Long-Term Care Survey Alert

Revised survey process would widen net for catching potential deficiencies.

Nursing facilities with quality-of-care issues can't run or hide from a new computer-driven Quality Indicators Survey (QIS) that could be rolling out as early as next year.

The Centers for Medicare & Medicaid Services is in the beginning phases of a "staged implementation" of the QIS to replace the current or traditional survey process, according to an advance copy of revisions to the State Operations Manual Appendix P issued as part of a survey and certification memo (SC-05-34). If CMS approves the QIS after pilot testing it in several states, the revisions to Appendix P would allow the agency to proceed with "staggered national implementation" in order to accommodate surveyors' needs to receive intensive training on the QIS, according to the memo.

Experts say that if the QIS does go into effect as envisioned, nursing homes will have to keep pace with a more real-time, computerized oversight system. "Depending on how the process works and the underlying algorithms, a facility's own data could be used to identify and correlate patterns [indicating] potential deficiencies," says Chris Puri, JD, legal counsel for the Tennessee Health Care Association.

Prepare now: Facilities should keep an eye on the QIS as it evolves in pilot studies in several states. Also bone up on your MDS accuracy and initiate quality improvements.

Look for Two-Stage Survey

The QIS is a two-stage, computer-assisted survey process, according to the advance copy of the revised SOM. In stage one, survey agencies will use computerized analysis of a facility's minimum data set information. Surveyors will also go on site to perform reviews of a large computer-selected resident sample. "It appears that the new QIS process would result in a larger and more diversified sample size than the current offsite selection," observes Puri.

Facilities will be targeted for a stage two review if they score higher than a designated threshold compared to national norms on 160 Quality of Care Indicators, which would reportedly include the existing quality indicators and measures.

In the stage two survey review, surveyors will investigate "triggered issues and residents" using what are known as "critical elements protocols," states the advance copy of the revised Appendix P of the SOM. The QIS also contains several facility-level tasks that surveyors will complete on every survey - or when triggered as "areas of concern."

Surveyors to See Bigger Picture

Surveyors could use the data-based system to look across domains and identify whether a facility has systemic quality of care and life issues. And that could be good news or bad news, according to Puri. "A data-driven system is helpful ... if the system improves accuracy and consistency of the survey process," he notes. "But the concern arises that the [computerized] system could just prompt surveyors to cite 'suggested deficiencies' without [doing] any critical analysis."

The American Health Care Association doesn't yet have a formal position on the QIS but does support the concept because it focuses on the role of surveyors in the survey process and appears aimed at improving survey consistency, says AHCA spokesman Tom Burke. "For example, surveyors will use laptop computers with specialized software which should help consistency," Burke tells Eli. CMS also intends to share the QIS process software with facilities, according to AHCA.

Pilot to Pave Way for Rollout

CMS has selected California, Connecticut, Kansas, Louisiana and Ohio (with Florida and Illinois as alternates) to pilot test the QIS survey. Survey teams will reportedly be trained this fall in three states. "CMS will just be training one to two survey teams in each of the [pilot] states, so the QIS process won't be used state- wide," says Diane Brown, a consultant in Boston, MA. The QIS survey will become the survey of record in the pilot states for surveys conducted by the trained teams. CMS expects to complete the pilot by mid-2006 and may possibly implement the QIS nationwide by the end of 2006.