Statement of Dara Corrigan 

Acting Principal Deputy Inspector General 

U. S. Department of Health and Human Services 

Before the 

Senate Finance Committee 

July 17, 2003 

Good morning Mr. Chairman and Members of the Committee. I am pleased to have this 
opportunity to speak to you about quality of nursing home care -- a subject of intense, 
continuing interest to the Office of Inspector General. 
As you know, we have been working in this field for a number of years, covering all 
aspects of Medicare and Medicaid nursing home services, focusing our audits, 
evaluations, investigations, and legal attention on issues relating to funding, access, and 
quality oversight. In fact, it was almost exactly four years ago (March, 1999) our office 
testified before you, Mr. Chairman, and other members of the Senate Aging Committee, 
advising you of our concerns about deficiencies in nursing home care and weaknesses in 
the survey and certification process. We made numerous recommendations to improve 
nursing home care, which addressed the survey and certification system, the ombudsman 
program, resident abuse safeguards, care guidelines, and access to information for family 
members of nursing home residents. 
Since that hearing, we have continued our work, completing studies on resident 
assessments, services for seriously mentally ill persons residing in nursing homes, the use 
of psychotropic drugs as chemical restraints, standards for nurse aid training, the efficacy 
of quality oversight committees, the role of medical directors, and adequacy of 
psychosocial services. Most recently, we repeated the earlier study of the survey and 
certification process and of trends in nursing home deficiency rates, which served as a 
general barometer for the measurement of care, as discussed in our earlier testimony. 
You have asked for our current assessment of nursing homes, based on the entire body of 
our work. In response, I would say that while we see glimmers of progress, we still have 
serious concerns about the quality of living conditions and care in nursing homes. 
Following is a more detailed description of our findings, recommendations, and 
enforcement actions.  We have divided our analysis into two broad sections:  conditions 
in nursing homes, and oversight and quality assurance systems. 
CONDITIONS IN NURSING HOMES 
Much of the information we have about conditions in nursing homes is derived from 
oversight, care planning, and protection systems that are discussed in the second half of 
this testimony.  Among them are the survey and certification system (the state-based 
quality oversight mechanism for nursing homes based on on-site visits by independent, 
professional teams, the Minimum Data Set (MDS) (used in connection with assessments 
of the care needs of individual nursing home residents), and the ombudsman complaint 
1
 system, one of several venues through which residents or their families can register their 
concerns about the safety and quality of conditions in the facilities and receive assistance 
from an independent advocate to get their problems resolved. 
We used several approaches to analyze this information. First, we examined data from 
all of these systems, assessing the consistency among them.  Second, we emphasized 
trends rather then absolute values so we could assess general directions over time. 
Finally, we sought other, corroborating evidence, such as complaints received by long-
term care ombudsmen and opinions of survey and certification officials who are in a 
position to know what is going on and whose judgment is informed by their experience 
and expertise. 
We also based our evaluation on our in-depth studies of assessment systems used to 
identify the needs of and develop plans of care for nursing home residents.  On a selected 
basis, we sampled residents records and assessments and subjected them to independent 
review by medical experts. We also sent our own teams to nursing homes to examine 
specific aspects of care. 
In addition, we compared our data and findings to those obtained by the General 
Accounting Office (GAO), which are also being presented at this hearing. Our 
information and analysis is consistent with GAOs.  We supplemented their findings by 
identifying those factors that lead to the kinds of critical care problems identified in their 
report and attempted to identify steps that can be taken to avoid the occurrence of these 
problems. Here is what we found. 
Overall Increase in Nursing Home Deficiencies 
General Rates of Increase.  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 and Medicaid 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 two 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 also 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 determine a scope and severity level for each 
deficiency. Scope indicates how widespread the deficiency is, while severity indicates 
potential for harm.  Survey data are entered into the Online Survey and Certification 
Reporting System. 
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 We compared the deficiencies cited by surveyors in 2001 and compared them to the 
citations in 1998.  We found that the overall number of survey and certification 
deficiencies went up, both in the aggregate and in the number of deficiencies per nursing 
home. 
Quality of Care.  We found that 78 percent of nursing homes received at least one 
deficiency in three categories related to quality of care. This is an 8-percentage point 
increase since 1998. These categories of deficiencies are  Quality of Care (covering 25 
deficiencies), Quality of Life (covering 19 deficiencies), and Resident Behavior and 
Facility Practices (covering six deficiencies). Deficiencies in each of these categories 
rose 9.1, 9.0, and 5.3 percent respectively. Some examples of deficiencies in these 
categories that we found in the survey and certification reports we reviewed are: 
	  A resident reported that a nurse aide tied a sheet around the residents neck and 
kept pulling it tighter; this resident had redness around his neck as a result.  A 
review of the aides file indicated that she had seven prior incidents of resident 
mistreatment. 
	  Two residents were admitted to a nursing home each with stage II or III 
pressure sores. Each developed stage IV pressure sores -- one within 24 hours. 
	 One resident who did not eat or drink and showed signs of dehydration 
continued to receive diuretics for 10 days. This resident was transferred to a 
hospital where he died. 
Resident Assessments and Care Plans.  Of particular concern is the category that 

