Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Quality of Care in Nursing Homes: 
An Overview 
JUNE GIBBS BROWN 
Inspector General 
MARCH 1999 
OEI-02-99-00060  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 
Demetra Arapakos  Susan Burbach 
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 general conditions in nursing homes and assess the overall capacity of systems 
designed to monitor and improve quality of care. 
This report is based primarily on recent studies conducted by the Office of Inspector 
General (OIG) on quality of care in nursing homes.  It draws additionally upon work 
completed by the General Accounting Office (GAO), the Health Care Financing 
Administration (HCFA), and others.  The report summarizes steps taken recently and now 
underway to address weaknesses in the system.  It also provides a long term program of 
action and research needed to assure nursing home care meets government standards for 
quality of care. 
BACKGROUND 
While some 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 patients, 
recent reports by HCFA and GAO have raised serious concerns about patient care and well-
being.  The Senate Special Committee on Aging held hearings in the summer of 1998 on 
these reports.  At the same time, the OIG undertook a series of studies aimed at assessing 
the quality of care in nursing homes. 
Various systems are in place to monitor and promote quality of care in nursing homes. 
These include the State survey and certification system, the State Long Term Care 
Ombudsman Program, State resident abuse safeguards, law enforcement, and legislative 
reforms established by the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). 
We used multiple methods for this report.  They consist of an analysis of national nursing 
home program data, a review of written program procedures, structured telephone 
interviews, an examination of nursing home survey results availability, a literature review, 
and an analysis of nursing home legislation. 
FINDINGS 
Serious Quality of Care Problems Persist in Nursing Homes 
An analysis of currently available program data reveals that problems with quality of care 
continue to exist in nursing homes.  First, according to survey and certification data, 13 of 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  25 quality of care deficiencies have increased in recent years.  They include a lack of 
supervision to prevent accidents, improper care for pressure sores, and lack of proper care 
for activities of daily living.  At the same time, ombudsman complaints have been steadily 
increasing since 1989 and complaints about resident care, such as pressure sores and 
hygiene, have been particularly prevalent.  Since 1995, the OIG has excluded 668 nursing 
home workers from participation in the Medicare/Medicaid programs as a result of a 
conviction related to patient abuse or neglect.  On a related note, approximately one percent 
or more of nursing home residents have had an experience serious enough to register an 
abuse complaint.  Lastly, survey and certification data, as well as discussions with survey 
and certification staff and ombudsmen, reveal that some nursing homes are chronically 
substandard. 
Experienced officials with inside information based on onsite visits to nursing homes, 
including State survey directors, surveyors, ombudsmen, and State Aging Unit Directors, 
express some reservations about relying exclusively on program data to gauge conditions in 
nursing homes. Nevertheless, they confirm that problems persist in nursing homes, such as 
malnutrition, abuse, pressure sores, and over-medication.  The problems they identify are 
similar to the problems highlighted in their program reporting systems. 
Evidence Suggests Inadequate Levels of Nursing Home Staff Contribute to Quality 
of Care Problems 
In all 10 sample States, survey and certification staff, State and local ombudsmen, as well as 
State Aging Unit Directors identify inadequate staffing levels as one of the major problems 
in nursing homes.  Most believe these staffing shortages lead to chronic quality of care 
problems, such as failure to adequately treat and prevent pressure sores. 
The type and extent of survey deficiencies and Ombudsman program complaints also 
suggest that nursing home staffing levels are inadequate.  Common personal care problems 
such as lack of nutrition and poor care for incontinence suggest that staffing is inadequate 
to provide the level of care needed to avoid these problems.  Furthermore, specific 
complaints about nursing home staff are some of the most common types of Ombudsman 
program complaints in 1997. 
Survey and Certification Agencies are Following Required Standard Protocols but 
Weaknesses in the Survey System Itself Limit Their Effectiveness 
State survey and certification agencies monitor nursing home care with timely and standard 
surveys, complaint procedures, and other State procedures.  However, the survey and 
certification system has several weaknesses, such as the predictability of surveys.  Although 
all States use unannounced surveys, State directors and surveyors believe that nursing 
homes can anticipate their survey date and modify their procedures to avoid being cited for 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  deficiencies.  The system is also limited by weak enforcement, including inadequate follow-
up and common inaction on abuse complaints.  State directors and surveyors believe that 
the current process allows deficient facilities too many opportunities to avoid enforcement 
action.  Lastly, survey and certification agencies have some staffing constraints and do not 
always effectively coordinate with ombudsmen. 
While the Ombudsman Program is Well Designed, Inadequate Resources Limit Its 
Capacity 
The Ombudsman program has several functions to promote and monitor quality of care in 
nursing homes, including identifying and resolving complaints, making regular visits to 
nursing homes, and engaging in a variety of different advocacy activities.  While lacking 
enforcement and regulatory oversight, ombudsmen act as independent advocates and work 
solely on behalf of residents to ensure they have a voice in their own care.  However, the 
Ombudsman program is limited by inadequate resources, including inadequate staffing. 
Only 1 of 10 States in our sample had a paid ombudsman to bed ratio higher than the 
standard suggested by the Institute of Medicine.  This lack of adequate staffing is 
particularly evident in the limited extent to which ombudsmen make regular nursing homes 
visits.  The program is further constrained by the lack of a common standard for complaint 
response and resolution, inconsistent advocacy efforts, a lack of support, and limited 
collaboration with surveyors. 
State Systems to Safeguard Nursing Home Residents from Abuse are Inconsistent 
and Unreliable 
Based on findings from a recent OIG audit, Safeguarding Long Term Care Residents, A-
12-97-0003, it appears that some weaknesses exist in State efforts to safeguard nursing 
home residents from abuse.  This audit revealed great diversity in the way States 
systematically identify, report, and investigate suspected abuse, and it found that there was 
no assurance that individuals who posed a risk of abuse were systematically identified and 
barred from nursing home employment.  Additionally, a more in-depth audit of Maryland 
examined eight nursing homes in the State and found that five percent of employees in those 
homes had criminal records. 
Public Awareness and Access to Nursing Home Survey Results is Limited 
Public awareness of nursing home survey results is limited and these results are not always 
readily available.  Two-thirds of 155 families interviewed in eight sample cities did not 
know that the results of Federal and State nursing home inspections are available on 
request.  Additionally, half were unaware such inspections are required, and only 15 had 
ever requested a copy of survey results.  Of the 11 who obtained a copy, 6 said the results 
were not based on the most recent survey.  Furthermore, when staff from the OIG visited 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  the 32 sampled nursing homes, most did not fully meet the requirements for making survey 
results available.  The HCFA has established a more easily accessible version of nursing 
home survey results with an internet site entitled Nursing Home Compare which appears 
promising. 
New Initiatives Based on Law Enforcement Approaches are Being Considered 
Initiatives that use the False Claims Act and other law enforcement approaches as a way to 
strengthen nursing homes are relatively new.  National task forces comprised of 
representatives from the Department of Justice, HCFA, OIG, and others are being formed 
at the local, State, and national levels.  These groups will examine the full range of 
enforcement issues and develop corresponding action plans for each.  By targeting key 
strategic areas and coordinating among the various agencies responsible for nursing home 
enforcement, these initiatives appear promising.  However, it is too soon to determine their 
full impact. 
Nursing Home Reforms Established by OBRA 1987 Have Not Been Systematically 
Assessed 
The nursing home reforms created by OBRA 1987 impacted both nursing home systems 
and nursing home care.  The OBRA 1987 mandated that residents be given certain rights 
and services and also added several administrative standards that nursing homes are 
required to meet.  It further changed enforcement and survey procedures.  While it has now 
been more than a decade later since this legislation was passed, there has been no systematic 
assessment of its extensive agenda and no methodical evaluation of whether the reforms it 
intended are actually working.  While some studies have attributed positive changes to 
OBRA 1987, the lack of a systematic review makes it difficult to determine if this major 
legislation has been successful in improving nursing home care. 
AN AGENDA FOR CONTINUING IMPROVEMENT IN NURSING HOME 
CARE 
Since OBRA 1987 was first passed, real improvements have been made in nursing home 
care.  More recently, considerable attention has been paid to addressing persisting concerns 
about nursing home conditions and systems.  In particular, we commend the Health Care 
Financing Administration (HCFA) for its extensive nursing home initiative since it addresses 
many of these persisting problems.  This initiative includes many individual action items 
which should result in positive changes.  Additionally, the Administration on Aging (AoA) 
has been taking steps to enhance the Ombudsman program, including improving the 
program reporting system and conducting annual training of ombudsman staff. 
The problems we describe in this report will require continuing attention, possibly for 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  several years.  The broad outline of an effective strategy would include actions to: 
<  enhance the survey and certification process;

