Department of Health and Human Services 


OFFICE OF 

INSPECTOR GENERAL 

INFORMAL DISPUTE RESOLUTION 


FOR NURSING FACILITIES


Inspector General 

March 2005 

OEI-06-02-00750 
Office of Inspector General 
 http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as required 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. The OEI also 

oversees State Medicaid fraud control units, which investigate and prosecute fraud and 

patient abuse in the Medicaid program. 

Office of Investiga ions t

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. 

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 compliance program guidances, renders advisory opinions on OIG sanctions to 

the health care community, and issues fraud alerts and other industry guidance. 
∆ E X E C U T I V E S U M M A R Y 

OBJECTIVES 

To determine if all States have written informal dispute resolution 

(IDR) policies as required by Federal regulations and to describe policy 

content. 

To determine if 14 selected States comply with Federal requirements for 

State IDR notification and closure letters and if nursing facilities in 

these States comply with the Federal requirements for IDR requests. 

To determine the length of time taken by States to complete IDR 

reviews and to identify IDR outcomes for disputed survey deficiencies. 

BACKGROUND 

This inspection of the IDR process is part of the Office of Inspector 

General’s (OIG) ongoing evaluation of the quality of care provided to 

nursing facility residents, particularly as measured by survey 

deficiencies and by how States and the Centers for Medicare & Medicaid 

Services (CMS) manage them. The IDR process is important because it 

provides nursing facilities the opportunity for avoiding costly formal 

appeals and for communicating better with State survey agencies about 

certification standards that facilities must meet. State procedures and 

outcomes of the IDR process have not previously been studied by OIG. 

CMS contracts with State agencies to conduct standard surveys of 

nursing facilities for compliance with the Federal standards no less 

than once every 15 months. Any deficiency in quality of care, safety, or 

patient rights, as determined through the surveys, may trigger CMS 

enforcement action(s). The enforcement regulations for nursing facility 

certification standards issued after passage of the Omnibus Budget 

Reconciliation Act of 1987 require all States to provide Medicare- and 

Medicaid-certified nursing facilities an opportunity for an IDR review to 

dispute cited deficiencies in patient care and safety. 

Before proceeding with a formal appeal, which can be costly and 

lengthy, the IDR process permits the nursing facility to submit 

documentation supporting its dispute to the State agency for a review 

that could potentially delete or lower the severity of the cited 

deficiencies. CMS, which has oversight responsibility for the IDR 

process, requires in its “State Operations Manual” that States have 

written IDR policies, although the policy content is not specified. The 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES i 
EXECUTIVE SUMMARY 

manual also includes instructions States should provide to nursing 

facilities to request an IDR review, specific details about the IDR 

process, and circumstances under which a State must inform a nursing 

facility of an IDR outcome. 

We analyzed 48 States’ written IDR policies and case documentation for 

a random sample of 415 IDR reviews done by 14 selected States in 

calendar year 2002. We determined if States have written IDR policies 

and the extent to which the States and nursing facilities met the 

Federal requirements in their actual conduct of IDR reviews. We also 

used the case documentation provided by the 14 States to determine 

outcomes for disputed deficiencies and to determine the length of time 

for States to complete IDR reviews. 

FINDINGS 

Forty-eight of fifty States have written IDR policies that are available upon 

request, as required; however, the content of their written policies varies. 

Of the 50 States, Alaska and Connecticut did not provide us copies of 

their own written policies. However, both indicated they provide a copy 

of the IDR portion of the “State Operations Manual” upon a request for 

information. 

Most States’ written IDR policies address the requirements of providing 

instructions to facilities for an IDR request, including specific details 

about the IDR, and information on how States will inform nursing 

facilities of IDRs’ outcomes. Other useful information, although not 

required, is often omitted. For example, the written policies do not 

always address inappropriate reasons for an IDR request or that 

nursing facilities must be notified an IDR review is available to them. 

Finally, 38 of the 48 States’ policies do not specify time limits for 

completion of the IDR process. 

All 14 of the States, for which we reviewed case documentation, are 

performing IDR reviews and generally comply with the IDR requirements; 

yet, most notification letters omit some required technical information. 

State IDR Notification Letters. All notification letters to nursing 

facilities stated that the nursing facility IDR request must be submitted 

in writing and must include an explanation of disputed deficiencies. 

However, few notifications included two required details: only 37 

percent of notifications indicated how the IDR review would be 

conducted and only 6 percent indicated by whom. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES ii 
EXECUTIVE SUMMARY 

State IDR Closure Letters. The 14 States exceed Federal requirements 

by routinely sending closure letters to facilities to inform them of all 

IDR outcomes. Federal requirements specify that States must send 

closure letters only if the facilities are unsuccessful at demonstrating 

that deficiencies should not have been cited. 

Nursing facility IDR requests typically met the requirements. 

Ninety-nine percent of requests for IDR review were in writing, as 

required. Eighty-six percent included an explanation of the specific 

deficiencies being disputed, and 91 percent provided appropriate 

reasons for the IDR requests. 

Eighty percent of IDR cases were completed within 60 days, and 45 percent 

of the disputed deficiencies resulted in citation changes. 

There is no requirement for IDRs to be completed within 60 days, but it 

is beneficial if they are done within this timeframe. This is due to the 

fact that a nursing facility has only 60 days from its receipt of the 

formal notice of the imposition of any enforcement remedies to formally 

appeal deficiency citations, whether or not the IDR process is completed. 

The nursing facility’s decision to pursue a formal appeal could be 

affected by the outcome of the IDR. On the other hand, deficiency 

citations are not supposed to be posted on CMS’s Nursing Home 

Compare Web site, which is available for public reference, until the IDR 

is completed. Finally, the fact that 45 percent of the disputed 

deficiencies were changed through the IDR process indicates that IDRs 

do affect the citation outcomes. 

RECOMMENDATIONS 

We recommended that CMS require that the two States without the 

required written IDR polices, Alaska and Connecticut, prepare them 

since they are technically noncompliant. Alternatively, CMS should 

determine if these States’ practice of providing, instead, the IDR portion 

of CMS’s “State Operations Manual” to nursing facilities satisfies the 

requirement of written IDR policies. We also recommended that CMS 

ensure that all required information is included in all States’ IDR 

notification letters to the nursing facilities. Although not required by 

law, regulation, or CMS policy, we also identified opportunities for 

improvement. 

Agency Comments 

CMS concurred with our recommendations and suggested opportunities 

for improvement. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES iii 
B L E

EXECUTIVE SUMMARY

. . . . . . 1

I N T ROD U C T ON 

. . . . . 

FINDINGS ...................................................... 6

Written Policies. . . . 

. .. 

Practices of Selected Sta

Nursing Facility Requests. . . . . . 

. . . . . . . . . . . . . . . . . . . . . . . . .. 

Performance. . . . . . 

. .. 

R E COM MEN D A 

T ION S . . . . . . . . . . . . . 

A P PEN D I XES. . 

