oversight

Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight

Published by the Government Accountability Office on 2003-07-15.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States General Accounting Office

GAO          Report to Congressional Requesters




July 2003
             NURSING HOME
             QUALITY
             Prevalence of Serious
             Problems, While
             Declining, Reinforces
             Importance of
             Enhanced Oversight




GAO-03-561
                                                July 2003


                                                NURSING HOME QUALITY

                                                Prevalence of Serious Problems, While
Highlights of GAO-03-561, a report to           Declining, Reinforces Importance of
congressional requesters
                                                Enhanced Oversight



Since July 1998, GAO has reported               The proportion of nursing homes with serious quality problems remains
numerous times on nursing home                  unacceptably high, despite a decline in the incidence of such reported
quality-of-care issues and identified           problems. Actual harm or more serious deficiencies were cited for 20
significant weaknesses in federal               percent or about 3,500 nursing homes during an 18-month period ending
and state oversight. GAO was                    January 2002, compared to 29 percent for an earlier period. Fewer
asked to assess the extent of the
progress made in improving the
                                                discrepancies between federal and state surveys of the same homes suggests
quality of care provided by nursing             that state surveyors are doing a better job of documenting serious
homes to vulnerable elderly and                 deficiencies and that the decline in serious quality problems is potentially
disabled individuals, including                 real. Despite these improvements, the continuing prevalence of and state
(1) trends in measured nursing                  surveyor understatement of actual harm deficiencies is disturbing. For
home quality, (2) state responses to            example, 39 percent of 76 state surveys from homes with a history of quality-
previously identified weaknesses in             of-care problems—but whose current survey found no actual harm
their survey, complaint, and                    deficiencies—had documented problems that should have been classified as
enforcement activities, and (3) the             actual harm or higher, such as serious, avoidable pressure sores.
status of oversight and quality
improvement efforts by the Centers              Weaknesses persist in state survey, complaint, and enforcement activities.
for Medicare & Medicaid Services
(CMS).
                                                According to CMS and states, several factors contribute to the
                                                understatement of serious quality problems, including poor investigation and
                                                documentation of deficiencies, limited quality assurance systems, and a large
                                                number of inexperienced surveyors in some states. In addition, GAO found
                                                that about one-third of the most recent state surveys nationwide remained
GAO is making several                           predictable in their timing, allowing homes to conceal problems if they
recommendations to the                          chose to do so. Considerable state variation remains regarding the ease of
Administrator of CMS to                         filing a complaint, the appropriateness of the investigation priorities, and the
(1) strengthen the nursing home
                                                timeliness of investigations. Some states attributed timeliness problems to
survey process, (2) ensure that
state survey and complaint                      inadequate staff and an increase in the number of complaints. Although the
activities adequately assess quality-           agency strengthened enforcement policy by requiring states to refer for
of-care problems, and (3) improve               immediate sanction homes that had repeatedly harmed residents, GAO
CMS oversight of state survey                   found that states failed to refer a substantial number of such homes,
activities. CMS concurred with the              significantly undermining the policy’s intended deterrent effect.
report’s recommendations, but its
comments on intended actions                    CMS oversight of state survey activities has improved but requires continued
were not fully responsive to all of             attention to help ensure compliance with federal requirements. While CMS
the recommendations. Eleven                     strengthened oversight by initiating annual state performance reviews,
states provided comments that                   officials acknowledged that the reviews’ effectiveness could be improved.
most often focused on the resource
                                                For the initial fiscal year 2001 review, officials said they lacked the capability
constraints states face in meeting
federal standards for oversight of              to systematically distinguish between minor lapses and more serious
nursing homes.                                  problems that required intervention. CMS oversight is also hampered by
                                                continuing database limitations, the inability of some CMS regions to use
                                                available data to monitor state activities, and inadequate oversight in areas
                                                such as survey predictability and state referral of homes for enforcement.
                                                Three key CMS initiatives have been significantly delayed—strengthening
www.gao.gov/cgi-bin/getrpt?GAO-03-561.
                                                the survey methodology, improving surveyor guidance for determining the
To view the full product, including the scope   scope and severity of deficiencies, and producing greater standardization in
and methodology, click on the link above.       state complaint processes. These initiatives are critical to reducing the
For more information, contact Kathryn G.
Allen at (202) 512-7118.
                                                subjectivity evident in current state survey and complaint activities.
Contents


Letter                                                                                 1
               Results in Brief                                                        3
               Background                                                              6
               Magnitude of Problems Remains Cause for Concern Even Though
                 Fewer Serious Nursing Home Quality Problems Reported                11
               Weaknesses Persist in State Survey, Complaint, and Enforcement
                 Activities                                                          18
               CMS Oversight of State Survey Activities Requires Further
                 Strengthening                                                       29
               Conclusions                                                           40
               Recommendations for Executive Action                                  42
               Agency and State Comments and Our Evaluation                          43

Appendix I     Scope and Methodology                                                  51



Appendix II    Trends in The Proportion of Nursing Homes Cited
               for Actual Harm or Immediate Jeopardy
               Deficiencies, 1997-2002                                                55



Appendix III   Abstracts of Nursing Home Survey Reports That
               Understated Quality-of-Care Problems                                   58



Appendix IV    Information on State Nursing Home Surveyor
               Staffing                                                               78



Appendix V     Predictability of Standard Nursing Home Surveys                        80



Appendix VI    Immediate Sanctions Implemented Under CMS’s
               Expanded Immediate Sanctions Policy                                    83




               Page i                                    GAO-03-561 Nursing Home Quality
Appendix VII           Cases States Did Not Refer to CMS for Immediate
                       Sanction                                                                86



Appendix VIII          HCFA State Performance Standards for Fiscal
                       Year 2001                                                               88



Appendix IX            Highlights of State Compliance with CMS
                       Performance Standards                                                   90



Appendix X             Comments from the Centers for Medicare &
                       Medcaid Services                                                        91



Appendix XI            GAO Contact and Staff Acknowledgements                                  95
                       GAO Contact                                                            95
                       Acknowledgements                                                       95

Related GAO Products                                                                           96



Tables
                       Table 1: Scope and Severity of Deficiencies Identified During
                                Nursing Home Surveys                                            8
                       Table 2: Change in the Percentage of Nursing Homes Cited for
                                Actual Harm or Immediate Jeopardy during State
                                Standard Surveys between the periods January 1, 1999,
                                through July 10, 2000, and July 11, 2000, through
                                January 31, 2002, by State                                    13
                       Table 3: Incidence of Underreported Actual Harm Deficiencies in
                                Surveys GAO Reviewed                                          17
                       Table 4: Predictability of Nursing Home Surveys                        22
                       Table 5: Key Findings of Report to CMS on State Complaint
                                Investigation Processes                                       25




                       Page ii                                    GAO-03-561 Nursing Home Quality
         Table 6: Quality of Care Requirements Reviewed in a Sample of
                   State Survey Reports                                          52
         Table 7: Trends in the Percentage of Nursing Homes Cited for
                   Actual Harm or Immediate Jeopardy during State
                   Standard Surveys, by State                                    56
         Table 8: Abstracts of the 39 Nursing Home Deficiencies that
                   Understated Actual Harm from a Sample of 76 Nursing
                   Home Survey Reports                                           59
         Table 9: State Survey Agency Responses to Questions about
                   Surveyor Experience, Vacancies, Hiring Freezes,
                   Competitiveness of Salaries, and Minimum Required
                   Experience                                                    78
         Table 10: Predictability of Current Nursing Home Surveys, by State      81
         Table 11: Federal Sanctions Implemented against Nursing Homes
                   Referred for Immediate Sanction, January 14, 2000,
                   through March 28, 2002                                        83
         Table 12: Federal CMPs Implemented under CMS’s Immediate
                   Sanctions Policy, January 2000 through March 2002             84
         Table 13: Number of Cases States Did Not Refer for Sanction, as
                   Required, and the Number States Appropriately Referred,
                   January 2000 through March 2002                               86
         Table 14: Overview of HCFA’s Seven State Performance Standards
                   for Nursing Home Survey Activities for Fiscal Year 2001       88
         Table 15: State Compliance with Selected CMS Performance
                   Standards, Fiscal Year 2001                                   90


Figure
         Figure 1: Four States with the Greatest Number of Cases that
                   Should Have Been Referred for Immediate Sanctions,
                   January 14, 2000, through March 28, 2002                      27




         Page iii                                    GAO-03-561 Nursing Home Quality
Abbreviations

ACTS              ASPEN Complaint Tracking System
CMS               Centers for Medicare & Medicaid Services
CMP               civil money penalties
HCFA              Health Care Financing Administration
MDS               minimum data set
OSCAR             On-Line Survey, Certification, and Reporting system
RN                registered nurse



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Page iv                                                GAO-03-561 Nursing Home Quality
United States General Accounting Office
Washington, DC 20548




                                   July 15, 2003

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

                                   The Honorable Christopher S. Bond
                                   United States Senate

                                   A number of congressional hearings since July 1998 have focused
                                   considerable attention on the need to improve the quality of care for the
                                   nation’s 1.7 million nursing home residents, a highly vulnerable population
                                   of elderly and disabled individuals. As we previously reported, poor quality
                                   of care at about 15 percent of the nation’s approximately 17,000 nursing
                                   homes—an unacceptably high proportion—had repeatedly caused actual
                                   harm to residents, such as worsening pressure sores or untreated weight
                                   loss, or had placed them at risk of death or serious injury.1 Significant
                                   weaknesses in federal and state nursing home oversight that we identified
                                   in a series of reports and testimonies since 1998 included (1) periodic state
                                   inspections, known as surveys, that understated the extent of serious care
                                   problems due to procedural weaknesses, (2) considerable state delays in
                                   investigating public complaints alleging harm to residents, (3) federal
                                   enforcement policies that did not ensure deficiencies were addressed and
                                   remained corrected, and (4) federal oversight of state survey activities that
                                   was limited in scope and effectiveness.2

                                   In July 1998, the Health Care Financing Administration (HCFA)—the
                                   federal agency with responsibility for managing Medicare and Medicaid
                                   and overseeing compliance with federal nursing home quality standards—
                                   launched a series of actions intended to address many of the weaknesses
                                   we identified.3 Since 1998, the agency has worked to strengthen surveyors’


                                   1
                                    See U.S. General Accounting Office, Nursing Homes: Proposal to Enhance Oversight of
                                   Poorly Performing Homes Has Merit, GAO/HEHS-99-157 (Washington, D.C.: June 30,
                                   1999).
                                   2
                                    A list of related GAO products is at the end of this report.
                                   3
                                    Effective July 1, 2001, HCFA’s name changed to the Centers for Medicare & Medicaid
                                   Services (CMS). In this report we continue to refer to HCFA where our findings apply to
                                   the organizational structure and operations associated with that name.



                                   Page 1                                                    GAO-03-561 Nursing Home Quality
    ability to detect quality-of-care deficiencies; required states to investigate
    complaints alleging resident harm within 10 days; mandated immediate
    sanctions for nursing homes with a pattern of harming residents;4 and
    begun measuring state compliance with federal survey requirements and
    reviewing data on the results of state surveys to help pinpoint
    shortcomings in state survey activities.

    To evaluate the extent of the progress made in improving the quality of
    nursing home care since we last addressed this issue in September 2000,
    you asked us to assess:

•   trends in measured nursing home quality;
•   state responses to previously identified weaknesses in their survey,
    complaint, and enforcement activities; and
•   the status of key federal efforts to oversee state survey agency
    performance and improve quality.

    To assess recent trends in measured nursing home quality, we analyzed
    survey results for the period July 11, 2000, through January 31, 2002, and
    compared them to survey results for two earlier 18-month periods: (1)
    January 1, 1997, through June 30, 1998, and (2) January 1, 1999, through
    July 10, 2000. Our analysis relied on data from the Centers for Medicare &
    Medicaid Services’ (CMS) On-Line Survey, Certification, and Reporting
    (OSCAR) system, which compiles the results of all state nursing home
    surveys nationwide. To better understand the trends identified through
    our OSCAR analysis, we analyzed the results of federal comparative
    surveys, conducted at recently surveyed nursing homes to assess the
    adequacy of the state surveys, for two time periods—October 1998
    through May 2000 and June 2000 through February 2002. We also reviewed
    76 survey reports from homes with a history of actual harm deficiencies
    but whose most recent survey found no such deficiencies in states where
    the percentage of homes cited for actual harm had declined to below the
    national average since mid-2000. Our review of deficiencies from these
    survey reports focused on the types of quality-of-care deficiencies most
    frequently cited nationwide.




    4
     The term used in the law and regulations to describe a nursing home penalty for
    noncompliance is “remedy.” Throughout this report, we use a more common term,
    “sanction,” to refer to such penalties. Sanctions include actions such as fines, denial of
    payment for new admissions, and termination from the Medicare and Medicaid programs.




    Page 2                                                 GAO-03-561 Nursing Home Quality
                   To assess state survey activities as well as federal oversight, we analyzed
                   the conduct and results of fiscal year 2001 state survey agency
                   performance reviews during which CMS regional offices determined state
                   compliance with seven federal standards; we focused on the five standards
                   related to statutory survey intervals, survey documentation, complaint
                   activities, enforcement requirements, and OSCAR data entry. We
                   conducted structured interviews with officials from CMS, CMS’s 10
                   regional offices, and 16 state survey agencies to discuss trends in survey
                   deficiencies, the underlying causes of problems identified during the
                   performance reviews, and state and federal efforts to address these
                   problems.5 We also discussed these issues with officials from 10 additional
                   states during a governing board meeting of the Association of Health
                   Facility Survey Agencies. We selected the 16 states with the goal of
                   including states that (1) were from diverse geographic areas, (2) had
                   shown either increases or decreases in the percentage of homes cited for
                   actual harm, (3) had been contacted in our prior work, and (4) represented
                   a mixture of strong and weak performance based on the results of federal
                   performance reviews of state survey activities. We also obtained data from
                   most state survey agencies on staffing issues such as nursing home
                   surveyor experience and vacancies. To assess enforcement actions, we
                   analyzed data in CMS’s enforcement database and compared homes
                   identified in OSCAR as requiring immediate sanctions with those actually
                   referred to CMS for sanctions by state survey agencies. See appendix I for
                   a more detailed description of our scope and methodology. Our work was
                   performed from January 2002 through June 2003 in accordance with
                   generally accepted government auditing standards.


                   State survey data indicate that the proportion of nursing homes with
Results in Brief   serious quality problems remains unacceptably high, despite a decline in
                   such reported problems since mid-2000. Compared to the prior 18-month
                   period, the percentage of nursing homes cited for actual harm or
                   immediate jeopardy from July 2000 through January 2002 declined by
                   about one-third—from 29 percent (about 5,000 homes) to 20 percent
                   (about 3,500 homes). Consistent with this reported improvement in
                   quality, federal comparative surveys completed during a recent 20-month
                   period found actual harm or higher-level deficiencies in 22 percent of



                   5
                   We contacted officials in Alabama, California, Colorado, Connecticut, Iowa, Louisiana,
                   Maryland, Michigan, Missouri, Nebraska, New York, Oklahoma, Pennsylvania, Tennessee,
                   Washington, and Virginia.




                   Page 3                                               GAO-03-561 Nursing Home Quality
homes where state surveyors found no such deficiencies, compared to 34
percent in an earlier period. Fewer discrepancies between federal and
state surveys suggest that state surveyors’ performance in documenting
serious deficiencies has improved and that the decline in serious quality
problems nationwide is potentially real. Despite this improvement,
however, the magnitude of understatement of actual harm deficiencies
remains a cause for concern. Federal surveyors found examples of actual
harm deficiencies in about one-fifth of homes that states had judged to be
deficiency free. Moreover, 39 percent of 76 surveys we reviewed from
homes with a history of quality-of-care problems—but whose current
survey indicated no actual harm deficiencies—had documented problems
that should have been classified as actual harm: serious, avoidable
pressure sores; severe weight loss; and multiple falls resulting in broken
bones and other injuries.

Weaknesses persist in state survey, complaint investigation, and
enforcement activities. Several factors at the state level contribute to the
understatement of serious quality-of-care problems. Poor investigation and
documentation of deficiencies identified during nursing home surveys
preclude a determination of the seriousness of some deficiencies.
According to some state officials, the large number of inexperienced
surveyors due to high attrition and hiring limitations has also had a
negative impact on the quality of surveys. While most of the 16 states we
contacted had a quality assurance process in place to review deficiencies
cited at the actual harm level and higher, half did not have such a process
to help ensure that the scope and severity of less serious deficiencies were
not understated. The continued predictability of the occurrence of
standard surveys also likely contributes to the understatement of
deficiencies. Our analysis of OSCAR data indicated that about one-third of
the most recent state surveys nationwide occurred on a predictable
schedule, allowing homes to conceal problems if they chose to do so. In
addition, many states’ complaint investigation policies and procedures
were still inadequate to provide intended protections. For example, 15
states did not provide toll-free hotlines to facilitate the filing of complaints,
the majority of states lacked adequate systems for managing complaints,
and one or more states in most of CMS’s 10 regions did not correctly
determine the investigation priority for complaints. Moreover, most states
did not investigate all complaints involving actual harm within 10 days, as
required. Some states attributed the timeliness problem to insufficient
staff and an increase in the number of complaints. Although HCFA
strengthened its enforcement policy by requiring state survey agencies,
beginning in January 2000, to refer for immediate sanction homes that had
a pattern of harming residents, we found that states failed to refer a


Page 4                                           GAO-03-561 Nursing Home Quality
substantial number of such homes, significantly undermining the intended
deterrent effect of this policy.

While CMS has increased its oversight of state survey and complaint
activities, continued attention is required to help ensure compliance with
federal requirements. In October 2000, HCFA implemented new annual
performance reviews to measure state performance in seven areas,
including the timeliness of survey and complaint investigations and the
proper documentation of survey findings. The first round of results,
however, did not produce information enabling the agency to identify and
initiate needed improvements. For example, some regional office summary
reports provided too little information to determine if a state did not meet
a particular standard by a wide or a narrow margin—information that
could help CMS to judge the seriousness of problems identified. We also
found inconsistencies in how CMS regions conducted their reviews,
raising questions about the validity and fairness of the results. Rather than
relying on its regional offices, CMS plans to more centrally manage future
state performance reviews to improve consistency and to help ensure that
the results of those reviews could be used to more readily identify serious
problems. Implementation has been significantly delayed for three other
federal initiatives that are critical to reducing the subjectivity evident in
the state survey process for identifying deficiencies and investigating
complaints. These delayed initiatives were intended to strengthen the
methodology for conducting surveys, improve surveyor guidance for
determining the scope and severity of deficiencies, and increase
standardization in state complaint investigation processes.

We are recommending that the Administrator of CMS strengthen survey,
complaint, enforcement, and oversight processes by (1) finishing the
development of a more rigorous survey methodology, (2) requiring states
to implement a quality assurance process to test the validity of cited
deficiencies for surveys that include deficiencies below the actual harm
level, (3) developing guidance for states that addresses key weaknesses in
their complaint investigation processes, and (4) improving the ability of
federal oversight of state survey activities to distinguish between systemic
and less serious state survey performance problems. Although CMS
concurred with our recommendations, its comments did not fully address
our concerns about the status of the initiative intended to improve the
effectiveness of the survey process or the recommendation regarding state
quality assurance systems. Eleven states provided comments that most
often focused on the resource constraints states face in meeting federal
standards for oversight of nursing homes.



Page 5                                        GAO-03-561 Nursing Home Quality
                   Combined Medicare and Medicaid payments to nursing homes for care
Background         provided to vulnerable elderly and disabled beneficiaries were expected to
                   total about $63 billion in 2002, with a federal share of approximately $42
                   billion. Oversight of nursing homes is a shared federal-state responsibility.
                   Based on statutory requirements, CMS defines standards that nursing
                   homes must meet to participate in the Medicare and Medicaid programs
                   and contracts with states to assess whether homes meet these standards
                   through annual surveys and complaint investigations. A range of
                   statutorily defined sanctions is available to help ensure that homes
                   maintain compliance with federal quality requirements. CMS is also
                   responsible for monitoring the adequacy of state survey activities.


Standard Surveys   Every nursing home receiving Medicare or Medicaid payment must
                   undergo a standard survey not less than once every 15 months, and the
                   statewide average interval for these surveys must not exceed 12 months.6
                   A standard survey entails a team of state surveyors, including registered
                   nurses (RN), spending several days in the nursing home to assess
                   compliance with federal long-term care facility requirements, particularly
                   whether care and services provided meet the assessed needs of the
                   residents and whether the home is providing adequate quality care, such
                   as preventing avoidable pressure sores, weight loss, or accidents. Based
                   on our earlier work indicating that facilities could mask certain
                   deficiencies, such as routinely having too few staff to care for residents, if
                   they could predict the survey timing, HCFA directed states in 1999 to (1)
                   avoid scheduling a home’s survey for the same month of the year as the
                   home’s previous standard survey and (2) begin at least 10 percent of
                   standard surveys outside the normal workday (either on weekends, early
                   in the morning, or late in the evening).

                   State surveyors’ assessment of the quality of care provided to a sample of
                   residents during the standard survey serves as the basis for evaluating
                   nursing homes’ compliance with federal requirements. CMS establishes
                   specific investigative protocols for state surveyors to use in conducting
                   these comprehensive surveys. These procedural instructions are intended
                   to make the on-site surveys thorough and consistent across states. In
                   response to our earlier recommendations concerning the need to better
                   ensure that surveyors do not miss significant care problems, HCFA



                   6
                   CMS generally interprets these requirements to permit a statewide average interval of 12.9
                   months and a maximum interval of 15.9 months for each home.




                   Page 6                                                 GAO-03-561 Nursing Home Quality
                           planned a two-phase revision of the survey process. In phase one, HCFA
                           instructed states in 1999 to (1) begin using a series of new investigative
                           protocols covering pressure sores, weight loss, dehydration, and other key
                           quality areas, (2) increase the sample of residents reviewed with
                           conditions related to these areas, and (3) review “quality indicator”
                           information on the care provided to a home’s residents, before actually
                           visiting the home, to help guide survey activities. Quality indicators are
                           essentially numeric warning signs of the prevalence of care problems such
                           as greater-than-expected instances of weight loss, dehydration, or
                           pressures sores.7 They are derived from nursing homes’ assessments of
                           residents and rank a facility in 24 areas compared with other nursing
                           homes in the state.8 By using the quality indicators to select a preliminary
                           sample of residents before the on-site review, surveyors are better
                           prepared to identify potential care problems. Surveyors augment this
                           preliminary sample with additional resident cases once they arrive in the
                           home. To address remaining problems with sampling and the investigative
                           protocols, CMS is planning a second set of revisions to its survey
                           methodology. The focus of phase two is (1) improving the on-site
                           augmentation of the preliminary sample selected off-site using the quality
                           indicators and (2) strengthening the protocols used by surveyors to ensure
                           more rigor in their on-site investigations.


Complaint Investigations   Complaint investigations provide an opportunity for state surveyors to
                           intervene promptly if quality-of-care problems arise between standard
                           surveys. Within certain federal guidelines and time frames, surveyors
                           generally follow state procedures when investigating complaints filed
                           against a home by a resident, the resident’s family, or nursing home
                           employees, and typically target a single area in response to the complaint.



                           7
                            Quality indicators were the result of a HCFA-funded project at the University of
                           Wisconsin. The developers based their work on nursing home resident assessment
                           information, known as the minimum data set (MDS)—data on each resident that homes are
                           required to report to CMS. See Center for Health Systems Research and Analysis, Facility
                           Guide for the Nursing Home Quality Indicators (University of Wisconsin-Madison: Sept.
                           1999).
                           8
                            Because resident assessment data are used by CMS and states to calculate quality
                           indicators and to determine the level of nursing homes’ payments for Medicare (and for
                           Medicaid in some states), ensuring accuracy at the facility level is critical. We have made
                           earlier recommendations to CMS on ways to improve the accuracy of these data. See U.S.
                           General Accounting Office, Nursing Homes: Federal Efforts to Monitor Resident
                           Assessment Data Should Complement State Activities, GAO-02-279 (Washington, D.C.:
                           Feb. 15, 2002).




                           Page 7                                                  GAO-03-561 Nursing Home Quality
                       Historically, HCFA had played a minimal role in providing states with
                       guidance and oversight of complaint investigations. Until 1999, federal
                       guidelines were limited to requiring the investigation of complaints
                       alleging immediate jeopardy conditions within 2 workdays. In March 1999,
                       HCFA acted to strengthen state complaint procedures by instructing states
                       to investigate any complaint alleging harm to a nursing home resident
                       within 10 workdays. Additional guidance provided to states in late 1999
                       specified that, as with immediate jeopardy complaints, investigations
                       should generally be conducted on-site at the nursing home. This guidance
                       also identified techniques to help states identify complaints having a
                       higher level of actual harm. As part of a complaint improvement project,
                       also initiated in late 1999, HCFA plans to issue more detailed guidance to
                       states, such as identifying model programs or practices to increase the
                       effectiveness of complaint investigations.


Deficiency Reporting   Quality-of-care deficiencies identified during either standard surveys or
                       complaint investigations are classified in 1of 12 categories according to
                       their scope (i.e., the number of residents potentially or actually affected)
                       and their severity. An A-level deficiency is the least serious and is isolated
                       in scope, while an L-level deficiency is the most serious and is considered
                       to be widespread in the nursing home (see table 1). States are required to
                       enter information about surveys and complaint investigations, including
                       the scope and severity of deficiencies identified, in CMS’s OSCAR
                       database.

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

                                                                                            Scope
                           Severity                                         Isolated      Pattern     Widespread
                           Immediate jeopardya                              J             K           L
                           Actual harm                                      G             H           I
                           Potential for more than minimal harm             D             E           F
                           Potential for minimal harmb                      A             B           C
                       Source: CMS.
                       a
                       Actual or potential for death/serious injury.
                       b
                       Nursing home is considered to be in “substantial compliance.”




                       Page 8                                                      GAO-03-561 Nursing Home Quality
                     The importance of accurate and timely reporting of nursing home
                     deficiency data has increased with the public reporting of survey
                     deficiencies, which HCFA initiated in 1998 on its Nursing Home Compare
                     Web site.9 The public reporting of deficiency data is intended to assist
                     individuals in differentiating among nursing homes. In November 2002,
                     CMS augmented the deficiency data available on its Web site with 10
                     clinical indicators of quality, such as the percentage of residents with
                     pressure sores, in nursing homes nationwide. While the intent of this new
                     initiative is worthwhile, CMS had not resolved several important issues
                     that we raised prior to moving from a six-state pilot to nationwide
                     implementation.10 These issues included: (1) the ability of the new
                     information to accurately identify differences in nursing home quality,
                     (2) the accuracy of the underlying data used to calculate the quality
                     indicators, and (3) the potential for public confusion over the available
                     data.


