“Nursing facility” defined
Requirements relating to provision of services
Quality of life
In general
A nursing facility must care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident.
Quality assessment and assurance
A nursing facility must maintain a quality assessment and assurance committee, consisting of the director of nursing services, a physician designated by the facility, and at least 3 other members of the facility’s staff, which (i) meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary and (ii) develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this subparagraph.
Scope of services and activities under plan of care
Residents’ assessment
Requirement
Certification
In general
Each such assessment must be conducted or coordinated (with the appropriate participation of health professionals) by a registered professional nurse who signs and certifies the completion of the assessment. Each individual who completes a portion of such an assessment shall sign and certify as to the accuracy of that portion of the assessment.
Penalty for falsification
Use of independent assessors
If a State determines, under a survey under subsection (g) or otherwise, that there has been a knowing and willful certification of false assessments under this paragraph, the State may require (for a period specified by the State) that resident assessments under this paragraph be conducted and certified by individuals who are independent of the facility and who are approved by the State.
Frequency
In general
Resident review
The nursing facility must examine each resident no less frequently than once every 3 months and, as appropriate, revise the resident’s assessment to assure the continuing accuracy of the assessment.
Use
The results of such an assessment shall be used in developing, reviewing, and revising the resident’s plan of care under paragraph (2).
Coordination
Such assessments shall be coordinated with any State-required preadmission screening program to the maximum extent practicable in order to avoid duplicative testing and effort. In addition, a nursing facility shall notify the State mental health authority or State mental retardation or developmental disability authority, as applicable, promptly after a significant change in the physical or mental condition of a resident who is mentally ill or mentally retarded.
Requirements relating to preadmission screening for mentally ill and mentally retarded individuals
Provision of services and activities
In general
Qualified persons providing services
Services described in clauses (i), (ii), (iii), (iv), and (vi) of subparagraph (A) must be provided by qualified persons in accordance with each resident’s written plan of care.
Required nursing care; facility waivers
General requirements
Waiver by State
Assumption of waiver authority by Secretary
If the Secretary determines that a State has shown a clear pattern and practice of allowing waivers in the absence of diligent efforts by facilities to meet the staffing requirements, the Secretary shall assume and exercise the authority of the State to grant waivers.
Required training of nurse aides
In general
Offering competency evaluation programs for current employees
A nursing facility must provide, for individuals used as a nurse aide by the facility as of , for a competency evaluation program approved by the State under subsection (e)(1) and such preparation as may be necessary for the individual to complete such a program by .
Competency
The nursing facility must not permit an individual, other than in a training and competency evaluation program approved by the State, to serve as a nurse aide or provide services of a type for which the individual has not demonstrated competency and must not use such an individual as a nurse aide unless the facility has inquired of any State registry established under subsection (e)(2)(A) that the facility believes will include information concerning the individual.
Re-training required
For purposes of subparagraph (A), if, since an individual’s most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual performed nursing or nursing-related services for monetary compensation, such individual shall complete a new training and competency evaluation program, or a new competency evaluation program.
Regular in-service education
The nursing facility must provide such regular performance review and regular in-service education as assures that individuals used as nurse aides are competent to perform services as nurse aides, including training for individuals providing nursing and nursing-related services to residents with cognitive impairments.
“Nurse aide” defined
Licensed health professional defined
In this paragraph, the term “licensed health professional” means a physician, physician assistant, nurse practitioner, physical, speech, or occupational therapist, physical or occupational therapy assistant, registered professional nurse, licensed practical nurse, or licensed or certified social worker.
Physician supervision and clinical records
Required social services
In the case of a nursing facility with more than 120 beds, the facility must have at least one social worker (with at least a bachelor’s degree in social work or similar professional qualifications) employed full-time to provide or assure the provision of social services.
Information on nurse staffing
In general
A nursing facility shall post daily for each shift the current number of licensed and unlicensed nursing staff directly responsible for resident care in the facility. The information shall be displayed in a uniform manner (as specified by the Secretary) and in a clearly visible place.
Publication of data
A nursing facility shall, upon request, make available to the public the nursing staff data described in subparagraph (A).
Requirements relating to residents’ rights
General rights
Specified rights
Free choice
The right to choose a personal attending physician, to be fully informed in advance about care and treatment, to be fully informed in advance of any changes in care or treatment that may affect the resident’s well-being, and (except with respect to a resident adjudged incompetent) to participate in planning care and treatment or changes in care and treatment.
Free from restraints
Privacy
The right to privacy with regard to accommodations, medical treatment, written and telephonic communications, visits, and meetings of family and of resident groups.
Confidentiality
The right to confidentiality of personal and clinical records and to access to current clinical records of the resident upon request by the resident or the resident’s legal representative, within 24 hours (excluding hours occurring during a weekend or holiday) after making such a request.
Accommodation of needs
Grievances
The right to voice grievances with respect to treatment or care that is (or fails to be) furnished, without discrimination or reprisal for voicing the grievances and the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.
Participation in resident and family groups
The right of the resident to organize and participate in resident groups in the facility and the right of the resident’s family to meet in the facility with the families of other residents in the facility.
Participation in other activities
The right of the resident to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Examination of survey results
The right to examine, upon reasonable request, the results of the most recent survey of the facility conducted by the Secretary or a State with respect to the facility and any plan of correction in effect with respect to the facility.
Refusal of certain transfers
The right to refuse a transfer to another room within the facility, if a purpose of the transfer is to relocate the resident from a portion of the facility that is not a skilled nursing facility (for purposes of subchapter XVIII) to a portion of the facility that is such a skilled nursing facility.
Other rights
Any other right established by the Secretary.
Notice of rights
Rights of incompetent residents
In the case of a resident adjudged incompetent under the laws of a State, the rights of the resident under this subchapter shall devolve upon, and, to the extent judged necessary by a court of competent jurisdiction, be exercised by, the person appointed under State law to act on the resident’s behalf.
Use of psychopharmacologic drugs
Psychopharmacologic drugs may be administered only on the orders of a physician and only as part of a plan (included in the written plan of care described in paragraph (2)) designed to eliminate or modify the symptoms for which the drugs are prescribed and only if, at least annually an independent, external consultant reviews the appropriateness of the drug plan of each resident receiving such drugs.
Transfer and discharge rights
In general
Pre-transfer and pre-discharge notice
In general
Timing of notice
Items included in notice
Orientation
A nursing facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.
Notice on bed-hold policy and readmission
Notice before transfer
Notice upon transfer
At the time of transfer of a resident to a hospital or for therapeutic leave, a nursing facility must provide written notice to the resident and an immediate family member or legal representative of the duration of any period described in clause (i).
Permitting resident to return
Information respecting advance directives
section 1396a(w) of this titleA nursing facility must comply with the requirement of (relating to maintaining written policies and procedures respecting advance directives).
Continuing rights in case of voluntary withdrawal from participation
In general
Information for new residents
Continuation of payments and oversight authority
No application to new residents
This paragraph (other than subclause (III) of clause (i)) shall not apply to an individual who begins residence in a facility on or after the effective date of the withdrawal from participation under this subparagraph.
Access and visitation rights
Equal access to quality care
In general
A nursing facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services required under the State plan for all individuals regardless of source of payment.
Construction
Nothing prohibiting any charges for non-medicaid patients
Subparagraph (A) shall not be construed as prohibiting a nursing facility from charging any amount for services furnished, consistent with the notice in paragraph (1)(B) describing such charges.
No additional services required
Subparagraph (A) shall not be construed as requiring a State to offer additional services on behalf of a resident than are otherwise provided under the State plan.
Admissions policy
Admissions
Construction
No preemption of stricter standards
Subparagraph (A) shall not be construed as preventing States or political subdivisions therein from prohibiting, under State or local law, the discrimination against individuals who are entitled to medical assistance under the State plan with respect to admissions practices of nursing facilities.
Contracts with legal representatives
Subparagraph (A)(ii) shall not be construed as preventing a facility from requiring an individual, who has legal access to a resident’s income or resources available to pay for care in the facility, to sign a contract (without incurring personal financial liability) to provide payment from the resident’s income or resources for such care.
Charges for additional services requested
Subparagraph (A)(iii) shall not be construed as preventing a facility from charging a resident, eligible for medical assistance under the State plan, for items or services the resident has requested and received and that are not specified in the State plan as included in the term “nursing facility services”.
Bona fide contributions
Subparagraph (A)(iii) shall not be construed as prohibiting a nursing facility from soliciting, accepting, or receiving a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to the resident (or potential resident), but only to the extent that such contribution is not a condition of admission, expediting admission, or continued stay in the facility.
Treatment of continuing care retirement communities admission contracts
section 1396r–5 of this titleNotwithstanding subclause (II) of subparagraph (A)(i), subject to subsections (c) and (d) of , contracts for admission to a State licensed, registered, certified, or equivalent continuing care retirement community or life care community, including services in a nursing facility that is part of such community, may require residents to spend on their care resources declared for the purposes of admission before applying for medical assistance.