. . . . . . . . . . . . . . . . . . .. 

A: Inspection Methodology. . . . . . . . 

. . . . . . . . . . . . . . . . . . . . . .. 

B: Calendar Year 2002 State Nursing Facilty IDR Requests. .. 20

C: Calculated Weights for Selected States' IDR Cases. . . . . . . .. 

D: Point Estimates and Confidence Intervals. . . . 

. . . . . . . . . . .. 

E: Requirements in States' Written Policies. . . . . . . . . . . . . . . .. 

F: Additional Information in Written State IDR Policies. . . . . . . ' 24

G: Centers for Medicare & Medicaid Services Comments. . . . .. 

A C K NOW LED G MEN T S . . .. .. . . 

. .. .. . . .. . . . .. . .. . .. .. .. . .. . .. ... 

END NOT E S .................................................... 30
∆ I N T R O D U C T I O N 

OBJECTIVES 

To determine if all States have written informal dispute resolution (IDR) 

policies as required by Federal regulations and to describe policy content. 

To determine if 14 selected States comply with requirements for State 

IDR notification and closure letters and if nursing facilities within these 

States comply with the requirements for IDR requests. 

To determine the length of time taken by States to complete IDR reviews 

and to identify IDR outcomes for disputed survey deficiencies. 

BACKGROUND 

The Omnibus Budget Reconciliation Act of 1987 (OBRA) amended 

sections 1819 and 1919 of the Social Security Act by requiring all nursing 

facilities participating in the Medicare and Medicaid programs to meet a 

common set of certification standards, many of which focus on patient 

care and safety. The Centers for Medicare & Medicaid Services (CMS) 

contracts with State agencies to conduct standard surveys of nursing 

facilities for compliance with the Federal standards no less than once 

every 15 months. Any deficiency in quality of care, safety, or patient 

rights, as determined through the surveys, may trigger CMS enforcement 

action(s). 

The Administrative Dispute Resolution Act of 1990 required State 

agencies to develop and implement policies addressing alternative dispute 

resolution methods. However, it was not until July 1, 1995,1 the effective 

date of the OBRA enforcement regulations, that alternative dispute 

resolution became a process requirement for nursing facilities certified for 

Medicare and Medicaid. For nursing facilities, this process is called IDR. 

This inspection of the IDR process is part of the Office of Inspector 

General’s (OIG) ongoing evaluation of the quality of care provided to 

nursing facility residents, particularly as measured by survey deficiencies 

and how States and CMS manage them. The IDR process is important 

because it provides nursing facilities the opportunity for avoiding costly 

formal appeals and for communicating better with State survey agencies 

about certification standards that facilities must meet. State procedures 

and outcomes of the IDR process have not previously been studied by 

OIG. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 1 
INTROD UCTION

Informal Dispute Resolution 

Nursing facilities have both a formal and an informal process for 

disputing cited deficiencies resulting from standard surveys. The nursing 

facility may file a formal appeal request within 60 days of the facility’s 

receipt of the formal notice of the imposition of any enforcement remedies 

resulting from the cited survey deficiencies. The purpose of the formal 

appeal is to provide the nursing facility a structured review of disputed 

deficiencies by the Departmental Appeals Board of the Department of 

Health and Human Services. 

Effective July 1, 1995, as part of the nursing facility enforcement 

regulations, CMS required States to provide nursing facilities the 

opportunity for IDR reviews in order to avoid the potentially prolonged 

resolution process associated with more formal appeals. The IDR process 

does not prevent a nursing facility from pursuing a formal appeal of the 

disputed deficiency concurrently or at a later date. CMS incorporated 

IDR procedural requirements into their final written enforcement policies 

located in the “State Operations Manual,” section 7212. 

The IDR process provides a nursing facility with an opportunity to 

dispute cited survey deficiencies at the State level. After a nursing 

facility has been cited for a survey deficiency, the State agency is required 

to notify the facility in writing of the IDR opportunity. If the State agency 

receives a written request from a nursing facility within the required 

timeframe (10 calendar days), the IDR process then commences. The 

State reviews documentation submitted by the nursing facility to dispute 

deficiency citations. Additional steps may include an in-person interview 

or telephone conference between nursing facility representatives and 

State agency staff. As a final step, the State may send the nursing facility 

a closure letter indicating the outcome of the review.2 Some States have 

posted information about their IDR process on their health departments’ 

Web sites,3 and 27 States have incorporated an IDR process into their 

State laws or regulations.4 

Federal regulations and policy5 further specify that an IDR-disputed 

deficiency should not be entered into CMS’s Online Survey, Certification, 

and Reporting (OSCAR) system. Additionally, the disputed deficiency is 

not supposed to be posted to CMS’s Nursing Home Compare Web site, 

which is available for public reference, while the IDR case is pending. At 

the conclusion of an IDR, upheld deficiencies are input into OSCAR and 

subsequently made available on the Nursing Home Compare Web site. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 2 
INTRODUCTION

IDR Requirements. IDR requirements appear in Federal regulations at 

42 CFR § 488.331 and in CMS’s “State Operations Manual.” section 7212. 

Federal Regulations. The Federal regulations require: 

1. States to provide nursing facilities the opportunity for an IDR 

review; 

2. States to provide written notification of the IDR process to nursing 

facilities; 

3. any enforcement actions initiated as a result of the survey to 

proceed, regardless of an IDR request; and 

4. in the event that the nursing facility’s dispute is upheld, State 

removal of the deficiency from the statement of deficiencies and 

rescission of any enforcement actions imposed solely as a result of 

the disputed deficiency. 

Centers f r Medicare & Medicaid Services Policy o . The “State Operations

Manual” provides CMS’s policy statement of specific requirements for the 

IDR process following the citation of survey deficiencies, including that 

each State is required to have a written policy available upon request. 

The requirements for State IDR notifications, nursing facility IDR 

requests, and State closure letters are shown in Table 1 on the next page. 

Recent Federal Initiatives 

C n e s fo e i r e i i rv c s e t r r M d ca e & M d ca d Se i e . CMS is currently requiring that 

States input IDR information into a new component of its Automated 

Survey Processing Environment software. This software, the IDR 

Manager, tracks and collects data on disputed surveys. However, the 

functionalities of the IDR Manager have been used to varying degrees, 

depending on the needs of the States. CMS has both an extramural pilot 

study and a contracted grant underway to evaluate the effectiveness of 

the current IDR process. Reports from these studies are anticipated in 

early 2005, but are intended to serve as internal documents for CMS’s 

useage.6,7,8 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 3 
INTRODUCTION 

Table 1: Requirements for State IDR Notification Letters, 

Nursing Facility IDR Requests, and State Closure Letters 

State IDR Notification and Closure Letters Nursing Facility IDR Requests 

1) Each State must notify the nursing facilities of the availability of an The nursing facility IDR request: 

