Department of Health and Human Services
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
N   H C
URSING  OME  ORPORATIONS 
 
U Q C
ND ER  UALITY OF  ARE 
 
C I
ORPORATE  NTEGRITY 
 
 
A  
GREEMENTS 
 
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
April 2009 
OEI-06-06-00570   
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs, as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine 
the performance of HHS programs and/or its grantees and contractors in carrying out their 
respective responsibilities and are intended to provide independent assessments of HHS 
programs and operations.  These assessments help reduce waste, abuse, and mismanagement 
and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, 
Congress, and the public with timely, useful, and reliable information on significant issues.  
These evaluations focus on preventing fraud, waste, or abuse and promoting economy, 
efficiency, and effectiveness of departmental programs.  To promote impact, OEI reports also 
present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources by 
actively coordinating with the Department of Justice and other Federal, State, and local law 
enforcement authorities.  The investigative efforts of OI often lead to criminal convictions, 
administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, 
rendering advice and opinions on HHS programs and operations and providing all legal support 
for OIGs internal operations.  OCIG represents OIG in all civil and administrative fraud and 
abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil 
monetary penalty cases.  In connection with these cases, OCIG also negotiates and monitors 
corporate integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care industry 
concerning the anti-kickback statute and other OIG enforcement authorities.   
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OBJECTIVE
 
To review nursing home corporations under quality of care Corporate 
Integrity Agreements (CIA) to: 
1.  determine the extent to which they implemented required quality of 
care structures and processes,  
2.  determine their responsiveness to quality monitoring, and 
3.  describe challenges encountered when implementing the 
requirements of their CIAs. 
BACKGROUND 
Under quality of care CIAs, nursing home corporations with identified 
quality of care problems consent to certain requirements in exchange for 
an agreement by the Department of Health and Human Services, Office 
of Inspector General (OIG), not to exclude them from participation in 
Federal health care programs.  A nursing home quality of care CIA is a 
contract that is typically entered into for 3 to 5 years and requires 
implementation of quality of care structures and processes and 
monitoring by an independent monitor.   
This study examined the 15 nursing home corporations that began 
quality of care CIAs between June 2000 and December 2005.  To review 
these corporations, we examined corporate documents and reports from 
corporations and their quality monitors and interviewed corporate 
representatives and monitors. 
FINDINGS 
All 15 corporations enhanced quality of care structures and 
processes while under their CIAs and cited positive effects of the 
CIAs.  Each corporation had written policies and procedures regarding 
quality of care, codes of conduct, and training required by their CIAs.  
All 15 corporations monitored their quality of care by using 
standardized data and internal self-assessment tools and by tracking 
complaints.  They all created or expanded their compliance 
infrastructure to integrate quality of care.  In interviews, corporate 
representatives cited positive effects that the CIAs had on their 
corporations. 
  OEI-06-06-00570  NURSING HOMES CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS    i  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY   
Despite some initial resistance from 3 corporations, all 15 were 
ultimately responsive to their quality monitors guidance and 
corporate representatives reported that they valued the input. 
Quality monitors reported that 12 of the 15 corporations accepted and 
acted on the monitors guidance from the start of their CIAs and that  
3 initially resistant corporations became responsive (following OIG 
intervention) while under the CIAs.  Our review of quality monitoring 
reports and corporate annual reports confirmed the monitors opinions 
that the 15 corporations were largely responsive to the monitors 
guidance.  Additionally, corporate representatives cited several benefits 
of quality monitoring, e.g., monitors offered new ideas and fresh ways of 
thinking about quality of care structures and processes.   
Representatives of all 15 corporations described challenges 
encountered when implementing CIA requirements.  Corporations 
with multiple nursing homes encountered challenges to ensuring 
consistency in quality of care systems across all layers of their 
organizations and across geographic regions.  For example, an analysis of 
Quality Assessment and Assurance (QAA) committee meeting minutes 
indicated that nursing homes implementation of quality of care systems 
was inconsistent.  Other challenges involved organizational disruptions, 
staff resistance to implementation, use of staff time to implement the 
requirements of the CIAs, and financial costs associated with CIAs.  
Inherent limitations of commonly used quality of care measures 
prevented our assessment of the quality of care performance of 
nursing homes under CIAs.  We analyzed data from sources commonly 
used by the Centers for Medicare and Medicaid Services, quality 
monitors, and nursing home corporations as indicators of nursing home 
quality.  However, we could not use these data to adequately assess the 
quality of care performance of nursing homes under CIAs because these 
measures do not have established benchmarks that set standards for 
what constitutes quality care. 
CONCLUSION 
All 15 corporations enhanced quality of care structures and processes to 
meet the CIA requirements.  Corporate representatives from each 
corporation cited positive effects of their CIAs.  Although all 
corporations were ultimately responsive to their quality monitors 
guidance and valued their input, three corporations were initially 
resistant until OIG intervened.  All corporations faced challenges in 
  OEI-06-06-00570  NURSING HOME CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS   ii  E X E C U T I V E   S U M M A R Y  
implementing CIA requirements, such as difficulties in implementing 
quality systems throughout all levels of the corporations, including 
systems at the nursing home level.  Based on these findings, areas that 
OIG will explore for its oversight of future CIAs include the following: 
  Responding swiftly to noncompliant corporations and those that fail 
to address quality problems by using available enforcement 
remedies, such as monetary penalties or, if appropriate, exclusion 
from Federal health care programs.  Additionally, a providers 
continued failure to address quality of care may warrant opening 
new investigations by OIG.   
  Including specific requirements regarding documentation of nursing 
home QAA committee activities to ensure that quality of care 
monitoring and improvement systems are implemented at the 
nursing home level. 
  Sharing lessons learned by corporations and quality monitors with 
other corporations placed under subsequent CIAs. 
  OEI-06-06-00570  NURSING HOME CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS   iii   
 T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
I N T RO DUC T IO N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
 
 
F I N D IN G S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 
All corporations enhanced quality of care structures and         
processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 
All corporations were ultimately responsive to quality             
monitors  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 
All corporations cited challenges to implementing CIAs . . . . . . . . 13 
Quality measures limitations prevented assessment of quality           
of care performance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 
 
 
CONC LUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 
  A:  Nursing Home Corporations Included in This Review. . . . . . . 18 
B:  Quality Assessment and Assurance Committee             
Methodology and Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 
  C:  Quality Indicators/Quality Measures . . . . . . . . . . . . . . . . . . . . 24 
  D:  State Survey Deficiencies Data by Corporation . . . . . . . . . . . . 40 
 
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 
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OBJECTIVE 
To review nursing home corporations under quality of care Corporate 
Integrity Agreements (CIA) to: 
1.  determine the extent to which they implemented required quality of 
care structures and processes,  
2.  determine their responsiveness to quality monitoring, and 
3.  describe challenges encountered when implementing the 
requirements of their CIAs. 
BACKGROUND 
Nursing home quality of care problems come to the attention of the 
Department of Health and Human Services, Office of Inspector General 
(OIG), through different avenues.  For example, quality problems may 
become apparent when allegations of poor patient care are brought 
against providers under the False Claims Act.1  Some quality of care 
problems are brought to OIGs attention through referrals from State 
and local law enforcement agencies.  Still others come to OIGs attention 
from other sources, such as media reports or Medicare and the OIG 
hotline. 
As part of the resolution of quality of care cases, OIG may agree not to 
exclude a nursing home corporation from participation in Federal health 
care programs if the corporation enters into a quality of care CIA with 
OIG.2  A quality of care CIA typically lasts 3 to 5 years and includes 
requirements that the corporation: 
  contract with an independent quality monitor authorized by OIG 
and provide the monitor with relatively unfettered access to 
facilities, staff, residents, documents, and management at all levels 
of the organization; 
  designate a compliance officer and appoint a corporate-level Quality 
Assurance Committee to oversee clinical improvement and 
compliance issues throughout the corporation; 
 
1 31 U.S.C.   37293733. 
2 42 U.S.C.   1320a-7 provides the authority for excluding entities from participation in 
Medicare, Medicaid, and other Federal health care programs. 
  OEI-06-06-00570  NURSING HOME CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS    1  I N T R O D U C T I O N  
  implement internal monitoring of quality of care; 
  establish a confidential disclosure program, e.g., a hotline;  
  develop written standards, policies, and procedures;  
  screen to ensure that ineligible persons are not hired;3 
  implement competency-based employee training programs; and 
  submit status reports to OIG and report certain events, e.g., serious 
quality of care problems, to the quality monitor and OIG within 
specific timeframes. 
If the corporation fails to comply with the CIA, OIG may impose 
monetary penalties or, in the case of a material breach by the 
corporation, OIG may exclude one or more of the corporations nursing 
homes from participation in Federal health care programs. 
Nursing Home Quality of Care Corporate Integrity Agreements 
The first nursing home quality of care CIA went into effect in  
June 2000.  By June 2008, 35 nursing home corporations had entered 
into such agreements, 16 corporations under original CIAs and  
19 corporations under successor agreements.  A successor agreement 
is initiated when a corporation under a CIA sells nursing homes, splits 
into two or more corporations, or reorganizes to form a new corporation.  
Nursing homes that are sold, or those that are under the newly formed 
or reorganized corporation, are sometimes placed under successor 
agreements to ensure that they fulfill the original CIA requirements.   
This is the first review of nursing home corporations under CIAs since 
OIG began entering into quality of care CIAs. 
 
3 An ineligible person is any individual or entity who:  (1) is currently excluded, 
suspended, debarred, or otherwise ineligible to participate in the Federal health care 
programs or (2) has been convicted of a criminal offense related to the provision of health 
care items or services that falls within the ambit of 42 U.S.C.  1320a-7(a) but has not yet 
been excluded. 
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Quality of Care Structures and Processes 
Quality of care CIAs include requirements about the structures and 
processes of corporations related to quality of care.   
  Quality of care is the degree to which health services for individuals 
and populations increase the likelihood of desired health outcomes 
and are consistent with current professional knowledge.4 
  Quality of care structures are the framework of policies and rules 
within which the corporation arranges its lines of authority and 
communication, division of labor, and formal powers that direct 
organizational activities affecting quality of care. 
  Quality of care processes are the activities that take place within 
these structures. 
For example, a structural change to address quality of care problems in 
a nursing home where residents have a higher than normal number of 
falls may involve writing a new policy for fall prevention.  The 
associated process change would be the activities undertaken to 
implement the new policy. 
Quality Monitoring 
In addition to undergoing monitoring by OIG, each corporation under a 
quality of care CIA is required to contract and pay for the services of an 
independent quality monitor, which is selected by OIG.5  CIAs require 
corporations to give monitors relatively unfettered access to nursing 
home records and staff.  Quality monitors set their own fees with the 
corporations, and corporations pay for the monitors services.6  OIG 
expects that the monitors will work with the corporations so that the 
corporations can learn to identify and resolve quality of care concerns.   
Quality monitors employ a variety of strategies to identify quality of 
care problems.  They discuss quality of care issues with key personnel at 
 
4 Measuring the Quality of Health Care:  A Statement of the National Roundtable on 
Healthcare Quality Division of Healthcare Services, National Academy Press, 1999.   
5 Monitors are individuals or entities that OIG has determined have competency in key 
areas, including knowledge and experience with long-term care quality, clinical practice, 
data technology, data analysis, monitoring of quality of care, and general management. 
6 Testimony of Lewis Morris, Office of Counsel to the Inspector General,                        
U.S. Department of Health and Human Services, to the U.S. House of Representatives 
Committee on Energy and Commerce, Subcommittee on Oversight and Investigations.   
May 15, 2008.  Available online at 
http://oig.hhs.gov/testimony/docs/2008/testimony051508.pdf.  Accessed on June 20, 2008. 
  OEI-06-06-00570  NURSING HOME CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS    3  the corporate level, conduct site visits to individual nursing homes, 
review structures and processes related to the delivery of resident care, 
and analyze relevant data.  Monitors provide periodic reports to OIG 
and the corporations with findings from their monitoring activities.   
These reports include guidance for corporations presented as 
recommendations, observations, or suggestions.  The findings and 
guidance reflect systemic issues noted by monitors rather than problems 
encountered in each individual nursing home. 
One indicator of whether systemic solutions are being applied at the 
nursing home level is reflected in the individual nursing homes Quality 
Assessment and Assurance (QAA) committee activities.  Federal 
regulations require a QAA committee at each nursing home.7  The 
committee must meet at least once each quarter, and membership must 
include the Director of Nursing Services, a physician, and at least three 
other members of the nursing homes staff.8  The role of the QAA 
committee in a nursing home includes identifying quality problems by 
analyzing quality of care data, identifying the root causes of quality 
problems,9 developing and implementing action plans to correct quality 
problems, monitoring the effect of implemented changes, and revising 
the action plans if needed.10     
Quality of care CIAs have requirements that corporations appoint 
Quality Assurance Committees at the corporate level but do not have 
particular requirements for QAA committees in individual nursing 
homes.  However, the CIA quality monitors assess quality assurance 
activities and review quality-assurance-related documents during site 
visits to nursing homes under CIAs.  Further, monitors consider QAA 
committees as vehicles through which corporate-level quality of care 
 
