Department of Health and Human Services


OFFICE OF 

INSPECTOR GENERAL 

STATE REFERRAL OF


NURSING HOME 


ENFORCEMENT CASES


Daniel R. Levinson 

Inspector General 

December 2005


OEI-06-03-00400

Office of Inspector General 
 http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 

as amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors 

in carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts management and program 

evaluations (called inspections) that focus on issues of concern to HHS, Congress, and 

the public. The findings and recommendations contained in the inspections generate 

rapid, accurate, and up-to-date information on the efficiency, vulnerability, and 

effectiveness of departmental programs. OEI also oversees State Medicaid Fraud 

Control Units which investigate and prosecute fraud and patient abuse in the Medicaid 

program. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 

and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 

convictions, administrative sanctions, or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support in OIG's internal operations. OCIG imposes program exclusions and civil 

monetary penalties on health care providers and litigates those actions within HHS. 

OCIG also represents OIG in the global settlement of cases arising under the Civil False 

Claims Act, develops and monitors corporate integrity agreements, develops compliance 

program guidances, renders advisory opinions on OIG sanctions to the health care 

community, and issues fraud alerts and other industry guidance. 
Δ EXECUTIVE SUMMAR Y 

OBJECTIVE 

To determine the extent to which State survey agencies refer nursing 

home enforcement cases, as required, to the Centers for Medicare & 

Medicaid Services (CMS). 

BACKGROUND 

The Omnibus Budget Reconciliation Act of 1987 established a survey 

and certification process to maintain Federal standards in nursing 

homes certified for participation in the Medicare and/or Medicaid 

programs. CMS has the responsibility for enforcement at the Federal 

level and contracts with States to survey facilities to certify compliance. 

Deficiencies in patient care are considered in conjunction with facility 

history to determine any CMS enforcement action. 

For CMS to enforce standards, States are required to refer three types 

of cases to CMS: immediate jeopardy cases, which involve actual (or 

potential for) death or serious injury; double G cases, which identify 

facilities with a historical pattern of high-level noncompliance; and 

opportunity to correct cases, which involve facilities failing to correct 

less severe problems within a given timeframe. 

For this inspection, we identified cases between July 2002 and June 

2003 that were not referred, reviewed documentation for these cases 

from CMS and States, and interviewed CMS and State staff. 

FINDINGS 

States failed to refer almost 8 percent of required nursing home 

enforcement cases. Although States referred most nursing home cases 

warranting enforcement during the study period, we estimate that 

7.6 percent of cases were not referred. Two problems accounted for 

78 percent of nonreferrals: difficulty identifying double G cases and 

attempted referrals that were not recognized as such by CMS. The 

remaining nonreferrals were caused by random human error and a 

variety of other, less common policy and procedural problems. 

Difficulty identifying double G cases, resulting from problems with 

reviews of facility history, caused 47 percent of nonreferrals. Double 

G cases require that State staff review facility history to establish a 

pattern of noncompliance. We found two primary difficulties in properly 

identifying double G cases during these reviews: State staff did not 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES i 
EXE CUTIVE S U MMAR Y

conduct a thorough review to detect all prior high-level deficiencies, and 

State staff misunderstood the fairly complex double G criteria. There is 

also evidence that these criteria are not completely clear to some CMS 

regional office staff. In 21 percent of double G cases that were not 

referred, State staff received incorrect or insufficient guidance from 

CMS. 

Unsuccessful referrals, resulting in 31 percent of nonreferrals, were 

those attempted by States but not recognized as referrals by CMS. 

For these cases, States documented that they provided a referral to CMS, 

but CMS staff reported they never received the referral. When we 

pursued these cases further, we found that either the methods States 

used to refer the cases were inadequate to alert CMS staff that a referral 

had been made, or that States sent sufficient documentation but the 

referrals were still missed. Neither States nor CMS reported having a 

routine process for verifying whether CMS received referrals. 

RECOMMENDATIONS 

CMS should address the failure to identify double G cases. CMS 

should clarify and communicate specific criteria for identifying double G 

cases to both State and CMS regional office staff, focusing on common 

areas of misunderstanding. CMS should also provide technical 

assistance to States to assist in improving State reviews of facility 

history which would identify double G cases. 

CMS should address the incidence of attempted but unsuccessful 

referrals by developing a uniform referral process. To ensure that all 

State referrals are received, CMS should implement a uniform referral 

process that could include a standard referral document or an automated 

referral mechanism within the enforcement data system shared by States 

and CMS. CMS should also develop a method for verifying that cases 

referred by States are received by CMS. 

AGENCY COMMENTS 

CMS concurred with our recommendations. The agency further 

commented that it has recently or will soon implement all of the Office 

of Inspector General’s recommendations. 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES ii 
Δ T ABLE OF CONTENTS 

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

INTR O D U C T I ON ........................................... 1

FINDI NGS ................................................. 6

Incidence of nonreferral .................................. 6

Causes of nonreferral .................................... 6

 Double G cases ......................................... 7

Attempted but unsuccessful referrals ....................... 9

RECOM M E NDATI O NS ..................................... 11

ENDN OTE S ............................................... 14

APPENDIXES ............................................. 16

A: Detailed Methdology ................................. 16

B: Confidence Intervals ................................. 22

C: Other Policy and Procedural Problems................... 23

D: Double G Case Example .............................. 25

E: Agency Comments ................................... 26

ACKN O W LEDGMENTS .................................... 30
Δ INTRODU C TION 

OBJECTIVE 

To determine the extent to which State survey agencies refer nursing 

home enforcement cases, as required, to the Centers for Medicare & 

Medicaid Services (CMS). 

BACKGROUND 

Enforcement Process 

The Social Security Act (the Act) establishes requirements for nursing 

home participation in the Medicare and Medicaid programs. The 

Secretary is responsible for ensuring that these requirements and their 

enforcement “are adequate to protect the health, safety, welfare, and 

rights of residents and to promote the effective and efficient use of public 

moneys.”1 The Omnibus Budget Reconciliation Act of 1987 establishes a 

survey and certification process for CMS and States to use to verify that 

Federal standards are maintained in nursing homes certified for 

participation in the Medicare and/or Medicaid programs. 

