Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Nursing Home Deficiency Trends and 
Survey and Certification Process Consistency 
JANET REHNQUIST 
Inspector General 
MARCH 2003 
OEI-02-01-00600  O I G
FFICE OF  NSPECTOR  ENERAL

http://www.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 OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and operations in 
order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the 
Department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and the 
public.  The findings and recommendations contained in the inspections reports generate rapid, accurate, 
and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil 
monetary penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
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 in OIGs internal 
operations.  The OCIG imposes program exclusions and civil monetary penalties on health care providers 
and litigates those actions within the Department.  The OCIG also represents OIG in the global settlement 
of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E  S U M M A R Y  
OBJECTIVE 
To describe trends in nursing home deficiencies and to assess consistency in the state 
implementation of the Medicare survey and certification process. 
BACKGROUND 
All Medicare and/or Medicaid participating nursing homes must be certified as meeting certain 
federal requirements.  This certification is achieved through routine facility surveys, which the 
Centers for Medicare & Medicaid Services (CMS) contracts with states to perform.  Nursing 
homes are typically surveyed by survey teams within 9-to-15 month intervals. 
This inspection uses data from 7 different sources: (1) national data from the Online Survey and 
Certification Reporting (OSCAR) system; (2) a mail questionnaire of all 51 state survey and 
certification directors; (3) telephone interviews with staff from all 10 regional CMS offices; (4) 
observations of nursing home surveys in a purposive sample of 6 states; (5) a review of 310 
survey reports from the same 6 states; (6) telephone interviews with a purposive sample of 32 
surveyors from 8 states; and (7) telephone interviews with a purposive sample of 32 nursing 
home administrators from the same 8 states. 
FINDINGS 
Nursing home deficiencies have increased since 1998 
Eighty-nine percent of nursing homes received at least one deficiency, an increase of 8 
percentage points. In 2001, 89 percent of all nursing homes that were surveyed received at 
least one deficiency, an increase from 81 percent in 1998. Only 11 percent, or 1,690 nursing 
homes, were deficiency-free in 2001.  The total number of deficiencies rose from 64,608 in 
1998 to 94,131 in 2001. The average number of deficiencies increased from 5.1 in 1998 to 
6.2 in 2001. 
i 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Seventy-eight percent of nursing homes received a deficiency in one of the categories 
related to CMS definition of substandard quality of care, an increase of 
8 percentage points. The proportion of nursing homes that received a deficiency in any of the 
three categories related to substandard quality of care increased by 8 percentage points from 
70 percent in 1998 to 78 percent in 2001. The proportion of nursing homes that received an 
immediate jeopardy deficiency (2.3 percent) has increased slightly from 1998 to 2001. 
Wide variation exists among states in the number of deficiencies 
Nationally, 11 percent of all nursing homes surveyed in 2001 had no deficiencies. The 
proportion of deficiency-free nursing homes ranged from 33.5 percent in Virginia to  0 
percent in Nevada. Nationally, the average deficiency rate for nursing homes surveyed in 2001 
was 6.2 per nursing home; this ranged from 2.9 deficiencies per nursing home in Vermont to 
11.2 deficiencies in California. 
States differ in how they determine specific deficiency citations 
Our review of 310 survey reports reveals that different deficiency tags are being used to cite the 
same problem. In five of the six standard surveys we observed, we noted instances where 
surveyors did not consistently cite deficiencies. Further, states differ on how many deficiencies 
they will cite for a single problem of non-compliance. 
Four factors contribute to variability in citing deficiencies 
First, state agency directors acknowledge that the nursing home survey process has either a 
consultative or enforcement focus that affects the scope of the review.  Second, unclear 
guidelines may contribute to different interpretations by surveyors when citing deficiencies. 
Third, while most states report some level of supervisory review for draft survey reports, the 
scope of these reviews differs, and states have various additional review processes they follow. 
Lastly, nearly all states report a high surveyor staff turnover, which contributes to inconsistency. 
States report following CMS nursing home survey protocols for staffing, 
scheduling, and pre-survey preparation; in the six sample states, survey teams 
completed all on-site survey tasks 
All state agency directors report following protocols for survey team size, make-up, and basic 
CMS training requirements.  All state agencies report following protocols for pre-survey 
preparation and scheduling standard surveys within a 9-to-15 month interval. In 
ii 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  addition, our on-site visits revealed the completion of all six on-site survey tasks and proper use 
of investigative protocols. Further, our review of survey reports shows that surveyors in the six 
sample states rely on the same types of evidence to document deficiencies. 
CONCLUSION 
Our analysis shows an increase in nursing home deficiencies since 1998.  The proportion of 
nursing homes receiving deficiencies, the total number of deficiencies, and the key categories of 
deficiencies directly related to quality of care have all increased since 1998.  In addition, wide 
variation exists among states in the proportion of deficiency-free nursing homes and in average 
deficiency rates. 
Our review of the survey process reveals states differ in how they determine both the number 
and type of deficiencies. We identified four factors that contribute to this variability in citing 
deficiencies: (1) an inconsistent survey focus; (2) unclear guidelines; (3) the lack of a common 
review process for draft survey reports; and (4) high surveyor staff turnover. As a result, we 
conclude that nursing home survey results are not always consistent among states, therefore 
limiting the comparability of the data. Further, we cannot conclude whether trends in 
deficiencies are due to deteriorating care, variations in the survey process, and/or increased 
enforcement.  However, deficiencies are a key indicator of care in nursing homes and, 
therefore, the number of deficiencies and the increase in the number of deficiencies over the 
past four years raise concerns. 
RECOMMENDATIONS 
The Centers for Medicare & Medicaid Services should continue to improve its 
guidance to state agencies on citing deficiencies by providing guidelines that are both 
clear and explicit. Based on our findings, we recommend that CMS provide more specific 
guidance to states on quality of life deficiency tags and clearer directives on when to cite single 
or multiple deficiencies. We also recommend that CMS more clearly communicate to states 
that the focus of the nursing home survey process is not consultative. They should remind states 
of the dual function of this process, as specified in the Interpretive Guidelines. These two 
functions are: (1) to ensure compliance; and (2) to enter into a non-consultative information 
exchange for the purpose of information dissemination that may be of assistance to the facility in 
meeting long term care requirements. 
iii 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  The Centers for Medicare & Medicaid Services, together with states, should develop 
common review criteria for draft survey reports.  While most states incorporate some 
level of supervisory review for draft survey reports, they do not follow a standard  process with 
common evaluation criteria.  A more standard review process that utilizes the same criteria for 
assessing draft reports will help to ensure greater consistency across states. The CMS could 
incorporate this standardized assessment criteria as part of the Nursing Home State 
Performance Measures: Review Protocol Guidance, which all states are now required to 
follow. 
AGENCY COMMENTS 
We received comments on our draft report from the Centers for Medicare & Medicaid 
Services (CMS).  The CMS concurred with our recommendations that it should continue to 
improve guidance to state agencies on citing deficiencies by providing guidelines that are both 
clear and explicit and that it should develop, together with states, a common review criteria for 
draft survey reports.  The CMS also highlighted several actions they have taken to improve 
such guidance. The full text of CMS comments are contained in Appendix G. 
iv 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY ...................................................... i

INTRODUCTION .............................................................1

FINDINGS 
Nursing home deficiencies have increased since 1998  ..............................7

Wide variation exists among states in deficiencies  ................................14

States differ in how they determine deficiency citations  ............................15

Four factors contribute to variability ..........................................16

States report following CMS survey protocols  ..................................20

CONCLUSION  ............................................................. 23

RECOMMENDATIONS ...................................................... 24

AGENCY COMMENTS  ...................................................... 25

APPENDICES

A: Quality of care deficiency definitions  .......................................26

B:  Selected deficiency definitions  ............................................29

C: Proportion of quality of care deficiencies ....................................30

D: Scope and severity deficiencies ...........................................35

E: Proportions Deficiency-Free Facilities, Deficiency Removals by Deficiency Rates . .....3 6

F: Federal Standards for Surveyor Training Requirements  .........................38

