Nursing Home Operators Welcome CMS Risk-Based Surveys Despite High Eligibility Bar 

The nursing home industry has generally welcomed the risk-based survey approach announced last month by the Centers for Medicare and Medicaid Services (CMS), which rewards high-performing facilities with surveys that take half the time and require fewer surveyors.

But the new surveys aren’t simply a Five-star ratings shortcut.

CMS created an eligibility test that only 12% of nursing homes in the country currently pass – and the facilities chosen for the risk-based survey need to clear every criterion. Moreover, other steps involved in determining eligibility may limit the number of facilities that will ultimately be able to participate in the new surveys.

. It’s a high bar that Brian Ellsworth, vice president of strategy and policy at Health Dimensions Group, expects to be modified in the future.

Overall, the new risk-based surveys are a long time coming, Ellsworth said, with provider advocates pushing federal and state governments for a long time to target their oversight efforts toward consistent lower performers and incentivize consistently good performance.

That said, Michelle Stuercke, chief clinical officer at Transitional Care Management, said it’s a great first step by CMS. She’s encouraged to see the agency recognizing high-performing buildings in this way.

“If I’m a high-performing building and I’m constantly a Five-star building, I have good surveys, I think there should be some reward for that. I do applaud CMS for taking a carrot instead of a stick approach,” said Stuercke. “Having said that, we all often talk about the flaws in the Five-Star system to begin with. And with surveys, there’s still a lot of subjectivity.”

Variability between states and between surveyors can make eligibility much more fragile, she said.

Criteria spans star ratings, audits, SFF and schizophrenia diagnosis

To qualify for the risk-based survey, nursing homes must not have less than a Five-star overall rating and not have less than a 3-star staffing rating, according to a CMS memo. Qualifying nursing homes can’t have any citation for actual harm or immediate jeopardy, or substandard quality of care in the last survey cycle.

Additionally, facilities can’t have gone for more than 18 months without a standard survey, have any staffing waivers in effect, failed Payroll-Based Journal (PBJ) staffing data audits, failed the resident assessment Minimum Data Set (MDS) audit, or have a health inspection score higher than the 50^th percentile in their state.

“There’s all kinds of things that go into survey eligibility, but it really focuses on being a Five-star building, right? That’s the first step,” said Stuercke. “You need to consistently focus on things like survey readiness … we all know how important that is. Also, make sure that you’re reviewing your PBJ data and your staffing data to make sure that it’s all there. Make sure that you’ve got your eyes on your QM data.”

Three more criteria must be met: facilities can’t have two or more residents aged 65 or older that are coded with schizophrenia after being admitted without the diagnosis, there can’t be a change in ownership since the last standard survey, and a facility can’t be a Special Focused Facility candidate, CMS said.

Ellsworth expects qualifying criteria for this survey program to be examined and tweaked.

“They might want to consider expanding the program to four star rated facilities and other ways to more flexibly measure consistent good performance,” he said. “Measuring quality is not an exact science and we all need as many tools in the toolbox as we can get.”

Risk-based surveys may also help at a time when states are having difficulties hiring surveyors, Ellsworth said, not only due to level funding but also because of the same workforce shortages providers see every day.

“It is indeed an irony that one of the disqualifying criteria for the new risk-based program is not having had a standard survey in the last 18 months,” said Ellsworth. “The very backlog of surveys that this new policy is trying to address may be the cause of some otherwise qualified facilities missing out on this opportunity.”

The change of ownership criteria is another source of frustration for providers, Stuercke said. A provider could be waiting 18 months to finally be eligible for the risk-based survey, if ownership changed since its last standard survey.

“You have to have some surveys under your belt before you’re eligible again, and I know that’s a frustrating thing … nothing’s changed other than the owner,” said Stuercke.

How providers can prepare for risk-based surveys

Stuercke pointed to systems management as a way for providers to prepare for risk-based surveys and eventually meet criteria if they don’t right now. Providers that are constantly challenged with different quality measures oftentimes have an underlying systems issue, not an MDS coding issue.

“Buildings that tend to have challenges with their survey often have challenges with their systems as well,” said Stuercke. “Make sure that you focus on a systematic approach to whatever you’re looking at. What is our system? How is it working?”

Figuring out where a system breakdown happened can solve multiple issues at once, Stuercke said, if it’s a training or education issue, a process and procedure issue, or more of a management and supervision problem.

Having a continuous QAPI approach will help too, she said. In the event that a facility gets cited for actual harm, immediate jeopardy or substandard quality of care, it’s incredibly important to react with a root cause analysis to figure out what happened, what’s wrong with the system and what the facility can do better.

The operator must be transparent on what happened and what they did about it, including getting the medical director involved, doing more education or shoring up systems management. Then being proactive and digging down to root cause analysis.

“Change your clinical huddles, your daily morning meeting, into more of a proactive conversation,” said Stuercke. “When we focus on what outcome we’re expecting and what outcome we’re looking for, it changes the conversation, and it all becomes more proactive. The more proactive you are, the more that you find landmines that can cause you to have issues either during survey or with a [medical] event.”

One more piece of advice from Stuercke: providers should pay attention not only to their surveys and star ratings, but also to survey trends in their region or state.

“If you know that all of your peers are getting written on a certain tag, it makes sense to shore up on that tag,” said Stuercke. “And make sure that you understand what it says in the guidance to surveyors. Those critical element pathways are truly your friend … that’s what the surveyors are going to use.”