A new report from the Government Accountability Office highlights ways in which the Centers for Medicare & Medicaid Services could do a better job of overseeing underperforming nursing homes, also known as Special Focus Facilities (SFF).

Under the SFF program, CMS directs each states to identify 15 poorly performing facilities. It then directs those states to survey those facilities twice as frequently, and to propose “more robust enforcement” for facilities that don’t improve within 18 months, according to the GAO report. The GAO discovered that many states inconsistently follow the CMS requirements for the SFF program, partly because CMS’ enforcement guidance is vague.

As many as eight states did not double their SFF survey efforts in 2008, the report found. Also, penalties against nursing homes in the program were applied unevenly: One SFF was not given a civil monetary penalty (CMP) for a deficiency that should have carried an $825-per-day fine. Meanwhile, another facility with a similar history was assessed fines that increased from $300 to $600 per day of noncompliance. Among the 133 active SFFs as of February 2009, 17% (23 facilities) were in the program for 25 months or more, and 11 had been in the program since 2005—significantly longer than the 18-month cut-off point. The program limits the number of special focus facilities to 136 due to resource constraints.

The GAO made six recommendations to CMS. These include: notifying nursing homes that have been identified as SFF program candidates that they are at risk of being selected as an SFF; and ensuring that states impose more stringent enforcement, such as higher CMPs or termination, and monitoring those sanctions more closely. The Department of Health and Human Services said it agreed with five recommendations and would consider the other.