Nursing Home Quality
Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight
Gao ID: GAO-03-561 July 15, 2003
Since July 1998, GAO has reported numerous times on nursing home quality-of-care issues and identified significant weaknesses in federal and state oversight. GAO was asked to assess the extent of the progress made in improving the quality of care provided by nursing homes to vulnerable elderly and disabled individuals, including (1) trends in measured nursing home quality, (2) state responses to previously identified weaknesses in their survey, complaint, and enforcement activities, and (3) the status of oversight and quality improvement efforts by the Centers for Medicare & Medicaid Services (CMS).
The proportion of nursing homes with serious quality problems remains unacceptably high, despite a decline in the incidence of such reported problems. Actual harm or more serious deficiencies were cited for 20 percent or about 3,500 nursing homes during an 18-month period ending January 2002, compared to 29 percent for an earlier period. Fewer discrepancies between federal and state surveys of the same homes suggests that state surveyors are doing a better job of documenting serious deficiencies and that the decline in serious quality problems is potentially real. Despite these improvements, the continuing prevalence of and state surveyor understatement of actual harm deficiencies is disturbing. For example, 39 percent of 76 state surveys from homes with a history of quality-of-care problems--but whose current survey found no actual harm deficiencies--had documented problems that should have been classified as actual harm or higher, such as serious, avoidable pressure sores. Weaknesses persist in state survey, complaint, and enforcement activities. 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 predictable in their timing, allowing homes to conceal problems if they chose to do so. Considerable state variation remains regarding the ease of filing a complaint, the appropriateness of the investigation priorities, and the timeliness of investigations. Some states attributed timeliness problems to inadequate staff and an increase in the number of complaints. Although the agency strengthened enforcement policy by requiring states to refer for immediate sanction homes that had repeatedly harmed residents, GAO found that states failed to refer a substantial number of such homes, significantly undermining the policy's intended deterrent effect. CMS oversight of state survey activities has improved but requires continued attention to help ensure compliance with federal requirements. While CMS strengthened oversight by initiating annual state performance reviews, officials acknowledged that the reviews' effectiveness could be improved. For the initial fiscal year 2001 review, officials said they lacked the capability to systematically distinguish between minor lapses and more serious 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 the survey methodology, improving surveyor guidance for determining the scope and severity of deficiencies, and producing greater standardization in state complaint processes. These initiatives are critical to reducing the subjectivity evident in current state survey and complaint activities.
Recommendations
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GAO-03-561, Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight
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Declining, Reinforces Importance of Enhanced Oversight' which was
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Report to Congressional Requesters:
United States General Accounting Office:
GAO:
July 2003:
Nursing Home Quality:
Prevalence of Serious Problems, While Declining, Reinforces Importance
of Enhanced Oversight:
GAO-03-561:
GAO Highlights:
Highlights of GAO-03-561, a report to congressional requesters
Why GAO Did This Study:
Since July 1998, GAO has reported numerous times on nursing home
quality-of-care issues and identified significant weaknesses in
federal and state oversight. GAO was asked to assess the extent of
the progress made in improving the quality of care provided by nursing
homes to vulnerable elderly and disabled individuals, including
(1) trends in measured nursing home quality, (2) state responses to
previously identified weaknesses in their survey, complaint, and
enforcement activities, and (3) the status of oversight and quality
improvement efforts by the Centers for Medicare & Medicaid Services
(CMS).
what GAO Found:
The proportion of nursing homes with serious quality problems remains
unacceptably high, despite a decline in the incidence of such reported
problems. Actual harm or more serious deficiencies were cited for 20
percent or about 3,500 nursing homes during an 18-month period ending
January 2002, compared to 29 percent for an earlier period. Fewer
discrepancies between federal and state surveys of the same homes
suggests that state surveyors are doing a better job of documenting
serious deficiencies and that the decline in serious quality problems
is potentially real. Despite these improvements, the continuing
prevalence of and state surveyor understatement of actual harm
deficiencies is disturbing. For example, 39 percent of 76 state
surveys from homes with a history of quality-of-care problems”but
whose current survey found no actual harm deficiencies”had documented
problems that should have been classified as actual harm or higher,
such as serious, avoidable pressure sores.
Weaknesses persist in state survey, complaint, and enforcement
activities. 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 predictable in their timing,
allowing homes to conceal problems if they chose to do so.
Considerable state variation remains regarding the ease of filing a
complaint, the appropriateness of the investigation priorities, and
the timeliness of investigations. Some states attributed timeliness
problems to inadequate staff and an increase in the number of
complaints. Although the agency strengthened enforcement policy by
requiring states to refer for immediate sanction homes that had
repeatedly harmed residents, GAO found that states failed to refer a
substantial number of such homes, significantly undermining the
policy‘s intended deterrent effect.
CMS oversight of state survey activities has improved but requires
continued attention to help ensure compliance with federal
requirements. While CMS strengthened oversight by initiating annual
state performance reviews, officials acknowledged that the reviews‘
effectiveness could be improved.
For the initial fiscal year 2001 review, officials said they lacked
the capability to systematically distinguish between minor lapses and
more serious 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 the survey methodology,
improving surveyor guidance for determining the scope and severity of
deficiencies, and producing greater standardization in state complaint
processes. These initiatives are critical to reducing the subjectivity
evident in current state survey and complaint activities.
What GAO Recommends:
GAO is making several recommendations to the Administrator of CMS to
(1) strengthen the nursing home survey process, (2) ensure that state
survey and complaint activities adequately assess quality-of-care
problems, and (3) improve CMS oversight of state survey activities.
CMS concurred with the report‘s recommendations, but its comments on
intended actions were not fully responsive to all of the
recommendations. Eleven states provided comments that most often
focused on the resource constraints states face in meeting federal
standards for oversight of nursing homes.
www.gao.gov/cgi-bin/getrpt?GAO-03-561.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Kathryn G. Allen at
(202) 512-7118.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Magnitude of Problems Remains Cause for Concern Even Though Fewer
Serious Nursing Home Quality Problems Reported:
Weaknesses Persist in State Survey, Complaint, and Enforcement
Activities:
CMS Oversight of State Survey Activities Requires Further
Strengthening:
Conclusions:
Recommendations for Executive Action:
Agency and State Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Trends in The Proportion of Nursing Homes Cited for Actual
Harm or Immediate Jeopardy Deficiencies, 1997-2002:
Appendix III: Abstracts of Nursing Home Survey Reports That Understated
Quality-of-Care Problems:
Appendix IV: Information on State Nursing Home Surveyor Staffing:
Appendix V: Predictability of Standard Nursing Home Surveys:
Appendix VI: Immediate Sanctions Implemented Under CMS's Expanded
Immediate Sanctions Policy:
Appendix VII: Cases States Did Not Refer to CMS for Immediate Sanction:
Appendix VIII: HCFA State Performance Standards for Fiscal Year 2001:
Appendix IX: Highlights of State Compliance with CMS Performance
Standards:
Appendix X: Comments from the Centers for Medicare & Medcaid Services:
Appendix XI: GAO Contact and Staff Acknowledgements:
GAO Contact:
Acknowledgements:
Related GAO Products:
Tables:
Table 1: Scope and Severity of Deficiencies Identified During Nursing
Home Surveys:
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:
Table 3: Incidence of Underreported Actual Harm Deficiencies in Surveys
GAO Reviewed:
Table 4: Predictability of Nursing Home Surveys:
Table 5: Key Findings of Report to CMS on State Complaint Investigation
Processes:
Table 6: Quality of Care Requirements Reviewed in a Sample of State
Survey Reports:
Table 7: Trends in the Percentage of Nursing Homes Cited for Actual
Harm or Immediate Jeopardy during State Standard Surveys, by State:
Table 8: Abstracts of the 39 Nursing Home Deficiencies that Understated
Actual Harm from a Sample of 76 Nursing Home Survey Reports:
Table 9: State Survey Agency Responses to Questions about Surveyor
Experience, Vacancies, Hiring Freezes, Competitiveness of Salaries, and
Minimum Required Experience:
Table 10: Predictability of Current Nursing Home Surveys, by State:
Table 11: Federal Sanctions Implemented against Nursing Homes Referred
for Immediate Sanction, January 14, 2000, through March 28, 2002:
Table 12: Federal CMPs Implemented under CMS's Immediate Sanctions
Policy, 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:
Table 14: Overview of HCFA's Seven State Performance Standards for
Nursing Home Survey Activities for Fiscal Year 2001:
Table 15: State Compliance with Selected CMS Performance Standards,
Fiscal Year 2001:
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:
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:
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.[Footnote 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.[Footnote
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.[Footnote 3] Since 1998, the agency has worked
to strengthen surveyors' 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;[Footnote 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.
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.[Footnote 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.
Results in Brief:
State survey data indicate that the proportion of nursing homes with
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
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 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.
Background:
Combined Medicare and Medicaid payments to nursing homes for care
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.[Footnote
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 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.[Footnote 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.[Footnote 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. 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:
Severity: Immediate jeopardy[A]; Scope: Isolated: J; Scope: Pattern: K;
Scope: Widespread: L.
Severity: Actual harm; Scope: Isolated: G; Scope: Pattern: H; Scope:
Widespread: I.
Severity: Potential for more than minimal harm; Scope: Isolated: D;
Scope: Pattern: E; Scope: Widespread: F.
Severity: Potential for minimal harm[B]; Scope: Isolated: A; Scope:
Pattern: B; Scope: Widespread: C.
Source: CMS.
[A] Actual or potential for death/serious injury.
[B] Nursing home is considered to be in "substantial compliance.":
[End of table]
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.[Footnote 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.[Footnote 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.[Footnote 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 cited for actual harm on successive surveys.[Footnote 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.[Footnote 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 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.
Magnitude of Problems Remains Cause for Concern Even Though Fewer
Serious Nursing Home Quality Problems Reported:
The magnitude of the problems uncovered during standard nursing home
surveys remains a cause for concern even though OSCAR deficiency data
indicate that state surveyors are finding fewer serious quality
problems. Compared to an earlier period, the percentage of homes
nationwide cited since mid-2000 for actual harm or immediate jeopardy
has decreased in over three-quarters of states--with seven states
reporting a drop of 20 percentage points or more. State surveys
conducted since about mid-2000 showed less variance from federal
comparative surveys, suggesting that (1) state surveyors' performance
in documenting serious deficiencies has 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.
Proportion of Nursing Homes with Documented Actual Harm or Immediate
Jeopardy Care Problems Has Declined since 2000:
Compared to the preceding 18-month period, the proportion of nursing
homes cited for actual harm or immediate jeopardy has declined
nationally from 29 percent to 20 percent since mid-2000.[Footnote 14]
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.[Footnote 15] 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.[Footnote 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.[Footnote 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, 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:
Decrease of 5 percentage points or greater:
State[A]: Arizona; Number of homes surveyed (7/00-1/02): 147;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 33.8; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 8.8; Percentage point
difference[B]: -25.0.
State[A]: Alabama; Number of homes surveyed (7/00-1/02): 228;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 42.2; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 18.4; Percentage point
difference[B]: -23.8.
State[A]: Pennsylvania; Number of homes surveyed (7/00-1/02): 764;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 32.2; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 11.6; Percentage point
difference[B]: -20.6.
State[A]: California; Number of homes surveyed (7/00-1/02): 1,348;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 29.1; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 9.3; Percentage point
difference[B]: -19.9.
State[A]: Indiana; Number of homes surveyed (7/00-1/02): 573;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 45.3; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 26.2; Percentage point
difference[B]: -19.1.
State[A]: Michigan; Number of homes surveyed (7/00-1/02): 441;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 42.1; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 24.7; Percentage point
difference[B]: -17.4.
State[A]: Washington; Number of homes surveyed (7/00-1/02): 275;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 54.1; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 38.5; Percentage point
difference[B]: -15.6.
State[A]: Oregon; Number of homes surveyed (7/00-1/02): 152; Percentage
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 47.5; Percentage of homes with actual harm or immediate jeopardy
deficiencies: 7/00-1/02: 33.6; Percentage point difference[B]: -13.9.
State[A]: Illinois; Number of homes surveyed (7/00-1/02): 881;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 29.3; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 15.4; Percentage point
difference[B]: -13.9.
State[A]: Mississippi; Number of homes surveyed (7/00-1/02): 219;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 33.2; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 19.6; Percentage point
difference[B]: -13.5.
State[A]: Minnesota; Number of homes surveyed (7/00-1/02): 431;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 31.7; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 18.8; Percentage point
difference[B]: -12.9.
State[A]: Montana; Number of homes surveyed (7/00-1/02): 103;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 37.5; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 25.2; Percentage point
difference[B]: -12.3.
State[A]: Missouri; Number of homes surveyed (7/00-1/02): 569;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 22.3; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 10.2; Percentage point
difference[B]: -12.1.
State[A]: South Carolina; Number of homes surveyed (7/00-1/02): 180;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 28.7; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 17.8; Percentage point
difference[B]: -10.9.
State[A]: North Carolina; Number of homes surveyed (7/00-1/02): 419;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 40.8; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 30.1; Percentage point
difference[B]: -10.7.
State[A]: Arkansas; Number of homes surveyed (7/00-1/02): 267;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 37.7; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 27.3; Percentage point
difference[B]: -10.4.
State[A]: Massachusetts; Number of homes surveyed (7/00-1/02): 512;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 33.0; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 22.9; Percentage point
difference[B]: -10.2.
State[A]: Iowa; Number of homes surveyed (7/00-1/02): 494; Percentage
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 19.3; Percentage of homes with actual harm or immediate jeopardy
deficiencies: 7/00-1/02: 9.9; Percentage point difference[B]: -9.4.
State[A]: Tennessee; Number of homes surveyed (7/00-1/02): 377;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 26.0; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 16.7; Percentage point
difference[B]: -9.3.
Nation: Number of homes surveyed (7/00-1/02): 17,149;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 29.3; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 20.5; Percentage point
difference[B]: -8.8.
State[A]: Virginia; Number of homes surveyed (7/00-1/02): 285;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 19.9; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 11.6; Percentage point
difference[B]: -8.3.
State[A]: Kansas; Number of homes surveyed (7/00-1/02): 400; Percentage
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 37.1; Percentage of homes with actual harm or immediate jeopardy
deficiencies: 7/00-1/02: 29.0; Percentage point difference[B]: -8.1.
State[A]: Nebraska; Number of homes surveyed (7/00-1/02): 243;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 26.0; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 18.9; Percentage point
difference[B]: -7.1.
State[A]: Wisconsin; Number of homes surveyed (7/00-1/02): 421;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 14.0; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 7.1; Percentage point
difference[B]: -6.9.
State[A]: Maryland; Number of homes surveyed (7/00-1/02): 248;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 25.6; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 20.2; Percentage point
difference[B]: -5.5.
State[A]: Ohio; Number of homes surveyed (7/00-1/02): 1,029; Percentage
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 29.0; Percentage of homes with actual harm or immediate jeopardy
deficiencies: 7/00-1/02: 23.7; Percentage point difference[B]: -5.3.
Change of less than 5 percentage points:
State[A]: Kentucky; Number of homes surveyed (7/00-1/02): 306;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 28.8; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 25.2; Percentage point
difference[B]: -3.7.
