U.S Code last checked for updates: May 18, 2024
All TitlesTitle 42Chapter 7Subchapter XVIIIPart A
§ 1395i–3.
Requirements for, and assuring quality of care in, skilled nursing facilities
(a)
“Skilled nursing facility” defined
In this subchapter, the term “skilled nursing facility” means an institution (or a distinct part of an institution) which—
(1)
is primarily engaged in providing to residents—
(A)
skilled nursing care and related services for residents who require medical or nursing care, or
(B)
rehabilitation services for the rehabilitation of injured, disabled, or sick persons,
and is not primarily for the care and treatment of mental diseases;
(2)
has in effect a transfer agreement (meeting the requirements of section 1395x(l) of this title) with one or more hospitals having agreements in effect under section 1395cc of this title; and
(3)
meets the requirements for a skilled nursing facility described in subsections (b), (c), and (d) of this section.
(b)
Requirements relating to provision of services
(1)
Quality of life
(A)
In general
(B)
Quality assessment and assurance
(2)
Scope of services and activities under plan of care
A skilled nursing facility must provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with a written plan of care which—
(A)
describes the medical, nursing, and psychosocial needs of the resident and how such needs will be met;
(B)
is initially prepared, with the participation to the extent practicable of the resident or the resident’s family or legal representative, by a team which includes the resident’s attending physician and a registered professional nurse with responsibility for the resident; and
(C)
is periodically reviewed and revised by such team after each assessment under paragraph (3).
(3)
Residents’ assessment
(A)
Requirement
A skilled nursing facility must conduct a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity, which assessment—
(i)
describes the resident’s capability to perform daily life functions and significant impairments in functional capacity;
(ii)
is based on a uniform minimum data set specified by the Secretary under subsection (f)(6)(A);
(iii)
uses an instrument which is specified by the State under subsection (e)(5); and
(iv)
includes the identification of medical problems.
(B)
Certification
(i)
In general
(ii)
Penalty for falsification
(I)
An individual who willfully and knowingly certifies under clause (i) a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 with respect to each assessment.
(II)
An individual who willfully and knowingly causes another individual to certify under clause (i) a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 with respect to each assessment.
(III)
The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under this clause in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.
(iii)
Use of independent assessors
(C)
Frequency
(i)
In general
Subject to the timeframes prescribed by the Secretary under section 1395yy(e)(6) of this title, such an assessment must be conducted—
(I)
promptly upon (but no later than 14 days after the date of) admission for each individual admitted on or after October 1, 1990, and by not later than January 1, 1991, for each resident of the facility on that date;
(II)
promptly after a significant change in the resident’s physical or mental condition; and
(III)
in no case less often than once every 12 months.
(ii)
Resident review
(D)
Use
(E)
Coordination
(4)
Provision of services and activities
(A)
In general
To the extent needed to fulfill all plans of care described in paragraph (2), a skilled nursing facility must provide, directly or under arrangements (or, with respect to dental services, under agreements) with others for the provision of—
(i)
nursing services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident;
(ii)
medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident;
(iii)
pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident;
(iv)
dietary services that assure that the meals meet the daily nutritional and special dietary needs of each resident;
(v)
an on-going program, directed by a qualified professional, of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident;
(vi)
routine and emergency dental services to meet the needs of each resident; and
(vii)
treatment and services required by mentally ill and mentally retarded residents not otherwise provided or arranged for (or required to be provided or arranged for) by the State.
The services provided or arranged by the facility must meet professional standards of quality. Nothing in clause (vi) shall be construed as requiring a facility to provide or arrange for dental services described in that clause without additional charge.
(B)
Qualified persons providing services
(C)
Required nursing care
(i)
In general
(ii)
Exception
To the extent that clause (i) may be deemed to require that a skilled nursing facility engage the services of a registered professional nurse for more than 40 hours a week, the Secretary is authorized to waive such requirement if the Secretary finds that—
(I)
the facility is located in a rural area and the supply of skilled nursing facility services in such area is not sufficient to meet the needs of individuals residing therein,
(II)
the facility has one full-time registered professional nurse who is regularly on duty at such facility 40 hours a week,
(III)
the facility either has only patients whose physicians have indicated (through physicians’ orders or admission notes) that each such patient does not require the services of a registered nurse or a physician for a 48-hour period, or has made arrangements for a registered professional nurse or a physician to spend such time at such facility as may be indicated as necessary by the physician to provide necessary skilled nursing services on days when the regular full-time registered professional nurse is not on duty,
(IV)
the Secretary provides notice of the waiver to the State long-term care ombudsman (established under section 307(a)(12) 1
1
 See References in Text note below.
of the Older Americans Act of 1965) and the protection and advocacy system in the State for the mentally ill and the mentally retarded, and
(V)
the facility that is granted such a waiver notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver.