IDR in the letter from the State transmitting the official Form 

CMS-2567, the Statement of Deficiencies. 1) must be in writing, 

2) State notification of the IDR process should inform the nursing 2) must be submitted within the same 10-calendar day period as for 

facility that the nursing facility’s IDR request: submitting an acceptable plan of correction to the State surveying 

a. must be in writing, entity, 

b. must be submitted within the same 10-calendar day period as 

for submitting an acceptable plan of correction to the State 3) must not be used to:

surveying entity, and a. delay the formal imposition of remedies and 

c. must include an explanation of the specific deficiencies being b. challenge other aspects of the survey process, including: 

disputed. - scope and severity of cited deficiencies, except in those 

instances when the cited deficiency constitutes substandard 

3) State notification of the IDR process should also inform the nursing quality of care or immediate jeopardy;

facility of some basic information about the State’s IDR, specifically: - remedies imposed by the enforcing agency for cited 

a. how the IDR may be accomplished (e.g., by telephone, in deficiencies; 

writing, or in a face-to-face meeting); - allegation of failure of the survey team to comply with the 

b. the name, address, and telephone number of the contact survey process requirements;

person for requesting the IDR; and - allegation of inconsistency of the survey team citing 

c. the name and/or position title of the person who will conduct the deficiencies among facilities; and 

IDR, if known. - allegation of inadequacy or inaccuracy of the IDR process; 

and 

4) The State survey entity must notify the nursing facility in writing if 

the nursing facility is unsuccessful at demonstrating, during the IDR, 4) must include an explanation of the specific deficiencies being 

that a deficiency should not have been cited. disputed. 

Source: CMS’s “State Operations Manual,” section 7212. 

METHODOLOGY 

We contacted 50 States for information about their IDR processes. We 

also selected a random sample of 415 IDR reviews done by 14 selected 

States in calendar year 2002. These 14 States represent 50 percent of the 

nursing facilities nationwide and 62 percent of the total number of 

deficiencies cited at scope (number of affected residents) and severity 

(degree of harm) levels E or above. These are the more serious 

deficiencies. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 4 
INTRODUCTION 

We used the following sources of information for this inspection: 

o telephone interviews with all 50 State representatives having 

responsibility for their respective IDR processes, 

o written State IDR policies from 48 of 50 States, 

o written case documentation for the sample of 415 IDR reviews from 

the 14 selected States, and 

o onsite visits with 6 of the 14 selected States. 

We analyzed this information to determine: (1) if States have the 

required written IDR policy, available on request, and what information it 

contains; (2) if States and nursing facilities actually perform the 

Federally required key steps in each IDR case; (3) the extent to which the 

IDR documentation itself, such as State notices to facilities, incorporated 

the IDR requirements of the “State Operations Manual,” section 7212; 

and (4) the total processing time and outcomes of cited deficiencies for the 

documented IDR cases. Complete information regarding the inspection 

methodology is provided in Appendix A 

Inspection Limitations 

This inspection has the following limitations: 

o We only examined the IDR process for standard surveys; we did not 

include extended surveys, follow-up surveys, or complaint surveys 

in our review. We used standard surveys because CMS requires 

States to conduct a standard survey on all certified nursing facilities 

at least once every 15 months. Other types of surveys occur as 

needed. 

o We only examined the more serious deficiency citations of scope 

(number of affected residents) and severity (degree of harm) levels E 

or above. 

o We did not independently verify all of the information reported to 

us by State IDR representatives during telephone discussions and 

onsite visits, or reported to us from the State agencies through the 

mail. 

Inspection Conduct 

We conducted this inspection in accordance with the Quality S andards t

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

Efficiency. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 5 
∆ FINDINGS 


Forty-eight of fifty States have written IDR 

policies that are available upon request, as 

required; however, the content of their written 

policies varies. 

Compliance. Section 7212 of the 

“State Operations Manual” requires 

that all States have their IDR 

processes in writing so that they can 

be made available upon request. 

Forty-eight States provided us with 

copies of their written IDR policies as documentation of availability. 

Alaska and Connecticut did not provide us copies of their own written 

policies. Both States indicated that when facilities request written policy, 

each State provides a copy of the IDR portion of the “State Operations 

Manual.” State staff reported that IDR requests in Alaska are rare (3 in 

15 years), whereas Connecticut processed approximately 88 IDR cases in 

2003. 

Written State Policy Content for 48 States. Federal regulations and policy 

specify key steps of the IDR process, but they do not require inclusion of 

these steps in each State’s written IDR policy. Nevertheless, we 

compared, for informational purposes, the 48 States’ written policies with 

the “State Operations Manual” requirements to determine the extent to 

which they cover the whole IDR process. (See Appendix E.) Most States’ 

policies specify that the State will inform nursing facilities that IDR 

requests should: 

o be in writing (44 States), 

o be submitted within a 10-calendar day period (43 States), 

o include an explanation of deficiencies (41 States), and 

o identify who will conduct the IDR review (42 States). 

States’ written policies less often cover other requirements included in 

the “State Operations Manual,” such as: 

o what the nursing facility IDR request cannot be used for, such as to 

challenge the scope and severity of cited deficiencies, except in those 

instances when the cited deficiency constitutes substandard quality 

of care or immediate jeopardy (33 States); and 

o how the nursing facilities should be notified of the availability of an 

IDR process (28 States). 

Additionally, only four States (Arizona, Hawaii, Ohio, and Oklahoma) 

provide examples of their standard IDR notification letters in their 

written policies. These examples of letters have potential value for 

providing clear guidance regarding that State’s IDR process. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 6 
FINDINGS INDINGS

We also compared the States’ written policies against the Federal 

requirements to determine how accurately they reflect these 

requirements. We found no inaccurate statements in States’ written 

IDR policies in this comparison. 

States’ written IDR policies show some differences between States’ IDR 

processes. Some examples (see Appendix F for all of them) include: 

o whether a desk review will be performed (48 States), 

o the time limitation for an in-person or telephone conference 

(13 States), and 

o the attendance limitations at an in-person conference (12 States). 

Additionally, 48 States’ written policies indicate an opportunity for 

participation in the IDR process by individuals not directly involved in 

the survey that resulted in the disputed deficiency.9 At the same time, 

40 States, including Alaska, reported that they routinely include the 

original surveyors or survey representatives in the IDR process to provide 

additional information or explanation, as needed, to questions which may 

arise during the IDR review (25 States), to attend the IDR review as 

nonparticipants (20 States), and to conduct the initial review (4 States). 

Thirty-eight of forty-eight States’ written IDR policies do not specify time 

limits for completion of the IDR process. There are no Federal regulations 

or policy requiring and defining “timeliness” from receipt of a nursing 

facility’s IDR request to the completion of the IDR review. Ten States’ 

policies specify time limits ranging from 10 to 40 days for their IDR 

processes. 

All 14 of the States, for which we reviewed case 

documentation, are performing the IDRs and 

generally comply with the IDR requirements; 

yet, most notification letters omit some required 

technical information. 

