U.S. Department of Health and Human Services Office of Inspector General Addendum to OEI-01-20-00430 July 2021, OEI-01-20-00431 States' Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic Our report, Onsite Surveys of Nursing Homes During the COVID-19 Key Takeaway Pandemic: March 23 – May 30, 2020, found that State Survey States' backlogs of standard agencies (States) faced backlogs of standard surveys of nursing nursing home surveys have grown homes early in the COVID-19 pandemic, with 8 percent of nursing substantially, even after August homes having gone at least 16 months without a standard survey as 2020 when CMS lifted its of June 2020. This Addendum updates that analysis. We found that suspension of those surveys States' backlogs grew substantially during the COVID-19 pandemic. (which it had suspended due to Nationally, 71 percent of nursing homes (10,913 of 15,295) had gone the COVID-19 pandemic). at least 16 months without a standard survey as of May 31, 2021. By Nationally, 71 percent of nursing State, the backlogs for standard surveys ranged from 22 percent to homes had gone at least 16 months without a standard survey 96 percent of nursing homes (see Table 1 on page 2 for the as of May 31, 2021. The rising backlogs for each State). backlogs add urgency to our States, on behalf of the Centers for Medicare & Medicaid Services existing recommendation that CMS clarify expectations and (CMS), are required to conduct standard surveys of provide guidance to States on Medicare/Medicaid-certified nursing homes at least every completing these important 15 months to ensure that they meet Federal requirements. 1, 2 surveys. Standard surveys are comprehensive onsite inspections that evaluate the safety and quality of care provided by nursing homes. 3, 4 Surveyors cite deficiencies during these surveys when they observe a nursing home violating a Federal requirement. These deficiencies can result in CMS imposing remedies, such as civil monetary penalties, on the nursing home. 5 In addition, surveyors discuss observations with nursing home staff throughout these surveys and may alert them to concerns with resident care, providing the nursing home with the opportunity to address these concerns by presenting additional information to the surveyors. 6 In March 2020, to protect public health and address other concerns associated with the Public Health Emergency, CMS suspended standard surveys in nursing homes to reduce surveyor time on site. CMS shifted oversight to infection control surveys, which are more limited in scope than the standard surveys. 7 States also continued to conduct surveys for the most serious nursing home complaints while CMS suspended standard surveys. 8 In August 2020, CMS authorized States to resume standard surveys "as soon as they have the resources (e.g., staff and/or Personal Protective Equipment) to do so." 9 Backlogs in Standard Surveys Need CMS's Attention Comprehensive nursing home inspections-standard surveys-are CMS's main tool to ensure that nursing homes meet the minimum standards necessary for the safety and wellbeing of residents. Yet, Addendum: States' Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic OEI-01-20-00431 1 due to the COVID-19 pandemic, States have conducted substantially fewer of these standard surveys, which help to identify and address deficiencies. Our updated analysis underscores the importance and urgency of our previous recommendation to CMS to clarify expectations for States to complete backlogs of standard surveys, including by issuing guidance on prioritization of surveys and required timeframes to complete these backlogs. In its response to this recommendation in our report, issued in December 2020, CMS said it will continue working with States on how to address these backlogs. We encourage CMS to take the steps described above to implement this recommendation and help States provide needed oversight of nursing homes. Table 1: Number and Percent of Nursing Homes Without a Standard Survey for at Least 16 Months (February 1, 2020, through May 31, 2021) by State Number of nursing Percent of nursing homes without Total nursing homes without State standard survey homes standard survey Connecticut 201 209 96% Georgia 335 359 93% Oregon 120 130 92% Vermont 32 35 91% Maryland 202 226 89% Delaware 41 46 89% Oklahoma 265 298 89% California 1,037 1,183 88% Idaho 71 81 88% Washington 176 201 88% Ohio 828 954 87% Massachusetts 315 371 85% Utah 82 97 85% Kentucky 240 284 85% Montana 59 70 84% Tennessee 263 313 84% Indiana 440 533 83% Mississippi 168 204 82% South Dakota 84 104 81% Virginia 228 286 80% Maine 74 93 80% New York 490 616 80% Minnesota 284 364 78% North Carolina 329 428 77% District of Columbia 13 17 76% Colorado 171 225 76% Addendum: States' Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic OEI-01-20-00431 2 Number of nursing Percent of nursing homes without Total nursing homes without State standard survey homes standard survey Alabama 173 228 76% Missouri 390 516 76% Wisconsin 259 348 74% Arizona 107 146 73% Nevada 47 66 71% Alaska 14 20 70% Iowa 296 431 69% Texas 818 1,211 68% Hawaii 29 43 67% West Virginia 79 123 64% Wyoming 23 36 64% New Jersey 215 359 60% Louisiana 165 276 60% Michigan 259 435 60% North Dakota 47 79 59% Kansas 173 324 53% South Carolina 100 189 53% Pennsylvania 344 687 50% New Hampshire 35 73 48% Illinois 336 708 47% Rhode Island 35 78 45% Florida 284 704 40% Nebraska 71 195 36% Arkansas 51 224 23% New Mexico 15 69 22% National 10,913 15,295 71% Source: OIG analysis of CMS Care Compare data, 2021. 1 Social Security Act § 1864(a); 42 CFR § 488.330; SOM, ch. 1, Section 1002. 2 Social Security Act §§ 1819(g) and 1919(g). 3 Social Security Act §§ 1819(g)(2) and 1919(g)(2); CMS, SOM, Pub. No. 100-07, ch. 7, Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities (Revised 185, 11-16-18). 4 CMS, SOM, Pub. No. 100-07 Appendix P: Survey Protocol for Long Term Care Facilities-Part I. Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/GuidanceforLawsAndRegulations/Downloads/som107ap_p_ltcf.pdf on June 16, 2021. 5 Social Security Act §§ 1819(h) and 1919(h); CMS, SOM, Pub. No. 100-07, ch. 7, Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities (Revised 185, 11-16-18). Addendum: States' Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic OEI-01-20-00431 3 6 CMS, Long-Term Care Survey Process (LTCSP) Procedure Guide (Effective February 6, 2021). Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/GuidanceforLawsAndRegulations/Downloads/LTCSP-Procedure-Guide.pdf on July 7, 2021. 7 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 20, 2020. Accessed at https://www.cms.gov/files/document/qso-20-20-allpdf.pdf-0 on June 15, 2021. 8 Ibid. 9 CMS, Enforcement Cases Held during the Prioritization Period and Revised Survey Prioritization, Ref: QSO-20-35- ALL, August 17, 2020. Accessed at https://www.cms.gov/files/document/qso-20-35-all.pdf on June 15, 2021. Addendum: States' Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic OEI-01-20-00431 4