Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

INSPECTOR GENERAL 

JANUARY 2003 

OEI-01-01-00090 

Quality Assurance Committees in 

Nursing Homes 
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 assess nursing home compliance with federal requirements pertaining to quality assessment 

and assurance committees and to describe the committees. 

BACKGROUND 

Quality assessment and assurance committees (QA committees) represent key points of 

accountability for ensuring both quality of care and quality of life in nursing homes. The 

Omnibus Budget Reconciliation Act of 1987 (OBRA 87) required nursing homes to maintain 

QA committees that meet at least quarterly and identify and correct quality deficiencies and 

improve care. The Centers for Medicare & Medicaid Services (CMS) determines whether 

nursing homes meet those requirements through the survey and certification process. 

This inspection is based on 384 responses to a mail survey of nursing homes, analysis of data 

from CMS’ Online Survey Certification and Reporting (OSCAR) system, site visits to 3 nursing 

homes, and 33 stakeholder interviews. 

FINDINGS 

The OBRA 87 mandates that nursing homes maintain QA committees as vehicles for improving 

quality of care and life in nursing homes. Our assessment shows that nearly all nursing homes 

meet CMS’ requirements for QA committee membership and frequency of meetings. 

Furthermore, QA committees have an array of data sources to help target problem areas in 

their nursing homes. However, a lack of knowledge on conducting QA committee work, as 

well as staff shortages and turnover, challenge QA committees. 

Overall, nursing homes are in compliance with QA committee requirements but 

face some barriers. 

Nursing homes meet requirements for QA committee membership. From 1997 to 2001, 

99 percent of nursing homes met CMS’ requirements for QA committee membership. In 80 

percent of the nursing homes that we surveyed, QA committees consisted of 7 or more 

members from several areas of their nursing homes. 

Nursing homes meet requirements for frequency of QA committee meetings. From 

1997 to 2001, 99 percent of nursing homes met CMS’ requirements for quarterly QA 

committee meetings. Additionally, 61 percent of nursing homes indicated on our survey 

Nursing Home QA Committees i OEI-01-01-00090 
that their QA committees meet more frequently than required by regulation. 

The QA committees use an array of data sources to target problem areas in their 

nursing homes. The QA committees reported relying on an average of eight sources of 

information to assess the care their nursing homes provide as well as other aspects of the 

nursing home’s operations. These sources include CMS’ quality indicators, certification survey 

results, and staff and resident input. 

However, knowledge deficits impede QA committees. While QA committees have an 

array of information to help them pinpoint problems in nursing homes, knowledge of how to use 

this information to execute projects remains a key barrier. 

Staff shortages and turnover challenge QA committees. On our survey, 53 percent of 

nursing homes reported that not having enough staff was a barrier to a more effective QA 

committee, and 47 percent of nursing homes cited general staff turnover, such as among 

certified nursing assistants, as a barrier. 

. 

CONCLUSION 

Our review shows that nearly all nursing homes meet CMS’ two requirements for QA 

committees. The QA committees also have many sources of information available to them. 

However, a lack of knowledge on how to use this available information impedes QA 

committees. Additionally, staff shortages and turnover in nursing homes are further barriers to 

QA committees. These fundamental challenges can impede the work of even the most diligent 

QA committee. 

Nursing Home QA Committees ii OEI-01-01-00090 
TABLE OF CONTENTS 

PAGE

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

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

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

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

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

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

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

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

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

Nursing Home QA Committees iii OEI-01-01-00090 
INTRODUCTION 

OBJECTIVE 

To assess nursing home compliance with federal requirements pertaining to quality assessment 

and assurance committees and to describe the committees. 

BACKGROUND 

OBRA 87 and Quality Assessment and Assurance Committees 

Concerns about substandard care and resident quality of life as well as inadequate oversight of 

substandard nursing homes led to a landmark 1986 study by the Institute of Medicine (IOM). 

Among its findings, the IOM wrote that “more effective government regulation can substantially 

improve quality in nursing homes.”1 In response to the report, Congress passed a number of 

nursing home provisions as a part of the Omnibus Budget Reconciliation Act of 1987 (OBRA 

87). 

OBRA 87 instituted substantial reforms in nursing homes to improve quality of care and quality 

of life, and to protect residents’ rights. Quality assessment and assurance committees (QA 

committees) represent a vehicle mandated by OBRA 87 to achieve those improvements. 

