Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

MARCH 1999 

OEI-02-99-00060 

Quality of Care in Nursing Homes: 

An Overview 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 

protect the integrity of the Department of Health and Human Services programs as well as the 

health and welfare of beneficiaries served by them. This statutory mission is carried out through a 

nationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The 

Inspector General informs the Secretary of program and management problems and recommends 

legislative, regulatory, and operational approaches to correct them. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 

Inspector General. It conducts short-term management and program evaluations (called 

inspections) that focus on issues of concern to the Department, the Congress, and the public. The 

inspection reports provide findings and recommendations on the efficiency, vulnerability, and 

effectiveness of departmental programs. 

OEI's New York regional office prepared this report under the direction of John I. Molnar, 

Regional Inspector General and Renee C. Dunn, Deputy Regional Inspector General. Principal 

OEI staff included: 

REGION HEADQUARTERS 

Demetra Arapakos Susan Burbach 

To obtain copies of this report, please call the New York Regional Office at 212-264-2000. 

Reports are also available on the World Wide Web at our home page address: 

http://www.dhhs.gov/progorg/oei 
EXECUTIVE SUMMARY 

PURPOSE 

To describe general conditions in nursing homes and assess the overall capacity of systems 

designed to monitor and improve quality of care. 

This report is based primarily on recent studies conducted by the Office of Inspector 

General (OIG) on quality of care in nursing homes. It draws additionally upon work 

completed by the General Accounting Office (GAO), the Health Care Financing 

Administration (HCFA), and others. The report summarizes steps taken recently and now 

underway to address weaknesses in the system. It also provides a long term program of 

action and research needed to assure nursing home care meets government standards for 

quality of care. 

BACKGROUND 

While some studies indicate that changes in law and regulations may have had a positive 

effect on improving the environment and overall health care of nursing home patients, 

recent reports by HCFA and GAO have raised serious concerns about patient care and wellbeing. The Senate Special Committee on Aging held hearings in the summer of 1998 on 

these reports. At the same time, the OIG undertook a series of studies aimed at assessing 

the quality of care in nursing homes. 

Various systems are in place to monitor and promote quality of care in nursing homes. 

These include the State survey and certification system, the State Long Term Care 

Ombudsman Program, State resident abuse safeguards, law enforcement, and legislative 

reforms established by the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). 

We used multiple methods for this report. They consist of an analysis of national nursing 

home program data, a review of written program procedures, structured telephone 

interviews, an examination of nursing home survey results availability, a literature review, 

and an analysis of nursing home legislation. 

FINDINGS 

Serious Quality of Care Problems Persist in Nursing Homes 

An analysis of currently available program data reveals that problems with quality of care 

continue to exist in nursing homes. First, according to survey and certification data, 13 of 

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Quality of Care in Nursing Homes: An Overview 1 OEI-02-99-00060 
25 “quality of care” deficiencies have increased in recent years. They include a lack of 

supervision to prevent accidents, improper care for pressure sores, and lack of proper care 

for activities of daily living. At the same time, ombudsman complaints have been steadily 

increasing since 1989 and complaints about resident care, such as pressure sores and 

hygiene, have been particularly prevalent. Since 1995, the OIG has excluded 668 nursing 

home workers from participation in the Medicare/Medicaid programs as a result of a 

conviction related to patient abuse or neglect. On a related note, approximately one percent 

or more of nursing home residents have had an experience serious enough to register an 

abuse complaint. Lastly, survey and certification data, as well as discussions with survey 

and certification staff and ombudsmen, reveal that some nursing homes are chronically 

substandard. 

Experienced officials with inside information based on onsite visits to nursing homes, 

including State survey directors, surveyors, ombudsmen, and State Aging Unit Directors, 

express some reservations about relying exclusively on program data to gauge conditions in 

nursing homes. Nevertheless, they confirm that problems persist in nursing homes, such as 

malnutrition, abuse, pressure sores, and over-medication. The problems they identify are 

similar to the problems highlighted in their program reporting systems. 

Evidence Suggests Inadequate Levels of Nursing Home Staff Contribute to Quality 

of Care Problems 

In all 10 sample States, survey and certification staff, State and local ombudsmen, as well as 

State Aging Unit Directors identify inadequate staffing levels as one of the major problems 

in nursing homes. Most believe these staffing shortages lead to chronic quality of care 

problems, such as failure to adequately treat and prevent pressure sores. 

The type and extent of survey deficiencies and Ombudsman program complaints also 

suggest that nursing home staffing levels are inadequate. Common personal care problems 

such as lack of nutrition and poor care for incontinence suggest that staffing is inadequate 

to provide the level of care needed to avoid these problems. Furthermore, specific 

complaints about nursing home staff are some of the most common types of Ombudsman 

program complaints in 1997. 

Survey and Certification Agencies are Following Required Standard Protocols but 

Weaknesses in the Survey System Itself Limit Their Effectiveness 

State survey and certification agencies monitor nursing home care with timely and standard 

surveys, complaint procedures, and other State procedures. However, the survey and 

certification system has several weaknesses, such as the predictability of surveys. Although 

all States use unannounced surveys, State directors and surveyors believe that nursing 

homes can anticipate their survey date and modify their procedures to avoid being cited for 

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Quality of Care in Nursing Homes: An Overview 2 OEI-02-99-00060 
deficiencies. The system is also limited by weak enforcement, including inadequate followup and common inaction on abuse complaints. State directors and surveyors believe that 

the current process allows deficient facilities too many opportunities to avoid enforcement 

action. Lastly, survey and certification agencies have some staffing constraints and do not 

always effectively coordinate with ombudsmen. 

While the Ombudsman Program is Well Designed, Inadequate Resources Limit Its 

Capacity 

The Ombudsman program has several functions to promote and monitor quality of care in 

nursing homes, including identifying and resolving complaints, making regular visits to 

nursing homes, and engaging in a variety of different advocacy activities. While lacking 

enforcement and regulatory oversight, ombudsmen act as independent advocates and work 

solely on behalf of residents to ensure they have a voice in their own care. However, the 

Ombudsman program is limited by inadequate resources, including inadequate staffing. 

Only 1 of 10 States in our sample had a paid ombudsman to bed ratio higher than the 

standard suggested by the Institute of Medicine. This lack of adequate staffing is 

particularly evident in the limited extent to which ombudsmen make regular nursing homes 

visits. The program is further constrained by the lack of a common standard for complaint 

response and resolution, inconsistent advocacy efforts, a lack of support, and limited 

collaboration with surveyors. 

State Systems to Safeguard Nursing Home Residents from Abuse are Inconsistent 

and Unreliable 

Based on findings from a recent OIG audit, “Safeguarding Long Term Care Residents,” A12-97-0003, it appears that some weaknesses exist in State efforts to safeguard nursing 

home residents from abuse. This audit revealed great diversity in the way States 

systematically identify, report, and investigate suspected abuse, and it found that there was 

no assurance that individuals who posed a risk of abuse were systematically identified and 

barred from nursing home employment. Additionally, a more in-depth audit of Maryland 

examined eight nursing homes in the State and found that five percent of employees in those 

homes had criminal records. 

Public Awareness and Access to Nursing Home Survey Results is Limited 

Public awareness of nursing home survey results is limited and these results are not always 

readily available. Two-thirds of 155 families interviewed in eight sample cities did not 

know that the results of Federal and State nursing home inspections are available on 

request. Additionally, half were unaware such inspections are required, and only 15 had 

ever requested a copy of survey results. Of the 11 who obtained a copy, 6 said the results 

were not based on the most recent survey. Furthermore, when staff from the OIG visited 

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Quality of Care in Nursing Homes: An Overview 3 OEI-02-99-00060 
the 32 sampled nursing homes, most did not fully meet the requirements for making survey 

results available. The HCFA has established a more easily accessible version of nursing 

home survey results with an internet site entitled Nursing Home Compare which appears 

promising. 

