Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Quality Assurance Committees in 
Nursing Homes 
JANET REHNQUIST 
INSPECTOR GENERAL 
JANUARY 2003 
OEI-01-01-00090  O I G
FFICE OF  NSPECTOR  ENERAL

http://www.oig.hhs.gov/ 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, 
is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as 
the health and welfare of beneficiaries served by those programs.  This statutory mission is carried out 
through a nationwide network of audits, investigations, and inspections conducted by the following 
operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and operations in 
order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the 
Department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and the 
public.  The findings and recommendations contained in the inspections reports generate rapid, accurate, 
and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil 
monetary penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support in OIGs internal 
operations.  The OCIG imposes program exclusions and civil monetary penalties on health care providers 
and litigates those actions within the Department.  The OCIG also represents OIG in the global settlement 
of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E   S U M M A R Y  
OBJECTIVE 
To assess nursing home compliance with federal requirements pertaining to quality assessment 
and assurance committees and to describe the committees. 
BACKGROUND 
Quality assessment and assurance committees (QA committees) represent key points of 
accountability for ensuring both quality of care and quality of life in nursing homes. The 
Omnibus Budget Reconciliation Act of 1987 (OBRA 87) required nursing homes to maintain 
QA committees that meet at least quarterly and identify and correct quality deficiencies and 
improve care. The Centers for Medicare & Medicaid Services (CMS) determines whether 
nursing homes meet those requirements through the survey and certification process. 
This inspection is based on 384 responses to a mail survey of nursing homes, analysis of data 
from CMS Online Survey Certification and Reporting (OSCAR) system, site visits to 3 nursing 
homes, and 33 stakeholder interviews. 
FINDINGS 
The OBRA 87 mandates that nursing homes maintain QA committees as vehicles for improving 
quality of care and life in nursing homes. Our assessment shows that nearly all nursing homes 
meet CMS requirements for QA committee membership and frequency of meetings. 
Furthermore, QA committees have an array of data sources to help target problem areas in 
their nursing homes.  However, a lack of knowledge on conducting QA committee work, as 
well as staff shortages and turnover, challenge QA committees. 
Overall, nursing homes are in compliance with QA committee requirements but 
face some barriers. 
Nursing homes meet requirements for QA committee membership. From 1997 to 2001, 
99 percent of nursing homes met CMS requirements for QA committee membership. In 80 
percent of the nursing homes that we surveyed, QA committees consisted of 7 or more 
members from several areas of their nursing homes. 
Nursing homes meet requirements for frequency of QA committee meetings. From 
1997 to 2001, 99 percent of nursing homes met CMS requirements for quarterly QA 
committee meetings. Additionally, 61 percent of nursing homes indicated on our survey 
i 
Nursing Home QA Committees  OEI-01-01-00090  that their QA committees meet more frequently than required by regulation. 
The QA committees use an array of data sources to target problem areas in their 
nursing homes. The QA committees reported relying on an average of eight sources of 
information to assess the care their nursing homes provide as well as other aspects of the 
nursing homes operations. These sources include CMS quality indicators, certification survey 
results, and staff and resident input. 
However, knowledge deficits impede QA committees.  While QA committees have an 
array of information to help them pinpoint problems in nursing homes, knowledge of how to use 
this information to execute projects remains a key barrier. 
Staff shortages and turnover challenge QA committees. On our survey, 53 percent of 
nursing homes reported that not having enough staff was a barrier to a more effective QA 
committee, and 47 percent of nursing homes cited general staff turnover, such as among 
certified nursing assistants, as a barrier. 
. 
CONCLUSION 
Our review shows that nearly all nursing homes meet CMS two requirements for QA 
committees.  The QA committees also have many sources of information available to them. 
However, a lack of knowledge on how to use this available information impedes QA 
committees.  Additionally, staff shortages and turnover in nursing homes are further barriers to 
QA committees. These fundamental challenges can impede the work of even the most diligent 
QA committee. 
ii 
Nursing Home QA Committees  OEI-01-01-00090  T A B L E   O F   C O N T E N T S  
PAGE

