Nursing Homes
Federal Monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weaknesses Gao ID: GAO-08-517 May 9, 2008GAO reports since 1998 have demonstrated that state surveyors, who evaluate the quality of nursing home care on behalf of CMS, sometimes understate the extent of serious care problems in homes because they miss deficiencies. CMS oversees the effectiveness of state surveys through the federal monitoring survey program. In this program, federal surveyors in CMS's regional offices either independently evaluate state surveys by resurveying a home (comparative surveys) or directly observe state surveyors during a routine nursing home survey (observational surveys). GAO was asked to evaluate the information federal monitoring surveys provide on understatement and the effectiveness of CMS management and oversight of the survey program. To do this, GAO analyzed the results of federal monitoring surveys for fiscal years 2002 through 2007, reviewed CMS guidance for the survey program, and interviewed headquarters and regional office officials.
A substantial proportion of federal comparative surveys identify missed deficiencies at the potential for more than minimal harm level or above. During fiscal years 2002 through 2007, about 15 percent of federal comparative surveys nationwide identified state surveys that failed to cite at least one deficiency at the most serious levels of noncompliance--actual harm and immediate jeopardy. Overall, nine states missed serious deficiencies on 25 percent or more of comparative surveys; in seven states federal surveyors identified no such missed deficiencies. During the same period, missed deficiencies at the lowest level of noncompliance--the potential for more than minimal harm--were more widespread: nationwide, approximately 70 percent of federal comparative surveys identified state surveys missing at least one deficiency at the lowest level of noncompliance, and in all but five states the number of state surveys with such missed deficiencies was greater than 40 percent. Undetected care problems at this level are a concern because they could become more serious if nursing homes are not required to take corrective action. The most frequently missed type of deficiency on comparative surveys, at the potential for more than minimal harm level and above, was poor quality of care, such as ensuring proper nutrition and hydration and preventing pressure sores. Federal observational surveys highlighted two factors that may contribute to understatement of deficiencies: weaknesses in state surveyors' (1) investigative skills and (2) ability to integrate and analyze information collected to make an appropriate deficiency determination. These factors may contribute to understatement because they directly affect the appropriate identification and citation of deficiencies. CMS has taken steps to improve the federal monitoring survey program, but weaknesses remain in program management and oversight. For example, CMS has improved processes to ensure that comparative surveys more accurately reflect conditions at the time of the state survey, such as requiring that comparative surveys occur within 30 working days of the state survey rather than within the 2 months set in statute. Despite these improvements, the management and oversight potential of the program has not been fully realized. For example, CMS has only begun to explore options for identifying understatement that occurs in cases where state surveys cite deficiencies at too low a level, for possible implementation in fiscal year 2009. In addition, CMS is not effectively managing the federal monitoring survey database to ensure that the regional offices are entering data accurately and reliably--CMS was unaware, for example, that a considerable number of comparative surveys had not been entered. Furthermore, CMS is not using the database to oversee consistent implementation of the program by the regional offices--for example, the agency is not using the database to identify inconsistencies between comparative and observational survey results.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-08-517, Nursing Homes: Federal Monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weaknesses
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
May 2008:
Nursing Homes:
Federal Monitoring Surveys Demonstrate Continued Understatement of
Serious Care Problems and CMS Oversight Weaknesses:
Federal Monitoring Surveys for Nursing Homes:
GAO-08-517:
GAO Highlights:
Highlights of GAO-08-517, a report to congressional requesters.
Why GAO Did This Study:
GAO reports since 1998 have demonstrated that state surveyors, who
evaluate the quality of nursing home care on behalf of CMS, sometimes
understate the extent of serious care problems in homes because they
miss deficiencies. CMS oversees the effectiveness of state surveys
through the federal monitoring survey program. In this program, federal
surveyors in CMS‘s regional offices either independently evaluate state
surveys by resurveying a home (comparative surveys) or directly observe
state surveyors during a routine nursing home survey (observational
surveys). GAO was asked to evaluate the information federal monitoring
surveys provide on understatement and the effectiveness of CMS
management and oversight of the survey program. To do this, GAO
analyzed the results of federal monitoring surveys for fiscal years
2002 through 2007, reviewed CMS guidance for the survey program, and
interviewed headquarters and regional office officials.
What GAO Found:
A substantial proportion of federal comparative surveys identify missed
deficiencies at the potential for more than minimal harm level or
above. During fiscal years 2002 through 2007, about 15 percent of
federal comparative surveys nationwide identified state surveys that
failed to cite at least one deficiency at the most serious levels of
noncompliance”actual harm and immediate jeopardy. Overall, nine states
missed serious deficiencies on 25 percent or more of comparative
surveys; in seven states federal surveyors identified no such missed
deficiencies. During the same period, missed deficiencies at the lowest
level of noncompliance”the potential for more than minimal harm”were
more widespread: nationwide, approximately 70 percent of federal
comparative surveys identified state surveys missing at least one
deficiency at the lowest level of noncompliance, and in all but five
states the number of state surveys with such missed deficiencies was
greater than 40 percent. Undetected care problems at this level are a
concern because they could become more serious if nursing homes are not
required to take corrective action. The most frequently missed type of
deficiency on comparative surveys, at the potential for more than
minimal harm level and above, was poor quality of care, such as
ensuring proper nutrition and hydration and preventing pressure sores.
Federal observational surveys highlighted two factors that may
contribute to understatement of deficiencies: weaknesses in state
surveyors‘ (1) investigative skills and (2) ability to integrate and
analyze information collected to make an appropriate deficiency
determination. These factors may contribute to understatement because
they directly affect the appropriate identification and citation of
deficiencies.
CMS has taken steps to improve the federal monitoring survey program,
but weaknesses remain in program management and oversight. For example,
CMS has improved processes to ensure that comparative surveys more
accurately reflect conditions at the time of the state survey, such as
requiring that comparative surveys occur within 30 working days of the
state survey rather than within the 2 months set in statute. Despite
these improvements, the management and oversight potential of the
program has not been fully realized. For example, CMS has only begun to
explore options for identifying understatement that occurs in cases
where state surveys cite deficiencies at too low a level, for possible
implementation in fiscal year 2009. In addition, CMS is not effectively
managing the federal monitoring survey database to ensure that the
regional offices are entering data accurately and reliably”CMS was
unaware, for example, that a considerable number of comparative surveys
had not been entered. Furthermore, CMS is not using the database to
oversee consistent implementation of the program by the regional
offices”for example, the agency is not using the database to identify
inconsistencies between comparative and observational survey results.
What GAO Recommends:
GAO is making four recommendations to the CMS Administrator to address
weaknesses in CMS‘s management of the federal monitoring survey
database that affect the agency‘s ability to track understatement and
CMS‘s ability to oversee regional office implementation of the federal
monitoring survey program. In its comments on a draft of this report,
HHS fully endorsed and indicated it would implement GAO‘s
recommendations.
To view the full product, including the scope and methodology, click on
[http://www.gao.gov/cgi-bin/getrpt?GAO-08-517]. For more information,
contact John E. Dicken at (202) 512-7114 or dickenj@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Substantial Proportion of Federal Comparative Surveys Identify Missed
Deficiencies:
CMS Has Taken Steps to Improve the Federal Monitoring Survey Program,
but Weaknesses in Management and Oversight Remain:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Percentage of Nursing Homes Cited for Actual Harm or
Immediate Jeopardy during Standard Surveys:
Appendix II: Percentage of Comparative Surveys Identifying Missed
Deficiencies at Actual Harm or Immediate Jeopardy Level:
Appendix III: Percentage of Comparative Surveys Identifying Missed
Deficiencies with Potential for More Than Minimal Harm:
Appendix IV: Percentage of Comparative Surveys with at Least One Missed
Deficiency, by Federal Quality Standard Category:
Appendix V: Percentage of Below Satisfactory State Survey Ratings for
General Investigation and Deficiency Determination:
Appendix VI: Comments from the Department of Health & Human Services:
Appendix VII: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Scope and Severity of Deficiencies Identified during Nursing
Home Surveys:
Table 2: States with 25 Percent or More of Comparative Surveys
Identifying Missed Deficiencies at the Actual Harm or Immediate
Jeopardy Levels, Fiscal Years 2002 through 2007:
Table 3: States with 25 Percent or More of Comparative Surveys with
Missed Deficiencies and Percentage of Their Observational Surveys with
Less Than Satisfactory Ratings on General Investigation and Deficiency
Determination, Fiscal Years 2002 through 2007:
Table 4: Percentage of Nursing Homes Cited for Actual Harm or Immediate
Jeopardy, by State, Fiscal Years 2002 through 2007:
Figures:
Figure 1: Percentage of Comparative Surveys Nationwide Citing at Least
One Missed Deficiency at the Actual Harm or Immediate Jeopardy Level,
Fiscal Years 2002 through 2007:
Figure 2: National Percentage of Comparative Surveys Citing at Least
One Missed Deficiency at the Potential for More Than Minimal Harm
Level, Fiscal Years 2002 through 2007:
Figure 3: Percentage of Comparative Surveys Nationwide with
Understatement of Actual Harm and Immediate Jeopardy Deficiencies, with
Scope and Severity Differences Included, Fiscal Years 2002 through
2007:
Abbreviations:
CMS: Centers for Medicare & Medicaid Services:
HHS: Department of Health & Human Services:
OSCAR: On-Line Survey, Certification, and Reporting system:
United States Government Accountability Office:
Washington, DC 20548:
May 9, 2008:
The Honorable Herb Kohl:
Chairman:
Special Committee on Aging:
United States Senate:
The Honorable Charles E. Grassley:
Ranking Member:
Committee on Finance:
United States Senate:
Since 1998, Congress has focused considerable attention on the need to
improve the quality of care for the nation's 1.5 million nursing home
residents, a highly vulnerable population of elderly and disabled
individuals for whom remaining at home is no longer feasible. Poor
quality of care--worsening pressure sores or untreated weight loss--in
a small but unacceptably high number of nursing homes continues to harm
residents or place them in immediate jeopardy, that is, at risk of
death or serious injury. About 1 in 5 homes nationwide were cited for
such serious deficiencies on state inspections, known as surveys, in
fiscal year 2007 (see app. I). Our previous work, however, demonstrated
that state surveys sometimes understated the extent of serious care
problems and that federal oversight of state survey activities had
weaknesses.[Footnote 1] Understatement can occur when a state surveyor
fails to cite a deficiency altogether or cites a deficiency at too low
a level.
The Centers for Medicare & Medicaid Services (CMS) is the federal
agency responsible for ensuring the effectiveness of state
surveys.[Footnote 2] Through CMS's federal monitoring survey program,
federal surveyors either (1) independently evaluate state surveys by
resurveying a home recently inspected by state surveyors and comparing
the deficiencies identified during the two surveys, known as a
comparative survey, or (2) directly observe state surveyors during a
routine nursing home survey, known as an observational survey. Results
from both federal comparative and observational surveys--which are
recorded in the federal monitoring survey database--allow CMS to gauge
states' abilities to accurately assess nursing home quality.
Recently, we reported that federal comparative surveys in five large
states identified the continuing understatement of serious care
problems by state surveyors.[Footnote 3] You asked us to look at the
understatement of serious deficiencies by state surveyors nationwide.
In this report we address two questions: (1) what information do
federal monitoring surveys provide about understatement nationwide, and
(2) how effective are CMS management and oversight of the federal
monitoring survey program?
To answer the first question, we analyzed the results of comparative
and observational surveys nationwide for fiscal years 2002 through 2007
using the federal monitoring survey database.[Footnote 4] During this
period, federal surveyors conducted 976 comparative surveys and 4,023
observational surveys. To identify understatement on comparative
surveys, we focused our analysis on cases where federal surveyors
determined that state surveyors should have cited a deficiency but
failed to do so or where state surveyors cited a deficiency at too low
a level. We analyzed the results of observational surveys in order to
better understand why understatement might occur. Deficiencies
identified during nursing home surveys are categorized according to
their scope (i.e., the number of residents potentially or actually
affected) and severity (i.e., the degree of relative harm involved).
Homes with deficiencies at the A though C levels are considered to be
in substantial compliance, while those with deficiencies at the D
through L levels are considered out of compliance. (See table 1.)
Throughout this report, we refer to deficiencies at the actual harm and
immediate jeopardy levels as serious deficiencies.
Table 1: Scope and Severity of Deficiencies Identified during Nursing
Home Surveys:
Severity: Immediate jeopardy[A];
Scope: Isolated: J;
Scope: Pattern: K;
Scope: Widespread: L.
Severity: Actual harm;
Scope: Isolated: G;
Scope: Pattern: H;
Scope: Widespread: I.
Severity: Potential for more than minimal harm;
Scope: Isolated: D;
Scope: Pattern: E;
Scope: Widespread: F.
Severity: Potential for minimal harm[B];
Scope: Isolated: A;
Scope: Pattern: B;
Scope: Widespread: C.
Source: CMS.
[A] Actual or potential for death/serious injury.
[B] Nursing home is considered to be in substantial compliance.
[End of table]
To ensure reliability of the federal monitoring survey database, we
discussed data entry procedures with all 10 CMS regional offices, whose
staff enter information into the database. In addition, we conducted
several data reliability tests, including (1) automated checks of data
fields to ensure that they contained complete information and (2)
manual reviews of a random sample of all deficiencies cited by federal
but not state surveyors to ensure that federal surveyors had used the
data fields appropriately. We also eliminated a small number of
deficiencies that did not correspond to a defined severity level or
contained illogical survey dates--such as a comparative survey that
began prior to the state survey. Based on these activities, we
determined that the information was sufficiently reliable for our
purposes. Data on comparative surveys, however, cannot be used to
project the extent of understatement across all state surveys because
the state surveys selected for federal monitoring surveys are not
representative of all nursing home surveys or survey teams within each
state.
To answer the second question, we reviewed CMS guidance for the federal
monitoring survey program and interviewed officials in CMS headquarters
and all 10 regional offices. Our work focused on CMS's (1) efforts to
improve the use of comparative surveys as an oversight tool; (2)
ability to track the understatement of deficiencies; and (3) management
of the federal monitoring survey database, including the use of the
database to oversee regional office implementation of the federal
monitoring survey program. We also analyzed (1) the comments entered
into the federal monitoring survey database by federal surveyors for
certain discrepancies between federal and state survey findings and (2)
the consistency between comparative and observational survey results
within states and CMS regional offices. We performed our work from July
2007 through May 2008 in accordance with generally accepted government
auditing standards.
Results in Brief:
A substantial proportion of federal comparative surveys identify missed
deficiencies at the potential for more than minimal harm level or
above. From fiscal year 2002 through 2007, about 15 percent of federal
comparative surveys nationwide identified state surveys that failed to
cite at least one deficiency at the most serious levels of
noncompliance--the actual harm and immediate jeopardy levels. Overall,
in nine states federal surveyors identified missed serious deficiencies
on 25 percent or more of comparative surveys, but in seven states they
identified no missed serious deficiencies. During the same period,
missed deficiencies at the potential for more than minimal harm level
were more widespread: nationwide, approximately 70 percent of federal
comparative surveys identified state surveys missing at least one
deficiency at the potential for more than minimal harm level, and in
all but five states the number of state surveys with such missed
deficiencies was greater than 40 percent. Such undetected care problems
are of concern because they could become more serious over time if
nursing homes are not required to take corrective actions. The most
frequently missed deficiencies identified on comparative surveys--from
the potential for more than minimal harm through immediate jeopardy
levels--involved poor quality of care, such as ensuring proper
nutrition and hydration and preventing pressure sores. Federal
observational surveys highlighted two factors that may contribute to
the understatement of deficiencies--weaknesses in state surveyors'
investigative skills and in their ability to integrate and analyze the
information collected to make an appropriate deficiency determination.
Six of the nine states that missed serious deficiencies on 25 percent
or more of comparative surveys had observational survey ratings for
these two dimensions that were worse than the national average.
CMS has taken steps to improve the federal monitoring survey program,
but weaknesses remain in program management and oversight. For example,
CMS has improved processes to ensure that comparative surveys more
accurately reflect conditions at the time of the state survey, such as
requiring that comparative surveys occur within 30 working days of the
state survey rather than within the 2 months set in statute. However,
despite these improvements, the management and oversight potential of
the program has not been fully realized. First, we found that the
federal monitoring survey database did not capture the full extent of
understatement because CMS does not require regional offices to
determine when state surveyors cite a deficiency at too low a level.
The agency has only begun exploring options for identifying potential
scope and severity understatement. When we manually analyzed optional
comment fields in the database to assess how often a deficiency was
cited at too low a level, we were able to confirm this type of
understatement in 38 percent of the cases we examined; when combined
with understatement caused by missed deficiencies, overall
understatement of serious deficiencies by state surveyors increased
from about 15 percent to about 16 percent for fiscal years 2002 through
2007. Second, we found that CMS was not effectively managing the
database to ensure that the regional offices were entering data
accurately and reliably. CMS was unaware, for example, that a
considerable number of comparative surveys had not been entered.