<  strengthen the Ombudsman program with increased resources;

<  improve nursing home staffing levels; and,

<  improve coordination between State survey agencies and ombudsmen. 

We also believe that further evaluation and progress measurement would make an important 
contribution to efforts to advance nursing home care.  We specifically suggest: 
<  a systematic assessment of OBRA 1987 and

<  the creation of a periodic report card on conditions in nursing homes.

We have incorporated action items from HCFAs nursing home initiative, AoAs 
ombudsman activities, recommendations for additional steps to be taken, current OIG work, 
and areas requiring further evaluation into one comprehensive, long term agenda to 
continue improvements in nursing home care.  This agenda consists of a three stage 
approach of immediate action, research and evaluation, and continued progress 
measurement. The full agenda can be found on page 28. 
AGENCY COMMENTS 
This report is based primarily on a series of recent studies conducted by the Office of 
Inspector General on nursing home care.  They are: 
Nursing Home Survey and Certification: Deficiency Trends, OEI-02-98-00331;

Nursing Home Survey and Certification: Overall Capacity, OEI 02-98-00330;

Long Term Care Ombudsman Program: Complaints Trends, OEI-02-98-00350;

Long Term Care Ombudsman Program: Overall Capacity, OEI-02-98-00351;

Public Access to Nursing Home Survey and Certification Results, OEI-06-98-

00280; and

Safeguarding Long Term Care Residents, A-12-97-0003.

We received detailed comments from HCFA, AoA, and the Assistant Secretary for Planning 
and Evaluation on the above reports.  We made modifications in each report to respond to 
the comments received and to reflect the actions already being taken to improve nursing 
home conditions.  This overview report also incorporates many of these modifications.  We 
encourage everyone to read the individual reports and the comments we received on them. 
The comments are included in each report. 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  T A B L E  O F   O F  C O N T E N T S  
PAGE

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

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

FINDINGS

Serious Quality of Care Problems Persist  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  18

Nursing Home Staffing is Inadequate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  22

Survey and Certification Follows Protocols but Limited by System Weaknesses . . . . . . .  22

Ombudsman Program Well Designed but Lacks Adequate Resources . . . . . . . . . . . . . . .  23

State Resident Abuse Safeguards Inconsistent and Unreliable . . . . . . . . . . . . . . . . . . . . .  25

Awareness and Access to Survey Results Limited  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  25

New Law Enforcement Initiatives Being Considered  . . . . . . . . . . . . . . . . . . . . . . . . . . .  26

OBRA 1987 Lacks Systematic Assessment  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  26

AN AGENDA FOR CONTINUING IMPROVEMENT IN NURSING HOME CARE  . . . . .  28

Immediate Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  29

Research and Evaluation  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  30

