GAO

United States General Accounting Office

Report to Congressional Requesters

September 2000 NURSING HOMES

Sustained Efforts Are

Essential to Realize

Potential of the

Quality Initiatives

GAO/HEHS-00-197

Page 1 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Contents

Letter 5

Results in Brief 6

Background 8

Progress Made in Improving Annual Surveys, but Measuring the

Effect Is Problematic 11

Complaint and Enforcement Processes Are Improving, but States

Report Fiscal Year 1999 Federal Initiatives Funding Was Largely

Unspent 21

Improvements Continue in Federal Oversight of State Survey

Activities 36

Conclusions 44

Agency Comments and Our Evaluation 45

Appendixes Appendix I: Implementation Chronology for Key Nursing Home

Quality Initiatives 48

Appendix II: State Survey Findings for Periods Before and After the

Administration's Nursing Home Initiatives 50

Appendix III: State Efforts to Address Nursing Home Staffing

Shortages 53

Appendix IV: Additional Information on Federal Oversight

Activities 59

Appendix V: Comments From the Health Care Financing

Administration 63

Appendix VI: Comments From California's Department of Health

Services 66

Appendix VII: Comments From Michigan's Department of Consumer

and Industry Services 70

Appendix VIII:Comments From Missouri's Department of Social

Services 74

Appendix IX: Comments From Washington's Department of Social

and Health Services 81

Appendix X: GAO Contact and Staff Acknowledgments 82

Related GAO Products 83
Contents

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Tables Table 1: Scope and Severity of Deficiencies 9

Table 2: Predictable Surveys for Nursing Homes in Six States 15

Table 3: Examples of Planned State Funding Increases to Hire

Additional Surveyors and Enhance Oversight of Nursing

Homes 16

Table 4: Homes With Actual Harm and Immediate Jeopardy

Deficiencies Before and After Implementation of the

Quality Initiatives 18

Table 5: State Investigative Time Frames for Complaints Prior

to the Initiatives and Extent to Which States Meet the

10-Day Requirement for Actual Harm 22

Table 6: Federal Medicare and Medicaid Funding for State Survey

and Certification Activities 26

Table 7: Summary of Information Provided by Nine States on Their

Fiscal Year 1999 Nursing Home Initiatives Allocation 28

Table 8: Comparison of Pending Appeals and Increased Staffing

at the Departmental Appeals Board 33

Table 9: Comparison of Per-Instance and Per-Day Fines for Fiscal

Year 2000, as of August 8, 2000 34

Table 10: HCFA Analysis of OSCAR Data and Comparative Surveys

Could Have Raised Questions About the Performance of

Oklahoma’s State Survey Agency 40

Table 11: HCFA Analysis of Available Data Could Have Raised

Questions About the Performance of Missouri’s State Survey

Agency 41

Table 12: Results of Federal Surveys of 16 Nursing Homes in

Oklahoma 43

Table 13: Implementation Chronology for Key Nursing Home

Initiatives 48

Table 14: Percentage of Homes at Each Deficiency Level Before

and After the Nursing Home Initiatives, by State 51

Table 15: States With Programs to Address Nursing Home

Staff Shortages 53

Table 16: GAO Analysis of the Results of Federal Comparative

Surveys Conducted Between October 1998 and May 2000 60

Table 17: New State Performance Standards, Relationship to SAQIP,

and Federal Evaluation Data Sources 61
Contents

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Figures Figure 1: Comparison of State and Federal Quality-of-Care

Deficiencies for 16 Nursing Homes in Oklahoma 62

Abbreviations

CPR cardiopulmonary resuscitation

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

OSCAR On-Line Survey, Certification, and Reporting System

SAQIP State Agency Quality Improvement Program
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United States General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-284751 Letr

September 28, 2000

The Honorable Charles E. Grassley

Chairman

The Honorable John B. Breaux

Ranking Minority Member

Special Committee on Aging

United States Senate

The Honorable Christopher S. Bond

United States Senate

Since 1997, the Senate Special Committee on Aging has focused

considerable attention on the need to improve the quality of care for the

nation’s 1.6 million nursing home residents, a highly vulnerable population

of elderly and disabled individuals. In a series of reports and testimonies

prepared at the Committee’s request, we found significant weaknesses in

federal and state survey and oversight activities designed to detect and

correct quality problems.1 For example, we reported that about 15 percent

of the nation’s 17,000 nursing homes—an unacceptably high number—

repeatedly had serious care problems that caused actual harm to residents

or placed them at risk of death or serious injury (immediate jeopardy). Our

key findings on the nursing home survey process included the following:

• The results of state surveys understated the extent of serious care

problems, reflecting procedural weaknesses in the surveys and their

predictability.

• Serious complaints by residents, family members, or staff alleging harm

to residents remained uninvestigated for weeks or months.

• When serious deficiencies were identified, federal and state

enforcement policies did not ensure that the deficiencies were

addressed and remained corrected.

• Federal mechanisms for overseeing state monitoring of nursing home

quality were limited in their scope and effectiveness.

Concurrent with the Committee’s July 1998 hearing, the President

announced a series of initiatives intended to address many of the

1

See related GAO products listed at the end of this report.
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weaknesses we identified. Since that time, the Administration has

expanded the number of initiatives to about 30 and the Congress has

appropriated additional funds to support the increased workload

associated with implementing the initiatives. To determine the effect of the

initiatives, you asked us to assess (1) progress in improving the detection

of quality problems and changes in measured nursing home quality, (2) the

status of efforts to strengthen states’ complaint investigation processes and

federal enforcement policies, and (3) additional steps taken at the federal

level to improve oversight of states’ quality assurance activities.

In conducting our review, we analyzed data from the federal On-Line

Survey, Certification, and Reporting (OSCAR) System, which compiles the

results of state nursing home surveys. We visited California, Missouri,

Tennessee, and Washington, interviewing officials in state survey agencies

and their district offices.2 California and Missouri represented states that

were about average in terms of the number of actual harm and immediate

jeopardy deficiencies cited in state surveys prior to the initiatives.

Tennessee represented the low end of the range and Washington the high

end. We also contacted officials in Maryland and Michigan, states that were

included in our prior work. In addition, we interviewed Health Care

Financing Administration (HCFA) officials at both headquarters and

regional offices. HCFA, an agency within the Department of Health and

Human Services (HHS), is responsible for ensuring that each state

establishes and maintains the capability to periodically survey nursing

homes that receive federal payments in order to ensure that the homes

provide quality care to residents. Finally, we reviewed relevant documents

from both state agencies and HCFA. We conducted our review from

January to August 2000 in accordance with generally accepted government

auditing standards.

Results in Brief Overall, the introduction of the recent federal quality initiatives has

generated a range of nursing home oversight activities that need continued

federal and state attention to reach their full potential. The states are in a

period of transition with regard to the implementation of the quality

2

State surveyors are typically assigned to local district offices (sometimes referred to as

regional offices) that are responsible for conducting nursing home surveys and complaint

investigations. In Missouri, separate state offices are responsible for overseeing hospitalbased and all other nursing homes. We focused our work on the Missouri office that

oversees the approximately 85 percent of all nursing homes that are not hospital-based.
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initiatives, in part because HCFA is phasing them in and in part because

states did not begin their efforts from a common starting point. Efforts at

the federal level toward improving the oversight of states’ quality assurance

activities have commenced but are unfinished or need refinement.

Federal initiatives were introduced to strengthen the rigor with which

states conduct required annual nursing home surveys. The states we visited

have begun to use the new methods introduced by the initiatives to spot

serious deficiencies when conducting surveys, but HCFA is still developing

important additional steps that may not be introduced until 2002 or 2003.

Likewise, efforts to reduce the predictable timing of the surveys—that is, to

minimize the opportunity for homes so inclined to cover up problems—

have been modest to date. To measure the effect of the survey process

improvements, we analyzed the change in the number of nursing homes

cited for serious deficiencies in the periods before and after the

introduction of the quality initiatives. Our results showed a marginal

increase nationwide in the proportion of homes with documented actual

harm and immediate jeopardy deficiencies, although there was

considerable variation across states, with some states experiencing a

decrease in homes with these deficiencies. These results suggest that states

may have become more rigorous in their identification and classification of

serious deficiencies. The results could also indicate that the volume of such

deficiencies has actually increased slightly nationwide, a situation

consistent with states’ heightened concerns about potential facility staff

shortages during this same time period.

The states we contacted also have made strides in improving their

investigations of and follow-up to complaints, but not enough time has

elapsed to consider these efforts complete. For example, the states in our

review were not yet investigating all complaints that allege actual harm to a

resident within 10 days, as HCFA now requires, but were working toward

that goal by hiring additional surveyors to staff the investigations,

establishing procedures that make it easier to file complaints, or

developing new tracking systems to improve their oversight of complaint

investigations by local district offices. For some states, the provision of

federal funding to support the nursing home initiatives came too late in the

state budget cycle for agencies to capitalize on the additional funds for

fiscal year 1999. HCFA also has strengthened the enforcement tools

available to sanction nursing homes that are cited for actual harm and

immediate jeopardy violations, but too little time has elapsed to assess the

application of these tools. Early indications from some states are that their

referrals of homes to HCFA for sanctions are on the rise. Finally, additional
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funds were provided in fiscal years 1999 and 2000 to hire new HHS staff in

order to reduce the large number of pending appeals by nursing homes and

to collect assessed fines faster. The expectation is that the more

expeditious resolution of appeals will heighten the deterrent effect of civil

fines. It is too early to assess the effect of the additional funding on the

number of pending appeals because the new staff were only hired within

the past year and other changes in enforcement policy are expected to

increase the volume of nursing home appeals.

To improve nursing home oversight at the federal level, HCFA has made

recent organizational changes to address past consistency and

coordination problems between its central office and 10 regional offices. It

also intends to intensify its use of management information data systems

and reports to verify and assess states’ oversight activities and view more

closely the performance of the homes themselves. Our review showed that

an examination of previously available information could have identified

shortcomings in a state’s survey activities even before they came to light as

the result of a criminal investigation.

Background Oversight of nursing homes is a shared federal and state responsibility. On

the basis of statutory requirements, HCFA defines standards that nursing

homes must meet to participate in the Medicare and Medicaid programs

and contracts with states to assess whether homes meet these standards

through annual surveys and complaint investigations. The “annual”

standard survey, which must be conducted on average every 12 months and

no less than once every 15 months at each home, entails a team of state

surveyors spending several days in the home to determine whether care

and services meet the assessed needs of the residents and whether the

home is in compliance with long-term-care facility requirements. HCFA

establishes specific protocols, or investigative procedures, for state

surveyors to use in conducting these comprehensive surveys. In contrast,

complaint investigations, also conducted by state surveyors but following

the individual state’s procedures, within certain federal guidelines and time

frames, typically target a single area in response to a complaint filed

against a home by a resident, the resident’s family or friends, or nursing

home employees. Quality-of-care problems identified during either

standard surveys or complaint investigations are classified in one of 12

categories according to their scope (the number of residents potentially or

actually affected) and their severity. An A-level deficiency is the least

serious and is isolated in scope, while an L-level deficiency is the most
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serious and is considered to be widespread in the nursing home (see table

1). At some homes, state surveyors identify no deficiencies.

Table 1: Scope and Severity of Deficiencies

a

Actual or potential for death/serious injury.

b

Nursing home is considered to be in “substantial compliance.”

Ensuring that documented deficiencies are corrected is likewise a shared

responsibility. HCFA is responsible for enforcement actions involving

homes with Medicare certification—about 86 percent of all homes.3 The

scope and severity of a deficiency determines the applicable enforcement

action and whether it is optional or mandatory. Enforcement actions can

involve, among other things, requiring corrective action plans; monetary

fines; denying the home Medicare and Medicaid payments; and, ultimately,

terminating the home from participation in these programs. Sanctions are

imposed by HCFA on the basis of state referrals. HCFA normally accepts a

state’s recommendations for sanctions or other corrective actions but can

modify them. Before a sanction is imposed, federal policy generally gives

nursing homes a grace period of 30 to 60 days to correct a deficiency. States

may also use their state licensure authority to impose state sanctions, and

some prefer to do so because they may impose them immediately, without

giving the home a grace period to correct the deficiency.4 States are

responsible for enforcing standards in homes with Medicaid-only

certification—about 14 percent of the total. They may use the federal

Scope

Severity Isolated Pattern Widespread

Immediate jeopardya J KL

Actual harm G H I

Potential for more than minimal harm D E F

Potential for minimal harmb ABC

3

Included in this percentage are homes certified for both Medicaid and Medicare.

4

If a state has a unique enforcement sanction, it may obtain HCFA approval to use it in lieu

of a federal remedy. The state must satisfy HCFA that its sanction is as effective as a federal

remedy in deterring noncompliance and correcting deficiencies. In addition, state sanctions

must meet several general requirements, including timing and notice requirements in federal

regulations and, according to HCFA, consistency with statutory intent.
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sanctions or rely upon their own state licensure authority and nursing

home sanctions.

HCFA also is responsible for overseeing each state survey agency’s

performance in ensuring quality of care in its nursing homes. Its primary

oversight tools are the federal comparative and observational surveys

conducted annually in at least 5 percent of the nation’s certified Medicare

and Medicaid nursing homes. A comparative survey involves a federal

survey team conducting a complete, independent survey of a home within 2

months of the completion of a state’s survey in order to compare and

contrast the findings.5 In an observational survey, one or two federal

surveyors accompany a state survey team to a nursing home to watch the

team conduct survey tasks, give immediate feedback, and later rate the

team’s performance. The vast majority of federal surveys are observational.

Additionally, in 1996 HCFA initiated the State Agency Quality Improvement

Program (SAQIP), which requires states to self-report their compliance

with seven performance standards and to implement quality improvement

plans to address any deficiencies identified in their survey processes.

In its federal monitoring role, HCFA directs the states’ implementation of

the Administration’s nursing home initiatives, which are intended to

improve nursing home oversight and quality of care. Many of the initiatives

address previous problems identified by us, HCFA, and others. This report

focuses on selected initiatives from the following three areas:

• Improving nursing home reviews. These initiatives are intended to

strengthen states’ periodic surveys and complaint investigations,

enabling surveyors to better detect quality-of-care deficiencies.

• Ensuring compliance. These initiatives are intended to ensure that

homes with serious deficiencies or homes that repeatedly cause harm to

residents promptly correct deficiencies and sustain compliance with

federal requirements thereafter.

• Improving federal monitoring. These initiatives are intended to ensure

that HCFA and its regional offices use appropriate oversight

mechanisms and data systems to assess the effectiveness of states’

survey activities.

5

The Omnibus Budget Reconciliation Act of 1987 requires HCFA to conduct comparative

surveys within 2 months of states’ surveys. In August 1999, HCFA urged its regional offices

to commence comparative surveys within 14 to 28 days after a state’s survey.
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Appendix I provides a chronology of and summarizes the key quality

initiatives discussed in this report. Though many initiatives were

announced in July 1998, some important changes were not implemented

until the second half of 1999 and others are still in the planning phase.

Progress Made in

Improving Annual

Surveys, but Measuring

the Effect Is

Problematic

HCFA and the six states we contacted have taken important steps toward

improving the rigor of nursing home surveys. HCFA has begun a major

redesign of its nursing home survey methodology, but only phase one of the

overall plan has been implemented by state survey agencies. When phase

two is completed, HCFA should have significantly improved the tools for

effectively identifying the scope and severity of care problems. However,

the second phase is not expected to be implemented until 2002 or 2003.