Finally, we found weaknesses in CMS's use of the database for regional
office oversight. For example, despite the fact that inconsistencies in
comparative and observational survey findings in specific states could
indicate that some CMS regional offices did not follow CMS guidance in
assessing state surveyor performance, CMS officials told us that they
did not plan to follow up with regional offices about these
inconsistencies.
We are making four recommendations to the CMS Administrator to address
weaknesses in CMS's management and oversight of federal monitoring
surveys. We recommend that CMS (1) require regional offices to
determine if there was understatement when state surveyors cite a
deficiency at a lower scope and severity level than federal surveyors
and to track this information, (2) establish quality controls to
improve the accuracy and reliability of information entered into the
federal monitoring survey database, (3) routinely examine comparative
survey data and hold regional offices accountable for implementing CMS
guidance that is intended to ensure that comparative surveys more
accurately capture the conditions at the time of the state survey, and
(4) regularly analyze and compare federal comparative and observational
survey results. We provided a draft of this report to CMS through the
Department of Health & Human Services (HHS). The comments we received
were submitted by HHS. HHS fully endorsed and indicated it would
implement our recommendations.
Background:
Oversight of nursing homes is a shared federal-state responsibility.
Based on statutory requirements, CMS (1) defines quality standards that
nursing homes must meet to participate in the Medicare and Medicaid
programs and (2) contracts with state survey agencies to assess whether
homes meet those standards through annual surveys and complaint
investigations.[Footnote 5] Although CMS has issued extensive guidance
to states on determining compliance with federal quality requirements,
we have found that some state surveys understate quality problems at
nursing homes.[Footnote 6]
Federal Quality Standards:
Federal nursing home quality standards focus on the delivery of care,
resident outcomes, and facility conditions. These standards, totaling
approximately 200, are grouped into 15 categories, such as Resident
Rights, Quality of Life, Resident Assessment, Quality of Care, Pharmacy
Services, and Administration.[Footnote 7] For example, there are 23
standards within the Quality of Care category ranging from "promote the
prevention of pressure [sore] development" to "the resident environment
remains as free of accident hazards as is possible." CMS has also
developed detailed investigative protocols to assist state survey
agencies in determining whether nursing homes are in compliance with
federal quality standards. This guidance is intended to ensure the
thoroughness and consistency of state surveys and complaint
investigations.
Standard Surveys and Complaint Investigations:
Every nursing home receiving Medicare or Medicaid payment must undergo
a standard state survey not less than once every 15 months, and the
statewide average interval for these surveys must not exceed 12 months.
During a standard survey, teams of state surveyors--generally
consisting of registered nurses, social workers, dieticians, or other
specialists--evaluate compliance with federal quality standards. Based
on the care provided to a sample of residents, the survey team (1)
determines whether the care and services provided meet the assessed
needs of the residents and (2) measures resident outcomes, such as the
incidence of preventable pressure sores, weight loss, and accidents. In
contrast to a standard survey, a complaint investigation generally
focuses on a specific allegation regarding a resident's care or safety
and provides an opportunity for state surveyors to intervene promptly
if problems arise between standard surveys. Surveyors generally follow
state procedures when investigating complaints, but must comply with
certain federal guidelines and time frames.
Enforcement:
When deficiencies are identified, federal sanctions can be imposed to
help encourage homes to correct them. Sanctions are generally reserved
for serious deficiencies--those at the G through L levels--which
constitute actual harm and immediate jeopardy.[Footnote 8] Sanctions
for such serious quality problems can affect a home's revenues and
provide financial incentives to return to and maintain compliance. Such
sanctions include fines known as civil money penalties, denial of
payment for new Medicare or Medicaid admissions, or termination from
the Medicare and Medicaid programs.
State surveys that miss serious deficiencies or cite deficiencies at
too low a scope and severity level have enforcement implications
because a nursing home may escape sanctions intended to discourage
repeated noncompliance. For example, facilities that receive at least
one G through L level deficiency on successive standard surveys or
complaint investigations must be referred for immediate
sanctions.[Footnote 9] In addition, CMS guidance calls for higher fines
when a home has a poor compliance history and requires that state
survey teams revisit a home to verify that serious deficiencies have
actually been corrected (such revisits are not required for most
deficiencies cited below the actual harm level--A through F).[Footnote
10]
CMS Oversight of State Surveys:
Statutorily required federal monitoring surveys, which are conducted
annually in at least 5 percent of state-surveyed Medicare and Medicaid
nursing homes in each state, are a key CMS oversight tool in ensuring
the adequacy of state surveys.[Footnote 11] CMS headquarters--
specifically, CMS's Survey and Certification Group--is responsible for
the management of the federal monitoring survey database and for
oversight of the 10 CMS regional offices' implementation of the federal
monitoring survey program.[Footnote 12] Federal surveyors located in
regional offices conduct federal monitoring surveys. The surveys can be
either comparative or observational, with each offering unique
advantages and disadvantages as an oversight tool. For example, an
advantage of comparative surveys is that they are an independent
evaluation of a nursing home recently surveyed by a state survey agency
team. A disadvantage is that the time lag between the two surveys can
make analysis of differences difficult.
* Comparative survey. A federal survey team conducts an independent
survey of a home recently surveyed by a state survey agency in order to
compare and contrast the findings. This comparison takes place after
completion of the federal survey. When federal surveyors identify a
deficiency not cited by state surveyors, they assess whether the
deficiency existed at the time of the state survey and should have been
cited by entering either yes or no to the question, "Based on the
evidence available to the [state], should the [state survey] team have
cited this [deficiency]?" This assessment is critical in determining
whether understatement occurred because some deficiencies cited by
federal surveyors may not have existed at the time of the state survey.
For example, a deficiency identified during a federal survey could
involve a resident who was not in the nursing home at the time of the
earlier state survey. By statute, comparative surveys must be conducted
within 2 months of the completion of the state survey. However,
differences in timing, resident sample selection, and staffing can make
analysis of differences between the state and federal comparative
surveys difficult. On the basis of our prior recommendations, CMS has
taken several steps to ensure that comparative surveys more accurately
capture conditions at the time of the state survey.[Footnote 13] For
example, CMS now calls for the length of time between the state and
federal surveys to be between 10 and 30 working days and requires
federal surveyors conducting a comparative survey in a nursing home to
include at least half of the state survey's sample of residents from
that nursing home in the comparative survey sample, making it easier to
determine whether state surveyors missed a deficiency.[Footnote 14]
Furthermore, federal comparative survey teams are expected to mimic the
number of staff assigned to the state survey. CMS also issued guidance
in October 2002 defining the criteria for federal surveyors to consider
when selecting facilities for comparative surveys.[Footnote 15] These
selection criteria can generally be categorized as state survey team
performance and facility characteristics. Regional offices were given
latitude in their use of these criteria and may supplement them with
other selection factors unique to their regions. For example, some
regions use statistics on the prevalence of pressure sores in a nursing
home's resident population as a comparative survey selection factor.
* Observational survey. Federal surveyors accompany a state survey team
to a nursing home to evaluate the team's on-site survey performance and
ability to document survey deficiencies. State teams are evaluated in
six areas--Concern Identification, Sample Selection, General
Investigation, Food-Borne Illness Investigation, Medication
Investigations, and Deficiency Determination--and are rated in one of
five categories for each of the six measures. The rating categories--
from highest to lowest--are extremely effective, very effective,
satisfactory, less than satisfactory, and much less than satisfactory.
CMS annual state performance reviews require that state survey teams
achieve an average rating of satisfactory. Observational surveys allow
federal surveyors to provide more immediate feedback to state surveyors
and to identify state surveyor training needs. However, observational
surveys are not independent evaluations of the state survey. Because
state surveyors may perform their survey tasks more attentively than
they would if federal surveyors were not present, observational surveys
may not provide an accurate picture of state surveyors' typical
performance. Since 2001, CMS has also taken steps to strengthen
observational surveys. For example, the agency issued written guidance
defining a standard process for resolving disagreements and a new
manual to increase consistency across observational surveys.
The 976 federal comparative surveys conducted from fiscal year 2002
through 2007 ranged from as few as 10 in Vermont, which has about 40
facilities, to as many as 49 in California, which has about 1,300
facilities. Of the 4,023 federal observational surveys conducted during
the same period, the number ranged from 16 in New Hampshire to 346 in
California.
The results of federal monitoring surveys, including information on the
corresponding state surveys, are entered in the federal monitoring
survey database. In fiscal year 2002, CMS began including information
on comparative surveys in the database, and the agency began requiring
federal surveyors to determine whether a deficiency cited by federal
but not state surveyors had been missed by determining whether state
surveyors should have cited the deficiency.
Understatement of Deficiency Scope and Severity Level:
Although comparative surveys and the wide variability across states in
the proportion of homes with deficiencies at the actual harm and
immediate jeopardy levels indicate that state surveyors miss some
serious deficiencies, our prior work has also indicated that state
surveyors sometimes understate the scope and severity of a deficiency.
In 2003, we found widespread understatement of actual harm deficiencies
in a sample of surveys from homes with a history of harming
residents.[Footnote 16] Overall, 39 percent of the 76 state surveys we
reviewed had documented problems that should have been classified as
actual harm instead of as lower-level deficiencies.
Substantial Proportion of Federal Comparative Surveys Identify Missed
Deficiencies:
A substantial proportion of federal comparative surveys identify missed
deficiencies at the potential for more than minimal harm level or
above. From fiscal year 2002 through 2007, about 15 percent of federal
comparative surveys nationwide identified state surveys that failed to
cite at least one deficiency at the most serious levels of
noncompliance--the actual harm and immediate jeopardy levels (G through
L). There was wide variation across states in the proportion of
comparative surveys that found at least one missed serious deficiency,
from more than 25 percent in nine states to none in seven others. In
contrast to missed serious deficiencies, missed deficiencies at the
potential for more than minimal harm level (D through F) were
considerably more widespread, with such missed deficiencies greater
than 40 percent in all but five states. Every state had at least one
comparative survey with missed D through F level deficiencies. At both
levels of noncompliance, the most frequently missed deficiencies
involved Quality of Care standards. Federal observational survey
results and prior GAO reports have highlighted several factors that may
contribute to the understatement of deficiencies.
Small but Unacceptably High Proportion of Federal Comparative Surveys
Found That State Survey Teams Missed Serious Deficiencies:
About 15 percent (142) of the 976 comparative surveys conducted from
fiscal year 2002 through 2007 identified state surveys that missed at
least one deficiency at the actual harm or immediate jeopardy level (G
through L), the most serious levels of noncompliance. This proportion
fluctuated from a high of 17.5 percent in fiscal year 2003 to a low of
11.1 percent in fiscal year 2004, but it has remained relatively
constant at about 15 percent for the last several fiscal years (see
fig. 1). This proportion is small, but CMS maintains that any missed
serious deficiencies are unacceptable.
Figure 1: Percentage of Comparative Surveys Nationwide Citing at Least
One Missed Deficiency at the Actual Harm or Immediate Jeopardy Level,
Fiscal Years 2002 through 2007:
This figure is a line graph showing percentage of comparative surveys
nationwide citing at least one missed deficiency at the actual harm or
immediate jeopardy level, fiscal years 2002 through 2007. The X axis
represents the fiscal year, and the Y axis represents the percentage of
comparative surveys.
Fiscal year: 2002;
Percentage of comparative surveys: 13.8.
Fiscal year: 2003;
Percentage of comparative surveys: 17.5.
Fiscal year: 2004;
Percentage of comparative surveys: 11.1.
Fiscal year: 2005;
Percentage of comparative surveys: 14.3.
Fiscal year: 2006;
Percentage of comparative surveys: 15.3.
Fiscal year: 2007;
Percentage of comparative surveys: 15.3.
[See PDF for image]
Source: GAO analysis of federal monitoring survey data.
[End of figure]
From fiscal year 2002 through 2007, federal surveyors identified missed
serious deficiencies in 25 percent or more of their comparative surveys
in nine states. The proportion of missed serious deficiencies in these
nine states ranged from 26.3 percent in Tennessee to 33.3 percent in
New Mexico, South Carolina, South Dakota, and Wyoming (see table
2).[Footnote 17] The total number of missed deficiencies at the G
through L levels also varied across these nine states, from a low of 4
in South Dakota to a high of 19 in South Carolina. Federal surveyors
identified no missed serious deficiencies in seven states (see app. II
for complete state results).[Footnote 18]
Table 2: States with 25 Percent or More of Comparative Surveys
Identifying Missed Deficiencies at the Actual Harm or Immediate
Jeopardy Levels, Fiscal Years 2002 through 2007:
State: New Mexico;
Number of homes in fiscal year 2007: 72;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 33.3;
Total number missed G-L deficiencies: 9.
State: South Carolina;
Number of homes in fiscal year 2007: 176;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 6;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 33.3;
Total number missed G-L deficiencies: 19.
State: South Dakota;
Number of homes in fiscal year 2007: 112;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 33.3;
Total number missed G-L deficiencies: 4.
State: Wyoming;
Number of homes in fiscal year 2007: 39;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 33.3;
Total number missed G-L deficiencies: 5.
State: Oklahoma;
Number of homes in fiscal year 2007: 348;
Total comparative surveys: 20;
Total comparative surveys with at least one missed G-L deficiency: 6;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 30.0;
Total number missed G-L deficiencies: 11.
State: Missouri;
Number of homes in fiscal year 2007: 530;
Total comparative surveys: 28;
Total comparative surveys with at least one missed G-L deficiency: 8;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 28.6;
Total number missed G-L deficiencies: 14.
State: Alabama;
Number of homes in fiscal year 2007: 233;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 5;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 27.8;
Total number missed G-L deficiencies: 13.
State: Arizona;
Number of homes in fiscal year 2007: 137;
Total comparative surveys: 15;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 26.7;
Total number missed G-L deficiencies: 6.
State: Tennessee;
Number of homes in fiscal year 2007: 332;
Total comparative surveys: 19;
Total comparative surveys with at least one missed G-L deficiency: 5;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 26.3;
Total number missed G-L deficiencies: 10.
Source: GAO analysis of federal monitoring survey data.
[End of table]
Missed Deficiencies at the Potential for More Than Minimal Harm Level
Were Widespread on Federal Comparative Surveys:
Figure: Example of a Missed Deficiency at the Potential for More Than
Minimal Harm Level:
On a fiscal year 2007 comparative survey, federal surveyors found an F-
level deficiency”that is, a deficiency widespread throughout the
facility”that the state survey team had not cited at any level. After
verifying that the evidence used by federal surveyors was available at
the time of the state survey, the federal surveyors commented that
’Deficiency [is] based on a systemic lack of monthly drug reviews
dating back to June 2006. [State surveyors] would have been expected to
cite this deficient practice.“
In contrast to missed serious deficiencies, missed deficiencies at the
potential for more than minimal harm level (D through F) were
considerably more widespread on comparative surveys conducted during
fiscal years 2002 through 2007. Approximately 70 percent of comparative
surveys conducted nationwide identified state surveys that missed at
least one deficiency at the potential for more than minimal harm level
(D through F), with such missed deficiencies identified on greater than
40 percent of comparative surveys in all but five states--Alaska, Ohio,
Vermont, West Virginia, and Wisconsin.[Footnote 19] On average, state
surveys selected for comparative surveys failed to identify 2.5 D
through F level deficiencies per survey. Undetected care problems at
the D through F level are of concern because they could become more
serious over time if nursing homes are not required to take corrective
actions. Missed deficiencies at the potential for more than minimal
harm level were not isolated to a single year during the 6 fiscal years
we examined and continued to be a problem for states in fiscal year
2007. Nationally, the proportion of comparative surveys identifying at
least one missed D through F level deficiency in fiscal year 2007 was
about 74 percent (see fig. 2). For results by state, see appendix III.
Figure 2: National Percentage of Comparative Surveys Citing at Least
One Missed Deficiency at the Potential for More Than Minimal Harm
Level, Fiscal Years 2002 through 2007:
This figure is a line graph showing national percentage of comparative
surveys citing at least one missed deficiency at the potential for more
than minimal harm level, fiscal years 2002 through 2007. The X axis
represents the fiscal year, and the Y axis represents the percentage of
comparative surveys.
Fiscal year: 2002;
Percentage of comparative surveys: 55.0.
Fiscal year: 2003;
Percentage of comparative surveys: 66.3.
Fiscal year: 2004;
Percentage of comparative surveys: 66.0.
Fiscal year: 2005;
Percentage of comparative surveys: 76.4.
Fiscal year: 2006;
Percentage of comparative surveys: 72.0.
Fiscal year: 2007;
Percentage of comparative surveys: 74.1.
[See PDF for image]
Source: GAO analysis of federal monitoring survey data.
