---
kind: "section"
citation: "42 U.S.C. § 1395bbb"
title: "42"
title_heading: "The Public Health and Welfare"
number: "1395bbb"
heading: "Conditions of participation for home health agencies; home health quality"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/1395bbb"
units:
  - "Chapter 7 — Social Security"
  - "Subchapter XVIII — Health Insurance for Aged and Disabled"
  - "Part E — Miscellaneous Provisions"
---

# §1395bbb. Conditions of participation for home health agencies; home health quality

- (a) **Conditions of participation; protection of individual rights; notification of State entities; use of home health aides; medical equipment; individual’s plan of care; compliance with Federal, State, and local laws and regulations—** The conditions of participation that a [home health agency](/usc/42/1395x.md?p=o) is required to meet under this subsection are as follows:
  - (1) The [agency](/usc/42/1397n–12.md?p=1) protects and promotes the rights of each individual under its care, [including](/usc/42/1301.md?p=b) each of the following rights:
    - (A) The right to be fully informed in advance about the care and [treatment](/usc/42/11851.md?p=11) to be provided by the [agency](/usc/42/1397n–12.md?p=1), to be fully informed in advance of any changes in the care or [treatment](/usc/42/11851.md?p=11) to be provided by the [agency](/usc/42/1397n–12.md?p=1) that may affect the individual’s well-being, and (except with respect to an individual adjudged incompetent) to participate in planning care and [treatment](/usc/42/11851.md?p=11) or changes in care or [treatment](/usc/42/11851.md?p=11).
    - (B) The right to voice grievances with respect to [treatment](/usc/42/11851.md?p=11) or care that is (or fails to be) furnished without discrimination or reprisal for voicing grievances.
    - (C) The right to confidentiality of the clinical records described in [section 1395x(o)(3)](/usc/42/1395x.md?p=o-3) of this title.
    - (D) The right to have one’s property treated with respect.
    - (E) The right to be fully informed orally and in writing (in advance of coming under the care of the [agency](/usc/42/1397n–12.md?p=1)) of—
      - (i) all items and services furnished by (or under [arrangements](/usc/42/1395x.md?p=w-1) with) the [agency](/usc/42/1397n–12.md?p=1) for which payment may be made under this subchapter,
      - (ii) the coverage available for such items and services under this subchapter, subchapter XIX, and any other Federal program of which the [agency](/usc/42/1397n–12.md?p=1) is reasonably aware,
      - (iii) any charges for items and services not covered under this subchapter and any charges the individual may have to pay with respect to items and services furnished by (or under [arrangements](/usc/42/1395x.md?p=w-1) with) the [agency](/usc/42/1397n–12.md?p=1), and
      - (iv) any changes in the charges or items and services described in clause [(i)](#a-1-E-i), [(ii)](#a-1-E-ii), or [(iii)](#a-1-E-iii).
    - (F) The right to be fully informed in writing (in advance of coming under the care of the [agency](/usc/42/1397n–12.md?p=1)) of the individual’s rights and obligations under this subchapter.
    - (G) The right to be informed of the availability of the [State](/usc/42/1395x.md?p=x) [home health agency](/usc/42/1395x.md?p=o) hot-line established under [section 1395aa(a) of this title](/usc/42/1395aa.md?p=a).
  - (2) The [agency](/usc/42/1397n–12.md?p=1) notifies the [State](/usc/42/1395x.md?p=x) entity responsible for the licensing or certification of the [agency](/usc/42/1397n–12.md?p=1) of a change in—
    - (A) the [persons](/usc/42/1301.md?p=a-3) with an ownership or control interest (as defined in [section 1320a–3(a)(3) of this title](/usc/42/1320a–3.md?p=a-3)) in the [agency](/usc/42/1397n–12.md?p=1),
    - (B) the [persons](/usc/42/1301.md?p=a-3) who are officers, [directors](/usc/42/11851.md?p=5), agents, or [managing employees](/usc/42/1320a–3.md?p=c-5-C) (as defined in [section 1320a–5(b) of this title](/usc/42/1320a–5.md?p=b)) of the [agency](/usc/42/1397n–12.md?p=1), and
    - (C) the [corporation](/usc/42/1301.md?p=a-4), association, or other company responsible for the management of the [agency](/usc/42/1397n–12.md?p=1).

    Such notice shall be given at the time of the change and shall include the identity of each new [person](/usc/42/1301.md?p=a-3) or company described in the previous sentence.