New Initiatives Based on Law Enforcement Approaches are Being Considered 

Initiatives that use the False Claims Act and other law enforcement approaches as a way to 

strengthen nursing homes are relatively new. National task forces comprised of 

representatives from the Department of Justice, HCFA, OIG, and others are being formed 

at the local, State, and national levels. These groups will examine the full range of 

enforcement issues and develop corresponding action plans for each. By targeting key 

strategic areas and coordinating among the various agencies responsible for nursing home 

enforcement, these initiatives appear promising. However, it is too soon to determine their 

full impact. 

Nursing Home Reforms Established by OBRA 1987 Have Not Been Systematically 

Assessed 

The nursing home reforms created by OBRA 1987 impacted both nursing home systems 

and nursing home care. The OBRA 1987 mandated that residents be given certain rights 

and services and also added several administrative standards that nursing homes are 

required to meet. It further changed enforcement and survey procedures. While it has now 

been more than a decade later since this legislation was passed, there has been no systematic 

assessment of its extensive agenda and no methodical evaluation of whether the reforms it 

intended are actually working. While some studies have attributed positive changes to 

OBRA 1987, the lack of a systematic review makes it difficult to determine if this major 

legislation has been successful in improving nursing home care. 

AN AGENDA FOR CONTINUING IMPROVEMENT IN NURSING HOME 

CARE 

Since OBRA 1987 was first passed, real improvements have been made in nursing home 

care. More recently, considerable attention has been paid to addressing persisting concerns 

about nursing home conditions and systems. In particular, we commend the Health Care 

Financing Administration (HCFA) for its extensive nursing home initiative since it addresses 

many of these persisting problems. This initiative includes many individual action items 

which should result in positive changes. Additionally, the Administration on Aging (AoA) 

has been taking steps to enhance the Ombudsman program, including improving the 

program reporting system and conducting annual training of ombudsman staff. 

The problems we describe in this report will require continuing attention, possibly for 

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Quality of Care in Nursing Homes: An Overview 4 OEI-02-99-00060 
several years. The broad outline of an effective strategy would include actions to: 

< enhance the survey and certification process;

< strengthen the Ombudsman program with increased resources;

< improve nursing home staffing levels; and,

< improve coordination between State survey agencies and ombudsmen. 

We also believe that further evaluation and progress measurement would make an important 

contribution to efforts to advance nursing home care. We specifically suggest: 

< a systematic assessment of OBRA 1987 and

< the creation of a periodic report card on conditions in nursing homes.

We have incorporated action items from HCFA’s nursing home initiative, AoA’s 

ombudsman activities, recommendations for additional steps to be taken, current OIG work, 

and areas requiring further evaluation into one comprehensive, long term agenda to 

continue improvements in nursing home care. This agenda consists of a three stage 

approach of immediate action, research and evaluation, and continued progress 

measurement. The full agenda can be found on page 28. 

AGENCY COMMENTS 

This report is based primarily on a series of recent studies conducted by the Office of 

Inspector General on nursing home care. They are: 

Nursing Home Survey and Certification: Deficiency Trends, OEI-02-98-00331;

Nursing Home Survey and Certification: Overall Capacity, OEI 02-98-00330;

Long Term Care Ombudsman Program: Complaints Trends, OEI-02-98-00350;

Long Term Care Ombudsman Program: Overall Capacity, OEI-02-98-00351;

Public Access to Nursing Home Survey and Certification Results, OEI-06-98-

00280; and

Safeguarding Long Term Care Residents, A-12-97-0003.

We received detailed comments from HCFA, AoA, and the Assistant Secretary for Planning 

and Evaluation on the above reports. We made modifications in each report to respond to 

the comments received and to reflect the actions already being taken to improve nursing 

home conditions. This overview report also incorporates many of these modifications. We 

encourage everyone to read the individual reports and the comments we received on them. 

The comments are included in each report. 

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Quality of Care in Nursing Homes: An Overview 5 OEI-02-99-00060 
TABLE OF OF CONTENTS 

PAGE

EXECUTIVE SUMMARY ..................................................... 1

INTRODUCTION ........................................................... 7

FINDINGS

Serious Quality of Care Problems Persist .................................... 18

Nursing Home Staffing is Inadequate ....................................... 22

Survey and Certification Follows Protocols but Limited by System Weaknesses ....... 22

Ombudsman Program Well Designed but Lacks Adequate Resources ............... 23

State Resident Abuse Safeguards Inconsistent and Unreliable ..................... 25

Awareness and Access to Survey Results Limited ............................. 25

New Law Enforcement Initiatives Being Considered ........................... 26

OBRA 1987 Lacks Systematic Assessment .................................. 26

AN AGENDA FOR CONTINUING IMPROVEMENT IN NURSING HOME CARE ..... 28

Immediate Action ...................................................... 29

Research and Evaluation ................................................ 30

Progress Measurement .................................................. 32

AGENCY COMMENTS ..................................................... 33

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Quality of Care in Nursing Homes: An Overview 6 OEI-02-99-00060 
INTRODUCTION 

PURPOSE 

To describe general conditions in nursing homes and assess the overall capacity of systems 

designed to monitor and improve quality of care. 

This report is based primarily on recent studies conducted by the Office of Inspector 

General (OIG) on quality of care in nursing homes. It additionally draws upon work 

completed by the General Accounting Office (GAO), the Health Care Financing 

Administration (HCFA), and others. The report summarizes steps recently taken and now 

underway to address weaknesses in the system. It also provides a long term program of 

action and research needed to assure nursing home care meets government standards for 

quality of care. 

BACKGROUND 

While some studies indicate that changes in law and regulations may have had a positive 

effect on improving the environment and overall health care of nursing home residents, 

recent reports by HCFA and GAO have raised serious concerns about residents’ care and 

well-being. The Senate Special Committee on Aging held hearings in the summer of 1998 

on these results. The OIG subsequently undertook a series of studies aimed at assessing 

the quality of care in nursing homes. This report looks at both the general state of nursing 

home care as well as the systems designed to oversee that care. 

Generally, a nursing home is a residential facility offering daily living assistance to 

individuals who are physically or mentally unable to live independently. Residents are 

provided rooms, meals, assistance with daily living, and in most cases, some medical 

treatment. In 1989 Medicare paid $2.8 billion to nursing homes, an amount totaling 4.7 

percent of the Medicare budget. In 1996 this amount had increased to $10.6 billion, 

totaling 9 percent of the Medicare budget. Medicaid expenditures for nursing homes in 

1996 totaled $24.3 billion. 

In 1986, the Institute of Medicine conducted a study on nursing home regulations and 

reported prevalent problems regarding the quality of care for nursing home residents, as 

well as the need for stronger Federal regulations. Just one year later, GAO reported that 

over one third of nursing homes were operating below Federal minimum standards. These 

reports, along with widespread concern regarding nursing home conditions, persuaded 

Congress to pass the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). As a part 

of OBRA 1987, Congress passed the comprehensive Nursing Home Reform Act (PL 100-

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Quality of Care in Nursing Homes: An Overview 7 OEI-02-99-00060 
203). These actions expanded requirements that nursing facilities had to comply with in 

order to obtain Medicare certification. The Nursing Home Reform Act also strengthened 

the rights to nursing home residents, such as the right to be free of physical or mental abuse, 

and the right to be free from chemical and physical restraints. It additionally altered the 

enforcement of Federal standards for nursing home care. 

Medicare Nursing Home Requirements 

The Health Care Financing Administration (HCFA) has the responsibility to act as a 

“prudent purchaser” by ensuring that nursing homes participating in Medicare and/or 

Medicaid meet certain requirements for quality environment and services. These 

requirements are found at 42 Code of Federal Regulations (CFR) Part 483, Subpart B. The 

Nursing Home Reform Act added to these requirements by introducing an increased focus 

on the quality of life and care, the importance of the individual resident, the need to help 

residents reach the “highest practicable level” of functioning, and the requirement that 

residents be interviewed and assessed. 

