CMS Releases Results, Revisions to State Survey Agency Performance Standards

Regulation | October 21, 2019

CMS has released data and revised guidance on the State Performance Standards System that evalutes the performance of State Survey Agencies.

CMS released a pair of administrative memos on October 17 related to State Survey Agencies’ performance in the survey process. Admin Info: 20-01-ALL detailed results from the State Performance Standards System (SPSS) for Fiscal Years (FY) 2016 – 2018. Admin Info: 20-02-ALL announced revisions to the FY 2020 SPSS Guidance.

The SPSS measures State Survey Agencies’ (SSAs) survey performance according to 3 domains: Frequency, Quality, and Coordination of Noncompliance (formerly “Enforcement and Remedy”). This structure provides a framework for organizing and measuring important aspects of survey activities and, according to CMS, helps support efforts to standardize and promote consistency among SSAs. What follows is a brief explanation of each domain and the revisions for FY 2020.


What It Measures

The Frequency domain includes 5 scored measures. This domain evaluates State Survey Agencies’ performance on completing required surveys within specified timeframes. In addition to standard surveys, this includes off-hours surveys and surveys for nursing homes in the Special Focus Facility (SFF) program. This domain also measures timeliness of uploading survey information into the Certification and Survey Provider Enhanced Reports (CASPER) System.

Revisions for FY 2020

SSAs will have the ability to request that certain surveys are excluded from measurements. For example, if an SSA is unable to complete a survey due to a natural disaster, it can request that CMS exclude this survey from the measurement calculations. CMS will begin providing information to SSAs and Regional Offices (ROs) at specified intervals through the year about their progress toward measure goals. Also new for FY 2020, the measure of Special Focus Facility (SFF) surveys will be moved from the Enforcement and Remedy domain to the Frequency domain.


What It Measures

The Quality domain includes 9 scored measures. This domain evaluates SSAs’ performance in identifying and documenting noncompliance according to federal guidelines. This includes the identification and documentation of health, life safety code, and emergency preparedness deficiencies on standard and complaint surveys and the prioritization and investigation of complaints and facility-reported incidents.

Revisions for FY 2020

Measures will be divided to score performance on standard and complaint surveys separately. The method and criteria for the documentation of deficiencies measure has been revised. It will now include emergency preparedness tags and the criteria for meeting the measure has been reduced to 4 criteria for nursing homes. An excerpt containing these criteria is available in Tables 7 and 8 here.

Measures that previously focused on the Federal Oversight Support Survey (FOSS) will now include a new “Focused Concern” survey process to evaluate surveyors’ performance in identifying state-specific aspects of noncompliance. The evaluation of comparative nursing home surveys will include 2 years of comparative survey data, meaning that SSAs will be evaluated on their performance to cite deficiencies at a consistent scope and severity level using 2 years’ worth of survey data.

A new measure has been added to evaluate SSAs’ use of the new Immediate Jeopardy (IJ) template released in March. To meet criteria for this measure, SSAs must issue the IJ template at or before the exit conference and the IJ template must be completed appropriately as follows:

  • In the Noncompliance section: The f-tag was identified and the issues that led to the determination of noncompliance were provided.
  • In the Serious Injury, Serious Harm, Serious Impairment or Death section: The summary provided support that a serious adverse outcome occurred, or a serious adverse outcome was likely.
  • In the Need for Immediate Action section: The summary explained why the entity needed to take immediate action to correct noncompliance that caused or was likely to cause serious injury, serious harm, serious impairment, or death.

Lastly, a non-scored State Performance Indicator measure will be added to the Quality domain to help identify state-specific opportunities for improvement. CMS released the first wave of State Performance Indicators in Appendix 16 of the updated SPSS Guidance. An excerpt containing these indicators is available here.

Coordination of Provider Noncompliance

What It Measures

The Coordination of Provider Noncompliance domain, formerly “Enforcement and Remedy”, includes 3 scored measures. This domain evaluates SSAs’ performance in timeliness of processing for IJ cases, notification of Denial of Payment for New Admissions, and processing of provider agreement terminations.

Revisions for FY 2020

As noted above, the measure related to SFF nursing homes have been moved to the Frequency domain. A non-scored State Performance Indicator measure will also be added to this domain.

How Your State Survey Agency Measures Up

CMS found that in FY 2018, less than half (46%) of SSAs met requirements for frequency of nursing home standard surveys. Even fewer (39%) met requirements for timeliness of non-IJ complaint and incident investigations. CMS notes that complaints and facility-reported incidents have increased year over year, impeding the ability of SSAs to conduct timely investigations. A quick view of which states failed to meet thresholds for each measure in FY 2018 (the most recent FY for which data is available) can be found here.

SSAs complete corrective action plans for any unmet measures. According to CMS, this is done in collaboration with the ROs. Steps for improving performance include survey scheduling revisions, surveyor compensation enhancements, new recruitment strategies, surveyor training, increased communication with ROs, and consultative site visits. If these actions are unsuccessful at improving performance, CMS may withhold funding or enter into a Systems Improvement Agreement. This may include hiring outside contractors to conduct root cause analysis and consultation. If all above actions are unsuccessful, CMS may engage in communication with state senior leadership to “engage in further solution-driven communications.”

What This All Means for Providers

Broadly, expect SSAs to exert more effort on timely completion of surveys, identification and documentation of noncompliance, and use of the new IJ template. As we have noted previously, CMS’ efforts to increase consistency in the survey and certification process likely means higher numbers of citations and providers should expect that incidents and complaints related to potential abuse and neglect will receive significant scrutiny.

Additionally, now that CMS has introduced the Focused Concern Survey aspect of the Federal Oversight Support Survey, you can anticipate that areas of noncompliance that have been identified as a particular concern for your state, such as infection control, will be a significant focus in the survey process. Similarly, expect the survey process to be impacted by the State Performance Indicator chosen for your SSA.

For states that have fallen short on any SPSS measures in the past, such as meeting the threshold for off-hours surveys, you may have noticed concerted efforts in these areas in FY 2019. Expect that this will continue in FY 2020. Note that at least 50% of all off-hours surveys must be completed on weekends. If your nursing home has recognized staffing issues, you are more likely to receive an off-hours survey, as at least 50% of all off-hours surveys must also be completed from a list of nursing homes with potential staffing issues.

LeadingAge continues to advocate to CMS for improvements in the survey and certification process to include more consistency and a more constructive approach that will allow SSAs and providers to collaborate on improving quality of care.