Nursing Homes: Federal Monitoring Surveys Demonstrate Continued  
Understatement of Serious Care Problems and CMS Oversight	 
Weaknesses (09-MAY-08, GAO-08-517).				 
                                                                 
GAO reports since 1998 have demonstrated that state surveyors,	 
who evaluate the quality of nursing home care on behalf of CMS,  
sometimes understate the extent of serious care problems in homes
because they miss deficiencies. CMS oversees the effectiveness of
state surveys through the federal monitoring survey program. In  
this program, federal surveyors in CMS's regional offices either 
independently evaluate state surveys by resurveying a home	 
(comparative surveys) or directly observe state surveyors during 
a routine nursing home survey (observational surveys). GAO was	 
asked to evaluate the information federal monitoring surveys	 
provide on understatement and the effectiveness of CMS management
and oversight of the survey program. To do this, GAO analyzed the
results of federal monitoring surveys for fiscal years 2002	 
through 2007, reviewed CMS guidance for the survey program, and  
interviewed headquarters and regional office officials. 	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-517 					        
    ACCNO:   A82081						        
  TITLE:     Nursing Homes: Federal Monitoring Surveys Demonstrate    
Continued Understatement of Serious Care Problems and CMS	 
Oversight Weaknesses						 
     DATE:   05/09/2008 
  SUBJECT:   Comparative analysis				 
	     Data collection					 
	     Data integrity					 
	     Elder care 					 
	     Health care programs				 
	     Health surveys					 
	     Investigations by federal agencies 		 
	     Medical care evaluation				 
	     Medicare						 
	     Monitoring 					 
	     Noncompliance					 
	     Nursing homes					 
	     Program evaluation 				 
	     Program management 				 
	     Quality of care					 
	     Standards evaluation				 
	     State-administered programs			 
	     Surveys						 
	     Health and behavioral care standards		 
	     Reporting requirements				 
	     Corrective action					 
	     Policies and procedures				 
	     Program implementation				 
	     Surveyors						 

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GAO-08-517

   

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Report to Congressional Requesters: 

United States Government Accountability Office: 

GAO: 

May 2008: 

Nursing Homes: 

Federal Monitoring Surveys Demonstrate Continued Understatement of 
Serious Care Problems and CMS Oversight Weaknesses: 

Federal Monitoring Surveys for Nursing Homes: 

GAO-08-517: 

GAO Highlights: 

Highlights of GAO-08-517, a report to congressional requesters. 

Why GAO Did This Study: 

GAO reports since 1998 have demonstrated that state surveyors, who 
evaluate the quality of nursing home care on behalf of CMS, sometimes 
understate the extent of serious care problems in homes because they 
miss deficiencies. CMS oversees the effectiveness of state surveys 
through the federal monitoring survey program. In this program, federal 
surveyors in CMSï¿½s regional offices either independently evaluate state 
surveys by resurveying a home (comparative surveys) or directly observe 
state surveyors during a routine nursing home survey (observational 
surveys). GAO was asked to evaluate the information federal monitoring 
surveys provide on understatement and the effectiveness of CMS 
management and oversight of the survey program. To do this, GAO 
analyzed the results of federal monitoring surveys for fiscal years 
2002 through 2007, reviewed CMS guidance for the survey program, and 
interviewed headquarters and regional office officials. 

What GAO Found: 

A substantial proportion of federal comparative surveys identify missed 
deficiencies at the potential for more than minimal harm level or 
above. During fiscal years 2002 through 2007, about 15 percent of 
federal comparative surveys nationwide identified state surveys that 
failed to cite at least one deficiency at the most serious levels of 
noncomplianceï¿½actual harm and immediate jeopardy. Overall, nine states 
missed serious deficiencies on 25 percent or more of comparative 
surveys; in seven states federal surveyors identified no such missed 
deficiencies. During the same period, missed deficiencies at the lowest 
level of noncomplianceï¿½the potential for more than minimal harmï¿½were 
more widespread: nationwide, approximately 70 percent of federal 
comparative surveys identified state surveys missing at least one 
deficiency at the lowest level of noncompliance, and in all but five 
states the number of state surveys with such missed deficiencies was 
greater than 40 percent. Undetected care problems at this level are a 
concern because they could become more serious if nursing homes are not 
required to take corrective action. The most frequently missed type of 
deficiency on comparative surveys, at the potential for more than 
minimal harm level and above, was poor quality of care, such as 
ensuring proper nutrition and hydration and preventing pressure sores. 
Federal observational surveys highlighted two factors that may 
contribute to understatement of deficiencies: weaknesses in state 
surveyorsï¿½ (1) investigative skills and (2) ability to integrate and 
analyze information collected to make an appropriate deficiency 
determination. These factors may contribute to understatement because 
they directly affect the appropriate identification and citation of 
deficiencies. 

CMS has taken steps to improve the federal monitoring survey program, 
but weaknesses remain in program management and oversight. For example, 
CMS has improved processes to ensure that comparative surveys more 
accurately reflect conditions at the time of the state survey, such as 
requiring that comparative surveys occur within 30 working days of the 
state survey rather than within the 2 months set in statute. Despite 
these improvements, the management and oversight potential of the 
program has not been fully realized. For example, CMS has only begun to 
explore options for identifying understatement that occurs in cases 
where state surveys cite deficiencies at too low a level, for possible 
implementation in fiscal year 2009. In addition, CMS is not effectively 
managing the federal monitoring survey database to ensure that the 
regional offices are entering data accurately and reliablyï¿½CMS was 
unaware, for example, that a considerable number of comparative surveys 
had not been entered. Furthermore, CMS is not using the database to 
oversee consistent implementation of the program by the regional 
officesï¿½for example, the agency is not using the database to identify 
inconsistencies between comparative and observational survey results. 

What GAO Recommends: 

GAO is making four recommendations to the CMS Administrator to address 
weaknesses in CMSï¿½s management of the federal monitoring survey 
database that affect the agencyï¿½s ability to track understatement and 
CMSï¿½s ability to oversee regional office implementation of the federal 
monitoring survey program. In its comments on a draft of this report, 
HHS fully endorsed and indicated it would implement GAOï¿½s 
recommendations. 

To view the full product, including the scope and methodology, click on 
[http://www.gao.gov/cgi-bin/getrpt?GAO-08-517]. For more information, 
contact John E. Dicken at (202) 512-7114 or [email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Substantial Proportion of Federal Comparative Surveys Identify Missed 
Deficiencies: 

CMS Has Taken Steps to Improve the Federal Monitoring Survey Program, 
but Weaknesses in Management and Oversight Remain: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Percentage of Nursing Homes Cited for Actual Harm or 
Immediate Jeopardy during Standard Surveys: 

Appendix II: Percentage of Comparative Surveys Identifying Missed 
Deficiencies at Actual Harm or Immediate Jeopardy Level: 

Appendix III: Percentage of Comparative Surveys Identifying Missed 
Deficiencies with Potential for More Than Minimal Harm: 

Appendix IV: Percentage of Comparative Surveys with at Least One Missed 
Deficiency, by Federal Quality Standard Category: 

Appendix V: Percentage of Below Satisfactory State Survey Ratings for 
General Investigation and Deficiency Determination: 

Appendix VI: Comments from the Department of Health & Human Services: 

Appendix VII: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Scope and Severity of Deficiencies Identified during Nursing 
Home Surveys: 

Table 2: States with 25 Percent or More of Comparative Surveys 
Identifying Missed Deficiencies at the Actual Harm or Immediate 
Jeopardy Levels, Fiscal Years 2002 through 2007: 

Table 3: States with 25 Percent or More of Comparative Surveys with 
Missed Deficiencies and Percentage of Their Observational Surveys with 
Less Than Satisfactory Ratings on General Investigation and Deficiency 
Determination, Fiscal Years 2002 through 2007: 

Table 4: Percentage of Nursing Homes Cited for Actual Harm or Immediate 
Jeopardy, by State, Fiscal Years 2002 through 2007: 

Figures: 

Figure 1: Percentage of Comparative Surveys Nationwide Citing at Least 
One Missed Deficiency at the Actual Harm or Immediate Jeopardy Level, 
Fiscal Years 2002 through 2007: 

Figure 2: National Percentage of Comparative Surveys Citing at Least 
One Missed Deficiency at the Potential for More Than Minimal Harm 
Level, Fiscal Years 2002 through 2007: 

Figure 3: Percentage of Comparative Surveys Nationwide with 
Understatement of Actual Harm and Immediate Jeopardy Deficiencies, with 
Scope and Severity Differences Included, Fiscal Years 2002 through 
2007: 

Abbreviations: 

CMS: Centers for Medicare & Medicaid Services: 

HHS: Department of Health & Human Services: 

OSCAR: On-Line Survey, Certification, and Reporting system: 

United States Government Accountability Office: 

Washington, DC 20548: 

May 9, 2008: 

The Honorable Herb Kohl: 
Chairman: 
Special Committee on Aging: 
United States Senate: 

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

Since 1998, Congress has focused considerable attention on the need to 
improve the quality of care for the nation's 1.5 million nursing home 
residents, a highly vulnerable population of elderly and disabled 
individuals for whom remaining at home is no longer feasible. Poor 
quality of care--worsening pressure sores or untreated weight loss--in 
a small but unacceptably high number of nursing homes continues to harm 
residents or place them in immediate jeopardy, that is, at risk of 
death or serious injury. About 1 in 5 homes nationwide were cited for 
such serious deficiencies on state inspections, known as surveys, in 
fiscal year 2007 (see app. I). Our previous work, however, demonstrated 
that state surveys sometimes understated the extent of serious care 
problems and that federal oversight of state survey activities had 
weaknesses.[Footnote 1] Understatement can occur when a state surveyor 
fails to cite a deficiency altogether or cites a deficiency at too low 
a level. 

The Centers for Medicare & Medicaid Services (CMS) is the federal 
agency responsible for ensuring the effectiveness of state 
surveys.[Footnote 2] Through CMS's federal monitoring survey program, 
federal surveyors either (1) independently evaluate state surveys by 
resurveying a home recently inspected by state surveyors and comparing 
the deficiencies identified during the two surveys, known as a 
comparative survey, or (2) directly observe state surveyors during a 
routine nursing home survey, known as an observational survey. Results 
from both federal comparative and observational surveys--which are 
recorded in the federal monitoring survey database--allow CMS to gauge 
states' abilities to accurately assess nursing home quality. 

Recently, we reported that federal comparative surveys in five large 
states identified the continuing understatement of serious care 
problems by state surveyors.[Footnote 3] You asked us to look at the 
understatement of serious deficiencies by state surveyors nationwide. 
In this report we address two questions: (1) what information do 
federal monitoring surveys provide about understatement nationwide, and 
(2) how effective are CMS management and oversight of the federal 
monitoring survey program? 

To answer the first question, we analyzed the results of comparative 
and observational surveys nationwide for fiscal years 2002 through 2007 
using the federal monitoring survey database.[Footnote 4] During this 
period, federal surveyors conducted 976 comparative surveys and 4,023 
observational surveys. To identify understatement on comparative 
surveys, we focused our analysis on cases where federal surveyors 
determined that state surveyors should have cited a deficiency but 
failed to do so or where state surveyors cited a deficiency at too low 
a level. We analyzed the results of observational surveys in order to 
better understand why understatement might occur. Deficiencies 
identified during nursing home surveys are categorized according to 
their scope (i.e., the number of residents potentially or actually 
affected) and severity (i.e., the degree of relative harm involved). 
Homes with deficiencies at the A though C levels are considered to be 
in substantial compliance, while those with deficiencies at the D 
through L levels are considered out of compliance. (See table 1.) 
Throughout this report, we refer to deficiencies at the actual harm and 
immediate jeopardy levels as serious deficiencies. 

Table 1: Scope and Severity of Deficiencies Identified during Nursing 
Home Surveys: 

Severity: Immediate jeopardy[A]; 
Scope: Isolated: J; 
Scope: Pattern: K; 
Scope: Widespread: L. 

Severity: Actual harm; 
Scope: Isolated: G; 
Scope: Pattern: H; 
Scope: Widespread: I. 

Severity: Potential for more than minimal harm; 
Scope: Isolated: D; 
Scope: Pattern: E; 
Scope: Widespread: F. 

Severity: Potential for minimal harm[B]; 
Scope: Isolated: A; 
Scope: Pattern: B; 
Scope: Widespread: C. 

Source: CMS. 

[A] Actual or potential for death/serious injury. 

[B] Nursing home is considered to be in substantial compliance. 

[End of table] 

To ensure reliability of the federal monitoring survey database, we 
discussed data entry procedures with all 10 CMS regional offices, whose 
staff enter information into the database. In addition, we conducted 
several data reliability tests, including (1) automated checks of data 
fields to ensure that they contained complete information and (2) 
manual reviews of a random sample of all deficiencies cited by federal 
but not state surveyors to ensure that federal surveyors had used the 
data fields appropriately. We also eliminated a small number of 
deficiencies that did not correspond to a defined severity level or 
contained illogical survey dates--such as a comparative survey that 
began prior to the state survey. Based on these activities, we 
determined that the information was sufficiently reliable for our 
purposes. Data on comparative surveys, however, cannot be used to 
project the extent of understatement across all state surveys because 
the state surveys selected for federal monitoring surveys are not 
representative of all nursing home surveys or survey teams within each 
state. 

To answer the second question, we reviewed CMS guidance for the federal 
monitoring survey program and interviewed officials in CMS headquarters 
and all 10 regional offices. Our work focused on CMS's (1) efforts to 
improve the use of comparative surveys as an oversight tool; (2) 
ability to track the understatement of deficiencies; and (3) management 
of the federal monitoring survey database, including the use of the 
database to oversee regional office implementation of the federal 
monitoring survey program. We also analyzed (1) the comments entered 
into the federal monitoring survey database by federal surveyors for 
certain discrepancies between federal and state survey findings and (2) 
the consistency between comparative and observational survey results 
within states and CMS regional offices. We performed our work from July 
2007 through May 2008 in accordance with generally accepted government 
auditing standards. 

Results in Brief: 

A substantial proportion of federal comparative surveys identify missed 
deficiencies at the potential for more than minimal harm level or 
above. From fiscal year 2002 through 2007, about 15 percent of federal 
comparative surveys nationwide identified state surveys that failed to 
cite at least one deficiency at the most serious levels of 
noncompliance--the actual harm and immediate jeopardy levels. Overall, 
in nine states federal surveyors identified missed serious deficiencies 
on 25 percent or more of comparative surveys, but in seven states they 
identified no missed serious deficiencies. During the same period, 
missed deficiencies at the potential for more than minimal harm level 
were more widespread: nationwide, approximately 70 percent of federal 
comparative surveys identified state surveys missing at least one 
deficiency at the potential for more than minimal harm level, and in 
all but five states the number of state surveys with such missed 
deficiencies was greater than 40 percent. Such undetected care problems 
are of concern because they could become more serious over time if 
nursing homes are not required to take corrective actions. The most 
frequently missed deficiencies identified on comparative surveys--from 
the potential for more than minimal harm through immediate jeopardy 
levels--involved poor quality of care, such as ensuring proper 
nutrition and hydration and preventing pressure sores. Federal 
observational surveys highlighted two factors that may contribute to 
the understatement of deficiencies--weaknesses in state surveyors' 
investigative skills and in their ability to integrate and analyze the 
information collected to make an appropriate deficiency determination. 
Six of the nine states that missed serious deficiencies on 25 percent 
or more of comparative surveys had observational survey ratings for 
these two dimensions that were worse than the national average. 

CMS has taken steps to improve the federal monitoring survey program, 
but weaknesses remain in program management and oversight. For example, 
CMS has improved processes to ensure that comparative surveys more 
accurately reflect conditions at the time of the state survey, such as 
requiring that comparative surveys occur within 30 working days of the 
state survey rather than within the 2 months set in statute. However, 
despite these improvements, the management and oversight potential of 
the program has not been fully realized. First, we found that the 
federal monitoring survey database did not capture the full extent of 
understatement because CMS does not require regional offices to 
determine when state surveyors cite a deficiency at too low a level. 
The agency has only begun exploring options for identifying potential 
scope and severity understatement. When we manually analyzed optional 
comment fields in the database to assess how often a deficiency was 
cited at too low a level, we were able to confirm this type of 
understatement in 38 percent of the cases we examined; when combined 
with understatement caused by missed deficiencies, overall 
understatement of serious deficiencies by state surveyors increased 
from about 15 percent to about 16 percent for fiscal years 2002 through 
2007. Second, we found that CMS was not effectively managing the 
database to ensure that the regional offices were entering data 
accurately and reliably. CMS was unaware, for example, that a 
considerable number of comparative surveys had not been entered. 
Finally, we found weaknesses in CMS's use of the database for regional 
office oversight. For example, despite the fact that inconsistencies in 
comparative and observational survey findings in specific states could 
indicate that some CMS regional offices did not follow CMS guidance in 
assessing state surveyor performance, CMS officials told us that they 
did not plan to follow up with regional offices about these 
inconsistencies. 

We are making four recommendations to the CMS Administrator to address 
weaknesses in CMS's management and oversight of federal monitoring 
surveys. We recommend that CMS (1) require regional offices to 
determine if there was understatement when state surveyors cite a 
deficiency at a lower scope and severity level than federal surveyors 
and to track this information, (2) establish quality controls to 
improve the accuracy and reliability of information entered into the 
federal monitoring survey database, (3) routinely examine comparative 
survey data and hold regional offices accountable for implementing CMS 
guidance that is intended to ensure that comparative surveys more 
accurately capture the conditions at the time of the state survey, and 
(4) regularly analyze and compare federal comparative and observational 
survey results. We provided a draft of this report to CMS through the 
Department of Health & Human Services (HHS). The comments we received 
were submitted by HHS. HHS fully endorsed and indicated it would 
implement our recommendations. 