State[A]: New Jersey; Number of homes surveyed (7/00-1/02): 366;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 24.5; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 22.4; Percentage point
difference[B]: -2.1.
State[A]: Georgia; Number of homes surveyed (7/00-1/02): 370;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 22.6; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 20.5; Percentage point
difference[B]: -2.0.
State[A]: West Virginia; Number of homes surveyed (7/00-1/02): 143;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 15.6; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 14.0; Percentage point
difference[B]: -1.7.
State[A]: Texas; Number of homes surveyed (7/00-1/02): 1,275;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 26.9; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 25.5; Percentage point
difference[B]: -1.5.
State[A]: Florida; Number of homes surveyed (7/00-1/02): 742;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 20.8; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 20.1; Percentage point
difference[B]: -0.8.
State[A]: Maine; Number of homes surveyed (7/00-1/02): 124; Percentage
of homes with actual harm or immediate jeopardy deficiencies: 1/99-7/
00: 10.3; Percentage of homes with actual harm or immediate jeopardy
deficiencies: 7/00-1/02: 9.7; Percentage point difference[B]: -0.6.
State[A]: New York; Number of homes surveyed (7/00-1/02): 671;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 32.2; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 32.3; Percentage point
difference[B]: 0.2.
State[A]: Connecticut; Number of homes surveyed (7/00-1/02): 259;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 48.5; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 49.4; Percentage point
difference[B]: 0.9.
State[A]: Louisiana; Number of homes surveyed (7/00-1/02): 367;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 19.9; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 23.4; Percentage point
difference[B]: 3.5.
State[A]: Oklahoma; Number of homes surveyed (7/00-1/02): 394;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 16.7; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 20.6; Percentage point
difference[B]: 3.9.
Increase of 5 percentage points or greater:
State[A]: South Dakota; Number of homes surveyed (7/00-1/02): 114;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 24.1; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 30.7; Percentage point
difference[B]: 6.6.
State[A]: Colorado; Number of homes surveyed (7/00-1/02): 225;
Percentage of homes with actual harm or immediate jeopardy
deficiencies: 1/99-7/00: 15.4; Percentage of homes with actual harm or
immediate jeopardy deficiencies: 7/00-1/02: 26.2; Percentage point
difference[B]: 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.
[End of table]
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 Surveys Show Decreased Variance with State Survey
Findings, but Understatement of Actual Harm Deficiencies Continued:
Our analysis of federal comparative surveys conducted nationwide prior
to and since June 2000 showed a decreased variance between federal and
state survey findings (see app. I for a description of our scope and
methodology). For comparative surveys completed from October 1998
through May 2000, federal surveyors found actual harm or higher-level
deficiencies in 34 percent of homes where state surveyors had found no
such deficiencies, compared to 22 percent for comparative surveys
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'
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.[Footnote 18]
Quality-of-Care Problems Were Understated in Homes with a History of
Problems:
Even with the reported decline in serious deficiencies, an unacceptably
high number of nursing homes--one in five nationwide--still had actual
harm or immediate jeopardy deficiencies. Moreover, we found widespread
understatement of actual harm deficiencies in a sample of surveys we
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 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.
Table 3: Incidence of Underreported Actual Harm Deficiencies in Surveys
GAO Reviewed:
State: Alabama; Number of surveys from state: 6; Number of surveys in
which GAO identified G-level deficiencies: 2; Number of G-level
deficiencies GAO identified: 2.
State: Arizona; Number of surveys from state: 3; Number of surveys in
which GAO identified G-level deficiencies: 1; Number of G-level
deficiencies GAO identified: 2.
State: California; Number of surveys from state: 22; Number of surveys
in which GAO identified G-level deficiencies: 13; Number of G-level
deficiencies GAO identified: 17.
State: Iowa; Number of surveys from state: 7; Number of surveys in
which GAO identified G-level deficiencies: 5; Number of G-level
deficiencies GAO identified: 7.
State: Maryland; Number of surveys from state: 3; Number of surveys in
which GAO identified G-level deficiencies: 1; Number of G-level
deficiencies GAO identified: 1.
State: Minnesota; Number of surveys from state: 5; Number of surveys in
which GAO identified G-level deficiencies: 0; Number of G-level
deficiencies GAO identified: 0.
State: Mississippi; Number of surveys from state: 1; Number of surveys
in which GAO identified G-level deficiencies: 0; Number of G-level
deficiencies GAO identified: 0.
State: Missouri; Number of surveys from state: 4; Number of surveys in
which GAO identified G-level deficiencies: 1; Number of G-level
deficiencies GAO identified: 1.
State: Nebraska; Number of surveys from state: 4; Number of surveys in
which GAO identified G-level deficiencies: 2; Number of G-level
deficiencies GAO identified: 2.
State: Pennsylvania; Number of surveys from state: 11; Number of
surveys in which GAO identified G-level deficiencies: 2; Number of G-
level deficiencies GAO identified: 3.
State: South Carolina; Number of surveys from state: 1; Number of
surveys in which GAO identified G-level deficiencies: 0; Number of G-
level deficiencies GAO identified: 0.
State: Virginia; Number of surveys from state: 7; Number of surveys in
which GAO identified G-level deficiencies: 3; Number of G-level
deficiencies GAO identified: 4.
State: West Virginia; Number of surveys from state: 1; Number of
surveys in which GAO identified G-level deficiencies: 0; Number of G-
level deficiencies GAO identified: 0.
State: Wisconsin; Number of surveys from state: 1; Number of surveys in
which GAO identified G-level deficiencies: 0; Number of G-level
deficiencies GAO identified: 0.
State: Total; Number of surveys from state: 76; Number of surveys in
which GAO identified G-level deficiencies: 30; Number of G-level
deficiencies GAO identified: 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).
[End of table]
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.[Footnote 19] According
to the surveyor, a resident with dementia, experiencing long-and short-
term memory problems, fell 11 times and 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.
Weaknesses Persist in State Survey, Complaint, and Enforcement
Activities:
Widespread weaknesses persist in state survey, complaint investigation,
and enforcement activities despite increased attention to these issues
in recent years. Several factors at the state level contribute to the
understatement of serious quality-of-care problems, including poor
investigation and documentation of deficiencies, the absence of
adequate quality assurance processes, and a large number of
inexperienced surveyors in some states due to high attrition or hiring
limitations. In 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.
Investigation Weaknesses and Other Factors Contribute to Underreporting
of Care Problems:
CMS and state officials identified several factors that they believe
contribute to state surveys continuing to miss significant care
problems. These weaknesses persist, in part, because many states lack
adequate quality assurance processes to ensure that deficiencies
identified by surveyors are appropriately classified. According to
officials we 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 Documentation Weaknesses:
Consistent with the investigation and documentation weaknesses we 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.
Inadequate Quality Assurance Processes:
Some state officials told us that considerable staff resources are
devoted 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.[Footnote 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, respectively, had less than 2 years of on-the-job
experience.[Footnote 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.[Footnote 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 table 4. In 9 states, more than 50 percent of
current surveys were predictable.[Footnote 23]
Table 4: Predictability of Nursing Home Surveys:
Percentage of predictable surveys[A]: More than 50 percent; Number of
states[B]: 9.
Percentage of predictable surveys[A]: 25 percent to 50 percent; Number
of states[B]: 34.
Percentage of predictable surveys[A]: Less than 25 percent; Number of
states[B]: 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.
[End of table]
Many State Complaint Investigation Systems Still Have Timeliness
Problems and Other Weaknesses:
Most state agencies did not investigate serious complaints filed
against nursing homes within required time frames, and practices for
investigating 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 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.[Footnote 24] As a
result of our findings, HCFA began requiring states to investigate
complaints that allege actual harm, but do not rise to the level of
immediate jeopardy, within 10 workdays.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 28] Both CMS and
California officials indicated that the priority the state attaches to
investigating complaints affected survey timeliness. Officials 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.[Footnote 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
are unavailable.[Footnote 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: States vary in the ease with which the public can file a
complaint; Description: Thirty-four states indicated that they provide
toll-free hotlines for the public to file complaints. Twenty-nine of
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.
Finding: States need to improve their complaint intake and triaging
systems; Description: States need to better triage their complaints
and decide which complaints should be referred to other agencies for
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.
Finding: State survey staffs that conduct complaint intake and
investigation often have additional duties; Description: States should
use staff dedicated to investigating complaints to improve the quality
of investigations. This might include assigning responsibility for a
state's total complaint system to a single complaint supervisor or
coordinator and also may require more careful hiring standards with
specific job qualifications.
Finding: Investigation procedures vary across states; Description:
States do not use all available data when preparing for a complaint
investigation. There is little agreement among states regarding how
many resident records should be sampled during a complaint
investigation.[A].
Finding: Complaint investigation training is needed; Description:
Specialized complaint training and periodic refresher training on
complaint intake, triaging, and investigation techniques are needed to
improve the quality of complaint investigations.
Finding: Resolution of complaints is inconsistent across states;
Description: States have developed varying criteria for determining
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.
Finding: Not all states have comprehensive complaint tracking systems,
and CMS tracking systems are not up-to-date or user friendly.[B];
Description: Twenty states indicated that they could track the status
of complaints and produce summary reports.
Source: CMS.
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.
[End of table]
States Did Not Refer a Substantial Number of Nursing Homes to CMS for
Immediate Sanctions:
State survey agencies did not refer 711 cases in which nursing homes
were found to have a pattern of harming residents to CMS for immediate
sanction as required by CMS policy.[Footnote 31] Our earlier work found
that nursing homes tended to "yo-yo" in and out of compliance, in part
because HCFA rarely imposed sanctions on homes with a pattern of
deficiencies that harmed residents.[Footnote 32] In response, the
agency required that homes found to have harmed residents on successive
standard surveys be referred to it for immediate sanction.[Footnote 33]
Most states did not refer at least some cases that should have been
referred under this policy.[Footnote 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 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:
[See PDF for image]
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.
[End of figure]
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 us that they did not initially fully understand
the criteria for referring homes for immediate sanction.[Footnote 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, 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.[Footnote 36] A CMS
official indicated that New York began complying with the policy in
September 2002.[Footnote 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.
CMS Oversight of State Survey Activities Requires Further
Strengthening:
While CMS has increased its oversight of state survey and complaint
activities and instituted a more systematic oversight process by
initiating annual state performance reviews, CMS officials acknowledged
that the effectiveness of the reviews could be improved. In particular,
CMS officials told us that for the initial state performance review in
fiscal year 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.
CMS Reviews of State Performance Have Identified Areas for Improvement:
In the first of what is planned as an annual process, CMS's 10 regional
offices reviewed states' fiscal year 2001 performance for seven
standards to determine how well states met their nursing home survey
responsibilities (see app. VIII for a description of the seven
standards).[Footnote 38] 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.[Footnote 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.
CMS's State Performance Standards and Review Had Shortcomings:
Characterizing its fiscal year 2001 state performance review as a
"shakeout cruise," CMS is working to address several weaknesses
identified during 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 Performance Were Hard to Identify:
CMS officials acknowledged that the first performance review did not
provide adequate information regarding the seriousness of identified
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.[Footnote 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.
[Footnote 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 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 States' Documentation of Deficiencies Was
Flawed:
CMS's standard for measuring how well states document deficiencies
identified during standard surveys was flawed because it mixed major
and 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.[Footnote
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 Inconsistent:
CMS's regional offices were sometimes inconsistent in how they
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.
* 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 Excluded Some Important Areas:
While CMS has addressed some of the weaknesses in its 2001 state
performance review by revising the standards and guidance for the 2002
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
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.[Footnote 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 Inconsistent Use of Periodic Reports Hamper
Oversight:
CMS's oversight of state survey activities is further hampered by
limitations in the data used to develop the 19 periodic reports
intended to assist the regions in monitoring state performance and by
the regions' inconsistent use of the reports.[Footnote 44] For
instance, CMS's current complaint database does not provide key
information about the number of complaints each state receives
(including facility self-reported incidents) or the time frame in which
each complaint is investigated.[Footnote 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.[Footnote 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 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.[Footnote 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.[Footnote 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 but Also Encountering Delays in Several Key
Efforts:
CMS has taken, or is undertaking, several other efforts to improve
federal oversight and survey procedures, including making structural
changes to the regional offices to improve coordination, expanding the
number of comparative surveys conducted each year, improving the survey
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 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 to Address Inconsistencies in Regional
Office Performance and Improve Federal Oversight:
In December 2002, CMS reduced the number of regional managers in charge
of survey activities from 10 (1 per region) to 5, a change intended to
provide more management attention to survey matters and to improve
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 Survey Consistency and Complaint
Investigations Have Been Delayed:
CMS's implementation schedules have slipped for three critical
initiatives intended to enhance the consistency and accuracy of state
surveys and complaint investigations, delaying the introduction of
improved 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 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.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 52] Initial testing to
evaluate the proposed methodology focused primarily on the first phase
and was completed in 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.[Footnote
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
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.
Conclusions:
As we reported in September 2000, continued federal and state attention
is 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
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
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.
Recommendations for Executive Action:
To strengthen the ability of the nursing home survey process to
identify and address problems that affect the quality of care, we
recommend that 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.
Agency and State Comments and Our Evaluation:
We provided a draft of this report to CMS and the 22 states we
contacted during the course of our review. (CMS's comments are
reproduced in app. X.) CMS concurred with our findings and
recommendations, stating that it already had initiatives under way to
improve the effectiveness of the 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.[Footnote 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 Redesign:
In response to our recommendation that the agency finalize the
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.[Footnote 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 finding that state surveyors often
missed significant care problems due to weaknesses in the survey
process.
State Quality Assurance Systems:
We recommended that CMS 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 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.
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.
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.[Footnote 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.[Footnote 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 citations as well as a reaction to
administrative law hearing decisions.[Footnote 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 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.[Footnote 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 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.[Footnote 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.[Footnote 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.[Footnote 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,
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:
Signed by Kathryn G. Allen:
[End of section]
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.[Footnote 63] 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.[Footnote 64]
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 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: Necessary care and services;
Description: Facility must provide the necessary care and services for
each resident to attain or maintain the highest practicable well-
being.
Nursing home quality of care requirements: Pressure sores; Description:
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.
Nursing home quality of care requirements: Prevention of accidents;
Description: Facility must ensure each resident receives adequate
supervision and assistance devices to prevent accidents.
Nursing home quality of care requirements: Maintenance of nutrition;
Description: Facility must ensure each resident maintains acceptable
parameters of nutritional status, such as body weight.
Source: CMS's Medicare State Operations Manual.
[End of table]
Federal comparative surveys. In September 2000, we reported on the
results of 157 comparative surveys completed from October 1998 through
May 2000.[Footnote 65] 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.[Footnote 66]
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 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).[Footnote 67] We also
reviewed the report submitted to CMS by its contractor, which was
intended to assess and recommend ways to strengthen state complaint
practices.[Footnote 68] 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 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.[Footnote 69]
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.
[End of section]
Appendix II: Trends in The Proportion of 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.[Footnote 70] 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.[Footnote 71] 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.
Table 7: Trends in the Percentage of Nursing Homes Cited for Actual
Harm or Immediate Jeopardy during State Standard Surveys, by State:
State: Alabama; Number of homes surveyed: 1/97-6/98: 227;
Number of homes surveyed: 1/99-7/00: 225; Number of homes surveyed: 7/
00-1/02: 228; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 51.1; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 42.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -8.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -23.8.
