October 24, 2019

Special Focus Facility Programs for the Aging Population

Arkansas State University

Dr. Angela Stone Schmidt, Professor Emeritus
College of Nursing & Health Professions
Arkansas State University


The “Special Focus Facility” (SFF) program, is implemented by Centers for Medicare and Medicaid Services (CMS) for the aging and others requiring the need for long term nursing care. The purpose of this initiative is to keep the public, healthcare providers and consumers, informed when discussing long term care options.  The SFF report is a result of state agency inspections resulting in what that agency is doing to improve quality of care for the aging after deficiencies have been cited.  There are specific areas reviewed to determine quality and these reports are available online.  Those long term care facilities, identified as a “Special Focus Facility”, are identified and include measures of quality, or lack of, with available evidence, identifying high and low performing nursing homes.

In June 2019, the release of a list of 400 nursing homes across the country by the Senate Committee on Aging was deemed to have persistently poor survey inspection results. Policy makers took note and responded, directing attention to the quality issues of long term care. CMS gave the list to Senator Robert P. Casey (D-Pa.), a member of the special committee on aging, which included 6 from Arkansas. A subsequent announcement was made by CMS of how the list is being sorted for possible inclusion in its SFF Program. David Gifford, Senior Vice President of Quality and Regulatory Affairs, American Health Care Association (AHCA), supported making relevant, transparent information available to families and consumers so they could make informed care decisions for selecting a quality facility.

(https://www.aging.senate.gov/imo/media/doc/SFF%20List%20with%20Cover%20Letter%20051419%20-%20Casey.pdf )

CMS and state agencies have inspected nursing homes on a regular basis to determine if they are providing the quality of care that Medicare and Medicaid require to protect and improve residents’ health and safety. When nursing homes do not meet CMS’ health care or fire safety standards, these instances are cited as deficiencies, and CMS requires that the problems be corrected. Most nursing homes have some deficiencies identified, as reported by CMS, with the average being 6-7 deficiencies per inspection.

“Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in 42 CFR Part 483, Subpart B, to receive payment under the Medicare or Medicaid programs.  To certify a SNF or NF, a state surveyor completes at least a Life Safety Code (LSC) survey, and a Standard Survey. The State has the responsibility for certifying a SNF’s or NF’s compliance or noncompliance, except in the case of State-operated facilities.  However, the State’s certification for a skilled nursing facility is subject to CMS’ approval.  “Certification of compliance” means that a facility’s compliance with Federal participation requirements is ascertained.  In addition to certifying a facility’s compliance or noncompliance, the State recommends appropriate enforcement actions to the State Medicaid agency for Medicaid and to the regional office for Medicare.” (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/NHs.html )

Some nursing homes make unsustainable improvements to correct an identified problem on inspection but as a result, have repeated cycles of serious deficiencies because of not addressing the underlying systemic problems that contributed to the needed improvement to improve quality of care. These facilities identified as a SFF had a compliance history which posed risks to residents’ health and safety. The methodology for identifying facilities for the SFF program is based on the same methodology used in the health inspection domain of The Five-Star Quality Rating System. CMS calculates a total weighted health inspection score for each facility.  Results from over three cycles (approximately three years) of inspections are converted into points based on the number of deficiencies cited and the scope and severity level of those citations, including any repeat visits. The more deficiencies that are cited, and the more cited at higher levels of scope and severity, the more points are assigned. Note that a lower survey score corresponds to fewer deficiencies and revisits, and thus better performance on the health inspection domain. (Five Star Rating System for Special Focused Facility, updated 9/25/19, https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf)

The Nursing Home Compare Five Star Quality Rating System design was developed by CMS with leading researchers in the long-term care field and contributions by consumers and provider groups.  The rating system features an Overall Quality Rating of one to five stars based on nursing home performance on three domains, each of which has its own ratings. The three domains include:

1) Health Inspection measures derived from outcomes from state health inspections that are based on the number, scope, and severity of deficiencies identified during the three most recent annual inspection surveys, as well as substantiated findings from the most recent 36 months of complaint investigations.

2) Staffing measures that are based on nursing home staffing levels with ratings on the staffing domain including at least two measures: Registered nurse (RN) hours per resident day; and total nurse staffing (the sum of RN, licensed practical nurse (LPN), and nurse aide) hours per resident per day.

3) Quality Measures based on MDS and claims-based quality measures (QMs), reflect performance on 17 of the QMs that are currently posted on the Nursing Home Compare website. These include ten long-stay measures and seven short-stay measures. Quality Domain information for all measures are available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessmentinstruments/nursinghomequalityinits/nhqiqualitymeasures.html.


Therefore, the facilities with the most points in a State become candidates for the SFF program. The number of nursing homes on the candidate list is based on five candidates for each SFF slot, with a minimum candidate pool of five nursing homes and a maximum of 30 per State. State agencies use this list to select nursing homes to fill the SFF slot(s) in their state. Once a State selects a facility as an SFF, the State Survey Agency, conducts a full, onsite inspection of all Medicare health and safety requirements every six months and makes recommendations. These may include fines, denial of Medicare payment, or other measures, until the nursing home either (1) graduates from the SFF program; or (2) is terminated from the Medicare and/or Medicaid program(s). Once an SFF graduates or is terminated, each State then selects a new SFF from a monthly list of candidates. CMS also informs candidate nursing homes of their inclusion on the SFF candidate list in the monthly preview of the Five-Star Quality Rating System.

The Center for Medicare Advocacy looked at information on Nursing Home Compare for each of the 21 SFF graduates on CMS’s May 16, 2019 list. Four facilities had new names on Nursing Home Compare: https://www.medicare.gov/nursinghomecompare/search.html . According to their study, standards for graduation from SFF were vague. CMS describes graduates as SFFs that have “made significant improvements in quality of care – and those improvements are continued over time.”  CMS does not reflect the many recent graduates that continue to have serious deficiencies, multiple complaint surveys, and inadequate nurse staffing. Some facilities even change their name to avoid recognition and avoid scrutiny. This Center’s analysis is consistent with The New York Times report in July 2017, which found that 52% of 528 SFFs that graduated before 2014 were cited with serious harm or jeopardy in the years after they graduated. More than one-third of the facilities received the lowest federal rating for health and safety.( https://www.medicareadvocacy.org/cma-alert-june-20-2019/ )

This information of the SFF Program is necessary for discharge planners seeking nursing home placement and other healthcare providers, as well as consumers in response to advocacy for our aging population. When admission to a nursing home is considered, use the comparison website to determine results of the survey process for quality and performance. Compare website information about the nursing home’s star ratings, staffing, quality measures, and inspection results at: https://www.medicare.gov/nursinghomecompare/search.html .  Even as a healthcare provider making recommendations for placement, visit the nursing home and talk to staff, residents, physicians, and other families, to assist families to make informed decisions. Call the state survey agency (agency contact information is posted on Nursing Home Compare) to find out more about the nursing home.  If the nursing home is an SFF, look at the length of time that the nursing home has been on the SFF list. This has importance if the nursing home has been an SFF nursing home for more than 18 to 24 months, since such nursing homes are closer to either graduating (due to improvements) or ending their participation in Medicare and Medicaid.  CMS reports that most of the nursing homes in the SFF program significantly improve their quality of care within 18-24 months after being selected, while about 10% tend to be terminated from Medicare and Medicaid.  Lists are provided by state at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/sfflist.pdf