[End of figure]
Most Frequently Missed Deficiencies Involved Quality of Care:
Our analysis found that the most frequently missed deficiencies at both
the potential for more than minimal harm (D through F) and the actual
harm or immediate jeopardy (G through L) levels occurred in quality
standards under CMS's Quality of Care category. Missed deficiencies in
this category involved residents' receipt of the necessary care and
services to attain and maintain the highest practicable physical,
mental, and psychosocial well-being--such as prevention of pressure
sores, nutrition and hydration, accident prevention, and assistance
with bathing and grooming.
From fiscal year 2002 through 2007, 11.9 percent of federal comparative
surveys (116) cited at least one Quality of Care deficiency at the
actual harm or immediate jeopardy level that state survey teams failed
to cite. These 116 surveys contained a total of 143 missed serious
Quality of Care deficiencies. The category with the next highest
frequency of missed serious deficiencies was Resident Behavior and
Facility Practices, with only 2.2 percent of total federal comparative
surveys.[Footnote 20] At the potential for more than minimal harm
level, Quality of Care was one of two categories with the highest
frequency of missed deficiencies--31.7 percent.[Footnote 21] For the
percentage of missed deficiencies in each of the CMS quality standard
categories, see appendix IV.
Federal Observational Surveys and Prior GAO Reports Identified Factors
That May Contribute to Deficiency Understatement by State Survey Teams:
Both federal observational surveys and our prior reports have
identified factors that may contribute to the understatement of
deficiencies by state survey teams. From fiscal year 2002 through 2007,
80 percent of the 4,999 federal monitoring surveys were observational.
Our review of observational survey data--which are collected during
direct observation of state survey teams--found that some of the lowest
state survey team ratings nationwide were in the General Investigation
and Deficiency Determination areas. Together, these two areas directly
affect the appropriate identification and citation of deficiencies.
* The General Investigation segment of an observational survey
evaluates the effectiveness with which the state survey team collected
information to determine how the facility's environment and care of
residents affect residents' quality of life, health and safety, and
ability to reach their highest practicable physical, mental, and
psychosocial well-being. This segment includes observations of state
survey team actions such as collection of information, discussion of
survey observations, interviews with facility residents, and
implementation of CMS investigative protocols.
* The Deficiency Determination segment of an observational survey
evaluates the skill with which the state survey teams (1) integrate and
analyze all information collected and (2) use the guidance to surveyors
and regulatory requirements to make accurate compliance determinations.
This segment includes observations of state survey team actions such as
reviews of regulatory requirements, team participation in deficiency
discussions, presentation of complete information, accurate decision
making, and accurate citation of deficiencies.
Nationwide, 7.7 percent of the state survey teams observed by federal
surveyors received below satisfactory ratings on the General
Investigation measure from fiscal year 2002 through 2007.[Footnote 22]
During the same 6 fiscal years, 9.2 percent, or about 1 in 11, of the
state survey teams observed by federal surveyors received below
satisfactory ratings on the Deficiency Determination measure. Our
analysis found variation across states in survey team performance in
General Investigation and Deficiency Determination. Sixteen states had
more teams than the national average receive below satisfactory ratings
for both measures, while 28 states had fewer teams than the national
average receive below satisfactory ratings (see app. V).[Footnote 23]
Poor performance on these observational survey measures may be a
contributing factor to the understatement of deficiencies by state
survey teams. For example, of the nine states in table 2 with the
highest percentage of missed serious deficiencies on comparative
surveys, six had more teams than the national average receive below
satisfactory ratings for both General Investigation and Deficiency
Determination (see table 3).[Footnote 24]
Table 3: States with 25 Percent or More of Comparative Surveys with
Missed Deficiencies and Percentage of Their Observational Surveys with
Less Than Satisfactory Ratings on General Investigation and Deficiency
Determination, Fiscal Years 2002 through 2007:
State: Alabama;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 20.0;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 22.7;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 27.8.
State: Arizona;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 7.4;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 15.4;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 26.7.
State: Missouri;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 17.6;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 22.1;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 28.6.
State: New Mexico;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 26.3;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 31.6;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 33.3.
State: Oklahoma;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 12.1;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 16.5;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 30.0.
State: South Carolina;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 14.3;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 22.9;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 33.3.
State: South Dakota;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 0.0;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 0.0;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 33.3.
State: Tennessee;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 14.6;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 20.7;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 26.3.
State: Wyoming;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 0.0;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 0.0;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 33.3.
Nation;
Percentage of state observational surveys with below satisfactory
ratings: General investigation: 7.7;
Percentage of state observational surveys with below satisfactory
ratings: Deficiency determination: 9.2;
Percentage of comparative surveys that found at least one missed G-L
deficiency: 14.5.
Source: GAO analysis of federal monitoring survey data.
[End of table]
Our prior reports have described some other factors that may contribute
to survey inconsistency and the understatement of deficiencies by state
survey teams: (1) weaknesses in CMS's survey methodology, such as poor
documentation of deficiencies;[Footnote 25] (2) confusion about the
definition of actual harm;[Footnote 26] (3) predictability of surveys,
which allows homes to conceal problems if they so desire;[Footnote 27]
(4) inadequate quality assurance processes at the state level to help
detect understatement in the scope and severity of
deficiencies;[Footnote 28] and (5) inexperienced state surveyors as a
result of retention problems.[Footnote 29] In ongoing work, we are
investigating the factors that contribute to understatement.
CMS Has Taken Steps to Improve the Federal Monitoring Survey Program,
but Weaknesses in Management and Oversight Remain:
CMS has taken steps to improve the federal monitoring survey program,
but weaknesses remain in program management and oversight. For example,
CMS has improved processes to ensure that comparative surveys more
accurately reflect conditions at the time of the state survey, has
switched control of the federal monitoring survey database to the
office responsible for ensuring the effectiveness of state surveys, and
has begun examining how to use monitoring survey data to improve
oversight. Despite this progress, the management and oversight
potential of the program has not been fully realized. In particular,
CMS (1) has only begun exploring options for identifying understatement
that occurs in cases where state surveys cite deficiencies at too low a
level, for possible implementation in fiscal year 2009, and (2) is not
effectively managing the federal monitoring survey database or using
the database to oversee consistent implementation of the federal
monitoring survey program by its regional offices.
CMS Policy Changes Have Improved Federal Monitoring Surveys:
CMS has taken steps in three areas--time between surveys, resident
sample, and survey resources--to ensure that comparative surveys more
accurately capture the conditions at the time of the state survey.
* Time between surveys. In fiscal year 2002, CMS initiated a policy
that shortened the length of time between state and comparative surveys
from 2 months to 1 month. CMS relaxed the 1 month standard by changing
the requirement to 30 working days in fiscal year 2003. As a result of
shortening the time between the two surveys, the conditions at the time
of the comparative survey are more likely to reflect those at the time
of the state survey;
for example, the same residents are still likely to be in the nursing
home. Comparative surveys during fiscal year 2007 took place on average
21.4 working days (30.9 calendar days) after state surveys.
* Resident sample. Beginning in fiscal year 2003, CMS policy required
that comparative surveys include at least half of the residents from
state survey investigative samples. Officials from several regional
offices said that examining the same resident allows for more clear-cut
determinations of whether the state should have cited a deficiency.
Since the policy change, about 78 percent of comparative surveys from
fiscal year 2003 through 2007 included at least half the residents from
state surveys' investigative samples. By comparison, only 13 percent of
comparative surveys met that 50 percent threshold in fiscal year 2002,
the year before the policy went into effect.
* Survey resources. Beginning in fiscal year 2003, CMS initiated a
policy that each comparative survey should have the same number of
federal surveyors as its corresponding state survey, again to more
closely mirror the conditions under which the state survey was
conducted.[Footnote 30] We found that in fiscal year 2007, the average
state survey team (3.4 surveyors) was larger than the average federal
survey team (3.0 surveyors). However, on average, federal surveyors
remained on-site longer than state surveyors--4.3 days for federal
surveyors compared with 3.7 days for state surveyors. When the number
of surveyors and time on-site are taken together, state surveys
averaged 12.6 surveyor-days and federal comparative surveys averaged
12.9 surveyor-days.[Footnote 31]
Given these improvements, we asked the regional offices how receptive
state survey teams were to feedback that they had missed deficiencies.
Most regional office officials told us that in general the feedback
session with state surveyors on missed deficiencies was not contentious
and that state surveyors generally accepted the feedback provided.
However, CMS established a formal dispute resolution process for
comparative surveys in October 2007. The process is similar to the
process already in place for resolving disagreements about
observational survey results.[Footnote 32]
Federal Monitoring Survey Database Has Not Been Used to Capture
Understatement of Scope and Severity Levels:
While CMS requires federal surveyors to determine whether a deficiency
cited on a comparative but not a state survey was missed by state
surveyors, there is no comparable requirement for deficiencies that are
cited at different scope and severity levels. As a result, comparative
surveys do not effectively capture the extent of the understatement of
serious deficiencies by state surveyors. As with missed deficiencies, a
discrepancy between federal and state survey results does not
automatically indicate understatement. For example, the deficiency
could have worsened by the time of the federal survey.
Although CMS does not require federal surveyors to evaluate scope and
severity differences between the two sets of surveys, we found that
some regional offices used the validation question for missed
deficiencies--"based on the evidence available to the [state], should
the [state survey] team have cited this [deficiency]?"--to make such a
determination.[Footnote 33] Using the validation question to make these
determinations is contrary to CMS guidance issued in October 2003,
which instructed comparative survey teams to only answer this question
when the state failed to cite the deficiency altogether.
To assess whether differences in scope and severity levels were
actually understated--rather than deficiencies that worsened between
the state and federal surveys--we first identified all 71 deficiencies
on comparative surveys conducted from fiscal year 2002 through 2007
where federal survey teams cited actual harm or immediate jeopardy
deficiencies that state survey teams cited at a lower scope and
severity level.[Footnote 34] We then examined the comment fields in the
federal monitoring survey database associated with those deficiencies.
Our analysis identified 27 deficiencies (38 percent) in which federal
survey teams determined that a state's scope and severity citation was
too low. For another 22 deficiencies (31 percent), federal survey teams
found that the state's lower scope and severity determination was
appropriate, given the circumstances at the time of the state survey.
The remaining 22 deficiencies (31 percent) did not have comments or
contained remarks that were inconclusive about whether the state
deficiency citation was too low. When the confirmed scope and severity
understatement was included with understatement caused by missed
deficiencies, the total percentage of comparative surveys with
understatement of serious deficiencies increased by an average of about
1 percentage point over the 6 fiscal years we analyzed (see fig.
3).[Footnote 35]
Figure 3: Percentage of Comparative Surveys Nationwide with
Understatement of Actual Harm and Immediate Jeopardy Deficiencies, with
Scope and Severity Differences Included, Fiscal Years 2002 through
2007:
This figure is a double line graph showing percentage of comparative
surveys nationwide with understatement of actual harm and immediate
jeopardy deficiencies, with scope and severity differences included,
fiscal years 2002 through 2007. One line represents the percentage of
comparative surveys with missed deficiencies at the actual harm or
immediate jeopardy level. The other line represents the percentage of
comparative surveys with missed deficiencies and scope and severity
understatement at the actual harm of immediate jeopardy level.
Fiscal year: 2002;
Percentage of comparative surveys with missed deficiencies at the
actual harm or immediate jeopardy level: 13.8;
Percentage of comparative surveys with missed deficiencies and scope
and severity understatement at the actual harm of immediate jeopardy
level: 13.8.
Fiscal year: 2003;
Percentage of comparative surveys with missed deficiencies at the
actual harm or immediate jeopardy level: 17.5;
Percentage of comparative surveys with missed deficiencies and scope
and severity understatement at the actual harm of immediate jeopardy
level: 19.3.
Fiscal year: 2004;
Percentage of comparative surveys with missed deficiencies at the
actual harm or immediate jeopardy level: 11.1;
Percentage of comparative surveys with missed deficiencies and scope
and severity understatement at the actual harm of immediate jeopardy
level: 11.7.
Fiscal year: 2005;
Percentage of comparative surveys with missed deficiencies at the
actual harm or immediate jeopardy level: 14.3;
Percentage of comparative surveys with missed deficiencies and scope
and severity understatement at the actual harm of immediate jeopardy
level: 17.4.
Fiscal year: 2006;
Percentage of comparative surveys with missed deficiencies at the
actual harm or immediate jeopardy level: 15.3;
Percentage of comparative surveys with missed deficiencies and scope
and severity understatement at the actual harm of immediate jeopardy
level: 15.9.
Fiscal year: 2007;
Percentage of comparative surveys with missed deficiencies at the
actual harm or immediate jeopardy level: 15.3;
Percentage of comparative surveys with missed deficiencies and scope
and severity understatement at the actual harm of immediate jeopardy
level: 16.5.
[See PDF for image]
Source: GAO analysis of federal monitoring survey data.
[A] The inclusion of scope and severity understatement is based on our
analysis of 71 deficiencies that federal survey teams cited as actual
harm or immediate jeopardy deficiencies that state survey teams cited
at a lower scope and severity level.
[End of figure]
While CMS headquarters does not require federal surveyors to determine
whether a deficiency cited by state survey teams was cited at too low a
scope and severity level, some regional offices have developed their
own procedures to track this information and use it to provide feedback
to state survey agencies. For example, in one regional office an
individual reviews all comment fields for a year's worth of comparative
surveys, makes a hand count of scope and severity differences that
states should have cited, and then shares this with the state survey
agencies during their annual performance reviews. Because the federal
monitoring survey database does not automatically collect data on scope
and severity determinations, CMS headquarters does not have access to
the data analyses the regions have independently conducted. Some of the
regional offices told us that they would like to have a specific way
that the federal monitoring survey database could track scope and
severity understatement that is similar to how deficiencies missed by
state surveyors are tracked.
In January 2008, CMS officials told us that they had initiated a pilot
program in October 2007 to test the collection of data on
understatement of scope and severity differences.[Footnote 36]
According to CMS, the pilot, which will run through 2008 for possible
fiscal year 2009 implementation, is necessary because the agency needs
to determine which scope and severity understatement differences should
be captured. For example, CMS is uncertain whether regions should only
focus on differences that would raise the scope and severity level to
actual harm or immediate jeopardy and not assess differences for
understatement that occurs at lower scope and severity levels.
CMS Could More Effectively Manage the Federal Monitoring Survey
Database and Use It for Regional Office Oversight:
Our analysis found that CMS headquarters was not effectively managing
the federal monitoring survey database or using the database to oversee
consistent implementation of the federal monitoring survey program by
regional offices.[Footnote 37] While CMS uses data from comparative and
observational surveys to provide feedback to state survey agencies
during state performance reviews, CMS officials told us that they
recognized the need to improve their management and use of the database
for better oversight of the agency's 10 regional offices.
We identified two problems in CMS's management of the federal
monitoring survey database. CMS was not aware that (1) the results of a
considerable number of comparative surveys were missing from the
database and (2) the validation question for missed deficiencies was
being used by some regional offices to identify scope and severity
differences, contrary to CMS guidance.
* Missing data. In October 2007, we identified missing comparative
surveys for two regional offices dating back to 2005 and asked CMS to
follow up with officials in those regions. At least one of the regions
had completed the surveys but had failed to upload them into the
national database.[Footnote 38] We also found that CMS had not included
data in the federal monitoring survey database from 162 contractor-led
comparative surveys conducted between fiscal years 2004 and
2007.[Footnote 39]
* Use of validation question contrary to CMS guidance. Some regional
offices were using the missed deficiency validation question to make
determinations about whether scope and severity differences constituted
understatement, making it difficult to distinguish between missed
deficiencies and scope and severity understatement. In addition, we
found that the regional office answer to the validation question was
not always consistent with the information recorded in the comment box.
Similarly, we identified weaknesses in CMS's use of the database for
regional office oversight. For example, CMS was not (1) examining
comparative survey data to ensure that regional offices comply with CMS
guidance intended to ensure that comparative surveys more accurately
capture the conditions at the time of the state survey and (2) using
the database to identify inconsistencies between comparative and
observational survey results.
* Ensuring regional office compliance. While CMS has provided guidance
to its regional offices to help ensure that comparative surveys more
accurately capture the conditions at the time of the state survey, the
agency is not fully using available data to ensure that the regional
offices implement the agency's guidance. For example, we found that the
length of time between state and comparative surveys varied broadly by
CMS region. In 2007, the average time gap ranged from a low of 15.4
working days (22.5 calendar days) in the Boston region to a high of
38.5 working days (54.4 calendar days) in the New York region.
Furthermore, while 78 percent of comparative surveys from fiscal year
2003 through 2007 followed CMS's guidance to include at least half of
the residents from state surveys' investigative samples, 22 percent of
comparative surveys did not meet this threshold. Finally, when we
contacted officials in CMS headquarters to ask clarifying questions
about the data variables needed to conduct these analyses, the
headquarters officials were not familiar with a number of the variables
and referred us to a CMS staff person in one of the regional offices.
Together, these three examples suggest that CMS is not effectively
using the data to hold regional offices accountable for implementing
guidance.
