CMS Releases Guidance on Federal Monitoring Surveys

On Nov. 20, 2023, the Centers for Medicare and Medicaid Services (CMS) released Admin Info memorandum 24-05-NH regarding upcoming Federal Monitoring Surveys (FMSs). The memorandum describes the Fiscal Year (FY) 2024 and FY 2025 focus concerns and communicates the estimated number of Long-Term Care (LTC) FMSs for Health and Life Safety Code (LSC)/Emergency Preparedness (EP).

Per the memorandum, LTC FMSs must be performed by each CMS Location during each FY to meet the statutory requirement of Section 1819(g)(3)(B) of the Social Security Act, which requires FMSs of “at least 5 percent of the number of skilled nursing facilities surveyed by the State in the year, but in no case less than 5 skilled nursing facilities in the State.” LTC FMSs include the Health, LSC, and EP parts of the survey.

1. LTC Health FMSs are comprised of three survey processes described below and aimed at advising and evaluating State Agency (SA) Surveyors. An EP FMS is not conducted during a Health FMS.
   1. Resource and Support Surveys (RSSs) are surveys where the Federal Surveyor(s) accompany SA Surveyors on an initial, standard, revisit, or complaint survey to observe and assess overall SA Surveyor team performance and performance related to specific areas of concern.
   2. Focused Concern Surveys (FCSs) are one of the evaluative components of the FMS process. FCSs are completed by one or more Federal Surveyor(s) conducting an independent investigation of the identified concern areas. FCSs occur within 60 calendar days of an SA standard or complaint survey. The Federal Surveyor follows all investigative protocols and pathways for the concern areas to assess the effectiveness of SA performance.
   3. A Health Comparative is a full survey conducted by Federal Surveyors in the same facility, after a standard survey is conducted by the SA. The purpose of a Health Comparative survey is to monitor and evaluate SA performance. An LTC Health Comparative should be conducted within 60 calendar days of the SA’s standard survey.
2. LTC LSC FMSs are comprised of four survey processes aimed at advising and evaluating SA Surveyors.
   1. An LSC RSS is a survey where the Federal Surveyor will observe and assess the SA Survey team’s performance.
   2. An LSC Comparative is a full survey conducted by a Federal Surveyor in the same facility, after a standard survey is conducted by the SA. The purpose of an LSC Comparative survey is to monitor and evaluate SA performance. An EP survey will be conducted with all LSC Comparative surveys. LSC Comparative surveys will occur within 60 calendar days of the SA’s standard survey.
   3. An LSC Revisit RSS is a survey where the Federal Surveyor will observe and assess the SA Survey team performance.
   4. An LSC Revisit Comparative is a survey conducted by a Federal Surveyor in the same facility after a revisit survey is conducted by the SA. The purpose of an LSC Revisit Comparative survey is to monitor and evaluate SA performance. An EP survey will be conducted with all LSC Revisit Comparative surveys. LSC Revisit Comparative surveys will occur within 60 calendar days of the SA’s revisit survey. The Federal Surveyor will primarily evaluate compliance with the requirements cited during the SA’s standard survey.

For FY 2024 and FY 2025, CMS has identified three LTC Health National Concern Areas based on internal CMS data sources, Office of Inspector General (OIG) recommendations, and the White House Initiative to Improve Care in Nursing Homes. The three areas of focus concern include Nurse Staffing, Unnecessary Psychotropic Medication, and Facility-Initiated Discharges. The memorandum contains the associated F-tags and Critical Element Pathways to be used in the FMS.

The Federal Surveyor will have the option of selecting any additional area(s) of concern that are unique to the survey and do not fall within the concerns identified above. These concern areas can be selected when the Federal Surveyor is onsite and observes obvious issues with SA Surveyors’ performance in investigating compliance for areas that were not otherwise selected.

The memorandum goes on to describe the facility selection process, the timeframe for completion of the FMS within the calendar year, how feedback is provided, as well as the scoring process and any subsequent enforcement action in detail. This is a useful resource for facilities when trying to understand and decipher CMS FMSs and in identifying any areas of concern that may need to be addressed proactively.

Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147