Despite the progress to date in improving surveyors’ ability to detect

deficiencies, the timing of nursing home surveys in some states continues

to be predictable, allowing facilities to mask certain deficiencies if they

choose to do so. Recognizing the need for self-improvement in the type and

extent of oversight, the states we visited are beginning to identify and

address other weaknesses in the survey process not covered by the

Administration’s initiatives. Consistent with the expectation that

improvements in the survey process would lead to the identification of

more problems, the proportion of homes with serious deficiencies

increased in many states after the introduction of survey methodology

improvements. Although the identification of more deficiencies could be

the result of better detection, growing reports of problems with nursing

home staffing raise concerns that the actual proportion of homes with

deficiencies may have increased. This possibility underscores the

importance of adequate federal and state oversight of nursing homes.

Survey Methodology

Strengthened and Further

Improvements Are in the

Planning Phase

Annual standard surveys provide states the opportunity to systematically

and comprehensively assess nursing home quality. In our prior work, we

found that surveyors often missed significant care problems—such as

pressure sores, malnutrition, and dehydration—because the methods they

used lacked sufficient rigor.6 In addition, problems went undetected

because nursing homes were able to predict the timing of their next survey

6

California Nursing Homes: Care Problems Persist Despite Federal and State Oversight

(GAO/HEHS-98-202, July 27, 1998).
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and, if so inclined, conceal problems such as routinely having too few staff

to care for residents.

Sampling Methodology In response to survey methodology weaknesses, HCFA planned a twophase revision of the survey process. Phase one introduced a new tool to

help surveyors do a better job of selecting a resident sample, instructed

states to increase the sample size in areas of particular concern, and

required the use of investigative protocols intended to make the survey

process more systematic. Still in the planning stages, phase two

improvements will tackle problems that remain, such as ensuring rigor in

the augmentation of the initial sample selected off-site and improving the

thoroughness of the on-site investigations.

Surveyors’ assessment of the quality of care provided to a sample of

residents serves as the basis for evaluating nursing homes. Effective July

1999, HFCA instructed state survey agencies to begin using “quality

indicators” to review information on the care provided to a home’s

residents before actually visiting the home. Quality indicators are

essentially numeric warning signs of the prevalence of care problems, such

as greater-than-expected instances of weight loss, dehydration, or pressure

sores. They are derived from nursing homes’ assessments of residents and

rank a facility in 24 areas compared with other nursing homes in the state.7

By using the quality indicators to select a preliminary sample of residents

before the on-site review, surveyors are better prepared to identify

potential care problems.8 Surveyors augment this preliminary sample with

additional resident cases once they arrive at the nursing home. In

conjunction with the introduction of quality indicators, HCFA also

instructed surveyors to (1) increase the sample size in areas such as

maintaining proper body weight (nutrition), fluid intake (dehydration), and

pressure sores and (2) begin using a series of investigative protocols in

these and other areas. The protocols are procedural instructions intended

to provide greater standardization and make the on-site surveys thorough.

7

Quality indicators were the result of a HCFA-funded project at the University of Wisconsin.

The developers based their work on nursing home resident assessment information known

as the minimum data set—data that all homes are required to report to HCFA. See Center for

Health Systems Research and Analysis, Facility Guide for the Nursing Home Quality

Indicators (University of Wisconsin-Madison: Sept. 1999).

8

Prior to the introduction of quality indicators, selection of the sample was less systematic,

relying on a listing of residents and their conditions maintained at the nursing home and on

observation of residents made during a walk-through of the facility.
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Our prior work noted that the sample typically included an insufficient

number of different types of resident cases to adequately identify serious

quality problems.

The need to provide training in the use of quality indicators to the

approximately 3,500 state nursing home surveyors delayed

implementation. HCFA held four training sessions for about 800

supervisory-level staff—state survey directors, state trainers, and lead

surveyors—during April through June 1999. In turn, these individuals

trained surveyors in their local offices.

Though the use of quality indicators and protocols introduced more rigor

into the survey process, they are not a panacea for all survey methodology

problems. Because the basis for quality indicators is self-reported data by

nursing homes, there needs to be confidence that the data are accurate. In

addition, some portion of the residents selected using the quality indicators

may no longer be in the nursing home—a problem frequently identified by

the surveyors we interviewed. These problems highlight the importance of

on-site augmentation of the sample. Finally, the current protocols are a

starting point, but additional steps need to be taken to ensure that

surveyors thoroughly and systematically assess the care areas targeted

using the quality indicators.

To address these remaining problems with sampling and the investigative

protocols, HCFA is planning a second revision of its survey methodology to

be implemented in 2002 or 2003. The focus of phase two is (1) improving

the on-site augmentation of the preliminary sample selected off-site using

the quality indicators and (2) strengthening the protocols used by

surveyors to ensure more rigor in their on-site investigations. We continue

to believe that implementation of this phase is necessary for HCFA to fully

respond to our recommendation to significantly improve the ability of

surveys to effectively identify the existence and extent of deficiencies.

Survey Predictability To address the predictability problem, HCFA required states to start at least

10 percent of standard surveys outside the normal workday—either on

weekends, in the early morning, or in the evening—beginning January 1,

1999. HCFA also instructed the states to avoid, if possible, scheduling a

home’s survey for the same month as the one in which the home’s previous

standard survey was conducted.
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Tracking states’ progress in implementing surveys that begin outside the

normal workday has been problematic for HCFA. The agency did not

modify its data system to allow states to identify such surveys in OSCAR

until August 1999—8 months after the requirement to conduct such surveys

was implemented. In February 2000, HCFA instructed states to begin

identifying off-hours surveys in OSCAR for those conducted on or after

October 1, 1999. HCFA data for the period October 1, 1999, through June

30, 2000, indicate that nationally about 10 percent of surveys were started

outside normal working hours. However, in August 2000, HCFA sent letters

to states performing well below the 10-percent target, reminding them of

the requirement, asking them to confirm the accuracy of OSCAR data, and

asking how they intend to increase their percentage of off-hour surveys.9

Though varying the starting time of surveys may be beneficial, this

initiative is too limited in reducing survey predictability. Our analysis of the

most current survey data shows that between 29 percent and 56 percent of

the surveys conducted in six states were predictable (see table 2). Many

surveys could be viewed as being predictable because they were conducted

within a month of the 15-month limit between annual surveys. As the 15-

month limit approaches, homes are aware that the survey will soon occur.

Both California and Maryland officials attributed delays in conducting

annual surveys to the increased emphasis on investigating complaints more

promptly, which required delaying many annual surveys. In fact, a third of

the surveys in Maryland as well as 10 percent of California and 7 percent of

Michigan surveys were late—that is, conducted after the 16th month.

Surveys that occur at nearly the same time each year may also be

considered predictable. As table 2 shows, over half the surveys in

Tennessee were conducted within 15 days of the anniversary of the

previous standard survey. Tennessee officials told us that their

predictability problem resulted in large part from a state law requiring

homes to be surveyed at least every 12 months instead of the maximum 15

months permitted by federal law.10 We continue to believe that our July

1998 recommendation to make annual surveys less predictable by

segmenting them into more than one review throughout the year has merit.

9

States still have the opportunity to meet the 10-percent requirement by performing more

than 10 percent of surveys off-hours during the remainder of the fiscal year.

10In May 2000, Tennessee modified this law to permit homes to be surveyed at a maximum

interval of 15 months.
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Such an approach would give surveyors more opportunities to observe

problematic homes and initiate broader reviews when warranted.

Table 2: Predictable Surveys for Nursing Homes in Six States

Note: Data were extracted from OSCAR in August 2000. Homes not showing a prior survey date were

not included in this analysis.

a

For the “15-day” analysis, we included homes whose current survey was conducted between 15 days

preceding and 15 days following the 1-year anniversary of the prior survey.

b

For Missouri, hospital-based nursing homes were excluded (see footnote 2).

State Initiatives States are also undertaking their own initiatives to improve the survey

process. In some cases, these changes are under way but not complete.

Some states plan to hire new surveyors (see table 3) and have made efforts

to improve the monitoring of their local survey offices. California plans to

hire 200 new surveyors in 2000 in order to increase the frequency and

unpredictability of surveys and to expand its oversight of poorly

performing homes. In Maryland, the number of surveyors is projected to

reach 59 by January 2001—a 100-percent increase since July 1999. Prior to

the initiatives, local district offices in California had generally operated

with considerable autonomy and with little centralized control. When we

visited in April 2000, California was in the process of increasing the number

of district offices and realigning existing districts to obtain a more

appropriate balance between workload and staffing. To facilitate oversight,

each office will report to one of four field coordinators (north, central,

south, and Los Angeles) who report directly to the assistant deputy director

of the state survey agency. California is also expanding its quality assurance

reviews of survey findings after identifying significant problems in survey

documentation, including the scope and severity of deficiencies classified

lower than the evidence in the survey documentation warranted and errors

State Number of homes

Surveyed within 15

days of 1-year

anniversary of last

survey

(percent)a

Surveyed between

14 and 15 months

after last survey

(percent)

Surveyed between

15 and 16 months

after last survey

(percent)

Predictable

surveys

(percent)

California 1,301 8.0 31.4 15.0 54.4

Maryland 243 4.9 14.8 9.0 28.7

Michigan 434 14.0 14.3 9.9 38.2

Missouri 476 11.1 13.9 8.8 33.8

Tennessee 351 56.1 0 0 56.1

Washington 278 15.1 17.6 1.0 33.7
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in survey procedure. Missouri officials told us that by the end of 2000, they

plan to establish a new quality assurance unit that will be responsible for

reviewing a largely random sample of completed surveys and complaint

investigations from each of its seven district offices. Tennessee increased

oversight and control of district office operations by hiring a full-time

quality inspector to conduct targeted reviews in each of the state’s three

district offices. These reviews have resulted in the identification of serious

weaknesses in the survey process and the scheduling of remedial training

sessions for surveyors.

Table 3: Examples of Planned State Funding Increases to Hire Additional Surveyors and Enhance Oversight of Nursing Homes

Considerable Inter-State

Variation Still Exists in

Citation of Serious

Deficiencies, but Range Is

Beginning to Narrow

Consistent with the expectation that improvements in the survey process

would lead to the identification of more problems, the proportion of homes

identified with serious deficiencies increased in a majority of states after

the introduction of survey methodology improvements. The variation in

actual harm and immediate jeopardy deficiencies is still great—ranging

from 10.5 percent of homes in Maine to 58 percent in Washington—but

appears to be narrowing.

State Objective of state funding increase

California California’s 2000-2001 budget contained an “Aging With Dignity Initiative.” It provided over $15 million to hire more

than 200 new surveyors to (1) increase the frequency and unpredictability of nursing home surveys, (2) expand

reviews of poorly performing nursing homes, and (3) guarantee a rapid response to nonemergency complaints. This

initiative also included substantial funding for nursing home quality-of-care enhancements such as providing $10

million for cash awards to exemplary nursing homes. California officials estimate that about one-third of these

increases respond to Medicare requirements.

Maryland Maryland plans to provide $1.1 million for increased state oversight in a supplemental budget for fiscal 2001. Of that,

about $600,000 would hire 20 additional inspectors, allowing the state to visit nursing homes twice a year instead of

once.

Missouri Missouri’s state legislature provided $318,000 in appropriation authority to help fund 27 positions to meet new or

enhanced state and federal mandates related to survey, licensure, and complaint activities at long-term-care facilities.
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Table 4 shows the change in actual harm and immediate jeopardy

deficiencies in states where a minimum of 100 nursing homes was surveyed

since January 1999.11 In some states, these shifts were significant:

• Seventeen states had a 5 percentage point or greater increase in the

proportion of homes identified with actual harm and immediate

jeopardy deficiencies. Most were states with the lowest proportion of

homes with such serious deficiencies before the initiatives.

• Eight states experienced a 5 percentage point or greater decrease in the

identification of serious deficiencies. These states generally cited a high

proportion of homes with serious deficiencies before the initiatives

(well above the national average), and some were still near or above the

national average after the initiatives.

• The remaining 13 states were relatively stable—experiencing

approximately a 3-percentage-point change or less.

Our analysis suggests that the extent of the variation across states in actual

harm and immediate jeopardy citations has begun to narrow. This outcome

is consistent with the initiatives’ intent to reduce the considerable interstate variation through a strengthened and more consistent survey process.

11We excluded Alaska, Delaware, the District of Columbia, Hawaii, Idaho, Mississippi,

Montana, Nevada, New Hampshire, New Mexico, North Dakota, Rhode Island, and Wyoming

from this analysis because fewer than 100 homes were surveyed and even a small increase

or decrease in the number of homes with serious deficiencies in such states produces a

relatively large percentage point change.
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Table 4: Homes With Actual Harm and Immediate Jeopardy Deficiencies Before and After Implementation of the Quality

Initiatives

State (includes only

those in which 100 or

more homes were

surveyed since 1/99)

Number of homes

surveyed (1/99 to 7/00)

Percentage of homes with actual harm and

immediate jeopardy deficiencies

Percentage point

difference

Before initiatives

(1/97 to 7/98)

After initiatives

(1/99 to 7/00)

Increase of 5 percentage points or greater

Arizona 125a 17.2 36.8 19.6

Arkansas 253a 14.7 30.8 16.1

New York 606 13.3 27.6 14.3

Tennessee 353 11.1 24.1 13.0

North Carolina 409 31.0 42.1 11.1

New Jersey 336a 13.0 23.8 10.8

Oregon 157 43.9 53.5 9.6

Massachusetts 541 24.0 32.9 8.9

West Virginia 144 12.3 20.1 7.8

Indiana 581 40.5 48.2 7.7

Louisiana 365a 12.7 20.3 7.6

Georgia 364 17.8 25.0 7.2

Mississippi 196a 24.8 31.6 6.8

Oklahoma 394a 8.4 15.0 6.6

Colorado 229 11.1 16.6 5.5

Maryland 188a 19.0 24.5 5.5

Missourib 565 21.0 25.7 4.7

Change of less than 5 percentage points

Maine 124 7.4 10.5 3.1

Minnesota 437 29.6 32.5 2.9

Texas 1,313 22.2 24.9 2.7

Michigan 442 43.7 45.9 2.2

Nation 16,854 27.7 29.5 1.8

Pennsylvania 774 29.3 30.7 1.4

Illinois 891 29.8 31.1 1.3

South Carolina 176 28.6 29.5 0.9

Connecticut 260 52.9 53.5 0.6

Montana 105 38.7 39.0 0.3

California 1,301a 28.2 28.2 0.0

Wisconsin 424 17.1 14.6 -2.5

Ohio 995 31.2 28.6 -2.6
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a

Compared with the period before the initiatives, there was more than a 10-percent difference in the

number of homes analyzed for these states. In part, these differences are explained by the fact that

some states have still not recorded the results of a home’s most recent survey in OSCAR.

b

Although our work in Missouri focused on the agency responsible for oversight of non-hospital-based

nursing homes, hospital-based facilities in the state were included in developing this table.

