United States Government Accountability Office

GAO Report to the Ranking Minority 

Member, Committee on Finance, U.S. 

Senate 

NURSING HOMES

Efforts to Strengthen 

Federal Enforcement 

Have Not Deterred 

Some Homes from 

Repeatedly Harming 

Residents 

March 2007 

 

GAO-07-241 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

March 2007

NURSING HOMES

Efforts to Strengthen Federal 

Enforcement Have Not Deterred Some 

Homes from Repeatedly Harming 

Residents 

Highlights of GAO-07-241, a report to the 

Ranking Minority Member, Committee on 

Finance, U.S. Senate 

In 1998 and 1999 reports, GAO

concluded that enforcement

actions, known as sanctions, were

ineffective in encouraging nursing

homes to maintain compliance with 

federal quality requirements: 

sanctions were often rescinded 

before being implemented because 

homes had a grace period to

correct deficiencies. In response, 

the Centers for Medicare & 

Medicaid Services (CMS) began 

requiring immediate sanctions for 

homes that repeatedly harmed

residents. Using CMS enforcement 

and deficiency data, GAO 

(1) analyzed federal sanctions from 

fiscal years 2000 through 2005

against 63 homes previously

reviewed and (2) assessed CMS’s 

overall management of

enforcement. The 63 homes had a

history of harming residents and 

were located in 4 states that

account for about 22 percent of 

homes nationwide. 

What GAO Recommends

GAO recommends that the CMS 

Administrator (1) develop an 

administrative process for 

collecting civil money penalties 

more expeditiously and seek 

legislation to implement this

process effectively, as appropriate; 

(2) strengthen its immediate 

sanctions policy; (3) expand its 

oversight of homes with a history 

of harming residents; and 

(4) improve the effectiveness of its 

enforcement data systems. CMS 

generally concurred with GAO’s 

recommendations. 

From fiscal years 2000 through 2005, the number of sanctions decreased for 

the 63 nursing homes GAO reviewed that had a history of serious quality 

problems, a decline consistent with nationwide trends. While the decline 

may reflect improved quality or changes to enforcement policy, it may also 

mask survey weaknesses that understate quality problems, an issue GAO has 

reported on since 1998. Although the number of sanctions decreased, the 

homes generally were cited for more deficiencies that caused harm to 

residents than other homes in their states. Almost half of the homes 

reviewed continued to cycle in and out of compliance; 19 did so 4 times or 

more. These homes temporarily corrected deficiencies and, even with 

sanctions, were again found out of compliance on subsequent surveys. 

Several weaknesses appeared to undermine the effectiveness of the 

sanctions implemented against the homes reviewed. First, civil money 

penalties (CMP), which by statute are not paid while under appeal—a 

process that can take years—were generally imposed at the lower end of the 

allowable dollar range. For example, the median per day CMP ranged from 

$350 to $500, significantly below the maximum of $3,000 per day. Second, 

CMS favored the use of sanctions that give homes more time to correct 

deficiencies, increasing the likelihood that the sanctions would not be 

implemented. Thus, more than half of the denial of payment for new 

admissions (DPNA) that CMS imposed were the type that give homes 

3 months to correct deficiencies rather than those that only give homes up to 

15 days. Third, there was no record of a sanction for about 22 percent of the 

homes reviewed that met CMS’s criteria for immediate sanctions, a problem

GAO also identified in 2003; moreover, 60 percent of DPNAs imposed as

immediate sanctions were not implemented until 1 to 2 months after citation 

of the deficiency. Finally, involuntary termination of homes from 

participating in the Medicare or Medicaid programs was rare because of 

concerns about access to other nearby homes and resident transfer trauma;

2 of the 63 homes reviewed were involuntarily terminated because of quality 

problems. 

CMS’s management of enforcement is hampered by the complexity of its 

immediate sanctions policy and by its fragmented and incomplete data. Its 

policy allows some homes with the worst compliance histories to escape

immediate sanctions. For example, a home cited with a serious deficiency

and that has not yet corrected an earlier serious deficiency is spared an 

immediate sanction. Such rules may in part explain why the 63 homes 

reviewed only had 69 instances of immediate sanctions over a 6-year period 

despite being cited 444 times for deficiencies that harmed residents. 

Although CMS initiated development of a new enforcement data system 

6 years ago, it is fragmented and has incomplete national reporting 

capabilities. CMS is taking additional steps to improve nursing home 

enforcement, such as developing guidance to encourage more consistency in 

CMP amounts, but it is not clear whether and when these initiatives will 

address the enforcement weaknesses GAO found. 

www.gao.gov/cgi-bin/getrpt?GAO-07-241.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Kathryn G. 

Allen at (202) 512-7118 or allenk@gao.gov. 
Contents 

Letter 1

Results in Brief 4

Background 7

Number of Sanctions Has Decreased 17 

Despite Changes in Federal Enforcement Policy, Many Homes 

Continued to Cycle In and Out of Compliance 26 

Complex Immediate Sanctions Policy and Data Limitations 

Hamper CMS Management of Enforcement 40 

Conclusions 51

Recommendations for Executive Action 54 

Agency and State Comments and Our Evaluation 55 

Appendix I Scope and Methodology 59 

Appendix II Percentage of Nursing Homes Cited for Actual 

Harm or Immediate Jeopardy, by State, Fiscal 

Years 2000-2005 64 

Appendix III Federal Sanctions for Nursing Homes Reviewed, 

by State, Fiscal Years 2000-2005 66 

Appendix IV Examples of Homes Reviewed That Frequently 

Cycled In and Out of Compliance 68 

Appendix V Number of Days between Survey and 

Implementation Date of DPNA for Homes 

Reviewed, Fiscal Years 2000-2005 70 

Appendix VI Comments from the Centers for Medicare & 

Medicaid Services 71 

Page i GAO-07-241 Nursing Home Enforcement
Appendix VII Comments from the California Department of 

Health Services 79 

Appendix VIII Comments from the Michigan Department of 

Community Health 84 

Appendix IX Comments from the Texas Department of Aging 

and Disability Services 89 

Appendix X GAO Contact and Staff Acknowledgments 91 

Related GAO Products 92 

Tables 

Table 1: Number of Nursing Homes Reviewed in 1999 That Were 

Included in Our Analysis for This Report 3 

Table 2: Scope and Severity of Deficiencies Identified during 

Nursing Home Surveys 8 

Table 3: Sanctions Available to Encourage Nursing Home 

Compliance with Requirements 10 

Table 4: Sanctions Implemented for Homes Reviewed, Fiscal Years 

2000-2002 and 2003-2005 21 

Table 5: Examples of Homes with Low Implemented CMPs 24 

Table 6: Example of a Michigan Nursing Home That Frequently 

Cycled In and Out of Compliance and Was Still Open as of 

November 2006 29 

Table 7: Examples of Homes’ Deficiency Histories and Termination 

Actions, Fiscal Years 2000-2005 38 

Table 8: Number of Nursing Homes Reviewed in 1999 That Were 

Included in Our Analysis for This Report, by State 60 

Table 9: Percentage of Nursing Homes Cited for Actual Harm or 

Immediate Jeopardy during Standard Surveys, Fiscal Years 

2000-2005 64

Page ii GAO-07-241 Nursing Home Enforcement
Table 10: Number of Sanctions Implemented Among Homes We 

Reviewed, Fiscal Years 2000-2005 66 

Table 11: Examples of Homes that Frequently Cycled In and Out of 

Compliance 68

Figures 

Figure 1: Federal-State Responsibilities in the Enforcement 

Process 15

Figure 2: Percentage of Implemented Sanctions for Homes 

Reviewed Over Three Time Periods (July 1995-October 

1998, Fiscal Years 2000-2002, and Fiscal Years 2003-2005) 23 

Figure 3: Frequency that Reviewed Homes Cycled In and Out of 

Compliance, Fiscal Years 2000-2005 28 

Figure 4: Number of Days between Survey and Implementation of 

CMPs and DPNAs among Homes Reviewed, Fiscal Years 

2000-2005 33

Figure 5: Lag Time between Survey and CMP Payment for a 

Michigan Nursing Home 35 

Figure 6: Number of Homes with One or More Double Gs, Fiscal 

Years 2000-2005 36 

Figure 7: Impact of Intervening Periods of Compliance Rule on

Immediate Sanctions for One Pennsylvania Nursing 

Home, 2000 43 

Figure 8: Impact of Clearing Effect Rule on Immediate Sanctions 

for One Michigan Nursing Home, 2000-2002 45 

Page iii GAO-07-241 Nursing Home Enforcement
Abbreviations 

ACTS ASPEN Complaints/Incidents Tracking System 

AEM ASPEN Enforcement Manager 

ASPEN Automated Survey Processing Environment 

CMP civil money penalty 

CMPTS CMP Tracking System 

CMS Centers for Medicare & Medicaid Services 

DPNA denial of payment for new admissions 

LTC Long Term Care Enforcement Tracking System 

OBRA 87 Omnibus Budget Reconciliation Act of 1987 

OSCAR On-Line Survey, Certification, and Reporting system 

PDQ Providing Data Quickly 

QIO Quality Improvement Organization 

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Page iv GAO-07-241 Nursing Home Enforcement
United States Government Accountability Office

Washington, DC 20548 

March 26, 2007 

The Honorable Charles E. Grassley 

Ranking Minority Member 

Committee on Finance 

United States Senate 

Dear Senator Grassley: 

The nation’s 1.5 million nursing home residents are a highly vulnerable 

population of elderly and disabled individuals for whom remaining at 

home is no longer feasible. The federal government plays a key role in 

ensuring that nursing home residents receive appropriate care by setting

quality requirements that nursing homes must meet to participate in the 

Medicare and Medicaid programs and by contracting with states to 

routinely inspect homes and conduct complaint investigations.

1

 Moreover, 

to encourage compliance with these requirements, Congress has 

authorized certain enforcement actions, known as sanctions, including 

civil money penalties (CMP) or termination from participating in these 

programs. With the aging of the baby boom generation, the number of 

individuals needing nursing home care and the associated costs are 

expected to increase dramatically. Combined Medicare and Medicaid 

payments for nursing home services were about $67 billion in 2004, 

including a federal share of about $46 billion.2

In 1998 and 1999 reports, we identified significant weaknesses in federal 

and state activities designed to detect and correct quality problems at 

nursing homes.3

 A key finding was that sanctions imposed on nursing 

homes, including those that repeatedly harmed residents, often did not 

 1

Medicare is the federal health care program for elderly and disabled people. Medicare

covers up to 100 days of skilled nursing home care following a hospital stay. Medicaid is 

the joint federal-state health care financing program for certain categories of low-income 

individuals. Medicaid also pays for long-term care services, including nursing home care. 

2

Data for 2004 are the most recent available. 

3

GAO, California Nursing Homes: Care Problems Persist Despite Federal and State 

Oversight, GAO/HEHS-98-202 (Washington, D.C.: July 27, 1998) and Nursing Homes:

Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards, 

GAO/HEHS-99-46 (Washington, D.C.: Mar. 18, 1999). See a list of related GAO products at

the end of this report. 

Page 1 GAO-07-241 Nursing Home Enforcement
take effect. Instead, the sanctions were rescinded prior to their effective 

dates because homes had a grace period in which they could and often did 

correct deficiencies. We referred to this phenomenon as a “yo-yo” pattern

of compliance because homes cycled in and out of compliance, harming 

residents while avoiding sanctions. Overall, we concluded that the goal of 

the enforcement process—to help ensure that homes maintain compliance 

with federal quality requirements—was not being realized. In response to 

our recommendations, the Centers for Medicare & Medicaid Services 

(CMS), the federal agency that manages these two public health care 

programs, took several steps, including the introduction of an immediate 

sanctions policy for homes found to repeatedly harm residents and the 

development of a new data system to improve management of the 

enforcement process. Under CMS’s immediate sanctions policy, sanctions 

may be imposed without giving homes an opportunity to correct serious 

deficiencies that resulted in actual resident harm or put residents at risk of 

death or serious injury. We also reported that the deterrent effect of CMPs 

can be hampered by a backlog of appeals, which further delays payment of 

CMPs; by statute, CMPs are not paid until appealed cases are closed. 

You asked us to assess CMS’s progress in improving the enforcement 

process, particularly for homes with a history of harming residents. In 

response to your request, we (1) analyzed federal sanctions from fiscal 

years 2000 through 2005 against 63 homes with a history of harming 

residents as well as nationwide trends in nursing home sanctions for the 

same time period, (2) evaluated the extent to which the homes cycled in 

and out of compliance and the impact of CMS’s immediate sanctions 

policy, and (3) assessed CMS’s management of enforcement activities. The 

nursing homes were located in California, Michigan, Pennsylvania, and 

Texas and their prior compliance and enforcement histories formed the 

basis for the conclusions in our March 1999 report.4

 These homes were 

selected for that report because of their serious or sustained compliance 

problems prior to 1999 and are not representative of homes in those states 

or homes nationwide.5

 The 63 homes we reviewed for this report 

 4

See GAO/HEHS-99-46. The 1999 report focused on 74 homes. We excluded 11 of the 

original 74 homes from our current analysis because they either closed before fiscal year 

2000 or closed within 6 months of the beginning of fiscal year 2000 and therefore had few

or no deficiencies or sanctions during the period we reviewed. Of the remaining 63 homes,

10 were located in California, 16 in Michigan, 14 in Pennsylvania, and 23 in Texas (see 

app. I). 

5

Overall, the nursing homes in these four states account for about 22 percent of nursing

homes nationwide. 

Page 2 GAO-07-241 Nursing Home Enforcement
participated in Medicare and Medicaid for at least 6 months during fiscal 

years 2000 through 2005. Table 1 shows the number of homes that 

participated by fiscal year. Changes in the number of homes from year to 

year are a result of homes’ closure, termination, or reinstatement of 

participation. For example, the change from 61 homes in fiscal year 2000

to 59 homes in fiscal year 2001 represents the voluntary closure of 

2 homes, the involuntary termination of 1, and the reinstatement of 1, for a 

net decrease of 2 homes.6

Table 1: Number of Nursing Homes Reviewed in 1999 That Were Included in Our Analysis for This Report 

Current report

Fiscal year 

1999 report 2000 2001 2002 

Average 

2000-2002 2003 2004 2005

Average 

2003-2005 

Total number of homes

with any participation

in 2000-2005

74 61 59 58 59 58 54 55 56 63

Source: GAO.

Note: Some of the 63 homes only participated in the Medicare and Medicaid programs for a portion of 

fiscal years 2000 through 2005 because they either closed permanently or closed temporarily and 

were subsequently reinstated. To be included in our analysis we required such homes to have 

participated for at least 6 months of the fiscal year.

Our analysis relied primarily on (1) deficiency data from CMS’s On-Line 

Survey, Certification, and Reporting system (OSCAR) and the CMS 

Providing Data Quickly (PDQ) Web site; (2) sanctions data from its Long 

Term Care Enforcement Tracking System (LTC) and ASPEN Enforcement 

Manager (AEM);7

 and (3) CMP payment information from its CMP 

Tracking System (CMPTS).8

 We also examined CMS regional office and

state enforcement case files for the nursing homes we reviewed. We 

analyzed deficiency and sanctions data to identify the number and type of 

sanctions implemented and their implementation rates; the extent to 

which homes cycled in and out of compliance; the use of immediate 

sanctions for homes that repeatedly harmed residents, including their 

 6

By state, the number of homes active for at least 6 months in fiscal years 2000 and 2005 did 

not change in California, decreased by one home in both Michigan and Texas, and

decreased by four homes in Pennsylvania (see app. I). The year-to-year changes in the

number of providers do not materially affect our findings on enforcement trends. 

7

ASPEN is an abbreviation for Automated Survey Processing Environment.

8

See appendix I for a more detailed description of our use of these CMS databases.

Page 3 GAO-07-241 Nursing Home Enforcement
deterrent effect; the use of termination; and variability in state approaches 

to enforcement. To identify trends, we compared deficiency and sanctions 

data across two time periods: fiscal years 2000 through 2002 and fiscal 

years 2003 through 2005.

9

 We focused our analysis on three types of 

sanctions—CMPs, denial of payment for new admissions (DPNA), and 

terminations—which accounted for about 81 percent of all sanctions from 

fiscal years 2000 through 2005. Although termination was used 

infrequently—less than 1 percent of all sanctions—we included it in our 

analysis because it is the most severe sanction, resulting in the loss of 

Medicare and Medicaid revenue.

10 Based on our assessment of the data 

from the case file review, we determined that the sanctions data were 

sufficiently reliable to assess general nationwide trends in implemented 

sanctions. Because we could not conduct such checks of the data in all 

50 states and the District of Columbia, we did not analyze trends across 

the individual states.11 We also reviewed CMS enforcement policy and 

guidance and discussed the immediate sanctions policy and data reliability 

issues with CMS and state officials. Finally, we obtained perspectives from

regional office and state officials on the sanctions used for the homes we 

reviewed. Our findings on sanctions, such as implementation rates and use 

of the available range of sanctions, against these homes cannot be 

generalized to all homes in the 4 states or to all nursing homes nationwide. 

However, we believe that the findings are illustrative of the overall 

adequacy of federal and state responses to nursing homes with a history of

serious noncompliance with federal quality requirements. Appendix I 

provides a more detailed description of our scope and methodology, 

including steps taken to ensure the reliability of the data used in this 

report. We performed our work from January 2005 through January 2007 

in accordance with generally accepted government auditing standards. 

For the homes we reviewed in four states, the number of sanctions 

implemented as well as the number of serious deficiencies cited declined Results in Brief 

 9

Our analysis of the implementation rate of sanctions includes a third baseline time period

of July 1995 to October 1998, which we previously reported on in 1999. Our current analysis 

starts with fiscal year 2000, excluding fiscal year 1999, because one of the major 

enforcement policies we evaluated was modified in 2000. 

10Throughout this report, we use the term “termination” to refer to a home’s closure for 

cause, also known as involuntary closure. Homes can and do close voluntarily. 

11In this report, we use the term “states” to include the 50 states and the District of 

Columbia.

Page 4 GAO-07-241 Nursing Home Enforcement
from fiscal years 2000 through 2005—trends that were also seen 

nationwide. While the decline may reflect improved quality or changes to 

enforcement policy, it may also mask survey weaknesses that understate 

quality problems, an issue we have reported on since 1998. In general, the 

homes were cited for more deficiencies that caused harm to residents than

other homes in their respective states. For example, the homes we 

reviewed in California had three times as many serious deficiencies as 

other homes in the state. We also found differences in the implementation

rate of various sanctions for the homes we reviewed. Comparing results 

from the baseline period of July 1995 to October 1998 with the period 

fiscal years 2003 through 2005, the implementation rate of CMPs increased 

from 32 percent to 86 percent but declined for DPNAs by about 20 percent.

However, the deterrent effect of CMPs was diluted because CMS imposed 

CMPs at the lower end of the allowable range for the homes we reviewed. 

For example, the median per day CMP amount imposed for deficiencies 

that do not cause immediate jeopardy to residents was $500 in fiscal years 

2000 through 2002 and $350 in fiscal years 2003 through 2005; the 

allowable range is $50 to $3,000 per day. Generally, CMS did not exercise 

its discretionary authority to impose DPNAs and terminations for the 

homes; rather, it waited until these sanctions could be imposed on a 

mandatory basis, allowing the homes more opportunities to escape 

sanctions prior to implementation. Moreover, in some instances, CMS 

extended the implementation dates of imposed terminations, thus allowing 

homes additional time to avoid being terminated by correcting 

deficiencies.

