    Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not
    Deterred Some Homes from Repeatedly Harming Residents (26-MAR-07,
    GAO-07-241).

    In 1998 and 1999 reports, GAO concluded that enforcement actions,
    known as sanctions, were ineffective in encouraging nursing homes
    to maintain compliance with federal quality requirements:
    sanctions were often rescinded before being implemented because
    homes had a grace period to correct deficiencies. In response,
    the Centers for Medicare & Medicaid Services (CMS) began
    requiring immediate sanctions for homes that repeatedly harmed
    residents. Using CMS enforcement and deficiency data, GAO (1)
    analyzed federal sanctions from fiscal years 2000 through 2005
    against 63 homes previously reviewed and (2) assessed CMS's
    overall management of enforcement. The 63 homes had a history of
    harming residents and were located in 4 states that account for
    about 22 percent of homes nationwide.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-07-241
        ACCNO:   A67245
      TITLE:     Nursing Homes: Efforts to Strengthen Federal Enforcement
    Have Not Deterred Some Homes from Repeatedly Harming Residents
         DATE:   03/26/2007
      SUBJECT:   Appeals
    	     Health care programs
    	     Health surveys
    	     Medicaid
    	     Medicare
    	     Noncompliance
    	     Nursing homes
    	     Sanctions
    	     Policy evaluation
    	     Policies and procedures

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    GAO-07-241

         * [1]Results in Brief
         * [2]Background

              * [3]Ensuring Compliance with Federal Quality Requirements
              * [4]Range of Federal Sanctions
              * [5]Imposition of Sanctions
              * [6]State and CMS Roles in Sanctioning Homes
              * [7]CMS Enforcement Initiatives

         * [8]Number of Sanctions Has Decreased

              * [9]Sanctions Have Declined Nationwide
              * [10]Decline in Sanctions and Deficiencies for the Homes Reviewed
              * [11]Implementation Rate of Some Sanctions Has Declined for the H
              * [12]CMS Did Not Take Advantage of the Full Range of Sanctions fo

         * [13]Despite Changes in Federal Enforcement Policy, Many Homes Co

              * [14]Many Homes Cycled In and Out of Compliance, Continuing to Ha
              * [15]Relatively Few Homes Reviewed Were Cited for Double Gs
              * [16]Immediate Sanctions Often Not Immediate and Do Not Appear to
              * [17]Termination Used Infrequently

         * [18]Complex Immediate Sanctions Policy and Data Limitations Hamp

              * [19]Immediate Sanctions Policy Is Complex and Fails to Hold Some
              * [20]CMS Oversight Continues to Be Hampered by Data Limitations
              * [21]Other CMS Initiatives to Improve Enforcement

         * [22]Conclusions
         * [23]Recommendations for Executive Action
         * [24]Agency and State Comments and Our Evaluation
         * [25]Appendix I: Scope and Methodology
         * [26]Appendix II: Percentage of Nursing Homes Cited for Actual Ha
         * [27]Appendix III: Federal Sanctions for Nursing Homes Reviewed,
         * [28]Appendix IV: Examples of Homes Reviewed That Frequently Cycl
         * [29]Appendix V: Number of Days between Survey and Implementation
         * [30]Appendix VI: Comments from the Centers for Medicare & Medica
         * [31]Appendix VII: Comments from the California Department of Hea
         * [32]Appendix VIII: Comments from the Michigan Department of Comm
         * [33]Appendix IX: Comments from the Texas Department of Aging and
         * [34]Appendix X: GAO Contact and Staff Acknowledgments

              * [35]GAO Contact
              * [36]Acknowledgments

         * [37]Related GAO Products

              * [38]Order by Mail or Phone

    Report to the Ranking Minority Member, Committee on Finance, U.S. Senate

    United States Government Accountability Office

    GAO

    March 2007

    NURSING HOMES

    Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes
    from Repeatedly Harming Residents

    GAO-07-241

    Contents

    Letter 1

    Results in Brief 4
    Background 7
    Number of Sanctions Has Decreased 17
    Despite Changes in Federal Enforcement Policy, Many Homes Continued to
    Cycle In and Out of Compliance 26
    Complex Immediate Sanctions Policy and Data Limitations Hamper CMS
    Management of Enforcement 40
    Conclusions 51
    Recommendations for Executive Action 54
    Agency and State Comments and Our Evaluation 55
    Appendix I Scope and Methodology 59
    Appendix II Percentage of Nursing Homes Cited for Actual Harm or Immediate
    Jeopardy, by State, Fiscal Years 2000-2005 64
    Appendix III Federal Sanctions for Nursing Homes Reviewed, by State,
    Fiscal Years 2000-2005 66
    Appendix IV Examples of Homes Reviewed That Frequently Cycled In and Out
    of Compliance 68
    Appendix V Number of Days between Survey and Implementation Date of DPNA
    for Homes Reviewed, Fiscal Years 2000-2005 70
    Appendix VI Comments from the Centers for Medicare & Medicaid Services 71
    Appendix VII Comments from the California Department of Health Services 79
    Appendix VIII Comments from the Michigan Department of Community Health 84
    Appendix IX Comments from the Texas Department of Aging and Disability
    Services 89
    Appendix X GAO Contact and Staff Acknowledgments 91
    Related GAO Products 92

    Tables

    Table 1: Number of Nursing Homes Reviewed in 1999 That Were Included in
    Our Analysis for This Report 3
    Table 2: Scope and Severity of Deficiencies Identified during Nursing Home
    Surveys 8
    Table 3: Sanctions Available to Encourage Nursing Home Compliance with
    Requirements 10
    Table 4: Sanctions Implemented for Homes Reviewed, Fiscal Years 2000-2002
    and 2003-2005 21
    Table 5: Examples of Homes with Low Implemented CMPs 24
    Table 6: Example of a Michigan Nursing Home That Frequently Cycled In and
    Out of Compliance and Was Still Open as of November 2006 29
    Table 7: Examples of Homes' Deficiency Histories and Termination Actions,
    Fiscal Years 2000-2005 38
    Table 8: Number of Nursing Homes Reviewed in 1999 That Were Included in
    Our Analysis for This Report, by State 60
    Table 9: Percentage of Nursing Homes Cited for Actual Harm or Immediate
    Jeopardy during Standard Surveys, Fiscal Years 2000-2005 64
    Table 10: Number of Sanctions Implemented Among Homes We Reviewed, Fiscal
    Years 2000-2005 66
    Table 11: Examples of Homes that Frequently Cycled In and Out of
    Compliance 68

    Figures

    Figure 1: Federal-State Responsibilities in the Enforcement Process 15
    Figure 2: Percentage of Implemented Sanctions for Homes Reviewed Over
    Three Time Periods (July 1995-October 1998, Fiscal Years 2000-2002, and
    Fiscal Years 2003-2005) 23
    Figure 3: Frequency that Reviewed Homes Cycled In and Out of Compliance,
    Fiscal Years 2000-2005 28
    Figure 4: Number of Days between Survey and Implementation of CMPs and
    DPNAs among Homes Reviewed, Fiscal Years 2000-2005 33
    Figure 5: Lag Time between Survey and CMP Payment for a Michigan Nursing
    Home 35
    Figure 6: Number of Homes with One or More Double Gs, Fiscal Years
    2000-2005 36
    Figure 7: Impact of Intervening Periods of Compliance Rule on Immediate
    Sanctions for One Pennsylvania Nursing Home, 2000 43
    Figure 8: Impact of Clearing Effect Rule on Immediate Sanctions for One
    Michigan Nursing Home, 2000-2002 45

    Abbreviations

    ACTS ASPEN Complaints/Incidents Tracking System
    AEM ASPEN Enforcement Manager
    ASPEN Automated Survey Processing Environment
    CMP civil money penalty
    CMPTS CMP Tracking System
    CMS Centers for Medicare & Medicaid Services
    DPNA denial of payment for new admissions
    LTC Long Term Care Enforcement Tracking System
    OBRA 87 Omnibus Budget Reconciliation Act of 1987
    OSCAR On-Line Survey, Certification, and Reporting system
    PDQ Providing Data Quickly
    QIO Quality Improvement Organization

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    separately.

    United States Government Accountability Office
    Washington, DC 20548

    March 26, 2007

    The Honorable Charles E. Grassley
    Ranking Minority Member
    Committee on Finance
    United States Senate

    Dear Senator Grassley:

    The nation's 1.5 million nursing home residents are a highly vulnerable
    population of elderly and disabled individuals for whom remaining at home
    is no longer feasible. The federal government plays a key role in ensuring
    that nursing home residents receive appropriate care by setting quality
    requirements that nursing homes must meet to participate in the Medicare
    and Medicaid programs and by contracting with states to routinely inspect
    homes and conduct complaint investigations.^1 Moreover, to encourage
    compliance with these requirements, Congress has authorized certain
    enforcement actions, known as sanctions, including civil money penalties
    (CMP) or termination from participating in these programs. With the aging
    of the baby boom generation, the number of individuals needing nursing
    home care and the associated costs are expected to increase dramatically.
    Combined Medicare and Medicaid payments for nursing home services were
    about $67 billion in 2004, including a federal share of about $46
    billion.^2

    In 1998 and 1999 reports, we identified significant weaknesses in federal
    and state activities designed to detect and correct quality problems at
    nursing homes.^3 A key finding was that sanctions imposed on nursing
    homes, including those that repeatedly harmed residents, often did not
    take effect. Instead, the sanctions were rescinded prior to their
    effective dates because homes had a grace period in which they could and
    often did correct deficiencies. We referred to this phenomenon as a
    "yo-yo" pattern of compliance because homes cycled in and out of
    compliance, harming residents while avoiding sanctions. Overall, we
    concluded that the goal of the enforcement process--to help ensure that
    homes maintain compliance with federal quality requirements--was not being
    realized. In response to our recommendations, the Centers for Medicare &
    Medicaid Services (CMS), the federal agency that manages these two public
    health care programs, took several steps, including the introduction of an
    immediate sanctions policy for homes found to repeatedly harm residents
    and the development of a new data system to improve management of the
    enforcement process. Under CMS's immediate sanctions policy, sanctions may
    be imposed without giving homes an opportunity to correct serious
    deficiencies that resulted in actual resident harm or put residents at
    risk of death or serious injury. We also reported that the deterrent
    effect of CMPs can be hampered by a backlog of appeals, which further
    delays payment of CMPs; by statute, CMPs are not paid until appealed cases
    are closed.

    ^1Medicare is the federal health care program for elderly and disabled
    people. Medicare covers up to 100 days of skilled nursing home care
    following a hospital stay. Medicaid is the joint federal-state health care
    financing program for certain categories of low-income individuals.
    Medicaid also pays for long-term care services, including nursing home
    care.

    ^2Data for 2004 are the most recent available.

    ^3GAO, California Nursing Homes: Care Problems Persist Despite Federal and
    State Oversight, [39]GAO/HEHS-98-202 (Washington, D.C.: July 27, 1998) and
    Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
    Federal Quality Standards, [40]GAO/HEHS-99-46 (Washington, D.C.: Mar. 18,
    1999). See a list of related GAO products at the end of this report.

    You asked us to assess CMS's progress in improving the enforcement
    process, particularly for homes with a history of harming residents. In
    response to your request, we (1) analyzed federal sanctions from fiscal
    years 2000 through 2005 against 63 homes with a history of harming
    residents as well as nationwide trends in nursing home sanctions for the
    same time period, (2) evaluated the extent to which the homes cycled in
    and out of compliance and the impact of CMS's immediate sanctions policy,
    and (3) assessed CMS's management of enforcement activities. The nursing
    homes were located in California, Michigan, Pennsylvania, and Texas and
    their prior compliance and enforcement histories formed the basis for the
    conclusions in our March 1999 report.^4 These homes were selected for that
    report because of their serious or sustained compliance problems prior to
    1999 and are not representative of homes in those states or homes
    nationwide.^5 The 63 homes we reviewed for this report participated in
    Medicare and Medicaid for at least 6 months during fiscal years 2000
    through 2005. Table 1 shows the number of homes that participated by
    fiscal year. Changes in the number of homes from year to year are a result
    of homes' closure, termination, or reinstatement of participation. For
    example, the change from 61 homes in fiscal year 2000 to 59 homes in
    fiscal year 2001 represents the voluntary closure of 2 homes, the
    involuntary termination of 1, and the reinstatement of 1, for a net
    decrease of 2 homes.^6

    4See [41]GAO/HEHS-99-46 . The 1999 report focused on 74 homes. We excluded
    11 of the original 74 homes from our current analysis because they either
    closed before fiscal year 2000 or closed within 6 months of the beginning
    of fiscal year 2000 and therefore had few or no deficiencies or sanctions
    during the period we reviewed. Of the remaining 63 homes, 10 were located
    in California, 16 in Michigan, 14 in Pennsylvania, and 23 in Texas (see
    app. I).

    ^5Overall, the nursing homes in these four states account for about 22
    percent of nursing homes nationwide.

    Table 1: Number of Nursing Homes Reviewed in 1999 That Were Included in
    Our Analysis for This Report

                                        Current report
                                          Fiscal year
                                                                  Total number of
                                                                   homes with any
    1999                    Average                  Average  participation in
    report 2000 2001 2002 2000-2002 2003 2004 2005 2003-2005         2000-2005
    74       61   59   58        59   58   54   55        56                63

    Source: GAO.

    Note: Some of the 63 homes only participated in the Medicare and Medicaid
    programs for a portion of fiscal years 2000 through 2005 because they
    either closed permanently or closed temporarily and were subsequently
    reinstated. To be included in our analysis we required such homes to have
    participated for at least 6 months of the fiscal year.

    Our analysis relied primarily on (1) deficiency data from CMS's On-Line
    Survey, Certification, and Reporting system (OSCAR) and the CMS Providing
    Data Quickly (PDQ) Web site; (2) sanctions data from its Long Term Care
    Enforcement Tracking System (LTC) and ASPEN Enforcement Manager (AEM);^7
    and (3) CMP payment information from its CMP Tracking System (CMPTS).^8 We
    also examined CMS regional office and state enforcement case files for the
    nursing homes we reviewed. We analyzed deficiency and sanctions data to
    identify the number and type of sanctions implemented and their
    implementation rates; the extent to which homes cycled in and out of
    compliance; the use of immediate sanctions for homes that repeatedly
    harmed residents, including their deterrent effect; the use of
    termination; and variability in state approaches to enforcement. To
    identify trends, we compared deficiency and sanctions data across two time
    periods: fiscal years 2000 through 2002 and fiscal years 2003 through
    2005.^9 We focused our analysis on three types of sanctions--CMPs, denial
    of payment for new admissions (DPNA), and terminations--which accounted
    for about 81 percent of all sanctions from fiscal years 2000 through 2005.
    Although termination was used infrequently--less than 1 percent of all
    sanctions--we included it in our analysis because it is the most severe
    sanction, resulting in the loss of Medicare and Medicaid revenue.^10 Based
    on our assessment of the data from the case file review, we determined
    that the sanctions data were sufficiently reliable to assess general
    nationwide trends in implemented sanctions. Because we could not conduct
    such checks of the data in all 50 states and the District of Columbia, we
    did not analyze trends across the individual states.^11 We also reviewed
    CMS enforcement policy and guidance and discussed the immediate sanctions
    policy and data reliability issues with CMS and state officials. Finally,
    we obtained perspectives from regional office and state officials on the
    sanctions used for the homes we reviewed. Our findings on sanctions, such
    as implementation rates and use of the available range of sanctions,
    against these homes cannot be generalized to all homes in the 4 states or
    to all nursing homes nationwide. However, we believe that the findings are
    illustrative of the overall adequacy of federal and state responses to
    nursing homes with a history of serious noncompliance with federal quality
    requirements. Appendix I provides a more detailed description of our scope
    and methodology, including steps taken to ensure the reliability of the
    data used in this report. We performed our work from January 2005 through
    January 2007 in accordance with generally accepted government auditing
    standards.

    ^6By state, the number of homes active for at least 6 months in fiscal
    years 2000 and 2005 did not change in California, decreased by one home in
    both Michigan and Texas, and decreased by four homes in Pennsylvania (see
    app. I). The year-to-year changes in the number of providers do not
    materially affect our findings on enforcement trends.

    ^7ASPEN is an abbreviation for Automated Survey Processing Environment.

    ^8See appendix I for a more detailed description of our use of these CMS
    databases.

    Results in Brief

    For the homes we reviewed in four states, the number of sanctions
    implemented as well as the number of serious deficiencies cited declined
    from fiscal years 2000 through 2005--trends that were also seen
    nationwide. While the decline may reflect improved quality or changes to
    enforcement policy, it may also mask survey weaknesses that understate
    quality problems, an issue we have reported on since 1998. In general, the
    homes were cited for more deficiencies that caused harm to residents than
    other homes in their respective states. For example, the homes we reviewed
    in California had three times as many serious deficiencies as other homes
    in the state. We also found differences in the implementation rate of
    various sanctions for the homes we reviewed. Comparing results from the
    baseline period of July 1995 to October 1998 with the period fiscal years
    2003 through 2005, the implementation rate of CMPs increased from 32
    percent to 86 percent but declined for DPNAs by about 20 percent. However,
    the deterrent effect of CMPs was diluted because CMS imposed CMPs at the
    lower end of the allowable range for the homes we reviewed. For example,
    the median per day CMP amount imposed for deficiencies that do not cause
    immediate jeopardy to residents was $500 in fiscal years 2000 through 2002
    and $350 in fiscal years 2003 through 2005; the allowable range is $50 to
    $3,000 per day. Generally, CMS did not exercise its discretionary
    authority to impose DPNAs and terminations for the homes; rather, it
    waited until these sanctions could be imposed on a mandatory basis,
    allowing the homes more opportunities to escape sanctions prior to
    implementation. Moreover, in some instances, CMS extended the
    implementation dates of imposed terminations, thus allowing homes
    additional time to avoid being terminated by correcting deficiencies.

    ^9Our analysis of the implementation rate of sanctions includes a third
    baseline time period of July 1995 to October 1998, which we previously
    reported on in 1999. Our current analysis starts with fiscal year 2000,
    excluding fiscal year 1999, because one of the major enforcement policies
    we evaluated was modified in 2000.

    ^10Throughout this report, we use the term "termination" to refer to a
    home's closure for cause, also known as involuntary closure. Homes can and
    do close voluntarily.

    ^11In this report, we use the term "states" to include the 50 states and
    the District of Columbia.