Background: 

Oversight of nursing homes is a shared federal-state responsibility. 
Based on statutory requirements, CMS (1) defines quality standards that 
nursing homes must meet to participate in the Medicare and Medicaid 
programs and (2) contracts with state survey agencies to assess whether 
homes meet those standards through annual surveys and complaint 
investigations.[Footnote 5] Although CMS has issued extensive guidance 
to states on determining compliance with federal quality requirements, 
we have found that some state surveys understate quality problems at 
nursing homes.[Footnote 6] 

Federal Quality Standards: 

Federal nursing home quality standards focus on the delivery of care, 
resident outcomes, and facility conditions. These standards, totaling 
approximately 200, are grouped into 15 categories, such as Resident 
Rights, Quality of Life, Resident Assessment, Quality of Care, Pharmacy 
Services, and Administration.[Footnote 7] For example, there are 23 
standards within the Quality of Care category ranging from "promote the 
prevention of pressure [sore] development" to "the resident environment 
remains as free of accident hazards as is possible." CMS has also 
developed detailed investigative protocols to assist state survey 
agencies in determining whether nursing homes are in compliance with 
federal quality standards. This guidance is intended to ensure the 
thoroughness and consistency of state surveys and complaint 
investigations. 

Standard Surveys and Complaint Investigations: 

Every nursing home receiving Medicare or Medicaid payment must undergo 
a standard state survey not less than once every 15 months, and the 
statewide average interval for these surveys must not exceed 12 months. 
During a standard survey, teams of state surveyors--generally 
consisting of registered nurses, social workers, dieticians, or other 
specialists--evaluate compliance with federal quality standards. Based 
on the care provided to a sample of residents, the survey team (1) 
determines whether the care and services provided meet the assessed 
needs of the residents and (2) measures resident outcomes, such as the 
incidence of preventable pressure sores, weight loss, and accidents. In 
contrast to a standard survey, a complaint investigation generally 
focuses on a specific allegation regarding a resident's care or safety 
and provides an opportunity for state surveyors to intervene promptly 
if problems arise between standard surveys. Surveyors generally follow 
state procedures when investigating complaints, but must comply with 
certain federal guidelines and time frames. 

Enforcement: 

When deficiencies are identified, federal sanctions can be imposed to 
help encourage homes to correct them. Sanctions are generally reserved 
for serious deficiencies--those at the G through L levels--which 
constitute actual harm and immediate jeopardy.[Footnote 8] Sanctions 
for such serious quality problems can affect a home's revenues and 
provide financial incentives to return to and maintain compliance. Such 
sanctions include fines known as civil money penalties, denial of 
payment for new Medicare or Medicaid admissions, or termination from 
the Medicare and Medicaid programs. 

State surveys that miss serious deficiencies or cite deficiencies at 
too low a scope and severity level have enforcement implications 
because a nursing home may escape sanctions intended to discourage 
repeated noncompliance. For example, facilities that receive at least 
one G through L level deficiency on successive standard surveys or 
complaint investigations must be referred for immediate 
sanctions.[Footnote 9] In addition, CMS guidance calls for higher fines 
when a home has a poor compliance history and requires that state 
survey teams revisit a home to verify that serious deficiencies have 
actually been corrected (such revisits are not required for most 
deficiencies cited below the actual harm level--A through F).[Footnote 
10] 

CMS Oversight of State Surveys: 

Statutorily required federal monitoring surveys, which are conducted 
annually in at least 5 percent of state-surveyed Medicare and Medicaid 
nursing homes in each state, are a key CMS oversight tool in ensuring 
the adequacy of state surveys.[Footnote 11] CMS headquarters-- 
specifically, CMS's Survey and Certification Group--is responsible for 
the management of the federal monitoring survey database and for 
oversight of the 10 CMS regional offices' implementation of the federal 
monitoring survey program.[Footnote 12] Federal surveyors located in 
regional offices conduct federal monitoring surveys. The surveys can be 
either comparative or observational, with each offering unique 
advantages and disadvantages as an oversight tool. For example, an 
advantage of comparative surveys is that they are an independent 
evaluation of a nursing home recently surveyed by a state survey agency 
team. A disadvantage is that the time lag between the two surveys can 
make analysis of differences difficult. 

* Comparative survey. A federal survey team conducts an independent 
survey of a home recently surveyed by a state survey agency in order to 
compare and contrast the findings. This comparison takes place after 
completion of the federal survey. When federal surveyors identify a 
deficiency not cited by state surveyors, they assess whether the 
deficiency existed at the time of the state survey and should have been 
cited by entering either yes or no to the question, "Based on the 
evidence available to the [state], should the [state survey] team have 
cited this [deficiency]?" This assessment is critical in determining 
whether understatement occurred because some deficiencies cited by 
federal surveyors may not have existed at the time of the state survey. 
For example, a deficiency identified during a federal survey could 
involve a resident who was not in the nursing home at the time of the 
earlier state survey. By statute, comparative surveys must be conducted 
within 2 months of the completion of the state survey. However, 
differences in timing, resident sample selection, and staffing can make 
analysis of differences between the state and federal comparative 
surveys difficult. On the basis of our prior recommendations, CMS has 
taken several steps to ensure that comparative surveys more accurately 
capture conditions at the time of the state survey.[Footnote 13] For 
example, CMS now calls for the length of time between the state and 
federal surveys to be between 10 and 30 working days and requires 
federal surveyors conducting a comparative survey in a nursing home to 
include at least half of the state survey's sample of residents from 
that nursing home in the comparative survey sample, making it easier to 
determine whether state surveyors missed a deficiency.[Footnote 14] 
Furthermore, federal comparative survey teams are expected to mimic the 
number of staff assigned to the state survey. CMS also issued guidance 
in October 2002 defining the criteria for federal surveyors to consider 
when selecting facilities for comparative surveys.[Footnote 15] These 
selection criteria can generally be categorized as state survey team 
performance and facility characteristics. Regional offices were given 
latitude in their use of these criteria and may supplement them with 
other selection factors unique to their regions. For example, some 
regions use statistics on the prevalence of pressure sores in a nursing 
home's resident population as a comparative survey selection factor. 

* Observational survey. Federal surveyors accompany a state survey team 
to a nursing home to evaluate the team's on-site survey performance and 
ability to document survey deficiencies. State teams are evaluated in 
six areas--Concern Identification, Sample Selection, General 
Investigation, Food-Borne Illness Investigation, Medication 
Investigations, and Deficiency Determination--and are rated in one of 
five categories for each of the six measures. The rating categories-- 
from highest to lowest--are extremely effective, very effective, 
satisfactory, less than satisfactory, and much less than satisfactory. 
CMS annual state performance reviews require that state survey teams 
achieve an average rating of satisfactory. Observational surveys allow 
federal surveyors to provide more immediate feedback to state surveyors 
and to identify state surveyor training needs. However, observational 
surveys are not independent evaluations of the state survey. Because 
state surveyors may perform their survey tasks more attentively than 
they would if federal surveyors were not present, observational surveys 
may not provide an accurate picture of state surveyors' typical 
performance. Since 2001, CMS has also taken steps to strengthen 
observational surveys. For example, the agency issued written guidance 
defining a standard process for resolving disagreements and a new 
manual to increase consistency across observational surveys. 

The 976 federal comparative surveys conducted from fiscal year 2002 
through 2007 ranged from as few as 10 in Vermont, which has about 40 
facilities, to as many as 49 in California, which has about 1,300 
facilities. Of the 4,023 federal observational surveys conducted during 
the same period, the number ranged from 16 in New Hampshire to 346 in 
California. 

The results of federal monitoring surveys, including information on the 
corresponding state surveys, are entered in the federal monitoring 
survey database. In fiscal year 2002, CMS began including information 
on comparative surveys in the database, and the agency began requiring 
federal surveyors to determine whether a deficiency cited by federal 
but not state surveyors had been missed by determining whether state 
surveyors should have cited the deficiency. 

Understatement of Deficiency Scope and Severity Level: 

Although comparative surveys and the wide variability across states in 
the proportion of homes with deficiencies at the actual harm and 
immediate jeopardy levels indicate that state surveyors miss some 
serious deficiencies, our prior work has also indicated that state 
surveyors sometimes understate the scope and severity of a deficiency. 
In 2003, we found widespread understatement of actual harm deficiencies 
in a sample of surveys from homes with a history of harming 
residents.[Footnote 16] Overall, 39 percent of the 76 state surveys we 
reviewed had documented problems that should have been classified as 
actual harm instead of as lower-level deficiencies. 

Substantial Proportion of Federal Comparative Surveys Identify Missed 
Deficiencies: 

A substantial proportion of federal comparative surveys identify missed 
deficiencies at the potential for more than minimal harm level or 
above. From fiscal year 2002 through 2007, about 15 percent of federal 
comparative surveys nationwide identified state surveys that failed to 
cite at least one deficiency at the most serious levels of 
noncompliance--the actual harm and immediate jeopardy levels (G through 
L). There was wide variation across states in the proportion of 
comparative surveys that found at least one missed serious deficiency, 
from more than 25 percent in nine states to none in seven others. In 
contrast to missed serious deficiencies, missed deficiencies at the 
potential for more than minimal harm level (D through F) were 
considerably more widespread, with such missed deficiencies greater 
than 40 percent in all but five states. Every state had at least one 
comparative survey with missed D through F level deficiencies. At both 
levels of noncompliance, the most frequently missed deficiencies 
involved Quality of Care standards. Federal observational survey 
results and prior GAO reports have highlighted several factors that may 
contribute to the understatement of deficiencies. 

Small but Unacceptably High Proportion of Federal Comparative Surveys 
Found That State Survey Teams Missed Serious Deficiencies: 

About 15 percent (142) of the 976 comparative surveys conducted from 
fiscal year 2002 through 2007 identified state surveys that missed at 
least one deficiency at the actual harm or immediate jeopardy level (G 
through L), the most serious levels of noncompliance. This proportion 
fluctuated from a high of 17.5 percent in fiscal year 2003 to a low of 
11.1 percent in fiscal year 2004, but it has remained relatively 
constant at about 15 percent for the last several fiscal years (see 
fig. 1). This proportion is small, but CMS maintains that any missed 
serious deficiencies are unacceptable. 

Figure 1: Percentage of Comparative Surveys Nationwide Citing at Least 
One Missed Deficiency at the Actual Harm or Immediate Jeopardy Level, 
Fiscal Years 2002 through 2007: 

This figure is a line graph showing percentage of comparative surveys 
nationwide citing at least one missed deficiency at the actual harm or 
immediate jeopardy level, fiscal years 2002 through 2007. The X axis 
represents the fiscal year, and the Y axis represents the percentage of 
comparative surveys. 

Fiscal year: 2002; 
Percentage of comparative surveys: 13.8. 

Fiscal year: 2003; 
Percentage of comparative surveys: 17.5. 

Fiscal year: 2004; 
Percentage of comparative surveys: 11.1. 

Fiscal year: 2005; 
Percentage of comparative surveys: 14.3. 

Fiscal year: 2006; 
Percentage of comparative surveys: 15.3. 

Fiscal year: 2007; 
Percentage of comparative surveys: 15.3. 

[See PDF for image] 

Source: GAO analysis of federal monitoring survey data. 

[End of figure] 

From fiscal year 2002 through 2007, federal surveyors identified missed 
serious deficiencies in 25 percent or more of their comparative surveys 
in nine states. The proportion of missed serious deficiencies in these 
nine states ranged from 26.3 percent in Tennessee to 33.3 percent in 
New Mexico, South Carolina, South Dakota, and Wyoming (see table 
2).[Footnote 17] The total number of missed deficiencies at the G 
through L levels also varied across these nine states, from a low of 4 
in South Dakota to a high of 19 in South Carolina. Federal surveyors 
identified no missed serious deficiencies in seven states (see app. II 
for complete state results).[Footnote 18] 

Table 2: States with 25 Percent or More of Comparative Surveys 
Identifying Missed Deficiencies at the Actual Harm or Immediate 
Jeopardy Levels, Fiscal Years 2002 through 2007: 

State: New Mexico; 
Number of homes in fiscal year 2007: 72; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 33.3; 
Total number missed G-L deficiencies: 9. 

State: South Carolina; 
Number of homes in fiscal year 2007: 176; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 6; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 33.3; 
Total number missed G-L deficiencies: 19. 

State: South Dakota; 
Number of homes in fiscal year 2007: 112; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 33.3; 
Total number missed G-L deficiencies: 4. 

State: Wyoming; 
Number of homes in fiscal year 2007: 39; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 33.3; 
Total number missed G-L deficiencies: 5. 

State: Oklahoma; 
Number of homes in fiscal year 2007: 348; 
Total comparative surveys: 20; 
Total comparative surveys with at least one missed G-L deficiency: 6; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 30.0; 
Total number missed G-L deficiencies: 11. 

State: Missouri; 
Number of homes in fiscal year 2007: 530; 
Total comparative surveys: 28; 
Total comparative surveys with at least one missed G-L deficiency: 8; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 28.6; 
Total number missed G-L deficiencies: 14. 

State: Alabama; 
Number of homes in fiscal year 2007: 233; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 5; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 27.8; 
Total number missed G-L deficiencies: 13. 

State: Arizona; 
Number of homes in fiscal year 2007: 137; 
Total comparative surveys: 15; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 26.7; 
Total number missed G-L deficiencies: 6. 

State: Tennessee; 
Number of homes in fiscal year 2007: 332; 
Total comparative surveys: 19; 
Total comparative surveys with at least one missed G-L deficiency: 5; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 26.3; 
Total number missed G-L deficiencies: 10. 

Source: GAO analysis of federal monitoring survey data. 

[End of table] 

Missed Deficiencies at the Potential for More Than Minimal Harm Level 
Were Widespread on Federal Comparative Surveys: 

Figure: Example of a Missed Deficiency at the Potential for More Than 
Minimal Harm Level: 

On a fiscal year 2007 comparative survey, federal surveyors found an F-
level deficiencyï¿½that is, a deficiency widespread throughout the 
facilityï¿½that the state survey team had not cited at any level. After 
verifying that the evidence used by federal surveyors was available at 
the time of the state survey, the federal surveyors commented that 
ï¿½Deficiency [is] based on a systemic lack of monthly drug reviews 
dating back to June 2006. [State surveyors] would have been expected to 
cite this deficient practice.ï¿½ 

In contrast to missed serious deficiencies, missed deficiencies at the 
potential for more than minimal harm level (D through F) were 
considerably more widespread on comparative surveys conducted during 
fiscal years 2002 through 2007. Approximately 70 percent of comparative 
surveys conducted nationwide identified state surveys that missed at 
least one deficiency at the potential for more than minimal harm level 
(D through F), with such missed deficiencies identified on greater than 
40 percent of comparative surveys in all but five states--Alaska, Ohio, 
Vermont, West Virginia, and Wisconsin.[Footnote 19] On average, state 
surveys selected for comparative surveys failed to identify 2.5 D 
through F level deficiencies per survey. Undetected care problems at 
the D through F level are of concern because they could become more 
serious over time if nursing homes are not required to take corrective 
actions. Missed deficiencies at the potential for more than minimal 
harm level were not isolated to a single year during the 6 fiscal years 
we examined and continued to be a problem for states in fiscal year 
2007. Nationally, the proportion of comparative surveys identifying at 
least one missed D through F level deficiency in fiscal year 2007 was 
about 74 percent (see fig. 2). For results by state, see appendix III. 

Figure 2: National Percentage of Comparative Surveys Citing at Least 
One Missed Deficiency at the Potential for More Than Minimal Harm 
Level, Fiscal Years 2002 through 2007: 

This figure is a line graph showing national percentage of comparative 
surveys citing at least one missed deficiency at the potential for more 
than minimal harm level, fiscal years 2002 through 2007. The X axis 
represents the fiscal year, and the Y axis represents the percentage of 
comparative surveys. 

Fiscal year: 2002; 
Percentage of comparative surveys: 55.0. 

Fiscal year: 2003; 
Percentage of comparative surveys: 66.3. 

Fiscal year: 2004; 
Percentage of comparative surveys: 66.0. 

Fiscal year: 2005; 
Percentage of comparative surveys: 76.4. 

Fiscal year: 2006; 
Percentage of comparative surveys: 72.0.  

Fiscal year: 2007; 
Percentage of comparative surveys: 74.1. 

[See PDF for image] 

Source: GAO analysis of federal monitoring survey data. 

[End of figure] 

Most Frequently Missed Deficiencies Involved Quality of Care: 

Our analysis found that the most frequently missed deficiencies at both 
the potential for more than minimal harm (D through F) and the actual 
harm or immediate jeopardy (G through L) levels occurred in quality 
standards under CMS's Quality of Care category. Missed deficiencies in 
this category involved residents' receipt of the necessary care and 
services to attain and maintain the highest practicable physical, 
mental, and psychosocial well-being--such as prevention of pressure 
sores, nutrition and hydration, accident prevention, and assistance 
with bathing and grooming. 