* Identify inconsistencies between comparative and observational
results. CMS officials told us that they have begun to explore regional
office differences in less than satisfactory ratings for state survey
teams on observational surveys.[Footnote 40] However, CMS officials
told us that they do not plan to use the database to identify
inconsistencies between comparative and observational surveys that may
warrant follow-up to ensure that regional offices are adhering to CMS
guidance and consistently assessing state surveyor
performance.[Footnote 41] For example, some states that performed below
the national average in identifying serious deficiencies on comparative
surveys received above-average marks on observational survey measures
for Deficiency Determination and General Investigation. Wyoming's 33.3
percent rate for surveys with missed serious deficiencies was more than
double the national average of about 15 percent for surveys conducted
during fiscal years 2002 and 2007. Yet Wyoming never received a below
satisfactory rating on its General Investigation or Deficiency
Determination measures during 18 observational surveys over that same 6-
year period. We found similar inconsistencies in the results of federal
monitoring surveys for South Dakota and a few other states. Although
inconsistencies between comparative and observational surveys may not
necessarily indicate a problem, they may warrant investigation. For
example, in a small state like Wyoming it is likely that comparative
and observational surveys have evaluated the same group of state
surveyors. Further, Wyoming and South Dakota are two of six states
whose federal monitoring surveys are conducted by CMS's Denver regional
office. Of the 140 observational surveys conducted from fiscal year
2002 through 2007, federal surveyors from the Denver regional office
gave one below satisfactory rating on the Deficiency Determination
measure. That 0.7 percent rate of below satisfactory performance was
more than four times lower than the regional office with the next-
lowest percentage--the Chicago regional office--which awarded below
satisfactory ratings to 3.3 percent of state survey teams it observed.
Conclusions:
With about 1 in 6 comparative surveys concluding that state survey
teams had missed a serious deficiency or understated its scope and
severity level, it is evident that state survey agency performance
limits the federal government's ability to obtain an accurate picture
of how often nursing home residents face actual harm or are at risk of
serious injury or death. These missed serious deficiencies most
frequently involved Quality of Care, reflecting shortcomings in
fundamental provider responsibilities such as ensuring proper nutrition
and hydration, accident prevention, and preventing pressure sores.
Observational survey results also underscore problems state surveyors
may face in identifying facility deficiencies; about 1 in 11 state
survey teams nationwide were rated as below satisfactory by CMS
surveyors on the Deficiency Determination measure.
We found that comparative survey data may mask the true extent of
understatement because CMS's current protocol does not require regional
offices to track in the federal monitoring survey database when state
surveyors cite lower-than-appropriate scope and severity levels. As we
conducted our work, CMS officials recognized this problem and in
October 2007 began to experiment with a pilot program to measure
understated scope and severity. However, at the conclusion of the
pilot, scheduled for fiscal year 2008, CMS may decide not to implement
a validation question for all scope and severity differences. We
believe it is important to assess differences for understatement that
occurs at the D through L levels--potential for more than minimal harm,
actual harm, and immediate jeopardy.
We also found that CMS was not effectively managing the federal
monitoring survey database to ensure that regional offices were
entering data in a timely and consistent fashion. Lack of accurate and
reliable data hinders effective oversight. For example, we found that
the database was missing a considerable number of comparative surveys.
Further, CMS has not used the federal monitoring survey database to its
full potential as an oversight tool. For example, CMS is not fully
using data on comparative surveys to ensure that regional offices are
implementing guidance intended to improve federal monitoring surveys.
Although CMS's Survey and Certification Group assumed control of the
database in January 2007, headquarters staff often referred us to CMS
regional office staff to answer specific database questions, suggesting
a lack of familiarity with the organization and content of the
database. In addition, agency officials told us that they do not plan
to follow up on inconsistencies between comparative and observational
survey results that could indicate weaknesses in how regional offices
evaluate state surveyors' performance. Identifying and following up on
such inconsistencies could help ensure database reliability and hold
regional office officials accountable for their implementation of the
federal monitoring survey program, a program required by statute.
Recommendations for Executive Action:
To address weaknesses in CMS's management of the federal monitoring
survey database that also affect the agency's ability to effectively
track understatement, we recommend that the Administrator of CMS take
the following two actions:
* Require regional offices to determine if there was understatement
when state surveyors cite a deficiency at a lower scope and severity
level than federal surveyors do and to track this information in the
federal monitoring survey database.
* Establish quality controls to improve the accuracy and reliability of
information entered into the federal monitoring survey database.
To address weaknesses that affect CMS's ability to oversee regional
office implementation of the federal monitoring survey program, we
recommend that the Administrator of CMS take the following two actions:
* Routinely examine comparative survey data and hold regional offices
accountable for implementing CMS guidance that is intended to ensure
that comparative surveys more accurately capture the conditions at the
time of the state survey.
* Regularly analyze and compare federal comparative and observational
survey results.
Agency Comments:
In written comments on our draft report, HHS indicated that it fully
endorsed and would implement our four recommendations intended to
strengthen management and oversight of the federal monitoring survey
program. The comments generally outlined CMS's implementation plan
through 2009 and indicated that some steps, such as improved management
of the federal monitoring survey database, are already under way. HHS's
comments are reproduced in appendix VI.
The majority of HHS's comments focused on its strategic approach to
improving oversight: (1) ensuring that all nursing homes are surveyed
at least once every 15 months, (2) improving surveyor understanding of
federal quality requirements through improved guidance and training,
(3) increasing the consistency of state surveys through the
introduction of a new nursing home survey methodology, and (4)
improving the use of data generated by federal monitoring surveys. Many
of these strategies aim to address the underlying causes of
understatement, the topic of a forthcoming GAO report. HHS also noted
that limitations in the Medicare survey and certification budget
underscore the agency's need to target resources effectively to
maximize results. For example, HHS indicated that the implementation of
the new survey methodology will be dependent on the level of funding in
the overall survey and certification budget through fiscal year 2014.
Survey and Certification funding is the subject of another forthcoming
GAO report.
Two of HHS's observations merit further discussion. First, HHS noted
that understatement that arises from a lack of understanding or
confusion about federal requirements would generally not be detected
through federal monitoring surveys because both federal and state
surveyors would be affected by the same limitation. We believe that the
consistency with which federal surveys have identified serious
deficiencies missed by state surveyors from fiscal year 2002 through
2007--about 15 percent, on average--suggests that federal surveyors
have a better understanding of CMS quality requirements than do state
surveyors. We have previously reported that the limited experience
level of state surveyors because of the high turnover rate was a
contributing factor to deficiency understatement.[Footnote 42]
Second, HHS questioned our use of "one missed deficiency per survey" as
a measure of understatement. We believe that this standard is
appropriate for serious deficiencies that result in harm or immediate
jeopardy (G through L level) because the goal of state surveys should
be to identify and require nursing homes to address all such
deficiencies. CMS itself uses this standard during annual state
performance reviews. We also used this standard to describe the
proportion of comparative surveys that identified missed deficiencies
at the potential for more than minimal harm level (D through F).
Identifying and requiring nursing homes to correct such deficiencies is
important because if uncorrected they have the potential to become more
serious. Compared to missed serious deficiencies, we found that
understatement of potential for more than minimal harm deficiencies was
more widespread--about 70 percent of comparative surveys identified at
least one state survey with such missed deficiencies. The number of
state surveys with missed deficiencies at the D through F level was
greater than 40 percent in all but five states, and state surveys
selected for comparative surveys failed to identify an average of 2.5
deficiencies in this range per survey. In short, the magnitude of
understatement at the potential for more than minimal harm level should
be a cause for concern.
HHS also provided technical comments, which we incorporated as
appropriate.
As arranged with your offices, unless you publicly announce its
contents earlier, we plan no further distribution of this report until
30 days after its issue date. At that time, we will send copies to the
Administrator of the Centers for Medicare & Medicaid Services and
appropriate congressional committees. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on GAO's Web site at [hyperlink,
http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact me at (202) 512-7114 or dickenj@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made major contributions to
this report are listed in appendix VII.
Signed by:
John E. Dicken:
Director, Health Care:
[End of section]
Appendix I: Percentage of Nursing Homes Cited for Actual Harm or
Immediate Jeopardy during Standard Surveys:
In order to identify trends in the percentage of nursing homes cited
with actual harm or immediate jeopardy deficiencies, we analyzed data
from the Centers for Medicare & Medicaid Service's (CMS) On-Line
Survey, Certification, and Reporting system (OSCAR) database for fiscal
years 2002 through 2007 (see table 4). Because homes must be surveyed
at least every 15 months, with a required 12-month statewide average,
it is possible that a home was surveyed more than once in any fiscal
year. To avoid double counting homes, we included only a home's most
recent survey from each fiscal year. Because CMS conducts a relatively
small number of comparative surveys, it is not possible to compare the
results of comparative surveys to the results of all state surveys.
Table 4: Percentage of Nursing Homes Cited for Actual Harm or Immediate
Jeopardy, by State, Fiscal Years 2002 through 2007:
State: Alabama;
Number of homes in fiscal year 2007: 233;
Fiscal year: 2002: 12.7;
Fiscal year: 2003: 18.1;
Fiscal year: 2004: 16.6;
Fiscal year: 2005: 24.3;
Fiscal year: 2006: 23.6;
Fiscal year: 2007: 16.3.
State: Alaska;
Number of homes in fiscal year 2007: 15;
Fiscal year: 2002: 26.7;
Fiscal year: 2003: 0.0;
Fiscal year: 2004: 0.0;
Fiscal year: 2005: 0.0;
Fiscal year: 2006: 26.7;
Fiscal year: 2007: 13.3.
State: Arizona;
Number of homes in fiscal year 2007: 137;
Fiscal year: 2002: 7.3;
Fiscal year: 2003: 6.6;
Fiscal year: 2004: 9.4;
Fiscal year: 2005: 9.9;
Fiscal year: 2006: 25.4;
Fiscal year: 2007: 26.4.
State: Arkansas;
Number of homes in fiscal year 2007: 248;
Fiscal year: 2002: 22.3;
Fiscal year: 2003: 24.8;
Fiscal year: 2004: 21.5;
Fiscal year: 2005: 17.6;
Fiscal year: 2006: 13.6;
Fiscal year: 2007: 14.2.
State: California;
Number of homes in fiscal year 2007: 1,285;
Fiscal year: 2002: 5.1;
Fiscal year: 2003: 3.7;
Fiscal year: 2004: 6.5;
Fiscal year: 2005: 8.0;
Fiscal year: 2006: 13.9;
Fiscal year: 2007: 12.0.
State: Colorado;
Number of homes in fiscal year 2007: 212;
Fiscal year: 2002: 32.7;
Fiscal year: 2003: 20.9;
Fiscal year: 2004: 25.9;
Fiscal year: 2005: 40.4;
Fiscal year: 2006: 43.8;
Fiscal year: 2007: 42.4.
State: Connecticut;
Number of homes in fiscal year 2007: 244;
Fiscal year: 2002: 45.8;
Fiscal year: 2003: 43.1;
Fiscal year: 2004: 55.4;
Fiscal year: 2005: 44.2;
Fiscal year: 2006: 46.5;
Fiscal year: 2007: 38.3.
State: Delaware;
Number of homes in fiscal year 2007: 45;
Fiscal year: 2002: 11.1;
Fiscal year: 2003: 5.3;
Fiscal year: 2004: 15.0;
Fiscal year: 2005: 35.7;
Fiscal year: 2006: 21.1;
Fiscal year: 2007: 33.3.
State: District of Columbia;
Number of homes in fiscal year 2007: 20;
Fiscal year: 2002: 30.0;
Fiscal year: 2003: 41.2;
Fiscal year: 2004: 40.0;
Fiscal year: 2005: 30.0;
Fiscal year: 2006: 25.0;
Fiscal year: 2007: 36.8.
State: Florida;
Number of homes in fiscal year 2007: 683;
Fiscal year: 2002: 14.9;
Fiscal year: 2003: 10.2;
Fiscal year: 2004: 8.6;
Fiscal year: 2005: 4.2;
Fiscal year: 2006: 8.0;
Fiscal year: 2007: 8.3.
State: Georgia;
Number of homes in fiscal year 2007: 362;
Fiscal year: 2002: 23.7;
Fiscal year: 2003: 24.6;
Fiscal year: 2004: 17.9;
Fiscal year: 2005: 19.3;
Fiscal year: 2006: 15.0;
Fiscal year: 2007: 14.9.
State: Hawaii;
Number of homes in fiscal year 2007: 48;
Fiscal year: 2002: 21.2;
Fiscal year: 2003: 12.1;
Fiscal year: 2004: 22.9;
Fiscal year: 2005: 2.8;
Fiscal year: 2006: 2.1;
Fiscal year: 2007: 7.3.
State: Idaho;
Number of homes in fiscal year 2007: 79;
Fiscal year: 2002: 39.2;
Fiscal year: 2003: 31.9;
Fiscal year: 2004: 27.3;
Fiscal year: 2005: 40.5;
Fiscal year: 2006: 44.9;
Fiscal year: 2007: 27.1.
State: Illinois;
Number of homes in fiscal year 2007: 810;
Fiscal year: 2002: 15.3;
Fiscal year: 2003: 18.4;
Fiscal year: 2004: 16.3;
Fiscal year: 2005: 16.7;
Fiscal year: 2006: 20.3;
Fiscal year: 2007: 25.1.
State: Indiana;
Number of homes in fiscal year 2007: 520;
Fiscal year: 2002: 23.2;
Fiscal year: 2003: 19.7;
Fiscal year: 2004: 24.5;
Fiscal year: 2005: 29.6;
Fiscal year: 2006: 30.6;
Fiscal year: 2007: 35.2.
State: Iowa;
Number of homes in fiscal year 2007: 463;
Fiscal year: 2002: 8.0;
Fiscal year: 2003: 9.2;
Fiscal year: 2004: 12.4;
Fiscal year: 2005: 11.7;
Fiscal year: 2006: 9.6;
Fiscal year: 2007: 16.3.
State: Kansas;
Number of homes in fiscal year 2007: 358;
Fiscal year: 2002: 32.9;
Fiscal year: 2003: 26.5;
Fiscal year: 2004: 31.9;
Fiscal year: 2005: 36.6;
Fiscal year: 2006: 37.7;
Fiscal year: 2007: 29.4.
State: Kentucky;
Number of homes in fiscal year 2007: 293;
Fiscal year: 2002: 23.2;
Fiscal year: 2003: 26.1;
Fiscal year: 2004: 15.0;
Fiscal year: 2005: 8.0;
Fiscal year: 2006: 10.6;
Fiscal year: 2007: 7.6.
State: Louisiana;
Number of homes in fiscal year 2007: 299;
Fiscal year: 2002: 21.8;
Fiscal year: 2003: 16.2;
Fiscal year: 2004: 13.8;
Fiscal year: 2005: 16.3;
Fiscal year: 2006: 16.1;
Fiscal year: 2007: 11.7.
State: Maine;
Number of homes in fiscal year 2007: 113;
Fiscal year: 2002: 6.6;
Fiscal year: 2003: 11.1;
Fiscal year: 2004: 12.8;
Fiscal year: 2005: 7.0;
Fiscal year: 2006: 9.8;
Fiscal year: 2007: 7.2.
State: Maryland;
Number of homes in fiscal year 2007: 234;
Fiscal year: 2002: 26.1;
Fiscal year: 2003: 15.4;
Fiscal year: 2004: 18.3;
Fiscal year: 2005: 7.6;
Fiscal year: 2006: 7.6;
Fiscal year: 2007: 17.1.
State: Massachusetts;
Number of homes in fiscal year 2007: 452;
Fiscal year: 2002: 24.6;
Fiscal year: 2003: 25.9;
Fiscal year: 2004: 17.4;
Fiscal year: 2005: 22.9;
Fiscal year: 2006: 20.6;
Fiscal year: 2007: 16.6.
State: Michigan;
Number of homes in fiscal year 2007: 439;
Fiscal year: 2002: 29.7;
Fiscal year: 2003: 26.9;
Fiscal year: 2004: 23.6;
Fiscal year: 2005: 23.1;
Fiscal year: 2006: 27.9;
Fiscal year: 2007: 29.8.
State: Minnesota;
Number of homes in fiscal year 2007: 398;
Fiscal year: 2002: 22.3;
Fiscal year: 2003: 18.3;
Fiscal year: 2004: 14.3;
Fiscal year: 2005: 14.4;
Fiscal year: 2006: 17.5;
Fiscal year: 2007: 16.0.
State: Mississippi;
Number of homes in fiscal year 2007: 206;
Fiscal year: 2002: 18.8;
Fiscal year: 2003: 16.0;
Fiscal year: 2004: 19.5;
Fiscal year: 2005: 18.7;
Fiscal year: 2006: 8.4;
Fiscal year: 2007: 9.1.
State: Missouri;
Number of homes in fiscal year 2007: 530;
Fiscal year: 2002: 15.6;
Fiscal year: 2003: 12.5;
Fiscal year: 2004: 12.5;
Fiscal year: 2005: 15.8;
Fiscal year: 2006: 15.2;
Fiscal year: 2007: 15.5.