showed the greatest overall increase--resident assessment. Resident assessments are 

required to be conducted by inter-disciplinary teams comprised of nursing home staff 

when individuals first enter the facilities and at other prescribed intervals. These routine 

assessments may trigger additional, more specific assessment protocols depending on 

clinical and functional conditions observed. Such protocols in turn provide the 

framework for developing care plans to address the needs of the residents. These 

protocols relate to such things as pressure ulcers, dehydration and fluid maintenance, 

delirium, dementia, urinary incontinence and indwelling catheter, psychosocial well-

being, mood state, behavior symptoms, falls, nutrition, feeding tubes, dental care, 

psychotropic drug use, physical restraints, visual function, communication, and 

functional abilities for activities of daily living. If resident assessments are not done or 

are not performed correctly, residents with conditions such as these may not receive the 

care they need. 

In 2001, 50.1 percent of nursing homes had at least one deficiency related to resident 

assessments. This is an increase of 11.6 percentage points since 1998.  This is significant 

because the resident assessment is the foundation for care planning for residents. 

Without reliable assessments, residents needs cannot be appropriately addressed and 

they may therefore not get the care they need. 

In reviewing survey reports for our inspection work, we have noted a number of resident 

assessment deficiencies that have resulted in actual or potential harm.  For example, a 

