Report to Congressional Requesters

United States General Accounting Office 

GAO 

July 2003 NURSING HOME 

QUALITY 

Prevalence of Serious 

Problems, While 

Declining, Reinforces 

Importance of 

Enhanced Oversight 

GAO-03-561 
The proportion of nursing homes with serious quality problems remains 

unacceptably high, despite a decline in the incidence of such reported 

problems. Actual harm or more serious deficiencies were cited for 20 

percent or about 3,500 nursing homes during an 18-month period ending 

January 2002, compared to 29 percent for an earlier period. Fewer 

discrepancies between federal and state surveys of the same homes suggests 

that state surveyors are doing a better job of documenting serious 

deficiencies and that the decline in serious quality problems is potentially 

real. Despite these improvements, the continuing prevalence of and state 

surveyor understatement of actual harm deficiencies is disturbing. For 

example, 39 percent of 76 state surveys from homes with a history of qualityof-care problems—but whose current survey found no actual harm 

deficiencies—had documented problems that should have been classified as 

actual harm or higher, such as serious, avoidable pressure sores. 

Weaknesses persist in state survey, complaint, and enforcement activities. 

According to CMS and states, several factors contribute to the 

understatement of serious quality problems, including poor investigation and 

documentation of deficiencies, limited quality assurance systems, and a large 

number of inexperienced surveyors in some states. In addition, GAO found 

that about one-third of the most recent state surveys nationwide remained 

predictable in their timing, allowing homes to conceal problems if they 

chose to do so. Considerable state variation remains regarding the ease of 

filing a complaint, the appropriateness of the investigation priorities, and the 

timeliness of investigations. Some states attributed timeliness problems to 

inadequate staff and an increase in the number of complaints. Although the 

agency strengthened enforcement policy by requiring states to refer for 

immediate sanction homes that had repeatedly harmed residents, GAO 

found that states failed to refer a substantial number of such homes, 

significantly undermining the policy’s intended deterrent effect. 

CMS oversight of state survey activities has improved but requires continued 

attention to help ensure compliance with federal requirements. While CMS 

strengthened oversight by initiating annual state performance reviews, 

officials acknowledged that the reviews’ effectiveness could be improved. 

For the initial fiscal year 2001 review, officials said they lacked the capability 

to systematically distinguish between minor lapses and more serious 

problems that required intervention. CMS oversight is also hampered by 

continuing database limitations, the inability of some CMS regions to use 

available data to monitor state activities, and inadequate oversight in areas 

such as survey predictability and state referral of homes for enforcement. 

Three key CMS initiatives have been significantly delayed—strengthening 

the survey methodology, improving surveyor guidance for determining the 

scope and severity of deficiencies, and producing greater standardization in 

state complaint processes. These initiatives are critical to reducing the 

subjectivity evident in current state survey and complaint activities. 

Since July 1998, GAO has reported 

numerous times on nursing home 

quality-of-care issues and identified 

significant weaknesses in federal 

and state oversight. GAO was 

asked to assess the extent of the 

progress made in improving the 

quality of care provided by nursing 

homes to vulnerable elderly and 

disabled individuals, including 

(1) trends in measured nursing 

home quality, (2) state responses to 

previously identified weaknesses in 

their survey, complaint, and 

enforcement activities, and (3) the 

status of oversight and quality 

improvement efforts by the Centers 

for Medicare & Medicaid Services 

(CMS). 

GAO is making several 

recommendations to the 

Administrator of CMS to 

(1) strengthen the nursing home 

survey process, (2) ensure that 

state survey and complaint 

activities adequately assess qualityof-care problems, and (3) improve 

CMS oversight of state survey 

activities. CMS concurred with the 

report’s recommendations, but its 

comments on intended actions 

were not fully responsive to all of 

the recommendations. Eleven 

states provided comments that 

most often focused on the resource 

constraints states face in meeting 

federal standards for oversight of 

nursing homes. 

www.gao.gov/cgi-bin/getrpt?GAO-03-561.

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. 

Highlights of GAO-03-561, a report to 

congressional requesters 

July 2003 

NURSING HOME QUALITY 

Prevalence of Serious Problems, While 

Declining, Reinforces Importance of 

Enhanced Oversight 
Page i GAO-03-561 Nursing Home Quality 

Letter 1

Results in Brief 3

Background 6

Magnitude of Problems Remains Cause for Concern Even Though 

Fewer Serious Nursing Home Quality Problems Reported 11

Weaknesses Persist in State Survey, Complaint, and Enforcement 

Activities 18

CMS Oversight of State Survey Activities Requires Further 

Strengthening 29

Conclusions 40

Recommendations for Executive Action 42

Agency and State Comments and Our Evaluation 43

Appendix I Scope and Methodology 51 

Appendix II Trends in The Proportion of Nursing Homes Cited 

for Actual Harm or Immediate Jeopardy 

Deficiencies, 1997-2002 55 

Appendix III Abstracts of Nursing Home Survey Reports That 

Understated Quality-of-Care Problems 58 

Appendix IV Information on State Nursing Home Surveyor 

Staffing 78 

Appendix V Predictability of Standard Nursing Home Surveys 80 

Appendix VI Immediate Sanctions Implemented Under CMS’s 

Expanded Immediate Sanctions Policy 83 

Contents 
Page ii GAO-03-561 Nursing Home Quality 

Appendix VII Cases States Did Not Refer to CMS for Immediate 

Sanction 86 

Appendix VIII HCFA State Performance Standards for Fiscal 

Year 2001 88 

Appendix IX Highlights of State Compliance with CMS 

Performance Standards 90 

Appendix X Comments from the Centers for Medicare & 

Medcaid Services 91 

Appendix XI GAO Contact and Staff Acknowledgements 95 

GAO Contact 95

Acknowledgements 95

Related GAO Products 96 

Tables 

Table 1: Scope and Severity of Deficiencies Identified During 

 Nursing Home Surveys 8

Table 2: Change in the Percentage of Nursing Homes Cited for 

 Actual Harm or Immediate Jeopardy during State 

 Standard Surveys between the periods January 1, 1999, 

 through July 10, 2000, and July 11, 2000, through 

 January 31, 2002, by State 13

Table 3: Incidence of Underreported Actual Harm Deficiencies in 

 Surveys GAO Reviewed 17

Table 4: Predictability of Nursing Home Surveys 22

Table 5: Key Findings of Report to CMS on State Complaint 

 Investigation Processes 25
Page iii GAO-03-561 Nursing Home Quality 

Table 6: Quality of Care Requirements Reviewed in a Sample of 

 State Survey Reports 52

Table 7: Trends in the Percentage of Nursing Homes Cited for 

 Actual Harm or Immediate Jeopardy during State 

 Standard Surveys, by State 56

Table 8: Abstracts of the 39 Nursing Home Deficiencies that 

 Understated Actual Harm from a Sample of 76 Nursing 

 Home Survey Reports 59

Table 9: State Survey Agency Responses to Questions about 

 Surveyor Experience, Vacancies, Hiring Freezes, 

 Competitiveness of Salaries, and Minimum Required 

 Experience 78

Table 10: Predictability of Current Nursing Home Surveys, by State 81

Table 11: Federal Sanctions Implemented against Nursing Homes 

 Referred for Immediate Sanction, January 14, 2000, 

 through March 28, 2002 83

Table 12: Federal CMPs Implemented under CMS’s Immediate 

 Sanctions Policy, January 2000 through March 2002 84

Table 13: Number of Cases States Did Not Refer for Sanction, as 

 Required, and the Number States Appropriately Referred, 

 January 2000 through March 2002 86

Table 14: Overview of HCFA’s Seven State Performance Standards 

 for Nursing Home Survey Activities for Fiscal Year 2001 88

Table 15: State Compliance with Selected CMS Performance 

 Standards, Fiscal Year 2001 90

Figure 

Figure 1: Four States with the Greatest Number of Cases that 

 Should Have Been Referred for Immediate Sanctions, 

 January 14, 2000, through March 28, 2002 27
Page iv GAO-03-561 Nursing Home Quality 

Abbreviations 

ACTS ASPEN Complaint Tracking System 

CMS Centers for Medicare & Medicaid Services 

CMP civil money penalties 

HCFA Health Care Financing Administration 

MDS minimum data set 

OSCAR On-Line Survey, Certification, and Reporting system 

RN registered nurse 

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Page 1 GAO-03-561 Nursing Home Quality 

July 15, 2003 

The Honorable Charles E. Grassley 

Chairman 

Committee on Finance 

United States Senate 

The Honorable Christopher S. Bond 

United States Senate 

A number of congressional hearings since July 1998 have focused 

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

nation’s 1.7 million nursing home residents, a highly vulnerable population 

of elderly and disabled individuals. As we previously reported, poor quality 

of care at about 15 percent of the nation’s approximately 17,000 nursing 

homes—an unacceptably high proportion—had repeatedly caused actual 

harm to residents, such as worsening pressure sores or untreated weight 

loss, or had placed them at risk of death or serious injury.1

 Significant 

weaknesses in federal and state nursing home oversight that we identified 

in a series of reports and testimonies since 1998 included (1) periodic state 

inspections, known as surveys, that understated the extent of serious care 

problems due to procedural weaknesses, (2) considerable state delays in 

investigating public complaints alleging harm to residents, (3) federal 

enforcement policies that did not ensure deficiencies were addressed and 

remained corrected, and (4) federal oversight of state survey activities that 

was limited in scope and effectiveness.2

In July 1998, the Health Care Financing Administration (HCFA)—the 

federal agency with responsibility for managing Medicare and Medicaid 

and overseeing compliance with federal nursing home quality standards—

launched a series of actions intended to address many of the weaknesses 

we identified.3

 Since 1998, the agency has worked to strengthen surveyors’ 

 1

See U.S. General Accounting Office, Nursing Homes: Proposal to Enhance Oversight of 

Poorly Performing Homes Has Merit, GAO/HEHS-99-157 (Washington, D.C.: June 30, 

1999). 

2

A list of related GAO products is at the end of this report. 

3

Effective July 1, 2001, HCFA’s name changed to the Centers for Medicare & Medicaid 

Services (CMS). In this report we continue to refer to HCFA where our findings apply to 

the organizational structure and operations associated with that name. 

United States General Accounting Office

Washington, DC 20548 
Page 2 GAO-03-561 Nursing Home Quality 

ability to detect quality-of-care deficiencies; required states to investigate 

complaints alleging resident harm within 10 days; mandated immediate 

sanctions for nursing homes with a pattern of harming residents;4

 and 

begun measuring state compliance with federal survey requirements and 

reviewing data on the results of state surveys to help pinpoint 

shortcomings in state survey activities. 

To evaluate the extent of the progress made in improving the quality of 

nursing home care since we last addressed this issue in September 2000, 

you asked us to assess: 

• trends in measured nursing home quality; 

• state responses to previously identified weaknesses in their survey, 

complaint, and enforcement activities; and 

• the status of key federal efforts to oversee state survey agency 

performance and improve quality. 

To assess recent trends in measured nursing home quality, we analyzed 

survey results for the period July 11, 2000, through January 31, 2002, and 

compared them to survey results for two earlier 18-month periods: (1) 

January 1, 1997, through June 30, 1998, and (2) January 1, 1999, through 

July 10, 2000. Our analysis relied on data from the Centers for Medicare & 

Medicaid Services’ (CMS) On-Line Survey, Certification, and Reporting 

(OSCAR) system, which compiles the results of all state nursing home 

surveys nationwide. To better understand the trends identified through 

our OSCAR analysis, we analyzed the results of federal comparative 

surveys, conducted at recently surveyed nursing homes to assess the 

adequacy of the state surveys, for two time periods—October 1998 

through May 2000 and June 2000 through February 2002. We also reviewed 

76 survey reports from homes with a history of actual harm deficiencies 

but whose most recent survey found no such deficiencies in states where 

the percentage of homes cited for actual harm had declined to below the 

national average since mid-2000. Our review of deficiencies from these 

survey reports focused on the types of quality-of-care deficiencies most 

frequently cited nationwide. 

 4

The term used in the law and regulations to describe a nursing home penalty for 

noncompliance is “remedy.” Throughout this report, we use a more common term, 

“sanction,” to refer to such penalties. Sanctions include actions such as fines, denial of 

payment for new admissions, and termination from the Medicare and Medicaid programs. 
Page 3 GAO-03-561 Nursing Home Quality 

To assess state survey activities as well as federal oversight, we analyzed 

the conduct and results of fiscal year 2001 state survey agency 

performance reviews during which CMS regional offices determined state 

compliance with seven federal standards; we focused on the five standards 

related to statutory survey intervals, survey documentation, complaint 

activities, enforcement requirements, and OSCAR data entry. We 

conducted structured interviews with officials from CMS, CMS’s 10 

regional offices, and 16 state survey agencies to discuss trends in survey 

deficiencies, the underlying causes of problems identified during the 

performance reviews, and state and federal efforts to address these 

problems.5

 We also discussed these issues with officials from 10 additional 

states during a governing board meeting of the Association of Health 

Facility Survey Agencies. We selected the 16 states with the goal of 

including states that (1) were from diverse geographic areas, (2) had 

shown either increases or decreases in the percentage of homes cited for 

actual harm, (3) had been contacted in our prior work, and (4) represented 

a mixture of strong and weak performance based on the results of federal 

performance reviews of state survey activities. We also obtained data from 

most state survey agencies on staffing issues such as nursing home 

surveyor experience and vacancies. To assess enforcement actions, we 

analyzed data in CMS’s enforcement database and compared homes 

identified in OSCAR as requiring immediate sanctions with those actually 

referred to CMS for sanctions by state survey agencies. See appendix I for 

a more detailed description of our scope and methodology. Our work was 

performed from January 2002 through June 2003 in accordance with 

generally accepted government auditing standards. 

State survey data indicate that the proportion of nursing homes with 

serious quality problems remains unacceptably high, despite a decline in 

such reported problems since mid-2000. Compared to the prior 18-month 

period, the percentage of nursing homes cited for actual harm or 

immediate jeopardy from July 2000 through January 2002 declined by 

about one-third—from 29 percent (about 5,000 homes) to 20 percent 

(about 3,500 homes). Consistent with this reported improvement in 

quality, federal comparative surveys completed during a recent 20-month 

period found actual harm or higher-level deficiencies in 22 percent of 

 5

We contacted officials in Alabama, California, Colorado, Connecticut, Iowa, Louisiana, 

Maryland, Michigan, Missouri, Nebraska, New York, Oklahoma, Pennsylvania, Tennessee, 

Washington, and Virginia. 

Results in Brief 
Page 4 GAO-03-561 Nursing Home Quality 

homes where state surveyors found no such deficiencies, compared to 34 

percent in an earlier period. Fewer discrepancies between federal and 

state surveys suggest that state surveyors’ performance in documenting 

serious deficiencies has improved and that the decline in serious quality 

problems nationwide is potentially real. Despite this improvement, 

however, the magnitude of understatement of actual harm deficiencies 

remains a cause for concern. Federal surveyors found examples of actual 

harm deficiencies in about one-fifth of homes that states had judged to be 

deficiency free. Moreover, 39 percent of 76 surveys we reviewed from 

homes with a history of quality-of-care problems—but whose current 

survey indicated no actual harm deficiencies—had documented problems 

that should have been classified as actual harm: serious, avoidable 

pressure sores; severe weight loss; and multiple falls resulting in broken 

bones and other injuries. 

Weaknesses persist in state survey, complaint investigation, and 

enforcement activities. Several factors at the state level contribute to the 

understatement of serious quality-of-care problems. Poor investigation and 

documentation of deficiencies identified during nursing home surveys 

preclude a determination of the seriousness of some deficiencies. 

According to some state officials, the large number of inexperienced 

surveyors due to high attrition and hiring limitations has also had a 

negative impact on the quality of surveys. While most of the 16 states we 

contacted had a quality assurance process in place to review deficiencies 

cited at the actual harm level and higher, half did not have such a process 

to help ensure that the scope and severity of less serious deficiencies were 

not understated. The continued predictability of the occurrence of 

standard surveys also likely contributes to the understatement of 

deficiencies. Our analysis of OSCAR data indicated that about one-third of 

the most recent state surveys nationwide occurred on a predictable 

schedule, allowing homes to conceal problems if they chose to do so. In 

addition, many states’ complaint investigation policies and procedures 

were still inadequate to provide intended protections. For example, 15 

states did not provide toll-free hotlines to facilitate the filing of complaints, 

the majority of states lacked adequate systems for managing complaints, 

and one or more states in most of CMS’s 10 regions did not correctly 

determine the investigation priority for complaints. Moreover, most states 

did not investigate all complaints involving actual harm within 10 days, as 

required. Some states attributed the timeliness problem to insufficient 

staff and an increase in the number of complaints. Although HCFA 

strengthened its enforcement policy by requiring state survey agencies, 

beginning in January 2000, to refer for immediate sanction homes that had 

a pattern of harming residents, we found that states failed to refer a 
Page 5 GAO-03-561 Nursing Home Quality 

substantial number of such homes, significantly undermining the intended 

deterrent effect of this policy. 

While CMS has increased its oversight of state survey and complaint 

activities, continued attention is required to help ensure compliance with 

federal requirements. In October 2000, HCFA implemented new annual 

performance reviews to measure state performance in seven areas, 

including the timeliness of survey and complaint investigations and the 

proper documentation of survey findings. The first round of results, 

however, did not produce information enabling the agency to identify and 

initiate needed improvements. For example, some regional office summary 

reports provided too little information to determine if a state did not meet 

a particular standard by a wide or a narrow margin—information that 

could help CMS to judge the seriousness of problems identified. We also 

found inconsistencies in how CMS regions conducted their reviews, 

raising questions about the validity and fairness of the results. Rather than 

relying on its regional offices, CMS plans to more centrally manage future 

state performance reviews to improve consistency and to help ensure that 

the results of those reviews could be used to more readily identify serious 

problems. Implementation has been significantly delayed for three other 

federal initiatives that are critical to reducing the subjectivity evident in 

the state survey process for identifying deficiencies and investigating 

complaints. These delayed initiatives were intended to strengthen the 

methodology for conducting surveys, improve surveyor guidance for 

determining the scope and severity of deficiencies, and increase 

standardization in state complaint investigation processes. 

We are recommending that the Administrator of CMS strengthen survey, 

complaint, enforcement, and oversight processes by (1) finishing the 

development of a more rigorous survey methodology, (2) requiring states 

to implement a quality assurance process to test the validity of cited 

deficiencies for surveys that include deficiencies below the actual harm 

level, (3) developing guidance for states that addresses key weaknesses in 

their complaint investigation processes, and (4) improving the ability of 

federal oversight of state survey activities to distinguish between systemic 

and less serious state survey performance problems. Although CMS 

concurred with our recommendations, its comments did not fully address 

our concerns about the status of the initiative intended to improve the 

effectiveness of the survey process or the recommendation regarding state 

quality assurance systems. Eleven states provided comments that most 

often focused on the resource constraints states face in meeting federal 

standards for oversight of nursing homes. 
Page 6 GAO-03-561 Nursing Home Quality 

Combined Medicare and Medicaid payments to nursing homes for care 

provided to vulnerable elderly and disabled beneficiaries were expected to 

total about $63 billion in 2002, with a federal share of approximately $42 

billion. Oversight of nursing homes is a shared federal-state responsibility. 

Based on statutory requirements, CMS defines standards that nursing 

homes must meet to participate in the Medicare and Medicaid programs 

and contracts with states to assess whether homes meet these standards 

through annual surveys and complaint investigations. A range of 

statutorily defined sanctions is available to help ensure that homes 

maintain compliance with federal quality requirements. CMS is also 

responsible for monitoring the adequacy of state survey activities. 

Every 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.6

A standard survey entails a team of state surveyors, including registered 

nurses (RN), spending several days in the nursing home to assess 

compliance with federal long-term care facility requirements, particularly 

whether care and services provided meet the assessed needs of the 

residents and whether the home is providing adequate quality care, such 

as preventing avoidable pressure sores, weight loss, or accidents. Based 

on our earlier work indicating that facilities could mask certain 

deficiencies, such as routinely having too few staff to care for residents, if 

they could predict the survey timing, HCFA directed states in 1999 to (1) 

avoid scheduling a home’s survey for the same month of the year as the 

home’s previous standard survey and (2) begin at least 10 percent of 

standard surveys outside the normal workday (either on weekends, early 

in the morning, or late in the evening). 

State surveyors’ assessment of the quality of care provided to a sample of 

residents during the standard survey serves as the basis for evaluating 

nursing homes’ compliance with federal requirements. CMS establishes 

specific investigative protocols for state surveyors to use in conducting 

these comprehensive surveys. These procedural instructions are intended 

to make the on-site surveys thorough and consistent across states. In 

response to our earlier recommendations concerning the need to better 

ensure that surveyors do not miss significant care problems, HCFA 

 6

CMS generally interprets these requirements to permit a statewide average interval of 12.9 

months and a maximum interval of 15.9 months for each home. 

Background 

Standard Surveys 
Page 7 GAO-03-561 Nursing Home Quality 

planned a two-phase revision of the survey process. In phase one, HCFA 

instructed states in 1999 to (1) begin using a series of new investigative 

protocols covering pressure sores, weight loss, dehydration, and other key 

quality areas, (2) increase the sample of residents reviewed with 

conditions related to these areas, and (3) review “quality indicator” 

information on the care provided to a home’s residents, before actually 

visiting the home, to help guide survey activities. Quality indicators are 

essentially numeric warning signs of the prevalence of care problems such 

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

pressures sores.7

 They are derived from nursing homes’ assessments of 

residents and rank a facility in 24 areas compared with other nursing 

homes in the state.8

 By using the quality indicators to select a preliminary 

sample of residents before the on-site review, surveyors are better 

prepared to identify potential care problems. Surveyors augment this 

preliminary sample with additional resident cases once they arrive in the 

home. To address remaining problems with sampling and the investigative 

protocols, CMS is planning a second set of revisions to its survey 

methodology. The focus of phase two is (1) improving the on-site 

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

indicators and (2) strengthening the protocols used by surveyors to ensure 

more rigor in their on-site investigations. 

Complaint investigations provide an opportunity for state surveyors to 

intervene promptly if quality-of-care problems arise between standard 

surveys. Within certain federal guidelines and time frames, surveyors 

generally follow state procedures when investigating complaints filed 

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

employees, and typically target a single area in response to the complaint. 

 7

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

Wisconsin. The developers based their work on nursing home resident assessment 

information, known as the minimum data set (MDS)—data on each resident that homes are 

required to report to CMS. See Center for Health Systems Research and Analysis, Facility 

Guide for the Nursing Home Quality Indicators (University of Wisconsin-Madison: Sept. 

1999). 

8

Because resident assessment data are used by CMS and states to calculate quality 

indicators and to determine the level of nursing homes’ payments for Medicare (and for 

Medicaid in some states), ensuring accuracy at the facility level is critical. We have made 

earlier recommendations to CMS on ways to improve the accuracy of these data. See U.S. 

General Accounting Office, Nursing Homes: Federal Efforts to Monitor Resident 

Assessment Data Should Complement State Activities, GAO-02-279 (Washington, D.C.: 

Feb. 15, 2002). 

Complaint Investigations 
Page 8 GAO-03-561 Nursing Home Quality 

Historically, HCFA had played a minimal role in providing states with 

guidance and oversight of complaint investigations. Until 1999, federal 

guidelines were limited to requiring the investigation of complaints 

alleging immediate jeopardy conditions within 2 workdays. In March 1999, 

HCFA acted to strengthen state complaint procedures by instructing states 

to investigate any complaint alleging harm to a nursing home resident 

within 10 workdays. Additional guidance provided to states in late 1999 

specified that, as with immediate jeopardy complaints, investigations 

should generally be conducted on-site at the nursing home. This guidance 

also identified techniques to help states identify complaints having a 

higher level of actual harm. As part of a complaint improvement project, 

also initiated in late 1999, HCFA plans to issue more detailed guidance to 

states, such as identifying model programs or practices to increase the 

effectiveness of complaint investigations. 

Quality-of-care deficiencies identified during either standard surveys or 

complaint investigations are classified in 1of 12 categories according to 

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

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

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

to be widespread in the nursing home (see table 1). States are required to 

enter information about surveys and complaint investigations, including 

the scope and severity of deficiencies identified, in CMS’s OSCAR 

database. 

Table 1: 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.” 

Deficiency Reporting 
Page 9 GAO-03-561 Nursing Home Quality 

The importance of accurate and timely reporting of nursing home 

deficiency data has increased with the public reporting of survey 

deficiencies, which HCFA initiated in 1998 on its Nursing Home Compare 

Web site.9 The public reporting of deficiency data is intended to assist 

individuals in differentiating among nursing homes. In November 2002, 

CMS augmented the deficiency data available on its Web site with 10 

clinical indicators of quality, such as the percentage of residents with 

pressure sores, in nursing homes nationwide. While the intent of this new 

initiative is worthwhile, CMS had not resolved several important issues 

that we raised prior to moving from a six-state pilot to nationwide 

implementation.10 These issues included: (1) the ability of the new 

information to accurately identify differences in nursing home quality, 

(2) the accuracy of the underlying data used to calculate the quality 

indicators, and (3) the potential for public confusion over the available 

data. 

