Help, my nursing home may end up in the SFF Program!

Help, my nursing home may end up in the SFF Program!

Many nursing homes don’t know much about the Special Focus Facility (SFF) Program, other than it’s a bad sign and a letter you don’t want to receive from the Centers for Medicare & Medicaid Services (CMS) shows up. CMS has indicated that it has strengthened this program, so here at CMS Compliance Group, we wanted to make sure providers understand what happens throughout the lifecycle of being included as a potential candidate to the SFF Program and then through the facility’s either graduation or termination, depending on the outcome. Let’s look at what happens once a facility has been initially selected as a SFF.


When a facility is selected for the SFF Program, it is the State Agency’s (SA) responsibility to notify the facility and “all accountable parties” by a letter that states:

  • Selection: The facility has been selected as a Special Focus Facility due to its “persistent pattern of poor quality on its last three standard surveys and complaint surveys”
  • Graduation: In order to graduate from the SFF program, the selected facility must have:
    • Completed two standard surveys with no deficiencies cited at a Scope/Severity of F or greater and
      • S/S not of “G” or greater for LSC deficiencies
    • Have no complaint surveys with deficiencies cited at a S/S of “F” or higher (“G” for LSC) in between those two standard surveys
    • The exception to this is if the only S/S “F” deficiency is related to food safety, the RO may allow the facility to graduate
  • Imposition of Remedies: If the facility fails to achieve and maintain significant improvement in correcting deficiencies on the first and each subsequent survey after it is designated as a SFF, CMS or the SA will impose an immediate remedy/remedies on the facility.
    • What is “significant improvement?” Per CMS, this is when the SFF demonstrates that its practices have resulted in no deficiencies with a S/S of “E” or higher (“F” or higher for LSC citations)
  • Enforcement Remedies: SFFs that do not show significant improvement with each standard survey and intervening complaint survey will see enforcement remedies of increasing severity. Remedies include:
    • Civil Monetary Penalties (CMP)
    • Discretionary Denial of Payment for New Admissions (DPNA)
    • Directed Plan of Correction (DPOC)
    • Temporary Management

CMS’s strict outlining of increasing enforcement remedies signals its intent to force nursing homes to quickly address long-standing issues or they will feel it in their pockets. This follow suit with the Mandatory Imposition of Federal Remedies notice that CMS issued in 2016.

  • Termination: “Section 1819(h)(2)(C) of the Social Security Act requires any nursing home that does not achieve substantial compliance with the Federal requirements within six months to be terminated from participation in the Medicare and/ or Medicaid programs . . .”
    • CMS may terminate the facility’s provider agreement at any time prior to six months if the facility is not in substantial compliance, “irrespective of the presence of immediate jeopardy”
  • Denial of Payment for New Admissions (DPNA): DPNA is required if a facility fails to achieve substantial compliance within three months

But wait, that’s not all. Here’s what else is included in the letter:

  • Last Chance Survey: If a nursing home remains in the SFF Program after three consecutive standard surveys (a full survey cycle), and the most recent standard survey had deficiencies cited at a S/S of “F” or greater (“G” or greater for LSC), then the SA will schedule another standard survey – a “last chance” survey.
  • Appeal: A facility cannot appeal its selection as a SFF. It can appeal the noncompliance resulting in an enforcement remedy determined under a SFF survey to an Administrative Law Judge of the HHS Department Appeals Board
    • IDR/IIDR: A SFF facility has the right to IDR/IIDR

In response to this letter, it is the nursing home’s responsibility to provide the following information within five business days to the SA and RO:

    • Names, phone numbers, email addresses and physical addresses of:
      • Chairperson of the Governing Body
      • Holder of the provider agreement
      • Any party who owns 5% of greater of the facility
      • Management company (if applicable)
      • Landlord (if applicable)
      • Mortgage holder
      • Any corporate owner if the nursing home is part of a chain
  • The nursing home must also tell the following people that it has been selected as an SFF due to its persistent pattern of poor quality on its last three standard surveys and complaint surveys and provide information for individuals that residents/families may contact for more information:
    • Residents
    • Resident Representatives
    • Families
    • Resident Council and/or Family Council primary contacts

In our next blog post, we will look more at survey results and how progressive enforcement will be implemented. If you missed our first two blog posts, CMS strengthens SFF program with FY 2017 Special Focus Facility S&C Memo and How Nursing Homes are Selected as Special Focus Facilities, they provide good background information on this program.

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