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 large, suburban California nursing home failed to develop comprehensive care plans for 7 
of 31 sampled residents. One resident suffered with severe pain, but had no pain 
management plan; another at risk for weight loss actually lost weight because diet was 
not addressed in the plan; and the plan for a third resident with a history of falling did not 
identify approaches to prevent further falls. Other examples of resident assessment 
deficiencies include a Downs syndrome resident with a history of wandering and 
resistance to care; the staff simply acknowledged that these behaviors were ongoing 
problems, but they were not addressed in the care plan.  At another facility, a resident 
whose care plan did not address his violent behavior had to be transferred to another 
facility after he assaulted another resident. 
Our inspection reports note vulnerabilities in the resident assessment process. In 2001, 
we released a report on the nursing home resident assessment processes, including the use 
of the Minimum Data Set. In this inspection, we sampled medical records and had them 
reviewed by medical experts to assess the accuracy of the resident assessments and the 
appropriateness of additional assessment protocols required by conditions found in the 
initial review. They found that 17 percent of assessment data fields contained errors and 
25 percent of the additional assessment protocols triggered by the initial assessments 
were questionable. Furthermore, 25 percent of the protocols which were completed did 
not have associated care plans. 
In that same year, we examined the independent physical and mental evaluations that are 
required for Medicaid beneficiaries with serious mental illnesses who were in nursing 
homes. We focused on younger patients, those under 65.  We found that only 41 percent 
of the required evaluations were conducted, as were only 29 percent of required re-
assessments. 
Additionally, in March of this year we released a report on psychosocial services in 
nursing homes.  In it we reported that 10 percent of residents missed one or more 
required assessments and that 39 percent of residents with psychosocial needs had 
inadequate care plans. Furthermore, we found that 46 percent of those with care plans 
did not receive all planned services. 
Further evidence of shortcomings in resident assessment comes from the state 
ombudsman reporting system whose data show a 70 percent increase since 1996 in 
complaints related to care plans and assessments. 
Other Deficiencies. Deficiencies in other categories also increased. These include 
pharmacy services (21.1 percent of nursing homes had at least one deficiency in this 
category in 2001, an increase of 7.9 percentage points since 1998), infection control (20.7 
percent, up 5.1 percentage points), physical environment (25.8 percent, up 5.1 percentage 
points), and residents rights (29 percent, up 3.7 percentage points). 
Decrease in Consecutive Deficiencies.  We did find some signs of improvement. One 
indicator of nursing home care is whether a nursing home has actual harm or 
immediate jeopardy deficiencies in consecutive standard surveys. In 2001, 7 percent of 
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 the nursing homes had repeat deficiencies of this severity.  We analyzed deficiency data 
going back to 1998 and found that this represents a decline from 11.5 percent in 1999. 
Other Evidence Corroborating Deficiency Trends 
Ombudsman Complaints.  Data from the National Ombudsman Reporting System show 
that between 1996 and 2000 the total number of complaints have risen 28 percent to 
186,000. This translates to 102 complaints per 1,000 beds -- a 30 percent increase. 
The characteristics of these complaints, however, did not change significantly over time. 
The top 12 categories, which account for one-third of all complaints, remained the same. 
Accidents and request for assistance remained the top two most common complaints. In 
addition, personal hygiene, medication administration and symptoms unattended, 
complaints categorized under resident care, also remained in the top 12 categories 
between 1996 and 2000. These types of complaints may include unexplained bruises, 
unanswered requests for assistance, a resident not bathed in a timely manner, medications 
not given, and failure to provide services to a residents changed condition. Staff 
turnover, while not one of the top 12, did show the greatest increase at over 200 percent. 
State Survey Staff. To gain further insight into the state of care in nursing homes, we 
surveyed all State Survey and Certification Directors in all States and the District of 
Columbia, and interviewed a purposive sample of 32 surveyors.  With regard to the trend 
in the quality of care, 45 percent of Directors believe it has remained the same, but 27 
percent believe it has in fact declined over the past 3 years. Similarly, 34 percent of front 
line surveyors believe quality of care has remained the same, while the same number 
believes quality has declined. On the other hand, 19 of 32 of nursing home 
administrators we interviewed reported that the quality of care has improved over the past 
3 years. The others believe it has remained the same or declined. 
OVERSIGHT AND QUALITY ASSURANCE SYSTEMS 
As noted in the previous section on conditions in nursing homes, most of the data we use 
to monitor the quality of life and care is derived from systems whose primary purpose is 
to provide oversight and enforce compliance with quality of life and care requirements, to 
plan and care for residents, and to protect them when things go wrong. The following is 
a discussion of the major oversight and quality assurance systems. 
5
 Survey and Certification Process 
Inconsistencies in the Citing of Deficiencies. We found many inconsistencies in the 

citation of deficiencies at all levels -- among States, between Federal and State reviews, 

and even among individual survey reports. Such inconsistencies can weaken the efficacy 

of the survey and certification process.  Residents receiving inadequate care or living in 

substandard conditions may not be protected as a result of the failure to cite the 

deficiencies.

The inconsistencies could also open deficiency citations to legal challenges. 

This in turn might make surveyors and State administrators wary of citing deficiencies 

even when they are clearly justified. As a result, the entire process can be encumbered 

with administrative delays and expenses resulting from preparing and responding to 

appeals, remedies delayed or foregone, and residents needs untended. 

In our most recent study of survey and certification deficiencies, we found wide variance 

in individual State-level deficiency data. In 2001, for example, one-third of the nursing 

homes in Virginia were deficiency-free while none in Nevada were. In five States almost 

a quarter or more of homes were deficiency-free; in 12 other States, 5 percent or less 

were. The national average for deficiency-free nursing homes was 11 percent in 2001. 

The rate of deficiencies per nursing home also varied. This ranged from a high of 11.2 

deficiencies per nursing home in California to a low of 2.9 in Vermont. Nationally, the 

average deficiency rate in 2001 was 6.2 deficiencies per nursing home. 

Differences Between Federal and State Surveys. Federal oversight surveys, conducted 

by the Centers for Medicare and Medicaid Services on a sample of State surveys, provide 

additional evidence of the inconsistency in the application of deficiency standards. 

Furthermore, the inconsistency between Federal and State surveys runs overwhelmingly 

in one directionFederal survey teams find larger numbers of, and more serious, 

deficiencies than State teams. In 166 comparative surveys conducted in 2002, Federal 

surveyors found 1303 deficiencies compared to 851 identified by State surveyors. 

Federal surveyors found deficiencies involving actual harm or immediate jeopardy to 

residents in 24 percent of facilities, while for State surveyors, this number was only 13 

percent. Overall, Federal and State surveyors cited the same deficiency only 124 times. 