Despite changes in federal enforcement policy, almost half of the 

63 homes we reviewed—homes with prior serious quality problems—

continued to cycle in and out of compliance during fiscal years 2000 

through 2005, causing harm to residents. These homes corrected 

deficiencies only temporarily and, despite having had sanctions 

implemented, were again found to be out of compliance, including 

8 homes that cycled in and out of compliance 7 or more times. During this 

same time period, 27 of the 63 homes were cited 69 times for deficiencies 

that warranted immediate sanctions, but 15 of these cases did not result in 

immediate sanctions. Moreover, the “immediate sanctions” label is 

misleading because CMS’s policy requires only that homes be notified 

immediately of CMS’s intent to implement sanctions, not that sanctions be

implemented immediately. When DPNAs are imposed, the lag time 

between the occurrence of a deficiency that results in an immediate 

sanction and the sanction’s implementation date provides a de facto grace 

period; if the home is able to correct the deficiency, it can escape 

sanctions. Although the use of CMPs avoids this de facto grace period 

Page 5 GAO-07-241 Nursing Home Enforcement
because they can be implemented retroactively, by statute, payment of 

CMPs may be delayed until after exhausting appeals of the underlying 

deficiency, a process that can take years. Nor did CMS’s implementation of 

immediate sanctions appear to deter future repeat deficiencies—18 of the 

27 homes with immediate sanctions had multiple instances of such 

sanctions in fiscal years 2000 through 2005. Termination of a home from 

the Medicare and Medicaid programs was infrequent. By the end of fiscal

year 2005, only 2 homes were terminated involuntarily because of quality

problems. Another 9 that closed did so voluntarily. In effect, these homes 

picked their own closure dates and may have continued to harm residents 

before closing. For example, 2 such homes were cited for harming 

residents 21 and 26 times, respectively, and had sanctions implemented 

numerous times from fiscal year 2000 until their voluntary closures in 

2004. 

In general, the effectiveness of CMS’s management of nursing home 

enforcement is hampered by the overall complexity of its immediate 

sanctions policy, intended to deter repeated noncompliance, and by its 

fragmented data systems and incomplete national reporting capabilities. 

First, the complexity of the immediate sanctions policy allows some 

homes with the worst compliance histories—the very homes the policy

was designed to address—to escape immediate sanctions. For example, 

homes that do not correct deficiencies can avoid immediate sanctions 

because of the requirement for an intervening period of compliance 

between the pair of surveys that identify serious deficiencies—that is, a 

new serious deficiency will not trigger an immediate sanction unless the 

prior serious deficiency has been corrected. Thus, if a state survey agency

cited a home for a serious deficiency and 2 weeks later—before the first 

deficiency was corrected—cited the home for another serious deficiency,

the home might not receive an immediate sanction. In addition, homes—

even those with a history of multiple serious deficiencies—may escape 

immediate sanctions because a routine inspection without such a serious 

deficiency, in effect, clears the home’s record for determining if immediate 

sanctions are applicable. The immediate sanctions associated with CMS’s 

policy also are often inequitable; multiple serious deficiencies during one 

inspection may result in the same sanction as an inspection with a single 

serious deficiency. Second, CMS’s fragmented and incomplete data 

systems continue to hamper its ability to monitor enforcement. We 

previously reported that CMS lacked a data system that integrated 

enforcement data nationwide and that the lack of such a system made it 

difficult for CMS to consistently manage and monitor sanctions across 

states and its regional offices. Although CMS has developed a new data 

system, the system’s components are not integrated, and the national 

Page 6 GAO-07-241 Nursing Home Enforcement
reporting capabilities are not complete. Finally, CMS is taking steps to 

improve its enforcement of nursing home quality requirements. In addition

to its new data system, the agency piloted new guidance in 2006 designed

to encourage more consistency across states in the amount of CMPs, 

revised a program that provides enhanced enforcement and monitoring of 

some homes with a history of harming residents in each state, and funded

studies to examine the effectiveness of nursing home enforcement. 

We are recommending that, to increase the deterrent effect of CMPs, the 

Administrator of CMS develop an administrative process to collect CMPs 

prior to exhaustion of appeals, seek legislation for the implementation of 

this process, and address any due process concerns, as appropriate. We 

are also recommending that the CMS Administrator take actions to 

(1) improve the immediate sanctions policy to help ensure that homes that 

repeatedly harm residents or place them in immediate jeopardy do not 

escape immediate sanctions, (2) strengthen the deterrent effect of certain

sanctions, (3) expand a program of enhanced enforcement for homes with 

a history of noncompliance, and (4) improve the effectiveness of the 

agency’s data systems used for enforcement. In commenting on a draft of

this report, CMS generally concurred with our recommendations but did 

not always specify how it would implement them. In addition, CMS noted 

that implementation of three of our recommendations raised resource 

issues and that others required additional research. The four states in 

which the nursing homes we reviewed were located generally concurred 

with our findings. 

Ensuring the quality and safety of nursing home care has been a focus of 

considerable congressional attention since 1998. Titles XVIII and XIX of 

the Social Security Act establish minimum requirements in statute that all

nursing homes must meet to participate in the Medicare and Medicaid 

programs, respectively. With the Omnibus Budget Reconciliation Act of 

1987 (OBRA 87), Congress focused the requirements on the quality of care 

actually provided by a home.12 To help ensure that homes maintained 

compliance with the new requirements, OBRA 87 also established the 

range of available sanctions, to include CMPs, DPNAs, and termination.13

Background 

 12Pub. L. No. 100-203, §§4201, 4211, 101 Stat. 1330-160, 1330-182. 

13Pub. L. No. 100-203, §§4203, 4213, 101 Stat. 1330-179, 1330-213. 

Page 7 GAO-07-241 Nursing Home Enforcement
CMS contracts with state survey agencies to assess whether homes meet 

federal quality requirements through routine inspections, known as 

standard surveys,14 and complaint investigations. The requirements are 

intended to ensure that residents receive the care needed to protect their 

health and safety, such as preventing avoidable pressure sores, weight 

loss, and accidents. While a standard survey involves a comprehensive 

assessment of federal quality requirements, a complaint investigation 

generally focuses on a specific allegation regarding resident care or safety; 

complaints can be lodged by a resident, family member, or nursing home 

employee. Deficiencies identified during either standard surveys or 

complaint investigations are classified in 1 of 12 categories according to 

their scope (i.e., the number of residents potentially or actually affected) 

and severity. An A-level deficiency is the least serious and is isolated in 

scope, while an L-level deficiency is the most serious and is considered to 

be widespread in the nursing home (see table 2).15 When state surveyors 

identify and cite B-level or higher deficiencies, the home is required to 

prepare a plan of correction and, depending on the severity of the 

deficiency, surveyors conduct revisits to ensure that the home actually 

implemented its plan and corrected the deficiencies.16

Ensuring Compliance with 

Federal Quality 

Requirements 

Table 2: Scope and Severity of Deficiencies Identified during Nursing Home 

Surveys 

Scope

Severity Isolated Pattern Widespread

Immediate jeopardya J K L

Actual harm G H I 

Potential for more than minimal harm D E F

Potential for minimal harmb A B C

Source: CMS. 

a

Actual or potential for death/serious injury. 

b

Nursing home is considered to be in substantial compliance. 

 14Every nursing home receiving Medicare or Medicaid payment must undergo a standard

survey not less than once every 15 months, and the statewide average interval for these 

surveys must not exceed 12 months. 

15Throughout this report, we use the term serious deficiency to refer to care problems at 

the level of actual harm or immediate jeopardy. 

16State survey teams generally consist of registered nurses, social workers, dieticians, and

other specialists. 

Page 8 GAO-07-241 Nursing Home Enforcement
Homes with deficiencies at the A, B, or C levels are considered to be in 

substantial compliance with federal quality requirements, while homes 

with D-level or higher deficiencies are considered noncompliant. A 

noncompliance period begins when a survey finds noncompliance and 

ends when the home either achieves substantial compliance by correcting 

the deficiencies or when the home is terminated from Medicare and 

Medicaid. Since 1998, the deficiencies cited during standard surveys have

been summarized on CMS’s Nursing Home Compare Web site, and CMS 

subsequently added data on the results of complaint investigations.17 These 

data are intended to help consumers select a nursing home that takes into

account the quality of care provided to residents. 

Range of Federal 

Sanctions

CMS and the states can use a variety of federal sanctions to help 

encourage compliance with quality requirements ranging from less severe 

sanctions, such as indicating the specific actions needed to address a 

deficiency and providing an implementation time frame, to those that can 

affect a home’s revenues and provide financial incentives to return to and

maintain compliance (see table 3).18 Overall, two sanctions—CMPs and 

DPNAs—accounted for 80 percent of federal sanctions from fiscal years 

2000 through 2005. 

 17See http://www.medicare.gov/NHCompare. 

18In addition to federal sanctions, states may impose their own sanctions under their state 

licensure authority. 

Page 9 GAO-07-241 Nursing Home Enforcement
Table 3: Sanctions Available to Encourage Nursing Home Compliance with

Requirements

Sanction Description

CMP The home pays a fine for each day or instance of 

noncompliance.

DPNA Medicare and/or Medicaid payments can be denied for all 

newly admitted eligible residents.a 

Directed in-service training The home is required to provide training to staff on a 

specific issue identified as a problem in the survey. 

Directed plan of correction The home is required to take action within specified time 

frames according to a plan of correction developed by 

CMS, the state, or a temporary manager. 

State monitoring An on-site monitor is placed in the home to help ensure 

that the home achieves and maintains compliance. 

Temporary management The nursing home accepts a substitute manager appointed 

by the state with the authority to hire, terminate, and 

reassign staff; obligate funds; and alter the nursing home’s 

procedures, as appropriate. 

Termination Termination from the Medicare and Medicaid programs. 

The home is no longer eligible to receive Medicare and 

Medicaid payments for beneficiaries residing in the home. 

Source: CMS. 

Notes: Most of the above sanctions are authorized by statute (see 42 U.S.C. §1395i-3(h) and 42 

U.S.C. §1396r(h)), while directed in-service training is authorized by regulation (see 42 C.F.R §

488.406(a)). Additional or alternative sanctions may also be used (see 42 C.F.R. § 488.406(c)). 

a

CMS may also deny payment for all Medicare- and/or Medicaid-covered residents but seldom does 

so because it may severely limit the homes’ revenues for patient care. 

The majority of federal sanctions implemented from fiscal years 2000

through 2005—about 54 percent—were CMPs. CMPs may be either per 

day or per instance. CMS regulations specify a per day CMP range from 

$50 to $10,000 for each day a home is noncompliant—from $50 to $3,000 

for nonimmediate jeopardy and $3,050 to $10,000 for immediate jeopardy. 

The overall amount of the fine increases the longer a home is out of 

compliance.19 For example, a home with a per day CMP of $5,000 that is 

out of compliance for 10 days would accrue a total penalty of $50,000. A 

per day CMP can be assessed retroactively, starting from the first day of 

noncompliance, even if that date is prior to the date of the survey that 

identified the deficiency.

 19Federal statutes specify that CMPs may not exceed $10,000 for each day of

noncompliance. 42 U.S.C. §1395i-3(h)(2)(B)(ii) and 42 U.S.C. §1396r(h)(3)(C)(ii). 

Page 10 GAO-07-241 Nursing Home Enforcement
Per instance CMPs range from $1,000 to $10,000 per episode of

noncompliance.20 While multiple per instance CMPs can be imposed for 

deficiencies identified during a survey, the total amount cannot exceed 

$10,000. Per day and per instance CMPs cannot be imposed as a result of 

the same survey, but a per day CMP can be added when a deficiency is 

identified on a subsequent survey if a per instance CMP was the type of

CMP initially imposed. Unlike other sanctions, CMPs require no notice 

period. However, if a home appeals the deficiency, by statute, payment of 

the CMP—whether received directly from the home or withheld from the 

home’s Medicare and Medicaid payments—is deferred until the appeal is 

resolved.21

DPNAs made up about 26 percent of federal sanctions from fiscal years 

2000 through 2005. A DPNA denies a home payments for new admissions 

until deficiencies are corrected. In contrast to CMPs, CMS regulations 

require that homes be provided a notice period of at least 15 days for other 

sanctions, including DPNAs; the notice period is shortened to 2 days in the 

case of immediate jeopardy. As a result, homes can avoid DPNAs if they 

are able to correct deficiencies during the notice period, which provides a 

de facto grace period. Unlike CMPs, DPNAs cannot be imposed 

retroactively, and payment denial is not deferred until appeals are 

resolved. 

Although nursing homes can be terminated involuntarily from 

participation in Medicare and Medicaid, which can result in a home’s 

closure, termination is used infrequently.22 Terminations were less than 

1 percent of total sanctions from fiscal years 2000 through 2005. Four of 

the seven types of sanctions described above were used less frequently 

than CMPs and DPNAs—directed plan of correction, state monitoring, 

directed in-service training, and temporary management—these sanctions 

 20Unlike for per day CMPs, CMS does not specify a particular per instance CMP range for

cases of immediate jeopardy. 

21If efforts to collect the CMP directly from the home fail, Medicare and Medicaid payments

are withheld. 

22Homes also can choose to close voluntarily, but we do not consider voluntary closure to

be a sanction. When a home is terminated, it loses any income from Medicare and 

Medicaid, which accounted for about 40 percent of nursing home payments in 2004.

Residents who receive support through Medicare or Medicaid must be moved to other 

facilities. However, a terminated home generally can apply for reinstatement if it corrects 

its deficiencies. 

Page 11 GAO-07-241 Nursing Home Enforcement
accounted for about 19 percent of sanctions nationwide from 2000 through 

2005. 

Imposition of Sanctions The statute permits and, in some cases, requires that DPNAs or 

termination be imposed for homes found out of compliance with federal 

quality requirements. Mandatory termination and DPNA are required, as 

follows: 

• Termination—Termination is required by regulations under the statute if 

within 23 days of the end of a survey a home fails to correct immediate 

jeopardy deficiencies,23 or within 6 months of the end of a survey the home 

fails to correct nonimmediate jeopardy deficiencies. 

• DPNA—A DPNA is required by statute if within 3 months of the end of a 

survey a home fails to correct deficiencies and return to compliance or 

when a home’s last three standard surveys reveal substandard quality of 

care.24

The statute also authorizes CMS to impose discretionary DPNAs and 

discretionary terminations in situations other than those specified above.25

Federal regulations further stipulate that such discretionary sanctions may 

be implemented as long as a facility is given the appropriate notice period. 

By regulation, the notice period for implementing both discretionary and

mandatory DPNAs and terminations is 15 days; in cases of immediate 

jeopardy, however, the notice period is 2 days. 

 23Instead of termination, a temporary manager may be appointed to remove the immediate 

jeopardy. 

24According to CMS, substandard quality of care exists when a home is cited for a

deficiency at the F, H, I, J, K, or L level in any of three areas: quality of care, which can 

include deficiencies such as inadequate treatment or prevention of pressure sores; quality 

of life, which can include deficiencies such as a failure to accommodate the needs and 

preferences of residents; and resident behavior, which can include deficiencies such as a 

failure to protect residents from abuse. This definition excludes deficiencies at the G level 

(actual harm). For purposes of this report, we define serious deficiencies as G-level or 

higher deficiencies. The statute allows CMS to deny payment for all residents; however, our 

analysis focuses on the denial of payment for new admissions, a more frequently used 

sanction. 

25By implementing either a mandatory or discretionary termination, CMS is acting to 

involuntarily terminate the nursing home. 

Page 12 GAO-07-241 Nursing Home Enforcement
In imposing sanctions, CMS takes into account four factors: (1) the scope 

and severity of the deficiency, (2) a home’s prior compliance history, 

(3) desired corrective action and long-term compliance, and (4) the 

number and severity of all the home’s deficiencies. In general, the severity 

of the sanction increases with the severity of the deficiency. For example, 

for immediate jeopardy deficiencies (J, K, and L on CMS’s scope and 

severity grid) the regulations require that either or both temporary 

management or termination be imposed, and also permits use of CMPs of 

from $3,050 to $10,000 per day or $1,000 to $10,000 per instance of 

noncompliance. Similarly, for deficiencies at the actual harm level (G, H, 

and I on the scope and severity grid) the regulations require one or a 

combination of the following sanctions: temporary management, a DPNA, 

a per day CMP of $50 to $3,000, or a per instance CMP of $1,000 to $10,000 

per instance of noncompliance. In addition to these required sanctions, 

other sanctions can be included; for example, depending on the severity of

the deficiency and a home’s compliance history, it could have a 

combination of state monitoring, a DPNA, and a CMP. Finally, CMS is 

required to consider the immediacy of sanctions. The statute stipulates 

that sanctions should be designed to minimize the time between the 

identification of violations and the final imposition of the sanctions.26

Enforcement of nursing home quality-of-care requirements is a shared 

federal-state responsibility. In general, sanctions are (1) initially proposed 

by the state survey agency based on a cited deficiency, (2) reviewed and 

imposed by CMS regional offices, and (3) implemented—that is, put into

effect—by the same CMS regional office, usually after a required notice 

period (see fig. 1).27 CMS regional offices typically accept state-proposed 

sanctions but can modify them. The regional office notifies the home by 

letter that a sanction is being imposed—that is, its intent to implement a 

sanction—and the date it will be implemented. State surveyors may make 

follow-up visits to the home to determine whether the deficiencies have 

been corrected. The CMS regional office implements the sanctions if the 

deficiencies are not corrected. Homes may appeal the cited deficiency and, 

State and CMS Roles in 

Sanctioning Homes 

 26See 42 U.S.C. §1395i-3(h)(2)(B) and 42 U.S.C. § 1396r(h)(2)(A). 

27While this description applies to the approximately 93 percent of homes that receive 

either Medicare or both Medicare and Medicaid payments, states are responsible for 

enforcing standards in the 7 percent of homes that only receive Medicaid payments and 

may impose certain sanctions, such as state monitoring and DPNAs. Notice periods for 

most sanctions are required by CMS regulations. 

Page 13 GAO-07-241 Nursing Home Enforcement
if the appeal is successful, the severity of the sanction could be reduced or 

the sanction could be rescinded. Homes have several avenues of appeal, 

including informal dispute resolution at the state survey agency level or a 

hearing before an administrative law judge, as well as before the 

Department of Health and Human Services Departmental Appeals Board. 

Under CMS policy, homes automatically receive a 35 percent reduction in

the amount of a CMP if they waive their right to appeal before the 

Departmental Appeals Board.28

 28See 42 C.F.R. § 488.436. 

Page 14 GAO-07-241 Nursing Home Enforcement
Figure 1: Federal-State Responsibilities in the Enforcement Process 

Notes: States may impose lower-level sanctions, such as state monitoring, without federal approval. 

Some state survey agencies also have the ability to impose federal sanctions such as DPNAs.

Nursing homes are notified of their appeal rights when CMS imposes a sanction. 

In response to our earlier recommendations, CMS undertook a number of 

initiatives intended to strengthen enforcement, many of which we 

reported on in 2005.29 For example, CMS (1) revised its revisits policy by 

Source: GAO.

State survey agency responsible for action

Federal agency (CMS) responsible for action

Nursing home surveyed and deficiency cited.

Sanction proposed.

Deficiency/sanction reviewed and amended as needed.

Sanction imposed.

Follow-up visit to determine if deficiency is corrected.