Protection of resident funds
In general
Management of personal funds
Deposit
The facility must deposit any amount of personal funds in excess of $50 with respect to a resident in an interest bearing account (or accounts) that is separate from any of the facility’s operating accounts and credits all interest earned on such separate account to such account. With respect to any other personal funds, the facility must maintain such funds in a non-interest bearing account or petty cash fund.
Accounting and records
The facility must assure a full and complete separate accounting of each such resident’s personal funds, maintain a written record of all financial transactions involving the personal funds of a resident deposited with the facility, and afford the resident (or a legal representative of the resident) reasonable access to such record.
Notice of certain balances
section 1382(a)(3)(B) of this titleThe facility must notify each resident receiving medical assistance under the State plan under this subchapter when the amount in the resident’s account reaches $200 less than the dollar amount determined under and the fact that if the amount in the account (in addition to the value of the resident’s other nonexempt resources) reaches the amount determined under such section the resident may lose eligibility for such medical assistance or for benefits under subchapter XVI.
Conveyance upon death
Upon the death of a resident with such an account, the facility must convey promptly the resident’s personal funds (and a final accounting of such funds) to the individual administering the resident’s estate.
Assurance of financial security
The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.
Limitation on charges to personal funds
The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under this subchapter or subchapter XVIII.
Limitation on charges in case of medicaid-eligible individuals
In general
A nursing facility may not impose charges, for certain medicaid-eligible individuals for nursing facility services covered by the State under its plan under this subchapter, that exceed the payment amounts established by the State for such services under this subchapter.
“Certain medicaid-eligible individual” defined
In subparagraph (A), the term “certain medicaid-eligible individual” means an individual who is entitled to medical assistance for nursing facility services in the facility under this subchapter but with respect to whom such benefits are not being paid because, in determining the amount of the individual’s income to be applied monthly to payment for the costs of such services, the amount of such income exceeds the payment amounts established by the State for such services under this subchapter.
Posting of survey results
A nursing facility must post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility conducted under subsection (g).
Requirements relating to administration and other matters
Administration
In general
A nursing facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (consistent with requirements established under subsection (f)(5)).
Nursing facility administrator
The administrator of a nursing facility must meet standards established by the Secretary under subsection (f)(4).
22 So in original. There are no subpars. (C) to (U). Availability of survey, certification, and complaint investigation reports
Licensing and Life Safety Code
Licensing
A nursing facility must be licensed under applicable State and local law.
Life Safety Code
Sanitary and infection control and physical environment
Miscellaneous
Compliance with Federal, State, and local laws and professional standards
section 1320a–3 of this titleA nursing facility must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations (including the requirements of ) and with accepted professional standards and principles which apply to professionals providing services in such a facility.
Other
A nursing facility must meet such other requirements relating to the health and safety of residents or relating to the physical facilities thereof as the Secretary may find necessary.
State requirements relating to nursing facility requirements
Specification and review of nurse aide training and competency evaluation programs and of nurse aide competency evaluation programs
Nurse aide registry
In general
By not later than , the State shall establish and maintain a registry of all individuals who have satisfactorily completed a nurse aide training and competency evaluation program, or a nurse aide competency evaluation program, approved under paragraph (1) in the State, or any individual described in subsection (f)(2)(B)(ii) or in subparagraph (B), (C), or (D) of section 6901(b)(4) of the Omnibus Budget Reconciliation Act of 1989.
Information in registry
The registry under subparagraph (A) shall provide (in accordance with regulations of the Secretary) for the inclusion of specific documented findings by a State under subsection (g)(1)(C) of resident neglect or abuse or misappropriation of resident property involving an individual listed in the registry, as well as any brief statement of the individual disputing the findings. The State shall make available to the public information in the registry. In the case of inquiries to the registry concerning an individual listed in the registry, any information disclosed concerning such a finding shall also include disclosure of any such statement in the registry relating to the finding or a clear and accurate summary of such a statement.
Prohibition against charges
A State may not impose any charges on a nurse aide relating to the registry established and maintained under subparagraph (A).
State appeals process for transfers and discharges
The State, for transfers and discharges from nursing facilities effected on or after , must provide for a fair mechanism, meeting the guidelines established under subsection (f)(3), for hearing appeals on transfers and discharges of residents of such facilities; but the failure of the Secretary to establish such guidelines under such subsection shall not relieve any State of its responsibility under this paragraph.
Nursing facility administrator standards
By not later than , the State must have implemented and enforced the nursing facility administrator standards developed under subsection (f)(4) respecting the qualification of administrators of nursing facilities.
Specification of resident assessment instrument
Notice of medicaid rights
Each State, as a condition of approval of its plan under this subchapter, effective , must develop (and periodically update) a written notice of the rights and obligations of residents of nursing facilities (and spouses of such residents) under this subchapter.
State requirements for preadmission screening and resident review
Preadmission screening
In general
Effective , the State must have in effect a preadmission screening program, for making determinations (using any criteria developed under subsection (f)(8)) described in subsection (b)(3)(F) for mentally ill and mentally retarded individuals (as defined in subparagraph (G)) who are admitted to nursing facilities on or after . The failure of the Secretary to develop minimum criteria under subsection (f)(8) shall not relieve any State of its responsibility to have a preadmission screening program under this subparagraph or to perform resident reviews under subparagraph (B).
Clarification with respect to certain readmissions
The preadmission screening program under clause (i) need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital.
Exception for certain hospital discharges
State requirement for resident review
For mentally ill residents
For mentally retarded residents
Review required upon change in resident’s condition
A review and determination under clause (i) or (ii) must be conducted promptly after a nursing facility has notified the State mental health authority or State mental retardation or developmental disability authority, as applicable, under subsection (b)(3)(E) with respect to a mentally ill or mentally retarded resident, that there has been a significant change in the resident’s physical or mental condition.
Prohibition of delegation
A State mental health authority, a State mental retardation or developmental disability authority, and a State may not delegate (by subcontract or otherwise) their responsibilities under this subparagraph to a nursing facility (or to an entity that has a direct or indirect affiliation or relationship with such a facility).
Response to preadmission screening and resident review
Long-term residents not requiring nursing facility services, but requiring specialized services
Other residents not requiring nursing facility services, but requiring specialized services
Residents not requiring nursing facility services and not requiring specialized services
Annual report
Each State shall report to the Secretary annually concerning the number and disposition of residents described in each of clauses (ii) and (iii).
Denial of payment
For failure to conduct preadmission screening or review
section 1396b(a) of this titleNo payment may be made under with respect to nursing facility services furnished to an individual for whom a determination is required under subsection (b)(3)(F) or subparagraph (B) but for whom the determination is not made.
For certain residents not requiring nursing facility level of services
section 1396b(a) of this titleNo payment may be made under with respect to nursing facility services furnished to an individual (other than an individual described in subparagraph (C)(i)) who does not require the level of services provided by a nursing facility.
Permitting alternative disposition plans
With respect to residents of a nursing facility who are mentally retarded or mentally ill and who are determined under subparagraph (B) not to require the level of services of such a facility, but who require specialized services for mental illness or mental retardation, a State and the nursing facility shall be considered to be in compliance with the requirements of subparagraphs (A) through (C) of this paragraph if, before , the State and the Secretary have entered into an agreement relating to the disposition of such residents of the facility and the State is in compliance with such agreement. Such an agreement may provide for the disposition of the residents after the date specified in subparagraph (C). The State may revise such an agreement, subject to the approval of the Secretary, before , but only if, under the revised agreement, all residents subject to the agreement who do not require the level of services of such a facility are discharged from the facility by not later than .
Appeals procedures
Each State, as a condition of approval of its plan under this subchapter, effective , must have in effect an appeals process for individuals adversely affected by determinations under subparagraph (A) or (B).
Definitions
Responsibilities of Secretary relating to nursing facility requirements
General responsibility
It is the duty and responsibility of the Secretary to assure that requirements which govern the provision of care in nursing facilities under State plans approved under this subchapter, and the enforcement of such requirements, are adequate to protect the health, safety, welfare, and rights of residents and to promote the effective and efficient use of public moneys.
Requirements for nurse aide training and competency evaluation programs and for nurse aide competency evaluation programs
In general
Approval of certain programs
Waiver authorized
Waiver of disapproval of nurse-aide training programs
Upon application of a nursing facility, the Secretary may waive the application of subparagraph (B)(iii)(I)(c) if the imposition of the civil monetary penalty was not related to the quality of care provided to residents of the facility. Nothing in this subparagraph shall be construed as eliminating any requirement upon a facility to pay a civil monetary penalty described in the preceding sentence.
