In less than two months on Sept. 8, the Centers for Medicare and Medicaid Services (CMS) plans to implement its nationwide Nursing Home Risk-Based Survey (RBS) process, broadening a pilot program to the entire country. The development is a major shift for CMS and was what one expert earlier on Thursday called “a thoughtful evolution in how CMS approaches oversight.”

The Quality, Safety, & Oversight (QSO) Memo outlines this RBS process that 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.

The agency 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.”

Park Place offered extensive coverage of the news, and the day’s wraparound article is here.

The Process Explained

To clarify the nuts and bolts of the new process, Hawley Hunt, senior director, quality and regulatory services, American Health Care Association/National Center for Assisted Living (AHCA/NCAL), wrote a blog post detailing what to expect.

CMS said in its announcement that about 12 percent of all nursing facilities will qualify for the new RBS survey process, and the July 16 QSO memo provides the current number and percentage of nursing facilities that qualify under the current RBS criteria in each state, along with the number of facilities that do not qualify and the reasons for their exclusion.

Hunt said at the end of each quarter, CMS plans to provide state agencies with a list of RBS-qualified facilities. The list of qualifying nursing homes, each quarter, will be made publicly available on CMS's Provider Data Catalog and the Nursing Home Care Compare website beginning Sept. 30.

To identify the higher-performing facilities that qualify for the RBS, CMS will include an icon of a gold trophy on the facility's Care Compare site as recognition.

Examples of reasons why a facility would not qualify for an RBS include:

1. Less than a 5-Star Overall Rating

2. Less than 3-star Staffing Rating

3. Any citation(s) for Actual Harm, or Immediate Jeopardy (IJ), or Substandard Quality of Care (SQC) in the last survey cycle (the last standard survey and any complaint investigations in the last year)

4. More than 18 months without a standard survey

5. Any staffing waivers in effect

6. Failed Payroll-Based Journal (PBJ) staffing data audit

7. Failed resident assessment Minimum Data Set audit (MDS)

8. Health Inspection Score higher than the 50th percentile in the state (lower scores indicate better performance)

9. Two or more residents aged 65 or older who are coded with a diagnosis of schizophrenia after being admitted without this diagnosis

10. A change in ownership since the last standard survey

11. Special Focused Facility Candidate

See QSO-26-14-NH and the announcement from CMS for more information.

Checklist of Concerns, Strengths

In our earlier coverage, Steven Littlehale, chief innovation officer, Zimmet Healthcare Services Group, listed his concerns about the RBS process, and also named the plan’s strengths.

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.

Overall, Littlehale said, "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.”

“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."

Questions or comments on this article? Contact Patrick Connole at pconnole@parkplacelive.com.