    Despite changes in federal enforcement policy, almost half of the 63 homes
    we reviewed--homes with prior serious quality problems--continued to cycle
    in and out of compliance during fiscal years 2000 through 2005, causing
    harm to residents. These homes corrected deficiencies only temporarily
    and, despite having had sanctions implemented, were again found to be out
    of compliance, including 8 homes that cycled in and out of compliance 7 or
    more times. During this same time period, 27 of the 63 homes were cited 69
    times for deficiencies that warranted immediate sanctions, but 15 of these
    cases did not result in immediate sanctions. Moreover, the "immediate
    sanctions" label is misleading because CMS's policy requires only that
    homes be notified immediately of CMS's intent to implement sanctions, not
    that sanctions be implemented immediately. When DPNAs are imposed, the lag
    time between the occurrence of a deficiency that results in an immediate
    sanction and the sanction's implementation date provides a de facto grace
    period; if the home is able to correct the deficiency, it can escape
    sanctions. Although the use of CMPs avoids this de facto grace period
    because they can be implemented retroactively, by statute, payment of CMPs
    may be delayed until after exhausting appeals of the underlying
    deficiency, a process that can take years. Nor did CMS's implementation of
    immediate sanctions appear to deter future repeat deficiencies--18 of the
    27 homes with immediate sanctions had multiple instances of such sanctions
    in fiscal years 2000 through 2005. Termination of a home from the Medicare
    and Medicaid programs was infrequent. By the end of fiscal year 2005, only
    2 homes were terminated involuntarily because of quality problems. Another
    9 that closed did so voluntarily. In effect, these homes picked their own
    closure dates and may have continued to harm residents before closing. For
    example, 2 such homes were cited for harming residents 21 and 26 times,
    respectively, and had sanctions implemented numerous times from fiscal
    year 2000 until their voluntary closures in 2004.

    In general, the effectiveness of CMS's management of nursing home
    enforcement is hampered by the overall complexity of its immediate
    sanctions policy, intended to deter repeated noncompliance, and by its
    fragmented data systems and incomplete national reporting capabilities.
    First, the complexity of the immediate sanctions policy allows some homes
    with the worst compliance histories--the very homes the policy was
    designed to address--to escape immediate sanctions. For example, homes
    that do not correct deficiencies can avoid immediate sanctions because of
    the requirement for an intervening period of compliance between the pair
    of surveys that identify serious deficiencies--that is, a new serious
    deficiency will not trigger an immediate sanction unless the prior serious
    deficiency has been corrected. Thus, if a state survey agency cited a home
    for a serious deficiency and 2 weeks later--before the first deficiency
    was corrected--cited the home for another serious deficiency, the home
    might not receive an immediate sanction. In addition, homes--even those
    with a history of multiple serious deficiencies--may escape immediate
    sanctions because a routine inspection without such a serious deficiency,
    in effect, clears the home's record for determining if immediate sanctions
    are applicable. The immediate sanctions associated with CMS's policy also
    are often inequitable; multiple serious deficiencies during one inspection
    may result in the same sanction as an inspection with a single serious
    deficiency. Second, CMS's fragmented and incomplete data systems continue
    to hamper its ability to monitor enforcement. We previously reported that
    CMS lacked a data system that integrated enforcement data nationwide and
    that the lack of such a system made it difficult for CMS to consistently
    manage and monitor sanctions across states and its regional offices.
    Although CMS has developed a new data system, the system's components are
    not integrated, and the national reporting capabilities are not complete.
    Finally, CMS is taking steps to improve its enforcement of nursing home
    quality requirements. In addition to its new data system, the agency
    piloted new guidance in 2006 designed to encourage more consistency across
    states in the amount of CMPs, revised a program that provides enhanced
    enforcement and monitoring of some homes with a history of harming
    residents in each state, and funded studies to examine the effectiveness
    of nursing home enforcement.

    We are recommending that, to increase the deterrent effect of CMPs, the
    Administrator of CMS develop an administrative process to collect CMPs
    prior to exhaustion of appeals, seek legislation for the implementation of
    this process, and address any due process concerns, as appropriate. We are
    also recommending that the CMS Administrator take actions to (1) improve
    the immediate sanctions policy to help ensure that homes that repeatedly
    harm residents or place them in immediate jeopardy do not escape immediate
    sanctions, (2) strengthen the deterrent effect of certain sanctions, (3)
    expand a program of enhanced enforcement for homes with a history of
    noncompliance, and (4) improve the effectiveness of the agency's data
    systems used for enforcement. In commenting on a draft of this report, CMS
    generally concurred with our recommendations but did not always specify
    how it would implement them. In addition, CMS noted that implementation of
    three of our recommendations raised resource issues and that others
    required additional research. The four states in which the nursing homes
    we reviewed were located generally concurred with our findings.

    Background

    Ensuring the quality and safety of nursing home care has been a focus of
    considerable congressional attention since 1998. Titles XVIII and XIX of
    the Social Security Act establish minimum requirements in statute that all
    nursing homes must meet to participate in the Medicare and Medicaid
    programs, respectively. With the Omnibus Budget Reconciliation Act of 1987
    (OBRA 87), Congress focused the requirements on the quality of care
    actually provided by a home.^12 To help ensure that homes maintained
    compliance with the new requirements, OBRA 87 also established the range
    of available sanctions, to include CMPs, DPNAs, and termination.^13

    12Pub. L. No. 100-203, SS4201, 4211, 101 Stat. 1330-160, 1330-182.

    ^13Pub. L. No. 100-203, SS4203, 4213, 101 Stat. 1330-179, 1330-213.

    Ensuring Compliance with Federal Quality Requirements

    CMS contracts with state survey agencies to assess whether homes meet
    federal quality requirements through routine inspections, known as
    standard surveys,^14 and complaint investigations. The requirements are
    intended to ensure that residents receive the care needed to protect their
    health and safety, such as preventing avoidable pressure sores, weight
    loss, and accidents. While a standard survey involves a comprehensive
    assessment of federal quality requirements, a complaint investigation
    generally focuses on a specific allegation regarding resident care or
    safety; complaints can be lodged by a resident, family member, or nursing
    home employee. 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 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).^15 When
    state surveyors identify and cite B-level or higher deficiencies, the home
    is required to prepare a plan of correction and, depending on the severity
    of the deficiency, surveyors conduct revisits to ensure that the home
    actually implemented its plan and corrected the deficiencies.^16

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

                                                       Scope
    Severity                             Isolated Pattern Widespread
    Immediate jeopardy^a                        J           K    L
    Actual harm                                 G           H    I
    Potential for more than minimal harm        D           E    F
    Potential for minimal harm^b                A           B    C

    Source: CMS.

    aActual or potential for death/serious injury.

    bNursing home is considered to be in substantial compliance.

    ^14Every nursing home receiving Medicare or Medicaid payment must undergo
    a standard survey not less than once every 15 months, and the statewide
    average interval for these surveys must not exceed 12 months.

    ^15Throughout this report, we use the term serious deficiency to refer to
    care problems at the level of actual harm or immediate jeopardy.

    ^16State survey teams generally consist of registered nurses, social
    workers, dieticians, and other specialists.

    Homes with deficiencies at the A, B, or C levels are considered to be in
    substantial compliance with federal quality requirements, while homes with
    D-level or higher deficiencies are considered noncompliant. A
    noncompliance period begins when a survey finds noncompliance and ends
    when the home either achieves substantial compliance by correcting the
    deficiencies or when the home is terminated from Medicare and Medicaid.
    Since 1998, the deficiencies cited during standard surveys have been
    summarized on CMS's Nursing Home Compare Web site, and CMS subsequently
    added data on the results of complaint investigations.^17 These data are
    intended to help consumers select a nursing home that takes into account
    the quality of care provided to residents.

    Range of Federal Sanctions

    CMS and the states can use a variety of federal sanctions to help
    encourage compliance with quality requirements ranging from less severe
    sanctions, such as indicating the specific actions needed to address a
    deficiency and providing an implementation time frame, to those that can
    affect a home's revenues and provide financial incentives to return to and
    maintain compliance (see table 3).^18 Overall, two sanctions--CMPs and
    DPNAs--accounted for 80 percent of federal sanctions from fiscal years
    2000 through 2005.

    ^17See http://www.medicare.gov/NHCompare .

    ^18In addition to federal sanctions, states may impose their own sanctions
    under their state licensure authority.

    Table 3: Sanctions Available to Encourage Nursing Home Compliance with
    Requirements

    Sanction             Description
    CMP                  The home pays a fine for each day or instance of
                            noncompliance.
    DPNA                 Medicare and/or Medicaid payments can be denied for
                            all newly admitted eligible residents.^a
    Directed in-service  The home is required to provide training to staff on
    training             a specific issue identified as a problem in the
                            survey.
    Directed plan of     The home is required to take action within specified
    correction           time frames according to a plan of correction
                            developed by CMS, the state, or a temporary manager.
    State monitoring     An on-site monitor is placed in the home to help
                            ensure that the home achieves and maintains
                            compliance.
    Temporary management The nursing home accepts a substitute manager
                            appointed by the state with the authority to hire,
                            terminate, and reassign staff; obligate funds; and
                            alter the nursing home's procedures, as appropriate.
    Termination          Termination from the Medicare and Medicaid programs.
                            The home is no longer eligible to receive Medicare
                            and Medicaid payments for beneficiaries residing in
                            the home.

    Source: CMS.

    Notes: Most of the above sanctions are authorized by statute (see 42
    U.S.C. S1395i-3(h) and 42 U.S.C. S1396r(h)), while directed in-service
    training is authorized by regulation (see 42 C.F.R S 488.406(a)).
    Additional or alternative sanctions may also be used (see 42 C.F.R. S
    488.406(c)).

    aCMS may also deny payment for all Medicare- and/or Medicaid-covered
    residents but seldom does so because it may severely limit the homes'
    revenues for patient care.

    The majority of federal sanctions implemented from fiscal years 2000
    through 2005--about 54 percent--were CMPs. CMPs may be either per day or
    per instance. CMS regulations specify a per day CMP range from $50 to
    $10,000 for each day a home is noncompliant--from $50 to $3,000 for
    nonimmediate jeopardy and $3,050 to $10,000 for immediate jeopardy. The
    overall amount of the fine increases the longer a home is out of
    compliance.^19 For example, a home with a per day CMP of $5,000 that is
    out of compliance for 10 days would accrue a total penalty of $50,000. A
    per day CMP can be assessed retroactively, starting from the first day of
    noncompliance, even if that date is prior to the date of the survey that
    identified the deficiency.

    ^19Federal statutes specify that CMPs may not exceed $10,000 for each day
    of noncompliance. 42 U.S.C. S1395i-3(h)(2)(B)(ii) and 42 U.S.C.
    S1396r(h)(3)(C)(ii).

    Per instance CMPs range from $1,000 to $10,000 per episode of
    noncompliance.^20 While multiple per instance CMPs can be imposed for
    deficiencies identified during a survey, the total amount cannot exceed
    $10,000. Per day and per instance CMPs cannot be imposed as a result of
    the same survey, but a per day CMP can be added when a deficiency is
    identified on a subsequent survey if a per instance CMP was the type of
    CMP initially imposed. Unlike other sanctions, CMPs require no notice
    period. However, if a home appeals the deficiency, by statute, payment of
    the CMP--whether received directly from the home or withheld from the
    home's Medicare and Medicaid payments--is deferred until the appeal is
    resolved.^21

    DPNAs made up about 26 percent of federal sanctions from fiscal years 2000
    through 2005. A DPNA denies a home payments for new admissions until
    deficiencies are corrected. In contrast to CMPs, CMS regulations require
    that homes be provided a notice period of at least 15 days for other
    sanctions, including DPNAs; the notice period is shortened to 2 days in
    the case of immediate jeopardy. As a result, homes can avoid DPNAs if they
    are able to correct deficiencies during the notice period, which provides
    a de facto grace period. Unlike CMPs, DPNAs cannot be imposed
    retroactively, and payment denial is not deferred until appeals are
    resolved.

    Although nursing homes can be terminated involuntarily from participation
    in Medicare and Medicaid, which can result in a home's closure,
    termination is used infrequently.^22 Terminations were less than 1 percent
    of total sanctions from fiscal years 2000 through 2005. Four of the seven
    types of sanctions described above were used less frequently than CMPs and
    DPNAs--directed plan of correction, state monitoring, directed in-service
    training, and temporary management--these sanctions accounted for about 19
    percent of sanctions nationwide from 2000 through 2005.

    ^20Unlike for per day CMPs, CMS does not specify a particular per instance
    CMP range for cases of immediate jeopardy.

    ^21If efforts to collect the CMP directly from the home fail, Medicare and
    Medicaid payments are withheld.

    ^22Homes also can choose to close voluntarily, but we do not consider
    voluntary closure to be a sanction. When a home is terminated, it loses
    any income from Medicare and Medicaid, which accounted for about 40
    percent of nursing home payments in 2004. Residents who receive support
    through Medicare or Medicaid must be moved to other facilities. However, a
    terminated home generally can apply for reinstatement if it corrects its
    deficiencies.

    Imposition of Sanctions

    The statute permits and, in some cases, requires that DPNAs or termination
    be imposed for homes found out of compliance with federal quality
    requirements. Mandatory termination and DPNA are required, as follows:

               o Termination--Termination is required by regulations under the
               statute if within 23 days of the end of a survey a home fails to
               correct immediate jeopardy deficiencies,^23 or within 6 months of
               the end of a survey the home fails to correct nonimmediate
               jeopardy deficiencies.

               o DPNA--A DPNA is required by statute if within 3 months of the
               end of a survey a home fails to correct deficiencies and return to
               compliance or when a home's last three standard surveys reveal
               substandard quality of care.^24

               The statute also authorizes CMS to impose discretionary DPNAs and
               discretionary terminations in situations other than those
               specified above.^25 Federal regulations further stipulate that
               such discretionary sanctions may be implemented as long as a
               facility is given the appropriate notice period. By regulation,
               the notice period for implementing both discretionary and
               mandatory DPNAs and terminations is 15 days; in cases of immediate
               jeopardy, however, the notice period is 2 days.

               In imposing sanctions, CMS takes into account four factors: (1)
               the scope and severity of the deficiency, (2) a home's prior
               compliance history, (3) desired corrective action and long-term
               compliance, and (4) the number and severity of all the home's
               deficiencies. In general, the severity of the sanction increases
               with the severity of the deficiency. For example, for immediate
               jeopardy deficiencies (J, K, and L on CMS's scope and severity
               grid) the regulations require that either or both temporary
               management or termination be imposed, and also permits use of CMPs
               of from $3,050 to $10,000 per day or $1,000 to $10,000 per
               instance of noncompliance. Similarly, for deficiencies at the
               actual harm level (G, H, and I on the scope and severity grid) the
               regulations require one or a combination of the following
               sanctions: temporary management, a DPNA, a per day CMP of $50 to
               $3,000, or a per instance CMP of $1,000 to $10,000 per instance of
               noncompliance. In addition to these required sanctions, other
               sanctions can be included; for example, depending on the severity
               of the deficiency and a home's compliance history, it could have a
               combination of state monitoring, a DPNA, and a CMP. Finally, CMS
               is required to consider the immediacy of sanctions. The statute
               stipulates that sanctions should be designed to minimize the time
               between the identification of violations and the final imposition
               of the sanctions.^26

    		   State and CMS Roles in Sanctioning Homes

               Enforcement of nursing home quality-of-care requirements is a
               shared federal-state responsibility. In general, sanctions are (1)
               initially proposed by the state survey agency based on a cited
               deficiency, (2) reviewed and imposed by CMS regional offices, and
               (3) implemented--that is, put into effect--by the same CMS
               regional office, usually after a required notice period (see fig.
               1).^27 CMS regional offices typically accept state-proposed
               sanctions but can modify them. The regional office notifies the
               home by letter that a sanction is being imposed--that is, its
               intent to implement a sanction--and the date it will be
               implemented. State surveyors may make follow-up visits to the home
               to determine whether the deficiencies have been corrected. The CMS
               regional office implements the sanctions if the deficiencies are
               not corrected. Homes may appeal the cited deficiency and, if the
               appeal is successful, the severity of the sanction could be
               reduced or the sanction could be rescinded. Homes have several
               avenues of appeal, including informal dispute resolution at the
               state survey agency level or a hearing before an administrative
               law judge, as well as before the Department of Health and Human
               Services Departmental Appeals Board. Under CMS policy, homes
               automatically receive a 35 percent reduction in the amount of a
               CMP if they waive their right to appeal before the Departmental
               Appeals Board.^28

               Figure 1: Federal-State Responsibilities in the Enforcement
               Process

               Notes: States may impose lower-level sanctions, such as state
               monitoring, without federal approval. Some state survey agencies
               also have the ability to impose federal sanctions such as DPNAs.
               Nursing homes are notified of their appeal rights when CMS imposes
               a sanction.

    		   CMS Enforcement Initiatives

               In response to our earlier recommendations, CMS undertook a number
               of initiatives intended to strengthen enforcement, many of which
               we reported on in 2005.^29 For example, CMS (1) revised its
               revisits policy by requiring surveyors to return to nursing homes
               to verify that serious deficiencies had actually been corrected;
               (2) hired more staff to reduce the backlog of appeals at the
               Health and Human Services Departmental Appeals Boards, the entity
               that adjudicates nursing home appeals of deficiency citations; (3)
               began annual assessments of state survey activities, known as
               state performance reviews, which cover, among other things, the
               timeliness of sanction referrals from state survey agencies to CMS
               regional offices; and (4) revised its past noncompliance policy
               for citing and reporting serious deficiencies that were missed by
               state surveyors during earlier surveys of a home.

               A key CMS enforcement initiative was the two-stage implementation
               of an immediate sanctions policy. In the first stage, effective
               September 1998, CMS required states to refer for immediate
               sanction homes found to have a pattern of harming or exposing
               residents to actual harm or potential death or serious injury
               (H-level or higher deficiencies on the agency's scope and severity
               grid) on successive surveys.^30 Effective January 2000, CMS
               expanded the policy, requiring referral of homes found to have
               harmed one or a small number of residents (G-level deficiencies)
               on successive routine surveys or intervening complaint
               investigations.^31 After expansion of the immediate sanctions
               policy to include G-level deficiencies, it became known as the
               double G immediate sanctions policy.

               CMS also took steps to improve its ability to manage and oversee
               the enforcement process. Our 1999 report described how CMS regions
               and states were using their own systems to track sanctions rather
               than CMS's OSCAR database. Regional office systems ranged from
               manual, paper-based records to complex computer programs; none of
               the four states included in our 1999 report had tracking systems
               compatible with OSCAR or the regional office systems in use. Until
               it implemented a new enforcement data collection system, CMS used
               LTC, an interim enforcement tracking system developed and first
               used by its Chicago regional office. LTC was operational in all 10
               regions by January 2000. CMS's enforcement data collection
               system--AEM--replaced LTC and was implemented 4 years later, on
               October 4, 2004.