CMS has primary responsibility for enforcement of these standards, and 

contracts with State survey and certification agencies to survey each 

facility no less than once every 15 months to certify compliance with 

Federal standards.2 Surveyors revisit noncompliant facilities to 

determine whether deficiencies have been corrected and to investigate 

complaints. These surveys are abbreviated versions of the standard 

surveys. Any deficiency in quality of care, safety, or patient rights, as 

determined through these surveys, may lead to CMS enforcement actions. 

Deficiencies identified during any facility survey are evaluated against a 

set of factors to determine a scope and severity rating.3 The Scope and 

Severity Grid (Table 1) ranks deficiencies according to how widespread 

they are and their outcomes, such as harm to residents.4 The scope and 

severity levels of the deficiencies are considered in conjunction with the 

facility’s compliance history to determine the enforcement actions taken 

by CMS, including imposing remedies such as denial of payment and civil 

money penalties.5 Successful referral of nursing home enforcement cases 

by States is essential to CMS’s efforts to enforce Federal standards of 

care. 

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INTROD UCT ION

 Table 1: Scope and Severity Grid for Deficiencies 

 Deficiency Severity 

Deficiency Scope 

Isolated Pattern Widespread

 Actual or potential for death or serious 

 injury (immediate jeopardy) J K L 

 Actual harm that is not immediate jeopardy G H I 

 Potential for more than minimal harm D E F 

Potential for minimal harm; substantial 

compliance exists A B C 

Source: CMS State Operations Manual, Chapter 7. 

Case Referral Requirements 

States are required by CMS to refer three types of enforcement cases to 

CMS regional offices, as described below. When CMS receives such a 

referral, case information is entered into the Long Term Care 

Enforcement Tracking System (LTC), a compilation of each region’s 

nursing home enforcement case files. Once a case is referred, CMS 

considers the State recommendations and imposes remedies on the 

facility. An enforcement case includes all enforcement activity with 

respect to a particular facility during a continuous period of 

noncompliance, which enforcement staff refer to as a cycle.6 The three 

types of cases requiring referral are: 

Immediate Jeopardy Cases. These are cases in which there is actual (or 

potential for) death or serious injury. They involve the highest level of 

noncompliance by a facility, i.e., scope and severity ratings of J, K, and L. 

States must refer these facilities to CMS within 2 calendar days of finding 

the deficiency so that CMS can initiate required enforcement activities.7 

Because of the severity of noncompliance, CMS will terminate the 

Medicare contract of facilities with immediate jeopardy citations lasting 

23 days or more. 

Double G Cases.8 The Poor Performer Rule was developed in 1998 as a 

method for identifying historical patterns of high-level noncompliance by 

facilities and expanded in 1999 to the Double G Rule.9 The expanded rule 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES 2 
INTROD UCT ION 

requires States to establish a double G case when a facility is cited for 

G-level or higher deficiencies on two surveys, hence the term double G. 10 

When a G-level deficiency is cited on a current survey, State staff must 

review facility history to determine whether the facility was previously 

cited with a G-level deficiency. However, not all G-level deficiencies found 

in facility histories count toward a double G. Therefore, establishing a 

double G case hinges on correct identification of the “prior G.” 

Double G criteria are defined as follows: double G cases are established 

when G-level deficiencies are cited on a current survey and on a prior 

survey. These surveys can be standard, complaint, or revisit surveys. 

Prior G-level deficiencies count toward establishing a case if they were 

cited on the most recent completed standard survey (completed indicating 

that compliance was eventually achieved). Prior G-level deficiencies also 

count if they were cited on any intervening survey between the most 

recently completed standard survey and the current survey, as long as 

they are not in the same period of noncompliance as the current survey. 

(A pattern of noncompliance is indicated when the two G-level deficiencies 

occur in separate periods of noncompliance.) 

Opportunity to Correct Cases. For most cases that are not rated as 

immediate jeopardy or double G, facilities are provided an opportunity to 

correct problems. In these cases, facilities are allowed a period during 

which they can come into compliance without the involvement of CMS. 

Upon revisit by State surveyors, if deficiencies at a scope and severity 

level of D or above are not corrected, States are required to refer the case 

to CMS. Generally, States are expected to conduct the revisit within 60 

days of the initial finding of noncompliance. Then, if referral is needed, 

States are required to refer the case to CMS within 70 days of the initial 

finding of noncompliance. Adherence to this timeframe is important 

because it provides CMS time to impose a denial of payment for new 

admissions by the 90th day of noncompliance, as required in the Act.11 

The Referral Process 

The term “referral” describes the process by which State survey agencies 

notify CMS about cases of noncompliance and recommend enforcement 

actions. Without a successful referral, CMS cannot fulfill its obligation to 

enforce Medicare standards for nursing homes. For the purposes of this 

report, a succesful referral indicates that the State agency appropriately 

identified the case as requiring CMS involvement and provided CMS with 

sufficient information to alert them to begin the enforcement process. To 

assist in determining case referrals, CMS provides guidance to States 

through written instructions provided in the “State Operations Manual” 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES 3 
INTROD UCT ION 

(SOM) and ongoing dialogue between State and CMS regional office staff. 

Once the case is referred, CMS determines what enforcement action to 

take and imposes remedies. 

Shared Data Systems 

After referral, case information is maintained through data systems 

shared by CMS and States. Traditionally, CMS has used the Online 

Survey, Certification and Reporting System (OSCAR) to record the results 

of standard, complaint, and revisit surveys. In October 2004, CMS 

completed national implementation of the new Automated Survey 

Processing Environment (ASPEN) Enforcement Manager (AEM). The 

ASPEN is used by CMS and States to record and access both survey 

results and enforcement data. State surveyors enter survey findings into 

a local ASPEN database, then upload the data into a central ASPEN 

system and also into OSCAR. 

CMS Oversight 

Although there is no explicit requirement that CMS oversee State referral 

of nursing home enforcement cases, the Act gives CMS responsibility for 

enforcing Federal requirements regarding the health and safety of 

nursing home residents.12 The Act also specifies that States must assist 

in enforcement procedures as part of the survey process.13 State 

performance in survey and certification is evaluated annually through 

State Performance Reviews (SPR), which are conducted by CMS regional 

offices and include general performance standards. One of the SPR 

standards addresses the referral process, but only with regard to the 

timeliness of referrals. 