State: Alaska; Number of homes surveyed: 1/97-6/98: 16; Number
of homes surveyed: 1/99-7/00: 15; Number of homes surveyed: 7/00-1/02:
15; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 37.5; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 20.0; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 33.3; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: -17.5; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: 13.3.
State: Arizona; Number of homes surveyed: 1/97-6/98: 163;
Number of homes surveyed: 1/99-7/00: 142; Number of homes surveyed: 7/
00-1/02: 147; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 17.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 33.8; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 8.8;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 16.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -25.0.
State: Arkansas; Number of homes surveyed: 1/97-6/98: 285;
Number of homes surveyed: 1/99-7/00: 273; Number of homes surveyed: 7/
00-1/02: 267; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 14.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 37.7; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 27.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 23.0;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.4.
State: California; Number of homes surveyed: 1/97-6/98: 1,435;
Number of homes surveyed: 1/99-7/00: 1,400; Number of homes surveyed:
7/00-1/02: 1,348; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 28.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 29.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 9.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -19.9.
State: Colorado; Number of homes surveyed: 1/97-6/98: 234;
Number of homes surveyed: 1/99-7/00: 227; Number of homes surveyed: 7/
00-1/02: 225; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 11.1; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 15.4; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 26.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 10.8.
State: Connecticut; Number of homes surveyed: 1/97-6/98: 263;
Number of homes surveyed: 1/99-7/00: 262; Number of homes surveyed: 7/
00-1/02: 259; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 52.9; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 48.5; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 49.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.4;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 0.9.
State: Delaware; Number of homes surveyed: 1/97-6/98: 44;
Number of homes surveyed: 1/99-7/00: 42; Number of homes surveyed: 7/
00-1/02: 42; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 45.5; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 52.4; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 14.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 6.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -38.1.
State: District of Columbia; Number of homes surveyed: 1/97-6/
98: 24; Number of homes surveyed: 1/99-7/00: 20; Number of homes
surveyed: 7/00-1/02: 21; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 12.5; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 10.0; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 33.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -2.5;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 23.3.
State: Florida; Number of homes surveyed: 1/97-6/98: 730;
Number of homes surveyed: 1/99-7/00: 753; Number of homes surveyed: 7/
00-1/02: 742; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 36.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 20.8; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -15.5;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -0.8.
State: Georgia; Number of homes surveyed: 1/97-6/98: 371;
Number of homes surveyed: 1/99-7/00: 368; Number of homes surveyed: 7/
00-1/02: 370; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 17.8; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 22.6; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.0.
State: Hawaii; Number of homes surveyed: 1/97-6/98: 45; Number
of homes surveyed: 1/99-7/00: 47; Number of homes surveyed: 7/00-1/02:
46; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 24.4; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 25.5; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 15.2; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: 1.1; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -10.3.
State: Idaho; Number of homes surveyed: 1/97-6/98: 86; Number
of homes surveyed: 1/99-7/00: 83; Number of homes surveyed: 7/00-1/02:
84; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 55.8; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 54.2; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 31.0; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: -1.6; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -23.3.
State: Illinois; Number of homes surveyed: 1/97-6/98: 899;
Number of homes surveyed: 1/99-7/00: 900; Number of homes surveyed: 7/
00-1/02: 881; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 29.8; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 29.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 15.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -0.5;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.9.
State: Indiana; Number of homes surveyed: 1/97-6/98: 602;
Number of homes surveyed: 1/99-7/00: 590; Number of homes surveyed: 7/
00-1/02: 573; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 40.5; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 45.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 26.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -19.1.
State: Iowa; Number of homes surveyed: 1/97-6/98: 525; Number
of homes surveyed: 1/99-7/00: 492; Number of homes surveyed: 7/00-1/02:
494; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 39.2; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 19.3; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 9.9; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: -19.9; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -9.4.
State: Kansas; Number of homes surveyed: 1/97-6/98: 445;
Number of homes surveyed: 1/99-7/00: 410; Number of homes surveyed: 7/
00-1/02: 400; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 47.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 37.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 29.0;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -9.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.1.
State: Kentucky; Number of homes surveyed: 1/97-6/98: 318;
Number of homes surveyed: 1/99-7/00: 312; Number of homes surveyed: 7/
00-1/02: 306; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 28.6; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 28.8; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -3.7.
State: Louisiana; Number of homes surveyed: 1/97-6/98: 433;
Number of homes surveyed: 1/99-7/00: 387; Number of homes surveyed: 7/
00-1/02: 367; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 12.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 19.9; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 23.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 7.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 3.5.
State: Maine; Number of homes surveyed: 1/97-6/98: 135; Number
of homes surveyed: 1/99-7/00: 126; Number of homes surveyed: 7/00-1/02:
124; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 7.4; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 10.3; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 9.7; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: 2.9; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -0.6.
State: Maryland; Number of homes surveyed: 1/97-6/98: 258;
Number of homes surveyed: 1/99-7/00: 242; Number of homes surveyed: 7/
00-1/02: 248; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 19.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 25.6; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 6.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -5.5.
State: Massachusetts; Number of homes surveyed: 1/97-6/98:
576; Number of homes surveyed: 1/99-7/00: 542; Number of homes
surveyed: 7/00-1/02: 512; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 24.0; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 33.0; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 22.9;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 9.0;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.2.
State: Michigan; Number of homes surveyed: 1/97-6/98: 451;
Number of homes surveyed: 1/99-7/00: 449; Number of homes surveyed: 7/
00-1/02: 441; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 43.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 42.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 24.7;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -1.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -17.4.
State: Minnesota; Number of homes surveyed: 1/97-6/98: 446;
Number of homes surveyed: 1/99-7/00: 439; Number of homes surveyed: 7/
00-1/02: 431; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 29.6; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 31.7; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.8;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 2.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.9.
State: Mississippi; Number of homes surveyed: 1/97-6/98: 218;
Number of homes surveyed: 1/99-7/00: 202; Number of homes surveyed: 7/
00-1/02: 219; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 24.8; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 33.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 19.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 8.4;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.5.
State: Missouri; Number of homes surveyed: 1/97-6/98: 595;
Number of homes surveyed: 1/99-7/00: 584; Number of homes surveyed: 7/
00-1/02: 569; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 21.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 22.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 10.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 1.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.1.
State: Montana; Number of homes surveyed: 1/97-6/98: 106;
Number of homes surveyed: 1/99-7/00: 104; Number of homes surveyed: 7/
00-1/02: 103; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 38.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 37.5; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -1.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.3.
State: Nebraska; Number of homes surveyed: 1/97-6/98: 263;
Number of homes surveyed: 1/99-7/00: 242; Number of homes surveyed: 7/
00-1/02: 243; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 32.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 26.0; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.9;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -6.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -7.1.
State: Nevada; Number of homes surveyed: 1/97-6/98: 49; Number
of homes surveyed: 1/99-7/00: 52; Number of homes surveyed: 7/00-1/02:
51; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 40.8; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 32.7; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 9.8; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: -8.1; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -22.9.
State: New Hampshire; Number of homes surveyed: 1/97-6/98: 86;
Number of homes surveyed: 1/99-7/00: 83; Number of homes surveyed: 7/
00-1/02: 79; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 30.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 37.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 21.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 7.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -15.8.
State: New Jersey; Number of homes surveyed: 1/97-6/98: 377;
Number of homes surveyed: 1/99-7/00: 359; Number of homes surveyed: 7/
00-1/02: 366; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 13.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 24.5; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 22.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 11.5;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.1.
State: New Mexico; Number of homes surveyed: 1/97-6/98: 88;
Number of homes surveyed: 1/99-7/00: 82; Number of homes surveyed: 7/
00-1/02: 82; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 11.4; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 31.7; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 17.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 20.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -14.6.
State: New York; Number of homes surveyed: 1/97-6/98: 662;
Number of homes surveyed: 1/99-7/00: 668; Number of homes surveyed: 7/
00-1/02: 671; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 13.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 32.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 32.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 18.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 0.2.
State: North Carolina; Number of homes surveyed: 1/97-6/98:
407; Number of homes surveyed: 1/99-7/00: 414; Number of homes
surveyed: 7/00-1/02: 419; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 31.0; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 40.8; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 30.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 9.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.7.
State: North Dakota; Number of homes surveyed: 1/97-6/98: 88;
Number of homes surveyed: 1/99-7/00: 89; Number of homes surveyed: 7/
00-1/02: 88; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 55.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 21.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 28.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -34.4;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 7.1.
State: Ohio; Number of homes surveyed: 1/97-6/98: 1,043;
Number of homes surveyed: 1/99-7/00: 1,047; Number of homes surveyed:
7/00-1/02: 1,029; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 31.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 29.0; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 23.7;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -2.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -5.3.
State: Oklahoma; Number of homes surveyed: 1/97-6/98: 463;
Number of homes surveyed: 1/99-7/00: 432; Number of homes surveyed: 7/
00-1/02: 394; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 8.4; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 16.7; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 8.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 3.9.
State: Oregon; Number of homes surveyed: 1/97-6/98: 171;
Number of homes surveyed: 1/99-7/00: 158; Number of homes surveyed: 7/
00-1/02: 152; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 43.9; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 47.5; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 33.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 3.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.9.
State: Pennsylvania; Number of homes surveyed: 1/97-6/98: 811;
Number of homes surveyed: 1/99-7/00: 788; Number of homes surveyed: 7/
00-1/02: 764; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 29.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 32.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 11.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 2.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -20.6.
State: Rhode Island; Number of homes surveyed: 1/97-6/98: 102;
Number of homes surveyed: 1/99-7/00: 99; Number of homes surveyed: 7/
00-1/02: 99; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 11.8; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 12.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 10.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.0.
State: South Carolina; Number of homes surveyed: 1/97-6/98:
175; Number of homes surveyed: 1/99-7/00: 178; Number of homes
surveyed: 7/00-1/02: 180; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 28.6; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 28.7; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 17.8;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.9.
State: South Dakota; Number of homes surveyed: 1/97-6/98: 124;
Number of homes surveyed: 1/99-7/00: 112; Number of homes surveyed: 7/
00-1/02: 114; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 40.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 24.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 30.7;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -16.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 6.6.
State: Tennessee; Number of homes surveyed: 1/97-6/98: 361;
Number of homes surveyed: 1/99-7/00: 354; Number of homes surveyed: 7/
00-1/02: 377; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 11.1; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 26.0; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 16.7;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 14.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -9.3.
State: Texas; Number of homes surveyed: 1/97-6/98: 1,381;
Number of homes surveyed: 1/99-7/00: 1,336; Number of homes surveyed:
7/00-1/02: 1,275; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 22.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 26.9; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.7;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -1.5.
State: Utah; Number of homes surveyed: 1/97-6/98: 98; Number
of homes surveyed: 1/99-7/00: 95; Number of homes surveyed: 7/00-1/02:
95; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 15.3; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 15.8; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 15.8; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: 0.5; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: 0.0.
State: Vermont; Number of homes surveyed: 1/97-6/98: 45;
Number of homes surveyed: 1/99-7/00: 46; Number of homes surveyed: 7/
00-1/02: 45; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 20.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 15.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 17.8;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 2.6.
State: Virginia; Number of homes surveyed: 1/97-6/98: 279;
Number of homes surveyed: 1/99-7/00: 287; Number of homes surveyed: 7/
00-1/02: 285; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 24.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 19.9; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 11.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.3.
State: Washington; Number of homes surveyed: 1/97-6/98: 288;
Number of homes surveyed: 1/99-7/00: 279; Number of homes surveyed: 7/
00-1/02: 275; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 63.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 54.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 38.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -9.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -15.6.
State: West Virginia; Number of homes surveyed: 1/97-6/98:
130; Number of homes surveyed: 1/99-7/00: 147; Number of homes
surveyed: 7/00-1/02: 143; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 12.3; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 15.6; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 14.0;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 3.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -1.7.
State: Wisconsin; Number of homes surveyed: 1/97-6/98: 438;
Number of homes surveyed: 1/99-7/00: 428; Number of homes surveyed: 7/
00-1/02: 421; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 17.1; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 14.0; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 7.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -3.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -6.9.
State: Wyoming; Number of homes surveyed: 1/97-6/98: 38;
Number of homes surveyed: 1/99-7/00: 41; Number of homes surveyed: 7/
00-1/02: 40; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 28.9; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 43.9; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 22.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 15.0;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -21.4.
State: Nation; Number of homes surveyed: 1/97-6/98: 17,897;
Number of homes surveyed: 1/99-7/00: 17,452; Number of homes surveyed:
7/00-1/02: 17,149; Percentage of homes cited for actual harm
or immediate jeopardy: 1/97-6/98: 27.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 29.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 1.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.8.
Source: GAO analysis of OSCAR data as of June 24, 2002.
[A] Differences are based on numbers before rounding.
[End of table]
[End of section]
Appendix III: Abstracts of Nursing Home 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).[Footnote 72]
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.
Table 8: Abstracts of the 39 Nursing Home Deficiencies that Understated
Actual Harm from a Sample of 76 Nursing Home Survey Reports:
State and date of survey[A]: Alabama-1 November 2001; Requirement and
scope and severity cited: Provide necessary care and services: D;
Resident description and relevant diagnoses[B]: Resident admitted to
facility 5/15/01 with a fractured hip; a gastrostomy tube was inserted
through the abdomen into the stomach to maintain feeding. On 10/9/01,
resident was hospitalized for abdominal pain and signs of infection
related to the gastrostomy tube. On return to facility, physician
orders state, "clean G tube site with soap and water, apply a drain
sponge."; Actual harm to resident documented by surveyor: Site of
gastrostomy tube insertion became reddened with thick yellow-green
drainage, and had an odor, indicating signs of infection, on 11/7/01;
Deficiencies in care cited by surveyor: Facility failed to provide
proper care and services: daily cleaning and application of a drain
sponge around the gastrostomy tube; Family indicated no one changed
the dressing. There is no documentation to show resident's gastrostomy
tube site was cleansed as ordered 12 out of 16 opportunities.
State and date of survey[A]: Alabama-5 March 2001; Requirement and
scope and severity cited: Provide supervision and devices to prevent
accidents: D; Resident description and relevant diagnoses[B]: Resident
1 admitted to facility 11/6/00 with diagnoses of stroke, pressure
sores, and kidney failure. On 11/16/00, resident was noted to have
abrasions and bruises; Actual harm to resident documented by surveyor:
Resident 1 sustained four skin tears on right arm and leg and multiple
bruises to both legs from 1/16/01 to 3/21/01; Deficiencies in care
cited by surveyor: The facility failed to consistently reassess for
preventive measures to address the problem of skin tears and bruises
for both residents. Staff were unable to provide documentation of
preventive interventions.
Resident description and relevant diagnoses[B]: State and date of
survey[A]Arizona-3 July 2000: Resident 2 was admitted to the facility
11/23/98 with anemia, depression, urinary incontinence, and a history
of falls. She was identified as having a problem with skin tears and
bruising.[C]; Actual harm to resident documented by surveyor: State and
date of survey[A]Arizona-3 July 2000: Resident 2 sustained seven skin
tears and bruises to legs from 12/29/99 to 10/9/00; Deficiencies in
care cited by surveyor: State and date of survey[A]Arizona-3 July 2000:
[Empty].
