Twenty states reduced their recertification survey backlog by at least 50% in 2023, but the latest performance review from the Centers for Medicare & Medicaid Services underscores persistent problems with untimely follow-up investigations at nursing homes.
That has left many facilities and consumers reliant on outdated data, leading to inaccurate ratings and, sometimes, more penalties.
CMS measures state-survey agency performance across six metrics for both nursing homes and acute and continuing care providers. In State Performance Standards System findings released Aug. 1, the Center for Clinical Standards and Quality acknowledged ongoing challenges for state inspection organizations, including staffing and funding shortfalls.
“During the COVID-19 public health emergency, many [state agencies] received a large volume of complaints for healthcare providers, resulting in unanticipated and unprecedented challenges with investigating these complaints,” the report noted. “Since the public health emergency, serious complaints have continued to increase across provider and supplier settings while in the context of a flat budget.”
Last fiscal year, the report revealed, CMS required states to reduce delays in processing Immediate Jeopardy investigations by 25%. Among the 17 states it scored on that measure, 14 had done so.
CMS also required states to reduce the number of past-due recertification surveys by 50% in fiscal 2023. Thirty-four states had enough past-due nursing home recertification surveys to receive a score on that measure; 20 hit the target of 50%.
(In many categories, CMS did not report findings for all states, giving a “not applicable” when enough data wasn’t available.)
Still, more up-to-date information shows that many states are still months, if not years, behind schedule, according to an analysis by Formation Healthcare.
“While some states have caught up on their backlog from a year ago or made improvements, nationally the standard survey backlog remained at 11%, year over year, as of July 2024,” Managing Partner Jessica Curtis told McKnight’s Long-Term Care News on Tuesday. “Some states have fallen even further behind, including five states with 50% to 75% of communities not receiving a standard survey in over two years. Based on this, as well as the nursing staffing shortage affecting state survey offices, it’s unclear if 2024 will see overall improvement.”
Several states, including Delaware and Missouri, haven recently touted their gains on routine surveys, which are technically required at least every 15 months. Some states had allowed the frequency of those standard nursing home inspections to creep up to a three-year span, drawing ire from both consumers and nursing homes who need timely surveys to feed publicly available data on their performance.
“Old standard surveys continue affecting a community’s CMS 5-star rating until a new standard survey occurs and the older surveys either cycle off or are reduced in weight,” Curtis said. “This can have a significant impact on a community’s census, marketing, satisfaction, staffing and financing.”
Delayed follow-up problems also continue
Another area where nursing homes operators have repeatedly expressed concern over state survey timeliness is on the onsite revisits needed to confirm a facility has addressed previously cited deficiencies.
Those delays continued to happen in most states in 2023, CMS acknowledged.
To meet expectations on the standard, survey agencies needed to complete 70% of follow-up visits within the required 60-day window for nursing homes.
Among the 47 agencies with at least five surveys requiring a nursing home revisit, 33 states met the goal. Performance was even worse for acute and continuing care providers needing follow-ups: Of 39 states with at least five surveys requiring a revisit, just 10 met a goal of 70% within 45 days.
“Timely revisits are important to ensure that mandatory enforcement remedies are not inadvertently triggered unrelated to the provider’s achieving compliance,” CMS reminded in its memo to state survey agency directors.
Too often, those revisits are butting up against the start of payment denial triggers, one expert told McKnight’s.
“When the revisits do not occur timely, [providers] are at risk of going into a denial of payment for new admissions status,” said Kimberly Cox, RN, IP-BC, a senior consultant with Formation. “If a facility receives a revisit just a few days prior to the proposed [denial of payment] date or after the proposed date and results in an additional deficiency/failed revisit, they have no opportunity to correct.”
Additionally, Cox explained, if a complaint survey occurs prior to the surveyors conducting a revisit on a prior survey, a facility’s noncompliance timeline is extended. That makes it more difficult to achieve substantial compliance prior to the DPNA date and could lead to fines or penalties as a result of continued noncompliance.
From a consumer perspective, slow responses to Immediate Jeopardy tags have been a major concern since the pandemic forced a temporary halt to most inspection work. CMS requires that states start the surveys intake process for IJ complaints within two days, and agencies must start at least 80% on time to meet the standard. In nursing homes, 41 states hit that mark last year.
Despite agencies’ inability to meet critical and legally required performance in many states, CMS said it remained “heartened” by the survey teams’ work.
“CMS views Fiscal Year 2023 SPSS findings in the context of flat SA funding levels since FY2015 despite considerable resource and workload challenges resulting from the COVID19 pandemic and continuing after the end of the COVID-19 public health emergency on May 11, 2023,” the memo said. “CMS does not take these challenges lightly and will continue to work with SAs towards ensuring the highest quality of care and safest health care environments for all beneficiaries.”
A full state-by-state breakdown of performance metrics can be viewed here.
