Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

JUNE GIBBS BROWN

Inspector General

MARCH 1999

OEI-02-98-00331

Nursing Home Survey and Certification:

Deficiency Trends
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

Lucille Cop, RN Susan Burbach, Program Specialist

Danielle Fletcher

Daniel Ginsberg

Steve Shaw

Patricia Banta, RN intern

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
Survey and Certification: Deficiency Trends 1 OEI-02-98-00331

EXECUTIVE SUMMARY

PURPOSE

To describe deficiency trends indicated by survey data and the extent to which these trends

indicate quality of care in nursing homes. 

BACKGROUND

While many 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 the Health Care Financing Administration and the General Accounting

Office 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. At the

same time, the Office of Inspector General undertook a series of studies aimed at assessing

the quality of care in nursing homes. 

The 1987 Nursing Home Reform Act introduced an increased focus on the quality of life

and care, the importance of the individual resident, and the need to help the Medicare and

Medicaid nursing home residents reach the “highest practicable level” of functioning. 

Enforcement policies were established that gave the Health Care Financing Administration

the authority to impose a variety of corrective measures when a facility is not in substantial

compliance with the requirements for participation in the Medicare and/or Medicaid

program. 

This report examines trends in the Online Survey Certification and Reporting System

(OSCAR) data that indicate quality of care problems in nursing homes survey and

certification programs. A companion report describes the overall capacity of the State

survey and certification program to monitor quality of care in nursing homes. Other OIG

reports address the trend in reported abuse in nursing home residents and the role of the

ombudsman in protecting nursing home residents.

We selected a purposive sample of ten States: New York, California, Texas, Ohio, Illinois,

Pennsylvania, Massachusetts, Florida, New Jersey, and Tennessee. We analyzed OSCAR

data in these States to identify trends in the amount and nature of deficiencies in nursing

home quality of care. To better understand the overall context of these deficiencies, we

conducted structured interviews with the State director and surveyors. 
Survey and Certification: Deficiency Trends 2 OEI-02-98-00331

FINDINGS

Overall Deficiencies Are Decreasing, but “Quality of Care” Deficiencies Are

Increasing and Other Serious Deficiencies Persist at High Levels

Deficiencies are classified into 17 major categories containing 185 subcategories of

specific deficiencies. If a nursing home has deficiencies in three specific categories, it is

considered to have substandard quality of care, for enforcement purposes, depending on

the scope and severity. The three categories are: “quality of care”, “resident behavior and

facility practices”, and “quality of life”.

While almost all deficiencies have declined over the past four surveys, substandard quality

of care deficiencies have decreased at a slower rate than all others. The 49 substandard

quality of care deficiencies have decreased by only 14 percent over the last four standard

surveys compared to a decrease of 32 percent for the other 136 deficiencies which do not

fall into the substandard quality of care categories. 

Although in total, substandard quality of care deficiencies have decreased, the

subcategory “quality of care” has increased. Thirteen of the 25 deficiencies in the “quality

of care” subcategory are higher on the current survey than they were three surveys prior. 

Some noteworthy deficiency increases include the failure to provide range of motion

treatment, lack of adequate supervision or devices to prevent accidents, and catheterizing

residents without clinical need. Additionally, three of those 13 have increased in every

survey over the past four standard surveys. 

Although some deficiencies have declined over the years, the number of deficiencies that

continue to be cited remains a cause for concern. For example, pressure sores are bruises

or open sores on the skin which could be an indication that other kinds of problems are

occurring such as urinary incontinence, malnutrition or dehydration. If a resident has a

cognitive loss or dementia, or physical restraints, or psychotropic drugs are being used, 

the resident is vulnerable to resultant pressure sores. 

 

Nursing Homes with Chronic Quality of Care Problems Exist

The OSCAR data identifies some nursing homes that continue to have the same

deficiencies every survey. Four hundred and sixty three nursing homes have been cited

with the same deficiencies over the past four contiguous surveys, representing 6 percent of

all homes in the sample States. Nursing homes with serious deficiencies or constant noncompliance issues are considered to have chronic quality of care problems. 

State survey and certification directors and surveyors describe circumstances similar to

what the OSCAR data show. They cite that the percentage of nursing homes with these

problems is between one and 20 percent of all homes in their respective States. Half of
Survey and Certification: Deficiency Trends 3 OEI-02-98-00331

the State directors mention pressure sores and nutrition issues as frequent chronic quality

of care problems in their nursing homes. The OSCAR data show the deficiency that

occurs the most frequently, both in our sample States and nationally, is the failure to give

proper treatment to prevent or treat pressure sores. Surveyors concur with directors;

most also mention that staffing shortages and inferior staff proficiency levels precipitate

chronic quality of care in nursing homes.

State Directors and Surveyors Express Reservations about Relying Exclusively

on Oscar Data to Identify and Understand Problems in Nursing Homes 

Most surveyors and more than half of directors are satisfied with OSCAR data but

propose changes. OSCAR data may not catch all the problems that exist in a nursing

home due to the current survey process. Surveyors visit most facilities only once a year

and cannot be cognizant of problems that occur throughout the year. Surveyors suggest

using OSCAR data in conjunction with other tools to obtain an accurate view of quality of

care.

The majority of the State survey and certification directors and surveyors we interviewed

believe that certain deficiencies have unclear definitions. They note some specific

deficiencies that are open to individual interpretation and discretion. Of the 17 categories,

those that are considered most problematic are “resident rights”, “resident behavior and

facility practices”, “quality of life”, “quality of care”, and “nursing services.” 

