Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

N H E :

URSING  OME  NFORCEMENT
A
PPLICATION OF 

M R
ANDATORY  EMEDIES

Daniel R. Levinson

Inspector General 

May 2006

OEI-06-03-00410
 Office of Inspector General 

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs, as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides 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. These assessments help reduce waste, abuse, and mismanagement 
and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations  to provide HHS, 
Congress, and the public with timely, useful, and reliable information on significant issues.  
Specifically, these evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness in departmental programs.  To promote impact, the 
reports also present practical recommendations for improving program operations. 
Office of Investigations 
The 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.  
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 OIG's internal operations.  OCIG imposes program exclusions and civil monetary 
penalties on health care providers and litigates those actions within HHS. OCIG also 
represents OIG in the global settlement of cases arising under the Civil False Claims Act, 
develops and monitors corporate integrity agreements, develops compliance programs, 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 determine the extent to which the Centers for Medicare & Medicaid 
Services (CMS) applied the statutorily required mandatory remedies for 
nursing homes not in compliance with Federal quality of care standards. 
BACKGROUND 
The Omnibus Budget Reconciliation Act of 1987 established a survey and 
certification process to maintain Federal standards in nursing homes 
certified for participation in the Medicare and/or Medicaid programs.  
CMS contracts with States to certify compliance by surveying facilities.  
When facilities are found to be out of compliance for designated time 
periods or have deficiencies that are considered to put residents in 
immediate jeopardy, States are required to refer case information to CMS 
for enforcement action.  Mandatory remedies are enforcement actions that 
CMS is statutorily required to take to address these particularly 
egregious or extended cases of noncompliance.  Mandatory remedies 
include termination of the facilitys Medicare contract and the denial of 
payment for new admissions (DPNA).  CMS depends upon the States to 
inform its regional offices when enforcement action is warranted in time 
for the regional offices to take action.  Therefore, CMS evaluates State 
performance annually using criteria that measure States effectiveness in 
referring, in a timely manner, cases that require imposition of remedies. 
For this inspection, we reviewed all nursing home enforcement cases that 
required termination in 2000-2002 and all cases that required DPNA 
remedies in 2002.  We also evaluated State Performance Review (SPR) 
data for 2002-2004 and conducted interviews with State and CMS staff. 
FINDINGS 
Of the 55 cases requiring termination during 2000-2002, CMS did not 
apply the mandatory remedy as required in 30 cases (55 percent). 
CMS is required to terminate nursing homes that fail to return to 
substantial compliance within 6 months, or have unabated immediate 
jeopardy deficiencies for 23 days.  We found that 23 cases that required 
termination because they were noncompliant for 6 months were not 
terminated; these facilities returned to compliance on average 17 days 
after the termination should have been applied. Seven cases with 
unabated immediate jeopardy deficiencies were not terminated; these 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  i  E X E C U T I V E   S U M M A R Y  
facilities removed the immediate jeopardy within 7 days after the 
termination should have been applied.   
Through reviews of surveys following our study period, we found that all 
of the facilities not terminated had, in subsequent surveys, new cases of 
noncompliance serious enough to again require referral to CMS for 
enforcement action.  Reasons for not terminating include late referral by 
States and reluctance by CMS staff to take action that would result in 
removing residents from the facility. 
Of the 706 cases requiring DPNA remedies in 2002, 28 percent were 
never applied and 14 percent were applied late, largely due to late 
referral of cases by State survey agencies. CMS is required to apply 
the DPNA remedy for facilities that fail to return to substantial 
compliance within 3 months.  In those instances for which the mandatory 
remedy was never applied, the facilities were out of compliance an 
average of 19 days past the required date to begin denying payments. In 
those instances in which the mandatory remedy was applied late, the 
facilities were out of compliance an average of 40 days past the required 
date to begin denying payments.  In both situations, facilities were 
allowed to receive payment past the required date. 
In addition, in 95 percent of cases for which mandatory DPNA was 
handled inappropriately, States did not refer cases to CMS on time.  
CMSs SPRs also found late case referral by States. In 2002, our primary 
study period, the SPR data showed that 38 of the 48 States that had cases 
requiring the DPNA did not meet the SPR standard of referring 95 
percent of these cases on time.  After CMS eased the standard in 2003 
and again in 2004, 24 States still did not meet the performance standard 
regarding timely completion of these referral tasks in 2003, and 10 States 
did not meet the current standard of referring 80 percent of their cases on 
time in 2004. 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  ii  E X E C U T I V E   S U M M A R Y

RECOMMENDATIONS 
CMS should ensure that facilities facing termination either reach 
compliance or are terminated within required timeframes. This effort 
could include encouraging State survey agencies to further prioritize 
termination cases, raising awareness of termination deadlines among 
CMS and State staff, and special monitoring of pending termination cases 
by CMS regional offices. 
CMS should address late referral of enforcement cases by States to 
ensure that mandatory remedies are applied as required.  CMS should 
issue a written directive to States to reinforce referral requirements, 
increase monitoring of State referral timeliness using shared data 
systems, and promote stronger adherence to the SPR standards regarding 
case referral. CMS should also strongly consider raising the SPR 
standards for timely case referral.  
AGENCY COMMENTS 
While CMS agrees that enforcement and the timely remedy of identified 
problems in nursing homes are very important, it did not concur with all 
of our recommendations.  In its comments, CMS identifies efforts recently 
underway or soon to be implemented to address timeliness issues. 
However, contrary to our recommendation regarding facility termination, 
CMS notes that it does not expect to make a great deal of change with 
respect to its implementation of this remedy.  Instead, it will continue to 
apply the remedy in a manner that it believes best protects the well-being 
of residents. 
OFFICE OF INSPECTOR GENERAL RESPONSE 
We recognize that since this inspection concluded, CMS has taken a 
number of positive steps toward ensuring that deadlines are met. 
However, we are concerned about CMSs implied interpretation that the 
deadlines for mandatory termination are flexible.  While exceptional cases 
may exist, the 6-month termination requirement is statutory and the 23-
day termination is in current regulation.  We believe that CMS, through 
active case management and earlier intervention, can motivate 
improvements and lasting corrections within the required timeframes for 
termination of facilities.  
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  iii    T A B L E   O F   C O N T E N T S  