Based on documentary evidence, 

interviews with State agency staff, 

and onsite State visits, we 

confirmed that all 14 selected States 

are performing the Federally 

required IDR steps of sending 

notification letters, receiving 

requests from facilities, and informing facilities of IDR outcomes in 

closure letters. For our sample of 415 IDR cases, we either obtained 

copies of, or could infer the existence of, 99 percent of notification letters, 

99 percent of nursing facility IDR requests, and 96 percent of closure 

letters. Follow-up discussions with State staff suggested that cases 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 7 
FINDING S 

without all three letters were due to missing documents rather than the 

basic IDR steps not being performed. 

For the second part of this analysis, we reviewed case documentation for 

the State notice and closure letters to determine the extent to which the 

“State Operations Manual” requirements are included in both types of 

correspondence between the State and nursing facilities. 

State IDR Notification Letters 

States’ IDR notification letters include most, but not all, of the required 

information. Case documentation shows that each of the 14 selected 

States uses a standard form letter that notifies nursing facilities of their 

opportunity for requesting an IDR review but tailors the letter to each 

nursing facility’s particular circumstances. Modifications include 

specifying cited deficiencies and possible enforcement actions. All State 

IDR notification letters provided information about IDR availability, 

notified the nursing facility that the IDR request must be submitted in 

writing within 10 calendar days, and indicated that the written IDR 

request must include an explanation of specific deficiencies being 

disputed. Other requirements concerning the details of the IDR process, 

such as the method for conducting an IDR review, e.g., telephone, in 

writing, or who will be conducting the IDR, often did not appear in the 

notification letters. (See Table 2.) 

Table 2: Required Information Included in 14 Selected States’ IDR Notification Letters* 

Required Information for Notification Letters 

Letters Including 

Required 

Information 

(n = 367) 

Number of States’ 

Standard Letters With 

Required 

Information* 

Notification of this process should inform the facility of 

some basic information about the State’s IDR process, 

specifically: 

a. how the IDR review may be accomplished (e.g., by 

telephone, in writing, or in a face-to-face meeting); 

b. the name, address, and telephone number of the 

contact person for the IDR request; and 

c. the name and/or position title of the person who will 

conduct the IDR review, if known. 

37% 

93% 

6% 

3 

12 

1 

* Because we received at least 1 notification form letter from each of the 14 States, we could determine how 

many of the States included the required information in their notification letters. 

Source: OIG analysis of State IDR notification letters (weighted). 

Current CMS policy also requires that nursing facilities’ requests not be 

used for certain purposes but does not prescribe that the State 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 8 
FINDING S 

notification letters contain this information. Nevertheless, we reviewed 

the State notification letters for inclusion as a point of information. With 

the exception of the notification letters specifying that requesting an IDR 

review to delay the formal imposition of remedies is not permissible, most 

letters did not include other required reasons for not requesting an IDR 

review. (See Table 3.) 

Table 3: Inappropriate Reasons for an IDR Request Included 

In 14 Selected States Notification Letters 

Inappropriate Reasons for Requests 

Letters Including 

Inappropriate Reason 

(n = 367) 

Number of States’ 

Standard Letters 

Including Inappropriate 

Reason* 

Notification includes that the facility request 

must not be used to: 

a. delay the formal imposition of remedies; 

b. challenge the scope and severity of cited 

deficiencies, except in those instances 

when the cited deficiency constitutes 

substandard quality of care or immediate 

jeopardy; 

c. challenge the remedies imposed by the 

enforcing agency for cited deficiencies; 

d. allege failure of the survey team to comply 

with the survey process requirements; 

e. allege inconsistency of the survey team 

citing deficiencies among facilities; and 

f. allege inadequacy or inaccuracy of the IDR 

process. 

72% 

50% 

18% 

36% 

36% 

18% 

11 

5 

2 

3 

3 

2 

* Because we received at least one notification form letter from each of the 14 States, we could 

determine how many of the States included the required information in their notification letters. 

Source: OIG analysis of State IDR notification letters (weighted). 

State IDR Closure Letters 

All closure letters to nursing facilities requesting IDR reviews met the one 

applicable requirement to notify nursing facilities in writing when they have 

been unsuccessful at demonstrating that a deficiency should not have been 

cited. However, all 14 selected States routinely provide closure letters to 

nursing facilities, regardless of outcomes. Further, 9 of the 14 selected 

States consistently provided information in their closure letters concerning 

all disputed deficiencies, rather than outcomes of only deficiencies changed 

as a result of the IDR review. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 9 
FINDINGS FINDINGS 

We reviewed case documentation to 

determine the extent to which the

Nursing facility IDR requests typically met the 

Federal requirements. 

nursing facility IDR requests met 

“State Operations Manual” 

requirements. (See Table 4.) All requests, except one by telephone, were 

submitted in writing. Eighty-six percent included an explanation of 

specific deficiencies being disputed. Of the IDR cases with sufficient 

documentation to analyze, 91 percent cited appropriate reasons for the 

IDR requests. 

Table 4: Requirements Met in 

Nursing Facility IDR Requests for 13 Selected States* 

Requirement for IDR Requests 

IDR Requests Meeting 

Requirements 

(n = 371) 

Submitted in writing 99% 

Included an explanation for specific disputed deficiencies 86% 

Provided correct reasons for the IDR request 91% 

Submitted timely** 86% 

* Massachusetts was excluded from this review. 

** We defined “timely” as the request being submitted within 15 days (a few days for the State’s 

notification letter to reach the facility by mail, 10 days to respond, and a few days for the 

State to receive the IDR request). 

Source: OIG analysis of nursing facility IDR requests. 

The 9 percent of facilities using an incorrect reason for an IDR request, 

namely, challenging the scope and severity of cited deficiencies, were 

significantly10 more likely to be in States that did not provide this 

information in their State notification letters. Further, none of the 

nursing facilities comprising the 9 percent was refused an IDR review by 

the States. 

Nursing facilities largely adhere to the 10-calendar day request 

requirement, when additional days are allowed for mail receipt and 

return. The “State Operations Manual” requires nursing facilities to 

submit their IDR requests within the same 10-calendar day period for 

submission of an approved plan of correction, i.e., it is required within 

10 days of the nursing facility’s receipt of the official Statement of 

Deficiencies, form CMS-2567. The CMS-2567 usually accompanies the 

State IDR notification letter. 

Allowing a few days for the State’s notification letter to reach the facility 

by mail, 10 days to respond, and a few days for the State to receive the 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 10 
FINDINGS 

IDR request (we allowed 15 days total), 86 percent of the IDR requests fell 

within the required timeframe. Late submission of an IDR request does 

not appear to impact whether an IDR review is performed by a State; only 

one Texas nursing facility was refused an IDR review for not meeting a 

timeframe requirement. 

Ten of the fourteen selected States define the 10-calendar day period for 

requesting an IDR review in their written policies. Seven of the ten use 

the same definition as the “State Operations Manual” requirement for the 

plan of correction, with no mention of days allowed for mailing. Two of 

the ten use a more restrictive definition11 and one specifies an actual due 

date in the State IDR notification letters. 

