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Testimony:

Before the Committee on Finance, U.S. Senate:

United States General Accounting Office:

GAO:

For Release on Delivery Expected at 10:00 a.m.

Thursday, July 17, 2003:

NURSING HOMES:

Prevalence of Serious Quality Problems Remains Unacceptably High, 
Despite Some Decline:

Statement of William J. Scanlon:

Director--Health Care Issues:

GAO-03-1016T:

GAO Highlights:

Highlights of GAO-03-1016T, a testimony before the Committee on 
Finance, U.S. Senate 

Why GAO Did This Study:

Since 1998, the Congress and Administration have focused considerable 
attention on improving the quality of care in the nation’s nursing 
homes, which provide care for about 1.7 million elderly and disabled 
residents in about 17,000 homes. GAO has earlier reported on serious 
weaknesses in processes for conducting routine state inspections 
(surveys) of nursing homes and complaint investigations, ensuring that 
homes with identified deficiencies correct the problems without 
recurrence, and providing consistent federal oversight of state survey 
activities to ensure that nursing homes comply with federal quality 
standards. 

GAO was asked to update its work on these issues and to testify on its 
findings, as reported in Nursing Home Quality: Prevalence of Serious 
Problems, While Declining, Reinforces Importance of Enhanced 
Oversight, GAO-03-561 (July 15, 2003). In commenting on this report, 
the Centers for Medicare & Medicaid Services (CMS) generally concurred 
with the recommendations to address survey and oversight weaknesses. 
In this testimony, GAO addresses (1) the prevalence of serious nursing 
home quality problems nationwide, (2) factors contributing to 
continuing weaknesses in states’ survey, complaint, and enforcement 
activities, and (3) the status of key federal efforts to oversee state 
survey agency performance and improve quality.

What GAO Found:

The magnitude of documented serious deficiencies that harmed nursing 
home residents remains unacceptably high, despite some decline. For 
the most recent period reviewed, one in five nursing homes nationwide 
(about 3,500 homes) had serious deficiencies that caused residents 
actual harm or placed them in immediate jeopardy. Moreover, GAO found 
significant understatement of care problems that should have been 
classified as actual harm or higher—serious avoidable pressure sores, 
severe weight loss, and multiple falls resulting in broken bones and 
other injuries—for a sample of homes with a history of harming 
residents. Several factors contributed to such understatement, 
including confusion about the definition of harm; inadequate state 
review of surveys to identify potential understatement; large numbers 
of inexperienced state surveyors; and a continuing problem with survey 
timing being predictable to nursing homes. States continue to have 
difficulty identifying and responding in a timely fashion to public 
complaints alleging actual harm—delays state officials attributed to 
an increase in the volume of complaints and to insufficient staff. 
Although federal enforcement policy was strengthened in January 2000 
by requiring state survey agencies to refer for immediate sanction 
homes that had a pattern of harming residents, many states did not 
fully comply with this new requirement, significantly undermining the 
policy’s intended deterrent effect. 

While CMS has increased its oversight of state survey and complaint 
investigation activities, continued attention is required to help 
ensure compliance with federal requirements. In October 2000, the 
agency implemented new annual performance reviews to measure state 
performance in seven areas, including the timeliness of survey and 
complaint investigations and the proper documentation of survey 
findings. The first round of results, however, did not produce 
information enabling the agency to identify and initiate needed 
improvements. For example, some regional office summary reports 
provided too little information to determine if a state did not meet a 
particular standard by a wide or a narrow margin—information that 
could help CMS to judge the seriousness of problems identified and 
target remedial interventions. Rather than relying on its regional 
offices, CMS plans to more centrally manage future state performance 
reviews to improve consistency and to help ensure that the results of 
those reviews could be used to more readily identify serious problems. 
Finally, implementation has been significantly delayed for three 
federal initiatives that are critical to reducing the variation 
evident in the state survey process in categorizing the seriousness of 
deficiencies and investigating complaints. These delayed initiatives 
were intended to strengthen the methodology for conducting surveys, 
improve surveyor guidance for determining the scope and severity of 
deficiencies, and increase standardization in state complaint 
investigation processes. 

www.gao.gov/cgi-bin/getrpt?GAO-03-1016T.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Kathryn G. Allen on 
(202) 512-7118.

[End of section]

Mr. Chairman and Members of the Committee:

I am pleased to be here today as you address the quality of care 
provided to the nation's 1.7 million nursing home residents, a highly 
vulnerable population of elderly and disabled individuals. The federal 
government plays a major role in ensuring nursing home quality and in 
financing nursing home care. Medicare and Medicaid paid the nation's 
approximately 17,000 homes an estimated $42 billion in 2002 to care for 
beneficiaries. More specifically, Medicaid pays for care provided to 
about two-thirds of all nursing home residents nationwide. In addition, 
the Department of Veterans Affairs contracts with many of these same 
nursing homes to provide long-term care to veterans at a cost of more 
than $250 million in fiscal year 2002. In 1998, the Senate Special 
Committee on Aging held a hearing to address nursing home care problems 
in California. Troubled by our findings of poor care in that state's 
homes and weak federal oversight in general, the Committee held 
additional hearings on nursing home quality nationwide in 1999 and 
2000. In response to congressional oversight and our recommendations, 
the Administration has taken actions intended to address many of the 
weaknesses we identified. These weaknesses included:

* periodic state inspections, known as surveys, that understated the 
extent of serious care problems due to procedural weaknesses;

* considerable delays that occurred in states investigating complaints 
by residents, family members or friends, and nursing home staff 
alleging actual harm to residents;

* federal enforcement policies that did not ensure that identified 
deficiencies were addressed and remained corrected; and:

* federal oversight of state survey activities that was often 
inconsistent across states and limited in scope and effectiveness.