From fiscal year 2002 through 2007, 11.9 percent of federal comparative 
surveys (116) cited at least one Quality of Care deficiency at the 
actual harm or immediate jeopardy level that state survey teams failed 
to cite. These 116 surveys contained a total of 143 missed serious 
Quality of Care deficiencies. The category with the next highest 
frequency of missed serious deficiencies was Resident Behavior and 
Facility Practices, with only 2.2 percent of total federal comparative 
surveys.[Footnote 20] At the potential for more than minimal harm 
level, Quality of Care was one of two categories with the highest 
frequency of missed deficiencies--31.7 percent.[Footnote 21] For the 
percentage of missed deficiencies in each of the CMS quality standard 
categories, see appendix IV. 

Federal Observational Surveys and Prior GAO Reports Identified Factors 
That May Contribute to Deficiency Understatement by State Survey Teams: 

Both federal observational surveys and our prior reports have 
identified factors that may contribute to the understatement of 
deficiencies by state survey teams. From fiscal year 2002 through 2007, 
80 percent of the 4,999 federal monitoring surveys were observational. 
Our review of observational survey data--which are collected during 
direct observation of state survey teams--found that some of the lowest 
state survey team ratings nationwide were in the General Investigation 
and Deficiency Determination areas. Together, these two areas directly 
affect the appropriate identification and citation of deficiencies. 

* The General Investigation segment of an observational survey 
evaluates the effectiveness with which the state survey team collected 
information to determine how the facility's environment and care of 
residents affect residents' quality of life, health and safety, and 
ability to reach their highest practicable physical, mental, and 
psychosocial well-being. This segment includes observations of state 
survey team actions such as collection of information, discussion of 
survey observations, interviews with facility residents, and 
implementation of CMS investigative protocols. 

* The Deficiency Determination segment of an observational survey 
evaluates the skill with which the state survey teams (1) integrate and 
analyze all information collected and (2) use the guidance to surveyors 
and regulatory requirements to make accurate compliance determinations. 
This segment includes observations of state survey team actions such as 
reviews of regulatory requirements, team participation in deficiency 
discussions, presentation of complete information, accurate decision 
making, and accurate citation of deficiencies. 

Nationwide, 7.7 percent of the state survey teams observed by federal 
surveyors received below satisfactory ratings on the General 
Investigation measure from fiscal year 2002 through 2007.[Footnote 22] 
During the same 6 fiscal years, 9.2 percent, or about 1 in 11, of the 
state survey teams observed by federal surveyors received below 
satisfactory ratings on the Deficiency Determination measure. Our 
analysis found variation across states in survey team performance in 
General Investigation and Deficiency Determination. Sixteen states had 
more teams than the national average receive below satisfactory ratings 
for both measures, while 28 states had fewer teams than the national 
average receive below satisfactory ratings (see app. V).[Footnote 23] 

Poor performance on these observational survey measures may be a 
contributing factor to the understatement of deficiencies by state 
survey teams. For example, of the nine states in table 2 with the 
highest percentage of missed serious deficiencies on comparative 
surveys, six had more teams than the national average receive below 
satisfactory ratings for both General Investigation and Deficiency 
Determination (see table 3).[Footnote 24] 

Table 3: States with 25 Percent or More of Comparative Surveys with 
Missed Deficiencies and Percentage of Their Observational Surveys with 
Less Than Satisfactory Ratings on General Investigation and Deficiency 
Determination, Fiscal Years 2002 through 2007: 

State: Alabama; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 20.0; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 22.7; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 27.8. 

State: Arizona; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 7.4; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 15.4; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 26.7. 

State: Missouri; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 17.6; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 22.1; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 28.6. 

State: New Mexico; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 26.3; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 31.6; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 33.3. 

State: Oklahoma; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 12.1; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 16.5; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 30.0. 

State: South Carolina; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 14.3; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 22.9; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 33.3. 

State: South Dakota; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 0.0; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 0.0; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 33.3. 

State: Tennessee; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 14.6; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 20.7; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 26.3. 

State: Wyoming; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 0.0; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 0.0; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 33.3. 

Nation; 
Percentage of state observational surveys with below satisfactory 
ratings: General investigation: 7.7; 
Percentage of state observational surveys with below satisfactory 
ratings: Deficiency determination: 9.2; 
Percentage of comparative surveys that found at least one missed G-L 
deficiency: 14.5. 

Source: GAO analysis of federal monitoring survey data. 

[End of table] 

Our prior reports have described some other factors that may contribute 
to survey inconsistency and the understatement of deficiencies by state 
survey teams: (1) weaknesses in CMS's survey methodology, such as poor 
documentation of deficiencies;[Footnote 25] (2) confusion about the 
definition of actual harm;[Footnote 26] (3) predictability of surveys, 
which allows homes to conceal problems if they so desire;[Footnote 27] 
(4) inadequate quality assurance processes at the state level to help 
detect understatement in the scope and severity of 
deficiencies;[Footnote 28] and (5) inexperienced state surveyors as a 
result of retention problems.[Footnote 29] In ongoing work, we are 
investigating the factors that contribute to understatement. 

CMS Has Taken Steps to Improve the Federal Monitoring Survey Program, 
but Weaknesses in Management and Oversight Remain: 

CMS has taken steps to improve the federal monitoring survey program, 
but weaknesses remain in program management and oversight. For example, 
CMS has improved processes to ensure that comparative surveys more 
accurately reflect conditions at the time of the state survey, has 
switched control of the federal monitoring survey database to the 
office responsible for ensuring the effectiveness of state surveys, and 
has begun examining how to use monitoring survey data to improve 
oversight. Despite this progress, the management and oversight 
potential of the program has not been fully realized. In particular, 
CMS (1) has only begun exploring options for identifying understatement 
that occurs in cases where state surveys cite deficiencies at too low a 
level, for possible implementation in fiscal year 2009, and (2) is not 
effectively managing the federal monitoring survey database or using 
the database to oversee consistent implementation of the federal 
monitoring survey program by its regional offices. 

CMS Policy Changes Have Improved Federal Monitoring Surveys: 

CMS has taken steps in three areas--time between surveys, resident 
sample, and survey resources--to ensure that comparative surveys more 
accurately capture the conditions at the time of the state survey. 

* Time between surveys. In fiscal year 2002, CMS initiated a policy 
that shortened the length of time between state and comparative surveys 
from 2 months to 1 month. CMS relaxed the 1 month standard by changing 
the requirement to 30 working days in fiscal year 2003. As a result of 
shortening the time between the two surveys, the conditions at the time 
of the comparative survey are more likely to reflect those at the time 
of the state survey; 
for example, the same residents are still likely to be in the nursing 
home. Comparative surveys during fiscal year 2007 took place on average 
21.4 working days (30.9 calendar days) after state surveys. 

* Resident sample. Beginning in fiscal year 2003, CMS policy required 
that comparative surveys include at least half of the residents from 
state survey investigative samples. Officials from several regional 
offices said that examining the same resident allows for more clear-cut 
determinations of whether the state should have cited a deficiency. 
Since the policy change, about 78 percent of comparative surveys from 
fiscal year 2003 through 2007 included at least half the residents from 
state surveys' investigative samples. By comparison, only 13 percent of 
comparative surveys met that 50 percent threshold in fiscal year 2002, 
the year before the policy went into effect. 

* Survey resources. Beginning in fiscal year 2003, CMS initiated a 
policy that each comparative survey should have the same number of 
federal surveyors as its corresponding state survey, again to more 
closely mirror the conditions under which the state survey was 
conducted.[Footnote 30] We found that in fiscal year 2007, the average 
state survey team (3.4 surveyors) was larger than the average federal 
survey team (3.0 surveyors). However, on average, federal surveyors 
remained on-site longer than state surveyors--4.3 days for federal 
surveyors compared with 3.7 days for state surveyors. When the number 
of surveyors and time on-site are taken together, state surveys 
averaged 12.6 surveyor-days and federal comparative surveys averaged 
12.9 surveyor-days.[Footnote 31] 

Given these improvements, we asked the regional offices how receptive 
state survey teams were to feedback that they had missed deficiencies. 
Most regional office officials told us that in general the feedback 
session with state surveyors on missed deficiencies was not contentious 
and that state surveyors generally accepted the feedback provided. 
However, CMS established a formal dispute resolution process for 
comparative surveys in October 2007. The process is similar to the 
process already in place for resolving disagreements about 
observational survey results.[Footnote 32] 

Federal Monitoring Survey Database Has Not Been Used to Capture 
Understatement of Scope and Severity Levels: 

While CMS requires federal surveyors to determine whether a deficiency 
cited on a comparative but not a state survey was missed by state 
surveyors, there is no comparable requirement for deficiencies that are 
cited at different scope and severity levels. As a result, comparative 
surveys do not effectively capture the extent of the understatement of 
serious deficiencies by state surveyors. As with missed deficiencies, a 
discrepancy between federal and state survey results does not 
automatically indicate understatement. For example, the deficiency 
could have worsened by the time of the federal survey. 

Although CMS does not require federal surveyors to evaluate scope and 
severity differences between the two sets of surveys, we found that 
some regional offices used the validation question for missed 
deficiencies--"based on the evidence available to the [state], should 
the [state survey] team have cited this [deficiency]?"--to make such a 
determination.[Footnote 33] Using the validation question to make these 
determinations is contrary to CMS guidance issued in October 2003, 
which instructed comparative survey teams to only answer this question 
when the state failed to cite the deficiency altogether. 

To assess whether differences in scope and severity levels were 
actually understated--rather than deficiencies that worsened between 
the state and federal surveys--we first identified all 71 deficiencies 
on comparative surveys conducted from fiscal year 2002 through 2007 
where federal survey teams cited actual harm or immediate jeopardy 
deficiencies that state survey teams cited at a lower scope and 
severity level.[Footnote 34] We then examined the comment fields in the 
federal monitoring survey database associated with those deficiencies. 
Our analysis identified 27 deficiencies (38 percent) in which federal 
survey teams determined that a state's scope and severity citation was 
too low. For another 22 deficiencies (31 percent), federal survey teams 
found that the state's lower scope and severity determination was 
appropriate, given the circumstances at the time of the state survey. 
The remaining 22 deficiencies (31 percent) did not have comments or 
contained remarks that were inconclusive about whether the state 
deficiency citation was too low. When the confirmed scope and severity 
understatement was included with understatement caused by missed 
deficiencies, the total percentage of comparative surveys with 
understatement of serious deficiencies increased by an average of about 
1 percentage point over the 6 fiscal years we analyzed (see fig. 
3).[Footnote 35] 

Figure 3: Percentage of Comparative Surveys Nationwide with 
Understatement of Actual Harm and Immediate Jeopardy Deficiencies, with 
Scope and Severity Differences Included, Fiscal Years 2002 through 
2007: 

This figure is a double line graph showing percentage of comparative 
surveys nationwide with understatement of actual harm and immediate 
jeopardy deficiencies, with scope and severity differences included, 
fiscal years 2002 through 2007. One line represents the percentage of 
comparative surveys with missed deficiencies at the actual harm or 
immediate jeopardy level. The other line represents the percentage of 
comparative surveys with missed deficiencies and scope and severity 
understatement at the actual harm of immediate jeopardy level. 

Fiscal year: 2002; 
Percentage of comparative surveys with missed deficiencies at the 
actual harm or immediate jeopardy level: 13.8; 
Percentage of comparative surveys with missed deficiencies and scope 
and severity understatement at the actual harm of immediate jeopardy 
level: 13.8. 

Fiscal year: 2003; 
Percentage of comparative surveys with missed deficiencies at the 
actual harm or immediate jeopardy level: 17.5; 
Percentage of comparative surveys with missed deficiencies and scope 
and severity understatement at the actual harm of immediate jeopardy 
level: 19.3. 

Fiscal year: 2004; 
Percentage of comparative surveys with missed deficiencies at the 
actual harm or immediate jeopardy level: 11.1; 
Percentage of comparative surveys with missed deficiencies and scope 
and severity understatement at the actual harm of immediate jeopardy 
level: 11.7. 

Fiscal year: 2005; 
Percentage of comparative surveys with missed deficiencies at the 
actual harm or immediate jeopardy level: 14.3; 
Percentage of comparative surveys with missed deficiencies and scope 
and severity understatement at the actual harm of immediate jeopardy 
level: 17.4. 

Fiscal year: 2006; 
Percentage of comparative surveys with missed deficiencies at the 
actual harm or immediate jeopardy level: 15.3; 
Percentage of comparative surveys with missed deficiencies and scope 
and severity understatement at the actual harm of immediate jeopardy 
level: 15.9. 

Fiscal year: 2007; 
Percentage of comparative surveys with missed deficiencies at the 
actual harm or immediate jeopardy level: 15.3; 
Percentage of comparative surveys with missed deficiencies and scope 
and severity understatement at the actual harm of immediate jeopardy 
level: 16.5. 

[See PDF for image] 

Source: GAO analysis of federal monitoring survey data. 

[A] The inclusion of scope and severity understatement is based on our 
analysis of 71 deficiencies that federal survey teams cited as actual 
harm or immediate jeopardy deficiencies that state survey teams cited 
at a lower scope and severity level. 

[End of figure] 

While CMS headquarters does not require federal surveyors to determine 
whether a deficiency cited by state survey teams was cited at too low a 
scope and severity level, some regional offices have developed their 
own procedures to track this information and use it to provide feedback 
to state survey agencies. For example, in one regional office an 
individual reviews all comment fields for a year's worth of comparative 
surveys, makes a hand count of scope and severity differences that 
states should have cited, and then shares this with the state survey 
agencies during their annual performance reviews. Because the federal 
monitoring survey database does not automatically collect data on scope 
and severity determinations, CMS headquarters does not have access to 
the data analyses the regions have independently conducted. Some of the 
regional offices told us that they would like to have a specific way 
that the federal monitoring survey database could track scope and 
severity understatement that is similar to how deficiencies missed by 
state surveyors are tracked. 

In January 2008, CMS officials told us that they had initiated a pilot 
program in October 2007 to test the collection of data on 
understatement of scope and severity differences.[Footnote 36] 
According to CMS, the pilot, which will run through 2008 for possible 
fiscal year 2009 implementation, is necessary because the agency needs 
to determine which scope and severity understatement differences should 
be captured. For example, CMS is uncertain whether regions should only 
focus on differences that would raise the scope and severity level to 
actual harm or immediate jeopardy and not assess differences for 
understatement that occurs at lower scope and severity levels. 

CMS Could More Effectively Manage the Federal Monitoring Survey 
Database and Use It for Regional Office Oversight: 

Our analysis found that CMS headquarters was not effectively managing 
the federal monitoring survey database or using the database to oversee 
consistent implementation of the federal monitoring survey program by 
regional offices.[Footnote 37] While CMS uses data from comparative and 
observational surveys to provide feedback to state survey agencies 
during state performance reviews, CMS officials told us that they 
recognized the need to improve their management and use of the database 
for better oversight of the agency's 10 regional offices. 

We identified two problems in CMS's management of the federal 
monitoring survey database. CMS was not aware that (1) the results of a 
considerable number of comparative surveys were missing from the 
database and (2) the validation question for missed deficiencies was 
being used by some regional offices to identify scope and severity 
differences, contrary to CMS guidance. 

* Missing data. In October 2007, we identified missing comparative 
surveys for two regional offices dating back to 2005 and asked CMS to 
follow up with officials in those regions. At least one of the regions 
had completed the surveys but had failed to upload them into the 
national database.[Footnote 38] We also found that CMS had not included 
data in the federal monitoring survey database from 162 contractor-led 
comparative surveys conducted between fiscal years 2004 and 
2007.[Footnote 39] 

* Use of validation question contrary to CMS guidance. Some regional 
offices were using the missed deficiency validation question to make 
determinations about whether scope and severity differences constituted 
understatement, making it difficult to distinguish between missed 
deficiencies and scope and severity understatement. In addition, we 
found that the regional office answer to the validation question was 
not always consistent with the information recorded in the comment box. 

Similarly, we identified weaknesses in CMS's use of the database for 
regional office oversight. For example, CMS was not (1) examining 
comparative survey data to ensure that regional offices comply with CMS 
guidance intended to ensure that comparative surveys more accurately 
capture the conditions at the time of the state survey and (2) using 
the database to identify inconsistencies between comparative and 
observational survey results. 

* Ensuring regional office compliance. While CMS has provided guidance 
to its regional offices to help ensure that comparative surveys more 
accurately capture the conditions at the time of the state survey, the 
agency is not fully using available data to ensure that the regional 
offices implement the agency's guidance. For example, we found that the 
length of time between state and comparative surveys varied broadly by 
CMS region. In 2007, the average time gap ranged from a low of 15.4 
working days (22.5 calendar days) in the Boston region to a high of 
38.5 working days (54.4 calendar days) in the New York region. 
Furthermore, while 78 percent of comparative surveys from fiscal year 
2003 through 2007 followed CMS's guidance to include at least half of 
the residents from state surveys' investigative samples, 22 percent of 
comparative surveys did not meet this threshold. Finally, when we 
contacted officials in CMS headquarters to ask clarifying questions 
about the data variables needed to conduct these analyses, the 
headquarters officials were not familiar with a number of the variables 
and referred us to a CMS staff person in one of the regional offices. 
Together, these three examples suggest that CMS is not effectively 
using the data to hold regional offices accountable for implementing 
guidance. 

