Department of Health and Human Services


OFFICE OF 

INSPECTOR GENERAL 

NURSING HOME ENFORCEMENT:


APPLICATION OF 


MANDATORY REMEDIES


Daniel R. Levinson


Inspector General 


May 2006


OEI-06-03-00410

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. These assessments help reduce waste, abuse, and mismanagement 

and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, 

Congress, and the public with timely, useful, and reliable information on significant issues. 

Specifically, these evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness in departmental programs. To promote impact, the 

reports also present practical recommendations for improving program operations. 

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 programs, 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 the Centers for Medicare & Medicaid 

Services (CMS) applied the statutorily required “mandatory remedies” for 

nursing homes not in compliance with Federal quality of care standards. 

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 contracts with States to certify compliance by surveying facilities. 

When facilities are found to be out of compliance for designated time 

periods or have deficiencies that are considered to put residents in 

immediate jeopardy, States are required to refer case information to CMS 

for enforcement action. Mandatory remedies are enforcement actions that 

CMS is statutorily required to take to address these particularly 

egregious or extended cases of noncompliance. Mandatory remedies 

include termination of the facility’s Medicare contract and the denial of 

payment for new admissions (DPNA). CMS depends upon the States to 

inform its regional offices when enforcement action is warranted in time 

for the regional offices to take action. Therefore, CMS evaluates State 

performance annually using criteria that measure States’ effectiveness in 

referring, in a timely manner, cases that require imposition of remedies. 

For this inspection, we reviewed all nursing home enforcement cases that 

required termination in 2000-2002 and all cases that required DPNA 

remedies in 2002. We also evaluated State Performance Review (SPR) 

data for 2002-2004 and conducted interviews with State and CMS staff. 

FINDINGS 

Of the 55 cases requiring termination during 2000-2002, CMS did not 

apply the mandatory remedy as required in 30 cases (55 percent). 

CMS is required to terminate nursing homes that fail to return to 

“substantial compliance” within 6 months, or have unabated immediate 

jeopardy deficiencies for 23 days. We found that 23 cases that required 

termination because they were noncompliant for 6 months were not 

terminated; these facilities returned to compliance on average 17 days 

after the termination should have been applied. Seven cases with 

unabated immediate jeopardy deficiencies were not terminated; these 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S i 
EXE CUTIVE S U MMAR Y 

facilities removed the immediate jeopardy within 7 days after the 

termination should have been applied. 

Through reviews of surveys following our study period, we found that all 

of the facilities not terminated had, in subsequent surveys, new cases of 

noncompliance serious enough to again require referral to CMS for 

enforcement action. Reasons for not terminating include late referral by 

States and reluctance by CMS staff to take action that would result in 

removing residents from the facility. 

Of the 706 cases requiring DPNA remedies in 2002, 28 percent were 

never applied and 14 percent were applied late, largely due to late 

referral of cases by State survey agencies. CMS is required to apply 

the DPNA remedy for facilities that fail to return to substantial 

compliance within 3 months. In those instances for which the mandatory 

remedy was never applied, the facilities were out of compliance an 

average of 19 days past the required date to begin denying payments. In 

those instances in which the mandatory remedy was applied late, the 

facilities were out of compliance an average of 40 days past the required 

date to begin denying payments. In both situations, facilities were 

allowed to receive payment past the required date. 

In addition, in 95 percent of cases for which mandatory DPNA was 

handled inappropriately, States did not refer cases to CMS on time. 

CMS’s SPRs also found late case referral by States. In 2002, our primary 

study period, the SPR data showed that 38 of the 48 States that had cases 

requiring the DPNA did not meet the SPR standard of referring 95 

percent of these cases on time. After CMS eased the standard in 2003 

and again in 2004, 24 States still did not meet the performance standard 

regarding timely completion of these referral tasks in 2003, and 10 States 

did not meet the current standard of referring 80 percent of their cases on 

time in 2004. 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S ii 
EXECUTIVE SUMMAR Y

RECOMMENDATIONS 

CMS should ensure that facilities facing termination either reach 

compliance or are terminated within required timeframes. This effort 

could include encouraging State survey agencies to further prioritize 

termination cases, raising awareness of termination deadlines among 

CMS and State staff, and special monitoring of pending termination cases 

by CMS regional offices. 

CMS should address late referral of enforcement cases by States to 

ensure that mandatory remedies are applied as required. CMS should 

issue a written directive to States to reinforce referral requirements, 

increase monitoring of State referral timeliness using shared data 

systems, and promote stronger adherence to the SPR standards regarding 

case referral. CMS should also strongly consider raising the SPR 

standards for timely case referral. 

AGENCY COMMENTS 

While CMS agrees that enforcement and the timely remedy of identified 

problems in nursing homes are very important, it did not concur with all 

of our recommendations. In its comments, CMS identifies efforts recently 

underway or soon to be implemented to address timeliness issues. 

However, contrary to our recommendation regarding facility termination, 

CMS notes that it does not expect to make a great deal of change with 

respect to its implementation of this remedy. Instead, it will continue to 

apply the remedy in a manner that it believes best protects the well-being 

of residents. 

OFFICE OF INSPECTOR GENERAL RESPONSE 

We recognize that since this inspection concluded, CMS has taken a 

number of positive steps toward ensuring that deadlines are met. 

