CMS Strengthens Oversight of Nation’s Poorest-Performing Nursing Homes

October 21, 2022
Policy Snapshot

The Centers for Medicare & Medicaid Services (CMS) is increasing scrutiny and oversight over the country’s poorest-performing nursing facilities in an effort to immediately improve the care they deliver. In a series of revisions to the Special Focus Facility (SFF) Program, CMS will toughen requirements for completion of the program and increase enforcement actions for facilities that fail to demonstrate improvement. CMS is also calling on states to consider a facility’s staffing level in determining which facilities enter the SFF Program. The announcement is part of a series of new actions the Biden-Harris Administration is taking to increase accountability of bad actors in the nursing home industry, improve the quality of nursing homes, and make them safer.

CMS is announcing the following revisions to the SFF Program:

  • Making requirements tougher: CMS is strengthening the criteria for successful completion of the SFF Program by adding a threshold that prevents a facility from exiting based on the total number of deficiencies cited—no more “graduating” from the program’s enhanced scrutiny without demonstrating systemic improvements in quality.
  • Terminating federal funding for facilities that don’t improve: CMS is considering all facilities cited with immediate jeopardy deficiencies on any two surveys while in the SFF Program for discretionary termination from the Medicare and/or Medicaid programs.
  • Increasing enforcement actions: CMS is imposing more severe, escalating enforcement remedies for SFF Program facilities that have continued noncompliance and little or no demonstrated effort to improve performance.
  • Incentivizing sustainable improvements: CMS is extending the monitoring period and maintaining readiness to impose progressively severe enforcement actions against nursing homes whose performance declines after graduation from the SFF Program.

In another revision to the SFF Program, CMS is advising state survey agencies to consider a facility’s staffing level, in addition to its compliance history, when selecting candidates from their state for inclusion in the SFF Program. This recommendation is the latest action by CMS to focus on the importance of staffing to quality care, another key component of President Biden’s Action Plan for Nursing Homes. 

The changes CMS is implementing are designed to incentivize facilities to quickly improve their quality and safety performance, allow the SFF Program to scrutinize more facilities over time by moving facilities through the program more quickly, and promote sustainability of facilities’ improvements to ensure they do not regress post-program.

These changes to the SFF Program will help drive improvements to resident care in affected facilities. While the revised SFF Program increases scrutiny and enforcement consequences for poor-performing nursing homes, CMS is also emphasizing a number of efforts facilities can take to support quality improvement, including engaging CMS Quality Improvement Organizations and hiring external consultants to support performance improvement. While in the SFF program, CMS is encouraging facilities to make good-faith efforts (and provide evidence of these efforts) to improve quality and measurable changes, such as changes in staffing, leadership, or increased overall staffing. These efforts will be considered when evaluating potential enforcement actions for noncompliance. For example, SFFs with noncompliance and no evidence of good-efforts to improve quality will be subject to more severe enforcement sanctions, such as higher penalties, or suspension or termination of federal funding.

Currently, 88 nursing homes participate in the SFF Program, approximately 0.5% of all nursing homes in the country.

While the SFF Program has helped many nursing homes improve their compliance and quality, some facilities fail to reach the standards necessary to graduate from the program. Additionally, some facilities demonstrate improvement, only to regress and fail to sustain their improvements and compliance.

Since its inception, the SFF Program has identified the poorest-performing nursing homes in the country for increased scrutiny to rapidly make and sustain improvements in the quality of care they deliver. These facilities continue to be inspected roughly twice as often as all other nursing homes—no less than once every six months—and face increasingly severe enforcement actions if improvement is not demonstrated. Facilities must pass two consecutive inspections to complete the program. These changes enhance the existing program to drive rapid and sustained quality and seek to more effectively protect the health and safety of nursing home residents in these facilities.

CMS’ Quality, Safety & Oversight memorandum on the revisions to the Special Focus Facilities (SFF) Program can be viewed here.

Read the White House Fact Sheet: Biden-Harris Administration Announces New Steps to Improve Quality of Nursing Homes.