Nursing homes that consistently perform the worst compared with their peers will have to meet tougher standards and demonstrate systemic quality improvements in order to avoid enforcement actions, including being excluded from Medicare and Medicaid, the Health and Human Services Department announced Friday.

The Centers for Medicare and Medicaid Services is revising the Special Focus Facility Program, which addresses poor nursing home performance, to make it harder for troubled facilities to meet its requirements.

“Poor-performing nursing homes have the opportunity to improve, but if they fail to do so, the changes we are making to CMS’ Special Focus Facilities Program will hold these facilities accountable for the health and safety of their residents,” CMS Administrator Chiquita Brooks-LaSure said in a news release.

This increased scrutiny is part of President Joe Biden’s plan—announced in February just ahead of the State of the Union address—to boost nursing home quality and safety by requiring minimum staffing levels, enhanced infection control measures and oversight of nursing homes owned by for- profit companies, among other policies.

There are 88 nursing homes with persistent records of noncompliance participating in the Special Focus Facilities Program this year, or about 0.5% of all nursing homes. To complete the program, nursing homes must pass two consecutive inspections that occur approximately every six months.

The revised program won’t allow nursing homes to exit the program if inspections reveal more than a certain number of deficiencies, or if facilities haven’t significantly improved.

CMS recommends that skilled nursing facilities work with quality improvement organizations and external consultants to implement evidence-based interventions and make meaningful changes to staffing and leadership.

The agency also advises State Survey Agencies to take nursing homes’ staffing levels into consideration, in addition to their compliance histories, when selecting candidates for the Special Focus Facilities Program.

If nursing homes demonstrate continued noncompliance with quality rules or little-to-no demonstrated efforts to improve, CMS will subject them to severe enforcement sanctions, such as discretionary denials of payment for new admissions, civil monetary penalties or directed plans of correction. Any facilities cited for “immediate jeopardy” deficiencies in two surveys while participating in the Special Focus Facilities Program may be terminated from Medicare and Medicaid.

Additionally, CMS is extending the monitoring period for nursing homes that have left the program for possible enforcement actions if their performances decline after they are no longer subject to the extra oversight.