---
kind: "section"
citation: "42 U.S.C. § 1395i–3"
title: "42"
title_heading: "The Public Health and Welfare"
number: "1395i–3"
heading: "Requirements for, and assuring quality of care in, skilled nursing facilities"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/1395i-3"
units:
  - "Chapter 7 — Social Security"
  - "Subchapter XVIII — Health Insurance for Aged and Disabled"
  - "Part A — Hospital Insurance Benefits for Aged and Disabled"
---

# §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](/usc/42/1397j.md?p=17-A)” 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](/usc/42/1301.md?p=a-3),

    and is not primarily for the care and [treatment](/usc/42/11851.md?p=11) of mental diseases;

  - (2) has in effect a transfer agreement (meeting the requirements of [section 1395x(l)](/usc/42/1395x.md?p=l) of this title) with one or more [hospitals](/usc/42/300s–3.md?p=1) having agreements in effect under [section 1395cc of this title](/usc/42/1395cc.md); and
  - (3) meets the requirements for a skilled [nursing facility](/usc/42/1397j.md?p=17-A) described in subsections [(b)](#b), [(c)](#c), and [(d)](#d) of this section.
- (b) **Requirements relating to provision of services—**
  - (1) **Quality of life—**
    - (A) **In general—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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.
    - (B) **Quality assessment and assurance—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must maintain a quality assessment and assurance committee, consisting of the [director](/usc/42/11851.md?p=5) of nursing services, a [physician](/usc/42/1301.md?p=a-7) designated by the [facility](/usc/42/1320a–3.md?p=c-5-B), and at least 3 other members of the [facility](/usc/42/1320a–3.md?p=c-5-B)’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](/usc/42/619.md?p=5) or the [Secretary](/usc/42/1301.md?p=a-6) 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.
  - (2) **Scope of services and activities under plan of care—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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](/usc/42/1301.md?p=b) the resident’s attending [physician](/usc/42/1301.md?p=a-7) 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)](#b-3).
  - (3) **Residents’ assessment—**
    - (A) **Requirement—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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](/usc/42/1301.md?p=a-6) under [subsection (f)(6)(A)](#f-6-A);
      - (iii) uses an instrument which is specified by the [State](/usc/42/619.md?p=5) under [subsection (e)(5)](#e-5); and
      - (iv) [includes](/usc/42/1301.md?p=b) the identification of medical problems.
    - (B) **Certification—**
      - (i) **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.
      - (ii) **Penalty for falsification—**
        - (I) An individual who willfully and knowingly certifies under [clause (i)](#b-3-B-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)](#b-3-B-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](/usc/42/1320a–7a.md) (other than subsections [(a)](#a) and [(b)](#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](/usc/42/1320a–7a.md?p=a).
      - (iii) **Use of independent assessors—** If a [State](/usc/42/619.md?p=5) determines, under a survey under [subsection (g)](#g) or otherwise, that there has been a knowing and willful certification of false assessments under this paragraph, the [State](/usc/42/619.md?p=5) may require (for a period specified by the [State](/usc/42/619.md?p=5)) that resident assessments under this paragraph be conducted and certified by individuals who are independent of the [facility](/usc/42/1320a–3.md?p=c-5-B) and who are approved by the [State](/usc/42/619.md?p=5).
    - (C) **Frequency—**
      - (i) **In general—** Subject to the timeframes prescribed by the [Secretary](/usc/42/1301.md?p=a-6) under [section 1395yy(e)(6) of this title](/usc/42/1395yy.md?p=e-6), 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](/usc/42/1320a–3.md?p=c-5-B) 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—** The skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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.
    - (D) **Use—** The results of such an assessment shall be used in developing, reviewing, and revising the resident’s plan of care under [paragraph (2)](#b-2).
    - (E) **Coordination—** Such assessments shall be coordinated with any [State](/usc/42/619.md?p=5)-required preadmission screening program to the maximum extent practicable in order to avoid duplicative testing and effort.
  - (4) **Provision of services and activities—**
    - (A) **In general—** To the extent needed to fulfill all plans of care described in [paragraph (2)](#b-2), a skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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](/usc/42/1397j.md?p=20) services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident;
      - (iii) pharmaceutical services ([including](/usc/42/1301.md?p=b) procedures that assure the accurate acquiring, receiving, dispensing, and administering of all [drugs](/usc/42/11851.md?p=4) 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](/usc/42/11851.md?p=11) 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](/usc/42/619.md?p=5).

      The services provided or arranged by the [facility](/usc/42/1320a–3.md?p=c-5-B) must meet professional [standards](/usc/42/1320d.md?p=7) of quality. Nothing in [clause (vi)](#b-4-A-vi) shall be construed as requiring a [facility](/usc/42/1320a–3.md?p=c-5-B) to provide or arrange for dental services described in that clause without additional charge.

    - (B) **Qualified persons providing services—** Services described in clauses [(i)](#b-4-A-i), [(ii)](#b-4-A-ii), [(iii)](#b-4-A-iii), [(iv)](#b-4-A-iv), and [(vi)](#b-4-A-vi) of subparagraph (A) must be provided by qualified [persons](/usc/42/1301.md?p=a-3) in accordance with each resident’s written plan of care.
    - (C) **Required nursing care—**
      - (i) **In general—** Except as provided in [clause (ii)](#b-4-C-ii), a skilled [nursing facility](/usc/42/1397j.md?p=17-A) must provide 24-hour licensed nursing service which is sufficient to meet nursing needs of its residents and must use the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week.
      - (ii) **Exception—** To the extent that [clause (i)](#b-4-C-i) may be deemed to require that a skilled [nursing facility](/usc/42/1397j.md?p=17-A) engage the services of a registered professional nurse for more than 40 hours a week, the [Secretary](/usc/42/1301.md?p=a-6) is authorized to waive such requirement if the [Secretary](/usc/42/1301.md?p=a-6) finds that—
        - (I) the [facility](/usc/42/1320a–3.md?p=c-5-B) is located in a rural area and the supply of skilled [nursing facility](/usc/42/1397j.md?p=17-A) services in such area is not sufficient to meet the needs of individuals residing therein,
        - (II) the [facility](/usc/42/1320a–3.md?p=c-5-B) has one full-time registered professional nurse who is regularly on duty at such [facility](/usc/42/1320a–3.md?p=c-5-B) 40 hours a week,
        - (III) the [facility](/usc/42/1320a–3.md?p=c-5-B) either has only patients whose [physicians](/usc/42/1301.md?p=a-7) have indicated (through [physicians](/usc/42/1301.md?p=a-7)’ orders or admission notes) that each such patient does not require the services of a registered nurse or a [physician](/usc/42/1301.md?p=a-7) for a 48-hour period, or has made arrangements for a registered professional nurse or a [physician](/usc/42/1301.md?p=a-7) to spend such time at such [facility](/usc/42/1320a–3.md?p=c-5-B) as may be indicated as necessary by the [physician](/usc/42/1301.md?p=a-7) to provide necessary skilled nursing services on days when the regular full-time registered professional nurse is not on duty,
        - (IV) the [Secretary](/usc/42/1301.md?p=a-6) provides notice of the waiver to the [State long-term care ombudsman](/usc/42/1397j.md?p=22) (established under section 307(a)(12)[^1] of the Older Americans Act of 1965) and the protection and advocacy system in the [State](/usc/42/619.md?p=5) for the mentally ill and the mentally retarded, and
        - (V) the [facility](/usc/42/1320a–3.md?p=c-5-B) that is granted such a waiver notifies residents of the [facility](/usc/42/1320a–3.md?p=c-5-B) (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)](#b-5-A-ii), a skilled [nursing facility](/usc/42/1397j.md?p=17-A) must not use on a full-time basis any individual as a nurse aide in the [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/619.md?p=5) under [subsection (e)(1)(A)](#e-1-A), and
        - (II) is competent to provide nursing or nursing-related services.
      - (ii) A skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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](/usc/42/1320a–3.md?p=c-5-B) on or after January 1, 1991, unless the individual meets the requirements described in [clause (i)](#b-5-A-i).
    - (B) **Offering competency evaluation programs for current employees—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must provide, for individuals used as a nurse aide[^2] by the [facility](/usc/42/1320a–3.md?p=c-5-B) as of January 1, 1990, for a competency evaluation program approved by the [State](/usc/42/619.md?p=5) under [subsection (e)(1)](#e-1) and such preparation as may be necessary for the individual to complete such a program by October 1, 1990.
    - (C) **Competency—** The skilled [nursing facility](/usc/42/1397j.md?p=17-A) must not permit an individual, other than in a training and competency evaluation program approved by the [State](/usc/42/619.md?p=5), 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](/usc/42/1320a–3.md?p=c-5-B) has inquired of any [State](/usc/42/619.md?p=5) registry established under [subsection (e)(2)(A)](#e-2-A) that the [facility](/usc/42/1320a–3.md?p=c-5-B) believes will include information concerning the individual.
    - (D) **Re-training required—** For purposes of [subparagraph (A)](#b-5-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.
    - (E) **Regular in-service education—** The skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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](/usc/42/1301.md?p=b) training for individuals providing nursing and nursing-related services to residents with cognitive impairments.
    - (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](/usc/42/1397j.md?p=17-A), but does not include an individual—
      - (i) who is a licensed health professional (as defined in [subparagraph (G)](#b-5-G)) or a registered dietician, or
      - (ii) who volunteers to provide such services without monetary compensation.

      Such term [includes](/usc/42/1301.md?p=b) an individual who provides such services through an [agency](/usc/42/1397n–12.md?p=1) or under a contract with the [facility](/usc/42/1320a–3.md?p=c-5-B).

    - (G) **“Licensed health professional” defined—** In this paragraph, the term “licensed health professional” means a [physician](/usc/42/1301.md?p=a-7), [physician](/usc/42/1301.md?p=a-7) assistant, nurse practitioner, physical, speech, or occupational therapist, physical or occupational therapy assistant, registered professional nurse, licensed practical nurse, licensed or certified [social](/usc/42/1397j.md?p=20) worker, registered respiratory therapist, or certified respiratory therapy technician.
  - (6) **Physician supervision and clinical records—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must—
    - (A) require that the [medical care](/usc/42/1301.md?p=a-7) of every resident be provided under the supervision of a [physician](/usc/42/1301.md?p=a-7);
    - (B) provide for having a [physician](/usc/42/1301.md?p=a-7) available to furnish necessary [medical care](/usc/42/1301.md?p=a-7) in case of emergency; and
    - (C) maintain clinical records on all residents, which records include the plans of care (described in [paragraph (2)](#b-2)) and the residents’ assessments (described in [paragraph (3)](#b-3)).
  - (7) **Required social services—** In the case of a skilled [nursing facility](/usc/42/1397j.md?p=17-A) with more than 120 beds, the [facility](/usc/42/1320a–3.md?p=c-5-B) must have at least one [social](/usc/42/1397j.md?p=20) worker (with at least a bachelor’s degree in [social](/usc/42/1397j.md?p=20) work or similar professional qualifications) employed full-time to provide or assure the provision of [social](/usc/42/1397j.md?p=20) services.
  - (8) **Information on nurse staffing—**
    - (A) **In general—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) shall post daily for each shift the current number of licensed and unlicensed nursing staff directly responsible for resident care in the [facility](/usc/42/1320a–3.md?p=c-5-B). The information shall be displayed in a uniform manner (as specified by the [Secretary](/usc/42/1301.md?p=a-6)) and in a clearly visible place.
    - (B) **Publication of data—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) shall, upon request, make available to the public the nursing staff data described in [subparagraph (A)](#b-8-A).
- (c) **Requirements relating to residents’ rights—**
  - (1) **General rights—**
    - (A) **Specified rights—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must protect and promote the rights of each resident, [including](/usc/42/1301.md?p=b) each of the following rights:
      - (i) **Free choice—** The right to choose a personal attending [physician](/usc/42/1301.md?p=a-7), to be fully informed in advance about care and [treatment](/usc/42/11851.md?p=11), to be fully informed in advance of any changes in care or [treatment](/usc/42/11851.md?p=11) that may affect the resident’s well-being, and (except with respect to a resident adjudged incompetent) to participate in planning care and [treatment](/usc/42/11851.md?p=11) or changes in care and [treatment](/usc/42/11851.md?p=11).
      - (ii) **Free from restraints—** The right to be free from physical or mental [abuse](/usc/42/1397j.md?p=1), 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](/usc/42/1301.md?p=a-7) that specifies the duration and circumstances under which the restraints are to be used (except in emergency circumstances specified by the [Secretary](/usc/42/1301.md?p=a-6) until such an order could reasonably be obtained).
      - (iii) **Privacy—** The right to privacy with regard to accommodations, medical [treatment](/usc/42/11851.md?p=11), written and telephonic communications, visits, and meetings of family and of resident groups.
      - (iv) **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.
      - (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](/usc/42/1320a–3.md?p=c-5-B) is changed.
      - (vi) **Grievances—** 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 the grievances and the right to prompt efforts by the [facility](/usc/42/1320a–3.md?p=c-5-B) to resolve grievances the resident may have, [including](/usc/42/1301.md?p=b) those with respect to the behavior of other residents.
      - (vii) **Participation in resident and family groups—** The right of the resident to organize and participate in resident groups in the [facility](/usc/42/1320a–3.md?p=c-5-B) and the right of the resident’s family to meet in the [facility](/usc/42/1320a–3.md?p=c-5-B) with the families of other residents in the [facility](/usc/42/1320a–3.md?p=c-5-B).
      - (viii) **Participation in other activities—** The right of the resident to participate in [social](/usc/42/1397j.md?p=20), religious, and community activities that do not interfere with the rights of other residents in the [facility](/usc/42/1320a–3.md?p=c-5-B).
      - (ix) **Examination of survey results—** The right to examine, upon reasonable request, the results of the most recent survey of the [facility](/usc/42/1320a–3.md?p=c-5-B) conducted by the [Secretary](/usc/42/1301.md?p=a-6) or a [State](/usc/42/619.md?p=5) with respect to the [facility](/usc/42/1320a–3.md?p=c-5-B) and any plan of correction in effect with respect to the [facility](/usc/42/1320a–3.md?p=c-5-B).
      - (x) **Refusal of certain transfers—** The right to refuse a transfer to another room within the [facility](/usc/42/1320a–3.md?p=c-5-B), if a purpose of the transfer is to relocate the resident from a portion of the [facility](/usc/42/1320a–3.md?p=c-5-B) that is a skilled [nursing facility](/usc/42/1397j.md?p=17-A) (for purposes of this subchapter) to a portion of the [facility](/usc/42/1320a–3.md?p=c-5-B) that is not such a skilled [nursing facility](/usc/42/1397j.md?p=17-A).
      - (xi) **Other rights—** Any other right established by the [Secretary](/usc/42/1301.md?p=a-6).

