Standard Health Surveys: The 9-to-15 Month Cycle
For any nursing home to be certified for participation in the Medicare and Medicaid programs, it must be in substantial compliance with federal health and safety regulations. The Centers for Medicare & Medicaid Services (CMS) oversees this process, and while CMS sets the federal requirements, state survey agencies are primarily responsible for conducting the on-site inspections.
The most common type of inspection is the standard, or comprehensive, health survey. Federal law dictates that a state survey agency must conduct a standard survey of each nursing facility no later than 15 months after the last survey was completed. Furthermore, to ensure regular oversight, the statewide average interval between consecutive standard surveys must be 12 months or less. This means while an individual facility can go slightly longer than a year between inspections, the average across all facilities in a state must be annually. This frequency requirement, while providing a baseline of accountability, has faced challenges over the years, including significant backlogs reported by the U.S. Senate Special Committee on Aging.
The Unannounced Nature of Inspections
To ensure that facilities are constantly meeting federal standards rather than preparing for a known inspection date, all standard surveys are unannounced. This surprise factor is a crucial component of the survey process. Surveyors can show up at any time, including evenings, nights, weekends, and holidays, to observe the facility during different shifts. A typical survey can last several days, depending on the facility's size and complexity. Any individual found to have notified a nursing home of a scheduled survey is subject to a federal civil money penalty.
Beyond Standard Surveys: Additional Inspections
While the standard survey is the most common, it is not the only type of inspection a nursing home may face. The frequency of additional surveys is directly tied to a facility's performance and responsiveness to issues.
Complaint Investigations
Residents, family members, or staff can file a complaint with the state survey agency or directly with CMS. Federal regulations require a survey agency to investigate all allegations of potential violations of requirements. The agency will conduct a standard or abbreviated survey to determine if a deficiency exists. The priority and timeliness of the investigation will depend on the severity of the alleged issue.
Follow-Up or Revisit Surveys
If a standard survey finds deficiencies in a nursing home's operations, the facility is required to submit a plan of correction. A follow-up survey, or 'revisit,' is then conducted to verify that the identified issues have been accurately and timely implemented. The purpose is to ensure the facility has rectified the problems and is now in compliance. This process adds an extra layer of accountability beyond the initial survey.
Risk-Based Surveys and Special Surveys
CMS is constantly looking for ways to modernize its oversight. In recent years, CMS has piloted a risk-based survey (RBS) approach. This model allows consistently high-quality facilities to receive a more focused, and potentially shorter, survey, while enabling regulators to spend more time on higher-risk facilities. This approach is designed to allocate resources more efficiently. Additionally, CMS may conduct special surveys within 60 days of significant changes, such as a change in ownership, management, or key leadership like the administrator or director of nursing.
What Surveyors Look For
The comprehensive nature of a CMS survey covers a wide range of operational and care standards. The survey team, often composed of health care professionals like registered nurses and dietitians, assesses multiple aspects of facility performance. Key areas of focus include:
- Quality of Care and Services: Evaluation of resident care plans, medical, nursing, and rehabilitative care.
- Resident Rights: Observation of whether residents are treated with dignity and respect, and whether their autonomy is valued.
- Medication Management: Assessment of medication records, administration procedures, and storage protocols.
- Infection Prevention and Control: Reviewing staff adherence to protocols that minimize illness spread, especially relevant since the COVID-19 pandemic.
- Safety and Emergency Preparedness: Compliance with federal and state regulations for fire safety, evacuation plans, and other emergency protocols.
- Dietary and Kitchen Services: Inspection of kitchen and food storage areas to ensure safety and sanitation standards are met.
Consequences of Failing a Survey
When a survey reveals deficiencies, CMS, along with the state agency, can impose a range of enforcement actions, known as remedies. The severity of the remedy depends on the scope and severity of the violation. Potential consequences include:
- Civil Monetary Penalties: Fines can be levied against the nursing home.
- Denial of Payment: CMS can deny Medicare or Medicaid payments for new admissions.
- Directed Plan of Correction: The facility is required to take specific, directed actions to fix the problem.
- Increased Monitoring: Increased oversight and scrutiny by the state or CMS.
- Temporary Management: In severe cases, the government can appoint temporary management to oversee the facility.
- Revocation of Certification: For persistent or very serious noncompliance, CMS can revoke the facility's Medicare and Medicaid certifications, essentially shutting it down.
Comparison of Nursing Home Survey Types
| Feature | Standard Survey | Complaint Survey | Follow-Up Survey |
|---|---|---|---|
| Purpose | Comprehensive check of all federal requirements for certification. | Investigate specific allegations of non-compliance. | Verify that previously cited deficiencies have been corrected. |
| Initiated By | Federal law and CMS requirements for state agencies. | Complaint from a resident, family member, or staff. | Previous standard survey that identified deficiencies. |
| Frequency | At least every 15 months, with a statewide average of 12 months. | Varies, initiated when a complaint is filed. | Follows a survey with deficiencies; occurs as needed. |
| Timing | Unannounced, including nights, weekends, and holidays. | Unannounced, with priority given to severity of complaint. | Unannounced, conducted after the plan of correction is approved. |
| Scope | Broad assessment covering all aspects of care and operations. | Focuses specifically on the nature of the complaint. | Limited to confirming the correction of specific deficiencies. |
How Families Can Stay Informed and Participate
For families of residents, staying informed about the survey process is vital for ensuring loved ones receive quality care. You can use the official Medicare Care Compare website to review a nursing home's survey findings and health inspection ratings. It's also important to remember that families have the right to voice concerns and file complaints with the state survey agency, which can trigger an unannounced complaint investigation.
In conclusion, CMS surveys are a critical component of federal oversight designed to protect the health, safety, and welfare of nursing home residents. By understanding the standard 9-to-15 month cycle, the purpose of unannounced inspections, and the availability of additional complaint-based and follow-up surveys, both families and residents can be more informed and engaged participants in ensuring quality care. While survey backlogs have been a past concern, ongoing monitoring and modernization efforts, such as risk-based pilots, continue to evolve the process, with the goal of providing timely and effective oversight.
For more information on health inspections and nursing home quality ratings, please visit Medicare's Care Compare tool.
