Nursing Home Surveyor and Survey Team Characteristics Across States

Since the 1987 Nursing Home Reform Act, nursing homes (NHs) are required to receive annual “recertification” surveys to continue participation in the Medicare and Medicaid programs and “complaint” surveys following allegations of poor-quality care [1]. These onsite surveys review resident care quality and safety and are typically conducted by surveyors employed by state survey agencies (SSAs). Using unannounced visits [2], surveyors interview residents and staff, conduct records reviews, observe resident care, and conduct safety inspections [3]. In concluding the survey visit, surveyors identify any relevant deficiencies and may produce corrective action plans for NH staff to implement [3]. Prior studies have attempted to assess how NH surveys influence resident quality [4, 5]. For example, research has found that NHs respond to deficiency citations, improving care on dimensions of cited deficiencies, although these improvements may be offset by reduced NH focus on areas of care related to lesser cited deficiencies [5]. There is little evidence on how survey teams and surveyors may influence deficiency patterns, limiting insights of previous work that controls for state-level trends and assumes SSA-wide homogeneity in surveyor stringency. Additionally, the research literature has not categorized how surveyor team characteristics vary across states or how this variation affects survey quality. Although the Centers for Medicare & Medicaid Services (CMS) provides guidelines for the NH survey process in the State Operations Manual, SSAs are tasked with hiring surveyors and deploying survey teams [3, 6]. For example, federal regulations stipulate that surveys must contain at least one registered nurse (RN) on a recertification survey, but SSAs may vary the professional qualifications of the remaining survey team members [6, 7]. Our analysis assesses variation in the RN share of the survey workload. Although CASPER data include classifications for 36 possible surveyor professions, RNs predominate providing 66% of the surveyor-survey workload (Table S1). Existing qualitative research suggests surveyor discretion can influence regulatory outcomes, but we are unaware of research exploring how surveyor team characteristics may influence these decisions [8]. Also, government reports have noted surveyor staffing challenges for decades [6, 9]. This paper augments these findings by assessing variation in surveyor staffing and workload across SSAs. We examine NH surveyors and survey teams using a dataset of survey and surveyor-level recertification and complaint surveys. We use Certification and Survey Provider Enhanced Reports (CASPER) data combined with surveyor-level information from CMS for 2023 [10]. These 2023 data are used to produce state-level descriptive statistics of the number of active surveyors (surveyors conducting at least one survey), surveyor team size, the number of NHs visited by individual surveyors, and RN involvement in NH surveys. To assess RN involvement, we calculate the proportion of surveyor-survey combinations associated with RNs, summing the total number of RN surveyors on recertification and complaint surveys in 2023 for each state and dividing by the total number of surveyors. Additionally, we merge these data with information from Quality, Certification, and Oversight Reports from CMS for 2023 to acquire the number of NH residents in each state [11]. These data are used to estimate state-level active surveyors per 1000 NH residents. We find large variation in the number of active surveyors per 1000 NH residents across states. For example, we find that Alaska had 12.5 active surveyors per 1000 NH residents in 2023, compared to Alabama, Mississippi, New York, and Pennsylvania who had fewer than 2.5 surveyors per 1000 NH residents (Figure 1). Source: Number of active surveyors in 2023 is sourced from CMS surveyor staffing data. This number represents the unique count of surveyors who conducted any recertification or complaint survey in 2023. The number of residents in 2023 is sourced from the quality, certification, and oversight reports from CMS. Similarly, we find variation in the number of surveyors per NH, ranging from 1 surveyor per NH in Puerto Rico to 0.14 surveyors per NH in Kansas. We find wide variation in the intensity of RN usage and in surveyor experience. In Alaska and Minnesota, 85% of surveyor-survey combinations are associated with an RN compared to only 18% in Colorado and South Carolina. In Table 1, the number of NHs visited per surveyor and the proportion of surveyors with 4+ years of experience varies widely across states. Our results show wide variation in surveyor-level metrics across SSAs. Existing government reports have categorized differences in surveyor vacancies and salaries across states [6, 9]. Our work adds further context, analyzing states' NH surveyor capacity and composition. Since the survey process involves interviewing residents and staff, the number of surveyors per resident may suggest a greater ability for SSAs to monitor NH quality. In addition, the greater usage of RN and experienced surveyors conveys resource investments that could bolster survey teams' effectiveness. The most common surveyor qualification after RNs is surveyor generalists, who have passed the surveyor qualification test and training course, but do not necessarily have other clinical expertise. We do not assess state variation in non-RN surveyor qualifications. We provide the number of NHs visited per surveyor to show variation in the deployment of surveyors to NHs. Additionally, SSAs have reported challenges completing surveys post-COVID-19 due to staff turnover and a large survey backlog from the suspension of recertification surveys during the public health emergency [12]. Our 2023 findings overlap with this tumultuous period. In addition, our surveyor-level metrics are not a proxy of SSA survey stringency which has been shown to vary across states [4]. Nonetheless, these surveyor-level data provide insights into how states approach the NH survey process. Future work should explore the relationship between surveyor-level metrics, survey stringency and performance, the timeliness of recertification and complaint surveys, and resident quality of care. Robert J. Skinner and David G. Stevenson both engaged in the study concept and design, acquisition of data, analysis and interpretation of data, and critical revision of the manuscript. Robert J. Skinner drafted the manuscript. The authors declare no conflicts of interest. Table S1: Share of surveyor-surveys by occupation in 2023. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.