Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

 

Daniel R. Levinson 

Inspector General 

April 2009 

OEI-06-06-00570 

 

NURSING HOME CORPORATIONS 

UNDER QUALITY OF CARE 

CORPORATE INTEGRITY 

AGREEMENTS 
Office of Inspector General 

http://oig.hhs.gov 

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

amended, is to protect the integrity of the Department of Health and Human Services (HHS) 

programs, as well as the health and welfare of beneficiaries served by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits examine 

the performance of HHS programs and/or its grantees and contractors in carrying out their 

respective responsibilities and are intended to provide independent assessments of HHS 

programs and operations. These assessments help reduce waste, abuse, and mismanagement 

and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, 

Congress, and the public with timely, useful, and reliable information on significant issues. 

These evaluations focus on preventing fraud, waste, or abuse and promoting economy, 

efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also 

present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 

fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources by 

actively coordinating with the Department of Justice and other Federal, State, and local law 

enforcement authorities. The investigative efforts of OI often lead to criminal convictions, 

administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, 

rendering advice and opinions on HHS programs and operations and providing all legal support 

for OIG’s internal operations. OCIG represents OIG in all civil and administrative fraud and 

abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil 

monetary penalty cases. In connection with these cases, OCIG also negotiates and monitors 

corporate integrity agreements. OCIG renders advisory opinions, issues compliance program 

guidance, publishes fraud alerts, and provides other guidance to the health care industry 

concerning the anti-kickback statute and other OIG enforcement authorities. 
ΔEXECUTIVE SUMMARY EXECUTIVE SUMMARY EXECUTIVE SUMMA RY 

OBJECTIVE

To review nursing home corporations under quality of care Corporate 

Integrity Agreements (CIA) to: 

1. determine the extent to which they implemented required quality of 

care structures and processes, 

2. determine their responsiveness to quality monitoring, and 

3. describe challenges encountered when implementing the 

requirements of their CIAs. 

BACKGROUND 

Under quality of care CIAs, nursing home corporations with identified 

quality of care problems consent to certain requirements in exchange for 

an agreement by the Department of Health and Human Services, Office 

of Inspector General (OIG), not to exclude them from participation in 

Federal health care programs. A nursing home quality of care CIA is a 

contract that is typically entered into for 3 to 5 years and requires 

implementation of quality of care structures and processes and 

monitoring by an independent monitor. 

This study examined the 15 nursing home corporations that began 

quality of care CIAs between June 2000 and December 2005. To review 

these corporations, we examined corporate documents and reports from 

corporations and their quality monitors and interviewed corporate 

representatives and monitors. 

FINDINGS 

All 15 corporations enhanced quality of care structures and 

processes while under their CIAs and cited positive effects of the 

CIAs. Each corporation had written policies and procedures regarding 

quality of care, codes of conduct, and training required by their CIAs. 

All 15 corporations monitored their quality of care by using 

standardized data and internal self-assessment tools and by tracking 

complaints. They all created or expanded their compliance 

infrastructure to integrate quality of care. In interviews, corporate 

representatives cited positive effects that the CIAs had on their 

corporations.

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EXECUTIVE SUMMARY 

Despite some initial resistance from 3 corporations, all 15 were 

ultimately responsive to their quality monitors’ guidance and 

corporate representatives reported that they valued the input. 

Quality monitors reported that 12 of the 15 corporations accepted and 

acted on the monitors’ guidance from the start of their CIAs and that 

3 initially resistant corporations became responsive (following OIG 

intervention) while under the CIAs. Our review of quality monitoring 

reports and corporate annual reports confirmed the monitors’ opinions 

that the 15 corporations were largely responsive to the monitors’ 

guidance. Additionally, corporate representatives cited several benefits 

of quality monitoring, e.g., monitors offered new ideas and fresh ways of 

thinking about quality of care structures and processes. 

Representatives of all 15 corporations described challenges 

encountered when implementing CIA requirements. Corporations 

with multiple nursing homes encountered challenges to ensuring 

consistency in quality of care systems across all layers of their 

organizations and across geographic regions. For example, an analysis of 

Quality Assessment and Assurance (QAA) committee meeting minutes 

indicated that nursing homes’ implementation of quality of care systems 

was inconsistent. Other challenges involved organizational disruptions, 

staff resistance to implementation, use of staff time to implement the 

requirements of the CIAs, and financial costs associated with CIAs. 

Inherent limitations of commonly used quality of care measures 

prevented our assessment of the quality of care performance of 

nursing homes under CIAs. We analyzed data from sources commonly 

used by the Centers for Medicare and Medicaid Services, quality 

monitors, and nursing home corporations as indicators of nursing home 

quality. However, we could not use these data to adequately assess the 

quality of care performance of nursing homes under CIAs because these 

measures do not have established benchmarks that set standards for 

what constitutes quality care.

CONCLUSION 

All 15 corporations enhanced quality of care structures and processes to 

meet the CIA requirements. Corporate representatives from each 

corporation cited positive effects of their CIAs. Although all 

corporations were ultimately responsive to their quality monitors’ 

guidance and valued their input, three corporations were initially 

resistant until OIG intervened. All corporations faced challenges in 

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EXECUTIVE SUMMARY 

implementing CIA requirements, such as difficulties in implementing 

quality systems throughout all levels of the corporations, including 

systems at the nursing home level. Based on these findings, areas that 

OIG will explore for its oversight of future CIAs include the following: 

• Responding swiftly to noncompliant corporations and those that fail 

to address quality problems by using available enforcement 

remedies, such as monetary penalties or, if appropriate, exclusion 

from Federal health care programs. Additionally, a provider’s 

continued failure to address quality of care may warrant opening 

new investigations by OIG. 

• Including specific requirements regarding documentation of nursing 

home QAA committee activities to ensure that quality of care 

monitoring and improvement systems are implemented at the 

nursing home level. 

• Sharing lessons learned by corporations and quality monitors with 

other corporations placed under subsequent CIAs. 

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

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

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 

All corporations enhanced quality of care structures and 

processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 

All corporations were ultimately responsive to quality 

monitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 

All corporations cited challenges to implementing CIAs . . . . . . . . 13 

Quality measures limitations prevented assessment of quality 

of care performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 

CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 

APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 

 A: Nursing Home Corporations Included in This Review . . . . . . . 18 

B: Quality Assessment and Assurance Committee 

Methodology and Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 

 C: Quality Indicators/Quality Measures . . . . . . . . . . . . . . . . . . . . 24 

 D: State Survey Deficiencies Data by Corporation . . . . . . . . . . . . 40 

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Δ TABLE OF CONTENTS 
Δ INTRODUCTION INTRODUCTION

OBJECTIVE 

To review nursing home corporations under quality of care Corporate 

Integrity Agreements (CIA) to: 

1. determine the extent to which they implemented required quality of 

care structures and processes, 

2. determine their responsiveness to quality monitoring, and 

3. describe challenges encountered when implementing the 

requirements of their CIAs. 

BACKGROUND 

Nursing home quality of care problems come to the attention of the 

Department of Health and Human Services, Office of Inspector General 

(OIG), through different avenues. For example, quality problems may 

become apparent when allegations of poor patient care are brought 

against providers under the False Claims Act.1 Some quality of care 

problems are brought to OIG’s attention through referrals from State 

and local law enforcement agencies. Still others come to OIG’s attention 

from other sources, such as media reports or Medicare and the OIG 

hotline. 

As part of the resolution of quality of care cases, OIG may agree not to 

exclude a nursing home corporation from participation in Federal health 

care programs if the corporation enters into a quality of care CIA with 

OIG.2 A quality of care CIA typically lasts 3 to 5 years and includes 

requirements that the corporation: 

• contract with an independent quality monitor authorized by OIG 

and provide the monitor with relatively unfettered access to 

facilities, staff, residents, documents, and management at all levels 

of the organization; 

• designate a compliance officer and appoint a corporate-level Quality 

Assurance Committee to oversee clinical improvement and 

compliance issues throughout the corporation; 

1 31 U.S.C. §§ 3729–3733. 

2 42 U.S.C. § 1320a-7 provides the authority for excluding entities from participation in 

Medicare, Medicaid, and other Federal health care programs. 

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• implement internal monitoring of quality of care; 

• establish a confidential disclosure program, e.g., a hotline; 

• develop written standards, policies, and procedures; 

• screen to ensure that ineligible persons are not hired;3

• implement competency-based employee training programs; and 

• submit status reports to OIG and report certain events, e.g., serious 

quality of care problems, to the quality monitor and OIG within 

specific timeframes. 

If the corporation fails to comply with the CIA, OIG may impose 

monetary penalties or, in the case of a material breach by the 

corporation, OIG may exclude one or more of the corporation’s nursing 

homes from participation in Federal health care programs. 

Nursing Home Quality of Care Corporate Integrity Agreements 

The first nursing home quality of care CIA went into effect in 

June 2000. By June 2008, 35 nursing home corporations had entered 

into such agreements, 16 corporations under original CIAs and 

19 corporations under “successor agreements.” A successor agreement 

is initiated when a corporation under a CIA sells nursing homes, splits 

into two or more corporations, or reorganizes to form a new corporation. 

Nursing homes that are sold, or those that are under the newly formed 

or reorganized corporation, are sometimes placed under successor 

agreements to ensure that they fulfill the original CIA requirements. 

This is the first review of nursing home corporations under CIAs since 

OIG began entering into quality of care CIAs. 

2 

3 An “ineligible person” is any individual or entity who: (1) is currently excluded, 

suspended, debarred, or otherwise ineligible to participate in the Federal health care 

programs or (2) has been convicted of a criminal offense related to the provision of health 

care items or services that falls within the ambit of 42 U.S.C. § 1320a-7(a) but has not yet 

been excluded. 

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INTRODUCTION 

Quality of Care Structures and Processes 

Quality of care CIAs include requirements about the structures and 

processes of corporations related to quality of care. 

• Quality of care is “the degree to which health services for individuals 

and populations increase the likelihood of desired health outcomes 

and are consistent with current professional knowledge.”4

• Quality of care “structures” are the framework of policies and rules

within which the corporation arranges its lines of authority and 

communication, division of labor, and formal powers that direct 

organizational activities affecting quality of care. 

• Quality of care “processes” are the activities that take place within 

these structures. 

For example, a structural change to address quality of care problems in 

a nursing home where residents have a higher than normal number of 

falls may involve writing a new policy for fall prevention. The 

associated process change would be the activities undertaken to 

implement the new policy. 

Quality Monitoring 

In addition to undergoing monitoring by OIG, each corporation under a 

quality of care CIA is required to contract and pay for the services of an 

independent quality monitor, which is selected by OIG.5 CIAs require 

corporations to give monitors relatively unfettered access to nursing 

home records and staff. Quality monitors set their own fees with the 

corporations, and corporations pay for the monitors’ services.6 OIG 

expects that the monitors will work with the corporations so that the 

corporations can learn to identify and resolve quality of care concerns. 

Quality monitors employ a variety of strategies to identify quality of 

care problems. They discuss quality of care issues with key personnel at 

3 

4 “Measuring the Quality of Health Care: A Statement of the National Roundtable on 

Healthcare Quality Division of Healthcare Services,” National Academy Press, 1999. 

5 Monitors are individuals or entities that OIG has determined have competency in key 

areas, including knowledge and experience with long-term care quality, clinical practice, 

data technology, data analysis, monitoring of quality of care, and general management. 

6 Testimony of Lewis Morris, Office of Counsel to the Inspector General, 

U.S. Department of Health and Human Services, to the U.S. House of Representatives 

Committee on Energy and Commerce, Subcommittee on Oversight and Investigations. 

May 15, 2008. Available online at 

http://oig.hhs.gov/testimony/docs/2008/testimony051508.pdf. Accessed on June 20, 2008. 

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the corporate level, conduct site visits to individual nursing homes, 

review structures and processes related to the delivery of resident care, 

and analyze relevant data. Monitors provide periodic reports to OIG 

and the corporations with findings from their monitoring activities. 

These reports include guidance for corporations presented as 

recommendations, observations, or suggestions. The findings and 

guidance reflect systemic issues noted by monitors rather than problems 

encountered in each individual nursing home. 

One indicator of whether systemic solutions are being applied at the 

nursing home level is reflected in the individual nursing home’s Quality 

Assessment and Assurance (QAA) committee activities. Federal 

regulations require a QAA committee at each nursing home.7 The 

committee must meet at least once each quarter, and membership must 

include the Director of Nursing Services, a physician, and at least three 

other members of the nursing home’s staff.8 The role of the QAA 

committee in a nursing home includes identifying quality problems by 

analyzing quality of care data, identifying the root causes of quality 

problems,9 developing and implementing action plans to correct quality 

problems, monitoring the effect of implemented changes, and revising 

the action plans if needed.10 

Quality of care CIAs have requirements that corporations appoint 

Quality Assurance Committees at the corporate level but do not have 

particular requirements for QAA committees in individual nursing 

homes. However, the CIA quality monitors assess quality assurance 

activities and review quality-assurance-related documents during site 

visits to nursing homes under CIAs. Further, monitors consider QAA 

committees as vehicles through which corporate-level quality of care 

4 

7 42 CFR § 483.75(o)(2)(i). Nursing homes sometimes refer to these committees as 

“quality improvement committees,” “performance improvement committees,” and “quality 

assurance committees.” 

8 42 CFR § 483.75(o)(2)(i). 

9 Often referred to as “root cause analysis,” a method for exploring underlying issues that 

result in quality of care problems. U.S. Department of Veterans Affairs, National Center 

for Patient Safety, Root Cause Analysis. Available online at 

http://www.patientsafety.gov/rca.html. Accessed on June 20, 2008. 

10 “State Operations Manual,” Appendix PP, “Interpretive Guidelines for Long Term 

Care Nursing Homes,” guidance for 483.75(o). Available online at 

http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf. 

Accessed on June 20, 2008. 

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INTRODUCTION 

structures and processes can be integrated into care practices at the 

nursing home level. 

METHODOLOGY 

Scope 

This study examines the 15 nursing home corporations under quality of 

care CIAs with start dates between June 2000 and December 2005. 

These 15 were the only nursing home corporations that were under 

quality of care CIAs for at least a year prior to December 2006, when we 

began this review. Ten corporations were under their original CIAs and 

five were under successor agreements. The 15 corporations collectively 

operated 1,104 nursing homes nationwide as of December 31, 2006. 

These included four corporations with 100 or more nursing homes, three 

corporations with 10 to 99 nursing homes, four corporations with 

2 to 9 nursing homes, and 4 individual nursing homes. Three of the 

individual nursing homes were owned by parent corporations and one 

was independently owned. Additional information about the 

15 corporations is in Appendix A. 