G: Agency Comments  ....................................................39

ACKNOWLEDGMENTS  ..................................................... 42

v 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  I N T R O D U C T I O N  
OBJECTIVE 
To describe trends in nursing home deficiencies and to assess consistency in the state 
implementation of the Medicare survey and certification process. 
BACKGROUND 
Survey and Certification Process 
All Medicare and/or Medicaid participating nursing homes must be certified as meeting certain 
federal requirements. Certification is achieved through routine facility surveys, which the 
Centers for Medicaid & Medicare Services (CMS) contracts with states to perform.  Nursing 
homes are subject to unannounced standard surveys no later than 15 months after the date of 
the previous standard survey.  If, during the standard survey, a nursing home is found to have 
provided substandard quality of care, an additional extended survey is conducted within 2 
weeks. Nursing home surveys are typically conducted by a team of surveyors, with a team 
leader assigned to manage the process while on site.  The survey team conducts various pre-
survey tasks, such as reviewing existing program data, before going to the facility. 
When a nursing home fails to meet a specific requirement, the facility receives a deficiency 
citation.  These deficiencies are categorized into 1 of 17 major areas, such as quality of care 
and physical environment.  A total of 190 deficiencies with different tag numbers can be cited. 
Surveyors also consult a scope and severity matrix in determining the level of each deficiency. 
Survey data are entered into the Online Survey and Certification Reporting System (OSCAR). 
OBRA 1987 
The Omnibus Budget Reconciliation Act (OBRA) of 1987 (P.L. 100-203) expanded 
requirements that nursing homes had to comply with prior to Medicare certification, altered the 
principles for enforcement, and defined the state survey and certification process for 
determining compliance with federal standards of care.  The CMS had several process goals 
for the implementation of the survey and enforcement systems: promoting consistency through 
extensive training, linking appropriate remedies to deficiencies, and avoiding unnecessary 
procedures. 
1 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  1998 Nursing Home Oversight Improvement Program 
Ten years after the passage of OBRA 1987, a series of research studies and Senate hearings 
called attention to serious concerns about residents well-being. In response to these concerns, 
the 1998 Nursing Home Oversight Improvement Program,1 designed to improve enforcement 
of nursing home quality, was announced.  To implement the Nursing Home Oversight 
Improvement Program, CMS initiated steps to improve nursing home survey procedures, 
including: 
C  staggering nursing home inspections, and starting a certain number on weekends 
and evenings; 
C  more frequently inspecting nursing homes that are repeat offenders; 
C  enhancing CMS review of nursing home surveys conducted by states; 
C  terminating federal nursing home survey funding to states that fail to perform 
adequate surveys; 
C  imposing immediate sanctions for a second violation of harming residents; and 
C  ensuring that state agencies enforce sanctions and that sanctions are not lifted 
until compliance is verified. 
In September 2000, the General Accounting Office (GAO) reported that more deficiencies in 
nursing homes were being detected by state survey agencies, although it remained unclear if this 
was due to more skillful enforcement or deteriorating care.  The GAO also reported that wide 
variation existed among states with regard to the proportion of homes cited for serious care 
deficiencies, ranging from 10.5 percent in Maine to 
58 percent in Washington.2 This gap suggests variability within and between states in the 
consistency of adherence to survey interpretive guidelines in deficiency citations is problematic, 
at least on the basis of interstate variability in the number and types of deficiencies cited in the 
survey process.3 Additionally, a 2000 interim report from CMS on the Nursing Home 
Oversight Improvement Program noted some positive progress (such as more surveys being 
conducted during off-hours), but also identified areas where stronger efforts were needed. For 
example, the report found that significant variation in state deficiency citations may indicate 
problems with the state survey process.  [Further], 
1
 Enacted in 1998 during the Clinton administration as the Nursing Home Initiative. 
2
 GAO, Sustained Efforts are Essential to Realize the Potential of Quality Initiatives, (GAO/HEHS-00-197), 
September, 2000 
3
Wunderlich, G., Kohler, P., Improving the Quality of Long Term Care, (Editors: Committee on Improving 
Quality in Long Term Care, Division of Health Care Services, National Institute of Medicine), 2001 
2 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  this degree of variation suggests that we need to be cautious when comparing results across 
states.4 
CMS Oversight 
The CMS has various ongoing initiatives that address the issue of consistency and accuracy in 
the survey and certification process.  These initiatives include: a national automated tracking 
system for surveyor training; an improved scope and severity matrix; cross regional surveys to 
assess consistency; the redesign of surveyor training; the development of surveyor performance 
measures; and contracting out for more comparative surveys. 
The CMS is also currently funding the second year of a contract to improve interpretive 
guidelines for scope and severity and deficiency tags.  To date, CMS has reviewed five sets of 
tags and is beginning work for the next grouping of tags. 
METHODOLOGY 
This inspection uses data from 7 different sources: (1) national data from the Online Survey and 
Certification Reporting (OSCAR) system; (2) a mail questionnaire of all  51 state Survey and 
Certification Directors; (3) telephone interviews with staff from all 10 regional CMS offices; (4) 
observations of nursing home surveys in a purposive sample of 6 states; (5) a review of 310 
survey reports from the same 6 states; (6) telephone interviews with a purposive sample of 32 
surveyors 8 states; and (7) telephone interviews with a purposive sample of 32 nursing home 
administrators from the same 8 states. 
Analysis of OSCAR data 
We analyzed national data from OSCAR, which includes the results of all state nursing home 
surveys.  This system contains the most current survey and the three previous surveys for every 
nursing home that is certified for Medicare and/or Medicaid.  We downloaded all surveys 
conducted in 1998, 1999, 2000, and 2001. 
Our analysis is based on data we downloaded in May 2002.  If a nursing home had more than 
one standard survey in a particular year, we included only the most recent standard survey for 
that year. We determined the total number of nursing homes surveyed, the 
4
 Michael Hash, Deputy Administrator of the Centers for Medicare & Medicaid Services, Interim Report on 
Nursing Homes, 2000. 
3 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  total number of deficiencies cited in those surveys, and the total number of nursing homes 
surveyed that had no deficiencies. We then calculated average deficiency rates by dividing the 
number of deficiencies by the number of nursing homes surveyed. 
Observations of nursing home surveys 
In order to get a wide variety of states, we selected a purposive sample of six states based on 
the following four criteria: 1) the number of nursing homes in the state, 2) the average deficiency 
rate, 3) the CMS regional office jurisdiction, and 4) geographical location.  The six states 
include: Alabama, California, Maryland, Missouri, New York, and South Dakota. In five of 
the six sample states, we observed the final 2 days of a standard nursing home survey; in the 
sixth state, the survey ended earlier than anticipated, and we, therefore, observed only the final 
day. To reduce observer bias and enhance comparability across cases, we developed field 
instrumentation for observing and recording events. This included a structured checklist for the 
observation of survey activities and survey team interaction.  We were especially interested in 
observations related to survey Task 5 (information gathering) and Task 6 (information analysis 
for deficiency determination). Further, we used a common interview guide to ask surveyors 
about their experiences and perspectives on the survey process. 
Review of survey reports 
From the 6 sample states, we reviewed 310 survey reports for standard surveys completed in 
calendar year 2001. We asked each of the 6 states to send us reports that included one or 
more citations for 13 specific deficiency tags. We focused our review on these 13 tags, either 
because they were among the top 10 deficiencies in 2000, and/or because we identified them 
as being potentially vulnerable to inconsistent citation.  These 13 tags and the number of survey 
reports for each are identified in Appendix B. 
For each report, we used a standardized review protocol to determine the scope and severity 
of the deficiency cited, the nature of the problem cited, the sample size used in survey, and the 
type of evidence given to support the citation. 
State survey agency directors mail questionnaire 
We mailed a questionnaire to state nursing home Survey and Certification Directors in April and 
May 2002.  All states and Washington D.C. responded to the questionnaire.  We asked about 
each state agencys program staffing and structure, survey process, state surveyor training and 
education, and state initiatives and experience with federal nursing home surveys.  In addition, 
we asked respondents to rate the quality of care in nursing homes in their state and whether it 
has improved, declined, or remained about the same in 
4 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  the last 3 years. Many of our questions were based on federal nursing home survey regulations 
and the State Operations Manual surveyor guidelines. 
Telephone interviews with CMS regional offices 
We interviewed staff from all 10 regional offices of the CMS in May 2002. In most cases, we 
interviewed the branch chief or regional administrator responsible for state operations and/or 
long term care survey and certification. During these interviews, we asked CMS staff about 
their oversight and monitoring activities. We specifically inquired about their regional staffing, 
the data they use to review state agencies performance, their survey protocols for Federal 
Oversight and Support surveys (FOSS) and comparative surveys, and their state training 
activities. 
Telephone interviews with state surveyors and nursing home administrators 
For the telephone interviews with state surveyors and nursing home administrators, we used the 
same purposive state sample selected for the on-site visits and survey report reviews.  In 