 A waiver under this subparagraph shall be subject to annual renewal.
(5)
Required training of nurse aides
(A)
In general
(i)
Except as provided in clause (ii), a skilled nursing facility must not use on a full-time basis any individual as a nurse aide in the facility on or after October 1, 1990 for more than 4 months unless the individual—
(I)
has completed a training and competency evaluation program, or a competency evaluation program, approved by the State under subsection (e)(1)(A), and
(II)
is competent to provide nursing or nursing-related services.
(ii)
A skilled nursing facility must not use on a temporary, per diem, leased, or on any basis other than as a permanent employee any individual as a nurse aide in the facility on or after January 1, 1991, unless the individual meets the requirements described in clause (i).
(B)
Offering competency evaluation programs for current employees
(C)
Competency
(D)
Re-training required
(E)
Regular in-service education
(F)
“Nurse aide” defined
In this paragraph, the term “nurse aide” means any individual providing nursing or nursing-related services to residents in a skilled nursing facility, but does not include an individual—
(i)
who is a licensed health professional (as defined in subparagraph (G)) or a registered dietician, or
(ii)
who volunteers to provide such services without monetary compensation.
Such term includes an individual who provides such services through an agency or under a contract with the facility.
(G)
“Licensed health professional” defined
(6)
Physician supervision and clinical records
A skilled nursing facility must—
(A)
require that the medical care of every resident be provided under the supervision of a physician;
(B)
provide for having a physician available to furnish necessary medical care in case of emergency; and
(C)
maintain clinical records on all residents, which records include the plans of care (described in paragraph (2)) and the residents’ assessments (described in paragraph (3)).
(7)
Required social services
(8)
Information on nurse staffing
(A)
In general
(B)
Publication of data
(c)
Requirements relating to residents’ rights
(1)
General rights
(A)
Specified rights
A skilled nursing facility must protect and promote the rights of each resident, including each of the following rights:
(i)
Free choice
(ii)
Free from restraints
The right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms. Restraints may only be imposed—
(I)
to ensure the physical safety of the resident or other residents, and
(II)
only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used (except in emergency circumstances specified by the Secretary until such an order could reasonably be obtained).
(iii)
Privacy
(iv)
Confidentiality
(v)
Accommodation of needs
The right—
(I)
to reside and receive services with reasonable accommodation of individual needs and preferences, except where the health or safety of the individual or other residents would be endangered, and
(II)
to receive notice before the room or roommate of the resident in the facility is changed.
(vi)
Grievances
(vii)
Participation in resident and family groups
(viii)
Participation in other activities
(ix)
Examination of survey results
(x)
Refusal of certain transfers
(xi)
Other rights
(B)
Notice of rights and services
A skilled nursing facility must—
(i)
inform each resident, orally and in writing at the time of admission to the facility, of the resident’s legal rights during the stay at the facility;
(ii)
make available to each resident, upon reasonable request, a written statement of such rights (which statement is updated upon changes in such rights) including the notice (if any) of the State developed under section 1396r(e)(6) of this title; and
(iii)
inform each other resident, in writing before or at the time of admission and periodically during the resident’s stay, of services available in the facility and of related charges for such services, including any charges for services not covered under this subchapter or by the facility’s basic per diem charge.
The written description of legal rights under this subparagraph shall include a description of the protection of personal funds under paragraph (6) and a statement that a resident may file a complaint with a State survey and certification agency respecting resident abuse and neglect and misappropriation of resident property in the facility.
(C)
Rights of incompetent residents
(D)
Use of psychopharmacologic drugs
(E)
Information respecting advance directives
(2)
Transfer and discharge rights
(A)
In general
A skilled nursing facility must permit each resident to remain in the facility and must not transfer or discharge the resident from the facility unless—
(i)
the transfer or discharge is necessary to meet the resident’s welfare and the resident’s welfare cannot be met in the facility;
(ii)
the transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility;
(iii)
the safety of individuals in the facility is endangered;
(iv)
the health of individuals in the facility would otherwise be endangered;
(v)
the resident has failed, after reasonable and appropriate notice, to pay (or to have paid under this subchapter or subchapter XIX on the resident’s behalf) for a stay at the facility; or
(vi)
the facility ceases to operate.
In each of the cases described in clauses (i) through (v), the basis for the transfer or discharge must be documented in the resident’s clinical record. In the cases described in clauses (i) and (ii), the documentation must be made by the resident’s physician, and in the cases described in clauses (iii) and (iv) the documentation must be made by a physician.
