Survey & Oversight Changes in Nursing Homes – What to Know (Pt 2)

On November 12, 2021, the Centers for Medicare & Medicaid (CMS) released a QSO Memo, “Changes to COVID-19 Survey Activities and Increased Oversight in Nursing Homes” (QSO-22-02-ALL). The Memo provides information on changes that CMS is making to help State Survey Agencies (SAs) get caught up with a significant backlog of recertification and complaint surveys. In Part 2 of our “Survey & Oversight Changes in Nursing Homes – What to Know” CMSCG Blog series, we will review significant updates to the recertification survey process.

Changes to Recertification Surveys

As noted above, way too many nursing homes have been waiting and waiting for a survey, but the surveyors haven’t been showing. Even after CMS directed State Agencies to resume routine survey & certification activities (so long as they had adequate PPE and staff), the backlog has not been sufficiently addressed. According to the CASPER data, CMS Region 10 has 64.4% of its providers at 24+ months waiting for their annual recertification. Likewise, Region 9’s backlog for recertification surveys includes 54.2% of their nursing homes. In recognition that surveyors are unlikely to close those type of gaps by conducting the overdue recertification survey and conduct the next recertification survey (generally between 12-15 months after the previous one), CMS is making a significant change to its guidance.

CMS states in this Memo that the Agency believes all State Agencies are able to resume recertification surveys on a “routine” basis at this point in time. CMS is now directing SAs to resume recertification surveys by establishing new intervals based on a facility’s next survey instead of based on the last survey that was conducted prior to the COVID-19 PHE. This means that when a survey team does finally make it through your doors, regardless of how overdue the survey is, the date of completion for your next survey is the date from when your next survey will be calculated, whether it is 15 months out or 6 months out if the facility is a Special Focus Facility (SFF).

Updated Survey Prioritization

Providers should also be aware that CMS has also guided State Survey Agencies to prioritize recertification surveys based on certain criteria, so now that the length of time a survey is overdue is less important, there are several other factors at play that could make your survey jump the line ahead of others who are more overdue than your facility. The updated prioritization is risk-based, and directs SAs to prioritize surveys for facilities that have a history of noncompliance or allegations of noncompliance in the following areas:

  • Abuse or Neglect
  • Infection Control
  • Violations of Transfer or Discharge Requirements
  • Insufficient Staffing
  • Staff Competency Issues
  • Other quality of care issues such as falls or pressure ulcers

Facilities that are Special Focus Facility (SFF) candidates or on the Special Focus Facility list are also expected to be prioritized.

Increasing Oversight in Key Quality of Life & Quality of Care Areas

CMS states that it is “very concerned” about how the limitations to its oversight and visibility into nursing homes throughout the COVID-10 Pandemic has potentially impacted nursing home residents. As such, the Agency has guided surveyors to pay close attention to several areas that may require further investigation during survey, including:

  • Weight Loss
  • Pressure Ulcers
  • Abuse or Neglect
  • Loss of Function/Mobility
  • Depression
  • Nurse Competency, particularly as it relates to facilities ensuring nursing staff has the appropriate competencies, including identifying and addressing a resident’s change in condition.
  • Inappropriate Use of Antipsychotic Medications, which has been a long-standing concern of CMS. F758 Free From Unnecessary Psychotropic Medications/PRN Use is the 9th most frequently cited Ftag on standard surveys in 2021, so pay attention to what’s going on in your facility.
Temporary Changes to the Long-Term Care Survey Process (LTCSP) During Recertification

But wait – there’s more. As part of the LTCSP, the survey team conducts offsite preparation activities. CMS is providing some additional flexibility to the surveyors to allow a handful of mandatory tasks to be discretionary or triggered based on the offsite preparation activities. If there are concerns identified while the surveyor is onsite for survey and conducting observations, interviews and record reviews, or if a complaint is being brought into the recertification survey, then these mandatory tasks can trigger. The following flexibilities will be temporarily in place:

  • Resident Council Meeting
  • Dining Observation Task
  • Medication Storage

Since surveyors are interviewing multiple residents as part of the Initial Pool Process, concerns can be identified there. However, if concerns arise that would usually be investigated during the Resident Council mandatory task, then the survey team would be expected to actually complete the task. Likewise, CMS has limited the need to conduct the mandatory Dining Observation task to only when a resident is being investigated for nutrition, weight loss, or there have been concerns identified related to dialysis. The Medication Storage task also is currently not mandatory unless it is triggered by a surveyor identifying concerns with medication storage during the Medication Administration Observation. Interestingly, it would seem that CMS is very aware that issues related to F761 Storage of Drugs & Biologicals can easily be identified – given that it is the third most frequently cited deficient practice in nursing homes on standard surveys in 2021 – but this task will temporarily be skipped on many surveys.

CMS notes in the Memo that updates to the LTCSP materials are coming, so when they do, CMSCG will provide an update on any specific changes that facilities should be aware of ahead of their next survey.


In the final part of this blog series, we will review what you need to know about the CMS guidance related to complaints and Facility-Reported Incidents (FRIs) as well some hot button areas that surveyors will be reviewing going forward.


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