Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

I D R
NFORMAL  ISPUTE  ESOLUTION 

F N F
OR  URSING  ACILITIES

Inspector General 
March 2005 
OEI-06-02-00750  Office of Inspector General 

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as required by Public Law 95-452, 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs. This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors 
in carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management 
and program evaluations (called inspections) that focus on issues of concern to the 
department, the Congress, and the public. The findings and recommendations contained 
in the inspections reports generate rapid, accurate, and up-to-date information on the 
efficiency, vulnerability, and effectiveness of departmental programs.  The OEI also 
oversees State Medicaid fraud control units, which investigate and prosecute fraud and 
patient abuse in the Medicaid program. 
Office of Investigations
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers.  The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, or civil monetary penalties. 
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.  The OCIG imposes program exclusions and 
civil monetary penalties on health care providers and litigates those actions within the 
department.  The OCIG also represents OIG in the global settlement of cases arising 
under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops compliance program guidances, 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   
OBJECTIVES 
To determine if all States have written informal dispute resolution 
(IDR) policies as required by Federal regulations and to describe policy 
content. 
To determine if 14 selected States comply with Federal requirements for 
State IDR notification and closure letters and if nursing facilities in 
these States comply with the Federal requirements for IDR requests. 
To determine the length of time taken by States to complete IDR 
reviews and to identify IDR outcomes for disputed survey deficiencies. 
BACKGROUND 
This inspection of the IDR process is part of the Office of Inspector 
Generals (OIG) ongoing evaluation of the quality of care provided to 
nursing facility residents, particularly as measured by survey 
deficiencies and by how States and the Centers for Medicare & Medicaid 
Services (CMS) manage them.  The IDR process is important because it 
provides nursing facilities the opportunity for avoiding costly formal 
appeals and for communicating better with State survey agencies about 
certification standards that facilities must meet. State procedures and 
outcomes of the IDR process have not previously been studied by OIG. 
CMS contracts with State agencies to conduct standard surveys of 
nursing facilities for compliance with the Federal standards no less 
than once every 15 months.  Any deficiency in quality of care, safety, or 
patient rights, as determined through the surveys, may trigger CMS 
enforcement action(s).  The enforcement regulations for nursing facility 
certification standards issued after passage of the Omnibus Budget 
Reconciliation Act of 1987 require all States to provide Medicare- and 
Medicaid-certified nursing facilities an opportunity for an IDR review to 
dispute cited deficiencies in patient care and safety. 
Before proceeding with a formal appeal, which can be costly and 
lengthy, the IDR process permits the nursing facility to submit 
documentation supporting its dispute to the State agency for a review 
that could potentially delete or lower the severity of the cited 
deficiencies. CMS, which has oversight responsibility for the IDR 
process, requires in its State Operations Manual that States have 
written IDR policies, although the policy content is not specified.  The 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  i  E X E C U T I V E   S U M M A R Y  
manual also includes instructions States should provide to nursing 
facilities to request an IDR review, specific details about the IDR 
process, and circumstances under which a State must inform a nursing 
facility of an IDR outcome. 
We analyzed 48 States written IDR policies and case documentation for 
a random sample of 415 IDR reviews done by 14 selected States in 
calendar year 2002. We determined if States have written IDR policies 
and the extent to which the States and nursing facilities met the 
Federal requirements in their actual conduct of IDR reviews.  We also 
used the case documentation provided by the 14 States to determine 
outcomes for disputed deficiencies and to determine the length of time 
for States to complete IDR reviews. 
FINDINGS 
Forty-eight of fifty States have written IDR policies that are available upon 
request, as required; however, the content of their written policies varies.    
Of the 50 States, Alaska and Connecticut did not provide us copies of 
their own written policies. However, both indicated they provide a copy 
of the IDR portion of the State Operations Manual upon a request for 
information. 
Most States written IDR policies address the requirements of providing 
instructions to facilities for an IDR request, including specific details 
about the IDR, and information on how States will inform nursing 
facilities of IDRs outcomes.  Other useful information, although not 
required, is often omitted.  For example, the written policies do not 
always address inappropriate reasons for an IDR request or that 
nursing facilities must be notified an IDR review is available to them. 
Finally, 38 of the 48 States policies do not specify time limits for 
completion of the IDR process. 
All 14 of the States, for which we reviewed case documentation, are 
performing IDR reviews and generally comply with the IDR requirements; 
yet, most notification letters omit some required technical information. 
State IDR Notification Letters. All notification letters to nursing 
facilities stated that the nursing facility IDR request must be submitted 
in writing and must include an explanation of disputed deficiencies.  
However, few notifications included two required details:  only 37 
percent of notifications indicated how the IDR review would be 
conducted and only 6 percent indicated by whom. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  ii  E X E C U T I V E   S U M M A R Y  
State IDR Closure Letters. The 14 States exceed Federal requirements 
by routinely sending closure letters to facilities to inform them of all 
IDR outcomes.  Federal requirements specify that States must send 
closure letters only if the facilities are unsuccessful at demonstrating 
that deficiencies should not have been cited. 
Nursing facility IDR requests typically met the requirements. 
Ninety-nine percent of requests for IDR review were in writing, as 
required.  Eighty-six percent included an explanation of the specific 
deficiencies being disputed, and 91 percent provided appropriate 
reasons for the IDR requests. 
Eighty percent of IDR cases were completed within 60 days, and 45 percent 
of the disputed deficiencies resulted in citation changes.  
There is no requirement for IDRs to be completed within 60 days, but it 
is beneficial if they are done within this timeframe.  This is due to the 
fact that a nursing facility has only 60 days from its receipt of the 
formal notice of the imposition of any enforcement remedies to formally 
appeal deficiency citations, whether or not the IDR process is completed. 
The nursing facilitys decision to pursue a formal appeal could be 
affected by the outcome of the IDR. On the other hand, deficiency 
citations are not supposed to be posted on CMSs Nursing Home 
Compare Web site, which is available for public reference, until the IDR 
is completed. Finally, the fact that 45 percent of the disputed 
deficiencies were changed through the IDR process indicates that IDRs 
do affect the citation outcomes. 
RECOMMENDATIONS 
We recommended that CMS require that the two States without the 
required written IDR polices, Alaska and Connecticut, prepare them 
since they are technically noncompliant.  Alternatively, CMS should 
determine if these States practice of providing, instead, the IDR portion 
of CMSs State Operations Manual to nursing facilities satisfies the 
requirement of written IDR policies. We also recommended that CMS 
ensure that all required information is included in all States IDR 
notification letters to the nursing facilities.  Although not required by 
law, regulation, or CMS policy, we also identified opportunities for 
improvement. 
Agency Comments 
CMS concurred with our recommendations and suggested opportunities 
for improvement. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  iii   .  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  .. .  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..
. .. .. . 
. ..  ..  ...   ...   ...   ...   ....    ....  .. .  . ..  ....    .....     .....     .....    ......      ......      ..... .    . .... .   .  .. ....   .  ... ..   .  ... ..    . ..... .    . ....  .   .. .. .. .  . .. . ..   ....  ...    .. . ....  .  .   .. .. .. . . .. . . . .  ..   .. .. . ..  .  .  ...  .. ..  .   ..  ....  ....     ..   ... .. ..   ..  .  ...  ... .   .   ... .. ...  ..  .   .   .... ...    .  .... . .  .. .... .....      .. 
B L E
EXECUTIVE SUMMARY
. . . . . . 1
I N T ROD U C T 
ON 
FINDINGS  ...................................................... 6
Written Policies. . . . 
 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .setatS detceleS fo secitcarP
Nursing Facility Requests. . . . . . 
Performance. . . . . . 
R E COM MEN D A 
 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S NOI T
A P PEN D I XES. . 
A: Inspection Methodology. . . . . . . . 
B: Calendar Year 2002 State Nursing Facilty IDR Requests. 
.. 20
C: Calculated Weights for Selected States' IDR Cases. . . . . . . .. 
D: Point Estimates and Confidence Intervals. . . . 
E: Requirements in States' Written Policies. . . . . . . . . . . . . . . .. 
F: Additional Information in Written State IDR 
Policies. . . . . . . ' 24
G: Centers for Medicare & Medicaid Services Comments. . . . .. 
A C K NOW LED G MEN T S . . .. .. . . 
END NOT 
E S .................................................... 30   I N T R O D U C  T I O N
OBJECTIVES 
To determine if all States have written informal dispute resolution (IDR) 
policies as required by Federal regulations and to describe policy content. 
To determine if 14 selected States comply with requirements for State 
IDR notification and closure letters and if nursing facilities within these 
States comply with the requirements for IDR requests. 
To determine the length of time taken by States to complete IDR reviews 
and to identify IDR outcomes for disputed survey deficiencies.  
BACKGROUND 
The Omnibus Budget Reconciliation Act of 1987 (OBRA) amended 
sections 1819 and 1919 of the Social Security Act by requiring all nursing 
facilities participating in the Medicare and Medicaid programs to meet a 
common set of certification standards, many of which focus on patient 
care and safety.  The Centers for Medicare & Medicaid Services (CMS) 
contracts with State agencies to conduct standard surveys of nursing 
facilities for compliance with the Federal standards no less than once 
every 15 months.  Any deficiency in quality of care, safety, or patient 
rights, as determined through the surveys, may trigger CMS enforcement 
action(s). 
The Administrative Dispute Resolution Act of 1990 required State 
agencies to develop and implement policies addressing alternative dispute 
resolution methods. However, it was not until July 1, 1995,1 the effective 
date of the OBRA enforcement regulations, that alternative dispute 
resolution became a process requirement for nursing facilities certified for 
Medicare and Medicaid. For nursing facilities, this process is called IDR.  
This inspection of the IDR process is part of the Office of Inspector 
Generals (OIG) ongoing evaluation of the quality of care provided to 
nursing facility residents, particularly as measured by survey deficiencies 
and how States and CMS manage them.  The IDR process is important 
because it provides nursing facilities the opportunity for avoiding costly 
formal appeals and for communicating better with State survey agencies 
about certification standards that facilities must meet. State procedures 
and outcomes of the IDR process have not previously been studied by 
OIG. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  1  II NN TT RR OO DD
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Informal Dispute Resolution 
Nursing facilities have both a formal and an informal process for 
disputing cited deficiencies resulting from standard surveys. The nursing 
facility may file a formal appeal request within 60 days of the facilitys 
receipt of the formal notice of the imposition of any enforcement remedies 
resulting from the cited survey deficiencies. The purpose of the formal 
appeal is to provide the nursing facility a structured review of disputed 
deficiencies by the Departmental Appeals Board of the Department of 
Health and Human Services. 
Effective July 1, 1995, as part of the nursing facility enforcement 
regulations, CMS required States to provide nursing facilities the 
opportunity for IDR reviews in order to avoid the potentially prolonged 
resolution process associated with more formal appeals. The IDR process 
does not prevent a nursing facility from pursuing a formal appeal of the 
disputed deficiency concurrently or at a later date. CMS incorporated 
IDR procedural requirements into their final written enforcement policies 
located in the State Operations Manual, section 7212. 
The IDR process provides a nursing facility with an opportunity to 
dispute cited survey deficiencies at the State level. After a nursing 
facility has been cited for a survey deficiency, the State agency is required 
to notify the facility in writing of the IDR opportunity. If the State agency 
receives a written request from a nursing facility within the required 
timeframe (10 calendar days), the IDR process then commences. The 
State reviews documentation submitted by the nursing facility to dispute 
deficiency citations. Additional steps may include an in-person interview 
or telephone conference between nursing facility representatives and 
State agency staff. As a final step, the State may send the nursing facility 
a closure letter indicating the outcome of the review.2  Some States have 
posted information about their IDR process on their health departments 
Web sites,3 and 27 States have incorporated an IDR process into their 
State laws or regulations.4 
Federal regulations and policy5 further specify that an IDR-disputed 
deficiency should not be entered into CMSs Online Survey, Certification, 
and Reporting (OSCAR) system. Additionally, the disputed deficiency is 
not supposed to be posted to CMSs Nursing Home Compare Web site, 
which is available for public reference, while the IDR case is pending. At 
the conclusion of an IDR, upheld deficiencies are input into OSCAR and 
subsequently made available on the Nursing Home Compare Web site. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  2  III NNN TTT RRR OOO DDD UUU CCC TTT III OOO NNN
IDR Requirements. IDR requirements appear in Federal regulations at 
42 CFR  488.331 and in CMSs State Operations Manual. section 7212. 
Federal Regulations. The Federal regulations require: 
1. 	 States to provide nursing facilities the opportunity for an IDR 
review; 
2. 	 States to provide written notification of the IDR process to nursing 
facilities; 
3. 	 any enforcement actions initiated as a result of the survey to 
proceed, regardless of an IDR request; and 
4. 	 in the event that the nursing facilitys dispute is upheld, State 
removal of the deficiency from the statement of deficiencies and 
rescission of any enforcement actions imposed solely as a result of 
the disputed deficiency. 
Centers forMedicare &Medicaid ServicesPolicy. The State Operations
Manual provides CMSs policy statement of specific requirements for the 
IDR process following the citation of survey deficiencies, including that 
each State is required to have a written policy available upon request. 
The requirements for State IDR notifications, nursing facility IDR 
requests, and State closure letters are shown in Table 1 on the next page. 
Recent Federal Initiatives 
Centers forMedicare&MedicaidServices. CMS is currently requiring that 
States input IDR information into a new component of its Automated 
Survey Processing Environment software. This software, the IDR 
Manager, tracks and collects data on disputed surveys. However, the 
functionalities of the IDR Manager have been used to varying degrees, 
depending on the needs of the States.  CMS has both an extramural pilot 
study and a contracted grant underway to evaluate the effectiveness of 
the current IDR process. Reports from these studies are anticipated in 
early 2005, but are intended to serve as internal documents for CMSs 
useage.6,7,8 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  3  I N T R O D U C T I O N  
Table 1:  Requirements for State IDR Notification Letters, 
Nursing Facility IDR Requests, and State Closure Letters 
State IDR Notification and Closure Letters  Nursing Facility IDR Requests  
1) Each State must notify the nursing facilities of the availability of an  The nursing facility IDR request: 

