Combined Medicare and Medicaid payments to nursing homes for care provided to vulnerable elderly and disabled beneficiaries totaled about $64 billion in 2002, with total federal payments of approximately $45.5 billion. Oversight of nursing home quality is a shared federal-state responsibility. On the basis of statutory requirements, CMS defines standards that nursing homes must meet to participate in the Medicare and Medicaid programs, and contracts with states to assess, through annual surveys and complaint investigations, whether homes meet these standards. CMS is also responsible for monitoring the adequacy of state survey activities. Arkansas’s unique 1999 law requires investigations by county officials, such as coroners, of nursing home residents’ deaths and referral of any cases of suspected neglect to the state survey agency and the MFCU. Every nursing home receiving Medicare or Medicaid payments must undergo an unannounced standard survey not less than once every 15 months, and the statewide average interval for these surveys must not exceed 12 months. A standard survey entails a team of state surveyors, including registered nurses, 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 of care, such as preventing avoidable pressure sores, weight loss, or accidents. State surveyors assess the quality of care provided to a sample of residents during the standard survey, which is 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. When a deficiency is identified, the nursing home is required to prepare a plan of correction that must be approved by the state survey agency. Our earlier work indicated that facilities could mask certain deficiencies, such as routinely having too few staff to care for residents, if they could predict the survey timing; CMS therefore directed states, effective 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). Complaint investigations provide an opportunity for state surveyors to intervene promptly if quality-of-care problems arise between standard surveys. A nursing home resident, family member, friend, nursing home employee, or others may file complaints. CMS requires the investigation of complaints that represent immediate jeopardy to resident health and safety within 2 working days and considers such complaints to be those where one or more of the conditions alleged in the complaint, if true, may have caused or is likely to cause serious injury, harm, impairment, or death to a resident. Beginning in 1999, CMS required investigation of complaints that allege harm to a resident (but which do not rise to the level of immediate jeopardy) within 10 working days, but did not provide detailed guidance to the states about what constitutes harm until November 2003. In November 2003 guidance, CMS generally defined two categories of complaints representing harm: (1) those that, if true, would impair the resident’s mental, physical, and/or psychosocial status, which must be investigated within 10 working days, and (2) those that would not significantly impair the resident’s mental, physical, and/or psychosocial status, which must be investigated within 45 calendar days. Other complaints that do not rise to the level of either immediate jeopardy or harm do not have to be investigated until the home’s next survey, or in some cases, not at all if the state survey agency can determine with certainty that no investigation, analysis, or action is necessary. The requirements identified in the November 2003 guidance became effective on January 1, 2004. Generally, nurse surveyors investigate complaints onsite at the nursing home by reviewing medical records and interviewing staff and residents. The investigations typically include a sample of residents in addition to the resident who is the subject of the complaint to help determine if the problems are systemic. Depending on the volume of complaints against a particular home, several complaints for different residents may be investigated concurrently. Each complaint may contain one or more allegations that a facility is violating federal quality-of-care standards. For example, a single complaint could allege problems with resident abuse, treatment of pressure sores, and proper feeding and hydration. In the course of complaint investigations, the state survey agency can either substantiate or not substantiate the specific allegations or discover other, unreported violations of federal standards (see table 1). A substantiated complaint, however, does not necessarily mean that the state survey agency found neglect of the resident who was the subject of the complaint but rather may indicate other, unrelated care problems. If the state survey agency finds a current violation of a federal standard during a complaint investigation—even if the violation does not relate to the specific allegations being investigated or the residents who are the subject of the complaint—it is required to cite a deficiency against the home. If a complaint investigation reveals no current violation of federal standards but determines that an egregious violation of federal standards occurred in the past that was not identified during earlier surveys, a deficiency known as past noncompliance should be cited and a civil monetary penalty imposed. CMS does not define egregious but indicates that it includes noncompliance related to a resident’s death. Quality-of-care deficiencies identified during either standard surveys or complaint investigations are classified in 1 of 12 categories according to their scope (i.e., the number of residents potentially or actually affected) and 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 2). States are required to enter information about surveys and complaint investigations, including the scope and severity of deficiencies identified, in CMS’s OSCAR database. Since 1998, such information has been available to the public through CMS’s Nursing Home Compare Web site. CMS is responsible for overseeing each state survey agency’s performance in ensuring nursing homes’ compliance with federal standards for quality of care. Its primary oversight tools are statutorily required federal monitoring surveys conducted annually in at least 5 percent of Medicare and Medicaid nursing homes surveyed by each state, 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 81 percent of federal surveys conducted in fiscal year 2003 were observational. State performance reviews, implemented in October 2000, measure state performance against seven standards, including statutory requirements on 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, CMS 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 timeliness (quarterly); tallies of state surveys that find homes deficiency- free (semiannually); and analyses, by state, of the most frequently cited deficiencies (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. In July 1999, Arkansas enacted a law requiring nursing homes to immediately report the deaths of residents to the local coroner, regardless of the cause of death. The law included a similar reporting requirement for a hospital when a resident died within 5 days after transferring from a nursing home. Coroners who find reasonable cause to suspect that the death is due to maltreatment are directed to report their findings to the state Department of Human Services and to law enforcement and the appropriate prosecuting attorney. The statute leaves the scope of the investigation up to each coroner. Like most states, Arkansas already required unnatural deaths to be reported to the coroner for investigation before enactment of the 1999 law. According to a coroner who was instrumental in demonstrating the need for the legislation, nursing home administrators chose to release decedents to funeral homes despite the existing requirement for a coroner investigation of deaths that occurred under suspicious circumstances. From 1994 to 1998, this coroner’s office conducted six exhumations of nursing home residents and, after full postmortem examinations, all six were determined to have died unnatural deaths. Two cases were ruled medication errors and four were deaths caused by suffocation. For example, one resident was found to have suffocated while tied to his nursing home bed, but the home never reported the death to the coroner. The Arkansas state survey agency, an entity within the Department of Human Services, and the MFCU, an organization within Arkansas’s Office of the Attorney General, receive and investigate coroner referrals. Referrals also may be sent to a local city or county prosecutor. The Arkansas state survey agency treats referrals of suspected neglect of nursing home residents as complaints. As with other complaints, they are prioritized for investigation on the basis of the seriousness of the allegations. Arkansas, like other states, has additional categories with longer investigation time frames (45 days and next survey) for complaints judged to be less serious than immediate jeopardy (2 working days) and actual harm (10 working days). Complaint allegations are entered on an intake form that also includes the source of the complaint and eventually the outcome of the investigation.