METHODOLOGY 

To determine the extent to which States refer required nursing home 

enforcement cases to CMS, we analyzed available administrative data 

and reviewed case documents obtained from CMS regional offices and 

State agencies. Based on our initial review of OSCAR data, we identified 

3,663 cases believed to require referral as the result of Medicare 

certification surveys conducted between July 1, 2002, and June 30, 2003. 

A review of the regionally based LTC revealed evidence of referral for 

3,106 of those cases. Timeliness of those referrals was not assessed. 

For the remaining 557 cases, we selected a stratified random sample 

consisting of 200 records for further investigation. Stratification was 

based on the case type (i.e., immediate jeopardy, double G, or opportunity 

to correct) initially identified through analysis of the OSCAR data. For 

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INTROD UCT ION 

each sample case, we requested case information and documentation of 

referral from State agencies and CMS regional offices. Their combined 

responses were used to categorize each sample case into one of three 

categories: successful referral, nonreferral (referral error), or did not 

require referral. Referral errors were further evaluated to determine a 

primary cause of nonreferral and those causes were then explored during 

interviews with CMS and State staff. 

Our overall estimate reflects necessary adjustments to the population to 

remove cases found not to require referral. Adjustments to the population 

had minimal impact on our estimates. Additional information on 

adjustments and the specifics of our methodology are presented in 

Appendix A. Confidence intervals for point estimates are provided in 

Appendix B. 

Quality Standards 

This study was conducted in accordance with the “Quality Standards for 

Inspections” issued by the President’s Council on Integrity and Efficiency. 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES 5 
ΔF I NDING S FINDINGS 

States failed to refer almost 8 percent of cases 

warranting enforcement, thereby limiting CMS’s 

ability to address poor care at some facilities 

While States referred most of the cases 

requiring referral to CMS during the 

study period, we found that 7.6 percent 

of enforcement cases (estimated 253 of 

3,323) were never referred or the attempted referral did not adequately 

alert CMS regional office staff that a referral was made. Because CMS 

was not aware of these cases, the agency had no opportunity to address 

noncompliance. The potential result of not enforcing Federal standards is 

continued poor-quality care of residents in the facilities involved in these 

cases. 

States are required to refer three types of cases: immediate jeopardy, 

double G, and opportunity to correct. Immediate jeopardy cases⎯often 

the most serious cases, involving actual or the potential for death or 

serious injury⎯that were not referred included a case of a resident who 

sustained a bone-breaking fall as the result of a building hazard. Double 

G cases⎯those with a pattern of noncompliance⎯that were not referred 

included citations for improper treatment of pressure sores and 

employment of staff previously found guilty of abuse. Opportunity to 

correct cases⎯those involving deficiencies of a lower scope and severity 

that were not corrected over time⎯that were not referred included a case 

of inappropriate use of physical restraints. 

Two causes accounted for 78 percent of 

nonreferrals: difficulty identifying double G 

cases and attempted referrals that were not 

recognized as such by CMS staff 

For the 7.6 percent of enforcement 

cases not referred, two problems 

emerged as the primary causes of 

nonreferrals (see Chart 1 on page 7). 

Difficulty identifying double G cases 

was the most prominent cause, accounting for 47 percent of total 

nonreferrals. Unsuccessful referrals accounted for 31 percent of total 

nonreferrals and occurred when States attempted to refer a case but the 

referral was not recognized as such by CMS regional office staff. 

An additional 9 percent of total nonreferrals were due to random human 

error. We found no patterns indicating systemic problems in these cases 

and we do not discuss them further. The remaining 13 percent of 

nonreferrals were the result of less-common policy and procedural 

problems, primarily involving incorrect decisions to not refer cases or to 

delay referral. Detailed descriptions of these problems are included in 

Appendix C. 

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F I NDING S 

CHART 1 

CAUSES OF 

NONREFERRALS OF 

NURSING HOME 

ENFORCEMENT CASES 

Unsuccessful 

Referral 

31% 

Difficulty 

Identifying 

Double G 

47% 

Other Policy 

and Random Procedural Human Error Problems 9% 13% 

Source: OIG analysis of 125 cases requiring referral, July 2002–June 2003. 

Double G Cases 

Difficulty identifying double G cases, which account for 47 percent of 

nonreferrals, resulted from problems with reviews of facility history. 

Because double G cases are based on establishing a pattern of high-level 

noncompliance, identifying double G cases requires that State staff review 

facility survey history to determine if a prior G-level deficiency has been 

cited and whether the case should be referred. State staff must follow 

specific criteria for determining whether G-level deficiencies previously 

cited for the facility count toward a double G designation. We found two 

difficulties in identifying double G cases: staff did not conduct a thorough 

review of facility history (34 percent), and staff misunderstood Federal 

double G criteria (13 percent). 

State staff missed prior G-level deficiencies when conducting reviews of 

facility history 

In our case reviews, we found that 34 percent of nonreferrals resulted 

from State staff failing to identify a G-level deficiency from a prior survey. 

When staff offered an explanation, they either reported that they 

neglected to review the facility survey history, or that they reviewed the 

history but missed the prior deficiency. CMS staff confirmed in 

interviews that it can be difficult to find prior G-level deficiencies in 

survey records. 

Based on case reviews and interviews with CMS and State staff, the 

following two factors contribute to staff missing prior G-level deficiencies 

during reviews of facility survey history: 

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F I NDING S 

Facilities with many surveys can have complicated histories. Cases in our 

sample had as many as 12 surveys for State staff to review for a single 

facility (including standard and complaint surveys, as well as revisits), 

each with varying levels of deficiencies and encompassing multiple 

periods of noncompliance. In these cases, determining whether a prior 

G-level deficiency meets Federal double G criteria requires substantial 

and careful scrutiny of survey records. 

OSCAR and ASPEN data can be inaccurate. State staff reported that they 

often rely on data in OSCAR and ASPEN to review facility histories, yet 

prior G-level deficiencies were not always included in database records of 

cases in our sample. In interviews, State and CMS staff identified the 

following potential causes of inaccurate data: State staff not entering 

survey data timely due to workload, neglecting to upload data into the 

national ASPEN and OSCAR databases after entering the data in their 

local ASPEN system, failing to correct and resubmit data that were 

rejected in the uploading process as the result of errors, and failing to 

upload deficiencies retained after an informal dispute resolution.14 

State staff failed to identify double G cases due to misinterpretation of Federal 

double G criteria 

In some cases, we found that State staff misinterpreted Federal criteria 

for identifying double G cases. Such errors accounted for 13 percent of 

total nonreferrals. Both CMS and State staff reported that this 

misunderstanding is caused in part by the complexity of the double G 

criteria. Correctly identifying a double G case requires that State staff 

fully understand which prior G-level deficiencies count toward a double G 

and correctly apply the criteria to individual cases. 

