Nursing Home Surveys: When Will I Have Mine?

Since many nursing home members have not had a Department of Health (DOH) recertification survey in some time, many wonder when that survey will happen. The only thing LeadingAge NY ProCare is certain about is that it will happen. We took a look at some data, specifically the number of surveys that were completed between September 2021 and January 2022. As there is a lag of two to three months before surveys are uploaded to the Centers for Medicare and Medicaid Services (CMS), we chose January 2022 for that reason.

Here is what we found: the average time between surveys for this period was 27 months. In 2019, for the same five-month period, the average time between surveys was 18 months. In the most recent period of September 2021 to January 2022, 65 surveys were completed, compared to 125 in the same, pre-pandemic 2019 period. Regionally, the data highlights significant differences in the pace of the survey. In this comparison, we looked at the period of August 2021, when CMS provided guidance to State Survey Agencies that recertification surveys could resume, to January 2022. In that time period, the Hudson Valley completed 10 surveys, Syracuse 25, Rochester 20, Long Island 19, New York City (NYC) 34, Albany 19, and Buffalo 19. Syracuse and Rochester account for 13 percent and 10 percent, respectively, of the nursing homes statewide, so they positively impacted the statewide completion rate. In all cases, the number of surveys was down significantly from the similar pre-pandemic timeframe.

Interestingly, the deficiencies cited were very similar for the two timeframes we compared. Infection Control and Accidents continued to be the most cited deficiencies. Seven of the top 10 were identical, but may have been different in their order in the top 10. The average number of deficiencies per survey by region was as follows: Buffalo (3.5), Rochester (2.7), Syracuse (5.1), Albany (6.1), Hudson Valley (1.6), NYC (4.9), and Long Island (3.0). Most revealing about the data was the scope and severity. D-level deficiencies accounted for 73 percent of all citations, E-level 17 percent, and F-level 2.7 percent. In other words, 92.7 percent of the citations were "No actual harm with potential for more than minimal harm." Only 1.2 percent of citations were at the G level (harm). It is hard to know whether this pattern will continue, as we suspect that the reasons for the low scope and severity may have been driven by a number of factors, including DOH staffing, current survey schedules, complaint backlog, and the CMS mandate for 20 percent of nursing homes to have a Focused Infection Control Survey.

Although the number of citations is down, members should actively prepare for the survey and in particular review CMS guidance outlined in QSO 22-02, which identifies some survey changes as well as areas for increased survey focus. LeadingAge NY ProCare has been active in helping members prepare for their survey by conducting mock surveys. For many members, it has helped to identify high-vulnerability resident care areas as well as potential compliance issues that may have been overlooked during these last two years, as members have understandably focused on infection control-related issues. 

Special thanks to Darius Kirstein, who contributed the data and insight for this article.

Contact: Elliott Frost, efrost@leadingageny.org, 518-441-8761