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

I N T RO DUC T IO N   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

F I N D IN G S   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

  MandatoryTermination  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

Mandatory Denial of Payment forNew Admissions  . . . . . . . . . . . .  8

R E C O MMEN D A T ION S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11

  AgencyComments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13

Office of Inspector General Response. . . . . . . . . . . . . . . . . . . . . . .  14

ENDNOTES ..................................................... 15

APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  19 

A.  DetailedMethodology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  19

B.  AgencyComments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  21

ACKNOWLEDGMENTS ......................................... 26

OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES    I N T R O D U C T I O N  

OBJECTIVE 
To determine the extent to which the Centers for Medicare & Medicaid 
Services (CMS) applied the statutorily required mandatory remedies for 
nursing homes not in compliance with Federal quality of care standards.1 
BACKGROUND 
This inspection is part of the Office of Inspector Generals (OIG) ongoing 
evaluation of the quality of care provided to nursing home residents, 
particularly as measured by CMSs enforcement of survey deficiencies.   
Enforcement Process 
Titles 18 and 19 of the Social Security Act (the Act), as amended by the 
Omnibus Budget Reconciliation Act of 1987, establishes a survey and 
certification process to verify that Federal standards are maintained in 
Medicare and/or Medicaid certified nursing homes.  The Secretary of the 
Department of Health and Human Services, through CMS, is responsible 
for assuring that these requirements and their enforcement are adequate 
to protect the health, safety, welfare, and rights of residents and to 
promote the effective and efficient use of public moneys.2  To accomplish 
this, CMS contracts with State agencies to survey each participating 
facility no less than once every 15 months to certify compliance.3 
Additional surveys are also used to investigate complaints from residents, 
their families, or the general public. 
Deficiencies identified during a survey are evaluated against a set of 
factors to determine a scope and severity rating.4  CMS created the Scope 
and Severity Grid (Table 1) so that deficiencies could be ranked in 
accordance with outcomes, such as harm to patients and prevalence.5  The 
scope and severity level of the highest deficiency is considered in 
conjunction with the facilitys compliance history to determine the 
appropriate enforcement actions.6 
The Act lists several remedies that may be applied when a facility is not 
in substantial compliance with the requirements for participation in the 
Medicare and Medicaid programs.7  A facility is not in substantial 
compliance if the survey finds deficiencies that pose immediate jeopardy, 
actual harm, or potential for more than minimal harm to patients.8  The 
shaded portion of Table 1 comprises an additional severity category, 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  1  II NN TT RR OO  DD UU CC TT II OO NN

substandard quality of care.  This includes deficiencies in resident 
behavior and facility practices, quality of life, and quality of care.9 
Table 1 
Scope and Severity Grid for Deficiencies 
Deficiency Scope 
Deficiency Severity 
Isolated  Pattern  Widespread 
Actual or potential for death or serious 
J  K  L 
injury (immediate jeopardy) 
Actual harm that is not immediate 
G  H  I 
jeopardy 
Potential for more than minimal harm  D  E  F 
Potential for minimal harm, substantial 
A  B  C 
compliance exists 
Source: CMS State Operations Manual, Chapter 7. 
To initiate the Acts enforcement requirements, States must refer 
enforcement cases to CMS regional offices.10  An enforcement case 
includes all enforcement activity with respect to a particular facility 
during a continuous period of noncompliance.  Once the State refers a 
case, CMS determines what enforcement actions are warranted for each 
case.  In addition to mandatory remedies, CMS may choose to apply 
discretionary, or optional, remedies such as civil money penalties. 
Mandatory Remedies 
Mandatory remedies are enforcement actions that the Act requires CMS 
to use to address particularly egregious or extended cases of 
noncompliance.11  For these cases, the Act sets forth the types of remedies 
that must be applied.  For purposes of this report, we use the term 
applied to indicate the action of putting mandatory remedies into effect.   
The four circumstances that require mandatory remedies and the 
remedies that must be applied are as follows:  
Immediate Jeopardy. If, within 23 days of the initial finding, a facility fails 
to eliminate a deficiency deemed to pose immediate jeopardy or fails to 
reduce the deficiency to the point that it no longer poses a threat of actual 
harm, CMS must either terminate the facilitys Medicare contract or 
appoint a temporary manager to remove the immediate jeopardy and 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  2  I N T R O  D U C T I O N