Federal guidelines for State appeals process for transfers and discharges
For purposes of subsections (c)(2)(B)(iii) and (e)(3), by not later than , the Secretary shall establish guidelines for minimum standards which State appeals processes under subsection (e)(3) must meet to provide a fair mechanism for hearing appeals on transfers and discharges of residents from nursing facilities.
Secretarial standards qualification of administrators
For purposes of subsections (d)(1)(C) and (e)(4), the Secretary shall develop, by not later than , standards to be applied in assuring the qualifications of administrators of nursing facilities.
Criteria for administration
Specification of resident assessment data set and instruments
List of items and services furnished in nursing facilities not chargeable to the personal funds of a resident
Regulations required
Pursuant to the requirement of section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, the Secretary shall issue regulations, on or before the first day of the seventh month to begin after , that define those costs which may be charged to the personal funds of residents in nursing facilities who are individuals receiving medical assistance with respect to nursing facility services under this subchapter and those costs which are to be included in the payment amount under this subchapter for nursing facility services.
Rule if failure to publish regulations
section 1396a(a)(28)(B) of this titleIf the Secretary does not issue the regulations under subparagraph (A) on or before the date required in that subparagraph, in the case of a resident of a nursing facility who is eligible to receive benefits for nursing facility services under this subchapter, for purposes of , the Secretary shall be deemed to have promulgated regulations under this paragraph which provide that the costs which may not be charged to the personal funds of such resident (and for which payment is considered to be made under this subchapter) include, at a minimum, the costs for routine personal hygiene items and services furnished by the facility.
Federal minimum criteria and monitoring for preadmission screening and resident review
Minimum criteria
The Secretary shall develop, by not later than , minimum criteria for States to use in making determinations under subsections (b)(3)(F) and (e)(7)(B) and in permitting individuals adversely affected to appeal such determinations, and shall notify the States of such criteria.
Monitoring compliance
The Secretary shall review, in a sufficient number of cases to allow reasonable inferences, each State’s compliance with the requirements of subsection (e)(7)(C)(ii) (relating to discharge and placement for active treatment of certain residents).
Criteria for monitoring State waivers
The Secretary shall develop, by not later than , criteria and procedures for monitoring State performances in granting waivers pursuant to subsection (b)(4)(C)(ii).
Special focus facility program
In general
The Secretary shall conduct a special focus facility program for enforcement of requirements for nursing facilities that the Secretary has identified as having substantially failed to meet applicable requirements of this chapter.
Periodic surveys
Under such program the Secretary shall conduct surveys of each facility in the program not less often than once every 6 months.
Survey and certification process
State and Federal responsibility
In general
Under each State plan under this subchapter, the State shall be responsible for certifying, in accordance with surveys conducted under paragraph (2), the compliance of nursing facilities (other than facilities of the State) with the requirements of subsections (b), (c), and (d). The Secretary shall be responsible for certifying, in accordance with surveys conducted under paragraph (2), the compliance of State nursing facilities with the requirements of such subsections.
Educational program
Each State shall conduct periodic educational programs for the staff and residents (and their representatives) of nursing facilities in order to present current regulations, procedures, and policies under this section.
Investigation of allegations of resident neglect and abuse and misappropriation of resident property
The State shall provide, through the agency responsible for surveys and certification of nursing facilities under this subsection, for a process for the receipt and timely review and investigation of allegations of neglect and abuse and misappropriation of resident property by a nurse aide of a resident in a nursing facility or by another individual used by the facility in providing services to such a resident. The State shall, after notice to the individual involved and a reasonable opportunity for a hearing for the individual to rebut allegations, make a finding as to the accuracy of the allegations. If the State finds that a nurse aide has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the nurse aide and the registry of such finding. If the State finds that any other individual used by the facility has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the appropriate licensure authority. A State shall not make a finding that an individual has neglected a resident if the individual demonstrates that such neglect was caused by factors beyond the control of the individual.
Removal of name from nurse aide registry
In general
Timing of determination
In no case shall a determination on a petition submitted under clause (i) be made prior to the expiration of the 1-year period beginning on the date on which the name of the petitioner was added to the registry under subparagraph (C).
Construction
The failure of the Secretary to issue regulations to carry out this subsection shall not relieve a State of its responsibility under this subsection.
Surveys
Annual standard survey
In general
section 1320a–7a of this titlesection 1320a–7a(a) of this titleEach nursing facility shall be subject to a standard survey, to be conducted without any prior notice to the facility. Any individual who notifies (or causes to be notified) a nursing facility of the time or date on which such a survey is scheduled to be conducted is subject to a civil money penalty of not to exceed $2,000. The provisions of (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under . The Secretary shall review each State’s procedures for scheduling and conduct of standard surveys to assure that the State has taken all reasonable steps to avoid giving notice of such a survey through the scheduling procedures and the conduct of the surveys themselves.
Contents
Frequency
In general
Each nursing facility shall be subject to a standard survey not later than 15 months after the date of the previous standard survey conducted under this subparagraph. The statewide average interval between standard surveys of a nursing facility shall not exceed 12 months.
Special surveys
If not otherwise conducted under subclause (I), a standard survey (or an abbreviated standard survey) may be conducted within 2 months of any change of ownership, administration, management of a nursing facility, or director of nursing in order to determine whether the change has resulted in any decline in the quality of care furnished in the facility.
Extended surveys
In general
Each nursing facility which is found, under a standard survey, to have provided substandard quality of care shall be subject to an extended survey. Any other facility may, at the Secretary’s or State’s discretion, be subject to such an extended survey (or a partial extended survey).
Timing
The extended survey shall be conducted immediately after the standard survey (or, if not practicable, not later than 2 weeks after the date of completion of the standard survey).
Contents
In such an extended survey, the survey team shall review and identify the policies and procedures which produced such substandard quality of care and shall determine whether the facility has complied with all the requirements described in subsections (b), (c), and (d). Such review shall include an expansion of the size of the sample of residents’ assessments reviewed and a review of the staffing, of in-service training, and, if appropriate, of contracts with consultants.
Construction
Nothing in this paragraph shall be construed as requiring an extended or partial extended survey as a prerequisite to imposing a sanction against a facility under subsection (h) on the basis of findings in a standard survey.
Survey protocol
Consistency of surveys
Each State shall implement programs to measure and reduce inconsistency in the application of survey results among surveyors.
Survey teams
In general
Surveys under this subsection shall be conducted by a multidisciplinary team of professionals (including a registered professional nurse).
Prohibition of conflicts of interest
A State may not use as a member of a survey team under this subsection an individual who is serving (or has served within the previous 2 years) as a member of the staff of, or as a consultant to, the facility surveyed respecting compliance with the requirements of subsections (b), (c), and (d), or who has a personal or familial financial interest in the facility being surveyed.
Training
The Secretary shall provide for the comprehensive training of State and Federal surveyors in the conduct of standard and extended surveys under this subsection, including the auditing of resident assessments and plans of care. No individual shall serve as a member of a survey team unless the individual has successfully completed a training and testing program in survey and certification techniques that has been approved by the Secretary.
Validation surveys
In general
The Secretary shall conduct onsite surveys of a representative sample of nursing facilities in each State, within 2 months of the date of surveys conducted under paragraph (2) by the State, in a sufficient number to allow inferences about the adequacies of each State’s surveys conducted under paragraph (2). In conducting such surveys, the Secretary shall use the same survey protocols as the State is required to use under paragraph (2). If the State has determined that an individual nursing facility meets the requirements of subsections (b), (c), and (d), but the Secretary determines that the facility does not meet such requirements, the Secretary’s determination as to the facility’s noncompliance with such requirements is binding and supersedes that of the State survey.
Scope
With respect to each State, the Secretary shall conduct surveys under subparagraph (A) each year with respect to at least 5 percent of the number of nursing facilities surveyed by the State in the year, but in no case less than 5 nursing facilities in the State.
Reduction in administrative costs for substandard performance
section 1396b(a)(2)(D) of this titlesection 1316 of this titlesection 1316(a)(1) of this titleIf the Secretary finds, on the basis of such surveys, that a State has failed to perform surveys as required under paragraph (2) or that a State’s survey and certification performance otherwise is not adequate, the Secretary may provide for the training of survey teams in the State and shall provide for a reduction of the payment otherwise made to the State under with respect to a quarter equal to 33 percent multiplied by a fraction, the denominator of which is equal to the total number of residents in nursing facilities surveyed by the Secretary that quarter and the numerator of which is equal to the total number of residents in nursing facilities which were found pursuant to such surveys to be not in compliance with any of the requirements of subsections (b), (c), and (d). A State that is dissatisfied with the Secretary’s findings under this subparagraph may obtain reconsideration and review of the findings under in the same manner as a State may seek reconsideration and review under that section of the Secretary’s determination under .
Special surveys of compliance
Where the Secretary has reason to question the compliance of a nursing facility with any of the requirements of subsections (b), (c), and (d), the Secretary may conduct a survey of the facility and, on the basis of that survey, make independent and binding determinations concerning the extent to which the nursing facility meets such requirements.
