Special Focus Facility Program

“While we are still reviewing the report in detail, we agree that the Special Focus Facility program is not working.”

–Holly Harmon, the AHCA Senior Vice President of Quality, Regulatory and Clinical Services.

The Special Focus Facility, or SFF, was created in 1998 to encourage the worst nursing homes in the U.S. to improve their quality of care. It reserves a whopping 88 spots for less-than-low-quality nursing homes in each state and works with the states to conduct quality inspections.

Essentially, the bottom-tear quality of nursing homes is placed in the “flagship” program. After making slight improvements to overcome basic benchmarks, nursing homes are able to graduate from the program. If they refuse to improve while in the program, they endure fines.

However, 27 years later, it’s been found that SFF’s use of financial penalties is not enough to deter homes from providing neglectful care to their residents. In fact, more than 64% of program graduates were known to commit a serious violation within 3 years after graduating. Worse, one-third of the graduates received a violation every year for three years following their graduation—and that’s only for the ones that actually make it to graduation.

In total, CMS always maintains a list of 440 potential nursing homes to be added to the two-year-long SFF program upon the graduation or termination of other homes. Yet this is a great deal of time, money, and energy going into nursing homes that seem to be completely hopeless in providing decent care.

To add more perspective, 88% of the nursing homes that were bad enough to be placed in the SFF program in the first place are for-profit, with only 8% nonprofit and 3% government-owned. This is a clear indication that profit-driven care facilities have no interest in improving the well-being of their residents. Moreover, the for-profit facilities likely produce so much revenue that nursing homes’ fines are irrelevant to them and not worth changing their harmful ways. For example, the median penalty was a mere $9,750.

Part of the hidden benefit for for-profit nursing homes also lies in the lack of accountability that exists for directors. “Ownership, management, and leadership materially affect nursing home quality,” said Jodi Eyigor, the Senior Director of Nursing Home Quality. “We agree that ownership performance should be part of SFF evaluation and note recent CMS steps to link ownership data and display affiliated entities’ performances on Care Compare.”

Fortunately, in 2023 CMS finally made the first rule requiring nursing homes to provide a bit more detailed information related to ownership, financial control, and management, slightly closing the accountability loophole for directors. Still, this is a very slight remedy for a very serious issue; the Office of Inspector General (OIG) does not recognize this rule as successful in establishing ownership, and even points out the tendency for many of the same poor-quality nursing homes to be operated by the same shameless owners.

The vast majority of nursing homes placed in SFF programs were there for infection control issues, with 90% of nursing homes having a serious deficiency in preventing the spread of infection. One can only wonder how bad the sanitary precautions must be for so many facilities to have so many infection control deficiencies. (Which is even more concerning, considering the extra-vulnerable immune systems of adults in nursing homes.)

Meanwhile, AHCA, HHS, CMS will continue to work on finding a way for nursing homes to start offering the safe care they promise all their residents. The OIG officially recommends that CMS impose non-financial consequences on noncompliant nursing homes, actually determine and focus on the ownership of poor-quality homes, and finally, develop a detailed report that evaluates the actions of SFF alumni post-graduation.