Timeliness. We paired each nursing 

facility IDR request letter with its 

Eighty percent of the IDR cases were completed 

within 60 days, and 45 percent of the disputed 

corresponding State closure letter. deficiencies resulted in citation changes. Eighty percent of the pairs showed 

completion of IDR cases within 60 days, 13 percent took 61 to 90 days, 

and 7 percent took more than 90 days. Overall, time for completion of 

cases in our selected States (excluding Massachusetts) ranged from 2 to 

312 days. 

Federal regulations and policy do not define “timely” completion of an IDR 

case review, although the failure to complete an IDR review will not delay 

the effective date of any enforcement action. However, Federal 

regulations and policy allow nursing facilities to file a formal appeal and 

an IDR request concurrently. The nursing facility may file a formal 

appeal request within 60 days of the facility’s receipt of the formal notice 

of the imposition of any enforcement remedies, resulting from the cited 

survey deficiencies. If the outcome of an IDR review is in the nursing 

facility’s favor, e.g., deletion or lowering of scope and severity level for the 

cited deficiency, even though not requested by the nursing facility, the 

nursing facility may choose not to file a request for a formal appeal, 

assuming that the outcome is known before 60 days have elapsed, or the 

nursing facility can withdraw the concurrent request for a formal appeal 

made early in the process. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 11 
FINDING S 

Outcomes. Of the initially disputed 1,211 deficiencies from 347 cases, 

45 percent had a change in citation, almost always in the nursing 

facility’s favor. (See Table 5.) An IDR outcome may be considered in the 

facility’s favor if the disputed deficiency is deleted, “lessened” in impact by 

a modification to how the disputed citation is written, e.g., one or more 

examples are deleted from the citation, or lowered in scope and severity 

level, even though not requested by the nursing facility. 

Of the deficiency citations that were changed, 19 percent had 

modifications to the way the deficiency was written, and 19 percent had 

the citation deleted. An increase in the scope and severity level of the 

disputed deficiency for the nursing facility, a negative outcome of an IDR 

review, appears to happen rarely. Insufficient outcome information was 

documented for 3 percent of the reviewed cases. 

Table 5: IDR Outcomes for Disputed Deficiencies 

Percent of 1,211 Disputed 

IDR Outcomes Deficiencies 

(n = 347 cases) 

No change in citation 52% 

Changes in citation 45% 

- Modification to the way the deficiency was written 19% 

- Deletion of cited deficiency 19% 

- Decrease in scope and severity level 6% 

- Increase in scope and severity level <1% 

Insufficient information provided in the letter 3% 

Source: OIG analysis of 347 paired nursing facility IDR requests and State IDR closure letters. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 12 
∆ R E C O M M E N D A T I O N S 


We found substantial State and nursing facility compliance with 

requirements for the IDR process. We also identified a few technical 

compliance issues as well as opportunities for improvements to the IDR 

process under CMS’s leadership. We recognize that our findings about 

IDR performance are statistically projectable only to the 14 selected 

States and their IDR cases. However, these findings would likely be 

useful for improving IDR processes in all States. The following 

recommendations and opportunities for improvement are offered to CMS 

as possible ways to help all States to strengthen their IDR policies and 

practices. 

RECOMMENDATIONS 

CMS should secure compliance of States’ IDR policies and practices 

with requirements by: 

Ensuring that all States have written IDR policies. Alaska and 

Connecticut do not technically comply with the requirement for having 

their own written IDR policies. Instead, these two States provide copies of 

the IDR portion of CMS’s “State Operations Manual” to nursing facilities 

requesting information. CMS should require the two States without the 

required written IDR policies to prepare them. Alternatively, CMS should 

review the two States’ practice to determine if it meets the requirement for 

a State to have a written IDR policy and if the “State Operations Manual” 

IDR section alone is sufficient to fully inform nursing facilities about the 

IDR process. 

Ensuring that States include all required information in their IDR 

notification letters to the nursing facilities. We found that the specific 

information required by the “State Operations Manual” regarding how 

and by whom the IDR review would be conducted is missing from State 

notification letters to varying degrees. To correct this, CMS could remind 

States, in writing, of the requirement for including this information, 

e.g., develop a template or standard notification letter for adaptation by 

the States, and periodically review States’ letters for inclusion of these 

requirements. 

OPPORTUNITIES FOR IMPROVEMENT 

We also noticed two areas for improvement of the IDR notification, 

request, and closure processes which are not compliance issues, but could 

improve the IDR process. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 13 
RECOMMENDATIONS 

Written IDR Policies. CMS may wish to consider emphasizing to all States 

the benefit of including all IDR requirements contained in regulation and 

the “State Operations Manual” in their own written policies, along with 

discussion of their individual State practices. While the actual content of 

States’ written policies is at the State’s discretion, the written policies are 

likely used by State staff in administering their IDR processes, as well as 

informing interested parties, such as nursing facilities. We found that at 

least 14 of 48 States’ written policies do not address what an IDR review 

cannot be used for. (See Appendix E.) Further, the “State Operations 

Manual” policy is unclear if States are required to include this information 

in their IDR notification letters to the nursing facilities. Twenty of fortyeight States’ written IDR policies do not include information indicating how 

facilities should be notified about the availability of the IDR process. 

We offer several options for CMS’s encouraging completeness of States’ 

written IDR policies: (1) share this report with States, emphasizing findings 

about written State policy; (2) suggest, in writing, that each State’s policy 

could benefit from incorporating the “State Operations Manual” IDR 

sections into their written policy; and (3) suggest, in writing, that States 

incorporate a sample State IDR notification letter into the written policy, 

which currently only four States (Arizona, Hawaii, Ohio, and Oklahoma) 

provide. 

Timeframe for States’ Completion of IDR Reviews. The IDR process can 

potentially save Federal, State, and facility dollars through the avoidance of 

a lengthy, formal appeal process. The nursing facility may file a formal 

appeal request within 60 days of the facility’s receipt of the formal notice of 

the imposition of any enforcement remedies resulting from the cited survey 

deficiencies, and we found that 80 percent of the IDR cases were completed 

within 60 days. To enhance the possibility that nursing facilities can avoid 

formal appeals by using the IDR process, CMS’s defining an explicit 

timeframe of something less than 60 days for IDR completion appears 

feasible and useful. Federal regulations and policy do not define “timely” 

completion of an IDR case, although the failure to complete an IDR review 

will not delay the effective date of any enforcement action against the 

nursing facility. At the same time, only 10 of 48 States’ IDR written policies 

identify self-imposed timeframe limitations for completing an IDR case. 

Another benefit of setting a time limit for IDR case completion is that until 

the case is completed, any deficiency citation under dispute is not placed on 

CMS’s Nursing Home Compare Web site. Lack of timeliness also 

compromises the integrity of the OSCAR system data. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 14 
RECOMMENDATIONS 

AGENCY COMMENTS 

CMS concurred with our recommendations and opportunities for 

improvement. The agency further commented they have already begun 

work to ensure that all States maintain written policies and that States 

review their policies for consistency with the minimum requirements 

listed in Federal regulations and the State Operations Manual. 