If deficiency is not corrected,

the sanction is implemented.

If deficiency is corrected,

the sanction is rescinded.

If deficiency is not 

corrected within 

6 months, home 

terminated.

If deficiency is

corrected the 

sanction is

ended.

Follow-up visit to determine

if deficiency is corrected.

CMS Enforcement 

Initiatives 

 29See GAO, Nursing Homes: Despite Increased Oversight, Challenges Remain in

Ensuring High-Quality Care and Resident Safety, GAO-06-117 (Washington, D.C.:

Dec. 28, 2005). 

Page 15 GAO-07-241 Nursing Home Enforcement
requiring surveyors to return to nursing homes to verify that serious 

deficiencies had actually been corrected; (2) hired more staff to reduce the

backlog of appeals at the Health and Human Services Departmental 

Appeals Boards, the entity that adjudicates nursing home appeals of 

deficiency citations; (3) began annual assessments of state survey 

activities, known as state performance reviews, which cover, among other 

things, the timeliness of sanction referrals from state survey agencies to 

CMS regional offices; and (4) revised its past noncompliance policy for 

citing and reporting serious deficiencies that were missed by state 

surveyors during earlier surveys of a home. 

A key CMS enforcement initiative was the two-stage implementation of an

immediate sanctions policy. In the first stage, effective September 1998, 

CMS required states to refer for immediate sanction homes found to have 

a pattern of harming or exposing residents to actual harm or potential 

death or serious injury (H-level or higher deficiencies on the agency’s 

scope and severity grid) on successive surveys.30 Effective January 2000, 

CMS expanded the policy, requiring referral of homes found to have 

harmed one or a small number of residents (G-level deficiencies) on 

successive routine surveys or intervening complaint investigations.31 After 

expansion of the immediate sanctions policy to include G-level 

deficiencies, it became known as the double G immediate sanctions 

policy. 

CMS also took steps to improve its ability to manage and oversee the 

enforcement process. Our 1999 report described how CMS regions and 

states were using their own systems to track sanctions rather than CMS’s 

OSCAR database. Regional office systems ranged from manual, paperbased records to complex computer programs; none of the four states 

included in our 1999 report had tracking systems compatible with OSCAR 

or the regional office systems in use. Until it implemented a new 

 30Although the policy requires the immediate imposition of sanctions, CMS has not defined

a time standard for “immediate.” The policy only requires that homes with a pattern of 

harming residents be denied a grace period to correct deficiencies before the sanctions are 

imposed. Prior to the policy, homes were given a grace period in which they could correct 

deficiencies before sanctions were imposed. 

31CMS guidance also gives states and regional offices the option to rescind a home’s 

“opportunity to correct” based on (1) scope and severity of the deficiency, 

(2) unwillingness and inability of the facility to correct the deficiency, and (3) the

effectiveness of the facility’s quality assurance and monitoring system to prevent 

recurrence of the deficiency. 

Page 16 GAO-07-241 Nursing Home Enforcement
enforcement data collection system, CMS used LTC, an interim 

enforcement tracking system developed and first used by its Chicago 

regional office. LTC was operational in all 10 regions by January 2000. 

CMS’s enforcement data collection system—AEM—replaced LTC and was 

implemented 4 years later, on October 4, 2004. 

Recognizing the need to focus more attention on homes that historically 

provided poor care, CMS designed and launched a Special Focus Facility 

program in January 1999, instructing states to select 2 homes each for 

enhanced monitoring. Surveys were to be conducted at 6-month intervals

rather than annually. In September 2000, CMS reported that semiannual 

surveys had been conducted at a little more than half of the original 

110 facilities. In late 2004, CMS modified the program by (1) expanding its

scope to include more homes, (2) revising the selection criteria for homes, 

and (3) strengthening sanctions for homes that did not improve within 

18 months. In a relevant but unrelated initiative, CMS established a 

voluntary program to help nursing homes improve the quality of care 

provided to residents. In 2002, Medicare Quality Improvement 

Organizations (QIO) began working intensively on issues such as 

preventing pressure sores and pain management with 10 percent to 

15 percent of nursing homes in each state.32 Responding to concerns that 

QIOs were not working with homes that needed the most help, CMS 

established a separate pilot program in 2004; QIOs worked for 12 months 

with 1 to 5 nursing homes with significant quality problems in 18 states to 

help them redesign their clinical practices. Unlike the Special Focus 

Facility program, the participation of homes in the pilot was voluntary. To 

distinguish it from the Special Focus Facility program, the pilot was 

known as the Collaborative Focus Facility program. 

Among the homes we reviewed in four states, the number of implemented 

sanctions and serious deficiencies declined across two time periods—

fiscal years 2000 through 2002 and fiscal years 2003 through 2005. Federal

data show similar declines for homes nationwide, a trend consistent with 

the decline in the proportion of homes cited for serious deficiencies that 

Number of Sanctions 

Has Decreased 

 32Under contract with CMS, QIOs (formerly known as Peer Review Organizations) working

in all 50 states and the District of Columbia help to ensure the quality of care delivered to 

Medicare beneficiaries. Prior to 2002, QIOs’ work focused on care delivered in acute care

settings such as hospitals. 

Page 17 GAO-07-241 Nursing Home Enforcement
generally result in sanctions.33 Despite the decline in the number of serious 

deficiencies, the homes we reviewed generally were cited for more 

deficiencies that caused harm to residents than other homes in the four 

states. While the numbers of implemented CMPs and DPNAs at the homes 

we reviewed declined across the two time periods, the amount of CMPs 

paid increased. Not all imposed sanctions for these homes were 

implemented, however, which may reduce the deterrent effect of 

sanctions; in fact, we found that the implementation rate of certain 

sanctions, such as DPNAs, decreased. The deterrent effect of sanctions for 

the homes was further eroded because CMS generally imposed CMPs on 

the lower end of the allowable dollar range and did not exercise its 

authority to use discretionary DPNAs and terminations, allowing the 

homes more opportunities to escape sanctions prior to implementation. 

Among all nursing homes nationwide, sanctions declined across the two 

time periods—fiscal years 2000 through 2002 and fiscal years 2003 through 

2005.

34 Implemented terminations declined the most across the two time 

periods (about 41 percent) and CMPs declined the least (about 

12 percent), while the number of DPNAs declined by about 31 percent. In

the same time periods, the average number of serious deficiencies per 

home declined by about 33 percent nationwide, from about 0.8 to about 

0.5. These downward trends are also consistent with the nationwide 

decline in the proportion of homes with serious deficiencies—from about 

28 percent in fiscal year 2000 to about 17 percent in fiscal year 2005 (see 

app. II). While the reported decline in serious deficiencies and the 

proportion of homes cited for such deficiencies may be due to improved 

quality, our earlier reports noted similar declines that masked 

(1) understatement of serious quality problems, and (2) inconsistency in 

how states conduct surveys.35 For example, our current analysis found that 

the proportion of homes cited for serious deficiencies ranged from a low 

of about 4 percent in Florida to a high of about 44 percent in Connecticut

Sanctions Have Declined 

Nationwide 

 33While the reported decline in the proportion of homes with serious deficiencies could be 

due to improved quality, we have also documented the underreporting of serious

deficiencies. See GAO, Nursing Home Quality: Prevalence of Serious Problems, While 

Declining, Reinforces Importance of Enhanced Oversight, GAO-03-561 (Washington, D.C.: 

July 15, 2003) and GAO-06-117. 

34Although sanctions declined during the period we reviewed, they nearly doubled from

fiscal years 1999 to 2000. 

35See GAO/HEHS-98-202, GAO-03-561, or GAO-06-117. 

Page 18 GAO-07-241 Nursing Home Enforcement
during fiscal year 2005.

36 Across the four states we reviewed, the 

proportion of homes with serious deficiencies in fiscal year 2005 ranged 

from 8 percent in California to 23 percent in Michigan. As we previously 

reported, such disparities are more likely to reflect inconsistency in how 

states conduct surveys rather than actual differences in the quality of care 

provided by homes.37 In addition, in commenting on a draft of this report, 

CMS noted concerns about whether the immediate sanctions policy has 

had a negative effect on state citations of serious deficiencies. 

The number of implemented sanctions at the homes we reviewed as well 

as the number of serious deficiencies cited in these homes declined across 

two time periods—fiscal years 2000 through 2002 and fiscal years 2003

through 2005—consistent with nationwide trends. 

Deficiency trends. The average number of serious deficiencies per home 

we reviewed decreased from about 1.8 in fiscal years 2000 through 2002 to

about 0.7 in fiscal years 2003 through 2005, about a 61 percent decline; this 

decline was consistent with the national trend. During both time periods, 

however, the homes we reviewed generally performed more poorly than 

other homes in their states, having, on average, more G-level or higher 

deficiencies and more double Gs. For example, the Texas homes we 

reviewed had on average 1.3 times as many G-level or higher deficiencies 

as all other homes in the state and the California homes we reviewed had 

on average 3 times as many as all other California nursing homes.38

CMP trends. Due in part to the closure of some poorly performing homes

and the citation of fewer serious deficiencies, the homes we reviewed had

Decline in Sanctions and 

Deficiencies for the Homes 

Reviewed Is Consistent 

with Nationwide Trends 

 36This analysis excluded 13 states because fewer than 100 homes were surveyed, and even a 

small increase or decrease in the number of homes with serious deficiencies in such states 

may produce a relatively large percentage point change. 

37CMS acknowledges that there is inconsistency in how states conduct surveys and is trying 

to address this issue by piloting a revised survey methodology. In commenting on a draft of

this report, California noted that until late 2004 its CMS regional office required evidence of

permanent harm in order for a deficiency to be cited as actual harm. After California 

received new guidance on the definition of actual harm, we noted that the number of 

determinations of harm increased. 

38Despite the poor performance histories of some of the 63 homes, only 1 of these homes

was part of CMS’s original Special Focus Facilities program. In 2005, only 2 of the homes 

we reviewed were designated Special Focus Facilities and in 2006, only 4 were so 

designated. 

Page 19 GAO-07-241 Nursing Home Enforcement
fewer CMPs in fiscal years 2003 through 2005 than in the prior 3 fiscal 

years, but the amount paid was higher (see table 4). Among the homes, the 

number of implemented CMPs declined by about 42 percent from the first 

to the second time period. Although the number of CMPs among the 

homes we reviewed decreased, the amount of CMPs paid in Michigan 

more than doubled between the two time periods, accounting for much of 

the increase in the amount of CMPs paid across the two time periods (see 

app. III). States’ preferences for either state or federal CMPs may in part 

affect their use. In Michigan, state officials are more likely to use federal 

CMPs and implement them in greater amounts than other states we 

reviewed. In contrast, the homes we reviewed in Pennsylvania had only 

one implemented CMP and paid no federal CMPs from fiscal years 2003 

through 2005; however, during the same period, the Pennsylvania state

survey agency implemented seven state CMPs and collected $12,050.

39 A 

Pennsylvania state survey agency official said that the state prefers to use 

state sanctions because they can be implemented more quickly and are 

believed to be more effective than federal sanctions. The Texas state 

survey agency does not recommend more than one type of money penalty 

for the same deficiency and chooses among one of two state money 

penalties or a federal CMP.40

 39In addition to federal sanctions, states can impose state sanctions on noncompliant 

homes. The revenue from state CMPs accrues to the state but must be applied to the 

protection of the health or property of nursing home residents. 

40According to Texas officials, this money penalty policy took effect on September 1, 2003,

as a result of a state statutory change. Prior to the statutory change, the state survey agency

could recommend both a state money penalty as well as a federal CMP. 

Page 20 GAO-07-241 Nursing Home Enforcement
Table 4: Sanctions Implemented for Homes Reviewed, Fiscal Years 2000-2002 and 2003-2005 

 Fiscal years 2000-2002 Fiscal years 2003-2005 

Sanction Number

Duration/

amount paid Number

Duration/ 

amount paid 

Percentage change

in number between

two time periods

CMPa,b 93 $534,527 54 $617,552 -42%

DPNAc52 2,451days 30 1,245 days -42%

Involuntary termination 1 NA 1 NA 0%

Source: GAO analysis of LTC data, AEM, CMS regional office and state enforcement case files, and CMPTS. 

Note: Includes homes that were open for at least part of the 6-year period. 

NA = Not applicable. 

a

Includes per day and per instance CMPs. 

b

Amount paid for CMPs implemented in these fiscal years. 

c

Includes mandatory and discretionary DPNAs. 

DPNA trends. The number of DPNAs declined by 42 percent from fiscal 

years 2000 through 2002 to fiscal years 2003 through 2005 for the homes 

we reviewed. Overall, the duration of the DPNAs decreased by 12 percent

from the first to the second time period. The duration of DPNAs among the 

Texas homes we reviewed decreased the most—from an average of 

46 days in the first time period to an average of 26 days in the second time 

period. The duration of DPNAs among the Michigan and Pennsylvania 

homes also decreased (see app. III). In California, however, the DPNAs 

were in effect longer in the second time period—from an average of 

39 days in fiscal years 2000 through 2002 to an average of 63 days in fiscal

years 2003 through 2005. As a result, homes in California were out of 

compliance for longer periods of time. 

Termination trends. Only two of the homes we reviewed closed 

involuntarily—that is, they were terminated for cause by CMS because of 

health and safety issues. One of the two homes has since been certified to

participate in Medicare again.41 An additional nine other homes closed 

voluntarily, although four reopened at some point during fiscal years 2000 

 41This home is located in Texas, where the state issues a license to the person or entity 

operating the nursing home rather than the owner of the real property. The majority of 

nursing homes in Texas are operated out of leased property. When the home was

recertified, the new operator was licensed; there was no change in the owner of the real 

property. 

Page 21 GAO-07-241 Nursing Home Enforcement
through 2005.42 However, a home’s voluntary closure may not accurately

reflect the degree to which the home had quality problems, such as a 

history of harming residents, that put the home at risk of involuntary 

termination. The reasons for closure, as recorded by CMS, are general and 

do not always reflect that homes may have histories of harming residents 

and may have been at risk of involuntary termination. 

Implementation Rate of 

Some Sanctions Has 

Declined for the Homes 

Reviewed 

The implementation rate of DPNAs and terminations declined for the 

homes we reviewed, while the implementation rate of CMPs increased 

across three time periods (see fig. 2). Some sanctions are never

implemented because CMS rescinds them if homes correct deficiencies 

before the implementation date, a situation we noted in our 1999 report.43

Thus, sanctions may be considered more of a threat than a real 

consequence of noncompliance. 

We compared the implementation rates of CMPs, DPNAs, and 

terminations across three time periods: (1) July 1995 to October 1998, the 

time period covered in our March 1999 report;44 (2) fiscal years 2000 

through 2002; and (3) fiscal years 2003 through 2005. From the first time 

period to the third, the implementation rate for DPNAs declined by about 

20 percent and the implementation rate for terminations declined by about 

97 percent. In contrast, across the same time periods, the overall 

implementation rate for CMPs increased from 32 percent in the first time 

period to 86 percent in the third time period, an almost threefold increase. 

The timing of this increase coincides with the January 2000 

implementation of the immediate sanctions policy, suggesting that the

increase may in part be related to the policy’s implementation.

 42Although the homes were closed for some part of the period we reviewed, fiscal years

2000 through 2005, we determined that there were sufficient data to include the homes in 

our sample. 

43GAO/HEHS-99-46. 

44GAO/HEHS-99-46. 

Page 22 GAO-07-241 Nursing Home Enforcement
Figure 2: Percentage of Implemented Sanctions for Homes Reviewed Over Three 

Time Periods (July 1995-October 1998, Fiscal Years 2000-2002, and Fiscal Years 

2003-2005) 

0

20

40

60

80

100

Terminations

DPNAs

CMPs

FY 2003–

2005

FY 2000–

2002

July 1995–

Oct. 1998

Percentage

Survey period

Source: GAO analysis of LTC, OSCAR, and CMS regional office and state enforcement case files.

CMS Did Not Take 

Advantage of the Full 

Range of Sanctions for the 

Homes Reviewed 

Among the homes we reviewed, CMS did not use the full range of its 

sanctions authority, generally imposing CMPs on the lower end of the 

allowable range.45 In addition, CMS imposes DPNAs and involuntary 

terminations when they are mandatory, but generally not when they are 

discretionary. Homes subject to such mandatory sanctions have more 

opportunities to escape sanctions prior to implementation. The median 

per instance CMP implemented was $2,000 in fiscal years 2000 through 

2002 and $1,750 in fiscal years 2003 through 2005, although the maximum 

per instance CMP can be as high as $10,000. The median per day CMP 

 45As previously described, the allowable range for a per day CMP is $50 to $10,000 for each 

day a home is noncompliant, and the allowable range for a per instance CMP is $1,000 to

$10,000 for each episode of noncompliance. 

Page 23 GAO-07-241 Nursing Home Enforcement
implemented for nonimmediate jeopardy deficiencies was $500 in fiscal 

years 2000 through 2002 and $350 in fiscal years 2003 through 2005, 

significantly below the maximum of $3,000 per day. In cases in which 

homes were cited for immediate jeopardy and the maximum potential per 

day CMP is $10,000, the median per day CMP implemented was $3,050 in

fiscal years 2000 through 2002 and $5,050 in fiscal years 2003 through 2005. 

According to one CMS official, the agency generally hesitates to impose 

CMPs that are higher than $200 per day, in part because of concerns that 

higher per day CMPs could bankrupt some homes.46 But the same official 

noted that the CMPs being imposed are not enough to “make nursing 

homes take notice” or to deter them from deficient practices. Another 

CMS official stated that some homes consider CMPs a part of the “cost of 

doing business” or as having no more effect than a “slap on the wrist.” 

Table 5 provides examples of homes we reviewed with implemented CMPs 

that were at the low end of the allowable CMP range. 

Table 5: Examples of Homes with Low Implemented CMPs 

Home’s 

location Surveyors’ comments 

Summary of 

deficiencies CMP implemented Allowable CMP range

Michigan “A significant medication error occurred when 

resident #8 was administered [the wrong 

medication] over a three day period. The 

resident experienced hypoglycemia and 

required hospitalization. Upon return from the 

hospital there was evidence of actual harm: a 

decline in ability to perform activities of daily 

living.” 

1 G $1,500 per instance $1,000 - $10,000 per 

instance of 

noncompliance

Texas “Facility nurse aides failed to promptly report

an allegation of possible sexual abuse. 

Resident reported the incident to two nurse 

aides, however, it was not reported. Also, 

reference checks were not documented for 4 

employees and 4 employees had not attended

an inservice [training session] on abuse.” 

3 F, 1 E $250 per day for 150 

days 

$50 - $3,000 per day 

for noncompliance 

other than immediate 

jeopardy 

 46An official in one state told us that a home’s financial status should not be considered

when assessing CMPs because it could result in inconsistent CMPs for similar quality 

problems.

Page 24 GAO-07-241 Nursing Home Enforcement
Home’s 

location Surveyors’ comments 

Summary of 

deficiencies CMP implemented Allowable CMP range

Texas “There was an [immediate jeopardy deficiency

for staff mistreatment of residents]. There was 

a failure to monitor residents in distress.” 

1 L (immediate

jeopardy), 9 G

Immediate jeopardy: 

$3,050 per day for 

14 days 

After immediate 

jeopardy removed: 

$400 per day for 

86 days; $300 per day 

for 46 days; $50 per 

day for 6 days

$3,050 - $10,000 per 

day for immediate 

jeopardy 

$50 - $3,000 per day 

for nonimmediate 

jeopardy 

Source: GAO analysis of CMS regional office and state case files and LTC.