However, we are concerned about CMS’s implied interpretation that the 

deadlines for mandatory termination are flexible. While exceptional cases 

may exist, the 6-month termination requirement is statutory and the 23-

day termination is in current regulation. We believe that CMS, through 

active case management and earlier intervention, can motivate 

improvements and lasting corrections within the required timeframes for 

termination of facilities. 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S iii 
Δ T ABLE OF CONTENTS 

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

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

FINDI NGS ................................................. 7

 Mandatory Termination .................................. 7

Mandatory Denial of Payment for New Admissions ............ 8

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

 Agency Comments ...................................... 13

Office of Inspector General Response ....................... 14

ENDNOTE S ..................................................... 15

APPENDIXES ............................................... 19 

A. Detailed Methodology ................................ 19

B. Agency Comments ................................... 21

ACKN O W LEDGMENTS ......................................... 26

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S 
Δ INTRODU C TION 

OBJECTIVE 

To determine the extent to which the Centers for Medicare & Medicaid 

Services (CMS) applied the statutorily required “mandatory remedies” for 

nursing homes not in compliance with Federal quality of care standards.1 

BACKGROUND 

This inspection is part of the Office of Inspector General’s (OIG) ongoing 

evaluation of the quality of care provided to nursing home residents, 

particularly as measured by CMS’s enforcement of survey deficiencies. 

Enforcement Process 

Titles 18 and 19 of the Social Security Act (the Act), as amended by the 

Omnibus Budget Reconciliation Act of 1987, establishes a survey and 

certification process to verify that Federal standards are maintained in 

Medicare and/or Medicaid certified nursing homes. The Secretary of the 

Department of Health and Human Services, through CMS, is responsible 

for assuring 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.”2 To accomplish 

this, CMS contracts with State agencies to survey each participating 

facility no less than once every 15 months to certify compliance.3 

Additional surveys are also used to investigate complaints from residents, 

their families, or the general public. 

Deficiencies identified during a survey are evaluated against a set of 

factors to determine a scope and severity rating.4 CMS created the Scope 

and Severity Grid (Table 1) so that deficiencies could be ranked in 

accordance with outcomes, such as harm to patients and prevalence.5 The 

scope and severity level of the highest deficiency is considered in 

conjunction with the facility’s compliance history to determine the 

appropriate enforcement actions.6 

The Act lists several remedies that may be applied when a facility is not 

in “substantial compliance” with the requirements for participation in the 

Medicare and Medicaid programs.7 A facility is not in substantial 

compliance if the survey finds deficiencies that pose immediate jeopardy, 

actual harm, or potential for more than minimal harm to patients.8 The 

shaded portion of Table 1 comprises an additional severity category, 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 1 
Deficiency Scope 

INT R O D UCTION

“substandard quality of care.” This includes deficiencies in resident 

behavior and facility practices, quality of life, and quality of care.9 

Table 1 

Scope and Severity Grid for Deficiencies 

Deficiency Severity 

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. 

To initiate the Act’s enforcement requirements, States must refer 

enforcement cases to CMS regional offices.10 An enforcement “case” 

includes all enforcement activity with respect to a particular facility 

during a continuous period of noncompliance. Once the State refers a 

case, CMS determines what enforcement actions are warranted for each 

case. In addition to mandatory remedies, CMS may choose to apply 

discretionary, or optional, remedies such as civil money penalties. 

Mandatory Remedies 

“Mandatory remedies” are enforcement actions that the Act requires CMS 

to use to address particularly egregious or extended cases of 

noncompliance.11 For these cases, the Act sets forth the types of remedies 

that must be applied. For purposes of this report, we use the term 

“applied” to indicate the action of putting mandatory remedies into effect. 

The four circumstances that require mandatory remedies and the 

remedies that must be applied are as follows: 

Immediate Jeopardy. If, within 23 days of the initial finding, a facility fails 

to eliminate a deficiency deemed to pose immediate jeopardy or fails to 

reduce the deficiency to the point that it no longer poses a threat of actual 

harm, CMS must either terminate the facility’s Medicare contract or 

appoint a temporary manager to remove the immediate jeopardy and 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 2 
INT R O D UCTION

correct the deficiencies.12 To terminate a facility in this circumstance, the 

State must refer the case to CMS within 2 days of the finding of 

immediate jeopardy, conduct a revisit to determine whether the jeopardy 

was abated, and report its finding to CMS. If the immediate jeopardy 

condition is not abated, CMS must notify the facility 2 days prior to the 

termination.13 

Three Months of Noncompliance. For all facilities that fail to reach 

substantial compliance within 3 months after the initial deficiency, CMS 

must apply the mandatory denial of payment for new admissions (DPNA) 

remedy.14 Before CMS can apply this remedy, the State must conduct a 

revisit, and if the facility is still out of compliance, refer the case to CMS. 

CMS must then notify the facility 15 days prior to application of the 

remedy, which should occur at the end of the 3-month period.15 

Six Months of Noncompliance. For all facilities that fail to reach substantial 

compliance within 6 months after the initial deficiency, CMS is required 

to terminate the Medicare contract.16 This type of case arises when the 

facility still has not reached compliance after application of the required 

DPNA at 3 months. To terminate a facility in this circumstance, the 

State must conduct a revisit, and if the facility is still out of compliance, 

refer the case to CMS. CMS must then notify the facility 15 days prior to 

the termination, which should occur at the end of the 6-month period.17 

Repeated Substandard Quality of Care. For all facilities found to have 

provided substandard quality of care on the last three consecutive 

standard surveys, CMS must apply the remedies of DPNA and State 

monitoring of the facility.18 Additionally, the State must notify the 

attending physician of each affected resident and the State licensing 

board.19 To apply the DPNA, the State must refer the case to CMS 

following the third finding of substandard quality of care. CMS must 

then notify the facility 15 days prior to application of the remedy. 

Timely Notice to Facilities 

CMS must notify nursing homes prior to applying a mandatory remedy.20 

For immediate jeopardy cases, notice must occur at least 2 days prior to 

applying the remedy. For all other cases requiring mandatory remedies, 

notice must be sent 15 days prior to applying the remedy, e.g., on day 

75 for 3 months of noncompliance. 

