Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

Inspector General 

MARCH 2003 

OEI-02-01-00600 

Nursing Home Deficiency Trends and 

Survey and Certification Process Consistency 
OFFICE OF INSPECTOR GENERAL

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 OIG’s internal 

operations. The OCIG imposes program exclusions and civil monetary penalties on health care providers 

and litigates those actions within the Department. The OCIG also represents OIG in the global settlement 

of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 

develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 

community, and issues fraud alerts and other industry guidance. 
EXECUTIVE SUMMARY 

OBJECTIVE 

To describe trends in nursing home deficiencies and to assess consistency in the state 

implementation of the Medicare survey and certification process. 

BACKGROUND 

All Medicare and/or Medicaid participating nursing homes must be certified as meeting certain 

federal requirements. This certification is achieved through routine facility surveys, which the 

Centers for Medicare & Medicaid Services (CMS) contracts with states to perform. Nursing 

homes are typically surveyed by survey teams within 9-to-15 month intervals. 

This inspection uses data from 7 different sources: (1) national data from the Online Survey and 

Certification Reporting (OSCAR) system; (2) a mail questionnaire of all 51 state survey and 

certification directors; (3) telephone interviews with staff from all 10 regional CMS offices; (4) 

observations of nursing home surveys in a purposive sample of 6 states; (5) a review of 310 

survey reports from the same 6 states; (6) telephone interviews with a purposive sample of 32 

surveyors from 8 states; and (7) telephone interviews with a purposive sample of 32 nursing 

home administrators from the same 8 states. 

FINDINGS 

Nursing home deficiencies have increased since 1998 

Eighty-nine percent of nursing homes received at least one deficiency, an increase of 8 

percentage points. In 2001, 89 percent of all nursing homes that were surveyed received at 

least one deficiency, an increase from 81 percent in 1998. Only 11 percent, or 1,690 nursing 

homes, were deficiency-free in 2001. The total number of deficiencies rose from 64,608 in 

1998 to 94,131 in 2001. The average number of deficiencies increased from 5.1 in 1998 to 

6.2 in 2001. 

Deficiency Trends and Survey and Certification Process Consistency i OEI-02-01-00600 
Seventy-eight percent of nursing homes received a deficiency in one of the categories 

related to CMS’ definition of “substandard quality of care,” an increase of 

8 percentage points. The proportion of nursing homes that received a deficiency in any of the 

three categories related to “substandard quality of care” increased by 8 percentage points from 

70 percent in 1998 to 78 percent in 2001. The proportion of nursing homes that received an 

immediate jeopardy deficiency (2.3 percent) has increased slightly from 1998 to 2001. 

Wide variation exists among states in the number of deficiencies 

Nationally, 11 percent of all nursing homes surveyed in 2001 had no deficiencies. The 

proportion of deficiency-free nursing homes ranged from 33.5 percent in Virginia to 0 

percent in Nevada. Nationally, the average deficiency rate for nursing homes surveyed in 2001 

was 6.2 per nursing home; this ranged from 2.9 deficiencies per nursing home in Vermont to 

11.2 deficiencies in California. 

States differ in how they determine specific deficiency citations 

Our review of 310 survey reports reveals that different deficiency tags are being used to cite the 

same problem. In five of the six standard surveys we observed, we noted instances where 

surveyors did not consistently cite deficiencies. Further, states differ on how many deficiencies 

they will cite for a single problem of non-compliance. 

Four factors contribute to variability in citing deficiencies 

First, state agency directors acknowledge that the nursing home survey process has either a 

consultative or enforcement focus that affects the scope of the review. Second, unclear 

guidelines may contribute to different interpretations by surveyors when citing deficiencies. 

Third, while most states report some level of supervisory review for draft survey reports, the 

scope of these reviews differs, and states have various additional review processes they follow. 

Lastly, nearly all states report a high surveyor staff turnover, which contributes to inconsistency. 

States report following CMS nursing home survey protocols for staffing, 

scheduling, and pre-survey preparation; in the six sample states, survey teams 

completed all on-site survey tasks 

All state agency directors report following protocols for survey team size, make-up, and basic 

CMS training requirements. All state agencies report following protocols for pre-survey 

preparation and scheduling standard surveys within a 9-to-15 month interval. In 

Deficiency Trends and Survey and Certification Process Consistency ii OEI-02-01-00600 
addition, our on-site visits revealed the completion of all six on-site survey tasks and proper use 

of investigative protocols. Further, our review of survey reports shows that surveyors in the six 

sample states rely on the same types of evidence to document deficiencies. 

CONCLUSION 

Our analysis shows an increase in nursing home deficiencies since 1998. The proportion of 

nursing homes receiving deficiencies, the total number of deficiencies, and the key categories of 

deficiencies directly related to quality of care have all increased since 1998. In addition, wide 

variation exists among states in the proportion of deficiency-free nursing homes and in average 

deficiency rates. 

Our review of the survey process reveals states differ in how they determine both the number 

and type of deficiencies. We identified four factors that contribute to this variability in citing 

deficiencies: (1) an inconsistent survey focus; (2) unclear guidelines; (3) the lack of a common 

review process for draft survey reports; and (4) high surveyor staff turnover. As a result, we 

conclude that nursing home survey results are not always consistent among states, therefore 

limiting the comparability of the data. Further, we cannot conclude whether trends in 

deficiencies are due to deteriorating care, variations in the survey process, and/or increased 

enforcement. However, deficiencies are a key indicator of care in nursing homes and, 

therefore, the number of deficiencies and the increase in the number of deficiencies over the 

past four years raise concerns. 

RECOMMENDATIONS 

The Centers for Medicare & Medicaid Services should continue to improve its 

guidance to state agencies on citing deficiencies by providing guidelines that are both 

clear and explicit. Based on our findings, we recommend that CMS provide more specific 

guidance to states on quality of life deficiency tags and clearer directives on when to cite single 

or multiple deficiencies. We also recommend that CMS more clearly communicate to states 

that the focus of the nursing home survey process is not consultative. They should remind states 

of the dual function of this process, as specified in the Interpretive Guidelines. These two 

functions are: (1) to ensure compliance; and (2) to enter into a non-consultative information 

exchange for the purpose of information dissemination that may be of assistance to the facility in 

meeting long term care requirements. 

Deficiency Trends and Survey and Certification Process Consistency iii OEI-02-01-00600 
The Centers for Medicare & Medicaid Services, together with states, should develop 

common review criteria for draft survey reports. While most states incorporate some 

level of supervisory review for draft survey reports, they do not follow a standard process with 

common evaluation criteria. A more standard review process that utilizes the same criteria for 

assessing draft reports will help to ensure greater consistency across states. The CMS could 

incorporate this standardized assessment criteria as part of the Nursing Home State 

Performance Measures: Review Protocol Guidance, which all states are now required to 

follow. 

AGENCY COMMENTS 

We received comments on our draft report from the Centers for Medicare & Medicaid 

Services (CMS). The CMS concurred with our recommendations that it should continue to 

improve guidance to state agencies on citing deficiencies by providing guidelines that are both 

clear and explicit and that it should develop, together with states, a common review criteria for 

draft survey reports. The CMS also highlighted several actions they have taken to improve 

such guidance. The full text of CMS’ comments are contained in Appendix G. 

Deficiency Trends and Survey and Certification Process Consistency iv OEI-02-01-00600 
TABLE OF CONTENTS 

PAGE

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

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

FINDINGS 

Nursing home deficiencies have increased since 1998 .............................. 7

Wide variation exists among states in deficiencies ................................ 14

States differ in how they determine deficiency citations ............................ 15

Four factors contribute to variability .......................................... 16

States report following CMS survey protocols .................................. 20

CONCLUSION ............................................................. 23

RECOMMENDATIONS ...................................................... 24

AGENCY COMMENTS ...................................................... 25

APPENDICES

A: Quality of care deficiency definitions ....................................... 26

B: Selected deficiency definitions ............................................ 29

C: Proportion of quality of care deficiencies .................................... 30

D: Scope and severity deficiencies ........................................... 35

E: Proportions Deficiency-Free Facilities, Deficiency Removals by Deficiency Rates . ..... 36

F: Federal Standards for Surveyor Training Requirements ......................... 38

G: Agency Comments .................................................... 39

ACKNOWLEDGMENTS ..................................................... 42

Deficiency Trends and Survey and Certification Process Consistency v OEI-02-01-00600 
INTRODUCTION 

OBJECTIVE 

To describe trends in nursing home deficiencies and to assess consistency in the state 

implementation of the Medicare survey and certification process. 

BACKGROUND 

Survey and Certification Process 

All Medicare and/or Medicaid participating nursing homes must be certified as meeting certain 

federal requirements. Certification is achieved through routine facility surveys, which the 

Centers for Medicaid & Medicare Services (CMS) contracts with states to perform. Nursing 

homes are subject to unannounced standard surveys no later than 15 months after the date of 

the previous standard survey. If, during the standard survey, a nursing home is found to have 

provided substandard quality of care, an additional extended survey is conducted within 2 

weeks. Nursing home surveys are typically conducted by a team of surveyors, with a team 

leader assigned to manage the process while on site. The survey team conducts various presurvey tasks, such as reviewing existing program data, before going to the facility. 

When a nursing home fails to meet a specific requirement, the facility receives a deficiency 

citation. These deficiencies are categorized into 1 of 17 major areas, such as quality of care 

and physical environment. A total of 190 deficiencies with different tag numbers can be cited. 

Surveyors also consult a scope and severity matrix in determining the level of each deficiency. 

Survey data are entered into the Online Survey and Certification Reporting System (OSCAR). 