Data Collection and Analysis 

Implementation of required quality of care structures and processes. To 

determine the structures and processes that corporations had in place to 

meet the CIA requirements, we reviewed documents from each of the 

15 corporations. These included copies of organizational charts, policies 

and procedures, codes of conduct, information publicizing corporations’ 

complaint hotlines, logs of complaints received, training materials and 

training attendance logs, internal quality assessment instruments and 

reports, and implementation and annual reports that corporations 

submitted to OIG. 

We also conducted structured interviews with representatives of 

corporations, e.g., compliance officers and chief executive officers (CEO). 

We inquired about corporate quality of care structures and processes; 

the way in which the corporation addressed each of the requirements of 

the CIA; and the corporation’s experiences under the CIA, including the 

positive and negative aspects. We interviewed representatives of 

corporations with 10 or more nursing homes in person and 

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INTRODUCTION 

representatives of corporations with 2 to 9 nursing homes and the 

individual nursing homes by telephone.11

Responsiveness to quality monitoring. To determine corporations’ 

responsiveness to quality monitoring, we used all 168 quality monitor 

reports submitted to OIG, covering the period between June 2000 and 

December 2006 (the end date for our document requests), by the 

five entities that conducted quality monitoring for the 15 nursing home 

corporations. We requested monitors’ protocols and conducted 

structured interviews with each quality monitor by telephone. We 

inquired about their monitoring activities and protocols and their 

experiences with each corporation. 

To assess corporations’ responsiveness to guidance provided by quality 

monitors, we identified 611 recommendations, suggestions, or concerns 

(hereinafter referred to as “guidance items”) that the five monitors 

provided to corporations in the 168 quality monitor reports submitted to 

OIG from June 2000 through December 2006. We then examined 

subsequent reports issued by monitors and the corporations’ reports to 

OIG to find evidence that the corporations responded to the quality 

monitors’ guidance. We determined that the corporation was responsive 

if there was evidence in a subsequent monitoring report or annual 

report that the corporation had acted on the quality monitor’s guidance. 

Follow-up information was available for 485 (79 percent) of the 

611 guidance items identified. We had no subsequent monitoring or 

annual reports to review for the other 126 guidance items and could not 

assess corporate responsiveness to them. We based our findings on the 

485 guidance items for which follow-up information was available. 

Challenges encountered when implementing CIA requirements. In 

conducting interviews, we included questions about challenges that 

corporations encountered when implementing CIA requirements. 

To assess the extent to which quality systems were consistently 

implemented at the nursing home level of the corporation, we examined 

the corporations’ use of quality assurance processes at that level. We 

requested written minutes from QAA committee meetings for a random 

sample of 407 nursing homes. We determined whether the minutes 

documented that QAA committees met quarterly, as required, for each 

11 We were not able to interview representatives from one corporation with two to nine 

nursing homes because the CIA had expired and all individuals who had been involved were 

no longer with the corporation. 

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INTRODUCTION 

quarter from July 2005 through December 2006.12 We also determined 

whether minutes reflected that nursing homes used data to identify 

problems, conducted root cause analysis, developed action plans to 

address identified problems, and followed up on those action plans. 

Additional information about the QAA committee analysis is presented 

in Appendix B. 

Limitations 

Our analysis of nursing home QAA committees relies on the written 

minutes of meetings that corporations submitted to us. It is possible 

that some QAA committees held meetings but did not document their 

activities or that nursing homes did not retain the meeting minutes, 

and we would not be aware of these meetings or the committees’ 

activities. 

Standards 

This study was conducted in accordance with the “Quality Standards for 

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

Efficiency and the Executive Council on Integrity and Efficiency. 

7 

12 We selected the most recent 18-month period because many nursing homes did not 

have minutes available for a longer period of time. 

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FINDINGS 

Each of the 15 corporations 

developed new, or improved 

existing, quality of care structures 

and processes as they implemented 

the requirements of the CIA. For purposes of this review, we grouped 

these structures and processes into three areas: 

(1) written policies and procedures, codes of conduct, and training 

related to quality of care; (2) tools and activities to monitor quality of 

care; and (3) the organizations’ infrastructure related to quality of care. 

All 15 corporations enhanced quality of care 

structures and processes while under their CIAs 

and cited positive effects of the CIAs 

Δ FINDINGS 

The 15 corporations had written policies and procedures regarding quality 

of care, codes of conduct, and training required by their CIAs 

Corporate representatives reported that their organizations revised and 

updated many policies and procedures to comply with the CIA 

requirements and to align them with the nursing home compliance 

program guidance issued by OIG in 2000.13 As of January 2007, each 

corporation had written policies and procedures that specifically 

addressed quality of care issues. These materials contained information 

relating to corporate structures, such as the QAA committee 

membership and responsibilities. Other topics dealt with clinical 

procedures, staff training, procedures for handling complaints, and 

screening of employees or contractors to identify persons ineligible for 

participation in Federal health care programs. 

Each corporation also had a written code of conduct that described the 

organization’s principles and values and set general expectations for all 

employees. The levels of detail and presentation of the codes varied 

across corporations, ranging from brief statements that fit on a single 

sheet of paper to more detailed booklets. All corporations provided 

codes of conduct to employees during orientation and training sessions, 

as required by their CIAs. 

Corporations also trained employees on the CIA requirements and 

various aspects of providing coordinated interdisciplinary care to 

residents. Corporations reported that they identified training needs 

through their internal monitoring systems. Although each corporation 

approached employee training differently, they all developed systems to 

ensure that each employee took the required training when initially 

hired and annually thereafter. Notably, staff from one corporation 

8 

13 65 Fed. Reg. 14289 (Mar. 16, 2000). 

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FINDINGS 

reported that an Internet-based training system developed to facilitate 

and track training required by the CIA was eventually turned into a 

separate product that it markets to other corporations and nursing 

homes. 

The 15 corporations monitored quality of care by using standardized data 

and internal self-assessment tools and by tracking complaints 

Each corporation had methods for identifying quality of care problems 

and monitoring quality improvement progress. Some of these tools were 

in use before the CIA, and each corporation either developed or adopted 

additional assessment tools or expanded upon existing tools to meet the 

CIA requirements. 

Standardized data. Corporations reported that they routinely used 

readily available, standardized data to monitor each nursing home’s 

performance. For example, corporations used the Centers for Medicare 

and Medicaid Services’ (CMS) Quality Indicators/Quality Measures 

(QI/QM) to identify trends in specific care areas, such as pressure sores 

and urinary tract infections.14 The QI/QMs are 28 prevalence or 

incidence measures derived from information recorded during periodic 

assessments of residents performed by nursing home staff and 

contained in the Minimum Data Set (MDS).15 

Corporations also used State survey deficiency citations to gauge 

compliance with Federal standards. State survey deficiencies are 

generated during surveys of each nursing home, which must be 

conducted every 9 to 15 months.16 CMS contracts with States to 

conduct these surveys to verify whether nursing homes maintain 

Federal quality of care standards. Corporations used these data to 

identify recurring problems across nursing homes that would suggest 

the need for systemic solutions and specific nursing homes or areas 

needing targeted attention. Corporate compliance officers explained 

14 The initial Quality Indicators were developed, under a contract with CMS, by the 

Center for Health Systems Research and Analysis at the University of Wisconsin – 

Madison. D. Zimmerman, “Improving nursing home quality of care through outcomes data: 

the MDS quality indicators,” International Journal of Geriatric Psychiatry, Volume 18, 

2003. They were later revised to include Quality Measures. 

15 Section 1819(f)(6)(A) of the Social Security Act, added by the Omnibus Budget 

Reconciliation Act of 1987, 42 CFR § 483.20(b-c), and CMS, “Resident Assessment 

Instrument Version 2.0 Manual.” 

16 Social Security Act §§ 1819 (g) and 1919(g). 

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FINDINGS 

how identified problems prompted the development of action plans to 

address them. 

Internal self-assessment tools. To supplement information from 

standardized data, all 15 corporations developed their own 

self-assessment tools or adapted existing tools used by others in the 

nursing home industry. One type of self-assessment tool involved onsite 

nursing home reviews, known as quality control reviews or mock 

surveys, conducted by internal teams. The review results took various 

forms, e.g., “scorecards,” and provided nursing home administrators and 

other corporate employees with in-depth information about aspects of 

quality of care. 

Corporations also reported using satisfaction surveys, chart audits, and 

staffing measures to monitor quality of care. Satisfaction surveys were 

used to provide nursing homes with direct feedback from residents and 

family members. Chart audits enabled homes to monitor compliance 

with established resident care standards and guided training when staff 

deviated from established care standards. Monitoring of each nursing 

home’s staffing levels and turnover identified nursing homes with 

insufficient staff to deliver quality care. 

Complaints. Another form of internal monitoring used by corporations 

was reviewing complaints from residents, family members, nursing 

home staff, and others. All 15 corporations had some type of telephone 

complaint “hotline” that satisfied the confidential disclosure program 

requirement of the CIAs. All corporations also took steps to protect 

caller confidentiality, such as removing identifiable information before 

sending a record of the complaint to a nursing home’s administrator. 

Corporate representatives described a variety of methods used to track 

and follow up on complaints to ensure that issues were resolved. One of 

the more elaborate examples involved a corporation whose vendor 

uploads complaint information to a limited-access Internet Web site. 

Each complainant is provided an access code to track the status and 

eventual resolution of the complaint. In addition to tracking each 

complaint, corporate staff use the tracking system to monitor the 

number and nature of complaints lodged against each nursing home and 

to identify recurring or widespread problems. Corporations also 

received complaints through other mechanisms, including anonymous 

complaint boxes at individual nursing homes and in-person complaints 

made to social workers and other staff. 

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FINDINGS 

The 15 corporations created or expanded their compliance infrastructure to 

integrate quality of care 

Six corporations created new compliance programs that included quality 

of care as part of the new programs’ responsibilities, including the four 

new corporations that were formed when larger corporations under 

CIAs reorganized. The other nine corporations expanded the scope of 

their existing compliance programs. Representatives of these nine 

corporations reported that prior to their CIAs, quality of care was 

primarily within the purview of clinical operations and their compliance 

departments generally focused on other aspects, such as financial 

integrity. Because their CIAs explicitly identified quality of care as a 

compliance issue, these corporations integrated quality of care into their 

corporate compliance infrastructure. 

As required by the CIA, each corporation had a compliance program led 

by a designated compliance officer. All compliance officers whom we 

interviewed expressed that they had sufficient authority and support to 

perform their duties to address quality of care issues. Several also 

explained that their approach to quality assurance was less a matter of 

exerting authority than a process of collaborating with clinical 

managers and others throughout their corporations. 

Corporate representatives cited positive effects that the CIAs had on their 

corporations 

Corporate representatives from each corporation named at least one 

positive effect that the CIA had on their corporations, and many named 

more than one. The most frequently cited positive effect was that the 

CIA helped guide the development of more standardized processes and 

quality systems. It made the corporation examine itself and its systems 

and track quality of care more closely. Corporate leaders indicated that 

the CIAs helped them to focus the corporations’ attention on quality of 

care and communicate to employees a clear message about its 

importance. Some corporate representatives described the CIA as a 

useful “hammer” or stated that it provided the “ammunition” needed to 

make the necessary changes. Four corporations attributed 

improvements in quality of care directly to implementation of the CIAs. 

Additionally, a representative of one individual nursing home reported 

that the nursing home now had a better standing in its community and 

among local physicians because of CIA-related improvements. 

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FINDINGS 

Although 12 of the 15 corporations 

seemed to readily accept and act 

on the quality monitors’ guidance, 

monitors reported that the other 

3 corporations were initially resistant to the added oversight. For 

example, one monitor reported that the owners of an individual nursing 

home tried to replace her. According to the monitor, after OIG refused 

the nursing home’s request, the nursing home staff and owner began 

working effectively with the monitor. The other two of these three 

corporations delayed executing their quality monitor agreements. One 

of the two refused to pay the quality monitor. Only when OIG issued a 

demand letter for monetary penalties did the corporation comply. The 

other corporation did not execute its agreement until 10 months after 

the CIA went into effect. Also in this case, OIG had to levy a monetary 

penalty to gain the corporation’s compliance. Both were under 

successor agreements and OIG extended the end dates for the quality 

monitoring because of the corporations’ delays. Quality monitors 

reported that all three of these corporations eventually were cooperative 

and responsive to guidance. 

Despite some initial resistance from 3 corporations, 

all 15 were ultimately responsive to their quality 

monitors’ guidance and corporate representatives 

reported that they valued the input

Guidance provided to the 15 corporations by the quality monitors, 

presented as recommendations, suggestions, or concerns, often 

identified specific areas needing improvement and suggested actions 

that the corporations could take. Quality monitors’ reports most 

frequently called for improvements related to resident assessments, 

care planning, residents’ physical functioning (also referred to as 

activities of daily living), skin care, nutrition/eating, and activities for 

residents to engage in. Monitors most frequently recommended that 

corporations conduct assessments or evaluations of the areas needing 

improvement and/or conduct staff training on the topic. Monitors’ 

guidance also frequently stressed corporations’ implementation of a 

system, program, or protocol to spur improvement; making better use of 

the QAA process in individual nursing homes; and/or creating an action 

plan. 

Our review of quality monitoring reports and corporate annual reports 

submitted to OIG confirmed the monitors’ opinions that corporations were 

largely responsive to monitors’ guidance 

We found that subsequent reports from the monitors and/or 

corporations indicated that corporations had responded to 75 percent of 

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FINDINGS 

the 485 guidance items provided by monitors to the corporations in their 

reports. Examples of corporate responses included developing corrective 

action plans and implementing policy or practice changes. For another 

18 percent of the guidance items provided by quality monitors, no 

subsequent monitor or corporation reports mentioned the problems that 

prompted the guidance. According to the monitors, this was an 

indication that corporations had addressed or resolved the concerns. 

However, for 6 percent of written guidance, quality monitors repeated 

concerns or recommendations in subsequent reports, suggesting that 

the corporations had not yet sufficiently responded to the original 

guidance.17 

Corporate representatives cited several benefits of quality monitoring

Corporate representatives described the monitors as valuable experts 

who brought in new ideas and fresh ways of thinking about quality of 

care processes. Several representatives mentioned that their 

corporations benefited from the monitors’ educational efforts to help 

nursing home staff identify and address the root cause of problems. 

Additionally, corporate representatives commented that the quality 

monitors helped emphasize the importance of quality of care within the 

organizations and helped garner support for quality improvement 

initiatives that otherwise might not have been undertaken. Finally, 

representatives expressed that the monitors provided a “second set of 

eyes” that were focused on improving quality of care. 

During interviews, corporate 

representatives identified several 

challenges to implementing the CIA 

requirements. The most common 

challenges identified were: ensuring consistency across their 

organizations, organizational disruptions, staff resistance to 

implementation, use of staff time to implement the requirements of the 

CIAs, and financial costs. 