      [Clause (iii)](#c-1-A-iii) shall not be construed as requiring the provision of a private room. A resident’s exercise of a right to refuse transfer under [clause (x)](#c-1-A-x) shall not affect the resident’s eligibility or entitlement to benefits under this subchapter or to medical assistance under subchapter XIX of this chapter.

    - (B) **Notice of rights and services—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must—
      - (i) inform each resident, orally and in writing at the time of admission to the [facility](/usc/42/1320a–3.md?p=c-5-B), of the resident’s legal rights during the stay at the [facility](/usc/42/1320a–3.md?p=c-5-B);
      - (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](/usc/42/1301.md?p=b) the notice (if any) of the [State](/usc/42/619.md?p=5) developed under [section 1396r(e)(6) of this title](/usc/42/1396r.md?p=e-6); 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](/usc/42/1320a–3.md?p=c-5-B) and of related charges for such services, [including](/usc/42/1301.md?p=b) any charges for services not covered under this subchapter or by the [facility](/usc/42/1320a–3.md?p=c-5-B)’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)](#c-6) and a statement that a resident may file a complaint with a [State](/usc/42/619.md?p=5) survey and certification [agency](/usc/42/1397n–12.md?p=1) respecting resident [abuse](/usc/42/1397j.md?p=1) and [neglect](/usc/42/1397j.md?p=16) and misappropriation of resident property in the [facility](/usc/42/1320a–3.md?p=c-5-B).

    - (C) **Rights of incompetent residents—** In the case of a resident adjudged incompetent under the laws of a [State](/usc/42/619.md?p=5), 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](/usc/42/1301.md?p=a-3) appointed under [State](/usc/42/619.md?p=5) law to act on the resident’s behalf.
    - (D) **Use of psychopharmacologic drugs—** Psychopharmacologic [drugs](/usc/42/11851.md?p=4) may be administered only on the orders of a [physician](/usc/42/1301.md?p=a-7) and only as part of a plan (included in the written plan of care described in [paragraph (2)](#c-2)) designed to eliminate or modify the symptoms for which the [drugs](/usc/42/11851.md?p=4) are prescribed and only if, at least annually, an independent, external consultant reviews the appropriateness of the [drug](/usc/42/11851.md?p=4) plan of each resident receiving such [drugs](/usc/42/11851.md?p=4). In determining whether such a consultant is qualified to conduct reviews under the preceding sentence, the [Secretary](/usc/42/1301.md?p=a-6) shall take into account the needs of [nursing facilities](/usc/42/1397j.md?p=17-A) under this subchapter to have access to the services of such a consultant on a timely basis.
    - (E) **Information respecting advance directives—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must comply 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).
  - (2) **Transfer and discharge rights—**
    - (A) **In general—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must permit each resident to remain in the [facility](/usc/42/1320a–3.md?p=c-5-B) and must not transfer or discharge the resident from the [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/1320a–3.md?p=c-5-B);
      - (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](/usc/42/1320a–3.md?p=c-5-B);
      - (iii) the safety of individuals in the [facility](/usc/42/1320a–3.md?p=c-5-B) is endangered;
      - (iv) the health of individuals in the [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/1320a–3.md?p=c-5-B); or
      - (vi) the [facility](/usc/42/1320a–3.md?p=c-5-B) ceases to operate.

      In each of the cases described in clauses [(i)](#c-2-A-i) through [(v)](#c-2-A-v), the basis for the transfer or discharge must be documented in the resident’s clinical record. In the cases described in clauses [(i)](#c-2-A-i) and [(ii)](#c-2-A-ii), the documentation must be made by the resident’s [physician](/usc/42/1301.md?p=a-7), and in the cases described in clauses [(iii)](#c-2-A-iii) and [(iv)](#c-2-A-iv) the documentation must be made by a [physician](/usc/42/1301.md?p=a-7).

    - (B) **Pre-transfer and pre-discharge notice—**
      - (i) **In general—** Before effecting a transfer or discharge of a resident, a skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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](/usc/42/1301.md?p=b) any documentation required under [subparagraph (A)](#c-2-A)), and
        - (III) include in the notice the items described in [clause (iii)](#c-2-B-iii).
      - (ii) **Timing of notice—** The notice under [clause (i)(I)](#c-2-B-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)](#c-2-A-iii) or [(iv)](#c-2-A-iv) of subparagraph (A);
        - (II) in a case described in [clause (ii)](#c-2-A-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)](#c-2-A-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](/usc/42/1320a–3.md?p=c-5-B) 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)](#c-2-B-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](/usc/42/619.md?p=5) process established under [subsection (e)(3)](#e-3); and
        - (II) the name, mailing address, and telephone number of the [State long-term care ombudsman](/usc/42/1397j.md?p=22) (established under title III or VII of the Older Americans Act of 1965 [[42 U.S.C. 3021](/usc/42/3021.md) et seq., 3058 et seq.] in accordance with section 712 of the Act [[42 U.S.C. 3058g](/usc/42/3058g.md)]).
    - (C) **Orientation—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the [facility](/usc/42/1320a–3.md?p=c-5-B).
  - (3) **Access and visitation rights—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must—
    - (A) permit immediate access to any resident by any representative of the [Secretary](/usc/42/1301.md?p=a-6), by any representative of the [State](/usc/42/619.md?p=5), by an ombudsman described in [paragraph (2)(B)(iii)(II)](#c-2-B-iii-II), or by the resident’s individual [physician](/usc/42/1301.md?p=a-7);
    - (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](/usc/42/1397j.md?p=20), 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](/usc/42/619.md?p=5) ombudsman (described in [paragraph (2)(B)(iii)(II)](#c-2-B-iii-II)), with the permission of the resident (or the resident’s legal representative) and consistent with [State](/usc/42/619.md?p=5) law, to examine a resident’s clinical records.
  - (4) **Equal access to quality care—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must establish and maintain identical policies and [practices](/usc/42/17061.md?p=19) regarding transfer, discharge, and covered services under this subchapter for all individuals regardless of source of payment.
  - (5) **Admissions policy—**
    - (A) **Admissions—** With respect to admissions [practices](/usc/42/17061.md?p=19), a skilled [nursing facility](/usc/42/1397j.md?p=17-A) must—
      - (i)
        - (I) not require individuals applying to reside or residing in the [facility](/usc/42/1320a–3.md?p=c-5-B) to waive their rights to benefits under this subchapter or under a [State](/usc/42/619.md?p=5) 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](/usc/42/619.md?p=5) plan, and (III) prominently display in the [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/1320a–3.md?p=c-5-B) as a condition of admission (or expedited admission) to, or continued stay in, the [facility](/usc/42/1320a–3.md?p=c-5-B).
    - (B) **Construction—**
      - (i) **No preemption of stricter standards—** [Subparagraph (A)](#c-5-A) shall not be construed as preventing [States](/usc/42/619.md?p=5) or political subdivisions therein from prohibiting, under [State](/usc/42/619.md?p=5) or local law, the discrimination against individuals who are entitled to medical assistance under this subchapter with respect to admissions [practices](/usc/42/17061.md?p=19) of skilled [nursing facilities](/usc/42/1397j.md?p=17-A).
      - (ii) **Contracts with legal representatives—** [Subparagraph (A)(ii)](#c-5-A-ii) shall not be construed as preventing a [facility](/usc/42/1320a–3.md?p=c-5-B) from requiring an individual, who has legal access to a resident’s income or resources available to pay for care in the [facility](/usc/42/1320a–3.md?p=c-5-B), to sign a contract (without incurring personal financial liability) to provide payment from the resident’s income or resources for such care.
  - (6) **Protection of resident funds—**
    - (A) **In general—** The skilled [nursing facility](/usc/42/1397j.md?p=17-A)—
      - (i) may not require residents to deposit their personal funds with the [facility](/usc/42/1320a–3.md?p=c-5-B), 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](/usc/42/1320a–3.md?p=c-5-B) in accordance with this paragraph.
    - (B) **Management of personal funds—** Upon written authorization of a resident under [subparagraph (A)(ii)](#c-6-A-ii), the [facility](/usc/42/1320a–3.md?p=c-5-B) must manage and account for the personal funds of the resident deposited with the [facility](/usc/42/1320a–3.md?p=c-5-B) as follows:
      - (i) **Deposit—** The [facility](/usc/42/1320a–3.md?p=c-5-B) must deposit any amount of personal funds in excess of $100 with respect to a resident in an interest bearing account (or accounts) that is separate from any of the [facility](/usc/42/1320a–3.md?p=c-5-B)’s operating accounts and credits[^3] all interest earned on such separate account to such account. With respect to any other personal funds, the [facility](/usc/42/1320a–3.md?p=c-5-B) must maintain such funds in a non-interest bearing account or petty cash fund.
      - (ii) **Accounting and records—** The [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/1320a–3.md?p=c-5-B), and afford the resident (or a legal representative of the resident) reasonable access to such record.
      - (iii) **Conveyance upon death—** Upon the death of a resident with such an account, the [facility](/usc/42/1320a–3.md?p=c-5-B) must convey promptly the resident’s personal funds (and a final accounting of such funds) to the individual administering the resident’s estate.
    - (C) **Assurance of financial security—** The [facility](/usc/42/1320a–3.md?p=c-5-B) must purchase a surety bond, or otherwise provide assurance satisfactory to the [Secretary](/usc/42/1301.md?p=a-6), to assure the security of all personal funds of residents deposited with the [facility](/usc/42/1320a–3.md?p=c-5-B).
    - (D) **Limitation on charges to personal funds—** The [facility](/usc/42/1320a–3.md?p=c-5-B) 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 XIX.
- (d) **Requirements relating to administration and other matters—**
  - (1) **Administration—**
    - (A) **In general—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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)](#f-5)).
    - (B) **Skilled nursing facility administrator—** The [administrator](/usc/42/4005.md?p=1) of a skilled [nursing facility](/usc/42/1397j.md?p=17-A) must meet [standards](/usc/42/1320d.md?p=7) established by the [Secretary](/usc/42/1301.md?p=a-6) under [subsection (f)(4)](#f-4).
    - (C) **Availability of survey, certification, and complaint investigation reports—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must—
      - (i) have reports with respect to any surveys, certifications, and complaint investigations made respecting the [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/1320a–3.md?p=c-5-B) that are prominent and accessible to the public.

      The [facility](/usc/42/1320a–3.md?p=c-5-B) shall not make available under [clause (i)](#d-1-C-i) identifying information about complainants or residents.

  - (2) **Licensing and Life Safety Code—**
    - (A) **Licensing—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must be licensed under applicable [State](/usc/42/619.md?p=5) and local law.
    - (B) **Life Safety Code—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must meet such provisions of such edition (as specified by the [Secretary](/usc/42/1301.md?p=a-6) in regulation) of the Life Safety Code of the National Fire Protection Association as are applicable to nursing homes; except that—
      - (i) the [Secretary](/usc/42/1301.md?p=a-6) 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](/usc/42/1320a–3.md?p=c-5-B), 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](/usc/42/619.md?p=5) if the [Secretary](/usc/42/1301.md?p=a-6) finds that in such [State](/usc/42/619.md?p=5) there is in effect a fire and safety code, imposed by [State](/usc/42/619.md?p=5) law, which adequately protects residents of and personnel in skilled [nursing facilities](/usc/42/1397j.md?p=17-A).
  - (3) **Sanitary and infection control and physical environment—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must operate and provide services in compliance with all applicable Federal, [State](/usc/42/619.md?p=5), 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 services in such a [facility](/usc/42/1320a–3.md?p=c-5-B).
    - (B) **Other—** A skilled [nursing facility](/usc/42/1397j.md?p=17-A) must meet such other requirements relating to the health, safety, and well-being of residents or relating to the physical [facilities](/usc/42/1320a–3.md?p=c-5-B) thereof as the [Secretary](/usc/42/1301.md?p=a-6) may find necessary.
- (e) **State requirements relating to skilled nursing facility requirements—** The requirements, referred to in [section 1395aa(d) of this title](/usc/42/1395aa.md?p=d), with respect to a [State](/usc/42/619.md?p=5) are as follows:
  - (1) **Specification and review of nurse aide training and competency evaluation programs and of nurse aide competency evaluation programs—** The [State](/usc/42/619.md?p=5) must—
    - (A) by not later than January 1, 1989, specify those training and competency evaluation programs, and those competency evaluation programs, that the [State](/usc/42/619.md?p=5) approves for purposes of [subsection (b)(5)](#b-5) and that meet the requirements established under [subsection (f)(2)](#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)](#f-2-A-iii).

    The failure of the [Secretary](/usc/42/1301.md?p=a-6) to establish requirements under [subsection (f)(2)](#f-2) shall not relieve any [State](/usc/42/619.md?p=5) of its responsibility under this paragraph.

