Two new reports from the US Department of Health and Human Services (HHS) Office of Inspector General (OIG), released October 24, 2025, raise concerns about the effectiveness of the Centers for Medicare & Medicaid Services’ (CMS) Special Focus Facility (SFF) program for nursing homes. The program targets a small number of facilities with persistent and serious compliance issues and is intended to help them make and sustain significant improvements in quality of care. However, the findings indicate that while the program is designed to help these nursing homes improve, many fail to maintain those improvements after graduation.
Between 2013 and 2022, nearly two-thirds of nursing homes that completed the SFF program later showed the same types of quality problems that had led to their selection. The OIG concluded that the SFF program is not working as intended, emphasizing that CMS relies too heavily on financial penalties that do not require facilities to make operational or systemic changes.
Nursing homes that sustained improvements after graduation generally maintained higher staffing levels than those that did not. However, CMS has made only minimal use of staffing information in the SFF program. Ownership was also identified as an overlooked factor, with the OIG noting that a small number of owners control many low-quality nursing homes, suggesting poor management practices that may influence performance. State survey agencies told the OIG that ownership involvement often determines whether a facility makes lasting improvements.
The OIG also found that some states have developed their own quality improvement initiatives that build on the SFF framework, offering lessons that CMS could use to strengthen the program nationally. To enhance effectiveness, the OIG recommended that CMS impose more nonfinancial enforcement remedies that promote sustainable compliance, such as directed plans of correction or temporary management; evaluate whether enhanced enforcement actions have been effective, particularly for SFF graduates cited for staffing deficiencies; and incorporate ownership information when selecting or monitoring SFFs. CMS concurred with the recommendation to evaluate enforcement actions but did not agree with the other two recommendations.
A companion OIG data snapshot released the same day provides a detailed look at nursing homes that participated in the SFF program from 2013 through 2022. During that period, 645 nursing homes entered the program. Most were for-profit, non-rural facilities, and infection control deficiencies were the most common reason for selection.
While most SFFs graduated from the program within two years, many continued to receive serious deficiencies while participating. Of the 429 nursing homes that both entered and exited the program during the ten-year period, 64 percent received a serious deficiency within three years of graduation. More than half of the enforcement actions imposed on SFFs were civil monetary penalties, which the OIG noted are less likely to produce lasting operational improvements.
According to the OIG, despite increased oversight and regular surveys under the SFF program, many facilities have not achieved sustained quality improvement. The OIG urged CMS to strengthen the program by focusing on systemic change, sustainable staffing practices, and accountability at the ownership level.
The reports and related materials are available on the OIG’s website: CMS’s Special Focus Facility Program for Nursing Homes Has Not Yielded Lasting Improvements and Special Focus Facility Program Nursing Homes, 2013–2022.
Compliance Perspective
Issue
Sustaining long-term quality improvement remains a significant challenge for nursing homes that have previously demonstrated serious compliance problems. Facilities that achieve short-term improvement under intensive oversight programs, such as the SFF program, may struggle to maintain those gains once external monitoring decreases. Ensuring that corrective actions lead to lasting operational change requires active leadership oversight, adequate staffing resources, and ongoing evaluation of quality and compliance practices.
Discussion Points
- Facilities should review and, where necessary, strengthen policies and procedures to support sustained quality improvement efforts and compliance with CMS participation requirements. Policies should address maintaining adequate staffing, strengthening oversight of quality operations, and monitoring long-term performance following significant corrective actions. Engaging an external consultant to conduct focused mock surveys or operational reviews can also help assess quality improvement initiatives and identify emerging compliance risks.
- Facilities should ensure that staff and leadership receive education on the intent and expectations of the SFF program and its connection to ongoing quality improvement. Med-Net Academy offers the course, Special Focus Facilities, which reviews the background of the SFF program, explains how it functions, outlines the SFF categories, identifies red flags to watch for, and details how a facility becomes eligible to graduate from the program.
- Regular internal audits help ensure that quality and compliance improvements remain effective over time. Facilities should routinely review staffing data, quality metrics, and deficiency trends to identify early signs of performance decline. Partnering with a consultant for modified or targeted mock surveys can provide an objective assessment of sustained compliance and provide recommendations for continuous improvement through the facility’s QAPI process.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*