CMS must receive a case referral from the State survey agency in 

sufficient time prior to the notice period to apply the remedies on time. 

States must also notify facilities that they have referred the case to CMS 

and that a particular remedy is mandated. The CMS central office policy 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 3 
INT R O D UCTION 

allows CMS regional offices to approve the State sending a letter that 

serves as the “official” notice to facilities.21 

To meet referral deadlines for mandatory DPNA cases specifically, the 

State Performance Review (SPR) standards in effect during our study 

period required States to conduct a revisit within 60 days of the initial 

finding of noncompliance.22 If the revisit reveals that the facility is still 

noncompliant, in accordance with the SPR, States must refer the case 

information to CMS within 70 days of the initial finding of 

noncompliance. Adherence to this timeframe provides CMS with 5 days 

to send the 15-day notice to facilities (75th day) prior to applying the 

DPNA on the 90th day of noncompliance. 

Applying Mandatory Remedies Late 

Based on CMS central office managers’ interpretation of the regulation, 

as reported in interviews, mandatory remedies can still be applied when 

CMS regional offices are late in providing notice but only if both of the 

following criteria are met: (1) the required 2-or 15-day notice was 

ultimately sent and the notice period has elapsed; and (2) the facility is 

still out of compliance when the notice period has elapsed. Therefore, 

mandatory remedies cannot be applied retroactively in cases in which the 

facility reaches substantial compliance before CMS applies the remedy.23 

In such cases, CMS can still choose to apply a civil money penalty. 

State Performance Review 

CMS evaluates State survey agency performance in nursing home 

enforcement by using criteria based in regulation and contained within 

the SPR.24 The SPR includes three particular measures that are relevant 

to this inspection: 

Timeliness of Referral of Unabated Immediate Jeopardy Cases.

25 To meet the 

expected performance level, States must refer cases within 2 days of an 

immediate jeopardy deficiency finding and follow all necessary procedures 

to ensure terminations can occur within the 23-day timeframe in 

95 percent of cases in which facilities fail to remove the immediate 

jeopardy deficiency.26 

Timeliness of Referral and Notification in DPNA Cases. During our study 

period of 2002, State agencies were required to conduct facility revisits by 

the 60th day of noncompliance, and either send deficiency information to 

CMS or send an approved notice of the remedy to the facility within 

70 days of the end of the survey for 95 percent of cases. Therefore, a 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 4 
 IN T R O D UCTION 

typical case requiring the DPNA might unfold as follows: the State refers 

the case on the 70th day, giving CMS up to 5 days to send the facility 

notice (75th day), which would allow the facility 15 days notice prior to 

imposing the DPNA within the time required (90th day). In 2003, CMS 

changed the SPR criteria for referring DPNA cases by lowering the 

requirement from 95 percent to 80 percent of cases referred on time.27 In 

2004, CMS changed the standard further by omitting the requirement 

that States conduct facility revisits by the 60th day of noncompliance.28 

Timeliness of Referral of 6-month Noncompliance Cases. State agencies must 

follow appropriate termination procedures for 80 percent of applicable 

cases.29 This requires sending deficiency information to CMS or sending 

an approved notice of the remedy to the facility within 70 days, allowing 

for the required 15-day notice period. Therefore, a typical case requiring 

termination for 6 months of noncompliance might unfold as follows: the 

State refers the case on the 160th day (70 days after the application of the 

DPNA on the 90th day), giving CMS up to 5 days to send the facility notice 

(165th day), which would allow the facility 15 days notice prior to 

termination within the time required (180th day). 

Data Systems 

Case information is maintained through data systems shared by CMS and 

States. Traditionally, CMS has used the Online Survey, Certification, 

and Reporting (OSCAR) system to record the results of standard, 

complaint, and revisit surveys. More recently, CMS has employed the 

Automated Survey Processing Environment (ASPEN), which allows 

States and CMS to input and access both survey results and enforcement 

information. State surveyors enter survey findings into a local ASPEN 

database, then upload the data into a central ASPEN system (and also 

into OSCAR). Enforcement case information in ASPEN is accessible to 

CMS regional office staff through the ASPEN Enforcement Module 

(AEM), implemented in October 2004. The AEM includes several 

reporting functions that facilitate case monitoring, including reports 

focused on the DPNA remedy. 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 5
INT R O D UCTION

INT R O D UCTION

METHODOLOGY 

Following preliminary analysis of enforcement data, we narrowed the 

scope of our inspection to focus on the most common circumstances and 

remedies. This report addresses the three most common circumstances 

warranting mandatory remedies (immediate jeopardy, 3 months of 

continued noncompliance, and 6 months of continued noncompliance). We 

excluded from our review cases of repeated substandard quality of care 

because only a few occur each year. This study also does not examine 

cases for which only discretionary remedies were used, those that States 

failed to refer to CMS for enforcement, or Medicaid-only cases. 

For this inspection we reviewed CMS data for all enforcement cases that 

began in calendar years 2000, 2001, and 2002 to identify cases that 

required mandatory remedies. We found 55 cases warranting 

termination during the study period and 2,140 cases warranting 

mandatory DPNA remedies. We reviewed all 55 termination cases and 

limited our analysis of mandatory DPNA cases to the 706 cases begun in 

2002. We then collected documentation for all cases for which data 

indicated that CMS did not apply remedies as required, and interviewed 

CMS regional and central office staff regarding procedures for applying 

mandatory remedies. To verify our findings regarding State referral of 

enforcement cases, we evaluated all State Agency Performance 

Evaluation records for 2002 and for its successor, the SPR, in 2003 and 

2004. Because we analyzed all cases and not a sample, all data reported 

within this report represent actual cases, not estimates or projections. A 

detailed methodology is included in Appendix A. 

