‘Driving Good People from Our Sector’: Nursing Home Operators Warn that Survey Process Worsens Labor Crisis

Nursing home operators and workers are warning that an onerous and punitive approach to surveys is contributing to administrator burnout and deepening the ongoing labor crisis.

“I was working at least 12 hour days every single day, and working the floor as a CNA as well, in addition to doing the administrator job because of short staffing,” former lead administrator Brynna Urich told Skilled Nursing News.

Colleagues describe Urich as dedicated and hardworking; after graduating college in 2018, she became an assistant administrator and later a lead administrator at a skilled nursing facility in Wisconsin. But she ultimately resigned, and she cites the survey process as one major factor that pushed her over the edge.

“I resigned my position because I was completely burned out,” she said. “Having three or four surveys in a row, back to back, with no break in between was absolutely and utterly exhausting.”

Urich now works as the admissions coordinator for Ingleside Communities. Yet she is still an advocate for survey reform for the skilled nursing industry, which, in the past three years, has paid nearly $500 billion in noncompliance penalties, according to CMS data.

“Over the last two years, [surveyors] put me in double-timelines, where they have come in and given a citation without time to complete my plan of correction and have that approved before they come back in again and cite me again,” Urich said.

In the midst of significant staffing shortages the past three years, operators have come to terms with how difficult it is to find and keep good administrators – and how, when a long-time administrator leaves, other staff may follow. This situation is making survey reform more pressing than ever, operators say.

Skilled nursing facilities are typically surveyed five to seven times a year; once annually, and otherwise as a response to complaints by residents; family members; current and former staff; or others, including many submitted anonymously. Survey guidelines are issued by the Centers for Medicare & Medicaid Services (CMS), although each state has its own survey agency responsible for quality assurance.

Wisconsin is one state where it is particularly difficult for administrators to navigate the survey process, according to Rick Abrams, CEO of the Wisconsin Health Care Association. He said that the administrator turn over and exodus from the profession is extremely troubling.

“Since January 1, 2022, there have been over 200 changes in administrators at our Wisconsin nursing facilities,” he told SNN. “In many of these instances, the administrator has not moved on to a different facility but has left the profession entirely. Just by speaking with [skilled nursing] owners personally, I can tell you the survey process is driving good people from our sector, and that’s got to change.”

Operators playing ‘catch up’ across the country

Skilled Nursing News reached out to the Wisconsin Division of Quality Assurance, which is in charge of administering nursing home surveys.

Wisconsin State Survey Agency Director Otis L. Woods told Skilled Nursing News in an email that there has been no shift in CMS guidance since the pandemic, and while operators may want a more “collaborative” survey environment, DQA is required to meet CMS standards as outlined in the State Operations Manual and federal memos, and does not have the authority to change the federal timeframe for correction.

Nursing home operators express frustration with what they perceive to be different approaches to surveys across different regions, and a generally more “punitive” survey regimen taking hold at the same time that the pandemic and a staffing crisis have made operating facilities harder than ever.

Skilled Nursing News analyzed CMS data on nursing home penalties and payment denials received by nursing homes for the past three years, which showed that penalties have increased to varying degrees in every region since 2019.

Operators in California, for example, were fined over $1 million in 2019, over $8 million in 2020, and over $9 million in 2021. Although 2022 reporting is not complete, the data shows that California and Texas, the states with the largest populations of older adults, paid nearly $24 million and $47 million, respectively, in fines the past three years.

Even in Vermont and Puerto Rico, with smaller populations of older adults, fines more than quadrupled over the past three years.

Bob Lane, CEO of The American College of HealthCare Administrators (ACHCA), said that the survey process has become more punitive across the country. He told SNN that operators feel like they are playing “catch up” in an effort to prepare for staffing mandates, which according to one estimate would require 191,000 nurses at an annual cost of $11.3 billion. That would be in order for nursing homes to meet a potential staffing minimum of 4.1 hours per resident day.

“The survey process has always been somewhat of a cause for a lot of stress for administrators,” he said. “ … The pandemic exacerbated things in a lot of ways because you have this whole other level of infection control specific surveys that have been going on.”

With the first major COVID-19 outbreaks occurring in skilled nursing facilities and nursing homes, the development of infection control guidelines did help to mitigate the spread of the virus and saved lives.

“There were some positive things that came out of [the pandemic] in terms of increased emphasis on infection control,” he said. “Probably a higher degree, in most cases, of attention to quality improvement efforts, looking at your processes and systems a little bit more closely.”

A more collaborative environment

Katie Casey has been a skilled nursing administrator for over six years, mainly working with facilities in the Midwest. She said most administrators, including herself, respect the role of surveyors and consider them to be working toward a shared goal: providing the best possible care and quality of life for the residents.

“Since COVID, and even during the pandemic, things seemed to really kind of change and it became a little bit more punitive,” she said. “There wasn’t really a lot of grace being given to those of us who were locked down for over a year with an unknown virus and staffing challenges to boot.”

State surveyors are typically registered nurses or other healthcare professionals. The most common citations SNFs receive are for infection control procedures, like handwashing, proper foley care, personal protective equipment protocol and medical recordkeeping, according to CMS data.

Depending on the nature of the noncompliance citation, penalties can range from $5,000 to $20,000.

“Hypothetically, when you get citations for infection control because you don’t have an infection preventionist on site [the day of the survey] it is because you have no staff to cover that role because you’re so busy working the floor,” Casey said. “I feel like a little grace should have been given maybe instead of a ‘harm-level’ citation because you didn’t have that designated infection preventionist.”

Operators are typically given a three-month window for when their annual survey might occur, although Casey said annual surveys do occasionally occur outside of the designated window.

“It’s very hard to be liable for things that are completely out of your control, like a pandemic, like labor shortages that you can’t handle,” she said.

But the wishes of people such as Casey can be hard to jibe with the perspective of surveyors that are governed by federal mandates.

Wisconsin’s Division of Quality Assurance does not have the authority to change the federal timeframe for correction, Woods told SNN.

“The CMS State Operations Manual (SOM) establishes mandatory standards for scheduling surveys and complaint investigations, classification of deficiencies, enforcement remedies, timelines for correction, and reporting requirements,” he wrote. “DQA is required to conduct all surveys of federally certified nursing homes as outlined in the federal State Operations Manual. DQA is required to meet CMS standards as outlined in the State Operations Manual and federal memos.”

Steve LaForte, Cascadia Healthcare’s director of corporate affairs and general counsel, told SNN the survey process can lead to unnecessary attrition in the industry.

“With the general nature of the staffing crisis that’s going on, it puts pressure on facility administrators,” he said. “There are easier ways and equally fulfilling ways to be employed.”

Laforte said the Joint Commission accreditation process, which most skilled nursing communities complete for certification, could serve as a model for an updated compliance survey process that keeps the realities of running a skilled nursing facility in mind.

“It’s not coming in with an eye on how we beat you up or how we find you know what, everything that’s wrong and punish you,” he said. “It’s how do we create a system and how do we create a dialogue with the state survey agency and the operators such that both want to raise the level of care and the quality of care and the quality of outcomes, without it being solely about how many tags they can give out.”