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

INTRODUCTION ............................................................. 1

FINDINGS  .................................................................. 4

Nursing homes are in compliance with requirements but face barriers.  .................. 4

CONCLUSION  ..............................................................9

APPENDICES .............................................................. 10

A: Methodology ......................................................... 10

B: Endnotes ............................................................14

ACKNOWLEDGMENTS ..................................................... 15

iii 
Nursing Home QA Committees  OEI-01-01-00090  I N T R O D U C T I O N  
OBJECTIVE 
To assess nursing home compliance with federal requirements pertaining to quality assessment 
and assurance committees and to describe the committees. 
BACKGROUND 
OBRA 87 and Quality Assessment and Assurance Committees 
Concerns about substandard care and resident quality of life as well as inadequate oversight of 
substandard nursing homes led to a landmark 1986 study by the Institute of Medicine (IOM). 
Among its findings, the IOM wrote that more effective government regulation can substantially 
improve quality in nursing homes.1 In response to the report, Congress passed a number of 
nursing home provisions as a part of the Omnibus Budget Reconciliation Act of 1987 (OBRA 
87). 
OBRA 87 instituted substantial reforms in nursing homes to improve quality of care and quality 
of life, and to protect residents rights.  Quality assessment and assurance committees (QA 
committees) represent a vehicle mandated by OBRA 87 to achieve those improvements. 
Specifically, OBRA 87 requires nursing homes to maintain a quality assessment and assurance 
committee, consisting of the director of nursing services, a physician designated by the facility, 
and three other members of the facilitys staff. The committee must meet at least quarterly to 
identify issues with respect to which quality assessment and assurance activities are necessary, 
and develop and implement appropriate plans of action to correct identified quality 
deficiencies. 
Holding Nursing Homes Accountable for Quality Assurance 
The Centers for Medicare & Medicaid Services (CMS) implemented final regulations for 
OBRA 87 provisions in July 1995.  Nursing homes participating in Medicare must meet these 
requirements.  Among the requirements are two specifically about QA committees.  These 
requirements mirror the provisions of OBRA 87. One requirement calls for the existence and 
specific membership of a committee, and the other calls for the committee to meet quarterly and 
to identify issues in the nursing home requiring QA committee activity. 
The CMS determines whether nursing homes meet those requirements through the survey and 
certification process. Surveyors assess QA committee requirements by interview and 
observation.  The CMS instructs surveyors to interview a facilitys administrative staff to 
1 
Nursing Home QA Committees  OEI-01-01-00090  determine that it has a QA committee and that its required membership and frequency of 
meetings comply with the requirements. Surveyors do not have access to QA committee 
minutes due to the confidentiality of these documents mandated by OBRA 87.  The CMS 
instructs surveyors to describe in the survey report how the facility identifies quality deficiencies 
and responds to the identified issues. 
Significance of QA Committees 
The QA committees provide an important point of accountability for ensuring both quality of 
care and quality of life in nursing homes.  They represent key internal mechanisms that allow 
nursing homes opportunities to deal with quality concerns in a confidential manner and can help 
them sustain a culture of quality improvement.  Nursing homes are already subject to significant 
external oversight, such as the Medicare and Medicaid certification process and ombudsman 
program. However, because of their external nature, they are outside the scope of a nursing 
homes own control.  The QA committees, on the other hand, are internal and ideally can 
complement the external oversight. 
To date, CMS has provided limited guidance to help QA committees. Guidance on quality 
assurance and improvement can come from the survey process in the form of what CMS calls 
information transfer. This permits the surveyor to inform the nursing home about care and 
regulatory topics that would be useful to the facility for understanding and applying best 
practices in the care and treatment of long term care residents.2 Yet, information transfer is 
not consultative. The CMS State Operations Manual, which provides guidance to state 
agencies, states that This information exchange is not a consultation with the facility but is a 
means of disseminating information that may be of assistance to the facility in meeting long term 
care requirements.3 
METHODOLOGY 
We selected a national, simple random sample of 601 nursing homes from CMS Online 
Survey Certification and Reporting (OSCAR) system. We mailed surveys to the administrators 