Standards 

We conducted this inspection in accordance with the “Quality Standards 

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

Efficiency and the Executive Council on Integrity and Efficiency. 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 6 
Δ FINDINGS 

CMS did not terminate the facility in 30 of 

the 55 cases requiring termination during 

our study period of 2000–2002 

CMS must terminate facilities that 

remain out of substantial compliance 

for more than 6 months or do not 

remove an immediate jeopardy 

deficiency within 23 days. Few 

facilities warranted termination during our study period. However, 

termination did not occur in 30 of the 55 cases in which it was required 

(55 percent). Twenty-three of the thirty cases involved facilities that were 

out of substantial compliance for 6 months, and the other seven cases 

involved facilities that had not succeeded in removing immediate jeopardy 

deficiencies within 23 days. 

Reasons for not terminating as required include late referral by States and 

CMS staff reluctance to displace facility residents 

While we are not able to determine the exact cause of CMS’s failure to 

terminate in each case, several factors appear to contribute to the lack of 

action. In a number of cases, States did not refer cases to CMS 

sufficiently in advance of the required date and the facilities were allowed 

to return to compliance late. States referred cases late in 5 of the 

7 immediate jeopardy cases and in 4 of the 23 6-month noncompliance 

cases. Even when referrals were timely, CMS staff reported that 

procedural delays could occur for a number of reasons, such as the 

handling of cases by multiple staff members. 

Also, some CMS regional office staff reported that, in their reluctance to 

displace residents, they might opt to delay termination if they believed 

the facility would soon come back into compliance. Indeed, facilities that 

CMS did not terminate as required did return to compliance shortly after 

the date they should have been terminated. The 23 cases that were not 

terminated after continued noncompliance returned to substantial 

compliance an average of 17 days after the 6-month mark, and all 7 cases 

that were not terminated after uncorrected immediate jeopardy 

deficiencies reached compliance within 7 additional days. 

All facilities not terminated were found to be out of compliance again 

For the 29 facilities involved in the 30 cases that were not terminated as 

required, we reviewed all available subsequent surveys through May 31, 

2005. We found that all of the facilities that were not terminated had 

new cases of noncompliance serious enough to again require referral to 

CMS for enforcement action, including cases of extended noncompliance 

and immediate jeopardy to residents. Ten of the twenty-nine facilities 

were subsequently cited with immediate jeopardy deficiencies, and in one 

case the facility was cited with an immediate jeopardy deficiency four 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 7 
FIN D I N GS 

times in consecutive years. Additionally, many of the facilities required 

referral to CMS multiple times—14 of the 29 facilities had deficiencies 

that warranted referral to CMS in 3 or more subsequent surveys. 

Of the 706 DPNA cases in 2002, 28 percent were 

never applied and 14 percent were applied late, 

due largely to late referral by States 

CMS must apply the DPNA for 

facilities that fail to return to 

substantial compliance within 3 

months. The remedy denies Medicare 

payment for residents newly admitted while the facility is out of 

compliance. Delays in applying denials of payment allow facilities more 

time than regulation permits to return to compliance and avoid the 

remedy. 

Forty-two percent of DPNA remedies were never applied or were applied 

late 

Of the 706 cases in 2002 which should have received a DPNA remedy, 

CMS applied the remedy on time in 58 percent of cases. CMS never 

applied the remedy in 28 percent of cases; these facilities came back into 

compliance after the required date, but before CMS took action. The 

facilities were out of compliance an average of 111 days (19 days past the 

required 3-month effective date of the remedy), allowing the facilities the 

opportunity to erroneously receive payment for newly admitted residents 

during the interim period.30 In the remaining 14 percent of cases, the 

facilities were still out of compliance when CMS acted to put the remedy 

into effect, so the required DPNA was applied late. These late remedies 

were applied after an average of 132 days of noncompliance (40 days past 

the required 3-month effective date of the remedy) also allowing the 

facilities the opportunity to erroneously receive payment. 

Despite not applying this remedy on time in 42 percent of the cases, CMS 

and State staff reported in interviews that they consider denial of 

payment to be a very effective tool in enforcing nursing home standards. 

Staff reported that, unlike other remedies such as civil money penalties, 

denial of payment can cause facilities to turn away new residents and is 

therefore likely to affect the image of the facility in the community and 

among medical facilities that may refer clients. 

Late referral of cases by States was the primary cause when DPNA 

remedies were never applied or were applied late 

In the 196 cases for which the DPNA was never applied, facilities 

returned to compliance after the deadline but before notice was sent or 

the notice period had elapsed. Case documents showed that late referral 

by States caused delays in 92 percent of these cases (Table 2). 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 8 
FIN D I N GS 

Referrals in these cases were sent an average of 28 days late, with the 

latest case sent 101 days after the required date.31 For the remaining 

8 percent of cases, States referred the cases on time, but CMS regional 

offices still did not apply the mandatory DPNA remedies. In interviews, 

CMS staff reported a number of possible problems, including notice 

letters not sent to facilities and staff turnover interrupting case tracking. 

In the 102 cases for which the DPNA was applied late, the facilities were 

still out of compliance when the case was referred to CMS by the State. 

Late referral by State survey agencies was a cause of delay in 97 percent 

of these cases. Referrals in these cases were sent an average of 18 days 

late, with the latest case sent 82 days after the required date.32 Once 

CMS received referrals from States for these cases, it began the DPNA 

remedy after the required 15-day notice period to facilities. 

Table 2 

DPNA Remedies Never Applied or Applied Late 

Reasons for Never Applying 196 Cases 

Late referral by State 92% 

- Late referral by State the only reason - 87% 

- Late action by both State and CMS regional office - 5% 

Late action by CMS regional office only 8% 

Reasons for Applying Late 102 Cases 

Late referral by State 97% 

Late action by CMS regional office 3% 

Source: OIG analysis of 706 cases warranting DPNA remedy in 2002. 