7 42 CFR  483.75(o)(2)(i).  Nursing homes sometimes refer to these committees as 
quality improvement committees, performance improvement committees, and quality 
assurance committees. 
8 42 CFR  483.75(o)(2)(i). 
9 Often referred to as root cause analysis, a method for exploring underlying issues that 
result in quality of care problems.  U.S. Department of Veterans Affairs, National Center 
for Patient Safety, Root Cause Analysis.  Available online at 
http://www.patientsafety.gov/rca.html.  Accessed on June 20, 2008. 
10 State Operations Manual, Appendix PP, Interpretive Guidelines for Long Term 
Care Nursing Homes, guidance for 483.75(o).  Available online at 
http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf.                  
Accessed on June 20, 2008. 
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structures and processes can be integrated into care practices at the 
nursing home level. 
METHODOLOGY 
Scope 
This study examines the 15 nursing home corporations under quality of 
care CIAs with start dates between June 2000 and December 2005.  
These 15 were the only nursing home corporations that were under 
quality of care CIAs for at least a year prior to December 2006, when we 
began this review.  Ten corporations were under their original CIAs and 
five were under successor agreements.  The 15 corporations collectively 
operated 1,104 nursing homes nationwide as of December 31, 2006.  
These included four corporations with 100 or more nursing homes, three 
corporations with 10 to 99 nursing homes, four corporations with  
2 to 9 nursing homes, and 4 individual nursing homes.  Three of the 
individual nursing homes were owned by parent corporations and one 
was independently owned.  Additional information about the  
15 corporations is in Appendix A. 
Data Collection and Analysis 
Implementation of required quality of care structures and processes.  To 
determine the structures and processes that corporations had in place to 
meet the CIA requirements, we reviewed documents from each of the  
15 corporations.  These included copies of organizational charts, policies 
and procedures, codes of conduct, information publicizing corporations 
complaint hotlines, logs of complaints received, training materials and 
training attendance logs, internal quality assessment instruments and 
reports, and implementation and annual reports that corporations 
submitted to OIG.  
We also conducted structured interviews with representatives of 
corporations, e.g., compliance officers and chief executive officers (CEO).  
We inquired about corporate quality of care structures and processes; 
the way in which the corporation addressed each of the requirements of 
the CIA; and the corporations experiences under the CIA, including the 
positive and negative aspects.  We interviewed representatives of 
corporations with 10 or more nursing homes in person and 
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representatives of corporations with 2 to 9 nursing homes and the 
individual nursing homes by telephone.11 
Responsiveness to quality monitoring.  To determine corporations 
responsiveness to quality monitoring, we used all 168 quality monitor 
reports submitted to OIG, covering the period between June 2000 and 
December 2006 (the end date for our document requests), by the  
five entities that conducted quality monitoring for the 15 nursing home 
corporations.  We requested monitors protocols and conducted 
structured interviews with each quality monitor by telephone.  We 
inquired about their monitoring activities and protocols and their 
experiences with each corporation. 
To assess corporations responsiveness to guidance provided by quality 
monitors, we identified 611 recommendations, suggestions, or concerns 
(hereinafter referred to as guidance items) that the five monitors 
provided to corporations in the 168 quality monitor reports submitted to 
OIG from June 2000 through December 2006.  We then examined 
subsequent reports issued by monitors and the corporations reports to 
OIG to find evidence that the corporations responded to the quality 
monitors guidance.  We determined that the corporation was responsive 
if there was evidence in a subsequent monitoring report or annual 
report that the corporation had acted on the quality monitors guidance.  
Follow-up information was available for 485 (79 percent) of the  
611 guidance items identified.  We had no subsequent monitoring or 
annual reports to review for the other 126 guidance items and could not 
assess corporate responsiveness to them.  We based our findings on the  
485 guidance items for which follow-up information was available.   
Challenges encountered when implementing CIA requirements.  In 
conducting interviews, we included questions about challenges that 
corporations encountered when implementing CIA requirements.   
To assess the extent to which quality systems were consistently 
implemented at the nursing home level of the corporation, we examined 
the corporations use of quality assurance processes at that level.  We 
requested written minutes from QAA committee meetings for a random 
sample of 407 nursing homes.  We determined whether the minutes 
documented that QAA committees met quarterly, as required, for each 
 
11 We were not able to interview representatives from one corporation with two to nine 
nursing homes because the CIA had expired and all individuals who had been involved were 
no longer with the corporation. 
  OEI-06-06-00570  NURSING HOME CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS    6  II NN TT RR OO DD UU CC TT II OO NN   
quarter from July 2005 through December 2006.12  We also determined 
whether minutes reflected that nursing homes used data to identify 
problems, conducted root cause analysis, developed action plans to 
address identified problems, and followed up on those action plans.  
Additional information about the QAA committee analysis is presented 
in Appendix B. 
Limitations 
Our analysis of nursing home QAA committees relies on the written 
minutes of meetings that corporations submitted to us.  It is possible 
that some QAA committees held meetings but did not document their 
activities or that nursing homes did not retain the meeting minutes, 
and we would not be aware of these meetings or the committees 
activities. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency. 
 
12 We selected the most recent 18-month period because many nursing homes did not 
have minutes available for a longer period of time.  
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 F I N D I N G S  
Each of the 15 corporations 
All 15 corporations enhanced quality of care 
developed new, or improved 
structures and processes while under their CIAs 
existing, quality of care structures 
and cited positive effects of the CIAs  
and processes as they implemented 
the requirements of the CIA.  For purposes of this review, we grouped 
these structures and processes into three areas:   
(1) written policies and procedures, codes of conduct, and training 
related to quality of care; (2) tools and activities to monitor quality of 
care; and (3) the organizations infrastructure related to quality of care.   
The 15 corporations had written policies and procedures regarding quality 
of care, codes of conduct, and training required by their CIAs 
Corporate representatives reported that their organizations revised and 
updated many policies and procedures to comply with the CIA 
requirements and to align them with the nursing home compliance 
program guidance issued by OIG in 2000.13  As of January 2007, each 
corporation had written policies and procedures that specifically 
addressed quality of care issues.  These materials contained information 
relating to corporate structures, such as the QAA committee 
membership and responsibilities.  Other topics dealt with clinical 
procedures, staff training, procedures for handling complaints, and 
screening of employees or contractors to identify persons ineligible for 
participation in Federal health care programs.   
Each corporation also had a written code of conduct that described the 
organizations principles and values and set general expectations for all 
employees.  The levels of detail and presentation of the codes varied 
across corporations, ranging from brief statements that fit on a single 
sheet of paper to more detailed booklets.  All corporations provided 
codes of conduct to employees during orientation and training sessions, 
as required by their CIAs. 
Corporations also trained employees on the CIA requirements and 
various aspects of providing coordinated interdisciplinary care to 
residents.  Corporations reported that they identified training needs 
through their internal monitoring systems.  Although each corporation 
approached employee training differently, they all developed systems to 
ensure that each employee took the required training when initially 
hired and annually thereafter.  Notably, staff from one corporation 
 
13 65 Fed. Reg. 14289 (Mar. 16, 2000). 
  OEI-06-06-00570  NURSING HOME CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS    8  F I N D I N G S  
reported that an Internet-based training system developed to facilitate 
and track training required by the CIA was eventually turned into a 
separate product that it markets to other corporations and nursing 
homes. 
The 15 corporations monitored quality of care by using standardized data 
and internal self-assessment tools and by tracking complaints  
Each corporation had methods for identifying quality of care problems 
and monitoring quality improvement progress.  Some of these tools were 
in use before the CIA, and each corporation either developed or adopted 
additional assessment tools or expanded upon existing tools to meet the 
CIA requirements.  
Standardized data.  Corporations reported that they routinely used 
readily available, standardized data to monitor each nursing homes 
performance.  For example, corporations used the Centers for Medicare 
and Medicaid Services (CMS) Quality Indicators/Quality Measures 
(QI/QM) to identify trends in specific care areas, such as pressure sores 
and urinary tract infections.14   The QI/QMs are 28 prevalence or 
incidence measures derived from information recorded during periodic 
assessments of residents performed by nursing home staff and 
contained in the Minimum Data Set (MDS).15   
Corporations also used State survey deficiency citations to gauge 
compliance with Federal standards.  State survey deficiencies are 
generated during surveys of each nursing home, which must be 
conducted every 9 to 15 months.16  CMS contracts with States to 
conduct these surveys to verify whether nursing homes maintain 
Federal quality of care standards.  Corporations used these data to 
identify recurring problems across nursing homes that would suggest 
the need for systemic solutions and specific nursing homes or areas 
needing targeted attention.  Corporate compliance officers explained 
 
14 The initial Quality Indicators were developed, under a contract with CMS, by the 
Center for Health Systems Research and Analysis at the University of Wisconsin  
Madison.  D. Zimmerman, Improving nursing home quality of care through outcomes data:  
the MDS quality indicators, International Journal of Geriatric Psychiatry, Volume 18, 
2003.  They were later revised to include Quality Measures. 
15 Section 1819(f)(6)(A) of the Social Security Act, added by the Omnibus Budget 
Reconciliation Act of 1987, 42 CFR  483.20(b-c), and CMS, Resident Assessment 
Instrument Version 2.0 Manual. 
16 Social Security Act  1819 (g) and 1919(g). 
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how identified problems prompted the development of action plans to 
address them.   
Internal self-assessment tools.  To supplement information from 
standardized data, all 15 corporations developed their own  
self-assessment tools or adapted existing tools used by others in the 
nursing home industry.  One type of self-assessment tool involved onsite 
nursing home reviews, known as quality control reviews or mock 
surveys, conducted by internal teams.  The review results took various 
forms, e.g., scorecards, and provided nursing home administrators and 
other corporate employees with in-depth information about aspects of 
quality of care.   
Corporations also reported using satisfaction surveys, chart audits, and 
staffing measures to monitor quality of care.  Satisfaction surveys were 
used to provide nursing homes with direct feedback from residents and 
family members.  Chart audits enabled homes to monitor compliance 
with established resident care standards and guided training when staff 
deviated from established care standards.  Monitoring of each nursing 
homes staffing levels and turnover identified nursing homes with 
insufficient staff to deliver quality care.  
Complaints.  Another form of internal monitoring used by corporations 
was reviewing complaints from residents, family members, nursing 
home staff, and others.  All 15 corporations had some type of telephone 
complaint hotline that satisfied the confidential disclosure program 
requirement of the CIAs.  All corporations also took steps to protect 
caller confidentiality, such as removing identifiable information before 
sending a record of the complaint to a nursing homes administrator.  
Corporate representatives described a variety of methods used to track 
and follow up on complaints to ensure that issues were resolved.  One of 
the more elaborate examples involved a corporation whose vendor 
uploads complaint information to a limited-access Internet Web site.  
Each complainant is provided an access code to track the status and 
eventual resolution of the complaint.  In addition to tracking each 
complaint, corporate staff use the tracking system to monitor the 
number and nature of complaints lodged against each nursing home and 
to identify recurring or widespread problems.  Corporations also 
received complaints through other mechanisms, including anonymous 
complaint boxes at individual nursing homes and in-person complaints 
made to social workers and other staff. 
 
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The 15 corporations created or expanded their compliance infrastructure to 
integrate quality of care 
Six corporations created new compliance programs that included quality 
of care as part of the new programs responsibilities, including the four 
new corporations that were formed when larger corporations under 
CIAs reorganized.  The other nine corporations expanded the scope of 
their existing compliance programs.  Representatives of these nine 
corporations reported that prior to their CIAs, quality of care was 
primarily within the purview of clinical operations and their compliance 
departments generally focused on other aspects, such as financial 
integrity.  Because their CIAs explicitly identified quality of care as a 
compliance issue, these corporations integrated quality of care into their 
corporate compliance infrastructure.   
As required by the CIA, each corporation had a compliance program led 
by a designated compliance officer.  All compliance officers whom we 
interviewed expressed that they had sufficient authority and support to 
perform their duties to address quality of care issues.  Several also 
explained that their approach to quality assurance was less a matter of 
exerting authority than a process of collaborating with clinical 
managers and others throughout their corporations.  
Corporate representatives cited positive effects that the CIAs had on their 
corporations 
Corporate representatives from each corporation named at least one 
positive effect that the CIA had on their corporations, and many named 
more than one.  The most frequently cited positive effect was that the 
CIA helped guide the development of more standardized processes and 
quality systems.  It made the corporation examine itself and its systems 
and track quality of care more closely.  Corporate leaders indicated that 
the CIAs helped them to focus the corporations attention on quality of 
care and communicate to employees a clear message about its 
importance.  Some corporate representatives described the CIA as a 
useful hammer or stated that it provided the ammunition needed to 
make the necessary changes.  Four corporations attributed 
improvements in quality of care directly to implementation of the CIAs.  
Additionally, a representative of one individual nursing home reported 
that the nursing home now had a better standing in its community and 
among local physicians because of CIA-related improvements. 
 
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Despite some initial resistance from 3 corporations,  Although 12 of the 15 corporations 
all 15 were ultimately responsive to their quality  seemed to readily accept and act 
monitors guidance and corporate representatives  on the quality monitors guidance, 
monitors reported that the other  
reported that they valued the input
3 corporations were initially resistant to the added oversight.  For 
example, one monitor reported that the owners of an individual nursing 
home tried to replace her.  According to the monitor, after OIG refused 
the nursing homes request, the nursing home staff and owner began 
working effectively with the monitor.  The other two of these three 
corporations delayed executing their quality monitor agreements.  One 
of the two refused to pay the quality monitor.  Only when OIG issued a 
demand letter for monetary penalties did the corporation comply.  The 
other corporation did not execute its agreement until 10 months after 
the CIA went into effect.  Also in this case, OIG had to levy a monetary 
penalty to gain the corporations compliance.  Both were under 
successor agreements and OIG extended the end dates for the quality 
monitoring because of the corporations delays.  Quality monitors 
reported that all three of these corporations eventually were cooperative 
and responsive to guidance. 
Guidance provided to the 15 corporations by the quality monitors, 
presented as recommendations, suggestions, or concerns, often 
identified specific areas needing improvement and suggested actions 
that the corporations could take.  Quality monitors reports most 
frequently called for improvements related to resident assessments, 
care planning, residents physical functioning (also referred to as 
activities of daily living), skin care, nutrition/eating, and activities for 
residents to engage in.  Monitors most frequently recommended that 
corporations conduct assessments or evaluations of the areas needing 
improvement and/or conduct staff training on the topic.  Monitors 
guidance also frequently stressed corporations implementation of a 
system, program, or protocol to spur improvement; making better use of 
the QAA process in individual nursing homes; and/or creating an action 
plan.   
Our review of quality monitoring reports and corporate annual reports 
submitted to OIG confirmed the monitors opinions that corporations were 
largely responsive to monitors guidance   
We found that subsequent reports from the monitors and/or 
corporations indicated that corporations had responded to 75 percent of 
  OEI-06-06-00570  NURSING HOME CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS   12  FF II NN DD II NN GG SS   
the 485 guidance items provided by monitors to the corporations in their 
reports.  Examples of corporate responses included developing corrective 
action plans and implementing policy or practice changes.  For another 
18 percent of the guidance items provided by quality monitors, no 
subsequent monitor or corporation reports mentioned the problems that 
prompted the guidance.  According to the monitors, this was an 
indication that corporations had addressed or resolved the concerns.  
However, for 6 percent of written guidance, quality monitors repeated 
concerns or recommendations in subsequent reports, suggesting that 
the corporations had not yet sufficiently responded to the original 
guidance.17  
Corporate representatives cited several benefits of quality monitoring 
Corporate representatives described the monitors as valuable experts 
who brought in new ideas and fresh ways of thinking about quality of 
care processes.  Several representatives mentioned that their 
corporations benefited from the monitors educational efforts to help 
nursing home staff identify and address the root cause of problems.  
Additionally, corporate representatives commented that the quality 
monitors helped emphasize the importance of quality of care within the 
organizations and helped garner support for quality improvement 
initiatives that otherwise might not have been undertaken.  Finally, 
representatives expressed that the monitors provided a second set of 
eyes that were focused on improving quality of care.  
 
