Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Nursing Home Survey and Certification: 
Overall Capacity 
JUNE GIBBS BROWN 
Inspector General 
MARCH 1999 
OEI-02-98-00330  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's New York Regional Office prepared this report under the direction of John I. Molnar, 
Regional Inspector General and Renee C. Dunn, Deputy Regional Inspector General.  Principal 
OEI staff included: 
REGION  HEADQUARTERS 
Lucille Cop, RN  Susan Burbach, Program Specialist

Danielle Fletcher

Daniel Ginsberg

Steve Shaw

Patricia Banta, RN intern

To obtain copies of this report, please call the New York Regional Office at (212) 264-2000. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  E X E C U T I V E   S U M M A R Y  
PURPOSE 
To describe the overall capacity of  the State survey and certification program to monitor 
quality of care in nursing homes. 
BACKGROUND 
While many studies indicate that changes in law and regulations may have had a positive 
effect on improving the environment and overall health care of nursing home residents, 
recent reports by the Health Care Financing Administration and the General Accounting 
Office have raised serious concerns about residents care and well-being.  The Senate 
Special Committee on Aging held hearings in the summer of 1998 on these results.  At the 
same time, the Office of Inspector General  undertook additional studies aimed at 
assessing the quality of care in nursing homes. 
The 1987 Nursing Home Reform Act changed these requirements by introducing an 
increased focus on the quality of life and care, the importance of the individual resident, 
and the need to help the resident reach the highest practicable level of functioning. 
Enforcement policies were established that gave the Health Care Financing Administration 
the license to impose a variety of corrective measures when a facility is not in substantial 
compliance with the requirements for participation in the Medicare and/or Medicaid 
program. 
This report examines the capacity of the State nursing home survey and certification 
program to monitor quality of care.  A companion report analyzes trends in the Online 
Survey Certification and Reporting System (OSCAR) data that indicate quality of care 
problems in nursing homes.  Other Office of Inspector General reports address the trend in 
reported abuse in nursing home residents and the role of the ombudsman in protecting 
nursing home residents. 
We selected a purposive sample of ten States: New York, California, Texas, Ohio, Illinois, 
Pennsylvania, Massachusetts, Florida, New Jersey, and Tennessee.  We analyzed OSCAR 
data in these States to identify trends in the amount and nature of deficiencies in nursing 
homes quality of care.  We obtained and reviewed written procedures for State survey and 
certification programs.  To better understand the overall context of these deficiencies, we 
conducted structured interviews with the State directors and surveyors. 
1 
Survey and Certification: Overall Capacity  OEI-02-98-00330  FINDINGS 
Generally Mandatory Surveys Are Performed Timely and Follow the Prescribed 
Process 
All States report implementing the Health Care Financing Administrations guidelines in 
the same way,  including an entrance conference, resident interviews, reviewing medical 
records, and concluding the review with an exit conference to provide the home with 
information about their potentially deficient areas.  Based on OSCAR data over the last 
four standard surveys, all sample States completed 97 percent of standard surveys for all 
nursing homes in the mandated time frame of 9 to 15 months.  All States report having a 
complaint process, although their procedures vary by State. 
However, There Are Significant Weaknesses in the Process 
Although all States report that nursing home standard surveys are unannounced, almost all 
directors and surveyors believe that facilities can roughly predict the survey start date. 
Most State directors and surveyors say they do not begin standard surveys on the 
weekend or evenings, but do continue standard surveys into the evening hours and 
conduct complaint surveys on weekends and evenings. 
The OSCAR data  show 900 nursing homes have been cited with the same deficiencies 
over the past four contiguous surveys, representing 13 percent of all homes in sample 
States.  Nursing homes are given the opportunity to correct their deficiencies without 
penalty with a plan of correction.  State directors and surveyors cite concerns with 
provisions that allow facilities the opportunity to avoid penalties and comply with 
regulations after the citation of deficiencies.  Half of the State Directors and three-fourths 
of surveyors indicate that current enforcement measures are questionable, citing the lack 
of both the effectiveness of the penalties and the timeliness of the enforcement. 
The OSCAR data also show that nursing home abuse complaints receive little to no 
action.  Of the 4,707 substantiated and unsubstantiated abuse complaints reported between 
January 1997 and July 1998, ninety-seven percent of the complaint resolution concludes 
with no action, plans of correction, or other. 
Staff Resources May Be Inadequate in Some Cases 
The overall number of surveyors varies by State, which may affect the intensity and 
thoroughness of their surveys, their ability to conduct follow-up reviews to verify 
correction of deficiencies, and to respond to complaints.  The surveyor teams vary based 
upon facility size, resident characteristics, facility history, and surveyor availability.  Some 
surveyors note the need for more Health Care Financing Administration training which 
2 
Survey and Certification: Overall Capacity  OEI-02-98-00330  would provide a forum for surveyors to discuss issues and policy with other surveyors in 
different States. 
Coordination with Ombudsman Is Not Working Effectively 
Looking specifically at abuse complaints, the survey agency received only 13 percent of 
the total ombudsmen abuse complaints per month in 1997. Some States may have agencies 
other than the survey and certification agency designated to investigate abuse complaints. 
Ombudsman programs generally investigate and work to resolve complaints brought to 
their attention.  However, only 5 percent of all complaints to the State survey and 
certification agency originate from the ombudsmen. 
RECOMMENDATIONS 
The resident-centered long-term care requirements of the nursing home survey are

essential to guarantee the quality of care in nursing homes.  Clearly some major problems

need to be addressed.  Our findings support and elaborate on the Health Care Financing

Administrations (HCFA) initiative to strengthen the enforcement efforts by: 

<  making them more timely and effective,

<  changing the survey schedule to make surveys more unpredictable, 

<  increasing the number of night and weekend surveys,

<  increasing the number of surveys at nursing homes with chronic quality of care

problems, and 
<  focusing on specific problems such as pressure sores, dehydration, and 
malnutrition. 
These initiatives, if carried out completely, appear to be responsive to most of the 
problems in this report as well as our companion report Nursing Home Survey and 
Certification: Deficiency Trends. 
In light of our findings in this report, additional action is needed.  We recommend that 
HCFA: 
<	 evaluate the surveyor staffing in each State to assure that adequate staffing is 
available to complete all standard surveys, follow up surveys, and respond to 
complaints, 
<  provide additional training to State surveyors,

<  provide a forum for State surveyors to meet and discuss common issues, and

<  facilitate better coordination with the Ombudsman program.