Progress Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  32

AGENCY COMMENTS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  33

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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  I N T R O D U C T I O N  
PURPOSE 
To describe general conditions in nursing homes and assess the overall capacity of systems 
designed to monitor and improve quality of care. 
This report is based primarily on recent studies conducted by the Office of Inspector 
General (OIG) on quality of care in nursing homes.  It additionally draws upon work 
completed by the General Accounting Office (GAO), the Health Care Financing 
Administration (HCFA), and others.  The report summarizes steps recently taken and now 
underway to address weaknesses in the system.  It also provides a long term program of 
action and research needed to assure nursing home care meets government standards for 
quality of care. 
BACKGROUND 
While some 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 HCFA and 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 OIG subsequently undertook a series of studies aimed at assessing 
the quality of care in nursing homes.  This report looks at both the general state of nursing 
home care as well as the systems designed to oversee that care. 
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.  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.  Medicaid expenditures for nursing homes in 
1996 totaled $24.3 billion. 
In 1986, the Institute of Medicine conducted a study on nursing home regulations and 
reported prevalent problems regarding the quality of care for nursing home residents, as 
well as the need for stronger Federal regulations.  Just one year later, GAO reported that 
over one third of nursing homes were operating below Federal minimum standards.  These 
reports, along with widespread concern regarding nursing home conditions, persuaded 
Congress to pass the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987).  As a part 
of OBRA 1987, Congress passed the comprehensive Nursing Home Reform Act (PL 100-
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  203).  These actions expanded requirements that nursing facilities had to comply with in 
order to obtain Medicare certification.  The Nursing Home Reform Act also strengthened 
the 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 additionally altered the 
enforcement of Federal standards for nursing home care. 
Medicare Nursing Home Requirements 
The Health Care Financing Administration (HCFA) has the responsibility to act as a 
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 
Nursing Home Reform Act added to these requirements by introducing an increased focus 
on the quality of life and care, the importance of the individual resident, the need to help 
residents reach the highest practicable level of functioning, and the requirement that 
residents be interviewed and assessed. 
Nursing homes must conduct standardized, reproducible assessments of each residents 
functional capacity... within 14 days of admission.  Additionally, periodic assessments must 
occur throughout the duration of a patients stay in order to continually address their 
fluctuating needs.  With the Nursing Home Reform Act, HCFA developed the Minimum 
Data Set (MDS) which is comprised of core elements and common definitions used in 
conducting resident assessments.  The Minimum Data Set collects data through resident 
assessment measures, with subsequent progress or decline documented in electronic format. 
The Nursing Home Reform Act additionally established new enforcement provisions, which 
were enacted when the State Operations Manual (SOM) became effective on July 1, 1995. 
The HCFA had several process goals during the implementation of these new provisions: 
promoting consistency through extensive training; linking appropriate remedies to 
deficiencies; and avoiding unnecessary procedures.  Congress recognized that one 
enforcement response would not be appropriate for all deficiencies.  It therefore established 
enforcement policies that gave HCFA the license to impose a variety of corrective measures 
for noncompliant facilities.  These include: temporary management; denial of payment for 
new admissions; civil money penalties; termination of the facility; and State monitoring of 
the facility.  States are responsible for establishing their own remedy guidelines. 
Following the implementation of the State Operations Manual, HCFA also imposed a 
number of administrative changes on enforcement procedures .  In June 1995, HCFA 
enacted a temporary moratorium on the collection of certain lower-level money penalties 
(CMPs).  This 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 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  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. 
Nursing Home Systems 
Survey and Certification.  All nursing homes participating in Medicare and/or Medicaid 
must be certified in meeting certain Federal requirements.  The Nursing Home Reform Act 
defines the State survey and certification process for determining nursing home compliance 
with these Federal standards. The HCFA is responsible for certifying Medicare and dually-
eligible facilities, while States are responsible for Medicaid only facilities.  Nursing home 
certification is achieved through routine surveys, and HCFA contracts with States to 
perform such surveys for Medicare and dually-eligible nursing homes, in addition to those 
they perform for Medicaid nursing homes. 
State surveys determine the compliance or noncompliance of nursing homes.  When a 
nursing home fails to meet a specific requirement, surveyors give it a deficiency or citation. 
Generally, there are 20 principles that are considered in the citation of deficiencies on the 
HCFA-2567.  Surveyors also provide the reasons justifying any resulting enforcement 
action and the record on which to defend that action in the appeals process.  State survey 
teams generally consist of multi-disciplinary professionals and must include a registered 
professional nurse.  Other professionals who may be on the survey team include social 
workers, therapists, dieticians, pharmacists, administrators, and physicians. 
Each State is also required to maintain written procedures and adequate staff to investigate 
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. 
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.  Since the Statewide average interval between standard 
surveys must be 12 months or less, this creates a Federal standard survey window 
between 9 and 15 months.  Each standard survey includes a stratified case mix of nursing 
home residents, and measures their medical, nursing and rehabilitative care, dietary and 
nutrition services, activities, social participation, sanitation, infection control, and 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 with residents rights. 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  In addition to regular surveys, States also conduct 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 nursing home.  Extended surveys are performed 
immediately or within two weeks after the standard survey completion, on those nursing 
homes 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. 
Within two months of the State survey, HCFA conducts validation surveys on a 
representative sample of nursing homes in each State utilizing 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, and this number must 
never be less than five surveys a year. 
In order to improve the survey process, the State Agency Quality Improvement Program 
(SAQIP) was developed to establish a process for State agencies 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. 
The HCFAs Online Survey Certification and Reporting System (OSCAR) came online in 
October 1991.  The HCFA uses OSCAR in its survey of Medicare and Medicaid providers 
to monitor State agency and provider performance.  The 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 and is 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 on July 1, 1995. 
Ombudsman Program.  In response to growing concerns about poor quality care in 
nursing homes and to protect the interests of residents,  the State Long Term Care 
Ombudsman program was established in 1978 in the Older Americans Act.  The 
ombudsmen advocate on behalf of residents of all long term care facilities, including nursing 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  homes, to ensure residents have a strong voice in their own treatment and care.

The Ombudsman Program operates in all fifty States, the District of Columbia, and Puerto

Rico,  and in hundreds of local communities, and uses both paid and volunteer staff.  The

program receives funding from Federal, State and local levels, and is overseen by the

Administration on Aging (AoA).  Most State ombudsmen operate within the State Unit on

Aging, some of which are independent while others are part of a larger State umbrella

agency.  The remaining State Ombudsman programs are contracted out and administered by

an entity separate from the State Unit on Aging.  These programs are operated by non-

profit organizations, legal services agencies, or by freestanding Ombudsman program

agencies. 

State Ombudsman programs have multiple functions that are mandated by law, many of

which are closely tied to ensuring quality care for long term care residents.  They include:

C  identifying, investigating, and resolving complaints;

C  protecting the legal rights of patients; 

C  advocating for systemic change;

C  providing information and consultation to residents and their families; and

C  publicizing issues of importance to residents

States have recently started to collect and report data under a new system.  In FY 1995,

States began to systematically collect and report data under the National Ombudsman

Reporting System (NORS).  Prior to NORS, States reported data to AoA, which was of

limited use due to the lack of common definitions for key data elements.  The NORS was

created in response to earlier recommendations made by the General Accounting Office and

the Office of Inspector General, and was developed by the ombudsmen themselves.  It

includes more specific data elements than were reported before NORS.  For example, it

separates complaints by type, distinguishes between complaints and complainants, counts

unresolved complaints, and reports program funding streams.  Twenty-nine States reported

under NORS in 1995 and all States did so annually beginning in 1996.

Resident abuse safeguards.  Federal regulations require States to establish a registry of

nurse aides that includes information on any aide found guilty of abuse or neglect. 

Regulations also mandate that nursing homes not employ individuals who have been found

guilty of abusing or neglecting nursing home residents.  States are additionally required to

provide criminal information to the OIG national database, which is then used to publish a

monthly exclusion list.  However, there is no Federal requirement to conduct criminal

background checks of all current or prospective employees of Medicare and/or Medicaid

participating nursing homes.

