CMS Risk-Based Nursing Home Surveys: Why Staffing Strategy Matters

On July 16, 2026, the Centers for Medicare & Medicaid Services announced nationwide implementation of a new Risk-Based Survey process for higher-performing nursing homes. Beginning September 8, 2026, eligible facilities may receive a more focused version of the standard recertification survey that CMS says can be completed in roughly half the time and with fewer surveyors than the traditional Long-Term Care Survey Process.

The change is more than a survey-efficiency initiative. CMS also plans to identify qualifying nursing homes with a high-performing facility icon on Nursing Home Care Compare, creating a visible distinction that residents, families, referral sources, employees, and other stakeholders may see when comparing facilities.

Only a relatively small group is expected to qualify initially. CMS estimates that approximately 12% of nursing homes nationwide will meet the Risk-Based Survey criteria. The preliminary June 2026 data in the CMS memorandum identified 88 of Pennsylvania's 656 nursing facilities, or 13.41%, as qualifying at that time. Those figures are preliminary and will change as CMS incorporates more recent information.

For nursing home leaders, the operational message is direct: sustained performance may now lead not only to stronger quality outcomes and public ratings, but also to a less resource-intensive standard survey experience and a new public indicator of high performance.

Staffing is not the only factor in Risk-Based Survey eligibility, but it is one of the most important factors a facility can actively manage every day. CMS requires a qualifying facility to have a 5-star overall rating and at least a 3-star staffing rating. The agency also specifically identified staffing as a major reason facilities do not qualify. In the preliminary Pennsylvania data, 261 facilities, or 39.79% of facilities in the state, were excluded under the criterion for a staffing rating below 3 stars. Because facilities can fail more than one criterion, the exclusion categories should not be added together or treated as mutually exclusive.

That creates a strong reason for administrators, directors of nursing, and schedulers to treat external staffing support as part of a broader workforce resilience strategy. A responsive healthcare staffing agency cannot create a CMS rating, prevent every deficiency, or guarantee Risk-Based Survey eligibility. It can, however, help a facility respond to coverage gaps, stabilize difficult schedules, request personnel aligned with facility-specified role and credential requirements, and build more operational flexibility around the staffing conditions that CMS now places squarely within the high-performance framework.

What the CMS Risk-Based Survey process changes

State Survey Agencies must continue to conduct standard recertification surveys at least once every 15 months. The new Risk-Based Survey does not eliminate that requirement and does not remove federal health and safety standards. Instead, it modifies the survey process for facilities CMS identifies as lower risk and higher performing.

According to CMS, the Risk-Based Survey still reviews all required areas, but it uses fewer activities and a smaller resident sample. CMS's testing across 22 states and more than 100 facilities found that the process produced findings comparable to the traditional survey process. For a qualifying nursing home, the practical benefit may be a shorter onsite survey period, fewer surveyors in the building, and less operational disruption for leadership and frontline teams.

CMS will provide State Survey Agencies with updated qualified-facility lists at the end of each calendar quarter. A facility will remain eligible for six months after the state receives the list unless a disqualifying event occurs before the survey begins. State agencies and CMS retain discretion to use the traditional survey process when health or safety concerns warrant it.

To qualify for the quarterly list, a facility must avoid all of the following conditions:

• An overall rating below 5 stars.
• A staffing rating below 3 stars.
• Citations for actual harm, immediate jeopardy, or substandard quality of care during the last survey cycle.
• More than 18 months since the last standard survey.
• A staffing waiver in effect.
• A failed Payroll-Based Journal staffing data audit.
• A failed Minimum Data Set audit.
• A health inspection score above the 50th percentile in the state, where a lower score indicates better performance.
• Certain post-admission schizophrenia coding patterns identified by CMS.
• A change in ownership since the last standard survey.
• Special Focus Facility candidate status.

Even after appearing on the qualified list, a facility can be disqualified before the Risk-Based Survey begins because of specified citations, pending intake investigations, more than three qualifying pending non-immediate-jeopardy intakes, a CMS-approved nursing waiver, or a change in ownership.

The criteria show why no single vendor can "get" a nursing home into the program. Eligibility depends on a connected system of staffing, clinical performance, accurate reporting, survey history, complaint and incident management, ownership status, and other factors. The value of a staffing partner lies in helping the facility strengthen the workforce side of that system.

Why agency staffing has greater strategic value under the new model

1. Responsive coverage can help protect the staffing foundation behind eligibility

The most direct connection is the requirement for at least a 3-star staffing rating. CMS uses Payroll-Based Journal data and resident census information to evaluate staffing levels, and staffing is one of the domains used in the Five-Star Quality Rating System.