3 
Survey and Certification: Overall Capacity  OEI-02-98-00330  AGENCY COMMENTS 
We received comments on the draft report from HCFA, the Assistant Secretary for 
Planning and Evaluation (ASPE), the Administration on Aging (AoA), and informally 
from the Assistant Secretary for Legislation (ASL).  The HCFA and AoA generally concur 
with our recommendations.  The AoA and the ASL provided suggestions for clarifications 
of the text which have been incorporated into the final report. 
The ASPE expressed some concern about the ability of OSCAR data to assess quality of 
care in nursing homes.  We recognize the limitations of OSCAR but used it as only one 
indicator of quality. We are happy to re-emphasize here what we say in our report that 
OSCAR data should not be looked at independently.  In this report we used it in 
combination with the views of nursing home surveyors and State Directors. 
4 
Survey and Certification: Overall Capacity  OEI-02-98-00330  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

FINDINGS

Survey Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14

Weaknesses in the Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Staff Resources  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Coordination with Ombudsman  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  27

APPENDICES

A: Deficiency Tags . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  29

B: Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

5 
Survey and Certification: Overall Capacity  OEI-02-98-00330  I N T R O D U C T I O N  
PURPOSE 
To describe the overall capacity of  the State survey and certification program to monitor 
quality of care in nursing homes. 
BACKGROUND 
While many studies indicate that changes in law and regulations may have had a positive 
effect on improving the environment and overall health care of nursing home residents, 
recent reports by the Health Care Financing Administration (HCFA) and the General 
Accounting Office (GAO) have raised serious concerns about residents care and well-
being.  The Senate Special Committee on Aging held hearings in the summer of 1998 on 
these results.  The Office of Inspector General (OIG) undertook a series of studies aimed 
at assessing the quality of care in nursing homes.  This report examines the capacity of the 
State nursing home survey and certification program to monitor quality of care.  A 
companion report analyzes trends in the Online Survey Certification and Reporting System 
(OSCAR) data that indicate quality of care problems in nursing homes.  Future OIG 
reports will address the trend in reported abuse in nursing home residents, the role of the 
ombudsman, and the availability of nursing home survey results. 
Generally, a nursing home is a residential facility offering daily living assistance to 
individuals who are physically or mentally unable to live independently.  Residents are 
provided rooms, meals, assistance with daily living, and in most cases, some medical 
treatment for those who require it.  Medicare can help pay for skilled nursing facility 
(SNF) care for up to 100 days in a benefit period when a beneficiary meets certain 
conditions.  Medicaid coverage varies among States.  Medicaid eligible beneficiaries who 
require custodial care such as help with eating, bathing, taking medicine and toileting, as 
well as those who require skilled care may have nursing home stay paid for by Medicaid. 
Medicaid payments to nursing homes in 1996 totaled $29.6 billion.  In 1989 Medicare paid 
$2.8 billion to nursing homes, an amount totaling 4.7 percent of the Medicare budget.  In 
1996 this amount had increased to $10.6 billion, totaling 9 percent of the Medicare 
budget. 
In 1986 the Institute of Medicine conducted a study on nursing home regulation. The 
Institute reported prevalent problems regarding the quality of care for nursing home 
residents and the need for stronger Federal regulations.  In 1987 the General Accounting 
Office (GAO) reported that over one third of nursing homes were operating below the 
Federal minimum standards.  These reports, along with widespread concern regarding 
nursing home conditions, persuaded Congress to pass the Omnibus Budget Reconciliation 
6 
Survey and Certification: Overall Capacity  OEI-02-98-00330  Act of 1987 (OBRA 1987).  As a part of OBRA 1987, Congress passed the 
comprehensive Nursing Home Reform Act (PL 100-203).  These actions expanded 
requirements that nursing facilities had to comply with prior to Medicare certification. 
The Nursing Home Reform Act also ceded personal rights to nursing home residents such 
as the right to be free of physical or mental abuse, and the right to be free from chemical 
and physical restraints.  It also altered the principles for enforcement of Federal standards 
of care in nursing homes. 
Medicare Requirements 
The Health Care Financing Administration (HCFA) has the responsibility to act as 
prudent purchaser by ensuring that nursing homes participating in Medicare and/or 
Medicaid meet certain requirements for quality environment and services.  These 
requirements are found at 42 Code of Federal Regulations (CFR) Part 483, Subpart B. 
The OBRA 1987, as amended in 1988, 1989, and 1990, changed these requirements by 
introducing an increased focus on the quality of life and care, the importance of the 
individual resident, and the need to help the resident reach the highest practicable level 
of functioning.  It also included interviewing and assessing residents rather than simply 
reviewing medical records. 
Also, as part of  The Nursing Home Reform Act, HCFA developed the Minimum Data 
Sets (MDS) which required the Secretary to specify a minimum data set of core elements 
and common definitions in conducting the regulatory-required resident assessments and to 
establish guidelines for use of the data set.  The MDS collects data through resident 
assessment measures with subsequent progress or decline documented in electronic 
format.  Nursing homes must conduct standardized, reproducible assessments of each 
residents functional capacity... within 14 days of admission.  Additional assessments 
must be completed within 12 months of the most recent full assessment and following a 
significant change in the residents status.  This information tool, while aimed at improving 
assessment and consequent care planning, can also assist the surveyors in pre-survey 
preparation by highlighting potential areas of concern. 
Enforcement Procedures 
The 1987 Nursing Home Reform Act enforcement provisions were enacted when the 
State Operations Manual (SOM) became effective on July 1, 1995.  The HCFA had 
several process goals during the implementation of the new survey and enforcement 
systems.  The first was to promote consistency through extensive training, the second was 
to link appropriate remedies to deficiencies, and the third was to avoid unnecessary 
procedures.  Congress recognized that one enforcement response would not be 
appropriate for all deficiencies.  Enforcement policies were established that gave HCFA 
the license to impose a variety of corrective measures when a facility is not in substantial 
compliance with the requirements for participation in the Medicare and/or Medicaid 
7 
Survey and Certification: Overall Capacity  OEI-02-98-00330  program.  Some options include temporary management, denial of payment for new 
admissions, civil money penalties, termination of the facility, or State monitoring of the 
facility.  States are responsible for establishing their own remedy guidelines. 
The HCFA imposed a number of administrative changes on enforcement procedures 
following the implementation of the State Operations Manual.  In June of 1995, HCFA 
enacted a temporary moratorium on the collection of certain lower-level money penalties 
(CMPs).  The moratorium preceded HCFAs decision to alter the State Operations 
Manual in December of 1996.  Civil monetary penalties are now limited to situations of 
immediate jeopardy or to nursing facilities that are poor performers or have serious 
deficiencies that are not corrected at the time of a revisit.  Additional changes by HCFA 
redefined the scope of deficiencies, permitted States to avoid revisits in facilities that have 
lower level deficiencies, and established new terms to define facilities that are not in 
substantial compliance. 
Requirements of Surveys 
An important characteristic of nursing homes is their Federal certification status for the 
Medicare and/or Medicaid programs.  While some nursing homes may not meet 
certification requirements, or may elect not to participate in either program, nearly all 
nursing homes had some form of certification in 1996.  The Nursing Home Reform Act 