Representatives of all 15 corporations 

described challenges encountered 

when implementing CIA requirements 

Ensuring consistency. Corporations with multiple nursing homes 

encountered challenges to ensuring consistency in quality of care 

systems across all layers of their organizations and across geographic 

regions. For example, each of the four corporations with more than 

17 Percentages do not add to 100 percent because of rounding. 

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FINDINGS 

100 nursing homes was structured with multiple organizational levels 

between corporate headquarters and its nursing homes. For these 

organizations, new quality of care systems and policies developed in 

headquarters often had to be implemented at district and regional levels 

before finally reaching local nursing homes. Corporate representatives 

and quality monitors reported that it was a challenge to ensure that 

systems and policies were consistently passed through each 

organizational level and to all nursing homes. Representatives from 

four corporations with fewer than 100 nursing homes reported that the 

geographic dispersion of the corporations’ nursing homes created a 

similar impediment to ensuring consistency. 

Further, our analysis of individual nursing home QAA committee 

meeting minutes indicated that nursing home implementation of quality 

of care processes was inconsistent. QAA committee meeting minutes 

suggest that not all nursing homes’ committees met at least once per 

quarter, as required. Specifically, six corporations provided us with 

meeting minutes for less than half of the quarters reviewed and for only 

some portion of their nursing homes.18 Further, meeting documentation 

did not support that the committees always identified or addressed 

quality of care problems. For example, seven corporations had nursing 

homes with no documentation that they had followed up on their action 

plans. Finally, across the nursing homes of all corporations, we found 

little documentation confirming efforts to identify the root cause of 

problems, which leaves open the possibility that action plans developed 

by QAA committees might address only the symptoms of problems and 

not the underlying causes. For statistics about QAA committee 

meetings for each corporation, see Appendix B. 

The lack of consistent documentation could indicate inattention to 

required QAA processes and inconsistency among nursing homes in 

implementing corporate-level quality improvements. However, the 

absence of QAA meeting minutes or documentation of specific 

committee activities does not always mean that the committees did not 

meet, as required by regulation, or did not undertake activities such as 

developing corrective action plans. Alternatively, nursing homes may 

14 

18 We did not obtain any QAA committee meeting minutes from two additional 

corporations, but that does not necessarily indicate that the committees did not meet. 

Rather, one of the two corporations had been sold by the time of our data request, and the 

other corporation had hired a new management team that reported not having access to 

prior QAA committee meeting minutes. 

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FINDINGS 

have performed these activities but not have documented the meetings 

or retained the minutes. 

Organizational disruptions. Another reported challenge was that 

corporations experienced disruptions because of changes to their 

organizations after the CIAs began. For example, 4 of the 15 

corporations were formed as new companies when larger corporations 

split or sold nursing homes, and the new corporations were placed 

under successor agreement CIAs. These corporations had to design and 

implement quality of care systems to meet requirements of the CIAs as 

they grappled with establishing new companies. Other disruptions 

occurred when corporations purchased or sold nursing homes, 

restructured their organizations, or had significant changes in 

management. 

Staff resistance. Corporate representatives reported challenges 

involving staff resistance to the CIAs, and noted that these sometimes 

required making personnel changes. For example, representatives of 

one corporation reported replacing a nursing home administrator who, 

rather than implementing new procedures, stored new corporate 

procedural manuals in her personal car because she did not agree that 

changes were needed. Several corporate representatives described key 

personnel changes made during the CIAs, including replacing a CEO, a 

compliance officer, and a president of a nursing home division; two 

corporations replaced all of their corporate officers. Another corporation 

described high turnover and recruiting difficulties encountered because 

it was under the CIA. Representatives of this corporation perceived 

that the CIA created a stigma that may have deterred potential 

applicants from seeking employment with the corporation or its nursing 

homes. 

Staff time. Another challenge reported by corporate representatives was 

the time required to implement the CIA requirements. Implementation 

required staff to spend time on activities outside their regular duties. 

These activities included implementing quality systems, developing new 

policies and procedures, tracking quality outcomes, and attending 

training sessions. Corporate representatives reported that these 

activities, while beneficial, also diverted staff from providing resident 

care. 

Financial costs. Several corporate representatives reported that they 

were challenged by the financial costs associated with the CIA. 

Specifically, although they recognized certain benefits of quality 

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FINDINGS 

monitoring, they also expressed that the money spent to hire the 

monitors could have been spent for other purposes related to quality 

improvement, such as increasing staff or improving facilities. 

We initially sought to assess nursing home 

quality of care performance by analyzing 

data from two sources: QI/QMs and State 

survey deficiencies. Although neither 

QI/QMs nor State survey deficiency data 

were designed as a measure of quality, CIA quality monitors, CMS, and 

nursing home corporations commonly use them as indicators of nursing 

home quality.19 However, we could not use these data to determine the 

quality of care performance of nursing homes under CIAs because these 

measures lack established benchmarks that set standards for what 

constitutes quality care. For example, there is no agreement within the 

nursing home industry as to what would be an acceptable level of the 

incidence of cognitive impairment, which is measured by one of the QIs. 

Although we do not utilize available data to draw conclusions about the 

quality of care performance of nursing homes under CIAs, we do provide 

basic QI/QM and State survey deficiency data for the reader. See 

Appendixes C and D for these data from 1999 through 2007.

Inherent limitations of commonly used 

quality of care measures prevented our 

assessment of the quality of care 

performance of nursing homes under CIAs 

16 

19 For example, CMS’s Nursing Home Compare Web site contains information about 

Quality Measures, a variant of the QI that data we used, and State survey deficiencies for 

each nursing home in the country. Available online at: 

http://www.medicare.gov/NHCompare/Static/Related/DataCollection.asp?dest=NAV|Home|

DataDetails|DataCollection#TabTop. Accessed on November 21, 2008. 

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ΔEXECUTIVE SUMMARY CONCLUSION 

CIAs are entered into to improve quality of care in nursing homes by 

imposing certain requirements to build the corporations’ and their 

nursing homes’ internal quality assurance capabilities. The 

CIA-covered entities must develop, improve, and sustain their internal 

capacity to monitor their own quality and take corrective actions where 

indicated. We found that each of the 15 corporations enhanced quality 

of care structures and processes to meet the CIA requirements. Each 

corporation had written policies and procedures, codes of conduct, and 

training as required by the CIA; used tools and performed activities to 

monitor quality of care; and created or expanded its compliance 

infrastructure to integrate quality of care. Corporate representatives 

from all corporations cited positive effects of their CIAs. 

Although all corporations were ultimately responsive to their quality 

monitors’ guidance and valued their input, three corporations were 

initially resistant until OIG intervened. All corporations faced 

challenges in implementing CIA requirements, such as difficulties in 

implementing quality systems throughout all levels of the corporations, 

including systems at the nursing home level. Additionally, we found 

that lack of agreed-upon benchmarks for quality of care outcome 

measures throughout the nursing home industry limited our ability to 

assess the quality of care performance of nursing homes under CIAs. 

Based on our findings, areas that OIG will explore for its oversight of 

future CIAs include the following: 

• Responding swiftly to noncompliant corporations and those that fail 

to address quality problems by using available enforcement 

remedies, such as monetary penalties, or, if appropriate, exclusion 

from Federal health care programs. Additionally, a provider’s 

continued failure to address quality of care may warrant opening 

new investigations by OIG. 

• Including specific requirements regarding documentation of nursing 

home QAA committee activities to ensure that quality of care 

monitoring and improvement systems are implemented at the 

nursing home level. 

• Sharing lessons learned by corporations and quality monitors with 

other corporations placed under subsequent CIAs. 

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NURSING HOME CORPORATIONS INCLUDED IN THIS REVIEW

This study examined the 15 nursing home corporations that entered 

into quality of care Corporate Integrity Agreements (CIA) between 

June 2000 and December 2005. Table 1 provides information on the 

corporation size and start and end dates of the CIAs and indicates 

whether each was an original CIA or a successor agreement. 

Table 1: Corporations Under Quality of Care CIAs 

Corporation Size CIA Start Date CIA End Date Type of CIA 

100 or more nursing homes April 1, 2001 April 1, 2006 Original CIA 

100 or more nursing homes February 28, 2002 February 28, 2007 Original CIA 

100 or more nursing homes April 2, 2002 April 2, 2007 Successor Agreement 

100 or more nursing homes April 1, 2004 April 1, 2007 Original CIA 

10 to 99 nursing homes April 2, 2002 April 2, 2007 Successor Agreement 

10 to 99 nursing homes September 9, 2003 September 9, 2008 Successor Agreement 

10 to 99 nursing homes November 1, 2003 October 1, 2005 Successor Agreement 

2 to 9 nursing homes June 9, 2000 June 9, 2005 Original CIA 

2 to 9 nursing homes March 1, 2002 March 7, 2005 Original CIA 

2 to 9 nursing homes September 9, 2003 September 9, 2008 Successor Agreement 

2 to 9 nursing homes November 22, 2004 November 22, 2009 Original CIA 

Individual nursing home October 29, 2001 October 29, 2006 Original CIA 

Individual nursing home December 21, 2001 November 15, 2005 Original CIA 

Individual nursing home December 13, 2002 December 13, 2005 Original CIA 

Individual nursing home October 25, 2005 October 25, 2008 Original CIA 

Source: Office of Inspector General, 2008. 

Δ APPENDIX ~ A 

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QUALITY ASSESSMENT AND ASSURANCE COMMITTEE 

METHODOLOGY AND RESULTS 

Table 2 provides information on the nursing homes’ Quality Assessment 

and Assurance (QAA) committee meeting minutes’ sample sizes and 

response rates. We requested minutes for all nursing homes from 

corporations with two to nine homes and the four individual nursing 

homes. We randomly selected a sample of nursing homes from 

corporations with 10 or more nursing homes. We received at least some 

QAA committee minutes for 350 of the sample of 407 nursing homes 

that we requested to send minutes, representing an overall response 

rate of 86 percent. Response rates by corporation ranged from 0 to 100 

percent. Two corporations were unable to provide minutes because 

their nursing homes were under new ownership and the meeting 

minutes were no longer accessible. 

Results of analyses of QAA minutes are presented in Tables 3 and 4. 

Table 2: QAA Committee Meeting Minutes Request and Response 

Rates 

Corporation Size 

Number of 

Nursing Home 

Minutes 

Requested 

(Sample Size) 

Number of 

Nursing Home 

Minutes 

Received Response Rate 

More than 100 nursing homes 72 62 86% 

More than 100 nursing homes 58 57 98% 

More than 100 nursing homes 65 65 100% 

More than 100 nursing homes 77 77 100% 

10 to 99 nursing homes 34 13 38% 

10 to 99 nursing homes 43 41 95% 

10 to 99 nursing homes 21 17 81% 

2 to 9 nursing homes 8 0 0% 

2 to 9 nursing homes 9 9 100% 

2 to 9 nursing homes 9 0 0% 

2 to 9 nursing homes 7 5 71% 

Individual nursing home 1 1 100% 

Individual nursing home 1 1 100% 

Individual nursing home 1 1 100% 

Individual nursing home 1 1 100% 

 Total 407 350 86% 

Source: Office of Inspector General, 2008. 

Δ APPENDIX ~ B 

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APPENDIX~B 

RESULTS OF NURSING HOME QUALITY ASSESSMENT AND ASSURANCE ANAL

Table 3: CIA Nursing Homes’ QAA Committee Meeting Minutes Point Estimates and Confidence Intervals for CorporaHomes* 

100 or more nursing homes 

Corporation A Corporation B Corporation C Corporation D Corpo

Estimate 

95-Percent 

Confidence 

Interval Estimate

95-Percent 

Confidence 

Interval Estimate

95-Percent 

Confidence 

Interval Estimate

95-Percent 

Confidence 

Interval Estimat

CIA Corporation Documented Meeting Frequency All required quarters 46% 35%-57% 60% 50%-70% 68% 58%-77% 90% 83%-96% 48% At least half of required quarters but not all 

28% 18%-38% 11% 4%-17% 29% 20%-38% 10% 4%-17% 43% 

Less than half of required quarters 

26% 16%-36% 30% 20%-39% 3% 0%-11%*** 0% **0%-5% 10% 

CIA Corporation Documented Data Use To Monitor Performance Consistent data use 36% 25%-47% 51% 41%-61% 60% 50%-70% 69% 60%-78% 30% Inconsistent data use 64% 53%-75% 42% 32%-52% 40% 30%-50% 30% 21%-39% 60% No data use 0% 0%-6%*** 12% 2%-17% 0% 0%-6%*** 1% 0%-7%*** 10% CIA Corporation Documented Use of Root-Cause Analysis Consistent use 2% 0%-9%*** 0% 0%-6%*** 9% 3%-15% 35% 25%-45% 5% Inconsistent use 57% 46%-68% 30% 20%-39% 38% 29%-48% 51% 41%-61% 38% No use 41% 30%-52% 70% 61%-80% 52% 42%-62% 14% 7%-21% 58% *Confidence intervals were calculated only for corporations with 10 or more nursing homes because their estimates are based on samples. We did not include one corporation with 

content of the meeting minutes because the corporation provided minutes for only 38 percent of its nursing homes. **We did not compute confidence intervals for this corporation because it had fewer than 20 nursing homes in its population and sample. ***Confidence interval calculated with an exact method based on the binomial distribution. 

Source: Office of Inspector General analysis of 350 QAA committee meeting minutes for nursing home corporations under Corporate Integrity Agreements.  O E I - 0 6 - 0 6 - 0 0 5 7 0 NURSING H OME C ORPORATIONS UNDER QUALITY OF CARE C ORPORATE I NTEGRITY A GREEMENTS 20 
APPENDIX ~ B 

Table 3 (continued): CIA Nursing Homes’ QAA Committee Meeting Minutes Point Estimates and Confidence Intervals More Nursing Homes* 

100 or more nursing homes 

Corporation A Corporation B Corporation C Corporation D Corpo

Estimate 

95-Percent 

Confidence 

Interval Estimate

95-Percent 

Confidence 

Interval Estimate

95-Percent 

Confidence 

Interval Estimate

95-Percent 

Confidence 

Interval Estimat

CIA Corporation Documented Action Plans Consistent action plan 39% 28%-50% 39% 29%-49% 51% 41%-61% 65% 55%-75% 40% Inconsistent action plan 57% 46%-68% 54% 44%-65% 48% 38%-58% 35% 25%-45% 43% No action plan 3% 0%-11%*** 7% 2%-12% 2% 0%-8%*** 0% 0%-5%*** 18% CIA Corporation Documented Followup to Action Plans Consistent followup 10% 3%-17% 9% 3%-16% 34% 25%-44% 55% 45%-65% 30% Inconsistent followup 76% 66%-86% 77% 68%-86% 45% 35%-55% 42% 32%-51% 58% No followup 14% 6%-21% 13% 6%-21% 20% 12%-29% 4% 0%-8%*** 12% *Confidence intervals were calculated only for corporations with 10 or more nursing homes because their estimates are based on samples. We did not include one corporation with 

content of the meeting minutes because the corporation provided minutes for only 38 percent of its nursing homes. **We did not compute confidence intervals for this corporation because it had fewer than 20 nursing homes in its population and sample. ***Confidence interval calculated with an exact method based on the binomial distribution. 