In September 2000, we reported on progress made in addressing these 
weaknesses and concluded that the success of the Administration's 
actions to improve nursing home quality required sustained federal and 
state commitment to reach their full potential. My remarks today will 
address federal and state progress made since our September 2000 report 
and testimony, focusing in particular on (1) the prevalence of serious 
nursing home quality problems, (2) factors contributing to continuing 
weaknesses in states' survey, complaint, and enforcement activities, 
and (3) the status of key federal efforts to oversee state survey 
agency performance and improve quality. My remarks are based on our 
report being released today that addresses these issues in greater 
detail.[Footnote 1]

In summary, the magnitude of serious deficiencies that harmed nursing 
home residents remains unacceptably high, despite some decline. For the 
most recent period we reviewed, one in five of all nursing homes 
nationwide (about 3,500 homes) had serious deficiencies that caused 
residents actual harm or placed them in immediate jeopardy. Moreover, 
we found significant understatement of care problems that should have 
been classified as actual harm or higher--serious avoidable pressure 
sores, severe weight loss, and multiple falls resulting in broken bones 
and other injuries--for a sample of homes with a history of harming 
residents. We identified several factors that contributed to such 
understatement, including confusion about the definition of harm; 
inadequate state supervisory review of surveys to identify potential 
understatement; large numbers of inexperienced state surveyors; and a 
continuing, significant problem with survey timing being predictable to 
nursing homes. States also continue to have difficulty identifying and 
responding in a timely fashion to complaints alleging actual harm--
delays that state officials attributed to an increase in the volume of 
complaints and to insufficient staff. Although federal enforcement 
policy was strengthened in January 2000 by requiring state survey 
agencies to refer for immediate sanction homes that had a pattern of 
harming residents, we found that many states did not fully comply with 
this new requirement. States failed to refer hundreds of homes for 
immediate sanction, significantly undermining the policy's intended 
deterrent effect.

While the Centers for Medicare & Medicaid Services (CMS) has increased 
its oversight of state survey and complaint investigation activities, 
continued attention is required to help ensure compliance with federal 
requirements.[Footnote 2] In October 2000, the agency implemented new 
annual performance reviews to measure state performance in seven areas, 
including the timeliness of survey and complaint investigations and the 
proper documentation of survey findings. The first round of results, 
however, did not produce information enabling the agency to identify 
and initiate needed improvements. For example, some regional office 
summary reports provided too little information to determine if a state 
agency did not meet a particular standard by a wide or a narrow margin-
-information that could help CMS to judge the seriousness of problems 
identified and target remedial actions. Rather than relying on its 
regional offices, CMS plans to more centrally manage future state 
performance reviews to improve consistency and to help ensure that the 
results of those reviews could be used to more readily identify serious 
problems. Finally, implementation has been significantly delayed for 
three federal initiatives that are critical to reducing the variation 
evident in the state survey process in categorizing the seriousness of 
deficiencies and investigating complaints. These delayed initiatives 
were intended to strengthen the methodology for conducting surveys, 
improve surveyor guidance for determining the scope and severity of 
deficiencies, and increase standardization in state complaint 
investigation processes. In our view, finalizing and implementing these 
initiatives as quickly as possible would help bring more clarity and 
consistency to the process for assessing and improving the quality of 
care provided to the nation's nursing home residents.

Background:

Oversight of nursing homes is a shared federal and state 
responsibility. CMS is the federal agency that manages Medicare and 
Medicaid and oversees compliance with federal nursing home quality 
standards. On the basis of statutory requirements, CMS defines 
standards that nursing homes must meet to participate in the Medicare 
and Medicaid programs and contracts with states to certify that homes 
meet these standards through annual inspections and complaint 
investigations. The "annual" inspection, called a survey, which must be 
conducted on average every 12 months and no less than every 15 months 
at each home, entails a team of state surveyors spending several days 
in the home to determine whether care and services meet the assessed 
needs of the residents. CMS establishes specific protocols, or 
investigative procedures, for state surveyors to use in conducting 
these comprehensive surveys. In contrast, complaint investigations, 
also conducted by state surveyors within certain federal guidelines and 
time frames, typically target a single area in response to a complaint 
filed against a home by a resident, the resident's family or friends, 
or nursing home employees. Quality-of-care problems identified during 
either standard surveys or complaint investigations are classified in 1 
of 12 categories according to their scope (the number of residents 
potentially or actually affected) and their severity (potential for or 
occurrence of harm to residents).

Ensuring that documented deficiencies are corrected is likewise a 
shared responsibility. CMS is responsible for enforcement actions 
involving homes with Medicare or dual Medicare and Medicaid 
certification--about 86 percent of all homes. States are responsible 
for enforcing standards in homes with Medicaid-only certification--
about 14 percent of the total. Enforcement actions can involve, among 
other things, requiring corrective action plans, imposing monetary 
fines, denying the home Medicare and Medicaid payments for new 
admissions until corrections are in place, and, ultimately, terminating 
the home from participation in these programs. Sanctions are imposed by 
CMS on the basis of state referrals. States may also use their state 
licensure authority to impose state sanctions.