RECOMMENDATION

The resident-centered long-term care requirements of the nursing home survey are

essential tp guarantee the quality of care in nursing homes. Clearly some major problems

need to be addressed. Our findings support and elaborate on the Health Care Financing

Administration’s initiative to strengthen the enforcement efforts by: 

 < making them more timely and effective,

 < changing the survey schedule to make surveys more unpredictable, 

 < increasing the number of night and weekend surveys,

 < increasing the number of surveys at nursing homes with chronic quality of care

problems, and 

 < focusing on specific problems such as pressure sores, dehydration, and

malnutrition.

These initiatives, if carried out completely, appear to be responsive to most of the

problems in this report as well as our companion report “Nursing Home Survey and

Certification: Overall Capacity.”

Many of the most frequently cited deficiencies are directly related to reported shortage of
Survey and Certification: Deficiency Trends 4 OEI-02-98-00331

direct care staff. The failure to provide proper treatment to prevent or treat pressure sores

illustrates the lack of direct care staff to assure that residents are properly hydrated,

nourished and turned frequently. In light of our findings in this report, additional action is

needed. We recommend that the Health Care Financing Administration: 

 < 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. Staffing standards should account for the intensity of care needed,

qualifications of the staff, and the specific characteristics of both the nursing home

and the residents.

AGENCY COMMENTS

We received comments on the draft report from HCFA and the Assistant Secretary for

Planning and Evaluation (ASPE). The HCFA concurs with our recommendations. The

ASL informally commented on the reports, and we made the appropriate changes.

The ASPE expressed some concern about the ability of OSCAR data to assess quality of

care in nursing homes. We recognize the limitations of OSCAR but used it as only one

indicator of quality. We are happy to re-emphasize here what we say in our report that

OSCAR data should not be looked at independently. In this report we used it in

combination with the views of nursing home surveyors and State Directors.
Survey and Certification: Deficiency Trends 5 OEI-02-98-00331

TABLE OF CONTENTS

PAGE

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

INTRODUCTION .......................................................... 6

FINDINGS

Deficiency Trends .................................................... 14

Chronic Problems ..................................................... 20

Data Accuracy ....................................................... 22

RECOMMENDATION ..................................................... 24

APPENDICES

A: Substandard Quality of Care Deficiencies ................................ 26

B: Deficiency Tags .................................................... 31

C: Comments ........................................................ 35
Survey and Certification: Deficiency Trends 6 OEI-02-98-00331

INTRODUCTION

PURPOSE

To describe deficiency trends indicated by survey data and the extent to which these trends

indicate quality of care in nursing homes. 

BACKGROUND

While many 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 the Health Care Financing Administration (HCFA) and the General

Accounting Office 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. 

At the same time, the Office of Inspector General undertook additional studies aimed at

assessing the quality of care in nursing homes. Among these were studies on prescription

drug utilization, patient abuse, and criminal background on employees. This report

examines trends in the Online Survey Certification and Reporting System (OSCAR) data

that indicate quality of care problems in nursing homes survey and certification data. A

companion report describes the overall capacity of the State survey and certification

program to monitor quality of care in nursing homes. Future OIG reports will address the

trend in reported abuse in nursing home residents, the role of the ombudsman, and the

availability of nursing home survey results.

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 for those who require it. Medicare can help pay for skilled nursing facility

(SNF) care for up to 100 days in a benefit period when a beneficiary meets certain

conditions. Medicaid coverage varies among States. Medicaid eligible beneficiaries who

require custodial care such as help with eating, bathing, taking medicine and toileting, as

well as those who require skilled care may have nursing home stay paid for by Medicaid. 

Medicaid payments to nursing homes in 1996 totaled $29.6 billion. 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.

In 1986 the Institute of Medicine conducted a study on nursing home regulation. The

Institute reported prevalent problems regarding the quality of care for nursing home

residents and the need for stronger Federal regulations. In 1987 the General Accounting
Survey and Certification: Deficiency Trends 7 OEI-02-98-00331

Office (GAO) reported that over one third of nursing homes were operating below the

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 100-203). These actions expanded

requirements that nursing facilities had to comply with prior to Medicare certification. 

The Nursing Home Reform Act also ceded personal 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 also altered the principles for enforcement of Federal standards

of care in nursing homes.

Medicare Requirements

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

“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 OBRA 1987, as amended in 1988, 1989, and 1990, changed these requirements by

introducing an increased focus on the quality of life and care, the importance of the

individual resident, and the need to help the resident reach the “highest practicable level”

of functioning. It also included interviewing and assessing residents rather than simply

reviewing medical records. 

Enforcement Procedures

The 1987 Nursing Home Reform Act enforcement provisions were enacted when the

State Operations Manual (SOM) became effective on July 1, 1995. The HCFA had

several process goals during the implementation of the new survey and enforcement

systems. The first was to promote consistency through extensive training, the second was

to link appropriate remedies to deficiencies, and the third was to avoid unnecessary

procedures. Congress recognized that one enforcement response would not be

appropriate for all deficiencies. Enforcement policies were established that gave HCFA

the license to impose a variety of corrective measures when a facility is not in substantial

compliance with the requirements for participation in the Medicare and/or Medicaid

program. Some options include temporary management, denial of payment for new

admissions, civil money penalties, termination of the facility, or State monitoring of the

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

The HCFA imposed a number of administrative changes on enforcement procedures

following the implementation of the State Operations Manual. In June of 1995, HCFA

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

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

Manual in December of 1996. “Civil monetary penalties are now limited to situations of
Survey and Certification: Deficiency Trends 8 OEI-02-98-00331

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

deficiencies that 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. 