OBRA 1987 

The Omnibus Budget Reconciliation Act (OBRA) of 1987 (P.L. 100-203) expanded 

requirements that nursing homes had to comply with prior to Medicare certification, altered the 

principles for enforcement, and defined the state survey and certification process for 

determining compliance with federal standards of care. The CMS had several process goals 

for the implementation of the survey and enforcement systems: promoting consistency through 

extensive training, linking appropriate remedies to deficiencies, and avoiding unnecessary 

procedures. 

Deficiency Trends and Survey and Certification Process Consistency 1 OEI-02-01-00600 
1998 Nursing Home Oversight Improvement Program 

Ten years after the passage of OBRA 1987, a series of research studies and Senate hearings 

called attention to serious concerns about residents’ well-being. In response to these concerns, 

the 1998 Nursing Home Oversight Improvement Program,1 designed to improve enforcement 

of nursing home quality, was announced. To implement the Nursing Home Oversight 

Improvement Program, CMS initiated steps to improve nursing home survey procedures, 

including: 

C staggering nursing home inspections, and starting a certain number on weekends 

and evenings; 

C more frequently inspecting nursing homes that are repeat offenders; 

C enhancing CMS review of nursing home surveys conducted by states; 

C terminating federal nursing home survey funding to states that fail to perform 

adequate surveys; 

C imposing immediate sanctions for a second violation of harming residents; and 

C ensuring that state agencies enforce sanctions and that sanctions are not lifted 

until compliance is verified. 

In September 2000, the General Accounting Office (GAO) reported that more deficiencies in 

nursing homes were being detected by state survey agencies, although it remained unclear if this 

was due to more skillful enforcement or deteriorating care. The GAO also reported that wide 

variation existed among states with regard to the proportion of homes cited for serious care 

deficiencies, ranging from 10.5 percent in Maine to 

58 percent in Washington.2 This gap suggests “variability within and between states in the 

consistency of adherence to survey interpretive guidelines in deficiency citations is problematic, 

at least on the basis of interstate variability in the number and types of deficiencies cited in the 

survey process.”3 Additionally, a 2000 interim report from CMS on the Nursing Home 

Oversight Improvement Program noted some positive progress (such as more surveys being 

conducted during off-hours), but also identified areas where stronger efforts were needed. For 

example, the report found that “significant variation in state deficiency citations may indicate 

problems with the state survey process. [Further], 

1

 Enacted in 1998 during the Clinton administration as the Nursing Home Initiative. 

2

 GAO, “Sustained Efforts are Essential to Realize the Potential of Quality Initiatives,” (GAO/HEHS-00-197), 

September, 2000 

3

Wunderlich, G., Kohler, P., Improving the Quality of Long Term Care, (Editors: Committee on Improving 

Quality in Long Term Care, Division of Health Care Services, National Institute of Medicine), 2001 

Deficiency Trends and Survey and Certification Process Consistency 2 OEI-02-01-00600 
this degree of variation suggests that we need to be cautious when comparing results across 

states.”4 

CMS Oversight 

The CMS has various ongoing initiatives that address the issue of consistency and accuracy in 

the survey and certification process. These initiatives include: a national automated tracking 

system for surveyor training; an improved scope and severity matrix; cross regional surveys to 

assess consistency; the redesign of surveyor training; the development of surveyor performance 

measures; and contracting out for more comparative surveys. 

The CMS is also currently funding the second year of a contract to improve interpretive 

guidelines for scope and severity and deficiency tags. To date, CMS has reviewed five sets of 

tags and is beginning work for the next grouping of tags. 

METHODOLOGY 

This inspection uses data from 7 different sources: (1) national data from the Online Survey and 

Certification Reporting (OSCAR) system; (2) a mail questionnaire of all 51 state Survey and 

Certification Directors; (3) telephone interviews with staff from all 10 regional CMS offices; (4) 

observations of nursing home surveys in a purposive sample of 6 states; (5) a review of 310 

survey reports from the same 6 states; (6) telephone interviews with a purposive sample of 32 

surveyors 8 states; and (7) telephone interviews with a purposive sample of 32 nursing home 

administrators from the same 8 states. 

Analysis of OSCAR data 

We analyzed national data from OSCAR, which includes the results of all state nursing home 

surveys. This system contains the most current survey and the three previous surveys for every 

nursing home that is certified for Medicare and/or Medicaid. We downloaded all surveys 

conducted in 1998, 1999, 2000, and 2001. 

Our analysis is based on data we downloaded in May 2002. If a nursing home had more than 

one standard survey in a particular year, we included only the most recent standard survey for 

that year. We determined the total number of nursing homes surveyed, the 

4

 Michael Hash, Deputy Administrator of the Centers for Medicare & Medicaid Services, “Interim Report on 

Nursing Homes,” 2000. 

Deficiency Trends and Survey and Certification Process Consistency 3 OEI-02-01-00600 
total number of deficiencies cited in those surveys, and the total number of nursing homes 

surveyed that had no deficiencies. We then calculated average deficiency rates by dividing the 

number of deficiencies by the number of nursing homes surveyed. 

Observations of nursing home surveys 

In order to get a wide variety of states, we selected a purposive sample of six states based on 

the following four criteria: 1) the number of nursing homes in the state, 2) the average deficiency 

rate, 3) the CMS regional office jurisdiction, and 4) geographical location. The six states 

include: Alabama, California, Maryland, Missouri, New York, and South Dakota. In five of 

the six sample states, we observed the final 2 days of a standard nursing home survey; in the 

sixth state, the survey ended earlier than anticipated, and we, therefore, observed only the final 

day. To reduce observer bias and enhance comparability across cases, we developed field 

instrumentation for observing and recording events. This included a structured checklist for the 

observation of survey activities and survey team interaction. We were especially interested in 

observations related to survey Task 5 (information gathering) and Task 6 (information analysis 

for deficiency determination). Further, we used a common interview guide to ask surveyors 

about their experiences and perspectives on the survey process. 

Review of survey reports 

From the 6 sample states, we reviewed 310 survey reports for standard surveys completed in 

calendar year 2001. We asked each of the 6 states to send us reports that included one or 

more citations for 13 specific deficiency tags. We focused our review on these 13 tags, either 

because they were among the top 10 deficiencies in 2000, and/or because we identified them 

as being potentially vulnerable to inconsistent citation. These 13 tags and the number of survey 

reports for each are identified in Appendix B. 

For each report, we used a standardized review protocol to determine the scope and severity 

of the deficiency cited, the nature of the problem cited, the sample size used in survey, and the 

type of evidence given to support the citation. 

State survey agency directors mail questionnaire 

We mailed a questionnaire to state nursing home Survey and Certification Directors in April and 

May 2002. All states and Washington D.C. responded to the questionnaire. We asked about 

each state agency’s program staffing and structure, survey process, state surveyor training and 

education, and state initiatives and experience with federal nursing home surveys. In addition, 

we asked respondents to rate the quality of care in nursing homes in their state and whether it 

has improved, declined, or remained about the same in 

Deficiency Trends and Survey and Certification Process Consistency 4 OEI-02-01-00600 
the last 3 years. Many of our questions were based on federal nursing home survey regulations 

and the State Operations Manual surveyor guidelines. 

Telephone interviews with CMS regional offices 

We interviewed staff from all 10 regional offices of the CMS in May 2002. In most cases, we 

interviewed the branch chief or regional administrator responsible for state operations and/or 

long term care survey and certification. During these interviews, we asked CMS staff about 

their oversight and monitoring activities. We specifically inquired about their regional staffing, 

the data they use to review state agencies’ performance, their survey protocols for Federal 

Oversight and Support surveys (FOSS) and comparative surveys, and their state training 

activities. 

Telephone interviews with state surveyors and nursing home administrators 

For the telephone interviews with state surveyors and nursing home administrators, we used the 

same purposive state sample selected for the on-site visits and survey report reviews. In 

addition, we selected one state that had a large increase (Connecticut) and one state that had a 

large decrease (South Carolina) in quality of care deficiencies over the last 4 years. 

State Surveyors. We asked each of the state survey agencies for a list of all surveyors in 

their state who had been a nursing home surveyor for at least 3 years. We then selected a 

random sample of 4 surveyors in each of our 8 sampled states for a total of 32 respondents. 

We asked the same questions that we asked state survey agency directors in addition to other 

questions about their observations in nursing homes. 

Nursing Home Administrators. To select a sample of nursing home administrators, we 

generated a list from OSCAR of nursing homes in each of our eight sampled states that had at 

least four standard surveys. We then randomly selected 4 nursing homes in each state for a 

total of 32 respondents. We asked these administrators the same set of questions that we 

asked state surveyors so that we could compare their responses. 

Limitations 

This inspection has several limitations. First, we only examined the survey process for standard 

surveys; we did not include extended surveys, follow-up surveys, initial certification surveys, or 

complaint surveys in our review. Second, we did not independently verify all of the information 

reported to us by state agencies in the mail 

Deficiency Trends and Survey and Certification Process Consistency 5 OEI-02-01-00600 
questionnaire. Third, our more detailed review of eight states is based on a purposive sample 

and, therefore, cannot be generalized to the universe of all states. 

Standards 

This inspection was conducted in accordance with the Quality Standards for Inspections 

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

Deficiency Trends and Survey and Certification Process Consistency 6 OEI-02-01-00600 
FINDINGS 

In 2001, 89 percent of nursing homes received at least one deficiency, an increase from 81 

percent in 1998. Total deficiencies increased by 46 percent to over 94,000, and the average 

number of deficiencies per nursing home rose from 5.1 to 6.2. Our analysis of OSCAR data 

also shows wide variation among states in the proportion of deficiency-free nursing homes and 

in average deficiency rates. 