of the sampled nursing homes to learn about the work of their QA committees. We followed 
up with a second mailing to those nursing homes who had not responded.  We received 
responses from 384 nursing homes, yielding a 63.9 percent response rate. Appendix A 
contains additional information about the survey, including confidence intervals for key 
questions and a nonrespondent analysis. 
In addition, we judgementally selected and visited three nursing homes to learn more about their 
QA committees. In each nursing home, we met with the administrator and other individuals 
involved in the QA committee. In one nursing home we observed a QA committee meeting. 
We also interviewed a judgemental sample of stakeholders from organizations with interest and 
expertise in nursing home quality assurance, as well as nursing home executives and CMS 
regional office staff. Since the data collected from 
2 
Nursing Home QA Committees  OEI-01-01-00090  these entities were from a purposive sample, this information cannot be generalized to the 
population. 
We analyzed nursing home data from the OSCAR system to identify the frequency of 
deficiencies for QA committee survey requirements from 1997 to 2001.  We also reviewed 
relevant literature, laws, regulation, and other documents. 
We conducted this inspection in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
3 
Nursing Home QA Committees  OEI-01-01-00090  F I N D I N G S  
Our assessment shows that nearly all nursing homes meet CMS requirements for QA 
committee membership and frequency of meetings.  Furthermore, QA committees have an 
array of data sources to help target problem areas in their nursing homes.  However, a lack of 
knowledge on conducting QA committee work, as well as staff shortages and turnover, 
challenge QA committees. The OBRA 87 mandates that nursing homes maintain QA 
committees as vehicles for improving quality of care and life in nursing homes.  Our review is 
based on 384 responses to a mail survey of a national random sample of nursing homes; site 
visits to 3 nursing homes; 33 interviews with stakeholders with expertise and interest in nursing 
home quality; data from CMS OSCAR system; and relevant literature, laws, regulation, and 
other documents. 
Overall, nursing homes are in compliance with QA committee 
requirements but face some barriers. 
Nursing homes meet requirements for QA committee membership. 
Data from CMS OSCAR system show that from 1997 to 2001, 99 percent of nursing homes 
met CMS requirements for QA committee membership.  At a minimum, the QA committee 
must include the director of nursing, a physician, and 
three other members of the nursing homes staff. 
Table 1 
However, nursing homes include a variety of staff on their 
QA committees, including a core of key personnel (see  Participation of nursing home 
Table 1). In 80 percent of nursing homes we surveyed,  staff in QA committees 
QA committees consisted of 7 or more members from 
Director of nursing  99% 
several areas of their nursing homes. Committee 
Administrator  96% 
members identified by respondents include directors of 
Social services manager  93% 
dietary services, activities, and housekeeping  Medical director  90% 
departments; business office managers; minimum data set  Infection control manager  82% 
coordinators; medical records coordinators; and 
Source: OIG survey of nursing homes, 
environmental and maintenance staff.  Many QA 
committees also include individuals who are not on their 
staff. For example, 70 percent of nursing homes reported that pharmacy consultants regularly 
participate in committee meetings. 
Nursing home stakeholders we spoke with noted that including a broad membership on the QA 
committee helps to ensure that the committee represents all areas of the home. One nursing 
home administrator we spoke with includes all department managers on her nursing homes QA 
committee. The committee members are responsible for both 
4 
Nursing Home QA Committees  OEI-01-01-00090  handling committee work and communicating to their staff about what happens in each QA 
committee meeting. 
The QA committees, however, typically do not include certified nursing assistants (CNAs) as 
regularly participating members.  On our survey, just 24 percent of nursing homes reported that 
CNAs regularly participate on their QA committees. Nursing home professionals we spoke 
with stressed the value of including CNAs in QA committees.  As the CNAs are the primary 
caregivers in a nursing home, they possess a wealth of knowledge about a homes residents, as 
well as knowing which processes and products work best in caregiving. One director of 
nursing told us, CNAs know 90 percent of the answers. Nursing home professionals with 
whom we spoke who do not have CNAs participate on the QA committee cite time and staff 
shortages for the exclusion. When CNAs participate in a committee meeting, they are taken 
away from caring for residents. If a nursing home has a staffing shortage, as most do, taking 
time away from caregiving is a tradeoff that few nursing homes can afford. 
Nursing homes meet requirements for frequency of QA committee meetings. 
Data from OSCAR show that from 1997 to 2001, 98 percent of nursing homes met CMS