addition, we selected one state that had a large increase (Connecticut) and one state that had a 
large decrease (South Carolina) in quality of care deficiencies over the last 4 years. 
State Surveyors.  We asked each of the state survey agencies for a list of all surveyors in 
their state who had been a nursing home surveyor for at least 3 years. We then selected a 
random sample of 4 surveyors in each of our 8 sampled states for a total of 32 respondents. 
We asked the same questions that we asked state survey agency directors in addition to other 
questions about their observations in nursing homes. 
Nursing Home Administrators.  To select a sample of nursing home administrators, we 
generated a list from OSCAR of nursing homes in each of our eight sampled states that had at 
least four standard surveys.  We then randomly selected 4 nursing homes in each state for a 
total of 32 respondents.  We asked these administrators the same set of questions that we 
asked state surveyors so that we could compare their responses. 
Limitations 
This inspection has several limitations. First, we only examined the survey process for standard 
surveys; we did not include extended surveys, follow-up surveys, initial certification surveys, or 
complaint surveys in our review. Second, we did not independently verify all of the information 
reported to us by state agencies in the mail 
5 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  questionnaire.  Third, our more detailed review of eight states is based on a purposive sample 
and, therefore, cannot be generalized to the universe of all states. 
Standards 
This inspection was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
6 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  F I N D I N G S  
In 2001, 89 percent of nursing homes received at least one deficiency, an increase from 81 
percent in 1998.  Total deficiencies increased by 46 percent to over 94,000, and the average 
number of deficiencies per nursing home rose from 5.1 to 6.2. Our analysis of OSCAR data 
also shows wide variation among states in the proportion of deficiency-free nursing homes and 
in average deficiency rates. 
Our review of the survey process further reveals that states differ in how they determine both 
the number and type of deficiencies. We identified four factors that contribute to this variability 
in citing deficiencies: (1) an inconsistent survey focus; (2) unclear guidelines; (3) the lack of a 
common review process for draft survey reports; and (4) high surveyor staff turnover. As a 
result, we conclude that nursing home survey results are not always consistent among states, 
therefore limiting the comparability of the data. Further, we cannot conclude whether trends in 
deficiencies are due to deteriorating care, variations in the survey process, and/or increased 
enforcement. However, deficiencies are a key indicator of care in nursing homes, and 
therefore, the number of and the increase in deficiencies over the past four years raise concerns. 
Nursing home deficiencies have increased since 1998 
Eighty-nine percent of nursing homes received at least one deficiency, an 
increase of 8 percentage points since 1998 
Surveyors can cite a nursing home for  Figure 1 
one or more deficiencies if it fails to  Proportion of Nursing Homes that Received 
meet certain Medicare program  Any Deficiency, 1998-2001 
requirements.  In  2001,  89 
percent of all nursing homes that 
were surveyed received at least 
one deficiency. This proportion 
increased  by  8  percentage 
pointsfrom 81 percent in1998. 
(See Figure 1.) Conversely, the 
proportionofnursinghomesthat 
were deficiency-free decreased 
from 19 percent in 1998 to 
11 percent in 2001.  In2001, a 
Source: OSCAR data, 2002 
7 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  total of 15,077 nursing homes were surveyed; only 1,690 nursing homes did not receive any 
deficiencies. 
As shown in Table 1 below, in 2001, nursing homes received an average of  6.2 deficiencies, 
an increase from 5.1 deficiencies in 1998. The total number of deficiencies rose by 46 percent, 
from 64,608 in 1998 to 94,131 in 2001. The total number of nursing homes that were 
surveyed grew by 20 percent during this time period, from 12,555 in 1998 to 15,077 in 2001. 
Table 1 
Trends in Deficiencies, 1998-2001 
1998  1999  2000  2001  Percent 
Change 
1998-2001 
Total Number of Deficiencies  64,608  82,238  92,642  94,131  45.7% 
Total Number of Nursing Homes  12,555  14,313  14,879  15,077  20.1% 
Surveyed 
Average Deficiencies per  5.1  5.7  6.2  6.2 
Nursing Home 
Source: OSCAR data, 2002 
Seventy-eight percent of nursing homes received a deficiency in one of the 
categories related to substandard 
quality of care, an increase of 8 
percentage points from 1998 to 2001  Examples of Deficiencies in Three Categories 
Related to Substandard Quality of Care 
Quality of Care: includes 25 deficiencies, such as proper 
The proportion of nursing homes that  treatment to prevent and treat pressure sores, and resident 
receiveda deficiencyinanyofthe three  receives adequate supervision and assistance devices to 
prevent accidents. 
quality of care categories increased 
by  8  percentage  points,  from  70 
Quality of Life: includes 19 deficiencies, such as a facility 
percent in 1998 to 78 percent in 2001.  must promote care that maintains or enhances dignity, and 
These  three  categories  are  part  of  a facility must provide housekeeping and maintenance 
services necessary to maintain a sanitary, orderly, and 
CMSdefinitionofsubstandardquality 
comfortable interior. 
of care.  They include: one that is 
specifically  called  quality  of  care,  Resident Behavior and Facility Practices: includes 6 
another referred to as quality of life,  deficiencies, such as a resident has the right to be free 
from any physical restraint for purposes of discipline and 
and a third that is resident behavior and 
convenience, and the facility may not employ persons 
facility practices. See Appendix A for 
who have been found guilty of abuse. 
a  list  of  all  deficiencies  in  each 
category. 
8 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  As shown in Table 2, each of these three individual categories increased during this time.  The 
proportion of nursing homes that received a deficiency related to resident behavior and facility 
practices and to the specific quality of care category each increased by 9 percentage points 
between 1998 and 2001.  Quality of life deficiencies increased by 5 percentage points. 
Appendix C lists changes to each of the deficiencies in these categories. 
Table 2
Proportion of Nursing Homes that Received at Least One Deficiency by Category 
1998-2001 
1998  2001  Percentage Point Difference 
N=12,555  N=15,077  1998-2001 
Resident Assessment  38.6%  50.1%  11.6% 
Dietary Services  31.7%  42.1%  10.3% 
Resident Behavior & Facility  19.1%  28.2%  9.1% 
Practices 
Quality of Care  59.4%  68.4%  9.0% 
Pharmacy Services  12.1%  20.1%  7.9% 
Infection Control  15.6%  20.7%  5.1% 
Administration  20.9%  26.0%  5.1% 
Physical Environment  20.7%  25.8%  5.1% 
Quality of Life  37.8%  43.1%  5.3% 
Resident's Rights  26.2%  29.9%  3.7% 
Laboratory Services  2.9%  4.9%  1.9% 
Physician Services  3.4%  4.7%  1.2% 
Dental Services  0.7%  1.2%  0.5% 
Nursing Services  5.0%  5.1%  0.0% 
Rehabilitation Services  1.1%  1.0%  - 0.1% 
Other  0.4%  0.3%  - 0.1% 
Admission, Transfer, Discharge  2.5%  1.6%  - 0.9% 
Rights 
* Differences may be due to rounding.  Source: OSCAR data, 2002 
**Bold indicates quality of care categories. 
9 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  As also shown in Table 2, deficiencies in three other categories experienced considerable 
increases. These include resident assessment and pharmacy and dietary services. The largest 
increase was in the proportion of nursing homes that received a deficiency related to resident 
assessment. This category increased by nearly 12 percentage points, from almost 39 percent in 
1998 to 50 percent in 2001.  These deficiencies address whether a facility has developed care 
plans, provided the appropriate care and services to each resident, and modified the care plan 
based on the residents status. 
In addition, deficiencies related to dietary services rose by 10 percentage points from 32 
percent of nursing homes in 1998 to 42 percent in 2001. Deficiencies related to pharmacy 
services also increased by about 8 percentage points during this time.  Dietary services include 
deficiencies that address whether a nursing home has provided the appropriate diet to meet the 
daily nutritional needs of each resident. Pharmacy services include deficiencies related to 
assuring the accurate dispensation and administration of drugs to residents. 
Nursing homes receiving immediate jeopardy deficiencies have increased slightly 
Surveyors assign a scope and severity rating for each deficiency.  If a deficiency has a J, K, or 
L scope and severity rating as shown in Table 3 on the next page, it is considered to be 
immediate jeopardy. Immediate jeopardy is when death or serious injury actually or potentially 
occurs.  The proportion of nursing homes that received an immediate jeopardy deficiency 
stayed about the same between 1998 and 2001. In 2001, a total of 2.3 percent, or 353 
nursing homes, had at least one immediate jeopardy deficiency. This proportion rose slightly 
from 1.4 percent, or 172 nursing homes, in 1998. (See Appendix D.) 
The proportion of nursing homes that received a deficiency considered substandard quality of 
care did not change substantially from 1998 to 2001. Substandard quality of care is a 
deficiency in any of the three quality of care categories that has a scope and severity rating, as 
shown by the shaded area in Table 3 on the next page.  In total,  4.2 percent, or 639 nursing 
homes, received at least one substandard quality of care deficiency in 2001. This number 
decreased slightly from 4.5 percent in 1998. (See Appendix D.) 
10 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Table 3 
Percent of Nursing Homes with Deficiencies in Any of the Three Categories 
of Quality of Care by Scope and Severity in 2001 
Scope of the Deficiency 
Isolated  Pattern  Widespread 
y 
c
n
e
i Immediate jeopardy to resident  J  K  L 
c
i
f health or safety  1.0%  0.8%  0.2% 
e
D
e  Actual harm that is not  G  H  I 
h
t immediate jeopardy  18.6%  1.3%  0.0% 
f 
o
y  No actual harm with potential  D  E  F 
t
i
r for more than minimal harm that  64.1%  37.6%  1.6% 
e
v is not immediate jeopardy 
e
S
No actual harm with potential  A  B  C 
for minimal harm  0.0%  14.5%  7.7% 
*  Shading indicates the ratings classified as substandard quality of care.  Source: OSCAR data, 2002 
**Percentages in the table do not add to 4.2 percent because a nursing home may receive more than one deficiency 
. 
considered substandard quality of care
As shown in Table 4 on the next page, a review of the trends of the scope and severity of all 
deficiencies shows a shift from G-level to D-level and to E-level ratings between  1998 and 