Our review of the survey process further reveals that states differ in how they determine both 

the number and type of deficiencies. We identified four factors that contribute to this variability 

in citing deficiencies: (1) an inconsistent survey focus; (2) unclear guidelines; (3) the lack of a 

common review process for draft survey reports; and (4) high surveyor staff turnover. As a 

result, we conclude that nursing home survey results are not always consistent among states, 

therefore limiting the comparability of the data. Further, we cannot conclude whether trends in 

deficiencies are due to deteriorating care, variations in the survey process, and/or increased 

enforcement. However, deficiencies are a key indicator of care in nursing homes, and 

therefore, the number of and the increase in deficiencies over the past four years raise concerns. 

Nursing home deficiencies have increased since 1998 

Eighty-nine percent of nursing homes received at least one deficiency, an 

increase of 8 percentage points since 1998 

Surveyors can cite a nursing home for 

one or more deficiencies if it fails to 

meet certain Medicare program 

requirements. In 2001, 89 

percent of all nursing homes that 

were surveyed received at least 

one deficiency. This proportion 

increased by 8 percentage 

pointsfrom 81 percent in1998. 

(See Figure 1.) Conversely, the 

proportionofnursinghomesthat 

were deficiency-free decreased 

from 19 percent in 1998 to 

11 percent in 2001. In2001, a 

Figure 1 

Proportion of Nursing Homes that Received 

Any Deficiency, 1998-2001 

Source: OSCAR data, 2002 

Deficiency Trends and Survey and Certification Process Consistency 7 OEI-02-01-00600 
total of 15,077 nursing homes were surveyed; only 1,690 nursing homes did not receive any 

deficiencies. 

As shown in Table 1 below, in 2001, nursing homes received an average of 6.2 deficiencies, 

an increase from 5.1 deficiencies in 1998. The total number of deficiencies rose by 46 percent, 

from 64,608 in 1998 to 94,131 in 2001. The total number of nursing homes that were 

surveyed grew by 20 percent during this time period, from 12,555 in 1998 to 15,077 in 2001. 

Table 1 

Trends in Deficiencies, 1998-2001 

1998 1999 2000 2001 Percent 

Change 

1998-2001 

Total Number of Deficiencies 64,608 82,238 92,642 94,131 45.7% 

Total Number of Nursing Homes 12,555 14,313 14,879 15,077 20.1% 

Surveyed 

Average Deficiencies per 

Nursing Home 

5.1 5.7 6.2 6.2 

Source: OSCAR data, 2002 

Seventy-eight percent of nursing homes received a deficiency in one of the 

categories related to “substandard 

quality of care,” an increase of 8 

percentage points from 1998 to 2001 

The proportion of nursing homes that 

received a deficiencyinanyofthe three 

“quality of care” categories increased 

by 8 percentage points, from 70 

percent in 1998 to 78 percent in 2001. 

These three categories are part of 

CMS’ definitionofsubstandard quality 

of care. They include: one that is 

specifically called quality of care, 

another referred to as quality of life, 

and a third that is resident behavior and 

facility practices. See Appendix A for 

a list of all deficiencies in each 

category. 

Examples of Deficiencies in Three Categories 

Related to Substandard Quality of Care 

Quality of Care: includes 25 deficiencies, such as proper 

treatment to prevent and treat pressure sores, and resident 

receives adequate supervision and assistance devices to 

prevent accidents. 

Quality of Life: includes 19 deficiencies, such as a facility 

must promote care that maintains or enhances dignity, and 

a facility must provide housekeeping and maintenance 

services necessary to maintain a sanitary, orderly, and 

comfortable interior. 

Resident Behavior and Facility Practices: includes 6 

deficiencies, such as a resident has the right to be free 

from any physical restraint for purposes of discipline and 

convenience, and the facility may not employ persons 

who have been found guilty of abuse. 

Deficiency Trends and Survey and Certification Process Consistency 8 OEI-02-01-00600 
As shown in Table 2, each of these three individual categories increased during this time. The 

proportion of nursing homes that received a deficiency related to resident behavior and facility 

practices and to the specific quality of care category each increased by 9 percentage points 

between 1998 and 2001. Quality of life deficiencies increased by 5 percentage points. 

Appendix C lists changes to each of the deficiencies in these categories. 

Table 2 Proportion of Nursing Homes that Received at Least One Deficiency by Category 

1998-2001 

1998 2001 Percentage Point Difference 

N=12,555 N=15,077 1998-2001 

Resident Assessment 38.6% 50.1% 11.6% 

Dietary Services 31.7% 42.1% 10.3% 

Resident Behavior & Facility 19.1% 28.2% 9.1% 

Practices 

Quality of Care 59.4% 68.4% 9.0% 

Pharmacy Services 12.1% 20.1% 7.9% 

Infection Control 15.6% 20.7% 5.1% 

Administration 20.9% 26.0% 5.1% 

Physical Environment 20.7% 25.8% 5.1% 

Quality of Life 37.8% 43.1% 5.3% 

Resident's Rights 26.2% 29.9% 3.7% 

Laboratory Services 2.9% 4.9% 1.9% 

Physician Services 3.4% 4.7% 1.2% 

Dental Services 0.7% 1.2% 0.5% 

Nursing Services 5.0% 5.1% 0.0% 

Rehabilitation Services 1.1% 1.0% - 0.1% 

Other 0.4% 0.3% - 0.1% 

Admission, Transfer, Discharge 2.5% 1.6% - 0.9% 

Rights 

* Differences may be due to rounding. Source: OSCAR data, 2002 

**Bold indicates “quality of care” categories. 

Deficiency Trends and Survey and Certification Process Consistency 9 OEI-02-01-00600 
As also shown in Table 2, deficiencies in three other categories experienced considerable 

increases. These include resident assessment and pharmacy and dietary services. The largest 

increase was in the proportion of nursing homes that received a deficiency related to resident 

assessment. This category increased by nearly 12 percentage points, from almost 39 percent in 

1998 to 50 percent in 2001. These deficiencies address whether a facility has developed care 

plans, provided the appropriate care and services to each resident, and modified the care plan 

based on the resident’s status. 

In addition, deficiencies related to dietary services rose by 10 percentage points from 32 

percent of nursing homes in 1998 to 42 percent in 2001. Deficiencies related to pharmacy 

services also increased by about 8 percentage points during this time. Dietary services include 

deficiencies that address whether a nursing home has provided the appropriate diet to meet the 

daily nutritional needs of each resident. Pharmacy services include deficiencies related to 

assuring the accurate dispensation and administration of drugs to residents. 

Nursing homes receiving immediate jeopardy deficiencies have increased slightly 

Surveyors assign a scope and severity rating for each deficiency. If a deficiency has a J, K, or 

L scope and severity rating as shown in Table 3 on the next page, it is considered to be 

immediate jeopardy. Immediate jeopardy is when death or serious injury actually or potentially 

occurs. The proportion of nursing homes that received an immediate jeopardy deficiency 

stayed about the same between 1998 and 2001. In 2001, a total of 2.3 percent, or 353 

nursing homes, had at least one immediate jeopardy deficiency. This proportion rose slightly 

from 1.4 percent, or 172 nursing homes, in 1998. (See Appendix D.) 

The proportion of nursing homes that received a deficiency considered substandard quality of 

care did not change substantially from 1998 to 2001. Substandard quality of care is a 

deficiency in any of the three “quality of care” categories that has a scope and severity rating, as 

shown by the shaded area in Table 3 on the next page. In total, 4.2 percent, or 639 nursing 

homes, received at least one substandard quality of care deficiency in 2001. This number 

decreased slightly from 4.5 percent in 1998. (See Appendix D.) 

Deficiency Trends and Survey and Certification Process Consistency 10 OEI-02-01-00600 
Table 3 

Percent of Nursing Homes with Deficiencies in Any of the Three Categories 

of Quality of Care by Scope and Severity in 2001 

Severity of the Deficiency 

Scope of the Deficiency 

Isolated Pattern Widespread 

Immediate jeopardy to resident 

health or safety 

J 

1.0% 

K 

0.8% 

L 

0.2% 

Actual harm that is not 

immediate jeopardy 

G 

18.6% 

H 

1.3% 

I 

0.0% 

No actual harm with potential 

for more than minimal harm that 

is not immediate jeopardy 

D 

64.1% 

E 

37.6% 

F 

1.6% 

No actual harm with potential 

for minimal harm 

A 

0.0% 

B 

14.5% 

C 

7.7% 

* Shading indicates the ratings classified as substandard quality of care. Source: OSCAR data, 2002 

**Percentages in the table do not add to 4.2 percent because a nursing home may receive more than one deficiency 

considered substandard quality of care. 

As shown in Table 4 on the next page, a review of the trends of the scope and severity of all 

deficiencies shows a shift from G-level to D-level and to E-level ratings between 1998 and 

2001. This trend indicates that nursing homes are being cited for less severe deficiencies, while 

the scope of these deficiencies is staying the same or is slightly increasing. All of the other 

ratings have remained about the same or have increased slightly during this time period. The 

trends in the scope and severity ratings of deficiencies in the three “quality of care” categories 

follow a similar pattern to all deficiencies. (See Appendix D.) 