CMS is also responsible for overseeing each state survey agency's 
performance in ensuring quality of care in its nursing homes. One of 
its primary oversight tools is the federal monitoring survey, which is 
required annually for at least 5 percent of all Medicare-and Medicaid-
certified nursing homes. Federal monitoring surveys can be either 
comparative or observational. A comparative survey involves a federal 
survey team conducting a complete, independent survey of a home within 
2 months of the completion of a state's survey in order to compare and 
contrast the findings. In an observational survey, one or more federal 
surveyors accompany a state survey team to a nursing home to observe 
the team's performance. Roughly 85 percent of federal surveys are 
observational. Based on prior work, we have concluded that the 
comparative survey is the more effective of the two federal monitoring 
surveys for assessing state agencies' abilities to identify serious 
deficiencies in nursing homes and have recommended that more priority 
be given to them. A new federal oversight tool, state performance 
reviews, implemented in October 2000, measures state survey agency 
performance against seven standards, including statutory requirements 
regarding survey frequency, requirements for documenting deficiencies, 
and timeliness of complaint investigations. These reviews replaced 
state self-reporting of their compliance with federal requirements. CMS 
also maintains a central database--the On-Line Survey, Certification, 
and Reporting (OSCAR) system--that compiles, among other information, 
the results of every state survey conducted at Medicare-and Medicaid-
certified facilities nationwide.

Magnitude of Problems Remains Cause for Concern, Even Though Fewer 
Serious Nursing Home Quality Problems Were Reported:

State survey data indicate that the proportion of nursing homes with 
serious quality problems remains unacceptably high, despite a decline 
in such reported problems since mid-2000. For an 18-month period ending 
in January 2002, 20 percent of nursing homes (about 3,500) were cited 
for deficiencies involving actual harm or immediate jeopardy to 
residents. This share is down from 29 percent (about 5,000 homes) for 
the previous period.[Footnote 3] (Appendix I provides trend data on the 
percentage of nursing homes cited for serious deficiencies for all 50 
states and the District of Columbia.) Despite this decline, there is 
still considerable variation in the proportion of homes cited for such 
serious deficiencies, ranging from about 7 percent in Wisconsin to 
about 50 percent in Connecticut.

Federal comparative surveys completed during a recent 21-month period 
found actual harm or higher-level deficiencies in about 10 percent 
fewer homes where state surveyors found no such deficiencies, compared 
to an earlier period. Fewer discrepancies between federal and state 
surveys suggest that state surveyors' performance in documenting 
serious deficiencies has improved. However, the magnitude of the state 
surveyors' understatement of quality problems remains a serious issue. 
From June 2000 through February 2002, federal surveyors conducting 
comparative surveys found examples of actual harm deficiencies in about 
one fifth of homes that states had judged to be deficiency free. For 
example, federal surveyors found that a home had failed to prevent 
pressure sores, failed to consistently monitor pressure sores when they 
did develop, and failed to notify the physician promptly so that proper 
treatment could be started. These federal surveyors noted that 
inadequate monitoring of pressure sores was a problem during the 
state's survey that should have been found and cited. CMS plans to hire 
a contractor to perform approximately 170 additional comparative 
surveys each year, bringing the annual total to 330, including those 
conducted by CMS surveyors.[Footnote 4] We continue to believe that 
comparative surveys are the most effective technique for assessing 
state agencies' ability to identify serious deficiencies in nursing 
homes because they constitute an independent evaluation of the state 
survey.[Footnote 5]

Beyond the continuing high prevalence of actual harm or immediate 
jeopardy deficiencies, we found a disturbing understatement of actual 
harm or higher deficiencies in a sample of surveys that were conducted 
since July 2000 at homes with a history of harming residents but whose 
current surveys indicated no actual harm deficiencies. Overall, 39 
percent of 76 surveys we reviewed had documented problems that should 
have been classified as actual harm: serious, avoidable pressure sores; 
severe weight loss; and multiple falls resulting in broken bones and 
other injuries. We were unable to assess whether the scope and severity 
of other deficiencies in our sample of surveys were also understated 
because of weaknesses in how those deficiencies were documented.

Weaknesses Persist in State Survey, Complaint, and Enforcement 
Activities:

Despite increased attention in recent years, widespread weaknesses 
persist in state survey, complaint investigation, and enforcement 
activities. In our view, this reflects not necessarily a lack of effort 
but rather the magnitude of the challenge in effecting important and 
consistent systemic change across all states. We identified several 
factors that contributed to these weaknesses and the understatement of 
survey deficiencies, including confusion over the definition of actual 
harm. Moreover, many state complaint investigation systems still have 
timeliness problems and some states did not comply with HCFA's policy 
to refer to the agency for immediate sanction those nursing homes that 
showed a pattern of harming residents, resulting in hundreds of nursing 
homes not appropriately referred for action.

Confusion about Definition of Harm and Other Factors Contribute to 
Underreporting of Care Problems:

We identified several factors at the state level that contributed to 
the understatement of serious quality-of-care problems. State survey 
agency officials expressed confusion about the definitions of "actual 
harm" and "immediate jeopardy," which may contribute to the variability 
in identifying deficiencies among states. Several states' comments on 
our draft report underscored how the lack of clear and consistent CMS 
guidance on these definitions may have contributed to such confusion. 
For example, supplementary guidance provided to one state by its CMS 
regional office on how to assess the severity of a newly developing 
pressure sore was inconsistent with CMS's definition of actual harm.

