Due to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (“CMS”) suspended the majority of the regulatory surveys performed on Skilled Nursing Facilities, focusing on infection control violations and specific emergency situations. CMS implemented several changes, waivers, and temporary halts to normal survey and quality measure updates and reporting requirements. Below is a timeline of the changes that occurred during 2020.
► CMS waived the timeframes that facilities were required to submit resident assessment information through Minimum Data Sets (“MDS”). Much of this information is utilized as the underlying data to calculate measures that are posted to the Nursing Home Compare and Five Star Quality Rating System. As a result, the quality measures were temporarily held constant based on data collected through December 31, 2019.
► In March 2020, CMS suspended several regularly administered inspections, including standard and fire and safety inspections, and focused on infection control inspections to concentrate on limiting the spread of COVID-19. Infection control survey results were posted to the Nursing Home Compare database, however, they held the other quality measures including the Five Star Quality Rating System constant, which affected both the SFF listing as well as the abuse icon indicators.
► CMS waived the requirement for nursing homes to submit staffing data that was intended to be updated in April 2020. However, due to the importance of the staffing data, CMS revoked the waiver to report this information in June 2020. CMS then resumed updates to the staffing rating on Nursing Home Compare in October 2020.
► In August 2020, surveys were to resume, but they were only to be conducted with proper staffing and personal protective equipment (“PPE”). There was no waiver placed on infection control surveys.
► The transition from the “Nursing Home Compare” site to the new “Care Compare” website took place on December 1, 2020. The new website includes all of the same information in an updated, more user-friendly atmosphere.
► On January 27, 2021, CMS published data that factored the infection control survey results into each nursing home’s inspection rating. These findings will be included in the same way findings from complaint inspections are used in the Five Star Quality Rating System.
► Although the timeframe required to submit MDS was temporarily waived, facilities were still required to submit this data, which can and will be used to update each nursing home’s quality measures. This data can also be used to update claims-based quality measures. On January 27, 2021, the quality measures were updated by CMS and were based on data submitted through June 30, 2020. This update also included an automatic update to the SFF listing and abuse icon indicators.
By the Numbers
Despite a spike in “immediate jeopardy” complaints at nursing homes, the initial wave of emergency inspections during the COVID-19 crisis resulted in a significantly lower rate of violations.
Between March 2020 and May 2020, onsite inspections of 7,193 nursing homes resulted in cited deficiencies at 193 facilities, for a rate of 3%. That’s a significant drop from the 40% deficiency rate logged during the same period in 2019, though the 2020 data comes with a host of caveats.
As noted above, March 2020 is when CMS halted typical surveys and focused on infection control and immediate jeopardy situations. The overall number of complaints tumbled in the early days of the COVID-19 crisis, dropping from more than 14,000 between March 23 and May 30, 2019 to just under 7,000 during that same span last year.
However, during this same time frame the number and percentage of immediate jeopardy situations spiked significantly. During these nine weeks of 2020, immediate jeopardy tags comprised 31% of all deficiencies, while in the same nine-week period of 2019 they only represented 7% of all deficiencies noted.
The federal government has faced scrutiny from resident advocates and lawmakers over the seeming disconnect between the high infection and death rates in nursing homes and the lack of a corresponding uptick in safety violations.
In August, CMS directed states to resume normal survey work, however, clearing out the pile of inspections that were shoved to the back burner in March 2020 may take some time to achieve. By the end of June 2020, about 8% of facilities exceeded the required 15-month timeframe without receiving a standard survey according to the OIG.
A further 14%, or more than 2,000 facilities, were still awaiting inspections stemming from high-priority complaints, and relief is likely far off. One state reported that it would take two years to tackle the backlog and return to a typical survey schedule, while another state indicated that the task was impossible without additional help.
These backlogs — and the possibility that it could take years for states to return to normal survey timeframes — raise concerns for nursing home residents’ safety and quality of care,” the OIG concluded. “Standard surveys are critically important for protecting nursing home residents.”
CMS is aiming to create transparency and provide quality information to families, residents, and the general public by using available information to update nursing home quality measures. However, it is important to note that the performance metrics released in January 2021 are based on historical data provided to CMS through June 2020.
Despite CMS’ best efforts, getting caught up with the backlog of annual, fire and safety, and complaint surveys could take states several years. Given the reporting delays and survey backlogs, lenders must rely on timely due diligence examinations and communicative borrowers to adequately stay on top of their portfolio. Lenders must rely on their borrowers now more than ever to provide timely updates on quality metric and survey issues given CMS’ reporting backlog.