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Side-by-SideComparisonofCurrent&ProposedFederalNursingHomeRegulations(IncludingArbitrationAgreements)
Thisside-by-sidecomparisonhasbeenpreparedusingthecurrentNursingHomeRequirementsofParticipation,releasedin2016bytheCentersforMedicare&MedicaidServices(CMS);currentSurvey,Certification,andEnforcementProcedures;theproposedRequirementsforLong-TermCareFacilities(84Fed.Reg.34737,July18,2019)andfinalrulesRevisionofRequirementsforLTCFacilities:ArbitrationAgreements(84Fed.Reg.34718,July18,2019).
TableofContents
§483.1BasisandScope……………………………………………………………………………………………………………………………………………………………………………………………………………………4
§483.5Definitions……………………………………………………………………………………………………………………………………………………………………………………………………………………………5
§483.10Residentrights…………………………………………………………………………………………………………………………………………………………………………………………………………………14
§483.12Freedomfromabuse,neglect,andexploitation………………………………………………………………………………………………………………………………………………………………50
§483.15Admission,transfer,anddischargerights………………………………………………………………………………………………………………………………………………………………………..54
§483.20Residentassessment……………………………………………………………………………………………………………………………………………………………………………………………………….66
§483.21Comprehensiveperson-centeredcareplanning………………………………………………………………………………………………………………………………………………………………74
§483.24Qualityoflife…………………………………………………………………………………………………………………………………………………………………………………………………………………..81
§483.25Qualityofcare…………………………………………………………………………………………………………………………………………………………………………………………………………………84
§483.30Physicianservices…………………………………………………………………………………………………………………………………………………………………………………………………………….91
§483.35Nursingservices……………………………………………………………………………………………………………………………………………………………………………………………………………….94
§483.40Behavioralhealthservices……………………………………………………………………………………………………………………………………………………………………………………………..102
§483.45Pharmacyservices…………………………………………………………………………………………………………………………………………………………………………………………………………105
§483.50Laboratory,radiology,andotherdiagnosticservices……………………………………………………………………………………………………………………………………………………..111
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§483.55Dentalservices………………………………………………………………………………………………………………………………………………………………………………………………………………114
§483.60Foodandnutritionservices……………………………………………………………………………………………………………………………………………………………………………………………116
§483.65Specializedrehabilitativeservices………………………………………………………………………………………………………………………………………………………………………………….124
§483.70Administration……………………………………………………………………………………………………………………………………………………………………………………………………………….125
§483.75Qualityassuranceandperformanceimprovement………………………………………………………………………………………………………………………………………………………..142
§483.80Infectioncontrol…………………………………………………………………………………………………………………………………………………………………………………………………………….150
§483.85Complianceandethicsprogram…………………………………………………………………………………………………………………………………………………………………………………….154
§483.90Physicalenvironment…………………………………………………………………………………………………………………………………………………………………………………………………….160
§483.95Trainingrequirements……………………………………………………………………………………………………………………………………………………………………………………………………171
PART488–SURVEY,CERTIFICATIONANDENFORCEMENTPROCEDURES
§488.331InformalDisputeResolution…..……………………………………………………………………………………………………………………………………………………………………………………175
§488.431CivilMoneyPenaltiesImposedbyCMSandIndependentinformaldisputeresolution:forSNFs,duallyparticipatingSNFs/NFs,andNF-onlyfacilities…………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………176
§488.432CivilMoneyPenaltiesImposedbytheState:NF-only…..………………………………………………………………………………………………………………………………………………181
§488.442CivilMoneyPenalties:DueDateforPaymentofPenalty…………..…………………………………………………………………………………………………………………………………183
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Key
● Bold&blackfont–Denotessectionnumberandnameforbothcurrentandproposedregulations.● Blackfont–Proposedrulelanguageisexactlythesameascurrentlanguage;ORproposedlanguageisexactlythesameascurrentlanguagewiththe
exceptionofthesectionnumber,whichhaschanged.o NOTE:Implementationphasesforthecurrentregulationsarealsoinblackfont.Theimplementationphasesareasfollows:
▪ Phase1–TheseregulationshavebeenimplementedonNovember28,2016(theeffectivedateofthefinalrule).▪ Phase2–TheseregulationswillbeimplementedbyNovember28,2017(1yearfollowingtheeffectivedateofthefinalrule).▪ Phase3–TheseregulationswillbeimplementedbyNovember28,2019(3yearsfollowingtheeffectivedateofthefinalrule).
● Red&italicizedfont–Proposedrulelanguageisaversionofthecurrentlanguage.Notethatsometimestheonlyrevisionisachangeinacitationreferencedintheprovision.
● Blue&boldfont–ProposedrulelanguageisidentifiedbyCMSasnew.Notethatsometimestheproposedlanguage,althoughidentifiedbyCMSasnew,issimilartoorbasedonatleastsomeofthelanguageinthecurrentrule.
● Strikethroughfont–Currentrulelanguagewasremovedintheproposedrulelanguage.
Forquestionsormoreinformation,gotowww.theconsumervoice.org,[email protected]
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CURRENTSECTION CURRENTLANGUAGE CURRENTIMPLEMENTATI
ONPHASE
PROPOSEDSECTION/
FINALSECTION
FORARBITRATIONAGREEMENTS
PROPOSEDLANGUAGE/
FINALLANGUAGEFORARBITRATIONAGREEMENTS
SubpartB REQUIREMENTSFORLONGTERMCAREFACILITIES
§483.1 Basisandscope. Thisentiresectionwas
implementedinPhase1.
483.1(a) (a)Statutorybasis. 1 483.1(a)(1) (1)Sections1819(a),(b),(c),(d),and(f)
oftheActprovidethat—1
483.1(a)(1)(i) (i)SkillednursingfacilitiesparticipatinginMedicaremustmeetcertainspecifiedrequirements;and
1
483.1(a)(1)(ii) (ii)TheSecretarymayimposeadditionalrequirements(seesection1819(d)(4)(B))iftheyarenecessaryforthehealthandsafetyofindividualstowhomservicesarefurnishedinthefacilities.
1
483.1(a)(2) (2)Section1861(l)oftheActrequiresthefacilitytohaveineffectatransferagreementwithahospital.
1
483.1(a)(3) (3)Sections1919(a),(b),(c),(d),and(f)oftheActprovidethatnursingfacilitiesparticipatinginMedicaidmustmeetcertainspecificrequirements.
1
483.1(a)(4) (4)Sections1128I(b)and(c)requirethat--
1
483.1(a)(4)(i) (i)Skillednursingfacilitiesornursingfacilityhaveinoperationacompliance
1
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andethicsprogramthatiseffectiveinpreventinganddetectingcriminal,civil,andadministrativeviolations.
483.1(a)(4)(ii) (ii)TheSecretaryestablishandimplementaqualityassuranceandperformanceimprovementprogramforfacilities,includingmulti-unitchainsoffacilities
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483.1(a)(5) (5)Section1150BestablishesrequirementsforreportingtolawenforcementcrimesoccurringinfederallyfundedLTCfacilities.
1
483.1(b) (b)Scope.TheprovisionsofthispartcontaintherequirementsthataninstitutionmustmeetinordertoqualifytoparticipateasaSkilledNursingFacilityintheMedicareprogram,andasanursingfacilityintheMedicaidprogram.TheyserveasthebasisforsurveyactivitiesforthepurposeofdeterminingwhetherafacilitymeetstherequirementsforparticipationinMedicareandMedicaid.
1
§483.5 Definitions. Thisentiresectionwas
implementedinPhase1.
483.5 Asusedinthissubpart,thefollowingdefinitionsapply:
1
483.5inalphabeticalorder.
Abuse.Abuseisthewillfulinflictionofinjury,unreasonableconfinement,intimidation,orpunishmentwithresultingphysicalharm,painormentalanguish.Abusealsoincludesthedeprivationbyanindividual,includinga
1
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caretaker,ofgoodsorservicesthatarenecessarytoattainormaintainphysical,mental,andpsychosocialwell-being.Instancesofabuseofallresidents,irrespectiveofanymentalorphysicalcondition,causephysicalharm,painormentalanguish.Itincludesverbalabuse,sexualabuse,physicalabuse,andmentalabuseincludingabusefacilitatedorenabledthroughtheuseoftechnology.Willful,asusedinthisdefinitionofabuse,meanstheindividualmusthaveacteddeliberately,notthattheindividualmusthaveintendedtoinflictinjuryorharm.
483.5inalphabeticalorder.
Adverseevent.Anadverseeventisanuntoward,undesirable,andusuallyunanticipatedeventthatcausesdeathorseriousinjury,ortheriskthereof.
1
483.5inalphabeticalorder.
Commonarea.Commonareasareareasinthefacilitywhereresidentsmaygathertogetherwithotherresidents,visitors,andstafforengageinindividualpursuits,apartfromtheirresidentialrooms.Thisincludesbutisnotlimitedtolivingrooms,diningrooms,activityrooms,outdoorareas,andmeetingroomswhereresidentsarelocatedonaregularbasis.
1
483.5inalphabeticalorder.
Facilitydefined.Forpurposesofthissubpart,facilitymeansaskillednursingfacility(SNF)thatmeetstherequirementsofsections1819(a),(b),(c),and(d)oftheAct,oranursingfacility(NF)thatmeetstherequirementsofsections1919(a),(b),(c),and(d)oftheAct.“Facility”mayincludeadistinctpartofaninstitution(asdefinedinparagraph
1
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(b)ofthissectionandspecifiedin§440.40and§440.155ofthischapter),butdoesnotincludeaninstitutionforindividualswithintellectualdisabilitiesorpersonswithrelatedconditionsdescribedin§440.150ofthischapter.ForMedicareandMedicaidpurposes(includingeligibility,coverage,certification,andpayment),the“facility”isalwaystheentitythatparticipatesintheprogram,whetherthatentityiscomprisedofallof,oradistinctpartof,alargerinstitution.ForMedicare,anSNF(seesection1819(a)(1)oftheAct),andforMedicaid,anNF(seesection1919(a)(1)oftheAct)maynotbeaninstitutionformentaldiseasesasdefinedin§435.1010ofthischapter.
483.5inalphabeticalorder.
Distinctpart. 1
(1)Definition.AdistinctpartSNForNFisphysicallydistinguishablefromthelargerinstitutionorinstitutionalcomplexthathousesit,meetstherequirementsofthisparagraphandofparagraph(b)(2)ofthissection,andmeetstheapplicablestatutoryrequirementsforSNFsorNFsinsections1819or1919oftheAct,respectively.AdistinctpartSNForNFmaybecomprisedofoneormorebuildingsordesignatedpartsofbuildings(thatis,wings,wards,orfloors)thatare:Inthesamephysicalareaimmediatelyadjacenttotheinstitution'smainbuildings;otherareasandstructuresthat
1
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arenotstrictlycontiguoustothemainbuildingsbutarelocatedwithincloseproximityofthemainbuildings;andanyotherareasthatCMSdeterminesonanindividualbasis,tobepartoftheinstitution'scampus.Adistinctpartmustincludeallofthebedswithinthedesignatedarea,andcannotconsistofarandomcollectionofindividualroomsorbedsthatarescatteredthroughoutthephysicalplant.Theterm“distinctpart”alsoincludesacompositedistinctpartthatmeetstheadditionalrequirementsofparagraph(c)ofthissection.
(2)Requirements.Inadditiontomeetingtheparticipationrequirementsforlong-termcarefacilitiessetforthelsewhereinthissubpart,adistinctpartSNForNFmustmeetallofthefollowingrequirements:
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(i)TheSNForNFmustbeoperatedundercommonownershipandcontrol(thatis,commongovernance)bytheinstitutionofwhichitisadistinctpart,asevidencedbythefollowing:
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(A)TheSNForNFiswhollyownedbytheinstitutionofwhichitisadistinctpart.
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(B)TheSNForNFissubjecttotheby-lawsandoperatingdecisionsofacommongoverningbody.
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(C)TheinstitutionofwhichtheSNForNFisadistinctparthasfinalresponsibilityforthedistinctpart'sadministrativedecisionsandpersonnelpolicies,andfinalapprovalforthedistinctpart's
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personnelactions. (D)TheSNForNFfunctionsasanintegral
andsubordinatepartoftheinstitutionofwhichitisadistinctpart,withsignificantcommonresourceusageofbuildings,equipment,personnel,andservices.
1
(ii)TheadministratoroftheSNForNFreportstoandisdirectlyaccountabletothemanagementoftheinstitutionofwhichtheSNForNFisadistinctpart.
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(iii)TheSNForNFmusthaveadesignatedmedicaldirectorwhoisresponsibleforimplementingcarepoliciesandcoordinatingmedicalcare,andwhoisdirectlyaccountabletothemanagementoftheinstitutionofwhichitisadistinctpart.
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(iv)TheSNForNFisfinanciallyintegratedwiththeinstitutionofwhichitisadistinctpart,asevidencedbythesharingofincomeandexpenseswiththatinstitution,andthereportingofitscostsonthatinstitution'scostreport.
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(v)AsingleinstitutioncanhaveamaximumofonlyonedistinctpartSNFandonedistinctpartNF.
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(vi)(A)AninstitutioncannotdesignateadistinctpartSNForNF,butinsteadmustsubmitawrittenrequestwithdocumentationthatdemonstratesitmeetsthecriteriasetforthabovetoCMStodetermineifitmaybeconsideredadistinctpart.
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(B)TheeffectivedateofapprovalofadistinctpartisthedatethatCMS
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determinesallrequirements(includingenrollmentwiththefiscalintermediary(FI))aremetforapproval,andcannotbemaderetroactive.
(C)TheinstitutionmustrequestapprovalfromCMSforallproposedchangesinthenumberofbedsintheapproveddistinctpart.
1
483.5inalphabeticalorder.
Compositedistinctpart. 1
(1)Definition.Acompositedistinctpartisadistinctpartconsistingoftwoormorenoncontiguouscomponentsthatarenotlocatedwithinthesamecampus,asdefinedin§413.65(a)(2)ofthischapter.
1
(2)Requirements.Inadditiontomeetingtherequirementsofparagraph(b)ofthissection,acompositedistinctpartmustmeetallofthefollowingrequirements:
1
(i)ASNForNFthatisacompositeofmorethanonelocationwillbetreatedasasingledistinctpartoftheinstitutionofwhichitisadistinctpart.Assuch,thecompositedistinctpartwillhaveonlyoneprovideragreementandonlyoneprovidernumber.
1
(ii)Iftwoormoreinstitutions(eachwithadistinctpartSNForNF)undergoachangeofownership,CMSmustapprovetheexistingSNFsorNFsasmeetingtherequirementsbeforetheyareconsideredacompositedistinctpartofasingleinstitution.Inmakingsuchadetermination,CMSconsiderswhether
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itsapprovalordisapprovalofacompositedistinctpartpromotestheeffectiveandefficientuseofpublicmonieswithoutsacrificingthequalityofcare.
(iii)IfthereisachangeofownershipofacompositedistinctpartSNForNF,theassignmentoftheprovideragreementtothenewownerwillapplytoalloftheapprovedlocationsthatcomprisethecompositedistinctpartSNForNF.
1
(iv)Toensurequalityofcareandqualityoflifeforallresidents,thevariouscomponentsofacompositedistinctpartmustmeetalloftherequirementsforparticipationindependentlyineachlocation.
1
(v)Useofcompositedistinctpartstosegregateresidentsbypaymentsourceoronabasisotherthancareneedsisprohibited.
1
483.5inalphabeticalorder.
Exploitation.Exploitationmeanstakingadvantageofaresidentforpersonalgainthroughtheuseofmanipulation,intimidation,threats,orcoercion.
1
483.5inalphabeticalorder.
Fullysprinklered.AfullysprinkleredlongtermcarefacilityisonethathasallareassprinkleredinaccordancewithNationalFireProtectionAssociation13“StandardfortheInstallationofSprinklerSystems”withouttheuseofwaiversortheFireSafetyEvaluationSystem.
1
483.5inalphabeticalorder.
Licensedhealthprofessional.Alicensedhealthprofessionalisaphysician;physicianassistant;nursepractitioner;
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physical,speech,oroccupationaltherapist;physicaloroccupationaltherapyassistant;registeredprofessionalnurse;licensedpracticalnurse;orlicensedorcertifiedsocialworker;orregisteredrespiratorytherapytechnician.
483.5inalphabeticalorder.
Majormodificationmeansthemodificationofmorethan50percent,ormorethan4,500squarefeet,ofthesmokecompartment.
1
483.5inalphabeticalorder.
Misappropriationofresidentpropertymeansthedeliberatemisplacement,exploitation,orwrongful,temporary,orpermanentuseofaresident’sbelongingsormoneywithouttheresident’sconsent.
1
483.5inalphabeticalorder.
Mistreatmentmeansinappropriatetreatmentorexploitationofaresident.
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483.5inalphabeticalorder.
Neglectisthefailureofthefacility,itsemployeesorserviceproviderstoprovidegoodsandservicestoaresidentthatarenecessarytoavoidphysicalharm,pain,mentalanguishoremotionaldistress.
1
483.5inalphabeticalorder.
Nurseaide.Anurseaideisanyindividualprovidingnursingornursing-relatedservicestoresidentsinafacility.Thistermmayalsoincludeanindividualwhoprovidestheseservicesthroughanagencyorunderacontractwiththefacility,butisnotalicensedhealthprofessional,aregistereddietitian,orsomeonewhovolunteerstoprovidesuchserviceswithoutpay.Nurseaidesdonotincludethoseindividualswhofurnish
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servicestoresidentsonlyaspaidfeedingassistantsasdefinedin§488.301ofthischapter.
483.5inalphabeticalorder.
Person-centeredcare.Forpurposesofthissubpart,person-centeredcaremeanstofocusontheresidentasthelocusofcontrolandsupporttheresidentinmakingtheirownchoicesandhavingcontrolovertheirdailylives.
1
483.5inalphabeticalorder.
Residentrepresentative.Forpurposesofthissubpart,thetermresidentrepresentativemeansanyofthefollowing:
1
(1)Anindividualchosenbytheresidenttoactonbehalfoftheresidentinordertosupporttheresidentindecision-making;accessmedical,socialorotherpersonalinformationoftheresident;managefinancialmatters;orreceivenotifications;
1
(2)ApersonauthorizedbyStateorFederallaw(includingbutnotlimitedtoagentsunderpowerofattorney,representativepayees,andotherfiduciaries)toactonbehalfoftheresidentinordertosupporttheresidentindecision-making;accessmedical,socialorotherpersonalinformationoftheresident;managefinancialmatters;orreceivenotifications;
1
(3)Legalrepresentative,asusedinsection712oftheOlderAmericansAct;
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(4)Thecourt-appointedguardianorconservatorofaresident.
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(5)Nothinginthisruleisintendedto 1
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expandthescopeofauthorityofanyresidentrepresentativebeyondthatauthorityspecificallyauthorizedbytheresident,StateorFederallaw,oracourtofcompetentjurisdiction.
483.5inalphabeticalorder.
Sexualabuseisnon-consensualsexualcontactofanytypewitharesident.
1
483.5inalphabeticalorder.
Transferanddischargeincludesmovementofaresidenttoabedoutsideofthecertifiedfacilitywhetherthatbedisinthesamephysicalplantornot.Transferanddischargedoesnotrefertomovementofaresidenttoabedwithinthesamecertifiedfacility.
1
§483.10 Residentrights. ThissectionwasimplementedinPhase1,withthe
followingexception:
§483.10(g)(4)(ii)-(v),whichwasimplementedin
Phase2.
483.10(a) (a)ResidentsRights.Theresidenthasarighttoadignifiedexistence,self-determination,andcommunicationwithandaccesstopersonsandservicesinsideandoutsidethefacility,includingthosespecifiedinthissection.
1
483.10(a)(1)
(1)Afacilitymusttreateachresidentwithrespectanddignityandcareforeachresidentinamannerandinanenvironmentthatpromotesmaintenanceorenhancementofhisorherqualityof
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life,recognizingeachresident’sindividuality.Thefacilitymustprotectandpromotetherightsoftheresident.
483.10(a)(2)
(2)Thefacilitymustprovideequalaccesstoqualitycareregardlessofdiagnosis,severityofcondition,orpaymentsource.Afacilitymustestablishandmaintainidenticalpoliciesandpracticesregardingtransfer,discharge,andtheprovisionofservicesundertheStateplanforallresidentsregardlessofpaymentsource.
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483.10(b) (b)Exerciseofrights.TheresidenthastherighttoexercisehisorherrightsasaresidentofthefacilityandasacitizenorresidentoftheUnitedStates.
1
483.10(b)(1) (1)Thefacilitymustensurethattheresidentcanexercisehisorherrightswithoutinterference,coercion,discrimination,orreprisalfromthefacility
1
483.10(b)(2) (2)Theresidenthastherighttobefreeofinterference,coercion,discrimination,andreprisalfromthefacilityinexercisinghisorherrightsandtobesupportedbythefacilityintheexerciseofhisorherrightsasrequiredunderthissubpart.
1
483.10(b)(3) (3)Inthecaseofaresidentwhohasnotbeenadjudgedincompetentbythestatecourt,theresidenthastherighttodesignatearepresentative,inaccordancewithStatelawandanylegalsurrogatesodesignatedmayexercisetheresident’srightstotheextentprovidedbystatelaw.Thesame-sexspouseofaresidentmustbeaffordedtreatmentequaltothat
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affordedtoanopposite-sexspouseifthemarriagewasvalidinthejurisdictioninwhichitwascelebrated.
483.10(b)(3)(i) (i)Theresidentrepresentativehastherighttoexercisetheresident’srightstotheextentthoserightsaredelegatedtotheresidentrepresentative.
1
483.10(b)(3)(ii) (ii)Theresidentretainstherighttoexercisethoserightsnotdelegatedtoaresidentrepresentative,includingtherighttorevokeadelegationofrights,exceptaslimitedbyStatelaw.
1
483.10(b)(4) (4)Thefacilitymusttreatthedecisionsofaresidentrepresentativeasthedecisionsoftheresidenttotheextentrequiredbythecourtordelegatedbytheresident,inaccordancewithapplicablelaw.
1
483.10(b)(5) (5)Thefacilityshallnotextendtheresidentrepresentativetherighttomakedecisionsonbehalfoftheresidentbeyondtheextentrequiredbythecourtordelegatedbytheresident,inaccordancewithapplicablelaw.
1
483.10(b)(6) (6)Ifthefacilityhasreasontobelievethataresidentrepresentativeismakingdecisionsortakingactionsthatarenotinthebestinterestsofaresident,thefacilityshallreportsuchconcernsinthemannerrequiredunderStatelaw.
1
483.10(b)(7) (7)InthecaseofaresidentadjudgedincompetentunderthelawsofaStatebyacourtofcompetentjurisdiction,therightsoftheresidentdevolvetoandareexercisedbytheresidentrepresentativeappointedunderStatelawtoactonthe
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resident’sbehalf.Thecourt-appointedresidentrepresentativeexercisestheresident’srightstotheextentjudgednecessarybyacourtofcompetentjurisdiction,inaccordancewithStatelaw
483.10(b)(7)(i) (i)Inthecaseofaresidentrepresentativewhosedecision-makingauthorityislimitedbyStatelaworcourtappointment,theresidentretainstherighttomakethosedecisionoutsidetherepresentative’sauthority.
1
483.10(b)(7)(ii) (ii)Theresident’swishesandpreferencesmustbeconsideredintheexerciseofrightsbytherepresentative.
1
483.10(b)(7)(iii) (iii)Totheextentpracticable,theresidentmustbeprovidedwithopportunitiestoparticipateinthecareplanningprocess.
1
483.10(c) (c)Planningandimplementingcare.Theresidenthastherighttobeinformedof,andparticipatein,hisorhertreatment,including:
1
483.10(c)(1) (1)Therighttobefullyinformedinlanguagethatheorshecanunderstandofhisorhertotalhealthstatus,includingbutnotlimitedto,hisorhermedicalcondition.
1
483.10(c)(2) (2)Therighttoparticipateinthedevelopmentandimplementationofhisorherperson-centeredplanofcare,includingbutnotlimitedto:
1
483.10(c)(2)(i) (i)Therighttoparticipateintheplanningprocess,includingtherighttoidentifyindividualsorrolestobeincludedintheplanningprocess,therighttorequest
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meetingsandtherighttorequestrevisionstotheperson-centeredplanofcare.
483.10(c)(2)(ii) (ii)Therighttoparticipateinestablishingtheexpectedgoalsandoutcomesofcare,thetype,amount,frequency,anddurationofcare,andanyotherfactorsrelatedtotheeffectivenessoftheplanofcare.
1
483.10(c)(2)(iii) (iii)Therighttobeinformed,inadvance,ofchangestotheplanofcare.
1
483.10(c)(2)(iv) (iv)Therighttoreceivetheservicesand/oritemsincludedintheplanofcare.
1
483.10(c)(2)(v) (v)Therighttoseethecareplan,includingtherighttosignaftersignificantchangestotheplanofcare.
1
483.10(c)(3) (3)Thefacilityshallinformtheresidentoftherighttoparticipateinhisorhertreatmentandshallsupporttheresidentinthisright.Theplanningprocessmust—
1
483.10(c)(3)(i) (i)Facilitatetheinclusionoftheresidentand/orresidentrepresentative.
1
483.10(c)(3)(ii) (ii)Includeanassessmentoftheresident’sstrengthsandneeds.
1
483.10(c)(3)(iii) (iii)Incorporatetheresident’spersonalandculturalpreferencesindevelopinggoalsofcare.
1
483.10(c)(4) (4)Therighttobeinformed,inadvance,ofthecaretobefurnishedandthetypeofcaregiverorprofessionalthatwillfurnishcare.
1
483.10(c)(5) (5)Therighttobeinformedinadvance,bythephysicianorotherpractitionerorprofessional,oftherisksandbenefitsofproposedcare,oftreatmentand
1
19
treatmentalternativesortreatmentoptionsandtochoosethealternativeoroptionheorsheprefers.
483.10(c)(6) (6)Therighttorequest,refuse,and/ordiscontinuetreatment,toparticipateinorrefusetoparticipateinexperimentalresearch,andtoformulateanadvancedirective.
1
483.10(c)(7) (7)Therighttoself-administermedicationsiftheinterdisciplinaryteam,asdefinedby§483.21(b)(2)(ii),hasdeterminedthatthispracticeisclinicallyappropriate.
1
483.10(c)(8) (8)Nothinginthisparagraphshouldbeconstruedastherightoftheresidenttoreceivetheprovisionofmedicaltreatmentormedicalservicesdeemedmedicallyunnecessaryorinappropriate.
1
483.10(d) (d)Choiceofattendingphysician.Theresidenthastherighttochoosehisorherattendingphysician.
1
483.10(d)(1) (1)Thephysicianmustbelicensedtopractice,and
1
483.10(d)(2) (2)Ifthephysicianchosenbytheresidentrefusestoordoesnotmeetrequirementsspecifiedinthispart,thefacilitymayseekalternatephysicianparticipationasspecifiedinparagraphs(d)(4)and(5)ofthissectiontoassureprovisionofappropriateandadequatecareandtreatment.
1
483.10(d)(3)
(3)Thefacilitymustensurethateachresidentremainsinformedofthename,specialty,andwayofcontactingthephysicianandotherprimarycare
1 483.10(d)(3) (3)Thefacilitymustprovidetheprimarycarephysician’snameandcontactinformationuponadmission,withanychangeofsuchinformationorupontheresident’srequest.
20
professionalsresponsibleforhisorhercare.
483.10(d)(4) (4)Thefacilitymustinformtheresidentifthefacilitydeterminesthatthephysicianchosenbytheresidentisunableorunwillingtomeetrequirementsspecifiedinthispartandthefacilityseeksalternatephysicianparticipationtoassureprovisionofappropriateandadequatecareandtreatment.Thefacilitymustdiscussthealternativephysicianparticipationwiththeresidentandhonortheresident’spreferences,ifany,amongoptions.
1
483.10(d)(5) (5)Iftheresidentsubsequentlyselectsanotherattendingphysicianwhomeetstherequirementsspecifiedinthispart,thefacilitymusthonorthatchoice.
1
483.10(e) (e)Respectanddignity.Theresidenthasarighttobetreatedwithrespectanddignity,including:
1
483.10(e)(1) (1)Therighttobefreefromanyphysicalorchemicalrestraintsimposedforpurposesofdisciplineorconvenience,andnotrequiredtotreattheresident’smedicalsymptoms,consistentwith§483.12(a)(2).
1
483.10(e)(2) (2)Therighttoretainandusepersonalpossession,includingfurnishings,andclothing,asspacepermits,unlesstodosowouldinfringeupontherightsorhealthandsafetyofotherresidents.
1
483.10(e)(3) (3)Therighttoresideandreceiveservicesinthefacilitywithreasonableaccommodationofresidentneedsand
1
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preferencesexceptwhentodosowouldendangerthehealthorsafetyoftheresidentorotherresidents.
483.10(e)(4) (4)Therighttosharearoomwithhisorherspousewhenmarriedresidentsliveinthesamefacilityandbothspousesconsenttothearrangement.
1
483.10(e)(5) (5)Therighttosharearoomwithhisorherroommateofchoicewhenpracticable,whenbothresidentsliveinthesamefacilityandbothresidentsconsenttothearrangement.
1
483.10(e)(6) (6)Therighttoreceivewrittennotice,includingthereasonforthechange,beforetheresident’sroomorroommateinthefacilityischanged.
1
483.10(e)(7) (7)Therighttorefusetotransfertoanotherroominthefacility,ifthepurposeofthetransferis:
1
483.10(e)(7)(i) (i)TorelocatearesidentofaSNFfromthedistinctpartoftheinstitutionthatisaSNFtoapartoftheinstitutionthatisnotaSNF,or
1
483.10(e)(7)(ii) (ii)torelocatearesidentofaNFfromthedistinctpartoftheinstitutionthatisaNFtoadistinctpartoftheinstitutionthatisaSNF.
1
483.10(e)(7)(iii) (iii)solelyfortheconvenienceofstaff. 1 483.10(e)(8) (8)Aresident’sexerciseoftherightto
refusetransferdoesnotaffecttheresident’seligibilityorentitlementtoMedicareorMedicaidbenefits.
1
483.10(f) (f)Self-determination.Theresidenthastherighttoandthefacilitymustpromoteandfacilitateresidentself-determination
1
22
throughsupportofresidentchoice,includingbutnotlimitedtotherightsspecifiedinparagraphs(f)(1)through(11)ofthissection.
483.10(f)(1) (1)Theresidenthasarighttochooseactivities,schedules(includingsleepingandwakingtimes),healthcareandprovidersofhealthcareservicesconsistentwithhisorherinterests,assessments,planofcareandotherapplicableprovisionsofthispart.
1
483.10(f)(2) (2)Theresidenthastherighttomakechoicesaboutaspectsofhisorherlifeinthefacilitythataresignificanttotheresident.
1
483.10(f)(3) (3)Theresidenthasarighttointeractwithmembersofthecommunityandparticipateincommunityactivitiesbothinsideandoutsidethefacility.
1
483.10(f)(4) (4)Theresidenthasarighttoreceivevisitorsofhisorherchoosingatthetimeofhisorherchoosing,subjecttotheresident’srighttodenyvisitationwhenapplicable,andinamannerthatdoesnotimposeontherightsofanotherresident.