Source: Office of Inspector General analysis of 350 QAA committee meeting minutes for nursing home corporations under Corporate Integrity Agreements.  O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 21 
APPENDIX ~ B 

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Table 4: CIA Nursing Homes QAA Committee Meeting Minutes Analyses for Corporations With Nine or Fewer Nursing H

2 to 9 nursing homes Individual nursing home 

Corporation I Corporation K Corporation L Corporation M Corporatio

CIA Corporation Documented Meeting Frequency All required quarters 6 1 1 1 At least half of required quarters but not all 2 4 0 0 Less than half of required quarters 1 0 0 0 CIA Corporation Documented Data Use To Monitor Performance Consistent data use 2 4 0 1 Inconsistent data use 7 1 1 0 No data use 0 0 0 0 CIA Corporation Documented Use of Root-Cause Analysis Consistent use 0 0 0 0 Inconsistent use 4 1 0 1 No use 5 4 1 0 *Corporations with nine or fewer nursing homes are based on population outcomes. We did not include 2 of the 15 corporations (both with nine or fewer nursing homes) in any analysis homes of 1 corporation had been sold by the time of our data request and another corporation had engaged a new management team that, reportedly, did not have access to prior QAA Source: Office of Inspector General analysis of 350 QAA committee meeting minutes for nursing home corporations under Corporate Integrity Agreements. 
APPENDIX ~ B 

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Table 4 (continued): CIA Corporation QAA Committee Meeting Minutes Analyses for Corporations With Nine or Fewer N

2 to 9 nursing homes Individual nursing home 

Corporation I Corporation K Corporation L Corporation M Corporatio

CIA Corporation Documented Action Plans Consistent action plan 8 2 1 1 Inconsistent action plan 1 3 0 0 No action plan 0 0 0 0 CIA Corporation Documented Followup to Action Plans Consistent followup 7 2 0 1 Inconsistent followup 2 2 1 0 No followup 0 1 0 0 *Corporations with nine or fewer nursing homes are based on population outcomes. We did not include 2 of the 15 corporations (both with nine or fewer nursing homes) in any analysis homes of 1 corporation had been sold by the time of our data request and another corporation had engaged a new management team that, reportedly, did not have access to prior QAA Source: Office of Inspector General analysis of 350 QAA committee meeting minutes for nursing home corporations under Corporate Integrity Agreements. 
Δ APPENDIX ~ C

QUALITY INDICATORS/QUALITY MEASURES

A number of measures are used as indicators of quality of care in 

nursing homes. One prominent measure is the Quality 

Indicators/Quality Measures (QI/QM) developed by the Center for 

Health Systems Research and Analysis (CHSRA) at the University of 

Wisconsin – Madison.20

The QI/QMs are incidence or prevalence measures derived from 

information recorded during periodic assessments of residents 

performed by nursing home staff and contained in the Minimum Data 

Set (MDS).21 Information from these assessments is aggregated to the 

nursing home level for each QI/QM. The QI/QMs cover areas of care, 

such as accidents, behavioral and emotional patterns, quality of life, and 

skin care. Each QI/QM is calculated quarterly and represents the 

percentage of residents in the nursing home who meet the criteria for 

each specific condition. 

These nursing home level indicators can be compared to previous 

indicators for the same nursing home, other nursing homes, or the 

population of nursing homes. A higher percentage on a QI/QM for a 

particular nursing home, compared to that of other homes or its own 

prior performance, indicates a possible need for attention to the area of 

care measured by the QI/QM. Table 5 lists the 26 QI/QMs analyzed 

and describes how they are calculated. 

Table 5: Quality Indicators/Quality Measures 

Quality Indicator/Quality Measure Calculation 

Incidence of new fractures Residents with new fractures on target assessment divided by residents who did not 

have fractures on prior assessment. 

Prevalence of falls Residents who had falls within the past 30 days divided by residents assessed. 

Residents who have become more 

anxious or depressed 

Residents whose Mood Scale scores are greater on target assessment relative to prior 

assessment divided by residents with target assessment and prior assessment. 

Prevalence of behavioral symptoms 

affecting others 

Residents who have displayed any type of problem behavior toward others on target 

assessment divided by residents assessed. 

Prevalence of symptoms of depression 

without antidepressant therapy 

Residents with symptoms of depression and no antidepressant therapy on target 

assessment divided by residents assessed. 

20 D. Zimmerman, “Improving nursing home quality of care through outcomes data: the 

MDS quality indicators,” International Journal of Geriatric Psychiatry, Volume 18, 2003. 

21 Section 1819(f)(6)(A) of the Social Security Act, added by the Omnibus Budget 

Reconciliation Act of 1987, 42 CFR § 483.20(b-c), and CMS, “Resident Assessment 

Instrument Version 2.0 Manual.” 

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APPENDIX~C 

Table 5: Quality Indicators/Quality Measures (continued) 

Quality Indicator/Quality Measure Calculation 

Use of nine or more different 

medications 

Residents who received nine or more different medications on target assessment 

divided by residents assessed. 

Incidence of cognitive impairment Residents who are cognitively impaired on the target assessment divided by residents 

who were not cognitively impaired on previous assessment. 

Low-risk residents who lost control of 

their bowels or bladder 

Low-risk residents who were incontinent or frequently incontinent of either bladder or 

bowel on the target assessment divided by all residents assessed who did not qualify as 

high risk. 

Residents who have/had a catheter 

inserted and left in their bladder 

Residents with indwelling catheters on target assessment divided by residents 

assessed. 

Prevalence of occasional or frequent 

bladder or bowel incontinence without a 

toileting plan 

Residents with no scheduled toileting plan and no bladder-retraining program on target 

assessment and with occasional or frequent bladder or bowel incontinence divided by 

residents assessed. 

Prevalence of fecal impaction Residents with fecal impaction on most recent assessment divided by residents 

assessed. 

Residents with a urinary tract infection Residents with urinary tract infections on target assessment divided by residents 

assessed. 

Residents who lose too much weight Residents who have experienced weight loss of 5 percent or more during the last 

30 days or 10 percent or more during the last 6 months divided by residents assessed. 

Prevalence of tube feeding Residents with tube feeding on most recent assessment divided by residents assessed. 

Prevalence of dehydration Residents with dehydration on most recent assessment divided by residents assessed. 

Residents who have moderate to 

severe pain 

Residents with moderate pain at least daily or horrible/excruciating pain at any frequency 

on target assessment divided by residents assessed. 

Residents whose need for help with 

daily activities has increased 

Residents with late-loss activities of daily living self-performance at target assessment 

worsening relative to prior assessment divided by residents with a target and prior 

assessment. 

Residents who spend most of their time 

in a bed or in a chair 

Residents who are bedfast on target assessment divided by residents assessed. 

Residents whose ability to move in and 

around their rooms got worse 

Residents whose value for locomotion self-performance is greater at target relative to 

prior assessment divided by residents with a target assessment and prior assessment. 

Incidence of decline in range of motion 

(ROM) 

Residents with increased functional limitation in ROM between prior and target 

assessments divided by residents with a target assessment and prior assessment. 

Prevalence of antipsychotic use, in the 

absence of psychotic conditions 

Residents receiving antipsychotics divided by residents assessed without psychotic or 

related conditions. 

Prevalence of antianxiety/hypnotic drug 

use 

Residents who received antianxiety medications or hypnotics divided by residents 

assessed, except those with psychotic or related conditions. 

Prevalence of hypnotic use more than 

two times in the last week 

Residents who received hypnotics more than two times in the last week divided by 

residents assessed. 

Residents who were physically 

restrained 

Residents who were physically restrained daily divided by residents assessed. 

Prevalence of little or no activity Residents with little or no activity divided by residents assessed. 

Pressure ulcers Residents with pressure ulcers (stages 1–4) divided by all residents. 

Source: Center for Health Systems Research and Analysis 

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APPENDIX ~C 

Analysis of QI/QM data. Our data consisted of QI/QM scores for each 

quarter from January 1999 through December 2007. We obtained 

QI/QM data from CHSRA. We computed the means, standard 

deviations, and medians for each QI/QM by year for the national 

population from 1999 through 2007. We also computed the means for 

each QI/QM by year for each of the 15 corporations included in our 

review. These results are presented in Table 6. 

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APPENDIX ~ C 

Table 6: Quality Indicator/Quality Measure Annual Four-Quarter Average for 15 Corporate Integrity 

Agreement Corporations and National Population* 

Accidents: Incidence of New Fractures 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 1.8 1.7 1.6 1.6 1.6 1.5 1.5 1.5 1.5

Standard Deviation 3.7 3.0 3.0 3.1 2.8 2.8 2.5 2.6 2.4

Median 1.2 1.2 1.2 1.2 1.2 1.0 1.1 1.1 1.1

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 1.8 1.6 1.6 1.6 1.6 1.4 1.5 1.5 1.4

Q1 2002 5 Years 138 1.6 1.7 1.6 1.6 1.6 1.5 1.5 1.6 1.6

Q2 2002 5 Years 185 1.8 1.8 2.1 1.9 1.7 1.6 1.6 1.7 1.7

Q2 2004 3 Years 341 1.7 1.8 1.8 1.7 1.7 1.6 1.6 1.5 1.5

Q2 2002 5 Years 52 1.4 1.6 1.4 1.4 1.4 1.3 1.4 1.4 1.4

Q3 2003 5 Years 74 1.5 1.4 1.4 1.4 1.3 1.2 1.1 1.3 1.3

Q4 2003 2 Years 26 2.0 2.3 2.1 2.5 2.0 1.7 1.9 1.9 1.7

Q2 2000 5 Years 8 1.3 1.7 0.4 5.1 0.8 0.9 1.0 1.6 1.8

Q1 2002 3 Years 9 1.2 1.2 1.8 1.1 1.1 1.4 1.1 0.9 1.0

Q3 2003 5 Years 9 2.0 2.1 1.4 1.0 1.2 1.4 1.4 1.4 1.8

Q4 2004 5 Years 7 2.2 1.7 1.7 1.9 1.3 1. 9 1.5 2.0 2.3

Q4 2001 5 Years 1 0.2 3.4 2.0 2.2 0.5 0.3 0.3 1.2 2.3

Q4 2001 4 Years 1 2.3 2.1 3.2 2.1 3.3 0.5 1.4 1.3 1.2

Q4 2002 3 Years 1 1.9 1.8 2.1 1.0 1.9 1.0 1.5 2.4 1.1

Q4 2005 3 Years 1 1.6 0.3 1.6 0.9 0.9 0.2 2.1 0.5 1.3

Accidents: Prevalence of Falls 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 14.0 13.5 13.4 13.3 13.2 12.4 12.7 12.9 12.9

Standard Deviation 9.8 9.6 9.0 8.5 8.2 7.8 7.9 7.7 7.6

Median 13.0 12.7 12.5 12.5 12.5 11.8 12.0 12.3 12.3

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 14.8 14.6 14.2 14.1 13.5 13.0 13.5 13.8 13.5

Q1 2002 5 Years 138 14.1 13.5 13.4 13.4 13.6 12.4 12.0 13.2 13.4

Q2 2002 5 Years 185 12.9 12.9 13.4 13.7 13.6 13.0 13.2 13.6 13.7

Q2 2004 3 Years 341 14.2 14.1 14.2 14.2 13.8 12.8 13.5 14.0 14.0

Q2 2002 5 Years 52 10.2 9.9 9.0 9.6 9.9 9.0 9.2 10.1 9.2

Q3 2003 5 Years 74 12.8 12.7 12.3 12.1 11.7 11.1 11.1 11.2 11.1

Q4 2003 2 Years 26 14.2 13.3 13.8 13.1 12.8 12.1 12.6 13.1 12.0

Q2 2000 5 Years 8 21.8 31.2 19.1 7.4 8.5 5.9 5.0 5.9 7.4

Q1 2002 3 Years 9 11.5 10.8 10.5 10.6 10.9 10.4 10.9 10.2 11.2

Q3 2003 5 Years 9 14.6 13.3 12.2 13.1 12.9 10.2 10.4 10.7 11.0

Q4 2004 5 Years 7 15.5 14.0 11.9 12.5 13.7 12.3 15.5 16.3 12.2

Q4 2001 5 Years 1 4.5 8.2 13.0 14.3 14.8 13.5 11.8 11.5 16.7

Q4 2001 4 Years 1 15.3 8.4 18.7 15.4 18.0 17.0 5.1 6.0 6.6

Q4 2002 3 Years 1 14.4 20.5 15.1 14.0 15.0 17.5 14.9 16.1 13.0

Q4 2005 3 Years 1 10.2 8.2 8.0 9.7 14.1 10.1 13.6 14.6 19.2

*Corporate Integrity Agreements (CIA); shaded areas indicate the years during which the corporation was under the CIA. 