Investigation of complaints and monitoring nursing facility compliance
Disclosure of results of inspections and activities
Public information
Notice to ombudsman
42 U.S.C. 302142 U.S.C. 3058g5
Notice to physicians and nursing facility administrator licensing board
Access to fraud control units
section 1396b(q) of this titleEach State shall provide its State medicaid fraud and abuse control unit (established under ) with access to all information of the State agency responsible for surveys and certifications under this subsection.
Submission of survey and certification information to the Secretary
In order to improve the timeliness of information made available to the public under subparagraph (A) and provided on the Nursing Home Compare Medicare website under subsection (i), each State shall submit information respecting any survey or certification made respecting a nursing facility (including any enforcement actions taken by the State) to the Secretary not later than the date on which the State sends such information to the facility. The Secretary shall use the information submitted under the preceding sentence to update the information provided on the Nursing Home Compare Medicare website as expeditiously as practicable but not less frequently than quarterly.
Enforcement process
In general
Specified remedies
Listing
Deadline and guidance
Assuring prompt compliance
If a nursing facility has not complied with any of the requirements of subsections (b), (c), and (d), within 3 months after the date the facility is found to be out of compliance with such requirements, the State shall impose the remedy described in subparagraph (A)(i) for all individuals who are admitted to the facility after such date.
Repeated noncompliance
Funding
section 1396b(a)(7) of this titleThe reasonable expenditures of a State to provide for temporary management and other expenses associated with implementing the remedies described in clauses (iii) and (iv) of subparagraph (A) shall be considered, for purposes of , to be necessary for the proper and efficient administration of the State plan.
Incentives for high quality care
section 1396b(a)(7) of this titleIn addition to the remedies specified in this paragraph, a State may establish a program to reward, through public recognition, incentive payments, or both, nursing facilities that provide the highest quality care to residents who are entitled to medical assistance under this subchapter. For purposes of , proper expenses incurred by a State in carrying out such a program shall be considered to be expenses necessary for the proper and efficient administration of the State plan under this subchapter.
Secretarial authority
For State nursing facilities
With respect to a State nursing facility, the Secretary shall have the authority and duties of a State under this subsection, including the authority to impose remedies described in clauses (i), (ii), and (iii) of paragraph (2)(A).
Other nursing facilities
Specified remedies
Denial of payment
The Secretary may deny any further payments to the State for medical assistance furnished by the facility to all individuals in the facility or to individuals admitted to the facility after the effective date of the finding.
Authority with respect to civil money penalties
In general
section 1320a–7a of this titlesection 1320a–7a(a) of this titleSubject to subclause (II), the Secretary may impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance. The provisions of (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under .
Reduction of civil money penalties in certain circumstances
Subject to subclause (III), in the case where a facility self-reports and promptly corrects a deficiency for which a penalty was imposed under this clause not later than 10 calendar days after the date of such imposition, the Secretary may reduce the amount of the penalty imposed by not more than 50 percent.
Prohibitions on reduction for certain deficiencies
Repeat deficiencies
The Secretary may not reduce the amount of a penalty under subclause (II) if the Secretary had reduced a penalty imposed on the facility in the preceding year under such subclause with respect to a repeat deficiency.
Certain other deficiencies
The Secretary may not reduce the amount of a penalty under subclause (II) if the penalty is imposed on the facility for a deficiency that is found to result in a pattern of harm or widespread harm, immediately jeopardizes the health or safety of a resident or residents of the facility, or results in the death of a resident of the facility.
Collection of civil money penalties
Appointment of temporary management
Continuation of payments pending remediation
Effective period of denial of payment
A finding to deny payment under this subsection shall terminate when the State or Secretary (or both, as the case may be) finds that the facility is in substantial compliance with all the requirements of subsections (b), (c), and (d).
Immediate termination of participation for facility where State or Secretary finds noncompliance and immediate jeopardy
6
Special rules where State and Secretary do not agree on finding of noncompliance
State finding of noncompliance and no secretarial finding of noncompliance
If the Secretary finds that a nursing facility has met all the requirements of subsections (b), (c), and (d), but a State finds that the facility has not met such requirements and the failure does not immediately jeopardize the health or safety of its residents, the State’s findings shall control and the remedies imposed by the State shall be applied.
Secretarial finding of noncompliance and no State finding of noncompliance
Special rules for timing of termination of participation where remedies overlap
Construction
7
Sharing of information
Notwithstanding any other provision of law, all information concerning nursing facilities required by this section to be filed with the Secretary or a State agency shall be made available by such facilities to Federal or State employees for purposes consistent with the effective administration of programs established under this subchapter and subchapter XVIII, including investigations by State medicaid fraud control units.
Nursing Home Compare website
Inclusion of additional information
In general
Deadline for provision of information
In general
Except as provided in clause (ii), the Secretary shall ensure that the information described in subparagraph (A) is included on such website (or a successor website) not later than 1 year after .
Exception
section 1320a–7j(g) of this titleThe Secretary shall ensure that the information described in subparagraph (A)(i) is included on such website (or a successor website) not later than the date on which the requirements under are implemented.
Review and modification of website
In general
Consultation
Construction
section 1395i–3 of this titlesection 1395i–3 of this titleWhere requirements or obligations under this section are identical to those provided under , the fulfillment of those requirements or obligations under shall be considered to be the fulfillment of the corresponding requirements or obligations under this section.
Funding for State strike teams
section 1320b–5(g)(1)(B) of this titleIn addition to amounts otherwise available, there is appropriated to the Secretary, out of any monies in the Treasury not otherwise appropriated, $250,000,000, to remain available until expended, for purposes of allocating such amount among the States (including the District of Columbia and each territory of the United States) for such a State to establish and implement a strike team that will be deployed to a nursing facility in the State with diagnosed or suspected cases of COVID–19 among residents or staff for the purposes of assisting with clinical care, infection control, or staffing during the emergency period described in and the 1-year period immediately following the end of such emergency period.
Aug. 14, 1935, ch. 531Pub. L. 100–203, title IV101 Stat. 1330–182Pub. L. 100–360, title IV, § 411l102 Stat. 803–805Pub. L. 100–360, title III, § 303(a)(2)l102 Stat. 760Pub. L. 100–485, title VI, § 608(d)(27)(C)102 Stat. 2423Pub. L. 101–239, title VI, § 6901(b)(1)103 Stat. 2298–2301Pub. L. 101–508, title IV104 Stat. 1388–205Pub. L. 102–375, title VII, § 708(a)(1)(B)106 Stat. 1292Pub. L. 104–315110 Stat. 3824Pub. L. 105–15, § 1111 Stat. 34Pub. L. 105–33, title IV111 Stat. 526Pub. L. 106–4, § 2(a)113 Stat. 7Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 608(p)]113 Stat. 1536Pub. L. 106–402, title IV, § 401(b)(6)(A)114 Stat. 1738Pub. L. 106–554, § 1(a)(6) [title IX, § 941(b)]114 Stat. 2763Pub. L. 108–173, title IX, § 932(c)(2)117 Stat. 2401Pub. L. 109–171, title VI, § 6015(a)120 Stat. 65Pub. L. 109–432, div. B, title IV, § 405(c)(2)(B)120 Stat. 3000Pub. L. 111–148, title VI124 Stat. 702Pub. L. 117–2, title IX, § 9818135 Stat. 218(, title XIX, § 1919, as added and amended , §§ 4211(a)(3), (c), 4212(a), (b), 4213(a), 4216, , , 1330–196, 1330–207, 1330–213, 1330–220, as amended ()(3)(C)(ii), (6)(B), (8)(A), , ; , title IV, § 411()(2)(A)–(D), (F)–(K), (L)(ii), (3)(A), (B), (C)(iii), (D), (5), (6)(A), (7), (8)(B), , , 801–805, as amended –(E), (I), , ; , (3), (4)(A), (d)(1), (4), , ; , §§ 4751(b)(2), 4801(a)(2)–(6)(A), (7), (b)(2)–(5)(A), (6)–(8), (d)(1), (e)(2)–(7)(A), (8)–(10), (12)–(15), (18), , , 1388–211 to 1388–219; , , ; , §§ 1(a), 2(a), (b), , ; , , ; , §§ 4754(a), 4755(b), , ; , , ; , , , 1501A–397; , , ; , , , 2763A–586; , , ; , , ; , , ; , §§ 6101(c)(1)(B), 6103(b)(1), (2)(A), (3), (c)(2), 6111(b), 6121(b), , , 707–709, 715, 721; , , .)