Deficiency Trends and Survey and Certification Process Consistency 11 OEI-02-01-00600 
Table 4 

Percent of Nursing Homes that Received a Deficiency 

by Scope and Severity of All Deficiencies, 1998-2001 

Scope and 

Severity Level 1998 2001 

Percentage Point Difference* 

1998-2001 

A 0.0% 0.0% 0.0% 

B 30.2% 32.7% 2.5% 

C 21.4% 23.4% 2.0% 

D 63.5% 77.2% 13.6% 

E 47.1% 54.8% 7.7% 

F 15.4% 19.8% 4.4% 

G 28.1% 19.6% - 8.5% 

H 3.1% 1.5% - 1.6% 

I 0.3% 0.1% - 0.2% 

J 0.8% 1.2% 0.5% 

K 0.6% 1.0% 0.4% 

L 0.2% 0.4% 0.2% 

* Differences may be due to rounding Source: OSCAR data, 2002 

Over two-thirds of all state directors and sampled surveyors report that quality of 

care has stayed the same or declined over the last 3 years; nursing home 

administrators are more positive 

To gain further insight into the state of care in nursing homes, we surveyed all 51 state Survey 

and Certification Directors, and a purposive sample of 32 state surveyors and 32 nursing home 

administrators. As shown in Chart 1 on the next page, the majority of state directors and state 

surveyors report that quality of care has stayed the same or declined over the last 3 years. 

Nursing home administrators are more positive in that 59 percent say that care has improved 

over the last 3 years. 

Deficiency Trends and Survey and Certification Process Consistency 12 OEI-02-01-00600 
Chart 1 

Overall, has the quality of care in nursing homes improved, declined, or stayed about the 

same over the last 3 years? 

Sample Size Improved Declined Stayed the Same Don’t Know 

Surveyors n=32 31 % 34 % 34 % 0 % 

Survey and Certification 

Directors N=51 24 % 27 % 45 % 4 % 

Nursing Home n=32 59 % 9 % 31 % 0 % 

Administrators 

Source: OEI Survey, 2002 

Two-thirds of sampled surveyors further note that the percentage of nursing homes in their area 

that provide care they consider to be poor has increased or stayed about the same during this 

time. Some explain that staffing issues, such as high turnover, lack of training, poor quality staff, 

and less supervision contribute to “care getting worse.” In contrast, nursing home 

administrators most commonly attribute improvements in quality of care to committed staff, the 

survey process, quality initiatives, and the use of the clinical assessment tool, referred to as the 

Minimum Data Set. 

When asked to rate overall quality of care in nursing homes, some respondents expressed 

concerns. Chart 2 below shows that over one-third of sampled surveyors and 14 percent of all 

state directors rate quality of care as “fair” or “poor.” In addition, about two-thirds of 

surveyors and 44 percent of administrators report that at least 10 percent of nursing homes in 

their area provide care that they consider to be poor. 

Chart 2 

Overall, how would you rate the quality of care in nursing homes in your area? 

Sample Size Excellent Good Fair Poor Don’t Know 

Surveyors n=32 3 % 59 % 28 % 6 % 3 % 

Survey and Certification 

Directors N=51 6 % 78 % 14 % 0 % 2 % 

Nursing Home n=32 34 % 56 % 9 % 0 % 0 % 

Administrators 

Source: OEI Survey, 2002 

Deficiency Trends and Survey and Certification Process Consistency 13 OEI-02-01-00600 
Wide variation exists among states in the number of deficiencies 

Proportion of deficiency-free nursing homes. The proportion of nursing homes surveyed 

that were deficiency-free varied greatly among states. In 2001, 33.5 percent of nursing homes 

surveyed in Virginia had no deficiencies, while in Nevada no nursing home surveys resulted in 

deficiency-free nursing homes. Nationally, the average proportion of deficiency-free nursing 

homes for all surveys conducted in 2001 was 11 percent. Tables 5 and 6 below, show the five 

states with the highest and lowest proportion of deficiency-free nursing homes in 2001. 

Table 5 

Highest Deficiency-Free States 

Proportion 

State Deficiency-Free* 

Virginia 33.5 % 

Massachusetts 29.2 % 

Vermont 28.2 % 

New Hampshire 24.6 % 

Source: OSCAR data, 2002 

Table 6 

Lowest Deficiency-Free States 

State 

Proportion 

Deficiency-Free* 

Nevada 0 % 

California 2.1 % 

Florida 2.9 % 

Tennessee 3.3 % 

Source: OSCAR data, 2002 

Deficiency rates. Nationally, the average deficiency rate in 2001 was 6.2 deficiencies per 

nursing home. This ranged from a high of 11.2 deficiencies per nursing home in California to a 

low of 2.9 deficiencies per nursing home in Vermont. Tables 7 and 8 below show the five 

states with the highest deficiency rates and the five states with the lowest deficiency rates in 

2001. 

Table 7 

States with Highest Deficiency Rate 

State Deficiency Rate* 

California 11.2 

Arizona 10.2 

Washington 10 

D.C. 

Nevada 9.9 

Source: OSCAR data 2002 

Table 8 

States with Lowest Deficiency Rate 

State Deficiency Rate* 

Vermont 2.9 

Rhode Island 3.3 

Wisconsin 3.3 

Virginia 3.5 

Utah 3.7 

Source: OSCAR data 2002 

Deficiency Trends and Survey and Certification Process Consistency 14 OEI-02-01-00600 
In general, it appears that some states are more likely than others to cite deficiencies. For 

example, we observed that three states with the lowest deficiency rates (Vermont, Virginia, and 

Rhode Island) also have among the highest proportions of deficiency-free nursing homes. 

Three states with among the highest deficiency rates (California, Arizona, and Nevada) have the 

lowest proportions of deficiency-free nursing homes. Also overall, 20.4 percent of nursing 

homes are deficiency-free in states with low deficiency rates. For states with medium and high 

rates, the proportion of deficiency-free nursing homes is 10.9 percent and 5 percent, 

respectively. (See Appendix E.) 

This variability in the data was also discussed in a 2000 interim report from CMS on the 

Nursing Home Oversight Improvement Program. That report noted “significant variation in 

state deficiency citations from the national average of deficiencies cited may indicate problems 

with the state survey process. There is also substantial variation among states in all measures 

examined, which could be attributed to any number of different factors including actual 

differences in quality [of care], case-mix, or surveyor practices. This degree of variation 

suggests that we need to be cautious when comparing results across states.” 

States differ in how they determine specific deficiency citations 

Type of deficiency. Our review of 310 survey reports from the six sample states reveals that 

different deficiency tags are being used to cite the same problem. For example, in one state, 

two different survey teams cited the same problem under two different tags. In both cases, they 

observed that closets with cleaning compounds containing dangerous chemicals were not 

locked. In one survey, they cited this under tag F324 (inadequate supervision to prevent 

accidents). In the other survey, they cited this under tag F323 (the resident environment 

remains as free of accident hazards as is possible). Further, a survey report from one state cites 

tag F441 (infection control) for dietary staff not following hand washing policy. Two other 

survey reports in 2 different states cite tag F371 (store, prepare, distribute, and serve food 

under sanitary conditions) for the same problem. 

Our review of survey reports also reveals that different types of problems are being cited under 

the same deficiency tag. When reviewing 26 reports with a citation for F241 (resident dignity), 

we identified 17 different types of problems that were cited with this same deficiency. These 

included incidents as diverse as residents waiting for their food at mealtimes, facial hair on a 

female resident, staff using disrespectful language, and a bedpan not being emptied. We also 

noted that a few of the problems cited under the dignity tag, such as unanswered call lights, 

were cited under different deficiency tags in other survey reports. 

Deficiency Trends and Survey and Certification Process Consistency 15 OEI-02-01-00600 
Further, nine state agency directors volunteer that their staff will consider either the type of 

corrective action needed by the facility or a particular preference for one deficiency category 

over another when deciding what deficiencies to cite. Comments from two state agency 

directors illustrate these practices. One says that surveyors will look at the “main problem a 

facility needs to fix” when deciding what type of deficiency to cite, while another admits that 

surveyors “always go for a quality of care [deficiency], if relevant, over [an] assessment 

[deficiency].” 

Failure to cite deficiencies. In five of the six surveys we observed, we noted that surveyors 

did not consistently cite deficiencies for problems they observed in the nursing home. In one, 

the team did not cite a deficiency for a food service worker who failed to wash her hands until a 

surveyor told her to; the same team also did not cite a deficiency for the nursing home’s failure 

to write an incident report for a patient with a large bruise. Also, in three surveys we observed 

that surveyors did not cite deficiencies for problems because the nursing home submitted 

additional documentation that convinced the surveyors that corrective action was being initiated. 

For example, during one visit we observed that surveyors noted a strong, offensive smell in 

several of the residents’ rooms; CMS guidelines instruct surveyors to cite such a problem with 

a deficiency. However, the surveyors did not cite a deficiency because they accepted the 

facility’s assurance that soiled carpeting in those rooms would be removed and replaced with 

linoleum flooring. According to CMS guidelines, they should have cited this deficiency. 

Number of deficiencies. States differ on how many deficiencies they will cite for a single 

problem of non-compliance. While CMS guidelines do not prohibit that more than one 

deficiency be cited, eight state agency directors volunteer that their staff will cite only one tag 

for one problem of non-compliance. This is in direct contrast to other states in which surveyors 

may cite multiple tags for one problem of non-compliance. In one state we visited with a low 

deficiency rate, surveyors told us that they were instructed by the state agency to choose only 

one tag rather than multiple tags for a single observed problem. 

Four factors contribute to variability in citing deficiencies 

We identified four factors that contribute to variability in citing deficiencies across state agencies 

and among surveyors. These are: 

1. Inconsistent survey focus 

2. Unclear guidelines 

3. Lack of a common review process for draft survey reports 

4. High surveyor staff turnover 

Deficiency Trends and Survey and Certification Process Consistency 16 OEI-02-01-00600 
Inconsistent survey focus . Thirty-six state agency directors say that their state’s survey

process is only somewhat consistent, acknowledging that this process may have a particular

enforcement or consultative focus that affects the scope of the review. They cite several factors

affecting the focus of nursing home surveys, including the political climate, the strength of the

nursing home lobby, and changing federal and state regulations. Thirty-seven state agency

directors further note that the focus of nursing home surveys has changed in the last 3 years. 