Nursing homes must “conduct standardized, reproducible assessments of each resident’s 

functional capacity...” within 14 days of admission. Additionally, periodic assessments must 

occur throughout the duration of a patient’s stay in order to continually address their 

fluctuating needs. With the Nursing Home Reform Act, HCFA developed the Minimum 

Data Set (MDS) which is comprised of core elements and common definitions used in 

conducting resident assessments. The Minimum Data Set collects data through resident 

assessment measures, with subsequent progress or decline documented in electronic format. 

The Nursing Home Reform Act additionally established new enforcement provisions, which 

were enacted when the State Operations Manual (SOM) became effective on July 1, 1995. 

The HCFA had several process goals during the implementation of these new provisions: 

promoting consistency through extensive training; linking appropriate remedies to 

deficiencies; and avoiding unnecessary procedures. Congress recognized that one 

enforcement response would not be appropriate for all deficiencies. It therefore established 

enforcement policies that gave HCFA the license to impose a variety of corrective measures 

for noncompliant facilities. These include: temporary management; denial of payment for 

new admissions; civil money penalties; termination of the facility; and State monitoring of 

the facility. States are responsible for establishing their own remedy guidelines. 

Following the implementation of the State Operations Manual, HCFA also imposed a 

number of administrative changes on enforcement procedures . In June 1995, HCFA 

enacted a temporary moratorium on the collection of certain lower-level money penalties 

(CMPs). This moratorium preceded HCFA’s decision to alter the State Operations Manual 

in December of 1996. “Civil monetary penalties are now limited to situations of immediate 

jeopardy or to nursing facilities that are poor performers or have serious deficiencies that 

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Quality of Care in Nursing Homes: An Overview 8 OEI-02-99-00060 
are not corrected at the time of a revisit.” Additional changes by HCFA redefined the scope 

of deficiencies, permitted States to avoid revisits in facilities that have lower level 

deficiencies, and established new terms to define facilities that are not in substantial 

compliance. 

Nursing Home Systems 

Survey and Certification. All nursing homes participating in Medicare and/or Medicaid 

must be certified in meeting certain Federal requirements. The Nursing Home Reform Act 

defines the State survey and certification process for determining nursing home compliance 

with these Federal standards. The HCFA is responsible for certifying Medicare and duallyeligible facilities, while States are responsible for Medicaid only facilities. Nursing home 

certification is achieved through routine surveys, and HCFA contracts with States to 

perform such surveys for Medicare and dually-eligible nursing homes, in addition to those 

they perform for Medicaid nursing homes. 

State surveys determine the compliance or noncompliance of nursing homes. When a 

nursing home fails to meet a specific requirement, surveyors give it a deficiency or citation. 

Generally, there are 20 principles that are considered in the citation of deficiencies on the 

HCFA-2567. Surveyors also provide the reasons justifying any resulting enforcement 

action and the record on which to defend that action in the appeals process. State survey 

teams generally consist of multi-disciplinary professionals and must include a registered 

professional nurse. Other professionals who may be on the survey team include social 

workers, therapists, dieticians, pharmacists, administrators, and physicians. 

Each State is also required to maintain written procedures and adequate staff to investigate 

complaints of violations at nursing homes. States must review all allegations of resident 

neglect and abuse, and misappropriation of resident property. All allegations, regardless of 

source, must be reviewed in a timely manner. If an allegation is found to have occurred, the 

State must notify, in writing, the individuals implicated and the administrator of the nursing 

home where the incident transpired. 

A new survey and certification process was implemented in 1995. All nursing facilities are 

now subject to an unannounced standard survey “no later than 15 months after the date of 

the previous standard survey.” Since the Statewide average interval between standard 

surveys “must be 12 months or less,” this creates a Federal standard survey window 

between 9 and 15 months. Each standard survey includes a stratified case mix of nursing 

home residents, and measures their medical, nursing and rehabilitative care, dietary and 

nutrition services, activities, social participation, sanitation, infection control, and physical 

environment. Written plans of care are reviewed to determine their adequacy and an audit 

of residents’ assessments are conducted to determine the accuracy of such assessments. 

There is also a review of facility compliance with residents’ rights. 

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Quality of Care in Nursing Homes: An Overview 9 OEI-02-99-00060 
In addition to regular surveys, States also conduct “special” and “extended” surveys. 

Special surveys may be conducted within two months of any change in ownership, 

administration, management, or director of nursing to determine if the change is having an 

effect on the quality of care in the nursing home. Extended surveys are performed 

immediately or within two weeks after the standard survey completion, on those nursing 

homes found to have provided substandard quality of care. The survey team reviews the 

policies and procedures that produced the substandard care, expands the size of the sample 

of resident’s assessments, reviews staffing, in-service training, and if necessary, contracts 

with consultants. 

Within two months of the State survey, HCFA conducts validation surveys on a 

representative sample of nursing homes in each State utilizing the same survey procedure as 

the State agency. Recently, some HCFA regional offices have chosen to conduct these 

validation surveys simultaneously with the State. The HCFA must survey at least five 

percent of the number of facilities surveyed by the State each year, and this number must 

never be less than five surveys a year. 

In order to improve the survey process, the State Agency Quality Improvement Program 

(SAQIP) was developed to establish a process for State agencies and HCFA regional offices 

to work together to develop the State’s individual quality improvement plans (IQIPs). The 

regional office will assist the State by providing training, technical assistance, and support 

as necessary and appropriate. These individual plans are tailored to the specific needs and 

circumstances of each State, and are revised and improved based on changing needs. The 

SAQIP is designed to promote quality and ongoing improvement in survey and certification 

activities, and applies to all aspects of the survey and certification process. 

The HCFA’s Online Survey Certification and Reporting System (OSCAR) came online in 

October 1991. The HCFA uses OSCAR in its survey of Medicare and Medicaid providers 

to monitor State agency and provider performance. The OSCAR contains data for the 

current and 3 previous surveys. Some of the data is overwritten as new information is 

entered (e.g. number of beds, address, and employment information), but deficiency data 

remains and is tracked historically. The HCFA recently began tracking the scope and 

severity of deficiencies historically as well. Part of the OSCAR data is self-reported 

information by the nursing homes about the facility and its’ patients. The remaining data is 

information generated by the surveyors and is based on deficiencies. The Federal 

regulations detailing survey requirements are classified into 17 major categories. The 

specific survey requirements within these categories were consolidated from 325 individual 

items to 185 items on July 1, 1995. 

Ombudsman Program. In response to growing concerns about poor quality care in 

nursing homes and to protect the interests of residents, the State Long Term Care 

Ombudsman program was established in 1978 in the Older Americans Act. The 

ombudsmen advocate on behalf of residents of all long term care facilities, including nursing 

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Quality of Care in Nursing Homes: An Overview 10 OEI-02-99-00060 
homes, to ensure residents have a strong voice in their own treatment and care.

The Ombudsman Program operates in all fifty States, the District of Columbia, and Puerto

Rico, and in hundreds of local communities, and uses both paid and volunteer staff. The

program receives funding from Federal, State and local levels, and is overseen by the

Administration on Aging (AoA). Most State ombudsmen operate within the State Unit on

Aging, some of which are independent while others are part of a larger State umbrella

agency. The remaining State Ombudsman programs are contracted out and administered by

an entity separate from the State Unit on Aging. These programs are operated by nonprofit organizations, legal services agencies, or by freestanding Ombudsman program

agencies. 

State Ombudsman programs have multiple functions that are mandated by law, many of

which are closely tied to ensuring quality care for long term care residents. They include:

C identifying, investigating, and resolving complaints;

C protecting the legal rights of patients; 

C advocating for systemic change;

C providing information and consultation to residents and their families; and

C publicizing issues of importance to residents

States have recently started to collect and report data under a new system. In FY 1995,

States began to systematically collect and report data under the National Ombudsman

Reporting System (NORS). Prior to NORS, States reported data to AoA, which was of

limited use due to the lack of common definitions for key data elements. The NORS was

created in response to earlier recommendations made by the General Accounting Office and

the Office of Inspector General, and was developed by the ombudsmen themselves. It

includes more specific data elements than were reported before NORS. For example, it

separates complaints by type, distinguishes between complaints and complainants, counts

unresolved complaints, and reports program funding streams. Twenty-nine States reported

under NORS in 1995 and all States did so annually beginning in 1996.