               Recognizing the need to focus more attention on homes that
               historically provided poor care, CMS designed and launched a
               Special Focus Facility program in January 1999, instructing states
               to select 2 homes each for enhanced monitoring. Surveys were to be
               conducted at 6-month intervals rather than annually. In September
               2000, CMS reported that semiannual surveys had been conducted at a
               little more than half of the original 110 facilities. In late
               2004, CMS modified the program by (1) expanding its scope to
               include more homes, (2) revising the selection criteria for homes,
               and (3) strengthening sanctions for homes that did not improve
               within 18 months. In a relevant but unrelated initiative, CMS
               established a voluntary program to help nursing homes improve the
               quality of care provided to residents. In 2002, Medicare Quality
               Improvement Organizations (QIO) began working intensively on
               issues such as preventing pressure sores and pain management with
               10 percent to 15 percent of nursing homes in each state.^32
               Responding to concerns that QIOs were not working with homes that
               needed the most help, CMS established a separate pilot program in
               2004; QIOs worked for 12 months with 1 to 5 nursing homes with
               significant quality problems in 18 states to help them redesign
               their clinical practices. Unlike the Special Focus Facility
               program, the participation of homes in the pilot was voluntary. To
               distinguish it from the Special Focus Facility program, the pilot
               was known as the Collaborative Focus Facility program.

    		   Number of Sanctions Has Decreased

               Among the homes we reviewed in four states, the number of
               implemented sanctions and serious deficiencies declined across two
               time periods--fiscal years 2000 through 2002 and fiscal years 2003
               through 2005. Federal data show similar declines for homes
               nationwide, a trend consistent with the decline in the proportion
               of homes cited for serious deficiencies that generally result in
               sanctions.^33 Despite the decline in the number of serious
               deficiencies, the homes we reviewed generally were cited for more
               deficiencies that caused harm to residents than other homes in the
               four states. While the numbers of implemented CMPs and DPNAs at
               the homes we reviewed declined across the two time periods, the
               amount of CMPs paid increased. Not all imposed sanctions for these
               homes were implemented, however, which may reduce the deterrent
               effect of sanctions; in fact, we found that the implementation
               rate of certain sanctions, such as DPNAs, decreased. The deterrent
               effect of sanctions for the homes was further eroded because CMS
               generally imposed CMPs on the lower end of the allowable dollar
               range and did not exercise its authority to use discretionary
               DPNAs and terminations, allowing the homes more opportunities to
               escape sanctions prior to implementation.

    		   Sanctions Have Declined Nationwide

               Among all nursing homes nationwide, sanctions declined across the
               two time periods--fiscal years 2000 through 2002 and fiscal years
               2003 through 2005.^34 Implemented terminations declined the most
               across the two time periods (about 41 percent) and CMPs declined
               the least (about 12 percent), while the number of DPNAs declined
               by about 31 percent. In the same time periods, the average number
               of serious deficiencies per home declined by about 33 percent
               nationwide, from about 0.8 to about 0.5. These downward trends are
               also consistent with the nationwide decline in the proportion of
               homes with serious deficiencies--from about 28 percent in fiscal
               year 2000 to about 17 percent in fiscal year 2005 (see app. II).
               While the reported decline in serious deficiencies and the
               proportion of homes cited for such deficiencies may be due to
               improved quality, our earlier reports noted similar declines that
               masked (1) understatement of serious quality problems, and (2)
               inconsistency in how states conduct surveys.^35 For example, our
               current analysis found that the proportion of homes cited for
               serious deficiencies ranged from a low of about 4 percent in
               Florida to a high of about 44 percent in Connecticut during fiscal
               year 2005.^36 Across the four states we reviewed, the proportion
               of homes with serious deficiencies in fiscal year 2005 ranged from
               8 percent in California to 23 percent in Michigan. As we
               previously reported, such disparities are more likely to reflect
               inconsistency in how states conduct surveys rather than actual
               differences in the quality of care provided by homes.^37 In
               addition, in commenting on a draft of this report, CMS noted
               concerns about whether the immediate sanctions policy has had a
               negative effect on state citations of serious deficiencies.

    		   Decline in Sanctions and Deficiencies for the Homes Reviewed Is
    		   Consistent with Nationwide Trends

               The number of implemented sanctions at the homes we reviewed as
               well as the number of serious deficiencies cited in these homes
               declined across two time periods--fiscal years 2000 through 2002
               and fiscal years 2003 through 2005--consistent with nationwide
               trends.

               Deficiency trends. The average number of serious deficiencies per
               home we reviewed decreased from about 1.8 in fiscal years 2000
               through 2002 to about 0.7 in fiscal years 2003 through 2005, about
               a 61 percent decline; this decline was consistent with the
               national trend. During both time periods, however, the homes we
               reviewed generally performed more poorly than other homes in their
               states, having, on average, more G-level or higher deficiencies
               and more double Gs. For example, the Texas homes we reviewed had
               on average 1.3 times as many G-level or higher deficiencies as all
               other homes in the state and the California homes we reviewed had
               on average 3 times as many as all other California nursing
               homes.^38

               CMP trends. Due in part to the closure of some poorly performing
               homes and the citation of fewer serious deficiencies, the homes we
               reviewed had fewer CMPs in fiscal years 2003 through 2005 than in
               the prior 3 fiscal years, but the amount paid was higher (see
               table 4). Among the homes, the number of implemented CMPs declined
               by about 42 percent from the first to the second time period.
               Although the number of CMPs among the homes we reviewed decreased,
               the amount of CMPs paid in Michigan more than doubled between the
               two time periods, accounting for much of the increase in the
               amount of CMPs paid across the two time periods (see app. III).
               States' preferences for either state or federal CMPs may in part
               affect their use. In Michigan, state officials are more likely to
               use federal CMPs and implement them in greater amounts than other
               states we reviewed. In contrast, the homes we reviewed in
               Pennsylvania had only one implemented CMP and paid no federal CMPs
               from fiscal years 2003 through 2005; however, during the same
               period, the Pennsylvania state survey agency implemented seven
               state CMPs and collected $12,050.^39 A Pennsylvania state survey
               agency official said that the state prefers to use state sanctions
               because they can be implemented more quickly and are believed to
               be more effective than federal sanctions. The Texas state survey
               agency does not recommend more than one type of money penalty for
               the same deficiency and chooses among one of two state money
               penalties or a federal CMP.^40

    23Instead of termination, a temporary manager may be appointed to remove
    the immediate jeopardy.

    ^24According to CMS, substandard quality of care exists when a home is
    cited for a deficiency at the F, H, I, J, K, or L level in any of three
    areas: quality of care, which can include deficiencies such as inadequate
    treatment or prevention of pressure sores; quality of life, which can
    include deficiencies such as a failure to accommodate the needs and
    preferences of residents; and resident behavior, which can include
    deficiencies such as a failure to protect residents from abuse. This
    definition excludes deficiencies at the G level (actual harm). For
    purposes of this report, we define serious deficiencies as G-level or
    higher deficiencies. The statute allows CMS to deny payment for all
    residents; however, our analysis focuses on the denial of payment for new
    admissions, a more frequently used sanction.

    ^25By implementing either a mandatory or discretionary termination, CMS is
    acting to involuntarily terminate the nursing home.

    ^26See 42 U.S.C. S1395i-3(h)(2)(B) and 42 U.S.C. S 1396r(h)(2)(A).

    ^27While this description applies to the approximately 93 percent of homes
    that receive either Medicare or both Medicare and Medicaid payments,
    states are responsible for enforcing standards in the 7 percent of homes
    that only receive Medicaid payments and may impose certain sanctions, such
    as state monitoring and DPNAs. Notice periods for most sanctions are
    required by CMS regulations.

    ^28See 42 C.F.R. S 488.436.

    ^29See GAO, Nursing Homes: Despite Increased Oversight, Challenges Remain
    in Ensuring High-Quality Care and Resident Safety, [43]GAO-06-117
    (Washington, D.C.: Dec. 28, 2005).

    ^30Although the policy requires the immediate imposition of sanctions, CMS
    has not defined a time standard for "immediate." The policy only requires
    that homes with a pattern of harming residents be denied a grace period to
    correct deficiencies before the sanctions are imposed. Prior to the
    policy, homes were given a grace period in which they could correct
    deficiencies before sanctions were imposed.

    ^31CMS guidance also gives states and regional offices the option to
    rescind a home's "opportunity to correct" based on (1) scope and severity
    of the deficiency, (2) unwillingness and inability of the facility to
    correct the deficiency, and (3) the effectiveness of the facility's
    quality assurance and monitoring system to prevent recurrence of the
    deficiency.

    ^32Under contract with CMS, QIOs (formerly known as Peer Review
    Organizations) working in all 50 states and the District of Columbia help
    to ensure the quality of care delivered to Medicare beneficiaries. Prior
    to 2002, QIOs' work focused on care delivered in acute care settings such
    as hospitals.

    ^33While the reported decline in the proportion of homes with serious
    deficiencies could be due to improved quality, we have also documented the
    underreporting of serious deficiencies. See GAO, Nursing Home Quality:
    Prevalence of Serious Problems, While Declining, Reinforces Importance of
    Enhanced Oversight, [44]GAO-03-561 (Washington, D.C.: July 15, 2003) and
    [45]GAO-06-117 .

    ^34Although sanctions declined during the period we reviewed, they nearly
    doubled from fiscal years 1999 to 2000.

    ^35See [46]GAO/HEHS-98-202 , [47]GAO-03-561 , or [48]GAO-06-117 .

    ^36This analysis excluded 13 states because fewer than 100 homes were
    surveyed, and even a small increase or decrease in the number of homes
    with serious deficiencies in such states may produce a relatively large
    percentage point change.

    ^37CMS acknowledges that there is inconsistency in how states conduct
    surveys and is trying to address this issue by piloting a revised survey
    methodology. In commenting on a draft of this report, California noted
    that until late 2004 its CMS regional office required evidence of
    permanent harm in order for a deficiency to be cited as actual harm. After
    California received new guidance on the definition of actual harm, we
    noted that the number of determinations of harm increased.

    ^38Despite the poor performance histories of some of the 63 homes, only 1
    of these homes was part of CMS's original Special Focus Facilities
    program. In 2005, only 2 of the homes we reviewed were designated Special
    Focus Facilities and in 2006, only 4 were so designated.

    ^39In addition to federal sanctions, states can impose state sanctions on
    noncompliant homes. The revenue from state CMPs accrues to the state but
    must be applied to the protection of the health or property of nursing
    home residents.

    ^40According to Texas officials, this money penalty policy took effect on
    September 1, 2003, as a result of a state statutory change. Prior to the
    statutory change, the state survey agency could recommend both a state
    money penalty as well as a federal CMP.

    Table 4: Sanctions Implemented for Homes Reviewed, Fiscal Years 2000-2002
    and 2003-2005

                      Fiscal years        Fiscal years
                       2000-2002           2003-2005
                                                             Percentage change in
                            Duration/           Duration/ number between two time
    Sanction    Number amount paid  Number amount paid                 periods
    CMP^a,b         93    $534,527      54    $617,552                    -42%
    DPNA^c          52   2,451days      30  1,245 days                    -42%
    Involuntary
    termination      1          NA       1          NA                      0%

    Source: GAO analysis of LTC data, AEM, CMS regional office and state
    enforcement case files, and CMPTS.

    Note: Includes homes that were open for at least part of the 6-year
    period.

    NA = Not applicable.

    aIncludes per day and per instance CMPs.

    bAmount paid for CMPs implemented in these fiscal years.

    cIncludes mandatory and discretionary DPNAs.

    DPNA trends. The number of DPNAs declined by 42 percent from fiscal years
    2000 through 2002 to fiscal years 2003 through 2005 for the homes we
    reviewed. Overall, the duration of the DPNAs decreased by 12 percent from
    the first to the second time period. The duration of DPNAs among the Texas
    homes we reviewed decreased the most--from an average of 46 days in the
    first time period to an average of 26 days in the second time period. The
    duration of DPNAs among the Michigan and Pennsylvania homes also decreased
    (see app. III). In California, however, the DPNAs were in effect longer in
    the second time period--from an average of 39 days in fiscal years 2000
    through 2002 to an average of 63 days in fiscal years 2003 through 2005.
    As a result, homes in California were out of compliance for longer periods
    of time.

    Termination trends. Only two of the homes we reviewed closed
    involuntarily--that is, they were terminated for cause by CMS because of
    health and safety issues. One of the two homes has since been certified to
    participate in Medicare again.^41 An additional nine other homes closed
    voluntarily, although four reopened at some point during fiscal years 2000
    through 2005.^42 However, a home's voluntary closure may not accurately
    reflect the degree to which the home had quality problems, such as a
    history of harming residents, that put the home at risk of involuntary
    termination. The reasons for closure, as recorded by CMS, are general and
    do not always reflect that homes may have histories of harming residents
    and may have been at risk of involuntary termination.

    ^41This home is located in Texas, where the state issues a license to the
    person or entity operating the nursing home rather than the owner of the
    real property. The majority of nursing homes in Texas are operated out of
    leased property. When the home was recertified, the new operator was
    licensed; there was no change in the owner of the real property.

    Implementation Rate of Some Sanctions Has Declined for the Homes Reviewed

    The implementation rate of DPNAs and terminations declined for the homes
    we reviewed, while the implementation rate of CMPs increased across three
    time periods (see fig. 2). Some sanctions are never implemented because
    CMS rescinds them if homes correct deficiencies before the implementation
    date, a situation we noted in our 1999 report.^43 Thus, sanctions may be
    considered more of a threat than a real consequence of noncompliance.

    We compared the implementation rates of CMPs, DPNAs, and terminations
    across three time periods: (1) July 1995 to October 1998, the time period
    covered in our March 1999 report;^44 (2) fiscal years 2000 through 2002;
    and (3) fiscal years 2003 through 2005. From the first time period to the
    third, the implementation rate for DPNAs declined by about 20 percent and
    the implementation rate for terminations declined by about 97 percent. In
    contrast, across the same time periods, the overall implementation rate
    for CMPs increased from 32 percent in the first time period to 86 percent
    in the third time period, an almost threefold increase. The timing of this
    increase coincides with the January 2000 implementation of the immediate
    sanctions policy, suggesting that the increase may in part be related to
    the policy's implementation.

    ^42Although the homes were closed for some part of the period we reviewed,
    fiscal years 2000 through 2005, we determined that there were sufficient
    data to include the homes in our sample.

    ^43 [49]GAO/HEHS-99-46 .

    ^44 [50]GAO/HEHS-99-46 .

    Figure 2: Percentage of Implemented Sanctions for Homes Reviewed Over
    Three Time Periods (July 1995-October 1998, Fiscal Years 2000-2002, and
    Fiscal Years 2003-2005)

    CMS Did Not Take Advantage of the Full Range of Sanctions for the Homes Reviewed

    Among the homes we reviewed, CMS did not use the full range of its
    sanctions authority, generally imposing CMPs on the lower end of the
    allowable range.^45 In addition, CMS imposes DPNAs and involuntary
    terminations when they are mandatory, but generally not when they are
    discretionary. Homes subject to such mandatory sanctions have more
    opportunities to escape sanctions prior to implementation. The median per
    instance CMP implemented was $2,000 in fiscal years 2000 through 2002 and
    $1,750 in fiscal years 2003 through 2005, although the maximum per
    instance CMP can be as high as $10,000. The median per day CMP implemented
    for nonimmediate jeopardy deficiencies was $500 in fiscal years 2000
    through 2002 and $350 in fiscal years 2003 through 2005, significantly
    below the maximum of $3,000 per day. In cases in which homes were cited
    for immediate jeopardy and the maximum potential per day CMP is $10,000,
    the median per day CMP implemented was $3,050 in fiscal years 2000 through
    2002 and $5,050 in fiscal years 2003 through 2005. According to one CMS
    official, the agency generally hesitates to impose CMPs that are higher
    than $200 per day, in part because of concerns that higher per day CMPs
    could bankrupt some homes.^46 But the same official noted that the CMPs
    being imposed are not enough to "make nursing homes take notice" or to
    deter them from deficient practices. Another CMS official stated that some
    homes consider CMPs a part of the "cost of doing business" or as having no
    more effect than a "slap on the wrist." Table 5 provides examples of homes
    we reviewed with implemented CMPs that were at the low end of the
    allowable CMP range.

    ^45As previously described, the allowable range for a per day CMP is $50
    to $10,000 for each day a home is noncompliant, and the allowable range
    for a per instance CMP is $1,000 to $10,000 for each episode of
    noncompliance.

    Table 5: Examples of Homes with Low Implemented CMPs

    Home's                            Summary of   CMP           Allowable CMP
    location Surveyors' comments      deficiencies implemented   range
    Michigan "A significant           1 G          $1,500 per    $1,000 -
                medication error                      instance      $10,000 per
                occurred when resident                              instance of
                #8 was administered [the                            noncompliance
                wrong medication] over a
                three day period. The
                resident experienced
                hypoglycemia and
                required
                hospitalization. Upon
                return from the hospital
                there was evidence of
                actual harm: a decline
                in ability to perform
                activities of daily
                living."
    Texas    "Facility nurse aides    3 F, 1 E     $250 per day  $50 - $3,000
                failed to promptly                    for 150 days  per day for
                report an allegation of                             noncompliance
                possible sexual abuse.                              other than
                Resident reported the                               immediate
                incident to two nurse                               jeopardy
                aides, however, it was
                not reported. Also,
                reference checks were
                not documented for 4
                employees and 4
                employees had not
                attended an inservice
                [training session] on
                abuse."
    Texas    "There was an [immediate 1 L          Immediate     $3,050 -
                jeopardy deficiency for  (immediate   jeopardy:     $10,000 per
                staff mistreatment of    jeopardy), 9 $3,050 per    day for
                residents]. There was a  G            day for 14    immediate
                failure to monitor                    days          jeopardy
                residents in distress."
                                                      After         $50 - $3,000
                                                      immediate     per day for
                                                      jeopardy      nonimmediate
                                                      removed: $400 jeopardy
                                                      per day for
                                                      86 days; $300
                                                      per day for
                                                      46 days; $50
                                                      per day for 6
                                                      days

    ^46An official in one state told us that a home's financial status should
    not be considered when assessing CMPs because it could result in
    inconsistent CMPs for similar quality problems.

    Source: GAO analysis of CMS regional office and state case files and LTC.

    Note: In addition to CMPs, CMS also imposed DPNAs and terminations--either
    mandatory or discretionary. All of the DPNAs but none of the terminations
    were implemented.

