Government Reports

Bibliography
GAO, OIG and Other Reports on Nursing Home Quality
 & Survey and Certification—1997 to April 2014

Note:

This bibliography was prepared by Janet C. Wells for the Centers for Medicare and Medicaid Services Survey Executives Training Institute, Baltimore, MD, April 9, 2014.

Office Of Inspector General (OIG)

  • [February 2014] Adverse events in skilled Nursing Facility: National Incidence Among Medicare Beneficiaries (OEI-09-11-00370):
    Click Here
  • [November 18, 2013] Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring (OEI-06-11-00040):
    Click Here
  • [May 9, 2011] Overmedication of Nursing Home Patients Troubling:
    Click Here
  • [April 7, 2011] Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents (OEI-07-08-00150):
    Click Here
  • [September 2009] Memorandum Report: Trends in Nursing Home Deficiencies and Complaints (OEI-02-08-00140):
    Click Here
  • [April 2009] NURSING HOME CORPORATIONS UNDER QUALITY OF CARE CORPORATE INTEGRITY AGREEMENTS (OEI-06-06-00570):
    Click Here
  • [May 2008] Nursing Home Enforcement: Processing Denials of Medicare Payment (OEI-06-03-00390):
    Click Here
  • [July 2006] Nursing Home Complaint Investigations (OEI-01-04-00340):
    Click Here
  • [May 2006] NURSING HOME ENFORCEMENT: APPLICATION OF MANDATORY REMEDIES (OEI-06-03-00410):
    Click Here
  • [April 2005] NURSING HOME ENFORCEMENT: THE USE OF CIVIL MONEY PENALTIES (OEI-06-02-00720):
    Click Here
  • [December 2005] STATE REFERRAL OF NURSING HOME ENFORCEMENT CASES (OEI-06-03-00400):
    Click Here
  • [June 2004] INSPECTION RESULTS ON NURSING HOME COMPARE: COMPLETENESS AND ACCURACY (OEI -01-03-00130):
    Click Here
  • [June 2004] SURVEY OF PHYSICAL AND SEXUAL ABUSE IN ALABAMA NURSING HOMES (A-04-03-07027):
    Click Here
  • [March 2003] Nursing Home Deficiency Trends and Survey and Certification Process Consistency  (OEI-02-01-00600):
    Click Here
  • [March 2003] Nursing Home Deficiency Trends and Survey and Certification Process Consistency (OEI-02-01-00600):
    Click Here
  • [January 2003] Quality Assurance Committees in Nursing Homes (OEI-02-01-00600):
    Click Here
  • [Febrary 2003] Nursing Home Medical Directors Survey (OEI-06-99-00300):
    Click Here
  • [September 28, 2000]Success of Quality Initiatives Requires Sustained Federal and State Commitment (T-HEHS-00-209):
    Click Here
  • [June 2000] The Effect of Financial Screening and Distinct Part Rules on Access to Nursing Facilities; (OEI-02-99-00340):
    Click Here
  • [May 1999] Abuse Complaints of Nursing Home Patients (OEI-06-98-00340):
    Click Here
  • [March 1999] Public Access to Nursing Home Survey and Certification Results (OEI-06-98-00280):
    Click Here
  • Nursing Home Resident Assessment: Quality of Care (OEI-02-99-00040):
    Click Here
  • Nursing Home Survey and Certification: Deficiency Trends (OEI-02-98-00331):
    Click Here
  • Nursing Home Survey and Certification: Overall Capacity (OEI-02-98-00330):
    Click Here