State staff responses in case reviews and interviews indicated a number 

of misunderstandings regarding double G criteria. For example, staff in 

eight sample cases did not understand that the prior standard survey that 

creates the timeframe for review has to be the most recent completed 

standard survey—meaning the last one for which compliance was 

eventually achieved (see example in Appendix D).15 Other examples 

include the misperception that only deficiencies cited on standard surveys 

(not complaint or revisit surveys) should count toward a double G, and 

that the two G-level deficiency findings must involve the same specific 

deficiency (even though the nature of the deficiency does not matter). 

Other State staff reported they believed (incorrectly) that they should 

review all surveys in the same period of noncompliance as the most recent 

completed standard survey to find the prior G-level deficiency, rather 

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F I NDING S 

than just looking to the most recent completed standard survey and any 

intervening surveys. This misunderstanding could cause staff to count 

“prior G” deficiencies that were cited before the most recent completed 

standard survey but in the same period of noncompliance, inappropriately 

designating a double G to facilities that did not meet the criteria. 

Insufficient or incorrect guidance from CMS contributed to State staff 

misunderstanding of double G criteria 

Our case reviews and staff interviews revealed difficulties with CMS 

guidance to States. We found that State staff involved in our sample 

cases had difficulty applying the written instructions in the SOM to the 

actual cases that they were reviewing. The SOM provides only a brief 

description of double G criteria and does not provide examples of its 

application.16 A clarification was added to the manual in May 2004, but it 

addresses just one aspect of the criteria (that double G cases must involve 

two distinct cycles of noncompliance).17 

In addition to guidance provided in the SOM, State staff frequently 

contacted CMS regional offices for additional clarification when making 

double G determinations. However, this guidance sometimes contributed 

to the misunderstanding of double G criteria. Specifically, we found that 

in 21 percent of nonreferred double G cases, State staff received incorrect 

or incomplete guidance from CMS. Further, interviews with CMS 

regional office staff confirmed that they sometimes have the same 

difficulties as State staff in fully understanding and applying double G 

criteria. For example, staff from 5 of the 10 CMS regional offices gave 

descriptions of double G criteria that were inconsistent with the criteria 

developed by the CMS central office and included in the SOM.18 

Attempted but Unsuccessful Referrals 

Thirty-one percent of nonreferrals were attempted by States but not 

recognized as referrals by CMS regional offices 

For these cases, States documented or attested that they provided some 

type of notice to CMS, but CMS regional office staff reported they never 

received the referral. Unsuccessful referrals in our sample included all 

3 case types and 7 of the 10 CMS regions. When we pursued these cases 

further, we found that either the methods States used to refer the cases 

were insufficient to alert CMS staff that a referral had been made, or that 

States sent sufficient documentation but CMS still missed the referrals. 

Neither States nor CMS reported having a routine process for verifying 

whether referrals are actually received. 

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F I NDING S 

In 15 percent of nonreferrals, States only sent CMS a copy of the 

noncompliance letter that the State sent to the facility as notice of an 

enforcement action. Forwarding copies of these letters might appear to be 

an efficient way to alert CMS of the enforcement case because these 

letters include the deficiencies cited and the recommended remedies. 

However, CMS regional office staff reported they might miss these 

referrals because there is no clear request that action be taken by CMS, 

regional offices receive large volumes of mail, and letters may be 

intermingled with communication regarding other business. 

The remaining 16 percent of nonreferrals in this group were unsuccessful 

because, although States sent what appeared to be sufficient referrals, 

CMS staff still did not recognize them. While it is difficult to determine 

why this happened in specific cases, both CMS and State staff reported 

occasional careless practices that could cause missed referrals. Examples 

include a report of staff in one State mailing all referral documents in a 

large box at the end of each week with no cover letter or list of contents, 

and staff in one CMS regional office reporting that documents received on 

a shared fax machine are not always routed to the appropriate person to 

initiate enforcement. 

An underlying cause of unsuccessful referrals may be that CMS does not 

require States to use a uniform referral process or a standard referral 

document. Staff in four CMS regional offices reported that they do not 

specify any method or content for State referrals and that they will accept 

as sufficient a copy of the facility noncompliance letter or a brief e-mail 

message. However, even though these are considered acceptable referral 

methods, we documented cases sent to the regions by these methods that 

were not recognized by CMS staff as referrals. 

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Δ RECOMME NDA TIONS 

Although successful referrals occurred in most cases, improvements could 

be made to the process to better ensure that all cases are referred. Our 

recommendations speak to reinforcement of procedures or policies already 

in place that States and CMS staff do not always practice. They address 

the following problems: difficulty identifying double G cases and 

attempted referrals that are unsuccessful because they are not recognized 

as such by CMS staff. 

CMS should address the failure to identify double G cases by ensuring that 

CMS and State staff apply double G criteria correctly and by working with 

States to improve reviews of facility history 

CMS should clarify and communicate specific criteria for identifying double G 

cases. Misunderstanding of the criteria for determining double G cases 

was a primary cause of nonreferral and was found among both State and 

CMS regional office staff. CMS should clarify and communicate these 

criteria to staff, including ensuring that the SOM serves as a clear and 

practical guide to determining double G cases. 

Owing to the complexity of the double G criteria, clearer instruction may 

not completely alleviate problems. CMS might also wish to consider 

simplifying the double G criteria while still preserving their purpose of 

identifying facilities with a pattern of noncompliance. 

CMS should provide technical assistance to States to address inaccurate data. 

CMS and State staffs reported that inaccurate data in OSCAR and 

ASPEN contributed to staff’s missing double G cases when reviewing 

facility histories. CMS should ensure that States properly enter survey 

results in these databases and target specific problems raised by staff, 

such as not entering survey data timely, neglecting to upload data to the 

national ASPEN and OSCAR databases, failing to correct and resubmit 

data that were rejected as the result of errors, and failing to upload 

deficiencies retained after an informal dispute resolution. 