2001.  This trend indicates that nursing homes are being cited for less severe deficiencies, while 
the scope of these deficiencies is staying the same or is slightly increasing. All of the other 
ratings have remained about the same or have increased slightly during this time period. The 
trends in the scope and severity ratings of deficiencies in the three quality of care categories 
follow a similar pattern to all deficiencies.  (See Appendix D.) 
11 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Table 4 
Percent of Nursing Homes that Received a Deficiency 
by Scope and Severity of All Deficiencies, 1998-2001 
Scope and  Percentage Point Difference* 
Severity Level  1998  2001  1998-2001 
A  0.0%  0.0%  0.0% 
B  30.2%  32.7%  2.5% 
C  21.4%  23.4%  2.0% 
D  63.5%  77.2%  13.6% 
E  47.1%  54.8%  7.7% 
F  15.4%  19.8%  4.4% 
G  28.1%  19.6%  - 8.5% 
H  3.1%  1.5%  - 1.6% 
I  0.3%  0.1%  - 0.2% 
J  0.8%  1.2%  0.5% 
K  0.6%  1.0%  0.4% 
L  0.2%  0.4%  0.2% 
* Differences may be due to rounding  Source: OSCAR data, 2002 
Over two-thirds of all state directors and sampled surveyors report that quality of 
care has stayed the same or declined over the last 3 years; nursing home 
administrators are more positive 
To gain further insight into the state of care in nursing homes, we surveyed all 51 state Survey 
and Certification Directors, and a purposive sample of 32 state surveyors and 32 nursing home 
administrators.  As shown in Chart 1 on the next page, the majority of state directors and state 
surveyors report that quality of care has stayed the same or declined over the last 3 years. 
Nursing home administrators are more positive in that 59 percent say that care has improved 
over the last 3 years. 
12 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Chart 1 
Overall, has the quality of care in nursing homes improved, declined, or stayed about the 
same over the last 3 years? 
Sample Size  Improved  Declined  Stayed the Same  Dont Know 
Surveyors  n=32  31 %  34 %  34 %  0 % 
Survey and Certification 
Directors  N=51  24 %  27 %  45 %  4 % 
Nursing Home  n=32  59 %  9 %  31 %  0 % 
Administrators 
Source: OEI Survey, 2002 
Two-thirds of sampled surveyors further note that the percentage of nursing homes in their area 
that provide care they consider to be poor has increased or stayed about the same during this 
time. Some explain that staffing issues, such as high turnover, lack of training, poor quality staff, 
and less supervision contribute to care getting worse.  In contrast, nursing home 
administrators most commonly attribute improvements in quality of care to committed staff, the 
survey process, quality initiatives, and the use of the clinical assessment tool, referred to as the 
Minimum Data Set. 
When asked to rate overall quality of care in nursing homes, some respondents expressed 
concerns.  Chart 2 below shows that over one-third of sampled surveyors and 14 percent of all 
state directors rate quality of care as fair or poor. In addition, about two-thirds of 
surveyors and 44 percent of administrators report that at least 10 percent of nursing homes in 
their area provide care that they consider to be poor. 
Chart 2 
Overall, how would you rate the quality of care in nursing homes in your area? 
Sample Size  Excellent  Good  Fair  Poor  Dont Know 
Surveyors  n=32  3 %  59 %  28 %  6 %  3 % 
Survey and Certification 
Directors  N=51  6 %  78 %  14 %  0 %  2 % 
Nursing Home  n=32  34 %  56 %  9 %  0 %  0 % 
Administrators 
Source: OEI Survey, 2002 
13 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Wide variation exists among states in the number of deficiencies 
Proportion of deficiency-free nursing homes. The proportion of nursing homes surveyed 
that were deficiency-free varied greatly among states.  In 2001, 33.5 percent of nursing homes 
surveyed in Virginia had no deficiencies, while in Nevada no nursing home surveys resulted in 
deficiency-free nursing homes.  Nationally, the average proportion of deficiency-free nursing 
homes for all surveys conducted in 2001 was 11 percent. Tables 5 and 6 below, show the five 
states with the highest and lowest proportion of deficiency-free nursing homes in 2001. 
Table 5  Table 6 
Highest Deficiency-Free States  Lowest Deficiency-Free States 
Proportion  Proportion 
State  Deficiency-Free*  State  Deficiency-Free* 
Virginia  33.5 %  Nevada  0 % 
Massachusetts  29.2 %  California  2.1 % 
Vermont  28.2 %  Florida  2.9 % 
New Hampshire  24.6 %  Tennessee  3.3 % 
Source: OSCAR data, 2002  Source: OSCAR data, 2002 
Deficiency rates. Nationally, the average deficiency rate in 2001 was 6.2 deficiencies per 
nursing home. This ranged from a high of 11.2 deficiencies per nursing home in California to a 
low of 2.9 deficiencies per nursing home in Vermont. Tables 7 and 8 below show the five 
states with the highest deficiency rates and the five states with the lowest deficiency rates in 
2001. 
Table 7  Table 8 
States with Highest Deficiency Rate  States with Lowest Deficiency Rate 
State  Deficiency Rate*  State  Deficiency Rate* 
California  11.2  Vermont  2.9 
Arizona  10.2  Rhode Island  3.3 
Washington  10  Wisconsin  3.3 
D.C. 
Virginia  3.5 
Nevada  9.9 
Utah  3.7 
Source: OSCAR data 2002 
Source: OSCAR data 2002 
14 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  In general, it appears that some states are more likely than others to cite deficiencies. For 
example, we observed that three states with the lowest deficiency rates (Vermont, Virginia, and 
Rhode Island) also have among the highest proportions of deficiency-free nursing homes. 
Three states with among the highest deficiency rates (California, Arizona, and Nevada) have the 
lowest proportions of deficiency-free nursing homes.  Also overall, 20.4 percent of nursing 
homes are deficiency-free in states with low deficiency rates.  For states with medium and high 
rates, the proportion of deficiency-free nursing homes is 10.9 percent and 5 percent, 
respectively.  (See Appendix E.) 
This variability in the data was also discussed in a 2000 interim report from CMS on the 
Nursing Home Oversight Improvement Program. That report noted significant variation in 
state deficiency citations from the national average of deficiencies cited may indicate problems 
with the state survey process.  There is also substantial variation among states in all measures 
examined, which could be attributed to any number of different factors including actual 
differences in quality [of care], case-mix, or surveyor practices. This degree of variation 
suggests that we need to be cautious when comparing results across states. 
States differ in how they determine specific deficiency citations 
Type of deficiency. Our review of 310 survey reports from the six sample states reveals that 
different deficiency tags are being used to cite the same problem.  For example, in one state, 
two different survey teams cited the same problem under two different tags. In both cases, they 
observed that closets with cleaning compounds containing dangerous chemicals were not 
locked.  In one survey, they cited this under tag F324 (inadequate supervision to prevent 
accidents). In the other survey, they cited this under tag F323 (the resident environment 
remains as free of accident hazards as is possible).  Further, a survey report from one state cites 
tag F441 (infection control) for dietary staff not following hand washing policy.  Two other 
survey reports in 2 different states cite tag F371 (store, prepare, distribute, and serve food 
under sanitary conditions) for the same problem. 
Our review of survey reports also reveals that different types of problems are being cited under 
the same deficiency tag.  When reviewing 26 reports with a citation for  F241 (resident dignity), 
we identified 17 different types of problems that were cited with this same deficiency.  These 
included incidents as diverse as residents waiting for their food at mealtimes, facial hair on a 
female resident, staff using disrespectful language, and a bedpan not being emptied. We also 
noted that a few of the problems cited under the dignity tag, such as unanswered call lights, 
were cited under different deficiency tags in other survey reports. 
15 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Further, nine state agency directors volunteer that their staff will consider either the type of 
corrective action needed by the facility or a particular preference for one deficiency category 
over another when deciding what deficiencies to cite. Comments from two state agency 
directors illustrate these practices. One says that surveyors will look at the main problem a 
facility needs to fix when deciding what type of deficiency to cite, while another admits that 
surveyors always go for a quality of care [deficiency], if relevant, over [an] assessment 
[deficiency]. 
Failure to cite deficiencies. In five of the six surveys we observed, we noted that surveyors 
did not consistently cite deficiencies for problems they observed in the nursing home.  In one, 
the team did not cite a deficiency for a food service worker who failed to wash her hands until a 
surveyor told her to; the same team also did not cite a deficiency for the nursing homes failure 
to write an incident report for a patient with a large bruise.  Also, in three surveys we observed 
that surveyors did not cite deficiencies for problems because the nursing home submitted 
additional documentation that convinced the surveyors that corrective action was being initiated. 
For example, during one visit we observed that surveyors noted a strong, offensive smell in 
several of the residents rooms; CMS guidelines instruct surveyors to cite such a problem with 
a deficiency. However, the surveyors did not cite a deficiency because they accepted the 
facilitys assurance that soiled carpeting in those rooms would be removed and replaced with 
linoleum flooring. According to CMS guidelines, they should have cited this deficiency. 
Number of deficiencies. States differ on how many deficiencies they will cite for a single 
problem of non-compliance.  While CMS guidelines do not prohibit that more than one 
deficiency be cited, eight state agency directors volunteer that their staff will cite only one tag 
for one problem of non-compliance. This is in direct contrast to other states in which surveyors 
may cite multiple tags for one problem of non-compliance.  In one state we visited with a low 
deficiency rate, surveyors told us that they were instructed by the state agency to choose only 
one tag rather than multiple tags for a single observed problem. 
Four factors contribute to variability in citing deficiencies 
We identified four factors that contribute to variability in citing deficiencies across state agencies 
and among surveyors. These are: 
1.  Inconsistent survey focus 
2.  Unclear guidelines 
3.  Lack of a common review process for draft survey reports 
4.  High surveyor staff turnover 
16 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Inconsistent survey focus . Thirty-six state agency directors say that their states survey

