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Why Some Nursing Homes Are In a Federal Improvement Program

Additional facilities rack up citations and are put on a 'waiting list'

By Liz Seegert

Two U.S. senators recently released a bipartisan report that included a list of over 400 nursing homes with health and safety violations serious enough to warrant additional government oversight.

Nursing Homes
Credit: Adobe

Sen. Pat Toomey (R-Pa.) and Bob Casey (D-Pa.) put a spotlight on the Centers for Medicare and Medicaid Services (CMS) “Special Focus Facility” (SFF) program for nursing homes with deficiencies in quality and safety. And they raised important new questions about nursing homes that should be in the program but aren’t, due to inadequate government resources.

SSFs have more violations and more serious violations than other nursing homes over the course of several inspection periods, according to CMS, which oversees nursing homes, along with state regulators.

"They're so problematic that government is doing surveys of them every six months."

The SSF program has capacity for 88 nursing homes, but there are some 400 additional nursing homes with very serious deficiencies that don’t make it into the program. That list of candidates had been kept hidden from the public until the Senators made it public.

While SFFs are identified on CMS’ Nursing Home Compare website as those with no Medicare “star” ratings and have a yellow symbol next to their names, there’s no identifying information for SFF candidates. That potentially puts thousands of older adults at risk.

“Choosing a nursing home is a difficult, and often painful, decision to make. Individuals and families deserve to have all the information available to choose the facility that is right for them,” Casey said in a press release on his Senate web page. “I will continue to press the [Trump] administration to ensure every person has ready access to the information they need to make a fully informed choice.”

Citations Lead to More Oversight

There are more than 15,700 nursing homes throughout the U.S. All must comply with hundreds of federal and state regulations to ensure safety, adequate staffing and quality of care. All facilities are subject to surprise visits by state inspectors, who issue citations when nursing homes do not comply with regulations.

On average, nursing homes receive six or seven citations per visit and usually correct deficiencies by the time of the next survey.

However, a small group of facilities that consistently show poor compliance and receive a higher-than-average number of citations over several survey periods become candidates for the SFF program.

“Think of it as a watch list put out by the state,” says Charlene Harrington, a professor of nursing and sociology at the University of California San Francisco who has advised CMS on nursing home quality for more than a decade. “They're so problematic that government is doing surveys of them every six months.”

SFF participants are subject to more intense, more frequent state oversight. They must correct their deficiencies within 18 to 24 months or risk serious penalties. These can range from heavy monetary fines to termination from Medicare and Medicaid.

Limited Program Capacity

However, there are more deficient facilities than there is room for in the SFF program. Budget cuts dating back to the 2014 sequestration effort limited SFF participation to the 88 slots and 440 candidates now allowed, CMS Administrator Seema Verma told Casey in a letter. So, it’s up to state regulators to select which ones actually participate in the program.

New slots open when an existing SFF “graduates” by passing subsequent inspections or is terminated from the program. Then, another candidate can cycle in.

It can take years for this process to play out. Meanwhile, the candidate facilities are not subject to any more stringent oversight than any other non-SFF nursing home.

But what happens to the facilities on the “waiting list” for the SFF program? Not only is it impossible to identify them on Nursing Home Compare, lag time in updating the website means some still show ratings of two, three or more stars.

Other facilities that recently became part of the SFF program were not identified either, according to the senators' report.

“If facilities are rated below average, I would try to stay away from them at all costs,” says Harrington. “But sometimes you can't, if you’re in a rural area or an underserved region.” She also points out that some deficiencies can be subjective, depending on state regulations and individual inspectors.


Updated Nursing Home List To Come

Casey and Toomey obtained the most recent list of the more than 400 SFF candidates, which they have since made public. The senators want CMS to regularly publish an updated list, alongside the SFF participant list to help consumers determine whether to include these facilities in any comparison.

After the senators’ report became public, CMS announced it would begin publishing the SFF candidate list on Nursing Home Compare but did not specify a timeframe.

Meanwhile, consumers can help protect themselves by looking at a few key elements of Nursing Home Compare’s star ratings. One of most important is the staffing ratio, both for nursing assistants (CNAs) and registered nurses, according to Harrington, who has been working on staffing issues for 30 years.

“If they don't have four or five stars on staffing, pass them by,” she says. Most nursing homes with four- or five-star ratings usually are still deficient in what Harrington considers adequate staffing.

Ideally, a CNA should care for seven or fewer patients per shift, and the nurse in charge should be responsible for 18 or fewer patients at a time, says Harrington, who has written on this topic. Yet, many U.S. nursing homes do not meet this staffing level.

Star Ratings Don’t Tell the Whole Story

Patients and families often find themselves searching for a nursing home when a loved one is about to be discharged from a hospital. Typically, the hospital gives the family a list of facilities and tells them to pick one.

Star ratings on Nursing Home Compare offer one way to determine quality and safety. Another, as Next Avenue has said, is to look at Yelp reviews and comments for a nursing home you're interested in. But these ratings and reviews tell only part of the story.

Harrington suggests visiting facilities whenever possible, and asking the staff how many patients they’re responsible for. Observe whether residents are being helped with feeding during meal times or with activities like toileting, bathing or even just being turned in bed.

“Too often people just choose the facility closest to home and think that since they’re all licensed by the government, they’re all going to be the same,” she says. “But there are huge differences.” It’s far better to drive another 20 minutes than sacrifice quality, she adds.

Other suggestions include considering a nonprofit- or even government-run facility over a for-profit nursing home since studies show that commercial nursing homes may cut corners by keeping staffing levels too low.

Also, check with your state regulatory agency for inspection reports or other key information produced by state regulators. In addition to Nursing Home Compare, some states, like California, incorporate both federal and state data on a separate website.

Families need to stay on top of the situation because state oversight is weak in many parts of the U.S., Harrington says.

Liz Seegert
Liz Seegert New York-based journalist Liz Seegert has spent more than 30 years reporting and writing about health and general news topics for print, digital and broadcast media. Her primary beats currently include aging, boomers, social determinants of health and health policy. She is topic editor on aging for the Association of Health Care Journalists. Her work has appeared in numerous media outlets, including Consumer Reports,, Medical Economics, The Los Angeles Times and The Hartford Courant.  Read More
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