IDR in the letter from the State transmitting the official Form 

CMS-2567, the Statement of Deficiencies. 
 1) must be in writing, 
2) State notification of the IDR process should inform the nursing  2) must be submitted within the same 10-calendar day period as for 
facility that the nursing facilitys IDR request:  submitting an acceptable plan of correction to the State surveying 
a.  must be in writing,  entity, 
b. 	 must be submitted within the same 10-calendar day period as 

for submitting an acceptable plan of correction to the State 
 3) must not be used to:

surveying entity, and 
 a.  delay the formal imposition of remedies and 
c.  must include an explanation of the specific deficiencies being  b.  challenge other aspects of the survey process, including: 
disputed.  - scope and severity of cited deficiencies, except in those 
instances when the cited deficiency constitutes substandard 
3) State notification of the IDR process should also inform the nursing  quality of care or immediate jeopardy;

facility of some basic information about the States IDR, specifically: 
 - remedies imposed by the enforcing agency for cited 
a.  how the IDR may be accomplished (e.g., by telephone, in  deficiencies; 
writing, or in a face-to-face meeting);  - allegation of failure of the survey team to comply with the 
b.  the name, address, and telephone number of the contact  survey process requirements;

person for requesting the IDR; and 
 - allegation of inconsistency of the survey team citing 
c. the name and/or position title of the person who will conduct the  deficiencies among facilities; and 

