In an April 2024 Update, the Centers for Medicare & Medicaid Services (CMS) describes a risk-based survey (RBS) that it is testing to provide shorter, “more focused” surveys for “consistently higher-quality facilities.” CMS does not describe the components of the focused survey, how many facilities are included in the test, or how results will be evaluated. However, the limited information provided by CMS raises many red flags.
The criteria for selecting “consistently higher-quality facilities” are disturbingly weak. Criteria may include “a history of fewer citations for noncompliance,” “no citations related to resident harm or abuse,” and “no pending investigations for residents at immediate jeopardy for serious harm,” among others. CMS does not list any criterion reflecting a facility’s financial stability, despite the recent rash of abrupt closures of facilities that missed payroll (e.g., Northview Village Nursing Home, St. Louis’s largest nursing home, December 15, 2023; Princeton Care Center, September 1, 2023). The Center for Medicare Advocacy strongly opposes RSB and urges CMS to focus, instead, on more effectively using data to improve and strengthen the survey process for all facilities.
The RBS survey is part of CMS’s apparent response to Congress’s flat-line federal funding for surveys for the past decade. (The President’s budget for fiscal year 2025 includes a proposed increase in federal funding.) However, RBS may violate the federal Nursing Home Reform Law, which states at 42 U.S.C. §§1395i-3(g)(2)(A)(i), 1396r(g)(2)(A)(i), Medicare and Medicaid, respectively, “Each skilled nursing facility shall be subject to a standard survey.” Moreover, federal law already gives state survey agencies flexibility to inspect facilities less frequently (every 15 months, rather than annually), an option they can use with facilities that appear to be providing higher quality care to residents.
Identifying “consistently higher-quality facilities” is difficult, if not impossible, as confirmed in 2007 by prominent nursing home researchers Charles D. Phillips, Catherine Hawes, Trudy Lieberman, and Mary Jane Koren. Describing “the multidimensional nature of nursing homes and their residents” in “Where Should Momma Go? Current nursing home performance measurement strategies and a less ambitious approach,” they concluded that performance measurement systems are better at identifying problem facilities than good facilities.
Advocates for residents have little confidence in designations of “consistently higher-quality facilities.” As documented by decades of reports by the Government Accountability Office and HHS Office of Inspector General, the survey and enforcement systems are excessively tolerant of poor care, fail to cite deficiencies, and undercode many deficiencies that they do cite. In addition, the quality of care in facilities can change rapidly and dramatically, for better or worse, following changes in key staff, such as the Administrator and Director of Nursing.
The Center for Medicare Advocacy will be following this initiative closely.
April 11, 2024 -T. Edelman