Casey Pushes for Information from State Nursing Home Inspectors Amidst Staffing Shortages, Widespread Inspection Delays

Washington, D.C. – U.S. Senator Bob Casey (D-PA) is pushing for information on how staffing shortages at state survey agencies are affecting their ability to ensure the health and safety of residents at long-term care facilities. Senator Casey is sending a letter to survey agencies in all 50 states as well as Washington, D.C. and Puerto Rico after reports from federal watchdogs repeatedly link staffing shortages at survey agencies with failures to conduct timely, high-quality nursing home surveys. The Office of the Inspector General for the Department of Health and Human Services (OIG) issued a report in January identifying “staffing shortages as a root cause of State survey performance problems.” As of mid-August, Centers for Medicare & Medicaid Services data show that nearly 30 percent of the national total of nursing homes are overdue for these standard surveys.

“State survey agencies are integral to ensuring the health and safety of Americans reliant on our Nation’s health care providers, ranging from hospitals to nursing homes to intermediate care facilities and more. These agencies play a particularly important role in oversight of the country’s more than 15,000 nursing homes, enforcing federal standards related to medical care, adequate staffing and safeguarding residents from abuse and neglect, among others. By conducting comprehensive inspections, known as standard surveys, every 15 months and promptly investigating complaints, state surveyors are the eyes and ears ensuring quality care is delivered,” wrote Senator Casey.

Current and former state survey agency officials have reported challenges hiring and retaining surveyors, which affects the frequency and quality of nursing home surveys, as local governments experience broader challenges attracting and retaining workers. In order to fulfill the annual requirements, states have used stopgap measures including hiring contract inspectors at high costs, encouraging overtime for surveyors and sending surveyors outside their regular regions. As such, Senator Casey is seeking details from states on how the availability and experience of surveyors affect their ability to carry out oversight responsibilities, data regarding turnover among agency staff as well as information on how rising salaries in the nursing profession affect hiring and retention.

Senator Casey secured a one-time $100 million funding boost for nursing home oversight in the CARES Act of March 2020, the first increase for nursing home oversight since fiscal year 2014. In August 2021, he introduced the Nursing Home Improvement and Accountability Act, which would address gaps in staffing, transparency, accountability and oversight of long-term care facilities. The legislation would further increase funding for nursing home surveys to improve oversight processes and hire, train, and retain surveyors, a provision the Biden Administration adopted in its fiscal year 2023 budget request.

Read the letters to state survey agencies here and below.

September 12, 2022

Dear Director,

State survey agencies are integral to ensuring the health and safety of Americans reliant on our Nation’s health care providers, ranging from hospitals to nursing homes to intermediate care facilities and more. These agencies play a particularly important role in oversight of the country’s more than 15,000 nursing homes, enforcing federal standards related to medical care, adequate staffing and safeguarding residents from abuse and neglect, among others. By conducting comprehensive inspections, known as standard surveys, every 15 months and promptly investigating complaints, state surveyors are the eyes and ears ensuring quality care is delivered. Given their critical role, I am requesting information related to your agency’s staffing needs as the U.S. Senate Special Committee on Aging (Aging Committee) seeks to better understand the scope and severity of staffing shortages affecting state survey agencies’ ability to carry out their work.

The Government Accountability Office (GAO) and the Office of the Inspector General for the Department of Health and Human Services (OIG) have repeatedly linked survey agency staffing shortages with failures to conduct timely, high quality nursing home surveys.  Most recently, a January OIG report identified “staffing shortages as a root cause of State survey performance problems,” adding that “many of the staffing shortages occur in States with widespread nurse shortages and that these States have difficulty attracting and retaining nurses to conduct surveys.” Similarly, the National Academies of Sciences, Engineering, and Medicine found in a report this year that “states have difficulty finding qualified surveyors,” and survey agencies “may not have adequate capacity or resources to fulfill all their responsibilities.” In addition, the Centers for Medicare & Medicaid Services recently informed my office that “many states have reported shortages that impact their ability to respond timely to complaints and recertification surveys,” an issue exacerbated by the COVID-19 pandemic.

Current and former state survey agency officials across our Nation report challenges with hiring and retaining surveyors, particularly nurses who make up the majority of their workforce, leading to high turnover. These challenges come as recent news reports have highlighted the broader challenges state and local governments have experienced attracting and retaining workers. Survey agency officials repeatedly voiced concerns regarding state and federal budget shortfalls and difficulty offering competitive wages in a highly competitive health care market. Over the last decade nursing salaries have increased 21 percent and survey agencies have been unable to keep up. These concerns are consistent with those states have communicated to the OIG in recent years and, based on briefings with states, appear to have worsened during the COVID-19 pandemic. Drained by physically and emotionally demanding work, agency officials have said that the pandemic led many surveyors to find new health care jobs, leave the field or retire, further worsening vacancy rates.