IDR, if known.
 -	 allegation of inadequacy or inaccuracy of the IDR process; 
and 
4) 	The State survey entity must notify the nursing facility in writing if 
the nursing facility is unsuccessful at demonstrating, during the IDR,  4) must include an explanation of the specific deficiencies being 
that a deficiency should not have been cited.  disputed. 
Source: CMSs State Operations Manual, section 7212. 
METHODOLOGY 
We contacted 50 States for information about their IDR processes. We 
also selected a random sample of 415 IDR reviews done by 14 selected 
States in calendar year 2002.  These 14 States represent 50 percent of the 
nursing facilities nationwide and 62 percent of the total number of 
deficiencies cited at scope (number of affected residents) and severity 
(degree of harm) levels E or above. These are the more serious 
deficiencies. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  4  I N T R O D U C T I O N  
We used the following sources of information for this inspection:  
o 	 telephone interviews with all 50 State representatives having 
responsibility for their respective IDR processes, 
o 	 written State IDR policies from 48 of 50 States, 
o 	 written case documentation for the sample of 415 IDR reviews from 
the 14 selected States, and 
o 	 onsite visits with 6 of the 14 selected States. 
We analyzed this information to determine: (1) if States have the 
required written IDR policy, available on request, and what information it 
contains; (2) if States and nursing facilities actually perform the 
Federally required key steps in each IDR case; (3) the extent to which the 
IDR documentation itself, such as State notices to facilities, incorporated 
the IDR requirements of the State Operations Manual, section 7212; 
and (4) the total processing time and outcomes of cited deficiencies for the 
documented IDR cases. Complete information regarding the inspection 
methodology is provided in Appendix A 
Inspection Limitations 
This inspection has the following limitations: 
o 	 We only examined the IDR process for standard surveys; we did not 
include extended surveys, follow-up surveys, or complaint surveys 
in our review. We used standard surveys because CMS requires 
States to conduct a standard survey on all certified nursing facilities 
at least once every 15 months.  Other types of surveys occur as 
needed.  
o 	 We only examined the more serious deficiency citations of scope 
(number of affected residents) and severity (degree of harm) levels E 
or above. 
o 	 We did not independently verify all of the information reported to 
us by State IDR representatives during telephone discussions and 
onsite visits, or reported to us from the State agencies through the 
mail. 
Inspection Conduct 
We conducted this inspection in accordance with the Quality Standards
for Inspections issued by the Presidents Council on Integrity and 
Efficiency. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  5  
 F I N D I N G S
Compliance.  Section 7212 of the 
Forty-eight of fifty States have written IDR 
State Operations Manual requires 
policies that are available upon request, as 
that all States have their IDR 
required; however, the content of their written 
processes in writing so that they can 
policies varies.  be made available upon request.  
Forty-eight States provided us with 
copies of their written IDR policies as documentation of availability.   
Alaska and Connecticut did not provide us copies of their own written 
policies.  Both States indicated that when facilities request written policy, 
each State provides a copy of the IDR portion of the State Operations 
Manual. State staff reported that IDR requests in Alaska are rare (3 in 
15 years), whereas Connecticut processed approximately 88 IDR cases in 
2003. 
Written State Policy Content for 48 States. Federal regulations and policy 
specify key steps of the IDR process, but they do not require inclusion of 
these steps in each States written IDR policy.  Nevertheless, we 
compared, for informational purposes, the 48 States written policies with 
the State Operations Manual requirements to determine the extent to 
which they cover the whole IDR process.  (See Appendix E.) Most States 
policies specify that the State will inform nursing facilities that IDR 
requests should: 
o 	 be in writing (44 States), 
o 	 be submitted within a 10-calendar day period (43 States), 
o 	 include an explanation of deficiencies (41 States), and 
o 	 identify who will conduct the IDR review (42 States). 
States written policies less often cover other requirements included in 
the State Operations Manual, such as: 
o 	 what the nursing facility IDR request cannot be used for, such as to 
challenge the scope and severity of cited deficiencies, except in those 
instances when the cited deficiency constitutes substandard quality 
of care or immediate jeopardy (33 States); and 
o 	 how the nursing facilities should be notified of the availability of an 
IDR process (28 States). 
Additionally, only four States (Arizona, Hawaii, Ohio, and Oklahoma) 
provide examples of their standard IDR notification letters in their 
written policies.  These examples of letters have potential value for 
providing clear guidance regarding that States IDR process. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  6  FF	 II NN DD II NN GG SS  
We also compared the States written policies against the Federal 
requirements to determine how accurately they reflect these 
requirements. We found no inaccurate statements in States written 
IDR policies in this comparison. 
States written IDR policies show some differences between States IDR 
processes. Some examples (see Appendix F for all of them) include: 
o 	 whether a desk review will be performed (48 States), 
o 	 the time limitation for an in-person or telephone conference 
(13 States), and 
o 	 the attendance limitations at an in-person conference (12 States). 
Additionally, 48 States written policies indicate an opportunity for 
participation in the IDR process by individuals not directly involved in 
the survey that resulted in the disputed deficiency.9  At the same time, 
40 States, including Alaska, reported that they routinely include the 
original surveyors or survey representatives in the IDR process to provide 
additional information or explanation, as needed, to questions which may 
arise during the IDR review (25 States), to attend the IDR review as 
nonparticipants (20 States), and to conduct the initial review (4 States). 
Thirty-eight of forty-eight States written IDR policies do not specify time 
limits for completion of the IDR process. There are no Federal regulations 
or policy requiring and defining timeliness from receipt of a nursing 
facilitys IDR request to the completion of the IDR review. Ten States 
policies specify time limits ranging from 10 to 40 days for their IDR 
processes. 
Based on documentary evidence, 
All 14 of the States, for which we reviewed case 
interviews with State agency staff, 
documentation, are performing the IDRs and 
and onsite State visits, we 
generally comply with the IDR requirements; 
confirmed that all 14 selected States 
yet, most notification letters omit some required  are performing the Federally 
technical information.  required IDR steps of sending 
notification letters, receiving 
requests from facilities, and informing facilities of IDR outcomes in 
closure letters. For our sample of 415 IDR cases, we either obtained 
copies of, or could infer the existence of, 99 percent of notification letters, 
99 percent of nursing facility IDR requests, and 96 percent of closure 
letters. Follow-up discussions with State staff suggested that cases 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  7  F I N D I N G
 S  
without all three letters were due to missing documents rather than the 
basic IDR steps not being performed. 
For the second part of this analysis, we reviewed case documentation for 
the State notice and closure letters to determine the extent to which the 
State Operations Manual requirements are included in both types of 
correspondence between the State and nursing facilities.   
State IDR Notification Letters 
States IDR notification letters include most, but not all, of the required 
information. Case documentation shows that each of the 14 selected 
States uses a standard form letter that notifies nursing facilities of their 
opportunity for requesting an IDR review but tailors the letter to each 
