For  example, a state should propose a CMP or a DPNA with the minimum  notice period. States Considered Factors Other Than Rank When Selecting SFFs, Which Were More Likely to Be Chain Affiliated and For-Profit Than Other Nursing Homes

When selecting SFFs from the candidate list, state officials considered  factors other than rank, such as their own knowledge of each candidate’s  circumstances. Such discretion is key not only because of states’  familiarity with each candidate’s circumstances but also because the list  has limitations. 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. While the first-ranked candidate (the worst performing  home) was selected about 17 percent of the time from January 2006  through February 2009, about 57 percent of SFFs selected during that  period were among the five worst-ranked candidates. As noted in our August 2009 report, the  candidate list identifies poorly performing nursing homes in each state but  does not necessarily identify the most poorly performing nursing homes in  the nation. Comparing the characteristics of 133 homes in the SFF  Program as of February 2009 to those of other homes, we found that they  differed in terms of type of organization and participation in Medicare and  Medicaid, the number of beds and residents, nurse staffing levels, and  ratings on CMS’s Five-Star System. State and Regional Office Adherence to SFF Program Guidance Was Uneven, but Most SFFs Improved Their Performance While in the Program

We found that some states did not consistently follow CMS’s basic SFF  Program requirements, such as surveying SFFs twice a year. We also  found that CMS’s enforcement guidance is vague and results in  inconsistent interpretations. Most SFFs did eventually graduate, not all  met CMS’s graduation criteria, and some remained in the program well  beyond CMS’s 18-month time frame for improvement. While states improved their compliance with this  requirement in fiscal year 2008—8 states did not conduct two surveys for  SFFs, compared to 26 states in the previous fiscal year—some SFFs were  still not receiving increased scrutiny through additional standard surveys,  a fundamental component of the program. Active SFFs. For example, CMS began identifying SFFs on its Nursing Home  Compare Web site each month. Other Quality Improvement Strategies to Assist SFFs Have Merit, and Some Could Inform CMS Efforts

While the core of the SFF Program is more frequent surveys and stringent  enforcement, CMS and others have adopted a variety of other quality  improvement strategies to help address care problems identified at SFFs  and other nursing homes; both the HHS OIG and state strategies hold  potential lessons that could help inform CMS’s efforts. In general, regional offices have used SIAs as an alternative to terminating  homes that had been in the program for 18 months. For example, QIOs are required  to conduct an on-site assessment of each home to identify the underlyin causes of poor quality of care, prepare a root-cause analysis based on  those findings, and develop an action plan to address the home’s  problems. Some States Have Also Adopted Nursing Home Quality Improvement Strategies That Are Relevant to CMS’s Efforts to Address SFF Quality Problems

Officials from the majority of the 14 states we interviewed detailed  strategies they use to promote quality improvement in nursing homes,  including poorly performing homes. For example,  one SFF received no civil money penalties even though it was cited for  consecutive deficiencies that could have resulted in fines ranging from  $300 to $825 per day of noncompliance, while a home with a similar  compliance history received CMPs that increased from $300 to $600 per  day of noncompliance, suggesting that CMS’s monitoring of enforcement is  insufficient. We selected a nongeneralizable sample of 14 states to  interview based on a combination of factors, including: (1) the number of  SFFs allocated to the state, (2) the inclusion of at least one state from each  CMS region, (3) states that had many homes with high SFF scores, (4) the  number of SFFs that either graduated from the program or were  terminated from Medicare and Medicaid for failing to improve their  performance, (5) the use of Systems Improvement Agreements, and (6) the  existence of state ranking methodologies. To determine the factors that states considered in selecting SFFs from  January 2006 through February 2009, we determined the rank of each  home on the candidate list that was generated before, but closest to, the  date of that home’s selection for the program.
Why GAO Did This Study

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.

What GAO Found

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.