Requirements of Surveys

An important characteristic of nursing homes is their Federal certification status for the

Medicare and/or Medicaid programs. While some nursing homes may not meet

certification requirements, or may elect not to participate in either program, nearly all

nursing homes had some form of certification in 1996. The Nursing Home Reform Act

defines the State survey and certification process for determining nursing home

compliance with the Federal standards.

To ensure acceptable compliance, both the State for Medicaid facilities, and HCFA for

Medicare facilities, are responsible for performing routine facility surveys. For those

facilities designated as dually-certified, HCFA has the primary responsibility. The HCFA

contracts with States to perform the surveys for Medicare and dually-certified nursing

homes. The survey process determines, and the resulting survey documentation records

(HCFA-2567), the compliance or noncompliance of the facilities. When a facility fails to

meet a specific requirement, a deficiency or citation is given to the facility by the

surveyors. Surveyors provide the reasons justifying any resulting enforcement action and

the record on which to defend that action in the appeals process. Surveyors are instructed

to use the Principles of Documentation when determining the extent of non-compliance. 

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

on the HCFA-2567. These principals are generic and apply to the documentation of

survey outcomes regardless of the program (Medicare/Medicaid). 

As a result of the Nursing Home Reform Act, 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,” and the

Statewide average interval between standard surveys must be 12 months or less,” creating

a Federal standard survey window between 9 and 15 months. Each standard survey

includes a stratified case mix of nursing home residents measuring medical, nursing and

rehabilitative care, dietary and nutrition services, activities, social participation, sanitation,

infection control, and the 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

of residents’ rights.

In addition to the regular survey process there are “special” and “extended” surveys. 

Special surveys may be conducted within two months of any change in ownership,
Survey and Certification: Deficiency Trends 9 OEI-02-98-00331

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

effect on the quality of care in the facility. Extended surveys are performed immediately

or within two weeks after the standard survey completion on those facilities 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. 

Complaint Procedures

Each State is 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. In addition, each State is required to

notify the nurse aid registry and licensure boards when an abuse or neglect claim has been

substantiated. 

Online Survey Certification and Reporting System (OSCAR)

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

October 1991 as a replacement for the Medicare/Medicaid Automated Certification

System (MMACS) and the Rapid Data Retrieval System (RADARS). The HCFA uses

OSCAR in its survey of Medicare and Medicaid providers to monitor State agency and

provider performance. 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

based on deficiencies. The Federal regulations detailing survey requirements are classified

into 17 major categories in the HCFA State Operations Manual: 

 < resident rights; 

 < admission, transfer and discharge rights; 

 < resident behavior and facility practices; 

 < quality of life;

 < resident assessment;

 < quality of care;

 < nursing services; 
Survey and Certification: Deficiency Trends 10 OEI-02-98-00331

 < dietary services;

 < physician services;

 < rehabilitation services;

 < dental services;

 < pharmacy services;

 < infection control;

 < physical environment; 

 < administration;

 < laboratory; and

 < other.

The specific survey requirements within these categories were consolidated from 325

individual items to 185 items effective on July 1, 1995. When a nursing home fails to meet

a specific requirement which could result in a negative impact on the health and safety of

residents, a deficiency is given to the facility by a State surveyor team. A deficiency is

rated based on scope and severity for the purposes of enforcement. 

When a facility has one or more deficiencies related to resident behavior and facility

practices, quality of life, or quality of care that constitute either immediate jeopardy to

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

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

jeopardy with no actual harm it is considered substandard quality of care. Resident

behavior and facility practices includes the areas of restraints, abuse and staff treatment of

residents; quality if life includes the residents ability to make decisions about his or her

daily activities and the nursing home’s accommodation of those needs; and quality of care

includes the technical ability of the nursing home to prevent and treat the medical

conditions of the residents. For a complete listing of the deficiencies in each substandard

quality of care category see Appendix B.

Prior Studies

A recent study, “The Regulation and Enforcement of Federal Nursing Home Standards”

by Charlene Harrington published in March of 1998, details the problems with nursing

home certification that precipitated the action by Congress in passing the Nursing Home

Reform Act. 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.

“The National State Auditors Association Joint Performance Audit on Long-Term 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
Survey and Certification: Deficiency Trends 11 OEI-02-98-00331

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

delaying the investigation of complaints.

The Secretary released a report to Congress in July of 1998 indicating that significant

improvements were made since 1995 in the quality of care delivered by nursing homes. 

These improvements included more appropriate use of physical restraints, anti-psychotic

drugs, anti-depressants, urinary catheters, and hearing aids. The report also found 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 bed

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. 

In conjunction with the Secretary’s report to Congress, 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, increasing the number of night and weekend

surveys, and re-authorizing the Ombudsman program in the Older Americans Act.

One week after the President’s initiative, the Government 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, chaired by Senator Charles Grassley, held hearings in July

1998 to discuss the findings on the quality of care in nursing homes.

The HCFA has a number of studies in progress evaluating various aspects of survey and

certification. Some studies include staffing ratios, quality of care, and resident assessment. 
Survey and Certification: Deficiency Trends 12 OEI-02-98-00331

METHODOLOGY

This inspection is based on information gathered from three different sources: OSCAR

data, interviews with State survey and certification directors and State survey and

certification surveyors. We looked for consistencies between the data and the

observations of the insiders we interviewed. We selected a purposive sample of ten

States: New York, California, Texas, Ohio, Illinois, Pennsylvania, Massachusetts, Florida,

New Jersey, and Tennessee. These States have comprehensive survey and certification

programs and represent 55.8 percent of the nation’s total skilled nursing beds. In addition,

they represent 56 percent ($23 billion) of Medicaid institutional long-term care

expenditures in 1996. The purposive sample represents States of various sizes in different

parts of the country.