(B)
Pre-transfer and pre-discharge notice
(i)
In general
Before effecting a transfer or discharge of a resident, a skilled nursing facility must—
(I)
notify the resident (and, if known, a family member of the resident or legal representative) of the transfer or discharge and the reasons therefor,
(II)
record the reasons in the resident’s clinical record (including any documentation required under subparagraph (A)), and
(III)
include in the notice the items described in clause (iii).
(ii)
Timing of notice
The notice under clause (i)(I) must be made at least 30 days in advance of the resident’s transfer or discharge except—
(I)
in a case described in clause (iii) or (iv) of subparagraph (A);
(II)
in a case described in clause (ii) of subparagraph (A), where the resident’s health improves sufficiently to allow a more immediate transfer or discharge;
(III)
in a case described in clause (i) of subparagraph (A), where a more immediate transfer or discharge is necessitated by the resident’s urgent medical needs; or
(IV)
in a case where a resident has not resided in the facility for 30 days.
 In the case of such exceptions, notice must be given as many days before the date of the transfer or discharge as is practicable.
(iii)
Items included in notice
Each notice under clause (i) must include—
(I)
for transfers or discharges effected on or after October 1, 1990, notice of the resident’s right to appeal the transfer or discharge under the State process established under subsection (e)(3); and
(II)
the name, mailing address, and telephone number of the State long-term care ombudsman (established under title III or VII of the Older Americans Act of 1965 [42 U.S.C. 3021 et seq., 3058 et seq.] in accordance with section 712 of the Act [42 U.S.C. 3058g]).
(C)
Orientation
(3)
Access and visitation rights
A skilled nursing facility must—
(A)
permit immediate access to any resident by any representative of the Secretary, by any representative of the State, by an ombudsman described in paragraph (2)(B)(iii)(II), or by the resident’s individual physician;
(B)
permit immediate access to a resident, subject to the resident’s right to deny or withdraw consent at any time, by immediate family or other relatives of the resident;
(C)
permit immediate access to a resident, subject to reasonable restrictions and the resident’s right to deny or withdraw consent at any time, by others who are visiting with the consent of the resident;
(D)
permit reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident’s right to deny or withdraw consent at any time; and
(E)
permit representatives of the State ombudsman (described in paragraph (2)(B)(iii)(II)), with the permission of the resident (or the resident’s legal representative) and consistent with State law, to examine a resident’s clinical records.
(4)
Equal access to quality care
(5)
Admissions policy
(A)
Admissions
With respect to admissions practices, a skilled nursing facility must—
(i)
(I)
not require individuals applying to reside or residing in the facility to waive their rights to benefits under this subchapter or under a State plan under subchapter XIX, (II) not require oral or written assurance that such individuals are not eligible for, or will not apply for, benefits under this subchapter or such a State plan, and (III) prominently display in the facility and provide to such individuals written information about how to apply for and use such benefits and how to receive refunds for previous payments covered by such benefits; and
(ii)
not require a third party guarantee of payment to the facility as a condition of admission (or expedited admission) to, or continued stay in, the facility.
(B)
Construction
(i)
No preemption of stricter standards
(ii)
Contracts with legal representatives
(6)
Protection of resident funds
(A)
In general
The skilled nursing facility—
(i)
may not require residents to deposit their personal funds with the facility, and
(ii)
upon the written authorization of the resident, must hold, safeguard, and account for such personal funds under a system established and maintained by the facility in accordance with this paragraph.
(B)
Management of personal funds
Upon written authorization of a resident under subparagraph (A)(ii), the facility must manage and account for the personal funds of the resident deposited with the facility as follows:
(i)
Deposit
(ii)
Accounting and records
(iii)
Conveyance upon death
(C)
Assurance of financial security
(D)
Limitation on charges to personal funds
(d)
Requirements relating to administration and other matters
(1)
Administration
(A)
In general
(B)
Required notices
If a change occurs in—
(i)
the persons with an ownership or control interest (as defined in section 1320a–3(a)(3) of this title) in the facility,
(ii)
the persons who are officers, directors, agents, or managing employees (as defined in section 1320a–5(b) of this title) of the facility,
(iii)
the corporation, association, or other company responsible for the management of the facility, or
(iv)
the individual who is the administrator or director of nursing of the facility,
the skilled nursing facility must provide notice to the State agency responsible for the licensing of the facility, at the time of the change, of the change and of the identity of each new person, company, or individual described in the respective clause.
(C)
 4
4
 So in original. Two subpars. (C) have been enacted. See Amendment of Subsection (d)(1) note below.
Skilled nursing facility administrator
(C)
 4 Availability of survey, certification, and complaint investigation reports
A skilled nursing facility must—
(i)
have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years available for any individual to review upon request; and
(ii)
post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
The facility shall not make available under clause (i) identifying information about complainants or residents.