defines the State survey and certification process for determining nursing home 
compliance with the Federal standards. 
To ensure acceptable compliance, both the State for Medicaid facilities, and HCFA for 
Medicare facilities, are responsible for performing routine facility surveys.  For those 
facilities designated as dually-certified, HCFA has the primary responsibility.  The HCFA 
contracts with States to perform the surveys for Medicare and dually-certified nursing 
homes.  The survey process determines, and the resulting survey documentation records 
(HCFA-2567), the compliance or noncompliance of the facilities.  When a facility fails to 
meet a specific requirement, a deficiency or citation is given to the facility by the 
surveyors.  Surveyors provide the reasons justifying any resulting enforcement action and 
the record on which to defend that action in the appeals process.  Surveyors are instructed 
to use the Principles of Documentation when determining the extent of non-compliance. 
Generally, there are 20 principles that should be considered in the citation of deficiencies 
on the HCFA-2567.  These principals are generic and apply to the documentation of 
survey outcomes regardless of the program (Medicare/Medicaid). 
As a result of the Nursing Home Reform Act, a new survey and certification process was 
implemented in 1995.  All nursing facilities are now subject to an unannounced standard 
survey no later than 15 months after the date of the previous standard survey, and the 
Statewide average interval between standard surveys must be 12 months or less, creating 
a Federal standard survey window between 9 and 15 months.  Each standard survey 
8 
Survey and Certification: Overall Capacity  OEI-02-98-00330  includes a stratified case mix of nursing home residents measuring medical, nursing and 
rehabilitative care, dietary and nutrition services, activities, social participation, sanitation, 
infection control, and the physical environment.  Written plans of care are reviewed to 
determine their adequacy and an audit of residents assessments are conducted to 
determine the accuracy of such assessments.  There is also a review of facility compliance 
of residents rights. 
In addition to the regular survey process there are special and extended surveys. 
Special surveys may be conducted within two months of any change in ownership, 
administration, management, or director of nursing to determine if the change is having an 
effect on the quality of care in the facility.  Extended surveys are performed immediately 
or within two weeks after the standard survey completion on those facilities found to have 
provided substandard quality of care.  The survey team reviews the policies and 
procedures that produced the substandard care, expands the size of the sample of 
residents assessments, reviews staffing, in-service training, and if necessary, contracts 
with consultants. 
The team for all surveys consists of multi-disciplinary professionals, which must include a 
registered professional nurse.  Other professionals who may be on the survey team include 
social workers, therapists, dieticians, pharmacists, administrators, physicians, or others as 
selected by the State.  Each State and the Health and Human Services Secretary must 
implement programs to measure and reduce inconsistency in the application of results 
among surveyors. 
Validation surveys are generally conducted by HCFA on a representative sample of 
facilities in each State and must be conducted within two months of the State survey.  The 
HCFA utilizes the same survey procedure as the State agency.  Recently, some HCFA 
regional offices have chosen to conduct these validation surveys simultaneously with the 
State.  The HCFA must survey at least five percent of the number of facilities surveyed by 
the State each year, but this number must never be less than five surveys a year. 
The State Agency Quality Improvement Program (SAQIP) is a process calling for the 
State Agency and HCFA regional offices to work together to develop the States 
individual quality improvement plans (IQIPs).  The regional office will assist the State by 
providing training, technical assistance, and support as necessary and appropriate.  These 
individual plans are tailored to the specific needs and circumstances of each State, and are 
revised and improved based on changing needs.  The SAQIP is designed to promote 
quality and ongoing improvement in survey and certification activities, and applies to all 
aspects of the survey and certification process. 
Complaint Procedures 
Each State is required to maintain written procedures and adequate staff to investigate 
9 
Survey and Certification: Overall Capacity  OEI-02-98-00330  complaints of violations at nursing homes.  States must review all allegations of resident 
neglect and abuse, and misappropriation of resident property.  All allegations, regardless 
of source, must be reviewed in a timely manner.  If an allegation is found to have 
occurred, the State must notify in writing, the individuals implicated and the administrator 
of the nursing home where the incident transpired.  In addition, each State is required to 
notify the nurse aid registry and licensure boards when an abuse or neglect claim has been 
substantiated. 
Online Survey Certification and Reporting System (OSCAR) 
The HCFAs Online Survey Certification and Reporting System (OSCAR) came online in 
October 1991 as a replacement for the Medicare/Medicaid Automated Certification 
System (MMACS) and the Rapid Data Retrieval System (RADARS).  The HCFA uses 
OSCAR in its survey of Medicare and Medicaid providers to monitor State agency and 
provider performance.  OSCAR contains data for the current and 3 previous surveys. 
Some of the data is overwritten as new information is entered (e.g. number of beds, 
address, and employment information), but deficiency data remains and is tracked 
historically.  The HCFA recently began tracking the scope and severity of deficiencies 
historically as well. 
Part of the OSCAR data is self-reported information by the nursing homes about the 
facility and its patients.  The remaining data is information generated by the surveyors 
based on deficiencies.  The Federal regulations detailing survey requirements are classified 
into 17 major categories.  The specific survey requirements within these categories were 
consolidated from 325 individual items to 185 items effective on July 1, 1995. 
Prior Studies 
A recent study, The Regulation and Enforcement of Federal Nursing Home Standards 
by Charlene Harrington published in March of 1998, details the problems with nursing 
home certification that precipitated the action by Congress in passing the Nursing Home 
Reform Act.  She challenges the declining State deficiency averages by raising the notion 
that the enforcement process may be weakening rather than nursing facilities improving 
quality of care. 
The National State Auditors Association Joint Performance Audit on Long-Term Care, 
completed in May of 1998 by the Louisiana Office of the Legislative Auditor, compiled 
information from ten States regarding survey and certification concerns.  Issues discussed 
include licensing, inspection, sanctions, complaints, and reimbursement.  The audit 
findings conclude that States should vary the timing of inspections, evaluate how 
aggressively they are imposing State sanctions on facilities with deficiencies, and avoid 
delaying the investigation of complaints. 
10 
Survey and Certification: Overall Capacity  OEI-02-98-00330  The Secretary released a report to Congress in July of 1998 indicating that significant 
improvements were made since 1995 in the quality of care delivered by nursing homes. 
These improvements included more appropriate use of physical restraints, anti-psychotic 
drugs, anti-depressants, urinary catheters, and hearing aids.  The report also found a need 
for further improvements by States, nursing homes, and others.  Additional steps will be 
taken to address the problems identified in the report and include tougher enforcement of 
Medicare and/or Medicaid rules.  Efforts will be aimed at preventing instances of bed 
sores, dehydration, and nutrition problems.  The following are new approaches aimed at 
improving quality of care: facilities that have repeat offenses will face sanctions without a 
grace period; inspections will be conducted more frequently for repeat offenders without 
decreasing inspections at other facilities; inspections will be staggered; a set amount of 
inspections will be conducted on weekends; and efforts will be focused on facilities within 
chains that have a record of non-compliance. 