Kentucky 306 28.6 25.2 -3.4

Decrease of 5 percentage points or greater

Virginia 282 24.7 19.5 -5.2

Washington 281 63.2 57.7 -5.5

Nebraska 241 32.3 26.6 -5.7

Alabama 225 51.1 41.3 -9.8

Kansas 404a 47.0 36.9 -10.1

South Dakota 112a 40.3 29.5 -10.8

Florida 746 36.3 21.7 -14.6

Iowa 428a 39.2 22.7 -16.5

(Continued From Previous Page)

State (includes only

those in which 100 or

more homes were

surveyed since 1/99)

Number of homes

surveyed (1/99 to 7/00)

Percentage of homes with actual harm and

immediate jeopardy deficiencies

Percentage point

difference

Before initiatives

(1/97 to 7/98)

After initiatives

(1/99 to 7/00)
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Concerns Exist That Quality

Has Been Affected by

Problems in Maintaining

Adequate Facility Staffing

Although increased deficiencies could be the result of better detection,

reports from states of problems with nursing home staffing raise concerns

that actual deficiencies may have increased. In July 2000, HCFA released a

report that found a direct relationship between low nursing home staffing

levels and poor quality of care.12 Recruiting and retaining staff for nursing

homes has been a long-term concern. According to state officials and

nursing home surveyors we interviewed in the spring of 2000, however,

recruiting and retaining nursing home aides has become more difficult, a

situation that they also believe has affected the quality of care provided to

nursing home residents. We were told that nursing homes often have

difficulty filling vacancies, resulting in an inadequate number of qualified

and trained staff. Reasons cited for the growing staffing problems include a

highly competitive job market resulting from the robust economy;

increased demand for staff from alternatives to nursing homes, such as

assisted living facilities; and lower wages and benefits for nursing aides

compared with other health- and non-health-sector opportunities.13

A significant number of states have taken steps that attempt to improve the

recruitment and retention of direct care staff. We identified 16 states that

have increased and 4 others that plan to increase Medicaid payments to

supplement nursing home staff wages and/or benefits by a specific amount,

commonly referred to as a “wage pass-through.”14 For example, Michigan’s

current wage pass-through provides for a maximum increase of 75 cents

per hour for staff. Maine has implemented a one-time supplement to its

payments, which gives nursing homes the flexibility to either establish new

positions or to increase the wages of direct care staff. Some states are

requiring that facilities maintain minimum staffing levels in order to receive

the additional funding through their wage pass-through programs. In

12See Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes (Baltimore, Md.:

HCFA, Summer 2000), Vols. I-III.

13A 1996 Institute of Medicine study documented similar reasons for turnover and retention

problems among nurse’s aides: Institute of Medicine, Nursing Staff in Hospitals and Nursing

Homes: Is It Adequate? (Washington, D.C.: National Academy Press, 1996).

14Wage pass-throughs provide a specific amount or percentage increase in reimbursement,

earmarked typically for direct care staff’s—such as nurses and nurse’s aides—salaries

and/or benefits. States that have enacted wage pass-throughs include Arkansas, California,

Connecticut, Florida, Kansas, Maine, Michigan, Minnesota, Montana, Oklahoma, South

Carolina, Texas, Utah, Vermont, Virginia, and Wisconsin. Four other states—Louisiana,

Maryland, Massachusetts, and Missouri—recently passed legislation and have not yet

implemented their wage pass-through programs.
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Arkansas, facilities are required to maintain state established minimum

staffing levels based on the number of facility residents if they choose to

receive the $4.93 increase in Medicaid reimbursement per patient day. (See

app. III for a brief description of each state’s program.)

Complaint and

Enforcement

Processes Are

Improving, but States

Report Fiscal Year 1999

Federal Initiatives

Funding Was Largely

Unspent

In addition to taking steps to improve the detection of serious deficiencies

during annual surveys, the Administration’s nursing home initiatives

instructed states to investigate complaints that allege actual harm more

promptly. Recognizing that this change and others required by the

initiatives, such as the introduction of quality indicators and investigative

protocols, would increase the workload of state survey agencies, the

Congress appropriated additional funds for their implementation. States

reported that their fiscal year 1999 initiatives funds were not fully used, in

part due to their late distribution. This situation, in turn, slowed down the

hiring of additional staff needed to be fully responsive to the initiatives,

including investigating complaints more promptly. Finally, it is too early to

determine whether the changes in federal enforcement policy intended to

make it harder for nursing homes to avoid sanctions will achieve their goal

of encouraging facilities to sustain compliance with federal requirements.

States Have Increased

Priority Attached to

Complaints but Generally

Have Been Unable to Meet

New Investigative Time

Frames

Complaint investigations provide an opportunity for state surveyors to

intervene promptly if quality-of-care problems arise between surveys.

However, in our prior work we found numerous problems in states’

complaint investigation processes. For instance, some states were making

it unnecessarily complicated for individuals to file complaints; some were

inappropriately classifying complaints of actual harm as low priority for

investigation; and some frequently did not investigate complaints within

required time frames, potentially prolonging harm to residents.15 HCFA had

historically played a minimal role in providing states with guidance and

oversight of complaint investigations.16

15Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents

(GAO/HEHS-99-80, Mar. 22, 1999).

16Nursing Homes: Stronger Complaint and Enforcement Practices Needed to Better Ensure

Adequate Care (GAO/T-HEHS-99-89, Mar. 22, 1999).
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In March 1999, HCFA took a major step to strengthen state complaint

procedures by instructing the states to investigate complaints alleging

actual harm to a resident within 10 working days of receiving the

complaint. Previously, states could set their own investigative time frames,

except that they were required to investigate within 2 working days all

complaints alleging immediate jeopardy conditions. Two of the six states

we contacted previously had requirements for investigating complaints

alleging actual harm that exceeded 10 days, but have since formally

modified their complaint criteria in response to HCFA’s instruction.17

Despite modifying their complaint investigation time frames to include a

10-day requirement, states generally have not been able to investigate all

such complaints on time. For instance, Tennessee was able to investigate

about one-fourth of its actual harm complaints within 10 days, while

Washington was able to investigate more than three-fourths on time. (See

table 5.) State officials we interviewed generally attributed their inability to

investigate all actual harm complaints in 10 days to an increase in the

number of complaints received, limited staff, and competing priorities,

particularly the need to complete standard surveys on time.

Table 5: State Investigative Time Frames for Complaints Prior to the Initiatives and

Extent to Which States Meet the 10-Day Requirement for Actual Harm

a

Data for Maryland, Michigan, and Tennessee represent the last 6 months of 1999 and thus do not

portray all complaints received in 1999. Data for Missouri are for the 12-month period ending June 30,

2000.

17Because of the requirement for annual surveys and other priorities, HCFA recognized that

not all states would be able to meet the 10-day standard and, in October 1999, issued

guidance including techniques to help states identify complaints having a higher level of

actual harm.

State

Had a 10-day requirement

prior to HCFA’s March 1999

instruction?

Number of 10-

day complaints

received in 1999

Percentage of 10-

day complaints

investigated timely

in 1999

California Yes 6,484 56b

Maryland Yes 547a 33c

Michigan No—30 days 17a 100d

Missouri e 2,577a 74f

Tennessee No—60 days 563a About 25f

Washington Yes 2,614 76
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b

California’s low percentage is due in part to state regulations that permit only two categories of

complaints: (1) complaints alleging immediate jeopardy requiring investigation within 2 days and (2) all

other complaints that must be investigated within 10 days. To ensure that actual harm complaints are

investigated within 10 days, California officials told us that they first attempt to identify such complaints

and then triage those to ensure that the most serious are promptly investigated.

c

This represents a substantial improvement from early 1998, when it investigated only 1 of 18

complaints—about 6 percent—within 10 days.

d

Although Michigan investigated all actual harm complaints timely, it categorized only 17 of 902

complaints received in the last half of 1999 as actual harm. It categorized 67 complaints as immediate

jeopardy, requiring investigation in 24 hours, and 818 as nonpriority, requiring a visit to the home within

15 days.

e

Prior to Missouri’s adoption of the 10-day requirement, complaint investigations were initiated within

24 hours if there was “imminent danger” to a resident or a “direct or immediate relationship to the

health, safety or welfare of any resident, but which did not create any imminent danger.” Missouri

officials told us that some actual harm complaints fell into this latter category but that not all could be

initiated within 24 hours. Those not investigated within 24 hours would have slipped into the next

category, which at the time was 90 days. In addition to creating a 10-day category, Missouri no longer

allows complaint investigations of less serious complaints to be delayed as long as 180 days. The

maximum time for investigating complaints is now 60 days.

f

Officials told us that this is an estimate because the state’s ongoing transition to a new complaint

tracking system makes it difficult to determine the exact percentage.

Source: State survey agency officials.

The increased attention HCFA and the states have placed on conducting

complaint investigations in the past 18 months has had some positive

results. For example, among the states we visited, as well as Maryland and

Michigan, we noted the following improvements:

• Increased survey resources. Several states have increased, or plan to

increase, the number of surveyors, some of whom will be assigned to

complaint investigations. The increased staff will enable states to devote

more attention to complaint investigations. Some states also have

dedicated staff to conducting complaint investigations. For instance,

Michigan has created a complaint investigation team of 11 surveyors

representing about 10 percent of the state’s total surveyors. Washington

also plans to increase its number of complaint investigators from 8 to 13.

• Improvements in classifying complaints and setting investigation

priorities. All the states in our study require that the seriousness of

complaints be determined by an experienced surveyor, and Tennessee

and Washington further require that the surveyor be a licensed nurse. In

Missouri, individuals without survey experience had been responsible

for classifying complaints, but now an experienced district office

surveyor, normally a nurse, does so. While positive, these changes do

not obviate the need for centralized oversight by state survey agency

management. Thus, the low number of actual harm complaints in

Michigan compared with other states raises a question about whether
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complaints are being appropriately classified. We noted a similar issue

in one of Tennessee’s three district offices.

• Organizational changes. To improve control and oversight of complaint

investigations, both Maryland and Michigan have consolidated their

nursing home complaint and survey activities into one office under a

single manager. In addition, Michigan added a manager responsible for

direct oversight of the complaint investigation team. Missouri created a

state complaint coordinator to ensure that complaints are handled in a

timely manner.

• Upgraded information systems. Several states now are automating their

information systems to help track complaints more effectively. Such

data systems are necessary to ensure compliance with HCFA guidance

on complaint investigation prioritization and timeliness. For example,

Missouri plans to implement a new automated system in 2001 that is

expected to significantly improve management’s ability to track the

status and results of complaint investigations. Tennessee is

implementing a new system that will replace the manual tracking of

complaints. Also, in early 1999, Washington modified its complaint

tracking system to permit its district offices to better track complaints

during the investigation process.

HCFA intends to issue more detailed guidance to the states in 2001 as part

of its complaint investigation improvement project. Among other things,

the project will (1) identify complaint investigation processes that all states

could implement, (2) establish elements of a national reporting system, (3)

identify methods for HCFA to monitor state complaint investigation

processes, and (4) identify model programs or practices that make

complaint investigations more effective and prevent abuse and neglect. Our

comparison of six states’ complaint processes also identified variations in

practices and results that HCFA could address in any additional guidance it

issues. For instance, although there is no federal requirement that states

operate a toll-free complaints line, Tennessee was the only state among

those we visited that has chosen not to provide this service. Tennessee

received only about half as many complaints per nursing home in 1999 as

Missouri and Washington, both of which have a consumer-friendly toll-free

service that is an integral part of the complaint intake process. Maryland

partially attributes a recent 250-percent increase in the number of

complaints received to its new toll-free number. In addition, some

significant differences appear to exist in how states classify complaints.

For instance, during the last 6 months of 1999, Maryland categorized 62

percent of the complaints it received as potential actual harm, while
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Michigan put only 2 percent of its complaints in this category during the

same period.

States Report That

Additional Federal Funds

Provided for Nursing Home

Initiatives Were Largely

Unspent During Fiscal Year

1999

The Administration and the Congress recognized that additional resources

were needed to address expanded workloads associated with

implementing the nursing home quality initiatives.18 However, the

distribution of initiatives funding late in the fiscal year contributed to

implementation delays. The Medicare survey and certification budget was

increased significantly in fiscal years 1999 and 2000 (see table 6). About $8

million of a $21 million fiscal year 1999 increase and $23.5 million of a $34.7

million fiscal year 2000 funding infusion were for workload growth

attributable to the nursing home initiatives. However, the initial federal

allocation of fiscal year 1999 money to the states occurred in March 1999

and the final federal allocation in June 1999.19 Although several reporting

discrepancies are evident, a majority of states reported not using (that is,

expending or obligating) their full fiscal year 1999 initiatives allocation.

However, interviews with state officials sometimes contradicted

information provided in these reports, raising questions about the actual

disposition of these funds. According to state officials we interviewed,

other factors that contributed to some or all of the initiatives funds not

being used in fiscal year 1999 included (1) the need for state legislative

authorizations to raise staffing ceilings and to use the new federal funds

and (2) problems in meeting HCFA’s requirement to account for initiative

funds separately from other survey and certification funding.20 States have

not yet submitted final expenditure reports for their fiscal year 2000

initiative allocations.

18HCFA determined that additional state resources would be consumed by initiatives that

required states to better target and monitor poorly performing homes and to investigate any

complaint alleging actual harm within 10 days of complaint receipt. HCFA also anticipated

that the use of quality indicators would increase surveyor preparation time prior to visiting a

nursing home and that this could lead to a net increase in total survey time.

19Appropriated funds are neither automatically nor immediately available for use. First, the

funds must be apportioned by the Office of Management and Budget to HHS and allotted (a

delegation of authority to incur obligations) by HHS to HCFA. HCFA then determines, on the

basis of state workload and expenditure data, what amount should be allocated to each

state and advises its regional offices of these suggested amounts. In fiscal year 1999,

regional offices could reallocate among the states up to 15 percent of the suggested

amounts. The regional office then notifies states of award determinations and the ability to

incur obligations for these amounts.

20This requirement applies to nursing home initiatives funding for fiscal years 1999 and 2000.
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Table 6: Federal Medicare and Medicaid Funding for State Survey and Certification

Activities

Dollars in millions

Note: The state survey and certification budget is used to ensure that institutions providing health care

services to Medicare and Medicaid beneficiaries meet federal health, safety, and quality standards.

Institutions covered include hospitals, home health agencies, and end-stage renal disease facilities, as

well as nursing homes. The federal government funds 100 percent of costs associated with certifying

that nursing homes meet Medicare requirements and 75 percent of the costs associated with Medicaid

standards. States usually pay additional costs associated with ensuring that nursing homes meet

state-established licensing standards.

a

Medicaid funding is reported retrospectively on state expenditure reports. The 2000 level is projected

on the basis of the expenditure reports that have been received to date (the first 2-3 quarters of fiscal

year 2000).

b

In fiscal year 1999, the Congress appropriated $4 million for initiative-related costs (P.L. 105-277, Oct.

21, 1998). Subsequently, HCFA reprogrammed another $4 million to help the states cover four key

initiatives.

c

For fiscal year 2000, Medicare funding to states included about $5 million that was reprogrammed

from the Medicare contractor termination budget. The $5 million reprogramming was primarily

intended to support additional complaint investigations required by one of the initiatives.

d

President’s budget request.

Source: Center for Medicaid and State Operations, HCFA.

Fiscal year

Medicare

funding

Medicare funding

associated with

initiatives

Medicaid

fundinga

Total federal

funding

1994 $145.8 $130.4 $276.2

1995 145.8 133.0 278.8

1996 147.6 136.2 283.8

1997 158.0 127.4 285.4

1998 154.0 136.2 290.2

1999 175.0 $8.0b 135.1 310.1

2000 209.7c 23.5 149.0 358.7

2001d 234.1 29.7 Not available Not available
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According to fiscal year 1999 initiatives expenditure reports, only six states

used their full fiscal year 1999 initiatives allocation, and less than $4 million

of the $8 million available for the initiatives was spent.21 Discrepancies

between the initiatives expenditure reports and the separate reports that

capture all survey and certification expenditures (including the initiatives)

raise the possibility that some states may have spent their initiatives

funding but failed to account separately for initiatives expenditures as

required by HCFA.22 Overall, however, the two reports indicated that 28

states did not use their full fiscal year 1999 initiatives or survey and

certification funding allocations, suggesting that a substantial portion of

the $8 million was not used for the nursing home initiatives during fiscal

year 1999.