process is only somewhat consistent, acknowledging that this process may have a particular

enforcement or consultative focus that affects the scope of the review.  They cite several factors

affecting the focus of nursing home surveys, including the political climate, the strength of the

nursing home lobby, and changing federal and state regulations. Thirty-seven state agency

directors further note that the focus of nursing home surveys has changed in the last 3 years. 

Section IX of the State Operations Manual discusses the focus of the nursing home survey

process by stating that, in addition to ensuring compliance with federal standards, surveyors

should also transfer information to the facility about care and regulatory topics. The manual

specifically states, This information exchange is not a consultation with the facility, but is a

means of disseminating information that may be of assistance to the facility in meeting long term

care requirements.5

During our on-site visits to the six sample states, we observed survey teams utilizing different

foci in their reviews.  In one state, surveyors used a more consultative approach in making

specific recommendations to the nursing home staff about treatment protocols for an individual

resident.  This approach contrasted with a more enforcement approach we observed in another

state survey, where very little dialogue occurred between the survey team and nursing home

staff. 

Lastly, 21 states have state specific criteria governing nursing home surveys that may affect the

focus of their federal surveys. These state criteria most commonly include nursing home staffing

ratios and state life safety codes.  In 14 of these states, the criteria have changed over the past

3 years. 

Unclear guidelines. Twenty-three state agency directors and 17 of 32 sampled surveyors

assert that some groups of deficiencies are more vulnerable to inconsistent citation.  Both of

these groups identify deficiencies that are categorized under quality of life as being 

the most vulnerable due to the lack of clarity and complexity of the federal guidelines. 

They claim this fosters a subjective interpretation, thereby contributing to inconsistent citation

between surveyors.  One state agency director, voicing a common concern, asserts that it is

difficult to assign harm or immediate jeopardy to the quality of life tags.  Quality of life tags can

be more subjective. A clear directive is needed. 

As part of our analysis, we reviewed the State Operations Manual for deficiency tags under the

quality of life and quality of care categories. We found some of the guidance to be

inherently confusing. For example, guidance for tag F250 (social services)

5 
Title XVIII of the Social Security Act (the Act) is administered by CMS. Section 1819 (g)(2)(c) Survey 
Protocols, states that standard and extended surveys are to be conducted, based upon protocols prescribed by CMS 
in the State Operations Manual, to determine nursing home compliance. 
17 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  offers 14 examples of medically-related social services, 6 types of unmet needs, and  10 
conditions to which the nursing home must respond with social services.  Also, some of the 
definitions for these tags are general and subjective, and while the guidance does offer 
numerous examples of specific scenarios that can be cited under each deficiency tag, in some 
cases the broad range of examples can be confusing.  Lastly, we also noted that for certain 
deficiencies, surveyors are directed to refer to more than one deficiency category or tag for the 
same issue, without any explicit direction to cite or not cite under multiple tags when the facility 
is found to be out of compliance. For example, for tag F323 (facility is free of accident 
hazards), surveyors are instructed: see F221 for guidance concerning the use of bed rails.  See 
also 483.70(h) - Safe Environment. (F454 under Physical Environment). 
Lack of consistent review process for draft survey reports. States do not utilize the same 
review processes for draft survey reports, as illustrated in Table 9 below.  Only  42 states 
report that all of their draft reports had supervisory reviews in 2001. Further, 31 states have 
developed internal quality assurance (QA) teams and two states developed continuous quality 
improvement (CQI) teams (17 states have both).  Only 18 states conduct reviews when reports 
change significantly from draft to final, while a few also incorporate specialized assessments as 
part of their review process. 
Table 9 
State Survey Report Review Processes 
Review Processes  Number of 
States 
Supervisory Review for 100% of draft reports  42 
QA Teams  31 
Reviews for reports that changed significantly  18 
from draft to final 
Specialized reviews for Deficiencies with  8 
Scope and Severity of G level * and above 
Specialized review by Field Managers,  7 
Compliance Reviewers, or Enforcement Team 
Specialized reviews by Licensure and/or  3 
Certification Administrators 
CQI Teams  2 
Source: State Agency Director Mail Questionnaire, 2002 
18 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  This inconsistency in state agencies review processes is reflected in the wide variation in 
revisions made to draft deficiency reports. State agencies report that an average of 5 percent 
of deficiencies are removed from draft survey reports before they become final.  However, this 
removal rate ranges from 25 percent in one state to 0 percent in three other states.  Further, 
state agencies report that an average of 6 percent of scope and severity determinations are 
downgraded from draft surveyors reports before they become final.  This ranges from one 
state that reports 38 percent of deficiencies are downgraded to two states that say no 
deficiencies are downgraded. 
In addition, our analysis shows that the states with lower deficiency rates removed more 
deficiencies, on average, from draft survey reports than states with higher rates.  Figure 2 below 
shows the average proportion of deficiencies removed from surveyors draft reports, for states 
with high, medium, and low deficiency rates. 
Figure 2

Proportion of Deficiencies Removed by 

Average Deficiency Rate

8 
7.4 
7 
6 
5 
3.8 
4 
3 
3 
2 
1 
0 
2.9 - 4.6  5 - 6.9  7 - 11.2 
Range of average deficiency rates 
[ low - medium - high ] 
Source: OSCAR Data 2002 and State Agency Director Mail 
Questionnaire 
High surveyor staff turnover.  Fifty state agency directors report that it is very or somewhat 
difficult to replace survey staff when they leave, and more than half (31) say that registered 
nurses are the most difficult to replace.  Based on their reporting, we determined that nationally, 
surveyors work an average of only 6.5 years for the state agency.  We also determined that 
state agency directors have held their jobs on average for only 6.4 years. This high staff 
turnover affects the consistency of the survey process, as acknowledged by one survey director 
who says, It is impossible to achieve consistency when surveyor turnover is 50 percent every 
year.  While states identified high survey staff turnover rates to be a problem, only three 
regional CMS offices look at staff turnover rates in their oversight of state agencies. 
On all our visits to the six sample states, surveyors told us that finding and retaining staff were 
problematic. They also express concern that high staff turnover impacts on the 
19 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  consistency of the survey process, since a high proportion of newer staff detracts from the 
continuity of surveyors experience.  In fact, in one nursing home that we visited the survey 
team members were new, and we observed that these surveyors were more uncertain about 
what problems to cite and which deficiency tags to cite them with. 
States report following CMS nursing home survey protocols for 
staffing, scheduling, and pre-survey preparation; in the six sample 
states, survey teams completed all on-site survey tasks 
Survey team staff. States are required to place at least one qualified health professional on 
their survey team and all states agency directors report that they do so. More specifically, all 
states report that they included at least one registered nurse on their survey teams.6 Most states 
(75 percent) also report that they include a dietician or nutritionist on the team, and over half 
(57 percent) typically include a social worker. On all six of the surveys we observed, the teams 
had at least one registered nurse and one dietician or nutritionist. 
General guidelines from CMS suggest that the size of teams be governed by the size and type of 
the facility being surveyed, and 44 states say they typically use teams with three to four 
surveyors.7 In our purposive sample of six states, we observed an appropriate ratio of 
surveyors to facility size.  In one of these states, we observed a survey being conducted  for a 
350-bed facility, and the survey team included seven members.  In two other states where 
surveys were conducted for smaller nursing homes, the survey teams were comprised of only 
three members. 
Surveyor training. Nearly all state surveyors meet basic CMS training requirements.  On 
average, state agencies report that 96 percent of their surveyors have successfully completed 
CMS training - modules A and B of the Surveyor Minimum Qualifications Test (SMQT) (see 
Appendix F). Nationally, the average number of training days for surveyors last year was 10. 
Further, all 10 regional offices of the CMS say they review state surveyor training to ensure that 
state agency surveyors are meeting federal qualification standards. 
6 
Sections 1819(g)(2)(E) and 1919(g)(2)(E) of the Act and 42 CFR 488.314 require that: skilled nursing facility 
[SNF] and nursing facility [NF] standard surveys be conducted by a multidisciplinary team of professionals, at least 
one must be a registered nurse. 
7 
7201. State Operations Manual Survey Team Size and Composition - A. Survey Team Size.--Survey team 
size will vary, depending primarily on the size of the facility being surveyed. 
20 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Nearly all state agencies report that they conduct their own training in addition to CMS training. 

Forty-eight have a training coordinator and 49 also have their own state surveyor training

program. States typically use videos, satellite communications, presentations, and informal

sessions during or following on-site visits to train their survey staff.  Also, nearly all state

agencies told us that they specifically focus their surveyor training in response to survey findings

and provide training related to the documentation of deficiencies. 

Team approach. All states report using a team approach in their survey process as suggested

by CMS.8 State agencies say that they follow CMS guidelines on team communication that

require teams to have daily discussions among themselves about their observations in order to

facilitate information gathering and decision making. All state agencies report that their survey

teams formally meet on a daily basis to discuss their findings and observations, to consult with

each other, and to talk about scheduling uncompleted survey tasks. We also noted a strong

team approach in the six surveys we observed. Surveyors continually consulted with one

another regarding their findings, conferred with each other on any questions or concerns they

had, and checked in on their individual progress to assure all necessary work was being

completed.

