Nursing Homes
Some Improvement Seen in Understatement of Serious Deficiencies, but Implications for the Longer-Term Trend Are Unclear Gao ID: GAO-10-434R April 28, 2010Federal and state governments share responsibility for ensuring that nursing homes provide quality care in a safe environment for vulnerable elderly or disabled individuals who can no longer care for themselves. States survey nursing homes annually under contract with the Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for ensuring the effectiveness of state surveys. To evaluate state surveyors' performance, CMS conducts federal comparative surveys in which federal surveyors independently resurvey a home recently inspected by state surveyors and compare and contrast the deficiencies identified during the two surveys. Federal comparative surveys can find two types of understatement: (1) missed deficiencies, which can occur when a state surveyor fails to cite a deficiency altogether, or (2) cases where state surveyors cite deficiencies at too low a level. In May 2008, we reported that a substantial proportion of federal comparative surveys conducted from fiscal years 2002 through 2007 identified missed deficiencies that either had the potential to or did result in harm, death, or serious injury to nursing home residents.
We found that 12.3 percent of fiscal year 2008 comparative surveys identified at least one missed serious deficiency, compared to 14.7 percent in fiscal year 2007. Because the percentage of comparative surveys identifying at least one missed serious deficiency has fluctuated from as low as 11.1 percent to as high as 17.5 percent since fiscal year 2002, the longer-term trend is unclear. Overall, the number of states with missed serious deficiencies on 25 percent or more of their comparative surveys declined from nine to six states, with eight of those states improving their overall performance. As we reported in 2008, understatement can also occur when state survey teams cite some serious deficiencies at too low a level, and we found that the extent of such understatement in fiscal year 2008 was consistent with prior fiscal years. Although, combining such understatement with missed serious deficiencies increased overall understatement nationwide by about 1 percentage point for the entire period, total understatement for fiscal year 2008 declined to 14.1 percent from the 16.5 percent observed in fiscal year 2007. Finally, we found that missed deficiencies at lower-levels continued to remain more widespread than serious missed deficiencies on fiscal year 2008 comparative surveys, increasing slightly from 73.5 percent of comparative surveys with at least one lower-level missed deficiency in fiscal year 2007 to 74.8 percent in fiscal year 2008. Over the period fiscal years 2002 through 2008, the level of missed deficiencies at lower-levels remained steady with about 70 percent of federal comparative surveys identifying at least one such lower-level missed deficiency.
GAO-10-434R, Nursing Homes: Some Improvement Seen in Understatement of Serious Deficiencies, but Implications for the Longer-Term Trend Are Unclear
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GAO-10-434R:
April 28, 2010:
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:
Subject: Nursing Homes: Some Improvement Seen in Understatement of
Serious Deficiencies, but Implications for the Longer-Term Trend Are
Unclear:
Federal and state governments share responsibility for ensuring that
nursing homes provide quality care in a safe environment for
vulnerable elderly or disabled individuals who can no longer care for
themselves. States survey nursing homes annually under contract with
the Centers for Medicare & Medicaid Services (CMS), the federal agency
responsible for ensuring the effectiveness of state surveys.[Footnote
1] To evaluate state surveyors' performance, CMS conducts federal
comparative surveys in which federal surveyors independently resurvey
a home recently inspected by state surveyors and compare and contrast
the deficiencies identified during the two surveys. Federal
comparative surveys can find two types of understatement: (1) missed
deficiencies, which can occur when a state surveyor fails to cite a
deficiency altogether, or (2) cases where state surveyors cite
deficiencies at too low a level. In May 2008, we reported that a
substantial proportion of federal comparative surveys conducted from
fiscal years 2002 through 2007 identified missed deficiencies that
either had the potential to or did result in harm, death, or serious
injury to nursing home residents.[Footnote 2] You asked us to update
our May 2008 report on the extent of nursing home understatement.
Specifically, we analyzed the results of the most recent data
available on federal comparative surveys conducted during fiscal year
2008 and updated the data included in our May 2008 report to reflect
this additional information.
To update our analysis of comparative surveys conducted nationwide
from fiscal years 2002 through 2007, we incorporated the results of
163 fiscal year 2008 comparative surveys.[Footnote 3] From fiscal
years 2002 through 2008, federal surveyors conducted 1,139 comparative
surveys.[Footnote 4] CMS maintains the results of these comparative
surveys in the federal monitoring survey database.[Footnote 5] As a
part of our prior work, we completed a number of reliability checks to
ensure that the federal monitoring survey data was sufficiently
reliable for our work, including interviewing representatives of all
10 CMS regional offices. For this update, we repeated a number of
these reliability checks on fiscal year 2008 data to ensure it was
sufficiently reliable for our work. Federal comparative survey data
cannot be projected to all state surveys either within a state or
across the nation because state surveys are not randomly selected for
federal monitoring and therefore are not representative of state
surveys.
We conducted this performance audit from January 2010 through April
2010 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
In summary, we found that 12.3 percent of fiscal year 2008 comparative
surveys identified at least one missed serious deficiency, compared to
14.7 percent in fiscal year 2007. Because the percentage of
comparative surveys identifying at least one missed serious deficiency
has fluctuated from as low as 11.1 percent to as high as 17.5 percent
since fiscal year 2002, the longer-term trend is unclear. Overall, the
number of states with missed serious deficiencies on 25 percent or
more of their comparative surveys declined from nine to six states,
with eight of those states improving their overall performance. As we
reported in 2008, understatement can also occur when state survey
teams cite some serious deficiencies at too low a level, and we found
that the extent of such understatement in fiscal year 2008 was
consistent with prior fiscal years. Although, combining such
understatement with missed serious deficiencies increased overall
understatement nationwide by about 1 percentage point for the entire
period, total understatement for fiscal year 2008 declined to 14.1
percent from the 16.5 percent observed in fiscal year 2007. Finally,
we found that missed deficiencies at lower-levels continued to remain
more widespread than serious missed deficiencies on fiscal year 2008
comparative surveys, increasing slightly from 73.5 percent of
comparative surveys with at least one lower-level missed deficiency in
fiscal year 2007 to 74.8 percent in fiscal year 2008. Over the period
fiscal years 2002 through 2008, the level of missed deficiencies at
lower-levels remained steady with about 70 percent of federal
comparative surveys identifying at least one such lower-level missed
deficiency.
Background:
Oversight of nursing homes is a shared federal-state responsibility,
with CMS defining quality standards that nursing homes must meet to
participate in the Medicare and Medicaid programs and state survey
agencies assessing whether nursing homes meet these standards through
annual standard surveys and complaint investigations.[Footnote 6]
Survey Process:
During a standard survey, state surveyors evaluate compliance with
federal quality standards, which focus on the delivery of care,
resident outcomes, and facility conditions. Based on the care provided
to a sample of residents, the survey team (1) determines whether the
care and services meet the assessed needs of the residents and (2)
measures residents' outcomes such as incidents of pressure sores,
weight loss, and accidents.
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 through 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).[Footnote 7]
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]
CMS Oversight of State Surveys:
Statutorily required federal monitoring surveys are a key CMS
oversight tool in ensuring the adequacy of state surveys.[Footnote 8]
Federal monitoring surveys are conducted annually in at least 5
percent of state-surveyed Medicare and Medicaid nursing homes in each
state. 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. Federal surveyors located in each of CMS's
10 regional offices conduct federal monitoring surveys.