nursing facilitys particular circumstances.  Modifications include 
specifying cited deficiencies and possible enforcement actions.  All State 
IDR notification letters provided information about IDR availability, 
notified the nursing facility that the IDR request must be submitted in 
writing within 10 calendar days, and indicated that the written IDR 
request must include an explanation of specific deficiencies being 
disputed.  Other requirements concerning the details of the IDR process, 
such as the method for conducting an IDR review, e.g., telephone, in 
writing, or who will be conducting the IDR, often did not appear in the 
notification letters.  (See Table 2.) 
Table 2:  Required Information Included in 14 Selected States IDR Notification Letters* 
Letters Including  Number of States 
Required  Standard Letters With 
Required Information for Notification Letters 
Information   Required 
(n = 367)  Information* 
Notification of this process should inform the facility of 
some basic information about the States IDR process, 
specifically:  
a. how the IDR review may be accomplished (e.g., by  37%  3 
telephone, in writing, or in a face-to-face meeting); 
b. the name, address, and telephone number of the  93%  12 
contact person for the IDR request; and 
c.  the name and/or position title of the person who will 
6%  1 
conduct the IDR review, if known. 
* Because we received at least 1 notification form letter from each of the 14 States, we could determine how 
many of the States included the required information in their notification letters. 
Source: OIG analysis of State IDR notification letters (weighted). 
Current CMS policy also requires that nursing facilities requests not be 
used for certain purposes but does not prescribe that the State 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  8  FFF III NNN DDD III NNN GGG
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notification letters contain this information. Nevertheless, we reviewed 
the State notification letters for inclusion as a point of information. With 
the exception of the notification letters specifying that requesting an IDR 
review to delay the formal imposition of remedies is not permissible, most 
letters did not include other required reasons for not requesting an IDR 
review. (See Table 3.) 
Table 3: Inappropriate Reasons for an IDR Request Included 
In 14 Selected States Notification Letters 
Number of States 
Letters Including 
Standard Letters 
Inappropriate Reasons for Requests  Inappropriate Reason 
Including Inappropriate 
(n = 367) 
Reason* 
Notification includes that the facility request 
must not be used to: 
a. delay the formal imposition of remedies;  72%  11 
b. challenge the scope and severity of cited  50%  5 
deficiencies, except in those instances 
when the cited deficiency constitutes 
substandard quality of care or immediate 
jeopardy; 
c. challenge the remedies imposed by the  18%  2 
enforcing agency for cited deficiencies; 
d. allege failure of the survey team to comply  36%  3 
with the survey process requirements; 
e. allege inconsistency of the survey team  36%  3 
citing deficiencies among facilities; and 
f.  allege inadequacy or inaccuracy of the IDR  18%  2 
process. 
* Because we received at least one notification form letter from each of the 14 States, we could 
determine how many of the States included the required information in their notification letters. 
Source: OIG analysis of State IDR notification letters (weighted). 
State IDR Closure Letters 
All closure letters to nursing facilities requesting IDR reviews met the one 
applicable requirement to notify nursing facilities in writing when they have 
been unsuccessful at demonstrating that a deficiency should not have been 
cited. However, all 14 selected States routinely provide closure letters to 
nursing facilities, regardless of outcomes. Further, 9 of the 14 selected 
States consistently provided information in their closure letters concerning 
all disputed deficiencies, rather than outcomes of only deficiencies changed 
as a result of the IDR review. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  9  FFF III NNN DDD III NNN GGG SSS  
Nursing facility IDR requests typically met the  We reviewed case documentation to 
Federal requirements.  determine the extent to which the
nursing facility IDR requests met 
State Operations Manual 
requirements. (See Table 4.) All requests, except one by telephone, were 
submitted in writing. Eighty-six percent included an explanation of 
specific deficiencies being disputed. Of the IDR cases with sufficient 
documentation to analyze, 91 percent cited appropriate reasons for the 
IDR requests. 
Table 4: Requirements Met in 
Nursing Facility IDR Requests for 13 Selected States* 
IDR Requests Meeting 
Requirement for IDR Requests  Requirements 
(n = 371) 
Submitted in writing  99% 
Included an explanation for specific disputed deficiencies  86% 
Provided correct reasons for the IDR request  91% 
Submitted timely**  86% 
* Massachusetts was excluded from this review. 
** We defined timely as the request being submitted within 15 days (a few days for the States 
notification letter to reach the facility by mail, 10 days to respond, and a few days for the 
State to receive the IDR request). 
Source: OIG analysis of nursing facility IDR requests. 
The 9 percent of facilities using an incorrect reason for an IDR request, 
namely, challenging the scope and severity of cited deficiencies, were 
significantly10 more likely to be in States that did not provide this 
information in their State notification letters. Further, none of the 
nursing facilities comprising the 9 percent was refused an IDR review by 
the States. 
Nursing facilities largely adhere to the 10-calendar day request 
requirement, when additional days are allowed for mail receipt and 
return. The State Operations Manual requires nursing facilities to 
submit their IDR requests within the same 10-calendar day period for 
submission of an approved plan of correction, i.e., it is required within 
10 days of the nursing facilitys receipt of the official Statement of 
Deficiencies, form CMS-2567. The CMS-2567 usually accompanies the 
State IDR notification letter. 
Allowing a few days for the States notification letter to reach the facility 
by mail, 10 days to respond, and a few days for the State to receive the 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  10  F I N D I N G S  
IDR request (we allowed 15 days total), 86 percent of the IDR requests fell 
within the required timeframe. Late submission of an IDR request does 
not appear to impact whether an IDR review is performed by a State; only 
one Texas nursing facility was refused an IDR review for not meeting a 
timeframe requirement. 
Ten of the fourteen selected States define the 10-calendar day period for 
requesting an IDR review in their written policies.  Seven of the ten use 
the same definition as the State Operations Manual requirement for the 
plan of correction, with no mention of days allowed for mailing.  Two of 
the ten use a more restrictive definition11 and one specifies an actual due 
date in the State IDR notification letters. 
Eighty percent of the IDR cases were completed  Timeliness.  We paired each nursing 
within 60 days, and 45 percent of the disputed  facility IDR request letter with its 
corresponding State closure letter. 
deficiencies resulted in citation changes. 
Eighty percent of the pairs showed 
completion of IDR cases within 60 days, 13 percent took 61 to 90 days, 
and 7 percent took more than 90 days.  Overall, time for completion of 
cases in our selected States (excluding Massachusetts) ranged from 2 to 
312 days. 
Federal regulations and policy do not define timely completion of an IDR 
case review, although the failure to complete an IDR review will not delay 
the effective date of any enforcement action.  However, Federal 
regulations and policy allow nursing facilities to file a formal appeal and 
an IDR request concurrently. The nursing facility may file a formal 
appeal request within 60 days of the facilitys receipt of the formal notice 
of the imposition of any enforcement remedies, resulting from the cited 
survey deficiencies.  If the outcome of an IDR review is in the nursing 
facilitys favor, e.g., deletion or lowering of scope and severity level for the 
cited deficiency, even though not requested by the nursing facility, the 
nursing facility may choose not to file a request for a formal appeal, 
