    Nursing Home Deaths: Arkansas Coroner Referrals Confirm
    Weaknesses in State and Federal Oversight of Quality of Care
    (12-NOV-04, GAO-05-78).

    GAO was asked to assess the effectiveness of nursing home
    oversight by considering the effect of a unique Arkansas law that
    requires county coroners to investigate all nursing home deaths.
    Coroners refer cases of suspected neglect to the state survey
    agency and law enforcement entities such as the state Medicaid
    Fraud Control Unit (MFCU). The Centers for Medicare & Medicaid
    Services (CMS) contracts with survey agencies in every state to
    periodically inspect nursing homes and investigate allegations of
    poor care or neglect. MFCUs are charged with investigating and
    prosecuting resident neglect. GAO examined (1) the results of
    Arkansas coroner investigations, (2) the state survey agency's
    experience in investigating coroner referrals, and (3) whether
    weaknesses in state and federal nursing home oversight identified
    in prior GAO reports were evident in the survey agency's
    investigation of coroner referrals.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-05-78
        ACCNO:   A13455
      TITLE:     Nursing Home Deaths: Arkansas Coroner Referrals Confirm
    Weaknesses in State and Federal Oversight of Quality of Care
         DATE:   11/12/2004
      SUBJECT:   Elder care
    	     Elderly persons
    	     Long-term care
    	     Medical records
    	     Nursing homes
    	     Reporting requirements
    	     Surveys
    	     Investigations by federal agencies
    	     Federal/state relations
    	     Quality-of-care
    	     Arkansas

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    GAO-05-78

    United States Government Accountability Office

    GAO

                           Report to Congressional Requesters

    November 2004

    NURSING HOME DEATHS

    Arkansas Coroner Referrals Confirm Weaknesses in State and Federal Oversight of
                                    Quality of Care

    GAO-05-78

    Highlights of GAO-05-78, a report to congressional requesters

    GAO was asked to assess the effectiveness of nursing home oversight by
    considering the effect of a unique Arkansas law that requires county
    coroners to investigate all nursing home deaths. Coroners refer cases of
    suspected neglect to the state survey agency and law enforcement entities
    such as the state Medicaid Fraud Control Unit (MFCU). The Centers for
    Medicare & Medicaid Services (CMS) contracts with survey agencies in every
    state to periodically inspect nursing homes and investigate allegations of
    poor care or neglect. MFCUs are charged with investigating and prosecuting
    resident neglect. GAO examined (1) the results of Arkansas coroner
    investigations, (2) the state survey agency's experience in investigating
    coroner referrals, and (3) whether weaknesses in state and federal nursing
    home oversight identified in prior GAO reports were evident in the survey
    agency's investigation of coroner referrals.

    GAO recommends that the CMS Administrator revise CMS's policy on citing
    deficiencies to better ensure that nursing homes are held accountable for
    care problems identified after a resident's death. CMS concurred with
    GAO's recommendations and listed numerous initiatives it plans in response
    to the report's findings.

    www.gao.gov/cgi-bin/getrpt?GAO-05-78.

    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.

    November 2004

    NURSING HOME DEATHS

    Arkansas Coroner Referrals Confirm Weaknesses in State and Federal Oversight of
    Quality of Care

    According to the Pulaski County coroner, he referred 86 cases of suspected
    resident neglect to the state survey agency for the period July 1999, when
    the Arkansas law took effect, through December 2003. Agency officials said
    that other state coroners referred four cases during this time period.
    Importantly, these 86 referrals constituted just 2.2 percent of all
    nursing home deaths the coroner investigated. However, the referrals
    included disturbing photos and descriptions of the decedents, suggesting
    serious, avoidable care problems; more than two-thirds of the 86 referrals
    listed pressure sores as the primary indicator of neglect. Some photos of
    decedents' pressure sores depicted skin conditions so deteriorated that
    bone or ligament was visible, as were signs of infection and dead tissue.
    The referrals involved 27 homes, over half of which had at least 3
    referrals.

    Arkansas state survey agency officials told GAO that they received 36
    (fewer than half) of the Pulaski County coroner's referrals. The 50
    referrals not received described decedents' conditions similar to those
    the survey agency did receive. Of the 36 referrals for alleged neglect
    that it received, the survey agency complaint investigations substantiated
    22 and eventually it closed the home with the largest number of referrals.
    However, the agency's investigations often understated serious care
    problems-both when neglect was substantiated and when it was not. For 11
    of the 22 substantiated referrals, the state survey agency either cited no
    deficiency for the decedent or cited a deficiency at a level lower than
    actual harm for the predominant care problem identified by the coroner. In
    contrast, MFCU investigations of many of the 11 referrals found the homes
    negligent in caring for decedents, and the MFCU reached settlements with
    the owners of several homes. In half of the 14 referrals not
    substantiated, the MFCU or an independent expert in long-term care either
    found neglect or questioned the "not substantiated" finding. Moreover,
    they found gaps and contradictions in the medical records for some
    decedents, raising a question about the survey agency's conclusions that
    the same records indicated appropriate care had been provided.

    GAO's prior work on nursing home quality of care found that weaknesses in
    federal and state oversight nationwide contributed to serious, undetected
    care problems indicative of resident neglect. GAO's review of the Arkansas
    survey agency's investigations of coroner referrals confirmed that
    serious, systemic weaknesses remain. Oversight weaknesses GAO previously
    identified nationwide and those it found in Arkansas included (1)
    complaint investigations that understated the seriousness of allegations
    and were not timely; (2) predictable timing of annual state surveys that
    could enable nursing homes so inclined to cover up deficiencies; (3)
    survey methodology weaknesses, coupled with surveyor reliance on
    misleading medical records, that resulted in missed care problems; and (4)
    a policy that did not always hold homes accountable for neglect associated
    with a resident's death.

    Contents

      Letter

    Results in Brief
    Background
    Coroner Referrals of Suspected Neglect, While Few in Number,

    Indicated Serious Care Problems The State Survey Agency's Investigation of
    Coroner Referrals Often Understated Neglect of Residents Resident Neglect
    May Go Undetected Because of Well-

    Documented Oversight Weaknesses Conclusions Recommendations for Executive
    Action Agency and State Comments and Our Evaluation

                                           1

                                          3 6

    12

    17

    30 36 37 38

    Appendix I	Coroner Referrals for Pressure Sores and the Seriousness of
    Deficiencies Cited on Standard Surveys

    Appendix II	Coroner Referrals That the State Survey Agency Reported as Not
    Received, Substantiated, or Not Substantiated

    Appendix III	Comments from the Centers for Medicare & Medicaid Services

    Appendix IV	Comments from the Arkansas Department of Human Services

                                Related GAO Products 68

      Tables

    Table 1: Possible Outcomes of State Survey Agency Complaint Investigations
    8

    Table 2: Scope and Severity of Deficiencies Identified during

    Nursing Home Surveys 9 Table 3: Description of Pressure Sore Stages 15
    Table 4: Pulaski County Coroner Referrals Received by State

    Survey Agency and MFCU, July 1999 through December

    2003 19 Table 5: Extent to which the State Survey Agency Cited Serious

    Deficiencies for Substantiated Referrals from the Pulaski

    County Coroner 21 Table 6: Six Coroner Referrals Where the MFCU Found
    Negligence

    by the Nursing Home but the State Survey Agency either

    Cited No Deficiency or a Deficiency at Less than Actual

    Harm for the Decedent 25

      Figures

    Figure 1: Predominant Care Problems Identified in Pulaski County Coroner
    Referrals to State Survey Agency and the MFCU, July 1999 through December
    2003 14

    Figure 2: Number of Pulaski County Coroner Referrals of Suspected Neglect,
    by Nursing Home, July 1999 through December 2003 17

    Figure 3: Elapsed Working and Calendar Days between Receipt of Coroner's
    Referral and Start of Investigation by Arkansas State Survey Agency 32

    Abbreviations

    CMS Centers For Medicare & Medicaid Services
    MFCU Medicaid Fraud Control Unit
    OSCAR On-Line Survey, Certification, and Reporting system

    This is a work of the U.S. government and is not subject to copyright
    protection in the United States. It may be reproduced and distributed in
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    separately.

    United States Government Accountability Office Washington, DC 20548

    November 12, 2004

    The Honorable Charles E. Grassley
    Chairman
    Committee on Finance
    United States Senate

    The Honorable Christopher S. Bond
    United States Senate

    An October 2002 series in the St. Louis Post Dispatch concluded that
    avoidable deaths of vulnerable nursing home residents was a widespread
    but rarely investigated problem. The series spotlighted an Arkansas law
    requiring investigations by county officials, such as coroners, of all
    nursing
    home deaths.1 Under this law, deaths associated with suspected resident
    neglect, including poor quality care, are referred to the state survey
    agency
    and to law enforcement entities. The Centers for Medicare & Medicaid
    Services (CMS), the federal agency responsible for managing Medicare
    and Medicaid, contracts with survey agencies in every state to oversee the
    quality of nursing home care. In 1998, we reviewed allegations that
    thousands of California nursing home residents died because of poor care.
    We found oversight weaknesses that were systemic and not limited to
    California. Despite federal and state oversight, over half of the
    decedents
    in our sample had received unacceptable care that sometimes endangered
    their health and safety.2 We also found that state surveyors sometimes
    classified deficiencies at homes where residents had died as less serious
    than warranted. Our subsequent reports on nursing home quality
    continued to demonstrate that (1) an unacceptably large proportion of
    nursing homes-one-fifth as of early 2002-harmed residents and

    1Ark. Code Ann. S: 5-28-204 (Michie 2003).

    2In the absence of autopsy information that establishes the cause of
    death, we were unable to determine the extent to which unacceptable care
    may have contributed directly to individual deaths. See GAO, California
    Nursing Homes: Care Problems Persist Despite Federal and State Oversight,
    GAO/HEHS-98-202 (Washington, D.C.: July 27, 1998).

    (2) states' periodic inspections of nursing homes failed to identify all
    serious deficiencies, such as preventable weight loss and pressure sores.3

    Our preliminary work on this report found that the 1999 Arkansas law was
    the only such law nationwide.4 You asked us to consider Arkansas's
    experience with required coroner investigations to assess the
    effectiveness of nursing home oversight by the Arkansas state survey
    agency and by CMS. Specifically, we examined (1) the results of Arkansas
    coroner investigations of nursing home resident deaths, (2) the experience
    of the Arkansas state survey agency in investigating suspected cases of
    resident neglect referred by county coroners, and (3) whether systemic
    weaknesses in state and federal nursing home oversight identified in our
    prior reports were evident in the survey agency's investigations of
    coroner referrals.5

    To identify the results of nursing home death investigations by Arkansas's
    75 coroners, we asked the Arkansas Office of Long Term Care, the state
    survey agency, to identify referrals from each county coroner since the
    law's effective date.6 Because the agency told us that all but four of the
    referrals were made by the Pulaski County coroner, where the state capital
    Little Rock is located, we focused on that county's referrals. We obtained
    and reviewed copies of the coroner's referrals, including the
    investigative reports, autopsy reports (if one was conducted), and photos
    of decedents that documented suspected care problems. We interviewed the
    Pulaski County coroner to determine how reported deaths were investigated,
    the basis for determining when referrals were warranted, and the process
    for transmitting referrals to the state survey agency and law enforcement
    entities. To evaluate state survey agency investigations of coroner
    referrals

    3See GAO, Nursing Homes: Sustained Efforts Are Essential to Realize
    Potential of the Quality Initiatives, GAO/HEHS-00-197 (Washington, D.C.:
    Sept. 28, 2000) and Nursing Home Quality: Prevalence of Serious Problems,
    While Declining, Reinforces Importance of Enhanced Oversight, GAO-03-561
    (Washington, D.C.: July 15, 2003).

    4Starting in August 2003, Missouri nursing homes were required to report
    resident deaths to county officials, such as coroners. The Missouri law,
    however, does not require coroner investigations of the deaths. See Mo.
    Ann. Stat. S: 198-071 (West 2004).

    5A list of related GAO products is at the end of this report.

    6Arkansas has two state survey agencies-the Office of Long Term Care in
    the Department of Human Services and the Division of Health Facility
    Services in the Department of Health. The former is responsible for
    surveying nursing homes and the latter surveys other providers who
    participate in Medicare and Medicaid, such as hospitals and home health
    agencies. In this report, we use the term state survey agency to refer to
    the Office of Long Term Care.

    of suspected nursing home neglect, we asked the Arkansas survey agency to
    provide documentation on the results of its investigations. Since the
    agency treats such referrals as complaints, we reviewed the agency's
    guidance to surveyors on complaint investigations and discussed the
    procedures with agency officials. We followed up with agency staff to
    clarify facts regarding specific investigations of coroner referrals, as
    needed. To assess the overall quality of care provided at homes with
    coroner referrals, we obtained data from the survey agency on other
    complaints against these homes and analyzed data in CMS's On-line Survey,
    Certification, and Reporting system (OSCAR). CMS officials generally
    recognize OSCAR data to be reliable, and we judged it to be appropriate
    for our work.

