Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies to Better Ensure Quality Care

Published by the Government Accountability Office on 1999-11-04.

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

                             United States General Accounting Office

GAO                          Before the Special Committee on Aging, U.S. Senate

For Release on Delivery
Expected at 10:00 a.m.
Thursday, November 4, 1999   NURSING HOMES

                             Enhanced HCFA Oversight
                             of State Programs Would
                             Better Ensure Quality Care
                             Statement of William J. Scanlon, Director
                             Health Financing and Public Health Issues
                             Health, Education, and Human Services Division

Nursing Homes: Enhanced HCFA Oversight
of State Programs Would Better Ensure
Quality Care
             Mr. Chairman and Members of the Committee:

             We appreciate the opportunity to participate in the Committee’s hearing
             focusing on HCFA’s regional offices and their ability to oversee state
             agencies they contract with to ensure that nursing homes comply with
             federal quality standards. Today, I will discuss our study of HCFA’s
             implementation of two of its nursing home initiatives: one requiring
             enhanced federal review of state agencies’ survey processes, and the other
             addressing remedies and sanctions to be applied when inadequate state
             performance is identified.

             The 1.6 million elderly and disabled residents of the nation’s more than
             17,000 nursing homes are among the sickest and most vulnerable
             populations in the nation, often needing extensive assistance with basic
             activities of daily living such as dressing, grooming, feeding, and using the
             bathroom. In 1999, these nursing homes are expected to receive nearly $39
             billion in federal payments from the Medicare and Medicaid programs. To
             help ensure that they provide proper care to their residents, state agencies,
             under contract with the federal government, perform detailed inspections
             at each of the homes. The purpose of these state agency surveys is to
             ensure that nursing homes comply with federal quality standards and that
             inadequate resident care is identified and corrected. HCFA, in turn, is
             statutorily required to make sure that each state agency has an effective
             survey process in place.

             The series of hearings this Committee has held over the past 15 months
             has highlighted both the disturbingly high frequency of unacceptably poor
             care that many nursing home residents receive as well as weaknesses in
             federal and state programs charged with ensuring quality care. This has
             helped to generate a renewed commitment by HCFA and many states to
             improve their programs to ensure that nursing homes meet quality
             standards, including a broad range of about 30 initiatives that HCFA has
             undertaken to strengthen federal standards, oversight, and enforcement
             for nursing homes. In reports issued at the Committee’s request since July
             1998, we have documented the severity of care problems nationwide and
             inadequacies in the survey and enforcement process that too often leave
             these problems unidentified or uncorrected, and have made
             recommendations to strengthen HCFA’s oversight of nursing homes.1 This
             summer, we testified that the initial implementation of some of HCFA’s

             1A list of related GAO products is at the end of this statement.

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Nursing Homes: Enhanced HCFA Oversight
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initiatives has been uneven among the states and will require continued
commitment by the Congress, HCFA, and the states.2

The focus of today’s hearing is HCFA regional offices’ oversight of state
agencies that perform the surveys of nursing homes. The hearing
addresses issues fundamental to ensuring that homes meet federal care
standards protecting residents and ensuring that the states adhere to the
new, stronger federal policies resulting from HCFA’s nursing home
initiatives. The information we are presenting here discusses HCFA’s
progress in implementing two important initiatives to improve its state
oversight. In a report we are releasing today, we provide more detailed

In brief, we found that HCFA’s mechanisms for assessing state agency
survey performance are limited in their scope and effectiveness and are
not being applied consistently across each of HCFA’s 10 regional offices.
As a result, HCFA does not have sufficient, consistent, and reliable data to
evaluate state agencies or to measure the success of its other nursing
home initiatives. Given the wide range in the frequencies with which states
identify serious deficiencies, HCFA cannot be certain whether states with
lower rates of deficiencies have better quality homes or are failing to
identify deficiencies that harm nursing home residents.