Other factors that have contributed to the understatement of actual 
harm include lack of adequate state supervisory review of survey 
findings, large numbers of inexperienced surveyors, and continued 
survey predictability. While most of the 16 states we contacted had 
processes for supervisory review of deficiencies cited at the actual 
harm level and higher, half did not have similar processes to help 
ensure that the scope and severity of less serious deficiencies were 
not understated.[Footnote 6] According to state officials, the large 
number of inexperienced surveyors, which ranged from 25 percent to 70 
percent in 27 states and the District of Columbia and is due to high 
attrition and hiring limitations, has also had a negative impact on the 
quality of surveys. In addition, our analysis of OSCAR data indicated 
that the timing of about one-third of the most recent state surveys 
nationwide remained predictable--a slight reduction from homes' prior 
surveys, about 38 percent of which were predictable. Predictable 
surveys can allow quality-of-care problems to go undetected because 
homes, if they choose to do so, may conceal certain problems such as 
understaffing.

Many State Complaint Investigation Systems Still Have Timeliness 
Problems and Other Weaknesses:

CMS's 2001 review of a sample of complaints in all states demonstrated 
that many states were not complying with CMS complaint investigation 
timeliness requirements. Specifically, 12 states were not investigating 
all immediate jeopardy complaints within the required 2 workdays, and 
42 states were not complying with the new requirement established in 
1999 to investigate actual harm complaints within 10 days.[Footnote 7] 
Some states attributed the timeliness problem to an increase in the 
number of complaints and to insufficient staff. CMS also found that the 
triaging of complaints to determine how quickly to investigate each 
complaint was inadequate in some states. A CMS-sponsored study of the 
states' complaint practices also raised concerns about state approaches 
to accepting and investigating complaints. For example, 15 states did 
not provide toll-free hotlines to facilitate the filing of complaints 
and the majority of states lacked adequate systems for managing 
complaints. To address the latter problem, CMS planned to implement a 
new complaint tracking system nationwide in October 2002, but as of 
today, the system is still being tested and its implementation date is 
uncertain.

Substantial Number of Nursing Homes Were Not Referred to CMS for 
Immediate Sanctions:

State survey agencies did not refer a significant number of cases where 
nursing homes were found to have a pattern of harming residents to CMS 
for immediate sanction as required by CMS policy, significantly 
undermining the policy's intended deterrent effect. Our earlier work 
found that nursing homes tended to "yo-yo" in and out of compliance, in 
part because HCFA rarely imposed sanctions on homes with a pattern of 
deficiencies that harmed residents.[Footnote 8] In response, the agency 
required that, as of January 2000, homes found to have harmed residents 
on successive standard surveys be referred to it for immediate 
sanction.[Footnote 9] While most states did not forward at least some 
cases that should have been referred under this policy, four states 
accounted for over half of the 700 nursing homes not referred. One of 
these states did not fully implement the new CMS policy until mid-2002 
and another state implemented its own version of the policy through 
September 2002, resulting in relatively few referrals. In most other 
states, the failure to refer cases resulted from a misunderstanding of 
the policy by both some states and CMS regional offices and, in some 
states, from the lack of an adequate system for tracking a home's 
survey history to determine if it met the policy's criteria.

CMS Oversight of State Survey Activities Requires Further 
Strengthening:

While CMS has instituted a more systematic oversight process of state 
survey and complaint activities by initiating annual state performance 
reviews, CMS officials acknowledged that the effectiveness of the 
reviews could be improved. Major areas needing improvement as a result 
of the fiscal year 2001 review include (1) distinguishing between minor 
and major problems, (2) evaluating how well states document 
deficiencies, and (3) ensuring consistency in how regions conduct 
reviews. Data limitations, particularly involving complaints, and 
inconsistent use of periodic monitoring reports also hampered the 
effectiveness of state performance reviews. For subsequent reviews, CMS 
plans to more centrally manage the process to improve consistency and 
to help ensure that future reviews distinguish serious from minor 
problems.

Implementation has been significantly delayed for three federal 
initiatives that are critical to reducing the subjectivity in the state 
survey process for identifying deficiencies and determining the 
seriousness of complaints. These delayed initiatives were intended to 
strengthen the methodology for conducting surveys, improve surveyor 
guidance for determining the scope and severity of deficiencies, and 
increase standardization in state complaint investigation processes.

* Strengthening the survey methodology. Because surveyors often missed 
significant care problems due to weaknesses in the survey process, HCFA 
contracted in 1998 for the development of a revised survey methodology. 
The agency's contractor has proposed a two-phase survey process. In the 
first phase, surveyors would initially identify potential care problems 
using data generated off-site prior to the start of the survey and 
additional, standardized information collected on-site. During the 
second phase, surveyors would conduct an onsite investigation to 
confirm and document the care deficiencies initially identified. 
Compared to the current survey process, the revised methodology under 
development is designed to more systematically target potential 
problems at a home and give surveyors new tools to more adequately 
document care outcomes and conduct onsite investigations. In April 
2003, a CMS official told us that the agency lacked adequate funding to 
complete testing and implementation of the revised methodology under 
development for almost 5 years. Through September 2003, CMS will have 
committed about $4.7 million to this effort. While CMS did not address 
the lack of adequate funding in its comments on our draft report, a CMS 
official subsequently told us that about $508,000 has now been slated 
for additional field testing. This amount, however, has not yet been 
approved. Not funding the additional field testing could jeopardize the 
entire initiative, in which a substantial investment has already been 
made.