Government Accountability Office

  • [Reissued March 9, 2012/original February 1, 2012] CMS Should Improve Efforts to Monitor Implementation of the Quality Indicator Survey:
    Click Here
  • [July 15, 2011] Private Investment Homes Sometimes Differed from Others in Deficiencies, Staffing, and Financial Performance (GAO-11-571):
    Click Here
  • [Apr 7, 2011] More Reliable Data and Consistent Guidance Would Improve CMS Oversight of State Complaint Investigations (GAO-11-280):
    Click Here
  • [April 6, 2011] Implementation of the Quality Indicator Survey (GAO-11-403R):
    Click Here
  • [September 30, 2010] Complexity of Private Investment Purchases Demonstrates Need for CMS to Improve the Usability and Completeness of Ownership Data (GAO-10-710):
    Click Here
  • [April 28, 1010] Some Improvement Seen in Understatement of Serious Deficiencies, but Implications for the Longer-Term Trend Are Unclear (GAO-10-434R):
    Click Here
  • [November 24, 2009] Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained CMS and State Commitment (GAO-10-70):
    Click Here
  • [November 24, 2009] Responses from Two Web-based questionnaires to Nursing Home Surveyors and State Agency Directors (GAO-10-74SP),
    an e-supplement to GAO-10-70:
    Click Here
  • [November 20, 2009] Opportunities Exist to Facilitate the Use of the Temporary Management Sanction (GAO-10-37R):
    Click Here
  • [August 28, 2009] CMS’s Special Focus Facility Methodology Should Better Target the Most Poorly Performing Homes,
    Which Tended to Be Chain Affiliated and For-Profit (GAO-09-698):
    Click Here
  • [February 13, 2009] CMS Needs to Reexamine Its Approach for Funding State Oversight of Health Care Facilities (GAO-09-64):
    Click Here
  • [February 2009] CMS Needs to Reexamine Its Approach for Funding State Oversight of Health Care Facilities Click Here
  • [May 9, 2008] Federal Monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weaknesses (GAO-08-517):
    Click Here
  • [May 29, 2007] Federal Actions Needed to Improve Targeting and Evaluation of Assistance by Quality Improvement Organizations (GAO-07-373):
    Click Here
  • [May 2, 2007] Continued Attention Is Needed to Improve Quality of Care in Small but Significant Share of Homes (GAO-07-794T:
    Click Here
  • [March 26, 2007] Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes from Repeatedly Harming Residents (GAO-07-241):
    Click Here
  • [March 31, 2006] Information on Residents Who Are Registered Sex Offenders or Are Paroled for Other Crimes (GAO-06-326):
    Click Here
  • [December 28, 2005] Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety (GAO-06-117):
    Click Here
  • [November 12, 2004] Arkansas Coroner Referrals Confirm Weaknesses in State and Federal Oversight of Quality of Care (GAO-05-78):
    Click Here
  • [July 17, 2003] Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline (GAO-03-1016T):
    Click Here
  • [November 13, 2002] Available Data Show Average Nursing Staff Time Changed Little after Medicare Payment Increase (GAO-03-176):
    Click Here
  • [October 31, 2002] Public Reporting of Quality Indicators Has Merit, but National Implementation Is Premature (GAO-03-187):
    Click Here
  • [June 13, 2002] Quality of Care More Related to Staffing than Spending (GAO-02-431R):
    Click Here
  • [February 15, 2002] Federal Efforts to Monitor Resident Assessment Data Should Complement State Activities (GAO-02-279):
    Click Here
  • [March 1, 2002] More Can Be Done to Protect Residents from Abuse (GAO-02-312):
    Click Here
  • [March 4, 2002] Many Shortcomings Exist in Efforts to Protect Residents from Abuse (GAO-02-448T):
    Click Here
  • [September 28, 2000] Sustained Efforts Are Essential to Realize Potential of the Quality Initiatives (HEHS-00-197):
    Click Here
  • [November 4, 1999] Enhanced HCFA Oversight of State Programs Would Better Ensure Quality (HEHS-00-6):
    Click Here
  • [November 4, 1999] HCFA Should Strengthen Its Oversight of State Agencies to Better Ensure Quality Care (T-HEHS-00-27):
    Click Here
  • [August 13, 1999] Industry Examples Do Not Demonstrate That Regulatory Actions Were Unreasonable (HEHS-99-154):
    Click Here
  • [June 30, 1999] HCFA Initiatives to Improve Care Are Under Way but Will Require Continued Commitment (T-HEHS-99-155):
    Click Here
  • [June 30, 1999] Proposal To Enhance Oversight of Poorly Performing Homes Has Merit (HEHS-99-157):
    Click Here
  • [June 15, 1999] Complaint Investigation Processes in Maryland (T-HEHS-99-146):
    Click Here
  • [March 22, 1999] Stronger Complaint and Enforcement Practices Needed to Better Ensure Adequate Care (T-HEHS-99-89):
    Click Here
  • [March 18, 1999] Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards (HEHS-99-46):
    Click Here
  • [July 28, 1998] Federal and State Oversight Inadequate to Protect Residents in Homes With Serious Care Violations (T-HEHS-98-219):
    Click Here
  • [April 16, 1997] Too Early to Assess New Efforts to Control Fraud and Abuse (T-HEHS-97-114):
    Click Here

Other Government Reports

  • Official Nursing Home Compare Data – CMS datasets used on the Nursing Home Compare Website These data allow you to compare the quality of care at every
    Medicare and Medicaid-certified nursing home in the country, including over 15,000 nationwide.
    Click Here to view
  • Percent of Nursing Facilities with Deficiencies, January 2011 through February 2012 Henry J. Kaiser Family Foundation. Analysis of 2011 Online Survey,
    Certification, and Reporting system (OSCAR) data.
    Click Here to view
  • Average Number of Deficiencies per Certified Nursing Facility, Henry J. Kaiser Family Foundation, 2011 Online Survey, Certification, and Reporting system
    (OSCAR) data:
    Click Here to view