Specifically, OBRA 87 requires nursing homes to “maintain a quality assessment and assurance 

committee, consisting of the director of nursing services, a physician designated by the facility, 

and three other members of the facility’s staff.” The committee must meet “at least quarterly to 

identify issues with respect to which quality assessment and assurance activities are necessary, 

and develop and implement appropriate plans of action to correct identified quality 

deficiencies.” 

Holding Nursing Homes Accountable for Quality Assurance 

The Centers for Medicare & Medicaid Services (CMS) implemented final regulations for 

OBRA 87 provisions in July 1995. Nursing homes participating in Medicare must meet these 

requirements. Among the requirements are two specifically about QA committees. These 

requirements mirror the provisions of OBRA 87. One requirement calls for the existence and 

specific membership of a committee, and the other calls for the committee to meet quarterly and 

to identify issues in the nursing home requiring QA committee activity. 

The CMS determines whether nursing homes meet those requirements through the survey and 

certification process. Surveyors assess QA committee requirements by interview and 

observation. The CMS instructs surveyors to interview a facility’s administrative staff to 

Nursing Home QA Committees 1 OEI-01-01-00090 
determine that it has a QA committee and that its required membership and frequency of 

meetings comply with the requirements. Surveyors do not have access to QA committee 

minutes due to the confidentiality of these documents mandated by OBRA 87. The CMS 

instructs surveyors to describe in the survey report how the facility identifies quality deficiencies 

and responds to the identified issues. 

Significance of QA Committees 

The QA committees provide an important point of accountability for ensuring both quality of 

care and quality of life in nursing homes. They represent key internal mechanisms that allow 

nursing homes opportunities to deal with quality concerns in a confidential manner and can help 

them sustain a culture of quality improvement. Nursing homes are already subject to significant 

external oversight, such as the Medicare and Medicaid certification process and ombudsman 

program. However, because of their external nature, they are outside the scope of a nursing 

home’s own control. The QA committees, on the other hand, are internal and ideally can 

complement the external oversight. 

To date, CMS has provided limited guidance to help QA committees. Guidance on quality 

assurance and improvement can come from the survey process in the form of what CMS calls 

“information transfer.” This permits the surveyor to inform the nursing home about “care and 

regulatory topics that would be useful to the facility for understanding and applying best 

practices in the care and treatment of long term care residents.”2 Yet, information transfer is 

not consultative. The CMS’ State Operations Manual, which provides guidance to state 

agencies, states that “This information exchange is not a consultation with the facility but is a 

means of disseminating information that may be of assistance to the facility in meeting long term 

care requirements.”3 

METHODOLOGY 

We selected a national, simple random sample of 601 nursing homes from CMS’ Online 

Survey Certification and Reporting (OSCAR) system. We mailed surveys to the administrators 

of the sampled nursing homes to learn about the work of their QA committees. We followed 

up with a second mailing to those nursing homes who had not responded. We received 

responses from 384 nursing homes, yielding a 63.9 percent response rate. Appendix A 

contains additional information about the survey, including confidence intervals for key 

questions and a nonrespondent analysis. 

In addition, we judgementally selected and visited three nursing homes to learn more about their 

QA committees. In each nursing home, we met with the administrator and other individuals 

involved in the QA committee. In one nursing home we observed a QA committee meeting. 

We also interviewed a judgemental sample of stakeholders from organizations with interest and 

expertise in nursing home quality assurance, as well as nursing home executives and CMS 

regional office staff. Since the data collected from 

Nursing Home QA Committees 2 OEI-01-01-00090 
these entities were from a purposive sample, this information cannot be generalized to the 

population. 

We analyzed nursing home data from the OSCAR system to identify the frequency of 

deficiencies for QA committee survey requirements from 1997 to 2001. We also reviewed 

relevant literature, laws, regulation, and other documents. 