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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  Other procedures have also been established to coordinate the reporting of resident abuse 
allegations.  Each State is required to designate a coordinator with central State authority to 
receive complaints of mistreatment or neglect of nursing home residents.  While this 
individual or entity may be located in any number of State agencies or within a designated 
complaint unit, the responsibility is often assigned to an employee of the State survey and 
certification agency. 
Families.  Families are in the best position to help choose a nursing home and to monitor 
the care provided in that home.  To do this, they need accurate and timely information 
about the quality of care in the nursing home they choose.  A nursing homes most recent 
annual survey results are, theoretically, ideally suited for this purpose.  Various laws and 
regulations are intended to make these results available to the public, including the 
requirement that nursing homes post a notice giving the location and availability of its most 
recent survey results. 
Law enforcement.  Several different agencies have responsibility for nursing home law 
enforcement, including the Department of Justice, the OIG, and State agencies such as the 
State Attorney General.  The local police force also plays an enforcement role.  A nursing 
home facility, owner, or other employee (such as a nurse aide or administrator) may be 
excluded from participation in Medicare and Medicaid after appropriate enforcement action 
is taken. 
Recently, poor quality of care has been the basis of a prosecution under the False Claims 
Act.  When providers submit claims for reimbursement, they certify either explicitly or 
implicitly that the services provided meet professional standards; if they "knowingly" 
present a claim for substandard services, they could be liable under the False Claims Act. 
Thus, under appropriate circumstances, the Government can use the False Claims Act to 
prosecute a provider who knowingly presents false or fraudulent claims to the government 
for substandard care in nursing homes.  The two major cases where the False Claims Act 
has been used involve grossly deficient diabetes monitoring, pressure sore care, and other 
nursing care.  In both the landmark 1996 case against Geriatric & Medical Cos., Inc. and its 
Tucker House facility and the 1998 case against the Chester Care chain of four nursing 
homes, the OIG obtained civil settlements for $500,000 each.  As part of the settlement 
agreements, the companies were required to develop comprehensive compliance programs. 
In addition, in the Chester Care case, the company was required to pay for a temporary 
manager and monitor to oversee provision of care. 
Legislative reforms (OBRA 1987).  As previously noted, the OBRA 1987 legislation and 
ensuing regulations established a framework for nursing home reform.  It specifically 
provided an agenda for nursing home care by mandating that residents be given certain 
rights and services, and adding several administrative standards that nursing homes were 
required to meet.  It also established new survey and enforcement requirements, including 
making surveys more resident focused and augmenting existing enforcement options. 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  Prior Studies and Recent Initiatives 
Several studies have been completed which have examined the survey and certification 
process.  One recent study entitled The Regulation and Enforcement of Federal Nursing 
Home Standards, written by Charlene Harrington and published in March of 1998, details 
problems with nursing home certification.  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. 
Furthermore, 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. 
Many studies have also reported on the progress and impact of the Ombudsman Program. 
One of the most recent, Real People, Real Problems, published in 1995 by the National 
Academy of Sciences Institute of Medicine, looked at the Ombudsman program overall. 
This study reported on State compliance, conflicts of interest, effectiveness, resources, and 
the need for future expansion of the program.  It found that, overall, the Ombudsman 
program is effective.  It also reported lack of access to ombudsman services by residents 
and their families, disparities in ombudsman visitation patterns and service provision, and 
uneven legal services available to ombudsmen. 
Additionally, the Inspector General issued several reports on the Program in 1991 and 
1992.  First, Successful Ombudsman Programs, (OEI-02-90-02120), the main report in a 
series of reports on the Ombudsman program, found that successful programs are highly 
visible and obtain adequate funding and support.  Furthermore, State Implementation of 
the Ombudsman Requirements of the Older Americans Act, (OEI-02-91-01516), found, 
among other things, that State program staffing and long term care facility visitation varies 
significantly.  It also found that ombudsmen use many methods to increase their visibility. 
In July, 1998, 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, and increasing the 
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13 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  number of night and weekend surveys. 
In conjunction with the Presidents nursing home initiative, the Secretary released a report 
to Congress in July of 1998, a Study of Private Accreditation (Deeming) of Nursing 
Homes, Regulatory Incentives and Non-Regulatory Initiatives, and Effectiveness of the 
Survey and Certification System, indicating that significant improvements in the quality of 
care had been made since 1995.  These improvements included more appropriate use of 
physical restraints, anti-psychotic drugs, anti-depressants, urinary catheters, and hearing 
aids.  However, the report did find 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 pressure 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. 
One week after the Presidents initiative, the General 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 held hearings in July 1998 to discuss the findings on the quality of care in nursing 
homes. 
METHODOLOGY 
Multiple methods were used for this report.  They include an analysis of national nursing 
home program data, a review of written program procedures, structured telephone 
interviews, a literature review, and an analysis of nursing home legislation. 
Description of nursing home conditions 
Data Analysis 
Survey and certification data.  We used a purposive sample of 10 States which represent 
55.8 percent of total skilled nursing beds nationally.  These States are New York, 
California, Texas, Ohio, Illinois, Pennsylvania, Massachusetts, Florida, New Jersey, and 
Tennessee.  The OSCAR contains data for the current and 3 previous surveys and 
categorizes deficiencies into 17 major categories.  Using the most recently available 
OSCAR data (from August 4, 1998), 3 of the 17 categories which could determine poor 
quality of care were analyzed.  These are: 1) resident behavior and facility practices, 
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14 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  including the areas of restraints, abuse and staff treatment of residents; 2) quality of life, 
including the residents ability to make decisions about his or her daily activities and the 
nursing homes accommodation of his or her needs; and 3) quality of care, including the 
technical ability of the nursing home to prevent and treat the medical conditions of its 
residents.  Substandard quality of care deficiencies repeated over the last four surveys and 
abuse complaint data were also examined. 
Ombudsman data.  Using the same purposive sample of 10 States, we analyzed 2 sets of 
Ombudsman program data.  For 1996 and 1997, data from the National Ombudsman 
Reporting System (NORS) was examined; from 1989 to 1994, data from the pre-NORS 
reporting system was used.  Data from 1995 is not analyzed due to a lack of comparable 
data elements for that year. For both pre-NORS and NORS data, figures for both total 
complaints and broad complaint categories are presented; for NORS data, 125 specific 
complaint types were also looked at.  Finally, data on Ombudsman program staffing, 
visitation rates, advocacy activities, and coordination with survey and certification agencies 
was also examined. 
Abuse complaints.  Using a fax survey, we obtained data from all 10 States on the 
numbers and types of nursing home resident abuse complaints.  We specifically analyzed 
data on four types of complaints selected as key indicators of recent abuse trends: physical 
abuse, inappropriate use of restraints, physical neglect, and medical neglect. 
OIG convictions.  We reviewed data from the Office of Inspector General on nursing home 
convictions relating to resident abuse or neglect, from 1995 to 1998. 
Literature review 
We examined findings on nursing home conditions from several studies, particularly the 
recent GAO report entitled California Nursing Homes: Care Problems Persist Despite 
Federal and State Oversight. 
Assessment of nursing home systems 
Procedures review 
Survey and certification procedures.  For the eight States that have their own survey 