State staff were not able to document a cause for all late referrals in 2002, 

but a late revisit by surveyors to the facility was the cause mentioned 

most frequently by staff during case reviews and interviews. Other, less 

prominent, causes for late referral reported by State or CMS regional 

office staff include transmission errors when referrals are made 

electronically, insufficient survey documentation that requires States to 

resubmit case information, and State staff misunderstanding regarding 

referral requirements.33 Two CMS regional offices reported ad hoc efforts 

to track referrals through the ASPEN system, but no regional offices 

reported routine, comprehensive monitoring of current enforcement cases 

to determine if referrals were made by States when required. 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 9 
FIN D I N GS 

State Performance Reviews by CMS confirm that States have problems 

referring enforcement cases on time 

The SPR data for 2002 reveals that 38 of the 48 States that had cases 

warranting a mandatory DPNA remedy did not meet the standard for 

timely referral of cases.34 In 2002, the SPR protocol required States to 

conduct a revisit of facilities by the 60th day of noncompliance, then to 

either send deficiency information to CMS or send an approved notice of 

the remedy to the facility by the 70th day. To meet this standard, States 

had to accomplish these tasks in 95 percent of cases warranting a 

mandatory DPNA remedy. 

Despite easing these SPR standards in 2003 and 2004, CMS reviews still 

found a substantial number of States to be underperforming.35 In 2003, 

24 States did not meet the standard for timely case referral although 

CMS lowered the standard from 95 percent to 80 percent of applicable 

cases. In 2004, 10 States still did not meet the performance standard 

although CMS further changed it by requiring only that States refer 

80 percent of cases by the 70th day and omitting the requirement to 

conduct revisits within the 60th day of noncompliance.36 

While the variable SPR standards make it inappropriate to compare State 

performance across 2002-2004, it is evident that some States continue to 

have problems with late referrals, and that even States passing the 

current SPR standard could have late referrals in up to 20 percent of 

cases. CMS has the ability to impose a variety of remedies and sanctions 

on States that fail SPR criteria; yet six States failed the criteria for 

referral timeliness in all 3 years we reviewed without CMS seeking any 

remedies or sanctions.37 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 10 
Δ RECOMME NDA TIONS

Timely application of mandatory remedies encourages facilities to achieve 

and sustain compliance with Federal quality standards and is essential to 

CMS efforts to address noncompliance. However, facility terminations 

did not occur as required in 55 percent of cases in 2000-2002, due to both 

late case referral by States and CMS staff reluctance to impose this 

severe remedy. All of these facilities were later referred to CMS for new 

findings of noncompliance or immediate jeopardy. CMS also did not apply 

the DPNA as required in 42 percent of cases in 2002. Late referral of 

enforcement cases caused nearly all errors in applying mandatory DPNA 

remedies. These errors allowed facilities the opportunity to receive 

payment by Federal programs while out of compliance with resident care 

standards. 

To address these issues, OIG recommends the following: 

CMS should ensure that all facilities facing termination either reach 

compliance or are terminated within required timeframes 

To strengthen its effectiveness in addressing these egregious or extended 

cases of noncompliance, CMS should focus attention on termination cases 

to better ensure that facilities reach compliance by the required date, or, 

failing that, are terminated as required. This effort could include 

encouraging State survey agencies to further prioritize termination cases, 

raising awareness of termination deadlines among State and CMS staff, 

and conducting special monitoring of pending terminations. 

CMS should address late referral of nursing home enforcement cases by 

States to ensure that mandatory remedies are applied as required 

Guidance to States. CMS should make addressing the timely referral of 

enforcement cases an organizational priority. CMS should issue a 

program transmittal or other written guidance to reinforce for States the 

Federal requirements for referring enforcement cases on time. This 

directive should emphasize completing revisits on time, which was 

identified as a common cause of late referral. 

Routine Monitoring. CMS should actively monitor pending nursing home 

enforcement cases. In interviews, no CMS regional office reported routine 

use of ASPEN to monitor enforcement case referrals from States. To 

accomplish this, CMS should make full use of the monitoring capabilities 

of the ASPEN data management system. According to CMS staff, the 

ASPEN system allows input and access by CMS central office, its regional 

offices, and States, and includes enforcement case information in its 

ASPEN enforcement module. Proactive use of ASPEN to monitor current 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 11 
RECOMMENDA TIONS

enforcement cases would allow regional offices to address problems with 

specific cases before it is too late to take action. 

CMS regional offices should regularly utilize the reporting functions 

available in ASPEN, including reports that can identify cases 

approaching the DPNA deadlines. In addition, CMS should consider 

developing an automated function in ASPEN that alerts both CMS 

caseworkers and State staff when cases have reached the 70th day of 

noncompliance. Such an automated alert or indicator would serve as a 

reminder to State staff to refer the case and as a prompt for CMS staff to 

ask States if they have sent the expected case documentation. Finally, 

ASPEN allows CMS staff to review survey data online at any time, 

including before a case is referred to the regional office. While not 

practical in every case, this access could allow CMS staff to monitor the 

status of facilities with particularly troublesome histories. 

Use of State Performance Review. As part of the effort to address late 

referrals, CMS should also promote stronger adherence to the SPR 

standards. The SPR provides a potentially valuable tool for enforcing 

State referral requirements, yet it is evident that some States have 

continued to have problems with late referrals well after the time period 

of our primary analysis (2002). CMS regional offices should fully enforce 

the case referral standards contained in the SPR, including employing the 

prescribed remedies and sanctions when States fall below the SPR 

standards for timely referral. CMS should also consider focusing efforts 

on underperforming States. 