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 27 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Behavior/Emotional Patterns: Residents Who Have Become More Anxious or Depressed 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 16.5 14.5 14.3 14.5 14.7 14.6 14.7 14.7 14.6

Standard Deviation 10.7 9.9 9.6 9.7 9.8 9.9 9.9 9.9 9.9

Median 15.0 13.0 12.8 12.0 13.1 12.8 13.0 13.0 12.8

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 18.4 16.3 16.2 16.0 15.6 15.6 16.4 17.0 15.7

Q1 2002 5 Years 138 16.2 14.2 12.6 15.5 15.4 15.0 15.0 16.3 15.8

Q2 2002 5 Years 185 15.2 14.3 14.7 14.2 15.1 16.4 17.0 16.9 21.2

Q2 2004 3 Years 341 17.9 15.1 15.6 16.8 17.7 22.1 21.5 22.2 22.1

Q2 2002 5 Years 52 15.0 13.4 13.2 13.2 14.1 15.3 15.6 13.0 11.8

Q3 2003 5 Years 74 15.1 12.7 13.0 13.7 13.7 13.2 13.9 13.7 14.0

Q4 2003 2 Years 26 16.4 15.3 14.5 16.3 13.2 12.7 11.7 12.6 11.7

Q2 2000 5 Years 8 19.3 21.3 21.9 12.2 14.2 13.3 10.9 10.1 11.4

Q1 2002 3 Years 9 11.7 12.6 9.0 11.0 7.1 6.0 5.3 6.8 5.8

Q3 2003 5 Years 9 19.9 20.1 16.3 17.9 16.6 12.7 13.2 19.0 19.8

Q4 2004 5 Years 7 11.6 9.3 6.5 5.9 8.1 7.3 11.1 8.6 11.0

Q4 2001 5 Years 1 11.5 12.1 12.9 11.5 23.9 21.7 5.6 12.6 20.3

Q4 2001 4 Years 1 17.6 11.9 13.8 12.5 15.3 15.0 13.5 14.0 15.9

Q4 2002 3 Years 1 11.0 14.3 17.0 10.3 9.5 8.5 12.0 11.3 8.1

Q4 2005 3 Years 1 18.4 16.9 8.8 7.4 7.8 8.4 6.9 7.9 10.1

Behavior/Emotional Patterns: Prevalence of Behavior Symptoms Affecting Others 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 23.0 21.9 21.0 20.4 19.7 19.5 18.7 18.0 17.6

Standard Deviation 14.5 14.0 13.7 13.6 13.4 13.5 13.5 13.1 13.1

Median 20.8 19.8 18.6 17.9 17.2 16.9 16.0 15.3 14.8

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 21.7 21.7 20.9 20.2 19.7 18.6 17.8 17.7 17.0

Q1 2002 5 Years 138 25.0 24.3 21.9 22.3 22.7 21.4 20.2 19.2 18.1

Q2 2002 5 Years 185 19.2 17.9 16.6 15.6 14.1 15.1 13.9 12.8 12.9

Q2 2004 3 Years 341 22.4 21.0 20.2 19.5 18.7 19.9 17.2 16.1 15.8

Q2 2002 5 Years 52 17.5 16.8 15.6 14.2 13.3 13.9 12.4 10.8 11.4

Q3 2003 5 Years 74 21.6 21.6 20.3 20.4 19.0 19.2 19.1 18.2 17.5

Q4 2003 2 Years 26 13.8 14.6 14.4 14.4 12.0 11.4 10.7 11.8 10.6

Q2 2000 5 Years 8 16.2 21.7 15.4 16.4 15.0 13.8 11.7 12.4 11.4

Q1 2002 3 Years 9 20.5 17.2 15.1 14.2 14.7 11.8 10.0 7.8 7.0

Q3 2003 5 Years 9 19.6 21.2 21.5 22.0 19.4 13.8 12.0 13.5 14.2

Q4 2004 5 Years 7 32.4 29.6 29.9 28.1 24.8 23.0 27.2 29.3 30.9

Q4 2001 5 Years 1 19.7 10.1 10.6 27.5 24.7 19.3 8.7 10.7 21.3

Q4 2001 4 Years 1 18.2 17.1 17.3 20.2 25.4 32.0 24.6 24.3 22.8

Q4 2002 3 Years 1 15.9 24.6 26.1 19.0 10.1 7.6 14.3 14.4 13.7

Q4 2005 3 Years 1 11.8 19.6 19.1 18.8 19.5 23.1 15.7 19.4 20.8

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 28 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Behavior/Emotional Patterns: Prevalence of Symptoms of Depression Without Antidepressant Therapy 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 7.9 6.8 6.1 5.6 5.5 5.2 5.2 4.9 4.7

Standard Deviation 9.2 8.2 7.6 6.8 6.8 6.7 6.8 6.4 6.2

Median 5.4 4.5 4.0 3.7 3.6 3.2 3.2 2.9 2.8

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 8.1 7.0 6.2 5.7 5.5 4.8 4.7 4.6 4.2

Q1 2002 5 Years 138 8.0 6.1 5.1 5.8 5.6 5.3 5.3 5.2 5.1

Q2 2002 5 Years 185 4.4 3.7 3.7 3.2 2.9 3.1 3.2 2.8 4.0

Q2 2004 3 Years 341 7.0 5.9 5.2 4.3 4.3 5.5 5.7 5.4 5.3

Q2 2002 5 Years 52 4.7 3.8 3.1 2.3 2.1 2.1 2.5 2.5 2.0

Q3 2003 5 Years 74 6.3 5.7 5.3 5.3 5.4 5.6 5.5 4.5 4.6

Q4 2003 2 Years 26 3.7 3.2 3.3 3.1 2.2 2.1 1.7 1.9 2.1

Q2 2000 5 Years 8 7.9 11.6 10.7 6.1 6.9 4.1 2.6 3.0 3.6

Q1 2002 3 Years 9 10.0 4.2 4.5 2.6 2.3 1.2 1.5 1.8 1.9

Q3 2003 5 Years 9 7.9 9.1 6.9 7.1 5.6 3.1 3.6 4.6 3.6

Q4 2004 5 Years 7 9.1 8.1 6.9 5.9 6.3 2.6 2.9 4.2 6.5

Q4 2001 5 Years 1 2.7 2.9 8.6 5.6 13.8 23.1 3.7 7.3 3.2

Q4 2001 4 Years 1 10.3 13.7 9.8 6.2 5.6 3.4 2.5 0.9 3.0

Q4 2002 3 Years 1 1.7 2.8 3.2 4.0 2.5 2.5 6.4 4.0 5.0

Q4 2005 3 Years 1 0.9 0.6 1.8 0.7 0.0 0.0 0.5 0.2 0.0

Clinical Management: Use of Nine or More Different Medications 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 39.3 42.3 46.4 50.6 54.4 58.6 61.9 64.2 66.1

Standard Deviation 16.6 16.0 15.7 15.4 14.8 14.5 13.9 13.3 13.0

Median 37.9 41.4 45.8 50.0 54.5 59.0 62.5 65.0 67.0

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 36.1 39.7 44.4 49.1 53.6 57.9 61.3 64.2 66.1

Q1 2002 5 Years 138 33.9 38.1 42.4 46.5 50.4 54.9 58.8 61.7 63.8

Q2 2002 5 Years 185 37.0 40.5 44.8 49.2 53.9 59.4 62.9 62.5 62.6

Q2 2004 3 Years 341 38.7 42.0 45.9 49.6 53.2 57.4 60.9 63.4 65.8

Q2 2002 5 Years 52 34.0 37.2 40.5 44.3 49.1 54.9 59.1 61.5 63.4

Q3 2003 5 Years 74 38.3 40.1 45.4 49.1 53.5 58.3 63.5 65.8 67.6

Q4 2003 2 Years 26 40.5 45.0 48.1 52.5 58.1 61.9 64.9 66.3 67.6

Q2 2000 5 Years 8 39.4 45.5 39.3 38.2 39.1 40.0 48.0 56.0 54.5

Q1 2002 3 Years 9 36.8 39.7 43.0 48.2 51.3 51.5 58.8 62.0 65.8

Q3 2003 5 Years 9 49.8 50.0 53.5 59.7 63.8 68.3 70.1 72.7 72.4

Q4 2004 5 Years 7 26.0 31.2 33.8 39.4 43.3 50.2 48.6 54.0 52.3

Q4 2001 5 Years 1 43.5 44.8 57.9 60.1 59.4 62.9 67.0 72.8 71.3

Q4 2001 4 Years 1 51.5 58.8 53.5 59.4 65.3 70.0 68.9 69.5 70.4

Q4 2002 3 Years 1 34.8 37.8 45.8 48.2 51.5 54.8 64.2 60.5 64.9

Q4 2005 3 Years 1 46.0 46.4 48.7 44.9 50.8 57.1 67.2 69.7 71.0

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 29 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Cognitive Patterns: Incidence of Cognitive Impairment 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 11.6 11.4 11.6 11.7 11.7 11.5 12.0 12.1 12.0

Standard Deviation 12.5 12.1 12.3 12.4 12.4 12.9 13.3 13.2 13.1

Median 9.1 9.1 9.1 9.1 9.1 8.7 9.1 9.1 9.1

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 14.4 14.0 13.5 12.6 12.8 12.6 12.1 13.0 12.3

Q1 2002 5 Years 138 10.9 10.5 11.0 12.7 12.0 12.8 12.2 12.9 13.6

Q2 2002 5 Years 185 16.5 15.4 16.5 16.8 16.4 16.3 16.9 15.7 15.1

Q2 2004 3 Years 341 12.6 13.5 14.9 14.7 15.1 14.3 14.0 14.3 15.6

Q2 2002 5 Years 52 13.1 13.7 12.9 16.9 14.9 14.8 14.7 13.6 15.2

Q3 2003 5 Years 74 12.1 11.6 12.1 11.5 11.0 10.5 11.3 11.6 12.0

Q4 2003 2 Years 26 11.4 15.2 14.6 14.5 14.4 13.8 13.9 12.0 12.6

Q2 2000 5 Years 8 16.9 12.4 19.6 13.6 12.2 16.6 12.6 9.1 6.7

Q1 2002 3 Years 9 14.6 7.8 8.4 9.9 7.3 6.2 7.1 10.1 5.8

Q3 2003 5 Years 9 10.9 10.4 10.9 11.5 13.9 15.3 10.7 13.7 13.8

Q4 2004 5 Years 7 4.5 3.4 2.2 7.8 5.2 5.9 7.9 9.2 10.0

Q4 2001 5 Years 1 7.2 13.0 18.7 12.7 3.6 5.9 5.5 15.6 8.2

Q4 2001 4 Years 1 10.4 5.7 18.4 6.6 18.7 11.4 10.1 11.0 15.1

Q4 2002 3 Years 1 12.4 8.2 10.5 8.6 7.4 4.9 5.4 4.0 6.5

Q4 2005 3 Years 1 6.1 7.8 8.6 5.5 7.9 5.9 7.3 10.9 11.3

Elimination/Incontinence: Low-Risk Residents Who Lost Control of Their Bowels or Bladders 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 42.4 43.6 44.5 45.0 45.6 47.8 47.9 47.8 48.5

Standard Deviation 17.0 16.7 16.6 16.7 16.7 16.8 16.9 16.7 16.7

Median 42.6 43.8 44.8 45.3 45.9 48.2 48.2 48.3 49.1

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 45.0 47.2 47.8 47.7 47.7 50.6 50.2 50.0 51.2

Q1 2002 5 Years 138 40.1 42.3 42.6 44.2 44.8 48.3 49.0 48.8 48.3

Q2 2002 5 Years 185 42.7 44.1 44.6 45.1 45.6 49.2 50.7 51.1 58.1

Q2 2004 3 Years 341 44.4 45.5 47.2 47.4 47.8 51.9 54.3 52.9 52.7

Q2 2002 5 Years 52 49.1 52.4 52.8 54.0 51.9 55.3 56.2 56.5 54.7

Q3 2003 5 Years 74 48.0 48.8 49.0 49.2 48.5 49.3 49.3 50.2 49.4

Q4 2003 2 Years 26 42.3 42.4 41.8 44.9 48.1 51.7 53.8 54.1 54.9

Q2 2000 5 Years 8 52.5 61.0 59.6 63.3 66.6 68.9 67.9 65.5 59.0

Q1 2002 3 Years 9 53.4 55.4 53.1 54.5 53.2 53.5 53.4 54.2 56.7

Q3 2003 5 Years 9 55.8 54.7 51.2 49.1 47.7 50.1 49.7 50.0 45.5

Q4 2004 5 Years 7 38.1 37.9 33.3 35.0 38.6 40.0 37.7 33.6 37.7

Q4 2001 5 Years 1 31.4 44.6 56.8 48.0 35.9 32.2 26.6 26.7 33.5

Q4 2001 4 Years 1 38.7 24.0 25.8 33.7 36.9 35.4 29.1 21.0 23.0

Q4 2002 3 Years 1 41.7 44.8 45.0 37.9 42.0 40.8 38.2 31.6 29.8

Q4 2005 3 Years 1 31.5 33.9 32.0 36.2 37.1 47.0 40.6 41.1 46.3

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 30 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Elimination/Incontinence: Residents Who Have/Had a Catheter Inserted and Left in Their Bladder 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 55.5 46.1 43.9 42.9 42.1 43.2 44.7 45.2 45.5

Standard Deviation 33.9 33.6 33.5 33.3 33.2 33.9 34.7 34.7 34.9

Median 55.6 40.0 36.4 35.0 33.3 35.5 37.5 38.5 38.9

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 60.5 49.6 45.4 45.1 43.1 42.9 47.4 47.4 49.4

Q1 2002 5 Years 138 60.9 54.5 52.7 55.3 36.6 25.2 24.0 32.5 33.7

Q2 2002 5 Years 185 69.7 55.8 56.0 55.4 53.5 53.1 39.4 38.8 39.4

Q2 2004 3 Years 341 58.5 48.4 46.8 46.5 42.6 43.3 44.5 43.9 41.7

Q2 2002 5 Years 52 74.8 41.3 51.7 49.2 53.3 49.1 36.7 49.3 51.4

Q3 2003 5 Years 74 75.2 63.5 64.0 56.7 52.3 57.7 62.0 62.8 54.6

Q4 2003 2 Years 26 46.1 33.5 29. 39.9 39.8 45.0 44.1 47.1 44.1

Q2 2000 5 Years 8 84.8 79.5 69.7 51.9 28.0 23.8 17.4 9.2 18.4

Q1 2002 3 Years 9 40.3 38.1 43.3 46.8 60.3 46.7 36.3 45.6 44.9

Q3 2003 5 Years 9 55.0 46.5 57.4 59.9 52.8 57.4 68.0 66.2 65.6

Q4 2004 5 Years 7 34.3 24.1 22.6 24.1 26.2 27.0 9.2 10.2 7.9

Q4 2001 5 Years 1 60.0 85.2 55.4 41.1 55.6 54.6 25.0 25.3 78.6

Q4 2001 4 Years 1 53.1 62.5 27.8 14.1 6.4 16.0 29.9 15.0 54.9

Q4 2002 3 Years 1 85.3 25.9 15.4 83.5 94.3 29.2 39.9 17.9 29.7

Q4 2005 3 Years 1 54.5 14.9 8.4 26.8 56.7 57.6 42.3 46.9 48.3

Elimination/Incontinence: Prevalence of Occasional or Frequent Bladder or Bowel Incontinence 

Without a Toileting Plan 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 9.3 9.1 9.2 9.4 9.3 8.6 9.3 8.8 8.5

Standard Deviation 12.0 11.1 10.5 10.2 9.8 8.7 9.0 8.3 8.0

Median 7.0 7.1 7.4 7.8 7.7 7.2 7.9 7.5 7.3

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 8.5 8.6 9.5 9.8 9.5 9.0 9.6 9.2 9.2