We attempted to clarify these issues by contacting nine states, including

seven that HCFA officials indicated had not filed a nursing home initiatives

expenditure report. Officials in three states told us that, essentially, these

funds were used even though their initiatives expenditure reports showed

otherwise. Officials in the other six states said that they did not expend

their full fiscal year 1999 initiatives allocation. (See table 7.) In some cases,

however, what state officials told us appears inconsistent with their other

survey and certification expenditure reports. Neither HCFA nor state

officials were able to explain these discrepancies. For example, two

Missouri budget officials told us that none of the state’s $262,000 fiscal year

1999 initiatives funding was used, while an official at the state survey

agency was certain that an undetermined amount had been expended on

initiatives related training. This latter interpretation is supported by the

state’s survey and certification expenditure report that suggests that

$161,000 of these funds may have been spent during fiscal year 1999.

21According to HCFA officials, nursing home initiatives funds appropriated in fiscal year

1999 may only be used for this purpose. These officials advised us that after HCFA makes

the funds available to the states, the states must expend or obligate the funds during the

same federal fiscal year. They explained that HCFA may reallocate funds not spent by one

state during a particular fiscal year to a state that expended more than it was initially

provided for that fiscal year.

22One possible explanation of these discrepancies is the fact that HCFA did not require

states to specifically account for nursing home initiatives expenditures until December

1999.
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Table 7: Summary of Information Provided by Nine States on Their Fiscal Year 1999 Nursing Home Initiatives Allocation

a

Though state officials said some of their initiatives allocation was not used, the state’s survey and

certification expenditure report showed that the entire budget was used during fiscal year 1999,

including the allocation targeted for the initiatives.

b

Missouri’s survey and certification expenditure report showed only $101,000 unspent, suggesting that

it may have spent $161,000 of its initiatives allocation in fiscal year 1999.

State Allocation

amount

Amount reported as

not expended

Summary of remarks by state officials

California $1,002,400 $277,508 State officials told us that the full nursing home initiatives

allocation was used and indicated a supplemental expenditure

report would be submitted to HCFA.

Delaware 24,540 24,540 None of the state’s allocation was used because of

reorganization issues, existing surveyor vacancies, and late

availability of funds.

Illinois 432,316 325,544a The full allocation was not used because of the late availability

of funds and the provision of more funds than were needed for

new mandates.

Kansas 125,245 67,700a The full allocation was not used because start-up of several

initiatives was delayed past originally expected dates.

Missouri 261,958 Someb Only part of the allocation was used because of the late

availability of funds and the difficulty meeting accounting

requirements.

Nebraska 70,179 1,604 HCFA did not have the state’s initiatives expenditure report and

believed the state had not used any of these funds. The state

was able to provide a copy of its report showing that all but a

small amount of its allocation had been used.

Pennsylvania 286,030 154,200a The full allocation was not used because of delays in the startup of initiatives (July 1999). Labor relations issues related to

surveys initiated outside normal work hours were also a

problem.

Tennessee 100,974 94,530a Although the late availability of initiatives funding was a problem,

most of the money was used. The state would have preferred

using the money to hire additional surveyors but, because of late

availability, used most of the funds for a surveyor pay increase.

Utah 49,351 24,675 The full allocation was not used because of late availability of

funds.
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In Missouri, state officials said that the initiatives placed new requirements

on the state agency but did not provide resources quickly enough to

support these initiatives in fiscal year 1999. The state survey agency’s

budget authority is set legislatively and cannot be used for new

requirements, such as the initiatives, without legislative approval (unless

the agency’s appropriations bill allows for spending unanticipated federal

funds up to a preestablished spending level).23 Missouri officials also stated

that there was insufficient time to implement system adjustments to

separately account for the fiscal year 1999 initiatives dollars, as HCFA

required. The timing of the fiscal year 1999 increase was considered

problematic by several other states, though they were able to use some of

these funds. States were not aware of the initiatives when their legislatures

met in early to mid-1998 as the initiatives were not announced until July

1998. In addition, officials told us that the availability of funds late in the

fiscal year limited their efforts to respond to the new initiatives.

A primary objective of the initiatives funding was to enable states to hire

additional nursing home surveyors, particularly to perform complaint

investigations. Generally, state officials told us that hiring in the current

competitive economy is difficult, that state hiring processes are lengthy

and may require legislative authorizations, and that new surveyors are not

fully trained for up to a year after they are hired. For example, a Missouri

official told us that the time needed to hire surveyors made it hard for the

state to use initiatives funds during fiscal year 1999 for this purpose. A

Tennessee official said that because of the need for legislative approval to

increase staffing the state was unable to use initiatives funds during fiscal

1999 for this purpose. Even with such approval, we were told, it takes 6

months to hire—assuming suitable candidates are available. Instead,

Tennessee used the bulk of its initiatives funding for pay increases for longterm-care facility surveyors.

Initiatives Intended to Put

More Teeth Into

Enforcement Options

Overall, it is too early to tell whether the improvements in federal

enforcement policies will have their intended effect of encouraging nursing

homes to sustain compliance with federal requirements. The weaknesses in

federal enforcement policies we identified in previous reports were

essentially attributable to the ability of nursing homes to evade sanctions.

For example, our prior work found that the threat of federal sanctions did

23Thirty states provide gubernatorial budget authority to spend unanticipated federal funds

without approval of the legislature.
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not prevent homes from cycling in and out of compliance. In virtually every

case of noncompliance, homes were granted a grace period to correct

deficiencies before sanctions were recommended or imposed, even when

homes had been cited repeatedly for actual harm violations. HCFA

guidance also allowed states to accept, in some cases, a home’s assertion

that it had returned to compliance rather than confirming the correction of

serious deficiencies through an on-site visit (“revisit”). Under these

circumstances, most deficient homes, even those with repeated

deficiencies that harmed residents, did not have sanctions that actually

took effect.

HCFA and HHS have attempted to put more teeth into enforcement options

by (1) requiring immediate imposition of sanctions without a grace period

for homes that repeatedly cause harm to residents, (2) issuing new

guidance on revisits, (3) increasing funding for the board that handles

nursing home appeals to reduce the backlog of cases, (4) introducing a new

type of civil monetary penalty, (5) taking measures intended to reduce

delays in imposing a denial of payment for new admissions, (6) closing

loopholes associated with its most severe sanction—termination from

Medicare and Medicaid, and (7) increasing oversight of certain facilities

with histories of providing poor care. In addition, HCFA’s Long Term Care

Enforcement Tracking System—the first comprehensive national database

on federal enforcement actions against nursing homes—became

operational in all regions in January 2000 and includes data beginning with

fiscal year 2000.24

Denial of a Grace Period The denial of a grace period for serious repeated deficiencies was

implemented in two stages. In September 1998, HCFA modified its policy to

require that states refer for immediate imposition of a sanction any nursing

home with a pattern of harming a significant number of residents on

successive surveys (levels H and above in HCFA’s scope and severity grid).

Effective December 15, 1999, HCFA expanded this policy to include

deficiencies that harmed only one or a small number of residents (level G

24OSCAR does not contain complete or reliable data on enforcement actions. As a result,

each region maintained its own enforcement action data, which varied in sophistication

from comprehensive computer databases to illegible hand-kept logs with inconsistent

formats.
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deficiencies) on successive standard surveys.25 In an earlier report, we

estimated that this change could increase the percentage of homes referred

immediately for sanctions from approximately 1 percent to as many as 15

percent of homes nationally.26 The regional offices we visited in 2000

reported an increase in enforcement referrals over a similar period during

the previous year. For example, HCFA’s Kansas City office reported that

between January and June 2000, almost one-half of the 127 referrals were

due to HCFA’s elimination of a grace period for certain homes. Washington,

where about 50 percent of nursing homes have been cited for isolated

actual harm, began implementing this policy in March 2000. For the period

March 1 through August 17, 2000, the state recommended 63 enforcement

actions that it would not have a year earlier—23 percent of surveyed

homes, compared with our national estimate of 15 percent. Because

Washington has historically cited actual harm deficiencies at a greater

percentage of nursing homes than any other state, referrals under HCFA’s

new policy were expected to be high. According to state officials, this large

number of referrals created a significant additional workload for the state

survey agency.

Revisits In August 1998, HCFA began requiring states to perform revisits to ensure

that homes with serious deficiencies had in fact returned to compliance. In

some cases, states were previously allowed to accept a nursing home’s

“credible allegation”—a declaration that it was back in compliance—

without on-site verification. HCFA’s new guidance requires state survey

agencies to conduct one or more revisits at a nursing home for any

deficiency originally classified as having caused actual harm or placed

residents in immediate jeopardy (G-level or higher), until the agency has

verified that the home is in full compliance for each deficiency cited. The

policy applies even if the severity of the original deficiency was reduced

during a prior revisit.

25Previously, states referred for sanction any homes with deficiencies at the immediate

jeopardy level (J-L) without granting a grace period. However, because of the very serious

nature of immediate jeopardy deficiencies, the state, nursing home, and regional office often

work in concert to resolve the situation as soon as possible. States are now required to deny

a grace period to homes that are assessed one or more deficiencies at the actual harm level

or above (G-L in HCFA’s scope and severity grid) in each of two successive surveys within a

survey cycle. A survey cycle is two successive standard surveys and any intervening survey,

such as a complaint investigation.

26Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will Require

Continued Commitment (GAO/T-HEHS-99-155, June 30, 1999), p. 12.
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Departmental Appeals Board HCFA has taken actions intended to reduce delays in collecting fines—

called civil monetary penalties—from nursing homes. A fine is the only

federal sanction that can be imposed retroactively against a nursing home,

making it impossible for a home to avoid having the sanction become

effective. However, if a nursing home appeals its fine, payment is

automatically suspended until the appeal is resolved. Before the initiatives,

insufficient staffing at the HHS Departmental Appeals Board and HHS

Office of General Counsel resulted in delayed resolution of pending cases

and corresponding delays in collection of fines, enabling nursing homes to

indefinitely postpone payment of fines by filing an appeal. To provide for

the more timely processing of nursing home appeals, the Congress, at HHS’

request, increased funding for the Appeals Board by a total of $2.8 million

in fiscal years 1999 and 2000.27 Many of the 15 new positions created with

this increased funding were only filled within the past year. In addition, the

HHS Office of General Counsel received $4.4 million in fiscal year 2000 to

hire 33 additional regional office attorneys to handle appeal cases. After

increasing rapidly between September 1996 and September 1998, the

number of pending nursing home appeals decreased in 1999 and then rose

again in 2000 (see table 8). It is unlikely, however, that many enforcement

actions resulting from the new policy of denying a grace period to homes

that repeatedly harm residents have yet reached the point of appeal; when

they do, this may result in a significant increase in the volume of nursing

home appeals.28

27The Departmental Appeals Board provides the administrative law judge review and the

final administrative appellate level review for nursing home appeals of any federal

enforcement sanction. The HHS Office of General Counsel includes the regional office

attorneys who represent HHS and HCFA in such appeals.

28In commenting on our draft report, California officials indicated that an additional effect of

appeals is that HHS’ attorneys are requiring state surveyor and consultant staff to provide

testimony to support HCFA’s action. The state said that preparation time and hearings can

last 8 to 10 days and that during this time the involved surveyors are not available to

accomplish survey and certification work.
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Table 8: Comparison of Pending Appeals and Increased Staffing at the Departmental Appeals Board

Note: Staffing data for fiscal years 1996-98 are not available. Staffing levels are for the component of

the Board that hears nursing home cases. The 1999 staffing levels do not include individuals who were

temporarily assigned to the Board.

Per-Instance Fines In May 1999, HCFA issued regulations giving states an additional

enforcement option—a per-instance fine—that is imposed immediately. In

the past, fines could only be levied for each day of noncompliance. The perinstance authority allows states to recommend a fine for a specific instance

of non-compliance. Such fines may be more easily applied, particularly in

circumstances in which states find it difficult to determine the number of

days the home was noncompliant.29 HCFA reported that the number of perinstance fines is increasing, from 33 between May and September 30, 1999,

to 354 for the period October 1, 1999, through August 31, 2000.30 In

comparison, per-day fines for the first 10 months of fiscal year 2000 totaled

1,359 (see table 9). Per-instance fines are capped at $10,000 and therefore

may not be as effective a deterrent to noncompliance as per-day fines,

which can rise to higher dollar amounts.31 For example, the average perinstance fine was about $2,000, while the average per-day fine totaled

almost $8,000.

Date

Pending nursing

home appeals

Appeals Board staffing

Administrative law

judges Attorneys

Paralegals and

clerical staff Total

Sept. 30, 1996 234

Sept. 30, 1997 472

Sept. 30, 1998 605

Sept. 30, 1999 555 4 9 4 17

Sept. 25, 2000 698 8 13 11 32

29For example, HCFA’s San Francisco regional office suggested that it was appropriate to use

per-instance fines for isolated instances of noncompliance at a nursing home with a

generally good compliance record.

30A HCFA official noted that although states had the authority to use the per-instance fine in

May 1999, they may have been reluctant to do so before the issuance of HCFA’s

implementing guidance in March 2000.

31In contrast to the per-instance maximum of $10,000 per survey, the per-day monetary fine

has a $10,000 per-day limit, which accrues until the home achieves substantial compliance.

HCFA regulations preclude use of a per-instance and a per-day monetary fine on the same

survey.
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Table 9: Comparison of Per-Instance and Per-Day Fines for Fiscal Year 2000, as of

August 8, 2000

a

Amount due excludes cases where (1) the nursing home’s 60-day period to appeal the fine had not yet

expired or (2) the fine had been appealed.

Source: HCFA.

Denial of Payment for New

Admissions

HCFA has also made efforts to ensure that the sanction of denial of

payments for new admissions is imposed in a timely manner, as required by

law. Modified regulations now permit states to provide the notice to the

nursing home within 2 days of submitting a recommendation to HCFA (if

not disapproved). HCFA also encourages states to meet referral deadlines

so that the denial of payment can be imposed within 3 months as required

by statute. One of the four regional offices we visited was piloting an

optional expedited notice provision. HCFA is considering whether to make

such an expedited notice mandatory in all cases. We found, however, that

some states still had problems meeting the deadline for imposing the

sanction.

Termination HCFA took two actions to increase the deterrent effect of its most severe

sanction—termination from the Medicare and Medicaid programs. First, it

altered its policy to require pretermination performance to be considered

in determining any future enforcement actions against terminated homes

subsequently readmitted to Medicare. Second, it gave additional guidance

to HCFA regional offices about the length of the so-called “reasonable

assurance period” during which terminated homes must demonstrate that

they have corrected the deficient practices that led to their terminations.32

Special-Focus Facilities In January 1999, HCFA instructed each state to begin enhanced monitoring

of 2 nursing homes that historically had records of providing poor care

Type of civil monetary

penalty

Number

imposed Amount duea

Amount

collected

Per-instance 354 $749,436 $312,548

Per-day 1,359 $10,722,899 $4,023,795

32Before readmitting a terminated facility to Medicare, HCFA requires nursing homes to

address the situation that led to termination and provide reasonable assurance that it will

not recur. To give this assurance, a home is required to have two surveys not more than 180

days apart, each of which shows the problem to be corrected. The reasonable assurance

period is the time between these two surveys.
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(some states selected an additional one or two homes). Surveys were to be

conducted at 6-month intervals rather than annually. Known as focused

enforcement, the initiative was modeled after a similar California program.

In September 2000, HCFA reported that semiannual surveys had only been

conducted at a little more than half of the original 110 facilities. HCFA

indicated that both state survey agencies and HCFA regional offices have

been reminded, in writing, of the semiannual survey requirements for

special-focus facilities and that its regional offices are now working closely

with states to achieve better compliance. Of the 60 homes that received

semiannual surveys

• 12 have been terminated or have voluntarily withdrawn from the

Medicare and Medicaid programs,

• 31 have had civil monetary fines imposed and 18 have received a denial

of payment for new admissions sanction, and

• 28 are now in substantial compliance.