During interviews, corporate 
Representatives of all 15 corporations 
representatives identified several 
described challenges encountered 
challenges to implementing the CIA 
when implementing CIA requirements 
requirements.  The most common 
challenges identified were:  ensuring consistency across their 
organizations, organizational disruptions, staff resistance to 
implementation, use of staff time to implement the requirements of the 
CIAs, and financial costs. 
Ensuring consistency.  Corporations with multiple nursing homes 
encountered challenges to ensuring consistency in quality of care 
systems across all layers of their organizations and across geographic 
regions.  For example, each of the four corporations with more than  
 
17 Percentages do not add to 100 percent because of rounding. 
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100 nursing homes was structured with multiple organizational levels 
between corporate headquarters and its nursing homes.  For these 
organizations, new quality of care systems and policies developed in 
headquarters often had to be implemented at district and regional levels 
before finally reaching local nursing homes.  Corporate representatives 
and quality monitors reported that it was a challenge to ensure that 
systems and policies were consistently passed through each 
organizational level and to all nursing homes.  Representatives from 
four corporations with fewer than 100 nursing homes reported that the 
geographic dispersion of the corporations nursing homes created a 
similar impediment to ensuring consistency.   
Further, our analysis of individual nursing home QAA committee 
meeting minutes indicated that nursing home implementation of quality 
of care processes was inconsistent.  QAA committee meeting minutes 
suggest that not all nursing homes committees met at least once per 
quarter, as required.  Specifically, six corporations provided us with 
meeting minutes for less than half of the quarters reviewed and for only 
some portion of their nursing homes.18  Further, meeting documentation 
did not support that the committees always identified or addressed 
quality of care problems.  For example, seven corporations had nursing 
homes with no documentation that they had followed up on their action 
plans.  Finally, across the nursing homes of all corporations, we found 
little documentation confirming efforts to identify the root cause of 
problems, which leaves open the possibility that action plans developed 
by QAA committees might address only the symptoms of problems and 
not the underlying causes.  For statistics about QAA committee 
meetings for each corporation, see Appendix B. 
The lack of consistent documentation could indicate inattention to 
required QAA processes and inconsistency among nursing homes in 
implementing corporate-level quality improvements.  However, the 
absence of QAA meeting minutes or documentation of specific 
committee activities does not always mean that the committees did not 
meet, as required by regulation, or did not undertake activities such as 
developing corrective action plans.  Alternatively, nursing homes may 
 
18 We did not obtain any QAA committee meeting minutes from two additional 
corporations, but that does not necessarily indicate that the committees did not meet.  
Rather, one of the two corporations had been sold by the time of our data request, and the 
other corporation had hired a new management team that reported not having access to 
prior QAA committee meeting minutes.   
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have performed these activities but not have documented the meetings 
or retained the minutes.   
Organizational disruptions.  Another reported challenge was that 
corporations experienced disruptions because of changes to their 
organizations after the CIAs began.  For example, 4 of the 15 
corporations were formed as new companies when larger corporations 
split or sold nursing homes, and the new corporations were placed 
under successor agreement CIAs.  These corporations had to design and 
implement quality of care systems to meet requirements of the CIAs as 
they grappled with establishing new companies.  Other disruptions 
occurred when corporations purchased or sold nursing homes, 
restructured their organizations, or had significant changes in 
management. 
Staff resistance.  Corporate representatives reported challenges 
involving staff resistance to the CIAs, and noted that these sometimes 
required making personnel changes.  For example, representatives of 
one corporation reported replacing a nursing home administrator who, 
rather than implementing new procedures, stored new corporate 
procedural manuals in her personal car because she did not agree that 
changes were needed.  Several corporate representatives described key 
personnel changes made during the CIAs, including replacing a CEO, a 
compliance officer, and a president of a nursing home division; two 
corporations replaced all of their corporate officers.  Another corporation 
described high turnover and recruiting difficulties encountered because 
it was under the CIA.  Representatives of this corporation perceived 
that the CIA created a stigma that may have deterred potential 
applicants from seeking employment with the corporation or its nursing 
homes.   
Staff time.  Another challenge reported by corporate representatives was 
the time required to implement the CIA requirements.  Implementation 
required staff to spend time on activities outside their regular duties.  
These activities included implementing quality systems, developing new 
policies and procedures, tracking quality outcomes, and attending 
training sessions.  Corporate representatives reported that these 
activities, while beneficial, also diverted staff from providing resident 
care. 
Financial costs.  Several corporate representatives reported that they 
were challenged by the financial costs associated with the CIA.  
Specifically, although they recognized certain benefits of quality 
  OEI-06-06-00570  NURSING HOME CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS   15  F I N D I N G S  
monitoring, they also expressed that the money spent to hire the 
monitors could have been spent for other purposes related to quality 
improvement, such as increasing staff or improving facilities. 
 
Inherent limitations of commonly used  We initially sought to assess nursing home 
quality of care measures prevented our  quality of care performance by analyzing 
data from two sources:  QI/QMs and State 
assessment of the quality of care 
survey deficiencies.  Although neither     
performance of nursing homes under CIAs 
QI/QMs nor State survey deficiency data 
were designed as a measure of quality, CIA quality monitors, CMS, and 
nursing home corporations commonly use them as indicators of nursing 
home quality.19  However, we could not use these data to determine the 
quality of care performance of nursing homes under CIAs because these 
measures lack established benchmarks that set standards for what 
constitutes quality care.  For example, there is no agreement within the 
nursing home industry as to what would be an acceptable level of the 
incidence of cognitive impairment, which is measured by one of the QIs.  
Although we do not utilize available data to draw conclusions about the 
quality of care performance of nursing homes under CIAs, we do provide 
basic QI/QM and State survey deficiency data for the reader.  See 
Appendixes C and D for these data from 1999 through 2007.
 
19 For example, CMSs Nursing Home Compare Web site contains information about 
Quality Measures, a variant of the QI that data we used, and State survey deficiencies for 
each nursing home in the country.  Available online at: 
http://www.medicare.gov/NHCompare/Static/Related/DataCollection.asp?dest=NAV|Home|
DataDetails|DataCollection#TabTop.  Accessed on November 21, 2008. 
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E X E C U T I V E   S U M M A R Y  
 
CIAs are entered into to improve quality of care in nursing homes by 
imposing certain requirements to build the corporations and their 
nursing homes internal quality assurance capabilities.  The  
CIA-covered entities must develop, improve, and sustain their internal 
capacity to monitor their own quality and take corrective actions where 
indicated.  We found that each of the 15 corporations enhanced quality 
of care structures and processes to meet the CIA requirements.  Each 
corporation had written policies and procedures, codes of conduct, and 
training as required by the CIA; used tools and performed activities to 
monitor quality of care; and created or expanded its compliance 
infrastructure to integrate quality of care.  Corporate representatives 
from all corporations cited positive effects of their CIAs.   
Although all corporations were ultimately responsive to their quality 
monitors guidance and valued their input, three corporations were 
initially resistant until OIG intervened.  All corporations faced 
challenges in implementing CIA requirements, such as difficulties in 
implementing quality systems throughout all levels of the corporations, 
including systems at the nursing home level.  Additionally, we found 
that lack of agreed-upon benchmarks for quality of care outcome 
measures throughout the nursing home industry limited our ability to 
assess the quality of care performance of nursing homes under CIAs.  
Based on our findings, areas that OIG will explore for its oversight of 
future CIAs include the following: 
  Responding swiftly to noncompliant corporations and those that fail 
to address quality problems by using available enforcement 
remedies, such as monetary penalties, or, if appropriate, exclusion 
from Federal health care programs.  Additionally, a providers 
continued failure to address quality of care may warrant opening 
new investigations by OIG.   
  Including specific requirements regarding documentation of nursing 
home QAA committee activities to ensure that quality of care 
monitoring and improvement systems are implemented at the 
nursing home level. 
  Sharing lessons learned by corporations and quality monitors with 
other corporations placed under subsequent CIAs. 
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NURSING HOME CORPORATIONS INCLUDED IN THIS REVIEW 
This study examined the 15 nursing home corporations that entered 
into quality of care Corporate Integrity Agreements (CIA) between  
June 2000 and December 2005.  Table 1 provides information on the 
corporation size and start and end dates of the CIAs and indicates 
whether each was an original CIA or a successor agreement.   
 
Table 1:  Corporations Under Quality of Care CIAs  
 
Corporation Size  CIA Start Date  CIA End Date  Type of CIA 
100 or more nursing homes  April 1, 2001  April 1, 2006  Original CIA 
100 or more nursing homes  February 28, 2002  February 28, 2007  Original CIA 
100 or more nursing homes  April 2, 2002  April 2, 2007  Successor Agreement 
100 or more nursing homes  April 1, 2004  April 1, 2007  Original CIA 
10 to 99 nursing homes  April 2, 2002  April 2, 2007  Successor Agreement 
10 to 99 nursing homes  September 9, 2003  September 9, 2008  Successor Agreement 
10 to 99 nursing homes  November 1, 2003  October 1, 2005  Successor Agreement 
2 to 9 nursing homes  June 9, 2000  June 9, 2005  Original CIA 
2 to 9 nursing homes  March 1, 2002  March 7, 2005  Original CIA 
2 to 9 nursing homes  September 9, 2003  September 9, 2008  Successor Agreement 
2 to 9 nursing homes  November 22, 2004  November 22, 2009  Original CIA 
Individual nursing home  October 29, 2001  October 29, 2006  Original CIA 
Individual nursing home  December 21, 2001  November 15, 2005  Original CIA 
Individual nursing home  December 13, 2002  December 13, 2005  Original CIA 
Individual nursing home  October 25, 2005  October 25, 2008  Original CIA 
Source:  Office of Inspector General, 2008. 
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QUALITY ASSESSMENT AND ASSURANCE COMMITTEE 
METHODOLOGY AND RESULTS  
Table 2 provides information on the nursing homes Quality Assessment 
and Assurance (QAA) committee meeting minutes sample sizes and 
response rates.  We requested minutes for all nursing homes from 
corporations with two to nine homes and the four individual nursing 
homes.  We randomly selected a sample of nursing homes from 
corporations with 10 or more nursing homes.  We received at least some 
QAA committee minutes for 350 of the sample of 407 nursing homes 
that we requested to send minutes, representing an overall response 
rate of 86 percent.  Response rates by corporation ranged from 0 to 100 
percent.  Two corporations were unable to provide minutes because 
their nursing homes were under new ownership and the meeting 
minutes were no longer accessible.   
Results of analyses of QAA minutes are presented in Tables 3 and 4. 
Table 2:  QAA Committee Meeting Minutes Request and Response 
Rates 
Number of 
Nursing Home  Number of 
Minutes  Nursing Home 
Requested  Minutes 
Corporation Size  (Sample Size)  Received  Response Rate 
More than 100 nursing homes  72  62  86% 
More than 100 nursing homes  58  57  98% 
More than 100 nursing homes  65  65  100% 
More than 100 nursing homes  77  77  100% 
10 to 99 nursing homes  34  13  38% 
10 to 99 nursing homes  43  41  95% 
10 to 99 nursing homes  21  17  81% 
2 to 9 nursing homes  8  0  0% 
2 to 9 nursing homes  9  9  100% 
2 to 9 nursing homes  9  0  0% 
2 to 9 nursing homes  7  5  71% 
Individual nursing home  1  1  100% 
Individual nursing home  1  1  100% 
Individual nursing home  1  1  100% 
Individual nursing home  1  1  100% 
     Total  407  350  86% 
Source:  Office of Inspector General, 2008. 
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A P P E N D I X ~ B  
RESULTS OF NURSING HOME QUALITY ASSESSMENT AND ASSURANCE ANALYSIS 
Table 3:  CIA Nursing Homes QAA Committee Meeting Minutes Point Estimates and Confidence Intervals for Corporations With 10 or More Nursing 
Homes* 
100 or more nursing homes  10 to 99 nursing homes* 
Corporation A  Corporation B  Corporation C  Corporation D  Corporation F  Corporation G 
95-Percent  95-Percent  95-Percent  95-Percent  95-Percent 
Percentage Found in 
Confidence  Confidence  Confidence  Confidence  Confidence 
Sample** 
  Estimate  Interval Estimate Interval Estimate Interval  Estimate Interval Estimate Interval
CIA Corporation Documented Meeting Frequency 
All required quarters  46%  35%-57%  60%  50%-70%  68%  58%-77%  90%  83%-96%  48%  37%-58%  71% 
At least half of required 
28%  18%-38%  11%  4%-17%  29%  20%-38%  10%  4%-17%  43%  32%-53%  12% 
quarters but not all 
Less than half of required 
26%  16%-36%  30%  20%-39%  3%  0%-11%***  0%  **0%-5%  10%  3%-17%  18% 
quarters 
CIA Corporation Documented Data Use To Monitor Performance 
Consistent data use  36%  25%-47%  51%  41%-61%  60%  50%-70%  69%  60%-78%  30%  20%-40%  59% 
Inconsistent data use  64%  53%-75%  42%  32%-52%  40%  30%-50%  30%  21%-39%  60%  49%-71%  24% 
No data use  0%  0%-6%***  12%  2%-17%  0%  0%-6%***  1%  0%-7%***  10%  3%-17%  18% 
CIA Corporation Documented Use of Root-Cause Analysis 
Consistent use  2%  0%-9%***  0%  0%-6%***  9%  3%-15%  35%  25%-45%  5%  0%-10%  0% 
Inconsistent use  57%  46%-68%  30%  20%-39%  38%  29%-48%  51%  41%-61%  38%  27%-48%  24% 
No use  41%  30%-52%  70%  61%-80%  52%  42%-62%  14%  7%-21%  58%  47%-68%  76% 
*Confidence intervals were calculated only for corporations with 10 or more nursing homes because their estimates are based on samples.  We did not include one corporation with 10 to 99 nursing homes in the analysis of the 
content of the meeting minutes because the corporation provided minutes for only 38 percent of its nursing homes. 
**We did not compute confidence intervals for this corporation because it had fewer than 20 nursing homes in its population and sample. 
***Confidence interval calculated with an exact method based on the binomial distribution. 
 