correct the deficiencies.12  To terminate a facility in this circumstance, the 
State must refer the case to CMS within 2 days of the finding of 
immediate jeopardy, conduct a revisit to determine whether the jeopardy 
was abated, and report its finding to CMS.  If the immediate jeopardy 
condition is not abated, CMS must notify the facility 2 days prior to the 
termination.13 
Three Months of Noncompliance. For all facilities that fail to reach 
substantial compliance within 3 months after the initial deficiency, CMS 
must apply the mandatory denial of payment for new admissions (DPNA) 
remedy.14  Before CMS can apply this remedy, the State must conduct a 
revisit, and if the facility is still out of compliance, refer the case to CMS. 
CMS must then notify the facility 15 days prior to application of the 
remedy, which should occur at the end of the 3-month period.15 
Six Months of Noncompliance. For all facilities that fail to reach substantial 
compliance within 6 months after the initial deficiency, CMS is required 
to terminate the Medicare contract.16  This type of case arises when the 
facility still has not reached compliance after application of the required 
DPNA at 3 months.  To terminate a facility in this circumstance, the 
State must conduct a revisit, and if the facility is still out of compliance, 
refer the case to CMS. CMS must then notify the facility 15 days prior to 
the termination, which should occur at the end of the 6-month period.17 
Repeated Substandard Quality of Care. For all facilities found to have 
provided substandard quality of care on the last three consecutive 
standard surveys, CMS must apply the remedies of DPNA and State 
monitoring of the facility.18  Additionally, the State must notify the 
attending physician of each affected resident and the State licensing 
board.19  To apply the DPNA, the State must refer the case to CMS 
following the third finding of substandard quality of care.  CMS must 
then notify the facility 15 days prior to application of the remedy.  
Timely Notice to Facilities 
CMS must notify nursing homes prior to applying a mandatory remedy.20 
For immediate jeopardy cases, notice must occur at least 2 days prior to 
applying the remedy.  For all other cases requiring mandatory remedies, 
notice must be sent 15 days prior to applying the remedy, e.g., on day   
75 for 3 months of noncompliance.   
CMS must receive a case referral from the State survey agency in 
sufficient time prior to the notice period to apply the remedies on time. 
States must also notify facilities that they have referred the case to CMS 
and that a particular remedy is mandated.  The CMS central office policy 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  3  II NN TT RR
 OO DD UU CC TT II OO NN  
allows CMS regional offices to approve the State sending a letter that 
serves as the official notice to facilities.21 
To meet referral deadlines for mandatory DPNA cases specifically, the 
State Performance Review (SPR) standards in effect during our study 
period required States to conduct a revisit within 60 days of the initial 
finding of noncompliance.22  If the revisit reveals that the facility is still 
noncompliant, in accordance with the SPR, States must refer the case 
information to CMS within 70 days of the initial finding of 
noncompliance.  Adherence to this timeframe provides CMS with 5 days 
to send the 15-day notice to facilities (75th day) prior to applying the 
DPNA on the 90th day of noncompliance.   
Applying Mandatory Remedies Late 
Based on CMS central office managers interpretation of the regulation, 
as reported in interviews, mandatory remedies can still be applied when 
CMS regional offices are late in providing notice but only if both of the 
following criteria are met:  (1) the required 2-or 15-day notice was 
ultimately sent and the notice period has elapsed; and (2) the facility is 
still out of compliance when the notice period has elapsed.  Therefore, 
mandatory remedies cannot be applied retroactively in cases in which the 
facility reaches substantial compliance before CMS applies the remedy.23 
In such cases, CMS can still choose to apply a civil money penalty.    
State Performance Review 
CMS evaluates State survey agency performance in nursing home 
enforcement by using criteria based in regulation and contained within 
the SPR.24  The SPR includes three particular measures that are relevant 
to this inspection: 
Timeliness of Referral of Unabated Immediate Jeopardy Cases.25  To meet the 
expected performance level, States must refer cases within 2 days of an 
immediate jeopardy deficiency finding and follow all necessary procedures 
to ensure terminations can occur within the 23-day timeframe in 
95 percent of cases in which facilities fail to remove the immediate 
jeopardy deficiency.26 
Timeliness of Referral and Notification in DPNA Cases. During our study 
period of 2002, State agencies were required to conduct facility revisits by 
the 60th day of noncompliance, and either send deficiency information to 
CMS or send an approved notice of the remedy to the facility within   
70 days of the end of the survey for 95 percent of cases.  Therefore, a  
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  4    I N T R O D U C T I O N  
typical case requiring the DPNA might unfold as follows:  the State refers 
the case on the 70th day, giving CMS up to 5 days to send the facility 
notice (75th day), which would allow the facility 15 days notice prior to 
imposing the DPNA within the time required (90th day).  In 2003, CMS 
changed the SPR criteria for referring DPNA cases by lowering the 
requirement from 95 percent to 80 percent of cases referred on time.27 In 
2004, CMS changed the standard further by omitting the requirement 
that States conduct facility revisits by the 60th day of noncompliance.28 
Timeliness of Referral of 6-month Noncompliance Cases. State agencies must 
follow appropriate termination procedures for 80 percent of applicable 
cases.29  This requires sending deficiency information to CMS or sending 
an approved notice of the remedy to the facility within 70 days, allowing 
for the required 15-day notice period.  Therefore, a typical case requiring 
termination for 6 months of noncompliance might unfold as follows: the 
State refers the case on the 160th day (70 days after the application of the 
DPNA on the 90th day), giving CMS up to 5 days to send the facility notice 
(165th day), which would allow the facility 15 days notice prior to 
termination within the time required (180th day). 
Data Systems 
Case information is maintained through data systems shared by CMS and 
States. Traditionally, CMS has used the Online Survey, Certification, 
and Reporting (OSCAR) system to record the results of standard, 
complaint, and revisit surveys.  More recently, CMS has employed the 
Automated Survey Processing Environment (ASPEN), which allows 
States and CMS to input and access both survey results and enforcement 
information.  State surveyors enter survey findings into a local ASPEN 
database, then upload the data into a central ASPEN system (and also 
into OSCAR). Enforcement case information in ASPEN is accessible to 
CMS regional office staff through the ASPEN Enforcement Module 
(AEM), implemented in October 2004.  The AEM includes several 
reporting functions that facilitate case monitoring, including reports 
focused on the DPNA remedy.  
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  5 I N T R O  D U C T I O N

