Nursing Home Operators Optimistic About CMS Survey Testing, But Devil Lies in the Details

Potential changes to the nursing home survey process being mulled over by federal authorities – and aimed at standardization across states – have many operators feeling optimistic for the years ahead, especially given that regional differences in implementation can lead to extra administrative burdens and survey backlogs.

Toward the end of 2023, the Centers for Medicare & Medicaid Services (CMS) announced it would test new survey processes to facilitate timely completion of surveys at high risk nursing homes.

These new processes are being tested in the first couple months of 2024, CMS said, and are focused on allowing nursing homes to complete surveys more efficiently when the risk of resident harm is lower, thus saving more time and resources for surveys where the risk of resident harm is higher. The agency also hopes the new process will help address the survey backlog.

Operators often have to contend with varying scope and severity, said Lisa Chubb, chief clinical officer for Indiana-based Brickyard Healthcare, citing another reason to support survey process changes.

“CMS has known about this issue for quite some time,” said Chubb. “When you look at the CMS regions as a whole based on the data in the Casper citation reports – you can certainly see what regions are drastically behind when it comes to timeliness and backlog of surveys.”

Steve LaForte, chief legal officer and EVP of Corporate Affairs for Cascadia Healthcare based in Idaho, called the prospect of change to surveys “fantastic.”

“While I don’t think it fixes the many problems in the survey and regulatory process, it’s a start and seems positive in a common sense manner,” LaForte said. His one reservation is related to the lower risk surveys being in “limited instances,” per CMS.

The devil is in the details, he said, especially when it comes to how CMS defines “limited instances.” If the agency’s intent is to just arbitrarily utilize those more efficient surveys at a very small group of facilities and increase scrutiny everywhere else – that’s cause for concern, he said.

Since CMS’ announcement, LeadingAge sent a letter to the agency asking that CMS engage with stakeholders, including its national and state teams, to consider all options for survey reform.

“Nursing home leaders have first-hand experience; their input would ensure a well-rounded and viable result. Similarly, surveyors and survey agency leaders know the strengths and limitations of the current system well. Please allow us to collaborate with you in this endeavor,” Katie Smith-Sloan, president and CEO of LeadingAge, said in the letter dated Jan. 4.

American Health Care Association/National Center for Assisted Living (AHCA/NCAL) said it is awaiting more details about what this new approach entails, but from a high-level perspective, the organization supports a more effective survey process.

“A survey process that adds efficiencies could be helpful to reduce unnecessary administrative and workforce demands for both state survey agencies and nursing homes,” AHCA/NCAL said in an emailed statement to SNN. “This could help state survey agencies to catch up on delayed recertification surveys and maintain a timely pattern of surveys moving forward.”

Implications for the future

Chubb believes this move from CMS can shift processes to a more standardized approach, especially when it comes to survey outcomes and severity of citations. Meanwhile, LaForte hopes changes to the survey process will make lower risk surveys less “onerous” and “less punitive feeling.”

If this is the case for lower risk surveys, LaForte believes there will be a positive effect on staff morale.

“On the opposite side, those facilities at higher risk should be held to higher scrutiny and be surveyed in a more timely manner,” said LaForte.

LaForte is “always hopeful” that operators and CMS can get to a more collaborative place in the process that increases quality while avoiding unnecessary regulation, or excessive remedial measures. Such measures don’t really benefit the residents, and instead reduce funding for their care, he said.

“This seems like it could have the seeds of a change going in that direction, subject to my reservation,” said LaForte, referring to a concern around potentially less low risk surveys which only affect a handful of operators. “On their face [potential survey changes] make sense, and in that context I have to assume that they will stick, assuming proper surveyor training in the process.”

Operators will ultimately know more once CMS shares the results of its survey testing and any related actions, according to AHCA/NCAL.

While CMS can certainly take a more punitive approach to the industry at times, Chubb believes the agency and industry are on the same mission to provide better quality of care to residents. The current system treats nursing homes like they are all bad actors, AHCA/NCAL said in its email. As a result, the system has been shown to be inconsistent and ineffective, according to the association.

An approach where providers and regulators have a shared responsibility to do what is best for the residents, recognize good faith efforts and effectively remedy identified issues is the best path forward, AHCA/NCAL said.

Operator executives echoed these views.

“When innovation is brought to the industry that provides for better care and outcomes, we all certainly hope it sticks,” said Chubb. “We need to stand together to continue to make the magic happen inside the walls of these centers.”

Collaboration between providers and CMS has worked in the past, Smith-Sloan said in her letter, referring to a 2008 report on the survey process titled “Broken and Beyond Repair: Recommendations to Reform the Survey and Certification Systems.”

An example of this positive collaboration between nursing homes and federal agencies is in the area information exchange of policy and regulatory changes. One major change was the public availability of surveyor education and training materials, according to LeadingAge. CMS also now communicates policy changes through Quality, Safety and Oversight memos on a public-facing website, and the CMS Division of Nursing Homes hosts monthly calls with provider associations, including LeadingAge.

“Regulators and providers working together can be a force for positive, lasting change. However, many of the issues identified in 2008 persist today,” said Smith-Sloan. “The most common concerns that we hear from our members and state partners are that surveys are inconsistent, with wide variability in citation and enforcement across the country and a punitive, ‘gotcha’ approach that does not aid in quality improvement.”

Advice for operators during testing

AHCA/NCAL expects more surveyors will be on-site during these survey testing days. The association’s advice to operators is to participate in the process testing and seek to learn from it. But, it’s still going to cause strain in already understaffed buildings.

“While we understand there may be a need for additional surveyors during this process, we urge CMS to recognize this will add more strain on the nursing home staff and residents’ home environment,” AHCA/NCAL said in its statement.

Assuming quality operations are at a baseline, LaForte says he wouldn’t change anything just yet. If a facility is low risk, it’s still in the administration’s best interest to maintain the highest quality, along with the highest level of control and survey preparedness.

Higher risk facilities, regardless of the intended level of scrutiny from CMS, need to elevate quality and performance to ensure substantial compliance, said LaForte.

Generally, state surveys are disruptive to the day-to-day operations at facilities, Chubb said. With a projected increase in the number of surveyors on site during survey testing, this disruption may be more challenging despite being an indication for more streamlined processes.

“The advice that I would offer is to ensure that you are survey ready each day, that you have rounding in place, and to share any and all outcomes and experiences with the industry at large,” said Chubb. “We all collaborate at a higher level through state organizations, AHCA committees, and the Nurse Executive Council.”