CMS should address the incidence of attempted but unsuccessful referrals 

by developing a uniform referral process and verifying that referrals are 

received 

Twenty-nine percent of State referrals were unsuccessful in alerting CMS 

that a referral was made. To ensure that all State referrals are received, 

CMS should implement a uniform referral process. This process could 

include a standard referral document that could be adapted to various 

State transmittal methods, such as mail, fax, or e-mail, yet still be easily 

recognized by CMS staff. Alternatively, CMS could create an automated 

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referral process in ASPEN that would notify regional offices of any 

enforcement case entered by State staff. Regardless of the uniform 

process chosen, CMS should also develop a method for verifying that cases 

referred by States are received by CMS. 

AGENCY COMMENTS 

CMS concurred with each of our recommendations, and commented that it 

has recently or will soon take action related to each of them. We agree 

that these actions will be useful in addressing the problems identified. 

However, based on our report findings, we are concerned that CMS’s 

comments to the draft report may not fully address each recommendation. 

The areas that we continue to believe require additional attention by 

CMS are listed below: 

Double G Criteria 

In response to our recommendation that CMS should clarify and 

communicate specific criteria for identifying double G cases, CMS cited its 

May 2004 addition to the SOM, discussed on page 9 of this report. This 

addition instructed State staff to ensure that the two G-level deficiencies 

that constitute a double G case are found in separate periods of 

noncompliance. While it is an important clarification, it addresses only 

one of several problems with interpretation of the double G criteria by 

State and CMS regional office staff. In conducting this study, we found it 

clear from our discussions with State and CMS staff that specific 

technical assistance or training, beyond the issuance of the SOM 

clarification, is needed to encourage proper application of the criteria and 

to address common areas of misunderstanding. 

We continue to recommend that the guidance provided to States, in the 

form of the language used in the SOM and the ongoing dialogue between 

State and CMS regional office staff, be improved to better clarify and 

communicate double G criteria. 

Inaccurate Data 

In response to the recommendation that CMS should provide technical 

assistance to States to address inaccurate data, CMS articulated steps 

taken to address data problems through full implementation of 

enforcement-related components of the ASPEN data system. We agree 

that the newly implemented data systems have the potential to help 

ensure that survey and enforcement case information is accurate, but 

CMS should specifically and proactively address problems with data 

accuracy to more fully alleviate them. 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES 12 
A G E N C Y CO MMENT S

CMS also addressed in its comments our finding that failing to upload 

case and survey information was a barrier to data accuracy, citing 

recently issued guidance to States regarding requirements for uploading 

data timely. We agree that this may improve State accountability in this 

area; however, other problems with data accuracy remain, including 

coordination among multiple points of data entry and problems with 

uploading data that are initially rejected by the data system. 

Attempted but Unsuccessful Referrals 

Regarding our recommendation that CMS should address the incidence of 

attempted but unsuccessful referrals, CMS referenced a specific field in 

the AEM that will allow regional office staff to identify cases that have 

been referred by States and anticipate their arrival. If used routinely, 

this would address the incidence of cases wherein States sent sufficient 

case information and the referral was not recognized as such by CMS, but 

it would not address cases that were not referred by States at all. CMS 

believes these nonreferred cases can be detected as regional office staff 

monitor key dates in the AEM. However, our understanding is that 

regional offices are not specifically tasked with such monitoring and are 

likely to do so only on an ad hoc basis, if at all. Therefore, CMS should 

direct regional offices to make full use of these promising tools. 

Technical Comments 

CMS submitted technical comments, and we have made changes where 

appropriate (which caused slight changes to some of the percentages CMS 

referenced in its comments). 

The full text of CMS’s comments is presented in Appendix E. 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES 13 
Δ ENDNOTE S 

1 Section 1819 (f)(1) of the Social Security Act (SSA). 

2 42 CFR § 488.330. 

3 42 CFR §§ 488.404, 488.406, and 488.408; and the State Operations 

Manual (SOM), Chapter 7, § 7400 (E)(3) (2003). 

4 SOM, Chapter 7, § 7400 (E)(1) (2003). 

5 42 CFR §§ 488.404 and 488.406. 

6 When the results of a survey indicate that a facility is not in substantial 

compliance with Federal regulations, it is considered to be noncompliant 

until it returns to substantial compliance. If the facility requires further 

enforcement action as a result of new deficiencies without first reaching 

compliance on the original deficiencies, all enforcement activity is 

considered to be in the same cycle of noncompliance and a part of the 

same enforcement case. 

7 Although findings of immediate jeopardy must be included in the initial 

2-day notice, the State has 5 calendar days to forward all documentation 

(notice letter, contact reports, and Form HCFA-1539 Statement of 

Deficiencies, if completed) to the CMS regional office. 42 CFR § 488.410, 

as well as SOM, Chapter 7, § 7309(A) (2003). 

8 CMS requires referral of cases in which facilities are not given an 

opportunity to correct, but which do not involve immediate jeopardy. 

Nearly all of the cases in this category are double G cases, but in a small 

number of cases States may have chosen not to give the facility an 

opportunity to correct due to other circumstances. Because we are only 

able to identify double G cases in OSCAR and they represent nearly all of 

the cases in this category, we will use double G cases to represent the 

group of cases not given an opportunity to correct deficiencies. 

9 In 1998, CMS issued a memorandum to State survey agencies instructing 

them to include nursing homes cited with repeated patterns of actual 

harm (H-level or above) deficiencies in the category of poor-performing 

facilities that are denied an opportunity to correct, which became known 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES 14 
as the Poor Performer Rule. In 1999, CMS issued a second memorandum 

that expanded this provision to include facilities cited with G-level 

(isolated actual harm) deficiencies. 

10 Double G criteria apply to any G-level or higher deficiencies. For this 

report, when we refer to a G-level deficiency it should be assumed that 

we refer to any deficiency at a G level or higher. 

11 SSA § 1864 and SOM, Chapter 8, § 8000(D)(7) (2003). 

12 SSA § 1819 (f)(1) (2003). 

13 SSA § 1864 and SOM, Chapter 8, § 8000(D)(7) (2003). 

14 When an IDR is pending, State staff are instructed by CMS to delay 

uploading deficiencies into the ASPEN system until the IDR is resolved. 