Enforcement Policy   Ensuring that documented deficiencies are corrected is a shared federal-
                     state responsibility. CMS imposes sanctions on homes with Medicare or
                     dual Medicare and Medicaid certification on the basis of state referrals.11
                     CMS normally accepts a state’s recommendation for sanctions but can
                     modify it. The scope and severity of a deficiency determine the applicable
                     sanctions that can involve, among other things, requiring training for staff
                     providing care to residents, imposing monetary fines, denying the home
                     Medicare and Medicaid payments for new admissions, and terminating the
                     home from participation in these programs. Before a sanction is imposed,
                     federal policy generally gives nursing homes a grace period of 30 to 60
                     days to correct the deficiency. We earlier reported, however, that the
                     threat of federal sanctions did not prevent nursing homes from cycling in
                     and out of compliance because they were able to avoid sanctions by
                     returning to compliance within the grace period, even when they had been




                     9
                     http://www.medicare.gov/NHCompare/home.asp.
                     10
                      U.S. General Accounting Office, Public Reporting of Quality Indicators Has Merit, but
                     National Implementation Is Premature, GAO-03-187 (Washington, D.C.: Oct. 31, 2002).
                     11
                       States are responsible for enforcing standards in homes with Medicaid-only
                     certification—about 14 percent of homes. They may use the federal sanctions or rely on
                     their own state licensure authority and nursing home sanctions. States are responsible for
                     ensuring that homes that have a pattern of harming residents are immediately sanctioned.




                     Page 9                                                 GAO-03-561 Nursing Home Quality
                cited for actual harm on successive surveys.12 In 1998, HCFA began a two-
                stage phase-in of a new enforcement policy. In the first stage, effective
                September 1998, HCFA required states to refer for immediate sanction
                homes found to have a pattern of harming residents or exposing them to
                actual or potential death or serious injury (H-level deficiencies and above
                on CMS’s scope and severity grid). Effective January 14, 2000, HCFA
                expanded this policy to also require referral of homes found to have
                harmed one or a small number of residents (G-level deficiencies) on
                successive standard surveys.13


CMS Oversight   CMS is responsible for overseeing each state survey agency’s performance
                in ensuring quality of care in state nursing homes. Its primary oversight
                tools are statutorily required federal monitoring surveys conducted
                annually in 5 percent of the nation’s certified Medicare and Medicaid
                nursing homes, on-site annual state performance reviews instituted during
                fiscal year 2001, and analysis of periodic oversight reports that have been
                produced since 2000. Federal monitoring surveys can be either
                comparative or observational. A comparative survey involves a federal
                survey team conducting a complete, independent survey of a home within
                2 months of the completion of a state’s survey in order to compare and
                contrast the findings. In an observational survey, one or more federal
                surveyors accompany a state survey team to a nursing home to observe
                the team’s performance. Roughly 85 percent of federal surveys are
                observational. State performance reviews, implemented in October 2000,
                measure state performance against seven standards, including statutory
                requirements regarding survey frequency, requirements for documenting
                deficiencies, timeliness of complaint investigations, and timely and
                accurate entry of deficiencies into OSCAR. These reviews replaced state
                self-reporting of their compliance with federal requirements. In October
                2000, HCFA also began to produce 19 periodic reports to monitor both
                state and regional office performance. The reports are based on OSCAR
                and other CMS databases. Examples of reports that track state activities
                include pending nursing home terminations (weekly), data entry


                12
                 U. S. General Accounting Office, Nursing Homes: Additional Steps Needed to Strengthen
                Enforcement of Federal Quality Standards, GAO/HEHS-99-46 (Washington, D.C.: Mar.18,
                1999).
                13
                  States are now required to deny a grace period to homes that are assessed one or more
                deficiencies at the actual harm level or above (G-L on CMS’s scope and severity grid) in
                each of two successive surveys within a survey cycle. A survey cycle is two successive
                standard surveys and any intervening survey, such as a complaint investigation.




                Page 10                                                GAO-03-561 Nursing Home Quality
                    timeliness (quarterly), tallies of state surveys that find homes deficiency
                    free (semiannually), and analyses of the most frequently cited deficiencies
                    by states (annually). These reports, in a standard format, enable
                    comparisons within and across states and regions and are intended to help
                    identify problems and the need for intervention. Certain reports—such as
                    the timeliness of state survey activities—are used to monitor compliance
                    with state performance standards.


                    The magnitude of the problems uncovered during standard nursing home
Magnitude of        surveys remains a cause for concern even though OSCAR deficiency data
Problems Remains    indicate that state surveyors are finding fewer serious quality problems.
                    Compared to an earlier period, the percentage of homes nationwide cited
Cause for Concern   since mid-2000 for actual harm or immediate jeopardy has decreased in
Even Though Fewer   over three-quarters of states—with seven states reporting a drop of 20
                    percentage points or more. State surveys conducted since about mid-2000
Serious Nursing     showed less variance from federal comparative surveys, suggesting that
Home Quality        (1) state surveyors’ performance in documenting serious deficiencies has
Problems Reported   improved and (2) the decline in serious nursing home quality problems is
                    potentially real. However, federal comparative surveys, as well as our
                    review of a sample of survey reports from homes with a history of quality-
                    of-care problems, continued to find understatement of actual harm
                    deficiencies.




                    Page 11                                      GAO-03-561 Nursing Home Quality
Proportion of Nursing          Compared to the preceding 18-month period, the proportion of nursing
Homes with Documented          homes cited for actual harm or immediate jeopardy has declined
Actual Harm or Immediate       nationally from 29 percent to 20 percent since mid-2000.14 In contrast, from
                               early 1997 through mid-2000, the percentage of homes cited for such
Jeopardy Care Problems         serious deficiencies was either relatively stable or increased in 31 states.15
Has Declined since 2000        From July 2000 through January 2002, 40 states cited a smaller percentage
                               of homes with such serious deficiencies, while only 9 states and the
                               District of Columbia cited a larger proportion of homes with such
                               deficiencies.16 Despite these changes, there is still considerable variation in
                               the proportion of homes cited for serious deficiencies, ranging from about
                               7 percent in Wisconsin to about 50 percent in Connecticut. Appendix II
                               provides trend data on the percentage of nursing homes cited for serious
                               deficiencies for all 50 states and the District of Columbia.

                               Table 2 shows the recent change in actual harm and immediate jeopardy
                               deficiencies for states that surveyed at least 100 nursing homes.17
                               Specifically:

                           •   Twenty-five states had a 5 percentage point or greater decrease in the
                               proportion of homes identified with actual harm or immediate jeopardy.
                               For over two-thirds of these states, the decrease in serious deficiencies
                               was greater than 10 percentage points. Seven states—Arizona, Alabama,



                               14
                                We analyzed OSCAR data for surveys performed from January 1, 1999, through July 10,
                               2000, and from July 11, 2000, through January 31, 2002, and entered into OSCAR as of June
                               24, 2002. See app. I for our complete scope and methodology. Our analysis considered only
                               standard surveys. In commenting on a draft of this report, Missouri stated that our findings
                               would have shown that quality had remained “fairly stable” had we included actual harm
                               and immediate jeopardy deficiencies identified during complaint investigations in our
                               analysis in table 2. However, we found that both nationally and in Missouri, the proportion
                               of homes cited for actual harm or immediate jeopardy showed a similar decline even when
                               complaint surveys were considered.
                               15
                                 The two earlier time periods we analyzed are for surveys conducted from January 1, 1997,
                               through June 30, 1998, and from January 1, 1999, through July 10, 2000. See U.S. General
                               Accounting Office, Nursing Homes: Sustained Efforts Are Essential to Realize Potential
                               of the Quality Initiatives, GAO/HEHS-00-197 (Washington, D.C.: Sept. 28, 2000).
                               16
                                The proportion of nursing homes in Utah cited with serious deficiencies remained the
                               same between the two time periods.
                               17
                                 We excluded Alaska, Delaware, the District of Columbia, Hawaii, Idaho, Nevada, New
                               Hampshire, New Mexico, North Dakota, Rhode Island, Utah, Vermont, and Wyoming from
                               this analysis because fewer than 100 homes were surveyed and even a small increase or
                               decrease in the number of homes with serious deficiencies in such states produces a
                               relatively large percentage point change.




                               Page 12                                                 GAO-03-561 Nursing Home Quality
                                         California, Michigan, Indiana, Pennsylvania, and Washington—
                                         experienced declines of 15 percentage points or more.
                                     •   Two states, South Dakota and Colorado, experienced an increase of 5
                                         percentage points or greater in the proportion of homes with actual harm
                                         or immediate jeopardy deficiencies (6.6 and 10.8, respectively).
                                     •   The remaining 11 states were relatively stable—experiencing
                                         approximately a 4 percentage point change or less.

Table 2: Change in the Percentage of Nursing Homes Cited for Actual Harm or Immediate Jeopardy during State Standard
Surveys between the periods January 1, 1999, through July 10, 2000, and July 11, 2000, through January 31, 2002, by State

                                                                    Percentage of homes with actual
                                                                      harm or immediate jeopardy
                                                                             deficiencies
                                               Number of homes
                                                      surveyed                                            Percentage point
      a
State                                                (7/00-1/02)              1/99-7/00       7/00-1/02         differenceb
Decrease of 5 percentage points or greater
Arizona                                                       147                  33.8            8.8                 -25.0
Alabama                                                       228                  42.2           18.4                 -23.8
Pennsylvania                                                  764                  32.2           11.6                 -20.6
California                                                  1,348                  29.1            9.3                 -19.9
Indiana                                                       573                  45.3           26.2                 -19.1
Michigan                                                      441                  42.1           24.7                 -17.4
Washington                                                    275                  54.1           38.5                 -15.6
Oregon                                                        152                  47.5           33.6                 -13.9
Illinois                                                      881                  29.3           15.4                 -13.9
Mississippi                                                   219                  33.2           19.6                 -13.5
Minnesota                                                     431                  31.7           18.8                 -12.9
Montana                                                       103                  37.5           25.2                 -12.3
Missouri                                                      569                  22.3           10.2                 -12.1
South Carolina                                                180                  28.7           17.8                 -10.9
North Carolina                                                419                  40.8           30.1                 -10.7
Arkansas                                                      267                  37.7           27.3                 -10.4
Massachusetts                                                 512                  33.0           22.9                 -10.2
Iowa                                                          494                  19.3            9.9                  -9.4
Tennessee                                                     377                  26.0           16.7                  -9.3
Nation                                                     17,149                  29.3           20.5                  -8.8
Virginia                                                      285                  19.9           11.6                  -8.3
Kansas                                                        400                  37.1           29.0                  -8.1
Nebraska                                                      243                  26.0           18.9                  -7.1
Wisconsin                                                     421                  14.0            7.1                  -6.9
Maryland                                                      248                  25.6           20.2                  -5.5
Ohio                                                        1,029                  29.0           23.7                  -5.3
Change of less than 5 percentage points
Kentucky                                                      306                  28.8           25.2                  -3.7




                                         Page 13                                           GAO-03-561 Nursing Home Quality
                                                                                         Percentage of homes with actual
                                                                                           harm or immediate jeopardy
                                                                                                  deficiencies
                                                                 Number of homes
                                                                        surveyed                                                      Percentage point
         a                                                                                                                                             b
 State                                                                 (7/00-1/02)                   1/99-7/00         7/00-1/02            difference
 New Jersey                                                                   366                         24.5              22.4                    -2.1
 Georgia                                                                      370                         22.6              20.5                    -2.0
 West Virginia                                                                143                         15.6              14.0                    -1.7
 Texas                                                                      1,275                         26.9              25.5                    -1.5
 Florida                                                                      742                         20.8              20.1                    -0.8
 Maine                                                                        124                         10.3               9.7                    -0.6
 New York                                                                     671                         32.2              32.3                     0.2
 Connecticut                                                                  259                         48.5              49.4                     0.9
 Louisiana                                                                    367                         19.9              23.4                     3.5
 Oklahoma                                                                     394                         16.7              20.6                     3.9
 Increase of 5 percentage points or greater
 South Dakota                                                                    114                       24.1              30.7                   6.6
 Colorado                                                                        225                       15.4              26.2                  10.8
Source: GAO analysis of OSCAR data as of June 24, 2002.
                                                          a
                                                          Includes only those states in which 100 or more homes were surveyed since July 2000.
                                                          b
                                                          Differences are based on numbers before rounding.


                                                          States offered several explanations for the declines in actual harm and
                                                          immediate jeopardy deficiencies, including (1) changing guidance from
                                                          CMS regional offices as to what constitutes actual harm, (2) hiring
                                                          additional staff, and (3) surveyors failing to properly identify actual harm
                                                          deficiencies.


Federal Comparative                                       Our analysis of federal comparative surveys conducted nationwide prior to
Surveys Show Decreased                                    and since June 2000 showed a decreased variance between federal and
Variance with State Survey                                state survey findings (see app. I for a description of our scope and
                                                          methodology). For comparative surveys completed from October 1998
Findings, but                                             through May 2000, federal surveyors found actual harm or higher-level
Understatement of Actual                                  deficiencies in 34 percent of homes where state surveyors had found no
Harm Deficiencies                                         such deficiencies, compared to 22 percent for comparative surveys
Continued                                                 completed from June 2000 through February 2002. In addition, while
                                                          federal surveyors found more serious care problems than state surveyors
                                                          on 70 percent of the earlier comparative surveys, this percentage declined
                                                          to 60 percent for the more recent surveys.

                                                          Despite the decline in understatement of actual harm deficiencies from 34
                                                          percent to 22 percent, the magnitude of the state surveyors’



                                                          Page 14                                                   GAO-03-561 Nursing Home Quality
                           understatement of quality problems remains an issue. For example, from
                           June 2000 through February 2002, federal surveyors found at least one
                           actual harm or immediate jeopardy quality-of-care deficiency in 16 of the
                           85 homes (19 percent) that the states had found to be free of deficiencies.
                           For example, federal surveyors found that 1 of the 16 homes failed to
                           prevent pressure sores, failed to consistently monitor pressure sores when
                           they did develop, and failed to notify the physician promptly so that proper
                           treatment could be started. The federal surveyors who conducted the
                           comparative survey of this nursing home noted in the file that a lack of
                           consistent monitoring of pressure sores existed at the home during the
                           time of the state’s survey and that the state surveyors should have found
                           the deficiency.

                           Several states that reviewed a draft of this report questioned the value of
                           federal comparative surveys because of their timing. Arizona noted that
                           comparative surveys do not have to begin until up to 2 months after the
                           state’s survey, and Iowa and Virginia officials said they might occur so
                           long after the state’s survey that conditions in the home may have
                           significantly changed. Although legislation requires comparative surveys
                           to begin within 2 months of the state’s survey, CMS is continuing to make
                           progress in reducing the timeframe between the state and the comparative
                           survey. Based on our earlier recommendation that comparative surveys
                           begin as soon after the state’s survey as possible, CMS instructed the
                           regions to begin these surveys no later than one month following the
                           state’s survey, and the average time between surveys nationally has
                           decreased from 33 calendar days in 1999 to about 26 calendar days for
                           surveys conducted from June 2000 through February 2002.18


Quality-of-Care Problems   Even with the reported decline in serious deficiencies, an unacceptably
Were Understated in        high number of nursing homes—one in five nationwide—still had actual
Homes with a History of    harm or immediate jeopardy deficiencies. Moreover, we found widespread
                           understatement of actual harm deficiencies in a sample of surveys we
Problems                   reviewed that were conducted since July 2000 at homes with a history of
                           harming residents (see app. I for a description of our methodology in
                           selecting this sample). In 39 percent of the 76 survey reports we reviewed,
                           we found sufficient evidence to conclude that deficiencies cited at a lower
                           level (generally, potential for more than minimal harm, D or E) should



                           18
                            U.S. General Accounting Office, Nursing Homes: Enhanced HCFA Oversight of State
                           Programs Would Better Ensure Quality, GAO/HEHS-00-6 (Washington, D.C.: Nov. 4, 1999).




                           Page 15                                            GAO-03-561 Nursing Home Quality
have been cited at the level of actual harm or higher (G level or higher on
CMS’s scope and severity grid). We were unable to assess whether the
scope and severity of other deficiencies in our sample of surveys were also
understated because of weaknesses in the investigations conducted by
surveyors and in the adequacy with which they documented those
deficiencies.

Of the surveys we reviewed, 30 (39 percent) contained sufficient evidence
for us to conclude that deficiencies cited at the D and E level should have
been cited as at least actual harm because a deficient practice was
identified and linked to documented actual harm involving at least one
resident (see table 3). These 30 survey reports depicted examples of actual
harm, including serious, avoidable pressure sores; severe weight loss; and
multiple falls resulting in broken bones and other injuries (see app. III for
abstracts of these 30 survey reports). The following example illustrates
understated actual harm involving the failure to provide necessary care
and services. A nurse at one facility noted a large area of bruising and
swelling on an 89-year-old resident’s chest. Nothing further was done to
explore this injury until 11 days later when the resident began to
experience shortness of breath and diminished breath sounds. Then a
chest x ray was taken, revealing that the resident had sustained two
fractured ribs and fluid had accumulated in the resident’s left lung. A
facility investigation determined that the resident had been injured by a lift
used to transfer the resident to and from the bed. It was clear from the
surveyor’s information that the facility failed to take appropriate action to
assess and provide the necessary care until the resident developed serious
symptoms of chest trauma. Nevertheless, the surveyor concluded that
there was no actual harm and cited a D-level deficiency—potential for
more than minimal harm.




Page 16                                        GAO-03-561 Nursing Home Quality
Table 3: Incidence of Underreported Actual Harm Deficiencies in Surveys GAO
Reviewed

                                                    Number of surveys
                                                        in which GAO          Number of G-level
                               Number of surveys     identified G-level       deficiencies GAO
 State                                from state          deficiencies                identified
 Alabama                                       6                      2                        2
 Arizona                                       3                      1                        2
 California                                   22                     13                       17
 Iowa                                          7                      5                        7
 Maryland                                      3                      1                        1
 Minnesota                                     5                      0                        0
 Mississippi                                   1                      0                        0
 Missouri                                      4                      1                        1
 Nebraska                                      4                      2                        2
 Pennsylvania                                 11                      2                        3
 South Carolina                                1                      0                        0
 Virginia                                      7                      3                        4
 West Virginia                                 1                      0                        0
 Wisconsin                                     1                      0                        0
 Total                                        76                    30                        39
Source: GAO analysis of state surveys.

Note: We reviewed surveys where state surveyors had cited deficiencies at the D or E level (potential
for more than minimal harm) in one or more of four quality-of-care areas (see app. I, table 6). We
reviewed all such deficiencies to determine if, in our judgment, the deficiencies should have been
cited at the G level or higher (actual harm).


State survey agency officials in Alabama, California, Iowa, and Nebraska
told us that surveyors had originally cited G-level deficiencies in 10 of the
surveys we reviewed, but that the deficiencies had been reduced to the D
level during the states’ reviews because of inadequate surveyor
documentation. We concluded that 5 of the 10 surveys did contain
adequate documentation to support actual harm because there was a clear
link between the deficient facility practice and the documented harm to a
resident. For example, the survey managers in one state changed a G- to a
D-level deficiency because the surveyor only cited one source of evidence
to support the deficiency—nurses’ notes in the residents’ medical
records.19 According to the surveyor, a resident with dementia,
experiencing long- and short-term memory problems, fell 11 times and



19
 Instructions from the state’s CMS regional office suggest, but do not require, the use of
more than one source of information to support a deficiency.




Page 17                                                      GAO-03-561 Nursing Home Quality
                        sustained a fractured wrist, three fractured ribs, and numerous bruises,
                        abrasions, and skin tears. According to the notes of facility nurses, a
                        personal alarm unit was in place as a safety device to prevent falls. The
                        surveyor found that the facility had (1) failed to provide adequate
                        interventions to prevent accidents and (2) continued to use the alarm unit
                        even though it did not prevent any of the falls. The medical record
                        documentation of these events was extensive and, in our judgment, was
                        sufficient evidence of a deficiency that resulted in actual harm to the
                        resident.

                        In many of the 76 surveys we reviewed, including surveys in which we
                        found no D- or E-level deficiencies that would appear to meet the criteria
                        for actual harm deficiencies, we identified serious investigation or
                        documentation weaknesses that could further contribute to the
                        understatement of serious deficiencies in nursing homes. In some cases,
                        the survey did not clearly describe the elements of the deficient practice,
                        such as whether the resident developed a pressure sore in the facility or
                        what the facility did to prevent the development of a facility-acquired
                        pressure sore. In other cases, the survey omitted critical facts, such as
                        whether a pressure sore had worsened or the size of the pressure sore.


                        Widespread weaknesses persist in state survey, complaint investigation,
Weaknesses Persist in   and enforcement activities despite increased attention to these issues in
State Survey,           recent years. Several factors at the state level contribute to the
                        understatement of serious quality-of-care problems, including poor
Complaint, and          investigation and documentation of deficiencies, the absence of adequate
Enforcement             quality assurance processes, and a large number of inexperienced
                        surveyors in some states due to high attrition or hiring limitations. In
Activities              addition, our analysis of OSCAR data indicated that the timing of a
                        significant proportion of state surveys remained predictable, allowing
                        homes to conceal problems if they choose to do so. Many states’ complaint
                        investigation policies and procedures were still inadequate to provide
                        intended protections. For example, many states do not investigate all
                        complaints identified as alleging actual harm in a timely manner, a
                        problem some states attributed to insufficient staff and an increase in the
                        number of complaints. Although HCFA strengthened its enforcement
                        policy by requiring state survey agencies, beginning in January 2000, to
                        refer for immediate sanction homes that had a pattern of harming
                        residents, we found that many states did not fully comply with this new
                        requirement. States failed to refer a substantial number of homes for
                        sanction, significantly undermining the policy’s intended deterrent effect.



                        Page 18                                       GAO-03-561 Nursing Home Quality
Investigation Weaknesses       CMS and state officials identified several factors that they believe
and Other Factors              contribute to state surveys continuing to miss significant care problems.
Contribute to                  These weaknesses persist, in part, because many states lack adequate
                               quality assurance processes to ensure that deficiencies identified by
Underreporting of Care         surveyors are appropriately classified. According to officials we
Problems                       interviewed, the large number of inexperienced surveyors in some states
                               due to high attrition has also had a negative impact on the quality of state
                               surveys and investigations. Our analysis of OSCAR data also indicated that
                               nursing homes could conceal problems if they choose to do so because a
                               significant proportion of current state surveys remain predictable.

Investigation and              Consistent with the investigation and documentation weaknesses we
Documentation Weaknesses       found in our review of a sample of survey reports from homes with a
                               history of actual harm deficiencies, CMS officials told us that their own
                               activities had identified similar problems that could contribute to an
                               understatement of serious deficiencies at nursing homes.

                           •   CMS reviews of state survey reports during fiscal year 2001 demonstrated
                               weaknesses in a majority of states, including: (1) inadequate investigation
                               and documentation of a poor outcome, such as reviewing available
                               records to help identify when a pressure sore was first observed and how
                               it changed over time, (2) failure to specifically identify the deficient
                               practice that contributed to a poor outcome, or (3) understatement of the
                               seriousness of a deficiency, such as citing a deficiency at the D level
                               (potential for actual harm) when there was sufficient evidence in the
                               survey report to cite the deficiency at the G level (actual harm).
                           •   State survey agency officials expressed confusion about the definition of
                               “actual harm” and “immediate jeopardy,” suggesting that such confusion
                               contributes to the variability in state deficiency trends. For example,
                               officials in one state told us that, in their view, residents must experience
                               functional impairment for state surveyors to cite an actual harm
                               deficiency, an interpretation that CMS officials told us was incorrect.
                               Under such a definition, repeated falls that resulted in bruises, cuts, and
                               painful skin tears would not be cited as actual harm, even if the facility
                               failed to assess the resident for measures to prevent falls.
                           •   CMS officials also told us that, contrary to federal guidance, state
                               surveyors in at least one state did not cite all identified deficiencies but
                               rather brought them to the homes’ attention with the expectation that the
                               deficiencies would be corrected. CMS officials told us that they identified
                               the problem by asking state officials about the unusually high number of
                               homes with no deficiencies on their standard surveys.




                               Page 19                                        GAO-03-561 Nursing Home Quality
Inadequate Quality Assurance    Some state officials told us that considerable staff resources are devoted
Processes                       to scrutinizing the support for actual harm and higher-level deficiencies
                                that could lead to the imposition of a sanction. While most of the 16 states
                                we contacted had quality assurance processes to review deficiencies cited
                                at the actual harm level and higher, half did not have such processes to
                                help ensure that the scope and severity of less serious deficiencies were
                                not understated.20 State officials generally told us that they lacked the staff
                                and time to review deficiencies that did not involve actual harm or
                                immediate jeopardy, but some states have established such programs. For
                                example, Maryland established a technical assistance unit in early 2001 to
                                review a sample of survey reports; the review looks at all deficiencies—
                                not just those involving actual harm or immediate jeopardy. A Maryland
                                official told us that she had the resources to do so because the state
                                legislature authorized a substantial increase in the number of surveyors in
                                1999. However, staff cutbacks in late 2002 due to the state’s budget crisis
                                have resulted in the reviews being less systematic than originally planned.
                                In Colorado, two long-term-care supervisors reviewed all 1,351
                                deficiencies cited in fiscal year 2001. Maryland and Colorado officials told
                                us that the reviews have identified shortcomings in the investigation and
                                documentation of deficiencies, such as the failure to interview residents or
                                the classification of deficiencies as process issues when they actually
                                involved quality of care. The reviews, we were told, provide an
                                opportunity for surveyor feedback or training that improves the quality
                                and consistency of future surveys.

Inexperienced State Surveyors   State officials cited the limited experience level of state surveyors as a
                                factor contributing to the variability in citing actual harm or higher-level
                                deficiencies and the understatement of such deficiencies. Data we
                                obtained from 42 state survey agencies in July 2002 revealed the
                                magnitude of the problem: in 11 states, 50 percent or more of surveyors
                                had 2-years’ experience or less; in another 13 states, from 30 percent to 48
                                percent of surveyors had similarly limited experience (see app. IV). For
                                example, Alabama’s and Louisiana’s recent annual attrition rates were 29
                                percent and 18 percent, respectively, and, as a result, almost half of the
                                surveyors in both states had been on the job for 2 years or less. In
                                California and Maryland—states that hired a significant number of new
                                surveyors since 2000—52 percent and 70 percent of surveyors,



                                20
                                 Officials explained the focus on actual harm or higher-level deficiencies by noting that the
                                potential for sanctions increased the likelihood that the deficiencies would be challenged
                                by the nursing home and perhaps appealed in an administrative hearing.




                                Page 20                                                 GAO-03-561 Nursing Home Quality
                      respectively, had less than 2 years of on-the-job experience.21 According to
                      CMS regional office and state officials, the first year for a new surveyor is
                      essentially a period of training and low productivity, and it takes as long as
                      3 years for a surveyor to gain sufficient knowledge, experience, and
                      confidence to perform the job well. High staff turnover was attributed, in
                      part, to low salaries for RN surveyors—salaries that may not be
                      competitive with other employment opportunities for nurses. Overall, 29
                      of the 42 states that responded to our inquiry indicated that they believed
                      nurse surveyor salaries were not competitive (see app. IV). Officials in
                      several states also told us that the combination of low starting salaries and
                      a highly competitive market forced them to hire less qualified candidates
                      with less breadth of experience.

