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Highlights

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.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare and Medicaid Services 1. To improve the targeting of scarce survey resources, the Administrator of CMS should consider an alternative approach for allocating the 136 SFFs across states, by placing more emphasis on the relative performance of homes nationally rather than on a state-by-state basis, which could result in some states having only one or not any SFFs and other states having more than they are currently allocated.
Closed - Not Implemented
Given the length of time since the issuance of this report, the lack of progress on implementing this recommendation, and HHS's August 2015 written comments indicating the agency's nonconcurrence at this time, GAO has decided to close this recommendation as not implemented.
Centers for Medicare and Medicaid Services 2. To improve the SFF methodology's ability to identify the most poorly performing nursing homes, the Administrator of CMS should assign points to G-level deficiencies in substandard quality of care (SQC) areas equivalent to those additional points assigned to H- and I-level deficiencies in SQC areas.
Closed - Not Implemented
In written responses to GAO regarding open recommendations received on July 8, 2010, CMS noted that the agency will not implement our recommendation.
Centers for Medicare and Medicaid Services 3. To improve the SFF methodology's ability to identify the most poorly performing nursing homes, the Administrator of CMS should account for a nursing home's full compliance history regardless of technical status changes.
Closed - Not Implemented
In written responses to GAO regarding open recommendations received on July 8, 2010, CMS noted that the agency will not implement our recommendation because the frequency of technical status changes is sufficiently low not to warrant making the changes that would need to be made to the database.
Centers for Medicare and Medicaid Services 4. To improve the SFF methodology's ability to identify the most poorly performing nursing homes, the Administrator of CMS should consider using a common set of numeric points for identifying poorly performing nursing homes by determining the effect of adopting those associated with the Five-Star System for the SFF methodology.
Closed - Implemented
The Centers for Medicare & Medicaid Services (CMS) established the Special Focus Facility (SFF) Program in 1998 to help address poor nursing home performance. 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 SFF Program. When compared to the points assigned to deficiencies in the SFF Program, we found that deficiency points that CMS developed for its Five-Star System compensate somewhat for understatement and the interstate variation in the citation of serious deficiencies. To improve the SFF methodology's ability to identify the most poorly performing nursing homes, we recommended that CMS consider using a common set of numeric points for identifying poorly performing nursing homes by determining the effect of adopting those associated with the Five-Star System for the SFF methodology. In response to our recommendation, CMS modified the SFF methodology by using the points assigned to deficiencies in the Five-Star System and began using the revised SFF methodology in April 2010.
Centers for Medicare and Medicaid Services 5. To ensure consistency with the SFF methodology, CMS should consider making two of these modifications--the SQC and full compliance history changes--to its Five Star System.
Closed - Not Implemented
In written responses to GAO regarding open recommendations received on July 8, 2010, CMS noted that the agency will not implement our recommendation that it make modifications to the Five Star System.

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