For a 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, selection of residents
for the survey sample, and staffing can make analysis of differences
between the state and federal comparative surveys difficult. On the
basis of our prior recommendations, 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 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. Furthermore, federal comparative survey teams are expected
to mimic the number of staff assigned to the state survey.
As a part of comparative surveys, federal surveyors also comment on
the appropriateness of the scope and severity levels assigned by state
survey teams during standard surveys. This commentary can help track
when state surveyors cite these deficiencies at too low a level. In
response to our May 2008 recommendation, CMS added specific fields to
the federal monitoring survey database in October 2008 to address the
understatement of scope and severity and instructed regional offices
on how to collect such information.
Understatement of Serious Nursing Home Deficiencies Declined
Nationally in Fiscal Year 2008, but It Is Unclear if This Improvement
Will Be Sustained:
Understatement of serious deficiencies saw an improvement in the
yearly percentage of comparative surveys identifying at least one
missed serious deficiency in fiscal year 2008. However, it is unclear
if this improvement will be sustained because the level of
understatement has fluctuated since fiscal year 2002. In addition, we
also observed an improvement in the performance of eight of the nine
states we previously reported with 25 percent or more of their state's
comparative surveys identifying at least one missed serious deficiency
when fiscal year 2008 comparative surveys were taken into account.
Understatement as a result of state survey teams citing some
deficiencies at too low a level of scope and severity remained a
problem in fiscal year 2008, increasing the overall level of
understatement from 12.3 percent to 14.1 percent when combined with
missed serious deficiencies. Finally, the percentage of surveys with
missed deficiencies at the potential for more than minimal harm level
(D through F level) remained relatively stable in fiscal year 2008 and
more widespread on comparative surveys than missed serious
deficiencies.
Number of Comparative Surveys with Serious Missed Deficiencies
Decreased by a Small Amount in Fiscal Year 2008:
In fiscal year 2008, 12.3 percent of comparative surveys identified at
least one missed serious deficiency, compared to 14 percent or more in
the prior 3 fiscal years. It is unclear if this trend will be
sustained in later fiscal years because a similar improvement was seen
from fiscal years 2003 to 2004, when the percentage of surveys with
missed serious deficiencies declined from 17.5 percent to 11.1
percent. However in fiscal year 2005, the percentage of surveys with
at least one missed serious deficiency increased again to 14.3 percent
(see fig. 1). Despite the improvement seen in fiscal year 2008, the
national percentage of surveys with at least one missed serious
deficiency remained at an average of about 14 percent (161) of the
1,139 comparative surveys conducted from fiscal years 2002 through
2008.
Figure 1: National Percentage of Comparative Surveys Citing at Least
One Missed Deficiency at the Actual Harm or Immediate Jeopardy Level,
Fiscal Years 2002 through 2008:
[Refer to PDF for image: line graph]
Fiscal year: 2002;
Percentage: 13.8%.
Fiscal year: 2003;
Percentage: 17.5%.
Fiscal year: 2004;
Percentage: 11.1%.
Fiscal year: 2005;
Percentage: 14.3%.
Fiscal year: 2006;
Percentage: 15.3%.
Fiscal year: 2007;
Percentage: 14.7%[A];
Fiscal year: 2008;
Percentage: 12.3%.
Source: GAO analysis of federal monitoring survey data.
[A] Since our May 2008 report, CMS changed a deficiency citation on a
fiscal year 2007 comparative survey from a serious deficiency to a
lower level deficiency, reducing the nationwide percentage of
comparative surveys that identified at least one missed serious
deficiency from 15.3 percent to 14.7 percent for that fiscal year.
This report reflects this change.
[End of figure]
When we updated our earlier analysis with fiscal year 2008 data, we
found that eight of nine states that missed at least one serious
deficiency on 25 percent or more of their comparative surveys improved
their overall performance for fiscal years 2002 through 2008,
including three states where understatement dropped below 25 percent--
Alabama (23.8), New Mexico (21.4), and Tennessee (22.7). Six states
continued to have at least one serious missed deficiency on 25 percent
or more of their comparative surveys (see table 2). One of the nine
state's performance on comparative surveys for the period fiscal years
2002 through 2008 deteriorated. The percentage of comparative surveys
identifying at least one missed serious deficiency in South Dakota
increased from 33.3 percent to 35.7 percent. See enclosure I for full
state results.
Table 2: Six States with 25 Percent or More of Comparative Surveys
Identifying Missed Deficiencies at the Actual Harm or Immediate
Jeopardy Levels, Fiscal Years 2002 through 2008:
State: South Dakota;
Number of homes, in fiscal year 2008: 108;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 5;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 5;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 33.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 35.7.
State: South Carolina;
Number of homes, in fiscal year 2008: 160;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 6;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 19;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 33.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 28.6.
State: Missouri;
Number of homes, in fiscal year 2008: 497;
Total comparative surveys, fiscal years 2002-2008: 32;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 9;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 15;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 28.6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 28.1.
State: Wyoming;
Number of homes, in fiscal year 2008: 37;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 4;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 5;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 33.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 26.7.
State: Arizona;
Number of homes, in fiscal year 2008: 132;
Total comparative surveys, fiscal years 2002-2008: 16;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 4;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 26.7;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 25.0.
State: Oklahoma;
Number of homes, in fiscal year 2008: 293;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 6;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 11;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 30.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 25.0.
Source: GAO analysis of federal monitoring survey data.
[End of table]
Federal Comparative Surveys Continued to Identify Serious Deficiencies
Cited at Too Low a Scope and Severity Level in Fiscal Year 2008:
Our analysis demonstrated that the amount of additional understatement
attributed to state surveyors citing deficiencies at too low a scope
and severity level remained about the same in fiscal year 2008 as in
prior fiscal years. In fiscal year 2008, federal survey teams
determined that states' scope and severity citations were too low for
5 deficiencies, increasing the total number of such understated
deficiencies to 32 from the 27 we reported for fiscal years 2002
through 2007.[Footnote 9]
When combined with understatement resulting from missed deficiencies,
scope and severity understatement increases total understatement
nationwide for fiscal year 2008 to 14.1 percent (see fig. 2). From
fiscal years 2002 through 2008, overall understatement averaged 15.5
percent, about 1 percentage point more than missed deficiency
understatement alone. See enclosure II for full state results.
Although Alabama and New Mexico had missed deficiencies on fewer than
25 percent of their comparative surveys from fiscal years 2002 through
2008, the percentages of their comparative surveys with understatement
were 38.1 percent and 28.6 percent, respectively, when surveys with
understated scope and severity levels are included.
Figure 2: Percentage of Comparative Surveys Nationwide with
Understatement of Actual Harm and Immediate Jeopardy Deficiencies When
Scope and Severity Differences Are Included, Fiscal Years 2002 through
2008:
[Refer to PDF for image: multiple line graph]
Fiscal year: 2002;
Percentage of total comparative surveys with G-L missed deficiencies:
13.8%;
Percentage of total comparative surveys with G-L missed deficiencies
and scope and severity understatement[A]: 13.8%.
Fiscal year: 2003;
Percentage of total comparative surveys with G-L missed deficiencies:
17.5%;
Percentage of total comparative surveys with G-L missed deficiencies
and scope and severity understatement[A]: 19.3%.
Fiscal year: 2004;
Percentage of total comparative surveys with G-L missed deficiencies:
11.1%;
Percentage of total comparative surveys with G-L missed deficiencies
and scope and severity understatement[A]: 11.7%.