Section IX of the State Operations Manual discusses the focus of the nursing home survey

process by stating that, in addition to ensuring compliance with federal standards, surveyors

should also transfer information to the facility about care and regulatory topics. The manual

specifically states, “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.”5

During our on-site visits to the six sample states, we observed survey teams utilizing different

foci in their reviews. In one state, surveyors used a more consultative approach in making

specific recommendations to the nursing home staff about treatment protocols for an individual

resident. This approach contrasted with a more enforcement approach we observed in another

state survey, where very little dialogue occurred between the survey team and nursing home

staff. 

Lastly, 21 states have state specific criteria governing nursing home surveys that may affect the

focus of their federal surveys. These state criteria most commonly include nursing home staffing

ratios and state life safety codes. In 14 of these states, the criteria have changed over the past

3 years. 

Unclear guidelines. Twenty-three state agency directors and 17 of 32 sampled surveyors

assert that some groups of deficiencies are more vulnerable to inconsistent citation. Both of

these groups identify deficiencies that are categorized under “quality of life” as being 

the most vulnerable due to the lack of clarity and complexity of the federal guidelines. 

They claim this fosters a subjective interpretation, thereby contributing to inconsistent citation

between surveyors. One state agency director, voicing a common concern, asserts that “it is

difficult to assign harm or immediate jeopardy to the quality of life tags. Quality of life tags can

be more subjective. A clear directive is needed.” 

As part of our analysis, we reviewed the State Operations Manual for deficiency tags under the

“quality of life” and “quality of care” categories. We found some of the guidance to be

inherently confusing. For example, guidance for tag F250 (social services)

5 Title XVIII of the Social Security Act (the Act) is administered by CMS. Section 1819 (g)(2)(c) Survey 

Protocols, states that standard and extended surveys are to be conducted, based upon protocols prescribed by CMS 

in the State Operations Manual, to determine nursing home compliance. 

Deficiency Trends and Survey and Certification Process Consistency 17 OEI-02-01-00600 
offers 14 examples of medically-related social services, 6 types of unmet needs, and 10 

conditions to which the nursing home must respond with social services. Also, some of the 

definitions for these tags are general and subjective, and while the guidance does offer 

numerous examples of specific scenarios that can be cited under each deficiency tag, in some 

cases the broad range of examples can be confusing. Lastly, we also noted that for certain 

deficiencies, surveyors are directed to refer to more than one deficiency category or tag for the 

same issue, without any explicit direction to cite or not cite under multiple tags when the facility 

is found to be out of compliance. For example, for tag F323 (facility is free of accident 

hazards), surveyors are instructed: “see F221 for guidance concerning the use of bed rails. See 

also §483.70(h) - Safe Environment. (F454 under Physical Environment).” 

Lack of consistent review process for draft survey reports. States do not utilize the same 

review processes for draft survey reports, as illustrated in Table 9 below. Only 42 states 

report that all of their draft reports had supervisory reviews in 2001. Further, 31 states have 

developed internal quality assurance (QA) teams and two states developed continuous quality 

improvement (CQI) teams (17 states have both). Only 18 states conduct reviews when reports 

change significantly from draft to final, while a few also incorporate specialized assessments as 

part of their review process. 

Table 9 

State Survey Report Review Processes 

Review Processes Number of 

States 

Supervisory Review for 100% of draft reports 42 

QA Teams 31 

Reviews for reports that changed significantly 

from draft to final 

18 

Specialized reviews for Deficiencies with 

Scope and Severity of G level * and above 

8 

Specialized review by Field Managers, 

Compliance Reviewers, or Enforcement Team 

7 

Specialized reviews by Licensure and/or 

Certification Administrators 

3 

CQI Teams 2 

Source: State Agency Director Mail Questionnaire, 2002 

Deficiency Trends and Survey and Certification Process Consistency 18 OEI-02-01-00600 
This inconsistency in state agencies’ review processes is reflected in the wide variation in 

revisions made to draft deficiency reports. State agencies report that an average of 5 percent 

of deficiencies are removed from draft survey reports before they become final. However, this 

removal rate ranges from 25 percent in one state to 0 percent in three other states. Further, 

state agencies report that an average of 6 percent of scope and severity determinations are 

downgraded from draft surveyors’ reports before they become final. This ranges from one 

state that reports 38 percent of deficiencies are downgraded to two states that say no 

deficiencies are downgraded. 

In addition, our analysis shows that the states with lower deficiency rates removed more 

deficiencies, on average, from draft survey reports than states with higher rates. Figure 2 below 

shows the average proportion of deficiencies removed from surveyors’ draft reports, for states 

with high, medium, and low deficiency rates. 

Figure 2

Proportion of Deficiencies Removed by 

Average Deficiency Rate

8 

7 

6 

5 

4 

3 

2 

1 

0 

7.4 

3 

3.8 

2.9 - 4.6 5 - 6.9 7 - 11.2 

Range of average deficiency rates 

[ low - medium - high ] 

Source: OSCAR Data 2002 and State Agency Director Mail 

Questionnaire 

High surveyor staff turnover. Fifty state agency directors report that it is very or somewhat 

difficult to replace survey staff when they leave, and more than half (31) say that registered 

nurses are the most difficult to replace. Based on their reporting, we determined that nationally, 

surveyors work an average of only 6.5 years for the state agency. We also determined that 

state agency directors have held their jobs on average for only 6.4 years. This high staff 

turnover affects the consistency of the survey process, as acknowledged by one survey director 

who says, “It is impossible to achieve consistency when surveyor turnover is 50 percent every 

year.” While states identified high survey staff turnover rates to be a problem, only three 

regional CMS offices look at staff turnover rates in their oversight of state agencies. 

On all our visits to the six sample states, surveyors told us that finding and retaining staff were 

problematic. They also express concern that high staff turnover impacts on the 

Deficiency Trends and Survey and Certification Process Consistency 19 OEI-02-01-00600 
consistency of the survey process, since a high proportion of newer staff detracts from the 

continuity of surveyors’ experience. In fact, in one nursing home that we visited the survey 

team members were new, and we observed that these surveyors were more uncertain about 

what problems to cite and which deficiency tags to cite them with. 

States report following CMS nursing home survey protocols for 

staffing, scheduling, and pre-survey preparation; in the six sample 

states, survey teams completed all on-site survey tasks 

Survey team staff. States are required to place at least one qualified health professional on 

their survey team and all states’ agency directors report that they do so. More specifically, all 

states report that they included at least one registered nurse on their survey teams.6 Most states 

(75 percent) also report that they include a dietician or nutritionist on the team, and over half 

(57 percent) typically include a social worker. On all six of the surveys we observed, the teams 

had at least one registered nurse and one dietician or nutritionist. 

General guidelines from CMS suggest that the size of teams be governed by the size and type of 

the facility being surveyed, and 44 states say they typically use teams with three to four 

surveyors.7 In our purposive sample of six states, we observed an appropriate ratio of 

surveyors to facility size. In one of these states, we observed a survey being conducted for a 

350-bed facility, and the survey team included seven members. In two other states where 

surveys were conducted for smaller nursing homes, the survey teams were comprised of only 

three members. 

Surveyor training. Nearly all state surveyors meet basic CMS training requirements. On 

average, state agencies report that 96 percent of their surveyors have successfully completed 

CMS training - modules A and B of the Surveyor Minimum Qualifications Test (SMQT) (see 

Appendix F). Nationally, the average number of training days for surveyors last year was 10. 

Further, all 10 regional offices of the CMS say they review state surveyor training to ensure that 

state agency surveyors are meeting federal qualification standards. 

6 Sections 1819(g)(2)(E) and 1919(g)(2)(E) of the Act and 42 CFR 488.314 require that: skilled nursing facility 

[SNF] and nursing facility [NF] standard surveys be conducted by a multidisciplinary team of professionals, at least 

one must be a registered nurse. 

7 7201. State Operations Manual Survey Team Size and Composition - A. Survey Team Size.--Survey team 

size will vary, depending primarily on the size of the facility being surveyed. 

Deficiency Trends and Survey and Certification Process Consistency 20 OEI-02-01-00600 
Nearly all state agencies report that they conduct their own training in addition to CMS training. 

Forty-eight have a training coordinator and 49 also have their own state surveyor training

program. States typically use videos, satellite communications, presentations, and informal

sessions during or following on-site visits to train their survey staff. Also, nearly all state

agencies told us that they specifically focus their surveyor training in response to survey findings

and provide training related to the documentation of deficiencies. 

Team approach. All states report using a team approach in their survey process as suggested

by CMS.8 State agencies say that they follow CMS guidelines on team communication that

require teams to have daily discussions among themselves about their observations in order to

facilitate information gathering and decision making. All state agencies report that their survey

teams formally meet on a daily basis to discuss their findings and observations, to consult with

each other, and to talk about scheduling uncompleted survey tasks. We also noted a strong

team approach in the six surveys we observed. Surveyors continually consulted with one

another regarding their findings, conferred with each other on any questions or concerns they

had, and checked in on their individual progress to assure all necessary work was being

completed.

Survey schedule. All states report scheduling standard surveys within a 9-to-15 month

interval as required by CMS guidelines.9 Twenty-six states report that in 2001 the interval

between consecutive nursing home standard surveys in their state averaged 

12 months. Eleven states told us they conducted these surveys within a shorter 

(10-to-11 month) interval on average, and 14 states report conducting surveys within a longer

(13-to-15 month) interval on average. 