guidelines which they use in addition to HCFA guidelines, we obtained and reviewed their 
written program procedures and other related documents.  The remaining two States had no 
survey requirements of their own. 
Ombudsman procedures.  Written procedures for all 10 sample State Ombudsman 
programs were obtained and reviewed.  Using a structured review guide, these procedures 
were reviewed to determine the different processes used by ombudsmen to monitor and 
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15 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  promote quality of care in nursing homes.  Standards mandated for these processes, such as 
complaint response times, were also looked at. 
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16 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  Interviews 
Survey and certification telephone interviews.  A total of thirty structured telephone 
interviews were  conducted.  In each of the 10 sample States, one interview was conducted 
with the State survey and certification director (or designee) and two State surveyors.  The 
two State surveyors were selected randomly from a list of at least 10 surveyors submitted 
by the State director.  During these interviews, information was obtained 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.  Information provided by the directors was 
compared to that provided by surveyors, and special attention was given to consensus 
within and among the groups. 
Ombudsman telephone interviews.  A total of 30 structured telephone interviews were 
conducted.  In each of the 10 sample States, one interview was conducted with the State 
ombudsman, one local program ombudsman, and the State Aging Unit Director or 
designee.  In selecting ombudsmen from local programs to interview, individuals from a 
variety of local program structures were chosen.  These three groups of respondents were 
selected to obtain their different perspectives of the program and consensus among the 
groups was particularly noted while analyzing the interviews. 
Examination of nursing home survey results availability 
To examine the availability of survey results, we used a different sample and methodology. 
We selected a purposive sample of eight cities, each one having a regional Office of 
Evaluations and Inspections (San Francisco, Atlanta, Chicago, Boston, Kansas City, New 
York, Philadelphia, and Boston).  We then combined five methods to assess the availability 
of survey results: telephone interviews with 155 family members; a simulation by OIG staff 
of families access to nursing home results;  telephone requests to HCFA and State officials 
for survey results; a review of HCFAs new internet site for survey results; and a review of 
Federal rules and procedures regarding access to survey results. 
Literature review 
We also conducted a literature review of recent nursing home studies which assessed 
nursing home systems.  We particularly used an OIG report entitled Safeguarding Long 
Term Care Residents. 
Legislation review 
Finally, we reviewed nursing home legislation, particularly OBRA 1987.  We identified each 
of the individual reforms outlined in OBRA 87 and determined which ones had been 
assessed for impact and outcome.  Lastly, we reviewed the mission statement and agenda 
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17 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  for recent nursing home law enforcement initiatives. 
This inspection was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
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18 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  F I N D I N G S  
Serious quality of care problems persist in nursing homes 
Survey and certification deficiencies.  An analysis of survey and certification deficiencies 
indicates that problems with quality of care continue to exist in nursing homes.  Deficiencies 
are grouped into one of three main categories, and while two of these categories have been 
decreasing, many deficiencies in the quality of care category have actually been 
increasing.  More specifically, 13 of the 25 deficiencies that make up this category are 
higher now than they were on the last 3 surveys.  These 13 deficiencies were cited 6,413 
times on the current survey, compared to 5,246 times three surveys prior, an increase of 
almost 25 percent.  They include a lack of adequate supervision to prevent accidents, a lack 
of appropriate care for activities of daily living, and improper care for pressure sores. 
Graph A below shows how some of these serious deficiencies have grown over the prior 3 
surveys. 
Graph A 
Some Serious Quality of Care Deficiencies Have Been Increasing 
Deficiencies often lead to further medical problems or indicate other issues.  For example, 
pressure sores could be an indication that residents also have other problems, such as 
urinary incontinence, malnutrition, or dehydration.  Table 1 below shows the nature and 
extent of the top 10 substandard quality of care deficiencies from the latest standard survey 
in the 10 sample States. 
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19 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  Table 1 
The Top 10 Substandard Quality of Care Deficiencies 
Include Some Serious Problems 
# of Sample State  % of Sample State 
Deficiency  Deficiencies  Facilities 
Proper treatment to prevent  1186  16% 
or treat pressure sores 
Facility free of accident  1164  16% 
hazards 
Facility promotes care that  1115  16% 
maintains/enhances dignity 
Housekeeping and  1023  14% 
maintenance 
Provides necessary care for  972  14% 
highest practicable well-
being 
Right to be free from  958  13% 
physical restraints 
Should have policies that  787  11% 
accommodate needs 
Drug regimen free from  768  11% 
unnecessary drugs 
Appropriate treatment for  750  10% 
incontinence 
Activities of daily living  699  10% 
care provided for dependent 
residents 
In its recent report entitled California Nursing Homes: Care Problems Persist Despite 
Federal and State Oversight the GAO examined the quality of care in 1,370 nursing homes 
in California.  It found that 30 percent had violations that caused death or life-threatening 
harm to residents, or had understated the frequency of poor care by falsifying records. 
Among the problems it reports are poor nutrition, dehydration, and improper care of 
incontinent and immobile residents which leads to pressure sores. 
Ombudsman complaints.  Ombudsman nursing home complaints have also been steadily 
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20 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  increasing, as illustrated in graph B below.  Based on data from 1989 to 1994, total 
complaints in the 10 sample States grew from 57,954 to 83,669, an increase of 44 percent. 
(Due to the transition to a new data system in 1995, we do not have comparable complaint 
rates for that year). 
Graph B 
At the Same Time, Ombudsman Program Complaints 
Increased from 1989 to 1994 
Beginning in 1996, a new Ombudsman program reporting system was used that counted 
complaints differently from the prior system.  Data from 1996 and 1997 also show that 
complaints increased seven percent between these two years, from 60,926 to 65,123, as 
illustrated in Graph C below. 
Graph C 
Ombudsman Program Complaints Also Increased from 1996 to 1997 
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21 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  Ombudsman complaints about resident care have been particulary prevalent.  Of the five 
main Ombudsman program complaint categories, the resident care category increased the 
most from 1996 to 1997, growing by 13 percent.  This category includes specific 
complaints about personal care (such as pressure sores and hygiene), lack of rehabilitation, 
and the inappropriate use of restraints.  On a more specific level, 12 complaints had 
increases of 24 percent or more from 1996 to 1997.  Two of these -- staff turnover and lack 
of staff training -- may indicate other problems with resident care. 
In 1997, the majority of all Ombudsman program complaints (63 percent) fell into 2 of 5 
categories -- resident care (32 percent) and residents rights (31 percent).  The top 10 
complaints for that year include 3 related to inadequate nursing home staffing, as well as 
specific complaints about poor quality of care, such as poor hygiene, physical abuse, and 
improper handling and accidents. 
Resident abuse complaints.  Data obtained from nursing home abuse complaint 
coordinators in the 10 sample States lack common definitions and are therefore inconsistent. 
Furthermore, these complaints are not always substantiated.  Among the 10 States, there 
are no obvious trends in reported complaints; some States have upward trends and others 
downward trends.  Nevertheless, approximately one percent or more of nursing home 
residents in the 10 States have had an experience serious enough to register an abuse 
complaint. 
Additionally, since 1995 the OIG has excluded 668 nursing home workers from 
participation in the Medicare or Medicaid programs as a result of a conviction related to 
patient abuse or neglect.  The excluded workers were primarily nurses and nurse aides. 
Chronically substandard homes.  Some nursing homes appear to be chronically 
