BriggsNetNews

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

Today, October 21, 2022, CMS posted QSO-23-01-NH with the same title as this blog.

Background:

Sections 1819(f)(8) and 1919(f)(10) of the Social Security Act require CMS to conduct a Special Focus Facility (SFF) program which focuses on nursing homes that have a persistent record of noncompliance leading to poor quality of care. CMS’ SFF program requires the persistently poorest performing facilities selected in each state to be inspected no less than once every six months and that increasingly severe (progressive) enforcement actions are taken when warranted. CMS expects that selected facilities will rapidly make and sustain improvements so that they graduate from the program.

While the SFF program has helped facilities improve their compliance and quality, there are some facilities that have not seen the same results. Some facilities fail to demonstrate the improvements needed to graduate from the program and can therefore remain in the program for a prolonged period of time. Additionally, there are some that graduate from the program only to see their compliance and quality regress later (commonly known as “yo-yo” noncompliance). Both of these scenarios place nursing home residents’ health and safety at risk. Therefore, CMS is revising the SFF program to protect and improve the quality of care that residents living in these facilities receive. This action is being taken as part of the Administration’s priority to improving the safety and quality of care in nursing homes, as outlined in a White House Fact Sheet. These changes aim to address facilities remaining in the SFF program for too long and facilities with “yo-yo” noncompliance after graduating. Additionally, because of the importance of nursing home staffing, CMS is informing State Survey Agencies (SAs) to consider a facility’s staffing levels data when selecting SFFs from the SFF candidate list.

[Above italics added by me.]

The 11-page Memorandum covers these steps:

• SECTION I: SFF CANDIDATE LIST
• SECTION II: INITIAL SELECTION OF SFF
• SECTION III: PROGRESSIVE ENFORCEMENT
• SECTION IV: GRADUATION FROM THE SFF PROGRAM
• SECTION V: TERMINATION
• SECTION VI: FACTORS CONSIDERED FOR GRADUATION OR TERMINATION
• SECTION VII: POST-GRADUATION
• SECTION VIII: OPERATIONAL PROCEDURES

CMS is also revising the monthly SFF postings at https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/Downloads/SFFList.pdf. These listings are being updated to reflect a listing of all SFFs, including the number of months spent in the SFF program, their most recent standard health survey findings, recent terminations, and facilities that recently graduated from the SFF program. Facilities that have graduated from the SFF program are included in the downloadable file on the cms.gov website for a period

of three years. A facility’s SFF designation on the Medicare.gov Care Compare website will be removed in the month following the facility’s graduation from the SFF program.