Nursing home operators are facing burdens and pressures related to the survey process, in yet another consequence of the severe labor shortages facing the sector.
Just as nursing homes have struggled to fill open positions, so too have survey agencies been dealing with worker shortages. Survey agencies are trying to shore up their ranks by making new hires — meaning that nursing home providers are interacting with less experienced surveyors than in the past.
As a result, survey timelines are sometimes being extended, concerns are mounting over incorrect citations, and surveys are causing undue stress on staff members who are already burned out and even suffering from post-traumatic stress due to their experiences during the Covid-19 pandemic, provider executives told Skilled Nursing News.
“We’re seeing green people coming in excited to do their job — I’m not saying they’re being vicious, but excited to do their job [and] not necessarily understanding their job, creating what we believe may be some errors that we then have to fight,” Kimberly Green, COO of Diakonos Group, told SNN. Diakonos operates eight skilled nursing and rehab centers, five intermediate care facilities and one assisted living community, all in Oklahoma.
Green and Erin Shvetzoff Hennessey, CEO of Health Dimensions Group (HDG), said their organizations have robust survey preparation processes in place, and do have open channels of communication with state officials overseeing surveys. Minneapolis-based HDG manages 30 health care properties, including SNFs, in seven states, and provides a range of other services and solutions.
Health department officials in states such as Oklahoma and Minnesota acknowledge the staffing-related strains that their survey teams have been facing, and are taking some steps to mitigate the resulting challenges.
But with skilled nursing providers already stretched thinly from an operational and financial perspective, survey-related challenges are yet another significant obstacle to overcome after the last three turbulent years.
Widespread surveyor shortages
The lack of surveyors is garnering notable attention, with several news reports in the last week focused on the issue.
An article in the Lexington Herald-Leader described the situation in Kentucky, where fewer than one in five surveyor positions were filled as of Oct. 2022.
A similar report came out of the Tarheel State.
“In North Carolina, we have about 420 nursing homes but less than 100 inspectors to ensure the facilities are maintaining high standards of care,” Lauren Schuster reported last week for NBC affiliate WCET. “Of the 97 inspectors, about 15% of those positions go unfilled and the turnover rate is nearly 35%, meaning more than one out of three inspectors leave the job within their first year.”
Meanwhile, the number of complaints against nursing homes in the state has risen 27% since 2016, she reported.
In West Virginia, seven of 16 surveyor positions are currently vacant, meaning about 44% of positions are not filled, Suzanne E. Messenger, the state’s long-term care ombudsman, said last week on a webinar hosted by the Long Term Care Community Coalition (LTCCC).
Another speaker on that webinar was Peter Gartrell, who is a member of Democratic Pennsylvania Sen. Bob Casey’s staff and serves as chief investigator on the U.S. Senate Special Committee on Aging. In that role, he was a leading force behind the “Uninspected and Neglected” report that was issued in May 2023, which put a spotlight on nationwide surveyor shortages.
Surveyor shortages contributed to survey delays across 27 states, the District of Columbia and Puerto Rico, that report revealed. The report also highlighted in stark terms the inexperience of many surveyors and the factors contributing to shortages.
For instance, the report cited officials in Kentucky, who explained, “Sixty-seven percent of our workforce have two years or less of surveying experience, which affects the quantity and quality of our work product. So training is crucial for these staff, however, at this time, Kentucky’s five trainer positions are vacant. Although we continue to post positions and conduct interviews routinely, once candidates are offered the position, they decline citing the low pay.”
In Minnesota, the survey agency’s federal survey team vacancy rate at one point was 30% and now is down to 25%, Health Regulation Division Director Maria King told SNN in an email. The state is continuing to “actively recruit new talent.” The reduced workforce has created difficulties in completing annual recertification surveys, particularly in light of the backlog created by a pause in such surveys during the Public Health Emergency (PHE), King noted.
