Nursing Home Survey & Certification Process Reform: Priorities & Progress
LeadingAge identifies our nonprofit and mission-driven members’ greatest challenges and outlines our organization’s top advocacy priorities.
Overview: What’s the Issue?
The survey and certification process for nursing homes has been broken for years—and has now become a workforce issue. The stress of the intensely negative survey experience, and often demoralizing relations with surveyors, drive quality staff away from nursing homes. There exists a real struggle to attract workers to a sector where the focus is on regulatory compliance, rather than on care provision and quality improvement. Nursing homes and survey agencies alike are crippled by workforce shortages—and with the nursing home staffing standard on the horizon, these issues cannot be ignored any longer.
After convening our 36 state partners representing more than 2,000 mission-driven nursing home members across 41 states, we have identified priorities for reforming the nursing home survey and certification process. These priorities outlined below target the most commonly identified issues experienced by LeadingAge members, many of which are within the bounds of the Centers for Medicare & Medicaid Services’ power and regulatory authority to change.
Priorities & Action Areas
OUR GOAL: Logical consistency in citations and enforcement through increased surveyor accountability and fair appeals processes.
Rates of citation and enforcement vary widely from state to state. In Fiscal Year 2023 (FY 23), the average number of deficiencies on a standard survey ranged from 2.7 in one midwestern state to 22.6 in one mid-Atlantic state. The average dollar amount of a per day civil money penalty (CMP) in one mid-Atlantic state was $127,974.37, despite this state ranking third-lowest in the nation for actual harm deficiencies. Our members tell us that inconsistencies also exist among survey regions within the state, with interpretation of regulations and deficient practice guidance varying widely by surveyor. Despite these known inconsistencies, the process by which a provider may appeal a citation is limited in scope, varies from state to state, and lacks neutrality. Without consistent enforcement, we have no way to reliably measure nursing home quality.
To address these issues, we’re exploring strategies related to:
- Surveyor education, training, and experience standards.
- Surveyor compliance with statutory and regulatory requirements.
- Surveyor accountability, best practices, and evaluation systems.
- Informal Dispute Resolution and Independent Informal Dispute Resolution processes.
OUR GOAL: Revised survey processes and procedures that prioritize safety and quality of nursing home care.
Nursing homes are surveyed more frequently than any other CMS setting. Standard certification surveys are required every 9-15 months for nursing homes, compared to every 36 months for other CMS-certified providers. Rising numbers of complaint surveys coupled with workforce shortages and challenges encountered during the COVID-19 public health emergency have created a significant strain on the surveyor workforce and resulted in staggering backlogs. In FY 23, standard surveys were overdue for more than 75% of the nursing homes in the state in 20 states. Survey processes focus more on regulatory compliance than actual resident outcomes, with 93.7% of all citations issued for non-harm level deficient practice, compared to only 0.06% of citations where actual resident harm occurred in FY 23. When surveyors and nursing home providers are required to spend exorbitant amounts of time on paper compliance, there is less time for providing resident care and addressing true quality issues.
To address these issues, we’re exploring strategies related to:
- Survey cycles.
- Survey duration.
- Survey response times.
OUR GOAL: Culture change within CMS, CMS locations, and state agencies that emphasize shared investment in quality improvement and mutual respect for clinical expertise.
For years, the Administration has disparaged nursing home quality, yet consistently applied policies that present active barriers to quality improvement. Public officials have adopted tones and language that convey, “Nursing homes are not to be trusted,” enforcing a dichotomy within the system. CMS strictly prohibits surveyors from providing explanations or constructive feedback when citing deficient practice. Surveyor workforce shortages and increased workloads mean fewer state agencies are providing off-survey opportunities for education and consultation. Incident reporting processes are enforcement-oriented, requiring immediate reporting and automatic citation, compared to incident reporting processes in other CMS-certified settings that allow for thorough investigation and remediation prior to enforcement. Until regulators and providers can work collaboratively toward the shared goal of safe, high-quality nursing home care, the system will remain broken.
To address these issues, we’re exploring strategies related to:
- Language, attitude, and approach of surveyors and the Administration.
- Constructive survey processes.
- Incident reporting and quality assurance processes.
What We’re Doing
We take every opportunity to put our priorities front and center—whether it is calling out Administration language in the media or reminding CMS in a comment letter that the problems they seek to solve through heightened scrutiny and enforcement could be better addressed through constructive and collaborative survey processes.
LeadingAge meets with CMS monthly to discuss all issues affecting our members, and periodically with CMS administration to recommend best practices and solutions for large scale survey process reform. We also acknowledge shared responsibility for process improvement by providing education and resources to members.
jeyigor@leadingage.org