10 Mar
Understanding SFFs
CMS’s Special Focus Facility (SFF) Program was implemented in 1998 and has made its share of the headlines over the years. Senators Bob Casey and Pat Toomey raised concerns in 2019, leading to the first publication of the list of SFF Candidates. Their 2021 proposal calls for further oversight and expansion of the program and perhaps in response, CMS has updated the guidance on SFFs.
The Latest Updates
In addition to more stringent requirements for homes in the program, CMS also directs State Survey Agencies to consider Staffing in their selection of a new SFF from the list of SFF Candidates. Also, changes have come to the SFF list published by CMS each month. SFF designations have changed from “Improving” or “Not Improving” to “Met” or “Unmet”, referring to their meeting the criteria for graduation. We also discovered a little secret about the SFF List that CMS publishes each month — read on for more.
With all the news swirling around the program, we wanted to make sure our customers have the best possible information on these homes, which we hope we’ve done by rolling out our new SFF Watchlist feature. This new pop-up screen combines existing data in our system with new data culled from the PDF-based SFF List that CMS publishes each month. As a disclaimer, the rest of this piece assumes a working knowledge of the SFF program — if you’d like a refresher, please see our SFF Explainer.
The Revelation About the SFF List
When we went to integrate the SFF List PDF, we noticed something strange. Some homes’ status didn’t match Care Compare or the back-end data that it uses. We asked CMS, and they told us that there’s a one month lag between the two. After further analysis, we discovered that the SFF List is actually a month ahead. So StarPRO is now ever so slightly more current than Care Compare. Useful if you’re watching a home in SFF or Candidate Status and want a peek into what will change next month.
Lingering Ambiguity on SFF Selection & Graduation
A crystal ball into the “future” notwithstanding, there are still questions about the SFF program’s inner workings. The “graduation criteria” for SFFs are clear – a home needs two Surveys in a row with fewer than 8 deficiencies, none with a scope/severity higher than E. What’s less clear is what happens after that. CMS’s new designation of “Met” raises more questions than it answers – if the facility has met the criteria for graduation, why don’t they graduate immediately? We asked CMS, but haven’t get gotten a response. One reason for the delay may be to allow time for a new SFF to be chosen from the list of candidates. This is another gray area. While CMS provides guidance to the State Survey Agencies (SAs) on which candidates should be considered – poor performance, yes, but also homes that have “yo-yo’d” and now, homes with poor staffing levels. I’m sure the SAs have been left scratching their collective heads. Since we can’t write an AI to tap into their minds, we do the best we can in our SFF Watchlist, which is to show the past 3 Surveys and include the Staffing Star Rating in the list for each SFF Candidate:
Back in our workshop, we’re looking for ways to bring back the spirit of the “improving” designation by indicating which SFFs have had at least one conforming Survey. We’re also looking at the “yo-yo” homes to show which Candidates have been SFFs in the past. Keep an eye out for these additions to the SFF Watchlist soon.
The Proactive Plan to Avoid the SFF Candidate List
What’s thankfully much more clear is how homes come on and off of the SFF Candidate list. Thanks to pressure form Senators Casey & Toomey, in addition to revealing the list of SFF Candidates, CMS also outlined the methodology used to select them. The SFF Candidates in each state are simply the worst-performing homes in terms of Weighted Survey Score (WSS). Armed with this information, homes can aim to improve their WSS by turning in a new Survey with as few citations as possible. StarPRO can also help them understand when their WSS may improve without a new Survey (hint: it has to do with infection control and complaint deficiencies).
While CMS doesn’t really “Rank” SFF Candidates, we can deduce where they stand using the WSS. So our SFF Watchlist shows candidates in ranked order, along with their change from the previous month:
Notice the red 14 on the first home? We highlight homes that haven’t been Surveyed in the past year. For these Survey-expectant homes, it’s nice to know if it’s even possible to get off the SFF Candidate list. This isn’t as straightforward as it seems though. If the home has had a really bad recent survey, it’s possible that even with a perfect, zero-point survey, they won’t be able to get off the list. On the other hand, if a facility has their worst behind them, they may have more wiggle room for a few tags on their next Survey. That’s why our watchlist shows both the lowest WSS possible with a perfect Survey and a simple yes/no of whether or not they can get off the list.
The Passive Plan to Avoid the SFF Candidate List
Interestingly, homes can come onto or off of the list with no change at all to their WSS. We like to think of the SFF Candidate list as a having a floating admissions policy. In any given month, the SFF Candidate with the lowest WSS is in an unlucky position – they’re one slot away from not being an SFF Candidate.
This screenshot of our SFF Watchlist for Wisconsin shows that SFF Candidate Cutoff – With a WSS of 312.5, Bay at Burlington Health is an SFF Candidate while Aria of Bloomfield is very close with a WSS of 299.67. The good news for Bay at Burlington Health is that if more homes have bad surveys than good next month, they may be pushed into the pool of SFF Candidates, pushing them right out of SFF Candidate status. Here’s what that scenario might look like:
On the other hand, Aria of Bloomfield also has to keep an eye out. If the opposite happens and some SFF Candidate has a stellar 0-point survey, they may rocket out of the pool causing Aria to sink down and become the newest SFF Candidate:
For this reason, we include a list of “At-Risk” facilities in our SFF watchlist. This isn’t a formal designation and of course, one bad survey can sink a home into SFF Candidate status at any time, but these homes may find themselves on the wrong end of the stick if the current candidates happen to have a good day.
Summary
The SFF program seems simple, but new layers keep getting peeled back. For those focused in on these homes, we hope that our tools provide a sharper vegetable peeler. As always, we want to know what you think. Get in touch with any questions or suggestions.