Ensuring that documented deficiencies are corrected is a shared federalstate responsibility. CMS imposes sanctions on homes with Medicare or 

dual Medicare and Medicaid certification on the basis of state referrals.11

CMS normally accepts a state’s recommendation for sanctions but can 

modify it. The scope and severity of a deficiency determine the applicable 

sanctions that can involve, among other things, requiring training for staff 

providing care to residents, imposing monetary fines, denying the home 

Medicare and Medicaid payments for new admissions, and terminating the 

home from participation in these programs. Before a sanction is imposed, 

federal policy generally gives nursing homes a grace period of 30 to 60 

days to correct the deficiency. We earlier reported, however, that the 

threat of federal sanctions did not prevent nursing homes from cycling in 

and out of compliance because they were able to avoid sanctions by 

returning to compliance within the grace period, even when they had been 

 9

http://www.medicare.gov/NHCompare/home.asp. 

10U.S. General Accounting Office, Public Reporting of Quality Indicators Has Merit, but 

National Implementation Is Premature, GAO-03-187 (Washington, D.C.: Oct. 31, 2002). 

11States are responsible for enforcing standards in homes with Medicaid-only 

certification—about 14 percent of homes. They may use the federal sanctions or rely on 

their own state licensure authority and nursing home sanctions. States are responsible for 

ensuring that homes that have a pattern of harming residents are immediately sanctioned. 

Enforcement Policy 
Page 10 GAO-03-561 Nursing Home Quality 

cited for actual harm on successive surveys.12 In 1998, HCFA began a twostage phase-in of a new enforcement policy. In the first stage, effective 

September 1998, HCFA required states to refer for immediate sanction 

homes found to have a pattern of harming residents or exposing them to 

actual or potential death or serious injury (H-level deficiencies and above 

on CMS’s scope and severity grid). Effective January 14, 2000, HCFA 

expanded this policy to also require referral of homes found to have 

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

successive standard surveys.13

CMS is responsible for overseeing each state survey agency’s performance 

in ensuring quality of care in state nursing homes. Its primary oversight 

tools are statutorily required federal monitoring surveys conducted 

annually in 5 percent of the nation’s certified Medicare and Medicaid 

nursing homes, on-site annual state performance reviews instituted during 

fiscal year 2001, and analysis of periodic oversight reports that have been 

produced since 2000. Federal monitoring surveys can be either 

comparative or observational. A comparative survey involves a federal 

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

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

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

surveyors accompany a state survey team to a nursing home to observe 

the team’s performance. Roughly 85 percent of federal surveys are 

observational. State performance reviews, implemented in October 2000, 

measure state performance against seven standards, including statutory 

requirements regarding survey frequency, requirements for documenting 

deficiencies, timeliness of complaint investigations, and timely and 

accurate entry of deficiencies into OSCAR. These reviews replaced state 

self-reporting of their compliance with federal requirements. In October 

2000, HCFA also began to produce 19 periodic reports to monitor both 

state and regional office performance. The reports are based on OSCAR 

and other CMS databases. Examples of reports that track state activities 

include pending nursing home terminations (weekly), data entry 

 12U. S. General Accounting Office, Nursing Homes: Additional Steps Needed to Strengthen 

Enforcement of Federal Quality Standards, GAO/HEHS-99-46 (Washington, D.C.: Mar.18, 

1999). 

13States are now required to deny a grace period to homes that are assessed one or more 

deficiencies at the actual harm level or above (G-L on CMS’s scope and severity grid) in 

each of two successive surveys within a survey cycle. A survey cycle is two successive 

standard surveys and any intervening survey, such as a complaint investigation. 

CMS Oversight 
Page 11 GAO-03-561 Nursing Home Quality 

timeliness (quarterly), tallies of state surveys that find homes deficiency 

free (semiannually), and analyses of the most frequently cited deficiencies 

by states (annually). These reports, in a standard format, enable 

comparisons within and across states and regions and are intended to help 

identify problems and the need for intervention. Certain reports—such as 

the timeliness of state survey activities—are used to monitor compliance 

with state performance standards. 

The magnitude of the problems uncovered during standard nursing home 

surveys remains a cause for concern even though OSCAR deficiency data 

indicate that state surveyors are finding fewer serious quality problems. 

Compared to an earlier period, the percentage of homes nationwide cited 

since mid-2000 for actual harm or immediate jeopardy has decreased in 

over three-quarters of states—with seven states reporting a drop of 20 

percentage points or more. State surveys conducted since about mid-2000 

showed less variance from federal comparative surveys, suggesting that 

(1) state surveyors’ performance in documenting serious deficiencies has 

improved and (2) the decline in serious nursing home quality problems is 

potentially real. However, federal comparative surveys, as well as our 

review of a sample of survey reports from homes with a history of qualityof-care problems, continued to find understatement of actual harm 

deficiencies. 

Magnitude of 

Problems Remains 

Cause for Concern 

Even Though Fewer 

Serious Nursing 

Home Quality 

Problems Reported 
Page 12 GAO-03-561 Nursing Home Quality 

Compared to the preceding 18-month period, the proportion of nursing 

homes cited for actual harm or immediate jeopardy has declined 

nationally from 29 percent to 20 percent since mid-2000.14 In contrast, from 

early 1997 through mid-2000, the percentage of homes cited for such 

serious deficiencies was either relatively stable or increased in 31 states.15

From July 2000 through January 2002, 40 states cited a smaller percentage 

of homes with such serious deficiencies, while only 9 states and the 

District of Columbia cited a larger proportion of homes with such 

deficiencies.16 Despite these changes, there is still considerable variation in 

the proportion of homes cited for serious deficiencies, ranging from about 

7 percent in Wisconsin to about 50 percent in Connecticut. Appendix II 

provides trend data on the percentage of nursing homes cited for serious 

deficiencies for all 50 states and the District of Columbia. 

Table 2 shows the recent change in actual harm and immediate jeopardy 

deficiencies for states that surveyed at least 100 nursing homes.17

Specifically: 

• Twenty-five states had a 5 percentage point or greater decrease in the 

proportion of homes identified with actual harm or immediate jeopardy. 

For over two-thirds of these states, the decrease in serious deficiencies 

was greater than 10 percentage points. Seven states—Arizona, Alabama, 

 14We analyzed OSCAR data for surveys performed from January 1, 1999, through July 10, 

2000, and from July 11, 2000, through January 31, 2002, and entered into OSCAR as of June 

24, 2002. See app. I for our complete scope and methodology. Our analysis considered only 

standard surveys. In commenting on a draft of this report, Missouri stated that our findings 

would have shown that quality had remained “fairly stable” had we included actual harm 

and immediate jeopardy deficiencies identified during complaint investigations in our 

analysis in table 2. However, we found that both nationally and in Missouri, the proportion 

of homes cited for actual harm or immediate jeopardy showed a similar decline even when 

complaint surveys were considered. 

15The two earlier time periods we analyzed are for surveys conducted from January 1, 1997, 

through June 30, 1998, and from January 1, 1999, through July 10, 2000. See U.S. General 

Accounting Office, Nursing Homes: Sustained Efforts Are Essential to Realize Potential 

of the Quality Initiatives, GAO/HEHS-00-197 (Washington, D.C.: Sept. 28, 2000). 

16The proportion of nursing homes in Utah cited with serious deficiencies remained the 

same between the two time periods. 

17We excluded Alaska, Delaware, the District of Columbia, Hawaii, Idaho, Nevada, New 

Hampshire, New Mexico, North Dakota, Rhode Island, Utah, Vermont, and Wyoming from 

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

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

relatively large percentage point change. 

Proportion of Nursing 

Homes with Documented 

Actual Harm or Immediate 

Jeopardy Care Problems 

Has Declined since 2000 
Page 13 GAO-03-561 Nursing Home Quality 

California, Michigan, Indiana, Pennsylvania, and Washington—

experienced declines of 15 percentage points or more. 

• Two states, South Dakota and Colorado, experienced an increase of 5 

percentage points or greater in the proportion of homes with actual harm 

or immediate jeopardy deficiencies (6.6 and 10.8, respectively). 

• The remaining 11 states were relatively stable—experiencing 

approximately a 4 percentage point change or less. 

Table 2: Change in the Percentage of Nursing Homes Cited for Actual Harm or Immediate Jeopardy during State Standard 

Surveys between the periods January 1, 1999, through July 10, 2000, and July 11, 2000, through January 31, 2002, by State 

 

Percentage of homes with actual 

harm or immediate jeopardy 

deficiencies 

Statea

Number of homes 

surveyed 

(7/00-1/02) 1/99-7/00 7/00-1/02 

Percentage point 

differenceb

Decrease of 5 percentage points or greater 

Arizona 147 33.8 8.8 -25.0

Alabama 228 42.2 18.4 -23.8

Pennsylvania 764 32.2 11.6 -20.6

California 1,348 29.1 9.3 -19.9

Indiana 573 45.3 26.2 -19.1

Michigan 441 42.1 24.7 -17.4

Washington 275 54.1 38.5 -15.6

Oregon 152 47.5 33.6 -13.9

Illinois 881 29.3 15.4 -13.9

Mississippi 219 33.2 19.6 -13.5

Minnesota 431 31.7 18.8 -12.9

Montana 103 37.5 25.2 -12.3

Missouri 569 22.3 10.2 -12.1

South Carolina 180 28.7 17.8 -10.9

North Carolina 419 40.8 30.1 -10.7

Arkansas 267 37.7 27.3 -10.4

Massachusetts 512 33.0 22.9 -10.2

Iowa 494 19.3 9.9 -9.4

Tennessee 377 26.0 16.7 -9.3

Nation 17,149 29.3 20.5 -8.8

Virginia 285 19.9 11.6 -8.3

Kansas 400 37.1 29.0 -8.1

Nebraska 243 26.0 18.9 -7.1

Wisconsin 421 14.0 7.1 -6.9

Maryland 248 25.6 20.2 -5.5

Ohio 1,029 29.0 23.7 -5.3

Change of less than 5 percentage points 

Kentucky 306 28.8 25.2 -3.7
Page 14 GAO-03-561 Nursing Home Quality 

 

Percentage of homes with actual 

harm or immediate jeopardy 

deficiencies 

Statea

Number of homes 

surveyed 

(7/00-1/02) 1/99-7/00 7/00-1/02 

Percentage point 

differenceb

New Jersey 366 24.5 22.4 -2.1

Georgia 370 22.6 20.5 -2.0

West Virginia 143 15.6 14.0 -1.7

Texas 1,275 26.9 25.5 -1.5

Florida 742 20.8 20.1 -0.8

Maine 124 10.3 9.7 -0.6

New York 671 32.2 32.3 0.2

Connecticut 259 48.5 49.4 0.9

Louisiana 367 19.9 23.4 3.5

Oklahoma 394 16.7 20.6 3.9

Increase of 5 percentage points or greater 

South Dakota 114 24.1 30.7 6.6

Colorado 225 15.4 26.2 10.8

Source: GAO analysis of OSCAR data as of June 24, 2002. 

a

Includes only those states in which 100 or more homes were surveyed since July 2000. 

b

Differences are based on numbers before rounding. 

States offered several explanations for the declines in actual harm and 

immediate jeopardy deficiencies, including (1) changing guidance from 

CMS regional offices as to what constitutes actual harm, (2) hiring 

additional staff, and (3) surveyors failing to properly identify actual harm 

deficiencies. 

Our analysis of federal comparative surveys conducted nationwide prior to 

and since June 2000 showed a decreased variance between federal and 

state survey findings (see app. I for a description of our scope and 

methodology). For comparative surveys completed from October 1998 

through May 2000, federal surveyors found actual harm or higher-level 

deficiencies in 34 percent of homes where state surveyors had found no 

such deficiencies, compared to 22 percent for comparative surveys 

completed from June 2000 through February 2002. In addition, while 

federal surveyors found more serious care problems than state surveyors 

on 70 percent of the earlier comparative surveys, this percentage declined 

to 60 percent for the more recent surveys. 

Despite the decline in understatement of actual harm deficiencies from 34 

percent to 22 percent, the magnitude of the state surveyors’ 

Federal Comparative 

Surveys Show Decreased 

Variance with State Survey 

Findings, but 

Understatement of Actual 

Harm Deficiencies 

Continued 
Page 15 GAO-03-561 Nursing Home Quality 

understatement of quality problems remains an issue. For example, from 

June 2000 through February 2002, federal surveyors found at least one 

actual harm or immediate jeopardy quality-of-care deficiency in 16 of the 

85 homes (19 percent) that the states had found to be free of deficiencies. 

For example, federal surveyors found that 1 of the 16 homes failed to 

prevent pressure sores, failed to consistently monitor pressure sores when 

they did develop, and failed to notify the physician promptly so that proper 

treatment could be started. The federal surveyors who conducted the 

comparative survey of this nursing home noted in the file that a lack of 

consistent monitoring of pressure sores existed at the home during the 

time of the state’s survey and that the state surveyors should have found 

the deficiency. 

Several states that reviewed a draft of this report questioned the value of 

federal comparative surveys because of their timing. Arizona noted that 

comparative surveys do not have to begin until up to 2 months after the 

state’s survey, and Iowa and Virginia officials said they might occur so 

long after the state’s survey that conditions in the home may have 

significantly changed. Although legislation requires comparative surveys 

to begin within 2 months of the state’s survey, CMS is continuing to make 

progress in reducing the timeframe between the state and the comparative 

survey. Based on our earlier recommendation that comparative surveys 

begin as soon after the state’s survey as possible, CMS instructed the 

regions to begin these surveys no later than one month following the 

state’s survey, and the average time between surveys nationally has 

decreased from 33 calendar days in 1999 to about 26 calendar days for 

surveys conducted from June 2000 through February 2002.18

Even with the reported decline in serious deficiencies, an unacceptably 

high number of nursing homes—one in five nationwide—still had actual 

harm or immediate jeopardy deficiencies. Moreover, we found widespread 

understatement of actual harm deficiencies in a sample of surveys we 

reviewed that were conducted since July 2000 at homes with a history of 

harming residents (see app. I for a description of our methodology in 

selecting this sample). In 39 percent of the 76 survey reports we reviewed, 

we found sufficient evidence to conclude that deficiencies cited at a lower 

level (generally, potential for more than minimal harm, D or E) should 

 18U.S. General Accounting Office, Nursing Homes: Enhanced HCFA Oversight of State 

Programs Would Better Ensure Quality, GAO/HEHS-00-6 (Washington, D.C.: Nov. 4, 1999). 

Quality-of-Care Problems 

Were Understated in 

Homes with a History of 

Problems 
Page 16 GAO-03-561 Nursing Home Quality 

have been cited at the level of actual harm or higher (G level or higher on 

CMS’s scope and severity grid). We were unable to assess whether the 

scope and severity of other deficiencies in our sample of surveys were also 

understated because of weaknesses in the investigations conducted by 

surveyors and in the adequacy with which they documented those 

deficiencies. 

Of the surveys we reviewed, 30 (39 percent) contained sufficient evidence 

for us to conclude that deficiencies cited at the D and E level should have 

been cited as at least actual harm because a deficient practice was 

identified and linked to documented actual harm involving at least one 

resident (see table 3). These 30 survey reports depicted examples of actual 

harm, including serious, avoidable pressure sores; severe weight loss; and 

multiple falls resulting in broken bones and other injuries (see app. III for 

abstracts of these 30 survey reports). The following example illustrates 

understated actual harm involving the failure to provide necessary care 

and services. A nurse at one facility noted a large area of bruising and 

swelling on an 89-year-old resident’s chest. Nothing further was done to 

explore this injury until 11 days later when the resident began to 

experience shortness of breath and diminished breath sounds. Then a 

chest x ray was taken, revealing that the resident had sustained two 

fractured ribs and fluid had accumulated in the resident’s left lung. A 

facility investigation determined that the resident had been injured by a lift 

used to transfer the resident to and from the bed. It was clear from the 

surveyor’s information that the facility failed to take appropriate action to 

assess and provide the necessary care until the resident developed serious 

symptoms of chest trauma. Nevertheless, the surveyor concluded that 

there was no actual harm and cited a D-level deficiency—potential for 

more than minimal harm. 
Page 17 GAO-03-561 Nursing Home Quality 

Table 3: Incidence of Underreported Actual Harm Deficiencies in Surveys GAO 

Reviewed 

State 

Number of surveys 

from state 

Number of surveys 

in which GAO 

identified G-level 

deficiencies 

Number of G-level 

deficiencies GAO 

identified 

Alabama 6 2 2

Arizona 3 1 2

California 22 13 17

Iowa 7 5 7

Maryland 3 1 1

Minnesota 5 0 0

Mississippi 1 0 0

Missouri 4 1 1

Nebraska 4 2 2

Pennsylvania 11 2 3

South Carolina 1 0 0

Virginia 7 3 4

West Virginia 1 0 0

Wisconsin 1 0 0

Total 76 30 39

Source: GAO analysis of state surveys. 

Note: We reviewed surveys where state surveyors had cited deficiencies at the D or E level (potential 

for more than minimal harm) in one or more of four quality-of-care areas (see app. I, table 6). We 

reviewed all such deficiencies to determine if, in our judgment, the deficiencies should have been 

cited at the G level or higher (actual harm). 

State survey agency officials in Alabama, California, Iowa, and Nebraska 

told us that surveyors had originally cited G-level deficiencies in 10 of the 

surveys we reviewed, but that the deficiencies had been reduced to the D 

level during the states’ reviews because of inadequate surveyor 

documentation. We concluded that 5 of the 10 surveys did contain 

adequate documentation to support actual harm because there was a clear 

link between the deficient facility practice and the documented harm to a 

resident. For example, the survey managers in one state changed a G- to a 

D-level deficiency because the surveyor only cited one source of evidence 

to support the deficiency—nurses’ notes in the residents’ medical 

records.19 According to the surveyor, a resident with dementia, 

experiencing long- and short-term memory problems, fell 11 times and 

 19Instructions from the state’s CMS regional office suggest, but do not require, the use of 

more than one source of information to support a deficiency. 
Page 18 GAO-03-561 Nursing Home Quality 

sustained a fractured wrist, three fractured ribs, and numerous bruises, 

abrasions, and skin tears. According to the notes of facility nurses, a 

personal alarm unit was in place as a safety device to prevent falls. The 

surveyor found that the facility had (1) failed to provide adequate 

interventions to prevent accidents and (2) continued to use the alarm unit 

even though it did not prevent any of the falls. The medical record 

documentation of these events was extensive and, in our judgment, was 

sufficient evidence of a deficiency that resulted in actual harm to the 

resident. 

In many of the 76 surveys we reviewed, including surveys in which we 

found no D- or E-level deficiencies that would appear to meet the criteria 

for actual harm deficiencies, we identified serious investigation or 

documentation weaknesses that could further contribute to the 

understatement of serious deficiencies in nursing homes. In some cases, 

the survey did not clearly describe the elements of the deficient practice, 

such as whether the resident developed a pressure sore in the facility or 

what the facility did to prevent the development of a facility-acquired 

pressure sore. In other cases, the survey omitted critical facts, such as 

whether a pressure sore had worsened or the size of the pressure sore. 

Widespread weaknesses persist in state survey, complaint investigation, 

and enforcement activities despite increased attention to these issues in 

recent years. Several factors at the state level contribute to the 

understatement of serious quality-of-care problems, including poor 

investigation and documentation of deficiencies, the absence of adequate 

quality assurance processes, and a large number of inexperienced 

surveyors in some states due to high attrition or hiring limitations. In 

addition, our analysis of OSCAR data indicated that the timing of a 

significant proportion of state surveys remained predictable, allowing 

homes to conceal problems if they choose to do so. Many states’ complaint 

investigation policies and procedures were still inadequate to provide 

intended protections. For example, many states do not investigate all 

complaints identified as alleging actual harm in a timely manner, a 

problem some states attributed to insufficient staff and an increase in the 

number of complaints. Although HCFA strengthened its enforcement 

policy by requiring state survey agencies, beginning in January 2000, to 

refer for immediate sanction homes that had a pattern of harming 

residents, we found that many states did not fully comply with this new 

requirement. States failed to refer a substantial number of homes for 

sanction, significantly undermining the policy’s intended deterrent effect. 

Weaknesses Persist in 

State Survey, 

Complaint, and 

Enforcement 

Activities 
Page 19 GAO-03-561 Nursing Home Quality 

CMS and state officials identified several factors that they believe 

contribute to state surveys continuing to miss significant care problems. 

These weaknesses persist, in part, because many states lack adequate 

quality assurance processes to ensure that deficiencies identified by 

surveyors are appropriately classified. According to officials we 

interviewed, the large number of inexperienced surveyors in some states 

due to high attrition has also had a negative impact on the quality of state 

surveys and investigations. Our analysis of OSCAR data also indicated that 

nursing homes could conceal problems if they choose to do so because a 

significant proportion of current state surveys remain predictable. 

Consistent with the investigation and documentation weaknesses we 

found in our review of a sample of survey reports from homes with a 

history of actual harm deficiencies, CMS officials told us that their own 

activities had identified similar problems that could contribute to an 

understatement of serious deficiencies at nursing homes. 

• CMS reviews of state survey reports during fiscal year 2001 demonstrated 

weaknesses in a majority of states, including: (1) inadequate investigation 

and documentation of a poor outcome, such as reviewing available 

records to help identify when a pressure sore was first observed and how 

it changed over time, (2) failure to specifically identify the deficient 

practice that contributed to a poor outcome, or (3) understatement of the 

seriousness of a deficiency, such as citing a deficiency at the D level 

(potential for actual harm) when there was sufficient evidence in the 

survey report to cite the deficiency at the G level (actual harm). 

• State survey agency officials expressed confusion about the definition of 

“actual harm” and “immediate jeopardy,” suggesting that such confusion 

contributes to the variability in state deficiency trends. For example, 

officials in one state told us that, in their view, residents must experience 

functional impairment for state surveyors to cite an actual harm 

deficiency, an interpretation that CMS officials told us was incorrect. 

Under such a definition, repeated falls that resulted in bruises, cuts, and 

painful skin tears would not be cited as actual harm, even if the facility 

failed to assess the resident for measures to prevent falls. 

• CMS officials also told us that, contrary to federal guidance, state 

surveyors in at least one state did not cite all identified deficiencies but 

rather brought them to the homes’ attention with the expectation that the 

deficiencies would be corrected. CMS officials told us that they identified 

the problem by asking state officials about the unusually high number of 

homes with no deficiencies on their standard surveys. 

Investigation Weaknesses 

and Other Factors 

Contribute to 

Underreporting of Care 

Problems 

Investigation and 

Documentation Weaknesses 
Page 20 GAO-03-561 Nursing Home Quality 

Some state officials told us that considerable staff resources are devoted 

to scrutinizing the support for actual harm and higher-level deficiencies 

that could lead to the imposition of a sanction. While most of the 16 states 

we contacted had quality assurance processes to review deficiencies cited 

at the actual harm level and higher, half did not have such processes to 

help ensure that the scope and severity of less serious deficiencies were 

not understated.20 State officials generally told us that they lacked the staff 

and time to review deficiencies that did not involve actual harm or 

immediate jeopardy, but some states have established such programs. For 

example, Maryland established a technical assistance unit in early 2001 to 

review a sample of survey reports; the review looks at all deficiencies—

not just those involving actual harm or immediate jeopardy. A Maryland 

official told us that she had the resources to do so because the state 

legislature authorized a substantial increase in the number of surveyors in 

1999. However, staff cutbacks in late 2002 due to the state’s budget crisis 

have resulted in the reviews being less systematic than originally planned. 

In Colorado, two long-term-care supervisors reviewed all 1,351 

deficiencies cited in fiscal year 2001. Maryland and Colorado officials told 

us that the reviews have identified shortcomings in the investigation and 

documentation of deficiencies, such as the failure to interview residents or 

the classification of deficiencies as process issues when they actually 

involved quality of care. The reviews, we were told, provide an 

opportunity for surveyor feedback or training that improves the quality 

and consistency of future surveys. 

State officials cited the limited experience level of state surveyors as a 

factor contributing to the variability in citing actual harm or higher-level 

deficiencies and the understatement of such deficiencies. Data we 

obtained from 42 state survey agencies in July 2002 revealed the 

magnitude of the problem: in 11 states, 50 percent or more of surveyors 

had 2-years’ experience or less; in another 13 states, from 30 percent to 48 

percent of surveyors had similarly limited experience (see app. IV). For 

example, Alabama’s and Louisiana’s recent annual attrition rates were 29 

percent and 18 percent, respectively, and, as a result, almost half of the 

surveyors in both states had been on the job for 2 years or less. In 

California and Maryland—states that hired a significant number of new 

surveyors since 2000—52 percent and 70 percent of surveyors, 

 20Officials explained the focus on actual harm or higher-level deficiencies by noting that the 

potential for sanctions increased the likelihood that the deficiencies would be challenged 

by the nursing home and perhaps appealed in an administrative hearing. 