Reasons for Inconsistencies. There are many possible explanations for these 

inconsistencies. Presumably, they reflect variations in the conditions of nursing homes. 

However, a greater number of citations may also reflect more intense efforts to identify

and correct deficiencies rather than a greater incidence of them. Or, they may reflect 

longstanding practices that have varied from State to State or region to region over many 

years. In order to gain a greater understanding of the underlying causes, we reviewed 

documentation for 310 different deficiencies from 135 survey reports. We also 

interviewed 32 surveyors in eight States, and gathered information from all 50 State 

agency directors and the District of Columbia concerning the way each conduct surveys. 

Based on our review, we identified four factors that contribute to variability in citing 

deficiencies across States. 

6
 Differences in Focus. We found considerable variation in the overall focus of State 
surveys. For example, the degree to which surveys emphasize enforcement aspects of the 
survey versus consultative aspects varies among States and from year to year. Thirty-six 
State agency directors said that their States survey process is only somewhat consistent 
in this regard, acknowledging that the difference between enforcement and consultative 
focus affects the scope of the review. 
During our on-site visits to the six sample States, we observed such differences in focus 
by survey teams. 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. 
Regarding the consultative approach, both GAO and our office note instances where 
surveyors fail to cite deficiencies. In five of the six surveys we observed, we noted that 
surveyors did not always cite deficiencies for problems they identified. This would 
occur, for example, if the nursing home said they were aware of the problem and were 
addressing it. 
The 51 State agency directors we surveyed also cited several other factors affecting the 
focus of nursing home surveys.  These included the political climate, the strength of the 
nursing home lobby, and changing Federal and State regulations. 
Lastly, 21 States have their own 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. Differences in these criteria among the States 
also accounts for some of the inconsistencies we found. 
Lack of Clarity in Guidelines. We found that surveyors occasionally had difficulty 
interpreting deficiency guidelines. Twenty-three State agency directors and 17 of 32 
sampled surveyors reported that some groups of deficiencies are inherently more 
vulnerable to inconsistent citation than others. They said deficiencies that are categorized 
under quality of life are most vulnerable due to the lack of clarity in and complexity of 
the Federal guidelines. They believe this fosters a subjective interpretation, thereby 
contributing to inconsistent citation among surveyors. 
We reviewed the State Operations Manuals quality of life and quality of care 
categories and found some of the guidance to be confusing. For example, guidance for 
tag F250 (social services) offers 14 examples of medically related social services, six 
types of unmet needs, and 10 conditions to which the nursing home must respond with 
social services.  Some of the definitions for these tags are general and subjective. 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.  We 
also noted that for certain deficiencies, surveyors are directed to refer to more than one 
7
 deficiency category or tag for the same issue, without explicit direction as to whether to 
cite under multiple tags when the facility is found to be out of compliance. 
Differences in the Way Draft Survey Reports Are Processed. States use different 
review processes for draft survey reports. In 42 States, all draft survey reports had 
supervisory reviews in 2001, but not in the remaining eight. Only 18 States conducted 
reviews when reports changed significantly from draft to final.  Thirty-one States had 
internal quality assurance teams and two States developed continuous quality 
improvement teams, while17 States had both. 
These inconsistencies in States review processes are 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 38 percent of deficiencies downgraded in one State to 0 downgraded in 
two other States. In addition, the States with lower deficiency rates removed more 
deficiencies, on average, from draft survey reports than States with higher rates. 
Turnover of Surveyor Staff.  We also learned that staff turnover influences survey 
results. Virtually every State survey director reported that it is very or somewhat difficult 
to replace survey staff when they leave.  Thirty-one said that registered nurses are the 
most difficult to replace. Based on our survey data, we determined that nationally, 
surveyors work an average of only 6.5 years for the State agency and that State survey 
directors have held their jobs on average for only 6.4 years. 
On all our visits to the six States, surveyors told us that finding and retaining staff was 
problematic. They also expressed concern that high staff turnover impacts the 
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 all had less that two years experience, and two had been on the job 
for only a few months. We observed that these surveyors were uncertain about what 
problems to cite and spent several hours debating which deficiency tags to cite. 