We conducted this inspection in accordance with the Quality Standards for Inspections 

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

Nursing Home QA Committees 3 OEI-01-01-00090 
FINDINGS 

Our assessment shows that nearly all nursing homes meet CMS’ requirements for QA 

committee membership and frequency of meetings. Furthermore, QA committees have an 

array of data sources to help target problem areas in their nursing homes. However, a lack of 

knowledge on conducting QA committee work, as well as staff shortages and turnover, 

challenge QA committees. The OBRA 87 mandates that nursing homes maintain QA 

committees as vehicles for improving quality of care and life in nursing homes. Our review is 

based on 384 responses to a mail survey of a national random sample of nursing homes; site 

visits to 3 nursing homes; 33 interviews with stakeholders with expertise and interest in nursing 

home quality; data from CMS’ OSCAR system; and relevant literature, laws, regulation, and 

other documents. 

Overall, nursing homes are in compliance with QA committee 

requirements but face some barriers. 

Nursing homes meet requirements for QA committee membership. 

Data from CMS’ OSCAR system show that from 1997 to 2001, 99 percent of nursing homes 

met CMS’ requirements for QA committee membership. At a minimum, the QA committee 

must include the director of nursing, a physician, and 

three other members of the nursing home’s staff. 

However, nursing homes include a variety of staff on their 

QA committees, including a core of key personnel (see 

Table 1). In 80 percent of nursing homes we surveyed, 

QA committees consisted of 7 or more members from 

several areas of their nursing homes. Committee 

members identified by respondents include directors of 

dietary services, activities, and housekeeping 

departments; business office managers; minimum data set 

coordinators; medical records coordinators; and 

environmental and maintenance staff. Many QA 

committees also include individuals who are not on their 

Table 1 

Participation of nursing home 

staff in QA committees 

Director of nursing 99% 

Administrator 96% 

Social services manager 93% 

Medical director 90% 

Infection control manager 82% 

Source: OIG survey of nursing homes, 

staff. For example, 70 percent of nursing homes reported that pharmacy consultants regularly 

participate in committee meetings. 

Nursing home stakeholders we spoke with noted that including a broad membership on the QA 

committee helps to ensure that the committee represents all areas of the home. One nursing 

home administrator we spoke with includes all department managers on her nursing home’s QA 

committee. The committee members are responsible for both 

Nursing Home QA Committees 4 OEI-01-01-00090 
handling committee work and communicating to their staff about what happens in each QA 

committee meeting. 

The QA committees, however, typically do not include certified nursing assistants (CNAs) as 

regularly participating members. On our survey, just 24 percent of nursing homes reported that 

CNAs regularly participate on their QA committees. Nursing home professionals we spoke 

with stressed the value of including CNAs in QA committees. As the CNAs are the primary 

caregivers in a nursing home, they possess a wealth of knowledge about a home’s residents, as 

well as knowing which processes and products work best in caregiving. One director of 

nursing told us, “CNAs know 90 percent of the answers.” Nursing home professionals with 

whom we spoke who do not have CNAs participate on the QA committee cite time and staff 

shortages for the exclusion. When CNAs participate in a committee meeting, they are taken 

away from caring for residents. If a nursing home has a staffing shortage, as most do, taking 

time away from caregiving is a tradeoff that few nursing homes can afford. 

Nursing homes meet requirements for frequency of QA committee meetings. 

Data from OSCAR show that from 1997 to 2001, 98 percent of nursing homes met CMS’

requirement for quarterly QA committee

meetings. Additionally, 61 percent of nursing

homes indicated on our survey that their QA

committees meet more frequently than required

by regulation (see Figure 1). The more

frequently a QA committee meets, the more

visible the committee is likely to be in the

nursing home. Frequent meetings also can give

attention to issues in a timely manner. 

While time pressures and other priorities may

make it difficult for the QA committee to meet

often, nursing home professionals with whom

we spoke affirmed the importance of frequent

meetings. As one nursing home stakeholder

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

The QA committees use an array of data sources to target problem areas in their 

nursing homes. 

On our survey, QA committees reported relying on an average of eight sources of information 

to assess the care their nursing homes provide as well as other aspects of the nursing home’s 

operations. Of these sources, 73 percent of nursing homes reported that 

Nursing Home QA Committees 5 OEI-01-01-00090 
CMS’ quality indicators (QIs) were a major influence on the work of the QA committee. In 

1999, CMS introduced the QIs as a new means for nursing homes to pinpoint quality-of-care 

issues with data. The QIs encompass 11 areas of care: accidents, behavior/ emotional patterns, 

clinical management, cognitive patterns, elimination/incontinence, infection control, 

nutrition/eating, physical functioning, psychotropic drug use, quality of life, and skin care. One 

nursing home administrator commented, “They are the pulse of our residents’ quality-of-care 

issues.” 