requirement for quarterly QA committee

meetings. Additionally, 61 percent of nursing

homes indicated on our survey that their QA

committees meet more frequently than required

by regulation (see Figure 1). The more

frequently a QA committee meets, the more

visible the committee is likely to be in the

nursing home. Frequent meetings also can give

attention to issues in a timely manner. 

While time pressures and other priorities may

make it difficult for the QA committee to meet

often, nursing home professionals with whom

we spoke affirmed the importance of frequent

meetings.  As one nursing home stakeholder

said, Does anyone think that meeting once a quarter is going to improve quality?

The QA committees use an array of data sources to target problem areas in their 
nursing homes. 
On our survey, QA committees reported relying on an average of eight sources of information 
to assess the care their nursing homes provide as well as other aspects of the nursing homes 
operations.  Of these sources, 73 percent of nursing homes reported that 
5 
Nursing Home QA Committees  OEI-01-01-00090  CMS quality indicators (QIs) were a major influence on the work of the QA committee.  In 
1999, CMS introduced the QIs as a new means for nursing homes to pinpoint quality-of-care 
issues with data. The QIs encompass 11 areas of care: accidents, behavior/ emotional patterns, 
clinical management, cognitive patterns, elimination/incontinence, infection control, 
nutrition/eating, physical functioning, psychotropic drug use, quality of life, and skin care.  One 
nursing home administrator commented, They are the pulse of our residents quality-of-care 
issues. 
Nursing homes reported that they systematically review and use the QIs, with 68 percent 
reviewing QIs monthly. Some nursing homes review their QIs even more often; 17 percent 
reported reviewing them weekly or more frequently. Almost 80 percent detected concerns 
through their review of QIs and launched projects to further examine these areas. Of these, the 
most common areas of the QIs in which projects 
were undertaken were accidents (77 percent), 
skin care (76 percent), nutrition/eating (71  Using established agendas ensure 
systematic detection of problems 
percent), and elimination/incontinence (63 
percent). 
Such an agenda identifies topics and 
establishes the frequency of their review. For 
Some nursing homes also rely on clinical  example, the agenda could require that falls 
indicators other than QIs that are created  be reviewed weekly, while resident 
satisfaction surveys be reviewed annually. 
specifically by the nursing home or their corporate 
This institutionalizes the agenda. 
or parent office.  On our survey, 65 percent noted 
that such indicators had a major influence on the  Source: OIG survey of nursing homes and 
work of their QA committees. One nursing home  stakeholder interviews, 2001-2002. 
we visited uses its own indicators. It created 
them to target certain problem areas that they had, both clinical and nonclinical, such as 
medication transcription errors and resident activity participation. 
Committees also use results from surveys to target their work. For example, 81 percent of 
nursing homes reported that results from certification surveys were a major influence on the 
work of their QA committees.  Surveys review a nursing homes entire operation, from quality 
of care to administration to safety. The results of the survey and the deficiencies found alert the 
committee to areas of concern, which they then may address. 
Lastly, QA committees also rely on input from staff and residents to detect problems in the 
nursing home. On our survey, 66 percent of nursing homes reported that staff input and 55 
percent reported that resident input had a major influence on committee work. One nursing 
