The Centers for Medicare and Medicaid Services (CMS) recently issued CMS S&C 12:12-ALL summarizing prudent action being considered by CMS for the FY 2012 Medicare survey & certification budget.

CMS states that since 2001 there has been a 21.4% increase in the overall number of Medicare-certified providers to be surveyed. Among all types of facilities, the numbers of home health agencies (HHAs), ambulatory surgical centers (ASCs), and dialysis facilities (ESRD) have grown the fastest (increasing by 69.3%, 60.8%, and 37.3% respectively, between 2001 and 2010). New and expanded responsibilities have further increased the survey and certification (S&C) workload. For example, due to improved Centers for Medicare & Medicaid Services (CMS) quality of care and safety expectations for dialysis facilities, average hours per ESRD survey recently increased by 37%.

While the federal fiscal year 2012 has already begun, CMS expects it will still take some time before the full Congress acts on legislation to fund the FY2012 Centers for Medicare & Medicaid budget. However, early indications are that the budget level for Medicare S&C will most likely be 10%–12% less than the level requested by the President. Therefore, CMS is preparing for a lower FY2012 funding level than previously expected.

CMS has been working with states to develop a variety of methods to increase efficiency and effectiveness. While these efforts may not entirely address the difference between the requested and likely budget levels, they will mitigate negative effects. Additional efforts will be necessary, and expectations for FY2012 funding will need to be adjusted.

The CMS S&C memo outlines a number of initiatives they have already implemented to reduce workload or expenses:

• Increased use of targeted surveys based on performance data for dialysis facilities and nursing homes.
• Increased public notification using the Five-Star Quality Rating System, Nursing Home Compare, and Special Focus Facility (SFF) list.
• Increased use of provider attestations with follow-up.
• Redoubled efforts to collaborate with consumers, providers, and professionals.

Based on FY2012 projections, CMS also intends to act on two additional sets of endeavors:

1. Adjust State FY 2012 Medicare S&C expected allocations. Examples include:

• Slow down the rate new states are added to the Quality Indicator Survey (QIS)
• Stretching out the timeline to collect nursing home staffing data
• Delaying initial certification surveys to favor statutorily-required surveys, targeted surveys of poorly performing facilities, and complaint surveys.
• Review with each state’s S&C division their staffing levels, vacancies, training plans, and workload to determine needed resources.

2. Further advance efficiencies and effectiveness initiatives. Examples include:

• QIS expansion: CMS will stretch out the timeline for adding new states to the Quality Indicator Survey (QIS) for nursing homes, and concentrate on fully and effectively implementing the QIS in those states that are already implementing the system. They consider the QIS to add considerable value and prospects for improved consistency in the survey process. These advantages are due to a number of notable design features, such as its greater use of data for each nursing home, greater resident sample sizes, more structured survey protocols, tools for quality improvement, and ability to tailor onsite time according to the seriousness of the initial findings.

• Government Accountability Organization (GAO) and Office of the Inspector General (OIG) recommendations: CMS is deferring into FY2013 or FY2014 follow-up action on many GAO and OIG recommendations that were otherwise scheduled for action in FY2012, in order to design and implement additional efficiency initiatives. They will prepare a revised schedule of such activities when Congress passes the final FY2012 budget, one which seeks to maintain as much positive momentum as possible for the continued improvement of survey processes. However, there are certain key recommendations that they will continue to advance in FY2012 with vigor.

• Hospice: CMS is expanding the tier III maximum time interval between surveys of any one hospice facility to once every 7 years from once every 6.5 years. However, they retain as a high (tier II) priority the survey of a 5% sample of the lowest-performing providers. They continue to examine additional methods to target survey attention to those providers where the risk of non-compliance with CMS quality of care requirements is greatest.

• Nursing home staffing data: CMS is stretching out the timeline for the design and implementation of the system identified in section 6106 of the Affordable Care Act for quarterly, electronic collection of staffing information in nursing homes. Such a system requires a considerable investment in information systems. Such an informational infrastructure must be capable of collecting and processing large amounts of information from 15,800 nursing homes each quarter, and rendering the information in a displayed and usable manner on CMS’ Nursing Home Compare website. It must also support quarterly calculation of measures and data for use in CMS’ Five-Star Quality Rating System. Since the sizable resources needed for this enterprise are not likely to be found in the FY2012 budget, CMS will continue with their design work but stretch out the timeline. As a result, the system will not be implemented by the March 23, 2012 date envisioned by the Affordable Care Act.

• CMS is exploring potential expansion of the SFF initiative, as well as methods to coordinate with other entities (such as the QIOs) that can provide increased technical assistance to poorly-performing facilities that serve a high proportion of low-income recipients, or nursing homes in areas where there are access-to-care problems. In addition, CMS might focus their validation surveys on those facilities rated as lower in quality (e.g., the one, two or three-star nursing homes). Further, they might no longer require the LSC portion of the survey for the non-annual (6th-month) survey of Special Focus Facilities (because SFFs are surveyed twice per year).

• In collaboration with consumer groups, nursing homes, educational providers, professionals, QIOs, and others, CMS is exploring methods to design and implement a multi-faceted program to reduce inappropriate use of medications, particularly inappropriate use of anti-psychotics. CMS hopes that this will include new quality measures that can be posted on the CMS NH Compare website and a broad partnership with consumers, nursing homes, and professionals.

• CMS is exploring a new measure, and effort, to reduce avoidable falls on the part of nursing home residents.

• CMS is exploring methods to reduce the amount of surveyor time required for onsite inspection of life safety code requirements. An example may be increased documentation and attestation that could be made available to surveyors by the nursing homes that will provide evidence of the regular conduct of maintenance checks, fire drills, emergency preparedness, etc. LSC requirements might conveniently be described as consisting of two major components: (a) structural requirements, such as one-hour fire walls and smoke compartments, and (b) maintenance requirements. Structural configurations change infrequently.

• To enable more time to focus on poorly-performing facilities, CMS is exploring methods to reduce the amount of time required for surveys of facilities that are consistently rated as five-star facilities on the CMS’ Five-Star Quality Rating System published on CMS’ NH Compare website, except that serious complaints or initial worrisome findings would always trigger the longer survey.

View the entire CMS S&C memo here.

Doug Beardsley
952.851.2489
dbeardsl@careproviders.org

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