(2)
Licensing and Life Safety Code
(A)
Licensing
(B)
Life Safety Code
A skilled nursing facility must meet such provisions of such edition (as specified by the Secretary in regulation) of the Life Safety Code of the National Fire Protection Association as are applicable to nursing homes; except that—
(i)
the Secretary may waive, for such periods as he deems appropriate, specific provisions of such Code which if rigidly applied would result in unreasonable hardship upon a facility, but only if such waiver would not adversely affect the health and safety of residents or personnel, and
(ii)
the provisions of such Code shall not apply in any State if the Secretary finds that in such State there is in effect a fire and safety code, imposed by State law, which adequately protects residents of and personnel in skilled nursing facilities.
(3)
Sanitary and infection control and physical environment
A skilled nursing facility must—
(A)
establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection, and
(B)
be designed, constructed, equipped, and maintained in a manner to protect the health and safety of residents, personnel, and the general public.
(4)
Miscellaneous
(A)
Compliance with Federal, State, and local laws and professional standards
(B)
Other
(e)
State requirements relating to skilled nursing facility requirements
The requirements, referred to in section 1395aa(d) of this title, with respect to a State are as follows:
(1)
Specification and review of nurse aide training and competency evaluation programs and of nurse aide competency evaluation programs
The State must—
(A)
by not later than January 1, 1989, specify those training and competency evaluation programs, and those competency evaluation programs, that the State approves for purposes of subsection (b)(5) and that meet the requirements established under subsection (f)(2), and
(B)
by not later than January 1, 1990, provide for the review and reapproval of such programs, at a frequency and using a methodology consistent with the requirements established under subsection (f)(2)(A)(iii).
The failure of the Secretary to establish requirements under subsection (f)(2) shall not relieve any State of its responsibility under this paragraph.
(2)
Nurse aide registry
(A)
In general
(B)
Information in registry
(C)
Prohibition against charges
(3)
State appeals process for transfers and discharges
(4)
Skilled nursing facility administrator standards
(5)
Specification of resident assessment instrument
Effective July 1, 1990, the State shall specify the instrument to be used by nursing facilities in the State in complying with the requirement of subsection (b)(3)(A)(iii). Such instrument shall be—
(A)
one of the instruments designated under subsection (f)(6)(B), or
(B)
an instrument which the Secretary has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines specified by the Secretary under subsection (f)(6)(A).
(f)
Responsibilities of Secretary relating to skilled nursing facility requirements
(1)
General responsibility
(2)
Requirements for nurse aide training and competency evaluation programs and for nurse aide competency evaluation programs
(A)
In general
For purposes of subsections (b)(5) and (e)(1)(A), the Secretary shall establish, by not later than September 1, 1988—
(i)
requirements for the approval of nurse aide training and competency evaluation programs, including requirements relating to (I) the areas to be covered in such a program (including at least basic nursing skills, personal care skills, recognition of mental health and social service needs, care of cognitively impaired residents, basic restorative services, and residents’ rights) and content of the curriculum (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,5
5
 So in original. A closing parenthesis probably should appear before the comma.
(II) minimum hours of initial and ongoing training and retraining (including not less than 75 hours in the case of initial training), (III) qualifications of instructors, and (IV) procedures for determination of competency;
(ii)
requirements for the approval of nurse aide competency evaluation programs, including requirement relating to the areas to be covered in such a program, including at least basic nursing skills, personal care skills, recognition of mental health and social service needs, care of cognitively impaired residents, basic restorative services, residents’ rights, and procedures for determination of competency;
(iii)
requirements respecting the minimum frequency and methodology to be used by a State in reviewing such programs’ compliance with the requirements for such programs; and
(iv)
requirements, under both such programs, that—
(I)
provide procedures for determining competency that permit a nurse aide, at the nurse aide’s option, to establish competency through procedures or methods other than the passing of a written examination and to have the competency evaluation conducted at the nursing facility at which the aide is (or will be) employed (unless the facility is described in subparagraph (B)(iii)(I)),
(II)
prohibit the imposition on a nurse aide 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 of any charges (including any charges for textbooks and other required course materials and any charges for the competency evaluation) for either such program, and
(III)
in the case of a nurse aide not described in subclause (II) who is employed by (or who has received an offer of employment from) a facility not later than 12 months after completing either such program, the State shall provide for the reimbursement of costs incurred in completing such program on a prorata 6
6
 So in original. Probably should be “pro rata”.
basis during the period in which the nurse aide is so employed.