substandard.  Data from OSCAR show that some are repeatedly deficient; 463 nursing 
homes have been cited with the same deficiencies over their last past four surveys, 
representing 6 percent of all homes in the 10 sample States.  State directors and surveyors 
also report that between 1 to 20 percent of nursing homes in their State have chronic quality 
of care problems.  Finally, three-fourths of ombudsmen say there are some homes (10 
percent or fewer) that routinely treat residents poorly. 
Insiders perspectives.  Survey and certification staff and ombudsmen express some 
reservations about relying exclusively on program data to identify nursing home problems. 
While generally satisfied with OSCAR data, more than half of State directors and surveyors 
believe it is not a true indicator of nursing home quality of care since it only portrays the 
situation of the nursing home at the time surveyors are physically conducting the survey. 
Ombudsmen also say that higher complaint rates do not always indicate more problems, 
pointing out that higher complaint rates could be due to a greater presence of Ombudsman 
staff in nursing homes. 
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22 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  Nevertheless, in all 10 sample States, State surveyors and survey directors, State and local 
ombudsmen, and State Aging Unit Directors confirm that problems with care persist in 
nursing homes.  These are many of the same problems reported in program data.  State 
surveyors and survey directors say the biggest problems they see are resident abuse, failure 
to treat incontinent patients, and improper medication distribution.  Ombudsmen and State 
Aging Unit Directors identify malnutrition and other dietary concerns, bed sores, 
dehydration, poor hygiene, over-medication, toileting, and physical abuse as problems 
nursing home residents face. 
Evidence suggests inadequate levels of nursing home staff 
contribute to quality of care problems 
In all 10 sample States, survey and certification staff, State and local ombudsmen, and State 
Aging Unit Directors identify inadequate staffing levels as one of the major problems with 
nursing homes in their States.  Most believe that these staffing shortages leads to chronic 
quality of care problems, such as failure to adequately treat and prevent pressure sores. 
They cite further concerns about the proficiency and training of nursing home staff. 
The type and extent of survey deficiencies and Ombudsman program complaints also 
suggest that nursing home staffing levels are inadequate.  Common personal care problems 
such as lack of nutrition and poor care for incontinence suggest that staffing is inadequate 
to provide the level of care needed to avoid these problems.  Furthermore, specific 
complaints about nursing home staff are some of the most common types of Ombudsman 
program complaints.  The top complaint in 1997 was unanswered call lights and requests 
for assistance, while staff attitudes and lack of respect was third and shortage of staff was 
ninth. 
Survey and certification agencies are following required 
standard protocols but weaknesses in the survey system 
itself limit their effectiveness 
State survey and certification agencies monitor nursing home care with timely and standard 
surveys, complaint procedures, and additional State processes.  Based on OSCAR data over 
the last 4 standard surveys, all sample States completed 97 percent of their standard surveys 
in the mandated time frame of 9 to 15 months.  Furthermore, all State survey directors and 
surveyors report following HCFA guidelines for their surveys, including starting with an 
entrance conference, touring the facility, interviewing residents and family members, 
reviewing medical records, and concluding with an exit conference.  They also report 
having a complaint process to address complaints about nursing home practices.  Seven 
States have their own survey guidelines which they use in addition to HCFA guidelines, and 
some have additional databases and information sources. 
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23 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  Despite following standard procedures, however, the survey and certification system has 
several weaknesses, including the predictability of surveys.  Although all States use 
unannounced nursing home surveys, almost all directors and surveyors believe that facilities 
can anticipate the survey start date.  They say that facilities often modify their normal daily 
procedures to reduce potential deficiencies, such as increasing staff on certain shifts.  In 
most States, surveyors also do not begin or continue standard surveys on the weekend or in 
evening hours.  State directors and surveyors therefore voice concerns about whether 
standard surveys represent an accurate reflection of quality of care in nursing homes. 
The survey and certification process is also limited by weak enforcement, including inaction 
on abuse complaints.  From January 1997 to July 1998, OSCAR data reports 4,707 abuse 
complaints (involving almost one third of all nursing homes) in the 10 sample States.  Two-
thirds of these were unsubstantiated and the remaining third were substantiated.  Over 90 
percent of both substantiated and unsubstantiated complaints concluded with no action, 
plans of correction, or other remedy.  Furthermore, half of the State directors and three-
fourths of surveyors indicate that current enforcement measures are questionable.  They 
express concern that civil monetary penalties do not compel nursing homes to observe 
Federal regulations, are insufficient to influence nursing home chains, and are not imposed 
immediately, allowing facilities to remain non-compliant for longer periods of time.  Others 
believe that current enforcement process allows deficient facilities far too many 
opportunities to avoid enforcement action. 
Finally, survey and certification agencies have a number of staffing constraints.  The overall 
number of surveyors varies by State, thereby affecting the number of standard, follow-up, 
and complaint surveys each team can conduct.  For example, the number of standard 
surveys on the 10 States ranges from 12 to 26 per year.  State directors also express 
concern about high staff turnover rates, difficulties replacing staff once they leave, and 
limited surveyor training.  They additionally report weaknesses in coordination between 
their staff and ombudsman staff.  Surveyors received 13 percent of all Ombudsman program 
abuse complaints per month in 1997. 
While the Ombudsman program is well designed, inadequate 
resources limit its capacity 
The Ombudsman program has several functions to promote and monitor quality of care in 
nursing homes, including identifying and resolving complaints, making regular visits to 
nursing homes, and engaging in a variety of different advocacy activities.  Discussions with 
State and local ombudsmen, as well as State Aging Unit Directors, emphasize the 
uniqueness of this program.  In contrast to other programs, ombudsmen lack enforcement 
and regulatory oversight authorities.  As independent advocates, they work solely on behalf 
of residents and are often the only voice residents have in their own care.  An ongoing, 
routine nursing home presence is therefore essential to the ombudsman role.  In fact, most 
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24 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  State ombudsmen (6 of 10) believe this presence is the most important part of their 
program.  This presence provides ombudsmen with the opportunity to develop personal and 
confidential relationships with residents and enables them to identify and address individual 
issues before they become larger, systemic problems. 
Nevertheless, the overall capacity of the Ombudsman program is limited by inadequate 
resources, including inadequate staffing.  Paid staffing and volunteer levels among the 10 
States vary considerably, ranging from 4,618 nursing home beds per paid staff in one State 
to 1,115 beds per paid staff in another.  While no minimum staffing ratios are required by 
law, a 1995 Institute of Medicine study on the Ombudsman program recommends a 
standard staffing ratio of 1 paid Ombudsman staff person per 2,000  long term care facility 
beds; only 1 in the 10 sample States, Massachusetts, meets this standard.  Furthermore, a 
majority of State and local Ombudsmen identify insufficient program staffing and an 
inadequate number of volunteers as obstacles which detract from their programs 
effectiveness. 
Inadequate program staffing is particularly evident in the limited extent to which 
ombudsmen make regular nursing home visits.  In the nine States that make such visits, 
volunteers are generally assigned to just one nursing home and visit this home on a weekly 
basis.  However, most nursing homes in the 10 States do not have volunteers assigned to 
them, and these homes are usually visited by paid staff just once or twice a year for no 
longer than one to three hours.  In fact, in four States there are nursing homes that are 
never visited by volunteers or paid staff. 
Other limitations affect the Ombudsman programs overall capacity.  Lacking a common 
standard for complaint response and resolution, ombudsman staff in some States are not 