A staffing agency can help a facility respond when its internal schedule cannot fully cover planned or unexpected demand. Common examples include call-offs, vacancies, leave coverage, weekend gaps, overnight openings, admissions, census changes, and temporary increases in resident acuity. In these situations, having an established process for requesting qualified RNs, LPNs, CNAs, and medication personnel, when appropriate for the facility and assignment, can give schedulers another tool for maintaining coverage.

Agency support should not replace recruitment, retention, or sound internal scheduling. Its strategic value is flexibility. It can help bridge the period between an employee's departure and a new hire's start date, reinforce a difficult shift while a permanent solution is developed, or provide additional capacity during an unusually demanding period.

For facilities near a staffing-rating threshold, repeated uncovered shifts or prolonged vacancies can be more than a daily scheduling problem. They may become a performance risk. A staffing relationship established before a crisis gives the facility a faster and more organized way to seek support when internal options are exhausted.

2. Flexible staffing can reduce the operational instability created by last-minute gaps

An open shift rarely affects only the schedule. It can lead to reassignment, overtime requests, supervisor coverage, delayed non-urgent work, heavier workloads for the team that remains, and substantial administrative time spent searching for coverage. When gaps recur, these effects can compound.

A staffing partner helps by creating a defined external coverage channel. Instead of beginning from zero each time, a scheduler can communicate the role, date, shift, unit, reporting instructions, credential expectations, and other facility-specific requirements through an established process. The agency can then assess available personnel and communicate realistic next steps, subject to availability and the facility's requirements.

This matters under the Risk-Based Survey framework because high performance must be sustained. Qualification is assessed through quarterly lists, and facilities can lose eligibility before the survey starts. The goal is not to temporarily improve a schedule for a single reporting period. The goal is to build a more resilient operating model that can absorb routine disruption without allowing every vacancy or call-off to become a facility-wide crisis.

3. Adequate coverage can support the environment in which quality systems operate

CMS's eligibility criteria extend well beyond staffing. Citations for actual harm, immediate jeopardy, and substandard quality of care can prevent qualification. Complaints and facility-reported incidents can also disqualify a facility after it appears on the list.

It would be inaccurate to claim that using agency staff prevents citations or complaints. Survey findings depend on the facility's actual practices, leadership, policies, documentation, resident needs, staff competency, supervision, and many other factors. However, staffing capacity is part of the operating environment in which those systems function.

When coverage is more stable, facility leaders may have a better opportunity to maintain assignments, preserve supervisory capacity, complete required work, support resident routines, and respond to emerging concerns. When every shift is operating in crisis mode, even strong teams may have less flexibility to manage unexpected events.

The correct value proposition is therefore not "agency staff will protect your survey." It is that responsive staffing support can help reduce one source of operational strain so the facility's own clinical, quality, compliance, and leadership systems have more capacity to work as designed.

4. Facilities should establish a clear PBJ reconciliation process for agency hours

Accurate data is a separate Risk-Based Survey requirement. A failed Payroll-Based Journal staffing audit disqualifies a facility from the qualified list. CMS requires facilities to submit direct-care staffing information based on payroll and other auditable data, and its PBJ guidance expressly includes agency and contract staff.

This makes administrative coordination with a staffing agency important. Facilities remain responsible for understanding CMS rules, determining what documentation is required, preparing accurate PBJ submissions, meeting deadlines, maintaining required records, and responding to audits. A staffing agency does not take over that responsibility merely by supplying personnel.

Before using an agency, administrators should define the ordinary time-approval and invoice records the agency will provide under the parties' agreement, how discrepancies will be corrected, who handles questions, and when records will be available. The facility should reconcile those records against its own scheduling and timekeeping information and should not assume that an agency invoice, by itself, satisfies CMS requirements.

The agency's appropriate role is to follow the agreed time-approval and billing process and respond to questions about its own records. The facility retains responsibility for PBJ reporting, supporting documentation, reconciliation, and audit readiness. Med Plus Staffing does not offer or imply a PBJ compliance, submission, reconciliation, or audit service.

5. External coverage can be part of a plan to avoid relying on staffing waivers

The CMS criteria exclude facilities with certain staffing or nursing waivers. A waiver may be necessary and appropriate in some circumstances, and a staffing agency should never advise a facility to avoid a legally available option without reviewing its specific facts with qualified compliance and legal professionals.

From a workforce-planning perspective, however, facilities have a reason to explore available coverage resources before a persistent staffing shortage becomes severe. A combination of internal recruitment, retention work, schedule redesign, leadership coverage, and qualified temporary staffing may provide more options than relying on any single tactic.

An agency's role is most useful when it is engaged early. If a facility waits until a shortage has become prolonged and urgent, the range of available personnel and scheduling solutions may be narrower. Sharing recurring needs, difficult shifts, anticipated leaves, and upcoming census changes in advance can help a staffing partner understand the facility's priorities and discuss realistic coverage options.

