The Special Focus Facility (SFF) designation is a federal program administered by the Centers for Medicare & Medicaid Services (CMS) to address the nation’s poorest-performing nursing homes. It identifies facilities with persistent records of poor quality and serious health and safety deficiencies. The SFF program operates as a quality improvement mechanism, placing intense scrutiny on a small number of facilities to force sustained compliance with federal requirements. This designation signifies that a nursing home has repeatedly failed to maintain acceptable standards of care. The goal is to correct underlying systemic problems, ultimately protecting residents and improving the quality of care in these facilities.
The Criteria for SFF Designation
A nursing home is selected for the SFF program after demonstrating a long-term pattern of non-compliance. To be considered, a facility must have a history of serious quality issues, typically measured over the last three standard health surveys and three years of complaint investigations. These facilities typically have approximately twice the average number of deficiencies cited during inspections compared to other nursing homes. The severity of problems is a major factor, as the cited deficiencies often include those that resulted in actual harm to residents or placed them in immediate jeopardy. State survey agencies, in coordination with CMS, use a scoring methodology that heavily weighs the number, scope, and severity of these deficiencies.
Facilities are first placed on a candidate list, which includes hundreds of nursing homes waiting for an open slot in the limited SFF program. When selecting from this candidate pool, state agencies are advised by CMS to consider a facility’s staffing levels, prioritizing those with lower staffing ratios or star ratings. The SFF designation targets facilities with a “yo-yo” compliance history, meaning they temporarily fix problems just long enough to pass an inspection, only to have serious issues resurface shortly thereafter.
Increased Regulatory Oversight and Monitoring
Once a facility receives the SFF designation, it is subjected to an intensified level of regulatory scrutiny. The standard practice for most nursing homes is to undergo one comprehensive survey per year; SFFs are required to have two full, unannounced standard surveys annually, occurring approximately every six months. This increased frequency of inspection is designed to monitor the facility’s compliance more closely and prevent the resurfacing of deficiencies. These inspections are often conducted by specialized survey teams who are looking specifically for systemic failures and a failure to implement lasting corrective actions. The facility is required to submit comprehensive plans of correction for any deficiencies found during these frequent surveys.
CMS also imposes immediate and escalating enforcement sanctions on an SFF that fails to achieve and maintain significant improvement following a survey. The agency closely monitors the facility’s progress, and a lack of demonstrated effort to improve can lead to increasingly severe remedies. This regulatory pressure aims to ensure the facility addresses the root causes of its poor performance rather than implementing only temporary fixes.
Consequences for Facilities and Program Exit
The SFF designation carries serious consequences for the facility’s operation and financial viability. Enforcement actions are tiered, starting with increasingly severe civil monetary penalties, or fines, imposed by CMS for non-compliance. A more significant penalty includes the denial of payment for new Medicare and Medicaid admissions, which effectively halts its ability to admit new residents. The ultimate threat is termination from the Medicare and Medicaid programs, which fund the majority of nursing home residents. If a facility is cited with “Immediate Jeopardy” deficiencies on any two surveys while in the SFF program, CMS will consider it for discretionary termination. Termination essentially forces the facility to close or drastically restructure.
A facility leaves the program in one of two ways: “Graduation” or “Termination.” Graduation occurs when the facility achieves significant and sustained improvement, demonstrated by two consecutive standard health surveys with a limited number of relatively minor deficiencies. The typical timeframe for a facility to achieve graduation is around 18 to 24 months, after which CMS monitors the facility for three years to ensure improvements are sustained.
Accessing the SFF List
The Centers for Medicare & Medicaid Services maintains a publicly available list of all facilities currently designated as Special Focus Facilities. This list is a tool for consumers seeking to make informed decisions about long-term care options. Readers can access this official list through the CMS Care Compare website, which provides detailed information about nursing homes nationwide. The list is updated regularly and includes facilities actively in the SFF program and those that have recently graduated. By making this information transparent, CMS encourages public scrutiny and empowers families to discuss the facility’s poor performance and corrective actions with administrators. State health departments often provide localized information on SFFs and SFF candidates within their boundaries.