Note: In addition to CMPs, CMS also imposed DPNAs and terminations—either mandatory or 

discretionary. All of the DPNAs but none of the terminations were implemented. 

CMS is likely to impose DPNAs and terminations only when required to do

so. However, CMS also has broad authority to impose DPNAs and 

terminations at its discretion, which can facilitate quicker implementation. 

Discretionary DPNAs and terminations can be implemented any time after

a survey if the sanction is appropriate for the cited deficiencies and the 

required notice period is met. In contrast, the soonest that mandatory 

DPNAs and terminations for nonimmediate jeopardy can be implemented 

is 3 and 6 months, respectively, after the survey on which the deficiencies

were cited.47 Despite the greater expediency of discretionary DPNAs, 

64 percent of the DPNAs CMS imposed were mandatory for fiscal years 

2000 through 2005 for the homes we reviewed. For example, CMS imposed 

a total of six DPNAs during fiscal years 2000 through 2003 on a 

Pennsylvania home with demonstrated compliance problems. Of those six 

DPNAs, the first five were mandatory DPNAs. Only the last DPNA—

imposed after multiple years of repeated noncompliance at the G-level or

higher—was a discretionary DPNA. 

Moreover, CMS imposed significantly more mandatory terminations than 

discretionary terminations; in fiscal years 2000 through 2005, 118

mandatory and 5 discretionary terminations were imposed on the homes 

we reviewed.48 None of the mandatory terminations were implemented, 

but 2 discretionary terminations were implemented—one each in Michigan 

 47By regulation, where no immediate jeopardy is found, CMS must provide homes with 

15 days’ notice before implementing any DPNA or termination. In cases of immediate 

jeopardy, however, the notice period is 2 days. 

48This analysis excludes Texas nursing homes because the data did not always allow us to 

distinguish between mandatory and discretionary terminations in Texas.

Page 25 GAO-07-241 Nursing Home Enforcement
and Texas.49 An official from the Texas state survey agency said that the 

CMS regional office in Dallas prefers to impose mandatory terminations, 

unless there is cause to believe there will be no improvements in the care 

provided by the nursing home. Mandatory terminations give homes 

6 months to correct deficiencies before being implemented, as opposed to

discretionary terminations, which can be implemented more quickly. 

Even when CMS imposes terminations, their deterrent effect is weakened

because the agency sometimes extends the termination dates. For 

example, CMS extended the discretionary termination dates for up to 

6 months for some of the Texas homes we reviewed if the nursing homes 

had lower-level deficiencies on subsequent surveys. The termination date

imposed on one Texas nursing home we reviewed was extended three 

times in fiscal year 2001 from the original date of April 18 to June 26, then 

to July 26, and finally to September 26. The first extension occurred 

because the home corrected the deficiencies that caused immediate 

jeopardy cited during the first survey. Therefore, despite the fact that this

home continued to be found out of compliance for deficiencies such as 

mistreatment or neglect of residents during subsequent surveys, CMS 

extended the termination date twice to give the home an additional 

opportunity to correct those deficiencies and achieve substantial 

compliance. The termination ultimately was rescinded because the home 

corrected the deficiencies, but the home was subsequently cited for eight 

G-level deficiencies such as inadequate treatment or prevention of 

pressure sores, employing convicted abusers, and poor accident 

supervision or prevention. In 2004, the home closed voluntarily. 

Despite changes in federal enforcement policy, almost half of the homes 

we reviewed—homes with prior serious quality problems—continued to 

cycle in and out of compliance, continuing to harm residents. These homes 

corrected deficiencies only temporarily and, despite having sanctions 

implemented, were again found to be out of compliance during subsequent 

surveys. Our analysis also showed that in some cases the double Gs did 

not result in immediate sanctions as required, even though about 

40 percent of the homes were cited for double Gs during fiscal years 2000 

through 2005. In addition, the term “immediate sanctions policy” is 

misleading because the policy requires only that sanctions be imposed, 

that is, that homes be notified immediately of CMS’s intent to implement 

Despite Changes in 

Federal Enforcement 

Policy, Many Homes 

Continued to Cycle In 

and Out of 

Compliance 

 49Our case file review found that one discretionary termination was implemented in Texas.

Page 26 GAO-07-241 Nursing Home Enforcement
sanctions, not that sanctions must be implemented immediately. 

Furthermore, when a sanction is implemented for a double G citation, 

there is a lag time between when the double G occurs and the sanction’s 

effective date. CMS cited double Gs multiple times at several of the homes 

we reviewed, suggesting that immediate sanctions did not deter future 

noncompliance as intended. Terminations of homes is infrequent, in part 

because of concerns such as local access to other nursing facilities and the 

effect on residents if they are moved, and in part because CMS allows 

some problem homes to continue operating until the homes eventually

close voluntarily. 

Many Homes Cycled In 

and Out of Compliance, 

Continuing to Harm 

Residents 

Consistent with our earlier work, our current analysis showed that 

sanctions appear to have induced homes to correct deficiencies only 

temporarily because surveyors found that many of the homes we reviewed 

with implemented sanctions were again out of compliance on subsequent 

surveys.50 Commenting on this phenomenon, state survey agency officials 

said that improvements resulting from sanctions might last about 

6 months. From fiscal years 2000 through 2005, 31 of the 63 homes we 

reviewed (about 49 percent) cycled in and out of compliance more than 

once, harming residents, even after sanctions had been implemented, 

including 8 homes that did so seven times or more (see fig. 3). 

 50GAO/HEHS-99-46. 

Page 27 GAO-07-241 Nursing Home Enforcement
Figure 3: Frequency that Reviewed Homes Cycled In and Out of Compliance, Fiscal 

Years 2000-2005 

Source: GAO analysis of LTC, OSCAR, and CMS regional office and state enforcement case files.

Number of homes

Cycle in and out of compliance (the yo-yo pattern)

Period of noncompliance

A home is considered out of compliance if surveyors cite D-level or higher 

deficiencies on a survey. A home is deemed back in substantial compliance when 

it corrects deficiencies and is considered in substantial compliance until the next 

survey on which surveyors cite D-level or higher deficiencies. 

3 Homes cycled 

eight times

Frequency that homes cycled in and out of compliance:

Number of times cycled: 2 3 4 5 6 7 8 More than 8

Number of homes: 9 3 8 3 0 2 3 3

Time

3

Number of homes

In compliance

 Out of compliance

10/1999 9/2005

Note: This figure illustrates the concept of a yo-yo pattern of compliance. While the time periods that 

a home is in or out of compliance appear to be of uniform duration, the duration can vary. 

Each of the 31 homes that cycled in and out of compliance more than once 

during the period we reviewed had at least one G-level or higher 

deficiency in at least one period of noncompliance; 19 had at least one 

G-level or higher deficiency in every noncompliance period. Table 6 shows 

the number and length of noncompliance periods for a Michigan home we 

reviewed that cycled in and out of compliance nine times from fiscal years 

2000 through 2005; the home remained open as of November 2006. 

Appendix IV provides similar examples for homes in California, 

Pennsylvania, and Texas. Homes’ correction of deficiencies often was 

temporary, despite receiving sanctions. Thus, once the homes we reviewed

corrected deficiencies, they maintained compliance for a median of 

133 days and then cycled out of compliance again. Some homes cycled out 

Page 28 GAO-07-241 Nursing Home Enforcement
of compliance more quickly—homes were again out of compliance in 

30 days or less about 8 percent of the time and within 60 days about 

28 percent of the time. 

Table 6: Example of a Michigan Nursing Home That Frequently Cycled In and Out of Compliance and Was Still Open as of

November 2006 

Noncompliance

period in fiscal 

years 2000-2005 

(no. of days) Examples of the nature of deficienciesa

Summary of G-level 

or higher

deficiencies Enforcement action implementedb

1st (41 days) • Inadequate treatment or prevention of 

pressure sores

• Poor quality of care 

1 G • Per instance CMP ($1,000) 

2nd (185 days) • Poor nutrition 

• Poor quality of care 

1 G • 1st per day CMP ($10,000/day) 

• 2nd per day CMP ($100/day) 

• Per instance CMP ($1,500) 

• Mandatory DPNA (109 days)

3rd (176 days) • Inadequate treatment or prevention of 

pressure sores

• Poor accident supervision or prevention 

5 G • Per instance CMP ($10,000) 

• Mandatory DPNA (85 days) 

4th (158 days) • Resident abuse 

• Employing convicted abusers

1 J (immediate

jeopardy), 3 G

• 1st per day CMP ($850/day) 

• 2nd per day CMP ($3,500/day)

• 3rd per day CMP ($1,000/day)

• Discretionary DPNA (127 days) 

5th (107 days) • Resident abuse 

• Failure to provide necessary services for 

daily living

3 H, 3 G • Per day CMP ($200/day) 

• Discretionary DPNA (74 days) 

6th (94 days) • Poor accident supervision or prevention 1 G • Per day CMP ($350/day) 

• Discretionary DPNA (62 days) 

7th (127 days) • Failure to provide necessary services for 

daily living

• Poor accident supervision or prevention 

1 J (immediate

jeopardy), 1 G

• 1st per day CMP ($3,550/day)

• 2nd per day CMP ($450/day) 

• Mandatory DPNA (35 days) 

8th (89 days) • Inadequate treatment or prevention of 

pressure sores

• Employing convicted abusers

• Medication errors 

2 G • Per day CMP ($500/day) 

• Discretionary DPNA (59 days) 

9th (83 days) • Inadequate treatment or prevention of 

pressure sores

• Medication errors 

1 H • Per day CMP ($750/day) 

• Discretionary DPNA (51 days) 

Source: GAO analysis of OSCAR, ETS, and AEM data. 

Note: The table only includes federal sanctions imposed and implemented; sanctions imposed but not 

implemented and state sanctions are not included.

a

Examples of the nature of deficiencies include D-level or higher deficiencies. 

Page 29 GAO-07-241 Nursing Home Enforcement
b

In a number of cases, more than one per day CMP is listed because CMS can raise or lower per day 

CMP amounts based on changes in deficiencies. 

Relatively Few Homes 

Reviewed Were Cited for 

Double Gs 

Despite the large number of G-level or higher deficiencies cited for the 

homes we reviewed, relatively few of these homes were cited for double 

Gs, and some double G citations did not result in sanctions. Over the 

6-year period, 27 of the homes we reviewed had 69 double Gs. However, 

47 of the homes had 444 G-level or higher deficiencies. We found no 

record that CMS imposed a sanction for 15 of the 69 double Gs, but the 

data did show that CMS implemented sanctions for the remaining double 

G cases.51

Across the four states we reviewed, there was variation in the citation of 

G-level or higher deficiencies and the implementation of immediate 

sanctions. For example, from fiscal years 2000 through 2005, 35 percent of

G-level or higher deficiencies and 52 percent of double Gs among the 

homes we reviewed were cited in Michigan, while 9 percent of the G-level 

or higher deficiencies and 4 percent of the double Gs were cited in homes 

in California. In California, complaints typically are investigated under 

state licensure authority and the findings generally are not recorded in the 

same manner as deficiencies cited under the federal process,52 which may 

contribute to lower double G citation rates in the state.53 Thus, California 

homes are not cited for a double G when the subsequent deficiency 

equivalent to a G-level or higher deficiency was found during a complaint 

 51In July 2003, we reported that from January 2000 through March 2002, states did not refer 

a substantial number of nursing homes with a pattern of harming residents to CMS for 

immediate sanctions. See GAO-03-561. Eight of the 15 cases occurred after March 2002. 

From fiscal years 2000 through 2005, 40 CMPs and 25 DPNAs were implemented during

periods of noncompliance in which there was a double G. 

52California records findings from complaints investigated under state licensure in a 

separate and dedicated state-licensure component of the federal system for tracking 

complaints. The state complaints are recorded using the state system for classifying 

violations. According to the state, complaints investigated under state licensure are

recorded separately because state law prohibits the issuance of both a state citation, which

carries with it a mandatory state civil monetary penalty, and the recommendation that a

federal CMP be imposed. 

53If, during a complaint investigation, state surveyors identify deficiencies that would be

equivalent to immediate jeopardy or substandard quality of care, the surveyors 

automatically complete the investigation under the federal enforcement process.

Page 30 GAO-07-241 Nursing Home Enforcement
investigation.54 Complaint surveys with G-level or higher deficiencies often 

lead to double Gs. One CMS official stated that if complaints against 

California nursing homes were investigated under the federal complaint 

investigation procedure, more double Gs would be cited in California.55

The California Department of Health Services conducted a pilot to test the 

use of the federal complaint procedure in select district offices, in part 

because of the low double G citation rate. As of November 2006, the 

department decided not to expand or complete a formal evaluation of the 

pilot; instead, the department is focusing on eliminating its backlog of 

complaints and initiating complaint investigations within required time 

frames.56

Immediate Sanctions Often 

Not Immediate and Do Not 

Appear to Deter 

Noncompliance 

Although referred to as the “immediate sanctions” policy, the term is 

misleading because (1) there is a lag between when the double G is cited 

and when the sanction is implemented, negating the sanction’s immediacy; 

(2) the policy only requires that sanctions be imposed immediately, which

does not guarantee that the sanction will be implemented; and (3) homes 

may not actually pay a CMP, the most frequently implemented sanction, 

until years after citation of the double G because payment is suspended 

until after appeals have been adjudicated. Delays in implementing DPNAs 

and in collecting CMPs—which diminish their immediacy—coupled with 

their nominal amounts may undermine their deterrent effect. 

 54The violations and resulting sanctions are categorized according to the state’s 

classification framework. For example, a class AA violation is one that, among other things, 

is a “direct proximate cause of death of a patient or resident,” and the resulting sanction is

a fine from $25,000 to $100,000. The state system for classifying violations and sanctions 

does not directly correlate to the federal scope and severity grid, and there is no direct 

equivalent to a G-level deficiency. According to a California state survey agency official, a

class A violation is approximately equivalent to a G-level deficiency, but there may be 

instances in which other classes of violations are also equivalent to a G-level deficiency. 

55Although California homes with histories of harming residents may not be cited for

double Gs and thus referred for immediate sanctions under federal requirements, the state 

has it own policy for encouraging such homes to improve quality of care—the state can 

triple CMPs for violations that are repeated in a 12-month period. An assessment of the 

effectiveness of California’s approach under state licensure for sanctioning homes with

repeat violations was beyond the scope of this report. 

56The select district offices that participated in the pilot will continue to cite federal 

deficiencies and impose federal sanctions; in the uncommon situation where there is a 

violation of a state regulation but not a federal regulation, the offices will use a state 

sanction. According to comments from California, if complaint investigations find harm to

residents, all district offices are directed to complete the investigations under state 

licensure authority or the federal complaint procedure, depending on multiple variables. 

Page 31 GAO-07-241 Nursing Home Enforcement
Immediate sanctions often are not immediate because there is a lag time

between the identification of deficiencies during the survey and when a 

sanction (i.e., a CMP or DPNA) is actually implemented.57 CMS 

implemented about 68 percent of the DPNAs for double Gs among the 

homes we reviewed during fiscal years 2000 through 2005 more than 

30 days after the survey (see app. V). In contrast, CMPs can go into effect

as early as the first day the home was out of compliance, even if that date

is prior to the survey date, because, unlike DPNAs, CMPs do not require a 

notice period.

58 About 98 percent of CMPs imposed for double Gs took 

effect on or before the survey date. Figure 4 illustrates the lag time that 

can occur between the survey date and the implementation date of the

sanction, especially with regard to DPNAs. For example, in fiscal years 

2000 through 2005, 60 percent of the DPNAs in the homes we reviewed 

were implemented 31 to 60 days from the date of the survey citing 

deficiencies. In contrast, nearly all CMPs were implemented on or before

the survey date. 

 57We excluded terminations from this analysis because terminations rarely are 

implemented. 

58When the CMP goes into effect, the fine starts accruing as of that date. 

Page 32 GAO-07-241 Nursing Home Enforcement
Figure 4: Number of Days between Survey and Implementation of CMPs and DPNAs 

among Homes Reviewed, Fiscal Years 2000-2005 

Percentage

Number of days

Source: GAO analysis of LTC, OSCAR, and CMS regional office and state enforcement case files.

0

20

40

60

80

100

DPNAs

CMPs

< 0 days 1–15 days 16–30 days 31–60 days 61–90 days > 90 days

Note: CMPs can take effect prior to the date of the survey, if the date of noncompliance can be 

established. In cases where an appeal has changed the determination of the date of noncompliance,

the implementation date of CMPs would be modified accordingly. Some CMPs and DPNAs were not 

included in this analysis because implementation dates were not available. 

While the immediate sanctions policy requires that sanctions be imposed 

immediately, it is silent on how quickly sanctions should be implemented. 

A sanction is considered imposed when a home is notified of CMS’s intent 

to implement a sanction—15 days from the date of the notice. If during the 

15-day notice period the nursing home corrects the deficiencies, no 

sanction is implemented. Thus, even under the immediate sanctions 

policy, which is intended to eliminate grace periods for nursing homes 

repeatedly cited for deficiencies at the actual harm level or higher, nursing 

homes have a de facto grace period. 

While CMPs can be implemented closer to the date of survey than DPNAs, 

the immediacy and the effect of CMPs may be diminished by (1) the 

significant time that can pass between the citation of deficiencies on a 

survey and the home’s payment of the CMP and (2) the low amounts 

Page 33 GAO-07-241 Nursing Home Enforcement
imposed, as described earlier in this report.59 By statute, payment of CMPs 

is delayed until appeals are exhausted.60 For example, a Michigan home did 

not pay its CMP of $21,600 until more than 2 years after a February 2003 

survey had cited a G-level deficiency.61 (See fig. 5.) The February G-level 

citation was a repeat deficiency: less than a month earlier, the home had 

received another G-level deficiency in the same quality of care area. The 

delay in collecting the fine in this case is consistent with a 2005 report 

from the Office of Inspector General of the Department of Health and 

Human Services that found that the collection of CMPs in appealed cases 

takes an average of 420 days—a 110 percent increase in time over 

nonappealed cases—and “consequently, nursing homes are insulated from 

the repercussions of enforcement by well over a year.”62

Unlike the Social Security Act, the federal Surface Mining Control and 

Reclamation Act of 1977 provides for the collection of CMPs prior to 

exhaustion of administrative appeals.63 Under this statute, mining 

operators charged with civil money penalties have 30 days to either pay

the penalty in full or forward the proposed amount for placement in an 

escrow account pending resolution of appeals. This provision, requiring 

escrow deposit of a proposed penalty assessment, has been upheld by 

three federal circuit courts of appeal, all citing the various procedural 

safeguards as helping to ensure sufficient due process to affected 

operators.64 For example, these courts cited the availability of an informal 

conference at which mining operators may present information relevant to

an assessment of a penalty. It is unclear whether the informal dispute 

resolution process available to nursing homes would provide due process

similar to that provided under the Federal Mining statute. Nonetheless, the 

 59As noted, unlike CMPs, payment denial for DPNAs is required upon implementation, not 

after appeal. 

60See 42 U.S.C. §§ 1395i-3(h)(2)(B)(ii), 1396r(h)(3)(C)(ii), and 1320a-7a. 

61In contrast, Pennsylvania nursing homes pay state CMPs upon implementation, even if an

appeal is pending. However, the state agency may grant exceptions to this requirement for 

good cause. 