State: Montana;
Number of homes in fiscal year 2007: 96;
Fiscal year: 2002: 12.0;
Fiscal year: 2003: 20.0;
Fiscal year: 2004: 18.0;
Fiscal year: 2005: 17.9;
Fiscal year: 2006: 16.7;
Fiscal year: 2007: 23.9.
State: Nebraska;
Number of homes in fiscal year 2007: 228;
Fiscal year: 2002: 20.1;
Fiscal year: 2003: 14.8;
Fiscal year: 2004: 15.8;
Fiscal year: 2005: 14.4;
Fiscal year: 2006: 25.0;
Fiscal year: 2007: 26.4.
State: Nevada;
Number of homes in fiscal year 2007: 48;
Fiscal year: 2002: 11.9;
Fiscal year: 2003: 9.1;
Fiscal year: 2004: 17.5;
Fiscal year: 2005: 21.7;
Fiscal year: 2006: 21.3;
Fiscal year: 2007: 12.5.
State: New Hampshire;
Number of homes in fiscal year 2007: 81;
Fiscal year: 2002: 29.4;
Fiscal year: 2003: 24.4;
Fiscal year: 2004: 25.6;
Fiscal year: 2005: 26.3;
Fiscal year: 2006: 22.9;
Fiscal year: 2007: 14.7.
State: New Jersey;
Number of homes in fiscal year 2007: 368;
Fiscal year: 2002: 18.8;
Fiscal year: 2003: 10.5;
Fiscal year: 2004: 12.9;
Fiscal year: 2005: 18.2;
Fiscal year: 2006: 14.6;
Fiscal year: 2007: 16.5.
State: New Mexico;
Number of homes in fiscal year 2007: 72;
Fiscal year: 2002: 14.9;
Fiscal year: 2003: 21.3;
Fiscal year: 2004: 25.7;
Fiscal year: 2005: 32.4;
Fiscal year: 2006: 25.0;
Fiscal year: 2007: 28.6.
State: New York;
Number of homes in fiscal year 2007: 657;
Fiscal year: 2002: 34.2;
Fiscal year: 2003: 15.2;
Fiscal year: 2004: 11.0;
Fiscal year: 2005: 14.4;
Fiscal year: 2006: 17.5;
Fiscal year: 2007: 17.2.
State: North Carolina;
Number of homes in fiscal year 2007: 422;
Fiscal year: 2002: 25.6;
Fiscal year: 2003: 29.0;
Fiscal year: 2004: 22.1;
Fiscal year: 2005: 18.8;
Fiscal year: 2006: 16.7;
Fiscal year: 2007: 10.7.
State: North Dakota;
Number of homes in fiscal year 2007: 83;
Fiscal year: 2002: 17.9;
Fiscal year: 2003: 12.4;
Fiscal year: 2004: 13.6;
Fiscal year: 2005: 17.7;
Fiscal year: 2006: 20.5;
Fiscal year: 2007: 15.6.
State: Ohio;
Number of homes in fiscal year 2007: 984;
Fiscal year: 2002: 25.4;
Fiscal year: 2003: 19.1;
Fiscal year: 2004: 11.8;
Fiscal year: 2005: 14.4;
Fiscal year: 2006: 13.4;
Fiscal year: 2007: 14.4.
State: Oklahoma;
Number of homes in fiscal year 2007: 348;
Fiscal year: 2002: 22.2;
Fiscal year: 2003: 26.4;
Fiscal year: 2004: 17.1;
Fiscal year: 2005: 26.5;
Fiscal year: 2006: 18.7;
Fiscal year: 2007: 18.7.
State: Oregon;
Number of homes in fiscal year 2007: 139;
Fiscal year: 2002: 23.7;
Fiscal year: 2003: 20.3;
Fiscal year: 2004: 16.7;
Fiscal year: 2005: 18.9;
Fiscal year: 2006: 17.8;
Fiscal year: 2007: 17.6.
State: Pennsylvania;
Number of homes in fiscal year 2007: 724;
Fiscal year: 2002: 13.5;
Fiscal year: 2003: 17.2;
Fiscal year: 2004: 19.9;
Fiscal year: 2005: 15.5;
Fiscal year: 2006: 12.0;
Fiscal year: 2007: 11.9.
State: Rhode Island;
Number of homes in fiscal year 2007: 87;
Fiscal year: 2002: 5.6;
Fiscal year: 2003: 8.1;
Fiscal year: 2004: 9.3;
Fiscal year: 2005: 9.5;
Fiscal year: 2006: 4.4;
Fiscal year: 2007: 1.3.
State: South Carolina;
Number of homes in fiscal year 2007: 176;
Fiscal year: 2002: 19.8;
Fiscal year: 2003: 29.6;
Fiscal year: 2004: 33.3;
Fiscal year: 2005: 25.5;
Fiscal year: 2006: 16.5;
Fiscal year: 2007: 8.8.
State: South Dakota;
Number of homes in fiscal year 2007: 112;
Fiscal year: 2002: 26.8;
Fiscal year: 2003: 32.1;
Fiscal year: 2004: 23.4;
Fiscal year: 2005: 12.8;
Fiscal year: 2006: 18.4;
Fiscal year: 2007: 22.6.
State: Tennessee;
Number of homes in fiscal year 2007: 332;
Fiscal year: 2002: 20.7;
Fiscal year: 2003: 21.8;
Fiscal year: 2004: 24.1;
Fiscal year: 2005: 17.6;
Fiscal year: 2006: 11.5;
Fiscal year: 2007: 16.2.
State: Texas;
Number of homes in fiscal year 2007: 1,195;
Fiscal year: 2002: 22.4;
Fiscal year: 2003: 18.0;
Fiscal year: 2004: 12.8;
Fiscal year: 2005: 16.7;
Fiscal year: 2006: 18.1;
Fiscal year: 2007: 14.7.
State: Utah;
Number of homes in fiscal year 2007: 94;
Fiscal year: 2002: 25.6;
Fiscal year: 2003: 19.0;
Fiscal year: 2004: 12.2;
Fiscal year: 2005: 8.4;
Fiscal year: 2006: 16.7;
Fiscal year: 2007: 7.5.
State: Vermont;
Number of homes in fiscal year 2007: 41;
Fiscal year: 2002: 15.0;
Fiscal year: 2003: 10.0;
Fiscal year: 2004: 19.5;
Fiscal year: 2005: 23.7;
Fiscal year: 2006: 13.5;
Fiscal year: 2007: 12.1.
State: Virginia;
Number of homes in fiscal year 2007: 281;
Fiscal year: 2002: 11.7;
Fiscal year: 2003: 13.7;
Fiscal year: 2004: 10.2;
Fiscal year: 2005: 16.3;
Fiscal year: 2006: 15.2;
Fiscal year: 2007: 18.3.
State: Washington;
Number of homes in fiscal year 2007: 247;
Fiscal year: 2002: 37.0;
Fiscal year: 2003: 30.9;
Fiscal year: 2004: 28.5;
Fiscal year: 2005: 27.6;
Fiscal year: 2006: 23.5;
Fiscal year: 2007: 23.7.
State: West Virginia;
Number of homes in fiscal year 2007: 133;
Fiscal year: 2002: 20.4;
Fiscal year: 2003: 12.7;
Fiscal year: 2004: 11.5;
Fiscal year: 2005: 17.7;
Fiscal year: 2006: 10.5;
Fiscal year: 2007: 21.7.
State: Wisconsin;
Number of homes in fiscal year 2007: 401;
Fiscal year: 2002: 11.2;
Fiscal year: 2003: 10.9;
Fiscal year: 2004: 13.1;
Fiscal year: 2005: 18.8;
Fiscal year: 2006: 21.6;
Fiscal year: 2007: 29.8.
State: Wyoming;
Number of homes in fiscal year 2007: 39;
Fiscal year: 2002: 25.0;
Fiscal year: 2003: 22.9;
Fiscal year: 2004: 17.1;
Fiscal year: 2005: 11.8;
Fiscal year: 2006: 16.2;
Fiscal year: 2007: 24.2.
Nation;
Number of homes in fiscal year 2007: 16,114;
Fiscal year: 2002: 20.2;
Fiscal year: 2003: 17.8;
Fiscal year: 2004: 16.4;
Fiscal year: 2005: 17.4;
Fiscal year: 2006: 17.9;
Fiscal year: 2007: 17.8[A].
Source: GAO analysis of OSCAR data.
Note: Data presented in this table may be slightly different from those
presented in earlier reports because we (1) used final year-end OSCAR
files when they were available or (2) the OSCAR extracts contained
surveys that had not previously been entered in the database.
[A] Fiscal year 2007 results are incomplete and use all available
information as of January 2008.
[End of section]
Appendix II: Percentage of Comparative Surveys Identifying Missed
Deficiencies at Actual Harm or Immediate Jeopardy Level:
Table 5:
State: Alabama;
Number of homes in fiscal year 2007: 233;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 5;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 27.8;
Total number missed G-L deficiencies: 13.
State: Alaska;
Number of homes in fiscal year 2007: 15;
Total comparative surveys: 11;
Total comparative surveys with at least one missed G-L deficiency: 0;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 0.0;
Total number missed G-L deficiencies: 0.
State: Arizona;
Number of homes in fiscal year 2007: 137;
Total comparative surveys: 15;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 26.7;
Total number missed G-L deficiencies: 6.
State: Arkansas;
Number of homes in fiscal year 2007: 248;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 5.6;
Total number missed G-L deficiencies: 1.
State: California;
Number of homes in fiscal year 2007: 1,285;
Total comparative surveys: 49;
Total comparative surveys with at least one missed G-L deficiency: 5;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 10.2;
Total number missed G-L deficiencies: 6.
State: Colorado;
Number of homes in fiscal year 2007: 212;
Total comparative surveys: 22;
Total comparative surveys with at least one missed G-L deficiency: 3;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 13.6;
Total number missed G-L deficiencies: 4.
State: Connecticut;
Number of homes in fiscal year 2007: 244;
Total comparative surveys: 16;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 6.3;
Total number missed G-L deficiencies: 1.
State: Delaware;
Number of homes in fiscal year 2007: 45;
Total comparative surveys: 13;
Total comparative surveys with at least one missed G-L deficiency: 2;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 15.4;
Total number missed G-L deficiencies: 2.
State: District of Columbia;
Number of homes in fiscal year 2007: 20;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 8.3;
Total number missed G-L deficiencies: 1.
State: Florida;
Number of homes in fiscal year 2007: 683;
Total comparative surveys: 26;
Total comparative surveys with at least one missed G-L deficiency: 3;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 11.5;
Total number missed G-L deficiencies: 6.
State: Georgia;
Number of homes in fiscal year 2007: 362;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 3;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 16.7;
Total number missed G-L deficiencies: 4.
State: Hawaii;
Number of homes in fiscal year 2007: 48;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 8.3;
Total number missed G-L deficiencies: 1.
State: Idaho;
Number of homes in fiscal year 2007: 79;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 0;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 0.0;
Total number missed G-L deficiencies: 0.
State: Illinois;
Number of homes in fiscal year 2007: 810;
Total comparative surveys: 32;
Total comparative surveys with at least one missed G-L deficiency: 7;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 21.9;
Total number missed G-L deficiencies: 12.
State: Indiana;
Number of homes in fiscal year 2007: 520;
Total comparative surveys: 25;
Total comparative surveys with at least one missed G-L deficiency: 3;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 12.0;
Total number missed G-L deficiencies: 4.
State: Iowa;
Number of homes in fiscal year 2007: 463;
Total comparative surveys: 19;
Total comparative surveys with at least one missed G-L deficiency: 3;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 15.8;
Total number missed G-L deficiencies: 4.
State: Kansas;
Number of homes in fiscal year 2007: 358;
Total comparative surveys: 24;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 16.7;
Total number missed G-L deficiencies: 8.
State: Kentucky;
Number of homes in fiscal year 2007: 293;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 2;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 11.1;
Total number missed G-L deficiencies: 2.
State: Louisiana;
Number of homes in fiscal year 2007: 299;
Total comparative surveys: 17;
Total comparative surveys with at least one missed G-L deficiency: 3;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 17.6;
Total number missed G-L deficiencies: 6.
State: Maine;
Number of homes in fiscal year 2007: 113;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 0;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 0.0;
Total number missed G-L deficiencies: 0.
State: Maryland;
Number of homes in fiscal year 2007: 234;
Total comparative surveys: 19;
Total comparative surveys with at least one missed G-L deficiency: 2;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 10.5;
Total number missed G-L deficiencies: 2.
State: Massachusetts;
Number of homes in fiscal year 2007: 452;
Total comparative surveys: 17;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 5.9;
Total number missed G-L deficiencies: 1.
State: Michigan;
Number of homes in fiscal year 2007: 439;
Total comparative surveys: 25;
Total comparative surveys with at least one missed G-L deficiency: 5;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 20.0;
Total number missed G-L deficiencies: 5.
State: Minnesota;
Number of homes in fiscal year 2007: 398;
Total comparative surveys: 21;
Total comparative surveys with at least one missed G-L deficiency: 2;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 9.5;
Total number missed G-L deficiencies: 2.
State: Mississippi;
Number of homes in fiscal year 2007: 206;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 22.2;
Total number missed G-L deficiencies: 8.
State: Missouri;
Number of homes in fiscal year 2007: 530;
Total comparative surveys: 28;
Total comparative surveys with at least one missed G-L deficiency: 8;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 28.6;
Total number missed G-L deficiencies: 14.
State: Montana;
Number of homes in fiscal year 2007: 96;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 2;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 16.7;
Total number missed G-L deficiencies: 2.
State: Nebraska;
Number of homes in fiscal year 2007: 228;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 5.6;
Total number missed G-L deficiencies: 1.
State: Nevada;
Number of homes in fiscal year 2007: 48;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 8.3;
Total number missed G-L deficiencies: 2.
State: New Hampshire;
Number of homes in fiscal year 2007: 81;
Total comparative surveys: 14;
Total comparative surveys with at least one missed G-L deficiency: 2;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 14.3;
Total number missed G-L deficiencies: 2.
State: New Jersey;
Number of homes in fiscal year 2007: 368;
Total comparative surveys: 24;
Total comparative surveys with at least one missed G-L deficiency: 5;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 20.8;
Total number missed G-L deficiencies: 16.
State: New Mexico;
Number of homes in fiscal year 2007: 72;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 33.3;
Total number missed G-L deficiencies: 9.
State: New York;
Number of homes in fiscal year 2007: 657;
Total comparative surveys: 27;
Total comparative surveys with at least one missed G-L deficiency: 6;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 22.2;
Total number missed G-L deficiencies: 12.
State: North Carolina;
Number of homes in fiscal year 2007: 422;
Total comparative surveys: 21;
Total comparative surveys with at least one missed G-L deficiency: 3;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 14.3;
Total number missed G-L deficiencies: 3.
State: North Dakota;
Number of homes in fiscal year 2007: 83;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 0;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 0.0;
Total number missed G-L deficiencies: 0.
State: Ohio;
Number of homes in fiscal year 2007: 984;
Total comparative surveys: 31;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 3.2;
Total number missed G-L deficiencies: 1.
State: Oklahoma;
Number of homes in fiscal year 2007: 348;
Total comparative surveys: 20;
Total comparative surveys with at least one missed G-L deficiency: 6;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 30.0;
Total number missed G-L deficiencies: 11.
State: Oregon;
Number of homes in fiscal year 2007: 139;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 0;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 0.0;
Total number missed G-L deficiencies: 0.
State: Pennsylvania;
Number of homes in fiscal year 2007: 724;
Total comparative surveys: 37;
Total comparative surveys with at least one missed G-L deficiency: 6;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 16.2;
Total number missed G-L deficiencies: 6.
State: Rhode Island;
Number of homes in fiscal year 2007: 87;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 2;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 16.7;
Total number missed G-L deficiencies: 3.
State: South Carolina;
Number of homes in fiscal year 2007: 176;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 6;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 33.3;
Total number missed G-L deficiencies: 19.
State: South Dakota;
Number of homes in fiscal year 2007: 112;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 33.3;
Total number missed G-L deficiencies: 4.
State: Tennessee;
Number of homes in fiscal year 2007: 332;
Total comparative surveys: 19;
Total comparative surveys with at least one missed G-L deficiency: 5;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 26.3;
Total number missed G-L deficiencies: 10.
State: Texas;
Number of homes in fiscal year 2007: 1,195;
Total comparative surveys: 38;
Total comparative surveys with at least one missed G-L deficiency: 5;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 13.2;
Total number missed G-L deficiencies: 7.
State: Utah;
Number of homes in fiscal year 2007: 94;
Total comparative surveys: 11;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 9.1;
Total number missed G-L deficiencies: 1.