1
483.10(f)(4)(i) (i)Thefacilitymustprovideimmediateaccesstoanyresidentby—
1
483.10(f)(4)(i)(A) (A)AnyrepresentativeoftheSecretary, 1 483.10(f)(4)(i)(B) (B)AnyrepresentativeoftheState, 1 483.10(f)(4)(i)(C) (C)AnyrepresentativeoftheOfficeof
theStatelongtermcareombudsman,(establishedundersection712oftheOlderAmericansActof1965,asamended2016(42U.S.C.3001etseq.),
1
483.10(f)(4)(i)(D) (D)Theresident’sindividualphysician, 1
23
483.10(f)(4)(i)(E) (E)Anyrepresentativeoftheprotectionandadvocacysystems,asdesignatedbythestate,andasestablishedundertheDevelopmentalDisabilitiesAssistanceandBillofRightsActof2000(42U.S.C.15001etseq.),
1
483.10(f)(4)(i)(F) (F)Anyrepresentativeoftheagencyresponsiblefortheprotectionandadvocacysystemforindividualswithamentaldisorder(establishedundertheProtectionandAdvocacyforMentallyIllIndividualsActof2000(42U.S.C.10801etseq.),and
1
483.10(f)(4)(i)(G) (G)Theresidentrepresentative. 1 483.10(f)(4)(ii) (ii)Thefacilitymustprovideimmediate
accesstoaresidentbyimmediatefamilyandotherrelativesoftheresident,subjecttotheresident’srighttodenyorwithdrawconsentatanytime;
1
483.10(f)(4)(iii) (iii)Thefacilitymustprovideimmediateaccesstoaresidentbyotherswhoarevisitingwiththeconsentoftheresident,subjecttoreasonableclinicalandsafetyrestrictionsandtheresident’srighttodenyorwithdrawconsentatanytime;
1
483.10(f)(4)(iv) (iv)Thefacilitymustprovidereasonableaccesstoaresidentbyanyentityorindividualthatprovideshealth,social,legal,orotherservicestotheresident,subjecttotheresident’srighttodenyorwithdrawconsentatanytime;and
1
483.10(f)(4)(v) (v)Thefacilitymusthavewrittenpoliciesandproceduresregardingthevisitationrightsofresidents,includingthosesettingforthanyclinicallynecessaryor
1
24
reasonablerestrictionorlimitationorsafetyrestrictionorlimitation,whensuchlimitationsmayapplyconsistentwiththerequirementsofthissubpart,thatthefacilitymayneedtoplaceonsuchrightsandthereasonsfortheclinicalorsafetyrestrictionorlimitation.
483.10(f)(4)(vi) (vi)Afacilitymustmeetthefollowingrequirements:
1
483.10(f)(4)(vi)(A) (A)Informeachresident(orresidentrepresentative,whereappropriate)ofhisorhervisitationrightsandrelatedfacilitypolicyandprocedures,includinganyclinicalorsafetyrestrictionorlimitationonsuchrights,consistentwiththerequirementsofthissubpart,thereasonsfortherestrictionorlimitation,andtowhomtherestrictionsapply,whenheorsheisinformedofhisorherotherrightsunderthissection.
1
483.10(f)(4)(vi)(B) (B)Informeachresidentoftheright,subjecttohisorherconsent,toreceivethevisitorswhomheorshedesignates,including,butnotlimitedto,aspouse(includingasame-sexspouse),adomesticpartner(includingasame-sexdomesticpartner),anotherfamilymember,orafriend,andhisorherrighttowithdrawordenysuchconsentatanytime.
1
483.10(f)(4)(vi)(C) (C)Notrestrict,limit,orotherwisedenyvisitationprivilegesonthebasisofrace,color,nationalorigin,religion,sex,genderidentity,sexualorientation,ordisability.
1
25
483.10(f)(4)(vi)(D) (D)Ensurethatallvisitorsenjoyfullandequalvisitationprivilegesconsistentwithresidentpreferences.
1
483.10(f)(5)
(5)Theresidenthasarighttoorganizeandparticipateinresidentgroupsinthefacility.
1
483.10(f)(5)(i) (i)Thefacilitymustprovidearesidentorfamilygroup,ifoneexists,withprivatespace;andtakereasonablesteps,withtheapprovalofthegroup,tomakeresidentsandfamilymembersawareofupcomingmeetingsinatimelymanner.
1
483.10(f)(5)(ii) (ii)Staff,visitors,orotherguestsmayattendresidentgrouporfamilygroupmeetingsonlyattherespectivegroup’sinvitation.
1
483.10(f)(5)(iii) (iii)Thefacilitymustprovideadesignatedstaffpersonwhoisapprovedbytheresidentorfamilygroupandthefacilityandwhoisresponsibleforprovidingassistanceandrespondingtowrittenrequeststhatresultfromgroupmeetings.
1
483.10(f)(5)(iv) (iv)Thefacilitymustconsidertheviewsofaresidentorfamilygroupandactpromptlyuponthegrievancesandrecommendationsofsuchgroupsconcerningissuesofresidentcareandlifeinthefacility.
1
483.10(f)(5)(iv)(A) (A)Thefacilitymustbeabletodemonstratetheirresponseandrationaleforsuchresponse.
1
483.10(f)(5)(iv)(B) (B)Thisshouldnotbeconstruedtomeanthatthefacilitymustimplementasrecommendedeveryrequestofthe
1
26
residentorfamilygroup.483.10(f)(6) (6)Theresidenthasarighttoparticipate
infamilygroups.1
483.10(f)(7)
(7)Theresidenthasarighttohavefamilymember(s)orotherresidentrepresentative(s)meetinthefacilitywiththefamiliesorresidentrepresentative(s)ofotherresidentsinthefacility.
1
483.10(f)(8) (8)Theresidenthasarighttoparticipateinotheractivities,includingsocial,religious,andcommunityactivitiesthatdonotinterferewiththerightsofotherresidentsinthefacility.
1
483.10(f)(9) (9)Theresidenthasarighttochoosetoorrefusetoperformservicesforthefacilityandthefacilitymustnotrequirearesidenttoperformservicesforthefacility.Theresidentmayperformservicesforthefacility,ifheorshechooses,when—
1
483.10(f)(9)(i) (i)Thefacilityhasdocumentedtheresident’sneedordesireforworkintheplanofcare;
1
483.10(f)(9)(ii) (ii)Theplanspecifiesthenatureoftheservicesperformedandwhethertheservicesarevoluntaryorpaid;
1
483.10(f)(9)(iii) (iii)Compensationforpaidservicesisatoraboveprevailingrates;and
1
483.10(f)(9)(iv) (iv)Theresidentagreestotheworkarrangementdescribedintheplanofcare.
1
483.10(f)(10) (10)Theresidenthasarighttomanagehisorherfinancialaffairs.Thisincludestherighttoknow,inadvance,whatchargesafacilitymayimposeagainsta
1
27
resident’spersonalfunds.483.10(f)(10)(i) (i)Thefacilitymustnotrequireresidents
todeposittheirpersonalfundswiththefacility.Ifaresidentchoosestodepositpersonalfundswiththefacility,uponwrittenauthorizationofaresident,thefacilitymustactasafiduciaryoftheresident’sfundsandhold,safeguard,manage,andaccountforthepersonalfundsoftheresidentdepositedwiththefacility,asspecifiedinthissection.
1
483.10(f)(10)(ii) (ii)Depositoffunds. 1 483.10(f)(10)(ii)(A) (A)Ingeneral:Exceptassetoutin
paragraph(f)(10)(ii)(B)ofthissection,thefacilitymustdepositanyresidents’personalfundsinexcessof$100inaninterestbearingaccount(oraccounts)thatisseparatefromanyofthefacility’soperatingaccounts,andthatcreditsallinterestearnedonresident’sfundstothataccount.(Inpooledaccounts,theremustbeaseparateaccountingforeachresident’sshare.)Thefacilitymustmaintainaresident’spersonalfundsthatdonotexceed$100inanoninterestbearingaccount,interest-bearingaccount,orpettycashfund.
1
483.10(f)(10)(ii)(B)
(B)ResidentswhosecareisfundedbyMedicaid:Thefacilitymustdeposittheresidents’personalfundsinexcessof$50inaninterestbearingaccount(oraccounts)thatisseparatefromanyofthefacility’soperatingaccounts,andthatcreditsallinterestearnedonresident’sfundstothataccount.(Inpooled
1
28
accounts,theremustbeaseparateaccountingforeachresident’sshare.)Thefacilitymustmaintainpersonalfundsthatdonotexceed$50inanon-interestbearingaccount,interest-bearingaccount,orpettycashfund.
483.10(f)(10)(iii) (iii)Accountingandrecords. 1 483.10(f)(10)(iii)(A)
(A)Thefacilitymustestablishandmaintainasystemthatassuresafullandcompleteandseparateaccounting,accordingtogenerallyacceptedaccountingprinciples,ofeachresident’spersonalfundsentrustedtothefacilityontheresident’sbehalf.
1
483.10(f)(10)(iii)(B)
(B)Thesystemmustprecludeanycomminglingofresidentfundswithfacilityfundsorwiththefundsofanypersonotherthananotherresident.
1
483.10(f)(10)(iii)(C)
(C)Theindividualfinancialrecordmustbeavailabletotheresidentthroughquarterlystatementsanduponrequest.
1
483.10(f)(10)(iv) (iv)Noticeofcertainbalances.ThefacilitymustnotifyeachresidentthatreceivesMedicaidbenefits—
1
483.10(f)(10)(iv)(A)
(A)Whentheamountintheresident’saccountreaches$200lessthantheSSIresourcelimitforoneperson,specifiedinsection1611(a)(3)(B)oftheAct;and
1
483.10(f)(10)(iv)(B)
(B)That,iftheamountintheaccount,inadditiontothevalueoftheresident’sothernonexemptresources,reachestheSSIresourcelimitforoneperson,theresidentmayloseeligibilityforMedicaidorSSI.
1
483.10(f)(10)(v) (v)Conveyanceupondischarge,eviction, 1
29
ordeath.Uponthedischarge,eviction,ordeathofaresidentwithapersonalfunddepositedwiththefacility,thefacilitymustconveywithin30daystheresident’sfunds,andafinalaccountingofthosefunds,totheresident,orinthecaseofdeath,theindividualorprobatejurisdictionadministeringtheresident’sestate,inaccordancewithStatelaw.
483.10(f)(10)(vi) (vi)Assuranceoffinancialsecurity.Thefacilitymustpurchaseasuretybond,orotherwiseprovideassurancesatisfactorytotheSecretary,toassurethesecurityofallpersonalfundsofresidentsdepositedwiththefacility.
1
483.10(f)(11) (11)ThefacilitymustnotimposeachargeagainstthepersonalfundsofaresidentforanyitemorserviceforwhichpaymentismadeunderMedicaidorMedicare(exceptforapplicabledeductibleandcoinsuranceamounts).Thefacilitymaychargetheresidentforrequestedservicesthataremoreexpensivethanorinexcessofcoveredservicesinaccordancewith§489.32ofthischapter.(ThisdoesnotaffecttheprohibitiononfacilitychargesforitemsandservicesforwhichMedicaidhaspaid.See§447.15ofthischapter,whichlimitsparticipationintheMedicaidprogramtoproviderswhoaccept,aspaymentinfull,Medicaidpaymentplusanydeductible,coinsurance,orcopaymentrequiredbytheplantobepaidbytheindividual.)
1
483.10(f)(11)(i) (i)ServicesincludedinMedicareorMedicaidpayment.Duringthecourseof
1
30
acoveredMedicareorMedicaidstay,facilitiesmustnotchargearesidentforthefollowingcategoriesofitemsandservices:
483.10(f)(11)(i)(A) (A)Nursingservicesasrequiredat§483.35.
1
483.10(f)(11)(i)(B) (B)FoodandNutritionservicesasrequiredat§483.60.
1
483.10(f)(11)(i)(C) (C)Anactivitiesprogramasrequiredat§483.24(c).
1
483.10(f)(11)(i)(D) (D)Room/bedmaintenanceservices. 1 483.10(f)(11)(i)(E) (E)Routinepersonalhygieneitemsand
servicesasrequiredtomeettheneedsofresidents,including,butnotlimitedto,hairhygienesupplies,comb,brush,bathsoap,disinfectingsoapsorspecializedcleansingagentswhenindicatedtotreatspecialskinproblemsortofightinfection,razor,shavingcream,toothbrush,toothpaste,dentureadhesive,denturecleaner,dentalfloss,moisturizinglotion,tissues,cottonballs,cottonswabs,deodorant,incontinencecareandsupplies,sanitarynapkinsandrelatedsupplies,towels,washcloths,hospitalgowns,overthecounterdrugs,hairandnailhygieneservices,bathingassistance,andbasicpersonallaundry.
1
483.10(f)(11)(i)(F) (F)Medically-relatedsocialservicesasrequiredat§483.40(d).
1 483.10(f)(11)(i)(F)
(F)Medically-relatedsocialservicesasrequiredat§483.40(c).
483.10(f)(11)(i)(G) (G)HospiceserviceselectedbytheresidentandpaidforundertheMedicareHospiceBenefitorpaidforbyMedicaidunderastateplan.
1
483.10(f)(11)(ii) (ii)Itemsandservicesthatmaybe 1
31
chargedtoresidents’funds.Paragraphs(f)(11)(ii)(A)through(L)ofthissectionaregeneralcategoriesandexamplesofitemsandservicesthatthefacilitymaychargetoresidents’fundsiftheyarerequestedbyaresident,iftheyarenotrequiredtoachievethegoalsstatedintheresident’scareplan,ifthefacilityinformstheresidentthattherewillbeacharge,andifpaymentisnotmadebyMedicareorMedicaid:
483.10(f)(11)(ii)(A) (A)Telephone,includingacellularphone. 1 483.10(f)(11)(ii)(B) (B)Television/radio,personalcomputer
orotherelectronicdeviceforpersonaluse.
1
483.10(f)(11)(ii)(C) (C)Personalcomfortitems,includingsmokingmaterials,notionsandnovelties,andconfections.
1
483.10(f)(11)(ii)(D) (D)CosmeticandgroomingitemsandservicesinexcessofthoseforwhichpaymentismadeunderMedicaidorMedicare.
1
483.10(f)(11)(ii)(E) (E)Personalclothing. 1 483.10(f)(11)(ii)(F) (F)Personalreadingmatter. 1 483.10(f)(11)(ii)(G) (G)Giftspurchasedonbehalfofa
resident.1
483.10(f)(11)(ii)(H) (H)Flowersandplants. 1 483.10(f)(11)(ii)(I) (I)Costtoparticipateinsocialeventsand
entertainmentoutsidethescopeoftheactivitiesprogram,providedunder§483.24(c).
1
483.10(f)(11)(ii)(J) (J)Non-coveredspecialcareservicessuchasprivatelyhirednursesoraides.
1
483.10(f)(11)(ii)(K) (K)Privateroom,exceptwhentherapeuticallyrequired(forexample,
1
32
isolationforinfectioncontrol).483.10(f)(11)(ii)(L) (L)Exceptasprovidedin(e)(11)(ii)(L)(1)
and(2)ofthissection,speciallypreparedoralternativefoodrequestedinsteadofthefoodandmealsgenerallypreparedbythefacility,asrequiredby§483.60.
1
483.10(f)(11)(ii)(L)(1)
(1)Thefacilitymaynotchargeforspecialfoodsandmeals,includingmedicallyprescribeddietarysupplements,orderedbytheresident’sphysician,physicianassistant,nursepractitioner,orclinicalnursespecialist,astheseareincludedinaccordancewith§483.60.
1
483.10(f)(11)(ii)(L)(2)
(2)Inaccordancewith§483.60(c)through(f),whenpreparingfoodsandmeals,afacilitymusttakeintoconsiderationresidents’needsandpreferencesandtheoverallculturalandreligiousmake-upofthefacility’spopulation.
1
483.10(f)(11)(iii) (iii)Requestsforitemsandservices. 1 483.10(f)(11)(iii)(A)
(A)Thefacilitycanonlychargearesidentforanynon-covereditemorserviceifsuchitemorserviceisspecificallyrequestedbytheresident.
1
483.10(f)(11)(iii)(B)
(B)Thefacilitymustnotrequirearesidenttorequestanyitemorserviceasaconditionofadmissionorcontinuedstay.
1
483.10(f)(11)(iii)(C)
(C)Thefacilitymustinform,orallyandinwriting,theresidentrequestinganitemorserviceforwhichachargewillbemadethattherewillbeachargefortheitemorserviceandwhatthechargewillbe.
1
33
483.10(g) (g)Informationandcommunication. 1 483.10(g)(1)
(1)Theresidenthastherighttobeinformedofhisorherrightsandofallrulesandregulationsgoverningresidentconductandresponsibilitiesduringhisorherstayinthefacility.
1
483.10(g)(2) (2)Theresidenthastherighttoaccesspersonalandmedicalrecordspertainingtohimorherself.
1
483.10(g)(2)(i)
(i)Thefacilitymustprovidetheresidentwithaccesstopersonalandmedicalrecordspertainingtohimorherself,uponanoralorwrittenrequest,intheformandformatrequestedbytheindividual,ifitisreadilyproducibleinsuchformandformat(includinginanelectronicformorformatwhensuchrecordsaremaintainedelectronically);or,ifnot,inareadablehardcopyformorsuchotherformandformatasagreedtobythefacilityandtheindividual,within24hours(excludingweekendsandholidays);and
1
483.10(g)(2)(ii) (ii)Thefacilitymustallowtheresidenttoobtainacopyoftherecordsoranyportionsthereof(includinginanelectronicformorformatwhensuchrecordsaremaintainedelectronically)uponrequestand2workingdaysadvancenoticetothefacility.Thefacilitymayimposeareasonable,cost-basedfeeontheprovisionofcopies,providedthatthefeeincludesonlythecostof:
1
483.10(g)(2)(ii)(A) (A)Laborforcopyingtherecordsrequestedbytheindividual,whetherin
1
34
paperorelectronicform;483.10(g)(2)(ii)(B) (B)Suppliesforcreatingthepapercopy
orelectronicmediaiftheindividualrequeststhattheelectroniccopybeprovidedonportablemedia;and
1
483.10(g)(2)(ii)(C) (C)Postage,whentheindividualhasrequestedthecopybemailed.
1
483.10(g)(3) (3)Withtheexceptionofinformationdescribedinparagraphs(g)(2)and(g)(11)ofthissection,thefacilitymustensurethatinformationisprovidedtoeachresidentinaformandmannertheresidentcanaccessandunderstand,includinginanalternativeformatorinalanguagethattheresidentcanunderstand.Summariesthattranslateinformationdescribedinparagraph(g)(2)ofthissectionmaybemadeavailabletothepatientattheirrequestandexpenseinaccordancewithapplicablelaw.
1
483.10(g)(4)
(4)Theresidenthastherighttoreceivenoticesorally(meaningspoken)andinwriting(includingBraille)inaformatandalanguageheorsheunderstands,including;
1
483.10(g)(4)(i) (i)Requirednoticesasspecifiedinthissection.Thefacilitymustfurnishtoeachresidentawrittendescriptionoflegalrightswhichincludes—
1
483.10(g)(4)(i)(A)
(A)Adescriptionofthemannerofprotectingpersonalfunds,underparagraph(f)(10)ofthissection;
1
483.10(g)(4)(i)(B)
(B)AdescriptionoftherequirementsandproceduresforestablishingeligibilityforMedicaid,includingtherighttorequest
1
35
anassessmentofresourcesundersection1924(c)oftheSocialSecurityAct.
483.10(g)(4)(i)(C)
(C)Alistofnames,addresses(mailingandemail),andtelephonenumbersofallpertinentStateregulatoryandinformationalagencies,residentadvocacygroupssuchastheStateSurveyAgency,theStatelicensureoffice,theStateLong-TermCareOmbudsmanprogram,theprotectionandadvocacyagency,adultprotectiveserviceswherestatelawprovidesforjurisdictioninlong-termcarefacilities,thelocalcontactagencyforinformationaboutreturningtothecommunityandtheMedicaidFraudControlUnit;and
1
483.10(g)(4)(i)(D)
(D)AstatementthattheresidentmayfileacomplaintwiththeStateSurveyAgencyconcerninganysuspectedviolationofstateorfederalnursingfacilityregulations,includingbutnotlimitedtoresidentabuse,neglect,exploitation,misappropriationofresidentpropertyinthefacility,noncompliancewiththeadvancedirectivesrequirementsandrequestsforinformationregardingreturningtothecommunity.
1
483.10(g)(4)(ii)
(ii)InformationandcontactinformationforStateandlocaladvocacyorganizations,includingbutnotlimitedtotheStateSurveyAgency,theStateLong-TermCareOmbudsmanprogram(establishedundersection712oftheOlderAmericansActof1965,asamended2016(42U.S.C.3001etseq.)andtheprotectionandadvocacysystem
2
36
(asdesignatedbythestate,andasestablishedundertheDevelopmentalDisabilitiesAssistanceandBillofRightsActof2000(42U.S.C.15001etseq.);
483.10(g)(4)(iii)
(iii)InformationregardingMedicareandMedicaideligibilityandcoverage;
2
483.10(g)(4)(iv) (iv)ContactinformationfortheAgingandDisabilityResourceCenter(establishedunderSection202(a)(20)(B)(iii)oftheOlderAmericansAct);orotherNoWrongDoorProgram
2
483.10(g)(4)(v)
(v)ContactinformationfortheMedicaidFraudControlUnit;and
2
483.10(g)(4)(vi)
(vi)Informationandcontactinformationforfilinggrievancesorcomplaintsconcerninganysuspectedviolationofstateorfederalnursingfacilityregulations,includingbutnotlimitedtoresidentabuse,neglect,exploitation,misappropriationofresidentpropertyinthefacility,noncompliancewiththeadvancedirectivesrequirementsandrequestsforinformationregardingreturningtothecommunity.
1
483.10(g)(5)**TheCMScrosswalkcitesthat483.10(g)(5)(i)-(v)wasrevisedfrom483.10(b)(8).However,webelievethistobeincorrectduetothelackof
(5)Thefacilitymustpost,inaformandmanneraccessibleandunderstandabletoresidents,andresidentrepresentatives:
1
37
similarityinlanguageandthefactthat483.10(g)(5)(iii)-(v)doesnotexistinthepublishedrevisedregulations.Wehaveindicatedbelowthat483.10(b)(8)inthepreviousregulationswasrevisedto483.10(g)(12)intherevisedregulations.483.10(g)(5)(i)*
(i)Alistofnames,addresses(mailingandemail),andtelephonenumbersofallpertinentStateagenciesandadvocacygroups,suchastheStateSurveyAgency,theStatelicensureoffice,adultprotectiveserviceswherestatelawprovidesforjurisdictioninlong-termcarefacilities,theOfficeoftheStateLong-TermCareOmbudsmanprogram,theprotectionandadvocacynetwork,homeandcommunitybasedserviceprograms,andtheMedicaidFraudControlUnit;and
1
483.10(g)(5)(ii)
(ii)AstatementthattheresidentmayfileacomplaintwiththeStateSurveyAgencyconcerninganysuspectedviolationofstateorfederalnursingfacilityregulations,includingbutnotlimitedtoresidentabuse,neglect,exploitation,misappropriationofresidentpropertyin
1
38
thefacility,noncompliancewiththeadvancedirectivesrequirements(42CFRpart489subpartI)andrequestsforinformationregardingreturningtothecommunity.
483.10(g)(6) (6)Theresidenthastherighttohavereasonableaccesstotheuseofatelephone,includingTTYandTDDservices,andaplaceinthefacilitywherecallscanbemadewithoutbeingoverheard.Thisincludestherighttoretainanduseacellularphoneattheresident’sownexpense.
1
483.10(g)(7) (7)Thefacilitymustprotectandfacilitatethatresident’srighttocommunicatewithindividualsandentitieswithinandexternaltothefacility,includingreasonableaccessto:
1
483.10(g)(7)(i) (i)Atelephone,includingTTYandTDDservices;
1
483.10(g)(7)(ii) (ii)Theinternet,totheextentavailabletothefacility;and
1
483.10(g)(7)(iii)
(iii)Stationery,postage,writingimplementsandtheabilitytosendmail.
1
483.10(g)(8) (8)Theresidenthastherighttosendandreceivemail,andtoreceiveletters,packagesandothermaterialsdeliveredtothefacilityfortheresidentthroughameansotherthanapostalservice,includingtherightto:
1
483.10(g)(8)(i) (i)Privacyofsuchcommunicationsconsistentwiththissection;and
1
483.10(g)(8)(ii) (ii)Accesstostationery,postage,andwritingimplementsattheresident’sownexpense.
1
39
483.10(g)(9) (9)TheresidenthastherighttohavereasonableaccesstoandprivacyintheiruseofelectroniccommunicationssuchasemailandvideocommunicationsandforInternetresearch.
1
483.10(g)(9)(i) (i)Iftheaccessisavailabletothefacility 1 483.10(g)(9)(ii) (ii)Attheresident’sexpense,ifany
additionalexpenseisincurredbythefacilitytoprovidesuchaccesstotheresident.
1
483.10(g)(9)(iii) (iii)Suchusemustcomplywithstateandfederallaw.
1
483.10(g)(10) (10)Theresidenthastherightto— 1 483.10(g)(10)(i) (i)Examinetheresultsofthemostrecent
surveyofthefacilityconductedbyFederalorStatesurveyorsandanyplanofcorrectionineffectwithrespecttothefacility;and
1
483.10(g)(10)(ii) (ii)Receiveinformationfromagenciesactingasclientadvocates,andbeaffordedtheopportunitytocontacttheseagencies.
1
483.10(g)(11) (11)Thefacilitymust— 1 483.10(g)(11)(i)
(i)Postinaplacereadilyaccessibletoresidents,andfamilymembersandlegalrepresentativesofresidents,theresultsofthemostrecentsurveyofthefacility.
1
483.10(g)(11)(ii) (ii)Havereportswithrespecttoanysurveys,certifications,andcomplaintinvestigationsmaderespectingthefacilityduringthe3precedingyears,andanyplanofcorrectionineffectwithrespecttothefacility,availableforanyindividualtoreviewuponrequest;and
1
483.10(g)(11)(iii) (iii)Postnoticeoftheavailabilityofsuch 1
40
reportsinareasofthefacilitythatareprominentandaccessibletothepublic.
483.10(g)(11)(iv) (iv)Thefacilityshallnotmakeavailableidentifyinginformationaboutcomplainantsorresidents.
1
483.10(g)(12)**TheCMScrosswalkcitesthat483.10(b)(8)wasrevisedto483.10(g)(5)(i)-(v),when483.10(g)(5)(iii)-(v)donotexistinthepublishedrevisedregulations.
(12)Thefacilitymustcomplywiththerequirementsspecifiedin42CFRpart489,subpartI(AdvanceDirectives).
1
483.10(g)(12)(i) (i)Theserequirementsincludeprovisionstoinformandprovidewritteninformationtoalladultresidentsconcerningtherighttoacceptorrefusemedicalorsurgicaltreatmentand,attheresident’soption,formulateanadvancedirective.
1
483.10(g)(12)(ii) (ii)Thisincludesawrittendescriptionofthefacility’spoliciestoimplementadvancedirectivesandapplicableStatelaw.
1
483.10(g)(12)(iii) (iii)Facilitiesarepermittedtocontractwithotherentitiestofurnishthisinformationbutarestilllegallyresponsibleforensuringthattherequirementsofthissectionaremet.
1
483.10(g)(12)(iv) (iv)Ifanadultindividualisincapacitatedatthetimeofadmissionandisunableto
1
41
receiveinformationorarticulatewhetherornotheorshehasexecutedanadvancedirective,thefacilitymaygiveadvancedirectiveinformationtotheindividual’sresidentrepresentativeinaccordancewithStatelaw.
483.10(g)(12)(v) (v)Thefacilityisnotrelievedofitsobligationtoprovidethisinformationtotheindividualonceheorsheisabletoreceivesuchinformation.Follow-upproceduresmustbeinplacetoprovidetheinformationtotheindividualdirectlyattheappropriatetime.
1
483.10(g)(13) (13)Thefacilitymustdisplayinthefacilitywritteninformation,andprovidetoresidentsandapplicantsforadmission,oralandwritteninformationabouthowtoapplyforanduseMedicareandMedicaidbenefits,andhowtoreceiverefundsforpreviouspaymentscoveredbysuchbenefits.
1
483.10(g)(14) (14)Notificationofchanges. 1 483.10(g)(14)(i) (i)Afacilitymustimmediatelyinformthe
resident;consultwiththeresident’sphysician;andnotify,consistentwithhisorherauthority,theresidentrepresentative(s),whenthereis—
1
483.10(g)(14)(i)(A) (A)Anaccidentinvolvingtheresidentwhichresultsininjuryandhasthepotentialforrequiringphysicianintervention;
1
483.10(g)(14)(i)(B) (B)Asignificantchangeintheresident’sphysical,mental,orpsychosocialstatus(thatis,adeteriorationinhealth,mental,orpsychosocialstatusineitherlife-
1
42
threateningconditionsorclinicalcomplications);
483.10(g)(14)(i)(C) (C)Aneedtoaltertreatmentsignificantly(thatis,aneedtodiscontinueorchangeanexistingformoftreatmentduetoadverseconsequences,ortocommenceanewformoftreatment);or
1
483.10(g)(14)(i)(D) (D)Adecisiontotransferordischargetheresidentfromthefacilityasspecifiedin§483.15(c)(1)(ii).
1
483.10(g)(14)(ii) (ii)Whenmakingnotificationunderparagraph(g)(14)(i)ofthissection,thefacilitymustensurethatallpertinentinformationspecifiedin§483.15(c)(2)isavailableandprovideduponrequesttothephysician.
1
483.10(g)(14)(iii) (iii)Thefacilitymustalsopromptlynotifytheresidentandtheresidentrepresentative,ifany,whenthereis—
1
483.10(g)(14)(iii)(A)
(A)Achangeinroomorroommateassignmentasspecifiedin§483.10(e)(6);or
1
483.10(g)(14)(iii)(B)
(B)AchangeinresidentrightsunderFederalorStatelaworregulationsasspecifiedinparagraph(e)(10)ofthissection.
1
483.10(g)(14)(iv) (iv)Thefacilitymustrecordandperiodicallyupdatetheaddress(mailingandemail)andphonenumberoftheresidentrepresentative(s).
1
483.10(g)(15) (15)Admissiontoacompositedistinctpart.Afacilitythatisacompositedistinctpart(asdefinedin§483.5mustdiscloseinitsadmissionagreementitsphysicalconfiguration,includingthevarious
1
43
locationsthatcomprisethecompositedistinctpart,andmustspecifythepoliciesthatapplytoroomchangesbetweenitsdifferentlocationsunder§483.15(c)(9).
483.10(g)(16) (16)Thefacilitymustprovideanoticeofrightsandservicestotheresidentpriortooruponadmissionandduringtheresident’sstay.
1
483.10(g)(16)(i) (i)Thefacilitymustinformtheresidentbothorallyandinwritinginalanguagethattheresidentunderstandsofhisorherrightsandallrulesandregulationsgoverningresidentconductandresponsibilitiesduringthestayinthefacility.
1
483.10(g)(16)(ii) (ii)ThefacilitymustalsoprovidetheresidentwiththeState-developednoticeofMedicaidrightsandobligations,ifany.