Resident abuse safeguards. Federal regulations require States to establish a registry of

nurse aides that includes information on any aide found guilty of abuse or neglect. 

Regulations also mandate that nursing homes not employ individuals who have been found

guilty of abusing or neglecting nursing home residents. States are additionally required to

provide criminal information to the OIG national database, which is then used to publish a

monthly exclusion list. However, there is no Federal requirement to conduct criminal

background checks of all current or prospective employees of Medicare and/or Medicaid

participating nursing homes.

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Quality of Care in Nursing Homes: An Overview 11 OEI-02-99-00060 
Other procedures have also been established to coordinate the reporting of resident abuse 

allegations. Each State is required to designate a coordinator with central State authority to 

receive complaints of mistreatment or neglect of nursing home residents. While this 

individual or entity may be located in any number of State agencies or within a designated 

complaint unit, the responsibility is often assigned to an employee of the State survey and 

certification agency. 

Families. Families are in the best position to help choose a nursing home and to monitor 

the care provided in that home. To do this, they need accurate and timely information 

about the quality of care in the nursing home they choose. A nursing home’s most recent 

annual survey results are, theoretically, ideally suited for this purpose. Various laws and 

regulations are intended to make these results available to the public, including the 

requirement that nursing homes post a notice giving the location and availability of its most 

recent survey results. 

Law enforcement. Several different agencies have responsibility for nursing home law 

enforcement, including the Department of Justice, the OIG, and State agencies such as the 

State Attorney General. The local police force also plays an enforcement role. A nursing 

home facility, owner, or other employee (such as a nurse aide or administrator) may be 

excluded from participation in Medicare and Medicaid after appropriate enforcement action 

is taken. 

Recently, poor quality of care has been the basis of a prosecution under the False Claims 

Act. When providers submit claims for reimbursement, they certify either explicitly or 

implicitly that the services provided meet professional standards; if they "knowingly" 

present a claim for substandard services, they could be liable under the False Claims Act. 

Thus, under appropriate circumstances, the Government can use the False Claims Act to 

prosecute a provider who knowingly presents false or fraudulent claims to the government 

for substandard care in nursing homes. The two major cases where the False Claims Act 

has been used involve grossly deficient diabetes monitoring, pressure sore care, and other 

nursing care. In both the landmark 1996 case against Geriatric & Medical Cos., Inc. and its 

Tucker House facility and the 1998 case against the Chester Care chain of four nursing 

homes, the OIG obtained civil settlements for $500,000 each. As part of the settlement 

agreements, the companies were required to develop comprehensive compliance programs. 

In addition, in the Chester Care case, the company was required to pay for a temporary 

manager and monitor to oversee provision of care. 

Legislative reforms (OBRA 1987). As previously noted, the OBRA 1987 legislation and 

ensuing regulations established a framework for nursing home reform. It specifically 

provided an agenda for nursing home care by mandating that residents be given certain 

rights and services, and adding several administrative standards that nursing homes were 

required to meet. It also established new survey and enforcement requirements, including 

making surveys more resident focused and augmenting existing enforcement options. 

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Quality of Care in Nursing Homes: An Overview 12 OEI-02-99-00060 
Prior Studies and Recent Initiatives 

Several studies have been completed which have examined the survey and certification 

process. One recent study entitled “The Regulation and Enforcement of Federal Nursing 

Home Standards,” written by Charlene Harrington and published in March of 1998, details 

problems with nursing home certification. She challenges the declining State deficiency 

averages by raising the notion that the enforcement process may be weakening rather than 

nursing facilities improving quality of care. 

Furthermore, “The National State Auditors Association Joint Performance Audit on LongTerm Care,” completed in May of 1998 by the Louisiana Office of the Legislative Auditor, 

compiled information from ten States regarding survey and certification concerns. Issues 

discussed include licensing, inspection, sanctions, complaints, and reimbursement. The 

audit findings conclude that States should vary the timing of inspections, evaluate how 

aggressively they are imposing State sanctions on facilities with deficiencies, and avoid 

delaying the investigation of complaints. 

Many studies have also reported on the progress and impact of the Ombudsman Program. 

One of the most recent, “Real People, Real Problems,” published in 1995 by the National 

Academy of Sciences’ Institute of Medicine, looked at the Ombudsman program overall. 

This study reported on State compliance, conflicts of interest, effectiveness, resources, and 

the need for future expansion of the program. It found that, overall, the Ombudsman 

program is effective. It also reported lack of access to ombudsman services by residents 

and their families, disparities in ombudsman visitation patterns and service provision, and 

uneven legal services available to ombudsmen. 

Additionally, the Inspector General issued several reports on the Program in 1991 and 

1992. First, “Successful Ombudsman Programs,” (OEI-02-90-02120), the main report in a 

series of reports on the Ombudsman program, found that successful programs are highly 

visible and obtain adequate funding and support. Furthermore, “State Implementation of 

the Ombudsman Requirements of the Older Americans Act,” (OEI-02-91-01516), found, 

among other things, that State program staffing and long term care facility visitation varies 

significantly. It also found that ombudsmen use many methods to increase their visibility. 

In July, 1998, the President announced a new nursing home care initiative to provide 

enhanced protections and to target needed improvement in nursing home care. Proposed 

actions include checking criminal backgrounds of nursing home workers, establishing a 

national registry of employees convicted of abusing patients, targeting nursing home chains 

with poor records, cutting off inspection funds to States with poor records of citing 

substandard quality of care, publishing annual nursing home surveys on the Internet, 

increasing Federal oversight of State inspections, providing additional training to State 

officials, changing the survey schedule to make them more unpredictable, and increasing the 

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Quality of Care in Nursing Homes: An Overview 13 OEI-02-99-00060 
number of night and weekend surveys. 

In conjunction with the President’s nursing home initiative, the Secretary released a report 

to Congress in July of 1998, a “Study of Private Accreditation (Deeming) of Nursing 

Homes, Regulatory Incentives and Non-Regulatory Initiatives, and Effectiveness of the 

Survey and Certification System,” indicating that significant improvements in the quality of 

care had been made since 1995. These improvements included more appropriate use of 

physical restraints, anti-psychotic drugs, anti-depressants, urinary catheters, and hearing 

aids. However, the report did find a need for further improvements by States, nursing 

homes, and others. Additional steps will be taken to address the problems identified in the 

report and include tougher enforcement of Medicare and/or Medicaid rules. Efforts will be 

aimed at preventing instances of pressure sores, dehydration, and nutrition problems. The 

following are new approaches aimed at improving quality of care: facilities that have repeat 

offenses will face sanctions without a grace period; inspections will be conducted more 

frequently for repeat offenders without decreasing inspections at other facilities; inspections 

will be staggered; a set amount of inspections will be conducted on weekends; and efforts 

will be focused on facilities within chains that have a record of non-compliance. 

One week after the President’s initiative, the General Accounting Office (GAO) published a 

report examining the quality of care in 1,370 California nursing homes that were inspected 

from 1995 to 1998. They found 30 percent of the homes had violations that caused death 

or life-threatening harm to residents, or had understated the frequency of poor care by 

falsifying medical records. As a result of this report, the US Senate Special Committee on 

Aging held hearings in July 1998 to discuss the findings on the quality of care in nursing 

homes. 

METHODOLOGY 

Multiple methods were used for this report. They include an analysis of national nursing 

home program data, a review of written program procedures, structured telephone 

interviews, a literature review, and an analysis of nursing home legislation. 