* Identify inconsistencies between comparative and observational 
results. CMS officials told us that they have begun to explore regional 
office differences in less than satisfactory ratings for state survey 
teams on observational surveys.[Footnote 40] However, CMS officials 
told us that they do not plan to use the database to identify 
inconsistencies between comparative and observational surveys that may 
warrant follow-up to ensure that regional offices are adhering to CMS 
guidance and consistently assessing state surveyor 
performance.[Footnote 41] For example, some states that performed below 
the national average in identifying serious deficiencies on comparative 
surveys received above-average marks on observational survey measures 
for Deficiency Determination and General Investigation. Wyoming's 33.3 
percent rate for surveys with missed serious deficiencies was more than 
double the national average of about 15 percent for surveys conducted 
during fiscal years 2002 and 2007. Yet Wyoming never received a below 
satisfactory rating on its General Investigation or Deficiency 
Determination measures during 18 observational surveys over that same 6-
year period. We found similar inconsistencies in the results of federal 
monitoring surveys for South Dakota and a few other states. Although 
inconsistencies between comparative and observational surveys may not 
necessarily indicate a problem, they may warrant investigation. For 
example, in a small state like Wyoming it is likely that comparative 
and observational surveys have evaluated the same group of state 
surveyors. Further, Wyoming and South Dakota are two of six states 
whose federal monitoring surveys are conducted by CMS's Denver regional 
office. Of the 140 observational surveys conducted from fiscal year 
2002 through 2007, federal surveyors from the Denver regional office 
gave one below satisfactory rating on the Deficiency Determination 
measure. That 0.7 percent rate of below satisfactory performance was 
more than four times lower than the regional office with the next-
lowest percentage--the Chicago regional office--which awarded below 
satisfactory ratings to 3.3 percent of state survey teams it observed. 

Conclusions: 

With about 1 in 6 comparative surveys concluding that state survey 
teams had missed a serious deficiency or understated its scope and 
severity level, it is evident that state survey agency performance 
limits the federal government's ability to obtain an accurate picture 
of how often nursing home residents face actual harm or are at risk of 
serious injury or death. These missed serious deficiencies most 
frequently involved Quality of Care, reflecting shortcomings in 
fundamental provider responsibilities such as ensuring proper nutrition 
and hydration, accident prevention, and preventing pressure sores. 
Observational survey results also underscore problems state surveyors 
may face in identifying facility deficiencies; about 1 in 11 state 
survey teams nationwide were rated as below satisfactory by CMS 
surveyors on the Deficiency Determination measure. 

We found that comparative survey data may mask the true extent of 
understatement because CMS's current protocol does not require regional 
offices to track in the federal monitoring survey database when state 
surveyors cite lower-than-appropriate scope and severity levels. As we 
conducted our work, CMS officials recognized this problem and in 
October 2007 began to experiment with a pilot program to measure 
understated scope and severity. However, at the conclusion of the 
pilot, scheduled for fiscal year 2008, CMS may decide not to implement 
a validation question for all scope and severity differences. We 
believe it is important to assess differences for understatement that 
occurs at the D through L levels--potential for more than minimal harm, 
actual harm, and immediate jeopardy. 

We also found that CMS was not effectively managing the federal 
monitoring survey database to ensure that regional offices were 
entering data in a timely and consistent fashion. Lack of accurate and 
reliable data hinders effective oversight. For example, we found that 
the database was missing a considerable number of comparative surveys. 
Further, CMS has not used the federal monitoring survey database to its 
full potential as an oversight tool. For example, CMS is not fully 
using data on comparative surveys to ensure that regional offices are 
implementing guidance intended to improve federal monitoring surveys. 
Although CMS's Survey and Certification Group assumed control of the 
database in January 2007, headquarters staff often referred us to CMS 
regional office staff to answer specific database questions, suggesting 
a lack of familiarity with the organization and content of the 
database. In addition, agency officials told us that they do not plan 
to follow up on inconsistencies between comparative and observational 
survey results that could indicate weaknesses in how regional offices 
evaluate state surveyors' performance. Identifying and following up on 
such inconsistencies could help ensure database reliability and hold 
regional office officials accountable for their implementation of the 
federal monitoring survey program, a program required by statute. 

Recommendations for Executive Action: 

To address weaknesses in CMS's management of the federal monitoring 
survey database that also affect the agency's ability to effectively 
track understatement, we recommend that the Administrator of CMS take 
the following two actions: 

* Require regional offices to determine if there was understatement 
when state surveyors cite a deficiency at a lower scope and severity 
level than federal surveyors do and to track this information in the 
federal monitoring survey database. 

* Establish quality controls to improve the accuracy and reliability of 
information entered into the federal monitoring survey database. 

To address weaknesses that affect CMS's ability to oversee regional 
office implementation of the federal monitoring survey program, we 
recommend that the Administrator of CMS take the following two actions: 

* Routinely examine comparative survey data and hold regional offices 
accountable for implementing CMS guidance that is intended to ensure 
that comparative surveys more accurately capture the conditions at the 
time of the state survey. 

* Regularly analyze and compare federal comparative and observational 
survey results. 

Agency Comments: 

In written comments on our draft report, HHS indicated that it fully 
endorsed and would implement our four recommendations intended to 
strengthen management and oversight of the federal monitoring survey 
program. The comments generally outlined CMS's implementation plan 
through 2009 and indicated that some steps, such as improved management 
of the federal monitoring survey database, are already under way. HHS's 
comments are reproduced in appendix VI. 

The majority of HHS's comments focused on its strategic approach to 
improving oversight: (1) ensuring that all nursing homes are surveyed 
at least once every 15 months, (2) improving surveyor understanding of 
federal quality requirements through improved guidance and training, 
(3) increasing the consistency of state surveys through the 
introduction of a new nursing home survey methodology, and (4) 
improving the use of data generated by federal monitoring surveys. Many 
of these strategies aim to address the underlying causes of 
understatement, the topic of a forthcoming GAO report. HHS also noted 
that limitations in the Medicare survey and certification budget 
underscore the agency's need to target resources effectively to 
maximize results. For example, HHS indicated that the implementation of 
the new survey methodology will be dependent on the level of funding in 
the overall survey and certification budget through fiscal year 2014. 
Survey and Certification funding is the subject of another forthcoming 
GAO report. 

Two of HHS's observations merit further discussion. First, HHS noted 
that understatement that arises from a lack of understanding or 
confusion about federal requirements would generally not be detected 
through federal monitoring surveys because both federal and state 
surveyors would be affected by the same limitation. We believe that the 
consistency with which federal surveys have identified serious 
deficiencies missed by state surveyors from fiscal year 2002 through 
2007--about 15 percent, on average--suggests that federal surveyors 
have a better understanding of CMS quality requirements than do state 
surveyors. We have previously reported that the limited experience 
level of state surveyors because of the high turnover rate was a 
contributing factor to deficiency understatement.[Footnote 42] 

Second, HHS questioned our use of "one missed deficiency per survey" as 
a measure of understatement. We believe that this standard is 
appropriate for serious deficiencies that result in harm or immediate 
jeopardy (G through L level) because the goal of state surveys should 
be to identify and require nursing homes to address all such 
deficiencies. CMS itself uses this standard during annual state 
performance reviews. We also used this standard to describe the 
proportion of comparative surveys that identified missed deficiencies 
at the potential for more than minimal harm level (D through F). 
Identifying and requiring nursing homes to correct such deficiencies is 
important because if uncorrected they have the potential to become more 
serious. Compared to missed serious deficiencies, we found that 
understatement of potential for more than minimal harm deficiencies was 
more widespread--about 70 percent of comparative surveys identified at 
least one state survey with such missed deficiencies. The number of 
state surveys with missed deficiencies at the D through F level was 
greater than 40 percent in all but five states, and state surveys 
selected for comparative surveys failed to identify an average of 2.5 
deficiencies in this range per survey. In short, the magnitude of 
understatement at the potential for more than minimal harm level should 
be a cause for concern. 

HHS also provided technical comments, which we incorporated as 
appropriate. 

As arranged with your offices, unless you publicly announce its 
contents earlier, we plan no further distribution of this report until 
30 days after its issue date. At that time, we will send copies 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 GAO's Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staffs have any questions about this report, please 
contact me at (202) 512-7114 or [email protected]. 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 VII. 

Signed by: 

John E. Dicken: 

Director, Health Care: 

[End of section] 

Appendix I: Percentage of Nursing Homes Cited for Actual Harm or 
Immediate Jeopardy during Standard Surveys: 

In order to identify trends in the percentage of nursing homes cited 
with actual harm or immediate jeopardy deficiencies, we analyzed data 
from the Centers for Medicare & Medicaid Service's (CMS) On-Line 
Survey, Certification, and Reporting system (OSCAR) database for fiscal 
years 2002 through 2007 (see table 4). Because homes must be surveyed 
at least every 15 months, with a required 12-month statewide average, 
it is possible that a home was surveyed more than once in any fiscal 
year. To avoid double counting homes, we included only a home's most 
recent survey from each fiscal year. Because CMS conducts a relatively 
small number of comparative surveys, it is not possible to compare the 
results of comparative surveys to the results of all state surveys. 

Table 4: Percentage of Nursing Homes Cited for Actual Harm or Immediate 
Jeopardy, by State, Fiscal Years 2002 through 2007: 

State: Alabama; 
Number of homes in fiscal year 2007: 233; 
Fiscal year: 2002: 12.7; 
Fiscal year: 2003: 18.1; 
Fiscal year: 2004: 16.6; 
Fiscal year: 2005: 24.3; 
Fiscal year: 2006: 23.6; 
Fiscal year: 2007: 16.3. 

State: Alaska; 
Number of homes in fiscal year 2007: 15; 
Fiscal year: 2002: 26.7; 
Fiscal year: 2003: 0.0; 
Fiscal year: 2004: 0.0; 
Fiscal year: 2005: 0.0; 
Fiscal year: 2006: 26.7; 
Fiscal year: 2007: 13.3. 

State: Arizona; 
Number of homes in fiscal year 2007: 137; 
Fiscal year: 2002: 7.3; 
Fiscal year: 2003: 6.6; 
Fiscal year: 2004: 9.4; 
Fiscal year: 2005: 9.9; 
Fiscal year: 2006: 25.4; 
Fiscal year: 2007: 26.4. 

State: Arkansas; 
Number of homes in fiscal year 2007: 248; 
Fiscal year: 2002: 22.3; 
Fiscal year: 2003: 24.8; 
Fiscal year: 2004: 21.5; 
Fiscal year: 2005: 17.6; 
Fiscal year: 2006: 13.6; 
Fiscal year: 2007: 14.2. 

State: California; 
Number of homes in fiscal year 2007: 1,285; 
Fiscal year: 2002: 5.1; 
Fiscal year: 2003: 3.7; 
Fiscal year: 2004: 6.5; 
Fiscal year: 2005: 8.0; 
Fiscal year: 2006: 13.9; 
Fiscal year: 2007: 12.0. 

State: Colorado; 
Number of homes in fiscal year 2007: 212; 
Fiscal year: 2002: 32.7; 
Fiscal year: 2003: 20.9; 
Fiscal year: 2004: 25.9; 
Fiscal year: 2005: 40.4; 
Fiscal year: 2006: 43.8; 
Fiscal year: 2007: 42.4. 

State: Connecticut; 
Number of homes in fiscal year 2007: 244; 
Fiscal year: 2002: 45.8; 
Fiscal year: 2003: 43.1; 
Fiscal year: 2004: 55.4; 
Fiscal year: 2005: 44.2; 
Fiscal year: 2006: 46.5; 
Fiscal year: 2007: 38.3. 

State: Delaware; 
Number of homes in fiscal year 2007: 45; 
Fiscal year: 2002: 11.1; 
Fiscal year: 2003: 5.3; 
Fiscal year: 2004: 15.0; 
Fiscal year: 2005: 35.7; 
Fiscal year: 2006: 21.1; 
Fiscal year: 2007: 33.3. 

State: District of Columbia; 
Number of homes in fiscal year 2007: 20; 
Fiscal year: 2002: 30.0; 
Fiscal year: 2003: 41.2; 
Fiscal year: 2004: 40.0; 
Fiscal year: 2005: 30.0; 
Fiscal year: 2006: 25.0; 
Fiscal year: 2007: 36.8. 

State: Florida; 
Number of homes in fiscal year 2007: 683; 
Fiscal year: 2002: 14.9; 
Fiscal year: 2003: 10.2; 
Fiscal year: 2004: 8.6; 
Fiscal year: 2005: 4.2; 
Fiscal year: 2006: 8.0; 
Fiscal year: 2007: 8.3. 

State: Georgia; 
Number of homes in fiscal year 2007: 362; 
Fiscal year: 2002: 23.7; 
Fiscal year: 2003: 24.6; 
Fiscal year: 2004: 17.9; 
Fiscal year: 2005: 19.3; 
Fiscal year: 2006: 15.0; 
Fiscal year: 2007: 14.9. 

State: Hawaii; 
Number of homes in fiscal year 2007: 48; 
Fiscal year: 2002: 21.2; 
Fiscal year: 2003: 12.1; 
Fiscal year: 2004: 22.9; 
Fiscal year: 2005: 2.8; 
Fiscal year: 2006: 2.1; 
Fiscal year: 2007: 7.3. 

State: Idaho; 
Number of homes in fiscal year 2007: 79; 
Fiscal year: 2002: 39.2; 
Fiscal year: 2003: 31.9; 
Fiscal year: 2004: 27.3; 
Fiscal year: 2005: 40.5; 
Fiscal year: 2006: 44.9; 
Fiscal year: 2007: 27.1. 

State: Illinois; 
Number of homes in fiscal year 2007: 810; 
Fiscal year: 2002: 15.3; 
Fiscal year: 2003: 18.4; 
Fiscal year: 2004: 16.3; 
Fiscal year: 2005: 16.7; 
Fiscal year: 2006: 20.3; 
Fiscal year: 2007: 25.1. 

State: Indiana; 
Number of homes in fiscal year 2007: 520; 
Fiscal year: 2002: 23.2; 
Fiscal year: 2003: 19.7; 
Fiscal year: 2004: 24.5; 
Fiscal year: 2005: 29.6; 
Fiscal year: 2006: 30.6; 
Fiscal year: 2007: 35.2. 

State: Iowa; 
Number of homes in fiscal year 2007: 463; 
Fiscal year: 2002: 8.0; 
Fiscal year: 2003: 9.2; 
Fiscal year: 2004: 12.4; 
Fiscal year: 2005: 11.7; 
Fiscal year: 2006: 9.6; 
Fiscal year: 2007: 16.3. 

State: Kansas; 
Number of homes in fiscal year 2007: 358; 
Fiscal year: 2002: 32.9; 
Fiscal year: 2003: 26.5; 
Fiscal year: 2004: 31.9; 
Fiscal year: 2005: 36.6; 
Fiscal year: 2006: 37.7; 
Fiscal year: 2007: 29.4. 

State: Kentucky; 
Number of homes in fiscal year 2007: 293; 
Fiscal year: 2002: 23.2; 
Fiscal year: 2003: 26.1; 
Fiscal year: 2004: 15.0; 
Fiscal year: 2005: 8.0; 
Fiscal year: 2006: 10.6; 
Fiscal year: 2007: 7.6. 

State: Louisiana; 
Number of homes in fiscal year 2007: 299; 
Fiscal year: 2002: 21.8; 
Fiscal year: 2003: 16.2; 
Fiscal year: 2004: 13.8; 
Fiscal year: 2005: 16.3; 
Fiscal year: 2006: 16.1; 
Fiscal year: 2007: 11.7. 

State: Maine; 
Number of homes in fiscal year 2007: 113; 
Fiscal year: 2002: 6.6; 
Fiscal year: 2003: 11.1; 
Fiscal year: 2004: 12.8; 
Fiscal year: 2005: 7.0; 
Fiscal year: 2006: 9.8; 
Fiscal year: 2007: 7.2. 

State: Maryland; 
Number of homes in fiscal year 2007: 234; 
Fiscal year: 2002: 26.1; 
Fiscal year: 2003: 15.4; 
Fiscal year: 2004: 18.3; 
Fiscal year: 2005: 7.6; 
Fiscal year: 2006: 7.6; 
Fiscal year: 2007: 17.1. 

State: Massachusetts; 
Number of homes in fiscal year 2007: 452; 
Fiscal year: 2002: 24.6; 
Fiscal year: 2003: 25.9; 
Fiscal year: 2004: 17.4; 
Fiscal year: 2005: 22.9; 
Fiscal year: 2006: 20.6; 
Fiscal year: 2007: 16.6. 

State: Michigan; 
Number of homes in fiscal year 2007: 439; 
Fiscal year: 2002: 29.7; 
Fiscal year: 2003: 26.9; 
Fiscal year: 2004: 23.6; 
Fiscal year: 2005: 23.1; 
Fiscal year: 2006: 27.9; 
Fiscal year: 2007: 29.8. 

State: Minnesota; 
Number of homes in fiscal year 2007: 398; 
Fiscal year: 2002: 22.3; 
Fiscal year: 2003: 18.3; 
Fiscal year: 2004: 14.3; 
Fiscal year: 2005: 14.4; 
Fiscal year: 2006: 17.5; 
Fiscal year: 2007: 16.0. 

State: Mississippi; 
Number of homes in fiscal year 2007: 206; 
Fiscal year: 2002: 18.8; 
Fiscal year: 2003: 16.0; 
Fiscal year: 2004: 19.5; 
Fiscal year: 2005: 18.7; 
Fiscal year: 2006: 8.4; 
Fiscal year: 2007: 9.1. 

State: Missouri; 
Number of homes in fiscal year 2007: 530; 
Fiscal year: 2002: 15.6; 
Fiscal year: 2003: 12.5; 
Fiscal year: 2004: 12.5; 
Fiscal year: 2005: 15.8; 
Fiscal year: 2006: 15.2; 
Fiscal year: 2007: 15.5. 

