More details are emerging about the risk-based survey process in nursing homes

The Centers for Medicare and Medicaid Services has released for the first time key facts about the shorter survey option for select “higher quality” nursing homes, including the number of state research agencies involved and the evolving nature of the program.

Risk-based surveys were formally launched this spring and were intended to help CMS help state research agencies catch up on routine recertifications following significant delays caused by the Covid-19 era. But officials are not releasing details of the process — or which facilities qualify.

In a letter responding to concerns from the Center for Medicare Advocacy and others, Dora L. Hughes, M.D., chief medical officer of CMS and acting director of the Center for Clinical Standards and Quality, disclosed that providers in at least 20 states will be involved during the period test.

“Our primary goal is to test RBS in as many states as needed to ensure that the study is tested in facilities and among inspectors who are a general representation of facilities and inspectors across the country,” Hughes wrote in an Oct. 17 letter shared by the CMA on Thursday.

“States will be selected in collaboration with state agencies based on the availability of inspectors referenced for RBS-eligible nursing homes,” she added.

That eligibility threshold raised concerns among the Medicare Advocacy Center, but also left nursing home operators unclear about whether they had done the work necessary to benefit from a potentially shorter inspection.

On a short website announcement in AprilCMS stated that higher quality “may be indicated by fewer non-compliance citations, greater staffing levels, fewer hospitalizations, and other characteristics (e.g., no citations related to harm or abuse to residents, no ongoing investigations for residents at immediate risk serious harm), compliance with personnel and data transfer requirements).

In May, the Medicare Advocacy Center was one of 15 groups protest against an unclear definition in a letter to CMS Administrator Chaquita Brooks-LaSure.

“The criteria are inappropriately limited: a history of fewer non-compliance citations is not a meaningful criterion when many facilities have not undergone standard (recertification) testing for two to three years or more,” the CMA wrote at the time.

The organization remained unmoved by Hughes’ letter last week, in which he wrote that the definition was “extremely weak” and again cited “decades of reports” from the General Accounting Office documenting undercoding deficiencies as less serious than they actually were; 2% of cited facilities with a direct threat and an unclear “higher staffing” criterion.

While Hughes would not share specific CMS criteria and acknowledges that the RBS process may vary by state, Hughes insisted that inspectors will have high expectations of providers who join the program.

“Regardless of the RBS criteria or process, if any concerns related to resident care are identified, inspectors will expand the survey and will not leave the facility until all concerns related to resident safety have been resolved,” she wrote. “Resident safety will always be our top priority, regardless of the type of testing process.”

Hughes also said that even in states with shorter surveys, states still exercise broader oversight of the handling of complaints where an allegation of noncompliance could put residents at imminent risk of serious harm.

CMS stated that it will continue to improve the risk-based survey and its effectiveness by comparing the results to those of the full recertification survey; including additional inspectors in the testing to investigate whether there were any concerns that were not addressed; and conducting “comprehensive debriefing sessions” after each round of testing to obtain feedback on future potential changes.

The uncertainty continues

This latest testing process adds to uncertainty among providers, who have anecdotally reported that the length of traditional testing has increased, even though many states still do not re-inspect every facility annually as required by the federal government.

“We know there are many inconsistencies in the survey and certification system,” said LeadingAge Vice President of Health Policy Janine Finck-Boyle, who described CMS’ current efforts as “beta testing.”

“Instead of the normal survey process with all the tasks and all the detailed requirements, it would be a shorter time and fewer real requirements,” she told participants in a federal policy discussion at Sunday’s LeadingAge annual meeting.

Given the new expanded civil monetary penalties; testing delays in most states; and other concerns about inspectors’ interactions with nursing homes, LeadingAge is conducting a project to highlight discrepancies in states’ interpretations of CMS rules.

“As CMS conducts the risk-based survey and does its job, we look at the inconsistencies in the survey process itself: the good, the bad and the ugly, and we try to bring that to CMS when we recommend making some changes,” Finck-Boyle said.

In addition to the risk-based approach, last week CMS also announced it was adopting new performance metric for routine recertification inspectors. The composite score includes target shortages per 1,000 beds; percentage of studies free from deficiencies; percentage of studies identifying the extent and severity of G, H, or I; and the percentage of studies identifying the scope and severity of J, K, or L.

Some see this as pressure on state agencies to start moving toward national citation standards.