Inadequate Quality Assurance 

Processes 

Inexperienced State Surveyors
Page 21 GAO-03-561 Nursing Home Quality 

respectively, had less than 2 years of on-the-job experience.21 According to 

CMS regional office and state officials, the first year for a new surveyor is 

essentially a period of training and low productivity, and it takes as long as 

3 years for a surveyor to gain sufficient knowledge, experience, and 

confidence to perform the job well. High staff turnover was attributed, in 

part, to low salaries for RN surveyors—salaries that may not be 

competitive with other employment opportunities for nurses. Overall, 29 

of the 42 states that responded to our inquiry indicated that they believed 

nurse surveyor salaries were not competitive (see app. IV). Officials in 

several states also told us that the combination of low starting salaries and 

a highly competitive market forced them to hire less qualified candidates 

with less breadth of experience. 

Even though HCFA directed states, beginning January 1, 1999, to avoid 

scheduling a nursing home’s survey for the same month of the year as its 

previous survey, over one-third of state surveys remain predictable. Our 

analysis demonstrated little change in the proportion of predictable 

nursing home surveys. Predictable surveys can allow quality-of-care 

problems to go undetected because homes, if they choose to do so, may 

conceal problems.22 We recommended in 1998 that HCFA segment the 

standard survey into more than one review throughout the year, 

simultaneously increasing state surveyor presence in nursing homes and 

decreasing survey predictability. Although HCFA disagreed with 

segmenting the survey, it did recognize the need to reduce predictability. 

Our analysis of OSCAR data demonstrated that, on average, the timing of 

34 percent of current surveys nationwide could have been predicted by 

nursing homes, a slight reduction from the prior surveys when about 38 

percent of all surveys were predictable. The predictability of current 

surveys ranged from 83 percent in Alabama to 10 percent in Michigan (see 

app. V for data on all 50 states and the District of Columbia). In 34 states, 

25 percent to 50 percent of current surveys were predictable, as shown in 

 21As of July 2002, both states had vacant surveyor positions and a surveyor hiring freeze. 

22In commenting on a draft of this report, Arizona disagreed with the significance we 

attribute to survey predictability, questioning whether poor homes would, or even could, 

hide problems if they knew a survey was imminent. However, advocates and family 

members have told us that a home that operates with too few staff could temporarily 

augment its staff during the expected period of a survey in order to mask an otherwise 

serious deficiency—a common practice based on advocates’ own observations. 

Predictable Surveys 
Page 22 GAO-03-561 Nursing Home Quality 

table 4. In 9 states, more than 50 percent of current surveys were 

predictable.23

Table 4: Predictability of Nursing Home Surveys 

Percentage of predictable surveysa Number of statesb

More than 50 percent 9

25 percent to 50 percent 34

Less than 25 percent 8

Source: GAO analysis of OSCAR data as of April 9, 2002. 

a

We considered surveys to be predictable if (1) homes were surveyed within 15 days of the 1-year 

anniversary of their prior surveys, or (2) homes were surveyed within 1 month of the maximum 15-

month interval between standard surveys. 

b

Includes the District of Columbia. 

Most state agencies did not investigate serious complaints filed against 

nursing homes within required time frames, and practices for investigating 

complaints in many states may not be as effective as they could be. A CMS 

review of states’ timeliness in investigating complaints alleging harm to 

residents revealed that most states did not investigate all such complaints 

within 10 days, as CMS requires. Additionally, a CMS-sponsored study of 

complaint practices in 47 states raised concerns about state approaches to 

accepting and investigating complaints. 

Until March 1999, states could set their own complaint investigation time 

frames, except that they were required to investigate within 2 workdays all 

complaints alleging immediate jeopardy conditions. In March 1999, we 

reported that inadequate complaint intake and investigation practices in 

states we reviewed had too often resulted in extensive delays in 

investigating serious complaints.24 As a result of our findings, HCFA began 

requiring states to investigate complaints that allege actual harm, but do 

 23We considered surveys to be predictable if (1) homes were surveyed within 15 days of the 

1-year anniversary of their prior surveys (13 percent of homes, nationally) or (2) homes 

were surveyed within 1 month of the maximum 15-month interval between standard 

surveys (21 percent of homes, nationally). Because homes know the maximum allowable 

interval between surveys, those whose prior surveys were conducted 14 or 15 months 

earlier are aware that they are likely to be surveyed soon. 

24U.S. General Accounting Office, Nursing Homes: Complaint Investigation Processes 

Often Inadequate to Protect Residents, GAO/HEHS-99-80 (Washington, D.C.: Mar. 22, 1999). 

Many State Complaint 

Investigation Systems Still 

Have Timeliness Problems 

and Other Weaknesses 
Page 23 GAO-03-561 Nursing Home Quality 

not rise to the level of immediate jeopardy, within 10 workdays.25 CMS’s 

2001 review of a sample of complaints in all states demonstrated that 

many states were not complying with these requirements. Specifically, 12 

states were not investigating all immediate jeopardy complaints within the 

required 2 workdays, and 42 states were not complying with the 

requirement to investigate actual harm complaints within 10 days.26 The 

agency also found that the triaging of complaints to determine how quickly 

each complaint should be investigated was inadequate in many states. 

The extent to which states did not meet the 2-day and 10-day investigation 

requirements varied considerably. Officials from 12 of the 16 states we 

contacted indicated that they were unable to investigate complaints on 

time because of staff shortages. Oklahoma investigated only 3 of the 21 

immediate jeopardy complaints that CMS sampled within the required 2-

day period and none of 14 sampled actual harm complaints in 10 days. 

Oklahoma officials attributed this timeliness problem to staff shortages 

and a surge in the number of complaints received in 2000, from about 5 per 

day to about 35. The rising volume of complaints is a particular problem 

for California, which receives about 10,000 complaints annually, and had a 

20 percent increase in complaints from January 2001 through July 2002. 

State officials told us that California law requires all complaints alleging 

immediate jeopardy to a resident to be investigated within 24 hours and all 

others to be investigated within 10 days, and that the increase in the 

number of complaints requires an additional 32 surveyor positions.27 CMS 

regional officials told us that the vast majority of California complaints 

were investigated within 10 days. However, the 2001 review also showed 

that about 9 percent of the state’s standard surveys were conducted late.28

Both CMS and California officials indicated that the priority the state 

attaches to investigating complaints affected survey timeliness. Officials 

 25In some states, the 10-day requirement significantly compressed the time frame in which 

complaints alleging potential actual harm must be investigated. For instance, prior to 

HCFA’s change, such complaints were supposed to be investigated within 30 days in 

Michigan and 60 days in Tennessee. 

26Staff from each of CMS’s regional offices reviewed a 10 percent random sample of 

complaint files (maximum of 40 files) in each state. 

27According to a state official, a hiring freeze precluded increasing the number of surveyors. 

28Because CMS based its analysis of timeliness only on nursing homes that actually were 

surveyed during fiscal year 2001—and not on all homes in the state—the 9 percent figure is 

understated. Our analysis of all homes indicated that about 12 percent of the state’s homes 

were not surveyed within the required time frame. 
Page 24 GAO-03-561 Nursing Home Quality 

from Washington told us that their practice of investigating facility selfreported incidents led to their not meeting the 10-day requirement on all 

complaints that CMS reviewed. Washington investigated 18 of 20 sampled 

actual harm complaints on time—missing the 10-day requirement for the 

other two by 2 days and 4 days, respectively. Washington officials pointed 

out that the two complaints not investigated within 10 days were facility 

self-reported incidents and commented that many other states do not even 

require investigation of such incidents. Thus, in these other states, such 

incidents would not even have been included in CMS’s review. 

In its review of state complaint files, CMS also evaluated whether states 

had appropriately triaged complaints—that is, determined how quickly 

each complaint should be investigated. Most of the regions told us that one 

or more of their states had difficulty determining the investigation priority 

for complaints. In an extreme case, a regional office discovered that one of 

its states was prioritizing its complaints on the basis of staff availability 

rather than on the seriousness of the complaints. Several regions indicated 

that some states improperly assigned complaints to categories that 

permitted longer investigation time frames, and one region indicated that 

triaging difficulties involved state personnel not collecting enough 

information from the complainant to make a proper decision. Officials 

from some of the 16 state survey agencies we contacted indicated that 

HCFA’s 1999 guidance to states on what constitutes an actual harm 

complaint was unclear and confusing. 

In an effort to improve state responsiveness to complaints, HCFA hired a 

contractor in 1999 to assess and recommend improvements to state 

complaint practices. The study identified significant problems with states’ 

complaint processes, including complaint intake activities, investigation 

procedures, and complaint substantiation practices.29 For example, the 

report noted that 15 states did not have toll-free hotlines for the public to 

file complaints. In our earlier reports, we noted that the process of filing a 

complaint should not place an unnecessary burden on a complainant and 

that an easy-to-use complaint process should include a toll-free number 

that permits the complainant to leave a recorded message when state staff 

 29Center for Health Systems Research and Analysis at the University of Wisconsin, 

Madison, Final Report: Complaint Improvement Project, prepared for CMS, June 3, 2002. 

The report is based on a questionnaire sent to the 50 states, the District of Columbia, 

Puerto Rico, and CMS’s 10 regional offices. Three states did not respond to the 

questionnaire. The report treated the District of Columbia and Puerto Rico as states. 
Page 25 GAO-03-561 Nursing Home Quality 

are unavailable.30 Table 5 summarizes major findings from the contractor’s 

report to CMS. 

Table 5: Key Findings of Report to CMS on State Complaint Investigation Processes 

Finding Description 

States vary in the ease with 

which the public can file a 

complaint. 

Thirty-four states indicated that they provide toll-free 

hotlines for the public to file complaints. Twenty-nine of 

the 34 states indicated that they operate their hotlines 24 

hours a day, 7 days a week, and 5 said their hotlines 

were answered during business hours. Nineteen states 

had no provisions or plans to handle non-English 

speaking complainants. 

States need to improve their 

complaint intake and triaging 

systems. 

States need to better triage their complaints and decide 

which complaints should be referred to other agencies for 

investigation. They should also improve procedures for 

merging complaints with ongoing survey activities at a 

nursing home. More consistency is needed in handling 

facility self-reported incidents. 

State survey staffs that 

conduct complaint intake 

and investigation often have 

additional duties. 

States should use staff dedicated to investigating 

complaints to improve the quality of investigations. This 

might include assigning responsibility for a state’s total 

complaint system to a single complaint supervisor or 

coordinator and also may require more careful hiring 

standards with specific job qualifications. 

Investigation procedures 

vary across states. 

States do not use all available data when preparing for a 

complaint investigation. There is little agreement among 

states regarding how many resident records should be 

sampled during a complaint investigation.a 

 

Complaint investigation 

training is needed. 

Specialized complaint training and periodic refresher 

training on complaint intake, triaging, and investigation 

techniques are needed to improve the quality of 

complaint investigations. 

Resolution of complaints is 

inconsistent across states. 

States have developed varying criteria for determining 

what constitutes a substantiated complaint and varying 

practices for communicating the results of investigations 

to complainants. Twenty-two states could not indicate 

how long it takes them to provide the results of an 

investigation to the complainant, and at least four states 

do not inform the complainant of the results. 

Not all states have 

comprehensive complaint 

tracking systems, and CMS 

tracking systems are not upto-date or user friendly.b

Twenty states indicated that they could track the status of 

complaints and produce summary reports. 

Source: CMS. 

 30See GAO/HEHS-99-80 and U.S. General Accounting Office, Medicare Home Health 

Agencies: Weaknesses in Federal and State Oversight Mask Potential Quality Issues, 

GAO-02-382 (Washington, D.C.: July 19, 2002). 
Page 26 GAO-03-561 Nursing Home Quality 

Note: GAO analysis of information from Center for Health Systems Research and Analysis at the 

University of Wisconsin, Madison, Final Report: Complaint Improvement Project, prepared for CMS, 

June 3, 2002. 

a

In 1999, we reported that HCFA had not provided states with guidance on when to expand a 

complaint review beyond the residents who were the subject of the original complaint. See 

GAO/HEHS-99-80. 

b

CMS is planning to implement a new complaint tracking system nationwide that should address this 

shortcoming. 

State survey agencies did not refer 711 cases in which nursing homes were 

found to have a pattern of harming residents to CMS for immediate 

sanction as required by CMS policy.31 Our earlier work found that nursing 

homes tended to “yo-yo” in and out of compliance, in part because HCFA 

rarely imposed sanctions on homes with a pattern of deficiencies that 

harmed residents.32 In response, the agency required that homes found to 

have harmed residents on successive standard surveys be referred to it for 

immediate sanction.33 Most states did not refer at least some cases that 

should have been referred under this policy.34 Figure 1 shows the results of 

our analysis for the four states—Massachusetts, New York, Pennsylvania, 

and Texas—with the greatest numbers of cases that should have been 

 31Using CMS data, we identified 1,334 cases that appeared to meet the criteria for 

immediate sanctions but that did not appear to have been referred to CMS by states. (See 

app. I for a description of our methodology.) We use the term “cases” rather than “nursing 

homes” because some nursing homes had multiple referrals for immediate sanctions. At 

our request, CMS reviewed most of these cases and determined that 711 (62 percent of 

those CMS reviewed) should have been—but were not—referred for immediate sanction. 

CMS did not analyze 155 of the cases we asked it to examine and was unable to determine 

the status of an additional 30 cases. 

32See GAO/HEHS-99-46. 

33This policy was implemented in two stages, and our analysis focused on implementation 

of the second stage in January 2000. Beginning in September 1998, HCFA required states to 

refer homes that had a pattern of harming a significant number of residents or placed 

residents at high risk of death or serious injury (H-level deficiencies and above on CMS’s 

scope and severity grid). Effective January 14, 2000, HCFA expanded this policy by 

requiring state survey agencies to refer for immediate sanction homes that had harmed 

residents—G-level deficiencies on the agency’s scope and severity grid—on successive 

surveys. States are now required to deny a grace period to homes that are assessed one or 

more deficiencies at the actual harm level or above (G-L on CMS’s scope and severity grid) 

in each of two surveys within a survey cycle. A survey cycle is two successive standard 

surveys and any intervening survey, such as a complaint investigation. 

34We found that states did refer 4,310 cases over a 27-month period. See app. VI for a 

summary of all sanctions that were implemented, including the amount of civil money 

penalties (CMPs) by state. 

States Did Not Refer a 

Substantial Number of 

Nursing Homes to CMS for 

Immediate Sanctions 
Page 27 GAO-03-561 Nursing Home Quality 

referred and for the nation (see app. VII for information on all states). 

These four states accounted for 55 percent of the 711 cases. 

Figure 1: Four States with the Greatest Number of Cases that Should Have Been Referred for Immediate Sanctions, January 

14, 2000, through March 28, 2002 

Note: Analysis includes cases entered in CMS’s enforcement database by March 28, 2002. 

a

According to a Dallas regional office official, Texas referred most of the 423 cases because the 

nursing homes had a “poor enforcement history,” not because of repeat harm level deficiencies. 

However, based on other information, the region coded these cases as requiring immediate sanction. 

State and CMS officials identified several reasons why state agencies failed 

to forward cases to CMS for immediate sanction, including (1) an initial 

misunderstanding of the policy on the part of some states and regions, (2) 

poor state systems for monitoring the survey history of homes to identify 

those meeting the criteria for referral for immediate sanction, and (3) 

actions, by two states, that were at variance with CMS policy. First, 

officials from some states—and some CMS regional officials as well—told 

0 100 200 300 400 500 600 700 800

Pennsylvania

Massachusetts

New York

Texasa

Nation

State

5000

164

81

22

423

38

46

140

169

50

0

0

66

4310

711

155

CMS did not determine if cases should have been referred

Cases that should have been referred and were not

Cases that were referred 

Cases

Source: GAO and CMS analysis of OSCAR and enforcement data.
Page 28 GAO-03-561 Nursing Home Quality 

us that they did not initially fully understand the criteria for referring 

homes for immediate sanction.35 For example, several states and CMS 

regional offices reported that they did not understand that CMS required 

states to look back before the January 2000 policy implementation date to 

determine if there was an earlier survey with an actual-harm-level 

deficiency. The look-back requirement was specifically addressed in a 

February 10, 2000, CMS policy clarification specifying that state agencies 

were to consider the home’s survey history before the January 14, 2000, 

implementation date in determining if a home met the criteria for 

immediate referral for sanction. However, officials in one region told us 

that they had instructed three of four states not to look back before the 

January 2000 implementation date of the policy. Two other regional offices 

told us that CMS policy did not require the state to look back before 

January 2000 for earlier surveys. Officials at another regional office did not 

recall the look-back policy at the time we talked to them in mid-2002, and 

were not sure what advice they had given their states when the policy was 

first implemented. 

Second, some state survey agencies told us that their managers 

responsible for enforcement did not have an adequate methodology for 

checking the survey history of homes to identify those meeting the criteria. 

Some states said that their managers relied on manual systems, which are 

less accurate and sometimes failed to identify cases that should have been 

referred. Officials in one state told us that its district offices had no 

consistent procedure for checking the survey history of homes. An official 

in another state told us that some cases were not referred because time 

lags in reporting some surveys meant that an earlier survey—such as a 

complaint survey—with an actual harm deficiency might not have been 

entered in the state’s tracking system until after a later survey that also 

found harm-level deficiencies. 

Third, two states did not implement CMS’s expanded policy on immediate 

sanctions. New York was in direct conflict with CMS policy. Although CMS 

policy calls for state referrals to CMS regardless of the type of deficiency, 

 35Arizona’s comments on a draft of this report indicated that eight of the nine cases not 

referred for immediate sanction were during the period January through October 2000 

when the state was struggling with various interpretations of CMS’s new requirement. 

Similarly, Missouri officials indicated in their comments that the majority of cases they did 

not refer occurred during the initial stages of the new policy, which Missouri believes was 

“complicated, at best.” Missouri officials added that the number of missed cases 

significantly declined as the state gained a better understanding of the policy. 
Page 29 GAO-03-561 Nursing Home Quality 

a state agency official told us that the state only referred a home to CMS 

for immediate sanction if both actual harm citations were for the exact 

same deficiency.36 A CMS official indicated that New York began 

complying with the policy in September 2002.37 Texas, the second state, 

did not implement the CMS policy statewide until July 2002, when it 

received our inquiry about the cases not referred for immediate sanction. 

In the interim from January 2000 through July 2002, three of Texas’s 11 

district offices specifically requested from state survey agency officials, 

and were granted, permission to implement the policy. 

While CMS has increased its oversight of state survey and complaint 

activities and instituted a more systematic oversight process by initiating 

annual state performance reviews, CMS officials acknowledged that the 

effectiveness of the reviews could be improved. In particular, CMS 

officials told us that for the initial state performance review in fiscal year 

2001, they lacked the capability to systematically distinguish between 

minor lapses identified during the reviews and more serious problems that 

require intervention. CMS oversight is also hampered by continuing 

limitations in OSCAR data, the inability or reluctance of some CMS regions 

to use such data to monitor state activities, and inadequate oversight of 

certain areas, such as survey predictability and state referral of homes for 

immediate enforcement actions. CMS has restructured regional office 

responsibilities to improve the consistency of federal oversight and plans 

to further strengthen oversight by increasing the number of federal 

comparative surveys. However, three federal initiatives critical to reducing 

the subjectivity evident in the current survey process and the investigation 

of complaints have been delayed. 

 36This New York state official told us that the state believed it was in compliance with 

CMS’s policy because it imposed one of two minor federal sanctions and a state civil 

money penalty on all consecutive G-level cases. This state official also indicated that state 

fines were imposed in place of federal civil money penalties in all cases. (The maximum 

state fine is $2,000 per violation, lower than the federal maximum of $10,000 per instance 

or per day of noncompliance.) However, when we discussed this explanation with officials 

in the CMS central office, they disagreed that the state was in compliance. 

37In commenting on a draft of our report, New York officials indicated that their initial 

failure to refer nursing homes for immediate sanctions was based on their 

misinterpretation of the new policy and not on a deliberate refusal to implement it. They 

also indicated that their procedures are now consistent with the federal policy. 

CMS Oversight of 

State Survey 

Activities Requires 

Further Strengthening 
Page 30 GAO-03-561 Nursing Home Quality 

In the first of what is planned as an annual process, CMS’s 10 regional 

offices reviewed states’ fiscal year 2001 performance for seven standards 

to determine how well states met their nursing home survey 

responsibilities (see app. VIII for a description of the seven standards).38

This enhanced oversight of state survey agency performance responds to 

our prior recommendations. In 1999, we reported that HCFA’s oversight of 

state efforts had limitations preventing it from developing accurate and 

reliable assessments of state performance.39 HCFA regional office policies, 

practices, and oversight had been inconsistent, a reflection of coordination 

problems between HCFA’s central office and its regional staffs. In 

important areas, such as the adequacy of surveyors’ findings and 

complaint investigations, HCFA relied on states to evaluate their own 

performance and report their findings to HCFA. Although OSCAR data 

were available to HCFA for monitoring state performance, they were 

infrequently used, and neither the states nor HCFA’s regional offices were 

held accountable for failing to meet or enforce established performance 

standards. 

To promote consistent application of the standards across the 10 regions, 

the agency developed detailed guidance for measuring each standard, 

including the method of evaluation, the data sources to be used, and the 

criteria for determining whether a state met a standard. Only two states 

met each of the five standards we reviewed and many did not meet several 

standards. Appendix IX identifies the standards we analyzed and the 

results of CMS’s review of these standards. During the 2001 review, CMS 

elected not to impose the most serious sanctions available for inadequate 

state performance, including reducing federal payments to the state or 

initiating action to terminate the state’s agreement, but advised the states 

that annual reviews in subsequent years will serve as the basis for such 

actions. While imposing no sanctions during the 2001 review, CMS did 

require several states to prepare corrective action plans. Each year, CMS 

plans to update and improve the standards based on experience gained in 

prior years. 

 38The CMS regions assessed each state’s performance by (1) reviewing a set of standardized 

reports drawn from information contained in CMS’s databases and (2) visiting states to 

review procedures and to examine a sample of records, such as complaint investigation 

files. Some reviews, such as assessing state complaint investigation timeliness, were 

performed semiannually, enabling regional office staff to provide midpoint feedback 

intended to correct any deficiencies identified. 

39GAO/HEHS-00-6. 

CMS Reviews of State 

Performance Have 

Identified Areas for 

Improvement 
Page 31 GAO-03-561 Nursing Home Quality 

Characterizing its fiscal year 2001 state performance review as a “shakeout 

cruise,” CMS is working to address several weaknesses identified during 

the reviews, including difficulty in determining if identified problems were 

isolated incidents or systemic problems, flawed criteria for evaluating a 

critical standard, and inconsistencies in how regional offices conducted 

the reviews. In our discussions of the results of the performance reviews 

with officials of CMS’s regional offices, it was evident that some regions 

had a much better appreciation of the strengths and weaknesses of survey 

activities in their respective states than was reflected in the state 

performance reports. However, this information was not readily available 

to CMS’s central office. In addition, CMS has not released a summary of 

the review to permit easy comparison of the results. For subsequent 

reviews, CMS plans to more centrally manage the process to improve 

consistency and help ensure that future reviews distinguish serious from 

minor problems. 

CMS officials acknowledged that the first performance review did not 

provide adequate information regarding the seriousness of identified 

problems. The agency indicated that it had since revised the performance 

standards to enable it to determine the seriousness of the problems 

identified. Some regional office summary reports provided insufficient 

information to determine whether a state did not meet a particular 

standard by a wide or a narrow margin. For example, although California 

did not meet the standard to investigate all complaints alleging actual 

harm within 10 days, the regional office summary provided no details 

about the results. Regional officials told us that they found very few 

California complaints that were not investigated within the 10-day 

deadline and those that were not were generally investigated by the 13th 

day.40 Conversely, although the report for Oregon shows that the state met 

the 10-day requirement, our discussions with regional officials revealed 

that serious shortcomings nevertheless existed in the state’s complaint 

investigation practices. 41 Officials in the Seattle region told us that for 

many years Oregon had contracted out investigations of complaints to 

local government entities not under the control of the state agency and, as 

 40According to CMS regional officials, California state law requires that all complaints other 

than those alleging immediate jeopardy be investigated within 10 days, irrespective of the 

seriousness of the allegation. 

41CMS’s database showed that Oregon conducted only 14 on-site complaint investigations 

during fiscal year 2001. Because of this low number, the region reviewed the entire 

universe of complaints (instead of a sample), but did not identify the number reviewed in 

its report. 

CMS’s State Performance 

Standards and Review Had 

Shortcomings 

Distinctions in State 

Performance Were Hard to 

Identify 
Page 32 GAO-03-561 Nursing Home Quality 

a result, exercised little control over the roughly 2,000 complaints the state 

receives against nursing homes each year. For instance, under this 

arrangement, information about complaint investigations, including 

deficiencies identified, was not entered into CMS’s database. Regional 

officials told us that the Oregon state agency recently assumed 

responsibility for investigating complaints filed by the public, but that the 

local government entities continue to investigate facility self-reported 

incidents. 

CMS’s standard for measuring how well states document deficiencies 

identified during standard surveys was flawed because it mixed major and 

minor issues, blurring the significance of findings. CMS’s protocol required 

assessment of 33 items, ranging from the important issue of whether state 

surveyors cited deficiencies at the correct scope and severity level to the 

less significant issue of whether they used active voice when writing 

deficiencies. Because of the complexity of the criteria and concerns about 

the consistency of regional office reviews of states’ documentation 

practices, CMS decided not to report the results for this standard for 2001. 

