Poorly Performing Nursing Homes:

Special Focus Facilities Are Often Improving, but CMS's Program Could Be Strengthened

GAO-10-197: Published: Mar 19, 2010. Publicly Released: Apr 19, 2010.

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CMS established the Special Focus Facility (SFF) Program in 1998 to help address poor nursing home performance. States select a subset of homes as SFFs from a list of the 15 poorest performing homes in each state, but the program is limited to 136 homes nationwide because of resource constraints. CMS guidance directs states to survey SFFs twice as frequently as other homes and to propose more robust enforcement, including termination, for SFFs that fail to improve within about 18 months. GAO was asked to (1) determine the factors states consider in selecting SFFs and how SFFs differed from other nursing homes, (2) evaluate CMS regional office and state adherence to program guidance and the program's impact on homes' performance, and (3) identify other strategies that have been used to improve poorly performing homes. In general, GAO's analysis used CMS data from 2005 through 2009 on SFFs and other homes as well as interviews with officials in 14 states selected based on the number of SFFs in each state and other factors.

When selecting SFFs from the candidate list, state officials considered factors other than rank on that list, such as their own knowledge of each candidate's circumstances. For example, state officials might not select a nursing home as an SFF if the home had a new owner they perceived as committed to addressing the home's quality problems. GAO found that states selected SFFs from among the five worst-ranked candidates about 57 percent of the time from January 2006 through February 2009. State discretion in selecting SFFs is key not only because of states' familiarity with each candidate's circumstances but because the list has limitations. Some officials from the 14 states that GAO interviewed noted that candidate lists included current SFFs, resulting in an insufficient number of homes from which to select new SFFs. The characteristics of SFFs differed from those of other nursing homes in terms of organization type and the number of beds and residents. For example, SFFs were more likely than other homes to be chain affiliated and for-profit and to have more beds and more total residents. GAO found that some states did not consistently follow CMS's basic SFF Program requirements. When CMS began monitoring SFF survey frequency in fiscal year 2008, 8 states did not conduct twice as many surveys for SFFs as required--a significant improvement compared to 26 states in the previous fiscal year. GAO also found that CMS's enforcement guidance is vague and results in inconsistent interpretations. For example, one SFF was assessed no civil money penalties (CMP) even though it was cited for consecutive deficiencies that could have resulted in fines of up to $825 per day of noncompliance while a home with a similar compliance history was assessed CMPs that increased from $300 to $600 per day of noncompliance. Most SFFs did eventually graduate, but not all met CMS's graduation criteria, and some SFFs remained in the program well beyond CMS's expected 18-month time frame for improvement. For example, 17 percent of active SFFs as of February 2009 had been in the program for 25 months or longer--some since 2005. However, most graduates showed significant improvement while in the program but some failed to sustain that improved performance after graduation. CMS and states have used a variety of additional strategies to help address care problems identified at SFFs and other nursing homes. For example, a few CMS regional offices have negotiated agreements requiring SFFs to take specific actions, such as hiring quality improvement consultants. In addition, each year one SFF per state can volunteer to work with an organization under contract with CMS to deal more directly with the root causes of poor quality. Some states have adopted their own quality improvement strategies that offer assistance to both poorly performing and other homes, including on-site technical assistance from nurse consultants or monthly training opportunities for nursing home staff on the most frequently cited care problems. Further, one state charges homes for the cost of additional surveys that it conducts under a program that resembles the SFF Program.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In response to our recommendation, CMS is notifying nursing homes if they are among the 15 Special Focus Facility (SFF) candidates in each state through communication about the Five-Star Nursing Home Quality Rating system. Specifically, CMS explained in its April 16, 2010 survey and certification letter that the following message will be provided to SFF candidates: "IMPORTANT MESSAGE: Your health inspection score currently makes you a candidate for the Special Focus Facility Program. Please note that this does not necessarily mean that your nursing home will be selected for the Special Focus Facility program. For more information about the program, please go to: http://www.cms.hhs.gov/CertificationandComplianc/12_NHs/asp."