Nursing homes reported that they systematically review and use the QIs, with 68 percent 

reviewing QIs monthly. Some nursing homes review their QIs even more often; 17 percent 

reported reviewing them weekly or more frequently. Almost 80 percent detected concerns 

through their review of QIs and launched projects to further examine these areas. Of these, the 

most common areas of the QIs in which projects 

were undertaken were accidents (77 percent), 

skin care (76 percent), nutrition/eating (71 

percent), and elimination/incontinence (63 

percent). 

Some nursing homes also rely on clinical 

indicators other than QIs that are created 

specifically by the nursing home or their corporate 

or parent office. On our survey, 65 percent noted 

that such indicators had a major influence on the 

work of their QA committees. One nursing home 

we visited uses its own indicators. It created 

Using established agendas ensure 

systematic detection of problems 

Such an agenda identifies topics and 

establishes the frequency of their review. For 

example, the agenda could require that falls 

be reviewed weekly, while resident 

satisfaction surveys be reviewed annually. 

This institutionalizes the agenda. 

Source: OIG survey of nursing homes and 

stakeholder interviews, 2001-2002. 

them to target certain problem areas that they had, both clinical and nonclinical, such as 

medication transcription errors and resident activity participation. 

Committees also use results from surveys to target their work. For example, 81 percent of 

nursing homes reported that results from certification surveys were a major influence on the 

work of their QA committees. Surveys review a nursing home’s entire operation, from quality 

of care to administration to safety. The results of the survey and the deficiencies found alert the 

committee to areas of concern, which they then may address. 

Lastly, QA committees also rely on input from staff and residents to detect problems in the 

nursing home. On our survey, 66 percent of nursing homes reported that staff input and 55 

percent reported that resident input had a major influence on committee work. One nursing 

home that we visited also conducts focus groups with residents and their families. As this 

nursing home has an ethnically diverse population, these focus groups have allowed the 

committee to make changes in the nursing home, especially in dining and activities, that better 

reflect the residents’ needs. 

Nursing Home QA Committees 6 OEI-01-01-00090 
However, knowledge deficits impede QA committees. 

While QA committees have an array of information to help them pinpoint problems in nursing 

homes, the QA committee’s knowledge of how to use this information to execute projects 

remains a key barrier. On our survey, we asked an open-ended question regarding what 

additional steps CMS could take to help increase the effectiveness of QA committees. The top 

response, reported by 39 percent of nursing homes, was a call for more guidance and examples 

about how to best use their QA committees. Additionally, in its 2001 report examining the 

quality of nursing home care, the IOM found that “most nursing homes, even highly motivated 

ones, may lack the technical expertise and resources—including but not limited to staffing 

levels—necessary to translate...quality improvement systems into practice.”4 

Nursing home stakeholders with whom we spoke reflected those findings and also noted that 

nursing homes are well behind the curve in going beyond traditional quality assurance —finding 

problems and fixing them without necessarily identifying their core causes—to continuous 

quality improvement. Some nursing homes do carry out quality improvement projects, which 

involve measuring baseline performance, collecting appropriate data and information, 

implementing an intervention based on the data, and monitoring the results over time. However, 

it is a more analytic and intensive approach, requiring knowledge of systems and principles of 

measurement, which nursing homes are hard-pressed to meet, and with which they have limited 

experience. 

Nursing homes reported struggles with knowledge on how best to use their QA committees on 

our survey. Thirty-three percent reported a lack of knowledge about how to conduct QA 

committee work as a barrier to the committees’s 

overall effectiveness and 29 percent reported 

unclear guidelines and regulations concerning 

QA committees as a barrier. One particular 

area in which QA committees have a knowledge 

deficit is with CMS’ quality indicators (QIs). 

While most nursing homes use the QIs, 35 

percent of nursing homes reported that their lack 

of knowledge on how to use these indicators has 

been a barrier to using them more effectively. 

Despite their struggle with executing QA 

committee work, a number of resources exist for 

nursing homes. For example, some nursing 

homes have formed alliances to share such 

information (see box at right for an example). 