  - (2) **Nurse aide registry—**
    - (A) **In general—** By not later than January 1, 1989, the [State](/usc/42/619.md?p=5) 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)](#e-1) in the [State](/usc/42/619.md?p=5), or any individual described in [subsection (f)(2)(B)(ii)](#f-2-B-ii) or in subparagraph [(B)](/usc/42/6901.md), [(C)](/usc/42/6901.md), or [(D)](/usc/42/6901.md) of section 6901(b)(4) of the Omnibus Budget Reconciliation Act of 1989.
    - (B) **Information in registry—** The registry under [subparagraph (A)](#e-2-A) shall provide (in accordance with regulations of the [Secretary](/usc/42/1301.md?p=a-6)) for the inclusion of specific documented findings by a [State](/usc/42/619.md?p=5) under [subsection (g)(1)(C)](#g-1-C) of resident [neglect](/usc/42/1397j.md?p=16) or [abuse](/usc/42/1397j.md?p=1) or misappropriation of resident property involving an individual listed in the registry, as well as any brief statement of the individual disputing the findings, but shall not include any allegations of resident [abuse](/usc/42/1397j.md?p=1) or [neglect](/usc/42/1397j.md?p=16) or misappropriation of resident property that are not specifically documented by the [State](/usc/42/619.md?p=5) under such subsection. The [State](/usc/42/619.md?p=5) 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.
    - (C) **Prohibition against charges—** A [State](/usc/42/619.md?p=5) may not impose any charges on a nurse aide relating to the registry established and maintained under [subparagraph (A)](#e-2-A).
  - (3) **State appeals process for transfers and discharges—** The [State](/usc/42/619.md?p=5), for transfers and discharges from skilled [nursing facilities](/usc/42/1397j.md?p=17-A) effected on or after October 1, 1989, must provide for a fair mechanism for hearing appeals on transfers and discharges of residents of such [facilities](/usc/42/1320a–3.md?p=c-5-B). Such mechanism must meet the guidelines established by the [Secretary](/usc/42/1301.md?p=a-6) under [subsection (f)(3)](#f-3); but the failure of the [Secretary](/usc/42/1301.md?p=a-6) to establish such guidelines shall not relieve any [State](/usc/42/619.md?p=5) of its responsibility to provide for such a fair mechanism.
  - (4) **Skilled nursing facility administrator standards—** By not later than January 1, 1990, the [State](/usc/42/619.md?p=5) must have implemented and enforced the skilled [nursing facility](/usc/42/1397j.md?p=17-A) [administrator](/usc/42/4005.md?p=1) [standards](/usc/42/1320d.md?p=7) developed under [subsection (f)(4)](#f-4) respecting the qualification of [administrators](/usc/42/4005.md?p=1) of skilled [nursing facilities](/usc/42/1397j.md?p=17-A).
  - (5) **Specification of resident assessment instrument—** Effective July 1, 1990, the [State](/usc/42/619.md?p=5) shall specify the instrument to be used by [nursing facilities](/usc/42/1397j.md?p=17-A) in the [State](/usc/42/619.md?p=5) in complying with the requirement of [subsection (b)(3)(A)(iii)](#b-3-A-iii). Such instrument shall be—
    - (A) one of the instruments designated under [subsection (f)(6)(B)](#f-6-B), or
    - (B) an instrument which the [Secretary](/usc/42/1301.md?p=a-6) has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines specified by the [Secretary](/usc/42/1301.md?p=a-6) under [subsection (f)(6)(A)](#f-6-A).
- (f) **Responsibilities of Secretary relating to skilled nursing facility requirements—**
  - (1) **General responsibility—** It is the duty and responsibility of the [Secretary](/usc/42/1301.md?p=a-6) to assure that requirements which govern the provision of care in skilled [nursing facilities](/usc/42/1397j.md?p=17-A) 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.
  - (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)](#b-5) and [(e)(1)(A)](#e-1-A), the [Secretary](/usc/42/1301.md?p=a-6) shall establish, by not later than September 1, 1988—
      - (i) requirements for the approval of nurse aide training and competency evaluation programs, [including](/usc/42/1301.md?p=b) requirements relating to (I) the areas to be covered in such a program ([including](/usc/42/1301.md?p=b) at least basic nursing skills, personal care skills, recognition of mental health and [social](/usc/42/1397j.md?p=20) service needs, care of cognitively impaired residents, basic restorative services, and residents’ rights) and content of the curriculum ([including](/usc/42/1301.md?p=b), in the case of initial training and, if the [Secretary](/usc/42/1301.md?p=a-6) determines appropriate, in the case of ongoing training, dementia management training, and patient [abuse](/usc/42/1397j.md?p=1) prevention training,[^4] (II) minimum hours of initial and ongoing training and retraining ([including](/usc/42/1301.md?p=b) 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](/usc/42/1301.md?p=b) requirement relating to the areas to be covered in such a program, [including](/usc/42/1301.md?p=b) at least basic nursing skills, personal care skills, recognition of mental health and [social](/usc/42/1397j.md?p=20) 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](/usc/42/619.md?p=5) 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](/usc/42/1397j.md?p=17-A) at which the aide is (or will be) employed (unless the [facility](/usc/42/1320a–3.md?p=c-5-B) is described in [subparagraph (B)(iii)(I)](#f-2-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](/usc/42/1320a–3.md?p=c-5-B) on the date on which the aide begins either such program of any charges ([including](/usc/42/1301.md?p=b) 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)](#f-2-A-iv-II) who is employed by (or who has received an offer of employment from) a [facility](/usc/42/1320a–3.md?p=c-5-B) not later than 12 months after completing either such program, the [State](/usc/42/619.md?p=5) shall provide for the reimbursement of costs incurred in completing such program on a prorata[^5] 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](/usc/42/1320a–3.md?p=c-5-B) (subject to [clause (iii)](#f-2-B-iii)), as well as outside [facilities](/usc/42/1320a–3.md?p=c-5-B) ([including](/usc/42/1301.md?p=b) employee organizations), and of programs in effect on December 22, 1987;
      - (ii) shall permit a [State](/usc/42/619.md?p=5) 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)](#b-5) if the [State](/usc/42/619.md?p=5) 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)](#f-2-C) and [(D)](#f-2-D), shall prohibit approval of such a program—
        - (I) offered by or in a skilled [nursing facility](/usc/42/1397j.md?p=17-A) which, within the previous 2 years—
        - (II) offered by or in a skilled [nursing facility](/usc/42/1397j.md?p=17-A) unless the [State](/usc/42/619.md?p=5) 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](/usc/42/1397j.md?p=17-A).

      A [State](/usc/42/619.md?p=5) may not delegate (through subcontract or otherwise) its responsibility under [clause (iii)(II)](#f-2-B-iii-II) to the skilled [nursing facility](/usc/42/1397j.md?p=17-A).

    - (C) **Waiver authorized—** [Clause (iii)(I)](#f-2-B-iii-I) of subparagraph (B) shall not apply to a program offered in (but not by) a [nursing facility](/usc/42/1397j.md?p=17-A) (or skilled [nursing facility](/usc/42/1397j.md?p=17-A) for purposes of this subchapter) in a [State](/usc/42/619.md?p=5) if the [State](/usc/42/619.md?p=5)—
      - (i) determines that there is no other such program offered within a reasonable distance of the [facility](/usc/42/1320a–3.md?p=c-5-B),
      - (ii) assures, through an oversight effort, that an adequate environment exists for operating the program in the [facility](/usc/42/1320a–3.md?p=c-5-B), and
      - (iii) provides notice of such determination and assurances to the [State long-term care ombudsman](/usc/42/1397j.md?p=22).
    - (D) **Waiver of disapproval of nurse-aide training programs—** Upon application of a [nursing facility](/usc/42/1397j.md?p=17-A), the [Secretary](/usc/42/1301.md?p=a-6) 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](/usc/42/1320a–3.md?p=c-5-B). Nothing in this subparagraph shall be construed as eliminating any requirement upon a [facility](/usc/42/1320a–3.md?p=c-5-B) to pay a civil monetary penalty described in the preceding sentence.
  - (3) **Federal guidelines for State appeals process for transfers and discharges—** For purposes of subsections [(c)(2)(B)(iii)(I)](#c-2-B-iii-I) and [(e)(3)](#e-3), by not later than October 1, 1988, the [Secretary](/usc/42/1301.md?p=a-6) shall establish guidelines for minimum [standards](/usc/42/1320d.md?p=7) which [State](/usc/42/619.md?p=5) appeals processes under [subsection (e)(3)](#e-3) must meet to provide a fair mechanism for hearing appeals on transfers and discharges of residents from skilled [nursing facilities](/usc/42/1397j.md?p=17-A).
  - (4) **Secretarial standards for qualification of administrators—** For purposes of subsections [(d)(1)(C)](#d-1-C) and [(e)(4)](#e-4), the [Secretary](/usc/42/1301.md?p=a-6) shall develop, by not later than March 1, 1989, [standards](/usc/42/1320d.md?p=7) to be applied in assuring the qualifications of [administrators](/usc/42/4005.md?p=1) of skilled [nursing facilities](/usc/42/1397j.md?p=17-A).
  - (5) **Criteria for administration—** The [Secretary](/usc/42/1301.md?p=a-6) shall establish criteria for assessing a skilled [nursing facility](/usc/42/1397j.md?p=17-A)’s compliance with the requirement of [subsection (d)(1)](#d-1) with respect to—
    - (A) its governing body and management,
    - (B) agreements with [hospitals](/usc/42/300s–3.md?p=1) regarding transfers of residents to and from the [hospitals](/usc/42/300s–3.md?p=1) and to and from other skilled [nursing facilities](/usc/42/1397j.md?p=17-A),
    - (C) [disaster](/usc/42/5204.md?p=2) preparedness,
    - (D) direction of [medical care](/usc/42/1301.md?p=a-7) by a [physician](/usc/42/1301.md?p=a-7),
    - (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](/usc/42/1301.md?p=a-6) shall—
    - (A) not later than January 1, 1989, specify a minimum data set of core elements and common definitions for use by [nursing facilities](/usc/42/1397j.md?p=17-A) in conducting the assessments required under [subsection (b)(3)](#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)](#f-6-A) and which a [State](/usc/42/619.md?p=5) may specify under [subsection (e)(5)(A)](#e-5-A) for use by [nursing facilities](/usc/42/1397j.md?p=17-A) in complying with the requirements of [subsection (b)(3)(A)(iii)](#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—** Pursuant to the requirement of section 21(b) of the Medicare-Medicaid Anti-Fraud and [Abuse](/usc/42/1397j.md?p=1) Amendments of 1977, the [Secretary](/usc/42/1301.md?p=a-6) shall issue regulations, on or before the first day of the seventh month to begin after December 22, 1987, that define those costs which may be charged to the personal funds of residents in skilled [nursing facilities](/usc/42/1397j.md?p=17-A) who are individuals receiving benefits under this part and those costs which are to be included in the reasonable cost (or other payment amount) under this subchapter for extended care services.
    - (B) **Rule if failure to publish regulations—** If the [Secretary](/usc/42/1301.md?p=a-6) does not issue the regulations under [subparagraph (A)](#f-7-A) on or before the date required in such subparagraph, in the case of a resident of a skilled [nursing facility](/usc/42/1397j.md?p=17-A) who is eligible to receive benefits under this part, 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) shall include, at a minimum, the costs for routine personal hygiene items and services furnished by the [facility](/usc/42/1320a–3.md?p=c-5-B).
  - (8) **Special focus facility program—**
    - (A) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) shall conduct a special focus [facility](/usc/42/1320a–3.md?p=c-5-B) program for enforcement of requirements for skilled [nursing facilities](/usc/42/1397j.md?p=17-A) that the [Secretary](/usc/42/1301.md?p=a-6) has identified as having substantially failed to meet applicable requirement[^6] of this chapter.
    - (B) **Periodic surveys—** Under such program the [Secretary](/usc/42/1301.md?p=a-6) shall conduct surveys of each [facility](/usc/42/1320a–3.md?p=c-5-B) in the program not less than once every 6 months.
- (g) **Survey and certification process—**
  - (1) **State and Federal responsibility—**
    - (A) **In general—** Pursuant to an agreement under [section 1395aa of this title](/usc/42/1395aa.md), each [State](/usc/42/619.md?p=5) shall be responsible for certifying, in accordance with surveys conducted under [paragraph (2)](#g-2), the compliance of skilled [nursing facilities](/usc/42/1397j.md?p=17-A) (other than [facilities](/usc/42/1320a–3.md?p=c-5-B) of the [State](/usc/42/619.md?p=5)) with the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d). The [Secretary](/usc/42/1301.md?p=a-6) shall be responsible for certifying, in accordance with surveys conducted under [paragraph (2)](#g-2), the compliance of [State](/usc/42/619.md?p=5) skilled [nursing facilities](/usc/42/1397j.md?p=17-A) with the requirements of such subsections.
    - (B) **Educational program—** Each [State](/usc/42/619.md?p=5) shall conduct periodic educational programs for the staff and residents (and their representatives) of skilled [nursing facilities](/usc/42/1397j.md?p=17-A) in order to present current regulations, procedures, and policies under this section.
    - (C) **Investigation of allegations of resident neglect and abuse and misappropriation of resident property—** The [State](/usc/42/619.md?p=5) shall provide, through the [agency](/usc/42/1397n–12.md?p=1) responsible for surveys and certification of [nursing facilities](/usc/42/1397j.md?p=17-A) under this subsection, for a process for the receipt and timely review and investigation of allegations of [neglect](/usc/42/1397j.md?p=16) and [abuse](/usc/42/1397j.md?p=1) and misappropriation of resident property by a nurse aide of a resident in a [nursing facility](/usc/42/1397j.md?p=17-A) or by another individual used by the [facility](/usc/42/1320a–3.md?p=c-5-B) in providing services to such a resident. The [State](/usc/42/619.md?p=5) shall, after providing the individual involved with a written notice of the allegations ([including](/usc/42/1301.md?p=b) a statement of the availability of a hearing for the individual to rebut the allegations) and the opportunity for a hearing on the record, make a written finding as to the accuracy of the allegations. If the [State](/usc/42/619.md?p=5) finds that a nurse aide has neglected or abused a resident or misappropriated resident property in a [facility](/usc/42/1320a–3.md?p=c-5-B), the [State](/usc/42/619.md?p=5) shall notify the nurse aide and the registry of such finding. If the [State](/usc/42/619.md?p=5) finds that any other individual used by the [facility](/usc/42/1320a–3.md?p=c-5-B) has neglected or abused a resident or misappropriated resident property in a [facility](/usc/42/1320a–3.md?p=c-5-B), the [State](/usc/42/619.md?p=5) shall notify the appropriate licensure authority. A [State](/usc/42/619.md?p=5) shall not make a finding that an individual has neglected a resident if the individual demonstrates that such [neglect](/usc/42/1397j.md?p=16) was caused by factors beyond the control of the individual.
    - (D) **Removal of name from nurse aide registry—**
      - (i) **In general—** In the case of a finding of [neglect](/usc/42/1397j.md?p=16) under [subparagraph (C)](#g-1-C), the [State](/usc/42/619.md?p=5) shall establish a procedure to permit a nurse aide to petition the [State](/usc/42/619.md?p=5) to have his or her name removed from the registry upon a determination by the [State](/usc/42/619.md?p=5) that—
        - (I) the employment and personal history of the nurse aide does not reflect a pattern of abusive behavior or [neglect](/usc/42/1397j.md?p=16); and
        - (II) the [neglect](/usc/42/1397j.md?p=16) involved in the original finding was a singular occurrence.
      - (ii) **Timing of determination—** In no case shall a determination on a petition submitted under [clause (i)](#g-1-D-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)](#g-1-C).
    - (E) **Construction—** The failure of the [Secretary](/usc/42/1301.md?p=a-6) to issue regulations to carry out this subsection shall not relieve a [State](/usc/42/619.md?p=5) of its responsibility under this subsection.
  - (2) **Surveys—**
    - (A) **Standard survey—**
      - (i) **In general—** Each skilled [nursing facility](/usc/42/1397j.md?p=17-A) shall be subject to a [standard](/usc/42/1320d.md?p=7) survey, to be conducted without any prior notice to the [facility](/usc/42/1320a–3.md?p=c-5-B). Any individual who notifies (or causes to be notified) a skilled [nursing facility](/usc/42/1397j.md?p=17-A) 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 the previous sentence 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 [Secretary](/usc/42/1301.md?p=a-6) shall review each [State](/usc/42/619.md?p=5)’s procedures for the scheduling and conduct of [standard](/usc/42/1320d.md?p=7) surveys to assure that the [State](/usc/42/619.md?p=5) has taken all reasonable steps to avoid giving notice of such a survey through the scheduling procedures and the conduct of the surveys themselves.
      - (ii) **Contents—** Each [standard](/usc/42/1320d.md?p=7) 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](/usc/42/1397j.md?p=20) participation, and sanitation, infection control, and the physical environment,
        - (II) written plans of care provided under [subsection (b)(2)](#b-2) and an audit of the residents’ assessments under [subsection (b)(3)](#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)](#c).
      - (iii) **Frequency—**
        - (I) **In general—** Each skilled [nursing facility](/usc/42/1397j.md?p=17-A) shall be subject to a [standard](/usc/42/1320d.md?p=7) survey not later than 15 months after the date of the previous [standard](/usc/42/1320d.md?p=7) survey conducted under this subparagraph. The Statewide average interval between [standard](/usc/42/1320d.md?p=7) surveys of skilled [nursing facilities](/usc/42/1397j.md?p=17-A) under this subsection shall not exceed 12 months.
        - (II) **Special surveys—** If not otherwise conducted under [subclause (I)](#g-2-A-iii-I), a [standard](/usc/42/1320d.md?p=7) survey (or an abbreviated [standard](/usc/42/1320d.md?p=7) survey) may be conducted within 2 months of any change of ownership, [administration](/usc/42/1301.md?p=a-10), management of a skilled [nursing facility](/usc/42/1397j.md?p=17-A), or the [director](/usc/42/11851.md?p=5) of nursing in order to determine whether the change has resulted in any decline in the quality of care furnished in the [facility](/usc/42/1320a–3.md?p=c-5-B).
    - (B) **Extended surveys—**
      - (i) **In general—** Each skilled [nursing facility](/usc/42/1397j.md?p=17-A) which is found, under a [standard](/usc/42/1320d.md?p=7) survey, to have provided substandard quality of care shall be subject to an extended survey. Any other [facility](/usc/42/1320a–3.md?p=c-5-B) may, at the [Secretary](/usc/42/1301.md?p=a-6)’s or [State](/usc/42/619.md?p=5)’s discretion, be subject to such an extended survey (or a partial extended survey).
      - (ii) **Timing—** The extended survey shall be conducted immediately after the [standard](/usc/42/1320d.md?p=7) survey (or, if not practicable, not later than 2 weeks after the date of completion of the [standard](/usc/42/1320d.md?p=7) survey).
      - (iii) **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](/usc/42/1320a–3.md?p=c-5-B) has complied with all the requirements described in subsections [(b)](#b), [(c)](#c), and [(d)](#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.
      - (iv) **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](/usc/42/1320a–3.md?p=c-5-B) under [subsection (h)](#h) on the basis of findings in a [standard](/usc/42/1320d.md?p=7) survey.
    - (C) **Survey protocol—** [Standard](/usc/42/1320d.md?p=7) and extended surveys shall be conducted—
      - (i) based upon a protocol which the [Secretary](/usc/42/1301.md?p=a-6) 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](/usc/42/1301.md?p=a-6) establishes by not later than such date.

