Spencer Blackman

When the Centers for Medicare & Medicaid Services unlocked survey ratings for the first time since April, we analysts dove into the numbers expecting big changes. But as an earlier McKnight’s article points out, there wasn’t that much movement. 

Why? One obvious factor is the dearth of new standard surveys. The latest data from CMS shows only 9% of homes have had a new standardsSurvey since the freeze set in on March 3, 2020. That’s not a total surprise given the restrictions of the pandemic, but CMS issued guidance as early as May on how states could resume Standard Survey activity. In that same timeframe, we’d normally expect that number to be closer to 75%.  

Another key factor is that the state-based survey cut points did what they were supposed to do, adjusting to the new reality on the ground. Cutpoints were “loosened” in 39 states, meaning that a slightly higher overall weighted survey score doesn’t necessarily mean a lower star rating.

If 39 states “loosened,” it must mean that all things equal, overall weighted survey scores in those states actually got worse since the cut points were last calculated.  Seems strange given the freeze, but the numbers bear this out: The average overall weighted survey score rose 4% from 60.13 to 62.57 nationwide. So, if standard surveys didn’t move much, what did? 

Complaint surveys

Typically, complaint deficiencies account for over 25% of all deficiencies and over a third of all deficiency points. But Covid-19 slowed complaint survey activity down by nearly 50%. 

Number of complaint surveys conducted

  • 2018: 15,120
  • 2019: 16,662
  • 2020: 8,999

Fewer surveys should mean fewer points, and that happens through a process we call complaint deficiency aging. As we know, complaint deficiencies (and now focused infection control deficiencies, as well) operate on a 12-month rotation that’s independent of standard surveys. Since that time frame was just reset for the first time since March 2020, thousands of complaint deficiencies just moved from cycle 1 to cycle 2, cycle 2 to cycle 3, and from cycle 3 to not impacting scores anymore.

Normally, new complaint deficiencies roll in to replace what cycles out, but with complaint survey volume down nearly half, there are fewer new points to replace the old ones.  In fact, we found 10,000 fewer complaint deficiencies in cycle 1 this month compared to the last time CMS published data.

The impact of infection control

So with standard surveys mostly stagnant and complaint deficiencies declining, why are scores still going up? Time to look at the new kid on the block — infection control. 

CMS announced in December that the results of Focused Infection Control Surveys conducted during the pandemic would be included in the health inspection domain of the Five-Star program. This reversed course from a previous statement that these deficiencies would not contribute to Five Star. We think this change – and the Focused Infection Control Survey – is here to stay.

As we know, these FIC deficiencies only affect cycle 1 so far.  Keeping in mind that CMS may mark a deficiency as more than one type, and that CMS took a break from publishing data in December, let’s look at how FIC citations stack up to standard and complaint deficiencies:

Deficiency count as a percent of total – Cycle 1

  • CMS Data as of November 2020
    • Standard: 79.90%
    • Complaint: 27.50%
    • Infection Control: 0%
  • CMS Data as of January 2021
    • Standard: 80.54%
    • Complaint: 20.08%
    • Infection Control: 9.68%

This makes sense. The tens of thousands of FIC deficiencies seem to have filled in for the “missing” complaint deficiencies. But a different story emerges when we look at points:

Average points per deficiency – Cycle 1 – January 2021

  • Standard: 6.4
  • Complaint: 10.4
  • Infection Control: 14.1

That’s a big difference. The bottom line here is that in their first month, FIC deficiencies are moving the needle significantly in terms of how the survey star rating is calculated.

It may be that FIC survey activity will slow as the pandemic thankfully eases. But FIC surveys are still new, and deficiencies are still being handed out in a disturbingly uneven way. So while cutpoint shifts will likely continue to soften the blow at the national level, operators and administrators need to take a close look at how FIC Surveys are being conducted in their areas to avoid losing stars.

Spencer Blackman is director of product for StarPRO, a provider of analytics and star-rating software for the SNF industry.