In conjunction with the Secretarys report to Congress, the President announced a new 
nursing home care initiative to provide enhanced protections and to target needed 
improvement in nursing home care.  Proposed actions include checking criminal 
backgrounds of nursing home workers, establishing a national registry of employees 
convicted of abusing patients, targeting nursing home chains with poor records, cutting off 
inspection funds to States with poor records of citing substandard quality of care, 
publishing annual nursing home surveys on the Internet, increasing Federal oversight of 
State inspections, providing additional training to State officials, changing the survey 
schedule to make them more unpredictable,  increasing the number of night and weekend 
surveys, and re-authorizing the Ombudsman program in the Older Americans Act. 
One week after the Presidents initiative, the Government Accounting Office (GAO) 
published a report examining the quality of care in 1,370 California nursing homes that 
were inspected from 1995 to 1998.  They found 30 percent of the homes had violations 
that caused death or life-threatening harm to residents, or had understated the frequency 
of poor care by falsifying medical records.  As a result of this report, the US Senate 
Special Committee on Aging, chaired by Senator Charles Grassley, held hearings in July 
1998 to discuss the findings on the quality of care in nursing homes. 
METHODOLOGY 
This inspection is based on information gathered from four different sources: OSCAR 
data, a review of individual State survey procedures, interviews with State survey and 
certification directors, and State survey and certification surveyors.  We looked for 
consistencies between the data and the observations of the insiders we interviewed.  We 
selected a purposive sample of ten States: New York, California, Texas, Ohio, Illinois, 
Pennsylvania, Massachusetts, Florida, New Jersey, and Tennessee.  These States have 
comprehensive survey and certification programs and represent 55.8 percent of the 
11 
Survey and Certification: Overall Capacity  OEI-02-98-00330  nations total skilled nursing beds.  In addition, they represent 56 percent ($23 billion) of 
Medicaid institutional long-term care expenditures in 1996.  The purposive sample 
represents States of various sizes in different parts of the country. 
OSCAR Data 
The Online Survey Certification and Reporting System (OSCAR) is the system HCFA 
uses in its survey of Medicare and Medicaid providers to monitor State agency and 
provider performance.  OSCAR contains data for the current and 3 previous standard 
surveys.  The second part of OSCAR is information generated by the surveyors based on 
deficiencies.  The Federal regulations detailing survey requirements are classified into 17 
major categories.  We analyzed three of these categories which could determine poor 
quality of care depending on their scope and severity.  Resident behavior and facility 
practices includes the areas of restraints, abuse and staff treatment of residents; quality if 
life includes the residents ability to make decisions about his or her daily activities and the 
nursing homes accommodation of those needs; and quality of care includes the technical 
ability of the nursing home to prevent and treat the medical conditions of the residents. 
We looked at those substandard quality of care deficiencies repeated over the last four 
standard surveys.  We also looked at OSCAR complaint data specifically at complaints of 
abuse.  We compared complaints of abuse filed from January 1997 to July 1998 to abuse 
deficiencies in the most current survey.  The direct relationship between abuse codes in the 
deficiency and complaint tables allowed us to look closely at the scope of abuse and 
examine enforcement patterns and outcomes. 
Since information in the OSCAR database is constantly being updated, we downloaded 
OSCAR data on August 4, 1998.  In all cases we compared our 10 sample States to 
aggregate national data both for deficiencies and complaints. 
Procedures Review 
We requested each State survey and certification director to send us any written 
procedures, as well as any other relevant documentation, to obtain an overall 
understanding of the survey and certification process.  We reviewed procedures and other 
State specific documentation from the eight State survey and certification agencies that 
submitted information.  We examined this information for any additional State procedures 
that were not included in the Federal survey and certification guidelines. 
Interviews 
We also conducted a total of thirty structured interviews; three interviews in each of the 
ten sample States, one with the State survey and certification director or a designee, and 
two with State surveyors within each State.  The two State surveyors were selected 
12 
Survey and Certification: Overall Capacity  OEI-02-98-00330  randomly from a list of at least ten surveyors submitted by the State director.  During 
these interviews, we obtained information about the State survey and certification program 
structure, the processes utilized to monitor quality of care, how deficiencies are addressed, 
and the satisfaction of State survey and certification directors and surveyors with the 
process. 
We selected both directors and surveyors for their different perspectives on the survey and 
certification process.  We compared the information provided by the directors to 
information provided by surveyors.  In our analysis we paid special attention to consensus 
within and among the groups. 
This inspection was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and Efficiency. 
F I N D I N G S  
13 
Survey and Certification: Overall Capacity  OEI-02-98-00330  Generally mandatory surveys are performed timely and 
follow the prescribed process 
Timely surveys 
Based on OSCAR data over the last four standard surveys, all sample States completed 97 
percent of standard surveys for all nursing homes in the mandated time frame of 9 to 15 
months.  An average of 3 percent of standard surveys were conducted below 9 months, 
while an average of 2 percent were conducted above 15 months. 
Survey protocol 
All State survey and certification directors and surveyors report using HCFA guidelines 
that outline the protocol for the implementation of nursing home surveys.  The HCFA 
survey protocol provides instructions, check lists, and other tools for use both in 
preparation for the survey and when surveyors are on-site performing the survey.  Survey 
protocols are to be used by all surveyors to measure compliance with Federal 
requirements.  The following description of the survey process is based upon a consensus 
of  State directors and surveyors responses. 
Entrance conference 
During the entrance conference, the team leader meets with nursing home administration, 
introduces the survey team, discusses the purpose of the visit, and requests all necessary 
paperwork.  The survey team tours the facility and makes observations about the quality 
of resident care and the nursing homes overall condition.  During this initial tour, 
surveyors talk to residents and start to select residents for the interview and medical 
record review portion of the survey.  The initial tour also helps surveyors to determine 
whether their pre-survey concerns found while examining data from prior surveys, 
complaints, and long-term care Ombudsman discussions continue to be concerns. 
Interviews 
Many surveyors believe that an accurate picture cannot be formalized until they tour a 
nursing home and meet the residents.  The HCFA guidelines require surveyors to select a 
case-mix stratified sample of facility residents in order to assess compliance with the 
resident-centered long term care requirements based on findings from previous surveys, 
Ombudsman information, and surveyor observations.  Thus, residents are selected and 
interviewed based upon many different factors.  Many surveyors feel the shift from former 
paperwork surveys, where there was little contact with residents or nursing home staff, 
to current resident and outcome oriented surveys, as a result of the Nursing Home Reform 
14 
Survey and Certification: Overall Capacity  OEI-02-98-00330  Act in 1995, has improved the survey process. 
In order to gain a comprehensive understanding of the facility, surveyors report they will 
also interview anyone on the nursing home staff who can discuss the treatment and the 
activities of the residents and answer their quality of care concerns.  In addition to staff, 
family members also provide beneficial information to the surveyors. 
Exit conference 