This uncertainty results, in part, because HCFA makes negligible use of
independent inspections, known as comparative surveys, that could
surface information about whether states appropriately cite deficiencies.
Generally, only one to two comparative surveys per state were conducted
in the more than 17,000 nursing homes over the last year. Nevertheless,
two-thirds of these surveys found deficiencies that were more serious than
those found by state surveyors during their reviews conducted typically 1
or 2 months earlier. About 90 percent of the inspections HCFA conducts
nationwide are, instead, observational surveys. These surveys, in which
HCFA surveyors accompany state survey teams, are useful in helping
HCFA to provide training to state surveyors, but are limited as a method
for evaluating state agencies’ performance. HCFA’s presence during these
surveys is likely to make state surveyors more attentive to their survey
tasks than they would be if they were not being observed–the Hawthorne
effect. Beyond these surveys, HCFA also relies on a quality improvement
program that is largely based on states’ self-reported performance

2Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will Require Continued
Commitment (GAO/T-HEHS-99-155, June 30, 1999).
3See Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better Ensure Quality
(GAO/HEHS-00-6, Nov. 4, 1999).

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             Nursing Homes: Enhanced HCFA Oversight
             of State Programs Would Better Ensure
             Quality Care

             measures, which do not accurately or completely reflect problems in the
             state’s performance.

             These limitations in HCFA’s oversight methods are compounded by
             inconsistencies in how the methods are applied by its regions. For
             example, the regions vary in how they select nursing home surveys to
             review and how they choose samples of residents to review. Regions also
             commit differing amounts of time to conduct observational surveys,
             ranging on average from 27 to 71 hours, which raises questions about
             whether the level of effort some regions dedicate to observational surveys
             is sufficient to thoroughly review state surveyors’ performance.

             Furthermore, for state agencies whose performance has been found
             inadequate, HCFA has not developed a sufficient array of alternatives to
             encourage agencies to correct serious deficiencies in their processes. Our
             report includes several recommendations to assist the HCFA
             Administrator in improving the rigor, consistency, and effectiveness of
             HCFA’s programs to oversee state agencies responsible for certifying that
             nursing homes meet federal standards for participation in Medicare and

Background   On the basis of statutory requirements, HCFA defines standards that
             nursing homes must meet to participate in the Medicare and Medicaid
             programs and contracts with states to certify that homes meet these
             standards through annual inspections and other types of reviews,
             including complaint investigations. The annual inspection, which must be
             conducted no less than every 15 months at each home, entails a team of
             state surveyors spending several days on-site conducting a broad review to
             determine whether care and services meet the assessed needs of residents.
             HCFA has established specific protocols for state surveyors to use in
             conducting these comprehensive reviews.

             HCFA is statutorily required to establish an oversight program for
             evaluating the adequacy and effectiveness of each state’s nursing home
             survey process, relying on its 122 surveyors in 10 regional offices to carry
             out these oversight responsibilities. While HCFA’s Center for Medicaid and
             State Operations is the central HCFA division responsible for developing
             guidance to states embodying national policies related to nursing home
             oversight and enforcement, the regional officials who oversee the state
             survey agencies are not formally subordinated to this Center. Rather, they
             report to a Regional Administrator. The 10 regions are further organized
             into 4 regional consortia, and both the regional consortia heads and the
             Director of the Center for Medicaid and State Operations report directly to

             Page 3                                                      GAO/T-HEHS-00-27
Nursing Homes: Enhanced HCFA Oversight
of State Programs Would Better Ensure
Quality Care

HCFA’s Administrator.4 In addition to developing overall policy guidance,
the Center’s staff carry out their day-to-day role of coordinating regional
office oversight of the states through numerous less formal interactions
with regional officials, including meetings and conference calls between
managers and staff from the Center and the regions. If a disagreement
between the Center and a regional office cannot be informally settled at a
lower level, it can only be resolved at the level of the HCFA Administrator.

The Omnibus Budget Reconciliation Act of 1987 requires HCFA’s
surveyors to conduct federal monitoring surveys in at least 5 percent of
the nursing homes in each state each year within 2 months of the state’s
completion of its survey. HCFA uses a mix of two types of on-site reviews
to fulfill this 5-percent mandate: (1) comparative surveys, in which a team
of federal surveyors conducts a complete, independent survey of a nursing
home after the state has finished its survey and compares the state’s
survey results with its own, and (2) observational surveys, in which federal
surveyors accompany and observe the state surveyors as they perform a
variety of survey tasks, give state surveyors verbal feedback, and later
provide a written rating of the state surveyors’ performance to state
managers. HCFA introduced revisions in its federal monitoring program in
October 1998 that require a minimum of 1 to 3 comparative surveys in
each state each year and that also developed a standard set of procedures
all regions are expected to follow in conducting an observational survey.
In addition to the comparative and observational surveys, HCFA has other
sources of information available for evaluating state agency performance,
including a quality improvement program that requires state agencies to
establish performance measures and develop action plans addressing
deficiencies in the state’s survey process.

