A year and a half after a federal watchdog blasted the Centers for Medicare & Medicaid Services over extensive delays in nursing home inspections, year-end data for fiscal year 2023 shows there has been little improvement.

Nearly 30% of nursing homes (29.9%) have not had a recertification survey in more than 15 months, according to CASPER data captured between Oct. 1, 2022 and Sept. 30, 2023.

In an analysis conducted for a recent blog, ProActive LTC Consulting Director of Regulatory Services Shelly Maffia, RN, also reported that 21.3% of nursing homes have not had a recertification survey in more than 18 months. Among those, Kentucky had the greatest share not inspected for over 18 months at 84.4%.

That confirmed earlier trends reported by Sen. Bob Casey (D-PA), when his office issued its own scathing report on the survey system in May. Casey outlined staggering findings from a year-long investigation in which the Senate Special Committee on Aging gathered 2,000 pages of documents and data on survey lapses. The investigation found 32 survey agencies had inspector vacancy rates of 20% or higher, with the highest in Kentucky, Alabama, and Idaho.

The ProActive analysis also showed that at the end of fiscal 2023, 11.3% of the nation’s nursing homes had not had recertification surveys in over 24 months, with another 5.1%, or 757 facilities, not recertified in more than 36 months. Kentucky led the last group with 63.3%.

Overall, just 57.6% of the nation’s nursing homes had a recertification survey last fiscal year. Routine surveys are required at least once every 15 months.

Janine Finck-Boyle, vice president of Health Policy & Regulatory Affairs for LeadingAge, told McKnight’s Long-Term Care News that delays in annual surveys of up to two years are “not uncommon complaints” from the organization’s 38 state partners and thousands of members.

“Surveys, while stressful, are important to nursing homes’ operations because they validate the quality of care provided to residents,” Finck-Boyle said in an email Monday. ”Survey delays create problems, particularly when a provider has addressed an issue from a prior survey and needs an update on status. Delays can lead to limited access — not at the fault of the provider — for older adults and families.” 

Complaints and infection control dominate

In the absence of a full staff, it appears many state agencies are allowing complaints to direct their survey activity. Maffia found that 80% of nursing homes had a complaint survey last fiscal year.

Region IX in San Francisco conducted the most, hitting 93.9% of providers there, while the state of Delaware had the fewest complaint surveys completed at zero percent.

Infection control surveys remain prevalent, with 50.1% of all nursing homes receiving one last year, Maffia’s data showed.

“While COVID infections rise and fall, it is still present, which means surveyors are paying attention,” Finck-Boyle noted. “But the F0880 tag is not by any means limited to COVID. It is a tag that applies to mistakes made out of forgetfulness and small oversights (i.e., handwashing, not wearing gloves to hand out snacks or beverages, not changing gloves between treatments and wearing gloves in an elevator and pushing the buttons).”

She said providers could avoid or remedy such “common mistakes” with thorough and frequent education, signage and rounding by teams.

“Getting all employees involved in helping and using the ‘teaching moment’ — when a team member sees a problem and offers a correction, on sight — can be effective,” she said.

Infection control and COVID-related reporting are key citation triggers; Finck-Boyle puts F0884 at No. 1 for 2023. It’s cited for noncompliance with required reporting to the National Health Safety Network (NHSN). She puts F0880 at No. 3; it’s related to infection prevention and control, which could be fed by the number of infection control surveys still taking place.

Overall, US nursing homes received an average of 7.1 deficiency per recertification survey, with the highest average rate coming in Maryland (23 per survey) and the lowest in Mississippi (4 per survey). 

Maffia’s analysis included a Top 10 list of citations for the fiscal year. It’s available here.