1
483.10(g)(16)(iii) (iii)Receiptofsuchinformation,andanyamendmentstoit,mustbeacknowledgedinwriting;
1
483.10(g)(17) (17)Thefacilitymust— 1 483.10(g)(17)(i) (i)InformeachMedicaid-eligible
resident,inwriting,atthetimeofadmissiontothenursingfacilityandwhentheresidentbecomeseligibleforMedicaidof—
1
483.10(g)(17)(i)(A) (A)TheitemsandservicesthatareincludedinnursingfacilityservicesundertheStateplanandforwhichtheresidentmaynotbecharged;
1
483.10(g)(17)(i)(B) (B)Thoseotheritemsandservicesthatthefacilityoffersandforwhichtheresidentmaybecharged,andthe
1
44
amountofchargesforthoseservices;and
483.10(g)(17)(ii) (ii)InformeachMedicaid-eligibleresidentwhenchangesaremadetotheitemsandservicesspecifiedin§483.10(g)(17)(i)(A)and(B)ofthissection.
1
483.10(g)(18) (18)Thefacilitymustinformeachresidentbefore,oratthetimeofadmission,andperiodicallyduringtheresident’sstay,ofservicesavailableinthefacilityandofchargesforthoseservices,includinganychargesforservicesnotcoveredunderMedicare/Medicaidorbythefacility’sperdiemrate.
1
483.10(g)(18)(i) (i)WherechangesincoveragearemadetoitemsandservicescoveredbyMedicareand/orbytheMedicaidStateplan,thefacilitymustprovidenoticetoresidentsofthechangeassoonasisreasonablypossible.
1
483.10(g)(18)(ii) (ii)Wherechangesaremadetochargesforotheritemsandservicesthatthefacilityoffers,thefacilitymustinformtheresidentinwritingatleast60dayspriortoimplementationofthechange.
1
483.10(g)(18)(iii)
(iii)Ifaresidentdiesorishospitalizedoristransferredanddoesnotreturntothefacility,thefacilitymustrefundtotheresident,residentrepresentative,orestate,asapplicable,anydepositorchargesalreadypaid,lessthefacility’sperdiemrate,forthedaystheresidentactuallyresidedorreservedorretainedabedinthefacility,regardlessofany
1
45
minimumstayordischargenoticerequirements.
483.10(g)(18)(iv)
(iv)Thefacilitymustrefundtotheresidentorresidentrepresentativeanyandallrefundsduetheresidentwithin30daysfromtheresident’sdateofdischargefromthefacility.
1
483.10(g)(18)(v) (v)Thetermsofanadmissioncontractbyoronbehalfofanindividualseekingadmissiontothefacilitymustnotconflictwiththerequirementsoftheseregulations.
1
483.10(h) (h)Privacyandconfidentiality.Theresidenthasarighttopersonalprivacyandconfidentialityofhisorherpersonalandmedicalrecords.
1
483.10(h)(1) (1)Personalprivacyincludesaccommodations,medicaltreatment,writtenandtelephonecommunications,personalcare,visits,andmeetingsoffamilyandresidentgroups,butthisdoesnotrequirethefacilitytoprovideaprivateroomforeachresident.
1
483.10(h)(2) (2)Thefacilitymustrespecttheresidentsrighttopersonalprivacy,includingtherighttoprivacyinhisorheroral(thatis,spoken),written,andelectroniccommunications,includingtherighttosendandpromptlyreceiveunopenedmailandotherletters,packagesandothermaterialsdeliveredtothefacilityfortheresident,includingthosedeliveredthroughameansotherthanapostalservice.
1
483.10(h)(3) (3)Theresidenthasarighttosecureand 1
46
confidentialpersonalandmedicalrecords.
483.10(h)(3)(i) (i)Theresidenthastherighttorefusethereleaseofpersonalandmedicalrecordsexceptasprovidedat§483.70(i)(2)orotherapplicablefederalorstatelaws.
1
483.10(h)(3)(ii) (ii)ThefacilitymustallowrepresentativesoftheOfficeoftheStateLong-TermCareOmbudsmantoexaminearesident’smedical,social,andadministrativerecordsinaccordancewithStatelaw.
1
483.10(i) (i)Safeenvironment.Theresidenthasarighttoasafe,clean,comfortableandhomelikeenvironment,includingbutnotlimitedtoreceivingtreatmentandsupportsfordailylivingsafely.Thefacilitymustprovide—
1
483.10(i)(1) (1)Asafe,clean,comfortable,andhomelikeenvironment,allowingtheresidenttousehisorherpersonalbelongingstotheextentpossible.
1
483.10(i)(1)(i) (i)Thisincludesensuringthattheresidentcanreceivecareandservicessafelyandthatthephysicallayoutofthefacilitymaximizesresidentindependenceanddoesnotposeasafetyrisk.
1
483.10(i)(1)(ii) (ii)Thefacilityshallexercisereasonablecarefortheprotectionoftheresident’spropertyfromlossortheft.
1
483.10(i)(2) (2)Housekeepingandmaintenanceservicesnecessarytomaintainasanitary,orderly,andcomfortableinterior;
1
483.10(i)(3) (3)Cleanbedandbathlinensthatareingoodcondition;
1
483.10(i)(4) (4)Privateclosetspaceineachresident 1
47
room,asspecifiedin§483.90(d)(2)(iv);483.10(i)(5) (5)Adequateandcomfortablelighting
levelsinallareas;1
483.10(i)(6) (6)Comfortableandsafetemperaturelevels.FacilitiesinitiallycertifiedafterOctober1,1990mustmaintainatemperaturerangeof71to81°F;and
1
483.10(i)(7) (7)Forthemaintenanceofcomfortablesoundlevels.
1
483.10(j) (j)Grievances. 1 483.10(j)(1) (1)Theresidenthastherighttovoice
grievancestothefacilityorotheragencyorentitythathearsgrievanceswithoutdiscriminationorreprisalandwithoutfearofdiscriminationorreprisal.Suchgrievancesincludethosewithrespecttocareandtreatmentwhichhasbeenfurnishedaswellasthatwhichhasnotbeenfurnished,thebehaviorofstaffandofotherresidents;andotherconcernsregardingtheirLTCfacilitystay.
1 483.10(j)(1) (1)Theresidenthastherighttovoicegrievancestothefacilityorotheragencyorentitythathearsgrievanceswithoutdiscriminationorreprisalandwithoutfearofdiscriminationorreprisal.Suchgrievancesincludethosewithrespecttocareandtreatmentwhichhasbeenfurnishedaswellasthatwhichhasnotbeenfurnished,thebehaviorofstaffandofotherresidents;andotherconcernsregardingtheirLTCfacilitystaythatdifferfromgeneralfeedbackfromresidentsortheirresidentrepresentative.
483.10(j)(2) (2)Theresidenthastherighttoandthefacilitymustmakeprompteffortsbythefacilitytoresolvegrievancestheresidentmayhave,inaccordancewiththisparagraph.
1 483.10(j)(2) (2)Theresidenthastherighttoandthefacilitymustmakeprompteffortstoresolvegrievancestheresidentmayhave,inaccordancewiththisparagraph(j).
483.10(j)(3) (3)Thefacilitymustmakeinformationonhowtofileagrievanceorcomplaintavailabletotheresident.
1
483.10(j)(4) (4)Thefacilitymustestablishagrievancepolicytoensurethepromptresolutionofallgrievancesregardingtheresidents’rightscontainedinthisparagraph.Uponrequest,theprovidermustgiveacopyofthegrievancepolicytotheresident.The
1
48
grievancepolicymustinclude:483.10(j)(4)(i) (i)Notifyingresidentindividuallyor
throughpostingsinprominentlocationsthroughoutthefacilityoftherighttofilegrievancesorally(meaningspoken)orinwriting;therighttofilegrievancesanonymously;thecontactinformationofthegrievanceofficialwithwhomagrievancecanbefiled,thatis,hisorhername,businessaddress(mailingandemail)andbusinessphonenumber;areasonableexpectedtimeframeforcompletingthereviewofthegrievance;therighttoobtainawrittendecisionregardinghisorhergrievance;andthecontactinformationofindependententitieswithwhomgrievancesmaybefiled,thatis,thepertinentStateagency,QualityImprovementOrganization,StateSurveyAgencyandStateLong-TermCareOmbudsmanprogramorprotectionandadvocacysystem;
1 483.10(j)(4)(i) (i)Notifyingresidentindividuallyorthroughpostingsinprominentlocationsthroughoutthefacilityoftherighttofilegrievancesorally(meaningspoken)orinwriting;therighttofilegrievancesanonymously;areasonableexpectedtimeframeforcompletingthereviewofthegrievance;therighttoobtainawrittendecisionregardinghisorhergrievance;andthecontactinformationofindependententitieswithwhomgrievancesmaybefiled,thatis,thepertinentStateAgency,QualityImprovementOrganization,StateSurveyAgencyandStateLong-TermCareOmbudsmanprogramorprotectionandadvocacysystem;
483.10(j)(4)(ii) (ii)IdentifyingaGrievanceOfficialwhoisresponsibleforoverseeingthegrievanceprocess,receivingandtrackinggrievancesthroughtotheirconclusion;leadinganynecessaryinvestigationsbythefacility;maintainingtheconfidentialityofallinformationassociatedwithgrievances,forexample,theidentityoftheresidentforthosegrievancessubmittedanonymously;issuingwrittengrievancedecisionstotheresident;andcoordinatingwithstateandfederalagenciesasnecessaryinlightofspecificallegations;
1 483.10(4)(ii) (ii)Identifyinganindividualwhoisresponsibleforoverseeingthegrievanceprocess.
49
483.10(j)(4)(iii) (iii)Asnecessary,takingimmediateactiontopreventfurtherpotentialviolationsofanyresidentrightwhiletheallegedviolationisbeinginvestigated;
1
483.10(j)(4)(iv) (iv)Consistentwith§483.12(c)(1),immediatelyreportingallallegedviolationsinvolvingneglect,abuse,includinginjuriesofunknownsource,and/ormisappropriationofresidentproperty,byanyonefurnishingservicesonbehalfoftheprovider,totheadministratoroftheprovider;andasrequiredbyStatelaw;
1
483.10(j)(4)(v) (v)Ensuringthatallwrittengrievancedecisionsincludethedatethegrievancewasreceived,asummarystatementoftheresident’sgrievance,thestepstakentoinvestigatethegrievance,asummaryofthepertinentfindingsorconclusionsregardingtheresident’sconcern(s),astatementastowhetherthegrievancewasconfirmedornotconfirmed,anycorrectiveactiontakenortobetakenbythefacilityasaresultofthegrievance,andthedatethewrittendecisionwasissued;
1 483.10(j)(4)(v) (v)Ensuringthatallwrittengrievancedecisionsincludeanypertinentinformationincludingbutnotlimitedtoasummaryofthefindingsorconclusionsandanycorrectiveactiontakenortobetakenbythefacilityasaresultofthegrievance;
483.10(j)(4)(vi) (vi)TakingappropriatecorrectiveactioninaccordancewithStatelawiftheallegedviolationoftheresidents’rightsisconfirmedbythefacilityorifanoutsideentityhavingjurisdiction,suchastheStateSurveyAgency,QualityImprovementOrganization,orlocallawenforcementagencyconfirmsaviolationofanyoftheseresidents’rightswithinitsareaofresponsibility;and
1
50
483.10(j)(4)(vii) (vii)Maintainingevidencedemonstratingtheresultsofallgrievancesforaperiodofnolessthan3yearsfromtheissuanceofthegrievancedecision.
1 483.10(j)(4)(vii) (vii)Maintainingevidencedemonstratingtheresultsofallgrievancesforaperiodofnolessthan18monthsfromtheissuanceofthegrievancedecision.
483.10(k) (k)Contactwithexternalentities.Afacilitymustnotprohibitorinanywaydiscouragearesidentfromcommunicatingwithfederal,state,orlocalofficials,including,butnotlimitedto,federalandstatesurveyors,otherfederalorstatehealthdepartmentemployees,includingrepresentativesoftheOfficeoftheStateLong-TermCareOmbudsman,andanyrepresentativeoftheagencyresponsiblefortheprotectionandadvocacysystemforindividualswithmentaldisorder(establishedundertheProtectionandAdvocacyforMentallyIllIndividualsActof2000(42U.S.C.10801etseq.),regardinganymatter,whetherornotsubjecttoarbitrationoranyothertypeofjudicialorregulatoryaction.
1
§483.12 Freedomfromabuse,neglect,andexploitation.
ThissectionwasimplementedinPhase1withthe
followingexceptions:
§483.12(b)(4),whichwillbe
implementedinPhase3,and§483.12(b)(5),whichwas
implementedinPhase2.
483.12 Theresidenthastherighttobefreefrom 1
51
abuse,neglect,misappropriationofresidentproperty,andexploitationasdefinedinthissubpart.Thisincludesbutisnotlimitedtofreedomfromcorporalpunishment,involuntaryseclusionandanyphysicalorchemicalrestraintnotrequiredtotreattheresident’smedicalsymptoms.
483.12(a) (a)Thefacilitymust— 1 483.12(a)(1) (1)Notuseverbal,mental,sexual,or
physicalabuse,corporalpunishment,orinvoluntaryseclusion;
1
483.12(a)(2)
(2)Ensurethattheresidentisfreefromphysicalorchemicalrestraintsimposedforpurposesofdisciplineorconvenienceandthatarenotrequiredtotreattheresident’smedicalsymptoms.Whentheuseofrestraintsisindicated,thefacilitymustusetheleastrestrictivealternativefortheleastamountoftimeanddocumentongoingre-evaluationoftheneedforrestraints.
1
483.12(a)(3) (3)Notemployorotherwiseengageindividualswho—
1
483.12(a)(3)(i) (i)Havebeenfoundguiltyofabuse,neglect,exploitation,misappropriationofproperty,ormistreatmentbyacourtoflaw;
1
483.12(a)(3)(ii) (ii)HavehadafindingenteredintotheStatenurseaideregistryconcerningabuse,neglect,exploitation,mistreatmentofresidentsormisappropriationoftheirproperty;or
1
483.12(a)(3)(iii) (iii)Haveadisciplinaryactionineffectagainsthisorherprofessionallicenseby
1
52
astatelicensurebodyasaresultofafindingofabuse,neglect,exploitation,mistreatmentofresidentsormisappropriationofresidentproperty.
483.12(a)(4) (4)ReporttotheStatenurseaideregistryorlicensingauthoritiesanyknowledgeithasofactionsbyacourtoflawagainstanemployee,whichwouldindicateunfitnessforserviceasanurseaideorotherfacilitystaff.
1
483.12(b) (b)Thefacilitymustdevelopandimplementwrittenpoliciesandproceduresthat:
1
483.12(b)(1) (1)Prohibitandpreventabuse,neglect,andexploitationofresidentsandmisappropriationofresidentproperty,
1
483.12(b)(2) (2)Establishpoliciesandprocedurestoinvestigateanysuchallegations,and
1
483.12(b)(3) (3)Includetrainingasrequiredatparagraph§483.95.
1
483.12(b)(4) (4)EstablishcoordinationwiththeQAPIprogramrequiredunder§483.75.
3
483.12(b)(5) (5)Ensurereportingofcrimesoccurringinfederally-fundedlong-termcarefacilitiesinaccordancewithsection1150BoftheAct.Thepoliciesandproceduresmustincludebutarenotlimitedtothefollowingelements.
2
483.12(b)(5)(i) (i)Annuallynotifyingcoveredindividuals,asdefinedatsection1150B(a)(3)oftheAct,ofthatindividual’sobligationtocomplywiththefollowingreportingrequirements.
2
483.12(b)(5)(i)(A) (A)EachcoveredindividualshallreporttotheStateAgencyandoneormorelaw
2
53
enforcemententitiesforthepoliticalsubdivisioninwhichthefacilityislocatedanyreasonablesuspicionofacrimeagainstanyindividualwhoisaresidentof,orisreceivingcarefrom,thefacility.
483.12(b)(5)(i)(B) (B)Eachcoveredindividualshallreportimmediately,butnotlaterthan2hoursafterformingthesuspicion,iftheeventsthatcausethesuspicionresultinseriousbodilyinjury,ornotlaterthan24hoursiftheeventsthatcausethesuspiciondonotresultinseriousbodilyinjury.
2
483.12(b)(5)(ii) (ii)Postingaconspicuousnoticeofemployeerights,asdefinedatsection1150B(d)(3)oftheAct.
2
483.12(b)(5)(iii) (iii)Prohibitingandpreventingretaliation,asdefinedatsection1150B(d)(1)and(2)oftheAct.
2
483.12(c) (c)Inresponsetoallegationsofabuse,neglect,exploitation,ormistreatment,thefacilitymust:
1
483.12(c)(1) (1)Ensurethatallallegedviolationsinvolvingabuse,neglect,exploitationormistreatment,includinginjuriesofunknownsourceandmisappropriationofresidentproperty,arereportedimmediately,butnotlaterthan2hoursaftertheallegationismade,iftheeventsthatcausetheallegationinvolveabuseorresultinseriousbodilyinjury,ornotlaterthan24hoursiftheeventsthatcausetheallegationdonotinvolveabuseanddonotresultinseriousbodilyinjury,totheadministratorofthefacilityandtootherofficials(includingtotheStateSurvey
1
54
Agencyandadultprotectiveserviceswherestatelawprovidesforjurisdictioninlong-termcarefacilities)inaccordancewithStatelawthroughestablishedprocedures.
483.12(c)(2) (2)Haveevidencethatallallegedviolationsarethoroughlyinvestigated.
1
483.12(c)(3) (3)Preventfurtherpotentialabuse,neglect,exploitation,ormistreatmentwhiletheinvestigationisinprogress.
1
483.12(c)(4) (4)ReporttheresultsofallinvestigationstotheadministratororhisorherdesignatedrepresentativeandtootherofficialsinaccordancewithStatelaw,includingtotheStateSurveyAgency,within5workingdaysoftheincident,andiftheallegedviolationisverifiedappropriatecorrectiveactionmustbetaken.
1
§483.15 Admission,transfer,anddischargerights.
ThissectionwasimplementedinPhase1withthe
followingexception:
§483.15(c)(2),whichwas
implementedinPhase2.
483.15(a) (a)Admissionspolicy.(1)Thefacilitymustestablishandimplementanadmissionspolicy.
1
483.15(a)(2) (2)Thefacilitymust— 1 483.15(a)(2)(i) (i)Notrequestorrequireresidentsor
potentialresidentstowaivetheirrightsassetforthinthissubpartandin
1
55
applicablestate,federalorlocallicensingorcertificationlaws,includingbutnotlimitedtotheirrightstoMedicareorMedicaid;and
483.15(a)(2)(ii) (ii)Notrequestorrequireoralorwrittenassurancethatresidentsorpotentialresidentsarenoteligiblefor,orwillnotapplyfor,MedicareorMedicaidbenefits.
1
483.15(a)(2)(iii) (iii)Notrequestorrequireresidentsorpotentialresidentstowaivepotentialfacilityliabilityforlossesofpersonalproperty
1
483.15(a)(3) (3)Thefacilitymustnotrequestorrequireathirdpartyguaranteeofpaymenttothefacilityasaconditionofadmissionorexpeditedadmission,orcontinuedstayinthefacility.However,thefacilitymayrequestandrequirearesidentrepresentativewhohaslegalaccesstoaresident’sincomeorresourcesavailabletopayforfacilitycaretosignacontract,withoutincurringpersonalfinancialliability,toprovidefacilitypaymentfromtheresident’sincomeorresources.
1
483.15(a)(4) (4)InthecaseofapersoneligibleforMedicaid,anursingfacilitymustnotcharge,solicit,accept,orreceive,inadditiontoanyamountotherwiserequiredtobepaidundertheStateplan,anygift,money,donation,orotherconsiderationasapreconditionofadmission,expeditedadmissionorcontinuedstayinthefacility.However,—
1
483.15(a)(4)(i) (i)Anursingfacilitymaychargea 1
56
residentwhoiseligibleforMedicaidforitemsandservicestheresidenthasrequestedandreceived,andthatarenotspecifiedintheStateplanasincludedintheterm‘‘nursingfacilityservices’’solongasthefacilitygivespropernoticeoftheavailabilityandcostoftheseservicestoresidentsanddoesnotconditiontheresident’sadmissionorcontinuedstayontherequestforandreceiptofsuchadditionalservices;and
483.15(a)(4)(ii) (ii)Anursingfacilitymaysolicit,accept,orreceiveacharitable,religious,orphilanthropiccontributionfromanorganizationorfromapersonunrelatedtoaMedicaideligibleresidentorpotentialresident,butonlytotheextentthatthecontributionisnotaconditionofadmission,expeditedadmission,orcontinuedstayinthefacilityforaMedicaideligibleresident.
1
483.15(a)(5) (5)StatesorpoliticalsubdivisionsmayapplystricteradmissionsstandardsunderStateorlocallawsthanarespecifiedinthissection,toprohibitdiscriminationagainstindividualsentitledtoMedicaid.
1
483.15(a)(6) (6)Anursingfacilitymustdiscloseandprovidetoaresidentorpotentialresidentpriortotimeofadmission,noticeofspecialcharacteristicsorservicelimitationsofthefacility.
1
483.15(a)(7)
(7)Anursingfacilitythatisacompositedistinctpartasdefinedin§483.5mustdiscloseinitsadmissionagreementitsphysicalconfiguration,includingthe
1
57
variouslocationsthatcomprisethecompositedistinctpart,andmustspecifythepoliciesthatapplytoroomchangesbetweenitsdifferentlocationsunderparagraph(b)(10)ofthissection.
483.15(b) (b)Equalaccesstoqualitycare. 1 483.15(b)(1)
(1)Afacilitymustestablish,maintainandimplementidenticalpoliciesandpracticesregardingtransferanddischarge,asdefinedin§483.5andtheprovisionofservicesforallindividualsregardlessofsourceofpayment,consistentwith§483.10(a)(2);
1
483.15(b)(2)
(2)Thefacilitymaychargeanyamountforservicesfurnishedtonon-Medicaidresidentsunlessotherwiselimitedbystatelawandconsistentwiththenoticerequirementin§483.10(g)(3)and(g)(4)(i)describingthecharges;and
1
483.15(b)(3) (3)TheStateisnotrequiredtoofferadditionalservicesonbehalfofaresidentotherthanservicesprovidedintheStateplan.
1
483.15(c) (c)Transferanddischarge— 1 483.15(c)(1) (1)Facilityrequirements— 1 483.15(c)(1)(i) (i)Thefacilitymustpermiteachresident
toremaininthefacility,andnottransferordischargetheresidentfromthefacilityunless—
1
483.15(c)(1)(i)(A) (A)Thetransferordischargeisnecessaryfortheresident’swelfareandtheresident’sneedscannotbemetinthefacility;
1
483.15(c)(1)(i)(B) (B)Thetransferordischargeisappropriatebecausetheresident’s
1
58
healthhasimprovedsufficientlysotheresidentnolongerneedstheservicesprovidedbythefacility;
483.15(c)(1)(i)(C) (C)Thesafetyofindividualsinthefacilityisendangeredduetotheclinicalorbehavioralstatusoftheresident;
1
483.15(c)(1)(i)(D) (D)Thehealthofindividualsinthefacilitywouldotherwisebeendangered;
1
483.15(c)(1)(i)(E) (E)Theresidenthasfailed,afterreasonableandappropriatenotice,topayfor(ortohavepaidunderMedicareorMedicaid)astayatthefacility.Nonpaymentappliesiftheresidentdoesnotsubmitthenecessarypaperworkforthirdpartypaymentorafterthethirdparty,includingMedicareorMedicaid,deniestheclaimandtheresidentrefusestopayforhisorherstay.ForaresidentwhobecomeseligibleforMedicaidafteradmissiontoafacility,thefacilitymaychargearesidentonlyallowablechargesunderMedicaid;or
1
483.15(c)(1)(i)(F) (F)Thefacilityceasestooperate. 1 483.15(c)(1)(ii) (ii)Thefacilitymaynottransferor
dischargetheresidentwhiletheappealispending,pursuantto§431.230ofthischapter,whenaresidentexerciseshisorherrighttoappealatransferordischargenoticefromthefacilitypursuantto§431.220(a)(3)ofthischapter,unlessthefailuretodischargeortransferwouldendangerthehealthorsafetyoftheresidentorotherindividualsinthefacility.Thefacilitymustdocumentthedangerthatfailuretotransferor
1 483.15(c)(1)(ii) (ii)Thefacilitymaynottransferordischargetheresidentwhiletheappealispending,pursuantto§431.230ofthischapter,whenaresidentexerciseshisorherrighttoappealatransferordischargenoticefromthefacilitypursuantto§431.220(a)(2)ofthischapter,unlessthefailuretodischargeortransferwouldendangerthehealthorsafetyoftheresidentorotherindividualsinthefacility.Thefacilitymustdocumentthedangerthatfailuretotransferordischargewouldpose.
59
dischargewouldpose.483.15(c)(2) (2)Documentation.Whenthefacility
transfersordischargesaresidentunderanyofthecircumstancesspecifiedinparagraphs(c)(1)(i)(A)through(F)ofthissection,thefacilitymustensurethatthetransferordischargeisdocumentedintheresident’smedicalrecordandappropriateinformationiscommunicatedtothereceivinghealthcareinstitutionorprovider.
2
483.15(c)(2)(i) (i)Documentationintheresident’smedicalrecordmustinclude:
2
483.15(c)(2)(i)(A) (A)Thebasisforthetransferperparagraph(c)(1)(i)ofthissection.
2
483.15(c)(2)(i)(B) (B)Inthecaseofparagraph(c)(1)(i)(A)ofthissection,thespecificresidentneed(s)thatcannotbemet,facilityattemptstomeettheresidentneeds,andtheserviceavailableatthereceivingfacilitytomeettheneed(s).
2
483.15(c)(2)(ii) (ii)Thedocumentationrequiredbyparagraph(c)(2)(i)ofthissectionmustbemadeby—
1**PerCMSSurveyandCertificationMemo,S&C17-07-NH,p.65,
11/9/16
483.15(c)(2)(ii)(A) (A)Theresident’sphysicianwhentransferordischargeisnecessaryunderparagraph(c)(1)(A)or(B)ofthissection;and
1**PerCMSSurveyandCertificationMemo,S&C17-07-NH,p.65,
11/9/16
483.15(c)(2)(ii)(B) (B)Aphysicianwhentransferordischargeisnecessaryunderparagraph
1**PerCMSSurvey
60
(b)(1)(i)(C)or(D)ofthissection. andCertificationMemo,S&C17-07-NH,p.65,
11/9/16483.15(c)(2)(iii) (iii)Informationprovidedtothereceiving
providermustincludeaminimumofthefollowing:
2
483.15(c)(2)(iii)(A) (A)Contactinformationofthepractitionerresponsibleforthecareoftheresident
2
483.15(c)(2)(iii)(B) (B)Residentrepresentativeinformationincludingcontactinformation.
2
483.15(c)(2)(iii)(C) (C)AdvanceDirectiveinformation. 2 483.15(c)(2)(iii)(D) (D)Allspecialinstructionsorprecautions
forongoingcare,asappropriate.2
483.15(c)(2)(iii)(E) (E)Comprehensivecareplangoals, 2 483.15(c)(2)(iii)(F) (F)Allothernecessaryinformation,
includingacopyoftheresidentsdischargesummary,consistentwith§483.21(c)(2),asapplicable,andanyotherdocumentation,asapplicable,toensureasafeandeffectivetransitionofcare.
2
483.15(c)(3) (3)Noticebeforetransfer.Beforeafacilitytransfersordischargesaresident,thefacilitymust—
1
483.15(c)(3)(i) (i)Notifytheresidentandtheresident’srepresentative(s)ofthetransferordischargeandthereasonsforthemoveinwritingandinalanguageandmannertheyunderstand.ThefacilitymustsendacopyofthenoticetoarepresentativeoftheOfficeoftheStateLong-TermCareOmbudsman.
1 483.15(c)(3)(i) (i)Notifytheresidentandtheresident’srepresentative(s)ofthetransferordischargeandthereasonsforthemoveinwritingandinalanguageandmannertheyunderstand.Forfacility-initiatedinvoluntarytransfersordischarges,otherthanemergencytransferstoanacutecarefacilitywhenreturnisexpected,thefacilitymustsendacopyofthenoticetoarepresentativeoftheOfficeoftheStateLong-TermCareOmbudsman.
483.15(c)(3)(ii) (ii)Recordthereasonsforthetransferor 1
61
dischargeintheresident’smedicalrecordinaccordancewithparagraph(c)(2)ofthissection;and
483.15(c)(3)(iii) (iii)Includeinthenoticetheitemsdescribedinparagraph(b)(5)ofthissection.
1
483.15(c)(4) (4)Timingofthenotice. 1 483.15(c)(4)(i) (i)Exceptasspecifiedinparagraphs
(b)(4)(ii)and(b)(8)ofthissection,thenoticeoftransferordischargerequiredunderthissectionmustbemadebythefacilityatleast30daysbeforetheresidentistransferredordischarged.
1
483.15(c)(4)(ii) (ii)Noticemustbemadeassoonaspracticablebeforetransferordischargewhen—
1
483.15(c)(4)(ii)(A) (A)Thesafetyofindividualsinthefacilitywouldbeendangeredunderparagraph(b)(1)(ii)(C)ofthissection;
1
483.15(c)(4)(ii)(B) (B)Thehealthofindividualsinthefacilitywouldbeendangered,underparagraph(b)(1)(ii)(D)ofthissection;
1
483.15(c)(4)(ii)(C) (C)Theresident’shealthimprovessufficientlytoallowamoreimmediatetransferordischarge,underparagraph(b)(1)(ii)(B)ofthissection;
1
483.15(c)(4)(ii)(D) (D)Animmediatetransferordischargeisrequiredbytheresident’surgentmedicalneeds,underparagraph(b)(1)(ii)(A)ofthissection;or
1
483.15(c)(4)(ii)(E) (E)Aresidenthasnotresidedinthefacilityfor30days.
1
483.15(c)(5) (5)Contentsofthenotice.Thewrittennoticespecifiedinparagraph(b)(3)ofthissectionmustincludethefollowing:
1
62
483.15(c)(5)(i) (i)Thereasonfortransferordischarge; 1 483.15(c)(5)(ii) (ii)Theeffectivedateoftransferor
discharge;1
483.15(c)(5)(iii) (iii)Thelocationtowhichtheresidentistransferredordischarged;
1
483.15(c)(5)(iv)
(iv)Astatementoftheresident’sappealrights,includingthename,address(mailingandemail),andtelephonenumberoftheentitywhichreceivessuchrequests;andinformationonhowtoobtainanappealformandassistanceincompletingtheformandsubmittingtheappealhearingrequest;
1
483.15(c)(5)(v) (v)Thename,address(mailingandemail)andtelephonenumberoftheOfficeoftheStateLong-TermCareOmbudsman;
1
483.15(c)(5)(vi) (vi)Fornursingfacilityresidentswithintellectualanddevelopmentaldisabilitiesorrelateddisabilities,themailingandemailaddressandtelephonenumberoftheagencyresponsiblefortheprotectionandadvocacyofindividualswithdevelopmentaldisabilitiesestablishedunderPartCoftheDevelopmentalDisabilitiesAssistanceandBillofRightsActof2000(Pub.L.106–402,codifiedat42U.S.C.15001etseq.);and
1
483.15(c)(5)(vii) (vii)Fornursingfacilityresidentswithamentaldisorderorrelateddisabilities,themailingandemailaddressandtelephonenumberoftheagencyresponsiblefortheprotectionandadvocacyofindividualswithamentaldisorderestablishedundertheProtection
1
63
andAdvocacyforMentallyIllIndividualsAct.