Description of nursing home conditions 

Data Analysis 

Survey and certification data. We used a purposive sample of 10 States which represent 

55.8 percent of total skilled nursing beds nationally. These States are New York, 

California, Texas, Ohio, Illinois, Pennsylvania, Massachusetts, Florida, New Jersey, and 

Tennessee. The OSCAR contains data for the current and 3 previous surveys and 

categorizes deficiencies into 17 major categories. Using the most recently available 

OSCAR data (from August 4, 1998), 3 of the 17 categories which could determine poor 

quality of care were analyzed. These are: 1) resident behavior and facility practices, 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 14 OEI-02-99-00060 
including the areas of restraints, abuse and staff treatment of residents; 2) quality of life, 

including the resident’s ability to make decisions about his or her daily activities and the 

nursing home’s accommodation of his or her needs; and 3) quality of care, including the 

technical ability of the nursing home to prevent and treat the medical conditions of its 

residents. Substandard quality of care deficiencies repeated over the last four surveys and 

abuse complaint data were also examined. 

Ombudsman data. Using the same purposive sample of 10 States, we analyzed 2 sets of 

Ombudsman program data. For 1996 and 1997, data from the National Ombudsman 

Reporting System (NORS) was examined; from 1989 to 1994, data from the pre-NORS 

reporting system was used. Data from 1995 is not analyzed due to a lack of comparable 

data elements for that year. For both pre-NORS and NORS data, figures for both total 

complaints and broad complaint categories are presented; for NORS data, 125 specific 

complaint types were also looked at. Finally, data on Ombudsman program staffing, 

visitation rates, advocacy activities, and coordination with survey and certification agencies 

was also examined. 

Abuse complaints. Using a fax survey, we obtained data from all 10 States on the 

numbers and types of nursing home resident abuse complaints. We specifically analyzed 

data on four types of complaints selected as key indicators of recent abuse trends: physical 

abuse, inappropriate use of restraints, physical neglect, and medical neglect. 

OIG convictions. We reviewed data from the Office of Inspector General on nursing home 

convictions relating to resident abuse or neglect, from 1995 to 1998. 

Literature review 

We examined findings on nursing home conditions from several studies, particularly the 

recent GAO report entitled “California Nursing Homes: Care Problems Persist Despite 

Federal and State Oversight.” 

Assessment of nursing home systems 

Procedures review 

Survey and certification procedures. For the eight States that have their own survey 

guidelines which they use in addition to HCFA guidelines, we obtained and reviewed their 

written program procedures and other related documents. The remaining two States had no 

survey requirements of their own. 

Ombudsman procedures. Written procedures for all 10 sample State Ombudsman 

programs were obtained and reviewed. Using a structured review guide, these procedures 

were reviewed to determine the different processes used by ombudsmen to monitor and 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 15 OEI-02-99-00060 
promote quality of care in nursing homes. Standards mandated for these processes, such as 

complaint response times, were also looked at. 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 16 OEI-02-99-00060 
Interviews 

Survey and certification telephone interviews. A total of thirty structured telephone 

interviews were conducted. In each of the 10 sample States, one interview was conducted 

with the State survey and certification director (or designee) and two State surveyors. The 

two State surveyors were selected randomly from a list of at least 10 surveyors submitted 

by the State director. During these interviews, information was obtained about the State 

survey and certification program structure, the processes utilized to monitor quality of care, 

how deficiencies are addressed, and the satisfaction of State survey and certification 

directors and surveyors with the process. Information provided by the directors was 

compared to that provided by surveyors, and special attention was given to consensus 

within and among the groups. 

Ombudsman telephone interviews. A total of 30 structured telephone interviews were 

conducted. In each of the 10 sample States, one interview was conducted with the State 

ombudsman, one local program ombudsman, and the State Aging Unit Director or 

designee. In selecting ombudsmen from local programs to interview, individuals from a 

variety of local program structures were chosen. These three groups of respondents were 

selected to obtain their different perspectives of the program and consensus among the 

groups was particularly noted while analyzing the interviews. 

Examination of nursing home survey results availability 

To examine the availability of survey results, we used a different sample and methodology. 

We selected a purposive sample of eight cities, each one having a regional Office of 

Evaluations and Inspections (San Francisco, Atlanta, Chicago, Boston, Kansas City, New 

York, Philadelphia, and Boston). We then combined five methods to assess the availability 

of survey results: telephone interviews with 155 family members; a simulation by OIG staff 

of families’ access to nursing home results; telephone requests to HCFA and State officials 

for survey results; a review of HCFA’s new internet site for survey results; and a review of 

Federal rules and procedures regarding access to survey results. 

Literature review 

We also conducted a literature review of recent nursing home studies which assessed 

nursing home systems. We particularly used an OIG report entitled “Safeguarding Long 

Term Care Residents.” 

Legislation review 

Finally, we reviewed nursing home legislation, particularly OBRA 1987. We identified each 

of the individual reforms outlined in OBRA 87 and determined which ones had been 

assessed for impact and outcome. Lastly, we reviewed the mission statement and agenda 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 17 OEI-02-99-00060 
for recent nursing home law enforcement initiatives. 

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

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

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Quality of Care in Nursing Homes: An Overview 18 OEI-02-99-00060 
FINDINGS 

Serious quality of care problems persist in nursing homes 

Survey and certification deficiencies. An analysis of survey and certification deficiencies 

indicates that problems with quality of care continue to exist in nursing homes. Deficiencies 

are grouped into one of three main categories, and while two of these categories have been 

decreasing, many deficiencies in the “quality of care” category have actually been 

increasing. More specifically, 13 of the 25 deficiencies that make up this category are 

higher now than they were on the last 3 surveys. These 13 deficiencies were cited 6,413 

times on the current survey, compared to 5,246 times three surveys prior, an increase of 

almost 25 percent. They include a lack of adequate supervision to prevent accidents, a lack 

of appropriate care for activities of daily living, and improper care for pressure sores. 

Graph A below shows how some of these serious deficiencies have grown over the prior 3 

surveys. 

Graph A 

Some Serious Quality of Care Deficiencies Have Been Increasing 

Deficiencies often lead to further medical problems or indicate other issues. For example, 

pressure sores could be an indication that residents also have other problems, such as 

urinary incontinence, malnutrition, or dehydration. Table 1 below shows the nature and 

extent of the top 10 substandard quality of care deficiencies from the latest standard survey 

in the 10 sample States. 

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Quality of Care in Nursing Homes: An Overview 19 OEI-02-99-00060 
Table 1 

The Top 10 Substandard Quality of Care Deficiencies 

Include Some Serious Problems 

Deficiency Deficiencies 

# of Sample State 

Facilities 

% of Sample State 

Proper treatment to prevent 

or treat pressure sores 

Facility free of accident 

hazards 

Facility promotes care that 

maintains/enhances dignity 

Housekeeping and 

maintenance 

Provides necessary care for 

highest practicable wellbeing 

Right to be free from 

physical restraints 

Should have policies that 

accommodate needs 

Drug regimen free from 

unnecessary drugs 

Appropriate treatment for 

incontinence 

“Activities of daily living” 

care provided for dependent 

residents 

1186 

1164 

1115 

1023 

972 

958 

787 

768 

750 

699 

16% 

16% 

16% 

14% 

14% 

13% 

11% 

11% 

10% 

10% 

In its recent report entitled “California Nursing Homes: Care Problems Persist Despite 

Federal and State Oversight” the GAO examined the quality of care in 1,370 nursing homes 

in California. It found that 30 percent had violations that caused death or life-threatening 

harm to residents, or had understated the frequency of poor care by falsifying records. 

Among the problems it reports are poor nutrition, dehydration, and improper care of 

incontinent and immobile residents which leads to pressure sores. 

Ombudsman complaints. Ombudsman nursing home complaints have also been steadily 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 20 OEI-02-99-00060 
increasing, as illustrated in graph B below. Based on data from 1989 to 1994, total 

complaints in the 10 sample States grew from 57,954 to 83,669, an increase of 44 percent. 

(Due to the transition to a new data system in 1995, we do not have comparable complaint 

rates for that year). 

Graph B 

At the Same Time, Ombudsman Program Complaints 

Increased from 1989 to 1994 

Beginning in 1996, a new Ombudsman program reporting system was used that counted 

complaints differently from the prior system. Data from 1996 and 1997 also show that 

complaints increased seven percent between these two years, from 60,926 to 65,123, as 

illustrated in Graph C below. 