I N T R O D U C T I O N
METHODOLOGY 
Following preliminary analysis of enforcement data, we narrowed the 
scope of our inspection to focus on the most common circumstances and 
remedies.  This report addresses the three most common circumstances 
warranting mandatory remedies (immediate jeopardy, 3 months of 
continued noncompliance, and 6 months of continued noncompliance).  We 
excluded from our review cases of repeated substandard quality of care 
because only a few occur each year.  This study also does not examine 
cases for which only discretionary remedies were used, those that States 
failed to refer to CMS for enforcement, or Medicaid-only cases. 
For this inspection we reviewed CMS data for all enforcement cases that 
began in calendar years 2000, 2001, and 2002 to identify cases that 
required mandatory remedies. We found 55 cases warranting 
termination during the study period and 2,140 cases warranting 
mandatory DPNA remedies.  We reviewed all 55 termination cases and 
limited our analysis of mandatory DPNA cases to the 706 cases begun in 
2002. We then collected documentation for all cases for which data 
indicated that CMS did not apply remedies as required, and interviewed 
CMS regional and central office staff regarding procedures for applying 
mandatory remedies.  To verify our findings regarding State referral of 
enforcement cases, we evaluated all State Agency Performance 
Evaluation records for 2002 and for its successor, the SPR, in 2003 and 
2004. Because we analyzed all cases and not a sample, all data reported 
within this report represent actual cases, not estimates or projections.  A 
detailed methodology is included in Appendix A. 
Standards 
We conducted this inspection in accordance with the Quality Standards 
for Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency. 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  6    F I N D I N G S  
CMS must terminate facilities that 
CMS did not terminate the facility in 30 of 
remain out of substantial compliance 
the 55 cases requiring termination during 
for more than 6 months or do not 
our study period of 20002002  remove an immediate jeopardy 
deficiency within 23 days.  Few 
facilities warranted termination during our study period.  However, 
termination did not occur in 30 of the 55 cases in which it was required 
(55 percent). Twenty-three of the thirty cases involved facilities that were 
out of substantial compliance for 6 months, and the other seven cases 
involved facilities that had not succeeded in removing immediate jeopardy 
deficiencies within 23 days. 
Reasons for not terminating as required include late referral by States and 
CMS staff reluctance to displace facility residents 
While we are not able to determine the exact cause of CMSs failure to 
terminate in each case, several factors appear to contribute to the lack of 
action.  In a number of cases, States did not refer cases to CMS 
sufficiently in advance of the required date and the facilities were allowed 
to return to compliance late.  States referred cases late in 5 of the  
7 immediate jeopardy cases and in 4 of the 23 6-month noncompliance 
cases.  Even when referrals were timely, CMS staff reported that 
procedural delays could occur for a number of reasons, such as the 
handling of cases by multiple staff members.   
Also, some CMS regional office staff reported that, in their reluctance to 
displace residents, they might opt to delay termination if they believed 
the facility would soon come back into compliance.  Indeed, facilities that 
CMS did not terminate as required did return to compliance shortly after 
the date they should have been terminated.  The 23 cases that were not 
terminated after continued noncompliance returned to substantial 
compliance an average of 17 days after the 6-month mark, and all 7 cases 
that were not terminated after uncorrected immediate jeopardy 
deficiencies reached compliance within 7 additional days.   
All facilities not terminated were found to be out of compliance again 
For the 29 facilities involved in the 30 cases that were not terminated as 
required, we reviewed all available subsequent surveys through May 31, 
2005. We found that all of the facilities that were not terminated had 
new cases of noncompliance serious enough to again require referral to 
CMS for enforcement action, including cases of extended noncompliance 
and immediate jeopardy to residents.  Ten of the twenty-nine facilities 
were subsequently cited with immediate jeopardy deficiencies, and in one 
case the facility was cited with an immediate jeopardy deficiency four 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  7  F I N D I  N G S  

times in consecutive years.  Additionally, many of the facilities required 
referral to CMS multiple times14 of the 29 facilities had deficiencies 
that warranted referral to CMS in 3 or more subsequent surveys. 
CMS must apply the DPNA for 
Of the 706 DPNA cases in 2002, 28 percent were 
facilities that fail to return to 
never applied and 14 percent were applied late, 
substantial compliance within 3 
due largely to late referral by States 
months. The remedy denies Medicare 
payment for residents newly admitted while the facility is out of 
compliance.  Delays in applying denials of payment allow facilities more 
time than regulation permits to return to compliance and avoid the 
remedy.  
Forty-two percent of DPNA remedies were never applied or were applied 
late 
Of the 706 cases in 2002 which should have received a DPNA remedy, 
CMS applied the remedy on time in 58 percent of cases.  CMS never 
applied the remedy in 28 percent of cases; these facilities came back into 
compliance after the required date, but before CMS took action.  The 
facilities were out of compliance an average of 111 days (19 days past the 
required 3-month effective date of the remedy), allowing the facilities the 
opportunity to erroneously receive payment for newly admitted residents 
during the interim period.30  In the remaining 14 percent of cases, the 
facilities were still out of compliance when CMS acted to put the remedy 
into effect, so the required DPNA was applied late.  These late remedies 
were applied after an average of 132 days of noncompliance (40 days past 
the required 3-month effective date of the remedy) also allowing the 
facilities the opportunity to erroneously receive payment. 
Despite not applying this remedy on time in 42 percent of the cases, CMS 
and State staff reported in interviews that they consider denial of 
payment to be a very effective tool in enforcing nursing home standards.  
Staff reported that, unlike other remedies such as civil money penalties, 
denial of payment can cause facilities to turn away new residents and is 
therefore likely to affect the image of the facility in the community and 
among medical facilities that may refer clients.   
Late referral of cases by States was the primary cause when DPNA 
remedies were never applied or were applied late 
In the 196 cases for which the DPNA was never applied, facilities 
returned to compliance after the deadline but before notice was sent or 
the notice period had elapsed.  Case documents showed that late referral 
by States caused delays in 92 percent of these cases (Table 2). 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  8  F I N D I  N G S  

