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
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Please contact me at (202) 512-7118 or Walter Ochinko, Assistant Director,
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made key contributions to this report include Jack Brennan, Lisanne
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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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