Source:  Office of Inspector General analysis of 350 QAA committee meeting minutes for nursing home corporations under Corporate Integrity Agreements. 
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A P P E N D I X ~ B  
 
 
Table 3 (continued):  CIA Nursing Homes QAA Committee Meeting Minutes Point Estimates and Confidence Intervals for Corporations With 10 or 
More Nursing Homes* 
100 or more nursing homes  10 to 99 nursing homes 
Corporation A  Corporation B  Corporation C  Corporation D  Corporation F  Corporation G 
95-Percent  95-Percent  95-Percent  95-Percent  95-Percent 
Percentage Found in 
Confidence  Confidence  Confidence  Confidence  Confidence 
Sample** 
  Estimate  Interval Estimate Interval Estimate Interval  Estimate Interval Estimate Interval
CIA Corporation Documented Action Plans 
Consistent action plan  39%  28%-50%  39%  29%-49%  51%  41%-61%  65%  55%-75%  40%  29%-51%  24% 
Inconsistent action plan  57%  46%-68%  54%  44%-65%  48%  38%-58%  35%  25%-45%  43%  32%-53%  41% 
No action plan  3%  0%-11%***  7%  2%-12%  2%  0%-8%***  0%  0%-5%***  18%  9%-26%  35% 
CIA Corporation Documented Followup to Action Plans 
Consistent followup  10%  3%-17%  9%  3%-16%  34%  25%-44%  55%  45%-65%  30%  18%-43%  0% 
Inconsistent followup  76%  66%-86%  77%  68%-86%  45%  35%-55%  42%  32%-51%  58%  44%-71%  73% 
No followup  14%  6%-21%  13%  6%-21%  20%  12%-29%  4%  0%-8%***  12%  3%-21%  27% 
*Confidence intervals were calculated only for corporations with 10 or more nursing homes because their estimates are based on samples.  We did not include one corporation with 10 to 99 nursing homes in the analysis of the 
content of the meeting minutes because the corporation provided minutes for only 38 percent of its nursing homes. 
**We did not compute confidence intervals for this corporation because it had fewer than 20 nursing homes in its population and sample. 
***Confidence interval calculated with an exact method based on the binomial distribution.  
Source:  Office of Inspector General analysis of 350 QAA committee meeting minutes for nursing home corporations under Corporate Integrity Agreements. 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   21  A P  P E N D I X ~ B  
 
Table 4:  CIA Nursing Homes QAA Committee Meeting Minutes Analyses for Corporations With Nine or Fewer Nursing Homes* 
2 to 9 nursing homes  Individual nursing home 
  Corporation I  Corporation K  Corporation L  Corporation M  Corporation N  Corporation O 
CIA Corporation Documented Meeting Frequency 
All required quarters  6  1  1  1  0  0 
At least half of required 
2  4  0  0  1  1 
quarters but not all 
Less than half of required 
1  0  0  0  0  0 
quarters 
CIA Corporation Documented Data Use To Monitor Performance 
Consistent data use  2  4  0  1  1  1 
Inconsistent data use  7  1  1  0  0  0 
No data use  0  0  0  0  0  0 
CIA Corporation Documented Use of Root-Cause Analysis 
Consistent use  0  0  0  0  0  1 
Inconsistent use  4  1  0  1  1  0 
No use  5  4  1  0  0  0 
*Corporations with nine or fewer nursing homes are based on population outcomes.  We did not include 2 of the 15 corporations (both with nine or fewer nursing homes) in any analysis of QAA meeting minutes because all nursing 
homes of 1 corporation had been sold by the time of our data request and another corporation had engaged a new management team that, reportedly, did not have access to prior QAA committee meeting minutes.   
Source:  Office of Inspector General analysis of 350 QAA committee meeting minutes for nursing home corporations under Corporate Integrity Agreements. 
 
 
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Table 4 (continued):  CIA Corporation QAA Committee Meeting Minutes Analyses for Corporations With Nine or Fewer Nursing Homes* 
2 to 9 nursing homes  Individual nursing home 
  Corporation I  Corporation K  Corporation L  Corporation M  Corporation N  Corporation O 
CIA Corporation Documented Action Plans 
Consistent action plan  8  2  1  1  1  1 
Inconsistent action plan  1  3  0  0  0  0 
No action plan  0  0  0  0  0  0 
CIA Corporation Documented Followup to Action Plans 
Consistent followup  7  2  0  1  0  1 
Inconsistent followup  2  2  1  0  1  0 
No followup  0  1  0  0  0  0 
*Corporations with nine or fewer nursing homes are based on population outcomes.  We did not include 2 of the 15 corporations (both with nine or fewer nursing homes) in any analysis of QAA meeting minutes because all nursing 
homes of 1 corporation had been sold by the time of our data request and another corporation had engaged a new management team that, reportedly, did not have access to prior QAA committee meeting minutes. 
Source:  Office of Inspector General analysis of 350 QAA committee meeting minutes for nursing home corporations under Corporate Integrity Agreements. 
 
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 A P P E N D I X ~ C  
QUALITY INDICATORS/QUALITY MEASURES 
A number of measures are used as indicators of quality of care in 
nursing homes.  One prominent measure is the Quality 
Indicators/Quality Measures (QI/QM) developed by the Center for 
Health Systems Research and Analysis (CHSRA) at the University of 
Wisconsin  Madison.20  
The QI/QMs are incidence or prevalence measures derived from 
information recorded during periodic assessments of residents 
performed by nursing home staff and contained in the Minimum Data 
Set (MDS).21  Information from these assessments is aggregated to the 
nursing home level for each QI/QM.  The QI/QMs cover areas of care, 
such as accidents, behavioral and emotional patterns, quality of life, and 
skin care.  Each QI/QM is calculated quarterly and represents the 
percentage of residents in the nursing home who meet the criteria for 
each specific condition.   
These nursing home level indicators can be compared to previous 
indicators for the same nursing home, other nursing homes, or the 
population of nursing homes.  A higher percentage on a QI/QM for a 
particular nursing home, compared to that of other homes or its own 
prior performance, indicates a possible need for attention to the area of 
care measured by the QI/QM.  Table 5 lists the 26 QI/QMs analyzed  
and describes how they are calculated. 
 
Table 5:  Quality Indicators/Quality Measures  
Quality Indicator/Quality Measure  Calculation 
Incidence of new fractures  Residents with new fractures on target assessment divided by residents who did not 
have fractures on prior assessment. 
Prevalence of falls  Residents who had falls within the past 30 days divided by residents assessed. 
Residents who have become more  Residents whose Mood Scale scores are greater on target assessment relative to prior 
anxious or depressed  assessment divided by residents with target assessment and prior assessment. 
Prevalence of behavioral symptoms  Residents who have displayed any type of problem behavior toward others on target 
affecting others  assessment divided by residents assessed. 
Prevalence of symptoms of depression  Residents with symptoms of depression and no antidepressant therapy on target 
without antidepressant therapy  assessment divided by residents assessed. 
 
20 D. Zimmerman, Improving nursing home quality of care through outcomes data:  the 
MDS quality indicators, International Journal of Geriatric Psychiatry, Volume 18, 2003. 
21 Section 1819(f)(6)(A) of the Social Security Act, added by the Omnibus Budget 
Reconciliation Act of 1987, 42 CFR  483.20(b-c), and CMS, Resident Assessment 
Instrument Version 2.0 Manual. 
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A P P E N D I X ~ C  
 
Table 5:  Quality Indicators/Quality Measures (continued) 
Quality Indicator/Quality Measure  Calculation 
Use of nine or more different  Residents who received nine or more different medications on target assessment 
medications  divided by residents assessed. 
Incidence of cognitive impairment  Residents who are cognitively impaired on the target assessment divided by residents 
who were not cognitively impaired on previous assessment. 
Low-risk residents who lost control of  Low-risk residents who were incontinent or frequently incontinent of either bladder or 
their bowels or bladder  bowel on the target assessment divided by all residents assessed who did not qualify as 
high risk. 
Residents who have/had a catheter  Residents with indwelling catheters on target assessment divided by residents 
inserted and left in their bladder  assessed. 
Prevalence of occasional or frequent  Residents with no scheduled toileting plan and no bladder-retraining program on target 
bladder or bowel incontinence without a  assessment and with occasional or frequent bladder or bowel incontinence divided by 
toileting plan  residents assessed. 
Prevalence of fecal impaction  Residents with fecal impaction on most recent assessment divided by residents 
assessed. 
Residents with a urinary tract infection  Residents with urinary tract infections on target assessment divided by residents 
assessed. 
Residents who lose too much weight  Residents who have experienced weight loss of 5 percent or more during the last         
30 days or 10 percent or more during the last 6 months divided by residents assessed. 
Prevalence of tube feeding  Residents with tube feeding on most recent assessment divided by residents assessed. 
Prevalence of dehydration  Residents with dehydration on most recent assessment divided by residents assessed. 
Residents who have moderate to  Residents with moderate pain at least daily or horrible/excruciating pain at any frequency 
severe pain  on target assessment divided by residents assessed. 
Residents whose need for help with  Residents with late-loss activities of daily living self-performance at target assessment 
daily activities has increased  worsening relative to prior assessment divided by residents with a target and prior 
assessment. 
Residents who spend most of their time  Residents who are bedfast on target assessment divided by residents assessed. 
in a bed or in a chair 
Residents whose ability to move in and  Residents whose value for locomotion self-performance is greater at target relative to 
around their rooms got worse  prior assessment divided by residents with a target assessment and prior assessment. 
Incidence of decline in range of motion  Residents with increased functional limitation in ROM between prior and target 
(ROM)  assessments divided by residents with a target assessment and prior assessment. 
Prevalence of antipsychotic use, in the  Residents receiving antipsychotics divided by residents assessed without psychotic or 
absence of psychotic conditions  related conditions. 
Prevalence of antianxiety/hypnotic drug  Residents who received antianxiety medications or hypnotics divided by residents 
use  assessed, except those with psychotic or related conditions. 
Prevalence of hypnotic use more than  Residents who received hypnotics more than two times in the last week divided by 
two times in the last week  residents assessed. 
Residents who were physically  Residents who were physically restrained daily divided by residents assessed. 
restrained 
Prevalence of little or no activity  Residents with little or no activity divided by residents assessed. 
Pressure ulcers  Residents with pressure ulcers (stages 14) divided by all residents. 
Source:  Center for Health Systems Research and Analysis 
 
 
 
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   25   
A P P E N D I X   ~ C  
Analysis of QI/QM data.  Our data consisted of QI/QM scores for each 
quarter from January 1999 through December 2007.  We obtained 
QI/QM data from CHSRA.  We computed the means, standard 
deviations, and medians for each QI/QM by year for the national 
population from 1999 through 2007.  We also computed the means for 
each QI/QM by year for each of the 15 corporations included in our 
review.  These results are presented in Table 6.   
 
 
 
 
 
 
 
 
 
 
 
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   26  A P P E N D I X   ~   C  
 
Table 6:  Quality Indicator/Quality Measure Annual Four-Quarter Average for 15 Corporate Integrity 
Agreement Corporations and National Population*  
Accidents:  Incidence of New Fractures 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  1.8  1.7 1.6 1.6 1.6 1.5  1.5  1.5 1.5
Standard Deviation  3.7  3.0 3.0 3.1 2.8 2.8  2.5  2.6 2.4
Median  1.2  1.2 1.2 1.2 1.2 1.0  1.1  1.1 1.1
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  1.8  1.6 1.6 1.6 1.6 1.4  1.5  1.5 1.4
Q1 2002  5 Years  138  1.6  1.7 1.6 1.6 1.6 1.5  1.5  1.6 1.6
Q2 2002  5 Years  185  1.8  1.8 2.1 1.9 1.7 1.6  1.6  1.7 1.7
Q2 2004  3 Years  341  1.7  1.8 1.8 1.7 1.7 1.6  1.6  1.5 1.5
Q2 2002  5 Years  52  1.4  1.6 1.4 1.4 1.4 1.3  1.4  1.4 1.4
Q3 2003  5 Years  74  1.5  1.4 1.4 1.4 1.3 1.2  1.1  1.3 1.3
Q4 2003  2 Years  26  2.0  2.3 2.1 2.5 2.0 1.7  1.9  1.9 1.7
Q2 2000  5 Years  8  1.3  1.7 0.4 5.1 0.8 0.9  1.0  1.6 1.8
Q1 2002  3 Years  9  1.2  1.2 1.8 1.1 1.1 1.4  1.1  0.9 1.0
Q3 2003  5 Years  9  2.0  2.1 1.4 1.0 1.2 1.4  1.4  1.4 1.8
Q4 2004  5 Years  7  2.2  1.7 1.7 1.9 1.3 1. 9  1.5  2.0 2.3
Q4 2001  5 Years  1  0.2  3.4 2.0 2.2 0.5 0.3  0.3  1.2 2.3
Q4 2001  4 Years  1  2.3  2.1 3.2 2.1 3.3 0.5  1.4  1.3 1.2
Q4 2002  3 Years  1  1.9  1.8 2.1 1.0 1.9 1.0  1.5  2.4 1.1
Q4 2005  3 Years  1  1.6  0.3 1.6 0.9 0.9 0.2  2.1  0.5 1.3
Accidents:  Prevalence of Falls 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  14.0  13.5 13.4 13.3 13.2 12.4  12.7  12.9 12.9
Standard Deviation  9.8  9.6 9.0 8.5 8.2 7.8  7.9  7.7 7.6
Median  13.0  12.7 12.5 12.5 12.5 11.8  12.0  12.3 12.3
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  14.8  14.6 14.2 14.1 13.5 13.0  13.5  13.8 13.5
Q1 2002  5 Years  138  14.1  13.5 13.4 13.4 13.6 12.4  12.0  13.2 13.4
Q2 2002  5 Years  185  12.9  12.9 13.4 13.7 13.6 13.0  13.2  13.6 13.7
Q2 2004  3 Years  341  14.2  14.1 14.2 14.2 13.8 12.8  13.5  14.0 14.0
Q2 2002  5 Years  52  10.2  9.9 9.0 9.6 9.9 9.0  9.2  10.1 9.2
Q3 2003  5 Years  74  12.8  12.7 12.3 12.1 11.7 11.1  11.1  11.2 11.1
Q4 2003  2 Years  26  14.2  13.3 13.8 13.1 12.8 12.1  12.6  13.1 12.0
Q2 2000  5 Years  8  21.8  31.2 19.1 7.4 8.5 5.9  5.0  5.9 7.4
Q1 2002  3 Years  9  11.5  10.8 10.5 10.6 10.9 10.4  10.9  10.2 11.2
Q3 2003  5 Years  9  14.6  13.3 12.2 13.1 12.9 10.2  10.4  10.7 11.0
Q4 2004  5 Years  7  15.5  14.0 11.9 12.5 13.7 12.3  15.5  16.3 12.2
Q4 2001  5 Years  1  4.5  8.2 13.0 14.3 14.8 13.5  11.8  11.5 16.7
Q4 2001  4 Years  1  15.3  8.4 18.7 15.4 18.0 17.0  5.1  6.0 6.6
Q4 2002  3 Years  1  14.4  20.5 15.1 14.0 15.0 17.5  14.9  16.1 13.0
Q4 2005  3 Years  1  10.2  8.2 8.0 9.7 14.1 10.1  13.6  14.6 19.2
*Corporate Integrity Agreements (CIA); shaded areas indicate the years during which the corporation was under the CIA. 
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   27  A P P E N D I X   ~   C  
 