home that we visited also conducts focus groups with residents and their families. As this 
nursing home has an ethnically diverse population, these focus groups have allowed the 
committee to make changes in the nursing home, especially in dining and activities, that better 
reflect the residents needs. 
6 
Nursing Home QA Committees  OEI-01-01-00090  However, knowledge deficits impede QA committees. 
While QA committees have an array of information to help them pinpoint problems in nursing 
homes, the QA committees knowledge of how to use this information to execute projects 
remains a key barrier.  On our survey, we asked an open-ended question regarding what 
additional steps CMS could take to help increase the effectiveness of QA committees.  The top 
response, reported by 39 percent of nursing homes, was a call for more guidance and examples 
about how to best use their QA committees.  Additionally, in its 2001 report examining the 
quality of nursing home care, the IOM found that most nursing homes, even highly motivated 
ones, may lack the technical expertise and resourcesincluding but not limited to staffing 
levelsnecessary to translate...quality improvement systems into practice.4 
Nursing home stakeholders with whom we spoke reflected those findings and also noted that 
nursing homes are well behind the curve in going beyond traditional quality assurance finding 
problems and fixing them without necessarily identifying their core causesto continuous 
quality improvement.  Some nursing homes do carry out quality improvement projects, which 
involve measuring baseline performance, collecting appropriate data and information, 
implementing an intervention based on the data, and monitoring the results over time. However, 
it is a more analytic and intensive approach, requiring knowledge of systems and principles of 
measurement, which nursing homes are hard-pressed to meet, and with which they have limited 
experience. 
Nursing homes reported struggles with knowledge on how best to use their QA committees on 
our survey. Thirty-three percent reported a lack of knowledge about how to conduct QA 
committee work as a barrier to the committeess 
overall effectiveness and 29 percent reported 
Wellspring: sharing innovations among 
unclear guidelines and regulations concerning 
nursing homes 
QA committees as a barrier. One particular 
area in which QA committees have a knowledge  Nursing homes that are a part of Wellspring 
Innovative Solutions have the benefit of 
deficit is with CMS quality indicators (QIs). 
collaborative relationships they can use to help 
While most nursing homes use the QIs, 35 
each other solve their problems. Wellspring is a 
percent of nursing homes reported that their lack  cooperative alliance of independent nursing 
of knowledge on how to use these indicators has  homes, established in 1994, that came together 
to enhance quality, promote culture change, 
been a barrier to using them more effectively. 
and provide efficient and caring services to 
elders. 
Despite their struggle with executing QA 
committee work, a number of resources exist for  A key element of Wellspring is that all nursing 
nursing homes.  For example, some nursing  homes collect and use best practices. As staff 
from all levels in Wellspring homes participate 
homes have formed alliances to share such 
in teams that look at data, these teams are able 
information (see box at right for an example). 
to consult staff in other Wellspring homes on 
The parent organizations of some nursing homes  their experiences. This way, each nursing home 
have quality processes and systems that can  is able to benefit from the knowledge of the 
other nursing homes. 
guide the work of QA 
Source: OIG stakeholder interviews, 2001. 
7 