    Recommendation: To increase the SFF Program's effectiveness in helping to address quality of care problems at poorly performing nursing homes, the Administrator of CMS should expand the SFF Program's public disclosure strategy by directing states to notify nursing homes that have been identified as SFF Program candidates that they are at risk of being selected as an SFF.

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

  2. Status: Closed - Implemented

    Comments: CMS established the Special Focus Facility (SFF) Program in 1998 to help address poor nursing home performance. We reported that state discretion in selecting SFFs from the candidate list is a key element of the program, especially due to limitations in the candidate list. For instance, some states told us that the SFF candidate list did not provide states with a sufficient number of nursing homes from which to select new SFFs. Specifically, we noted that the list included current SFFs if they were still ranked among the worst 15 homes in the state, which narrowed the state's selection possibilities. Officials from Indiana, Illinois, and California, which were allocated 4, 5, and 6 SFFs, respectively, explained that having existing SFFs on their list left them with fewer than 15 nursing homes to consider for the program. We recommended that CMS revise the SFF candidate list by removing homes that states have selected as SFFs and include additional homes so that states with a large number of SFFs have a full complement of candidates to choose from each time they select a new SFF. In response to our recommendation, CMS revised the size of its SFF candidate list to provide additional options to states with a large number of SFFs. Specifically, CMS explained in its September 17, 2010 survey and certification letter that 5 SFF candidates will be provided on the candidate list for each SFF slot the state is allocated. In addition, CMS noted that if the candidate list includes nursing homes already enrolled in the SFF Program, then the candidate list may be augmented by the state to include the full complement of candidates from which a replacement can be chosen. In conjunction with this revision to the candidate list, CMS also adjusted the number of SFF slots to reflect the current population of nursing homes in each state and increased the number of SFF slots nationally by 10 percent. These changes took effect on effective October 1, 2010.

    Recommendation: To increase the SFF Program's effectiveness in helping to address quality of care problems at poorly performing nursing homes, the Administrator of CMS should revise the SFF candidate list by removing homes that states have selected as SFFs and including additional homes so that states with a large number of SFFs have a full complement of candidates to choose from each time they select a new SFF.

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

  3. Status: Closed - Implemented

    Comments: CMS established the Special Focus Facility (SFF) Program in 1998 to help address poor nursing home performance. We reported that CMS's SFF enforcement guidance, under which states and regions must impose more robust enforcement on SFFs that do not demonstrate significant improvement, is vague and results in inconsistent interpretations. For example, we found that one SFF was assessed no civil money penalties (CMP) even though it was cited for consecutive deficiencies that could have resulted in fines of up to $825 per day of noncompliance while a home with a similar compliance history was assessed CMPs that increased from $300 to $600 per day of noncompliance. In our interviews with CMS's central office, an official stated that CMS's SFF enforcement guidance could be more specific and noted that CMS plans to release descriptive guidance explaining exactly how states and regions should apply more robust enforcement. We recommended that CMS ensure that states impose more stringent enforcement, such as higher CMPs or termination, clarify SFF Program guidance regarding appropriate sanctions, and monitor SFF sanctions more closely. In response to our recommendation, CMS issued guidance to states and regions which explains the agency's expectations for progressive enforcement actions and improved monitoring of SFFs. Specifically, CMS explained in its September 17, 2010 survey and certification letter that states and regions must impose an immediate remedy on each SFF that fails to achieve and maintain significant improvements in correcting deficiencies on the first and subsequent standard survey after the nursing home becomes an SFF. The letter provided a detailed table describing which enforcement actions states and regions should use for the types of deficiencies that are found on different surveys. In addition, CMS told GAO that the agency now holds quarterly conference calls with regions and states to monitor the enforcement actions imposed on SFFs.

