The Centers for Medicare & Medicaid Services is changing how states select candidates for the Special Focus Facility Program to put more emphasis on fall rates as a reflection of quality, the agency announced Wednesday.

Consistently low-performing facilities are named to the federal program for additional oversight. Inspections also could increase and become less predictable under the first significant revisions to the SFF program since CMS added staffing to its selection criteria in 2022.

While just 88 nursing homes are currently in the SFF program, each state can select between five and 30 candidates, with a combined potential for up to 440 more facilities to be under consideration at any one time.

Compliance experts reacted to the changes announced Wednesday with surprise, with one calling the updates to the selection criteria “huge in many ways.”

In its memo to state survey agency directors, CMS officials said they were asking states to begin considering falls — in addition to survey scores — partly in response to watchdog calls for better scrutiny of falls prevention and reporting. Updates to the directive remove language that previously told state teams to consider staffing ratings or ratios, given staffing’s “importance of staffing and its relationship to quality.”

The change is a major departure from CMS, which had increasingly aligned staffing metrics — more readily available with the advent and expansion of Payroll Based Journal reporting — with quality measurement and enforcement priorities.

States are now being advised that they should use falls prevalence as captured through the MDS 3.0 Facility-Level Quality Measure as a factor when deciding which nursing homes to move into the Special Focus Facility program.

“This action is being taken following the Office of Inspector General’s Report, which highlighted the seriousness of nursing home resident falls and the importance of improving fall safety,” Wednesday’s memo said. “For example, if an [agency] is considering two SFF candidates with a similar compliance history, CMS recommends selecting the facility with the higher prevalence of falls. SAs may also take into consideration other relevant findings, like previous complaint findings or enforcement actions.”

The September OIG report accused nursing homes of failing to report 43% of major falls, though data experts and providers questioned how the agency had interpreted multiple data sets across post-acute and hospital settings.

New calculations in play

The change also comes just months after CMS changed its definition of major falls and required more reporting by nursing homes. MDS rules also now require reporting of intercepted falls and falls resulting from an overwhelming external force, “which could increase the facility’s percentage of long-stay residents who had a fall,” Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance at Zimmet Healthcare Services Group, said Wednesday.

Some compliance experts have expressed concern that those changes and some subjectivity in the new definitions could increase compliance and risks — even with no new actual risk or harm to patients.

“First, we have the change to the Fall with Major Injury coding,” Amy Stewart, chief nursing officer for the American Association of Post-Acute Care Nursing said Wednesday. “Now surveyors can use falls to help determine who should be on the SFF list? Yikes.”

Stewart offered a four point attack plan as providers face increasing scrutiny of resident falls, starting with a review of all falls within the last six to 12 months.

“Look at the root cause of the falls and see if there are any trends,” Stewart wrote in an email to McKnight’s. “Do they occur the same shift, the same day of the week? I would certainly review staffing patterns during peak fall times.”

She also called on nursing home teams to review their fall prevention program with the medical director, pharmacist and therapy team; to investigate every fall for new and specific interventions that can mitigate future risk; and to train all staff on the falls program well enough that they can perform the duties and explain them to a surveyor.

Urged to consider ‘totality’

Steve LaForte is CFO and principal of Cascadia Healthcare, which has taken on several SFF buildings in turn-around efforts over the years.

He welcomed the programs’ move away from staffing as “a realization and recognition … that staffing is an endless challenge, demographically, and that quality care can be delivered in staffing numbers less than the ratios that were set out” by the now-repealed staffing mandate.

But he also warned that falls could be somewhat arbitrary as a selection factor, depending on a facility’s resident population and their level of ambulation. He suggested that CMS consider the affect of falls, not just that they happen. He also told McKnight’sit was concerning that state surveyors aren’t being directed to look at a “totality of quality measures.”

Even with the shift in selection criteria, Stewart and Cantinieri underscored the need for providers to stay vigilant about staffing levels.

“I am a bit surprised to see that staffing was struck out rather than ‘in addition to’ staffing,”  Cantinieri told McKnight’s, saying it could have been removed to align with the staffing mandate’s repeal. Previous references to President Biden’s broader nursing home reform agenda were also removed from the memo.

But with surveys and audits, “staffing isn’t being forgotten,” she said. “Prevalence of falls is one of the criteria used to determine which facilities are designated as SFF candidates and SFF facilities. It is still the facility’s health inspection scores that will drive the decision of whether or not a facility ends up on either list, so facilities should ensure they are compliant and survey-ready at all times.”

Less predictability?

While maintaining a twice-yearly minimum survey requirement for SFF participants — double that required for other nursing homes — CMS also said Wednesday that it expects the timing of SFF health surveys to be as “unpredictable as possible.”

In December, the National Bureau of Economic Research published a study that found making the time between nursing home inspections less predictable and more erratically spaced could better protect patients. The researchers found doing so could potentially save 12% more lives.

The SFF program itself has been criticized by the OIG, most recently in October when the oversight body called on CMS to make improvements because most facilities that graduate do not sustain improvements.

It reported that between 2013 and 2022, about two-thirds of the nursing homes that were in the SFF program improved enough to graduate but soon afterward began having the same quality problems that landed them on the SFF list initially.

As of April 2024, compliance issues that might lead to selection included having around twice the average number of deficiencies as other nursing homes; having more serious citations, including for harm or injury experienced by residents; and a pattern of serious problems that have persisted over a long period of time, typically at least three years.