  - (3)
    - (A) The [agency](/usc/42/1397n–12.md?p=1) must not use as a [home](/usc/42/1395x.md?p=iii-3-B) health aide (on a full-time, temporary, per diem, or other basis), any individual to provide items or services described in [section 1395x(m) of this title](/usc/42/1395x.md?p=m) on or after January 1, 1990, unless the individual—
      - (i) has completed a training and competency evaluation program, or a competency evaluation program, that meets the minimum [standards](/usc/42/1320d.md?p=7) established by the [Secretary](/usc/42/1301.md?p=a-6) under [subparagraph (D)](#a-3-D), and
      - (ii) is competent to provide such items and services.

      For purposes of [clause (i)](#a-3-A-i), an individual is not considered to have completed a training and competency evaluation program, or a competency evaluation program if, since the individual’s most recent completion of such a program, there has been a continuous period of 24 consecutive months during none of which the individual provided items and services described in [section 1395x(m) of this title](/usc/42/1395x.md?p=m) for compensation.

    - (B)
      - (i) The [agency](/usc/42/1397n–12.md?p=1) must provide, with respect to individuals used as a [home](/usc/42/1395x.md?p=iii-3-B) health aide by the [agency](/usc/42/1397n–12.md?p=1) as of July 1, 1989, for a competency evaluation program (as described in [subparagraph (A)(i)](#a-3-A-i)) and such preparation as may be necessary for the individual to complete such a program by January 1, 1990.
      - (ii) The [agency](/usc/42/1397n–12.md?p=1) must provide such regular performance review and regular in-service education as assures that individuals used to provide items and services described in [section 1395x(m) of this title](/usc/42/1395x.md?p=m) are competent to provide those items and services.
    - (C) The [agency](/usc/42/1397n–12.md?p=1) must not permit an individual, other than in a training and competency evaluation program that meets the minimum [standards](/usc/42/1320d.md?p=7) established by the [Secretary](/usc/42/1301.md?p=a-6) under [subparagraph (D)](#a-3-D), to provide items or services of a type for which the individual has not demonstrated competency.
    - (D)
      - (i) The [Secretary](/usc/42/1301.md?p=a-6) shall establish minimum [standards](/usc/42/1320d.md?p=7) for the programs described in [subparagraph (A)](#a-3-A) by not later than October 1, 1988.
      - (ii) Such [standards](/usc/42/1320d.md?p=7) shall include the content of the curriculum, minimum hours of training, qualification of instructors, and procedures for determination of competency.
      - (iii) Such [standards](/usc/42/1320d.md?p=7) may permit approval of programs offered by or in [home health agencies](/usc/42/1395x.md?p=o), as well as outside [agencies](/usc/42/1397n–12.md?p=1) ([including](/usc/42/1301.md?p=b) employee organizations), and of programs in effect on December 22, 1987; except that they may not provide for the approval of a program offered by or in a [home health agency](/usc/42/1395x.md?p=o) which, within the previous 2 years—
        - (I) has been determined to be out of compliance with subparagraph [(A)](#a-3-A), [(B)](#a-3-B), or [(C)](#a-3-C);
        - (II) has been subject to an extended (or partial extended) survey under [subsection (c)(2)(D)](#c-2-D);
        - (III) has been assessed a civil money penalty described in [subsection (f)(2)(A)(i)](#f-2-A-i) of not less than $5,000; or
        - (IV) has been subject to the remedies described in [subsection (e)(1)](#e-1) or in clauses [(ii)](#f-2-A-ii) or [(iii)](#f-2-A-iii) of subsection (f)(2)(A).
      - (iv) Such [standards](/usc/42/1320d.md?p=7) shall permit a determination that an individual who has completed (before July 1, 1989) a training and competency evaluation program or a competency evaluation program shall be deemed for purposes of [subparagraph (A)](#a-3-A) to have completed a program that is approved by the [Secretary](/usc/42/1301.md?p=a-6) under the [standards](/usc/42/1320d.md?p=7) established under this subparagraph if the [Secretary](/usc/42/1301.md?p=a-6) determines that, at the time the program was offered, the program met such [standards](/usc/42/1320d.md?p=7).
    - (E) In this paragraph, the term “[home](/usc/42/1395x.md?p=iii-3-B) health aide” means any individual who provides the items and services described in [section 1395x(m) of this title](/usc/42/1395x.md?p=m), but does not include an individual—
      - (i) who is a licensed health professional (as defined in [subparagraph (F)](#a-3-F)), or
      - (ii) who volunteers to provide such services without monetary compensation.
    - (F) In this paragraph, the term “licensed health professional” means a [physician](/usc/42/1395x.md?p=r), [physician assistant](/usc/42/1395x.md?p=aa-5-A), [nurse practitioner](/usc/42/1395x.md?p=aa-5-A), [physical](/usc/42/1395x.md?p=g), speech, or occupational therapist, [physical](/usc/42/1395x.md?p=g) or occupational therapy assistant, registered professional nurse, licensed practical nurse, or licensed or certified [social](/usc/42/1397j.md?p=20) worker.
  - (4) The [agency](/usc/42/1397n–12.md?p=1) [includes](/usc/42/1301.md?p=b) an individual’s plan of care required under [section 1395x(m) of this title](/usc/42/1395x.md?p=m) as part of the clinical records described in [section 1395x(o)(3)](/usc/42/1395x.md?p=o-3) of this title.
  - (5) The [agency](/usc/42/1397n–12.md?p=1) operates and provides services in compliance with all applicable Federal, [State](/usc/42/1395x.md?p=x), and local laws and regulations ([including](/usc/42/1301.md?p=b) the requirements of [section 1320a–3 of this title](/usc/42/1320a–3.md)) and with accepted professional [standards](/usc/42/1320d.md?p=7) and principles which apply to professionals providing items and services in such an [agency](/usc/42/1397n–12.md?p=1).
  - (6) The [agency](/usc/42/1397n–12.md?p=1) complies with the requirement of [section 1395cc(f) of this title](/usc/42/1395cc.md?p=f) (relating to maintaining written policies and procedures respecting advance directives).