OSCAR Data

The Online Survey Certification and Reporting System (OSCAR) is the system HCFA

uses in its survey of Medicare and Medicaid providers to monitor State agency and

provider performance. OSCAR contains data for the current and three previous standard

surveys. The second part of OSCAR is information generated by the surveyors based on

deficiencies. The Federal regulations detailing survey requirements are classified into 17

major categories. We analyzed three of these categories which could determine poor

quality of care depending on their scope and severity. Resident behavior and facility

practices includes the areas of restraints, abuse and staff treatment of residents; quality of

life includes the residents ability to make decisions about his or her daily activities and the

nursing home’s accommodation of those needs; and quality of care includes the technical

ability of the nursing home to prevent and treat the medical conditions of the residents. 

We looked at those substandard quality of care deficiencies which increased over the last

four standard surveys, those that decreased and those that remained high, and those

deficiencies that repeated over the last four surveys. 

Additionally, we looked at the top 10 of all deficiencies to determine which deficiencies

are cited most frequently. We also looked at OSCAR complaint data specifically at

complaints of abuse. We compared complaints of abuse filed from January 1997 to July

1998 to abuse deficiencies in the most current survey. The direct relationship between

abuse codes in the deficiency and complaint tables allowed us to look closely at the scope

of abuse and examine enforcement patterns and outcomes. Since information in the

OSCAR database is constantly being updated, we downloaded OSCAR data on August 4,

1998. In all cases we compared our 10 sample States to aggregate national data both for

deficiencies and complaints. 
Survey and Certification: Deficiency Trends 13 OEI-02-98-00331

Interviews

We also conducted a total of thirty structured interviews; three interviews in each of the

ten sample States, one with the State survey and certification director or a designee, and

two with State surveyors within each State. The two State surveyors were selected

randomly from a list of at least ten surveyors submitted by the State director. During

these interviews, we obtained information about the State survey and certification program

structure, the processes utilized to monitor quality of care, how deficiencies are addressed,

and the respondents satisfaction with the process.

We selected both directors and surveyors for their different perspectives on the survey and

certification process. We compared the information provided by the directors to

information provided by surveyors. In our analysis we paid special attention to consensus

within and among the groups. 

This inspection was conducted in accordance with the Quality Standards for

Inspections issued by the President’s Council on Integrity and Efficiency. 
Survey and Certification: Deficiency Trends 14 OEI-02-98-00331

FINDINGS

Overall deficiencies are decreasing, but “quality of care” 

deficiencies are increasing and other serious deficiencies

persist at high levels

General trends 

Potential deficiencies are classified into 17 major categories containing 185 subcategories

of specific deficiencies. If a nursing home has deficiencies in three specific categories, it 

is considered to have substandard quality of care for enforcement purposes depending on

the scope and severity. These three categories are: “quality of care”, “resident behavior

and facility practices”, and “quality of life”. 

“Resident behavior and facility practices” and “quality of life,” two of the three

substandard quality of care categories, are lower in the current standard survey than they

were in the prior three. See Appendix A for a complete listing of the deficiencies in these

categories. In addition, some “quality of care” deficiencies have also decreased over the

past four surveys. In all three substandard quality of care categories, nine deficiencies

have decreased by more than 50 percent between the current survey and three surveys

prior. See Table I below.

Table I

Deficiencies that have Decreased by More than 50 percent

Deficiencies Percent Decrease

Facility promotes/enhances -87%

quality of life

Facility must employ a qualified social -79%

worker

Private closet space -74%

Facility must listen and respond to -72%

groups

Adequate and comfortable light -61%

Clean bed and bath linens -55%
Survey and Certification: Deficiency Trends 15 OEI-02-98-00331

Gradual dose reduction of -55%

antipsychotic drugs

No naso-gastric tube unless unavoidable -53%

Right to be free from chemical restraints -52%

Source: OSCAR Data

On the national level, six deficiencies decreased by 50 percent or more. Five deficiencies

mirror those of the sample States in addition to failure to provide activities of daily living

to dependent residents which has also declined over 50 percent. About 40 percent (20 out

of 49) of all deficiencies in the three substandard quality of care categories have declined

every survey for the past four surveys. These declines range from a 10 percent decline to

a 79 percent decline. Nationally, 30 percent (15 out of 49) of all deficiencies declined

every survey with decreases ranging from 17 percent to 75 percent. 

We compared the 49 deficiencies in the 3 substandard quality of care categories to the

other 136 deficiencies. The 49 substandard quality of care deficiencies have decreased by

only 14 percent over the last four standard surveys compared to a 32 percent decrease for

all other deficiencies that do not fall in the substandard quality of care category. See

Figure I below. 

Figure I

Sample State Deficiency Trends in Four Consecutive Surveys

Source: OSCAR Data
Survey and Certification: Deficiency Trends 16 OEI-02-98-00331

The slower decrease in substandard quality of care deficiencies has in effect increased

their proportion among all OSCAR deficiencies. As mentioned before, certain

substandard quality of care deficiencies in the ‘quality of care’ category have actually

increased such as the failure to supply range of motion treatment and services, failure to

provide supervision or devices to prevent accidents, and failure to provide proper

treatment or heal pressure sores. When we look at national substandard quality of care

deficiencies, they mirror the trend of those in sample States.

Sample State outliers to the above trend include New Jersey, Florida, and Illinois. New

Jersey differs from the trend because substandard quality of care deficiencies decreased at

a faster rate (46 percent) than all others (26 percent). Substandard quality of care

deficiencies in Florida and Illinois have actually increased (12 percent in Florida and 11 

percent in Illinois), while all other deficiencies decreased (6 percent in Florida and 33

percent in Illinois).