Referrals in these cases were sent an average of 28 days late, with the 
latest case sent 101 days after the required date.31 For the remaining 
8 percent of cases, States referred the cases on time, but CMS regional 
offices still did not apply the mandatory DPNA remedies.  In interviews, 
CMS staff reported a number of possible problems, including notice 
letters not sent to facilities and staff turnover interrupting case tracking. 
In the 102 cases for which the DPNA was applied late, the facilities were 
still out of compliance when the case was referred to CMS by the State.  
Late referral by State survey agencies was a cause of delay in 97 percent 
of these cases.  Referrals in these cases were sent an average of 18 days 
late, with the latest case sent 82 days after the required date.32  Once 
CMS received referrals from States for these cases, it began the DPNA 
remedy after the required 15-day notice period to facilities. 
Table 2 
DPNA Remedies Never Applied or Applied Late 
Reasons for Never Applying  196 Cases 
Late referral by State  92% 
- Late referral by State the only reason  - 87% 
- Late action by both State and CMS regional office  - 5% 
Late action by CMS regional office only  8% 
Reasons for Applying Late  102 Cases 
Late referral by State  97% 
Late action by CMS regional office  3% 
Source: OIG analysis of 706 cases warranting DPNA remedy in 2002. 
State staff were not able to document a cause for all late referrals in 2002, 
but a late revisit by surveyors to the facility was the cause mentioned 
most frequently by staff during case reviews and interviews.  Other, less 
prominent, causes for late referral reported by State or CMS regional 
office staff include transmission errors when referrals are made 
electronically, insufficient survey documentation that requires States to 
resubmit case information, and State staff misunderstanding regarding 
referral requirements.33  Two CMS regional offices reported ad hoc efforts 
to track referrals through the ASPEN system, but no regional offices 
reported routine, comprehensive monitoring of current enforcement cases 
to determine if referrals were made by States when required.  
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  9  F I N D I  N G S  

State Performance Reviews by CMS confirm that States have problems 
referring enforcement cases on time 
The SPR data for 2002 reveals that 38 of the 48 States that had cases 
warranting a mandatory DPNA remedy did not meet the standard for 
timely referral of cases.34  In 2002, the SPR protocol required States to 
conduct a revisit of facilities by the 60th day of noncompliance, then to 
either send deficiency information to CMS or send an approved notice of 
the remedy to the facility by the 70th day. To meet this standard, States 
had to accomplish these tasks in 95 percent of cases warranting a 
mandatory DPNA remedy.  
Despite easing these SPR standards in 2003 and 2004, CMS reviews still 
found a substantial number of States to be underperforming.35 In 2003, 
24 States did not meet the standard for timely case referral although 
CMS lowered the standard from 95 percent to 80 percent of applicable 
cases.  In 2004, 10 States still did not meet the performance standard 
although CMS further changed it by requiring only that States refer 
80 percent of cases by the 70th day and omitting the requirement to 
conduct revisits within the 60th day of noncompliance.36 
While the variable SPR standards make it inappropriate to compare State 
performance across 2002-2004, it is evident that some States continue to 
have problems with late referrals, and that even States passing the 
current SPR standard could have late referrals in up to 20 percent of 
cases.  CMS has the ability to impose a variety of remedies and sanctions 
on States that fail SPR criteria; yet six States failed the criteria for 
referral timeliness in all 3 years we reviewed without CMS seeking any 
remedies or sanctions.37 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  10    R E C O M M E N D A T I O N S

Timely application of mandatory remedies encourages facilities to achieve 
and sustain compliance with Federal quality standards and is essential to 
CMS efforts to address noncompliance.  However, facility terminations 
did not occur as required in 55 percent of cases in 2000-2002, due to both 
late case referral by States and CMS staff reluctance to impose this 
severe remedy.  All of these facilities were later referred to CMS for new 
findings of noncompliance or immediate jeopardy.  CMS also did not apply 
the DPNA as required in 42 percent of cases in 2002.  Late referral of 
enforcement cases caused nearly all errors in applying mandatory DPNA 
remedies. These errors allowed facilities the opportunity to receive 
payment by Federal programs while out of compliance with resident care 
standards. 
To address these issues, OIG recommends the following: 
CMS should ensure that all facilities facing termination either reach 
compliance or are terminated within required timeframes 
To strengthen its effectiveness in addressing these egregious or extended 
cases of noncompliance, CMS should focus attention on termination cases 
to better ensure that facilities reach compliance by the required date, or, 
failing that, are terminated as required.  This effort could include 
encouraging State survey agencies to further prioritize termination cases, 
raising awareness of termination deadlines among State and CMS staff, 
and conducting special monitoring of pending terminations.  
CMS should address late referral of nursing home enforcement cases by 
States to ensure that mandatory remedies are applied as required 
Guidance to States. CMS should make addressing the timely referral of 
enforcement cases an organizational priority.  CMS should issue a 
program transmittal or other written guidance to reinforce for States the 
Federal requirements for referring enforcement cases on time. This 
directive should emphasize completing revisits on time, which was 
identified as a common cause of late referral.  
Routine Monitoring. CMS should actively monitor pending nursing home 
enforcement cases.  In interviews, no CMS regional office reported routine 
use of ASPEN to monitor enforcement case referrals from States.  To 
accomplish this, CMS should make full use of the monitoring capabilities 
of the ASPEN data management system. According to CMS staff, the 
ASPEN system allows input and access by CMS central office, its regional 
offices, and States, and includes enforcement case information in its 
ASPEN enforcement module.  Proactive use of ASPEN to monitor current 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  11  R E C O M M E N D A T I O N S

enforcement cases would allow regional offices to address problems with 
specific cases before it is too late to take action.  
CMS regional offices should regularly utilize the reporting functions 
available in ASPEN, including reports that can identify cases 
approaching the DPNA deadlines.  In addition, CMS should consider 
developing an automated function in ASPEN that alerts both CMS 
caseworkers and State staff when cases have reached the 70th day of 
noncompliance. Such an automated alert or indicator would serve as a 
reminder to State staff to refer the case and as a prompt for CMS staff to 
ask States if they have sent the expected case documentation. Finally, 
ASPEN allows CMS staff to review survey data online at any time, 
including before a case is referred to the regional office. While not 
practical in every case, this access could allow CMS staff to monitor the 
status of facilities with particularly troublesome histories. 
Use of State Performance Review. As part of the effort to address late 
referrals, CMS should also promote stronger adherence to the SPR 
standards.  The SPR provides a potentially valuable tool for enforcing 
State referral requirements, yet it is evident that some States have 
continued to have problems with late referrals well after the time period 
of our primary analysis (2002).  CMS regional offices should fully enforce 
the case referral standards contained in the SPR, including employing the 
prescribed remedies and sanctions when States fall below the SPR 
standards for timely referral.  CMS should also consider focusing efforts 
on underperforming States.  
Finally, we believe that recent changes in the SPR standards regarding 
referral timeliness make the SPR a less effective tool for identifying 
States with problems referring cases. Currently, States could refer up to 
20 percent of cases late, yet still pass the SPR standard.  Considering that 
late referrals are the primary cause when CMS does not apply DPNA 
remedies as required, the SPR should promote a higher level of State 
performance regarding this critical function.  By restoring the 
performance standard to 95 percent, CMS could further draw State 
attention to correcting the problem, while still allowing for late referrals 
under exceptional circumstances. 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  12  R E C O M M E N D A T I O N S