Q1 2002 5 Years 138 7.7 7.9 8.2 8.5 8.6 8.2 8.6 8.9 8.3

Q2 2002 5 Years 185 8.3 8.6 9.5 10.0 9.3 8.6 9.2 8.2 7.6

Q2 2004 3 Years 341 8.2 8.3 8.6 8.8 8.8 8.6 8.8 8.5 5.3

Q2 2002 5 Years 52 8.4 8.5 9.1 9.2 7.9 7.8 7.8 7.8 7.0

Q3 2003 5 Years 74 8.8 9.4 9.8 9.9 9.8 9.7 11.4 9.5 9.6

Q4 2003 2 Years 26 8.2 8.6 9.8 10.0 10.5 9.8 10.4 9.4 9.0

Q2 2000 5 Years 8 13.1 13.5 18.8 11.8 8.1 5.7 6.7 9.6 11.8

Q1 2002 3 Years 9 7.4 6.0 6.6 7.3 7.2 7.3 7.9 7.6 8.2

Q3 2003 5 Years 9 13.2 13.1 13.1 15.3 15.3 12.1 14.1 13.0 11.4

Q4 2004 5 Years 7 7.1 6.9 8.6 8.1 8.8 10.6 10.7 8.7 8.1

Q4 2001 5 Years 1 11.1 16.2 11.2 10.8 7.7 3.1 6.3 5.8 5.7

Q4 2001 4 Years 1 9.0 13.6 11.8 8.8 9.2 8.7 3.3 5.5 3.9

Q4 2002 3 Years 1 10.1 8.1 13.6 15.1 11.6 11.2 11.7 9.4 10.0

Q4 2005 3 Years 1 5.6 4.4 5.8 3.5 4.9 4.6 6.9 6.2 7.2

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 31 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Elimination/Incontinence: Prevalence of Fecal Impaction 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 1.1 0.4 0.3 0.2 0.2 0.1 0.1 0.1 0.1

Standard Deviation 3.5 2.0 1.8 1.2 1.3 1.0 1.2 1.3 0.9

Median 0 0 0 0 0 0 0 0 0

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 0.8 0.2 0.2 0.1 0.1 0.0 0.0 0.0 0.0

Q1 2002 5 Years 138 1.4 0.6 0.2 0.1 0.2 0.1 0.0 0.0 0.1

Q2 2002 5 Years 185 1.0 0.3 0.2 0.2 0.1 0.1 0.0 0.0 0.0

Q2 2004 3 Years 341 1.9 0.2 0.1 0.0 0.0 0.0 0.0 0.0 0.0

Q2 2002 5 Years 52 0.7 0.2 0.3 0.1 0.0 0.0 0.0 0.0 0.0

Q3 2003 5 Years 74 1.2 0.3 0.2 0.2 0.2 0.1 0.1 0.0 0.0

Q4 2003 2 Years 26 0.6 0.1 0.0 0.1 0.1 0.1 0.0 0.0 0.0

Q2 2000 5 Years 8 0.8 0.6 0.2 0.0 0.1 0.0 0.0 0.0 0.0

Q1 2002 3 Years 9 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Q3 2003 5 Years 9 0.6 0.4 0.2 0.2 0.1 0.1 0.0 0.0 0.0

Q4 2004 5 Years 7 0.4 0.1 0.0 0.1 0.4 0.0 0.0 0.0 0.0

Q4 2001 5 Years 1 0.5 0.3 2.7 0.0 0.0 0.5 0.0 0.0 0.0

Q4 2001 4 Years 1 1.3 1.5 1.0 0.9 0.4 0.0 0.0 0.0 0.0

Q4 2002 3 Years 1 1.4 0.0 0.6 0.1 0.0 0.1 0.0 0.0 0.0

Q4 2005 3 Years 1 2.1 0.0 0.0 0.0 0.2 0.0 0.2 0.0 0.0

Infection Control: Residents With a Urinary Tract Infection 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 8.7 8.4 8.6 9.0 9.0 9.0 9.5 9.6 9.7

Standard Deviation 9.3 8.4 8.2 8.2 7.6 7.5 7.8 7.4 7.4

Median 7.2 7.1 7.4 7.8 8.0 8.0 8.5 8.6 8.8

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 8.4 9.0 9.6 10.0 10.1 10.1 11.1 10.8 10.7

Q1 2002 5 Years 138 8.7 8.4 8.0 8.5 9.1 9.0 9.4 9.6 10.3

Q2 2002 5 Years 185 7.6 7.3 7.9 8.4 8.3 8.6 9.2 9.2 9.1

Q2 2004 3 Years 341 9.2 8.9 8.8 9.1 8.8 8.2 7.9 8.2 8.6

Q2 2002 5 Years 52 7.9 7.5 8.3 7.8 8.9 8.2 9.1 9.5 10.3

Q3 2003 5 Years 74 8.9 8.8 9.7 9.0 9.8 9.8 11.6 11.3 12.1

Q4 2003 2 Years 26 10.0 10.2 9.7 11.2 11.0 11.2 11.3 11.8 12.5

Q2 2000 5 Years 8 10.9 10.4 7.9 8.5 6.8 6.7 5.5 7.2 10.2

Q1 2002 3 Years 9 8.2 7.6 7.8 8.3 8.0 9.0 9.3 7.8 11.2

Q3 2003 5 Years 9 13.0 11.4 11.3 11.9 14.8 13.2 14.8 13.6 10.6

Q4 2004 5 Years 7 6.5 6.7 5.2 8.0 5.3 7.3 7.2 8.0 9.9

Q4 2001 5 Years 1 9.6 12.7 16.3 14.1 12.2 7.2 5.2 10.6 16.0

Q4 2001 4 Years 1 5.7 8.1 3.1 3.6 5.1 6.0 2.6 2.1 7.0

Q4 2002 3 Years 1 8.4 8.7 11.4 13.1 13.4 17.2 16.7 14.3 14.1

Q4 2005 3 Years 1 5.7 3.6 5.1 2.7 4.2 7.4 8.8 5.7 13.5

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 32 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Nutrition/Eating: Residents Who Lose Too Much Weight 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 12.3 11.5 11.4 10.9 10.8 9.8 10.4 10.0 9.9

Standard Deviation 10.8 9.9 9.5 9.1 8.7 7.8 8.2 7.7 7.5

Median 10.7 10.1 10.1 9.8 9.7 8.9 9.5 9.1 9.0

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 13.6 12.8 12.6 12.2 11.3 10.3 11.0 10.1 10.0

Q1 2002 5 Years 138 12.8 11.8 11.2 10.5 10.9 10.0 10.4 10.0 10.0

Q2 2002 5 Years 185 13.3 12.4 13.0 12.0 11.6 10.6 11.0 10.3 10.4

Q2 2004 3 Years 341 11.9 11.0 10.7 10.3 9.9 8.5 8.5 7.8 7.5

Q2 2002 5 Years 52 12.1 11.2 11.7 10.9 10.5 9.3 9.9 10.6 10.3

Q3 2003 5 Years 74 11.2 12.5 12.0 11.6 11.4 10.6 10.5 9.9 10.9

Q4 2003 2 Years 26 12.9 12.5 13.1 12.6 11.5 10.4 11.6 12.2 10.3

Q2 2000 5 Years 8 16.7 21.7 20.3 18.6 10.7 9.0 11.9 8.8 8.2

Q1 2002 3 Years 9 13.4 10.4 10.9 9.9 10.4 9.5 10.0 12.8 12.3

Q3 2003 5 Years 9 20.0 14.2 14.4 14.2 14.2 12.4 14.2 13.0 11.7

Q4 2004 5 Years 7 11.3 12.3 11.0 10.7 13.8 9.7 12.1 13.1 16.1

Q4 2001 5 Years 1 16.0 15.7 15.1 10.6 12.8 13.1 10.5 9.3 10.3

Q4 2001 4 Years 1 13.1 15.5 11.4 10.3 12.0 18.6 15.6 18.0 12.7

Q4 2002 3 Years 1 8.1 12.2 12.2 4.8 8.9 13.2 8.7 10.2 10.2

Q4 2005 3 Years 1 10.2 9.2 11.5 10.0 8.1 10.3 8.6 8.1 9.0

Nutrition/Eating: Prevalence of Tube Feeding 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 8.1 8.0 7.8 7.7 7.6 7.3 7.2 7.0 6.7

Standard Deviation 9.3 10.7 10.4 10.4 10.3 10.1 10.1 9.9 9.6

Median 7.2 5.4 5.3 5.2 5.1 4.8 4.7 4.6 4.4

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 7.1 7.0 6.8 6.8 6.9 6.4 6.2 6.3 6.3

Q1 2002 5 Years 138 5.7 5.6 5.8 6.0 5.7 5.3 5.5 5.3 5.1

Q2 2002 5 Years 185 9.3 9.0 9.0 8.9 8.8 8.8 8.9 8.5 8.3

Q2 2004 3 Years 341 7.0 6.8 6.6 6.3 5.8 5.5 5.3 5.1 4.8

Q2 2002 5 Years 52 11.8 12.7 13.4 13.7 12.9 11.5 11.7 11.3 9.9

Q3 2003 5 Years 74 10.1 10.2 10.1 10.9 11.3 9.9 10.0 10.8 10.4

Q4 2003 2 Years 26 7.7 8.2 8.9 9.2 9.4 8.2 8.3 8.3 8.6

Q2 2000 5 Years 8 9.3 16.6 5.6 8.4 5.6 5.9 7.3 6.6 8.8

Q1 2002 3 Years 9 18.8 20.6 19.1 18.3 18.9 17.6 17.5 19.1 18.0

Q3 2003 5 Years 9 16.8 16.0 16.2 15.9 15.5 14.2 14.9 13.9 12.6

Q4 2004 5 Years 7 2.3 2.7 3.5 2.4 3.4 4.4 3.2 2.8 2.7

Q4 2001 5 Years 1 7.7 9.8 3.7 4.1 5.7 5.6 9.1 8.2 9.0

Q4 2001 4 Years 1 2.0 2.2 1.9 2.8 2.7 0.9 1.3 2.8 4.2

Q4 2002 3 Years 1 7.5 6.9 6.0 5.6 4.3 5.0 7.8 7.9 9.9

Q4 2005 3 Years 1 20.9 19.2 17.2 14.3 12.9 7.4 6.4 5.3 6.6

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 33 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Nutrition/Eating: Prevalence of Dehydration 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 1.6 1.0 0.8 0.7 0.6 0.4 0.4 0.4 0.3

Standard Deviation 5.8 4.7 3.8 3.3 2.9 2.3 2.7 2.5 2.0

Median 0 0 0 0 0 0 0 0 0

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 1.9 1.0 0.8 0.7 0.5 0.3 0.2 0.3 0.2

Q1 2002 5 Years 138 1.6 1.0 0.8 1.0 0.8 0.7 0.4 0.3 0.2

Q2 2002 5 Years 185 2.1 0.8 0.7 0.5 0.3 0.2 0.2 0.1 0.1

Q2 2004 3 Years 341 1.1 0.4 0.3 0.2 0.2 0.1 0.1 0.1 0.1

Q2 2002 5 Years 52 2.4 1.1 0.7 0.5 0.2 0.1 0.4 0.3 0.2

Q3 2003 5 Years 74 1.5 0.8 0.6 0.7 0.5 0.5 0.7 0.4 0.3

Q4 2003 2 Years 26 1.5 0.4 0.2 0.3 0.2 0.2 0.2 0.1 0.1

Q2 2000 5 Years 8 3.2 4.5 3.2 0.6 0.3 0.1 0.6 0.0 0.2

Q1 2002 3 Years 9 0.4 0.1

34 

0.1 0.2 0.1 0.0 0.0 0.0 0.0

Q3 2003 5 Years 9 4.2 1.3 1.1 1.2 1.1 0.7 0.9 1.0 0.6

Q4 2004 5 Years 7 0.6 0.3 0.6 0.3 0.1 0.5 0.1 0.3 0.3

Q4 2001 5 Years 1 0.0 0.0 0.2 0.0 0.3 0.0 0.3 1.4 1.1

Q4 2001 4 Years 1 3.4 2.4 0.2 0.0 0.2 0.0 0.0 0.0 0.0

Q4 2002 3 Years 1 2.1 0.2 0.3 0.2 0.4 0.1 0.3 0.4 0.4

Q4 2005 3 Years 1 0.7 0.6 0.2 0.0 0.0 0.0 0.0 0.3 0.2

Pain Management: Residents Who Have Moderate to Severe Pain 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 13.7 13.2 13.1 12.5 10.7 9.8 10.1 9.3 8.7

Standard Deviation 13.2 12.3 12.3 11.9 11.0 10.1 10.6 9.8 9.5

Median 10.7 10.4 10.3 9.8 8.0 7.3 7.6 7.0 6.4

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 14.2 13.8 14.3 14.1 12.6 11.1 10.6 8.8 7.5

Q1 2002 5 Years 138 13.9 14.3 13.8 14.5 14.3 13.1 12.9 11.0 9.6

Q2 2002 5 Years 185 11.5 12.1 12.5 11.5 8.6 8.4 8.9 8.1 7.6

Q2 2004 3 Years 341 12.9 12.9 12.6 11.3 7.0 5.2 5.1 4.6 4.6

Q2 2002 5 Years 52 10.3 9.8 11.0 10.3 7.4 7.2 7.9 7.4 7.6

Q3 2003 5 Years 74 12.9 11.9 12.2 11.9 10.4 10.2 11.3 9.2 6.7

Q4 2003 2 Years 26 13.8 12.2 13.3 13.4 11.2 10.6 10.5 10.0 7.8

Q2 2000 5 Years 8 22.7 30.9 17.9 15.6 10.7 8.2 12.2 12.0 7.4

Q1 2002 3 Years 9 11.3 10.8 9.8 7.4 5.4 4.5 4.7 5.0 4.9

Q3 2003 5 Years 9 13.8 12.9 12.2 12.1 13.1 13.8 13.3 15.6 13.3

Q4 2004 5 Years 7 13.7 9.2 6.7 9.2 10.4 8.3 5.6 7.8 8.5

Q4 2001 5 Years 1 13.3 13.5 19.3 21.5 16.4 12.8 17.3 11.9 5.9

Q4 2001 4 Years 1 13.7 25.4 25.0 11.5 8.0 9.4 11.3 1.4 1.4

Q4 2002 3 Years 1 7.0 6.2 11.2 12.5 7.3 5.9 9.9 13.8 14.2

Q4 2005 3 Years 1 18.6 16.5 13.5 14.1 8.2 8.5 5.6 5.8 8.2

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Physical Functioning: Residents Whose Need for Help With Daily Activities Has Increased 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 15.9 15.8 15.8 15.9 15.8 15.8 15.8 15.9 15.4

Standard Deviation 10.8 10.3 10.0 10.1 9.7 9.7 9.8 9.8 9.4

Median 14.3 14.3 14.3 14.4 14.4 14.3 14.3 14.5 14.1

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 18.0 18.6 18.9 18.3 18.2 18.2 18.0 20.2 19.1