Nursing Home QA Committees  OEI-01-01-00090  committees. The American Association for Homes and Services for the Aging published a 
guide for its member nursing homes on steps to a successful quality assurance program and has 
held training courses on using the guide. Other organizations, such as the American Medical 
Directors Association, conduct training seminars on using the QIs for quality improvement 
projects.  Furthermore, some states have initiatives aimed at helping nursing homes with quality 
assurance and improvement work. 
The extent to which nursing homes and their QA committees take advantage of these resources 
is unknown. Some suggest that CMS needs to exert leadership in this capacity. As discussed 
below, staff shortages and time constraints can impede QA committee work.  As a result, QA 
committees may be hard pressed to take full advantage of such resources. 
Staff shortages and turnover challenge QA committees. 
Because members of QA committees handle committee work on top of their regular tasks in 
the nursing home, staff shortages and turnover remain a key barrier to the QA committees 
work. On our survey, 53 percent of nursing homes reported that not having enough staff was a 
barrier to a more effective committee, and 47 percent of nursing homes cited general staff 
turnover, such as among certified nursing assistants, as a barrier. As a recent national study has 
reported that 9 out of 10 nursing homes are seriously understaffed, these barriers to effective 
QA committees may frequently occur.5 
Staff shortages and turnover can impede QA committees in many ways. With such shortages, 
resident care will take a priority over QA committee work. Turnover also challenges a nursing 
homes ability to have a QA committee that can effectively  follow-up and be accountable for 
ensuring improvements in the home. With a continual influx of new staff and their needs for 
orientation and training, getting staff up to speed with what is happening in a homes QA 
committee may not be a priority. Turnover of QA committee members may especially impede 
the committee, as the persons knowledge and expertise about committee work leave the 
nursing home with the person. 
Turnover at the leadership level of a nursing home further impedes the QA committee. 
Leadership commitment to quality improvement is vital for instilling a culture that can promote 
accountability for quality. As an executive from one nursing home told us, Having a (QA) 
committee is one piece, but it is not the answer...it has to permeate your organization. 
According to stakeholders, having someone champion quality at the helm can promote buy in 
for quality efforts throughout the home.  However, the reality for many homes is that turnover in 
key leadership positions makes that culture elusive. On our survey, 27 percent cited turnover in 
such positions as a barrier to a more effective QA committee. In some cases, nursing homes 
responding to our survey were unable to answer basic questions about their QA committee, 
noting a recent turnover in leadership positions.  In fact, filling leadership positions are becoming 
increasingly difficult as fewer candidates are being attracted to the administrators position: from 
1997 to 2000, the number of candidates taking the long-term care administrators exam 
declined by 37 percent.6 
8 
Nursing Home QA Committees  OEI-01-01-00090  C O N C L U S I O N
Our review shows that nearly all nursing homes meet CMS two requirements for QA
committees.  The QA committees also have many sources of information available to them. 
However, a lack of knowledge on how to use this available information impedes QA
committees.  Additionally, staff shortages and turnover in nursing homes are further barriers to
QA committees.  These fundamental challenges can impede the work of even the most diligent
QA committee. 
 