Furthermore, while CMS believes no immediate action is needed to 

specify a timeframe in which the IDR process must be completed, the 

agency has established it as a topic at the 2005 annual meeting with the 

State agencies. 

CMS also provided technical comments for which we made revisions 

where appropriate. The full text of CMS’s comments is presented in 

Appendix G. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 15 
∆ APPENDIX ~ A 

Inspection Methodology 

We used four sources of information in this inspection: 

o telephone interviews with all 50 State representatives having 

responsibility for their respective IDR processes, 

o written State IDR policies from 48 of 50 States, 

o cases with written documentation from a stratified random sample 

of IDR cases within 14 selected States, and 

o onsite visits with 6 of the 14 selected States. 

Telephone Interviews. We first interviewed the State representative for 

each of the 50 States. We used a standardized questionnaire to ask each 

about available written IDR policy and process. We also conducted 

subsequent follow-up discussions with IDR representatives from the 

14 selected States. We gathered information regarding how each State 

notifies nursing facilities of the availability of the IDR process and how it 

conducts the IDR review. 

Written State IDR Policies. We asked all 50 States to provide written 

documentation of their IDR processes; 48 of the 50 States provided the 

information. This documentation: (1) validated whether each State has 

the required written IDR policy and its availability upon request, and 

(2) provided the content of the written policies for review. As previously 

noted, Federal regulations and policy do not specify any requirements for 

the content of States’ written IDR policies. Nevertheless, for 

informational purposes, we reviewed the extent to which States’ written 

policies included IDR procedural requirements from the “State Operations 

Manual.” (See Table 1 on page 4.) 

Random Sample of IDR Cases within 14 Selected States 

There is no national listing of IDR cases from which to sample. Therefore, 

we used a two-step process to identify a group of States from which to 

sample the IDR cases: 

o identification of States having the highest number of deficiencies 

cited at E or above during calendar year (CY) 2002 standard 

surveys of nursing facilities12 and 

o determination of the number of nursing facilities in each of those 

States. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 16 
A P P E N D I X ~ A 

CMS classifies deficiencies cited by standard surveys of nursing facilities 

on a scale of A through L according to their scope and severity.13 The 

“severity” of the deficiency refers to the degree of harm, while the “scope” 

of the deficiency refers to the number of affected residents. 

We used CMS’s OSCAR system to identify for each State the total number 

of deficiencies cited during standard surveys of nursing facilities at scope 

and severity levels greater than or equal to E during CY 2002. We ranked 

this listing by State from highest to lowest number of deficiencies. We 

then identified the number of certified nursing facilities in each State. 

We selected States from highest to lowest number of deficiencies until we 

had selected States representing at least 50 percent of the nursing 

facilities nationwide. This resulted in our selection of 14 States, 

representing 62 percent of the total number of deficiencies cited at E or 

above, and 50 percent of the nursing facilities. These selected 14 States 

were California, Florida, Indiana, Kansas, Louisiana, Massachusetts, 

Michigan, Missouri, New York, Ohio, Oklahoma, Tennessee, Texas, and 

Washington.14 (See Appendix B.) 

To generalize to the 14 States, we treated each State as a separate 

stratum. The number of IDR cases sampled within each State was 

determined by the State’s population of IDR cases. If a State had 35 or 

fewer IDR cases, we sampled all of them. If a State had more than 

35 IDR cases, we randomly selected a sample of 35 cases. From our 

population of 893 IDR cases from the 14 selected States, we randomly 

chose a total of 415 cases for analysis. (For further details of the sample 

selection process, see Appendix C.) 

Data Collection. For each of the 415 sampled IDR cases, we requested case 

documentation from the States comprised of: 

o the State IDR notification letter to the nursing facility, 

o the nursing facility IDR request, and 

o the closure letter resulting from the completed IDR sent by the 

State to the nursing facility. 

We did not receive the same number of each of these three documents 

from the sampled cases. Only 4 of the14 selected States provided all the 

requested documentation. Across all 415 cases, we actually received 

documentation for 367 State notification letters to nursing facilities, 

371 nursing facility IDR requests, and 400 closure letters. Massachusetts 

provided no nursing facility IDR requests, only one of the requested 

notification letters, and all requested closure letters. While missing 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 17 
APPENDIX A APPENDIX A 

documentation limited our data analysis in some instances, we were able 

to make assumptions about the process, which we discuss below. (For 

details, see Appendix C.) 

Data Analysis. We examined documentation from the sampled IDR cases 

to determine State practice from three perspectives: (1) actual 

performance of the Federally required key steps in each IDR case, 

(2) the extent to which the IDR documentation incorporated the IDR 

requirements of the “State Operations Manual,” Section 7212, and (3) 

the total processing time and outcomes of cited deficiencies for the 

documented IDR cases. 

(1) Performance of the IDR steps for notification, request, and closure. 

We considered documentation for each of the IDR cases as 

confirmation that the IDR process steps of notification, request, and 

closure had occurred. In some cases documentation was missing for 

the IDR notification and subsequent request. We did receive 

documentation for 400 closure letters. Using the documentation 

received, we were able to infer that a certain step in the IDR process 

had probably occurred. For example, since a closure letter would 

not be generated unless an IDR had been requested, we assumed for 

the analysis that the notification and request had occurred. We 

concluded that of the 415 cases, there was a State notification letter 

for 413 cases and nursing facility requests for 412 cases, although 

we did not always see all of the documents. This was the only 

analysis for which we used inferred data. 

(2) Extent to which IDR case documentation incorporated the 

requirements of the “State Operations Manual,” section 7212. 

We compared the language of each of the three types of documents 

received for each IDR case to the “State Operations Manual” 

requirements. For this analysis, we used the documents we 

actually received, which consisted of 367 State notification letters to 

nursing facilities, 371 nursing facility IDR requests, and 400 State 

closure letters. 

We also compared the dates on the notification letters and nursing 

facility requests. This identified whether the nursing facility IDR 

requests were received within the same 10-calendar day period 

required for submitting an acceptable plan of correction to the State 

survey entity. Although the “State Operations Manual” requires 10 

days to respond, in our analysis, we used a conservative approach, 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 18 
APPENDIX A 

allowing 15 days total from the time a State notification letter was 

sent to the time the State received the IDR request. 

(3) Total IDR processing time for documented sample IDR cases and 

documented outcomes of cited/disputed deficiencies through the IDR 

process. 

Processing Time. Available documentation allowed us to match 347 

cases where we had both the IDR facility request and the State 

outcome letter. This subset of cases allowed us to calculate the 

number of days for completing the IDRs. 

IDR Outcomes. We compared the documented 400 IDR closure 

letters to their corresponding nursing facility IDR request letters to 

create a subset of 347 paired IDR cases documenting 1,211 

initially disputed deficiencies for which we could identify outcomes. 