For the 2002 review, CMS reduced the number of criteria to be assessed 

from 33 to 7.42 Based on the available evidence of the understatement of 

actual harm deficiencies, we believe that successful implementation of the 

documentation standard in 2002 and future years is critical to help ensure 

that deficiencies are cited at the appropriate scope and severity level. 

CMS’s regional offices were sometimes inconsistent in how they 

conducted their reviews, raising questions about the validity and fairness 

of the results. For example: 

• Although the guidelines for the review indicated that the regional offices 

were to assess the timeliness of complaint investigations based on the 

state’s prioritization of the complaint, officials from one region told us that 

they judged timeliness based on their opinion of how the complaint should 

have been prioritized. 

 42CMS’s criteria for evaluating the documentation standard in 2002 are (1) the proper 

regulation is cited for each deficiency, (2) evidence supports the cited area of 

noncompliance, (3) several components required by the relevant regulation for each 

deficiency, such as identifying the citation number, are included, (4) the deficient practice 

is identified, (5) the cited severity of each deficiency is accurate, (6) the cited scope of each 

deficiency is accurate, and (7) the sources and identifiers in the deficient practice 

statement match the sources and identifiers in the findings. 

CMS’s Standard for Measuring 

States’ Documentation of 

Deficiencies Was Flawed 

CMS Regions’ Reviews Were 

Inconsistent 
Page 33 GAO-03-561 Nursing Home Quality 

• Two regional offices acknowledged that they did not use clinicians to 

review complaint triaging. Officials from two states questioned the 

credibility of reviews not conducted by clinicians. 

• Although one objective of the reviews was to review some immediate 

jeopardy complaints in every state, the random samples selected in some 

states did not yield such complaints. In such cases, one region indicated 

that it specifically selected a few immediate jeopardy complaints outside 

the sample while another region did not. To eliminate this inconsistency in 

future years, CMS has instructed the regions to expand their sample to 

ensure that at least two immediate jeopardy complaints are reviewed in 

each state. 

• While some regions examined more than the required number of 

complaints to assess overall timeliness, one region felt that additional 

reviews were unnecessary. For instance, surveyors reviewing California, 

which receives thousands of complaints per year, expanded the number of 

complaints reviewed beyond the minimum number required because they 

felt that the required random sample of 40 complaints did not provide 

sufficient information about overall timeliness in the state. To assess 

overall timeliness, they visited all but 1 of the state’s 17 district offices to 

review complaints. However, surveyors from another CMS region 

reviewed only 3 or 4 of the roughly 18 complaints a state received and told 

us that additional reviews were unnecessary because the state had already 

failed the timeliness criterion based on the few complaints reviewed. 

Although the review of 3 or 4 complaints technically met CMS’s sampling 

requirement, we believe examination of most or all of the relatively few 

remaining complaints would have provided a more complete picture of the 

state’s overall timeliness. 

While CMS has addressed some of the weaknesses in its 2001 state 

performance review by revising the standards and guidance for the 2002 

review, including simplifying the criteria for assessing documentation and 

requiring regions to assess states’ complaint prioritization efforts 

separately from the timeliness issue, the performance standards do not yet 

address certain issues that are important for assessing state performance 

and that would further strengthen CMS oversight of state survey activities. 

These issues include: 

• Assessing the predictability of state surveys. Although CMS 

monitored compliance with its requirement for state survey agencies to 

initiate at least 10 percent of their standard surveys outside normal 

working hours to reduce predictability, it did not examine compliance 

with its 1999 instructions for states to avoid scheduling a home’s survey 

during the same month each year. As shown in app. V, our analysis of CMS 

data found that from 10 percent to 31 percent of surveys in 31 states were 

Performance Standards 

Excluded Some Important 

Areas 
Page 34 GAO-03-561 Nursing Home Quality 

predictable because they were initiated within 15 days of the 1-year 

anniversary of the prior survey. 

• Evaluating states’ compliance with the requirement to refer 

nursing homes that have a pattern of harming residents for 

immediate sanctions. CMS officials confirmed that there was no 

consistent oversight of state agencies’ implementation of this policy. 

Several CMS regional offices generally did not know, for example, how 

their states were monitoring homes’ survey history to detect cases that 

should be referred for immediate sanction. CMS could have used the 

enforcement database to determine that New York was not adhering to the 

agency’s immediate sanctions policy. During calendar years 2000 and 2001, 

New York cited actual harm at a relatively high proportion of its nursing 

homes but only referred 19 cases for immediate sanction. Over a 

comparable period, New Jersey, a state with far fewer homes and 

citations, referred almost three times as many cases.43

• Developing better measures of the quality of state performance, in 

addition to process measures. Several CMS regional officials believed 

that the scope of the state performance standards should address 

additional areas of performance, including assessing the adequacy of 

nursing homes’ plans of correction submitted in response to deficiencies 

and the appropriateness of states’ recommended enforcement remedies. In 

particular, several regions noted that rather than focusing only on the 

timeliness of complaint investigations, regions should also assess the 

adequacy of the investigation itself, including whether the complaint 

should have been substantiated. The introduction of a new CMS complaint 

tracking database, discussed below, should enable regions to automate the 

review of complaint timeliness, thereby allowing them to focus more 

attention on such issues. 

CMS’s oversight of state survey activities is further hampered by 

limitations in the data used to develop the 19 periodic reports intended to 

assist the regions in monitoring state performance and by the regions’ 

inconsistent use of the reports.44 For instance, CMS’s current complaint 

database does not provide key information about the number of 

 43While cases referred by states were typically recorded in CMS’s enforcement database, a 

New York regional official indicated that because of the departure of key staff members, 

the region had not entered all cases into the database. 

44CMS’s central office and the regions have jointly produced the reports since they were 

created in 2000. As CMS’s systems become more user-friendly, the regions will be able to 

produce them independently. 

Data Limitations and 

Inconsistent Use of 

Periodic Reports Hamper 

Oversight 
Page 35 GAO-03-561 Nursing Home Quality 

complaints each state receives (including facility self-reported incidents) 

or the time frame in which each complaint is investigated.45 In addition, 

officials from one region emphasized to us that information about 

complaints provided in the reports did not correspond with CMS’s 

required complaint investigation time frames. The reports identify the 

number of state on-site complaint investigations that took place in three 

different time periods—3 days, from 4 to 14 days, and 15 days or more; 

however, required time frames for complaint investigations are 2 days for 

complaints alleging immediate jeopardy and 10 days for those alleging 

harm. Additionally, a regional official pointed out that investigations 

shown in one of the reports as taking place within 3 days do not 

necessarily represent complaints that the state prioritized as immediate 

jeopardy. Despite the problems with these data, however, several regional 

offices indicated that the reports could at least serve as a starting point for 

discussions with states about their complaint programs and often lead to a 

better understanding of state complaint activities. CMS indicated that the 

deficiencies in complaint data should be addressed by the new automated 

complaint tracking system that it is developing for use by all states as part 

of the redesign of OSCAR.46

Officials from several regions also told us that the value of some of the 

19 periodic reports was unclear, and officials in three regions said they 

either lacked the staff expertise or the time to use the reports routinely to 

oversee state activities. For example, officials in one region told us that 

 45As we reported previously, although HCFA standards require states to report information 

about complaints, the process for collecting it results in inaccurate and incomplete 

information. For example, the form CMS requires states to use to record the results of 

complaint investigations was created to record information about a single complaint, but 

many states investigate multiple complaints at a nursing home during one on-site visit. As a 

result, the timeliness, prioritization, and other important tracking information related to 

multiple complaints is reported as though it applies to one complaint. See 

GAO/HEHS-99-80. 

46CMS planned to implement the new system, known as the ASPEN Complaint Tracking 

System, or ACTS, nationwide in October 2002. However, implementation was delayed 

because of several issues that surfaced during pilot testing: (1) states have different 

policies regarding the treatment of self-reported facility incidents, (2) complaints filed with 

some states may be investigated by entities other than the state survey agency (for 

instance, the Board of Nursing), and (3) 8 to 10 states have indicated that their current 

state complaint tracking systems have superior capability to ACTS and they do not wish to 

discontinue using their own system or maintain separate systems. CMS plans to evaluate 

this last issue during the extended pilot test. As of July 2003, nationwide implementation 

had been further delayed by the need to obtain approval from the Office of Management 

and Budget for publication of a notice in the Federal Register, a procedure that applies to 

establishing a system of federal records. 
Page 36 GAO-03-561 Nursing Home Quality 

they used one of the reports about complaints to ask states questions 

about their prioritization practices. But a different region appeared 

unaware that the reports showed that two of its states might be outliers in 

terms of the percentage of complaints they prioritized as actual harm or 

immediate jeopardy. Additionally, because the periodic reports do not 

include trend data, many regional offices were unaware of the trends in 

the percentage of homes cited in their states for actual harm or immediate 

jeopardy. We believe that such data could be useful to CMS’s regions in 

identifying significant trends in their states. 

CMS indicated that it is continuing to make progress in redesigning the 

OSCAR reporting system. In 1999, we recommended that the agency 

develop an improved management information system that would help it 

track the status and history of deficiencies, integrate the results of 

complaint investigations, and monitor enforcement actions.47 Another 

objective of the OSCAR redesign is to make it easier to analyze the data it 

contains, addressing the problem that generating analytical reports from 

OSCAR was difficult and most regions lacked the expertise to do so. The 

redesigned system, called the Quality Improvement and Evaluation 

System, would also eliminate the need for duplicate data entry, which 

should reduce the potential for data entry errors to which OSCAR is 

susceptible.48 CMS has faced some problems in the implementation of the 

new system, such as inadvertent modifications of survey data results when 

data are transferred from the old OSCAR database into the new system, 

but the agency indicated that its target date for completing the redesign is 

2005. 

CMS has taken, or is undertaking, several other efforts to improve federal 

oversight and survey procedures, including making structural changes to 

the regional offices to improve coordination, expanding the number of 

comparative surveys conducted each year, improving the survey 

methodology, developing clearer guidance for surveyors, and developing 

additional guidance to states for investigating complaints. As of April 2003, 

only the effort to restructure the regional offices had been completed. The 

 47GAO/HEHS-99-46. 

48Until recently, states had to manually enter data into a computerized system that 

generated survey reports and then manually reenter much of the same data into OSCAR. 

This duplicative data entry process increased the chances for errors in OSCAR. 

CMS Is Making Progress 

but Also Encountering 

Delays in Several Key 

Efforts 
Page 37 GAO-03-561 Nursing Home Quality 

other efforts critical to reducing the subjectivity evident in the current 

survey process and the investigation of complaints have been delayed. 

In December 2002, CMS reduced the number of regional managers in 

charge of survey activities from 10 (1 per region) to 5, a change intended 

to provide more management attention to survey matters and to improve 

accountability, direction, and leadership. Our prior and current work 

found that regional offices’ policies, practices, and oversight were often 

inconsistent. For example, in 1999 we reported that regional offices used 

different criteria for selecting and conducting comparative surveys. The 5 

regional managers will be responsible only for survey and certification 

activities, while in the past many of the 10 were also responsible for 

managing their regions’ Medicaid programs. 

In response to our prior recommendations, CMS plans to more than 

double the number of federal comparative surveys in which federal 

surveyors resurvey a nursing home within 2 months of the state survey to 

assess state performance. We noted in 1999 that, although insufficient in 

number, comparative surveys were the most effective technique for 

assessing state agencies’ abilities to identify serious deficiencies in nursing 

homes because they constitute an independent evaluation of the state 

survey. CMS plans to hire a contractor to perform approximately 170 

additional comparative surveys per year, bringing the annual total of 

comparative surveys performed by both CMS surveyors and the contractor 

to about 330. Although CMS had intended to award a contract and begin 

surveys by spring 2003, as of July 2003, it was still in the process of 

identifying qualified contractors. CMS officials stated that using a 

contractor would provide CMS flexibility because if it suspects that a state 

or region is having problems with surveys, it can quickly have the 

contractor conduct several comparative surveys there. Being able to direct 

the contractor to quickly focus on states or regions where state surveys 

may be problematic could represent a significant improvement in CMS’s 

oversight of state survey agencies. 

CMS’s implementation schedules have slipped for three critical initiatives 

intended to enhance the consistency and accuracy of state surveys and 

complaint investigations, delaying the introduction of improved 

methodologies or guidance until 2003 or 2004. Because surveyors often 

missed significant care problems due to weaknesses in the survey process, 

HCFA took some initial steps to strengthen the survey methodology, with 

the goal of introducing an improved survey process in 2000. In July 1999, 

the agency introduced quality indicators to help surveyors do a better job 

of selecting a resident sample, instructed states to increase the sample size 

CMS Is Taking Additional Steps 

to Address Inconsistencies in 

Regional Office Performance 

and Improve Federal Oversight 

Key Initiatives to Improve 

Survey Consistency and 

Complaint Investigations Have 

Been Delayed 
Page 38 GAO-03-561 Nursing Home Quality 

in areas of particular concern, and required the use of investigative 

protocols in certain areas, such as pressures sores and nutrition, to help 

make the survey process more systematic.49 However, HCFA recognized 

that additional steps were required to ensure that surveyors thoroughly 

and systematically identify and assess care problems. 

To address remaining problems with sampling and the investigative 

protocols, CMS contracted for the development of a revised survey 

methodology. The contractor has proposed a two-phase survey process.50

In the first phase, surveyors would initially identify potential care 

problems using quality indicators generated off-site prior to the start of the 

survey and additional, standardized information collected on-site, from a 

sample of as many as 70 residents. During the second phase, surveyors 

would conduct an investigation to confirm and document the care 

deficiencies initially identified.51 According to CMS officials, this process 

differs from the current methodology because it would more 

systematically target potential problems at a home and give surveyors new 

tools to more adequately document care outcomes and conduct on-site 

investigations. Use of the new methodology could result in survey findings 

that more accurately identify the quality of care provided by a nursing 

home to all of its residents.52 Initial testing to evaluate the proposed 

methodology focused primarily on the first phase and was completed in 

 49Quality indicators are derived from nursing homes’ assessments of residents and rank a 

facility in 24 areas compared with other nursing homes in a state. By using the quality 

indicators to select a preliminary sample of residents before the on-site review, surveyors 

are better prepared to identify potential care problems. 

50The agency is committed to implementing only those portions of the new methodology 

that are proven to be significantly more effective than the current survey methodology. 

CMS officials said the new process must be manageable and easy to use, add no additional 

time to surveys, and require limited additional training resources. Given the high turnover 

among surveyors and state budget constraints, the agency is particularly concerned about 

imposing new training requirements that would interfere with the conduct of mandatory 

surveys. 

51A minimum of three residents would be included in the sample for each of the care 

problems identified in phase one, which covers as many as 33-35 resident-care areas. 

52The goals of the new survey methodology are to (1) ensure that all areas of care are 

addressed, (2) make the survey process more data-driven and less reliant on surveyor 

judgment, thus reducing variability in the citation of serious deficiencies, (3) focus 

surveyors’ attention more on nursing homes with poor quality and less on better 

performing homes, (4) more reliably determine the scope of deficiencies at nursing homes, 

that is, the number of residents potentially or actually affected, and (5) produce better 

documented and defensible survey deficiencies. 
Page 39 GAO-03-561 Nursing Home Quality 

three states during 2002. As of April 2003, a CMS official told us that the 

agency lacked adequate funding to conduct further testing that more fully 

incorporates phase two. As a result, it is not clear when changes to survey 

methodology will be implemented. We continue to believe that redesign of 

the survey methodology, under way since 1998, is necessary for CMS to 

fully respond to our past recommendation to improve the ability of 

surveys to effectively identify the existence and extent of deficiencies. 

While CMS’s goal of not adding additional time to surveys is an important 

consideration, it should not take priority over the goal of ensuring that 

surveys are as effective as possible in identifying the quality of care 

provided to residents. 

Recognizing inconsistencies in how the scope and severity of deficiencies 

are cited across states, in October 2000, HCFA began developing more 

structured guidance for surveyors, including survey investigative protocols 

for assessing specific deficiencies. The intent of this initiative is to enable 

surveyors to better (1) identify specific deficiencies, (2) investigate 

whether a deficiency is the result of poor care, and (3) document the level 

of harm resulting from a home’s identified deficient care practices. The 

areas originally targeted for this initiative included deficiencies related to 

pressure sores, urinary catheters and incontinence, activities 

programming, safe food handling, and nutrition. Delays have occurred 

because CMS is committed to incorporating the work of multiple expert 

panels and two rounds of public comments for each deficiency. The 

project has been further delayed because the approach used to identify 

resident harm shifted during the course of work. The process should 

proceed more quickly, however, now that CMS has developed its 

approach. CMS expected to release the first new guidance, addressing 

pressure sores, in early 2003, but officials were unable to tell us how many 

of the 190 federal nursing home requirements will ultimately receive new 

guidance or a specific time line for when this initiative will be completed.53

As discussed earlier, CMS’s state performance reviews include an 

assessment of state surveyors’ documentation of the scope and severity of 

a sample of deficiencies cited, which should provide CMS with an 

opportunity to assess the effectiveness of the new guidance. 

Finally, despite initiation of a complaint improvement project in 1999, 

CMS has not yet developed detailed guidance for states to help improve 

their complaint systems. Effective complaint procedures are critical 

 53As of July 2003, the guidance had not yet been released. 
Page 40 GAO-03-561 Nursing Home Quality 

because complaints offer an opportunity to assess nursing home care 

between standard surveys, which can be as long as 15 months apart. In 

1999, HCFA commissioned a contractor to assess and recommend 

improvements to state complaint practices. CMS received the contractor’s 

final report in June 2002, and indicated agreement with the contractor that 

reforming the complaint system is urgently needed to achieve a more 

standardized, consistent, and effective process. The study identified 

serious weaknesses in state complaint processes (see table 5) and made 

numerous recommendations to CMS for strengthening them. Key 

recommendations were that CMS increase direction and oversight of 

states’ complaint processes and establish mechanisms to monitor states’ 

performance. CMS indicated that it has already taken steps to address 

these recommendations by initiating annual performance reviews that 

include evaluating the timeliness of state complaint investigations and the 

accuracy of states’ complaint triaging decisions, and by developing the 

new ASPEN complaint tracking system, which should provide more 

complete data about complaint activities than the current system. The 

contractor also recommended that CMS (1) expand outreach for the 

initiation of complaints, such as use of billboards or media advertising, 

(2) enhance complaint intake processes by using professional intake staff, 

(3) improve investigation and resolution processes by using available data 

about the home being investigated and establishing uniform definitions 

and criteria for substantiating complaints, (4) make the process more 

responsive by conducting timely investigations and allowing the 

complainant to track the progress of the investigation, and (5) establish a 

higher priority for complaint investigations in the state survey agency. 

CMS noted that some of these recommendations are beyond the agency’s 

purview and will require the support of all stakeholders to accomplish. 

CMS told us that it plans to issue new guidance to the states in late fiscal 

year 2003—about 4 years after the complaint improvement project 

initiative was launched. 

As we reported in September 2000, continued federal and state attention is 

required to ensure necessary improvements in the quality of care provided 

to the nation’s vulnerable nursing home residents. The reported decline in 

the percentage of homes cited for serious deficiencies that harm residents 

is consistent with the concerted congressional, federal, and state attention 

focused on addressing quality-of-care problems. More active and datadriven oversight is increasing CMS’s understanding of the nature and 

extent of weaknesses in state survey activities. Despite these efforts, 

however, the proportion of homes reported to have harmed residents is 

still unacceptably high. It is therefore essential that CMS fully implement 

Conclusions 
Page 41 GAO-03-561 Nursing Home Quality 

key initiatives to improve the rigor and consistency of state survey, 

complaint investigation, and enforcement processes. 

The seriousness of the challenge confronting CMS in ensuring consistency 

in state survey activities is also becoming more apparent. Our work, as 

well as that of CMS, demonstrates the persistence of several long-standing 

problems and also provides insights on factors that may be contributing to 

these shortcomings: 

• state surveyors continue to understate serious deficiencies that caused 

actual harm or placed residents in immediate jeopardy; 

• deficiencies are often poorly investigated and documented, making it 

difficult to determine the appropriate severity category; 

• states focus considerable effort on reviewing proposed actual harm 

deficiencies, but many have no quality assurance processes in place to 

determine if less serious deficiencies are understated or have investigation 

and documentation problems; 

• the timing of too many surveys remains predictable, allowing problems to 

go undetected if a home chooses to conceal deficiencies; 

• numerous weaknesses persist in many states’ complaint processes, 

including the lack of consumer toll-free hotlines in many states, confusion 

over prioritization of complaints, inconsistent complaint investigation 

procedures, and the failure of most states to investigate all complaints 

alleging actual harm within 10 days, as required; and 

• states did not refer a substantial number of homes that had a pattern of 

harming residents to CMS for immediate sanctions. 

Over the past several years, CMS has taken numerous steps to improve its 

oversight of state survey agencies, but needs to continue its efforts to help 

better ensure consistent compliance with federal requirements. Several 

areas that require CMS’s ongoing attention include (1) the newly 

established standard performance reviews to ensure that critical elements 

of the review, such as assessing states’ ability to properly document 

deficiencies, are successfully implemented, (2) the successful 

modernization of CMS’s data system by 2005 to support the survey process 

and provide key information for monitoring state survey activities, (3) the 

planned expansion of comparative surveys to improve federal oversight of 

the state survey process, (4) the survey methodology redesign intended to 

make the survey process more systematic, (5) the development of more 

structured guidance for surveyors to address inconsistencies in how the 

scope and severity of deficiencies are cited across states, and (6) the 

provision of detailed guidance to states to ensure thorough and consistent 

complaint investigations. Some of these efforts have been under way for 
Page 42 GAO-03-561 Nursing Home Quality 

several years, and CMS has consistently extended their estimated 

completion and implementation dates. We believe that effective 

implementation of planned improvements in each of these six areas is 

critical to ensuring better quality care for the nation’s 1.7 million nursing 

home residents. 

To strengthen the ability of the nursing home survey process to identify 

and address problems that affect the quality of care, we recommend that 

the Administrator of CMS 

• finalize the development, testing, and implementation of a more rigorous 

survey methodology, including guidance for surveyors in documenting 

deficiencies at the appropriate level of scope and severity. 

To better ensure that state survey and complaint activities adequately 

address quality-of-care problems, we recommend that the Administrator 

• require states to have a quality assurance process that includes, at a 

minimum, a review of a sample of survey reports below the level of actual 

harm (less than G level) to assess the appropriateness of the scope and 

severity cited and to help reduce instances of understated quality-of-care 

problems. 

• finalize the development of guidance to states for their complaint 

investigation processes and ensure that it addresses key weaknesses, 

including the prioritization of complaints for investigation, particularly 

those alleging harm to residents; the handling of facility self-reported 

incidents; and the use of appropriate complaint investigation practices. 

To better ensure that states comply with statutory, regulatory, and other 

CMS nursing home requirements designed to protect resident health and 

safety, we recommend that the Administrator 

• further refine annual state performance reviews so that they (1) 

consistently distinguish between systemic problems and less serious 

issues regarding state performance, (2) analyze trends in the proportion of 

homes that harm residents, (3) assess state compliance with the 

immediate sanctions policy for homes with a pattern of harming residents, 

and (4) analyze the predictability of state surveys. 

Recommendations for 

Executive Action 
Page 43 GAO-03-561 Nursing Home Quality 

We provided a draft of this report to CMS and the 22 states we contacted 

during the course of our review. (CMS’s comments are reproduced in app. 

X.) CMS concurred with our findings and recommendations, stating that it 

already had initiatives under way to improve the effectiveness of the 

survey process, address the understatement of serious deficiencies, 

provide better data on state complaint activities, and improve the annual 

federal performance reviews of state survey activities. Although CMS 

concurred with our recommendations, its comments on intended actions 

did not fully address our concerns about the status of the initiative to 

improve the effectiveness of the survey process or the recommendation 

regarding state quality assurance systems. Eleven of the 22 states also 

commented on our draft report.54 CMS and state comments generally 

covered five areas: survey methodology, state quality assurance systems, 

definition of actual harm, survey predictability, and resource constraints. 

In response to our recommendation that the agency finalize the 

development, testing, and implementation of a more rigorous nursing 

home survey methodology, under way since 1998, CMS commented that it 

had already taken steps to improve the effectiveness of the survey process, 

such as the development of surveyor guidance on a series of clinical 

issues.55 However, the agency did not specifically comment on any actions 

it would take to finalize and implement its new survey methodology, 

which is broader than the actions CMS described. Our draft report noted 

that, earlier this year, CMS said it lacked adequate funding for the 

additional field testing needed to implement the new survey methodology. 

Through September 2003, CMS will have committed $4.7 million to this 

effort. While CMS did not address the lack of adequate funding in its 

comments on our draft report, a CMS official subsequently told us that 

about $508,000 has now been slated for additional field testing. This 

amount, however, has not yet been approved. Not funding additional field 

testing could jeopardize the entire initiative, in which a substantial 

investment has already been made. We continue to believe that CMS 

should implement a revised survey methodology to address our 1998 

 54States that commented included Alabama, Arizona, California, Connecticut, Iowa, 

Missouri, Nebraska, New York, Pennsylvania, Tennessee, and Virginia. 