483.15(c)(6) (6)Changestothenotice.Iftheinformationinthenoticechangespriortoeffectingthetransferordischarge,thefacilitymustupdatetherecipientsofthenoticeassoonaspracticableoncetheupdatedinformationbecomesavailable.
1
483.15(c)(7) (7)Orientationfortransferordischarge.Afacilitymustprovideanddocumentsufficientpreparationandorientationtoresidentstoensuresafeandorderlytransferordischargefromthefacility.Thisorientationmustbeprovidedinaformandmannerthattheresidentcanunderstand.
1
483.15(c)(8) (8)Noticeinadvanceoffacilityclosure.Inthecaseoffacilityclosure,theindividualwhoistheadministratorofthefacilitymustprovidewrittennotificationpriortotheimpendingclosuretotheStateSurveyAgency,theOfficeoftheStateLong-TermCareOmbudsman,residentsofthefacility,andtheresidentrepresentatives,aswellastheplanforthetransferandadequaterelocationoftheresidents,asrequiredat§483.70(l).
1
483.15(c)(9) (9)Roomchangesinacompositedistinctpart.Roomchangesinafacilitythatisacompositedistinctpart(asdefinedin§483.5)aresubjecttotherequirementsof§483.10(e)(7)andmustbelimitedtomoveswithintheparticularbuildinginwhichtheresidentresides,unlesstheresidentvoluntarilyagreestomoveto
1
64
anotherofthecompositedistinctpart’slocations.
483.15(d) (d)Noticeofbed-holdpolicyandreturn—
1
483.15(d)(1) (1)Noticebeforetransfer.Beforeanursingfacilitytransfersaresidenttoahospitalortheresidentgoesontherapeuticleave,thenursingfacilitymustprovidewritteninformationtotheresidentorresidentrepresentativethatspecifies—
1
483.15(d)(1)(i) (i)Thedurationofthestatebed-holdpolicy,ifany,duringwhichtheresidentispermittedtoreturnandresumeresidenceinthenursingfacility;
1
483.15(d)(1)(ii) (ii)Thereservebedpaymentpolicyinthestateplan,under§447.40ofthischapter,ifany;
1
483.15(d)(1)(iii) (iii)Thenursingfacility’spoliciesregardingbed-holdperiods,whichmustbeconsistentwithparagraph(c)(3)ofthissection,permittingaresidenttoreturn;and
1
483.15(d)(1)(iv) (iv)Theinformationspecifiedinparagraph(c)(3)ofthissection.
1
483.15(d)(2) (2)Bed-holdnoticeupontransfer.Atthetimeoftransferofaresidentforhospitalizationortherapeuticleave,anursingfacilitymustprovidetotheresidentandtheresidentrepresentativewrittennoticewhichspecifiesthedurationofthebed-holdpolicydescribedinparagraph(c)(1)ofthissection.
1
483.15(e)(1) (1)Permittingresidentstoreturntofacility.Afacilitymustestablishand
1
65
followawrittenpolicyonpermittingresidentstoreturntothefacilityaftertheyarehospitalizedorplacedontherapeuticleave.Thepolicymustprovideforthefollowing.
483.15(e)(1)(i) (i)Aresident,whosehospitalizationortherapeuticleaveexceedsthebed-holdperiodundertheStateplan,returnstothefacilitytotheirpreviousroomifavailableorimmediatelyuponthefirstavailabilityofabedinasemiprivateroomiftheresident
1
483.15(e)(1)(i)(A) (A)Requirestheservicesprovidedbythefacility;and
1
483.15(e)(1)(i)(B) (B)IseligibleforMedicareskillednursingfacilityservicesorMedicaidnursingfacilityservices.
1
483.15(e)(1)(ii) (ii)Ifthefacilitythatdeterminesthataresidentwhowastransferredwithanexpectationofreturningtothefacilitycannotreturntothefacility,thefacilitymustcomplywiththerequirementsofparagraph(c)astheyapplytodischarges.
1
483.15(e)(2) (2)Readmissiontoacompositedistinctpart.Whenthefacilitytowhicharesidentreturnsisacompositedistinctpart(asdefinedin§483.5),theresidentmustbepermittedtoreturntoanavailablebedintheparticularlocationofthecompositedistinctpartinwhichheorsheresidedpreviously.Ifabedisnotavailableinthatlocationatthetimeofreturn,theresidentmustbegiventheoptiontoreturntothatlocationuponthefirstavailabilityofabedthere.
1
66
§483.20 Residentassessment. Thisentiresectionwas
implementedinPhase1.
483.20 Thefacilitymustconductinitiallyandperiodicallyacomprehensive,accurate,standardized,reproducibleassessmentofeachresident’sfunctionalcapacity.
1
483.20(a) (a)Admissionorders.Atthetimeeachresidentisadmitted,thefacilitymusthavephysicianordersfortheresident’simmediatecare.
1
483.20(b) (b)Comprehensiveassessments– 1 483.20(b)(1) (1)Residentassessmentinstrument.A
facilitymustmakeacomprehensiveassessmentofaresident’sneeds,strengths,goals,lifehistoryandpreferences,usingtheresidentassessmentinstrument(RAI)specifiedbyCMS.Theassessmentmustincludeatleastthefollowing:
1
483.20(b)(1)(i) (i)Identificationanddemographicinformation.
1
483.20(b)(1)(ii) (ii)Customaryroutine. 1 483.20(b)(1)(iii) (iii)Cognitivepatterns. 1 483.20(b)(1)(iv) (iv)Communication. 1 483.20(b)(1)(v) (v)Vision. 1 483.20(b)(1)(vi) (vi)Moodandbehaviorpatterns. 1 483.20(b)(1)(vii) (vii)Psychosocialwell-being. 1 483.20(b)(1)(viii) (viii)Physicalfunctioningandstructural
problems.1
483.20(b)(1)(ix) (ix)Continence. 1 483.20(b)(1)(x) (x)Diseasediagnosesandhealth
conditions.1
483.20(b)(1)(xi) (xi)Dentalandnutritionalstatus. 1
67
483.20(b)(1)(xii) (xii)Skincondition. 1 483.20(b)(1)(xiii) (xiii)Activitypursuit. 1 483.20(b)(1)(xiv) (xiv)Medications. 1 483.20(b)(1)(xv) (xv)Specialtreatmentsandprocedures. 1 483.20(b)(1)(xvi) (xvi)Dischargeplanning. 1 483.20(b)(1)(xvii) (xvii)Documentationofsummary
informationregardingtheadditionalassessmentperformedonthecareareastriggeredbythecompletionoftheMinimumDataSet(MDS).
1
483.20(b)(1)(xviii) (xviii)Documentationofparticipationinassessment.Theassessmentprocessmustincludedirectobservationandcommunicationwiththeresident,aswellascommunicationwithlicensedandnonlicenseddirectcarestaffmembersonallshifts.
1
483.20(b)(2) (2)Whenrequired.Subjecttothetimeframesprescribedin§413.343(b)ofthischapter,afacilitymustconductacomprehensiveassessmentofaresidentinaccordancewiththetimeframesspecifiedinparagraphs(b)(2)(i)through(iii)ofthissection.Thetimeframesprescribedin§413.343(b)ofthischapterdonotapplytoCAHs.
1
483.20(b)(2)(i) (i)Within14calendardaysafteradmission,excludingreadmissionsinwhichthereisnosignificantchangeintheresident’sphysicalormentalcondition.(Forpurposesofthissection,‘‘readmission’’meansareturntothefacilityfollowingatemporaryabsenceforhospitalizationorfortherapeuticleave.)
1
483.20(b)(2)(ii) (ii)Within14calendardaysafterthe 1
68
facilitydetermines,orshouldhavedetermined,thattherehasbeenasignificantchangeintheresident’sphysicalormentalcondition.(Forpurposesofthissection,a‘‘significantchange’’meansamajordeclineorimprovementintheresident’sstatusthatwillnotnormallyresolveitselfwithoutfurtherinterventionbystafforbyimplementingstandarddisease-relatedclinicalinterventions,thathasanimpactonmorethanoneareaoftheresident’shealthstatus,andrequiresinterdisciplinaryrevieworrevisionofthecareplan,orboth.)
483.20(b)(2)(iii) (iii)Notlessoftenthanonceevery12months.
1
483.20(c) (c)Quarterlyreviewassessment.AfacilitymustassessaresidentusingthequarterlyreviewinstrumentspecifiedbytheStateandapprovedbyCMSnotlessfrequentlythanonceevery3months.
1
483.20(d) (d)Use.Afacilitymustmaintainallresidentassessmentscompletedwithintheprevious15monthsintheresident’sactiverecordandusetheresultsoftheassessmentstodevelop,review,andrevisetheresident’scomprehensiveplanfcare.
1
483.20(e) (e)Coordination.Afacilitymustcoordinateassessmentswiththepreadmissionscreeningandresidentreview(PASARR)programunderMedicaidinsubpartCofthisparttothemaximumextentpracticabletoavoid
1
69
duplicativetestingandeffort.Coordinationincludes—
483.20(e)(1) (1)IncorporatingtherecommendationsfromthePASARRlevelIIdeterminationandthePASARRevaluationreportintoaresident’sassessment,careplanning,andtransitionsofcare.
1
483.20(e)(2) (2)ReferringalllevelIIresidentsandallresidentswithnewlyevidentorpossibleseriousmentaldisorder,intellectualdisability,orarelatedconditionforlevelIIresidentreviewuponasignificantchangeinstatusassessment.
1
483.20(f) (f)Automateddataprocessingrequirement—
1
483.20(f)(1) (1)Encodingdata.Within7daysafterafacilitycompletesaresident’sassessment,afacilitymustencodethefollowinginformationforeachresidentinthefacility:
1
483.20(f)(1)(i) (i)Admissionassessment. 1 483.20(f)(1)(ii) (ii)Annualassessmentupdates. 1 483.20(f)(1)(iii) (iii)Significantchangeinstatus
assessments.1
483.20(f)(1)(iv) (iv)Quarterlyreviewassessments. 1 483.20(f)(1)(v) (v)Asubsetofitemsuponaresident’s
transfer,reentry,discharge,anddeath.1
483.20(f)(1)(iv) (vi)Background(face-sheet)information,ifthereisnoadmissionassessment.
1
483.20(f)(2) (2)Transmittingdata.Within7daysafterafacilitycompletesaresident’sassessment,afacilitymustbecapableoftransmittingtotheCMSSysteminformationforeachresidentcontainedintheMDSinaformatthatconformsto
1
70
standardrecordlayoutsanddatadictionaries,andthatpassesstandardizededitsdefinedbyCMSandtheState.
483.20(f)(3) (3)Transmittalrequirements.Within14daysafterafacilitycompletesaresident’sassessment,afacilitymustelectronicallytransmitencoded,accurate,andcompleteMDSdatatotheCMSSystem,includingthefollowing:
1
483.20(f)(3)(i) (i)Admissionassessment. 1 483.20(f)(3)(ii) (ii)Annualassessment. 1 483.20(f)(3)(iii) (iii)Significantchangeinstatus
assessment.1
483.20(f)(3)(iv) (iv)Significantcorrectionofpriorfullassessment.
1
483.20(f)(3)(v) (v)Significantcorrectionofpriorquarterlyassessment.
1
483.20(f)(3)(vi) (vi)Quarterlyreview. 1 483.20(f)(3)(vii) (vii)Asubsetofitemsuponaresident’s
transfer,reentry,discharge,anddeath.1
483.20(f)(3)(viii) (viii)Background(face-sheet)information,foraninitialtransmissionofMDSdataonaresidentthatdoesnothaveanadmissionassessment.
1
483.20(f)(4) (4)Dataformat.ThefacilitymusttransmitdataintheformatspecifiedbyCMSor,foraStatewhichhasanalternateRAIapprovedbyCMS,intheformatspecifiedbytheStateandapprovedbyCMS.
1
483.20(f)(5) (5)Resident-identifiableinformation. 1 483.20(f)(5)(i) (i)Afacilitymaynotreleaseinformation
thatisresident-identifiabletothepublic.1
483.20(f)(5)(ii) (ii)Thefacilitymayreleaseinformation 1
71
thatisresident-identifiabletoanagentonlyinaccordancewithacontractunderwhichtheagentagreesnottouseordisclosetheinformationexcepttotheextentthefacilityitselfispermittedtodoso.
483.20(g) (g)Accuracyofassessments.Theassessmentmustaccuratelyreflecttheresident’sstatus.
1
483.20(h) (h)Coordination.Aregisterednursemustconductorcoordinateeachassessmentwiththeappropriateparticipationofhealthprofessionals.
1
483.20(i) (i)Certification. 1 483.20(i)(1) (1)Aregisterednursemustsignand
certifythattheassessmentiscompleted.1
483.20(i)(2) (2)Eachindividualwhocompletesaportionoftheassessmentmustsignandcertifytheaccuracyofthatportionoftheassessment.
1
483.20(j) (j)Penaltyforfalsification. 1 483.20(j)(1) (1)UnderMedicareandMedicaid,an
individualwhowillfullyandknowingly—1
483.20(j)(1)(i)
(i)Certifiesamaterialandfalsestatementinaresidentassessmentissubjecttoacivilmoneypenaltyofnotmorethan$1,000foreachassessment;or.
1
483.20(j)(1)(ii) (ii)Causesanotherindividualtocertifyamaterialandfalsestatementinaresidentassessmentissubjecttoacivilmoneypenaltyofnotmorethan$5,000foreachassessment
1
483.20(j)(2) (2)Clinicaldisagreementdoesnotconstituteamaterialandfalse
1
72
statement.483.20(k)
(k)Preadmissionscreeningforindividualswithamentaldisorderandindividualswithintellectualdisability.
1
483.20(k)(1) (1)Anursingfacilitymustnotadmit,onorafterJanuary1,1989,anynewresidentwith—
1
483.20(k)(1)(i) (i)Mentaldisorderasdefinedinparagraph(k)(3)(i)ofthissection,unlesstheStatementalhealthauthorityhasdetermined,basedonanindependentphysicalandmentalevaluationperformedbyapersonorentityotherthantheStatementalhealthauthority,priortoadmission,
1
483.20(k)(1)(i)(A) (A)That,becauseofthephysicalandmentalconditionoftheindividual,theindividualrequiresthelevelofservicesprovidedbyanursingfacility;and
1
483.20(k)(1)(i)(B) (B)Iftheindividualrequiressuchlevelofservices,whethertheindividualrequiresspecializedservices;or
1
483.20(k)(1)(ii) (ii)Intellectualdisability,asdefinedinparagraph(k)(3)(ii)ofthissection,unlesstheStateintellectualdisabilityordevelopmentaldisabilityauthorityhasdeterminedpriortoadmission—
1
483.20(k)(1)(ii)(A) (A)That,becauseofthephysicalandmentalconditionoftheindividual,theindividualrequiresthelevelofservicesprovidedbyanursingfacility;and
1
483.20(k)(1)(ii)(B) (B)Iftheindividualrequiressuchlevelofservices,whethertheindividualrequiresspecializedservicesforintellectualdisability.
1
73
483.20(k)(2) (2)Exceptions.Forpurposesofthissection—
1
483.20(k)(2)(i) (i)Thepreadmissionscreeningprogramunderparagraph(k)(1)ofthissectionneednotprovidefordeterminationsinthecaseofthereadmissiontoanursingfacilityofanindividualwho,afterbeingadmittedtothenursingfacility,wastransferredforcareinahospital.
483.20(k)(2)(ii) (ii)TheStatemaychoosenottoapplythepreadmissionscreeningprogramunderparagraph(k)(1)ofthissectiontotheadmissiontoanursingfacilityofanindividual—
1
483.20(k)(2)(ii)(A) (A)Whoisadmittedtothefacilitydirectlyfromahospitalafterreceivingacuteinpatientcareatthehospital,
1
483.20(k)(2)(ii)(B) (B)Whorequiresnursingfacilityservicesfortheconditionforwhichtheindividualreceivedcareinthehospital,and
1
483.20(k)(2)(ii)(C) (C)Whoseattendingphysicianhascertified,beforeadmissiontothefacilitythattheindividualislikelytorequirelessthan30daysofnursingfacilityservices.
1
483.20(k)(3) (3)Definition.Forpurposesofthissection—
1
483.20(k)(3)(i) (i)Anindividualisconsideredtohaveamentaldisorderiftheindividualhasaseriousmentaldisorderasdefinedin§483.102(b)(1).
1
483.20(k)(3)(ii) (ii)Anindividualisconsideredtohaveanintellectualdisabilityiftheindividualhasanintellectualdisabilityasdefinedin§483.102(b)(3)orisapersonwitharelatedconditionasdescribedin§
1
74
435.1010ofthischapter.483.20(k)(4) (4)Anursingfacilitymustnotifythestate
mentalhealthauthorityorstateintellectualdisabilityauthority,asapplicable,promptlyafterasignificantchangeinthementalorphysicalconditionofaresidentwhohasamentaldisorderorintellectualdisabilityforresidentreview.
1
§483.21 Comprehensiveperson-centeredcareplanning.
ThissectionwasimplementedinPhase1withthe
followingexceptions:§483.21(a),whichwillbe
implementedinPhase2,and
§483.21(b)(3)(iii),whichwillbe
implementedinPhase3.
483.21(a) (a)Baselinecareplans. 2 483.21(a)(1) (1)Thefacilitymustdevelopand
implementabaselinecareplanforeachresidentthatincludestheinstructionsneededtoprovideeffectiveandperson-centeredcareoftheresidentthatmeetprofessionalstandardsofqualitycare.Thebaselinecareplanmust—
2
483.21(a)(1)(i) (i)Bedevelopedwithin48hoursofaresident’sadmission.
2
483.21(a)(1)(ii) (ii)Includetheminimumhealthcareinformationnecessarytoproperlycareforaresidentincluding,butnotlimited
2
75
to483.21(a)(1)(ii)(A) (A)Initialgoalsbasedonadmission
orders.2
483.21(a)(1)(ii)(B) (B)Physicianorders. 2 483.21(a)(1)(ii)(C) (C)Dietaryorders. 2 483.21(a)(1)(ii)(D) (D)Therapyservices. 2 483.21(a)(1)(ii)(E) (E)Socialservices. 2 483.21(a)(1)(ii)(F) (F)PASARRrecommendation,if
applicable.2
483.21(a)(2) (2)Thefacilitymaydevelopacomprehensivecareplaninplaceofthebaselinecareplanifthecomprehensivecareplan—
2
483.21(a)(2)(i) (i)Isdevelopedwithin48hoursoftheresident’sadmission.
2
483.21(a)(2)(ii) (ii)Meetstherequirementssetforthinparagraph(b)ofthissection(exceptingparagraph(b)(2)(i)ofthissection).
2
483.21(a)(3) (3)Thefacilitymustprovidetheresidentandtheirrepresentativewithasummaryofthebaselinecareplanthatincludesbutisnotlimitedto:
2
483.21(a)(3)(i) (i)Theinitialgoalsoftheresident. 2 483.21(a)(3)(ii) (ii)Asummaryoftheresident’s
medicationsanddietaryinstructions.2
483.21(a)(3)(iii) (iii)Anyservicesandtreatmentstobeadministeredbythefacilityandpersonnelactingonbehalfofthefacility.
2
483.21(a)(3)(iv) (iv)Anyupdatedinformationbasedonthedetailsofthecomprehensivecareplan,asnecessary.
2
483.21(b) (b)Comprehensivecareplans. 1 483.21(b)(1) (1)Thefacilitymustdevelopand
implementacomprehensiveperson-centeredcareplanforeachresident,
1
76
consistentwiththeresidentrightssetforthat§483.10(c)(2)and§483.10(c)(3),thatincludesmeasurableobjectivesandtimeframestomeetaresident’smedical,nursing,andmentalandpsychosocialneedsthatareidentifiedinthecomprehensiveassessment.Thecomprehensivecareplanmustdescribethefollowing:
483.21(b)(1)(i) (i)Theservicesthataretobefurnishedtoattainormaintaintheresident’shighestpracticablephysical,mental,andpsychosocialwell-beingasrequiredunder§483.24,§483.25,or§483.40;and
1
483.21(b)(1)(ii) (ii)Anyservicesthatwouldotherwiseberequiredunder§483.24,§483.25,or§483.40butarenotprovidedduetotheresident’sexerciseofrightsunder§483.10,includingtherighttorefusetreatmentunder§483.10(c)(6).
1
483.21(b)(1)(iii) (iii)AnyspecializedservicesorspecializedrehabilitativeservicesthenursingfacilitywillprovideasaresultofPASARRrecommendations.IfafacilitydisagreeswiththefindingsofthePASARR,itmustindicateitsrationaleintheresident’smedicalrecord.
1
483.21(b)(1)(iv) (iv)Inconsultationwiththeresidentandtheresident’srepresentative(s)—
1
483.21(b)(1)(iv)(A) (A)Theresident’sgoalsforadmissionanddesiredoutcomes.
1
483.21(b)(1)(iv)(B) (B)Theresident’spreferenceandpotentialforfuturedischarge.Facilitiesmustdocumentwhethertheresident’s
1
77
desiretoreturntothecommunitywasassessedandanyreferralstolocalcontactagenciesand/orotherappropriateentities,forthispurpose.
483.21(b)(1)(iv)(C) (C)Dischargeplansinthecomprehensivecareplan,asappropriate,inaccordancewiththerequirementssetforthinparagraph(c)ofthissection.
1
483.21(b)(2) (2)Acomprehensivecareplanmustbe— 1 483.21(b)(2)(i) (i)Developedwithin7daysafter
completionofthecomprehensiveassessment.
1
483.21(b)(2)(ii) (ii)Preparedbyaninterdisciplinaryteam,thatincludesbutisnotlimitedto—
1
483.21(b)(2)(ii)(A) (A)Theattendingphysician. 1 483.21(b)(2)(ii)(B) (B)Aregisterednursewithresponsibility
fortheresident.1
483.21(b)(2)(ii)(C) (C)Anurseaidewithresponsibilityfortheresident.
1
483.21(b)(2)(ii)(D) (D)Amemberoffoodandnutritionservicesstaff.
1
483.21(b)(2)(ii)(E) (E)Totheextentpracticable,theparticipationoftheresidentandtheresident’srepresentative(s).Anexplanationmustbeincludedinaresident’smedicalrecordiftheparticipationoftheresidentandtheirresidentrepresentativeisdeterminednotpracticableforthedevelopmentoftheresident’scareplan.
1
483.21(b)(2)(ii)(F)
(F)Otherappropriatestafforprofessionalsindisciplinesasdeterminedbytheresident’sneedsorasrequestedbytheresident.
1
483.21(b)(2)(iii) (iii)Reviewedandrevisedbythe 1
78
interdisciplinaryteamaftereachassessment,includingboththecomprehensiveandquarterlyreviewassessments.
483.21(b)(3) (3)Theservicesprovidedorarrangedbythefacility,asoutlinedbythecomprehensivecareplan,must—
1
483.21(b)(3)(i) (i)Meetprofessionalstandardsofquality.
1
483.21(b)(3)(ii) (ii)Beprovidedbyqualifiedpersonsinaccordancewitheachresident’swrittenplanofcare.
1
483.21(b)(3)(iii) (iii)Beculturally-competentandtrauma–informed.
3
483.21(c) (c)Dischargeplanning— 1 483.21(c)(1) (1)Dischargeplanningprocess.The
facilitymustdevelopandimplementaneffectivedischargeplanningprocessthatfocusesontheresident’sdischargegoals,thepreparationofresidentstobeactivepartnersandeffectivelytransitionthemtopost-dischargecare,andthereductionoffactorsleadingtopreventablereadmissions.Thefacility’sdischargeplanningprocessmustbeconsistentwiththedischargerightssetforthat§483.15(b)asapplicableand—
1
483.21(c)(1)(i) (i)Ensurethatthedischargeneedsofeachresidentareidentifiedandresultinthedevelopmentofadischargeplanforeachresident.
1
483.21(c)(1)(ii) (ii)Includeregularre-evaluationofresidentstoidentifychangesthatrequiremodificationofthedischargeplan.Thedischargeplanmustbeupdated,as
1
79
needed,toreflectthesechanges.483.21(c)(1)(iii) (iii)Involvetheinterdisciplinaryteam,as
definedby§483.21(b)(2)(ii),intheongoingprocessofdevelopingthedischargeplan.
1
483.21(c)(1)(iv) (iv)Considercaregiver/supportpersonavailabilityandtheresident’sorcaregiver’s/supportperson(s)capacityandcapabilitytoperformrequiredcare,aspartoftheidentificationofdischargeneeds.
1
483.21(c)(1)(v) (v)Involvetheresidentandresidentrepresentativeinthedevelopmentofthedischargeplanandinformtheresidentandresidentrepresentativeofthefinalplan.
1
483.21(c)(1)(vi) (vi)Addresstheresident’sgoalsofcareandtreatmentpreferences.
1
483.21(c)(1)(vii) (vii)Documentthataresidenthasbeenaskedabouttheirinterestinreceivinginformationregardingreturningtothecommunity.
1
483.21(c)(1)(vii)(A) (A)Iftheresidentindicatesaninterestinreturningtothecommunity,thefacilitymustdocumentanyreferralstolocalcontactagenciesorotherappropriateentitiesmadeforthispurpose.
1
483.21(c)(1)(vii)(B) (B)Facilitiesmustupdatearesident’scomprehensivecareplananddischargeplan,asappropriate,inresponsetoinformationreceivedfromreferralstolocalcontactagenciesorotherappropriateentities.
1
483.21(c)(1)(vii)(C) (C)Ifdischargetothecommunityisdeterminedtonotbefeasible,thefacility
1
80
mustdocumentwhomadethedeterminationandwhy.
483.21(c)(1)(viii) (viii)ForresidentswhoaretransferredtoanotherSNForwhoaredischargedtoaHHA,IRF,orLTCH,assistresidentsandtheirresidentrepresentativesinselectingapost-acutecareproviderbyusingdatathatincludes,butisnotlimitedtoSNF,HHA,IRF,orLTCHstandardizedpatientassessmentdata,dataonqualitymeasures,anddataonresourceusetotheextentthedataisavailable.Thefacilitymustensurethatthepost-acutecarestandardizedpatientassessmentdata,dataonqualitymeasures,anddataonresourceuseisrelevantandapplicabletotheresident’sgoalsofcareandtreatmentpreferences.
1
483.21(c)(1)(ix) (ix)Document,completeonatimelybasisbasedontheresident’sneeds,andincludeintheclinicalrecord,theevaluationoftheresident’sdischargeneedsanddischargeplan.Theresultsoftheevaluationmustbediscussedwiththeresidentorresident’srepresentative.Allrelevantresidentinformationmustbeincorporatedintothedischargeplantofacilitateitsimplementationandtoavoidunnecessarydelaysintheresident’sdischargeortransfer.
1
483.21(c)(2) (2)Dischargesummary.Whenthefacilityanticipatesdischargearesidentmusthaveadischargesummarythatincludes,butisnotlimitedto,thefollowing:
1
483.21(c)(2)(i) (i)Arecapitulationoftheresident’sstay 1
81
thatincludes,butisnotlimitedto,diagnoses,courseofillness/treatmentortherapy,andpertinentlab,radiology,andconsultationresults.
483.21(c)(2)(ii) (ii)Afinalsummaryoftheresident’sstatustoincludeitemsinparagraph(b)(1)of§483.20,atthetimeofthedischargethatisavailableforreleasetoauthorizedpersonsandagencies,withtheconsentoftheresidentorresident’srepresentative.
1
483.21(c)(2)(iii) (iii)Reconciliationofallpre-dischargemedicationswiththeresident’spost-dischargemedications(bothprescribedandover-the-counter).
1
483.21(c)(2)(iv) (iv)Apost-dischargeplanofcarethatisdevelopedwiththeparticipationoftheresidentand,withtheresident’sconsent,theresidentrepresentative(s),whichwillassisttheresidenttoadjusttohisorhernewlivingenvironment.Thepost-dischargeplanofcaremustindicatewheretheindividualplanstoreside,anyarrangementsthathavebeenmadefortheresident’sfollowupcareandanypost-dischargemedicalandnon-medicalservices.
1
§483.24 Qualityoflife. Thisentiresectionwas
implementedinPhase1.
483.24
Qualityoflifeisafundamentalprinciplethatappliestoallcareandservicesprovidedtofacilityresidents.Eachresidentmustreceiveandthefacility
1
82
mustprovidethenecessarycareandservicestoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being,consistentwiththeresident’scomprehensiveassessmentandplanofcare.
483.24(a)
(a)Basedonthecomprehensiveassessmentofaresidentandconsistentwiththeresident’sneedsandchoices,thefacilitymustprovidethenecessarycareandservicestoensurethataresident’sabilitiesinactivitiesofdailylivingdonotdiminishunlesscircumstancesoftheindividual’sclinicalconditiondemonstratethatsuchdiminutionwasunavoidable.Thisincludesthefacilityensuringthat:
1
483.24(a)(1) (1)Aresidentisgiventheappropriatetreatmentandservicestomaintainorimprovehisorherabilitytocarryouttheactivitiesofdailyliving,includingthosespecifiedinparagraph(b)ofthissection,
1
483.24(a)(2) (2)Aresidentwhoisunabletocarryoutactivitiesofdailylivingreceivesthenecessaryservicestomaintaingoodnutrition,grooming,andpersonalandoralhygiene,and
1
483.24(a)(3) (3)Personnelprovidebasiclifesupport,includingCPR,toaresidentrequiringsuchemergencycarepriortothearrivalofemergencymedicalpersonnelandsubjecttorelatedphysicianordersandtheresident’sadvancedirectives.
1
483.24(b) (b)Activitiesofdailyliving.Thefacilitymustprovidecareandservicesin
1
83
accordancewithparagraph(a)ofthissectionforthefollowingactivitiesofdailyliving:
483.24(b)(1) (1)Hygiene—bathing,dressing,grooming,andoralcare,
1
483.24(b)(2) (2)Mobility—transferandambulation,includingwalking,
1
483.24(b)(3) (3)Elimination—toileting, 1 483.24(b)(4) (4)Dining—eating,includingmealsand
snacks,1
483.24(b)(5) (5)Communication,including 1 483.24(b)(5)(i) (i)Speech, 1 483.24(b)(5)(ii) (ii)Language, 1 483.24(b)(5)(iii) (iii)Otherfunctionalcommunication
systems.1
483.24(c) (c)Activities. 1 483.24(c)(1) (1)Thefacilitymustprovide,basedon
thecomprehensiveassessmentandcareplanandthepreferencesofeachresident,anongoingprogramtosupportresidentsintheirchoiceofactivities,bothfacility-sponsoredgroupandindividualactivitiesandindependentactivities,designedtomeettheinterestsofandsupportthephysical,mental,andpsychosocialwell-beingofeachresident,encouragingbothindependenceandinteractioninthecommunity.