Predictable Surveys   Even though HCFA directed states, beginning January 1, 1999, to avoid
                      scheduling a nursing home’s survey for the same month of the year as its
                      previous survey, over one-third of state surveys remain predictable. Our
                      analysis demonstrated little change in the proportion of predictable
                      nursing home surveys. Predictable surveys can allow quality-of-care
                      problems to go undetected because homes, if they choose to do so, may
                      conceal problems.22 We recommended in 1998 that HCFA segment the
                      standard survey into more than one review throughout the year,
                      simultaneously increasing state surveyor presence in nursing homes and
                      decreasing survey predictability. Although HCFA disagreed with
                      segmenting the survey, it did recognize the need to reduce predictability.

                      Our analysis of OSCAR data demonstrated that, on average, the timing of
                      34 percent of current surveys nationwide could have been predicted by
                      nursing homes, a slight reduction from the prior surveys when about 38
                      percent of all surveys were predictable. The predictability of current
                      surveys ranged from 83 percent in Alabama to 10 percent in Michigan (see
                      app. V for data on all 50 states and the District of Columbia). In 34 states,
                      25 percent to 50 percent of current surveys were predictable, as shown in




                      21
                       As of July 2002, both states had vacant surveyor positions and a surveyor hiring freeze.
                      22
                       In commenting on a draft of this report, Arizona disagreed with the significance we
                      attribute to survey predictability, questioning whether poor homes would, or even could,
                      hide problems if they knew a survey was imminent. However, advocates and family
                      members have told us that a home that operates with too few staff could temporarily
                      augment its staff during the expected period of a survey in order to mask an otherwise
                      serious deficiency—a common practice based on advocates’ own observations.




                      Page 21                                                 GAO-03-561 Nursing Home Quality
                              table 4. In 9 states, more than 50 percent of current surveys were
                              predictable.23

                              Table 4: Predictability of Nursing Home Surveys
                                                                                   a                                             b
                                  Percentage of predictable surveys                                        Number of states
                                  More than 50 percent                                                                     9
                                  25 percent to 50 percent                                                                34
                                  Less than 25 percent                                                                     8
                              Source: GAO analysis of OSCAR data as of April 9, 2002.
                              a
                               We considered surveys to be predictable if (1) homes were surveyed within 15 days of the 1-year
                              anniversary of their prior surveys, or (2) homes were surveyed within 1 month of the maximum 15-
                              month interval between standard surveys.
                              b
                              Includes the District of Columbia.




Many State Complaint          Most state agencies did not investigate serious complaints filed against
Investigation Systems Still   nursing homes within required time frames, and practices for investigating
Have Timeliness Problems      complaints in many states may not be as effective as they could be. A CMS
                              review of states’ timeliness in investigating complaints alleging harm to
and Other Weaknesses          residents revealed that most states did not investigate all such complaints
                              within 10 days, as CMS requires. Additionally, a CMS-sponsored study of
                              complaint practices in 47 states raised concerns about state approaches to
                              accepting and investigating complaints.

                              Until March 1999, states could set their own complaint investigation time
                              frames, except that they were required to investigate within 2 workdays all
                              complaints alleging immediate jeopardy conditions. In March 1999, we
                              reported that inadequate complaint intake and investigation practices in
                              states we reviewed had too often resulted in extensive delays in
                              investigating serious complaints.24 As a result of our findings, HCFA began
                              requiring states to investigate complaints that allege actual harm, but do




                              23
                                We considered surveys to be predictable if (1) homes were surveyed within 15 days of the
                              1-year anniversary of their prior surveys (13 percent of homes, nationally) or (2) homes
                              were surveyed within 1 month of the maximum 15-month interval between standard
                              surveys (21 percent of homes, nationally). Because homes know the maximum allowable
                              interval between surveys, those whose prior surveys were conducted 14 or 15 months
                              earlier are aware that they are likely to be surveyed soon.
                              24
                               U.S. General Accounting Office, Nursing Homes: Complaint Investigation Processes
                              Often Inadequate to Protect Residents, GAO/HEHS-99-80 (Washington, D.C.: Mar. 22, 1999).




                              Page 22                                                     GAO-03-561 Nursing Home Quality
not rise to the level of immediate jeopardy, within 10 workdays.25 CMS’s
2001 review of a sample of complaints in all states demonstrated that
many states were not complying with these requirements. Specifically, 12
states were not investigating all immediate jeopardy complaints within the
required 2 workdays, and 42 states were not complying with the
requirement to investigate actual harm complaints within 10 days.26 The
agency also found that the triaging of complaints to determine how quickly
each complaint should be investigated was inadequate in many states.

The extent to which states did not meet the 2-day and 10-day investigation
requirements varied considerably. Officials from 12 of the 16 states we
contacted indicated that they were unable to investigate complaints on
time because of staff shortages. Oklahoma investigated only 3 of the 21
immediate jeopardy complaints that CMS sampled within the required 2-
day period and none of 14 sampled actual harm complaints in 10 days.
Oklahoma officials attributed this timeliness problem to staff shortages
and a surge in the number of complaints received in 2000, from about 5 per
day to about 35. The rising volume of complaints is a particular problem
for California, which receives about 10,000 complaints annually, and had a
20 percent increase in complaints from January 2001 through July 2002.
State officials told us that California law requires all complaints alleging
immediate jeopardy to a resident to be investigated within 24 hours and all
others to be investigated within 10 days, and that the increase in the
number of complaints requires an additional 32 surveyor positions.27 CMS
regional officials told us that the vast majority of California complaints
were investigated within 10 days. However, the 2001 review also showed
that about 9 percent of the state’s standard surveys were conducted late.28
Both CMS and California officials indicated that the priority the state
attaches to investigating complaints affected survey timeliness. Officials



25
 In some states, the 10-day requirement significantly compressed the time frame in which
complaints alleging potential actual harm must be investigated. For instance, prior to
HCFA’s change, such complaints were supposed to be investigated within 30 days in
Michigan and 60 days in Tennessee.
26
 Staff from each of CMS’s regional offices reviewed a 10 percent random sample of
complaint files (maximum of 40 files) in each state.
27
 According to a state official, a hiring freeze precluded increasing the number of surveyors.
28
 Because CMS based its analysis of timeliness only on nursing homes that actually were
surveyed during fiscal year 2001—and not on all homes in the state—the 9 percent figure is
understated. Our analysis of all homes indicated that about 12 percent of the state’s homes
were not surveyed within the required time frame.




Page 23                                                 GAO-03-561 Nursing Home Quality
from Washington told us that their practice of investigating facility self-
reported incidents led to their not meeting the 10-day requirement on all
complaints that CMS reviewed. Washington investigated 18 of 20 sampled
actual harm complaints on time—missing the 10-day requirement for the
other two by 2 days and 4 days, respectively. Washington officials pointed
out that the two complaints not investigated within 10 days were facility
self-reported incidents and commented that many other states do not even
require investigation of such incidents. Thus, in these other states, such
incidents would not even have been included in CMS’s review.

In its review of state complaint files, CMS also evaluated whether states
had appropriately triaged complaints—that is, determined how quickly
each complaint should be investigated. Most of the regions told us that one
or more of their states had difficulty determining the investigation priority
for complaints. In an extreme case, a regional office discovered that one of
its states was prioritizing its complaints on the basis of staff availability
rather than on the seriousness of the complaints. Several regions indicated
that some states improperly assigned complaints to categories that
permitted longer investigation time frames, and one region indicated that
triaging difficulties involved state personnel not collecting enough
information from the complainant to make a proper decision. Officials
from some of the 16 state survey agencies we contacted indicated that
HCFA’s 1999 guidance to states on what constitutes an actual harm
complaint was unclear and confusing.

In an effort to improve state responsiveness to complaints, HCFA hired a
contractor in 1999 to assess and recommend improvements to state
complaint practices. The study identified significant problems with states’
complaint processes, including complaint intake activities, investigation
procedures, and complaint substantiation practices.29 For example, the
report noted that 15 states did not have toll-free hotlines for the public to
file complaints. In our earlier reports, we noted that the process of filing a
complaint should not place an unnecessary burden on a complainant and
that an easy-to-use complaint process should include a toll-free number
that permits the complainant to leave a recorded message when state staff



29
 Center for Health Systems Research and Analysis at the University of Wisconsin,
Madison, Final Report: Complaint Improvement Project, prepared for CMS, June 3, 2002.
The report is based on a questionnaire sent to the 50 states, the District of Columbia,
Puerto Rico, and CMS’s 10 regional offices. Three states did not respond to the
questionnaire. The report treated the District of Columbia and Puerto Rico as states.




Page 24                                              GAO-03-561 Nursing Home Quality
are unavailable.30 Table 5 summarizes major findings from the contractor’s
report to CMS.

Table 5: Key Findings of Report to CMS on State Complaint Investigation Processes

 Finding                       Description
 States vary in the ease with  Thirty-four states indicated that they provide toll-free
 which the public can file a   hotlines for the public to file complaints. Twenty-nine of
 complaint.                    the 34 states indicated that they operate their hotlines 24
                               hours a day, 7 days a week, and 5 said their hotlines
                               were answered during business hours. Nineteen states
                               had no provisions or plans to handle non-English
                               speaking complainants.
 States need to improve their States need to better triage their complaints and decide
 complaint intake and triaging which complaints should be referred to other agencies for
 systems.                      investigation. They should also improve procedures for
                               merging complaints with ongoing survey activities at a
                               nursing home. More consistency is needed in handling
                               facility self-reported incidents.
 State survey staffs that      States should use staff dedicated to investigating
 conduct complaint intake      complaints to improve the quality of investigations. This
 and investigation often have might include assigning responsibility for a state’s total
 additional duties.            complaint system to a single complaint supervisor or
                               coordinator and also may require more careful hiring
                               standards with specific job qualifications.
 Investigation procedures      States do not use all available data when preparing for a
 vary across states.           complaint investigation. There is little agreement among
                               states regarding how many resident records should be
                               sampled during a complaint investigation.a
 Complaint investigation       Specialized complaint training and periodic refresher
 training is needed.           training on complaint intake, triaging, and investigation
                               techniques are needed to improve the quality of
                               complaint investigations.
 Resolution of complaints is   States have developed varying criteria for determining
 inconsistent across states.   what constitutes a substantiated complaint and varying
                               practices for communicating the results of investigations
                               to complainants. Twenty-two states could not indicate
                               how long it takes them to provide the results of an
                               investigation to the complainant, and at least four states
                               do not inform the complainant of the results.
 Not all states have           Twenty states indicated that they could track the status of
 comprehensive complaint       complaints and produce summary reports.
 tracking systems, and CMS
 tracking systems are not up-
 to-date or user friendly.b
Source: CMS.




30
 See GAO/HEHS-99-80 and U.S. General Accounting Office, Medicare Home Health
Agencies: Weaknesses in Federal and State Oversight Mask Potential Quality Issues,
GAO-02-382 (Washington, D.C.: July 19, 2002).




Page 25                                                GAO-03-561 Nursing Home Quality
                           Note: GAO analysis of information from Center for Health Systems Research and Analysis at the
                           University of Wisconsin, Madison, Final Report: Complaint Improvement Project, prepared for CMS,
                           June 3, 2002.
                           a
                            In 1999, we reported that HCFA had not provided states with guidance on when to expand a
                           complaint review beyond the residents who were the subject of the original complaint. See
                           GAO/HEHS-99-80.
                           b
                            CMS is planning to implement a new complaint tracking system nationwide that should address this
                           shortcoming.


States Did Not Refer a     State survey agencies did not refer 711 cases in which nursing homes were
Substantial Number of      found to have a pattern of harming residents to CMS for immediate
Nursing Homes to CMS for   sanction as required by CMS policy.31 Our earlier work found that nursing
                           homes tended to “yo-yo” in and out of compliance, in part because HCFA
Immediate Sanctions        rarely imposed sanctions on homes with a pattern of deficiencies that
                           harmed residents.32 In response, the agency required that homes found to
                           have harmed residents on successive standard surveys be referred to it for
                           immediate sanction.33 Most states did not refer at least some cases that
                           should have been referred under this policy.34 Figure 1 shows the results of
                           our analysis for the four states—Massachusetts, New York, Pennsylvania,
                           and Texas—with the greatest numbers of cases that should have been




                           31
                             Using CMS data, we identified 1,334 cases that appeared to meet the criteria for
                           immediate sanctions but that did not appear to have been referred to CMS by states. (See
                           app. I for a description of our methodology.) We use the term “cases” rather than “nursing
                           homes” because some nursing homes had multiple referrals for immediate sanctions. At
                           our request, CMS reviewed most of these cases and determined that 711 (62 percent of
                           those CMS reviewed) should have been—but were not—referred for immediate sanction.
                           CMS did not analyze 155 of the cases we asked it to examine and was unable to determine
                           the status of an additional 30 cases.
                           32
                               See GAO/HEHS-99-46.
                           33
                             This policy was implemented in two stages, and our analysis focused on implementation
                           of the second stage in January 2000. Beginning in September 1998, HCFA required states to
                           refer homes that had a pattern of harming a significant number of residents or placed
                           residents at high risk of death or serious injury (H-level deficiencies and above on CMS’s
                           scope and severity grid). Effective January 14, 2000, HCFA expanded this policy by
                           requiring state survey agencies to refer for immediate sanction homes that had harmed
                           residents—G-level deficiencies on the agency’s scope and severity grid—on successive
                           surveys. States are now required to deny a grace period to homes that are assessed one or
                           more deficiencies at the actual harm level or above (G-L on CMS’s scope and severity grid)
                           in each of two surveys within a survey cycle. A survey cycle is two successive standard
                           surveys and any intervening survey, such as a complaint investigation.
                           34
                            We found that states did refer 4,310 cases over a 27-month period. See app. VI for a
                           summary of all sanctions that were implemented, including the amount of civil money
                           penalties (CMPs) by state.




                           Page 26                                                    GAO-03-561 Nursing Home Quality
                                                               referred and for the nation (see app. VII for information on all states).
                                                               These four states accounted for 55 percent of the 711 cases.

Figure 1: Four States with the Greatest Number of Cases that Should Have Been Referred for Immediate Sanctions, January
14, 2000, through March 28, 2002


             State
                                                       169
                   a
           Texas                                                                                    423
                                     66

                                                140
         New York          22
                       0

                                46
  Massachusetts                           81
                       0

                                38
    Pennsylvania                                  164
                                 50

                                                                                                                                                  711
                                                                                                                                                               4310
            Nation
                                                 155

                       0                  100            200               300              400              500              600           700         800     5000
                       Cases
                                                                         Cases that should have been referred and were not

                                                                         Cases that were referred

                                                                         CMS did not determine if cases should have been referred

Source: GAO and CMS analysis of OSCAR and enforcement data.

                                                               Note: Analysis includes cases entered in CMS’s enforcement database by March 28, 2002.
                                                               a
                                                                According to a Dallas regional office official, Texas referred most of the 423 cases because the
                                                               nursing homes had a “poor enforcement history,” not because of repeat harm level deficiencies.
                                                               However, based on other information, the region coded these cases as requiring immediate sanction.


                                                               State and CMS officials identified several reasons why state agencies failed
                                                               to forward cases to CMS for immediate sanction, including (1) an initial
                                                               misunderstanding of the policy on the part of some states and regions, (2)
                                                               poor state systems for monitoring the survey history of homes to identify
                                                               those meeting the criteria for referral for immediate sanction, and (3)
                                                               actions, by two states, that were at variance with CMS policy. First,
                                                               officials from some states—and some CMS regional officials as well—told




                                                               Page 27                                                              GAO-03-561 Nursing Home Quality
us that they did not initially fully understand the criteria for referring
homes for immediate sanction.35 For example, several states and CMS
regional offices reported that they did not understand that CMS required
states to look back before the January 2000 policy implementation date to
determine if there was an earlier survey with an actual-harm-level
deficiency. The look-back requirement was specifically addressed in a
February 10, 2000, CMS policy clarification specifying that state agencies
were to consider the home’s survey history before the January 14, 2000,
implementation date in determining if a home met the criteria for
immediate referral for sanction. However, officials in one region told us
that they had instructed three of four states not to look back before the
January 2000 implementation date of the policy. Two other regional offices
told us that CMS policy did not require the state to look back before
January 2000 for earlier surveys. Officials at another regional office did not
recall the look-back policy at the time we talked to them in mid-2002, and
were not sure what advice they had given their states when the policy was
first implemented.

Second, some state survey agencies told us that their managers
responsible for enforcement did not have an adequate methodology for
checking the survey history of homes to identify those meeting the criteria.
Some states said that their managers relied on manual systems, which are
less accurate and sometimes failed to identify cases that should have been
referred. Officials in one state told us that its district offices had no
consistent procedure for checking the survey history of homes. An official
in another state told us that some cases were not referred because time
lags in reporting some surveys meant that an earlier survey—such as a
complaint survey—with an actual harm deficiency might not have been
entered in the state’s tracking system until after a later survey that also
found harm-level deficiencies.

Third, two states did not implement CMS’s expanded policy on immediate
sanctions. New York was in direct conflict with CMS policy. Although CMS
policy calls for state referrals to CMS regardless of the type of deficiency,



35
  Arizona’s comments on a draft of this report indicated that eight of the nine cases not
referred for immediate sanction were during the period January through October 2000
when the state was struggling with various interpretations of CMS’s new requirement.
Similarly, Missouri officials indicated in their comments that the majority of cases they did
not refer occurred during the initial stages of the new policy, which Missouri believes was
“complicated, at best.” Missouri officials added that the number of missed cases
significantly declined as the state gained a better understanding of the policy.




Page 28                                                  GAO-03-561 Nursing Home Quality
                        a state agency official told us that the state only referred a home to CMS
                        for immediate sanction if both actual harm citations were for the exact
                        same deficiency.36 A CMS official indicated that New York began
                        complying with the policy in September 2002.37 Texas, the second state,
                        did not implement the CMS policy statewide until July 2002, when it
                        received our inquiry about the cases not referred for immediate sanction.
                        In the interim from January 2000 through July 2002, three of Texas’s 11
                        district offices specifically requested from state survey agency officials,
                        and were granted, permission to implement the policy.


                        While CMS has increased its oversight of state survey and complaint
CMS Oversight of        activities and instituted a more systematic oversight process by initiating
State Survey            annual state performance reviews, CMS officials acknowledged that the
                        effectiveness of the reviews could be improved. In particular, CMS
Activities Requires     officials told us that for the initial state performance review in fiscal year
Further Strengthening   2001, they lacked the capability to systematically distinguish between
                        minor lapses identified during the reviews and more serious problems that
                        require intervention. CMS oversight is also hampered by continuing
                        limitations in OSCAR data, the inability or reluctance of some CMS regions
                        to use such data to monitor state activities, and inadequate oversight of
                        certain areas, such as survey predictability and state referral of homes for
                        immediate enforcement actions. CMS has restructured regional office
                        responsibilities to improve the consistency of federal oversight and plans
                        to further strengthen oversight by increasing the number of federal
                        comparative surveys. However, three federal initiatives critical to reducing
                        the subjectivity evident in the current survey process and the investigation
                        of complaints have been delayed.




                        36
                          This New York state official told us that the state believed it was in compliance with
                        CMS’s policy because it imposed one of two minor federal sanctions and a state civil
                        money penalty on all consecutive G-level cases. This state official also indicated that state
                        fines were imposed in place of federal civil money penalties in all cases. (The maximum
                        state fine is $2,000 per violation, lower than the federal maximum of $10,000 per instance
                        or per day of noncompliance.) However, when we discussed this explanation with officials
                        in the CMS central office, they disagreed that the state was in compliance.
                        37
                          In commenting on a draft of our report, New York officials indicated that their initial
                        failure to refer nursing homes for immediate sanctions was based on their
                        misinterpretation of the new policy and not on a deliberate refusal to implement it. They
                        also indicated that their procedures are now consistent with the federal policy.




                        Page 29                                                  GAO-03-561 Nursing Home Quality
CMS Reviews of State   In the first of what is planned as an annual process, CMS’s 10 regional
Performance Have       offices reviewed states’ fiscal year 2001 performance for seven standards
Identified Areas for   to determine how well states met their nursing home survey
                       responsibilities (see app. VIII for a description of the seven standards).38
Improvement            This enhanced oversight of state survey agency performance responds to
                       our prior recommendations. In 1999, we reported that HCFA’s oversight of
                       state efforts had limitations preventing it from developing accurate and
                       reliable assessments of state performance.39 HCFA regional office policies,
                       practices, and oversight had been inconsistent, a reflection of coordination
                       problems between HCFA’s central office and its regional staffs. In
                       important areas, such as the adequacy of surveyors’ findings and
                       complaint investigations, HCFA relied on states to evaluate their own
                       performance and report their findings to HCFA. Although OSCAR data
                       were available to HCFA for monitoring state performance, they were
                       infrequently used, and neither the states nor HCFA’s regional offices were
                       held accountable for failing to meet or enforce established performance
                       standards.

                       To promote consistent application of the standards across the 10 regions,
                       the agency developed detailed guidance for measuring each standard,
                       including the method of evaluation, the data sources to be used, and the
                       criteria for determining whether a state met a standard. Only two states
                       met each of the five standards we reviewed and many did not meet several
                       standards. Appendix IX identifies the standards we analyzed and the
                       results of CMS’s review of these standards. During the 2001 review, CMS
                       elected not to impose the most serious sanctions available for inadequate
                       state performance, including reducing federal payments to the state or
                       initiating action to terminate the state’s agreement, but advised the states
                       that annual reviews in subsequent years will serve as the basis for such
                       actions. While imposing no sanctions during the 2001 review, CMS did
                       require several states to prepare corrective action plans. Each year, CMS
                       plans to update and improve the standards based on experience gained in
                       prior years.



                       38
                         The CMS regions assessed each state’s performance by (1) reviewing a set of standardized
                       reports drawn from information contained in CMS’s databases and (2) visiting states to
                       review procedures and to examine a sample of records, such as complaint investigation
                       files. Some reviews, such as assessing state complaint investigation timeliness, were
                       performed semiannually, enabling regional office staff to provide midpoint feedback
                       intended to correct any deficiencies identified.
                       39
                        GAO/HEHS-00-6.




                       Page 30                                               GAO-03-561 Nursing Home Quality
CMS’s State Performance    Characterizing its fiscal year 2001 state performance review as a “shakeout
Standards and Review Had   cruise,” CMS is working to address several weaknesses identified during
Shortcomings               the reviews, including difficulty in determining if identified problems were
                           isolated incidents or systemic problems, flawed criteria for evaluating a
                           critical standard, and inconsistencies in how regional offices conducted
                           the reviews. In our discussions of the results of the performance reviews
                           with officials of CMS’s regional offices, it was evident that some regions
                           had a much better appreciation of the strengths and weaknesses of survey
                           activities in their respective states than was reflected in the state
                           performance reports. However, this information was not readily available
                           to CMS’s central office. In addition, CMS has not released a summary of
                           the review to permit easy comparison of the results. For subsequent
                           reviews, CMS plans to more centrally manage the process to improve
                           consistency and help ensure that future reviews distinguish serious from
                           minor problems.

Distinctions in State      CMS officials acknowledged that the first performance review did not
Performance Were Hard to   provide adequate information regarding the seriousness of identified
Identify                   problems. The agency indicated that it had since revised the performance
                           standards to enable it to determine the seriousness of the problems
                           identified. Some regional office summary reports provided insufficient
                           information to determine whether a state did not meet a particular
                           standard by a wide or a narrow margin. For example, although California
                           did not meet the standard to investigate all complaints alleging actual
                           harm within 10 days, the regional office summary provided no details
                           about the results. Regional officials told us that they found very few
                           California complaints that were not investigated within the 10-day
                           deadline and those that were not were generally investigated by the 13th
                           day.40 Conversely, although the report for Oregon shows that the state met
                           the 10-day requirement, our discussions with regional officials revealed
                           that serious shortcomings nevertheless existed in the state’s complaint
                           investigation practices. 41 Officials in the Seattle region told us that for
                           many years Oregon had contracted out investigations of complaints to
                           local government entities not under the control of the state agency and, as


                           40
                             According to CMS regional officials, California state law requires that all complaints other
                           than those alleging immediate jeopardy be investigated within 10 days, irrespective of the
                           seriousness of the allegation.
                           41
                             CMS’s database showed that Oregon conducted only 14 on-site complaint investigations
                           during fiscal year 2001. Because of this low number, the region reviewed the entire
                           universe of complaints (instead of a sample), but did not identify the number reviewed in
                           its report.




                           Page 31                                                  GAO-03-561 Nursing Home Quality
                                   a result, exercised little control over the roughly 2,000 complaints the state
                                   receives against nursing homes each year. For instance, under this
                                   arrangement, information about complaint investigations, including
                                   deficiencies identified, was not entered into CMS’s database. Regional
                                   officials told us that the Oregon state agency recently assumed
                                   responsibility for investigating complaints filed by the public, but that the
                                   local government entities continue to investigate facility self-reported
                                   incidents.

CMS’s Standard for Measuring       CMS’s standard for measuring how well states document deficiencies
States’ Documentation of           identified during standard surveys was flawed because it mixed major and
Deficiencies Was Flawed            minor issues, blurring the significance of findings. CMS’s protocol required
                                   assessment of 33 items, ranging from the important issue of whether state
                                   surveyors cited deficiencies at the correct scope and severity level to the
                                   less significant issue of whether they used active voice when writing
                                   deficiencies. Because of the complexity of the criteria and concerns about
                                   the consistency of regional office reviews of states’ documentation
                                   practices, CMS decided not to report the results for this standard for 2001.
                                   For the 2002 review, CMS reduced the number of criteria to be assessed
                                   from 33 to 7.42 Based on the available evidence of the understatement of
                                   actual harm deficiencies, we believe that successful implementation of the
                                   documentation standard in 2002 and future years is critical to help ensure
                                   that deficiencies are cited at the appropriate scope and severity level.

CMS Regions’ Reviews Were          CMS’s regional offices were sometimes inconsistent in how they
Inconsistent                       conducted their reviews, raising questions about the validity and fairness
                                   of the results. For example:

                               •   Although the guidelines for the review indicated that the regional offices
                                   were to assess the timeliness of complaint investigations based on the
                                   state’s prioritization of the complaint, officials from one region told us that
                                   they judged timeliness based on their opinion of how the complaint should
                                   have been prioritized.




                                   42
                                     CMS’s criteria for evaluating the documentation standard in 2002 are (1) the proper
                                   regulation is cited for each deficiency, (2) evidence supports the cited area of
                                   noncompliance, (3) several components required by the relevant regulation for each
                                   deficiency, such as identifying the citation number, are included, (4) the deficient practice
                                   is identified, (5) the cited severity of each deficiency is accurate, (6) the cited scope of each
                                   deficiency is accurate, and (7) the sources and identifiers in the deficient practice
                                   statement match the sources and identifiers in the findings.




