The Fox Group has decades of experience supporting post-acute providers across regulatory compliance, survey readiness, and operational performance. With former licensed nursing home administrators on our leadership team, we understand both the regulatory demands facilities face and the practical challenges of the CMS survey process. Here, we explain what the new Risk-Based Survey Process means for nursing homes …
Executive Summary – Key Takeaways
- RBS eligibility can reduce survey burden for high-performing nursing homes
- Limited survey funding is driving CMS’s risk-based approach
- Leaders should assess eligibility gaps and target improvable criteria now
- Eligibility can change, requiring continuous monitoring until surveys begin
Table of contents
- What Is the CMS Risk-Based Survey Process for Nursing Homes?
- Why is CMS Implementing the Risk-Based Survey Process?
- What Should Nursing Home Administrators and other Leaders do with this information?
- How can Nursing Home Leaders Monitor Their Status with Respect to the RBS Survey Readiness?
- What are Some of the Readiness Gaps Facilities May Encounter when Preparing for an RBS Survey?
- Can a Nursing Home lose Eligibility for an RBS Survey after achieving it in the past 18 months?
- Why RBS Survey Readiness Matters for Nursing Homes
- Frequently Asked Questions About Nursing Home Survey Readiness
What Is the CMS Risk-Based Survey Process for Nursing Homes?
A new approach to surveys of nursing homes is on the near- term horizon. The Centers for Medicare and Medicaid Services (CMS) is in the middle of rolling out a new Risk-Based Survey Process. It applies to nursing home providers caring for patients covered by the Medicare and Medicaid programs. Nursing homes that qualify for the Risk-Based Survey (RBS) process may benefit from less intensive surveys than the traditional Long-Term Care Survey Process (LTCSP) initiated in 2017.
CMS is targeting “high-performing” nursing homes and has set specific criteria that will disqualify providers from being surveyed under the RBS Process. These include citations for actual harm or immediate jeopardy and more than 18 months without a standard survey. Failed reporting of payroll-based journal or minimum data sets can also disqualify a facility. CMS estimates that 12% of all nursing homes will initially qualify for the RBS survey. CMS scheduled RBS surveyor training to begin August 18, 2026, with nationwide implementation of the RBS process beginning September 8, 2026.
Why is CMS Implementing the Risk-Based Survey Process?
The short answer is money. The federal budget for nursing home surveys, which are conducted by state surveyors, has been frozen since 2015. CMS hopes to spend fewer resources on high-performing facilities. It can then spend more time and money on facilities that are not keeping up with reporting requirements, clinical quality outcomes, or other regulatory requirements.
What Should Nursing Home Administrators and other Leaders do with this information?
It’s fair to say most nursing home administrators and other managers would welcome a less comprehensive survey process. Eligibility for the upcoming rollout of the RBS process may already be “baked in”. Even so, all facilities have a chance to qualify for the RBS survey in the future.
Now is the time to assess your RBS readiness for future surveys. For instance, you may currently be qualifying in all but one or two of the criteria. If so, performance improvement strategies to reach the threshold for future RBS surveys may be easy to implement.
How can Nursing Home Leaders Monitor Their Status with Respect to the RBS Survey Readiness?
Title 42 Section 483.85 of federal regulations requires nursing home facilities to establish and operate a Compliance and Ethics Program. Moreover, this Program must include standards and policies that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under the Act. These standards and policies must also promote quality of care.
Ensuring compliance with RBS eligibility criteria would seem to fit naturally within this Program. The Program is designed to identify areas and maintain compliance.
What are Some of the Readiness Gaps Facilities May Encounter when Preparing for an RBS Survey?
There are at least two criteria a nursing home can’t do much about since they are independent of facility performance. One is a change of ownership since the last standard survey. The other is going more than 18 months without a standard survey.
Other criteria are ratings awarded by outside agencies such as the Star Ratings and Health Inspection Scores, although these factors certainly reflect facility performance against regulatory standards.
The other criteria reflect administrative processes that already exist in nursing homes participating in Medicare and Medicaid services, or outcomes of regular operations. The remaining full list of criteria, along with the national rates of facilities with these survey deficiencies/situations, includes:
- Less than a 5-Star Overall Rating (78.4%)
- Less than a 3-star Staffing Rating (29.4%)
- Any citations for Actual Harm (19.6%), Immediate Jeopardy (11.5%), or Substandard Quality of Care (11.2%) in the last survey cycle
- Any staffing waivers in effect (0.3%)
- Failed Payroll-Based Journal staffing data audit (1.8%)
- Failed resident assessment Minimum Data Set audit (0.4%)
- Health Inspection Score higher than the 50th percentile in the state (50.1%)
- Two or more residents aged 65 or older coded with a diagnosis of schizophrenia after admission without this diagnosis (15.2%)
- Special Focus Facility Candidate status (4.2%)
Can a Nursing Home lose Eligibility for an RBS Survey after achieving it in the past 18 months?
The short answer is yes. Facilities with citations for Actual Harm (AH), Immediate Jeopardy (IJ), or substandard quality of care (SQC) will lose eligibility. Facilities with more than three pending non-IJ active intakes will also lose eligibility. Facilities receiving CMS Nursing waivers and having a change in ownership will also lose eligibility for an RBS survey.
Why RBS Survey Readiness Matters for Nursing Homes
There is no doubt that owning and operating licensed nursing homes participating in Medicare and Medicaid services is now, and has been for a long time, challenging. Finding competent, caring staff, maintaining pleasant, well-equipped facilities, and achieving positive clinical outcomes for patients is hard on the best days. CMS plans to identify facilities that qualify for the RBS by placing an icon (a golden trophy cup) on each qualifying facility’s Nursing Home Care Compare profile. This may prove to be a valuable marketing element for facilities that maintain RBS eligibility.
The Fox Group can help nursing home leadership assess their current RBS readiness, identify eligibility gaps, and develop a practical path toward future qualification.
Frequently Asked Questions About Nursing Home Survey Readiness
Qualifying nursing homes may receive a less intense survey that requires fewer resources than the traditional Long-Term Care Survey Process.
CMS developed the process so survey resources can be directed toward facilities where residents face greater risk of harm. The RBS still assesses compliance with health and safety standards; it is a different survey process, not a departure from the underlying requirements.
Yes. A nursing home that does not qualify now may become eligible for an RBS in a future survey cycle.
Leadership should compare current performance against the eligibility criteria and identify where improvement is realistic. If the facility is missing only one or two criteria, performance improvement strategies may be applied to create a path toward future qualification.
Facilities can influence readiness factors tied to regulatory performance, reporting, documentation, and routine operations. But some criteria fall outside that level of control.
They can address PBJ staffing data, MDS accuracy, relevant citations, and schizophrenia coding. Star Ratings and Health Inspection Scores are awarded externally but still reflect facility performance. A change in ownership since the last standard survey, or an extended interval without a standard survey are less within the facility’s immediate control.
Yes. A nursing home can lose RBS eligibility after having qualified and before the RBS begins.
Eligibility may change if the facility receives an actual-harm, immediate-jeopardy, or substandard-quality-of-care citation; has more than three pending non-immediate-jeopardy active intakes; receives a CMS-approved nursing waiver; or changes ownership. Readiness monitoring should therefore continue until the survey begins.
RBS readiness should be assigned within the facility’s compliance program structure, with clear leadership accountability and regular review.
Federal regulations require the operating organization to maintain an effective compliance and ethics program with monitoring, auditing, reporting, enforcement, and annual review elements. That program is a natural place to track RBS criteria, identify gaps, assign corrective actions, and document facility follow-through.