    Since the Pulaski County coroner referrals were also sent to the Arkansas
    Medicaid Fraud Control Unit (MFCU), we obtained copies of its
    investigative files. MFCUs are charged with investigating and prosecuting
    Medicaid provider fraud and incidents of patient abuse and neglect. In
    Arkansas, the MFCU is located within the office of the state attorney
    general. We compared the results of the state survey agency and MFCU
    investigations to identify similarities and differences in their findings.
    For some coroner referrals of suspected resident neglect for which we
    questioned the state survey agency's decision to not substantiate the
    existence of serious care problems, we asked a professor of nursing with
    expertise in long-term care to assess the consistency between the findings
    from the agency's investigations and the decedents' conditions as
    documented by the coroner. The expert's assessment was based on a review
    of the various investigative reports, medical records we obtained, and
    photos of decedents taken by the coroner. We also discussed our evaluation
    of the investigations with officials from the Arkansas state survey
    agency, the MFCU, and CMS. To identify whether systemic weaknesses in
    state and federal nursing home oversight were evident in the survey
    agency's investigations of coroner referrals, we reviewed our findings
    regarding the Arkansas state survey agency's investigations in the context
    of our prior work on nursing home quality. We conducted our work from
    August 2003 through October 2004 in accordance with generally accepted
    government auditing standards.

    Results in Brief	According to the Pulaski County coroner, he made 86
    referrals to the state survey agency of nursing home deaths where neglect
    was suspected from July 1999, when the Arkansas law took effect, through
    December 2003. The 86 referrals, constituting 2.2 percent of the
    approximately 4,000 nursing home deaths the Pulaski County coroner
    investigated in the 4.5-

    year period, included disturbing photos and descriptions of the decedents
    that suggested the existence of serious, avoidable care problems. In over
    two-thirds of the coroner referrals, pressure sores were the predominant
    indication of suspected neglect identified during the physical
    examinations of the decedents, and for some decedents these were at the
    stage described as life-threatening. For example, the photos of some
    decedents' pressure sores depicted individuals with skin conditions so
    deteriorated that bone or ligament was visible, as were signs of infection
    and dead tissue. The coroner also cited injuries such as falls and broken
    bones in about 6 percent of the 86 cases. The referrals involved a total
    of 27 homes, over half of which had three or more referrals during the
    4.5year period.

    The Arkansas state survey agency informed us it received 36 coroner
    referrals-fewer than half of those the coroner said he referred-and the
    MFCU reported it received 51, almost three-fifths. According to the
    coroner, the referrals were hand delivered to ensure that none were lost
    and in March 2004, the coroner began requesting signed receipts. Of the 36
    referrals that it investigated, the survey agency substantiated 22 and
    eventually closed the home with the largest number of referrals. However,
    the survey agency's investigations often understated serious care
    problems-for both substantiated and unsubstantiated referrals. For 11 of
    the 22 substantiated referrals, the state survey agency found other care
    problems but either cited no deficiency or cited a deficiency at a level
    lower than actual harm for the predominant care problem identified by the
    coroner. The MFCU's investigations of 6 of these 11 referrals, however,
    found the nursing homes negligent in providing care, in effect
    substantiating the existence of serious care problems. Moreover, the MFCU
    reached settlements with owners of several of the nursing homes. Although
    we did not examine each of the 14 unsubstantiated referrals in detail, the
    state survey agency's findings for seven decedents were questioned by the
    MFCU's investigation, which identified neglect, or by our expert
    consultant, who questioned the basis for the not-substantiated finding.
    Examples of neglect they identified included the development of avoidable
    pressure sores and the lack of a treatment plan. The MFCU and our expert
    consultant also found omissions and contradictions in the medical records
    for 4 of the 14 referrals, raising a question about the state survey
    agency's conclusions that the same records indicated appropriate care had
    been provided.

    We found the same serious, systemic survey and oversight weaknesses in the
    Arkansas state survey agency's investigation of coroner referrals that our
    prior work on nursing home quality of care identified nationwide.

    These weaknesses included (1) understatement of the seriousness of
    complaints and a failure to investigate serious complaints promptly; (2)
    predictable timing of state surveys, which could enable a home so inclined
    to cover up deficiencies; (3) survey methodology weaknesses that result in
    overlooked care problems; and (4) not holding nursing homes accountable
    for neglect associated with a resident's death. CMS discourages surveyors
    from citing a deficiency for a care problem involving a deceased resident
    unless the problem was so serious that it contributed to or caused a
    resident's death or unless the same problem can be identified for
    individuals still residing at the nursing home. If a similar problem is
    not identified during a complaint investigation that assesses care
    provided to current residents, it is assumed to have been recognized by
    the home and corrected. However, our prior work demonstrated, and our work
    in Arkansas confirmed, that (1) nursing home records can contain
    misleading information or omit important data, making it difficult for
    surveyors to identify care deficiencies during their on-site reviews; and
    (2) states' surveys of nursing homes do not identify all serious
    deficiencies, such as preventable weight loss and pressure sores. Given
    the results of our prior work, we believe that the serious, undetected
    care problems identified by the Pulaski County coroner are likely a
    national problem not limited to Arkansas.

    We are recommending that the Administrator of CMS revise CMS's policy on
    citing deficiencies to better ensure that nursing homes are held
    accountable for care problems identified after a nursing home resident's
    death. CMS concurred with our recommendations to revise its policy on
    citing deficiencies for past noncompliance and also identified more than a
    dozen additional initiatives it plans to take to address shortcomings in
    the nursing home survey process. CMS commented that the focus of its
    initiatives, such as additional guidance on the scope and severity of
    deficiencies, would be broad, a recognition that the shortcomings we
    identified were systemic and not limited to Arkansas. Both CMS and the
    state survey agency raised concerns about the discrepancy we reported
    between the number of referrals the coroner said he made (86) and the
    number the survey agency said it received (36). In addition, the state
    survey agency commented that we had understated the number of
    investigations it actually conducted. We revised the report to address
    these concerns. In oral comments, the Pulaski County coroner indicated
    that he believes the law has had a significant, positive impact on the
    quality of care provided to nursing home residents in Pulaski County. The
    MFCU did not provide comments. We incorporated technical comments from
    CMS, the state survey agency, and the Pulaski County coroner, as
    appropriate.

    Background

    Combined Medicare and Medicaid payments to nursing homes for care provided
    to vulnerable elderly and disabled beneficiaries totaled about $64 billion
    in 2002, with total federal payments of approximately $45.5 billion.
    Oversight of nursing home quality is a shared federal-state
    responsibility. On the basis of statutory requirements, CMS defines
    standards that nursing homes must meet to participate in the Medicare and
    Medicaid programs, and contracts with states to assess, through annual
    surveys and complaint investigations, whether homes meet these standards.
    CMS is also responsible for monitoring the adequacy of state survey
    activities. Arkansas's unique 1999 law requires investigations by county
    officials, such as coroners, of nursing home residents' deaths and
    referral of any cases of suspected neglect to the state survey agency and
    the MFCU.

                                    Standard Surveys

    Every nursing home receiving Medicare or Medicaid payments must undergo an
    unannounced standard survey not less than once every 15 months, and the
    statewide average interval for these surveys must not exceed 12 months.7 A
    standard survey entails a team of state surveyors, including registered
    nurses, spending several days in the nursing home to assess compliance
    with federal long-term care facility requirements, particularly whether
    care and services provided meet the assessed needs of the residents and
    whether the home is providing adequate quality of care, such as preventing
    avoidable pressure sores, weight loss, or accidents. State surveyors
    assess the quality of care provided to a sample of residents during the
    standard survey, which is the basis for evaluating nursing homes'
    compliance with federal requirements. CMS establishes specific
    investigative protocols for state surveyors to use in conducting these
    comprehensive surveys. These procedural instructions are intended to make
    the on-site surveys thorough and consistent across states. When a
    deficiency is identified, the nursing home is required to prepare a plan
    of correction that must be approved by the state survey agency. Our
    earlier work indicated that facilities could mask certain deficiencies,
    such as routinely having too few staff to care for residents, if they
    could predict the survey timing; CMS therefore directed states, effective
    in 1999, to (1) avoid scheduling a home's survey for the same month of the
    year as the home's previous standard survey and (2) begin at least 10
    percent of

    7CMS 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.

    standard surveys outside the normal workday (either on weekends, early in
    the morning, or late in the evening).

                                Complaint Investigations

    Complaint investigations provide an opportunity for state surveyors to
    intervene promptly if quality-of-care problems arise between standard
    surveys. A nursing home resident, family member, friend, nursing home
    employee, or others may file complaints. CMS requires the investigation of
    complaints that represent immediate jeopardy to resident health and safety
    within 2 working days and considers such complaints to be those where one
    or more of the conditions alleged in the complaint, if true, may have
    caused or is likely to cause serious injury, harm, impairment, or death to
    a resident. Beginning in 1999, CMS required investigation of complaints
    that allege harm to a resident (but which do not rise to the level of
    immediate jeopardy) within 10 working days, but did not provide detailed
    guidance to the states about what constitutes harm until November 2003. In
    November 2003 guidance, CMS generally defined two categories of complaints
    representing harm: (1) those that, if true, would impair the resident's
    mental, physical, and/or psychosocial status, which must be investigated
    within 10 working days, and (2) those that would not significantly impair
    the resident's mental, physical, and/or psychosocial status, which must be
    investigated within 45 calendar days. Other complaints that do not rise to
    the level of either immediate jeopardy or harm do not have to be
    investigated until the home's next survey, or in some cases, not at all if
    the state survey agency can determine with certainty that no
    investigation, analysis, or action is necessary. The requirements
    identified in the November 2003 guidance became effective on January 1,
    2004.

    Generally, nurse surveyors investigate complaints onsite at the nursing
    home by reviewing medical records and interviewing staff and residents.
    The investigations typically include a sample of residents in addition to
    the resident who is the subject of the complaint to help determine if the
    problems are systemic. Depending on the volume of complaints against a
    particular home, several complaints for different residents may be
    investigated concurrently. Each complaint may contain one or more
    allegations that a facility is violating federal quality-of-care
    standards. For example, a single complaint could allege problems with
    resident abuse, treatment of pressure sores, and proper feeding and
    hydration. In the course of complaint investigations, the state survey
    agency can either substantiate or not substantiate the specific
    allegations or discover other, unreported violations of federal standards
    (see table 1). A substantiated complaint, however, does not necessarily
    mean that the state survey

    agency found neglect of the resident who was the subject of the complaint
    but rather may indicate other, unrelated care problems. If the state
    survey agency finds a current violation of a federal standard during a
    complaint investigation-even if the violation does not relate to the
    specific allegations being investigated or the residents who are the
    subject of the complaint-it is required to cite a deficiency against the
    home. If a complaint investigation reveals no current violation of federal
    standards but determines that an egregious violation of federal standards
    occurred in the past that was not identified during earlier surveys, a
    deficiency known as past noncompliance should be cited and a civil
    monetary penalty imposed. CMS does not define egregious but indicates that
    it includes noncompliance related to a resident's death.

    Table 1: Possible Outcomes of State Survey Agency Complaint Investigations

                    Complaint outcome Basis of outcome Substantiated

    Deficiency 	The investigation revealed a current violation of federal
    standards and resulted in the citation of one or more deficiencies.a The
    deficient practice had not been identified and corrected by the home prior
    to the investigation.

    Past noncompliance 	If the investigation revealed a past egregious
    violation of federal standards, such as causing the death of a resident,
    but identified no current violation, the home should be cited for past
    noncompliance and assessed a civil monetary penalty.b

    No deficiency 	The investigation revealed a nonegregious past violation of
    federal standards but the home had a quality assurance program in place
    that identified the deficient practice, took appropriate corrective action
    prior to the investigation, and implemented measures that prevented a
    recurrence.

    Not substantiated

    No deficiency The investigation identified no violation of federal
    standards.

    Source: CMS.

    aWhen a home does not participate in Medicare or Medicaid, the state may
    cite deficiencies under its state licensing regulations.

    bCMS does not define egregious but notes that it includes situations that
    caused the death of a resident.

    Deficiency Reporting 	Quality-of-care deficiencies identified during
    either standard surveys or complaint investigations are classified in 1 of
    12 categories according to their scope (i.e., the number of residents
    potentially or actually affected) and their severity. An A-level
    deficiency is the least serious and is isolated in scope, while an L-level
    deficiency is the most serious and is considered

    to be widespread in the nursing home (see table 2). States are required to
    enter information about surveys and complaint investigations, including
    the scope and severity of deficiencies identified, in CMS's OSCAR
    database. Since 1998, such information has been available to the public
    through CMS's Nursing Home Compare Web site.

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

                                         Scopea

                                             Severity Isolated Pattern Widespread
                                  Immediate jeopardyb    J           K          L
                                          Actual harm    G           H          I
                 Potential for more than minimal harm    D           E          F
                          Potential for minimal harmc    A           B          C

    Source: CMS.

    aCMS defines the scope levels as follows: isolated-affecting a single or a
    very limited number of residents; pattern-affecting more than a very
    limited number of residents; and widespread-affecting a large portion of
    or all residents.

    bActual or potential for death/serious injury.

    cNursing home is considered to be in "substantial compliance."

