As difficult as your job may be — and I know there are many long days — it’s worthwhile to remind yourself it could always be worse.
You could be a nursing home surveyor in Idaho.
To start, surveys are necessary in order for nursing homes to accept Medicare and Medicaid payments. The state’s Bureau of Facilities Standards, a subsection of the Department of Health and Welfare, hadn’t been meeting mandated intervals of nursing home surveys, causing payment problems for facilities. In Idaho, new skilled nursing facility operators are told it could be 18 months before a surveyor could visit, resulting in an estimated million a month in lost revenue for providers.
There’s no one who is benefitting from this current structure: Not overworked surveyors, not providers, not operators who want to expand and bring nursing home jobs into Idaho, and not residents.
The report from Office of Performance Evaluations, stemming from a Joint Legislative Committee request, found the delay in surveys is clearly related to workload. Nursing home surveyors “described the workplace at the division as hostile and demeaning. Surveyors feel berated and belittled; they also believe the work environment explains the ongoing retention problems of the survey team,” according to the January report. The current vacancy rate in the division is 50%, with generally 7 out of 13 positions filled over the past few years.
Apart from the inherent difficulties of the survey job anywhere — keeping up with federal regulations, the amount of responsibility for making sure residents are safe and walking on a day-to-day basis into places where everyone hates you — the surveyor-provider relationship in the state has a particularly large gap in trust.
What’s noteworthy is that it isn’t across all categories, demolishing the idea that Idaho healthcare professionals might be more paranoid than others. More than three-fourths of administrators at children’s residential facilities in the state said they had a high or very high level of confidence in the survey team, while almost half of assisted living administrators said the same. For the state’s 79 nursing homes, it’s under 10%, which is, frankly, appalling.
Ironically, there’s some evidence that some of the fear may be misplaced. The report found that there was little evidence the nursing home surveys led to excessive fines or citations, and the state’s citation rates were similar to others in its region.
What is unique for Idaho, however, is that it’s the only state that does not collect licensing fees for assisted living facilities or nursing homes. While I’m sure providers would complain, it seems pretty straightforward that the fees would provide extra revenue that could be allocated in a variety of ways — including for surveyor resources.
At the same time, the long-term care industry should push for changes in the state’s Medicaid structure. At the moment, 90% of the state’s 250-plus assisted living facilities accept Medicaid, which isn’t doing traditional nursing homes’ census levels any favors. The state has a flatter reimbursement system than neighboring states, which causes challenges related to hard-to-place patients. Facilities that closed over the past two years had more mentally ill residents and Medicaid patients. Incidentally, Idaho Medicaid beneficiaries in assisted living facilities also have to pay 21.5% of their bills, compared to Wyoming paying all of the bills for AL patients.
The Idaho providers that accept Medicaid said the state does not provide enough reimbursement for the level of care expected by surveyors, while the surveyors said they can’t take the payer aspect into account.
There’s also the line of thought that surveys should be helpful to providers, rather than simply noting flaws. It’s easy to scoff at this idea, but administrators in Wyoming and Idaho were asked the same questions, and in Wyoming 9.1% said they “never or only occasionally” received helpful information during a survey. In Idaho, more than 75% said the same.
No matter where you are, you’ve likely had a bad experience with a surveyor: I’ve heard problems ranging from misinterpretation of new guidance (which often can be solved when nursing home staff can point to what they are doing and why) to sheer politeness. (Surveyors, it’s not too much to ask for you to not chew gum, put away your phone and dress professionally.)
That means ultimately Idaho is to be commended for actually trying to address the problem. Now it’s up to the Legislature to ask, and for other states to take note, and dig into their own survey processes. The goal is for the surveys to allow nursing homes to improve and staff to learn, not to become one more reason for owners to close their doors.
Follow Senior Editor Elizabeth Newman @TigerELN.