Survey schedule. All states report scheduling standard surveys within a 9-to-15 month

interval as required by CMS guidelines.9 Twenty-six states report that in 2001 the interval

between consecutive nursing home standard surveys in their state averaged 

12 months.  Eleven states told us they conducted these surveys within a shorter 

(10-to-11 month) interval on average, and 14 states report conducting surveys within a longer

(13-to-15 month) interval on average. 

8 
State Operations Manual, Appendix P - Survey Protocol for Long Term Care Facilities - Part 1-
Introduction: 1D. TEAM COMMUNICATION - Throughout the survey process, the team (including specialty 
surveyors on-site at the time) should discuss among themselves, on a daily basis, observations made and 
information obtained in order to focus on the concerns of each team member, to facilitate information gathering and 
to facilitate decision making at the completion of the standard survey. 
9 
7205. State Operations Manual - SURVEY FREQUENCY--The survey and certification provisions set 
forth in 1819(g)(2)(A)(iii) and 1919(g)(2)(A)(iii) of the Act and in 42 CFR 488.308 require that each SNF and NF be 
subject to a standard survey no later than 15 months after the last day of the previous standard survey and that the 
statewide average interval between standard surveys of SNFs and NFs not exceed 12 months. 
21 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Pre-survey preparation.  Survey teams are required to prepare for surveys offsite by 
analyzing information about the nursing home that will enable them to focus their review most 
effectively.10 All state agencies report doing this pre-survey preparation.  First, they all report 
that their surveyors use quality indicator reports in this preparation.  These reports identify 
potential problems in the facility that may warrant further investigation, such as a high proportion 
of pressure sores or falls among its residents.  Further,  96 percent of states survey teams use 
facility level reports generated by OSCAR, while 92 percent will also typically review the 
facilitys prior statements of deficiencies.  Complaint data, information from the Ombudsman 
office, and resident level summary reports are also used by at least 72 percent of states in their 
pre-survey preparation. 
On-site survey tasks. In the surveys we observed in the six sample states, we saw evidence 
of, or directly observed the completion of, all on-site survey tasks required by CMS. We also 
observed survey teams use of specific investigative protocols suggested by CMS, such as 
medical record reviews, resident, group, and family interviews, observations of mealtimes, and 
direct care observations. In several of the states, surveyors expanded the initial scope of their 
review, based on observations from the initial facility tour. 
We observed that all six of the sample state surveys follow the same general process for Task 6 
of the survey process, information analysis for deficiency determination, and Task 7, the exit 
meeting with the nursing home.  On the final day of the survey, before the exit, the survey team 
in all six states conducted team meetings, reviewed and analyzed their worksheets, discussed 
their findings, and used a team approach to reach consensus and make decisions. In all six 
states, the survey team also shared their preliminary findings with the nursing home during the 
exit meeting, and in five states the facility was given the opportunity to provide additional 
information either then or at a later date that it believed was pertinent to the initial survey 
findings. 
10
 7203. State Operations Manual - SURVEY PROTOCOL A. Introduction.--This protocol is established 
pursuant to 1819(g)(2)(C) and 1919(g)(2)(C) of the Act to provide guidance to surveyors conducting surveys of 
long term care facilities participating in the Medicare and Medicaid programs. The protocol consists of survey 
procedures, worksheets, and interpretive guidelines. 
22 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  C O N C L U S I O N  
Our analysis shows an increase in nursing home deficiencies since 1998.  The proportion of 
nursing homes receiving deficiencies, the total number of deficiencies, and the key categories of 
deficiencies directly related to quality of care have all increased since 1998.  In addition, wide 
variation exists among states in the proportion of deficiency-free nursing homes and in average 
deficiency rates. 
Our review of the survey process reveals that states differ in how they determine both the 
number and type of deficiencies.  We identified four factors that contribute to this variability in 
citing deficiencies: (1) an inconsistent survey focus; (2) unclear guidelines; (3) the lack of a 
common review process for draft survey reports; and (4) high surveyor staff turnover. As a 
result, we conclude that nursing home survey results are not always consistent among states, 
therefore limiting the comparability of the data. Further, we cannot conclude whether trends in 
deficiencies are due to deteriorating care, variations in the survey process, and/or increased 
enforcement. However, deficiencies are a key indicator of care in nursing homes, and 
therefore, the number of deficiencies and the increase in the number of deficiencies over the 
past four years raise concerns. 
23 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  R E C O M M E N D A T I O N S  
The Centers for Medicare & Medicaid Services should continue to improve its 
guidance to state agencies on citing deficiencies by providing guidelines that are both 
clear and explicit. Based on our findings, we recommend that CMS provide more specific 
guidance to states for quality of life deficiency tags and clearer directives on when to cite single 
or multiple deficiencies. We also recommend that CMS more clearly communicate to states 
that the focus of the nursing home survey process is not consultative. They should remind states 
of the dual function of this process, as specified in the Interpretive Guidelines. These two 
functions are: 1) to ensure compliance; and  2) to enter into a non-consultative information 
exchange for the purpose of information dissemination that may be of assistance to the facility in 
meeting long term care requirements. 
The Centers for Medicare & Medicaid Services, together with states, should develop 
common review criteria for draft survey reports.  While most states incorporate some 
level of supervisory review for draft survey reports, they do not follow a standard process with 
common evaluation criteria.  A more standard review process that utilizes the same criteria for 
assessing draft reports will help to ensure greater consistency across states. The CMS could 
incorporate this standardized assessment criteria as part of the Nursing Home State 
Performance Measures: Review Protocol Guidance, which all states are now required to 
follow. 
24 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  A G E N C Y  C O M M E N T S  
We received comments on our draft report from the Centers for Medicare & Medicaid 
Services (CMS).  The CMS concurred with our recommendations that it should continue to 
improve guidance to state agencies on citing deficiencies by providing guidelines that are both 
clear and explicit and that it should develop, together with states, a common review criteria for 
draft survey reports.  The CMS also highlighted several actions they have taken to improve 
such guidance. The full text of CMS comments are contained in Appendix G. 
25 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  APPENDIX A 
Definitions of Quality of Care Deficiencies by Category 
Resident Behavior and Facility Practices 
Deficiency - (Ftag)  Definition 
F0221	 Resident has the right to be free from any physical restraint for purposes of 
discipline or convenience. 
F0222	 Resident has the right to be free from any chemical restraint for purposes of 
discipline or convenience. 
F0223	 Resident has the right to be free from verbal, sexual, physical and mental abuse, 
corporal punishment, and involuntary seclusion. 
F0224	 Facility must have written policies and procedures that prohibit abuse and 
neglect. 
F0225  Facility may not employ persons who have been found guilty of abuse. 
F0226	 Facility must develop and implement written policies and procedures that 
prohibit mistreatment, neglect, and abuse of residents, and misappropriation of 
resident property 
Quality of Life 
Deficiency - (Ftag)  Definition 
F0240  Facility must promote/enhance quality of life. 
F0241  Facility must promote care that maintains or enhances dignity. 
F0242	 Resident has the right to choose activities, schedules, interact with members of 
community, and make choices about aspects of life in the facility. 
F0243  Resident has the right to organize and participate in resident groups. 
F0244  Facility must listen and respond to resident or family group. 
F0245	 Resident has the right to participate in social, religious, and community 
activities. 
26 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  F0246	 Facility should have policies that accommodate residents needs and 
preferences. 
F0247  Resident to receive notice before room or roommate in the facility is changed. 
F0248  Facility is to provide ongoing program of activities that fit resident. 
F0249  Facilities director must be fully qualified. 
F0250  Facility must provide medically-related social services. 
F0251  Facility with more than 120 beds must employ a qualified social worker on a full 
time basis. 
F0252  Facility must provide a safe, clean, comfortable, and homelike environment. 
F0253	 Facility must provide housekeeping and maintenance services necessary to 
maintain a sanitary, orderly, and comfortable interior. 
F0254  Facility must provide clean bed and bath linens that are in good condition. 
F0255  Facility must provide private closet space in each residents room. 
F0256  Facility must provide adequate and comfortable lighting levels in all areas. 
F0257  Facility must provide comfortable and safe temperature levels. 
F0258  Facility must provide comfortable sound levels. 
Quality of Care 
Deficiency - (Ftag)  Definition 
F0309	 Facility to provide necessary care for the highest practicable physical, mental, 
and psychosocial well being. 
F0310  Activities of daily living do not decline unless unavoidable. 
F0311  Resident is given treatment to improve abilities. 
F0312  Activities of daily living care is provided for dependent residents. 
F0313  Resident receive treatment to maintain hearing and vision. 
27 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  F0314  Proper treatment to prevent or treat pressure sores.

F0315  Resident is not catheterized, unless unavoidable.

F0316  Appropriate treatment for incontinent resident.

F0317  No reduction of range of motion, unless unavoidable.

F0318  Resident with limited range of motion receives appropriate treatment. 

F0319  Appropriate treatment for mental or psychosocial problems.

F0320  No development of mental problems, unless unavoidable.

F0321  No naso-gastric tube, unless unavoidable.

F0322  Proper care and services for resident with naso-gastric tube.

F0323  Facility is free of accident hazards.