consistently handling complaints in a timely manner.  Ombudsman staff also devote varying 
amounts of time to outreach and advocacy activities, with some spending relatively little 
time on community education, work with the media, work on laws and policy, and nursing 
home staff training.  Also, half of State and local ombudsmen believe their programs lack 
of support in the State diminishes its capacity and limits their ability to influence nursing 
home policies.  Lastly, they believe better collaboration is needed with the survey and 
certification agency. 
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25 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  State systems to safeguard nursing home residents from 
abuse are inconsistent and unreliable 
Based on findings from a recent OIG audit, Safeguarding Long Term Care Residents, (A-
12-97-0003) it appears that some weaknesses exist in State efforts to safeguard nursing 
home residents from abuse.  This audit revealed great diversity in the way States 
systematically identify, report, and investigate suspected abuse.  While no Federal 
requirement exists for criminal background checks of nursing home staff, 33 States do 
mandate that such checks occur.  However, the methods used to identify individuals who 
pose a risk of abuse and the criteria followed for prohibiting employment vary widely 
among these States.  Furthermore, not all States systematically report convictions to central 
databases, such as the certified nurses aide registry.  It therefore appears that there is no 
assurance that individuals who may pose a risk to residents are systematically identified and 
barred from nursing home employment. 
A more in-depth audit of Maryland also found problems with nursing home hiring practices 
in that State.  In particular, this audit found that five percent of employees in eight nursing 
homes had criminal records.  It also noted that some of these individuals were not reported 
in the State or Federal systems used for criminal background checks, despite the fact that 
they had been convicted of elder abuse. 
Public awareness and access to nursing home survey results 
is limited 
Two-thirds of 155 families interviewed in eight sample cities did not know that the results 
of Federal and State nursing home inspections are available on request.  Half were also 
unaware that such inspections are required.  Only 15 of the 155 individuals we interviewed 
had ever requested a copy of the survey results, and of the 11 who obtained a copy, 6 said 
the results were not based on a recent survey conducted within the past 15 months. 
Most of the 32 sampled nursing homes visited by staff from the Office of Inspector General 
did not fully meet the requirements for making survey results available. In a majority of 
these homes, the notice identifying the location of the survey results was not posted and/or 
the survey results were in locations directly observed by staff, contrary to regulations.  Staff 
from the OIG had to ask for the survey results in 24 of the 32 homes they visited.  While 
most (27) did ultimately make the survey results available, the OIG staff had an advantage 
over other members of the public since they were aware of what to look for and how to ask 
for it. 
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26 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  The HCFA has recently established a more easily accessible version of nursing home survey 
results with an internet site entitled Nursing Home Compare.  For families with access to 
the internet, this is a promising development.  When staff from the OIG located this site, 
they found it easy to understand.  Most of the families interviewed said it could be very 
helpful in providing useful nursing home information. 
New initiatives based on law enforcement approaches are 
being considered 
Initiatives to strengthen nursing home law enforcement are relatively new.  Particularly 
noteworthy is the formation of nursing home task forces at the local, State, and national 
levels, comprised of representatives from the Department of Justice, HCFA, OIG, and other 
agencies.  These groups will examine and develop action plans for several enforcement 
strategic areas and will address the full range of nursing home enforcement issues. They will 
collaborate with Medicaid Fraud Control Units, the State Attorneys General, State survey 
agencies, and other oversight agencies.  Among the strategic areas targeted are: improving 
the handling of civil monetary penalty referrals; reviewing patient abuse and neglect 
legislation for model State legislation; recommending possible new legislation for 
prosecuting abuse and neglect; reviewing current services available to abuse victims; and 
identifying emerging quality of care and fraud problems in nursing homes. 
By targeting key strategic areas and coordinating among the various agencies responsible 
for nursing home enforcement, these initiatives appear promising.  If successful, they should 
strengthen enforcement of nursing home problems.  However, it is too soon to determine 
the full impact of these enforcement initiatives.  Some of the task forces and action plans 
will not be fully developed until early 1999, and at the earliest, preliminary results will not 
be available until later in that year. 
Nursing home reforms established by OBRA 1987 have not 
been systematically assessed 
The nursing home reforms created by OBRA 1987 impacted both nursing home systems 
and nursing home care.  First, these reforms essentially changed the focus from a nursing 
homes ability to provide care to the quality of the care actually provided.  The OBRA 87 
requires nursing homes participating in Medicare and Medicaid to comply with extensive 
standards.  These standards include ensuring various resident rights, rights related to 
admission, transfer and discharge, and the right to be free from restraints and abuse.  The 
OBRA 87 also requires nursing homes to promote residents quality of life, conduct 
periodic resident assessments, and provide the necessary care needed for residents to 
maintain the highest practicable physical, mental, and psychosocial well-being.  Additionally, 
OBRA 87 requires nursing homes to provide certain services, including nursing, dietary, 
physician, rehabilitative, dental, and pharmacy services.  Finally, several administrative 
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27 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  standards were also established, including requirements for nurse aide training, a medical 
director, and clinical records. 
The OBRA 87 also changed nursing home enforcement and survey procedures.  Among 
these changes are: the development of the Resident Assessment Instrument (RAI), which is 
a standardized assessment instrument for nursing home residents; a more outcome oriented 
survey that emphasizes gathering information by observing and interviewing residents; and 
new intermediate enforcement remedies that augment existing options for noncompliant 
nursing homes. 
While it has now been more than a decade since OBRA 1987 was first passed, there has 
been no systematic assessment of its extensive agenda and no methodical evaluation of 
whether or not the reforms it intended are actually working.  In its 1998 Report to 
Congress, HCFA attributes positive changes in the use and outcomes of resident assessment 
instruments and psycho-pharmacological medications to OBRA 87. The HCFA also 
concludes that new enforcement and survey regulations have been effective. Other studies 
have addressed additional OBRA reforms, including OIG reports on nursing home 
prescription drug use and resident abuse.  Furthermore, data from survey and certification 
and Ombudsman program reporting systems suggest the OBRA requirement that residents 
be free from restraints is having some effect; deficiencies on restraints and ombudsman 
restraint complaints have been decreasing over the past several years.  Nevertheless, the 
success of this major legislation has not yet been established.  A definitive assessment of the 
extent to which OBRA reforms have bettered conditions in nursing homes is therefore 
needed. 
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28 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  AN AGENDA FOR CONTINUING IMPROVEMENT IN 
NURSING HOME CARE 
Since OBRA 1987 was first passed, real improvements have been made in nursing home 
care.  More recently, considerable attention has been paid to addressing persisting concerns 
about nursing home conditions and systems.  In particular, we commend the Health Care 
Financing Administration (HCFA) for its extensive nursing home initiative since it addresses 
many of these persisting problems.  This initiative includes many individual action items 
which should result in positive changes.  Additionally, the Administration on Aging (AoA) 
has been taking steps to enhance the Ombudsman program, including improving the 
program reporting system and conducting annual training of ombudsman staff. 
The problems we describe in this report will require continuing attention, possibly for 
several years.  The broad outline of an effective strategy would include actions to: 
<  enhance the survey and certification process;