While the media and government reports have understandably been focused on concerns over resident wellbeing, some have flagged that the surveyor shortage and inspection backlog are giving rise to operational complications for nursing home providers.
The Lexington Herald-Leader quoted Betsy Johnson, president of the Kentucky Association of Health Care Facilities, who said, “We are concerned about the workforce shortages that the state survey agency is experiencing, because timely surveys, a transparent and fair process, as well as ongoing communication between surveyors and providers, are of the utmost importance.”
Indeed, finding ways to resolve survey-related issues is critical as operators try to achieve greater stability after the PHE, Green and Hennessey emphasized.
‘Everything is different’
Extended survey length is one of the issues that Diakonos is experiencing, Green told SNN.
“What we’re seeing is the surveys that used to be in and out within three days are taking up to nine to 10 days,” she said.
While surveys are occurring, staff in the building are “on high alert” in order to be responsive to surveyor requests, she noted. So, she described surveys that stretch to 10 days as “absolutely exhausting.”
In some instances, surveyors have unexpectedly left a Diakonos building, according to Green. For example, a survey might be called at noon, and the survey team then would leave a few hours later, to go to another facility they were surveying nearby.
“That’s not how that normally happens,” Green said.
She also described surveyors having to leave abruptly, perhaps due to not being able to work more than a certain number of hours in a given week.
“On Thursday at two, they’ll say, ‘I’ll see you Monday,’” she said. “I’ve had one at an ICF/ID [intermediate care facility for individuals with intellectual disability] where they said, ‘I don’t know when we’ll be back.’ And so we hung out for like 15 days, just waiting for this survey to end.”
Survey length varies from a few days up to weeks due to a variety of factors that are “situational,” including the number of complaints, Erica Rankin-Riley, Public Information Officer with the Oklahoma State Department of Health (OSDH), told SNN in an email.
“There are multiple items that are situational, when it comes to surveying nursing homes. They are all different and the survey process is based on the deficient practices identified at each facility,” Rankin-Riley wrote.
The timeliness of 2567 Statements of Deficiencies being delivered also has become an issue in some instances, HDG’s Shvetzoff Hennessey told SNN. The lack of timeliness increases the likelihood that multiple survey cycles overlap, such as when an annual survey is still ongoing when a complaint survey begins.
“It’s been a real issue in some states,” Shvetzoff Hennessey said.
Providers also are concerned that inexperienced survey teams are issuing unwarranted or otherwise flawed citations.
“We’ve had some good surveys, so I don’t I don’t want to act like we haven’t; but we do have a situation where we feel [the tag] was absolutely incorrect,” Green said. “And we tried everything we could at the state level … now we’re taking it up to the CMS level.”
Shvetzoff Hennessey also flagged challenges related to more surveyors working on a contract basis — an ironic situation, given that nursing home operators have been working so hard to decrease their own use of agency labor.
“That’s tough, because you used to have survey teams that were used to working together, and they knew our communities, and you’d have some existing relationships,” she said. “And when they use agency themselves, just like in our building, agency is not as easy to work with; they don’t know your systems, they don’t know you. They’re not working as cohesively as a team.”
Perhaps the most profound issue relates to the strained relationship between surveyors and the nursing home staff, according to Diakonos’ Green. She said that surveyors do not consistently appreciate the effects of Covid-19 on nursing home operations and on staff.
“We feel different, we act different — I mean, everything is different,” she said.
On the operations side, one example of a change is the added work of daily Covid assessments and monitoring and surveillance reporting.
“That’s almost a full-time job, and we don’t have enough staff as it is,” Green said.
Then there’s the emotional and psychological toll that Covid-19 has taken on nursing home workers.
“If you walk through some of the buildings that were hardest hit, you’ll still see the tape marks from all of the plastic being hung, and where the walls were sprayed with the sanitizer, the paint is melting down the walls, because it takes so long to redo an entire facility,” she said. “There’s just marks everywhere.”