Q1 2002 5 Years 138 15.2 16.5 16.0 16.8 15.0 15.2 17.0 17.4 18.6

Q2 2002 5 Years 185 17.0 17.6 17.8 20.3 23.3 22.9 23.0 23.7 23.1

Q2 2004 3 Years 341 17.9 19.3 22.2 23.3 22.2 22.9 18.4 18.2 17.7

Q2 2002 5 Years 52 14.5 14.6 15.2 17.9 19.8 18.4 17.7 17.9 17.8

Q3 2003 5 Years 74 13.8 13.7 14.9 16.5 18.2 18.8 18.5 19.9 18.9

Q4 2003 2 Years 26 16.3 16.8 17.7 21.0 19.6 19.7 18.7 17.7 17.4

Q2 2000 5 Years 8 16.8 3.3 12.6 13.3 12.5 14.9 11.7 15.7 11.0

Q1 2002 3 Years 9 16.0 13.9 11.5 12.2 14.7 12.3 13.4 16.1 14.6

Q3 2003 5 Years 9 14.9 15.9 18.9 16.5 18.6 14.3 14.5 16.5 21.6

Q4 2004 5 Years 7 12.1 12.6 9.3 10.1 11.1 13.5 12.2 12.3 15.8

Q4 2001 5 Years 1 21.8 24.8 20.2 11.9 17.6 20.2 21.6 27.0 24.5

Q4 2001 4 Years 1 14.8 14.5 17.1 14.2 19.8 14.8 14.2 21.0 14.7

Q4 2002 3 Years 1 11.8 18.1 15.6 9.9 11.3 8.2 13.0 7.1 8.4

Q4 2005 3 Years 1 14.2 12.9 10.7 11.9 12.2 12.4 13.4 16.1 13.5

Physical Functioning: Residents Who Spend Most of Their Time in a Bed or in a Chair 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 8.5 7.0 6.4 6.0 5.7 5.4 5.4 5.2 5.1

Standard Deviation 12.6 11.2 10.4 9.8 9.4 8.9 8.8 8.5 8.3

Median 5.1 4.0 3.7 3.4 3.2 3.0 3.0 2.9 2.8

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 8.0 6.6 6.3 6.1 6.1 6.2 5.6 5.6 5.9

Q1 2002 5 Years 138 7.5 6.9 6.4 6.5 6.3 5.5 5.1 4.9 4.5

Q2 2002 5 Years 185 9.7 8.5 7.7 7.1 6.5 6.3 6.2 5.9 5.7

Q2 2004 3 Years 341 7.1 5.6 5.4 5.2 4.6 4.1 3.5 3.2 3.3

Q2 2002 5 Years 52 11.4 8.3 8.0 7.4 6.7 6.8 6.7 6.2 5.6

Q3 2003 5 Years 74 8.8 7.8 7.1 7.6 9.2 9.6 10.0 9.1 9.2

Q4 2003 2 Years 26 8.2 6.4 5.2 5.2 5.6 5.0 5.3 5.3 6.1

Q2 2000 5 Years 8 11.1 13.0 10.4 11.2 7.1 5.1 4.4 3.3 5.4

Q1 2002 3 Years 9 11.9 6.3 5.3 5.2 6.3 7.3 8.3 10.2 10.0

Q3 2003 5 Years 9 13.5 10.3 12.5 14.3 13.9 12.8 13.1 15.1 11.8

Q4 2004 5 Years 7 4.0 3.4 3.8 2.1 2.4 3.3 2.3 2.9 2.0

Q4 2001 5 Years 1 6.9 13.2 4.9 11.8 10.1 4.5 3.6 2.5 5.6

Q4 2001 4 Years 1 13.0 6.2 4.1 9.4 2.4 1.8 3.5 2.1 4.7

Q4 2002 3 Years 1 6.8 6.8 4.8 2.9 1.8 1.4 2.1 1.9 4.4

Q4 2005 3 Years 1 8.9 5.8 5.2 3.2 4.1 5.3 5.7 6.5 6.6

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 35 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Physical Functioning: Residents Whose Ability To Move In and Around Their Rooms Got Worse 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 15.0 14.9 14.9 15.1 15.0 15.1 15.1 15.1 14.9

Standard Deviation 10.9 10.4 10.1 10.2 10.1 10.3 10.3 10.2 10.0

Median 13.3 13.3 13.5 13.6 13.6 13.6 13.5 13.6 13.3

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 17.4 17.5 17.6 17.2 17.1 16.7 16.5 17.1 15.9

Q1 2002 5 Years 138 14.0 14.5 14.6 15.1 14.2 14.5 13.9 14.2 15.5

Q2 2002 5 Years 185 15.6 15.6 16.5 18.2 20.6 21.3 21.7 22.1 23.4

Q2 2004 3 Years 341 15.7 17.0 19.7 21.2 20.9 21.5 19.9 19.7 19.1

Q2 2002 5 Years 52 14.2 15.1 15.0 18.1 18.5 17.3 19.0 18.3 16.9

Q3 2003 5 Years 74 13.1 11.8 12.6 13.9 14.9 15.9 16.4 17.3 17.7

Q4 2003 2 Years 26 15.9 16.1 17.3 19.2 18.8 18.6 19.9 17.0 17.9

Q2 2000 5 Years 8 20.4 14.9 11.4 12.6 14.6 16.0 13.1 19.4 13.9

Q1 2002 3 Years 9 17.4 13.0 13.0 13.1 13.7 13.7 14.5 15.6 14.2

Q3 2003 5 Years 9 16.8 15.2 16.6 18.6 18.6 13.9 14.9 13.8 21.9

Q4 2004 5 Years 7 8.4 10.2 7.7 9.2 8.0 11.5 8.5 10.1 11.9

Q4 2001 5 Years 1 14.3 21.9 16.9 8.8 12.4 10.3 8.1 11.0 12.7

Q4 2001 4 Years 1 10.8 17.3 20.8 16.1 14.9 12.2 13.0 18.4 10.5

Q4 2002 3 Years 1 10.6 8.2 12.6 10.5 11.8 7.5 11.5 7.0 8.8

Q4 2005 3 Years 1 12.7 10.9 9.2 11.4 11.4 12.9 13.2 15.3 12.1

Physical Functioning: Incidence of Decline in Range of Motion 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 9.8 8.9 8.3 8.1 7.7 7.4 7.4 7.2 6.9

Standard Deviation 9.7 8.9 8.3 8.2 7.7 7.4 7.6 7.5 7.1

Median 7.7 6.9 6.5 6.3 6.0 5.7 5.6 5.4 5.2

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 10.2 8.7 7.8 7.3 7.1 6.7 6.3 6.4 5.9

Q1 2002 5 Years 138 8.2 7.5 6.5 7.3 7.1 7.1 6.6 7.3 7.8

Q2 2002 5 Years 185 10.9 9.9 9.0 8.7 9.3 9.8 10.2 9.2 9.1

Q2 2004 3 Years 341 9.9 9.4 9.3 9.3 8.6 7.9 6.9 6.9 6.9

Q2 2002 5 Years 52 9.1 8.1 8.1 8.6 8.2 8.6 8.9 9.0 10.1

Q3 2003 5 Years 74 8.3 6.9 8.2 8.1 7.5 6.7 7.2 7.0 6.9

Q4 2003 2 Years 26 8.5 8.3 7.5 8.1 6.7 6.2 7.4 6.3 7.7

Q2 2000 5 Years 8 8.7 5.8 6.2 7.4 9.3 5.2 6.0 5.7 8.7

Q1 2002 3 Years 9 10.8 7.1 6.3 8.4 6.3 4.6 7.1 8.4 6.9

Q3 2003 5 Years 9 10.5 12.2 10.7 8.3 9.6 7.4 7.4 9.3 8.8

Q4 2004 5 Years 7 5.4 5.5 2.9 3.8 4.8 6.0 6.5 6.2 7.1

Q4 2001 5 Years 1 7.2 19.3 9.0 8.7 6.9 4.7 2.3 4.3 9.4

Q4 2001 4 Years 1 8.8 5.7 4.9 4.1 4.3 5.4 3.4 3.0 4.7

Q4 2002 3 Years 1 4.6 12.9 7.4 4.0 7.4 5.5 3.0 6.0 2.5

Q4 2005 3 Years 1 10.0 10.0 5.6 8.3 5.6 4.0 6.2 8.4 8.5

 O E I - 0 6 - 0 6 - 0 0 5 7 0 QUALITY OF CARE IN NURSING H OMES UNDER C ORPORATE I NTEGRITY A GREEMENTS 36 
APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Psychotropic Drug Use: Prevalence of Antipsychotic Use, in the Absence of Psychotic Conditions 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 16.4 17.3 18.6 20.5 21.6 22.0 21.6 20.9 20.2

Standard Deviation 11.5 11.4 11.7 12.2 12.4 12.8 12.7 12.6 12.6

Median 14.8 15.8 17.1 19.1 20.2 20.6 20.0 19.4 18.6

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 14.6 16.9 18.5 20.8 21.7 22.1 20.7 18.8 18.9

Q1 2002 5 Years 138 19.8 20.2 21.4 23.7 24.3 22.6 20.9 20.9 21.1

Q2 2002 5 Years 185 18.2 19.4 20.7 22.7 23.6 22.6 20.1 17.1 14.8

Q2 2004 3 Years 341 16.0 17.0 18.8 19.8 18.9 17.9 18.3 18.7 18.1

Q2 2002 5 Years 52 14.6 14.8 16.3 18.4 18.1 17.8 17.7 18.1 19.2

Q3 2003 5 Years 74 14.2 14.5 15.6 17.5 17.5 18.4 17.5 17.2 16.8

Q4 2003 2 Years 26 12.1 13.0 12.3 12.7 15.6 15.6 14.0 13.6 12.3

Q2 2000 5 Years 8 14.8 16.5 16.0 18.3 15.3 16.3 13.4 12.2 13.7

Q1 2002 3 Years 9 17.2 16.0 17.8 19.5 17.0 18.6 16.8 16.2 15.9

Q3 2003 5 Years 9 10.5 11.7 13.7 18.5 20.0 19.5 18.5 18.2 17.7

Q4 2004 5 Years 7 16.2 19.3 23.1 24.4 22.9 19.0 15.7 18.9 22.3

Q4 2001 5 Years 1 23.8 22.0 24.0 24.8 27.3 33.7 21.2 17.3 31.7

Q4 2001 4 Years 1 14.7 17.0 16.2 19.4 24.8 23.8 25.1 27.7 21.0

Q4 2002 3 Years 1 12.6 12.9 13.2 18.0 27.1 31.1 28.5 25.5 25.4

Q4 2005 3 Years 1 10.6 6.9 10.4 15.1 20.4 21.0 26.2 19.2 19.2

Psychotropic Drug Use: Prevalence of Antianxiety/Hypnotic Drug Use 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 18.2 17.7 17.9 18.1 18.1 18.2 19.1 20.3 21.2

Standard Deviation 12.1 11.6 11.5 11.3 11.0 10.9 11.1 11.3 11.6

Median 16.7 16.1 16.3 16.7 16.7 16.7 17.6 18.9 20.0

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 18.4 18.3 18.6 18.2 18.4 18.3 19.1 19.8 20.6

Q1 2002 5 Years 138 18.1 17.6 18.8 18.7 19.1 17.7 19.0 20.4 21.6

Q2 2002 5 Years 185 17.5 16.7 16.4 16.7 18.0 17.7 19.0 19.9 20.5

Q2 2004 3 Years 341 16.9 16.7 17.1 17.1 16.6 16.2 17.2 19.3 19.8

Q2 2002 5 Years 52 15.0 14.6 15.4 15.9 15.8 16.3 17.3 18.3 19.3

Q3 2003 5 Years 74 16.9 16.6 16.5 18.0 19.3 19.6 19.8 21.6 22.8

Q4 2003 2 Years 26 21.3 20.9 21.7 21.2 22.9 24.6 24.0 26.7 26.9

Q2 2000 5 Years 8 25.9 26.0 11.9 14.5 12.8 14.4 17.8 20.4 20.4

Q1 2002 3 Years 9 9.9 8.8 8.1 7.7 8.2 7.5 7.6 8.0 9.1

Q3 2003 5 Years 9 21.7 19.0 22.4 22.4 23.0 20.1 23.5 28.2 26.3

Q4 2004 5 Years 7 20.2 21.2 22.5 22.7 22.4 20.4 16.0 14.2 17.3

Q4 2001 5 Years 1 17.7 11.1 17.3 19.8 25.9 25.5 26.9 23.9 20.4

Q4 2001 4 Years 1 15.4 15.4 16.5 25.7 21.0 20.6 11.8 20.3 24.3

Q4 2002 3 Years 1 14.3 14.9 10.9 9.7 9.2 7.3 12.6 10.9 10.4

Q4 2005 3 Years 1 21.1 17.3 12.2 13.8 14.5 12.2 17.7 20.3 24.7

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APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Psychotropic Drug Use: Prevalence of Hypnotic Use More Than Two Times in Last Week 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 3.9 3.6 3.7 3.7 3.9 3.9 4.1 4.6 5.0

Standard Deviation 6.6 5.9 5.9 5.7 5.6 5.5 5.5 5.6 5.8

Median 2.5 2.3 2.4 2.5 2.7 2.6 2.9 3.3 3.7

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 3.4 3.3 3.4 3.3 3.4 3.3 3.8 4.1 4.5

Q1 2002 5 Years 138 3.5 3.1 3.1 3.6 3.6 3.5 3.7 4.3 5.0

Q2 2002 5 Years 185 3.7 3.2 3.4 3.4 4.0 3.9 4.3 5.0 5.3

Q2 2004 3 Years 341 2.8 2.7 2.5 2.6 2.6 2.5 2.9 3.4 3.7

Q2 2002 5 Years 52 3.1 3.1 3.6 3.7 3.8 4.9 5.2 5.6 5.7

Q3 2003 5 Years 74 3.7 3.5 3.9 4.0 4.4 4.4 4.4 5.1 5.8

Q4 2003 2 Years 26 5.2 5.3 5.6 5.5 5.7 5.8 6.4 6.5 6.9

Q2 2000 5 Years 8 10.0 4.6 4.8 5.2 3.7 3.9 7.1 10.1 8.2

Q1 2002 3 Years 9 1.3 1.1 1.4 1.7 1.8 1.9 1.8 2.2 1.9

Q3 2003 5 Years 9 4.5 3.9 5.9 5.2 5.7 4.7 5.2 6.7 6.7

Q4 2004 5 Years 7 6.1 4.8 3.9 3.8 4.8 5.7 1.3 1.0 1.6

Q4 2001 5 Years 1 7.6 1.9 4.9 6.1 12.8 15.4 12.4 13.9 10.4

Q4 2001 4 Years 1 5.7 2.6 3.1 6.0 3.3 2.8 3.0 6.5 7.9

Q4 2002 3 Years 1 1.0 0.5 0.8 1.0 1.3 1.0 2.9 2.0 2.4

Q4 2005 3 Years 1 7.7 4.2 1.5 1.5 3.6 3.7 4.5 6.0 8.0

Quality of Life: Residents Who Were Physically Restrained 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 10.5 10.2 10.1 9.4 8.0 7.4 6.7 6.0 5.2