Fiscal year: 2005;
Percentage of total comparative surveys with G-L missed deficiencies:
14.3%;
Percentage of total comparative surveys with G-L missed deficiencies
and scope and severity understatement[A]: 17.4%.
Fiscal year: 2006;
Percentage of total comparative surveys with G-L missed deficiencies:
15.3%;
Percentage of total comparative surveys with G-L missed deficiencies
and scope and severity understatement[A]: 15.9%.
Fiscal year: 2007;
Percentage of total comparative surveys with G-L missed deficiencies:
14.7%[B];
Percentage of total comparative surveys with G-L missed deficiencies
and scope and severity understatement[A]: 16.5%.
Fiscal year: 2008;
Percentage of total comparative surveys with G-L missed deficiencies:
12.3%;
Percentage of total comparative surveys with G-L missed deficiencies
and scope and severity understatement[A]: 14.1%.
Source: GAO analysis of federal monitoring survey data.
[A] The inclusion of scope and severity understatement is based on our
analysis of 87 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.
[B] Since our May 2008 report, CMS changed a deficiency citation on a
fiscal year 2007 comparative survey from a serious deficiency to a
lower-level deficiency, reducing the nationwide percentage of
comparative surveys that identified at least one missed serious
deficiency from 15.3 percent to 14.7 percent for that fiscal year.
This report reflects this change.
[End of figure]
Missed Deficiencies at the Potential for More Than Minimal Harm Level
Continue to Be Widespread:
In fiscal year 2008, the percentage of comparative surveys with missed
deficiencies at the potential for more than minimal harm level (D
through F) increased to 74.8 percent from 73.5 percent the prior
fiscal year (see figure 3). Undetected care problems at the D through
F level remain of concern because they could become more serious over
time if nursing homes are not required to take corrective actions. The
percentage of comparative surveys conducted nationwide identifying at
least one missed deficiency at the D through F level remained at
approximately 70 percent (69.2) for the fiscal year 2002 through 2008
period, with such missed deficiencies identified on greater than 40
percent of comparative surveys in all but three states--Alaska,
Wisconsin, and West Virginia.[Footnote 10] See enclosure III for full
state results.
Figure 3: National Percentage of Comparative Surveys Citing at Least
One Missed Deficiency at the Potential for More Than Minimal Harm
Level, Fiscal Years 2002 through 2008:
[Refer to PDF for image: line graph]
Fiscal year: 2002;
Percentage: 55.0%.
Fiscal year: 2003;
Percentage: 66.3%.
Fiscal year: 2004;
Percentage: 66.0%.
Fiscal year: 2005;
Percentage: 76.4%.
Fiscal year: 2006;
Percentage: 72.0%.
Fiscal year: 2007;
Percentage: 73.5;
Fiscal year: 2008;
Percentage: 74.8%.
Source: GAO analysis of federal monitoring survey data.
[End of figure]
Agency Comments and Our Evaluation:
We provided a draft of this report to the Department of Health and
Human Services for comment. In its written comments, CMS agreed that
it is too early to tell if the trend in decreased understatement will
be sustained and that the agency appreciated the thoughtful and
updated analysis from GAO. There were no recommendations in this
report; however, CMS noted that it had made progress on implementing
the recommendations from our May 2008 report.
In May 2008, GAO recommended that CMS regularly analyze and compare
federal comparative and observational survey results. We are
encouraged that CMS discussed analysis of comparative surveys in its
comments and hope that such analysis is routinely incorporated into
their oversight of state survey agencies. Specifically, CMS's comments
contained the agency's own preliminary analysis of understatement of
serious deficiencies as reflected in federal comparative surveys,
including fiscal year 2009 data which was unavailable at the time we
conducted our analysis. Although CMS's analysis of fiscal year 2009
data showed a continuing decline in the understatement of serious
deficiencies, the agency consistently found more actual harm and
immediate jeopardy level missed deficiencies and cases of understated
scope and severity levels for fiscal years 2002 through 2008 than did
our analysis. We believe there are two reasons for these differences.
First, differences in both missed deficiencies and cases of
understated scope and severity levels are due in part to the fact that
CMS did not clean the data to remove duplicate surveys, cases of
erroneous data entry, and other data outliers. Second, additional
differences in cases of understated scope and severity levels reflect
the fact that, unlike CMS, we reviewed federal surveyors' comments for
each potential case of understated scope and severity at the actual
harm and immediate jeopardy levels to determine whether they concluded
that state surveyors had inappropriately cited the deficiency at too
low a scope and severity level. Assessing the federal surveyor comment
fields is important because a resident's condition may have worsened
in the period between the state and federal surveys. As a result of
these methodological differences, we believe that our lower estimates
of understatement for fiscal years 2002 through 2008 are accurate.
Finally, CMS commented that our reporting threshold of one missed
deficiency per survey for deficiencies at the potential for more than
minimal harm level (D through F) may be inappropriate because such
deficiencies are more numerous than those at the actual harm or
immediate jeopardy levels. We believe that the threshold of reporting
surveys with at least one missed D through F level deficiency is
appropriate because undetected care problems at this level could
become more serious over time if nursing homes are not required to
take corrective actions.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
after its issue date. At that time, we will send copies to the
Administrator of CMS and appropriate congressional committees. The
report will also be available at no charge on GAO's Web site at
[hyperlink, http://www.gao.gov].
If you or your staff have any questions regarding 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. Walter Ochinko, Assistant Director;
Katherine Nicole Laubacher; Dan Lee; and Phillip J. Stadler were major
contributors to this report.
Signed by:
John E. Dicken:
Director, Health Care:
Enclosures - 4:
[End of section]
Enclosure I:
Percentage of Federal Comparative Surveys That Identified Missed
Deficiencies at the Actual Harm or Immediate Jeopardy Levels (G
through L), Fiscal Years 2002 through 2008:
State: Alabama;
Number of homes, fiscal year 2008: 232;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 5;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 13;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 27.8;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 23.8.
State: Alaska;
Number of homes, fiscal year 2008: 14;
Total comparative surveys, fiscal years 2002-2008: 13;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 0;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 0.0.
State: Arizona;
Number of homes, fiscal year 2008: 132;
Total comparative surveys, fiscal years 2002-2008: 16;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 4;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 26.7;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 25.0.
State: Arkansas;
Number of homes, fiscal year 2008: 239;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 1;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 5.6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 4.8.
State: California;
Number of homes, fiscal year 2008: 1,127;
Total comparative surveys, fiscal years 2002-2008: 59;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 8;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 9;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 10.2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 13.6.
State: Colorado;
Number of homes, fiscal year 2008: 198;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 4;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 7;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 13.6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 16.7.
State: Connecticut;
Number of homes, fiscal year 2008: 198;
Total comparative surveys, fiscal years 2002-2008: 18;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 1;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 6.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 5.6.
State: Delaware;
Number of homes, fiscal year 2008: 44;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 15.4;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 13.3.
State: District of Columbia;
Number of homes, fiscal year 2008: 18;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 1;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 8.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 7.1.
State: Florida;
Number of homes, fiscal year 2008: 643;
Total comparative surveys, fiscal years 2002-2008: 30;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 3;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 11.5;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 10.0.
State: Georgia;
Number of homes, fiscal year 2008: 334;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 3;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 4;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 16.7;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 14.3.
State: Hawaii;
Number of homes, fiscal year 2008: 46;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 8.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 14.3.