1
483.24(c)(2) (2)Theactivitiesprogrammustbedirectedbyaqualifiedprofessionalwhoisaqualifiedtherapeuticrecreationspecialistoranactivitiesprofessionalwho—
1
483.24(c)(2)(i) (i)Islicensedorregistered,ifapplicable,bytheStateinwhichpracticing;and
1
84
483.24(c)(2)(ii) (ii)Is: 1 483.24(c)(2)(ii)(A) (A)Eligibleforcertificationasa
therapeuticrecreationspecialistorasanactivitiesprofessionalbyarecognizedaccreditingbodyonorafterOctober1,1990;or
1
483.24(c)(2)(ii)(B) (B)Has2yearsofexperienceinasocialorrecreationalprogramwithinthelast5years,oneofwhichwasfull-timeinatherapeuticactivitiesprogram;or
1
483.24(c)(2)(ii)(C) (C)Isaqualifiedoccupationaltherapistoroccupationaltherapyassistant;or
1
483.24(c)(2)(ii)(D) (D)HascompletedatrainingcourseapprovedbytheState.
1
§483.25 Qualityofcare. ThissectionwasimplementedinPhase1withthe
followingexception:§483.25(m),whichwillbe
implementedinPhase3.
483.25
Qualityofcareisafundamentalprinciplethatappliestoalltreatmentandcareprovidedtofacilityresidents.Basedonthecomprehensiveassessmentofaresident,thefacilitymustensurethatresidentsreceivetreatmentandcareinaccordancewithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresident’schoices,includingbutnotlimitedtothefollowing:
1
483.25(a) (a)Visionandhearing.Toensurethat 1
85
residentsreceivepropertreatmentandassistivedevicestomaintainvisionandhearingabilities,thefacilitymust,ifnecessary,assisttheresident—
483.25(a)(1) (1)Inmakingappointments,and 1 483.25(a)(2) (2)Byarrangingfortransportationtoand
fromtheofficeofapractitionerspecializinginthetreatmentofvisionorhearingimpairmentortheofficeofaprofessionalspecializingintheprovisionofvisionorhearingassistivedevices.
1
483.25(b) (b)Skinintegrity— 1 483.25(b)(1) (1)Pressureulcers.Basedonthe
comprehensiveassessmentofaresident,thefacilitymustensurethat—
1
483.25(b)(1)(i)
(i)Aresidentreceivescare,consistentwithprofessionalstandardsofpractice,topreventpressureulcersanddoesnotdeveloppressureulcersunlesstheindividual’sclinicalconditiondemonstratesthattheywereunavoidable;and
1
483.25(b)(1)(ii) (ii)Aresidentwithpressureulcersreceivesnecessarytreatmentandservices,consistentwithprofessionalstandardsofpractice,topromotehealing,preventinfectionandpreventnewulcersfromdeveloping.
1
483.25(b)(2) (2)Footcare.Toensurethatresidentsreceivepropertreatmentandcaretomaintainmobilityandgoodfoothealth,thefacilitymust—
1
483.25(b)(2)(i)
(i)Providefootcareandtreatment,inaccordancewithprofessionalstandardsofpractice,includingtoprevent
1
86
complicationsfromtheresident’smedicalcondition(s)and
483.25(b)(2)(ii) (ii)Ifnecessary,assisttheresidentinmakingappointmentswithaqualifiedperson,andarrangingfortransportationtoandfromsuchappointments.
1
483.25(c)
(c)Mobility. 1
483.25(c)(1) (1)Thefacilitymustensurethataresidentwhoentersthefacilitywithoutlimitedrangeofmotiondoesnotexperiencereductioninrangeofmotionunlesstheresident’sclinicalconditiondemonstratesthatareductioninrangeofmotionisunavoidable;and
1
483.25(c)(2) (2)Aresidentwithlimitedrangeofmotionreceivesappropriatetreatmentandservicestoincreaserangeofmotionand/ortopreventfurtherdecreaseinrangeofmotion.
1
483.25(c)(3) (3)Aresidentwithlimitedmobilityreceivesappropriateservices,equipment,andassistancetomaintainorimprovemobilitywiththemaximumpracticableindependenceunlessareductioninmobilityisdemonstrablyunavoidable.
1
483.25(d) (d)Accidents.Thefacilitymustensurethat—
1
483.25(d)(1) (1)Theresidentenvironmentremainsasfreeofaccidenthazardsasispossible;and
1
483.25(d)(2) (2)Eachresidentreceivesadequatesupervisionandassistancedevicestopreventaccidents.
1
87
483.25(e) (e)Incontinence. 1 483.25(e)(1) (1)Thefacilitymustensurethata
residentwhoiscontinentofbladderandbowelonadmissionreceivesservicesandassistancetomaintaincontinenceunlesshisorherclinicalconditionisorbecomessuchthatcontinenceisnotpossibletomaintain.
1
483.25(e)(2) (2)Foraresidentwithurinaryincontinence,basedontheresident’scomprehensiveassessment,thefacilitymustensurethat—
1
483.25(e)(2)(i) (i)Aresidentwhoentersthefacilitywithoutanindwellingcatheterisnotcatheterizedunlesstheresident’sclinicalconditiondemonstratesthatcatheterizationwasnecessary;
1
483.25(e)(2)(ii) (ii)Aresidentwhoentersthefacilitywithanindwellingcatheterorsubsequentlyreceivesoneisassessedforremovalofthecatheterassoonaspossibleunlesstheresident’sclinicalconditiondemonstratesthatcatheterizationisnecessary,and
1
483.25(e)(2)(iii)
(iii)Aresidentwhoisincontinentofbladderreceivesappropriatetreatmentandservicestopreventurinarytractinfectionsandtorestorecontinencetotheextentpossible.
1
483.25(e)(3) (3)Foraresidentwithfecalincontinence,basedontheresident’scomprehensiveassessment,thefacilitymustensurethataresidentwhoisincontinentofbowelreceivesappropriatetreatmentandservicestorestoreasmuchnormalbowel
1
88
functionaspossible.483.25(f) (f)Colostomy,urostomy,orileostomy
care.Thefacilitymustensurethatresidentswhorequirecolostomy,urostomy,orileostomyservices,receivesuchcareconsistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresidents’goalsandpreferences.
1
483.25(g) (g)Assistednutritionandhydration.(Includesnaso-gastricandgastrostomytubes,bothpercutaneousendoscopicgastrostomyandpercutaneousendoscopicjejunostomy,andenteralfluids).Basedonaresident’scomprehensiveassessment,thefacilitymustensurethataresident—
1
483.25(g)(1) (1)Maintainsacceptableparametersofnutritionalstatus,suchasusualbodyweightordesirablebodyweightrangeandelectrolytebalance,unlesstheresident’sclinicalconditiondemonstratesthatthisisnotpossibleorresidentpreferencesindicateotherwise;
1
483.25(g)(2) (2)Isofferedsufficientfluidintaketomaintainproperhydrationandhealth;and
1
483.25(g)(3) (3)Isofferedatherapeuticdietwhenthereisanutritionalproblemandthehealthcareproviderordersatherapeuticdiet.
1
483.25(g)(4) (4)Aresidentwhohasbeenabletoeatenoughaloneorwithassistanceisnotfedbyenteralmethodsunlesstheresident’sclinicalconditiondemonstrates
1
89
thatenteralfeedingwasclinicallyindicatedandconsentedtobytheresident;and
483.25(g)(5) (5)Aresidentwhoisfedbyenteralmeansreceivestheappropriatetreatmentandservicestorestore,ifpossible,oraleatingskillsandtopreventcomplicationsofenteralfeedingincludingbutnotlimitedtoaspirationpneumonia,diarrhea,vomiting,dehydration,metabolicabnormalities,andnasal-pharyngealulcers.
1
483.25(h) (h)Parenteralfluids.Parenteralfluidsmustbeadministeredconsistentwithprofessionalstandardsofpracticeandinaccordancewithphysicianorders,thecomprehensiveperson-centeredcareplan,andtheresident’sgoalsandpreferences.
1
483.25(i) (i)Respiratorycare,includingtracheostomycareandtrachealsuctioning.Thefacilitymustensurethataresidentwhoneedsrespiratorycare,includingtracheostomycareandtrachealsuctioning,isprovidedsuchcare,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,theresidents’goalsandpreferences,and§483.65ofthissubpart.
1
483.25(j) (j)Prostheses.Thefacilitymustensurethataresidentwhohasaprosthesisisprovidedcareandassistance,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcare
1
90
plan,andtheresidents’goalsandpreferences,towearandbeabletousetheprostheticdevice.
483.25(k) (k)Painmanagement.Thefacilitymustensurethatpainmanagementisprovidedtoresidentswhorequiresuchservices,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresidents’goalsandpreferences.
1
483.25(l) (l)Dialysis.Thefacilitymustensurethatresidentswhorequiredialysisreceivesuchservices,consistentwithprofessionalstandardsofpractice,thecomprehensiveperson-centeredcareplan,andtheresidents’goalsandpreferences.
1
483.25(m) (m)Trauma-informedcare.Thefacilitymustensurethatresidentswhoaretraumasurvivorsreceiveculturally-competent,trauma-informedcareinaccordancewithprofessionalstandardsofpracticeandaccountingforresidents’experiencesandpreferencesinordertoeliminateormitigatetriggersthatmaycausere-traumatizationoftheresident.
3
483.25(n) (n)Bedrails.Thefacilitymustattempttouseappropriatealternativespriortoinstallingasideorbedrail.Ifabedorsiderailisused,thefacilitymustensurecorrectinstallation,use,andmaintenanceofbedrails,includingbutnotlimitedtothefollowingelements.
1 483.25(n) (n)Bedrails.Thefacilitymustattempttouseappropriatealternativespriortotheuseofasideorbedrail.Ifabedorsiderailisused,thefacilitymustensurecorrectinstallation,use,andmaintenanceofbedrails,includingbutnotlimitedtothefollowingelements.
483.25(n)(1) (1)Assesstheresidentforriskofentrapmentfrombedrailspriorto
1 483.25(n)(1) (1)Assesstheresidentforriskofentrapmentfrombedrailsuse.
91
installation.483.25(n)(2) (2)Reviewtherisksandbenefitsofbed
railswiththeresidentorresidentrepresentativeandobtaininformedconsentpriortoinstallation.
1 483.25(n)(2) (2)Reviewtherisksandbenefitsofbedrailswiththeresidentorresidentrepresentativeandobtaininformedconsentpriortouse.
483.25(n)(3) (3)Ensurethatthebed’sdimensionsareappropriatefortheresident’ssizeandweight.
1
483.25(n)(4) (4)Followthemanufacturers’recommendationsandspecificationsforinstallingandmaintainingbedrails.
1
§483.30 Physicianservices. Thisentiresectionwas
implementedinPhase1.
483.30 Aphysicianmustpersonallyapproveinwritingarecommendationthatanindividualbeadmittedtoafacility.Eachresidentmustremainunderthecareofaphysician.Aphysician,physicianassistant,nursepractitioner,orclinicalnursespecialistmustprovideordersfortheresident’simmediatecareandneeds.
1
483.30(a) (a)Physiciansupervision.Thefacilitymustensurethat—
1
483.30(a)(1) (1)Themedicalcareofeachresidentissupervisedbyaphysician;and
1
483.30(a)(2) (2)Anotherphysiciansupervisesthemedicalcareofresidentswhentheirattendingphysicianisunavailable.
1
483.30(b) (b)Physicianvisits.Thephysicianmust— 1 483.30(b)(1) (1)Reviewtheresident’stotalprogram
ofcare,includingmedicationsandtreatments,ateachvisitrequiredbyparagraph(c)ofthissection;
1
92
483.30(b)(2) (2)Write,sign,anddateprogressnotesateachvisit;and
1
483.30(b)(3) (3)Signanddateallorderswiththeexceptionofinfluenzaandpneumococcalvaccines,whichmaybeadministeredperphysician-approvedfacilitypolicyafteranassessmentforcontraindications.
1
483.30(c) (c)Frequencyofphysicianvisits. 1 483.30(c)(1) (1)Theresidentmustbeseenbya
physicianatleastonceevery30daysforthefirst90daysafteradmission,andatleastonceevery60daysthereafter.
1
483.30(c)(2) (2)Aphysicianvisitisconsideredtimelyifitoccursnotlaterthan10daysafterthedatethevisitwasrequired.
1
483.30(c)(3) (3)Exceptasprovidedinparagraphs(c)(4)and(f)ofthissection,allrequiredphysicianvisitsmustbemadebythephysicianpersonally.
1
483.30(c)(4) (4)Attheoptionofthephysician,requiredvisitsinSNFsaftertheinitialvisitmayalternatebetweenpersonalvisitsbythephysicianandvisitsbyaphysicianassistant,nursepractitioner,orclinicalnursespecialistinaccordancewithparagraph(e)ofthissection.
1
483.30(d) (d)Availabilityofphysiciansforemergencycare.Thefacilitymustprovideorarrangefortheprovisionofphysicianservices24hoursaday,incaseofanemergency.
1
483.30(e)**TheCMScrosswalkcitesthissectionas
(e)PhysiciandelegationoftasksinSNFs. 1
93
483.30(f)whilethepublishedrevisedregulationscitesthissectionas483.30(e).Since483.30(e)intherevisedregulationscontainssub-clauses(1)(i)-(iii)and(4)while483.30(f)doesnothavethosesub-clauses,wehaveusedtherevisedregulationscitation.483.30(e)(1)
(1)Exceptasspecifiedinparagraph(e)(2)ofthissection,aphysicianmaydelegatetaskstoaphysicianassistant,nursepractitioner,orclinicalnursespecialistwho—
1
483.30(e)(1)(i) (i)Meetstheapplicabledefinitionin§491.2ofthischapteror,inthecaseofaclinicalnursespecialist,islicensedassuchbytheState;
1
483.30(e)(1)(ii) (ii)IsactingwithinthescopeofpracticeasdefinedbyStatelaw;and
1
483.30(e)(1)(iii) (iii)Isunderthesupervisionofthephysician.
1
483.30(e)(2) (2)Aresident’sattendingphysicianmaydelegatethetaskofwritingdietaryorders,consistentwith§483.60,toaqualifieddietitianorotherclinicallyqualifiednutritionprofessionalwho—
1
483.30(e)(2)(i) (i)Isactingwithinthescopeofpractice 1
94
asdefinedbyStatelaw;and483.30(e)(2)(ii) (ii)Isunderthesupervisionofthe
physician.1
483.30(e)(3) (3)Aresident’sattendingphysicianmaydelegatethetaskofwritingtherapyorders,consistentwith§483.65,toaqualifiedtherapistwho—
1
483.30(e)(3)(i) (i)IsactingwithinthescopeofpracticeasdefinedbyStatelaw;and
1
483.30(e)(3)(ii) (ii)Isunderthesupervisionofthephysician.
1
483.30(e)(4) (4)Aphysicianmaynotdelegateataskwhentheregulationsspecifythatthephysicianmustperformitpersonally,orwhenthedelegationisprohibitedunderStatelaworbythefacility’sownpolicies.
1
483.30(f) (f)PerformanceofphysiciantasksinNFs.AttheoptionoftheState,anyrequiredphysiciantaskinaNF(includingtaskswhichtheregulationsspecifymustbeperformedpersonallybythephysician)mayalsobesatisfiedwhenperformedbyanursepractitioner,clinicalnursespecialist,orphysicianassistantwhoisnotanemployeeofthefacilitybutwhoisworkingincollaborationwithaphysician.
1
§483.35 Nursingservices. ThissectionwasimplementedinPhase1withthe
followingexception:
specificusageoftheFacility
Assessmentat§483.70(e),
95
whichwasimplementedin
Phase2.483.35
Thefacilitymusthavesufficientnursingstaffwiththeappropriatecompetenciesandskillssetstoprovidenursingandrelatedservicestoassureresidentsafetyandattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-beingofeachresident,asdeterminedbyresidentassessmentsandindividualplansofcareandconsideringthenumber,acuityanddiagnosesofthefacility’sresidentpopulationinaccordancewiththefacilityassessmentrequiredat§483.70(e).
2
483.35(a) (a)Sufficientstaff. 1 483.35(a)(1) (1)Thefacilitymustprovideservicesby
sufficientnumbersofeachofthefollowingtypesofpersonnelona24-hourbasistoprovidenursingcaretoallresidentsinaccordancewithresidentcareplans:
1
483.35(a)(1)(i) (i)Exceptwhenwaivedunderparagraph(c)ofthissection,licensednurses;and
1
483.35(a)(1)(ii) (ii)Othernursingpersonnel,includingbutnotlimitedtonurseaides.
1
483.35(a)(2) (2)Exceptwhenwaivedunderparagraph(c)ofthissection,thefacilitymustdesignatealicensednursetoserveasachargenurseoneachtourofduty.
1 483.35(a)(2) (2)Exceptwhenwaivedunderparagraph(e)ofthissection,thefacilitymustdesignatealicensednursetoserveasachargenurseoneachtourofduty.
483.35(a)(3) (3)Thefacilitymustensurethatlicensednurseshavethespecificcompetenciesandskillsetsnecessarytocareforresidents’needs,asidentifiedthrough
1
96
residentassessments,anddescribedintheplanofcare.
483.35(a)(4) (4)Providingcareincludesbutisnotlimitedtoassessing,evaluating,planningandimplementingresidentcareplansandrespondingtoresident’sneeds.
1
483.35(b) (b)Registerednurse. 1 483.35(b)(1) (1)Exceptwhenwaivedunderparagraph
(c)or(d)ofthissection,thefacilitymustusetheservicesofaregisterednurseforatleast8consecutivehoursaday,7daysaweek.
1
483.35(b)(2) (2)Exceptwhenwaivedunderparagraph(c)or(d)ofthissection,thefacilitymustdesignatearegisterednursetoserveasthedirectorofnursingonafulltimebasis.
1
483.35(b)(3) (3)Thedirectorofnursingmayserveasachargenurseonlywhenthefacilityhasanaveragedailyoccupancyof60orfewerresidents.
1
483.35(c) (c)Proficiencyofnurseaides.Thefacilitymustensurethatnurseaidesareabletodemonstratecompetencyinskillsandtechniquesnecessarytocareforresidents’needs,asidentifiedthroughresidentassessments,anddescribedintheplanofcare.
1
483.35(d) (d)Requirementsforfacilityhiringanduseofnursingaides--
1
483.35(d)(1) (1)Generalrule.Afacilitymustnotuseanyindividualworkinginthefacilityasanurseaideformorethan4months,onafull-timebasis,unless—
1
483.35(d)(1)(i) (i)Thatindividualiscompetentto 1
97
providenursingandnursingrelatedservices;and
483.35(d)(1)(ii)(A) (ii)(A)Thatindividualhascompletedatrainingandcompetencyevaluationprogram,oracompetencyevaluationprogramapprovedbytheStateasmeetingtherequirementsof§483.151through§483.154;or
1
483.35(d)(1)(ii)(B)
(B)Thatindividualhasbeendeemedordeterminedcompetentasprovidedin§483.150(a)and(b).
1
483.35(d)(2) (2)Non-permanentemployees.Afacilitymustnotuseonatemporary,perdiem,leased,oranybasisotherthanapermanentemployeeanyindividualwhodoesnotmeettherequirementsinparagraphs(d)(1)(i)and(ii)ofthissection.
1
483.35(d)(3) (3)Minimumcompetency.Afacilitymustnotuseanyindividualwhohasworkedlessthan4monthsasanurseaideinthatfacilityunlesstheindividual—
1
483.35(d)(3)(i) (i)Isafull-timeemployeeinaState-approvedtrainingandcompetencyevaluationprogram;
1
483.35(d)(3)(ii) (ii)HasdemonstratedcompetencethroughsatisfactoryparticipationinaState-approvednurseaidetrainingandcompetencyevaluationprogramorcompetencyevaluationprogram;or
1
483.35(d)(3)(iii) (iii)Hasbeendeemedordeterminedcompetentasprovidedin§483.150(a)and(b).
1
483.35(d)(4) (4)Registryverification.Beforeallowinganindividualtoserveasanurseaide,a
1
98
facilitymustreceiveregistryverificationthattheindividualhasmetcompetencyevaluationrequirementsunless—
483.35(d)(4)(i) (i)Theindividualisafull-timeemployeeinatrainingandcompetencyevaluationprogramapprovedbytheState;or
1
483.35(d)(4)(ii) (ii)TheindividualcanprovethatheorshehasrecentlysuccessfullycompletedatrainingandcompetencyevaluationprogramorcompetencyevaluationprogramapprovedbytheStateandhasnotyetbeenincludedintheregistry.Facilitiesmustfollowuptoensurethatsuchanindividualactuallybecomesregistered.
1
483.35(d)(5) (5)Multi-Stateregistryverification.Beforeallowinganindividualtoserveasanurseaide,afacilitymustseekinformationfromeveryStateregistryestablishedundersections1819(e)(2)(A)or1919(e)(2)(A)oftheActthatthefacilitybelieveswillincludeinformationontheindividual.
1
483.35(d)(6) (6)Requiredretraining.If,sinceanindividual’smostrecentcompletionofatrainingandcompetencyevaluationprogram,therehasbeenacontinuousperiodof24consecutivemonthsduringnoneofwhichtheindividualprovidednursingornursing-relatedservicesformonetarycompensation,theindividualmustcompleteanewtrainingandcompetencyevaluationprogramoranewcompetencyevaluationprogram.
1
483.35(d)(7) (7)Regularin-serviceeducation.The 1
99
facilitymustcompleteaperformancereviewofeverynurseaideatleastonceevery12months,andmustprovideregularin-serviceeducationbasedontheoutcomeofthesereviews.In-servicetrainingmustcomplywiththerequirementsof§483.95(g).
483.35(e) (e)Nursingfacilities:Waiverofrequirementtoprovidelicensednursesona24-hourbasis.Totheextentthatafacilityisunabletomeettherequirementsofparagraphs(a)(2)and(b)(1)ofthissection,aStatemaywaivesuchrequirementswithrespecttothefacilityif—
1
483.35(e)(1) (1)ThefacilitydemonstratestothesatisfactionoftheStatethatthefacilityhasbeenunable,despitediligentefforts(includingofferingwagesatthecommunityprevailingratefornursingfacilities),torecruitappropriatepersonnel;
1
483.35(e)(2) (2)TheStatedeterminesthatawaiveroftherequirementwillnotendangerthehealthorsafetyofindividualsstayinginthefacility;
1
483.35(e)(3) (3)TheStatefindsthat,foranyperiodsinwhichlicensednursingservicesarenotavailable,aregisterednurseoraphysicianisobligatedtorespondimmediatelytotelephonecallsfromthefacility;
1
483.35(e)(4) (4)Awaivergrantedundertheconditionslistedinparagraph(c)ofthissectionissubjecttoannualStatereview;
1 483.35(e)(4) (4)Awaivergrantedundertheconditionslistedinparagraph(e)ofthissectionissubjecttoannualStatereview;
100
483.35(e)(5) (5)Ingrantingorrenewingawaiver,afacilitymayberequiredbytheStatetouseotherqualified,licensedpersonnel;
1
483.35(e)(6) (6)TheStateagencygrantingawaiverofsuchrequirementsprovidesnoticeofthewaivertotheOfficeoftheStateLong-TermCareOmbudsman(establishedundersection712oftheOlderAmericansActof1965)andtheprotectionandadvocacysystemintheStateforindividualswithamentaldisorderwhoareeligibleforsuchservicesasprovidedbytheprotectionandadvocacyagency;and
1
483.35(e)(7) (7)ThenursingfacilitythatisgrantedsuchawaiverbyaStatenotifiesresidentsofthefacilityandtheirresidentrepresentativesofthewaiver.
1
483.35(f)
(f)SNFs:Waiveroftherequirementtoprovideservicesofaregisterednurseformorethan40hoursaweek.
1
483.35(f)(1) (1)TheSecretarymaywaivetherequirementthataSNFprovidetheservicesofaregisterednurseformorethan40hoursaweek,includingadirectorofnursingspecifiedinparagraph(b)ofthissection,iftheSecretaryfindsthat—
1
483.35(f)(1)(i) (i)Thefacilityislocatedinaruralareaandthesupplyofskillednursingfacilityservicesintheareaisnotsufficienttomeettheneedsofindividualsresidinginthearea;
1
483.35(f)(1)(ii) (ii)Thefacilityhasonefull-timeregisterednursewhoisregularlyonduty
1
101
atthefacility40hoursaweek;and483.35(f)(1)(iii) (iii)Thefacilityeither— 1 483.35(f)(1)(iii)(A) (A)Hasonlypatientswhosephysicians
haveindicated(throughphysicians’ordersoradmissionnotes)thattheydonotrequiretheservicesofaregisterednurseoraphysicianfora48-hoursperiod,or
1
483.35(f)(1)(iii)(B) (B)Hasmadearrangementsforaregisterednurseoraphysiciantospendtimeatthefacility,asdeterminednecessarybythephysician,toprovidenecessaryskillednursingservicesondayswhentheregularfull-timeregisterednurseisnotonduty;
1
483.35(f)(1)(iv) (iv)TheSecretaryprovidesnoticeofthewaivertotheOfficeoftheStateLong-TermCareOmbudsman(establishedundersection712oftheOlderAmericansActof1965)andtheprotectionandadvocacysystemintheStateforindividualswithdevelopmentaldisabilitiesormentaldisorders;and
1
483.35(f)(1)(v) (v)Thefacilitythatisgrantedsuchawaivernotifiesresidentsofthefacilityandtheirresidentrepresentativesofthewaiver.
1
483.35(f)(2) (2)Awaiveroftheregisterednurserequirementunderparagraph(d)(1)ofthissectionissubjecttoannualrenewalbytheSecretary.
1 483.35(f)(2) (2)Awaiveroftheregisterednurserequirementunderparagraph(f)(1)ofthissectionissubjecttoannualrenewalbytheSecretary.
483.35(g) (g)Nursestaffinginformation— 1 483.35(g)(1) (1)Datarequirements.Thefacilitymust
postthefollowinginformationonadailybasis:
1
102
483.35(g)(1)(i) (i)Facilityname. 1 483.35(g)(1)(ii) (ii)Thecurrentdate. 1 483.35(g)(1)(iii) (iii)Thetotalnumberandtheactual
hoursworkedbythefollowingcategoriesoflicensedandunlicensednursingstaffdirectlyresponsibleforresidentcarepershift:
1
483.35(g)(1)(iii)(A) (A)Registerednurses. 1 483.35(g)(1)(iii)(B) (B)Licensedpracticalnursesorlicensed
vocationalnurses(asdefinedunderStatelaw).
1
483.35(g)(1)(iii)(C) (C)Certifiednurseaides. 1 483.35(g)(1)(iv) (iv)Residentcensus. 1 483.35(g)(2) (2)Postingrequirements. 1 483.35(g)(2)(i) (i)Thefacilitymustpostthenurse
staffingdataspecifiedinparagraph(e)(1)ofthissectiononadailybasisatthebeginningofeachshift.
1
483.35(g)(2)(ii) (ii)Datamustbepostedasfollows: 1 483.35(g)(2)(ii)(A) (A)Clearandreadableformat. 1 483.35(g)(2)(ii)(B) (B)Inaprominentplacereadily
accessibletoresidentsandvisitors.1
483.35(g)(3) (3)Publicaccesstopostednursestaffingdata.Thefacilitymust,uponoralorwrittenrequest,makenursestaffingdataavailabletothepublicforreviewatacostnottoexceedthecommunitystandard.
1
483.35(g)(4) (4)Facilitydataretentionrequirements.Thefacilitymustmaintaintheposteddailynursestaffingdataforaminimumof18months,orasrequiredbyStatelaw,whicheverisgreater.
1 483.35(g)(4) (4)Facilitydataretentionrequirements.Thefacilitymustmaintaintheposteddailynursestaffingdataforaminimumof15months,orasrequiredbystatelaw,whicheverisgreater.
§483.40 Behavioralhealthservices. Thissectionwasimplementedin
103
Phase2withthefollowingexceptions:
§483.40(a)(1),whichwillbe
implementedinPhase3,and§483.40(b)(1),(b)(2),and§483.40(d),whichwere
implementedinPhase1.
483.40 Eachresidentmustreceiveandthefacilitymustprovidethenecessarybehavioralhealthcareandservicestoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-being,inaccordancewiththecomprehensiveassessmentandplanofcare.Behavioralhealthencompassesaresident’swholeemotionalandmentalwell-being,whichincludes,butisnotlimitedto,thepreventionandtreatmentofmentalandsubstanceusedisorders.
2
483.40(a) (a)Thefacilitymusthavesufficientstaffwhoprovidedirectservicestoresidentswiththeappropriatecompetenciesandskillssetstoprovidenursingandrelatedservicestoassureresidentsafetyandattainormaintainthehighestpracticablephysical,mentalandpsychosocialwell-beingofeachresident,asdeterminedbyresidentassessmentsandindividualplansofcareandconsideringthe
2
483.40(a) (a)Inaccordancewith§483.35,thefacilitymusthavesufficientstaffwhoprovidedirectservicestoresidentswithcompetenciesandskillssetsthatinclude,butarenotlimitedto,knowledgeofandappropriatetrainingandsupervisionfor:
104
number,acuityanddiagnosesofthefacility’sresidentpopulationinaccordancewith§483.70(e).Thesecompetenciesandskillssetsinclude,butarenotlimitedto,knowledgeofandappropriatetrainingandsupervisionfor:
483.40(a)(1) (1)Caringforresidentswithmentalandpsychosocialdisorders,aswellasresidentswithahistoryoftraumaand/orpost-traumaticstressdisorder,thathavebeenidentifiedinthefacilityassessmentconductedpursuantto§483.70(e),and
3
483.40(a)(2) (2)Implementingnonpharmacologicalinterventions.
2
483.40(b) (b)Basedonthecomprehensiveassessmentofaresident,thefacilitymustensurethat—
2
483.40(b)(1) (1)Aresidentwhodisplaysorisdiagnosedwithmentaldisorderorpsychosocialadjustmentdifficulty,orwhohasahistoryoftraumaand/orposttraumaticstressdisorder,receivesappropriatetreatmentandservicestocorrecttheassessedproblemortoattainthehighestpracticablementalandpsychosocialwell-being;
1
483.40(b)(2) (2)Aresidentwhoseassessmentdidnotrevealorwhodoesnothaveadiagnosisofamentalorpsychosocialadjustmentdifficultyoradocumentedhistoryoftraumaand/orpost-traumaticstressdisorderdoesnotdisplayapatternofdecreasedsocialinteractionand/orincreasedwithdrawn,angry,ordepressivebehaviors,unlessthe
1
105
resident’sclinicalconditiondemonstratesthatdevelopmentofsuchapatternwasunavoidable;and
483.40(b)(3) (3)Aresidentwhodisplaysorisdiagnosedwithdementia,receivestheappropriatetreatmentandservicestoattainormaintainhisorherhighestpracticablephysical,mental,andpsychosocialwell-being.
2
483.40(c) (c)Ifrehabilitativeservicessuchasbutnotlimitedtophysicaltherapy,speech-languagepathology,occupationaltherapy,andrehabilitativeservicesformentaldisordersandintellectualdisability,arerequiredintheresident’scomprehensiveplanofcare,thefacilitymust—
2 483.40(c) (c)Ifrehabilitativeservicessuchasbutnotlimitedtophysicaltherapy,speech-languagepathology,occupationaltherapy,andrehabilitativeservicesformentaldisordersandintellectualdisability,arerequiredintheresident’scomprehensiveplanofcare,thefacilitymust—
483.40(c)(1) (1)Providetherequiredservices,includingspecializedrehabilitationservicesasrequiredin§483.65;or
2 483.40(c)(1) (1)Providetherequiredservices,includingspecializedrehabilitationservicesasrequiredin§483.65;or
483.40(c)(2) (2)Obtaintherequiredservicesfromanoutsideresource(inaccordancewith§483.70(g)ofthispart)fromaMedicareand/orMedicaidproviderofspecializedrehabilitativeservices.