Because ASPEN data are uploaded to OSCAR, the objective behind this 

is to avoid displaying deficiencies in the Nursing Home Compare 

directory while they are in dispute. 

15 A recent addition to the SOM addresses this issue, stating “If the most 

recent standard survey is within the currently running noncompliance 

cycle, then look back to the most recent standard survey that is not in the 

currently running noncompliance cycle in making double G 

determinations.” SOM, Chapter 7, § 7304 (B)(1) (2004). 

16 The SOM guidance states “A double G facility is one that has been 

identified as noncompliant with a scope and severity level of ‘G’ or higher 

on a current survey and on the previous standard survey or any 

intervening survey (i.e., any survey between the current survey and the 

last standard survey).” SOM, Chapter 7, § 7304 (B) (2003). 

17 See endnote 16 for text. SOM, Chapter 7, § 7304 (B)(1) (2004). 

18 As indicated in Appendix A (Detailed Methodology), to ensure that this 

inspection relied on the correct interpretation of double G criteria to 

make case type and referral determinations, we consulted with CMS 

central office staff via telephone interviews and other correspondence. 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES 15 
Δ APPENDIX ~ A 

Detailed Methodology 

For this inspection, we examined nursing home enforcement cases that 

required State referral to CMS regional offices. Cases requiring referral 

include immediate jeopardy cases, double G cases, and opportunity to 

correct cases that failed to achieve subsequent compliance in the required 

time period. Our sampling frame was limited to cases resulting from 

surveys conducted during the 12-month period between July 1, 2002, and 

June 30, 2003. We used a combination of case reviews and interviews to 

determine the extent to which States refer required nursing home 

enforcement cases and to reveal any problems affecting the referral 

process. This study does not address the timeliness of referrals, but 

rather whether cases were referred at all. 

Sampling Design 

Initial identification of cases requiring referral was based on CMS’s 

Online Survey, Certification and Reporting System (OSCAR) data. 

Immediate jeopardy cases included all surveys containing a scope and 

severity rating of J, K, or L. Opportunity to correct cases that required 

referral included surveys and complaints with two or more associated 

revisits. Because of the complexities involved in identifying double G 

cases, a listing of those cases was provided by CMS central office staff 

who had previously developed an algorithm to extract such cases using 

OSCAR data. 

We compared the cases identified in the OSCAR data as requiring referral 

to case information in CMS’s Long Term Care Enforcement Tracking 

System (LTC). If case information was present in the LTC, we considered 

the case to have been successfully referred. From our population of cases 

(those that appeared to require referral based on our analysis of OSCAR) 

we identified two groups: those with evidence of referral in the LTC and 

those with no evidence of referral. Only cases in the second group (no 

evidence of referral in LTC) were included in our sampling frame, and 

then the two groups of cases were ultimately combined to calculate an 

overall rate of nonreferral. 

We selected a stratified random sample of 200 cases from the group that 

did not have evidence of referral in the LTC. Forty-two States and all 10 

regional offices were represented in this sample. Cases were stratified 

based on case type; i.e., immediate jeopardy, double G, and opportunity to 

correct, as determined through our initial review of OSCAR data. The 

breakdown of our sample by case type is presented in Table 2. 

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APP E N D I X ~ A 

Strata Population Sample 

Double G 254 75

Opportunity to Correct 234 70

Immediate Jeopardy 69 55

 Total 557 200 

Table 2: Sample Design for Cases With No Evidence of Referral 

Source: OIG analysis of 3,323 cases requiring referral, July 2002–June 2003. 

Case Type Identification 

The three strata are based on our determination of case type using 

OSCAR data. The case types are, by definition, the reason referral is 

required. We opted to stratify our sample based on this designation for 

two reasons: to ensure our ability to include issues involving the most 

egregious deficiencies (immediate jeopardy) and to be able to identify 

differences between the case types. Some enforcement cases have 

multiple reasons for referral, meaning that the case may meet the 

definition of more than one case type. 

In our initial determination, we prioritized these reasons by severity of 

the situation: immediate jeopardy, double G, and opportunity to correct. 

In reviewing the cases, however, we found the order of events to be more 

indicative of the reason for referral and adjusted the case types from our 

initial determinations. For example, if an initial survey meets the 

definition of a double G and a subsequent revisit meets the definition of 

an immediate jeopardy, then our case type classification would have 

switched from immediate jeopardy to double G. We did not, however, 

change the strata from which they were selected. Because of these 

changes, we are not providing error estimates for individual case types. 

Document Requests 

For cases in the sample, we requested case documentation pertaining to 

referral from both the State and the CMS regional office responsible for 

oversight of the facility. From the States, we asked for documentary 

evidence that a referral had taken place or an explanation of why the case 

had not been referred.1 We also allowed State staff who could not produce 

1 Acceptable forms of documentation included electronic mail, facsimile transmission reports, 

or any other documentation that included case-specific information and a date the 

information was sent. 

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ΔAPP APPENDIX ~ E N D I X ~ A A

documentation to attest that a referral to CMS had been made. From the 

CMS regional offices, we requested verification of whether the case was 

received and for additional comments pertaining to its referral. We 

followed up with individual States and regional offices to resolve 

inconsistencies and unclear responses. 

Criteria 

Case reviews were used to determine nonreferrals, as well as to catalogue 

the causes of nonreferral. Cases were categorized as successfully 

referred, referred in error, or did not require referral. The projected 

numbers, including the error rate, were calculated so that cases that did 

not require a referral were excluded. We determined a successful referral 

to include: 

• cases with evidence of referral in the LTC system, 

• cases that CMS acknowledged receiving, and 

• cases for which States provided clear documentation of referral. 

State and regional office responses to our requests yielded numerous 

explanations of why specific referrals were not believed to be required. 

We carefully considered these comments, but our decision for assessing 

whether a case required referral was based on clarifications sought from 

the CMS central office. 

We identified 75 cases in our sample that did not require referral. 

Reasons for not requiring referral include inaccurate OSCAR data and 

Medicaid-only facilities, among others. Cases that did not meet the 

criteria for successful referral or were exempt from referral were 

determined to be referral errors. As stated previously, we did not always 

accept CMS regional office or State responses that a case did not require 

referral. Some of these cases were classified as referral errors and are a 

source of our data to identify policy misinterpretations by CMS and/or 

State staff. 