In addition, the most recent surveys show that the percentage of homes

with deficiencies that harmed residents (G or higher) decreased from 66

percent to 50 percent.

Although this initiative is worthwhile, we believe that its narrow scope

excludes many homes that provide poor care. In contrast, California’s state

focused enforcement program, which began in June 1998, was significantly

larger, initially covering 36 of the state’s facilities with the worst

compliance histories.33 Based on the program’s success to date, California

plans to expand the number of closely monitored homes to 100 by June

2001. Rather than selecting two homes per district office, the expansion

will identify facilities throughout the state with the worst compliance

history. Of the original 36 facilities, 14 continue to be closely monitored.

The remainder have left the program because they returned to compliance

(11), changed ownership (10), or closed (1).

Nursing Home Chains With

Performance Problems

HCFA has not yet implemented an initiative that would deny a grace period

to homes belonging to nursing home chains with performance problems,

but it recently circulated draft guidance to states for implementing this

initiative. Problems with defining a chain and determining which homes

33Initially, California targeted 34 facilities—2 for each of the state’s 17 district offices. Two

additional homes were added to the list to replace homes that left the focused enforcement

program.
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belong to each chain contributed to the delay and remain a problem. As a

result, HCFA’s draft guidance is applicable only to chains with over 100

homes nationally. The policy will be phased in for all remaining chains

when data on chains’ ownership of homes become available on a broader

basis.

Improvements

Continue in Federal

Oversight of State

Survey Activities

In our prior work, we found that HCFA’s oversight of state efforts had

serious limitations that prevented it from developing accurate and reliable

assessments of state survey agency performance. HCFA regional offices’

policies, practices, and oversight were inconsistent, a reflection of

coordination problems between HCFA’s central office and its regional

staffs. Moreover, in important areas such as the adequacy of complaint

investigations or surveyors’ findings, HCFA relied on self-evaluation under

the SAQIP program that essentially allowed states to write their own report

cards. Though OSCAR data were available to monitor state performance,

they were infrequently used, and neither states nor HCFA regional offices

were held accountable for failing to meet or enforce established

performance standards. Finally, HCFA rarely conducted federal

comparative surveys that allowed a comprehensive look behind the state

survey process but instead relied primarily on limited, direct observation of

state surveyors—called an observational survey.

HCFA’s initial efforts to improve federal oversight were limited.34 However,

the agency recently embarked on a major overhaul of its oversight strategy.

In the late spring of 2000, it introduced several organizational changes

intended to improve consistency, coordination, and accountability. In

addition, effective October 2000, direct federal oversight using a new series

of periodic reports based largely on OSCAR data will replace states’ selfevaluation of their survey activities. According to HCFA, many

implementation details are still being worked out. In addition, HCFA is

exploring the feasibility of conducting more comparative surveys and

contemplating changes in the way it allocates funds for state survey and

certification activities. Because these changes are either recent or have not

34Effective October 1998, the number of comparative surveys was increased to about 10

percent of the approximately 900 federal surveys conducted annually—either one, two, or

three per state, depending on the number of nursing homes. Though the majority of federal

surveys continued to be observational, HCFA issued new protocols to ensure they were

conducted more consistently and set up a centralized tracking system to analyze the results.
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yet been introduced, it is too soon to tell how effective they will prove in

resolving past problems.

HCFA Has Created

Coordinating Mechanisms

to Ensure More Consistent

Federal Oversight

HCFA has established several coordinating mechanisms to improve the

consistency of federal oversight of state survey activities and to provide

greater accountability. In earlier work, we raised concerns about the lack

of a direct link between HCFA’s central and regional office components

regarding nursing home oversight. HCFA’s Medicaid and State Operations

Director was responsible for establishing national oversight policy, and the

10 regional offices were charged with day-to-day monitoring of state survey

agency activities.35 Both the director and the regional office administrators

answered separately to the HCFA Administrator without any formal

reporting links. These organizational reporting lines complicated

coordination and communication, weakened oversight, and blurred

accountability when problems arose. For example, we reported significant

differences in the nature and extent of the oversight provided by regions.

Recent or planned changes to improve consistency, coordination, and

accountability include the following:

• National Oversight Policy. In May 2000, HCFA established a Nursing

Home Survey and Certification Oversight Board. The Oversight Board,

which meets monthly, will make recommendations on oversight policy

to the HCFA administrator. Recent meetings involved the survey and

certification budget. Chaired by the Director of the Center for Medicaid

and State Operations, the Oversight Board includes two regional office

administrators as well as other central office representatives.36 Its

composition is intended to improve communication and coordination

among senior HCFA managers responsible for nursing home oversight.

35HCFA relies on 129 federal surveyors in 10 regional offices to carry out its responsibility

for evaluating the adequacy and effectiveness of each state’s nursing home survey process.

36Board members include representatives from HCFA’s Center for Medicaid and State

Operations, Center for Beneficiary Services, Center for Health Plans and Providers, Office

of Financial Management, Office of Clinical Standards and Quality, and two HCFA regional

administrators. The HCFA Administrator and Deputy Administrator are ex officio members,

and the Offices of General Counsel and Legislation have permanent, nonvoting members.
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• Managing Day-to-Day Oversight. HCFA designated two co-leaders—the

director of the Survey and Certification Group (who reports to the

Medicaid and State Operations Director) and the Philadelphia Regional

Office Administrator—to manage and coordinate day-to-day survey and

certification activities. The former is responsible for providing a

national perspective on oversight activities, while the latter works

directly with associate regional administrators—individuals with day-today responsibility for nursing home oversight—to help ensure greater

consistency across regions.37

• Regional Office Focal Points. By October 2000, each HCFA region will

assume the lead for ensuring consistency in 1 of 10 policy areas, such as

data collection and analysis, training, and survey and certification

budgets.38 HCFA is still working out details as to the specific duties in

each area and establishing coordination procedures. In the past, there

was inconsistency across regions, but the new focal points are expected

to overcome this problem. For example, concerning data collection and

analysis, some regions had the capability to use OSCAR data in their

monitoring efforts and others did not. The data tracking coordinator will

be responsible for ensuring that regions have the necessary trained

personnel and that regional administrators and the central office are

apprised of the results of tracking efforts.

• Policy Clearinghouse. Effective in June 2000, HCFA established a sevenmember policy clearinghouse, with representatives from the HCFA

central office, the four HCFA regional office consortia, and the states, to

ensure that regional office directives to states are consistent with

national policy.39 For example, the clearinghouse ordered the

withdrawal of guidance issued by the Dallas and Chicago regional

offices to state surveyors on how to determine the oral and dental health

of nursing home residents because of concern about the resource

implications. HCFA is now considering whether it should develop

national guidance on this issue. Achieving an appropriate balance

between the need to apply consistent national policy and fostering an

37In each regional office, the associate regional administrator responsible for nursing homes

reports to a regional administrator. The Philadelphia Regional Office Administrator will not

evaluate an associate administrator’s performance but will provide feedback to the

appropriate regional administrator.

38The other lead areas are state survey performance, cross-regional surveys, quality, federal

monitoring surveys, certification of new providers, surveyor staffing, and non-long-termcare surveys.

39States are represented by the Association of Health Facility Survey Agencies.
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environment that encourages regional offices to develop improved

practices will be an ongoing effort.

Increasing Federal

Oversight and Requiring

Greater Use of Management

Information Systems Should

Improve State and Regional

Office Accountability

HCFA will require regional offices to begin producing periodic reports on

state survey activities and, effective October 2000, these reports will be

used to assess state performance in key areas. HCFA officials recognized

that neither the central office nor the regional offices had made the most

effective use of existing data to monitor state activities and to take

appropriate action when serious state survey agency problems were

identified. For example, while the Atlanta regional office used OSCAR data

to actively monitor state performance and required state survey agencies to

correct problems, the other regions we visited did not. Recent state

experiences illustrate the opportunity to use OSCAR and other available

data to monitor state activities, including variations among local district

offices. HCFA is also examining ways to increase its use of comparative

federal surveys.

Standardized Reports to Assess

State and Regional Office

Performance

To provide both the central and regional offices with the basic data needed

to improve federal oversight, HCFA has directed its 10 regional offices to

periodically prepare 18 “tracking” reports on areas that measure both state

and regional office performance. Examples of reports that will track state

activities include pending nursing home terminations (weekly), oversight

at problem facilities selected for more frequent surveys (monthly), meeting

OSCAR data entry timeliness (quarterly), tallies of state surveys that find

homes deficiency-free (semiannually), and analyses of the most frequently

cited deficiencies by states (annually). Examples of reports that will track

regional office performance include those on the results of comparative

surveys (semiannually) and on the processing of enforcement cases

(monthly). These reports, in standard format, will enable comparisons

within and across states and regions and should help to surface problems

and identify the need for intervention—either by HCFA’s central office or

regional offices.

Tables 10 and 11 provide examples of how available data could have been

used to identify potential performance problems in state survey agencies

and district offices.
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Table 10: HCFA Analysis of OSCAR Data and Comparative Surveys Could Have Raised Questions About the Performance of

Oklahoma’s State Survey Agency

Note: The HHS Office of Inspector General, the Federal Bureau of Investigation, the Internal Revenue

Service, and the Oklahoma Attorney General’s Medicaid Fraud and Control Unit participated in an

investigation leading to the May 2000 legal charges brought against the Oklahoma State Department

of Health’s Deputy Commissioner, who was responsible for state nursing home survey activities. It has

been alleged this individual received payments from nursing homes in exchange for preferential state

survey treatment.

a

At our request, HCFA’s Dallas regional office determined that surveys had been conducted for some

of these homes in 1999 but that the results had not been entered into OSCAR—a violation of HCFA’s

guidance that states promptly enter survey results into OSCAR.

Background In May 2000, the state official responsible for nursing home survey activities was indicted for bribery. Allegedly,

in exchange for payments, the director gave some nursing homes preferential treatment, such as notifying

homes in advance about the date of their annual surveys so the homes had time to prepare for them.

Issue Although existing data from OSCAR or federal comparative survey results would not have uncovered bribery,

HCFA officials acknowledged that this information could have alerted them to shortcomings in Oklahoma’s

survey activities.

Deficiency citations Compared with the national average, Oklahoma had a higher percentage of deficiency-free homes (22 percent

versus 16 percent) and a lower percentage of homes with actual harm or immediate jeopardy deficiencies (15

percent versus 30 percent).

OSCAR data entry About 20 percent of the state’s annual nursing home surveys reported in OSCAR were from 1998 and some

were up to 2 years old, an apparent violation of the federal requirement to inspect each nursing home at least

once every 15 months.a

Revisits Since early 1999, the state had not entered any data on nursing home revisits into OSCAR, raising a question

as to whether the state had conducted the required on-site review to determine that cited deficiencies had been

corrected.

Comparative surveys Four 1999 federal comparative surveys in Oklahoma cited a total of 45 deficiencies, compared with the state’s

total of 3. Eight of the 45 federal citations involved quality of care, some at the actual harm level. In contrast,

none of the state surveys found any quality-of-care deficiencies. In fact, state surveyors found two of the homes

to be deficiency-free.
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Table 11: HCFA Analysis of Available Data Could Have Raised Questions About the Performance of Missouri’s State Survey

Agency

a

We examined the results of all complaints against deficiency-free homes that received 10 or more

complaints and a random sample of all complaints against 25 percent of deficiency-free homes that

received fewer than 10 complaints.

HCFA’s 18 new standardized status reports should help to track the states’

compliance with an initial set of seven state performance standards,

including survey timing, deficiency documentation, complaints

Issue Of the four states we visited, Missouri had the highest percentage of deficiency-free homes—both before and

after the introduction of the nursing home initiatives. For example, 3 percent of California nursing homes were

found deficiency-free on their most recent survey, compared with about 16 percent in Missouri. To gain a

better understanding of the adequacy of state surveys in Missouri, we reviewed the results of 368 complaints

registered against 34 of 84 homes found to be deficiency-free during the period January 1999 through

January 2000.a Our hypothesis was that deficiency-free homes should have few complaints. Missouri’s 84

deficiency-free homes received 605 complaints, an average of 7 complaints per home (compared with an

average of 2 per deficiency-free home in California). The number of complaints against Missouri’s deficiencyfree homes ranged from 1 to 39, and 19 homes had 10 or more complaints.

Complaints against

deficiency-free homes

Twenty-two of the 34 deficiency-free homes had substantiated complaints. For example, one home with a

total of 39 complaints had 17 actual harm deficiencies substantiated, including 3 substantiated at the

immediate jeopardy level, during complaint investigations.

Adequacy of complaint

investigations

The rate of substantiation of complaints was generally much lower in one of the state’s seven district offices—

one of the two districts that had a significantly higher percentage of deficiency-free homes (34 percent,

compared with a statewide average of slightly less than 16 percent). In reviewing complaints investigated by

this district over the past 3 years, we noted several anomalies and problematic investigations:

• Regarding one complaint, the district office wrote the complainant a letter indicating that the investigation

had substantiated the allegations and action was being taken. In fact, however, the district found the

allegation to be invalid and took no action against the nursing home.

• In another case, the district investigated a complaint about a resident who died without being provided CPR

(cardiopulmonary resuscitation), even though her husband had signed a form asking that CPR and all other

necessary measures be taken in the event of a medical crisis. The investigation concluded that there was no

evidence to suggest that the home’s staff did not act appropriately during the crisis, but it failed to address

the issue of whether the nursing home had a system in place to alert staff to a resident’s desire for

resuscitation. Instead, the investigation focused on whether performing CPR would have made a difference

in the resident’s outcome. The file also indicated that, during the course of the investigation, the home

advised the surveyors that it would have its lawyer present a seminar to the home’s staff about complying

with residents’ wishes for resuscitative measures. However, there is no indication in the file that the

surveyors verified that the home actually took such action.

Federal comparative

surveys

In February 2000, a federal comparative survey was conducted at a nursing home that was found to have had

no care-related deficiencies in its prior two annual surveys. The state surveys had been conducted by

surveyors assigned to the same district office discussed above.

• The comparative survey found 11 deficiencies, including actual harm to residents because of failure to

ensure that residents maintain their ability to perform normal daily functions and failure to provide adequate

nutrition.

• Federal surveyors told us that these care problems should have been detected by the state’s survey 1

month earlier, which found this home to be in substantial compliance with federal quality standards.

• Missouri’s state auditor had questioned the circumstances surrounding the deletion of all 11 deficiencies

from this same home’s 1998 survey, including deficiencies similar to those found in the federal comparative

survey.
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investigation, conduct of surveys in accordance with guidance, and OSCAR

data entry (see app. IV, table 17). In areas such as deficiency

documentation and complaints, the regional offices will go beyond

examining computerized data and review actual records. For example, the

appropriate documentation of survey findings will involve regional office

reviews of samples of survey reports from each state. As noted earlier, a

state that conducted similar reviews of a sample of its own surveys found

both an understatement of deficiencies and investigative weaknesses.

Regional offices will also conduct an on-site review of each state’s

complaints system and procedures. The seven standards are drawn largely

from those used under the SAQIP program, which will be discontinued as

of October 2000. HCFA is developing protocols to ensure that the regions

consistently enforce the seven standards.

HCFA is in the process of redesigning its on-line management information

system, OSCAR. OSCAR’s new nursing home module is projected to be

available in the summer of 2001. While OSCAR currently provides

extensive information about state surveys, including when surveys are

conducted, the deficiencies cited, and the length of time between a home’s

annual survey, generating analytical reports from OSCAR is difficult, and

most regions lack the expertise to do so. The new nursing home module in

OSCAR will be more user-friendly because it will require less computerprogramming experience to conduct data analysis.