55Our draft report discussed the problems CMS encountered in developing this guidance 

and pointed out that the guidance on the first clinical issue to be addressed, pressure sores, 

was expected in early 2003. As of July 2003, the guidance had not yet been released. 

Agency and State 

Comments and Our 

Evaluation 

Survey Methodology 

Redesign 
Page 44 GAO-03-561 Nursing Home Quality 

finding that state surveyors often missed significant care problems due to 

weaknesses in the survey process. 

We recommended that CMS require states to have a quality assurance 

process that includes, at a minimum, a review of a sample of survey 

reports below the level of actual harm to help reduce instances of 

understated quality-of-care problems. CMS commented on the importance 

of this concept and noted it had already incorporated such reviews into 

CMS regional offices’ reviews of the state performance standards. 

However, the agency did not indicate whether it would require states to 

initiate an ongoing process that would evaluate the appropriateness of the 

scope and severity of documented deficiencies, as we recommended. 

While federal oversight is critical, the annual performance reviews 

conducted by federal surveyors examine only a small, random sample of 

state survey reports and should not be considered a substitute for 

appropriate and ongoing state quality assurance mechanisms. In its 

comments, New York stated that, in April 2003, it had implemented a 

process consistent with our recommendation and it had already realized 

positive results. New York is using the results of these reviews to provide 

surveyor feedback and expects that instances where deficiencies may be 

understated will decrease. California also commented that it fully supports 

this recommendation but indicated that a new requirement could not be 

implemented without additional resources. 

Officials from five states indicated that resource shortages are a challenge 

in meeting federal standards for oversight of nursing homes. Alabama 

commented that there is a relationship among (1) the scheduling of 

nursing home standard surveys, (2) the number and timing of complaint 

surveys, (3) the tasks that must be accomplished during each survey, and 

(4) the resources that are available to state agencies. According to 

Alabama, the funding provided by CMS is insufficient to meet all of the 

CMS workload demands, and many of the serious problems identified in 

our draft report were attributable to insufficient funding for state agencies 

to hire and retain the staff necessary to do the required surveys. For 

example, Alabama indicated that the inability of some states to meet 

survey time frames—maintaining a 12-month average between standard 

surveys and investigating complaints alleging actual harm within 10 days—

is almost always the result of states not having enough surveyors to 

accomplish the required workload. 

State Quality Assurance 

Systems 

State Resource Constraints 
Page 45 GAO-03-561 Nursing Home Quality 

Comments from other states echoed Alabama’s concerns about the 

adequacy of funding provided by CMS. Arizona said that, in order to hire 

and retain qualified surveyors, it increased surveyor salaries in 2001. 

Because CMS did not increase the state’s survey and certification budget 

to accommodate these increases, the state left surveyor positions unfilled 

and curtailed training to make up for the funding shortfall. Arizona also 

observed that CMS’s priorities sometimes conflict, further complicating 

effective resource use. CMS’s performance standards require states to 

investigate all complaints alleging immediate jeopardy or actual harm in 2 

and 10 days, respectively. For budgeting purposes, however, CMS ranks 

complaint investigations as a lower priority than annual surveys and 

instructs states to ensure that annual surveys will be completed before 

beginning work on complaints. California and Connecticut officials said 

that the growing volume of complaints in their states, combined with 

limited resources, is a concern. California officials observed that the 

growth in the number of complaints, coupled with the lack of significant 

funding increase from CMS, has made it impossible to meet all federal and 

state standards. They added that they received a 3-percent increase in 

survey funding from fiscal years 2000 through 2003, but documented the 

need for a 24-percent increase over this period. As noted in our draft 

report, the higher priority California attaches to investigating complaints 

affected survey timeliness—about 12 percent of the state’s homes were 

not surveyed within the required 15 months. Connecticut indicated that 90 

percent of the complaints it receives allege actual harm and require 

investigation within 10 days, but that with fairly stagnant budget 

allocations from CMS, its ability to initiate investigations of so many 

complaints within 10 days was limited. CMS’s fiscal year 2001 state 

performance review found that Connecticut did not investigate about 30 

percent of the sampled actual harm complaints in a timely manner. 

Although not specifically mentioning resources, New York noted that the 

increasing volume of complaints was a concern and indicated that any 

assistance CMS could provide would be welcome. 

Comments from four states on our analysis of a sample of survey 

deficiencies from homes with a history of harming residents revealed state 

confusion about CMS’s definition of actual harm and immediate jeopardy, 

a situation that contributes to the variability in state deficiency trends 

shown in table 2. CMS’s written comments did not address our review of 

these deficiencies; however, during an interview to follow up on state 

comments, CMS officials told us that they agreed with our determinations 

of actual harm as detailed in appendix III. 

Definition of Actual Harm 
Page 46 GAO-03-561 Nursing Home Quality 

Arizona and California agreed that some of the deficiencies we reviewed 

for nursing homes in their states should have been cited at the level of 

actual harm. However, their disagreement regarding others stemmed from 

differing interpretations of CMS guidance, particularly the language on the 

extent of the consequences to a resident resulting from a deficiency.56 For 

example, Arizona stated that one of the two deficiencies we reviewed 

could not be supported at the actual harm level because the injuries from 

multiple falls—including skin tears and lacerations of the extremities and 

head requiring suturing—did not compromise the residents’ ability to 

function at their highest optimal level (table 8, Arizona 3). In these cases, it 

was documented that nursing home staff had failed to implement plans of 

care intended to prevent such falls. In contrast, California agreed with us 

that state surveyors should have cited actual harm for similar injuries 

resulting from falls—head lacerations and a minimal impaction fracture of 

the hip—due to the inappropriate use of bed side rails (table 8, California 

9). CMS officials noted that the definition of actual harm uses the term 

“well-being” rather than function because harm can be psychological as 

well as physical. Moreover, they indicated that whether the consequence 

was small or large was irrelevant to determining harm. CMS central office 

officials acknowledged that the language linking actual harm to practices 

that have “limited consequences” for a resident has created confusion for 

state surveyors and that this reference will be eliminated in an upcoming 

revision of the guidance. 

Regarding preventable stage II pressure sores, California stated that 

guidance received from CMS’s San Francisco regional office in November 

2000 precluded citing actual harm unless the pressure sores had an impact 

on residents’ ability to function.57 According to a California official, this 

and similar guidance on weight loss was the CMS regional office’s reaction 

to the growing volume of appeals by nursing homes of actual harm 

 56CMS guidance to states in the Medicare State Operations Manual defines actual harm as 

“noncompliance that results in a negative outcome that has compromised the resident’s 

ability to maintain and/or reach his/her highest practicable physical, mental and 

psychosocial well-being as defined by an accurate and comprehensive resident assessment, 

plan of care, and provision of services. This does not include a deficient practice that only 

could or has caused limited consequence to the resident.” 

57Stages of pressure sore formation are I—skin of involved area is reddened; II—upper 

layer of skin is involved and blistered or abraded; III—skin has an open sore and involves 

all layers of skin down to underlying connective tissue; and IV—tissue surrounding the sore 

has died and may extend to muscle and bone and involve infection. 
Page 47 GAO-03-561 Nursing Home Quality 

citations as well as a reaction to administrative law hearing decisions.58

Prior to this written guidance, which California received in late 2000, it 

routinely cited preventable stage II pressure sores as actual harm. The 

guidance noted that small stage II pressure sores seldom cause actual 

harm because they have the potential to heal relatively quickly and are 

usually of limited consequence to the resident’s ability to function. We 

discussed the San Francisco regional office guidance with another 

regional office as well as with CMS central office officials, who agreed that 

the San Francisco region’s pressure sore guidance was inconsistent with 

CMS’s definition of harm, which judges the impact of a deficiency on a 

resident’s “well-being” rather than functioning. Moreover, central office 

officials indicated that the regional office’s guidance should have been 

submitted to CMS’s Policy Clearinghouse for approval. This entity was 

created in June 2000 to ensure that regional directives to states are 

consistent with national policy. San Francisco regional office officials 

indicated that the individual responsible for the guidance provided to 

California had since left the agency. 

California also disagreed with our assessment that state surveyors should 

have cited immediate jeopardy for a resident who repeatedly wandered 

(eloped) outside the facility near a busy intersection. According to state 

officials, California’s policy on immediate jeopardy requires the surveyor 

to witness the incident. A San Francisco regional office official told us that 

surveyors did not have to witness an elopement to cite immediate 

jeopardy. An official from a different regional office agreed and noted that 

repeated elopements suggested the existence of a systemic problem that 

warranted citation of immediate jeopardy. 

Although Iowa and Nebraska did not comment specifically on the 

deficiencies in their surveys that we determined to be actual harm, they 

did address the definition of harm and the role of surveyor judgment in 

classifying deficiencies. Iowa officials indicated that a more precise 

definition of harm is needed because of varying emphasis over the last 

several years on the degree of harm—harm that has a small consequence 

for the resident or serious harm. Nebraska commented that we may have 

based our conclusion that two deficiencies in its surveys should have been 

cited at the actual harm level on insufficient information because citing 

 58Nursing homes can appeal civil money penalties imposed by CMS when they are found to 

have serious deficiencies. The appeals are decided by the Department of Health and 

Human Service’s Departmental Appeals Board. 
Page 48 GAO-03-561 Nursing Home Quality 

actual harm is a judgment call that varies among state and federal 

surveyors based on experience and expertise. As noted in our draft report, 

we found sufficient evidence in the surveys we reviewed to conclude that 

some deficiencies should have been cited as actual harm because a 

deficient practice was identified and linked to documented actual harm. 

CMS, Arizona, and Iowa commented that nursing home surveys, as 

currently structured, are inherently predictable because of the statutory 

requirement to survey nursing homes on average every 12 months with a 

maximum interval of 15 months between each home’s survey. We agree 

but believe that survey predictability could be further mitigated by 

segmenting the surveys into more than one visit, a recommendation we 

made in 1998 but that CMS has not implemented.59 Currently, surveys are 

comprehensive reviews that can last several days and entail examining not 

only a home’s compliance with resident care standards but also with 

administrative and housekeeping standards. Dividing the survey into 

segments performed over several visits, particularly for those homes with 

a history of serious deficiencies, would increase the presence of surveyors 

in these homes and provide an opportunity for surveyors to initiate 

broader reviews when warranted. With a segmented set of inspections, 

homes would be less able to predict their next scheduled visit and adjust 

the care they provide in anticipation of such visits. 

CMS also commented that our report captures only the number of days 

since the prior survey and does not take into account other predictors, for 

example the time of day or day of the week. Rather than segmenting 

standard surveys as we earlier recommended, the agency instructed states 

to reduce survey predictability by starting at least 10 percent of surveys 

outside the normal workday—either on weekends, in the early morning, or 

in the evening. It also instructed states to avoid, if possible, scheduling a 

home’s survey for the same month as its previous standard survey. Though 

varying the starting time of surveys may be beneficial, this initiative is too 

limited in reducing survey predictability, as evidenced by our finding that 

34 percent of current surveys were predictable. Arizona commented that it 

was unaware of any CMS guidance to avoid scheduling a home’s survey 

for the same month of the year as the home’s previous standard survey 

 59U.S. General Accounting Office, California Nursing Homes: Care Problems Persist 

Despite Federal and State Oversight, GAO/HEHS-98-202 (Washington, D.C.: July 27, 1998). 

Survey Predictability 
Page 49 GAO-03-561 Nursing Home Quality 

and indicated the state will now incorporate the requirement into its 

scheduling process. 

Comments from CMS and Arizona stated that the window of time for a 

survey to be unpredictable was limited and, as a result, little could be done 

to reduce predictability. CMS’s technical comments noted that many states 

have annual state licensing inspection requirements that would limit the 

window available to conduct surveys to 9 to 12 months after the prior 

survey, particularly since most inspections are done in conjunction with 

the federal survey to maximize available resources. CMS, however, was 

unable to provide a list of such states. None of the 10 states we 

subsequently contacted had state licensure inspection requirements that 

would explain their high levels of survey predictability.60 Arizona 

commented that the state’s licensing inspections are triggered by facilities 

applying to renew their licenses 60-120 days before their annual license 

expires. Due to budgetary constraints, Arizona conducts both this state 

and the federal survey at the same time. While not a requirement, the state 

strives to complete surveys during this 60-120 day period of time. Thus, 

nursing homes in Arizona may have some level of control over when 

federal surveys are conducted, particularly when the state begins 

complying with CMS guidance to avoid scheduling a home’s survey for the 

same month as its previous survey. As we reported in September 2000, 

Tennessee also had an annual licensing inspection requirement that 

contributed to survey predictability, but the state modified its law to 

permit homes to be surveyed at a maximum interval of 15 months.61 Since 

then, the proportion of predictable surveys in Tennessee decreased from 

about 56 percent to 29 percent. Arizona also stated that surveys had to be 

conducted within a 45-day window after the 1-year anniversary of the prior 

survey to be considered unpredictable.62 Arizona’s comments erroneously 

assume that a survey cannot take place before the 1-year anniversary of 

the prior survey. There is no prohibition on resurveying a home prior to 

the 1-year anniversary of its last survey, and many states do so. In fact, 

 60We contacted 10 states that were included in our review and that had a significant 

percentage of predictable surveys—Alabama, California, Connecticut, Maryland, Nebraska, 

New York, Oklahoma, Tennessee, Virginia, and Washington. As shown in table 10 (see app. 

V), the proportion of predictable surveys in these states ranged from 29 percent to 83 

percent. 

61See GAO/HEHS-00-197. 

62We considered surveys to be predictable if (1) homes were surveyed within 15 days of the 

1-year anniversary of their prior surveys or (2) homes were surveyed within 1 month of the 

maximum 15-month interval between standard surveys. 
Page 50 GAO-03-561 Nursing Home Quality 

from October 1, 2000 through September 30, 2001, Arizona conducted 23 

percent of its surveys before the 1-year anniversary. 

CMS provided several technical comments that we incorporated as 

appropriate. 

As arranged with your offices, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days after its 

issue date. At that time, we will send copies of this report to the 

Administrator of the Centers for Medicare & Medicaid Services and 

appropriate congressional committees. We also will 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. 

Please contact me at (202) 512-7118 or Walter Ochinko, Assistant Director 

at (202) 512-7157 if you or your staffs have any questions. GAO staff 

acknowledgments are listed in appendix XI. 

Kathryn G. Allen 

Director, Health Care—Medicaid 

 and Private Health Insurance Issues 
Appendix I: Scope and Methodology 

Page 51 GAO-03-561 Nursing Home Quality 

This appendix describes our scope and methodology following the order 

that findings appear in the report. 

Nursing home deficiency trends. To identify trends in the proportion of 

nursing homes cited for actual harm or immediate jeopardy, we analyzed 

data from CMS’s OSCAR system. We compared standard survey results for 

three approximately 18-month periods: (1) January 1, 1997, through June 

30, 1998, (2) January 1, 1999, through July 10, 2000, and (3) July 11, 2000, 

through January 31, 2002. Because surveys are to be conducted at least 

once every 15 months (with a required 12-month state average), it is 

possible that a facility was surveyed more than once in a time period. To 

avoid double counting of facilities, we included only the most recent 

survey of a facility from each of the time periods. The data from the two 

earliest time periods were included in our September 2000 report.1

 We 

updated our earlier analysis of surveys conducted from January 1, 1999, 

through July 10, 2000, because it excluded approximately 300 surveys that 

had been conducted but not entered into OSCAR at the time we conducted 

our analysis in July 2000. 

Sample of state survey reports. To assess the trends in actual harm and 

immediate jeopardy deficiencies discussed above, we (1) identified 14 

states in which the percentage of homes cited for actual harm had 

declined to below the national average since mid-2000 or was consistently 

below that average and (2) reviewed 76 survey reports from homes that 

had G-level or higher quality-of-care deficiencies on prior surveys but 

whose current survey had quality-of-care deficiencies at the D or E level, 

suggesting that the homes had improved.2

 All the surveys we reviewed 

were conducted from July 2000 through April 2002. Our review focused on 

four quality-of-care requirements that are the most frequently cited nursing 

home deficiencies nationwide (see table 6). According to OSCAR data, 99 

surveys in the 14 states conducted on or after July 2000 documented a Dor E-level deficiency in at least one of these four quality-of-care 

requirements. We reviewed all such deficiencies in surveys from 13 states 

but randomly selected 22 surveys from California, which cited the majority 

(45) of these deficiencies. In reviewing the surveys, we looked for a 

description of the resident’s diagnoses, any assessment of special 

problems, and a description of the care plan and physician orders 

 1

GAO/HEHS-00-197. 

2

The 14 states are Alabama, Arizona, California, Iowa, Maryland, Minnesota, Mississippi, 

Missouri, Nebraska, Pennsylvania, South Carolina, Virginia, West Virginia, and Wisconsin. 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 52 GAO-03-561 Nursing Home Quality 

connected with the deficiency identified. We also looked for a clear 

statement of the home’s deficient practice and the relationship between 

the deficiency and the care outcome. 

Table 6: Quality of Care Requirements Reviewed in a Sample of State Survey 

Reports 

Nursing home quality 

of care requirements Description 

Necessary care and 

services 

Facility must provide the necessary care and services for 

each resident to attain or maintain the highest practicable 

well-being. 

Pressure sores Facility must ensure residents entering facility without 

pressure sores do not develop sores, unless the individual’s 

clinical condition indicates the pressure sores were 

unavoidable, and that residents with sores receive necessary 

treatment to promote healing, prevent infection, and prevent 

new sores. 

Prevention of accidents Facility must ensure each resident receives adequate 

supervision and assistance devices to prevent accidents. 

Maintenance of nutrition Facility must ensure each resident maintains acceptable 

parameters of nutritional status, such as body weight. 

Source: CMS’s Medicare State Operations Manual. 

Federal comparative surveys. In September 2000, we reported on the 

results of 157 comparative surveys completed from October 1998 through 

May 2000.3

 To update our analysis, we asked each CMS region to provide 

the results of more recent comparative surveys, including data on the 

corresponding state survey. The regions identified and provided 

information on the deficiencies identified in 277 comparative surveys that 

were completed from June 2000 through February 2002.4

Survey predictability. In order to determine the predictability of nursing 

home surveys, we analyzed data from CMS’s OSCAR database. We 

considered surveys to be predictable if (1) homes were surveyed within 15 

days of the 1-year anniversary of their prior survey or (2) homes were 

surveyed within 1 month of the maximum 15-month interval between 

standard surveys. Consistent with CMS’s interpretation, we used 15.9 

months as the maximum allowable interval between surveys. Because 

homes know the maximum allowable interval between surveys, those 

 3

See GAO/HEHS-00-197. 

4

One of the comparative surveys in our updated analysis was completed in May 2000. 
Appendix I: Scope and Methodology 

Page 53 GAO-03-561 Nursing Home Quality 

whose prior surveys were conducted 14 or 15 months earlier are aware 

that they are likely to be surveyed soon. 

Complaints. We analyzed the results of CMS’s state performance review 

for fiscal year 2001 to determine states’ success in investigating both 

immediate jeopardy complaints and actual harm complaints within time 

frames required either by statute or by CMS instructions. To better 

understand the results of state performance as determined by CMS’s 

review, we interviewed officials from CMS’s 10 regional offices and 16 

state survey agencies (see state performance standards below for a 

description of how these states were chosen).5

 We also reviewed the 

report submitted to CMS by its contractor, which was intended to assess 

and recommend ways to strengthen state complaint practices.6

 Finally, to 

assess the implementation of CMS’s new automated system for tracking 

information about complaints, we reviewed CMS guidance materials and 

interviewed CMS officials and state survey agency officials from our 16 

sample states. 

Enforcement. To determine if states had consistently applied the 

expanded immediate sanction policy, we analyzed state surveys in OSCAR 

that were conducted before April 9, 2002, and identified homes that met 

the criteria for referral for immediate sanction. We included surveys 

conducted prior to the implementation of the expanded immediate 

sanction policy because actual harm deficiencies identified in such 

surveys were to be considered by states in recommending a home for 

immediate sanction beginning in January 2000. To be affected by CMS’s 

expanded policy, a home with actual harm on two surveys must have an 

intervening period of compliance between the two surveys. Because 

OSCAR is not structured to consistently record the date a home with 

deficiencies returned to compliance, we had to estimate compliance dates 

using revisit dates as a proxy. We compared the results of our analysis to 

CMS’s enforcement database to determine if CMS had opened 

enforcement cases for the homes we identified. Our analysis compared the 

survey date in OSCAR to the survey date in CMS’s enforcement database. 

We considered any survey date in the enforcement database within 30 

days of the OSCAR survey date to be a match. CMS officials reviewed and 

 5

We contacted officials in Alabama, California, Colorado, Connecticut, Iowa, Louisiana, 

Maryland, Michigan, Missouri, Nebraska, New York, Oklahoma, Pennsylvania, Tennessee, 

Washington, and Virginia. 

6

Center for Health Systems Research and Analysis at the University of Wisconsin, Madison. 
Appendix I: Scope and Methodology 

Page 54 GAO-03-561 Nursing Home Quality 

concurred with our methodology. We then asked CMS to analyze the 

resulting 1,334 unmatched cases to determine if a referral should have 

been made.7

State performance standards. To assess state survey activities as well as 

federal oversight of state performance, we analyzed the conduct and 

results of fiscal year 2001 state survey agency performance reviews during 

which the CMS regional offices determined compliance with seven federal 

standards; we focused on the five standards related to statutory survey 

intervals, deficiency documentation, complaint activities, enforcement 

requirements, and OSCAR data entry. Because some regional office 

summary reports on the results of their reviews for each state did not 

provide detailed information about the results, we also obtained and 

reviewed regions’ worksheets on which the summary reports were based. 

In addition, we conducted structured interviews with officials from CMS, 

CMS’s 10 regional offices, and 16 state survey agencies to discuss nursing 

home deficiency trends, the underlying causes of problems identified 

during the performance reviews, and state and federal efforts to address 

these problems. We also discussed these issues with officials from 10 

additional states during a governing board meeting of the Association of 

Health Facility Survey Agencies. We selected the 16 states with the goal of 

including states that (1) were from diverse geographic areas, (2) had 

shown either an increase or a decrease in the percentage of homes cited 

for actual harm, (3) had been contacted in our prior work, and (4) 

represented a mixture of results from federal performance reviews of state 

survey activities. We also obtained data from 42 state survey agencies on 

surveyor experience, vacancies, and related staffing issues. 

 7

CMS determined that for 438 of the 1,334 cases we asked it to examine, the state had 

indeed made a referral to CMS. In some of these 438 instances, there was no corresponding 

case in the enforcement database because OSCAR had a different survey date. The “survey 

date” variable in OSCAR is the latter of the health survey date and the life-safety code 

survey, while the corresponding date in the enforcement database is usually the health 

survey date. For others, an enforcement case was already open for the home at the time of 

the referral, and CMS officials did not open an additional case. There was also a small 

number of cases where the state agency referred the home for immediate sanction, and 

CMS chose not to accept the state’s recommendation. States failed to refer 711 cases that 

met CMS criteria for immediate referral. In addition, CMS did not analyze 155 other cases 

and was unable to determine the status of 30 cases. 
Appendix II: Trends in The Proportion of 

Nursing Homes Cited for Actual Harm or 

Immediate Jeopardy Deficiencies, 1997-2002 

Page 55 GAO-03-561 Nursing Home Quality 

Nationwide, the proportion of nursing homes cited for actual harm or 

immediate jeopardy during state standard surveys declined from 29 

percent in mid-2000 to 20 percent in January 2002. From July 2000 through 

January 2002, 40 states cited a smaller percentage of homes with such 

serious deficiencies while only 9 states and the District of Columbia cited 

a larger proportion of homes with such deficiencies.1

 In contrast, from 

early 1997 through mid-2000, the percentage of homes cited for such 

serious deficiencies was either relatively stable or increased in 31 states. 

To identify these trends, we analyzed data from CMS’s OSCAR system. We 

compared results for three approximately 18-month periods: (1) January 1, 

1997, through June 30, 1998, (2) January 1, 1999, through July 10, 2000, and 

(3) July 11, 2000, through January 31, 2002 (see table 7). Because surveys 

are to be conducted at least once every 15 months (with a required 12-

month state average), it is possible that a facility was surveyed more than 

once in a time period. To avoid double counting of facilities, we included 

only the most recent survey from each of the time periods. Some of the 

data in table 7 were included in our September 2000 report.2

 However, we 

updated our analysis of surveys conducted from January 1, 1999, through 

July 10, 2000, because it excluded approximately 300 surveys that had 

been conducted but not entered into OSCAR at the time we conducted our 

analysis in July 2000. 

 1

The proportion of nursing homes in Utah cited with serious deficiencies remained the 

same between the two time periods. 

2

GAO/HEHS-00-197. 

