Snapshot:

-              CMS unveils new risk-based survey process to reward higher-performing SNFs

-              CMS will add new icon to Care Compare tool to recognize these high performers

-              Providers must qualify for new survey process; about 12 percent currently would

-              Experts see CMS acting to reward quality and elevate data in importance

-              New survey process will be implemented in September

The Centers for Medicare and Medicaid Services (CMS) on July 16 introduced a more streamlined review process for higher-performing nursing homes as well as an easier way for consumers to discover them when searching the CMS website through a new icon.

The Quality, Safety, & Oversight (QSO) Memo outlines this risk-based survey (RBS) process that strategically directs state agencies’ limited resources where they are needed most — by focusing fewer resources on the nation’s higher-performing nursing homes so states can address issues in nursing homes where residents’ health and safety are at greater risk.

CMS said to identify these higher-performing facilities, the agency will place an icon on the Care Compare tool on Medicare.gov.

“Building on a successful pilot program conducted across 22 states, the new risk-based survey process is designed to improve efficiency and effectiveness in nursing home oversight,” CMS said. “This approach reduces both the time required and the number of staff members needed to conduct standard recertification surveys at the higher-performing facilities in the country.”

‘Thoughtful Evolution’

In response to the CMS announcement, Steven Littlehale, chief innovation officer, Zimmet Healthcare Services Group, hailed the effort and praised the nuances of the plan.

 "This is a thoughtful evolution in how CMS approaches oversight. Rather than treating every nursing home the same, the agency is directing limited survey resources where residents face the greatest risk while recognizing providers that have consistently demonstrated excellence,” he said.

“Just as important, CMS has made the qualification criteria refreshingly transparent, giving providers a clear roadmap for participation. The real test will be ensuring the program doesn't inadvertently widen the gap between high-performing and struggling facilities or create incentives to focus too narrowly on qualifying metrics, but overall, this is a smart, test, risk-based approach."

Littlehale did express concern that the new icon not be misinterpreted as a CMS endorsement, versus the icon’s real purpose, which is to signify that the facility had met qualifications for the designation.

Survey Frequency Same

CMS said all facilities will continue to be surveyed at least every 15 months. State agencies and CMS may still conduct the survey using the traditional long-term care (LTC) survey process in any RBS-qualifying facility, based on concerns related to residents’ health and safety, such as complaint reports.

“Strengthening oversight of long-term care facilities is one of many top priorities at CMS,” said CMS Administrator Mehmet Oz. “Nursing homes care for our seniors, and that care should be of the utmost quality. At CMS, we are continually looking for ways to recognize excellence for top performers and to encourage lower performers to improve.” 

CMS said the benefits of the new risk-based survey approach include:

• Greater Efficiency — States can decrease time spent conducting standard surveys and conduct serious complaint investigations without requiring additional funding.

  
  

• Budget Relief — Because annual survey budgets, which are set by Congress, have remained flat since 2015, this approach maximizes the impact of existing resources.

  
  

• Creates Incentives for Quality Improvement — The program is designed to encourage facilities to improve the quality of care they provide to qualify for the RBS and earn the corresponding icon on CMS’s Care Compare tool on Medicare.gov. “For example, because the staffing star rating is one of the qualification criteria — and adequate staffing is closely linked to many aspects of quality — the program creates an incentive for facilities to strengthen their staffing levels,” CMS said.

  
  

How to Qualify

About 12 percent of all nursing facilities will qualify for the new risk-based survey process initially.

To qualify for the risk-based assessment, a nursing home must meet several rigorous criteria quarterly, including a Five-Star overall facility rating on CMS’s Care Compare site, accurate data submission to CMS, zero citations indicating harm or substandard quality of care in the last survey cycle, and no recent ownership changes. Moving forward, qualified facilities will be designated as such on Care Compare at Medicare.gov, where users can compare different provider types.