assuming that the outcome is known before 60 days have elapsed, or the 
nursing facility can withdraw the concurrent request for a formal appeal 
made early in the process.  
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  11  FFF III NNN DDD III NNN GGG
 SSS  
Outcomes. Of the initially disputed 1,211 deficiencies from 347 cases, 
45 percent had a change in citation, almost always in the nursing 
facilitys favor. (See Table 5.) An IDR outcome may be considered in the 
facilitys favor if the disputed deficiency is deleted, lessened in impact by 
a modification to how the disputed citation is written, e.g., one or more 
examples are deleted from the citation, or lowered in scope and severity 
level, even though not requested by the nursing facility. 
Of the deficiency citations that were changed, 19 percent had 
modifications to the way the deficiency was written, and 19 percent had 
the citation deleted. An increase in the scope and severity level of the 
disputed deficiency for the nursing facility, a negative outcome of an IDR 
review, appears to happen rarely. Insufficient outcome information was 
documented for 3 percent of the reviewed cases. 
Table 5: IDR Outcomes for Disputed Deficiencies 
Percent of 1,211 Disputed 
IDR Outcomes  Deficiencies 
(n = 347 cases) 
No change in citation  52% 
Changes in citation  45% 
-Modification to the way the deficiency was written  19% 
- Deletion of cited deficiency  19% 
- Decrease in scope and severity level  6% 
- Increase in scope and severity level  <1% 
Insufficient information provided in the letter  3% 
Source: OIG analysis of 347 paired nursing facility IDR requests and State IDR closure letters. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  12  
 R E C O M M E N  D A T  I O N S  
We found substantial State and nursing facility compliance with 
requirements for the IDR process. We also identified a few technical 
compliance issues as well as opportunities for improvements to the IDR 
process under CMSs leadership.  We recognize that our findings about 
IDR performance are statistically projectable only to the 14 selected 
States and their IDR cases.  However, these findings would likely be 
useful for improving IDR processes in all States. The following 
recommendations and opportunities for improvement are offered to CMS 
as possible ways to help all States to strengthen their IDR policies and 
practices. 
RECOMMENDATIONS 
CMS should secure compliance of States IDR policies and practices 
with requirements by: 
Ensuring that all States have written IDR policies.  Alaska and 
Connecticut do not technically comply with the requirement for having 
their own written IDR policies.  Instead, these two States provide copies of 
the IDR portion of CMSs State Operations Manual to nursing facilities 
requesting information. CMS should require the two States without the 
required written IDR policies to prepare them.  Alternatively, CMS should 
review the two States practice to determine if it meets the requirement for 
a State to have a written IDR policy and if the State Operations Manual 
IDR section alone is sufficient to fully inform nursing facilities about the 
IDR process.  
Ensuring that States include all required information in their IDR 
notification letters to the nursing facilities. We found that the specific 
information required by the State Operations Manual regarding how 
and by whom the IDR review would be conducted is missing from State 
notification letters to varying degrees.  To correct this, CMS could remind 
States, in writing, of the requirement for including this information, 
e.g., develop a template or standard notification letter for adaptation by 
the States, and periodically review States letters for inclusion of these 
requirements. 
OPPORTUNITIES FOR IMPROVEMENT 
We also noticed two areas for improvement of the IDR notification, 
request, and closure processes which are not compliance issues, but could 
improve the IDR process. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  13  R E C O M M E N D A T I O N S  
Written IDR Policies. CMS may wish to consider emphasizing to all States 
the benefit of including all IDR requirements contained in regulation and 
the State Operations Manual in their own written policies, along with 
discussion of their individual State practices.  While the actual content of 
States written policies is at the States discretion, the written policies are 
likely used by State staff in administering their IDR processes, as well as 
informing interested parties, such as nursing facilities.  We found that at 
least 14 of 48 States written policies do not address what an IDR review 
cannot be used for.  (See Appendix E.) Further, the State Operations 
Manual policy is unclear if States are required to include this information 
in their IDR notification letters to the nursing facilities.  Twenty of forty-
eight States written IDR policies do not include information indicating how 
facilities should be notified about the availability of the IDR process. 
We offer several options for CMSs encouraging completeness of States 
written IDR policies: (1) share this report with States, emphasizing findings 
about written State policy; (2) suggest, in writing, that each States policy 
could benefit from incorporating the State Operations Manual IDR 
sections into their written policy; and (3) suggest, in writing, that States 
incorporate a sample State IDR notification letter into the written policy, 
which currently only four States (Arizona, Hawaii, Ohio, and Oklahoma) 
provide. 
Timeframe for States Completion of IDR Reviews. The IDR process can 
potentially save Federal, State, and facility dollars through the avoidance of 
a lengthy, formal appeal process.  The nursing facility may file a formal 
appeal request within 60 days of the facilitys receipt of the formal notice of 
the imposition of any enforcement remedies resulting from the cited survey 
deficiencies, and we found that 80 percent of the IDR cases were completed 
within 60 days. To enhance the possibility that nursing facilities can avoid 
formal appeals by using the IDR process, CMSs defining an explicit 
timeframe of something less than 60 days for IDR completion appears 
feasible and useful. Federal regulations and policy do not define timely 
completion of an IDR case, although the failure to complete an IDR review 
will not delay the effective date of any enforcement action against the 
nursing facility. At the same time, only 10 of 48 States IDR written policies 
identify self-imposed timeframe limitations for completing an IDR case. 
Another benefit of setting a time limit for IDR case completion is that until 
the case is completed, any deficiency citation under dispute is not placed on 
CMSs Nursing Home Compare Web site.  Lack of timeliness also 
compromises the integrity of the OSCAR system data.  
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  14  R E C O M M E N D A T I O N S  
AGENCY COMMENTS 
CMS concurred with our recommendations and opportunities for 
improvement.  The agency further commented they have already begun 
work to ensure that all States maintain written policies and that States 
review their policies for consistency with the minimum requirements 
listed in Federal regulations and the State Operations Manual.  
Furthermore, while CMS believes no immediate action is needed to 
specify a timeframe in which the IDR process must be completed, the 
agency has established it as a topic at the 2005 annual meeting with the 
State agencies. 
CMS also provided technical comments for which we made revisions 
where appropriate.  The full text of CMSs comments is presented in 
Appendix G. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  15    A P P E N D I X   ~   A
Inspection Methodology 
We used four sources of information in this inspection: 
o 	 telephone interviews with all 50 State representatives having 
responsibility for their respective IDR processes, 
o 	 written State IDR policies from 48 of 50 States, 
o 	 cases with written documentation from a stratified random sample 
of IDR cases within 14 selected States, and 
o 	 onsite visits with 6 of the 14 selected States. 
Telephone Interviews.  We first interviewed the State representative for 
each of the 50 States.  We used a standardized questionnaire to ask each 
about available written IDR policy and process.  We also conducted 
subsequent follow-up discussions with IDR representatives from the 