Based on our study, we recommended that the Centers for Medicare and Medicaid 
Services continue to improve its guidance to State agencies on citing deficiencies by 
providing guidelines that are both clear and explicit, and work with the States to develop 
a common review process for draft survey reports. 
The Federal False Claims Act As An Enforcement Tool 
The survey and certification process provides several mechanisms for enforcement of 
nursing home standards. These include corrective action plans, civil monetary penalties, 
suspension of intake of new Medicare and Medicaid patients, required changes in 
management, and even de-certification. In some cases, the quality of care is so deficient 
that remedies under the survey and certification process are not sufficient. If resident 
8
 care is so poor that it effectively represents a failure to provide care, the Federal False 
Claims Act can be invoked. In essence, this would amount to a charge that the Federal 
Government had been billed for services not rendered. More than 20 nursing home cases 
have been settled based on the False Claims Act since 1996. 
A hallmark of all of these settlements is the imposition of substantial quality of care 
obligations upon the facilities and the requirement the facilities pay for independent 
monitors. Depending upon the jurisdiction in which the case arose, these requirements 
are contained either in the body of the settlement agreement or in separate corporate 
integrity agreements with the OIG. Following are some recent examples of settled cases. 
	  Poor Care and Abrupt Closure. A nursing home company agreed to resolve 
its liability under the False Claims Act in a case involving allegations that two 
nursing homes owned by the company had failed to provide adequate nutrition, 
hydration, pressure ulcer prevention and treatment, dental care, and safety 
monitoring to its residents. During the course of the governments 
investigation, both nursing homes closed abruptly and all of the residents were 
transferred to other facilities with little advance notice.  As part of the 
settlement, the company agreed to fund a study of the effect of transfer trauma 
on residents. 
	  Infection, Pressure Ulcers, and More. A nursing home agreed to implement 
specific protocols, standards of care and compliance policies to resolve its 
liability for failing to provide appropriate care to one of its residents. The 
resident developed an infection and pressure ulcer due to a lack of care. The 
investigation also revealed facility-wide problems with respect to staffing, 
nutrition monitoring, pressure ulcer care, and treatment planning. The 
settlement required the facility to pay for an outside monitor selected by the 
government and to fund special quality of care/quality of life projects. 
	  Death and Cover-up.  The allegations in this case involved deficiencies with 
respect to admission assessments, pressure ulcer care, monitoring of residents 
hydration, medication administration, and pain management. The investigative 
focus of the case was on the facilitys failure to properly treat one particular 
resident that died as a result of medication errors that were then covered-up. 
The nursing home agreed to implement specific protocols, standards of care 
and compliance policies to resolve its liability. The nursing home also agreed 
to pay for an outside monitor selected by the government.  A nurse, who 
falsified records in the cover-up attempt, pled guilty to making false 
Statements and received a 10-month prison sentence. 
	  Infested Wounds.  Another nursing home agreed to enter into a 3-year 
comprehensive corporate integrity agreement that included the appointment of 
a monitor.  The allegations involved multiple findings of residents with maggot 
infested wounds, substandard catheter care, and significant staffing shortages. 
The damage aspect of the case focused on two patients whose care was 
particularly egregious. 
9
 Perspectives on Using the False Claims Act for Nursing Home Cases. As the terms of 
these particular settlement agreements reflect, our first priority is to ensure nursing home 
residents receive the care they need. We work closely with the Department of Justice on 
these settlements in order to achieve a balance between recovering a fair amount of 
dollars for restitution and damages, and establishing systematic changes in the way the 
nursing homes provide care. It is a very difficult balance because we do not want to take 
dollars away from the nursing home that would otherwise be spent on patient care. As 
part of that collaboration, last year the OIG sponsored a 1 1/2 day conference on nursing 
home quality of care.  During the conference, nearly 100 Federal prosecutors and 
investigators explored ways to effectively use our enforcement tools, including the False 
Claims Act, corporate integrity agreements, and program exclusions, to improve the 
quality of care residents receive. 
We will continue to investigate cases of care failure and resident harm for which 
application of the False Claims Act may be appropriate and to work with the Department 
of Justice, CMS, State officials, and others to resolve them expeditiously. 
Resident Assessment Needs to Be Performed and Improved 
I have already described inadequacies of the assessment processes related to the 
Minimum Data Set and stemming from special requirements for residents with serious 