(B)
Approval of certain programs
Such requirements—
(i)
may permit approval of programs offered by or in facilities (subject to clause (iii)), as well as outside facilities (including employee organizations), and of programs in effect on December 22, 1987;
(ii)
shall permit a State to find that an individual who has completed (before July 1, 1989) a nurse aide training and competency evaluation program shall be deemed to have completed such a program approved under subsection (b)(5) if the State determines that, at the time the program was offered, the program met the requirements for approval under such paragraph; and
(iii)
subject to subparagraphs (C) and (D), shall prohibit approval of such a program—
(I)
offered by or in a skilled nursing facility which, within the previous 2 years—
(II)
offered by or in a skilled nursing facility unless the State makes the determination, upon an individual’s completion of the program, that the individual is competent to provide nursing and nursing-related services in skilled nursing facilities.
(a)
has operated under a waiver under subsection (b)(4)(C)(ii)(II);
(b)
has been subject to an extended (or partial extended) survey under subsection (g)(2)(B)(i) or section 1396r(g)(2)(B)(i) of this title, unless the survey shows that the facility is in compliance with the requirements of subsections (b), (c), and (d) of this section; or
(c)
has been assessed a civil money penalty described in subsection (h)(2)(B)(ii) or section 1396r(h)(2)(A)(ii) of this title of not less than $5,000, or has been subject to a remedy described in clause (i) or (iii) of subsection (h)(2)(B), subsection (h)(4), section 1396r(h)(1)(B)(i) of this title, or in clause (i), (iii), or (iv) of section 1396r(h)(2)(A) of this title, or
 A State may not delegate (through subcontract or otherwise) its responsibility under clause (iii)(II) to the skilled nursing facility.
(C)
Waiver authorized
Clause (iii)(I) of subparagraph (B) shall not apply to a program offered in (but not by) a nursing facility (or skilled nursing facility for purposes of this subchapter) in a State if the State—
(i)
determines that there is no other such program offered within a reasonable distance of the facility,
(ii)
assures, through an oversight effort, that an adequate environment exists for operating the program in the facility, and
(iii)
provides notice of such determination and assurances to the State long-term care ombudsman.
(D)
Waiver of disapproval of nurse-aide training programs
(3)
Federal guidelines for State appeals process for transfers and discharges
(4)
Secretarial standards for qualification of administrators
(5)
Criteria for administration
The Secretary shall establish criteria for assessing a skilled nursing facility’s compliance with the requirement of subsection (d)(1) with respect to—
(A)
its governing body and management,
(B)
agreements with hospitals regarding transfers of residents to and from the hospitals and to and from other skilled nursing facilities,
(C)
disaster preparedness,
(D)
direction of medical care by a physician,
(E)
laboratory and radiological services,
(F)
clinical records, and
(G)
resident and advocate participation.
(6)
Specification of resident assessment data set and instruments
The Secretary shall—
(A)
not later than January 1, 1989, specify a minimum data set of core elements and common definitions for use by nursing facilities in conducting the assessments required under subsection (b)(3), and establish guidelines for utilization of the data set; and
(B)
by not later than April 1, 1990, designate one or more instruments which are consistent with the specification made under subparagraph (A) and which a State may specify under subsection (e)(5)(A) for use by nursing facilities in complying with the requirements of subsection (b)(3)(A)(iii).
(7)
List of items and services furnished in skilled nursing facilities not chargeable to the personal funds of a resident
(A)
Regulations required
(B)
Rule if failure to publish regulations
(8)
Special focus facility program
(A)
In general
(B)
Periodic surveys
(g)
Survey and certification process
(1)
State and Federal responsibility
(A)
In general
(B)
Educational program
(C)
Investigation of allegations of resident neglect and abuse and misappropriation of resident property
(D)
Removal of name from nurse aide registry
(i)
In general
In the case of a finding of neglect under subparagraph (C), the State shall establish a procedure to permit a nurse aide to petition the State to have his or her name removed from the registry upon a determination by the State that—
(I)
the employment and personal history of the nurse aide does not reflect a pattern of abusive behavior or neglect; and
(II)
the neglect involved in the original finding was a singular occurrence.
(ii)
Timing of determination
(E)
Construction
(2)
Surveys
(A)
Standard survey
(i)
In general
(ii)
Contents
Each standard survey shall include, for a case-mix stratified sample of residents—
(I)
a survey of the quality of care furnished, as measured by indicators of medical, nursing, and rehabilitative care, dietary and nutrition services, activities and social participation, and sanitation, infection control, and the physical environment,
(II)
written plans of care provided under subsection (b)(2) and an audit of the residents’ assessments under subsection (b)(3) to determine the accuracy of such assessments and the adequacy of such plans of care, and
(III)
a review of compliance with residents’ rights under subsection (c).
