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Caring for the Ages
Selected Articles from
September 2003;
Vol. 4, No. 9
CMS Proposes Survey Revisions
Supporting Roles
CMS Clarifies Physician Use of Mid-Level Practitioners
Assisted Living Report Neglects Medical Coordination
The Chronic Care Model--A Quality Innovation
Sleuthing Out Strokes
A Daughter's Journal: The Whole is More than the Sum of the Parts
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Following Month's Articles

CMS Proposes Survey Revisions

Real steps toward survey improvement?

by Steve Levenson, MD, CMD

On August 5, 2003, the Centers for Medicare and Medicaid Services (CMS) released the first two in a series of proposed revisions of key components of the OBRA survey process. These changes could potentially improve long-term care (LTC) nationwide.

To review, 16 years ago the original OBRA '87 legislation authorized CMS (then known as the Health Care Financing Administration) to create regulations governing care and services, and to revamp the existing survey process. The regulations and related components were developed piecemeal through much of the 1990s. (See "OBRA Survey Process: Key Components," below).

OBRA Survey Process:
Key Components
  • Regulations: the basic statements of requirements and expectations that carry the force of law.
  • Guidance to Surveyors: information to help surveyors interpret the meaning of specific regulations and related performance expectations.
  • Investigative protocol: instructions about how to investigate and draw conclusions about compliance with specific requirements.
  • Scope and severity determination: guidance for determining the seriousness and breadth of any deficient practices (i.e., those that fail to meet requirements), including their alleged impact on resident outcomes

Throughout the United States, many nursing home owners, staff, and practitioners have decried the unfairness of the survey process. That is, they believe the deficiencies cited during the survey process were unwarranted, inaccurate, or excessive. However, many studies and numerous anecdotal reports continue to allege inadequate performance and ineffective practices in nursing-home care--especially related to technical aspects of care, such as complex postacute care, recognition and management of delirium, and the effective use of medications, and recognition and prevention of adverse drug reactions.

How CMS Reconsiders Surveying

CMS has responded to these concerns by attempting to rectify shortcomings of the existing survey process guidance and protocols. Its overall goal is to provide a more consistent, usable, and evidence-based approach to surveying nursing facilities. At the same time, CMS intends to give facilities a much clearer explanation of what is expected of them vis-à-vis the survey process.

To approach these issues, CMS convened a number of expert panels during the past three years. The panels have consisted of CMS staff, surveyors from various states, and individuals recommended by various organizations, such as the American Medical Directors Association, the American Healthcare Association, and the American Society of Consultant Pharmacists, for their topical expertise and their nursing-home-care experience. Each panel convened in Baltimore for up to a week.

While the regulations themselves remain unchanged, each group was encouraged to critically review and revamp any and all of the other key components of survey protocol and surveyor guidance. The groups were also given a consistent framework to follow, with the goal of standardizing the approaches to surveying and also promoting a more effective care delivery process. Additionally, CMS staff members are reviewing related portions of the State Operations Manual (SOM), including key portions that help surveyors interpret the information they collect and determine whether deficient practices exist.

Initial Revisions

The first CMS release includes revisions of the guidance and related materials for Pressure Ulcers (F-TAG 314) and Catheters and Urinary Incontinence (F-TAGs 315 and 316). Interested parties have several months to comment. Other proposed revisions will be released during the next several months. They include Quality Assessment and Assurance (F520 and F521), Medical Direction (F501), Accidents and Supervision (F323 and F324), Unnecessary Drugs and Antipsychotic Medications (F329 and F330), and Pharmacy Services-Related TAGs (F425 through F432).

A multi-part series (see Caring June 2000 through Dec. 2002) pointed out that the survey process must promote desired performance and inhibit undesired performance. To do this well, regulations and the survey process must reflect proper approaches to the care of a complex population--not try to create new approaches. Survey expectations must be clear enough to enable facilities to meet them consistently. The survey must correctly identify both compliance and noncompliance. Survey interpretations and findings should be relatively consistent across individual surveyors and within and among states, while allowing for inevitable differences in individual interpretation.

The articles in the Caring series detailed the flaws in the original and subsequent versions of the surveyor guidance, investigative protocols, and scope and severity guidance. They discussed the unfortunate consequences of an inadequate survey process and often misguided facility, staff, and practitioner interpretations of the regulations on nursing-home care. (See "How Revised Survey Components Address Concerns about Survey Process," below.)

The Big Picture

Of course, regulations and surveys alone can't fix the problems of contemporary nursing-home care. But, as a recurrent source of feedback, they represent a powerful influence on performance and a major influence on care quality. Emphasizing a consistent care delivery process and evidence-based practices, along with adequate management, care oversight, and practitioner accountability (for example, in the revised quality assurance and medical director TAGs) as the primary route to regulatory compliance could potentially provide a major impetus to improving long-term care.

