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Will New Inspection System Bring Same Old Results?


The system California has used to inspect nursing homes for a quarter of a century is about to change.

On November 28, 2017, the California Department of Public Health (CDPH) and other state survey agencies throughout the nation will switch to a new nursing home inspection system. The new inspection system is being established by the Centers for Medicare and Medicaid Services (CMS), the federal agency that sets and enforces national standards for nursing homes that participate in the Medicare and Medicaid (Medi-Cal in California) programs. CMS contracts with CDPH to conduct nursing home inspections in California.

In creating the new system, federal officials cited the desire to establish a unified national inspection system for nursing homes. Currently, state survey agencies use either the “traditional” or “quality indicator” survey systems. California uses the traditional survey system, which was developed about 25 years ago after Congress passed the Nursing Home Reform Act in 1987.  About half of the states use the quality indicator survey system – a computer based model that was intended to modernize and eventually replace the traditional survey system – but it has flaws and never proved to be superior.

According to CMS, it is blending the best aspects of each system, making inspections computer based, increasing the focus on residents, and striking the right balance between surveyor autonomy and structure.

The new system does not appear to be much different than the old system. Much will remain the same. Standard inspections will still be carried out by the same teams of inspectors, last a few days and take place about once a year. Inspectors will review the care of a sample of residents, meet with the resident council and monitor meals, medication distribution and other aspects of care.

Simultaneously, certain revised regulatory requirements for nursing homes are being phased in. In September 2016, CMS finalized new standards for nursing homes that are being phased in over a three-year period. Most of the requirements took effect on November 28, 2016, but CMS gave some delayed effective dates of November 28, 2017 (Phase 2) or November 28, 2019 (Phase 3). Some of the requirements taking effect on November 28, 2017 include those on baseline care plans, reporting of crimes, behavioral health, psychotropic drugs, staffing and facility assessments, loss of dentures, infection control and antibiotic stewardship.

CMS has released and posted resources to prepare nursing homes and state survey agencies for these changes, including new interpretive guidelines for the regulatory requirements, a memo to survey agencies, and a listing of new F-tags. Additional resources are posted on the CMS webpage on nursing homes.

The big question is whether these changes will make any difference to nursing home residents. Inspections often fail to identify serious problems and almost all violations are cited at low levels that allow nursing homes to avoid enforcement. Many nursing homes are cited for the same problems year after year and nothing changes. The California Department of Public Health, which is charged with implementing these changes, has a long history of mismanagement and a very cozy relationship with the nursing home industry. Unless CDPH begins taking its mission to ensure that nursing home residents are treated with dignity and receive quality care seriously, it is not likely that residents will benefit from these changes.