    CMS is likely to impose DPNAs and terminations only when required to do
    so. However, CMS also has broad authority to impose DPNAs and terminations
    at its discretion, which can facilitate quicker implementation.
    Discretionary DPNAs and terminations can be implemented any time after a
    survey if the sanction is appropriate for the cited deficiencies and the
    required notice period is met. In contrast, the soonest that mandatory
    DPNAs and terminations for nonimmediate jeopardy can be implemented is 3
    and 6 months, respectively, after the survey on which the deficiencies
    were cited.^47 Despite the greater expediency of discretionary DPNAs, 64
    percent of the DPNAs CMS imposed were mandatory for fiscal years 2000
    through 2005 for the homes we reviewed. For example, CMS imposed a total
    of six DPNAs during fiscal years 2000 through 2003 on a Pennsylvania home
    with demonstrated compliance problems. Of those six DPNAs, the first five
    were mandatory DPNAs. Only the last DPNA--imposed after multiple years of
    repeated noncompliance at the G-level or higher--was a discretionary DPNA.

    Moreover, CMS imposed significantly more mandatory terminations than
    discretionary terminations; in fiscal years 2000 through 2005, 118
    mandatory and 5 discretionary terminations were imposed on the homes we
    reviewed.^48 None of the mandatory terminations were implemented, but 2
    discretionary terminations were implemented--one each in Michigan and
    Texas.^49 An official from the Texas state survey agency said that the CMS
    regional office in Dallas prefers to impose mandatory terminations, unless
    there is cause to believe there will be no improvements in the care
    provided by the nursing home. Mandatory terminations give homes 6 months
    to correct deficiencies before being implemented, as opposed to
    discretionary terminations, which can be implemented more quickly.

    ^47By regulation, where no immediate jeopardy is found, CMS must provide
    homes with 15 days' notice before implementing any DPNA or termination. In
    cases of immediate jeopardy, however, the notice period is 2 days.

    ^48This analysis excludes Texas nursing homes because the data did not
    always allow us to distinguish between mandatory and discretionary
    terminations in Texas.

    Even when CMS imposes terminations, their deterrent effect is weakened
    because the agency sometimes extends the termination dates. For example,
    CMS extended the discretionary termination dates for up to 6 months for
    some of the Texas homes we reviewed if the nursing homes had lower-level
    deficiencies on subsequent surveys. The termination date imposed on one
    Texas nursing home we reviewed was extended three times in fiscal year
    2001 from the original date of April 18 to June 26, then to July 26, and
    finally to September 26. The first extension occurred because the home
    corrected the deficiencies that caused immediate jeopardy cited during the
    first survey. Therefore, despite the fact that this home continued to be
    found out of compliance for deficiencies such as mistreatment or neglect
    of residents during subsequent surveys, CMS extended the termination date
    twice to give the home an additional opportunity to correct those
    deficiencies and achieve substantial compliance. The termination
    ultimately was rescinded because the home corrected the deficiencies, but
    the home was subsequently cited for eight G-level deficiencies such as
    inadequate treatment or prevention of pressure sores, employing convicted
    abusers, and poor accident supervision or prevention. In 2004, the home
    closed voluntarily.

    Despite Changes in Federal Enforcement Policy, Many Homes Continued to Cycle In
    and Out of Compliance

    Despite changes in federal enforcement policy, almost half of the homes we
    reviewed--homes with prior serious quality problems--continued to cycle in
    and out of compliance, continuing to harm residents. These homes corrected
    deficiencies only temporarily and, despite having sanctions implemented,
    were again found to be out of compliance during subsequent surveys. Our
    analysis also showed that in some cases the double Gs did not result in
    immediate sanctions as required, even though about 40 percent of the homes
    were cited for double Gs during fiscal years 2000 through 2005. In
    addition, the term "immediate sanctions policy" is misleading because the
    policy requires only that sanctions be imposed, that is, that homes be
    notified immediately of CMS's intent to implement sanctions, not that
    sanctions must be implemented immediately. Furthermore, when a sanction is
    implemented for a double G citation, there is a lag time between when the
    double G occurs and the sanction's effective date. CMS cited double Gs
    multiple times at several of the homes we reviewed, suggesting that
    immediate sanctions did not deter future noncompliance as intended.
    Terminations of homes is infrequent, in part because of concerns such as
    local access to other nursing facilities and the effect on residents if
    they are moved, and in part because CMS allows some problem homes to
    continue operating until the homes eventually close voluntarily.

    ^49Our case file review found that one discretionary termination was
    implemented in Texas.

    Many Homes Cycled In and Out of Compliance, Continuing to Harm Residents

    Consistent with our earlier work, our current analysis showed that
    sanctions appear to have induced homes to correct deficiencies only
    temporarily because surveyors found that many of the homes we reviewed
    with implemented sanctions were again out of compliance on subsequent
    surveys.^50 Commenting on this phenomenon, state survey agency officials
    said that improvements resulting from sanctions might last about 6 months.
    From fiscal years 2000 through 2005, 31 of the 63 homes we reviewed (about
    49 percent) cycled in and out of compliance more than once, harming
    residents, even after sanctions had been implemented, including 8 homes
    that did so seven times or more (see fig. 3).

    ^50 [51]GAO/HEHS-99-46 .

    Figure 3: Frequency that Reviewed Homes Cycled In and Out of Compliance,
    Fiscal Years 2000-2005

    Note: This figure illustrates the concept of a yo-yo pattern of
    compliance. While the time periods that a home is in or out of compliance
    appear to be of uniform duration, the duration can vary.

    Each of the 31 homes that cycled in and out of compliance more than once
    during the period we reviewed had at least one G-level or higher
    deficiency in at least one period of noncompliance; 19 had at least one
    G-level or higher deficiency in every noncompliance period. Table 6 shows
    the number and length of noncompliance periods for a Michigan home we
    reviewed that cycled in and out of compliance nine times from fiscal years
    2000 through 2005; the home remained open as of November 2006. Appendix IV
    provides similar examples for homes in California, Pennsylvania, and
    Texas. Homes' correction of deficiencies often was temporary, despite
    receiving sanctions. Thus, once the homes we reviewed corrected
    deficiencies, they maintained compliance for a median of 133 days and then
    cycled out of compliance again. Some homes cycled out of compliance more
    quickly--homes were again out of compliance in 30 days or less about 8
    percent of the time and within 60 days about 28 percent of the time.

    Table 6: Example of a Michigan Nursing Home That Frequently Cycled In and
    Out of Compliance and Was Still Open as of November 2006

    Noncompliance                           Summary of
    period in fiscal    Examples of the     G-level or
    years 2000-2005     nature of           higher         Enforcement action
    (no. of days)       deficiencies^a      deficiencies   implemented^b
    1^st (41 days)         o Inadequate     1 G               o Per instance
                              treatment or                       CMP ($1,000)
                              prevention of
                              pressure sores
                              o Poor quality
                              of care
    2^nd (185 days)        o Poor nutrition 1 G               o 1^st per day
                              o Poor quality                     CMP
                              of care                            ($10,000/day)
                                                                 o 2^nd per day
                                                                 CMP ($100/day)
                                                                 o Per instance
                                                                 CMP ($1,500)
                                                                 o Mandatory DPNA
                                                                 (109 days)
    3^rd (176 days)        o Inadequate     5 G               o Per instance
                              treatment or                       CMP ($10,000)
                              prevention of                      o Mandatory DPNA
                              pressure sores                     (85 days)
                              o Poor accident
                              supervision or
                              prevention
    4^th (158 days)        o Resident abuse 1 J (immediate    o 1^st per day
                              o Employing      jeopardy), 3 G    CMP ($850/day)
                              convicted                          o 2^nd per day
                              abusers                            CMP ($3,500/day)
                                                                 o 3^rd per day
                                                                 CMP ($1,000/day)
                                                                 o Discretionary
                                                                 DPNA (127 days)
    5^th (107 days)        o Resident abuse 3 H, 3 G          o Per day CMP
                              o Failure to                       ($200/day)
                              provide                            o Discretionary
                              necessary                          DPNA (74 days)
                              services for
                              daily living
    6^th (94 days)         o Poor accident  1 G               o Per day CMP
                              supervision or                     ($350/day)
                              prevention                         o Discretionary
                                                                 DPNA (62 days)
    7^th (127 days)        o Failure to     1 J (immediate    o 1^st per day
                              provide          jeopardy), 1 G    CMP ($3,550/day)
                              necessary                          o 2^nd per day
                              services for                       CMP ($450/day)
                              daily living                       o Mandatory DPNA
                              o Poor accident                    (35 days)
                              supervision or
                              prevention
    8^th (89 days)         o Inadequate     2 G               o Per day CMP
                              treatment or                       ($500/day)
                              prevention of                      o Discretionary
                              pressure sores                     DPNA (59 days)
                              o Employing
                              convicted
                              abusers
                              o Medication
                              errors
    9^th (83 days)         o Inadequate     1 H               o Per day CMP
                              treatment or                       ($750/day)
                              prevention of                      o Discretionary
                              pressure sores                     DPNA (51 days)
                              o Medication
                              errors

    Source: GAO analysis of OSCAR, ETS, and AEM data.

    Note: The table only includes federal sanctions imposed and implemented;
    sanctions imposed but not implemented and state sanctions are not
    included.

    aExamples of the nature of deficiencies include D-level or higher
    deficiencies.

    bIn a number of cases, more than one per day CMP is listed because CMS can
    raise or lower per day CMP amounts based on changes in deficiencies.

    Relatively Few Homes Reviewed Were Cited for Double Gs

    Despite the large number of G-level or higher deficiencies cited for the
    homes we reviewed, relatively few of these homes were cited for double Gs,
    and some double G citations did not result in sanctions. Over the 6-year
    period, 27 of the homes we reviewed had 69 double Gs. However, 47 of the
    homes had 444 G-level or higher deficiencies. We found no record that CMS
    imposed a sanction for 15 of the 69 double Gs, but the data did show that
    CMS implemented sanctions for the remaining double G cases.^51

    Across the four states we reviewed, there was variation in the citation of
    G-level or higher deficiencies and the implementation of immediate
    sanctions. For example, from fiscal years 2000 through 2005, 35 percent of
    G-level or higher deficiencies and 52 percent of double Gs among the homes
    we reviewed were cited in Michigan, while 9 percent of the G-level or
    higher deficiencies and 4 percent of the double Gs were cited in homes in
    California. In California, complaints typically are investigated under
    state licensure authority and the findings generally are not recorded in
    the same manner as deficiencies cited under the federal process,^52 which
    may contribute to lower double G citation rates in the state.^53 Thus,
    California homes are not cited for a double G when the subsequent
    deficiency equivalent to a G-level or higher deficiency was found during a
    complaint investigation.^54 Complaint surveys with G-level or higher
    deficiencies often lead to double Gs. One CMS official stated that if
    complaints against California nursing homes were investigated under the
    federal complaint investigation procedure, more double Gs would be cited
    in California.^55 The California Department of Health Services conducted a
    pilot to test the use of the federal complaint procedure in select
    district offices, in part because of the low double G citation rate. As of
    November 2006, the department decided not to expand or complete a formal
    evaluation of the pilot; instead, the department is focusing on
    eliminating its backlog of complaints and initiating complaint
    investigations within required time frames.^56

    51In July 2003, we reported that from January 2000 through March 2002,
    states did not refer a substantial number of nursing homes with a pattern
    of harming residents to CMS for immediate sanctions. See [52]GAO-03-561 .
    Eight of the 15 cases occurred after March 2002. From fiscal years 2000
    through 2005, 40 CMPs and 25 DPNAs were implemented during periods of
    noncompliance in which there was a double G.

    ^52California records findings from complaints investigated under state
    licensure in a separate and dedicated state-licensure component of the
    federal system for tracking complaints. The state complaints are recorded
    using the state system for classifying violations. According to the state,
    complaints investigated under state licensure are recorded separately
    because state law prohibits the issuance of both a state citation, which
    carries with it a mandatory state civil monetary penalty, and the
    recommendation that a federal CMP be imposed.

    ^53If, during a complaint investigation, state surveyors identify
    deficiencies that would be equivalent to immediate jeopardy or substandard
    quality of care, the surveyors automatically complete the investigation
    under the federal enforcement process.

    Immediate Sanctions Often Not Immediate and Do Not Appear to Deter Noncompliance

    Although referred to as the "immediate sanctions" policy, the term is
    misleading because (1) there is a lag between when the double G is cited
    and when the sanction is implemented, negating the sanction's immediacy;
    (2) the policy only requires that sanctions be imposed immediately, which
    does not guarantee that the sanction will be implemented; and (3) homes
    may not actually pay a CMP, the most frequently implemented sanction,
    until years after citation of the double G because payment is suspended
    until after appeals have been adjudicated. Delays in implementing DPNAs
    and in collecting CMPs--which diminish their immediacy--coupled with their
    nominal amounts may undermine their deterrent effect.

    ^54The violations and resulting sanctions are categorized according to the
    state's classification framework. For example, a class AA violation is one
    that, among other things, is a "direct proximate cause of death of a
    patient or resident," and the resulting sanction is a fine from $25,000 to
    $100,000. The state system for classifying violations and sanctions does
    not directly correlate to the federal scope and severity grid, and there
    is no direct equivalent to a G-level deficiency. According to a California
    state survey agency official, a class A violation is approximately
    equivalent to a G-level deficiency, but there may be instances in which
    other classes of violations are also equivalent to a G-level deficiency.

    ^55Although California homes with histories of harming residents may not
    be cited for double Gs and thus referred for immediate sanctions under
    federal requirements, the state has it own policy for encouraging such
    homes to improve quality of care--the state can triple CMPs for violations
    that are repeated in a 12-month period. An assessment of the effectiveness
    of California's approach under state licensure for sanctioning homes with
    repeat violations was beyond the scope of this report.

    ^56The select district offices that participated in the pilot will
    continue to cite federal deficiencies and impose federal sanctions; in the
    uncommon situation where there is a violation of a state regulation but
    not a federal regulation, the offices will use a state sanction. According
    to comments from California, if complaint investigations find harm to
    residents, all district offices are directed to complete the
    investigations under state licensure authority or the federal complaint
    procedure, depending on multiple variables.

    Immediate sanctions often are not immediate because there is a lag time
    between the identification of deficiencies during the survey and when a
    sanction (i.e., a CMP or DPNA) is actually implemented.^57 CMS implemented
    about 68 percent of the DPNAs for double Gs among the homes we reviewed
    during fiscal years 2000 through 2005 more than 30 days after the survey
    (see app. V). In contrast, CMPs can go into effect as early as the first
    day the home was out of compliance, even if that date is prior to the
    survey date, because, unlike DPNAs, CMPs do not require a notice
    period.^58 About 98 percent of CMPs imposed for double Gs took effect on
    or before the survey date. Figure 4 illustrates the lag time that can
    occur between the survey date and the implementation date of the sanction,
    especially with regard to DPNAs. For example, in fiscal years 2000 through
    2005, 60 percent of the DPNAs in the homes we reviewed were implemented 31
    to 60 days from the date of the survey citing deficiencies. In contrast,
    nearly all CMPs were implemented on or before the survey date.

    ^57We excluded terminations from this analysis because terminations rarely
    are implemented.

    ^58When the CMP goes into effect, the fine starts accruing as of that
    date.

    Figure 4: Number of Days between Survey and Implementation of CMPs and
    DPNAs among Homes Reviewed, Fiscal Years 2000-2005

    Note: CMPs can take effect prior to the date of the survey, if the date of
    noncompliance can be established. In cases where an appeal has changed the
    determination of the date of noncompliance, the implementation date of
    CMPs would be modified accordingly. Some CMPs and DPNAs were not included
    in this analysis because implementation dates were not available.

    While the immediate sanctions policy requires that sanctions be imposed
    immediately, it is silent on how quickly sanctions should be implemented.
    A sanction is considered imposed when a home is notified of CMS's intent
    to implement a sanction--15 days from the date of the notice. If during
    the 15-day notice period the nursing home corrects the deficiencies, no
    sanction is implemented. Thus, even under the immediate sanctions policy,
    which is intended to eliminate grace periods for nursing homes repeatedly
    cited for deficiencies at the actual harm level or higher, nursing homes
    have a de facto grace period.

    While CMPs can be implemented closer to the date of survey than DPNAs, the
    immediacy and the effect of CMPs may be diminished by (1) the significant
    time that can pass between the citation of deficiencies on a survey and
    the home's payment of the CMP and (2) the low amounts imposed, as
    described earlier in this report.^59 By statute, payment of CMPs is
    delayed until appeals are exhausted.^60 For example, a Michigan home did
    not pay its CMP of $21,600 until more than 2 years after a February 2003
    survey had cited a G-level deficiency.^61 (See fig. 5.) The February
    G-level citation was a repeat deficiency: less than a month earlier, the
    home had received another G-level deficiency in the same quality of care
    area. The delay in collecting the fine in this case is consistent with a
    2005 report from the Office of Inspector General of the Department of
    Health and Human Services that found that the collection of CMPs in
    appealed cases takes an average of 420 days--a 110 percent increase in
    time over nonappealed cases--and "consequently, nursing homes are
    insulated from the repercussions of enforcement by well over a year."^62

    Unlike the Social Security Act, the federal Surface Mining Control and
    Reclamation Act of 1977 provides for the collection of CMPs prior to
    exhaustion of administrative appeals.^63 Under this statute, mining
    operators charged with civil money penalties have 30 days to either pay
    the penalty in full or forward the proposed amount for placement in an
    escrow account pending resolution of appeals. This provision, requiring
    escrow deposit of a proposed penalty assessment, has been upheld by three
    federal circuit courts of appeal, all citing the various procedural
    safeguards as helping to ensure sufficient due process to affected
    operators.^64 For example, these courts cited the availability of an
    informal conference at which mining operators may present information
    relevant to an assessment of a penalty. It is unclear whether the informal
    dispute resolution process available to nursing homes would provide due
    process similar to that provided under the Federal Mining statute.
    Nonetheless, the Social Security Act would preclude a more expeditious
    collection of nursing home CMPs.

    ^59As noted, unlike CMPs, payment denial for DPNAs is required upon
    implementation, not after appeal.

    ^60See 42 U.S.C. SS 1395i-3(h)(2)(B)(ii), 1396r(h)(3)(C)(ii), and
    1320a-7a.

    ^61In contrast, Pennsylvania nursing homes pay state CMPs upon
    implementation, even if an appeal is pending. However, the state agency
    may grant exceptions to this requirement for good cause.

    ^62See Department of Health and Human Services, Office of Inspector
    General, Nursing Home Enforcement: The Use of Civil Money Penalties,
    OEI-06-02-00720 (April 2005).

    ^63See the federal Surface Mining Control and Reclamation Act of 1977,
    Pub. L. No. 95-87, S 518, 91 Stat. 499 (1977) (classified to 30 U.S.C. S
    1268, as amended).