State: Montana; 
Number of homes in fiscal year 2007: 96; 
Fiscal year: 2002: 12.0; 
Fiscal year: 2003: 20.0; 
Fiscal year: 2004: 18.0; 
Fiscal year: 2005: 17.9; 
Fiscal year: 2006: 16.7; 
Fiscal year: 2007: 23.9. 

State: Nebraska; 
Number of homes in fiscal year 2007: 228; 
Fiscal year: 2002: 20.1; 
Fiscal year: 2003: 14.8; 
Fiscal year: 2004: 15.8; 
Fiscal year: 2005: 14.4; 
Fiscal year: 2006: 25.0; 
Fiscal year: 2007: 26.4. 

State: Nevada; 
Number of homes in fiscal year 2007: 48; 
Fiscal year: 2002: 11.9; 
Fiscal year: 2003: 9.1; 
Fiscal year: 2004: 17.5; 
Fiscal year: 2005: 21.7; 
Fiscal year: 2006: 21.3; 
Fiscal year: 2007: 12.5. 

State: New Hampshire; 
Number of homes in fiscal year 2007: 81; 
Fiscal year: 2002: 29.4; 
Fiscal year: 2003: 24.4; 
Fiscal year: 2004: 25.6; 
Fiscal year: 2005: 26.3; 
Fiscal year: 2006: 22.9; 
Fiscal year: 2007: 14.7. 

State: New Jersey; 
Number of homes in fiscal year 2007: 368; 
Fiscal year: 2002: 18.8; 
Fiscal year: 2003: 10.5; 
Fiscal year: 2004: 12.9; 
Fiscal year: 2005: 18.2; 
Fiscal year: 2006: 14.6; 
Fiscal year: 2007: 16.5. 

State: New Mexico; 
Number of homes in fiscal year 2007: 72; 
Fiscal year: 2002: 14.9; 
Fiscal year: 2003: 21.3; 
Fiscal year: 2004: 25.7; 
Fiscal year: 2005: 32.4; 
Fiscal year: 2006: 25.0; 
Fiscal year: 2007: 28.6. 

State: New York; 
Number of homes in fiscal year 2007: 657; 
Fiscal year: 2002: 34.2; 
Fiscal year: 2003: 15.2; 
Fiscal year: 2004: 11.0; 
Fiscal year: 2005: 14.4; 
Fiscal year: 2006: 17.5; 
Fiscal year: 2007: 17.2. 

State: North Carolina; 
Number of homes in fiscal year 2007: 422; 
Fiscal year: 2002: 25.6; 
Fiscal year: 2003: 29.0; 
Fiscal year: 2004: 22.1; 
Fiscal year: 2005: 18.8; 
Fiscal year: 2006: 16.7; 
Fiscal year: 2007: 10.7. 

State: North Dakota; 
Number of homes in fiscal year 2007: 83; 
Fiscal year: 2002: 17.9; 
Fiscal year: 2003: 12.4; 
Fiscal year: 2004: 13.6; 
Fiscal year: 2005: 17.7; 
Fiscal year: 2006: 20.5; 
Fiscal year: 2007: 15.6. 

State: Ohio; 
Number of homes in fiscal year 2007: 984; 
Fiscal year: 2002: 25.4; 
Fiscal year: 2003: 19.1; 
Fiscal year: 2004: 11.8; 
Fiscal year: 2005: 14.4; 
Fiscal year: 2006: 13.4; 
Fiscal year: 2007: 14.4. 

State: Oklahoma; 
Number of homes in fiscal year 2007: 348; 
Fiscal year: 2002: 22.2; 
Fiscal year: 2003: 26.4; 
Fiscal year: 2004: 17.1; 
Fiscal year: 2005: 26.5; 
Fiscal year: 2006: 18.7; 
Fiscal year: 2007: 18.7. 

State: Oregon; 
Number of homes in fiscal year 2007: 139; 
Fiscal year: 2002: 23.7; 
Fiscal year: 2003: 20.3; 
Fiscal year: 2004: 16.7; 
Fiscal year: 2005: 18.9; 
Fiscal year: 2006: 17.8; 
Fiscal year: 2007: 17.6. 

State: Pennsylvania; 
Number of homes in fiscal year 2007: 724; 
Fiscal year: 2002: 13.5; 
Fiscal year: 2003: 17.2; 
Fiscal year: 2004: 19.9; 
Fiscal year: 2005: 15.5; 
Fiscal year: 2006: 12.0; 
Fiscal year: 2007: 11.9. 

State: Rhode Island; 
Number of homes in fiscal year 2007: 87; 
Fiscal year: 2002: 5.6; 
Fiscal year: 2003: 8.1; 
Fiscal year: 2004: 9.3; 
Fiscal year: 2005: 9.5; 
Fiscal year: 2006: 4.4; 
Fiscal year: 2007: 1.3. 

State: South Carolina; 
Number of homes in fiscal year 2007: 176; 
Fiscal year: 2002: 19.8; 
Fiscal year: 2003: 29.6; 
Fiscal year: 2004: 33.3; 
Fiscal year: 2005: 25.5; 
Fiscal year: 2006: 16.5; 
Fiscal year: 2007: 8.8. 

State: South Dakota; 
Number of homes in fiscal year 2007: 112; 
Fiscal year: 2002: 26.8; 
Fiscal year: 2003: 32.1; 
Fiscal year: 2004: 23.4; 
Fiscal year: 2005: 12.8; 
Fiscal year: 2006: 18.4; 
Fiscal year: 2007: 22.6. 

State: Tennessee; 
Number of homes in fiscal year 2007: 332; 
Fiscal year: 2002: 20.7; 
Fiscal year: 2003: 21.8; 
Fiscal year: 2004: 24.1; 
Fiscal year: 2005: 17.6; 
Fiscal year: 2006: 11.5; 
Fiscal year: 2007: 16.2. 

State: Texas; 
Number of homes in fiscal year 2007: 1,195; 
Fiscal year: 2002: 22.4; 
Fiscal year: 2003: 18.0; 
Fiscal year: 2004: 12.8; 
Fiscal year: 2005: 16.7; 
Fiscal year: 2006: 18.1; 
Fiscal year: 2007: 14.7. 

State: Utah; 
Number of homes in fiscal year 2007: 94; 
Fiscal year: 2002: 25.6; 
Fiscal year: 2003: 19.0; 
Fiscal year: 2004: 12.2; 
Fiscal year: 2005: 8.4; 
Fiscal year: 2006: 16.7; 
Fiscal year: 2007: 7.5. 

State: Vermont; 
Number of homes in fiscal year 2007: 41; 
Fiscal year: 2002: 15.0; 
Fiscal year: 2003: 10.0; 
Fiscal year: 2004: 19.5; 
Fiscal year: 2005: 23.7; 
Fiscal year: 2006: 13.5; 
Fiscal year: 2007: 12.1. 

State: Virginia; 
Number of homes in fiscal year 2007: 281; 
Fiscal year: 2002: 11.7; 
Fiscal year: 2003: 13.7; 
Fiscal year: 2004: 10.2; 
Fiscal year: 2005: 16.3; 
Fiscal year: 2006: 15.2; 
Fiscal year: 2007: 18.3. 

State: Washington; 
Number of homes in fiscal year 2007: 247; 
Fiscal year: 2002: 37.0; 
Fiscal year: 2003: 30.9; 
Fiscal year: 2004: 28.5; 
Fiscal year: 2005: 27.6; 
Fiscal year: 2006: 23.5; 
Fiscal year: 2007: 23.7. 

State: West Virginia; 
Number of homes in fiscal year 2007: 133; 
Fiscal year: 2002: 20.4; 
Fiscal year: 2003: 12.7; 
Fiscal year: 2004: 11.5; 
Fiscal year: 2005: 17.7; 
Fiscal year: 2006: 10.5; 
Fiscal year: 2007: 21.7. 

State: Wisconsin; 
Number of homes in fiscal year 2007: 401; 
Fiscal year: 2002: 11.2; 
Fiscal year: 2003: 10.9; 
Fiscal year: 2004: 13.1; 
Fiscal year: 2005: 18.8; 
Fiscal year: 2006: 21.6; 
Fiscal year: 2007: 29.8. 

State: Wyoming; 
Number of homes in fiscal year 2007: 39; 
Fiscal year: 2002: 25.0; 
Fiscal year: 2003: 22.9; 
Fiscal year: 2004: 17.1; 
Fiscal year: 2005: 11.8; 
Fiscal year: 2006: 16.2; 
Fiscal year: 2007: 24.2. 

Nation; 
Number of homes in fiscal year 2007: 16,114; 
Fiscal year: 2002: 20.2; 
Fiscal year: 2003: 17.8; 
Fiscal year: 2004: 16.4; 
Fiscal year: 2005: 17.4; 
Fiscal year: 2006: 17.9; 
Fiscal year: 2007: 17.8[A]. 

Source: GAO analysis of OSCAR data. 

Note: Data presented in this table may be slightly different from those 
presented in earlier reports because we (1) used final year-end OSCAR 
files when they were available or (2) the OSCAR extracts contained 
surveys that had not previously been entered in the database. 

[A] Fiscal year 2007 results are incomplete and use all available 
information as of January 2008. 

[End of section] 

Appendix II: Percentage of Comparative Surveys Identifying Missed 
Deficiencies at Actual Harm or Immediate Jeopardy Level: 

Table 5: 

State: Alabama; 
Number of homes in fiscal year 2007: 233; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 5; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 27.8; 
Total number missed G-L deficiencies: 13. 

State: Alaska; 
Number of homes in fiscal year 2007: 15; 
Total comparative surveys: 11; 
Total comparative surveys with at least one missed G-L deficiency: 0; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 0.0; 
Total number missed G-L deficiencies: 0. 

State: Arizona; 
Number of homes in fiscal year 2007: 137; 
Total comparative surveys: 15; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 26.7; 
Total number missed G-L deficiencies: 6. 

State: Arkansas; 
Number of homes in fiscal year 2007: 248; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 5.6; 
Total number missed G-L deficiencies: 1. 

State: California; 
Number of homes in fiscal year 2007: 1,285; 
Total comparative surveys: 49; 
Total comparative surveys with at least one missed G-L deficiency: 5; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 10.2; 
Total number missed G-L deficiencies: 6. 

State: Colorado; 
Number of homes in fiscal year 2007: 212; 
Total comparative surveys: 22; 
Total comparative surveys with at least one missed G-L deficiency: 3; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 13.6; 
Total number missed G-L deficiencies: 4. 

State: Connecticut; 
Number of homes in fiscal year 2007: 244; 
Total comparative surveys: 16; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 6.3; 
Total number missed G-L deficiencies: 1. 

State: Delaware; 
Number of homes in fiscal year 2007: 45; 
Total comparative surveys: 13; 
Total comparative surveys with at least one missed G-L deficiency: 2; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 15.4; 
Total number missed G-L deficiencies: 2. 

State: District of Columbia; 
Number of homes in fiscal year 2007: 20; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 8.3; 
Total number missed G-L deficiencies: 1. 

State: Florida; 
Number of homes in fiscal year 2007: 683; 
Total comparative surveys: 26; 
Total comparative surveys with at least one missed G-L deficiency: 3; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 11.5; 
Total number missed G-L deficiencies: 6. 

State: Georgia; 
Number of homes in fiscal year 2007: 362; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 3; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 16.7; 
Total number missed G-L deficiencies: 4. 

State: Hawaii; 
Number of homes in fiscal year 2007: 48; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 8.3; 
Total number missed G-L deficiencies: 1. 

State: Idaho; 
Number of homes in fiscal year 2007: 79; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 0; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 0.0; 
Total number missed G-L deficiencies: 0. 

State: Illinois; 
Number of homes in fiscal year 2007: 810; 
Total comparative surveys: 32; 
Total comparative surveys with at least one missed G-L deficiency: 7; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 21.9; 
Total number missed G-L deficiencies: 12. 

State: Indiana; 
Number of homes in fiscal year 2007: 520; 
Total comparative surveys: 25; 
Total comparative surveys with at least one missed G-L deficiency: 3; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 12.0; 
Total number missed G-L deficiencies: 4. 

State: Iowa; 
Number of homes in fiscal year 2007: 463; 
Total comparative surveys: 19; 
Total comparative surveys with at least one missed G-L deficiency: 3; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 15.8; 
Total number missed G-L deficiencies: 4. 

State: Kansas; 
Number of homes in fiscal year 2007: 358; 
Total comparative surveys: 24; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 16.7; 
Total number missed G-L deficiencies: 8. 

State: Kentucky; 
Number of homes in fiscal year 2007: 293; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 2; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 11.1; 
Total number missed G-L deficiencies: 2. 

State: Louisiana; 
Number of homes in fiscal year 2007: 299; 
Total comparative surveys: 17; 
Total comparative surveys with at least one missed G-L deficiency: 3; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 17.6; 
Total number missed G-L deficiencies: 6. 

State: Maine; 
Number of homes in fiscal year 2007: 113; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 0; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 0.0; 
Total number missed G-L deficiencies: 0. 

State: Maryland; 
Number of homes in fiscal year 2007: 234; 
Total comparative surveys: 19; 
Total comparative surveys with at least one missed G-L deficiency: 2; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 10.5; 
Total number missed G-L deficiencies: 2. 

State: Massachusetts; 
Number of homes in fiscal year 2007: 452; 
Total comparative surveys: 17; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 5.9; 
Total number missed G-L deficiencies: 1. 

State: Michigan; 
Number of homes in fiscal year 2007: 439; 
Total comparative surveys: 25; 
Total comparative surveys with at least one missed G-L deficiency: 5; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 20.0; 
Total number missed G-L deficiencies: 5. 

State: Minnesota; 
Number of homes in fiscal year 2007: 398; 
Total comparative surveys: 21; 
Total comparative surveys with at least one missed G-L deficiency: 2; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 9.5; 
Total number missed G-L deficiencies: 2. 

State: Mississippi; 
Number of homes in fiscal year 2007: 206; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 22.2; 
Total number missed G-L deficiencies: 8. 

State: Missouri; 
Number of homes in fiscal year 2007: 530; 
Total comparative surveys: 28; 
Total comparative surveys with at least one missed G-L deficiency: 8; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 28.6; 
Total number missed G-L deficiencies: 14. 

State: Montana; 
Number of homes in fiscal year 2007: 96; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 2; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 16.7; 
Total number missed G-L deficiencies: 2. 

State: Nebraska; 
Number of homes in fiscal year 2007: 228; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 5.6; 
Total number missed G-L deficiencies: 1. 

State: Nevada; 
Number of homes in fiscal year 2007: 48; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 8.3; 
Total number missed G-L deficiencies: 2. 

State: New Hampshire; 
Number of homes in fiscal year 2007: 81; 
Total comparative surveys: 14; 
Total comparative surveys with at least one missed G-L deficiency: 2; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 14.3; 
Total number missed G-L deficiencies: 2. 

State: New Jersey; 
Number of homes in fiscal year 2007: 368; 
Total comparative surveys: 24; 
Total comparative surveys with at least one missed G-L deficiency: 5; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 20.8; 
Total number missed G-L deficiencies: 16. 

State: New Mexico; 
Number of homes in fiscal year 2007: 72; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 33.3; 
Total number missed G-L deficiencies: 9. 

State: New York; 
Number of homes in fiscal year 2007: 657; 
Total comparative surveys: 27; 
Total comparative surveys with at least one missed G-L deficiency: 6; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 22.2; 
Total number missed G-L deficiencies: 12. 

State: North Carolina; 
Number of homes in fiscal year 2007: 422; 
Total comparative surveys: 21; 
Total comparative surveys with at least one missed G-L deficiency: 3; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 14.3; 
Total number missed G-L deficiencies: 3. 

State: North Dakota; 
Number of homes in fiscal year 2007: 83; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 0; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 0.0; 
Total number missed G-L deficiencies: 0. 

State: Ohio; 
Number of homes in fiscal year 2007: 984; 
Total comparative surveys: 31; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 3.2; 
Total number missed G-L deficiencies: 1. 

State: Oklahoma; 
Number of homes in fiscal year 2007: 348; 
Total comparative surveys: 20; 
Total comparative surveys with at least one missed G-L deficiency: 6; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 30.0; 
Total number missed G-L deficiencies: 11. 

State: Oregon; 
Number of homes in fiscal year 2007: 139; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 0; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 0.0; 
Total number missed G-L deficiencies: 0. 

State: Pennsylvania; 
Number of homes in fiscal year 2007: 724; 
Total comparative surveys: 37; 
Total comparative surveys with at least one missed G-L deficiency: 6; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 16.2; 
Total number missed G-L deficiencies: 6. 

State: Rhode Island; 
Number of homes in fiscal year 2007: 87; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 2; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 16.7; 
Total number missed G-L deficiencies: 3. 

State: South Carolina; 
Number of homes in fiscal year 2007: 176; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 6; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 33.3; 
Total number missed G-L deficiencies: 19. 

State: South Dakota; 
Number of homes in fiscal year 2007: 112; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 33.3; 
Total number missed G-L deficiencies: 4. 

State: Tennessee; 
Number of homes in fiscal year 2007: 332; 
Total comparative surveys: 19; 
Total comparative surveys with at least one missed G-L deficiency: 5; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 26.3; 
Total number missed G-L deficiencies: 10. 

State: Texas; 
Number of homes in fiscal year 2007: 1,195; 
Total comparative surveys: 38; 
Total comparative surveys with at least one missed G-L deficiency: 5; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 13.2; 
Total number missed G-L deficiencies: 7. 

State: Utah; 
Number of homes in fiscal year 2007: 94; 
Total comparative surveys: 11; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 9.1; 
Total number missed G-L deficiencies: 1. 