State: Vermont;
Number of homes in fiscal year 2007: 41;
Total comparative surveys: 10;
Total comparative surveys with at least one missed G-L deficiency: 0;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 0.0;
Total number missed G-L deficiencies: 0.
State: Virginia;
Number of homes in fiscal year 2007: 281;
Total comparative surveys: 17;
Total comparative surveys with at least one missed G-L deficiency: 1;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 5.9;
Total number missed G-L deficiencies: 1.
State: Washington;
Number of homes in fiscal year 2007: 247;
Total comparative surveys: 18;
Total comparative surveys with at least one missed G-L deficiency: 2;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 11.1;
Total number missed G-L deficiencies: 2.
State: West Virginia;
Number of homes in fiscal year 2007: 133;
Total comparative surveys: 13;
Total comparative surveys with at least one missed G-L deficiency: 0;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 0.0;
Total number missed G-L deficiencies: 0.
State: Wisconsin;
Number of homes in fiscal year 2007: 401;
Total comparative surveys: 21;
Total comparative surveys with at least one missed G-L deficiency: 2;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 9.5;
Total number missed G-L deficiencies: 2.
State: Wyoming;
Number of homes in fiscal year 2007: 39;
Total comparative surveys: 12;
Total comparative surveys with at least one missed G-L deficiency: 4;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 33.3;
Total number missed G-L deficiencies: 5.
State: Nation;
Number of homes in fiscal year 2007: 16,114;
Total comparative surveys: 976;
Total comparative surveys with at least one missed G-L deficiency: 142;
Percentage of total comparative surveys with at least one missed G-L
Deficiency: 14.5;
Total number missed G-L deficiencies: 232.
Source: GAO analysis of CMS's OSCAR data for the number of homes and
federal monitoring survey data for all other data presented.
[End of table]
[End of section]
Appendix III: Percentage of Comparative Surveys Identifying Missed
Deficiencies with Potential for More Than Minimal Harm:
Table 6:
State: Alabama;
Number of homes in fiscal year 2007: 233;
Total comparative surveys: 18;
Total comparative surveys with at least one missed D-F deficiency: 17;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 94.4;
Total number of missed D-F deficiencies: 61.
State: Alaska;
Number of homes in fiscal year 2007: 15;
Total comparative surveys: 11;
Total comparative surveys with at least one missed D-F deficiency: 4;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 36.4;
Total number of missed D-F deficiencies: 8.
State: Arizona;
Number of homes in fiscal year 2007: 137;
Total comparative surveys: 15;
Total comparative surveys with at least one missed D-F deficiency: 12;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 80.0;
Total number of missed D-F deficiencies: 73.
State: Arkansas;
Number of homes in fiscal year 2007: 248;
Total comparative surveys: 18;
Total comparative surveys with at least one missed D-F deficiency: 13;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 72.2;
Total number of missed D-F deficiencies: 50.
State: California;
Number of homes in fiscal year 2007: 1,285;
Total comparative surveys: 49;
Total comparative surveys with at least one missed D-F deficiency: 36;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 73.5;
Total number of missed D-F deficiencies: 104.
State: Colorado;
Number of homes in fiscal year 2007: 212;
Total comparative surveys: 22;
Total comparative surveys with at least one missed D-F deficiency: 21;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 95.5;
Total number of missed D-F deficiencies: 108.
State: Connecticut;
Number of homes in fiscal year 2007: 244;
Total comparative surveys: 16;
Total comparative surveys with at least one missed D-F deficiency: 8;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 50.0;
Total number of missed D-F deficiencies: 28.
State: Delaware;
Number of homes in fiscal year 2007: 45;
Total comparative surveys: 13;
Total comparative surveys with at least one missed D-F deficiency: 9;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 69.2;
Total number of missed D-F deficiencies: 29.
State: District of Columbia;
Number of homes in fiscal year 2007: 20;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 10;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 83.3;
Total number of missed D-F deficiencies: 26.
State: Florida;
Number of homes in fiscal year 2007: 683;
Total comparative surveys: 26;
Total comparative surveys with at least one missed D-F deficiency: 18;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 69.2;
Total number of missed D-F deficiencies: 53.
State: Georgia;
Number of homes in fiscal year 2007: 362;
Total comparative surveys: 18;
Total comparative surveys with at least one missed D-F deficiency: 13;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 72.2;
Total number of missed D-F deficiencies: 48.
State: Hawaii;
Number of homes in fiscal year 2007: 48;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 7;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 58.3;
Total number of missed D-F deficiencies: 22.
State: Idaho;
Number of homes in fiscal year 2007: 79;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 7;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 58.3;
Total number of missed D-F deficiencies: 18.
State: Illinois;
Number of homes in fiscal year 2007: 810;
Total comparative surveys: 32;
Total comparative surveys with at least one missed D-F deficiency: 17;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 53.1;
Total number of missed D-F deficiencies: 63.
State: Indiana;
Number of homes in fiscal year 2007: 520;
Total comparative surveys: 25;
Total comparative surveys with at least one missed D-F deficiency: 12;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 48.0;
Total number of missed D-F deficiencies: 31.
State: Iowa;
Number of homes in fiscal year 2007: 463;
Total comparative surveys: 19;
Total comparative surveys with at least one missed D-F deficiency: 13;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 68.4;
Total number of missed D-F deficiencies: 36.
State: Kansas;
Number of homes in fiscal year 2007: 358;
Total comparative surveys: 24;
Total comparative surveys with at least one missed D-F deficiency: 19;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 79.2;
Total number of missed D-F deficiencies: 66.
State: Kentucky;
Number of homes in fiscal year 2007: 293;
Total comparative surveys: 18;
Total comparative surveys with at least one missed D-F deficiency: 11;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 61.1;
Total number of missed D-F deficiencies: 33.
State: Louisiana;
Number of homes in fiscal year 2007: 299;
Total comparative surveys: 17;
Total comparative surveys with at least one missed D-F deficiency: 13;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 76.5;
Total number of missed D-F deficiencies: 73.
State: Maine;
Number of homes in fiscal year 2007: 113;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 6;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 50.0;
Total number of missed D-F deficiencies: 25.
State: Maryland;
Number of homes in fiscal year 2007: 234;
Total comparative surveys: 19;
Total comparative surveys with at least one missed D-F deficiency: 9;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 47.4;
Total number of missed D-F deficiencies: 16.
State: Massachusetts;
Number of homes in fiscal year 2007: 452;
Total comparative surveys: 17;
Total comparative surveys with at least one missed D-F deficiency: 8;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 47.1;
Total number of missed D-F deficiencies: 22.
State: Michigan;
Number of homes in fiscal year 2007: 439;
Total comparative surveys: 25;
Total comparative surveys with at least one missed D-F deficiency: 18;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 72.0;
Total number of missed D-F deficiencies: 37.
State: Minnesota;
Number of homes in fiscal year 2007: 398;
Total comparative surveys: 21;
Total comparative surveys with at least one missed D-F deficiency: 15;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 71.4;
Total number of missed D-F deficiencies: 29.
State: Mississippi;
Number of homes in fiscal year 2007: 206;
Total comparative surveys: 18;
Total comparative surveys with at least one missed D-F deficiency: 15;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 83.3;
Total number of missed D-F deficiencies: 57.
State: Missouri;
Number of homes in fiscal year 2007: 530;
Total comparative surveys: 28;
Total comparative surveys with at least one missed D-F deficiency: 22;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 78.6;
Total number of missed D-F deficiencies: 146.
State: Montana;
Number of homes in fiscal year 2007: 96;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 12;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 100.0;
Total number of missed D-F deficiencies: 52.
State: Nebraska;
Number of homes in fiscal year 2007: 228;
Total comparative surveys: 18;
Total comparative surveys with at least one missed D-F deficiency: 13;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 72.2;
Total number of missed D-F deficiencies: 42.
State: Nevada;
Number of homes in fiscal year 2007: 48;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 11;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 91.7;
Total number of missed D-F deficiencies: 33.
State: New Hampshire;
Number of homes in fiscal year 2007: 81;
Total comparative surveys: 14;
Total comparative surveys with at least one missed D-F deficiency: 9;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 64.3;
Total number of missed D-F deficiencies: 42.
State: New Jersey;
Number of homes in fiscal year 2007: 368;
Total comparative surveys: 24;
Total comparative surveys with at least one missed D-F deficiency: 14;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 58.3;
Total number of missed D-F deficiencies: 50.
State: New Mexico;
Number of homes in fiscal year 2007: 72;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 9;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 75.0;
Total number of missed D-F deficiencies: 27.
State: New York;
Number of homes in fiscal year 2007: 657;
Total comparative surveys: 27;
Total comparative surveys with at least one missed D-F deficiency: 15;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 55.6;
Total number of missed D-F deficiencies: 77.
State: North Carolina;
Number of homes in fiscal year 2007: 422;
Total comparative surveys: 21;
Total comparative surveys with at least one missed D-F deficiency: 17;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 81.0;
Total number of missed D-F deficiencies: 48.
State: North Dakota;
Number of homes in fiscal year 2007: 83;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 11;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 91.7;
Total number of missed D-F deficiencies: 32.
State: Ohio;
Number of homes in fiscal year 2007: 984;
Total comparative surveys: 31;
Total comparative surveys with at least one missed D-F deficiency: 12;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 38.7;
Total number of missed D-F deficiencies: 20.
State: Oklahoma;
Number of homes in fiscal year 2007: 348;
Total comparative surveys: 20;
Total comparative surveys with at least one missed D-F deficiency: 15;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 75.0;
Total number of missed D-F deficiencies: 96.
State: Oregon;
Number of homes in fiscal year 2007: 139;
Total comparative surveys: 18;
Total comparative surveys with at least one missed D-F deficiency: 12;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 66.7;
Total number of missed D-F deficiencies: 30.
State: Pennsylvania;
Number of homes in fiscal year 2007: 724;
Total comparative surveys: 37;
Total comparative surveys with at least one missed D-F deficiency: 23;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 62.2;
Total number of missed D-F deficiencies: 66.
State: Rhode Island;
Number of homes in fiscal year 2007: 87;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 9;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 75.0;
Total number of missed D-F deficiencies: 14.
State: South Carolina;
Number of homes in fiscal year 2007: 176;
Total comparative surveys: 18;
Total comparative surveys with at least one missed D-F deficiency: 15;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 83.3;
Total number of missed D-F deficiencies: 59.
State: South Dakota;
Number of homes in fiscal year 2007: 112;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 12;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 100.0;
Total number of missed D-F deficiencies: 44.
State: Tennessee;
Number of homes in fiscal year 2007: 332;
Total comparative surveys: 19;
Total comparative surveys with at least one missed D-F deficiency: 16;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 84.2;
Total number of missed D-F deficiencies: 50.
State: Texas;
Number of homes in fiscal year 2007: 1,195;
Total comparative surveys: 38;
Total comparative surveys with at least one missed D-F deficiency: 29;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 76.3;
Total number of missed D-F deficiencies: 119.
State: Utah;
Number of homes in fiscal year 2007: 94;
Total comparative surveys: 11;
Total comparative surveys with at least one missed D-F deficiency: 11;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 100.0;
Total number of missed D-F deficiencies: 94.
State: Vermont;
Number of homes in fiscal year 2007: 41;
Total comparative surveys: 10;
Total comparative surveys with at least one missed D-F deficiency: 4;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 40.0;
Total number of missed D-F deficiencies: 18.
State: Virginia;
Number of homes in fiscal year 2007: 281;
Total comparative surveys: 17;
Total comparative surveys with at least one missed D-F deficiency: 12;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 70.6;
Total number of missed D-F deficiencies: 31.
State: Washington;
Number of homes in fiscal year 2007: 247;
Total comparative surveys: 18;
Total comparative surveys with at least one missed D-F deficiency: 10;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 55.6;
Total number of missed D-F deficiencies: 20.
State: West Virginia;
Number of homes in fiscal year 2007: 133;
Total comparative surveys: 13;
Total comparative surveys with at least one missed D-F deficiency: 3;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 23.1;
Total number of missed D-F deficiencies: 3.
State: Wisconsin;
Number of homes in fiscal year 2007: 401;
Total comparative surveys: 21;
Total comparative surveys with at least one missed D-F deficiency: 8;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 38.1;
Total number of missed D-F deficiencies: 19.
State: Wyoming;
Number of homes in fiscal year 2007: 39;
Total comparative surveys: 12;
Total comparative surveys with at least one missed D-F deficiency: 12;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 100.0;
Total number of missed D-F deficiencies: 83.
State: Nation;
Number of homes in fiscal year 2007: 16,114;
Total comparative surveys: 976;
Total comparative surveys with at least one missed D-F deficiency: 667;
Percentage of total comparative surveys with at least one missed D-F
deficiency: 68.3;
Total number of missed D-F deficiencies: 2,431.
Source: GAO analysis of CMS's OSCAR data for the number of homes and
federal monitoring survey data for all other data presented.
[End of table]
[End of section]
Appendix IV: Percentage of Comparative Surveys with at Least One Missed
Deficiency, by Federal Quality Standard Category:
Table 7:
Federal quality standard category: Quality of Care;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 31.7;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 11.9.
Federal quality standard category: Resident Behavior and Facility
Practices;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 17.7;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 2.2.
Federal quality standard category: Resident Assessment;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 31.7;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 1.6.
Federal quality standard category: Administration;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 13.3;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 1.4.
Federal quality standard category: Resident Rights;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 10.8;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.5.
Federal quality standard category: Quality of Life;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 18.9;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.5.
Federal quality standard category: Nursing Services;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 1.3;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.4.
Federal quality standard category: Other;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 0.2;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.2.
Federal quality standard category: Dietary Services;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 18.5;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.1.
Federal quality standard category: Physician Services;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 3.0;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.1.
Federal quality standard category: Dental Services;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 0.2;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.1.
Federal quality standard category: Pharmacy Services;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 9.7;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.1.
Federal quality standard category: Infection Control;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 9.8;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.1.
Federal quality standard category: Physical Environment;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 14.5;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.1.
Federal quality standard category: Admission, Transfer, and Discharge
Rights;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 0.3;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.0.
Federal quality standard category: Specialized Rehabilitative;
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 0.3;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 0.0.
Federal quality standard category: National average[A];
Percentage of total comparative surveys citing at least one missed
deficiency: At the D through F level: 68.3;
Percentage of total comparative surveys citing at least one missed
deficiency: At the G through L level: 14.5.
Source: GAO analysis of federal monitoring survey data.
[A] Percentages for both the D through F and G through L levels do not
total the national average because some surveys cited missed
deficiencies in multiple categories.
[End of table]
[End of section]
Appendix V: Percentage of Below Satisfactory State Survey Ratings for
General Investigation and Deficiency Determination:
Table 8:
Alabama;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 27.8;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 20.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 22.7.
Alaska;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 5.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 5.3.
Arizona;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 26.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 7.4;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 15.4.
Arkansas;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 5.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 3.5;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 7.0.
California;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 10.2;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 10.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 6.1.
Colorado;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 13.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 4.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 0.0.
Connecticut;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 6.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 7.4;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 7.4.
Delaware;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 15.4;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 11.8.
District of Columbia;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 8.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 5.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 5.6.
Florida;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 11.5;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 16.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 19.5.
Georgia;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 16.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 12.5;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 21.6.
Hawaii;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 8.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 5.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 11.1.
Idaho;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 5.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 0.0.
Illinois;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 21.9;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 4.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 2.4.
Indiana;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 12.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 2.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 3.9.
Iowa;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 15.8;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 1.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 1.7.
Kansas;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 16.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 2.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 4.7.
Kentucky;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 11.1;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 11.4;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 21.4.
Louisiana;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 17.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 14.9;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 19.4.
Maine;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 12.5;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 4.2.
Maryland;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 10.5;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 2.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 6.0.
Massachusetts;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 5.9;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 0.8;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 0.8.
Michigan;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 20.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 2.9;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 6.8.
Minnesota;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 9.5;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 5.9;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 3.0.
Mississippi;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 22.2;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 16.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 21.4.
Missouri;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 28.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 17.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 22.1.
Montana;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 16.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 10.5;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 0.0.
Nebraska;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 5.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 4.1;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 2.0.
Nevada;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 8.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 11.1;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 11.1.
New Hampshire;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 14.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 25.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 18.8.
New Jersey;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 20.8;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 3.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 1.1.
New Mexico;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 33.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 26.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 31.6.
New York;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 22.2;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 14.4;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 14.5.
North Carolina;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 14.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 12.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 23.6.
North Dakota;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 0.0.
Ohio;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 3.2;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 0.8;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 2.7.
Oklahoma;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 30.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 12.1;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 16.5.
Oregon;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 4.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 8.7.
Pennsylvania;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 16.2;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 4.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 5.3.
Rhode Island;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 16.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 5.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 11.1.
South Carolina;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 33.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 14.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 22.9.
South Dakota;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 33.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 0.0.
Tennessee;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 26.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 14.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 20.7.
Texas;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 13.2;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 8.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 12.0.
Utah;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 9.1;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 5.6.
