CMS Provides Details on “Risk-Based Survey” Approach

The Centers for Medicare and Medicaid Services (CMS) announced that it is currently testing its risk-based survey (RBS) approach. This testing is projected to occur over the next few months. The Agency had floated the idea of a modified survey approach, but there weren’t any details to go with it. CMS indicated some pretty telling things in its update about the RBS, most notably:

  • CMS has limited resources for survey & certification activities, so it believes that the resources should be prioritized for activities related to nursing homes where there may be a greater risk to the health and safety of their residents.
  • Modifying surveys based on compliance and quality history would allow CMS to focus more on providers where there is a greater risk of harm to residents.
  • Risk-based surveys would be more of a focused version of the LTCSP, but if concerns related to resident safety were identified during one of these modified surveys, the entire survey process would be conducted.
  • The RBS would only be used for recertification surveys, not for the complaint survey process.
  • The risk-based approach would result in facilities that are better performers who provide higher quality care and services to have a more focused recertification survey.

The approach for determining which facilities are “higher quality” appears to be a bit subjective, while still linked with some concrete data that CMS could use to determine who provides consistently high quality of care. The following items were mentioned:

  • History of fewer citations for noncompliance
  • Higher staffing levels
  • Lower hospitalization rates

There are also examples of “other” characteristics which could indicate higher quality:

  • No resident harm or abuse citations
  • No open complaint investigations that have been triaged at a potential Immediate Jeopardy level
  • Compliance with Payroll-Based Journal (PBJ) data submission requirements
  • Compliance with other mandated data submissions

The information indicates that the number of RBS would be limited within each state, specifically mentioning that “up to 10 percent of nursing homes within a state” may qualify for RBS. That 10 percent could potentially be aligned with the Five-Star Quality Rating cut points since the highest performing providers in a state make the Five-Star threshold.

CMSCG will provide more information as it becomes available. CMS indicated that updates will likely be provided in the form of QSO Memos down the line.

Preparing for your next survey? Learn more about CMS Compliance Group’s Survey Readiness consulting services, including Mock Surveys/ Quality Reviews, proactive record review/auditing and more. Contact CMSCG to discuss how our interdisciplinarly team of experienced consultants can help your organization achieve better survey outcomes.

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