In its latest move to increase scrutiny of the skilled nursing industry, the Biden administration is toughening requirements for nursing homes that fall into its Special Focus Facilities (SFF) program.
Specifically, the Centers for Medicare & Medicaid Services (CMS) is making completion requirements more challenging and increasing enforcement actions if SNFs fail to show improvement, according to a statement issued by the federal agency on Friday.
The decision is in line with the administration’s focus on improving quality and cracking down on bad actors in the sector. Initial reform endeavors were outlined by President Biden in February and followed up with updates to requirements of participation (ROP) and the five-star rating system.
By imposing harsher penalties, CMS hopes operators will work harder to get facilities out of the program at a faster rate. This, in turn, would allow the federal entity to enroll more facilities in the program and “promote sustainability of facilities’ improvements.”
CMS also doesn’t want facilities to regress post-program.
Federal officials feel this action “fulfills a promise” from President Biden’s State of the Union plan to overhaul the SFF program by improving care for affected residents “more quickly” while holding facilities accountable for improper and unsafe care.
“Let us be clear: we are cracking down on enforcement of our nation’s poorest-performing nursing homes,” said Department of Health and Human Services (HHS) Secretary Xavier Becerra. “As President Biden directed, we are increasing scrutiny and taking aggressive action to ensure everyone living in nursing homes gets the high-quality care they deserve. We are demanding better, because our seniors deserve better.”
CMS Administrator Chiquita Brooks-LaSure echoed Beccerra’s thoughts on access to safe and quality care for nursing home residents in the country, and that facilities unable to provide that level of care need to “improve or face the consequences.”
Steve LaForte, director of corporate affairs and general counsel for Cascadia Healthcare, said the updates will make operators think “more than twice” before signing on to purchase a building that is already in the SFF program, or one that could be in the program once a deal goes through.
“How do you incentivize other operators, new operators to take over those operations and maintain the care and the access for the community, especially in rural areas,” LaForte told Skilled Nursing News. “You slog through it and you end up getting beat up. We’re proud of what we’ve done and we’re committed to these communities. We saved the only [ventilator] unit in a 300 mile radius in Nampa, Idaho.”
Eagle, Idaho-based Cascadia has taken on three SFF properties in the past and “graduated” them from the program. Five years after acquiring the Nampa facility, Cascadia received an award from the American Health Care Association (AHCA) recognizing its turnaround efforts.
“Everything about what came out today is punitive in nature. It doesn’t recognize the need for access, and it doesn’t do anything to incentivize good operators to save buildings,” said LaForte, while adding that Cascadia would never argue against enforcement of bad actors in the space.
Ongoing rhetoric will be harmful
While appreciative of the administration’s steps to address underperforming facilities, industry trade groups like AHCA remain concerned that ongoing rhetoric surrounding reforms is “degrading” to caregivers.
“Residents are not victims of the nursing home industry. Too many were victims of a vicious virus that targets the elderly as well as terrible public policy decisions — made by both parties — that failed to support and prioritize our most vulnerable,” said AHCA/NCAL President and CEO Mark Parkinson. “We hope to work with the administration to fully appreciate the role of nursing homes in our nation’s health care system, the dedication that our caregivers have to their residents, and the need for policy that pushes improvement, not punishment.”
LeadingAge President and CEO Katie Smith Sloan said in a statement that the organization reiterates its longstanding support of CMS’ initiatives to improve care in underperforming facilities, and that those who don’t show progress should close.
CMS should at the same time continue focusing on improving workforce numbers, as staffing goes hand in hand with quality care, she said.
“It is time to take an all of government approach to finding solutions that will address the chronic staffing challenges nursing homes and other providers of care to older adults and families continue to navigate,” said Smith Sloan. “Identifying, funding and implementing programs that bring more qualified staff to nursing homes, provide training and career ladders and lattices, are critical to ensuring that older adults and their families can access quality care.”
Breaking down the changes
Criteria for successful completion of the SFF program will now have a threshold that prevents a facility from exiting based on total number of deficiencies, according to CMS. There will be no more “graduating” from the program’s enhanced scrutiny without showing that a facility has made systemic improvements in quality.
The program’s monitoring period is being extended, what CMS calls “incentivizing sustainable improvements.” Surveyors maintain a readiness to impose increasingly harsh enforcement actions if a facility’s performance declines after graduation.
Also up for consideration – program facilities with immediate jeopardy (IJ) deficiencies on any two surveys risk federal Medicare and Medicaid funding termination.
SFF program facilities face more severe, escalating enforcement if they show continued noncompliance with “little or no” effort toward improving performance, CMS officials said.
The agency is also calling on states to consider staffing levels when admitting facilities to the SFF program.
AHCA called out CMS for its increase in citations and penalties in its statement. Parkinson argued that such punishment neither helped these facilities turn their situation around, nor prevented other facilities from becoming chronic poor performers.
Instead, the association urges CMS to adopt a five-step process on how to address chronic, poor-performing nursing homes in its surveys.
Coupled with increased scrutiny, CMS said, is a reinforced emphasis on what operators can do to make “good-faith efforts.” Engaging in CMS Quality Improvement Organizations and hiring external consultants were named as viable options, along with measurable changes like staffing levels and leadership updates.
About 88 nursing homes participate in the SFF program, amounting to roughly 0.5% of all nursing homes in the country. These facilities are inspected twice as often as other nursing homes.
That translates to no less than one inspection every six months, according to the agency, accompanied by increasingly severe enforcement actions if there is no improvement. In order to graduate from the program, facilities must pass two consecutive inspections.
Harvard University professor David Grabowski said the SFF updates were “necessary but not sufficient,” in terms of the overhaul needed to reform the nursing home sector. While the program has needed to be strengthened for some time, it makes up less than 1% of nursing homes in the country, he said.
“There’s this other group of 400-plus facilities that were candidates for the program,” noted Grabowski. “We know there’s more than 88 some facilities that need this attention. I guess you could say, well, these are the facilities that needed the most help, but I don’t know that this is going to dramatically fix nursing homes in this country.”
Programs that target the middle of the distribution in terms of quality metrics would be a valuable expansion by CMS, he said, ensuring that middle-of-the-pack facilities are providing person-centered care.
“Just because you’re out of this SFF program doesn’t mean you’re a strong performer. It just means you’re typically at the kind of boundary between being in and out of the program,” Grabowski said.
It will be interesting to track what happens once a facility enters the program, he noted, if they’ll linger in that low-quality area of quality distribution or ever truly graduate to a four- or five-star facility.
“I’m skeptical that happens very often,” he said.
Companies featured in this article:
AHCA/NCAL, Cascadia Healthcare, Centers for Medicare & Medicaid Services, Harvard University, LeadingAge