62See Department of Health and Human Services, Office of Inspector General, Nursing 

Home Enforcement: The Use of Civil Money Penalties, OEI-06-02-00720 (April 2005). 

63See the federal Surface Mining Control and Reclamation Act of 1977, Pub. L. No. 95-87, §

518, 91 Stat. 499 (1977) (classified to 30 U.S.C. § 1268, as amended). 

64B & M Coal v. Office of Surface Min. Reclamation, 699 F. 2d 381 (7th Cir. 1983); Graham

v. Office of Surface Min. Reclamation, 722 F. 2d 1106 (3rd Cir. 1983); Blackhawk Mining

Co., Inc. v. Andrus, 756 F. 2d. 755 (6th Cir. 1983). 

Page 34 GAO-07-241 Nursing Home Enforcement
Social Security Act would preclude a more expeditious collection of 

nursing home CMPs. 

Figure 5: Lag Time between Survey and CMP Payment for a Michigan Nursing Home 

Source: GAO analysis of LTC, CMPTS, and CMS regional office and state enforcement case files.

Feb. 

2003

May

2005

Day: 1 47 58 783 811

State cites deficiency

State proposes sanction

 CMS imposes sanction

 Home appeals

 Home corrects deficiency

 Settlement

 Home pays CMP

$

< < < < < < < < < < < < < < < < < < < < < < Lag time > > > > > > > > > > > > > > > > > > >

Despite the potentially negative consequences, CMS’s implementation of 

the immediate sanctions policy does not appear to deter homes from 

harming residents in the future. Two-thirds (18) of the 27 nursing homes 

cited for double Gs that subsequently had sanctions implemented went on 

to be cited again for one or more additional double Gs. (See fig. 6.) 

Page 35 GAO-07-241 Nursing Home Enforcement
Figure 6: Number of Homes with One or More Double Gs, Fiscal Years 2000-2005 

0

2

4

6

8

10

1 2 3 4 5 6 

Number of homes

Source: GAO analysis of CMS PDQ.

Number of double Gs

Termination Used 

Infrequently 

Nursing homes, even those that repeatedly harm residents, are 

infrequently terminated because of CMS’s concerns about access to other 

sources of nursing care and the impact of moving residents. Of the homes 

we reviewed, two were terminated involuntarily for cause. Another nine 

homes closed voluntarily,

65 which is not a sanction because the homes 

chose to close. However, the actual reason for closure is not always clear; 

a home may close to avoid involuntary termination because of quality 

problems cited by state surveyors.66 Allowing a problem home to close 

voluntarily rather than terminating it may result in continuing harm to 

residents until the home decides to close. For example, two homes we 

 65CMS classifies the reasons for voluntary closure as “merger/closure;” “dissatisfaction with 

reimbursement;” “risk of involuntary termination;” and “other reasons for withdrawal.” 

66In commenting on a draft of this report, CMS noted that some of the homes classified as

voluntary terminations closed as a result of coordinated CMS and state actions. In its 

comments, Michigan stated that some voluntary terminations were the result of business 

decisions after the homes received survey results that warranted serious sanctions. 

Page 36 GAO-07-241 Nursing Home Enforcement
reviewed in Pennsylvania and Texas closed voluntarily, but the histories of 

both homes show that they were repeatedly cited for harming residents 

from fiscal year 2000 through the time of their closures, over 4 years later 

in January 2004. The Pennsylvania home cycled in and out of compliance 

4 times during the period we reviewed and had noncompliance periods 

lasting an average of 170 days. The Texas home cycled in and out of 

compliance 10 times during the period reviewed and had average 

noncompliance periods of 46 days. On average, both homes had about 6 

G-level or higher deficiencies per year in areas such as inadequate 

treatment or prevention of pressure sores and resident abuse.

67 The home 

in Pennsylvania had an average of 31 other deficiencies per year and the 

Texas home had an average of 27.

68

Four homes we reviewed had similar deficiency histories. Two closed 

voluntarily and two remained open as of November 2006 (see table 7). 

Although the homes that remained open met the deadline to correct 

deficiencies before the termination would have been implemented, a 

home’s ability to correct deficiencies in a specified period of time may not 

be the strongest criteria upon which to determine whether a home should 

remain open, because correcting deficiencies does not ensure that the 

home will improve residents’ quality of care and does not prevent the 

home from again falling out of compliance. For example, the California 

and Michigan homes in table 7 were still operating as of November 2006 

but cycled in and out of compliance four and seven times, respectively. 

 67Nationwide, the average number of serious deficiencies per home from fiscal years 2000 

through 2005 was less than one. 

68This analysis includes cited deficiencies at the D, E, or F levels of scope and severity. We 

include these deficiencies because, as we previously reported, understatement by state 

surveyors of serious deficiencies that cause actual harm or immediate jeopardy to

residents remains a concern. See GAO-06-117. 

Page 37 GAO-07-241 Nursing Home Enforcement
Table 7: Examples of Homes’ Deficiency Histories and Termination Actions, Fiscal Years 2000-2005 

Examples of deficiencies causing

harm to residentsa

Deficiency history Enforcement historybCurrent status

California homec

• A resident choked to death when 

the suction machines that should 

have been maintained in working 

order did not have the requisite 

parts. Indeed, during an 

unannounced inspection 2 days 

following the death of this 

resident, it was noted that there 

were no functional suction 

machines in the facility. 

• 173 D-level or higher 

deficiencies 

• Cycled in and out of 

compliance 4 times 

• DPNA (142 days) 

• CMP ($193,780) 

• Mandatory termination 

imposed (4 times) 

• Discretionary termination 

imposed (0 times) 

In operation as of November 2006. 

Michigan home 

• The facility failed to provide 

proper respiratory treatment and 

care for a resident, resulting in the 

resident’s hospitalization for acute 

respiratory failure. 

• During an inspection, several 

residents’ pressure sores were 

observed to be untreated. For

example, one resident had two 

areas of dead tissue on his feet. 

The facility acknowledged that the 

resident should have been 

wearing protective heel pads 

when in bed, and yet his bare feet 

were uncovered, both heels 

rested directly on the mattress, 

and he was not wearing heel 

protectors, which were lying 

nearby. 

• 95 D-level or higher 

deficiencies 

• Cycled in and out of 

compliance 7 times 

• DPNA (58 days) 

• CMP ($40,970)

• Mandatory termination 

imposed (7 times) 

• Discretionary termination 

imposed (0 times) 

In operation as of November 2006. 

Pennsylvania home 

• “Resident eloped and was found 

on the courtyard froze (sic) to 

death.” 

• “A resident was found to have 

bruises on the inner thighs and 

arms and appeared to be a victim 

of abuse. The staff did not report 

this to the local police and bathed 

resident prior to assessment for 

sexual abuse.” 

• 159 D-level or higher 

deficiencies, fiscal 

years 2000-2004 

• Cycled in and out of 

compliance 4 times 

• DPNA (229 days) 

• CMPs ($47,700) 

• Mandatory termination 

imposed (6 times) 

• Discretionary termination 

imposed (0 times) 

Closed January 2004. 

Reason for closure: voluntarymerger/closure.

Page 38 GAO-07-241 Nursing Home Enforcement
Examples of deficiencies causing

harm to residentsa

Deficiency history Enforcement historybCurrent status

Texas home 

• “Conditions remain poor, 

residents are not clean or 

groomed, drug errors continue, 

restorative care is poor. Will give 

facility the full 6 months to try to 

come into compliance, continue 

all remedies.” 

• 141 D-level or higher 

deficiencies, fiscal 

years 2000-2004 

• Cycled in and out of 

compliance 10 times 

• DPNA (228 days) 

• CMPs ($146,244) 

• Mandatory or discretionary 

termination imposed 

(10 times)d

Closed January 2004. 

Reason for closure: voluntarymerger/closure.

Source: GAO analysis of LTC, OSCAR, CMPTS, and CMS regional office and state enforcement files. 

a

Statements are from surveyors’ notes and are either paraphrased or direct quotes. 

b

The CMP amount reflects the amount payable by the home, but is not necessarily the amount the 

home actually paid. 

c

These data likely understate the quality problems at this home because California primarily conducts

complaint investigations under its state licensure authority and did not record serious deficiencies

identified during such investigations in OSCAR. In commenting on a draft of this report, California 

noted that this home did receive the highest state deficiency citation and was assessed a state CMP 

of $60,000. 

d

Because the Texas data did not always allow us to distinguish between mandatory and discretionary 

terminations, we report the total number of imposed terminations. 

According to CMS and state officials, factors that may prevent or delay 

termination of problem nursing homes include (1) concerns regarding lack

of access to alternate local nursing facilities, (2) the potential for resident 

trauma as a result of transfer to another home, (3) the preference of 

residents’ families for homes located close by, and (4) pressure to keep 

homes open from families and other stakeholders.

69 Our analysis of 

alternatives to the 4 poorly performing homes in table 7—those that closed

voluntarily or are still open—showed that there were from 2 to 37 homes 

within 10 miles of these homes, and from 5 to 120 homes within 25 miles.70

 69In commenting on a draft of this report, Michigan noted that relocation is especially 

challenging in rural areas or for residents with special care needs. 

70For this analysis we used CMS’s Nursing Home Compare Web site 

(www.medicare.gov/NHCompare), which permits users to search for nursing homes by

proximity to specific zip codes. We did not analyze the number or availability of beds in the

homes. There may have been some changes in the number of nursing homes near the two 

homes that closed voluntarily in January 2004 because of the time difference between 

when these homes closed and the date we conducted our analysis (June 2006). 

Page 39 GAO-07-241 Nursing Home Enforcement
While the goal of enforcement is to help ensure nursing home compliance 

with federal quality requirements, CMS management of the process is 

hampered by the complexity of its immediate sanctions policy and by its

fragmented and incomplete data systems. The agency’s immediate 

sanctions policy, intended to deter repeat noncompliance, fails to hold 

some homes accountable for repeatedly harming residents. In addition, 

although CMS has developed a new data system, the system’s components 

are not integrated and the national reporting capabilities are not complete, 

hampering the agency’s ability to track and monitor enforcement. Finally, 

CMS has taken some steps intended to improve enforcement of nursing 

home quality requirements, such as developing guidance to help ensure 

greater consistency across states in CMP amounts, revising its Special 

Focus Facility program, and commissioning two studies to examine the 

effectiveness of nursing home enforcement. It is not clear, however, the 

extent to which—or when—these initiatives will address the enforcement 

weaknesses we found. 

The double G immediate sanctions policy is complex and fails to hold 

some homes accountable. In 2003, we reported that the early 

implementation of the policy was flawed.71 We found that between January 

2000 and March 2002 over 700 cases that should have been referred for 

immediate sanctions were not because (1) the policy was misunderstood 

by some states and regional offices, (2) states lacked adequate systems for 

identifying deficiencies that triggered an immediate sanction, and 

(3) actions of two of the four states were at variance with CMS policy. 

CMS developed an on-line reporting tool for use by survey agency and 

regional office staff to automate the identification of double Gs.72 CMS also 

offered training sessions and issued additional guidance to state survey 

agencies and regional offices. While the on-line reporting tool and training

were useful, they did not address the underlying complexity of the policy. 

For example, CMS staff told us that in developing the tool they had 

initially misinterpreted the double G immediate sanctions policy. As a 

result, the tool produced many false positives: that is, it identified 

deficiencies as triggering an immediate sanction that in fact did not occur. 

Moreover, a December 2005 report by the Office of the Inspector General

of the Department of Health and Human Services also reported that state 

Complex Immediate 

Sanctions Policy and 

Data Limitations 

Hamper CMS 

Management of 

Enforcement 

Immediate Sanctions 

Policy Is Complex and 

Fails to Hold Some Homes 

Accountable 

 71GAO-03-561. 

72The on-line reporting tool known as Providing Data Quickly (PDQ) is available through a 

Web site for use only by CMS and state survey agency employees. 

Page 40 GAO-07-241 Nursing Home Enforcement
survey agency staff continued to have difficulty identifying double G 

cases.73

Furthermore, our analysis of CMS’s application of the policy to the homes 

we reviewed demonstrated that the policy’s complex rules allowed homes 

to escape immediate sanctions even if they repeatedly harmed residents; 

these rules include (1) the requirement for an intervening period of 

compliance, (2) the clearing effect of standard surveys, and (3) the lack of

differentiation between single and multiple instances of harm. Such rules 

may in part explain why the homes we reviewed only had 69 instances of 

immediate sanctions over a 6-year period, despite being cited 444 times for 

deficiencies that harmed residents. 

Intervening period of compliance. G-level or higher deficiencies only 

count toward a double G immediate sanction if the home has an 

intervening period of compliance between the two G-level or higher 

deficiencies. In order to receive an immediate sanction, a home has to 

achieve substantial compliance between the pair of surveys on which the 

G-level or higher deficiencies are cited. As a result of this rule, homes that

do not correct deficiencies do not receive immediate sanctions, while 

homes that do correct deficiencies do receive immediate sanctions. CMS 

officials stated that the intent of the policy as written was to give nursing 

homes a chance to correct deficiencies and achieve a period of 

compliance. Without this provision, CMS officials believe that homes 

could get caught in endless double G cycles. 

The following example illustrates how the policy allows nursing homes to 

escape immediate sanctions if they do not correct deficiencies and have

ongoing noncompliance periods.74

• In a 9-month time period, a Pennsylvania home had seven surveys, each 

with at least one G-level deficiency (a total of 19 G-level deficiencies).75

However, double G immediate sanctions were triggered by only two pairs 

 73Department of Health and Human Services, Office of Inspector General, State Referral of

Nursing Home Enforcement Cases, OEI-06-03-00400 (December 2005). 

74This example only includes a limited portion of the home’s compliance history from fiscal 

years 2000 through 2005. 

75Three additional surveys conducted from March 27, 2000, through November 29, 2000, 

were not included in this analysis because none of the surveys had deficiencies at the 

G level or higher. 

Page 41 GAO-07-241 Nursing Home Enforcement
of surveys because the home had failed to correct some deficiencies 

before the next survey that again found actual harm.76 Figure 7 illustrates 

how some pairs of surveys with G-level deficiencies do not count as a 

double G because of the intervening period of compliance rule. For 

example, both the March and April surveys cited G-level deficiencies. 

However, the pair of surveys did not result in a double G, which would 

have triggered immediate sanctions because the home did not correct the

G-level deficiency cited on the March survey before the next G-level 

deficiency was cited in April. Following the April survey, the home 

corrected the deficiencies, resulting in a period of compliance. In July, 

another survey found a new G-level deficiency. Because of the intervening 

period of compliance, the March and July surveys resulted in a double G, 

for which immediate sanctions would have been warranted. 

 76While immediate sanctions were not imposed, CMS may have continued an existing 

sanction or imposed a new sanction, which was rescinded because the home corrected the 

deficiency. 

Page 42 GAO-07-241 Nursing Home Enforcement
Figure 7: Impact of Intervening Periods of Compliance Rule on Immediate Sanctions for One Pennsylvania Nursing Home, 

2000 

Source: GAO analysis of OSCAR and PDQ.

Pair of surveys resulting in a double G – immediate sanctions warranted

Pair of surveys not resulting in a double G due to period of noncompliance – no immediate sanctions

Period of noncompliance

3/27/00

Complaint

survey

1 G

7/6/00

Complaint

survey

1 G

8/2/00

Complaint

survey

1 G

8/11/00

Standard

survey

5 G

10/25/00

Complaint

survey

7 G

11/29/00

Complaint

survey

3 G

4/7/00

Complaint

survey

1 G

Intervening period

of compliance

Deficiencies corrected

No double G

No double G

No double G

Double G

Pairs of surveys with G-level or higher deficiencies do not count as a double G 

and do not trigger an immediate sanction unless there is an intervening period 

of compliance between the surveys. This home had four pairs of surveys, 

each with at least one G-level deficiency, which did not trigger an 

immediate sanction because of this rule. 

Double G

No double G

Clearing effect of standard surveys. Under the double G immediate 

sanctions policy, a standard survey without a G-level or higher deficiency 

“clears the home’s record” for the purposes of determining whether a 

double G occurred.77 As a result of this rule, surveys with G-level or higher 

deficiencies that occurred before the standard survey without a G-level or 

 77This aspect of the immediate sanctions policy does not affect the retention of data on 

prior G-level or higher deficiencies in CMS’s OSCAR database. 

Page 43 GAO-07-241 Nursing Home Enforcement
higher deficiency are not considered in determining whether a double G 

should be cited and an immediate sanction should be imposed. CMS 

officials believe that it is appropriate for standard surveys without G-level 

or higher deficiencies to clear the home’s record for double G purposes 

because standard surveys are comprehensive and occur regularly. Yet, we

have previously reported that weaknesses in the survey process result in 

surveyors’ missing serious deficiencies on standard surveys.78 Moreover, 

variability among states in the citation of serious deficiencies suggests that 

some states may not be citing deficiencies at the appropriate scope and 

severity (see app. II). For example, according to California officials, the 

guidance the state received from the CMS regional office created 

confusion as to what constituted actual harm, and this confusion 

contributed to the decline in citations of serious deficiencies in California. 

The regional office clarified its guidance in late 2004. 

The following example illustrates how a standard survey without G-level 

or higher deficiencies affects double G determinations and how having 

uncorrected deficiencies can prevent a home from receiving an immediate 

sanction.79

• In approximately a 12-month period, a Michigan home had five surveys, 

four of which had one G-level deficiency. However, the G-level 

deficiencies triggered double G immediate sanctions only once instead of 

three times because in one instance a standard survey cited no G-level 

deficiencies and in the other there was no intervening period of 

compliance.80 Figure 8 illustrates how some pairs of surveys with G-level 

deficiencies do not count as double Gs because of the clearing effect of 

standard surveys. For example, state surveyors found a G-level deficiency 

during a January 2000 complaint survey. However, on the home’s standard 

survey a month later (February 2000), no G-level or higher deficiencies 

were found by surveyors. As a result, when surveyors found another 

G-level deficiency on a complaint survey several months later (November 

2000), the G-level deficiency on the home’s January survey was not 

considered, and no immediate sanctions were triggered. The pair of 

 78See GAO/HEHS-98-202, GAO-03-561, and GAO-06-117. 

79This example only includes a limited portion of the home’s compliance history from fiscal 

years 2000 through 2005. 

80While immediate sanctions were not imposed, CMS may have continued an existing 

sanction or imposed a new sanction, which was rescinded because the home corrected the 

deficiency. 

Page 44 GAO-07-241 Nursing Home Enforcement
surveys in January 2000 and November 2000 did not trigger immediate 

sanctions because, in effect, the February 2000 standard survey cleared 

the home’s record. 

Figure 8: Impact of Clearing Effect Rule on Immediate Sanctions for One Michigan Nursing Home, 2000-2002 

Source: GAO analysis of OSCAR and PDQ.

Pair of surveys resulting in a double G – immediate sanctions warranted

Pair of surveys not resulting in a double G – no immediate sanctions

Period of noncompliance

1/28/00

Complaint

survey

1 G

11/6/00

Complaint

survey

1 G

12/7/00

Standard

survey

1 G

2/7/01

Complaint

survey

1 G

2/21/00

Standard

survey

0 G

of compliance

Intervening period

Deficiencies corrected

Pairs of surveys with G-level or higher deficiencies do not count as a double G and do not trigger an 

immediate sanction when there is a standard survey with no G-level or higher deficiencies between the pair. 

