As previously discussed, the Centers for Medicare & Medicaid Services (CMS) have an important role in the funding of healthcare and long term care for seniors. The reach of CMS extends over doctors, hospitals and healthcare facilities that accept Medicare and Medicaid insurance. This also includes nursing homes and long-term care facilities. Of course, when accepting federal dollars through CMS programs, these doctors, hospitals and other facilities are subject to rules and regulations on their conduct and performance on top of those already implemented by the relevant state agency. If they do not meet requirements under U.S. regulations, they will not receive Medicaid funding.
Tracking Care Quality
Like many state health agencies, CMS also gathers information on the performance records of health providers, like nursing homes. These nursing home reports are vital for those looking into placing a loved one into residence. CMS specifically releases a “Special Focus Facilities” (SFF) list that includes facilities with a particularly poor record of performance based on inspections and which garner specific attention from CMS for reform and fixing. These inspections are conducted by surprise, and can occur at any point, 24/7, during a week. CMS teams look for general shortcomings in terms of quality of care, as well as shortcomings related specifically to written requirements. If not up to code, the facilities must make proper changes or risk losing funding.
The SFF list deals with the smaller group of nursing homes that have “more problems than other nursing homes (about twice the average number of deficiencies), more serious problems than most other nursing homes . . . [and] a pattern of serious problems that has persisted over a long period of time” for up to three years before the first time the nursing home made the SFF list. The facilities with particularly “systemic problems” are found on this list. These include places that even attempted certain reforms that could bring them in compliance, but would soon fall back out again, thus demonstrating the problem is institutional and threatened to persist for the long term, thus threatening the quality of care for residents.
The nursing homes listed on the SFF must be visited by inspectors two times more than other homes throughout a year, and penalties, including financial fines, grow increasingly more severe as problems go on longer, and longer. The aim of CMS’s SFF program is to fix listed facilities within the next 18-24 months after making the list. There are likely to be three outcomes: either the facility improves and consistently meets requirements such that it can be removed from the SFF list; the facility can simply be denied Medicare or Medicaid funding, which is significant in amount, could potentially shut down the facility due to lack of money; or the facility is given more time to meet requirements based on promising progress to date. Where a facility is removed from the Medicare/Medicaid rolls, this does not mean the facility is shut down – it could still operate just under state laws (but again, the pulled funding may be so significant that it will cease to be financially operable going forward). For those looking to place a loved one in a nursing home, it is important to check the SFF list to be sure there is no concern with its performance, at least as far as CMS is concerned.
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