- (b) **Duty of Secretary—** It is the duty and responsibility of the [Secretary](/usc/42/1301.md?p=a-6) to assure that the conditions of participation and requirements specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title and [subsection (a)](#a) of this section and the enforcement of such conditions and requirements are adequate to protect the health and safety of individuals under the care of a [home health agency](/usc/42/1395x.md?p=o) and to promote the effective and efficient use of public moneys.
- (c) **Surveys of home health agencies—**
  - (1) Any agreement entered into or renewed by the [Secretary](/usc/42/1301.md?p=a-6) pursuant to [section 1395aa of this title](/usc/42/1395aa.md) relating to [home health agencies](/usc/42/1395x.md?p=o) shall provide that the appropriate [State](/usc/42/1395x.md?p=x) or local [agency](/usc/42/1397n–12.md?p=1) shall conduct, without any prior notice, a [standard](/usc/42/1320d.md?p=7) survey of each [home health agency](/usc/42/1395x.md?p=o). Any individual who notifies (or causes to be notified) a [home health agency](/usc/42/1395x.md?p=o) 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 [section 1320a–7a of this title](/usc/42/1320a–7a.md) (other than subsections [(a)](#a) and [(b)](#b)) shall apply to a civil money penalty under this paragraph in the same manner as such provisions apply to a penalty or proceeding under [section 1320a–7a of this title](/usc/42/1320a–7a.md). The [Secretary](/usc/42/1301.md?p=a-6) shall review each [State](/usc/42/1395x.md?p=x)’s or local [agency](/usc/42/1397n–12.md?p=1)’s procedures for scheduling and conduct of [standard](/usc/42/1320d.md?p=7) surveys to assure that the [State](/usc/42/1395x.md?p=x) or [agency](/usc/42/1397n–12.md?p=1) has taken all reasonable steps to avoid giving notice of such a survey through the scheduling procedures and the conduct of the surveys themselves.
  - (2)
    - (A) Except as provided in [subparagraph (B)](#c-2-B), each [home health agency](/usc/42/1395x.md?p=o) shall be subject to a [standard](/usc/42/1320d.md?p=7) survey not later than 36 months after the date of the previous [standard](/usc/42/1320d.md?p=7) survey conducted under this paragraph. The [Secretary](/usc/42/1301.md?p=a-6) shall establish a frequency for surveys of [home health agencies](/usc/42/1395x.md?p=o) within this 36-month interval commensurate with the need to assure the delivery of quality [home health services](/usc/42/1395x.md?p=m).
    - (B) If not otherwise conducted under [subparagraph (A)](#c-2-A), a [standard](/usc/42/1320d.md?p=7) survey (or an abbreviated [standard](/usc/42/1320d.md?p=7) survey) of an [agency](/usc/42/1397n–12.md?p=1)—
      - (i) may be conducted within 2 months of any change of ownership, [administration](/usc/42/1301.md?p=a-10), or management of the [agency](/usc/42/1397n–12.md?p=1) to determine whether the change has resulted in any decline in the quality of care furnished by the [agency](/usc/42/1397n–12.md?p=1), and
      - (ii) shall be conducted within 2 months of when a significant number of complaints have been reported with respect to the [agency](/usc/42/1397n–12.md?p=1) to the [Secretary](/usc/42/1301.md?p=a-6), the [State](/usc/42/1395x.md?p=x), the entity responsible for the licensing of the [agency](/usc/42/1397n–12.md?p=1), the [State](/usc/42/1395x.md?p=x) or local [agency](/usc/42/1397n–12.md?p=1) responsible for maintaining a toll-free hotline and investigative unit (under [section 1395aa(a) of this title](/usc/42/1395aa.md?p=a)), or any other appropriate Federal, [State](/usc/42/1395x.md?p=x), or local [agency](/usc/42/1397n–12.md?p=1).
    - (C) A [standard](/usc/42/1320d.md?p=7) survey conducted under this paragraph with respect to a [home health agency](/usc/42/1395x.md?p=o)—
      - (i) shall include (to the extent practicable), for a case-mix stratified sample of individuals furnished items or services by the [agency](/usc/42/1397n–12.md?p=1)—
        - (I) visits to the [homes](/usc/42/1395x.md?p=iii-3-B) of such individuals, but only with the consent of such individuals, for the purpose of evaluating (in accordance with a standardized reproducible assessment instrument (or instruments) approved by the [Secretary](/usc/42/1301.md?p=a-6) under [subsection (d)](#d)) the extent to which the quality and scope of items and services furnished by the [agency](/usc/42/1397n–12.md?p=1) attained and maintained the highest practicable functional capacity of each such individual as reflected in such individual’s written plan of care required under [section 1395x(m) of this title](/usc/42/1395x.md?p=m) and clinical records required under [section 1395x(o)(3)](/usc/42/1395x.md?p=o-3) of this title; and
        - (II) a survey of the quality of care and services furnished by the [agency](/usc/42/1397n–12.md?p=1) as measured by indicators of medical, nursing, and rehabilitative care;
      - (ii) shall be based upon a protocol that is developed, tested, and validated by the [Secretary](/usc/42/1301.md?p=a-6) not later than January 1, 1989; and
      - (iii) shall be conducted by an individual—
        - (I) who meets minimum qualifications established by the [Secretary](/usc/42/1301.md?p=a-6) not later than July 1, 1989,
        - (II) who is not serving (or has not served within the previous 2 years) as a member of the staff of, or as a consultant to, the [home health agency](/usc/42/1395x.md?p=o) surveyed respecting compliance with the conditions of participation specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title or [subsection (a)](#a) of this section, and
        - (III) who has no personal or familial financial interest in the [home health agency](/usc/42/1395x.md?p=o) surveyed.