After identifying referral errors, we determined a cause for each. When 

there were multiple causes for a single case, we selected a primary cause 

which appeared to be most responsible for the error. 

Population Adjustments 

Our review identified 75 cases that did not ultimately require referral (see 

Table 3). These cases were excluded from our projected numbers. 

Adjustments to the population had minimal impact on our estimates, 

changing our overall error rate from 7.4 percent to 7.6 percent. 

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APP E N D I X ~ A 

Table 3: Ineligible Cases 

Referral Not 

Strata Initial Sample Required Final Sample 

Double G 75 16 59 

Opportunity to Correct 70 46 24 

Immediate Jeopardy 55 13 42

 Total 200 75 125 

Source: OIG analysis of 3,323 cases requiring referral, July 2002–June 2003. 

Opportunity to correct. Two-thirds of the opportunity to correct cases in the 

initial sample were found not to require referral. The number in this 

stratum was reduced from 70 to 24. The cause of this significant change 

was the data proxy used to identify opportunity to correct cases. To 

create our proxy, we identified any case in OSCAR with more than one 

revisit (not including a superceding immediate jeopardy or double G 

designation) as having had an opportunity to correct. However, our proxy 

did not distinguish between documentation-only desk reviews and onsite 

revisits. Many cases with desk reviews (34 of 46) met the definition of 

substantial compliance and did not require referral. A second, but less 

frequent, problem was the result of the proxy being based on the number 

of revisits rather than the timeframe for referral (we subsequently 

determined that the 70th day of noncompliance is the critical point for 

requiring referral). The remaining opportunity to correct cases found not 

to require referral were the result of various data inconsistencies. 

Cases with evidence of referral in LTC. Because cases not requiring referral 

were prevalent in our sample, we took an additional sample of 300 cases 

from those deemed as successful referrals based on their presence in the 

LTC system. We randomly selected 100 cases from each stratum: double 

G, immediate jeopardy, and opportunity to correct. We reviewed casespecific data in OSCAR and LTC to ascertain that the case (1) was 

correctly identified as a referral, (2) had the appropriate case type 

designation, and (3) was eligible for review. Eleven of the 300 cases 

reviewed in this group were determined to be ineligible. Of these cases, 

three were from the immediate jeopardy stratum, four were from the 

double G stratum, and four were from the opportunity to correct stratum. 

All 11 were the result of the enforcement cycle being represented more 

than once. 

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APP E N D I X ~ A 

Table 4: Subpopulation Adjustments 

Stratum 

Evidence in LTC Record Review 

Original 

Population 

Adjusted 

Population 

Original 

Population 

Adjusted 

Population 

Double G 1,382 1,327 254 200 

Opportunity to Correct 908 872 234 80 

Immediate Jeopardy 816 792 69 53

 Total 3,106 2,990 557 333 

Source: OIG analysis of 3,323 cases requiring referral, July 2002–June 2003. 

Adjustment calculations. Population estimates were created by removing 

ineligible cases from the sample but retaining the original population 

weights (see Table 4). These estimates were used in the calculation of an 

overall error rate. Adjustments reduced the total population only slightly, 

from 3,663 to 3,323, with a confidence interval of plus or minus 3.0 

percent (see Table 5). Further analysis confirmed that the impact on our 

overall estimate was minimal, changing our error rate from 7.4 percent to 

7.6 percent. 

Adjusted Population 

In LTC 2,990 

Record Request 333 

Total 3,323 

Table 5: Overall Population Adjustments 

Confidence Interval 

2,922 to 3,058 

301 to 364

3,223 to 3,422 

Source: OIG analysis of 3,323 cases requiring referral, July 2002–June 2003. 

Statistics 

The SUDAAN statistical software was used to obtain population 

estimates for each group. The estimates for each group were combined to 

provide an estimate of the nonreferral rate overall. The estimates are 

reflective of population adjustments described above. Analysis of these 

adjustments was conducted by our mathematical statistician.2 

Our response rate was 100 percent. Confidence intervals were calculated 

at the 95-percent level and are presented in Appendix B. 

2 RAT-STATS is a statistical program developed by the Office of Audit Services, Office of 

Inspector General, Department of Health and Human Services. 

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APP E N D I X ~ A 

Interviews/Focus Groups 

During the course of this inspection, two sets of interviews were 

conducted to help us better understand the causes of nonreferral and 

CMS’s oversight of this process. Prior to reviewing specific case data, we 

conducted interviews with CMS regional and central office staff. The 

purpose of these interviews was to improve our understanding of the 

causes of nonreferral and to assess CMS guidance and oversight. 

Interviews were conducted in person by OEI analysts using a structured 

protocol. Additionally, we conducted follow-up telephone interviews with 

all CMS regions and 10 State agencies. States were selected for 

interviews to represent a broad range of case experiences. In these followup interviews, we raised issues that were identified during the individual 

case reviews. We asked respondents to provide us with additional context 

and plausible explanations or causes of nonreferral. Although many of 

the questions were related to specific cases, we provided the same 

scenarios in each interview to assess the potential for problems in other 

States and regions. 

After transcribing the interviews, analysts reviewed the material from all 

interviews collectively, identifying similarities and differences among the 

responses of different offices and gauging the impact of the information on 

the referrals process. 

Limitation 

Because we used the OSCAR database to identify sample cases, our 

analysis does not include any cases that States may have inappropriately 

omitted from OSCAR. To the extent that State survey agencies did not 

enter cases requiring referrals into ASPEN (and therefore OSCAR), our 

results would underestimate the extent of nonreferrals. However, 

because payments are based on these data (creating an incentive for 

States to enter the information) and because the annual State 

Performance Review includes components on survey conduct and data 

entry, we do not expect this limitation to substantively affect our 

estimates. 