* Developing clearer guidance for surveyors. Recognizing 
inconsistencies in how the scope and severity of deficiencies are cited 
across states, in October 2000, HCFA began developing more structured 
guidance for surveyors, including survey investigative protocols for 
assessing specific deficiencies. The intent of this initiative is to 
enable surveyors to better (1) identify specific deficiencies, (2) 
investigate whether a deficiency is the result of poor care, and (3) 
document the level of harm resulting from a home's identified deficient 
care practices. Delays have occurred, and the first such guidance to be 
completed--pressure sores--has not yet been released.

* Developing additional state guidance for investigating complaints. 
Despite initiation of a complaint improvement project in 1999, CMS has 
not yet developed detailed guidance for states to help improve their 
complaint investigation systems. CMS received its contractor's report 
in June 2002, and indicated agreement with the report's conclusion that 
reforming the complaint system is urgently needed to achieve a more 
standardized, consistent, and effective process. CMS told us that it 
plans to issue new guidance to the states in late fiscal year 2003--
about 4 years after the complaint improvement project initiative was 
launched.

Conclusions:

As we reported in September 2000, continued federal and state attention 
is required to ensure necessary improvements in the quality of care 
provided to the nation's vulnerable nursing home residents. The 
proportion of homes reported to have harmed residents is still 
unacceptably high, despite the reported decline in the incidence of 
such problems. This decline is consistent with the concerted 
congressional, federal, and state attention focused on addressing 
quality of care problems. Despite these efforts, however, CMS needs to 
continue its efforts to better ensure consistent compliance with 
federal quality requirements. Several areas that require CMS's ongoing 
attention include: (1) developing more structured guidance for 
surveyors to address inconsistencies in how the scope and severity of 
deficiencies are cited across states, (2) finalizing and implementing 
the survey methodology redesign intended to make the survey process 
more systematic, (3) implementing a nationwide complaint tracking 
system and providing states additional complaint investigation 
guidance, and (4) refining the newly established state agency 
performance standard reviews to ensure that states are held accountable 
for ensuring that nursing homes comply with federal nursing home 
quality standards. Some of these efforts have been underway for several 
years, with CMS consistently extending their estimated completion and 
implementation dates. The need to come to closure on these initiatives 
is clear. The report on which this testimony is based contained several 
new recommendations for needed CMS actions on these issues; CMS 
generally concurred with our recommendations.[Footnote 10] We believe 
that effective and timely implementation of planned improvements in 
each of these areas is critical to ensuring better quality care for the 
nation's 1.7 million vulnerable nursing home residents.

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

Contact and Staff Acknowledgments:

For further information about this testimony, please contact Kathryn G. 
Allen at (202) 512-7118 or Walter Ochinko at (202) 512-7157. Jack 
Brennan, Patricia A. Jones, and Dean Mohs also made key contributions 
to this statement.

[End of section]

Appendix I: Trends in The Proportion of Nursing Homes Cited for Actual 
Harm or Immediate Jeopardy Deficiencies, 1999-2002:

Table 1: 

State: Alabama; Number of homes surveyed: 1/97-6/98: 227; 
Number of homes surveyed: 1/99-7/00: 225; Number of homes surveyed: 7/
00-1/02: 228; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 51.1; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 42.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -8.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -23.8.

State: Alaska; Number of homes surveyed: 1/97-6/98: 16; Number 
of homes surveyed: 1/99-7/00: 15; Number of homes surveyed: 7/00-1/02: 
15; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 37.5; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 20.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 33.3; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: -17.5; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: 13.3.

State: Arizona; Number of homes surveyed: 1/97-6/98: 163; 
Number of homes surveyed: 1/99-7/00: 142; Number of homes surveyed: 7/
00-1/02: 147; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 17.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 33.8; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 8.8; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 16.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -25.0.

State: Arkansas; Number of homes surveyed: 1/97-6/98: 285; 
Number of homes surveyed: 1/99-7/00: 273; Number of homes surveyed: 7/
00-1/02: 267; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 14.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 37.7; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 27.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 23.0; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.4.

State: California; Number of homes surveyed: 1/97-6/98: 1,435; 
Number of homes surveyed: 1/99-7/00: 1,400; Number of homes surveyed: 
7/00-1/02: 1,348; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 28.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 29.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 9.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -19.9.

State: Colorado; Number of homes surveyed: 1/97-6/98: 234; 
Number of homes surveyed: 1/99-7/00: 227; Number of homes surveyed: 7/
00-1/02: 225; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 11.1; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 15.4; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 26.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 10.8.

State: Connecticut; Number of homes surveyed: 1/97-6/98: 263; 
Number of homes surveyed: 1/99-7/00: 262; Number of homes surveyed: 7/
00-1/02: 259; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 52.9; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 48.5; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 49.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.4; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 0.9.

State: Delaware; Number of homes surveyed: 1/97-6/98: 44; 
Number of homes surveyed: 1/99-7/00: 42; Number of homes surveyed: 7/
00-1/02: 42; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 45.5; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 52.4; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 14.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 6.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -38.1.

State: District of Columbia; Number of homes surveyed: 1/97-6/
98: 24; Number of homes surveyed: 1/99-7/00: 20; Number of homes 
surveyed: 7/00-1/02: 21; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 12.5; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 10.0; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 33.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -2.5; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 23.3.

State: Florida; Number of homes surveyed: 1/97-6/98: 730; 
Number of homes surveyed: 1/99-7/00: 753; Number of homes surveyed: 7/
00-1/02: 742; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 36.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 20.8; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -15.5; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -0.8.