    - (D) Each [home health agency](/usc/42/1395x.md?p=o) that is found, under a [standard](/usc/42/1320d.md?p=7) survey, to have provided substandard care shall be subject to an extended survey to review and identify the policies and procedures which produced such substandard care and to determine whether the [agency](/usc/42/1397n–12.md?p=1) has complied with the conditions of participation specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title or [subsection (a)](#a) of this section. Any other [agency](/usc/42/1397n–12.md?p=1) may, at the [Secretary](/usc/42/1301.md?p=a-6)’s or [State](/usc/42/1395x.md?p=x)’s discretion, be subject to such an extended survey (or a partial extended survey). The extended survey shall be conducted immediately after the [standard](/usc/42/1320d.md?p=7) survey (or, if not practical, not later than 2 weeks after the date of completion of the [standard](/usc/42/1320d.md?p=7) survey).
    - (E) Nothing in this paragraph shall be construed as requiring an extended (or partial extended) survey as a prerequisite to imposing a sanction against an [agency](/usc/42/1397n–12.md?p=1) under [subsection (e)](#e) on the basis of the findings of a [standard](/usc/42/1320d.md?p=7) survey.
- (d) **Assessment process; reports to Congress—**
  - (1) Not later than January 1, 1989, the [Secretary](/usc/42/1301.md?p=a-6) shall designate an assessment instrument (or instruments) for use by an [agency](/usc/42/1397n–12.md?p=1) in complying with [subsection (c)(2)(C)(i)(I)](#c-2-C-i-I).
  - (2)
    - (A) Not later than January 1, 1992, the [Secretary](/usc/42/1301.md?p=a-6) shall—
      - (i) evaluate the assessment process,
      - (ii) report to Congress on the results of such evaluation, and
      - (iii) based on such evaluation, make such modifications in the assessment process as the [Secretary](/usc/42/1301.md?p=a-6) determines are appropriate.
    - (B) The [Secretary](/usc/42/1301.md?p=a-6) shall periodically update the evaluation conducted under [subparagraph (A)](#d-2-A), report the results of such update to Congress, and, based on such update, make such modifications in the assessment process as the [Secretary](/usc/42/1301.md?p=a-6) determines are appropriate.
  - (3) The [Secretary](/usc/42/1301.md?p=a-6) shall provide for the comprehensive training of [State](/usc/42/1395x.md?p=x) and Federal surveyors in matters relating to the performance of [standard](/usc/42/1320d.md?p=7) and extended surveys under this section, [including](/usc/42/1301.md?p=b) the use of any assessment instrument (or instruments) designated under [paragraph (1)](#d-1).
- (e) **Enforcement—**
  - (1) If the [Secretary](/usc/42/1301.md?p=a-6) determines on the basis of a [standard](/usc/42/1320d.md?p=7), extended, or partial extended survey or otherwise, that a [home health agency](/usc/42/1395x.md?p=o) that is certified for participation under this subchapter is no longer in compliance with the requirements specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title or [subsection (a)](#a) and determines that the deficiencies involved immediately jeopardize the health and safety of the individuals to whom the [agency](/usc/42/1397n–12.md?p=1) furnishes items and services, the [Secretary](/usc/42/1301.md?p=a-6) shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in [subsection (f)(2)(A)(iii)](#f-2-A-iii) or terminate the certification of the [agency](/usc/42/1397n–12.md?p=1), and may provide, in addition, for 1 or more of the other remedies described in [subsection (f)(2)(A)](#f-2-A).
  - (2) If the [Secretary](/usc/42/1301.md?p=a-6) determines on the basis of a [standard](/usc/42/1320d.md?p=7), extended, or partial extended survey or otherwise, that a [home health agency](/usc/42/1395x.md?p=o) that is certified for participation under this subchapter is no longer in compliance with the requirements specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title or [subsection (a)](#a) and determines that the deficiencies involved do not immediately jeopardize the health and safety of the individuals to whom the [agency](/usc/42/1397n–12.md?p=1) furnishes items and services, the [Secretary](/usc/42/1301.md?p=a-6) may (for a period not to exceed 6 months) impose intermediate sanctions developed pursuant to [subsection (f)](#f), in lieu of terminating the certification of the [agency](/usc/42/1397n–12.md?p=1). If, after such a period of intermediate sanctions, the [agency](/usc/42/1397n–12.md?p=1) is still no longer in compliance with the requirements specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title or [subsection (a)](#a), the [Secretary](/usc/42/1301.md?p=a-6) shall terminate the certification of the [agency](/usc/42/1397n–12.md?p=1).
  - (3) If the [Secretary](/usc/42/1301.md?p=a-6) determines that a [home health agency](/usc/42/1395x.md?p=o) that is certified for participation under this subchapter is in compliance with the requirements specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title or [subsection (a)](#a) but, as of a previous period, did not meet such requirements, the [Secretary](/usc/42/1301.md?p=a-6) may provide for a civil money penalty under [subsection (f)(2)(A)(i)](#f-2-A-i) for the days in which it finds that the [agency](/usc/42/1397n–12.md?p=1) was not in compliance with such requirements.
  - (4) The [Secretary](/usc/42/1301.md?p=a-6) may continue payments under this subchapter with respect to a [home health agency](/usc/42/1395x.md?p=o) not in compliance with the requirements specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title or [subsection (a)](#a) over a period of not longer than 6 months, if—
    - (A) the [State](/usc/42/1395x.md?p=x) or local survey [agency](/usc/42/1397n–12.md?p=1) finds that it is more appropriate to take alternative action to assure compliance of the [agency](/usc/42/1397n–12.md?p=1) with the requirements than to terminate the certification of the [agency](/usc/42/1397n–12.md?p=1),
    - (B) the [agency](/usc/42/1397n–12.md?p=1) has submitted a plan and timetable for corrective action to the [Secretary](/usc/42/1301.md?p=a-6) for approval and the [Secretary](/usc/42/1301.md?p=a-6) approves the plan of corrective action, and
    - (C) the [agency](/usc/42/1397n–12.md?p=1) 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](/usc/42/1301.md?p=a-6) shall establish guidelines for approval of corrective actions requested by [home health agencies](/usc/42/1395x.md?p=o) under this subparagraph.

