Medicare (Title XVIII of the Social Security Act)
Survey and Certification Process

Survey and Certification Process

State and Federal Responsibility

The Secretary is responsible for certifying the compliance of state skilled nursing facilities with the requirements of this section; the state is responsible for certifying compliance of private skilled nursing facilities with these requirements.136

Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Property

Through the agency responsible for surveys and certification of nursing facilities, the state must provide for methods of receiving, reviewing and investigating allegations of patient neglect or abuse and misappropriation of resident property by any individual providing nurse aide services to a nursing facility resident.137  If the state finds that a nurse aide neglected or abused a resident or misappropriated resident property in a facility, the state must notify the aide and the registry of such finding; if the state finds that any other individual used by the facility to provide nurse aide services has neglected or abused a resident or misappropriated resident property in a facility, the state must notify the appropriate licensure authority.138    

Investigation of Complaints and Monitoring Compliance

The state must maintain procedures to investigate any violation of requirements of this section related to provision of services, residents’ rights and administration,139 and must monitor facilities that are, were or are suspected to be non-compliant with these requirements.140

Survey and Certification Process

For purposes of certifying compliance, each skilled nursing facility will be subject to a standard survey conducted without any prior notice141 at least every fifteen months142  Each survey will include, for a case-mix sample of residents:

·        A survey of the quality of care furnished;143

·        An audit of resident assessments to determine accuracy;144

·        A review of plans of care to determine adequacy;145 and

·        A review of compliance with residents’ rights.146

If a skilled nursing facility is found to have provided substandard quality of care, the facility will be subject to an extended survey,147  which will identify the policies and procedures that produced the substandard care and determine whether the facility has otherwise complied with nursing facility requirements.148  Within two months of either a standard survey or an extended survey conducted by the state, the Secretary will conduct validation surveys of a sample of nursing facilities to determine whether the state’s survey was adequate.149  If the Secretary has reason to question the compliance of a particular facility with requirements, the Secretary may conduct a special survey of compliance.150 The Secretary will also conduct a “special focus facility” program for skilled nursing facilities that have been identified as substantially failing to meet requirements;151 under this program, the Secretary will conduct surveys of facilities at least once every six months.152

Disclosure of Results of Inspections and Activities

All survey and certification information will be provided to the state’s Medicaid fraud and abuse control unit153 and be made public.154 The state must notify the long-term care ombudsman of any non-compliance and of adverse actions taken against a facility.155 If a skilled nursing facility is found to have provided substandard quality of care, the state must notify each affected resident’s attending physician,156 and the state board responsible for the licensing of the nursing facility administrator.157 Each state will submit information respecting any survey or certification made respecting a nursing facility, including enforcement actions taken by the state, to the Secretary; the Secretary will use this information to update the information provided on the Nursing Home Compare website.158

Nursing Home Compare Website

The Department of Health and Human Services will maintain a “Nursing Home Compare” Medicare website.159  The Secretary will ensure that the information provided on the website includes:

• Resident census data and data on the hours of care provided per resident per day;160
• Inspection reports, complaint investigation reports and plans of correction;161
• Summary information on the number, type, severity, and outcome of substantiated complaints;162
• The number of adjudicated instances of criminal violations committed inside the facility by the employees of a facility;163 and
• The number of violations or crimes committed inside the facility that were violations or crimes of abuse, neglect, exploitation, criminal sexual abuse, or other violations or crimes that resulted in serious bodily injury.164