White Paper on the survey process.

Some 130,000 pages of federal regulations govern nursing facilities in the United States, more than the accumulated regulations for the nuclear power industry. Each attempt to clarify, expand, or amend these statutes seems to intensify the debate on how to best bring quality care to those who spend part or the balance of their lives in a long-term care facility. Frail elders make up the vast majority of the long-term care population. The divine spark within us may be that humans are the only species that will sustain those who can no longer provide for themselves. While all agree sustenance is essential, few can agree on the best path—or regulatory model—to ensure that residents receive appropriate and adequate longterm care (LTC). The nation has attempted to ensure safe, effective care by creating an oversight process for LTC. The current regulatory path emerged from a study in the mid-1980s by the National Academy of Sciences Institute of Medicine (IOM) Committee on Nursing Home Regulation. Following a 2-year study of nursing home performance and existing nursing home regulation, this IOM Committee made recommendations to Congress and the administration on how to improve the regulatory process and the quality of care received by residents. In response to the IOM’s recommendations, Congress enacted the nursing home reform provisions contained within the Omnibus Reconciliation Act of 1987 (OBRA 87) and HCFA (now known as the Centers for Medicare and Medicaid Services [CMS]) subsequently issued implementing regulations and guidance for the survey process. Under OBRA 87 (codified at 42 CFR part 483) the federal government requires each nursing facility that receives Medicare or Medicaid funds to meet minimum standards for care. States are authorized to conduct on-site surveys in nursing homes to ensure provider compliance with those standards. To promote national consistency, CMS has published surveyor guidelines to assist surveyors and facilities in interpreting F-tags (requirements) and to help surveyors conduct surveys. The State Operations Manual (SOM) contains the procedures for conducting the survey. The SOM includes specific instructions about gathering and interpreting information collected before and during the survey, drafting and presenting the statement of deficiencies to facilities, drawing conclusions about the scope and severity of the facility’s alleged noncompliance, determining penalties for noncompliance, and other issues such as various levels of appeal. All state survey agencies must use the procedures and tasks in the SOM to conduct the survey. Each state may have additional