State: Idaho;
Number of homes, fiscal year 2008: 64;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 0;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 0.0.
State: Illinois;
Number of homes, fiscal year 2008: 760;
Total comparative surveys, fiscal years 2002-2008: 38;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 8;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 13;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 21.9;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 21.1.
State: Indiana;
Number of homes, fiscal year 2008: 468;
Total comparative surveys, fiscal years 2002-2008: 30;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 3;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 4;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 12.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 10.0.
State: Iowa;
Number of homes, fiscal year 2008: 404;
Total comparative surveys, fiscal years 2002-2008: 23;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 3;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 4;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 15.8;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 13.0.
State: Kansas;
Number of homes, fiscal year 2008: 317;
Total comparative surveys, fiscal years 2002-2008: 27;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 5;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 9;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 16.7;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 18.5.
State: Kentucky;
Number of homes, fiscal year 2008: 274;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 11.1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 9.5.
State: Louisiana;
Number of homes, fiscal year 2008: 260;
Total comparative surveys, fiscal years 2002-2008: 20;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 4;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 7;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 17.6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 20.0.
State: Maine;
Number of homes, fiscal year 2008: 109;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 0;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 0.0.
State: Maryland;
Number of homes, fiscal year 2008: 189;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 10.5;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 9.5.
State: Massachusetts;
Number of homes, fiscal year 2008: 410;
Total comparative surveys, fiscal years 2002-2008: 20;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 1;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 5.9;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 5.0.
State: Michigan;
Number of homes, fiscal year 2008: 397;
Total comparative surveys, fiscal years 2002-2008: 30;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 7;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 7;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 20.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 23.3.
State: Minnesota;
Number of homes, fiscal year 2008: 391;
Total comparative surveys, fiscal years 2002-2008: 26;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 9.5;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 7.7.
State: Mississippi;
Number of homes, fiscal year 2008: 204;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 4;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 8;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 22.2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 19.0.
State: Missouri;
Number of homes, fiscal year 2008: 497;
Total comparative surveys, fiscal years 2002-2008: 32;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 9;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 15;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 28.6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 28.1.
State: Montana;
Number of homes, fiscal year 2008: 90;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 16.7;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 14.3.
State: Nebraska;
Number of homes, fiscal year 2008: 222;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 1;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 5.6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 4.8.
State: Nevada;
Number of homes, fiscal year 2008: 48;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 8.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 14.3.
State: New Hampshire;
Number of homes, fiscal year 2008: 79;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 14.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 13.3.
State: New Jersey;
Number of homes, fiscal year 2008: 336;
Total comparative surveys, fiscal years 2002-2008: 27;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 5;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 16;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 20.8;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 18.5.
State: New Mexico[A];
Number of homes, fiscal year 2008: 72;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 3;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 8;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 25.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 21.4.
State: New York;
Number of homes, fiscal year 2008: 620;
Total comparative surveys, fiscal years 2002-2008: 33;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 8;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 22;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 22.2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 24.2.
State: North Carolina;
Number of homes, fiscal year 2008: 409;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 4;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 4;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 14.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 16.7.
State: North Dakota;
Number of homes, fiscal year 2008: 79;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 0;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 0.0.
State: Ohio;
Number of homes, fiscal year 2008: 845;
Total comparative surveys, fiscal years 2002-2008: 37;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 1;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 3.2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 2.7.
State: Oklahoma;
Number of homes, fiscal year 2008: 293;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 6;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 11;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 30.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 25.0.
State: Oregon;
Number of homes, fiscal year 2008: 124;
Total comparative surveys, fiscal years 2002-2008: 20;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 0;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 0.0.
State: Pennsylvania;
Number of homes, fiscal year 2008: 693;
Total comparative surveys, fiscal years 2002-2008: 42;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 6;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 6;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 16.2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 14.3.
State: Rhode Island;
Number of homes, fiscal year 2008: 86;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 16.7;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 14.3.
State: South Carolina;
Number of homes, fiscal year 2008: 160;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 6;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 19;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 33.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 28.6.
State: South Dakota;
Number of homes, fiscal year 2008: 108;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 5;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 5;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 33.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 35.7.
State: Tennessee;
Number of homes, fiscal year 2008: 270;
Total comparative surveys, fiscal years 2002-2008: 22;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 5;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 10;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 26.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 22.7.
State: Texas;
Number of homes, fiscal year 2008: 1,113;
Total comparative surveys, fiscal years 2002-2008: 46;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 6;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 12;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 13.2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 13.0.
State: Utah;
Number of homes, fiscal year 2008: 78;
Total comparative surveys, fiscal years 2002-2008: 13;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 9.1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 15.4.
State: Vermont;
Number of homes, fiscal year 2008: 34;
Total comparative surveys, fiscal years 2002-2008: 11;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 0;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 0.0.
State: Virginia;
Number of homes, fiscal year 2008: 268;
Total comparative surveys, fiscal years 2002-2008: 19;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 1;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 5.9;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 5.3.
State: Washington;
Number of homes, fiscal year 2008: 232;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 3;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 11.1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 14.3.
State: West Virginia;
Number of homes, fiscal year 2008: 108;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 1;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 1;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 6.7.
State: Wisconsin;
Number of homes, fiscal year 2008: 386;
Total comparative surveys, fiscal years 2002-2008: 26;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 2;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 2;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 9.5;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 7.7.
State: Wyoming;
Number of homes, fiscal year 2008: 37;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 4;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 5;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 33.3;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 26.7.
State: Nation[B];
Number of homes, fiscal year 2008: 14,759;
Total comparative surveys, fiscal years 2002-2008: 1,139;
Total comparative surveys with at least one missed G through L
deficiency, fiscal years 2002-2008: 161;
Total number of missed G through L deficiencies, fiscal years 2002-
2008: 265;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2007: 14.4;
Percentage of total comparative surveys with at least one missed G
through L deficiency, fiscal years: 2002-2008: 14.1.
Source: GAO analysis of federal monitoring survey data.
[A] Since our May 2008 report, CMS changed a deficiency citation on a
New Mexico fiscal year 2007 comparative survey from a serious
deficiency to a lower-level deficiency. This reduced the state's total
comparative surveys with at least one missed G through L deficiency
and the total number of missed G through L deficiencies by 1. This
also reduced New Mexico's fiscal years 2002 to 2007 percentage of
total comparative surveys with at least one missed G through L
deficiency from 33.3 percent to 25.0 percent. This report reflects
these changes.
[B] Due to the change in a New Mexico deficiency citation on a fiscal
year 2007 comparative survey from a serious deficiency to a lower-
level deficiency, the nationwide percentage of comparative surveys
that identified at least one missed serious deficiency for fiscal
years 2002 through 2007 was reduced from 14.5 percent to 14.4 percent.
This report reflects this change.
[End of table]
[End of Enclosure I]
Enclosure II:
Percentage of Federal Comparative Surveys That Identified Missed
Deficiencies and Understated Scope and Severity Deficiencies at the
Actual Harm or Immediate Jeopardy Levels (G through L), Fiscal Years
2002 through 2008:
State: Alabama;
Number of homes, fiscal year 2008: 232;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 8;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 17;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 44.4;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 38.1.
State: Alaska;
Number of homes, fiscal year 2008: 14;
Total comparative surveys, fiscal years 2002-2008: 13;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 0;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 0.0.