- (f) **Intermediate sanctions—**
  - (1) The [Secretary](/usc/42/1301.md?p=a-6) shall develop and implement, by not later than April 1, 1989—
    - (A) a range of intermediate sanctions to apply to [home health agencies](/usc/42/1395x.md?p=o) under the conditions described in [subsection (e)](#e), and
    - (B) appropriate procedures for appealing determinations relating to the imposition of such sanctions.
  - (2)
    - (A) The intermediate sanctions developed under [paragraph (1)](#f-1) shall include—
      - (i) civil money penalties in an amount not to exceed $10,000 for each day of noncompliance,
      - (ii) suspension of all or part of the payments to which a [home health agency](/usc/42/1395x.md?p=o) would otherwise be entitled under this subchapter with respect to items and services furnished by a [home health agency](/usc/42/1395x.md?p=o) on or after the date on which the [Secretary](/usc/42/1301.md?p=a-6) determines that intermediate sanctions should be imposed pursuant to [subsection (e)(2)](#e-2), and
      - (iii) the appointment of temporary management to oversee the operation of the [home health agency](/usc/42/1395x.md?p=o) and to protect and assure the health and safety of the individuals under the care of the [agency](/usc/42/1397n–12.md?p=1) while improvements are made in order to bring the [agency](/usc/42/1397n–12.md?p=1) into compliance with all the requirements specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title or [subsection (a)](#a).

