After two years in pandemic mode, many skilled nursing providers are still hoping for a routine visit from surveyors. Thousands need a fresh chance to improve ratings.

When a major government watchdog blasted the Centers for Medicare & Medicaid Services in January for a lack of timely survey activity, it detailed extensively what providers on the ground were experiencing — or more accurately, not experiencing.

“We know the surveyors are late,” says Melanie Tribe-Scott, RN, RAC-MT, director of quality initiatives for Zimmet Healthcare Services Group. “Facilities know they’re really, really late.”

Although some states have a history of extending standard surveys beyond the 15 months expected by federal regulators, Tribe-Scott calls the stats of the last two years “mind-boggling.”

As of May 31, 2021, 71% of nursing homes had gone at least 16 months without a standard survey, up from 8% in June 2020, Tribe-Scott notes.

More than half of states repeatedly failed to meet nursing home survey requirements over a four-year period, according to the Office of Inspector General, most often due to a lag in conducting high-priority complaint surveys or standard surveys.

The delays OIG identified through 2018 were of course compounded by temporary pandemic shutdowns in early 2020 and, later, a months-long shift in favor of COVID-driven Focused Infection Control surveys.

CMS in November directed state agencies to resume standard surveys, but since then, routine recertification activity has failed to materialize in many parts of the country.

A February analysis by consultancy firm Formation Healthcare found 5,249 facilities — or 34% — had still been waiting more than two years for a standard survey.

Early 2022 hasn’t looked like it’s on track to change those figures significantly. Among surveys of Formation’s hundreds of clients through early February, 52% were complaint investigations, 26% were Focused Infection Control surveys, 11% were fire safety surveys and 11% were annual surveys.

“It’s definitely survey agencies catching up from their backlog and having to prioritize some of those (complaints), depending on what the allegation is,” says Formation Managing Partner Jessica Curtis. “It’s probably a combination of the number of complaints that they need to go investigate, along with the staffing issues that I’m sure are affecting state agencies as well.”

Observers say the implications of missing surveys stretch from consumer confusion to extended admissions restrictions.

It also can have profound implications in the lending universe, where potential financing may be a lot more expensive to providers with a negative survey they’ve been unable to have updated.

“They’re trying to climb out of a hole if they’ve had a poor survey,” says Spencer Blackman, product director at data analytics firm StarPRO. “They’re trying to recover (and) they’re looking for a new standard survey to make sure they have a chance to rise.”

Nerves fraying

With little clarity around when that’s going to happen, anxiety has been building.

“Data derived from a survey reflects a snapshot in time — what’s happening in a nursing home over four or five days,” says Janine Finck-Boyle, vice president of regulatory affairs for LeadingAge. “So for residents, families and providers, that information is most meaningful while still fresh. … If a survey is delayed, information about a provider is incomplete or inaccurate. That’s a problem.”

LeadingAge has conveyed to CMS its members concerns’ about late surveys, including a lack of timely follow-up visits needed to confirm whether operators have corrected past problems in time.

That step is needed to assure the public a provider is back in compliance, and in many cases, it’s not happening in a timely manner.

But delays are just one of several regulatory concerns providers are facing. The year ahead also promises more financial penalties, struggles with new COVID-19 requirements and a bigger emphasis on quality-of-life metrics.

More tags ahead

“We’re not seeing major shifts as far as what’s being cited compared to last year and the year before,” Curtis says. The top citations her firm tracked in January were for infection control, COVID data reporting tag, quality of care issues and resident assessment.

While Finck-Boyle predicts infection control tags will remain in the top three even after omicron abates, CMS’ own instructions to surveyors likely indicate additional hot spots to come.

In a November memo, the agency encouraged a more critical look at “the competency of nursing staff, the use of any potentially inappropriate antipsychotic medications, and other areas of care, such as unplanned weight loss, loss of function/mobility, depression, abuse/neglect, or pressure ulcers.”

Data coming into CMS throughout the pandemic indicated backslides on such patient-centered metrics. That challenge will remain as long as buildings struggle with staffing, adds Formation Managing Partner Melissa Fedun.

“Operators should start to get back to some of the basics, like looking at those core programs that they do have in place: their nutrition programs, their skin programs, their ADLs,” Fedun says. “Go back to being more creative on how we can execute on those things like we did when the pandemic first started.”

The return of volunteers and visitors also may    bring an added bonus.

“Caregiving takes time. Concerns with the help on activities of daily living — brushing and combing a resident’s hair, for instance, or moving a resident from bed to chair — can arise when staff is limited,” Finck-Boyle says. “The good news is that providers can once again use volunteers and family members to help out a little bit, pick up on things where staff need a hand.”