                                     CMS Oversight

    CMS is responsible for overseeing each state survey agency's performance
    in ensuring nursing homes' compliance with federal standards for quality
    of care. Its primary oversight tools are statutorily required federal
    monitoring surveys conducted annually in at least 5 percent of Medicare
    and Medicaid nursing homes surveyed by each state, on-site annual state
    performance reviews instituted during fiscal year 2001, and analysis of
    periodic oversight reports that have been produced since 2000. Federal
    monitoring surveys can be either comparative or observational. A
    comparative survey involves a federal survey team conducting a complete,
    independent survey of a home within 2 months of the completion of a
    state's survey in order to compare and contrast the findings. In an
    observational survey, one or more federal surveyors accompany a state
    survey team to a nursing home to observe the team's performance. Roughly
    81 percent of federal surveys conducted in fiscal year 2003 were
    observational. State performance reviews, implemented in October 2000,
    measure state performance against seven standards, including statutory
    requirements on survey frequency, requirements for documenting
    deficiencies, timeliness of complaint investigations, and timely and
    accurate entry of deficiencies into OSCAR. These reviews replaced state

    self-reporting of their compliance with federal requirements. In October
    2000, CMS also began to produce 19 periodic reports to monitor both state
    and regional office performance. The reports are based on OSCAR and other
    CMS databases. Examples of reports that track state activities include
    pending nursing home terminations (weekly); data entry timeliness
    (quarterly); tallies of state surveys that find homes deficiencyfree
    (semiannually); and analyses, by state, of the most frequently cited
    deficiencies (annually). These reports, in a standard format, enable
    comparisons within and across states and regions and are intended to help
    identify problems and the need for intervention. Certain reports-such as
    the timeliness of state survey activities-are used to monitor compliance
    with state performance standards.

                                    The Arkansas Law

    In July 1999, Arkansas enacted a law requiring nursing homes to
    immediately report the deaths of residents to the local coroner,
    regardless of the cause of death.8 The law included a similar reporting
    requirement for a hospital when a resident died within 5 days after
    transferring from a nursing home. Coroners who find reasonable cause to
    suspect that the death is due to maltreatment are directed to report their
    findings to the state Department of Human Services and to law enforcement
    and the appropriate prosecuting attorney.9 The statute leaves the scope of
    the investigation up to each coroner.

    8Death investigations often vary considerably by jurisdiction (whether
    state, county, district, or city). Some states use a medical examiner (21
    states and the District of Columbia), some use a coroner (11 states), and
    some use a mixed system of medical examiners and coroners (18 states).
    Medical examiners and coroners are responsible for investigating sudden or
    violent deaths and for providing accurate, legally defensible
    determinations of the causes of these deaths. Generally, medical examiners
    are licensed physicians and are appointed, while coroners need not be
    physicians and are elected.

    9When enacted, the Arkansas law required a referral if there was
    reasonable cause to suspect that the resident died of abuse, sexual abuse,
    or neglect. In 2003, the law was amended to substitute maltreatment for
    these terms. Coroner referrals did not actually characterize the specific
    nature of each finding in relation to one of the statutory categories for
    referral. In the absence of such characterization, we characterize each
    referral under the law as based on a finding of neglect.

    Like most states, Arkansas already required unnatural deaths to be
    reported to the coroner for investigation before enactment of the 1999
    law.10 According to a coroner who was instrumental in demonstrating the
    need for the legislation, nursing home administrators chose to release
    decedents to funeral homes despite the existing requirement for a coroner
    investigation of deaths that occurred under suspicious circumstances. From
    1994 to 1998, this coroner's office conducted six exhumations of nursing
    home residents and, after full postmortem examinations, all six were
    determined to have died unnatural deaths. Two cases were ruled medication
    errors and four were deaths caused by suffocation. For example, one
    resident was found to have suffocated while tied to his nursing home bed,
    but the home never reported the death to the coroner.

        Coroner Referrals of Suspected Resident Neglect

    The Arkansas state survey agency, an entity within the Department of Human
    Services, and the MFCU, an organization within Arkansas's Office of the
    Attorney General, receive and investigate coroner referrals. Referrals
    also may be sent to a local city or county prosecutor.

    The Arkansas state survey agency treats referrals of suspected neglect of
    nursing home residents as complaints. As with other complaints, they are
    prioritized for investigation on the basis of the seriousness of the
    allegations. Arkansas, like other states, has additional categories with
    longer investigation time frames (45 days and next survey) for complaints
    judged to be less serious than immediate jeopardy (2 working days) and
    actual harm (10 working days). Complaint allegations are entered on an
    intake form that also includes the source of the complaint and eventually
    the outcome of the investigation. To document their actions, Arkansas
    surveyors generally prepare a one-to two-page summary specifically
    describing how the complaint was investigated and which specific
    allegations were or were not substantiated. Typically, the individual who
    filed the complaint is informed about the results of the complaint
    investigation. The Arkansas state survey agency uses a computerized system
    to track the status of complaint investigations.

    10Most states have laws that require suspicious or unusual deaths (or
    those for which the cause is unknown or unnatural) to be reported to a
    state or local authority, and some specifically require the reporting of
    deaths resulting from abuse or neglect. Prior to 1999, Arkansas law
    required the reporting of cases in which there was reasonable cause to
    suspect that any adult had died of abuse, sexual abuse, or negligence.

    In Arkansas, the MFCU's authority to investigate resident abuse and
    neglect is limited to nursing homes that receive Medicaid reimbursement;
    therefore, it cannot investigate such allegations in a nursing home that
    only participates in Medicare or that only accepts private pay patients.
    Generally, MFCUs have concurrent jurisdiction with local investigative and
    prosecutorial authorities and can both investigate and prosecute such
    cases statewide.11 On the basis of an investigation, a MFCU can initiate
    criminal actions in state court but must first obtain permission from the
    local prosecutor. In such cases, the focus is not on whether a home is
    providing appropriate care but rather on whether the MFCU can substantiate
    in court that an act of neglect occurred. These cases may be settled out
    of court by a payment to the state's Medicaid program without an admission
    of guilt.

      Coroner Referrals of Suspected Neglect, While Few in Number, Indicated Serious
      Care Problems

    Of the approximately 4,000 nursing home deaths investigated by the Pulaski
    County coroner from July 1999 through December 2003, the coroner informed
    us that he identified and referred 86 cases (2.2 percent) of suspected
    resident neglect to the state survey agency and the MFCU.12 Even when
    measured against the number of complaints filed against nursing homes and
    abuse and neglect case referrals to the MFCU, the number of coroner
    referrals was very small. However, the coroner's referrals, many
    accompanied by photos, often depicted signs of serious, avoidable care
    problems.

    11MFCUs were authorized by the Medicare-Medicaid Anti-Fraud and Abuse
    Amendments, Pub. L. No. 95-142 S:17, 91 Stat. 1175, 1201-1202 (1977).
    Currently, 47 states and the District of Columbia participate in the
    Medicaid fraud control grant program.

    12According to the state survey agency, only four referrals were received
    from coroners outside of Pulaski County, and we excluded these from our
    analysis. We did not contact Arkansas's 74 other coroners to determine
    whether any additional referrals were sent. Although assessing the
    effectiveness of the state's law was beyond the scope of our review, MFCU
    officials told us that few other coroners investigate nursing home
    resident deaths and that nursing homes may not be reporting all deaths to
    their local coroners as the state law requires. For example, MFCU
    officials told us that there were eight deaths in one home in the course
    of 1 month that were not reported to the coroner or investigated and at
    least one decedent was sent to a funeral home owned by the coroner. The
    Arkansas statute does not provide sanctions for failure to report nursing
    home deaths to coroners or for coroners' failure to investigate reported
    deaths. They also told us that all but two of the state's 75 county
    coroners are elected; therefore, most state coroners are not accountable
    to other county or state officials. The Pulaski County coroner is
    appointed by the county's chief executive officer.

    According to the Pulaski County coroner, his staff generally arrives at
    the nursing home or hospital within 15 to 20 minutes after the
    notification, which is expected to be immediate, of a resident's death.13
    Facilities have been instructed not to disturb the resident's body. The
    initial on-site investigation consists of (1) a physical examination of
    the body, which is photographed; (2) interviews with the treating
    physician, staff, and perhaps family members; and (3) a review of the
    decedent's medical records, including a comparison of doctors'
    prescriptions and nurses' notes to ensure that medications were properly
    administered. During the investigation, the coroner's staff looks for
    several key indicators of whether a decedent may have received poor care,
    including significant weight loss; dehydration; pressure sores;
    undocumented injuries, such as bruises or skin tears; and interviews with
    family members. Many of these care indicators are similar to those
    examined during the state survey agency's annual inspection of every
    nursing home. Before releasing the body to a funeral home, the coroner may
    order a toxicology report or ask the state medical examiner to conduct an
    autopsy to determine whether care problems, such as a medication error or
    blood poisoning (sepsis) from infected pressure sores, contributed to the
    resident's death. Of the 86 residents referred by the coroner to the state
    survey agency and the MFCU, 14 had autopsies completed.

    Pressure sores, typically serious and often numerous, were the predominant
    indication of care problems identified in 67 percent of the coroner's
    referrals (see fig. 1).14 Pressure sores are caused by unrelieved pressure
    on the skin that squeezes the tiny blood vessels supplying the skin with
    nutrients and oxygen, causing the skin and ultimately, underlying tissue
    to die. Most pressure sores can be prevented with adequate nutrition,
    sanitation and frequent repositioning of the resident.15

    13Two of the coroner's three staff members are licensed paramedics.

    14Although the referrals sometimes identified multiple care problems, we
    attempted to identify the primary cause for each of the coroner's 86
    referrals. Overall, 88 percent of decedents with pressure sores had stage
    III/IV pressure sores or necrotic or gangrenous tissue (see table 3).
    Fifty-seven percent of decedents with pressure sores had three or more
    pressure sores.

    15The risk factors for pressure sores include confinement to a bed or
    chair, inability to move, loss of bowel or bladder control, poor
    nutrition, and lowered mental awareness. Actions to prevent pressure sores
    include repositioning the patient every 1 to 2 hours; using a special
    pressure-relieving mattress or chair pad; placing pillows or wedges
    between the knees and ankles and under legs to keep the patient's heels
    off of the bed; cleaning skin as soon as possible after incontinence; and
    providing appropriate nutritional support.

    In some of the coroner's photos, bone or ligament was visible, as were
    signs of infection or dead tissue, indicating a serious stage IV pressure
    sore (see table 3).

    Figure 1: Predominant Care Problems Identified in Pulaski County Coroner
    Referrals to State Survey Agency and the MFCU, July 1999 through December
    2003

    Falls or broken bones

    Bruises, abrasions, and skin tearsa

    Otherb

    Pressure sores Source: GAO analysis of coroner's referrals.

    Note: Although the referrals sometimes identified multiple care problems,
    we attempted to identify the primary cause for each of the coroner's 86
    referrals.

    aSkin 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 structure. A skin tear is a painful but preventable
    injury. See Sharon Baronski, "Skin Tears: Staying on Guard Against the
    Enemy of Frail Skin," Nursing 2000, vol. 30, no. 9 (2000).

    bCare problems categorized as "other" included possible medication errors
    (3 decedents), a catheter problem (1 decedent), a resident with poor oral
    hygiene (1 decedent), a resident setting himself on fire (1 decedent), a
    home's failure to resuscitate a resident (1 decedent), a resident choking
    on food (1 decedent), a home's staff taking actions not approved by a
    physician (1 decedent), malnourishment (1 decedent), a family telling the
    coroner of poor care (1 decedent), a resident having difficulty breathing
    (1 decedent), and a resident suffering from a gangrenous colon (1
    decedent).

                      Table 3: Description of Pressure Sore Stages

    Description

    Stage I 	Skin is not broken but is red or discolored and does not return
    to normal within 30 minutes after pressure is removed.

    Stage II 	The topmost layer of the skin is broken, creating a shallow open
    sore; there may be drainage.

    Stage III 	The break in the skin extends through the second skin layer
    into the tissue below the skin. The wound is deeper than in stage II.

    Stage IV 	The tissue breakdown extends into the muscle and can extend as
    far as the bone. Typically, there is considerable dead tissue and
    drainage. Stage IV may be life-threatening.

    Source: University of Washington, Spinal Cord Injury Pamphlet, "Taking
    Care of Pressure Sores."

    Other indications of care problems identified by the coroner included
    bruises, abrasions, and skin tears (12 percent) and falls or broken bones
    (6 percent). For one referral, the bruise covered the decedent's entire
    upper chest and for another the arm from the elbow to the shoulder. In
    about 15 percent of referrals, the indications of care problems identified
    by the coroner were difficult to categorize, such as a decedent with a
    catheter whose penis was bloody and irritated, a resident who died when he
    attempted to burn off his restraints with a cigarette lighter, and a
    resident who was taken to the hospital with breathing problems. An autopsy
    of the last resident revealed the presence of toxic or excessive levels of
    drugs that likely caused the respiratory problems and contributed to the
    development of pneumonia and to death.

    For some referrals, the coroner found evidence of multiple care problems.
    For example, a 1999 referral involved a decedent with a 9-square inch
    pressure sore on her lower back, a gangrenous foot, and ants on her
    feeding tube and wounds. According to the resident's daughter, the odor in
    her mother's room at the nursing home was so great that she had to leave.
    The autopsy attributed the gangrene to arteriosclerosis that restricted
    the blood supply to her legs but also found that the resident suffocated
    when dried mucus that had accumulated in her mouth broke off and blocked
    her breathing passage. According to the MFCU, her wounds and oral care
    appeared to have been neglected for some time.