State: Arizona;
Number of homes, fiscal year 2008: 132;
Total comparative surveys, fiscal years 2002-2008: 16;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 6;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 26.7;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 25.0.
State: Arkansas;
Number of homes, fiscal year 2008: 239;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 1;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 1;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 5.6;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 4.8.
State: California;
Number of homes, fiscal year 2008: 1,127;
Total comparative surveys, fiscal years 2002-2008: 59;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 9;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 13;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 12.2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 15.3.
State: Colorado;
Number of homes, fiscal year 2008: 198;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 8;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 13.6;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 16.7.
State: Connecticut;
Number of homes, fiscal year 2008: 198;
Total comparative surveys, fiscal years 2002-2008: 18;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 4;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 12.5;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 11.1.
State: Delaware;
Number of homes, fiscal year 2008: 44;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 15.4;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 13.3.
State: District of Columbia;
Number of homes, fiscal year 2008: 18;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 1;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 1;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 8.3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 7.1.
State: Florida;
Number of homes, fiscal year 2008: 643;
Total comparative surveys, fiscal years 2002-2008: 30;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 3;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 6;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 11.5;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 10.0.
State: Georgia;
Number of homes, fiscal year 2008: 334;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 5;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 22.2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 19.0.
State: Hawaii;
Number of homes, fiscal year 2008: 46;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 8.3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 14.3.
State: Idaho;
Number of homes, fiscal year 2008: 64;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 0;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 0.0.
State: Illinois;
Number of homes, fiscal year 2008: 760;
Total comparative surveys, fiscal years 2002-2008: 38;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 9;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 15;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 25.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 23.7.
State: Indiana;
Number of homes, fiscal year 2008: 468;
Total comparative surveys, fiscal years 2002-2008: 30;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 5;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 12.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 13.3.
State: Iowa;
Number of homes, fiscal year 2008: 404;
Total comparative surveys, fiscal years 2002-2008: 23;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 5;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 15.8;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 17.4.
State: Kansas;
Number of homes, fiscal year 2008: 317;
Total comparative surveys, fiscal years 2002-2008: 27;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 5;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 9;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 16.7;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 18.5.
State: Kentucky;
Number of homes, fiscal year 2008: 274;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 11.1;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 9.5.
State: Louisiana;
Number of homes, fiscal year 2008: 260;
Total comparative surveys, fiscal years 2002-2008: 20;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 7;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 17.6;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 20.0.
State: Maine;
Number of homes, fiscal year 2008: 109;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 0;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 0.0.
State: Maryland;
Number of homes, fiscal year 2008: 189;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 10.5;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 9.5.
State: Massachusetts;
Number of homes, fiscal year 2008: 410;
Total comparative surveys, fiscal years 2002-2008: 20;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 1;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 1;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 5.9;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 5.0.
State: Michigan;
Number of homes, fiscal year 2008: 397;
Total comparative surveys, fiscal years 2002-2008: 30;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 7;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 9;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 20.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 23.3.
State: Minnesota;
Number of homes, fiscal year 2008: 391;
Total comparative surveys, fiscal years 2002-2008: 26;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 4;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 14.3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 15.4.
State: Mississippi;
Number of homes, fiscal year 2008: 204;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 8;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 22.2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 19.0.
State: Missouri;
Number of homes, fiscal year 2008: 497;
Total comparative surveys, fiscal years 2002-2008: 32;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 9;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 16;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 28.6;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 28.1.
State: Montana;
Number of homes, fiscal year 2008: 90;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 3;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 25.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 21.4.
State: Nebraska;
Number of homes, fiscal year 2008: 222;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 1;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 1;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 5.6;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 4.8.
State: Nevada;
Number of homes, fiscal year 2008: 48;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 3;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 4;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 16.7;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 21.4.
State: New Hampshire;
Number of homes, fiscal year 2008: 79;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 14.3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 13.3.
State: New Jersey;
Number of homes, fiscal year 2008: 336;
Total comparative surveys, fiscal years 2002-2008: 27;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 5;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 16;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 20.8;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 18.5.
State: New Mexico;
Number of homes, fiscal year 2008: 72;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 9;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 33.3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 28.6.
State: New York;
Number of homes, fiscal year 2008: 620;
Total comparative surveys, fiscal years 2002-2008: 33;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 8;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 23;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 22.2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 24.2.
State: North Carolina;
Number of homes, fiscal year 2008: 409;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 4;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 5;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 14.3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 16.7.
State: North Dakota;
Number of homes, fiscal year 2008: 79;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 0;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 0.0.
State: Ohio;
Number of homes, fiscal year 2008: 845;
Total comparative surveys, fiscal years 2002-2008: 37;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 1;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 1;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 3.2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 2.7.
State: Oklahoma;
Number of homes, fiscal year 2008: 293;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 6;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 13;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 30.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 25.0.
State: Oregon;
Number of homes, fiscal year 2008: 124;
Total comparative surveys, fiscal years 2002-2008: 20;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 0;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 0.0.
State: Pennsylvania;
Number of homes, fiscal year 2008: 693;
Total comparative surveys, fiscal years 2002-2008: 42;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 6;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 6;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 16.2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 14.3.
State: Rhode Island;
Number of homes, fiscal year 2008: 86;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 16.7;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 14.3.
State: South Carolina;
Number of homes, fiscal year 2008: 160;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 6;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 19;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 33.3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 28.6.
State: South Dakota;
Number of homes, fiscal year 2008: 108;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 5;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 5;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 33.3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 35.7.
State: Tennessee;
Number of homes, fiscal year 2008: 270;
Total comparative surveys, fiscal years 2002-2008: 22;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 5;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 10;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 26.3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 22.7.
State: Texas;
Number of homes, fiscal year 2008: 1,113;
Total comparative surveys, fiscal years 2002-2008: 46;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 6;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 13;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 13.2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 13.0.
State: Utah;
Number of homes, fiscal year 2008: 78;
Total comparative surveys, fiscal years 2002-2008: 13;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 9.1;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 15.4.
State: Vermont;
Number of homes, fiscal year 2008: 34;
Total comparative surveys, fiscal years 2002-2008: 11;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 0;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 0.0.
State: Virginia;
Number of homes, fiscal year 2008: 268;
Total comparative surveys, fiscal years 2002-2008: 19;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 11.8;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 10.5.
State: Washington;
Number of homes, fiscal year 2008: 232;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 3;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 3;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 11.1;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 14.3.
State: West Virginia;
Number of homes, fiscal year 2008: 108;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 1;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 1;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 0.0;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 6.7.
State: Wisconsin;
Number of homes, fiscal year 2008: 386;
Total comparative surveys, fiscal years 2002-2008: 26;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 2;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 2;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 9.5;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 7.7.
State: Wyoming;
Number of homes, fiscal year 2008: 37;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 5;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 6;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 41.7;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 33.3.
State: Nation;
Number of homes, fiscal year 2008: 14,759;
Total comparative surveys, fiscal years 2002-2008: 1,139;
Total comparative surveys with at least one understated G through L
deficiency, fiscal years 2002-2008: 177;
Total number of understated G through L deficiencies, fiscal years
2002-2008: 297;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2007: 15.8;
Percentage of total comparative surveys with at least one understated
G through L deficiency, fiscal years: 2002-2008: 15.5.
Source: GAO analysis of federal monitoring survey data.