Much remains to be done before these revisions can have their desired effect. Remaining issues include adequate surveyor and provider training, the promotion of a less fragmented, more holistic approach both to providing care and surveying compliance, and revamping more existing TAGs. But, at least, these proposed revisions represent a ray of hope for progress in the often contentious, counterproductive atmosphere of the nursing home survey and certification process of the past decade.

How Revised Survey Components Address Concerns about the Survey Process
Issue Concerns about Existing Approach How Revisions Address Concerns
Regulations as a basis for promoting effective care processes
  • OBRA regulations concentrate on data collecting and care planning. They contain little about critical intermediate steps, including problem definition and cause identification.
  • OBRA regulations allude to, but don't directly explain or list essential underlying geriatric principles and practices.
The entire care process, including cause identification, is emphasized more consistently (8/01*).
  • Regulations don't give either facilities or surveyors enough relevant detail about process expectations.
Guidance now provides clearer process expectations and acknowledges more clearly that regulations are not meant to direct selecting specific interventions in specific patients. Guidance clarifies external sources of desired practices (8/01, 10/01, 2/02).
  • Primary objective of many facility practices has become regulatory compliance instead of effective care.
Survey process is shifting to focus on reinforcing good care practice and facility processes as primary route to regulatory compliance (10/01).
Regulations and survey process as potential route to care quality improvement
  • OBRA regulations and surveyor guidance are not a manual for providing effective geriatric care--despite some beliefs to the contrary.
  • Regulations and survey guidance were never meant to provide comprehensive support for facility practices or processes.
Guidance now provides clearer process expectations and acknowledges more clearly that regulations aren't meant to direct selecting specific interventions in specific patients. Guidance clarifies external sources of desired practices (8/01, 10/01).
Procedural guidance for survey process
  • Surveyor guidelines contain too many details about potential treatments and practices and not enough detailed procedures to show surveyors how to systematically identify proper care processes.
  • Current information in the guidelines and protocols don't adequately show facilities how they can demonstrate a plausible basis for their care decisions.
  • Revised surveyor guidance clarifies expectation for facilities to explain the thought processes behind their selection of specific approaches. It also steers surveyors to look for concurrently documented explanations of the basis for a facility's care and treatment decisions.
  • Revised surveyor guidance gives clearer procedures to judge the adequacy of care processes and shifts away from trying to judge practices, especially where several reasonable treatment options exist (10/01).
Methods used by surveyors to gather information
  • Surveyors may draw conclusions about facility and practitioner performance before gathering enough relevant information.
  • The State Operations Manual (SOM) doesn't promote consistent rules of evidence and decision-making.
  • Some surveyor guidance permits (if not encourages) drawing conclusions based on limited evidence--especially when serious negative outcomes occur.
Surveyor guidance is being revamped to 1) emphasize more systematic collection and analysis of information in all circumstances prior to drawing firm conclusions about compliance and 2) correctly identify and document underlying causes of identified problems (10/01, 11/01, 1/02).
Survey emphasis on outcomes
  • The survey process overemphasizes finding negative outcomes of any level of severity at the expense of finding and fixing serious process problems--regardless of outcomes.
  • Surveyors may be prone to jump to premature or unwarranted conclusions about how processes or practices relate to outcomes.
  • Surveyors may fail to recognize situations when facility performance has most likely contributed to negative outcomes.
  • Revised guidance emphasizes more process review and judging outcomes based on appraising how process inadequacies contribute to ultimate results (1/02).
  • Revised surveyor guidance emphasizes clarifying the process failures or deficient practices (12/01).
  • Revised guidance offers more evidence-based information about appropriate or inappropriate practices related to specific aspects of care (12/01). Survey instructions attempt to clarify what constitutes "avoidable" and "unavoidable" outcomes.
Scope and severity determinations
  • Current scope and severity determinations are a confusing, often inconsistent, and contradictory hodgepodge of fact, speculation, and opinion.
  • Current guidance lacks clear, consistently usable criteria for determining levels of scope and severity.
Revisions strive to make scope and severity determinations more consistent (1/02, 3/02).
*Dates when related article on the survey process appeared in Caring for the Ages.

This article originally appeared in Caring for the Ages, September 2003; Vol. 4, No. 9, p. 1, 6-7. Caring for the Ages is an official publication of the American Medical Directors Association, published by Elsevier. This article may not be reproduced in any form, print or electronic, without permission.

The opinions expressed by the authors are their own
and not necessarily those of AMDA or of Elsevier.

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