      The failure of the [Secretary](/usc/42/1301.md?p=a-6) to develop, test, or validate such protocols or to establish such minimum qualifications shall not relieve any [State](/usc/42/619.md?p=5) of its responsibility (or the [Secretary](/usc/42/1301.md?p=a-6) of the [Secretary](/usc/42/1301.md?p=a-6)’s responsibility) to conduct surveys under this subsection.

    - (D) **Consistency of surveys—** Each [State](/usc/42/619.md?p=5) and the [Secretary](/usc/42/1301.md?p=a-6) shall implement programs to measure and reduce inconsistency in the application of survey results among surveyors.
    - (E) **Survey teams—**
      - (i) **In general—** Surveys under this subsection shall be conducted by a multidisciplinary team of professionals ([including](/usc/42/1301.md?p=b) a registered professional nurse).
      - (ii) **Prohibition of conflicts of interest—** A [State](/usc/42/619.md?p=5) 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](/usc/42/1320a–3.md?p=c-5-B) surveyed respecting compliance with the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d), or who has a personal or familial financial interest in the [facility](/usc/42/1320a–3.md?p=c-5-B) being surveyed.
      - (iii) **Training—** The [Secretary](/usc/42/1301.md?p=a-6) shall provide for the comprehensive training of [State](/usc/42/619.md?p=5) and Federal surveyors in the conduct of [standard](/usc/42/1320d.md?p=7) and extended surveys under this subsection, [including](/usc/42/1301.md?p=b) 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](/usc/42/1301.md?p=a-6).
  - (3) **Validation surveys—**
    - (A) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) shall conduct onsite surveys of a representative sample of skilled [nursing facilities](/usc/42/1397j.md?p=17-A) in each [State](/usc/42/619.md?p=5), within 2 months of the date of surveys conducted under [paragraph (2)](#g-2) by the [State](/usc/42/619.md?p=5), in a sufficient number to allow inferences about the adequacies of each [State](/usc/42/619.md?p=5)’s surveys conducted under [paragraph (2)](#g-2). In conducting such surveys, the [Secretary](/usc/42/1301.md?p=a-6) shall use the same survey protocols as the [State](/usc/42/619.md?p=5) is required to use under [paragraph (2)](#g-2). If the [State](/usc/42/619.md?p=5) has determined that an individual skilled [nursing facility](/usc/42/1397j.md?p=17-A) meets the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d), but the [Secretary](/usc/42/1301.md?p=a-6) determines that the [facility](/usc/42/1320a–3.md?p=c-5-B) does not meet such requirements, the [Secretary](/usc/42/1301.md?p=a-6)’s determination as to the [facility](/usc/42/1320a–3.md?p=c-5-B)’s noncompliance with such requirements is binding and supersedes that of the [State](/usc/42/619.md?p=5) survey.
    - (B) **Scope—** With respect to each [State](/usc/42/619.md?p=5), the [Secretary](/usc/42/1301.md?p=a-6) shall conduct surveys under [subparagraph (A)](#g-3-A) each year with respect to at least 5 percent of the number of skilled [nursing facilities](/usc/42/1397j.md?p=17-A) surveyed by the [State](/usc/42/619.md?p=5) in the year, but in no case less than 5 skilled [nursing facilities](/usc/42/1397j.md?p=17-A) in the [State](/usc/42/619.md?p=5).
    - (C) **Remedies for substandard performance—** If the [Secretary](/usc/42/1301.md?p=a-6) finds, on the basis of such surveys, that a [State](/usc/42/619.md?p=5) has failed to perform surveys as required under [paragraph (2)](#g-2) or that a [State](/usc/42/619.md?p=5)’s survey and certification performance otherwise is not adequate, the [Secretary](/usc/42/1301.md?p=a-6) shall provide for an appropriate remedy, which may include the training of survey teams in the [State](/usc/42/619.md?p=5).
    - (D) **Special surveys of compliance—** Where the [Secretary](/usc/42/1301.md?p=a-6) has reason to question the compliance of a skilled [nursing facility](/usc/42/1397j.md?p=17-A) with any of the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d), the [Secretary](/usc/42/1301.md?p=a-6) may conduct a survey of the [facility](/usc/42/1320a–3.md?p=c-5-B) and, on the basis of that survey, make independent and binding determinations concerning the extent to which the skilled [nursing facility](/usc/42/1397j.md?p=17-A) meets such requirements.
  - (4) **Investigation of complaints and monitoring compliance—** Each [State](/usc/42/619.md?p=5) shall maintain procedures and adequate staff to—
    - (A) investigate complaints of [violations](/usc/42/2000e–16a.md?p=c) of requirements by skilled [nursing facilities](/usc/42/1397j.md?p=17-A), and
    - (B) monitor, on-site, on a regular, as needed basis, a skilled [nursing facility](/usc/42/1397j.md?p=17-A)’s compliance with the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d), if—
      - (i) the [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/619.md?p=5) has reason to question the compliance of the [facility](/usc/42/1320a–3.md?p=c-5-B) with such requirements.

    A [State](/usc/42/619.md?p=5) may maintain and utilize a specialized team ([including](/usc/42/1301.md?p=b) 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](/usc/42/1397j.md?p=17-A).

  - (5) **Disclosure of results of inspections and activities—**
    - (A) **Public information—** Each [State](/usc/42/619.md?p=5), and the [Secretary](/usc/42/1301.md?p=a-6), shall make available to the public—
      - (i) information respecting all surveys and certifications made respecting skilled [nursing facilities](/usc/42/1397j.md?p=17-A), [including](/usc/42/1301.md?p=b) statements of deficiencies, within 14 calendar days after such information is made available to those [facilities](/usc/42/1320a–3.md?p=c-5-B), and approved plans of correction,
      - (ii) copies of cost reports of such [facilities](/usc/42/1320a–3.md?p=c-5-B) filed under this subchapter or subchapter XIX,
      - (iii) copies of statements of ownership under [section 1320a–3 of this title](/usc/42/1320a–3.md), and
      - (iv) information disclosed under [section 1320a–5 of this title](/usc/42/1320a–5.md).
    - (B) **Notice to ombudsman—** Each [State](/usc/42/619.md?p=5) shall notify the [State long-term care ombudsman](/usc/42/1397j.md?p=22) (established under title III or VII of the Older Americans Act of 1965 [[42 U.S.C. 3021](/usc/42/3021.md) et seq., 3058 et seq.] in accordance with section 712 of the Act [[42 U.S.C. 3058g](/usc/42/3058g.md)]) of the [State](/usc/42/619.md?p=5)’s findings of noncompliance with any of the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d), or of any adverse action taken against a skilled [nursing facility](/usc/42/1397j.md?p=17-A) under paragraph [(1)](#h-1), [(2)](#h-2), or [(4)](#h-4) of subsection (h), with respect to a skilled [nursing facility](/usc/42/1397j.md?p=17-A) in the [State](/usc/42/619.md?p=5).
    - (C) **Notice to physicians and skilled nursing facility administrator licensing board—** If a [State](/usc/42/619.md?p=5) finds that a skilled [nursing facility](/usc/42/1397j.md?p=17-A) has provided substandard quality of care, the [State](/usc/42/619.md?p=5) shall notify—
      - (i) the attending [physician](/usc/42/1301.md?p=a-7) of each resident with respect to which such finding is made, and
      - (ii) the [State](/usc/42/619.md?p=5) board responsible for the licensing of the skilled [nursing facility](/usc/42/1397j.md?p=17-A) [administrator](/usc/42/4005.md?p=1) at the [facility](/usc/42/1320a–3.md?p=c-5-B).
    - (D) **Access to fraud control units—** Each [State](/usc/42/619.md?p=5) shall provide its [State](/usc/42/619.md?p=5) medicaid fraud and [abuse](/usc/42/1397j.md?p=1) control unit (established under [section 1396b(q) of this title](/usc/42/1396b.md?p=q)) with access to all information of the [State agency](/usc/42/629a.md?p=a-3) responsible for surveys and certifications under this subsection.
    - (E) **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)](#g-5-A) and provided on the Nursing Home Compare Medicare website under [subsection (i)](#i), each [State](/usc/42/619.md?p=5) shall submit information respecting any survey or certification made respecting a skilled [nursing facility](/usc/42/1397j.md?p=17-A) ([including](/usc/42/1301.md?p=b) any enforcement actions taken by the [State](/usc/42/619.md?p=5)) to the [Secretary](/usc/42/1301.md?p=a-6) not later than the date on which the [State](/usc/42/619.md?p=5) sends such information to the [facility](/usc/42/1320a–3.md?p=c-5-B). The [Secretary](/usc/42/1301.md?p=a-6) 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.
- (h) **Enforcement process—**
  - (1) **In general—** If a [State](/usc/42/619.md?p=5) finds, on the basis of a [standard](/usc/42/1320d.md?p=7), extended, or partial extended survey under [subsection (g)(2)](#g-2) or otherwise, that a skilled [nursing facility](/usc/42/1397j.md?p=17-A) no longer meets a requirement of subsection [(b)](#b), [(c)](#c), or [(d)](#d), and further finds that the [facility](/usc/42/1320a–3.md?p=c-5-B)’s deficiencies—
    - (A) immediately jeopardize the health or safety of its residents, the [State](/usc/42/619.md?p=5) shall recommend to the [Secretary](/usc/42/1301.md?p=a-6) that the [Secretary](/usc/42/1301.md?p=a-6) take such action as described in [paragraph (2)(A)(i)](#h-2-A-i); or
    - (B) do not immediately jeopardize the health or safety of its residents, the [State](/usc/42/619.md?p=5) may recommend to the [Secretary](/usc/42/1301.md?p=a-6) that the [Secretary](/usc/42/1301.md?p=a-6) take such action as described in [paragraph (2)(A)(ii)](#h-2-A-ii).

    If a [State](/usc/42/619.md?p=5) finds that a skilled [nursing facility](/usc/42/1397j.md?p=17-A) meets the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d), but, as of a previous period, did not meet such requirements, the [State](/usc/42/619.md?p=5) may recommend a civil money penalty under [paragraph (2)(B)(ii)](#h-2-B-ii) for the days in which it finds that the [facility](/usc/42/1320a–3.md?p=c-5-B) was not in compliance with such requirements.

