In an era when surveys – and delay in surveys – have been the cause for much stress among nursing home operators, a sometimes undervalued and overlooked strategy to minimize survey risk involves operators developing strong relationships with their state survey agencies.

That’s certainly an easier task compared to getting approval from national agencies like the Centers for Medicare & Medicaid Services (CMS) – and one that is especially popular among larger operators in smaller states. And aside from that, doing mock surveys and building a good reputation can go a long way in mitigating risks stemming from the arduous survey process.

That said, operators also believe the survey process – particularly as it pertains to facilities that change ownership – needs to change, especially if it involves facilities that were given a Special Focus Facilities (SFF) status under older leadership.

Cascadia Healthcare is the largest operator in Idaho, with 25 of its facilities in the state. Idaho is a small state with about 2 million people, and there’s “instantaneously about one degree of separation from everybody,” said Steve LaForte, director of corporate affairs and general counsel for the operator.

The company has developed a strong relationship with the bureau director and the head of health and welfare, something that would be much more difficult to do in California or Washington, he said.

“When you go in, when you have a problem, it’s not just you asking for something. You’ve developed some collaboration,” he said. Cascadia worked with the state agency to develop the only Covid-only building, and that fostered a great relationship while also opening doors for more conversations and collaboration.

Cascadia also has strong clinical resource teams thanks to their scale, and they do a lot of mock surveys. In terms of operators protecting themselves from bad surveys, LaForte said the industry must be vigilant in the quality of care provided. It doesn’t mean a bad survey won’t come in from time to time, but operators will be able to lean on their reputation in some part.

Brickyard Healthcare has a similar process, conducting regular internal audits to identify and address compliance issues before they become problems during external surveys, said Mary Oliver, vice president of risk and regulatory compliance for the Indiana operator. Staff are cross trained as well, to cover essential functions if key personnel are unavailable.

CMS is a harder nut to crack, LaForte said, but collaboration with the agency is sorely needed for national initiatives like the SFF program.

Moreover, facilities need to be offered a grace period with surveys, while scrubbing civil monetary penalties when an SFF building changes hands can also ease financial and legal headaches that arise in the aftermath of a ownership change, according to LaForte.

“CMS tends to be a little bit monolithic, a little bit Wizard of Oz, you know, the power behind the curtain,” said LaForte. “I’ve found through the work that I do, you can develop those dialogues [with CMS] to some extent.”

SFF program holds its own survey risk

LaForte believes risk around special focus program facilities isn’t talked about enough – not just the SFF buildings, but the list CMS has of these facilities.

“You have a facility that’s struggling, it might be on this SFF list, then the surveyor comes in and boom, they get hit again with [civil monetary penalties] CMPs. And so now the poor get poorer,” said LaForte. “You’ve identified this as a struggling facility. How do we help it get better? How do we help access to be maintained? How do we help sustainability?”

Instead, facilities on the SFF list are hit with more fines, they might have their CNA program blocked, and in time it’s harder to find staff and harder to stay in business, he said. Cascadia has acquired two SFF buildings, and one that is expected to end up on the list. They’re turnaround properties but a lot of the time they’re not coming from bad actors, he said.

“We’ve graduated all of those buildings, and we preserve care,” said LaForte. “One of the buildings was at one time the only [ventilator] unit in the state of Idaho … if you had a patient in the hospital who needed to be discharged to a SNF with vent care, the closest vent unit was 300 miles away. We know what that does to families, we know what that does to residents.”

LaForte has spoken with AHCA and various legislators about issues surrounding the SFF program in the past.

When advocating for turning around an special focus facility, everyone involved needs to think about building a sustainable system, when demographics are telling operators more beds are needed than what’s currently online.

Collaboration needs to happen between CMS and operators – the company turning around a property could use a break in surveys for six months, or a reduction in CMPs.

“We had one case where we took it all the way up to the top of CMS, or pretty darn close to the top. Their take was, we can’t do it because we inherited another operator’s CMP and that operator went into Chapter 7 bankruptcy, and they went away,” said LaForte. “So now we’re sitting here with an almost million dollar CMP.”

Cascadia appealed the CMP with the agency, but CMS said if they waived the fee it would set a bad precedent.

“What’s the bad precedent? That an operator comes in and saves a struggling building and does everything you want out of the SFF program?,” said LaForte. It all comes back to figuring out a way to institutionalize a system for struggling facilities, and an avenue for existing operators to take them over and improve them, all with the goal in mind of maintaining access and sustainability within communities.

Juggling surveys, assessments

Between complaint surveys, annual surveys, and the 5-claim probe nursing homes are undergoing, LaForte said there’s at least three to five buildings in a survey at any one time.

He called it an “incredibly complex balancing act” with staff often overwhelmed with all of the paperwork associated with different kinds of surveys.

LaForte hopes CMS, state agencies and operators can come up with a better way to streamline the survey process, and work with states to get them done in a more efficient way.

Leadership at Brickyard plans for the annual surveys in advance, Olivers said, creating a timeline that outlines key preparation activities throughout the year. When it comes to preparing for the 5-claim probe, staff regularly review documentation practices to ensure compliance. Internal audits are conducted to prepare for potential probes, much like Cascadia’s mock surveys.

Fast approaching assessments related to the federal minimum staffing mandate, she said, requires monitoring staffing levels closely. Scheduling software will help optimize shifts and ensure compliance.

Complaint surveys at Brickyard facilities are addressed quickly and thoroughly, Oliver said, to prevent formal escalation to formal surveys.