8 State Operations Manual, Appendix P - Survey Protocol for Long Term Care Facilities - Part 1-

Introduction: 1D. TEAM COMMUNICATION - Throughout the survey process, the team (including specialty 

surveyors on-site at the time) should discuss among themselves, on a daily basis, observations made and 

information obtained in order to focus on the concerns of each team member, to facilitate information gathering and 

to facilitate decision making at the completion of the standard survey. 

9 

§7205. State Operations Manual - SURVEY FREQUENCY--The survey and certification provisions set 

forth in §§1819(g)(2)(A)(iii) and 1919(g)(2)(A)(iii) of the Act and in 42 CFR §488.308 require that each SNF and NF be 

subject to a standard survey no later than 15 months after the last day of the previous standard survey and that the 

statewide average interval between standard surveys of SNFs and NFs not exceed 12 months. 

Deficiency Trends and Survey and Certification Process Consistency 21 OEI-02-01-00600 
Pre-survey preparation. Survey teams are required to prepare for surveys offsite by 

analyzing information about the nursing home that will enable them to focus their review most 

effectively.10 All state agencies report doing this pre-survey preparation. First, they all report 

that their surveyors use quality indicator reports in this preparation. These reports identify 

potential problems in the facility that may warrant further investigation, such as a high proportion 

of pressure sores or falls among its residents. Further, 96 percent of states’ survey teams use 

facility level reports generated by OSCAR, while 92 percent will also typically review the 

facility’s prior statements of deficiencies. Complaint data, information from the Ombudsman 

office, and resident level summary reports are also used by at least 72 percent of states in their 

pre-survey preparation. 

On-site survey tasks. In the surveys we observed in the six sample states, we saw evidence 

of, or directly observed the completion of, all on-site survey tasks required by CMS. We also 

observed survey teams’ use of specific investigative protocols suggested by CMS, such as 

medical record reviews, resident, group, and family interviews, observations of mealtimes, and 

direct care observations. In several of the states, surveyors expanded the initial scope of their 

review, based on observations from the initial facility tour. 

We observed that all six of the sample state surveys follow the same general process for Task 6 

of the survey process, information analysis for deficiency determination, and Task 7, the exit 

meeting with the nursing home. On the final day of the survey, before the exit, the survey team 

in all six states conducted team meetings, reviewed and analyzed their worksheets, discussed 

their findings, and used a team approach to reach consensus and make decisions. In all six 

states, the survey team also shared their preliminary findings with the nursing home during the 

exit meeting, and in five states the facility was given the opportunity to provide additional 

information either then or at a later date that it believed was pertinent to the initial survey 

findings. 

10 §7203. State Operations Manual - SURVEY PROTOCOL A. Introduction.--This protocol is established 

pursuant to §§1819(g)(2)(C) and 1919(g)(2)(C) of the Act to provide guidance to surveyors conducting surveys of 

long term care facilities participating in the Medicare and Medicaid programs. The protocol consists of survey 

procedures, worksheets, and interpretive guidelines. 

Deficiency Trends and Survey and Certification Process Consistency 22 OEI-02-01-00600 
CONCLUSION 

Our analysis shows an increase in nursing home deficiencies since 1998. The proportion of 

nursing homes receiving deficiencies, the total number of deficiencies, and the key categories of 

deficiencies directly related to quality of care have all increased since 1998. In addition, wide 

variation exists among states in the proportion of deficiency-free nursing homes and in average 

deficiency rates. 

Our review of the survey process reveals that states differ in how they determine both the 

number and type of deficiencies. We identified four factors that contribute to this variability in 

citing deficiencies: (1) an inconsistent survey focus; (2) unclear guidelines; (3) the lack of a 

common review process for draft survey reports; and (4) high surveyor staff turnover. As a 

result, we conclude that nursing home survey results are not always consistent among states, 

therefore limiting the comparability of the data. Further, we cannot conclude whether trends in 

deficiencies are due to deteriorating care, variations in the survey process, and/or increased 

enforcement. However, deficiencies are a key indicator of care in nursing homes, and 

therefore, the number of deficiencies and the increase in the number of deficiencies over the 

past four years raise concerns. 

Deficiency Trends and Survey and Certification Process Consistency 23 OEI-02-01-00600 
RECOMMENDATIONS 

The Centers for Medicare & Medicaid Services should continue to improve its 

guidance to state agencies on citing deficiencies by providing guidelines that are both 

clear and explicit. Based on our findings, we recommend that CMS provide more specific 

guidance to states for quality of life deficiency tags and clearer directives on when to cite single 

or multiple deficiencies. We also recommend that CMS more clearly communicate to states 

that the focus of the nursing home survey process is not consultative. They should remind states 

of the dual function of this process, as specified in the Interpretive Guidelines. These two 

functions are: 1) to ensure compliance; and 2) to enter into a non-consultative information 

exchange for the purpose of information dissemination that may be of assistance to the facility in 

meeting long term care requirements. 

The Centers for Medicare & Medicaid Services, together with states, should develop 

common review criteria for draft survey reports. While most states incorporate some 

level of supervisory review for draft survey reports, they do not follow a standard process with 

common evaluation criteria. A more standard review process that utilizes the same criteria for 

assessing draft reports will help to ensure greater consistency across states. The CMS could 

incorporate this standardized assessment criteria as part of the Nursing Home State 

Performance Measures: Review Protocol Guidance, which all states are now required to 

follow. 

Deficiency Trends and Survey and Certification Process Consistency 24 OEI-02-01-00600 
AGENCY COMMENTS 

We received comments on our draft report from the Centers for Medicare & Medicaid 

Services (CMS). The CMS concurred with our recommendations that it should continue to 

improve guidance to state agencies on citing deficiencies by providing guidelines that are both 

clear and explicit and that it should develop, together with states, a common review criteria for 

draft survey reports. The CMS also highlighted several actions they have taken to improve 

such guidance. The full text of CMS’ comments are contained in Appendix G. 

Deficiency Trends and Survey and Certification Process Consistency 25 OEI-02-01-00600 
APPENDIX A 

Definitions of Quality of Care Deficiencies by Category 

Resident Behavior and Facility Practices 

Deficiency - (Ftag) Definition 

F0221 Resident has the right to be free from any physical restraint for purposes of 

discipline or convenience. 

F0222 Resident has the right to be free from any chemical restraint for purposes of 

discipline or convenience. 

F0223 Resident has the right to be free from verbal, sexual, physical and mental abuse, 

corporal punishment, and involuntary seclusion. 

F0224 Facility must have written policies and procedures that prohibit abuse and 

neglect. 

F0225 Facility may not employ persons who have been found guilty of abuse. 

F0226 Facility must develop and implement written policies and procedures that 

prohibit mistreatment, neglect, and abuse of residents, and misappropriation of 

resident property 

Quality of Life 

Deficiency - (Ftag) Definition 

F0240 Facility must promote/enhance quality of life. 

F0241 Facility must promote care that maintains or enhances dignity. 

F0242 Resident has the right to choose activities, schedules, interact with members of 

community, and make choices about aspects of life in the facility. 

F0243 Resident has the right to organize and participate in resident groups. 

F0244 Facility must listen and respond to resident or family group. 

F0245 Resident has the right to participate in social, religious, and community 

activities. 

Deficiency Trends and Survey and Certification Process Consistency 26 OEI-02-01-00600 
F0246 Facility should have policies that accommodate residents’ needs and 

preferences. 

F0247 Resident to receive notice before room or roommate in the facility is changed. 

F0248 Facility is to provide ongoing program of activities that fit resident. 

F0249 Facilities director must be fully qualified. 

F0250 Facility must provide medically-related social services. 

F0251 Facility with more than 120 beds must employ a qualified social worker on a full 

time basis. 

F0252 Facility must provide a safe, clean, comfortable, and homelike environment. 

F0253 Facility must provide housekeeping and maintenance services necessary to 

maintain a sanitary, orderly, and comfortable interior. 

F0254 Facility must provide clean bed and bath linens that are in good condition. 

F0255 Facility must provide private closet space in each resident’s room. 

F0256 Facility must provide adequate and comfortable lighting levels in all areas. 

F0257 Facility must provide comfortable and safe temperature levels. 

F0258 Facility must provide comfortable sound levels. 

Quality of Care 

Deficiency - (Ftag) Definition 

F0309 Facility to provide necessary care for the highest practicable physical, mental, 

and psychosocial well being. 

F0310 Activities of daily living do not decline unless unavoidable. 

F0311 Resident is given treatment to improve abilities. 

F0312 Activities of daily living care is provided for dependent residents. 

F0313 Resident receive treatment to maintain hearing and vision. 

Deficiency Trends and Survey and Certification Process Consistency 27 OEI-02-01-00600 
F0314 Proper treatment to prevent or treat pressure sores.

F0315 Resident is not catheterized, unless unavoidable.

F0316 Appropriate treatment for incontinent resident.

F0317 No reduction of range of motion, unless unavoidable.

F0318 Resident with limited range of motion receives appropriate treatment. 

F0319 Appropriate treatment for mental or psychosocial problems.

F0320 No development of mental problems, unless unavoidable.

F0321 No naso-gastric tube, unless unavoidable.

F0322 Proper care and services for resident with naso-gastric tube.

F0323 Facility is free of accident hazards.

F0324 Resident receives adequate supervision and assistance devices to prevent 

accidents. 

F0325 Facility must maintain acceptable parameters of nutritional status, unless 

unavoidable. 

F0326 Resident receives therapeutic diet, when required. 

F0327 Facility must provide sufficient fluid intake to maintain proper hydration and 

health. 