“Quality of care” deficiencies

Thirteen of the 25 “quality of care” deficiencies in sample States are higher on the current

survey than they were three surveys prior. 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. See Table II below for a listing of the 13 deficiencies that have increased over

the past 3 surveys. See Appendix A for a complete listing of all ‘quality of care’

deficiencies and their survey trends.

Table II

Increasing Deficiencies Over Past Three Surveys

Deficiencies Percent Increase

Adequate supervision and/or devices to prevent

accidents

+79%

Appropriate range of motion treatment +48%

Resident not catheterized unless unavoidable +42%

Resident receives treatment to maintain vision

and hearing

+35%

ADL care provided for dependent residents +33%

No reduction in range of motion unless

unavoidable

+29%
Survey and Certification: Deficiency Trends 17 OEI-02-98-00331

Proper treatment to prevent or treat pressure

sores

+21%

Resident given appropriate treatment to improve

abilities

+8%

Proper treatment and care for special needs +7%

No development of mental problems unless

unavoidable

+5%

Appropriate treatment for incontinence +5%

Provides necessary care for highest practicable

well-being 

+4%

Proper care for residents with naso-gastric tubes +1%

Source: OSCAR Data

Additionally, 3 of the 13 “quality of care” deficiencies that have increased, have increased

in every survey for the past four surveys. These three include nursing homes catheterizing

residents without demonstrating clinical need, the nursing homes failure to provide range

of motion treatment, and the lack of supervision and/or devices to prevent accidents. See

Figure II below. 

Figure II

Sample State Deficiencies Increasing Every Survey
Survey and Certification: Deficiency Trends 18 OEI-02-98-00331

When looking at the ‘quality of care’ deficiencies nationwide, 10 deficiencies are higher

on the current survey than they were three surveys prior. These ten deficiencies were

cited 10,497 times on the current survey compared to 7,726 times three surveys prior, an

increase of 36 percent. Four of these 10 deficiencies have increased in every survey for

the past four surveys. These include the nursing homes failure to provide necessary care

for high well-being, the failure to provide activities of daily living care for dependent

residents, the lack of supervision and/or devices to prevent accidents, and the failure to

provide range of motion treatment. See Figure III below.

Figure III

National Deficiencies Increasing Every Survey

Source: OSCAR Data

High deficiencies

Although some deficiencies have declined over the years, the number of deficiencies still 

cited is a cause for concern. Deficiencies often lead to further medical problems or

indicate other issues. For example, pressure sores are bruises or open sores on the skin

which could be an indication that other kinds of problems are occurring with residents in

the nursing home such as urinary incontinence, malnutrition or dehydration. If a resident

has a cognitive loss or dementia, physical restraints, or psychotropic drugs are being used, 

the resident is also vulnerable to resultant pressure sores. 
Survey and Certification: Deficiency Trends 19 OEI-02-98-00331

According to OSCAR data, a total of 7,196 nursing homes exist in sample States. Ten

substandard quality of care deficiencies in sample States have been cited more than 699

times on the latest standard survey, affecting more than 10 percent of nursing homes. Ten

substandard quality of care deficiencies also affect more than 10 percent of nursing homes

nationwide. Five deficiencies affect at least 13 percent of sample State and national

nursing homes and they include failure to prevent pressure sores, failure to remain free of

accident hazards, failure to maintain or enhance dignity, failure to provide 

housekeeping to maintain sanitary, orderly and comfortable interiors, and failure to

provide the necessary care for the highest practicable well-being. See Table III below. 

Table III

Top Ten Substandard Quality of Care Deficiencies 

Cited On Latest Standard Survey

Deficiency # of Sample % of # of % of

State Sample National National

Deficiencies State Deficiencies Facilities

Facilities

Proper treatment to prevent or 

treat pressure sores

1,186 16% 2,416 16%

Facility is free of accident hazards 1,164 16% 2,381 16%

Facility promotes care that

maintains/enhances dignity

1,115 16% 2,032 14%

Housekeeping and maintenance 1,023 14% 1,916 13%

Provides necessary care for 

highest practicable well-being

972 14% 2,247 15%

Right to be free from physical

restraints

958 13% 1,942 13%

Should have policies that accommodate

needs

787 11% 1,348 9%

Drug regimen free from unnecessary

drugs

768 11% 1,575 11%

Appropriate treatment for incontinence 750 10% 1,560 10%

“Activities of daily living” care

provided for dependent residents

699 10% 1,598 11%

Source: OSCAR data
Survey and Certification: Deficiency Trends 20 OEI-02-98-00331

As opposed to the deficiencies cited the most, some deficiencies remain low. Eighteen

substandard quality of care deficiencies in sample States have been cited less than 100

times on the latest standard survey, affecting less than one percent of nursing homes. 

Examples of some of these deficiencies include feeding residents with naso-gastric tubes

without medical need, hiring non-qualified social workers, facility prevents residents

participation in social, religious, or community activities, and the nursing home fails to

promote maintenance or enhancement of each resident’s quality of life.

Nursing homes with chronic quality of care problems exist

While State directors and surveyors express reservations about OSCAR data, interviews

with them support the OSCAR data about repeat offenders. The OSCAR data shows 463

nursing homes have been cited with the same deficiencies over the past four contiguous

surveys, representing 6 percent of all homes in the sample States. The number of nursing 

homes with repeat quality of care deficiencies ranges from 2 in New Jersey to 270 in

California. Table IV shows the number of nursing homes in sample States with repeat

quality of care deficiencies. 