The parent organizations of some nursing homes 

have quality processes and systems that can 

guide the work of QA 

Wellspring: sharing innovations among 

nursing homes 

Nursing homes that are a part of Wellspring 

Innovative Solutions have the benefit of 

collaborative relationships they can use to help 

each other solve their problems. Wellspring is a 

cooperative alliance of independent nursing 

homes, established in 1994, that came together 

to enhance quality, promote culture change, 

and provide efficient and caring services to 

elders. 

A key element of Wellspring is that all nursing 

homes collect and use best practices. As staff 

from all levels in Wellspring homes participate 

in teams that look at data, these teams are able 

to consult staff in other Wellspring homes on 

their experiences. This way, each nursing home 

is able to benefit from the knowledge of the 

other nursing homes. 

Source: OIG stakeholder interviews, 2001. 

Nursing Home QA Committees 7 OEI-01-01-00090 
committees. The American Association for Homes and Services for the Aging published a 

guide for its member nursing homes on steps to a successful quality assurance program and has 

held training courses on using the guide. Other organizations, such as the American Medical 

Directors Association, conduct training seminars on using the QIs for quality improvement 

projects. Furthermore, some states have initiatives aimed at helping nursing homes with quality 

assurance and improvement work. 

The extent to which nursing homes and their QA committees take advantage of these resources 

is unknown. Some suggest that CMS needs to exert leadership in this capacity. As discussed 

below, staff shortages and time constraints can impede QA committee work. As a result, QA 

committees may be hard pressed to take full advantage of such resources. 

Staff shortages and turnover challenge QA committees. 

Because members of QA committees handle committee work on top of their regular tasks in 

the nursing home, staff shortages and turnover remain a key barrier to the QA committee’s 

work. On our survey, 53 percent of nursing homes reported that not having enough staff was a 

barrier to a more effective committee, and 47 percent of nursing homes cited general staff 

turnover, such as among certified nursing assistants, as a barrier. As a recent national study has 

reported that 9 out of 10 nursing homes are seriously understaffed, these barriers to effective 

QA committees may frequently occur.5 

Staff shortages and turnover can impede QA committees in many ways. With such shortages, 

resident care will take a priority over QA committee work. Turnover also challenges a nursing 

home’s ability to have a QA committee that can effectively follow-up and be accountable for 

ensuring improvements in the home. With a continual influx of new staff and their needs for 

orientation and training, getting staff up to speed with what is happening in a home’s QA 

committee may not be a priority. Turnover of QA committee members may especially impede 

the committee, as the person’s knowledge and expertise about committee work leave the 

nursing home with the person. 

Turnover at the leadership level of a nursing home further impedes the QA committee. 

Leadership commitment to quality improvement is vital for instilling a culture that can promote 

accountability for quality. As an executive from one nursing home told us, “Having a (QA) 

committee is one piece, but it is not the answer...it has to permeate your organization.” 

According to stakeholders, having someone champion quality at the helm can promote buy in 

for quality efforts throughout the home. However, the reality for many homes is that turnover in 

key leadership positions makes that culture elusive. On our survey, 27 percent cited turnover in 

such positions as a barrier to a more effective QA committee. In some cases, nursing homes 

responding to our survey were unable to answer basic questions about their QA committee, 

noting a recent turnover in leadership positions. In fact, filling leadership positions are becoming 

increasingly difficult as fewer candidates are being attracted to the administrator’s position: from 

1997 to 2000, the number of candidates taking the long-term care administrator’s exam 

declined by 37 percent.6 

Nursing Home QA Committees 8 OEI-01-01-00090 
Nursing Home QA Committees 9 OEI-01-01-00090

CONCLUSION

Our review shows that nearly all nursing homes meet CMS’ two requirements for QA

committees. The QA committees also have many sources of information available to them. 

However, a lack of knowledge on how to use this available information impedes QA

committees. Additionally, staff shortages and turnover in nursing homes are further barriers to

QA committees. These fundamental challenges can impede the work of even the most diligent

QA committee. 
APPENDIX A 

Methodology 

Survey of Nursing Homes 

We mailed a survey to administrators of a national simple random sample of nursing homes in 

November 2001 and sent a follow-up mailing in December 2001 to those who had not 

responded . We preceded our survey mailing with a cover letter that was sent in October 2001 

informing the nursing home administrators about the survey and this inspection. 