    The 86 cases of suspected resident neglect occurred in 27 nursing homes.16
    Although it is difficult to precisely identify the proportion of Pulaski
    County nursing homes that had referrals because facilities closed and
    opened during the time period we examined, over half of the 27 homes had
    three or more referrals (see fig. 2). Fourteen homes accounted for almost
    80 percent of the referrals. Some homes had a pattern of referrals
    spanning several years. For example, one home had seven referrals-one in
    1999, two in 2000, two in 2001, and another two in 2002. Three of these
    seven referrals involved stage IV pressure sores, some of which were
    blackened with dead tissue, and one referral involved a resident who died
    because of an overdose of drugs administered by the nursing home. Nineteen
    of the 27 nursing homes were referred by the Pulaski County coroner, many
    of them more than once, because the deceased residents had pressure sores
    (see app. I). Eleven of the 12 referrals for one home involved pressure
    sores.17 The standard surveys of these homes, however, infrequently raised
    concerns about the care provided to prevent and treat pressure sores. As
    of November 2003, 15 of the 19 homes had not been cited on any of the
    previous four standard surveys for a pressure sore deficiency at the
    actual harm level or higher, while 3 homes each had one such deficiency.18

    16All but 5 of the 27 homes referred by the coroner were located in
    Pulaski County. The residents from these 5 homes died in a Pulaski County
    medical facility and, as a result, were referred by the Pulaski County
    coroner. Three of the 27 homes with coroner referrals have since closed.

    17The body of a resident who died in this same home prior to enactment of
    the 1999 Arkansas law was exhumed and the decedent was found to have
    suffocated while tied to his nursing home bed.

    18One of the 19 homes is a federal facility operated by the Department of
    Veterans Affairs and is not subject to surveys by the state survey agency.

    Figure 2: Number of Pulaski County Coroner Referrals of Suspected Neglect,
    by Nursing Home, July 1999 through December 2003

    Number of coroner referrals 14

    12

    12

    10

    8

    6

    4

    2

    0 1 home 1 home 2 homes 2 homes 3 homes 5 homes 5 homes 8 homes

    Number of nursing homes referred by coroner

    Source: GAO analysis of coroner referrals.

    According to Arkansas state survey agency officials, the agency received
    36 coroner referrals of suspected resident neglect, less than half of the
    86 referrals the coroner said he made. The agency's investigations of
    these coroner referrals often understated serious care problems-both when
    neglect was substantiated and not substantiated (see app. II). Even in the
    majority of substantiated referrals, the state survey agency failed to
    cite serious deficiencies involving care problems for the decedents who
    were the subject of the referrals, in effect not confirming the
    predominant care problems identified by the coroner. The MFCU's
    investigations of many of these same referrals, however, frequently found
    that facilities had been negligent in caring for the decedents by
    identifying serious lapses in care. In half of the referrals not
    substantiated by the state survey agency, either the MFCU investigation
    found neglect or we questioned the basis for the "not substantiated"
    findings, and our concerns were confirmed by a professor of nursing with
    expertise in long-term care. Moreover, the MFCU found inconsistencies in
    the medical records for some decedents, raising a question about the state
    survey agency's conclusion that the same records indicated care had been
    provided.

      The State Survey Agency's Investigation of Coroner Referrals Often Understated
      Neglect of Residents

        Fewer than Half of the Coroner Referrals Were Received by the State Survey
        Agency

    Although the Pulaski County coroner told us that he had referred 86 cases
    of suspected resident neglect from July 1999 through December 2003,
    Arkansas state survey agency officials said that they received fewer than
    half (see table 4) and investigated all but one of the referrals they
    received.19 MFCU officials, however, indicated that they received almost
    three-fifths of the 86 referrals.20 The MFCU received all but three of the
    referrals received by the state survey agency. Overall, 32 coroner
    referrals were not investigated by either agency.21

    19We excluded from our analysis cases for which a coroner's referral was
    not received but the state survey agency indicated it had conducted an
    investigation, primarily complaints filed by family members or others. We
    excluded such cases because the focus of our analysis was the state's
    disposition of coroner referrals, not a broader review of the state's
    disposition of all complaints, regardless of source. Nine of the survey
    agency's non-coroner complaint investigations were conducted prior to the
    residents' deaths and may not have raised concerns similar to those
    identified in the coroner's referrals. Elsewhere in the report, we
    acknowledge seven of the survey agency's non-coroner complaint
    investigations that involved allegations similar to the coroner's.

    20To help both the state survey agency and the MFCU identify all coroner
    referrals made since July 1999, we provided a list that we developed using
    the Pulaski County coroner's files. Both agencies used this list to
    identify coroner referrals they received but were unable to locate all 86
    referrals.

    21Five of the 27 homes, where the coroner identified 10 cases of potential
    neglect, had no state survey agency or MFCU investigations.

    Table 4: Pulaski County Coroner Referrals Received by State Survey Agency
    and MFCU, July 1999 through December 2003

                       Year of                    Received by
                                                  state
              resident's death Number of            survey agency     Received by
                               referrals                                     MFCU
                         1999a                 20               4
                          2000                 24             17b
                          2001                 23              11
                          2002                 18               3
                         2003c                  1               1
                         Total                 86             36b             51d

    Source: Coroner's office, Pulaski County; Arkansas state survey agency;
    and the MFCU.

    aThe Arkansas law became effective in July 1999 and the state survey
    agency received its first referral on September 27, 1999.

    bAlthough the state survey agency lacked routine documentation describing
    its investigation of two coroner referrals, we included these referrals in
    our analysis because agency officials were able to tell us the outcome of
    the investigations. However, we excluded three other coroner referrals
    that survey agency officials told us they had received but for which they
    could neither document their investigations nor tell us the outcomes.

    cThe coroner eventually referred six 2003 resident deaths to the state
    survey agency and the MFCU. We excluded five of the six because they were
    not actually referred until early 2004.

    dThe MFCU received all but 3 of the 36 referrals received by the state
    survey agency.

    According to the coroner, all the referrals were hand delivered rather
    than mailed to ensure that none were lost, but officials at the state
    survey agency and the MFCU told us that they did not know how referrals
    were delivered.22 We found inconsistencies in agency and MFCU
    recordkeeping. For example, the state survey agency told us that it had
    received five referrals on the coroner's list but could not provide a copy
    of any complaint intake forms for them or the results of its
    investigations for three of the five referrals. While a MFCU official told
    us that three other referrals were forwarded to it by the state survey
    agency, not the coroner, the state survey agency had no record of these
    referrals.

    The 50 coroner referrals not received by the state survey agency were
    similar to those received. For example, one decedent had large,
    unexplained bruises on her chest, upper right arm, and back, including a
    mass of more than nine square inches that likely consisted of clotted
    blood from a broken blood vessel. A second decedent had five pressure
    sores-

    22In March 2004, the coroner began requesting signed receipts.

    lower leg, heel, lower back, and both hips; according to the coroner's
    report, one of the pressure sores was "draining a dark-colored,
    pus-filled, and foul-smelling fluid." The decedent's medical records
    indicated admission to the nursing home 6 months before death without any
    pressure sores. A third decedent had 10 pressure sores with dead tissue on
    one heel. A fourth decedent had a large tear on the upper arm, a pressure
    sore on one foot with dead tissue extending to mid-calf, and a stage IV
    pressure sore on one buttock. Three coroner referrals not received by the
    state survey agency but investigated by the MFCU found negligent care that
    resulted in settlements and payments by the facilities.

        Serious Deficiencies Seldom Cited for Care Problems Involving Decedents,
        Even Though Referrals Were Often Substantiated

    With the exception of one home, we found that state survey agency
    complaint investigations of coroner referrals often failed to cite serious
    deficiencies for the decedents being investigated, even though over half
    of the referrals investigated were substantiated. Overall, the state
    survey agency substantiated 22 of the 36 coroner referrals it investigated
    at 12 nursing homes.23 However, the state survey agency cited actual harm
    or higher-level deficiencies in quality of care, abuse/neglect, or both
    for only 11 of these 22 substantiated referrals (see table 5).

    23In addition, the state survey agency substantiated two non-coroner
    complaints for decedents the coroner said he referred but which agency
    officials indicated were not received. In one case, a family member filed
    a complaint 6 days after a resident's death with allegations similar to
    those in the coroner's referral. The resident broke both hips when she
    fell out of bed. The state survey agency investigated the family member's
    complaint twice. According to state survey agency officials, a review of
    the initial investigation, which cited misuse of restraints at the less
    than actual harm level, indicated the need for another investigation. The
    second investigation cited two actual harm deficiencies for shortcomings
    in resident assessment and failure to prevent accidents. In the other
    case, state surveyors were at the nursing home when a resident, attempting
    to burn off his restraints, set himself on fire. Surveyors cited the home
    with several deficiencies at the immediate jeopardy level.

    Table 5: Extent to which the State Survey Agency Cited Serious
    Deficiencies for Substantiated Referrals from the Pulaski County Coroner

                                          Deficiencies cited for coroner referred
                                                                     decedents at
                                           actual harm or higher level in quality
              Nursing Number of referrals            of care and/or abuse/neglect
                 home substantiated          Deficiency cited No deficiency cited
                    A                   7                  6 decedents 1 decedent
                                        2                             2 decedents
                    E                  2a                   1 decedent 1 decedent
                                       2a                   1 decedent 1 decedent
                                        2                             2 decedents
                    B                   1                              1 decedent
                    D                  1a                              1 decedent
                    N                   1               1 decedent
                    Q                   1               1 decedentb
                    T                   1                              1 decedent
                                        1                              1 decedent
                   AA                   1               1 decedent
                Total                  22                   11

    Source: Arkansas state survey agency complaint investigation reports.

    Note: Of the 22 substantiated referrals for residents who died at these
    homes, 18 were referred for pressure sores, two for bruising, one for a
    fall, and one for catheter problems.

    aOne referral was substantiated without any deficiencies. Even though the
    investigation revealed a past violation of federal standards, no
    deficiencies were cited because the home had a quality assurance program
    in place that identified the deficient practice, took appropriate
    corrective action prior to the investigation, and implemented measures
    that prevented a recurrence.

    bPast noncompliance was cited for pressure sores at the immediate jeopardy
    level. Past noncompliance may be cited when no current violation of
    federal standards is found but the past violation was so egregious that
    the home should be cited for a deficiency and a civil monetary penalty
    imposed.

    Nursing home A accounted for 6 of 11 citations for neglect of decedents at
    the actual harm or higher level (see table 5). The neglect involved
    inadequate care to prevent and treat pressure sores. The home was
    terminated from participation in Medicare and Medicaid in November 2000,
    about 5 months after the first of a series of state survey agency

    complaint investigations initiated as a result of coroner referrals.24
    Although the agency found that six of the coroner-referred decedents had
    been neglected by home A, the results of this home's March 2000 standard
    survey and the timing and results of some complaint investigations prior
    to its closure were inconsistent with those findings. We identified the
    following inconsistencies in surveys of this home:

    o  	The home's March 3, 2000, standard survey found no deficiencies other
    than a C-level deficiency (potential for minimal harm) for inadequate
    housekeeping and maintenance, including a water-damaged ceiling tile,
    soiled carpeting, and worn upholstery on a sofa. The survey's resident
    sample, however, included a resident who died in mid-April, less than 6
    weeks after the standard survey, with five stage IV pressure sores.

    o  	Even though the photos accompanying coroner referrals for four
    decedents suggested serious, systemic care problems, the state survey
    agency did not initiate a complaint investigation until May 16, 2000,
    about 3 weeks after receiving the referrals, which were all sent at the
    same time.25 CMS guidance requires that such complaints be investigated
    within

    2 to 10 days, but state survey agency officials told us that they often
    gave a higher priority to investigating serious complaints for living
    residents. The state survey agency cited actual harm deficiencies for
    quality of care for three of the four decedents because similar care
    problems were found for current residents at the facility.

    o  	The May 16 investigation, however, included March 27 and April 3
    complaints from family members of one resident alleging that he (1) had
    deteriorating, unbandaged pressure sores and (2) was left wet and soiled
    for long periods, a situation that could have contributed to worsening

    24Although the state survey agency recommended termination of this home in
    October 2000, CMS's Dallas regional office imposed a directed plan of
    correction that included requirements that the home reduce the number of
    Medicare and Medicaid residents by 50 percent within about 2 weeks and
    hire independent third-party consultants in the areas of nursing services,
    pharmacy services, medical records and documentation, behavioral
    intervention, and quality assurance, as well as correct all conditions of
    immediate jeopardy. This approach gave the home significant leeway in
    returning to compliance. For example, the state survey agency was given
    the discretion to keep the home open if it showed good faith in removing
    immediate jeopardy. However, the home did not meet the terms of the
    directed plan of correction and thus was terminated in early November
    2000. The home reopened under new ownership, new management, and a new
    name in July 2001 but did not begin receiving Medicaid payments until June
    2002.

    25The decedents' deaths occurred from March 25, 2000, through April 13,
    2000, and the state survey agency received the coroner's referral for all
    four cases on April 25, 2000.

    pressure sores.26 These allegations went uninvestigated for almost 2
    months until they were confirmed in May. Investigation of a subsequent
    July complaint for this resident documented further deterioration of the
    pressure sores that began on his buttocks and extended all the way up his
    back.

    o  	Although this same resident was included in the sample of a subsequent
    September 2000 complaint investigation, his continuing pressure sores were
    not cited during that investigation. A final complaint investigation at
    the home about 6 weeks later-following the resident's death-found that he
    had 28 pressure sores when he died; 7 of the pressures sores, 2 of which
    were stage IV, did not have a physician's order for treatment.