Table IV

Number of Nursing Homes in Sample States with Repeat Substandard

Quality of Care Deficiencies over Four Surveys

State Number of Nursing Percent of Nursing Number of Repeat

Homes with Homes with Repeat Deficiencies

Repeat Deficiencies Deficiencies

CA 270 21% 369

FL 28 4% 33

IL 54 8% 62

MA 8 2% 8

NJ 2 1% 2

NY 4 1% 4

OH 28 3% 33

PA 10 1% 11

TN 3 1% 3

TX 56 5% 70

Source: OSCAR Data
Survey and Certification: Deficiency Trends 21 OEI-02-98-00331

Table V below identifies the number of nursing homes affected by the top 10 repeat

substandard quality of care deficiencies in the 10 sample States. Failure of the nursing

home to promote care that maintains or promotes dignity ranks first on the list in both the

sample States and the national numbers. 

Table V

Top 10 Substandard Quality of Care Repeat Deficiencies

Deficiency Facilities in Facilities

Sample States Nationwide

Facility promotes care that 142 174

maintains or enhances dignity 

Facility must provide necessary 91 151

housekeeping and maintenance services 

Facility should have policies that 68 80

accommodate needs and preferences 

Facility is free of accident hazards 64 99

Drug regimen free of unnecessary drugs 33 58

Proper treatment to prevent or treat 

pressure sores 

27 74

Right to be free from physical restraints 24 44

Adequate supervision and/or devices to 22 27

prevent accidents 

Facility provides medically related social 19 29

services 

Facility must provide a safe, clean, homelike 15 32

environment 

Source: OSCAR Data

State directors and surveyors report that nursing homes with chronic quality of care

problems exist in their individual States. Nursing homes with serious deficiencies or

constant non-compliance issues are considered to have chronic quality of care problems. 

They say that the percentage of nursing homes with these problems is between 1 and 20

percent of all nursing homes in their respective States. Half of the State directors mention

pressure sores and nutrition issues as frequent chronic quality of care problems in their

nursing homes. Consistent with these observations, OSCAR data show the deficiency that
Survey and Certification: Deficiency Trends 22 OEI-02-98-00331

occurs the most frequently, both in our sample States and nationwide, is the failure to give

proper treatment to prevent or treat pressure sores. See Table III on page 18.

Surveyors concur with directors, but most also mention that nursing home staffing

shortages and inferior staff proficiency levels precipitate chronic quality of care in nursing

homes. We looked at staffing ratios in the facility reported section of OSCAR data and

found between six to nine residents for each certified nurse assistant (CNA) and between

36 and 81 residents for each registered nurse (RN) considering three shifts per day. This

does not account for weekends and days off and is only an average. Some homes may

have a much higher ratio than others and there is no way of telling if some units within a

nursing home are better staffed than others. Abuse of restraints, failure to treat

incontinent patients, and improper medication distribution are also mentioned by State

directors and surveyors as deficiencies that lead to substandard quality of care.

State directors and surveyors express reservations about

relying exclusively on OSCAR data to identify and

understand problems in nursing homes 

Snapshot in time

OSCAR data may not catch all the problems that exist in a nursing home due to the

current survey process. Surveyors visit most facilities only once a year and cannot be

cognizant of problems that occur throughout the year. Because many surveys do not take

place on weekends on in the evenings, surveyors are limited in their assessment of the

nursing home. In order to gain the most comprehensive understanding at a nursing home,

OSCAR data should be used in combination with the surveyors visit and other State

specific information. 

More than half of respondents believe that OSCAR data are not a true indicator of nursing

home quality of care. The quality of care at the nursing home may have drastically

changed for the better or worse. A common theme among many surveyors and directors

is that OSCAR data only portray the situation of the nursing home at the time surveyors

are physically conducting the survey. One director remarked, “OSCAR is simply a profile

of what is found on the survey. Surveys depend on the characteristics of unique survey

teams. Some very bad nursing homes may have a survey that portrays them positively and

some very good nursing facilities may have a survey that portrays them negatively.” 

Most surveyors and more than half of directors are satisfied with OSCAR data but note

problems and propose changes. Surveyors suggest using OSCAR data in conjunction with

other tools to obtain an accurate view of quality of care. “OSCAR is only one part of the

quality of care story”, one surveyor said. A director notes that OSCAR is a useful
Survey and Certification: Deficiency Trends 23 OEI-02-98-00331

instrument to help focus a survey team during the pre-survey, but doesn’t indicate quality

of care when analyzed alone. Respondents are concerned that OSCAR data are not user

friendly, accurate, streamlined, accessible, or timely. Another director said, “OSCAR

generated reports are cumbersome and time consuming.” The consensus of the

respondents is that OSCAR is difficult to use.

Unclear definitions

Some deficiency definitions are clear and easy to interpret such as “ the facility may not

employ persons who have been found guilty of abuse.” The facility is responsible to

provide information about background checks of their staff. Other easy to interpret

deficiencies include; a facility with more than 120 beds must employ a qualified social

worker on a full time basis, or a facility must provide private closet space in each

resident’s room. 

However, other deficiencies hard to define or difficult to detect may be interpreted

differently by various teams of surveyors. People might feel differently about what

constitutes dignity or whether the nursing home is providing appropriate accident

prevention measures. 

