Navigating the CMS Hospice Special Focus Program (SFP): What It Means and Steps to Take if Your Hospice Has Been Selected

If your hospice has been selected for the CMS Hospice Special Focus Program (SFP), this is your chance to enhance care quality, align with CMS standards, and ultimately build a more resilient organization. CMS created the SFP to help hospices that may need extra guidance to meet Medicare standards, offering targeted oversight and support. This is more than just compliance—it’s about creating lasting improvements that directly benefit patients, families, and your team.

Here, we’ll explore what the SFP means, why your hospice may have been selected, practical steps to navigate the program successfully, and what to expect if you don’t meet the program’s criteria.

What is the Hospice Special Focus Program (SFP)?

The SFP is CMS’s way of identifying and supporting hospices that need focused improvement in care quality and compliance. By analyzing survey results, quality indicators, and patient feedback, CMS selects hospices for the program based on performance. While being chosen may feel overwhelming, the SFP is designed to provide a clear pathway for improvement.

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Why Was My Hospice Selected? Your hospice may have been selected based on:

Key Aspects of the Hospice Special Focus Program:

Identification Criteria: CMS evaluates hospices using recent data from the past three years, including:

• Results from recertification and substantiated complaint surveys.
• Scores from the Hospice Care Index (HCI), which is based on Medicare claims data.
• Feedback from the Consumer Assessment of Healthcare Providers and Systems (CAHPS?) Hospice Survey, focusing on areas like pain management, timely assistance, and overall satisfaction.

Once selected, CMS notifies your hospice, outlining the reasons for selection and expectations for improvement. This is the starting point for a focused journey of enhancement, where your team can implement lasting changes to achieve graduation from the program.CMS

Unannounced Surveys: What to Expect

Once in the SFP, your hospice will be subject to unannounced surveys by CMS. Although you’ll be notified of your selection, these follow-up visits are unscheduled, allowing CMS to observe your team’s daily practices and compliance without specific preparation.

Unannounced surveys can feel intense, but they’re also a chance to show CMS how your hospice delivers quality care every day. When your team adopts an “everyday readiness” mindset, these visits become less daunting and more of an opportunity to reinforce your commitment to excellence.

Steps to Take if Your Hospice is in the SFP

If your hospice is part of the SFP, a structured, proactive approach will help you achieve CMS’s standards and move toward graduation. Here’s a specific step-by-step guide to navigating the program successfully.

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1. Understand the SFP Graduation Criteria

To graduate from the SFP, your hospice must:

• Pass Two Consecutive Surveys: Within an 18-month period, you must complete two surveys without any condition-level deficiencies. These are major issues that indicate non-compliance with Medicare standards.
• Resolve All Identified Issues: Any initial deficiencies or complaints that led to SFP selection need to be fully addressed and corrected, showing sustainable improvements in quality.

By achieving these criteria, you demonstrate to CMS that your hospice is committed to high standards and prepared to maintain compliance.

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2. Conduct a Thorough Self-Assessment

Start with a detailed self-assessment to pinpoint specific areas needing improvement. This will help you understand where your hospice stands and where to focus your efforts.

• Example: If your self-assessment shows that family communication is inconsistent, set a goal to improve how often and how effectively you update families. Perhaps you find that family calls aren’t documented consistently. Recognizing this, you could implement a protocol for all team members to log family communications immediately in the patient’s chart.
• Involve All Departments: Engage nurses, social workers, aides, and chaplains in the review. Each discipline has unique insights that provide a holistic view of patient care, allowing you to capture the complete picture.

3. Develop a Targeted Improvement Plan

CMS expects a structured, actionable improvement plan focused on sustainable changes. Think of it as a roadmap to tackle specific compliance areas.

• Set SMART Goals: Goals should be Specific, Measurable, Achievable, Relevant, and Time-based. For instance, “Increase accuracy in pain management documentation by 40% within three months through weekly audits and focused staff training.”
• Break Down Each Goal into Actionable Steps: For example, if documentation is an area for improvement, implement weekly documentation reviews and create templates that guide staff through essential steps in patient notes. Host bi-weekly team check-ins to track progress.
• Assign Clear Responsibilities: Make sure each goal has a designated point person who is responsible for its execution. If reducing pain assessment errors is a priority, for instance, assign a team lead to monitor and follow up on pain management notes.
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4. Implement Ongoing Staff Training

Comprehensive, consistent training is crucial for achieving lasting improvements. Training can help your team develop new skills, reinforce best practices, and align with CMS expectations.