    ^64B & M Coal v. Office of Surface Min. Reclamation, 699 F. 2d 381 (7th
    Cir. 1983); Graham v. Office of Surface Min. Reclamation, 722 F. 2d 1106
    (3rd Cir. 1983); Blackhawk Mining Co., Inc. v. Andrus, 756 F. 2d. 755 (6th
    Cir. 1983).

    Figure 5: Lag Time between Survey and CMP Payment for a Michigan Nursing
    Home

    Despite the potentially negative consequences, CMS's implementation of the
    immediate sanctions policy does not appear to deter homes from harming
    residents in the future. Two-thirds (18) of the 27 nursing homes cited for
    double Gs that subsequently had sanctions implemented went on to be cited
    again for one or more additional double Gs. (See fig. 6.)

    Figure 6: Number of Homes with One or More Double Gs, Fiscal Years
    2000-2005

    Termination Used Infrequently

    Nursing homes, even those that repeatedly harm residents, are infrequently
    terminated because of CMS's concerns about access to other sources of
    nursing care and the impact of moving residents. Of the homes we reviewed,
    two were terminated involuntarily for cause. Another nine homes closed
    voluntarily,^65 which is not a sanction because the homes chose to close.
    However, the actual reason for closure is not always clear; a home may
    close to avoid involuntary termination because of quality problems cited
    by state surveyors.^66 Allowing a problem home to close voluntarily rather
    than terminating it may result in continuing harm to residents until the
    home decides to close. For example, two homes we reviewed in Pennsylvania
    and Texas closed voluntarily, but the histories of both homes show that
    they were repeatedly cited for harming residents from fiscal year 2000
    through the time of their closures, over 4 years later in January 2004.
    The Pennsylvania home cycled in and out of compliance 4 times during the
    period we reviewed and had noncompliance periods lasting an average of 170
    days. The Texas home cycled in and out of compliance 10 times during the
    period reviewed and had average noncompliance periods of 46 days. On
    average, both homes had about 6 G-level or higher deficiencies per year in
    areas such as inadequate treatment or prevention of pressure sores and
    resident abuse.^67 The home in Pennsylvania had an average of 31 other
    deficiencies per year and the Texas home had an average of 27.^68

    65CMS classifies the reasons for voluntary closure as "merger/closure;"
    "dissatisfaction with reimbursement;" "risk of involuntary termination;"
    and "other reasons for withdrawal."

    ^66In commenting on a draft of this report, CMS noted that some of the
    homes classified as voluntary terminations closed as a result of
    coordinated CMS and state actions. In its comments, Michigan stated that
    some voluntary terminations were the result of business decisions after
    the homes received survey results that warranted serious sanctions.

    Four homes we reviewed had similar deficiency histories. Two closed
    voluntarily and two remained open as of November 2006 (see table 7).
    Although the homes that remained open met the deadline to correct
    deficiencies before the termination would have been implemented, a home's
    ability to correct deficiencies in a specified period of time may not be
    the strongest criteria upon which to determine whether a home should
    remain open, because correcting deficiencies does not ensure that the home
    will improve residents' quality of care and does not prevent the home from
    again falling out of compliance. For example, the California and Michigan
    homes in table 7 were still operating as of November 2006 but cycled in
    and out of compliance four and seven times, respectively.

    ^67Nationwide, the average number of serious deficiencies per home from
    fiscal years 2000 through 2005 was less than one.

    ^68This analysis includes cited deficiencies at the D, E, or F levels of
    scope and severity. We include these deficiencies because, as we
    previously reported, understatement by state surveyors of serious
    deficiencies that cause actual harm or immediate jeopardy to residents
    remains a concern. See [53]GAO-06-117 .

    Table 7: Examples of Homes' Deficiency Histories and Termination Actions,
    Fiscal Years 2000-2005

      Examples of
      deficiencies
      causing harm to    Deficiency       Enforcement
      residents^a        history          history^b        Current status
      California home^c
         o A resident       o 173 D-level    o DPNA (142   In operation as of
         choked to death    or higher        days)         November 2006.
         when the           deficiencies     o CMP
         suction            o Cycled in      ($193,780)
         machines that      and out of       o Mandatory
         should have        compliance 4     termination
         been maintained    times            imposed (4
         in working                          times)
         order did not                       o
         have the                            Discretionary
         requisite                           termination
         parts. Indeed,                      imposed (0
         during an                           times)
         unannounced
         inspection 2
         days following
         the death of
         this resident,
         it was noted
         that there were
         no functional
         suction
         machines in the
         facility.
      Michigan home
         o The facility     o 95 D-level     o DPNA (58    In operation as of
         failed to          or higher        days)         November 2006.
         provide proper     deficiencies     o CMP
         respiratory        o Cycled in      ($40,970)
         treatment and      and out of       o Mandatory
         care for a         compliance 7     termination
         resident,          times            imposed (7
         resulting in                        times)
         the resident's                      o
         hospitalization                     Discretionary
         for acute                           termination
         respiratory                         imposed (0
         failure.                            times)
         o During an
         inspection,
         several
         residents'
         pressure sores
         were observed
         to be
         untreated. For
         example, one
         resident had
         two areas of
         dead tissue on
         his feet. The
         facility
         acknowledged
         that the
         resident should
         have been
         wearing
         protective heel
         pads when in
         bed, and yet
         his bare feet
         were uncovered,
         both heels
         rested directly
         on the
         mattress, and
         he was not
         wearing heel
         protectors,
         which were
         lying nearby.
      Pennsylvania home
         o "Resident        o 159 D-level    o DPNA (229   Closed January 2004.
         eloped and was     or higher        days)
         found on the       deficiencies,    o CMPs        Reason for closure:
         courtyard froze    fiscal years     ($47,700)     voluntary-merger/closure.
         (sic) to           2000-2004        o Mandatory
         death."            o Cycled in      termination
         o "A resident      and out of       imposed (6
         was found to       compliance 4     times)
         have bruises on    times            o
         the inner                           Discretionary
         thighs and arms                     termination
         and appeared to                     imposed (0
         be a victim of                      times)
         abuse. The
         staff did not
         report this to
         the local
         police and
         bathed resident
         prior to
         assessment for
         sexual abuse."
      Texas home
         o "Conditions      o 141 D-level    o DPNA (228   Closed January 2004.
         remain poor,       or higher        days)
         residents are      deficiencies,    o CMPs        Reason for closure:
         not clean or       fiscal years     ($146,244)    voluntary-merger/closure.
         groomed, drug      2000-2004        o Mandatory
         errors             o Cycled in      or
         continue,          and out of       discretionary
         restorative        compliance 10    termination
         care is poor.      times            imposed (10
         Will give                           times)^d
         facility the
         full 6 months
         to try to come
         into
         compliance,
         continue all
         remedies."

    Source: GAO analysis of LTC, OSCAR, CMPTS, and CMS regional office and
    state enforcement files.

    aStatements are from surveyors' notes and are either paraphrased or direct
    quotes.

    bThe CMP amount reflects the amount payable by the home, but is not
    necessarily the amount the home actually paid.

    cThese data likely understate the quality problems at this home because
    California primarily conducts complaint investigations under its state
    licensure authority and did not record serious deficiencies identified
    during such investigations in OSCAR. In commenting on a draft of this
    report, California noted that this home did receive the highest state
    deficiency citation and was assessed a state CMP of $60,000.

    dBecause the Texas data did not always allow us to distinguish between
    mandatory and discretionary terminations, we report the total number of
    imposed terminations.

    According to CMS and state officials, factors that may prevent or delay
    termination of problem nursing homes include (1) concerns regarding lack
    of access to alternate local nursing facilities, (2) the potential for
    resident trauma as a result of transfer to another home, (3) the
    preference of residents' families for homes located close by, and (4)
    pressure to keep homes open from families and other stakeholders.^69 Our
    analysis of alternatives to the 4 poorly performing homes in table
    7--those that closed voluntarily or are still open--showed that there were
    from 2 to 37 homes within 10 miles of these homes, and from 5 to 120 homes
    within 25 miles.^70

    69In commenting on a draft of this report, Michigan noted that relocation
    is especially challenging in rural areas or for residents with special
    care needs.

    ^70For this analysis we used CMS's Nursing Home Compare Web site
    (www.medicare.gov/NHCompare), which permits users to search for nursing
    homes by proximity to specific zip codes. We did not analyze the number or
    availability of beds in the homes. There may have been some changes in the
    number of nursing homes near the two homes that closed voluntarily in
    January 2004 because of the time difference between when these homes
    closed and the date we conducted our analysis (June 2006).

    Complex Immediate Sanctions Policy and Data Limitations Hamper CMS Management of
    Enforcement

    While the goal of enforcement is to help ensure nursing home compliance
    with federal quality requirements, CMS management of the process is
    hampered by the complexity of its immediate sanctions policy and by its
    fragmented and incomplete data systems. The agency's immediate sanctions
    policy, intended to deter repeat noncompliance, fails to hold some homes
    accountable for repeatedly harming residents. In addition, although CMS
    has developed a new data system, the system's components are not
    integrated and the national reporting capabilities are not complete,
    hampering the agency's ability to track and monitor enforcement. Finally,
    CMS has taken some steps intended to improve enforcement of nursing home
    quality requirements, such as developing guidance to help ensure greater
    consistency across states in CMP amounts, revising its Special Focus
    Facility program, and commissioning two studies to examine the
    effectiveness of nursing home enforcement. It is not clear, however, the
    extent to which--or when--these initiatives will address the enforcement
    weaknesses we found.

    Immediate Sanctions Policy Is Complex and Fails to Hold Some Homes Accountable

    The double G immediate sanctions policy is complex and fails to hold some
    homes accountable. In 2003, we reported that the early implementation of
    the policy was flawed.^71 We found that between January 2000 and March
    2002 over 700 cases that should have been referred for immediate sanctions
    were not because (1) the policy was misunderstood by some states and
    regional offices, (2) states lacked adequate systems for identifying
    deficiencies that triggered an immediate sanction, and (3) actions of two
    of the four states were at variance with CMS policy. CMS developed an
    on-line reporting tool for use by survey agency and regional office staff
    to automate the identification of double Gs.^72 CMS also offered training
    sessions and issued additional guidance to state survey agencies and
    regional offices. While the on-line reporting tool and training were
    useful, they did not address the underlying complexity of the policy. For
    example, CMS staff told us that in developing the tool they had initially
    misinterpreted the double G immediate sanctions policy. As a result, the
    tool produced many false positives: that is, it identified deficiencies as
    triggering an immediate sanction that in fact did not occur. Moreover, a
    December 2005 report by the Office of the Inspector General of the
    Department of Health and Human Services also reported that state survey
    agency staff continued to have difficulty identifying double G cases.^73

    71 [54]GAO-03-561 .

    ^72The on-line reporting tool known as Providing Data Quickly (PDQ) is
    available through a Web site for use only by CMS and state survey agency
    employees.

    Furthermore, our analysis of CMS's application of the policy to the homes
    we reviewed demonstrated that the policy's complex rules allowed homes to
    escape immediate sanctions even if they repeatedly harmed residents; these
    rules include (1) the requirement for an intervening period of compliance,
    (2) the clearing effect of standard surveys, and (3) the lack of
    differentiation between single and multiple instances of harm. Such rules
    may in part explain why the homes we reviewed only had 69 instances of
    immediate sanctions over a 6-year period, despite being cited 444 times
    for deficiencies that harmed residents.

    Intervening period of compliance. G-level or higher deficiencies only
    count toward a double G immediate sanction if the home has an intervening
    period of compliance between the two G-level or higher deficiencies. In
    order to receive an immediate sanction, a home has to achieve substantial
    compliance between the pair of surveys on which the G-level or higher
    deficiencies are cited. As a result of this rule, homes that do not
    correct deficiencies do not receive immediate sanctions, while homes that
    do correct deficiencies do receive immediate sanctions. CMS officials
    stated that the intent of the policy as written was to give nursing homes
    a chance to correct deficiencies and achieve a period of compliance.
    Without this provision, CMS officials believe that homes could get caught
    in endless double G cycles.

    The following example illustrates how the policy allows nursing homes to
    escape immediate sanctions if they do not correct deficiencies and have
    ongoing noncompliance periods.^74

               o In a 9-month time period, a Pennsylvania home had seven surveys,
               each with at least one G-level deficiency (a total of 19 G-level
               deficiencies).^75 However, double G immediate sanctions were
               triggered by only two pairs of surveys because the home had failed
               to correct some deficiencies before the next survey that again
               found actual harm.^76 Figure 7 illustrates how some pairs of
               surveys with G-level deficiencies do not count as a double G
               because of the intervening period of compliance rule. For example,
               both the March and April surveys cited G-level deficiencies.
               However, the pair of surveys did not result in a double G, which
               would have triggered immediate sanctions because the home did not
               correct the G-level deficiency cited on the March survey before
               the next G-level deficiency was cited in April. Following the
               April survey, the home corrected the deficiencies, resulting in a
               period of compliance. In July, another survey found a new G-level
               deficiency. Because of the intervening period of compliance, the
               March and July surveys resulted in a double G, for which immediate
               sanctions would have been warranted.

    ^73Department of Health and Human Services, Office of Inspector General,
    State Referral of Nursing Home Enforcement Cases, OEI-06-03-00400
    (December 2005).

    ^74This example only includes a limited portion of the home's compliance
    history from fiscal years 2000 through 2005.

    ^75Three additional surveys conducted from March 27, 2000, through
    November 29, 2000, were not included in this analysis because none of the
    surveys had deficiencies at the G level or higher.

    ^76While immediate sanctions were not imposed, CMS may have continued an
    existing sanction or imposed a new sanction, which was rescinded because
    the home corrected the deficiency.

    Figure 7: Impact of Intervening Periods of Compliance Rule on Immediate
    Sanctions for One Pennsylvania Nursing Home, 2000

    Clearing effect of standard surveys. Under the double G immediate
    sanctions policy, a standard survey without a G-level or higher deficiency
    "clears the home's record" for the purposes of determining whether a
    double G occurred.^77 As a result of this rule, surveys with G-level or
    higher deficiencies that occurred before the standard survey without a
    G-level or higher deficiency are not considered in determining whether a
    double G should be cited and an immediate sanction should be imposed. CMS
    officials believe that it is appropriate for standard surveys without
    G-level or higher deficiencies to clear the home's record for double G
    purposes because standard surveys are comprehensive and occur regularly.
    Yet, we have previously reported that weaknesses in the survey process
    result in surveyors' missing serious deficiencies on standard surveys.^78
    Moreover, variability among states in the citation of serious deficiencies
    suggests that some states may not be citing deficiencies at the
    appropriate scope and severity (see app. II). For example, according to
    California officials, the guidance the state received from the CMS
    regional office created confusion as to what constituted actual harm, and
    this confusion contributed to the decline in citations of serious
    deficiencies in California. The regional office clarified its guidance in
    late 2004.

    ^77This aspect of the immediate sanctions policy does not affect the
    retention of data on prior G-level or higher deficiencies in CMS's OSCAR
    database.

    The following example illustrates how a standard survey without G-level or
    higher deficiencies affects double G determinations and how having
    uncorrected deficiencies can prevent a home from receiving an immediate
    sanction.^79

               o In approximately a 12-month period, a Michigan home had five
               surveys, four of which had one G-level deficiency. However, the
               G-level deficiencies triggered double G immediate sanctions only
               once instead of three times because in one instance a standard
               survey cited no G-level deficiencies and in the other there was no
               intervening period of compliance.^80 Figure 8 illustrates how some
               pairs of surveys with G-level deficiencies do not count as double
               Gs because of the clearing effect of standard surveys. For
               example, state surveyors found a G-level deficiency during a
               January 2000 complaint survey. However, on the home's standard
               survey a month later (February 2000), no G-level or higher
               deficiencies were found by surveyors. As a result, when surveyors
               found another G-level deficiency on a complaint survey several
               months later (November 2000), the G-level deficiency on the home's
               January survey was not considered, and no immediate sanctions were
               triggered. The pair of surveys in January 2000 and November 2000
               did not trigger immediate sanctions because, in effect, the
               February 2000 standard survey cleared the home's record.

    ^78See [55]GAO/HEHS-98-202 , [56]GAO-03-561 , and [57]GAO-06-117 .

    ^79This example only includes a limited portion of the home's compliance
    history from fiscal years 2000 through 2005.

    ^80While immediate sanctions were not imposed, CMS may have continued an
    existing sanction or imposed a new sanction, which was rescinded because
    the home corrected the deficiency.

    Figure 8: Impact of Clearing Effect Rule on Immediate Sanctions for One
    Michigan Nursing Home, 2000-2002

    Multiple instances of harm. Multiple G-level or higher deficiencies
    identified on a survey that results in an immediate sanction are sometimes
    treated the same, in terms of enforcement, as a single instance of harm or
    immediate jeopardy cited on a survey. We examined the sanctions imposed
    for a single versus multiple instances of harm and found that the
    sanctions can be quite similar, despite the significant differences in the
    number of deficiencies.^81 The following example involves two surveys of a
    Michigan home with a history of repeated noncompliance. On a survey with
    only 1 G-level deficiency, CMS implemented a $350 per day CMP and a
    discretionary DPNA. On a different survey with 33 D-level or higher
    deficiencies and 6 G-level or higher deficiencies, CMS implemented a $200
    per day CMP and a discretionary DPNA. We found similar examples among
    other homes we reviewed.

    We discussed our concerns with CMS about how the double G immediate
    sanctions policy allows some homes to avoid immediate sanctions. CMS
    officials stated that regardless of the policy, state and regional office
    officials retain the discretion to impose immediate sanctions even when
    not required by the policy. However, based on a discussion with CMS
    officials, we believe that, instead of imposing sanctions of appropriate
    severity, state and regional office officials may impose weaker sanctions
    for problem homes that have escaped immediate sanctions because of the
    complexities of the policy. CMS agreed that this could happen.

    CMS Oversight Continues to Be Hampered by Data Limitations

    Fragmented data systems and incomplete national reporting capabilities
    continue to hamper CMS's ability to track and monitor enforcement. In
    March 1999, we reported that CMS lacked a system for effectively
    integrating enforcement data nationwide and that the lack of such a system
    weakened oversight.^82 Since 1999, CMS has made progress in developing an
    enforcement data collection system called the ASPEN Enforcement Manager
    (AEM). However, while AEM collects valuable data from the states and
    regions, it is not fully integrated with other CMS systems used to track
    nursing home survey and enforcement activities. For example, when regional
    and state survey officials want to evaluate complaint and enforcement
    data, they must access one system for complaint data and then access
    another system, AEM, for enforcement data. Because there is no direct
    interface between the two systems, CMS and states must rely on fragmented
    data systems for tracking and monitoring enforcement. Furthermore, CMS
    officials told us that the agency does not have a concrete plan to use the
    enforcement data to improve monitoring and oversight but that some
    national enforcement reports are under development.

