The Centers for Medicare & Medicaid Services is putting more pressure on state survey agencies to “identify appropriate deficiencies” and complete other tasks triggered by routine annual surveys.

But a new scoring element for those agencies shouldn’t be seen as an attempt to create a deficiency quota, federal leaders told state agency directors this week.

Fiscal 2025 State Performance Standards System Guidance, used to measure how successful surveyors are in inspecting federally and state-regulated nursing homes, was issued Tuesday but had become effective Oct. 1.

It lays out a series of goals that state agencies can meet, not meet, or partially meet, as of a 2023 change meant to recognize groups making progress on a goal from year to year. Small, routine annual changes are normal.

For 2025, the agency has added a single new measure: State agencies will be assessed on six items that, when combined, show how well agencies perform in Nursing Home Recertification Survey Deficiency Citation and Tasks Investigated.

The six measures that make up the overall score are:

• Number of deficiencies per 1,000 beds

• Percentage of deficiency-free surveys

• Percentage of surveys identifying G, H or I scope and severity

• Percentage of surveys identifying J, K or L scope and severity

• Percentage of surveys where one or more mandatory tasks were not investigated

• Percentage of surveys where one or more triggered tasks were not Investigated

Mandatory tasks include reviews of specific facility areas or programs, such as dining, medication administration or Quality and Performance Improvement. Triggered tasks come up if a surveyor has a concern while on site, such as with the physical environment, use of personal funds or discrepancies in resident assessments. 

CMS on defense

Even before news of the new measure was out, CMS seemed to anticipate that this effort could make it appear federal regulators are looking for more findings against nursing homes. The added pressure on surveyors comes months after the government gave itself the ability to fine providers on both a per-day and per-instance basis.

“This composite measure aims to gauge State Survey Agency performance but is not an attempt to establish deficiency or investigation quotas,” CMS said in its Wednesday memo, which was signed by David Wright, CMS director of Quality, Safety & Oversight Group, and colleague Karen L. Tritz, director of the Survey & Operations Group.

“CMS seeks to understand broader performance of the State Survey Agency and not impose quotas or limits,” they added. “In addition, lower scores on this composite measure would not necessarily indicate that a State Survey Agency is encountering challenges in its work because the measure itself is context free.”

However, by its own standards, CMS does appear to be looking for a baseline score. 

The new measure comes with a new score type of “requires research.” This designation forces a low-scoring state to “review its data and to explore with CMS potential underlying reasons for a lower composite score and, if necessary, strategies to improve its performance on these measures in the future.”

A state agency that scores a composite of less than 120 points (out of a possible 150) will be in the “requires research” category, while an agency scoring 120 points or more will get an N/A and not be required to undergo further assessment. No scores of met, not met, or partially met will be given, at least not in the measure’s first year.

CMS said it designed the new measure to “assess the frequency and type of nursing home deficiencies and the completion of mandatory or triggered tasks on health recertification surveys.”

“CMS is committed to working with State Survey Agencies to ensure that nursing home health recertification surveys are high quality and identify appropriate deficiencies that reflect nursing home quality of care, and that surveyors cite deficiencies at the appropriate level of scope and severity and complete mandatory or triggered survey tasks during nursing home surveys,” the memo states.

Fewer tags to be issued?

Spencer Blackman, director of product for post-acute analytics software provider StarPro, said it appears CMS is pushing surveyors further toward a national standard.

“The wording of the new measure seems gentle and the boundaries of the six components are wide, but the message is clear: Fall into line with national expectations in terms of the number and scope/severity of deficiencies cited,” he told McKnight’s Long-Term Care News Thursday. “I’m not surprised. Survey remains the only element of the Five Star program that’s state-specific and there’s still shockingly wide variation in aggregate survey scores between states.” 

He said the impact on facilities might not be immediate but rather might be felt as a trickle-down effect that sees the “strict states loosening up and the tag-happy ones rein it in a bit.”

He noted that differentiations in surveyors’ use of higher-severity tags has skewed how difficult it is to earn a high star rating in hard survey environments such as New Hampshire, Rhode Island and Tennessee.

“Bottomline is, CMS is holding SNFs accountable for their performance, and in order to do so, CMS needs to hold their enforcement agencies accountable,” added StarPro founder and managing director Colleen Muncy.

Other changes

Additional differences in the 63 pages of guidance were minimal.

CMS said it is retiring two measures from the previous fiscal year, a data submission measure and measures on the timeliness of upload of recertification surveys, because the new iQIES reporting system “will enable seamless survey uploads.”

The agency also reintroduced an updated version of the measure Assessment of Deficiency Identification using Federal Comparative Surveys, essentially comparing how a state agency inspects a facility versus how a team member from a CMS office does.

Despite providers’ concerns about lagging survey times and outdated data being reported on the Five-Star site, CMS hasn’t made a major move to bring state surveyors back into timely compliance.

A report this summer on 2023 surveyor performance found just 20 states had reduced their recertification survey backlog by at least 50%, but persistent problems remained with untimely follow-up investigations.

CMS said it would continue to give leeway to state agencies regarding catching up on recertification surveys in fiscal 2025 in light of ongoing COVID backlogs.

The agencies must conduct a recertification every 15.9 months, and the statewide average between consecutive recertifications must be 12.9 months or less. CMS said it would not assess the statewide average time this fiscal year.