Reevaluation of Comparative

and Observational Surveys

In October 1998, HCFA acknowledged the need to do more comparative

surveys than the 21 conducted in the previous 2 years. As a result, it

required regional offices to perform between one and three comparative

surveys per state annually, depending on the number of nursing homes.

Comparative surveys now account for about 10 percent of federal surveys.

The remaining 90 percent are observational.

HCFA currently is exploring the adequacy of the number of comparative

surveys and is considering either (1) increasing the number of federal

surveyors available to conduct them or (2) narrowing their scope to allow

more surveys to be done. Increasing the proportion of federal surveys that

are comparative would respond to our 1999 recommendation.40 We believe

that the results offer a more accurate picture of the adequacy of state

40California Nursing Homes: Care Problems Persist Despite Federal and State Oversight

(GAO/HEHS-98-202, July 27, 1998) and Nursing Home Care: Enhanced HCFA Oversight of

State Programs Would Better Ensure Quality (GAO/HEHS-00-6, Nov. 4, 1999).
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survey activities than do observational surveys, which primarily are used to

help identify training needs. Seventy percent of the 157 comparative

surveys conducted between October 1998 and May 2000 found more

serious care problems than did the corresponding state survey. On average,

state surveyors identified 3 deficiencies per home, while federal surveyors

found almost 10. Currently, however, too few comparative surveys are

completed in each state to assess whether the state appropriately identifies

serious deficiencies. Although most do not meet the timing requirement to

be classified as comparative surveys, the results of 16 federal surveys

recently conducted in Oklahoma underscore the value of increasing the

number of comparative surveys per state (see table 12).41 More

comparative surveys in Oklahoma could have provided HCFA with broader

evidence about the adequacy of state survey activities.

Table 12: Results of Federal Surveys of 16 Nursing Homes in Oklahoma

HCFA is also examining how its regional offices conduct observational

surveys and how the current scoring system may be improved to assess a

state’s performance on such surveys. First, HCFA is completing 10 crossregional surveys to identify differences in how regions conduct

observational surveys. Each HCFA cross-regional team consists of

surveyors from two regional offices who join the federal surveyors in a

third region to watch how they conduct an observational survey.

Differences are already emerging among regions, such as how a particular

41Comparative surveys are generally conducted within 2 months of the state’s survey to

ensure that conditions in the home are similar for both the federal and state survey team.

Four of these 16 federal surveys would qualify as comparatives because 2 months or less

had elapsed since the most recent state survey. As with typical comparative surveys, the

federal surveyors conducted a complete review of the care provided by each nursing home.

Issue Between April and June 2000, HCFA conducted federal surveys at the 16 nursing homes suspected of bribing

the state survey agency director. This number is significant because most states have only one or two federal

surveys each year.

Number of

deficiencies

In 8 of the 16 surveys, federal surveyors found a minimum of 20 more deficiencies than were cited on the most

recent state survey for the same homes. In one of the more glaring examples, the federal survey cited 37

deficiencies and the most recent state survey cited only 1.

Scope and severity In 15 of 16 surveys, federal surveyors also cited deficiencies at higher scope and severity levels than did state

surveyors.

Quality-of-care

problems

Overall, federal surveyors found significantly more quality-of-care problems than did state surveyors—

averaging 5.3 versus 1.5 quality-of-care deficiencies (see app. IV, fig. 1).
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nursing home is selected for a federal survey and the extent to which

federal surveyors identify nursing home deficiencies. During the fall of

2000, a report together with recommendations will be sent to the HCFA

Oversight Board concerning changes to ensure consistency in the federal

monitoring survey process. Second, the current methodology for scoring

the results of observational surveys only indicates whether a state team

performed a required survey task—not the quality of the survey or of the

judgment exercised by the state surveyors. HCFA has contracted for the

design of a scoring mechanism that would allow federal surveyors to better

and more consistently assess the quality of a state survey. Due in part to

concerns about the scoring system, HCFA has not issued a planned report

on the results of observational surveys conducted in fiscal year 1999.

Changes to Allocation of

Survey Funding Could

Enhance State Survey

Oversight

HCFA is exploring options for better distributing future survey and

certification funding. The current survey and certification budget process

bases funding requests and state funding allocations on past state practices

and costs, rewarding states that spent substantial amounts in the past by

establishing those expenditures as a budget baseline. Conversely, states

that spent less for survey and certification activities may have baseline

costs that are too low. Differences in state survey and certification budgets

may be a significant factor in the variations in time devoted to performing

surveys. A 1998 study by the Center for Health Systems Research and

Analysis identified significant imbalances in survey time and resource

utilization among the survey teams—imbalances that still exist. Our recent

analysis of OSCAR data showed that Tennessee surveyors spent an average

of 94 hours to perform a nursing home survey, whereas Washington

surveyors spent an average of about 162 hours. Differences such as these

may significantly affect the quality of oversight, because the Center’s study

showed a correlation between the average survey time and the number of

deficiencies identified.

HCFA officials reported that efforts are ongoing to identify better options

for distributing future survey and certification funding. The agency’s Fiscal

Year 2001 Annual Performance Plan establishes a performance goal of

moving from the current budget process to a price-based process. HCFA

proposes developing national standard survey measures and costs that

would be used to price the workload for each state survey agency.

Conclusions Sustained efforts by HCFA and the states are essential to realizing the

potential of the nursing home quality initiatives. For example, better
B-284751

Page 45 GAO/HEHS-00-197 Nursing Home Quality Initiatives

detection and classification of serious deficiencies through the standard

survey process will require further refinement of survey methods and a

reduction in survey predictability to limit the opportunities for homes to

prepare for these reviews. In the states we reviewed, efforts to expedite

complaint investigations and systematize the reporting of investigation

results are at various stages of implementation and remain incomplete. As

for the application of strengthened federal enforcement policies, more time

must elapse before progress in this area can be assessed. Similarly, with

respect to improved federal oversight, the effectiveness of recent internal

HCFA reorganizations and management information reporting

enhancements can only be judged in the months to come. In short, the

current momentum should neither be taken for granted nor relaxed. The

extent of the progress in improving quality of care is uncertain, but fully

and effectively implementing the initiatives is an essential component in

securing the necessary improvements.

Agency Comments and

Our Evaluation

We provided a copy of our draft report to HCFA and the states included in

the scope of our work. We received written comments from HCFA; the

California Department of Health Services; the Division of Aging, Missouri

Department of Social Services; the Michigan Department of Consumer and

Industry Services; and Residential Care Services, State of Washington

Aging and Adult Services Administration, Department of Social and Health

Services. Maryland and Tennessee had no comments other than that they

believed the report was fair.

HCFA generally agreed with our findings and conclusions. Recognizing that

progress had been made in improving the quality of care in nursing homes,

HCFA stated that it agreed with us that it is still too early to draw definitive

conclusions about the impact of various nursing home initiatives from the

preliminary data available. HCFA likewise agreed that sustained federal

and state actions are necessary to realize the full potential of the initiatives.

HCFA said that it was committed to taking additional steps on a number of

issues raised in our report such as (1) survey predictability, (2) the

continued variability across states in citing serious deficiencies, (3)

discrepancies in state reports regarding the expenditure of nursing home

initiatives funding, (4) the timeliness requirements for completing

complaint investigations, (5) regional office consistency in implementing

enforcement initiatives, (6) consistency in the monitoring of state

performance, and (7) refining data systems to provide more timely, useful,

and customer-friendly information. HCFA also indicated that it is

committed to specific actions that would help strengthen and build upon
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Page 46 GAO/HEHS-00-197 Nursing Home Quality Initiatives

the nursing home initiatives, including exploring ways to make optimal use

of available remedies as well as exploring the need for additional

authorities, working with states to meet the 10-percent goal for off-hour

surveys, and developing more streamlined methods for investigating

serious complaints. (HCFA’s comments are in app. V.)

California, Missouri, Michigan, and Washington also generally agreed with

our findings and conclusions. Washington reflected that the full

implementation of the nursing home initiatives is ongoing. California,

Michigan, and Missouri elaborated on the improvements made in their

oversight of nursing homes but also noted that implementation is not yet

complete. For example, California is in the process of implementing

recently enacted state legislation that will significantly increase survey

staff, and Missouri has not yet completed implementing its overhaul of

complaint investigations.

Missouri identified several areas where it believed continued dialogue

between HCFA and states would be fruitful, such as modifying the survey

process to focus on noncompliant homes, the use of the OSCAR system as

the primary data source on survey results, improvements needed in

resource planning, potential expansion of the special focus facilities

initiative, and consistency in surveyor training. It also believed that

refinements were required in federal comparative surveys because they are

conducted with criteria different from that set forth by HCFA for use by

state agencies and are not required to be legally defensible. While our

report acknowledges steps recently taken by HCFA to ensure consistency

in federal oversight, Missouri’s assertion that federal comparative surveys

are not required to be legally defensible is erroneous. Federal comparative

surveys must meet the same documentation standards as state surveys, and

the federal survey may be subject to administrative appeals if HCFA takes

enforcement action on the basis of the survey’s findings. Missouri also said

that the periods of time surveyed are not the same. Consistent with our

November 1999 recommendation, HCFA has directed its regional offices to

initiate comparative surveys within 14 to 28 days after the completion of

the state’s survey rather than within two months as specified in statute.

This step should further ensure that conditions in a home are as similar as

possible for both the state and federal survey. We had also recommended

that federal surveyors should include as many of the same residents as

possible in their comparative survey sample as the state included in its

sample.42 The similarities between the initial results of Missouri’s

November 1998 survey of a nursing home and the findings of a February

2000 federal comparative survey of that same home also suggest that
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Page 47 GAO/HEHS-00-197 Nursing Home Quality Initiatives

identified deficiencies can continue to exist over an extended period of

time. (Comments from the four states are included in apps. VI through IX.)

Technical comments provided by HCFA and the states were also

incorporated as appropriate.

As agreed with your offices, unless you publicly announce its contents

earlier, we plan no further distribution of this report until 30 days after its

issue date. At that time, we will send copies of this report to the Honorable

Nancy-Ann Min DeParle, Administrator of HCFA, and others upon request.

Please contact me or Kathryn G. Allen, Associate Director, at (202) 512-

7114 if you or your staffs have any questions. GAO staff acknowledgments

are listed in appendix X.

William J. Scanlon

Director, Health Financing

and Public Health Issues

42GAO/HEHS-00-6, Nov. 4, 1999, pg. 28.
Page 48 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix I

Implementation Chronology for Key Nursing Apendxies

Home Quality Initiatives ApendxiI

The implementation dates in this chronology generally reflect HCFA’s

issuance of final guidance to states. Actual implementation of many of the

Administration’s nursing home initiatives is dependent upon state action.

During our work, we encountered examples where state implementation

did not coincide with the HCFA “implementation” dates shown below in

table 13. Other activities to promote the consistency and effectiveness of

HCFA oversight of state survey activities are not being formally tracked as

initiatives.

Table 13: Implementation Chronology for Key Nursing Home Initiatives

Initiative and date Implementation status

Survey procedures

January 1999 Staggered surveys: State survey agencies required to initiate 10 percent of annual surveys

outside normal work hours.

July 1999 Survey methodology, phase one: HCFA instructed states to incorporate quality indicators

into the survey process. Quality indicators are derived from nursing homes’ assessments

of residents and rank a facility in 24 areas with other nursing homes in the state. By using

the quality indicators to select a preliminary sample of residents before the on-site review

begins, surveyors are better prepared to identify potential care problems. Concurrently,

HCFA published new investigative protocols for use by surveyors on key issues such as

abuse prevention, pressure sores, hydration, and unexplained weight loss.

Projected completion date 2002 or 2003 Survey methodology, phase two: As a follow-up to the quality indicator and protocol

initiative mentioned above, HCFA plans to (1) improve the on-site augmentation of the

preliminary sample selected off-site using the quality indicators and (2) strengthen the

protocols used by surveyors to ensure more rigor in their on-site investigations.

Complaints

March 1999 Actual harm complaints: Within 10 workdays, state survey agencies are to begin

investigating complaints that allege actual harm by conducting an on-site visit (when

necessary).

Enforcement

August 1998 Revisits: Revised revisit policy by requiring states to actually visit nursing homes to ensure

that serious deficiencies have in fact been corrected and that facilities have returned to

compliance.

September 1998 Grace period for H- and I-level deficiencies: HCFA eliminated the grace period for homes

with repeated serious violations (H- and I-level deficiencies). Now states are required to

refer such homes to HCFA for immediate sanctions.

January 1999 Special-focus facilities: State survey agencies instructed to begin enhanced monitoring of

two nursing homes per state—facilities with histories of providing poor care.

May 1999 Per-instance civil monetary penalties: States allowed to impose per-instance civil monetary

penalties when period of noncompliance is unclear or in other appropriate circumstances.

States may not impose both a per-instance and per-day fine for the same survey.
Appendix I

Implementation Chronology for Key Nursing

Home Quality Initiatives

Page 49 GAO/HEHS-00-197 Nursing Home Quality Initiatives

May 1999 Appeals backlog: For fiscal years 1999 and 2000, the HHS Departmental Appeals Board

received a $2.8 million funding increase to hire more personnel to help reduce the backlog

of nursing home appeals. The fiscal year 1999 increase was in the form of a supplemental

appropriation. The HHS Office of General Counsel also received a funding increase of

$4.4 million in fiscal year 2000 to hire 33 regional office attorneys to represent the

government in cases appealed to the Board.

December 1999 Reasonable assurance: States instructed to ensure adequate “reasonable assurance”

period for terminated homes seeking readmission to Medicare. Typically, two surveys are

required within this period to verify that the reason for termination no longer exists and that

the provider has maintained substantial compliance with all applicable participation

requirements.

December 1999 Considering pretermination history: States instructed to consider a nursing home’s

pretermination history when taking enforcement actions after a home has been readmitted.

December 1999 Grace period for G-level deficiencies: HCFA eliminated the grace period for homes with

repeated violations at the G level, and states are required to recommend such homes to

HCFA for immediate sanctions.

Projected completion date of late 2000 Poorly performing nursing home chains: HCFA has developed and released for comment

draft manual instructions that provide criteria for defining a nursing home chain with

performance problems. The instructions would require states to deny an opportunity to

correct (grace period) before sanctions are imposed on facilities that are part of a chain

with performance problems. The instructions would only be applicable to chains having

over 100 homes nationally. The policy would be phased in for all remaining chains when

data on chains become available on a broader basis.

Oversight

October 1998 Federal oversight surveys: Standardized protocols were issued for observational surveys,

and the number of comparative surveys was increased. HCFA now requires a minimum of

one comparative survey in states having fewer than 200 nursing homes, two in states with

200 to 599 nursing homes, and three in states with 600 or more homes. Ninety percent of

federal monitoring surveys will continue to be observational.

Projected completion date of summer 2001 OSCAR redesign: HCFA is in the process of redesigning its on-line management

information system, OSCAR. While OSCAR currently provides extensive information about

state surveys, including when surveys are conducted, the deficiencies cited, and the length

of time between a home’s annual surveys, generating analytical reports from OSCAR is

difficult, and most regions lack the expertise to do so. The new nursing home module in

OSCAR will be more user-friendly because it will require less computer programming

experience to conduct data analysis.