  - (2) **Secretarial authority—**
    - (A) **In general—** With respect to any skilled [nursing facility](/usc/42/1397j.md?p=17-A) in a [State](/usc/42/619.md?p=5), if the [Secretary](/usc/42/1301.md?p=a-6) finds, or pursuant to a recommendation of the [State](/usc/42/619.md?p=5) under [paragraph (1)](#h-1) finds, that a skilled [nursing facility](/usc/42/1397j.md?p=17-A) no longer meets a requirement of subsection [(b)](#b), [(c)](#c), [(d)](#d), or [(e)](#e), and further finds that the [facility](/usc/42/1320a–3.md?p=c-5-B)’s deficiencies—
      - (i) immediately jeopardize the health or safety of its residents, 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 [subparagraph (B)(iii)](#h-2-B-iii), or terminate the [facility](/usc/42/1320a–3.md?p=c-5-B)’s participation under this subchapter and may provide, in addition, for one or more of the other remedies described in [subparagraph (B)](#h-2-B); or
      - (ii) do not immediately jeopardize the health or safety of its residents, the [Secretary](/usc/42/1301.md?p=a-6) may impose any of the remedies described in [subparagraph (B)](#h-2-B).

      Nothing in this subparagraph shall be construed as restricting the remedies available to the [Secretary](/usc/42/1301.md?p=a-6) to remedy a skilled [nursing facility](/usc/42/1397j.md?p=17-A)’s deficiencies. If the [Secretary](/usc/42/1301.md?p=a-6) finds, or pursuant to the recommendation of the [State](/usc/42/619.md?p=5) under [paragraph (1)](#h-1) finds, that a skilled [nursing facility](/usc/42/1397j.md?p=17-A) meets such requirements 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 [subparagraph (B)(ii)](#h-2-B-ii) for the days on which he finds that the [facility](/usc/42/1320a–3.md?p=c-5-B) was not in compliance with such requirements.

    - (B) **Specified remedies—** The [Secretary](/usc/42/1301.md?p=a-6) may take the following actions with respect to a finding that a [facility](/usc/42/1320a–3.md?p=c-5-B) has not met an applicable requirement:
      - (i) **Denial of payment—** The [Secretary](/usc/42/1301.md?p=a-6) may deny any further payments under this subchapter with respect to all individuals entitled to benefits under this subchapter in the [facility](/usc/42/1320a–3.md?p=c-5-B) or with respect to such individuals admitted to the [facility](/usc/42/1320a–3.md?p=c-5-B) after the effective date of the finding.
      - (ii) **Authority with respect to civil money penalties—**
        - (I) **In general—** Subject to [subclause (II)](#h-2-B-ii-II), the [Secretary](/usc/42/1301.md?p=a-6) may impose a civil money penalty in an amount not to exceed $10,000 for each day of noncompliance. 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 the previous sentence 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).
        - (II) **Reduction of civil money penalties in certain circumstances—** Subject to [subclause (III)](#h-2-B-ii-III), in the case where a [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/1301.md?p=a-6) may reduce the amount of the penalty imposed by not more than 50 percent.
        - (III) **Prohibitions on reduction for certain deficiencies—**
          - (aa) **Repeat deficiencies—** The [Secretary](/usc/42/1301.md?p=a-6) may not reduce the amount of a penalty under [subclause (II)](#h-2-B-ii-II) if the [Secretary](/usc/42/1301.md?p=a-6) had reduced a penalty imposed on the [facility](/usc/42/1320a–3.md?p=c-5-B) in the preceding year under such subclause with respect to a repeat deficiency.
          - (bb) **Certain other deficiencies—** The [Secretary](/usc/42/1301.md?p=a-6) may not reduce the amount of a penalty under [subclause (II)](#h-2-B-ii-II) if the penalty is imposed on the [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/1320a–3.md?p=c-5-B), or results in the death of a resident of the [facility](/usc/42/1320a–3.md?p=c-5-B).
        - (IV) **Collection of civil money penalties—** In the case of a civil money penalty imposed under this clause, the [Secretary](/usc/42/1301.md?p=a-6) shall issue regulations that—
          - (aa) subject to [item (cc)](#h-2-B-ii-IV-cc), not later than 30 days after the imposition of the penalty, provide for the [facility](/usc/42/1320a–3.md?p=c-5-B) to have the opportunity to participate in an independent informal dispute resolution process which [generates](/usc/42/2021b.md?p=8) 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)](#h-2-B-ii-IV-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](/usc/42/1301.md?p=a-6) on the earlier of the date on which the informal dispute resolution process under [item (aa)](#h-2-B-ii-IV-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](/usc/42/1320a–3.md?p=c-5-B) successfully appeals the penalty, may provide for the return of such amounts collected (plus interest) to the [facility](/usc/42/1320a–3.md?p=c-5-B); 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](/usc/42/1301.md?p=b) assistance to support and protect residents of a [facility](/usc/42/1320a–3.md?p=c-5-B) that closes (voluntarily or involuntarily) or is decertified ([including](/usc/42/1301.md?p=b) offsetting costs of relocating residents to home and community-based settings or another [facility](/usc/42/1320a–3.md?p=c-5-B)), [projects](/usc/42/13641.md?p=2) that support resident and family councils and other consumer involvement in assuring quality care in [facilities](/usc/42/1320a–3.md?p=c-5-B), and [facility](/usc/42/1320a–3.md?p=c-5-B) improvement initiatives approved by the [Secretary](/usc/42/1301.md?p=a-6) ([including](/usc/42/1301.md?p=b) joint training of [facility](/usc/42/1320a–3.md?p=c-5-B) staff and surveyors, technical assistance for [facilities](/usc/42/1320a–3.md?p=c-5-B) implementing quality assurance programs, the appointment of temporary management firms, and other activities approved by the [Secretary](/usc/42/1301.md?p=a-6)).
      - (iii) **Appointment of temporary management—** In consultation with the [State](/usc/42/619.md?p=5), the [Secretary](/usc/42/1301.md?p=a-6) may appoint temporary management to oversee the operation of the [facility](/usc/42/1320a–3.md?p=c-5-B) and to assure the health and safety of the [facility](/usc/42/1320a–3.md?p=c-5-B)’s residents, where there is a need for temporary management while—
        - (I) there is an orderly closure of the [facility](/usc/42/1320a–3.md?p=c-5-B), or
        - (II) improvements are made in order to bring the [facility](/usc/42/1320a–3.md?p=c-5-B) into compliance with all the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d).

      The temporary management under this clause shall not be terminated under subclause (II) until the [Secretary](/usc/42/1301.md?p=a-6) has determined that the [facility](/usc/42/1320a–3.md?p=c-5-B) has the management capability to ensure continued compliance with all the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d).

      The [Secretary](/usc/42/1301.md?p=a-6) 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](/usc/42/2000e–16a.md?p=c) 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](/usc/42/1301.md?p=a-6) may provide for other specified remedies, such as directed plans of correction.

    - (C) **Continuation of payments pending remediation—** The [Secretary](/usc/42/1301.md?p=a-6) 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](/usc/42/1397j.md?p=17-A) not in compliance with a requirement of subsection [(b)](#b), [(c)](#c), or [(d)](#d), if—
      - (i) the [State](/usc/42/619.md?p=5) survey [agency](/usc/42/1397n–12.md?p=1) finds that it is more appropriate to take alternative action to assure compliance of the [facility](/usc/42/1320a–3.md?p=c-5-B) with the requirements than to terminate the certification of the [facility](/usc/42/1320a–3.md?p=c-5-B),
      - (ii) the [State](/usc/42/619.md?p=5) 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
      - (iii) the [facility](/usc/42/1320a–3.md?p=c-5-B) 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 [States](/usc/42/619.md?p=5) under this subparagraph.

    - (D) **Assuring prompt compliance—** If a skilled [nursing facility](/usc/42/1397j.md?p=17-A) has not complied with any of the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d), within 3 months after the date the [facility](/usc/42/1320a–3.md?p=c-5-B) is found to be out of compliance with such requirements, the [Secretary](/usc/42/1301.md?p=a-6) shall impose the remedy described in [subparagraph (B)(i)](#h-2-B-i) for all individuals who are admitted to the [facility](/usc/42/1320a–3.md?p=c-5-B) after such date.
    - (E) **Repeated noncompliance—** In the case of a skilled [nursing facility](/usc/42/1397j.md?p=17-A) which, on 3 consecutive [standard](/usc/42/1320d.md?p=7) surveys conducted under [subsection (g)(2)](#g-2), has been found to have provided substandard quality of care, the [Secretary](/usc/42/1301.md?p=a-6) shall (regardless of what other remedies are provided)—
      - (i) impose the remedy described in [subparagraph (B)(i)](#h-2-B-i), and
      - (ii) monitor the [facility](/usc/42/1320a–3.md?p=c-5-B) under [subsection (g)(4)(B)](#g-4-B),

      until the [facility](/usc/42/1320a–3.md?p=c-5-B) has demonstrated, to the satisfaction of the [Secretary](/usc/42/1301.md?p=a-6), that it is in compliance with the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d), and that it will remain in compliance with such requirements.

  - (3) **Effective period of denial of payment—** A finding to deny payment under this subsection shall terminate when the [Secretary](/usc/42/1301.md?p=a-6) finds that the [facility](/usc/42/1320a–3.md?p=c-5-B) is in substantial compliance with all the requirements of subsections [(b)](#b), [(c)](#c), and [(d)](#d).
  - (4) **Immediate termination of participation for facility where Secretary finds noncompliance and immediate jeopardy—** If the [Secretary](/usc/42/1301.md?p=a-6) finds that a skilled [nursing facility](/usc/42/1397j.md?p=17-A) has not met a requirement of subsection [(b)](#b), [(c)](#c), or [(d)](#d), and finds that the failure immediately jeopardizes the health or safety of its residents, 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 [paragraph (2)(B)(iii)](#h-2-B-iii), or the [Secretary](/usc/42/1301.md?p=a-6), subject to [section 1320a–7j(h) of this title](/usc/42/1320a–7j.md?p=h), shall terminate the [facility](/usc/42/1320a–3.md?p=c-5-B)’s participation under this subchapter. If the [facility](/usc/42/1320a–3.md?p=c-5-B)’s participation under this subchapter is terminated, the [State](/usc/42/619.md?p=5) shall provide for the safe and orderly transfer of the residents eligible under this subchapter consistent with the requirements of [subsection (c)(2)](#c-2) and [section 1320a–7j(h) of this title](/usc/42/1320a–7j.md?p=h).
  - (5) **Construction—** The remedies provided under this subsection are in addition to those otherwise available under [State](/usc/42/619.md?p=5) or Federal law and shall not be construed as limiting such other remedies, [including](/usc/42/1301.md?p=b) any remedy available to an individual at common law. The remedies described in clauses [(i)](#h-2-B-i), [(ii)(IV)](#h-2-B-ii-IV), and [(iii)](#h-2-B-iii) of paragraph (2)(B) may be imposed during the pendency of any hearing.
  - (6) **Sharing of information—** Notwithstanding any other provision of law, all information concerning skilled [nursing facilities](/usc/42/1397j.md?p=17-A) required by this section to be filed with the [Secretary](/usc/42/1301.md?p=a-6) or a [State agency](/usc/42/629a.md?p=a-3) shall be made available by such [facilities](/usc/42/1320a–3.md?p=c-5-B) to Federal or [State](/usc/42/619.md?p=5) employees for purposes consistent with the effective [administration](/usc/42/1301.md?p=a-10) of programs established under this subchapter and subchapter XIX, [including](/usc/42/1301.md?p=b) investigations by [State](/usc/42/619.md?p=5) medicaid fraud control units.
- (i) **Nursing Home Compare website—**
  - (1) **Inclusion of additional information—**
    - (A) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) shall ensure that the Department of Health and Human Services [includes](/usc/42/1301.md?p=b), 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](/usc/42/1397j.md?p=14-A) services, and searchable:
      - (i) Staffing data for each [facility](/usc/42/1320a–3.md?p=c-5-B) ([including](/usc/42/1301.md?p=b) 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](/usc/42/1320a–7j.md?p=g), [including](/usc/42/1301.md?p=b) information on staffing turnover and tenure, in a format that is clearly understandable to consumers of [long-term care](/usc/42/1397j.md?p=14-A) services and allows such consumers to compare differences in staffing between [facilities](/usc/42/1320a–3.md?p=c-5-B) and [State](/usc/42/619.md?p=5) and national averages for the [facilities](/usc/42/1320a–3.md?p=c-5-B). 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](/usc/42/619.md?p=5) Internet websites with information regarding [State](/usc/42/619.md?p=5) survey and certification programs, links to Form 2567 [State](/usc/42/619.md?p=5) inspection reports (or a successor form) on such websites, information to guide consumers in how to interpret and understand such reports, and the [facility](/usc/42/1320a–3.md?p=c-5-B) 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](/usc/42/1320a–7j.md?p=f), [including](/usc/42/1301.md?p=b) explanatory material on what complaint forms are, how they are used, and how to file a complaint with the [State](/usc/42/619.md?p=5) survey and certification program and the [State long-term care ombudsman](/usc/42/1397j.md?p=22) program.
      - (iv) Summary information on the number, type, severity, and outcome of substantiated complaints.
      - (v) The number of adjudicated instances of criminal [violations](/usc/42/2000e–16a.md?p=c) by a [facility](/usc/42/1320a–3.md?p=c-5-B) or the employees of a [facility](/usc/42/1320a–3.md?p=c-5-B)—
        - (I) that were committed inside the [facility](/usc/42/1320a–3.md?p=c-5-B);
        - (II) with respect to such instances of [violations](/usc/42/2000e–16a.md?p=c) or crimes committed inside of the [facility](/usc/42/1320a–3.md?p=c-5-B) that were the [violations](/usc/42/2000e–16a.md?p=c) or crimes of [abuse](/usc/42/1397j.md?p=1), [neglect](/usc/42/1397j.md?p=16), and [exploitation](/usc/42/1397j.md?p=8), criminal sexual [abuse](/usc/42/1397j.md?p=1), or other [violations](/usc/42/2000e–16a.md?p=c) or crimes that resulted in [serious bodily injury](/usc/42/1397j.md?p=19-A); and
      - (III) [^7] the number of civil monetary penalties levied against the [facility](/usc/42/1320a–3.md?p=c-5-B), employees, contractors, and other agents.
    - (B) **Deadline for provision of information—**
      - (i) **In general—** Except as provided in [clause (ii)](#i-1-B-ii), the [Secretary](/usc/42/1301.md?p=a-6) shall ensure that the information described in [subparagraph (A)](#i-1-A) is included on such website (or a successor website) not later than 1 year after March 23, 2010.
      - (ii) **Exception—** The [Secretary](/usc/42/1301.md?p=a-6) shall ensure that the information described in [subparagraph (A)(i)](#i-1-A-i) is included on such website (or a successor website) not later than the date on which the requirements under [section 1320a–7j(g) of this title](/usc/42/1320a–7j.md?p=g) are implemented.
  - (2) **Review and modification of website—**
    - (A) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) 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)](#i-2-A-i).
    - (B) **Consultation—** In conducting the review under [subparagraph (A)(i)](#i-2-A-i), the [Secretary](/usc/42/1301.md?p=a-6) shall consult with—
      - (i) [State long-term care ombudsman](/usc/42/1397j.md?p=22) programs;
      - (ii) consumer advocacy groups;
      - (iii) provider stakeholder groups; and
      - (iv) any other representatives of programs or groups the [Secretary](/usc/42/1301.md?p=a-6) determines appropriate.
  - (3) **Funding—** The [Secretary](/usc/42/1301.md?p=a-6) shall transfer to the Centers for Medicare & Medicaid Services Program Management Account, from the Federal [Hospital](/usc/42/300s–3.md?p=1) Insurance Trust Fund under [section 1395i of this title](/usc/42/1395i.md) a one-time [allocation](/usc/42/2021b.md?p=2) of $11,000,000. The amount shall be available on October 6, 2014. Such sums shall remain available until expended. Such sums shall be used to implement [section 1320a–7j(g) of this title](/usc/42/1320a–7j.md?p=g).
- (j) **Construction—** Where requirements or obligations under this section are identical to those provided under [section 1396r of this title](/usc/42/1396r.md), the fulfillment of those requirements or obligations under [section 1396r of this title](/usc/42/1396r.md) shall be considered to be the fulfillment of the corresponding requirements or obligations under this section.
- (k) **Funding for strike teams—** In addition to amounts otherwise available, there is appropriated to the [Secretary](/usc/42/1301.md?p=a-6), 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](/usc/42/619.md?p=5) ([including](/usc/42/1301.md?p=b) the District of Columbia and each [territory](/usc/42/701.md?p=c-5-C) of the [United States](/usc/42/1301.md?p=a-2)) for such a [State](/usc/42/619.md?p=5) to establish and implement a strike team that will be deployed to a skilled [nursing facility](/usc/42/1397j.md?p=17-A) in the [State](/usc/42/619.md?p=5) 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 [section 1320b–5(g)(1)(B)](/usc/42/1320b–5.md?p=g-1-B) of this section and the 1-year period immediately following the end of such emergency period.