We requested that the survey be completed by the home’s Director of Nursing (a required 

member of the QA committee) or another individual responsible for the QA committee. Our 

survey solicited information on the following areas: background information on the nursing 

home, structure of the QA committee, work of the QA committee, committee projects, CMS’ 

Quality Indicators, barriers to QA committee effectiveness, assessment of the QA committee, 

and an open-ended section for additional comments. 

We chose to survey a national simple random sample of nursing homes, because the 

requirements for QA committees apply to all nursing homes that participate in Medicare. Our 

original sample comprised 671 nursing homes randomly selected from CMS’ Online Survey 

Certification and Reporting (OSCAR) system database. We deleted 17 nursing homes from 

the original sample after consulting with other components of the Office of Inspector General, 

reducing our sample size to 654. We then were notified that 53 nursing homes had ceased 

operations, even though they still appeared in the OSCAR database, reducing our final sample 

size to 601. 

We received responses from 384 nursing homes, yielding a response rate of 63.9 percent. 

Nonrespondent Analysis 

To determine whether significant differences exist between survey respondents and 

nonrespondents, we conducted nonrespondent analyses using four variables. These variables 

included: average complaints per nursing home (using number of beds as the denominator), 

average deficiencies per nursing home (also using number of beds as the denominator), number 

of certified beds, and nursing home control. One nursing home that responded to our survey 

excluded identifying information; therefore, we based these analyses on 383 respondents. 

Nursing Home QA Committees 10 OEI-01-01-00090 
APPENDIX A 

Complaints and deficiencies 

We obtained data for the average complaints and average deficiencies from the OSCAR 

complaints files. Because 492 of the 601 nursing homes in our sample had a match to the 

complaints file, we limited the analyses for these two variables to these 492 nursing homes. Of 

the 492 nursing homes, 160 did not respond, and the remaining 332 responded. We used 

averages for the deficiencies and complaints to allow for the difference in the size among the 

nursing homes. 

The average number of complaints per nursing home was .0157 for nonrespondents, compared 

to .0155 for respondents. The average deficiencies per bed for nonrespondents was .115, 

compared to .0963 for responding nursing homes. No significant difference at the 95 percent 

confidence level existed between the average complaints, or average deficiencies, for the two 

groups. 

Analysis by number of certified beds and nursing home control 

The average number of certified beds in nursing homes responding to our survey was 113, 

compared to 100 for nonrespondents. A t-test found a statistically significant difference 

between the means at the 95 percent confidence level. 

Sample 

N=601 

Respondents 

N=383 

Nonrespondents 

N = 218 

Average number of certified beds 108 113 100 

t = - 2.07 Degrees of freedom = 599 

An analysis by nursing home control showed a significant difference between nonrespondents 

from for-profit nursing homes and not-for-profit/government-owned nursing homes. The Chisquare test was significant for the control variable, because it was greater than 3.84 at the 95 

percent confidence level. 

Sample Respondents Nonrespondents 

For-profit 441 (73.4%) 266 (69.5%) 175 (80.3%) 

Not-for-profit/government 160 (26.6%) 117 (30.5%) 43 (19.7%) 

Total 601 383 218 

Chi - square statistic = 8.33 Degrees of freedom = 1 

Nursing Home QA Committees 11 OEI-01-01-00090 
APPENDIX A 

Because of the significant differences from these analyses, we conducted further analysis to 

determine the effect of the relationship between the number of certified beds and response rate, 

and nursing home control and response rate. Assuming nonrespondents would have answered 

questions the same as respondents, we calculated hypothetical responses for key questions 

related to our findings. All calculations were within the 95 percent confidence intervals of the 

original estimates. Thus, we did not find statistical evidence of bias based on number of 

certified beds or nursing home control. 