                                   Page 32                                                   GAO-03-561 Nursing Home Quality
                          •   Two regional offices acknowledged that they did not use clinicians to
                              review complaint triaging. Officials from two states questioned the
                              credibility of reviews not conducted by clinicians.
                          •   Although one objective of the reviews was to review some immediate
                              jeopardy complaints in every state, the random samples selected in some
                              states did not yield such complaints. In such cases, one region indicated
                              that it specifically selected a few immediate jeopardy complaints outside
                              the sample while another region did not. To eliminate this inconsistency in
                              future years, CMS has instructed the regions to expand their sample to
                              ensure that at least two immediate jeopardy complaints are reviewed in
                              each state.
                          •   While some regions examined more than the required number of
                              complaints to assess overall timeliness, one region felt that additional
                              reviews were unnecessary. For instance, surveyors reviewing California,
                              which receives thousands of complaints per year, expanded the number of
                              complaints reviewed beyond the minimum number required because they
                              felt that the required random sample of 40 complaints did not provide
                              sufficient information about overall timeliness in the state. To assess
                              overall timeliness, they visited all but 1 of the state’s 17 district offices to
                              review complaints. However, surveyors from another CMS region
                              reviewed only 3 or 4 of the roughly 18 complaints a state received and told
                              us that additional reviews were unnecessary because the state had already
                              failed the timeliness criterion based on the few complaints reviewed.
                              Although the review of 3 or 4 complaints technically met CMS’s sampling
                              requirement, we believe examination of most or all of the relatively few
                              remaining complaints would have provided a more complete picture of the
                              state’s overall timeliness.

Performance Standards         While CMS has addressed some of the weaknesses in its 2001 state
Excluded Some Important       performance review by revising the standards and guidance for the 2002
Areas                         review, including simplifying the criteria for assessing documentation and
                              requiring regions to assess states’ complaint prioritization efforts
                              separately from the timeliness issue, the performance standards do not yet
                              address certain issues that are important for assessing state performance
                              and that would further strengthen CMS oversight of state survey activities.
                              These issues include:

                          •   Assessing the predictability of state surveys. Although CMS
                              monitored compliance with its requirement for state survey agencies to
                              initiate at least 10 percent of their standard surveys outside normal
                              working hours to reduce predictability, it did not examine compliance
                              with its 1999 instructions for states to avoid scheduling a home’s survey
                              during the same month each year. As shown in app. V, our analysis of CMS
                              data found that from 10 percent to 31 percent of surveys in 31 states were



                              Page 33                                         GAO-03-561 Nursing Home Quality
                              predictable because they were initiated within 15 days of the 1-year
                              anniversary of the prior survey.
                          •   Evaluating states’ compliance with the requirement to refer
                              nursing homes that have a pattern of harming residents for
                              immediate sanctions. CMS officials confirmed that there was no
                              consistent oversight of state agencies’ implementation of this policy.
                              Several CMS regional offices generally did not know, for example, how
                              their states were monitoring homes’ survey history to detect cases that
                              should be referred for immediate sanction. CMS could have used the
                              enforcement database to determine that New York was not adhering to the
                              agency’s immediate sanctions policy. During calendar years 2000 and 2001,
                              New York cited actual harm at a relatively high proportion of its nursing
                              homes but only referred 19 cases for immediate sanction. Over a
                              comparable period, New Jersey, a state with far fewer homes and
                              citations, referred almost three times as many cases.43
                          •   Developing better measures of the quality of state performance, in
                              addition to process measures. Several CMS regional officials believed
                              that the scope of the state performance standards should address
                              additional areas of performance, including assessing the adequacy of
                              nursing homes’ plans of correction submitted in response to deficiencies
                              and the appropriateness of states’ recommended enforcement remedies. In
                              particular, several regions noted that rather than focusing only on the
                              timeliness of complaint investigations, regions should also assess the
                              adequacy of the investigation itself, including whether the complaint
                              should have been substantiated. The introduction of a new CMS complaint
                              tracking database, discussed below, should enable regions to automate the
                              review of complaint timeliness, thereby allowing them to focus more
                              attention on such issues.


Data Limitations and          CMS’s oversight of state survey activities is further hampered by
Inconsistent Use of           limitations in the data used to develop the 19 periodic reports intended to
Periodic Reports Hamper       assist the regions in monitoring state performance and by the regions’
                              inconsistent use of the reports.44 For instance, CMS’s current complaint
Oversight                     database does not provide key information about the number of



                              43
                                While cases referred by states were typically recorded in CMS’s enforcement database, a
                              New York regional official indicated that because of the departure of key staff members,
                              the region had not entered all cases into the database.
                              44
                               CMS’s central office and the regions have jointly produced the reports since they were
                              created in 2000. As CMS’s systems become more user-friendly, the regions will be able to
                              produce them independently.




                              Page 34                                                GAO-03-561 Nursing Home Quality
complaints each state receives (including facility self-reported incidents)
or the time frame in which each complaint is investigated.45 In addition,
officials from one region emphasized to us that information about
complaints provided in the reports did not correspond with CMS’s
required complaint investigation time frames. The reports identify the
number of state on-site complaint investigations that took place in three
different time periods—3 days, from 4 to 14 days, and 15 days or more;
however, required time frames for complaint investigations are 2 days for
complaints alleging immediate jeopardy and 10 days for those alleging
harm. Additionally, a regional official pointed out that investigations
shown in one of the reports as taking place within 3 days do not
necessarily represent complaints that the state prioritized as immediate
jeopardy. Despite the problems with these data, however, several regional
offices indicated that the reports could at least serve as a starting point for
discussions with states about their complaint programs and often lead to a
better understanding of state complaint activities. CMS indicated that the
deficiencies in complaint data should be addressed by the new automated
complaint tracking system that it is developing for use by all states as part
of the redesign of OSCAR.46

Officials from several regions also told us that the value of some of the
19 periodic reports was unclear, and officials in three regions said they
either lacked the staff expertise or the time to use the reports routinely to
oversee state activities. For example, officials in one region told us that


45
  As we reported previously, although HCFA standards require states to report information
about complaints, the process for collecting it results in inaccurate and incomplete
information. For example, the form CMS requires states to use to record the results of
complaint investigations was created to record information about a single complaint, but
many states investigate multiple complaints at a nursing home during one on-site visit. As a
result, the timeliness, prioritization, and other important tracking information related to
multiple complaints is reported as though it applies to one complaint. See
GAO/HEHS-99-80.
46
  CMS planned to implement the new system, known as the ASPEN Complaint Tracking
System, or ACTS, nationwide in October 2002. However, implementation was delayed
because of several issues that surfaced during pilot testing: (1) states have different
policies regarding the treatment of self-reported facility incidents, (2) complaints filed with
some states may be investigated by entities other than the state survey agency (for
instance, the Board of Nursing), and (3) 8 to 10 states have indicated that their current
state complaint tracking systems have superior capability to ACTS and they do not wish to
discontinue using their own system or maintain separate systems. CMS plans to evaluate
this last issue during the extended pilot test. As of July 2003, nationwide implementation
had been further delayed by the need to obtain approval from the Office of Management
and Budget for publication of a notice in the Federal Register, a procedure that applies to
establishing a system of federal records.




Page 35                                                   GAO-03-561 Nursing Home Quality
                         they used one of the reports about complaints to ask states questions
                         about their prioritization practices. But a different region appeared
                         unaware that the reports showed that two of its states might be outliers in
                         terms of the percentage of complaints they prioritized as actual harm or
                         immediate jeopardy. Additionally, because the periodic reports do not
                         include trend data, many regional offices were unaware of the trends in
                         the percentage of homes cited in their states for actual harm or immediate
                         jeopardy. We believe that such data could be useful to CMS’s regions in
                         identifying significant trends in their states.

                         CMS indicated that it is continuing to make progress in redesigning the
                         OSCAR reporting system. In 1999, we recommended that the agency
                         develop an improved management information system that would help it
                         track the status and history of deficiencies, integrate the results of
                         complaint investigations, and monitor enforcement actions.47 Another
                         objective of the OSCAR redesign is to make it easier to analyze the data it
                         contains, addressing the problem that generating analytical reports from
                         OSCAR was difficult and most regions lacked the expertise to do so. The
                         redesigned system, called the Quality Improvement and Evaluation
                         System, would also eliminate the need for duplicate data entry, which
                         should reduce the potential for data entry errors to which OSCAR is
                         susceptible.48 CMS has faced some problems in the implementation of the
                         new system, such as inadvertent modifications of survey data results when
                         data are transferred from the old OSCAR database into the new system,
                         but the agency indicated that its target date for completing the redesign is
                         2005.


CMS Is Making Progress   CMS has taken, or is undertaking, several other efforts to improve federal
but Also Encountering    oversight and survey procedures, including making structural changes to
Delays in Several Key    the regional offices to improve coordination, expanding the number of
                         comparative surveys conducted each year, improving the survey
Efforts                  methodology, developing clearer guidance for surveyors, and developing
                         additional guidance to states for investigating complaints. As of April 2003,
                         only the effort to restructure the regional offices had been completed. The




                         47
                          GAO/HEHS-99-46.
                         48
                          Until recently, states had to manually enter data into a computerized system that
                         generated survey reports and then manually reenter much of the same data into OSCAR.
                         This duplicative data entry process increased the chances for errors in OSCAR.




                         Page 36                                             GAO-03-561 Nursing Home Quality
                                 other efforts critical to reducing the subjectivity evident in the current
                                 survey process and the investigation of complaints have been delayed.

CMS Is Taking Additional Steps   In December 2002, CMS reduced the number of regional managers in
to Address Inconsistencies in    charge of survey activities from 10 (1 per region) to 5, a change intended
Regional Office Performance      to provide more management attention to survey matters and to improve
and Improve Federal Oversight    accountability, direction, and leadership. Our prior and current work
                                 found that regional offices’ policies, practices, and oversight were often
                                 inconsistent. For example, in 1999 we reported that regional offices used
                                 different criteria for selecting and conducting comparative surveys. The 5
                                 regional managers will be responsible only for survey and certification
                                 activities, while in the past many of the 10 were also responsible for
                                 managing their regions’ Medicaid programs.

                                 In response to our prior recommendations, CMS plans to more than
                                 double the number of federal comparative surveys in which federal
                                 surveyors resurvey a nursing home within 2 months of the state survey to
                                 assess state performance. We noted in 1999 that, although insufficient in
                                 number, comparative surveys were the most effective technique for
                                 assessing state agencies’ abilities to identify serious deficiencies in nursing
                                 homes because they constitute an independent evaluation of the state
                                 survey. CMS plans to hire a contractor to perform approximately 170
                                 additional comparative surveys per year, bringing the annual total of
                                 comparative surveys performed by both CMS surveyors and the contractor
                                 to about 330. Although CMS had intended to award a contract and begin
                                 surveys by spring 2003, as of July 2003, it was still in the process of
                                 identifying qualified contractors. CMS officials stated that using a
                                 contractor would provide CMS flexibility because if it suspects that a state
                                 or region is having problems with surveys, it can quickly have the
                                 contractor conduct several comparative surveys there. Being able to direct
                                 the contractor to quickly focus on states or regions where state surveys
                                 may be problematic could represent a significant improvement in CMS’s
                                 oversight of state survey agencies.

Key Initiatives to Improve       CMS’s implementation schedules have slipped for three critical initiatives
Survey Consistency and           intended to enhance the consistency and accuracy of state surveys and
Complaint Investigations Have    complaint investigations, delaying the introduction of improved
Been Delayed                     methodologies or guidance until 2003 or 2004. Because surveyors often
                                 missed significant care problems due to weaknesses in the survey process,
                                 HCFA took some initial steps to strengthen the survey methodology, with
                                 the goal of introducing an improved survey process in 2000. In July 1999,
                                 the agency introduced quality indicators to help surveyors do a better job
                                 of selecting a resident sample, instructed states to increase the sample size


                                 Page 37                                         GAO-03-561 Nursing Home Quality
in areas of particular concern, and required the use of investigative
protocols in certain areas, such as pressures sores and nutrition, to help
make the survey process more systematic.49 However, HCFA recognized
that additional steps were required to ensure that surveyors thoroughly
and systematically identify and assess care problems.

To address remaining problems with sampling and the investigative
protocols, CMS contracted for the development of a revised survey
methodology. The contractor has proposed a two-phase survey process.50
In the first phase, surveyors would initially identify potential care
problems using quality indicators generated off-site prior to the start of the
survey and additional, standardized information collected on-site, from a
sample of as many as 70 residents. During the second phase, surveyors
would conduct an investigation to confirm and document the care
deficiencies initially identified.51 According to CMS officials, this process
differs from the current methodology because it would more
systematically target potential problems at a home and give surveyors new
tools to more adequately document care outcomes and conduct on-site
investigations. Use of the new methodology could result in survey findings
that more accurately identify the quality of care provided by a nursing
home to all of its residents.52 Initial testing to evaluate the proposed
methodology focused primarily on the first phase and was completed in



49
  Quality indicators are derived from nursing homes’ assessments of residents and rank a
facility in 24 areas compared with other nursing homes in a state. By using the quality
indicators to select a preliminary sample of residents before the on-site review, surveyors
are better prepared to identify potential care problems.
50
  The agency is committed to implementing only those portions of the new methodology
that are proven to be significantly more effective than the current survey methodology.
CMS officials said the new process must be manageable and easy to use, add no additional
time to surveys, and require limited additional training resources. Given the high turnover
among surveyors and state budget constraints, the agency is particularly concerned about
imposing new training requirements that would interfere with the conduct of mandatory
surveys.
51
 A minimum of three residents would be included in the sample for each of the care
problems identified in phase one, which covers as many as 33-35 resident-care areas.
52
  The goals of the new survey methodology are to (1) ensure that all areas of care are
addressed, (2) make the survey process more data-driven and less reliant on surveyor
judgment, thus reducing variability in the citation of serious deficiencies, (3) focus
surveyors’ attention more on nursing homes with poor quality and less on better
performing homes, (4) more reliably determine the scope of deficiencies at nursing homes,
that is, the number of residents potentially or actually affected, and (5) produce better
documented and defensible survey deficiencies.




Page 38                                                 GAO-03-561 Nursing Home Quality
three states during 2002. As of April 2003, a CMS official told us that the
agency lacked adequate funding to conduct further testing that more fully
incorporates phase two. As a result, it is not clear when changes to survey
methodology will be implemented. We continue to believe that redesign of
the survey methodology, under way since 1998, is necessary for CMS to
fully respond to our past recommendation to improve the ability of
surveys to effectively identify the existence and extent of deficiencies.
While CMS’s goal of not adding additional time to surveys is an important
consideration, it should not take priority over the goal of ensuring that
surveys are as effective as possible in identifying the quality of care
provided to residents.

Recognizing inconsistencies in how the scope and severity of deficiencies
are cited across states, in October 2000, HCFA began developing more
structured guidance for surveyors, including survey investigative protocols
for assessing specific deficiencies. The intent of this initiative is to enable
surveyors to better (1) identify specific deficiencies, (2) investigate
whether a deficiency is the result of poor care, and (3) document the level
of harm resulting from a home’s identified deficient care practices. The
areas originally targeted for this initiative included deficiencies related to
pressure sores, urinary catheters and incontinence, activities
programming, safe food handling, and nutrition. Delays have occurred
because CMS is committed to incorporating the work of multiple expert
panels and two rounds of public comments for each deficiency. The
project has been further delayed because the approach used to identify
resident harm shifted during the course of work. The process should
proceed more quickly, however, now that CMS has developed its
approach. CMS expected to release the first new guidance, addressing
pressure sores, in early 2003, but officials were unable to tell us how many
of the 190 federal nursing home requirements will ultimately receive new
guidance or a specific time line for when this initiative will be completed.53
As discussed earlier, CMS’s state performance reviews include an
assessment of state surveyors’ documentation of the scope and severity of
a sample of deficiencies cited, which should provide CMS with an
opportunity to assess the effectiveness of the new guidance.

Finally, despite initiation of a complaint improvement project in 1999,
CMS has not yet developed detailed guidance for states to help improve
their complaint systems. Effective complaint procedures are critical


53
 As of July 2003, the guidance had not yet been released.




Page 39                                                GAO-03-561 Nursing Home Quality
              because complaints offer an opportunity to assess nursing home care
              between standard surveys, which can be as long as 15 months apart. In
              1999, HCFA commissioned a contractor to assess and recommend
              improvements to state complaint practices. CMS received the contractor’s
              final report in June 2002, and indicated agreement with the contractor that
              reforming the complaint system is urgently needed to achieve a more
              standardized, consistent, and effective process. The study identified
              serious weaknesses in state complaint processes (see table 5) and made
              numerous recommendations to CMS for strengthening them. Key
              recommendations were that CMS increase direction and oversight of
              states’ complaint processes and establish mechanisms to monitor states’
              performance. CMS indicated that it has already taken steps to address
              these recommendations by initiating annual performance reviews that
              include evaluating the timeliness of state complaint investigations and the
              accuracy of states’ complaint triaging decisions, and by developing the
              new ASPEN complaint tracking system, which should provide more
              complete data about complaint activities than the current system. The
              contractor also recommended that CMS (1) expand outreach for the
              initiation of complaints, such as use of billboards or media advertising,
              (2) enhance complaint intake processes by using professional intake staff,
              (3) improve investigation and resolution processes by using available data
              about the home being investigated and establishing uniform definitions
              and criteria for substantiating complaints, (4) make the process more
              responsive by conducting timely investigations and allowing the
              complainant to track the progress of the investigation, and (5) establish a
              higher priority for complaint investigations in the state survey agency.
              CMS noted that some of these recommendations are beyond the agency’s
              purview and will require the support of all stakeholders to accomplish.
              CMS told us that it plans to issue new guidance to the states in late fiscal
              year 2003—about 4 years after the complaint improvement project
              initiative was launched.


              As we reported in September 2000, continued federal and state attention is
Conclusions   required to ensure necessary improvements in the quality of care provided
              to the nation’s vulnerable nursing home residents. The reported decline in
              the percentage of homes cited for serious deficiencies that harm residents
              is consistent with the concerted congressional, federal, and state attention
              focused on addressing quality-of-care problems. More active and data-
              driven oversight is increasing CMS’s understanding of the nature and
              extent of weaknesses in state survey activities. Despite these efforts,
              however, the proportion of homes reported to have harmed residents is
              still unacceptably high. It is therefore essential that CMS fully implement


              Page 40                                       GAO-03-561 Nursing Home Quality
    key initiatives to improve the rigor and consistency of state survey,
    complaint investigation, and enforcement processes.

    The seriousness of the challenge confronting CMS in ensuring consistency
    in state survey activities is also becoming more apparent. Our work, as
    well as that of CMS, demonstrates the persistence of several long-standing
    problems and also provides insights on factors that may be contributing to
    these shortcomings:

•   state surveyors continue to understate serious deficiencies that caused
    actual harm or placed residents in immediate jeopardy;
•   deficiencies are often poorly investigated and documented, making it
    difficult to determine the appropriate severity category;
•   states focus considerable effort on reviewing proposed actual harm
    deficiencies, but many have no quality assurance processes in place to
    determine if less serious deficiencies are understated or have investigation
    and documentation problems;
•   the timing of too many surveys remains predictable, allowing problems to
    go undetected if a home chooses to conceal deficiencies;
•   numerous weaknesses persist in many states’ complaint processes,
    including the lack of consumer toll-free hotlines in many states, confusion
    over prioritization of complaints, inconsistent complaint investigation
    procedures, and the failure of most states to investigate all complaints
    alleging actual harm within 10 days, as required; and
•   states did not refer a substantial number of homes that had a pattern of
    harming residents to CMS for immediate sanctions.

    Over the past several years, CMS has taken numerous steps to improve its
    oversight of state survey agencies, but needs to continue its efforts to help
    better ensure consistent compliance with federal requirements. Several
    areas that require CMS’s ongoing attention include (1) the newly
    established standard performance reviews to ensure that critical elements
    of the review, such as assessing states’ ability to properly document
    deficiencies, are successfully implemented, (2) the successful
    modernization of CMS’s data system by 2005 to support the survey process
    and provide key information for monitoring state survey activities, (3) the
    planned expansion of comparative surveys to improve federal oversight of
    the state survey process, (4) the survey methodology redesign intended to
    make the survey process more systematic, (5) the development of more
    structured guidance for surveyors to address inconsistencies in how the
    scope and severity of deficiencies are cited across states, and (6) the
    provision of detailed guidance to states to ensure thorough and consistent
    complaint investigations. Some of these efforts have been under way for



    Page 41                                       GAO-03-561 Nursing Home Quality
                      several years, and CMS has consistently extended their estimated
                      completion and implementation dates. We believe that effective
                      implementation of planned improvements in each of these six areas is
                      critical to ensuring better quality care for the nation’s 1.7 million nursing
                      home residents.


                      To strengthen the ability of the nursing home survey process to identify
Recommendations for   and address problems that affect the quality of care, we recommend that
Executive Action      the Administrator of CMS

                  •   finalize the development, testing, and implementation of a more rigorous
                      survey methodology, including guidance for surveyors in documenting
                      deficiencies at the appropriate level of scope and severity.

                      To better ensure that state survey and complaint activities adequately
                      address quality-of-care problems, we recommend that the Administrator

                  •   require states to have a quality assurance process that includes, at a
                      minimum, a review of a sample of survey reports below the level of actual
                      harm (less than G level) to assess the appropriateness of the scope and
                      severity cited and to help reduce instances of understated quality-of-care
                      problems.
                  •   finalize the development of guidance to states for their complaint
                      investigation processes and ensure that it addresses key weaknesses,
                      including the prioritization of complaints for investigation, particularly
                      those alleging harm to residents; the handling of facility self-reported
                      incidents; and the use of appropriate complaint investigation practices.

                      To better ensure that states comply with statutory, regulatory, and other
                      CMS nursing home requirements designed to protect resident health and
                      safety, we recommend that the Administrator

                  •   further refine annual state performance reviews so that they (1)
                      consistently distinguish between systemic problems and less serious
                      issues regarding state performance, (2) analyze trends in the proportion of
                      homes that harm residents, (3) assess state compliance with the
                      immediate sanctions policy for homes with a pattern of harming residents,
                      and (4) analyze the predictability of state surveys.




                      Page 42                                         GAO-03-561 Nursing Home Quality
                     We provided a draft of this report to CMS and the 22 states we contacted
Agency and State     during the course of our review. (CMS’s comments are reproduced in app.
Comments and Our     X.) CMS concurred with our findings and recommendations, stating that it
                     already had initiatives under way to improve the effectiveness of the
Evaluation           survey process, address the understatement of serious deficiencies,
                     provide better data on state complaint activities, and improve the annual
                     federal performance reviews of state survey activities. Although CMS
                     concurred with our recommendations, its comments on intended actions
                     did not fully address our concerns about the status of the initiative to
                     improve the effectiveness of the survey process or the recommendation
                     regarding state quality assurance systems. Eleven of the 22 states also
                     commented on our draft report.54 CMS and state comments generally
                     covered five areas: survey methodology, state quality assurance systems,
                     definition of actual harm, survey predictability, and resource constraints.


Survey Methodology   In response to our recommendation that the agency finalize the
Redesign             development, testing, and implementation of a more rigorous nursing
                     home survey methodology, under way since 1998, CMS commented that it
                     had already taken steps to improve the effectiveness of the survey process,
                     such as the development of surveyor guidance on a series of clinical
                     issues.55 However, the agency did not specifically comment on any actions
                     it would take to finalize and implement its new survey methodology,
                     which is broader than the actions CMS described. Our draft report noted
                     that, earlier this year, CMS said it lacked adequate funding for the
                     additional field testing needed to implement the new survey methodology.
                     Through September 2003, CMS will have committed $4.7 million to this
                     effort. While CMS did not address the lack of adequate funding in its
                     comments on our draft report, a CMS official subsequently told us that
                     about $508,000 has now been slated for additional field testing. This
                     amount, however, has not yet been approved. Not funding additional field
                     testing could jeopardize the entire initiative, in which a substantial
                     investment has already been made. We continue to believe that CMS
                     should implement a revised survey methodology to address our 1998




                     54
                      States that commented included Alabama, Arizona, California, Connecticut, Iowa,
                     Missouri, Nebraska, New York, Pennsylvania, Tennessee, and Virginia.
                     55
                      Our draft report discussed the problems CMS encountered in developing this guidance
                     and pointed out that the guidance on the first clinical issue to be addressed, pressure sores,
                     was expected in early 2003. As of July 2003, the guidance had not yet been released.




                     Page 43                                                  GAO-03-561 Nursing Home Quality
                             finding that state surveyors often missed significant care problems due to
                             weaknesses in the survey process.


State Quality Assurance      We recommended that CMS require states to have a quality assurance
Systems                      process that includes, at a minimum, a review of a sample of survey
                             reports below the level of actual harm to help reduce instances of
                             understated quality-of-care problems. CMS commented on the importance
                             of this concept and noted it had already incorporated such reviews into
                             CMS regional offices’ reviews of the state performance standards.
                             However, the agency did not indicate whether it would require states to
                             initiate an ongoing process that would evaluate the appropriateness of the
                             scope and severity of documented deficiencies, as we recommended.
                             While federal oversight is critical, the annual performance reviews
                             conducted by federal surveyors examine only a small, random sample of
                             state survey reports and should not be considered a substitute for
                             appropriate and ongoing state quality assurance mechanisms. In its
                             comments, New York stated that, in April 2003, it had implemented a
                             process consistent with our recommendation and it had already realized
                             positive results. New York is using the results of these reviews to provide
                             surveyor feedback and expects that instances where deficiencies may be
                             understated will decrease. California also commented that it fully supports
                             this recommendation but indicated that a new requirement could not be
                             implemented without additional resources.


State Resource Constraints   Officials from five states indicated that resource shortages are a challenge
                             in meeting federal standards for oversight of nursing homes. Alabama
                             commented that there is a relationship among (1) the scheduling of
                             nursing home standard surveys, (2) the number and timing of complaint
                             surveys, (3) the tasks that must be accomplished during each survey, and
                             (4) the resources that are available to state agencies. According to
                             Alabama, the funding provided by CMS is insufficient to meet all of the
                             CMS workload demands, and many of the serious problems identified in
                             our draft report were attributable to insufficient funding for state agencies
                             to hire and retain the staff necessary to do the required surveys. For
                             example, Alabama indicated that the inability of some states to meet
                             survey time frames—maintaining a 12-month average between standard
                             surveys and investigating complaints alleging actual harm within 10 days—
                             is almost always the result of states not having enough surveyors to
                             accomplish the required workload.




                             Page 44                                       GAO-03-561 Nursing Home Quality
                            Comments from other states echoed Alabama’s concerns about the
                            adequacy of funding provided by CMS. Arizona said that, in order to hire
                            and retain qualified surveyors, it increased surveyor salaries in 2001.
                            Because CMS did not increase the state’s survey and certification budget
                            to accommodate these increases, the state left surveyor positions unfilled
                            and curtailed training to make up for the funding shortfall. Arizona also
                            observed that CMS’s priorities sometimes conflict, further complicating
                            effective resource use. CMS’s performance standards require states to
                            investigate all complaints alleging immediate jeopardy or actual harm in 2
                            and 10 days, respectively. For budgeting purposes, however, CMS ranks
                            complaint investigations as a lower priority than annual surveys and
                            instructs states to ensure that annual surveys will be completed before
                            beginning work on complaints. California and Connecticut officials said
                            that the growing volume of complaints in their states, combined with
                            limited resources, is a concern. California officials observed that the
                            growth in the number of complaints, coupled with the lack of significant
                            funding increase from CMS, has made it impossible to meet all federal and
                            state standards. They added that they received a 3-percent increase in
                            survey funding from fiscal years 2000 through 2003, but documented the
                            need for a 24-percent increase over this period. As noted in our draft
                            report, the higher priority California attaches to investigating complaints
                            affected survey timeliness—about 12 percent of the state’s homes were
                            not surveyed within the required 15 months. Connecticut indicated that 90
                            percent of the complaints it receives allege actual harm and require
                            investigation within 10 days, but that with fairly stagnant budget
                            allocations from CMS, its ability to initiate investigations of so many
                            complaints within 10 days was limited. CMS’s fiscal year 2001 state
                            performance review found that Connecticut did not investigate about 30
                            percent of the sampled actual harm complaints in a timely manner.
                            Although not specifically mentioning resources, New York noted that the
                            increasing volume of complaints was a concern and indicated that any
                            assistance CMS could provide would be welcome.