In the face of staffing shortages now ranging up to 50 percent of budgeted positions, states are employing different measures to meet Federal requirements for survey timeliness. Stopgap measures include hiring contract inspectors, often at high cost; encouraging surveyors to work overtime; hiring retired annuitants to cover staffing gaps and sending surveyors outside their regular regions to cover shortfalls, requiring additional travel. State officials and outside observers have expressed concern that a strained workforce is not well-suited to carry out the critical work survey agencies perform, leaving nursing home residents at greater risk. Recognizing these and other challenges, I secured $100 million of additional funding for survey and certification activities to combat the COVID-19 pandemic in nursing homes. I also have advocated to increase funding for survey agencies going forward, which President Biden adopted in his FY2023 budget request.

At the same time, workloads have increased substantially, with the number of inspections in response to reported complaints increasing from 47,000 in 2011 to 71,000 in 2018, a trend that has continued during the pandemic. The OIG issued a report last year that found 71 percent of nursing homes nationally had gone at least 16 months without a standard survey as of May 31, 2021, with backlogs of nursing homes surveyed ranging from 22 percent to 96 percent by state. As of mid-August, CMS data show that 4,500 nursing homes (29.8 percent of the national total) are overdue for annual standard surveys.

Given these issues, the Aging Committee seeks information from survey agencies in all 50 states, the District of Columbia and Puerto Rico and I ask that you please answer the questions and other requests that follow. Please note that references to “previous five calendar years” mean full-year 2018, 2019, 2020, 2021 and year-to-date 2022; “previous five fiscal years” means your state’s fiscal years for FY2018, FY2019, FY2020, FY2021 and FY2022.

1. Please describe the scope and activities of your agency’s nursing home survey and certification program and issues, challenges or dynamics unique to your state.  Please describe the extent to which the availability and experience of surveyors affects, or has affected, your agency’s ability to carry out its responsibilities such as completing timely complaint and standard surveys, and strategies used to address any staffing shortfalls.
2. Multiple states and watchdog reports have identified staff turnover negatively affecting the timeliness and quality of nursing home surveys. To what extent has your agency experienced turnover among survey agency staff and how has it affected your agency’s ability to conduct its work? In your answer, please address reasons for staff departures (e.g. retirement, burnout, competing jobs), the effects of turnover, how the COVID-19 pandemic affected turnover rates and strategies used to reduce turnover.
3. Several state survey agencies reported that the national shortage of nurses has driven up salaries, challenging their ability to hire and retain nurses as surveyors. How has your agency been affected by rising competition for nurses, and how has it sought to attract and retain nurses for surveyor positions through pay increases, schedule changes or other incentives? In addition to the data requested in Question 7, please describe how your starting salary and salary range compares to salaries for other registered nurse positions in your state, to the extent you have visibility into the market. To what extent have private sector signing bonuses contributed to the difficulty of hiring and retaining nurse surveyors at your agency?
4. Multiple states have reported hiring contractors to fill surveyor vacancies and address survey backlogs. Please describe how your agency has used contractors to conduct surveys or other tasks such as informal dispute resolution (IDR). Please also provide all associated contracts for the previous five calendar years. Please describe why your agency has used contractors or is considering doing so, as well as the benefits and challenges of using contractors. How does your agency oversee contractors to ensure they are conducting timely, high-quality surveys? What should CMS be doing to oversee the use and effectiveness of contracted surveyors?
5. What could CMS do differently, including changes to policies, guidance or technical assistance, that would better help your agency conduct timely surveys in the context of surveyor staffing shortages? Please provide correspondence your agency has transmitted to CMS, the OIG or other Federal agencies within the previous five calendar years regarding concerns about survey agency staffing.
6. The 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act provided states with a one-time funding boost of approximately 7 percent for survey and certification activities that is set to sunset in 2023. How is your agency using the CARES Act funding? What affect, if any, will the sunsetting of this funding have on your agency?
7. Please provide the requested data in the attached Excel sheet:
   
   • The number of Medicare and Medicaid certified nursing homes and total number of certified nursing home beds located in your state.
   • The amount of (i) state and (ii) federal funding your agency has received for survey and certification activities over the previous five fiscal years.
   • The number of nursing home surveyor positions (full time equivalents) in your agency’s budget for the previous five fiscal years.
   • The number of nursing home surveyor positions that are currently vacant (not filled by full-time employees compensated directly by the state) for all staff and for nurses, specifically.
   • For each of the previous five fiscal years, how many new surveyors were hired by your agency and how many surveyors left your agency?
   • How many years of experience (i.e., years working at your agency), on average, do your current surveyors have? What percentage of your surveyors have two years or less experience; what percentage have five years or more?
   • What is your agency’s salary range for surveyors? Please separately indicate the range for registered nurses and non-nurse surveyors.
   • The total dollar amount your agency has spent on contractors for survey, IDR or other nursing home-related oversight activities for the previous five fiscal years.
   • The number of complaints received, by category (immediate jeopardy [IJ] and non-IJ) and the percentage of such surveys initiated within the federally required timeframe over the previous five calendar years.

Please provide the above requested information, documents and data no later than October 28, 2022.