Finally, we believe that recent changes in the SPR standards regarding 

referral timeliness make the SPR a less effective tool for identifying 

States with problems referring cases. Currently, States could refer up to 

20 percent of cases late, yet still pass the SPR standard. Considering that 

late referrals are the primary cause when CMS does not apply DPNA 

remedies as required, the SPR should promote a higher level of State 

performance regarding this critical function. By restoring the 

performance standard to 95 percent, CMS could further draw State 

attention to correcting the problem, while still allowing for late referrals 

under exceptional circumstances. 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 12 
RECOMMENDA TIONS

AGENCY COMMENTS 

While CMS agrees that enforcement and the timely remedy of identified 

problems in nursing homes are very important, it did not concur with all 

of our recommendations. 

In its comments, CMS identifies efforts recently underway or soon to be 

implemented to address timeliness issues. First, CMS affirms that the 

new ASPEN Enforcement Management System has improved its ability 

to manage enforcement cases resulting in more mandatory DPNAs being 

implemented timely. Additional changes to the State performance 

standards and the strengthening of the Special Focus Facility program 

signal the importance CMS places on nursing home quality of care. CMS 

plans to begin a new internal triage review geared to strategically assess 

individual cases at the 5-month point to identify any additional actions 

that might help bring a facility back into compliance before the 

termination deadline. CMS will also test a process to streamline the 

required notification process to alleviate the difficulties associated with 

timely implementation of the mandatory denial of payments for new 

admissions. 

Contrary to our recommendation regarding facility termination, CMS 

notes that it does not expect to make a great deal of change with respect 

to its implementation of this remedy. Instead, it will continue to apply 

the remedy in a manner that it believes best protects the well-being of 

residents. CMS cited specific difficulties in meeting the 6-month 

timeframe for termination. These include new unrelated deficiencies 

identified during the survey just prior to the termination date, the desire 

to both meet the 15-day public notice requirement and to maximize the 

facility’s opportunity to achieve compliance, and retention of the benefit of 

what it terms the “crisis environment” in the final hours before 

termination. CMS argues that imminent termination is instrumental in 

making positive reforms by causing the facility to apply more resources to 

correct deficiencies that led to termination. 

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

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 13 
RECOMMENDA TIONS

OFFICE OF INSPECTOR GENERAL RESPONSE 

We recognize that since this inspection concluded, CMS has taken a 

number of positive steps toward ensuring that deadlines are met. These 

new steps, in addition to the planned actions, should assist CMS in 

meeting the mandatory enforcement requirements on time in future 

cases. However, we are concerned about CMS’s implied interpretation 

that the deadlines for mandatory termination are flexible. While 

exceptional cases may exist, the 6-month termination requirement is 

statutory and the 23-day termination is in current regulation. 

Consequently, we see no room for discretion in the application of this 

remedy. 

CMS supported its position on two fundamental grounds: (1) that it is 

difficult to meet all scheduled timeframes and provide all reasonable 

opportunities for the facility to achieve compliance prior to termination 

and (2) that termination would be unnecessarily detrimental to the 

nursing home residents, particularly when compliance was achieved 

shortly after the termination deadline. 

First, we believe that actions similar to those CMS plans to implement for 

mandatory denials of payment, combined with active case management 

can reduce the number of missed deadlines in termination cases. For 

example, notification requirements can be streamlined so that they do not 

impede surveyors’ abilities to conduct a final revisit. Additionally, CMS 

can maintain the benefits of the “crisis environment,” which it believes 

promotes corrective action, by beginning sooner in the process to make it 

clear to facilities that decisive action will be taken. Second, we believe the 

pattern of noncompliance observed for the facilities that achieved 

compliance after the deadline, and thus were not terminated as required, 

deserves attention. One facility in this inspection that received additional 

time to achieve compliance was cited with an immediate jeopardy 

deficiency in each of its next four consecutive surveys. Nine others were 

cited with immediate jeopardy deficiencies during their very next survey. 

Given these considerations, we believe that CMS, through active case 

management and earlier intervention, can motivate improvements and 

lasting corrections within the required timeframes for termination of 

facilities. 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 14 
Δ ENDNOTE S 

1 While the Social Security Act (the Act) does not use the term “mandatory 

remedies,” CMS and the States use this term to distinguish between those 

remedies that must be imposed under certain circumstances and those 

remedies that CMS has the discretion to impose. 

2 The Act, § 1819(f)(1). 

3 42 CFR §§ 488.308 and 488.330. 

4 42 CFR §§ 488.404, 488.406, and 488.408; Department of Health and 

Human Services, Centers for Medicare & Medicare Services, State 

Operations Manual (SOM), Chapter 7, § 7400E1 (2004). 

5 The SOM, Chapter 7, § 7400E1. 

6 42 CFR § 488.404. 

7 The Act, §§ 1819(h) and 1919(h). See also 42 CFR §§ 488.400, 488.406, and 

488.408, and the SOM, Chapter 7, § 7400A. 

8 42 CFR § 488.301. 

9 “Substandard quality of care means one or more deficiencies related to 

participation requirements under § 483.15, Quality of life, or § 483.25, 

Quality of care of this chapter, which constitute either immediate jeopardy to 

resident health or safety; a pattern of widespread actual harm that is not 

immediate jeopardy; or a widespread potential for more than minimal harm, 

but less than immediate jeopardy, with no actual harm.” 42 CFR § 488.301. 

10 While there are circumstances in which an enforcement action can be 

referred to the State Medicaid agency, e.g., cases involving Medicaid-only 

facilities, this study examined only those cases in which the enforcement 

action was referred to CMS. CMS guidelines set forth three case types for 

referral: (1) immediate jeopardy cases, (2) cases in which facilities are not 

given an opportunity to correct, but do not involve immediate jeopardy, and 

(3) opportunity to correct cases which have failed to achieve subsequent 

compliance. The SOM, Chapter 7, §§ 7308A, 7316A, and 7316B. 