F0324	 Resident receives adequate supervision and assistance devices to prevent 
accidents. 
F0325	 Facility must maintain acceptable parameters of nutritional status, unless 
unavoidable. 
F0326  Resident receives therapeutic diet, when required. 
F0327	 Facility must provide sufficient fluid intake to maintain proper hydration and 
health. 
F0328  Facility must ensure that proper treatment and care is provided. 
F0329  Each residents drug regimen must be free from unnecessary drugs. 
F0330  No use of antipsychotic drugs, except when necessary. 
F0331  Residents who use antipsychotic drugs receive gradual dose reductions. 
F0332	 Facility must ensure that it is free of medication error rates of five percent or 
greater. 
F0333  Residents are free of any significant medication errors. 
28 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  APPENDIX B 
Definitions of Selected Deficiencies for State Survey Report Review 
Deficiency - (Ftag)  Definition 
F223  [n=14]  Resident has the right to be free from verbal, sexual, physical and mental abuse, 
corporal punishment, and involuntary seclusion. 
F241  [n=26]  Facility must promote care that maintains or enhances dignity. 
F279  [n=24]	 The facility must develop a comprehensive care plan for each resident that 
includes measurable objectives and timetables to meet a residents medical, 
nursing, and mental and psychosocial needs, as identified in the comprehensive 
assessment. The care plan must describe the services that are to be furnished 
and any services that would otherwise be required. 
F280  [n=18]	 A comprehensive care plan must be developed by an interdisciplinary team, 
within 7 days after the completion of the comprehensive assessment and be 
periodically reviewed and revised by a team of qualified persons after each 
assessment. 
F309  [n=34]  Facility to provide necessary care for the highest practicable physical, mental, 
and psychosocial well being. 
F314  [n=32]  Proper treatment to prevent or treat pressure sores. 
F323  [n=21]  Facility is free of accident hazards. 
F324  [n=37]  Resident receives adequate supervision to prevent accidents. 
F327  [n=13]  Facility must provide sufficient fluid intake to maintain proper hydration and 
health. 
F329  [n=18]  Each residents drug regimen must be free from unnecessary drugs. 
F353  [n=12]	 The facility must have sufficient nursing staff to provide nursing and related 
services to attain or maintain the highest practicable physical, mental, and 
psychosocial well-being of each resident, as determined by the resident 
assessments and individual plans of care. 
F371  [n=36]	 The facility must store, prepare, distribute, and serve food under sanitary 
conditions. 
F0441  [n=25]	 The facility must establish and maintain an infection control program designed 
to provide a safe, sanitary, and comfortable environment and to help prevent the 
development and transmission of disease and infection. 
29 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  APPENDIX C 
Table C-1

Proportion of Nursing Homes 

by Resident Behavior and Facility Practices Deficiencies, 1998-2001 
Percentage 
Deficiency  1998  1999  2000  2001  Point 
Difference* 
1998-2001 
Right to be free from physical  12.8%  11.5%  10.9%  11.0%  -1.8% 
restraints 
Right to be free from chemical  0.7%  0.4%  0.5%  0.4%  -0.3% 
restraints 
Right to be free from  1.7%  2.0%  1.7%  1.5%  -0.1% 
abuse 
Must have policies that  1.9%  2.6%  3.2%  2.5%  0.5% 
prohibit abuse and neglect 
May not employ persons guilty  6.7%  8.7%  11.6%  10.8%  4.1% 
of abuse 
Facility must develop and  0.0%  1.6%  8.7%  10.2%  10.2% 
implement written policies and 
procedures that prohibit 
mistreatment, neglect, and 
abuse of residents, and 
misappropriation of resident 
property** 
Total  19.1%  21.3%  28.0%  28.2%  9.1% 
* Differences may be due to rounding  Source: OSCAR data, 2002 
** Deficiency was instituted in 1999 
30 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Table C-2 
Proportion of Nursing Homes by Quality of Life Deficiencies, 1998-2001 
Percentage 
Deficiency  1998  1999  2000  2001  Point 
Difference* 
1998-2001 
Facility promotes/enhances  0.3%  0.2%  0.2%  0.3%  0.0% 
quality of life 
Facility promotes care that  14.4%  16.8%  17.3%  17.2%  2.9% 
maintains/enhances dignity 
Resident has the right to make  2.5%  2.6%  2.1%  2.0%  -0.5% 
choices about aspects of life in the 
facility 
Right to organize and participate in  0.5%  0.6%  0.3%  0.3%  -0.2% 
groups 
Facility must listen and respond to  0.4%  0.4%  0.6%  0.5%  0.0% 
groups 
Right to participate  0.1%  0.1%  0.1%  0.1%  0.0% 
in activities 
Should have policies that  9.2%  9.6%  10.0%  9.7%  0.5% 
accommodate needs 
Receive notice of room or  0.2%  0.2%  0.1%  0.1%  -0.1% 
roommate change 
Facility must provide an activity  7.9%  8.8%  8.2%  7.8%  -0.2% 
program 
Facilities activity director must be  0.4%  0.5%  0.5%  0.5%  0.1% 
fully qualified 
Facility provides medically-related  7.9%  7.9%  6.7%  6.8%  -1.1% 
social services 
Facility must employ a qualified  0.2%  0.3%  0.3%  0.2%  0.0% 
social worker 
Facility must provide a safe, clean,  7.1%  7.3%  7.6%  7.7%  0.6% 
homelike environment 
Housekeeping maintains sanitary  14.2%  15.5%  17.3%  16.7%  2.5% 
and comfortable interior 
31 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  (Continued) 
Percentage 
Deficiency  1998  1999  2000  2001  Point 
Difference* 
1998-2001 
Clean bed and  1.6%  1.7%  1.4%  1.2%  -0.4% 
bath linens 
Private closet  0.1%  0.1%  0.1%  0.1%  0.0% 
space 
Adequate and  0.6%  0.4%  0.6%  0.4%  -0.1% 
comfortable 
light 
Safe and  1.0%  0.9%  0.9%  0.8%  -0.2% 
comfortable 
temperature 
levels 
Maintenance of  1.7%  1.8%  1.8%  1.5%  -0.2% 
comfortable 
sound levels 
Total  37.8%  41.9%  43.6%  43.1%  5.3% 
* Differences may be due to rounding  Source: OSCAR data, 2002 
32 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  Table C-3 
Proportion of Nursing Homes by Quality of Care Deficiencies, 1998-2001 
Percentage 
Deficiency  1998  1999  2000  2001  Point 
Difference* 
1998-2001 
Provides necessary care for highest  17.0%  21.1%  23.5%  23.5%  6.6% 
practicable well-being 
ADLs dont decline unless  2.7%  2.2%  1.8%  1.6  -1.0% 
unavoidable 
Resident given appropriate  5.6%  6.5%  6.0%  4.8%  -0.8% 
treatment to improve abilities 
ADL care provided for dependent  11.9%  14.3%  13.7%  12.5%  0.6% 
residents 
Resident receives treatment to  0.6%  0.7%  0.6%  0.6%  0.0% 
maintain vision and hearing 
Proper treatment to prevent or treat  16.5%  18.1%  18.0%  17.1%  0.6% 
pressure sores 
Resident not catheterized, unless  1.4%  1.3%  1.2%  1.6%  0.2% 
unavoidable 
Appropriate treatment for  11.1%  11.7%  10.7%  10.2%  -0.9% 
incontinence 
No reduction in range of motion,  0.8%  0.9%  0.7%  0.6%  -0.2% 
unless unavoidable 
Appropriate range of motion  8.9%  9.9%  9.0%  8.0%  -0.9% 
treatment 
Appropriate treatment for mental or  2.5%  2.7%  2.3%  1.9%  -0.6% 
psychosocial functioning 
No development of mental  0.1%  0.2%  0.2%  0.2%  0.0% 
problems, unless unavoidable 
No naso-gastric tube, unless  0.2%  0.1%  0.1%  0.1%  -0.1% 
unavoidable 
Proper care for residents with naso 4.6%  5.3%  5.8%  5.2%  0.6% 
gastric tubes 
33 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  (Continued) 
Percentage 
Deficiency  1998  1999  2000  2001  Point 
Difference 
1998-2001 
Facility is free of accident hazards  18.0%  18.7%  20.4%  21.9%  3.9% 
Adequate supervision and/or  14.8%  17.9%  18.0%  18.5%  3.6% 
devices to prevent accidents 
Resident maintains nutrition status,  8.0%  9.9%  9.4%  8.3%  0.3% 
unless unavoidable 
Resident receives therapeutic diet,  1.9%  2.3%  3.1%  3.0%  1.1% 
when required 
Facility provides sufficient fluid  3.2%  5.4%  6.0%  5.0%  1.9% 
intake to maintain health 
Proper treatment and care for  3.6%  4.3%  4.6%  4.6%  1.0% 
special needs 
Drug regimen free from unnecessary  10.5%  11.8%  12.4%  12.5%  2.0% 
drugs 
No use of antipsychotic drugs  1.2%  0.8%  0.9%  0.9%  -0.3% 
except when necessary 
Gradual dose reduction of  1.2%  1.1%  0.9%  1.1%  -0.1% 
antipsychotic drugs 
Facility is free of medication error  5.6%  7.4%  10.0%  9.8%  4.2% 
rates of 5% or more 
Residents are free from significant  3.0%  3.7%  4.4%  3.8%  0.9% 
medication errors 
Total  59.4%  65.3%  68.1%  68.4%  9.0% 
* Differences may be due to rounding  Source: OSCAR data, 2002 
34 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  APPENDIX D 
Table D-1 
Percentage of Nursing Homes that Received Substandard Quality of Care 
and Immediate Jeopardy Deficiencies, 1998-2001 
Percentage Point 
1998  1999  2000  2001  Difference 
1998-2001 
Substandard Quality  4.5 %  4.8 %  4.5 %  4.2 %  -0.3 
of Care 
Immediate Jeopardy  1.4 %  1.4 %  2.1 %  2.3 %  0.9 
Source: OSCAR data, 2002 
Table D-2 
Percentage of Nursing Homes by Scope and Severity of Quality of Care Deficiencies, 
1998-2001 
Scope and  Difference 
Severity  1998  1999  2000  2001  1998-2001 
Level 
A  0 %  0 %  0 %  0 %  0 % 
B  13.0%  12.3%  14.3%  14.5%  1.5% 
C  6.4%  7.5%  9.0%  7.7%  1.3% 
D  51.1%  56.6%  61.8%  64.1%  13.0% 
E  32.8%  35.8%  38.9%  37.6%  4.8% 
F  1.5%  1.9%  1.8%  1.6%  0.2% 
G  26.5%  28.5%  22.7%  18.6%  -7.9% 
H  2.6%  2.7%  1.8%  1.3%  -1.3% 
I  0.1%  0.1%  0.1%  0.0%  -0.1% 
J  0.7%  0.7%  0.8%  1.0%  0.4% 
K  0.5%  0.4%  0.8%  0.8%  0.4% 
L  0.0%  0.1%  0.1%  0.2%  0.2% 
Source: OSCAR data, 2002 
35 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  APPENDIX E 
State Deficiency Rates, Deficiency-Free Nursing Homes, 
and Proportion of Deficiencies Removed From Draft Reports 
State  Deficiency Rate*  Deficiency-Free Homes  % Deficiencies Removed 
Vermont
 2.9  (low)  28.2  2% 
Rhode Island
 3.3  (low)  24.2  10% 
Wisconsin
 3.3  (low)  22.6  5% 
Virginia
 3.5  (low)  33.5  5% 
Utah
 3.7  (low)  16.5  1% 
North Dakota
 3.9  (low)  10.7  10% 
Iowa
 4.1  (low)  13.9  25% 
Pennsylvania
 4.2  (low)  15.1  5% 
Nebraska
 4.4  (low)  19.3  7% 
New Hampshire
 4.4  (low)  24.6  1% 
Minnesota
 4.6  (low)  14.4  No Response 
Massachusetts
 4.6  (low)  29.2  10% 
Maryland
 4.6  (low)  13.2  No Response 
Delaware
 5.1 (medium)  15.8  1% 
Maine
 5.1 (medium)  4.5  1% 
New Jersey
 5.1 (medium)  14.5  1% 
Illinois
 5.1 (medium)  13.3  No Response 
Montana
 5.2 (medium)  10.6  No Response 
Colorado
 5.2 (medium)  12.4  5% 
Ohio
 5.2 (medium)  13.7  2% 
South Dakota
 5.3 (medium)  6.5  1% 
New Mexico
 5.5 (medium)  19.4  2% 
Missouri
 5.5 (medium)  12.5  10% 
Connecticut
 5.6 (medium)  6.3  3% 
New York
 5.6 (medium)  8.6  10% 
Alaska
 5.8 (medium)  14.3  5% 
Georgia
 5.8 (medium)  9.5  No Response 
South Carolina
 5.8 (medium)  9.5  1% 
North Carolina
 6.1 (medium)  9.7  No Response 
Oregon
 6.1 (medium)  18.0  5% 
Indiana
 6.1 (medium)  12.9  No Response 
Mississippi
 6.3 (medium)  4.4  5% 
36 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  (continued) 
State  Deficiency Rate*  Deficiency-Free Homes  % Deficiencies Removed 
Oklahoma  6.4 (medium)  15.5  No Response 
Texas  6.4 (medium)  9.8  12% 
Idaho  6.5 (medium)  8.2  0% 
Alabama  6.5 (medium)  8.6  10% 
Tennessee  6.7 (medium)  3.3  1% 
Kansas  6.9 (medium)  11.8  1% 
Louisiana  7.0 (high)  9.8  2% 
West Virginia  7.5 (high)  7.0  2% 
Florida  7.9 (high)  2.9  No Response 
Arkansas  7.9 (high)  4.3  0% 
Kentucky  8.2 (high)  4.0  5% 
Michigan  8.4 (high)  4.0  5% 
Washington  8.6 (high)  4.8  No Response 
Wyoming  9.2 (high)  8.8  3% 
Hawaii  9.9 (high)  5.9  0% 
Nevada  9.9 (high)  0  5% 
D.C.  10.0 (high)  5.0  1% 
Arizona  10.2 (high)  3.9  2% 
California  11.2 (high)  2.1  8% 
Source Data - OSCAR 2002 CMS mainframe download 
*Deficiency Rate 