6. Consistent access to qualified personnel can strengthen workforce continuity during transitions

Nursing homes experience predictable periods of transition: open positions, onboarding delays, seasonal demand, leaves of absence, turnover, acquisitions, leadership changes, and shifts in resident needs. These periods may create temporary staffing pressure even in well-managed facilities.

A staffing agency can act as a bridge while the facility executes its longer-term plan. Temporary personnel may support an open schedule while new employees complete recruitment and onboarding, help cover approved leave, or provide capacity during a defined transition period. For recurring needs, facilities may also discuss per-diem or contract staffing arrangements when they fit the facility's needs and Med Plus Staffing's available personnel and service terms.

The strongest approach is deliberate. The facility should communicate the exact role, required credentials, schedule, unit expectations, orientation needs, documentation systems, reporting structure, and assignment length. Clear requirements help the staffing agency evaluate potential matches and help incoming personnel understand the environment they are entering.

7. Better schedule resilience can protect leadership time before and during a survey

The new survey model may reduce onsite time for qualifying facilities, but surveys still require preparation, access to records, staff participation, resident interviews, and leadership attention. A facility that begins the survey period with unresolved schedule gaps may find its leaders splitting attention between survey coordination and basic coverage management.

Workforce resilience helps preserve administrative bandwidth. When the staffing plan includes escalation paths for call-offs and open shifts, schedulers and nursing leaders can respond through an established process instead of improvising under pressure. That does not change what surveyors review, but it may reduce avoidable operational distraction while the facility is responding to the survey team.

The benefit continues after the survey. CMS can still conduct complaint investigations, and State Survey Agencies may use the traditional Long-Term Care Survey Process when health or safety concerns arise. A strong staffing strategy should therefore support ordinary operations every week, not merely the days surrounding a recertification survey.

8. Sustained staffing performance may contribute to a valuable public distinction

CMS plans to place a high-performing facility icon on Nursing Home Care Compare for nursing homes that qualify for the Risk-Based Survey. The icon is intended to make these facilities easier for consumers and stakeholders to identify in addition to the traditional Five-Star ratings.

That designation may become meaningful in a competitive market. Families may see it while comparing nursing homes. Hospital discharge planners and referral partners may encounter it while researching options. Current and prospective employees may view it as another public indicator of organizational performance. Operators may use qualification as one element in quality-improvement and market-positioning conversations.

Because the icon remains only while the facility is eligible, the distinction is not a permanent award. It reflects continuing qualification under CMS criteria. A staffing partner cannot promise that designation, but can support the facility's effort to maintain the workforce capacity that underlies one of the required ratings.

A practical staffing playbook for facilities pursuing sustained high performance

The Risk-Based Survey model rewards consistent operations rather than one-time preparation. Facilities can use the following process to make external staffing a more disciplined part of their workforce strategy.

Review staffing risk before the schedule is in crisis

Identify shifts, days, units, and roles with recurring coverage pressure. Look beyond the current week. Consider anticipated leave, open positions, onboarding timelines, known seasonal patterns, and changes in census or resident needs. Early visibility gives leaders more choices.

Establish an agency relationship before the first emergency request

Complete contracting, credential expectations, facility requirements, orientation planning, and communication protocols before a severe shortage occurs. An established relationship can reduce administrative delay when a time-sensitive need arises.

Make every staffing request complete

Provide the role, shift date and time, facility location, unit or assignment details, required credentials, dress and reporting instructions, documentation or electronic health record expectations, orientation requirements, and the correct point of contact. Incomplete requests create avoidable back-and-forth and can delay coverage coordination.

Separate urgent gaps from recurring demand

Use an urgent request process for unexpected call-offs and a planning process for repeated openings. A recurring weekend or overnight gap may require a different solution from a single same-day absence. Discuss whether per-diem or contract staffing is appropriate and available for the requested period.

Define escalation and update procedures

Schedulers should know whom to contact, how after-hours communication works, how cancellations or changes are reported, and who receives confirmation. A staffing partner should also know which facility leader can resolve questions when the primary scheduler is unavailable.

Define a facility-owned time and attendance reconciliation process

Determine how agency hours will be recorded and approved, which ordinary records the agency will provide under the agreement, and how the facility will reconcile those records for its own PBJ and audit processes. Investigate discrepancies promptly. The facility's compliance and reporting teams should determine whether its documentation and submissions meet CMS requirements.

Measure whether the relationship is working

Track useful operational indicators such as requested shifts, filled shifts, cancellations, timeliness, recurring hard-to-fill periods, documentation issues, and communication delays. Use the data to improve the request process and to decide where agency staffing is most valuable.

Keep the staffing agency inside a broader quality strategy

External staffing is one tool. It works best alongside internal recruiting, retention, employee engagement, scheduling discipline, orientation, competency processes, supervision, quality assurance, incident management, and accurate data submission. Risk-Based Survey qualification requires the entire system to perform.