Definition of Actual Harm   Comments from four states on our analysis of a sample of survey
                            deficiencies from homes with a history of harming residents revealed state
                            confusion about CMS’s definition of actual harm and immediate jeopardy,
                            a situation that contributes to the variability in state deficiency trends
                            shown in table 2. CMS’s written comments did not address our review of
                            these deficiencies; however, during an interview to follow up on state
                            comments, CMS officials told us that they agreed with our determinations
                            of actual harm as detailed in appendix III.



                            Page 45                                      GAO-03-561 Nursing Home Quality
Arizona and California agreed that some of the deficiencies we reviewed
for nursing homes in their states should have been cited at the level of
actual harm. However, their disagreement regarding others stemmed from
differing interpretations of CMS guidance, particularly the language on the
extent of the consequences to a resident resulting from a deficiency.56 For
example, Arizona stated that one of the two deficiencies we reviewed
could not be supported at the actual harm level because the injuries from
multiple falls—including skin tears and lacerations of the extremities and
head requiring suturing—did not compromise the residents’ ability to
function at their highest optimal level (table 8, Arizona 3). In these cases, it
was documented that nursing home staff had failed to implement plans of
care intended to prevent such falls. In contrast, California agreed with us
that state surveyors should have cited actual harm for similar injuries
resulting from falls—head lacerations and a minimal impaction fracture of
the hip—due to the inappropriate use of bed side rails (table 8, California
9). CMS officials noted that the definition of actual harm uses the term
“well-being” rather than function because harm can be psychological as
well as physical. Moreover, they indicated that whether the consequence
was small or large was irrelevant to determining harm. CMS central office
officials acknowledged that the language linking actual harm to practices
that have “limited consequences” for a resident has created confusion for
state surveyors and that this reference will be eliminated in an upcoming
revision of the guidance.

Regarding preventable stage II pressure sores, California stated that
guidance received from CMS’s San Francisco regional office in November
2000 precluded citing actual harm unless the pressure sores had an impact
on residents’ ability to function.57 According to a California official, this
and similar guidance on weight loss was the CMS regional office’s reaction
to the growing volume of appeals by nursing homes of actual harm




56
 CMS guidance to states in the Medicare State Operations Manual defines actual harm as
“noncompliance that results in a negative outcome that has compromised the resident’s
ability to maintain and/or reach his/her highest practicable physical, mental and
psychosocial well-being as defined by an accurate and comprehensive resident assessment,
plan of care, and provision of services. This does not include a deficient practice that only
could or has caused limited consequence to the resident.”
57
  Stages of pressure sore formation are I—skin of involved area is reddened; II—upper
layer of skin is involved and blistered or abraded; III—skin has an open sore and involves
all layers of skin down to underlying connective tissue; and IV—tissue surrounding the sore
has died and may extend to muscle and bone and involve infection.




Page 46                                                 GAO-03-561 Nursing Home Quality
citations as well as a reaction to administrative law hearing decisions.58
Prior to this written guidance, which California received in late 2000, it
routinely cited preventable stage II pressure sores as actual harm. The
guidance noted that small stage II pressure sores seldom cause actual
harm because they have the potential to heal relatively quickly and are
usually of limited consequence to the resident’s ability to function. We
discussed the San Francisco regional office guidance with another
regional office as well as with CMS central office officials, who agreed that
the San Francisco region’s pressure sore guidance was inconsistent with
CMS’s definition of harm, which judges the impact of a deficiency on a
resident’s “well-being” rather than functioning. Moreover, central office
officials indicated that the regional office’s guidance should have been
submitted to CMS’s Policy Clearinghouse for approval. This entity was
created in June 2000 to ensure that regional directives to states are
consistent with national policy. San Francisco regional office officials
indicated that the individual responsible for the guidance provided to
California had since left the agency.

California also disagreed with our assessment that state surveyors should
have cited immediate jeopardy for a resident who repeatedly wandered
(eloped) outside the facility near a busy intersection. According to state
officials, California’s policy on immediate jeopardy requires the surveyor
to witness the incident. A San Francisco regional office official told us that
surveyors did not have to witness an elopement to cite immediate
jeopardy. An official from a different regional office agreed and noted that
repeated elopements suggested the existence of a systemic problem that
warranted citation of immediate jeopardy.

Although Iowa and Nebraska did not comment specifically on the
deficiencies in their surveys that we determined to be actual harm, they
did address the definition of harm and the role of surveyor judgment in
classifying deficiencies. Iowa officials indicated that a more precise
definition of harm is needed because of varying emphasis over the last
several years on the degree of harm—harm that has a small consequence
for the resident or serious harm. Nebraska commented that we may have
based our conclusion that two deficiencies in its surveys should have been
cited at the actual harm level on insufficient information because citing



58
 Nursing homes can appeal civil money penalties imposed by CMS when they are found to
have serious deficiencies. The appeals are decided by the Department of Health and
Human Service’s Departmental Appeals Board.




Page 47                                             GAO-03-561 Nursing Home Quality
                        actual harm is a judgment call that varies among state and federal
                        surveyors based on experience and expertise. As noted in our draft report,
                        we found sufficient evidence in the surveys we reviewed to conclude that
                        some deficiencies should have been cited as actual harm because a
                        deficient practice was identified and linked to documented actual harm.


Survey Predictability   CMS, Arizona, and Iowa commented that nursing home surveys, as
                        currently structured, are inherently predictable because of the statutory
                        requirement to survey nursing homes on average every 12 months with a
                        maximum interval of 15 months between each home’s survey. We agree
                        but believe that survey predictability could be further mitigated by
                        segmenting the surveys into more than one visit, a recommendation we
                        made in 1998 but that CMS has not implemented.59 Currently, surveys are
                        comprehensive reviews that can last several days and entail examining not
                        only a home’s compliance with resident care standards but also with
                        administrative and housekeeping standards. Dividing the survey into
                        segments performed over several visits, particularly for those homes with
                        a history of serious deficiencies, would increase the presence of surveyors
                        in these homes and provide an opportunity for surveyors to initiate
                        broader reviews when warranted. With a segmented set of inspections,
                        homes would be less able to predict their next scheduled visit and adjust
                        the care they provide in anticipation of such visits.

                        CMS also commented that our report captures only the number of days
                        since the prior survey and does not take into account other predictors, for
                        example the time of day or day of the week. Rather than segmenting
                        standard surveys as we earlier recommended, the agency instructed states
                        to reduce survey predictability by starting at least 10 percent of surveys
                        outside the normal workday—either on weekends, in the early morning, or
                        in the evening. It also instructed states to avoid, if possible, scheduling a
                        home’s survey for the same month as its previous standard survey. Though
                        varying the starting time of surveys may be beneficial, this initiative is too
                        limited in reducing survey predictability, as evidenced by our finding that
                        34 percent of current surveys were predictable. Arizona commented that it
                        was unaware of any CMS guidance to avoid scheduling a home’s survey
                        for the same month of the year as the home’s previous standard survey




                        59
                         U.S. General Accounting Office, California Nursing Homes: Care Problems Persist
                        Despite Federal and State Oversight, GAO/HEHS-98-202 (Washington, D.C.: July 27, 1998).




                        Page 48                                              GAO-03-561 Nursing Home Quality
and indicated the state will now incorporate the requirement into its
scheduling process.

Comments from CMS and Arizona stated that the window of time for a
survey to be unpredictable was limited and, as a result, little could be done
to reduce predictability. CMS’s technical comments noted that many states
have annual state licensing inspection requirements that would limit the
window available to conduct surveys to 9 to 12 months after the prior
survey, particularly since most inspections are done in conjunction with
the federal survey to maximize available resources. CMS, however, was
unable to provide a list of such states. None of the 10 states we
subsequently contacted had state licensure inspection requirements that
would explain their high levels of survey predictability.60 Arizona
commented that the state’s licensing inspections are triggered by facilities
applying to renew their licenses 60-120 days before their annual license
expires. Due to budgetary constraints, Arizona conducts both this state
and the federal survey at the same time. While not a requirement, the state
strives to complete surveys during this 60-120 day period of time. Thus,
nursing homes in Arizona may have some level of control over when
federal surveys are conducted, particularly when the state begins
complying with CMS guidance to avoid scheduling a home’s survey for the
same month as its previous survey. As we reported in September 2000,
Tennessee also had an annual licensing inspection requirement that
contributed to survey predictability, but the state modified its law to
permit homes to be surveyed at a maximum interval of 15 months.61 Since
then, the proportion of predictable surveys in Tennessee decreased from
about 56 percent to 29 percent. Arizona also stated that surveys had to be
conducted within a 45-day window after the 1-year anniversary of the prior
survey to be considered unpredictable.62 Arizona’s comments erroneously
assume that a survey cannot take place before the 1-year anniversary of
the prior survey. There is no prohibition on resurveying a home prior to
the 1-year anniversary of its last survey, and many states do so. In fact,


60
 We contacted 10 states that were included in our review and that had a significant
percentage of predictable surveys—Alabama, California, Connecticut, Maryland, Nebraska,
New York, Oklahoma, Tennessee, Virginia, and Washington. As shown in table 10 (see app.
V), the proportion of predictable surveys in these states ranged from 29 percent to 83
percent.
61
 See GAO/HEHS-00-197.
62
 We considered surveys to be predictable if (1) homes were surveyed within 15 days of the
1-year anniversary of their prior surveys or (2) homes were surveyed within 1 month of the
maximum 15-month interval between standard surveys.




Page 49                                               GAO-03-561 Nursing Home Quality
from October 1, 2000 through September 30, 2001, Arizona conducted 23
percent of its surveys before the 1-year anniversary.

CMS provided several technical comments that we incorporated as
appropriate.


As arranged with your offices, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days after its
issue date. At that time, we will send copies of this report to the
Administrator of the Centers for Medicare & Medicaid Services and
appropriate congressional committees. We also will make copies available
to others upon request. In addition, the report will be available at no
charge on the GAO Web site at http://www.gao.gov.

Please contact me at (202) 512-7118 or Walter Ochinko, Assistant Director
at (202) 512-7157 if you or your staffs have any questions. GAO staff
acknowledgments are listed in appendix XI.




Kathryn G. Allen
Director, Health Care—Medicaid
 and Private Health Insurance Issues




Page 50                                         GAO-03-561 Nursing Home Quality
             Appendix I: Scope and Methodology
Appendix I: Scope and Methodology


             This appendix describes our scope and methodology following the order
             that findings appear in the report.

             Nursing home deficiency trends. To identify trends in the proportion of
             nursing homes cited for actual harm or immediate jeopardy, we analyzed
             data from CMS’s OSCAR system. We compared standard survey results for
             three approximately 18-month periods: (1) January 1, 1997, through June
             30, 1998, (2) January 1, 1999, through July 10, 2000, and (3) July 11, 2000,
             through January 31, 2002. Because surveys are to be conducted at least
             once every 15 months (with a required 12-month state average), it is
             possible that a facility was surveyed more than once in a time period. To
             avoid double counting of facilities, we included only the most recent
             survey of a facility from each of the time periods. The data from the two
             earliest time periods were included in our September 2000 report.1 We
             updated our earlier analysis of surveys conducted from January 1, 1999,
             through July 10, 2000, because it excluded approximately 300 surveys that
             had been conducted but not entered into OSCAR at the time we conducted
             our analysis in July 2000.

             Sample of state survey reports. To assess the trends in actual harm and
             immediate jeopardy deficiencies discussed above, we (1) identified 14
             states in which the percentage of homes cited for actual harm had
             declined to below the national average since mid-2000 or was consistently
             below that average and (2) reviewed 76 survey reports from homes that
             had G-level or higher quality-of-care deficiencies on prior surveys but
             whose current survey had quality-of-care deficiencies at the D or E level,
             suggesting that the homes had improved.2 All the surveys we reviewed
             were conducted from July 2000 through April 2002. Our review focused on
             four quality-of-care requirements that are the most frequently cited nursing
             home deficiencies nationwide (see table 6). According to OSCAR data, 99
             surveys in the 14 states conducted on or after July 2000 documented a D-
             or E-level deficiency in at least one of these four quality-of-care
             requirements. We reviewed all such deficiencies in surveys from 13 states
             but randomly selected 22 surveys from California, which cited the majority
             (45) of these deficiencies. In reviewing the surveys, we looked for a
             description of the resident’s diagnoses, any assessment of special
             problems, and a description of the care plan and physician orders


             1
              GAO/HEHS-00-197.
             2
             The 14 states are Alabama, Arizona, California, Iowa, Maryland, Minnesota, Mississippi,
             Missouri, Nebraska, Pennsylvania, South Carolina, Virginia, West Virginia, and Wisconsin.




             Page 51                                                GAO-03-561 Nursing Home Quality
Appendix I: Scope and Methodology




connected with the deficiency identified. We also looked for a clear
statement of the home’s deficient practice and the relationship between
the deficiency and the care outcome.

Table 6: Quality of Care Requirements Reviewed in a Sample of State Survey
Reports

    Nursing home quality
    of care requirements              Description
    Necessary care and                Facility must provide the necessary care and services for
    services                          each resident to attain or maintain the highest practicable
                                      well-being.
    Pressure sores                    Facility must ensure residents entering facility without
                                      pressure sores do not develop sores, unless the individual’s
                                      clinical condition indicates the pressure sores were
                                      unavoidable, and that residents with sores receive necessary
                                      treatment to promote healing, prevent infection, and prevent
                                      new sores.
    Prevention of accidents           Facility must ensure each resident receives adequate
                                      supervision and assistance devices to prevent accidents.
    Maintenance of nutrition          Facility must ensure each resident maintains acceptable
                                      parameters of nutritional status, such as body weight.
Source: CMS’s Medicare State Operations Manual.



Federal comparative surveys. In September 2000, we reported on the
results of 157 comparative surveys completed from October 1998 through
May 2000.3 To update our analysis, we asked each CMS region to provide
the results of more recent comparative surveys, including data on the
corresponding state survey. The regions identified and provided
information on the deficiencies identified in 277 comparative surveys that
were completed from June 2000 through February 2002.4

Survey predictability. In order to determine the predictability of nursing
home surveys, we analyzed data from CMS’s OSCAR database. We
considered surveys to be predictable if (1) homes were surveyed within 15
days of the 1-year anniversary of their prior survey or (2) homes were
surveyed within 1 month of the maximum 15-month interval between
standard surveys. Consistent with CMS’s interpretation, we used 15.9
months as the maximum allowable interval between surveys. Because
homes know the maximum allowable interval between surveys, those



3
See GAO/HEHS-00-197.
4
One of the comparative surveys in our updated analysis was completed in May 2000.




Page 52                                                         GAO-03-561 Nursing Home Quality
Appendix I: Scope and Methodology




whose prior surveys were conducted 14 or 15 months earlier are aware
that they are likely to be surveyed soon.

Complaints. We analyzed the results of CMS’s state performance review
for fiscal year 2001 to determine states’ success in investigating both
immediate jeopardy complaints and actual harm complaints within time
frames required either by statute or by CMS instructions. To better
understand the results of state performance as determined by CMS’s
review, we interviewed officials from CMS’s 10 regional offices and 16
state survey agencies (see state performance standards below for a
description of how these states were chosen).5 We also reviewed the
report submitted to CMS by its contractor, which was intended to assess
and recommend ways to strengthen state complaint practices.6 Finally, to
assess the implementation of CMS’s new automated system for tracking
information about complaints, we reviewed CMS guidance materials and
interviewed CMS officials and state survey agency officials from our 16
sample states.

Enforcement. To determine if states had consistently applied the
expanded immediate sanction policy, we analyzed state surveys in OSCAR
that were conducted before April 9, 2002, and identified homes that met
the criteria for referral for immediate sanction. We included surveys
conducted prior to the implementation of the expanded immediate
sanction policy because actual harm deficiencies identified in such
surveys were to be considered by states in recommending a home for
immediate sanction beginning in January 2000. To be affected by CMS’s
expanded policy, a home with actual harm on two surveys must have an
intervening period of compliance between the two surveys. Because
OSCAR is not structured to consistently record the date a home with
deficiencies returned to compliance, we had to estimate compliance dates
using revisit dates as a proxy. We compared the results of our analysis to
CMS’s enforcement database to determine if CMS had opened
enforcement cases for the homes we identified. Our analysis compared the
survey date in OSCAR to the survey date in CMS’s enforcement database.
We considered any survey date in the enforcement database within 30
days of the OSCAR survey date to be a match. CMS officials reviewed and


5
We contacted officials in Alabama, California, Colorado, Connecticut, Iowa, Louisiana,
Maryland, Michigan, Missouri, Nebraska, New York, Oklahoma, Pennsylvania, Tennessee,
Washington, and Virginia.
6
Center for Health Systems Research and Analysis at the University of Wisconsin, Madison.




Page 53                                              GAO-03-561 Nursing Home Quality
Appendix I: Scope and Methodology




concurred with our methodology. We then asked CMS to analyze the
resulting 1,334 unmatched cases to determine if a referral should have
been made.7

State performance standards. To assess state survey activities as well as
federal oversight of state performance, we analyzed the conduct and
results of fiscal year 2001 state survey agency performance reviews during
which the CMS regional offices determined compliance with seven federal
standards; we focused on the five standards related to statutory survey
intervals, deficiency documentation, complaint activities, enforcement
requirements, and OSCAR data entry. Because some regional office
summary reports on the results of their reviews for each state did not
provide detailed information about the results, we also obtained and
reviewed regions’ worksheets on which the summary reports were based.
In addition, we conducted structured interviews with officials from CMS,
CMS’s 10 regional offices, and 16 state survey agencies to discuss nursing
home deficiency trends, the underlying causes of problems identified
during the performance reviews, and state and federal efforts to address
these problems. We also discussed these issues with officials from 10
additional states during a governing board meeting of the Association of
Health Facility Survey Agencies. We selected the 16 states with the goal of
including states that (1) were from diverse geographic areas, (2) had
shown either an increase or a decrease in the percentage of homes cited
for actual harm, (3) had been contacted in our prior work, and (4)
represented a mixture of results from federal performance reviews of state
survey activities. We also obtained data from 42 state survey agencies on
surveyor experience, vacancies, and related staffing issues.




7
 CMS determined that for 438 of the 1,334 cases we asked it to examine, the state had
indeed made a referral to CMS. In some of these 438 instances, there was no corresponding
case in the enforcement database because OSCAR had a different survey date. The “survey
date” variable in OSCAR is the latter of the health survey date and the life-safety code
survey, while the corresponding date in the enforcement database is usually the health
survey date. For others, an enforcement case was already open for the home at the time of
the referral, and CMS officials did not open an additional case. There was also a small
number of cases where the state agency referred the home for immediate sanction, and
CMS chose not to accept the state’s recommendation. States failed to refer 711 cases that
met CMS criteria for immediate referral. In addition, CMS did not analyze 155 other cases
and was unable to determine the status of 30 cases.




Page 54                                               GAO-03-561 Nursing Home Quality
              Appendix II: Trends in The Proportion of
Appendix II: Trends in The Proportion of
              Nursing Homes Cited for Actual Harm or
              Immediate Jeopardy Deficiencies, 1997-2002


Nursing Homes Cited for Actual Harm or
Immediate Jeopardy Deficiencies, 1997-2002
              Nationwide, the proportion of nursing homes cited for actual harm or
              immediate jeopardy during state standard surveys declined from 29
              percent in mid-2000 to 20 percent in January 2002. From July 2000 through
              January 2002, 40 states cited a smaller percentage of homes with such
              serious deficiencies while only 9 states and the District of Columbia cited
              a larger proportion of homes with such deficiencies.1 In contrast, from
              early 1997 through mid-2000, the percentage of homes cited for such
              serious deficiencies was either relatively stable or increased in 31 states.

              To identify these trends, we analyzed data from CMS’s OSCAR system. We
              compared results for three approximately 18-month periods: (1) January 1,
              1997, through June 30, 1998, (2) January 1, 1999, through July 10, 2000, and
              (3) July 11, 2000, through January 31, 2002 (see table 7). Because surveys
              are to be conducted at least once every 15 months (with a required 12-
              month state average), it is possible that a facility was surveyed more than
              once in a time period. To avoid double counting of facilities, we included
              only the most recent survey from each of the time periods. Some of the
              data in table 7 were included in our September 2000 report.2 However, we
              updated our analysis of surveys conducted from January 1, 1999, through
              July 10, 2000, because it excluded approximately 300 surveys that had
              been conducted but not entered into OSCAR at the time we conducted our
              analysis in July 2000.




              1
               The proportion of nursing homes in Utah cited with serious deficiencies remained the
              same between the two time periods.
              2
              GAO/HEHS-00-197.




              Page 55                                               GAO-03-561 Nursing Home Quality
                                         Appendix II: Trends in The Proportion of
                                         Nursing Homes Cited for Actual Harm or
                                         Immediate Jeopardy Deficiencies, 1997-2002




Table 7: Trends in the Percentage of Nursing Homes Cited for Actual Harm or Immediate Jeopardy during State Standard
Surveys, by State

                                                               Percentage of homes cited for
                                                                 actual harm or immediate
                                                                                                                                  a
                           Number of homes surveyed                      jeopardy                     Percentage point difference
                                                                                                      1/97-6/98 and 1/99-7/00 and
State                    1/97-6/98   1/99-7/00     7/00-1/02   1/97-6/98   1/99-7/00   7/00-1/02          1/99-7/00      7/00-1/02
Alabama                        227         225           228        51.1        42.2        18.4                -8.9          -23.8
Alaska                          16          15            15        37.5        20.0        33.3               -17.5           13.3
Arizona                        163         142           147        17.2        33.8         8.8                16.6          -25.0
Arkansas                       285         273           267        14.7        37.7        27.3                23.0          -10.4
California                   1,435       1,400         1,348        28.2        29.1         9.3                 0.9          -19.9
Colorado                       234         227           225        11.1        15.4        26.2                 4.3           10.8
Connecticut                    263         262           259        52.9        48.5        49.4                -4.4            0.9
Delaware                        44          42            42        45.5        52.4        14.3                 6.9          -38.1
District of Columbia            24          20            21        12.5        10.0        33.3                -2.5           23.3
Florida                        730         753           742        36.3        20.8        20.1               -15.5           -0.8
Georgia                        371         368           370        17.8        22.6        20.5                 4.8           -2.0
Hawaii                          45          47            46        24.4        25.5        15.2                 1.1          -10.3
Idaho                           86          83            84        55.8        54.2        31.0                -1.6          -23.3
Illinois                       899         900           881        29.8        29.3        15.4                -0.5          -13.9
Indiana                        602         590           573        40.5        45.3        26.2                 4.8          -19.1
Iowa                           525         492           494        39.2        19.3         9.9               -19.9           -9.4
Kansas                         445         410           400        47.0        37.1        29.0                -9.9           -8.1
Kentucky                       318         312           306        28.6        28.8        25.2                 0.2           -3.7
Louisiana                      433         387           367        12.7        19.9        23.4                 7.2            3.5
Maine                          135         126           124         7.4        10.3         9.7                 2.9           -0.6
Maryland                       258         242           248        19.0        25.6        20.2                 6.6           -5.5
Massachusetts                  576         542           512        24.0        33.0        22.9                 9.0          -10.2
Michigan                       451         449           441        43.7        42.1        24.7                -1.6          -17.4
Minnesota                      446         439           431        29.6        31.7        18.8                 2.1          -12.9
Mississippi                    218         202           219        24.8        33.2        19.6                 8.4          -13.5
Missouri                       595         584           569        21.0        22.3        10.2                 1.3          -12.1
Montana                        106         104           103        38.7        37.5        25.2                -1.2          -12.3
Nebraska                       263         242           243        32.3        26.0        18.9                -6.3           -7.1
Nevada                          49          52            51        40.8        32.7         9.8                -8.1          -22.9
New Hampshire                   86          83            79        30.2        37.3        21.5                 7.1          -15.8
New Jersey                     377         359           366        13.0        24.5        22.4                11.5           -2.1
New Mexico                      88          82            82        11.4        31.7        17.1                20.3          -14.6
New York                       662         668           671        13.3        32.2        32.3                18.9            0.2
North Carolina                 407         414           419        31.0        40.8        30.1                 9.8          -10.7
North Dakota                    88          89            88        55.7        21.3        28.4               -34.4            7.1
Ohio                         1,043       1,047         1,029        31.2        29.0        23.7                -2.2           -5.3
Oklahoma                       463         432           394         8.4        16.7        20.6                 8.3            3.9
Oregon                         171         158           152        43.9        47.5        33.6                 3.6          -13.9




                                         Page 56                                                   GAO-03-561 Nursing Home Quality
                                                              Appendix II: Trends in The Proportion of
                                                              Nursing Homes Cited for Actual Harm or
                                                              Immediate Jeopardy Deficiencies, 1997-2002




                                                                                    Percentage of homes cited for
                                                                                      actual harm or immediate
                                                                                                                                                        a
                                          Number of homes surveyed                            jeopardy                      Percentage point difference
                                                                                                                            1/97-6/98 and 1/99-7/00 and
 State                                 1/97-6/98          1/99-7/00     7/00-1/02   1/97-6/98   1/99-7/00    7/00-1/02          1/99-7/00      7/00-1/02
 Pennsylvania                                811                788           764        29.3        32.2         11.6                 2.9          -20.6
 Rhode Island                                102                 99            99        11.8        12.1         10.1                 0.3           -2.0
 South Carolina                              175                178           180        28.6        28.7         17.8                 0.1          -10.9
 South Dakota                                124                112           114        40.3        24.1         30.7               -16.2            6.6
 Tennessee                                   361                354           377        11.1        26.0         16.7                14.9           -9.3
 Texas                                     1,381              1,336         1,275        22.2        26.9         25.5                 4.7           -1.5
 Utah                                         98                 95            95        15.3        15.8         15.8                 0.5            0.0
 Vermont                                      45                 46            45        20.0        15.2         17.8                -4.8            2.6
 Virginia                                    279                287           285        24.7        19.9         11.6                -4.8           -8.3
 Washington                                  288                279           275        63.2        54.1         38.5                -9.1          -15.6
 West Virginia                               130                147           143        12.3        15.6         14.0                 3.3           -1.7
 Wisconsin                                   438                428           421        17.1        14.0          7.1                -3.1           -6.9
 Wyoming                                      38                 41            40        28.9        43.9         22.5                15.0          -21.4
 Nation                                   17,897             17,452        17,149        27.7        29.3         20.5                 1.6           -8.8
Source: GAO analysis of OSCAR data as of June 24, 2002.
                                                              a
                                                              Differences are based on numbers before rounding.