• Prioritize Key Areas like Documentation and Communication: Accurate documentation and clear patient-family communication are essential for CMS compliance. Host monthly workshops focused on documenting patient symptoms, medication administration, and pain management clearly and thoroughly.
• Role-Specific Training: Customize training for each role. Nurses, for instance, might need in-depth sessions on assessment and documentation standards, while social workers may need training on effective communication techniques with families.
• Create a Culture of Continuous Learning: Encourage staff to ask questions, share ideas, and participate actively in training. This involvement not only reinforces knowledge but fosters team accountability.

5. Conduct Routine Internal Audits

Regular audits help you keep track of progress, catch issues early, and make any necessary adjustments. Treat audits as opportunities for improvement, not as a formality.

• Example Audit Process: If you’re focused on improving pain management documentation, conduct weekly audits of patient records to ensure that pain assessments are completed accurately and consistently.
• Follow Up Quickly on Findings: If any gaps or deficiencies are identified in an audit, address them immediately. CMS appreciates seeing a quick, proactive response, and this approach can reinforce your team’s commitment to continuous improvement.

6. Gather and Act on Patient and Family Feedback

Patient and family feedback is central to CMS’s evaluation, so it’s essential to collect and act on this input regularly.

• Supplement CAHPS? Surveys with Additional Feedback: Consider conducting short, focused surveys that address specific aspects of care, like timeliness in communication or satisfaction with pain management.
• Example of Using Feedback: If families frequently request more updates, implement a weekly check-in policy where families are contacted proactively. Document these interactions in patient care records, ensuring all team members are aware of and accountable for regular communication.
• Show Responsiveness: Keep families informed about how you’re using their feedback. If you add a protocol based on family input, communicate this openly. This transparency builds trust and reinforces a commitment to high-quality, responsive care.
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7. Prepare for CMS’s Unannounced Surveys

When CMS arrives for a follow-up survey, your documentation, team, and processes should all be ready. Organization and readiness are key to navigating unannounced surveys confidently.

• Organize Documentation Thoroughly: Ensure patient records, audit results, improvement plans, and training logs are accessible. Being able to quickly provide this information reflects positively on your hospice’s preparedness.
• Review Protocols and Prepare the Team: Regularly review policies and new practices with your team so they feel comfortable and confident. A well-prepared team can answer questions easily, demonstrating their knowledge and commitment.
• Highlight Your Achievements: Use the survey as an opportunity to show CMS the progress you’ve made. For instance, if documentation accuracy has improved, point out specific examples. Don’t be shy about highlighting successes—it shows that your hospice is serious about improvement.

What Happens if You Don’t Graduate from the SFP?

If your hospice doesn’t meet the SFP graduation criteria, CMS may impose further action to ensure compliance. Failing to graduate means CMS sees continued issues affecting care quality or compliance, which could lead to additional penalties.

Potential Consequences of Not Graduating:

• Financial Penalties: CMS may impose fines or reduce Medicare reimbursements if major deficiencies persist. This can have a serious financial impact on your organization.
• Temporary Management: If compliance problems remain unaddressed, CMS may appoint temporary management to oversee your hospice’s operations. Temporary managers ensure CMS standards are met and may implement new procedures to resolve lingering issues.
• Termination from Medicare: If substantial issues continue without resolution, CMS can terminate your hospice from the Medicare program. This step significantly impacts finances and may affect your ability to continue providing services.
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Not graduating from the SFP can disrupt operations, impact finances, and affect the trust patients and families place in your hospice. However, by focusing on proactive improvements and consistent quality, you can avoid these risks and meet CMS’s expectations.

Moving Forward: Building a Culture of Quality and Everyday Readiness

While being selected for the SFP can feel overwhelming, it’s also an opportunity to make lasting improvements in your hospice. By prioritizing everyday readiness, open communication, and structured improvements, you can build a foundation of high-quality, compliant care that meets CMS standards.

Whether you’re aiming to proactively prevent CMS Special Focus Program (SFP) selection or seeking support after being chosen, I’m here to guide your hospice toward strong compliance and readiness. With expertise in regulatory compliance and quality improvement, I can help your team implement best practices, enhance documentation, and build confidence in meeting CMS standards.

Let’s work together to prepare your hospice for consistent quality, ensuring it’s survey-ready and aligned with Medicare’s highest standards. Contact me today to create a tailored plan that not only supports compliance but fosters a culture of excellence and compassionate care.

About me: I’m Irene, and I specialize in helping hospice and home health agencies navigate the tricky waters of compliance, chart audits, and staff training. Through my Compliance Partnership Program, I provide hands-on guidance to ensure your agency is always survey-ready and delivering the highest quality care. Ready to take your compliance to the next level? Reach out to me directly or visit my page to learn how I can help your team thrive. Follow me for more compliance tips.

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