Credit: Luis Alvarez/Getty Images
Photo credit: Luis Alvarez/Getty Images

The Centers for Medicare & Medicaid Services on Wednesday revealed initial information about a potential “Risk-Based Survey” option that could be available to some of the nation’s best performing nursing homes.

Agency officials most recently teased the concept during a December Open Door Forum call, during which they described a truncated survey process for some nursing homes as a way to compensate with backlogs and staffing shortages in the survey world.

A more efficient survey process has long been requested by nursing homes, whose clinical and leadership teams can be tied up for days during on-site visits. CMS said in an update to its nursing home provider enrollment page Wednesday that it is working with states to test this process over the next several months.

CMS said the proposed risk-based survey, or RBS, approach would allow “consistently higher-quality facilities” to receive a more focused survey, while still ensuring compliance with health and safety standards.

“Higher quality could be indicated by a history of fewer citations for noncompliance, higher staffing, fewer hospitalizations, and other characteristics (e.g., no citations related to resident harm or abuse, no pending investigations for residents at immediate jeopardy for serious harm, compliance with staffing and data submission requirements),” CMS said.

The agency would limit the maximum number of participants, possibly to 10% of nursing homes in each state, the update noted.

“The survey resources saved by performing a more focused review of the required areas of a standard survey in these higher quality facilities would then be available to perform more timely oversight of facilities where the risks to residents’ health and safety are greater,” the update continued. “If any concerns about resident safety were encountered during the RBS, it would immediately be expanded. Resident safety will always be prioritized, regardless of the type of survey process.”

Jodi Eyigor, director of Nursing Home Quality & Policy for LeadingAge, told members on a call Wednesday that she was “really excited” to see any details about the new, focused survey. She said both LeadingAge and the Moving Forward Coalition had called for some kind of shortened survey process for consistent, high-quality performers.

“It will basically be a shortened survey time on site,” she explained. “You’ll still be surveyed, it seems, within the same window, every nine to 15 months, but this will replace your standard survey. So instead of being on site for like two weeks, they’re going to be on site for maybe just a few days.”

RBS would not be used for complaint surveys, CMS said.

Budget drives more efficient surveys

CMS noted that it had not received a funding bump for survey and certification activities since 2015, and it has previously noted staffing shortages across a wide swath of states. Those reports followed a Senate investigation that showed massive survey backlogs of up to three years in some states.

The president’s proposed fiscal 2025 budget includes an effort to move future survey spending from discretionary to mandatory and increase funding to cover all statutorily-mandated surveys, which are required to be done annually.

“CMS has always, in part, tried to explain the delays associated with surveys and follow-up surveys and backlogged surveys as tied to their funding,” Mark Reagan, managing shareholder of Hooper, Lundy & Bookman, told McKnight’s Long-Term Care News after that budget was published last month. “It is really designed to essentially say, if they structurally build this into mandatory spending, then they’re going to have what they consider a consistent stream of money they won’t have to fight over.”

But CMS has asked for other increases recently — including a 40% request last year following the Senate investigation that drew widespread condemnation of post-COVID nursing home survey delays — and been flatly denied or ignored by a Congress able to agree on few spending provisions.

Providers, Reagan said, want and deserve “a fair and reasonable process” that includes more timely follow-up surveys that help head off extended denials of new admissions, mounting penalties or the added stress and pressure that come with either.  

But given what Reagan called the “brokenness” of both the survey funding and budget systems, it appears unlikely that the Biden administration or CMS will get their wish for more cash next year. And that could make a successful risk-based survey process an important crutch in the coming months or years.

“By modifying some surveys based on compliance and quality history, we will be able to devote more time and resources to nursing homes with lower quality whose residents are at higher risk of harm,” CMS said of the process currently in development.