[End of table]
[End of Enclosure II]
Enclosure III:
Percentage of Federal Comparative Surveys That Identified Missed
Deficiencies at the Potential for More Than Minimal Harm Level (D
through F), Fiscal Years 2002 through 2008:
State: Alabama;
Number of homes, fiscal year 2008: 232;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 18;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 62;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 94.4;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 85.7.
State: Alaska;
Number of homes, fiscal year 2008: 14;
Total comparative surveys, fiscal years 2002-2008: 13;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 5;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 13;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 36.4;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 38.5.
State: Arizona;
Number of homes, fiscal year 2008: 132;
Total comparative surveys, fiscal years 2002-2008: 16;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 13;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 77;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 80.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 81.3.
State: Arkansas;
Number of homes, fiscal year 2008: 239;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 14;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 50;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 72.2;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 66.7.
State: California;
Number of homes, fiscal year 2008: 1,127;
Total comparative surveys, fiscal years 2002-2008: 59;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 46;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 155;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 73.5;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 78.0.
State: Colorado;
Number of homes, fiscal year 2008: 198;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 23;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 120;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 95.5;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 95.8.
State: Connecticut;
Number of homes, fiscal year 2008: 198;
Total comparative surveys, fiscal years 2002-2008: 18;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 10;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 32;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 50.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 55.6.
State: Delaware;
Number of homes, fiscal year 2008: 44;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 11;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 33;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 69.2;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 73.3.
State: District of Columbia;
Number of homes, fiscal year 2008: 18;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 12;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 32;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 83.3;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 85.7.
State: Florida;
Number of homes, fiscal year 2008: 643;
Total comparative surveys, fiscal years 2002-2008: 30;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 20;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 65;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 69.2;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 66.7.
State: Georgia;
Number of homes, fiscal year 2008: 334;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 15;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 51;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 72.2;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 71.4.
State: Hawaii;
Number of homes, fiscal year 2008: 46;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 9;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 35;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 58.3;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 64.3.
State: Idaho;
Number of homes, fiscal year 2008: 64;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 8;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 19;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 58.3;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 57.1.
State: Illinois;
Number of homes, fiscal year 2008: 760;
Total comparative surveys, fiscal years 2002-2008: 38;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 23;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 81;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 53.1;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 60.5.
State: Indiana;
Number of homes, fiscal year 2008: 468;
Total comparative surveys, fiscal years 2002-2008: 30;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 15;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 41;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 48.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 50.0.
State: Iowa;
Number of homes, fiscal year 2008: 404;
Total comparative surveys, fiscal years 2002-2008: 23;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 17;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 45;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 68.4;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 73.9.
State: Kansas;
Number of homes, fiscal year 2008: 317;
Total comparative surveys, fiscal years 2002-2008: 27;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 21;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 74;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 79.2;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 77.8.
State: Kentucky;
Number of homes, fiscal year 2008: 274;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 13;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 37;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 61.1;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 61.9.
State: Louisiana;
Number of homes, fiscal year 2008: 260;
Total comparative surveys, fiscal years 2002-2008: 20;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 14;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 76;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 76.5;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 70.0.
State: Maine;
Number of homes, fiscal year 2008: 109;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 7;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 26;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 50.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 50.0.
State: Maryland;
Number of homes, fiscal year 2008: 189;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 11;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 21;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 47.4;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 52.4.
State: Massachusetts;
Number of homes, fiscal year 2008: 410;
Total comparative surveys, fiscal years 2002-2008: 20;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 9;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 23;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 47.1;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 45.0.
State: Michigan;
Number of homes, fiscal year 2008: 397;
Total comparative surveys, fiscal years 2002-2008: 30;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 23;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 48;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 72.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 76.7.
State: Minnesota;
Number of homes, fiscal year 2008: 391;
Total comparative surveys, fiscal years 2002-2008: 26;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 19;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 38;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 71.4;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 73.1.
State: Mississippi;
Number of homes, fiscal year 2008: 204;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 17;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 67;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 83.3;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 81.0.
State: Missouri;
Number of homes, fiscal year 2008: 497;
Total comparative surveys, fiscal years 2002-2008: 32;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 26;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 165;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 78.6;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 81.3.
State: Montana;
Number of homes, fiscal year 2008: 90;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 14;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 59;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 100.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 100.0.
State: Nebraska;
Number of homes, fiscal year 2008: 222;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 15;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 55;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 72.2;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 71.4.
State: Nevada;
Number of homes, fiscal year 2008: 48;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 13;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 41;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 91.7;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 92.9.
State: New Hampshire;
Number of homes, fiscal year 2008: 79;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 10;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 43;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 64.3;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 66.7.
State: New Jersey;
Number of homes, fiscal year 2008: 336;
Total comparative surveys, fiscal years 2002-2008: 27;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 16;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 64;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 58.3;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 59.3.
State: New Mexico;
Number of homes, fiscal year 2008: 72;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 11;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 36;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 75.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 78.6.
State: New York;
Number of homes, fiscal year 2008: 620;
Total comparative surveys, fiscal years 2002-2008: 33;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 20;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 119;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 55.6;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 60.6.
State: North Carolina;
Number of homes, fiscal year 2008: 409;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 19;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 53;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 81.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 79.2.
State: North Dakota;
Number of homes, fiscal year 2008: 79;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 12;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 36;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 91.7;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 85.7.
State: Ohio;
Number of homes, fiscal year 2008: 845;
Total comparative surveys, fiscal years 2002-2008: 37;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 18;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 30;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 38.7;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 48.6.
State: Oklahoma;
Number of homes, fiscal year 2008: 293;
Total comparative surveys, fiscal years 2002-2008: 24;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 19;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 106;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 75.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 79.2.
State: Oregon;
Number of homes, fiscal year 2008: 124;
Total comparative surveys, fiscal years 2002-2008: 20;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 12;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 30;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 66.7;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 60.0.
State: Pennsylvania;
Number of homes, fiscal year 2008: 693;
Total comparative surveys, fiscal years 2002-2008: 42;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 28;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 75;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 62.2;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 66.7.
State: Rhode Island;
Number of homes, fiscal year 2008: 86;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 10;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 15;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 75.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 71.4.
State: South Carolina;
Number of homes, fiscal year 2008: 160;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 16;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 61;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 83.3;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 76.2.
State: South Dakota;
Number of homes, fiscal year 2008: 108;
Total comparative surveys, fiscal years 2002-2008: 14;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 14;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 51;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 100.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 100.0.
State: Tennessee;
Number of homes, fiscal year 2008: 270;
Total comparative surveys, fiscal years 2002-2008: 22;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 19;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 54;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 84.2;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 86.4.
State: Texas;
Number of homes, fiscal year 2008: 1,113;
Total comparative surveys, fiscal years 2002-2008: 46;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 35;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 145;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 73.7;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 76.1.
State: Utah;
Number of homes, fiscal year 2008: 78;
Total comparative surveys, fiscal years 2002-2008: 13;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 13;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 108;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 100.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 100.0.
State: Vermont;
Number of homes, fiscal year 2008: 34;
Total comparative surveys, fiscal years 2002-2008: 11;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 5;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 19;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 40.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 45.5.
State: Virginia;
Number of homes, fiscal year 2008: 268;
Total comparative surveys, fiscal years 2002-2008: 19;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 13;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 34;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 70.6;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 68.4.
State: Washington;
Number of homes, fiscal year 2008: 232;
Total comparative surveys, fiscal years 2002-2008: 21;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 12;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 26;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 55.6;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 57.1.
