Current Long-Term Care Facility Survey System Carries the Risk of Producing Sterilized Care

The current survey process in long-term care is flawed due to a punitive approach that prioritizes documenting care over the care itself. Surveyors are tasked with searching for violations, which means they are not allowed the opportunity to consider regional or cultural differences and nursing priorities. Nurses, in turn, become focused on not getting caught for violations, which prevents them from building real relationships with residents and learning how to best cater to their care needs. And regulations are often avoided until close to the survey date, rendering them a mere formality. All of these issues result in a form of sterilized care. 

Make no mistake about it: the problem has been known for decades. It was just never resolved. Back in 1982, the Health Care Financing Administration (HCFA) proposed changes to regulations, in response to long-term care providers complaining about the unreasonableness of some regulations. The proposed changes would have helped ease annual inspections in nursing homes. However, the proposition was strongly opposed by states and consumer groups who doubted that it would actually improve the quality of care in nursing homes. With nursing homes facing more challenges than ever, we can no longer sit back and accept the limitations of the current survey system. 

Surveys Are Not Focused on Quality of Life

Currently, surveys are a penalty-based compliance system that simply ensures facilities observe federal regulations. Unfortunately, the regulations are so burdensome that they discourage nurses and other team members from pursuing the actual goals of the facility: improving quality of life and maintaining dignity. As a result, there is a growing sentiment that they have simply become unreasonable. 

At the same time, the regulations in place are not encompassing enough. While PDPM has shifted focus to the complexity of care (as opposed to simply counting therapy minutes, for instance), the system still demands that surveyors focus on checking boxes, leaving them little opportunity to actually assess the nature of care at each specific facility. 

Technical regulations have resulted in surveyors becoming hyper-focused on details that don’t always affect a resident’s overall health and quality of life. Yes, terms like patient rights and dignity are used, but there is too much room for interpretation. We need to better define patient rights, which, as it stands, functions as nothing but an umbrella term for care in general. And we need to consider regional context and other circumstantial factors in our understanding of dignity. 

Consider these examples of violations that can be nitpicky, culturally, or regionally insensitive, or simply tone-deaf: 

• A visible privacy bag - A privacy bag can be as simple as a vinyl flap that covers the urine in the bag. The flap isn’t that durable, which means it can fold during use. If the bag of urine is visible, a surveyor is technically supposed to report a violation of the resident’s rights, even if the resident is not bothered by the incident at all.
• Endearing words - A nurse may come from a region where calling a senior “honey” or “sweetheart” is entirely acceptable. A surveyor with no awareness of this cultural or regional difference decides to issue a citation even though the resident is not bothered at all simply because it was not documented in the resident’s care plan.
• Calling a resident by their first name - A surveyor with no understanding of the dynamic between resident and employee can report the latter for not addressing the former using an honorific (“Mr.,” “Mrs.,” etc.). This is despite the fact that the resident might have actually requested to be called by their first name.
• Strong tones of voice - Different situations call for different tones. For example, in facilities with many veterans, the overall environment and tone of speech would be different compared to a facility where most residents were stay-at-home wives. The veterans’ environment may be more formal, with a direct and firm tone of voice being used by nurses. For a surveyor who is on the outside looking in, it might seem insensitive, but it could be that the former veterans prefer to be addressed that way on account of the value they place in being direct and disciplined.

Context, Communication, and Collaboration

Skilled nursing facilities should not be punished when regulations are not observed but the standard of care and outcomes remain unaffected. For instance, a resident may miss a lab test but suffer no harm as a result. The tendency is to issue a tag immediately, whereas a wiser approach would be for the surveyor to make a recommendation and thus encourage the facility to act responsibly as opposed to out of fear. 

There needs to be a collegial relationship between surveyors and facilities. In fact, that is the way it used to be. Prior to today’s (very extensive) regulations, surveyors would come in and talk with long-term care staff. If the surveyor saw something they didn’t like, they would ask for an explanation. Only if the explanation was insufficient would the facility get a tag. But surveyors are so overwhelmed with following protocols that they no longer have the time for such conversations with nurses and CNAs. Instead, they are asked to play the roles of both judge and jury for nursing homes. Surveyors need to be allowed to have open and honest conversations with nurses and the freedom to evaluate residents as people, as we are a complicated species that cannot be easily compartmentalized. 

Above, I mentioned examples in which a lack of contextual understanding could impel surveyors to cite a facility for something that didn’t even violate residents’ rights. But sometimes, it’s not even about context but rather basic empathy. As we face a devastating current staffing shortage, surveyors must be allowed to consider that nursing homes sometimes have to make tough decisions. A team may have to choose between giving residents their showers and documenting care. If they prioritize the hygiene and health of residents, though, they will receive tags. 

Another reason harmless incidents are identified as infractions is that some surveyors lack sufficient clinical training and are, rather, more experienced as social workers. Others may have clinical training but are far removed from their nursing days. So, when surveyors step inside a building, they may begin interpreting regulations based on their limited (or lost) understanding of the reality of how care is delivered. That means they miss certain things and misinterpret others, which forces nurses to contest their claims, taking time and care away from residents. This further makes evident the need for a dialogue between staff and surveyors. 

Problems with the Current Survey Method

Surveys are supposed to operate as pop quizzes that ensure facilities are on top of their game at all times. However, the reality is that it becomes apparent that surveyors are coming weeks in advance. And nearby facilities can give a heads-up as close as three to four days before a survey. That allows teams to conduct mock surveys to prepare and even delay observing the stricter (more irrational) regulations until close to the survey date. 

In many cases, a facility will know surveyors are coming in the next 30 minutes and will have the time to quickly write dates on oxygen tubes or fulfill other obligations that they normally would ignore. The receptionist may even use a fictitious name as a code word and page that name to alert the staff that the state surveyor is in the building, allowing the staff to address any last-minute issues.

In other words, the granularity expected of nursing homes is not sustainable and is only observed to appease surveyors. These details, thus, serve very little purpose. Facilities that know their turn for a survey is far in advance will go about their business as they see best, acting within the limitations of a shorthanded staff to provide what they think is the kind of care their residents require. They will then show something quite different when surveyors—especially those who are not clinically trained and thus will not be suspicious—arrive.

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Another issue with surveys is that the interview process is not thorough enough. Oftentimes, only five or six residents will be interviewed. Sometimes this is due to the limited number of residents with the appropriate BIMS scores, especially at smaller facilities. But another factor is the nature of these interviews. Surveyors may come across three residents that have nothing about which to comment and then simply be forced to move on to other areas due to the demanding nature of the current survey system. And because surveyors are tasked with adhering to predetermined questions and protocols, they are not able to give interviewees the opportunity to seriously contemplate and then articulate their concerns. Lastly, in complaint surveys (as opposed to broader, annual surveys), surveyors may have to limit the focus to a particular complaint wording, which prevents opening things up to other potential issues during interviews. 

Conclusion

Long-term care annual surveys operate as checklists, whereas they need to work more as evaluations that lead to a collaborative effort to improve care in accordance with the context at hand. An emphasis on detailed documentation—as opposed to things like how long residents need to wait before receiving care—wastes resources and distracts from more fundamental issues at facilities. 

Part of the problem is that surveyors are not always afforded sufficient training on the ins and outs of long-term care, or they may be far removed from their own clinical experiences in long-term care. And it is natural that those tasked with emphasizing regulations will occasionally fail to approach matters from a clinical perspective, especially as there is a great deal of room for interpretation. That is why we need more dialog and communication between surveyors and nurses in our facilities so that the two parties can learn to dig deeper and unearth the concerns and discomforts of our seniors.