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population  
Behavior/Emotional Patterns:  Residents Who Have Become More Anxious or Depressed 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  16.5  14.5 14.3 14.5 14.7 14.6  14.7  14.7 14.6
Standard Deviation  10.7  9.9 9.6 9.7 9.8 9.9  9.9  9.9 9.9
Median  15.0  13.0 12.8 12.0 13.1 12.8  13.0  13.0 12.8
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  18.4  16.3 16.2 16.0 15.6 15.6  16.4  17.0 15.7
Q1 2002  5 Years  138  16.2  14.2 12.6 15.5 15.4 15.0  15.0  16.3 15.8
Q2 2002  5 Years  185  15.2  14.3 14.7 14.2 15.1 16.4  17.0  16.9 21.2
Q2 2004  3 Years  341  17.9  15.1 15.6 16.8 17.7 22.1  21.5  22.2 22.1
Q2 2002  5 Years  52  15.0  13.4 13.2 13.2 14.1 15.3  15.6  13.0 11.8
Q3 2003  5 Years  74  15.1  12.7 13.0 13.7 13.7 13.2  13.9  13.7 14.0
Q4 2003  2 Years  26  16.4  15.3 14.5 16.3 13.2 12.7  11.7  12.6 11.7
Q2 2000  5 Years  8  19.3  21.3 21.9 12.2 14.2 13.3  10.9  10.1 11.4
Q1 2002  3 Years  9  11.7  12.6 9.0 11.0 7.1 6.0  5.3  6.8 5.8
Q3 2003  5 Years  9  19.9  20.1 16.3 17.9 16.6 12.7  13.2  19.0 19.8
Q4 2004  5 Years  7  11.6  9.3 6.5 5.9 8.1 7.3  11.1  8.6 11.0
Q4 2001  5 Years  1  11.5  12.1 12.9 11.5 23.9 21.7  5.6  12.6 20.3
Q4 2001  4 Years  1  17.6  11.9 13.8 12.5 15.3 15.0  13.5  14.0 15.9
Q4 2002  3 Years  1  11.0  14.3 17.0 10.3 9.5 8.5  12.0  11.3 8.1
Q4 2005  3 Years  1  18.4  16.9 8.8 7.4 7.8 8.4  6.9  7.9 10.1
Behavior/Emotional Patterns:  Prevalence of Behavior Symptoms Affecting Others 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  23.0  21.9 21.0 20.4 19.7 19.5  18.7  18.0 17.6
Standard Deviation  14.5  14.0 13.7 13.6 13.4 13.5  13.5  13.1 13.1
Median  20.8  19.8 18.6 17.9 17.2 16.9  16.0  15.3 14.8
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  21.7  21.7 20.9 20.2 19.7 18.6  17.8  17.7 17.0
Q1 2002  5 Years  138  25.0  24.3 21.9 22.3 22.7 21.4  20.2  19.2 18.1
Q2 2002  5 Years  185  19.2  17.9 16.6 15.6 14.1 15.1  13.9  12.8 12.9
Q2 2004  3 Years  341  22.4  21.0 20.2 19.5 18.7 19.9  17.2  16.1 15.8
Q2 2002  5 Years  52  17.5  16.8 15.6 14.2 13.3 13.9  12.4  10.8 11.4
Q3 2003  5 Years  74  21.6  21.6 20.3 20.4 19.0 19.2  19.1  18.2 17.5
Q4 2003  2 Years  26  13.8  14.6 14.4 14.4 12.0 11.4  10.7  11.8 10.6
Q2 2000  5 Years  8  16.2  21.7 15.4 16.4 15.0 13.8  11.7  12.4 11.4
Q1 2002  3 Years  9  20.5  17.2 15.1 14.2 14.7 11.8  10.0  7.8 7.0
Q3 2003  5 Years  9  19.6  21.2 21.5 22.0 19.4 13.8  12.0  13.5 14.2
Q4 2004  5 Years  7  32.4  29.6 29.9 28.1 24.8 23.0  27.2  29.3 30.9
Q4 2001  5 Years  1  19.7  10.1 10.6 27.5 24.7 19.3  8.7  10.7 21.3
Q4 2001  4 Years  1  18.2  17.1 17.3 20.2 25.4 32.0  24.6  24.3 22.8
Q4 2002  3 Years  1  15.9  24.6 26.1 19.0 10.1 7.6  14.3  14.4 13.7
Q4 2005  3 Years  1  11.8  19.6 19.1 18.8 19.5 23.1  15.7  19.4 20.8
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   28  A P P E N D I X   ~   C  
 
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Behavior/Emotional Patterns:  Prevalence of Symptoms of Depression Without Antidepressant  Therapy 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  7.9  6.8 6.1 5.6 5.5 5.2  5.2  4.9 4.7
Standard Deviation  9.2  8.2 7.6 6.8 6.8 6.7  6.8  6.4 6.2
Median  5.4  4.5 4.0 3.7 3.6 3.2  3.2  2.9 2.8
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  8.1  7.0 6.2 5.7 5.5 4.8  4.7  4.6 4.2
Q1 2002  5 Years  138  8.0  6.1 5.1 5.8 5.6 5.3  5.3  5.2 5.1
Q2 2002  5 Years  185  4.4  3.7 3.7 3.2 2.9 3.1  3.2  2.8 4.0
Q2 2004  3 Years  341  7.0  5.9 5.2 4.3 4.3 5.5  5.7  5.4 5.3
Q2 2002  5 Years  52  4.7  3.8 3.1 2.3 2.1 2.1  2.5  2.5 2.0
Q3 2003  5 Years  74  6.3  5.7 5.3 5.3 5.4 5.6  5.5  4.5 4.6
Q4 2003  2 Years  26  3.7  3.2 3.3 3.1 2.2 2.1  1.7  1.9 2.1
Q2 2000  5 Years  8  7.9  11.6 10.7 6.1 6.9 4.1  2.6  3.0 3.6
Q1 2002  3 Years  9  10.0  4.2 4.5 2.6 2.3 1.2  1.5  1.8 1.9
Q3 2003  5 Years  9  7.9  9.1 6.9 7.1 5.6 3.1  3.6  4.6 3.6
Q4 2004  5 Years  7  9.1  8.1 6.9 5.9 6.3 2.6  2.9  4.2 6.5
Q4 2001  5 Years  1  2.7  2.9 8.6 5.6 13.8 23.1  3.7  7.3 3.2
Q4 2001  4 Years  1  10.3  13.7 9.8 6.2 5.6 3.4  2.5  0.9 3.0
Q4 2002  3 Years  1  1.7  2.8 3.2 4.0 2.5 2.5  6.4  4.0 5.0
Q4 2005  3 Years  1  0.9  0.6 1.8 0.7 0.0 0.0  0.5  0.2 0.0
Clinical Management:  Use of Nine or More Different Medications 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  39.3  42.3 46.4 50.6 54.4 58.6  61.9  64.2 66.1
Standard Deviation  16.6  16.0 15.7 15.4 14.8 14.5  13.9  13.3 13.0
Median  37.9  41.4 45.8 50.0 54.5 59.0  62.5  65.0 67.0
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  36.1  39.7 44.4 49.1 53.6 57.9  61.3  64.2 66.1
Q1 2002  5 Years  138  33.9  38.1 42.4 46.5 50.4 54.9  58.8  61.7 63.8
Q2 2002  5 Years  185  37.0  40.5 44.8 49.2 53.9 59.4  62.9  62.5 62.6
Q2 2004  3 Years  341  38.7  42.0 45.9 49.6 53.2 57.4  60.9  63.4 65.8
Q2 2002  5 Years  52  34.0  37.2 40.5 44.3 49.1 54.9  59.1  61.5 63.4
Q3 2003  5 Years  74  38.3  40.1 45.4 49.1 53.5 58.3  63.5  65.8 67.6
Q4 2003  2 Years  26  40.5  45.0 48.1 52.5 58.1 61.9  64.9  66.3 67.6
Q2 2000  5 Years  8  39.4  45.5 39.3 38.2 39.1 40.0  48.0  56.0 54.5
Q1 2002  3 Years  9  36.8  39.7 43.0 48.2 51.3 51.5  58.8  62.0 65.8
Q3 2003  5 Years  9  49.8  50.0 53.5 59.7 63.8 68.3  70.1  72.7 72.4
Q4 2004  5 Years  7  26.0  31.2 33.8 39.4 43.3 50.2  48.6  54.0 52.3
Q4 2001  5 Years  1  43.5  44.8 57.9 60.1 59.4 62.9  67.0  72.8 71.3
Q4 2001  4 Years  1  51.5  58.8 53.5 59.4 65.3 70.0  68.9  69.5 70.4
Q4 2002  3 Years  1  34.8  37.8 45.8 48.2 51.5 54.8  64.2  60.5 64.9
Q4 2005  3 Years  1  46.0  46.4 48.7 44.9 50.8 57.1  67.2  69.7 71.0
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   29  A P P E N D I X   ~   C  
 
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Cognitive Patterns:  Incidence of Cognitive Impairment 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  11.6  11.4 11.6 11.7 11.7 11.5  12.0  12.1 12.0
Standard Deviation  12.5  12.1 12.3 12.4 12.4 12.9  13.3  13.2 13.1
Median  9.1  9.1 9.1 9.1 9.1 8.7  9.1  9.1 9.1
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  14.4  14.0 13.5 12.6 12.8 12.6  12.1  13.0 12.3
Q1 2002  5 Years  138  10.9  10.5 11.0 12.7 12.0 12.8  12.2  12.9 13.6
Q2 2002  5 Years  185  16.5  15.4 16.5 16.8 16.4 16.3  16.9  15.7 15.1
Q2 2004  3 Years  341  12.6  13.5 14.9 14.7 15.1 14.3  14.0  14.3 15.6
Q2 2002  5 Years  52  13.1  13.7 12.9 16.9 14.9 14.8  14.7  13.6 15.2
Q3 2003  5 Years  74  12.1  11.6 12.1 11.5 11.0 10.5  11.3  11.6 12.0
Q4 2003  2 Years  26  11.4  15.2 14.6 14.5 14.4 13.8  13.9  12.0 12.6
Q2 2000  5 Years  8  16.9  12.4 19.6 13.6 12.2 16.6  12.6  9.1 6.7
Q1 2002  3 Years  9  14.6  7.8 8.4 9.9 7.3 6.2  7.1  10.1 5.8
Q3 2003  5 Years  9  10.9  10.4 10.9 11.5 13.9 15.3  10.7  13.7 13.8
Q4 2004  5 Years  7  4.5  3.4 2.2 7.8 5.2 5.9  7.9  9.2 10.0
Q4 2001  5 Years  1  7.2  13.0 18.7 12.7 3.6 5.9  5.5  15.6 8.2
Q4 2001  4 Years  1  10.4  5.7 18.4 6.6 18.7 11.4  10.1  11.0 15.1
Q4 2002  3 Years  1  12.4  8.2 10.5 8.6 7.4 4.9  5.4  4.0 6.5
Q4 2005  3 Years  1  6.1  7.8 8.6 5.5 7.9 5.9  7.3  10.9 11.3
Elimination/Incontinence:  Low-Risk Residents Who Lost Control of Their Bowels or Bladders 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  42.4  43.6 44.5 45.0 45.6 47.8  47.9  47.8 48.5
Standard Deviation  17.0  16.7 16.6 16.7 16.7 16.8  16.9  16.7 16.7
Median  42.6  43.8 44.8 45.3 45.9 48.2  48.2  48.3 49.1
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  45.0  47.2 47.8 47.7 47.7 50.6  50.2  50.0 51.2
Q1 2002  5 Years  138  40.1  42.3 42.6 44.2 44.8 48.3  49.0  48.8 48.3
Q2 2002  5 Years  185  42.7  44.1 44.6 45.1 45.6 49.2  50.7  51.1 58.1
Q2 2004  3 Years  341  44.4  45.5 47.2 47.4 47.8 51.9  54.3  52.9 52.7
Q2 2002  5 Years  52  49.1  52.4 52.8 54.0 51.9 55.3  56.2  56.5 54.7
Q3 2003  5 Years  74  48.0  48.8 49.0 49.2 48.5 49.3  49.3  50.2 49.4
Q4 2003  2 Years  26  42.3  42.4 41.8 44.9 48.1 51.7  53.8  54.1 54.9
Q2 2000  5 Years  8  52.5  61.0 59.6 63.3 66.6 68.9  67.9  65.5 59.0
Q1 2002  3 Years  9  53.4  55.4 53.1 54.5 53.2 53.5  53.4  54.2 56.7
Q3 2003  5 Years  9  55.8  54.7 51.2 49.1 47.7 50.1  49.7  50.0 45.5
Q4 2004  5 Years  7  38.1  37.9 33.3 35.0 38.6 40.0  37.7  33.6 37.7
Q4 2001  5 Years  1  31.4  44.6 56.8 48.0 35.9 32.2  26.6  26.7 33.5
Q4 2001  4 Years  1  38.7  24.0 25.8 33.7 36.9 35.4  29.1  21.0 23.0
Q4 2002  3 Years  1  41.7  44.8 45.0 37.9 42.0 40.8  38.2  31.6 29.8
Q4 2005  3 Years  1  31.5  33.9 32.0 36.2 37.1 47.0  40.6  41.1 46.3
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   30  A P  P E N D I X   ~   C  
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Elimination/Incontinence:  Residents Who Have/Had a Catheter Inserted and Left in Their Bladder 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  55.5  46.1 43.9 42.9 42.1 43.2  44.7  45.2 45.5
Standard Deviation  33.9  33.6 33.5 33.3 33.2 33.9  34.7  34.7 34.9
Median  55.6  40.0 36.4 35.0 33.3 35.5  37.5  38.5 38.9
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  60.5  49.6 45.4 45.1 43.1 42.9  47.4  47.4 49.4
Q1 2002  5 Years  138  60.9  54.5 52.7 55.3 36.6 25.2  24.0  32.5 33.7
Q2 2002  5 Years  185  69.7  55.8 56.0 55.4 53.5 53.1  39.4  38.8 39.4
Q2 2004  3 Years  341  58.5  48.4 46.8 46.5 42.6 43.3  44.5  43.9 41.7
Q2 2002  5 Years  52  74.8  41.3 51.7 49.2 53.3 49.1  36.7  49.3 51.4
Q3 2003  5 Years  74  75.2  63.5 64.0 56.7 52.3 57.7  62.0  62.8 54.6
Q4 2003  2 Years  26  46.1  33.5 29. 39.9 39.8 45.0  44.1  47.1 44.1
Q2 2000  5 Years  8  84.8  79.5 69.7 51.9 28.0 23.8  17.4  9.2 18.4
Q1 2002  3 Years  9  40.3  38.1 43.3 46.8 60.3 46.7  36.3  45.6 44.9
Q3 2003  5 Years  9  55.0  46.5 57.4 59.9 52.8 57.4  68.0  66.2 65.6
Q4 2004  5 Years  7  34.3  24.1 22.6 24.1 26.2 27.0  9.2  10.2 7.9
Q4 2001  5 Years  1  60.0  85.2 55.4 41.1 55.6 54.6  25.0  25.3 78.6
Q4 2001  4 Years  1  53.1  62.5 27.8 14.1 6.4 16.0  29.9  15.0 54.9
Q4 2002  3 Years  1  85.3  25.9 15.4 83.5 94.3 29.2  39.9  17.9 29.7
Q4 2005  3 Years  1  54.5  14.9 8.4 26.8 56.7 57.6  42.3  46.9 48.3
Elimination/Incontinence:  Prevalence of Occasional or Frequent Bladder or Bowel Incontinence                   
Without a Toileting Plan 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  9.3  9.1 9.2 9.4 9.3 8.6  9.3  8.8 8.5
Standard Deviation  12.0  11.1 10.5 10.2 9.8 8.7  9.0  8.3 8.0
Median  7.0  7.1 7.4 7.8 7.7 7.2  7.9  7.5 7.3
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  8.5  8.6 9.5 9.8 9.5 9.0  9.6  9.2 9.2
Q1 2002  5 Years  138  7.7  7.9 8.2 8.5 8.6 8.2  8.6  8.9 8.3
Q2 2002  5 Years  185  8.3  8.6 9.5 10.0 9.3 8.6  9.2  8.2 7.6
Q2 2004  3 Years  341  8.2  8.3 8.6 8.8 8.8 8.6  8.8  8.5 5.3
Q2 2002  5 Years  52  8.4  8.5 9.1 9.2 7.9 7.8  7.8  7.8 7.0
Q3 2003  5 Years  74  8.8  9.4 9.8 9.9 9.8 9.7  11.4  9.5 9.6
Q4 2003  2 Years  26  8.2  8.6 9.8 10.0 10.5 9.8  10.4  9.4 9.0
Q2 2000  5 Years  8  13.1  13.5 18.8 11.8 8.1 5.7  6.7  9.6 11.8
Q1 2002  3 Years  9  7.4  6.0 6.6 7.3 7.2 7.3  7.9  7.6 8.2
Q3 2003  5 Years  9  13.2  13.1 13.1 15.3 15.3 12.1  14.1  13.0 11.4
Q4 2004  5 Years  7  7.1  6.9 8.6 8.1 8.8 10.6  10.7  8.7 8.1
Q4 2001  5 Years  1  11.1  16.2 11.2 10.8 7.7 3.1  6.3  5.8 5.7
Q4 2001  4 Years  1  9.0  13.6 11.8 8.8 9.2 8.7  3.3  5.5 3.9
Q4 2002  3 Years  1  10.1  8.1 13.6 15.1 11.6 11.2  11.7  9.4 10.0
Q4 2005  3 Years  1  5.6  4.4 5.8 3.5 4.9 4.6  6.9  6.2 7.2
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   31  A P  P E N D I X   ~   C  
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Elimination/Incontinence:  Prevalence of Fecal Impaction 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  1.1  0.4 0.3 0.2 0.2 0.1  0.1  0.1 0.1
Standard Deviation  3.5  2.0 1.8 1.2 1.3 1.0  1.2  1.3 0.9
Median  0  0 0 0 0 0  0  0 0
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  0.8  0.2 0.2 0.1 0.1 0.0  0.0  0.0 0.0
Q1 2002  5 Years  138  1.4  0.6 0.2 0.1 0.2 0.1  0.0  0.0 0.1
Q2 2002  5 Years  185  1.0  0.3 0.2 0.2 0.1 0.1  0.0  0.0 0.0
Q2 2004  3 Years  341  1.9  0.2 0.1 0.0 0.0 0.0  0.0  0.0 0.0
Q2 2002  5 Years  52  0.7  0.2 0.3 0.1 0.0 0.0  0.0  0.0 0.0
Q3 2003  5 Years  74  1.2  0.3 0.2 0.2 0.2 0.1  0.1  0.0 0.0
Q4 2003  2 Years  26  0.6  0.1 0.0 0.1 0.1 0.1  0.0  0.0 0.0
Q2 2000  5 Years  8  0.8  0.6 0.2 0.0 0.1 0.0  0.0  0.0 0.0
Q1 2002  3 Years  9  0.6  0.0 0.0 0.0 0.0 0.0  0.0  0.0 0.0
Q3 2003  5 Years  9  0.6  0.4 0.2 0.2 0.1 0.1  0.0  0.0 0.0
Q4 2004  5 Years  7  0.4  0.1 0.0 0.1 0.4 0.0  0.0  0.0 0.0
Q4 2001  5 Years  1  0.5  0.3 2.7 0.0 0.0 0.5  0.0  0.0 0.0
Q4 2001  4 Years  1  1.3  1.5 1.0 0.9 0.4 0.0  0.0  0.0 0.0
Q4 2002  3 Years  1  1.4  0.0 0.6 0.1 0.0 0.1  0.0  0.0 0.0
Q4 2005  3 Years  1  2.1  0.0 0.0 0.0 0.2 0.0  0.2  0.0 0.0
Infection Control:  Residents With a Urinary Tract Infection 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  8.7  8.4 8.6 9.0 9.0 9.0  9.5  9.6 9.7
Standard Deviation  9.3  8.4 8.2 8.2 7.6 7.5  7.8  7.4 7.4
Median  7.2  7.1 7.4 7.8 8.0 8.0  8.5  8.6 8.8
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  8.4  9.0 9.6 10.0 10.1 10.1  11.1  10.8 10.7
Q1 2002  5 Years  138  8.7  8.4 8.0 8.5 9.1 9.0  9.4  9.6 10.3
Q2 2002  5 Years  185  7.6  7.3 7.9 8.4 8.3 8.6  9.2  9.2 9.1
Q2 2004  3 Years  341  9.2  8.9 8.8 9.1 8.8 8.2  7.9  8.2 8.6
Q2 2002  5 Years  52  7.9  7.5 8.3 7.8 8.9 8.2  9.1  9.5 10.3
Q3 2003  5 Years  74  8.9  8.8 9.7 9.0 9.8 9.8  11.6  11.3 12.1
Q4 2003  2 Years  26  10.0  10.2 9.7 11.2 11.0 11.2  11.3  11.8 12.5
Q2 2000  5 Years  8  10.9  10.4 7.9 8.5 6.8 6.7  5.5  7.2 10.2
Q1 2002  3 Years  9  8.2  7.6 7.8 8.3 8.0 9.0  9.3  7.8 11.2
Q3 2003  5 Years  9  13.0  11.4 11.3 11.9 14.8 13.2  14.8  13.6 10.6
Q4 2004  5 Years  7  6.5  6.7 5.2 8.0 5.3 7.3  7.2  8.0 9.9
Q4 2001  5 Years  1  9.6  12.7 16.3 14.1 12.2 7.2  5.2  10.6 16.0
Q4 2001  4 Years  1  5.7  8.1 3.1 3.6 5.1 6.0  2.6  2.1 7.0
Q4 2002  3 Years  1  8.4  8.7 11.4 13.1 13.4 17.2  16.7  14.3 14.1
Q4 2005  3 Years  1  5.7  3.6 5.1 2.7 4.2 7.4  8.8  5.7 13.5
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   32  A P P E N D I X   ~   C  
 