State: Vermont; 
Number of homes in fiscal year 2007: 41; 
Total comparative surveys: 10; 
Total comparative surveys with at least one missed G-L deficiency: 0; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 0.0; 
Total number missed G-L deficiencies: 0. 

State: Virginia; 
Number of homes in fiscal year 2007: 281; 
Total comparative surveys: 17; 
Total comparative surveys with at least one missed G-L deficiency: 1; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 5.9; 
Total number missed G-L deficiencies: 1. 

State: Washington; 
Number of homes in fiscal year 2007: 247; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed G-L deficiency: 2; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 11.1; 
Total number missed G-L deficiencies: 2. 

State: West Virginia; 
Number of homes in fiscal year 2007: 133; 
Total comparative surveys: 13; 
Total comparative surveys with at least one missed G-L deficiency: 0; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 0.0; 
Total number missed G-L deficiencies: 0. 

State: Wisconsin; 
Number of homes in fiscal year 2007: 401; 
Total comparative surveys: 21; 
Total comparative surveys with at least one missed G-L deficiency: 2; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 9.5; 
Total number missed G-L deficiencies: 2. 

State: Wyoming; 
Number of homes in fiscal year 2007: 39; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed G-L deficiency: 4; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 33.3; 
Total number missed G-L deficiencies: 5. 

State: Nation; 
Number of homes in fiscal year 2007: 16,114; 
Total comparative surveys: 976; 
Total comparative surveys with at least one missed G-L deficiency: 142; 
Percentage of total comparative surveys with at least one missed G-L 
Deficiency: 14.5; 
Total number missed G-L deficiencies: 232. 

Source: GAO analysis of CMS's OSCAR data for the number of homes and 
federal monitoring survey data for all other data presented. 

[End of table] 

[End of section] 

Appendix III: Percentage of Comparative Surveys Identifying Missed 
Deficiencies with Potential for More Than Minimal Harm: 

Table 6: 

State: Alabama; 
Number of homes in fiscal year 2007: 233; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed D-F deficiency: 17; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 94.4; 
Total number of missed D-F deficiencies: 61. 

State: Alaska; 
Number of homes in fiscal year 2007: 15; 
Total comparative surveys: 11; 
Total comparative surveys with at least one missed D-F deficiency: 4; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 36.4; 
Total number of missed D-F deficiencies: 8. 

State: Arizona; 
Number of homes in fiscal year 2007: 137; 
Total comparative surveys: 15; 
Total comparative surveys with at least one missed D-F deficiency: 12; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 80.0; 
Total number of missed D-F deficiencies: 73. 

State: Arkansas; 
Number of homes in fiscal year 2007: 248; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed D-F deficiency: 13; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 72.2; 
Total number of missed D-F deficiencies: 50. 

State: California; 
Number of homes in fiscal year 2007: 1,285; 
Total comparative surveys: 49; 
Total comparative surveys with at least one missed D-F deficiency: 36; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 73.5; 
Total number of missed D-F deficiencies: 104. 

State: Colorado; 
Number of homes in fiscal year 2007: 212; 
Total comparative surveys: 22; 
Total comparative surveys with at least one missed D-F deficiency: 21; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 95.5; 
Total number of missed D-F deficiencies: 108. 

State: Connecticut; 
Number of homes in fiscal year 2007: 244; 
Total comparative surveys: 16; 
Total comparative surveys with at least one missed D-F deficiency: 8; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 50.0; 
Total number of missed D-F deficiencies: 28. 

State: Delaware; 
Number of homes in fiscal year 2007: 45; 
Total comparative surveys: 13; 
Total comparative surveys with at least one missed D-F deficiency: 9; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 69.2; 
Total number of missed D-F deficiencies: 29. 

State: District of Columbia; 
Number of homes in fiscal year 2007: 20; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 10; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 83.3; 
Total number of missed D-F deficiencies: 26. 

State: Florida; 
Number of homes in fiscal year 2007: 683; 
Total comparative surveys: 26; 
Total comparative surveys with at least one missed D-F deficiency: 18; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 69.2; 
Total number of missed D-F deficiencies: 53. 

State: Georgia; 
Number of homes in fiscal year 2007: 362; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed D-F deficiency: 13; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 72.2; 
Total number of missed D-F deficiencies: 48. 

State: Hawaii; 
Number of homes in fiscal year 2007: 48; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 7; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 58.3; 
Total number of missed D-F deficiencies: 22. 

State: Idaho; 
Number of homes in fiscal year 2007: 79; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 7; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 58.3; 
Total number of missed D-F deficiencies: 18. 

State: Illinois; 
Number of homes in fiscal year 2007: 810; 
Total comparative surveys: 32; 
Total comparative surveys with at least one missed D-F deficiency: 17; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 53.1; 
Total number of missed D-F deficiencies: 63. 

State: Indiana; 
Number of homes in fiscal year 2007: 520; 
Total comparative surveys: 25; 
Total comparative surveys with at least one missed D-F deficiency: 12; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 48.0; 
Total number of missed D-F deficiencies: 31. 

State: Iowa; 
Number of homes in fiscal year 2007: 463; 
Total comparative surveys: 19; 
Total comparative surveys with at least one missed D-F deficiency: 13; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 68.4; 
Total number of missed D-F deficiencies: 36. 

State: Kansas; 
Number of homes in fiscal year 2007: 358; 
Total comparative surveys: 24; 
Total comparative surveys with at least one missed D-F deficiency: 19; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 79.2; 
Total number of missed D-F deficiencies: 66. 

State: Kentucky; 
Number of homes in fiscal year 2007: 293; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed D-F deficiency: 11; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 61.1; 
Total number of missed D-F deficiencies: 33. 

State: Louisiana; 
Number of homes in fiscal year 2007: 299; 
Total comparative surveys: 17; 
Total comparative surveys with at least one missed D-F deficiency: 13; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 76.5; 
Total number of missed D-F deficiencies: 73. 

State: Maine; 
Number of homes in fiscal year 2007: 113; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 6; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 50.0; 
Total number of missed D-F deficiencies: 25. 

State: Maryland; 
Number of homes in fiscal year 2007: 234; 
Total comparative surveys: 19; 
Total comparative surveys with at least one missed D-F deficiency: 9; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 47.4; 
Total number of missed D-F deficiencies: 16. 

State: Massachusetts; 
Number of homes in fiscal year 2007: 452; 
Total comparative surveys: 17; 
Total comparative surveys with at least one missed D-F deficiency: 8; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 47.1; 
Total number of missed D-F deficiencies: 22. 

State: Michigan; 
Number of homes in fiscal year 2007: 439; 
Total comparative surveys: 25; 
Total comparative surveys with at least one missed D-F deficiency: 18; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 72.0; 
Total number of missed D-F deficiencies: 37. 

State: Minnesota; 
Number of homes in fiscal year 2007: 398; 
Total comparative surveys: 21; 
Total comparative surveys with at least one missed D-F deficiency: 15; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 71.4; 
Total number of missed D-F deficiencies: 29. 

State: Mississippi; 
Number of homes in fiscal year 2007: 206; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed D-F deficiency: 15; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 83.3; 
Total number of missed D-F deficiencies: 57. 

State: Missouri; 
Number of homes in fiscal year 2007: 530; 
Total comparative surveys: 28; 
Total comparative surveys with at least one missed D-F deficiency: 22; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 78.6; 
Total number of missed D-F deficiencies: 146. 

State: Montana; 
Number of homes in fiscal year 2007: 96; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 12; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 100.0; 
Total number of missed D-F deficiencies: 52. 

State: Nebraska; 
Number of homes in fiscal year 2007: 228; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed D-F deficiency: 13; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 72.2; 
Total number of missed D-F deficiencies: 42. 

State: Nevada; 
Number of homes in fiscal year 2007: 48; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 11; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 91.7; 
Total number of missed D-F deficiencies: 33. 

State: New Hampshire; 
Number of homes in fiscal year 2007: 81; 
Total comparative surveys: 14; 
Total comparative surveys with at least one missed D-F deficiency: 9; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 64.3; 
Total number of missed D-F deficiencies: 42. 

State: New Jersey; 
Number of homes in fiscal year 2007: 368; 
Total comparative surveys: 24; 
Total comparative surveys with at least one missed D-F deficiency: 14; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 58.3; 
Total number of missed D-F deficiencies: 50. 

State: New Mexico; 
Number of homes in fiscal year 2007: 72; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 9; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 75.0; 
Total number of missed D-F deficiencies: 27. 

State: New York; 
Number of homes in fiscal year 2007: 657; 
Total comparative surveys: 27; 
Total comparative surveys with at least one missed D-F deficiency: 15; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 55.6; 
Total number of missed D-F deficiencies: 77. 

State: North Carolina; 
Number of homes in fiscal year 2007: 422; 
Total comparative surveys: 21; 
Total comparative surveys with at least one missed D-F deficiency: 17; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 81.0; 
Total number of missed D-F deficiencies: 48. 

State: North Dakota; 
Number of homes in fiscal year 2007: 83; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 11; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 91.7; 
Total number of missed D-F deficiencies: 32. 

State: Ohio; 
Number of homes in fiscal year 2007: 984; 
Total comparative surveys: 31; 
Total comparative surveys with at least one missed D-F deficiency: 12; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 38.7; 
Total number of missed D-F deficiencies: 20. 

State: Oklahoma; 
Number of homes in fiscal year 2007: 348; 
Total comparative surveys: 20; 
Total comparative surveys with at least one missed D-F deficiency: 15; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 75.0; 
Total number of missed D-F deficiencies: 96. 

State: Oregon; 
Number of homes in fiscal year 2007: 139; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed D-F deficiency: 12; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 66.7; 
Total number of missed D-F deficiencies: 30. 

State: Pennsylvania; 
Number of homes in fiscal year 2007: 724; 
Total comparative surveys: 37; 
Total comparative surveys with at least one missed D-F deficiency: 23; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 62.2; 
Total number of missed D-F deficiencies: 66. 

State: Rhode Island; 
Number of homes in fiscal year 2007: 87; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 9; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 75.0; 
Total number of missed D-F deficiencies: 14. 

State: South Carolina; 
Number of homes in fiscal year 2007: 176; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed D-F deficiency: 15; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 83.3; 
Total number of missed D-F deficiencies: 59. 

State: South Dakota; 
Number of homes in fiscal year 2007: 112; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 12; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 100.0; 
Total number of missed D-F deficiencies: 44. 

State: Tennessee; 
Number of homes in fiscal year 2007: 332; 
Total comparative surveys: 19; 
Total comparative surveys with at least one missed D-F deficiency: 16; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 84.2; 
Total number of missed D-F deficiencies: 50. 

State: Texas; 
Number of homes in fiscal year 2007: 1,195; 
Total comparative surveys: 38; 
Total comparative surveys with at least one missed D-F deficiency: 29; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 76.3; 
Total number of missed D-F deficiencies: 119. 

State: Utah; 
Number of homes in fiscal year 2007: 94; 
Total comparative surveys: 11; 
Total comparative surveys with at least one missed D-F deficiency: 11; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 100.0; 
Total number of missed D-F deficiencies: 94. 

State: Vermont; 
Number of homes in fiscal year 2007: 41; 
Total comparative surveys: 10; 
Total comparative surveys with at least one missed D-F deficiency: 4; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 40.0; 
Total number of missed D-F deficiencies: 18. 

State: Virginia; 
Number of homes in fiscal year 2007: 281; 
Total comparative surveys: 17; 
Total comparative surveys with at least one missed D-F deficiency: 12; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 70.6; 
Total number of missed D-F deficiencies: 31. 

State: Washington; 
Number of homes in fiscal year 2007: 247; 
Total comparative surveys: 18; 
Total comparative surveys with at least one missed D-F deficiency: 10; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 55.6; 
Total number of missed D-F deficiencies: 20. 

State: West Virginia; 
Number of homes in fiscal year 2007: 133; 
Total comparative surveys: 13; 
Total comparative surveys with at least one missed D-F deficiency: 3; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 23.1; 
Total number of missed D-F deficiencies: 3. 

State: Wisconsin; 
Number of homes in fiscal year 2007: 401; 
Total comparative surveys: 21; 
Total comparative surveys with at least one missed D-F deficiency: 8; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 38.1; 
Total number of missed D-F deficiencies: 19. 

State: Wyoming; 
Number of homes in fiscal year 2007: 39; 
Total comparative surveys: 12; 
Total comparative surveys with at least one missed D-F deficiency: 12; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 100.0; 
Total number of missed D-F deficiencies: 83. 

State: Nation; 
Number of homes in fiscal year 2007: 16,114; 
Total comparative surveys: 976; 
Total comparative surveys with at least one missed D-F deficiency: 667; 
Percentage of total comparative surveys with at least one missed D-F 
deficiency: 68.3; 
Total number of missed D-F deficiencies: 2,431. 

Source: GAO analysis of CMS's OSCAR data for the number of homes and 
federal monitoring survey data for all other data presented. 

[End of table] 

[End of section] 

Appendix IV: Percentage of Comparative Surveys with at Least One Missed 
Deficiency, by Federal Quality Standard Category: 

Table 7: 

Federal quality standard category: Quality of Care; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 31.7; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 11.9. 

Federal quality standard category: Resident Behavior and Facility 
Practices; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 17.7; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 2.2. 

Federal quality standard category: Resident Assessment; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 31.7; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 1.6. 

Federal quality standard category: Administration; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 13.3; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 1.4. 

Federal quality standard category: Resident Rights; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 10.8; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.5. 

Federal quality standard category: Quality of Life; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 18.9; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.5. 

Federal quality standard category: Nursing Services; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 1.3; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.4. 

Federal quality standard category: Other; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 0.2; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.2. 

Federal quality standard category: Dietary Services; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 18.5; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.1. 

Federal quality standard category: Physician Services; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 3.0; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.1. 

Federal quality standard category: Dental Services; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 0.2; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.1. 

Federal quality standard category: Pharmacy Services; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 9.7; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.1. 

Federal quality standard category: Infection Control; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 9.8; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.1. 

Federal quality standard category: Physical Environment; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 14.5; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.1. 

Federal quality standard category: Admission, Transfer, and Discharge 
Rights; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 0.3; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.0. 

Federal quality standard category: Specialized Rehabilitative; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 0.3; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 0.0. 

Federal quality standard category: National average[A]; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the D through F level: 68.3; 
Percentage of total comparative surveys citing at least one missed 
deficiency: At the G through L level: 14.5. 

Source: GAO analysis of federal monitoring survey data. 

[A] Percentages for both the D through F and G through L levels do not 
total the national average because some surveys cited missed 
deficiencies in multiple categories. 

[End of table] 

[End of section] 

Appendix V: Percentage of Below Satisfactory State Survey Ratings for 
General Investigation and Deficiency Determination: 

Table 8: 

Alabama; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 27.8; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 20.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 22.7. 

Alaska; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 5.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 5.3. 

Arizona; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 26.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 7.4; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 15.4. 

Arkansas; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 5.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 3.5; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 7.0. 

California; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 10.2; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 10.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 6.1. 

Colorado; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 13.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 4.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 0.0. 

Connecticut; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 6.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 7.4; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 7.4. 

Delaware; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 15.4; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 11.8. 

District of Columbia; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 8.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 5.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 5.6. 

Florida; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 11.5; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 16.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 19.5. 

Georgia; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 16.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 12.5; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 21.6. 

Hawaii; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 8.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 5.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 11.1. 

Idaho; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 5.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 0.0. 

Illinois; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 21.9; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 4.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 2.4. 

Indiana; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 12.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 2.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 3.9. 

Iowa; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 15.8; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 1.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 1.7. 

Kansas; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 16.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 2.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 4.7. 

Kentucky; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 11.1; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 11.4; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 21.4. 

Louisiana; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 17.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 14.9; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 19.4. 

Maine; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 12.5; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 4.2. 

Maryland; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 10.5; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 2.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 6.0. 

Massachusetts; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 5.9; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 0.8; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 0.8. 

Michigan; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 20.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 2.9; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 6.8. 

Minnesota; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 9.5; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 5.9; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 3.0. 

Mississippi; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 22.2; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 16.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 21.4. 

Missouri; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 28.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 17.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 22.1. 

Montana; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 16.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 10.5; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 0.0. 

Nebraska; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 5.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 4.1; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 2.0. 

Nevada; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 8.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 11.1; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 11.1. 

New Hampshire; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 14.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 25.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 18.8. 

New Jersey; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 20.8; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 3.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 1.1. 

New Mexico; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 33.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 26.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 31.6. 

New York; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 22.2; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 14.4; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 14.5. 

North Carolina; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 14.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 12.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 23.6. 

North Dakota; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 0.0. 

Ohio; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 3.2; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 0.8; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 2.7. 

Oklahoma; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 30.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 12.1; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 16.5. 

Oregon; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 4.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 8.7. 

Pennsylvania; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 16.2; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 4.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 5.3. 

Rhode Island; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 16.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 5.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 11.1. 

South Carolina; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 33.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 14.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 22.9. 

South Dakota; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 33.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 0.0. 

Tennessee; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 26.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 14.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 20.7. 

Texas; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 13.2; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 8.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 12.0. 

Utah; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 9.1; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 5.6. 

Vermont; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 0.0. 

Virginia; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 5.9; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 4.8; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 6.3. 

Washington; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 11.1; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 5.2; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 3.4. 

West Virginia; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 3.6; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 7.1. 

Wisconsin; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 9.5; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 6.1; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 3.0. 

Wyoming; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 33.3; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 0.0; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 0.0. 

