated that they would routinely not assess charges for requests whose final product 
resulted in a total potential charge ranging from $1 to $5.  Two States indicated they would 
not charge for requests resulting in either less than nine pages or less than 19 pages, 
respectively.  Each HCFA regional office has established $15 as the amount at which charges 
will begin to be applied. 
Type of Fees and Number of Offices Charging Fees 
State  HCFA Regional 
Offices  Offices 
Record Search  3  8 
Processing Time  3  6 
Reproduction  8  9 
Standard Postage  2  2 
Special Postage*  3  10 
*Overnight mail, boxes, etc. 
Also unclear are the charges for the OSCAR reports when the request is made to HCFAs 
central office.  The HCFA Internet site indicates a potential for higher fees.  While HCFAs 
charge and fee standards follow the Freedom of Information Act standards,15 the applied 
8
  charges appear different for standard and ad hoc OSCAR report requests.16  According to 
HCFAs Internet information, a charge of $85 may be assessed for a single profile of a nursing 
home, such as OSCAR Reports 3 or 4.  A notation at the site does identify a $3,000 limit for 
requested OSCAR data.1 7
ACCESSING SURVEY RESULTS FROM THE INTERNET 
Locating HCFAs new Internet site for survey results proved somewhat difficult, but 
once located, it was easy to use.  We found survey results for 56 of our 64 sample nursing 
homes. 
As our methodology previously indicated, an OIG staff person very familiar with Internet 
research was assigned the project of accessing HCFAs Internet Home Page (main entry to 
HCFAs site and its accompanying links to other HCFA pages).  The staffer then attempted to 
locate the HCFA Internet site with the nursing home survey results, Nursing Home Compare,18 
and obtain that sites summary survey results for the 64 sample nursing homes in this 
inspection. 
The difficulty encountered was actually locating the new site.  Upon accessing HCFAs Home 
Page, several attempts were made to perform a search (asking the HCFA site to search its own 
location for links to the needed information).  Several syntax options were attempted; none 
were successful in reaching the specific site where the survey results are maintained.  Each link 
from the Home Page was also followed to no avail.  After three hours, the staffer resorted to 
asking for the specific site address.  Members of the public may have similar difficulties, 
especially if they are also unaware of HCFAs identity and responsibility for nursing homes, 
Medicare, and Medicaid. 
Ultimately, the staffer was able to obtain summary survey results information for 56 of our 64 
sample nursing homes.  Upon reaching the new HCFA Internet site, the searcher identifies the 
State in which the nursing home is located, and an automatic link takes the searcher to that 
States nursing home database.  Searches for specific nursing home information may then be 
made in several ways, allowing the individual every opportunity for success. 
Sixty-five percent of the families and others said the Internet could be helpful in 
providing useful nursing home information; another 28 percent were uncertain as to its 
usefulness. 
When we initiated this study, we knew that HCFA was planning to add nursing home summary 
survey information to its Internet site.  Given this, we asked the family and other individuals 
responsible for nursing home patients about the perceived usefulness of an Internet site 
providing such information.  Fully 65 percent of the families and others said Internet access to 
survey results would be helpful in making their decision concerning a nursing home.  However, 
9
  some of these individuals also said it would only be useful for those having access.  Another 28 
percent did not know the usefulness of the Internet, and six percent said it would not be 
helpful. 
REPORT LEGIBILITY 
The nursing home reports on HCFAs new Internet site appear far more readable and 
understandable than the OSCAR reports. 
Only 11 of our 155 families and others asked to see the survey results.  Of these, two said the 
results were not readable and three said they were somewhat difficult to understand. 
Further, a review of the one HCFA regional office response received by the OIG indicated the 
survey results (HCFA 2567L) lacked information, such as definitions, needed to understand 
and interpret the survey results.  We also found that the survey results were not sufficiently 
readable or understandable to assist a layman in making a decision. 
The OIG staff review of the five State responses received indicated the survey results for four 
did provide sufficient information to understand and interpret the results.  However, based on 
our review, we judged these survey results as not easily readable or understandable by a 
layman. 
As previously indicated, HCFAs new Internet site, Nursing Home Compare, provides public 
access to summary information about certified nursing home survey results.  The nursing home 
summary survey results format appeared very legible and understandable (Appendix A).  We 
compared this summary information on one sampled nursing home against the HCFA 2567L 
(Appendix B) of the same facility.  In our opinion, the HCFA Internet summary report is much 
more legible and understandable than the standard OSCAR report.  We have attached copies 
of both reports so that the reader may personally assess the differences between them. 
10
  RECOMMENDATIONS

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We conclude that the existing system for providing public access to nursing home survey 
information does not work as intended.  While HCFAs new Internet initiative will prove very 
helpful to those having access to the Internet, we believe it is equally important to strengthen 
all existing avenues for receiving information as well as to identify new avenues.  To 
accomplish this, we believe HCFA should: 
<	  Continue to promote public awareness of the required quality of care standards for nursing 
homes. 
<	  Work with States and patient advocacy associations to promote public awareness that 
nursing home survey results are available for review by any member of the public. 
<	  Include, in HCFAs Guide to Choosing a Nursing Home, language that explains simply 
what constitutes a nursing home survey and the availability and location of survey results. 
<	  Work with interested public and private entities to promote public knowledge about how 
and where to access HCFA survey reports on nursing homes. 
<	  Work with the States, patient advocacy associations, and nursing home industry 
associations to develop acceptable laymens language for HCFA nursing home reports 
provided in response to public requests for such information.  Some improvements can be 
made by modeling a summary report after the one that appears on HCFAs new Internet 
page. 
<	  Consider the feasibility of requiring nursing homes to provide a HCFA-prepared summary 
survey report as part of the admission process in each nursing home. 
<	  Promote awareness of the new HCFA Internet site providing summary nursing home 
survey report information. 
<	  Create a direct link to the summary nursing home information on HCFAs Internet home 
page. 
<	  Require the posting of available nursing home survey information in a standard, readily 
visible location in each nursing home. 
<	  Enforce the requirement to post survey results in locations not readily observable by 
nursing home staff. 
<	  Explore other avenues of providing nursing home information to the public.  For example, 
determine the feasibility of providing hospital discharge planners with nursing home survey 
reports to facilitate the choice of a nursing home when patients are transferred from the 
hospital to a nursing home. 
<	  Work with States and advocacy associations to explore additional means of providing 
nursing home profile information (e.g., advertised telephone number in each State and 
HCFA regional office for consumers to call). 
11
  AGENCY COMMENTS