(iii)
Frequency
(I)
In general
(II)
Special surveys
(B)
Extended surveys
(i)
In general
(ii)
Timing
(iii)
Contents
(iv)
Construction
(C)
Survey protocol
Standard and extended surveys shall be conducted—
(i)
based upon a protocol which the Secretary has developed, tested, and validated by not later than January 1, 1990, and
(ii)
by individuals, of a survey team, who meet such minimum qualifications as the Secretary establishes by not later than such date.
The failure of the Secretary to develop, test, or validate such protocols or to establish such minimum qualifications shall not relieve any State of its responsibility (or the Secretary of the Secretary’s responsibility) to conduct surveys under this subsection.
(D)
Consistency of surveys
(E)
Survey teams
(i)
In general
(ii)
Prohibition of conflicts of interest
(iii)
Training
(3)
Validation surveys
(A)
In general
(B)
Scope
(C)
Remedies for substandard performance
(D)
Special surveys of compliance
(4)
Investigation of complaints and monitoring compliance
Each State shall maintain procedures and adequate staff to—
(A)
investigate complaints of violations of requirements by skilled nursing facilities, and
(B)
monitor, on-site, on a regular, as needed basis, a skilled nursing facility’s compliance with the requirements of subsections (b), (c), and (d), if—
(i)
the facility has been found not to be in compliance with such requirements and is in the process of correcting deficiencies to achieve such compliance;
(ii)
the facility was previously found not to be in compliance with such requirements, has corrected deficiencies to achieve such compliance, and verification of continued compliance is indicated; or
(iii)
the State has reason to question the compliance of the facility with such requirements.
A State may maintain and utilize a specialized team (including an attorney, an auditor, and appropriate health care professionals) for the purpose of identifying, surveying, gathering and preserving evidence, and carrying out appropriate enforcement actions against substandard skilled nursing facilities.
(5)
Disclosure of results of inspections and activities
(A)
Public information
Each State, and the Secretary, shall make available to the public—
(i)
information respecting all surveys and certifications made respecting skilled nursing facilities, including statements of deficiencies, within 14 calendar days after such information is made available to those facilities, and approved plans of correction,
(ii)
copies of cost reports of such facilities filed under this subchapter or subchapter XIX,
(iii)
copies of statements of ownership under section 1320a–3 of this title, and
(iv)
information disclosed under section 1320a–5 of this title.
(B)
Notice to ombudsman
(C)
Notice to physicians and skilled nursing facility administrator licensing board
If a State finds that a skilled nursing facility has provided substandard quality of care, the State shall notify—
(i)
the attending physician of each resident with respect to which such finding is made, and
(ii)
the State board responsible for the licensing of the skilled nursing facility administrator at the facility.
(D)
Access to fraud control units
(E)
Submission of survey and certification information to the Secretary
(h)
Enforcement process
(1)
In general
If a State finds, on the basis of a standard, extended, or partial extended survey under subsection (g)(2) or otherwise, that a skilled nursing facility no longer meets a requirement of subsection (b), (c), or (d), and further finds that the facility’s deficiencies—
(A)
immediately jeopardize the health or safety of its residents, the State shall recommend to the Secretary that the Secretary take such action as described in paragraph (2)(A)(i); or
(B)
do not immediately jeopardize the health or safety of its residents, the State may recommend to the Secretary that the Secretary take such action as described in paragraph (2)(A)(ii).
If a State finds that a skilled nursing facility meets the requirements of subsections (b), (c), and (d), but, as of a previous period, did not meet such requirements, the State may recommend a civil money penalty under paragraph (2)(B)(ii) for the days in which it finds that the facility was not in compliance with such requirements.
(2)
Secretarial authority
(A)
In general
With respect to any skilled nursing facility in a State, if the Secretary finds, or pursuant to a recommendation of the State under paragraph (1) finds, that a skilled nursing facility no longer meets a requirement of subsection (b), (c), (d), or (e), and further finds that the facility’s deficiencies—
(i)
immediately jeopardize the health or safety of its residents, the Secretary shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in subparagraph (B)(iii), or terminate the facility’s participation under this subchapter and may provide, in addition, for one or more of the other remedies described in subparagraph (B); or
(ii)
do not immediately jeopardize the health or safety of its residents, the Secretary may impose any of the remedies described in subparagraph (B).
Nothing in this subparagraph shall be construed as restricting the remedies available to the Secretary to remedy a skilled nursing facility’s deficiencies. If the Secretary finds, or pursuant to the recommendation of the State under paragraph (1) finds, that a skilled nursing facility meets such requirements but, as of a previous period, did not meet such requirements, the Secretary may provide for a civil money penalty under subparagraph (B)(ii) for the days on which he finds that the facility was not in compliance with such requirements.