14 selected States.  We gathered information regarding how each State 
notifies nursing facilities of the availability of the IDR process and how it 
conducts the IDR review. 
Written State IDR Policies. We asked all 50 States to provide written 
documentation of their IDR processes; 48 of the 50 States provided the 
information. This documentation: (1) validated whether each State has 
the required written IDR policy and its availability upon request, and  
(2) provided the content of the written policies for review.  As previously 
noted, Federal regulations and policy do not specify any requirements for 
the content of States written IDR policies.  Nevertheless, for 
informational purposes, we reviewed the extent to which States written 
policies included IDR procedural requirements from the State Operations 
Manual. (See Table 1 on page 4.)   
Random Sample of IDR Cases within 14 Selected States 
There is no national listing of IDR cases from which to sample.  Therefore, 
we used a two-step process to identify a group of States from which to 
sample the IDR cases: 
o 	 identification of States having the highest number of deficiencies 
cited at E or above during calendar year (CY) 2002 standard 
surveys of nursing facilities12 and 
o 	 determination of the number of nursing facilities in each of those 
States. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  16  AA PP PP EE NN DD II XX ~~ AA  
CMS classifies deficiencies cited by standard surveys of nursing facilities 
on a scale of A through L according to their scope and severity.13 The 
severity of the deficiency refers to the degree of harm, while the scope 
of the deficiency refers to the number of affected residents. 
We used CMSs OSCAR system to identify for each State the total number 
of deficiencies cited during standard surveys of nursing facilities at scope 
and severity levels greater than or equal to E during CY 2002. We ranked 
this listing by State from highest to lowest number of deficiencies. We 
then identified the number of certified nursing facilities in each State. 
We selected States from highest to lowest number of deficiencies until we 
had selected States representing at least 50 percent of the nursing 
facilities nationwide. This resulted in our selection of 14 States, 
representing 62 percent of the total number of deficiencies cited at E or 
above, and 50 percent of the nursing facilities. These selected 14 States 
were California, Florida, Indiana, Kansas, Louisiana, Massachusetts, 
Michigan, Missouri, New York, Ohio, Oklahoma, Tennessee, Texas, and 
Washington.14  (See Appendix B.) 
To generalize to the 14 States, we treated each State as a separate 
stratum. The number of IDR cases sampled within each State was 
determined by the States population of IDR cases. If a State had 35 or 
fewer IDR cases, we sampled all of them. If a State had more than 
35 IDR cases, we randomly selected a sample of 35 cases. From our 
population of 893 IDR cases from the 14 selected States, we randomly 
chose a total of 415 cases for analysis. (For further details of the sample 
selection process, see Appendix C.) 
Data Collection. For each of the 415 sampled IDR cases, we requested case 
documentation from the States comprised of: 
o  the State IDR notification letter to the nursing facility, 
o  the nursing facility IDR request, and 
o  the closure letter resulting from the completed IDR sent by the 
State to the nursing facility. 
We did not receive the same number of each of these three documents 
from the sampled cases. Only 4 of the14 selected States provided all the 
requested documentation. Across all 415 cases, we actually received 
documentation for 367 State notification letters to nursing facilities, 
371 nursing facility IDR requests, and 400 closure letters. Massachusetts 
provided no nursing facility IDR requests, only one of the requested 
notification letters, and all requested closure letters. While missing 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  17  AA PP PP EE NN DD II XX    AA  
documentation limited our data analysis in some instances, we were able 
to make assumptions about the process, which we discuss below. (For 
details, see Appendix C.) 
Data Analysis. We examined documentation from the sampled IDR cases 
to determine State practice from three perspectives: (1) actual 
performance of the Federally required key steps in each IDR case, 
(2) the extent to which the IDR documentation incorporated the IDR 
requirements of the State Operations Manual, Section 7212, and (3) 
the total processing time and outcomes of cited deficiencies for the 
documented IDR cases. 
(1) 	Performance of the IDR steps for notification, request, and closure. 
We considered documentation for each of the IDR cases as 
confirmation that the IDR process steps of notification, request, and 
closure had occurred. In some cases documentation was missing for 
the IDR notification and subsequent request. We did receive 
documentation for 400 closure letters. Using the documentation 
received, we were able to infer that a certain step in the IDR process 
had probably occurred. For example, since a closure letter would 
not be generated unless an IDR had been requested, we assumed for 
the analysis that the notification and request had occurred. We 
concluded that of the 415 cases, there was a State notification letter 
for 413 cases and nursing facility requests for 412 cases, although 
we did not always see all of the documents. This was the only 
analysis for which we used inferred data. 
(2) 	Extent to which IDR case documentation incorporated the 
requirements of the State Operations Manual, section 7212. 
We compared the language of each of the three types of documents 
received for each IDR case to the State Operations Manual 
requirements. For this analysis, we used the documents we 
actually received, which consisted of 367 State notification letters to 
nursing facilities, 371 nursing facility IDR requests, and 400 State 
closure letters. 
We also compared the dates on the notification letters and nursing 
facility requests. This identified whether the nursing facility IDR 
requests were received within the same 10-calendar day period 
required for submitting an acceptable plan of correction to the State 
survey entity. Although the State Operations Manual requires 10 
days to respond, in our analysis, we used a conservative approach, 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  18  A P P E N D I X   A  
allowing 15 days total from the time a State notification letter was 
sent to the time the State received the IDR request. 
(3) 	Total IDR processing time for documented sample IDR cases and 
documented outcomes of cited/disputed deficiencies through the IDR 
process. 
Processing Time. Available documentation allowed us to match 347 
cases where we had both the IDR facility request and the State 
outcome letter.  This subset of cases allowed us to calculate the 
number of days for completing the IDRs. 
IDR Outcomes.  We compared the documented 400 IDR closure 
letters to their corresponding nursing facility IDR request letters to 
create a subset of 347 paired IDR cases documenting     1,211 
initially disputed deficiencies for which we could identify outcomes. 
Since our sampling frame did not include all 50 States, reported 
statistical estimates apply only to the 14 selected States.  However, we 
believe the inspections findings will be informative to all States.  These 
estimates and their confidence intervals were computed using SAS and 
SUDAAN statistical software packages.  (See Appendix D for confidence 
intervals.) 
Onsite State Visits. We conducted on-site visits with 6 of the 14 selected 
States to better understand their IDR processes.  We met with managers 
and staff who provided us with a walk through of their IDR processes.  In 
some instances, we attended actual in-person and telephone conferences, 
which followed the initial desk reviews. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  19  Calendar Year 2002 State Nursing Facilty IDR Requests
According to the 14 selected States, 5,042 standard surveys for nursing
facilities were conducted in CY 2002. Ofthese, the States initially
identified that 934 resulted in an IDR request from the nursing facilties.
From this 934, we drew an initial sample of 437 for review.
Subsequently, the 14 States conducted a second review of 
the 437 and
identified that 22 ofthese, from 8 ofthe 14 States, were incorrectly
reported as resulting in an IDR request, therefore resulting in a usable