## Footnotes

[^1]: See References in Text note below.
[^2]: So in original. Probably should be “as nurse aides”.
[^3]: So in original. Probably should be “credit”.
[^4]: So in original. A closing parenthesis probably should appear before the comma.
[^5]: So in original. Probably should be “pro rata”.
[^6]: So in original. Probably should be “requirements”.
[^7]: So in original. Probably should be cl. (vi).

## Source credit

(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.)

## Notes

### Editorial Notes

### References in Text

The Older Americans Act of 1965, referred to in subsecs. (b)(4)(C)(ii)(IV), (c)(2)(B)(iii)(II), and (g)(5)(B), is Pub. L. 89–73, July 14, 1965, 79 Stat. 218. Section 307(a)(12) of the Act was repealed by Pub. L. 106–501, title III, § 306(5), Nov. 13, 2000, 114 Stat. 2244. Similar provisions are now contained in section 307(a)(9) of the Act, which is classified to section 3027(a)(9) of this title. Titles III and VII of the Act are classified generally to subchapters III (§ 3021 et seq.) and XI (§ 3058 et seq.) of chapter 35 of this title. For complete classification of this Act to the Code, see Short Title note set out under section 3001 of this title and Tables.

Subparagraphs (B), (C), and (D) of section 6901(b)(4) of the Omnibus Budget Reconciliation Act of 1989 [Pub. L. 101–239], referred to in subsec. (e)(2)(A), are set out below.

Section 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, Pub. L. 95–142, which is set out as a note under section 1395x of this title.

### Amendments

2021—Subsec. (k). Pub. L. 117–2 added subsec. (k).

2014—Subsec. (i)(3). Pub. L. 113–185 added par. (3).

2010—Subsec. (b)(5)(F). Pub. L. 111–148, § 6121(a)(2), inserted concluding provisions.

Subsec. (d)(1)(B). Pub. L. 111–148, § 6101(c)(1)(A), 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 skilled nursing facility.

Subsec. (d)(1)(C). Pub. L. 111–148, § 6103(c)(1), added subpar. (C). Former subpar. (C) redesignated (B).

Subsec. (f)(2)(A)(i)(I). Pub. L. 111–148, § 6121(a)(1), 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” after “curriculum”.

Subsec. (f)(8). Pub. L. 111–148, § 6103(a)(3), added par. (8).

Subsec. (g)(5)(E). Pub. L. 111–148, § 6103(a)(2)(A), added subpar. (E).

Subsec. (h)(2)(B)(ii). Pub. L. 111–148, § 6111(a)(1), designated existing provisions as subcl. (I), inserted heading, substituted “Subject to subclause (II), the Secretary” for “The Secretary”, and added subcls. (II) to (IV).

Subsec. (h)(4). Pub. L. 111–148, § 6113(b), substituted “the Secretary, subject to section 1320a–7(h) of this title, shall terminate” for “the Secretary shall terminate” and “subsection (c)(2) and section 1320a–7j(h) of this title” for “subsection (c)(2)”.

Subsec. (h)(5). Pub. L. 111–148, § 6111(a)(2), inserted “(ii)(IV),” after “(i),”.

Subsecs. (i), (j). Pub. L. 111–148, § 6103(a)(1), added subsec. (i) and redesignated former subsec. (i) as (j).

2003—Subsec. (b)(4)(C)(i). Pub. L. 108–173, § 736(a)(8)(A), substituted “at least” for “at least at least”.

Subsec. (d)(1)(A). Pub. L. 108–173, § 736(a)(8)(B), substituted “physical, mental” for “physical mental”.

Subsec. (f)(2)(B)(iii). Pub. L. 108–173, § 932(c)(2)(A), substituted “subparagraphs (C) and (D)” for “subparagraph (C)” in introductory provisions.

Pub. L. 108–173, § 736(a)(8)(C), realigned margins of concluding provisions.

Subsec. (f)(2)(D). Pub. L. 108–173, § 932(c)(2)(B), added subpar. (D).

2000–Subsec. (b)(8). Pub. L. 106–554 added par. (8).

1997—Subsec. (b)(3)(C)(i). Pub. L. 105–33, § 4432(b)(5)(A), substituted “Subject to the timeframes prescribed by the Secretary under section 1395yy(e)(6) of this title, such” for “Such” in introductory provisions.

Subsec. (f)(2)(B)(iii). Pub. L. 105–15, § 1(1), inserted “subject to subparagraph (C),” after “(iii)”.

Subsec. (f)(2)(C). Pub. L. 105–15, § 1(2), added subpar. (C).

Subsec. (g)(1)(D), (E). Pub. L. 105–33, § 4755(a), added subpar. (D) and redesignated former subpar. (D) as (E).

1994—Subsec. (b)(3)(C)(i)(I). Pub. L. 103–432, § 110(b), substituted “but no later than 14 days” for “but no later than not later than 14 days”.

Subsec. (b)(5)(D). Pub. L. 103–432, § 106(d)(1), struck out comma before “or a new competency evaluation program”.

Subsec. (b)(5)(G). Pub. L. 103–432, § 106(d)(2), substituted “licensed or certified social worker, registered respiratory therapist, or certified respiratory therapy technician” for “or licensed or certified social worker”.

Subsec. (c)(1)(D). Pub. L. 103–432, § 106(c)(2)(A), inserted at end “In determining whether such a consultant is qualified to conduct reviews under the preceding sentence, the Secretary shall take into account the needs of nursing facilities under this subchapter to have access to the services of such a consultant on a timely basis.”

Subsec. (c)(6)(B)(i). Pub. L. 103–432, § 106(c)(3)(A), substituted “$100” for “$50”.

Subsec. (e)(2)(B). Pub. L. 103–432, § 106(c)(4)(A), inserted “, but shall not include any allegations of resident abuse or neglect or misappropriation of resident property that are not specifically documented by the State under such subsection” after “individual disputing the findings” in first sentence.

Subsec. (f)(2)(B)(i). Pub. L. 103–432, § 106(d)(3), substituted “facilities (subject to clause (iii)),” for “facilities,”.

Subsec. (f)(2)(B)(iii)(I)(b). Pub. L. 103–432, § 106(c)(1)(A), inserted before semicolon at end “, unless the survey shows that the facility is in compliance with the requirements of subsections (b), (c), and (d) of this section”.

Subsec. (f)(2)(B)(iii)(I)(c). Pub. L. 103–432, § 106(d)(4), substituted “clause” for “clauses” in two places.

Subsec. (g)(1)(C). Pub. L. 103–432, § 106(c)(4)(B), substituted second sentence for former second sentence which read as follows: “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.”

Subsec. (g)(5)(B). Pub. L. 103–432, § 106(d)(5), substituted “paragraph” for “paragraphs” before “(1), (2), or (4) of subsection (h)”.

1992—Subsecs. (c)(2)(B)(iii)(II), (g)(5)(B). Pub. L. 102–375 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”.

1990—Subsec. (b)(1)(B). Pub. L. 101–508, § 4008(h)(2)(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.”

Subsec. (b)(3)(C)(i)(I). Pub. L. 101–508, § 4008(h)(2)(C), substituted “not later than 14 days” for “4 days”.

Subsec. (b)(4)(A)(vii). Pub. L. 101–508, § 4008(h)(2)(D), added cl. (vii).

Subsec. (b)(4)(C)(ii)(IV), (V). Pub. L. 101–508, § 4008(h)(2)(E), added subcls. (IV) and (V).

Subsec. (b)(5)(A). Pub. L. 101–508, § 4008(h)(1)(B), designated existing provisions as cl. (i), in introductory provisions substituted “Except as provided in clause (ii), a skilled nursing facility” for “A skilled 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).

Subsec. (b)(5)(C). Pub. L. 101–508, § 4008(h)(1)(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”.

Subsec. (b)(5)(D). Pub. L. 101–508, § 4008(h)(1)(D), inserted before period at end “, or a new competency evaluation program” after “and competency evaluation program”.

Subsec. (b)(5)(F)(i). Pub. L. 101–508, § 4008(h)(2)(F), substituted “(G)) or a registered dietician,” for “(G)),”.

Subsec. (c)(1)(A). Pub. L. 101–508, § 4008(h)(2)(G)(B)[(ii)], 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 benefits under this subchapter or to medical assistance under subchapter XIX of this chapter.”

Subsec. (c)(1)(A)(iv). Pub. L. 101–508, § 4008(h)(2)(H), 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”.

Subsec. (c)(1)(A)(x), (xi). Pub. L. 101–508, § 4008(h)(2)(G)(i), added cl. (x) and redesignated former cl. (x) as (xi).

Subsec. (c)(1)(B)(ii). Pub. L. 101–508, § 4008(h)(2)(I), inserted “including the notice (if any) of the State developed under section 1396r(e)(6) of this title” after “in such rights)”.

Subsec. (c)(1)(E). Pub. L. 101–508, § 4206(d)(1), added subpar. (E).

Subsec. (e)(1)(A). Pub. L. 101–508, § 4008(h)(2)(J), substituted “subsection (f)(2)” for “clause (i) or (ii) of subsection (f)(2)(A)”.

Subsec. (e)(2)(A). Pub. L. 101–508, § 4008(h)(2)(K)(i), inserted before period at end “, 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”.

Subsec. (e)(2)(C). Pub. L. 101–508, § 4008(h)(2)(K)(ii), added subpar. (C).

Subsec. (f)(2)(A)(ii). Pub. L. 101–508, § 4008(m)(3)(F)[(E)], struck out “and” after semicolon at end.

Subsec. (f)(2)(A)(iv). Pub. L. 101–508, § 4008(h)(1)(E), struck out “and” at end of subcl. (I), 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” and substituted “, and” for period at end of subcl. (II), and added subcl. (III).

Subsec. (f)(2)(B). Pub. L. 101–508, § 4008(h)(1)(G), inserted “(through subcontract or otherwise)” after “may not delegate” in second sentence.

Subsec. (f)(2)(B)(iii)(I). Pub. L. 101–508, § 4008(h)(1)(F)(i), amended subcl. (I) generally. Prior to amendment, subcl. (I) read as follows: “offered by or in a skilled 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”.

Subsec. (g)(1)(C). Pub. L. 101–508, § 4008(h)(2)(L), 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.”

Subsec. (g)(5)(A)(i). Pub. L. 101–508, § 4008(h)(2)(M), substituted “deficiencies, within 14 calendar days after such information is made available to those facilities, and approved plans” for “deficiencies and plans”.

Subsec. (g)(5)(B). Pub. L. 101–508, § 4008(h)(2)(N), substituted “or of any adverse action taken against a skilled nursing facility under paragraphs (1), (2), or (4) of subsection (h), with respect” for “with respect”.

1989—Subsec. (b)(5)(A). Pub. L. 101–239, § 6901(b)(1)(A), substituted “October 1, 1990” for “January 1, 1990” in introductory provisions.

Subsec. (b)(5)(B). Pub. L. 101–239, § 6901(b)(1)(B), substituted “January 1, 1990” and “October 1, 1990” for “July 1, 1989” and “January 1, 1990”, respectively.

Subsec. (c)(1)(A)(ii)(II). Pub. L. 101–239, § 6901(d)(4)(A), substituted “Secretary until such an order could reasonably be obtained)” for “Secretary) until such an order could reasonably be obtained”.

Subsec. (c)(1)(A)(v)(I). Pub. L. 101–239, § 6901(d)(4)(B), substituted “accommodation” for “accommodations”.

Subsec. (f)(2)(A)(i)(I). Pub. L. 101–239, § 6901(d)(4)(C), 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,”.

Subsec. (f)(2)(A)(ii). Pub. L. 101–239, § 6901(b)(3)(B), substituted “recognition of mental health and social service needs, care of cognitively impaired residents” for “cognitive, behavioral and social care”.

Subsec. (f)(2)(A)(iv). Pub. L. 101–239, § 6901(b)(3)(C), (D), added cl. (iv).

Subsec. (h)(2)(C). Pub. L. 101–239, § 6901(d)(4)(D), inserted “after the effective date of the findings” after “6 months” in introductory provisions.

1988—Subsec. (b)(3)(A)(iii). Pub. L. 100–360, § 411(l)(2)(B), struck out “in the case of a resident eligible for benefits under subchapter XIX of this chapter,” before “uses an instrument”.