Nursing homes still have to operate in a compliant fashion, she emphasized, but she believes that survey teams — particularly those that are less experienced — are unnecessarily exacerbating challenges by taking a more combative rather than collaborative approach.
“We are trying to continue to run an industry on staff that have PTSD at such a [high] level, and they’re not getting help,” she said. “And so that does change how they perceive someone asking them questions … We were hoping [surveyors] would come in and have a lot of compassion and empathy for what we’ve been through, hold us accountable, but realize we’re partners.”
Moving forward
HDG is taking steps to prepare its teams for surveys, particularly by “doubling down” on mock surveys, Shvetzoff Hennessey said. That’s particularly important as team members who joined HDG — or even the nursing home industry itself — during Covid-19 have only gone through the more limited surveys focused on infection control.
Furthermore, HDG is focused on ensuring that nurse leaders are not being pulled onto the floor too frequently, so that they can provide the oversight and training needed to be fully prepared for surveys.
“Over those last two years, you had a lot of nurse leaders working the floor, which is a great example of respect and integrity and making sure residents have what they need — but when someone’s working at that level, they’re not able to audit the things that they should be,” Shvetzoff Hennessey said.
Diakonos Group likewise is focused on mock surveys.
“So far we’ve had excellent results from that; we’ve had a lot of brand new DONs and EDs go through that survey and [say], ‘I was fully prepared,’” Green said.
However, staffing challenges are sometimes an impediment to conducting the mock surveys on the ideal timelines. If a facility is lacking, say, a permanent DON, it’s not wise to call a mock survey and disrupt the building, Green noted.
She and Shvetzoff Hennessey both said their organizations are in contact with relevant officials to express concerns and discuss the way forward.
“A lot of us have really good relationships with people at the Department of Health, and so we can reach out and ask questions, as long as those people stay in place,” Green said, noting that she has seen some fluctuations in staffing at OSDH in the last two years.
But, she is grateful for “open conversations” with the Department of Health on monthly calls with providers.
“They’re hearing us, and if it gets too bad, I think that we could scream a little louder,” Green said.
Officials with OSDH and the Minnesota Department of Health also emphasized that all new surveyors go through the complete training as required by CMS. In Oklahoma, that takes the form of a five-month process that involves instructor-led and on-the-job training, with one component being about 150 hours of online training through the CMS Learning Management System.
In Minnesota, the survey agency also is “working to promote enhanced customer service skills,” including through the recent launch of an “updated survey experience feedback survey” that can be completed electronically and anonymously, King told SNN.
“MDH has also been working on a Collaborative Safety project which helps the SA look at causal factors of non-compliance and to identify potential measures (i.e., increased educational opportunities) to help address these issues,” King said.
And other states also are taking steps to try to address the survey issues, including surveyor shortages. In North Carolina, the governor has proposed surveyor salary increases and 15 additional positions, according to WECT. The state government in Kentucky also boosted the pay range for “nurse consultant inspectors” who lead survey teams, the Lexington Herald-Leader reported. The new salary range, effective July 1, is between $72,328 and $95,834.
At the federal level, Sen. Casey’s office is pushing for better funding to support survey activities. Congress appropriates less than 80 cents per day to nursing home oversight, the “Uninspected and Neglected” report stated.
While nursing home operators are seeking relief from the current survey crunch, they no doubt would like to see increased funding for purposes beyond oversight — including higher reimbursement rates and efforts to recruit and train more staff. And while they appreciate the challenges that survey agencies face in recruiting staff, operators also are downbeat to find themselves at loggerheads with survey teams after all the struggles of the last three years.
“I think that’s really disappointing, that post-Covid, after everything we’ve all been through together, that that didn’t bring us out better on the other side,” Green said.
Companies featured in this article:
CMS, Diakonos Group, HDG, Minnesota Department of Health, Oklahoma State Department of Health