This home had one pair of surveys, each with one G-level deficiency, which did not trigger an immediate 

sanction because of the clearing effect rule. The pair of surveys (beginning on 11/6/00) also did 

not trigger an immediate sanction because of the intervening period of compliance rule. 

Double G

No double G

No double G

 Survey clears record

Multiple instances of harm. Multiple G-level or higher deficiencies 

identified on a survey that results in an immediate sanction are sometimes 

treated the same, in terms of enforcement, as a single instance of harm or 

immediate jeopardy cited on a survey. We examined the sanctions 

imposed for a single versus multiple instances of harm and found that the 

sanctions can be quite similar, despite the significant differences in the 

Page 45 GAO-07-241 Nursing Home Enforcement
number of deficiencies.81 The following example involves two surveys of a 

Michigan home with a history of repeated noncompliance. On a survey 

with only 1 G-level deficiency, CMS implemented a $350 per day CMP and 

a discretionary DPNA. On a different survey with 33 D-level or higher 

deficiencies and 6 G-level or higher deficiencies, CMS implemented a 

$200 per day CMP and a discretionary DPNA. We found similar examples 

among other homes we reviewed. 

We discussed our concerns with CMS about how the double G immediate 

sanctions policy allows some homes to avoid immediate sanctions. CMS 

officials stated that regardless of the policy, state and regional office 

officials retain the discretion to impose immediate sanctions even when 

not required by the policy. However, based on a discussion with CMS 

officials, we believe that, instead of imposing sanctions of appropriate 

severity, state and regional office officials may impose weaker sanctions 

for problem homes that have escaped immediate sanctions because of the 

complexities of the policy. CMS agreed that this could happen. 

CMS Oversight Continues 

to Be Hampered by Data 

Limitations 

Fragmented data systems and incomplete national reporting capabilities 

continue to hamper CMS’s ability to track and monitor enforcement. In 

March 1999, we reported that CMS lacked a system for effectively 

integrating enforcement data nationwide and that the lack of such a 

system weakened oversight.82 Since 1999, CMS has made progress in 

developing an enforcement data collection system called the ASPEN 

Enforcement Manager (AEM). However, while AEM collects valuable data 

from the states and regions, it is not fully integrated with other CMS 

systems used to track nursing home survey and enforcement activities. 

For example, when regional and state survey officials want to evaluate

complaint and enforcement data, they must access one system for 

complaint data and then access another system, AEM, for enforcement 

data. Because there is no direct interface between the two systems, CMS 

and states must rely on fragmented data systems for tracking and 

monitoring enforcement. Furthermore, CMS officials told us that the 

agency does not have a concrete plan to use the enforcement data to 

 81To gain a sense of how frequently multiple instances of harm are treated the same as 

single instances of harm, we examined the enforcement history of some of the homes cited 

with double Gs. Over half of the surveys examined with multiple G-level or higher 

deficiencies received sanctions similar to homes with a single G-level or higher deficiency. 

82GAO/HEHS-99-46. 

Page 46 GAO-07-241 Nursing Home Enforcement
improve monitoring and oversight but that some national enforcement 

reports are under development. 

From 2000 to 2004, CMS tracked sanctions with LTC, a data system 

developed in the Chicago region that became operational in all 10 CMS 

regions in 2000. LTC was a relatively simple system designed to collect

sanctions data, automatically generate sanction imposition letters, and 

automatically calculate the 35 percent reduction in CMPs for homes that 

waive the right to appeal deficiencies. LTC was not always useful for 

enforcement oversight because it was sometimes incomplete. Data entry 

into the LTC system was optional, and many regional and state surveyors 

continued to rely on their own, state-specific tracking systems. Moreover, 

during the time LTC was in use, states and regions were expected to 

continue updating the enforcement component of OSCAR, which 

duplicated some of the information in LTC. This required separate manual 

data entry into both LTC and OSCAR. We were told by regional office 

officials that sometimes only one of the files would be updated. 

Furthermore, LTC had no internal quality control checks for ensuring all 

fields were completed or that the data were accurate; in its design of LTC, 

CMS chose flexibility in modifying the data to accommodate special 

circumstances over a more rigid field edits system that would have 

controlled the data more tightly. 

Since October 1, 2004, CMS has used AEM to collect state and regional 

data on sanctions and improve communications between state survey 

agencies and CMS regional offices. Specifically, AEM was designed to 

provide real-time entry and tracking of sanctions, issue monitoring alerts, 

generate enforcement letters, and facilitate analysis of enforcement 

patterns. CMS expects that the data collected in AEM will enable states, 

CMS regional offices, and the CMS central office to more easily track and 

evaluate sanctions against nursing homes as well as respond to emerging 

issues. Developed by CMS’s central office primarily for use by states and 

regions, AEM is one module of a broader data collection system called 

ASPEN. There are a number of other modules under the ASPEN umbrella, 

including the ASPEN Complaints/Incidents Tracking System (ACTS) 

module. The ASPEN modules—and other data systems related to 

enforcement such as the financial management system for tracking CMP 

collections—are fragmented and lack automated interfaces with each 

other. As a result, enforcement officials must pull discrete bits of data 

from the various systems and manually combine the data to develop a full

enforcement picture. For example, if regional office officials want to 

review a home’s complaint history, they must access ACTS to print a 

report on complaints, access AEM to print a report on corresponding 

Page 47 GAO-07-241 Nursing Home Enforcement
sanctions, manually compare the two reports, and then access the CMP 

tracking system to determine whether a corresponding CMP was paid. 

Each step adds to staff workload. 

AEM collects potentially useful enforcement data from the states and 

regions, but, as described, CMS has not integrated AEM with the other 

data collection systems (e.g., ACTS); furthermore, the agency has not 

defined a plan for using the AEM data to inform the tracking and 

monitoring of enforcement through national enforcement reports. In a 

December 2004 CMS report, the agency stated that AEM “will permit 

meaningful comparisons of like measures and will serve as a primary tool 

on which to base policy decisions, new initiatives and strategies for 

improving care to our Nation’s nursing home population.”83 While CMS is 

developing a few draft national enforcement reports, it has not developed 

a concrete plan and timeline for producing a full set of reports that use the 

AEM data to help in assessing the effectiveness of sanctions and its 

enforcement policies. In addition, while the full complement of 

enforcement data recorded by the states and regional offices in AEM is 

now being uploaded to CMS’s national system, CMS does not intend to 

upload any historical data. Efforts to track and monitor enforcement 

would be greatly enhanced by reports that contain the historical data; for 

example, with historical data the agency could generate reports that 

provide a longitudinal perspective of a home’s compliance history, 

compare trends across states and regions, and, overall, help evaluate the 

effectiveness of sanctions and policies. Finally, like LTC, AEM has quality 

control weaknesses. While AEM has some automatic quality control 

mechanisms to ensure that the data entered are complete and in a valid 

format, there are no systematic quality control mechanisms to ensure that

the data entered are accurate. For example, while the system

automatically requires the entry of valid survey dates, CMS does not 

conduct periodic data audits to check that the survey dates are correct. 

CMS officials told us they will continue to develop and implement 

enhancements to AEM to expand its capabilities over the next several 

years. However, until CMS develops a plan for integrating the fragmented 

systems and for using AEM data—along with other data the agency 

collects—efficient and effective tracking and monitoring of enforcement 

 83CMS’s December 2004 “Action Plan (For Further Improvement of) Nursing Home 

Quality.” 

Page 48 GAO-07-241 Nursing Home Enforcement
will continue to be hampered and, as a result, CMS will have difficulty 

assessing the effectiveness of sanctions and its enforcement policies. 

Other CMS Initiatives to 

Improve Enforcement 

In addition to its efforts to implement a new data system for managing 

enforcement, CMS has taken other steps to improve its enforcement of 

nursing home quality requirements. For example, the agency has 

developed guidance to help ensure greater consistency across states in 

CMP amounts imposed, revised its Special Focus Facility program, and 

commissioned two studies to examine the effectiveness of nursing home 

enforcement.84

To ensure greater consistency in CMP amounts proposed by states and 

imposed by regions, CMS, in conjunction with state survey agencies, 

developed a grid that provides guidance for states and regions. The CMP 

grid lists ranges for minimum CMP amounts while allowing for flexibility 

to adjust the penalties on the basis of factors such as the deficiency’s 

scope and severity, the care areas where the deficiency was cited, and a 

home’s past history of noncompliance. In August 2006, CMS completed the 

regional office pilot of its CMP grid. The results of the pilot, which are 

currently being analyzed, will be used to determine how the grid should be 

used by states; its use would be optional to provide states flexibility to 

tailor sanctions to specific circumstances. 

CMS revised its Special Focus Facility program, an initiative intended to 

increase the oversight of homes with a history of providing poor care. We 

had previously reported that the program was worthwhile but that its 

narrow scope excluded many homes that provide poor care.85 Moreover, 

according to CMS, the goal of two surveys per home per year was never 

achieved because of the relatively low priority assigned to the program 

and the lack of state survey agency resources. In December 2004, CMS 

announced three changes in the operation of the program. First, CMS 

expanded the scope of the program from about 100 homes nationwide to 

about 135 homes by making the number of Special Focus Facilities in each 

state proportional to the number of nursing homes. Second, CMS revised 

the method for selecting nursing homes by reviewing 3 years’ rather than 

 84Additional CMS nursing home initiatives are described in CMS’s 2007 “Action Plan for

(Further Improvement of) Nursing Home Quality.” 

85GAO, Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the 

Quality Initiatives, GAO/HEHS-00-197 (Washington, D.C.: Sept. 28, 2000). 

Page 49 GAO-07-241 Nursing Home Enforcement
1 year’s worth of deficiency data. This change was intended to ensure that 

the homes in the program had a history of noncompliance rather than a 

single episode of noncompliance. Third, CMS strengthened its 

enforcement for Special Focus Facilities by requiring immediate sanctions 

for homes that failed to significantly improve their performance from one 

survey to the next and by requiring termination for homes with no 

significant improvement after three surveys over an 18-month period.86

Despite these changes, however, many homes that could benefit from 

enhanced oversight and enforcement are still excluded from the program. 

As noted earlier, few of the homes we reviewed were or are part of CMS’s 

Special Focus Facilities program. In 2005, only 2 were designated Special 

Focus Facilities and in 2006, the number increased to 4. Of the 8 homes 

that cycled in and out of compliance seven or more times (see fig. 3), 6 are 

still open but only 1 is now a Special Focus Facility. Although CMS now 

requires QIOs to work with poorly performing nursing homes, this 

initiative also only targets a small number of homes—as few as 1 to 3 

facilities in each state. 

To enhance its understanding of and ability to improve the enforcement 

process, CMS has funded two studies that will examine the steps that lead 

to sanctions as well as the impact of enforcement on homes’ quality-ofcare processes. 

• Qualitative Enforcement Case Studies. This study, which began in the 

spring of 2003 and is scheduled to be completed in early 2007, required 

research nurses to visit 25 nursing homes in four states to evaluate how 

the survey and enforcement processes are carried out and assess the 

extent to which the enforcement process results in changes in nursing 

staff behavior and improved compliance with federal requirements. 

• Impact of Sanctions on Quality. The objective of this study is to test the 

effects of sanctions on facility behavior and resident outcomes. 

Researchers will identify and compare a group of nursing homes that had 

both deficiencies and sanctions to a group of nursing homes that had 

similar levels of deficiencies but no sanctions. A year later, researchers 

will review the nursing home’s subsequent survey to determine whether 

 86In commenting on a draft of this report, Michigan noted that it recommends termination 

dates of less than 6 months for its Special Focus Facilities and has received support from 

the CMS regional office to do so. Michigan also noted that after one of its homes with a 

history of cycling in and out of compliance was designated a Special Focus Facility, the 

home’s performance improved, and it will likely be removed from the Special Focus 

Facility list. 

Page 50 GAO-07-241 Nursing Home Enforcement
the sanctions resulted in any significant changes in the quality of care

delivered. The study began in the fall of 2004 and the first report is 

scheduled to be completed by mid-2007. 

Although CMS has taken several steps to improve its enforcement of 

nursing home requirements, its Nursing Home Compare Web site does not 

include information on sanctions. Thus, CMS does not indicate what 

sanctions have been implemented against nursing homes, nor does it 

identify homes that have received immediate sanctions for repeatedly

harming residents. 

As noted throughout this report, we found variation among the states we 

reviewed in areas such as the number and amount of CMPs implemented 

and the proportion of homes with double Gs. In general, these differences 

reflect the state survey agencies’ views on the effectiveness of certain 

sanctions and differences in state enforcement policies. For example, 

Pennsylvania state officials prefer state rather than federal sanctions 

because they believe the former are more effective, have a greater 

deterrent effect on providers, and are easier and quicker to impose. 

Pennsylvania requires homes to pay a state CMP prior to appeal, even if 

the home appeals the deficiency. In contrast, homes need not pay a federal 

CMP until after an appeal is resolved. Pennsylvania rarely implemented 

federal CMPs on the 14 state homes whose compliance history we 

reviewed, preferring to use state sanctions instead. In Michigan, state 

officials are more likely to use federal CMPs and implement them in 

greater amounts than other states we reviewed. Texas state officials often 

use state rather than federal sanctions for G-level or higher deficiencies, in

part because they cannot propose a federal CMP if they impose a state 

sanction and because the total state money penalty that may be imposed 

may be higher than federal CMPs. California had fewer sanctions than 

Michigan. California typically investigates complaints under its state 

licensure authority, which may partly explain why California has fewer 

reported deficiencies and federal sanctions. We believe it is important for 

CMS to explore the differences in state enforcement approaches and 

policies so that it can both identify problem areas and identify best 

practices that could be disseminated nationwide. 

Although CMS has taken steps to strengthen the nursing home 

enforcement process, our review of 63 homes in four states with a history 

of quality problems identified design weaknesses as well as flaws in the 

way sanctions are implemented that diminish their full deterrent effect. 

Some of these homes repeatedly harmed residents over a 6-year period 

Conclusions 

Page 51 GAO-07-241 Nursing Home Enforcement
and yet remain in the Medicare and Medicaid programs. Until these 

systemic weaknesses are addressed, the effectiveness of sanctions in 

encouraging homes to return to and maintain compliance will remain 

questionable and the safety and security of vulnerable residents will 

remain at risk. 

CMS’s immediate sanctions policy fails to hold homes with a long history 

of harming residents accountable for the poor care provided. The policy’s 

complexity, such as the requirement for an intervening period of 

compliance, prevents its use for the very homes it was designed to 

address—those with systemic quality problems. Furthermore, the 

immediate sanctions label is misleading because sanctions are not, in fact, 

immediate. The notice period required by CMS regulations for sanctions 

such as DPNAs and terminations provides homes with a de facto grace 

period during which they can correct deficiencies to avoid an immediate 

sanction. Moreover, in one state we reviewed, the immediate sanctions 

policy does not fully identify all homes with repeat serious deficiencies 

because most complaint deficiencies, which can often trigger a double G, 

were being cited under state licensure authority, not federal. 

Consequently, some problem homes in the state were not identified by the 

policy and thus were able to avoid double G immediate sanctions. 

Although CMPs and DPNAs were the most frequently used sanctions 

nationwide and for the homes we reviewed, their effectiveness was 

undermined by a number of weaknesses. The CMPs levied against the 

homes we reviewed were often nominal, significantly less than the 

maximum amounts Congress provided for in statute. To strengthen CMPs, 

CMS has been developing a CMP grid since 2004 to guide states and 

regional offices in determining appropriate CMP amounts, and CMS 

regional offices piloted the grid in 2006. However, its implementation is 

expected to be optional for states, once again contributing to interstate 

variation. Despite the nominal amounts, CMPs, unlike DPNAs, do not 

require a notice period and may be imposed retroactively before the date

of the survey. However, these advantages are countered by the fact that, 

under the Social Security Act, payment by homes of federally imposed 

CMPs is deferred if they appeal their deficiencies, a process that can take

years, diminishing the immediacy of the sanction and further undermining 

the sanction’s deterrent effect. While there is precedent under the federal

surface mining statute, which permits the collection of CMPs before 

exhaustion of appeals, it is unclear if the informal dispute resolution 

process available to nursing homes provides the same type of procedural 

safeguards that courts have pointed to in upholding the mining statute 

provision. Some states choose to use their own authority to impose state 

Page 52 GAO-07-241 Nursing Home Enforcement
fines, which can sometimes be implemented faster than is possible under 

federal law. Although CMS has the authority to implement discretionary 

DPNAs after a 15-day notice period for the homes we reviewed, it did not 

generally do so. It imposes mandatory DPNAs when criteria are met, 

which provide homes a 3-month de facto grace period to correct 

deficiencies. Because many homes we reviewed returned to compliance 

within 3 months—though often only temporarily—the DPNAs frequently 

were rescinded. 

Termination—the most powerful enforcement tool—was used infrequently

nationwide and for the homes we reviewed because of states’ and CMS’s 

concerns about potential access to care and resident transfer trauma. 

However, we found that some poorly performing homes are located in

areas with several other nearby nursing homes. Even though some homes 

we reviewed cycled in and out of compliance numerous times while 

continuing to harm residents, CMS allowed them to determine for 

themselves whether and when to leave the Medicare and Medicaid 

programs. Even when terminations were imposed, their deterrent effect

was undermined by extending some termination dates to give the homes 

more time to correct deficiencies. CMS’s earlier termination of such 

troubled homes could have cut short the cycle of poor care. CMS’s 

revamped Special Focus Facility program would provide for termination 

of poorly performing homes within 18 months if they fail to show 

significant improvement in the quality of care provided to residents. 

Despite the expansion of the program from about 100 to about 135 homes, 

the number of Special Focus Facilities is inadequate because, as our work 

has demonstrated, the program still fails to include many homes with a 

history of repeatedly harming residents. 

Although CMS has made progress in establishing a database to help it 

track and monitor the nursing home enforcement process, the 

development of AEM is not yet complete. AEM is not integrated with other 

important databases to help ensure that CMS has a comprehensive picture 

of a home’s deficiency history, and CMS has not developed a concrete plan

for using national enforcement reports—built off of AEM data—to help 

evaluate the effectiveness of sanctions and its enforcement polices. Having

longitudinal enforcement data available for homes would enable CMS to 

pursue increasing the severity of sanctions for homes that repeatedly harm

residents. Furthermore, CMS has not developed a system of quality checks 

to ensure the accuracy and integrity of AEM data. 

CMS’s Nursing Home Compare Web site has been modified a number of 

times to add important quality information about nursing homes. While 

Page 53 GAO-07-241 Nursing Home Enforcement
CMS now summarizes the results from both standard surveys and 

complaint investigations, the Web site contains no information about 

sanctions implemented against nursing homes, nor does it identify homes 

that have received immediate sanctions for repeatedly harming residents. 

Such information could be valuable to consumers who use the Web site to

help choose a home for family members or friends. 

To address weaknesses that undermine the effectiveness of the immediate 

sanctions policy, we recommend that the Administrator of CMS reassess 

and revise the policy to ensure that it accomplishes the following three 

objectives: (1) reduce the lag time between citation of a double G and the 

implementation of a sanction, (2) prevent nursing homes that repeatedly

harm residents or place them in immediate jeopardy from escaping 

sanctions, and (3) hold states accountable for reporting in federal data 

systems serious deficiencies identified during complaint investigations so 

that all complaint findings are considered in determining when immediate 

sanctions are warranted.

