Nursing Homes:

CMS's Special Focus Facility Methodology Should Better Target the Most Poorly Performing Homes, Which Tended to Be Chain Affiliated and For-Profit

GAO-09-689: Published: Aug 28, 2009. Publicly Released: Sep 28, 2009.

Additional Materials:

Contact:

John E. Dicken
(202) 512-7043
contact@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

In 1998, CMS established the Special Focus Facility (SFF) Program as one way to address poor performance by nursing homes. The SFF methodology assigns points to deficiencies cited on standard surveys and complaint investigations, and to revisits conducted to ensure that deficiencies have been corrected. CMS uses its methodology periodically to identify candidates for the program--nursing homes with the 15 worst scores in each state--but the program is limited to 136 homes at any point in time because of resource constraints. In 2008, CMS introduced a Five-Star Quality Rating System that draws on the SFF methodology to rank homes from one to five stars. GAO assessed CMS's SFF methodology, applied it on a nationwide basis using statistical scoring thresholds, and adopted several refinements to the methodology. Using this approach, GAO determined (1) the number of most poorly performing homes nationwide, (2) how their performance compared to that of homes identified using the SFF methodology, and (3) the characteristics of such homes.

According to GAO's estimate, almost 4 percent (580) of the roughly 16,000 nursing homes in the United States could be considered the most poorly performing. These 580 homes overlap somewhat with the 755 SFF Program candidates--the 15 worst homes in each state--and the 136 homes actually selected by states as SFFs. For example, GAO's estimate includes 40 percent of SFF Program candidates and about half of the active SFFs as of December 2008 and February 2009, respectively. Under GAO's estimate, however, the most poorly performing homes are distributed unevenly across states, with 8 states having no such homes and 10 others having from 21 to 52 such homes. CMS has structured the SFF Program so that every state (except Alaska) has at least one SFF even though the worst performing homes in each state are not necessarily the worst performing homes in the nation. To identify the worst homes in the nation, GAO applied CMS's SFF methodology on a nationwide basis using statistical scoring thresholds and made three refinements to that methodology, which strengthened GAO's estimate. The scoring thresholds were (1) necessary because there were no natural break points that delineated the most poorly performing homes from all other nursing homes and (2) conservative, focusing on chronic poor performance generally over a 2- or 3-year period or very poor performance over about 1 year. The most poorly performing homes identified by GAO averaged over 46 percent more serious deficiencies that caused harm to residents and over 19 percent more deficiencies that placed residents at risk of death or serious injury (immediate jeopardy), compared to the 755 SFF Program candidates identified by CMS's approach. GAO's three refinements to CMS's SFF methodology had a moderate effect on the composition of the list of homes that GAO identified as the most poorly performing. First, deficiency points from CMS's Five-Star Quality Rating System were used because they decreased the disparity between immediate jeopardy and lower-level deficiencies, such as those with the potential for more than minimal harm, which compensates somewhat for the understatement of serious deficiencies in some states. Second, homes received extra points when certain actual harm deficiencies occurred in standards areas that CMS categorizes as substandard quality of care, an important change because we found that many homes had at least one such deficiency. Third, the full deficiency history of homes was included. CMS recognizes that its methodology overlooks deficiencies for some homes, which almost always results in scores that are lower than if all deficiencies were included in the scores. GAO found that the most poorly performing nursing homes had notably more deficiencies with the potential for more than minimal harm or higher and more revisits than all other nursing homes. For example, the most poorly performing nursing homes averaged about 56 such deficiencies and 2 revisits, compared to about 20 such deficiencies and less than 1 revisit for all other homes. In addition, the most poorly performing homes tended to be chain affiliated and for-profit and have more beds and residents.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To improve the SFF methodology's ability to identify the most poorly performing nursing homes, the Administrator of CMS should consider using a common set of numeric points for identifying poorly performing nursing homes by determining the effect of adopting those associated with the Five-Star System for the SFF methodology.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Implemented

    Comments: The Centers for Medicare & Medicaid Services (CMS) established the Special Focus Facility (SFF) Program in 1998 to help address poor nursing home performance. The SFF methodology assigns points to deficiencies cited on standard surveys and complaint investigations, and to revisits conducted to ensure that deficiencies have been corrected. CMS uses its methodology periodically to identify candidates for the SFF Program. When compared to the points assigned to deficiencies in the SFF Program, we found that deficiency points that CMS developed for its Five-Star System compensate somewhat for understatement and the interstate variation in the citation of serious deficiencies. To improve the SFF methodology's ability to identify the most poorly performing nursing homes, we recommended that CMS consider using a common set of numeric points for identifying poorly performing nursing homes by determining the effect of adopting those associated with the Five-Star System for the SFF methodology. In response to our recommendation, CMS modified the SFF methodology by using the points assigned to deficiencies in the Five-Star System and began using the revised SFF methodology in April 2010.

    Recommendation: To improve the SFF methodology's ability to identify the most poorly performing nursing homes, the Administrator of CMS should account for a nursing home's full compliance history regardless of technical status changes.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Not Implemented

    Comments: In written responses to GAO regarding open recommendations received on July 8, 2010, CMS noted that the agency will not implement our recommendation because the frequency of technical status changes is sufficiently low not to warrant making the changes that would need to be made to the database.

    Recommendation: To improve the SFF methodology's ability to identify the most poorly performing nursing homes, the Administrator of CMS should assign points to G-level deficiencies in substandard quality of care (SQC) areas equivalent to those additional points assigned to H- and I-level deficiencies in SQC areas.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Not Implemented

    Comments: In written responses to GAO regarding open recommendations received on July 8, 2010, CMS noted that the agency will not implement our recommendation.

    Recommendation: To improve the targeting of scarce survey resources, the Administrator of CMS should consider an alternative approach for allocating the 136 SFFs across states, by placing more emphasis on the relative performance of homes nationally rather than on a state-by-state basis, which could result in some states having only one or not any SFFs and other states having more than they are currently allocated.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Open

    Comments: In written responses to GAO regarding open recommendations received in July 2013, CMS noted that due to budget constraints, states will not select new nursing homes for the SFF program when there is a vacancy (due to termination or because the home improves such that it can graduate from the SFF program). Thus, CMS has suspended its efforts to refine the SFF selection methodology. (During recommendation follow-up activities last year, CMS stated that it continues to work with a contractor to evaluate the SFF methodology.) Although CMS requested that we close this recommendation, we are keeping it open in the event that CMS's future budget situation improves and the agency is able to request again that states select new nursing homes for the SFF program. In this event, we would request that they give consideration to revising their methodology, as we had recommended.

    Recommendation: To ensure consistency with the SFF methodology, CMS should consider making two of these modifications--the SQC and full compliance history changes--to its Five Star System.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Not Implemented

    Comments: In written responses to GAO regarding open recommendations received on July 8, 2010, CMS noted that the agency will not implement our recommendation that it make modifications to the Five Star System.

    Apr 8, 2014

    Apr 2, 2014

    Mar 26, 2014

    Mar 24, 2014

    Mar 10, 2014

    Mar 7, 2014

    Mar 6, 2014

    Mar 4, 2014

    Looking for more? Browse all our products here