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Long-Term Care Survey Alert


Brace Yourself for Focused Surveys And Compliance Probes

Scrutiny of quality of care likely to reach new highs in 2016.

The Centers for Medicare & Medicaid Services (CMS) plans a myriad of new final rules for the long-term care (LTC) industry. Plus, you can expect greater attention to your self-reported data, infection control practices, and additional pilot surveys. Is your facility ready?

Your Self-Reported Data is Under Fire

At the very end of 2015, the Government Accountability Office (GAO) released a report that examined nursing home quality data, which likely indicates how 2016 will play out in terms of care quality reporting. The new report, “Nursing Home Quality: CMS Should Continue to Improve Data and Oversight,” analyzed nursing homes’ quality data to determine whether quality has improved in the last 10 years.

So has nursing home quality improved? “As the report shows, it’s not really a simple yes or no answer, thanks to a myriad of changes made in the way CMS completes its oversight,” said the CMS Compliance Group Inc. (CMSCG). Also impacting the data is the way different state agencies (SAs) and regional offices (ROs) conduct their work, “and one of the biggest factors — differences by state on how surveys are conducted.”

Case in point: The GAO report produced conflicting data, with more states experiencing an increase in consumer complaints during the last decade, while the number of genuine harm deficiencies on surveys actually decreased dramatically from 2005 to 2014. The average number of consumer complaints reported per nursing home increased by 21 percent during the 10-year span, but the number of serious deficiencies identified per nursing home with an on-site survey decreased by 41 percent in the same time period.

Problems: A variety of issues with the data make it difficult for CMS and other government agencies “to determine whether observed trends reflect actual changes in quality, data issues, or both,” the GAO lamented in the report. “For example, clinical quality measures use data that are self-reported by nursing homes, and while CMS has begun auditing the self-reported data, it does not have clear plans to continue.”

The GAO largely blames these data inconsistencies on the “numerous modifications” CMS has made to its nursing home oversight activities, while at the same time neglecting to monitor the potential effects of these changes on nursing home quality oversight. For instance, CMS reduced the number of nursing homes participating in the Special Focus Facility program, which provides additional oversight of facilities with a history of poor performance. Also, SAs have made modifications to how they conduct surveys, but CMS doesn’t have an effective mechanism for monitoring such changes, the GAO charged.

The GAO discovered a laundry list of changes that CMS and states have made to the way they record and report nursing home data, along with a variety of reasons why different data sources seem to contradict one another when showing indications of quality trends. For the increase in consumer complaints, the GAO found through interviews with SA officials that the upsurge may be due to new processes that make it easier for consumers to submit complaints, such as via email.

The survey-related quality data is somewhat unreliable, mainly because states are still using two different survey types: the paper-based traditional survey and the electronic Quality Indicator Survey (QIS), CMSCG pointed out. “It’s no wonder that there will be variations from state to state in performance on survey, particularly when the QIS is known to account for less serious deficiencies in quality of care areas.”

Look for 3 Final Rules in 2016

Based on these findings, the GAO recommended that CMS “implement a clear plan for ongoing auditing of self-reported data and establish a process for monitoring oversight modifications to better assess their effects.”

Because CMS agreed with the GAO’s recommendations, you will soon see even more oversight from the government on how you report your quality data, possibly within 2016.

What’s more: The coming year will also likely bring a final rule on the Conditions of Participation (CoP) to include the new Quality Assurance/Performance Improvement (QAPI) and final adoption of the 2012 edition of the Life Safety Code, according to a Dec. 17, 2015 American Health Care Association and National Center for Assisted Living (AHCA/NCAL) blog posting by Lyn Bentley, MSW. AHCA/NCAL also expects CMS to finalize the Emergency Preparedness rule in 2016.

Evaluate Your Infection Control/Prevention Practices

Also new for 2016 is yet another focused survey, this time on infection-control practices.

On Dec. 23, 2015, CMS issued a Survey & Certification (S&C) memo announcing a new three-year pilot project to improve assessment of infection control and prevention regulations in nursing homes, as well as in hospitals and during transitions of care. The pilot survey aims to create new surveyor infection-control tools and survey processes to optimize assessment of new infection-control regulations.

Significance: “F-441 — Infection Control is one of the most frequently cited deficiencies across the country most years when we review survey trends, so this comes as no surprise,” CMSCG said. “As a matter of fact, it’s this year’s [2015’s] most highly cited deficiency in the country.”

CMS is launching the new pilot project using funding from the U.S. Centers for Disease Control and Prevention (CDC), citing the recent U.S. experience with the Ebola outbreak as the trigger for the increased focus on infection prevention efforts.

CMS is basing its evaluation of long-term care facilities’ infection-control standards on the proposed regulations that it announced in July, 2015, CMSCG noted. These are sweeping proposed regulation changes aiming to modernize the LTC industry (see S&C: 15-46-NHs, “Publication of Medicare and Medicaid Programs; Reform of Requirements from Long-Term Care Facilities; Proposed Rule (CMS-3260-P) — Informational Only,”

Prepare Yourself for More Pilot Surveys

You’ll likely see a rash of pilot surveys like the infection control one, because CMS is testing tools to update the survey process as the new CoP make their way into the SOM over the coming years, noted Judy Wilhide Brandt, RN, BA, CPC, RAC-MT, C-NE of Judy Wilhide Consulting Inc. in a Dec. 27, 2015 blog posting. Unlike some of the other pilot surveys, the infection-control pilot doesn’t involve citations.

Not so fast: But keep in mind that “it will be surveyors in the building, and they can always call in complaints on any topic,” warned. “We must respond in full survey mode.”

Another caveat: Although CMS is identifying this pilot survey as “educational,” surveyors must notify the CMS Regional Office if they find an Immediate Jeopardy-level citation, CMSCG said.

You can also expect to see the MDS- and Staffing-Focused surveys, as well as the Dementia Care-Focused survey and the new Adverse Events-focused survey in 2016, Bentley noted. Make sure you use the CMS Trigger Tool to prepare for an adverse events-focused survey and review the dementia care-focused surveyor checklist that CMS recently released.

Also, Bentley recommended that you make sure you have a system to ensure:

  1. MDSs are completed and submitted on time;
  2. Care plans are consistent with the current MDS for each individual; and
  3. Your center has all posted nurse staffing data retained for 18 months.

Resources: The GAO report on nursing home quality data is available at To read the S&C 16-05-ALL memo regarding the new infection control-focused survey pilot, go to