State and date of survey[A]: Arizona-3 July 2000; Requirement and scope
and severity cited: Ensure prevention and healing of pressure sores: D;
Resident description and relevant diagnoses[B]: Resident admitted to
facility 08/24/99 with heart failure, high blood pressure, paraplegia,
and a stage II pressure sore on lower back.[D] Pressure sore remained a
stage II until May 2000, when wound was documented to be a stage III;
Actual harm to resident documented by surveyor: On 7/5/00, it was noted
that the resident had developed a stage IV pressure sore; Deficiencies
in care cited by surveyor: The necessary services and care to promote
healing and prevent worsening of existing pressure sore were not
provided. Even after the pressure sore progressed to stage IV and a
physician ordered that the resident be turned every hour, the staff
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.
State and date of survey[A]: Arizona-3 July 2000; Requirement and scope
and severity cited: Ensure adequate supervision to prevent accidents:
D; Resident description and relevant diagnoses[B]: Resident 1 admitted
to the facility 4/7/00 with diabetes, partial paralysis of left side,
and inability to speak. Resident also had a history of spinal
fractures, and a fall prevention plan was developed on 4/15/00; Actual
harm to resident documented by surveyor: Resident 1 fell four times and
sustained skin tears, abrasions, and lacerations; Deficiencies in care
cited by surveyor: Facility staff failed to implement a plan of care
that called for identifying resident as a fall risk by placing a star
on his door by his name. No other preventive measures were identified,
and surveyor observed no star next to resident's name outside his
door.
Resident description and relevant diagnoses[B]: State and date of
survey[A]California-2 September 2000: Resident 2 admitted to the
facility 12/10/97 with dementia, painful joints, and visual problems. A
7/13/00 assessment indicated resident was cognitively impaired and had
a mental function that varied throughout the day. She was also
identified as a wanderer; Actual harm to resident documented by
surveyor: State and date of survey[A]California-2 September 2000:
Resident sustained 12 falls from 2/18 to 7/8/00 with lacerations of
extremities and head requiring suturing and with other cuts and
bruises; Deficiencies in care cited by surveyor: State and date of
survey[A]California-2 September 2000: Although resident was identified
as at risk for falls in a care plan of 4/22/00, the facility staff
failed to develop approaches to prevent falls even though the resident
continued to fall and injure herself.
State and date of survey[A]: California-2 September 2000; Requirement
and scope and severity cited: Ensure prevention and healing of pressure
sores: D; Resident description and relevant diagnoses[B]: Resident 1
with leg contractures (permanent tightening of muscle, tendons,
ligaments, or skin that prevents normal movement) was noted to have a
small reddened area on left lower back on 9/20/00; Actual harm to
resident documented by surveyor: Resident 1 developed a reddened open
area .3 cm. in diameter, (stage II pressure sore) on left lower back by
9/23/00; Deficiencies in care cited by surveyor: The surveyor found
that the facility did not identify, document, or provide intervention
to prevent this facility-acquired pressure sore. The reddened area
noted was not documented in the medical record 9/20-9/22/00.
Resident description and relevant diagnoses[B]: Requirement and scope
and severity citedState and date of survey[A]: Maintain nutritional
status: D: Resident 2 was admitted to facility on 2/2/00. Family
identified resident as having a "skin problem" on 9/17/00; Actual harm
to resident documented by surveyor: Requirement and scope and severity
citedState and date of survey[A]: Maintain nutritional status: D:
Resident 2 developed a stage II pressure sore; Deficiencies in care
cited by surveyor: Requirement and scope and severity citedState and
date of survey[A]: Maintain nutritional status: D: The facility
developed a nursing care plan for prevention of pressure sores and
turning the resident every 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 description and relevant diagnoses[B]: State and date of
survey[A]California-2 September 2000: Resident 3 admitted to facility
9/20/00 with diagnoses of multiple sclerosis, bilateral fractures of
the femur, and obesity. Resident was unable to turn herself in bed;
physician documented resident had no areas of skin breakdown and
ordered resident to be up in a wheel chair two to three times a day;
Actual harm to resident documented by surveyor: State and date of
survey[A]California-2 September 2000: Seven days after admission,
resident 3 was noted to have four stage II pressure sores on right and
left shoulder blades and right buttock and three stage I pressure sores
on the left buttock; Deficiencies in care cited by surveyor: State and
date of survey[A]California-2 September 2000: The facility failed to
prevent a rapid decline in resident's condition and occurrence of
facility-acquired pressure sores. Staff said they were unable to turn
resident (a larger bed and mattress were not provided, which would have
facilitated turning). No pressure-relieving devices and staff
assistance in getting out of bed were provided. In the 7 days after
admission, the resident was out of bed only once, at which time the
pressure sores were discovered.
State and date of survey[A]: California-2 September 2000; Requirement
and scope and severity cited: Maintain nutritional status: D; Resident
description and relevant diagnoses[B]: Resident admitted to facility 7/
7/00 with a diagnosis of failure to thrive and a recorded weight of 89
pounds; Actual harm to resident documented by surveyor: Resident's
weight was recorded as 77 pounds 1 month after admission. Resident
sustained a severe loss of 12 pounds (13 percent) between July and
August; Deficiencies in care cited by surveyor: Facility failed to
provide a comprehensive nutritional assessment to meet resident's
nutritional needs in order to maintain body weight.
State and date of survey[A]: California-5 February 2001; Requirement
and scope and severity cited: Provide supervision and devices to
prevent accidents: D; Resident description and relevant diagnoses[B]:
Resident was identified as at high risk for falls in 5/00; Actual harm
to resident documented by surveyor: Resident fell while walking
unassisted on 6/21/00 and again on 2/22/01, fracturing his right hip
each time; Deficiencies in care cited by surveyor: Facility failed to
develop and implement a fall prevention plan when resident was
identified as being a high risk for falls and after the first hip
fracture.
State and date of survey[A]: California-6 May 2001; Requirement and
scope and severity cited: Provide supervision and devices to prevent
accidents: D; Resident description and relevant diagnoses[B]: Resident
admitted to facility on 2/12/01with dizziness, fainting, poor vision,
and cognitive impairment. Care plan of 2/20/01 identified resident as a
wanderer and at risk for falls. Interventions suggested were visual
checks every 2 hours and involvement of resident in facility
activities. On 2/20/01 at 9:30 pm resident was found wandering outside
on the patio and had fallen and sustained abrasions; Actual harm to
resident documented by surveyor: Resident wandered to an area 100 yards
from facility near two busy intersections on 3/26/01 and again on 5/19/
01; ; According to CMS, the failure of a facility to provide
supervision of a cognitively impaired individual with known risk for
wandering is considered failure to prevent neglect and places the
resident in immediate jeopardy for death or serious injury during such
an incident; Deficiencies in care cited by surveyor: Facility failed
to provide supervision and devices to prevent accidents even after
resident was found wandering outside the facility on 2/20/01. The
facility did not immediately implement procedures cited in the care
plan to supervise the resident and prevent accidents and wandering, nor
did the facility implement existing facility policies to prevent
wandering and injury.
State and date of survey[A]: California-8; June 2001; Requirement and
scope and severity cited: Ensure prevention and healing of pressure
sores: D; Resident description and relevant diagnoses[B]: Resident
admitted to facility in 1996 with stroke, paralysis of lower right
side, and senile dementia. Physician orders of 4/5/01 called for an air
mattress. Assessment of 4/24/01 noted resident had a stage IV pressure
sore on the right outer ankle. On 5/17/01, physician ordered cleansing
of the wound with saline and an anti-infective solution, dressing it
with soft protective gauze; Actual harm to resident documented by
surveyor: Resident sustained a facility-acquired stage IV pressure sore
of the right ankle measuring 7 cm. by 5 cm; Deficiencies in care cited
by surveyor: Facility failed to ensure necessary treatment and service
to promote healing and prevent infection of the pressure sore. Surveyor
observed on 6/20 and 6/21/01 that there was no air mattress on
resident's bed and on 6/20/01 that inappropriate technique was used in
changing the dressing on the resident's ankle.
State and date of survey[A]: California-8 June 2001; Requirement and
scope and severity cited: Ensure maintenance of nutritional status: D;
Resident description and relevant diagnoses[B]: Resident admitted to
facility in 1990 with a diagnosis of stroke and inability to speak. A
3/7/01 assessment noted erosive gastritis, anemia, and weight of 111
lbs. The county was the conservator and requested maximum treatment.
Resident was placed on an enriched pureed diet with supplemental
feedings three times daily; Actual harm to resident documented by
surveyor: Resident weighed 98.4 lbs and experienced a severe weight
loss of 13 pounds (12 percent) in 3 months; Deficiencies in care cited
by surveyor: Facility failed to ensure that the resident maintained
adequate nutrition. It did not monitor the amount of nutritional
supplements consumed by the resident and inconsistently recorded
weights, often without associated dates. It did not notify the
physician of the resident's weight loss.
State and date of survey[A]: California-9; December 2000; Requirement
and scope and severity cited: Provide supervision and devices to
prevent accidents: B[E,F]; Resident description and relevant
diagnoses[B]: Resident 1, 48 years old, admitted to facility after a
stroke with incontinence, inability to speak, right-side paralysis, and
functional use of his left side. Resident communicated by signs and
sounds; Actual harm to resident documented by surveyor: Resident fell
when trying to climb over side rails, sustaining a laceration to his
head; Deficiencies in care cited by surveyor: The facility failed to
supervise the resident and prevent accidents from occurring: staff
failed to accurately assess resident's safety needs and inappropriately
assumed resident needed full side rails on the bed.
Resident description and relevant diagnoses[B]: State and date of
survey[A]California-9: Resident 2 had a history of a right hip
fracture, chronic weakness in both legs, and dementia. Resident had a
physician's order (9/16/99) for soft belt restraints when in wheelchair
to prevent resident from getting up from wheelchair without
assistance; Actual harm to resident documented by surveyor: State and
date of survey[A]California-9: On 3/29/00, resident climbed over the
bed side rails and was found on the floor at the foot of his bed with
both side rails in the up position. Seven hours later, an x ray was
taken and found that resident had a "minimal impaction fracture" of the
left hip; ; 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; Deficiencies in care cited by surveyor: State and date of
survey[A]California-9: The facility failed to provide supervision and
appropriate interventions to prevent this resident's fall. According to
the surveyor, there were no orders for restraints in bed and no
indication that all reasonable efforts had been made to safeguard the
resident from additional injuries.
State and date of survey[A]: California-9; December 2000; Requirement
and scope and severity cited: Ensure maintenance of nutritional status:
D; Resident description and relevant diagnoses[B]: Resident was
readmitted (6/11/00) to facility following the removal of a hip
prosthesis and a surgical incision that became infected with a fungus,
resulting in a large gaping wound. Resident was unable to swallow
following a stroke and was fed via a nasogastric tube; Actual harm to
resident documented by surveyor: A stage IV pressure sore on right heel
was noted on 7/27/00; Deficiencies in care cited by surveyor: Facility
was slow to implement the dietician's recommendations of 6/15/00 for
caloric, protein, and water intake necessary for wound healing. Diet
ordered on 6/20/00. On 6/24/00 resident was admitted to the hospital
for care of gastrointestinal bleeding and found to need 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.
State and date of survey[A]: California-10 May 2001; Requirement and
scope and severity cited: Provide supervision and devices to prevent
accidents: D; Resident description and relevant diagnoses[B]: Resident
admitted to facility with diagnoses of dementia and Alzheimer's disease
and a history of falls, confusion, and unsteady gait. Resident
identified as high risk for falls and had a physician's order for a
restraining belt when in bed; Actual harm to resident documented by
surveyor: Resident fell while attempting to get out of bed and
lacerated left elbow; Deficiencies in care cited by surveyor: Facility
failed to provide supervision and devices to prevent accidents.
Specifically, resident was put to bed without a restraining belt.
State and date of survey[A]: California-11; May 2001; Requirement and
scope and severity cited: Provide necessary care and services: D;
Resident description and relevant diagnoses[B]: Resident admitted to
the facility in 1999 with dementia and neurological disorders. Resident
was receiving an antipsychotic medication that has a side effect of
constipation. Care plan of 1/04/01 called for (1) providing liquids,
roughage, and exercise, (2) monitoring for abdominal distention, pain,
cramps, nausea, and vomiting, and (3) checking for impaction every 3
days; Actual harm to resident documented by surveyor: Resident
admitted to hospital for "several days" to relieve a fecal impaction;
Deficiencies in care cited by surveyor: Staff failed to implement the
care plan. On 5/23/01 the surveyor noted the resident crying out,
moaning, grimacing, and moving her arms and legs about. Last bowel
movement recorded was on 5/19/01. The charge nurse administered Tylenol
with codeine for what she believed was an earache at 10 a.m. Resident
continued to cry out and the charge nurse called the physician who had
the resident transferred to a hospital emergency room.
State and date of survey[A]: California-11; Requirement and scope and
severity cited: Provide supervision and devices to prevent accidents:
E; Resident description and relevant diagnoses[B]: Resident was
admitted 4/25/01 with acute kidney failure and emphysema and was one of
five residents identified as being at risk for skin tears; all five
developed skin tears. A care plan for potential for skin breakdown and
treatment of the skin tears was developed; Actual harm to resident
documented by surveyor: Resident sustained a 9 cm. skin tear to the
lower left leg on 4/28/01 and two 3 cm. skin tears below the left knee
on 5/3/01. Four other residents also sustained multiple skin tears to
their extremities and hip; Deficiencies in care cited by surveyor:
Facility failed to develop skin tear prevention plans. Staff did not
fully investigate causes of the tears and did not know how to prevent
skin tears. The staff development director stated that she had never
provided instruction for the certified nurse aides on prevention of
skin tears.
State and date of survey[A]: California-14; March 2001; Requirement and
scope and severity cited: Ensure prevention and healing of pressure
sores: D; Resident description and relevant diagnoses[B]: Resident
admitted to facility 1/26/01 following a stroke, with inability to
swallow, a gastric tube in place for feedings, and a stage I pressure
sore on right hip; Actual harm to resident documented by surveyor:
Resident's pressure sore progressed to a stage II by 2/28/01 and a
stage III on 3/7/01; Deficiencies in care cited by surveyor: Facility
staff failed to promote healing or prevent worsening of pressure sore
by failing to employ the appropriate sheets that are used in
conjunction with the low-air-loss, pressure sore mattress, thereby
negating the pressure-relieving benefits of the mattress.
State and date of survey[A]: California-16; April 2001; Requirement and
scope and severity cited: Ensure prevention and healing of pressure
sores: D; Resident description and relevant diagnoses[B]: Resident
admitted to facility 11/16/98 with dementia, anemia, irregular
heartbeat, diabetes, high blood pressure, and difficulty in
swallowing; Actual harm to resident documented by surveyor: Resident
developed a new stage II pressure sore on 4/26/01; Deficiencies in
care cited by surveyor: Facility staff did not prevent the development
of a facility-acquired pressure sore. Specifically, the surveyor
observed on 4/24/01 that the staff did not turn resident every 2 hours
as directed by the care plan, and left her in the same position for as
long as 8 hours.