AGENCY COMMENTS 
While CMS agrees that enforcement and the timely remedy of identified 
problems in nursing homes are very important, it did not concur with all 
of our recommendations. 
In its comments, CMS identifies efforts recently underway or soon to be 
implemented to address timeliness issues.  First, CMS affirms that the 
new ASPEN Enforcement Management System has improved its ability 
to manage enforcement cases resulting in more mandatory DPNAs being 
implemented timely.  Additional changes to the State performance 
standards and the strengthening of the Special Focus Facility program 
signal the importance CMS places on nursing home quality of care.  CMS 
plans to begin a new internal triage review geared to strategically assess 
individual cases at the 5-month point to identify any additional actions 
that might help bring a facility back into compliance before the 
termination deadline.  CMS will also test a process to streamline the 
required notification process to alleviate the difficulties associated with 
timely implementation of the mandatory denial of payments for new 
admissions. 
Contrary to our recommendation regarding facility termination, CMS 
notes that it does not expect to make a great deal of change with respect 
to its implementation of this remedy.  Instead, it will continue to apply 
the remedy in a manner that it believes best protects the well-being of 
residents. CMS cited specific difficulties in meeting the 6-month 
timeframe for termination.  These include new unrelated deficiencies 
identified during the survey just prior to the termination date, the desire 
to both meet the 15-day public notice requirement and to maximize the 
facilitys opportunity to achieve compliance, and retention of the benefit of 
what it terms the crisis environment in the final hours before 
termination. CMS argues that imminent termination is instrumental in 
making positive reforms by causing the facility to apply more resources to 
correct deficiencies that led to termination.   
The full text of CMSs comments is presented in Appendix B. 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  13  R E C O M M E N D A T I O N S

OFFICE OF INSPECTOR GENERAL RESPONSE 
We recognize that since this inspection concluded, CMS has taken a 
number of positive steps toward ensuring that deadlines are met. These 
new steps, in addition to the planned actions, should assist CMS in 
meeting the mandatory enforcement requirements on time in future 
cases.  However, we are concerned about CMSs implied interpretation 
that the deadlines for mandatory termination are flexible.  While 
exceptional cases may exist, the 6-month termination requirement is 
statutory and the 23-day termination is in current regulation. 
Consequently, we see no room for discretion in the application of this 
remedy.   
CMS supported its position on two fundamental grounds: (1) that it is 
difficult to meet all scheduled timeframes and provide all reasonable 
opportunities for the facility to achieve compliance prior to termination 
and (2) that termination would be unnecessarily detrimental to the 
nursing home residents, particularly when compliance was achieved 
shortly after the termination deadline. 
First, we believe that actions similar to those CMS plans to implement for 
mandatory denials of payment, combined with active case management 
can reduce the number of missed deadlines in termination cases. For 
example, notification requirements can be streamlined so that they do not 
impede surveyors abilities to conduct a final revisit.  Additionally, CMS 
can maintain the benefits of the crisis environment, which it believes 
promotes corrective action, by beginning sooner in the process to make it 
clear to facilities that decisive action will be taken.  Second, we believe the 
pattern of noncompliance observed for the facilities that achieved 
compliance after the deadline, and thus were not terminated as required, 
deserves attention. One facility in this inspection that received additional 
time to achieve compliance was cited with an immediate jeopardy 
deficiency in each of its next four consecutive surveys.  Nine others were 
cited with immediate jeopardy deficiencies during their very next survey.  
Given these considerations, we believe that CMS, through active case 
management and earlier intervention, can motivate improvements and 
lasting corrections within the required timeframes for termination of 
facilities. 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  14    E N D N O T E S  