If HCFA determines that a state agency’s survey performance is
inadequate, it can impose appropriate remedies or sanctions against the
state agency. Among several remedies and sanctions HCFA can use
currently are requiring the state to submit a written plan of correction
explaining how it plans to eliminate the identified deficiencies; reducing
federal funds for state survey and certification activities; and ultimately,
terminating HCFA’s contract with the state.

To assess HCFA’s oversight activities, we obtained data about federal
monitoring surveys and other oversight efforts from HCFA and each of its

4The regional consortia play an important role in administering HCFA policies in other HCFA
functions, such as oversight of the Peer Review Organization program and Medicare+Choice plans. In
these areas, most functions have been consolidated into one of the two or three regional offices in the
consortium. However, each of the 10 regional offices carries out the full range of functions relating to
oversight of state agencies’ implementation of HCFA’s guidance relating to nursing homes.

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                          Nursing Homes: Enhanced HCFA Oversight
                          of State Programs Would Better Ensure
                          Quality Care

                          10 regions, interviewed officials at HCFA headquarters and 3 of its regions,
                          and met with state surveyors from four states (Florida, Missouri,
                          Tennessee, and Washington).

HCFA Makes Negligible     An effective HCFA program for assessing state agencies’ performance in
                          certifying that nursing homes meet federal standards for quality care is
Use of Comparative        especially important given concerns that some state agencies miss serious
Surveys to Assess State   care problems. Our work in California found that surveyors missed some
                          problems that affect the health and safety of residents. In addition, HCFA
Agencies’ Performance     data show significant variations in the extent to which state surveyors
                          identify serious deficiencies. For example, state survey agencies in
                          Washington, Idaho, North Dakota, and Kansas identified serious
                          deficiencies resulting in harm to residents in more than half their surveys–
                          more than 4 times the rate of serious deficiencies found by survey
                          agencies in Maine, Colorado, Tennessee, and Oklahoma. With such a
                          range, HCFA needs to know to what extent such data accurately portray
                          the quality of care provided or the adequacy of state performance in the
                          survey process.

                          However, HCFA makes negligible use of comparative surveys–
                          independent re-surveys of homes–which are its most effective technique
                          for determining whether state surveyors miss deficiencies. HCFA requires
                          that only 1 or 2 of these surveys be completed each year in most of the
                          states. Yet, more than two-thirds of the 64 comparative surveys HCFA
                          conducted between October 1998 and August 1999 identified more serious
                          deficiencies than the state identified.

                          For example, in one of its comparative surveys, surveyors from HCFA’s
                          Kansas City region found 24 deficiencies in a Missouri nursing home that
                          state surveyors did not identify during their survey conducted about 6
                          weeks earlier. One of these deficiencies identified six residents whose
                          nutritional status was not being adequately assessed by the nursing home,
                          resulting in significant weight loss in several cases. One resident lost 19
                          percent of his weight between June and October 1998. His weight at the
                          time of HCFA’s survey was 93 pounds, which HCFA indicated was
                          significantly below the resident’s minimally acceptable body weight of 108
                          pounds. Fewer than 4 months after his admission to the nursing home, this
                          resident also had developed two moderately severe pressure sores, which
                          the home was inappropriately treating with a cream the manufacturer
                          stated was not intended to heal pressure sores but rather to prevent
                          irritation to the skin. According to HCFA surveyors, these deficiencies
                          affecting multiple residents should have been evident at the time of the
                          state’s survey, but the state surveyors did not cite them.

                          Page 5                                                      GAO/T-HEHS-00-27
Nursing Homes: Enhanced HCFA Oversight
of State Programs Would Better Ensure
Quality Care

Because of the time that typically elapses between a state’s survey and
HCFA’s comparative survey, HCFA often cannot be certain whether
HCFA-identified deficiencies are the result of poor state agency
performance, such as state surveyors’ failure to identify deficiencies, or to
changed conditions in the nursing home following the state survey.
Typically, these surveys occur 1 month after the state completes its survey
but sometimes occur as much as 2 months later. In August 1999, HCFA
instructed its regions to start comparative surveys within 2 to 4 weeks
after the state’s survey, but even this delay could result in problems
comparing results. State and federal surveyors told us that comparative
surveys are more effective and reliable in assessing state performance if
they start immediately after the state has completed its survey, even as
soon as the day after the state’s exit from the home.