                                                              Page 57                                                    GAO-03-561 Nursing Home Quality
              Appendix III: Abstracts of Nursing Home
Appendix III: Abstracts of Nursing Home
              Survey Reports That Understated Quality-of-
              Care Problems


Survey Reports That Understated Quality-of-
Care Problems
              Our analysis of a sample of 76 nursing home survey reports demonstrated
              a substantial understatement of quality-of-care problems. Our sample was
              selected from 14 states in which the percentage of homes cited for actual
              harm had declined to below the national average since mid-2000 or was
              consistently below that average. We identified survey reports in these
              states from homes that had G-level or higher quality-of-care deficiencies
              (see table 1) on prior surveys but whose current survey had quality-of-care
              deficiencies at the D or E level, suggesting that the homes had improved.
              All the surveys we reviewed were conducted from July 2000 through April
              2002. Our review focused on four quality-of-care requirements that are the
              most frequently cited nursing home deficiencies nationwide (see table 6).1

              In our judgment, 30 of the 76 surveys (39 percent) from 9 of the 14 states
              had one or more deficiencies that documented actual harm to residents—
              G-level deficiencies—and 1 survey contained a deficiency that could have
              been cited at the immediate jeopardy level. While state surveyors
              classified these deficiencies as less severe, we believe that the survey
              reports document that poor care provided to and injuries sustained by
              these residents constituted at least actual harm. Table 8 provides abstracts
              of the 39 deficiencies that understated quality problems.




              1
               According to OSCAR data, 99 surveys in the 14 states conducted on or after July 2000
              documented a D- or E-level deficiency in at least one of the quality-of-care requirements we
              selected. We reviewed all such deficiencies in surveys from 13 states but randomly selected
              22 of the 45 California surveys. The 14 states are Alabama, Arizona, California, Iowa,
              Maryland, Minnesota, Mississippi, Missouri, Nebraska, Pennsylvania, South Carolina,
              Virginia, West Virginia, and Wisconsin.




              Page 58                                                GAO-03-561 Nursing Home Quality
                                          Appendix III: Abstracts of Nursing Home
                                          Survey Reports That Understated Quality-of-
                                          Care Problems




Table 8: Abstracts of the 39 Nursing Home Deficiencies that Understated Actual Harm from a Sample of 76 Nursing Home
Survey Reports

                 Requirement and
State and date   scope and            Resident description and       Actual harm to resident             Deficiencies in care cited by
         a                                                   b
of survey        severity cited       relevant diagnoses             documented by surveyor              surveyor
Alabama-1        Provide necessary    Resident admitted to           Site of gastrostomy tube            Facility failed to provide proper
November 2001    care and services:   facility 5/15/01with a         insertion became reddened           care and services: daily
                 D                    fractured hip; a               with thick yellow-green             cleaning and application of a
                                      gastrostomy tube was           drainage, and had an odor,          drain sponge around the
                                      inserted through the           indicating signs of infection, on   gastrostomy tube.
                                      abdomen into the stomach       11/7/01.                            Family indicated no one
                                      to maintain feeding. On                                            changed the dressing. There is
                                      10/9/01, resident was                                              no documentation to show
                                      hospitalized for abdominal                                         resident’s gastrostomy tube
                                      pain and signs of infection                                        site was cleansed as ordered
                                      related to the gastrostomy                                         12 out of 16 opportunities.
                                      tube. On return to facility,
                                      physician orders state,
                                      “clean G tube site with
                                      soap and water, apply a
                                      drain sponge.”
Alabama-5        Provide              Resident 1 admitted to         Resident 1 sustained four skin      The facility failed to
March 2001       supervision and      facility 11/6/00 with          tears on right arm and leg and      consistently reassess for
                 devices to prevent   diagnoses of stroke,           multiple bruises to both legs       preventive measures to
                 accidents: D         pressure sores, and            from 1/16/01 to 3/21/01.            address the problem of skin
                                      kidney failure. On                                                 tears and bruises for both
                                      11/16/00, resident was                                             residents. Staff were unable to
                                      noted to have abrasions                                            provide documentation of
                                      and bruises.                                                       preventive interventions.


                                      Resident 2 was admitted       Resident 2 sustained seven
                                      to the facility 11/23/98 with skin tears and bruises to legs
                                      anemia, depression,           from 12/29/99 to 10/9/00.
                                      urinary incontinence, and
                                      a history of falls. She was
                                      identified as having a
                                      problem with skin tears
                                      and bruising.c




                                          Page 59                                                    GAO-03-561 Nursing Home Quality
                                          Appendix III: Abstracts of Nursing Home
                                          Survey Reports That Understated Quality-of-
                                          Care Problems




                 Requirement and
State and date   scope and            Resident description and         Actual harm to resident          Deficiencies in care cited by
          a                                                 b
of survey        severity cited       relevant diagnoses               documented by surveyor           surveyor
Arizona-3        Ensure prevention    Resident admitted to             On 7/5/00, it was noted that the The necessary services and
July 2000        and healing of       facility 08/24/99 with heart     resident had developed a stage   care to promote healing and
                 pressure sores: D    failure, high blood              IV pressure sore.                prevent worsening of existing
                                      pressure, paraplegia, and                                         pressure sore were not
                                      a stage II pressure sore on                                       provided. Even after the
                                      lower back.d Pressure sore                                        pressure sore progressed to
                                      remained a stage II until                                         stage IV and a physician
                                      May 2000, when wound                                              ordered that the resident be
                                      was documented to be a                                            turned every hour, the staff
                                      stage III.                                                        failed to turn the resident as
                                                                                                        directed. Surveyor observed
                                                                                                        resident lying on her back for 2
                                                                                                        or more hours. Resident stated
                                                                                                        that frequently she was turned
                                                                                                        only twice in 8 hours. Charge
                                                                                                        nurse did not know physician
                                                                                                        had ordered resident to be
                                                                                                        turned every hour.
Arizona-3        Ensure adequate      Resident 1 admitted to the       Resident 1 fell four times and   Facility staff failed to
July 2000        supervision to       facility 4/7/00 with             sustained skin tears, abrasions, implement a plan of care that
                 prevent accidents:   diabetes, partial paralysis      and lacerations.                 called for identifying resident
                 D                    of left side, and inability to                                    as a fall risk by placing a star
                                      speak. Resident also had                                          on his door by his name. No
                                      a history of spinal                                               other preventive measures
                                      fractures, and a fall                                             were identified, and surveyor
                                      prevention plan was                                               observed no star next to
                                      developed on 4/15/00.                                             resident’s name outside his
                                                                                                        door.
                                      Resident 2 admitted to the       Resident sustained 12 falls      Although resident was
                                      facility 12/10/97 with           from 2/18 to 7/8/00 with         identified as at risk for falls in a
                                      dementia, painful joints,        lacerations of extremities and   care plan of 4/22/00, the
                                      and visual problems. A           head requiring suturing and      facility staff failed to develop
                                      7/13/00 assessment               with other cuts and bruises.     approaches to prevent falls
                                      indicated resident was                                            even though the resident
                                      cognitively impaired and                                          continued to fall and injure
                                      had a mental function that                                        herself.
                                      varied throughout the day.
                                      She was also identified as
                                      a wanderer.
California-2   Ensure prevention      Resident 1 with leg              Resident 1 developed a             The surveyor found that the
September 2000 and healing of         contractures (permanent          reddened open area .3 cm. in       facility did not identify,
               pressure sores: D      tightening of muscle,            diameter, (stage II pressure       document, or provide
                                      tendons, ligaments, or skin      sore) on left lower back by        intervention to prevent this
                                      that prevents normal             9/23/00.                           facility-acquired pressure sore.
                                      movement) was noted to                                              The reddened area noted was
                                      have a small reddened                                               not documented in the medical
                                      area on left lower back on                                          record 9/20-9/22/00.
                                      9/20/00.




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                                            Survey Reports That Understated Quality-of-
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                   Requirement and
State and date     scope and            Resident description and        Actual harm to resident      Deficiencies in care cited by
         a                                                     b
of survey          severity cited       relevant diagnoses              documented by surveyor       surveyor
                                        Resident 2 was admitted         Resident 2 developed a stage II
                                                                                                     The facility developed a
                                        to facility on 2/2/00. Family   pressure sore.               nursing care plan for
                                        identified resident as                                       prevention of pressure sores
                                        having a “skin problem” on                                   and turning the resident every
                                        9/17/00.                                                     2 hours on 9/8/00. The family
                                                                                                     identified a stage II pressure
                                                                                                     sore on 9/17/00. The surveyor
                                                                                                     found no evidence that the
                                                                                                     care plan was implemented at
                                                                                                     time of survey.
                                    Resident 3 admitted to          Seven days after admission,      The facility failed to prevent a
                                    facility 9/20/00 with           resident 3 was noted to have     rapid decline in resident’s
                                    diagnoses of multiple           four stage II pressure sores on condition and occurrence of
                                    sclerosis, bilateral            right and left shoulder blades   facility-acquired pressure
                                    fractures of the femur, and and right buttock and three          sores. Staff said they were
                                    obesity. Resident was           stage I pressure sores on the    unable to turn resident (a
                                    unable to turn herself in       left buttock.                    larger bed and mattress were
                                    bed; physician                                                   not provided, which would
                                    documented resident had                                          have facilitated turning). No
                                    no areas of skin                                                 pressure-relieving devices and
                                    breakdown and ordered                                            staff assistance in getting out
                                    resident to be up in a                                           of bed were provided. In the 7
                                    wheel chair two to three                                         days after admission, the
                                    times a day.                                                     resident was out of bed only
                                                                                                     once, at which time the
                                                                                                     pressure sores were
                                                                                                     discovered.
California-2   Maintain nutritional Resident admitted to            Resident’s weight was recorded Facility failed to provide a
September 2000 status: D            facility 7/7/00 with a          as 77 pounds 1 month after       comprehensive nutritional
                                    diagnosis of failure to         admission. Resident sustained assessment to meet resident’s
                                    thrive and a recorded           a severe loss of 12 pounds (13 nutritional needs in order to
                                    weight of 89 pounds.            percent) between July and        maintain body weight.
                                                                    August.
California-5   Provide              Resident was identified as Resident fell while walking           Facility failed to develop and
February 2001  supervision and      at high risk for falls in 5/00. unassisted on 6/21/00 and        implement a fall prevention
               devices to prevent                                   again on 2/22/01, fracturing his plan when resident was
               accidents: D                                         right hip each time.             identified as being a high risk
                                                                                                     for falls and after the first hip
                                                                                                     fracture.




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                                           Survey Reports That Understated Quality-of-
                                           Care Problems




                 Requirement and
State and date   scope and             Resident description and        Actual harm to resident           Deficiencies in care cited by
           a                                                   b
of survey        severity cited        relevant diagnoses              documented by surveyor            surveyor
California-6     Provide               Resident admitted to            Resident wandered to an area      Facility failed to provide
May 2001         supervision and       facility on 2/12/01with         100 yards from facility near two  supervision and devices to
                 devices to prevent    dizziness, fainting, poor       busy intersections on 3/26/01     prevent accidents even after
                 accidents: D          vision, and cognitive           and again on 5/19/01.             resident was found wandering
                                       impairment. Care plan of                                          outside the facility on 2/20/01.
                                       2/20/01 identified resident     According to CMS, the failure of The facility did not immediately
                                       as a wanderer and at risk       a facility to provide supervision implement procedures cited in
                                       for falls. Interventions        of a cognitively impaired         the care plan to supervise the
                                       suggested were visual           individual with known risk for    resident and prevent accidents
                                       checks every 2 hours and        wandering is considered failure and wandering, nor did the
                                       involvement of resident in      to prevent neglect and places     facility implement existing
                                       facility activities. On         the resident in immediate         facility policies to prevent
                                       2/20/01 at 9:30 pm              jeopardy for death or serious     wandering and injury.
                                       resident was found              injury during such an incident.
                                       wandering outside on the
                                       patio and had fallen and
                                       sustained abrasions.
California-8     Ensure prevention     Resident admitted to            Resident sustained a facility-      Facility failed to ensure
June 2001        and healing of        facility in 1996 with stroke,   acquired stage IV pressure          necessary treatment and
                 pressure sores: D     paralysis of lower right        sore of the right ankle             service to promote healing and
                                       side, and senile dementia.      measuring 7 cm. by 5 cm.            prevent infection of the
                                       Physician orders of 4/5/01                                          pressure sore. Surveyor
                                       called for an air mattress.                                         observed on 6/20 and 6/21/01
                                       Assessment of 4/24/01                                               that there was no air mattress
                                       noted resident had a stage                                          on resident’s bed and on
                                       IV pressure sore on the                                             6/20/01 that inappropriate
                                       right outer ankle. On                                               technique was used in
                                       5/17/01, physician ordered                                          changing the dressing on the
                                       cleansing of the wound                                              resident’s ankle.
                                       with saline and an anti-
                                       infective solution, dressing
                                       it with soft protective
                                       gauze.
California-8     Ensure                Resident admitted to            Resident weighed 98.4 lbs and       Facility failed to ensure that
June 2001        maintenance of        facility in 1990 with a         experienced a severe weight         the resident maintained
                 nutritional status:   diagnosis of stroke and         loss of 13 pounds (12 percent)      adequate nutrition. It did not
                 D                     inability to speak. A 3/7/01    in 3 months.                        monitor the amount of
                                       assessment noted erosive                                            nutritional supplements
                                       gastritis, anemia, and                                              consumed by the resident and
                                       weight of 111 lbs. The                                              inconsistently recorded
                                       county was the                                                      weights, often without
                                       conservator and requested                                           associated dates. It did not
                                       maximum treatment.                                                  notify the physician of the
                                       Resident was placed on                                              resident’s weight loss.
                                       an enriched pureed diet
                                       with supplemental
                                       feedings three times daily.




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                 Requirement and
State and date   scope and            Resident description and        Actual harm to resident             Deficiencies in care cited by
           a                                                 b
of survey        severity cited       relevant diagnoses              documented by surveyor              surveyor
California-9     Provide              Resident 1, 48 years old,       Resident fell when trying to        The facility failed to supervise
December 2000    supervision and      admitted to facility after a    climb over side rails, sustaining   the resident and prevent
                 devices to prevent   stroke with incontinence,       a laceration to his head.           accidents from occurring: staff
                             e,f
                 accidents: B         inability to speak, right-                                          failed to accurately assess
                                      side paralysis, and                                                 resident’s safety needs and
                                      functional use of his left                                          inappropriately assumed
                                      side. Resident                                                      resident needed full side rails
                                      communicated by signs                                               on the bed.
                                      and sounds.

                                      Resident 2 had a history of     On 3/29/00, resident climbed        The facility failed to provide
                                      a right hip fracture, chronic   over the bed side rails and was     supervision and appropriate
                                      weakness in both legs,          found on the floor at the foot of   interventions to prevent this
                                      and dementia. Resident          his bed with both side rails in     resident’s fall. According to the
                                      had a physician’s order         the up position. Seven hours        surveyor, there were no orders
                                      (9/16/99) for soft belt         later, an x ray was taken and       for restraints in bed and no
                                      restraints when in              found that resident had a           indication that all reasonable
                                      wheelchair to prevent           “minimal impaction fracture” of     efforts had been made to
                                      resident from getting up        the left hip.                       safeguard the resident from
                                      from wheelchair without                                             additional injuries.
                                      assistance.                     Because restraints, including
                                                                      side rails, can pose a serious
                                                                      health and safety risk to nursing
                                                                      home residents if used
                                                                      improperly, CMS requires that
                                                                      restraints should only be used
                                                                      when other, less severe
                                                                      alternatives fail to address a
                                                                      resident’s medical needs, and
                                                                      the benefits outweigh the
                                                                      potential risks. In such cases,
                                                                      the nursing home must ensure
                                                                      that any restraints are used
                                                                      safely and properly.




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                                          Survey Reports That Understated Quality-of-
                                          Care Problems




                 Requirement and
State and date   scope and            Resident description and       Actual harm to resident           Deficiencies in care cited by
           a                                                 b
of survey        severity cited       relevant diagnoses             documented by surveyor            surveyor
California-9     Ensure               Resident was readmitted        A stage IV pressure sore on       Facility was slow to implement
December 2000    maintenance of       (6/11/00) to facility          right heel was noted on           the dietician’s
                 nutritional          following the removal of a     7/27/00.                          recommendations of 6/15/00
                 status: D            hip prosthesis and a                                             for caloric, protein, and water
                                      surgical incision that                                           intake necessary for wound
                                      became infected with a                                           healing. Diet ordered on
                                      fungus, resulting in a large                                     6/20/00. On 6/24/00 resident
                                      gaping wound. Resident                                           was admitted to the hospital
                                      was unable to swallow                                            for care of gastrointestinal
                                      following a stroke and was                                       bleeding and found to need
                                      fed via a nasogastric tube.                                      nutritional supplements to
                                                                                                       address gastrointestinal
                                                                                                       bleeding and promote wound
                                                                                                       healing. Resident was
                                                                                                       readmitted to facility on
                                                                                                       6/29/00. Following
                                                                                                       readmission, the facility also
                                                                                                       failed to implement both the
                                                                                                       hospital’s and its own
                                                                                                       dietician’s recommendations
                                                                                                       for increased protein, calories,
                                                                                                       and water to encourage wound
                                                                                                       healing.
California-10    Provide              Resident admitted to           Resident fell while attempting to Facility failed to provide
May 2001         supervision and      facility with diagnoses of     get out of bed and lacerated left supervision and devices to
                 devices to prevent   dementia and Alzheimer’s       elbow.                            prevent accidents. Specifically,
                 accidents: D         disease and a history of                                         resident was put to bed
                                      falls, confusion, and                                            without a restraining belt.
                                      unsteady gait. Resident
                                      identified as high risk for
                                      falls and had a physician’s
                                      order for a restraining belt
                                      when in bed.
California-11    Provide necessary    Resident admitted to the     Resident admitted to hospital        Staff failed to implement the
May 2001         care and services:   facility in 1999 with        for “several days” to relieve a      care plan. On 5/23/01 the
                 D                    dementia and neurological fecal impaction.                        surveyor noted the resident
                                      disorders. Resident was                                           crying out, moaning,
                                      receiving an antipsychotic                                        grimacing, and moving her
                                      medication that has a side                                        arms and legs about. Last
                                      effect of constipation. Care                                      bowel movement recorded
                                      plan of 1/04/01 called for                                        was on 5/19/01. The charge
                                      (1) providing liquids,                                            nurse administered Tylenol
                                      roughage, and exercise,                                           with codeine for what she
                                      (2) monitoring for                                                believed was an earache at 10
                                      abdominal distention, pain,                                       a.m. Resident continued to cry
                                      cramps, nausea, and                                               out and the charge nurse
                                      vomiting, and (3) checking                                        called the physician who had
                                      for impaction every 3 days.                                       the resident transferred to a
                                                                                                        hospital emergency room.




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                                          Survey Reports That Understated Quality-of-
                                          Care Problems




                 Requirement and
State and date   scope and            Resident description and        Actual harm to resident            Deficiencies in care cited by
           a                                                 b
of survey        severity cited       relevant diagnoses              documented by surveyor             surveyor
California-11    Provide              Resident was admitted           Resident sustained a 9 cm. skin    Facility failed to develop skin
                 supervision and      4/25/01 with acute kidney       tear to the lower left leg on      tear prevention plans. Staff did
                 devices to prevent   failure and emphysema           4/28/01 and two 3 cm. skin         not fully investigate causes of
                 accidents: E         and was one of five             tears below the left knee on       the tears and did not know
                                      residents identified as         5/3/01. Four other residents       how to prevent skin tears. The
                                      being at risk for skin tears;   also sustained multiple skin       staff development director
                                      all five developed skin         tears to their extremities and     stated that she had never
                                      tears. A care plan for          hip.                               provided instruction for the
                                      potential for skin                                                 certified nurse aides on
                                      breakdown and treatment                                            prevention of skin tears.
                                      of the skin tears was
                                      developed.
California-14    Ensure prevention    Resident admitted to            Resident’s pressure sore           Facility staff failed to promote
March 2001       and healing of       facility 1/26/01 following a    progressed to a stage II by        healing or prevent worsening
                 pressure sores: D    stroke, with inability to       2/28/01 and a stage III on         of pressure sore by failing to
                                      swallow, a gastric tube in      3/7/01.                            employ the appropriate sheets
                                      place for feedings, and a                                          that are used in conjunction
                                      stage I pressure sore on                                           with the low-air-loss, pressure
                                      right hip.                                                         sore mattress, thereby
                                                                                                         negating the pressure-relieving
                                                                                                         benefits of the mattress.
California-16    Ensure prevention    Resident admitted to            Resident developed a new           Facility staff did not prevent
April 2001       and healing of       facility 11/16/98 with          stage II pressure sore on          the development of a facility-
                 pressure sores: D    dementia, anemia,               4/26/01.                           acquired pressure sore.
                                      irregular heartbeat,                                               Specifically, the surveyor
                                      diabetes, high blood                                               observed on 4/24/01 that the
                                      pressure, and difficulty in                                        staff did not turn resident every
                                      swallowing.                                                        2 hours as directed by the care
                                                                                                         plan, and left her in the same
                                                                                                         position for as long as 8 hours.
California-18    Provide necessary    Resident admitted to the        Resident was observed              Facility staff failed to assess
April 2001       care and services:   facility with a steel plate     screaming and writhing in          the resident’s pain levels after
                 E                    implanted in her back           unrelieved pain for greater than   decreasing her Methadone.
                                      following a fracture.           an hour.                           They did not do an in-depth
                                      Nursing care plan called                                           pain assessment at any time
                                      for comfort measures for                                           after admission. The surveyor
                                      back pain, such as                                                 observed the staff ignoring the
                                      heat/cold application,                                             resident’s cries for help and
                                      therapeutic touch, and                                             relief, which continued until the
                                      staying with resident when                                         surveyor intervened.
                                      she was in distress.
                                      Resident also had an
                                      order for Methadone 20
                                      mg. that had been reduced
                                      to 2.5 mg.




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                                          Survey Reports That Understated Quality-of-
                                          Care Problems




                 Requirement and
State and date   scope and            Resident description and        Actual harm to resident             Deficiencies in care cited by
           a                                                 b
of survey        severity cited       relevant diagnoses              documented by surveyor              surveyor
California-19    Provide necessary    Resident admitted to            As a result of the facility’s       Facility staff did not reassess
June 2001        care and services:   facility on 3/97 with stroke,   failure to address the resident’s   this resident’s pain level and
                 D                    one-sided paralysis, and        pain, the resident refused the      need for stronger pain relief.
                                      moderate contractures of        splints used to control the
                                      upper and lower                 contractures and the
                                      extremities. Resident took      contractures worsened, leading
                                      Tylenol four times a day        to greater pain.
                                      since 2/98 for pain. As his
                                      pain worsened, he began
                                      to refuse the splinting of
                                      his contracted extremities
                                      because it was too painful.
California-20    Provide              Resident was admitted to        Resident fell and sustained         Facility failed to implement
January 2001     supervision and      facility on 3/6/00 and          abrasions to her right flank and    care plan of 12/19/00 that
                 devices to prevent   identified as a high risk for   hip on 12/24/00 and again on        called for safety assessment
                 accidents: D         falls on 12/6/00 because of     1/7/01, sustaining a scalp          and rehabilitation screening
                                      resident’s failure to           laceration on the back of her       related to falls. In addition,
                                      remember warnings about         head.                               facility failed to reassess
                                      personal safety and poor                                            resident’s safety needs and
                                      safety awareness.                                                   alternative preventive
                                                                                                          measures after the two falls,
                                                                                                          as called for by facility policy
                                                                                                          and the care plan. Physical
                                                                                                          therapy staff did not assess
                                                                                                          resident for safety needs
                                                                                                          either. There was no
                                                                                                          documented evidence that a
                                                                                                          plan was implemented to
                                                                                                          prevent future falls.
California-22    Provide              Resident had diagnoses of       Resident fell 17 documented         Facility failed to provide
October 2000     supervision and      diabetes, bipolar disease,      times from 4/21 to 10/14/00,        supervision and prevent
                 devices to prevent   and high blood pressure.        when she sustained a bruising       accidents. Specifically, facility
                 accidents: D         Resident was assessed as        of the right eye, and a bruise      staff did not provide a self-
                                      at risk for falls.              and an abrasion to her              releasing seat belt or pressure
                                                                      forehead.                           sensitive alarm on resident’s
                                                                                                          wheelchair as recommended
                                                                                                          by the facility’s fall/risk
                                                                                                          committee. Although the MDS
                                                                                                          assessment of 9/4/00
                                                                                                          indicated that the resident had
                                                                                                          no falls for 180 days, the
                                                                                                          resident’s medical record
                                                                                                          indicated that the resident fell
                                                                                                          at least six times in this period.




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                                         Survey Reports That Understated Quality-of-
                                         Care Problems




                 Requirement and
State and date   scope and           Resident description and       Actual harm to resident            Deficiencies in care cited by
         a                                                 b
of survey        severity cited      relevant diagnoses             documented by surveyor             surveyor
Iowa-1           Ensure prevention   Resident 1 had diagnoses       Resident’s stage II pressure       Facility staff failed to provide
June 2001        and healing of      that included renal failure,   sores healed and then              appropriate treatment to
                 pressure sores: D   diabetes, and dementia.        reopened repeatedly from           prevent reoccurrence of
                                     Resident’s record noted        1/9/01 to 6/20/01.                 pressure sores, resulting in the
                                     the presence of two                                               reappearance of pressure
                                     pressure sores, one on                                            sores after they had resolved.
                                     1/9/01 and the second on                                          Specifically, the facility did not
                                     4/1/01, between the                                               reassess the current plan of
                                     buttocks and on the lower                                         treatment and did not modify
                                     right back, respectively.                                         the care plan to meet the
                                                                                                       needs of the resident.

                                     Resident 2 had a history of    Resident developed an infected Facility staff failed to prevent
                                     stroke and dementia. A         stage II pressure ulcer at the an avoidable pressure sore.
                                     4/20/01 assessment note        base of the right thumb.       After the resident was
                                     indicated that the resident                                   readmitted with the cast on his
                                     had no ulcers, skin                                           arm, the staff did not assess
                                     problems, or lesions. On                                      whether the skin around the
                                     4/22/01, the resident fell,                                   cast was intact for 18 days
                                     was admitted to the                                           (4/27-5/14/01), at which time
                                     hospital for treatment of a                                   the nurse noted a foul odor
                                     fracture of the right wrist,                                  and a reddened thumb.
                                     and was readmitted to
                                     nursing home on 4/27/01
                                     with a cast on the right
                                     arm, including the lower
                                     half of the hand and
                                     thumb.
Iowa-2           (1) Ensure          On 2/25/02, surveyor           Resident developed a stage II      Facility staff failed to ensure
March 2002       prevention and      observed resident being        pressure sore that persisted       that a resident with a pressure
                 healing of          transferred using a            and reopened after resolving.      sore received necessary
                 pressure sores: D   mechanical lift and noted                                         treatment to promote healing
                                     an open stage II pressure                                         and to prevent new sores from
                                     sore on the lower back. A                                         developing. Specifically, the
                                     record review revealed a                                          record lacked evidence of
                                     history of healing and                                            assessment of potential causal
                                     reoccurrence of a lower-                                          factors and interventions to
                                     back pressure sore on                                             prevent the reoccurring
                                     several occasions from                                            pressure sore.
                                     7/8/01 through 2/26/02.