Appendix II: Trends in The Proportion of 

Nursing Homes Cited for Actual Harm or 

Immediate Jeopardy Deficiencies, 1997-2002 
Appendix II: Trends in The Proportion of 

Nursing Homes Cited for Actual Harm or 

Immediate Jeopardy Deficiencies, 1997-2002 

Page 56 GAO-03-561 Nursing Home Quality 

Table 7: Trends in the Percentage of Nursing Homes Cited for Actual Harm or Immediate Jeopardy during State Standard 

Surveys, by State 

Number of homes surveyed 

Percentage of homes cited for 

actual harm or immediate 

jeopardy Percentage point differencea

State 1/97-6/98 1/99-7/00 7/00-1/02 1/97-6/98 1/99-7/00 7/00-1/02 

1/97-6/98 and 

1/99-7/00 

1/99-7/00 and 

7/00-1/02

Alabama 227 225 228 51.1 42.2 18.4 -8.9 -23.8

Alaska 16 15 15 37.5 20.0 33.3 -17.5 13.3

Arizona 163 142 147 17.2 33.8 8.8 16.6 -25.0

Arkansas 285 273 267 14.7 37.7 27.3 23.0 -10.4

California 1,435 1,400 1,348 28.2 29.1 9.3 0.9 -19.9

Colorado 234 227 225 11.1 15.4 26.2 4.3 10.8

Connecticut 263 262 259 52.9 48.5 49.4 -4.4 0.9

Delaware 44 42 42 45.5 52.4 14.3 6.9 -38.1

District of Columbia 24 20 21 12.5 10.0 33.3 -2.5 23.3

Florida 730 753 742 36.3 20.8 20.1 -15.5 -0.8

Georgia 371 368 370 17.8 22.6 20.5 4.8 -2.0

Hawaii 45 47 46 24.4 25.5 15.2 1.1 -10.3

Idaho 86 83 84 55.8 54.2 31.0 -1.6 -23.3

Illinois 899 900 881 29.8 29.3 15.4 -0.5 -13.9

Indiana 602 590 573 40.5 45.3 26.2 4.8 -19.1

Iowa 525 492 494 39.2 19.3 9.9 -19.9 -9.4

Kansas 445 410 400 47.0 37.1 29.0 -9.9 -8.1

Kentucky 318 312 306 28.6 28.8 25.2 0.2 -3.7

Louisiana 433 387 367 12.7 19.9 23.4 7.2 3.5

Maine 135 126 124 7.4 10.3 9.7 2.9 -0.6

Maryland 258 242 248 19.0 25.6 20.2 6.6 -5.5

Massachusetts 576 542 512 24.0 33.0 22.9 9.0 -10.2

Michigan 451 449 441 43.7 42.1 24.7 -1.6 -17.4

Minnesota 446 439 431 29.6 31.7 18.8 2.1 -12.9

Mississippi 218 202 219 24.8 33.2 19.6 8.4 -13.5

Missouri 595 584 569 21.0 22.3 10.2 1.3 -12.1

Montana 106 104 103 38.7 37.5 25.2 -1.2 -12.3

Nebraska 263 242 243 32.3 26.0 18.9 -6.3 -7.1

Nevada 49 52 51 40.8 32.7 9.8 -8.1 -22.9

New Hampshire 86 83 79 30.2 37.3 21.5 7.1 -15.8

New Jersey 377 359 366 13.0 24.5 22.4 11.5 -2.1

New Mexico 88 82 82 11.4 31.7 17.1 20.3 -14.6

New York 662 668 671 13.3 32.2 32.3 18.9 0.2

North Carolina 407 414 419 31.0 40.8 30.1 9.8 -10.7

North Dakota 88 89 88 55.7 21.3 28.4 -34.4 7.1

Ohio 1,043 1,047 1,029 31.2 29.0 23.7 -2.2 -5.3

Oklahoma 463 432 394 8.4 16.7 20.6 8.3 3.9

Oregon 171 158 152 43.9 47.5 33.6 3.6 -13.9
Appendix II: Trends in The Proportion of 

Nursing Homes Cited for Actual Harm or 

Immediate Jeopardy Deficiencies, 1997-2002 

Page 57 GAO-03-561 Nursing Home Quality 

Number of homes surveyed 

Percentage of homes cited for 

actual harm or immediate 

jeopardy Percentage point differencea

State 1/97-6/98 1/99-7/00 7/00-1/02 1/97-6/98 1/99-7/00 7/00-1/02 

1/97-6/98 and 

1/99-7/00 

1/99-7/00 and 

7/00-1/02

Pennsylvania 811 788 764 29.3 32.2 11.6 2.9 -20.6

Rhode Island 102 99 99 11.8 12.1 10.1 0.3 -2.0

South Carolina 175 178 180 28.6 28.7 17.8 0.1 -10.9

South Dakota 124 112 114 40.3 24.1 30.7 -16.2 6.6

Tennessee 361 354 377 11.1 26.0 16.7 14.9 -9.3

Texas 1,381 1,336 1,275 22.2 26.9 25.5 4.7 -1.5

Utah 98 95 95 15.3 15.8 15.8 0.5 0.0

Vermont 45 46 45 20.0 15.2 17.8 -4.8 2.6

Virginia 279 287 285 24.7 19.9 11.6 -4.8 -8.3

Washington 288 279 275 63.2 54.1 38.5 -9.1 -15.6

West Virginia 130 147 143 12.3 15.6 14.0 3.3 -1.7

Wisconsin 438 428 421 17.1 14.0 7.1 -3.1 -6.9

Wyoming 38 41 40 28.9 43.9 22.5 15.0 -21.4

Nation 17,897 17,452 17,149 27.7 29.3 20.5 1.6 -8.8

Source: GAO analysis of OSCAR data as of June 24, 2002. 

a

Differences are based on numbers before rounding. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 58 GAO-03-561 Nursing Home Quality 

Our analysis of a sample of 76 nursing home survey reports demonstrated 

a substantial understatement of quality-of-care problems. Our sample was 

selected from 14 states in which the percentage of homes cited for actual 

harm had declined to below the national average since mid-2000 or was 

consistently below that average. We identified survey reports in these 

states from homes that had G-level or higher quality-of-care deficiencies 

(see table 1) on prior surveys but whose current survey had quality-of-care 

deficiencies at the D or E level, suggesting that the homes had improved. 

All the surveys we reviewed were conducted from July 2000 through April 

2002. Our review focused on four quality-of-care requirements that are the 

most frequently cited nursing home deficiencies nationwide (see table 6).1

In our judgment, 30 of the 76 surveys (39 percent) from 9 of the 14 states 

had one or more deficiencies that documented actual harm to residents—

G-level deficiencies—and 1 survey contained a deficiency that could have 

been cited at the immediate jeopardy level. While state surveyors 

classified these deficiencies as less severe, we believe that the survey 

reports document that poor care provided to and injuries sustained by 

these residents constituted at least actual harm. Table 8 provides abstracts 

of the 39 deficiencies that understated quality problems. 

 1

According to OSCAR data, 99 surveys in the 14 states conducted on or after July 2000 

documented a D- or E-level deficiency in at least one of the quality-of-care requirements we 

selected. We reviewed all such deficiencies in surveys from 13 states but randomly selected 

22 of the 45 California surveys. The 14 states are Alabama, Arizona, California, Iowa, 

Maryland, Minnesota, Mississippi, Missouri, Nebraska, Pennsylvania, South Carolina, 

Virginia, West Virginia, and Wisconsin. 

Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 59 GAO-03-561 Nursing Home Quality 

Table 8: Abstracts of the 39 Nursing Home Deficiencies that Understated Actual Harm from a Sample of 76 Nursing Home 

Survey Reports 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Alabama-1 

November 2001 

Provide necessary 

care and services: 

D 

Resident admitted to 

facility 5/15/01with a 

fractured hip; a 

gastrostomy tube was 

inserted through the 

abdomen into the stomach 

to maintain feeding. On 

10/9/01, resident was 

hospitalized for abdominal 

pain and signs of infection 

related to the gastrostomy 

tube. On return to facility, 

physician orders state, 

“clean G tube site with 

soap and water, apply a 

drain sponge.” 

Site of gastrostomy tube 

insertion became reddened 

with thick yellow-green 

drainage, and had an odor, 

indicating signs of infection, on 

11/7/01. 

Facility failed to provide proper 

care and services: daily 

cleaning and application of a 

drain sponge around the 

gastrostomy tube. 

Family indicated no one 

changed the dressing. There is 

no documentation to show 

resident’s gastrostomy tube 

site was cleansed as ordered 

12 out of 16 opportunities. 

Alabama-5 

March 2001 

Provide 

supervision and 

devices to prevent 

accidents: D 

Resident 1 admitted to 

facility 11/6/00 with 

diagnoses of stroke, 

pressure sores, and 

kidney failure. On 

11/16/00, resident was 

noted to have abrasions 

and bruises. 

Resident 1 sustained four skin 

tears on right arm and leg and 

multiple bruises to both legs 

from 1/16/01 to 3/21/01. 

The facility failed to 

consistently reassess for 

preventive measures to 

address the problem of skin 

tears and bruises for both 

residents. Staff were unable to 

provide documentation of 

preventive interventions. 

 

 Resident 2 was admitted 

to the facility 11/23/98 with 

anemia, depression, 

urinary incontinence, and 

a history of falls. She was 

identified as having a 

problem with skin tears 

and bruising.c

Resident 2 sustained seven 

skin tears and bruises to legs 

from 12/29/99 to 10/9/00. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 60 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Arizona-3 

July 2000 

Ensure prevention 

and healing of 

pressure sores: D 

Resident admitted to 

facility 08/24/99 with heart 

failure, high blood 

pressure, paraplegia, and 

a stage II pressure sore on 

lower back.d

 Pressure sore 

remained a stage II until 

May 2000, when wound 

was documented to be a 

stage III. 

On 7/5/00, it was noted that the 

resident had developed a stage 

IV pressure sore. 

The necessary services and 

care to promote healing and 

prevent worsening of existing 

pressure sore were not 

provided. Even after the 

pressure sore progressed to 

stage IV and a physician 

ordered that the resident be 

turned every hour, the staff 

failed to turn the resident as 

directed. Surveyor observed 

resident lying on her back for 2 

or more hours. Resident stated 

that frequently she was turned 

only twice in 8 hours. Charge 

nurse did not know physician 

had ordered resident to be 

turned every hour. 

Arizona-3 

July 2000 

Ensure adequate 

supervision to 

prevent accidents: 

D 

Resident 1 admitted to the 

facility 4/7/00 with 

diabetes, partial paralysis 

of left side, and inability to 

speak. Resident also had 

a history of spinal 

fractures, and a fall 

prevention plan was 

developed on 4/15/00. 

Resident 1 fell four times and 

sustained skin tears, abrasions, 

and lacerations. 

Facility staff failed to 

implement a plan of care that 

called for identifying resident 

as a fall risk by placing a star 

on his door by his name. No 

other preventive measures 

were identified, and surveyor 

observed no star next to 

resident’s name outside his 

door. 

 Resident 2 admitted to the 

facility 12/10/97 with 

dementia, painful joints, 

and visual problems. A 

7/13/00 assessment 

indicated resident was 

cognitively impaired and 

had a mental function that 

varied throughout the day. 

She was also identified as 

a wanderer. 

Resident sustained 12 falls 

from 2/18 to 7/8/00 with 

lacerations of extremities and 

head requiring suturing and 

with other cuts and bruises. 

Although resident was 

identified as at risk for falls in a 

care plan of 4/22/00, the 

facility staff failed to develop 

approaches to prevent falls 

even though the resident 

continued to fall and injure 

herself. 

California-2 

September 2000 

Ensure prevention 

and healing of 

pressure sores: D 

Resident 1 with leg 

contractures (permanent 

tightening of muscle, 

tendons, ligaments, or skin 

that prevents normal 

movement) was noted to 

have a small reddened 

area on left lower back on 

9/20/00. 

Resident 1 developed a 

reddened open area .3 cm. in 

diameter, (stage II pressure 

sore) on left lower back by 

9/23/00. 

The surveyor found that the 

facility did not identify, 

document, or provide 

intervention to prevent this 

facility-acquired pressure sore. 

The reddened area noted was 

not documented in the medical 

record 9/20-9/22/00. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 61 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

 Resident 2 was admitted 

to facility on 2/2/00. Family 

identified resident as 

having a “skin problem” on 

9/17/00. 

Resident 2 developed a stage II 

pressure sore. 

The facility developed a 

nursing care plan for 

prevention of pressure sores 

and turning the resident every 

2 hours on 9/8/00. The family 

identified a stage II pressure 

sore on 9/17/00. The surveyor 

found no evidence that the 

care plan was implemented at 

time of survey. 

 Resident 3 admitted to 

facility 9/20/00 with 

diagnoses of multiple 

sclerosis, bilateral 

fractures of the femur, and 

obesity. Resident was 

unable to turn herself in 

bed; physician 

documented resident had 

no areas of skin 

breakdown and ordered 

resident to be up in a 

wheel chair two to three 

times a day. 

Seven days after admission, 

resident 3 was noted to have 

four stage II pressure sores on 

right and left shoulder blades 

and right buttock and three 

stage I pressure sores on the 

left buttock. 

The facility failed to prevent a 

rapid decline in resident’s 

condition and occurrence of 

facility-acquired pressure 

sores. Staff said they were 

unable to turn resident (a 

larger bed and mattress were 

not provided, which would 

have facilitated turning). No 

pressure-relieving devices and 

staff assistance in getting out 

of bed were provided. In the 7 

days after admission, the 

resident was out of bed only 

once, at which time the 

pressure sores were 

discovered. 

California-2 

September 2000 

Maintain nutritional 

status: D 

Resident admitted to 

facility 7/7/00 with a 

diagnosis of failure to 

thrive and a recorded 

weight of 89 pounds. 

Resident’s weight was recorded 

as 77 pounds 1 month after 

admission. Resident sustained 

a severe loss of 12 pounds (13 

percent) between July and 

August. 

Facility failed to provide a 

comprehensive nutritional 

assessment to meet resident’s 

nutritional needs in order to 

maintain body weight. 

California-5 

February 2001 

Provide 

supervision and 

devices to prevent 

accidents: D 

Resident was identified as 

at high risk for falls in 5/00. 

Resident fell while walking 

unassisted on 6/21/00 and 

again on 2/22/01, fracturing his 

right hip each time. 

Facility failed to develop and 

implement a fall prevention 

plan when resident was 

identified as being a high risk 

for falls and after the first hip 

fracture. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 62 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

California-6 

May 2001 

Provide 

supervision and 

devices to prevent 

accidents: D 

Resident admitted to 

facility on 2/12/01with 

dizziness, fainting, poor 

vision, and cognitive 

impairment. Care plan of 

2/20/01 identified resident 

as a wanderer and at risk 

for falls. Interventions 

suggested were visual 

checks every 2 hours and 

involvement of resident in 

facility activities. On 

2/20/01 at 9:30 pm 

resident was found 

wandering outside on the 

patio and had fallen and 

sustained abrasions. 

Resident wandered to an area 

100 yards from facility near two 

busy intersections on 3/26/01 

and again on 5/19/01. 

According to CMS, the failure of 

a facility to provide supervision 

of a cognitively impaired 

individual with known risk for 

wandering is considered failure 

to prevent neglect and places 

the resident in immediate 

jeopardy for death or serious 

injury during such an incident. 

Facility failed to provide 

supervision and devices to 

prevent accidents even after 

resident was found wandering 

outside the facility on 2/20/01. 

The facility did not immediately 

implement procedures cited in 

the care plan to supervise the 

resident and prevent accidents 

and wandering, nor did the 

facility implement existing 

facility policies to prevent 

wandering and injury. 

California-8 

June 2001 

Ensure prevention 

and healing of 

pressure sores: D 

Resident admitted to 

facility in 1996 with stroke, 

paralysis of lower right 

side, and senile dementia. 

Physician orders of 4/5/01 

called for an air mattress. 

Assessment of 4/24/01 

noted resident had a stage 

IV pressure sore on the 

right outer ankle. On 

5/17/01, physician ordered 

cleansing of the wound 

with saline and an antiinfective solution, dressing 

it with soft protective 

gauze. 

Resident sustained a facilityacquired stage IV pressure 

sore of the right ankle 

measuring 7 cm. by 5 cm. 

Facility failed to ensure 

necessary treatment and 

service to promote healing and 

prevent infection of the 

pressure sore. Surveyor 

observed on 6/20 and 6/21/01 

that there was no air mattress 

on resident’s bed and on 

6/20/01 that inappropriate 

technique was used in 

changing the dressing on the 

resident’s ankle. 

California-8 

June 2001 

Ensure 

maintenance of 

nutritional status: 

D 

Resident admitted to 

facility in 1990 with a 

diagnosis of stroke and 

inability to speak. A 3/7/01 

assessment noted erosive 

gastritis, anemia, and 

weight of 111 lbs. The 

county was the 

conservator and requested 

maximum treatment. 

Resident was placed on 

an enriched pureed diet 

with supplemental 

feedings three times daily. 

Resident weighed 98.4 lbs and 

experienced a severe weight 

loss of 13 pounds (12 percent) 

in 3 months. 

Facility failed to ensure that 

the resident maintained 

adequate nutrition. It did not 

monitor the amount of 

nutritional supplements 

consumed by the resident and 

inconsistently recorded 

weights, often without 

associated dates. It did not 

notify the physician of the 

resident’s weight loss. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 63 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

California-9 

December 2000 

Provide 

supervision and 

devices to prevent 

accidents: Be,f

Resident 1, 48 years old, 

admitted to facility after a 

stroke with incontinence, 

inability to speak, rightside paralysis, and 

functional use of his left 

side. Resident 

communicated by signs 

and sounds. 

Resident fell when trying to 

climb over side rails, sustaining 

a laceration to his head. 

The facility failed to supervise 

the resident and prevent 

accidents from occurring: staff 

failed to accurately assess 

resident’s safety needs and 

inappropriately assumed 

resident needed full side rails 

on the bed. 

 

 Resident 2 had a history of 

a right hip fracture, chronic 

weakness in both legs, 

and dementia. Resident 

had a physician’s order 

(9/16/99) for soft belt 

restraints when in 

wheelchair to prevent 

resident from getting up 

from wheelchair without 

assistance. 

On 3/29/00, resident climbed 

over the bed side rails and was 

found on the floor at the foot of 

his bed with both side rails in 

the up position. Seven hours 

later, an x ray was taken and 

found that resident had a 

“minimal impaction fracture” of 

the left hip. 

Because restraints, including 

side rails, can pose a serious 

health and safety risk to nursing 

home residents if used 

improperly, CMS requires that 

restraints should only be used 

when other, less severe 

alternatives fail to address a 

resident’s medical needs, and 

the benefits outweigh the 

potential risks. In such cases, 

the nursing home must ensure 

that any restraints are used 

safely and properly. 

The facility failed to provide 

supervision and appropriate 

interventions to prevent this 

resident’s fall. According to the 

surveyor, there were no orders 

for restraints in bed and no 

indication that all reasonable 

efforts had been made to 

safeguard the resident from 

additional injuries. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 64 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

California-9 

December 2000 

Ensure 

maintenance of 

nutritional 

status: D 

Resident was readmitted 

(6/11/00) to facility 

following the removal of a 

hip prosthesis and a 

surgical incision that 

became infected with a 

fungus, resulting in a large 

gaping wound. Resident 

was unable to swallow 

following a stroke and was 

fed via a nasogastric tube. 

A stage IV pressure sore on 

right heel was noted on 

7/27/00. 

Facility was slow to implement 

the dietician’s 

recommendations of 6/15/00 

for caloric, protein, and water 

intake necessary for wound 

healing. Diet ordered on 

6/20/00. On 6/24/00 resident 

was admitted to the hospital 

for care of gastrointestinal 

bleeding and found to need 

nutritional supplements to 

address gastrointestinal 

bleeding and promote wound 

healing. Resident was 

readmitted to facility on 

6/29/00. Following 

readmission, the facility also 

failed to implement both the 

hospital’s and its own 

dietician’s recommendations 

for increased protein, calories, 

and water to encourage wound 

healing. 

California-10 

May 2001 

Provide 

supervision and 

devices to prevent 

accidents: D 

Resident admitted to 

facility with diagnoses of 

dementia and Alzheimer’s 

disease and a history of 

falls, confusion, and 

unsteady gait. Resident 

identified as high risk for 

falls and had a physician’s 

order for a restraining belt 

when in bed. 

Resident fell while attempting to 

get out of bed and lacerated left 

elbow. 

Facility failed to provide 

supervision and devices to 

prevent accidents. Specifically, 

resident was put to bed 

without a restraining belt. 

California-11 

May 2001 

Provide necessary 

care and services: 

D 

Resident admitted to the 

facility in 1999 with 

dementia and neurological 

disorders. Resident was 

receiving an antipsychotic 

medication that has a side 

effect of constipation. Care 

plan of 1/04/01 called for 

(1) providing liquids, 

roughage, and exercise, 

(2) monitoring for 

abdominal distention, pain, 

cramps, nausea, and 

vomiting, and (3) checking 

for impaction every 3 days.

Resident admitted to hospital 

for “several days” to relieve a 

fecal impaction. 

Staff failed to implement the 

care plan. On 5/23/01 the 

surveyor noted the resident 

crying out, moaning, 

grimacing, and moving her 

arms and legs about. Last 

bowel movement recorded 

was on 5/19/01. The charge 

nurse administered Tylenol 

with codeine for what she 

believed was an earache at 10 

a.m. Resident continued to cry 

out and the charge nurse 

called the physician who had 

the resident transferred to a 

hospital emergency room. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 65 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

California-11 Provide 

supervision and 

devices to prevent 

accidents: E 

Resident was admitted 

4/25/01 with acute kidney 

failure and emphysema 

and was one of five 

residents identified as 

being at risk for skin tears; 

all five developed skin 

tears. A care plan for 

potential for skin 

breakdown and treatment 

of the skin tears was 

developed. 

Resident sustained a 9 cm. skin 

tear to the lower left leg on 

4/28/01 and two 3 cm. skin 

tears below the left knee on 

5/3/01. Four other residents 

also sustained multiple skin 

tears to their extremities and 

hip. 

Facility failed to develop skin 

tear prevention plans. Staff did 

not fully investigate causes of 

the tears and did not know 

how to prevent skin tears. The 

staff development director 

stated that she had never 

provided instruction for the 

certified nurse aides on 

prevention of skin tears. 

California-14 

March 2001 

Ensure prevention 

and healing of 

pressure sores: D 

Resident admitted to 

facility 1/26/01 following a 

stroke, with inability to 

swallow, a gastric tube in 

place for feedings, and a 

stage I pressure sore on 

right hip. 

Resident’s pressure sore 

progressed to a stage II by 

2/28/01 and a stage III on 

3/7/01. 

Facility staff failed to promote 

healing or prevent worsening 

of pressure sore by failing to 

employ the appropriate sheets 

that are used in conjunction 

with the low-air-loss, pressure 

sore mattress, thereby 

negating the pressure-relieving 

benefits of the mattress. 

California-16 

April 2001 

Ensure prevention 

and healing of 

pressure sores: D 

Resident admitted to 

facility 11/16/98 with 

dementia, anemia, 

irregular heartbeat, 

diabetes, high blood 

pressure, and difficulty in 

swallowing. 

Resident developed a new 

stage II pressure sore on 

4/26/01. 

Facility staff did not prevent 

the development of a facilityacquired pressure sore. 

Specifically, the surveyor 

observed on 4/24/01 that the 

staff did not turn resident every 

2 hours as directed by the care 

plan, and left her in the same 

position for as long as 8 hours.

California-18 

April 2001 

Provide necessary 

care and services: 

E 

Resident admitted to the 

facility with a steel plate 

implanted in her back 

following a fracture. 

Nursing care plan called 

for comfort measures for 

back pain, such as 

heat/cold application, 

therapeutic touch, and 

staying with resident when 

she was in distress. 

Resident also had an 

order for Methadone 20 

mg. that had been reduced 

to 2.5 mg. 

Resident was observed 

screaming and writhing in 

unrelieved pain for greater than 

an hour. 

Facility staff failed to assess 

the resident’s pain levels after 

decreasing her Methadone. 

They did not do an in-depth 

pain assessment at any time 

after admission. The surveyor 

observed the staff ignoring the 

resident’s cries for help and 

relief, which continued until the 

surveyor intervened. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 66 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

California-19 

June 2001 

Provide necessary 

care and services: 

D 

Resident admitted to 

facility on 3/97 with stroke, 

one-sided paralysis, and 

moderate contractures of 

upper and lower 

extremities. Resident took 

Tylenol four times a day 

since 2/98 for pain. As his 

pain worsened, he began 

to refuse the splinting of 

his contracted extremities 

because it was too painful. 

As a result of the facility’s 

failure to address the resident’s 

pain, the resident refused the 

splints used to control the 

contractures and the 

contractures worsened, leading 

to greater pain. 

Facility staff did not reassess 

this resident’s pain level and 

need for stronger pain relief. 

California-20 

January 2001 

Provide 

supervision and 

devices to prevent 

accidents: D 

Resident was admitted to 

facility on 3/6/00 and 

identified as a high risk for 

falls on 12/6/00 because of 

resident’s failure to 

remember warnings about 

personal safety and poor 

safety awareness. 

Resident fell and sustained 

abrasions to her right flank and 

hip on 12/24/00 and again on 

1/7/01, sustaining a scalp 

laceration on the back of her 

head. 