(Continued From Previous Page)

Initiative and date Implementation status
Page 50 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix II

State Survey Findings for Periods Before and

After the Administration's Nursing Home

Initiatives ApendxiI

In order to compare trends in nursing home deficiency citations, we

analyzed data from HCFA's OSCAR System. We compared results for two

time periods—one before and one after implementation of the nursing

home initiatives: (1) January 1, 1997 through June 30, 1998 (base) and (2)

January 1, 1999 through July 10, 2000 (current). Because surveys are

conducted at least every 15 months (with a required 12-month state

average), it is possible that a facility was surveyed twice in either time

period. To avoid double counting of facilities, we included only the most

recent survey from each of the two time periods. Because some states do

not enter survey results promptly, the current period did not include all

surveyed facilities. The results of our analysis are presented in table 14.
Appendix II

State Survey Findings for Periods Before and

After the Administration's Nursing Home

Initiatives

Page 51 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Table 14: Percentage of Homes at Each Deficiency Level Before and After the Nursing Home Initiatives, by State

Number of homes

Actual harm/

immediate jeopardy

(percent)

Potential for more

than minimal harm

(percent)

Potential for

minimal harm

(percent)

Deficiency-free

(percent)

State Before After Before After Before After Before After Before After

Alabama 227 225 51.1 41.3 32.2 52.9 6.6 0.9 10.1 4.9

Alaska 16 15 37.5 33.3 43.8 46.7 0.0 6.7 18.8 13.3

Arizona 163 125 17.2 36.8 71.8 56.8 4.9 2.4 6.1 4.0

Arkansas 285 253 14.7 30.8 56.8 57.7 22.8 5.9 5.6 5.5

California 1,435 1,301 28.2 28.2 65.0 65.7 4.0 3.0 2.7 3.1

Colorado 234 229 11.1 16.6 38.5 49.8 5.1 3.9 45.3 29.7

Connecticut 263 260 52.9 53.5 19.4 30.8 0.4 0.4 27.4 15.4

Delaware 44 41 45.5 53.7 36.4 34.1 6.8 2.4 11.4 9.8

District of Columbia 24 18 12.5 5.6 37.5 61.1 41.7 33.3 8.3 0.0

Florida 730 746 36.3 21.7 51.1 62.5 1.6 1.7 11.0 14.1

Georgia 371 364 17.8 25.0 41.8 46.4 10.2 7.7 30.2 20.9

Hawaii 45 46 24.4 23.9 33.3 67.4 33.3 4.3 8.9 4.3

Idaho 86 83 55.8 54.2 36.0 37.3 1.2 0.0 7.0 8.4

Illinois 899 891 29.8 31.1 55.2 51.9 6.8 7.0 8.2 10.1

Indiana 602 581 40.5 48.2 46.2 40.1 4.8 2.4 8.5 9.3

Iowa 525 428 39.2 22.7 42.9 55.6 1.0 3.0 17.0 18.7

Kansas 445 404 47.0 36.9 32.6 45.8 1.8 0.0 18.7 17.3

Kentucky 318 306 28.6 25.2 37.1 61.4 7.9 3.9 26.4 9.5

Louisiana 433 365 12.7 20.3 31.6 50.4 27.5 6.3 28.2 23.0

Maine 135 124 7.4 10.5 62.2 64.5 7.4 5.6 23.0 19.4

Maryland 258 188 19.0 24.5 34.1 37.2 8.9 8.5 38.0 29.8

Massachusetts 576 541 24.0 32.9 24.0 34.2 3.3 4.4 48.8 28.5

Michigan 451 442 43.7 45.9 51.7 49.5 1.8 1.4 2.9 3.2

Minnesota 446 437 29.6 32.5 40.4 45.1 6.7 5.5 23.3 16.9

Mississippi 218 196 24.8 31.6 44.0 50.5 8.3 8.2 22.9 9.7

Missouri 595 565 21.0 25.7 43.7 55.8 6.2 3.0 29.1 15.6

Montana 106 105 38.7 39.0 39.6 50.5 5.7 1.9 16.0 8.6

Nebraska 263 241 32.3 26.6 24.7 48.5 3.0 3.7 39.9 21.2

Nevada 49 50 40.8 24.0 55.1 64.0 2.0 4.0 2.0 8.0

New Hampshire 86 82 30.2 35.4 25.6 32.9 14.0 4.9 30.2 26.8

New Jersey 377 336 13.0 23.8 24.4 38.1 15.4 11.0 47.2 27.1

New Mexico 88 82 11.4 30.5 44.3 45.1 11.4 1.2 33.0 23.2

New York 662 606 13.3 27.6 38.4 41.3 7.9 5.4 40.5 25.7
Appendix II

State Survey Findings for Periods Before and

After the Administration's Nursing Home

Initiatives

Page 52 GAO/HEHS-00-197 Nursing Home Quality Initiatives

North Carolina 407 409 31.0 42.1 33.2 37.9 4.7 2.9 31.2 17.1

North Dakota 88 89 55.7 24.7 35.2 52.8 2.3 5.6 6.8 16.9

Ohio 1,043 995 31.2 28.6 41.3 50.3 4.9 3.3 22.6 17.8

Oklahoma 463 394 8.4 15.0 55.7 58.6 6.7 4.6 29.2 21.8

Oregon 171 157 43.9 53.5 26.3 27.4 2.9 0.0 26.9 19.1

Pennsylvania 811 774 29.3 30.7 44.4 47.7 3.6 3.2 22.7 18.3

Rhode Island 102 96 11.8 13.5 54.9 45.8 3.9 5.2 29.4 35.4

South Carolina 175 176 28.6 29.5 65.7 64.8 0.6 0.6 5.1 5.1

South Dakota 124 112 40.3 29.5 37.1 55.4 3.2 4.5 19.4 10.7

Tennessee 361 353 11.1 24.1 58.4 65.4 3.6 2.5 26.9 7.9

Texas 1,381 1,313 22.2 24.9 36.4 42.7 19.7 14.1 21.7 18.4

Utah 98 93 15.3 17.2 61.2 65.6 0.0 1.1 23.5 16.1

Vermont 45 45 20.0 13.3 35.6 48.9 11.1 2.2 33.3 35.6

Virginia 279 282 24.7 19.5 34.8 39.4 4.7 6.4 35.8 34.8

Washington 288 281 63.2 57.7 32.3 37.7 1.0 1.4 3.5 3.2

West Virginia 130 144 12.3 20.1 63.8 65.3 16.2 11.8 7.7 2.8

Wisconsin 438 424 17.1 14.6 53.7 50.5 5.3 3.3 24.0 31.6

Wyoming 38 41 28.9 34.1 55.3 46.3 2.6 2.4 13.2 17.1

Nation 17,897 16,854 27.7 29.5 43.8 49.8 7.1 4.7 21.3 16.0

(Continued From Previous Page)

Number of homes

Actual harm/

immediate jeopardy

(percent)

Potential for more

than minimal harm

(percent)

Potential for

minimal harm

(percent)

Deficiency-free

(percent)

State Before After Before After Before After Before After Before After
Page 53 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix III

State Efforts to Address Nursing Home

Staffing Shortages ApendxiI

We identified 20 states that have enacted legislation that establish wage

pass-throughs, wage supplements, or related programs to provide

supplemental wages, fringe benefits, or funds for additional nursing home

staff. Fourteen of these state programs were implemented since January

1998—3 in 1998; 9 in 1999; and 2 in 2000. Two other states—Michigan and

Utah—enacted wage pass-throughs prior to 1998. The remaining four

states only recently enacted legislation and have not yet implemented their

programs. To identify these 20 states, we began with a September 1999

study based on a 50-state survey that identified seven state programs.1 To

update this study, we contacted the National Conference of State

Legislatures, the Paraprofessional Healthcare Institute, and the Service

Employees International Union and conducted an Internet search on “wage

pass-through programs” during the summer of 2000. Because we did not

survey all 50 states, there may be additional state programs. Table 15

provides a general description of each state’s program.

Table 15: States With Programs to Address Nursing Home Staff Shortages

1

North Carolina Division of Facility Services, Comparing State Efforts to Address the

Recruitment and Retention of Nurse Aide and Other Paraprofessional Aide Workers (Sept.

1999).

State Time period Amount appropriated Program description

Arkansas Program began

July 1, 1999.

The wage pass-through appropriation

was $25 million ($7 million state and $18

million federal dollars) for the nursing

home staff wage enhancement.

The wage pass-through provided an increase of $4.93

on the facility’s daily rate; requires participating facilities

to maintain minimum staffing levels. Facilities will be

required to submit quarterly staffing reports to the

Arkansas Department of Human Services for review to

determine compliance with the minimum staffing

requirements. The Department may also perform

periodic on-site reviews—which may be unannounced—

to determine the correctness and completeness of the

quarterly reports. Failure to meet minimum staffing

requirements will result in the repayment by the facility of

100 percent of the enhancement payments received for

services occurring in that quarter.
Appendix III

State Efforts to Address Nursing Home

Staffing Shortages

Page 54 GAO/HEHS-00-197 Nursing Home Quality Initiatives

California First wage passthrough

implemented on

August 1, 1999. A

second wage passthrough was

implemented

August 1, 2000.

For the 1999 pass-through, the estimated

annual total cost was $51.2 million ($25.6

million state and $25.6 million federal

dollars); for the 2000 pass-through, the

estimated annual total cost was $148.4

million ($74.2 million state and $74.2

million federal).

The 1999 wage pass-through provided funds for salary,

wage and benefit increases for nursing facility direct care

staff—registered nurses, licensed vocational nurses,

and nurse assistants. The second wage pass-through in

2000 was expanded to include other staff such as

housekeeping and dietary staff. The pass-through is

calculated on a per-patient-day basis and added to the

per diem rate paid to each facility. Compliance of

facilities will be on a retrospective basis, with a sample of

facilities being audited. Facilities that did not comply

with the wage pass-through provisions will be subject to

recoupment of the undistributed wage pass-through

funds plus a 10 percent penalty.

Connecticut State fiscal year

2000

The state legislature appropriated a wage

enhancement for nursing homes of $75

million ($37.5 million state and $37.5

million federal) for state FY 2000. The

state has appropriated $77 million ($38.5

million state and $38.5 million federal) for

the state FY 2001 wage enhancement.

The facility’s share of the enhancement program funds is

based upon its percentage of total direct and indirect

costs in relation to all facilities, adjusted for Medicaid

days. Enhancement payments can be used for wage,

benefit, and staffing increases for a nursing home. The

Commissioner of the Connecticut Department of Social

Services may require facilities to file cost reporting

forms, in addition to the annual cost report, to verify the

appropriate application of wage, benefit, and staffing

enhancement rate adjustment payments.

Florida Program began

April 1, 2000.

Appropriated approximately $32 million

($13.9 million state and $18.1 million

federal) annually for a “direct care staff

adjustment.”

The funds are to be used to reimburse nursing facilities

for the costs of hiring additional certified nursing

assistants and licensed nurses or for the cost of salary

or benefit enhancements to retain such staff. All

providers receiving the additional funds must provide

documentation of direct care expenditures over that time

period. The documentation is to be submitted to the

Florida Agency for Health Care Administration in a

format similar to the base data period documentation.

Any amount deemed not to have been appropriately

expended is to be reimbursed to the Agency. Cost report

audits will be conducted.

Kansas Program began in

September 1999.

$4.3 million (approximately $1.7 million

state and approximately $2.6 million

federal) was awarded in total funds for

state FY 2000 to establish a wage passthrough program for nursing facilities.

Another $4.2 million (approximately $1.7

million state and approximately $2.5

million federal) was appropriated for FY

2001, but it is contingent upon HCFA’s

approval of a state plan amendment.

Funds are targeted for nursing facility front-line staff.

Providers apply for a per diem add-on to the Medicaid

rate and are responsible for documenting legitimate use

of funds through quarterly reports. Statistics are being

collected on turnover.

(Continued From Previous Page)

State Time period Amount appropriated Program description
Appendix III

State Efforts to Address Nursing Home

Staffing Shortages

Page 55 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Louisiana Legislature passed

a bill during the first

special session of

2000; program has

not yet been

implemented.

Louisiana’s wage pass-through is

contingent upon HCFA’s approval of a

state plan amendment.

A portion of the earnings on the investment from the

state’s Medicaid Trust Fund for the Elderly are to be

used for providing for a wage enhancement for direct

care personnel working in Medicaid-certified nursing

homes in accordance with a plan established by the

Department of Health and Hospitals and representatives

of the nursing facility industry. The plan will provide for a

direct pass-through of the costs of such wage

enhancements in a manner to ensure that the nursing

home rate is adjusted to reflect the full costs of such

wage enhancement.

Maine Program began

July 1, 1999.

$3.68 million ($1.25 million state and

$2.43 million federal) was provided for a

one-time nursing home supplement for

the direct care rate.

The supplement is intended to address the problem of

recruitment and retention of nonadministrative staff.

Facilities had flexibility to use it for either new positions

or increasing wages of direct care staff. State will audit

through cost reports.

Maryland Program not yet

implemented.

Intention is to provide $10 million in

general funds for FY 2002 and $10 million

in general funds for FY 2003.

Intent of the General Assembly is that the Governor

provide in the state budget for FY 2002 and FY 2003

additional funds to increase payments in the Nursing

Service Cost Center of the Medicaid nursing home

reimbursement. The funds are to be used to enable

nursing homes to address recommendations of the

state’s Task Force on Quality of Care in Nursing Homes

in order to (1) increase hours of direct care to residents;

(2) increase nursing staff; and (3) increase wages, fringe

benefits, and other forms of compensation provided to

direct care personnel. Expenditures by nursing homes

shall be subject to audit and cost settlement by the

Maryland Department of Health and Mental Hygiene.

Massachusetts Program began

January 2000.

According to the state’s fiscal year 2001

budget, appropriated $35 million ($17.5

million state and $17.5 million federal) for

the exclusive purpose of funding

increases in wages and related employee

costs for certified nurse’s aides at nursing

facilities.

The Massachusetts Division of Medical Assistance and

the Massachusetts Division of Health Care Finance and

Policy were to establish criteria for the disbursement of

the funds appropriated and report to the Senate and

House Committees on Ways and Means on the criteria

to be used by September 1, 2000. Criteria will mandate

the degree to which such nursing facilities provide

enhanced wages for certified nurse’s aides and report to

the two committees on the wage increases given at each

facility by January 4, 2001.

(Continued From Previous Page)

State Time period Amount appropriated Program description
Appendix III

State Efforts to Address Nursing Home

Staffing Shortages

Page 56 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Michigan The state

established its first

nursing home staff

wage pass-through

in state FY 1990

with limited

participation. The

state’s most current

wage pass-through

is for state FY 2000.

In state FY 2000, approximately $33.6

million (approximately $15.08 million state

and approximately $18.52 million federal)

has been appropriated for a wage passthrough. For state FY 2001, the amount

for the wage pass-through is not

specifically identified. The FY 2001

appropriated inflationary allowance may

be used to cover any allowable variable

cost increases and is sufficient to provide

a 50-cent-per-hour wage increase for

nurse’s aides at all facilities.

The current state FY 2000 wage pass-through provides

a maximum increase of an additional 75 cents per hour

and the reimbursement limit is to be applied on a peremployee basis. The provider must report actual wage

pass-through cost data in the annual cost report for the

wage pass-through year. In addition to a copy of the

facility’s written policy for internal administration of the

wage pass-through, the provider must maintain, at the

facility, information on individual employee wage

increases and new benefits costs. The support

schedule and associated payroll records must be

available for Medicaid program audit verification. Failure

to provide all supporting data for audit will result in

disallowance of the wage pass-through reimbursement.

Minnesota First wage

adjustment bill

passed in 1998 for

state FY 1999.

There have been

two other separate

wage adjustment

bills for state FY

2000 and state FY

2001.

In state FY 2001, approximately $92.7

million (approximately $45.4 million state

and approximately $47.3 million federal)

was appropriated for a wage adjustment.

For the first two wage adjustment bills, the legislation left

it to the nursing facility to decide which employees to

give the money to. For the latest wage adjustment, they

passed a bill that provides for everyone in the nursing

facility (except the administrator, central office

employees, and anyone paid through a management

fee) to get an equal per-hour increase in wages. Each

facility’s per diem rate was increased $1.00 plus a

portion of $3.13 depending on facilities’ average

operating rate. Facilities must file a distribution plan

showing how they plan to give the money to their

employees. The plans must then be approved by the

Minnesota Department of Human Services before the

rate adjustment is implemented. The plans are also

subject to a look-behind audit.