Editorial Notes
References in Text
Pub. L. 89–7379 Stat. 218Pub. L. 106–501, title III, § 306(5)114 Stat. 2244section 3027(a)(9) of this titlesection 3001 of this titleThe Older Americans Act of 1965, referred to in subsecs. (b)(4)(C)(ii)(IV), (c)(2)(B)(iii)(II), and (g)(5)(B), is , , . Section 307(a)(12) of the Act was repealed by , , , and provisions formerly appearing in section 307(a)(12) of the Act are now contained in section 307(a)(9) of the Act, which is classified to . Titles III and VII of the Act are classified generally to subchapters III (§ 3021 et seq.) and XI (§ 3058 et seq.), respectively, of chapter 35 of this title. For complete classification of this Act to the Code, see Short Title note set out under and Tables.
Pub. L. 106–402114 Stat. 1677section 15001 of this titleThe Developmental Disabilities Assistance and Bill of Rights Act of 2000, referred to in subsec. (c)(2)(B)(iii)(III), is , , . Subtitle C of the Act probably means subtitle C of title I of the Act, which is classified generally to part C (§ 15041 et seq.) of subchapter I of chapter 144 of this title. For complete classification of this Act to the Code, see Short Title note set out under and Tables.
Pub. L. 99–319100 Stat. 478Pub. L. 99–319Pub. L. 106–310, div. B, title XXXII, § 3206(a)114 Stat. 1193section 10801 of this titleThe Protection and Advocacy for Mentally Ill Individuals Act [of 1986], referred to in subsec. (c)(2)(B)(iii)(IV), was , , . was renamed the Protection and Advocacy for Individuals with Mental Illness Act by , , , and is classified generally to chapter 114 (§ 10801 et seq.) of this title. For complete classification of this Act to the Code, see Short Title note set out under and Tables.
Pub. L. 101–239section 1395i–3 of this titleSection 6901(b)(4)(B)–(D) of the Omnibus Budget Reconciliation Act of 1989, referred to in subsec. (e)(2)(A), is section 6901(b)(4)(B)–(D) of , which is set out as a note under .
Pub. L. 95–142section 1395x of this titleSection 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, referred to in subsec. (f)(7)(A), probably means section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments, , which is set out as a note under .
Prior Provisions
section 1396r–3 of this titleA prior section 1919 of act , was renumbered section 1922 and is classified to .
Amendments
Pub. L. 117–22021—Subsec. (k). added subsec. (k).
Pub. L. 111–148, § 6121(b)(2)2010—Subsec. (b)(5)(F). , inserted concluding provisions.
Pub. L. 111–148, § 6101(c)(1)(B)Subsec. (d)(1)(B), (C). , redesignated subpar. (C) as (B) and struck out former subpar. (B) which related to required notice to a State licensing agency of change in ownership, control interest, management, or certain positions of responsibility for a nursing facility.
Pub. L. 111–148, § 6103(c)(2)Subsec. (d)(1)(V). , added subpar. (V).
Pub. L. 111–148, § 6121(b)(1)Subsec. (f)(2)(A)(i)(I). , inserted “ (including, in the case of initial training and, if the Secretary determines appropriate, in the case of ongoing training, dementia management training, and patient abuse prevention training” before “, (II)”.
Pub. L. 111–148, § 6103(b)(3)Subsec. (f)(10). , added par. (10).
Pub. L. 111–148, § 6103(b)(2)(A)Subsec. (g)(5)(E). , added subpar. (E).
Pub. L. 111–148, § 6111(b)(1)Subsec. (h)(3)(C)(ii). , designated existing provisions as subcl. (I), inserted heading, substituted “Subject to subclause (II), the Secretary” for “The Secretary”, and added subcls. (II) to (IV).
Pub. L. 111–148, § 6111(b)(2)Subsec. (h)(8). , which directed insertion of “(ii)(IV),” after “(i),” in subsec. “(h)(5)(8)” of this section, was executed to subsec. (h)(8), to reflect the probable intent of Congress. Subsec. (h)(5) does not contain “(i),”.
Pub. L. 111–148, § 6103(b)(1)Subsecs. (i), (j). , added subsec. (i) and redesignated former subsec. (i) as (j).
Pub. L. 109–4322006—Subsec. (c)(5)(A)(i)(II). substituted “subparagraph (B)(v)” for “clause (v)”.
Pub. L. 109–171, § 6015(a)(1), inserted “subject to clause (v)” after “(II)”.
Pub. L. 109–171, § 6015(a)(2)Subsec. (c)(5)(B)(v). , added cl. (v).
Pub. L. 108–173, § 932(c)(2)(A)2003—Subsec. (f)(2)(B)(iii). , substituted “subparagraphs (C) and (D)” for “subparagraph (C)” in introductory provisions.
Pub. L. 108–173, § 932(c)(2)(B)Subsec. (f)(2)(D). , added subpar. (D).
Pub. L. 106–5542000—Subsec. (b)(8). added par. (8).
Pub. L. 106–402Subsec. (c)(2)(B)(iii)(III). substituted “subtitle C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000” for “part C of the Developmental Disabilities Assistance and Bill of Rights Act”.
Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(p)(1)]1999—Subsec. (b)(3)(C)(i)(I). , struck out “not later than” before “14 days”.
Pub. L. 106–4Subsec. (c)(2)(F). added subpar. (F).
Pub. L. 106–113, § 1000(a)(6) [title VI, § 608(p)(2)]section 1320a–3 of this titleSubsec. (d)(4)(A). , inserted closing parenthesis after “”.
Pub. L. 105–15, § 1(1)1997—Subsec. (f)(2)(B)(iii). , inserted “subject to subparagraph (C),” after “(iii)”.
Pub. L. 105–15, § 1(2)Subsec. (f)(2)(C). , added subpar. (C).
Pub. L. 105–33, § 4755(b)Subsec. (g)(1)(D), (E). , added subpar. (D) and redesignated former subpar. (D) as (E).
Pub. L. 105–33, § 4754(a)Subsec. (h)(3)(D). , inserted “and” at end of cl. (i), substituted a period for “, and” at end of cl. (ii), and struck out cl. (iii) which read as follows: “the State agrees to repay to the Federal Government payments received under this subparagraph if the corrective action is not taken in accordance with the approved plan and timetable.”
Pub. L. 104–315, § 2(a)1996—Subsec. (b)(3)(E). , inserted at end “In addition, a nursing facility shall notify the State mental health authority or State mental retardation or developmental disability authority, as applicable, promptly after a significant change in the physical or mental condition of a resident who is mentally ill or mentally retarded.”
Pub. L. 104–315, § 1(a)(1)(A)Subsec. (e)(7)(B). , struck out “annual” before “resident review” in heading.
Pub. L. 104–315, § 2(b)Subsec. (e)(7)(B)(iii). , added cl. (iii).
Pub. L. 104–315, § 1(a)(1)(B), struck out cl. (iii) which related to frequency of reviews as annual, preadmission, and initial.
Pub. L. 104–315, § 1(a)(2)Subsec. (e)(7)(D)(i). , struck out “annual” before “review” in heading.
Pub. L. 102–3751992—Subsecs. (c)(2)(B)(iii)(II), (g)(5)(B). substituted “title III or VII of the Older Americans Act of 1965 in accordance with section 712 of the Act” for “section 307(a)(12) of the Older Americans Act of 1965”.
Pub. L. 101–508, § 4801(e)(2)1990—Subsec. (b)(1)(B). , inserted at end “A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this subparagraph.”
Pub. L. 101–508, § 4801(e)(3)Subsec. (b)(3)(C)(i)(I). , substituted “not later than 14 days” for “4 days”.
Pub. L. 101–508, § 4801(b)(8)Subsec. (b)(3)(F). , substituted “specialized services” for “active treatment” in cls. (i) and (ii).
Pub. L. 101–508, § 4801(b)(4)(A), inserted at end “A State mental health authority and a State mental retardation or developmental disability authority may not delegate (by subcontract or otherwise) their responsibilities under this subparagraph to a nursing facility (or to an entity that has a direct or indirect affiliation or relationship with such a facility).”
Pub. L. 101–508, § 4801(b)(2)(A), substituted “Except as provided in clauses (ii) and (iii) of subsection (e)(7)(A), a nursing facility” for “A nursing facility” in introductory provisions.
Pub. L. 101–508, § 4801(e)(4)Subsec. (b)(4)(A)(vii). , added cl. (vii).
Pub. L. 101–508, § 4801(e)(5)(A)Subsec. (b)(4)(C)(ii). , substituted “To the extent that a facility is unable to meet the requirements of clause (i), a State may waive such requirements with respect to the facility if” for “A State may waive the requirement of subclause (I) or (II) of clause (i) with respect to a facility if” in introductory provisions.
Pub. L. 101–508, § 4801(e)(5)(B)Subsec. (b)(4)(C)(ii)(IV), (V). –(D), which directed amendment of cl. (ii) by adding subcls. (IV) and (V) at the end, was executed by adding subcls. (IV) and (V) after subcl. (III) and before concluding provisions to reflect the probable intent of Congress.