Graph C 

Ombudsman Program Complaints Also Increased from 1996 to 1997 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 21 OEI-02-99-00060 
Ombudsman complaints about resident care have been particulary prevalent. Of the five 

main Ombudsman program complaint categories, the resident care category increased the 

most from 1996 to 1997, growing by 13 percent. This category includes specific 

complaints about personal care (such as pressure sores and hygiene), lack of rehabilitation, 

and the inappropriate use of restraints. On a more specific level, 12 complaints had 

increases of 24 percent or more from 1996 to 1997. Two of these -- staff turnover and lack 

of staff training -- may indicate other problems with resident care. 

In 1997, the majority of all Ombudsman program complaints (63 percent) fell into 2 of 5 

categories -- resident care (32 percent) and residents’ rights (31 percent). The top 10 

complaints for that year include 3 related to inadequate nursing home staffing, as well as 

specific complaints about poor quality of care, such as poor hygiene, physical abuse, and 

improper handling and accidents. 

Resident abuse complaints. Data obtained from nursing home abuse complaint 

coordinators in the 10 sample States lack common definitions and are therefore inconsistent. 

Furthermore, these complaints are not always substantiated. Among the 10 States, there 

are no obvious trends in reported complaints; some States have upward trends and others 

downward trends. Nevertheless, approximately one percent or more of nursing home 

residents in the 10 States have had an experience serious enough to register an abuse 

complaint. 

Additionally, since 1995 the OIG has excluded 668 nursing home workers from 

participation in the Medicare or Medicaid programs as a result of a conviction related to 

patient abuse or neglect. The excluded workers were primarily nurses and nurse aides. 

Chronically substandard homes. Some nursing homes appear to be chronically 

substandard. Data from OSCAR show that some are repeatedly deficient; 463 nursing 

homes have been cited with the same deficiencies over their last past four surveys, 

representing 6 percent of all homes in the 10 sample States. State directors and surveyors 

also report that between 1 to 20 percent of nursing homes in their State have chronic quality 

of care problems. Finally, three-fourths of ombudsmen say there are some homes (10 

percent or fewer) that routinely treat residents poorly. 

Insiders’ perspectives. Survey and certification staff and ombudsmen express some 

reservations about relying exclusively on program data to identify nursing home problems. 

While generally satisfied with OSCAR data, more than half of State directors and surveyors 

believe it is not a true indicator of nursing home quality of care since it only portrays the 

situation of the nursing home at the time surveyors are physically conducting the survey. 

Ombudsmen also say that higher complaint rates do not always indicate more problems, 

pointing out that higher complaint rates could be due to a greater presence of Ombudsman 

staff in nursing homes. 

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Quality of Care in Nursing Homes: An Overview 22 OEI-02-99-00060 
Nevertheless, in all 10 sample States, State surveyors and survey directors, State and local 

ombudsmen, and State Aging Unit Directors confirm that problems with care persist in 

nursing homes. These are many of the same problems reported in program data. State 

surveyors and survey directors say the biggest problems they see are resident abuse, failure 

to treat incontinent patients, and improper medication distribution. Ombudsmen and State 

Aging Unit Directors identify malnutrition and other dietary concerns, bed sores, 

dehydration, poor hygiene, over-medication, toileting, and physical abuse as problems 

nursing home residents face. 

Evidence suggests inadequate levels of nursing home staff 

contribute to quality of care problems 

In all 10 sample States, survey and certification staff, State and local ombudsmen, and State 

Aging Unit Directors identify inadequate staffing levels as one of the major problems with 

nursing homes in their States. Most believe that these staffing shortages leads to chronic 

quality of care problems, such as failure to adequately treat and prevent pressure sores. 

They cite further concerns about the proficiency and training of nursing home staff. 

The type and extent of survey deficiencies and Ombudsman program complaints also 

suggest that nursing home staffing levels are inadequate. Common personal care problems 

such as lack of nutrition and poor care for incontinence suggest that staffing is inadequate 

to provide the level of care needed to avoid these problems. Furthermore, specific 

complaints about nursing home staff are some of the most common types of Ombudsman 

program complaints. The top complaint in 1997 was unanswered call lights and requests 

for assistance, while staff attitudes and lack of respect was third and shortage of staff was 

ninth. 

Survey and certification agencies are following required 

standard protocols but weaknesses in the survey system 

itself limit their effectiveness 

State survey and certification agencies monitor nursing home care with timely and standard 

surveys, complaint procedures, and additional State processes. Based on OSCAR data over 

the last 4 standard surveys, all sample States completed 97 percent of their standard surveys 

in the mandated time frame of 9 to 15 months. Furthermore, all State survey directors and 

surveyors report following HCFA guidelines for their surveys, including starting with an 

entrance conference, touring the facility, interviewing residents and family members, 

reviewing medical records, and concluding with an exit conference. They also report 

having a complaint process to address complaints about nursing home practices. Seven 

States have their own survey guidelines which they use in addition to HCFA guidelines, and 

some have additional databases and information sources. 

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Quality of Care in Nursing Homes: An Overview 23 OEI-02-99-00060 
Despite following standard procedures, however, the survey and certification system has 

several weaknesses, including the predictability of surveys. Although all States use 

unannounced nursing home surveys, almost all directors and surveyors believe that facilities 

can anticipate the survey start date. They say that facilities often modify their normal daily 

procedures to reduce potential deficiencies, such as increasing staff on certain shifts. In 

most States, surveyors also do not begin or continue standard surveys on the weekend or in 

evening hours. State directors and surveyors therefore voice concerns about whether 

standard surveys represent an accurate reflection of quality of care in nursing homes. 

The survey and certification process is also limited by weak enforcement, including inaction 

on abuse complaints. From January 1997 to July 1998, OSCAR data reports 4,707 abuse 

complaints (involving almost one third of all nursing homes) in the 10 sample States. Twothirds of these were unsubstantiated and the remaining third were substantiated. Over 90 

percent of both substantiated and unsubstantiated complaints concluded with no action, 

plans of correction, or other remedy. Furthermore, half of the State directors and threefourths of surveyors indicate that current enforcement measures are questionable. They 

express concern that civil monetary penalties do not compel nursing homes to observe 

Federal regulations, are insufficient to influence nursing home chains, and are not imposed 

immediately, allowing facilities to remain non-compliant for longer periods of time. Others 

believe that current enforcement process allows deficient facilities far too many 

opportunities to avoid enforcement action. 

Finally, survey and certification agencies have a number of staffing constraints. The overall 

number of surveyors varies by State, thereby affecting the number of standard, follow-up, 

and complaint surveys each team can conduct. For example, the number of standard 

surveys on the 10 States ranges from 12 to 26 per year. State directors also express 

concern about high staff turnover rates, difficulties replacing staff once they leave, and 

limited surveyor training. They additionally report weaknesses in coordination between 

their staff and ombudsman staff. Surveyors received 13 percent of all Ombudsman program 

abuse complaints per month in 1997. 

While the Ombudsman program is well designed, inadequate 

resources limit its capacity 

The Ombudsman program has several functions to promote and monitor quality of care in 

nursing homes, including identifying and resolving complaints, making regular visits to 

nursing homes, and engaging in a variety of different advocacy activities. Discussions with 

State and local ombudsmen, as well as State Aging Unit Directors, emphasize the 

uniqueness of this program. In contrast to other programs, ombudsmen lack enforcement 

and regulatory oversight authorities. As independent advocates, they work solely on behalf 

of residents and are often the only voice residents have in their own care. An ongoing, 

routine nursing home presence is therefore essential to the ombudsman role. In fact, most 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 24 OEI-02-99-00060 
State ombudsmen (6 of 10) believe this presence is the most important part of their 

program. This presence provides ombudsmen with the opportunity to develop personal and 

confidential relationships with residents and enables them to identify and address individual 

issues before they become larger, systemic problems. 