1 While the Social Security Act (the Act) does not use the term mandatory 
remedies, CMS and the States use this term to distinguish between those 
remedies that must be imposed under certain circumstances and those 
remedies that CMS has the discretion to impose. 
2 The Act,  1819(f)(1). 
3 42 CFR  488.308 and 488.330.  
4 42 CFR  488.404, 488.406, and 488.408; Department of Health and 
Human Services, Centers for Medicare & Medicare Services, State 
Operations Manual (SOM), Chapter 7,  7400E1 (2004). 
5 The SOM, Chapter 7,  7400E1. 
6 42 CFR  488.404.  
7 The Act,  1819(h) and 1919(h).  See also 42 CFR  488.400, 488.406, and 
488.408, and the SOM, Chapter 7,  7400A. 
8 42 CFR  488.301. 
9 Substandard quality of care means one or more deficiencies related to 
participation requirements under  483.15, Quality of life, or  483.25, 
Quality of care of this chapter, which constitute either immediate jeopardy to 
resident health or safety; a pattern of widespread actual harm that is not 
immediate jeopardy; or a widespread potential for more than minimal harm, 
but less than immediate jeopardy, with no actual harm. 42 CFR  488.301. 
10 While there are circumstances in which an enforcement action can be 
referred to the State Medicaid agency, e.g., cases involving Medicaid-only 
facilities, this study examined only those cases in which the enforcement 
action was referred to CMS.  CMS guidelines set forth three case types for 
referral: (1) immediate jeopardy cases, (2) cases in which facilities are not 
given an opportunity to correct, but do not involve immediate jeopardy, and 
(3) opportunity to correct cases which have failed to achieve subsequent 
compliance.  The SOM, Chapter 7,  7308A, 7316A, and 7316B. 
11 The Act,  1819(h)(1)(A), 1819(h)(2)(D), 1819(h)(2)(C), and 1819(h)(2)(E). 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  15  12 42 CFR  488.410(a), the SOM, Chapter 7,  7301A. 
13 The SOM, Chapter 7,  7305B(3)(a) and 7309A. 
14 The Act,  1819(h)(2)(D); 42 CFR  488.412(c) and 488.417(b); the SOM, 
Chapter 7, 7506C 
15 The remedy is to be applied at the end of 3 full months, rather than after a 
certain number of days.  For example, if the deficiency is cited on January 1, 
the denial of payment should be applied on April 1.  Policies about 
Verification of Compliance and Setting 3-and 6-month Remedy Effective 
Dates, Memorandum S&C01-10, Center for Medicaid and State Operations, 
Centers for Medicare & Medicaid Services, 2001. 
16 The Act,  1819(h)(2)(c); 42 CFR  488.412(a) and (b); the SOM, Chapter 7, 
 7556C 
17 42 CFR  488.402(f)(4) and 488.456(c)(2); the SOM, Chapter 7,  
7305B3(b) 
18 The Act,  1819(h)(2)(E); 42 CFR  488.414(a) and 488.417(b)(2).  Certain 
types of deficiencies may not fall within the definition of substandard quality 
of care because they do not relate to resident behavior and facility practices 
or quality of life or quality of care.   
19 The Act,  1819(g)(5)(C); 42 CFR  488.410(e). 
20 42 CFR  488.402(f). 
21 The [CMS] regional office or State Medicaid agency must provide formal 
notice of the remedies imposed unless official notice has already been 
provided by the State, as authorized by CMS and/or the State Medicaid 
agency. The SOM, Chapter 7,  7316B(4). 
22 Centers for Medicare & Medicaid Services, Survey and Certification Group, 
Center for Medicaid and State Operations, State Agency Performance 
Standards for Fiscal Year 2002, (Standard 4, Emphasis B), REF:S&C-02-28 
and State Agency Performance Standards for Fiscal Year 2003, (Standard 
4, Emphasis B), REF: S&C-03-27.    
23 To understand this interpretation of policy, CMS staff in interviews 
pointed to the following two regulations:  42 CFR  488.417(d) states that 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  16  . . . [w]hen a facility does not have repeated instances of substandard quality 
of care, payments to the facility or, under Medicaid, CMS payments to the 
State on behalf of the facility, resume prospectively on the date that the 
facility achieves substantial compliance, as indicated by a revisit or written 
credible evidence acceptable to CMS (under Medicare) or the State (under 
Medicaid)  . . . and 42 CFR  488.402(f)(3) and (4) state that . . . for all 
remedies imposed when there is immediate jeopardy, the notice must be 
given at least 2 calendar days before the effective date of the enforcement 
action. and . . . notice must be given at least 15 calendar days before the 
effective date of the enforcement action in situations in which there is no 
immediate jeopardy.  CMS staff explained that mandatory remedies 
therefore (1) cannot be applied to facilities that are in substantial compliance, 
and (2) cannot be applied without proper notice.    
24 The Act,  1864, Article II(J); the SOM, Chapter 8,  8000C and 8000D. 
25 Immediate jeopardy deficiencies that are downgraded to a scope and 
severity level below immediate jeopardy upon citation are considered 
abated and are not subject to these referral guidelines.  Some CMS regional 
offices request that States refer all immediate jeopardy cases, and may 
choose to apply discretionary remedies, even in cases that were fully 
corrected. 
26 OIG analysis of the SPR results revealed that in 2004, 31 of the 33 States     
(94 percent) that had unabated immediate jeopardy cases met the standard 
of 95 percent referral as required. 
27 Centers for Medicare & Medicaid Services, Survey and Certification Group, 
Center for Medicaid and State Operations, State Agency Performance 
Standards for Fiscal Year 2002, (Standard 4, Emphasis B), REF:S&C-02-28 
and State Agency Performance Standards for Fiscal Year 2003, (Standard 
4, Emphasis B), REF: S&C-03-27.   
28 Centers for Medicare & Medicaid Services, Survey and Certification Group, 
Center for Medicaid and State Operations, State Agency Performance 
Standards for Fiscal Year 2003, (Standard 4, Emphasis B),  REF: S&C-03-27 
and FY 2004 State Performance Review Protocol Guidance, (Standard 4, 
Emphasis B), REF: S&C-04-47.   
29 Centers for Medicare & Medicaid Services, Survey and Certification Group, 
Center for Medicaid and State Operations, State Agency Performance 
Standards for Fiscal Year 2003, (Standard 4, Emphasis B),  REF: S&C-03-27 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  17  and FY 2004 State Performance Review Protocol Guidance, (Standard 4, 
Emphasis B), REF: S&C-04-47.    
30 Denial of payment for new admissions is to be applied at the end of 3 full 
months.  (Policies about Verification of Compliance and Setting 3- and      
6-month Remedy Effective Dates, Memorandum S&C01-10, Center for 
Medicaid and State Operations, Centers for Medicare & Medicaid Services, 
2001.) We used 92 days for calculating expected application dates.   
31 Due to incomplete data, average and maximum referral times are based on 
171 of the 196 cases in which denial of payment was never applied.   
32 Due to incomplete data, average and maximum referral times are based on 
75 of the 102 cases in which denial of payment was never applied.   
33 Timeliness is not the only problem with the State referral process. In the 
report, State Referral of Nursing Home Enforcement Cases (OEI-06-02-
00400), OIG found that while States referred most nursing home cases 
warranting enforcement during the study period, an estimated 8 percent of 
cases were not referred.  Primary causes of nonreferral included State staff 
misunderstanding referral requirements and attempted referrals that were 
not recognized as such by CMS staff.   
34 OIG analysis of the 2002 State Agency Performance Evaluation results 
provided by CMS regional offices. 
35 OIG analysis of the 2003 and 2004 State Performance Review results, 
provided by CMS central office. 
36 OIG analysis of the SPR results includes 50 States and the District of 
Columbia for a total of 51. 
37 These potential remedies and sanctions include submitting a corrective 
plan of action, undergoing supplemental training, meeting with State 
officials, and ultimately, facing reductions in Federal financial participation 
and even the termination of their contract to survey facilities.  The SOM, 
Chapter 8,  8000G, ( 2004). 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  18     A P P E N D I X   ~   A  
   A P P E N D I X   ~   A  
Detailed Methodology  
We reviewed all nursing home enforcement cases that began in calendar 
years 2000, 2001, and 2002 to identify those that required mandatory 
remedies as a result of one of the four statutorily required conditions:  
immediate jeopardy, noncompliance lasting 3 months, noncompliance 
lasting 6 months, or a third instance of substandard quality of care. 
We identified enforcement cases from CMSs Online Survey, 
Certification, and Reporting (OSCAR) system, and determined 
enforcement activity from the Long Term Care Enforcement Tracking 
System (LTC).  The OSCAR system contains information collected 
during nursing home surveys and complaint investigations conducted 
by State agencies.  This information includes survey dates, the type of 
survey, cited deficiencies and the scope and severity of those 
deficiencies, as well as demographic and historical information about 
individual facilities.  The LTC database is a compilation of each CMS 
regions nursing home enforcement case files.  It contains basic facility 
descriptors, as well as data from all stages of the enforcement 
processfrom receipt of a case in the CMS regional office to final 
disposition. 
Because the LTC database includes only cases that States have referred 
to CMS, our analysis did not examine cases where the facility 
successfully corrected its deficiencies after being given an opportunity to 
correct or any cases not referred by States.  We used State survey data 
from OSCAR to identify the date a deficiency was found and 
enforcement data from the LTC database to determine the date 
remedies were applied.   
For immediate jeopardy cases, we reviewed scope and severity ratings 
in OSCAR and included any case which had not returned to compliance 
or been terminated by the end of the 23rd day following the first day of 
the survey visit.  For cases requiring termination at the end of                
6 months, we included those which were still out of compliance after  
185 days instead of 180 days because there are 5 months which contain 
31 days.  Similarly, for cases requiring the DPNA remedies after            
3 months, we allowed 92 days.  (Because of the large number of cases 
requiring the DPNA remedies, we narrowed our examination to cases in 
2002.)  Finally, we also used OSCAR deficiency data to identify facilities 
that were cited for a third instance of substandard quality of care.   
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  19  A P P E N D I X ~ A  
From this universe of cases, we identified those which required 
mandatory remedies.  We found a total of 55 cases requiring 
termination. These included 20 cases in which an immediate jeopardy 
deficiency was identified during a survey, yet had not been corrected by 
the 23rd day and 35 cases for which the facility was subject to 
termination for failure to return to compliance within 6 months between 
2000 and 2002.  We initially identified 750 cases in 2002 requiring the 
DPNA remedies.  However, 44 were exempted from the remedy as a 
result of settlements, informal dispute resolution, or because they were 
terminated from the Medicare program altogether due to other, more 
severe, enforcement cases, effectively sanctioning them for failing to 
return to compliance.  This exemption reduced the number of 
mandatory DPNA cases for review to 706. 
Once we identified the cases, we requested additional information from 
States and CMS regional offices about cases for which no record of the 
remedy existed in the data.  We reviewed these cases further to confirm 
that they met our criteria and warranted additional analysis.  We then 
considered additional LTC and OSCAR data elements and State and 
CMS responses to ensure the remedies had not been rescinded as the 
result of an appeal or informal dispute resolution.  
Because there are many explanations for a case not facing a remedy 
that might not be captured in administrative databases, we also 
requested additional information from CMS regional offices to explain 
what happened with each of the cases in this subset.  Further, we 
conducted structured interviews with CMS regional office staff to 
determine why required remedies were not applied.   
To verify our findings regarding State referral of enforcement cases, we 
evaluated all State Agency Performance Evaluation records for 2002 
and all records for its successor, the SPR, in 2003 and 2004. 
This study does not examine Medicaid-only cases, cases for which only 
discretionary remedies were indicated, or those that States failed to 
refer to CMS for enforcement.   
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  20    A P P E N D I X   ~   B  
Agency Comments 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  21  A P P E N D I X ~ B

OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  22  A P P E N D I X ~ B  

OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  23  A P P E N D I X ~ B  

OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  24  A P P E N D I X ~ B  

OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  25    A C K N O W L E D G M E N T S

This report was prepared under the direction of Judith V. Tyler, 
Regional Inspector General for Evaluation and Inspections of the Dallas 
regional office, and Kevin Golladay, Assistant Regional Inspector 
General of the Dallas regional office.  Other principal Office of 
Evaluation and Inspections staff who contributed include: 
Amy Ashcraft, Team Leader 
Clark Thomas, Project Leader 
Blaine Collins, Program Analyst 
Ruth Ann Dorrill, Program Analyst 
Sarah Craren, Program Analyst 
Susan Wolfe, Program Analyst 
Sandy Khoury, Program Specialist 
Technical Assistance 
Barbara Tedesco, Mathematical Statistician 
Kevin Farber, Mathematical Statistician 
Scott Horning, Program Analyst 
Field Assistance 
Tara Bernabe, Program Analyst, Philadelphia 
Sylvia Chin, Program Analyst, San Francisco 
Tricia Fields, Program Analyst, Kansas City 
Graham Rawsthorn, Assistant Regional Inspector General, Atlanta 
David Rudich, Program Analyst, New York 
Marco Villagrana, Program Analyst, Chicago 
OEI-06-03-00410  NURSING HOME ENFORCEMENT:  APPLICATION OF MANDATORY REMEDIES  26