Low  (2.9 - 4.6 deficiencies per facility)

Medium (5 - 6.9 deficiencies per facility)

High  (7.0 - 11.24 deficiencies per facility) 

For the population of states we categorized deficiency rates into low, medium, and high by determining the 
proportional deficiency rate (mean of deficiencies) and the distribution of the means or the maximum and minimum in 
each category of low, medium, and high rates of deficiencies. We computed a correlation coefficient (-.22425) for the 
variables, deficiency rate, and removal of deficiencies, which does not imply causal relationship. 
------------------------- STATES WITH LOW DEFICIENCY RATES ------------------------------
Variable  N  Mean  Minimum  Maximum 
Deficiency rate  13  3.96158  2.87179  4.64091 
------------------------STATES WITH MEDIUM DEFICIENCY RATES -----------------------------
Variable  N  Mean  Minimum  Maximum 
Deficiency rate  25  5.80444  5.05263  6.88184 
-------------------------STATES WITH HIGH DEFICIENCY RATES-------------------------------
Variable  N  Mean  Minimum  Maximum 
Deficiency rate  13  8.93332  7.03797  11.24108 
37 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  APPENDIX F 
4009.1 Federal Minimum Qualification Standards For Long Term Care (LTC) Facility Surveyors 
Sections 1819(g)(2)(C)(ii), 1819(g)(2)(E)(iii), 1919(g)(2)(C)(ii), and 1919(g)(2)(E)(iii) of the Act require that 
individual members of long term care (LTC) survey teams meet minimum qualifications, established by the 
Secretary, and successfully complete a training and testing program in survey and certification techniques. 
In addition, LTC surveyors must successfully complete a training and testing program, which includes the 
Surveyor Minimum Qualifications Test (SMQT). 
A. Purpose.--The SMQT is part of the training and testing program and addresses the 
knowledge, skills, and abilities needed to conduct standard and extended surveys in LTC 
facilities. 
B. Prerequisites.--Prior to taking the SMQT, a LTC surveyor must complete the CMS 
Orientation Program, and the Basic Long Term Care Health Facility Surveyor Training Course. 
C. Test Composition.--The SMQT is composed of two modules: 
1. Module A.--Includes the following LTC facility survey tasks: 
o Offsite Survey Preparation; 
o Entrance Conference and Onsite Preparatory Activities; 
o Initial Tour; 
o Resident Sampling; 
o Environmental Assessment (including the environmental aspects of Dietary 
Services); 
o Quality of Life Assessment; 
o Information Analysis and Decision Making; and 
o Exit Conference. 
2. Module B.--Includes: 
o Resident Review (including resident assessments and plans of care); 
o Closed Record Review; 
o Nutritional Aspects of Dietary Services System Assessment; and 
o Medications Review. 
D. Successful Performance.--
1. Successful Completion of Module A.--An individual must successfully 
complete Module A to be a member of a LTC facility survey team. 
2. Successful Completion of Module B.--Individuals who are expected by the state agency 
to conduct the tasks addressed by Module B may survey these areas only after 
they successfully complete both Module A and Module B. Specific individual 
survey assignments are at your discretion. 
38 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  APPENDIX G 
39 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  40 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  41 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600  A C K N O W L E D G M E N T S  
This report was prepared under the direction of John I. Molnar, Regional Inspector General for 
Evaluation and Inspections in the New York Regional Office, and Jodi Nudelman, Assistant Regional 
Inspector General. Other principal Office of Evaluation and Inspections staff who contributed include: 
Demetra Arapakos, Project Leader  Sandy Khoury, Program Specialist, Division

Patricia Banta, Lead Analyst  of Medicare and Medicaid, Baltimore

Danielle Fletcher, Lead Analyst

Thomas Zimmermann, Program Analyst

Renee Dunn, Former Deputy Inspector General

Technical Assistance 
Brian Ritchie, Director Technical Support Staff, Baltimore

Barbara Tedesco, Mathematical Statistician, Baltimore

Scott Horning, Program Analyst

Linda Moscoe, Program Analyst

Robert L. Gibbons, Program Analyst, San Francisco

For information or copies of this report, please contact

the Office of Inspector Generals

Public Affairs office at (202) 619-1343.

Reports are also available on the World Wide Web at our home page address:

http://www.oig.hhs.gov

42 
Deficiency Trends and Survey and Certification Process Consistency  OEI-02-01-00600