The majority of the State survey and certification directors and surveyors we interviewed

believe that certain deficiencies have unclear definitions. They note some specific

deficiencies that are open to individual interpretation and discretion. Of the 17 categories,

those that are considered most problematic are “resident rights”, “resident behavior and

facility practices”, “quality of life”, “quality of care”, and “nursing services.” Specific

deficiencies in these categories include physical and chemical restraints, activities of daily

living, and accidents. Unclear definitions can cause significant problems when surveyors

are writing their survey reports. One surveyor notes, “some problems just don’t fit nicely

into the deficiency categories.” Another surveyor states that the “use of psychoactive

drugs is an awkward deficiency because the use of these drugs may be appropriate but the

nursing home may have a poor way of documenting the need.”
Survey and Certification: Deficiency Trends 24 OEI-02-98-00331

RECOMMENDATION

The resident-centered long-term care requirements of the nursing home survey are essential

tp guarantee the quality of care in nursing homes. Clearly some major problems need to be

addressed. Our findings support and elaborate on the Health Care Financing

Administration’s (HCFA) initiative to strengthen the enforcement efforts by: 

 < making them more timely and effective,

 < changing the survey schedule to make surveys more unpredictable, 

 < increasing the number of night and weekend surveys,

 < increasing the number of surveys at nursing homes with chronic quality of care

problems, and 

 < focusing on specific problems such as pressure sores, dehydration, and malnutrition.

These initiatives, if carried out completely, appear to be responsive to most of the problems

in this report as well as our companion report “Nursing Home Survey and Certification:

Overall Capacity.”

Many of the most frequently cited deficiencies are directly related to reported shortage of

direct care staff. The failure to provide proper treatment to prevent or treat pressure sores

illustrates the lack of direct care staff to assure that residents are properly hydrated,

nourished and turned frequently. In light of our findings in this report, additional action is

needed. We recommend that HCFA: 

 < 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. Staffing standards should account for the intensity of care needed,

qualifications of the staff, and the specific characteristics of both the nursing home

and the residents.

AGENCY COMMENTS

We received comments on the draft report from HCFA and the Assistant Secretary for

Planning and Evaluation (ASPE). The HCFA concurs with our recommendations. The

ASL informally commented on the reports, and we made the appropriate changes.

The ASPE expressed some concern about the ability of OSCAR data to assess quality of

care in nursing homes. We recognize the limitations of OSCAR but used it as only one

indicator of quality. We are happy to re-emphasize here what we say in our report that
Survey and Certification: Deficiency Trends 25 OEI-02-98-00331

OSCAR data should not be looked at independently. In this report we used it in

combination with the views of nursing home surveyors and State Directors.
Survey and Certification: Deficiency Trends 26 OEI-02-98-00331

APPENDIX A

Substandard Quality of Care Deficiencies

Table VI

“Resident Behavior and Facility Practices” Deficiencies in Sample States

Deficiency 3 Surveys 2 Surveys 1 Survey Current Percent

Prior Prior Prior Survey Change 

Right to be free from 1145 1245 1109 958 -16%

physical restraints

Right to be free from 102 83 68 49 -52%

chemical restraints

Right to be free from abuse 205 144 117 112 -45%

Must have policies that 198 172 122 162 -18%

prohibit abuse and neglect

May not employ persons 409 382 300 341 -17%

guilty of abuse

Total 2059 2026 1716 1622 -21%

Source: OSCAR data
Survey and Certification: Deficiency Trends 27 OEI-02-98-00331

Table VII

“Quality of Life” Deficiencies in Sample States

Deficiency 3 Surveys 2 Surveys 1 Survey Current Percent

Prior Prior Prior Survey Change

Facility promotes/enhances 117 38 14 15 -87%

quality of life

Facility promotes care that 1470 1367 1164 1115 -24%

maintains/enhances dignity

Resident has the right to 188 166 148 138 -27%

make choices about aspects

of life in the facility

Right to organize and 60 59 40 35 -42%

participate in groups

Facility must listen and 123 33 27 34 -72%

respond to groups

Right to participate 15 16 11 15 00%

in activities

Should have policies that 1357 1147 835 787 -42%

accommodate needs

Receive notice of room or 51 28 23 31 -39%

roommate change

Facility must provide an 826 810 659 641 -22%

activity program

Facilities activity director 66 46 34 53 -20%

must be fully qualified

Facility provides medically 766 758 712 647 -16%

related social services 

Facility must employ a 56 27 26 12 -79%

qualified social worker

Facility must provide a safe, 984 774 548 510

clean, homelike environment

-48%
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Housekeeping maintains 1242 1076 1057 1023 -18%

sanitary and comfortable

interior

Clean bed and bath linens 214 150 121 96 -55%

Private closet space 57 33 14 15 -74%

Adequate and comfortable 90 67 44 35 -61%

light

Safe and comfortable 119 76 61 75 -37%

temperature levels

Maintenance of comfortable 220 204 178 157 -29%

sound levels

Total 8021 6875 5716 5434 -32%

Source: OSCAR data
Survey and Certification: Deficiency Trends 29 OEI-02-98-00331