State: West Virginia;
Number of homes, fiscal year 2008: 108;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 3;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 3;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 23.1;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 20.0.
State: Wisconsin;
Number of homes, fiscal year 2008: 386;
Total comparative surveys, fiscal years 2002-2008: 26;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 8;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 19;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 38.1;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 30.8.
State: Wyoming;
Number of homes, fiscal year 2008: 37;
Total comparative surveys, fiscal years 2002-2008: 15;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 14;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 85;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 100.0;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 93.3.
State: Nation;
Number of homes, fiscal year 2008: 14,759;
Total comparative surveys, fiscal years 2002-2008: 1,139;
Total comparative surveys with at least one missed D through F
deficiency, fiscal years 2002-2008: 788;
Total number of missed D through F deficiencies, fiscal years 2002-
2008: 2,853;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2007: 68.2;
Percentage of total comparative surveys with at least one missed D
through F deficiency, fiscal years: 2002-2008: 69.2.
Source: GAO analysis of federal monitoring survey data.
[End of table]
[End of Enclosure III]
Enclosure IV:
Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
April 9, 1010:
John E. Dicken:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Mr. Dicken:
Enclosed are comments on the U.S. Government Accountability Office's
(GAO) report entitled: "Nursing Homes: Some Improvement Seen in
Understatement of Serious Deficiencies, but Implications for the
Longer-Term Trend Are Unclear" (GAO-10-434R).
The Department appreciates the opportunity to review this report
before its publication.
Sincerely,
Signed by:
[Illegible, for]
Andrea Palm:
Acting Assistant Secretary for Legislation:
Enclosure:
[End of letter]
Department Of Health & Human Services:
Centers for Medicare & Medicaid Services:
Administrator:
Washington, DC 20201:
Date: April 8, 2010:
To: Andrea Palm:
Acting Assistant Secretary for Legislation:
Office of the Secretary:
From: [Signed by] Charlene Frizzera:
Acting Administrator:
Subject: Government Accountability Office (GAO) Proposed Report:
"Nursing Homes: Some Improvement Seen in Understatement of Serious
Deficiencies, but Implications for the Longer-Term Trend are Unclear"
(GAO-10-434R):
In this report, the GAO updated its earlier analysis of the Centers
for Medicare & Medicaid Services' (CMS) comparative nursing home
surveys[Footnote 11] that are designed to determine whether State
survey agencies miss or understate the degree of serious deficiencies
in nursing homes. The GAO observes that:
* Missed Serious Deficiencies Decline: Between fiscal year (FY) 2006
and FY 2008, there was an improvement in the yearly percentage of
comparative surveys indicating that a State had missed a serious
deficiency;
* Trend is Uncertain: Despite recent improvement in identifying
deficiencies, it is unclear if the improvement will be sustained over
time; and;
* Rating the Seriousness of Deficiencies: While a lower proportion of
serious deficiencies was missed between FY 2006 and FY 2008,
comparative surveys continue to demonstrate that States understate the
scope and severity of serious deficiencies.
As CMS expanded its efforts to improve oversight of States, it is
reasonable to expect there would be some improvement in State surveyor
identification of deficiencies. In fact, the average number of
deficiencies identified in each standard survey increased from 6.5 in
2005 to 6.8 in 2009, which suggests that this is the case. CMS and
State improvements include:
* Improved Training of States: CMS increased the number and broadened
the scope of training, and made in-person, as well as web-based, on-
demand training more accessible across the country;
* Guidance for Surveyors: As the GAO has noted in other reports, CMS
substantially upgraded the quality of surveyor guidance published
online in the State Operations Manual (SOM). For example, publication
of the revised medication guidance in late 2006, together with the
accompanying training of surveyors, produced an increase in the
percentage of surveys in which the use of unnecessary medications was
cited as a deficiency (from about 13 percent of surveys in 2006 to 18
percent in 2007 and 19 percent in both 2008 and 2009); and;
* CMS Comparative Surveys: CMS improved its fulfillment of the
statutory obligation to conduct validation surveys on a 5 percent
sample of State surveys. Pursuant to a GAO report on fire safety in
2005, CMS also ensured for the first time that every comparative
survey included assessed compliance with life safety code requirements.
While the above examples suggest reasons why we should expect
improvement, we fully agree with the GAO that it is too early to tell
if the trendline of improvement will be sustained. To shed more light
on this question, we examined more recent data from 2009 that were not
available at the time the GAO performed its analysis.
Figure 1 displays data produced by the GAO analysis and data from our
own analysis. It is important to note that CMS's data are preliminary,
and that the raw CMS data have consistently indicated more missed
deficiencies than the GAO methodology. Nonetheless, the CMS analysis
fully confirms the GAO findings and indicates that the improvement did
not end in 2008, but continued throughout 2009, declining from 16.7
percent in 2006 to 13.9 percent in 2008 and 8.2 percent in 2009.
Figure 1. Percentage of Comparative Surveys Nationwide with Missing
Deficiencies of Actual Harm or Higher (G-L), Fiscal Years 2002 through
2009: Comparison of GAO and CMS Findings:
[Refer to PDF for image: multiple line graph]
Fiscal year: 2002;
Percent of surveys missing G-L deficiencies (CMS): 14.8%;
Percent of surveys missing G-L deficiencies (GAO): 13.8%.
Fiscal year: 2003;
Percent of surveys missing G-L deficiencies (CMS): 20.2%;
Percent of surveys missing G-L deficiencies (GAO): 17.5%.
Fiscal year: 2004;
Percent of surveys missing G-L deficiencies (CMS): 12.1%;
Percent of surveys missing G-L deficiencies (GAO): 11.1%.
Fiscal year: 2005;
Percent of surveys missing G-L deficiencies (CMS): 18.7%;
Percent of surveys missing G-L deficiencies (GAO): 14.3%.
Fiscal year: 2006;
Percent of surveys missing G-L deficiencies (CMS): 16.7%;
Percent of surveys missing G-L deficiencies (GAO): 15.3%.
Fiscal year: 2007;
Percent of surveys missing G-L deficiencies (CMS): 15.6%;
Percent of surveys missing G-L deficiencies (GAO): 14.7%.
Fiscal year: 2008;
Percent of surveys missing G-L deficiencies (CMS): 13.9%;
Percent of surveys missing G-L deficiencies (GAO): 12.3%.
Fiscal year: 2009;
Percent of surveys missing G-L deficiencies (CMS): 8.2%;
Percent of surveys missing G-L deficiencies (GAO): [Empty].
Sources: CMS Analysis of Comparative Surveys; and the GAO Analysis of
CMS Comparative Surveys.
[End of figure]
The GAO examined the extent to which serious deficiencies were not
missed by States, but where States rated the deficiencies at a lower
scope or severity than did the CMS regional office surveyors. When
data for both missed and under-rated serious deficiencies are
combined, we see the same trendline as the trendline for missed
deficiencies alone. Figure 2 displays the GAO and the CMS data for the
combined phenomena. The CMS data, for example, show that the
combination of missed or under-rated deficiencies declined from 21.7
percent in 2005 to 19.9 percent in 2008, and then further to 15.3
percent in 2009.
Figure 2. Percentage of Comparative Surveys Nationwide with Either
Under-Rated or Missed Deficiencies of Actual Harm or Higher (G-L),
Fiscal Years 2002 through 2009: Comparison of GAO and CMS Findings:
[Refer to PDF for image: multiple line graph]
Fiscal year: 2002;
Percent of surveys missing or undercited G-L deficiencies (CMS): 15.4%;
Percent of surveys missing or undercited G-L deficiencies (GAO): 13.8%.