The risk-based survey implementation is scheduled to begin in September 2026, following state agency training. The designations for high-performing facilities are expected to appear in Care Compare in September 2026.

Analytical Breakdown

Lauren Stenson, curriculum development specialist, American Association of Post-Acute Care Nursing (AAPACN), said at first glance, QSO-26-14-NH may not seem to have major clinical implications because it doesn't introduce new regulations or change the standard of care. “However, it does change how CMS plans to focus its survey resources, and that should get the attention of every Director of Nursing Services.”

She said the biggest takeaway is that consistently providing high-quality care now has another benefit.

“Facilities with a strong history of positive quality outcomes, adequate staffing, accurate data reporting, and regulatory compliance may qualify for the new Risk-Based Survey process, allowing surveyors to focus more of their time on facilities with a higher likelihood of resident harm,” Stenson said.

From a clinical leadership standpoint, this reinforces something many nurse leaders have been saying for years: survey readiness doesn't begin when the survey team walks through the door. It is the result of strong clinical systems that are built into daily practice, she said.

“Preventing falls, pressure injuries, infections, avoidable hospitalizations, and other adverse outcomes has always been about protecting residents. Now, those same outcomes also influence how CMS approaches the survey process,” Stenson said.

Data Accuracy or Perish

Another important takeaway is the continued emphasis on data accuracy.

“MDS coding and PBJ reporting are no longer viewed simply as reimbursement or staffing requirements. CMS is using these data, along with Five-Star ratings, prior survey history, and other quality indicators, to help determine which facilities may qualify for the Risk-Based Survey process. That makes accurate documentation and reporting more important than ever,” she said.

The memo also extends beyond the survey process with CMS planning to add a Quality Indicator icon to the Nursing Home Care Compare website.

“While it does not replace the Five-Star Rating System, it gives consumers another way to recognize facilities that have consistently demonstrated strong performance. This indicator reinforces that the work done to improve resident outcomes, maintain accurate documentation, support adequate staffing, and lead quality improvement efforts is becoming increasingly visible, not only to surveyors, but also to residents, families, referral sources, and hospitals,” Stenson said.

For leadership, this memo reinforces the importance of building a strong clinical culture. “Organizations that invest in consistent assessment practices, timely follow-up, interdisciplinary communication, staff education, and proactive quality improvement are not just improving resident care; they are also positioning themselves as lower-risk facilities in the eyes of CMS,” she noted.

The big picture isn't really about surveying less. “It's about recognizing facilities that have demonstrated, over time, that quality and compliance are embedded in their daily operations. The organizations that benefit will be those that focus on doing the right things consistently, not just when survey is around the corner,” Stenson said.

Checklist Pro’s and Con’s

Littlehale further boiled down the CMS program by listing the good points and the concerns. First, the concerns:

• Performance gap: Could further widen the divide between high-performing facilities and those working to improve.

  
  

• Five-Star reliance: Eligibility is heavily dependent on Five-Star ratings, which are not a perfect proxy for quality. Also does not directly consider the Quality Measure domain.

  
  

• Metric gaming: Incentivizes organizations to focus on qualifying measures rather than broader quality improvement.

  
  

• Consumer confusion: The "High Performing Facility" icon may be interpreted as an endorsement, rather than simply meeting eligibility criteria.

  
  

• State variation: Differences in cross-state, and intra-state survey practices may affect which facilities qualify, despite CMS's efforts to normalize comparisons.

  
  

Now, the Littlehale strengths:

• Risk-based oversight: Directs limited survey resources to facilities where resident risk is greatest.

  
  

• Transparent criteria: Providers know exactly what standards must be met.

  
  

• Recognition of excellence: Rewards sustained, measurable performance.

  
  

• Operational efficiency: Reduces regulatory burden without eliminating oversight.

  
  

• Data-driven approach: Builds on a successful multi-state pilot before national rollout.

  
  

Comments or questions on this article? Contact Patrick Connole at pconnole@parkplacelive.com.