Vermont;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 0.0.
Virginia;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 5.9;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 4.8;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 6.3.
Washington;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 11.1;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 5.2;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 3.4.
West Virginia;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 3.6;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 7.1.
Wisconsin;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 9.5;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 6.1;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 3.0.
Wyoming;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 33.3;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 0.0;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 0.0.
Nation;
Percentage of total comparative surveys with at least one missed G-L
deficiency: 14.5;
Percentage of state surveys receiving below satisfactory ratings[A]:
General Investigation: 7.7;
Percentage of state surveys receiving below satisfactory ratings[A]:
Deficiency Determination: 9.2.
Source: GAO analysis of federal monitoring survey data.
[A] Federal observational surveys use a five-point rating scale to
evaluate state survey teams. Our analysis collapsed the ratings in the
lowest two categories--much less than satisfactory and less than
satisfactory--into a single category of below satisfactory results.
[End of table]
[End of section]
Appendix VI: Comments from the Department of Health & Human Services:
Department Of Health & Human Services:
Office of the Assistant Secretary for Legislation:
Washington, D.C. 20201:
Mr. John Dicken:
Director, Health Care:
Government Accountability Office:
441 G Street NW:
Washington, DC 20548:
Dear Mr. Dicken:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) Draft Report: "Nursing Homes: Federal
Monitoring Surveys Demonstrate Continued Understatement of Serious Care
Problems and CMS Oversight Weaknesses" (GAO-08-517).
The Department appreciates the opportunity to review and comment on
this report before its publication.
Sincerely,
Signed by:
Jennifer P. Lnoury:
for:
Vincent J. Vehtimiglia, Jr.:
Assistant Secretary for Legislation:
Attachment:
General Comments Of The Department Of Health And Human Services (HHS)
On The U.S. Government Accountability Office's (GAO) Draft Report
Entitled: Nursing Homes: Federal Monitoring Surveys Demonstrate
Continued Understatement Of Serious Care Problems And CMS Oversight
Weaknesses (GAO 08-517):
The report was prepared at the request of the Special Committee on
Aging and the Committee on Finance. The GAO evaluated the Centers for
Medicare and Medicaid (CMS) oversight of States and potential
understatement of deficiencies by States as States survey the nation's
nursing homes.
We fully endorse and will implement all of the GAO recommendations. The
GAO recommendations are consistent with the direction that CMS is
taking. In the following remarks, we convey CMS' strategic approach for
targeting scarce taxpayer dollars to areas in the Medicare and Medicaid
quality assurance system that will yield the greatest benefit. We then
discuss the GAO recommendations and the manner in which they relate to
CMS activities. A strategic approach to quality requires that we
establish clear priorities for action and then seek those leverage
points by which we can achieve the greatest possible quality assurance
results and protections for nursing home residents.
Leverage Point #1: Fixing "Missed" Surveys (A Key to Reducing "Missed"
Deficiencies):
Figure 1: Missed Surveys as Percent of Total Required Surveys 2000-
2007:
This figure appears in the Department of Health and Human Services
comment letter to the Government Accountability regarding GAO-08-517.
The X axis represents the fiscal year, and the Y axis represents the
percentage.
FY 2000: 4.1%;
FY 2001: 3.0%;
FY 2002: 3.0%;
FY 2003: 0.9%;
FY 2004: 0.6%;
FY 2005: 0.2%;
FY 2006: 0.1%;
FY 2007: 0.4%.
[See PDF for image]
Source: Department of Health
[End of figure]
While the GAO report focuses on deficiencies that States may have
missed when they conduct surveys, we placed an even higher priority on
remedial action to prevent entire surveys from being missed. The Social
Security Act, for example, requires that every nursing home be surveyed
at least every I5 months. Yet this did not always occur. As a result of
redoubled attention from CMS and States, the number and percent of
surveys missed by States has decreased substantially (portrayed in
Figure 1), despite well-known limitations in the Medicare survey and
certification budget. In the process CMS strengthened the State
Performance Standards System and introduced fiscal consequences when
State performance did not fully meet standards. States responded by
reducing missed surveys from 4.I percent in fiscal year (FY) 2000 to
0.4 percent in 2007. When an entire survey is missed, all deficiencies
are missed (not just those that State surveyors may have missed
compared to Federal surveyors). Reducing the extent to which surveys
were missed entirely has considerably reduced the overall number of
missed deficiencies. CMS, therefore, continues to make the elimination
of missed surveys one of its top priorities, a key strategy for
improving overall oversight of nursing home quality within the
resources appropriated to the Medicare and Medicaid survey and
certification budget.
Leverage Point #2: Improving Surveyor Knowledge and Understanding:
Another high priority for CMS is ensuring that both State and Federal
surveyors possess optimum understanding of both the care processes
being surveyed and the Federal quality of care and safety requirements.
CMS therefore placed a priority on surveyor training and clarifying
interpretive guidance to all surveyors (both State and Federal). Figure
2 lists the topic areas for which improved guidance was recently
issued. Such guidance was accompanied by additional training.
Figure 2 – New Guidance to Surveyors to Improve Accuracy Citation:
This figure appears in the Department of Health and Human Services
comment letter to the Government Accountability regarding GAO-08-517.
Citation "F-Tags": 314;
Topic: Pressure Ulcers;
Implementation data: November 14, 2004.
Citation "F-Tags": 315;
Topic: Incontinence;
Implementation data: June 27, 2005.
Citation "F-Tags": 501;
Topic: Medical Director;
Implementation data: November 18, 2005.
Citation "F-Tags": 520;
Topic: Quality Assurance;
Implementation data: June 1, 2006.
Citation "F-Tags": 248/249;
Topic: Activities;
Implementation data: June 1, 2006.
Citation "F-Tags": [Empty];
Topic: Psychological Severity Guidance;
Implementation data: June 8, 2006.
Citation "F-Tags": 329, 425, 428, & 431;
Topic: Unnecessary Drugs & Pharmacy Services;
Implementation data: December 18, 2006.
Citation "F-Tags": 323;
Topic: Accidents & Supervision;
Implementation data: July 6, 2007.
[See PDF for image]
Source: Department of Health and Human Services.
[End of figure]
The goal of the guidance update initiative has been to improve accuracy
and consistency, as well as keep pace with advances in the field.
However, where understatement of deficiencies previously prevailed, an
important by- product of the guidance update initiative has been to
remedy understatement (or under-identification) of deficiencies. This
is particularly important because understatement that arises from a
lack of understanding or confusion about federal requirements would
generally not be detected through the validation survey process that is
the subject of the GAO report. The GAO report focuses on discrepancies
that CMS detects by comparing the results of a sample of State surveys
with results from federal surveys of the same facilities. If CMS
requirements are unclear, then both Federal and State surveyors would
be affected by the same limitation and a discrepancy between State and
Federal surveys would be less likely to become manifest. Even more
importantly, providers would be unclear.
One example of the impact that the guidance update initiative has had
in curing under-identification of deficiencies can be seen in the rate
at which the use of unnecessary drugs has been identified. Figure 3 (on
the following page) shows the change in citations of unnecessary drug
use in nursing homes after CMS issued better guidance and training in
late 2006. Between 2000 and 2006, the percent of surveys in which the
use of unnecessary drugs was identified consistently ranged between 13
percent and 14 percent. After the new guidance, the rate increased to
18 percent, reflecting surveyors' improved understanding of medication
issues.
Leverage Point #3: Quality Indicator Survey:
Figure 3: Percent of Surveys Citing Unnecessary Drug Use:
This figure appears in the Department of Health and Human Services
comment letter to the Government Accountability regarding GAO-08-517.
The X axis represents the calendar year, and the Y axis represents the
percent of surveys.
Calendar Year: 2000;
Percent of Surveys: 13%.
Calendar Year: 2001;
Percent of Surveys: 14%.
Calendar Year: 2002;
Percent of Surveys: 14%.
Calendar Year: 2003;
Percent of Surveys: 13%.
Calendar Year: 2004;
Percent of Surveys: 13%.
Calendar Year: 2005;
Percent of Surveys: 13%.
Calendar Year: 2006;
Percent of Surveys: 13%.
Calendar Year: 2007;
Percent of Surveys: 18%.
[See PDF for Image]
Source: Department of Health and Human Services.
[End of figure]
The Quality Indicator Survey (QIS) holds considerable promise for (a)
improving CMS' validation capability, as well as (b) providing State
Agency directors and supervisors with more tools to do their own
validation analyses. As such, we believe it merits discussion in the
context of our overall strategy for improving oversight. 19%
The QIS is a new two–stage survey process used by surveyors to
systematically review specific nursing home requirements and
objectively investigate any regulatory areas that are triggered. The
QIS uses customized software (Data Collection Tool-DCT) on tablet
personal computers to guide surveyors through a structured
investigation.
The QIS is currently being implemented statewide in eight States.
Further expansion will be dependent on the level of funding in the
overall Medicare and Calendar Year Medicaid survey and certification
budget in FYs 2009-2014.
The QIS is not likely to increase the accuracy of deficiency
identification, since accuracy may be more a function of training and
CMS interpretive guidance. But we do expect that the QIS will have
significant advantages directly pertinent to the quality control issues
raised in the GAO report, such as the following:
1. Consistency: We expect the QIS to increase the consistency of survey
process both between States and within States;
2. Tools for State Quality Control: We expect the QIS will provide
better information and tools for State survey teams and supervisors to
analyze findings and provide feedback to survey teams themselves.
Information collected during the QIS supports an offsite monitoring
process, which helps to ensure that State surveyors are complying with
the QIS process. It also identifies areas of concern with regard to
consistency and accuracy of survey performance.
3. Tools for CMS Quality Control: We expect the QIS will provide better
information and tools for CMS ROs to analyze findings and provide
feedback to States. QIS information available to the RO provides
comparison information at four levels - national, regional, State, and
district within a State. Such information will assist the ROs to
conduct quality improvement activities with the SAs in their region.
Communications will occur between the RO and key SA staff using a
process developed by the University of Colorado to help the SA
understand and correct sources of inconsistency identified in a QIS.
Certain standardized output reports assist both the State and the RO to
identify areas in which quality improvement is needed. The "Desk Audit
Reports" will also assist CMS to identify States and/or particular
survey teams that need more specific training, technical assistance or
oversight in order to improve accuracy of the surveys.
The same reports provided to the RO will be summarized and provided to
the Central Office (CO). Review of this information at the CO creates
the opportunity to evaluate the program for Federal monitoring at a
macro or national level. We envision the CO utilizing this information
to promote discussion with the RO regarding oversight of States. Use of
the reports will focus on RO oversight, including the opportunity to
discuss specific concerns that may be present at a State level.
Leverage Point #4: Improving CMS Validation Surveys as a Quality
Control System:
CMS ROs maintain a quality oversight system for surveys conducted by
State surveyors. The essence of this validation system is a 5 percent
sample of State surveys in which the ROs either (a) accompany State
surveyors in which CMS staff observe both the surveyors and conditions
in the nursing home (so- called "follow-along" or "Federal
Oversight/Support Survey (FOSS)" surveys); or (b) conduct an
independent survey of the nursing home within 60 days after the State
survey (so-called "comparative" surveys). The ROs then compare the
results and enter the information into CMS databases, noting any
discrepancies in the findings between State and Federal survey teams.
CMS ROs then follow-up with the States to address any deficiencies. The
GAO report focuses entirely on this particular area using data that CMS
maintains as part of its internal quality control system. CMS has been
entirely successful in ensuring that 100 percent of required validation
surveys are performed each year. This enables greater attention to be
placed on improving the methodologies and use of the data. The GAO
recommendations fit well with such a goal.
GAO Recommendations:
1. Require regional offices to determine if there was an understatement
when States cite a deficiency at a lower scope and severity level than
Federal surveyors, and to track this information.
2. Establish quality controls to improve the accuracy and reliability
of information entered into the Federal monitoring survey database.
3. Routinely examine comparative survey data and hold ROs accountable
for implementing CMS guidance that is intended to ensure comparative
surveys more accurately capture the conditions at the time of the State
survey.
4. Regularly analyze and compare Federal comparative and observational
survey results.
HHS Responses:
Recommendation #1 suggests that the Federal Monitoring Survey (FMS)
database contain an explicit field for registering understatement of a
deficiency. The current CMS database provides methods for CMS ROs to
register where there are missed deficiencies. Yet the database does not
have a specific field in which the RO can render a judgment to identify
clearly those areas in which both the State and Federal teams
identified the same deficiency, but cited it at a significantly
different scope or severity level. We agree with the GAO recommendation
and have planned for the future development of such capability as an
action item in our 2008 Nursing Home Action Plan. The 2008 Action Plan
can be found at: [hyperlink,
http://www.cros.hhs.v/CertificationandComilianc/Downloads/2008NHActionPl
an.pdf]
Recommendation #2 accurately reflects the fact that there have been
problems in the FMS database that CMS maintains. CMS identified these
problems a few years ago and took action in 2007 to move the FMS
database and vendor contract to the CMS Survey & Certification Group in
order to (a) bring it closer to the end users of the data and (b)
facilitate integration of the data into the State Performance Standards
System. Data entry and accuracy issues always become more prominent,
and more likely to be remedied, the closer the data are to regular use
in management of a program. Such remedial actions are well underway.
Figure 4 lists various steps for improving the FMS database. Attachment
I provides additional information and timetables.
Figure 4: Steps to Improve the Federal Monitoring System Database:
This figure appears in the Department of Health and Human Services
comment letter to the Government Accountability regarding GAO-08-517.
January to June 2007;
Move the database close to end users and procure a new contractor to
maintain & update the database. (Completed)
Sept. 2007;
Implement monthly teleconference calls with the contractor, CMS CO, and
RO staffs. The purpose of the teleconference calls is to answer
questions, accept suggestions for improving the database, and
communicate updates. (Completed and held every month since Sept 2007).
Nov. 2007;
Overcome glitches in the transition from operating components in CO,
provide assistance in downloading data from ROs, including written
instructions. (Completed)
Dec. 2007- June 2008;
Institute CO monitoring of the database on a quarterly basis to assure
that ROs are June 2008 downloading data quarterly.
Jan. 2008 – Nov. 2009;
Modify the database to develop data fields that will document and track
discrepancies between RO and State Survey Agency (SA) scope and
severity for every deficiency cited. Strengthen the database to improve
the accuracy and reliability of the data entered.
Feb. 2008 – Jan. 2009;
Modify the database to develop data fields that will document and track
discrepancies between RO and State Survey Agency (SA) scope and
severity for every deficiency cited. Strengthen the database to improve
the accuracy and reliability of the data entered.
Feb. 2008 – Nov. 2008;
Issue a FOSS Database User's Manual. (Now in draft form).
Nov. 2008 – May 2009;
Develop new analytic reports to provide RO and CO an analysis of the
differences between comparative and observational survey results.
Source: Department of Health and Human Services.
[End of table]
Recommendation #3 suggests that CMS CO routinely examine comparative
survey data and hold regional offices accountable for implementing CMS
guidance. We intend to develop additional output reports that will be
useful to both CO and RO in analyzing State performance. Processes to
ensure that CMS validation surveys are conducted in conformance with
CMS guidance are the subject of current CMS discussion and will be
finalized later in 2008.
Recommendation #4 indicates the need for (a) regular analysis of the
FMS data and (b) regular comparison between results from the two
validation processes (comparative and observational). Additional output
reports from the FMS database will assist in this effort. We will then
identify further methods by which the analyses may be put to effective
use. For example, the GAO report noted that available data could be
better utilized to identify areas in which particular CMS ROs merit
additional attention. This is an observation that will be an important
focus for CMS' 2009 Nursing Home Action Plan.
One aspect of quality control that we have not solved, and that the GAO
report does not resolve, is the setting of appropriate thresholds for
missed deficiencies. No system involving multiple parties will yield
the identical result every time. An entire field of statistics is
devoted to issues of inter-rater agreement. In the present case, the
challenge is to identify the level of "missed deficiencies" that goes
beyond statistical chance and beyond issues of inter-rater agreement to
reveal a level of discrepancy that ought to give concern and demand
response from CMS. GAO adopted a measure of "one missed deficiency per
survey," and then counted the percentage of a State's surveys for which
Federal surveyors identified one or more deficiencies that the State
missed. It is not clear that "one missed deficiency per survey" is the
proper standard, nor is it clear what percentage of a State's surveys
ought to trigger assertive response even when the "one missed
deficiency per survey" standard is used. In this sense, the GAO
analysis is helpful but not conclusive. We will need to devote more
thought to these matters so that we can make more effective use of the
approach in the State Performance Standards System .