2 483.40(c)(2) (2)Obtaintherequiredservicesfromanoutsideresource(inaccordancewith§483.70(g)ofthispart)fromaMedicareand/orMedicaidproviderofspecializedrehabilitativeservices.
483.40(d) (d)Thefacilitymustprovidemedically-relatedsocialservicestoattainormaintainthehighestpracticablephysical,mentalandpsychosocialwell-beingofeachresident.
1 483.40(c) (c)Thefacilitymustprovidemedically-relatedsocialservicestoattainormaintainthehighestpracticablephysical,mentalandpsychosocialwell-beingofeachresident.
§483.45 Pharmacyservices. ThissectionwasimplementedinPhase1withthe
followingexceptions:
106
§483.45(c)(2)and§483.45(e),
whichwasimplementedin
Phase2.483.45 Thefacilitymustprovideroutineand
emergencydrugsandbiologicalstoitsresidents,orobtainthemunderanagreementdescribedin§483.75(h)ofthispart.ThefacilitymaypermitunlicensedpersonneltoadministerdrugsifStatelawpermits,butonlyunderthegeneralsupervisionofalicensednurse.
1
483.45(a) (a)Procedures.Afacilitymustprovidepharmaceuticalservices(includingproceduresthatassuretheaccurateacquiring,receiving,dispensing,andadministeringofalldrugsandbiologicals)tomeettheneedsofeachresident.
1
483.45(b) (b)Serviceconsultation.Thefacilitymustemployorobtaintheservicesofalicensedpharmacistwho—
1
483.45(b)(1) (1)Providesconsultationonallaspectsoftheprovisionofpharmacyservicesinthefacility;
1
483.45(b)(2) (2)Establishesasystemofrecordsofreceiptanddispositionofallcontrolleddrugsinsufficientdetailtoenableanaccuratereconciliation;and
1
483.45(b)(3) (3)Determinesthatdrugrecordsareinorderandthatanaccountofallcontrolleddrugsismaintainedandperiodicallyreconciled.
1
483.45(c) (c)Drugregimenreview. 1 483.45(c)(1) (1)Thedrugregimenofeachresident 1
107
mustbereviewedatleastonceamonthbyalicensedpharmacist.
483.45(c)(2) (2)Thisreviewmustincludeareviewoftheresident’smedicalchart.
2
483.45(c)(3) (3)Apsychotropicdrugisanydrugthataffectsbrainactivitiesassociatedwithmentalprocessesandbehavior.Thesedrugsinclude,butarenotlimitedto,drugsinthefollowingcategories:
1
483.45(c)(3)(i) (i)Anti-psychotic; 1 483.45(c)(3)(ii) (ii)Anti-depressant; 1 483.45(c)(3)(iii) (iii)Anti-anxiety;and 1 483.45(c)(3)(iv) (iv)Hypnotic. 1 483.45(c)(4) (4)Thepharmacistmustreportany
irregularitiestotheattendingphysicianandthefacility’smedicaldirectoranddirectorofnursing,andthesereportsmustbeactedupon.
1
483.45(c)(4)(i) (i)Irregularitiesinclude,butarenotlimitedto,anydrugthatmeetsthecriteriasetforthinparagraph(d)ofthissectionforanunnecessarydrug.
1
483.45(c)(4)(ii) (ii)Anyirregularitiesnotedbythepharmacistduringthisreviewmustbedocumentedonaseparate,writtenreportthatissenttotheattendingphysicianandthefacility’smedicaldirectoranddirectorofnursingandlists,ataminimum,theresident’sname,therelevantdrug,andtheirregularitythepharmacistidentified.
1
483.45(c)(4)(iii) (iii)Theattendingphysicianmustdocumentintheresident’smedicalrecordthattheidentifiedirregularityhas
1
108
beenreviewedandwhat,ifany,actionhasbeentakentoaddressit.Ifthereistobenochangeinthemedication,theattendingphysicianshoulddocumenthisorherrationaleintheresident’smedicalrecord.
483.45(c)(5) (5)Thefacilitymustdevelopandmaintainpoliciesandproceduresforthemonthlydrugregimenreviewthatinclude,butarenotlimitedto,timeframesforthedifferentstepsintheprocessandstepsthepharmacistmusttakewhenheorsheidentifiesanirregularitythatrequiresurgentactiontoprotecttheresident.
1
483.45(d) (d)Unnecessarydrugs—General.Eachresident’sdrugregimenmustbefreefromunnecessarydrugs.Anunnecessarydrugisanydrugwhenused—
1
483.45(d)(1) (1)Inexcessivedose(includingduplicatedrugtherapy);or
1
483.45(d)(2) (2)Forexcessiveduration;or 1 483.45(d)(3) (3)Withoutadequatemonitoring;or 1 483.45(d)(4) (4)Withoutadequateindicationsforits
use;or1
483.45(d)(5) (5)Inthepresenceofadverseconsequenceswhichindicatethedoseshouldbereducedordiscontinued;or
1
483.45(d)(6) (6)Anycombinationsofthereasonsstatedinparagraphs(d)(1)through(5)ofthissection.
1
483.45(e) (e)Psychotropicdrugs.Basedonacomprehensiveassessmentofaresident,thefacilitymustensurethat—
2
483.45(e)(1) (1)Residentswhohavenotused 2
109
psychotropicdrugsarenotgiventhesedrugsunlessthemedicationisnecessarytotreataspecificconditionasdiagnosedanddocumentedintheclinicalrecord;
483.45(e)(2) (2)Residentswhousepsychotropicdrugsreceivegradualdosereductions,andbehavioralinterventions,unlessclinicallycontraindicated,inanefforttodiscontinuethesedrugs;
2
483.45(e)(3) (3)ResidentsdonotreceivepsychotropicdrugspursuanttoaPRNorderunlessthatmedicationisnecessarytotreatadiagnosedspecificconditionthatisdocumentedintheclinicalrecord;and
2
483.45(e)(4) (4)PRNordersforpsychotropicdrugsarelimitedto14days.Exceptasprovidedin§483.45(e)(5),iftheattendingphysicianorprescribingpractitionerbelievesthatitisappropriateforthePRNordertobeextendedbeyond14days,heorsheshoulddocumenttheirrationaleintheresident’smedicalrecordandindicatethedurationforthePRNorder.
2 483.45(e)(4) (4)PRNordersforpsychotropicdrugsarelimitedto14days.IftheattendingphysicianorprescribingpractitionerbelievesthatitisappropriateforthePRNordertobeextendedbeyond14days,theordercanbeextendedinaccordancewithfacilitypolicyifheorshedocumentshisorherrationaleintheresident’smedicalrecordandindicatesthedurationforthePRNorder.
483.45(e)(5) (5)PRNordersforanti-psychoticdrugsarelimitedto14daysandcannotberenewedunlesstheattendingphysicianorprescribingpractitionerevaluatestheresidentfortheappropriatenessofthatmedication.
2 483.45(e)(5) (5)Itdevelopsandmaintainspolicies,standards,andproceduresregardingtheuseofPRNordersforpsychotropics,usingrecognizedstandardsofpractice,includingthecircumstancesinwhichPRNordersforpsychotropicdrugscanbeextendedbeyond14days.Thepolicymust:
483.45(e)(5)(i) (i)Takeintoconsiderationthefacility’sresidentpopulation,theindividualresidents’needsforpsychotropicdrugs,andtheiraccesstophysiciansandotherhealthcarepractitioners;and
483.45(e)(5)(ii) (ii)Include,ataminimum,thefollowingelements: 483.45(e)(5)(ii)( (A)Standardsregardingthefrequencywithwhichthe
110
A) attendingphysicianortheprescribingpractitionermustreviewthePRNorder.ThefrequencyofPRNreviewmustbenolessthanthefrequencyoftherequiredphysicianvisitsassetforthat§483.30(c).(483.30(c)(1)statesatleastevery30daysforfirst90daysafteradmission;thenatleastevery60daysthereafter.483.30(c)(2)statesthatavisitisconsideredtimelyifwithin10daysafterthevisitwasrequired.)
483.45(e)(5)(ii)(B)
(B)Documentationrequirementsregardingthediagnosis,indicationsforuse,includingnursingdocumentationdescribingthecircumstancesthatsupporttheadministrationofthemedication,andjustificationforprolongeduse.
483.45(e)(5)(ii)(C)
(C)Disclosurerequirementsthatthefacilitymustmaketotheresidentandhisorherrepresentativeforwhenaresidentisprescribedananti-psychotic.
483.45(f) (f)Medicationerrors.Thefacilitymustensurethatits—
1
483.45(f)(1) (1)Medicationerrorratesarenot5percentorgreater;and
1
483.45(f)(2) (2)Residentsarefreeofanysignificantmedicationerrors.
1
483.45(g) (g)Labelingofdrugsandbiologicals.Drugsandbiologicalsusedinthefacilitymustbelabeledinaccordancewithcurrentlyacceptedprofessionalprinciples,andincludetheappropriateaccessoryandcautionaryinstructions,andtheexpirationdatewhenapplicable.
1
483.45(h) (h)Storageofdrugsandbiologicals. 1 483.45(h)(1) (1)InaccordancewithStateandFederal
laws,thefacilitymuststorealldrugsandbiologicalsinlockedcompartmentsunderpropertemperaturecontrols,andpermitonlyauthorizedpersonneltohave
1
111
accesstothekeys.483.45(h)(2) (2)Thefacilitymustprovideseparately
locked,permanentlyaffixedcompartmentsforstorageofcontrolleddrugslistedinScheduleIIoftheComprehensiveDrugAbusePreventionandControlActof1976andotherdrugssubjecttoabuse,exceptwhenthefacilityusessingleunitpackagedrugdistributionsystemsinwhichthequantitystoredisminimalandamissingdosecanbereadilydetected.
1
§483.50 Laboratory,radiology,andotherdiagnosticservices.
Thisentiresectionwas
implementedinPhase1.
483.50(a) (a)Laboratoryservices. 1 483.50(a)(1) (1)Thefacilitymustprovideorobtain
laboratoryservicestomeettheneedsofitsresidents.Thefacilityisresponsibleforthequalityandtimelinessoftheservices.
1
483.50(a)(1)(i) (i)Ifthefacilityprovidesitsownlaboratoryservices,theservicesmustmeettheapplicablerequirementsforlaboratoriesspecifiedinpart493ofthischapter.
1
483.50(a)(1)(ii) (ii)Ifthefacilityprovidesbloodbankandtransfusionservices,itmustmeettheapplicablerequirementsforlaboratoriesspecifiedinpart493ofthischapter.
1
483.50(a)(1)(iii) (iii)Ifthelaboratorychoosestoreferspecimensfortestingtoanotherlaboratory,thereferrallaboratorymustbecertifiedintheappropriatespecialties
1
112
andsubspecialtiesofservicesinaccordancewiththerequirementsofpart493ofthischapter.
483.50(a)(1)(iv) (iv)Ifthefacilitydoesnotprovidelaboratoryservicesonsite,itmusthaveanagreementtoobtaintheseservicesfromalaboratorythatmeetstheapplicablerequirementsofpart493ofthischapter.
1
483.50(a)(2) (2)Thefacilitymust: 1 483.50(a)(2)(i) (i)Provideorobtainlaboratoryservices
onlywhenorderedbyaphysician;physicianassistant;nursepractitionerorclinicalnursespecialistinaccordancewithStatelaw,includingscopeofpracticelaws.
1
483.50(a)(2)(ii)
(ii)Promptlynotifytheorderingphysician,physicianassistant,nursepractitioner,orclinicalnursespecialistoflaboratoryresultsthatfalloutsideofclinicalreferencerangesinaccordancewithfacilitypoliciesandproceduresfornotificationofapractitionerorpertheorderingphysician’sorders.
1
483.50(a)(2)(iii) (iii)Assisttheresidentinmakingtransportationarrangementstoandfromthesourceofservice,iftheresidentneedsassistance;and
1
483.50(a)(2)(iv) (iv)Fileintheresident’sclinicalrecordlaboratoryreportsthataredatedandcontainthenameandaddressofthetestinglaboratory.
1
483.50(b) (b)Radiologyandotherdiagnosticservices.
1
483.50(b)(1) (1)Thefacilitymustprovideorobtain 1
113
radiologyandotherdiagnosticservicestomeettheneedsofitsresidents.Thefacilityisresponsibleforthequalityandtimelinessoftheservices.
483.50(b)(1)(i) (i)Ifthefacilityprovidesitsowndiagnosticservices,theservicesmustmeettheapplicableconditionsofparticipationforhospitalscontainedin§482.26ofthissubchapter.
1
483.50(b)(1)(ii) (ii)Ifthefacilitydoesnotprovideitsowndiagnosticservices,itmusthaveanagreementtoobtaintheseservicesfromaproviderorsupplierthatisapprovedtoprovidetheseservicesunderMedicare.
1
483.50(b)(2) (2)Thefacilitymust: 1 483.50(b)(2)(i) (i)Provideorobtainradiologyandother
diagnosticservicesonlywhenorderedbyaphysician;physicianassistant;nursepractitionerorclinicalnursespecialistinaccordancewithStatelaw,includingscopeofpracticelaws.
1
483.50(b)(2)(ii) (ii)Promptlynotifytheorderingphysician,physicianassistant,nursepractitioner,orclinicalnursespecialistofresultsthatfalloutsideofclinicalreferencerangesinaccordancewithfacilitypoliciesandproceduresfornotificationofapractitionerorpertheorderingphysician’sorders.
1
483.50(b)(2)(iii) (iii)Assisttheresidentinmakingtransportationarrangementstoandfromthesourceofservice,iftheresidentneedsassistance;and
1
483.50(b)(2)(iv) (iv)Fileintheresident’sclinicalrecordsignedanddatedreportsofx-rayand
1
114
otherdiagnosticservices.§483.55 Dentalservices. Thissectionwas
implementedinPhase1withthe
followingexceptions:
§483.55(a)(3),(a)(5),(b)(3),and(b)(4),whichwasimplementedin
Phase2.
483.55 Thefacilitymustassistresidentsinobtainingroutineand24-houremergencydentalcare.
1
483.55(a) (a)Skillednursingfacilities.Afacility 1 483.55(a)(1) (1)Mustprovideorobtainfroman
outsideresource,inaccordancewith§483.75(h)ofthispart,routineandemergencydentalservicestomeettheneedsofeachresident;
1
483.55(a)(2) (2)MaychargeaMedicareresidentanadditionalamountforroutineandemergencydentalservices;
1
483.55(a)(3) (3)Musthaveapolicyidentifyingthosecircumstanceswhenthelossordamageofdenturesisthefacility’sresponsibilityandmaynotchargearesidentforthelossordamageofdenturesdeterminedinaccordancewithfacilitypolicytobethefacility’sresponsibility;
2
483.55(a)(4) (4)Mustifnecessaryorifrequested,assisttheresident—
1
483.55(a)(4)(i) (i)Inmakingappointments;and 1 483.55(a)(4)(ii) (ii)Byarrangingfortransportationtoand
fromthedentalserviceslocation;and1
115
483.55(a)(5) (5)Mustpromptly,within3days,referresidentswithlostordamageddenturesfordentalservices.Ifareferraldoesnotoccurwithin3days,thefacilitymustprovidedocumentationofwhattheydidtoensuretheresidentcouldstilleatanddrinkadequatelywhileawaitingdentalservicesandtheextenuatingcircumstancesthatledtothedelay.
2
483.55(b) (b)Nursingfacilities.Thefacility 1 483.55(b)(1) (1)Mustprovideorobtainfroman
outsideresource,inaccordancewith§483.70(g)ofthispart,thefollowingdentalservicestomeettheneedsofeachresident:
1
483.55(b)(1)(i) (i)Routinedentalservices(totheextentcoveredundertheStateplan);and(ii)Emergencydentalservices;
1
483.55(b)(2) (2)Must,ifnecessaryorifrequested,assisttheresident—
1
483.55(b)(2)(i) (i)Inmakingappointments;and 1 483.55(b)(2)(ii) (ii)Byarrangingfortransportationtoand
fromthedentalserviceslocations;1
483.55(b)(3) (3)Mustpromptly,within3days,referresidentswithlostordamageddenturesfordentalservices.Ifareferraldoesnotoccurwithin3days,thefacilitymustprovidedocumentationofwhattheydidtoensuretheresidentcouldstilleatanddrinkadequatelywhileawaitingdentalservicesandtheextenuatingcircumstancesthatledtothedelay;
2
483.55(b)(4) (4)Musthaveapolicyidentifyingthosecircumstanceswhenthelossordamageofdenturesisthefacility’sresponsibility
2
116
andmaynotchargearesidentforthelossordamageofdenturesdeterminedinaccordancewithfacilitypolicytobethefacility’sresponsibility;and
483.55(b)(5) (5)MustassistresidentswhoareeligibleandwishtoparticipatetoapplyforreimbursementofdentalservicesasanincurredmedicalexpenseundertheStateplan.
1
§483.60 Foodandnutritionservices. ThissectionwasimplementedinPhase1withthe
followingexceptions:§483.60(a)as
linkedtoFacilityAssessmentat§483.70(e),whichwas
implementedinPhase2;
§483.60(a)(1)(iv),whichwillbeimplemented5yearsfollowingeffectivedateofthefinalrule;§483.60(a)(2)(i)whichwillbe
implemented5yearsfollowingtheeffective
dateofthefinalrule;and
§483.60(a)(2)(i)whichwillbe
117
implemented1yearfollowingtheeffective
dateofthefinalrule.
483.60 Thefacilitymustprovideeachresidentwithanourishing,palatable,well-balanceddietthatmeetshisorherdailynutritionalandspecialdietaryneeds,takingintoconsiderationthepreferencesofeachresident.
1
483.60(a) (a)Staffing.Thefacilitymustemploysufficientstaffwiththeappropriatecompetenciesandskillssetstocarryoutthefunctionsofthefoodandnutritionservice,takingintoconsiderationresidentassessments,individualplansofcareandthenumber,acuityanddiagnosesofthefacility’sresidentpopulationinaccordancewiththefacilityassessmentrequiredat§483.70(e).Thisincludes:
2
483.60(a)(1) (1)Aqualifieddietitianorotherclinicallyqualifiednutritionprofessionaleitherfull-time,part-time,oronaconsultantbasis.Aqualifieddietitianorotherclinicallyqualifiednutritionprofessionalisonewho—
1
483.60(a)(1)(i) (i)Holdsabachelor’sorhigherdegreegrantedbyaregionallyaccreditedcollegeoruniversityintheUnitedStates(oranequivalentforeigndegree)withcompletionoftheacademicrequirementsofaprograminnutritionordieteticsaccreditedbyanappropriate
1
118
nationalaccreditationorganizationrecognizedforthispurpose.
483.60(a)(1)(ii) (ii)Hascompletedatleast900hoursofsuperviseddieteticspracticeunderthesupervisionofaregistereddietitianornutritionprofessional.
1
483.60(a)(1)(iii) (iii)IslicensedorcertifiedasadietitianornutritionprofessionalbytheStateinwhichtheservicesareperformed.Inastatethatdoesnotprovideforlicensureorcertification,theindividualwillbedeemedtohavemetthisrequirementifheorsheisrecognizedasa‘‘registereddietitian’’bytheCommissiononDieteticRegistrationoritssuccessororganization,ormeetstherequirementsofparagraphs(a)(1)(i)and(ii)ofthissection.
1
483.60(a)(1)(iv) (iv)FordietitianshiredorcontractedwithpriortoNovember28,2016,meetstheserequirementsnolaterthan5yearsafterNovember28,2016orasrequiredbystatelaw.
ImplementationbyNovember28,
2021.
483.60(a)(2) (2)Ifaqualifieddietitianorotherclinicallyqualifiednutritionprofessionalisnotemployedfull-time,thefacilitymustdesignateapersontoserveasthedirectoroffoodandnutritionserviceswho—
1 483.60(a)(2) (2)Ifaqualifieddietitianorotherclinicallyqualifiednutritionprofessionalisnotemployedfull-time,thefacilitymustdesignateapersontoserveasthedirectoroffoodandnutritionservices.
483.60(a)(2)(i) (i)FordesignationspriortoNovember28,2016,meetsthefollowingrequirementsnolaterthan5yearsafterNovember28,2016,ornolaterthan1yearafterNovember28,2016fordesignationsafterNovember28,2016,is:
1 483.60(a)(2)(i) (i)Thedirectoroffoodandnutritionservicesisonewhoataminimum—
483.60(a)(2)(i)(A) (A)Acertifieddietarymanager;or Bynolaterthan 483.60(a)(2)(i)( (A)Hastwoormoreyearsofexperienceintheposition
119
November28,2021if
designatedpriortoNovember28,
2016;BynolaterthanNovember28,
2017ifdesignatedafterNovember28,
2016.
A) ofdirectoroffoodandnutritionservicesinanursingfacilitysettingor;
483.60(a)(2)(i)(B) (B)Acertifiedfoodservicemanager,or BynolaterthanNovember28,
2021ifdesignatedpriortoNovember28,
2016;BynolaterthanNovember28,
2017ifdesignatedafterNovember28,
2016.
483.60(a)(2)(i)(B)
(B)Hascompletedacourseofstudyinfoodsafetyandmanagementthatincludestopicsintegraltomanagingdietaryoperationssuchas,butnotlimitedto,foodborneillness,sanitationprocedures,andfoodpurchasing/receiving.
483.60(a)(2)(i)(C) (C)Hassimilarnationalcertificationforfoodservicemanagementandsafetyfromanationalcertifyingbody;or
BynolaterthanNovember28,
2021ifdesignatedpriortoNovember28,
2016;BynolaterthanNovember28,
2017ifdesignatedafterNovember28,
2016.
483.60(a)(2)(i)(C)
(C)Hassimilarnationalcertificationforfoodservicemanagementandsafetyfromanationalcertifyingbody;or
483.60(a)(2)(i)(D) (D)Hasanassociate’sorhigherdegreein Bynolaterthan 483.60(a)(2)(i)( (D)Hasanassociate’sorhigherdegreeinfoodservice
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foodservicemanagementorinhospitality,ifthecoursestudyincludesfoodserviceorrestaurantmanagement,fromanaccreditedinstitutionofhigherlearning;and
November28,2021if
designatedpriortoNovember28,
2016;BynolaterthanNovember28,
2017ifdesignatedafterNovember28,
2016.
D) managementorinhospitality,ifthecoursestudyincludesfoodserviceorrestaurantmanagement,fromanaccreditedinstitutionofhigherlearning;and
483.60(a)(2)(ii) (ii)InStatesthathaveestablishedstandardsforfoodservicemanagersordietarymanagers,meetsStaterequirementsforfoodservicemanagersordietarymanagers,and
1 483.60(a)(2)(ii) (ii)InStatesthathaveestablishedstandardsforfoodservicemanagersordietarymanagers,meetsStaterequirementsforfoodservicemanagersordietarymanagers,and
483.60(a)(2)(iii)
(iii)Receivesfrequentlyscheduledconsultationsfromaqualifieddietitianorotherclinicallyqualifiednutritionprofessional.
1 483.60(a)(2)(ii) (ii)Thedirectoroffoodandnutritionservicesmustreceivefrequentlyscheduledconsultationfromaqualifieddietitianorotherclinicallyqualifiednutritionprofessional.
483.60(a)(3) (3)Supportstaff.Thefacilitymustprovidesufficientsupportpersonneltosafelyandeffectivelycarryoutthefunctionsofthefoodandnutritionservice.
1
483.60(b) (b)AmemberoftheFoodandNutritionServicesstaffmustparticipateontheinterdisciplinaryteamasrequiredin§483.21(b)(2)(ii).
1
483.60(c) (c)Menusandnutritionaladequacy.Menusmust—
1
483.60(c)(1) (1)Meetthenutritionalneedsofresidentsinaccordancewithestablishednationalguidelines.;
1
483.60(c)(2) (2)Bepreparedinadvance; 1
121
483.60(c)(3) (3)Befollowed; 1 483.60(c)(4) (4)Reflect,basedonafacility’s
reasonableefforts,thereligious,cultural,andethnicneedsoftheresidentpopulation,aswellasinputreceivedfromresidentsandresidentgroups;
1
483.60(c)(5) (5)Beupdatedperiodically; 1 483.60(c)(6) (6)Bereviewedbythefacility’sdietitian
orotherclinicallyqualifiednutritionprofessionalfornutritionaladequacy;and
1
483.60(c)(7) (7)Nothinginthisparagraphshouldbeconstruedtolimittheresident’srighttomakepersonaldietarychoices.
1
483.60(d) (d)Foodanddrink.Eachresidentreceivesandthefacilityprovides—
1
483.60(d)(1) (1)Foodpreparedbymethodsthatconservenutritivevalue,flavor,andappearance;
1
483.60(d)(2) (2)Foodanddrinkthatispalatable,attractive,andatasafeandappetizingtemperature;
1
483.60(d)(3) (3)Foodpreparedinaformdesignedtomeetindividualneeds;
1
483.60(d)(4) (4)Foodthataccommodatesresidentallergies,intolerances,andpreferences;
1
483.60(d)(5) (5)Appealingoptionsofsimilarnutritivevaluetoresidentswhochoosenottoeatfoodthatisinitiallyservedorwhorequestadifferentmealchoice;and
1
483.60(d)(6) (6)Drinks,includingwaterandotherliquidsconsistentwithresidentneedsandpreferencesandsufficienttomaintainresidenthydration.
1
483.60(e) (e)Therapeuticdiets. 1
122
483.60(e)(1) (1)Therapeuticdietsmustbeprescribedbytheattendingphysician.
1
483.60(e)(2) (2)Theattendingphysicianmaydelegatetoaregisteredorlicenseddietitianthetaskofprescribingaresident’sdiet,includingatherapeuticdiet,totheextentallowedbyStatelaw.
1
483.60(f) (f)Frequencyofmeals. 1 483.60(f)(1) (1)Eachresidentmustreceiveandthe
facilitymustprovideatleastthreemealsdaily,atregulartimescomparabletonormalmealtimesinthecommunityorinaccordancewithresidentneeds,preferences,requests,andplanofcare.
1
483.60(f)(2)
(2)Theremustbenomorethan14hoursbetweenasubstantialeveningmealandbreakfastthefollowingday,exceptwhenanourishingsnackisservedatbedtime,upto16hoursmayelapsebetweenasubstantialeveningmealandbreakfastthefollowingdayifaresidentgroupagreestothismealspan.
1
483.60(f)(3) (3)Suitable,nourishingalternativemealsandsnacksmustbeprovidedtoresidentswhowanttoeatatnontraditionaltimesoroutsideofscheduledmealservicetimes,consistentwiththeresidentplanofcare.
1
483.60(g) (g)Assistivedevices.Thefacilitymustprovidespecialeatingequipmentandutensilsforresidentswhoneedthemandappropriateassistancetoensurethattheresidentcanusetheassistivedeviceswhenconsumingmealsandsnacks.
1
483.60(h) (h)Paidfeedingassistants— 1
123
483.60(h)(1) (1)State-approvedtrainingcourse.Afacilitymayuseapaidfeedingassistant,asdefinedin§488.301ofthischapter,if—
1
483.60(h)(1)(i) (i)ThefeedingassistanthassuccessfullycompletedaState-approvedtrainingcoursethatmeetstherequirementsof§483.160beforefeedingresidents;and
1
483.60(h)(1)(ii) (ii)TheuseoffeedingassistantsisconsistentwithStatelaw.
1
483.60(h)(2) (2)Supervision. 1 483.60(h)(2)(i) (i)Afeedingassistantmustworkunder
thesupervisionofaregisterednurse(RN)orlicensedpracticalnurse(LPN).
1
483.60(h)(2)(ii) (ii)Inanemergency,afeedingassistantmustcallasupervisorynurseforhelp.
1
483.60(h)(3) (3)Residentselectioncriteria. 1 483.60(h)(3)(i) (i)Afacilitymustensurethatafeeding
assistantprovidesdiningassistanceonlyforresidentswhohavenocomplicatedfeedingproblems.
1
483.60(h)(3)(ii) (ii)Complicatedfeedingproblemsinclude,butarenotlimitedto,difficultyswallowing,recurrentlungaspirations,andtubeorparenteral/IVfeedings.
1
483.60(h)(3)(iii) (iii)Thefacilitymustbaseresidentselectionontheinterdisciplinaryteam’sassessmentandtheresident’slatestassessmentandplanofcare.Appropriatenessforthisprogramshouldbereflectedinthecomprehensivecareplan.
1
483.60(i) (i)Foodsafetyrequirements.Thefacilitymust—
1
483.60(i)(1) (1)Procurefoodfromsourcesapproved 1
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orconsideredsatisfactorybyfederal,state,orlocalauthorities;
483.60(i)(1)(i) (i)Thismayincludefooditemsobtaineddirectlyfromlocalproducers,subjecttoapplicableStateandlocallawsorregulations.
1
483.60(i)(1)(ii) (ii)Thisprovisiondoesnotprohibitorpreventfacilitiesfromusingproducegrowninfacilitygardens,subjecttocompliancewithapplicablesafegrowingandfood-handlingpractices.
1
483.60(i)(1)(iii) (iii)Thisprovisiondoesnotprecluderesidentsfromconsumingfoodsnotprocuredbythefacility.
1
483.60(i)(2) (2)Store,prepare,distribute,andservefoodinaccordancewithprofessionalstandardsforfoodservicesafety.
1
483.60(i)(3) (3)Haveapolicyregardinguseandstorageoffoodsbroughttoresidentsbyfamilyandothervisitorstoensuresafeandsanitarystorage,handling,andconsumption,and
1
483.60(i)(4) (4)Disposeofgarbageandrefuseproperly.
1
§483.65 Specializedrehabilitativeservices. Thisentiresectionwas
implementedinPhase1.
483.65(a) (a)Provisionofservices.Ifspecializedrehabilitativeservicessuchasbutnotlimitedtophysicaltherapy,speech-languagepathology,occupationaltherapy,respiratorytherapy,andrehabilitativeservicesforamentaldisorderandintellectualdisabilityor
1
125
servicesofalesserintensityassetforthat§483.120(c),arerequiredintheresident’scomprehensiveplanofcare,thefacilitymust—
483.65(a)(1) (1)Providetherequiredservices;or 1 483.65(a)(2) (2)Inaccordancewith§483.70(g),obtain
therequiredservicesfromanoutsideresourcethatisaproviderofspecializedrehabilitativeservicesandisnotexcludedfromparticipatinginanyfederalorstatehealthcareprogramspursuanttosection1128and1156oftheAct.
1
483.65(b) (b)Qualifications.Specializedrehabilitativeservicesmustbeprovidedunderthewrittenorderofaphysicianbyqualifiedpersonnel.
1
§483.70 Administration. ThissectionwasimplementedinPhase1withthe
followingexceptions:
§483.70(d)(3),whichwillbe
implementedinPhase3,and§483.70(e),whichwas
implementedinPhase2.
483.70 Afacilitymustbeadministeredinamannerthatenablesittouseitsresourceseffectivelyandefficientlytoattainormaintainthehighestpracticablephysical,mental,andpsychosocialwell-beingofeachresident.
1
126
483.70(a) (a)Licensure.AfacilitymustbelicensedunderapplicableStateandlocallaw.