All standard surveys close with the exit conference where surveyors present their findings 
to the nursing home.  State survey and certification directors and surveyors report that 
deficient areas are noted although the scope and severity of the deficiency may or may not 
be discussed at the exit conference.  The nursing home can provide additional information 
to refute potentially deficient areas.  At the conclusion of the meeting, the survey team 
fields questions about the standard survey process or their findings.  All surveyors list the 
survey team, the nursing home administrator, the Ombudsman, and the resident council, as 
groups who usually attend the exit conference. 
Final survey report 
All State survey and certification directors and surveyors remark that the final survey 
report is a collaborative effort. It is a  result of the survey team convening to discuss the 
deficiency list and agreeing on scope and severity designations.  The survey report may 
then be reviewed by State regional supervisors or a centrally located enforcement 
committee in the State.  Deficiencies may be added, deleted, or substantially changed at 
any time during the review process.  Almost all State survey and certification directors and 
surveyors say that deficiencies noted by surveyors are seldom removed from the final data, 
although they may be changed after discussion.  The most frequently cited reason for any 
deficiency change or removal is a failure to meet the principles of documentation, a 
requirement so that the deficiency can be supported on appeal or during enforcement 
proceedings. 
Nursing home response 
If deficiencies have been cited, most State survey and certification directors and surveyors 
say nursing homes must complete a plan of correction within 10 days of receiving the 
survey report.  The plan of correction addresses, in four distinct parts, how each 
deficiency will be rectified and how soon the corrections will take effect.  Almost all 
directors and surveyors indicate there is a mandated time frame to correct deficiencies. 
This time frame varies, depending on the severity of each deficiency.  Within two days of 
receiving notice of an immediate jeopardy deficiency, the nursing home must correct the 
problem or penalties will take effect.  Deficiencies with no immediate jeopardy may have a 
15 day correction window before penalties take effect. 
15 
Survey and Certification: Overall Capacity  OEI-02-98-00330  It is incumbent upon the State to verify that the facility corrects any deficiencies.  States 
vary on the scope and severity of deficiencies that require surveyor revisits.  Only one 
State revisits nursing homes for all deficiencies, but all States revisit in person, as required, 
for deficiencies that meet certain scope and severity requirements.  For those deficiencies 
that do not require a revisit, a letter or phone call to the State agency suffice as proof of 
correction. 
Additional State requirements 
While all States report using HCFA guidelines from the State Operations Manual, seven 
Directors report that they have State specific criteria in addition to HCFA guidelines. In 
practice, the more stringent of the two are implemented.  Our review of the State specific 
requirements submitted by the State Directors found they include, but are not limited to, 
State licensure requirements for nursing homes.  For example, one State specifies nursing 
staff  resident ratios at various shifts throughout the day and night and this is measured 
during the survey.  Another State requires measuring water temperature to prevent patient 
burns. 
Some States have additional databases and information sources.  For example, one State 
has a web site for nursing home consumers that numerically rates nursing homes.  The site 
includes the survey date, administration, nursing, resident rights, food service, and 
environment, totaling all categories for an overall score.  Another State developed a 
specific database that logs information such as inspection information, license status at 
notice of violation, license status after hearings, and quality assurance licensure logs.  This 
database is useful because it is tailored to the individual States needs and the information 
is not compiled in OSCAR. 
Complaints procedures 
All States are required to establish procedures and maintain adequate staff to investigate 
complaints of nursing home violations.  All State survey and certification directors and 
surveyors report the existence of a complaint process to address the complaints received 
concerning nursing home practices.  All States log incoming phone calls which are then 
directed to the appropriate region or staff to follow up on the complaint.  In some States 
separate complaint departments handle all surveys.  Complaints are ranked according to 
severity of the allegation.  In all cases of immediate jeopardy, an investigation must be 
initiated promptly.  States vary in their response to the remainder of the calls.  The balance 
of the complaints are handled anywhere from seven to 45 days.  Some complaints are 
rolled into the next scheduled survey if the complaint does not warrant an abbreviated 
survey and/or the surveyors are approaching the next scheduled survey. 
According to OSCAR data almost half (44 percent) of the national complaints reported to 
the survey agency from January 1997 to July 1998 are from residents or families of 
16 
Survey and Certification: Overall Capacity  OEI-02-98-00330  residents.  A quarter are from employees or ex-employees of nursing homes, 15 percent 
are anonymous and 11 percent are some other non-specified source.  Only 5 percent of 
complaints come from Ombudsmen.  Figure I below displays the sources of nursing home 
complaints nationwide. 
Figure I 
Sources of Complaints Nationwide 
However,  there are 
significant  weaknesses in 
the process 
Predictability 
Although all States report that nursing home standard surveys are unannounced, almost all 
directors and surveyors believe that facilities can roughly predict the survey start date. 
The OSCAR data for three consecutive surveys indicates that 11 percent of nursing homes 
are surveyed within a two week time period of the previous survey.  Since nursing home 
administrators know the Federal standard survey window is between 9 and 15 months, and 
also realize that the outcome of their latest standard survey will dictate the following 
years start date, those facilities with quality of care issues know their survey will fall 
closer to the 9 month end of the survey spectrum, and those with fewer deficiencies closer 
to the 15 month end of the survey spectrum.  One State director declared adhering to the 
Federal 12 month average requirement makes it extremely difficult to be totally 
unpredictable. 
A few States note that facilities have been alerted about approaching surveys by friends 
17 
Survey and Certification: Overall Capacity  OEI-02-98-00330  operating local hotel accommodations.  Some surveyors mention that conference rooms at 
nursing homes are sometimes prepared in anticipation of the survey teams arrival.  Most 
often, facilities will simply compare the survey start dates from previous years in order to 
estimate when the upcoming survey will occur. 
States report nursing homes anticipate their annual standard survey and often modify their 
normal daily procedures to reduce potential deficiencies.  In one example, facilities 
increase the number of staff on certain shifts.  To alleviate this practice, directors and 
surveyors suggest more randomness in the survey schedule.  One director says that 
surveys are started for all nursing homes in chain organizations on the same day to prevent 
staff shifts among nursing homes in the chain.  Directors and surveyors voice concerns 
about whether or not standard surveys represent an accurate reflection of quality of care in 
nursing home.  One surveyor notes, annual standard surveys are only a snapshot in time. 
We are not seeing the true picture of these facilities throughout the year. 
Most States say they do not begin or continue standard surveys on the weekend.  One 
director notes that their union rules prohibit standard surveys on weekend hours. 
However one State has a requirement that 20 percent of surveys in each region be on the 
weekend or off hours.  In addition, many States report not starting standard surveys in the 
evening hours, but almost all States cite a policy of continuing standard surveys into the 
evening hours. The policy of continuing surveys into evening hours seems to mainly be a 
function of the surveyors extended work day schedules. 
Questions often arise about the quality of care in nursing facilities during the weekend and 