Nevertheless, the overall capacity of the Ombudsman program is limited by inadequate 

resources, including inadequate staffing. Paid staffing and volunteer levels among the 10 

States vary considerably, ranging from 4,618 nursing home beds per paid staff in one State 

to 1,115 beds per paid staff in another. While no minimum staffing ratios are required by 

law, a 1995 Institute of Medicine study on the Ombudsman program recommends a 

standard staffing ratio of 1 paid Ombudsman staff person per 2,000 long term care facility 

beds; only 1 in the 10 sample States, Massachusetts, meets this standard. Furthermore, a 

majority of State and local Ombudsmen identify insufficient program staffing and an 

inadequate number of volunteers as obstacles which detract from their program’s 

effectiveness. 

Inadequate program staffing is particularly evident in the limited extent to which 

ombudsmen make regular nursing home visits. In the nine States that make such visits, 

volunteers are generally assigned to just one nursing home and visit this home on a weekly 

basis. However, most nursing homes in the 10 States do not have volunteers assigned to 

them, and these homes are usually visited by paid staff just once or twice a year for no 

longer than one to three hours. In fact, in four States there are nursing homes that are 

never visited by volunteers or paid staff. 

Other limitations affect the Ombudsman program’s overall capacity. Lacking a common 

standard for complaint response and resolution, ombudsman staff in some States are not 

consistently handling complaints in a timely manner. Ombudsman staff also devote varying 

amounts of time to outreach and advocacy activities, with some spending relatively little 

time on community education, work with the media, work on laws and policy, and nursing 

home staff training. Also, half of State and local ombudsmen believe their program’s lack 

of support in the State diminishes its capacity and limits their ability to influence nursing 

home policies. Lastly, they believe better collaboration is needed with the survey and 

certification agency. 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 25 OEI-02-99-00060 
State systems to safeguard nursing home residents from 

abuse are inconsistent and unreliable 

Based on findings from a recent OIG audit, “Safeguarding Long Term Care Residents,” (A12-97-0003) it appears that some weaknesses exist in State efforts to safeguard nursing 

home residents from abuse. This audit revealed great diversity in the way States 

systematically identify, report, and investigate suspected abuse. While no Federal 

requirement exists for criminal background checks of nursing home staff, 33 States do 

mandate that such checks occur. However, the methods used to identify individuals who 

pose a risk of abuse and the criteria followed for prohibiting employment vary widely 

among these States. Furthermore, not all States systematically report convictions to central 

databases, such as the certified nurses aide registry. It therefore appears that there is no 

assurance that individuals who may pose a risk to residents are systematically identified and 

barred from nursing home employment. 

A more in-depth audit of Maryland also found problems with nursing home hiring practices 

in that State. In particular, this audit found that five percent of employees in eight nursing 

homes had criminal records. It also noted that some of these individuals were not reported 

in the State or Federal systems used for criminal background checks, despite the fact that 

they had been convicted of elder abuse. 

Public awareness and access to nursing home survey results 

is limited 

Two-thirds of 155 families interviewed in eight sample cities did not know that the results 

of Federal and State nursing home inspections are available on request. Half were also 

unaware that such inspections are required. Only 15 of the 155 individuals we interviewed 

had ever requested a copy of the survey results, and of the 11 who obtained a copy, 6 said 

the results were not based on a recent survey conducted within the past 15 months. 

Most of the 32 sampled nursing homes visited by staff from the Office of Inspector General 

did not fully meet the requirements for making survey results available. In a majority of 

these homes, the notice identifying the location of the survey results was not posted and/or 

the survey results were in locations directly observed by staff, contrary to regulations. Staff 

from the OIG had to ask for the survey results in 24 of the 32 homes they visited. While 

most (27) did ultimately make the survey results available, the OIG staff had an advantage 

over other members of the public since they were aware of what to look for and how to ask 

for it. 

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Quality of Care in Nursing Homes: An Overview 26 OEI-02-99-00060 
The HCFA has recently established a more easily accessible version of nursing home survey 

results with an internet site entitled Nursing Home Compare. For families with access to 

the internet, this is a promising development. When staff from the OIG located this site, 

they found it easy to understand. Most of the families interviewed said it could be very 

helpful in providing useful nursing home information. 

New initiatives based on law enforcement approaches are 

being considered 

Initiatives to strengthen nursing home law enforcement are relatively new. Particularly 

noteworthy is the formation of nursing home task forces at the local, State, and national 

levels, comprised of representatives from the Department of Justice, HCFA, OIG, and other 

agencies. These groups will examine and develop action plans for several enforcement 

strategic areas and will address the full range of nursing home enforcement issues. They will 

collaborate with Medicaid Fraud Control Units, the State Attorneys General, State survey 

agencies, and other oversight agencies. Among the strategic areas targeted are: improving 

the handling of civil monetary penalty referrals; reviewing patient abuse and neglect 

legislation for model State legislation; recommending possible new legislation for 

prosecuting abuse and neglect; reviewing current services available to abuse victims; and 

identifying emerging quality of care and fraud problems in nursing homes. 

By targeting key strategic areas and coordinating among the various agencies responsible 

for nursing home enforcement, these initiatives appear promising. If successful, they should 

strengthen enforcement of nursing home problems. However, it is too soon to determine 

the full impact of these enforcement initiatives. Some of the task forces and action plans 

will not be fully developed until early 1999, and at the earliest, preliminary results will not 

be available until later in that year. 

Nursing home reforms established by OBRA 1987 have not 

been systematically assessed 

The nursing home reforms created by OBRA 1987 impacted both nursing home systems 

and nursing home care. First, these reforms essentially changed the focus from a nursing 

home’s ability to provide care to the quality of the care actually provided. The OBRA 87 

requires nursing homes participating in Medicare and Medicaid to comply with extensive 

standards. These standards include ensuring various resident rights, rights related to 

admission, transfer and discharge, and the right to be free from restraints and abuse. The 

OBRA 87 also requires nursing homes to promote residents’ quality of life, conduct 

periodic resident assessments, and provide the necessary care needed for residents to 

maintain the highest practicable physical, mental, and psychosocial well-being. Additionally, 

OBRA 87 requires nursing homes to provide certain services, including nursing, dietary, 

physician, rehabilitative, dental, and pharmacy services. Finally, several administrative 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 27 OEI-02-99-00060 
standards were also established, including requirements for nurse aide training, a medical 

director, and clinical records. 

The OBRA 87 also changed nursing home enforcement and survey procedures. Among 

these changes are: the development of the Resident Assessment Instrument (RAI), which is 

a standardized assessment instrument for nursing home residents; a more outcome oriented 

survey that emphasizes gathering information by observing and interviewing residents; and 

new intermediate enforcement remedies that augment existing options for noncompliant 

nursing homes. 

While it has now been more than a decade since OBRA 1987 was first passed, there has 

been no systematic assessment of its extensive agenda and no methodical evaluation of 

whether or not the reforms it intended are actually working. In its 1998 Report to 

Congress, HCFA attributes positive changes in the use and outcomes of resident assessment 

instruments and psycho-pharmacological medications to OBRA 87. The HCFA also 

concludes that new enforcement and survey regulations have been effective. Other studies 

have addressed additional OBRA reforms, including OIG reports on nursing home 

prescription drug use and resident abuse. Furthermore, data from survey and certification 

and Ombudsman program reporting systems suggest the OBRA requirement that residents 

be free from restraints is having some effect; deficiencies on restraints and ombudsman 

restraint complaints have been decreasing over the past several years. Nevertheless, the 

success of this major legislation has not yet been established. A definitive assessment of the 

extent to which OBRA reforms have bettered conditions in nursing homes is therefore 

needed. 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 28 OEI-02-99-00060 
AN AGENDA FOR CONTINUING IMPROVEMENT IN 

NURSING HOME CARE 

Since OBRA 1987 was first passed, real improvements have been made in nursing home 

care. More recently, considerable attention has been paid to addressing persisting concerns 

about nursing home conditions and systems. In particular, we commend the Health Care 

Financing Administration (HCFA) for its extensive nursing home initiative since it addresses 

many of these persisting problems. This initiative includes many individual action items 

which should result in positive changes. Additionally, the Administration on Aging (AoA) 

has been taking steps to enhance the Ombudsman program, including improving the 

program reporting system and conducting annual training of ombudsman staff. 