1
483.70(b) (b)CompliancewithFederal,State,andlocallawsandprofessionalstandards.ThefacilitymustoperateandprovideservicesincompliancewithallapplicableFederal,State,andlocallaws,regulations,andcodes,andwithacceptedprofessionalstandardsandprinciplesthatapplytoprofessionalsprovidingservicesinsuchafacility.
1
483.70(c) (c)RelationshiptootherHHSregulations.Inadditiontocompliancewiththeregulationssetforthinthissubpart,facilitiesareobligedtomeettheapplicableprovisionsofotherHHSregulations,includingbutnotlimitedtothosepertainingtonondiscriminationonthebasisofrace,color,ornationalorigin(45CFRpart80);nondiscriminationonthebasisofdisability(45CFRpart84);nondiscriminationonthebasisofage(45CFRpart91);nondiscriminationonthebasisofrace,color,nationalorigin,sex,age,ordisability(45CFRpart92);protectionofhumansubjectsofresearch(45CFRpart46);andfraudandabuse(42CFRpart455)andprotectionofindividuallyidentifiablehealthinformation(45CFRparts160and164).Violationsofsuchotherprovisionsmayresultinafindingofnon-compliancewiththisparagraph.
1
483.70(d) (d)Governingbody. 1 483.70(d)(1) (1)Thefacilitymusthavegoverning 1
127
body,ordesignatedpersonsfunctioningasagoverningbody,thatislegallyresponsibleforestablishingandimplementingpoliciesregardingthemanagementandoperationofthefacility;and
483.70(d)(2) (2)Thegoverningbodyappointstheadministratorwhois—
1
483.70(d)(2)(i) (i)LicensedbytheState,wherelicensingisrequired;
1
483.70(d)(2)(ii) (ii)Responsibleformanagementofthefacility;and
1
483.70(d)(2)(iii) (iii)Reportstoandisaccountabletothegoverningbody.
1
483.70(d)(3) (3)ThegoverningbodyisresponsibleandaccountablefortheQAPIprogram,inaccordancewith§483.75(f).
3
483.70(e) (e)Facilityassessment.Thefacilitymustconductanddocumentafacility-wideassessmenttodeterminewhatresourcesarenecessarytocareforitsresidentscompetentlyduringbothday-to-dayoperationsandemergencies.Thefacilitymustreviewandupdatethatassessment,asnecessary,andatleastannually.Thefacilitymustalsoreviewandupdatethisassessmentwheneverthereis,orthefacilityplansfor,anychangethatwouldrequireasubstantialmodificationtoanypartofthisassessment.Thefacilityassessmentmustaddressorinclude:
2 483.70(e) (e)Facilityassessment.Thefacilitymustconductanddocumentafacility-wideassessmenttodeterminewhatresourcesarenecessarytocareforitsresidentscompetentlyduringbothday-to-dayoperationsandemergencies.Thefacilitymust,incoordinationwith§§483.35,483.40(a),483.60(a),and483.75,utilizeinformationcollectedunderthefacilityassessmenttoinformpoliciesandprocedures;reviewandupdatethatassessment,asnecessary,andatleastbiennially;andreviewandupdatethisassessmentwheneverthereis,orthefacilityplansfor,anychangethatwouldrequireasubstantialmodificationtoanypartofthisassessment.Thefacilityassessmentmustaddressorinclude:
483.70(e)(1) (1)Thefacility’sresidentpopulation,including,butnotlimitedto,
2
483.70(e)(1)(i) (i)Boththenumberofresidentsandthefacility’sresidentcapacity;
2
128
483.70(e)(1)(ii) (ii)Thecarerequiredbytheresidentpopulationconsideringthetypesofdiseases,conditions,physicalandcognitivedisabilities,overallacuity,andotherpertinentfactsthatarepresentwithinthatpopulation;
2
483.70(e)(1)(iii) (iii)Thestaffcompetenciesthatarenecessarytoprovidethelevelandtypesofcareneededfortheresidentpopulation;
2
483.70(e)(1)(iv) (iv)Thephysicalenvironment,equipment,services,andotherphysicalplantconsiderationsthatarenecessarytocareforthispopulation;and
2
483.70(e)(1)(v) (v)Anyethnic,cultural,orreligiousfactorsthatmaypotentiallyaffectthecareprovidedbythefacility,including,butnotlimitedto,activitiesandfoodandnutritionservices.
2
483.70(e)(2) (2)Thefacility’sresources,includingbutnotlimitedto,
2
483.70(e)(2)(i) (i)Allbuildingsand/orotherphysicalstructuresandvehicles;
2
483.70(e)(2)(ii) (ii)Equipment(medicalandnonmedical); 2 483.70(e)(2)(iii) (iii)Servicesprovided,suchasphysical
therapy,pharmacy,andspecificrehabilitationtherapies;
2
483.70(e)(2)(iv) (iv)Allpersonnel,includingmanagers,staff(bothemployeesandthosewhoprovideservicesundercontract),andvolunteers,aswellastheireducationand/ortrainingandanycompetenciesrelatedtoresidentcare;
2
483.70(e)(2)(v) (v)Contracts,memorandumsofunderstanding,orotheragreementswith
2
129
thirdpartiestoprovideservicesorequipmenttothefacilityduringbothnormaloperationsandemergencies;and
483.70(e)(2)(vi) (vi)Healthinformationtechnologyresources,suchassystemsforelectronicallymanagingpatientrecordsandelectronicallysharinginformationwithotherorganizations.
2
483.70(e)(3) (3)Afacility-basedandcommunity-basedriskassessment,utilizinganall-hazardsapproach.
2
483.70(f) (f)Staffqualifications. 1 483.70(f)(1) (1)Thefacilitymustemployonafull-
time,part-timeorconsultantbasisthoseprofessionalsnecessarytocarryouttheprovisionsoftheserequirements.
1
483.70(f)(2) (2)Professionalstaffmustbelicensed,certified,orregisteredinaccordancewithapplicableStatelaws.
1
483.70(g) (g)Useofoutsideresources. 1 483.70(g)(1) (1)Ifthefacilitydoesnotemploya
qualifiedprofessionalpersontofurnishaspecificservicetobeprovidedbythefacility,thefacilitymusthavethatservicefurnishedtoresidentsbyapersonoragencyoutsidethefacilityunderanarrangementdescribedinsection1861(w)oftheActor(withrespecttoservicesfurnishedtoNFresidentsanddentalservicesfurnishedtoSNFresidents)anagreementdescribedinparagraph(g)(2)ofthissection.
1
483.70(g)(2) (2)Arrangementsasdescribedinsection1861(w)oftheActoragreementspertainingtoservicesfurnishedby
1
130
outsideresourcesmustspecifyinwritingthatthefacilityassumesresponsibilityfor—
483.70(g)(2)(i) (i)Obtainingservicesthatmeetprofessionalstandardsandprinciplesthatapplytoprofessionalsprovidingservicesinsuchafacility;and
1
483.70(g)(2)(ii) (ii)Thetimelinessoftheservices. 1 483.70(h) (h)Medicaldirector. 1 483.70(h)(1) (1)Thefacilitymustdesignateaphysician
toserveasmedicaldirector.1
483.70(h)(2) (2)Themedicaldirectorisresponsiblefor—
1
483.70(h)(2)(i) (i)Implementationofresidentcarepolicies;and
1
483.70(h)(2)(ii) (ii)Thecoordinationofmedicalcareinthefacility.
1
483.70(i) (i)Medicalrecords. 1 483.70(i)(1) (1)Inaccordancewithaccepted
professionalstandardsandpractices,thefacilitymustmaintainmedicalrecordsoneachresidentthatare—
1
483.70(i)(1)(i) (i)Complete; 1 483.70(i)(1)(ii) (ii)Accuratelydocumented; 1 483.70(i)(1)(iii) (iii)Readilyaccessible;and 1 483.70(i)(1)(iv) (iv)Systematicallyorganized. 1 483.70(i)(2) (2)Thefacilitymustkeepconfidentialall
informationcontainedintheresident’srecords,regardlessoftheformorstoragemethodoftherecords,exceptwhenreleaseis—
1
483.70(i)(2)(i) (i)Totheindividual,ortheirresidentrepresentativewherepermittedbyapplicablelaw;
1
483.70(i)(2)(ii) (ii)Requiredbylaw; 1
131
483.70(i)(2)(iii) (iii)Fortreatment,payment,orhealthcareoperations,aspermittedbyandincompliancewith45CFR164.506;
1
483.70(i)(2)(iv) (iv)Forpublichealthactivities,reportingofabuse,neglect,ordomesticviolence,healthoversightactivities,judicialandadministrativeproceedings,lawenforcementpurposes,organdonationpurposes,researchpurposes,ortocoroners,medicalexaminers,funeraldirectors,andtoavertaseriousthreattohealthorsafetyaspermittedbyandincompliancewith45CFR164.512.
1
483.70(i)(3) (3)Thefacilitymustsafeguardmedicalrecordinformationagainstloss,destruction,orunauthorizeduse;
1
483.70(i)(4) (4)Medicalrecordsmustberetainedfor—
1
483.70(i)(4)(i) (i)TheperiodoftimerequiredbyStatelaw;or
1
483.70(i)(4)(ii) (ii)FiveyearsfromthedateofdischargewhenthereisnorequirementinStatelaw;or
1
483.70(i)(4)(iii) (iii)Foraminor,3yearsafteraresidentreacheslegalageunderStatelaw.
1
483.70(i)(5) (5)Themedicalrecordmustcontain— 1 483.70(i)(5)(i) (i)Sufficientinformationtoidentifythe
resident;1
483.70(i)(5)(ii) (ii)Arecordoftheresident’sassessments;
1
483.70(i)(5)(iii) (iii)Thecomprehensiveplanofcareandservicesprovided;
1
483.70(i)(5)(iv) (iv)Theresultsofanypreadmissionscreeningandresidentreviewevaluationsanddeterminations
1
132
conductedbytheState;483.70(i)(5)(v) (v)Physician’s,nurse’s,andother
licensedprofessional’sprogressnotes;and
1
483.70(i)(5)(vi) (vi)Laboratory,radiologyandotherdiagnosticservicesreportsasrequiredunder§483.50.
1
483.70(j) (j)Transferagreement. 1 483.70(j)(1) (1)Inaccordancewithsection1861(l)of
theAct,thefacility(otherthananursingfacilitywhichislocatedinaStateonanIndianreservation)musthaveineffectawrittentransferagreementwithoneormorehospitalsapprovedforparticipationundertheMedicareandMedicaidprogramsthatreasonablyassuresthat—
1
483.70(j)(1)(i) (i)Residentswillbetransferredfromthefacilitytothehospital,andensuredoftimelyadmissiontothehospitalwhentransferismedicallyappropriateasdeterminedbytheattendingphysicianor,inanemergencysituation,byanotherpractitionerinaccordancewithfacilitypolicyandconsistentwithstatelaw;and
1
483.70(j)(1)(ii) (ii)Medicalandotherinformationneededforcareandtreatmentofresidentsand,whenthetransferringfacilitydeemsitappropriate,fordeterminingwhethersuchresidentscanreceiveappropriateservicesorreceiveservicesinalessrestrictivesettingthaneitherthefacilityorthehospital,orreintegratedintothecommunity,willbeexchangedbetweentheproviders,includingbutnotlimitedtothe
1
133
informationrequiredunder§483.15(c)(2)(iii).
483.70(j)(2) (2)Thefacilityisconsideredtohaveatransferagreementineffectifthefacilityhasattemptedingoodfaithtoenterintoanagreementwithahospitalsufficientlyclosetothefacilitytomaketransferfeasible.
1
483.70(k) (k)Disclosureofownership. 1 483.70(k)(1) (1)Thefacilitymustcomplywiththe
disclosurerequirementsof§§420.206and455.104ofthischapter.
1
483.70(k)(2) (2)ThefacilitymustprovidewrittennoticetotheStateagencyresponsibleforlicensingthefacilityatthetimeofchange,ifachangeoccursin—
1
483.70(k)(2)(i) (i)Personswithanownershiporcontrolinterest,asdefinedin§§420.201and455.101ofthischapter;
1
483.70(k)(2)(ii) (ii)Theofficers,directors,agents,ormanagingemployees;
1
483.70(k)(2)(iii) (iii)Thecorporation,association,orothercompanyresponsibleforthemanagementofthefacility;or
1
483.70(k)(2)(iv) (iv)Thefacility’sadministratorordirectorofnursing.
1
483.70(k)(3) (3)Thenoticespecifiedinparagraph(p)(2)ofthissectionmustincludetheidentityofeachnewindividualorcompany.
1
483.70(l)
(l)Facilityclosure-Administrator.Anyindividualwhoistheadministratorofthefacilitymust:
1
483.70(l)(1) (1)SubmittotheSecretary,theStateLTCombudsman,residentsofthefacility,and
1
134
thelegalrepresentativesofsuchresidentsorotherresponsibleparties,writtennotificationofanimpendingclosure:
483.70(l)(1)(i) (i)Atleast60dayspriortothedateofclosure;or
1
483.70(l)(1)(ii) (ii)InthecaseofafacilitywheretheSecretaryoraStateterminatesthefacility’sparticipationintheMedicareand/orMedicaidprograms,notlaterthanthedatethattheSecretarydeterminesappropriate;
1
483.70(l)(2) (2)Ensurethatthefacilitydoesnotadmitanynewresidentsonorafterthedateonwhichsuchwrittennotificationissubmitted;and
1
483.70(l)(3) (3)IncludeinthenoticetheplanforthetransferandadequaterelocationoftheresidentsofthefacilitybyadatethatwouldbespecifiedbytheStatepriortoclosure,includingassurancesthattheresidentswouldbetransferredtothemostappropriatefacilityorothersettingintermsofquality,services,andlocation,takingintoconsiderationtheneeds,choice,andbestinterestsofeachresident.
1
483.70(m) (m)Facilityclosure.Thefacilitymusthaveinplacepoliciesandprocedurestoensurethattheadministrator’sdutiesandresponsibilitiesinvolveprovidingtheappropriatenoticesintheeventofafacilityclosure,asrequiredatparagraph(l)ofthissection.
1
483.70(n) (n)Bindingarbitrationagreements. FinalRule 483.70(n) (n)Bindingarbitrationagreements.Ifafacilitychooses
135
ReleasedJuly18,2019
toaskaresidentorhisorherrepresentativetoenterintoanagreementforbindingarbitration,thefacilitymustcomplywithalloftherequirementsinthissection.
483.70(n)(1) (1)Afacilitymustnotenterintoapre-disputeagreementforbindingarbitrationwithanyresidentorresident’srepresentativenorrequirethataresidentsignanarbitrationagreementasaconditionofadmissiontotheLTCfacility.
FinalRuleReleased
July18,2019
483.70(n)(1) (1)Thefacilitymustnotrequireanyresidentorhisorherrepresentativetosignanagreementforbindingarbitrationasaconditionofadmissionto,orasarequirementtocontinuetoreceivecareat,thefacilityandmustexplicitlyinformtheresidentorhisorherrepresentativeofhisorherrightnottosigntheagreementasaconditionofadmissionto,orasarequirementtocontinuetoreceivecareat,thefacility.
483.70(n)(2) (2)If,afteradisputebetweenthefacilityandaresidentarises,andafacilitychoosestoaskaresidentorhisorherrepresentativetoenterintoanagreementforbindingarbitration,thefacilitymustcomplywithalloftherequirementsinthissection.
FinalRuleReleased
July18,2019
483.70(n)(2) (2)If,afteradisputebetweenthefacilityandaresidentarises,andafacilitychoosestoaskaresidentorhisorherrepresentativetoenterintoanagreementforbindingarbitration,thefacilitymustcomplywithalloftherequirementsinthissection.
483.70(n)(2)(i) (i)Thefacilitymustensurethat: FinalRuleReleased
July18,2019
483.70(n)(2) (2)Thefacilitymustensurethat:
483.70(n)(2)(i)(A) (A)Theagreementisexplainedtotheresidentandtheirrepresentativeinaformandmannerthatheorsheunderstands,includinginalanguagetheresidentandtheirrepresentativeunderstands,and
FinalRuleReleased
July18,2019
483.70(n)(2)(i) (i)Theagreementisexplainedtotheresidentandhisorherrepresentativeinaformandmannerthatheorsheunderstands,includinginalanguagetheresidentandhisorherrepresentativeunderstands;
483.70(n)(2)(i)(B) (B)Theresidentacknowledgesthatheorsheunderstandstheagreement.
FinalRuleReleased
July18,2019
483.70(n)(2)(ii) (ii)Theresidentorhisorherrepresentativeacknowledgesthatheorsheunderstandstheagreement;
483.70(n)(2)(ii) (ii)Theagreementmust: FinalRuleReleased
July18,2019
483.70(n)(2)(ii) (ii)Theagreementmust:
483.70(n)(2)(ii)(A) (A)Beenteredintobytheresidentvoluntarily.
FinalRuleReleased
483.70(n)(2)(ii)(A)
(A)Beenteredintobytheresidentvoluntarily.
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July18,2019483.70(n)(2)(ii)(B) (B)Providefortheselectionofaneutral
arbitratoragreeduponbybothparties.FinalRuleReleased
July18,2019
483.70(n)(2)(iii) (iii)Theagreementprovidesfortheselectionofaneutralarbitratoragreeduponbybothparties;and
483.70(n)(2)(ii)(C) (C)Provideforselectionofavenueconvenienttobothparties.
FinalRuleReleased
July18,2019
483.70(n)(2)(iv) (iv)Theagreementprovidesfortheselectionofavenuethatisconvenienttobothparties.
483.70(n)(2)(iii) (iii)Aresident’scontinuingrighttoremaininthefacilitymustnotbecontingentupontheresidentortheresident’srepresentativesigningabindingarbitrationagreement.
FinalRuleReleased
July18,2019
483.70(n)(2)(iii) (iii)Aresident’scontinuingrighttoremaininthefacilitymustnotbecontingentupontheresidentortheresident’srepresentativesigningabindingarbitrationagreement.
FinalRuleReleased
July18,2019
483.70(n)(3) (3)Theagreementmustexplicitlygranttheresidentorhisorherrepresentativetherighttorescindtheagreementwithin30calendardaysofsigningit.
FinalRuleReleased
July18,2019
483.70(n)(4) (4)Theagreementmustexplicitlystatethatneithertheresidentnorhisorherrepresentativeisrequiredtosignanagreementforbindingarbitrationasaconditionofadmissionto,orasarequirementtocontinuetoreceivecareat,thefacility.
483.70(n)(2)(iv) (iv)Theagreementmustnotcontainanylanguagethatprohibitsordiscouragestheresidentoranyoneelsefromcommunicatingwithfederal,state,orlocalofficials,includingbutnotlimitedto,federalandstatesurveyors,otherfederalorstatehealthdepartmentemployees,andrepresentativesoftheOfficeoftheStateLong-TermCareOmbudsman,inaccordancewith§483.10(k).
FinalRuleReleased
July18,2019
483.70(n)(5) (5)Theagreementmaynotcontainanylanguagethatprohibitsordiscouragestheresidentoranyoneelsefromcommunicatingwithfederal,state,orlocalofficials,includingbutnotlimitedto,federalandstatesurveyors,otherfederalorstatehealthdepartmentemployees,andrepresentativesoftheOfficeoftheStateLong-TermCareOmbudsman,inaccordancewith§483.10(k).
483.70(n)(2)(v) (v)Theagreementmaybesignedbyanotherindividualif:
FinalRuleReleased
483.70(n)(2)(v) (v)Theagreementmaybesignedbyanotherindividualif:
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July18,2019483.70(n)(2)(v)(A) (A)Allowedbystatelaw; FinalRule
ReleasedJuly18,2019
483.70(n)(2)(v)(A)
(A)Allowedbystatelaw;
483.70(n)(2)(v)(B) (B)Alloftherequirementsinthissectionaremet;and
FinalRuleReleased
July18,2019
483.70(n)(2)(v)(B)
(B)Alloftherequirementsinthissectionaremet;and
483.70(n)(2)(v)(C) (C)Thatindividualhasnointerestinthefacility.
FinalRuleReleased
July18,2019
483.70(n)(2)(v)(C)
(C)Thatindividualhasnointerestinthefacility.
483.70(n)(2)(vi) (vi)Whenthefacilityandaresidentresolveadisputewitharbitration,acopyofthesignedagreementforbindingarbitrationandthearbitrator’sfinaldecisionmustberetainedbythefacilityfor5yearsandbeavailableforinspectionuponrequestbyCMSoritsdesignee.
FinalRuleReleased
July18,2019
483.70(n)(6) (6)Whenthefacilityandaresidentresolveadisputethrougharbitration,acopyofthesignedagreementforbindingarbitrationandthearbitrator’sfinaldecisionmustberetainedbythefacilityfor5yearsaftertheresolutionofthatdisputeonandbeavailableforinspectionuponrequestbyCMSoritsdesignee.
483.70(o) (o)Hospiceservices. 1 483.70(o)(1) (1)Along-termcare(LTC)facilitymaydo
eitherofthefollowing:1
483.70(o)(1)(i) (i)ArrangefortheprovisionofhospiceservicesthroughanagreementwithoneormoreMedicare-certifiedhospices.
1
483.70(o)(1)(ii) (ii)NotarrangefortheprovisionofhospiceservicesatthefacilitythroughanagreementwithaMedicare-certifiedhospiceandassisttheresidentintransferringtoafacilitythatwillarrangefortheprovisionofhospiceserviceswhenaresidentrequestsatransfer.
1
483.70(o)(2) (2)IfhospicecareisfurnishedinanLTCfacilitythroughanagreementasspecifiedinparagraph(o)(1)(i)ofthissectionwithahospice,theLTCfacility
1
138
mustmeetthefollowingrequirements:483.70(o)(2)(i) (i)Ensurethatthehospiceservicesmeet
professionalstandardsandprinciplesthatapplytoindividualsprovidingservicesinthefacility,andtothetimelinessoftheservices.
1
483.70(o)(2)(ii) (ii)HaveawrittenagreementwiththehospicethatissignedbyanauthorizedrepresentativeofthehospiceandanauthorizedrepresentativeoftheLTCfacilitybeforehospicecareisfurnishedtoanyresident.Thewrittenagreementmustsetoutatleastthefollowing:
1
483.70(o)(2)(ii)(A) (A)Theservicesthehospicewillprovide. 1 483.70(o)(2)(ii)(B) (B)Thehospice’sresponsibilitiesfor
determiningtheappropriatehospiceplanofcareasspecifiedin§418.112(d)ofthischapter.
1
483.70(o)(2)(ii)(C) (C)TheservicestheLTCfacilitywillcontinuetoprovide,basedoneachresident’splanofcare.
1
483.70(o)(2)(ii)(D) (D)Acommunicationprocess,includinghowthecommunicationwillbedocumentedbetweentheLTCfacilityandthehospiceprovider,toensurethattheneedsoftheresidentareaddressedandmet24hoursperday.
1
483.70(o)(2)(ii)(E) (E)AprovisionthattheLTCfacilityimmediatelynotifiesthehospiceaboutthefollowing:
1
483.70(o)(2)(ii)(E)(1)
(1)Asignificantchangeintheresident’sphysical,mental,social,oremotionalstatus.
1
483.70(o)(2)(ii)(E)(2)
(2)Clinicalcomplicationsthatsuggestaneedtoaltertheplanofcare.
1
139
483.70(o)(2)(ii)(E)(3)
(3)Aneedtotransfertheresidentfromthefacilityforanycondition.
1
483.70(o)(2)(ii)(E)(4)
(4)Theresident’sdeath. 1
483.70(o)(2)(ii)(F) (F)Aprovisionstatingthatthehospiceassumesresponsibilityfordeterminingtheappropriatecourseofhospicecare,includingthedeterminationtochangethelevelofservicesprovided.
1
483.70(o)(2)(ii)(G) (G)AnagreementthatitistheLTCfacility’sresponsibilitytofurnish24–hourroomandboardcare,meettheresident’spersonalcareandnursingneedsincoordinationwiththehospicerepresentative,andensurethatthelevelofcareprovidedisappropriatelybasedontheindividualresident’sneeds.
1
483.70(o)(2)(ii)(H) (H)Adelineationofthehospice’sresponsibilities,includingbutnotlimitedto,providingmedicaldirectionandmanagementofthepatient;nursing;counseling(includingspiritual,dietary,andbereavement);socialwork;providingmedicalsupplies,durablemedicalequipment,anddrugsnecessaryforthepalliationofpainandsymptomsassociatedwiththeterminalillnessandrelatedconditions;andallotherhospiceservicesthatarenecessaryforthecareoftheresident’sterminalillnessandrelatedconditions.
1
483.70(o)(2)(ii)(I) (I)AprovisionthatwhentheLTCfacilitypersonnelareresponsiblefortheadministrationofprescribedtherapies,includingthosetherapiesdetermined
1
140
appropriatebythehospiceanddelineatedinthehospiceplanofcare,theLTCfacilitypersonnelmayadministerthetherapieswherepermittedbyStatelawandasspecifiedbytheLTCfacility.
483.70(o)(2)(ii)(J) (J)AprovisionstatingthattheLTCfacilitymustreportallallegedviolationsinvolvingmistreatment,neglect,orverbal,mental,sexual,andphysicalabuse,includinginjuriesofunknownsource,andmisappropriationofpatientpropertybyhospicepersonnel,tothehospiceadministratorimmediatelywhentheLTCfacilitybecomesawareoftheallegedviolation.
1
483.70(o)(2)(ii)(K) (K)AdelineationoftheresponsibilitiesofthehospiceandtheLTCfacilitytoprovidebereavementservicestoLTCfacilitystaff.
1
483.70(o)(3) (3)EachLTCfacilityarrangingfortheprovisionofhospicecareunderawrittenagreementmustdesignateamemberofthefacility’sinterdisciplinaryteamwhoisresponsibleforworkingwithhospicerepresentativestocoordinatecaretotheresidentprovidedbytheLTCfacilitystaffandhospicestaff.Theinterdisciplinaryteammembermusthaveaclinicalbackground,functionwithintheirStatescopeofpracticeact,andhavetheabilitytoassesstheresidentorhaveaccesstosomeonethathastheskillsandcapabilitiestoassesstheresident.Thedesignatedinterdisciplinaryteammemberisresponsibleforthefollowing:
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483.70(o)(3)(i) (i)CollaboratingwithhospicerepresentativesandcoordinatingLTCfacilitystaffparticipationinthehospicecareplanningprocessforthoseresidentsreceivingtheseservices.
1
483.70(o)(3)(ii) (ii)Communicatingwithhospicerepresentativesandotherhealthcareprovidersparticipatingintheprovisionofcarefortheterminalillness,relatedconditions,andotherconditions,toensurequalityofcareforthepatientandfamily.
1
483.70(o)(3)(iii) (iii)EnsuringthattheLTCfacilitycommunicateswiththehospicemedicaldirector,thepatient’sattendingphysician,andotherpractitionersparticipatingintheprovisionofcaretothepatientasneededtocoordinatethehospicecarewiththemedicalcareprovidedbyotherphysicians.
1
483.70(o)(3)(iv) (iv)Obtainingthefollowinginformationfromthehospice:
1
483.70(o)(3)(iv)(A) (A)Themostrecenthospiceplanofcarespecifictoeachpatient.
1
483.70(o)(3)(iv)(B) (B)Hospiceelectionform. 1 483.70(o)(3)(iv)(C) (C)Physiciancertificationand
recertificationoftheterminalillnessspecifictoeachpatient.
1
483.70(o)(3)(iv)(D) (D)Namesandcontactinformationforhospicepersonnelinvolvedinhospicecareofeachpatient.
1
483.70(o)(3)(iv)(E) (E)Instructionsonhowtoaccessthehospice’s24–houron-callsystem.
1
483.70(o)(3)(iv)(F) (F)Hospicemedicationinformationspecifictoeachpatient.
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483.70(o)(3)(iv)(G) (G)Hospicephysicianandattendingphysician(ifany)ordersspecifictoeachpatient.
1
483.70(o)(3)(v) (v)EnsuringthattheLTCfacilitystaffprovidesorientationinthepoliciesandproceduresofthefacility,includingpatientrights,appropriateforms,andrecordkeepingrequirements,tohospicestafffurnishingcaretoLTCresidents.
1
483.70(o)(4) (4)EachLTCfacilityprovidinghospicecareunderawrittenagreementmustensurethateachresident’swrittenplanofcareincludesboththemostrecenthospiceplanofcareandadescriptionoftheservicesfurnishedbytheLTCfacilitytoattainormaintaintheresident’shighestpracticablephysical,mental,andpsychosocialwell-being,asrequiredat§483.25.
1
483.70(p) (p)Socialworker.Anyfacilitywithmorethan120bedsmustemployaqualifiedsocialworkeronafull-timebasis.Aqualifiedsocialworkeris:
1
483.70(p)(1) (1)Anindividualwithaminimumofabachelor’sdegreeinsocialworkorabachelor’sdegreeinahumanservicesfieldincluding,butnotlimitedto,sociology,gerontology,specialeducation,rehabilitationcounseling,andpsychology;and
1
483.70(p)(2) (2)Oneyearofsupervisedsocialworkexperienceinahealthcaresettingworkingdirectlywithindividuals.
1
§483.75 Qualityassuranceandperformanceimprovement.
Thissectionwillbeimplemented
143
inPhase3withthefollowingexceptions:
§483.75(a)(2),whichwas
implementedinPhase2,
§483.75(g)(1)(i)-(iii),whichwereimplementedin
Phase1,§483.75(h),whichwas
implementedinPhase1,and
§483.75(i),whichwas
implementedinPhase1.
483.75(a) (a)Qualityassuranceandperformanceimprovement(QAPI)program.EachLTCfacility,includingafacilitythatispartofamultiunitchain,mustdevelop,implement,andmaintainaneffective,comprehensive,data-drivenQAPIprogramthatfocusesonindicatorsoftheoutcomesofcareandqualityoflife.Thefacilitymust—
3
483.75(a)(1) (1)MaintaindocumentationanddemonstrateevidenceofitsongoingQAPIprogramthatmeetstherequirementsofthissection.Thismayincludebutisnotlimitedtosystemsandreportsdemonstratingsystematicidentification,reporting,investigation,analysis,andpreventionofadverse
3
144
events;anddocumentationdemonstratingthedevelopment,implementation,andevaluationofcorrectiveactionsorperformanceimprovementactivities;
483.75(a)(2) (2)PresentitsQAPIplantotheStateSurveyAgencynolaterthan1yearafterthepromulgationofthisregulation;
2
483.75(a)(3) (3)PresentitsQAPIplantoaStateSurveyAgencyorFederalsurveyorateachannualrecertificationsurveyanduponrequestduringanyothersurveyandtoCMSuponrequest;and
3
483.75(a)(4) (4)PresentdocumentationandevidenceofitsongoingQAPIprogram’simplementationandthefacility’scompliancewithrequirementstoaStateSurveyAgency,FederalsurveyororCMSuponrequest.
3
483.75(b) (b)Programdesignandscope.AfacilitymustdesignitsQAPIprogramtobeongoing,comprehensive,andtoaddressthefullrangeofcareandservicesprovidedbythefacility.Itmust:
3 483.75(b) (b)Programdesignandscope.AfacilitymustdesignitsQAPIprogramtobeongoing,comprehensive,andcapableofaddressingthefullrangeofcareandservicesprovidedbythefacility.