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Nutrition/Eating:  Residents Who Lose Too Much Weight 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  12.3  11.5 11.4 10.9 10.8 9.8  10.4  10.0 9.9
Standard Deviation  10.8  9.9 9.5 9.1 8.7 7.8  8.2  7.7 7.5
Median  10.7  10.1 10.1 9.8 9.7 8.9  9.5  9.1 9.0
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  13.6  12.8 12.6 12.2 11.3 10.3  11.0  10.1 10.0
Q1 2002  5 Years  138  12.8  11.8 11.2 10.5 10.9 10.0  10.4  10.0 10.0
Q2 2002  5 Years  185  13.3  12.4 13.0 12.0 11.6 10.6  11.0  10.3 10.4
Q2 2004  3 Years  341  11.9  11.0 10.7 10.3 9.9 8.5  8.5  7.8 7.5
Q2 2002  5 Years  52  12.1  11.2 11.7 10.9 10.5 9.3  9.9  10.6 10.3
Q3 2003  5 Years  74  11.2  12.5 12.0 11.6 11.4 10.6  10.5  9.9 10.9
Q4 2003  2 Years  26  12.9  12.5 13.1 12.6 11.5 10.4  11.6  12.2 10.3
Q2 2000  5 Years  8  16.7  21.7 20.3 18.6 10.7 9.0  11.9  8.8 8.2
Q1 2002  3 Years  9  13.4  10.4 10.9 9.9 10.4 9.5  10.0  12.8 12.3
Q3 2003  5 Years  9  20.0  14.2 14.4 14.2 14.2 12.4  14.2  13.0 11.7
Q4 2004  5 Years  7  11.3  12.3 11.0 10.7 13.8 9.7  12.1  13.1 16.1
Q4 2001  5 Years  1  16.0  15.7 15.1 10.6 12.8 13.1  10.5  9.3 10.3
Q4 2001  4 Years  1  13.1  15.5 11.4 10.3 12.0 18.6  15.6  18.0 12.7
Q4 2002  3 Years  1  8.1  12.2 12.2 4.8 8.9 13.2  8.7  10.2 10.2
Q4 2005  3 Years  1  10.2  9.2 11.5 10.0 8.1 10.3  8.6  8.1 9.0
Nutrition/Eating:  Prevalence of Tube Feeding 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  8.1  8.0 7.8 7.7 7.6 7.3  7.2  7.0 6.7
Standard Deviation  9.3  10.7 10.4 10.4 10.3 10.1  10.1  9.9 9.6
Median  7.2  5.4 5.3 5.2 5.1 4.8  4.7  4.6 4.4
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  7.1  7.0 6.8 6.8 6.9 6.4  6.2  6.3 6.3
Q1 2002  5 Years  138  5.7  5.6 5.8 6.0 5.7 5.3  5.5  5.3 5.1
Q2 2002  5 Years  185  9.3  9.0 9.0 8.9 8.8 8.8  8.9  8.5 8.3
Q2 2004  3 Years  341  7.0  6.8 6.6 6.3 5.8 5.5  5.3  5.1 4.8
Q2 2002  5 Years  52  11.8  12.7 13.4 13.7 12.9 11.5  11.7  11.3 9.9
Q3 2003  5 Years  74  10.1  10.2 10.1 10.9 11.3 9.9  10.0  10.8 10.4
Q4 2003  2 Years  26  7.7  8.2 8.9 9.2 9.4 8.2  8.3  8.3 8.6
Q2 2000  5 Years  8  9.3  16.6 5.6 8.4 5.6 5.9  7.3  6.6 8.8
Q1 2002  3 Years  9  18.8  20.6 19.1 18.3 18.9 17.6  17.5  19.1 18.0
Q3 2003  5 Years  9  16.8  16.0 16.2 15.9 15.5 14.2  14.9  13.9 12.6
Q4 2004  5 Years  7  2.3  2.7 3.5 2.4 3.4 4.4  3.2  2.8 2.7
Q4 2001  5 Years  1  7.7  9.8 3.7 4.1 5.7 5.6  9.1  8.2 9.0
Q4 2001  4 Years  1  2.0  2.2 1.9 2.8 2.7 0.9  1.3  2.8 4.2
Q4 2002  3 Years  1  7.5  6.9 6.0 5.6 4.3 5.0  7.8  7.9 9.9
Q4 2005  3 Years  1  20.9  19.2 17.2 14.3 12.9 7.4  6.4  5.3 6.6
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   33  A P P E N D I X   ~   C  
 
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population   
Nutrition/Eating:  Prevalence of Dehydration 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  1.6  1.0 0.8 0.7 0.6 0.4  0.4  0.4 0.3
Standard Deviation  5.8  4.7 3.8 3.3 2.9 2.3  2.7  2.5 2.0
Median  0  0 0 0 0 0  0  0 0
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  1.9  1.0 0.8 0.7 0.5 0.3  0.2  0.3 0.2
Q1 2002  5 Years  138  1.6  1.0 0.8 1.0 0.8 0.7  0.4  0.3 0.2
Q2 2002  5 Years  185  2.1  0.8 0.7 0.5 0.3 0.2  0.2  0.1 0.1
Q2 2004  3 Years  341  1.1  0.4 0.3 0.2 0.2 0.1  0.1  0.1 0.1
Q2 2002  5 Years  52  2.4  1.1 0.7 0.5 0.2 0.1  0.4  0.3 0.2
Q3 2003  5 Years  74  1.5  0.8 0.6 0.7 0.5 0.5  0.7  0.4 0.3
Q4 2003  2 Years  26  1.5  0.4 0.2 0.3 0.2 0.2  0.2  0.1 0.1
Q2 2000  5 Years  8  3.2  4.5 3.2 0.6 0.3 0.1  0.6  0.0 0.2
Q1 2002  3 Years  9  0.4  0.1 0.1 0.2 0.1 0.0  0.0  0.0 0.0
Q3 2003  5 Years  9  4.2  1.3 1.1 1.2 1.1 0.7  0.9  1.0 0.6
Q4 2004  5 Years  7  0.6  0.3 0.6 0.3 0.1 0.5  0.1  0.3 0.3
Q4 2001  5 Years  1  0.0  0.0 0.2 0.0 0.3 0.0  0.3  1.4 1.1
Q4 2001  4 Years  1  3.4  2.4 0.2 0.0 0.2 0.0  0.0  0.0 0.0
Q4 2002  3 Years  1  2.1  0.2 0.3 0.2 0.4 0.1  0.3  0.4 0.4
Q4 2005  3 Years  1  0.7  0.6 0.2 0.0 0.0 0.0  0.0  0.3 0.2
Pain Management:  Residents Who Have Moderate to Severe Pain 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  13.7  13.2 13.1 12.5 10.7 9.8  10.1  9.3 8.7
Standard Deviation  13.2  12.3 12.3 11.9 11.0 10.1  10.6  9.8 9.5
Median  10.7  10.4 10.3 9.8 8.0 7.3  7.6  7.0 6.4
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  14.2  13.8 14.3 14.1 12.6 11.1  10.6  8.8 7.5
Q1 2002  5 Years  138  13.9  14.3 13.8 14.5 14.3 13.1  12.9  11.0 9.6
Q2 2002  5 Years  185  11.5  12.1 12.5 11.5 8.6 8.4  8.9  8.1 7.6
Q2 2004  3 Years  341  12.9  12.9 12.6 11.3 7.0 5.2  5.1  4.6 4.6
Q2 2002  5 Years  52  10.3  9.8 11.0 10.3 7.4 7.2  7.9  7.4 7.6
Q3 2003  5 Years  74  12.9  11.9 12.2 11.9 10.4 10.2  11.3  9.2 6.7
Q4 2003  2 Years  26  13.8  12.2 13.3 13.4 11.2 10.6  10.5  10.0 7.8
Q2 2000  5 Years  8  22.7  30.9 17.9 15.6 10.7 8.2  12.2  12.0 7.4
Q1 2002  3 Years  9  11.3  10.8 9.8 7.4 5.4 4.5  4.7  5.0 4.9
Q3 2003  5 Years  9  13.8  12.9 12.2 12.1 13.1 13.8  13.3  15.6 13.3
Q4 2004  5 Years  7  13.7  9.2 6.7 9.2 10.4 8.3  5.6  7.8 8.5
Q4 2001  5 Years  1  13.3  13.5 19.3 21.5 16.4 12.8  17.3  11.9 5.9
Q4 2001  4 Years  1  13.7  25.4 25.0 11.5 8.0 9.4  11.3  1.4 1.4
Q4 2002  3 Years  1  7.0  6.2 11.2 12.5 7.3 5.9  9.9  13.8 14.2
Q4 2005  3 Years  1  18.6  16.5 13.5 14.1 8.2 8.5  5.6  5.8 8.2
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   34  A P P E N D I X   ~   C  
 