To strengthen the deterrent effect of available sanctions and to ensure that 

sanctions are used to their fullest potential, we recommend that the 

Administrator of CMS take the following three actions: 

Recommendations for 

Executive Action 

• Ensure the consistency of CMPs by issuing guidance such as the 

standardized CMP grid piloted during 2006. 

• Increase use of discretionary DPNAs to help ensure the speedier 

implementation of appropriate sanctions. 

• Strengthen the criteria for terminating homes with a history of serious, 

repeated noncompliance by limiting the extension of termination dates, 

increasing the use of discretionary terminations, and exploring alternative 

thresholds for termination, such as the cumulative duration of 

noncompliance. 

To collect CMPs more expeditiously, which could increase their deterrent 

effect, we recommend that the Administrator of CMS develop an 

administrative process under which CMPs would be paid—or Medicare 

and Medicaid payments in equivalent amounts would be withheld—prior 

to exhaustion of appeals and seek legislation for the implementation of 

this process, as appropriate. Payments could be refunded with interest if 

the deficiencies are modified or overturned at appeal. 

Page 54 GAO-07-241 Nursing Home Enforcement
To strengthen sanctions for homes with a history of noncompliance, such 

as a large number of deficiencies or a large number of actual harm and 

immediate jeopardy deficiencies, we recommend that the Administrator of 

CMS consider further expanding the Special Focus Facility program with

its enhanced enforcement requirements to include all homes that meet a 

threshold, established by CMS, to qualify as poorly performing homes. 

To improve the effectiveness of its new enforcement data system, we 

recommend that the Administrator of CMS take the following three 

actions: 

• Develop the enforcement-related data systems’ abilities to interface with 

each other in order to improve the tracking and monitoring of 

enforcement, such as by developing an automatic interface between 

systems such as AEM and ACTS. 

• Expedite the development of national enforcement reports, including 

longitudinal and trend reports designed to evaluate the effectiveness of 

sanctions and enforcement policies, and a concrete plan for using the 

reports. 

• Develop and institute a system of quality checks to ensure the accuracy 

and integrity of AEM data, such as periodic data audits conducted as part 

of CMS’s annual state performance reviews. 

To improve public information available to consumers that helps them 

assess the quality of nursing home care, we recommend that the 

Administrator of CMS expand CMS’s Nursing Home Compare Web site to 

include implemented sanctions, such as the amount of CMPs and the 

duration of DPNAs, and homes subjected to immediate sanctions. 

We obtained written comments on our draft report from CMS and three of 

the four states in which the homes we studied were located—California, 

Michigan, and Texas. We also received e-mail comments from the Director 

of the Division of Nursing Care Facilities in Pennsylvania. CMS’s 

comments are reproduced in appendix VI. California’s, Michigan’s and

Texas’s comments are reproduced in appendixes VII, VIII, and IX, 

respectively. CMS generally concurred with our 12 recommendations in 

six areas intended to strengthen the enforcement process but did not 

always specify how it would implement the recommendations. In addition, 

CMS noted that implementation of 3 of our recommendations raised 

resource issues and that others required additional research. California 

Agency and State 

Comments and Our 

Evaluation 

Page 55 GAO-07-241 Nursing Home Enforcement
concurred with our conclusions and recommendations, while Michigan 

and Pennsylvania indicated appreciation or general agreement. However, 

most state comments, including Texas’s, were technical in nature. Our 

evaluation responds to CMS and state comments in the six areas covered 

by our recommendations. 

Addressing weaknesses in the double G immediate sanctions policy. 

CMS agreed that homes that repeatedly harm residents should not escape 

immediate sanctions and stated that it would remove the limitation on 

applying an additional sanction when a home failed to correct a deficiency 

that gave rise to a prior sanction. CMS also agreed to reduce the lag time 

between citation and implementation of a double G immediate sanction by 

limiting the prospective effective date for DPNAs to no more than 30 to 

60 days. Reducing the lag time as much as possible is critical because it 

provides homes with a de facto grace period in which to correct 

deficiencies and avoid sanctions. Michigan commented about the need to 

increase the immediacy of DPNAs, noting that even the 15-day notice 

period associated with discretionary DPNAs was outdated now that homes 

are notified electronically and delivery can be verified. Currently, CMS has 

an incomplete picture of serious deficiencies cited against homes that 

could result in immediate sanctions because California investigates many 

nursing home complaints under state licensure authority. CMS agreed to 

collect additional information on complaints for which data are not 

reported in federal data systems. We believe that CMS’s commitment to do 

this will help better identify and deal with consistently poorly performing 

homes. CMS commented that the Social Security Act does not provide 

authority for CMS to require states to report enforcement actions taken 

under state-only authority if federal resources are not used for the 

complaint investigation; however, to the extent that federal funds are used

for complaint investigations, our findings and recommendations remain 

valid. Michigan concurred that CMS needs the complete compliance 

history of a facility to assess its overall performance. 

CMS acknowledged that the complexity of its immediate sanctions policy 

may be an inherent limitation and indicated that it intends to either 

strengthen the policy or replace it with a policy that achieves similar goals 

through alternative methods. CMS noted that it is concerned about 

whether the immediate sanctions policy has negatively affected the rates 

of state deficiency citations and may ultimately be ineffective with the 

most problematic facilities. We believe the policy has merit but that its 

complex requirements have prevented many homes from receiving

immediate sanctions. 

Page 56 GAO-07-241 Nursing Home Enforcement
Strengthening the deterrent effect of sanctions. CMS agreed to issue 

a CMP analytic tool, or grid, and to provide states with further guidance on

discretionary DPNAs and terminations. The CMP grid is a tool to help 

ensure national consistency in CMPs and to assist CMS regional offices in

monitoring enforcement actions. Texas commented that it had been using

the grid since June 2006 and found it to be very helpful. Michigan noted

that it had independently developed and implemented a CMP grid in 2000 

but expressed disappointment that CMS had not mandated state use of the 

agency’s grid. In addition, Michigan supported the need for additional CMS 

guidance on the use of discretionary termination. Such guidance, it 

commented, was necessary to ensure a consistent national approach. In 

response to our recommendation to increase the use of discretionary 

terminations, CMS stated that it will continue its research to design 

proposals that yield a more effective combination of robust enforcement 

actions but that do not penalize vulnerable residents. While we encourage 

CMS’s commitment to further research to improve the effectiveness of 

enforcement actions, we believe that CMS must also be committed to 

protecting residents from actual harm in poorly performing facilities—

including terminating homes from the Medicare or Medicaid programs—

when other steps fail to ensure the quality of resident care. 

Collecting CMPs more expeditiously. CMS agreed to seek legislative

authority to collect CMPs prior to the exhaustion of appeals, which could 

increase their deterrent effect. California commented that it supported this 

recommendation. 

Expanding the Special Focus Facility program. CMS agreed with the 

concept of expanding the program to include all homes that meet a 

threshold to qualify as poorly performing homes, but said it lacks the 

resources needed for this expansion because of decreases in its budget 

and increases in both the number of providers and quality assurance 

responsibilities for state and federal surveyors. CMS stated that it 

envisioned expansion of the program if Congress fully funds the 

President’s proposed fiscal year 2008 budget for survey and certification 

activities. CMS specified other initiatives it will implement to improve the 

Special Focus Facility program. 

Improving the effectiveness of enforcement data. CMS agreed to 

develop and implement a system of quality checks to ensure the accuracy

of its data systems, including AEM. While the agency agreed to study the 

feasibility of linking the separate data systems used for enforcement and 

to develop other national standard enforcement reports, CMS indicated

that available resources may limit its ability to take further action on these 

Page 57 GAO-07-241 Nursing Home Enforcement
issues. CMS has already invested significant resources in developing 

potentially powerful data systems intended to improve the tracking and 

monitoring of enforcement, and we believe the agency should place a 

priority on ensuring that these systems operate effectively. 

Improving information available to consumers. Rather than agreeing

to report all implemented sanctions on its Nursing Home Compare Web 

site, CMS proposed reporting implemented sanctions only for poorly 

performing homes that meet an undefined threshold. CMS’s response was 

therefore not fully responsive to our recommendation. By only reporting 

sanctions for homes that meet a certain threshold—eight or more 

sanctions in a 3-year period, in an example provided by CMS—consumers 

might incorrectly assume that other homes have received no sanctions. 

Furthermore, CMS’s plan to post such limited sanctions data in an 

accessible location on its Web site is vague. We believe that consumers 

must be able to easily link deficiency and sanctions data. 

CMS and three of the four states also provided technical comments, which 

we incorporated as appropriate. 

As arranged with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days after its 

issue date. At that time, we will send copies to the Administrator of the 

Centers for Medicare & Medicaid Services and appropriate congressional 

committees. We will also make copies available to others upon request. In

addition, the report will be available at no charge on the GAO Web site at 

http://www.gao.gov. 

If you or your staff have any questions about this report, please contact me 

at (202) 512-7118 or allenk@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix X. 

Sincerely yours, 

Kathryn G. Allen 

Director, Health Care 

Page 58 GAO-07-241 Nursing Home Enforcement
Appendix I: Scope and Methodology Appendix I: Scope and Methodology 

This appendix provides a more detailed description of our scope and 

methodology and generally follows the order that findings appear in the 

report. We analyzed the fiscal years 2000 through 2005 enforcement and 

deficiency history for a total of 63 of the 74 nursing homes in four states—

California, Michigan, Pennsylvania, and Texas—whose compliance history 

informed the conclusions of our March 1999 report.1

 These homes had a 

history of providing poor quality care to residents prior to 1999. We 

excluded 11 of the original 74 homes from our analysis because they either

closed before fiscal year 2000 or closed within 6 months of the beginning 

of fiscal year 2000 and had few or no deficiencies or sanctions.2

 Some of 

the remaining 63 homes participated in the Medicare and Medicaid 

programs for only a portion of fiscal years 2000 through 2005 because they

either closed permanently or closed temporarily and were subsequently 

reinstated. For these homes, we set a criterion that required that the home 

participate for at least 6 months of the fiscal year in order for its 

enforcement data in that fiscal year to be included in our analysis. Table 8

shows the distribution of homes across the four states in our 1999 report, 

the distribution of those homes for this report, and the number of 

providers participating for at least 6 months by fiscal year. Although the 

table shows some year-to-year fluctuation in the number of providers, the

changes do not significantly influence our findings. While the focus of our 

analysis was the compliance history of these 63 homes, we also analyzed

general trends in (1) implemented sanctions nationwide for the same 

6-year period and (2) the proportion of homes in each state cited for 

serious deficiencies—that is, those at the actual harm or immediate 

jeopardy level. 

 1

See GAO/HEHS-99-46. Because the homes reviewed for this report were selected based on

their poor compliance histories, the findings of this report cannot be generalized to nursing 

homes in the states in which the homes are located or to nursing homes nationwide. 

However, we believe that the findings of this report illustrate the adequacy of federal and 

state sanctions taken against homes with histories of providing poor quality care to 

residents.

2

Of the 11 original 74 homes we excluded, CMS involuntarily terminated 5, and 6 closed 

voluntarily. 

Page 59 GAO-07-241 Nursing Home Enforcement
Appendix I: Scope and Methodology 

Table 8: Number of Nursing Homes Reviewed in 1999 That Were Included in Our Analysis for This Report, by State 

Current report

State 1999 report

Any participation in

fiscal years 2000-2005 2000 2001 2002 2003 2004 2005

California 12 10 10 10 10 10 10 10

Michigan 18 16 14 14 13 13 12 13

Pennsylvania 17 14 14 13 13 12 10 10

Texas 27 23 23 22 22 23 22 22

Total 74 63 61 59 58 58 54 55

Source: GAO.

CMS deficiency data. To determine the number, scope, and severity of 

deficiencies cited for the 63 homes, we analyzed OSCAR (On-Line Survey, 

Certification, and Reporting system) deficiency data resulting from 

standard surveys and complaint investigations. We also used OSCAR data 

on deficiencies identified during standard surveys to analyze state trends

in the proportion of nursing homes cited for actual harm or immediate 

jeopardy during fiscal years 2000 through 2005. Because a home may be 

surveyed more than once a year, we counted a home only once if it was 

cited for actual harm or immediate jeopardy on more than one survey 

during the year. CMS officials generally recognize OSCAR data to be 

reliable. We have used OSCAR data in our prior work to examine nursing

home quality. 

CMS enforcement data and reliability issues. Because CMS used 

multiple data systems during the 6-year period we reviewed and because

of data reliability issues, such as incomplete or inaccurate data, we used

several sources to validate and analyze the enforcement history of the 

63 homes. Based on discussions with CMS regional staff who were 

responsible for inputting the data, our primary data source for homes in 

California, Michigan, and Pennsylvania for the period fiscal years 2000 

through 2004 was the Long Term Care Enforcement Tracking System 

(LTC).3

 Because CMS’s Dallas regional office expressed concern about 

reliability of LTC data in the region, we relied primarily on regional office 

and state enforcement case files for the Texas homes we reviewed. CMS 

phased out use of LTC at the end of fiscal year 2004 and began using 

Aspen Enforcement Manager (AEM) to track sanctions. We obtained data

 3

We obtained the data from CMS on July 26, 2005. 

Page 60 GAO-07-241 Nursing Home Enforcement
Appendix I: Scope and Methodology 

for fiscal year 2005 sanctions from the limited AEM data stored in the 

OSCAR enforcement file. To clarify data from LTC or AEM and to perform 

some basic data checks, we relied on regional office and state 

enforcement case files and made adjustments as appropriate. We 

discussed the reliability of LTC and AEM enforcement data with CMS and 

state survey agency officials. CMS informed us that the data generally 

were reliable. We determined that the data were sufficiently reliable to 

assess broad trends in implemented sanctions nationwide, and to analyze 

sanctions among the 63 homes we reviewed because we could conduct 

checks of the homes’ enforcement data using CMS regional office and 

state case files. Because we could not conduct such checks of the data in 

all 50 states and the District of Columbia, we did not analyze trends across 

the individual states. 

Trends in sanctions. Based on our assessment of data reliability, we 

determined that we could assess broad trends in implemented sanctions 

nationwide, but because we could not conduct checks of the data in all 

50 states and the District of Columbia, we did not analyze trends across 

the states. For the homes we reviewed, using data from LTC, AEM, and 

regional office and state enforcement case files as described above, we 

analyzed the number of civil money penalties (CMP), denial of payments 

for new admissions (DPNA), and terminations implemented over two 

3-year time periods—fiscal years 2000 through 2002 and fiscal years 2003 

through 2005. We aggregated sanctions into fiscal years on the basis of 

their implementation dates. To determine the duration of DPNAs across 

the two time periods, we calculated the difference between the effective 

dates and the end of the DPNAs. To determine the amount of CMPs paid, 

we used the CMP Tracking System (CMPTS), a CMS financial management 

system,4

 and aggregated CMPs into fiscal years according to the year in 

which they were implemented. Based on discussions with CMS officials 

we determined that data in CMPTS are generally reliable. They also stated 

that the system is the primary system used by CMS for the collection of 

CMPs and is the only source for CMP payment data used by CMS. We 

matched CMP data in LTC and CMPTS based on their collection number. 

For fiscal year 2005, we relied on regional enforcement files for the 

amount of paid CMPs. 

 4

We received CMPTS data from CMS on April 21, 2006.

Page 61 GAO-07-241 Nursing Home Enforcement
Appendix I: Scope and Methodology 

Implementation rate of sanctions. We determined the implementation 

rate of sanctions imposed for the homes we reviewed in fiscal years 2000 

through 2005. The percentage of implemented sanctions was calculated by

dividing the number of implemented sanctions by the total number of 

imposed sanctions. The total number of imposed sanctions included those 

that were implemented, not implemented, and were pending. We used data 

from our March 1999 report on imposed and implemented sanctions for 

the period July 1995 through October 1998.5

Range of sanctions. CMS enforcement data allowed us to differentiate 

between per day and per instance CMPs and mandatory and discretionary 

DPNAs and terminations. We counted the number of sanctions by type and 

aggregated the number by fiscal year based on the date of implementation. 

The data provided the value of per day and per instance CMPs, which were 

used to calculate the median values of CMPs across the two time 

periods—fiscal years 2000 through 2002 and 2003 through 2005. 

Cycling in and out of compliance. We analyzed the enforcement data 

from LTC, AEM, and CMS regional office and state records to determine if 

the 63 homes we reviewed cycled in and out of compliance from fiscal 

years 2000 through 2005. To determine the number of times homes cycled

in and out of compliance, we counted the number of noncompliance 

cycles recorded for the 63 homes. A noncompliance cycle begins on the 

date of the survey finding noncompliance and ends when the home has 

achieved substantial compliance by correcting deficiencies. For 

noncompliance cycles for which sanctions were implemented, we 

examined survey dates, the date substantial compliance was achieved, and

the sanctions that were implemented as a result of the deficiencies cited.

To determine how quickly homes were again noncompliant, we calculated

the difference between the date of the first survey of the subsequent 

noncompliance cycle and the substantial compliance date of the preceding 

noncompliance cycle. To quantify the number of noncompliance cycles 

during which actual harm occurred, we assessed whether homes were 

cited for G-level or higher deficiencies on the surveys within the 

noncompliance cycle. 

Immediate sanctions policy. We identified instances in which the 

63 homes we reviewed were cited for repeatedly harming residents to 

determine if immediate sanctions were imposed and their effect on 

 5

See GAO/HEHS-99-46. 

Page 62 GAO-07-241 Nursing Home Enforcement
Appendix I: Scope and Methodology 

deterring subsequent noncompliance. To identify sanctions imposed as a 

result of the immediate sanctions policy, we first identified homes that 

qualified for immediate sanctions using CMS’s Providing Data Quickly 

(PDQ) system which prepares a variety of reports using survey and 

certification data. CMS officials indicate that the data in Providing Data 

Quickly are generally recognized as reliable. We then matched the survey

date in Providing Data Quickly with the survey date in the enforcement 

data to identify the noncompliance cycle during which qualifying 

deficiencies were cited.6

 This step enabled us to identify the sanctions 

imposed. We reviewed each case individually to verify that the sanction 

was the result of actual harm or higher-level deficiencies that denied the

home an opportunity-to-correct period or simply resulted from another 

survey in the same noncompliance cycle. We also compared the date of

survey with the imposition and effective dates of sanctions to assess how 

much time passed between identification of the deficiency that led to the 

immediate sanction and the imposition and implementation of the 

sanction. During the course of our work, we also discussed the rationale 

behind the specific formulation of the immediate sanctions policy with 

CMS officials. 

 6

In a small number of cases, the survey date recorded in PDQ did not match the survey date 

in the enforcement data. Mismatches generally occurred because the survey date in PDQ

erroneously reflected another survey, usually the first of the noncompliance cycle, even if 

there was no G-level or higher deficiency on that survey, rather than the survey on which 

the G-level or higher deficiency was cited. After consulting with CMS, we adjusted the 

survey dates to reflect the correct dates. 

Page 63 GAO-07-241 Nursing Home Enforcement
Appendix II: Percentage of Nursing Homes

Cited for Actual Harm or Immediate 

Jeopardy, by State, Fiscal Years 2000-2005 

In order to identify trends in the proportion of nursing homes cited with 

actual harm or immediate jeopardy deficiencies, we analyzed data from 

CMS’s OSCAR database for fiscal years 2000 through 2005 (see table 9). 