State: Georgia; Number of homes surveyed: 1/97-6/98: 371; 
Number of homes surveyed: 1/99-7/00: 368; Number of homes surveyed: 7/
00-1/02: 370; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 17.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 22.6; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.0.

State: Hawaii; Number of homes surveyed: 1/97-6/98: 45; Number 
of homes surveyed: 1/99-7/00: 47; Number of homes surveyed: 7/00-1/02: 
46; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 24.4; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 25.5; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 15.2; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: 1.1; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -10.3.

State: Idaho; Number of homes surveyed: 1/97-6/98: 86; Number 
of homes surveyed: 1/99-7/00: 83; Number of homes surveyed: 7/00-1/02: 
84; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 55.8; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 54.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 31.0; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: -1.6; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -23.3.

State: Illinois; Number of homes surveyed: 1/97-6/98: 899; 
Number of homes surveyed: 1/99-7/00: 900; Number of homes surveyed: 7/
00-1/02: 881; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 29.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 29.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 15.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -0.5; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.9.

State: Indiana; Number of homes surveyed: 1/97-6/98: 602; 
Number of homes surveyed: 1/99-7/00: 590; Number of homes surveyed: 7/
00-1/02: 573; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 40.5; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 45.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 26.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -19.1.

State: Iowa; Number of homes surveyed: 1/97-6/98: 525; Number 
of homes surveyed: 1/99-7/00: 492; Number of homes surveyed: 7/00-1/02: 
494; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 39.2; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 19.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 9.9; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: -19.9; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -9.4.

State: Kansas; Number of homes surveyed: 1/97-6/98: 445; 
Number of homes surveyed: 1/99-7/00: 410; Number of homes surveyed: 7/
00-1/02: 400; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 47.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 37.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 29.0; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -9.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.1.

State: Kentucky; Number of homes surveyed: 1/97-6/98: 318; 
Number of homes surveyed: 1/99-7/00: 312; Number of homes surveyed: 7/
00-1/02: 306; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 28.6; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 28.8; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -3.7.

State: Louisiana; Number of homes surveyed: 1/97-6/98: 433; 
Number of homes surveyed: 1/99-7/00: 387; Number of homes surveyed: 7/
00-1/02: 367; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 12.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 19.9; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 23.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 7.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 3.5.

State: Maine; Number of homes surveyed: 1/97-6/98: 135; Number 
of homes surveyed: 1/99-7/00: 126; Number of homes surveyed: 7/00-1/02: 
124; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 7.4; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 10.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 9.7; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: 2.9; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -0.6.

State: Maryland; Number of homes surveyed: 1/97-6/98: 258; 
Number of homes surveyed: 1/99-7/00: 242; Number of homes surveyed: 7/
00-1/02: 248; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 19.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 25.6; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 6.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -5.5.

State: Massachusetts; Number of homes surveyed: 1/97-6/98: 
576; Number of homes surveyed: 1/99-7/00: 542; Number of homes 
surveyed: 7/00-1/02: 512; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 24.0; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 33.0; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 22.9; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 9.0; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.2.

State: Michigan; Number of homes surveyed: 1/97-6/98: 451; 
Number of homes surveyed: 1/99-7/00: 449; Number of homes surveyed: 7/
00-1/02: 441; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 43.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 42.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 24.7; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -1.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -17.4.

State: Minnesota; Number of homes surveyed: 1/97-6/98: 446; 
Number of homes surveyed: 1/99-7/00: 439; Number of homes surveyed: 7/
00-1/02: 431; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 29.6; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 31.7; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.8; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 2.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.9.

State: Mississippi; Number of homes surveyed: 1/97-6/98: 218; 
Number of homes surveyed: 1/99-7/00: 202; Number of homes surveyed: 7/
00-1/02: 219; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 24.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 33.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 19.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 8.4; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.5.

State: Missouri; Number of homes surveyed: 1/97-6/98: 595; 
Number of homes surveyed: 1/99-7/00: 584; Number of homes surveyed: 7/
00-1/02: 569; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 21.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 22.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 10.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 1.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.1.

State: Montana; Number of homes surveyed: 1/97-6/98: 106; 
Number of homes surveyed: 1/99-7/00: 104; Number of homes surveyed: 7/
00-1/02: 103; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 38.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 37.5; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.2; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -1.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.3.

State: Nebraska; Number of homes surveyed: 1/97-6/98: 263; 
Number of homes surveyed: 1/99-7/00: 242; Number of homes surveyed: 7/
00-1/02: 243; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 32.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 26.0; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.9; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -6.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -7.1.

State: Nevada; Number of homes surveyed: 1/97-6/98: 49; Number 
of homes surveyed: 1/99-7/00: 52; Number of homes surveyed: 7/00-1/02: 
51; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 40.8; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 32.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 9.8; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: -8.1; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: -22.9.

State: New Hampshire; Number of homes surveyed: 1/97-6/98: 86; 
Number of homes surveyed: 1/99-7/00: 83; Number of homes surveyed: 7/
00-1/02: 79; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 30.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 37.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 21.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 7.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -15.8.

State: New Jersey; Number of homes surveyed: 1/97-6/98: 377; 
Number of homes surveyed: 1/99-7/00: 359; Number of homes surveyed: 7/
00-1/02: 366; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 13.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 24.5; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 22.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 11.5; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.1.

State: New Mexico; Number of homes surveyed: 1/97-6/98: 88; 
Number of homes surveyed: 1/99-7/00: 82; Number of homes surveyed: 7/
00-1/02: 82; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 11.4; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 31.7; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 17.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 20.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -14.6.