      The provisions of [section 1320a–7a of this title](/usc/42/1320a–7a.md) (other than subsections [(a)](#a) and [(b)](#b)) shall apply to a civil money penalty under [clause (i)](#f-2-A-i) in the same manner as such provisions apply to a penalty or proceeding under [section 1320a–7a(a) of this title](/usc/42/1320a–7a.md?p=a). The temporary management under [clause (iii)](#f-2-A-iii) shall not be terminated until the [Secretary](/usc/42/1301.md?p=a-6) has determined that the [agency](/usc/42/1397n–12.md?p=1) has the management capability to ensure continued compliance with all the requirements referred to in that clause.

    - (B) The sanctions specified in [subparagraph (A)](#f-2-A) are in addition to sanctions otherwise available under [State](/usc/42/1395x.md?p=x) or Federal law and shall not be construed as limiting other remedies, [including](/usc/42/1301.md?p=b) any remedy available to an individual at common law.
    - (C) A finding to suspend payment under [subparagraph (A)(ii)](#f-2-A-ii) shall terminate when the [Secretary](/usc/42/1301.md?p=a-6) finds that the [home health agency](/usc/42/1395x.md?p=o) is in substantial compliance with all the requirements specified in or pursuant to [section 1395x(o)](/usc/42/1395x.md?p=o) of this title and [subsection (a)](#a).
  - (3) The [Secretary](/usc/42/1301.md?p=a-6) shall develop and implement, by not later than April 1, 1989, specific procedures with respect to the conditions under which each of the intermediate sanctions developed under [paragraph (1)](#f-1) is to be applied, [including](/usc/42/1301.md?p=b) the amount of any fines and the severity of each of these sanctions. Such procedures shall be designed so as to minimize the time between identification of deficiencies and imposition of these sanctions and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies.
- (g) **Payment on basis of location of service—** A [home health agency](/usc/42/1395x.md?p=o) shall submit claims for payment for [home health services](/usc/42/1395x.md?p=m) under this subchapter only on the basis of the geographic location at which the service is furnished, as determined by the [Secretary](/usc/42/1301.md?p=a-6).

## Source credit

(Aug. 14, 1935, ch. 531, title XVIII, § 1891, as added and amended Pub. L. 100–203, title IV, §§ 4021(b), 4022(a), 4023(a), Dec. 22, 1987, 101 Stat. 1330–67, 1330–69, 1330–71; Pub. L. 100–360, title IV, § 411(d)(1)(A), (2)–(3)(B), July 1, 1988, 102 Stat. 773, 774; Pub. L. 100–485, title VI, § 608(d)(20)(A), Oct. 13, 1988, 102 Stat. 2419; Pub. L. 101–508, title IV, §§ 4206(d)(2), 4207(i)(1), formerly 4027(i)(1), Nov. 5, 1990, 104 Stat. 1388–116, 1388–123, renumbered Pub. L. 103–432, title I, § 160(d)(4), Oct. 31, 1994, 108 Stat. 4444; Pub. L. 104–134, title I, § 101(d) [title V, § 516(a)], Apr. 26, 1996, 110 Stat. 1321–211, 1321–246; renumbered title I, Pub. L. 104–140, § 1(a), May 2, 1996, 110 Stat. 1327; Pub. L. 105–33, title IV, § 4604(a), Aug. 5, 1997, 111 Stat. 472; Pub. L. 108–173, title VII, § 736(c)(3), Dec. 8, 2003, 117 Stat. 2356.)