    Only five of the referrals for decedents at other homes resulted in the
    citation of a deficiency at the actual harm or higher level for the
    decedent in question (see table 5). The deficiencies cited involved
    quality of care or abuse/neglect for four of the five decedents. For one
    of the five decedents, who had numerous, serious pressure sores, no
    current violations of federal standards were identified during the
    investigation of the coroner's referral. Under CMS guidance, surveyors
    would need to identify a current resident with inadequate treatment to
    prevent and heal pressure sores in order to cite a pressure sore
    deficiency at the actual harm level. However, the surveyor determined that
    an egregious past violation of federal standards involving this decedent
    warranted citing a deficiency known as past noncompliance and imposition
    of a civil monetary penalty.27 Because the deficiency occurred in the past
    and was assumed to have been corrected by the facility, a plan of
    correction was not required and no deficiency could be cited for the
    underlying care issue-inadequate treatment to prevent and heal pressure
    sores.28 Although Arkansas state

    26A similar October 1999 complaint by family members was not
    substantiated. Overall, at least 25 percent of the decedents referred by
    the coroner were also the subject of complaints by family members or
    others.

    27The state survey agency recommended a $10,000 civil monetary penalty.
    CMS reduced the penalty to $2,000, which the facility paid.

    28Although federal guidance sets a high threshold of immediate jeopardy
    for citing past noncompliance, the Arkansas state survey agency's
    complaint investigation guidance indicates that past noncompliance may be
    cited whenever the violation resulted in actual harm or immediate jeopardy
    to a resident.

    survey agency officials told us that they frequently cite past
    noncompliance, we found that it was cited for only one coroner referral.29

    For the remaining 11 substantiated coroner referrals, the state survey
    agency cited either no deficiency for the decedent or cited a deficiency
    at a level lower than actual harm for the predominant care problem
    identified by the coroner, even though the MFCU's investigations found
    neglect for six of the decedents, in effect substantiating the existence
    of serious care problems in these cases (see table 6). The MFCU's findings
    raise a question about the thoroughness of state survey agency complaint
    surveys. Because the nature of the problems identified by the coroner in
    these 11 referrals did not appear to differ significantly from referrals
    for home A that were substantiated at the actual harm or higher level (see
    table 5), we asked the state survey agency to review the 11 referrals to
    determine why no serious deficiencies were cited and if past noncompliance
    should have been cited. Noting their current heavy workload, state survey
    agency officials agreed to review 2 of the 11 cases. They told us that
    they could not cite an actual harm pressure sore deficiency for either
    decedent because the decedents were not in the facility at the time of the
    complaint investigations and under CMS guidance, surveyors would need to
    identify a current resident with inadequate treatment to prevent and heal
    pressure sores in order to cite a pressure sore deficiency at the actual
    harm level. In one of these cases, however, agency officials told us that
    they should have cited past noncompliance because of the serious nature of
    the decedent's condition.

    29Nationwide, past noncompliance appears to be rarely used, cited in less
    than 1 percent of standard surveys and less than 1 percent of complaint
    investigations. During the last 4 standard surveys for each nursing home
    nationwide, 204 instances of past noncompliance were cited on about 63,000
    surveys. Overall, about half of the state survey agencies cited past
    noncompliance. The Arkansas state survey agency accounted for about 10
    percent of such citations.

    Table 6: Six Coroner Referrals Where the MFCU Found Negligence by the
    Nursing Home but the State Survey Agency either Cited No Deficiency or a
    Deficiency at Less than Actual Harm for the Decedent

                                Results of investigation

                        Problems              State survey
    Home  Resident   identified by            agency              MFCU
                        coroner
        B   Resident 59 Numerous pressure  No deficiency was     Negligence found
                        sores; ulcers        cited for this     and fraud case is
                        on the roof of      decedent, but a        pending.
                        decedent's mouth;    deficiency for
                         leaking feeding   pressure sores was
                              tube.        cited at the D
                                           level for another
                                               resident.

    E Resident 5 	Numerous pressure sores; dirty No deficiency was cited for
    this Inadequate care found, leading to a unchanged bandages; ulcer on
    decedent. $30,000 settlement agreement with

    a

    the roof of decedent's mouth; the home.
    resident and medical equipment
    covered with live ants; foot and
    ankle in advanced stages of
    decomposition.

    Resident 40 Numerous pressure       No deficiencies      "Absence of care"
                   sores; ulcers           cited for this         found and fraud
                   on the roof of             decedent.       case is pending.
                   decedent's mouth.
    Resident 25 Pressure sores and skin
                       discoloration.

    Cited the home for a B-level deficiency for this resident due to
    incomplete records. (It also cited pressure sores at the immediate
    jeopardy level but not for this decedent).

    Included among 42 residents of a chain of nursing homes whose care the
    MFCU found negligent, leading to a $1.5 million settlement with the

                                           a

                                        owners.

    Resident 52	Numerous pressure sores and skin tears.

    Cited the home for two B-level deficiencies for this decedent, both
    related to the home's

                                           b

    recordkeeping.

    Included among 42 residents of a chain of nursing homes whose care the
    MFCU found negligent, leading to a $1.5 million settlement with the

                                           a

                                        owners.

    T Resident 48  Bruises on face   Cited the home for two  Found evidence of
                         and head,             E-level            neglect, but
                      possibly due to  violations for this             MFCU cited
                       falls; family   decedent-one for              insufficient
                           told                                         resources
                     coroner that the  improper use of          as the reason for
                       home did not    restraints and one        not pursuing the
                     monitor resident  for accident prevention.       case.
                     properly to avoid
                          falls.

    Source: GAO analysis of Pulaski County coroner referrals and Arkansas
    state survey agency and MFCU investigative reports.

    aAs of January 2004, 12 coroner referrals were included in MFCU
    settlements totaling $1,767,000 with five nursing homes. Some of the
    settlements, however, involved residents who were not referred by the
    Pulaski County coroner. For example, the largest settlement for $1.5
    million involved 42 residents, 2 of whom were referred by the coroner.

    bThe state survey agency noted that this home had been cited for immediate
    jeopardy for pressure sores during a survey conducted about 5 weeks before
    this decedent's death. Although the decedent was a resident of the home
    during the earlier survey, she was not included in the sample of residents
    reviewed at that time.

        State Survey Agency Decision Not to Substantiate Some Coroner Referrals Was
        Questionable

    On the basis of the MFCU's investigations and our own review, we question
    the state survey agency's decision not to substantiate more of the
    coroner's referrals or forward them to another agency for further
    investigation. Overall, the state survey agency did not substantiate 14 of
    the 36 coroner referrals that it investigated.30 Although we did not
    assess each of the 14 unsubstantiated referrals in detail, the state
    survey agency's findings for 7 decedents were challenged either by the
    results of the MFCU's investigations or by an expert review conducted at
    our request. Both the MFCU and our expert noted omissions and
    contradictions in the medical records of some of the 14 decedents, raising
    a question about the state survey agency's conclusions that the same
    records indicated care had been provided.

    The MFCU's investigations identified neglect of two decedents that the
    state survey agency failed to substantiate.31 In one of the cases, the
    MFCU found that the nursing home failed to (1) accurately assess changes
    in the resident's status, allowing the resident to develop stage II
    pressure sores before the staff was even aware that he had a skin problem;
    (2) track the resident's ability to perform certain basic activities of
    daily living; (3) routinely monitor his weight despite continued weight
    loss; and (4) follow physician orders, sometimes delaying prescribed
    treatment. In the other case, the MFCU found that the nursing home failed
    to provide

    30The state survey agency investigated but did not substantiate
    non-coroner complaints for five decedents the coroner said he referred and
    agency officials indicated they did not receive. The allegations in the
    non-coroner complaints were similar to those contained in the Pulaski
    County coroner's referrals. In one case, the survey agency referred the
    complaint to the MFCU that requested an exhumation of the decedent's body
    for an autopsy. Before the autopsy results were obtained, the survey
    agency determined that the complaint was unsubstantiated. In a second
    case, the survey agency received the complaint alleging a fall 3 weeks
    before the resident's death; the complaint was investigated 6 months after
    the resident's death but without the benefit of the coroner's photos of
    the decedent's bruises. For a third case, nursing home staff filed two
    complaints before the resident's death alleging poor pressure sore care.
    When he died, the resident had 12 pressure sores, but again, surveyors
    lacked the coroner's photos of the decedent.

    31Although neither the MFCU nor the state survey agency substantiated the
    alleged neglect for 8 of the same 14 referrals, we believe that several
    factors raise questions about the thoroughness of some MFCU
    investigations. In 2000, MFCU investigators were authorized to declare
    cases inactive and some cases were closed on the basis that medical
    records documented the receipt of necessary care, without a thorough
    review of the records by a registered nurse. (The MFCU now employs two
    nurse investigators who typically perform a review of medical records
    intended, in part, to identify inconsistencies and gaps in documentation
    of resident care.) In addition, the MFCU did not pursue every case it
    received, citing the difficulty of proving that neglect by a facility was
    the direct, natural, or probable cause of a resident's condition and
    because the agency's resources were limited.

    necessary treatment, rehabilitation, care, food, and medical services. In
    particular, the resident had no skin breakdown upon admission to the
    facility. But 7.5 months later, she had six pressure sores, including one
    on her right hip that was almost 4 inches across and had progressed to
    stage IV and two others that had progressed to stage III. There was no
    comprehensive care plan to address the resident's pressure sores. Other
    care was also found negligent. For example, during a hospital stay about 2
    months before the resident's death, the hospital found a large area on the
    back of her tongue with a thick buildup of saliva that had not been
    properly cleaned at the nursing home for up to 7 days.

    For five other coroner referrals not substantiated by the state survey
    agency, the expert agreed that we had a basis to question the state survey
    agency's findings.32 For example, the expert found that (1) some
    facilities were not removing the dead tissue around pressure sores; (2)
    the color of one decedent's skin suggested it was urine stained, a
    situation that contributes to skin breakdown and infection; and (3) two
    decedents were not receiving oral care, the lack of which the expert
    characterized as "profound" for one decedent. For three of the five cases,
    the expert found evidence that neglect contributed to the residents'
    physical condition as documented in the coroner's referrals. In general,
    the expert found the degree of skin damage and pressures sores in the
    reviewed cases to be "very suspicious" and concluded that preventive
    measures, such as special mattresses, would have precluded the development
    of such severe pressure sores, despite the decedents' health status. The
    expert also found the scarce and inconsistent mention of pain assessment
    and management

    32To support its "not substantiated" finding, the state survey agency
    cited several factors, including documentation that the facility was
    following the plan of care, the fact that the pressure sores were reported
    to have developed in the hospital, or that the family wanted to be
    conservative in the care provided. Because of concern about the basis for
    some "not substantiated" findings, we asked our expert to review seven
    cases in which the seriousness of the decedents' conditions as documented
    in the coroner's photos raised a question about the validity of the
    conclusions reached during the state survey agency's investigations. This
    assessment was based on a review of the various investigative reports,
    medical records we obtained, and photos of decedents taken by the coroner.
    All of the decedents had serious pressure sores, and four referrals
    involved two nursing homes. In two of the seven cases reviewed, our expert
    found that there was not enough documentation to draw a definitive
    conclusion.

    to be suspicious enough to warrant concern about abuse.33 Although three
    of the five deceased residents were receiving hospice care at the nursing
    home, our expert questioned the apparent lack of care for these residents.
    Ideally, hospice care provides consistent pain assessment and
    intervention, measures to prevent further skin breakdown and the
    associated discomfort, and local treatment to minimize odor. These
    standards are inconsistent with not changing pressure sore dressings, even
    if a family member asks not to have them changed. Finally, our expert
    questioned if some of the facilities had a quality assurance process in
    place to identify systemic problems, such as the incidence of pressure
    sores. We found that the state survey agency had cited the facility where
    two of the five decedents had resided for immediate jeopardy regarding the
    federal requirements to maintain a quality assurance committee that meets
    regularly. This deficiency was cited about 9 months before and 9 months
    after the residents' deaths.

    In two of the five cases, the state survey agency had concluded that
    serious pressure sores were acquired during hospitalizations but did not
    identify other care problems noted by our expert consultant. For example,
    one of the nursing homes failed to remove dead tissue around the pressure
    sores, an indication of poor care. In addition, the expert noted the lack
    of oral care for one of these decedents, again raising questions about the
    quality of care provided by the home. Even if the state survey agency had
    justifiably concluded that the decedents' serious pressure sores were
    acquired during hospitalizations rather than in the nursing homes where
    the residents died, neither case was referred to Arkansas's Division of
    Health Facility Services, the entity responsible for oversight of
    hospitals that serve Medicare and Medicaid beneficiaries. State survey
    agency officials agreed that it might have been appropriate to refer such
    cases to this division. CMS's 1999 guidelines for complaint investigations
    instruct state survey agencies to refer cases to another agency when it
    lacks jurisdiction.

