Happy Hump Day!
Yesterday I wrote about the OIG’s (Department of Health and Human Services) report and focus on CMS’ oversight of state survey agencies. The impetus behind this focus no doubt comes from the U.S. Senate Special Committee on Aging’s investigation into nursing home survey activities at the state level. The report is available here: UNINSPECTED & NEGLECTED – FINAL REPORT (1)
From the report (and notice, how the information dovetails with the OIG report I posted yesterday).
Every year, the federal government spends tens of billions of dollars on nursing home care, but
Congress appropriates less than 80 cents per resident per day to nursing home oversight. This
investigation shows how these inadequate investments for much of the last decade has put older
adults and people with disabilities at risk.
Nearly a third of the Nation’s 15,000 nursing homes are behind on comprehensive annual
inspections, including one in nine that have not received an annual inspection in two years or
more. Infrequent annual inspections have led more residents and families to file complaints.
However, advocates shared stories of nursing home residents waiting months for complaints to be
investigated, even when abuse, neglect, and serious health deficiencies were reported.
More than half the Nation’s state inspection agencies said such delays are directly linked to
underfunding for—and understaffing—within these critical state offices. The investigation found
that 32 agencies have vacancy rates of 20 percent or higher among nursing home inspectors, and
nine of those agencies have vacancy rates of 50 percent or higher. More than 80 percent of States
pointed to noncompetitive salaries as a barrier to recruiting and retaining inspectors.
The report is a worthwhile read/review, primarily because it highlights a broken system. The fix is not more regulation, more funding, or more attention to surveys. The fix is a fundamental revamp of what compliance with best practices means, how it can be achieved, how the same can be monitored, and how violations of proper care delivery, should be handled.
The current process focuses significantly on paper compliance. The rules or code is inches thick and ripe with interpretations. It is 863 pages long. The current State Operations Manual (the survey guide with the SNF Federal Conditions of Participation) is available here: Appendix PP State Operations Manual
There are multiple reasons why the care in SNFs has not significantly improved or deteriorated over the decades that I have been involved (one way or another) in the industry. The rules have grown significantly, and the costs associated with compliance have as well. Unfortunately, reimbursement (revenue) necessary to comply has not. One needs only to look at the quixotic venture CMS/DHHS is on regarding staffing levels and the resultant mandate or rule. While all research reports that higher staffing levels don’t directly correlate to improved care, the mandate moves ahead, despite clear data illustrating that compliance will be nearly impossible industry-wide and the expense associated, potentially devastating to many facilities. Rural facilities will be most at-risk of collapse. Abt-Associates-CMS-NH-Staffing-Study_Final-Report_-Apndx_June_2023
I have written and spoken on compliance and survey activity for SNFs for decades. On the Presentations page, readers can find some content on seminars or webinars that I have done on this subject. I have been a vocal proponent for wholesale change to the survey and certification process and to creating a provision (minimally) for deemed status for SNFs (private accreditation versus state survey reviews). I have also been a vocal proponent for faster removal/closure of consistently poor performing facilities and reward/oversight minimalization for consistently excellent facilities. Drawing a COVID analogy, a risk-focused or focused intervention approach. The current process just doesn’t work, and hasn’t for decades.