Since our sampling frame did not include all 50 States, reported 

statistical estimates apply only to the 14 selected States. However, we 

believe the inspection’s findings will be informative to all States. These 

estimates and their confidence intervals were computed using SAS and 

SUDAAN statistical software packages. (See Appendix D for confidence 

intervals.) 

Onsite State Visits. We conducted on-site visits with 6 of the 14 selected 

States to better understand their IDR processes. We met with managers 

and staff who provided us with a “walk through” of their IDR processes. In 

some instances, we attended actual in-person and telephone conferences, 

which followed the initial desk reviews. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 19 
OEI. 06. 02. 00750

Calendar Year 2002 State Nursing Facilty IDR Requests

According to the 14 selected States, 5,042 standard surveys for nursing

facilities were conducted in CY 2002. Ofthese, the States initially

identified that 934 resulted in an IDR request from the nursing facilties.

From this 934, we drew an initial sample of 437 for review.

Subsequently, the 14 States conducted a second review of the 437 and

identified that 22 ofthese, from 8 ofthe 14 States, were incorrectly

reported as resulting in an IDR request, therefore resulting in a usable

sample of 415 cases.

To estimate the reduced population of IDR cases in the 14 selected States

we used the sample proportion of actual IDR cases within the 8 States

where the State incorrectly reported the number of cases. Therefore, we

assumed that in each of the eight States, the original population would be

reduced by the same proportion as the sample. This resulted in 893

CY 2002 IDR requests for the 14 selected States as shown in Appendix C.

Nursing Facilty IDR Requests by State for CY 2002 Surveys Citing

Deficiencies at Scope and Severity Levels of E or Higher

Number of IDRs Initially Adjusted Adjusted Percent

States CY 2002 Identified as Number of IDRs of Surveys

Surveys Requested Requested Resulting in IDR

(unadjusted) Requests

California 656

Florida 557 10%

Indiana 276 19%

Kansas 217 25%

Louisiana 235 11%

Massachusetts 225 15%

Michigan 300 21%

Missouri 342

New York 436 137 125 29%

Ohio 546 192 187 34%

Oklahoma 205 15%

Tennessee 226 15%

Texas 627 153 153 24%

Washington 194 27%

TOTAL 042 934 893 18%

Source: OIG OSCAR extract for CY 2002.

INFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES
∆ APPENDIX ~ C APPENDIX ~ D APPENDIX ~ C 

Calculated Weights for Selected States’ IDR Cases* 

States 

Adjusted Number of 

IDRs Requested for 

CY 2002 Surveys 

(A) 

Sampled IDR Cases 

(B) 

Calculated Weights 

(A/B) 

California* 15 15 1.00 

Florida* 55 32 1.72 

Indiana 53 35 1.51 

Kansas* 54 32 1.69 

Louisiana 26 26 1.00 

Massachusetts 33 33 1.00 

Michigan* 64 34 1.88 

Missouri* 12 12 1.00 

New York* 125 32 3.91 

Ohio* 187 34 5.44 

Oklahoma 30 30 1.00 

Tennessee* 34 30 1.13 

Texas 153 35 4.37 

Washington 52 35 1.49 

TOTAL 893 415 2.15 

* The 14 selected States initially identified 934 surveys resulting in IDR requests. A second review of the requested 

sample of 437 IDRs by these 8 States showed they had incorrectly reported 22 surveys that resulted in an IDR 

request. This lowered the number of surveys, from which the 415 sampled IDR cases were drawn, from 934 to 

893 (weighted). 

Source: OIG analysis of State-provided documentation for requested IDR cases. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 21 
∆ APPENDIX ~ D 

Point Estimates and Confidence Intervals for IDR Requirements 

“State Operations Manual”-Requirements 

Percent Affirmative 

Response Point 

Estimate 

(weighted)* 

Percent (+/-) 

Confidence 

Interval 

State IDR Notice 

State notifies nursing facilities of IDR availability in the letter from the 

State transmitting the official Form CMS-2567, Statement of Deficiencies. 

100 (n = 367) N/A 

Notice informs facility that the request must: 

a. be in writing, 

b. be submitted within the same 10-calendar day period as plan of 

correction, and 

c. include an explanation of the specific deficiencies disputed. 

100 (n = 367) 

100 (n = 367) 

100 (n = 367) 

N/A 

N/A 

N/A 

Notice informs facility of : 

a. how the IDR may be accomplished; 

b. the name, address, and telephone number of contact person for 

requesting the IDR; and 

c. the name and/or position title of the person who will conduct the IDR, 

if known. 

37 (n = 331) 

93 (n = 365) 

6 (n = 364) 

1.3 

0.5 

0.7 

State agency will notify the nursing facility in writing if the IDR outcome is 

not in the facility’s favor. 22 (n = 361) 1.4 

Notice includes that the request must not be used to: 

a. delay the formal imposition of remedies, 

b. challenge the scope and severity of cited deficiencies, 

c. challenge the imposed remedies for cited deficiencies, 

d. allege failure of survey team to comply with survey requirements, 

e. allege inconsistency of survey team citing deficiencies among 

facilities, and 

f. allege inadequacy or inaccuracy of the IDR process. 

72 (n = 367) 

50 (n = 367) 

18 (n = 367) 

36 (n = 367) 

36 (n = 367) 

18 (n = 367) 

0.9 

0.9 

0.7 

0.9 

0.9 

0.7 

Nursing Facility IDR Request 

Request was submitted in writing. 99.8 (n = 371) 0.2 

Request was submitted within the same 10-calendar day period as plan of 

correction.* 86 (n = 343) 3.3 

Request included an explanation of the disputed deficiencies. 86 (n = 349) 1.8 

Request provided correct reasons for requesting the IDR. 

(Of 9 percent not requesting correctly, attempted to 

challenge deficiency scope and severity.) 

91 (n = 284) 

(100 [n = 33]) 

2.7 

(N/A) 

State Closure Letter 

Closure letter was provided to facility, regardless of IDR outcome. 99.9 (n = 400) 0.1 

1,211 Deficiencies Disputed 

No change in deficiency citation. 52.2 (n = 1,211) 0.04 

Changes in deficiency citation: 

a. modification to how deficiency was written, 

b. increase in scope and severity level, and 

c. decrease in scope and severity level. 

25.7 (n = 1,211) 

(74.3) 

(1.5) 

(24.2) 

0.03 

Deletion of cited deficiency. 18.9 (n = 1,211) 0.03 

Insufficient information on disputed deficiency IDR outcome. 3.1 (n = 1,211) .008 

* Weighted responses for affirmative responses are for received documentation and do not include in the calculation 

any missing documentation. 

Source: OIG analysis of State-provided documentation for requested IDR case documentation. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 22 
∆ APPENDIX ~ E 

Requirements Included in States’ Written IDR Policies 

“State Operations Manual”-Requirements Number of 

States 

The State will notify the facilities of the availability of an IDR in the letter from the State 28 

transmitting the official Form CMS-2567, Statement of Deficiencies. 