    33Pressure sores can be painful. For example, a physician more than
    quadrupled the amount of pain medication for one decedent over about a two
    and one-half month period because of pressure sores at the base of her
    spine. We found that pain management was a problem in other coroner
    referrals. For example, the medical records associated with one coroner
    referral noted that the resident had complained to her daughter of foot
    pain. When the daughter removed her mother's shoe and sock she found
    bloody toes from pressure sores that the home had failed to document. Two
    other decedents did not receive pain medication as prescribed.

    Omissions and contradictions in the medical records for four other
    decedents whose referrals were not substantiated raise a question about
    the state survey agency's conclusions that these same records indicated
    care had been provided. For example, in two cases, the MFCU found numerous
    omissions in the facility's care and treatment records, such as missing
    entries on the medication records and nurse assistant flow sheets, as well
    as a discrepancy as to when a pressure sore was first noted. In another
    case, the MFCU concluded that there were so many documentation problems
    that it was difficult to follow the course of one decedent's care,
    including late entries that were "questionable and too many." In addition,
    in another case, our expert consultant found that the seriousness of a
    pressure sore was understated by the home.

    Federal surveyors also found evidence that state surveyors missed or
    failed to cite deficiencies, including some that harmed residents. A March
    2000 federal comparative survey of an Arkansas nursing home, some of whose
    residents were the subject of coroner referrals, found care issues that
    had not been identified by the state survey agency.34 A comparative survey
    is conducted within 2 months of a state survey to independently verify its
    accuracy. Overall, federal surveyors cited 19 health-related deficiencies
    that state surveyors did not, including failure of the nursing home to
    develop and implement effective procedures to prevent neglect and abuse of
    residents. Three of the 19 deficiencies that state surveyors did not
    identify were cited by federal surveyors at the actual harm level: failure
    to provide (1) necessary care and services to maintain a resident's
    highest well being; (2) good nutrition, grooming, and personal and oral
    hygiene; and (3) treatment and services to increase and prevent further
    degradation in a resident's range of motion. Federal surveyors also cited
    a widespread failure in infection control procedures at the potential for
    more than minimum harm level. One of the coroner-referred deaths at this
    facility occurred within 6 weeks of both the state and federal surveys
    that were about 1 month apart. The decedent arrived in the hospital
    emergency room with a fever of 104DEG, an indication of infection, as well
    as ragged tears on his right knee and shin and serious pressure sores on
    both buttocks. Though documentation was not available, a state survey
    agency official told us that this complaint was unsubstantiated.

    34The state's February 2000 survey was conducted to allow this nursing
    home to again serve Medicaid beneficiaries. The home had been terminated
    from participation in the Medicaid program in January 2000 for poor
    performance after an October 1999 survey that found actual harm and
    immediate jeopardy deficiencies in quality of care.

      Resident Neglect May Go Undetected Because of Well-Documented Oversight
      Weaknesses

    Because of oversight weaknesses that are well-documented nationwide,
    neglect of nursing home residents may often go undetected. We found the
    same systemic oversight weaknesses in the Arkansas state survey agency's
    investigation of coroner referrals that our prior work on nursing home
    quality of care identified nationwide. These oversight weaknesses include
    (1) complaint investigations that understated the seriousness of the
    allegations and were not conducted promptly; (2) annual standard survey
    schedules that allowed nursing homes to predict when the next survey would
    occur; (3) survey methodology weaknesses, coupled with surveyor reliance
    on misleading medical records, that resulted in overlooked care problems;
    and (4) a policy that did not always hold nursing homes accountable for
    care problems identified after a resident's death.

        Serious Complaints Were Inappropriately Prioritized and Not Promptly
        Investigated

    In 1999, we reported that many survey agencies in the 14 states we
    examined often assigned inappropriately low investigation priorities to
    complaints and failed to investigate serious complaints promptly.35 Such
    practices may delay the identification and correction of care problems
    that may involve other residents of a nursing home in addition to the
    resident who is the subject of the complaint. Based on our draft report,
    CMS reviewed the Arkansas state survey agency's prioritization of the 36
    coroner referrals the agency said it received. CMS concluded that about 31
    percent of the referrals should have been prioritized for more prompt
    investigation.36 Furthermore, CMS found that 5 referrals prioritized by
    the state as requiring an investigation within 10 working days suggested
    the potential for immediate jeopardy and should have been prioritized for
    investigation within 2 working days.37 The state survey agency prioritized
    6 other referrals as not requiring investigation for up to 45 days, but
    CMS indicated that 1 of these referrals should have been prioritized for

    35GAO, Nursing Homes: Complaint Investigation Processes Often Inadequate
    to Protect Residents, GAO/HEHS-99-80 (Washington, D.C.: Mar. 22, 1999).

    36See Appendix III, amended attachment I to CMS comments.

    37CMS guidance instructs state survey agencies to establish complaint
    prioritization time frames for serious complaints in terms of working
    days, not calendar days. If a complaint judged to be immediate jeopardy
    was received on a Saturday, the survey agency would not be expected to
    initiate its investigation until Tuesday, 4 days after receipt of the
    complaint.

    investigation within 2 days, and the remaining referrals within 10 working
    days (actual harm).38

    Although the state survey agency classified most of the 36 referrals as
    requiring investigation within 10 working days, we found a significant
    disparity between the prioritization it assigned and the time it actually
    took to conduct the investigations. As shown in figure 3, 16 referrals
    were investigated in 10 working days or less and 19 referrals took between
    11 and 290 working days to investigate.39 Identifying time frames in terms
    of working days, as CMS's guidance requires, however, understates the
    actual elapsed time between receipt and investigation of referrals. The
    average elapsed time from the date the survey agency received a referral
    until it initiated its investigation was 46 calendar days. Seven referrals
    were not investigated for between 91 and 425 calendar days and the
    investigation of an additional 11 referrals took between 21 and 90
    calendar days (see fig. 3). State survey agency officials told us that
    because of surveyor turnover and the number of complaints received from
    all sources, the agency could not investigate all coroner complaints
    quickly; CMS has identified untimely complaint investigations in many
    other states. Moreover, Arkansas state survey agency officials told us
    that they gave priority to allegations involving residents who were still
    living in a facility over comparable allegations involving deceased
    residents, even though the coroner's referrals were accompanied by photos
    that suggested the possibility of systemic care problems.

    38State survey agency officials were unable to identify the investigation
    priority for 2 of the 36 coroner referrals. However, over 3 months elapsed
    between the time the state survey agency received and investigated one of
    these referrals. For the second referral, the survey agency could not
    identify the date of receipt, but nevertheless completed its investigation
    within 12 working days of the resident's death.

    39Our analysis includes 35 of the 36 coroner referrals because the survey
    agency was unable to provide the date of receipt for 1 referral.

    Figure 3: Elapsed Working and Calendar Days between Receipt of Coroner's
    Referral and Start of Investigation by Arkansas State Survey Agency

    Number of coroner referrals

                             Number of coroner referrals 20

    16

                                           15

                                           14

                                          10 5

                                           0

    10 or fewer days

    11-20 days

    21-40 days

    41-90 days

    91-290 days

                                    10 or fewer days

    11-20 days

    21-40 days

    41-90 days

    91-425 days

                       Elapsed working days Elapsed calendar days

                     Source: Arkansas state survey agency records.

    Note: One of the 36 referrals is excluded from this figure because the
    state survey agency was unable to identify the date the referral was
    received from the coroner.

        Predictable Surveys Allow Nursing Homes to Conceal Care Problems

    In 1998 and subsequent work, we found that nursing homes could conceal
    care problems if they chose to do so because annual state surveys were
    often predictable.40 For example, a home could (1) significantly change
    its level of care, food, and cleanliness by temporarily augmenting its
    staff just prior to or during the period of the survey and (2) adjust
    resident records to improve the overall impression of the home's care. We
    believe that the striking disparity between annual survey findings that
    failed to identify serious problems in preventing and treating pressure
    sores and the numerous instances of serious pressure sores identified by
    the coroner is partly the result of the predictability of annual surveys.
    In July 2003, we reported that standard surveys in Arkansas, as well as
    those nationwide, continued to be highly predictable.

    40GAO/HEHS-98-202, GAO/HEHS-00-197, and GAO-03-561.

    In 2003, we reported that the timing of 36 percent of Arkansas's most
    recent surveys (34 percent nationwide) could have been predicted by
    nursing homes.41 We considered nursing home surveys predictable if homes
    were surveyed within (1) 15 days of the 1-year anniversary of their prior
    survey (28 percent for Arkansas) or (2) 1 month of the maximum 15-month
    interval between standard surveys (8 percent for Arkansas).42 The director
    of the Arkansas state survey agency acknowledged that the predictability
    of the state's standard surveys allowed homes to mask problems by having
    more staff on hand during surveys. On the basis of the finding in our 2003
    report, she told us she has tried to reduce survey predictability, in part
    by using computer programs to vary the timing of homes' surveys. For 168
    of Arkansas's approximately 236 nursing homes surveyed since our last
    report (August 1, 2003, through June 22, 2004), 22.6 percent of the
    surveys were predictable.

    In 1998, we recommended that CMS segment the standard survey into more
    than one review throughout the year, simultaneously increasing state
    surveyor presence in nursing homes and decreasing survey predictability.43
    Although CMS disagreed with segmenting the survey, it did recognize the
    need to reduce predictability. CMS directed states in 1999 to (1) begin at
    least 10 percent of standard surveys outside the normal workday (either on
    weekends, early in the morning, or late in the evening) and (2) avoid
    scheduling, if possible, a home's survey for the same month of the year as
    the home's previous standard survey. We reported previously that CMS's
    focus on so-called staggered surveys, though beneficial, was too limited
    to reduce survey predictability.44

    41See GAO-03-561. This analysis was based on states' most recent surveys
    in OSCAR as of April 9, 2002 and represents a reduction from prior surveys
    when about 45 percent of Arkansas's standard surveys were predictable (38
    percent nationwide).

    42In contrast, fewer surveys nationally were predictable for the former
    (13 percent) than the latter (21 percent) reason.

    43GAO/HEHS-98-202.

    44GAO/HEHS-00-197.

        Survey Methodology Weaknesses and Misleading Medical Records Contribute to
        Undetected Care Problems

    Our 1998 work on California nursing homes revealed that surveyors may
    overlook significant care problems because (1) the federal survey protocol
    they follow does not rely on an adequate sample for detecting potential
    problems and their prevalence and (2) some resident medical records omit
    or contain misleading information.45 Because CMS has not yet completed the
    redesign of the survey methodology, nearly 7 years later Arkansas
    surveyors, as well as those in other states, still rely on a flawed survey
    methodology to detect resident care problems. As noted earlier, omissions
    and contradictions in the decedents' medical records, as well as the
    coroner's photos, sometimes raised questions about whether appropriate
    care had been provided in cases the state survey agency did not
    substantiate.

    Our 1998 report recommended that CMS revise federal survey procedures by
    using a stratified random sample of resident cases and reviewing
    sufficient numbers and types of resident cases. Under development since
    1998, CMS's redesigned survey methodology is intended to more
    systematically target potential problems at a home and give surveyors new
    tools to better document care outcomes and conduct on-site investigations.
    Use of the new methodology could result in survey findings that more
    accurately portray the quality of care provided by a nursing home to all
    residents. CMS officials told us that the new methodology would be piloted
    in 2005 in conjunction with an evaluation that compares its effectiveness
    with that of the current survey methodology. Our work in Arkansas
    suggested the existence of sampling problems, underscoring the importance
    of implementing the revised survey methodology. For example, three
    residents with serious pressure sores who died on March 7, March 29, and
    April 3, 2000, and were the subject of coroner referrals were not included
    in the resident sample for one home's March 3, 2000, annual standard
    survey. The survey failed to identify any pressure sore or other quality
    of care deficiencies. It is difficult to understand how residents with
    such serious care problems could have been omitted from the survey. In
    addition, the extent of the physical deterioration of some decedents where
    the MFCU identified neglect but the state survey agency did not find
    similar problems for current residents also raises a question about state
    survey agency sampling methodology because the seriousness of decedents'
    conditions suggested that care problems were systemic.

    45GAO/HEHS-98-202.

    In some coroner referrals that the state survey agency did not
    substantiate, surveyors noted that the medical records indicated that care
    had been provided. However, the MFCU found omissions and contradictions in
    decedents' medical records, including missing entries and late entries
    that were "too many and questionable." The medical record for one decedent
    showed the resident's height as 10 inches different from the height in her
    nutritional assessment (height is an important factor in determining a
    resident's appropriate weight). Since surveyors screen residents' medical
    records for indicators of improper care, misleading or inaccurate data may
    result in care deficiencies being overlooked. We also found evidence that
    Arkansas surveyors took medical records at face value even when these
    records were contradicted by color photos that documented decedents'
    physical conditions. For example, our expert consultant found that the
    coroner's photos of one decedent clearly showed that dead tissue around
    pressure sores had not been removed even though the state surveyor cited
    medical records indicating such care was provided just 11 days before the
    resident's death. The coloration of the same decedent's skin also
    suggested that she was left in her own waste for extended periods.
    However, the surveyor noted that the family's concern about staff's
    unresponsiveness to resident call lights was not substantiated because
    residents who were interviewed said that staff response was prompt.