Questions administrators should ask a staffing agency

When evaluating a staffing partner in light of the new CMS framework, nursing home leaders should ask operational questions rather than relying on broad promises:

• Which nursing roles does the agency regularly support in skilled nursing and long-term care environments?
• How does the agency receive urgent, recurring, and planned coverage requests?
• What information does the agency need to evaluate a request efficiently?
• How are credentials and facility-specific requirements coordinated before an assignment?
• Which ordinary time-approval and invoice records will the agency provide under the agreement?
• How are schedule changes, cancellations, and after-hours issues communicated?
• Who is the operational contact when a problem needs escalation?
• Can the agency discuss per-diem or contract staffing arrangements when appropriate and available?
• How does the agency help personnel understand reporting instructions and assignment expectations?
• What process is used to review service issues and improve future coordination?

The answer should not be a guarantee of a star rating or survey result. The answer should demonstrate clear communication, realistic expectations, organized documentation, and an understanding of how nursing home schedules actually operate.

How Med Plus Staffing can support a facility's workforce strategy

Med Plus Staffing supports healthcare facilities across Southwestern Pennsylvania with temporary staffing for core roles including RNs, LPNs, CNAs, and Medication Aides / Med Techs, subject to personnel availability, facility requirements, and the needs of each assignment. Medication-support duties and credential requirements must be confirmed for the specific facility, role, and assignment.

Our value is practical: we help facility leaders communicate coverage needs, coordinate available personnel for requested roles after facility requirements are confirmed, and respond to urgent and planned staffing pressure through a local staffing relationship. We can discuss short-notice gaps, recurring open shifts, per-diem needs, and contract staffing when those arrangements are appropriate and available.

For nursing homes pursuing sustained high performance, this flexibility can support several important goals:

• Maintain a more resilient schedule when internal coverage is limited.
• Respond more effectively to call-offs, vacancies, leave, and changing demand.
• Reduce the administrative friction involved in repeatedly starting an external search from scratch.
• Establish clear schedule-confirmation and time-approval steps that support the facility's own reconciliation process.
• Preserve leadership attention for resident care, quality, compliance, and workforce management.
• Build a repeatable coverage process that supports operations throughout the year—not only before a survey.

Med Plus Staffing does not determine CMS ratings; provide PBJ compliance, submission, reconciliation, or audit services; interpret regulatory eligibility; guarantee survey outcomes; or promise that a facility will qualify for or remain eligible for the Risk-Based Survey. Those decisions remain with CMS and State Survey Agencies and depend on the facility's complete performance record.

What we can do is help nursing home leaders strengthen one of the operating systems that matters most: access to responsive staffing support when the schedule needs additional capacity.

The strategic takeaway

CMS's Risk-Based Survey model gives higher-performing nursing homes a new combination of potential benefits: a more focused standard survey, less onsite disruption, and a public icon designed to recognize high performance. The qualification standards are rigorous, updated regularly, and vulnerable to disqualifying events before the survey begins.

Staffing is central to this framework. A facility needs at least a 3-star staffing rating, accurate auditable PBJ data, no applicable staffing waiver, and the broader quality and survey performance required for a 5-star overall rating. The preliminary data show that a low staffing rating is already keeping a substantial number of facilities outside the qualified group.

For administrators and schedulers, the response should not be a short-term push to fill more shifts just before a reporting date. It should be a durable workforce strategy that combines internal recruitment and retention with reliable contingency coverage, accurate documentation, clear communication, and early planning for recurring gaps.

A healthcare staffing agency cannot produce high performance on a facility's behalf. The right agency can help the facility protect schedule resilience, access qualified personnel when needs arise, and reduce avoidable workforce disruption. Under the new CMS model, that operational flexibility has become even more strategically valuable.

Need to strengthen your facility's staffing contingency plan? Contact Med Plus Staffing to discuss current coverage pressure, recurring open shifts, or upcoming staffing needs in Southwestern Pennsylvania.

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Sources

1. Centers for Medicare & Medicaid Services, QSO-26-14-NH: Nursing Home Risk-Based Survey National Implementation, July 16, 2026.
2. Centers for Medicare & Medicaid Services, CMS Modernizes Nursing Home Oversight with New Risk-Based Survey Approach Designed to Highlight High Performance, Encourage Improvement, July 16, 2026.
3. Centers for Medicare & Medicaid Services, Five-Star Quality Rating System, current page and July 2026 Technical Users' Guide.
4. Centers for Medicare & Medicaid Services, Staffing Data Submission Payroll-Based Journal, current page reviewed July 16, 2026.

This article provides general operational information, not legal, regulatory, clinical, or compliance advice. Facilities should review current CMS guidance and consult their own qualified advisors regarding their obligations and eligibility.