## Notes

### Editorial Notes

### Amendments

2003—Subsec. (d)(1). Pub. L. 108–173 substituted “subsection (c)(2)(C)(i)(I)” for “subsection (c)(2)(C)(I)”.

1997—Subsec. (g). Pub. L. 105–33 added subsec. (g).

1996—Subsec. (c)(2)(A). Pub. L. 104–134 substituted “36 months” for “15 months” in first sentence and amended last sentence generally. Prior to amendment, last sentence read as follows: “The statewide average interval between standard surveys of any home health agency shall not exceed 12 months.”

1990—Subsec. (a)(3)(D)(iii). Pub. L. 101–508, § 4207(i)(1), formerly § 4027(i)(1), as renumbered by Pub. L. 103–432, substituted “which, within the previous 2 years—” and subcls. (I) to (IV) for “which has been determined to be out of compliance with the requirements specified in or pursuant to section 1395x(o) of this title or subsection (a) of this section within the previous 2 years.”

Subsec. (a)(6). Pub. L. 101–508, § 4206(d)(2), added par. (6).

1988—Subsec. (a)(3)(A). Pub. L. 100–360, § 411(d)(1)(A)(i), struck out “who is not a licensed health care professional (as defined in subparagraph (F))” after “any individual” in introductory provisions.

Subsec. (a)(3)(F). Pub. L. 100–360, § 411(d)(1)(A)(ii), inserted “physical or occupational therapy assistant,” after “occupational therapist”.

Subsec. (a)(4) to (6). Pub. L. 100–360, § 411(d)(1)(A)(iii), redesignated pars. (5) and (6) as (4) and (5), respectively, and struck out former par. (4) which read as follows: “With respect to durable medical equipment furnished to individuals for whom the agency provides items and services, suppliers of such equipment do not use (on a full-time, temporary, per diem, or other basis) any individual who does not meet minimum training standards (established by the Secretary by October 1, 1988) for the demonstration and use of any such equipment furnished to individuals with respect to whom payments may be made under this subchapter.”

Subsec. (c)(1). Pub. L. 100–360, § 411(d)(2)(A), as amended by Pub. L. 100–485, § 608(d)(20)(A), 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 section 1320a–7a of this title.”

Subsec. (d)(2)(A). Pub. L. 100–360, § 411(d)(2)(B), substituted “1992” for “1991” in introductory provisions.

Subsecs. (e), (f). Pub. L. 100–360, § 411(d)(3)(A), made technical amendment to Pub. L. 100–203, § 4023(a), see 1987 Amendment note below.

Subsec. (f)(2)(A). Pub. L. 100–360, § 411(d)(3)(B)(iii), inserted before last sentence “The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title.”

Pub. L. 100–360, § 411(d)(3)(B)(i), realigned the margins of cls. (i) to (iii) and concluding provisions.

Subsec. (f)(2)(A)(i). Pub. L. 100–360, § 411(d)(3)(B)(ii), substituted “in an amount not to exceed $10,000 for each day of noncompliance” for “for each day of noncompliance”.

1987—Subsecs. (c), (d). Pub. L. 100–203, § 4022(a), added subsecs. (c) and (d).

Subsecs. (e), (f). Pub. L. 100–203, § 4023(a), as amended by Pub. L. 100–360, § 411(d)(3)(A), added subsecs. (e) and (f).

### Statutory Notes and Related Subsidiaries

### Effective Date of 1997 Amendment

Amendment by Pub. L. 105–33 applicable to cost reporting periods beginning on or after Oct. 1, 1997, see section 4604(c) of Pub. L. 105–33, set out as a note under section 1395x of this title.

### Effective Date of 1990 Amendment

Amendment by section 4206(d)(2) of Pub. L. 101–508 applicable with respect to services furnished on or after the first day of the first month beginning more than 1 year after Nov. 5, 1990, see section 4206(e)(1) of Pub. L. 101–508, set out as a note under section 1395i–3 of this title.

Pub. L. 101–508, title IV, § 4207(i)(1), formerly § 4027(i)(1), Nov. 5, 1990, 104 Stat. 1388–123, as renumbered by Pub. L. 103–432, title I, § 160(d)(4), Oct. 31, 1994, 108 Stat. 4444, provided that the amendment made by that section is effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203.

