With termination notices rising for special focus facilities (SFF) list nursing homes, operators and lawyers close to this issue say they are ripe for overhauling the program.
First of all, independent dispute resolution (IDR) processes need to be revised, and a more timely appeal process should be essential. Furthermore, changes made to the deficiency criteria during the Biden administration must be reversed as SFF list facilities have made it more difficult for others to be added to the list. And finally, we need to provide incentives to allow star operators to flip through facilities on the SFF list.
Bill Miller, CEO of Washington-based Vertical Health Services, says that state surveyors (the same individuals who provide the quote tags) are currently reviewing the IDR. Independent bodies must lead the IDR process to eliminate bias.
“It has to be independent from regulatory authorities and it has to be final,” Miller said of the IDR process. “If recommendations are possible from people who wrote the tag, what is the IDR process? Then they often say, we don't agree with you (with the IDR).”
Notifications after the closing of the appeal process often take up to a year to resolve, by which time residents have already been evacuated and operators have absorbed catastrophic financial losses.
This situation occurred in Liberty Health and Wellness in Missouri, which was operated by Vertical before the March closure.
Vertical took over Liberty's fortune, which was plagued a year and a half ago, turning it around, and ultimately relied on lawsuits to continue to flow Medicare and Medicaid reimbursements, followed by a notice of fire.
The Department of Health and Human Services (HHS) gave Liberty quick to submit a closure plan despite efforts to amend the company, giving 30 days of funding after a termination notice was sent.
Steverafort, Corporate Affairs and General Counsel at Idaho-based Cascadia Healthcare, is working with the state association and the American Healthcare Association to improve the SFF list to better understand the root cause and what lands facilities at Rockbottom, and identify best practices for operators to dig out of the SFF list.
One way to remove SFF status is if a new operator takes over the SFF facility and spins it. And to promote this, policymakers need to provide better incentives. For example, pausing in a survey will help new operators implement the right people and practices and begin improving quality measurements.
“We need to take a break when new operators come in. So we're going to avoid having surveyors coming in and giving them a tsunami (of quotes) based on what the past operators have left behind,” says Laforte. “We need some kind of research leave, for operators who occupy special focus buildings, to survive.”
Appeal Process and Arbitrary Standards
According to Miller, the timeline of closures offered to SFF facilities should create space for the appeal process. Otherwise, unnecessary closures occur, giving way to unnecessary relocations of residents while operators fight to stay open.
“Shutting down nursing homes should be a last resort. They need to force receivers. There's a lot that many residents can do before moving out of their homes,” Miller said.
Instead, state research agencies should work with operators and the Centers for Medicare and Medicaid Services (CMS) to create distributions and incentives for model operators to turn these facilities around, Laforte said.
“If not, we'll lose our facilities. They'll be closed and you'll lose access. We're already outweighing supply where demographics are determining demand,” Lafort said. The situation will only become even more disastrous over the next decade or so, he said baby boomers are circulating through their care systems.
Cascadia closed the SFF property in January 2017 and saved it for the community, Laforte said. Another building, which the operator turned to, had the only ventilator building in 300 miles for patients when the state wanted to close it. Cascadia graduated from the building in 18 months.
However, the process of turning a tormented facility is not without risk, and not all turnarounds will be successful, even if the new operator has the best intentions.
“Ironically, two years later, we were unable to safely create a care plan for the resident (artificial building). We had to move that resident and move the next nearby building that made the specialist that this resident needed 300 miles away,” Laforte said. “The state told us, if you move this resident 300 miles, you create psychological harm and we give you a G-tag.”
Another recommendation change to the SFF programme relates to graduation standards from the programme updated by the Biden administration in 2022, according to Miller. Facilities can graduate from the SFF list if they have two consecutive standard health surveys with 2 defects below 12 in terms of range and severity of “E”;
The number of tags was arbitrary, saying that some nursing homes have shown significant improvements and blocked them from graduating from the program.
Furthermore, buildings with significant improvements are still on the list, but buildings with far worse results with results cannot be offered through the SFF program. It's not a sustainable standard, he said, and considers it to be the biggest threat to the program.
Access issues and operator priorities shift
If changes are not made to the SFF list, Miller hopes that access issues for residents across the country will continue to occur, making it less likely that operators will take on higher vision patients for fear of high range and severity tags.
This also applies to patients with behavioral health problems. This is a riskier outlook for operators without programs that help programs like SFF lists improve quality.
“Improvements are by no means linear. They require time, work processes and investment,” he said.
The arbitrary standard, and the possibility of more sudden termination notices, will alienate operators from turning the property suffered in an already challenging industry, especially if the decision to take on such a property is already associated with higher costs and numerous resources, Miller said.
“Even if we get this unprecedented behaviour from blue, we're still quite proud of our story,” Miller said. “I spent a lot of money trying to find an agreement with CMS, which is fine, but my main goal is to try and maintain the reputation of the people who work there. They try to cut their tails every day to take care of people in an incomplete system.”