Confidence Intervals for Key Questions (95 percent) 

Description Point 

estimate 

Confidence 

Interval 

QA committees with 7 or more members 80% +/- 4.0% 

QA committees with regularly participating CNAs 24% +/- 4.3% 

QA committees that meet monthly or more frequently 61% +/- 4.9% 

QIs are a major influence on the work of the QA committee 73% +/- 4.4% 

Certification surveys are a major influence on the QA committee 81% +/- 3.9% 

Nursing homes want more QA committee guidance from CMS 39% +/- 4.9% 

Lack of knowledge on how to use QIs is a barrier to effective 

use 

35% +/- 4.8% 

Lack of staff to do QA committee work is a barrier to having an 

effective QA committee 

53% +/- 5.0% 

General staff turnover is a barrier to overall effectiveness of QA 

committee 

47% +/- 5.0% 

Leadership turnover is a barrier to an effective QA committee 27% +/- 4.4% 

Site Visits 

We judgementally selected and visited three nursing homes in Massachusetts, New Hampshire, 

and Wisconsin to learn more about their QA committees. In one nursing home we observed a 

QA committee meeting. In each nursing home, we met with the administrator as well as key 

staff involved in the QA committee, including directors of nursing, other nursing staff, minimum 

data set coordinators, department managers, and certified nursing assistants. Since the data 

collected from these entities were from a purposive sample, this information obtained cannot be 

generalized to the population. 

Nursing Home QA Committees 12 OEI-01-01-00090 
APPENDIX A 

Stakeholder Interviews 

We judgementally selected and interviewed, either in person or by telephone, 33 stakeholders 

with expertise and interest in nursing home quality assurance. These stakeholders included 

CMS central office staff and senior nursing home surveyors in CMS regional offices. Since the 

data collected from these entities was from a purposive sample, this information obtained 

cannot be generalized to the population. We also interviewed representatives from the 

American Association of Homes and Services for the Aging, American Health Care 

Association, the National Citizens’ Coalition for Nursing Home Reform, the American College 

of Health Care Administrators, and the Pioneer Network, as well as representatives from state 

affiliates of these organizations. Additionally, we interviewed executives and staff from nursing 

homes and nursing home corporations. 

OSCAR data analysis 

We analyzed all nursing home data from CMS’ OSCAR system for the years 1997 to 2001 to 

identify the frequency of deficiencies for QA committee survey requirements (F520 and F521). 

The deficiency rates presented below are for the number of deficiencies for each requirement in 

a calendar year divided by the number of surveys conducted in that year. 

Deficiency Rates for QA Requirements for Nursing Homes, 1997 - 2001 

Requirement 1997 1998 1999 2000 2001 

Committee membership (F520) 0.7% 0.5% 1.0% 1.2% 0.9% 

Quarterly Meetings (F521) 2.0% 1.8% 2.0% 2.5% 2.1% 

Document review 

We reviewed relevant federal laws and regulations, as well as chapters of CMS’ State 

Operations Manual relative to the Survey and Enforcement Process for Skilled Nursing 

Facilities and Nursing Facilities. We also reviewed plans of correction completed by nursing 

homes and survey deficiency reports. Lastly, we reviewed articles, books, and reports relative 

to quality assessment and assurance in nursing homes. 

Nursing Home QA Committees 13 OEI-01-01-00090 
APPENDIX B 

Endnotes 

1. Institute of Medicine, Improving the Quality of Care in Nursing Homes (Washington, DC: 

National Academy Press, 1986), 21. 

2. Centers for Medicare & Medicaid Services, State Operations Manual, page P-77. 

3. Ibid. 

4. Institute of Medicine, Improving the Quality of Long-Term Care (Washington, DC: National 

Academy Press, 2001), 15. 

5. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report 

(Cambridge, MA: Abt Associates, 2001), 1-7. Accessed from 

http://www.house.gov/reform/min/inves_nursing/nursing_cms_rep.htm on April 25, 2002. 

6. National Association of Boards of Examiners of Long Term Care Administrators press release, 

Nursing Home Administrators: A Vanishing Profession? Third Year of Decline, Increasing Need, 

Signals Crisis-in-the-Making. March 2, 2001 

Nursing Home QA Committees 14 OEI-01-01-00090 
Nursing Home QA Committees 15 OEI-01-01-00090

ACKNOWLEDGMENTS

This report was prepared under the direction of Mark R. Yessian, Ph.D., Regional Inspector General

for Evaluation and Inspections in Boston and Joyce M. Greenleaf, M.B.A., Assistant Regional

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

Maria E. Maddaloni, M.A., Lead Analyst Sandy Khoury, Program Specialist

Christopher T. Gould, M.S., Program Analyst Bambi D. Straw, Program Specialist

Barbara Tedesco, Mathematical Statistician

Linda Moscoe, Technical Support Staff 

For information or copies of this report, please contact

the Office of Inspector 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/