Pub. L. 101–508, § 4801(a)(2)Subsec. (b)(5)(A). , designated existing provision as cl. (i), substituted “Except as provided in clause (ii), a nursing facility” for “A nursing facility” and “on a full-time basis” for “(on a full-time, temporary, per diem, or other basis)”, redesignated former cls. (i) and (ii) as subcls. (I) and (II), respectively, and added cl. (ii).
Pub. L. 101–508, § 4801(a)(3)Subsec. (b)(5)(C). , substituted “any State registry established under subsection (e)(2)(A) that the facility believes will include information” for “the State registry established under subsection (e)(2)(A) as to information in the registry”.
Pub. L. 101–508, § 4801(a)(4)Subsec. (b)(5)(D). , inserted before period at end “, or a new competency evaluation program”.
Pub. L. 101–508, § 4801(e)(6)Subsec. (b)(5)(F)(i). , substituted “(G)) or a registered dietician” for “(G))”.
Pub. L. 101–508, § 4801(d)(1)Subsec. (b)(6)(A). , inserted before semicolon at end “(or, at the option of a State, under the supervision of a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility but who is working in collaboration with a physician)”.
Pub. L. 101–508, § 4801(e)(8)(B)Subsec. (c)(1)(A). , inserted at end “A resident’s exercise of a right to refuse transfer under clause (x) shall not affect the resident’s eligibility or entitlement to medical assistance under this subchapter or a State’s entitlement to Federal medical assistance under this subchapter with respect to services furnished to such a resident.”
Pub. L. 101–508, § 4801(e)(9)Subsec. (c)(1)(A)(iv). , inserted before period at end “and to access to current clinical records of the resident upon request by the resident or the resident’s legal representative, within 24 hours (excluding hours occurring during a weekend or holiday) after making such a request”.
Pub. L. 101–508, § 4801(e)(8)(A)Subsec. (c)(1)(A)(x), (xi). , added cl. (x) and redesignated former cl. (x) as (xi).
Pub. L. 101–508, § 4801(e)(10)Subsec. (c)(1)(B)(ii). , inserted “including the notice (if any) of the State developed under subsection (e)(6)” after “in such rights)”.
Pub. L. 101–508, § 4751(b)(2)Subsec. (c)(2)(E). , added subpar. (E).
Pub. L. 101–508, § 4801(e)(7)(A)Subsec. (c)(7), (8). , added par. (7) and redesignated former par. (7) as (8).
Pub. L. 101–508, § 4801(e)(18)Subsec. (e)(1)(A). , substituted “under subsection (f)(2)” for “under clause (i) or (ii) of subsection (f)(2)(A)”.
Pub. L. 101–508, § 4801(e)(12)(A)Subsec. (e)(2)(A). , inserted “, or any individual described in subsection (f)(2)(B)(ii) or in subparagraph (B), (C), or (D) of section 6901(b)(4) of the Omnibus Budget Reconciliation Act of 1989” after “in the State”.
Pub. L. 101–508, § 4801(e)(12)(B)Subsec. (e)(2)(C). , added subpar. (C).
Pub. L. 101–508, § 4801(b)(2)(B)Subsec. (e)(7)(A). , designated existing provision as cl. (i), inserted cl. (i) heading, and added cls. (ii) and (iii).
Pub. L. 101–508, § 4801(b)(8)Subsec. (e)(7)(B)(i)(II), (ii)(II). , substituted “specialized services” for “active treatment”.
Pub. L. 101–508, § 4801(b)(4)(B)Subsec. (e)(7)(B)(iv). , added cl. (iv).
Pub. L. 101–508, § 4801(b)(8)Subsec. (e)(7)(C)(i) to (iii). , substituted “specialized services” for “active treatment” wherever appearing.
Pub. L. 101–508, § 4801(b)(5)(A)Subsec. (e)(7)(C)(iv). , added cl. (iv).
Pub. L. 101–508, § 4801(b)(3)(A)Subsec. (e)(7)(D). , struck out “where failure to conduct preadmission screening” after “Denial of payment” in heading, designated existing provisions as cl. (i), inserted cl. (i) heading, and added cl. (ii).
Pub. L. 101–508, § 4801(b)(8)Subsec. (e)(7)(E). , substituted “specialized services” for “active treatment”.
Pub. L. 101–508, § 4801(b)(6), inserted at end “The State may revise such an agreement, subject to the approval of the Secretary, before , but only if, under the revised agreement, all residents subject to the agreement who do not require the level of services of such a facility are discharged from the facility by not later than .”
Pub. L. 101–508, § 4801(b)(3)(B), substituted “the requirements of subparagraphs (A) through (C) of this paragraph” for “the requirement of this paragraph”.
Pub. L. 101–508, § 4801(b)(7)Subsec. (e)(7)(G)(i). , substituted “serious mental illness (as defined by the Secretary in consultation with the National Institute of Mental Health)” for “primary or secondary diagnosis of mental disorder (as defined in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition)” and inserted before period at end “or a diagnosis (other than a primary diagnosis) of dementia and a primary diagnosis that is not a serious mental illness”.
Pub. L. 101–508, § 4801(b)(8)Subsec. (e)(7)(G)(iii). , substituted “specialized services” for “active treatment”.
Pub. L. 101–508, § 4801(a)(5)(B)Subsec. (f)(2)(A)(iv)(II). , inserted “who is employed by (or who has received an offer of employment from) a facility on the date on which the aide begins either such program” after “nurse aide”.
Pub. L. 101–508, § 4801(a)(5)(A)Subsec. (f)(2)(A)(iv)(III). , (C), (D), added subcl. (III).
Pub. L. 101–508, § 4801(a)(7)Subsec. (f)(2)(B). , inserted “(through subcontract or otherwise)” after “may not delegate” in last sentence.
Pub. L. 101–508, § 4801(a)(6)(A)Subsec. (f)(2)(B)(iii)(I). , amended subcl. (I) generally. Prior to amendment, subcl. (I) read as follows: “offered by or in a nursing facility which has been determined to be out of compliance with the requirements of subsection (b), (c), or (d) of this section, within the previous 2 years, or”.
Pub. L. 101–508, § 4801(e)(13)Subsec. (g)(1)(C). , inserted at end “A State shall not make a finding that an individual has neglected a resident if the individual demonstrates that such neglect was caused by factors beyond the control of the individual.”
Pub. L. 101–508, § 4801(e)(14)Subsec. (g)(5)(A)(i). , substituted “deficiencies, within 14 calendar days after such information is made available to those facilities, and approved plans” for “deficiencies and plans”.
Pub. L. 101–508, § 4801(e)(15)Subsec. (g)(5)(B). , substituted “or of any adverse action taken against a nursing facility under paragraphs (1), (2), or (3) of subsection (h), with respect” for “with respect”.
Pub. L. 101–239, § 6901(b)(1)(A)1989—Subsec. (b)(5)(A). , substituted “” for “” in introductory provisions.
Pub. L. 101–239, § 6901(b)(1)(B)Subsec. (b)(5)(B). , substituted “” and “” for “” and “”, respectively.
Pub. L. 101–239, § 6901(d)(4)(A)Subsec. (c)(1)(A)(ii)(II). , substituted “Secretary until such an order could reasonably be obtained)” for “Secretary) until such an order could reasonably be obtained”.
Pub. L. 101–239, § 6901(d)(4)(B)Subsec. (c)(1)(A)(v)(I). , substituted “accommodation” for “accommodations”.
Pub. L. 101–239, § 6901(d)(4)(C)Subsec. (f)(2)(A)(i)(I). , substituted “and content of the curriculum” for “, content of the curriculum”.
Pub. L. 101–239, § 6901(b)(3)(A), inserted “care of cognitively impaired residents,” after “social service needs,”.
Pub. L. 101–239, § 6901(b)(3)(B)Subsec. (f)(2)(A)(ii). , substituted “recognition of mental health and social service needs, care of cognitively impaired residents” for “cognitive, behavioral and social care”.
Pub. L. 101–239, § 6901(b)(3)(C)Subsec. (f)(2)(A)(iv). , (D), added cl. (iv).
Pub. L. 101–239, § 6901(b)(4)(A)Subsec. (f)(2)(B)(ii). , substituted “” for “”.
Pub. L. 101–239, § 6901(d)(4)(D)Subsec. (h)(3)(D). , substituted “not longer than 6 months after the effective date of the findings” for “not longer than 6 months”.
Pub. L. 101–239, § 6901(d)(1)Subsec. (h)(8). , inserted at end “The provisions of this subsection shall apply to a nursing facility (or portion thereof) notwithstanding that the facility (or portion thereof) also is a skilled nursing facility for purposes of subchapter XVIII.”
Pub. L. 100–360, § 411l1988—Subsec. (b)(3)(A)(iii). ()(2)(B), struck out “in the case of a resident eligible for benefits under this subchapter,” before “uses an instrument”.