9     
Nursing Home QA Committees OEI-01-01-00090 APPENDIX A 
Methodology 
Survey of Nursing Homes 
We mailed a survey to administrators of a national simple random sample of nursing homes in 
November 2001 and sent a follow-up mailing in December 2001 to those who had not 
responded .  We preceded our survey mailing with a cover letter that was sent in October 2001 
informing the nursing home administrators about the survey and this inspection. 
We requested that the survey be completed by the homes Director of Nursing (a required 
member of the QA committee) or another individual responsible for the QA committee.  Our 
survey solicited information on the following areas: background information on the nursing 
home, structure of the QA committee, work of the QA committee, committee projects, CMS 
Quality Indicators, barriers to QA committee effectiveness, assessment of the QA committee, 
and an open-ended section for additional comments. 
We chose to survey a national simple random sample of nursing homes, because the 
requirements for QA committees apply to all nursing homes that participate in Medicare.  Our 
original sample comprised 671 nursing homes randomly selected from CMS Online Survey 
Certification and Reporting (OSCAR) system database. We deleted 17 nursing homes from 
the original sample after consulting with other components of the Office of Inspector General, 
reducing our sample size to 654.  We then were notified that 53 nursing homes had ceased 
operations, even though they still appeared in the OSCAR database, reducing our final sample 
size to 601. 
We received responses from 384 nursing homes, yielding a response rate of 63.9 percent. 
Nonrespondent Analysis 
To determine whether significant differences exist between survey respondents and 
nonrespondents, we conducted nonrespondent analyses using four variables. These variables 
included: average complaints per nursing home (using number of beds as the denominator), 
average deficiencies per nursing home (also using number of beds as the denominator), number 
of certified beds, and nursing home control. One nursing home that responded to our survey 
excluded identifying information; therefore, we based these analyses on 383 respondents. 
10 
Nursing Home QA Committees  OEI-01-01-00090  APPENDIX A 
Complaints and deficiencies 
We obtained data for the average complaints and average deficiencies from the OSCAR 
complaints files.  Because 492 of the 601 nursing homes in our sample had a match to the 
complaints file, we limited the analyses for these two variables to these 492 nursing homes.  Of 
the 492 nursing homes, 160 did not respond, and the remaining 332 responded. We used 
averages for the deficiencies and complaints to allow for the difference in the size among the 
nursing homes. 
The average number of complaints per nursing home was .0157 for nonrespondents, compared 
to .0155 for respondents. The average deficiencies per bed for nonrespondents was .115, 
compared to .0963 for responding nursing homes. No significant difference at the 95 percent 
confidence level existed between the average complaints, or average deficiencies, for the two 
groups. 
Analysis by number of certified beds and nursing home control 
The average number of certified beds in nursing homes responding to our survey was 113, 
compared to 100 for nonrespondents.  A t-test found a statistically significant difference 
between the means at the 95 percent confidence level. 
Sample  Respondents  Nonrespondents 
N=601  N=383  N = 218 
Average number of certified beds  108  113  100 
t = - 2.07  Degrees of freedom = 599 
An analysis by nursing home control showed a significant difference between nonrespondents 
from for-profit nursing homes and not-for-profit/government-owned nursing homes.  The Chi-
square test was significant for the control variable, because it was greater than 3.84 at the 95 
percent confidence level. 
Sample  Respondents  Nonrespondents 
For-profit  441 (73.4%)  266 (69.5%)  175 (80.3%) 
Not-for-profit/government  160 (26.6%)  117 (30.5%)  43 (19.7%) 
Total  601  383  218 
Chi - square statistic = 8.33  Degrees of freedom = 1 
11 
Nursing Home QA Committees  OEI-01-01-00090  APPENDIX A 
Because of the significant differences from these analyses, we conducted further analysis to 
determine the effect of the relationship between the number of certified beds and response rate, 
and nursing home control and response rate. Assuming nonrespondents would have answered 
questions the same as respondents, we calculated hypothetical responses for key questions 
related to our findings. All calculations were within the 95 percent confidence intervals of the 
original estimates. Thus, we did not find statistical evidence of bias based on number of 
certified beds or nursing home control. 
Confidence Intervals for Key Questions (95 percent) 
Description  Point  Confidence 
estimate  Interval 
QA committees with 7 or more members  80%  +/- 4.0% 
QA committees with regularly participating CNAs  24%  +/- 4.3% 