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Physical Functioning:  Residents Whose Need for Help With Daily Activities Has Increased 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  15.9  15.8 15.8 15.9 15.8 15.8  15.8  15.9 15.4
Standard Deviation  10.8  10.3 10.0 10.1 9.7 9.7  9.8  9.8 9.4
Median  14.3  14.3 14.3 14.4 14.4 14.3  14.3  14.5 14.1
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  18.0  18.6 18.9 18.3 18.2 18.2  18.0  20.2 19.1
Q1 2002  5 Years  138  15.2  16.5 16.0 16.8 15.0 15.2  17.0  17.4 18.6
Q2 2002  5 Years  185  17.0  17.6 17.8 20.3 23.3 22.9  23.0  23.7 23.1
Q2 2004  3 Years  341  17.9  19.3 22.2 23.3 22.2 22.9  18.4  18.2 17.7
Q2 2002  5 Years  52  14.5  14.6 15.2 17.9 19.8 18.4  17.7  17.9 17.8
Q3 2003  5 Years  74  13.8  13.7 14.9 16.5 18.2 18.8  18.5  19.9 18.9
Q4 2003  2 Years  26  16.3  16.8 17.7 21.0 19.6 19.7  18.7  17.7 17.4
Q2 2000  5 Years  8  16.8  3.3 12.6 13.3 12.5 14.9  11.7  15.7 11.0
Q1 2002  3 Years  9  16.0  13.9 11.5 12.2 14.7 12.3  13.4  16.1 14.6
Q3 2003  5 Years  9  14.9  15.9 18.9 16.5 18.6 14.3  14.5  16.5 21.6
Q4 2004  5 Years  7  12.1  12.6 9.3 10.1 11.1 13.5  12.2  12.3 15.8
Q4 2001  5 Years  1  21.8  24.8 20.2 11.9 17.6 20.2  21.6  27.0 24.5
Q4 2001  4 Years  1  14.8  14.5 17.1 14.2 19.8 14.8  14.2  21.0 14.7
Q4 2002  3 Years  1  11.8  18.1 15.6 9.9 11.3 8.2  13.0  7.1 8.4
Q4 2005  3 Years  1  14.2  12.9 10.7 11.9 12.2 12.4  13.4  16.1 13.5
Physical Functioning:  Residents Who Spend Most of Their Time in a Bed or in a Chair 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  8.5  7.0 6.4 6.0 5.7 5.4  5.4  5.2 5.1
Standard Deviation  12.6  11.2 10.4 9.8 9.4 8.9  8.8  8.5 8.3
Median  5.1  4.0 3.7 3.4 3.2 3.0  3.0  2.9 2.8
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  8.0  6.6 6.3 6.1 6.1 6.2  5.6  5.6 5.9
Q1 2002  5 Years  138  7.5  6.9 6.4 6.5 6.3 5.5  5.1  4.9 4.5
Q2 2002  5 Years  185  9.7  8.5 7.7 7.1 6.5 6.3  6.2  5.9 5.7
Q2 2004  3 Years  341  7.1  5.6 5.4 5.2 4.6 4.1  3.5  3.2 3.3
Q2 2002  5 Years  52  11.4  8.3 8.0 7.4 6.7 6.8  6.7  6.2 5.6
Q3 2003  5 Years  74  8.8  7.8 7.1 7.6 9.2 9.6  10.0  9.1 9.2
Q4 2003  2 Years  26  8.2  6.4 5.2 5.2 5.6 5.0  5.3  5.3 6.1
Q2 2000  5 Years  8  11.1  13.0 10.4 11.2 7.1 5.1  4.4  3.3 5.4
Q1 2002  3 Years  9  11.9  6.3 5.3 5.2 6.3 7.3  8.3  10.2 10.0
Q3 2003  5 Years  9  13.5  10.3 12.5 14.3 13.9 12.8  13.1  15.1 11.8
Q4 2004  5 Years  7  4.0  3.4 3.8 2.1 2.4 3.3  2.3  2.9 2.0
Q4 2001  5 Years  1  6.9  13.2 4.9 11.8 10.1 4.5  3.6  2.5 5.6
Q4 2001  4 Years  1  13.0  6.2 4.1 9.4 2.4 1.8  3.5  2.1 4.7
Q4 2002  3 Years  1  6.8  6.8 4.8 2.9 1.8 1.4  2.1  1.9 4.4
Q4 2005  3 Years  1  8.9  5.8 5.2 3.2 4.1 5.3  5.7  6.5 6.6
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   35  A P P E N D I X   ~   C  
 
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Physical Functioning:  Residents Whose Ability To Move In and Around Their Rooms Got Worse 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  15.0  14.9 14.9 15.1 15.0 15.1  15.1  15.1 14.9
Standard Deviation  10.9  10.4 10.1 10.2 10.1 10.3  10.3  10.2 10.0
Median  13.3  13.3 13.5 13.6 13.6 13.6  13.5  13.6 13.3
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  17.4  17.5 17.6 17.2 17.1 16.7  16.5  17.1 15.9
Q1 2002  5 Years  138  14.0  14.5 14.6 15.1 14.2 14.5  13.9  14.2 15.5
Q2 2002  5 Years  185  15.6  15.6 16.5 18.2 20.6 21.3  21.7  22.1 23.4
Q2 2004  3 Years  341  15.7  17.0 19.7 21.2 20.9 21.5  19.9  19.7 19.1
Q2 2002  5 Years  52  14.2  15.1 15.0 18.1 18.5 17.3  19.0  18.3 16.9
Q3 2003  5 Years  74  13.1  11.8 12.6 13.9 14.9 15.9  16.4  17.3 17.7
Q4 2003  2 Years  26  15.9  16.1 17.3 19.2 18.8 18.6  19.9  17.0 17.9
Q2 2000  5 Years  8  20.4  14.9 11.4 12.6 14.6 16.0  13.1  19.4 13.9
Q1 2002  3 Years  9  17.4  13.0 13.0 13.1 13.7 13.7  14.5  15.6 14.2
Q3 2003  5 Years  9  16.8  15.2 16.6 18.6 18.6 13.9  14.9  13.8 21.9
Q4 2004  5 Years  7  8.4  10.2 7.7 9.2 8.0 11.5  8.5  10.1 11.9
Q4 2001  5 Years  1  14.3  21.9 16.9 8.8 12.4 10.3  8.1  11.0 12.7
Q4 2001  4 Years  1  10.8  17.3 20.8 16.1 14.9 12.2  13.0  18.4 10.5
Q4 2002  3 Years  1  10.6  8.2 12.6 10.5 11.8 7.5  11.5  7.0 8.8
Q4 2005  3 Years  1  12.7  10.9 9.2 11.4 11.4 12.9  13.2  15.3 12.1
Physical Functioning:  Incidence of Decline in Range of Motion 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  9.8  8.9 8.3 8.1 7.7 7.4  7.4  7.2 6.9
Standard Deviation  9.7  8.9 8.3 8.2 7.7 7.4  7.6  7.5 7.1
Median  7.7  6.9 6.5 6.3 6.0 5.7  5.6  5.4 5.2
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  10.2  8.7 7.8 7.3 7.1 6.7  6.3  6.4 5.9
Q1 2002  5 Years  138  8.2  7.5 6.5 7.3 7.1 7.1  6.6  7.3 7.8
Q2 2002  5 Years  185  10.9  9.9 9.0 8.7 9.3 9.8  10.2  9.2 9.1
Q2 2004  3 Years  341  9.9  9.4 9.3 9.3 8.6 7.9  6.9  6.9 6.9
Q2 2002  5 Years  52  9.1  8.1 8.1 8.6 8.2 8.6  8.9  9.0 10.1
Q3 2003  5 Years  74  8.3  6.9 8.2 8.1 7.5 6.7  7.2  7.0 6.9
Q4 2003  2 Years  26  8.5  8.3 7.5 8.1 6.7 6.2  7.4  6.3 7.7
Q2 2000  5 Years  8  8.7  5.8 6.2 7.4 9.3 5.2  6.0  5.7 8.7
Q1 2002  3 Years  9  10.8  7.1 6.3 8.4 6.3 4.6  7.1  8.4 6.9
Q3 2003  5 Years  9  10.5  12.2 10.7 8.3 9.6 7.4  7.4  9.3 8.8
Q4 2004  5 Years  7  5.4  5.5 2.9 3.8 4.8 6.0  6.5  6.2 7.1
Q4 2001  5 Years  1  7.2  19.3 9.0 8.7 6.9 4.7  2.3  4.3 9.4
Q4 2001  4 Years  1  8.8  5.7 4.9 4.1 4.3 5.4  3.4  3.0 4.7
Q4 2002  3 Years  1  4.6  12.9 7.4 4.0 7.4 5.5  3.0  6.0 2.5
Q4 2005  3 Years  1  10.0  10.0 5.6 8.3 5.6 4.0  6.2  8.4 8.5
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   36  A P P E N D I X   ~   C  
 