Because surveys are conducted at least every 15 months (with a required 

12-month statewide average), it is possible that a home was surveyed 

twice in any time period. If a home was cited for a G-level or higher 

deficiency on more than one survey during the fiscal year, we only 

counted it once. 

Table 9: Percentage of Nursing Homes Cited for Actual Harm or Immediate Jeopardy during Standard Surveys, Fiscal Years 

2000-2005 

Fiscal year 

State 

Number of 

 homes, 2005a2000 2001 2002 2003 2004 2005

Alabama 229 35.5 23.0 12.7 18.1 15.6 23.1

Alaska 14 28.6 26.7 26.7 0.0 0.0 0.0

Arizona 135 24.2 12.6 7.3 6.6 9.4 9.9

Arkansas 245 38.1 27.7 22.3 24.7 19.5 15.9

California 1,329 24.1 10.9 5.1 3.7 6.1 8.0

Colorado 215 20.4 26.4 32.7 20.9 25.9 40.4

Connecticut 247 41.9 51.6 45.8 43.1 54.4 44.2

Delaware 42 47.5 14.6 10.8 5.3 15.0 35.7

District of Columbia 20 17.7 28.6 30.0 41.2 40.0 30.0

Florida 691 22.8 20.2 14.9 10.2 7.8 4.2

Georgia 370 19.5 21.0 23.7 24.6 16.6 18.0

Hawaii 45 23.8 14.3 21.2 12.1 22.9 2.8

Idaho 81 51.4 29.7 39.2 31.9 27.3 38.4

Illinois 836 28.4 19.2 15.3 18.3 15.1 15.7

Indiana 518 45.0 29.4 23.2 19.7 24.1 28.3

Iowa 465 14.7 12.0 8.0 9.1 11.8 11.2

Kansas 374 37.9 30.7 32.9 26.5 30.3 34.9

Kentucky 297 26.8 29.1 23.2 26.1 14.6 7.7

Louisiana 321 21.8 29.9 21.7 16.2 12.0 15.4

Maine 116 11.1 13.9 6.6 11.1 12.8 7.0

Maryland 239 22.4 16.5 26.1 15.4 17.8 7.6

Massachusetts 466 29.1 24.4 24.6 25.9 16.7 22.6

Michigan 432 42.8 24.5 29.7 26.9 22.9 22.9

Minnesota 411 30.4 17.3 22.3 18.3 14.3 14.4

Mississippi 210 33.0 19.8 18.7 16.0 18.9 18.1

Appendix II: Percentage of Nursing Homes 

Cited for Actual Harm or Immediate 

Jeopardy, by State, Fiscal Years 2000-2005 

Page 64 GAO-07-241 Nursing Home Enforcement
Appendix II: Percentage of Nursing Homes

Cited for Actual Harm or Immediate 

Jeopardy, by State, Fiscal Years 2000-2005 

Fiscal year 

State 

Number of 

 homes, 2005a 2000 2001 2002 2003 2004 2005

Missouri 532 19.8 13.0 15.6 12.5 11.7 15.4

Montana 100 33.3 29.7 12.0 20.0 18.0 17.9

Nebraska 235 19.2 21.1 20.1 14.8 15.3 14.4

Nevada 47 34.8 14.6 11.9 9.1 17.5 19.6

New Hampshire 82 37.8 31.1 29.4 24.1 25.6 26.3

New Jersey 364 25.5 27.8 18.8 10.5 13.5 18.2

New Mexico 77 23.7 16.9 14.9 21.3 24.3 29.4

New York 662 33.8 37.1 34.2 15.2 11.0 14.0

North Carolina 426 43.6 35.8 25.6 29.0 21.1 18.5

North Dakota 83 25.9 28.7 17.9 12.4 13.6 17.7

Ohio 993 26.6 27.3 25.4 19.1 11.4 13.8

Oklahoma 387 19.3 21.3 22.0 26.3 13.9 23.2

Oregon 139 45.5 32.6 23.7 20.3 15.9 19.8

Pennsylvania 727 30.3 19.2 13.5 17.2 19.5 15.2

Rhode Island 92 14.3 12.9 5.6 6.7 9.3 9.5

South Carolina 177 26.4 17.2 19.8 29.6 32.7 24.8

South Dakota 112 27.1 26.7 26.8 32.1 21.6 12.8

Tennessee 337 28.2 20.2 20.7 21.8 22.9 17.3

Texas 1,174 29.7 30.5 22.4 18.0 12.0 16.2

Utah 93 19.5 14.1 25.6 19.0 11.1 8.4

Vermont 41 22.5 18.2 15.0 10.0 19.5 23.7

Virginia 281 19.2 14.3 11.6 13.7 10.2 15.5

Washington 251 46.9 38.3 37.0 30.9 28.1 27.2

West Virginia 133 12.1 17.7 20.4 12.7 9.8 15.0

Wisconsin 405 15.8 15.6 11.2 10.9 13.1 18.2

Wyoming 39 52.8 32.4 25.0 22.9 17.1 11.8

Nation 16,337 28.4 23.3 20.2 17.8 15.7 16.8

Source: GAO analysis of OSCAR and PDQ data. 

a

These numbers illustrate the significant variation in the number of active nursing homes across

states. 

Page 65 GAO-07-241 Nursing Home Enforcement
Appendix III: Federal Sanctions for Nursing 

Homes Reviewed, by State, Fiscal Years Appendix III: Federal Sanctions for Nursing 2000-2005 

Homes Reviewed, by State, Fiscal Years 

2000-2005 

Table 10 provides the number of CMPs, DPNAs, and terminations 

implemented in the nursing homes we reviewed, by state for fiscal years 

2000-2002 and fiscal years 2003-2005. It also provides the total amount of 

CMPs paid and the total duration of DPNAs implemented during the two 

time periods. The total amount of CMPs payable in the fiscal years may 

differ from what was paid. 

Table 10: Number of Sanctions Implemented Among Homes We Reviewed, Fiscal Years 2000-2005 

FY 2000-2002 FY 2003-2005

State Sanction

Average 

number of 

homes

reviewed Numbera

Amount 

paid/ 

duration

Average 

number of 

homes

reviewed Numbera

Amount 

paid/ 

duration 

Percentage change

in number from first 

to second time

period

California 10 10

CMPb5 $109,394 7 $166,480 40%

DPNAc4 155 days 3 189 days -25%

Involuntary

terminationd

0 NA 0 NA NA

Michigan 14 13

CMPb40 $186,313 35 $419,401 -13%

DPNAc26 1,206 days 19 796 days -27%

Involuntary

terminationd

0 NA 1 NA 100%

Pennsylvania 13 11

CMPb 7 $62,400 1 $0 -86%

DPNAc9 499 days 5 181 days -44%

Involuntary

terminationd

0 NA 0 NA NA

Texas 22 22

CMPb41 $176,420 11 $31,671 -73%

DPNAc13 591 days 3 79 days -77%

Involuntary

terminationd

1eNA 0 NA -100%

Source: GAO analysis of LTC, OSCAR, CMS regional office and state enforcement case files, and CMPTS. 

Note: Includes sanctions data from LTC as of July 26, 2005; OSCAR as of November 22, 2005; CMS 

regional office and state enforcement case files; and CMPTS data as of April 21, 2006. 

NA = not applicable. 

a

Number of sanctions implemented in the time period. 

b

Includes per day and per instance CMPs. 

c

Includes mandatory and discretionary DPNAs. 

Page 66 GAO-07-241 Nursing Home Enforcement
Appendix III: Federal Sanctions for Nursing 

Homes Reviewed, by State, Fiscal Years 

2000-2005 

d

Includes mandatory and discretionary involuntary terminations. 

e

Although the home did not participate for 6 months of fiscal year 2001 because it was involuntarily 

terminated in February 2001, the involuntary termination is counted because involuntary termination 

is the most severe sanction and because it occurs so infrequently. 

Page 67 GAO-07-241 Nursing Home Enforcement
Appendix IV: Examples of Homes Reviewed 

That Frequently Cycled In and Out of 

Compliance 

This appendix provides additional examples of the compliance history of

homes we reviewed that frequently cycled in and out of compliance (see 

table 6). The table also includes examples of the nature of the deficiencies 

cited in each noncompliance period. The three homes in table 11 were 

cited for serious deficiencies—those at the actual harm or immediate 

jeopardy level—and corrected these deficiencies only temporarily, despite 

receiving sanctions; on subsequent surveys, they were again found to be 

out of compliance, sometimes for the same deficiencies. A noncompliance 

period begins on the first day a survey finds noncompliance and ends 

when a home both corrects the deficiencies and achieves substantial 

compliance or the home is terminated from Medicare and Medicaid. Only 

federal sanctions that were imposed and implemented are included in the 

table. 

Table 11: Examples of Homes that Frequently Cycled In and Out of Compliance 

Noncompliance period 

(no. of days) 

Examples of the nature of

deficienciesa

Summary of G-level or

higher deficiencies Enforcement action implementedb

California homec

1st (84 days) • Resident abuse 

• Poor quality of care 

10 G • Per day CMP ($500/day) 

• Discretionary DPNA (42 days) 

2nd (131 days) • Inadequate treatment or 

prevention of pressure sores 

• Poor quality of care 

1 G • Per day CMP ($100/day) 

• Discretionary DPNA (13 days) 

3rd (126 days) • Resident abuse 

• Inadequate treatment or 

prevention of pressure sores 

2 G, 3 H • 1st per day CMP ($3,000/day)

• 2nd per day CMP ($500/day) 

• Discretionary DPNA (87 days) 

4th (181 days) • Resident abuse 3 G • Per instance CMPs (3 at 

$1,500/each) 

• Discretionary DPNA (89 days) 

Pennsylvania homed

1st (204 days) • Inadequate treatment or 

prevention of pressure sores 

• Poor accident supervision or 

prevention 

17 G • Per day CMP ($1,000/day) 

• Mandatory DPNA (74 days) 

2nd (147 days) • Employing convicted abusers

• Inadequate treatment of 

incontinence or unnecessary 

use of catheters 

1 G • Per instance CMP ($10,000) 

• Mandatory DPNA (12 days) 

3rd (188 days) • Employing convicted abusers

• Medication errors 

1 G • Mandatory DPNA (82 days) 

4th (140 days) • Poor nutrition 

• Poor accident supervision or 

prevention 

2 H • Discretionary DPNA (61 days) 

Appendix IV: Examples of Homes Reviewed 

That Frequently Cycled In and Out of 

Compliance 

Page 68 GAO-07-241 Nursing Home Enforcement
Appendix IV: Examples of Homes Reviewed 

That Frequently Cycled In and Out of 

Compliance 

Noncompliance period 

(no. of days) 

Examples of the nature of

deficienciesa

Summary of G-level or

higher deficiencies Enforcement action implementedb

Texas homee

1st (105 days) • Staff mistreatment of residents 

• Inadequate treatment or 

prevention of pressure sores 

• Use of unnecessary drugs 

4 G • 1st per instance CMP ($6,000)

• 2nd per instance CMP ($2,500)

2nd (1 day) • Staff mistreatment of residents 

• Employing convicted abusers

1 K • 1st per day CMP ($3,050/day)

• 2nd per day CMP ($750/day) 

3rd (11 days) • Resident abuse 

• Employing convicted abusers

1 G, 1 J • Per day CMP ($1,000/day) 

4th (147 days) • Medication errors 

• Employing convicted abusers

8 G, 2 H • 1st per day CMP ($3,050/day)

• 2nd per day CMP ($400/day) 

• 3rd per day CMP ($300/day) 

• 4th per day CMP ($50/day) 

• Discretionary DPNA (141 days) 

5th (19 days) • Inadequate treatment or 

prevention of pressure sores 

• Accident hazards 

1 G • Per day CMP ($500/day) 

6th (98 days) • Poor nutrition 

• Employing convicted abusers

• Poor quality of care 

2 G, 1 K • 1st per day CMP ($3,050/day)

• 2nd per day CMP ($750/day) 

• 3rd per day CMP ($50/day) 

• 4th per day CMP ($500/day) 

• Discretionary DPNA (67 days) 

7th (52 days) • Poor nutrition 0 G-level or higher; 1 E, 2 F • Per day CMP ($50/day) 

• Discretionary DPNA (20 days) 

8th (19 days) • Home failed to provide 

necessary services for daily 

living 

• Employing convicted abusers

4 K • Per instance CMP ($10,000) 

9th (1 days) • Poor quality of care 1 G • Per instance CMP ($5,000) 

10th (5 days) • Poor nutrition 0 G-level or higher; 1 E, 2 F • Per day CMP ($500/day) 

Source: GAO analysis of LTC, OSCAR, and CMS regional office and state enforcement case files. 

Notes: Enforcement actions listed were federal sanctions imposed and implemented (sanctions

imposed but not implemented and state sanctions are not included). The total number of D-level or 

higher deficiencies includes all deficiencies—not just the deficiencies that occurred during the 

noncompliance cycles cited—for the period fiscal years 2000 through 2005. 

a

Examples of the nature of deficiencies include D-level or higher deficiencies. 

b

In a number of cases, there is more than one per day CMP listed as an enforcement action because 

CMPs can be raised or lowered based on changes in deficiencies. 

c

Home open as of November 2006.

d

Home closed in January 2004. 

e

Home closed in January 2004. 

Page 69 GAO-07-241 Nursing Home Enforcement
Appendix V: Number of Days between Survey 

and Implementation Date of DPNA for Homes Appendix V Reviewed, Fiscal Years 2000-2005 : Number of Days between Survey 

and Implementation Date of DPNA for 

Homes Reviewed, Fiscal Years 2000-2005 

Days Number of DPNAs Percentage of total

<0 days 1 4

1-15 days 3 12

16-30 days 4 16

31-60 days 15 60

61-90 days 1 4

More than 90 days 1 4

Source: GAO analysis.

Notes: This analysis only includes DPNAs for which survey and implementation dates were available. 

DPNAs implemented less than 15 days from the date of the survey were for deficiencies cited in a 

prior survey; in these cases, CMS continued the DPNA as the sanction for the current deficiencies. 

Page 70 GAO-07-241 Nursing Home Enforcement
Appendix VI: Comments from the Centers for Appendix VI: Comments from the Centers for Medicare & Medicaid Services 

Medicare & Medicaid Services 

Page 71 GAO-07-241 Nursing Home Enforcement
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Page 72 GAO-07-241 Nursing Home Enforcement
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Page 73 GAO-07-241 Nursing Home Enforcement
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Now on p. 35. 

Page 74 GAO-07-241 Nursing Home Enforcement
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Page 75 GAO-07-241 Nursing Home Enforcement
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Page 76 GAO-07-241 Nursing Home Enforcement
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Page 77 GAO-07-241 Nursing Home Enforcement
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Page 78 GAO-07-241 Nursing Home Enforcement
Appendix VII: Comments from the State of 

California—Health and Human Services Appendix VII: Comments from the California Agency Department of Health Services 

Department of Health Services 

Page 79 GAO-07-241 Nursing Home Enforcement
Appendix VII: Comments from the State of 

California—Health and Human Services 

Agency Department of Health Services 

Page 80 GAO-07-241 Nursing Home Enforcement
Appendix VII: Comments from the State of 

California—Health and Human Services 

Agency Department of Health Services 

Now on p. 19. 

Now on p. 30. 

Now on p. 31. 

Page 81 GAO-07-241 Nursing Home Enforcement
Appendix VII: Comments from the State of 

California—Health and Human Services 

Agency Department of Health Services 

Now on p. 38. 

Now on p. 39. 

Now on p. 44. 

Now on p. 47. 

Page 82 GAO-07-241 Nursing Home Enforcement
Appendix VII: Comments from the State of 

California—Health and Human Services 

Agency Department of Health Services 

Page 83 GAO-07-241 Nursing Home Enforcement
Appendix VIII: Comments from the Michigan

Appendix VIII: Comments from the Michigan Department of Community Health 

Department of Community Health 

Page 84 GAO-07-241 Nursing Home Enforcement
Appendix VIII: Comments from the Michigan

Department of Community Health 

Page 85 GAO-07-241 Nursing Home Enforcement
Appendix VIII: Comments from the Michigan

Department of Community Health 

Page 86 GAO-07-241 Nursing Home Enforcement
Appendix VIII: Comments from the Michigan

Department of Community Health 

Page 87 GAO-07-241 Nursing Home Enforcement
Appendix VIII: Comments from the Michigan

Department of Community Health 

Page 88 GAO-07-241 Nursing Home Enforcement
Appendix IX: Comments from the Texas Appendix IX: Comments from the T Department of Aging and Disability Services exas 

Department of Aging and Disability Services 

Now on p. 20. 

Page 89 GAO-07-241 Nursing Home Enforcement
Appendix IX: Comments from the Texas 

Department of Aging and Disability Services 

Now footnote 41 on p. 21. 

Now on p. 51. 

Page 90 GAO-07-241 Nursing Home Enforcement
Appendix X: 

A

GAO Contact and Staff 

cknowledgments 

Page 91 GAO-07-241 

Appendix X: GAO Contact and Staff 

Acknowledgments 

GAO Contact Kathryn G. Allen, (202) 512-7118 or allenk@gao.gov

In addition to the contact names above, Walter Ochinko, Assistant 

Director; Elizabeth Bradley; Jacquelyn Clinton; Joanne Jee; Elizabeth T. 

Morrison; Colbie Porter; Jessica Smith; and Karin Wallestad made key 

contributions to this report 

Acknowledgments 

 Nursing Home Enforcement
Related GAO Products Related GAO Products 

Nursing Homes: Despite Increased Oversight, Challenges Remain in 

Ensuring High-Quality Care and Resident Safety. GAO-06-117. 

Washington, D.C.: December 28, 2005. 

Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses 

in State and Federal Oversight of Quality of Care. GAO-05-78. 

Washington, D.C.: November 12, 2004. 

Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in 

Federal Standards and Oversight. GAO-04-660. Washington D.C.: July 16, 

2004. 

Nursing Home Quality: Prevalence of Serious Problems, While 

Declining, Reinforces Importance of Enhanced Oversight. GAO-03-561. 

Washington, D.C.: July 15, 2003. 

Nursing Homes: Public Reporting of Quality Indicators Has Merit, but 

National Implementation Is Premature. GAO-03-187. Washington, D.C.: 

October 31, 2002. 

Nursing Homes: Quality of Care More Related to Staffing than Spending. 

GAO-02-431R. Washington, D.C.: June 13, 2002. 

Nursing Homes: More Can Be Done to Protect Residents from Abuse. 

GAO-02-312. Washington, D.C.: March 1, 2002. 

Nursing Homes: Federal Efforts to Monitor Resident Assessment Data 

Should Complement State Activities. GAO-02-279. Washington, D.C.: 

February 15, 2002. 

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of 

the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: 

September 28, 2000. 

Nursing Home Care: Enhanced HCFA Oversight of State Programs 

Would Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: 

November 4, 1999. 

Nursing Home Oversight: Industry Examples Do Not Demonstrate That 

Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington, 

D.C.: August 13, 1999. 

Page 92 GAO-07-241 Nursing Home Enforcement
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Nursing Homes: Proposal to Enhance Oversight of Poorly Performing 

Homes Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999. 

Nursing Homes: Complaint Investigation Processes Often Inadequate to 

Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999. 

Nursing Homes: Additional Steps Needed to Strengthen Enforcement of 

Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: 

March 18, 1999. 

California Nursing Homes: Care Problems Persist Despite Federal and

State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998. 

(290440) Page 93 GAO-07-241 Nursing Home Enforcement
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