F0328 Facility must ensure that proper treatment and care is provided. 

F0329 Each resident’s drug regimen must be free from unnecessary drugs. 

F0330 No use of antipsychotic drugs, except when necessary. 

F0331 Residents who use antipsychotic drugs receive gradual dose reductions. 

F0332 Facility must ensure that it is free of medication error rates of five percent or 

greater. 

F0333 Residents are free of any significant medication errors. 

Deficiency Trends and Survey and Certification Process Consistency 28 OEI-02-01-00600 
APPENDIX B 

Definitions of Selected Deficiencies for State Survey Report Review 

Deficiency - (Ftag) Definition 

F223 [n=14] Resident has the right to be free from verbal, sexual, physical and mental abuse, 

corporal punishment, and involuntary seclusion. 

F241 [n=26] Facility must promote care that maintains or enhances dignity. 

F279 [n=24] The facility must develop a comprehensive care plan for each resident that 

includes measurable objectives and timetables to meet a resident’s medical, 

nursing, and mental and psychosocial needs, as identified in the comprehensive 

assessment. The care plan must describe the services that are to be furnished 

and any services that would otherwise be required. 

F280 [n=18] A comprehensive care plan must be developed by an interdisciplinary team, 

within 7 days after the completion of the comprehensive assessment and be 

periodically reviewed and revised by a team of qualified persons after each 

assessment. 

F309 [n=34] Facility to provide necessary care for the highest practicable physical, mental, 

and psychosocial well being. 

F314 [n=32] Proper treatment to prevent or treat pressure sores. 

F323 [n=21] Facility is free of accident hazards. 

F324 [n=37] Resident receives adequate supervision to prevent accidents. 

F327 [n=13] Facility must provide sufficient fluid intake to maintain proper hydration and 

health. 

F329 [n=18] Each resident’s drug regimen must be free from unnecessary drugs. 

F353 [n=12] The facility must have sufficient nursing staff to provide nursing and related 

services to attain or maintain the highest practicable physical, mental, and 

psychosocial well-being of each resident, as determined by the resident 

assessments and individual plans of care. 

F371 [n=36] The facility must store, prepare, distribute, and serve food under sanitary 

conditions. 

F0441 [n=25] The facility must establish and maintain an infection control program designed 

to provide a safe, sanitary, and comfortable environment and to help prevent the 

development and transmission of disease and infection. 

Deficiency Trends and Survey and Certification Process Consistency 29 OEI-02-01-00600 
APPENDIX C 

Table C-1

Proportion of Nursing Homes 

by Resident Behavior and Facility Practices Deficiencies, 1998-2001 

Percentage 

Deficiency 1998 1999 2000 2001 Point 

Difference* 

1998-2001 

Right to be free from physical 12.8% 11.5% 10.9% 11.0% -1.8% 

restraints 

Right to be free from chemical 0.7% 0.4% 0.5% 0.4% -0.3% 

restraints 

Right to be free from 1.7% 2.0% 1.7% 1.5% -0.1% 

abuse 

Must have policies that 1.9% 2.6% 3.2% 2.5% 0.5% 

prohibit abuse and neglect 

May not employ persons guilty 6.7% 8.7% 11.6% 10.8% 4.1% 

of abuse 

Facility must develop and 0.0% 1.6% 8.7% 10.2% 10.2% 

implement written policies and 

procedures that prohibit 

mistreatment, neglect, and 

abuse of residents, and 

misappropriation of resident 

property** 

Total 19.1% 21.3% 28.0% 28.2% 9.1% 

* Differences may be due to rounding Source: OSCAR data, 2002 

** Deficiency was instituted in 1999 

Deficiency Trends and Survey and Certification Process Consistency 30 OEI-02-01-00600 
Table C-2 

Proportion of Nursing Homes by Quality of Life Deficiencies, 1998-2001 

Percentage 

Deficiency 1998 1999 2000 2001 Point 

Difference* 

1998-2001 

Facility promotes/enhances 0.3% 0.2% 0.2% 0.3% 0.0% 

quality of life 

Facility promotes care that 14.4% 16.8% 17.3% 17.2% 2.9% 

maintains/enhances dignity 

Resident has the right to make 2.5% 2.6% 2.1% 2.0% -0.5% 

choices about aspects of life in the 

facility 

Right to organize and participate in 0.5% 0.6% 0.3% 0.3% -0.2% 

groups 

Facility must listen and respond to 0.4% 0.4% 0.6% 0.5% 0.0% 

groups 

Right to participate 0.1% 0.1% 0.1% 0.1% 0.0% 

in activities 

Should have policies that 9.2% 9.6% 10.0% 9.7% 0.5% 

accommodate needs 

Receive notice of room or 0.2% 0.2% 0.1% 0.1% -0.1% 

roommate change 

Facility must provide an activity 7.9% 8.8% 8.2% 7.8% -0.2% 

program 

Facilities activity director must be 0.4% 0.5% 0.5% 0.5% 0.1% 

fully qualified 

Facility provides medically-related 7.9% 7.9% 6.7% 6.8% -1.1% 

social services 

Facility must employ a qualified 0.2% 0.3% 0.3% 0.2% 0.0% 

social worker 

Facility must provide a safe, clean, 7.1% 7.3% 7.6% 7.7% 0.6% 

homelike environment 

Housekeeping maintains sanitary 14.2% 15.5% 17.3% 16.7% 2.5% 

and comfortable interior 

Deficiency Trends and Survey and Certification Process Consistency 31 OEI-02-01-00600 
(Continued) 

Deficiency 1998 1999 2000 2001 

Percentage 

Point 

Difference* 

1998-2001 

Clean bed and 

bath linens 

1.6% 1.7% 1.4% 1.2% -0.4% 

Private closet 

space 

0.1% 0.1% 0.1% 0.1% 0.0% 

Adequate and 

comfortable 

light 

0.6% 0.4% 0.6% 0.4% -0.1% 

Safe and 

comfortable 

temperature 

levels 

1.0% 0.9% 0.9% 0.8% -0.2% 

Maintenance of 

comfortable 

sound levels 

1.7% 1.8% 1.8% 1.5% -0.2% 

Total 37.8% 41.9% 43.6% 43.1% 5.3% 

* Differences may be due to rounding Source: OSCAR data, 2002 

Deficiency Trends and Survey and Certification Process Consistency 32 OEI-02-01-00600 
Table C-3 

Proportion of Nursing Homes by Quality of Care Deficiencies, 1998-2001 

Deficiency 1998 1999 2000 2001 

Percentage 

Point 

Difference* 

1998-2001 

Provides necessary care for highest 

practicable well-being 

17.0% 21.1% 23.5% 23.5% 6.6% 

ADL’s don’t decline unless 

unavoidable 

2.7% 2.2% 1.8% 1.6 -1.0% 

Resident given appropriate 

treatment to improve abilities 

5.6% 6.5% 6.0% 4.8% -0.8% 

ADL care provided for dependent 

residents 

11.9% 14.3% 13.7% 12.5% 0.6% 

Resident receives treatment to 

maintain vision and hearing 

0.6% 0.7% 0.6% 0.6% 0.0% 

Proper treatment to prevent or treat 

pressure sores 

16.5% 18.1% 18.0% 17.1% 0.6% 

Resident not catheterized, unless 

unavoidable 

1.4% 1.3% 1.2% 1.6% 0.2% 

Appropriate treatment for 

incontinence 

11.1% 11.7% 10.7% 10.2% -0.9% 

No reduction in range of motion, 

unless unavoidable 

0.8% 0.9% 0.7% 0.6% -0.2% 

Appropriate range of motion 

treatment 

8.9% 9.9% 9.0% 8.0% -0.9% 

Appropriate treatment for mental or 

psychosocial functioning 

2.5% 2.7% 2.3% 1.9% -0.6% 

No development of mental 

problems, unless unavoidable 

0.1% 0.2% 0.2% 0.2% 0.0% 

No naso-gastric tube, unless 

unavoidable 

0.2% 0.1% 0.1% 0.1% -0.1% 

Proper care for residents with nasogastric tubes 4.6% 5.3% 5.8% 5.2% 0.6% 

Deficiency Trends and Survey and Certification Process Consistency 33 OEI-02-01-00600 
(Continued) 

Percentage 

Deficiency 1998 1999 2000 2001 Point 

Difference 

1998-2001 

Facility is free of accident hazards 18.0% 18.7% 20.4% 21.9% 3.9% 

Adequate supervision and/or 14.8% 17.9% 18.0% 18.5% 3.6% 

devices to prevent accidents 

Resident maintains nutrition status, 8.0% 9.9% 9.4% 8.3% 0.3% 

unless unavoidable 

Resident receives therapeutic diet, 1.9% 2.3% 3.1% 3.0% 1.1% 

when required 

Facility provides sufficient fluid 3.2% 5.4% 6.0% 5.0% 1.9% 

intake to maintain health 

Proper treatment and care for 3.6% 4.3% 4.6% 4.6% 1.0% 

special needs 

Drug regimen free from unnecessary 10.5% 11.8% 12.4% 12.5% 2.0% 

drugs 

No use of antipsychotic drugs 1.2% 0.8% 0.9% 0.9% -0.3% 

except when necessary 

Gradual dose reduction of 1.2% 1.1% 0.9% 1.1% -0.1% 

antipsychotic drugs 

Facility is free of medication error 5.6% 7.4% 10.0% 9.8% 4.2% 

rates of 5% or more 

Residents are free from significant 3.0% 3.7% 4.4% 3.8% 0.9% 

medication errors 

Total 59.4% 65.3% 68.1% 68.4% 9.0% 

* Differences may be due to rounding Source: OSCAR data, 2002 

Deficiency Trends and Survey and Certification Process Consistency 34 OEI-02-01-00600 
APPENDIX D 