(B)
Specified remedies
The Secretary may take the following actions with respect to a finding that a facility has not met an applicable requirement:
(i)
Denial of payment
(ii)
Authority with respect to civil money penalties
(I)
In general
(II)
Reduction of civil money penalties in certain circumstances
(III)
Prohibitions on reduction for certain deficiencies
(aa)
Repeat deficiencies
(bb)
Certain other deficiencies
(IV)
Collection of civil money penalties
In the case of a civil money penalty imposed under this clause, the Secretary shall issue regulations that—
(aa)
subject to item (cc), not later than 30 days after the imposition of the penalty, provide for the facility to have the opportunity to participate in an independent informal dispute resolution process which generates a written record prior to the collection of such penalty;
(bb)
in the case where the penalty is imposed for each day of noncompliance, provide that a penalty may not be imposed for any day during the period beginning on the initial day of the imposition of the penalty and ending on the day on which the informal dispute resolution process under item (aa) is completed;
(cc)
may provide for the collection of such civil money penalty and the placement of such amounts collected in an escrow account under the direction of the Secretary on the earlier of the date on which the informal dispute resolution process under item (aa) is completed or the date that is 90 days after the date of the imposition of the penalty;
(dd)
may provide that such amounts collected are kept in such account pending the resolution of any subsequent appeals;
(ee)
in the case where the facility successfully appeals the penalty, may provide for the return of such amounts collected (plus interest) to the facility; and
(ff)
in the case where all such appeals are unsuccessful, may provide that some portion of such amounts collected may be used to support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or involuntarily) or is decertified (including offsetting costs of relocating residents to home and community-based settings or another facility), projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by the Secretary (including joint training of facility staff and surveyors, technical assistance for facilities implementing quality assurance programs, the appointment of temporary management firms, and other activities approved by the Secretary).
(iii)
Appointment of temporary management
In consultation with the State, the Secretary may appoint temporary management to oversee the operation of the facility and to assure the health and safety of the facility’s residents, where there is a need for temporary management while—
(I)
there is an orderly closure of the facility, or
(II)
improvements are made in order to bring the facility into compliance with all the requirements of subsections (b), (c), and (d).
 The temporary management under this clause shall not be terminated under subclause (II) until the Secretary has determined that the facility has the management capability to ensure continued compliance with all the requirements of subsections (b), (c), and (d).
The Secretary shall specify criteria, as to when and how each of such remedies is to be applied, the amounts of any fines, and the severity of each of these remedies, to be used in the imposition of such remedies. Such criteria shall be designed so as to minimize the time between the identification of violations and final imposition of the remedies and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies. In addition, the Secretary may provide for other specified remedies, such as directed plans of correction.
(C)
Continuation of payments pending remediation
The Secretary may continue payments, over a period of not longer than 6 months after the effective date of the findings, under this subchapter with respect to a skilled nursing facility not in compliance with a requirement of subsection (b), (c), or (d), if—
(i)
the State survey agency finds that it is more appropriate to take alternative action to assure compliance of the facility with the requirements than to terminate the certification of the facility,
(ii)
the State has submitted a plan and timetable for corrective action to the Secretary for approval and the Secretary approves the plan of corrective action, and
(iii)
the facility 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.
The Secretary shall establish guidelines for approval of corrective actions requested by States under this subparagraph.
(D)
Assuring prompt compliance
(E)
Repeated noncompliance
In the case of a skilled nursing facility which, on 3 consecutive standard surveys conducted under subsection (g)(2), has been found to have provided substandard quality of care, the Secretary shall (regardless of what other remedies are provided)—
(i)
impose the remedy described in subparagraph (B)(i), and
(ii)
monitor the facility under subsection (g)(4)(B),
until the facility has demonstrated, to the satisfaction of the Secretary, that it is in compliance with the requirements of subsections (b), (c), and (d), and that it will remain in compliance with such requirements.
(3)
Effective period of denial of payment
(4)
Immediate termination of participation for facility where Secretary finds noncompliance and immediate jeopardy
(5)
Construction
(6)
Sharing of information
(i)
Nursing Home Compare website
(1)
Inclusion of additional information
(A)
In general
The Secretary shall ensure that the Department of Health and Human Services includes, as part of the information provided for comparison of nursing homes on the official Internet website of the Federal Government for Medicare beneficiaries (commonly referred to as the “Nursing Home Compare” Medicare website) (or a successor website), the following information in a manner that is prominent, updated on a timely basis, easily accessible, readily understandable to consumers of long-term care services, and searchable:
(i)
Staffing data for each facility (including resident census data and data on the hours of care provided per resident per day) based on data submitted under section 1320a–7j(g) of this title, including information on staffing turnover and tenure, in a format that is clearly understandable to consumers of long-term care services and allows such consumers to compare differences in staffing between facilities and State and national averages for the facilities. Such format shall include—
(I)
concise explanations of how to interpret the data (such as a plain English explanation of data reflecting “nursing home staff hours per resident day”);
(II)
differences in types of staff (such as training associated with different categories of staff);
(III)
the relationship between nurse staffing levels and quality of care; and
(IV)
an explanation that appropriate staffing levels vary based on patient case mix.