Subsec. (b)(3)(A)(iv). Pub. L. 100–360, § 411(l)(2)(A), as amended by Pub. L. 100–485, § 608(d)(27)(C), struck out “in the case of a resident eligible for benefits under this part,” before “includes the identification”.

Subsec. (b)(3)(B)(ii)(III). Pub. L. 100–360, § 411(l)(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 section 1320a–7a of this title.”

Subsec. (b)(3)(C)(i)(I). Pub. L. 100–360, § 411(l)(1)(A)(i), substituted “than January 1, 1991” for “than October 1, 1990”.

Subsec. (b)(4)(C)(i). Pub. L. 100–360, § 411(l)(1)(A)(ii), substituted “24-hour licensed nursing” for “24-hour nursing”, “must use” for “must employ”, and “at least 8 consecutive hours a day,” for “during the day tour of duty (of at least 8 hours a day)”.

Subsec. (b)(5)(A). Pub. L. 100–360, § 411(l)(2)(D)(i), as amended by Pub. L. 100–485, § 608(d)(27)(D), struck out “, who is not a licensed health professional (as defined in subparagraph (E)),” after “any individual”.

Pub. L. 100–360, § 411(l)(1)(A)(iii), substituted “January 1, 1990” for “October 1, 1989, (or January 1, 1990, in the case of an individual used by the facility as a nurse aide before July 1, 1989)”.

Subsec. (b)(5)(A)(ii). Pub. L. 100–360, § 411(l)(2)(D)(ii), substituted “nursing or nursing-related services” for “such services”.

Subsec. (b)(5)(G). Pub. L. 100–360, § 411(l)(2)(D)(iii), inserted “physical or occupational therapy assistant,” after “occupational therapist,”.

Subsec. (c)(1)(D). Pub. L. 100–360, § 411(l)(1)(A)(iv), as added by Pub. L. 100–485, § 608(d)(27)(A), added subpar. (D).

Subsec. (c)(2)(A)(v). Pub. L. 100–360, § 411(l)(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 XIX of this chapter”.

Subsec. (c)(6). Pub. L. 100–360, § 411(l)(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).

Subsec. (e)(1)(A). Pub. L. 100–360, § 411(l)(1)(A)(v), formerly § 411(l)(1)(A)(iv), as redesignated by Pub. L. 100–485, § 608(d)(27)(A), substituted “January” for “March”.

Subsec. (e)(1)(B). Pub. L. 100–360, § 411(l)(1)(A)(vi), formerly § 411(l)(1)(A)(v), as redesignated by Pub. L. 100–485, § 608(d)(27)(A), substituted “January” for “March”.

Subsec. (e)(2)(A). Pub. L. 100–360, § 411(l)(1)(A)(vii), formerly § 411(l)(1)(A)(vi), as redesignated by Pub. L. 100–485, § 608(d)(27)(A), substituted “January” for “March”.

Subsec. (e)(2)(B). Pub. L. 100–360, § 411(l)(2)(H), inserted after first sentence “The State shall make available to the public information in the registry.”

Subsec. (e)(3). Pub. L. 100–360, § 411(l)(2)(I), inserted “and discharges” after “transfers” in heading and in two places in text.

Pub. L. 100–360, § 411(l)(1)(A)(viii), formerly § 411(l)(1)(A)(vii), as redesignated by Pub. L. 100–485, § 608(d)(27)(A), substituted “1989” for “1990”.

Subsec. (e)(5). Pub. L. 100–360, § 411(l)(1)(A)(ix), formerly § 411(l)(1)(A)(viii), as redesignated by Pub. L. 100–485, § 608(d)(27)(A), substituted “1990” for “1989” in introductory provisions.

Subsec. (f)(2)(A)(i)(I). Pub. L. 100–360, § 411(l)(2)(J), substituted “recognition of mental health and social service needs” for “cognitive, behavioral and social care”.

Subsec. (f)(3). Pub. L. 100–360, § 411(l)(2)(I), inserted “and discharges” after “transfers” in heading and in text.

Pub. L. 100–360, § 411(l)(1)(A)(x), formerly § 411(l)(1)(A)(ix), as redesignated by Pub. L. 100–485, § 608(d)(27)(A), substituted “1988” for “1989”.

Subsec. (f)(6)(A). Pub. L. 100–360, § 411(l)(1)(A)(xi), formerly § 411(l)(1)(A)(x), as redesignated by Pub. L. 100–485, § 608(d)(27)(A), substituted “January” for “July”.

Subsec. (f)(6)(B). Pub. L. 100–360, § 411(l)(1)(A)(xii), formerly § 411(l)(1)(A)(xi), as redesignated by Pub. L. 100–485, § 608(d)(27)(A), substituted “April” for “October”.

Subsec. (f)(7)(A). Pub. L. 100–360, § 411(l)(2)(K), substituted “residents” for “patients”.

Subsec. (f)(7)(B). Pub. L. 100–360, § 411(l)(2)(L)(i), substituted “shall include” for “shall not include”.

Subsec. (g)(1)(C). Pub. L. 100–360, § 411(l)(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.”

Subsec. (g)(1)(D). Pub. L. 100–360, § 411(l)(5)(D), substituted “to issue regulations to carry out this subsection” for “to establish standards under subsection (f) of this section”.

Subsec. (g)(2)(A)(i). Pub. L. 100–360, § 411(l)(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 section 1320a–7a of this title.”

Subsec. (g)(2)(B)(ii). Pub. L. 100–360, § 411(l)(5)(F), as added by Pub. L. 100–485, § 608(d)(27)(I), substituted “practicable” for “practical”.

Subsec. (g)(2)(C)(i). Pub. L. 100–360, § 411(l)(4), substituted “January” for “October”.

Subsec. (g)(3)(D). Pub. L. 100–360, § 411(l)(5)(G), formerly § 411(l)(5)(F), as redesignated by Pub. L. 100–485, § 608(d)(27)(I), substituted “on the basis of that survey” for “on that basis”.

Subsec. (g)(4). Pub. L. 100–360, § 411(l)(5)(H), formerly § 411(l)(5)(G), as redesignated by Pub. L. 100–485, § 608(d)(27)(I), struck out “chronically” after “enforcement actions against” in last sentence.

Subsec. (h)(2)(B)(ii). Pub. L. 100–360, § 411(l)(7)(A), substituted “. The provisions of section 1320a–7a of this title (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 section 1320a–7a(a) of this title.” for “and the Secretary shall impose and collect such a penalty in the same manner as civil money penalties are imposed and collected under section 1320a–7a of this title.”

Subsec. (h)(5). Pub. L. 100–360, § 411(l)(11), as added by Pub. L. 100–485, § 608(d)(27)(L), substituted “clauses (i), and (iii) of paragraph (2)(B)” for “clauses (i), (iii), and (iv) of paragraph (2)(A)”.

Subsec. (h)(6). Pub. L. 100–360, § 411(l)(7)(B), inserted “by such facilities” after “be made available”.

1987—Subsecs. (g) to (i). Pub. L. 100–203, §§ 4202(a)(2), 4203(a)(2), 4206, added subsecs. (g), (h), and (i), respectively.

### Statutory Notes and Related Subsidiaries

### Effective Date of 2010 Amendment

Pub. L. 111–148, title VI, § 6101(c)(2), Mar. 23, 2010, 124 Stat. 702, provided that: “The amendments made by paragraph (1) [amending this section and section 1396r of this title] shall take effect on the date on which the Secretary [of Health and Human Services] makes the information described in subsection (b)(1) [probably means subsec. (b) of section 6101, which is set out as a note under section 1320a–3 of this title] available to the public under such subsection.” [The Centers for Medicare and Medicaid Services made the information described in subsec. (b) of section 6101 of Pub. L. 111–148 available to the public on Nov. 21, 2024.]

Pub. L. 111–148, title VI, § 6103(a)(2)(B), Mar. 23, 2010, 124 Stat. 706, provided that: “The amendment made by this paragraph [amending this section] shall take effect 1 year after the date of the enactment of this Act [Mar. 23, 2010].”

Pub. L. 111–148, title VI, § 6103(c)(3), Mar. 23, 2010, 124 Stat. 710, provided that: “The amendments made by this subsection [amending this section and section 1396r of this title] shall take effect 1 year after the date of the enactment of this Act [Mar. 23, 2010].”

Pub. L. 111–148, title VI, § 6111(c), Mar. 23, 2010, 124 Stat. 716, provided that: “The amendments made by this section [amending this section and section 1396r of this title] shall take effect 1 year after the date of the enactment of this Act [Mar. 23, 2010].”

Amendment by section 6113(b) of Pub. L. 111–148 effective 1 year after Mar. 23, 2010, see section 6113(c) of Pub. L. 111–148, set out as a note under section 1320a–7j of this title.

Pub. L. 111–148, title VI, § 6121(c), Mar. 23, 2010, 124 Stat. 721, provided that: “The amendments made by this section [amending this section and section 1396r of this title] shall take effect 1 year after the date of the enactment of this Act [Mar. 23, 2010].”

### Effective Date of 2003 Amendment

Pub. L. 108–173, title IX, § 932(d), Dec. 8, 2003, 117 Stat. 2402, provided that: “The amendments made by this section [amending this section and sections 1395cc, 1395ff, and 1396r of this title] shall apply to appeals filed on or after October 1, 2004.”

### Effective Date of 2000 Amendment

Pub. L. 106–554, § 1(a)(6) [title IX, § 941(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–586, provided that: “The amendments made by this section [amending this section and section 1396r of this title] shall take effect on January 1, 2003.”

### Effective Date of 1997 Amendment

Pub. L. 105–33, title IV, § 4432(d), Aug. 5, 1997, 111 Stat. 422, provided that: “The amendments made by this section [amending this section and sections 1395k, 1395l, 1395u, 1395x, 1395y, 1395cc, 1395tt, and 1395yy of this title] are effective for cost reporting periods beginning on or after July 1, 1998; except that the amendments made by subsection (b) [amending this section and sections 1395k, 1395l, 1395u, 1395x, 1395y, 1395cc, 1395tt, and 1395yy of this title] shall apply to items and services furnished on or after July 1, 1998.”

### Effective Date of 1994 Amendment

Pub. L. 103–432, title I, § 106(c)(1)(B), Oct. 31, 1994, 108 Stat. 4406, provided that: “The amendment made by subparagraph (A) [amending this section] shall take effect as if included in the enactment of OBRA–1990 [Pub. L. 101–508].”

Pub. L. 103–432, title I, § 106(c)(2)(B), Oct. 31, 1994, 108 Stat. 4406, provided that: “The amendment made by subparagraph (A) [amending this section] shall take effect as if included in the enactment of OBRA–1987 [Pub. L. 100–203].”

Pub. L. 103–432, title I, § 106(c)(3)(B), Oct. 31, 1994, 108 Stat. 4406, provided that: “The amendment made by subparagraph (A) [amending this section] shall take effect January 1, 1995.”

Pub. L. 103–432, title I, § 106(c)(4)(C), Oct. 31, 1994, 108 Stat. 4407, provided that: “The amendments made by this paragraph [amending this section] shall take effect January 1, 1995.”

Pub. L. 103–432, title I, § 106(d)(7), Oct. 31, 1994, 108 Stat. 4407, provided that: “The amendments made by this subsection [amending this section and provisions set out as a note below] shall take effect as if included in the enactment of OBRA–1990 [Pub. L. 101–508].”

### Effective Date of 1992 Amendment

Amendment by Pub. L. 102–375 inapplicable with respect to fiscal year 1993, see section 4(b) of Pub. L. 103–171, set out as a note under section 3001 of this title.

Amendment by Pub. L. 102–375 inapplicable with respect to fiscal year 1992, see section 905(b)(6) of Pub. L. 102–375, set out as a note under section 3001 of this title.

### Effective Date of 1990 Amendment

Pub. L. 101–508, title IV, § 4008(h)(1)(F)(ii), Nov. 5, 1990, 104 Stat. 1388–47, as amended by Pub. L. 103–432, title I, § 106(d)(6), Oct. 31, 1994, 108 Stat. 4407, provided that: The amendments made by clause (i) [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 a State may not approve a training and competency evaluation program or a competency evaluation program offered by or in a skilled nursing facility 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.] or under the State plan under title XIX of such Act [42 U.S.C. 1396 et seq.]; was subject to a denial of payment under either such title; was assessed a civil money penalty not less than $5,000 for deficiencies in skilled nursing facility standards; operated under a temporary management appointed to oversee the operation of the facility and to ensure the health and safety of the facility’s residents; or pursuant to State action, was closed or had its residents transferred. Notwithstanding subclause (I) and subject to section 1819(f)(2)(B)(iii)(I) of the Social Security Act [42 U.S.C. 1395i–3(f)(2)(B)(iii)(I)] (as amended by clause (i)), a State may approve a training and competency evaluation program or a competency evaluation program offered by or in a skilled nursing facility described in subclause (I) if, during the previous 2 years, item (aa), (bb), (cc), (dd), or (ee) of subclause (I) did not apply to the facility.”

Pub. L. 101–508, title IV, § 4008(h)(1)(H), Nov. 5, 1990, 104 Stat. 1388–48, provided that: “Except as provided in subparagraph (F) [amending this section and enacting provisions set out as a note above], the amendments made by this subsection [probably means this paragraph, amending this section] shall take effect as if they were included in the enactment of the Omnibus Budget Reconciliation Act of 1987 [Pub. L. 100–203].”

Pub. L. 101–508, title IV, § 4008(h)(2)(P), Nov. 5, 1990, 104 Stat. 1388–50, provided that: “The amendments made by this paragraph [amending this section and sections 1395x and 1395yy of this title] shall take effect as if they were included in the enactment of the Omnibus Budget Reconciliation Act of 1987 [Pub. L. 100–203].”

Pub. L. 101–508, title IV, § 4206(e)(1), Nov. 5, 1990, 104 Stat. 1388–117, provided that: “The amendments made by subsections (a) and (d) [amending this section and sections 1395cc and 1395bbb of this title] shall apply with respect to services furnished on or after the first day of the first month beginning more than 1 year after the date of the enactment of this Act [Nov. 5, 1990].”

### Effective Date of 1989 Amendment

Pub. L. 101–239, title VI, § 6901(b)(6), Dec. 19, 1989, 103 Stat. 2300, provided that: In general.—Except as provided in subparagraph (B), the amendments made by this subsection [amending this section and sections 1396b and 1396r of this title] shall take effect as if they were included in the enactment of the Omnibus Budget Reconciliation Act of 1987 [Pub. L. 100–203]. Exception.—The amendments made by paragraph (3) [amending this section and section 1396r of this title] shall apply to nurse aide training and competency evaluation programs, and nurse aide competency evaluation programs, offered on or after the end of the 90-day period beginning on the date of the enactment of this Act [Dec. 19, 1989], but shall not affect competency evaluations conducted under programs offered before the end of such period.”