The problems we describe in this report will require continuing attention, possibly for 

several years. The broad outline of an effective strategy would include actions to: 

< enhance the survey and certification process;

< strengthen the Ombudsman program with increased resources;

< improve nursing home staffing levels; and

< improve coordination between State survey agencies and ombudsmen. 

We also believe that further evaluation and progress measurement would make an important 

contribution to efforts to advance nursing home care. We specifically suggest: 

< a systematic assessment of OBRA 1987; and

< the creation of a periodic report card on conditions in nursing homes.

We have incorporated action items from HCFA’s nursing home initiative, AoA’s 

Ombudsman program activities, recommendations for additional steps to be taken, current 

OIG work, and areas requiring further evaluation into one comprehensive, long term agenda 

to continue improvements in nursing home care. This agenda consists of a three stage 

approach of immediate action, research and evaluation, and continued progress 

measurement. It is outlined below. 

I. Immediate Action 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 29 OEI-02-99-00060 
We believe immediate action should be taken to strengthen the capacity of systems designed 

to oversee nursing home care. We also believe improvements should be made in nursing 

home staffing levels, since this directly impacts on the care residents receive. 

Survey and Certification 

Survey enforcement efforts. Strengthen survey enforcement 

efforts by: making surveys more timely, effective, and 

unpredictable; increasing the number of night and weekend 

surveys and surveys at chronically substandard homes; 

focusing on specific problems, such as pressure sores; 

eliminating grace periods for homes with repeat serious 

violations; proposing new civil monetary penalties; and placing 

survey results on the internet. 

Addressed in 

HCFA initiative 

Enhanced monitoring. Enhance monitoring of special focus 

facilities. 

Addressed in 

HCFA initiative. 

Surveyor training. Provide additional training and assistance 

to State surveyors. 

Partially 

addressed in 

HCFA initiative 

Surveyor staffing. Evaluate State surveyor staffing to assure 

adequate staffing is available. 

Action under 

consideration by 

HCFA 

Surveyor coordination. Provide a forum for surveyors to meet 

and discuss common issues. 

Action under 

consideration by 

HCFA 

Abuse. Add survey task to look at provider’s abuse 

intervention system, develop national abuse intervention 

campaign, and promote prosecution of egregious violators. 

Addressed in 

HCFA initiative 

Ombudsman Program 

Visibility. Develop guidelines for minimum levels of 

Ombudsman program visibility, including criteria for 

frequency and length of regular visits and staffing ratios. 

Partially 

addressed by 

AoA through 

annual training 

Volunteers. Formulate strategies for recruiting, training, and 

supervising more ombudsman volunteers. 

Partially 

addressed by 

AoA through 

annual training 

and Ombudsman 

Resource Center 

))))))))))) 

Quality of Care in Nursing Homes: An Overview 30 OEI-02-99-00060 
Complaint response and resolution. Develop guidelines for 

ombudsman complaint response and resolution times. 

Not currently 

addressed 

Reporting system. Continue to refine and improve the 

Ombudsman program’s data reporting system. 

Continuing 

attention by AoA 

Coordination with Survey and Certification. Establish ways 

to enhance coordination between survey and certification and 

Ombudsman programs. 

Continuously 

addressed 

Resident Abuse Safeguards 

Employment safeguards. Improve the safety of residents and 

strengthen safeguards against employment of abusive workers. 

Addressed in 

HCFA initiative 

Nursing Home Staffing 

Staffing standards. Develop staffing standards for registered 

nurses and certified nurse assistants in nursing homes to assure 

sufficient staff on all shifts to enable residents to have proper 

care. 

Currently being 

studied by HCFA 

Care Guidelines 

Malnutrition and dehydration. Develop best practice 

guidelines for malnutrition and dehydration care and national 

campaign to increase awareness of these problems. 

Addressed in 

HCFA initiative 

Drug usage. Develop guidelines and protocols for using 

effective drugs. 

Addressed in 

HCFA initiative 

Family Involvement 

Family awareness and access. Promote and facilitate greater 

awareness and access to survey results by strengthening 

existing avenues for receiving information and identifying new 

avenues. 

Action under 

consideration by 

HCFA 

II. Research and Evaluation 

We also propose the development of a research and evaluation program to assess the 

quality of care in nursing homes, including a systematic look at each of the legislative 

reforms established with OBRA 1987 and other quality of care issues. In the following 

table, we indicate where the OIG is conducting or planning work. As the Office of 

Inspector General, we have a particular interest in assuring that the standards mandated by 

OBRA 1987 are being met. Since we do not expect to address all of the nursing home 

requirements and issues we have identified, we invite others to join us in this evaluation. 

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Quality of Care in Nursing Homes: An Overview 31 OEI-02-99-00060 
OBRA 1987 

Prescription Drugs. Assess the extent and appropriateness of 

prescription drug use by nursing home residents and describe 

consultant pharmacists’ concerns about drug use. 

OIG report 

issued 

Resident assessment. Determine the systems used by nursing 

homes to conduct periodic resident assessments and plans of 

care and evaluate how this impacts reimbursement. 

OIG study 

underway 

Nurse aide training. Evaluate nurse aide training In OIG workplan 

Abuse reporting. Examine the extent to which States have 

implemented abuse reporting requirements. 

In OIG workplan 

Medical director. Examine the role medical directors play in 

assuring quality of care. 

In OIG workplan 

Resident rights. Assess the extent to which nursing homes are 

assuring resident rights. 

Admission rights. Assess the extent to which nursing homes 

are assuring admission, transfer, and discharge rights. 

Restraints and abuse. Assess whether rights to be free from 

restraints and abuse are being met. 

Quality of life. Assess whether or not nursing homes are 

providing care which promotes each resident’s quality of life. 

Resident well-being. Determine if nursing homes are 

providing care and services to maintain the highest levels of 

residents’ physical, mental, and psychosocial well-being. 

Nursing home services. Determine if nursing home staffing 

levels are adequate to provide required nursing, dietary, 

physician, rehabilitative, dental, and pharmacy services. 

Physical environment. Determine if nursing homes are 

maintaining a healthy and safe physical environment. 

Other Quality of Care 

Resident satisfaction. Determine the level of resident 

satisfaction with nursing home care. 

OIG study 

underway 

Immunizations. Examine the obstacles to immunizing 80% of 

nursing home residents against pneumoccocal disease and 

influenza. 

OIG study 

underway 

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Quality of Care in Nursing Homes: An Overview 32 OEI-02-99-00060 
III. Progress Measurement 

Finally, an independent, continuous assessment is needed to measure the progress made in 

raising the standard of nursing home care. 

Periodic Assessments 

Periodic report card. Conduct periodic evaluations describing 

conditions in nursing homes based on deficiency trends, 

ombudsman complaints, resident satisfaction, and insiders’ 

perspectives. 

Under 

consideration by 

OIG 

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Quality of Care in Nursing Homes: An Overview 33 OEI-02-99-00060 
AGENCY COMMENTS 

This report is based primarily on a series of recent studies conducted by the Office of 

Inspector General on nursing home care. They are: 

Nursing Home Survey and Certification: Deficiency Trends, OEI-02-98-00331;

Nursing Home Survey and Certification: Overall Capacity, OEI 02-98-00330;

Long Term Care Ombudsman Program: Complaints Trends, OEI-02-98-00350;

Long Term Care Ombudsman: Overall Capacity, OEI-02-98-00351;

Public Access to Nursing Home Survey and Certification Results, OEI-06-98-

00280; and

Safeguarding Long Term Care Residents, A-12-97-0003.

We received detailed comments from HCFA, AoA, and the Assistant Secretary for Planning 

and Evaluation on the above reports. We made modifications in each report to respond to 

the comments received and to reflect the actions already being taken to improve nursing 

home conditions. This overview report also incorporates many of these modifications. We 

encourage everyone to read the individual reports and the comments we received on them. 

The comments are included in each report. 

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Quality of Care in Nursing Homes: An Overview 34 OEI-02-99-00060