The SFF candidates are those nursing homes with the 15  highest total scores in each state. The SFF methodology assigns points to deficiencies on standard surveys  and complaint investigations, and to revisits associated with deficiencies  cited on standard surveys, as follows:    Deficiencies. Revisits. These 580 homes overlap somewhat with the 755 SFF Program candidates  and the 136 nursing homes actually selected as SFFs. 2) and (2) 65 nursing homes that 31 states selected as SFFs from  among the SFF Program candidates, or about half of the active SFFs as of  February 2009. In addition, our estimate resulted in some states having  fewer or more poorly performing homes than CMS currently allocates to  states under the SFF Program. Eight states had no such nursing homes. CMS’s Application of the SFF Methodology Misses Many of the Nation’s Most Poorly Performing Nursing Homes

CMS has structured the SFF Program so that every state (except Alaska)  has at least one SFF, and therefore the agency applies the SFF  methodology to identify the 15 worst performing nursing homes in each  state, which are not necessarily the worst performing homes in the  nation. We developed an estimate that identified homes with worse  compliance histories—more deficiencies at the potential for more than  minimal harm level or higher and more revisits—than SFF Program  candidates by applying CMS’s SFF methodology on a nationwide basis and  using statistical scoring thresholds. For example, the most poorly performing nursing  homes averaged 46.5 percent more actual harm–level deficiencies and   19.5 percent more immediate jeopardy–level deficiencies, compared to the  755 SFF Program candidates. Absent a fixed number of homes per  state, we developed statistical scoring thresholds because there was no  natural break point delineating the most poorly performing nursing homes  from all other homes. The two statistical scoring thresholds we used  were conservative, because they focused on chronic poor performance  and nonchronic, very poor performance. Our three refinements  to CMS’s SFF methodology had a moderate effect on the composition of  the list of homes we identified as the most poorly performing. Deficiency points. For  example, in 2008, about 11.3 percent of deficiencies were at the immediate  jeopardy level in one state, but less than 1.0 percent of deficiencies were  cited at that level in 26 states. Key Characteristics, such as Chain Affiliation and For- Profit Status Differentiated the Most Poorly Performing Nursing Homes

Compared to all other nursing homes, the most poorly performing nursing  homes in the nation averaged notably more deficiencies at the D level or  higher, more serious deficiencies, and more revisits. For example, in fiscal  year 2008, about 33 percent of the most poorly performing homes may  have been at risk of having at least one immediate sanction imposed,  compared to about 4 percent for all other nursing homes. Beds and residents. We found that a larger percentage of the most  poorly performing homes had more than 100 beds, compared to all other  nursing homes. Furthermore, we believe that CMS’s SFF Program and the Five-Star  System could be strengthened by incorporating the three enhancements  we made to identify the most poorly performing homes nationwide:    First, we adopted the deficiency points that CMS developed for its Five- Star System because they compensate somewhat for understatement and  the interstate variation in the citation of serious deficiencies, an important  consideration for our nationwide estimate of the most poorly performing  nursing homes. 2. 3. Determining the Number and Comparing the Performance of the Most Poorly Performing Nursing Homes

To determine the number of most poorly performing nursing homes in the  nation and compare their performance to that of homes identified using  the Centers for Medicare & Medicaid Services’ (CMS) approach, we began  by interviewing agency officials about the Special Focus Facility (SFF)  Program and methodology and by reviewing documentation related to the  methodology. To ensure that we calculated the  scores for each nursing home consistent with CMS’s SFF methodology, we  obtained a copy of the computer programming that CMS used to score and  rank nursing homes, verified that our use of CMS’s program generated  results that were consistent with output on scores that CMS provided to  states, and used the program as the basis for our estimate of the most  poorly performing nursing homes in the United States. Additional points are assigned to deficiencies classified as substandard  quality of care (SQC).
Why GAO Did This Study

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.

What GAO Found

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.