        Under CMS Policy, Nursing Homes Not Always Held Accountable for Past
        Noncompliance

    In our current work, we found that many Arkansas nursing homes with
    coroner referrals escaped accountability for providing poor care when the
    state survey agency investigated the neglect of nursing home residents
    after their deaths. We believe that CMS's vague policy on past
    noncompliance is partly responsible for this situation. First, the
    Arkansas state survey agency did not always cite past noncompliance when
    warranted. For example, the MFCU found that nursing homes had neglected
    eight decedents referred by the coroner but the state survey agency either
    cited no deficiency for the decedents, cited a deficiency at a level lower
    than actual harm for the predominant care problems identified by the
    coroner, or found the referrals to be unsubstantiated. According to state
    survey agency officials, care problems similar to those of the decedents
    were not identified in a sample of current residents and, under CMS
    policy, the decedents' care problems were assumed to have been identified
    and corrected by the home. Second, for the one coroner referral that the
    Arkansas state survey agency did cite for past noncompliance, the home was
    not required to prepare a plan of correction because no current deficiency
    was identified. When past noncompliance is identified, it is recorded in
    OSCAR and on CMS's Nursing Home Compare Web site simply

    as past noncompliance without additional information on the specific
    deficient practice(s), such as failure to prevent and treat pressure
    sores.

    Moreover, CMS policy discourages citing past noncompliance unless the
    violation is egregious. Although CMS officials indicate that "egregious"
    includes noncompliance related to a resident's death, the term is
    undefined and is not used in CMS's scope and severity grid, which defines
    serious deficiencies as actual harm or immediate jeopardy.46 According to
    CMS officials, the objective of its survey policy is to focus surveys on
    current residents and care problems rather than on poor care provided in
    the past. We question CMS's assumption that if a decedent's care problem
    is not found to affect other residents at the time of a complaint
    investigation, it was identified earlier by the home and corrected.47 On
    the basis of our past work, it is also possible that the state survey
    agency's complaint investigation missed serious care issues. CMS and
    Arkansas state survey agency officials agreed that the poor physical
    condition of the decedents referred by the coroner suggested the existence
    of systemic care problems.

                                      Conclusions

    The Arkansas law requiring coroner investigations of nursing home
    residents' deaths has helped to demonstrate that a small number of
    residents died in deplorable physical condition. The Arkansas law also
    confirmed the systemic weaknesses in state and federal oversight of
    nursing home quality of care that we identified in prior reports. On the
    basis of our prior work, we believe it is likely that serious care
    problems similar to those identified by the Pulaski County coroner exist
    in other Arkansas counties and in other states. Despite Arkansas's annual
    standard surveys and intervening complaint investigations, the negligent
    care provided to some residents before they died was never detected. In
    addition, complaint investigations initiated by the state survey agency in

    46In 1999, we reported that CMS guidance on past noncompliance did not
    require the imposition of a sanction, even for a deficiency that
    contributed to the death of a resident. CMS concurred with our
    recommendation to revise its guidance and on May 28, 2004, instructed
    state survey agencies to impose a civil monetary penalty when citing past
    noncompliance. See GAO, Nursing Homes: Additional Steps Needed to
    Strengthen Enforcement of Federal Quality Standards, GAO/HEHS-99-46
    (Washington, D.C.: Mar. 18, 1999).

    47No plan of correction is required because the deficiency is assumed to
    have been corrected and no longer exists. However, CMS could require the
    facility to document how it discovered the deficient practice and the
    corrective action it took.

    response to coroner referrals often failed to cite deficiencies for
    serious care problems that, according to the MFCU's investigations and our
    expert consultant, constituted or suggested neglect. Even when the
    Arkansas state survey agency found the neglect to be egregious, it did not
    hold the nursing home accountable by citing a little used deficiency known
    as past noncompliance.

    We believe that CMS's policy on past noncompliance is flawed for three
    reasons. First, the policy involves considerable ambiguity. CMS does not
    define what constitutes an egregious violation yet implies that one exists
    where care problems relate to a resident's death, which is often difficult
    to demonstrate without an autopsy. Moreover, the term egregious is not
    clearly related to CMS's scope and severity grid, which defines serious
    deficiencies as actual harm or immediate jeopardy. Second, CMS's policy on
    past noncompliance does not hold homes accountable for negligence
    associated with a resident's death unless similar care problems are
    identified for current residents. CMS assumes that (1) similar care
    problems were not found because they have already been identified and
    corrected by the home and (2) the state survey agency did not miss the
    deficiency for current residents. However, our prior work demonstrated,
    and our work in Arkansas confirmed, that (1) nursing home records can
    contain misleading information or omit important data, making it difficult
    for surveyors to identify care deficiencies during their on-site reviews
    and (2) states' surveys of nursing homes do not identify all serious
    deficiencies, such as preventable weight loss and pressure sores. Third,
    the policy obscures the nature of the specific care problem, such as
    avoidable pressure sores, because the only deficiency reported in OSCAR
    and to the public on CMS's Nursing Home Compare Web site is "past
    noncompliance." We believe that the goal of preventing resident neglect by
    requiring nursing homes to comply with federal quality standards is
    inconsistent with a policy that discourages citing deficiencies because
    the harm was simply not egregious enough or was potentially missed for
    current residents.

    Recommendations for We recommend that the Administrator of CMS revise the
    agency's current policy on citing deficiencies for past noncompliance with
    federal qualityExecutive Action standards by taking the following two
    actions:

    o  	hold homes accountable for all past noncompliance resulting in harm to
    residents, not just care problems deemed to be egregious, and

    o

      Agency and State Comments and Our Evaluation

    develop an approach for citing such past noncompliance in a manner that
    clearly identifies the specific nature of the care problem both in the
    OSCAR database and on CMS's Nursing Home Compare Web site.

    We provided a draft of this report to CMS; the Arkansas Department of
    Human Services, Office of Long Term Care (the state survey agency); the
    Arkansas MFCU; and the Pulaski County coroner. We received written
    comments from CMS and the survey agency, and oral comments from the
    coroner. The MFCU stated that it did not have comments. CMS concurred with
    our recommendations to revise its policy on citing deficiencies for past
    noncompliance and also identified more than a dozen additional initiatives
    it plans to take to address shortcomings in the nursing home survey
    process. CMS commented that the focus of its initiatives, such as
    additional guidance on the scope and severity of deficiencies, would be
    broad, in effect supporting our conclusion that the shortcomings we
    identified were systemic and not limited to Arkansas. CMS and the state
    survey agency raised concerns about (1) the discrepancy we reported
    between the number of referrals the coroner said he made (86) and the
    number the survey agency said it received (36) and (2) the relevance of
    survey predictability to complaint investigations based on coroner
    referrals. In addition, the state survey agency commented that we had
    understated the number of investigations it actually conducted. (CMS's
    comments are reproduced in app. III,48 and the state survey agency's
    comments are reproduced in app. IV.) Our evaluation of CMS, survey agency,
    and coroner comments covers the following six areas: CMS's past
    noncompliance policy, shortcomings in state survey agency investigations,
    lessons from implementing the Arkansas law, the number of coroner
    referrals and survey agency investigations, survey predictability and
    methodology redesign, and the impact of the Arkansas law.

    CMS Policy on Past CMS agreed with our recommendations to revise its past
    noncompliance

    Noncompliance 	policy. We found that some nursing homes were not held
    accountable for serious deficiencies, even though some coroner referrals
    were substantiated, because of flaws in CMS's policy governing past

    48A portion of CMS's comments was based on tables presented in attachment
    1 to its comments. Because the tables did not accurately reflect the
    coroner's cases discussed in our report, CMS submitted an amended
    attachment 1 which we have substituted for the original. CMS, however, did
    not make corresponding changes on pages 6 and 7 of its comments.

    noncompliance. Following a planned review of the policy, CMS indicated
    that it would (1) clarify expectations for the manner in which state
    survey agencies should address past deficiencies that have only recently
    come to light, (2) further define important terms, particularly egregious,
    (3) ensure that the specific nature of the care problems was identified in
    OSCAR, and (4) strengthen criteria for determining whether a nursing home
    had actually taken steps to address deficiencies that contributed to past
    noncompliance. CMS did not indicate whether it also planned to identify
    the specific nature of deficiencies associated with past noncompliance on
    its Nursing Home Compare Web site, but we continue to believe that posting
    such information would provide valuable assistance to consumers.

        Shortcomings in State Survey Agency Investigations Nationwide

    Because of the seriousness of the shortcomings identified in our report,
    CMS sent a clinical fact-finding team to Arkansas for 3 days after
    receiving a draft of our report. The CMS clinical team found that some,
    but not all, of the referrals for which lower-level deficiencies were
    cited should have received a higher-level severity rating. In addition,
    from among six coroner referrals that were not substantiated by the survey
    agency, the team believed two should have been substantiated, a higher
    disparity rate than CMS said it has typically found for Arkansas surveys
    in general. As a result of its team's visit, CMS concluded that additional
    training and clarification of its guidance were warranted, including (1)
    increased training for state surveyors in determining the appropriate
    scope and severity of deficiencies as well as the development of
    additional CMS guidance and analysis of patterns in state deficiency
    citations and (2) the development of an advanced course in complaint
    investigations to be piloted in Arkansas and evaluated for potential
    expansion and replication nationwide. CMS noted that these initiatives
    would be applied broadly, a recognition that the shortcomings we
    identified were systemic and not limited to Arkansas.

    While we fully support CMS's new initiatives, timely and sustained
    followup to ensure effective implementation is critical; earlier CMS
    initiatives to address these same problems were not timely or were
    ineffective. We reported in July 2003 that CMS began a complaint
    improvement project in 1999 but did not provide more detailed guidance to
    states until almost 5 years later.49 Similarly, we reported that CMS began
    developing more structured guidance for surveyors in October 2000 to
    address

    49GAO-03-561.

    inconsistencies in how the scope and severity of deficiencies are cited
    across states, but the first installment on pressure sores had not yet
    been released as of September 2004.50 Our 2003 report also noted that CMS
    began annual reviews of a sample of deficiency citations from each state
    in October 2000 to identify shortcomings and the need for additional
    training, but CMS's recognition that additional guidance and training are
    required raises a question about the sufficiency and effectiveness of
    these reviews. Furthermore, we believe that other factors may be
    contributing to survey shortcomings. Our 2003 report noted that some state
    officials cited inexperienced surveyors, the result of a high turnover
    rate, as a factor contributing to the understatement of serious quality of
    care deficiencies.

    CMS commented that the photos conveyed from the coroner's office were
    graphic, serious, and require careful investigation. The CMS clinical team
    found that the photos were very helpful in a number of investigations. We
    agree with CMS's view that the photos alone do not represent sufficient
    evidence to render a conclusion that there was poor care, neglect, or
    avoidable outcomes, or that the nursing home caused the death. On the
    basis of its visit to Arkansas, the CMS clinical team concluded that not
    all referred cases could be substantiated with the photos, medical
    records, and other information available to it; as we noted in the report,
    our expert consultant reached the same conclusion on two of the seven
    cases she reviewed. We nevertheless continue to believe that the state
    survey agency at times appeared to dismiss photographic evidence of
    potential neglect and to rely instead on observations of and interviews
    with current residents. In response to our findings, CMS said it would
    study the issues involved in the use of photos and would issue additional
    guidance for use by state survey agencies.

        Lessons from Implementing Arkansas's Law on Nursing Home Deaths

    CMS made a number of observations about lessons from the Arkansas
    experience that would improve the effectiveness of mandatory reporting
    systems, such as the coroner referrals required by the Arkansas law. These
    lessons related to the implementation of the Arkansas law by local
    coroners and the quality and timeliness of referrals made by the Pulaski
    County coroner. We agree that these factors are important to the ability
    of state survey agencies to promptly and effectively complete their own
    investigations based on coroner referrals of potential neglect. However,

    50CMS officials told us that the pressure sore guidance is expected to be
    released before the end of 2004.

    because we lack the authority to evaluate the implementation of state
    laws, we excluded such an analysis from the scope of our work. We do have
    the authority to evaluate the performance of federally funded
    entities-such as the state survey agency and the MFCU-that are responsible
    for ensuring that Medicare and Medicaid nursing home residents receive
    quality care, and we therefore focused our work on how these entities
    responded to the cases referred to them.

    In particular, CMS highlighted the lack of referrals from most Arkansas
    coroners and the processes followed by coroners, primarily the Pulaski
    County coroner, in making referrals to the state survey agency. During our
    interviews, the Pulaski County coroner and MFCU officials demonstrated
    their awareness of the absence of an enforcement mechanism in the state
    law to ensure that nursing homes and coroners comply with the law; the
    Pulaski County coroner told us that he intends to pursue this issue with
    the state legislature. According to CMS, the quality of the documentation
    provided by coroners did not conform to key principles of forensic
    science, such as embedded photo dating and subject identification, photo
    scale metrics and color charting, and interviews with residents'
    physicians. While the coroner referrals may have lacked these features,
    the referral packages we examined clearly identified the decedents, the
    time the coroner's office was notified of the deaths, and the time the
    coroner's staff arrived at the homes. It is also clear from the
    documentation that the photos were taken shortly after death. Requiring
    such a level of forensic evidence from the coroner substantially exceeds
    the burden of proof the state survey agency requires for other complaints
    filed, which is how the coroner referrals are treated. The coroner
    referrals are intended to be the starting point for the state's
    investigation, not a substitute for its own thorough investigation.