    Recommendation: To increase the SFF Program's effectiveness in helping to address quality of care problems at poorly performing nursing homes, the Administrator of CMS should ensure that states impose more stringent enforcement, such as higher CMPs or termination; clarify SFF Program guidance regarding appropriate sanctions; and monitor SFF sanctions more closely.

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

  4. 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. Our evaluation of the SFF Program noted that Systems Improvement Agreements (SIA)--agreements between CMS and SFFs that identify concrete actions that the homes are required to take in order to avoid termination from Medicare--have the potential to help SFFs improve the quality of care provided to residents. However, at the time of our report in 2010, we found that the use of SIAs had been limited, with CMS regional offices only negotiating a total of 10 SIAs. Our review of the SIAs found that they share some common requirements, but may differ to reflect each SFF?s particular circumstances. In addition, we found that most SIAs were initiated by regional offices with limited CMS central office involvement and that CMS?s central office had not disseminated information to the regional offices on what should be included in SIAs. We recommended that CMS provide the regional offices with a description of the elements that should be part of SIAs and catalogue any lessons learned from their use. CMS has informed us that they have taken actions to address our recommendation. Specifically, in 2013, they drafted new guidance on SIAs, which includes a Standard Operating Procedure and draft SIA templates, which is currently pending final approval. The draft materials are currently available for CMS regional offices to use in developing new SIAs. In addition, CMS guidance requires the CMS central office to have teleconferences on lessons learned from SIAs with both its regional office staff and the provider within 30 days of closing the SIA.

    Recommendation: To increase the SFF Program's effectiveness in helping to address quality of care problems at poorly performing nursing homes, the Administrator of CMS should provide CMS regional offices with a description of the elements that should be part of SIAs and catalogue any lessons learned from their use.

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

  5. Status: Closed - Implemented

    Comments: The Centers for Medicare & Medicaid Services (CMS) established the Special Focus Facility (SF) Program in 1998 to help address poor nursing home performance. Our evaluation of the SF Program noted that the Department of Health and Human Services Office of the Inspector General (HHS ORIG) has considerable experience negotiating legal agreements with corporations that own poorly performing nursing homes to address quality problems across the chain's homes. Under these agreements, known as quality of care Corporate Integrity Agreements (CIA), HHS ORIG requires the corporations that are subject to them to hire an independent entity to assess the quality assurance and quality improvement systems in place in their nursing homes. We concluded that the HHS OIG's experience with quality of care CIAs may contain lessons that could improve the effectiveness of CMS's efforts to deal with poorly performing nursing homes. However, we found that there is little coordination between CMS and the HHS, even though we found that some regional offices also work with chain corporate offices and three of the corporations under a CIA had homes that were also in the SF Program. We recommended that CMS coordinate more systematically with the HHS ORIG regarding its experiences with CIAs. CMS has taken steps which address our recommendation. Specifically, according to CMS officials, the agency began holding regular and ad hoc meetings in September 2011 with HHS ORIG officials to review current activities related to the SF Program. Although, according to CMS, the HHS ORIG told CMS at a meeting in September 2011 that it does not plan to continue issuing CIAs for nursing homes, ORIG will continue to work with CMS when CMS officials have concerns about poorly performing nursing homes, particularly nursing home chains.

    Recommendation: To increase the SFF Program's effectiveness in helping to address quality of care problems at poorly performing nursing homes, the Administrator of CMS should coordinate more systematically with the HHS OIG regarding its experiences with CIAs.

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

  6. Status: Closed - Not Implemented

    Comments: In written responses to GAO regarding open recommendations received on July 8, 2010, CMS indicated that it would not seek legislative authority to charge Special Focus Facilities (SFFs) for the costs associated with conducting additional surveys.

    Recommendation: To offset the additional costs imposed by SFFs and create incentives for poorly performing nursing homes to improve resident care more quickly, the Administrator of CMS should seek legislative authority to charge SFFs for the costs associated with conducting additional surveys.

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

 

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