2024-020 Oregon Department of Human Services
Ensure nursing facility recertification surveys are completed
Management Response:
We agree with this recommendation.
The department is committed to regaining full compliance with CMS Survey timelines. While staffing shortages, multiple changes to the CMS...
2024-020 Oregon Department of Human Services
Ensure nursing facility recertification surveys are completed
Management Response:
We agree with this recommendation.
The department is committed to regaining full compliance with CMS Survey timelines. While staffing shortages, multiple changes to the CMS Long-term Care Survey Process (LTCSP), COVID-19 disruptions and increased complaints have impacted recertification timeliness, we have taken significant steps to address these challenges over the last several years.
Key strategies include:
• Staffing & Recruitment – Streamlined hiring and onboarding by assigning a dedicated hiring manager to oversee recruitment, hiring onboarding and retention strategies which have reduced surveyor vacancies from 30% to 15% as of March 2025.
• Efficiency Improvements – Streamlined workflows by adopting electronic documentation, reorganized teams to 3 regions that include a complaint team, adjusted team sizes to maximize survey completion rates, increased offsite reviews for certain types of revisits as allowed by State and CMS guidelines, prioritization of facilities with longest intervals since their last recertification to systemically lower the overall average survey interval.
• Data-Driven performance evaluations – Ongoing evaluations reviewing survey and surveyor turnaround time using data.
With these actions, we are confident in our ability to restore compliance and build a more resilient, effective survey system for Oregon’s nursing facilities.
Anticipated Completion Date: October 30, 2026
Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director