Fiscal year: 2003;
Percent of surveys missing or undercited G-L deficiencies (CMS): 21.4%;
Percent of surveys missing or undercited G-L deficiencies (GAO): 19.3%.
Fiscal year: 2004;
Percent of surveys missing or undercited G-L deficiencies (CMS): 15.8%;
Percent of surveys missing or undercited G-L deficiencies (GAO): 11.7%.
Fiscal year: 2005;
Percent of surveys missing or undercited G-L deficiencies (CMS): 21.7%;
Percent of surveys missing or undercited G-L deficiencies (GAO): 17.4%.
Fiscal year: 2006;
Percent of surveys missing or undercited G-L deficiencies (CMS): 21.9%;
Percent of surveys missing or undercited G-L deficiencies (GAO): 15.9%.
Fiscal year: 2007;
Percent of surveys missing or undercited G-L deficiencies (CMS): 21.5%;
Percent of surveys missing or undercited G-L deficiencies (GAO): 16.5%.
Fiscal year: 2008;
Percent of surveys missing or undercited G-L deficiencies (CMS): 19.9%;
Percent of surveys missing or undercited G-L deficiencies (GAO): 14.1%.
Fiscal year: 2009;
Percent of surveys missing or undercited G-L deficiencies (CMS): 15.3%;
Percent of surveys missing or undercited G-L deficiencies (GAO):
[Empty].
[End of figure]
The GAO also examined the extent to which less serious deficiencies
were missed or underrated. Such deficiencies, identified at the "D
through F" scope and severity level, indicate a potential for more
than minimal harm without actual harm occurring. The GAO indicated
that the percentage of surveys with at least one missed or under-rated
"D-F" deficiency increased from 2002 to 2008. For a number of reasons,
we believe that more analysis is needed before conclusions are drawn
about these deficiencies.
In addition, the "D-F" deficiencies are much more numerous than the
more serious deficiencies, and we wonder if "one missed deficiency" is
an appropriate threshold for a useful measurement metric of these
deficiencies. It may, therefore, be worth investing in a more
sophisticated metric for the D-L deficiencies.
We appreciate the thoughtful and updated analysis from the GAO. There
were no recommendations in this most recent update. In its prior work,
the GAO made a number of recommendations, on which we are taking
action. CMS appreciates the opportunity to comment on this draft
report and we look forward to working with the GAO on this and other
issues.
[End of enclosure IV]
Related GAO Products:
Nursing Homes: Addressing the Factors Underlying Understatement of
Serious Care Problems Requires Sustained CMS and State Commitment.
[hyperlink, http://www.gao.gov/products/GAO-10-70]. Washington, D.C.:
November 24, 2009.
Nursing Homes: Opportunities Exist to Facilitate the Use of the
Temporary Management Sanction. [hyperlink,
http://www.gao.gov/products/GAO-10-37R]. Washington, D.C.: November
20, 2009.
Nursing Homes: CMS's Special Focus Facility Methodology Should Better
Target the Most Poorly Performing Homes, Which Tended to Be Chain
Affiliated and For-Profit. [hyperlink,
http://www.gao.gov/products/GAO-09-689]. Washington, D.C.: August 28,
2009.
Medicare and Medicaid Participating Facilities: CMS Needs to Reexamine
Its Approach for Funding State Oversight of Health Care Facilities.
[hyperlink, http://www.gao.gov/products/GAO-09-64]. Washington, D.C.:
February 13, 2009.
Nursing Homes: Federal Monitoring Surveys Demonstrate Continued
Understatement of Serious Care Problems and CMS Oversight Weaknesses.
[hyperlink, http://www.gao.gov/products/GAO-08-517]. Washington, D.C.:
May 9, 2008.
Nursing Home Reform: Continued Attention Is Needed to Improve Quality
of Care in Small but Significant Share of Homes. [hyperlink,
http://www.gao.gov/products/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. [hyperlink,
http://www.gao.gov/products/GAO-07-241]. Washington, D.C.: March 26,
2007.
Nursing Homes: Despite Increased Oversight, Challenges Remain in
Ensuring High-Quality Care and Resident Safety. [hyperlink,
http://www.gao.gov/products/GAO-06-117]. Washington, D.C.: December
28, 2005.
Nursing Home Quality: Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight. [hyperlink,
http://www.gao.gov/products/GAO-03-561]. Washington, D.C.: July 15,
2003.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
the Quality Initiatives. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-197]. Washington, D.C.:
September 28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-6]. Washington, D.C.: November
4, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing
Homes Has Merit. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-157]. Washington, D.C.: June
30, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-46]. Washington, D.C.: March
18, 1999.
California Nursing Homes: Care Problems Persist Despite Federal and
State Oversight. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-98-202]. Washington, D.C.: July
27, 1998.
[End of section]
Footnotes:
[1] 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. 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 $82 billion in 2008,
including a federal share of about $58 billion.
[2] See GAO, Nursing Homes: Federal Monitoring Surveys Demonstrate
Continued Understatement of Serious Care Problems and CMS Oversight
Weaknesses, [hyperlink, http://www.gao.gov/products/GAO-08-517]
(Washington, D.C.: May 9, 2008). This report also examined CMS's
management of the federal monitoring survey program and database and
made recommendations to address weaknesses that affect the agency's
ability to track understatement and oversee regional office
implementation of the federal monitoring survey program. CMS
implemented all of the report's recommendations. We also issued a
companion report in November 2009 that examined how four factors
affect the understatement of nursing home deficiencies. See GAO,
Nursing Homes: Addressing the Factors Underlying Understatement of
Serious Care Problems Requires Sustained CMS and State Commitment,
[hyperlink, http://www.gao.gov/products/GAO-10-70] (Washington, D.C.:
Nov. 24, 2009).
[3] Since our May 2008 report, CMS changed a deficiency citation on a
fiscal year 2007 comparative survey from a serious deficiency to a
lower-level deficiency, reducing the nationwide percentage of
comparative surveys that identified at least one missed serious
deficiency from 15.3 percent to 14.7 percent for that fiscal year.
This report reflects this change.
[4] We did not review federal comparative surveys of state life safety
code surveys because they focus on fire safety and do not assess
compliance with federal health regulations.
[5] Fiscal year 2002 was the first year that the database contained
all the information needed to assess the results of federal
comparative surveys.
[6] 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.
[7] Throughout this report, we refer to deficiencies at the actual
harm and immediate jeopardy levels--G through L--as serious
deficiencies and deficiencies at the D through F level as lower-level
deficiencies.
[8] CMS indicates that it meets this statutory requirement by
conducting both comparative and observational surveys. Observational
surveys are surveys in which 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.
[9] To assess whether these differences in scope and severity levels
were actually understated, we examined comments entered by federal
surveyors in the federal monitoring survey database associated with
these deficiencies to determine if federal surveyors believed the
state survey team should have cited the deficiency at a higher scope
and severity level.
[10] 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.
[11] Nursing Homes: Federal Monitoring Surveys Demonstrate Continued
Understatement of Serious Care Problems and CMS Oversight Weaknesses
[hyperlink, http://www.gao.gov/products/GA0-08-517], Washington, DC:
May 9, 2008.
[End of section]
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