Nursing Home Survey and Certification System Needs More Nationwide Consistency

Regulation | August 28, 2017 | by Marsha R. Greenfield

Inconsistency across state lines and between reviewing agencies makes it difficult to determe which nursing homes are excellent and which have substantial problems. 

The nursing home survey and certification system is plagued by inconsistencies, a concern expressed by the Government Accountability Office (GAO) on numerous occasions.  While LeadingAge may not agree with all the conclusions the GAO reached, our members concur that inconsistency across state lines and between reviewing agencies makes it hard to determine which nursing homes are excellent and which have substantial problems.

According to federal law, every nursing home must be surveyed every 12 - 18 months by state agencies to maintain its eligibility to provide care covered by Medicare and Medicaid.  CMS also has federal surveyor responsibility, usually as a follow-up to state surveys.  This system is overly complex, which makes compliance difficult for nursing homes, and it lacks federal standards for surveyors, leading to inconsistent results from state to state. The GAO has noted with great concern in several reports that the results of surveys are inconsistent.

Inconsistency means that consumers seeking high quality nursing homes cannot rely on survey results; nursing homes may be treated differently for the same alleged deficiencies depending on the state or even the area within a state in which they are located; and residents of nursing homes cannot rely on surveyors to identify problems within a facility accurately.

We have three relatively simple recommendations to address these issues at least on a preliminary level. Ultimately we believe the system should be carefully examined to ensure that it reflects and enhances quality of care and life for residents, accurately identifies poorly performing nursing homes, and provides a better approach for improvement than simply punishing poor performers.

Related Statute/Regulation:

42 USC 1395(i), et seq.

Proposed Solution:

  1. Joint education of providers and surveyors:  CMS should support, and Congress should legislate if necessary, joint education of surveyors and nursing homes to ensure that both parties have the same understanding of the regulations, especially when new regulations are adopted.  This would be particularly relevant to the requirements of participation finalized in September 2016.
  1. Improve and make uniform survey workforce training and development:  There are no national standards for surveyors which, as the GAO studies reveal, has an impact on consistency and accuracy in the survey process.  CMS should identify a standard list of core skills and competencies for surveyors; recommend a set of core surveyor and survey team leader attributes, skills, knowledge and competencies; identify the critical components of an orientation and training curriculum for all surveyors; develop recommendations for measurable criteria by which the skills and competencies of the surveyor and survey team leader can be evaluated on an ongoing basis; and support the "credentialing" of surveyors based on demonstrated knowledge, skills and competencies.  In addition, CMS should establish a method to obtain feedback about survey teams from providers.
  1. Allow more flexibility in sequence, timing and/or intensity of nursing home surveys.  CMS should support and Congress should legislate if necessary, greater flexibility in the survey system, so that CMS and the states can focus limited resources on the oversight of poor-performing nursing facilities. This policy shift would allow state survey agencies to spend more time identifying deficiencies in poor-performing facilities and working closely with those facilities to correct deficiencies and improve quality of care. At the same time, CMS and state survey agencies would be rewarding consistently superior nursing facilities with surveys that are either less frequent or less intensive.