Rather than making more extensive use of comparative surveys, HCFA
instead conducts 90 percent of its surveys as “observational” surveys, in
which its regional surveyors accompany and observe state surveyors as
they conduct all or a portion of their survey. These observational surveys
may help HCFA to identify state agency training needs, but several
problems inhibit their ability to give a clear and accurate picture of a
state’s survey capability. Perhaps most importantly, HCFA’s presence may
make state surveyors more attentive to their survey tasks than they would
be if they were not being observed. This is an example of the Hawthorne
effect, in which individuals tend to improve their performance when they
are aware they are being studied. As a result, observational surveys do not
necessarily provide a valid assessment of typical state surveyor

Another HCFA oversight mechanism, which predates HCFA’s recent
nursing home initiatives, also has significant shortcomings. Under the
State Agency Quality Improvement Program, each state does a yearly self-
assessment and informs HCFA as to whether it is in compliance with
seven survey requirements, such as investigating complaints effectively. As
an oversight program, its effectiveness is limited because HCFA does not
validate the information included in the states’ self-assessment as was
required under this program’s predecessor, and thus has no assurance that
the states surface all serious problems or that they correct all the
problems they have identified. For instance, in our prior work we found
that some states were not promptly reviewing complaints filed against
nursing homes, yet they had not identified this problem to HCFA as part of
their quality improvement program.5 In addition, HCFA has no policy
regarding consequences for states that do not provide accurate

5GAO/HEHS-99-80, Mar. 22, 1999.

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                           Nursing Homes: Enhanced HCFA Oversight
                           of State Programs Would Better Ensure
                           Quality Care

                           information through this program. Furthermore, although the program
                           also addresses some state agency performance standards that must be
                           reviewed by HCFA’s staff, these standards do not include some important
                           aspects of a state agency’s performance, such as determining whether the
                           timing of a state agency’s surveys can be predicted by the nursing homes.

HCFA Regions Are           In addition to these weaknesses in its oversight mechanisms, HCFA
                           regions are uneven in the way they implement them, resulting in limited
Inconsistent in How        assurance that states are being held equally accountable to federal
They Conduct Oversight     standards, including the recent initiatives. Although HCFA established the
                           current federal monitoring surveys to develop a uniform national approach
Activities                 for regions to follow, the regions use different methods for selecting
                           surveys to review and for conducting reviews. Examples follow:

                         • Some regions comply with HCFA guidance on comparative surveys by
                           selecting homes with no established pattern of deficiencies, while other
                           regions focus on homes that the state has already identified as having
                           serious deficiencies. By doing the latter, HCFA is unlikely to identify
                           situations in which state surveyors underreport serious deficiencies.
                           Furthermore, HCFA’s broad guidance for selecting observational surveys
                           does not ensure that its reviews assess as many state surveyors as possible
                           to maximize the training effect.

                         • In conducting comparative surveys, the regions vary in how they select
                           resident samples, with some regions selecting a sample that includes some
                           overlap with the state’s sample and other regions making no attempt to do

                         • The regions also, on average, spend very different amounts of time to
                           conduct an observational survey. While the average time spent on these
                           surveys is 52 hours, the regions range from an average of 27 hours to 71
                           hours to conduct these surveys, thus raising questions about the level of
                           effort some regions devote to gauging state performance. Table 1 provides
                           additional detail on the variation in regional resources available and in the
                           time spent to complete observational surveys.