Pub. L. 100–360, § 411lPub. L. 100–485, § 608(d)(27)(C)Subsec. (b)(3)(A)(iv). ()(2)(A), as amended by , struck out “in the case of a resident eligible for benefits under part A of subchapter XVIII of this chapter,” before “includes the identification of medical problems”.
Pub. L. 100–360, § 411lsection 1320a–7a of this titleSubsec. (b)(3)(B)(ii)(III). ()(2)(C), amended subcl. (III) generally. Prior to amendment, subcl. (III) read as follows: “The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under .”
Pub. L. 100–360, § 411lSubsec. (b)(4)(C)(i)(II). ()(3)(A)(i), inserted “professional” after “registered”.
Pub. L. 100–360, § 411lSubsec. (b)(4)(C)(ii). ()(3)(A)(i)–(iv), in heading, substituted “(ii) Waiver” for “(ii) Facility waivers.—(i) Waiver”, in subcl. (III), inserted “professional” after “registered”, and in concluding provisions, substituted “clause (iii)” for “clause (ii)” and “use” for “employ”.
Pub. L. 100–360, § 411lSubsec. (b)(4)(C)(iii). ()(3)(A)(v), (vi), substituted “(iii) Assumption” for “(ii) Assumption” in heading and “exercise” for “excercise” in text.
Pub. L. 100–360, § 411lPub. L. 100–360, § 411lSubsec. (b)(5)(A). ()(3)(B), which directed amendment of subpar. (A) by striking “subparagraph (E)” and inserting “subparagraph (F)”, could not be executed because of prior amendment by ()(2)(D)(i), see Amendment note below.
Pub. L. 100–360, § 411lPub. L. 100–485, § 608(d)(27)(D)()(2)(D)(i), as amended by , struck out “, who is not a licensed health professional (as defined in subparagraph (E)),” after “any individual” in introductory provisions.
Pub. L. 100–360, § 411lSubsec. (b)(5)(A)(ii). ()(2)(D)(ii), substituted “nursing or nursing-related services” for “such services”.
Pub. L. 100–360, § 411lSubsec. (b)(5)(G). ()(2)(D)(iii), inserted “physical or occupational therapy assistant,” after “occupational therapist,”.
Pub. L. 100–360, § 303(a)(2)section 1396r–5(c)(1)(B) of this titleSubsec. (c)(1)(B)(i). , inserted before semicolon at end “and of the requirements and procedures for establishing eligibility for medical assistance under this subchapter, including the right to request an assessment under ”.
Pub. L. 100–360, § 411lSubsec. (c)(2)(A)(v). ()(2)(F), substituted “for a stay at the facility” for “an allowable charge imposed by the facility for an item or service requested by the resident and for which a charge may be imposed consistent with this subchapter and subchapter XVIII of this chapter”.
Pub. L. 100–360, § 411lPub. L. 100–485, § 608(d)(27)(E)Subsec. (c)(2)(B)(iii)(III). ()(3)(C)(iii), as added by , substituted “responsible” for “responsibile”.
Pub. L. 100–360, § 411lSubsec. (c)(6). ()(2)(G), substituted “upon the written” for “once the facility accepts the written” in subpar. (A)(ii) and “Upon written” for “Upon a facility’s acceptance of written” in subpar. (B).
Pub. L. 100–360, § 411lPub. L. 100–203, § 4212(b)Subsec. (c)(7). ()(6)(B), amended , see 1987 Amendment note below.
Pub. L. 100–360, § 411lPub. L. 100–485, § 608(d)(27)(E)Pub. L. 100–203, § 4211Subsec. (e). ()(3)(C)(ii), as added by , amended , see 1987 Amendment note below.
Pub. L. 100–360, § 411lSubsec. (e)(1). ()(3)(D)(i), (ii), substituted “” for “” in subpar. (A) and “January” for “September” in subpar. (B).
Pub. L. 100–360, § 411lSubsec. (e)(2)(B). ()(2)(H), inserted after first sentence “The State shall make available to the public information in the registry.”
Pub. L. 100–360, § 411lSubsec. (e)(3). ()(2)(I), inserted “and discharges” after “transfers” in heading and two places in text.
Pub. L. 100–360, § 411lSubsec. (e)(7)(E). ()(3)(D)(iii), substituted “” for “”.
Pub. L. 100–360, § 411lPub. L. 100–485, § 608(d)(27)(E)Pub. L. 100–203, § 4211Subsec. (f). ()(3)(C)(ii), as added by , amended , see 1987 Amendment note below.
Pub. L. 100–360, § 411lSubsec. (f)(2)(A). ()(3)(D)(iv), substituted “September” for “July” in introductory provisions.
Pub. L. 100–360, § 411lSubsec. (f)(2)(A)(i)(I). ()(2)(J), substituted “recognition of mental health and social service needs” for “cognitive, behavioral and social care”.
Pub. L. 100–360, § 411lSubsec. (f)(3). ()(2)(I), inserted “and discharges” after “transfers” in heading and in text.
Pub. L. 100–360, § 411lSubsec. (f)(7)(A). ()(2)(K), substituted “residents” for “patients”.
Pub. L. 100–360, § 411lSubsec. (f)(7)(B). ()(2)(L)(ii), substituted “include” for “do not include”.
Pub. L. 100–360, § 411lSubsec. (g)(1)(C). ()(5)(A)–(C), substituted “and timely review” for “, review,”, inserted “or by another individual used by the facility in providing services to such a resident” after “a nursing facility”, and substituted “The State shall, after notice to the individual involved and a reasonable opportunity for a hearing for the individual to rebut allegations, make a finding as to the accuracy of the allegations. If the State finds that a nurse aide has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the nurse aide and the registry of such finding. If the State finds that any other individual used by the facility has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the appropriate licensure authority” for “If the State finds, after notice to the nurse aide involved and a reasonable opportunity for a hearing for the nurse aide to rebut allegations, that a nurse aide whose name is contained in a nurse aide registry has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the nurse aide and the registry of such finding”.
Pub. L. 100–360, § 411lSubsec. (g)(1)(D). ()(5)(D), substituted “to issue regulations to carry out this subsection” for “to establish standards under subsection (f) of this section”.
Pub. L. 100–360, § 411lsection 1320a–7a of this titleSubsec. (g)(2)(A)(i). ()(5)(E), amended third sentence generally. Prior to amendment, third sentence read as follows: “The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under .”
Pub. L. 100–360, § 411lPub. L. 100–485, § 608(d)(27)(I)Subsec. (g)(2)(B)(ii). ()(5)(F), as added by , substituted “practicable” for “practical”.
Pub. L. 100–360, § 411lSubsec. (g)(3)(C). ()(6)(A), redesignated subpar. (C), relating to special surveys of compliance, as (D).
Pub. L. 100–360, § 411llPub. L. 100–485, § 608(d)(27)(I)Subsec. (g)(3)(D). ()(5)(G), formerly § 411()(5)(F), as redesignated by , substituted “on the basis of that survey” for “on that basis”.
Pub. L. 100–360, § 411llPub. L. 100–485, § 608(d)(27)(I)Subsec. (g)(4). ()(5)(H), formerly § 411()(5)(G), as redesignated by , struck out “chronically” after “enforcement actions against” in last sentence.
Pub. L. 100–360, § 411lPub. L. 100–203, § 4213(a)Subsec. (h). ()(8)(A), made technical correction to directory language of , see 1987 Amendment note below.
Pub. L. 100–360, § 411lSubsec. (h)(1). ()(8)(B)(i), substituted “paragraph (2)(A)(ii)”for “paragraph (2)(A)(i)” in last sentence.
Pub. L. 100–360, § 411lSubsec. (h)(2)(B)(i). ()(8)(B)(ii), struck out “or otherwise” after “regulations”.
Pub. L. 100–360, § 411lsection 1320a–7a of this titlesection 1320a–7a(a) of this titlesection 1320a–7a of this titleSubsec. (h)(3)(C)(ii). ()(7)(A), substituted “. The provisions of (other than subsections (a) and (b)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under ” for “and the Secretary shall impose and collect such a penalty in the same manner as civil money penalties are imposed and collected under ”.
Pub. L. 100–360, § 411lSubsec. (h)(5). ()(8)(B)(iii), substituted “State or the Secretary, respectively” for “State and the Secretary”.
Pub. L. 100–360, § 411lSubsec. (h)(9). ()(7)(B), inserted “by such facilities” after “be made available”.
Pub. L. 100–203, § 4212(b)Pub. L. 100–360, § 411l1987—Subsec. (c)(7). , as amended by ()(6)(B), added par. (7).
Pub. L. 100–203, § 4211Pub. L. 100–360, § 411lsection 4211(a)(3) of Pub. L. 100–203Subsecs. (e), (f). , which contained two subsecs. (c), the first of which amended this section and the second of which enacted provisions set out as a note below, was amended by ()(3)(C)(ii), to delete the designation, heading, and directory language of the first subsec. (c), resulting in subsecs. (e) and (f) being added by , which enacted subsecs. (a) to (d) of this section.