New COVID F-tag worries

Still, COVID headaches will make themselves felt indefinitely.

The F-884 tag for reporting COVID-related data to NHSN quickly became the most cited in the U.S., and providers often were financially penalized even if they missed a single reporting day, Finck-Boyle notes.

Only starting to become clear now is the impact of F-888, which will be cited when providers fail to meet elements of the staff vaccination mandate.  Workers in all states except Texas were expected to have both shots by March 15. In addition to reporting vaccinations, providers will also need to have exemption policies and procedures ready to share with survey teams.

They should expect to have surveyors on site longer than usual, experts warn. Completion of a vaccination matrix to be compared to NHSN could take up to four hours alone, CMS has acknowledged.

“It’s an extreme amount of work on the facility to comply not only day-to-day with their NHSN reporting and tracking requirements but now to comply with what they have to do with F-888,” Curtis says. “What they have to do during the actual survey window, the things they have to provide to the surveyors as far as completing the matrix … it’s a huge, huge burden.”

Curtis described the process as almost punitive in nature, saying she expects to see the tag cited “quite frequently” this year.

Paying the price

In any case, providers should be prepared to face higher financial penalties. Average fines were up 64% in data published in the CMS December refresh and cited by Curtis.

“It’s very clear that they’re coming down with a heavy hand on the enforcement side,” Curtis says. “The change from the per-instance fines that we saw under the previous administration back to the per-day fines as a default is resulting in some very heavy fines and past non-compliance fines that are really adding up quickly.”

That makes internal documentation of corrected actions all the more critical for providers waiting on a follow-up survey to indicate a return to compliance.

For those who continue accepting residents pending a discretionary denial of payment for new admissions, there’s even greater risk, Fedun notes. Those providers accept new patients assuming they have corrected a prior deficiency. If a delayed follow-up survey results in still-unmet corrections,  the provider would not be reimbursed for care provided in that time period. That could be financially devastating.

When surveyors are late, providers also need to be ready for a longer look-back period, Tribe-Scott adds. Facilities Zimmet works with have reported reviews extending to their most recent survey, which could have been two years ago.

“It puts the facility more at risk for having more citations during that time frame,” Tribe-Scott says.

Not enough to catch up

Of course, no one outside a nursing home can understand what’s happening in real time if fresh survey data just doesn’t exist.

OIG noted that CMS has five remedies to address “inadequate” state survey performance.

The agency can: offer training; offer technical assistance; actively schedule the surveys that states must conduct; direct states to include specific improvement activities; and institute corrective action plans, through which states must adopt written plans to address the performance problems such as timely inspections.

But the January report found that CMS had already issued corrective action plans in half of the problem cases tied to survey timeliness; they did little to move the needle.

State agencies repeatedly cited staffing-related problems as a major contributor to falling behind. In Colorado, for example, 15 of 47 surveyor positions were vacant during the OIG study timeframe. State officials cited long hours and low pay as causes for resignations. One consultant told McKnight’s that at least one nursing home in that state was approaching three years without a standard survey.

 CMS did not respond to several requests for comment from McKnight’s.

 But CMS told the OIG that survey staffing shortages overlap states with widespread nurse shortages, exacerbating recruitment. In one state, the staffing situation “was so problematic” that CMS provided additional funding for new surveyor positions. 

Tribe-Scott suggests CMS consider a collaboration with other Health and Human Services agencies or use vendors with relevant expertise to help state agencies tackle the backlog.

CMS can also impose sanctions or slap states with financial penalties. 

The agency, in a memo to state agency directors in February, reiterated the importance of timely and complete surveys, threatening to recoup budgeted money or send outside contractors to states that fail to meet their obligations.

Whether that happens — and whether CMS or anyone has the manpower to follow through — remains to be seen. Meanwhile, providers must stay vigilant for surveys that could come tomorrow or in weeks or months.

As of January, StarPRO data showed the average standard survey was about 500 days old. Pre-pandemic, the average was closer to 270 days.

State by state, there are wide variations. In Oregon, the average number of days between the last standard survey and a January data publish date was at 900, according to a StarPRO analysis. By January, only four states were doing better than the “normal” goal of 270 days, including the tiny states of Rhode Island and New Hampshire.

“They fell behind quite a bit throughout 2020, and they haven’t really done a great job of recovering,” notes Blackman. “It’s trending in the right direction, but they’re still not really getting it done.”