11 The Act, §§ 1819(h)(1)(A), 1819(h)(2)(D), 1819(h)(2)(C), and 1819(h)(2)(E). 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 15 
12 42 CFR § 488.410(a), the SOM, Chapter 7, § 7301A. 

13 The SOM, Chapter 7, §§ 7305B(3)(a) and 7309A. 

14 The Act, § 1819(h)(2)(D); 42 CFR §§ 488.412(c) and 488.417(b); the SOM, 

Chapter 7, §7506C 

15 The remedy is to be applied at the end of 3 full months, rather than after a 

certain number of days. For example, if the deficiency is cited on January 1, 

the denial of payment should be applied on April 1. “Policies about 

Verification of Compliance and Setting 3-and 6-month Remedy Effective 

Dates,” Memorandum S&C01-10, Center for Medicaid and State Operations, 

Centers for Medicare & Medicaid Services, 2001. 

16 The Act, § 1819(h)(2)(c); 42 CFR §§ 488.412(a) and (b); the SOM, Chapter 7, 

§ 7556C 

17 42 CFR §§ 488.402(f)(4) and 488.456(c)(2); the SOM, Chapter 7, § 

7305B3(b) 

18 The Act, § 1819(h)(2)(E); 42 CFR §§ 488.414(a) and 488.417(b)(2). Certain 

types of deficiencies may not fall within the definition of substandard quality 

of care because they do not relate to resident behavior and facility practices 

or quality of life or quality of care. 

19 The Act, § 1819(g)(5)(C); 42 CFR § 488.410(e). 

20 42 CFR § 488.402(f). 

21 The [CMS] regional office or State Medicaid agency must provide formal 

notice of the remedies imposed unless official notice has already been 

provided by the State, as authorized by CMS and/or the State Medicaid 

agency. The SOM, Chapter 7, § 7316B(4). 

22 Centers for Medicare & Medicaid Services, Survey and Certification Group, 

Center for Medicaid and State Operations, “State Agency Performance 

Standards for Fiscal Year 2002,” (Standard 4, Emphasis B), REF:S&C-02-28 

and “State Agency Performance Standards for Fiscal Year 2003,” (Standard 

4, Emphasis B), REF: S&C-03-27. 

23 To understand this interpretation of policy, CMS staff in interviews 

pointed to the following two regulations: 42 CFR § 488.417(d) states that 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 16 
“. . . [w]hen a facility does not have repeated instances of substandard quality 

of care, payments to the facility or, under Medicaid, CMS payments to the 

State on behalf of the facility, resume prospectively on the date that the 

facility achieves substantial compliance, as indicated by a revisit or written 

credible evidence acceptable to CMS (under Medicare) or the State (under 

Medicaid) . . .” and 42 CFR §§ 488.402(f)(3) and (4) state that “. . . for all 

remedies imposed when there is immediate jeopardy, the notice must be 

given at least 2 calendar days before the effective date of the enforcement 

action.” and “. . . notice must be given at least 15 calendar days before the 

effective date of the enforcement action in situations in which there is no 

immediate jeopardy.” CMS staff explained that mandatory remedies 

therefore (1) cannot be applied to facilities that are in substantial compliance, 

and (2) cannot be applied without proper notice. 

24 The Act, § 1864, Article II(J); the SOM, Chapter 8, §§ 8000C and 8000D. 

25 Immediate jeopardy deficiencies that are downgraded to a scope and 

severity level below immediate jeopardy upon citation are considered 

“abated” and are not subject to these referral guidelines. Some CMS regional 

offices request that States refer all immediate jeopardy cases, and may 

choose to apply discretionary remedies, even in cases that were fully 

corrected. 

26 OIG analysis of the SPR results revealed that in 2004, 31 of the 33 States 

(94 percent) that had unabated immediate jeopardy cases met the standard 

of 95 percent referral as required. 

27 Centers for Medicare & Medicaid Services, Survey and Certification Group, 

Center for Medicaid and State Operations, “State Agency Performance 

Standards for Fiscal Year 2002,” (Standard 4, Emphasis B), REF:S&C-02-28 

and “State Agency Performance Standards for Fiscal Year 2003,” (Standard 

4, Emphasis B), REF: S&C-03-27. 

28 Centers for Medicare & Medicaid Services, Survey and Certification Group, 

Center for Medicaid and State Operations, “State Agency Performance 

Standards for Fiscal Year 2003,” (Standard 4, Emphasis B), REF: S&C-03-27 

and “FY 2004 State Performance Review Protocol Guidance,” (Standard 4, 

Emphasis B), REF: S&C-04-47. 

29 Centers for Medicare & Medicaid Services, Survey and Certification Group, 

Center for Medicaid and State Operations, “State Agency Performance 

Standards for Fiscal Year 2003,” (Standard 4, Emphasis B), REF: S&C-03-27 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 17 
and “FY 2004 State Performance Review Protocol Guidance,” (Standard 4, 

Emphasis B), REF: S&C-04-47. 

30 Denial of payment for new admissions is to be applied at the end of 3 full 

months. (“Policies about Verification of Compliance and Setting 3- and 

6-month Remedy Effective Dates,” Memorandum S&C01-10, Center for 

Medicaid and State Operations, Centers for Medicare & Medicaid Services, 

2001.) We used 92 days for calculating expected application dates. 

31 Due to incomplete data, average and maximum referral times are based on 

171 of the 196 cases in which denial of payment was never applied. 

32 Due to incomplete data, average and maximum referral times are based on 

75 of the 102 cases in which denial of payment was never applied. 