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Psychotropic Drug Use:  Prevalence of Antipsychotic Use, in the Absence of Psychotic Conditions 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  16.4  17.3 18.6 20.5 21.6 22.0  21.6  20.9 20.2
Standard Deviation  11.5  11.4 11.7 12.2 12.4 12.8  12.7  12.6 12.6
Median  14.8  15.8 17.1 19.1 20.2 20.6  20.0  19.4 18.6
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  14.6  16.9 18.5 20.8 21.7 22.1  20.7  18.8 18.9
Q1 2002  5 Years  138  19.8  20.2 21.4 23.7 24.3 22.6  20.9  20.9 21.1
Q2 2002  5 Years  185  18.2  19.4 20.7 22.7 23.6 22.6  20.1  17.1 14.8
Q2 2004  3 Years  341  16.0  17.0 18.8 19.8 18.9 17.9  18.3  18.7 18.1
Q2 2002  5 Years  52  14.6  14.8 16.3 18.4 18.1 17.8  17.7  18.1 19.2
Q3 2003  5 Years  74  14.2  14.5 15.6 17.5 17.5 18.4  17.5  17.2 16.8
Q4 2003  2 Years  26  12.1  13.0 12.3 12.7 15.6 15.6  14.0  13.6 12.3
Q2 2000  5 Years  8  14.8  16.5 16.0 18.3 15.3 16.3  13.4  12.2 13.7
Q1 2002  3 Years  9  17.2  16.0 17.8 19.5 17.0 18.6  16.8  16.2 15.9
Q3 2003  5 Years  9  10.5  11.7 13.7 18.5 20.0 19.5  18.5  18.2 17.7
Q4 2004  5 Years  7  16.2  19.3 23.1 24.4 22.9 19.0  15.7  18.9 22.3
Q4 2001  5 Years  1  23.8  22.0 24.0 24.8 27.3 33.7  21.2  17.3 31.7
Q4 2001  4 Years  1  14.7  17.0 16.2 19.4 24.8 23.8  25.1  27.7 21.0
Q4 2002  3 Years  1  12.6  12.9 13.2 18.0 27.1 31.1  28.5  25.5 25.4
Q4 2005  3 Years  1  10.6  6.9 10.4 15.1 20.4 21.0  26.2  19.2 19.2
Psychotropic Drug Use:  Prevalence of Antianxiety/Hypnotic Drug Use 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  18.2  17.7 17.9 18.1 18.1 18.2  19.1  20.3 21.2
Standard Deviation  12.1  11.6 11.5 11.3 11.0 10.9  11.1  11.3 11.6
Median  16.7  16.1 16.3 16.7 16.7 16.7  17.6  18.9 20.0
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  18.4  18.3 18.6 18.2 18.4 18.3  19.1  19.8 20.6
Q1 2002  5 Years  138  18.1  17.6 18.8 18.7 19.1 17.7  19.0  20.4 21.6
Q2 2002  5 Years  185  17.5  16.7 16.4 16.7 18.0 17.7  19.0  19.9 20.5
Q2 2004  3 Years  341  16.9  16.7 17.1 17.1 16.6 16.2  17.2  19.3 19.8
Q2 2002  5 Years  52  15.0  14.6 15.4 15.9 15.8 16.3  17.3  18.3 19.3
Q3 2003  5 Years  74  16.9  16.6 16.5 18.0 19.3 19.6  19.8  21.6 22.8
Q4 2003  2 Years  26  21.3  20.9 21.7 21.2 22.9 24.6  24.0  26.7 26.9
Q2 2000  5 Years  8  25.9  26.0 11.9 14.5 12.8 14.4  17.8  20.4 20.4
Q1 2002  3 Years  9  9.9  8.8 8.1 7.7 8.2 7.5  7.6  8.0 9.1
Q3 2003  5 Years  9  21.7  19.0 22.4 22.4 23.0 20.1  23.5  28.2 26.3
Q4 2004  5 Years  7  20.2  21.2 22.5 22.7 22.4 20.4  16.0  14.2 17.3
Q4 2001  5 Years  1  17.7  11.1 17.3 19.8 25.9 25.5  26.9  23.9 20.4
Q4 2001  4 Years  1  15.4  15.4 16.5 25.7 21.0 20.6  11.8  20.3 24.3
Q4 2002  3 Years  1  14.3  14.9 10.9 9.7 9.2 7.3  12.6  10.9 10.4
Q4 2005  3 Years  1  21.1  17.3 12.2 13.8 14.5 12.2  17.7  20.3 24.7
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   37  A P  P E N D I X   ~   C  
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Psychotropic Drug Use:  Prevalence of Hypnotic Use More Than Two Times in Last Week 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  3.9  3.6 3.7 3.7 3.9 3.9  4.1  4.6 5.0
Standard Deviation  6.6  5.9 5.9 5.7 5.6 5.5  5.5  5.6 5.8
Median  2.5  2.3 2.4 2.5 2.7 2.6  2.9  3.3 3.7
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  3.4  3.3 3.4 3.3 3.4 3.3  3.8  4.1 4.5
Q1 2002  5 Years  138  3.5  3.1 3.1 3.6 3.6 3.5  3.7  4.3 5.0
Q2 2002  5 Years  185  3.7  3.2 3.4 3.4 4.0 3.9  4.3  5.0 5.3
Q2 2004  3 Years  341  2.8  2.7 2.5 2.6 2.6 2.5  2.9  3.4 3.7
Q2 2002  5 Years  52  3.1  3.1 3.6 3.7 3.8 4.9  5.2  5.6 5.7
Q3 2003  5 Years  74  3.7  3.5 3.9 4.0 4.4 4.4  4.4  5.1 5.8
Q4 2003  2 Years  26  5.2  5.3 5.6 5.5 5.7 5.8  6.4  6.5 6.9
Q2 2000  5 Years  8  10.0  4.6 4.8 5.2 3.7 3.9  7.1  10.1 8.2
Q1 2002  3 Years  9  1.3  1.1 1.4 1.7 1.8 1.9  1.8  2.2 1.9
Q3 2003  5 Years  9  4.5  3.9 5.9 5.2 5.7 4.7  5.2  6.7 6.7
Q4 2004  5 Years  7  6.1  4.8 3.9 3.8 4.8 5.7  1.3  1.0 1.6
Q4 2001  5 Years  1  7.6  1.9 4.9 6.1 12.8 15.4  12.4  13.9 10.4
Q4 2001  4 Years  1  5.7  2.6 3.1 6.0 3.3 2.8  3.0  6.5 7.9
Q4 2002  3 Years  1  1.0  0.5 0.8 1.0 1.3 1.0  2.9  2.0 2.4
Q4 2005  3 Years  1  7.7  4.2 1.5 1.5 3.6 3.7  4.5  6.0 8.0
Quality of Life:  Residents Who Were Physically Restrained 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  10.5  10.2 10.1 9.4 8.0 7.4  6.7  6.0 5.2
Standard Deviation  11.2  11.0 10.7 10.2 8.8 8.5  8.1  7.7 7.0
Median  7.3  7.1 7.2 6.5 5.5 4.9  4.2  3.6 2.9
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  7.7  8.0 8.1 8.0 6.8 7.0  6.1  5.6 4.9
Q1 2002  5 Years  138  7.9  8.1 8.2 7.9 7.9 7.3  6.0  5.3 4.4
Q2 2002  5 Years  185  11.7  11.4 11.7 11.6 8.6 7.3  6.7  6.7 5.4
Q2 2004  3 Years  341  6.0  6.3 6.5 5.4 3.9 2.8  1.9  1.9 1.9
Q2 2002  5 Years  52  16.7  16.5 17.9 16.9 12.1 9.7  8.1  7.1 6.9
Q3 2003  5 Years  74  9.3  11.0 11.0 9.5 7.4 7.3  6.3  5.3 3.6
Q4 2003  2 Years  26  6.4  6.7 6.7 7.6 7.1 8.5  8.4  9.0 7.9
Q2 2000  5 Years  8  19.5  20.7 15.7 15.8 14.7 16.1  16.6  11.6 7.1
Q1 2002  3 Years  9  15.2  12.9 11.1 7.0 7.0 8.6  7.2  3.8 2.9
Q3 2003  5 Years  9  7.8  12.2 13.9 10.3 7.0 6.8  5.3  5.5 3.7
Q4 2004  5 Years  7  11.2  9.3 11.2 12.8 14.3 13.1  4.6  2.0 1.1
Q4 2001  5 Years  1  23.2  3.4 12.5 9.7 7.8 15.8  5.4  9.7 9.0
Q4 2001  4 Years  1  5.7  10.5 10.3 14.7 9.5 3.0  2.8  2.1 0.2
Q4 2002  3 Years  1  5.8  10.7 14.0 12.3 17.0 11.9  9.9  8.4 7.6
Q4 2005  3 Years  1  16.9  28.7 24.4 19.8 6.8 5.3  3.9  6.5 2.7
 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   38  A P P  E N D I X   ~   C  
Table 6 (continued):  Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 
Integrity Agreement Corporations and National Population 
Quality of Life:  Prevalence of Little or No Activity 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  30.9  20.8 15.9 13.1 11.1 9.5  8.7  8.1 7.5
Standard Deviation  22.1  17.8 15.6 14.3 13.4 12.5  12.2  11.8 11.3
Median  27.6  17.2 12.0 9.1 7.0 5.5  4.5  3.9 3.4
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  28.3  18.8 14.1 10.5 7.7 6.6  5.7  5.3 4.4
Q1 2002  5 Years  138  31.5  19.9 14.5 13.6 10.8 9.9  7.9  7.7 5.3
Q2 2002  5 Years  185  32.1  20.5 14.9 11.6 8.6 6.0  5.6  4.3 3.4
Q2 2004  3 Years  341  26.8  17.6 12.7 9.7 7.1 5.5  4.4  3.9 4.1
Q2 2002  5 Years  52  28.8  17.8 13.8 9.8 6.8 5.5  4.4  4.5 4.1
Q3 2003  5 Years  74  33.8  19.0 13.3 12.2 11.4 9.8  7.1  6.0 5.7
Q4 2003  2 Years  26  23.5  13.5 10.7 8.9 4.6 3.2  2.6  2.6 1.6
Q2 2000  5 Years  8  19.3  15.7 11.9 8.2 5.6 5.6  3.5  0.6 1.4
Q1 2002  3 Years  9  33.0  18.7 11.6 6.9 5.4 2.5  1.6  1.3 0.5
Q3 2003  5 Years  9  38.5  23.1 15.6 14.4 16.5 11.2  8.4  10.6 5.9
Q4 2004  5 Years  7  22.8  18.3 14.8 10.9 10.1 9.7  2.6  2.7 1.8
Q4 2001  5 Years  1  55.4  68.4 69.0 12.9 9.9 23.8  4.5  3.1 2.4
Q4 2001  4 Years  1  40.9  41.0 31.9 22.9 16.0 18.2  13.5  16.6 23.4
Q4 2002  3 Years  1  57.2  27.4 28.6 25.5 24.9 18.9  7.3  7.3 7.5
Q4 2005  3 Years  1  22.1  4.3 4.2 4.4 0.8 0.0  0.4  0.0 0.3
Skin Care:  Residents With Pressure Ulcers 
  1999  2000 2001 2002 2003 2004  2005  2006 2007
National Population Average  10.8  10.3 10.4 10.3 10.5 9.9  10.3  9.8 9.5
Standard Deviation  11.1  10.3 10.2 9.8 9.5 8.8  9.1  8.5 8.1
Median  9.0  8.7 8.9 8.8 9.1 8.7  9.0  8.6 8.3
Number of Nursing Homes  17,370  17,214 17,011 16,763 16,558 16,346  16,196  16,026 15,964
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  10.1  10.3 10.4 10.4 10.3 9.5  9.9  9.2 9.3
Q1 2002  5 Years  138  8.3  8.7 9.2 9.1 9.3 8.9  8.9  9.1 9.2
Q2 2002  5 Years  185  11.0  10.4 10.9 10.6 10.5 9.5  10.1  9.6 10.0
Q2 2004  3 Years  341  8.5  8.8 8.7 8.3 8.1 7.3  7.4  7.1 6.9
Q2 2002  5 Years  52  14.0  12.8 13.0 12.0 11.5 11.7  11.9  11.7 13.2
Q3 2003  5 Years  74  11.9  11.6 11.3 11.7 11.9 11.9  12.6  12.4 11.5
Q4 2003  2 Years  26  11.7  11.8 11.8 12.2 11.4 11.7  13.0  12.8 13.0
Q2 2000  5 Years  8  24.7  31.6 18.5 18.9 12.9 11.0  11.9  13.7 14.1
Q1 2002  3 Years  9  14.8  11.6 13.9 15.0 16.5 14.5  15.9  16.8 18.7
Q3 2003  5 Years  9  21.4  19.4 21.2 20.0 18.1 14.5  16.2  15.1 13.4
Q4 2004  5 Years  7  11.4  11.6 10.7 9.4 11.3 15.2  9.9  6.9 8.6
Q4 2001  5 Years  1  7.4  14.3 11.2 7.7 12.2 9.1  8.1  11.6 9.6
Q4 2001  4 Years  1  8.5  6.0 9.8 8.5 6.9 7.1  1.0  3.5 4.2
Q4 2002  3 Years  1  15.9  9.0 15.1 11.6 10.8 9.3  7.9  8.9 6.6
Q4 2005  3 Years  1  9.5  6.5 6.5 6.5 7.0 4.6  10.7  10.1 14.2
Source:  Office of Inspector General Analysis of Quality Indicator/Quality Measure data. 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   39   
 A P P E N D I X ~ D  
STATE SURVEY DEFICIENCIES DATA BY CORPORATION 
 
State Survey Deficiencies.  The Centers for Medicare & Medicaid 
Services (CMS) contracts with States to survey nursing homes initially, 
and routinely thereafter, for participation in the Medicare and Medicaid 
programs.22  States verify that the nursing homes maintain Federal 
quality of care standards by conducting a standard survey of each 
nursing home every 9 to 15 months.  When surveyors determine that an 
area of care in a nursing home does not meet Federal standards, they 
issue a deficiency tag.  Each deficiency tag includes a number that 
describes the specific infraction and a letter indicating the scope and 
severity.  (See Table 7.)  The scope refers to the number of affected 
residents and the severity refers to the degree of harm.  CMS uses  
47 deficiency tags to determine whether a nursing home is providing 
substandard quality of care.  These deficiency tags refer to quality of 
life, quality of care, and  participation requirements for resident 
behavior and facility practices.23   
State survey deficiency data are maintained in CMSs Online Survey,  
Certification, and Reporting (OSCAR) system.  We obtained OSCAR 
data for the national population of nursing homes for all standard 
surveys conducted between January 1, 1999, and December 31, 2007. 
  Table 7.  Scope and Severity Matrix for State Survey Deficiencies 
Deficiency Scope 
Deficiency Severity  Isolated  Pattern  Widespread 
Actual or potential for 
death or serious injury  J  K  L 
(immediate jeopardy) 
Actual harm that is not 
G  H  I 
immediate jeopardy 
Potential for more than 
D  E  F 
minimal harm 
Potential for minimal 
harm, substantial  A  B  C 
compliance exists 
  Source:  CMS, State Operations Manual. 
 
22 Sections 1819(g) and 1919(g) of the Social Security Act. 
23 CMS, State Operations Manual, section 7001.  Available online at 
http://www.cms.hhs.gov/manuals/downloads/som107c07.pdf.  Accessed on June 20, 2008. 
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   40   
A P P E N D I X   ~   D  
Selection of Deficiency Tags for Inclusion.  For this analysis, we included 
the 47 deficiency tags that CMS uses to determine whether a nursing 
home is providing substandard quality of care.  The deficiency tags 
used are listed in Table 8.   
 
Table 8:  Quality of Care Survey Deficiency Tags Selected for Analysis 
Resident Behavior and Facility Practices  
42 CFR   F-Tag Deficiency
483.13(a)   F221, F222 Restraints
483.13(b)   F223 Abuse
483.13(c)   F224, F226 Staff Treatment of Residents
Quality of Life 
42 CFR   F-Tag Deficiency
483.15(a)  F241 Dignity
483.15(b)  F242 Self-Determination and Participation
483.15(c)  F243, F244 Participation in Resident and Family 
Groups
483.15(d)  F245 Participation in Other Activities
483.15(e)  F246, F247 Accommodation of Needs
483.15(f)  F248, F249 Activities
483.15(g)  F250, F251 Social Services
483.15(h)  F252, F253, F254, F255,  Environment
F256, F257, F258
Quality of Care 
42 CFR   F-Tag Deficiency
483.05  F309 Quality of Care Deficiencies Not Covered 
by  483.25(a)(m)
483.25(a)  F310, F311, F312 Activities of Daily Living
483.25(b)  F313 Vision and Hearing
483.25(c)  F314 Pressure Sores
483.25(d)  F315, F316 Urinary Incontinence
483.25(e)  F317, F318 Range of Motion
483.25(f)  F319, F320 Mental and Psychosocial Functioning
483.25(g)  F321, F322 Naso-Gastric Tubes
483.25(h)  F323, F324 Accidents
483.25(i)  F325, F326 Nutrition
483.25(j)  F327 Hydration
483.25(k)  F328 Special Needs
483.25(l)  F329 Unnecessary Drugs
483.25(m)   F332, F333 Medication Errors
483.25(n)   F334 Influenza and Pneumococcal 
Immunizations
Source:  CMS State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care 
Facilities,  Rev. 26, August 17, 2007. 
Analysis of survey deficiency data.  We took the following steps to analyze 
the survey deficiency data: 
1.  For each survey of each nursing home, we computed the total 
number of deficiencies of a scope and severity of D or higher.  
We did not include scope and severity levels A through C 
because they are considered to be substantial compliance by 
CMS.   
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   41   
A P P E N D I X   ~   D  
2.  We computed the average number of deficiencies in each State 
for each year from 1999 through 2007.   
3.  We created an index for each nursing home for each standard 
survey that was computed as the number of deficiencies for the 
survey divided by the average number of deficiencies for the 
State for the year of the survey.24  These deficiency index scores 
for each corporation are presented in Table 9.  The national 
index score equals 1; therefore, scores above 1 indicate that the 
corporation had more deficiencies than the average, and scores 
lower than 1 indicate that the corporation had fewer than 
average. 
Table 9:  Index Scores for CIA Corporations for Quality of Care Deficiencies of Scope and Severity of D or 
Higher*  
CIA Corporations 
Number of 
CIA Start  Term of  Nursing 
Quarter  CIA  Homes  1999  2000 2001 2002 2003 2004  2005  2006 2007
Q2 2001  5 Years  251  1.11  1.15 1.23 1.19 1.10 1.14  1.04  1.14 1.21
Q1 2002  5 Years  138  1.14  1.11 1.36 1.05 1.05 1.19  1.05  1.03 1.11
Q2 2002  5 Years  185  1.03  1.05 1.17 1.15 1.20 1.13  1.16  1.20 1.34
Q2 2004  3 Years  341  1.03  1.06 1.08 1.01 0.96 0.83  0.83  0.89 1.12
Q2 2002  5 Years  52  1.17  1.36 1.12 1.08 1.05 1.11  0.76  1.48 1.22
Q3 2003  5 Years  74  1.18  1.10 1.09 1.04 1.16 1.02  1.20  1.66 1.38
Q4 2003  2 Years  26  0.99  0.77 1.03 1.22 1.14 0.94  0.97  0.95 1.55
Q2 2000  5 Years  8  0.88  1.04 1.20 1.51 1.69 0.73  0.88  1.33 0.77
Q1 2002  3 Years  9  0.68  1.90 1.36 1.09 1.45 1.30  2.05  1.44 1.70
Q3 2003  5 Years  9  1.27  0.73 1.44 1.20 1.63 0.55  0.83  2.20 0.78
Q4 2004  5 Years  7  0.35  0.96 0.37 1.02 1.58 1.74  0.60  0.97 1.36
Q4 2001  5 Years  1  2.97  1.79 0.70 1.32 0.31 0.29  2.16  2.97 1.79
Q4 2001  4 Years  1    1.11 0.32 0.28 0.30 0.28  1.03  0.23 1.11
Q4 2002  3 Years  1  1.09  3.61 0.96 1.95 1.41 1.55  2.16  1.09
Q4 2005  3 Years  1  3.28  0.29 0.37 0.33 1.30 1.10  1.35  0.65 3.28
*Shaded areas indicate the years during which the corporation was under the CIA. 
Source:  Office of Inspector General analysis of OSCAR quality of care deficiencies on standard surveys. 
 
 
 
24 Prior Office of Inspector General (OIG) work found that there was variation across 
States in the number of deficiencies cited and that States differ in how they determine 
specific deficiency citations.  Using same-State nursing homes as a denominator, rather 
than all nursing homes in the Nation, helped to account for any variation in surveyor 
practices across States and create a meaningful comparative index.  OIG, Deficiency 
Trends and Survey and Certification Process Consistency (OEI-02-01-00600), March 2003.   
  OEI-06-06-00570  QUALITY OF CARE IN NURSING HOMES UNDER CORPORATE INTEGRITY AGREEMENTS   42   
 A C K N O W L E D G M E N T S  
 
This report was prepared under the direction of Kevin K. Golladay, 
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office, and A. Blaine Collins, Deputy Regional Inspector 
General.   
Susan M. Wolfe served as the team leader for this study.  Other 
principal Office of Evaluation and Inspections staff from the Dallas 
regional office who contributed to the report include Amy Ashcraft, 
Dustin Johnson, Sai Loganathan, Margaret Knight, and Dana 
McClellan; other staff who contributed include Kevin Farber, Jennifer 
Jones, Sandy Khoury, and Barbara Tedesco. 
 
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