Nation; 
Percentage of total comparative surveys with at least one missed G-L 
deficiency: 14.5; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
General Investigation: 7.7; 
Percentage of state surveys receiving below satisfactory ratings[A]: 
Deficiency Determination: 9.2. 

Source: GAO analysis of federal monitoring survey data. 

[A] Federal observational surveys use a five-point rating scale to 
evaluate state survey teams. Our analysis collapsed the ratings in the 
lowest two categories--much less than satisfactory and less than 
satisfactory--into a single category of below satisfactory results. 

[End of table] 

[End of section] 

Appendix VI: Comments from the Department of Health & Human Services: 

Department Of Health & Human Services: 
Office of the Assistant Secretary for Legislation: 
Washington, D.C. 20201: 

Mr. John Dicken: 
Director, Health Care: 
Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Mr. Dicken: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) Draft Report: "Nursing Homes: Federal 
Monitoring Surveys Demonstrate Continued Understatement of Serious Care 
Problems and CMS Oversight Weaknesses" (GAO-08-517). 

The Department appreciates the opportunity to review and comment on 
this report before its publication.

Sincerely,

Signed by: 

Jennifer P. Lnoury: 

for: 

Vincent J. Vehtimiglia, Jr.: 
Assistant Secretary for Legislation: 

Attachment: 

General Comments Of The Department Of Health And Human Services (HHS) 
On The U.S. Government Accountability Office's (GAO) Draft Report 
Entitled: Nursing Homes: Federal Monitoring Surveys Demonstrate 
Continued Understatement Of Serious Care Problems And CMS Oversight 
Weaknesses (GAO 08-517): 

The report was prepared at the request of the Special Committee on 
Aging and the Committee on Finance. The GAO evaluated the Centers for 
Medicare and Medicaid (CMS) oversight of States and potential 
understatement of deficiencies by States as States survey the nation's 
nursing homes. 

We fully endorse and will implement all of the GAO recommendations. The 
GAO recommendations are consistent with the direction that CMS is 
taking. In the following remarks, we convey CMS' strategic approach for 
targeting scarce taxpayer dollars to areas in the Medicare and Medicaid 
quality assurance system that will yield the greatest benefit. We then 
discuss the GAO recommendations and the manner in which they relate to 
CMS activities. A strategic approach to quality requires that we 
establish clear priorities for action and then seek those leverage 
points by which we can achieve the greatest possible quality assurance 
results and protections for nursing home residents. 

Leverage Point #1: Fixing "Missed" Surveys (A Key to Reducing "Missed" 
Deficiencies): 

Figure 1: Missed Surveys as Percent of Total Required Surveys 2000-
2007: 

This figure appears in the Department of Health and Human Services 
comment letter to the Government Accountability regarding GAO-08-517. 
The X axis represents the fiscal year, and the Y axis represents the 
percentage. 

FY 2000: 4.1%; 
FY 2001: 3.0%; 
FY 2002: 3.0%; 
FY 2003: 0.9%; 
FY 2004: 0.6%; 
FY 2005: 0.2%; 
FY 2006: 0.1%; 
FY 2007: 0.4%. 

[See PDF for image] 

Source: Department of Health 

[End of figure] 

While the GAO report focuses on deficiencies that States may have 
missed when they conduct surveys, we placed an even higher priority on 
remedial action to prevent entire surveys from being missed. The Social 
Security Act, for example, requires that every nursing home be surveyed 
at least every I5 months. Yet this did not always occur. As a result of 
redoubled attention from CMS and States, the number and percent of 
surveys missed by States has decreased substantially (portrayed in 
Figure 1), despite well-known limitations in the Medicare survey and 
certification budget. In the process CMS strengthened the State 
Performance Standards System and introduced fiscal consequences when 
State performance did not fully meet standards. States responded by 
reducing missed surveys from 4.I percent in fiscal year (FY) 2000 to 
0.4 percent in 2007. When an entire survey is missed, all deficiencies 
are missed (not just those that State surveyors may have missed 
compared to Federal surveyors). Reducing the extent to which surveys 
were missed entirely has considerably reduced the overall number of 
missed deficiencies. CMS, therefore, continues to make the elimination 
of missed surveys one of its top priorities, a key strategy for 
improving overall oversight of nursing home quality within the 
resources appropriated to the Medicare and Medicaid survey and 
certification budget. 

Leverage Point #2: Improving Surveyor Knowledge and Understanding: 

Another high priority for CMS is ensuring that both State and Federal 
surveyors possess optimum understanding of both the care processes 
being surveyed and the Federal quality of care and safety requirements. 
CMS therefore placed a priority on surveyor training and clarifying 
interpretive guidance to all surveyors (both State and Federal). Figure 
2 lists the topic areas for which improved guidance was recently 
issued. Such guidance was accompanied by additional training. 

Figure 2 ï¿½ New Guidance to Surveyors to Improve Accuracy Citation: 

This figure appears in the Department of Health and Human Services 
comment letter to the Government Accountability regarding GAO-08-517. 

Citation "F-Tags": 314; 
Topic: Pressure Ulcers; 
Implementation data: November 14, 2004. 

Citation "F-Tags": 315; 
Topic: Incontinence; 
Implementation data: June 27, 2005. 

Citation "F-Tags": 501; 
Topic: Medical Director; 
Implementation data: November 18, 2005. 

Citation "F-Tags": 520; 
Topic: Quality Assurance; 
Implementation data: June 1, 2006. 

Citation "F-Tags": 248/249; 
Topic: Activities; 
Implementation data: June 1, 2006. 

Citation "F-Tags": [Empty]; 
Topic: Psychological Severity Guidance; 
Implementation data: June 8, 2006. 

Citation "F-Tags": 329, 425, 428, & 431; 
Topic: Unnecessary Drugs & Pharmacy Services; 
Implementation data: December 18, 2006. 

Citation "F-Tags": 323; 
Topic: Accidents & Supervision; 
Implementation data: July 6, 2007. 

[See PDF for image] 

Source: Department of Health and Human Services. 

[End of figure] 

The goal of the guidance update initiative has been to improve accuracy 
and consistency, as well as keep pace with advances in the field. 
However, where understatement of deficiencies previously prevailed, an 
important by- product of the guidance update initiative has been to 
remedy understatement (or under-identification) of deficiencies. This 
is particularly important because understatement that arises from a 
lack of understanding or confusion about federal requirements would 
generally not be detected through the validation survey process that is 
the subject of the GAO report. The GAO report focuses on discrepancies 
that CMS detects by comparing the results of a sample of State surveys 
with results from federal surveys of the same facilities. If CMS 
requirements are unclear, then both Federal and State surveyors would 
be affected by the same limitation and a discrepancy between State and 
Federal surveys would be less likely to become manifest. Even more 
importantly, providers would be unclear. 

One example of the impact that the guidance update initiative has had 
in curing under-identification of deficiencies can be seen in the rate 
at which the use of unnecessary drugs has been identified. Figure 3 (on 
the following page) shows the change in citations of unnecessary drug 
use in nursing homes after CMS issued better guidance and training in 
late 2006. Between 2000 and 2006, the percent of surveys in which the 
use of unnecessary drugs was identified consistently ranged between 13 
percent and 14 percent. After the new guidance, the rate increased to 
18 percent, reflecting surveyors' improved understanding of medication 
issues. 

Leverage Point #3: Quality Indicator Survey: 

Figure 3: Percent of Surveys Citing Unnecessary Drug Use: 

This figure appears in the Department of Health and Human Services 
comment letter to the Government Accountability regarding GAO-08-517. 
The X axis represents the calendar year, and the Y axis represents the 
percent of surveys. 

Calendar Year: 2000; 
Percent of Surveys: 13%. 

Calendar Year: 2001; 
Percent of Surveys: 14%. 

Calendar Year: 2002; 
Percent of Surveys: 14%. 

Calendar Year: 2003; 
Percent of Surveys: 13%. 

Calendar Year: 2004; 
Percent of Surveys: 13%. 

Calendar Year: 2005; 
Percent of Surveys: 13%. 

Calendar Year: 2006; 
Percent of Surveys: 13%. 

Calendar Year: 2007; 
Percent of Surveys: 18%. 

[See PDF for Image] 

Source: Department of Health and Human Services. 

[End of figure] 

The Quality Indicator Survey (QIS) holds considerable promise for (a) 
improving CMS' validation capability, as well as (b) providing State 
Agency directors and supervisors with more tools to do their own 
validation analyses. As such, we believe it merits discussion in the 
context of our overall strategy for improving oversight. 19% 

The QIS is a new twoï¿½stage survey process used by surveyors to 
systematically review specific nursing home requirements and 
objectively investigate any regulatory areas that are triggered. The 
QIS uses customized software (Data Collection Tool-DCT) on tablet 
personal computers to guide surveyors through a structured 
investigation. 

The QIS is currently being implemented statewide in eight States. 
Further expansion will be dependent on the level of funding in the 
overall Medicare and Calendar Year Medicaid survey and certification 
budget in FYs 2009-2014. 

The QIS is not likely to increase the accuracy of deficiency 
identification, since accuracy may be more a function of training and 
CMS interpretive guidance. But we do expect that the QIS will have 
significant advantages directly pertinent to the quality control issues 
raised in the GAO report, such as the following: 

1. Consistency: We expect the QIS to increase the consistency of survey 
process both between States and within States; 

2. Tools for State Quality Control: We expect the QIS will provide 
better information and tools for State survey teams and supervisors to 
analyze findings and provide feedback to survey teams themselves. 
Information collected during the QIS supports an offsite monitoring 
process, which helps to ensure that State surveyors are complying with 
the QIS process. It also identifies areas of concern with regard to 
consistency and accuracy of survey performance. 

3. Tools for CMS Quality Control: We expect the QIS will provide better 
information and tools for CMS ROs to analyze findings and provide 
feedback to States. QIS information available to the RO provides 
comparison information at four levels - national, regional, State, and 
district within a State. Such information will assist the ROs to 
conduct quality improvement activities with the SAs in their region. 
Communications will occur between the RO and key SA staff using a 
process developed by the University of Colorado to help the SA 
understand and correct sources of inconsistency identified in a QIS. 
Certain standardized output reports assist both the State and the RO to 
identify areas in which quality improvement is needed. The "Desk Audit 
Reports" will also assist CMS to identify States and/or particular 
survey teams that need more specific training, technical assistance or 
oversight in order to improve accuracy of the surveys. 

The same reports provided to the RO will be summarized and provided to 
the Central Office (CO). Review of this information at the CO creates 
the opportunity to evaluate the program for Federal monitoring at a 
macro or national level. We envision the CO utilizing this information 
to promote discussion with the RO regarding oversight of States. Use of 
the reports will focus on RO oversight, including the opportunity to 
discuss specific concerns that may be present at a State level. 

Leverage Point #4: Improving CMS Validation Surveys as a Quality 
Control System: 

CMS ROs maintain a quality oversight system for surveys conducted by 
State surveyors. The essence of this validation system is a 5 percent 
sample of State surveys in which the ROs either (a) accompany State 
surveyors in which CMS staff observe both the surveyors and conditions 
in the nursing home (so- called "follow-along" or "Federal 
Oversight/Support Survey (FOSS)" surveys); or (b) conduct an 
independent survey of the nursing home within 60 days after the State 
survey (so-called "comparative" surveys). The ROs then compare the 
results and enter the information into CMS databases, noting any 
discrepancies in the findings between State and Federal survey teams. 
CMS ROs then follow-up with the States to address any deficiencies. The 
GAO report focuses entirely on this particular area using data that CMS 
maintains as part of its internal quality control system. CMS has been 
entirely successful in ensuring that 100 percent of required validation 
surveys are performed each year. This enables greater attention to be 
placed on improving the methodologies and use of the data. The GAO 
recommendations fit well with such a goal. 

GAO Recommendations: 

1. Require regional offices to determine if there was an understatement 
when States cite a deficiency at a lower scope and severity level than 
Federal surveyors, and to track this information.

2. Establish quality controls to improve the accuracy and reliability 
of information entered into the Federal monitoring survey database. 

3. Routinely examine comparative survey data and hold ROs accountable 
for implementing CMS guidance that is intended to ensure comparative 
surveys more accurately capture the conditions at the time of the State 
survey. 

4. Regularly analyze and compare Federal comparative and observational 
survey results. 

HHS Responses: 

Recommendation #1 suggests that the Federal Monitoring Survey (FMS) 
database contain an explicit field for registering understatement of a 
deficiency. The current CMS database provides methods for CMS ROs to 
register where there are missed deficiencies. Yet the database does not 
have a specific field in which the RO can render a judgment to identify 
clearly those areas in which both the State and Federal teams 
identified the same deficiency, but cited it at a significantly 
different scope or severity level. We agree with the GAO recommendation 
and have planned for the future development of such capability as an 
action item in our 2008 Nursing Home Action Plan. The 2008 Action Plan 
can be found at: [hyperlink, 
http://www.cros.hhs.v/CertificationandComilianc/Downloads/2008NHActionPl
an.pdf] 

Recommendation #2 accurately reflects the fact that there have been 
problems in the FMS database that CMS maintains. CMS identified these 
problems a few years ago and took action in 2007 to move the FMS 
database and vendor contract to the CMS Survey & Certification Group in 
order to (a) bring it closer to the end users of the data and (b) 
facilitate integration of the data into the State Performance Standards 
System. Data entry and accuracy issues always become more prominent, 
and more likely to be remedied, the closer the data are to regular use 
in management of a program. Such remedial actions are well underway. 
Figure 4 lists various steps for improving the FMS database. Attachment 
I provides additional information and timetables. 

Figure 4: Steps to Improve the Federal Monitoring System Database: 

This figure appears in the Department of Health and Human Services 
comment letter to the Government Accountability regarding GAO-08-517. 

January to June 2007; 
Move the database close to end users and procure a new contractor to 
maintain & update the database. (Completed) 

Sept. 2007; 
Implement monthly teleconference calls with the contractor, CMS CO, and 
RO staffs. The purpose of the teleconference calls is to answer 
questions, accept suggestions for improving the database, and 
communicate updates. (Completed and held every month since Sept 2007). 

Nov. 2007; 
Overcome glitches in the transition from operating components in CO, 
provide assistance in downloading data from ROs, including written 
instructions. (Completed) 

Dec. 2007- June 2008; 
Institute CO monitoring of the database on a quarterly basis to assure 
that ROs are June 2008 downloading data quarterly. 

Jan. 2008 ï¿½ Nov. 2009; 
Modify the database to develop data fields that will document and track 
discrepancies between RO and State Survey Agency (SA) scope and 
severity for every deficiency cited. Strengthen the database to improve 
the accuracy and reliability of the data entered. 

Feb. 2008 ï¿½ Jan. 2009; 
Modify the database to develop data fields that will document and track 
discrepancies between RO and State Survey Agency (SA) scope and 
severity for every deficiency cited. Strengthen the database to improve 
the accuracy and reliability of the data entered. 

Feb. 2008 ï¿½ Nov. 2008; 
Issue a FOSS Database User's Manual. (Now in draft form). 

Nov. 2008 ï¿½ May 2009; 
Develop new analytic reports to provide RO and CO an analysis of the 
differences between comparative and observational survey results. 

Source: Department of Health and Human Services. 

[End of table] 

Recommendation #3 suggests that CMS CO routinely examine comparative 
survey data and hold regional offices accountable for implementing CMS 
guidance. We intend to develop additional output reports that will be 
useful to both CO and RO in analyzing State performance. Processes to 
ensure that CMS validation surveys are conducted in conformance with 
CMS guidance are the subject of current CMS discussion and will be 
finalized later in 2008. 

Recommendation #4 indicates the need for (a) regular analysis of the 
FMS data and (b) regular comparison between results from the two 
validation processes (comparative and observational). Additional output 
reports from the FMS database will assist in this effort. We will then 
identify further methods by which the analyses may be put to effective 
use. For example, the GAO report noted that available data could be 
better utilized to identify areas in which particular CMS ROs merit 
additional attention. This is an observation that will be an important 
focus for CMS' 2009 Nursing Home Action Plan. 

One aspect of quality control that we have not solved, and that the GAO 
report does not resolve, is the setting of appropriate thresholds for 
missed deficiencies. No system involving multiple parties will yield 
the identical result every time. An entire field of statistics is 
devoted to issues of inter-rater agreement. In the present case, the 
challenge is to identify the level of "missed deficiencies" that goes 
beyond statistical chance and beyond issues of inter-rater agreement to 
reveal a level of discrepancy that ought to give concern and demand 
response from CMS. GAO adopted a measure of "one missed deficiency per 
survey," and then counted the percentage of a State's surveys for which 
Federal surveyors identified one or more deficiencies that the State 
missed. It is not clear that "one missed deficiency per survey" is the 
proper standard, nor is it clear what percentage of a State's surveys 
ought to trigger assertive response even when the "one missed 
deficiency per survey" standard is used. In this sense, the GAO 
analysis is helpful but not conclusive. We will need to devote more 
thought to these matters so that we can make more effective use of the 
approach in the State Performance Standards System . 

Regardless of the particular thresholds chosen, we do agree with GAO 
that effective follow-up with States must be assured when it is clear 
the State surveys exhibit a high level of discrepancy in survey 
findings compared to the Federal validation surveys. For example, GAO 
identified nine States in which more than 25 percent of the surveys 
indicated a missed deficiency at a very serious (G-L) level. We note 
that assertive follow-up actions have been made by CMS ROs or are 
occurring in most of these States. In Alabama, for example, the CMS RO 
issued a very pointed series of evidence-based performance 
communications in 2007 and raised performance issues to the top agency 
levels. CMS CO made a $90,421 deduction in Alabama's Medicare budget in 
2008 due to 2007 performance issues. We are pleased to report that the 
State of Alabama is in the process of effectively responding to these 
problems in 2008. The State has recruited additional survey staff and 
made important organizational changes. FMS validation surveys indicate 
that the Alabama State surveyors have not missed any serious deficiency 
determinations so far in 2008. 