State and date of survey[A]: California-18; April 2001; Requirement and
scope and severity cited: Provide necessary care and services: E;
Resident description and relevant diagnoses[B]: Resident admitted to
the facility with a steel plate implanted in her back following a
fracture. Nursing care plan called for comfort measures for back pain,
such as heat/cold application, therapeutic touch, and staying with
resident when she was in distress. Resident also had an order for
Methadone 20 mg. that had been reduced to 2.5 mg; Actual harm to
resident documented by surveyor: Resident was observed screaming and
writhing in unrelieved pain for greater than an hour; Deficiencies in
care cited by surveyor: Facility staff failed to assess the resident's
pain levels after decreasing her Methadone. They did not do an in-depth
pain assessment at any time after admission. The surveyor observed the
staff ignoring the resident's cries for help and relief, which
continued until the surveyor intervened.
State and date of survey[A]: California-19; June 2001; Requirement and
scope and severity cited: Provide necessary care and services: D;
Resident description and relevant diagnoses[B]: Resident admitted to
facility on 3/97 with stroke, one-sided paralysis, and moderate
contractures of upper and lower extremities. Resident took Tylenol four
times a day since 2/98 for pain. As his pain worsened, he began to
refuse the splinting of his contracted extremities because it was too
painful; Actual harm to resident documented by surveyor: As a result
of the facility's failure to address the resident's pain, the resident
refused the splints used to control the contractures and the
contractures worsened, leading to greater pain; Deficiencies in care
cited by surveyor: Facility staff did not reassess this resident's pain
level and need for stronger pain relief.
State and date of survey[A]: California-20 January 2001; Requirement
and scope and severity cited: Provide supervision and devices to
prevent accidents: D; Resident description and relevant diagnoses[B]:
Resident was admitted to facility on 3/6/00 and identified as a high
risk for falls on 12/6/00 because of resident's failure to remember
warnings about personal safety and poor safety awareness; Actual harm
to resident documented by surveyor: Resident fell and sustained
abrasions to her right flank and hip on 12/24/00 and again on 1/7/01,
sustaining a scalp laceration on the back of her head; Deficiencies in
care cited by surveyor: Facility failed to implement care plan of 12/
19/00 that called for safety assessment and rehabilitation screening
related to falls. In addition, facility failed to reassess resident's
safety needs and 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.
State and date of survey[A]: California-22; October 2000; Requirement
and scope and severity cited: Provide supervision and devices to
prevent accidents: D; Resident description and relevant diagnoses[B]:
Resident had diagnoses of diabetes, bipolar disease, and high blood
pressure. Resident was assessed as at risk for falls; Actual harm to
resident documented by surveyor: Resident fell 17 documented times from
4/21 to 10/14/00, when she sustained a bruising of the right eye, and a
bruise and an abrasion to her forehead; Deficiencies in care cited by
surveyor: Facility failed to provide supervision and prevent accidents.
Specifically, facility staff did not provide a self-releasing seat belt
or pressure 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.
State and date of survey[A]: Iowa-1; June 2001; Requirement and scope
and severity cited: Ensure prevention and healing of pressure sores: D;
Resident description and relevant diagnoses[B]: Resident 1 had
diagnoses that included renal failure, diabetes, and dementia.
Resident's record noted the presence of two pressure sores, one on 1/9/
01 and the second on 4/1/01, between the buttocks and on the lower
right back, respectively; Actual harm to resident documented by
surveyor: Resident's stage II pressure sores healed and then reopened
repeatedly from 1/9/01 to 6/20/01; Deficiencies in care cited by
surveyor: Facility staff failed to provide appropriate treatment to
prevent reoccurrence of pressure sores, resulting in the reappearance
of pressure sores after they had resolved. Specifically, the facility
did not reassess the current plan of treatment and did not modify the
care plan to meet the needs of the resident.
Resident description and relevant diagnoses[B]: State and date of
survey[A]Iowa-2: Resident 2 had a history of stroke and dementia. A 4/
20/01 assessment note indicated that the resident had no ulcers, skin
problems, or lesions. On 4/22/01, the resident fell, was admitted to
the hospital for treatment of a fracture of the right wrist, 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; Actual harm to
resident documented by surveyor: State and date of survey[A]Iowa-2:
Resident developed an infected stage II pressure ulcer at the base of
the right thumb; Deficiencies in care cited by surveyor: State and
date of survey[A]Iowa-2: Facility staff failed to prevent an avoidable
pressure sore. After the resident was readmitted with the cast on his
arm, the staff did not assess whether the skin around the cast was
intact for 18 days (4/27-5/14/01), at which time the nurse noted a foul
odor and a reddened thumb.
State and date of survey[A]: Iowa-2; March 2002; Requirement and scope
and severity cited: (1) Ensure prevention and healing of pressure
sores: D; Resident description and relevant diagnoses[B]: On 2/25/02,
surveyor observed resident being transferred using a mechanical lift
and noted an open stage II pressure sore on the lower back. A record
review revealed a history of healing and reoccurrence of a lower-back
pressure sore on several occasions from 7/8/01 through 2/26/02; Actual
harm to resident documented by surveyor: Resident developed a stage II
pressure sore that persisted and reopened after resolving;
Deficiencies in care cited by surveyor: Facility staff failed to ensure
that a resident with a pressure sore received necessary treatment to
promote healing and to prevent new sores from developing. Specifically,
the record lacked evidence of assessment of potential causal factors
and interventions to prevent the reoccurring pressure sore.
Requirement and scope and severity cited: State and date of
survey[A]Iowa-4: (2) Provide supervision and devices to prevent
accidents: D; Resident description and relevant diagnoses[B]: State and
date of survey[A]Iowa-4: During the above cited observation of the same
resident on the mechanical lift, the surveyor also noted bilateral
purple bruises on the resident's lower legs and later checked the
resident more fully and noted a total of five bruises and a scrape to
the legs. A review of the resident's record revealed multiple bruises,
abrasions, and skin tears going back 1 year. The surveyor observed that
there was no padding on the mechanical lift; Actual harm to resident
documented by surveyor: State and date of survey[A]Iowa-4: Resident
sustained multiple bruises, skin tears, and scrapes; Deficiencies in
care cited by surveyor: State and date of survey[A]Iowa-4: Facility
failed to prevent bruises and skin tear injuries. The staff did not
assess the cause of the injuries or implement protective devices, such
as padding of the lift and wheelchair. On 2/26/02, a staff member
stated that the probable cause of the bruises was the resident's
hitting the mechanical Hoyer lift during transfers and that the lift
should be padded.
State and date of survey[A]: Iowa-4; February 2001; Requirement and
scope and severity cited: Provide necessary care and; services: E;
Resident description and relevant diagnoses[B]: Resident with a
diagnosis of multiple sclerosis required extensive assistance with
transfers, walking, and other activities of daily living. Care plan of
1/19/01 directed staff to monitor and record all skin changes. Surveyor
noted multiple bruises on resident's legs; Actual harm to resident
documented by surveyor: Surveyor noted bruises on resident's legs and
saw how resident's legs and feet were twisted between the wheelchair
pedals and dragged and bumped against the wheelchair on 1/30 and 1/31/
01. Resident sustained multiple bruises on both lower legs;
Deficiencies in care cited by surveyor: Facility staff failed to
provide the necessary care and services in accordance with the plan of
care. Staff failed to assess for risk of skin injury from wheelchair
transfers and to protect resident from harm during transfers. Staff
also failed to document resident's bruises.
State and date of survey[A]: Iowa-5; March 2001; Requirement and scope
and severity cited: Provide necessary care and; services: D; Resident
description and relevant diagnoses[B]: Resident admitted to facility on
7/6/99 with Alzheimer's disease, high blood pressure, and anemia.
Resident was receiving a diuretic to reduce blood pressure and an
antihistamine for itching. Both drugs can 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; Actual
harm to resident documented by surveyor: Resident fell five documented
times, sustaining abrasions to the forehead, a bloody nose and mouth, a
bump to the forehead, a broken tooth, a carpet burn of the knees, and a
broken nose; Deficiencies in care cited by surveyor: Facility failed
to properly assess and monitor after the resident fell, striking her
head on all five occasions. There was no documentation of weekly
monitoring of blood pressure or for neurological status after resident
struck her head.
State and date of survey[A]: Iowa-7; August 2001; Requirement and scope
and severity cited: Provide necessary care and services: D; Resident
description and relevant diagnoses[B]: Resident 1 admitted to facility
on 3/2/01 with history of stroke, heart failure, and poor circulation,
with related rash of the legs and feet. Assessment revealed a small
scab on the left ankle that healed by 5/01. Resident developed a
scabbed area on right foot. The physician ordered skin and heel
protectors to be worn at night on 5/29/01; Actual harm to resident
documented by surveyor: Resident developed two stage II ulcers of the
foot and ankle, one on 6/18/01 and the other on 6/26/01, which were
still present, unhealed, on 8/7/01; Deficiencies in care cited by
surveyor: Facility staff did not consistently follow the orders and
provide the necessary care for the resident. According to the surveyor,
the skin and heel protectors were left off and the wheelchair was not
padded and was causing additional erosion of the ankle lesions.
Resident description and relevant diagnoses[B]: State and date of
survey[A]Iowa-7: Resident 2 was admitted with lung cancer, degenerative
arthritis, osteoporosis, and anxiety. Physician's note of 5/16/01
indicated that resident was dying and would need to be assessed for
pain relief as the disease progressed and that stronger, more 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; Actual harm to resident documented by surveyor: State
and date of survey[A]Iowa-7: Resident 2 experienced severe unrelieved
pain; Deficiencies in care cited by surveyor: State and date of
survey[A]Iowa-7: Facility staff failed to provide the necessary care
for this resident to maintain comfort measures and avoid pain. The care
plan of 5/21 and 6/13/01 did not include pain management. The staff did
not assess the resident's complaints of pain and need for effective
pain relief.
State and date of survey[A]: Iowa-7; August 2001; Requirement and scope
and severity cited: Provide supervision and devices to prevent
accidents: D; Resident description and relevant diagnoses[B]: Resident
1 has diagnoses of dementia and depression with long-and short-term
memory deficits. Surveyor noted resident had fallen frequently from 2/
23/01 through 7/23/01 and sustained serious injuries. Personal safety
alarms selected for resident were ineffective in preventing falls;
Actual harm to resident documented by surveyor: Resident 1 fell 11
times and sustained a fractured wrist, three fractured ribs, bruises,
abrasions, and a skin tear, plus pain associated with all these falls
and injuries; Deficiencies in care cited by surveyor: The facility
failed to provide adequate interventions to prevent accidents. The
personal alarm system was the only safety device employed, and there is
no evidence that the staff evaluated its effectiveness and selected
other measures.
Resident description and relevant diagnoses[B]: State and date of
survey[A]Maryland-1: Resident 2 was admitted to facility on 8/8/00 with
renal failure and impaired mobility. On 4/3/01, he was assessed as
being mentally confused at times. Surveyor noted the resident's record
stated that resident fell 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; Actual harm to resident documented
by surveyor: State and date of survey[A]Maryland-1: Resident 2 fell 21
times from 1/6/01 to 6/26/01 and sustained multiple skin tears, two
lacerations to the head and elbow requiring emergency room or clinic
visits for sutures, multiple bruises and abrasions, and head injuries;
Deficiencies in care cited by surveyor: State and date of
survey[A]Maryland-1: The facility failed to provide adequate
interventions to prevent accidents. The personal alarm unit in use for
this resident did not prevent his falls from occurring and there is no
indication that other safety options were considered.
State and date of survey[A]: Maryland-1; August 2001; Requirement and
scope and severity cited: Provide supervision and devices to prevent
accidents: D; Resident description and relevant diagnoses[B]: Resident
admitted to facility with multiple diagnoses including congestive heart
failure, high blood pressure, and obesity. Resident suffered from
shortness of breath and required oxygen at 3 liters per minute. She
also had a history of falls and was considered a high risk for falls.
Resident had a physician order for a quick-release belt while in
wheelchair for safety; Actual harm to resident documented by surveyor:
Resident fell out of the wheelchair, was bleeding from nose and mouth,
and was in acute respiratory distress. Staff did not intervene to
address respiratory distress until resident stopped breathing and her
pulse stopped. At this time the staff began to administer
cardiopulmonary resuscitation (CPR); Deficiencies in care cited by
surveyor: The facility failed to provide supervision and devices to
prevent accidents by not placing safety belt around resident while she
was in the wheelchair. Staff also did not provide the resident with
oxygen as ordered while she was in the wheelchair. Staff did not
respond in a timely and appropriate manner to resident's onset of
respiratory distress following the fall from the wheelchair. Staff did
not initiate CPR until resident was no longer breathing and her pulse
stopped.
State and date of survey[A]: Missouri-3; May 2001; Requirement and
scope and severity cited: Ensure adequate nutritional status: D;
Resident description and relevant diagnoses[B]: Resident had diagnoses
of peptic ulcer disease, aspiration pneumonia, and a penicillin-
resistant infection requiring long-term antibiotic treatment. From 11/
00 through 2/01, resident sustained a severe weight loss of 10 to 12
percent; Actual harm to resident documented by surveyor: Resident
experienced another severe weight loss, dropping from 126 lbs in 3/01
to 116.9 lbs in 4/01, a loss of 7.2 percent in 1 month; Deficiencies
in care cited by surveyor: The facility failed to ensure adequate
nutritional status. After noting resident's weight loss in 2/01, no
care plan was developed to address the weight loss. In March, the
dietician recommended a dietary supplement, which did not begin for a
month.
State and date of survey[A]: Nebraska-1; September 2000; Requirement
and scope and severity cited: Provide necessary care and services: D;
Resident description and relevant diagnoses[B]: Resident 1 readmitted
to facility from hospital with a diagnosis of insulin-dependent
diabetes. Physician orders stated that the physician was to be called
when resident's blood sugar fell below 40 or rose above 350 (normal
range is 70 to 110). Resident received insulin on a sliding scale
(insulin dose based on most recent blood sugar), and a variety of
dietary interventions; Actual harm to resident documented by surveyor:
Over a period of 9 months, resident's blood sugar fluctuated, including
frequent episodes of symptomatic hypoglycemia (low blood sugar between
48 and 60) and loss of consciousness; Deficiencies in care cited by
surveyor: Facility failed to provide the necessary care and services
required to manage resident's diabetes. Specifically, (1) the staff
infrequently called the physician about blood sugars below 40, the
frequent blood sugar fluctuations, or the resident's episodes of
symptomatic hypoglycemia, (2) fluctuating blood sugars were not
identified as a problem in the care plan, and (3) there was no
assessment of the resident's diabetes, appropriate diet, treatment
effectiveness of hypoglycemic episodes, and administration of insulin
on a sliding scale.