mental illness and psychosocial service needs. Several additional Office of Inspector 
General reports shed more light on this subject. They are listed in an attachment to this 
testimony and can be readily accessed on the Internet. 
In our reports on this topic, we have recommended that the Centers for Medicare and 
Medicaid Services more clearly define the MDS elements; work with the nursing home 
industry to enhance MDS training; and focus on psychosocial services as part of resident 
assessment oversight. With regard to Medicaid, we recommended they ensure the 
completion of the required assessments for residents with severe mental illness and 
require State Medicaid agencies to work with State mental health agencies on community 
based treatment alternatives. 
Quality Assurance Programs Also Need Attention 
Through our studies, the Office of Inspector General has also examined other systems 
mandated by the Omnibus Reconciliation Act of 1987 to assure that residents receive 
appropriate care in nursing homes. Our reports cover such topics as training 
requirements for nurse aides; the role of medical directors; and the efficacy of quality 
assurance committees. In general, we found that the most fundamental requirements 
were being met: aides were receiving the required training; medical directors were 
assigned to nursing homes and were working to provide general oversight of residents 
medical care; quality assurance committees were appointed and met regularly to advise 
on nursing home conditions and care; and psychotropic drugs were generally not being 
used as chemical restraints. 
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 However, all of these programs could benefit from improvements. Training standards 
need to be modernized; the practice of medical directors would be enhanced if more 
specific standards and clearer expectations were developed for them; quality assurance 
committees could make better use of available information to inform their deliberations; 
and psychotropic drugs may still be over-utilized and need to be subjected to stronger 
drug utilization review procedures. The relevant reports and their Internet addresses are 
listed in the attachment. 
LOOKING AHEAD 
In light of the findings cited above and based on our work over the last several years, I 
recommend a three-pronged strategy to improve the quality of living conditions and care 
in nursing homes: 
	  Strengthen the enforcement system, especially the survey and certification 
process. This includes improving the reliability of deficiency citations 
though clearer definition and report processing standards; following up on 
repeat offenders; and working to investigate, and resolve complaints 
expeditiously. 
	  Make sure that patient assessments are performed, that they are accurate, and 
that care plans are prepared and followed. 
	  Establish continuous improvement programs for quality assurance 
infrastructures such as those relating to nurse aide training, medial directors, 
drug utilization review, quality assurance committees, long-term care 
ombudsmen, and quality of care information for residents and their families. 
CMS has already taken steps in this regard. I refer to their initiatives over the last several 
years related to such things as the scheduling and conduct of surveys, resident 
assessment, performance measures, and publication on the Internet of information about 
quality of care in each and every nursing home. It is critical for CMS to follow through 
on its plans to improve all these systems in a timely manner. 
Improving nursing home services will also require the combined efforts, over many 
years, of all stakeholders -- the residents and their families, the nursing home industry, 
health care professionals, Medicare and Medicaid program administrators, and State 
quality assurance organizations. 
CONCLUSION 
Much has been done, but much still remains to improve conditions in nursing homes and 
guarantee that the improvements take hold. The Office of Inspector General will 
continue to do its part through its evaluations, audits, investigations, and legal services. 
We hope our contributions are constructive. 
11
 Selected Nursing Home Reports 
U.S. Department of Health and Human Services 
Office of Inspector General 
July 2003 
Recently Completed Work 
Nursing Home Deficiency Trends and Survey and 
Certification Process Consistency 
http://oig.hhs.gov/oei/reports/oei-02-01-00600.pdf 
Nurse Aide Training 
http://oig.hhs.gov/oei/reports/oei-05-01-00030.pdf 
Quality Assurance Committees in Nursing Homes 
http://oig.hhs.gov/oei/reports/oei-01-01-00090.pdf 
Nursing Home Medical Directors 
http://oig.hhs.gov/oei/reports/oei-06-99-00300.pdf 
Psychosocial Services in Skilled Nursing Facilities 
http://oig.hhs.gov/oei/reports/oei-02-01-00610.pdf 
Prior Work 
Nursing Home Survey and Certification:  Deficiency Trends 
http://oig.hhs.gov/oei/reports/oei-02-98-00331.pdf 
Nursing Home Survey and Certification:  Overall Capacity 
http://oig.hhs.gov/oei/reports/oei-02-98-00330.pdf 
Nursing Home Resident Assessment:  Quality of Care 
http://oig.hhs.gov/oei/reports/oei-02-99-00040.pdf 
Psychotropic Drug Use in Nursing Homes 
http://oig.hhs.gov/oei/reports/oei-02-00-00490.pdf 
Younger Nursing Facility Residents with Mental Illness: 
Preadmission Screening and Resident Review (PASRR) 
Implementation and Oversight 
http://oig.hhs.gov/oei/reports/oei-05-99-00700.pdf 
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