Similarly, in Tennessee a new survey agency director was enlisted in 
October 2007, the State retrained all staff (utilizing CMS RO staff to 
assist in training for investigative skills and deficiency 
determinations). Based on two comparative FMS surveys so far in 2008, 
the State surveyors have not missed any serious deficiency findings. 

The GAO report noted that available data could be better utilized to 
identify areas in which particular CMS ROs merit additional attention. 
This is an observation that is an important focus of action for CMS' 
2009 Nursing Home Action Plan. 

Due to the well-known limitations in the Medicare survey and 
certification budget, it has been particularly important that CMS 
target its resources effectively and apply its knowledge of system 
leverage points to gain maximum results from scarce resources. We hope 
that our explanation of the four leverage points outlined in our 
response is useful in placing CMS actions in context. We appreciate the 
opportunity to respond to the GAO draft report. 

Attachment 1: 

CMS Action Plan: GAO-08-517: Nursing Homes: Federal Monitoring Surveys 
Demonstrate Continued Understatement of Serious Care Problems and CMS 
Oversight Weaknesses: 

GAO Recommendation: A. Regional Office Oversight: Require ROS to 
determine if there was an understatement when state surveyors cite a 
deficiency at a lower scope and severity level than Federal Surveyors 
and track this information;  
CMS Action: A1: FMS Database Users' Manual - As stated in our 2008 
Nursing Home Action Plan, CMS will issue instruction to the ROs that 
defines all data fields and includes procedures for entering all data 
into the FMS database. This document currently exists in draft form and 
will be finalized for release by November 30, 2008. 

GAO Recommendation: A. Regional Office Oversight: Require ROS to 
determine if there was an understatement when state surveyors cite a 
deficiency at a lower scope and severity level than Federal Surveyors 
and track this information; 
CMS Action: A2: FMS Database - We will modify the FMS Database to allow 
tracking the variance between RO and State findings at the scope and 
severity level. The RO will be able to enter their findings, and 
production reporting capability will be developed to allow easy 
analysis of these data by November 30, 2009. 
 
GAO Recommendation: A. Regional Office Oversight: Require ROS to 
determine if there was an understatement when state surveyors cite a 
deficiency at a lower scope and severity level than Federal Surveyors 
and track this information; 
CMS Action: A3: Communication between ROs and Central Office (CO) via 
Regular Teleconference Calls ï¿½ We have implemented a system of regular 
conference calls between CO, a core group from the ROs, and the 
database contractor to answer questions, discuss best practices, 
suggest and communicate database improvements, set expectations, and 
provide updates. 

GAO Recommendation: B. Quality Controls: Establishing quality controls 
to improve the accuracy and reliability of information entered into the 
Federal monitoring survey database; 
CMS Action: B1: Strengthening the database ï¿½ We will modify the 
database to incorporate additional edits (e.g., assuring that the 
correct data is entered in the appropriate data field before the 
surveyor can move onto the next data field). 

GAO Recommendation: B. Quality Controls: Establishing quality controls 
to improve the accuracy and reliability of information entered into the 
Federal monitoring survey database; 
CMS Action: B2: RO Reporting ï¿½ We will implement Quality Assurance 
reports by November 30, 2009 for use by the ROs. The reports will 
describe the results of their review of the accuracy and reliability of 
the data entered into the database. These reports will be sent to CO 
quarterly for assessment. We will routinely monitor the database to 
assure ROs are downloading data. 

GAO Recommendation: C. Analysis & Follow- Routinely examine comparative 
survey data and hold regional offices accountable for implementing CMS 
guidance; 
CMS Action: C1: Develop RO Start Date Reports ï¿½ We will develop a 
report that will show the number of work days between the SA's 
comparative end date and the RO's start date. CMS will generate these 
reports quarterly for assessment. We will operationalize these reports 
no later than November 30, 2008. 

GAO Recommendation: C. Analysis & Follow- Routinely examine comparative 
survey data and hold regional offices accountable for implementing CMS 
guidance; 
CMS Action: C2: RO Feedback Mechanism ï¿½ We will implement by November 
30, 2009 a feedback system based on RO reporting and CO analysis of 
comparative survey results. One component of this feedback system will 
be a standing agenda item on internal management meetings at least once 
a quarter. 

GAO Recommendation: D. Compare Comparative & FOSS Data: Regularly 
analyze and compare Federal comparative and observational survey 
results;  
CMS Action: Dl: RO Reporting ï¿½ We will implement a system of QA reports 
for the ROs describing the results of their review of the accuracy and 
reliability of the data entered into the database. These reports will 
he sent to CO quarterly for assessment and begin no later than November 
30, 2009. 

[End of section] 

Appendix VII: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

John E. Dicken, (202) 512-7114 or [email protected]: 

Acknowledgments: 

In addition to the contact named above, Walter Ochinko, Assistant 
Director; Katherine Nicole Laubacher; Dan Lee; Elizabeth T. Morrison; 
Steve Robblee; Karin Wallestad; and Rachael Wojnowicz made key 
contributions to this report. 

[End of section] 

Related GAO Products: 

Nursing Home Reform: Continued Attention Is Needed to Improve Quality 
of Care in Small but Significant Share of Homes. GAO-07-794T. 
Washington, D.C.: May 2, 2007. 

Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not 
Deterred Some Homes from Repeatedly Harming Residents. GAO-07-241. 
Washington, D.C.: March 26, 2007. 

Nursing Homes: Despite Increased Oversight, Challenges Remain in 
Ensuring High-Quality Care and Resident Safety. GAO-06-117. Washington, 
D.C.: December 28, 2005. 

Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses in 
State and Federal Oversight of Quality of Care. GAO-05-78. Washington, 
D.C.: November 12, 2004. 

Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal 
Standards and Oversight. GAO-04-660. Washington D.C.: July 16, 2004. 

Nursing Home Quality: Prevalence of Serious Problems, While Declining, 
Reinforces Importance of Enhanced Oversight. GAO-03-561. Washington, 
D.C.: July 15, 2003. 

Nursing Homes: Public Reporting of Quality Indicators Has Merit, but 
National Implementation Is Premature. GAO-03-187. Washington, D.C.: 
October 31, 2002. 

Nursing Homes: Quality of Care More Related to Staffing than Spending. 
GAO-02-431R. Washington, D.C.: June 13, 2002. 

Nursing Homes: More Can Be Done to Protect Residents from Abuse. GAO- 
02-312. Washington, D.C.: March 1, 2002. 

Nursing Homes: Federal Efforts to Monitor Resident Assessment Data 
Should Complement State Activities. GAO-02-279. Washington, D.C.: 
February 15, 2002. 

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of 
the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: September 
28, 2000. 

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would 
Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: November 4, 
1999. 

Nursing Home Oversight: Industry Examples Do Not Demonstrate That 
Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington, 
D.C.: August 13, 1999. 

Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes 
Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999. 

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

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

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

[End of section] 

Footnotes: 

[1] See GAO, California Nursing Homes: Care Problems Persist Despite 
Federal and State Oversight, GAO/HEHS-98-202 (Washington, D.C.: July 
27, 1998); Nursing Home Care: Enhanced HCFA Oversight of State Programs 
Would Better Ensure Quality, GAO/HEHS-00-06 (Washington, D.C.: Nov. 4, 
1999); and Nursing Home Quality: Prevalence of Serious Problems, While 
Declining, Reinforces Importance of Enhanced Oversight, GAO-03-561 
(Washington, D.C.: July 15, 2003). A list of related GAO products is at 
the end of this report. 

[2] All homes that participate in the Medicare and Medicaid programs 
are subject to periodic surveys to ensure that they are in compliance 
with federal quality standards. CMS contracts with state survey 
agencies to conduct the surveys. Medicare, the federal health care 
program for elderly and disabled individuals, covers up to 100 days of 
skilled nursing home care following a hospital stay. Medicaid, the 
joint federal-state health care financing program for certain 
categories of low-income individuals, pays for the nursing home care of 
qualifying individuals who can no longer live at home. Combined 
Medicare and Medicaid payments for nursing home services were about $75 
billion in 2006, including a federal share of about $51 billion. 

[3] See GAO, Despite Increased Oversight, Challenges Remain in Ensuring 
High-Quality Care and Resident Safety, GAO-06-117 (Washington, D.C.: 
Dec. 28, 2005); and Nursing Home Reform: Continued Attention Is Needed 
to Improve Quality of Care in Small but Significant Share of Homes, GAO-
07-794T (Washington, D.C.: May 2, 2007). In both reports, we examined 
understatement for five states--California, Florida, New York, Ohio, 
and Texas. Results from the May 2007 report showed that understatement 
of serious deficiencies varied across these states from a low of 4 
percent in Ohio to a high of 26 percent in New York during the 5-year 
period March 2002 through March 2007. 

[4] Fiscal year 2002 was the first year that the database contained all 
the information needed to assess the results of federal comparative 
surveys. 

[5] In addition to nursing homes, CMS and state survey agencies are 
responsible for oversight of other Medicare and Medicaid providers, 
such as home health agencies, intermediate care facilities for the 
mentally retarded, and hospitals. 

[6] Several GAO reports have documented understatement of serious 
deficiencies by state surveyors. For one report, in 1998, we arranged 
for a team of registered nurses to accompany state surveyors and 
conduct concurrent surveys designed specifically to identify quality- 
of-care problems. The survey methodology we used differed from the 
methodology used by state surveyors in that it was more rigorous and 
reviewed a larger sample of cases. Using this methodology, our surveys 
spotted cases in which the homes had not intervened appropriately for 
residents experiencing weight loss, dehydration, pressure sores, and 
incontinence--cases the state surveyors either missed or identified as 
affecting fewer residents. (See GAO/HEHS-98-202.) In addition, we have 
documented considerable interstate variation in the proportion of homes 
cited for serious care problems. For example, 8 percent of Florida's 
683 homes and 38 percent of Connecticut's 244 homes were cited for 
serious care problems in fiscal year 2007. The extent of this variation 
suggests inconsistency in how states conduct surveys and understatement 
of serious quality problems. App. I shows the proportion of homes in 
each state cited by state surveyors for serious deficiencies from 
fiscal year 2002 through 2007. 

[7] Other areas include Admission, Transfer and Discharge Rights; 
Resident Behavior and Facility Practices; Nursing Services; Dietary 
Services; Physician Services; Specialized Rehabilitative Services; 
Dental Services; Infection Control; and Physical Environment. Surveys 
also examine compliance with federal fire safety requirements. 

[8] The scope and severity of a deficiency is one of four factors that 
CMS takes into account when imposing sanctions. CMS also considers a 
home's prior compliance history, desired corrective action and long- 
term compliance, and the number and severity of all the home's 
deficiencies. 

[9] See GAO, Nursing Homes: Efforts to Strengthen Federal Enforcement 
Have Not Deterred Some Homes from Repeatedly Harming Residents, GAO-07-
241 (Washington, D.C.: Mar. 26, 2007). 

[10] A revisit is required for F level deficiencies that are cited in 
one 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 and Facility Practices, which can include deficiencies such as 
a failure to protect residents from abuse. 

[11] In addition, CMS also conducts annual state performance reviews, 
which include an examination of the quality of state survey agency 
investigations and decision making and the timeliness and quality of 
complaint investigations. 

[12] Throughout this report, when we refer to CMS headquarters or CMS 
headquarters officials, we mean the Survey and Certification Group and 
its officials. 

[13] See GAO/HEHS-00-6. 

[14] In December 2001, CMS requested that regional offices conduct 
comparative surveys between 2 weeks and 1 month after the state survey. 
In October 2002, CMS relaxed this standard by changing the requirement 
to between 10 and 30 working days. In general, it is easier for federal 
surveyors to determine whether state surveyors should have identified 
deficiencies when conditions during the comparative survey are as close 
as possible to those existing during the state survey. Reducing the 
time between state and federal surveys and requiring a review of the 
quality of care provided to as many of the same nursing home residents 
as possible enhances the similarities between state and federal 
surveys. 

[15] In 1999, we reported that there was little consistency across CMS 
regional offices in the criteria used to select homes for comparative 
surveys. For example, some regions were selecting homes that had no 
serious deficiencies, while others were focusing on homes with serious 
deficiencies. We noted that federal surveyors were less likely to find 
missed deficiencies at homes where state surveyors found serious care 
problems. See GAO/HEHS-00-6. 

[16] See GAO-03-561. 

[17] We examined missed deficiencies by state for each fiscal year from 
2002 through 2007 and found that for most states the failure to cite 
deficiencies at the actual harm and immediate jeopardy levels was not 
isolated to a single year during the 6 fiscal years we examined, and it 
continued to be a problem for many states in fiscal year 2007. 

[18] Alaska, Idaho, Maine, North Dakota, Oregon, Vermont, and West 
Virginia had no missed serious deficiencies. 

[19] This finding was consistent with the overall prevalence of D 
through F level deficiencies cited by state survey teams during annual 
standard surveys. Approximately 84 percent of all deficiencies 
identified during these surveys in 2006 were at the D through F level. 
In contrast, only about 5 percent of deficiencies cited on state 
surveys were at the actual harm and immediate jeopardy (G through L) 
levels. 

[20] Examples of deficiencies related to Resident Behavior and Facility 
Practices include resident abuse and the misuse of restraints. 

[21] In addition, 31.7 percent of total comparative surveys found at 
least one missed potential for more than minimal harm level deficiency 
in the Resident Assessment category. An example of a deficiency related 
to Resident Assessment is the failure to develop a comprehensive care 
plan that meets a resident's physical, mental, and psychosocial needs. 

[22] Federal observational surveys use a five-point rating scale to 
evaluate state survey teams. Our analysis collapsed the ratings in the 
lowest two categories--much less than satisfactory and less than 
satisfactory--into a single category of below satisfactory results. 

[23] An additional seven states had mixed performance on these two 
measures--performing above the national average for one measure and 
below the national average for the other. 

[24] Later in this report, we observe that no Wyoming and South Dakota 
survey teams received below satisfactory ratings on observational 
surveys. 

[25] See GAO-03-561 and GAO-07-794T. In response to our recommendation 
to finalize the development, testing, and implementation of a more 
rigorous survey methodology, CMS developed and is currently evaluating 
a revised survey methodology. 

[26] See GAO-06-117. 

[27] See GAO-03-561. Our analysis of survey predictability considered 
surveys to be predictable if (1) homes were surveyed within 15 days of 
the 1-year anniversary of the prior survey or (2) homes were surveyed 
within 1 month of the maximum 15-month interval between standard 
surveys. We used this rationale because homes know the maximum 
allowable interval between surveys, and those whose prior surveys were 
conducted 14 or 15 months earlier are aware that they are likely to be 
surveyed soon. 

[28] See GAO-03-561. 

[29] See GAO-03-561. 

[30] On a comparative survey, CMS does not evaluate the adequacy of 
state survey team staffing. 

[31] Surveyor-days are calculated as the total number of days on-site 
times the number of surveyors who worked full-time on that nursing home 
survey. If three surveyors were on-site and the survey took 3 days, 
then the survey would have used 9 surveyor-days. 

[32] Because the establishment of the dispute resolution process for 
comparative surveys is relatively recent, we did not assess how often 
states challenge comparative findings. 

[33] Five of the 10 CMS regions made determinations on multiple 
occasions about whether the state "should have cited" a deficiency, 
even though the only discrepancy was the scope and severity level. 

[34] We did not examine the 388 instances where federal survey teams 
cited potential for more than minimal harm deficiencies and state 
survey teams cited the same deficiencies at a lower scope and severity 
level. 

[35] Overall, federal surveyors identified understated scope and 
severity levels on 2.4 percent of state surveys during fiscal years 
2002 through 2007. The 1 percent average increase in the total 
percentage of comparative surveys is lower because comparative surveys 
with both types of understatement--failing to cite a deficiency or 
citing a deficiency at too low a scope and severity level--were counted 
only once. 

[36] CMS became aware in October 2007 that some regional offices were 
using the validation question designed to identify missed deficiencies 
when our preliminary analysis identified missing data in several 
regions. 

[37] Officials from CMS's Survey and Certification Group--the component 
responsible for ensuring the effectiveness of state survey activities-
-assumed control of the database in January 2007 from CMS's Division of 
National Systems. While officials from the Survey and Certification 
Group are still familiarizing themselves with the database, they stated 
that this change in control was necessary to move it closer to the 
component responsible for managing the federal monitoring survey 
program. 

[38] Subsequently, CMS informed us that all comparative surveys from 
the two regions were now accessible in the database. 

[39] CMS indicated that the results of contractor-led comparative 
health surveys--which began in fiscal year 2004--are not included in 
the federal monitoring survey database because those surveys are in 
addition to the federal monitoring surveys required by statute and that 
inclusion of the contractor-led data would hinder CMS's ability to 
collect and analyze data about CMS staff resources that are devoted to 
comparative surveys. 

[40] However, CMS officials told us that they have been unable to 
identify whether region-to-region differences were the result of 
inconsistencies in state survey agency performance or regional 
variation among nursing homes. 

[41] Comparative and observational surveys each measure some of the 
same skills required for effective surveying, particularly state survey 
team general investigative techniques and ability to accurately 
identify deficiencies. 

[42] See GAO-03-561 and GAO-06-117. 

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