Table VIII

“Quality of Care” Deficiencies in Sample States

Deficiency 3 Surveys 2 Surveys 1 Survey Current Percent

Prior Prior Prior Survey Change

Provides necessary care for 939 887 923 972 +04%

highest practicable well-being 

ADL’s don’t decline unless 346 268 212 201 -42%

unavoidable

Resident given appropriate 314 313 320 339 +08%

treatment to improve abilities

ADL care provided for 527 654 568 699 +33%

dependent residents

Resident receives treatment to 37 56 58 50 +35%

maintain vision and hearing

Proper treatment to prevent 984 1061 1005 1186 +21%

or treat pressure sores

Resident not catheterized 72 97 98 102 +42%

unless unavoidable

Appropriate treatment for 714 730 663 750 +05%

incontinence

No reduction in range of 51 67 66 66 +29%

motion unless unavoidable

Appropriate range of motion 411 537 548 607 +48%

treatment

Appropriate treatment for 280 261 221 208 -26%

mental or psychosocial

functioning

No development of mental 20 22 13 21 +05%

problems unless unavoidable

No naso-gastric tube unless 19 26 15 9 -53%

unavoidable
Survey and Certification: Deficiency Trends 30 OEI-02-98-00331

Proper care for residents with 367 364 308 369 +01%

naso-gastric tubes

Facility is free of accident 1402 1255 1147 1164 -17%

hazards

Adequate supervision and/or 532 699 778 954 +79%

devices to prevent accidents

Resident maintains nutrition 633 612 600 569 -10%

status unless unavoidable

Resident receives therapeutic 325 216 153 179 -45%

diet when required

Facility provides sufficient 261 251 226 230 -12%

fluid intake to maintain health

Proper treatment and care for 278 282 257 298 +07%

special needs

Drug regimen free from 785 784 786 768 -02%

unnecessary drugs

No use of antipsychotic drugs 101 75 69 65 -36%

except when necessary

Gradual dose reduction of 115 90 76 52 -55%

antipsychotic drugs

Facility is free of medication 436 391 345 330 -24%

error rates of 5% or more

Residents are free from 272 216 188 215 -21%

significant medication errors

Total 10221 10214 9643 10403 0.02

Source: OSCAR data
Survey and Certification: Deficiency Trends 31 OEI-02-98-00331

APPENDIX B

Definitions of Substandard Quality of Care Deficiencies

“Resident Behavior and Facility Practices” Category

Deficiency - (Ftag) Definition

F0221 Resident has the right to be free from any physical restraint for

purposes of discipline or convenience.

F0222 Resident has the right to be free from any chemical restraint for

purposes of discipline or convenience.

F0223 Resident has the right to be free from verbal, sexual, physical and

mental abuse, corporal punishment, and involuntary seclusion.

F0224 Facility must have written policies and procedures that prohibit

abuse and neglect.

F0225 Facility may not employ persons who have been found guilty of

abuse

. 

“Quality of Life” Category

Deficiency - (Ftag) Definition

F0240 Facility must promote/enhances quality of life.

F0241 Facility must promote care that maintains or enhances dignity.

F0242 Resident has the right to choose activities, schedules, interact with

members of community, and make choices about aspects of life in

the facility.

F0243 Resident has the right to organize and participate in resident

groups.

F0244 Facility must listen and respond to resident or family group.

F0245 Resident has the right to participate in social, religious, and

community activities.
Survey and Certification: Deficiency Trends 32 OEI-02-98-00331

F0246 Facility should have policies that accommodate residents’ needs and

preferences.

F0247 Resident to receive notice before room or roommate in the facility

is changed.

F0248 Facility is to provide ongoing program of activities that fit resident.

F0249 Facilities director must be fully qualified.

F0250 Facility must provide medically related social services.

F0251 Facility with more than 120 beds must employ a qualified social

worker on a full time basis.

F0252 Facility must provide a safe, clean, comfortable, and homelike

environment.

F0253 Facility must provide housekeeping and maintenance services

necessary to maintain a sanitary, orderly and comfortable interior.

F0254 Facility must provide clean bed and bath linens that are in good

condition.

F0255 Facility must provide private closet space in each resident’s room.

F0256 Facility must provide adequate and comfortable lighting levels in all

areas.

F0257 Facility must provide comfortable and safe temperature levels.

F0258 Facility must provide comfortable sound levels.

“Quality of Care” Category

Deficiency - (Ftag) Definition

F0309 Facility to provide necessary care for the highest practicable

physical, mental, and psychosocial well being.

F0310 Activities of daily living do not decline unless unavoidable.

F0311 Resident is given treatment to improve abilities.
Survey and Certification: Deficiency Trends 33 OEI-02-98-00331

F0312 Activities of daily living care is provided for dependent residents.

F0313 Resident receive treatment to maintain hearing and vision.

F0314 Proper treatment to prevent or treat pressure sores.

F0315 Resident is not catheterized unless unavoidable.

F0316 Appropriate treatment for incontinent resident.

F0317 No reduction of range of motion unless unavoidable.

F0318 Resident with limited range of motion receives appropriate

treatment. 

F0319 Appropriate treatment for mental or psychosocial problems.

F0320 No development of mental problems unless unavoidable.

F0321 No naso-gastric tube unless unavoidable.

F0322 Proper care and services for resident with naso-gastric tube.

F0323 Facility is free of accident hazards.

F0324 Resident receives adequate supervision and assistance devices to

prevent accidents.

F0325 Facility must maintain acceptable parameters of nutritional status

unless unavoidable.

F0326 Resident receives therapeutic diet when required.

F0327 Facility must provide sufficient fluid intake to maintain proper

hydration and health.

F0328 Facility must ensure that proper treatment and care is provided.

F0329 Each resident’s drug regimen must be free from unnecessary drugs.

F0330 No use of antipsychotic drugs except when necessary.
Survey and Certification: Deficiency Trends 34 OEI-02-98-00331

F0331 Residents who use antipsychotic drugs receive gradual dose

reductions.

F0332 Facility must ensure that it is free of medication error rates of five

percent or greater.

F0333 Residents are free of any significant medication errors.
Survey and Certification: Deficiency Trends 35 OEI-02-98-00331

APPENDIX C

Comments on the Draft Report

In this appendix, we present in full the comments form the Health Care Financing

Administration, and the Assistant Secretary for Planning and Evaluation.
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