State: New York; Number of homes surveyed: 1/97-6/98: 662; 
Number of homes surveyed: 1/99-7/00: 668; Number of homes surveyed: 7/
00-1/02: 671; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 13.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 32.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 32.3; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 18.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 0.2.

State: North Carolina; Number of homes surveyed: 1/97-6/98: 
407; Number of homes surveyed: 1/99-7/00: 414; Number of homes 
surveyed: 7/00-1/02: 419; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 31.0; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 40.8; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 30.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 9.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.7.

State: North Dakota; Number of homes surveyed: 1/97-6/98: 88; 
Number of homes surveyed: 1/99-7/00: 89; Number of homes surveyed: 7/
00-1/02: 88; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 55.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 21.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 28.4; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -34.4; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 7.1.

State: Ohio; Number of homes surveyed: 1/97-6/98: 1,043; 
Number of homes surveyed: 1/99-7/00: 1,047; Number of homes surveyed: 
7/00-1/02: 1,029; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 31.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 29.0; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 23.7; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -2.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -5.3.

State: Oklahoma; Number of homes surveyed: 1/97-6/98: 463; 
Number of homes surveyed: 1/99-7/00: 432; Number of homes surveyed: 7/
00-1/02: 394; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 8.4; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 16.7; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 8.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 3.9.

State: Oregon; Number of homes surveyed: 1/97-6/98: 171; 
Number of homes surveyed: 1/99-7/00: 158; Number of homes surveyed: 7/
00-1/02: 152; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 43.9; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 47.5; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 33.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 3.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.9.

State: Pennsylvania; Number of homes surveyed: 1/97-6/98: 811; 
Number of homes surveyed: 1/99-7/00: 788; Number of homes surveyed: 7/
00-1/02: 764; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 29.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 32.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 11.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 2.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -20.6.

State: Rhode Island; Number of homes surveyed: 1/97-6/98: 102; 
Number of homes surveyed: 1/99-7/00: 99; Number of homes surveyed: 7/
00-1/02: 99; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 11.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 12.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 10.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.0.

State: South Carolina; Number of homes surveyed: 1/97-6/98: 
175; Number of homes surveyed: 1/99-7/00: 178; Number of homes 
surveyed: 7/00-1/02: 180; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 28.6; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 28.7; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 17.8; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.9.

State: South Dakota; Number of homes surveyed: 1/97-6/98: 124; 
Number of homes surveyed: 1/99-7/00: 112; Number of homes surveyed: 7/
00-1/02: 114; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 40.3; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 24.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 30.7; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -16.2; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 6.6.

State: Tennessee; Number of homes surveyed: 1/97-6/98: 361; 
Number of homes surveyed: 1/99-7/00: 354; Number of homes surveyed: 7/
00-1/02: 377; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 11.1; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 26.0; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 16.7; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 14.9; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -9.3.

State: Texas; Number of homes surveyed: 1/97-6/98: 1,381; 
Number of homes surveyed: 1/99-7/00: 1,336; Number of homes surveyed: 
7/00-1/02: 1,275; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 22.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 26.9; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.7; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -1.5.

State: Utah; Number of homes surveyed: 1/97-6/98: 98; Number 
of homes surveyed: 1/99-7/00: 95; Number of homes surveyed: 7/00-1/02: 
95; Percentage of homes cited for actual harm or immediate 
jeopardy: 1/97-6/98: 15.3; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/99-7/00: 15.8; Percentage of homes cited for 
actual harm or immediate jeopardy: 7/00-1/02: 15.8; Percentage 
point difference[A]: 1/97-6/98 and 1/99-7/00: 0.5; Percentage point 
difference[A]: 1/99-7/00 and 7/00-1/02: 0.0.

State: Vermont; Number of homes surveyed: 1/97-6/98: 45; 
Number of homes surveyed: 1/99-7/00: 46; Number of homes surveyed: 7/
00-1/02: 45; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 20.0; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 15.2; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 17.8; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 2.6.

State: Virginia; Number of homes surveyed: 1/97-6/98: 279; 
Number of homes surveyed: 1/99-7/00: 287; Number of homes surveyed: 7/
00-1/02: 285; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 24.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 19.9; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 11.6; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.8; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.3.

State: Washington; Number of homes surveyed: 1/97-6/98: 288; 
Number of homes surveyed: 1/99-7/00: 279; Number of homes surveyed: 7/
00-1/02: 275; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 63.2; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 54.1; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 38.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -9.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -15.6.

State: West Virginia; Number of homes surveyed: 1/97-6/98: 
130; Number of homes surveyed: 1/99-7/00: 147; Number of homes 
surveyed: 7/00-1/02: 143; Percentage of homes cited for actual 
harm or immediate jeopardy: 1/97-6/98: 12.3; Percentage of homes cited 
for actual harm or immediate jeopardy: 1/99-7/00: 15.6; Percentage of 
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 14.0; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 3.3; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -1.7.

State: Wisconsin; Number of homes surveyed: 1/97-6/98: 438; 
Number of homes surveyed: 1/99-7/00: 428; Number of homes surveyed: 7/
00-1/02: 421; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 17.1; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 14.0; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 7.1; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -3.1; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -6.9.

State: Wyoming; Number of homes surveyed: 1/97-6/98: 38; 
Number of homes surveyed: 1/99-7/00: 41; Number of homes surveyed: 7/
00-1/02: 40; Percentage of homes cited for actual harm or 
immediate jeopardy: 1/97-6/98: 28.9; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 43.9; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 22.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 15.0; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -21.4.