Resident description and relevant diagnoses[B]: State and date of
survey[A]Nebraska-3 September 2001: Resident 2 with diagnoses of
emphysema, Parkinson's disease, and osteoarthritis was receiving
hospice services. Resident experienced increasing pain on a daily
basis, unrelieved by regular Tylenol, a tranquilizer, and an
antipsychotic drug specific for schizophrenia and mania. Resident
obtained short-term (2.5 hours) relief from Tylox (Tylenol and
oxycodone for pain relief and sedation); Actual harm to resident
documented by surveyor: State and date of survey[A]Nebraska-3 September
2001: This terminally ill resident suffered with unrelieved pain for at
least 4 months; Deficiencies in care cited by surveyor: State and date
of survey[A]Nebraska-3 September 2001: Facility staff did not provide
the necessary care and services to this resident. The staff did not
assess or respond to the resident's continuing complaints of pain and
noted in the record that the resident was demanding and manipulative.
Nor did they monitor the effectiveness of the medications administered,
resulting (according to the surveyor) in the resident's voicing
thoughts of suicide.
State and date of survey[A]: Nebraska-3 September 2001; Requirement and
scope and severity cited: Ensure prevention and healing of pressure
sores: D; Resident description and relevant diagnoses[B]: Resident was
readmitted to facility 5/24/01 with diagnoses of stroke, diabetes, and
one stage II pressure sore of the lower back and one stage I pressure
sore between the buttocks. Resident was totally dependent on staff for
bed mobility because of a right-sided paralysis and developed pressure
sores of both heels that were noted on 6/3/01 and identified as stage
II on 7/24/01. A pressure-reducing mattress was added to the care plan
on 9/4/01; Actual harm to resident documented by surveyor: Resident
developed a stage III pressure sore on the right heel with thick green
drainage and foul odor; Deficiencies in care cited by surveyor:
Facility failed to ensure that a resident did not develop a pressure
sore in the facility. Specifically, the facility staff failed to
recognize the challenge the resident had in moving in bed because of
the right-sided paralysis. In addition, they were slow to use a
pressure-reducing mattress. When the mattress was placed on the bed the
staff did not discontinue use of the fleece-lined protection booties
and continued use for 3 weeks, which negated the pressure-reducing
effects of the mattress.
State and date of survey[A]: Pennsylvania-3; May 2001; Requirement and
scope and severity cited: Ensure prevention and healing of pressure
sores: D; Resident description and relevant diagnoses[B]: Resident had
a left hip fracture and was identified as high risk for skin breakdown
on 12/18/00. A stage I pressure sore of the left heel was noted on 3/7/
01 and by 3/14/01 it had progressed to stage II. A special boot to keep
left heel elevated was not applied until 3/21/01 and was then left on
continuously. A second stage II pressure sore was noted on the left
outer foot 4/10/01. The boot was discontinued on 4/11/01. A nutrition
assessment on 3/27/01 indicated resident's skin was intact and
recommended no increase in protein in the diet; Actual harm to
resident documented by surveyor: In addition to the stage II pressure
sore of the foot, resident developed a second stage II facility-
acquired pressure sore on 4/10/01; Deficiencies in care cited by
surveyor: Facility failed to prevent the development of pressure sores.
Specifically, the boot, which was left on continuously, contributed to
the development of the pressure sore identified on 4/10/01. In
addition, the dietician did not note the existing original pressure
sore and wrongly assumed the resident had no extra need for protein.
The need for additional protein in the diet was confirmed by laboratory
tests indicating the resident's protein levels were below the normal
range.
State and date of survey[A]: Pennsylvania-3; May 2001; Requirement and
scope and severity cited: Provide supervision and devices to prevent
accidents: E; Resident description and relevant diagnoses[B]: Resident
had piriformis syndrome (compression of the sciatic nerve by the
piriformis muscle) with a physician's order for physical therapy using
stretching exercises and heat application. Physical therapy used a
hydrocollator pack to provide moist heat treatments.[G]; Actual harm to
resident documented by surveyor: Resident developed a second-degree
burn of the right buttock, which blistered and was still healing after
a month; Deficiencies in care cited by surveyor: Facility staff failed
to provide supervision and prevent injury; During a routine check on
1/9/01, the facility found that the temperature on the hydrocollator
pack was 11 degrees above the manufacturer's recommended temperature.
On 4/16/01 the hydrocollator pack was applied to the resident's right
buttock. 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 description and relevant diagnoses[B]: State and date of
survey[A]Pennsylvania-9: Resident 2 had diagnoses that included
dementia, poor vision, and Parkinson's disease and was assessed as a
moderate risk for falls on 12/29/00. The MDS significant change
assessment of 1/24/01 and the 4/9/01 quarterly review noted a history
of falls, impaired decision making, and the need for assistance for
transferring and walking. The records noted interventions found to be
ineffective continued to be used; Actual harm to resident documented
by surveyor: State and date of survey[A]Pennsylvania-9: Resident 2 fell
nine documented times and, as a result of these falls, sustained a skin
tear, a laceration requiring transfer to the hospital for treatment,
and a dislocated hip requiring another hospital visit; Deficiencies in
care cited by surveyor: State and date of survey[A]Pennsylvania-9: The
facility failed to ensure adequate supervision and assistance devices
to prevent accidents. According to the surveyor, there was no evidence
that the facility had implemented effective interventions to avoid the
risk of such accidents for the resident. The surveyor noted that this
at-risk resident's room was too far from the nurses' station, making
observation difficult.
State and date of survey[A]: Pennsylvania-9; May 2001; Requirement and
scope and severity cited: Provide supervision and devices to prevent
accidents: D; Resident description and relevant diagnoses[B]: A
dependent resident with cognitive impairment was assessed as at risk
for falls and skin tears. Interventions to prevent falls listed in the
care plan included use of personal alarms, protective sleeves, and
padded side rails; Actual harm to resident documented by surveyor:
Resident sustained eight skin tears on 6/27/00, 7/24/00, 7/31/00, 8/16/
00, 9/20/00, 10/24/00, 1/8/01, and 1/27/01; Deficiencies in care cited
by surveyor: Surveyor stated that the facility failed to ensure that
the necessary safety measures and/or devices were implemented and
failed to adequately assess the ongoing use of these devices given
their ineffectiveness in preventing falls and skin tears.
State and date of survey[A]: Virginia-1; August 2000; Requirement and
scope and severity cited: Provide necessary care and; services: D;
Resident description and relevant diagnoses[B]: Resident admitted to
facility for pain management associated with spread of cancer to the
spine. Resident had physician orders for Oxycontin every 12 hours for
long-term pain relief, as needed, and Percocet every 4 hours for any
additional pain, as needed. Staff noted resident lay very still in bed
and seldom asked for pain 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; Actual harm to
resident documented by surveyor: This resident suffered with severe
pain that was incompletely relieved by the use of Percocet. The longer
acting Oxycontin was never used; Deficiencies in care cited by
surveyor: The facility did not provide necessary care and services to
manage this resident's pain. Resident did not receive any of the
longer-acting Oxycontin and received only 10 doses of the Percocet
during the 6 days he was in the facility. He was not offered pain
relief in the morning when he was being turned and bathed. Monitoring
of medication effectiveness was incomplete. Percocet was given, on
average, once a day.
State and date of survey[A]: Virginia-2; March 2001; Requirement and
scope and severity cited: Provide necessary care and; services: D;
Resident description and relevant diagnoses[B]: Resident was admitted
to facility 11/4/97, with diagnoses of stroke, depression, and
delusions. An MDS of 11/9/00 indicated the resident was cognitively
impaired and required lift transfer. On 12/27/00 the nurse noted a
large area of bruising on the left chest and left underarm with
swelling around the rib cage. On 1/6/01 resident began to experience
shallow breathing. Physician ordered a chest x ray if resident's
breathing difficulties continued; Actual harm to resident documented
by surveyor: Resident sustained fractures of the eighth and ninth ribs
with fluid in the left lower lobe of the lung demonstrated by x ray;
Deficiencies in care cited by surveyor: The facility failed to provide
the necessary care and services to provide prompt treatment of the
resident's chest injury. Specifically, the facility failed to take
appropriate action to assess and provide the necessary care for this
resident's injury for 11 days. The results of an investigation
implicated the lift used to transfer the resident to and from the bed.
State and date of survey[A]: Virginia-2; March 2001; Requirement and
scope and severity cited: Ensure prevention and healing of pressure
sores: D; Resident description and relevant diagnoses[B]: Resident 1
admitted to the facility with diagnoses of Alzheimer's disease, anemia,
depression, and joint pain. No pressure sores were noted on the
admission assessment form. The care plan on 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); Actual harm to
resident documented by surveyor: Resident developed three open pressure
sores of the buttocks, evident 2 days after the MDS assessment. One of
the pressure sores was a stage III; Deficiencies in care cited by
surveyor: The facility failed to prevent the development of facility-
acquired pressure sores. The staff did not obtain timely alternative
treatments and interventions to promote healing of early pressure
sores.
Resident description and relevant diagnoses[B]: State and date of
survey[A]Virginia-4: Resident 2 admitted to facility on 12/24/00 with
diabetes, stroke, prostate cancer, requiring limited assistance for
activities of daily living, and incontinent of bowel and bladder. As of
12/31/00 resident had an unhealed surgical wound of the back, two 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; Actual harm to resident documented by surveyor: State and
date of survey[A]Virginia-4: Resident developed an open stage III
pressure sore with yellow drainage; Deficiencies in care cited by
surveyor: State and date of survey[A]Virginia-4: Staff failed to obtain
timely alternative treatments and interventions to promote healing upon
worsening of these sores from1/18/01 through 3/1/01. Specifically, the
staff continued to treat the pressure sores without evaluating the
effectiveness of the treatment.
State and date of survey[A]: Virginia-4; March 2001; Requirement and
scope and severity cited: Provide necessary care and services: D;
Resident description and relevant diagnoses[B]: Resident was an 81-
year-old admitted to the facility on 8/17/90 with psychoses and
hypothyroidism. Recent assessment (1/22/01) indicated long-and short-
term memory loss and moderate dependency for activities of daily
living. Care plan identified resident as at risk for falls. A list of
preventive measures was provided. On 9/14/00 at 7:30 p.m., resident
fell and complained of pain all over; Actual harm to resident
documented by surveyor: Resident sustained a nondisplaced fracture of
the left wrist and suffered unnecessary pain; Deficiencies in care
cited by surveyor: Facility failed to provide necessary care and
services. The facility failed to assess and investigate the source of
the resident's pain. Nurses' notes indicate no apparent injury after
fall. On 9/15/00 at 6:30 p.m., resident complained of pain in left arm.
There was bruising on wrist and thumb, and the arm was swollen and
tender to touch. According to the surveyor, there was a delay in
seeking more aggressive treatment or service, as evidenced by the 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.
[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.
[End of table]
[End of section]
Appendix IV: Information on State Nursing 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:
State[A]: Maryland; Surveyors with: 2 years or less experience:
(percent): 70; Surveyor positions vacant (percent): 9; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
0 to 2.
State[A]: Oklahoma; Surveyors with: 2 years or less experience:
(percent): 67; Surveyor positions vacant (percent): 4; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
0 to1.
State[A]: New Hampshire; Surveyors with: 2 years or less experience:
(percent): 60; Surveyor positions vacant (percent): 12; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
2.
State[A]: Florida; Surveyors with: 2 years or less experience:
(percent): 55; Surveyor positions vacant (percent): 8; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
0.
State[A]: Idaho; Surveyors with: 2 years or less experience: (percent):
54; Surveyor positions vacant (percent): 0; Surveyor hiring freeze in
effect as of mid-2002: Yes; RN surveyor salaries are competitive: No;
Minimum required experience for RN surveyors (years): 1.
State[A]: Washington; Surveyors with: 2 years or less experience:
(percent): 54; Surveyor positions vacant (percent): 0; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
2.
State[A]: California; Surveyors with: 2 years or less experience:
(percent): 52; Surveyor positions vacant (percent): 6; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
1.
State[A]: Georgia; Surveyors with: 2 years or less experience:
(percent): 51; Surveyor positions vacant (percent): 14; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
3.
State[A]: Kentucky; Surveyors with: 2 years or less experience:
(percent): 51; Surveyor positions vacant (percent): 17; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
4.
State[A]: District of Columbia; Surveyors with: 2 years or less
experience: (percent): 50; Surveyor positions vacant (percent): 9;
Surveyor hiring freeze in effect as of mid-2002: Yes; RN surveyor
salaries are competitive: Yes; Minimum required experience for RN
surveyors (years): 3.
State[A]: Utah; Surveyors with: 2 years or less experience: (percent):
50; Surveyor positions vacant (percent): 8; Surveyor hiring freeze in
effect as of mid-2002: No; RN surveyor salaries are competitive: No;
Minimum required experience for RN surveyors (years): 2.
State[A]: Louisiana; Surveyors with: 2 years or less experience:
(percent): 48; Surveyor positions vacant (percent): 6; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
2 to 3.
State[A]: Alabama; Surveyors with: 2 years or less experience:
(percent): 48; Surveyor positions vacant (percent): 10; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
0.
State[A]: Tennessee; Surveyors with: 2 years or less experience:
(percent): 45; Surveyor positions vacant (percent): 18; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
3.
State[A]: Maine; Surveyors with: 2 years or less experience: (percent):
42; Surveyor positions vacant (percent): 9; Surveyor hiring freeze in
effect as of mid-2002: Yes; RN surveyor salaries are competitive: No;
Minimum required experience for RN surveyors (years): 5.
State[A]: Hawaii; Surveyors with: 2 years or less experience:
(percent): 40; Surveyor positions vacant (percent): 17; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
2-½.
State[A]: New York; Surveyors with: 2 years or less experience:
(percent): 40; Surveyor positions vacant (percent): 4; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
1 to 2.
State[A]: Missouri; Surveyors with: 2 years or less experience:
(percent): 36; Surveyor positions vacant (percent): 11; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
2.
State[A]: Oregon; Surveyors with: 2 years or less experience:
(percent): 34; Surveyor positions vacant (percent): 12; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
5.
State[A]: Arkansas; Surveyors with: 2 years or less experience:
(percent): 33; Surveyor positions vacant (percent): 20; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
2.
State[A]: North Carolina; Surveyors with: 2 years or less experience:
(percent): 33; Surveyor positions vacant (percent): 18; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
4.
State[A]: Texas; Surveyors with: 2 years or less experience: (percent):
32; Surveyor positions vacant (percent): 20[B]; Surveyor hiring freeze
in effect as of mid-2002: No[B]; RN surveyor salaries are competitive:
No; Minimum required experience for RN surveyors (years): 1.
State[A]: New Mexico; Surveyors with: 2 years or less experience:
(percent): 30; Surveyor positions vacant (percent): 34; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
3.
State[A]: New Jersey; Surveyors with: 2 years or less experience:
(percent): 30; Surveyor positions vacant (percent): 23; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
3.
State[A]: Nebraska; Surveyors with: 2 years or less experience:
(percent): 29; Surveyor positions vacant (percent): 6; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
1 to 2.
State[A]: Connecticut; Surveyors with: 2 years or less experience:
(percent): 29; Surveyor positions vacant (percent): 1; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
4.
State[A]: Alaska; Surveyors with: 2 years or less experience:
(percent): 29; Surveyor positions vacant (percent): 22; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
2.
State[A]: Wisconsin; Surveyors with: 2 years or less experience:
(percent): 25; Surveyor positions vacant (percent): 15; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
0.
State[A]: Colorado; Surveyors with: 2 years or less experience:
(percent): 24; Surveyor positions vacant (percent): 17; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
1.
