'Risk-based survey' nursing home inspection process raises concerns despite some support

Highly rated nursing homes, including those on Long Island, that have no serious recent health and safety violations or low-staffing issues, could face "streamlined" and less time-consuming inspections under a new nationwide "risk-based survey" process announced last month by the Trump administration.

The plan, introduced July 16 by the Centers for Medicare & Medicaid Services, would allow about 12% of U.S. nursing homes that are determined to be "lower risk" to receive a more "focused" inspection that would address fewer activities, take roughly half the time and require a smaller survey team.

Few nursing homes qualify

CMS contends the plan, which will be implemented nationwide on Sept. 8 and follows a pilot program conducted in 22 states, will allow state agencies to strategically direct their limited resources to perform more impactful nursing home inspections.

But critics contend that reducing longstanding inspection requirements will exacerbate already vulnerable nursing home residents’ exposure to avoidable harm, including abuse and neglect.

"Under the existing system, far too many violations are missed or under-coded," wrote Richard Mollot, executive director of the Long Term Care Community Coalition, a Manhattan group that advocates for nursing home residents, in an alert responding to the change. "As a result, nursing home residents continue to be plagued by poor care and inhumane conditions while too many operators flout minimum standards and manipulate so-called quality indicators in order to maximize profits."

To qualify for a "risk-based survey" (RBS), nursing homes must have a five-star rating from CMS; at least a three-star staffing rating; have received a standard survey during the previous 18 months; and cannot have received a citation during their most recent inspection for "actual harm," "immediate jeopardy" or "substandard quality of care," the agency said.

In New York, only 57 of the state's 596 nursing homes — or 9.5% — would qualify for a RBS, according to federal data, with most excluded because they don't have a five-star overall rating or their staffing rating is less than three stars. The identity of those facilities, officials said, will be publicly disclosed in September.

Based exclusively on publicly available data, about 20% of the Island’s 78 nursing homes would appear to meet these specific criteria, according to a Newsday records analysis.

But other CMS qualifications for a risk-based survey, for which records were not available for review by Newsday, include nursing homes not having a staffing waiver in effect; passing all CMS payroll or resident assessment audits; having no recent change in ownership; a health inspection score higher than the 50th percentile in their state; and not having two or more residents 65 or older that are diagnosed with schizophrenia after being admitted with this diagnosis.

Funds for inspections lacking

CMS said states can continue to conduct traditional inspections at any RBS-qualifying facility if there are specific concerns related to residents' health and safety.

"Strengthening oversight of long-term care facilities is one of the many top priorities at CMS," Dr. Mehmet Oz, the agency’s administrator, said in a statement. "Nursing homes care for our seniors, and that care should be of the utmost quality."

State agencies — in the case of New York, the state Health Department — are required to conduct recertifications of nursing homes at least once every 15 months. Additional inspections are conducted based on complaints from residents, watchdogs and family members.

"The department holds nursing home operators accountable to all state regulations, taking enforcement actions when warranted," said Marissa Crary, a spokeswoman for the state Health Department, where inspectors will undergo training from CMS in August and September on how to comply with the new federal system.

CMS officials argued the federal budget to fund nursing home surveys has not increased since 2015 while the obligations to conduct complaint-based inspections has grown by 20%.

Without sufficient staffing to conduct these inspections, federal officials said a backlog has grown nationwide among Medicare and Medicaid-certified nursing homes that are waiting for their standard survey.

Stephen Hanse, president and chief executive of the New York State Health Facilities Association, which represents the nursing home industry, said there's been instances where elder care facilities have gone years without receiving a mandatory inspection.

"This plan modernizes the oversight of nursing homes," Hanse said. "And it moves away from a rigid, one-size-fits-all inspection model to a rational system that really matches regulatory intensity and oversight with actual potential risk."

Debate over designation

To identify these "higher-performing facilities," CMS said RBS-qualifying nursing homes will receive an icon on its Care Compare tool on Medicare.gov.

Consumer Voice, a Washington, D.C.-based nonprofit that advocates for nursing home residents, said this "golden trophy" from President Donald Trump's administration is misleading to residents and families.

"Consumers will likely view the designation as a mark of excellence, when in fact it simply means the nursing home meets the qualifications for a program CMS has created to address survey funding concerns," the group said in a statement.

Comprehensive nursing home inspections, which Newsday has reported on for years — along with fines and penalties that go along with them — are one of the key methods for holding nursing homes accountable for cases of abuse, neglect and substandard care, critics contend.

"It is, frankly, horrifying that the staffing rating cutoff point is only below three stars," Mollot said. "That is by far the most reliable indicator of quality we have, and I shudder to think about what goes on in a three-star staffing nursing home."

Supporters of CMS' plan, including Michael Balboni, a former Long Island state senator who now serves as executive director of the Greater New York Health Care Facilities Association, which represents nursing homes statewide, said the new strategy also will create an incentive for facilities to improve the quality of their care and boost their staffing levels to qualify for the RBS rating.

"This issue here is that there are not many homes that will be able to meet these measures on a regular basis so the impact to the majority of residents will be negligible," Balboni said. "I view this as an attempt to incentivize better care. Long-term care has always focused on penalties. Maybe this will improve care because it models and rewards good behavior."

By Robert Brodsky

robert.brodsky@newsday.com@BrodskyRobert

Robert Brodsky is a breaking news reporter who has worked at Newsday since 2011. He is a Queens College and American University alum.