Pub. L. 101–508, title IV, § 4207(i)(2), formerly § 4027(i)(2), Nov. 5, 1990, 104 Stat. 1388–124, as renumbered and amended by Pub. L. 103–432, title I, § 160(d)(4), (11), Oct. 31, 1994, 108 Stat. 4444, provided that: “The amendments made by paragraph (1) [amending this section] shall take effect as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987 [Pub. L. 100–203], except that the Secretary may not permit approval of a training and competency evaluation program or a competency evaluation program offered by or in a home health agency which, pursuant to any Federal or State law within the 2-year period beginning on October 1, 1988— had its participation terminated under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.]; was assessed a civil money penalty not less than $5,000 for deficiencies in applicable quality standards for home health agencies; was subject to suspension by the Secretary of all or part of the payments to which it would otherwise be entitled under such title; operated under a temporary management appointed to oversee the operation of the agency and to ensure the health and safety of the agency’s patients; or pursuant to State action, was closed or had its patients transferred.”

### Effective Date of 1988 Amendment

Amendment by Pub. L. 100–485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100–360, see section 608(g)(1) of Pub. L. 100–485, set out as a note under section 704 of this title.

Except as specifically provided in section 411 of Pub. L. 100–360, amendment by Pub. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, effective as if included in the enactment of that provision in Pub. L. 100–203, see section 411(a) of Pub. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.

### Effective Date of 1987 Amendment

Pub. L. 100–203, title IV, § 4022(b), Dec. 22, 1987, 101 Stat. 1330–71, provided that: “Except as otherwise specifically provided in section 1891(d) of the Social Security Act [42 U.S.C. 1395bbb(d)] (as added by subsection (a)), the amendment made by subsection (a) [amending this section] shall become effective on the first day of the 18th calendar month to begin after the date of the enactment of this Act [Dec. 22, 1987].”

Pub. L. 100–203, title IV, § 4023(b), Dec. 22, 1987, 101 Stat. 1330–73, as amended by Pub. L. 100–360, title IV, § 411(d)(3)(C), July 1, 1988, 102 Stat. 774, provided that: “Except as otherwise specifically provided in subsections (e) and (f) of section 1891 of the Social Security Act [42 U.S.C. 1395bbb(e), (f)] (as added by subsection (a)), the amendment made by subsection (a) [amending this section] shall become effective on the first day of the 18th calendar month to begin after the date of the enactment of this Act [Dec. 22, 1987], and no intermediate sanction described in section 1891(f)(2)(A) of such Act [42 U.S.C. 1395bbb(f)(2)(A)] shall be imposed for violations occurring before such effective date.”

### Effective Date

Section applicable to home health agencies as of the first day of the 18th calendar month that begins after Dec. 22, 1987, except as otherwise provided, see section 4021(c) of Pub. L. 100–203, set out as an Effective Date of 1987 Amendment note under section 1395x of this title.

### Treatment of Branch Offices; GAO Study on Supervision of Home Health Care Provided in Isolated Rural Areas

Pub. L. 106–554, § 1(a)(6) [title V, § 506], Dec. 21, 2000, 114 Stat. 2763, 2763A–531, provided that:Treatment of Branch Offices.— In general.—Notwithstanding any other provision of law, in determining for purposes of title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] whether an office of a home health agency constitutes a branch office or a separate home health agency, neither the time nor distance between a parent office of the home health agency and a branch office shall be the sole determinant of a home health agency’s branch office status. Consideration of forms of technology in definition of supervision.—The Secretary of Health and Human Services may include forms of technology in determining what constitutes ‘supervision’ for purposes of determining a home heath [sic] agency’s branch office status under paragraph (1).GAO Study.— Study.—The Comptroller General of the United States shall conduct a study of the provision of adequate supervision to maintain quality of home health services delivered under the medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] in isolated rural areas. The study shall evaluate the methods that home health agency branches and subunits use to maintain adequate supervision in the delivery of services to clients residing in those areas, how these methods of supervision compare to requirements that subunits independently meet medicare conditions of participation, and the resources utilized by subunits to meet such conditions. Report.—Not later than January 1, 2002, the Comptroller General shall submit to Congress a report on the study conducted under paragraph (1). The report shall include recommendations on whether exceptions are needed for subunits and branches of home health agencies under the medicare program to maintain access to the home health benefit or whether alternative policies should be developed to assure adequate supervision and access and recommendations on whether a national standard for supervision is appropriate.”