evening hours.  One director addressed this concern and replied, we need to change the 
Health Care Financing Administration guidelines to require more night and weekend 
visits.  State survey and certification directors and surveyors did indicate that they 
conduct complaint surveys during weekend or evening hours, particularly if the complaint 
originated during these hours.  Depending on the scope and severity of the complaint 
received, surveyors may initiate complaint surveys at any time of the day or week. 
Abuse complaints 
From January 1997 to July 1998, 4,707 abuse complaints were reported by friends, family 
members of residents, or nursing home staff in the ten sample States.  As defined by the 
Federal guidelines, abuse complaints and deficiencies violate "the residents right to be free 
from verbal, sexual, physical and mental abuse, corporal punishment, and voluntary 
seclusion."  These complaints involved almost one third or 2,306 nursing homes in all ten 
States.  In some situations, multiple complaints were filed against the same nursing home. 
These 4,707 complaints are divided between substantiated and unsubstantiated complaints. 
In order to substantiate a complaint a surveyor must establish that the action occurred. 
Abuse is often difficult to cite due to constraints placed on the surveyor.  Abuse must be 
"observed" by the surveyors rather than recounted by the resident or family member. 
18 
Survey and Certification: Overall Capacity  OEI-02-98-00330  Because of this limitation, many abuse complaints go without action taken against the
nursing home.  Unsubstantiated complaints do not indicate that the complaints are
illegitimate but rather that the surveyor could not authenticate the actions.  Of the 4,707
abuse complaints in the sample States, 1,524 (32 percent) are substantiated while 3,183
(68 percent) are unsubstantiated.
There are 18 possible action codes that complaints could receive.  Possible action
categories include: termination, plans of correction, denial of payment for new admissions,
fines, civil monetary penalties, license revocation, provisional licenses, receivership,
special monitoring, injunction, suspension of Medicare payments, no action, or "other". 
Despite the differences between substantiated and unsubstantiated complaints, the number
of complaints in both categories that conclude with no action, plans of correction, or
"other" remain comparable.  Unsubstantiated abuse complaints that conclude with no
action plans of correction, or "other" totals 99 percent of the total complaints. 
Notwithstanding that substantiated complaints are confirmed by surveyors, 92 percent of
them conclude with no action, plans of correction, or "other".  See Figures II and III
below.
      Figure II                       Figure III
Complaint Outcomes
When looking at all abuse complaints, two percent were reported after the standard survey
cited the nursing home with an abuse deficiency.  Despite the documented history of abuse
in a particular nursing home, the outcome of the complaint investigation is confined to the
three courses of action mentioned previously.  No action was taken in 71 percent of the
19
Survey and Certification: Overall Capacity OEI-02-98-00330 complaints, 14 percent were resolved with a plan of correction without sanction, and 12 
percent fell into the other category. 
Enforcement 
The OSCAR data shows 900 nursing homes have been cited with the same deficiencies 
over the past four contiguous surveys, representing 13 percent of all homes in the sample 
States.  The number of nursing homes with repeat deficiencies ranges from 5 in New York 
to 453 in California.  Table I shows the number of nursing homes in sample States with 
repeat deficiencies.  There are a total of 1,359 repeat deficiencies cited among sixty-three 
different deficiency types. When we looked at the top 10 repeat deficiencies, we found 
that five are in the substandard quality of care categories.  See table II below for the 
number of sample State nursing homes affected by the top 10 repeat deficiencies. 
Table I 
The Number of Nursing Homes in Sample States 
with Repeat Deficiencies over Four Surveys 
State  Number of Nursing  Percent of Nursing Homes  Number of Repeat 
Homes with Repeat Deficiencies  with Repeat Deficiencies  Deficiencies 
CA  453  35%  769 
FL  57  08%  74 
IL  134  21%  185 
MA  10  02%  21 
NJ  12  04%  13 
NY  5  01%  6 
OH  76  09%  94 
PA  29  04%  31 
TN  13  05%  17 
TX  111  10%  149 
Source: OSCAR Data 
20 
Survey and Certification: Overall Capacity  OEI-02-98-00330  These nursing homes are given the opportunity to correct their deficiencies without penalty with a 
plan of correction.  The nursing home submits an action plan to the State agency that addresses 
how each deficiency will be corrected and how soon the correction will take place.  The State 
agency either re-visits the facility to confirm the correction or phones or writes to the facility for 
proof of correction. 
Table II 
Top 10 Repeat Deficiencies 
Deficiency  Facilities in  Facilities 
Sample States  Nationwide 
Facility must store, prepare, distribute,  162  254 
and serve food under sanitary conditions 
Facility must develop comprehensive  156  221 
care plans for each resident 
Facility promotes care that maintains or  142  174 
enhances dignity 
Rooms measure 80 square feet  100  205 
Facility must make a comprehensive  95  187 
assessment of a residents needs 
Facility must provide necessary  91  151 
housekeeping and maintenance services 
Clinical records meet professional  84  100 
standards 
Facility should have policies that  68  80 
accommodate need and preferences 
Facility is free of accident hazards  64  99 
Drug regimen free of unnecessary drugs  33  58 
Source: OSCAR Data 
This data about repeat deficiencies supports the opinions of half of the State directors and 
three-fourths of surveyors indicating that current enforcement measures are questionable. 
21 
Survey and Certification: Overall Capacity  OEI-02-98-00330  State survey and certification directors and surveyors express concern that civil monetary 
penalties, as currently administered, do not compel facilities to observe Federal regulations 
and are insufficient to influence big facilities or nursing home conglomerates. 
Additionally, civil monetary penalties are not imposed immediately, allowing facilities to 
remain non-compliant for longer periods of time. 
State survey and certification directors and surveyors also cite concerns with provisions 
that allow facilities the opportunity to avoid penalties and comply with regulations after 
the citation of deficiencies.  One State director notes these provisions are contrary to 
perpetual adherence to regulations.  Another director expresses the need to break the 
cycle on non-compliant facilities and is concerned that nursing homes are not held 
accountable until there is actual harm to the resident.  Most State survey and certification 
directors and surveyors agree that civil monetary penalties could be effective, but are 
presently not enforced on a timely basis. 
A few surveyors suggest that previous enforcement efforts were more successful.  One 
surveyor states that the enforcement system functioned more effectively when facilities did 
not have as many opportunities to correct deficiencies.  Another surveyor adds that 
withholding payments to a deficient facility, referred to as vender hold enforcement, was 
much more effective because facilities would correct their deficiencies almost immediately. 
Some surveyors believe the current enforcement process allows deficient facilities far too 
many chances without sufficient enforcement. 
Two different opinions were expressed concerning the compliance function of the State 
survey and certification office: collaborative and punitive.  Those who advocate a 
collaborative relationship seek to maintain the highest possible quality of life and care at 
nursing facilities by working with the facility.  One State director remarks that nursing 
facilities are not negligent but simply do not know how to stay out of trouble.  Another 
surveyor adds that the purpose of the survey is not to be punitive.  The object of the 
survey should not be to close a facility, but to help it strive for compliance.  Proponents 
of this opinion believe that surveyors need to better educate facility personnel, and 
constant communication is more effective than harsh penalties forcing nursing home 
closures. 
Other surveyors and State directors believe that policing efforts are most beneficial to 
nursing home residents.  Some State survey and certification directors and surveyors 