33 Timeliness is not the only problem with the State referral process. In the 

report, “State Referral of Nursing Home Enforcement Cases” (OEI-06-02-

00400), OIG found that while States referred most nursing home cases 

warranting enforcement during the study period, an estimated 8 percent of 

cases were not referred. Primary causes of nonreferral included State staff 

misunderstanding referral requirements and attempted referrals that were 

not recognized as such by CMS staff. 

34 OIG analysis of the 2002 State Agency Performance Evaluation results 

provided by CMS regional offices. 

35 OIG analysis of the 2003 and 2004 State Performance Review results, 

provided by CMS central office. 

36 OIG analysis of the SPR results includes 50 States and the District of 

Columbia for a total of 51. 

37 These potential remedies and sanctions include submitting a corrective 

plan of action, undergoing supplemental training, meeting with State 

officials, and ultimately, facing reductions in Federal financial participation 

and even the termination of their contract to survey facilities. The SOM, 

Chapter 8, § 8000G, ( 2004). 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY REM E D IES 18 
OEI-06-03-00410 NURSING H OME E NFORCEMENT: APPLICATION OF MANDATORY REMEDIES 19 

Detailed Methodology 

We reviewed all nursing home enforcement cases that began in calendar 

years 2000, 2001, and 2002 to identify those that required mandatory 

remedies as a result of one of the four statutorily required conditions: 

immediate jeopardy, noncompliance lasting 3 months, noncompliance 

lasting 6 months, or a third instance of substandard quality of care. 

We identified enforcement cases from CMS’s Online Survey, 

Certification, and Reporting (OSCAR) system, and determined 

enforcement activity from the Long Term Care Enforcement Tracking 

System (LTC). The OSCAR system contains information collected 

during nursing home surveys and complaint investigations conducted 

by State agencies. This information includes survey dates, the type of 

survey, cited deficiencies and the scope and severity of those 

deficiencies, as well as demographic and historical information about 

individual facilities. The LTC database is a compilation of each CMS 

region’s nursing home enforcement case files. It contains basic facility 

descriptors, as well as data from all stages of the enforcement 

process⎯from receipt of a case in the CMS regional office to final 

disposition. 

Because the LTC database includes only cases that States have referred 

to CMS, our analysis did not examine cases where the facility 

successfully corrected its deficiencies after being given an opportunity to 

correct or any cases not referred by States. We used State survey data 

from OSCAR to identify the date a deficiency was found and 

enforcement data from the LTC database to determine the date 

remedies were applied. 

For immediate jeopardy cases, we reviewed scope and severity ratings 

in OSCAR and included any case which had not returned to compliance 

or been terminated by the end of the 23rd day following the first day of 

the survey visit. For cases requiring termination at the end of 

6 months, we included those which were still out of compliance after 

185 days instead of 180 days because there are 5 months which contain 

31 days. Similarly, for cases requiring the DPNA remedies after 

3 months, we allowed 92 days. (Because of the large number of cases 

requiring the DPNA remedies, we narrowed our examination to cases in 

2002.) Finally, we also used OSCAR deficiency data to identify facilities 

that were cited for a third instance of substandard quality of care. 

ΔΔ

APPENDIX ~ A 

 APPENDIX ~ A 
APP E N D I X ~A 

From this universe of cases, we identified those which required 

mandatory remedies. We found a total of 55 cases requiring 

termination. These included 20 cases in which an immediate jeopardy 

deficiency was identified during a survey, yet had not been corrected by 

the 23rd day and 35 cases for which the facility was subject to 

termination for failure to return to compliance within 6 months between 

2000 and 2002. We initially identified 750 cases in 2002 requiring the 

DPNA remedies. However, 44 were exempted from the remedy as a 

result of settlements, informal dispute resolution, or because they were 

terminated from the Medicare program altogether due to other, more 

severe, enforcement cases, effectively sanctioning them for failing to 

return to compliance. This exemption reduced the number of 

mandatory DPNA cases for review to 706. 

Once we identified the cases, we requested additional information from 

States and CMS regional offices about cases for which no record of the 

remedy existed in the data. We reviewed these cases further to confirm 

that they met our criteria and warranted additional analysis. We then 

considered additional LTC and OSCAR data elements and State and 

CMS responses to ensure the remedies had not been rescinded as the 

result of an appeal or informal dispute resolution. 

Because there are many explanations for a case not facing a remedy 

that might not be captured in administrative databases, we also 

requested additional information from CMS regional offices to explain 

what happened with each of the cases in this subset. Further, we 

conducted structured interviews with CMS regional office staff to 

determine why required remedies were not applied. 

To verify our findings regarding State referral of enforcement cases, we 

evaluated all State Agency Performance Evaluation records for 2002 

and all records for its successor, the SPR, in 2003 and 2004. 

This study does not examine Medicaid-only cases, cases for which only 

discretionary remedies were indicated, or those that States failed to 

refer to CMS for enforcement. 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S 20 
Δ APPENDIX ~ B 

Agency Comments 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S 21 
APP E N D I X ~ B

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S 22 
APP E N D I X ~B 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S 23 
APP E N D I X ~ B

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S 24 
APP E N D I X ~B 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S 25 
Δ 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 

Clark Thomas, Project Leader 

Blaine Collins, Program Analyst 

Ruth Ann Dorrill, Program Analyst 

Sarah Craren, Program Analyst 

Susan Wolfe, Program Analyst 

Sandy Khoury, Program Specialist 

Technical Assistance 

Barbara Tedesco, Mathematical Statistician 

Kevin Farber, Mathematical Statistician 

Scott Horning, 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 

OE I-06-03-00 410 NURSI N G H O M E E N F O R C E M E N T: APPL I C AT I O N O F MAND AT O RY RE M E D I E S 26