                           Page 7                                                       GAO/T-HEHS-00-27
Nursing Homes: Enhanced HCFA Oversight
of State Programs Would Better Ensure
Quality Care

Table 1: Variation in Resources Available and in Time to Complete
Observational Surveys
                                                     Ratio of
                                               observational Average no. of hours
                                          surveys required in   per observational
                      Ratio of state to       1999 to federal  survey (Oct. 1998 -
Region              federal surveyors              surveyors           July 1999)
Boston                          14 to 1                 5 to 1                 27
New York                        33 to 1                 7 to 1                 31
Philadelphia                    16 to 1                 6 to 1                 49
Atlanta                         33 to 1                 7 to 1                 61
Chicago                         31 to 1                 8 to 1                 71
Dallas                          60 to 1                10 to 1                 38
Kansas City                     30 to 1                 6 to 1                 51
Denver                          18 to 1                 4 to 1                 59
San Francisco                   27 to 1                 8 to 1                 54
Seattle                         16 to 1                 3 to 1                 52
Nationwide                      28 to 1                 7 to 1                 52

In addition, HCFA regional officials make different use of the State Agency
Quality Improvement Program for overseeing state agency performance.
Some regions supplement information provided by the states through the
quality improvement program by extensively analyzing available survey
performance data, while other regions do not believe there is a need to use
these supplemental data to assess state survey performance. For example,
HCFA’s Atlanta region recently started a program to conduct in-depth
analyses of each state agency in its region using available survey data.
Through these analyses, the region determined that the annual state
surveys of nursing homes in four of its eight states are highly predictable,
contrary to HCFA policy. It also found that in four of the six states where
it has completed reviews, more than half of the time state surveyors did
not conduct revisits of nursing homes, to determine whether identified
deficiencies had been corrected, within the 55 days recommended by

In testimony before your Committee this summer, we also noted that the
HCFA regions do not consistently monitor state implementation of new,
stronger policies resulting from HCFA’s nursing home initiatives. When we
asked the regional offices how they were monitoring states’
implementation of these initiatives, their responses ranged from no
monitoring of most of the implemented initiatives to requiring states to
submit special monthly reports on how they were implementing several of
the initiatives. These uneven monitoring practices, combined with the
limitations we found in HCFA’s more formalized monitoring approaches,

Page 8                                                           GAO/T-HEHS-00-27
                     Nursing Homes: Enhanced HCFA Oversight
                     of State Programs Would Better Ensure
                     Quality Care

                     result in HCFA not being sufficiently informed about what the states are
                     doing to implement these initiatives.

HCFA’s Options for   Even if HCFA identifies inadequate state agency performance, it currently
                     does not have an adequate array of effective remedies or sanctions to
Addressing Poorly    ensure corrections. Most commonly, HCFA provides training to surveyors
Performing State     or survey teams. HCFA may also require the state to submit a plan of
                     correction, provide technical assistance, and assume responsibility for
Agencies Are         developing the state’s survey schedule. If these remedies fail, HCFA has
Inadequate           two sanctions available that it may then apply–reducing a state’s survey
                     and certification funding or terminating its survey contract. Because of the
                     extreme nature of these sanctions, HCFA has only once reduced state
                     funding and has never terminated a state’s contract.

                     To support reducing the state’s survey and certification funding, HCFA
                     requires evidence showing a pattern of inadequate state performance,
                     which its current oversight structure does not effectively provide. In
                     essence, HCFA must show that a state agency demonstrates a pattern of
                     failing to identify serious deficiencies. However, because HCFA conducts
                     so few comparative surveys, and observational surveys are not intended to
                     identify all missed deficiencies, it is not currently possible for HCFA to
                     establish that a state consistently fails to identify serious deficiencies.

                     As part of its nursing home initiatives, HCFA established a task force in
                     late 1998 to expand and clarify the definition of inadequate state survey
                     performance and to suggest additional remedies and sanctions for state
                     agencies that perform poorly. The task force has preliminarily proposed
                     two additional sanctions for HCFA’s use: (1) placing a state agency on
                     notice that it is not in compliance with its Medicaid plan regarding nursing
                     home survey performance and (2) requiring HCFA officials to meet with
                     the governor and other high-level state officials. Although HCFA refers to
                     these two proposed actions as sanctions, they are not as severe as what
                     are normally thought of as sanctions and may not be forceful enough to
                     compel a state to improve its performance. Regarding placing the state
                     agency on notice, we were told that it means that HCFA expects its
                     regions to work collaboratively with state agencies to urge compliance
                     with the requirements in their state Medicaid plans. Furthermore, although
                     the proposed sanction requiring HCFA officials to meet with the governor
                     or other state officials can raise problems to a higher level in state
                     government and possibly secure greater state support to improve
                     performance, it is not clear what effect this sanction would have in
                     compelling a state agency to improve its performance. HCFA intends to
                     have these two new sanctions in place by the end of 1999. HCFA also plans