QA committees that meet monthly or more frequently  61%  +/- 4.9% 
QIs are a major influence on the work of the QA committee  73%  +/- 4.4% 
Certification surveys are a major influence on the QA committee  81%  +/- 3.9% 
Nursing homes want more QA committee guidance from CMS  39%  +/- 4.9% 
Lack of knowledge on how to use QIs is a barrier to effective  35%  +/- 4.8% 
use 
Lack of staff to do QA committee work is a barrier to having an  53%  +/- 5.0% 
effective QA committee 
General staff turnover is a barrier to overall effectiveness of QA  47%  +/- 5.0% 
committee 
Leadership turnover is a barrier to an effective QA committee  27%  +/- 4.4% 
Site Visits 
We judgementally selected and visited three nursing homes in Massachusetts, New Hampshire, 
and Wisconsin to learn more about their QA committees. In one nursing home we observed a 
QA committee meeting. In each nursing home, we met with the administrator as well as key 
staff involved in the QA committee, including directors of nursing, other nursing staff, minimum 
data set coordinators, department managers, and certified nursing assistants.  Since the data 
collected from these entities were from a purposive sample, this information obtained cannot be 
generalized to the population. 
12 
Nursing Home QA Committees  OEI-01-01-00090  APPENDIX A 
Stakeholder Interviews 
We judgementally selected and interviewed, either in person or by telephone, 33 stakeholders 
with expertise and interest in nursing home quality assurance.  These stakeholders included 
CMS central office staff and senior nursing home surveyors in CMS regional offices.  Since the 
data collected from these entities was from a purposive sample, this information obtained 
cannot be generalized to the population. We also interviewed representatives from the 
American Association of Homes and Services for the Aging, American Health Care 
Association, the National Citizens Coalition for Nursing Home Reform, the American College 
of Health Care Administrators, and the Pioneer Network, as well as representatives from state 
affiliates of these organizations. Additionally, we interviewed executives and staff from nursing 
homes and nursing home corporations. 
OSCAR data analysis 
We analyzed all nursing home data from CMS OSCAR system for the years 1997 to 2001 to 
identify the frequency of deficiencies for QA committee survey requirements (F520 and F521). 
The deficiency rates presented below are for the number of deficiencies for each requirement in 
a calendar year divided by the number of surveys conducted in that year. 
Deficiency Rates for QA Requirements for Nursing Homes, 1997 - 2001 
Requirement  1997  1998  1999  2000  2001 
Committee membership (F520)  0.7%  0.5%  1.0%  1.2%  0.9% 
Quarterly Meetings (F521)  2.0%  1.8%  2.0%  2.5%  2.1% 
Document review 
We reviewed relevant federal laws and regulations, as well as chapters of CMS State 
Operations Manual relative to the Survey and Enforcement Process for Skilled Nursing 
Facilities and Nursing Facilities.  We also reviewed plans of correction completed by nursing 
homes and survey deficiency reports.  Lastly, we reviewed articles, books, and reports relative 
to quality assessment and assurance in nursing homes. 
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Nursing Home QA Committees  OEI-01-01-00090  APPENDIX B 
Endnotes 
1. Institute of Medicine, Improving the Quality of Care in Nursing Homes (Washington, DC: 
National Academy Press, 1986), 21. 
2. Centers for Medicare & Medicaid Services, State Operations Manual, page P-77. 
3. Ibid. 
4. Institute of Medicine, Improving the Quality of Long-Term Care (Washington, DC: National 
Academy Press, 2001), 15. 
5. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report 
(Cambridge, MA: Abt Associates, 2001), 1-7. Accessed from 
http://www.house.gov/reform/min/inves_nursing/nursing_cms_rep.htm on April 25, 2002. 
6. National Association of Boards of Examiners of Long Term Care Administrators press release, 
Nursing Home Administrators: A Vanishing Profession?  Third Year of Decline, Increasing Need, 
Signals Crisis-in-the-Making. March 2, 2001 
14 
Nursing Home QA Committees  OEI-01-01-00090  A C K N O W L E D G M E N T S
This report was prepared under the direction of Mark R. Yessian, Ph.D.,  Regional Inspector General
for Evaluation and Inspections in Boston and Joyce M. Greenleaf, M.B.A., Assistant Regional
Inspector General.  Other principal Office of Evaluation and Inspections staff who contributed include:
Maria E. Maddaloni, M.A., Lead Analyst Sandy Khoury, Program Specialist
Christopher T. Gould, M.S., Program Analyst Bambi D. Straw, Program Specialist
Barbara Tedesco, Mathematical Statistician
Linda Moscoe, Technical Support Staff 
For information or copies of this report, please contact
the Office of Inspector Generals
Public Affairs office at (202) 619-1343.
Reports are also available on the World Wide Web at our home page address:
http://www.oig.hhs.gov/
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Nursing Home QA Committees OEI-01-01-00090