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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