Regardless of the particular thresholds chosen, we do agree with GAO
that effective follow-up with States must be assured when it is clear
the State surveys exhibit a high level of discrepancy in survey
findings compared to the Federal validation surveys. For example, GAO
identified nine States in which more than 25 percent of the surveys
indicated a missed deficiency at a very serious (G-L) level. We note
that assertive follow-up actions have been made by CMS ROs or are
occurring in most of these States. In Alabama, for example, the CMS RO
issued a very pointed series of evidence-based performance
communications in 2007 and raised performance issues to the top agency
levels. CMS CO made a $90,421 deduction in Alabama's Medicare budget in
2008 due to 2007 performance issues. We are pleased to report that the
State of Alabama is in the process of effectively responding to these
problems in 2008. The State has recruited additional survey staff and
made important organizational changes. FMS validation surveys indicate
that the Alabama State surveyors have not missed any serious deficiency
determinations so far in 2008.
Similarly, in Tennessee a new survey agency director was enlisted in
October 2007, the State retrained all staff (utilizing CMS RO staff to
assist in training for investigative skills and deficiency
determinations). Based on two comparative FMS surveys so far in 2008,
the State surveyors have not missed any serious deficiency findings.
The GAO report noted that available data could be better utilized to
identify areas in which particular CMS ROs merit additional attention.
This is an observation that is an important focus of action for CMS'
2009 Nursing Home Action Plan.
Due to the well-known limitations in the Medicare survey and
certification budget, it has been particularly important that CMS
target its resources effectively and apply its knowledge of system
leverage points to gain maximum results from scarce resources. We hope
that our explanation of the four leverage points outlined in our
response is useful in placing CMS actions in context. We appreciate the
opportunity to respond to the GAO draft report.
Attachment 1:
CMS Action Plan: GAO-08-517: Nursing Homes: Federal Monitoring Surveys
Demonstrate Continued Understatement of Serious Care Problems and CMS
Oversight Weaknesses:
GAO Recommendation: A. Regional Office Oversight: Require ROS to
determine if there was an understatement when state surveyors cite a
deficiency at a lower scope and severity level than Federal Surveyors
and track this information;
CMS Action: A1: FMS Database Users' Manual - As stated in our 2008
Nursing Home Action Plan, CMS will issue instruction to the ROs that
defines all data fields and includes procedures for entering all data
into the FMS database. This document currently exists in draft form and
will be finalized for release by November 30, 2008.
GAO Recommendation: A. Regional Office Oversight: Require ROS to
determine if there was an understatement when state surveyors cite a
deficiency at a lower scope and severity level than Federal Surveyors
and track this information;
CMS Action: A2: FMS Database - We will modify the FMS Database to allow
tracking the variance between RO and State findings at the scope and
severity level. The RO will be able to enter their findings, and
production reporting capability will be developed to allow easy
analysis of these data by November 30, 2009.
GAO Recommendation: A. Regional Office Oversight: Require ROS to
determine if there was an understatement when state surveyors cite a
deficiency at a lower scope and severity level than Federal Surveyors
and track this information;
CMS Action: A3: Communication between ROs and Central Office (CO) via
Regular Teleconference Calls ” We have implemented a system of regular
conference calls between CO, a core group from the ROs, and the
database contractor to answer questions, discuss best practices,
suggest and communicate database improvements, set expectations, and
provide updates.
GAO Recommendation: B. Quality Controls: Establishing quality controls
to improve the accuracy and reliability of information entered into the
Federal monitoring survey database;
CMS Action: B1: Strengthening the database ” We will modify the
database to incorporate additional edits (e.g., assuring that the
correct data is entered in the appropriate data field before the
surveyor can move onto the next data field).
GAO Recommendation: B. Quality Controls: Establishing quality controls
to improve the accuracy and reliability of information entered into the
Federal monitoring survey database;
CMS Action: B2: RO Reporting ” We will implement Quality Assurance
reports by November 30, 2009 for use by the ROs. The reports will
describe the results of their review of the accuracy and reliability of
the data entered into the database. These reports will be sent to CO
quarterly for assessment. We will routinely monitor the database to
assure ROs are downloading data.
GAO Recommendation: C. Analysis & Follow- Routinely examine comparative
survey data and hold regional offices accountable for implementing CMS
guidance;
CMS Action: C1: Develop RO Start Date Reports ” We will develop a
report that will show the number of work days between the SA's
comparative end date and the RO's start date. CMS will generate these
reports quarterly for assessment. We will operationalize these reports
no later than November 30, 2008.
GAO Recommendation: C. Analysis & Follow- Routinely examine comparative
survey data and hold regional offices accountable for implementing CMS
guidance;
CMS Action: C2: RO Feedback Mechanism ” We will implement by November
30, 2009 a feedback system based on RO reporting and CO analysis of
comparative survey results. One component of this feedback system will
be a standing agenda item on internal management meetings at least once
a quarter.
GAO Recommendation: D. Compare Comparative & FOSS Data: Regularly
analyze and compare Federal comparative and observational survey
results;
CMS Action: Dl: RO Reporting ” We will implement a system of QA reports
for the ROs describing the results of their review of the accuracy and
reliability of the data entered into the database. These reports will
he sent to CO quarterly for assessment and begin no later than November
30, 2009.
[End of section]
Appendix VII: GAO Contact and Staff Acknowledgments:
GAO Contact:
John E. Dicken, (202) 512-7114 or dickenj@gao.gov:
Acknowledgments:
In addition to the contact named above, Walter Ochinko, Assistant
Director; Katherine Nicole Laubacher; Dan Lee; Elizabeth T. Morrison;
Steve Robblee; Karin Wallestad; and Rachael Wojnowicz made key
contributions to this report.
[End of section]
Related GAO Products:
Nursing Home Reform: Continued Attention Is Needed to Improve Quality
of Care in Small but Significant Share of Homes. GAO-07-794T.
Washington, D.C.: May 2, 2007.
Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not
Deterred Some Homes from Repeatedly Harming Residents. GAO-07-241.
Washington, D.C.: March 26, 2007.
Nursing Homes: Despite Increased Oversight, Challenges Remain in
Ensuring High-Quality Care and Resident Safety. GAO-06-117. Washington,
D.C.: December 28, 2005.
Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses in
State and Federal Oversight of Quality of Care. GAO-05-78. Washington,
D.C.: November 12, 2004.
Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal
Standards and Oversight. GAO-04-660. Washington D.C.: July 16, 2004.
Nursing Home Quality: Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight. GAO-03-561. Washington,
D.C.: July 15, 2003.
Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
National Implementation Is Premature. GAO-03-187. Washington, D.C.:
October 31, 2002.
Nursing Homes: Quality of Care More Related to Staffing than Spending.
GAO-02-431R. Washington, D.C.: June 13, 2002.
Nursing Homes: More Can Be Done to Protect Residents from Abuse. GAO-
02-312. Washington, D.C.: March 1, 2002.
Nursing Homes: Federal Efforts to Monitor Resident Assessment Data
Should Complement State Activities. GAO-02-279. Washington, D.C.:
February 15, 2002.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: September
28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: November 4,
1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington,
D.C.: August 13, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes
Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March 18,
1999.
California Nursing Homes: Care Problems Persist Despite Federal and
State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998.
[End of section]
Footnotes:
[1] See GAO, California Nursing Homes: Care Problems Persist Despite
Federal and State Oversight, GAO/HEHS-98-202 (Washington, D.C.: July
27, 1998); Nursing Home Care: Enhanced HCFA Oversight of State Programs
Would Better Ensure Quality, GAO/HEHS-00-06 (Washington, D.C.: Nov. 4,
1999); and Nursing Home Quality: Prevalence of Serious Problems, While
Declining, Reinforces Importance of Enhanced Oversight, GAO-03-561
(Washington, D.C.: July 15, 2003). A list of related GAO products is at
the end of this report.
[2] All homes that participate in the Medicare and Medicaid programs
are subject to periodic surveys to ensure that they are in compliance
with federal quality standards. CMS contracts with state survey
agencies to conduct the surveys. Medicare, the federal health care
program for elderly and disabled individuals, covers up to 100 days of
skilled nursing home care following a hospital stay. Medicaid, the
joint federal-state health care financing program for certain
categories of low-income individuals, pays for the nursing home care of
qualifying individuals who can no longer live at home. Combined
Medicare and Medicaid payments for nursing home services were about $75
billion in 2006, including a federal share of about $51 billion.
[3] See GAO, Despite Increased Oversight, Challenges Remain in Ensuring
High-Quality Care and Resident Safety, GAO-06-117 (Washington, D.C.:
Dec. 28, 2005); and Nursing Home Reform: Continued Attention Is Needed
to Improve Quality of Care in Small but Significant Share of Homes, GAO-
07-794T (Washington, D.C.: May 2, 2007). In both reports, we examined
understatement for five states--California, Florida, New York, Ohio,
and Texas. Results from the May 2007 report showed that understatement
of serious deficiencies varied across these states from a low of 4
percent in Ohio to a high of 26 percent in New York during the 5-year
period March 2002 through March 2007.
[4] Fiscal year 2002 was the first year that the database contained all
the information needed to assess the results of federal comparative
surveys.
[5] In addition to nursing homes, CMS and state survey agencies are
responsible for oversight of other Medicare and Medicaid providers,
such as home health agencies, intermediate care facilities for the
mentally retarded, and hospitals.
[6] Several GAO reports have documented understatement of serious
deficiencies by state surveyors. For one report, in 1998, we arranged
for a team of registered nurses to accompany state surveyors and
conduct concurrent surveys designed specifically to identify quality-
of-care problems. The survey methodology we used differed from the
methodology used by state surveyors in that it was more rigorous and
reviewed a larger sample of cases. Using this methodology, our surveys
spotted cases in which the homes had not intervened appropriately for
residents experiencing weight loss, dehydration, pressure sores, and
incontinence--cases the state surveyors either missed or identified as
affecting fewer residents. (See GAO/HEHS-98-202.) In addition, we have
documented considerable interstate variation in the proportion of homes
cited for serious care problems. For example, 8 percent of Florida's
683 homes and 38 percent of Connecticut's 244 homes were cited for
serious care problems in fiscal year 2007. The extent of this variation
suggests inconsistency in how states conduct surveys and understatement
of serious quality problems. App. I shows the proportion of homes in
each state cited by state surveyors for serious deficiencies from
fiscal year 2002 through 2007.
[7] Other areas include Admission, Transfer and Discharge Rights;
Resident Behavior and Facility Practices; Nursing Services; Dietary
Services; Physician Services; Specialized Rehabilitative Services;
Dental Services; Infection Control; and Physical Environment. Surveys
also examine compliance with federal fire safety requirements.
[8] The scope and severity of a deficiency is one of four factors that
CMS takes into account when imposing sanctions. CMS also considers a
home's prior compliance history, desired corrective action and long-
term compliance, and the number and severity of all the home's
deficiencies.
[9] See GAO, Nursing Homes: Efforts to Strengthen Federal Enforcement
Have Not Deterred Some Homes from Repeatedly Harming Residents, GAO-07-
241 (Washington, D.C.: Mar. 26, 2007).
[10] A revisit is required for F level deficiencies that are cited in
one of three areas: Quality of Care, which can include deficiencies
such as inadequate treatment or prevention of pressure sores; Quality
of Life, which can include deficiencies such as a failure to
accommodate the needs and preferences of residents; and Resident
Behavior and Facility Practices, which can include deficiencies such as
a failure to protect residents from abuse.
[11] In addition, CMS also conducts annual state performance reviews,
which include an examination of the quality of state survey agency
investigations and decision making and the timeliness and quality of
complaint investigations.
[12] Throughout this report, when we refer to CMS headquarters or CMS
headquarters officials, we mean the Survey and Certification Group and
its officials.
[13] See GAO/HEHS-00-6.
[14] In December 2001, CMS requested that regional offices conduct
comparative surveys between 2 weeks and 1 month after the state survey.
In October 2002, CMS relaxed this standard by changing the requirement
to between 10 and 30 working days. In general, it is easier for federal
surveyors to determine whether state surveyors should have identified
deficiencies when conditions during the comparative survey are as close
as possible to those existing during the state survey. Reducing the
time between state and federal surveys and requiring a review of the
quality of care provided to as many of the same nursing home residents
as possible enhances the similarities between state and federal
surveys.
[15] In 1999, we reported that there was little consistency across CMS
regional offices in the criteria used to select homes for comparative
surveys. For example, some regions were selecting homes that had no
serious deficiencies, while others were focusing on homes with serious
deficiencies. We noted that federal surveyors were less likely to find
missed deficiencies at homes where state surveyors found serious care
problems. See GAO/HEHS-00-6.
[16] See GAO-03-561.
[17] We examined missed deficiencies by state for each fiscal year from
2002 through 2007 and found that for most states the failure to cite
deficiencies at the actual harm and immediate jeopardy levels was not
isolated to a single year during the 6 fiscal years we examined, and it
continued to be a problem for many states in fiscal year 2007.
[18] Alaska, Idaho, Maine, North Dakota, Oregon, Vermont, and West
Virginia had no missed serious deficiencies.
[19] This finding was consistent with the overall prevalence of D
through F level deficiencies cited by state survey teams during annual
standard surveys. Approximately 84 percent of all deficiencies
identified during these surveys in 2006 were at the D through F level.
In contrast, only about 5 percent of deficiencies cited on state
surveys were at the actual harm and immediate jeopardy (G through L)
levels.
[20] Examples of deficiencies related to Resident Behavior and Facility
Practices include resident abuse and the misuse of restraints.
[21] In addition, 31.7 percent of total comparative surveys found at
least one missed potential for more than minimal harm level deficiency
in the Resident Assessment category. An example of a deficiency related
to Resident Assessment is the failure to develop a comprehensive care
plan that meets a resident's physical, mental, and psychosocial needs.
[22] Federal observational surveys use a five-point rating scale to
evaluate state survey teams. Our analysis collapsed the ratings in the
lowest two categories--much less than satisfactory and less than
satisfactory--into a single category of below satisfactory results.
[23] An additional seven states had mixed performance on these two
measures--performing above the national average for one measure and
below the national average for the other.
[24] Later in this report, we observe that no Wyoming and South Dakota
survey teams received below satisfactory ratings on observational
surveys.
[25] See GAO-03-561 and GAO-07-794T. In response to our recommendation
to finalize the development, testing, and implementation of a more
rigorous survey methodology, CMS developed and is currently evaluating
a revised survey methodology.
[26] See GAO-06-117.
[27] See GAO-03-561. Our analysis of survey predictability considered
surveys to be predictable if (1) homes were surveyed within 15 days of
the 1-year anniversary of the prior survey or (2) homes were surveyed
within 1 month of the maximum 15-month interval between standard
surveys. We used this rationale because homes know the maximum
allowable interval between surveys, and those whose prior surveys were
conducted 14 or 15 months earlier are aware that they are likely to be
surveyed soon.
[28] See GAO-03-561.
[29] See GAO-03-561.
[30] On a comparative survey, CMS does not evaluate the adequacy of
state survey team staffing.
[31] Surveyor-days are calculated as the total number of days on-site
times the number of surveyors who worked full-time on that nursing home
survey. If three surveyors were on-site and the survey took 3 days,
then the survey would have used 9 surveyor-days.
[32] Because the establishment of the dispute resolution process for
comparative surveys is relatively recent, we did not assess how often
states challenge comparative findings.
[33] Five of the 10 CMS regions made determinations on multiple
occasions about whether the state "should have cited" a deficiency,
even though the only discrepancy was the scope and severity level.
[34] We did not examine the 388 instances where federal survey teams
cited potential for more than minimal harm deficiencies and state
survey teams cited the same deficiencies at a lower scope and severity
level.
[35] Overall, federal surveyors identified understated scope and
severity levels on 2.4 percent of state surveys during fiscal years
2002 through 2007. The 1 percent average increase in the total
percentage of comparative surveys is lower because comparative surveys
with both types of understatement--failing to cite a deficiency or
citing a deficiency at too low a scope and severity level--were counted
only once.
[36] CMS became aware in October 2007 that some regional offices were
using the validation question designed to identify missed deficiencies
when our preliminary analysis identified missing data in several
regions.
[37] Officials from CMS's Survey and Certification Group--the component
responsible for ensuring the effectiveness of state survey activities-
-assumed control of the database in January 2007 from CMS's Division of
National Systems. While officials from the Survey and Certification
Group are still familiarizing themselves with the database, they stated
that this change in control was necessary to move it closer to the
component responsible for managing the federal monitoring survey
program.
[38] Subsequently, CMS informed us that all comparative surveys from
the two regions were now accessible in the database.
[39] CMS indicated that the results of contractor-led comparative
health surveys--which began in fiscal year 2004--are not included in
the federal monitoring survey database because those surveys are in
addition to the federal monitoring surveys required by statute and that
inclusion of the contractor-led data would hinder CMS's ability to
collect and analyze data about CMS staff resources that are devoted to
comparative surveys.
[40] However, CMS officials told us that they have been unable to
identify whether region-to-region differences were the result of
inconsistencies in state survey agency performance or regional
variation among nursing homes.
[41] Comparative and observational surveys each measure some of the
same skills required for effective surveying, particularly state survey
team general investigative techniques and ability to accurately
identify deficiencies.
[42] See GAO-03-561 and GAO-06-117.
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