    Both CMS and the state survey agency expressed concern about the elapsed
    time between the dates of death and the receipt of coroner referrals by
    the survey agency. In particular, they noted that our analysis excluded
    five referrals the coroner made in 2004 that related to deaths in 2003,
    with the elapsed times from the deaths to receipt of the referrals

    ranging from 222 to 400 days.51 We excluded these five referrals because
    they had not yet been referred when we completed our data collection for
    this report, which covered referrals for the period July 1999 through
    December 2003.52 In principle, we agree with CMS's view that the value of
    a timely investigation by the state survey agency can be influenced by the
    length of time associated with referrals, even though we found that the
    coroner's referral of several cases up to 4 months after the residents'
    deaths did not appear to have handicapped the investigations. For example,
    the state survey agency substantiated three coroner referrals with
    deficiencies at the actual harm and immediate jeopardy level even though
    the referrals were not received for between 65 and 106 calendar days after
    residents' deaths. Although the survey agency did not substantiate one
    coroner referral that was not received until 102 days after the resident's
    death, the MFCU found neglect. For the 36 referrals the survey agency said
    it received from the coroner for the period we analyzed, the average
    elapsed time from the date of death until the coroner made his referral
    was 38 days (ranging from zero to 180 days), whereas the average elapsed
    time from the date the survey agency received the referral until it
    initiated its investigation was 46 days (ranging from zero to 425 days).53
    Notwithstanding these elapsed times for coroner referrals and state
    investigations, CMS commented that it would study its priority criteria
    for complaint triage and refine its policy with regard to the treatment of
    and response to complaints.

    51Our elapsed time calculation differs from that of CMS because we relied
    on copies of signed receipts provided by the coroner. These receipts
    indicated that the state survey agency received all of these referrals
    either on April 13, 2004, or on April 14, 2004, rather than on the dates
    indicated by CMS in amended attachment 1 to their comments. We believe
    that the approximately 2-week disparity between the dates shown on the
    signed receipts and the dates that the survey agency said it received four
    of these referrals raises a question about how promptly the survey agency
    registers complaints in its tracking system. Because the coroner did not
    begin requiring signed receipts for referrals of suspected neglect until
    March 2004, we were unable to determine if there were similar delays in
    registering the 36 coroner referrals received prior to 2004.

    52The coroner informed us that these five referrals were delayed while
    awaiting final autopsy reports, which can take 8 to 9 months to complete.

    53These averages and ranges differ from those CMS provided in its comments
    because CMS included the five 2004 coroner referrals that were outside the
    scope of our review.

        Number of Coroner Referrals and State Survey Agency Investigations

    Both CMS and the state survey agency questioned the validity of the number
    of Pulaski County coroner referrals, commenting that we lacked independent
    verification of the number actually referred; they also believed that the
    report's language suggested referrals had been received but not
    investigated. We revised the report to make it clear that the coroner told
    us he had referred 86 cases of suspected neglect of deceased nursing home
    residents to the state survey agency and the MFCU for investigation (and,
    as noted below, we reviewed the related case documentation for each of the
    86 referrals). We also revised the report to clarify that the state survey
    agency investigated the 36 coroner referrals that it told us it had
    received.54 CMS asserted that the coroner was unable to provide its
    clinical team with a list of his referrals; however, CMS's comments do not
    reflect that the coroner's case files were not automated. We compiled a
    list of the 86 referrals ourselves. Our list was based on documentation
    provided by the coroner for each of the cases he told us he referred,
    including a narrative summary describing the suspected neglect, copies of
    decedents' medical records, autopsy reports, and photos documenting the
    decedents' conditions. Although the state survey agency and the MFCU told
    us that they did not receive all 86 coroner referrals, we believe that the
    MFCU's receipt of almost three fifths of the coroner's referrals (compared
    with the state survey agency's receipt of fewer than half) provides
    independent corroboration that the Pulaski County coroner made more than
    36 referrals during the 4.5-year period we examined. As noted in the
    report, the coroner was instrumental in securing passage of the law, a
    fact that is inconsistent with the suggestion that the coroner withheld
    referrals. To address the disparity in the number of referrals the coroner
    told us he made and the number the state survey agency and the MFCU told
    us they received, the coroner began requiring signed receipts in March
    2004, a practice reflected in our draft report.

    The state survey agency commented that we had understated the number of
    investigations of nursing home deaths it had conducted. The agency
    identified 22 investigations that, in most cases, were based on the
    receipt of a complaint from individuals other than the coroner.

    o  	We excluded 9 of these 22 investigations because they were conducted
    prior to the residents' deaths. For example, one complaint of alleged rape
    of a 91-year-old resident was filed by a hospital that found the resident
    had

    54Arkansas state survey agency officials told us that they did not
    investigate one coroner referral they had received. We excluded this
    referral from those received by the survey agency.

    a sexually transmitted disease. The complaint was not substantiated. The
    coroner's investigation of the resident's death 5 months later resulted in
    a referral based on seven serious pressure sores on the decedent's feet,
    lower back, and hips, a problem that was not noted during the
    hospitalization.

    o  	We revised our analysis to include 1 of the 22 cases because the
    coroner confirmed that he had indeed made the referral. Thus, we adjusted
    the number of coroner referrals from 85 in the draft report to 86 in the
    final report. We also revised the number of referrals the state survey
    agency said it received from 35 to 36. We confirmed that this additional
    referral was not received or investigated by the MFCU.

    o  	For 7 cases, we determined that the allegations in the non-coroner
    complaints were similar to the concerns raised by the coroner's
    investigations and have added footnotes in the appropriate sections of the
    report, depending on whether the investigations substantiated (2
    complaints) or did not substantiate (5 complaints) the complainants'
    allegations.

    o  	For the remaining 5 cases, we made no changes in the report.55 In one
    case, the survey agency's complaint investigation focused on an issue
    different from the suspected neglect identified by the coroner. In four
    other cases, the agency included the decedents' records in its resident
    samples during standard surveys. The decedents were not included in any
    deficiencies cited during these surveys and, importantly, the surveyors
    lacked the coroner's photos of pressure sores, which would have been
    particularly useful in raising questions about the care provided as
    documented in the decedents' medical records.

        Survey Predictability and Methodology

    Both CMS and the state survey agency questioned the relevance of survey
    predictability to complaint investigations resulting from coroner
    referrals and suggested we delete this analysis from the final report.
    Neither organization commented on our assessment of the impact of survey
    methodology weaknesses and misleading medical records on detecting
    quality-of-care problems. We retained this analysis in the final report
    because we believe the issues of survey predictability and methodology are
    relevant to state survey complaint investigations of coroner referrals.
    Our 1998 and subsequent work found that predictable surveys allowed homes
    so inclined to (1) significantly change the level of care, food, and

    55Although the state survey agency said it received coroner referrals for
    2 of the 5 cases, we excluded the two from our analysis of referrals
    investigated by the state survey agency because it could provide no
    documentation of its investigation, including the outcome.

    cleanliness by temporarily augmenting staff just prior to or during a
    survey, and (2) adjust resident records to improve the overall impression
    of the home's care.56 We also reported in 1998 that surveyors may overlook
    significant care problems during annual surveys because of survey
    methodology weaknesses and omissions or misleading information in resident
    medical records.

    Although the predominant care problem identified in 67 percent of the
    coroner's referrals involved serious pressure sores, most of the nursing
    homes referred had not been cited for a pressure sore deficiency at the
    actual harm level or higher on any of their previous four standard
    surveys. We believe that the striking disparity between annual survey
    findings and the predominant care problems identified by the coroner
    relates to the predictability of annual surveys, weaknesses in survey
    methodology, and misleading medical records-all of which contribute to the
    phenomenon of undetected care problems. Our work in Arkansas suggested the
    existence of sampling problems in a home whose annual survey failed to
    detect any quality-of-care problems, even though three residents, all with
    serious pressure sores, died within 1 month. The fact that none of these
    residents was included in the nursing home's annual standard survey
    underscores the importance of implementing a revised survey methodology
    that CMS has had under development for 7 years. Our report also provides
    several examples where misleading medical records contributed to the
    failure of the Arkansas state survey agency to detect care problems that
    the MFCU or our expert consultant identified and were obvious in some of
    the coroner's photos of decedents.

    CMS further commented that our analysis of survey predictability
    resurrected prior reports and recommendations to which CMS has previously
    responded and that we failed to acknowledge CMS and state survey agency
    progress in reducing survey predictability. We believe that CMS's comments
    are inaccurate. In our 1998 report, we recommended segmenting the survey
    into more than one review throughout the year to reduce survey
    predictability. CMS responded to this recommendation by requiring that 10
    percent of state annual surveys be conducted on weekends, at night, or
    early in the morning. Despite CMS's introduction of "off hour" surveys, we
    reported in 2003 that about one-third of state surveys remained
    predictable (36 percent in Arkansas). Contrary to CMS's comments, the
    draft report did acknowledge that Arkansas appeared to be

    56See GAO/HEHS-98-202, GAO/HEHS-00-197, and GAO-03-561.

    making progress in reducing survey predictability through the use of
    computer programs to vary the timing of homes' surveys.

        Impact of the Arkansas Law

    In oral comments, the Pulaski County coroner indicated that our report was
    fair and accurate. He also told us that he believes the law has had a
    significant, positive impact on the quality of care provided to nursing
    home residents in Pulaski County. In particular, he rarely finds decedents
    with serious pressure sores and the pressure sores he does find are not as
    serious as those in earlier referrals. He also cited the declining number
    of referrals-only six 2003 resident deaths were referred compared to 18 in
    2002. He also provided 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 who
    made key contributions to this report include Jack Brennan, Lisanne
    Bradley, Patricia A. Jones, and Elizabeth T. Morrison.

    Kathryn G. Allen
    Director, Health Care-Medicaid

    and Private Health Insurance Issues

    Appendix I: Coroner Referrals for Pressure Sores and the Seriousness of
    Deficiencies Cited on Standard Surveys

    Number of coroner Number of deficiencies cited for pressure referrals for
    sores on homes' standard surveysa

    Nursing home pressure sores Actual harm or higher Below actual harm

    A 11

    B 51

    C 5

    D 41

    E 3

    F 3

    G 3

    H 3

    I 3

    J 3

    K 4

    L 21

    M 2

    N 1

    O 2

    P 1

    Q 1

    R 0 2
    Sb 1
    T 0
    U 021
    V 0 1
    W 0 1
    X 0
    Yb 0
    Z 1
    AAb 0
    Total 58 5 17

    Source: GAO analysis of coroner referrals and OSCAR data.

    aIncludes last four state surveys for each home as of October 24,
    2003,with the exception of homes Q and Z, which include the last four
    surveys as of July 30, 2004.

    bThe state survey agency is not required to survey these facilities under
    federal law.

    Appendix II: Coroner Referrals That the State Survey Agency Reported as Not
    Received, Substantiated, or Not Substantiated

                          Nursing Number of Number not Number

    Number not substantiated

                         home referrals received substantiated

    A 125 7

    B 731

    K 75

    C 642

    F 53

    H 55

    D 42 1a

    G 41

    M 42

    E 31 2a

    I 31 2a

    J 32

    L 312

    R 33

    O 22

    P 22

    S 22

    T 211
    N 101
    Q 101
    U 11
    V 11
    W 11
    X 101
    Y 11
    Z 11
    AA 1 1

    Total 86 50 22 14

    Source: Arkansas state survey agency.

    Note: Data on referrals made from July 1999 through December 2003 are
    based on information provided by the Pulaski County coroner.

    aOne referral was substantiated without any deficiencies.

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    A portion of CMS's response was based on tables presented in attachment 1
    to its comments. Because the tables did not accurately reflect the coroner
    cases discussed in our report, CMS submitted an amended attachment 1,
    which we have substituted for the original attachment 1. CMS, however, did
    not make corresponding changes on pages 6 and 7 of its letter. We have
    marked the text on those pages in the letter where the information in the
    amended attachment 1 supercedes data presented in the letter.

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    See attachment 1, p. 61, for CMS revisions to the bracketed material.

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    See attachment 1, pp. 6061, for CMS revisions to the bracketed material.

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix III: Comments from the Centers for Medicare & Medicaid Services

    Appendix IV: Comments from the Arkansas Department of Human Services

    Appendix IV: Comments from the Arkansas Department of Human Services

    Appendix IV: Comments from the Arkansas Department of Human Services

    Appendix IV: Comments from the Arkansas Department of Human Services

    Appendix IV: Comments from the Arkansas Department of Human Services

    Appendix IV: Comments from the Arkansas Department of Human Services

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    Nursing Homes: Complaint Investigation Processes in Maryland.
    GAO/T-HEHS-99-146. Washington, D.C.: June 15, 1999.

    Nursing Homes: Complaint Investigation Processes Often Inadequate to
    Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.

    Nursing Homes: Stronger Complaint and Enforcement Practices Needed to
    Better Ensure Adequate Care. GAO/T-HEHS-99-89. Washington, D.C.: March 22,
    1999.

    Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
    Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March 18,
    1999.

    California Nursing Homes: Federal and State Oversight Inadequate to
    Protect Residents in Homes With Serious Care Problems. GAO/T-HEHS98-219.
    Washington, D.C.: July 28, 1998.

    California Nursing Homes: Care Problems Persist Despite Federal and State
    Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998.

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