State[A]: Virginia; Surveyors with: 2 years or less experience:
(percent): 21; Surveyor positions vacant (percent): 5; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
0.
State[A]: Indiana; Surveyors with: 2 years or less experience:
(percent): 20; Surveyor positions vacant (percent): 18; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
1.
State[A]: Arizona; Surveyors with: 2 years or less experience:
(percent): 20; Surveyor positions vacant (percent): 24; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
2.
State[A]: South Dakota; Surveyors with: 2 years or less experience:
(percent): 18; Surveyor positions vacant (percent): 0; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
2.
State[A]: Ohio; Surveyors with: 2 years or less experience: (percent):
17; Surveyor positions vacant (percent): 5; Surveyor hiring freeze in
effect as of mid-2002: No; RN surveyor salaries are competitive: Yes;
Minimum required experience for RN surveyors (years): 0.
State[A]: Michigan; Surveyors with: 2 years or less experience:
(percent): 17; Surveyor positions vacant (percent): 5; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
0.
State[A]: Kansas; Surveyors with: 2 years or less experience:
(percent): 17; Surveyor positions vacant (percent): 4; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
[C].
State[A]: Massachusetts; Surveyors with: 2 years or less experience:
(percent): 16; Surveyor positions vacant (percent): 14; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
1 to 3.
State[A]: Pennsylvania; Surveyors with: 2 years or less experience:
(percent): 15; Surveyor positions vacant (percent): 7; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
1.
State[A]: Rhode Island; Surveyors with: 2 years or less experience:
(percent): 9; Surveyor positions vacant (percent): 13; Surveyor hiring
freeze in effect as of mid-2002: No; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
1.
State[A]: Illinois; Surveyors with: 2 years or less experience:
(percent): 5; Surveyor positions vacant (percent): 5; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: Yes; Minimum required experience for RN surveyors (years):
2 to 3.
State[A]: Iowa; Surveyors with: 2 years or less experience: (percent):
4; Surveyor positions vacant (percent): 0; Surveyor hiring freeze in
effect as of mid-2002: Yes; RN surveyor salaries are competitive: No;
Minimum required experience for RN surveyors (years): 5.
State[A]: Minnesota; Surveyors with: 2 years or less experience:
(percent): 0; Surveyor positions vacant (percent): 17; Surveyor hiring
freeze in effect as of mid-2002: Yes; RN surveyor salaries are
competitive: No; Minimum required experience for RN surveyors (years):
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.
[End of table]
[End of section]
Appendix V: Predictability of Standard 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.
Table 10: Predictability of Current Nursing Home Surveys, by State:
State: Alabama; Number of active homes with a current and prior survey:
225; Predictable surveys (percent): 82.7; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 5.8; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
76.9.
State: Oklahoma; Number of active homes with a current and prior
survey: 354; Predictable surveys (percent): 71.5; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 0.6; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 70.9.
State: South Carolina; Number of active homes with a current and prior
survey: 174; Predictable surveys (percent): 67.8; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 6.9; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 60.9.
State: Nebraska; Number of active homes with a current and prior
survey: 226; Predictable surveys (percent): 59.7; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 3.1; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 56.6.
State: Utah; Number of active homes with a current and prior survey:
91; Predictable surveys (percent): 52.7; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 1.1; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
51.6.
State: Montana; Number of active homes with a current and prior survey:
103; Predictable surveys (percent): 52.4; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 8.7; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
43.7.
State: Georgia; Number of active homes with a current and prior survey:
357; Predictable surveys (percent): 52.4; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 0.6; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
51.8.
State: Hawaii; Number of active homes with a current and prior survey:
44; Predictable surveys (percent): 52.3; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 13.6; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
38.6.
State: New York; Number of active homes with a current and prior
survey: 663; Predictable surveys (percent): 52.0; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 14.8; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 37.3.
State: Idaho; Number of active homes with a current and prior survey:
84; Predictable surveys (percent): 50.0; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 4.8; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
45.2.
State: New Mexico; Number of active homes with a current and prior
survey: 80; Predictable surveys (percent): 43.8; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 13.8; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 30.0.
State: Delaware; Number of active homes with a current and prior
survey: 42; Predictable surveys (percent): 42.9; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 31.0; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 11.9.
State: California; Number of active homes with a current and prior
survey: 1,324; Predictable surveys (percent): 41.2; Homes surveyed
within 15 days of 1-year anniversary of prior survey (percent): 9.5;
Homes surveyed within 1 month of 15-month maximum interval of prior
survey (percent): 31.7.
State: Nevada; Number of active homes with a current and prior survey:
45; Predictable surveys (percent): 40.0; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 24.4; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
15.6.
State: Arizona; Number of active homes with a current and prior survey:
138; Predictable surveys (percent): 39.9; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 21.0; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
18.8.
State: New Jersey; Number of active homes with a current and prior
survey: 359; Predictable surveys (percent): 39.0; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 18.7; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 20.3.
State: Oregon; Number of active homes with a current and prior survey:
142; Predictable surveys (percent): 38.0; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 14.1; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
23.9.
State: Maryland; Number of active homes with a current and prior
survey: 246; Predictable surveys (percent): 37.0; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 20.7; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 16.3.
State: Massachusetts; Number of active homes with a current and prior
survey: 497; Predictable surveys (percent): 36.2; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 17.3; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 18.9.
State: Arkansas; Number of active homes with a current and prior
survey: 239; Predictable surveys (percent): 35.6; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 27.6; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 7.9.
State: Virginia; Number of active homes with a current and prior
survey: 275; Predictable surveys (percent): 35.3; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 30.5; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 4.7.
State: Iowa; Number of active homes with a current and prior survey:
457; Predictable surveys (percent): 34.6; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 31.1; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
3.5.
State: Nation; Number of active homes with a current and prior survey:
16,332; Predictable surveys (percent): 34.0; Homes surveyed within 15
days of 1-year anniversary of prior survey (percent): 13.0; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 21.0.
State: Kentucky; Number of active homes with a current and prior
survey: 303; Predictable surveys (percent): 33.7; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 10.6; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 23.1.
State: Ohio; Number of active homes with a current and prior survey:
973; Predictable surveys (percent): 33.6; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 3.0; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
30.6.
State: North Dakota; Number of active homes with a current and prior
survey: 85; Predictable surveys (percent): 32.9; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 28.2; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 4.7.
State: Vermont; Number of active homes with a current and prior survey:
43; Predictable surveys (percent): 32.6; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 11.6; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
20.9.
State: New Hampshire; Number of active homes with a current and prior
survey: 83; Predictable surveys (percent): 32.5; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 12.0; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 20.5.
State: South Dakota; Number of active homes with a current and prior
survey: 111; Predictable surveys (percent): 32.4; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 18.9; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 13.5.
State: Wisconsin; Number of active homes with a current and prior
survey: 404; Predictable surveys (percent): 32.4; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 19.6; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 12.9.
State: Washington; Number of active homes with a current and prior
survey: 268; Predictable surveys (percent): 32.1; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 22.4; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 9.7.
State: Florida; Number of active homes with a current and prior survey:
718; Predictable surveys (percent): 32.0; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 9.3; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
22.7.
State: Mississippi; Number of active homes with a current and prior
survey: 187; Predictable surveys (percent): 31.6; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 2.1; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 29.4.
State: Rhode Island; Number of active homes with a current and prior
survey: 96; Predictable surveys (percent): 31.3; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 12.5; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 18.8.
State: Connecticut; Number of active homes with a current and prior
survey: 253; Predictable surveys (percent): 30.8; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 15.8; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 15.0.
State: Wyoming; Number of active homes with a current and prior survey:
39; Predictable surveys (percent): 30.8; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 10.3; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
20.5.
State: Indiana; Number of active homes with a current and prior survey:
550; Predictable surveys (percent): 30.7; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 14.4; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
16.4.
State: Tennessee; Number of active homes with a current and prior
survey: 324; Predictable surveys (percent): 29.0; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 6.2; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 22.8.
State: Louisiana; Number of active homes with a current and prior
survey: 315; Predictable surveys (percent): 28.6; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 19.0; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 9.5.
State: Texas; Number of active homes with a current and prior survey:
1,122; Predictable surveys (percent): 27.2; Homes surveyed within 15
days of 1-year anniversary of prior survey (percent): 15.7; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 11.5.
State: Colorado; Number of active homes with a current and prior
survey: 222; Predictable surveys (percent): 26.1; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 9.0; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 17.1.
State: Pennsylvania; Number of active homes with a current and prior
survey: 757; Predictable surveys (percent): 26.0; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 24.0; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 2.0.
State: Kansas; Number of active homes with a current and prior survey:
369; Predictable surveys (percent): 25.2; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 13.6; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
11.7.
State: Missouri; Number of active homes with a current and prior
survey: 531; Predictable surveys (percent): 25.0; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 11.9; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 13.2.
State: Maine; Number of active homes with a current and prior survey:
121; Predictable surveys (percent): 24.8; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 8.3; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
16.5.
State: Minnesota; Number of active homes with a current and prior
survey: 427; Predictable surveys (percent): 20.4; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 4.4; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 15.9.
State: Alaska; Number of active homes with a current and prior survey:
15; Predictable surveys (percent): 20.0; Homes surveyed within 15 days
of 1-year anniversary of prior survey (percent): 6.7; Homes surveyed
within 1 month of 15-month maximum interval of prior survey (percent):
13.3.
State: District of Columbia; Number of active homes with a current and
prior survey: 20; Predictable surveys (percent): 20.0; Homes surveyed
within 15 days of 1-year anniversary of prior survey (percent): 15.0;
Homes surveyed within 1 month of 15-month maximum interval of prior
survey (percent): 5.0.
State: North Carolina; Number of active homes with a current and prior
survey: 411; Predictable surveys (percent): 17.3; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 13.9; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 3.4.
State: Illinois; Number of active homes with a current and prior
survey: 849; Predictable surveys (percent): 15.2; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 9.7; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 5.5.
State: West Virginia; Number of active homes with a current and prior
survey: 138; Predictable surveys (percent): 10.9; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 8.7; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 2.2.
State: Michigan; Number of active homes with a current and prior
survey: 433; Predictable surveys (percent): 10.2; Homes surveyed within
15 days of 1-year anniversary of prior survey (percent): 8.8; Homes
surveyed within 1 month of 15-month maximum interval of prior survey
(percent): 1.4.
Source: GAO analysis of OSCAR data as of April 9, 2002.
[End of table]
[End of section]
Appendix VI: Immediate Sanctions 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.[Footnote 73] 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:
Type of sanction[A]: CMP; Number implemented: 2,933.
Type of sanction[A]: Denial of payment for new admissions; Number
implemented: 1,232.
Type of sanction[A]: Directed in-service training; Number implemented:
345.
Type of sanction[A]: State monitoring; Number implemented: 192.
Type of sanction[A]: Directed plan of correction; Number implemented:
77.
Type of sanction[A]: CMS approved alternative or additional state
sanction; Number implemented: 48.
Type of sanction[A]: Termination from the Medicare and Medicaid
programs; Number implemented: 26.
Type of sanction[A]: Temporary management; Number implemented: 4.
Type of sanction[A]: Denial of payment for all residents; Number
implemented: 2.
Type of sanction[A]: Transfer of residents and closure of facility;
Number implemented: 1.
Type of sanction[A]: Total; Number implemented: 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.
[End of table]
Table 12: Federal CMPs Implemented under CMS's Immediate Sanctions
Policy, January 2000 through March 2002:
State: Alabama; CMP amount: $375,627.50.
State: Alaska; CMP amount: 0.00.
State: Arizona; CMP amount: 350,652.50.
State: Arkansas; CMP amount: 1,571,654.04.
State: California; CMP amount: 1,681,813.50.
State: Colorado; CMP amount: 1,489,100.00.
State: Connecticut; CMP amount: 696,350.00.
State: Delaware; CMP amount: 214,342.50.
State: District of Columbia; CMP amount: 20,000.00.
State: Florida; CMP amount: 1,975,375.00.
State: Georgia; CMP amount: 487,050.00.
State: Hawaii; CMP amount: 20,000.00.
State: Idaho; CMP amount: 37,350.00.
State: Illinois; CMP amount: 2,801,656.50.
State: Indiana; CMP amount: 1,977,685.50.
State: Iowa; CMP amount: 175,945.00.
State: Kansas; CMP amount: 415,400.00.
State: Kentucky; CMP amount: 1,195,177.50.
State: Louisiana; CMP amount: 20,000.00.
State: Maine; CMP amount: 184,920.00.
State: Maryland; CMP amount: 290,270.00.
State: Massachusetts; CMP amount: 1,031,445.00.
State: Michigan; CMP amount: 1,035,815.00.
State: Minnesota; CMP amount: 66,307.50.
State: Mississippi; CMP amount: 186,977.50.
State: Missouri; CMP amount: 467,157.50.
State: Montana; CMP amount: 0.00.
State: Nebraska; CMP amount: 11,207.50.
State: Nevada; CMP amount: 429,500.00.
State: New Hampshire; CMP amount: 93,350.00.
State: New Jersey; CMP amount: 1,543,007.50.
State: New Mexico; CMP amount: 222,430.00.
State: New York; CMP amount: 0.00.
State: North Carolina; CMP amount: 2,171,013.75.
State: North Dakota; CMP amount: 15,730.00.
State: Ohio; CMP amount: 3,104,870.00.
State: Oklahoma; CMP amount: 1,075,036.50.
State: Oregon; CMP amount: 15,225.00.
State: Pennsylvania; CMP amount: 1,250,417.00.
State: Rhode Island; CMP amount: 9,425.00.
State: South Carolina; CMP amount: 29,250.00.
State: South Dakota; CMP amount: 0.00.
State: Tennessee; CMP amount: 381,432.50.
State: Texas; CMP amount: 7,677,219.58.
State: Utah; CMP amount: 37,157.00.
State: Vermont; CMP amount: 11,550.00.
State: Virginia; CMP amount: 934,425.00.
State: Washington; CMP amount: 0.00.
State: West Virginia; CMP amount: 112,160.00.
State: Wisconsin; CMP amount: 901,960.50.
State: Wyoming; CMP amount: 0.00.
State: Total; CMP amount: $38,794,439.37.
Source: CMS enforcement database.
[End of table]
[End of section]
Appendix VII: Cases States Did Not Refer to 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.[Footnote 74] 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:
State: Nation; State: 711; Number of cases referred[A]: 4,310.
State: Texas; State: 169; Number of cases referred[A]: 423.
State: New York; State: 140; Number of cases referred[A]: 22.
State: Massachusetts; State: 46; Number of cases referred[A]: 81.
State: Pennsylvania; State: 38; Number of cases referred[A]: 164.
State: Connecticut; State: 26; Number of cases referred[A]: 244.
State: Washington; State: 26; Number of cases referred[A]: 227.
State: Illinois; State: 24; Number of cases referred[A]: 241.
State: Florida; State: 21; Number of cases referred[A]: 150.
State: New Jersey; State: 20; Number of cases referred[A]: 56.
State: Tennessee; State: 20; Number of cases referred[A]: 46.
State: Minnesota; State: 19; Number of cases referred[A]: 68.
State: Missouri; State: 18; Number of cases referred[A]: 108.