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Δ APPENDIX ~ B 

CONFIDENCE INTERVALS 

POPULATION 

Error Rate* 

Error Cases 

Estimate 

95% Confidence Interval 

Low High 

7.6% 6.81% 8.30% 

253 228 278 

SUBSET OF NONREFERRAL ERRORS 

Difficulty Identifying Double G 

 - Staff Missed Double G 

- Staff Misinterpreted Double G Policy 

Unsuccessful Referral 

- State Sent Only Copy of Facility Letter 

 - Referral Documented but Never Received 

Random Human Error 

Other Policy and Procedural Problems 

Estimate 

95% Confidence Interval 

Low High 

47.0% 38.24% 55.76%

34.4% 25.60% 43.28% 

12.6% 5.94% 19.16% 

31.1% 22.12% 40.08% 

14.8% 7.63% 21.97%

16.3% 9.68% 22.92% 

8.5% 2.80% 14.20% 

13.4% 6.68% 20.12% 

SUBSET OF DOUBLE G ERRORS 

Incorrect CMS Guidance Given to State 

Estimate 

95% Confidence Interval 

Low High 

31.40% 18.97% 43.83% 

*The majority of cases were considered successful referrals based on their presence in the LTC data. 

Only errors in the remaining portion required estimation. 

Source: OIG analysis of 3,323 cases requiring referral, July 2002–June 2003. 

OE I-06-03-00 400 S TAT E REFERRA L O F NURS I N G H O M E E N F O R C E MENT CA SES 22 
Δ APPENDIX ~ C 

Other Policy and Procedural Problems 

An additional 13 percent of nonreferrals were attributable to specific 

Federal policies which are unclear or not routinely followed by state staff 

Although most nonreferrals were caused by problems with identifying 

double G cases and insufficient notice to CMS, a smaller number of 

nonreferrals (20 sample cases) were caused by a variety of other policy 

and procedural problems. We identified four specific problems within 

these cases that, although the cause of few nonreferrals, reflect either 

unclear Federal policies or incorrect State practices. 

Staff may restart correction period upon finding new deficiencies. Nonreferral of 

11 cases in our sample was the result of State staff not fully 

understanding Federal referral policy regarding opportunity to correct 

cases. Opportunity to correct cases which fail subsequent compliance 

should be referred within 70 days of the initial finding of noncompliance. 

In the case of these nonreferrals, the facilities were cited with new 

deficiencies when surveyors revisited them. Mistakenly thinking they 

must provide the maximum time for correction of the new deficiency, the 

States restarted the 70-day referral period at the time of the revisit. This 

allowed the facilities to be out of compliance for longer than 70 days 

without referral. 

State staff may determine not to refer. For four cases in our sample, States 

chose not to follow Federal referral policy at their own discretion. In 

these cases, State staff decided to delay referral pending the outcome of a 

second revisit. As a result, these cases were out of compliance past the 

date that CMS is required to impose a mandatory remedy for 

noncompliance. State staff reported that they did not refer these cases 

because they believed the facility would achieve compliance soon without 

imposition of a remedy. 

Informal Dispute Resolutions may delay referral. All respondents in our State 

and CMS interviews reported correctly that an Informal Dispute 

Resolution (IDR) would not delay enforcement action. However, our case 

reviews revealed three examples in which the State held referral of cases 

for a pending IDR, then never ultimately referred the cases because the 

IDR overturned the deficiency that warranted referral. This indicates 

that all State staff may not be clear regarding the required referral of 

enforcement cases regardless of whether the facility has initiated an IDR. 

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APP E N D I X ~ C 

Abated immediate jeopardy. According to CMS central and regional office 

staff, immediate jeopardy cases must be referred by States to CMS, even 

when the deficiency constituting the immediate jeopardy is removed 

(abated) while the survey is still in progress. In four CMS regions, staff 

reported that States are allowed more time to refer these cases than the 

required 2-day referral period for an immediate jeopardy case. For example, 

one CMS region requires States to refer abated immediate jeopardy cases 

within the time period expected for double G cases (10 days). However, in 

two cases in our sample, surveyors did not refer immediate jeopardy cases 

that were abated and gave the abatement as their reason for not referring 

them. 

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Δ APPENDIX ~ D

Double G Case Example 

Illustrating Federal criteria which require that States use the most recent 

completed standard survey in establishing a timeframe for review of 

facility survey history 

This example illustrates a potential problem in identifying double G 

cases (see Figure 1). In this case, a G-level deficiency is cited during a 

revisit. If State staff reviewed history only back to the most recent 

standard survey (following which the facility has not yet acheived 

compliance), the staff would incorrectly determine that this is not a 

double G case because the highest deficiency cited on that survey was 

an F-level. Rather, State staff should review history back to the most 

recent completed standard survey, meaning the most recent for which 

compliance was eventually achieved. 

The double G criteria are designed to identify a historical pattern of 

noncompliance. Counting deficiencies within the current period of 

noncompliance can limit the timeframe for review to as little as a few 

days or weeks. If State staff followed the incorrect policy of reviewing 

facility history only to the most recent standard survey, they would 

overlook a pattern of noncompliance. 

Source: Example drawn from OIG 2004 analysis of 3,323 cases requiring referral, July 2002–June 2003. 

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Δ APPENDIX ~ E 

Agency Comments to Draft Report 

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APP E N D I X ~E 

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APP E N D I X ~E 

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APP E N D I X ~E 

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Δ ENDNOTE S ACKNOWLEDGMENTS 

This report was prepared under the direction of Judith V. Tyler, Regional Inspector General for 

Evaluation and Inspections of the Dallas Regional Office, and Kevin Golladay, Assistant 

Regional Inspector General of the Dallas Regional Office. Other principal Office of Evaluation 

and Inspections staff who contributed include: 

Amy Ashcraft, Team Leader 

Ruth Ann Dorrill, Project Leader 

Blaine Collins, Program Analyst 

Sarah Craren, Program Analyst 

Clark Thomas, Program Analyst 

Susan Wolfe, Program Analyst 

Sandy Khoury, Program Specialist 

Technical Assistance 

Barbara Tedesco, Mathematical Statistician 

Kevin Farber, Mathematical Statistician 

David Graf, Program Analyst 

Scott Horning, Program Analyst 

Linda Moscoe, Program Analyst 

Field Assistance 

Tara Bernabe, Program Analyst, Philadelphia 

Sylvia Chin, Program Analyst, San Francisco 

Tricia Fields, Program Analyst, Kansas City 

Graham Rawsthorn, Assistant Regional Inspector General, Atlanta 

David Rudich, Program Analyst, New York 

Marco Villagrana, Program Analyst, Chicago 

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