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                                          Appendix III: Abstracts of Nursing Home
                                          Survey Reports That Understated Quality-of-
                                          Care Problems




                 Requirement and
State and date   scope and            Resident description and        Actual harm to resident           Deficiencies in care cited by
         a                                                     b
of survey        severity cited       relevant diagnoses              documented by surveyor            surveyor
                 (2) Provide          During the above cited          Resident sustained multiple       Facility failed to prevent
                 supervision and      observation of the same         bruises, skin tears, and          bruises and skin tear injuries.
                 devices to prevent   resident on the mechanical      scrapes.                          The staff did not assess the
                 accidents: D         lift, the surveyor also noted                                     cause of the injuries or
                                      bilateral purple bruises on                                       implement protective devices,
                                      the resident’s lower legs                                         such as padding of the lift and
                                      and later checked the                                             wheelchair. On 2/26/02, a staff
                                      resident more fully and                                           member stated that the
                                      noted a total of five bruises                                     probable cause of the bruises
                                      and a scrape to the legs. A                                       was the resident’s hitting the
                                      review of the resident’s                                          mechanical Hoyer lift during
                                      record revealed multiple                                          transfers and that the lift
                                      bruises, abrasions, and                                           should be padded.
                                      skin tears going back 1
                                      year. The surveyor
                                      observed that there was
                                      no padding on the
                                      mechanical lift.
Iowa-4           Provide necessary    Resident with a diagnosis       Surveyor noted bruises on         Facility staff failed to provide
February 2001    care and             of multiple sclerosis           resident’s legs and saw how       the necessary care and
                 services: E          required extensive              resident’s legs and feet were     services in accordance with
                                      assistance with transfers,      twisted between the wheelchair    the plan of care. Staff failed to
                                      walking, and other              pedals and dragged and            assess for risk of skin injury
                                      activities of daily living.     bumped against the wheelchair     from wheelchair transfers and
                                      Care plan of 1/19/01            on 1/30 and 1/31/01. Resident     to protect resident from harm
                                      directed staff to monitor       sustained multiple bruises on     during transfers. Staff also
                                      and record all skin             both lower legs.                  failed to document resident’s
                                      changes. Surveyor noted                                           bruises.
                                      multiple bruises on
                                      resident’s legs.
Iowa-5           Provide necessary    Resident admitted to            Resident fell five documented     Facility failed to properly
March 2001       care and             facility on 7/6/99 with         times, sustaining abrasions to    assess and monitor after the
                 services: D          Alzheimer’s disease, high       the forehead, a bloody nose       resident fell, striking her head
                                      blood pressure, and             and mouth, a bump to the          on all five occasions. There
                                      anemia. Resident was            forehead, a broken tooth, a       was no documentation of
                                      receiving a diuretic to         carpet burn of the knees, and a   weekly monitoring of blood
                                      reduce blood pressure and       broken nose.                      pressure or for neurological
                                      an antihistamine for                                              status after resident struck her
                                      itching. Both drugs can                                           head.
                                      reduce blood pressure
                                      below normal levels,
                                      causing dizziness or a
                                      drop in blood pressure
                                      when rising to stand
                                      (orthostatic hypotension).
                                      Resident’s plan of care
                                      called for staff to monitor
                                      blood pressure on a
                                      weekly basis.




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                                          Appendix III: Abstracts of Nursing Home
                                          Survey Reports That Understated Quality-of-
                                          Care Problems




                 Requirement and
State and date   scope and            Resident description and      Actual harm to resident            Deficiencies in care cited by
         a                                                   b
of survey        severity cited       relevant diagnoses            documented by surveyor             surveyor
Iowa-7           Provide necessary    Resident 1 admitted to        Resident developed two stage       Facility staff did not
August 2001      care and services:   facility on 3/2/01 with       II ulcers of the foot and ankle,   consistently follow the orders
                 D                    history of stroke, heart      one on 6/18/01 and the other       and provide the necessary
                                      failure, and poor             on 6/26/01, which were still       care for the resident.
                                      circulation, with related     present, unhealed, on 8/7/01.      According to the surveyor, the
                                      rash of the legs and feet.                                       skin and heel protectors were
                                      Assessment revealed a                                            left off and the wheelchair was
                                      small scab on the left                                           not padded and was causing
                                      ankle that healed by 5/01.                                       additional erosion of the ankle
                                      Resident developed a                                             lesions.
                                      scabbed area on right foot.
                                      The physician ordered skin
                                      and heel protectors to be
                                      worn at night on 5/29/01.

                                      Resident 2 was admitted       Resident 2 experienced severe      Facility staff failed to provide
                                      with lung cancer,             unrelieved pain.                   the necessary care for this
                                      degenerative arthritis,                                          resident to maintain comfort
                                      osteoporosis, and anxiety.                                       measures and avoid pain. The
                                      Physician’s note of 5/16/01                                      care plan of 5/21 and 6/13/01
                                      indicated that resident was                                      did not include pain
                                      dying and would need to                                          management. The staff did not
                                      be assessed for pain relief                                      assess the resident’s
                                      as the disease progressed                                        complaints of pain and need
                                      and that stronger, more                                          for effective pain relief.
                                      effective pain relievers
                                      would be considered. As
                                      the resident began to
                                      experience increasing
                                      pain, he was given Tylenol
                                      even when pain appeared
                                      severe and unrelieved.
Iowa-7           Provide              Resident 1 has diagnoses      Resident 1 fell 11 times and       The facility failed to provide
August 2001      supervision and      of dementia and               sustained a fractured wrist,       adequate interventions to
                 devices to prevent   depression with long- and     three fractured ribs, bruises,     prevent accidents. The
                 accidents: D         short-term memory             abrasions, and a skin tear, plus   personal alarm system was
                                      deficits. Surveyor noted      pain associated with all these     the only safety device
                                      resident had fallen           falls and injuries.                employed, and there is no
                                      frequently from 2/23/01                                          evidence that the staff
                                      through 7/23/01 and                                              evaluated its effectiveness and
                                      sustained serious injuries.                                      selected other measures.
                                      Personal safety alarms
                                      selected for resident were
                                      ineffective in preventing
                                      falls.




                                          Page 69                                                  GAO-03-561 Nursing Home Quality
                                           Appendix III: Abstracts of Nursing Home
                                           Survey Reports That Understated Quality-of-
                                           Care Problems




                 Requirement and
State and date   scope and             Resident description and      Actual harm to resident              Deficiencies in care cited by
         a                                                    b
of survey        severity cited        relevant diagnoses            documented by surveyor               surveyor
                                       Resident 2 was admitted       Resident 2 fell 21 times from        The facility failed to provide
                                       to facility on 8/8/00 with    1/6/01 to 6/26/01 and sustained      adequate interventions to
                                       renal failure and impaired    multiple skin tears, two             prevent accidents. The
                                       mobility. On 4/3/01, he       lacerations to the head and          personal alarm unit in use for
                                       was assessed as being         elbow requiring emergency            this resident did not prevent
                                       mentally confused at          room or clinic visits for sutures,   his falls from occurring and
                                       times. Surveyor noted the     multiple bruises and abrasions,      there is no indication that other
                                       resident’s record stated      and head injuries.                   safety options were
                                       that resident fell                                                 considered.
                                       frequently. The care plan
                                       and monthly summary for
                                       April identify the personal
                                       alarm unit as the safety
                                       device in use during this
                                       time (initiated 3/25/01).
                                       The resident frequently
                                       removed the unit or put it
                                       in his pocket.
Maryland-1       Provide               Resident admitted to          Resident fell out of the         The facility failed to provide
August 2001      supervision and       facility with multiple        wheelchair, was bleeding from    supervision and devices to
                 devices to prevent    diagnoses including           nose and mouth, and was in       prevent accidents by not
                 accidents: D          congestive heart failure,     acute respiratory distress. Staffplacing safety belt around
                                       high blood pressure, and      did not intervene to address     resident while she was in the
                                       obesity. Resident suffered    respiratory distress until       wheelchair. Staff also did not
                                       from shortness of breath      resident stopped breathing and   provide the resident with
                                       and required oxygen at 3      her pulse stopped. At this time  oxygen as ordered while she
                                       liters per minute. She also   the staff began to administer    was in the wheelchair. Staff
                                       had a history of falls and    cardiopulmonary resuscitation    did not respond in a timely and
                                       was considered a high risk    (CPR).                           appropriate manner to
                                       for falls. Resident had a                                      resident’s onset of respiratory
                                       physician order for a                                          distress following the fall from
                                       quick-release belt while in                                    the wheelchair. Staff did not
                                       wheelchair for safety.                                         initiate CPR until resident was
                                                                                                      no longer breathing and her
                                                                                                      pulse stopped.
Missouri-3       Ensure adequate       Resident had diagnoses of Resident experienced another         The facility failed to ensure
May 2001         nutritional status:   peptic ulcer disease,       severe weight loss, dropping       adequate nutritional status.
                 D                     aspiration pneumonia, and from 126 lbs in 3/01 to 116.9        After noting resident’s weight
                                       a penicillin-resistant      lbs in 4/01, a loss of 7.2 percent loss in 2/01, no care plan was
                                       infection requiring long-   in 1 month.                        developed to address the
                                       term antibiotic treatment.                                     weight loss. In March, the
                                       From 11/00 through 2/01,                                       dietician recommended a
                                       resident sustained a                                           dietary supplement, which did
                                       severe weight loss of 10 to                                    not begin for a month.
                                       12 percent.




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                                         Appendix III: Abstracts of Nursing Home
                                         Survey Reports That Understated Quality-of-
                                         Care Problems




                 Requirement and
State and date   scope and           Resident description and        Actual harm to resident          Deficiencies in care cited by
         a                                                  b
of survey        severity cited      relevant diagnoses              documented by surveyor           surveyor
Nebraska-1       Provide necessary   Resident 1 readmitted to        Over a period of 9 months,       Facility failed to provide the
September 2000   care and            facility from hospital with a   resident’s blood sugar           necessary care and services
                 services: D         diagnosis of insulin-           fluctuated, including frequent   required to manage resident’s
                                     dependent diabetes.             episodes of symptomatic          diabetes. Specifically, (1) the
                                     Physician orders stated         hypoglycemia (low blood sugar    staff infrequently called the
                                     that the physician was to       between 48 and 60) and loss of   physician about blood sugars
                                     be called when resident’s       consciousness.                   below 40, the frequent blood
                                     blood sugar fell below 40                                        sugar fluctuations, or the
                                     or rose above 350 (normal                                        resident’s episodes of
                                     range is 70 to 110).                                             symptomatic hypoglycemia,
                                     Resident received insulin                                        (2) fluctuating blood sugars
                                     on a sliding scale (insulin                                      were not identified as a
                                     dose based on most                                               problem in the care plan, and
                                     recent blood sugar), and a                                       (3) there was no assessment
                                     variety of dietary                                               of the resident’s diabetes,
                                     interventions.                                                   appropriate diet, treatment
                                                                                                      effectiveness of hypoglycemic
                                                                                                      episodes, and administration
                                                                                                      of insulin on a sliding scale.

                                     Resident 2 with diagnoses This terminally ill resident           Facility staff did not provide
                                     of emphysema,               suffered with unrelieved pain        the necessary care and
                                     Parkinson’s disease, and    for at least 4 months.               services to this resident. The
                                     osteoarthritis was                                               staff did not assess or respond
                                     receiving hospice services.                                      to the resident’s continuing
                                     Resident experienced                                             complaints of pain and noted
                                     increasing pain on a daily                                       in the record that the resident
                                     basis, unrelieved by                                             was demanding and
                                     regular Tylenol, a                                               manipulative. Nor did they
                                     tranquilizer, and an                                             monitor the effectiveness of
                                     antipsychotic drug specific                                      the medications administered,
                                     for schizophrenia and                                            resulting (according to the
                                     mania. Resident obtained                                         surveyor) in the resident’s
                                     short-term (2.5 hours)                                           voicing thoughts of suicide.
                                     relief from Tylox (Tylenol
                                     and oxycodone for pain
                                     relief and sedation).




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                                         Appendix III: Abstracts of Nursing Home
                                         Survey Reports That Understated Quality-of-
                                         Care Problems




                 Requirement and
State and date   scope and           Resident description and       Actual harm to resident           Deficiencies in care cited by
         a                                                  b
of survey        severity cited      relevant diagnoses             documented by surveyor            surveyor
Nebraska-3       Ensure prevention   Resident was readmitted        Resident developed a stage III    Facility failed to ensure that a
September 2001   and healing of      to facility 5/24/01 with       pressure sore on the right heel   resident did not develop a
                 pressure sores: D   diagnoses of stroke,           with thick green drainage and     pressure sore in the facility.
                                     diabetes, and one stage II     foul odor.                        Specifically, the facility staff
                                     pressure sore of the lower                                       failed to recognize the
                                     back and one stage I                                             challenge the resident had in
                                     pressure sore between the                                        moving in bed because of the
                                     buttocks. Resident was                                           right-sided paralysis. In
                                     totally dependent on staff                                       addition, they were slow to use
                                     for bed mobility because of                                      a pressure-reducing mattress.
                                     a right-sided paralysis and                                      When the mattress was placed
                                     developed pressure sores                                         on the bed the staff did not
                                     of both heels that were                                          discontinue use of the fleece-
                                     noted on 6/3/01 and                                              lined protection booties and
                                     identified as stage II on                                        continued use for 3 weeks,
                                     7/24/01. A pressure-                                             which negated the pressure-
                                     reducing mattress was                                            reducing effects of the
                                     added to the care plan on                                        mattress.
                                     9/4/01.
Pennsylvania-3   Ensure prevention   Resident had a left hip        In addition to the stage II       Facility failed to prevent the
May 2001         and healing of      fracture and was identified    pressure sore of the foot,        development of pressure
                 pressure sores: D   as high risk for skin          resident developed a second       sores. Specifically, the boot,
                                     breakdown on 12/18/00. A       stage II facility-acquired        which was left on continuously,
                                     stage I pressure sore of       pressure sore on 4/10/01.         contributed to the development
                                     the left heel was noted on                                       of the pressure sore identified
                                     3/7/01 and by 3/14/01 it                                         on 4/10/01. In addition, the
                                     had progressed to stage II.                                      dietician did not note the
                                     A special boot to keep left                                      existing original pressure sore
                                     heel elevated was not                                            and wrongly assumed the
                                     applied until 3/21/01 and                                        resident had no extra need for
                                     was then left on                                                 protein. The need for
                                     continuously. A second                                           additional protein in the diet
                                     stage II pressure sore was                                       was confirmed by laboratory
                                     noted on the left outer foot                                     tests indicating the resident’s
                                     4/10/01. The boot was                                            protein levels were below the
                                     discontinued on 4/11/01. A                                       normal range.
                                     nutrition assessment on
                                     3/27/01 indicated
                                     resident’s skin was intact
                                     and recommended no
                                     increase in protein in the
                                     diet.




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                                          Appendix III: Abstracts of Nursing Home
                                          Survey Reports That Understated Quality-of-
                                          Care Problems




                 Requirement and
State and date   scope and            Resident description and        Actual harm to resident              Deficiencies in care cited by
         a                                                  b
of survey        severity cited       relevant diagnoses              documented by surveyor               surveyor
Pennsylvania-3   Provide              Resident had piriformis         Resident developed a second-         Facility staff failed to provide
May 2001         supervision and      syndrome (compression of        degree burn of the right             supervision and prevent injury.
                 devices to prevent   the sciatic nerve by the        buttock, which blistered and         During a routine check on
                 accidents: E         piriformis muscle) with a       was still healing after a month.     1/9/01, the facility found that
                                      physician’s order for                                                the temperature on the
                                      physical therapy using                                               hydrocollator pack was 11
                                      stretching exercises and                                             degrees above the
                                      heat application. Physical                                           manufacturer’s recommended
                                      therapy used a                                                       temperature. On 4/16/01 the
                                      hydrocollator pack to                                                hydrocollator pack was applied
                                      provide moist heat                                                   to the resident’s right buttock.
                                      treatments.g                                                         Resident said that he told the
                                                                                                           therapy staff that the pack was
                                                                                                           getting too hot and the pack
                                                                                                           was removed. Facility staff did
                                                                                                           not check the water
                                                                                                           temperature after the incident.

                                      Resident 2 had diagnoses        Resident 2 fell nine                 The facility failed to ensure
                                      that included dementia,         documented times and, as a           adequate supervision and
                                      poor vision, and                result of these falls, sustained a   assistance devices to prevent
                                      Parkinson’s disease and         skin tear, a laceration requiring    accidents. According to the
                                      was assessed as a               transfer to the hospital for         surveyor, there was no
                                      moderate risk for falls on      treatment, and a dislocated hip      evidence that the facility had
                                      12/29/00. The MDS               requiring another hospital visit.    implemented effective
                                      significant change                                                   interventions to avoid the risk
                                      assessment of 1/24/01                                                of such accidents for the
                                      and the 4/9/01 quarterly                                             resident. The surveyor noted
                                      review noted a history of                                            that this at-risk resident’s room
                                      falls, impaired decision                                             was too far from the nurses’
                                      making, and the need for                                             station, making observation
                                      assistance for transferring                                          difficult.
                                      and walking. The records
                                      noted interventions found
                                      to be ineffective continued
                                      to be used.
Pennsylvania-9   Provide              A dependent resident with       Resident sustained eight skin        Surveyor stated that the facility
May 2001         supervision and      cognitive impairment was        tears on 6/27/00, 7/24/00,           failed to ensure that the
                 devices to prevent   assessed as at risk for         7/31/00, 8/16/00, 9/20/00,           necessary safety measures
                 accidents: D         falls and skin tears.           10/24/00, 1/8/01, and 1/27/01.       and/or devices were
                                      Interventions to prevent                                             implemented and failed to
                                      falls listed in the care plan                                        adequately assess the
                                      included use of personal                                             ongoing use of these devices
                                      alarms, protective sleeves,                                          given their ineffectiveness in
                                      and padded side rails.                                               preventing falls and skin tears.




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                                         Appendix III: Abstracts of Nursing Home
                                         Survey Reports That Understated Quality-of-
                                         Care Problems




                 Requirement and
State and date   scope and           Resident description and        Actual harm to resident               Deficiencies in care cited by
           a                                                 b
of survey        severity cited      relevant diagnoses              documented by surveyor                surveyor
Virginia-1       Provide necessary   Resident admitted to            This resident suffered with           The facility did not provide
August 2000      care and            facility for pain               severe pain that was                  necessary care and services
                 services: D         management associated           incompletely relieved by the          to manage this resident’s pain.
                                     with spread of cancer to        use of Percocet. The longer           Resident did not receive any of
                                     the spine. Resident had         acting Oxycontin was never            the longer-acting Oxycontin
                                     physician orders for            used.                                 and received only 10 doses of
                                     Oxycontin every 12 hours                                              the Percocet during the 6 days
                                     for long-term pain relief, as                                         he was in the facility. He was
                                     needed, and Percocet                                                  not offered pain relief in the
                                     every 4 hours for any                                                 morning when he was being
                                     additional pain, as needed.                                           turned and bathed. Monitoring
                                     Staff noted resident lay                                              of medication effectiveness
                                     very still in bed and                                                 was incomplete. Percocet was
                                     seldom asked for pain                                                 given, on average, once a day.
                                     medication but that it was
                                     obvious he was in a lot of
                                     pain whenever he was
                                     turned or touched.
                                     Resident’s daughter said
                                     her father was in constant
                                     pain and was depressed.
Virginia-2       Provide necessary   Resident was admitted to        Resident sustained fractures of       The facility failed to provide
March 2001       care and            facility 11/4/97, with          the eighth and ninth ribs with        the necessary care and
                 services: D         diagnoses of stroke,            fluid in the left lower lobe of the   services to provide prompt
                                     depression, and delusions.      lung demonstrated by x ray.           treatment of the resident’s
                                     An MDS of 11/9/00                                                     chest injury. Specifically, the
                                     indicated the resident was                                            facility failed to take
                                     cognitively impaired and                                              appropriate action to assess
                                     required lift transfer. On                                            and provide the necessary
                                     12/27/00 the nurse noted a                                            care for this resident’s injury
                                     large area of bruising on                                             for 11 days. The results of an
                                     the left chest and left                                               investigation implicated the lift
                                     underarm with swelling                                                used to transfer the resident to
                                     around the rib cage. On                                               and from the bed.
                                     1/6/01 resident began to
                                     experience shallow
                                     breathing. Physician
                                     ordered a chest x ray if
                                     resident’s breathing
                                     difficulties continued.




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                                         Appendix III: Abstracts of Nursing Home
                                         Survey Reports That Understated Quality-of-
                                         Care Problems




                 Requirement and
State and date   scope and           Resident description and      Actual harm to resident           Deficiencies in care cited by
           a                                               b
of survey        severity cited      relevant diagnoses            documented by surveyor            surveyor
Virginia-2       Ensure prevention   Resident 1 admitted to the    Resident developed three open     The facility failed to prevent
March 2001       and healing of      facility with diagnoses of    pressure sores of the buttocks,   the development of facility-
                 pressure sores: D   Alzheimer’s disease,          evident 2 days after the MDS      acquired pressure sores. The
                                     anemia, depression, and       assessment. One of the            staff did not obtain timely
                                     joint pain. No pressure       pressure sores was a stage III.   alternative treatments and
                                     sores were noted on the                                         interventions to promote
                                     admission assessment                                            healing of early pressure
                                     form. The care plan on                                          sores.
                                     2/22/00 noted the resident
                                     was incontinent of bowel
                                     and bladder and at risk for
                                     pressure sores. Resident’s
                                     blood protein was low. The
                                     most recent MDS
                                     (2/23/01) indicated no
                                     pressure sores but noted
                                     the resident was losing
                                     weight, 5 percent or more
                                     in the past 30 days
                                     (1/24/01- 2/23/01).

                                     Resident 2 admitted to        Resident developed an open        Staff failed to obtain timely
                                     facility on 12/24/00 with     stage III pressure sore with      alternative treatments and
                                     diabetes, stroke, prostate    yellow drainage.                  interventions to promote
                                     cancer, requiring limited                                       healing upon worsening of
                                     assistance for activities of                                    these sores from1/18/01
                                     daily living, and incontinent                                   through 3/1/01. Specifically,
                                     of bowel and bladder. As                                        the staff continued to treat the
                                     of 12/31/00 resident had                                        pressure sores without
                                     an unhealed surgical                                            evaluating the effectiveness of
                                     wound of the back, two                                          the treatment.
                                     stage IV pressure sores of
                                     the right and left heels,
                                     and an excoriated (stage I)
                                     buttock. After a brief
                                     hospitalization, resident
                                     was readmitted to facility
                                     and the clinical record on
                                     2/26/00 described the
                                     buttock sore as a stage II
                                     pressure sore. Treatment
                                     with a sealed dressing
                                     continued.




                                         Page 75                                                  GAO-03-561 Nursing Home Quality
                                                      Appendix III: Abstracts of Nursing Home
                                                      Survey Reports That Understated Quality-of-
                                                      Care Problems




                             Requirement and
 State and date              scope and            Resident description and         Actual harm to resident                Deficiencies in care cited by
            a                                                               b
 of survey                   severity cited       relevant diagnoses               documented by surveyor                 surveyor
 Virginia-4                  Provide necessary    Resident was an 81-year-         Resident sustained a                   Facility failed to provide
 March 2001                  care and services:   old admitted to the facility     nondisplaced fracture of the left      necessary care and services.
                             D                    on 8/17/90 with psychoses        wrist and suffered unnecessary         The facility failed to assess
                                                  and hypothyroidism.              pain.                                  and investigate the source of
                                                  Recent assessment                                                       the resident’s pain. Nurses’
                                                  (1/22/01) indicated long-                                               notes indicate no apparent
                                                  and short-term memory                                                   injury after fall. On 9/15/00 at
                                                  loss and moderate                                                       6:30 p.m., resident complained
                                                  dependency for activities                                               of pain in left arm. There was
                                                  of daily living. Care plan                                              bruising on wrist and thumb,
                                                  identified resident as at                                               and the arm was swollen and
                                                  risk for falls. A list of                                               tender to touch. According to
                                                  preventive measures was                                                 the surveyor, there was a
                                                  provided. On 9/14/00 at                                                 delay in seeking more
                                                  7:30 p.m., resident fell and                                            aggressive treatment or
                                                  complained of pain all                                                  service, as evidenced by the
                                                  over.                                                                   fact that an x-ray was not
                                                                                                                          obtained until 37 hours after
                                                                                                                          the resident’s fall.
Source: State nursing home survey reports.
                                                      a
                                                       To more easily distinguish among multiple surveys from the same state, we assigned consecutive
                                                      numbers to each state’s surveys.
                                                      b
                                                       The resident description and relevant diagnoses are limited to the information provided by the
                                                      surveyor. In some of the surveys, no background or diagnostic information was provided.
                                                      c
                                                       Skin tears and multiple bruises are serious and painful injuries for older individuals and should not be
                                                      considered in the same context as cuts and bruises sustained by healthy and younger adults. A skin
                                                      tear is a traumatic wound occurring principally on the extremities of older adults as a result of friction
                                                      alone or shearing and friction forces that separate the top layer of skin from the underlying layer or
                                                      both layers from the underlying structures. A skin tear is a painful but preventable injury. Individuals
                                                      most at risk for skin tears are those with (1) fragile skin, (2) advanced age, (3) assistance devices
                                                      (wheelchairs, lifts, walkers), (4) cognitive and sensory impairment, (5) history of skin tears, and
                                                      (6) total dependence for care. In addition, treatment of bruises and skin tears for elderly residents of a
                                                      nursing home is frequently complicated by diabetes, poor circulation, poor nutrition, and medications
                                                      with blood thinning effects. See Sharon Baranoski, “Skin Tears: Staying on Guard Against the Enemy
                                                      of Frail Skin,” Nursing 2000, vol. 30, no. 9, 2000.
                                                      d
                                                       Stages of pressure sore formation are I—skin of involved area is reddened, II—upper layer of skin is
                                                      involved and blistered or abraded, III—skin has an open sore and involves all layers of skin down to
                                                      underlying connective tissue, and IV—tissue surrounding the sore has died and may extend to
                                                      muscle and bone and involve infection.
                                                      e
                                                       The following two resident incidents were cited at the B level for scope and severity, which means
                                                      the surveyor found that both injuries were unavoidable and that the nursing home was in substantial
                                                      compliance with the requirements.
                                                      f
                                                       These two citations involve two residents, one cognitively competent and the other with dementia,
                                                      who were injured because side rails were in place on their beds. Numerous reports have cited the
                                                      danger of side rails. Residents trying to get out of bed over the rails have injured themselves by
                                                      falling. Other individuals have been caught between the bed rails and the mattress or have caught
                                                      their heads in the rails. Some of these injuries resulted in death.




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Appendix III: Abstracts of Nursing Home
Survey Reports That Understated Quality-of-
Care Problems




g
 A hydrocollator pack is a canvas bag containing a silicone gel paste that absorbs an amount of water
10 times its weight. The pack is placed in a heated water container, set at a temperature above 150°
F. When ready, it is placed in a protective dry terrycloth wrap and applied on top of the area where
the individual is experiencing pain. Lying or sitting on the pack negates the insulating effect of the
terrycloth and the individual may be burned.