(ii)
Links to State Internet websites with information regarding State survey and certification programs, links to Form 2567 State inspection reports (or a successor form) on such websites, information to guide consumers in how to interpret and understand such reports, and the facility plan of correction or other response to such report. Any such links shall be posted on a timely basis.
(iii)
The standardized complaint form developed under section 1320a–7j(f) of this title, including explanatory material on what complaint forms are, how they are used, and how to file a complaint with the State survey and certification program and the State long-term care ombudsman program.
(iv)
Summary information on the number, type, severity, and outcome of substantiated complaints.
(v)
The number of adjudicated instances of criminal violations by a facility or the employees of a facility—
(I)
that were committed inside the facility;
(II)
with respect to such instances of violations or crimes committed inside of the facility that were the violations or crimes of abuse, neglect, and exploitation, criminal sexual abuse, or other violations or crimes that resulted in serious bodily injury; and
(III)
 8
8
 So in original. Probably should be cl. (vi).
the number of civil monetary penalties levied against the facility, employees, contractors, and other agents.
(B)
Deadline for provision of information
(i)
In general
(ii)
Exception
(2)
Review and modification of website
(A)
In general
The Secretary shall establish a process—
(i)
to review the accuracy, clarity of presentation, timeliness, and comprehensiveness of information reported on such website as of the day before March 23, 2010; and
(ii)
not later than 1 year after March 23, 2010, to modify or revamp such website in accordance with the review conducted under clause (i).
(B)
Consultation
In conducting the review under subparagraph (A)(i), the Secretary shall consult with—
(i)
State long-term care ombudsman programs;
(ii)
consumer advocacy groups;
(iii)
provider stakeholder groups; and
(iv)
any other representatives of programs or groups the Secretary determines appropriate.
(3)
Funding
(j)
Construction
(k)
Funding for strike teams
(Aug. 14, 1935, ch. 531, title XVIII, § 1819, as added and amended Pub. L. 100–203, title IV, §§ 4201(a)(3), 4202(a)(2), 4203(a)(2), 4206, Dec. 22, 1987, 101 Stat. 1330–160, 1330–175, 1330–179, 1330–182; Pub. L. 100–360, title IV, § 411(l)(1)(A), (2)(A)–(D), (F)–(L)(i), (4), (5), (7), (11), July 1, 1988, 102 Stat. 800–805, as amended Pub. L. 100–485, title VI, § 608(d)(27)(A), (C), (D), (I), (L), Oct. 13, 1988, 102 Stat. 2422, 2423; Pub. L. 101–239, title VI, § 6901(b)(1), (3), (d)(4), Dec. 19, 1989, 103 Stat. 2298, 2301; Pub. L. 101–508, title IV, §§ 4008(h)(1)(B)–(F)(i), (G), (2)(B)–(N), (m)(3)(F)[(E)], 4206(d)(1), Nov. 5, 1990, 104 Stat. 1388–46 to 1388–50, 1388–54, 1388–116; Pub. L. 102–375, title VII, § 708(a)(1)(A), Sept. 30, 1992, 106 Stat. 1291; Pub. L. 103–432, title I, §§ 106(c)(1)(A), (2)(A), (3)(A), (4)(A), (B), (d)(1)–(5), 110(b), Oct. 31, 1994, 108 Stat. 4406–4408; Pub. L. 105–15, § 1, May 15, 1997, 111 Stat. 34; Pub. L. 105–33, title IV, §§ 4432(b)(5)(A), 4755(a), Aug. 5, 1997, 111 Stat. 421, 526; Pub. L. 106–554, § 1(a)(6) [title IX, § 941(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–585; Pub. L. 108–173, title VII, § 736(a)(8), title IX, § 932(c)(2), Dec. 8, 2003, 117 Stat. 2355, 2401; Pub. L. 111–148, title VI, §§ 6101(c)(1)(A), 6103(a)(1), (2)(A), (3), (c)(1), 6111(a), 6113(b), 6121(a), Mar. 23, 2010, 124 Stat. 702, 704, 706, 709, 713, 719, 720; Pub. L. 113–185, § 2(c)(4)(B), Oct. 6, 2014, 128 Stat. 1966; Pub. L. 117–2, title IX, § 9402, Mar. 11, 2021, 135 Stat. 127.)
cite as: 42 USC 1395i-3
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