    ^81To gain a sense of how frequently multiple instances of harm are
    treated the same as single instances of harm, we examined the enforcement
    history of some of the homes cited with double Gs. Over half of the
    surveys examined with multiple G-level or higher deficiencies received
    sanctions similar to homes with a single G-level or higher deficiency.

    ^82 [58]GAO/HEHS-99-46 .

    From 2000 to 2004, CMS tracked sanctions with LTC, a data system developed
    in the Chicago region that became operational in all 10 CMS regions in
    2000. LTC was a relatively simple system designed to collect sanctions
    data, automatically generate sanction imposition letters, and
    automatically calculate the 35 percent reduction in CMPs for homes that
    waive the right to appeal deficiencies. LTC was not always useful for
    enforcement oversight because it was sometimes incomplete. Data entry into
    the LTC system was optional, and many regional and state surveyors
    continued to rely on their own, state-specific tracking systems. Moreover,
    during the time LTC was in use, states and regions were expected to
    continue updating the enforcement component of OSCAR, which duplicated
    some of the information in LTC. This required separate manual data entry
    into both LTC and OSCAR. We were told by regional office officials that
    sometimes only one of the files would be updated. Furthermore, LTC had no
    internal quality control checks for ensuring all fields were completed or
    that the data were accurate; in its design of LTC, CMS chose flexibility
    in modifying the data to accommodate special circumstances over a more
    rigid field edits system that would have controlled the data more tightly.

    Since October 1, 2004, CMS has used AEM to collect state and regional data
    on sanctions and improve communications between state survey agencies and
    CMS regional offices. Specifically, AEM was designed to provide real-time
    entry and tracking of sanctions, issue monitoring alerts, generate
    enforcement letters, and facilitate analysis of enforcement patterns. CMS
    expects that the data collected in AEM will enable states, CMS regional
    offices, and the CMS central office to more easily track and evaluate
    sanctions against nursing homes as well as respond to emerging issues.
    Developed by CMS's central office primarily for use by states and regions,
    AEM is one module of a broader data collection system called ASPEN. There
    are a number of other modules under the ASPEN umbrella, including the
    ASPEN Complaints/Incidents Tracking System (ACTS) module. The ASPEN
    modules--and other data systems related to enforcement such as the
    financial management system for tracking CMP collections--are fragmented
    and lack automated interfaces with each other. As a result, enforcement
    officials must pull discrete bits of data from the various systems and
    manually combine the data to develop a full enforcement picture. For
    example, if regional office officials want to review a home's complaint
    history, they must access ACTS to print a report on complaints, access AEM
    to print a report on corresponding sanctions, manually compare the two
    reports, and then access the CMP tracking system to determine whether a
    corresponding CMP was paid. Each step adds to staff workload.

    AEM collects potentially useful enforcement data from the states and
    regions, but, as described, CMS has not integrated AEM with the other data
    collection systems (e.g., ACTS); furthermore, the agency has not defined a
    plan for using the AEM data to inform the tracking and monitoring of
    enforcement through national enforcement reports. In a December 2004 CMS
    report, the agency stated that AEM "will permit meaningful comparisons of
    like measures and will serve as a primary tool on which to base policy
    decisions, new initiatives and strategies for improving care to our
    Nation's nursing home population."^83 While CMS is developing a few draft
    national enforcement reports, it has not developed a concrete plan and
    timeline for producing a full set of reports that use the AEM data to help
    in assessing the effectiveness of sanctions and its enforcement policies.
    In addition, while the full complement of enforcement data recorded by the
    states and regional offices in AEM is now being uploaded to CMS's national
    system, CMS does not intend to upload any historical data. Efforts to
    track and monitor enforcement would be greatly enhanced by reports that
    contain the historical data; for example, with historical data the agency
    could generate reports that provide a longitudinal perspective of a home's
    compliance history, compare trends across states and regions, and,
    overall, help evaluate the effectiveness of sanctions and policies.
    Finally, like LTC, AEM has quality control weaknesses. While AEM has some
    automatic quality control mechanisms to ensure that the data entered are
    complete and in a valid format, there are no systematic quality control
    mechanisms to ensure that the data entered are accurate. For example,
    while the system automatically requires the entry of valid survey dates,
    CMS does not conduct periodic data audits to check that the survey dates
    are correct.

    CMS officials told us they will continue to develop and implement
    enhancements to AEM to expand its capabilities over the next several
    years. However, until CMS develops a plan for integrating the fragmented
    systems and for using AEM data--along with other data the agency
    collects--efficient and effective tracking and monitoring of enforcement
    will continue to be hampered and, as a result, CMS will have difficulty
    assessing the effectiveness of sanctions and its enforcement policies.

    ^83CMS's December 2004 "Action Plan (For Further Improvement of) Nursing
    Home Quality."

    Other CMS Initiatives to Improve Enforcement

    In addition to its efforts to implement a new data system for managing
    enforcement, CMS has taken other steps to improve its enforcement of
    nursing home quality requirements. For example, the agency has developed
    guidance to help ensure greater consistency across states in CMP amounts
    imposed, revised its Special Focus Facility program, and commissioned two
    studies to examine the effectiveness of nursing home enforcement.^84

    To ensure greater consistency in CMP amounts proposed by states and
    imposed by regions, CMS, in conjunction with state survey agencies,
    developed a grid that provides guidance for states and regions. The CMP
    grid lists ranges for minimum CMP amounts while allowing for flexibility
    to adjust the penalties on the basis of factors such as the deficiency's
    scope and severity, the care areas where the deficiency was cited, and a
    home's past history of noncompliance. In August 2006, CMS completed the
    regional office pilot of its CMP grid. The results of the pilot, which are
    currently being analyzed, will be used to determine how the grid should be
    used by states; its use would be optional to provide states flexibility to
    tailor sanctions to specific circumstances.

    CMS revised its Special Focus Facility program, an initiative intended to
    increase the oversight of homes with a history of providing poor care. We
    had previously reported that the program was worthwhile but that its
    narrow scope excluded many homes that provide poor care.^85 Moreover,
    according to CMS, the goal of two surveys per home per year was never
    achieved because of the relatively low priority assigned to the program
    and the lack of state survey agency resources. In December 2004, CMS
    announced three changes in the operation of the program. First, CMS
    expanded the scope of the program from about 100 homes nationwide to about
    135 homes by making the number of Special Focus Facilities in each state
    proportional to the number of nursing homes. Second, CMS revised the
    method for selecting nursing homes by reviewing 3 years' rather than 1
    year's worth of deficiency data. This change was intended to ensure that
    the homes in the program had a history of noncompliance rather than a
    single episode of noncompliance. Third, CMS strengthened its enforcement
    for Special Focus Facilities by requiring immediate sanctions for homes
    that failed to significantly improve their performance from one survey to
    the next and by requiring termination for homes with no significant
    improvement after three surveys over an 18-month period.^86 Despite these
    changes, however, many homes that could benefit from enhanced oversight
    and enforcement are still excluded from the program. As noted earlier, few
    of the homes we reviewed were or are part of CMS's Special Focus
    Facilities program. In 2005, only 2 were designated Special Focus
    Facilities and in 2006, the number increased to 4. Of the 8 homes that
    cycled in and out of compliance seven or more times (see fig. 3), 6 are
    still open but only 1 is now a Special Focus Facility. Although CMS now
    requires QIOs to work with poorly performing nursing homes, this
    initiative also only targets a small number of homes--as few as 1 to 3
    facilities in each state.

    ^84Additional CMS nursing home initiatives are described in CMS's 2007
    "Action Plan for (Further Improvement of) Nursing Home Quality."

    ^85GAO, Nursing Homes: Sustained Efforts Are Essential to Realize
    Potential of the Quality Initiatives, [59]GAO/HEHS-00-197 (Washington,
    D.C.: Sept. 28, 2000).

    To enhance its understanding of and ability to improve the enforcement
    process, CMS has funded two studies that will examine the steps that lead
    to sanctions as well as the impact of enforcement on homes'
    quality-of-care processes.

               o Qualitative Enforcement Case Studies. This study, which began in
               the spring of 2003 and is scheduled to be completed in early 2007,
               required research nurses to visit 25 nursing homes in four states
               to evaluate how the survey and enforcement processes are carried
               out and assess the extent to which the enforcement process results
               in changes in nursing staff behavior and improved compliance with
               federal requirements.

               o Impact of Sanctions on Quality. The objective of this study is
               to test the effects of sanctions on facility behavior and resident
               outcomes. Researchers will identify and compare a group of nursing
               homes that had both deficiencies and sanctions to a group of
               nursing homes that had similar levels of deficiencies but no
               sanctions. A year later, researchers will review the nursing
               home's subsequent survey to determine whether the sanctions
               resulted in any significant changes in the quality of care
               delivered. The study began in the fall of 2004 and the first
               report is scheduled to be completed by mid-2007.

    ^86In commenting on a draft of this report, Michigan noted that it
    recommends termination dates of less than 6 months for its Special Focus
    Facilities and has received support from the CMS regional office to do so.
    Michigan also noted that after one of its homes with a history of cycling
    in and out of compliance was designated a Special Focus Facility, the
    home's performance improved, and it will likely be removed from the
    Special Focus Facility list.

               Although CMS has taken several steps to improve its enforcement of
               nursing home requirements, its Nursing Home Compare Web site does
               not include information on sanctions. Thus, CMS does not indicate
               what sanctions have been implemented against nursing homes, nor
               does it identify homes that have received immediate sanctions for
               repeatedly harming residents.

               As noted throughout this report, we found variation among the
               states we reviewed in areas such as the number and amount of CMPs
               implemented and the proportion of homes with double Gs. In
               general, these differences reflect the state survey agencies'
               views on the effectiveness of certain sanctions and differences in
               state enforcement policies. For example, Pennsylvania state
               officials prefer state rather than federal sanctions because they
               believe the former are more effective, have a greater deterrent
               effect on providers, and are easier and quicker to impose.
               Pennsylvania requires homes to pay a state CMP prior to appeal,
               even if the home appeals the deficiency. In contrast, homes need
               not pay a federal CMP until after an appeal is resolved.
               Pennsylvania rarely implemented federal CMPs on the 14 state homes
               whose compliance history we reviewed, preferring to use state
               sanctions instead. In Michigan, state officials are more likely to
               use federal CMPs and implement them in greater amounts than other
               states we reviewed. Texas state officials often use state rather
               than federal sanctions for G-level or higher deficiencies, in part
               because they cannot propose a federal CMP if they impose a state
               sanction and because the total state money penalty that may be
               imposed may be higher than federal CMPs. California had fewer
               sanctions than Michigan. California typically investigates
               complaints under its state licensure authority, which may partly
               explain why California has fewer reported deficiencies and federal
               sanctions. We believe it is important for CMS to explore the
               differences in state enforcement approaches and policies so that
               it can both identify problem areas and identify best practices
               that could be disseminated nationwide.

    		   Conclusions

               Although CMS has taken steps to strengthen the nursing home
               enforcement process, our review of 63 homes in four states with a
               history of quality problems identified design weaknesses as well
               as flaws in the way sanctions are implemented that diminish their
               full deterrent effect. Some of these homes repeatedly harmed
               residents over a 6-year period and yet remain in the Medicare and
               Medicaid programs. Until these systemic weaknesses are addressed,
               the effectiveness of sanctions in encouraging homes to return to
               and maintain compliance will remain questionable and the safety
               and security of vulnerable residents will remain at risk.

               CMS's immediate sanctions policy fails to hold homes with a long
               history of harming residents accountable for the poor care
               provided. The policy's complexity, such as the requirement for an
               intervening period of compliance, prevents its use for the very
               homes it was designed to address--those with systemic quality
               problems. Furthermore, the immediate sanctions label is misleading
               because sanctions are not, in fact, immediate. The notice period
               required by CMS regulations for sanctions such as DPNAs and
               terminations provides homes with a de facto grace period during
               which they can correct deficiencies to avoid an immediate
               sanction. Moreover, in one state we reviewed, the immediate
               sanctions policy does not fully identify all homes with repeat
               serious deficiencies because most complaint deficiencies, which
               can often trigger a double G, were being cited under state
               licensure authority, not federal. Consequently, some problem homes
               in the state were not identified by the policy and thus were able
               to avoid double G immediate sanctions.

               Although CMPs and DPNAs were the most frequently used sanctions
               nationwide and for the homes we reviewed, their effectiveness was
               undermined by a number of weaknesses. The CMPs levied against the
               homes we reviewed were often nominal, significantly less than the
               maximum amounts Congress provided for in statute. To strengthen
               CMPs, CMS has been developing a CMP grid since 2004 to guide
               states and regional offices in determining appropriate CMP
               amounts, and CMS regional offices piloted the grid in 2006.
               However, its implementation is expected to be optional for states,
               once again contributing to interstate variation. Despite the
               nominal amounts, CMPs, unlike DPNAs, do not require a notice
               period and may be imposed retroactively before the date of the
               survey. However, these advantages are countered by the fact that,
               under the Social Security Act, payment by homes of federally
               imposed CMPs is deferred if they appeal their deficiencies, a
               process that can take years, diminishing the immediacy of the
               sanction and further undermining the sanction's deterrent effect.
               While there is precedent under the federal surface mining statute,
               which permits the collection of CMPs before exhaustion of appeals,
               it is unclear if the informal dispute resolution process available
               to nursing homes provides the same type of procedural safeguards
               that courts have pointed to in upholding the mining statute
               provision. Some states choose to use their own authority to impose
               state fines, which can sometimes be implemented faster than is
               possible under federal law. Although CMS has the authority to
               implement discretionary DPNAs after a 15-day notice period for the
               homes we reviewed, it did not generally do so. It imposes
               mandatory DPNAs when criteria are met, which provide homes a
               3-month de facto grace period to correct deficiencies. Because
               many homes we reviewed returned to compliance within 3
               months--though often only temporarily--the DPNAs frequently were
               rescinded.

               Termination--the most powerful enforcement tool--was used
               infrequently nationwide and for the homes we reviewed because of
               states' and CMS's concerns about potential access to care and
               resident transfer trauma. However, we found that some poorly
               performing homes are located in areas with several other nearby
               nursing homes. Even though some homes we reviewed cycled in and
               out of compliance numerous times while continuing to harm
               residents, CMS allowed them to determine for themselves whether
               and when to leave the Medicare and Medicaid programs. Even when
               terminations were imposed, their deterrent effect was undermined
               by extending some termination dates to give the homes more time to
               correct deficiencies. CMS's earlier termination of such troubled
               homes could have cut short the cycle of poor care. CMS's revamped
               Special Focus Facility program would provide for termination of
               poorly performing homes within 18 months if they fail to show
               significant improvement in the quality of care provided to
               residents. Despite the expansion of the program from about 100 to
               about 135 homes, the number of Special Focus Facilities is
               inadequate because, as our work has demonstrated, the program
               still fails to include many homes with a history of repeatedly
               harming residents.

               Although CMS has made progress in establishing a database to help
               it track and monitor the nursing home enforcement process, the
               development of AEM is not yet complete. AEM is not integrated with
               other important databases to help ensure that CMS has a
               comprehensive picture of a home's deficiency history, and CMS has
               not developed a concrete plan for using national enforcement
               reports--built off of AEM data--to help evaluate the effectiveness
               of sanctions and its enforcement polices. Having longitudinal
               enforcement data available for homes would enable CMS to pursue
               increasing the severity of sanctions for homes that repeatedly
               harm residents. Furthermore, CMS has not developed a system of
               quality checks to ensure the accuracy and integrity of AEM data.

               CMS's Nursing Home Compare Web site has been modified a number of
               times to add important quality information about nursing homes.
               While CMS now summarizes the results from both standard surveys
               and complaint investigations, the Web site contains no information
               about sanctions implemented against nursing homes, nor does it
               identify homes that have received immediate sanctions for
               repeatedly harming residents. Such information could be valuable
               to consumers who use the Web site to help choose a home for family
               members or friends.

    		   Recommendations for Executive Action

               To address weaknesses that undermine the effectiveness of the
               immediate sanctions policy, we recommend that the Administrator of
               CMS reassess and revise the policy to ensure that it accomplishes
               the following three objectives: (1) reduce the lag time between
               citation of a double G and the implementation of a sanction, (2)
               prevent nursing homes that repeatedly harm residents or place them
               in immediate jeopardy from escaping sanctions, and (3) hold states
               accountable for reporting in federal data systems serious
               deficiencies identified during complaint investigations so that
               all complaint findings are considered in determining when
               immediate sanctions are warranted.

               To strengthen the deterrent effect of available sanctions and to
               ensure that sanctions are used to their fullest potential, we
               recommend that the Administrator of CMS take the following three
               actions:

               o Ensure the consistency of CMPs by issuing guidance such as the
               standardized CMP grid piloted during 2006.

               o Increase use of discretionary DPNAs to help ensure the speedier
               implementation of appropriate sanctions.

               o Strengthen the criteria for terminating homes with a history of
               serious, repeated noncompliance by limiting the extension of
               termination dates, increasing the use of discretionary
               terminations, and exploring alternative thresholds for
               termination, such as the cumulative duration of noncompliance.

               To collect CMPs more expeditiously, which could increase their
               deterrent effect, we recommend that the Administrator of CMS
               develop an administrative process under which CMPs would be
               paid--or Medicare and Medicaid payments in equivalent amounts
               would be withheld--prior to exhaustion of appeals and seek
               legislation for the implementation of this process, as
               appropriate. Payments could be refunded with interest if the
               deficiencies are modified or overturned at appeal.

               To strengthen sanctions for homes with a history of noncompliance,
               such as a large number of deficiencies or a large number of actual
               harm and immediate jeopardy deficiencies, we recommend that the
               Administrator of CMS consider further expanding the Special Focus
               Facility program with its enhanced enforcement requirements to
               include all homes that meet a threshold, established by CMS, to
               qualify as poorly performing homes.

               To improve the effectiveness of its new enforcement data system,
               we recommend that the Administrator of CMS take the following
               three actions:

               o Develop the enforcement-related data systems' abilities to
               interface with each other in order to improve the tracking and
               monitoring of enforcement, such as by developing an automatic
               interface between systems such as AEM and ACTS.

               o Expedite the development of national enforcement reports,
               including longitudinal and trend reports designed to evaluate the
               effectiveness of sanctions and enforcement policies, and a
               concrete plan for using the reports.

               o Develop and institute a system of quality checks to ensure the
               accuracy and integrity of AEM data, such as periodic data audits
               conducted as part of CMS's annual state performance reviews.

               To improve public information available to consumers that helps
               them assess the quality of nursing home care, we recommend that
               the Administrator of CMS expand CMS's Nursing Home Compare Web
               site to include implemented sanctions, such as the amount of CMPs
               and the duration of DPNAs, and homes subjected to immediate
               sanctions.