Facility failed to implement 

care plan of 12/19/00 that 

called for safety assessment 

and rehabilitation screening 

related to falls. In addition, 

facility failed to reassess 

resident’s safety needs and 

alternative preventive 

measures after the two falls, 

as called for by facility policy 

and the care plan. Physical 

therapy staff did not assess 

resident for safety needs 

either. There was no 

documented evidence that a 

plan was implemented to 

prevent future falls. 

California-22 

October 2000 

Provide 

supervision and 

devices to prevent 

accidents: D 

Resident had diagnoses of 

diabetes, bipolar disease, 

and high blood pressure. 

Resident was assessed as 

at risk for falls. 

Resident fell 17 documented 

times from 4/21 to 10/14/00, 

when she sustained a bruising 

of the right eye, and a bruise 

and an abrasion to her 

forehead. 

Facility failed to provide 

supervision and prevent 

accidents. Specifically, facility 

staff did not provide a selfreleasing seat belt or pressure 

sensitive alarm on resident’s 

wheelchair as recommended 

by the facility’s fall/risk 

committee. Although the MDS 

assessment of 9/4/00 

indicated that the resident had 

no falls for 180 days, the 

resident’s medical record 

indicated that the resident fell 

at least six times in this period. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 67 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Iowa-1 

June 2001 

Ensure prevention 

and healing of 

pressure sores: D 

Resident 1 had diagnoses 

that included renal failure, 

diabetes, and dementia. 

Resident’s record noted 

the presence of two 

pressure sores, one on 

1/9/01 and the second on 

4/1/01, between the 

buttocks and on the lower 

right back, respectively. 

Resident’s stage II pressure 

sores healed and then 

reopened repeatedly from 

1/9/01 to 6/20/01. 

Facility staff failed to provide 

appropriate treatment to 

prevent reoccurrence of 

pressure sores, resulting in the 

reappearance of pressure 

sores after they had resolved. 

Specifically, the facility did not 

reassess the current plan of 

treatment and did not modify 

the care plan to meet the 

needs of the resident. 

 

 Resident 2 had a history of 

stroke and dementia. A 

4/20/01 assessment note 

indicated that the resident 

had no ulcers, skin 

problems, or lesions. On 

4/22/01, the resident fell, 

was admitted to the 

hospital for treatment of a 

fracture of the right wrist, 

and was readmitted to 

nursing home on 4/27/01 

with a cast on the right 

arm, including the lower 

half of the hand and 

thumb. 

Resident developed an infected 

stage II pressure ulcer at the 

base of the right thumb. 

Facility staff failed to prevent 

an avoidable pressure sore. 

After the resident was 

readmitted with the cast on his 

arm, the staff did not assess 

whether the skin around the 

cast was intact for 18 days 

(4/27-5/14/01), at which time 

the nurse noted a foul odor 

and a reddened thumb. 

Iowa-2 

March 2002 

(1) Ensure 

prevention and 

healing of 

pressure sores: D 

On 2/25/02, surveyor 

observed resident being 

transferred using a 

mechanical lift and noted 

an open stage II pressure 

sore on the lower back. A 

record review revealed a 

history of healing and 

reoccurrence of a lowerback pressure sore on 

several occasions from 

7/8/01 through 2/26/02. 

Resident developed a stage II 

pressure sore that persisted 

and reopened after resolving. 

Facility staff failed to ensure 

that a resident with a pressure 

sore received necessary 

treatment to promote healing 

and to prevent new sores from 

developing. Specifically, the 

record lacked evidence of 

assessment of potential causal 

factors and interventions to 

prevent the reoccurring 

pressure sore. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 68 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

 (2) Provide 

supervision and 

devices to prevent 

accidents: D 

During the above cited 

observation of the same 

resident on the mechanical 

lift, the surveyor also noted 

bilateral purple bruises on 

the resident’s lower legs 

and later checked the 

resident more fully and 

noted a total of five bruises 

and a scrape to the legs. A 

review of the resident’s 

record revealed multiple 

bruises, abrasions, and 

skin tears going back 1 

year. The surveyor 

observed that there was 

no padding on the 

mechanical lift. 

Resident sustained multiple 

bruises, skin tears, and 

scrapes. 

Facility failed to prevent 

bruises and skin tear injuries. 

The staff did not assess the 

cause of the injuries or 

implement protective devices, 

such as padding of the lift and 

wheelchair. On 2/26/02, a staff 

member stated that the 

probable cause of the bruises 

was the resident’s hitting the 

mechanical Hoyer lift during 

transfers and that the lift 

should be padded. 

Iowa-4 

February 2001 

Provide necessary 

care and 

services: E 

Resident with a diagnosis 

of multiple sclerosis 

required extensive 

assistance with transfers, 

walking, and other 

activities of daily living. 

Care plan of 1/19/01 

directed staff to monitor 

and record all skin 

changes. Surveyor noted 

multiple bruises on 

resident’s legs. 

Surveyor noted bruises on 

resident’s legs and saw how 

resident’s legs and feet were 

twisted between the wheelchair 

pedals and dragged and 

bumped against the wheelchair 

on 1/30 and 1/31/01. Resident 

sustained multiple bruises on 

both lower legs. 

Facility staff failed to provide 

the necessary care and 

services in accordance with 

the plan of care. Staff failed to 

assess for risk of skin injury 

from wheelchair transfers and 

to protect resident from harm 

during transfers. Staff also 

failed to document resident’s 

bruises. 

Iowa-5 

March 2001 

Provide necessary 

care and 

services: D 

Resident admitted to 

facility on 7/6/99 with 

Alzheimer’s disease, high 

blood pressure, and 

anemia. Resident was 

receiving a diuretic to 

reduce blood pressure and 

an antihistamine for 

itching. Both drugs can 

reduce blood pressure 

below normal levels, 

causing dizziness or a 

drop in blood pressure 

when rising to stand 

(orthostatic hypotension). 

Resident’s plan of care 

called for staff to monitor 

blood pressure on a 

weekly basis. 

Resident fell five documented 

times, sustaining abrasions to 

the forehead, a bloody nose 

and mouth, a bump to the 

forehead, a broken tooth, a 

carpet burn of the knees, and a 

broken nose. 

Facility failed to properly 

assess and monitor after the 

resident fell, striking her head 

on all five occasions. There 

was no documentation of 

weekly monitoring of blood 

pressure or for neurological 

status after resident struck her 

head. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 69 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Iowa-7 

August 2001 

Provide necessary 

care and services: 

D 

Resident 1 admitted to 

facility on 3/2/01 with 

history of stroke, heart 

failure, and poor 

circulation, with related 

rash of the legs and feet. 

Assessment revealed a 

small scab on the left 

ankle that healed by 5/01. 

Resident developed a 

scabbed area on right foot. 

The physician ordered skin 

and heel protectors to be 

worn at night on 5/29/01. 

Resident developed two stage 

II ulcers of the foot and ankle, 

one on 6/18/01 and the other 

on 6/26/01, which were still 

present, unhealed, on 8/7/01. 

Facility staff did not 

consistently follow the orders 

and provide the necessary 

care for the resident. 

According to the surveyor, the 

skin and heel protectors were 

left off and the wheelchair was 

not padded and was causing 

additional erosion of the ankle 

lesions. 

 

 Resident 2 was admitted 

with lung cancer, 

degenerative arthritis, 

osteoporosis, and anxiety. 

Physician’s note of 5/16/01 

indicated that resident was 

dying and would need to 

be assessed for pain relief 

as the disease progressed 

and that stronger, more 

effective pain relievers 

would be considered. As 

the resident began to 

experience increasing 

pain, he was given Tylenol 

even when pain appeared 

severe and unrelieved. 

Resident 2 experienced severe 

unrelieved pain. 

Facility staff failed to provide 

the necessary care for this 

resident to maintain comfort 

measures and avoid pain. The 

care plan of 5/21 and 6/13/01 

did not include pain 

management. The staff did not 

assess the resident’s 

complaints of pain and need 

for effective pain relief. 

Iowa-7 

August 2001 

Provide 

supervision and 

devices to prevent 

accidents: D 

Resident 1 has diagnoses 

of dementia and 

depression with long- and 

short-term memory 

deficits. Surveyor noted 

resident had fallen 

frequently from 2/23/01 

through 7/23/01 and 

sustained serious injuries. 

Personal safety alarms 

selected for resident were 

ineffective in preventing 

falls. 

Resident 1 fell 11 times and 

sustained a fractured wrist, 

three fractured ribs, bruises, 

abrasions, and a skin tear, plus 

pain associated with all these 

falls and injuries. 

The facility failed to provide 

adequate interventions to 

prevent accidents. The 

personal alarm system was 

the only safety device 

employed, and there is no 

evidence that the staff 

evaluated its effectiveness and 

selected other measures. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 70 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

 Resident 2 was admitted 

to facility on 8/8/00 with 

renal failure and impaired 

mobility. On 4/3/01, he 

was assessed as being 

mentally confused at 

times. Surveyor noted the 

resident’s record stated 

that resident fell 

frequently. The care plan 

and monthly summary for 

April identify the personal 

alarm unit as the safety 

device in use during this 

time (initiated 3/25/01). 

The resident frequently 

removed the unit or put it 

in his pocket. 

Resident 2 fell 21 times from 

1/6/01 to 6/26/01 and sustained 

multiple skin tears, two 

lacerations to the head and 

elbow requiring emergency 

room or clinic visits for sutures, 

multiple bruises and abrasions, 

and head injuries. 

The facility failed to provide 

adequate interventions to 

prevent accidents. The 

personal alarm unit in use for 

this resident did not prevent 

his falls from occurring and 

there is no indication that other 

safety options were 

considered. 

Maryland-1 

August 2001 

Provide 

supervision and 

devices to prevent 

accidents: D 

Resident admitted to 

facility with multiple 

diagnoses including 

congestive heart failure, 

high blood pressure, and 

obesity. Resident suffered 

from shortness of breath 

and required oxygen at 3 

liters per minute. She also 

had a history of falls and 

was considered a high risk 

for falls. Resident had a 

physician order for a 

quick-release belt while in 

wheelchair for safety. 

Resident fell out of the 

wheelchair, was bleeding from 

nose and mouth, and was in 

acute respiratory distress. Staff 

did not intervene to address 

respiratory distress until 

resident stopped breathing and 

her pulse stopped. At this time 

the staff began to administer 

cardiopulmonary resuscitation 

(CPR). 

The facility failed to provide 

supervision and devices to 

prevent accidents by not 

placing safety belt around 

resident while she was in the 

wheelchair. Staff also did not 

provide the resident with 

oxygen as ordered while she 

was in the wheelchair. Staff 

did not respond in a timely and 

appropriate manner to 

resident’s onset of respiratory 

distress following the fall from 

the wheelchair. Staff did not 

initiate CPR until resident was 

no longer breathing and her 

pulse stopped. 

Missouri-3 

May 2001 

Ensure adequate 

nutritional status: 

D 

Resident had diagnoses of 

peptic ulcer disease, 

aspiration pneumonia, and 

a penicillin-resistant 

infection requiring longterm antibiotic treatment. 

From 11/00 through 2/01, 

resident sustained a 

severe weight loss of 10 to 

12 percent. 

Resident experienced another 

severe weight loss, dropping 

from 126 lbs in 3/01 to 116.9 

lbs in 4/01, a loss of 7.2 percent 

in 1 month. 

The facility failed to ensure 

adequate nutritional status. 

After noting resident’s weight 

loss in 2/01, no care plan was 

developed to address the 

weight loss. In March, the 

dietician recommended a 

dietary supplement, which did 

not begin for a month. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 71 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Nebraska-1 

September 2000 

Provide necessary 

care and 

services: D 

Resident 1 readmitted to 

facility from hospital with a 

diagnosis of insulindependent diabetes. 

Physician orders stated 

that the physician was to 

be called when resident’s 

blood sugar fell below 40 

or rose above 350 (normal 

range is 70 to 110). 

Resident received insulin 

on a sliding scale (insulin 

dose based on most 

recent blood sugar), and a 

variety of dietary 

interventions. 

Over a period of 9 months, 

resident’s blood sugar 

fluctuated, including frequent 

episodes of symptomatic 

hypoglycemia (low blood sugar 

between 48 and 60) and loss of 

consciousness. 

Facility failed to provide the 

necessary care and services 

required to manage resident’s 

diabetes. Specifically, (1) the 

staff infrequently called the 

physician about blood sugars 

below 40, the frequent blood 

sugar fluctuations, or the 

resident’s episodes of 

symptomatic hypoglycemia, 

(2) fluctuating blood sugars 

were not identified as a 

problem in the care plan, and 

(3) there was no assessment 

of the resident’s diabetes, 

appropriate diet, treatment 

effectiveness of hypoglycemic 

episodes, and administration 

of insulin on a sliding scale. 

 

 Resident 2 with diagnoses 

of emphysema, 

Parkinson’s disease, and 

osteoarthritis was 

receiving hospice services. 

Resident experienced 

increasing pain on a daily 

basis, unrelieved by 

regular Tylenol, a 

tranquilizer, and an 

antipsychotic drug specific 

for schizophrenia and 

mania. Resident obtained 

short-term (2.5 hours) 

relief from Tylox (Tylenol 

and oxycodone for pain 

relief and sedation). 

This terminally ill resident 

suffered with unrelieved pain 

for at least 4 months. 

Facility staff did not provide 

the necessary care and 

services to this resident. The 

staff did not assess or respond 

to the resident’s continuing 

complaints of pain and noted 

in the record that the resident 

was demanding and 

manipulative. Nor did they 

monitor the effectiveness of 

the medications administered, 

resulting (according to the 

surveyor) in the resident’s 

voicing thoughts of suicide. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 72 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Nebraska-3 

September 2001 

Ensure prevention 

and healing of 

pressure sores: D 

Resident was readmitted 

to facility 5/24/01 with 

diagnoses of stroke, 

diabetes, and one stage II 

pressure sore of the lower 

back and one stage I 

pressure sore between the 

buttocks. Resident was 

totally dependent on staff 

for bed mobility because of 

a right-sided paralysis and 

developed pressure sores 

of both heels that were 

noted on 6/3/01 and 

identified as stage II on 

7/24/01. A pressurereducing mattress was 

added to the care plan on 

9/4/01. 

Resident developed a stage III 

pressure sore on the right heel 

with thick green drainage and 

foul odor. 

Facility failed to ensure that a 

resident did not develop a 

pressure sore in the facility. 

Specifically, the facility staff 

failed to recognize the 

challenge the resident had in 

moving in bed because of the 

right-sided paralysis. In 

addition, they were slow to use 

a pressure-reducing mattress. 

When the mattress was placed 

on the bed the staff did not 

discontinue use of the fleecelined protection booties and 

continued use for 3 weeks, 

which negated the pressurereducing effects of the 

mattress. 

Pennsylvania-3 

May 2001 

Ensure prevention 

and healing of 

pressure sores: D 

Resident had a left hip 

fracture and was identified 

as high risk for skin 

breakdown on 12/18/00. A 

stage I pressure sore of 

the left heel was noted on 

3/7/01 and by 3/14/01 it 

had progressed to stage II. 

A special boot to keep left 

heel elevated was not 

applied until 3/21/01 and 

was then left on 

continuously. A second 

stage II pressure sore was 

noted on the left outer foot 

4/10/01. The boot was 

discontinued on 4/11/01. A 

nutrition assessment on 

3/27/01 indicated 

resident’s skin was intact 

and recommended no 

increase in protein in the 

diet. 

In addition to the stage II 

pressure sore of the foot, 

resident developed a second 

stage II facility-acquired 

pressure sore on 4/10/01. 

Facility failed to prevent the 

development of pressure 

sores. Specifically, the boot, 

which was left on continuously, 

contributed to the development 

of the pressure sore identified 

on 4/10/01. In addition, the 

dietician did not note the 

existing original pressure sore 

and wrongly assumed the 

resident had no extra need for 

protein. The need for 

additional protein in the diet 

was confirmed by laboratory 

tests indicating the resident’s 

protein levels were below the 

normal range. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 73 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Pennsylvania-3 

May 2001 

Provide 

supervision and 

devices to prevent 

accidents: E 

Resident had piriformis 

syndrome (compression of 

the sciatic nerve by the 

piriformis muscle) with a 

physician’s order for 

physical therapy using 

stretching exercises and 

heat application. Physical 

therapy used a 

hydrocollator pack to 

provide moist heat 

treatments.g

Resident developed a seconddegree burn of the right 

buttock, which blistered and 

was still healing after a month. 

Facility staff failed to provide 

supervision and prevent injury. 

During a routine check on 

1/9/01, the facility found that 

the temperature on the 

hydrocollator pack was 11 

degrees above the 

manufacturer’s recommended 

temperature. On 4/16/01 the 

hydrocollator pack was applied 

to the resident’s right buttock. 

Resident said that he told the 

therapy staff that the pack was 

getting too hot and the pack 

was removed. Facility staff did 

not check the water 

temperature after the incident. 

 

 Resident 2 had diagnoses 

that included dementia, 

poor vision, and 

Parkinson’s disease and 

was assessed as a 

moderate risk for falls on 

12/29/00. The MDS 

significant change 

assessment of 1/24/01 

and the 4/9/01 quarterly 

review noted a history of 

falls, impaired decision 

making, and the need for 

assistance for transferring 

and walking. The records 

noted interventions found 

to be ineffective continued 

to be used. 

Resident 2 fell nine 

documented times and, as a 

result of these falls, sustained a 

skin tear, a laceration requiring 

transfer to the hospital for 

treatment, and a dislocated hip 

requiring another hospital visit. 

The facility failed to ensure 

adequate supervision and 

assistance devices to prevent 

accidents. According to the 

surveyor, there was no 

evidence that the facility had 

implemented effective 

interventions to avoid the risk 

of such accidents for the 

resident. The surveyor noted 

that this at-risk resident’s room 

was too far from the nurses’ 

station, making observation 

difficult. 

Pennsylvania-9 

May 2001 

Provide 

supervision and 

devices to prevent 

accidents: D 

A dependent resident with 

cognitive impairment was 

assessed as at risk for 

falls and skin tears. 

Interventions to prevent 

falls listed in the care plan 

included use of personal 

alarms, protective sleeves, 

and padded side rails. 

Resident sustained eight skin 

tears on 6/27/00, 7/24/00, 

7/31/00, 8/16/00, 9/20/00, 

10/24/00, 1/8/01, and 1/27/01. 

Surveyor stated that the facility 

failed to ensure that the 

necessary safety measures 

and/or devices were 

implemented and failed to 

adequately assess the 

ongoing use of these devices 

given their ineffectiveness in 

preventing falls and skin tears. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 74 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Virginia-1 

August 2000 

Provide necessary 

care and 

services: D 

Resident admitted to 

facility for pain 

management associated 

with spread of cancer to 

the spine. Resident had 

physician orders for 

Oxycontin every 12 hours 

for long-term pain relief, as 

needed, and Percocet 

every 4 hours for any 

additional pain, as needed. 

Staff noted resident lay 

very still in bed and 

seldom asked for pain 

medication but that it was 

obvious he was in a lot of 

pain whenever he was 

turned or touched. 

Resident’s daughter said 

her father was in constant 

pain and was depressed. 

This resident suffered with 

severe pain that was 

incompletely relieved by the 

use of Percocet. The longer 

acting Oxycontin was never 

used. 

The facility did not provide 

necessary care and services 

to manage this resident’s pain. 

Resident did not receive any of 

the longer-acting Oxycontin 

and received only 10 doses of 

the Percocet during the 6 days 

he was in the facility. He was 

not offered pain relief in the 

morning when he was being 

turned and bathed. Monitoring 

of medication effectiveness 

was incomplete. Percocet was 

given, on average, once a day. 

Virginia-2 

March 2001 

Provide necessary 

care and 

services: D 

Resident was admitted to 

facility 11/4/97, with 

diagnoses of stroke, 

depression, and delusions. 

An MDS of 11/9/00 

indicated the resident was 

cognitively impaired and 

required lift transfer. On 

12/27/00 the nurse noted a 

large area of bruising on 

the left chest and left 

underarm with swelling 

around the rib cage. On 

1/6/01 resident began to 

experience shallow 

breathing. Physician 

ordered a chest x ray if 

resident’s breathing 

difficulties continued. 

Resident sustained fractures of 

the eighth and ninth ribs with 

fluid in the left lower lobe of the 

lung demonstrated by x ray. 

The facility failed to provide 

the necessary care and 

services to provide prompt 

treatment of the resident’s 

chest injury. Specifically, the 

facility failed to take 

appropriate action to assess 

and provide the necessary 

care for this resident’s injury 

for 11 days. The results of an 

investigation implicated the lift 

used to transfer the resident to 

and from the bed. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 75 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Virginia-2 

March 2001 

Ensure prevention 

and healing of 

pressure sores: D 

Resident 1 admitted to the 

facility with diagnoses of 

Alzheimer’s disease, 

anemia, depression, and 

joint pain. No pressure 

sores were noted on the 

admission assessment 

form. The care plan on 

2/22/00 noted the resident 

was incontinent of bowel 

and bladder and at risk for 

pressure sores. Resident’s 

blood protein was low. The 

most recent MDS 

(2/23/01) indicated no 

pressure sores but noted 

the resident was losing 

weight, 5 percent or more 

in the past 30 days 

(1/24/01- 2/23/01). 

Resident developed three open 

pressure sores of the buttocks, 

evident 2 days after the MDS 

assessment. One of the 

pressure sores was a stage III. 

The facility failed to prevent 

the development of facilityacquired pressure sores. The 

staff did not obtain timely 

alternative treatments and 

interventions to promote 

healing of early pressure 

sores. 

 

 Resident 2 admitted to 

facility on 12/24/00 with 

diabetes, stroke, prostate 

cancer, requiring limited 

assistance for activities of 

daily living, and incontinent 

of bowel and bladder. As 

of 12/31/00 resident had 

an unhealed surgical 

wound of the back, two 

stage IV pressure sores of 

the right and left heels, 

and an excoriated (stage I) 

buttock. After a brief 

hospitalization, resident 

was readmitted to facility 

and the clinical record on 

2/26/00 described the 

buttock sore as a stage II 

pressure sore. Treatment 

with a sealed dressing 

continued. 

Resident developed an open 

stage III pressure sore with 

yellow drainage. 

Staff failed to obtain timely 

alternative treatments and 

interventions to promote 

healing upon worsening of 

these sores from1/18/01 

through 3/1/01. Specifically, 

the staff continued to treat the 

pressure sores without 

evaluating the effectiveness of 

the treatment. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 76 GAO-03-561 Nursing Home Quality 

State and date 

of surveya

Requirement and 

scope and 

severity cited 

Resident description and 

relevant diagnosesb 

Actual harm to resident 

documented by surveyor 

Deficiencies in care cited by 

surveyor 

Virginia-4 

March 2001 

Provide necessary 

care and services: 

D 

Resident was an 81-yearold admitted to the facility 

on 8/17/90 with psychoses 

and hypothyroidism. 

Recent assessment 

(1/22/01) indicated longand short-term memory 

loss and moderate 

dependency for activities 

of daily living. Care plan 

identified resident as at 

risk for falls. A list of 

preventive measures was 

provided. On 9/14/00 at 

7:30 p.m., resident fell and 

complained of pain all 

over. 

Resident sustained a 

nondisplaced fracture of the left 

wrist and suffered unnecessary 

pain. 

Facility failed to provide 

necessary care and services. 

The facility failed to assess 

and investigate the source of 

the resident’s pain. Nurses’ 

notes indicate no apparent 

injury after fall. On 9/15/00 at 

6:30 p.m., resident complained 

of pain in left arm. There was 

bruising on wrist and thumb, 

and the arm was swollen and 

tender to touch. According to 

the surveyor, there was a 

delay in seeking more 

aggressive treatment or 

service, as evidenced by the 

fact that an x-ray was not 

obtained until 37 hours after 

the resident’s fall. 

Source: State nursing home survey reports. 

a

To more easily distinguish among multiple surveys from the same state, we assigned consecutive 

numbers to each state’s surveys. 

b

The resident description and relevant diagnoses are limited to the information provided by the 

surveyor. In some of the surveys, no background or diagnostic information was provided. 

c

Skin tears and multiple bruises are serious and painful injuries for older individuals and should not be 

considered in the same context as cuts and bruises sustained by healthy and younger adults. A skin 

tear is a traumatic wound occurring principally on the extremities of older adults as a result of friction 

alone or shearing and friction forces that separate the top layer of skin from the underlying layer or 

both layers from the underlying structures. A skin tear is a painful but preventable injury. Individuals 

most at risk for skin tears are those with (1) fragile skin, (2) advanced age, (3) assistance devices 

(wheelchairs, lifts, walkers), (4) cognitive and sensory impairment, (5) history of skin tears, and 

(6) total dependence for care. In addition, treatment of bruises and skin tears for elderly residents of a 

nursing home is frequently complicated by diabetes, poor circulation, poor nutrition, and medications 

with blood thinning effects. See Sharon Baranoski, “Skin Tears: Staying on Guard Against the Enemy 

of Frail Skin,” Nursing 2000, vol. 30, no. 9, 2000. 

d

Stages of pressure sore formation are I—skin of involved area is reddened, II—upper layer of skin is 

involved and blistered or abraded, III—skin has an open sore and involves all layers of skin down to 

underlying connective tissue, and IV—tissue surrounding the sore has died and may extend to 

muscle and bone and involve infection. 

e

The following two resident incidents were cited at the B level for scope and severity, which means 

the surveyor found that both injuries were unavoidable and that the nursing home was in substantial 

compliance with the requirements. 

f

These two citations involve two residents, one cognitively competent and the other with dementia, 

who were injured because side rails were in place on their beds. Numerous reports have cited the 

danger of side rails. Residents trying to get out of bed over the rails have injured themselves by 

falling. Other individuals have been caught between the bed rails and the mattress or have caught 

their heads in the rails. Some of these injuries resulted in death. 
Appendix III: Abstracts of Nursing Home 

Survey Reports That Understated Quality-ofCare Problems 

Page 77 GAO-03-561 Nursing Home Quality 

g

A hydrocollator pack is a canvas bag containing a silicone gel paste that absorbs an amount of water 

10 times its weight. The pack is placed in a heated water container, set at a temperature above 150° 

F. When ready, it is placed in a protective dry terrycloth wrap and applied on top of the area where 

the individual is experiencing pain. Lying or sitting on the pack negates the insulating effect of the 

terrycloth and the individual may be burned. 
Appendix IV: Information on State Nursing 

Home Surveyor Staffing 

Page 78 GAO-03-561 Nursing Home Quality 

Table 9 summarizes state survey agencies’ responses to our July 2002 

questions about nursing home surveyor experience, vacancies, hiring 

freezes, competitiveness of salaries, and minimum required experience. 