Standard Deviation 11.2 11.0 10.7 10.2 8.8 8.5 8.1 7.7 7.0

Median 7.3 7.1 7.2 6.5 5.5 4.9 4.2 3.6 2.9

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 7.7 8.0 8.1 8.0 6.8 7.0 6.1 5.6 4.9

Q1 2002 5 Years 138 7.9 8.1 8.2 7.9 7.9 7.3 6.0 5.3 4.4

Q2 2002 5 Years 185 11.7 11.4 11.7 11.6 8.6 7.3 6.7 6.7 5.4

Q2 2004 3 Years 341 6.0 6.3 6.5 5.4 3.9 2.8 1.9 1.9 1.9

Q2 2002 5 Years 52 16.7 16.5 17.9 16.9 12.1 9.7 8.1 7.1 6.9

Q3 2003 5 Years 74 9.3 11.0 11.0 9.5 7.4 7.3 6.3 5.3 3.6

Q4 2003 2 Years 26 6.4 6.7 6.7 7.6 7.1 8.5 8.4 9.0 7.9

Q2 2000 5 Years 8 19.5 20.7 15.7 15.8 14.7 16.1 16.6 11.6 7.1

Q1 2002 3 Years 9 15.2 12.9 11.1 7.0 7.0 8.6 7.2 3.8 2.9

Q3 2003 5 Years 9 7.8 12.2 13.9 10.3 7.0 6.8 5.3 5.5 3.7

Q4 2004 5 Years 7 11.2 9.3 11.2 12.8 14.3 13.1 4.6 2.0 1.1

Q4 2001 5 Years 1 23.2 3.4 12.5 9.7 7.8 15.8 5.4 9.7 9.0

Q4 2001 4 Years 1 5.7 10.5 10.3 14.7 9.5 3.0 2.8 2.1 0.2

Q4 2002 3 Years 1 5.8 10.7 14.0 12.3 17.0 11.9 9.9 8.4 7.6

Q4 2005 3 Years 1 16.9 28.7 24.4 19.8 6.8 5.3 3.9 6.5 2.7

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APPENDIX ~ C 

Table 6 (continued): Quality Indicator/Quality Measure Annual Four-Quarter Averages for 15 Corporate 

Integrity Agreement Corporations and National Population 

Quality of Life: Prevalence of Little or No Activity 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 30.9 20.8 15.9 13.1 11.1 9.5 8.7 8.1 7.5

Standard Deviation 22.1 17.8 15.6 14.3 13.4 12.5 12.2 11.8 11.3

Median 27.6 17.2 12.0 9.1 7.0 5.5 4.5 3.9 3.4

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 28.3 18.8 14.1 10.5 7.7 6.6 5.7 5.3 4.4

Q1 2002 5 Years 138 31.5 19.9 14.5 13.6 10.8 9.9 7.9 7.7 5.3

Q2 2002 5 Years 185 32.1 20.5 14.9 11.6 8.6 6.0 5.6 4.3 3.4

Q2 2004 3 Years 341 26.8 17.6 12.7 9.7 7.1 5.5 4.4 3.9 4.1

Q2 2002 5 Years 52 28.8 17.8 13.8 9.8 6.8 5.5 4.4 4.5 4.1

Q3 2003 5 Years 74 33.8 19.0 13.3 12.2 11.4 9.8 7.1 6.0 5.7

Q4 2003 2 Years 26 23.5 13.5 10.7 8.9 4.6 3.2 2.6 2.6 1.6

Q2 2000 5 Years 8 19.3 15.7 11.9 8.2 5.6 5.6 3.5 0.6 1.4

Q1 2002 3 Years 9 33.0 18.7 11.6 6.9 5.4 2.5 1.6 1.3 0.5

Q3 2003 5 Years 9 38.5 23.1 15.6 14.4 16.5 11.2 8.4 10.6 5.9

Q4 2004 5 Years 7 22.8 18.3 14.8 10.9 10.1 9.7 2.6 2.7 1.8

Q4 2001 5 Years 1 55.4 68.4 69.0 12.9 9.9 23.8 4.5 3.1 2.4

Q4 2001 4 Years 1 40.9 41.0 31.9 22.9 16.0 18.2 13.5 16.6 23.4

Q4 2002 3 Years 1 57.2 27.4 28.6 25.5 24.9 18.9 7.3 7.3 7.5

Q4 2005 3 Years 1 22.1 4.3 4.2 4.4 0.8 0.0 0.4 0.0 0.3

Skin Care: Residents With Pressure Ulcers 

1999 2000 2001 2002 2003 2004 2005 2006 2007

National Population Average 10.8 10.3 10.4 10.3 10.5 9.9 10.3 9.8 9.5

Standard Deviation 11.1 10.3 10.2 9.8 9.5 8.8 9.1 8.5 8.1

Median 9.0 8.7 8.9 8.8 9.1 8.7 9.0 8.6 8.3

Number of Nursing Homes 17,370 17,214 17,011 16,763 16,558 16,346 16,196 16,026 15,964

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 10.1 10.3 10.4 10.4 10.3 9.5 9.9 9.2 9.3

Q1 2002 5 Years 138 8.3 8.7 9.2 9.1 9.3 8.9 8.9 9.1 9.2

Q2 2002 5 Years 185 11.0 10.4 10.9 10.6 10.5 9.5 10.1 9.6 10.0

Q2 2004 3 Years 341 8.5 8.8 8.7 8.3 8.1 7.3 7.4 7.1 6.9

Q2 2002 5 Years 52 14.0 12.8 13.0 12.0 11.5 11.7 11.9 11.7 13.2

Q3 2003 5 Years 74 11.9 11.6 11.3 11.7 11.9 11.9 12.6 12.4 11.5

Q4 2003 2 Years 26 11.7 11.8 11.8 12.2 11.4 11.7 13.0 12.8 13.0

Q2 2000 5 Years 8 24.7 31.6 18.5 18.9 12.9 11.0 11.9 13.7 14.1

Q1 2002 3 Years 9 14.8 11.6 13.9 15.0 16.5 14.5 15.9 16.8 18.7

Q3 2003 5 Years 9 21.4 19.4 21.2 20.0 18.1 14.5 16.2 15.1 13.4

Q4 2004 5 Years 7 11.4 11.6 10.7 9.4 11.3 15.2 9.9 6.9 8.6

Q4 2001 5 Years 1 7.4 14.3 11.2 7.7 12.2 9.1 8.1 11.6 9.6

Q4 2001 4 Years 1 8.5 6.0 9.8 8.5 6.9 7.1 1.0 3.5 4.2

Q4 2002 3 Years 1 15.9 9.0 15.1 11.6 10.8 9.3 7.9 8.9 6.6

Q4 2005 3 Years 1 9.5 6.5 6.5 6.5 7.0 4.6 10.7 10.1 14.2

Source: Office of Inspector General Analysis of Quality Indicator/Quality Measure data. 

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STATE SURVEY DEFICIENCIES DATA BY CORPORATION 

State Survey Deficiencies. The Centers for Medicare & Medicaid 

Services (CMS) contracts with States to survey nursing homes initially, 

and routinely thereafter, for participation in the Medicare and Medicaid 

programs.22 States verify that the nursing homes maintain Federal 

quality of care standards by conducting a standard survey of each 

nursing home every 9 to 15 months. When surveyors determine that an 

area of care in a nursing home does not meet Federal standards, they 

issue a “deficiency tag.” Each deficiency tag includes a number that 

describes the specific infraction and a letter indicating the scope and 

severity. (See Table 7.) The scope refers to the number of affected 

residents and the severity refers to the degree of harm. CMS uses 

47 deficiency tags to determine whether a nursing home is providing 

substandard quality of care. These deficiency tags refer to quality of 

life, quality of care, and participation requirements for resident 

behavior and facility practices.23 

State survey deficiency data are maintained in CMS’s Online Survey, 

Certification, and Reporting (OSCAR) system. We obtained OSCAR 

data for the national population of nursing homes for all standard 

surveys conducted between January 1, 1999, and December 31, 2007. 

Table 7. Scope and Severity Matrix for State Survey Deficiencies 

Deficiency Scope 

Deficiency Severity Isolated Pattern Widespread 

Actual or potential for 

death or serious injury 

(immediate jeopardy) 

J K L 

Actual harm that is not 

immediate jeopardy G H I 

Potential for more than 

minimal harm D E F 

Potential for minimal 

harm, substantial 

compliance exists 

A B C 

Source: CMS, “State Operations Manual.”

Δ APPENDIX ~ D 

22 Sections 1819(g) and 1919(g) of the Social Security Act. 

23 CMS, “State Operations Manual,” section 7001. Available online at 

http://www.cms.hhs.gov/manuals/downloads/som107c07.pdf. Accessed on June 20, 2008. 

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APPENDIX ~ D 

Selection of Deficiency Tags for Inclusion. For this analysis, we included 

the 47 deficiency tags that CMS uses to determine whether a nursing 

home is providing “substandard quality of care.” The deficiency tags 

used are listed in Table 8. 

Table 8: Quality of Care Survey Deficiency Tags Selected for Analysis 

Resident Behavior and Facility Practices 

42 CFR § F-Tag Deficiency

483.13(a) F221, F222 Restraints

483.13(b) F223 Abuse

483.13(c) F224, F226 Staff Treatment of Residents

Quality of Life

42 CFR § F-Tag Deficiency

483.15(a) F241 Dignity

483.15(b) F242 Self-Determination and Participation

483.15(c) F243, F244 Participation in Resident and Family 

Groups

483.15(d) F245 Participation in Other Activities

483.15(e) F246, F247 Accommodation of Needs

483.15(f) F248, F249 Activities

483.15(g) F250, F251 Social Services

483.15(h) F252, F253, F254, F255, 

F256, F257, F258

Environment

Quality of Care 

42 CFR § F-Tag Deficiency

483.05 F309 Quality of Care Deficiencies Not Covered 

by § 483.25(a)–(m)

483.25(a) F310, F311, F312 Activities of Daily Living

483.25(b) F313 Vision and Hearing

483.25(c) F314 Pressure Sores

483.25(d) F315, F316 Urinary Incontinence

483.25(e) F317, F318 Range of Motion

483.25(f) F319, F320 Mental and Psychosocial Functioning

483.25(g) F321, F322 Naso-Gastric Tubes

483.25(h) F323, F324 Accidents

483.25(i) F325, F326 Nutrition

483.25(j) F327 Hydration

483.25(k) F328 Special Needs

483.25(l) F329 Unnecessary Drugs

483.25(m) F332, F333 Medication Errors

483.25(n) F334 Influenza and Pneumococcal 

Immunizations

Source: “CMS State Operations Manual,” Appendix PP, “Guidance to Surveyors for Long Term Care 

Facilities,” Rev. 26, August 17, 2007. 

Analysis of survey deficiency data. We took the following steps to analyze 

the survey deficiency data: 

1. For each survey of each nursing home, we computed the total 

number of deficiencies of a scope and severity of “D” or higher. 

We did not include scope and severity levels “A” through “C” 

because they are considered to be substantial compliance by 

CMS. 

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APPENDIX ~ D 

2. We computed the average number of deficiencies in each State 

for each year from 1999 through 2007. 

3. We created an index for each nursing home for each standard 

survey that was computed as the number of deficiencies for the 

survey divided by the average number of deficiencies for the 

State for the year of the survey.24 These deficiency index scores 

for each corporation are presented in Table 9. The national 

index score equals 1; therefore, scores above 1 indicate that the 

corporation had more deficiencies than the average, and scores 

lower than 1 indicate that the corporation had fewer than 

average. 

Table 9: Index Scores for CIA Corporations for Quality of Care Deficiencies of Scope and Severity of D or 

Higher* 

CIA Corporations 

CIA Start 

Quarter 

Term of 

CIA 

Number of 

Nursing 

Homes 1999 2000 2001 2002 2003 2004 2005 2006 2007

Q2 2001 5 Years 251 1.11 1.15 1.23 1.19 1.10 1.14 1.04 1.14 1.21

Q1 2002 5 Years 138 1.14 1.11 1.36 1.05 1.05 1.19 1.05 1.03 1.11

Q2 2002 5 Years 185 1.03 1.05 1.17 1.15 1.20 1.13 1.16 1.20 1.34

Q2 2004 3 Years 341 1.03 1.06 1.08 1.01 0.96 0.83 0.83 0.89 1.12

Q2 2002 5 Years 52 1.17 1.36 1.12 1.08 1.05 1.11 0.76 1.48 1.22

Q3 2003 5 Years 74 1.18 1.10 1.09 1.04 1.16 1.02 1.20 1.66 1.38

Q4 2003 2 Years 26 0.99 0.77 1.03 1.22 1.14 0.94 0.97 0.95 1.55

Q2 2000 5 Years 8 0.88 1.04 1.20 1.51 1.69 0.73 0.88 1.33 0.77

Q1 2002 3 Years 9 0.68 1.90 1.36 1.09 1.45 1.30 2.05 1.44 1.70

Q3 2003 5 Years 9 1.27 0.73 1.44 1.20 1.63 0.55 0.83 2.20 0.78

Q4 2004 5 Years 7 0.35 0.96 0.37 1.02 1.58 1.74 0.60 0.97 1.36

Q4 2001 5 Years 1 2.97 1.79 0.70 1.32 0.31 0.29 2.16 2.97 1.79

Q4 2001 4 Years 1 1.11 0.32 0.28 0.30 0.28 1.03 0.23 1.11

Q4 2002 3 Years 1 1.09 3.61 0.96 1.95 1.41 1.55 2.16 1.09

Q4 2005 3 Years 1 3.28 0.29 0.37 0.33 1.30 1.10 1.35 0.65 3.28

*Shaded areas indicate the years during which the corporation was under the CIA. 

Source: Office of Inspector General analysis of OSCAR quality of care deficiencies on standard surveys. 

24 Prior Office of Inspector General (OIG) work found that there was variation across 

States in the number of deficiencies cited and that States differ in how they determine 

specific deficiency citations. Using same-State nursing homes as a denominator, rather 

than all nursing homes in the Nation, helped to account for any variation in surveyor 

practices across States and create a meaningful comparative index. OIG, “Deficiency 

Trends and Survey and Certification Process Consistency” (OEI-02-01-00600), March 2003. 
Δ ACKNOWLEDGMENTS 

This report was prepared under the direction of Kevin K. Golladay, 

Regional Inspector General for Evaluation and Inspections in the Dallas 

regional office, and A. Blaine Collins, Deputy Regional Inspector 

General. 

Susan M. Wolfe served as the team leader for this study. Other 

principal Office of Evaluation and Inspections staff from the Dallas 

regional office who contributed to the report include Amy Ashcraft, 

Dustin Johnson, Sai Loganathan, Margaret Knight, and Dana 

McClellan; other staff who contributed include Kevin Farber, Jennifer 

Jones, Sandy Khoury, and Barbara Tedesco. 

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