Page 77                                                       GAO-03-561 Nursing Home Quality
                                         Appendix IV: Information on State Nursing
Appendix IV: Information on State NursingHome Surveyor Staffing



Home Surveyor Staffing

                                         Table 9 summarizes state survey agencies’ responses to our July 2002
                                         questions about nursing home surveyor experience, vacancies, hiring
                                         freezes, competitiveness of salaries, and minimum required experience.

Table 9: State Survey Agency Responses to Questions about Surveyor Experience, Vacancies, Hiring Freezes,
Competitiveness of Salaries, and Minimum Required Experience

                       Surveyors with
                       2 years or less          Surveyor         Surveyor hiring      RN surveyor     Minimum required
                           experience    positions vacant      freeze in effect as     salaries are   experience for RN
     a
State                        (percent)           (percent)           of mid-2002       competitive    surveyors (years)
Maryland                            70                   9                    Yes              Yes                0 to 2
Oklahoma                            67                   4                    Yes              Yes                 0 to1
New Hampshire                       60                  12                    Yes               No                     2
Florida                             55                   8                     No               No                     0
Idaho                               54                   0                    Yes               No                     1
Washington                          54                   0                     No               No                     2
California                          52                   6                    Yes              Yes                     1
Georgia                             51                  14                     No               No                     3
Kentucky                            51                  17                     No              Yes                     4
District of Columbia                50                   9                    Yes              Yes                     3
Utah                                50                   8                     No               No                     2
Louisiana                           48                   6                    Yes               No                2 to 3
Alabama                             48                  10                     No               No                     0
Tennessee                           45                  18                     No               No                     3
Maine                               42                   9                    Yes               No                     5
Hawaii                              40                  17                     No               No                  2-½
New York                            40                   4                    Yes               No                1 to 2
Missouri                            36                  11                     No               No                     2
Oregon                              34                  12                    Yes               No                     5
Arkansas                            33                  20                     No               No                     2
North Carolina                      33                  18                     No               No                     4
                                                         b                       b
Texas                               32                 20                      No               No                     1
New Mexico                          30                  34                     No               No                     3
New Jersey                          30                  23                    Yes               No                     3
Nebraska                            29                   6                     No               No                1 to 2
Connecticut                         29                   1                    Yes              Yes                     4
Alaska                              29                  22                     No               No                     2
Wisconsin                           25                  15                     No               No                     0
Colorado                            24                  17                     No               No                     1
Virginia                            21                   5                     No               No                     0
Indiana                             20                  18                     No               No                     1
Arizona                             20                  24                    Yes               No                     2
South Dakota                        18                   0                     No              Yes                     2
Ohio                                17                   5                     No              Yes                     0




                                         Page 78                                        GAO-03-561 Nursing Home Quality
                                                               Appendix IV: Information on State Nursing
                                                               Home Surveyor Staffing




                                   Surveyors with
                                   2 years or less                        Surveyor         Surveyor hiring                RN surveyor          Minimum required
                                       experience                  positions vacant      freeze in effect as               salaries are        experience for RN
         a
 State                                   (percent)                         (percent)           of mid-2002                 competitive         surveyors (years)
 Michigan                                       17                                5                     Yes                         No                         0
                                                                                                                                                                    C
 Kansas                                         17                                4                      No                         No
 Massachusetts                                  16                               14                     Yes                        Yes                         1 to 3
 Pennsylvania                                   15                                7                      No                        Yes                              1
 Rhode Island                                    9                               13                      No                        Yes                              1
 Illinois                                        5                                5                     Yes                        Yes                         2 to 3
 Iowa                                            4                                0                     Yes                         No                              5
 Minnesota                                       0                               17                     Yes                         No                              3
Source: State survey agency responses to July 2002 GAO questions.
                                                               a
                                                               Nine states did not respond to our inquiry—Delaware, Mississippi, Montana, Nevada, North Dakota,
                                                               South Carolina, Vermont, West Virginia, and Wyoming.
                                                               b
                                                                Texas indicated that although there was no hiring freeze or layoffs, the survey staff was reduced by
                                                               107 positions through attrition from September 1, 2001, through June 1, 2002, in light of state funding
                                                               changes and agency cuts. As of mid-2002, Texas was authorized 215 nurse surveyors and had 42
                                                               positions vacant.
                                                               c
                                                               Kansas requires independent experience in professional health care, but does not specify a time
                                                               period for that experience.




                                                               Page 79                                                       GAO-03-561 Nursing Home Quality
               Appendix V: Predictability of Standard
Appendix V: Predictability of Standard
               Nursing Home Surveys



Nursing Home Surveys

               Our analysis found that 34 percent of current nursing home surveys were
               predictable, allowing nursing homes to conceal deficiencies if they choose
               to do so. In order to determine the predictability of nursing home surveys,
               we analyzed data from CMS’s OSCAR database (see table 10). We
               considered surveys to be predictable if (1) homes were surveyed within 15
               days of the 1-year anniversary of their prior survey or (2) homes were
               surveyed within 1 month of the maximum 15-month interval between
               standard surveys. Consistent with CMS’s interpretation, we used 15.9
               months as the maximum allowable interval between surveys. Because
               homes know the maximum allowable interval between surveys, those
               whose prior surveys were conducted 14 or 15 months earlier are aware
               that they are likely to be surveyed soon.




               Page 80                                      GAO-03-561 Nursing Home Quality
                                         Appendix V: Predictability of Standard
                                         Nursing Home Surveys




Table 10: Predictability of Current Nursing Home Surveys, by State

                                                                                                      Homes surveyed within 1
                           Number of active                             Homes surveyed within 15           month of 15-month
                        homes with a current    Predictable surveys     days of 1-year anniversary       maximum interval of
State                      and prior survey                (percent)      of prior survey (percent)     prior survey (percent)
Alabama                                  225                    82.7                            5.8                       76.9
Oklahoma                                 354                    71.5                            0.6                       70.9
South Carolina                           174                    67.8                            6.9                       60.9
Nebraska                                 226                    59.7                            3.1                       56.6
Utah                                      91                    52.7                            1.1                       51.6
Montana                                  103                    52.4                            8.7                       43.7
Georgia                                  357                    52.4                            0.6                       51.8
Hawaii                                    44                    52.3                           13.6                       38.6
New York                                 663                    52.0                           14.8                       37.3
Idaho                                     84                    50.0                            4.8                       45.2
New Mexico                                80                    43.8                           13.8                       30.0
Delaware                                  42                    42.9                           31.0                       11.9
California                             1,324                    41.2                            9.5                       31.7
Nevada                                    45                    40.0                           24.4                       15.6
Arizona                                  138                    39.9                           21.0                       18.8
New Jersey                               359                    39.0                           18.7                       20.3
Oregon                                   142                    38.0                           14.1                       23.9
Maryland                                 246                    37.0                           20.7                       16.3
Massachusetts                            497                    36.2                           17.3                       18.9
Arkansas                                 239                    35.6                           27.6                        7.9
Virginia                                 275                    35.3                           30.5                        4.7
Iowa                                     457                    34.6                           31.1                        3.5
Nation                                16,332                    34.0                           13.0                       21.0
Kentucky                                 303                    33.7                           10.6                       23.1
Ohio                                     973                    33.6                            3.0                       30.6
North Dakota                              85                    32.9                           28.2                        4.7
Vermont                                   43                    32.6                           11.6                       20.9
New Hampshire                             83                    32.5                           12.0                       20.5
South Dakota                             111                    32.4                           18.9                       13.5
Wisconsin                                404                    32.4                           19.6                       12.9
Washington                               268                    32.1                           22.4                        9.7
Florida                                  718                    32.0                            9.3                       22.7
Mississippi                              187                    31.6                            2.1                       29.4
Rhode Island                              96                    31.3                           12.5                       18.8
Connecticut                              253                    30.8                           15.8                       15.0
Wyoming                                   39                    30.8                           10.3                       20.5
Indiana                                  550                    30.7                           14.4                       16.4
Tennessee                                324                    29.0                            6.2                       22.8
Louisiana                                315                    28.6                           19.0                        9.5
Texas                                  1,122                    27.2                           15.7                       11.5



                                         Page 81                                              GAO-03-561 Nursing Home Quality
                                                          Appendix V: Predictability of Standard
                                                          Nursing Home Surveys




                                                                                                                       Homes surveyed within 1
                                        Number of active                                 Homes surveyed within 15           month of 15-month
                                     homes with a current        Predictable surveys     days of 1-year anniversary       maximum interval of
 State                                  and prior survey                    (percent)      of prior survey (percent)     prior survey (percent)
 Colorado                                             222                        26.1                            9.0                       17.1
 Pennsylvania                                         757                        26.0                           24.0                        2.0
 Kansas                                               369                        25.2                           13.6                       11.7
 Missouri                                             531                        25.0                           11.9                       13.2
 Maine                                                121                        24.8                            8.3                       16.5
 Minnesota                                            427                        20.4                            4.4                       15.9
 Alaska                                                15                        20.0                            6.7                       13.3
 District of Columbia                                  20                        20.0                           15.0                        5.0
 North Carolina                                       411                        17.3                           13.9                        3.4
 Illinois                                             849                        15.2                            9.7                        5.5
 West Virginia                                        138                        10.9                            8.7                        2.2
 Michigan                                             433                        10.2                            8.8                        1.4
Source: GAO analysis of OSCAR data as of April 9, 2002.




                                                          Page 82                                              GAO-03-561 Nursing Home Quality
             Appendix VI: Immediate Sanctions
Appendix VI: Immediate Sanctions
             Implemented Under CMS’s Expanded
             Immediate Sanctions Policy


Implemented Under CMS’s Expanded
Immediate Sanctions Policy
             From January 2000 through March 2002, states referred 4,310 cases to
             CMS under its expanded immediate sanctions policy when nursing homes
             were found to have a pattern of harming residents.1 Because some homes
             had more than one sanction or may have had multiple referrals for
             sanctions, 4,860 sanctions were implemented (see table 11). Table 12
             summarizes the amounts of federal civil money penalties (CMP)
             implemented against nursing homes referred for immediate sanction.
             Although these monetary sanctions were implemented, CMS’s
             enforcement database does not track collections. In addition, states may
             have imposed other sanctions under their own licensure authority, such as
             state monetary sanctions, in addition to or in lieu of federal sanctions.
             Such state sanctions are not recorded in CMS’s enforcement database.

             Table 11: Federal Sanctions Implemented against Nursing Homes Referred for
             Immediate Sanction, January 14, 2000, through March 28, 2002
                                      a
                 Type of sanction                                                  Number implemented
                 CMP                                                                            2,933
                 Denial of payment for new admissions                                           1,232
                 Directed in-service training                                                     345
                 State monitoring                                                                 192
                 Directed plan of correction                                                       77
                 CMS approved alternative or additional state sanction                             48
                 Termination from the Medicare and Medicaid programs                               26
                 Temporary management                                                               4
                 Denial of payment for all residents                                                2
                 Transfer of residents and closure of facility                                      1
                 Total                                                                          4,860
             Source: CMS enforcement database as of March 28, 2002.
             a
              We excluded sanctions that were not implemented either because they were pending as of March
             28, 2002, the date of our extract of CMS’s enforcement database, or because CMS withdrew them
             after imposition.




             1
              We use the term “cases” because some homes had multiple referrals for immediate
             sanctions.




             Page 83                                                   GAO-03-561 Nursing Home Quality
Appendix VI: Immediate Sanctions
Implemented Under CMS’s Expanded
Immediate Sanctions Policy




Table 12: Federal CMPs Implemented under CMS’s Immediate Sanctions Policy,
January 2000 through March 2002

State                                                            CMP amount
Alabama                                                           $375,627.50
Alaska                                                                   0.00
Arizona                                                            350,652.50
Arkansas                                                         1,571,654.04
California                                                       1,681,813.50
Colorado                                                         1,489,100.00
Connecticut                                                        696,350.00
Delaware                                                           214,342.50
District of Columbia                                                20,000.00
Florida                                                          1,975,375.00
Georgia                                                            487,050.00
Hawaii                                                              20,000.00
Idaho                                                               37,350.00
Illinois                                                         2,801,656.50
Indiana                                                          1,977,685.50
Iowa                                                               175,945.00
Kansas                                                             415,400.00
Kentucky                                                         1,195,177.50
Louisiana                                                           20,000.00
Maine                                                              184,920.00
Maryland                                                           290,270.00
Massachusetts                                                    1,031,445.00
Michigan                                                         1,035,815.00
Minnesota                                                           66,307.50
Mississippi                                                        186,977.50
Missouri                                                           467,157.50
Montana                                                                  0.00
Nebraska                                                            11,207.50
Nevada                                                             429,500.00
New Hampshire                                                       93,350.00
New Jersey                                                       1,543,007.50
New Mexico                                                         222,430.00
New York                                                                 0.00
North Carolina                                                   2,171,013.75
North Dakota                                                        15,730.00
Ohio                                                             3,104,870.00
Oklahoma                                                         1,075,036.50
Oregon                                                              15,225.00
Pennsylvania                                                     1,250,417.00
Rhode Island                                                         9,425.00
South Carolina                                                      29,250.00




Page 84                                        GAO-03-561 Nursing Home Quality
Appendix VI: Immediate Sanctions
Implemented Under CMS’s Expanded
Immediate Sanctions Policy




 State                                                 CMP amount
 South Dakota                                                  0.00
 Tennessee                                               381,432.50
 Texas                                                 7,677,219.58
 Utah                                                     37,157.00
 Vermont                                                  11,550.00
 Virginia                                                934,425.00
 Washington                                                    0.00
 West Virginia                                           112,160.00
 Wisconsin                                               901,960.50
 Wyoming                                                       0.00
 Total                                               $38,794,439.37
Source: CMS enforcement database.




Page 85                             GAO-03-561 Nursing Home Quality
              Appendix VII: Cases States Did Not Refer to
Appendix VII: Cases States Did Not Refer to
              CMS for Immediate Sanction



CMS for Immediate Sanction

              State survey agencies did not refer to CMS for immediate sanction a
              substantial number of nursing homes found to have a pattern of harming
              residents. Most states failed to refer at least some cases and a few states
              did not refer a significant number of cases.1 While seven states
              appropriately referred all cases, the number of cases that should have
              been but were not referred ranged from 1 to 169. Four states accounted for
              about 55 percent of cases that should have been referred. Table 13 shows
              the number of cases that states should have but did not refer for
              immediate sanction (711) as well as the number of cases that states
              appropriately referred (4,310) from January 2000 through March 2002.

              Table 13: Number of Cases States Did Not Refer for Sanction, as Required, and the
              Number States Appropriately Referred, January 2000 through March 2002

                                                     Number of cases not           Number of cases
                  State                               referred as required                referreda
                  Nation                                               711                    4,310
                  Texas                                                169                      423
                  New York                                             140                       22
                  Massachusetts                                         46                       81
                  Pennsylvania                                          38                      164
                  Connecticut                                           26                      244
                  Washington                                            26                      227
                  Illinois                                              24                      241
                  Florida                                               21                      150
                  New Jersey                                            20                       56
                  Tennessee                                             20                       46
                  Minnesota                                             19                       68
                  Missouri                                              18                      108
                  South Carolina                                        18                        3
                  North Carolina                                        10                      242
                  Arizona                                                9                       24
                  Maryland                                               9                       34
                  Wyoming                                                9                       11
                  California                                             7                       96
                  Michigan                                               7                      284
                  Arkansas                                               6                      115
                  Montana                                                6                       14
                  Ohio                                                   6                      323
                  Idaho                                                  5                       31



              1
               We use the term “cases” because some homes had multiple referrals for immediate
              sanctions.




              Page 86                                              GAO-03-561 Nursing Home Quality
Appendix VII: Cases States Did Not Refer to
CMS for Immediate Sanction




                                                       Number of cases not                          Number of cases
                                                                                                                    a
    State                                               referred as required                               referred
    Indiana                                                                5                                    270
    Louisiana                                                              5                                      82
    Oklahoma                                                               4                                      53
    West Virginia                                                          4                                      11
    Delaware                                                               3                                      14
    Georgia                                                                3                                      81
    Hawaii                                                                 3                                       1
    Iowa                                                                   3                                      44
    New Hampshire                                                          3                                      20
    Colorado                                                               2                                    116
    District of Columbia                                                   2                                       1
    Oregon                                                                 2                                      51
    Rhode Island                                                           2                                       3
    South Dakota                                                           2                                      18
    Virginia                                                               2                                      41
    Wisconsin                                                              2                                      61
    Alabama                                                                1                                      50
    Kansas                                                                 1                                    175
    Maine                                                                  1                                      18
    New Mexico                                                             1                                      19
    Nevada                                                                 1                                      12
    Alaska                                                                 0                                       0
    Kentucky                                                               0                                      75
    Mississippi                                                            0                                      23
    Nebraska                                                               0                                      30
    North Dakota                                                           0                                      20
    Utah                                                                   0                                      11
    Vermont                                                                0                                       3
Source: CMS regional office review of cases identified through GAO’s analysis of OSCAR data and the CMS Enforcement Database.
a
Reflects cases entered in CMS’s enforcement database by March 28, 2002.




Page 87                                                                      GAO-03-561 Nursing Home Quality
                                         Appendix VIII: HCFA State Performance
Appendix VIII: HCFA State Performance    Standards for Fiscal Year 2001



Standards for Fiscal Year 2001

                                         Table 14 summarizes HCFA’s state performance standards for fiscal year
                                         2001, describes the source of the information CMS used to assess
                                         compliance with each standard, and identifies the criteria the agency used
                                         to determine whether states met or did not meet each standard.

Table 14: Overview of HCFA’s Seven State Performance Standards for Nursing Home Survey Activities for Fiscal Year 2001

                                                                                     Criteria for determining compliance
Description                                 Source of information                    with standard
1. Surveys are planned, scheduled, and conducted in a timely manner
At least 10 percent of standard surveys     OSCAR and state survey schedules         At least 10 percent of standard surveys
begin on weekends or “off-hours”                                                     begin on weekends or off-hours
Standard surveys are conducted within       OSCAR                                    100 percent of nursing homes are
prescribed time limits                                                               surveyed within statutory time limits
2. Survey findings (deficiencies) are supportable
State surveyors explain and properly        A random sample of 10 percent            At least 85 percent of the deficiencies
document all deficiencies in survey reports (maximum of 40, minimum of 5) of the     reviewed meet the principles of
following HCFA guidance known as the        state’s survey results in which certain  documentation
“principles of documentation”               deficiencies were cited at “D” or higher
                                            levels of scope and severity
3. Surveys are fully documented and consistent with applicable laws, regulations, and general instructions
Surveys are adequately conducted by state Reports generated from HCFA’s database 100 percent of standard surveys are
agencies using the standards, protocols,    on federal monitoring surveys            adequately conducted by state agencies
forms, methods, procedures, policies, and                                            using the standards, protocols, forms,
systems specified by HCFA instructions                                               methods, procedures, policies, and
                                                                                     systems specified by HCFA instructions
4. When states certify that nursing homes are not in compliance, they follow adverse action procedures set forth in
    regulations and general instructions
“Immediate and Serious Threat” cases are    OSCAR, Enforcement Tracking System       In 95 percent of cases in which there is
processed in a timely manner                reports, and state agency provider       immediate jeopardy or a serious threat to
                                            certification files                      resident health and safety, the state
                                                                                     agency adheres to the 23-day termination
                                                                                     process
Payments are not made to nursing homes      OSCAR, Enforcement Tracking System       The state provides timely notice to HCFA
that have not achieved substantial          reports, and state agency provider       (i.e., 20 days prior to the home’s
compliance within 6 months of their last    certification files                      termination date) on 100 percent of the
surveys                                                                              cases in which the nursing home has not
                                                                                     achieved timely compliance
5. All expenditures and charges to the program are substantiated to the Secretary’s satisfaction
The state agency employs an acceptable      HCFA budget expenditure and workload     More than 20 different items on the two
process for charging federal programs       reports                                  reports submitted by the states are
                                                                                     reviewed for accuracy, completeness, and
                                                                                     timeliness and are scored as either on
                                                                                     time or late, or met or not met for a
                                                                                     reporting period
The state agency has an acceptable          OSCAR reports                            Numerous items submitted by the states,
method for monitoring its current rate of                                            such as quarterly expenditure reports and
expenditures                                                                         supplemental budget requests, are
                                                                                     reviewed to determine if state
                                                                                     requirements for monitoring expenditures
                                                                                     are met, not met, or not applicable




                                         Page 88                                             GAO-03-561 Nursing Home Quality
                                                                Appendix VIII: HCFA State Performance
                                                                Standards for Fiscal Year 2001




                                                                                      Criteria for determining compliance
 Description                                Source of information                     with standard
 6. Conduct and reporting of complaint investigations are timely and accurate, and comply with general instructions for
    handling complaints
 Investigate immediate jeopardy complaints  Semiannual review of a 10 percent         100 percent of immediate jeopardy
 within 2 workdays                          sample of a state’s complaint files       complaints are investigated within 2 days
 Investigate actual harm complaints within  (maximum of 20 cases)                     100 percent of actual harm complaints are
 10 workdays                                                                          investigated within 10 days
 Maintain and follow guidelines for the                                               The state agency has and follows its own
 prioritization of all other complaints                                               written criteria governing the prioritization
                                                                                      of complaints that do not allege immediate
                                                                                      jeopardy or actual harm
 State enters complaint data into OSCAR     Semiannual on-site reviews of 20 state    100 percent of deficiencies cited in the
 appropriately and in a timely manner       complaint survey reports                  sampled complaints are cited under the
                                                                                      correct federal citation
                                            OSCAR data are reviewed quarterly for     Average time to enter results of complaint
                                            timely entry                              investigations does not exceed 20
                                                                                      calendar days from completion of the case
 7. Accurate data on survey results are entered into OSCAR in a timely manner
 Results of standard surveys are entered    Semiannual review of all standard surveys The statewide average time between state
 into OSCAR in a timely manner              based on OSCAR data                       agency sign-off of the certification and
                                                                                      transmittal form and entry of the survey
                                                                                      results into OSCAR does not exceed 20
                                                                                      calendar days
 Results of surveys are entered into OSCAR Semiannual review of a random sample of No less than 85 percent of cases reviewed
 accurately                                 nursing home survey results               demonstrate that data were entered into
                                                                                      OSCAR accurately
Source: HCFA’s State Performance Review Protocol Guidance for fiscal year 2001.

                                                                Note: HCFA did not finalize and issue the fiscal 2001 performance standards and guidance until April
                                                                2001.




                                                                Page 89                                                      GAO-03-561 Nursing Home Quality
                                                               Appendix IX: Highlights of State Compliance
Appendix IX: Highlights of State Compliance                    with CMS Performance Standards



with CMS Performance Standards

                                                               Table 15 summarizes the results of CMS’s fiscal year 2001 state
                                                               performance review for each of the five standards we analyzed. We
                                                               focused on five of CMS’s seven performance standards: statutory survey
                                                               intervals, the supportability of survey findings, enforcement requirements,
                                                               the adequacy of complaint activities, and OSCAR data entry. Because
                                                               several standards included multiple requirements, the table shows the
                                                               results of each of these specific requirements separately.

Table 15: State Compliance with Selected CMS Performance Standards, Fiscal Year 2001

 CMS standard and requirements                                                                                     Number of states not meeting standard
 Survey timeliness
 The state begins no less than 10 percent of its standard surveys during                                                                                       2
 weekends or “off-hours.” (Standard 1, criterion 1)
 The state conducts standard surveys in prescribed times. (Standard 1,
 criterion 2)
 • The average statewide interval between consecutive standard surveys                                                                                         9
     is not greater than 12 months.
 • Each home is surveyed within 15 months of its prior survey.                                                                                                 17
 Supportability of survey findings
 The state explains and properly documents deficiencies. (Standard 2)                                     Due to complications with the review protocol, this
                                                                                                                                standard was not reported.
 Enforcement
 The state properly follows termination procedures. (Standard 4, criterion 1)                                                                                  3
 The state notifies CMS when a nursing home has not achieved substantial                                                                                       4
 compliance in a timely manner. (Standard 4, criterion 2)
 Complaints
 The state investigates all complaints alleging immediate jeopardy to a                                                                                        12
 resident within 2 workdays. (Standard 6, criterion 1)
 The state investigates all complaints alleging actual harm to a resident                                                                                      42
 within 10 workdays. (Standard 6, criterion 2)
 The state has and follows guidelines for prioritizing complaints not alleging                                                                                 15
 immediate jeopardy or actual harm. (Standard 6, criterion 3)
 The state enters citations resulting from complaint investigations into                                                                                       13
 CMS’s complaint database. (Standard 6, criterion 4)
 OSCAR
 The state enters survey results into CMS’s database in a timely manner.                                                                                       9
 (Standard 7, criterion 1)
 The state enters survey results into CMS’s database accurately. (Standard                                                                                     24
 7, criterion 2)
Source: GAO analysis of results of CMS Fiscal Year 2001 State Performance Standard Reviews.

                                                               Note: We reviewed five of the seven CMS performance standards. See app. VIII, table 14, for a
                                                               description of standards three and five, which we did not review.




                                                               Page 90                                                     GAO-03-561 Nursing Home Quality
             Appendix X: Comments from the Centers for Medicare & Medcaid Services
Appendix X: Comments from the Centers for
Medicare & Medcaid Services




             Page 91                                             GAO-03-561 Nursing Home Quality
Appendix X: Comments from the Centers for Medicare & Medcaid Services




Page 92                                             GAO-03-561 Nursing Home Quality
Appendix X: Comments from the Centers for Medicare & Medcaid Services




Page 93                                             GAO-03-561 Nursing Home Quality
Appendix X: Comments from the Centers for Medicare & Medcaid Services




Page 94                                             GAO-03-561 Nursing Home Quality
                   Appendix XI: GAO Contact and Staff
Appendix XI: GAO Contact and Staff
                   Acknowledgements



Acknowledgements

                   Walter Ochinko, (202) 512-7157
GAO Contact

                   The following staff made important contributions to this work: Jack
Acknowledgements   Brennan, Patricia A. Jones, Dan Lee, Dean Mohs, and Peter Schmidt.




                   Page 95                                     GAO-03-561 Nursing Home Quality
             Related GAO Products
Related GAO Products


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

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

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

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

             Nursing Homes: Success of Quality Initiatives Requires Sustained
             Federal and State Commitment. GAO/T-HEHS-00-209. Washington, D.C.:
             September 28, 2000.

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

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

             Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies
             to Better Ensure Quality of Care. GAO/T-HEHS-00-27. Washington, D.C.:
             November 4, 1999.

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

             Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but
             Will Require Continued Commitment. GAO/T-HEHS-99-155. Washington,
             D.C.: June 30, 1999.

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

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


             Page 96                                    GAO-03-561 Nursing Home Quality
           Related GAO Products




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

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

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

           California Nursing Homes: Federal and State Oversight Inadequate to
           Protect Residents in Homes with Serious Care Problems. GAO/T-HEHS-
           98-219. Washington, D.C.: July 28, 1998.

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




(290158)
           Page 97                                  GAO-03-561 Nursing Home Quality
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