maintain that leniency from the State leads to repeat deficiencies in nursing homes.  One 
surveyor says enforcement is the number one means to an end.  Another respondent 
feels surveyors are the true resident advocates, and no one is in a better position to really 
improve the lives of residents.  Many States suggest greater vigilance of nursing home 
conglomerates who are able to move across State lines and reestablish themselves without 
a prior record of impropriety from other States.  Nursing home lawyers utilize legal 
loopholes to place financial interests above resident well being.  One surveyor notes that 
22 
Survey and Certification: Overall Capacity  OEI-02-98-00330  valid deficiencies go by the wayside based on a legal technicality. 
OSCAR data 
Most surveyors and more than half of directors are satisfied with OSCAR data but 
propose changes.  During the pre-survey phase of a standard survey, OSCAR data from 
the previous survey are reviewed and specific quality of care issues are frequently 
targeted.  At the start of the nursing home tour, surveyors may find a very different 
situation from the previous survey.  The quality of care at the nursing home may have 
drastically changed for the better or worse.  Therefore, surveyors suggest using OSCAR 
data in conjunction with other tools to obtain an accurate view of quality of care. 
OSCAR is only one part of the quality of care story, one surveyor said.  A director 
notes that OSCAR is a useful instrument to help focus a survey team during the pre-
survey, but doesnt indicate quality of care when analyzed alone.  State survey and 
certification directors and surveyors are also concerned that OSCAR data is not user 
friendly, accurate, streamlined, accessible, or timely.  Another director said, OSCAR 
generated reports are cumbersome and time consuming.  The consensus of the State 
survey and certification directors and surveyors is that OSCAR is difficult to use. 
Staff resources may be inadequate in some cases 
Surveyor staffing 
The overall number of surveyors varies by States, thereby affecting the number of standard 
surveys each survey team is capable of conducting each year.  The average number of 
standard surveys per team is 19 a year based on four person survey teams.  However, the 
range of standard surveys among the 10 sample States falls between 12 and 26 nursing 
homes a year.  We are not in a position to judge the adequacy of surveyor staffing nor 
discern what is the ideal number of surveys per survey team. 
Although States complete their mandatory standard surveys, surveyors are also 
responsible to survey nursing homes where complaints were generated or when follow-up 
visits are required for nursing homes with deficiencies.  Surveyor constraints may be a 
cause for concern for two reasons.  First, States with a high survey per team ratio may be 
adversely affecting quality of care in nursing homes because of time constraints.  Second, 
revisiting deficient nursing homes to ensure compliance or follow-up on complaints could 
also be adversely affecting quality of care because there may not be enough surveyors to 
handle the work load.  Some States have surveyors dedicated solely to long term care 
while other States divide the surveyors responsibilities among all surveyed facilities.  We 
allowed for this fact in these numbers.  See Table III below for a list of surveyor staff 
dedicated to nursing home surveys  in sample States. 
23 
Survey and Certification: Overall Capacity  OEI-02-98-00330  Table III 
Surveyor Staffing in 10 States 
State  # of  # of  # of  # of Nursing  # of  Surveys  # of Residents 
Surveyors  Nursing  Residents  Homes to  per 4 Surveyor  to Surveyors 
Homes  Surveyors  Team 
CA  228  1309  100,391  5.74  22.96  440.3 
FL  128  732  68,969  5.72  22.88  538.8 
IL  216  650  66,187  3.01  12.04  306.4 
MA  80  524  50,542  6.55  26.20  631.8 
NJ  73  327  44,472  4.48  17.92  609.2 
NY  139  658  112,472  4.73  18.93  809.2 
OH  192  862  75,613  4.49  17.96  393.8 
PA  123  776  85,382  6.31  25.23  694.2 
TN  51  278  28,630  5.45  21.80  561.4 
TX  328  1077  72,996  3.28  13.13  222.5 
Source: OSCAR Data 
Surveyor teams 
All State survey and certification directors and surveyors have multi-disciplinary teams 
with at least one registered nurse, as required by HCFA.  Social workers, nutritionists, 
sanitarians, pharmacists, consultants, and health care generalists often complete the survey 
team composition.  One State is moving toward teams comprised solely of registered 
nurses with other professionals available as consultants.  Nine States report the survey 
team composition fluctuates based upon the characteristics at particular nursing homes. 
Surveyors listed the facility size, resident characteristics, facility history, and surveyor 
availability, as factors that determine survey team composition. 
Many surveyors note the dedication and competency of the surveyor staff as a strength in 
the survey process.  Surveyors believe the varied experience and background of staff is 
important for successful teams.  One surveyor describes the staff as unbiased people who 
are dedicated to change, while other surveyors emphasize excellent supervisors who 
respect and listen to surveyors. 
24 
Survey and Certification: Overall Capacity  OEI-02-98-00330  However, three State directors report high turnover rates for surveyors, and half of the 
directors acknowledge difficulties replacing staff once they leave.  Reasons for this 
difficulty include poor salary scales for surveyors, geographic constraints, and extensive 
training periods.  State directors mention a variety of specialties are difficult to replace 
such as nurses, pharmacists, and social workers. 
Surveyor training 
All State surveyors complete Federal training in HCFA headquarters in order to pass the 
required Standard Minimum Qualifications Test (SMQT).  While new surveyor training is 
consistent across sample States, on-going training ranges from no training up to 100 hours 
a year.  Most on-going training consists of in-service staff meetings facilitated internally or 
by outside consultants.  Many surveyors note a lack of time to schedule on-going training, 
while others cite a decrease in HCFA facilitated training as problems.  Some surveyors 
note the need for more HCFA training which would provide a forum for surveyors to 
discuss issues and policy with other surveyors in different States. 
Coordination with Ombudsman is not working effectively 
We examined abuse complaints in the National Ombudsman Reporting System (NORS), 
the data collected by each State Ombudsman Program.  NORS data shows 243 abuse 
complaints a month in sample States, while OSCAR data shows only 31 abuse complaints 
a month referred by the Ombudsmen to the State survey and certification agency.  This is 
13 percent of the total Ombudsmen abuse complaints per month.  Some States may have 
agencies other than the survey and certification agency designated to investigate abuse 
complaints.  Ombudsman programs generally investigate and work to resolve complaints 
brought to their attention.  Compared to other sources, the Ombudsmen have referred 
only 5 percent of the abuse complaints to the survey programs in sample States.  The 
number in each of the States varies as shown in Table IV below. 
25 
Survey and Certification: Overall Capacity  OEI-02-98-00330  Table IV 
Ombudsmen Abuse Complaints by Sample State 
State  Ombudsmen Abuse  % Of Ombudsmen Abuse  Total Abuse 
Complaints  Complaints To States Total  Complaints 
Abuse Complaints 
CA  169  18%  961 
FL  0  0%  124 
IL  9  2%  476 
MA  8  3%  314 
NJ  1  3%  38 
NY  5  2%  286 
OH  37  13%  277 
PA  15  10%  144 
TN  15  5%  282 
TX  65  2%  3299 
Total  324  5%  6201 
Source: OSCAR Data 
Although State survey and certification directors and surveyors report that State 
Ombudsmen provide useful information to the surveyor and all surveyors and State 
directors indicate that Ombudsmen are contacted either before entering, or immediately 
upon entering, the facility, surveyors report that Ombudsmen are not always available at 
the time of the survey.  One surveyor said, they are always invited and if available, they 
come.  Another surveyor said, I havent seen an Ombudsman in years.  Surveyors 
report that Ombudsman also provide information regarding the facility and about specific 
residents and this information is utilized during the pre-survey process to help select 
residents for the interview and medical records to review. 
26 
Survey and Certification: Overall Capacity  OEI-02-98-00330  R E C O M M E N D A T I O N S  
The resident-centered long-term care requirements of the nursing home survey are

