Nursing Home Operators Feel There’s a Lot to Learn From Hospice Surveys Despite Regulatory Differences

Many nursing home operators that also have hospice operations can’t help but notice that the survey process on the hospice end is generally a more positive experience than in the nursing home world. And some say the collaborative nature – between facilities and the federal government – of hospice surveys can and should be replicated for nursing homes.

The regulatory burden on skilled nursing facilities and conditions of participation are much heavier than in the hospice space, so it would make sense that the survey process is also more tedious and in turn more stressful.

And yet, while the highly regulated field of skilled nursing facilities likely won’t convert to a comparatively less burdensome approach any time soon, there is still a lot to learn from the hospice survey process, according to Elizabeth McLaren, senior vice president of revenue cycle, reimbursement and home and community-based services (HCBS) at Illinois-based Covenant Living Communities and Services. 


A focus on patient satisfaction and placing more value on staff interviews, along with less reliance on cumbersome documentation, could be adopted from hospice practices as well, other leaders said. Moreover, hospice surveys are less frequent with hospice providers undergoing a survey process for accreditation every three years while SNF surveys are annual.

“[The hospice survey] didn’t feel punitive … [Surveyors] spent time with the staff, spent time with the hospice physician, went over what we needed to do differently to be successful,” said McLaren. “It really was collaborative.”

Covenant recently went through its Community Health Accreditation Partner (CHAP) survey for hospice facilities and the surveyors’ feedback felt more constructive, McLaren said. Surveyors saw what facilities were trying to do with certain operations and suggested how things could be done differently moving forward, she said. The process seemed less about fault-finding.


“The ease and collaborative nature of it is not in SNFs,” she added.

Hospice surveys are “kinder, gentler” surveys than what nursing facilities go through, added Anne Shelley, director of professional development and home health, hospice regulatory relations with LeadingAge Ohio.

“I don’t know if that’s the nature of hospice, or if it’s the nature of the survey team, or what, but they just don’t seem to be as harsh,” she said.

An executive for an Ohio provider that serves both nursing home and hospice patients said the hospice survey process doesn’t seem to be as contentious, while the SNF survey process perpetuates a lot of anxiety and fear among staff. 

This executive agreed that hospice surveyors felt more like consultants, and the whole process was less punitive than it has been in the skilled nursing world. The “tone and tenor” of SNF surveyors, how they engage with staff, is more contentious.

A timing issue

Backlogs in the state skilled nursing survey may have something to do with the difficult nature of the SNF surveys. Survey teams have had a lot of turnover since Covid perhaps due to this aspect. And as people have retired, new survey staff replacing them may require more time to train, and they’re really backlogged, McLaren said. Burnout linked to the SNF survey process is nothing new, with administrators citing surveys as a major factor when considering resignation.

“I honestly think it’s a timing issue. They have a lot that they have to get done. They have to work backwards, work forwards, meet deadlines for licenses that are expiring,” said McLaren. “A lot of folks are being thrown in the middle of the pool on the state survey side and just don’t necessarily have the resources or the time to get adequately trained or shadow … things are on fire.”

For the train, probe and educate (TPE) five-claim reviews going through SNF facilities, operators have been able to get out in front of those, at least at Covenant. These surveys are flagged in an online system, she said, and the minute there’s a request, staff at Covenant can manage it well and get needed information to surveyors thanks to internal tracking for each community with timelines and names of those responsible for certain documentation. 

However, for other operators the process drags on, with claims being reviewed, operators being issued an error rate and asked to participate in training or webinars. Auditors come back and review claims again after that, hopefully with a marked improvement in the error rate. But if not, the cycle repeats. 

SNF operators have three chances to reach a certain threshold in error rate, she said, before more action is triggered. One Covenant community has gone through this process, she said, and it has been a “painful process” of six months.

“We have had some partial denials with missing documentation. We had it, we just didn’t include that piece of information,” McLaren said of the five-claim reviews. “I think that’s where a lot of providers are going to get tripped up is understanding that when a Medicare auditor is looking at your documentation, they don’t know your resident.”

Auditors are mostly looking at the documentation, she said, not talking to staff about residents. Documentation must provide an accurate snapshot of the resident and nothing should be assumed, she added.

McLaren suggests reducing the information overload to simplify the process. Facilities should come up with a checklist of required information to send in, as well as a list of the additional service documentation that would round out a patient’s snapshot – while not sending too much information either, she said.

“If you send the whole chart that can hurt you too, because there’s so much information to sift through as they’re trying to do the audit. [Facility staff should] make it as easy as possible to find the information [surveyors] need to validate what you’ve provided,” said McLaren.

Interview-driven hospice surveys

Surveyors on the hospice end appear to have more time to spend with each facility, according to the Ohio nursing home executive.

And, there are no competing demands for their time, which is the case for SNF surveyors.

Surveyors in the skilled nursing space seem to have their time and resources pushed thin, with surveyors spending time at one facility only to get pulled to another building under immediate jeopardy, the executive noted.

Generally, hospice providers undergo a survey process for accreditation every three years through CHAP or the Accreditation Commission for Health Care (ACHC).

Shelley said regulatory agencies tried to change the timing to annual accreditation rather than every three years, but that didn’t go through. One big change, however, was in an attempt to look more at quality of care among hospice providers. CMS also streamlined the survey process for hospice providers, with state agencies and accrediting organizations now using the same process.

“The sample selection is supposed to be done by the surveyors themselves, as opposed to the hospices suggesting what patients they might go see,” Shelley said of the new hospice survey process.

Surveyors are choosing which patients they want to go see, usually those with high acuity, and could even go so far as to call patients to see if they’d like to be interviewed as part of the survey. This aspect is “significantly different” from previous years, Shelley said.

This is something SNF surveyors could do more of, she said, instead of focusing mostly on documentation.

“They’re still very driven by the documentation as opposed to truly looking at how that patient is being cared for,” said Shelley. “When the surveyors are going out on home visits for hospice they’re really focusing on the patient and on the caregivers to the point of actually interviewing the patient and caregivers.”

The interview process along with placing importance on staff when conducting surveys, are aspects that should be considered in the skilled nursing space, Shelley said, despite vast regulatory differences.

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