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We solicited comments from agencies within the Department of Health and Human Services 
which have responsibilities for policies related to Medicare and Medicaid, as well as for long 
term care.  We received comments from HCFA concurring with each of our recommendations. 
The HCFA further emphasized their continued support for ensuring sufficient information is 
available to the public for their use in making informed decisions regarding long term care. 
They further indicated their additional interest in exploring the development of a national 1-800 
number to provide public access information and reports regarding nursing homes.  Comments 
of HCFA may be reviewed in total at Appendix F. 
12
  ENDNOTES

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1.  Sections 1819(g) and 1919(g)(3) of the Social Security Act. 
2.	  Code of Federal Regulations Title  42, Section 401, implements section 1106(a) of the 
Act as it applies to HCFA.  Specifically, they relate to the availability to the public, 
under 5 U. S. C. 552 (Freedom of Information Act (FOIA)), of records of HCFA and 
its components and how those records are available and may be obtained. 
3.	  The FOIA defines request as asking for the information, regardless of whether the 
individual refers specifically to the FOIA. 
4.  DHHS Requester Types and General Charges Applied: 
<  Commercial - DHHS will charge for costs of search, review, and duplication 
<  Education and Non-commercial  Scientific Institutions and News Media - If operating 
primarily for scholarly or scientific research and the request is not for a commercial use, 
DHHS will charge only for duplication of documents and will not charge copying costs for 
the first 100 pages of duplication. 
<  Other Requesters (the general public) - DHHS will charge for search and duplication, 
except that the first two hours of search time and the first 100 pages of duplication are free. 
5.	  Code of Federal Regulations, Title 45, Volume I, Parts 1 to 199, revised October 1997, 
via U.S. Government Printing Office, Internet cite 45CFR5. 
6.	  Each DHHS agency follows FOIA guidelines for assessing fees for searches, reviews, 
and photocopying.  Generally, DHHS policy allows charges for the following fees: 
(a)  Manual searching for records  Based on hourly rate and grade level grouping of
 
each employee performing the activity (usually
 
$10, $20, or $37)
 
(b)  Computer searching and printing  The actual cost of operating the computer plus
 
charges for the time spent by the operator, at the
 
same rates as a manual search
 
(c)  Photocopying standard size paper  $0.10 per page (which may be lowered in some
 
instances)
 
(d)  Photocopying odd-size paper  The actual costs of operating the equipment, plus
 
the actual cost of the materials used, plus charges
 
for the time spent by the operator at the same rates
 
as a manual search
 
(e)  Reproducing other records (tapes)  Same as (d) above
 
7.	  State Operations Manual, Section 483.10(g)(1)-(2), Health Care Financing 
Administration. 
8.  HCFA site:  http//www.medicare.gov/nursing/home.asp. 
9.	  The entire facility is certified only for Medicare; no beds are in the facility which may 
be converted to use by a Medicaid patient. 
13
  10.	  1997 Data Compendium and Medicaid Program and Financial Statistics Fiscal Year 
1996, Health Care Financing Administration. 
11.  Revision 273, State Operations Manual, PP-25, June 1995. 
12.	  The Social Security Administration, once a component in the Department of Health and 
Human Services, has historically been a source of Medicare information to the 
communities being serviced.  Today, they still maintain many materials for public use; 
however, they are not required to maintain nursing home survey results.  According to 
the SSA Dallas regional office, such a request would probably be sent to the Health 
Care Financing Administration. 
13.  This information is provided by HCFA on its Internet site. 
14.	  HCFA Internet site location of costs associated with most standard and ad hoc OSCAR 
reports:  http://www.hcfa.gov/wwwroot/medicare/hsqb/oscar1.htm. 
15.  Refer to Endnote 6. 
16.  Refer to Endnote 12. 
17.	  The HCFA Internet site location explains its Freedom of Information and Privacy Act 
policy.  It also explains processing times and internal requirements for making survey 
results  requests, including the potential charges.  The site address is 
http://www.hcfa.gov/foip/default.htm#contacts. 
18.  HCFA site:  http//www.medicare.gov/nursing/home.asp. 
14
  APPENDIX A
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Sample HCFA Internet Nursing Home Summary Report 
A - 1
     APPENDIX B
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Sample HCFA Form 2567L 
B - 1
    APPENDIX C
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Sample HCFA OSCAR Report 3
 
C - 1
   APPENDIX D

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Sample HCFA OSCAR Report 4
 
D - 1
   APPENDIX E

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Sample HCFA OSCAR Report 40
 
E - 1
    APPENDIX F

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HCFA Comments on Draft Report 
F - 1