SNF Survey and Certification Update

When the 2025 Final SNF PPS Rule was released, the focus was on Medicare rate increases.  This is typically known as the “headline”. But as readers and followers here know, there is always a regulatory tidbit or two that can be even more significant in terms of operations, particularly as more and more Medicare patient days are paid for by Medicare Advantage plans (50% plus).  MA plans are not required to follow Medicare rate updates.

In these Final PPS Rules, stuff like VBP, QRP, RUGs, PDPM, and staffing mandates were introduced. In this Final Rule, CMS changed how surveyors can impute fines, allowing for essentially a multiplication effect to occur (per instance and per day, whereby both can be imputed during the same survey). Here is CMS’ explanation.

CMS’ enforcement authority allows for the imposition of CMPs for noncompliance with federal requirements. Penalties can be imposed per day or per instance of non-compliance depending on the health and safety deficiencies identified, with per day CMPs applied until the noncompliance is corrected and per instance CMPs for isolated instances. However, per-day and per-instance penalties could not be imposed for deficiencies identified during the same survey, and per-instance penalties could not be imposed concurrently for the same deficiency. The severity of enforcement sanctions is based on the harm or potential harm to residents caused by non-compliance. This regulatory limitation prevented CMS and the state from imposing CMPs that were more commensurate with the identified noncompliance by restricting the use of multiple penalties for one deficiency, which prevents full use of CMPs to encourage faster correction and sustained compliance with health and safety requirements. 

In this final rule, CMS revises the regulation to expand the type of CMPs that can be imposed to allow for more per instance and per day CMPs to be imposed, as appropriate. The revisions in this rule will permit both types of penalties to be imposed, providing CMS with greater flexibility to impose penalties in a manner that more directly reflects the health and safety impact on residents and incentivizes permanent correction. It is important to note, however, that these CMPs are still subject to statutory daily limits, and CMS can exercise discretion with regard to a nursing home’s financial condition in determining the appropriate CMP. 

More on the Final Rule including the actual published rule is available here: https://rhislop3.com/2024/08/05/final-2025-snf-rule-rate-increase-more-fines/

The implementation of the CMP changes took effect on October 1, and as a result, application data is not yet available. However, this past Tuesday, the Centers for Medicare & Medicaid Services (CMS) started to exert more pressure on state survey agencies to “identify appropriate deficiencies” and carry out additional tasks resulting from routine annual surveys. The guidance comes via the Fiscal 2025 State Performance Standards System Guidance document, available here: Survey Agencies Performance Standards October 2024

In 2025, the agency will introduce a new measure wherein State survey agencies will be evaluated based on six criteria that combined indicate their performance 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

“This composite measure is designed to assess the performance of State Survey Agencies, not to set quotas for deficiencies or investigations,” CMS stated.

A survey agency with a composite score below 120 points (out of a potential 150) will fall into the “requires research” category. Conversely, an agency with a score of 120 or higher will receive an N/A and will be exempt from additional evaluation. In the first year of the measure, there will be no designations of met, not met, or partially met.

What I gleaned in reading through the document is that CMS is looking to advance more consistency among state agencies. If there is a veiled implication it is around getting scope and severity more tight, more correct, and perhaps, more frequent. The survey remains the one element of the Five Star program that is state-specific.

A complaint among providers and provider groups is the lack of consistency; wide variations are noticeable among states. Bottom-line, some states are more prone to issuing higher severity citations, negatively impacting Star ratings (New Hampshire and Tennessee as examples). It seems CMS wishes for more uniformity but based on my knowledge of the process and CMS, the bottom will move up (from less severity) more than the top (more severity) will move down.

Interesting enough, this all comes at a time when states are still struggling with survey backlogs.  Many states simply have been unable to attract and retain sufficient staff to meet complaint survey volumes and recertification volumes.  This is in spite of fundamentally, no new facilities coming online and many, with bed reductions (less time and resources to survey smaller facilities). While overall survey frequency improved, feds find widespread lag persists on follow-up inspections – McKnight’s Long-Term Care News

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