Table D-1 

Percentage of Nursing Homes that Received Substandard Quality of Care 

and Immediate Jeopardy Deficiencies, 1998-2001 

Percentage Point 

1998 1999 2000 2001 Difference 

1998-2001 

Substandard Quality 4.5 % 4.8 % 4.5 % 4.2 % -0.3 

of Care 

Immediate Jeopardy 1.4 % 1.4 % 2.1 % 2.3 % 0.9 

Source: OSCAR data, 2002 

Table D-2 

Percentage of Nursing Homes by Scope and Severity of Quality of Care Deficiencies, 

1998-2001 

Scope and 

Severity 

Level 

1998 1999 2000 2001 

Difference 

1998-2001 

A 0 % 0 % 0 % 0 % 0 % 

B 13.0% 12.3% 14.3% 14.5% 1.5% 

C 6.4% 7.5% 9.0% 7.7% 1.3% 

D 51.1% 56.6% 61.8% 64.1% 13.0% 

E 32.8% 35.8% 38.9% 37.6% 4.8% 

F 1.5% 1.9% 1.8% 1.6% 0.2% 

G 26.5% 28.5% 22.7% 18.6% -7.9% 

H 2.6% 2.7% 1.8% 1.3% -1.3% 

I 0.1% 0.1% 0.1% 0.0% -0.1% 

J 0.7% 0.7% 0.8% 1.0% 0.4% 

K 0.5% 0.4% 0.8% 0.8% 0.4% 

L 0.0% 0.1% 0.1% 0.2% 0.2% 

Source: OSCAR data, 2002 

Deficiency Trends and Survey and Certification Process Consistency 35 OEI-02-01-00600 
APPENDIX E 

State Deficiency Rates, Deficiency-Free Nursing Homes, 

and Proportion of Deficiencies Removed From Draft Reports 

State 

Vermont

Rhode Island

Wisconsin

Virginia

Utah

North Dakota

Iowa

Pennsylvania

Nebraska

New Hampshire

Minnesota

Massachusetts

Maryland

Delaware

Maine

New Jersey

Illinois

Montana

Colorado

Ohio

South Dakota

New Mexico

Missouri

Connecticut

New York

Alaska

Georgia

South Carolina

North Carolina

Oregon

Indiana

Mississippi

Deficiency Rate* Deficiency-Free Homes % Deficiencies Removed 

2.9 (low) 28.2 2% 

3.3 (low) 24.2 10% 

3.3 (low) 22.6 5% 

3.5 (low) 33.5 5% 

3.7 (low) 16.5 1% 

3.9 (low) 10.7 10% 

4.1 (low) 13.9 25% 

4.2 (low) 15.1 5% 

4.4 (low) 19.3 7% 

4.4 (low) 24.6 1% 

4.6 (low) 14.4 No Response 

4.6 (low) 29.2 10% 

4.6 (low) 13.2 No Response 

5.1 (medium) 15.8 1% 

5.1 (medium) 4.5 1% 

5.1 (medium) 14.5 1% 

5.1 (medium) 13.3 No Response 

5.2 (medium) 10.6 No Response 

5.2 (medium) 12.4 5% 

5.2 (medium) 13.7 2% 

5.3 (medium) 6.5 1% 

5.5 (medium) 19.4 2% 

5.5 (medium) 12.5 10% 

5.6 (medium) 6.3 3% 

5.6 (medium) 8.6 10% 

5.8 (medium) 14.3 5% 

5.8 (medium) 9.5 No Response 

5.8 (medium) 9.5 1% 

6.1 (medium) 9.7 No Response 

6.1 (medium) 18.0 5% 

6.1 (medium) 12.9 No Response 

6.3 (medium) 4.4 5% 

Deficiency Trends and Survey and Certification Process Consistency 36 OEI-02-01-00600 
(continued) 

State Deficiency Rate* Deficiency-Free Homes % Deficiencies Removed 

Oklahoma 6.4 (medium) 15.5 No Response 

Texas 6.4 (medium) 9.8 12% 

Idaho 6.5 (medium) 8.2 0% 

Alabama 6.5 (medium) 8.6 10% 

Tennessee 6.7 (medium) 3.3 1% 

Kansas 6.9 (medium) 11.8 1% 

Louisiana 7.0 (high) 9.8 2% 

West Virginia 7.5 (high) 7.0 2% 

Florida 7.9 (high) 2.9 No Response 

Arkansas 7.9 (high) 4.3 0% 

Kentucky 8.2 (high) 4.0 5% 

Michigan 8.4 (high) 4.0 5% 

Washington 8.6 (high) 4.8 No Response 

Wyoming 9.2 (high) 8.8 3% 

Hawaii 9.9 (high) 5.9 0% 

Nevada 9.9 (high) 0 5% 

D.C. 10.0 (high) 5.0 1% 

Arizona 10.2 (high) 3.9 2% 

California 11.2 (high) 2.1 8% 

Source Data - OSCAR 2002 CMS mainframe download 

*Deficiency Rate 

Low (2.9 - 4.6 deficiencies per facility)

Medium (5 - 6.9 deficiencies per facility)

High (7.0 - 11.24 deficiencies per facility) 

For the population of states we categorized deficiency rates into low, medium, and high by determining the 

proportional deficiency rate (mean of deficiencies) and the distribution of the means or the maximum and minimum in 

each category of low, medium, and high rates of deficiencies. We computed a correlation coefficient (-.22425) for the 

variables, deficiency rate, and removal of deficiencies, which does not imply causal relationship. 

------------------------- STATES WITH LOW DEFICIENCY RATES ------------------------------

Variable N Mean Minimum Maximum 

Deficiency rate 13 3.96158 2.87179 4.64091 

------------------------STATES WITH MEDIUM DEFICIENCY RATES -----------------------------

Variable N Mean Minimum Maximum 

Deficiency rate 25 5.80444 5.05263 6.88184 

-------------------------STATES WITH HIGH DEFICIENCY RATES-------------------------------

Variable N Mean Minimum Maximum 

Deficiency rate 13 8.93332 7.03797 11.24108 

Deficiency Trends and Survey and Certification Process Consistency 37 OEI-02-01-00600 
APPENDIX F 

4009.1 Federal Minimum Qualification Standards For Long Term Care (LTC) Facility Surveyors 

Sections 1819(g)(2)(C)(ii), 1819(g)(2)(E)(iii), 1919(g)(2)(C)(ii), and 1919(g)(2)(E)(iii) of the Act require that 

individual members of long term care (LTC) survey teams meet minimum qualifications, established by the 

Secretary, and successfully complete a training and testing program in survey and certification techniques. 

In addition, LTC surveyors must successfully complete a training and testing program, which includes the 

Surveyor Minimum Qualifications Test (SMQT). 

A. Purpose.--The SMQT is part of the training and testing program and addresses the 

knowledge, skills, and abilities needed to conduct standard and extended surveys in LTC 

facilities. 

B. Prerequisites.--Prior to taking the SMQT, a LTC surveyor must complete the CMS 

Orientation Program, and the Basic Long Term Care Health Facility Surveyor Training Course. 

C. Test Composition.--The SMQT is composed of two modules: 

1. Module A.--Includes the following LTC facility survey tasks: 

o Offsite Survey Preparation; 

o Entrance Conference and Onsite Preparatory Activities; 

o Initial Tour; 

o Resident Sampling; 

o Environmental Assessment (including the environmental aspects of Dietary 

Services); 

o Quality of Life Assessment; 

o Information Analysis and Decision Making; and 

o Exit Conference. 

2. Module B.--Includes: 

o Resident Review (including resident assessments and plans of care); 

o Closed Record Review; 

o Nutritional Aspects of Dietary Services System Assessment; and 

o Medications Review. 

D. Successful Performance.--

1. Successful Completion of Module A.--An individual must successfully 

complete Module A to be a member of a LTC facility survey team. 

2. Successful Completion of Module B.--Individuals who are expected by the state agency 

to conduct the tasks addressed by Module B may survey these areas only after 

they successfully complete both Module A and Module B. Specific individual 

survey assignments are at your discretion. 

Deficiency Trends and Survey and Certification Process Consistency 38 OEI-02-01-00600 
APPENDIX G 

Deficiency Trends and Survey and Certification Process Consistency 39 OEI-02-01-00600 
Deficiency Trends and Survey and Certification Process Consistency 40 OEI-02-01-00600 
Deficiency Trends and Survey and Certification Process Consistency 41 OEI-02-01-00600 
ACKNOWLEDGMENTS 

This report was prepared under the direction of John I. Molnar, Regional Inspector General for 

Evaluation and Inspections in the New York Regional Office, and Jodi Nudelman, Assistant Regional 

Inspector General. Other principal Office of Evaluation and Inspections staff who contributed include: 

Demetra Arapakos, Project Leader Sandy Khoury, Program Specialist, Division

Patricia Banta, Lead Analyst of Medicare and Medicaid, Baltimore

Danielle Fletcher, Lead Analyst

Thomas Zimmermann, Program Analyst

Renee Dunn, Former Deputy Inspector General

Technical Assistance 

Brian Ritchie, Director Technical Support Staff, Baltimore

Barbara Tedesco, Mathematical Statistician, Baltimore

Scott Horning, Program Analyst

Linda Moscoe, Program Analyst

Robert L. Gibbons, Program Analyst, San Francisco

For information or copies of this report, please contact

the Office of Inspector General’s

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

Deficiency Trends and Survey and Certification Process Consistency 42 OEI-02-01-00600