    		   Agency and State Comments and Our Evaluation

               We obtained written comments on our draft report from CMS and
               three of the four states in which the homes we studied were
               located--California, Michigan, and Texas. We also received e-mail
               comments from the Director of the Division of Nursing Care
               Facilities in Pennsylvania. CMS's comments are reproduced in
               appendix VI. California's, Michigan's and Texas's comments are
               reproduced in appendixes VII, VIII, and IX, respectively. CMS
               generally concurred with our 12 recommendations in six areas
               intended to strengthen the enforcement process but did not always
               specify how it would implement the recommendations. In addition,
               CMS noted that implementation of 3 of our recommendations raised
               resource issues and that others required additional research.
               California concurred with our conclusions and recommendations,
               while Michigan and Pennsylvania indicated appreciation or general
               agreement. However, most state comments, including Texas's, were
               technical in nature. Our evaluation responds to CMS and state
               comments in the six areas covered by our recommendations.

               Addressing weaknesses in the double G immediate sanctions policy.
               CMS agreed that homes that repeatedly harm residents should not
               escape immediate sanctions and stated that it would remove the
               limitation on applying an additional sanction when a home failed
               to correct a deficiency that gave rise to a prior sanction. CMS
               also agreed to reduce the lag time between citation and
               implementation of a double G immediate sanction by limiting the
               prospective effective date for DPNAs to no more than 30 to 60
               days. Reducing the lag time as much as possible is critical
               because it provides homes with a de facto grace period in which to
               correct deficiencies and avoid sanctions. Michigan commented about
               the need to increase the immediacy of DPNAs, noting that even the
               15-day notice period associated with discretionary DPNAs was
               outdated now that homes are notified electronically and delivery
               can be verified. Currently, CMS has an incomplete picture of
               serious deficiencies cited against homes that could result in
               immediate sanctions because California investigates many nursing
               home complaints under state licensure authority. CMS agreed to
               collect additional information on complaints for which data are
               not reported in federal data systems. We believe that CMS's
               commitment to do this will help better identify and deal with
               consistently poorly performing homes. CMS commented that the
               Social Security Act does not provide authority for CMS to require
               states to report enforcement actions taken under state-only
               authority if federal resources are not used for the complaint
               investigation; however, to the extent that federal funds are used
               for complaint investigations, our findings and recommendations
               remain valid. Michigan concurred that CMS needs the complete
               compliance history of a facility to assess its overall
               performance.

               CMS acknowledged that the complexity of its immediate sanctions
               policy may be an inherent limitation and indicated that it intends
               to either strengthen the policy or replace it with a policy that
               achieves similar goals through alternative methods. CMS noted that
               it is concerned about whether the immediate sanctions policy has
               negatively affected the rates of state deficiency citations and
               may ultimately be ineffective with the most problematic
               facilities. We believe the policy has merit but that its complex
               requirements have prevented many homes from receiving immediate
               sanctions.

               Strengthening the deterrent effect of sanctions. CMS agreed to
               issue a CMP analytic tool, or grid, and to provide states with
               further guidance on discretionary DPNAs and terminations. The CMP
               grid is a tool to help ensure national consistency in CMPs and to
               assist CMS regional offices in monitoring enforcement actions.
               Texas commented that it had been using the grid since June 2006
               and found it to be very helpful. Michigan noted that it had
               independently developed and implemented a CMP grid in 2000 but
               expressed disappointment that CMS had not mandated state use of
               the agency's grid. In addition, Michigan supported the need for
               additional CMS guidance on the use of discretionary termination.
               Such guidance, it commented, was necessary to ensure a consistent
               national approach. In response to our recommendation to increase
               the use of discretionary terminations, CMS stated that it will
               continue its research to design proposals that yield a more
               effective combination of robust enforcement actions but that do
               not penalize vulnerable residents. While we encourage CMS's
               commitment to further research to improve the effectiveness of
               enforcement actions, we believe that CMS must also be committed to
               protecting residents from actual harm in poorly performing
               facilities--including terminating homes from the Medicare or
               Medicaid programs--when other steps fail to ensure the quality of
               resident care.

               Collecting CMPs more expeditiously. CMS agreed to seek legislative
               authority to collect CMPs prior to the exhaustion of appeals,
               which could increase their deterrent effect. California commented
               that it supported this recommendation.

               Expanding the Special Focus Facility program. CMS agreed with the
               concept of expanding the program to include all homes that meet a
               threshold to qualify as poorly performing homes, but said it lacks
               the resources needed for this expansion because of decreases in
               its budget and increases in both the number of providers and
               quality assurance responsibilities for state and federal
               surveyors. CMS stated that it envisioned expansion of the program
               if Congress fully funds the President's proposed fiscal year 2008
               budget for survey and certification activities. CMS specified
               other initiatives it will implement to improve the Special Focus
               Facility program.

               Improving the effectiveness of enforcement data. CMS agreed to
               develop and implement a system of quality checks to ensure the
               accuracy of its data systems, including AEM. While the agency
               agreed to study the feasibility of linking the separate data
               systems used for enforcement and to develop other national
               standard enforcement reports, CMS indicated that available
               resources may limit its ability to take further action on these
               issues. CMS has already invested significant resources in
               developing potentially powerful data systems intended to improve
               the tracking and monitoring of enforcement, and we believe the
               agency should place a priority on ensuring that these systems
               operate effectively.

               Improving information available to consumers. Rather than agreeing
               to report all implemented sanctions on its Nursing Home Compare
               Web site, CMS proposed reporting implemented sanctions only for
               poorly performing homes that meet an undefined threshold. CMS's
               response was therefore not fully responsive to our recommendation.
               By only reporting sanctions for homes that meet a certain
               threshold--eight or more sanctions in a 3-year period, in an
               example provided by CMS--consumers might incorrectly assume that
               other homes have received no sanctions. Furthermore, CMS's plan to
               post such limited sanctions data in an accessible location on its
               Web site is vague. We believe that consumers must be able to
               easily link deficiency and sanctions data.

               CMS and three of the four states also provided technical comments,
               which we incorporated as appropriate.

               As arranged with your office, 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 to the Administrator of the Centers for Medicare & Medicaid
               Services and appropriate congressional committees. We will also
               make copies available to others upon request. In addition, the
               report will be available at no charge on the GAO Web site at
               http://www.gao.gov .

               If you or your staff have any questions about this report, please
               contact me at (202) 512-7118 or [61]allenk@gao.gov . Contact
               points for our Offices of Congressional Relations and Public
               Affairs may be found on the last page of this report. GAO staff
               who made major contributions to this report are listed in appendix
               X.

               Sincerely yours,

               Kathryn G. Allen
    		   Director, Health Care

    		   Appendix I: Scope and Methodology

               This appendix provides a more detailed description of our scope
               and methodology and generally follows the order that findings
               appear in the report. We analyzed the fiscal years 2000 through
               2005 enforcement and deficiency history for a total of 63 of the
               74 nursing homes in four states--California, Michigan,
               Pennsylvania, and Texas--whose compliance history informed the
               conclusions of our March 1999 report.^1 These homes had a history
               of providing poor quality care to residents prior to 1999. We
               excluded 11 of the original 74 homes from our analysis because
               they either closed before fiscal year 2000 or closed within 6
               months of the beginning of fiscal year 2000 and had few or no
               deficiencies or sanctions.^2 Some of the remaining 63 homes
               participated in the Medicare and Medicaid programs for only a
               portion of fiscal years 2000 through 2005 because they either
               closed permanently or closed temporarily and were subsequently
               reinstated. For these homes, we set a criterion that required that
               the home participate for at least 6 months of the fiscal year in
               order for its enforcement data in that fiscal year to be included
               in our analysis. Table 8 shows the distribution of homes across
               the four states in our 1999 report, the distribution of those
               homes for this report, and the number of providers participating
               for at least 6 months by fiscal year. Although the table shows
               some year-to-year fluctuation in the number of providers, the
               changes do not significantly influence our findings. While the
               focus of our analysis was the compliance history of these 63
               homes, we also analyzed general trends in (1) implemented
               sanctions nationwide for the same 6-year period and (2) the
               proportion of homes in each state cited for serious
               deficiencies--that is, those at the actual harm or immediate
               jeopardy level.

    ^1See [62]GAO/HEHS-99-46 . Because the homes reviewed for this report were
    selected based on their poor compliance histories, the findings of this
    report cannot be generalized to nursing homes in the states in which the
    homes are located or to nursing homes nationwide. However, we believe that
    the findings of this report illustrate the adequacy of federal and state
    sanctions taken against homes with histories of providing poor quality
    care to residents.

    ^2Of the 11 original 74 homes we excluded, CMS involuntarily terminated 5,
    and 6 closed voluntarily.

    Table 8: Number of Nursing Homes Reviewed in 1999 That Were Included in
    Our Analysis for This Report, by State

                                               Current report
                    1999       Any participation in
    State        report   fiscal years 2000-2005 2000 2001 2002 2003 2004 2005
    California       12                       10   10   10   10   10   10   10
    Michigan         18                       16   14   14   13   13   12   13
    Pennsylvania     17                       14   14   13   13   12   10   10
    Texas            27                       23   23   22   22   23   22   22
    Total            74                       63   61   59   58   58   54   55

    Source: GAO.

    CMS deficiency data. To determine the number, scope, and severity of
    deficiencies cited for the 63 homes, we analyzed OSCAR (On-Line Survey,
    Certification, and Reporting system) deficiency data resulting from
    standard surveys and complaint investigations. We also used OSCAR data on
    deficiencies identified during standard surveys to analyze state trends in
    the proportion of nursing homes cited for actual harm or immediate
    jeopardy during fiscal years 2000 through 2005. Because a home may be
    surveyed more than once a year, we counted a home only once if it was
    cited for actual harm or immediate jeopardy on more than one survey during
    the year. CMS officials generally recognize OSCAR data to be reliable. We
    have used OSCAR data in our prior work to examine nursing home quality.

    CMS enforcement data and reliability issues. Because CMS used multiple
    data systems during the 6-year period we reviewed and because of data
    reliability issues, such as incomplete or inaccurate data, we used several
    sources to validate and analyze the enforcement history of the 63 homes.
    Based on discussions with CMS regional staff who were responsible for
    inputting the data, our primary data source for homes in California,
    Michigan, and Pennsylvania for the period fiscal years 2000 through 2004
    was the Long Term Care Enforcement Tracking System (LTC).^3 Because CMS's
    Dallas regional office expressed concern about reliability of LTC data in
    the region, we relied primarily on regional office and state enforcement
    case files for the Texas homes we reviewed. CMS phased out use of LTC at
    the end of fiscal year 2004 and began using Aspen Enforcement Manager
    (AEM) to track sanctions. We obtained data for fiscal year 2005 sanctions
    from the limited AEM data stored in the OSCAR enforcement file. To clarify
    data from LTC or AEM and to perform some basic data checks, we relied on
    regional office and state enforcement case files and made adjustments as
    appropriate. We discussed the reliability of LTC and AEM enforcement data
    with CMS and state survey agency officials. CMS informed us that the data
    generally were reliable. We determined that the data were sufficiently
    reliable to assess broad trends in implemented sanctions nationwide, and
    to analyze sanctions among the 63 homes we reviewed because we could
    conduct checks of the homes' enforcement data using CMS regional office
    and state case files. Because we could not conduct such checks of the data
    in all 50 states and the District of Columbia, we did not analyze trends
    across the individual states.

    ^3We obtained the data from CMS on July 26, 2005.

    Trends in sanctions. Based on our assessment of data reliability, we
    determined that we could assess broad trends in implemented sanctions
    nationwide, but because we could not conduct checks of the data in all 50
    states and the District of Columbia, we did not analyze trends across the
    states. For the homes we reviewed, using data from LTC, AEM, and regional
    office and state enforcement case files as described above, we analyzed
    the number of civil money penalties (CMP), denial of payments for new
    admissions (DPNA), and terminations implemented over two 3-year time
    periods--fiscal years 2000 through 2002 and fiscal years 2003 through
    2005. We aggregated sanctions into fiscal years on the basis of their
    implementation dates. To determine the duration of DPNAs across the two
    time periods, we calculated the difference between the effective dates and
    the end of the DPNAs. To determine the amount of CMPs paid, we used the
    CMP Tracking System (CMPTS), a CMS financial management system,^4 and
    aggregated CMPs into fiscal years according to the year in which they were
    implemented. Based on discussions with CMS officials we determined that
    data in CMPTS are generally reliable. They also stated that the system is
    the primary system used by CMS for the collection of CMPs and is the only
    source for CMP payment data used by CMS. We matched CMP data in LTC and
    CMPTS based on their collection number. For fiscal year 2005, we relied on
    regional enforcement files for the amount of paid CMPs.

    ^4We received CMPTS data from CMS on April 21, 2006.

    Implementation rate of sanctions. We determined the implementation rate of
    sanctions imposed for the homes we reviewed in fiscal years 2000 through
    2005. The percentage of implemented sanctions was calculated by dividing
    the number of implemented sanctions by the total number of imposed
    sanctions. The total number of imposed sanctions included those that were
    implemented, not implemented, and were pending. We used data from our
    March 1999 report on imposed and implemented sanctions for the period July
    1995 through October 1998.^5

    Range of sanctions. CMS enforcement data allowed us to differentiate
    between per day and per instance CMPs and mandatory and discretionary
    DPNAs and terminations. We counted the number of sanctions by type and
    aggregated the number by fiscal year based on the date of implementation.
    The data provided the value of per day and per instance CMPs, which were
    used to calculate the median values of CMPs across the two time
    periods--fiscal years 2000 through 2002 and 2003 through 2005.

    Cycling in and out of compliance. We analyzed the enforcement data from
    LTC, AEM, and CMS regional office and state records to determine if the 63
    homes we reviewed cycled in and out of compliance from fiscal years 2000
    through 2005. To determine the number of times homes cycled in and out of
    compliance, we counted the number of noncompliance cycles recorded for the
    63 homes. A noncompliance cycle begins on the date of the survey finding
    noncompliance and ends when the home has achieved substantial compliance
    by correcting deficiencies. For noncompliance cycles for which sanctions
    were implemented, we examined survey dates, the date substantial
    compliance was achieved, and the sanctions that were implemented as a
    result of the deficiencies cited. To determine how quickly homes were
    again noncompliant, we calculated the difference between the date of the
    first survey of the subsequent noncompliance cycle and the substantial
    compliance date of the preceding noncompliance cycle. To quantify the
    number of noncompliance cycles during which actual harm occurred, we
    assessed whether homes were cited for G-level or higher deficiencies on
    the surveys within the noncompliance cycle.

    Immediate sanctions policy. We identified instances in which the 63 homes
    we reviewed were cited for repeatedly harming residents to determine if
    immediate sanctions were imposed and their effect on deterring subsequent
    noncompliance. To identify sanctions imposed as a result of the immediate
    sanctions policy, we first identified homes that qualified for immediate
    sanctions using CMS's Providing Data Quickly (PDQ) system which prepares a
    variety of reports using survey and certification data. CMS officials
    indicate that the data in Providing Data Quickly are generally recognized
    as reliable. We then matched the survey date in Providing Data Quickly
    with the survey date in the enforcement data to identify the noncompliance
    cycle during which qualifying deficiencies were cited.^6 This step enabled
    us to identify the sanctions imposed. We reviewed each case individually
    to verify that the sanction was the result of actual harm or higher-level
    deficiencies that denied the home an opportunity-to-correct period or
    simply resulted from another survey in the same noncompliance cycle. We
    also compared the date of survey with the imposition and effective dates
    of sanctions to assess how much time passed between identification of the
    deficiency that led to the immediate sanction and the imposition and
    implementation of the sanction. During the course of our work, we also
    discussed the rationale behind the specific formulation of the immediate
    sanctions policy with CMS officials.

    ^5See [63]GAO/HEHS-99-46 .

    ^6In a small number of cases, the survey date recorded in PDQ did not
    match the survey date in the enforcement data. Mismatches generally
    occurred because the survey date in PDQ erroneously reflected another
    survey, usually the first of the noncompliance cycle, even if there was no
    G-level or higher deficiency on that survey, rather than the survey on
    which the G-level or higher deficiency was cited. After consulting with
    CMS, we adjusted the survey dates to reflect the correct dates.

    Appendix II: Percentage of Nursing Homes Cited for Actual Harm or
    Immediate Jeopardy, by State, Fiscal Years 2000-2005

    In order to identify trends in the proportion of nursing homes cited with
    actual harm or immediate jeopardy deficiencies, we analyzed data from
    CMS's OSCAR database for fiscal years 2000 through 2005 (see table 9).
    Because surveys are conducted at least every 15 months (with a required
    12-month statewide average), it is possible that a home was surveyed twice
    in any time period. If a home was cited for a G-level or higher deficiency
    on more than one survey during the fiscal year, we only counted it once.

