Aug 28, 2019

Ensuring Safety and Quality in Nursing Homes: Five Part Strategy Deep Dive

Seema Verma
Administrator, Centers for Medicare & Medicaid Services

Ensuring Safety and Quality in Nursing Homes: Five Part Strategy Deep Dive

In April, I was proud to announce the five-part approach the Centers for Medicare & Medicaid Services (CMS) is using to guide our work as we ensure safety and quality in America’s nursing homes. We at CMS bear the responsibility to develop and enforce quality and safety standards across the nation’s health care system, and we are deeply committed to that job. Every nursing home resident deserves to be treated with dignity and respect, and all of our nursing home work at CMS is predicated upon that single goal.

Our five-part approach announcement only scratches the surface of our efforts, and there’s a lot more to share. So, in an effort to be transparent with Americans about what CMS is doing to ensure safety and quality in America’s nursing homes, I will publish a blog on each part of our five-part approach, digging into what CMS is doing – and what we hope to do – in this critically important area. As a reminder, our approach is:

  1. Strengthen Oversight
  2. Enhance Enforcement
  3. Increase Transparency
  4. Improve Quality
  5. Put Patients over Paperwork

I’m excited to share the details of our work to ensure safety and quality in nursing homes. I hope you’ll come away from this series with a more thorough understanding of CMS’s work in this area.


Part 1: Strengthening Oversight
Strengthening oversight is the first component of our five-part approach to nursing home safety. It’s also one of the most important, since it involves our longstanding partnerships with State Survey Agencies (SSAs), whose 5,000 surveyors visit each Medicare and Medicaid participating nursing home in the country at least once a year to evaluate their adherence to basic health and safety standards as well as state licensure requirements.

Our nation is vast, and the states vary widely with regard to culture, geography, and climate. But high-quality health care should be the same, no matter the location. This means that all SSAs must fairly and consistently apply CMS rules. Unfortunately, in recent years CMS has found variation across states in terms of the issues SSAs identify in nursing homes’ compliance with our requirements. CMS values our relationships with SSAs, and we are committed to ensuring they have the guidance and resources they need to do their work. Stakeholders can access the findings and associated enforcement actions of the surveys SSAs conduct on the Nursing Home Compare website.

In March 2019, we took an important step toward improving SSA consistency by issuing updated, streamlined guidance to SSAs regarding how they determine an imminent patient safety risk – called an “Immediate Jeopardy.” Immediate Jeopardy is a situation in which a patient has suffered – or is likely to suffer – serious injury, harm, impairment or death as a result of a nursing home’s noncompliance with one or more health and safety requirements. Examples of Immediate Jeopardy would be when a nursing home fails to protect a resident from abuse, or when a nursing home fails to provide the supervision needed to prevent a confused resident from wandering into a dangerous environment. Our new Immediate Jeopardy guidelines provide SSAs with clear and consistent procedures when evaluating noncompliance that constitute Immediate Jeopardy situations, which require immediate action to address. This not only protects patients by ensuring adherence to CMS safety standards, but it also ensures fairness for providers by holding them to uniform standards and process.

CMS has moved to a single, computer-based survey process, pairing it with updated guidance as we implemented revised requirements for participation for all nursing homes. This innovation allows for streamlined, clear direction to SSAs as they evaluate nursing home safety – while reducing burden. This new process also provides CMS standardized data on SSA performance.  As the survey results come in, we’re analyzing the data, including focusing on outliers, such as states reporting a significantly lower than average number of citations per survey. We review SSAs that are outliers and when warranted, require corrective action plans to ensure they are following CMS policies and procedures as expected.

CMS is also seeking excellence in survey operations and the surveyor workforce. In addition to monitoring the data we receive from our new computer-based survey process, we send federal survey teams onsite to nursing homes through the Federal Oversight Support Survey process. These teams monitor SSAs and determine if they are conducting surveys effectively. To further improve this oversight function, we recently revised how we conduct these monitoring visits. We will continue to analyze and evaluate the results from these activities, and it will inform our future work. Finally, earlier this year, CMS began efforts to modernize the IT system we use to track quality issues. A system that’s more user-friendly and flexible will make it easier for CMS to track quality and ensure transparency.

CMS is clearly hard at work improving the survey process and evaluating SSA performance against certain metrics, but we’re also working closely with states in these efforts. CMS communicates monthly with state leadership to aid in coordination and improvement. We’re helping states improve their survey processes by offering targeted contractor resources for states with significant performance issues. Finally, when states fail to meet our performance standards, we act quickly to identify corrective actions to remediate issues and ensure our standards for overseeing health and safety are met.

Going forward, we want to build on our successes, and we have a few ideas in mind. First, CMS is rethinking how we utilize our network of Regional Offices, who serve on the front lines. These diligent CMS staff are our eyes and ears across America, and they often have strong relationships with stakeholders and state officials. We’re considering how best to leverage those relationships to improve our survey work. We’re also thinking about how we can better provide feedback to SSAs and state officials so that we can ensure our rules are being enforced consistently around the country. Additionally, CMS is considering new ways to address SSA performance problems beyond financial penalties – which can sometimes make bad situations worse.

But CMS isn’t alone in this effort – we’re also asking Congress to do its part. Currently, CMS (through SSAs) is required by law to annually inspect each nursing home in America that participates in Medicare and Medicaid, a total of approximately 15,000 facilities. Additionally, SSAs inspect nursing homes upon receipt of complaints or facility-reported incidents. Combined, these surveys total roughly 70,000 inspections each year. This is a monumental task. The mandated annual survey cycle is costly to SSAs and requires us to use precious resources to survey each facility, regardless of their quality performance. In President Trump’s 2020 budget proposal, we’ve asked Congress for the authority to transition to a risk-based survey model for nursing homes so we can target low performing nursing homes with more frequent surveys. We propose to survey top performing facilities every 30 months, with no more than 36 months between surveys of any single facility. We would reinvest the savings to strengthen our oversight and quality improvement efforts for facilities that are low performers. We would also continue to inspect facilities in response to complaints, which can occur at both low and high performing facilities, giving providers incentive to continuously monitor quality.

Additionally, the President’s 2020 budget proposal asks Congress to increase our resources, namely our Survey and Certification budget. This budget funds SSAs and other kinds of CMS survey work beyond nursing homes. Unfortunately, this fund has remained flat for several years. President Trump’s budget requests $442.2 million, an increase of $44.9 million above what Congress enacted in 2019. We hope Congress will honor this request and allow CMS to ensure appropriate survey oversight of all Medicare and Medicaid certified providers and suppliers.

The health and safety of America’s nursing home patients is at the forefront of our minds, and is at the heart of all of our work in this area. Every action we take is because it will ultimately benefit the patient.

Please check out our podcast, “CMS: Beyond the Policy.” I recently sat down with Dr. Kate Goodrich, CMS Chief Medical Officer and Director of CMS’s Center for Clinical Standards and Quality, to discuss our oversight efforts. And check back soon for my next blog, when I will share detail on the next pillar of our five-part nursing home approach, Enhancing Enforcement.


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