essential to guarantee the quality of care in nursing homes.  Clearly some major problems

need to be addressed.  Our findings support and elaborate on the Health Care Financing

Administrations (HCFA) initiative to strengthen the enforcement efforts by: 

<  making them more timely and effective,

<  changing the survey schedule to make surveys more unpredictable, 

<  increasing the number of night and weekend surveys,

<  increasing the number of surveys at nursing homes with chronic quality of care

problems, and 
<  focusing on specific problems such as pressure sores, dehydration, and 
malnutrition. 
These initiatives, if carried out completely, appear to be responsive to most of the 
problems in this report as well as our companion report Nursing Home Survey and 
Certification: Deficiency Trends. 
In light of our findings in this report, additional action is needed.  We recommend that 
HCFA: 
<  evaluate the surveyor staffing in each State to assure that adequate staffing is 
available to complete all standard surveys, follow up surveys, and respond to 
complaints, 
<  provide additional training to State surveyors, 
<  provide a forum for State surveyors to meet and discuss common issues, and 
<  facilitate better coordination with the Ombudsman program. 
AGENCY COMMENTS 
We received comments on the draft report from HCFA, the Assistant Secretary for 
Planning and Evaluation (ASPE), the Administration on Aging (AoA), and informally 
from the Assistant Secretary for Legislation (ASL).  The HCFA and AoA generally concur 
with our recommendations.  The AoA and the ASL provided suggestions for clarifications 
of the text which have been incorporated into the final report. 
The ASPE expressed some concern about the ability of OSCAR data to assess quality of 
care in nursing homes.  We recognize the limitations of OSCAR but used it as only one 
indicator of quality. We are happy to re-emphasize here what we say in our report that 
Survey and Certification: Overall Capacity  OEI-02-98-00330 
27  OSCAR data should not be looked at independently.  In this report we used it in 
combination with the views of nursing home surveyors and State Directors. 
Survey and Certification: Overall Capacity  OEI-02-98-00330 
28
 APPENDIX A 
Definitions of Substandard Quality of Care Deficiencies 
Resident Behavior and Facility Practices Category 
Deficiency - (Ftag)  Definition 
F0221	 Resident has the right to be free from any physical restraint for 
purposes of discipline or convenience. 
F0222	 Resident has the right to be free from any chemical restraint for 
purposes of discipline or convenience. 
F0223	 Resident has the right to be free from verbal, sexual, physical and 
mental abuse, corporal punishment, and involuntary seclusion. 
F0224	 Facility must have written policies and procedures that prohibit 
abuse and neglect. 
F0225	 Facility may not employ persons who have been found guilty of 
abuse. 
Quality of Life Category 
Deficiency - (Ftag)  Definition 
F0240  Facility must promote/enhances quality of life. 
F0241  Facility must promote care that maintains or enhances dignity. 
F0242	 Resident has the right to choose activities, schedules, interact with 
members of community, and make choices about aspects of life in 
the facility. 
F0243	 Resident has the right to organize and participate in resident 
groups. 
F0244  Facility must listen and respond to resident or family group. 
Survey and Certification: Overall Capacity  OEI-02-98-00330 
29  F0245	 Resident has the right to participate in social, religious, and 
community activities. 
F0246	 Facility should have policies that accommodate residents needs and 
preferences. 
F0247	 Resident to receive notice before room or roommate in the facility 
is changed. 
F0248  Facility is to provide ongoing program of activities that fit resident. 
F0249  Facilities director must be fully qualified. 
F0250  Facility must provide medically related social services. 
F0251	 Facility with more than 120 beds must employ a qualified social 
worker on a full time basis. 
F0252	 Facility must provide a safe, clean, comfortable, and homelike 
environment. 
F0253	 Facility must provide housekeeping and maintenance services 
necessary to maintain a sanitary, orderly and comfortable interior. 
F0254	 Facility must provide clean bed and bath linens that are in good 
condition. 
F0255  Facility must provide private closet space in each residents room. 
F0256	 Facility must provide adequate and comfortable lighting levels in all 
areas. 
F0257  Facility must provide comfortable and safe temperature levels. 
F0258  Facility must provide comfortable sound levels. 
Quality of Care Category 
Deficiency - (Ftag)  Definition 
F0309  Facility to provide necessary care for the highest practicable 
physical, mental, and psychosocial well being. 
Survey and Certification: Overall Capacity  OEI-02-98-00330 
30  F0310  Activities of daily living do not decline unless unavoidable. 
F0311  Resident is given treatment to improve abilities. 
F0312  Activities of daily living care is provided for dependent residents. 
F0313  Resident receive treatment to maintain hearing and vision. 
F0314  Proper treatment to prevent or treat pressure sores. 
F0315  Resident is not catheterized unless unavoidable. 
F0316  Appropriate treatment for incontinent resident. 
F0317  No reduction of range of motion unless unavoidable. 
F0318	 Resident with limited range of motion receives appropriate 
treatment. 
F0319  Appropriate treatment for mental or psychosocial problems. 
F0320  No development of mental problems unless unavoidable. 
F0321  No naso-gastric tube unless unavoidable. 
F0322  Proper care and services for resident with naso-gastric tube. 
F0323  Facility is free of accident hazards. 
F0324	 Resident receives adequate supervision and assistance devices to 
prevent accidents. 
F0325	 Facility must maintain acceptable parameters of nutritional status 
unless unavoidable. 
F0326  Resident receives therapeutic diet when required. 
F0327	 Facility must provide sufficient fluid intake to maintain proper 
hydration and health. 
F0328  Facility must ensure that proper treatment and care is provided. 
F0329  Each residents drug regimen must be free from unnecessary drugs. 
Survey and Certification: Overall Capacity  OEI-02-98-00330 
31  F0330  No use of antipsychotic drugs except when necessary. 
F0331	 Residents who use antipsychotic drugs receive gradual dose 
reductions. 
F0332	 Facility must ensure that it is free of medication error rates of five 
percent or greater. 
F0333  Residents are free of any significant medication errors. 
Survey and Certification: Overall Capacity  OEI-02-98-00330 
32  APPENDIX B 
Comments on the Draft Report

In this appendix, we present in full the comments form the Health Care Financing 
Administration, the Administration on Aging, and the Assistant Secretary for Planning and 
Evaluation. 
Survey and Certification: Overall Capacity  OEI-02-98-00330 
33  Survey and Certification: Overall Capacity  OEI-02-98-00330 
34  Survey and Certification: Overall Capacity  OEI-02-98-00330 
35  Survey and Certification: Overall Capacity  OEI-02-98-00330 
36  Survey and Certification: Overall Capacity  OEI-02-98-00330 
37  Survey and Certification: Overall Capacity  OEI-02-98-00330 
38  Survey and Certification: Overall Capacity  OEI-02-98-00330 
39  Survey and Certification: Overall Capacity  OEI-02-98-00330 
40  Survey and Certification: Overall Capacity  OEI-02-98-00330 
41