CMS to Implement Stricter Standards for State Nursing Home Surveyors

The federal government on Thursday rolled out yet another initiative aimed at nursing home safety, announcing a multi-pronged effort to strengthen its oversight of State Survey Agencies (SSAs).

The Centers for Medicare & Medicaid Services (CMS) will implement a variety of new assessment tools in the State Performance Standards System (SPSS), its rubric for grading the network of SSAs, for the 2020 fiscal year — which began October 1.

CMS enumerated its full plan in an October 17 memo to SSA directors from David Wright, director of its Quality and Safety Oversight Group.


“Nursing home patient and resident safety is a top priority for the Trump administration. Abuse and neglect are never acceptable,” CMS administrator Seema Verma said in a statement announcing the move. “After careful study of state inspector performance, CMS is taking action to increase oversight of inspectors and ensure states are conducting thorough and appropriate inspections.”

The rules will include a set of new metrics that CMS intends to review more frequently, with the goal of holding SSAs accountable for timely survey reports.

Source: CMS

CMS will also institute quarterly reviews of new “state performance indicators” — which include “metrics to provide information related to citation rates and the timeliness of complaint investigations, to allow for quick mitigation of issues” — as well as an increased emphasis on ensuring that SSAs handle instances of “immediate jeopardy” incidents faster and more accurately.


Finally, the federal government is considering the implementation of state-specific metrics based on the prevalence of certain nursing home safety issues in different regions.

“For example, a state experiencing specific problems with the complaint investigation process could employ a measure related to the complaint investigation process,” CMS noted. “This flexibility will help states focus on any specific challenges they face in their work to keep patients and residents safe.”

The new guidance marks the latest step in CMS’s newly aggressive push toward improving nursing home transparency and safety, an effort that Verma formally laid out in a five-point plan back in July. Other initiatives included the controversial addition of a warning icon on Nursing Home Compare for properties with recent incidents of abuse, as well as an overhaul of the five-star quality rating system for the nation’s more than 15,000 nursing facilities.

LeadingAge, a national trade group that represents non-profit post-acute and long-term care operators, pointed to the warning icon flap in a statement that expressed tentative praise for the new survey rules’ focus on timeliness and accuracy — while also raising concerns about “an even more punitive approach to surveys.”

“For instance, earlier this month, CMS announced plans to flag providers with an icon on Nursing Home Compare if they have been cited for abuse,” LeadingAge senior vice president for policy Ruth Katz said in a statement. “This memo, though, seems to suggest that CMS and survey agencies aren’t sure of their ability to accurately assess abuse. So we want to be sure that the terms of this memo will lead to the quality of care we all want.”

Back in August, Verma hinted at changes to SSA oversight efforts in a blog post.

“As the survey results come in, we’re analyzing the data, including focusing on outliers, such as states reporting a significantly lower than average number of citations per survey,” Verma wrote. “We review SSAs that are outliers and when warranted, require corrective action plans to ensure they are following CMS policies and procedures as expected.”

She also emphasized that the agency was looking for methods of enforcing issues without necessarily resorting to civil monetary penalties, or CMPs; the Thursday release from CMS emphasized that enforcement actions such as CMPs “are applied consistently.”

“CMS is considering new ways to address SSA performance problems beyond financial penalties — which can sometimes make bad situations worse,” she wrote.

Verma and CMS have additionally expressed interest in reducing the survey frequency for top-performing nursing homes — and using the resulting savings to increase inspections of lower-rated properties — though such a move would require the approval of Congress.

“We propose to survey top performing facilities every 30 months, with no more than 36 months between surveys of any single facility,” Verma wrote last month. “We would reinvest the savings to strengthen our oversight and quality improvement efforts for facilities that are low performers.”