<  strengthen the Ombudsman program with increased resources;

<  improve nursing home staffing levels; and

<  improve coordination between State survey agencies and ombudsmen. 

We also believe that further evaluation and progress measurement would make an important 
contribution to efforts to advance nursing home care.  We specifically suggest: 
<  a systematic assessment of OBRA 1987; and

<  the creation of a periodic report card on conditions in nursing homes.

We have incorporated action items from HCFAs nursing home initiative, AoAs 
Ombudsman program activities, recommendations for additional steps to be taken, current 
OIG work, and areas requiring further evaluation into one comprehensive, long term agenda 
to continue improvements in nursing home care.  This agenda consists of a three stage 
approach of immediate action, research and evaluation, and continued progress 
measurement.  It is outlined below. 
I.  Immediate Action 
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29 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  We believe immediate action should be taken to strengthen the capacity of systems designed 
to oversee nursing home care.  We also believe improvements should be made in nursing 
home staffing levels, since this directly impacts on the care residents receive. 
Survey and Certification 
Survey enforcement efforts. Strengthen survey enforcement  Addressed in 
efforts by: making surveys more timely, effective, and  HCFA initiative 
unpredictable; increasing the number of night and weekend 
surveys and surveys at chronically substandard homes; 
focusing on specific problems, such as pressure sores; 
eliminating grace periods for homes with repeat serious 
violations; proposing new civil monetary penalties; and placing 
survey results on the internet. 
Enhanced monitoring. Enhance monitoring of special focus  Addressed in 
facilities.  HCFA initiative. 
Surveyor training.  Provide additional training and assistance  Partially 
to State surveyors.  addressed in 
HCFA initiative 
Surveyor staffing. Evaluate State surveyor staffing to assure  Action under 
adequate staffing is available.  consideration by 
HCFA 
Surveyor coordination. Provide a forum for surveyors to meet  Action under 
and discuss common issues.  consideration by 
HCFA 
Abuse. Add survey task to look at providers abuse  Addressed in 
intervention system, develop national abuse intervention  HCFA initiative 
campaign, and promote prosecution of egregious violators. 
Ombudsman Program 
Visibility. Develop guidelines for minimum levels of  Partially 
Ombudsman program visibility, including criteria for  addressed by 
frequency and length of regular visits and staffing ratios.  AoA through 
annual training 
Volunteers. Formulate strategies for recruiting, training, and  Partially 
supervising more ombudsman volunteers.  addressed by 
AoA through 
annual training 
and Ombudsman 
Resource Center 
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30 
Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  Complaint response and resolution. Develop guidelines for  Not currently 
ombudsman complaint response and resolution times.  addressed 
Reporting system. Continue to refine and improve the  Continuing 
Ombudsman programs data reporting system.  attention by AoA 
Coordination with Survey and Certification. Establish ways  Continuously 
to enhance coordination between survey and certification and  addressed 
Ombudsman programs. 
Resident Abuse Safeguards 
Employment safeguards. Improve the safety of residents and  Addressed in 
strengthen safeguards against employment of abusive workers.  HCFA initiative 
Nursing Home Staffing 
Staffing standards. Develop staffing standards for registered  Currently being 
nurses and certified nurse assistants in nursing homes to assure  studied by HCFA 
sufficient staff on all shifts to enable residents to have proper 
care. 
Care Guidelines 
Malnutrition and dehydration. Develop best practice  Addressed in 
guidelines for malnutrition and dehydration care and national  HCFA initiative 
campaign to increase awareness of these problems. 
Drug usage. Develop guidelines and protocols for using  Addressed in 
effective drugs.  HCFA initiative 
Family Involvement 
Family awareness and access. Promote and facilitate greater  Action under 
awareness and access to survey results by strengthening  consideration by 
existing avenues for receiving information and identifying new  HCFA 
avenues. 
II.  Research and Evaluation 
We also propose the development of a research and evaluation program to assess the 
quality of care in nursing homes, including a systematic look at each of the legislative 
reforms established with OBRA 1987 and other quality of care issues.  In the following 
table, we indicate where the OIG is conducting or planning work.  As the Office of 
Inspector General, we have a particular interest in assuring that the standards mandated by 
OBRA 1987 are being met.  Since we do not expect to address all of the nursing home 
requirements and issues we have identified, we invite others to join us in this evaluation. 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  OBRA 1987 
Prescription Drugs. Assess the extent and appropriateness of  OIG report 
prescription drug use by nursing home residents and describe  issued 
consultant pharmacists concerns about drug use. 
Resident assessment. Determine the systems used by  nursing  OIG study 
homes to conduct periodic resident assessments and plans of  underway 
care and evaluate how this impacts reimbursement. 
Nurse aide training. Evaluate nurse aide training  In OIG workplan 
Abuse reporting. Examine the extent to which States have  In OIG workplan 
implemented abuse reporting requirements. 
Medical director. Examine the role medical directors play in  In OIG workplan 
assuring quality of care. 
Resident rights. Assess the extent to which nursing homes are 
assuring resident rights. 
Admission rights. Assess the extent to which nursing homes 
are assuring admission, transfer, and discharge rights. 
Restraints and abuse. Assess whether rights to be free from 
restraints and abuse are being met. 
Quality of life. Assess whether or not nursing homes are 
providing care which promotes each residents quality of life. 
Resident well-being. Determine if nursing homes are 
providing care and services to maintain the highest levels of 
residents physical, mental, and psychosocial well-being. 
Nursing home services. Determine if nursing home staffing 
levels are adequate to provide required nursing, dietary, 
physician, rehabilitative, dental, and pharmacy services. 
Physical environment. Determine if nursing homes are 
maintaining a healthy and safe physical environment. 
Other Quality of Care 
Resident satisfaction. Determine the level of resident  OIG study 
satisfaction with nursing home care.  underway 
Immunizations. Examine the obstacles to immunizing 80% of  OIG study 
nursing home residents against pneumoccocal disease and  underway 
influenza. 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  III.  Progress Measurement 
Finally, an independent, continuous assessment is needed to measure the progress made in 
raising the standard of nursing home care. 
Periodic Assessments 
Periodic report card. Conduct periodic evaluations describing  Under 
conditions in nursing homes based on deficiency trends,  consideration by 
ombudsman complaints, resident satisfaction, and insiders  OIG 
perspectives. 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060  A G E N C Y  C O M M E N T S  
This report is based primarily on a series of recent studies conducted by the Office of 
Inspector General on nursing home care.  They are: 
Nursing Home Survey and Certification: Deficiency Trends, OEI-02-98-00331;

Nursing Home Survey and Certification: Overall Capacity, OEI 02-98-00330;

Long Term Care Ombudsman Program: Complaints Trends, OEI-02-98-00350;

Long Term Care Ombudsman: Overall Capacity, OEI-02-98-00351;

Public Access to Nursing Home Survey and Certification Results, OEI-06-98-

00280; and

Safeguarding Long Term Care Residents, A-12-97-0003.

We received detailed comments from HCFA, AoA, and the Assistant Secretary for Planning 
and Evaluation on the above reports.  We made modifications in each report to respond to 
the comments received and to reflect the actions already being taken to improve nursing 
home conditions.  This overview report also incorporates many of these modifications.  We 
encourage everyone to read the individual reports and the comments we received on them. 
The comments are included in each report. 
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Quality of Care in Nursing Homes: An Overview  OEI-02-99-00060