Notification should inform the facility that the request must: 

a. be in writing, 44 

b. be submitted within the same 10-calendar-day period as for submitting an 43 

acceptable plan of correction to the State surveying entity, and 

c. include an explanation of the specific deficiencies being disputed. 41 

Notification should also 

a. inform the facility how the IDR may be accomplished (e.g., by telephone, in writing, 39 

or in a face-to-face meeting); 

b. inform the facility of the name, address, and telephone number of the contact 35 

person for requesting the IDR; and 

c. include the name and/or position title of the person who will conduct the IDR, if 42 

known. 

State survey entity must notify the nursing facility in writing if the facility is unsuccessful 41 

at demonstrating during the IDR that a deficiency should not have been cited. 

The facility request must not be used to: 

- delay the formal imposition of remedies; 

- challenge the scope and severity of cited deficiencies, except in those instances 

when the cited deficiency constitutes substandard quality of care or immediate 

jeopardy; 

- challenge the remedies imposed by the enforcing agency for cited deficiencies; 

- allege failure of the survey team to comply with the survey process requirements; 

- allege inconsistency of the survey team citing deficiencies among facilities; and 

- allege inadequacy or inaccuracy of the IDR process. 

34 

33 

31 

30 

32 

29 

Source: OIG analysis of 48 States’ written IDR policies describing procedures. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 23 
∆ APPENDIX ~ F 

Additional Information in Written State IDR Policies 

Number of 

Additional State IDR Practices in Written Policies States 

(n = 48) 

Indicates conducting desk reviews of submitted documentation concerning disputed 

deficiencies. 48 

Specifies a maximum amount of time permitted for the in-person or telephone 

conferences. 13 

Limits attendance at in-person conferences. 12 

Defines the amount of time in which a decision must be made from the date of the 10 request. 

Prohibits attorney presence at IDRs. 7 

In-person conferences will be held based on the scope and severity levels of 

deficiencies under dispute. 7 

Provides conditions for overturning or deleting deficiencies. 6 

Limits IDRs to record reviews with no subsequent conferences. 5 

Telephone conferences will be held based on the scope and severity levels of 

deficiencies under dispute. 5 

Requires prior approval for attendees to in-person conferences. 3 

No IDR conference will be held for any deficiencies cited at scope and severity levels of 

C or below. 2 

In-person conferences will be the only means by which an IDR will be held. 2 

Source: OIG analysis of State written IDR processes. 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 24 
∆ APPENDIX ~ G APPENDIX ~ G 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 25 
APPENDIX~G

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 26 
APPENDIX~G

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 27 
APPENDIX~G

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 28 
∆ ACKNOWLEDGMENTS 


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

Inspector General for Evaluation and Inspections in the Dallas regional 

office, and Kevin Golladay, Assistant Regional Inspector General. Other 

principal Office of Evaluation and Inspections staff who contributed 

include: 

Leah K. Bostick, P oj er r ect Lead

Diahann L. Williams, Program Analyst 

Sandy Khoury, Program Specialist 

Technical Assistance: 

Barbara Tedesco, Mathematical Statistician

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 29 
∆ END NOTES 


1 42 CFR Part 488, Subpart F, Enforcement of Compliance for Long-Term 

Care Facilities with Deficiencies, and “State Operations Manual” 

Chapter 7, Survey and Enforcement Process. 

2 The State agency is required to provide written outcome information to 

the nursing facility only when the provider has been unsuccessful in its 

dispute of the deficiency. 

3 Within each State’s Internet site, we conducted a search for information 

regarding the State IDR processes. As of February 2004, only 14 of 

50 States have specific IDR process information available to the public: 

Idaho, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, 

Montana, North Carolina, New Jersey, Pennsylvania, Texas, 

Washington, West Virginia, and Wisconsin. Twenty-seven of fifty 

States have incorporated an IDR process into their written State law or 

regulation. 

u n a 4 Thompson Publishing Group, Nursing Home Reg latio s M nual, 

Tab 900, State Licensing and Enforcement; pp. 41-62, May 2001. 

5 42 CFR § 488, Enforcement of Compliance for Long-Term Care 

Facilities with Deficiencies, and “State Operations Manual” Chapter 7. 

6 “The Active Projects Report, 2002 Edition” (number 00-175), 

“Evaluation of Independent Informal Dispute Resolution Process 

(IDR),” and ongoing conversations with CMS Project Officer. 

7 Texas Assisted Living Association, TALA Update, March/April 2002. 

8 American Association of Facilities and Services for the Aging, Health 

Policy Bulletin (Web article), CMS S l cts Stat e e es to Partic e in IDR ipat

P oj r ect, September 24, 2001. 

9 As encouraged by “State Operations Manual,” section 7212 C(9). 

10 We used a chi-square statistic to determine whether the responses to 

the question asking if the State notification letter includes the 

required reasons for not requesting an IDR was significantly related to 

OEI-06-02-00750 I NFORMAL DISPUTE RESOLUTION FOR NURSING FACILITIES 30 
the responses to the question asking if the nursing facility 

appropriately (or inappropriately) requested an IDR. The probability 

of error threshold is less than or equal to 0.05; thus, the distribution is 

significant. 

11 The more restrictive definition of the 10-calendar day period starts 

from the date on the notice letter or from the survey exit conference. 

12 While there is not a one-to-one relationship between the number of 

 IDRs and the number of nursing facility standard surveys in each 

 State, we believe this represents a good approximation of which States 

 may have a high volume of IDRs. We also believed that nursing 

 facilities with higher levels of scope and severity ratings for their 

 deficiencies may be more apt to request an IDR; 70 percent of the State 

 respondents subsequently concurred. 

13 The following table was developed by CMS to provide clarity regarding 

 severity and scope levels for cited nursing facility surveys. 

Severity and Scope of Nursing Facility Survey Deficiencies 

Severity Category* 

Deficiency Scope 

Isolated Pattern Widespread 

Actual or potential for death or serious injury (immediate 

jeopardy) J K L 

Actual harm that is not immediate jeopardy G H I 

Potential for more than minimal harm D E F 

Potential for minimal harm, substantial compliance exists A B C 

* A fifth severity category, “substandard quality of care,” includes deficiencies in the areas of patient behavior 

and facility practices, quality of life, and quality of care. These fall into the shaded categories above. 

Source: Centers for Medicare & Medicaid Services, Form HSQ-156-F 

14 Office of Inspector General, Office of Evaluation and Inspections, 

Technical Support Staff’s extract of the OSCAR system on 

July 28, 2003, for CY 2002. Of the initial 14 States, 1 State 

(Pennsylvania) indicated during preinspection that it would be unable 

to participate. As this was a purposive sample, and in the interest of 

resource limitations, we subsequently replaced that State with the 15th 

State on our list. 

O E I - 0 6 - 0 2 - 0 0 7 5 0 I N F O R M A L DI S P U T E RE S O L U T I O N F O R NU R S I N G FA C I L I T I E S 31