CMS Updates Special Focus Facility (SFF) Program
CMS recently released a memo (QSO-23-01-NH REVISED) updating the selection criteria for the Special Focus Facility (SFF) Program. CMS will now emphasize the prevalence of falls among the resident population as the focus area for selection. CMS noted that this action is being taken following the Office of Inspector General’s recent report, which highlighted the importance of improving fall safety.
In addition, they are reducing survey predictability for the SFF Program. CMS is shifting from surveys once every six months to no less than twice annually. Life Safety Code (LSC) and Emergency Preparedness (EP) surveys will be conducted at least annually, or as determined by the State or CMS. Nursing homes are identified as SFF candidates based on their last two standard surveys, instead of the last three, which were previously used.
CMS will notify providers of their inclusion on the SFF candidate list via their Internet Quality Improvement and Evaluation System (iQIES) Five-Star Preview Report. Providers are encouraged to routinely check the folder, especially when it is time for a Preview Report to be loaded (typically about one week prior to when Nursing Home Care Compare refreshes).
Previously, CMS considered a facility’s staffing when determining if it was an SFF candidate. Moving forward, CMS will use the prevalence of falls when selecting an SFF. For example, if a State Agency (SA) is considering two SFF candidates with a similar compliance history, CMS recommends selecting the facility with the higher prevalence of falls among the resident population.
Facilities may review their current falls data, which is accessible to providers in iQIES through the MDS 3.0 Facility-Level Quality Measure (QM) report, located under the Quality Measure report category. Additionally, the MDS 3.0 Facility Characteristics and MDS 3.0 Resident-Level Quality Measure (QM) Reports identify other data, including which residents are included in the fall measure calculations.
To help with falls reduction, ahcancalED offers a six module Fall Prevention Guide which is free to AHCA/NCAL members. The guide covers a variety of topics such as Regulatory Requirements, Falls Education and Post-Falls Management.
CMS also noted that they are revising the monthly SFF postings on a different website.
For questions or concerns related to the memo or the SFF program, please contact [email protected].
For additional questions, please email [email protected].