Table 9: State Survey Agency Responses to Questions about Surveyor Experience, Vacancies, Hiring Freezes, 

Competitiveness of Salaries, and Minimum Required Experience 

Statea

Surveyors with 

2 years or less 

experience 

(percent) 

Surveyor 

positions vacant 

(percent)

Surveyor hiring 

freeze in effect as 

of mid-2002 

RN surveyor 

salaries are 

competitive

Minimum required 

experience for RN 

surveyors (years)

Maryland 70 9 Yes Yes 0 to 2

Oklahoma 67 4 Yes Yes 0 to1

New Hampshire 60 12 Yes No 2

Florida 55 8 No No 0

Idaho 54 0 Yes No 1

Washington 54 0 No No 2

California 52 6 Yes Yes 1

Georgia 51 14 No No 3

Kentucky 51 17 No Yes 4

District of Columbia 50 9 Yes Yes 3

Utah 50 8 No No 2

Louisiana 48 6 Yes No 2 to 3

Alabama 48 10 No No 0

Tennessee 45 18 No No 3

Maine 42 9 Yes No 5

Hawaii 40 17 No No 2-1⁄2 

New York 40 4 Yes No 1 to 2

Missouri 36 11 No No 2

Oregon 34 12 Yes No 5

Arkansas 33 20 No No 2

North Carolina 33 18 No No 4

Texas 32 20bNob No 1

New Mexico 30 34 No No 3

New Jersey 30 23 Yes No 3

Nebraska 29 6 No No 1 to 2

Connecticut 29 1 Yes Yes 4

Alaska 29 22 No No 2

Wisconsin 25 15 No No 0

Colorado 24 17 No No 1

Virginia 21 5 No No 0

Indiana 20 18 No No 1

Arizona 20 24 Yes No 2

South Dakota 18 0 No Yes 2

Ohio 17 5 No Yes 0

Appendix IV: Information on State Nursing 

Home Surveyor Staffing 
Appendix IV: Information on State Nursing 

Home Surveyor Staffing 

Page 79 GAO-03-561 Nursing Home Quality 

Statea

Surveyors with 

2 years or less 

experience 

(percent) 

Surveyor 

positions vacant 

(percent)

Surveyor hiring 

freeze in effect as 

of mid-2002 

RN surveyor 

salaries are 

competitive

Minimum required 

experience for RN 

surveyors (years)

Michigan 17 5 Yes No 0

Kansas 17 4 No No C 

Massachusetts 16 14 Yes Yes 1 to 3

Pennsylvania 15 7 No Yes 1

Rhode Island 9 13 No Yes 1

Illinois 5 5 Yes Yes 2 to 3

Iowa 4 0 Yes No 5

Minnesota 0 17 Yes No 3

Source: State survey agency responses to July 2002 GAO questions. 

a

Nine states did not respond to our inquiry—Delaware, Mississippi, Montana, Nevada, North Dakota, 

South Carolina, Vermont, West Virginia, and Wyoming. 

b

Texas indicated that although there was no hiring freeze or layoffs, the survey staff was reduced by 

107 positions through attrition from September 1, 2001, through June 1, 2002, in light of state funding 

changes and agency cuts. As of mid-2002, Texas was authorized 215 nurse surveyors and had 42 

positions vacant. 

c

Kansas requires independent experience in professional health care, but does not specify a time 

period for that experience. 
Appendix V: Predictability of Standard 

Nursing Home Surveys 

Page 80 GAO-03-561 Nursing Home Quality 

Our analysis found that 34 percent of current nursing home surveys were 

predictable, allowing nursing homes to conceal deficiencies if they choose 

to do so. In order to determine the predictability of nursing home surveys, 

we analyzed data from CMS’s OSCAR database (see table 10). We 

considered surveys to be predictable if (1) homes were surveyed within 15 

days of the 1-year anniversary of their prior survey or (2) homes were 

surveyed within 1 month of the maximum 15-month interval between 

standard surveys. Consistent with CMS’s interpretation, we used 15.9 

months as the maximum allowable interval between surveys. Because 

homes know the maximum allowable interval between surveys, those 

whose prior surveys were conducted 14 or 15 months earlier are aware 

that they are likely to be surveyed soon. 

Appendix V: Predictability of Standard 

Nursing Home Surveys 
Appendix V: Predictability of Standard 

Nursing Home Surveys 

Page 81 GAO-03-561 Nursing Home Quality 

Table 10: Predictability of Current Nursing Home Surveys, by State 

State 

Number of active 

homes with a current 

and prior survey

Predictable surveys 

(percent)

Homes surveyed within 15 

days of 1-year anniversary 

of prior survey (percent) 

Homes surveyed within 1 

month of 15-month 

maximum interval of 

prior survey (percent)

Alabama 225 82.7 5.8 76.9

Oklahoma 354 71.5 0.6 70.9

South Carolina 174 67.8 6.9 60.9

Nebraska 226 59.7 3.1 56.6

Utah 91 52.7 1.1 51.6

Montana 103 52.4 8.7 43.7

Georgia 357 52.4 0.6 51.8

Hawaii 44 52.3 13.6 38.6

New York 663 52.0 14.8 37.3

Idaho 84 50.0 4.8 45.2

New Mexico 80 43.8 13.8 30.0

Delaware 42 42.9 31.0 11.9

California 1,324 41.2 9.5 31.7

Nevada 45 40.0 24.4 15.6

Arizona 138 39.9 21.0 18.8

New Jersey 359 39.0 18.7 20.3

Oregon 142 38.0 14.1 23.9

Maryland 246 37.0 20.7 16.3

Massachusetts 497 36.2 17.3 18.9

Arkansas 239 35.6 27.6 7.9

Virginia 275 35.3 30.5 4.7

Iowa 457 34.6 31.1 3.5

Nation 16,332 34.0 13.0 21.0

Kentucky 303 33.7 10.6 23.1

Ohio 973 33.6 3.0 30.6

North Dakota 85 32.9 28.2 4.7

Vermont 43 32.6 11.6 20.9

New Hampshire 83 32.5 12.0 20.5

South Dakota 111 32.4 18.9 13.5

Wisconsin 404 32.4 19.6 12.9

Washington 268 32.1 22.4 9.7

Florida 718 32.0 9.3 22.7

Mississippi 187 31.6 2.1 29.4

Rhode Island 96 31.3 12.5 18.8

Connecticut 253 30.8 15.8 15.0

Wyoming 39 30.8 10.3 20.5

Indiana 550 30.7 14.4 16.4

Tennessee 324 29.0 6.2 22.8

Louisiana 315 28.6 19.0 9.5

Texas 1,122 27.2 15.7 11.5
Appendix V: Predictability of Standard 

Nursing Home Surveys 

Page 82 GAO-03-561 Nursing Home Quality 

State 

Number of active 

homes with a current 

and prior survey

Predictable surveys 

(percent)

Homes surveyed within 15 

days of 1-year anniversary 

of prior survey (percent) 

Homes surveyed within 1 

month of 15-month 

maximum interval of 

prior survey (percent)

Colorado 222 26.1 9.0 17.1

Pennsylvania 757 26.0 24.0 2.0

Kansas 369 25.2 13.6 11.7

Missouri 531 25.0 11.9 13.2

Maine 121 24.8 8.3 16.5

Minnesota 427 20.4 4.4 15.9

Alaska 15 20.0 6.7 13.3

District of Columbia 20 20.0 15.0 5.0

North Carolina 411 17.3 13.9 3.4

Illinois 849 15.2 9.7 5.5

West Virginia 138 10.9 8.7 2.2

Michigan 433 10.2 8.8 1.4

Source: GAO analysis of OSCAR data as of April 9, 2002. 
Appendix VI: Immediate Sanctions 

Implemented Under CMS’s Expanded 

Immediate Sanctions Policy 

Page 83 GAO-03-561 Nursing Home Quality 

From January 2000 through March 2002, states referred 4,310 cases to 

CMS under its expanded immediate sanctions policy when nursing homes 

were found to have a pattern of harming residents.1

 Because some homes 

had more than one sanction or may have had multiple referrals for 

sanctions, 4,860 sanctions were implemented (see table 11). Table 12 

summarizes the amounts of federal civil money penalties (CMP) 

implemented against nursing homes referred for immediate sanction. 

Although these monetary sanctions were implemented, CMS’s 

enforcement database does not track collections. In addition, states may 

have imposed other sanctions under their own licensure authority, such as 

state monetary sanctions, in addition to or in lieu of federal sanctions. 

Such state sanctions are not recorded in CMS’s enforcement database. 

Table 11: Federal Sanctions Implemented against Nursing Homes Referred for 

Immediate Sanction, January 14, 2000, through March 28, 2002 

Type of sanctiona

 Number implemented

CMP 2,933

Denial of payment for new admissions 1,232

Directed in-service training 345

State monitoring 192

Directed plan of correction 77

CMS approved alternative or additional state sanction 48

Termination from the Medicare and Medicaid programs 26

Temporary management 4

Denial of payment for all residents 2

Transfer of residents and closure of facility 1

Total 4,860

Source: CMS enforcement database as of March 28, 2002. 

a

We excluded sanctions that were not implemented either because they were pending as of March 

28, 2002, the date of our extract of CMS’s enforcement database, or because CMS withdrew them 

after imposition. 

 1

We use the term “cases” because some homes had multiple referrals for immediate 

sanctions. 

Appendix VI: Immediate Sanctions 

Implemented Under CMS’s Expanded 

Immediate Sanctions Policy 
Appendix VI: Immediate Sanctions 

Implemented Under CMS’s Expanded 

Immediate Sanctions Policy 

Page 84 GAO-03-561 Nursing Home Quality 

Table 12: Federal CMPs Implemented under CMS’s Immediate Sanctions Policy, 

January 2000 through March 2002 

State CMP amount

Alabama $375,627.50

Alaska 0.00

Arizona 350,652.50

Arkansas 1,571,654.04

California 1,681,813.50

Colorado 1,489,100.00

Connecticut 696,350.00

Delaware 214,342.50

District of Columbia 20,000.00

Florida 1,975,375.00

Georgia 487,050.00

Hawaii 20,000.00

Idaho 37,350.00

Illinois 2,801,656.50

Indiana 1,977,685.50

Iowa 175,945.00

Kansas 415,400.00

Kentucky 1,195,177.50

Louisiana 20,000.00

Maine 184,920.00

Maryland 290,270.00

Massachusetts 1,031,445.00

Michigan 1,035,815.00

Minnesota 66,307.50

Mississippi 186,977.50

Missouri 467,157.50

Montana 0.00

Nebraska 11,207.50

Nevada 429,500.00

New Hampshire 93,350.00

New Jersey 1,543,007.50

New Mexico 222,430.00

New York 0.00

North Carolina 2,171,013.75

North Dakota 15,730.00

Ohio 3,104,870.00

Oklahoma 1,075,036.50

Oregon 15,225.00

Pennsylvania 1,250,417.00

Rhode Island 9,425.00

South Carolina 29,250.00
Appendix VI: Immediate Sanctions 

Implemented Under CMS’s Expanded 

Immediate Sanctions Policy 

Page 85 GAO-03-561 Nursing Home Quality 

State CMP amount

South Dakota 0.00

Tennessee 381,432.50

Texas 7,677,219.58

Utah 37,157.00

Vermont 11,550.00

Virginia 934,425.00

Washington 0.00

West Virginia 112,160.00

Wisconsin 901,960.50

Wyoming 0.00

Total $38,794,439.37

Source: CMS enforcement database. 
Appendix VII: Cases States Did Not Refer to 

CMS for Immediate Sanction 

Page 86 GAO-03-561 Nursing Home Quality 

State survey agencies did not refer to CMS for immediate sanction a 

substantial number of nursing homes found to have a pattern of harming 

residents. Most states failed to refer at least some cases and a few states 

did not refer a significant number of cases.1 While seven states 

appropriately referred all cases, the number of cases that should have 

been but were not referred ranged from 1 to 169. Four states accounted for 

about 55 percent of cases that should have been referred. Table 13 shows 

the number of cases that states should have but did not refer for 

immediate sanction (711) as well as the number of cases that states 

appropriately referred (4,310) from January 2000 through March 2002. 

Table 13: Number of Cases States Did Not Refer for Sanction, as Required, and the 

Number States Appropriately Referred, January 2000 through March 2002 

State 

Number of cases not 

referred as required 

Number of cases 

referreda

Nation 711 4,310

Texas 169 423

New York 140 22

Massachusetts 46 81

Pennsylvania 38 164

Connecticut 26 244

Washington 26 227

Illinois 24 241

Florida 21 150

New Jersey 20 56

Tennessee 20 46

Minnesota 19 68

Missouri 18 108

South Carolina 18 3

North Carolina 10 242

Arizona 9 24

Maryland 9 34

Wyoming 9 11

California 7 96

Michigan 7 284

Arkansas 6 115

Montana 6 14

Ohio 6 323

Idaho 5 31

 1

We use the term “cases” because some homes had multiple referrals for immediate 

sanctions. 

Appendix VII: Cases States Did Not Refer to 

CMS for Immediate Sanction 
Appendix VII: Cases States Did Not Refer to 

CMS for Immediate Sanction 

Page 87 GAO-03-561 Nursing Home Quality 

State 

Number of cases not 

referred as required 

Number of cases 

referreda

Indiana 5 270

Louisiana 5 82

Oklahoma 4 53

West Virginia 4 11

Delaware 3 14

Georgia 3 81

Hawaii 3 1

Iowa 3 44

New Hampshire 3 20

Colorado 2 116

District of Columbia 2 1

Oregon 2 51

Rhode Island 2 3

South Dakota 2 18

Virginia 2 41

Wisconsin 2 61

Alabama 1 50

Kansas 1 175

Maine 1 18

New Mexico 1 19

Nevada 1 12

Alaska 0 0

Kentucky 0 75

Mississippi 0 23

Nebraska 0 30

North Dakota 0 20

Utah 0 11

Vermont 0 3

Source: CMS regional office review of cases identified through GAO’s analysis of OSCAR data and the CMS Enforcement Database. 

a

Reflects cases entered in CMS’s enforcement database by March 28, 2002. 
Appendix VIII: HCFA State Performance 

Standards for Fiscal Year 2001 

Page 88 GAO-03-561 Nursing Home Quality 

Table 14 summarizes HCFA’s state performance standards for fiscal year 

2001, describes the source of the information CMS used to assess 

compliance with each standard, and identifies the criteria the agency used 

to determine whether states met or did not meet each standard. 

Table 14: Overview of HCFA’s Seven State Performance Standards for Nursing Home Survey Activities for Fiscal Year 2001 

Description Source of information 

Criteria for determining compliance 

with standard 

1. Surveys are planned, scheduled, and conducted in a timely manner 

At least 10 percent of standard surveys 

begin on weekends or “off-hours” 

OSCAR and state survey schedules At least 10 percent of standard surveys 

begin on weekends or off-hours 

Standard surveys are conducted within 

prescribed time limits 

OSCAR 100 percent of nursing homes are 

surveyed within statutory time limits 

2. Survey findings (deficiencies) are supportable 

State surveyors explain and properly 

document all deficiencies in survey reports 

following HCFA guidance known as the 

“principles of documentation” 

A random sample of 10 percent 

(maximum of 40, minimum of 5) of the 

state’s survey results in which certain 

deficiencies were cited at “D” or higher 

levels of scope and severity 

At least 85 percent of the deficiencies 

reviewed meet the principles of 

documentation 

3. Surveys are fully documented and consistent with applicable laws, regulations, and general instructions 

Surveys are adequately conducted by state 

agencies using the standards, protocols, 

forms, methods, procedures, policies, and 

systems specified by HCFA instructions 

Reports generated from HCFA’s database 

on federal monitoring surveys 

100 percent of standard surveys are 

adequately conducted by state agencies 

using the standards, protocols, forms, 

methods, procedures, policies, and 

systems specified by HCFA instructions 

4. When states certify that nursing homes are not in compliance, they follow adverse action procedures set forth in 

regulations and general instructions 

“Immediate and Serious Threat” cases are 

processed in a timely manner 

OSCAR, Enforcement Tracking System 

reports, and state agency provider 

certification files 

In 95 percent of cases in which there is 

immediate jeopardy or a serious threat to 

resident health and safety, the state 

agency adheres to the 23-day termination 

process 

Payments are not made to nursing homes 

that have not achieved substantial 

compliance within 6 months of their last 

surveys 

OSCAR, Enforcement Tracking System 

reports, and state agency provider 

certification files 

The state provides timely notice to HCFA 

(i.e., 20 days prior to the home’s 

termination date) on 100 percent of the 

cases in which the nursing home has not 

achieved timely compliance 

5. All expenditures and charges to the program are substantiated to the Secretary’s satisfaction 

The state agency employs an acceptable 

process for charging federal programs 

HCFA budget expenditure and workload 

reports 

More than 20 different items on the two 

reports submitted by the states are 

reviewed for accuracy, completeness, and 

timeliness and are scored as either on 

time or late, or met or not met for a 

reporting period 

The state agency has an acceptable 

method for monitoring its current rate of 

expenditures 

OSCAR reports Numerous items submitted by the states, 

such as quarterly expenditure reports and 

supplemental budget requests, are 

reviewed to determine if state 

requirements for monitoring expenditures 

are met, not met, or not applicable 

Appendix VIII: HCFA State Performance 

Standards for Fiscal Year 2001 
Appendix VIII: HCFA State Performance 

Standards for Fiscal Year 2001 

Page 89 GAO-03-561 Nursing Home Quality 

Description Source of information 

Criteria for determining compliance 

with standard 

6. Conduct and reporting of complaint investigations are timely and accurate, and comply with general instructions for 

handling complaints 

Investigate immediate jeopardy complaints 

within 2 workdays 

Semiannual review of a 10 percent 

sample of a state’s complaint files 

100 percent of immediate jeopardy 

complaints are investigated within 2 days 

Investigate actual harm complaints within 

10 workdays 

(maximum of 20 cases) 100 percent of actual harm complaints are 

investigated within 10 days 

Maintain and follow guidelines for the 

prioritization of all other complaints 

 The state agency has and follows its own 

written criteria governing the prioritization 

of complaints that do not allege immediate 

jeopardy or actual harm 

State enters complaint data into OSCAR 

appropriately and in a timely manner 

Semiannual on-site reviews of 20 state 

complaint survey reports 

100 percent of deficiencies cited in the 

sampled complaints are cited under the 

correct federal citation 

OSCAR data are reviewed quarterly for 

timely entry 

Average time to enter results of complaint 

investigations does not exceed 20 

calendar days from completion of the case 

7. Accurate data on survey results are entered into OSCAR in a timely manner 

Results of standard surveys are entered 

into OSCAR in a timely manner 

Semiannual review of all standard surveys 

based on OSCAR data 

The statewide average time between state 

agency sign-off of the certification and 

transmittal form and entry of the survey 

results into OSCAR does not exceed 20 

calendar days 

Results of surveys are entered into OSCAR 

accurately 

Semiannual review of a random sample of 

nursing home survey results 

No less than 85 percent of cases reviewed 

demonstrate that data were entered into 

OSCAR accurately 

Source: HCFA’s State Performance Review Protocol Guidance for fiscal year 2001. 

Note: HCFA did not finalize and issue the fiscal 2001 performance standards and guidance until April 

2001. 
Appendix IX: Highlights of State Compliance 

with CMS Performance Standards 

Page 90 GAO-03-561 Nursing Home Quality 

Table 15 summarizes the results of CMS’s fiscal year 2001 state 

performance review for each of the five standards we analyzed. We 

focused on five of CMS’s seven performance standards: statutory survey 

intervals, the supportability of survey findings, enforcement requirements, 

the adequacy of complaint activities, and OSCAR data entry. Because 

several standards included multiple requirements, the table shows the 

results of each of these specific requirements separately. 

Table 15: State Compliance with Selected CMS Performance Standards, Fiscal Year 2001 

CMS standard and requirements Number of states not meeting standard 

Survey timeliness 

The state begins no less than 10 percent of its standard surveys during 

weekends or “off-hours.” (Standard 1, criterion 1) 

2 

The state conducts standard surveys in prescribed times. (Standard 1, 

criterion 2) 

• The average statewide interval between consecutive standard surveys 

is not greater than 12 months. 

9 

• Each home is surveyed within 15 months of its prior survey. 17 

Supportability of survey findings 

The state explains and properly documents deficiencies. (Standard 2) Due to complications with the review protocol, this 

standard was not reported. 

Enforcement 

The state properly follows termination procedures. (Standard 4, criterion 1) 3 

The state notifies CMS when a nursing home has not achieved substantial 

compliance in a timely manner. (Standard 4, criterion 2) 

4 

Complaints 

The state investigates all complaints alleging immediate jeopardy to a 

resident within 2 workdays. (Standard 6, criterion 1) 

12 

The state investigates all complaints alleging actual harm to a resident 

within 10 workdays. (Standard 6, criterion 2) 

42 

The state has and follows guidelines for prioritizing complaints not alleging 

immediate jeopardy or actual harm. (Standard 6, criterion 3) 

15 

The state enters citations resulting from complaint investigations into 

CMS’s complaint database. (Standard 6, criterion 4) 

13 

OSCAR 

The state enters survey results into CMS’s database in a timely manner. 

(Standard 7, criterion 1) 

9 

The state enters survey results into CMS’s database accurately. (Standard 

7, criterion 2) 

24 

Source: GAO analysis of results of CMS Fiscal Year 2001 State Performance Standard Reviews. 

Note: We reviewed five of the seven CMS performance standards. See app. VIII, table 14, for a 

description of standards three and five, which we did not review. 

Appendix IX: Highlights of State Compliance 

with CMS Performance Standards 
Appendix X: Comments from the Centers for Medicare & Medcaid Services 

Page 91 GAO-03-561 Nursing Home Quality 

Appendix X: Comments from the Centers for 

Medicare & Medcaid Services 
Appendix X: Comments from the Centers for Medicare & Medcaid Services 

Page 92 GAO-03-561 Nursing Home Quality 
Appendix X: Comments from the Centers for Medicare & Medcaid Services 

Page 93 GAO-03-561 Nursing Home Quality 
Appendix X: Comments from the Centers for Medicare & Medcaid Services 

Page 94 GAO-03-561 Nursing Home Quality 
Appendix XI: GAO Contact and Staff 

Acknowledgements 

Page 95 GAO-03-561 Nursing Home Quality 

Walter Ochinko, (202) 512-7157 

The following staff made important contributions to this work: Jack 

Brennan, Patricia A. Jones, Dan Lee, Dean Mohs, and Peter Schmidt. 

Appendix XI: GAO Contact and Staff 

Acknowledgements 

GAO Contact 

Acknowledgements 
Related GAO Products 

Page 96 GAO-03-561 Nursing Home Quality 

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: Success of Quality Initiatives Requires Sustained 

Federal and State Commitment. GAO/T-HEHS-00-209. Washington, D.C.: 

September 28, 2000. 

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 Homes: HCFA Should Strengthen Its Oversight of State Agencies 

to Better Ensure Quality of Care. GAO/T-HEHS-00-27. 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. 

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

Will Require Continued Commitment. GAO/T-HEHS-99-155. Washington, 

D.C.: June 30, 1999. 

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 in Maryland. 

GAO/T-HEHS-99-146. Washington, D.C.: June 15, 1999. 

Related GAO Products 
Related GAO Products 

Page 97 GAO-03-561 Nursing Home Quality 

Nursing Homes: Complaint Investigation Processes Often Inadequate to 

Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999. 

Nursing Homes: Stronger Complaint and Enforcement Practices Needed 

to Better Ensure Adequate Care. GAO/T-HEHS-99-89. 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: Federal and State Oversight Inadequate to 

Protect Residents in Homes with Serious Care Problems. GAO/T-HEHS98-219. Washington, D.C.: July 28, 1998. 

California Nursing Homes: Care Problems Persist Despite Federal and 

State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998. 

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