On October 21, the Centers for Medicare & Medicaid Services (CMS) released QSO-23-01-NH, which served to strengthen the Special Focus Facility (SFF) program through several changes. This program focuses on providers that have a record of persistent or recurring poor regulatory performance. As the designation is primarily based on points accrued through survey activity, citations issued due to annual surveys, infection control surveys, complaints, or revisits contribute to the total. The higher the point total, the more risk there is of an SFF designation.

The SFF program is designed to force facilities to make changes that are needed to improve quality of care and, ultimately, survey performance. For some facilities, this is the result of several years of survey cycles made up of long periods of non-compliance, admission bans, civil money penalties, and relatively constant survey involvement. For others, it is the result of episodes of compliance followed by an inability to sustain that compliance, creating a “yo-yo” effect. And for still others, a series of events results in high-level, high-point penalty citations even amidst an otherwise acceptable survey pattern.

Phase 1, Phase 2, Phase 3

There are three basic phases to be aware of. First, every facility should know where they stand in terms of points. You can see this in your star ratings. Remember, the association between survey points and star rating is a strong one; the higher your points, the lower your star rating. So, if you are persistently a one-star facility, take note. It’s time to make the changes necessary to avoid slipping any further and finding yourself in the second phase: the candidate list.

If you make the candidate list, you technically have qualified for the SFF program designation. When the State Survey Agency (SSA) receives the list of potential candidates from CMS each month, discretion kicks in:

  • It looks at the number of complaints that are coming in, whether from families, residents, staff, or the public. It looks at facility reported incidents (FRIs). Are there several? Are they increasing in frequency? Is there a pattern of incidents in common with the reports?
  • It looks at your Payroll Based Journal (PBJ) numbers. Are you short on weekends and evenings? Can it draw a nexus between your FRIs, complaints, and low levels of staffing?
  • What is the ombudsman seeing, hearing, and saying? Don’t ignore this point of contact. The ombudsman has a vote.
  • What is the relationship like with the SSA and the surveyors? Is it intentional and friendly, or do surveyors feel like the chaos and temperature rise when they walk in the door?
  • Is the facility part of a chain that is consistent in its poor compliance? Does it seem that repairs take too long or staffing just runs lower than average in all the facilities? Does it seem like the company may not be as invested in caring for its residents as it needs to be?
  • What is the pattern of turnover of leadership? Have there been multiple administrators or directors of nursing (DONs)? How often are those changes occurring?

All these considerations and more are on the table as the decisions are being made as to who is next for Phase 3: SFF designation.

What Are the Changes to the SFF Program?

Let’s take a look at the changes in the SFF program and how they might impact your operations.

  1. CMS has advised that SSAs consider staffing patterns, levels, and turnover as they select their SFF candidates and designated SFFs.As we covered above, poor staffing levels, gaps or inconsistent coverage, consistent lack of RN hours, and high turnover levels (especially of administrators and DONs) may reflect a climate of instability. The risk of the problems that resulted in candidacy continuing is higher in an unstable facility. CMS has conducted enough research to determine that low or inconsistent staffing is reflected in poor resident outcomes and contributes to this instability.
  2. Designated SFFs have an informational and programmatic conference with their SSA and CMS upon designation as an SFF. This is followed within two weeks by a comprehensive baseline survey to identify areas the facility will need to focus on to sufficiently improve prior to being permitted to exit or “graduate” from the SFF program.Under new rules, the facility cannot receive more than 12 citations, with scope and severity no higher than an F level, on this and any subsequent surveys while in the program without risk of an escalation in enforcement measures. Next, subsequent surveys should demonstrate that progress is being made. Fewer citations, no repeat citations, lower scope and severity—all are critical measures of that progress. And finally, while they will be scheduled for a full standard health survey at least once every six months, the SFF can have no intervening complaint, emergency preparedness, infection control, or life safety surveys that result in 13 or more citations or any citation higher than an F level in scope and severity.
  3. CMS has the discretion to impose immediate sanctions on an SFF that receives a high-level citation, especially one that represents Substandard Quality of Care (SQC), or that fails to produce measurable progress from survey to survey.Repeat citations that demonstrate a failure to follow the facility’s own plan of correction (POC) can be an important sign that the facility is not progressing toward sustained compliance. A failure to have corrected deficiencies cited with an accepted POC at the time of a first revisit is another important indicator that the facility is not improving. These indicators may result in escalation of enforcement action.
  4. If the SFF is cited at Immediate Jeopardy (IJ) on any two surveys during its time as an SFF, sanctions may include consideration of immediate and discretionary termination.In the event of such a determination, CMS and the SSA will notify the SFF that they should anticipate a “last chance survey.” Failure to pass that survey with clear demonstration of improvement may result in involuntary termination. It should be noted that if, for any reason, CMS and/or the SSA determine that the facility is not progressing, improving, or otherwise moving through a successful transition to sustained compliance and graduation from the program, the facility will be notified to anticipate a last chance survey. The results of that last chance survey will determine, at least in part, if the facility continues in the SFF program or if it faces termination of participation in the Medicare/Medicaid system.In order to graduate, an SFF must complete two standard health surveys consecutively, no less than six months apart, that demonstrate measurable progress and are within compliance standards as indicated above. Once this standard is met, the state can make a recommendation and CMS has the right to accept or deny that a facility be permitted to “graduate” from the SFF program, leaving a slot open for another candidate.
  5. An SFF graduate will continue to be monitored for a three-year period.During this time, repeat citations, high-level citations, large numbers of citations, multiple complaint surveys resulting in citations, rapid turnover of leadership, and FRIs—all these signs of returning instability or failure to sustain the improved compliance that was necessary to graduate—may result in discretionary termination.Candidates that are not designated as an SFF and providers that have accrued a high number of survey points are at highest risk of becoming a designated SFF. Having terminated participation, replaced administrators and DONs with temporary managers, closed facilities, and relocated residents, this writer can say firsthand that it is a painful process. It is a process that can be avoided by taking assertive action. By putting systems in place that promote and sustain permanent improvement, termination should be avoidable.

    Never question this premise: CMS equates poor survey performance with poor quality of care. If a facility is performing poorly, either consistently or with repeating patterns, that provider is viewed as delivering poor quality of care to residents.

How Can HDG Help?

Health Dimensions Group (HDG) has many years of experience helping facilities recognize gaps in systems and processes that are resulting in poor care and subpar survey performance. Let us complete a full survey of your facility and deliver efficient solutions that lead to sustainable improvements. We become part of your team to drive quality initiatives, recognize and reward excellence, and set your facility on a positive course into the future. If you would like to learn more about how HDG can help you navigate the SFF program changes, please contact us at 763.537.5700 or info@hdgi1.com.