Pub. L. 100–203, § 4212(a)Subsec. (g). , added subsec. (g).
Pub. L. 100–203, § 4213(a)Pub. L. 100–360, § 411lSubsec. (h). , as amended by ()(8)(A), added subsec. (h).
Pub. L. 100–203, § 4216Subsec. (i). , added subsec. (i).
Statutory Notes and Related Subsidiaries
Effective Date of 2010 Amendment
section 6101(c)(1)(B) of Pub. L. 111–148section 6101(b) of Pub. L. 111–148section 1320a–3 of this titlesection 6101(c)(2) of Pub. L. 111–148section 1395i–3 of this titleAmendment by effective on the date on which the Secretary of Health and Human Services makes the information described in , set out as a note under , available to the public, see , set out as a note under .
Pub. L. 111–148, title VI, § 6103(b)(2)(B)124 Stat. 709
section 6103(c)(2) of Pub. L. 111–148section 6103(c)(3) of Pub. L. 111–148section 1395i–3 of this titleAmendment by effective 1 year after , see , set out as a note under .
section 6111(b) of Pub. L. 111–148section 6111(c) of Pub. L. 111–148section 1395i–3 of this titleAmendment by effective 1 year after , see , set out as a note under .
section 6121(b) of Pub. L. 111–148section 6121(c) of Pub. L. 111–148section 1395i–3 of this titleAmendment by effective 1 year after , see , set out as a note under .
Effective Date of 2006 Amendment
Pub. L. 109–432, div. B, title IV, § 405(c)(2)(B)120 Stat. 3000Pub. L. 109–171, , , provided that the amendment made by section 405(c)(2)(B) is effective as if included in the amendment made by section 6015(a)(1) of the Deficit Reduction Act of 2005 [].
Effective Date of 2003 Amendment
Pub. L. 108–173section 932(d) of Pub. L. 108–173section 1395i–3 of this titleAmendment by applicable to appeals filed on or after , see , set out as a note under .
Effective Date of 2000 Amendment
Pub. L. 106–554Pub. L. 106–554section 1395i–3 of this titleAmendment by effective , see section 1(a)(6) [title IX, § 941(c)] of , set out as a note under .
Effective Date of 1999 Amendment
Pub. L. 106–4, § 2(b)113 Stat. 8
Effective Date of 1997 Amendment
Pub. L. 105–33, title IV, § 4754(b)111 Stat. 526
Effective Date of 1996 Amendment
Pub. L. 104–315, § 1(b)110 Stat. 3824
Pub. L. 104–315, § 2(c)110 Stat. 3825
Effective Date of 1992 Amendment
Pub. L. 102–375section 4(b) of Pub. L. 103–171section 3001 of this titleAmendment by inapplicable with respect to fiscal year 1993, see , set out as a note under .
Pub. L. 102–375section 905(b)(6) of Pub. L. 102–375section 3001 of this titleAmendment by inapplicable with respect to fiscal year 1992, see , set out as a note under .
Effective Date of 1990 Amendment
section 4751(b)(2) of Pub. L. 101–508section 4751(c) of Pub. L. 101–508section 1396a of this titleAmendment by applicable with respect to services furnished on or after the first day of the first month beginning more than 1 year after , see , set out as a note under .
Pub. L. 101–508, title IV, § 4801(a)(6)(B)104 Stat. 1388–212
Pub. L. 101–508Pub. L. 100–203section 4801(a)(9) of Pub. L. 101–508section 1396b of this titleAmendment by section 4801(a)(2)–(5), (7) of effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, , see , set out as a note under .
Pub. L. 101–508, title IV, § 4801(b)(9)104 Stat. 1388–215
In general .—
Exception .—
Pub. L. 101–508, title IV, § 4801(d)(2)104 Stat. 1388–215
Pub. L. 101–508, title IV, § 4801(e)(7)(B)104 Stat. 1388–217
Pub. L. 101–508Pub. L. 100–203section 4801(e)(19) of Pub. L. 101–508section 1396a of this titleAmendment by section 4801(e)(2)–(6), (8)–(10), (12)–(15), and (18) of effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, , see , set out as a note under .
Effective Date of 1989 Amendment
Pub. L. 101–239Pub. L. 100–203section 6901(b)(3) of Pub. L. 101–239section 6901(b)(6) of Pub. L. 101–239section 1395i–3 of this titleAmendment by section 6901(b)(1), (4)(A) of effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, , and amendment by applicable to nurse aide training and competency evaluation programs, and nurse aide competency evaluation programs, offered on or after end of 90-day period beginning on , but not to affect competency evaluations conducted under programs offered before end of that period, see , set out as a note under .
section 6901(d)(1) of Pub. L. 101–239section 6901(d)(4) of Pub. L. 101–239Pub. L. 100–203section 6901(d)(6) of Pub. L. 101–239section 1395i–3 of this titleAmendment by effective , and amendment by effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, , see , set out as a note under .
Effective Date of 1988 Amendment
Pub. L. 100–485Pub. L. 100–360section 608(g)(1) of Pub. L. 100–485section 704 of this titleAmendment by effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, , see , set out as a note under .
section 303(a)(2) of Pub. L. 100–360Pub. L. 100–360section 1396r–5 of this titleAmendment by applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after , without regard to whether or not final regulations to carry out such amendment has been promulgated by such date, see section 303(g)(1)(A), (5) of , set out as an Effective Date note under .
section 411 of Pub. L. 100–360lPub. L. 100–360Pub. L. 100–203Pub. L. 100–203section 411(a) of Pub. L. 100–360section 106 of Title 1Except as specifically provided in , amendment by section 411()(2)(A)–(D), (F)–(K), (L)(ii), (3)(A), (B), (C)(ii), (iii), (D), (5), (6)(A), (B), (7), and (8)(A), (B) of , as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, , effective as if included in the enactment of that provision in , see , set out as a Reference to OBRA; Effective Date note under , General Provisions.
Effective Date
Pub. L. 100–203, title IV, § 4214101 Stat. 1330–219Pub. L. 100–360, title IV, § 411l102 Stat. 806
New Requirements and Survey and Certification Process .—
Enforcement .—
Waiver of Paperwork Reduction .—
Retroactive Review
section 1395i–3(g)(1)(C) of this titlesection 4755(c) of Pub. L. 105–33section 1395i–3 of this titleFor requirement that procedures developed by a State permit individual to petition for review of any finding made by a State under subsec. (g)(1)(C) of this section or after , see , set out as a note under .
Nurse Aide Training and Competency Evaluation; Compliance Actions
Pub. L. 101–508, title IV, § 4801(a)(1)104 Stat. 1388–211
Preadmission Screening and Annual Resident Review; Compliance Actions
Pub. L. 101–508, title IV, § 4801(b)(1)104 Stat. 1388–213
Restriction on Enforcement Process
Pub. L. 101–508, title IV, § 4801(c)104 Stat. 1388–215
Staffing Requirements
Pub. L. 101–508, title IV, § 4801(e)(17)104 Stat. 1388–218Pub. L. 105–362, title VI, § 602(b)(1)112 Stat. 3286
Maintaining regulatory standards for certain services .—
Study on staffing requirements in nursing facilities .—
Nurse Aide Training and Competency Evaluation; Satisfaction of Requirements; Waiver
section 1395i–3(b)(5)(A) of this titlePub. L. 101–239section 1395i–3 of this titleFor satisfaction of training and competency evaluation requirements of subsec. (b)(5)(A) of this section and and authorization for a State to waive such competency evaluation requirements, see section 6901(b)(4)(B)–(D) of , set out as a note under .
Publication of Proposed Regulations Respecting Preadmission Screening and Annual Resident Review
Pub. L. 101–239, title VI, § 6901(c)103 Stat. 2300
Evaluation and Report on Implementation of Resident Assessment Process
Pub. L. 100–203, title IV, § 4211(c)101 Stat. 1330–196, , , directed Secretary of Health and Human Services to evaluate and report to Congress by not later than , on implementation of resident assessment process for residents of nursing facilities under amendments made by section 4211(c).
Report on Staffing Requirements
Pub. L. 100–203, title IV, § 4211(k)101 Stat. 1330–20742 U.S.C. 1396r(b)(4)(C), , , directed Secretary of Health and Human Services to report to Congress, by not later than , on progress made in implementing the nursing facility staffing requirements of , including the number and types of waivers approved under subparagraph (C)(ii) of such section and the number of facilities which received waivers.
Annual Report on Statutory Compliance and Enforcement Actions
Pub. L. 100–203, title IV, § 4215101 Stat. 1330–220Pub. L. 101–508, title IV, § 4801(b)(5)(B)104 Stat. 1388–214