                     Page 9                                                      GAO/T-HEHS-00-27
                             Nursing Homes: Enhanced HCFA Oversight
                             of State Programs Would Better Ensure
                             Quality Care

                             to issue additional state survey agency performance standards and
                             measures, and indicated that over the next 18 months it will determine
                             whether the expanded remedies and sanctions have been effective in
                             improving state agency performance. At that time, HCFA will determine
                             whether additional remedies or sanctions should be developed.

HCFA Should                  HCFA has taken many positive steps–including 30 wide-ranging
                             initiatives–that demonstrate its commitment to improving the quality of
Strengthen Its Oversight     care that nursing home residents receive. These steps include a major
of State Programs            effort to enhance its oversight of state agencies, but the limited scope and
                             rigor of its various state performance monitoring mechanisms, and their
                             uneven application across the regions, do not give HCFA a systematic,
                             consistent means of assessing state survey performance. Specifically, the
                             negligible use of comparative surveys, combined with delays in starting
                             them, does not provide HCFA with sufficient evidence to determine
                             whether states are appropriately assessing nursing homes’ compliance
                             with federal standards. Furthermore, inconsistencies among the regional
                             offices in their oversight of state agency performance hamper HCFA’s
                             ability to ensure that all state agencies are being held equally accountable
                             for their performance. Even though HCFA is strengthening its oversight
                             mechanisms to be able to establish a pattern of unacceptable state survey
                             performance, it has not developed effective alternatives for ensuring that
                             states meet federal standards.

                             Our report issued today contains several specific recommendations to
                             HCFA to strengthen its oversight of state survey agencies’ activities. These
                             recommendations are intended to help HCFA ensure that states meet
                             federal standards for certifying that nursing homes provide adequate care
                             and consistently implement the more stringent standards required by
                             HCFA’s recent initiatives. Our recommendations include that the HCFA

                           • Improve the scope and rigor of HCFA’s oversight process by
                             increasing the use of comparative surveys and ensuring that they are
                             initiated more promptly after states’ surveys.

                           • Improve the consistency of HCFA oversight across regional offices
                             by standardizing procedures for selecting and conducting federal
                             monitoring surveys.

                           • Further explore the feasibility of appropriate, alternative remedies
                             or sanctions for those states that prove unable or unwilling to meet
                             HCFA’s performance standards.

                             Page 10                                                     GAO/T-HEHS-00-27
                   Nursing Homes: Enhanced HCFA Oversight
                   of State Programs Would Better Ensure
                   Quality Care

                   In reviewing a draft of our report, HCFA reaffirmed that enhanced
                   oversight of state programs is critical to improving the quality of care in
                   nursing homes and generally agreed with our recommendations. Although
                   HCFA indicated that it needs to further evaluate the appropriate course of
                   action, it is clear that HCFA’s continued efforts and initiatives, in concert
                   with the Committee’s ongoing oversight, have the potential to make a
                   decided difference in the quality of care for the nation’s nursing home

                   Mr. Chairman, this concludes my statement. I will be happy to answer any
                   questions that you or other Members of the Committee may have.

GAO Contacts and   For further contacts regarding this testimony, please call William J.
                   Scanlon or Kathryn G. Allen at (202) 512-7114. Individuals making key
Acknowledgments    contributions to this testimony included John Dicken, Jack Brennan, and
                   Mary Ann Curran.

                   Page 11                                                      GAO/T-HEHS-00-27
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             Nursing Home Oversight: Industry Examples Do Not Demonstrate That
             Regulatory Actions Were Unreasonable (GAO/HEHS-99-154R, Aug. 13,

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

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

             Nursing Homes: Complaint Investigation Processes in Maryland (GAO/T-
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             Nursing Homes: Complaint Investigation Processes Often Inadequate to
             Protect Residents (GAO/HEHS-99-80, Mar. 22, 1999).

             Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
             Federal Quality Standards (GAO/HEHS-99-46, Mar. 18, 1999).

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


             Page 12                                                 GAO/T-HEHS-00-27
Page 13   GAO/T-HEHS-00-27
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