Nursing Home Quality: Prevalence of Serious Problems, While	 
Declining, Reinforces Importance of Enhanced Oversight		 
(15-JUL-03, GAO-03-561).					 
                                                                 
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).				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-561 					        
    ACCNO:   A07540						        
  TITLE:     Nursing Home Quality: Prevalence of Serious Problems,    
While Declining, Reinforces Importance of Enhanced Oversight	 
     DATE:   07/15/2003 
  SUBJECT:   Extended care facilities				 
	     Health care services				 
	     Nursing homes					 
	     Patient care services				 
	     Quality control					 
	     Standards evaluation				 
	     Surveys						 
	     CMS Online Survey Certification and		 
	     Reporting System					 
                                                                 
	     Medicaid Program					 
	     Medicare Program					 

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GAO-03-561

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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protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. It may contain
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materials separately from GAO*s product.

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 jeopardy a J K L Actual harm G H I Potential for more than
minimal harm D E F Potential for minimal harm b 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. 10 U. 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). 11 States 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

12 U. 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). 13 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 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,

14 We 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.

15 The 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).

16 The proportion of nursing homes in Utah cited with serious deficiencies
remained the same between the two time periods. 17 We 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 State a Number of homes surveyed (7/ 00- 1/ 02) 1/ 99- 7/ 00
7/ 00- 1/ 02 Percentage point

difference b 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 State a Number of homes surveyed (7/ 00- 1/ 02) 1/ 99- 7/ 00
7/ 00- 1/ 02 Percentage point

difference b

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

18 U. 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

19 Instructions 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,

20 Officials 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
21 As of July 2002, both states had vacant surveyor positions and a
surveyor hiring freeze. 22 In 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 surveys a Number of states b

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

23 We 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.

24 U. 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
25 In 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. 26 Staff from each of CMS*s regional
offices reviewed a 10 percent random sample of complaint files (maximum of
40 files) in each state. 27 According to a state official, a hiring freeze
precluded increasing the number of surveyors. 28 Because 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

29 Center 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.

30 See 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

31 Using 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. 32 See GAO/ HEHS- 99-
46. 33 This 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.

34 We 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

Texas a 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,

35 Arizona*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. 36 This 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. 37 In 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.

38 The 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.

39 GAO/ 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 40 According 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. 41 CMS*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.

42 CMS*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

43 While 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.

44 CMS*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

45 As 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. 46 CMS 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

47 GAO/ HEHS- 99- 46. 48 Until 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

49 Quality 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.

50 The 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. 51 A 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.

52 The 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

53 As 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

54 States that commented included Alabama, Arizona, California,
Connecticut, Iowa, Missouri, Nebraska, New York, Pennsylvania, Tennessee,
and Virginia. 55 Our 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

56 CMS 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.*

57 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.

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

58 Nursing 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 59
U. 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, 60 We 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.
61 See GAO/ HEHS- 00- 197.

62 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.

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 D- or 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 difference a

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 difference a

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 survey a Requirement and

scope and severity cited Resident description and

relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b Actual harm
to resident

documented by surveyor Deficiencies in care cited by surveyor

California- 9 December 2000 Provide

supervision and devices to prevent accidents: B e, f Resident 1, 48 years
old,

admitted to facility after a stroke with incontinence, inability to speak,
right- side 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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
insulin- dependent 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 fleece- lined 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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 facility- acquired
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 survey a Requirement and scope and

severity cited Resident description and relevant diagnoses b 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
long- and 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 150DEG 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

State a 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 20 b No b 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 State a 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 sanction a 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

referred a 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 referred a

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.

(290158)

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