State: South Carolina; State: 18; Number of cases referred[A]: 3.
State: North Carolina; State: 10; Number of cases referred[A]: 242.
State: Arizona; State: 9; Number of cases referred[A]: 24.
State: Maryland; State: 9; Number of cases referred[A]: 34.
State: Wyoming; State: 9; Number of cases referred[A]: 11.
State: California; State: 7; Number of cases referred[A]: 96.
State: Michigan; State: 7; Number of cases referred[A]: 284.
State: Arkansas; State: 6; Number of cases referred[A]: 115.
State: Montana; State: 6; Number of cases referred[A]: 14.
State: Ohio; State: 6; Number of cases referred[A]: 323.
State: Idaho; State: 5; Number of cases referred[A]: 31.
State: Indiana; State: 5; Number of cases referred[A]: 270.
State: Louisiana; State: 5; Number of cases referred[A]: 82.
State: Oklahoma; State: 4; Number of cases referred[A]: 53.
State: West Virginia; State: 4; Number of cases referred[A]: 11.
State: Delaware; State: 3; Number of cases referred[A]: 14.
State: Georgia; State: 3; Number of cases referred[A]: 81.
State: Hawaii; State: 3; Number of cases referred[A]: 1.
State: Iowa; State: 3; Number of cases referred[A]: 44.
State: New Hampshire; State: 3; Number of cases referred[A]: 20.
State: Colorado; State: 2; Number of cases referred[A]: 116.
State: District of Columbia; State: 2; Number of cases referred[A]: 1.
State: Oregon; State: 2; Number of cases referred[A]: 51.
State: Rhode Island; State: 2; Number of cases referred[A]: 3.
State: South Dakota; State: 2; Number of cases referred[A]: 18.
State: Virginia; State: 2; Number of cases referred[A]: 41.
State: Wisconsin; State: 2; Number of cases referred[A]: 61.
State: Alabama; State: 1; Number of cases referred[A]: 50.
State: Kansas; State: 1; Number of cases referred[A]: 175.
State: Maine; State: 1; Number of cases referred[A]: 18.
State: New Mexico; State: 1; Number of cases referred[A]: 19.
State: Nevada; State: 1; Number of cases referred[A]: 12.
State: Alaska; State: 0; Number of cases referred[A]: 0.
State: Kentucky; State: 0; Number of cases referred[A]: 75.
State: Mississippi; State: 0; Number of cases referred[A]: 23.
State: Nebraska; State: 0; Number of cases referred[A]: 30.
State: North Dakota; State: 0; Number of cases referred[A]: 20.
State: Utah; State: 0; Number of cases referred[A]: 11.
State: Vermont; State: 0; Number of cases referred[A]: 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.
[End of table]
[End of section]
Appendix VIII: HCFA State Performance 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:
Description: 1. Surveys are planned, scheduled, and conducted in a
timely manner;
Description: * At least 10 percent of standard surveys begin on
weekends or "off-hours"; Source of information: Surveys are planned,
scheduled, and conducted in a timely manner: OSCAR and state survey
schedules; Criteria for determining compliance with standard: At least
10 percent of standard surveys begin on weekends or off-hours.
Description: * Standard surveys are conducted within prescribed time
limits; Source of information: Surveys are planned, scheduled, and
conducted in a timely manner: OSCAR; Criteria for determining
compliance with standard: 100 percent of nursing homes are surveyed
within statutory time limits.
Description: 2. Survey findings (deficiencies) are supportable;
Description: * State surveyors explain and properly document all
deficiencies in survey reports following HCFA guidance known as the
"principles of documentation"; Source of information: Surveys are
planned, scheduled, and conducted in a timely manner: A random sample
of 10 percent (maximum of 40, minimum of 5) of the state's survey
results in which certain deficiencies were cited at "D" or higher
levels of scope and severity; Criteria for determining compliance with
standard: At least 85 percent of the deficiencies reviewed meet the
principles of documentation.
Description: 3. Surveys are fully documented and consistent with
applicable laws, regulations, and general instructions.
Description: * Surveys are adequately conducted by state agencies using
the standards, protocols, forms, methods, procedures, policies, and
systems specified by HCFA instructions; Source of information: Surveys
are planned, scheduled, and conducted in a timely manner: Reports
generated from HCFA's database on federal monitoring surveys; Criteria
for determining compliance with standard: 100 percent of standard
surveys are adequately conducted by state agencies using the standards,
protocols, forms, methods, procedures, policies, and systems specified
by HCFA instructions.
Description: 4. When states certify that nursing homes are not in
compliance, they follow adverse action procedures set forth in
regulations and general instructions.
Description: * "Immediate and Serious Threat" cases are processed in a
timely manner; Source of information: Surveys are planned, scheduled,
and conducted in a timely manner: OSCAR, Enforcement Tracking System
reports, and state agency provider certification files; Criteria for
determining compliance with standard: In 95 percent of cases in which
there is immediate jeopardy or a serious threat to resident health and
safety, the state agency adheres to the 23-day termination process.
Description: * Payments are not made to nursing homes that have not
achieved substantial compliance within 6 months of their last surveys;
Source of information: Surveys are planned, scheduled, and conducted in
a timely manner: OSCAR, Enforcement Tracking System reports, and state
agency provider certification files; Criteria for determining
compliance with standard: The state provides timely notice to HCFA
(i.e., 20 days prior to the home's termination date) on 100 percent of
the cases in which the nursing home has not achieved timely compliance.
Description: 5. All expenditures and charges to the program are
substantiated to the Secretary's satisfaction.
Description: * The state agency employs an acceptable process for
charging federal programs; Source of information: Surveys are planned,
scheduled, and conducted in a timely manner: HCFA budget expenditure
and workload reports; Criteria for determining compliance with
standard: More than 20 different items on the two 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.
Description: * The state agency has an acceptable method for monitoring
its current rate of expenditures; Source of information: Surveys are
planned, scheduled, and conducted in a timely manner: OSCAR reports;
Criteria for determining compliance with standard: Numerous items
submitted by the states, such as quarterly expenditure reports and
supplemental budget requests, are reviewed to determine if state
requirements for monitoring expenditures are met, not met, or not
applicable.
Description: 6. Conduct and reporting of complaint investigations are
timely and accurate, and comply with general instructions for handling
complaints.
Description: * Investigate immediate jeopardy complaints within 2
workdays; Source of information: Surveys are planned, scheduled, and
conducted in a timely manner: Semiannual review of a 10 percent sample
of a state's complaint files; Criteria for determining compliance with
standard: 100 percent of immediate jeopardy complaints are investigated
within 2 days.
Description: * Investigate actual harm complaints within 10 workdays;
Source of information: Surveys are planned, scheduled, and conducted in
a timely manner: (maximum of 20 cases); Criteria for determining
compliance with standard: 100 percent of actual harm complaints are
investigated within 10 days.
Description: * Maintain and follow guidelines for the prioritization of
all other complaints; Source of information: Surveys are planned,
scheduled, and conducted in a timely manner: [Empty]; Criteria for
determining compliance with standard: The state agency has and follows
its own written criteria governing the prioritization of complaints
that do not allege immediate jeopardy or actual harm.
Description: * State enters complaint data into OSCAR appropriately and
in a timely manner; Source of information: Surveys are planned,
scheduled, and conducted in a timely manner: Semiannual on-site reviews
of 20 state complaint survey reports; Criteria for determining
compliance with standard: 100 percent of deficiencies cited in the
sampled complaints are cited under the correct federal citation.
Source of information: Surveys are planned, scheduled, and conducted in
a timely manner: DescriptionAccurate data on survey results are entered
into OSCAR in a timely manner: OSCAR data are reviewed quarterly for
timely entry; Criteria for determining compliance with standard:
DescriptionAccurate data on survey results are entered into OSCAR in a
timely manner: Average time to enter results of complaint
investigations does not exceed 20 calendar days from completion of the
case.
Description: 7. Accurate data on survey results are entered into OSCAR
in a timely manner.
Description: * Results of standard surveys are entered into OSCAR in a
timely manner; Source of information: Surveys are planned, scheduled,
and conducted in a timely manner: Semiannual review of all standard
surveys based on OSCAR data; Criteria for determining compliance with
standard: The statewide average time between state agency sign-off of
the certification and transmittal form and entry of the survey results
into OSCAR does not exceed 20 calendar days.
Description: * Results of surveys are entered into OSCAR accurately;
Source of information: Surveys are planned, scheduled, and conducted in
a timely manner: Semiannual review of a random sample of nursing home
survey results; Criteria for determining compliance with standard: No
less than 85 percent of cases reviewed 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.
[End of table]
[End of section]
Appendix IX: Highlights of State Compliance 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:
[See PDF for image]
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.
[End of table]
[End of section]
Appendix X: Comments from the Centers for Medicare & Medcaid Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare a Medicaid Services:
Administrator
Washington, DC 20201:
DATE: JUN 20 2003:
TO: Kathryn G. Allen:
Director, Health Care-Medicaid and Private Health Insurance Issues:
FROM: Thomas A. Scully Administrator:
SUBJECT: General Accounting Office (GAO) Draft Report, NURSING HOME
QUALITY: Prevalence of Serious Problems, While Declining, Reinforces
Importance of Enhanced Oversight, (GAO-03-561):
Thank you for the opportunity to review your draft report to Congress
concerning enforcement and oversight of Federal nursing home standards.
We agree with the report's findings that the Centers for Medicare &
Medicaid Services should continue to strengthen its ability to make
sure that nursing homes comply with Medicare and Medicaid quality-of-
care standards.
Attached are our specific comments to the report. We look forward to
working with GAO on this and other issues in the future.
Attachment:
The Centers for Medicare & Medicaid Comments to GAO's Draft Report,
NURSING HOME QUALITY. Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight, (GAO-03-561):
GAO Recommendation:
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.
CMS Response:
We agree and have already taken steps to assist states in improving the
effectiveness of the survey process. For example, we led a contract to
develop a series of surveyor guidance on a series of clinical issues.
Some of the clinical areas that have been identified include pressure
sores, hydration and nutrition, accidents, unnecessary medications, and
psychosocial harm. Additionally, we're continuing to refine data used
by surveyors to help focus resources more effectively during a survey.
Lastly, we are communicating to states through the Budget Call Letter
more specific priorities of survey workload to assure that statutorily
mandated surveys be completed.
GAO Recommendation:
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.
CMS Response:
We believe this to be an important concept and have already
incorporated this concept into Standard 2 of the State Performance
Standards. This standard requires regions to take a sample of statement
of deficiencies to evaluate a state's ability to document deficiencies.
We will continue to refine this standard to better evaluate the
sufficiency of documentation of varying harm levels. In addition to
reviewing the appropriateness of the scope and severity of
deficiencies, we have completed a number of data analyses to look
nationally, and by state, at the number of deficiency free facilities
and those with high and low numbers of deficiencies. We are working on
a data system (Aspen Enforcement Module) so that we can more easily
assess these trends in deficiencies.
GAO Recommendation:
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 resident; the handling of facility
self-reported incidents; and, the use of appropriate complaint
investigation practices.
CMS Response:
We concur and are developing and implementing the Aspen Complaints/
Incident Tracking System (ACTS). The ACTS will be a national complaint
system that will standardize state complaints and incidents so that
analysis across states can be accomplished. Over time, we expect to
advance complaint improvement efforts that will not only address
complaint investigation practices toward improvement, but also the
prioritization of complaints.
GAO Recommendation:
Further refine annual state performance reviews so that they (1)
consistently distinguish between systemic problems and less serious
issues regarding state performance, (2) analyze the 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.
CMS Response:
We have already modified our FY '03 state performance standards to take
into account assessing state compliance in a manner that differentiates
between statutory and non-statutory performance standards. We have
built in the ability to distinguish between systemic problems and less
serious issues. We will continue to look at homes with varying levels
of harm though the work we have done with our Nursing Home Data
Compendium that is widely available to regions, states, Congress and
other stakeholders. We are working on a data program to ascertain when
individual nursing homes have deficiencies that would cause an
immediate sanction for repeated instances of actual harm.
Regarding predictability of nursing home surveys, the report shows that
two thirds of nursing home surveys are not predictable using the
definition established by GAO. There is "predictability" that the law
requires in that surveys be conducted other than on average of every
twelve months, not to exceed 15 months. Within the bounds of those
legal constraints, we have instituted a policy of "off-hour" surveys
where survey teams conduct surveys either before or after the regular
starting time, on weekends, evenings, and holidays. We have encouraged
surveyors to start at a different time of the week, i.e., Wednesday
instead of Monday. States have changed the way they are doing business.
The findings in the report only capture the
number of days from the previous survey and don't take into account
other predictors of when a survey occurs, for example the time of day
or day of the week.
In addition to the CMS initiatives mentioned in the report, CMS is also
working on other initiatives to help in the implementation, evaluation
and monitoring of the nursing home program.
* Compiling a nursing home data compendium with information on nursing
home characteristics, resident demographics and quality of care data,
* Evaluating the accuracy of the MDS through the Data Verification and
Evaluation (DAVE) contract,
* Publishing a proposed rule on Feeding Assistants in nursing homes,
and:
* Enhancing centralized data monitoring capabilities for use by CMS
staff, such as the ability to determine where states should refer cases
for immediate sanctions to states.
[End of section]
Appendix XI: GAO Contact and Staff Acknowledgements:
GAO Contact:
Walter Ochinko, (202) 512-7157:
Acknowledgements:
The following staff made important contributions to this work: Jack
Brennan, Patricia A. Jones, Dan Lee, Dean Mohs, and Peter Schmidt.
[End of section]
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.
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.
FOOTNOTES
[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.
[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.
[5] We contacted officials in Alabama, California, Colorado,
Connecticut, Iowa, Louisiana, Maryland, Michigan, Missouri, Nebraska,
New York, Oklahoma, Pennsylvania, Tennessee, Washington, and Virginia.
[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.
[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).
[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.
[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.
[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.
[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).
[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.
[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.
[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.
[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).
[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.
[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.
[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).
[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.
[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.
[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.
[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.
[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.
[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.
[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.
[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.
[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.
[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.
[53] As of July 2003, the guidance had not yet been released.
[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.
[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.
[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.
[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).
[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.
[63] GAO/HEHS-00-197.
[64] The 14 states are Alabama, Arizona, California, Iowa, Maryland,
Minnesota, Mississippi, Missouri, Nebraska, Pennsylvania, South
Carolina, Virginia, West Virginia, and Wisconsin.
[65] See GAO/HEHS-00-197.
[66] One of the comparative surveys in our updated analysis was
completed in May 2000.
[67] We contacted officials in Alabama, California, Colorado,
Connecticut, Iowa, Louisiana, Maryland, Michigan, Missouri, Nebraska,
New York, Oklahoma, Pennsylvania, Tennessee, Washington, and Virginia.
[68] Center for Health Systems Research and Analysis at the University
of Wisconsin, Madison.
[69] 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.
[70] The proportion of nursing homes in Utah cited with serious
deficiencies remained the same between the two time periods.
[71] GAO/HEHS-00-197.
[72] 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.
[73] We use the term "cases" because some homes had multiple referrals
for immediate sanctions.
[74] We use the term "cases" because some homes had multiple referrals
for immediate sanctions.
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