State: Nation; Number of homes surveyed: 1/97-6/98: 17,897; 
Number of homes surveyed: 1/99-7/00: 17,452; Number of homes surveyed: 
7/00-1/02: 17,149; Percentage of homes cited for actual harm 
or immediate jeopardy: 1/97-6/98: 27.7; Percentage of homes cited for 
actual harm or immediate jeopardy: 1/99-7/00: 29.3; Percentage of homes 
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.5; 
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 1.6; 
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.8.

Source: GAO analysis of OSCAR data as of June 24, 2002.

[A] Differences are based on numbers before rounding.

[End of table]

[End of section]

Related GAO Products:

Nursing Homes: Public Reporting of Quality Indicators Has Merit, but 
National Implementation Is Premature. GAO-03-187. Washington, D.C.: 
October 31, 2002.

Nursing Homes: Quality of Care More Related to Staffing than Spending. 
GAO-02-431R. Washington, D.C.: June 13, 2002.

Nursing Homes: More Can Be Done to Protect Residents from Abuse. GAO-
02-312. Washington, D.C.: March 1, 2002.

Nursing Homes: Federal Efforts to Monitor Resident Assessment Data 
Should Complement State Activities. GAO-02-279. Washington, D.C.: 
February 15, 2002.

VA Long-Term Care: Oversight of Community Nursing Homes Needs 
Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001.

Nursing Homes: Success of Quality Initiatives Requires Sustained 
Federal and State Commitment. GAO/T-HEHS-00-209. Washington, D.C.: 
September 28, 2000.

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of 
the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: September 
28, 2000.

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would 
Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: November 4, 
1999.

Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies 
to Better Ensure Quality of Care. GAO/T-HEHS-00-27. Washington, D.C.: 
November 4, 1999.

Nursing Home Oversight: Industry Examples Do Not Demonstrate That 
Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington, 
D.C.: August 13, 1999.

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

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

Nursing Homes: Complaint Investigation Processes in Maryland. GAO/T-
HEHS-99-146. Washington, D.C.: June 15, 1999.

Nursing Homes: Complaint Investigation Processes Often Inadequate to 
Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.

Nursing Homes: Stronger Complaint and Enforcement Practices Needed to 
Better Ensure Adequate Care. GAO/T-HEHS-99-89. Washington, D.C.: March 
22, 1999.

Nursing Homes: Additional Steps Needed to Strengthen Enforcement of 
Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March 18, 
1999.

California Nursing Homes: Federal and State Oversight Inadequate to 
Protect Residents in Homes with Serious Care Problems. GAO/T-HEHS-98-
219. Washington, D.C.: July 28, 1998.

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

FOOTNOTES

[1] U.S. General Accounting Office, Nursing Home Quality: Prevalence of 
Serious Problems, While Declining, Reinforces Importance of Enhanced 
Oversight, GAO-03-561 (Washington, D.C.: July 15, 2003).

[2] Effective July 1, 2001, the name of the Health Care Financing 
Administration (HCFA) was changed to the Centers for Medicare & 
Medicaid Services. In this testimony we continue to refer to HCFA where 
our findings apply to the organizational structure and operations 
associated with that name. 

[3] We analyzed OSCAR data for surveys performed from January 1, 1999, 
through July 10, 2000, and from July 11, 2000, through January 31, 
2002, and entered into OSCAR as of June 24, 2002. Immediate jeopardy 
involves situations with actual or potential for death/serious injury.

[4] Contractor proposals are due to CMS on July 19, 2003.

[5] In prior work completed on veterans' care in nursing homes, we 
recommended that the VA consider contracting with CMS to conduct these 
comparative surveys in order to better assess the quality of state data 
that are used in placing veterans in nursing homes. See U.S. General 
Accounting Office, VA Long-Term Care: Oversight of Community Nursing 
Homes Needs Strengthening, GAO-01-768 (Washington, D.C.: July 27, 
2001). VA has not contracted with CMS to conduct comparative surveys 
but is beginning to discuss the issue with CMS. 

[6] Officials explained the focus on actual harm or higher-level 
deficiencies by noting that the potential for sanctions increased the 
likelihood that the deficiencies would be challenged by the nursing 
home and perhaps appealed in an administrative hearing. 

[7] In March 1999, we reported that inadequate state complaint intake 
and investigation practices in states we reviewed had too often 
resulted in extensive delays in investigating serious complaints. As a 
result of our findings, HCFA began requiring states to investigate 
complaints that allege actual harm, but do not rise to the level of 
immediate jeopardy, within 10 working days. U.S. General Accounting 
Office, Nursing Homes: Complaint Investigation Processes Often 
Inadequate to Protect Residents, GAO/HEHS-99-80 (Washington, D.C.: Mar. 
22, 1999).

[8] See GAO/HEHS-99-46.

[9] This policy was implemented in two stages, and our analysis focused 
on implementation of the second stage beginning in January 2000. As of 
September 1998, HCFA required states to refer homes that had a pattern 
of harming a significant number of residents or placed residents at 
high risk of death or serious injury. Effective January 14, 2000, HCFA 
expanded this policy by requiring state survey agencies to refer for 
immediate sanction homes that had harmed residents on successive 
surveys. States are now required to deny a grace period to correct 
deficiencies without sanction to homes that are assessed one or more 
deficiencies at the actual harm level or above in each of two surveys 
within a survey cycle. A survey cycle is two successive standard 
surveys and any intervening survey, such as a complaint investigation.

[10] GAO-03-561.