sample of 415 cases.
To estimate the reduced population of IDR cases in the 14 selected States
we used the sample proportion of actual IDR cases within the 8 States
where the State incorrectly reported the number of 
cases. Therefore, we
assumed that in each of the eight States, the original population would be
reduced by the same proportion as the sample. This resulted in 893
CY 2002 IDR requests for the 14 selected States as shown in Appendix C.
Nursing Facilty IDR Requests by State for 
CY 2002 Surveys Citing
Deficiencies at Scope and Severity Levels of E or Higher
IDRs Initially
Number of Adjusted Adjusted Percent
States CY 2002 Identified as Number of IDRs of Surveys
Requested
Surveys Requested Resulting in IDR
(unadjusted) Requests
California 656
Florida 557
10%
Indiana 276
19%
Kansas 217
25%
Louisiana 235
11%
Massachusetts 225
15%
Michigan 300
21%
Missouri 342
New York 436 137 125 29%
Ohio 546 192 187 34%
Oklahoma 205
15%
Tennessee 226
15%
Texas 627 153 153 24%
Washington 194
27%
TOTAL 042 934 893 18%
Source: OIG OSCAR extract for CY 2002.
OEI.06.02.00750 INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES   AAA PPP PPP EEE NNN DDD III XXX     ~~~     CDC   
Calculated Weights for Selected States IDR Cases* 
Adjusted Number of 
IDRs Requested for  
States 
CY 2002 Surveys  Sampled IDR Cases  Calculated Weights 
(A)  (B)  (A/B) 
California*  15  15  1.00 
Florida*  55  32  1.72 
Indiana  53  35  1.51 
Kansas*  54  32  1.69 
Louisiana  26  26  1.00 
Massachusetts  33  33  1.00 
Michigan*  64  34  1.88 
Missouri*  12  12  1.00 
New York*  125  32  3.91 
Ohio*  187  34  5.44 
Oklahoma  30  30  1.00 
Tennessee*  34  30  1.13 
Texas  153  35  4.37 
Washington  52  35  1.49 
TOTAL  893  415  2.15 
* The 14 selected States initially identified 934 surveys resulting in IDR requests.  A second review of the requested 
sample of 437 IDRs by these 8 States showed they had incorrectly reported 22 surveys that resulted in an IDR 
request. This lowered the number of surveys, from which the 415 sampled IDR cases were drawn, from 934 to       
893 (weighted). 
Source: OIG analysis of State-provided documentation for requested IDR cases. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  21    A P P E N D I X   ~   D
Point Estimates and Confidence Intervals for IDR Requirements  
Percent Affirmative 
Percent (+/-) 
Response Point 
State Operations Manual-Requirements  Confidence 
Estimate 
Interval 
(weighted)* 
State IDR Notice 
State notifies nursing facilities of IDR availability in the letter from the  100 (n = 367)  N/A 
State transmitting the official Form CMS-2567, Statement of Deficiencies. 
Notice informs facility that the request must: 
a. be in writing,  100 (n = 367)  N/A 
b. be submitted within the same 10-calendar day period as plan of  100 (n = 367)  N/A 
correction, and 
c. include an explanation of the specific deficiencies disputed.  100 (n = 367)  N/A 
Notice informs facility of : 
a. how the IDR may be accomplished;  37 (n = 331)  1.3 
b. the name, address, and telephone number of contact person for  93 (n = 365)  0.5 
requesting the IDR; and 
c. the name and/or position title of the person who will conduct the IDR,  6 (n = 364)  0.7 
if known. 
State agency will notify the nursing facility in writing if the IDR outcome is 
22 (n = 361)  1.4 
not in the facilitys favor. 
Notice includes that the request must not be used to: 
a. delay the formal imposition of remedies,  72 (n = 367)  0.9 
b. challenge the scope and severity of cited deficiencies,  50 (n = 367)  0.9 
c. challenge the imposed remedies for cited deficiencies,  18 (n = 367)  0.7 
d. allege failure of survey team to comply with survey requirements,  36 (n = 367)  0.9 
e. allege inconsistency of survey team citing deficiencies among  36 (n = 367)  0.9 
facilities, and 
f. allege inadequacy or inaccuracy of the IDR process.  18 (n = 367)  0.7 
Nursing Facility IDR Request 
Request was submitted in writing.  99.8 (n = 371)  0.2 
Request was submitted within the same 10-calendar day period as plan of 
86 (n = 343)  3.3 
correction.* 
Request included an explanation of the disputed deficiencies.  86 (n = 349)  1.8 
Request provided correct reasons for requesting the IDR.  91 (n = 284)  2.7 
(Of 9 percent not requesting correctly, attempted to  (100 [n = 33])  (N/A) 
challenge deficiency scope and severity.) 
State Closure Letter 
Closure letter was provided to facility, regardless of IDR outcome.  99.9 (n = 400)  0.1 
1,211 Deficiencies Disputed 
No change in deficiency citation.  52.2 (n = 1,211)  0.04 
Changes in deficiency citation:    25.7 (n = 1,211)  0.03 
a. modification to how deficiency was written,  (74.3) 
b. increase in scope and severity level, and  (1.5) 
c. decrease in scope and severity level.  (24.2) 
Deletion of cited deficiency.  18.9 (n = 1,211)  0.03 
Insufficient information on disputed deficiency IDR outcome.  3.1 (n = 1,211)  .008 
* Weighted responses for affirmative responses are for received documentation and do not include in the calculation 
any missing documentation. 
Source: OIG analysis of State-provided documentation for requested IDR case documentation. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  22    A P P E N D I X   ~   E
Requirements Included in States Written IDR Policies 
Number of 
State Operations Manual-Requirements 
States 
The State will notify the facilities of the availability of an IDR in the letter from the State  28 
transmitting the official Form CMS-2567, Statement of Deficiencies. 
Notification should inform the facility that the request must: 
a. be in writing,  44 
b. be submitted within the same 10-calendar-day period as for submitting an  43 
acceptable plan of correction to the State surveying entity, and 
c. include an explanation of the specific deficiencies being disputed.  41 
Notification should also 
a. inform the facility how the IDR may be accomplished (e.g., by telephone, in writing,  39 
or in a face-to-face meeting); 
b. inform the facility of the name, address, and telephone number of the contact  35 
person for requesting the IDR; and 
c. include the name and/or position title of the person who will conduct the IDR, if  42 
known. 
State survey entity must notify the nursing facility in writing if the facility is unsuccessful  41 
at demonstrating during the IDR that a deficiency should not have been cited. 
The facility request must not be used to: 
- delay the formal imposition of remedies;  34 
- challenge the scope and severity of cited deficiencies, except in those instances  33 
when the cited deficiency constitutes substandard quality of care or immediate 
jeopardy; 
- challenge the remedies imposed by the enforcing agency for cited deficiencies;  31 
- allege failure of the survey team to comply with the survey process requirements;  30 
- allege inconsistency of the survey team citing deficiencies among facilities; and  32 
- allege inadequacy or inaccuracy of the IDR process.  29 
Source: OIG analysis of 48 States written IDR policies describing procedures. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  23    A P P E N D I X   ~   F
Additional Information in Written State IDR Policies  
Number of 
Additional State IDR Practices in Written Policies  States 
(n = 48) 
Indicates conducting desk reviews of submitted documentation concerning disputed 
48 
deficiencies. 
Specifies a maximum amount of time permitted for the in-person or telephone 
13 
conferences. 
Limits attendance at in-person conferences.  12 
Defines the amount of time in which a decision must be made from the date of the 
10 
request. 
Prohibits attorney presence at IDRs.  7 
In-person conferences will be held based on the scope and severity levels of 
7 
deficiencies under dispute. 
Provides conditions for overturning or deleting deficiencies.  6 
Limits IDRs to record reviews with no subsequent conferences.  5 
Telephone conferences will be held based on the scope and severity levels of 
5 
deficiencies under dispute. 
Requires prior approval for attendees to in-person conferences.  3 
No IDR conference will be held for any deficiencies cited at scope and severity levels of 
2 
C or below. 
In-person conferences will be the only means by which an IDR will be held.  2 
Source: OIG analysis of State written IDR processes. 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  24    AA PP PP EE NN DD II XX    ~~    GG  
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  25  AA PP PP EE NN DD II XX ~~ GG

OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  26  AA PP PP EE NN DD II XX ~~ GG

OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  27  A P P E N D I X ~ G

OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  28  
 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 in the Dallas regional 
office, and Kevin Golladay, Assistant Regional Inspector General.  Other 
principal Office of Evaluation and Inspections staff who contributed 
include: 
Leah K. Bostick, Project Leader
Diahann L. Williams, Program Analyst 
Sandy Khoury, Program Specialist 
Technical Assistance:  

Barbara Tedesco, Mathematical Statistician

OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  29  
 E N D   N O T E S
1 42 CFR Part 488, Subpart F, Enforcement of Compliance for Long-Term 
Care Facilities with Deficiencies, and State Operations Manual   
Chapter 7, Survey and Enforcement Process. 
2 The State agency is required to provide written outcome information to 
the nursing facility only when the provider has been unsuccessful in its 
dispute of the deficiency. 
3 Within each States Internet site, we conducted a search for information 
regarding the State IDR processes.  As of February 2004, only 14 of     
50 States have specific IDR process information available to the public: 
Idaho, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, 
Montana, North Carolina, New Jersey, Pennsylvania, Texas, 
Washington, West Virginia, and Wisconsin.  Twenty-seven of fifty 
States have incorporated an IDR process into their written State law or 
regulation.  
4 Thompson Publishing Group,Nursing Home Regulations Manual, 
Tab 900, State Licensing and Enforcement; pp. 41-62, May 2001. 
5 42 CFR  488, Enforcement of Compliance for Long-Term Care 
Facilities with Deficiencies, and State Operations Manual Chapter 7. 
6 The Active Projects Report, 2002 Edition (number 00-175), 
Evaluation of Independent Informal Dispute Resolution Process 
(IDR), and ongoing conversations with CMS Project Officer. 
7 Texas Assisted Living Association, TALA Update, March/April 2002. 
8 American Association of Facilities and Services for the Aging, Health 
Policy Bulletin (Web article), CMS Selects States to Participate in IDR 
Project, September 24, 2001. 
9 As encouraged by State Operations Manual, section 7212 C(9). 
10 We used a chi-square statistic to determine whether the responses to 
the question asking if the State notification letter includes the 
required reasons for not requesting an IDR was significantly related to 
OEI-06-02-00750  INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES  30  the responses to the question asking if the nursing facility 
appropriately (or inappropriately) requested an IDR.  The probability 
of error threshold is less than or equal to 0.05; thus, the distribution is 
significant. 
11 The more restrictive definition of the 10-calendar day period starts 
from the date on the notice letter or from the survey exit conference. 
12 While there is not a one-to-one relationship between the number of   
 IDRs and the number of nursing facility standard surveys in each   
 State, we believe this represents a good approximation of which States  
 may have a high volume of IDRs.  We also believed that nursing  
 facilities with higher levels of scope and severity ratings for their  
 deficiencies may be more apt to request an IDR; 70 percent of the State  
 respondents subsequently concurred. 
13  The following table was developed by CMS to provide clarity regarding  
  severity and scope levels for cited nursing facility surveys. 
Severity and Scope of Nursing Facility Survey Deficiencies 
Deficiency Scope 
Severity Category* 
Isolated  Pattern  Widespread 
Actual or potential for death or serious injury (immediate 
J  K  L 
jeopardy) 
Actual harm that is not immediate jeopardy  G  H  I 
Potential for more than minimal harm  D  E  F 
Potential for minimal harm, substantial compliance exists  A  B  C 
*  A fifth severity category, substandard quality of care, includes deficiencies in the areas of patient behavior 
and facility practices, quality of life, and quality of care.  These fall into the shaded categories above. 
Source:  Centers for Medicare & Medicaid Services, Form HSQ-156-F 
14  Office of Inspector General, Office of Evaluation and Inspections, 
Technical Support Staffs extract of the OSCAR system on 
July 28, 2003, for CY 2002.  Of the initial 14 States, 1 State 
(Pennsylvania) indicated during preinspection that it would be unable 
to participate.  As this was a purposive sample, and in the interest of 
resource limitations, we subsequently replaced that State with the 15th 
State on our list. 
O EI -06-02-007 50  INFO R M AL  DISPUT E RES O L U T IO N FO R NUR SING FAC I LI TI ES  31