Missouri Program not yet

implemented.

Appropriation formally approved for $22.7

million (approximately $8.9 million state

and approximately $13.8 million federal)

for quality-of-care wage enhancement for

direct care staff of nursing facilities.

Proposed regulation currently drafted and receiving

comments.

Montana Program began

July 1, 1999.

In state FY 2000, approximately $2.9

million (approximately $800,000 state and

approximately $2.1 million federal) was

appropriated for a nursing facility wage

add-on for enhancing the wages of direct

care staff in nursing homes. For state FY

2001, approximately $5.9 million

(approximately $1.6 million state and $4.3

million federal) was appropriated for the

nursing facility wage add-on.

For the state FY 2000 program, the nursing homes could

receive up to a $2.14 per Medicaid day add-on to the

rate for direct care staff wages. The nursing facility was

given flexibility in deciding which full-time-equivalent

classification would receive add-on (staff with patient

contact and food service were possible groups).

Providers were required to submit supporting

documentation for approval that detailed how the funds

would be used to provide for direct care staff wage

increases.

(Continued From Previous Page)

State Time period Amount appropriated Program description
Appendix III

State Efforts to Address Nursing Home

Staffing Shortages

Page 57 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Oklahoma First wage

enhancement

program was

implemented May

1998. The state

had a wage

enhancement in

state FY 1999 and

FY 2000 and

currently has one

for state FY 2001.

The estimated cost for the state FY 2001

wage enhancement is approximately $19

million (approximately $5.6 million state

and approximately $13.7 million federal).

The wage enhancement is an adjustment to the nursing

facility’s per diem rate equal to $3.15 per patient day.

The amount of the rate increase for nursing facilities was

calculated assuming that all nursing facilities would meet

the state’s minimum staffing requirements. Staffing

ratios will be reviewed on a monthly basis for all nursing

facilities. Those that demonstrate “willful”

noncompliance with staffing ratios will be subject to a

sizeable penalty.

South Carolina First wage add-on

began December

1, 1998. Second

wage add-on was

implemented

October 1, 1999.

The appropriation for the state FY 2000

wage add-on was approximately $4.5

million (approximately $1.35 million state

and approximately $3.15 million federal).

Effective December 1, 1998, a 75-cents per patient day

add-on was included in each nursing facility’s

reimbursement rate. The add-on was provided to assist

nursing facilities in retaining currently employed nurse’s

aide staff. If a nursing facility is cited during a survey for

inadequate nurse aide staff during the time period in

which the 75-cent add-on is provided, it will be required

to submit financial and statistical information relating to

the expenditure. If, as a result of the review, a payback

is warranted, it may not exceed the total amount

reimbursed through the add-on. Effective October 1,

1999, a certified nurse’s aide vacancy add-on was

included in each qualifying facility’s reimbursement rate.

The add-on will be provided in order that nursing

facilities can address the industrywide nurse’s aide

staffing turnover problem that was enhanced by a

change in the minimum staffing requirements.

Texas Program began

May 1, 2000.

The Texas Enhanced Direct Care Staff

Rate program provided $41 million ($15.8

million in general revenue funds and

$25.2 million in federal funds) during state

FY 2000 for reimbursement increases for

nursing homes and hospice room and

board (in nursing homes) and is providing

$40.9 million ($15.8 million state and

$25.1 million federal) during state FY

2001.

There is no specified portion of the funds that are to be

used for nursing homes versus hospice room and board.

The funds provide additional funds for direct care staff of

nursing homes—registered nurses, licensed vocational

nurses, and certified nurse’s aides. Participation in the

program requires the facility to maintain certain direct

care staffing levels. All contracted facilities will provide

the Texas Department of Human Services an Annual

Staffing and Compensation Report reflecting the

activities of the facility while delivering contracted

services over the rate year. This report will be used as

the basis for determining compliance with the staffing

requirements and recoupment amounts. Also, the

Department requires a 6-month staffing report that will

be used as the basis for determining compliance with

the staffing requirements and recoupment amounts.

(Continued From Previous Page)

State Time period Amount appropriated Program description
Appendix III

State Efforts to Address Nursing Home

Staffing Shortages

Page 58 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Utah State had

previously

implemented a

pass-through

program in 1990

and 1992 for

nursing facilities.

The most recent

nursing facility

pass-through

program began

July 1, 1998.

For the 1998 program, the state

implemented a wage pass-through, which

added $3.06 per day for nurse’s aides—

approximately $3.5 million (approximately

$945,000 state and $2.56 million federal)

was appropriated for the wage passthrough.

Hourly wages for nurse’s aides were monitored to

ensure funding was directed to the wage problem. In

addition, the nursing facility Medicaid payment rate has a

“nursing component” that is “provider specific.”

Payments are based on nursing costs reported for the

prior year. Therefore, if nursing expenditures are

reduced, future payment rates reflect that decrease.

Vermont Program began

July 1, 1999.

$4 million ($1.52 million state and $2.48

million federal) was appropriated for the

wage pass-through.

The supplement is to be calculated as the prorated

share of the net revenues based on the ratio of its

nursing wages, salaries, and fringe benefits to the total

of all nursing wages, salaries, and fringe benefits paid by

Vermont nursing homes participating in the Medicaid

program as reported on their 1997 Medicaid cost

reports. The supplement is then added to the facility’s

total per diem rate. Within 60 days after the end of each

state fiscal year during which wage supplement

payments are made, each facility is to file on forms

prescribed by the Vermont Division of Rate Setting a

report of the wages, salaries, fringe benefits, and

bonuses paid to employees during the state fiscal year.

Virginia Program began

July 1, 1999

$21.7 million (approximately $10.5 million

state and approximately $11.2 million

federal) was appropriated for the wage

supplement.

The nursing home wage supplement was to compensate

nursing facilities for increased costs of certified nurse’s

aides and other increases in direct care costs. The

nursing homes are to report what was actually spent,

and if the facility did not spend the money for the wage

supplement, then it must be returned to the state.

Wisconsin Program began

October 1, 1999.

The statewide amount of the nursing

home wage pass-through is not to exceed

$8.3 million (approximately $3.42 million

state and $4.88 million federal) in state FY

1999-2000 and $11.1 million

(approximately $4.53 million state and

$6.57 million federal) in state FY 2000-

2001.

A nursing home wage pass-through is provided to

facilities to increase wages and fringe benefits, or to

increase staff hours equal to 5% of the total amount of

wages reported in a facility’s 1998 cost report.

(Continued From Previous Page)

State Time period Amount appropriated Program description
Page 59 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix IV

Additional Information on Federal Oversight

Activities ApendxiIV

Federal Comparative

Surveys

Because HCFA does not expect to implement a centralized database on

comparative surveys until 2001, we manually compiled a summary of the

157 comparative surveys conducted between October 1998 and May 2000

by obtaining copies of the state and corresponding federal survey from

each regional office. Table 16 presents the results of our analysis.

• Compared with the results of state surveys, 70 percent of federal

comparative surveys found more serious care problems. On average,

state surveyors identified 3 deficiencies per home, while federal

surveyors found almost 10.

• Significant differences emerged among the 10 regions responsible for

conducting comparative surveys. In August 1999, HCFA instructed

regions to start their federal comparative surveys within 14 to 28 days

after the state’s survey was completed. Our analysis found that HCFA’s

New York and Philadelphia regions both had an average 39-day time

period between the conclusion of the state survey and the beginning of

the federal comparative survey. In contrast, the average interval for the

Denver region was 23 days. Our analysis also found that of the 10

regions, only Chicago cited fewer deficiencies, on average, than state

surveyors. Similarly, Boston was the only region to cite deficiencies at a

lower scope and severity level than state surveyors.
Appendix IV

Additional Information on Federal Oversight

Activities

Page 60 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Table 16: GAO Analysis of the Results of Federal Comparative Surveys Conducted Between October 1998 and May 2000

New Federal Nursing

Home Performance

Standards for States

Beginning October 2000, HCFA plans to track the states’ compliance with

an initial set of seven state performance standards. Based largely on

standards established for the SAQIP program, the seven standards are

scheduled to replace states’ self-evaluation of compliance. HCFA is in the

process of developing protocols to ensure that the regions consistently

enforce the seven standards. Table 17 summarizes the standards, indicates

whether the state or HCFA was previously responsible for assessing

compliance, and lists the data HCFA expects the regions to use in

evaluating performance.

HCFA region

Number of

surveys

Number of surveys

where scope and

severity of state

deficiency was higher

than that of federal

deficiency

Number of

surveys where scope

and severity of federal

deficiency was higher

than that of state

deficiency

Average

number of

days between

surveys

Average

number of

state

deficiencies

Average

number of

federal

deficiencies

Boston 13 4 3 28.6 3.7 5.6

New York 7 0 6 38.9 4.1 12.0

Philadelphia 16 2 11 39.1 2.8 6.3

Atlanta 28 5 19 28.6 3.7 8.1

Chicago 22 4 13 33.1 2.9 2.1

Dallas 23 0 23 25.1 2.0 14.5

Kansas City 13 1 9 32.8 3.2 14.2

Denver 16 1 11 22.6 2.3 11.7

San Francisco 10 0 10 24.5 7.3 23.6

Seattle 9 4 5 27.2 5.8 9.3

Total 157 21 110 29.6 3.4 9.9
Appendix IV

Additional Information on Federal Oversight

Activities

Page 61 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Table 17: New State Performance Standards, Relationship to SAQIP, and Federal Evaluation Data Sources

a

The current SAQIP Nursing Home Performance Standards for State Agencies are divided into two

sets of performance standards—one for states and one for HCFA regional offices. The states are

responsible for self-assessing their ability to meet the seven state standards and reporting those

results to their regional offices. The regional offices have an additional four performance standards

they are responsible for ensuring their state survey agencies meet. The “source of new standard”

column indicates whether it is a state or HCFA SAQIP standard.

Results of Recent

Federal Surveys in

Oklahoma

Between April and June 2000, HCFA conducted full federal surveys at the

16 nursing homes suspected of bribing the state survey agency director.1

This number is significant because most states have only two full federal

surveys each year. Figure 1 demonstrates that compared with the most

recent state survey, federal surveyors found significantly more quality-ofcare problems at these homes.

State performance area

New state performance standard

(effective October 1, 2000)

Source of new

performance

standarda Data source

Conduct of the

survey

Surveys are planned, scheduled, and

conducted in a timely manner.

SAQIP (State) OSCAR

Deficiency

documentation

Survey findings are supportable. SAQIP (State) State survey statement of

deficiencies

Consistency in survey

performance

Certifications of homes’ compliance with

federal standards are fully documented and

consistent with applicable law, regulations,

and general instructions.

SAQIP (State) Federal Monitoring Surveys

Enforcement actions When certifying noncompliance, adverse

action procedures set forth in regulations and

general instructions are to be adhered to.

SAQIP (State) Long-Term Care Enforcement

Tracking System

Federal expenditure

monitoring

All program expenditures and charges to be

substantiated to HHS Secretary.

SAQIP (HCFA) State Survey Agency

Budget/Expenditure Report and

Nursing Home Initiative

Expenditure Report

Complaints investigation Conducting and reporting of complaint

investigations is timely and accurate and

complies with general instructions for

complaint handling.

SAQIP (State) OSCAR

OSCAR data entry Accurate and timely data entry into OSCAR. SAQIP (HCFA) OSCAR

1

Four of these 16 federal surveys would qualify as comparatives because 2 months or less

had elapsed since the most recent state survey.
Appendix IV

Additional Information on Federal Oversight

Activities

Page 62 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Figure 1: Comparison of State and Federal Quality-of-Care Deficiencies for 16 Nursing Homes in Oklahoma

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

0

1

0

2

1

2

1

5

3

4

1

3

0

4 44

1

12

11

9

8

6 6

5

4

3 3

2 2

1

0 0

Number of State Deficiencies

Number of Federal Deficiencies

Nursing Homes
Page 63 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix V

Comments From the Health Care Financing

Administration ApendxiV
Appendix V

Comments From the Health Care Financing

Administration

Page 64 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix V

Comments From the Health Care Financing

Administration

Page 65 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Page 66 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix VI

Comments From California's Department of

Health Services ApendxiVI
Appendix VI

Comments From California's Department of

Health Services

Page 67 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix VI

Comments From California's Department of

Health Services

Page 68 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix VI

Comments From California's Department of

Health Services

Page 69 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Page 70 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix VII

Comments From Michigan's Department of

Consumer and Industry Services ApendxiVI
Appendix VII

Comments From Michigan's Department of

Consumer and Industry Services

Page 71 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix VII

Comments From Michigan's Department of

Consumer and Industry Services

Page 72 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix VII

Comments From Michigan's Department of

Consumer and Industry Services

Page 73 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Page 74 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix VIII

Comments From Missouri's Department of

Social Services ApendxiVI
Appendix VIII

Comments From Missouri's Department of

Social Services

Page 75 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix VIII

Comments From Missouri's Department of

Social Services

Page 76 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix VIII

Comments From Missouri's Department of

Social Services

Page 77 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix VIII

Comments From Missouri's Department of

Social Services

Page 78 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix VIII

Comments From Missouri's Department of

Social Services

Page 79 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Appendix VIII

Comments From Missouri's Department of

Social Services

Page 80 GAO/HEHS-00-197 Nursing Home Quality Initiatives
Page 81 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix IX

Comments From Washington's Department of

Social and Health Services ApendxiIX
Page 82 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Appendix X

GAO Contact and Staff Acknowledgments ApendxiX

GAO Contact Walter Ochinko, (202) 512-7157

Staff

Acknowledgments

This report was prepared by Connie Peebles Barrow, Jack Brennan, Leslie

V. Gordon, Bob Lappi, Peter Oswald, Sangeetha Raghunathan, Janet

Rosenblad, Peter Schmidt, Don Walthall, and Opal Winebrenner under the

direction of Walter Ochinko.
Page 83 GAO/HEHS-00-197 Nursing Home Quality Initiatives

Related GAO Products

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would

Better Ensure Quality (GAO/HEHS-00-6, Nov. 4, 1999).

Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies to

Better Ensure Quality Care (GAO/T-HEHS-00-27, Nov. 4, 1999).

Nursing Home Oversight: Industry Examples Do Not Demonstrate That

Regulatory Actions Were Unreasonable (GAO/HEHS-99-154R, Aug. 13,

1999).

Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will

Require Continued Commitment (GAO/T-HEHS-99-155, June 30, 1999).

Nursing Homes: Proposal to Enhance Oversight of Poorly Performing

Homes Has Merit (GAO/HEHS-99-157, June 30, 1999).

Nursing Homes: Complaint Investigation Processes in Maryland (GAO/THEHS-99-146, June 15, 1999).

Nursing Homes: Complaint Investigation Processes Often Inadequate to

Protect Residents (GAO/HEHS-99-80, Mar. 22, 1999).

Nursing Homes: Stronger Complaint and Enforcement Practices Needed to

Better Ensure Adequate Care (GAO/T-HEHS-99-89, Mar. 22, 1999).

Nursing Homes: Additional Steps Needed to Strengthen Enforcement of

Federal Quality Standards (GAO/HEHS-99-46, Mar. 18, 1999).

California Nursing Homes: Federal and State Oversight Inadequate to

Protect Residents in Homes With Serious Care Violations (GAO/T-HEHS-98-

219, July 28, 1998).

California Nursing Homes: Care Problems Persist Despite Federal and

State Oversight (GAO/HEHS-98-202, July 27, 1998).

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