The Centers for Medicare and Medicaid Services (CMS) requires nursing facilities (NFs) and skilled nursing facilities (SNFs) to undergo state inspections to ensure they meet the standards of care established by federal nursing home regulations. These inspections check to see if the minimum health and safety conditions are met in order for facilities to receive CMS reimbursement.
Here’s an overview of what facility leaders can expect during state nursing home inspections, with tips on how to prepare for and respond to inspections so your facility can participate in CMS programs.
The Nursing Home Reform Act, also known as the Omnibus Budget Reconciliation Act (OBRA-87) is a federal law administered by the Department of Health and Human Services (HHS) that establishes standards for nursing homes to reduce resident harm and improve the quality of life and care for elders. It requires nursing homes to:
Nursing homes are accountable to CMS, which is part of HHS, to uphold federal regulations for health and safety standards. Compliance checks are performed at the state level during state nursing home inspections.
During health and safety inspections, state survey agencies (SAs) follow CMS guidelines to check for compliance with federal standards. Surveys are conducted on a 9-15 month cycle, occurring about once a year. They’re unannounced and may occur at any time of day or day of the week, including weekends. Inspections involve a thorough review of compliance with health and safety standards by evaluating nursing home conditions that affect the well-being of residents living in the facility, such as:
After a nursing home passes a state inspection, it can then receive a CMS certification of compliance, which demonstrates compliance with federal regulations. This allows the facility to participate in Medicare or Medicaid programs.
State survey agencies (SAs) conduct surveys for all SNFs and NFs, regardless of whether the facility is state-operated. The SA certifies CMS compliance or noncompliance for all nursing homes except for those classified as dually participating facilities, which get certified for Medicare purposes by their respective CMS location.
Each state has its own state survey agency. They’re responsible for handling and investigating complaints, in addition to conducting inspections. The guidelines for the survey process for SNFs and NFs can be found in Chapter Seven of the CMS State Operations Manual.
During a nursing home inspection, SAs check to see if a nursing home meets federal health and safety standards. Surveyors must complete the following surveys to certify a SNF or NF:
| Nursing Home Inspection Surveys | |
|---|---|
| Standard Health Survey | Assesses whether conditions are established to ensure that high quality healthcare is being delivered at the facility |
| Life Safety Code | Covers fire protection requirements, including the operational features to protect nursing home residents from fire, smoke, and panic |
| Emergency Preparedness | Focuses on readiness to handle unexpected disruptive events, such as natural disasters, disease outbreaks, chemical spills, or power outages |
Prior to state nursing home inspections, SAs perform off-site and on-site preparation. Surveyors follow guidance from the state operations manual to perform the rest of the inspection, including federally mandated steps like:
Once all of these steps have been completed, a report is issued that outlines any deficiencies found during the inspection process and provides recommendations for improvement if necessary. The report also includes information on how long the facility has to make corrections before further action is taken by the state agency responsible for regulating nursing homes in that area.
State agencies may also conduct infection control inspections focused on a facility’s infection control policies and practices and evaluate residents’ risk of contracting an infectious disease. Surveyors look at staff’s use of personal protective equipment (PPE), hand hygiene, and disinfection practices.
A facility’s failure to meet a health or safety condition during the inspection is called a deficiency. Health and safety violations are cited on a statement of deficiencies form, along with the steps to correct the deficiency. Typically, a facility with a deficiency is responsible for formulating their own plan of correction (PoC) which then must be approved by CMS. The SA scores a deficiency using the following letter rating from A to L:
| Severity Level | Isolated | Pattern | Widespread |
|---|---|---|---|
| Level 1: No actual harm, with the potential for minimal harm. | A | B | C |
| Level 2: No actual harm, but the potential for more than minimal harm. | D | E | F |
| Level 3: Actual harm, but no immediate jeopardy. | G | H | I |
| Level 4: Immediate jeopardy to the health or safety of residents | J | K | L |
The scope of a deficiency describes how widespread the harm is, such as an issue affecting more than one resident. State agencies may also issue enforcement actions, or remedies, for noncompliance depending on the scope and severity of the citation.
Nursing home inspection reports, along with the number of nursing home deficiencies by state, are available to the public to help residents and their families make informed decisions about where to get care. Health consumers may visit CMS’s nursing home compare page to view how each nursing home performs based on the CMS five-star rating system.
A facility’s health inspection score, staffing levels, and quality measures are factored into the scoring system. Each facility is given a final overall quality score based on its performance during the most recent inspections.
If you operate a nursing home, you know the importance of performing well at state nursing home inspections. There’s so much at stake — from your facility’s reputation to its financial future. Be prepared for an unannounced visit and stay in the know about the latest CMS compliance updates with our latest free resources for facilities.