    Table 9: Percentage of Nursing Homes Cited for Actual Harm or Immediate
    Jeopardy during Standard Surveys, Fiscal Years 2000-2005

                                                             Fiscal year
    State                Number of homes, 2005^a 2000 2001 2002 2003 2004 2005
    Alabama                                  229 35.5 23.0 12.7 18.1 15.6 23.1
    Alaska                                    14 28.6 26.7 26.7  0.0  0.0  0.0
    Arizona                                  135 24.2 12.6  7.3  6.6  9.4  9.9
    Arkansas                                 245 38.1 27.7 22.3 24.7 19.5 15.9
    California                             1,329 24.1 10.9  5.1  3.7  6.1  8.0
    Colorado                                 215 20.4 26.4 32.7 20.9 25.9 40.4
    Connecticut                              247 41.9 51.6 45.8 43.1 54.4 44.2
    Delaware                                  42 47.5 14.6 10.8  5.3 15.0 35.7
    District of Columbia                      20 17.7 28.6 30.0 41.2 40.0 30.0
    Florida                                  691 22.8 20.2 14.9 10.2  7.8  4.2
    Georgia                                  370 19.5 21.0 23.7 24.6 16.6 18.0
    Hawaii                                    45 23.8 14.3 21.2 12.1 22.9  2.8
    Idaho                                     81 51.4 29.7 39.2 31.9 27.3 38.4
    Illinois                                 836 28.4 19.2 15.3 18.3 15.1 15.7
    Indiana                                  518 45.0 29.4 23.2 19.7 24.1 28.3
    Iowa                                     465 14.7 12.0  8.0  9.1 11.8 11.2
    Kansas                                   374 37.9 30.7 32.9 26.5 30.3 34.9
    Kentucky                                 297 26.8 29.1 23.2 26.1 14.6  7.7
    Louisiana                                321 21.8 29.9 21.7 16.2 12.0 15.4
    Maine                                    116 11.1 13.9  6.6 11.1 12.8  7.0
    Maryland                                 239 22.4 16.5 26.1 15.4 17.8  7.6
    Massachusetts                            466 29.1 24.4 24.6 25.9 16.7 22.6
    Michigan                                 432 42.8 24.5 29.7 26.9 22.9 22.9
    Minnesota                                411 30.4 17.3 22.3 18.3 14.3 14.4
    Mississippi                              210 33.0 19.8 18.7 16.0 18.9 18.1
    Missouri                                 532 19.8 13.0 15.6 12.5 11.7 15.4
    Montana                                  100 33.3 29.7 12.0 20.0 18.0 17.9
    Nebraska                                 235 19.2 21.1 20.1 14.8 15.3 14.4
    Nevada                                    47 34.8 14.6 11.9  9.1 17.5 19.6
    New Hampshire                             82 37.8 31.1 29.4 24.1 25.6 26.3
    New Jersey                               364 25.5 27.8 18.8 10.5 13.5 18.2
    New Mexico                                77 23.7 16.9 14.9 21.3 24.3 29.4
    New York                                 662 33.8 37.1 34.2 15.2 11.0 14.0
    North Carolina                           426 43.6 35.8 25.6 29.0 21.1 18.5
    North Dakota                              83 25.9 28.7 17.9 12.4 13.6 17.7
    Ohio                                     993 26.6 27.3 25.4 19.1 11.4 13.8
    Oklahoma                                 387 19.3 21.3 22.0 26.3 13.9 23.2
    Oregon                                   139 45.5 32.6 23.7 20.3 15.9 19.8
    Pennsylvania                             727 30.3 19.2 13.5 17.2 19.5 15.2
    Rhode Island                              92 14.3 12.9  5.6  6.7  9.3  9.5
    South Carolina                           177 26.4 17.2 19.8 29.6 32.7 24.8
    South Dakota                             112 27.1 26.7 26.8 32.1 21.6 12.8
    Tennessee                                337 28.2 20.2 20.7 21.8 22.9 17.3
    Texas                                  1,174 29.7 30.5 22.4 18.0 12.0 16.2
    Utah                                      93 19.5 14.1 25.6 19.0 11.1  8.4
    Vermont                                   41 22.5 18.2 15.0 10.0 19.5 23.7
    Virginia                                 281 19.2 14.3 11.6 13.7 10.2 15.5
    Washington                               251 46.9 38.3 37.0 30.9 28.1 27.2
    West Virginia                            133 12.1 17.7 20.4 12.7  9.8 15.0
    Wisconsin                                405 15.8 15.6 11.2 10.9 13.1 18.2
    Wyoming                                   39 52.8 32.4 25.0 22.9 17.1 11.8
    Nation                                16,337 28.4 23.3 20.2 17.8 15.7 16.8

    Source: GAO analysis of OSCAR and PDQ data.

    aThese numbers illustrate the significant variation in the number of
    active nursing homes across states.

    Appendix III: Federal Sanctions for Nursing Homes Reviewed, by State,
    Fiscal Years 2000-2005

    Table 10 provides the number of CMPs, DPNAs, and terminations implemented
    in the nursing homes we reviewed, by state for fiscal years 2000-2002 and
    fiscal years 2003-2005. It also provides the total amount of CMPs paid and
    the total duration of DPNAs implemented during the two time periods. The
    total amount of CMPs payable in the fiscal years may differ from what was
    paid.

    Table 10: Number of Sanctions Implemented Among Homes We Reviewed, Fiscal
    Years 2000-2005

                                      FY 2000-2002                         FY 2003-2005
                                                                                     Percentage
                                                                                      change in
                                                                                         number
                                Average                    Average                   from first
                                 number            Amount   number            Amount  to second
                               of homes             paid/ of homes             paid/       time
    State        Sanction      reviewed Number^a duration reviewed Number^a duration     period
    California                       10       10
                 CMP^b                         5 $109,394        7 $166,480      40%
                 DPNA^c                        4 155 days        3 189 days     -25%
                 Involuntary                   0       NA        0       NA       NA
                 termination^d
    Michigan                         14       13
                 CMP^b                        40 $186,313       35 $419,401     -13%
                 DPNA^c                       26    1,206       19 796 days     -27%
                                                     days
                 Involuntary                   0       NA        1       NA     100%
                 termination^d
    Pennsylvania                     13       11
                 CMP^b                         7  $62,400        1       $0     -86%
                 DPNA^c                        9 499 days        5 181 days     -44%
                 Involuntary                   0       NA        0       NA       NA
                 termination^d
    Texas                            22       22
                 CMP^b                        41 $176,420       11  $31,671     -73%
                 DPNA^c                       13 591 days        3  79 days     -77%
                 Involuntary                 1^e       NA        0       NA    -100%
                 termination^d

    Source: GAO analysis of LTC, OSCAR, CMS regional office and state
    enforcement case files, and CMPTS.

    Note: Includes sanctions data from LTC as of July 26, 2005; OSCAR as of
    November 22, 2005; CMS regional office and state enforcement case files;
    and CMPTS data as of April 21, 2006.

    NA = not applicable.

    aNumber of sanctions implemented in the time period.

    bIncludes per day and per instance CMPs.

    cIncludes mandatory and discretionary DPNAs.

    dIncludes mandatory and discretionary involuntary terminations.

    eAlthough the home did not participate for 6 months of fiscal year 2001
    because it was involuntarily terminated in February 2001, the involuntary
    termination is counted because involuntary termination is the most severe
    sanction and because it occurs so infrequently.

    Appendix IV: Examples of Homes Reviewed That Frequently Cycled In and Out
    of Compliance

    This appendix provides additional examples of the compliance history of
    homes we reviewed that frequently cycled in and out of compliance (see
    table 6). The table also includes examples of the nature of the
    deficiencies cited in each noncompliance period. The three homes in table
    11 were cited for serious deficiencies--those at the actual harm or
    immediate jeopardy level--and corrected these deficiencies only
    temporarily, despite receiving sanctions; on subsequent surveys, they were
    again found to be out of compliance, sometimes for the same deficiencies.
    A noncompliance period begins on the first day a survey finds
    noncompliance and ends when a home both corrects the deficiencies and
    achieves substantial compliance or the home is terminated from Medicare
    and Medicaid. Only federal sanctions that were imposed and implemented are
    included in the table.

    Table 11: Examples of Homes that Frequently Cycled In and Out of
    Compliance

                                               Summary of
    Noncompliance     Examples of the       G-level or
    period (no. of    nature of             higher         Enforcement action
    days)             deficiencies^a        deficiencies   implemented^b
    California home^c
    1^st (84 days)       o Resident abuse   10 G              o Per day CMP
                            o Poor quality of                    ($500/day)
                            care                                 o Discretionary
                                                                 DPNA (42 days)
    2^nd (131 days)      o Inadequate       1 G               o Per day CMP
                            treatment or                         ($100/day)
                            prevention of                        o Discretionary
                            pressure sores                       DPNA (13 days)
                            o Poor quality of
                            care
    3^rd (126 days)      o Resident abuse   2 G, 3 H          o 1^st per day
                            o Inadequate                         CMP ($3,000/day)
                            treatment or                         o 2^nd per day
                            prevention of                        CMP ($500/day)
                            pressure sores                       o Discretionary
                                                                 DPNA (87 days)
    4^th (181 days)      o Resident abuse   3 G               o Per instance
                                                                 CMPs (3 at
                                                                 $1,500/each)
                                                                 o Discretionary
                                                                 DPNA (89 days)
    Pennsylvania
    home^d
    1^st (204 days)      o Inadequate       17 G              o Per day CMP
                            treatment or                         ($1,000/day)
                            prevention of                        o Mandatory DPNA
                            pressure sores                       (74 days)
                            o Poor accident
                            supervision or
                            prevention
    2^nd (147 days)      o Employing        1 G               o Per instance
                            convicted abusers                    CMP ($10,000)
                            o Inadequate                         o Mandatory DPNA
                            treatment of                         (12 days)
                            incontinence or
                            unnecessary use of
                            catheters
    3^rd (188 days)      o Employing        1 G               o Mandatory DPNA
                            convicted abusers                    (82 days)
                            o Medication
                            errors
    4^th (140 days)      o Poor nutrition   2 H               o Discretionary
                            o Poor accident                      DPNA (61 days)
                            supervision or
                            prevention
    Texas home^e
    1^st (105 days)      o Staff            4 G               o 1^st per
                            mistreatment of                      instance CMP
                            residents                            ($6,000)
                            o Inadequate                         o 2^nd per
                            treatment or                         instance CMP
                            prevention of                        ($2,500)
                            pressure sores
                            o Use of
                            unnecessary drugs
    2^nd (1 day)         o Staff            1 K               o 1^st per day
                            mistreatment of                      CMP ($3,050/day)
                            residents                            o 2^nd per day
                            o Employing                          CMP ($750/day)
                            convicted abusers
    3^rd (11 days)       o Resident abuse   1 G, 1 J          o Per day CMP
                            o Employing                          ($1,000/day)
                            convicted abusers
    4^th (147 days)      o Medication       8 G, 2 H          o 1^st per day
                            errors                               CMP ($3,050/day)
                            o Employing                          o 2^nd per day
                            convicted abusers                    CMP ($400/day)
                                                                 o 3^rd per day
                                                                 CMP ($300/day)
                                                                 o 4^th per day
                                                                 CMP ($50/day)
                                                                 o Discretionary
                                                                 DPNA (141 days)
    5^th (19 days)       o Inadequate       1 G               o Per day CMP
                            treatment or                         ($500/day)
                            prevention of
                            pressure sores
                            o Accident hazards
    6^th (98 days)       o Poor nutrition   2 G, 1 K          o 1^st per day
                            o Employing                          CMP ($3,050/day)
                            convicted abusers                    o 2^nd per day
                            o Poor quality of                    CMP ($750/day)
                            care                                 o 3^rd per day
                                                                 CMP ($50/day)
                                                                 o 4^th per day
                                                                 CMP ($500/day)
                                                                 o Discretionary
                                                                 DPNA (67 days)
    7^th (52 days)       o Poor nutrition   0 G-level or      o Per day CMP
                                               higher; 1 E, 2    ($50/day)
                                               F                 o Discretionary
                                                                 DPNA (20 days)
    8^th (19 days)       o Home failed to   4 K               o Per instance
                            provide necessary                    CMP ($10,000)
                            services for daily
                            living
                            o Employing
                            convicted abusers
    9^th (1 days)        o Poor quality of  1 G               o Per instance
                            care                                 CMP ($5,000)
    10^th (5 days)       o Poor nutrition   0 G-level or      o Per day CMP
                                               higher; 1 E, 2    ($500/day)
                                               F

    Source: GAO analysis of LTC, OSCAR, and CMS regional office and state
    enforcement case files.

    Notes: Enforcement actions listed were federal sanctions imposed and
    implemented (sanctions imposed but not implemented and state sanctions are
    not included). The total number of D-level or higher deficiencies includes
    all deficiencies--not just the deficiencies that occurred during the
    noncompliance cycles cited--for the period fiscal years 2000 through 2005.

    aExamples of the nature of deficiencies include D-level or higher
    deficiencies.

    bIn a number of cases, there is more than one per day CMP listed as an
    enforcement action because CMPs can be raised or lowered based on changes
    in deficiencies.

    cHome open as of November 2006.

    dHome closed in January 2004.

    eHome closed in January 2004.

    Appendix V: Number of Days between Survey and Implementation Date of DPNA
    for Homes Reviewed, Fiscal Years 2000-2005

    Days              Number of DPNAs Percentage of total
                                       1                   4
    1-15 days                       3                  12
    16-30 days                      4                  16
    31-60 days                     15                  60
    61-90 days                      1                   4
    More than 90 days               1                   4

    Source: GAO analysis.

    Notes: This analysis only includes DPNAs for which survey and
    implementation dates were available. DPNAs implemented less than 15 days
    from the date of the survey were for deficiencies cited in a prior survey;
    in these cases, CMS continued the DPNA as the sanction for the current
    deficiencies.

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

    Now on p. 35.

    Appendix VII: Comments from the State of California--Health and Human
    Services Agency Department of Health Services

    Now on p. 31.

    Now on p. 30.

    Now on p. 19.

    Now on p. 47.

    Now on p. 44.

    Now on p. 39.

    Now on p. 38.

    Appendix VIII: Comments from the Michigan Department of Community Health

    Appendix IX: Comments from the Texas Department of Aging and Disability
    Services

    Now on p. 20.

    Now on p. 51.

    Now footnote 41 on p. 21.

    Appendix X: GAO Contact and Staff Acknowledgments

    GAO Contact

    Kathryn G. Allen, (202) 512-7118 or [64]allenk@gao.gov

    Acknowledgments

    In addition to the contact names above, Walter Ochinko, Assistant
    Director; Elizabeth Bradley; Jacquelyn Clinton; Joanne Jee; Elizabeth T.
    Morrison; Colbie Porter; Jessica Smith; and Karin Wallestad made key
    contributions to this report

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    (290440)

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    www.gao.gov/cgi-bin/getrpt?GAO-07-241 .

    To view the full product, including the scope
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    For more information, contact Kathryn G. Allen at (202) 512-7118 or
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    Highlights of [87]GAO-07-241 , a report to the Ranking Minority Member,
    Committee on Finance, U.S. Senate

    March 2007

    NURSING HOMES

    Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes
    from Repeatedly Harming Residents

    In 1998 and 1999 reports, GAO concluded that enforcement actions, known as
    sanctions, were ineffective in encouraging nursing homes to maintain
    compliance with federal quality requirements: sanctions were often
    rescinded before being implemented because homes had a grace period to
    correct deficiencies. In response, the Centers for Medicare & Medicaid
    Services (CMS) began requiring immediate sanctions for homes that
    repeatedly harmed residents. Using CMS enforcement and deficiency data,
    GAO (1) analyzed federal sanctions from fiscal years 2000 through 2005
    against 63 homes previously reviewed and (2) assessed CMS's overall
    management of enforcement. The 63 homes had a history of harming residents
    and were located in 4 states that account for about 22 percent of homes
    nationwide.

    [88]What GAO Recommends

    GAO recommends that the CMS Administrator (1) develop an administrative
    process for collecting civil money penalties more expeditiously and seek
    legislation to implement this process effectively, as appropriate; (2)
    strengthen its immediate sanctions policy; (3) expand its oversight of
    homes with a history of harming residents; and (4) improve the
    effectiveness of its enforcement data systems. CMS generally concurred
    with GAO's recommendations.

    From fiscal years 2000 through 2005, the number of sanctions decreased for
    the 63 nursing homes GAO reviewed that had a history of serious quality
    problems, a decline consistent with nationwide trends. While the decline
    may reflect improved quality or changes to enforcement policy, it may also
    mask survey weaknesses that understate quality problems, an issue GAO has
    reported on since 1998. Although the number of sanctions decreased, the
    homes generally were cited for more deficiencies that caused harm to
    residents than other homes in their states. Almost half of the homes
    reviewed continued to cycle in and out of compliance; 19 did so 4 times or
    more. These homes temporarily corrected deficiencies and, even with
    sanctions, were again found out of compliance on subsequent surveys.
    Several weaknesses appeared to undermine the effectiveness of the
    sanctions implemented against the homes reviewed. First, civil money
    penalties (CMP), which by statute are not paid while under appeal--a
    process that can take years--were generally imposed at the lower end of
    the allowable dollar range. For example, the median per day CMP ranged
    from $350 to $500, significantly below the maximum of $3,000 per day.
    Second, CMS favored the use of sanctions that give homes more time to
    correct deficiencies, increasing the likelihood that the sanctions would
    not be implemented. Thus, more than half of the denial of payment for new
    admissions (DPNA) that CMS imposed were the type that give homes 3 months
    to correct deficiencies rather than those that only give homes up to 15
    days. Third, there was no record of a sanction for about 22 percent of the
    homes reviewed that met CMS's criteria for immediate sanctions, a problem
    GAO also identified in 2003; moreover, 60 percent of DPNAs imposed as
    immediate sanctions were not implemented until 1 to 2 months after
    citation of the deficiency. Finally, involuntary termination of homes from
    participating in the Medicare or Medicaid programs was rare because of
    concerns about access to other nearby homes and resident transfer trauma;
    2 of the 63 homes reviewed were involuntarily terminated because of
    quality problems.

    CMS's management of enforcement is hampered by the complexity of its
    immediate sanctions policy and by its fragmented and incomplete data. Its
    policy allows some homes with the worst compliance histories to escape
    immediate sanctions. For example, a home cited with a serious deficiency
    and that has not yet corrected an earlier serious deficiency is spared an
    immediate sanction. Such rules may in part explain why the 63 homes
    reviewed only had 69 instances of immediate sanctions over a 6-year period
    despite being cited 444 times for deficiencies that harmed residents.
    Although CMS initiated development of a new enforcement data system 6
    years ago, it is fragmented and has incomplete national reporting
    capabilities. CMS is taking additional steps to improve nursing home
    enforcement, such as developing guidance to encourage more consistency in
    CMP amounts, but it is not clear whether and when these initiatives will
    address the enforcement weaknesses GAO found.

    References

    Visible links
      39. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-98-202
      40. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
      41. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
      43. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
      44. http://www.gao.gov/cgi-bin/getrpt?GAO-03-561
      45. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
      46. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-98-202
      47. http://www.gao.gov/cgi-bin/getrpt?GAO-03-561
      48. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
      49. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
      50. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
      51. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
      52. http://www.gao.gov/cgi-bin/getrpt?GAO-03-561
      53. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
      54. http://www.gao.gov/cgi-bin/getrpt?GAO-03-561
      55. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-98-202
      56. http://www.gao.gov/cgi-bin/getrpt?GAO-03-561
      57. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
      58. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
      59. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-197
      61. file:///home/webmaster/infomgt/d07241.htm#mailto:allenk@gao.gov
      62. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
      63. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
      64. file:///home/webmaster/infomgt/d07241.htm#mailto:allenk@gao.gov
      65. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
      66. http://www.gao.gov/cgi-bin/getrpt?GAO-05-78
      67. http://www.gao.gov/cgi-bin/getrpt?GAO-04-660
      68. http://www.gao.gov/cgi-bin/getrpt?GAO-03-561
      69. http://www.gao.gov/cgi-bin/getrpt?GAO-03-187
      70. http://www.gao.gov/cgi-bin/getrpt?GAO-02-431R
      71. http://www.gao.gov/cgi-bin/getrpt?GAO-02-312
      72. http://www.gao.gov/cgi-bin/getrpt?GAO-02-279
      73. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-197
      74. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-6
      75. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-154R
      76. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-157
      77. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-80
      78. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
      79. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-98-202
      87. http://www.gao.gov/cgi-bin/getrpt?GAO-07-241
    *** End of document. ***