Pub. L. 101–239, title VI, § 6901(d)(6), Dec. 19, 1989, 103 Stat. 2301, provided that: In general.—Except as provided in subparagraph (B), the amendments made by this subsection [amending this section and sections 1396i and 1396r of this title] shall take effect as if they were included in the enactment of the Omnibus Budget Reconciliation Act of 1987 [Pub. L. 100–203]. Exception.—The amendment made by paragraph (1) [amending section 1396r of this title] shall take effect on the date of the enactment of this Act [Dec. 19, 1989].”

### Effective Date of 1988 Amendment

Amendment by Pub. L. 100–485 effective as if originally included in 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

Pub. L. 100–203, title IV, § 4204, Dec. 22, 1987, 101 Stat. 1330–182, as amended by Pub. L. 100–360, title IV, § 411(l)(9), July 1, 1988, 102 Stat. 805; Pub. L. 100–485, title VI, § 608(d)(27)(K), Oct. 13, 1988, 102 Stat. 2423, provided that: New Requirements and Survey and Certification Process.—Except as otherwise specifically provided in section 1819 of the Social Security Act [42 U.S.C. 1395i–3], the amendments made by sections 4201 and 4202 [enacting and amending this section and amending sections 1395x, 1395aa, 1395tt, and 1395yy of this title] (relating to skilled nursing facility requirements and survey and certification requirements) shall apply to services furnished on or after October 1, 1990, without regard to whether regulations to implement such amendments are promulgated by such date. Enforcement.— Except as otherwise specifically provided in section 1819 of the Social Security Act [42 U.S.C. 1395i–3], the amendments made by section 4203 of this Act [amending this section and section 1395aa of this title] apply January 1, 1988, without regard to whether regulations to implement such amendments are promulgated by such date. In applying the amendments made by section 4203 of this Act for services furnished by a skilled nursing facility before October 1, 1990, any reference to a requirement of subsection (b), (c), or (d), of section 1819 of the Social Security Act is deemed a reference to the provisions of section 1861(j) of such Act [42 U.S.C. 1395x(j)]. Waiver of Paperwork Reduction.—Chapter 35 of title 44, United States Code, shall not apply to information required for purposes of carrying out this part [part 1 of subtitle C (§§ 4201–4206), enacting this section, amending this section and sections 1395x, 1395aa, 1395tt, and 1395yy of this title, and enacting provisions set out as notes under this section] and implementing the amendments made by this part.”

### Guidance to States on Form 2567 State Inspection Reports and Complaint Investigation Reports

Pub. L. 111–148, title VI, § 6103(d)(1), (3), Mar. 23, 2010, 124 Stat. 710, provided that: Guidance.—The Secretary of Health and Human Services (in this subtitle [subtitle B (§§ 6101–6121) of title VI of Pub. L. 111–148, enacting section 1320a–7j of this title, amending this section and sections 1320a–3, 1320a–7j, 1395yy, 1396a, and 1396r of this title, and enacting provisions set out as notes under this section and sections 1320a–3, 1320a–7j, and 1396r of this title] referred to as the ‘Secretary’) shall provide guidance to States on how States can establish electronic links to Form 2567 State inspection reports (or a successor form), complaint investigation reports, and a facility’s plan of correction or other response to such Form 2567 State inspection reports (or a successor form) on the Internet website of the State that provides information on skilled nursing facilities and nursing facilities and the Secretary shall, if possible, include such information on Nursing Home Compare. Definitions.—In this subsection: Nursing facility.—The term ‘nursing facility’ has the meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)). Secretary.—The term ‘Secretary’ means the Secretary of Health and Human Services. Skilled nursing facility.—The term ‘skilled nursing facility’ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395i–3(a)).”

### Development of Consumer Rights Information Page on Nursing Home Compare Website

Pub. L. 111–148, title VI, § 6103(e), Mar. 23, 2010, 124 Stat. 710, provided that: “Not later than 1 year after the date of enactment of this Act [Mar. 23, 2010], the Secretary [of Health and Human Services] shall ensure that the Department of Health and Human Services, as part of the information provided for comparison of nursing facilities on the Nursing Home Compare Medicare website develops and includes a consumer rights information page that contains links to descriptions of, and information with respect to, the following: The documentation on nursing facilities that is available to the public. General information and tips on choosing a nursing facility that meets the needs of the individual. General information on consumer rights with respect to nursing facilities. The nursing facility survey process (on a national and State-specific basis). On a State-specific basis, the services available through the State long-term care ombudsman for such State.”

### National Demonstration Projects on Culture Change and Use of Information Technology in Nursing Homes

Pub. L. 111–148, title VI, § 6114, Mar. 23, 2010, 124 Stat. 720, provided that: In General.—The Secretary [of Health and Human Services] shall conduct 2 demonstration projects, 1 for the development of best practices in skilled nursing facilities and nursing facilities that are involved in the culture change movement (including the development of resources for facilities to find and access funding in order to undertake culture change) and 1 for the development of best practices in skilled nursing facilities and nursing facilities for the use of information technology to improve resident care.Conduct of Demonstration Projects.— Grant award.—Under each demonstration project conducted under this section, the Secretary shall award 1 or more grants to facility-based settings for the development of best practices described in subsection (a) with respect to the demonstration project involved. Such award shall be made on a competitive basis and may be allocated in 1 lump-sum payment. Consideration of special needs of residents.—Each demonstration project conducted under this section shall take into consideration the special needs of residents of skilled nursing facilities and nursing facilities who have cognitive impairment, including dementia.Duration and Implementation.— Duration.—The demonstration projects shall each be conducted for a period not to exceed 3 years. Implementation.—The demonstration projects shall each be implemented not later than 1 year after the date of the enactment of this Act [Mar. 23, 2010]. Definitions.—In this section: Nursing facility.—The term ‘nursing facility’ has the meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)). Secretary.—The term ‘Secretary’ means the Secretary of Health and Human Services. Skilled nursing facility.—The term ‘skilled nursing facility’ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395(a) [1395i–3(a)]). Authorization of Appropriations.—There are authorized to be appropriated such sums as may be necessary to carry out this section. Report.—Not later than 9 months after the completion of the demonstration project, the Secretary shall submit to Congress a report on such project, together with recommendations for such legislation and administrative action as the Secretary determines appropriate.”

### Review and Report on Current Standards of Practice for Pharmacy Services Provided to Patients in Nursing Facilities

Pub. L. 108–173, title I, § 107(b), Dec. 8, 2003, 117 Stat. 2169, provided that:Review.— In general.—Not later than 12 months after the date of the enactment of this Act [Dec. 8, 2003], the Secretary [of Health and Human Services] shall conduct a thorough review of the current standards of practice for pharmacy services provided to patients in nursing facilities. Specific matters reviewed.—In conducting the review under subparagraph (A), the Secretary shall— assess the current standards of practice, clinical services, and other service requirements generally used for pharmacy services in long-term care settings; and evaluate the impact of those standards with respect to patient safety, reduction of medication errors and quality of care.Report.— In general.—Not later than the date that is 18 months after the date of the enactment of this Act [Dec. 8, 2003], the Secretary shall submit a report to Congress on the study conducted under paragraph (1)(A). Contents.—The report submitted under subparagraph (A) shall contain— a description of the plans of the Secretary to implement the provisions of this Act [see Tables for classification] in a manner consistent with applicable State and Federal laws designed to protect the safety and quality of care of nursing facility patients; and recommendations regarding necessary actions and appropriate reimbursement to ensure the provision of prescription drugs to medicare beneficiaries residing in nursing facilities in a manner consistent with existing patient safety and quality of care standards under applicable State and Federal laws.”

### Study and Report Regarding State Licensure and Certification Standards and Respiratory Therapy Competency Examinations

Pub. L. 106–113, div. B, § 1000(a)(6) [title I, § 107], Nov. 29, 1999, 113 Stat. 1536, 1501A–328, provided that the Secretary of Health and Human Services would conduct a study that identifies variations in State licensure and certification standards for health care providers and other individuals providing respiratory therapy in skilled nursing facilities, examines State requirements relating to respiratory therapy competency examinations for such providers and individuals and determines whether regular respiratory therapy competency examinations or certifications should be required under the medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), and submit a report of the results of the study and any recommendations by 18 months after Nov. 29, 1999.

### Retroactive Review

Pub. L. 105–33, title IV, § 4755(c), Aug. 5, 1997, 111 Stat. 527, provided that: “The procedures developed by a State under the amendments made by subsection[s] (a) and (b) [amending this section and section 1396r of this title] shall permit an individual to petition for a review of any finding made by a State under section 1819(g)(1)(C) or 1919(g)(1)(C) of the Social Security Act (42 U.S.C. 1395i-3(g)(1)(C) or 1396r(g)(1)(C)) after January 1, 1995.”

### Study and Report on Deeming for Nursing Facilities and Renal Dialysis Facilities

Pub. L. 104–134, title I, § 101(d) [title V, § 516(d)], Apr. 26, 1996, 110 Stat. 1321–211, 1321–248; renumbered title I, Pub. L. 104–140, § 1(a), May 2, 1996, 110 Stat. 1327, provided that: Study.—The Secretary of Health and Human Services shall provide for— a study concerning the effectiveness and appropriateness of the current mechanisms for surveying and certifying skilled nursing facilities for compliance with the conditions and requirements of sections 1819 and 1861(j) of the Social Security Act [42 U.S.C. 1395i–3, 1395x(j)] and nursing facilities for compliance with the conditions of section 1919 of such Act [42 U.S.C. 1396r], and a study concerning the effectiveness and appropriateness of the current mechanisms for surveying and certifying renal dialysis facilities for compliance with the conditions and requirements of section 1881(b) of the Social Security Act [42 U.S.C. 1395rr(b)]. Report.—Not later than July 1, 1997, the Secretary shall transmit to Congress a report on each of the studies provided for under paragraph (1). The report on the study under paragraph (1)(A) shall include (and the report on the study under paragraph (1)(B) may include) a specific framework, where appropriate, for implementing a process under which facilities covered under the respective study may be deemed to meet applicable medicare conditions and requirements if they are accredited by a national accreditation body.”

### Maintaining Regulatory Standards for Certain Services

Pub. L. 101–508, title IV, § 4008(h)(2)(O), Nov. 5, 1990, 104 Stat. 1388–50, provided that: “Any regulations promulgated and applied by the Secretary of Health and Human Services after the date of the enactment of the Omnibus Budget Reconciliation Act of 1987 [Dec. 22, 1987] with respect to services described in clauses (ii), (iv), and (v) of section 1819(b)(4)(A) of the Social Security Act [42 U.S.C. 1395i–3(b)(4)(A)(ii), (iv), and (v)] shall include requirements for providers of such services that are at least as strict as the requirements applicable to providers of such services prior to the enactment of the Omnibus Budget Reconciliation Act of 1987.”

### Nurse Aide Training and Competency Evaluation Programs; Publication of Proposed Regulations

Pub. L. 101–239, title VI, § 6901(b)(2), Dec. 19, 1989, 103 Stat. 2298, provided that: “The Secretary of Health and Human Services shall issue proposed regulations to establish the requirements described in sections 1819(f)(2) and 1919(f)(2) of the Social Security Act [42 U.S.C. 1395i–3(f)(2), 1396r(f)(2)] by not later than 90 days after the date of the enactment of this Act [Dec. 19, 1989].”

### Nurse Aide Training and Competency Evaluation; Satisfaction of Requirements; Waiver

Pub. L. 101–239, title VI, § 6901(b)(4)(B)–(D), Dec. 19, 1989, 103 Stat. 2299, provided that: A nurse aide shall be considered to satisfy the requirement of sections 1819(b)(5)(A) and 1919(b)(5)(A) of the Social Security Act [42 U.S.C. 1395i–3(b)(5)(A), 1396r(b)(5)(A)] (of having completed a training and competency evaluation program approved by a State under section 1819(e)(1)(A) or 1919(e)(1)(A) of such Act [42 U.S.C. 1395i–3(e)(1)(A), 1396r(e)(1)(A)]), if such aide would have satisfied such requirement as of July 1, 1989, if a number of hours (not less than 60 hours) were substituted for ‘75 hours’ in sections 1819(f)(2) and 1919(f)(2) of such Act [42 U.S.C. 1395i–3(f)(2), 1396r(f)(2)], respectively, and if such aide had received, before July 1, 1989, at least the difference in the number of such hours in supervised practical nurse aide training or in regular in-service nurse aide education. A nurse aide shall be considered to satisfy the requirement of sections 1819(b)(5)(A) and 1919(b)(5)(A) of the Social Security Act (of having completed a training and competency evaluation program approved by a State under section 1819(e)(1)(A) or 1919(e)(1)(A) of such Act), if such aide was found competent (whether or not by the State), before July 1, 1989, after the completion of a course of nurse aide training of at least 100 hours duration. With respect to the nurse aide competency evaluation requirements described in sections 1819(b)(5)(A) and 1919(b)(5)(A) of the Social Security Act, a State may waive such requirements with respect to an individual who can demonstrate to the satisfaction of the State that such individual has served as a nurse aide at one or more facilities of the same employer in the State for at least 24 consecutive months before the date of the enactment of this Act [Dec. 19, 1989].”

### Evaluation and Report on Implementation of Resident Assessment Process

Pub. L. 100–203, title IV, § 4201(c), Dec. 22, 1987, 101 Stat. 1330–174, provided that: “The Secretary of Health and Human Services shall evaluate, and report to Congress by not later than January 1, 1992, on the implementation of the resident assessment process for residents of skilled nursing facilities under the amendments made by this section [enacting this section and amending sections 1395x, 1395aa, 1395tt, and 1395yy of this title].”

### Annual Report on Statutory Compliance and Enforcement Actions

Pub. L. 100–203, title IV, § 4205, Dec. 22, 1987, 101 Stat. 1330–182, provided that: “The Secretary of Health and Human Services shall report to the Congress annually on the extent to which skilled nursing facilities are complying with the requirements of subsections (b), (c), and (d) of section 1819 of the Social Security Act [42 U.S.C. 1395i–3(b), (c), (d)] (as added by the amendments made by this part) and the number and type of enforcement actions taken by States and the Secretary under section 1819(h) of such Act (as added by section 4203 of this Act).”