483.75(b)(1) (1)Addressallsystemsofcareandmanagementpractices;
3 483.75(b)(1) (1)Addressallsystemsofcareandmanagementpractices;
483.75(b)(2) (2)Includeclinicalcare,qualityoflife,andresidentchoice;
3 483.75(b)(2) (2)Includeclinicalcare,qualityoflife,andresidentchoice;
483.75(b)(3) (3)UtilizethebestavailableevidencetodefineandmeasureindicatorsofqualityandfacilitygoalsthatreflectprocessesofcareandfacilityoperationsthathavebeenshowntobepredictiveofdesiredoutcomesforresidentsofaSNForNF.
3 483.75(b)(3) (3)UtilizethebestavailableevidencetodefineandmeasureindicatorsofqualityandfacilitygoalsthatreflectprocessesofcareandfacilityoperationsthathavebeenshowntobepredictiveofdesiredoutcomesforresidentsofaSNForNF.
483.75(b)(4) (4)Reflectthecomplexities,uniquecare, 3 483.75(b)(4) (4)Reflectthecomplexities,uniquecare,andservices
145
andservicesthatthefacilityprovides. thatthefacilityprovides.483.75(c) (c)Programfeedback,datasystemsand
monitoring.Afacilitymustestablishandimplementwrittenpoliciesandproceduresforfeedback,datacollectionssystems,andmonitoring,includingadverseeventmonitoring.Thepoliciesandproceduresmustinclude,ataminimum,thefollowing:
3 483.75(c) (c)Programfeedback,datasystemsandmonitoring.Afacilitymustestablishandimplementwrittenpoliciesandproceduresforfeedback,datacollectionssystems,andmonitoring,includingadverseeventmonitoring.
483.75(c)(1) (1)Facilitymaintenanceofeffectivesystemstoobtainanduseoffeedbackandinputfromdirectcarestaff,otherstaff,residents,andresidentrepresentatives,includinghowsuchinformationwillbeusedtoidentifyproblemsthatarehighrisk,highvolume,orproblem-prone,andopportunitiesforimprovement.
3 483.75(c)(1) (1)Facilitymaintenanceofeffectivesystemstoobtainanduseoffeedbackandinputfromdirectcarestaff,otherstaff,residents,andresidentrepresentatives,includinghowsuchinformationwillbeusedtoidentifyproblemsthatarehighrisk,highvolume,orproblem-prone,andopportunitiesforimprovement.
483.75(c)(2) (2)Facilitymaintenanceofeffectivesystemstoidentify,collect,andusedataandinformationfromalldepartments,includingbutnotlimitedtothefacilityassessmentrequiredat§483.70(e)andincludinghowsuchinformationwillbeusedtodevelopandmonitorperformanceindicators.
3 483.75(c)(2) (2)Facilitymaintenanceofeffectivesystemstoidentify,collect,andusedataandinformationfromalldepartments,includingbutnotlimitedtothefacilityassessmentrequiredat§483.70(e)andincludinghowsuchinformationwillbeusedtodevelopandmonitorperformanceindicators.
483.75(c)(3) (3)Facilitydevelopment,monitoring,andevaluationofperformanceindicators,includingthemethodologyandfrequencyforsuchdevelopment,monitoring,andevaluation.
3 483.75(c)(3) (3)Facilitydevelopment,monitoring,andevaluationofperformanceindicators,includingthemethodologyandfrequencyforsuchdevelopment,monitoring,andevaluation.
483.75(c)(4) (4)Facilityadverseeventmonitoring,includingthemethodsbywhichthefacilitywillsystematicallyidentify,report,track,investigate,analyzeandusedata
3 483.75(c)(4) (4)Facilityadverseeventmonitoring,includingthemethodsbywhichthefacilitywillsystematicallyidentify,report,track,investigate,analyzeandusedataandinformationrelatingtoadverseeventsinthe
146
andinformationrelatingtoadverseeventsinthefacility,includinghowthefacilitywillusethedatatodevelopactivitiestopreventadverseevents.
facility,includinghowthefacilitywillusethedatatodevelopactivitiestopreventadverseevents.
483.75(d) (d)Programsystematicanalysisandsystemicaction.
3 483.75(d) (d)Programsystematicanalysisandsystemicaction.Thefacilitymusttakeactionsaimedatperformanceimprovementand,afterimplementingthoseactions,measureitssuccess,andtrackperformancetoensurethatimprovementsarerealizedandsustained.
483.75(d)(1) (1)Thefacilitymusttakeactionsaimedatperformanceimprovementand,afterimplementingthoseactions,measureitssuccess,andtrackperformancetoensurethatimprovementsarerealizedandsustained.
3
483.75(d)(2) (2)Thefacilitywilldevelopandimplementpoliciesaddressing:
3 483.75(d)(2) (2)Thefacilitywilldevelopandimplementpoliciesaddressing:
483.75(d)(2)(i) (i)Howtheywilluseasystematicapproachtodetermineunderlyingcausesofproblemsimpactinglargersystems;
3 483.75(d)(2)(i) (i)Howtheywilluseasystematicapproachtodetermineunderlyingcausesofproblemsimpactinglargersystems;
483.75(d)(2)(ii) (ii)Howtheywilldevelopcorrectiveactionsthatwillbedesignedtoeffectchangeatthesystemsleveltopreventqualityofcare,qualityoflife,orsafetyproblems;and
3 483.75(d)(2)(ii) (ii)Howtheywilldevelopcorrectiveactionsthatwillbedesignedtoeffectchangeatthesystemsleveltopreventqualityofcare,qualityoflife,orsafetyproblems;and
483.75(d)(2)(iii) (iii)Howthefacilitywillmonitortheeffectivenessofitsperformanceimprovementactivitiestoensurethatimprovementsaresustained.
3 483.75(d)(2)(iii) (iii)Howthefacilitywillmonitortheeffectivenessofitsperformanceimprovementactivitiestoensurethatimprovementsaresustained.
483.75(e) (e)Programactivities. 3 483.75(e)(1) (1)Thefacilitymustsetprioritiesforits
performanceimprovementactivitiesthatfocusonhigh-risk,high-volume,orproblem-proneareas;considertheincidence,prevalence,andseverityof
3
147
problemsinthoseareas;andaffecthealthoutcomes,residentsafety,residentautonomy,residentchoice,andqualityofcare.
483.75(e)(2) (2)Performanceimprovementactivitiesmusttrackmedicalerrorsandadverseresidentevents,analyzetheircauses,andimplementpreventiveactionsandmechanismsthatincludefeedbackandlearningthroughoutthefacility.
3
483.75(e)(3) (3)Asapartoftheirperformanceimprovementactivities,thefacilitymustconductdistinctperformanceimprovementprojects.Thenumberandfrequencyofimprovementprojectsconductedbythefacilitymustreflectthescopeandcomplexityofthefacility’sservicesandavailableresources,asreflectedinthefacilityassessmentrequiredat§483.70(e).Improvementprojectsmustincludeatleastannuallyaprojectthatfocusesonhighriskorproblem-proneareasidentifiedthroughthedatacollectionandanalysisdescribedinparagraphs(c)and(d)ofthissection.
3
483.75(f) (f)Governanceandleadership.Thegoverningbodyand/orexecutiveleadership(ororganizedgrouporindividualwhoassumesfulllegalauthorityandresponsibilityforoperationofthefacility)isresponsibleandaccountableforensuringthat—
3
483.75(f)(1) (1)AnongoingQAPIprogramisdefined,implemented,andmaintainedandaddressesidentifiedpriorities.
3
148
483.75(f)(2) (2)TheQAPIprogramissustainedduringtransitionsinleadershipandstaffing;
3
483.75(f)(3) (3)TheQAPIprogramisadequatelyresourced,includingensuringstafftime,equipment,andtechnicaltrainingasneeded;
3
483.75(f)(4) (4)TheQAPIprogramidentifiesandprioritizesproblemsandopportunitiesthatreflectorganizationalprocess,functions,andservicesprovidedtoresidentbasedonperformanceindicatordata,andresidentandstaffinput,andotherinformation.
3
483.75(f)(5) (5)Correctiveactionsaddressgapsinsystems,andareevaluatedforeffectiveness;and
3
483.75(f)(6) (6)Clearexpectationsaresetaroundsafety,quality,rights,choice,andrespect.
3
483.75(g) (g)Qualityassessmentandassurance. 1 483.75(g)(1) (1)Afacilitymustmaintainaquality
assessmentandassurancecommitteeconsistingataminimumof:
1
483.75(g)(1)(i) (i)Thedirectorofnursingservices; 1 483.75(g)(1)(ii) (ii)TheMedicalDirectororhisorher
designee;1
483.75(g)(1)(iii) (iii)Atleastthreeothermembersofthefacility’sstaff,atleastoneofwhomustbetheadministrator,owner,aboardmemberorotherindividualinaleadershiprole;and
1
483.75(g)(1)(iv) (iv)Theinfectioncontrolandpreventionofficer.
3
483.75(g)(2) (2)Thequalityassessmentandassurancecommitteereportstothefacility’s
3
149
governingbody,ordesignatedperson(s)functioningasagoverningbodyregardingitsactivities,includingimplementationoftheQAPIprogramrequiredunderparagraphs(a)through(e)ofthissection.Thecommitteemust:
483.75(g)(2)(i) (i)MeetatleastquarterlyandasneededtocoordinateandevaluateactivitiesundertheQAPIprogram,suchasidentifyingissueswithrespecttowhichqualityassessmentandassuranceactivities,includingperformanceimprovementprojectsrequiredundertheQAPIprogram,arenecessary;and
3
483.75(g)(2)(ii) (ii)Developandimplementappropriateplansofactiontocorrectidentifiedqualitydeficiencies;and
3
483.75(g)(2)(iii) (iii)Regularlyreviewandanalyzedata,includingdatacollectedundertheQAPIprogramanddataresultingfromdrugregimenreviews,andactonavailabledatatomakeimprovements.
3
483.75(h)**TheCMScrosswalkcitesthissectionas483.75(h)(1)whilethepublishedrevisedregulationscitethissectionas483.75(h).Sincethereisno483.75(h)(1)intherevisedregulations,we
(h)Disclosureofinformation.AStateortheSecretarymaynotrequiredisclosureoftherecordsofsuchcommitteeexceptinsofarassuchdisclosureisrelatedtothecomplianceofsuchcommitteewiththerequirementsofthissection.
1
150
haveusedtherevisedregulationscitation.483.75(i) (i)Sanctions.Goodfaithattemptsbythe
committeetoidentifyandcorrectqualitydeficiencieswillnotbeusedasabasisforsanctions.
1
§483.80 Infectioncontrol. ThissectionwasimplementedinPhase1withthe
followingexceptions:§483.80(a)as
linkedtoFacilityAssessmentat§483.70(e),whichwas
implementedinPhase2;
§483.70(a)(3),whichwillbe
implementedinPhase2;
§483.80(b),whichwillbe
implementedinPhase3;and§483.80(c),whichwillbe
implementedinPhase3.
483.80 Thefacilitymustestablishandmaintainaninfectionpreventionandcontrolprogramdesignedtoprovideasafe,sanitary,andcomfortableenvironmentandtohelppreventthedevelopment
1
151
andtransmissionofcommunicablediseasesandinfections.
483.80(a) (a)Infectionpreventionandcontrolprogram.Thefacilitymustestablishaninfectionpreventionandcontrolprogram(IPCP)thatmustinclude,ataminimum,thefollowingelements:
1
483.80(a)(1) (1)Asystemforpreventing,identifying,reporting,investigating,andcontrollinginfectionsandcommunicablediseasesforallresidents,staff,volunteers,visitors,andotherindividualsprovidingservicesunderacontractualarrangementbaseduponthefacilityassessmentconductedaccordingto§483.70(e)andfollowingacceptednationalstandards;
2
483.80(a)(2) (2)Writtenstandards,policies,andproceduresfortheprogram,whichmustinclude,butarenotlimitedto:
1
483.80(a)(2)(i) (i)Asystemofsurveillancedesignedtoidentifypossiblecommunicablediseasesorinfectionsbeforetheycanspreadtootherpersonsinthefacility;
1
483.80(a)(2)(ii) (ii)Whenandtowhompossibleincidentsofcommunicablediseaseorinfectionsshouldbereported;
1
483.80(a)(2)(iii) (iii)Standardandtransmission-basedprecautionstobefollowedtopreventspreadofinfections;
1
483.80(a)(2)(iv) (iv)Whenandhowisolationshouldbeusedforaresident;includingbutnotlimitedto:
1
483.80(a)(2)(iv)(A) (A)Thetypeanddurationoftheisolation,dependingupontheinfectiousagentororganisminvolved,and
1
152
483.80(a)(2)(iv)(B) (B)Arequirementthattheisolationshouldbetheleastrestrictivepossiblefortheresidentunderthecircumstances.
1
483.80(a)(2)(v) (v)Thecircumstancesunderwhichthefacilitymustprohibitemployeeswithacommunicablediseaseorinfectedskinlesionsfromdirectcontactwithresidentsortheirfood,ifdirectcontactwilltransmitthedisease;and
1
483.80(a)(2)(vi) (vi)Thehandhygieneprocedurestobefollowedbystaffinvolvedindirectresidentcontact.
1
483.80(a)(3) (3)Anantibioticstewardshipprogramthatincludesantibioticuseprotocolsandasystemtomonitorantibioticuse.
2
483.80(a)(4)
(4)Asystemforrecordingincidentsidentifiedunderthefacility’sIPCPandthecorrectiveactionstakenbythefacility.
1
483.80(b) (b)Infectionpreventionist.Thefacilitymustdesignateoneormoreindividual(s)astheinfectionpreventionist(s)(IPs)whoareresponsibleforthefacility’sIPCP.TheIPmust:
3
483.80(b)(1) (1)Haveprimaryprofessionaltraininginnursing,medicaltechnology,microbiology,epidemiology,orotherrelatedfield;
3
483.80(b)(2) (2)Bequalifiedbyeducation,training,experienceorcertification;
3
483.80(b)(3) (3)Workatleastpart-timeatthefacility;and
3 483.80(b)(3) (3)Havesufficienttimeatthefacilitytoachievetheobjectivessetforthinthefacility’sIPCP.
483.80(b)(4) (4)Havecompletedspecializedtrainingininfectionpreventionandcontrol.
3
153
483.80(c) (c)IPparticipationonqualityassessmentandassurancecommittee.TheindividualdesignatedastheIP,oratleastoneoftheindividualsifthereismorethanoneIP,mustbeamemberofthefacility’squalityassessmentandassurancecommitteeandreporttothecommitteeontheIPCPonaregularbasis.
3
483.80(d) (d)Influenzaandpneumococcalimmunizations—
1
483.80(d)(1) (1)Influenza.Thefacilitymustdeveloppoliciesandprocedurestoensurethat—
1
483.80(d)(1)(i) (i)Beforeofferingtheinfluenzaimmunization,eachresidentortheresident’srepresentativereceiveseducationregardingthebenefitsandpotentialsideeffectsoftheimmunization;
1
483.80(d)(1)(ii) (ii)EachresidentisofferedaninfluenzaimmunizationOctober1throughMarch31annually,unlesstheimmunizationismedicallycontraindicatedortheresidenthasalreadybeenimmunizedduringthistimeperiod;
1
483.80(d)(1)(iii) (iii)Theresidentortheresident’srepresentativehastheopportunitytorefuseimmunization;and
1
483.80(d)(1)(iv) (iv)Theresident’smedicalrecordincludesdocumentationthatindicates,ataminimum,thefollowing:
1
483.80(d)(1)(iv)(A) (A)Thattheresidentorresident’srepresentativewasprovidededucationregardingthebenefitsandpotentialsideeffectsofinfluenzaimmunization;and
1
483.80(d)(1)(iv)(B) (B)Thattheresidenteitherreceivedthe 1
154
influenzaimmunizationordidnotreceivetheinfluenzaimmunizationduetomedicalcontraindicationsorrefusal.
483.80(d)(2) (2)Pneumococcaldisease.Thefacilitymustdeveloppoliciesandprocedurestoensurethat—
1
483.80(d)(2)(i) (i)Beforeofferingthepneumococcalimmunization,eachresidentortheresident’srepresentativereceiveseducationregardingthebenefitsandpotentialsideeffectsoftheimmunization;
1
483.80(d)(2)(ii) (ii)Eachresidentisofferedapneumococcalimmunization,unlesstheimmunizationismedicallycontraindicatedortheresidenthasalreadybeenimmunized;
1
483.80(d)(2)(iii) (iii)Theresidentortheresident’srepresentativehastheopportunitytorefuseimmunization;and
1
483.80(d)(2)(iv) (iv)Theresident’smedicalrecordincludesdocumentationthatindicates,ataminimum,thefollowing:
1
483.80(d)(2)(iv)(A) (A)Thattheresidentorresident’srepresentativewasprovidededucationregardingthebenefitsandpotentialsideeffectsofpneumococcalimmunization;and
1
483.80(d)(2)(iv)(B) (B)Thattheresidenteitherreceivedthepneumococcalimmunizationordidnotreceivethepneumococcalimmunizationduetomedicalcontraindicationorrefusal.
1
483.80(e) (e)Linens.Personnelmusthandle,store,process,andtransportlinenssoasto
1
155
preventthespreadofinfection.483.80(f) (f)Annualreview.Thefacilitywill
conductanannualreviewofitsIPCPandupdatetheirprogram,asnecessary.
1
§483.85 Complianceandethicsprogram. Thisentiresectionwillbeimplementedin
Phase3.
483.85(a) (a)Definitions.Forpurposesofthissection,thefollowingdefinitionsapply:Complianceandethicsprogrammeans,withrespecttoafacility,aprogramoftheoperatingorganizationthat—
3
483.85(a)(1) (1)Hasbeenreasonablydesigned,implemented,andenforcedsothatitislikelytobeeffectiveinpreventinganddetectingcriminal,civil,andadministrativeviolationsundertheActandinpromotingqualityofcare;and
3 483.85(a)(i) (i)Hasbeenreasonablydesigned,implemented,andenforcedsothatitislikelytobeeffectiveinpreventinganddetectingcriminal,civil,andadministrativeviolationsundertheActandinpromotingqualityofcare;and
483.85(a)(2) (2)Includes,ataminimum,therequiredcomponentsspecifiedinparagraph(c)ofthissection.High-levelpersonnelmeansindividual(s)whohavesubstantialcontrolovertheoperatingorganizationorwhohaveasubstantialroleinthemakingofpolicywithintheoperatingorganization.Operatingorganizationmeanstheindividual(s)orentitythatoperatesafacility.
3 483.85(a)(ii) (ii)Includes,ataminimum,therequiredcomponentsspecifiedinparagraph(c)ofthissection.High-levelpersonnelmeansindividual(s)whohavesubstantialcontrolovertheoperatingorganizationorwhohaveasubstantialroleinthemakingofpolicywithintheoperatingorganization.Operatingorganizationmeanstheindividual(s)orentitythatoperatesafacility.
483.85(b) (b)Generalrule.BeginningonNovember28,2017,theoperatingorganizationfor
3 483.85(b) (b)Generalrule.BeginningonNovember28,2019,theoperatingorganizationforeachfacilitymusthavein
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eachfacilitymusthaveinoperationacomplianceandethicsprogram(asdefinedinparagraph(a)ofthissection)thatmeetstherequirementsofthissection.
operationacomplianceandethicsprogram(asdefinedinparagraph(a)ofthissection)thatmeetstherequirementsofthissection.
483.85(c) (c)Requiredcomponentsforallfacilities.Theoperatingorganizationforeachfacilitymustdevelop,implement,andmaintainaneffectivecomplianceandethicsprogramthatcontains,ataminimum,thefollowingcomponents:
3
483.85(c)(1) (1)Establishedwrittencomplianceandethicsstandards,policies,andprocedurestofollowthatarereasonablycapableofreducingtheprospectofcriminal,civil,andadministrativeviolationsundertheActandpromotequalityofcare,whichinclude,butarenotlimitedto,thedesignationofanappropriatecomplianceandethicsprogramcontacttowhichindividualsmayreportsuspectedviolations,aswellasanalternatemethodofreportingsuspectedviolationsanonymouslywithoutfearofretribution;anddisciplinarystandardsthatsetouttheconsequencesforcommittingviolationsfortheoperatingorganization’sentirestaff;individualsprovidingservicesunderacontractualarrangement;andvolunteers,consistentwiththevolunteers’expectedroles.
3 483.85(c)(1) (1)Establishedwrittencomplianceandethicsstandards,policies,andprocedurestofollowthatarereasonablycapableofreducingtheprospectofcriminal,civil,andadministrativeviolationsundertheAct.
483.85(c)(2) (2)Assignmentofspecificindividualswithinthehigh-levelpersonneloftheoperatingorganizationwiththeoverallresponsibilitytooverseecompliancewith
3 483.85(c)(2) (2)Assignmentofspecificindividualswithinthehigh-levelpersonneloftheoperatingorganizationwiththeoverallresponsibilitytooverseecompliancewiththeoperatingorganization’scomplianceandethics
157
theoperatingorganization’scomplianceandethicsprogram’sstandards,policies,andprocedures,suchas,butnotlimitedto,thechiefexecutiveofficer(CEO),membersoftheboardofdirectors,ordirectorsofmajordivisionsintheoperatingorganization.
program’sstandards,policies,andprocedures.
483.85(c)(3) (3)Sufficientresourcesandauthoritytothespecificindividualsdesignatedinparagraph(c)(2)ofthissectiontoreasonablyassurecompliancewithsuchstandards,policies,andprocedures.
3
483.85(c)(4) (4)Duecarenottodelegatesubstantialdiscretionaryauthoritytoindividualswhotheoperatingorganizationknew,orshouldhaveknownthroughtheexerciseofduediligence,hadapropensitytoengageincriminal,civil,andadministrativeviolationsundertheSocialSecurityAct.
3
483.85(c)(5) (5)Thefacilitytakesstepstoeffectivelycommunicatethestandards,policies,andproceduresintheoperatingorganization’scomplianceandethicsprogramtotheoperatingorganization’sentirestaff;individualsprovidingservicesunderacontractualarrangement;andvolunteers,consistentwiththevolunteers’expectedroles.Requirementsinclude,butarenotlimitedto,mandatoryparticipationintrainingassetforthat§483.95(f)ororientationprograms,ordisseminatinginformationthatexplainsinapracticalmannerwhatisrequiredundertheprogram.
3
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483.85(c)(6) (6)Thefacilitytakesreasonablestepstoachievecompliancewiththeprogram’sstandards,policies,andprocedures.Suchstepsinclude,butarenotlimitedto,utilizingmonitoringandauditingsystemsreasonablydesignedtodetectcriminal,civil,andadministrativeviolationsundertheActbyanyoftheoperatingorganization’sstaff,individualsprovidingservicesunderacontractualarrangement,orvolunteers,havinginplaceandpublicizingareportingsystemwherebyanyoftheseindividualscouldreportviolationsbyothersanonymouslywithintheoperatingorganizationwithoutfearofretribution,andhavingaprocessforensuringtheintegrityofanyreporteddata.
3 483.85(c)(6) (6)Thefacilitytakesreasonablestepstoachievecompliancewiththeprogram’sstandards,policies,andprocedures.Suchstepsinclude,butarenotlimitedto,utilizingmonitoringandauditingsystemsreasonablydesignedtodetectcriminal,civil,andadministrativeviolationsundertheActbyanyoftheoperatingorganization’sstaff,individualsprovidingservicesunderacontractualarrangement,orvolunteers,havinginplaceandpublicizingareportingsystemwherebyanyoftheseindividualscouldreportviolationsbyotherswithintheoperatingorganizationwithoutfearofretribution.
483.85(c)(7) (7)Consistentenforcementoftheoperatingorganization’sstandards,policies,andproceduresthroughappropriatedisciplinarymechanisms,including,asappropriate,disciplineofindividualsresponsibleforthefailuretodetectandreportaviolationtothecomplianceandethicsprogramcontactidentifiedintheoperatingorganization’scomplianceandethicsprogram.
3 483.85(c)(7) (7)Consistentenforcementoftheoperatingorganization’sstandards,policies,andproceduresthroughappropriatedisciplinarymechanisms,including,asappropriate,disciplineofindividualsresponsibleforthefailuretodetectandreportaviolation(statutesays,‘‘offense’’)tothecomplianceandethicsprogramcontactidentifiedintheoperatingorganization’scomplianceandethicsprogram.
483.85(c)(8) (8)Afteraviolationisdetected,theoperatingorganizationmustensurethatallreasonablestepsidentifiedinitsprogramaretakentorespondappropriatelytotheviolationandtopreventfurthersimilarviolations,includinganynecessarymodificationtotheoperatingorganization’sprogramto
3
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preventanddetectcriminal,civil,andadministrativeviolationsundertheAct.
483.85(c)(9) (9)Thefacilityhasanalternatemethodofreportingsuspectedviolationsanonymously.
483.85(d) (d)Additionalrequiredcomponentsforoperatingorganizationswithfiveormorefacilities.Inadditiontoalloftheotherrequirementsinparagraphs(a),(b),(c),and(e)ofthissection,operatingorganizationsthatoperatefiveormorefacilitiesmustalsoinclude,ataminimum,thefollowingcomponentsintheircomplianceandethicsprogram:
3 483.85(d) (d)Additionalrequiredcomponentsforoperatingorganizationswithfiveormorefacilities.Inadditiontoalloftheotherrequirementsinparagraphs(a),(b),(c),and(e)ofthissection,operatingorganizationsthatoperatefiveormorefacilitiesandfacilitieswithcorporatelevelmanagementofmulti-unitnursinghomechainsmustcomplywiththeseadditionalrequirementsmust:
483.85(d)(1) (1)Amandatoryannualtrainingprogramontheoperatingorganization’scomplianceandethicsprogramthatmeetstherequirementssetforthin§483.95(f).
3 483.85(d)(1) (1)Haveamoreformalprogramthatincludesestablishedwrittenpoliciesdefiningthestandardsandprocedurestobefollowedbyitsemployees.
483.85(d)(2) (2)Adesignatedcomplianceofficerforwhomtheoperatingorganization’scomplianceandethicsprogramisamajorresponsibility.Thisindividualmustreportdirectlytotheoperatingorganization’sgoverningbodyandnotbesubordinatetothegeneralcounsel,chieffinancialofficerorchiefoperatingofficer.
3 483.85(d)(2) (2)Developacomplianceandethicsprogramthatisappropriateforthecomplexityoftheoperatingorganizationanditsfacilities.
483.85(d)(3) (3)Designatedcomplianceliaisonslocatedateachoftheoperatingorganization’sfacilities.
3 483.85(d)(3) (3)Designatedcomplianceliaisonslocatedateachoftheoperatingorganization’sfacilities.
483.85(e) (e)Annualreview.Theoperatingorganizationforeachfacilitymustreviewitscomplianceandethicsprogramannuallyandreviseitsprogramasneededtoreflectchangesinallapplicablelawsorregulationsandwithin
3 483.85(e) (e)Programreview.Theoperatingorganizationforeachfacilitymustperiodicallyreviewandreviseitscomplianceprogramtoidentifynecessarychangeswithintheorganizationanditsfacilities.
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theoperatingorganizationanditsfacilitiestoimproveitsperformanceindeterring,reducing,anddetectingviolationsundertheActandinpromotingqualityofcare.
§483.90 Physicalenvironment. ThissectionwasimplementedinPhase1withthe
followingexceptions:
§483.90(g)(1),*whichwillbe
implementedinPhase3,and§483.90(i)(5),*whichwas
implementedinPhase2.
Note:IntheCMScrosswalkandimplementationchartinthe
FederalRegisterandtheCMSSurveyandCertification
Memo,S&C17-07-NH,11/9/16,thesecitationsappeartobe
mistakenlylistedas§483.90(f)(1)
and§483.90(h)(5).
483.90 Thefacilitymustbedesigned,constructed,equipped,andmaintained
1
161
toprotectthehealthandsafetyofresidents,personnelandthepublic.
483.90(a) (a)Lifesafetyfromfire. 1 483.90(a)(1) (1)Exceptasotherwiseprovidedinthis
section—1
483.90(a)(1)(i) (i)Thefacilitymustmeettheapplicableprovisionsofthe2000editionoftheLifeSafetyCodeoftheNationalFireProtectionAssociation.TheDirectoroftheOfficeoftheFederalRegisterhasapprovedtheNFPA101Ò2000editionoftheLifeSafetyCode,issuedJanuary14,2000,forincorporationbyreferenceinaccordancewith5U.S.C.552(a)and1CFRpart51.AcopyoftheCodeisavailableforinspectionattheCMSInformationResourceCenter,7500SecurityBoulevard,Baltimore,MDorattheNationalArchivesandRecordsAdministration(NARA).ForinformationontheavailabilityofthismaterialatNARA,call202–741–6030,orgoto:http://www.archives.gov/federallregister/codeloflfederallregulations/ibrllocations.html.CopiesmaybeobtainedfromtheNationalFireProtectionAssociation,1BatterymarchPark,Quincy,MA02269.IfanychangesinthiseditionoftheCodeareincorporatedbyreference,CMSwillpublishnoticeintheFEDERALREGISTERtoannouncethechanges.
1
483.90(a)(1)(ii) (ii)Chapter19.3.6.3.2,exceptionnumber2oftheadoptededitionoftheLSCdoes
1
162
notapplytolong-termcarefacilities. 483.90(a)(1)(ii) (iii)IfafacilityisMedicare-orMedicaid-certified
beforeJuly5,2016andthefacilityhaspreviouslyusedtheFireSafetyEvaluationSystemforcompliance,thefacilitymayusethescoringvaluesintable1to§483.90(a)(1)(iii):Table1to§483.90(a)(1)(iii):MandatoryValues–NursingHomes Containme
nt(Sa)Extinguishment(Sb)
PeopleMovement(Sc)
ZoneLocation
New
Exist.
New Exist.
New
Exist.
1ststory
11 5 15(12)*
4 8(5)*
1
2ndor3rdstory
15 9 17(14)*
6 10(7)*
3
4thstoryorhigher
18 9 19(16)*
6 11(8)*
3
*Use()inzonesthatdonotcontainpatientsleepingrooms.
483.90(a)(2) (2)AfterconsiderationofStatesurveyagencyfindings,CMSmaywaivespecificprovisionsoftheLifeSafetycodewhich,ifrigidlyapplied,wouldresultinunreasonablehardshipuponthefacility,butonlyifthewaiverdoesnotadverselyaffectthehealthandsafetyofthepatients.
1
163
483.90(a)(3) (3)TheprovisionsoftheLifesafetyCodedonotapplyinaStatewhereCMSfinds,inaccordancewithapplicableprovisionsofsections1819(d)(2)(B)(ii)and1919(d)(2)(B)(ii)oftheAct,thatafireandsafetycodeimposedbyStatelawadequatelyprotectspatients,residentsandpersonnelinlongtermcarefacilities.
1
483.90(a)(4) (4)BeginningMarch13,2006,along-termcarefacilitymustbeincompliancewithChapter19.2.9,EmergencyLighting.
1
483.90(a)(5) (5)BeginningMarch13,2006,Chapter19.3.6.3.2,exceptionnumber2doesnotapplytolong-termcarefacilities.
1
483.90(a)(6) (6)Notwithstandinganyprovisionsofthe2000editionoftheLifeSafetyCodetothecontrary,along-termcarefacilitymayinstallalcohol-basedhandrubdispensersinitsfacilityif—
1
483.90(a)(6)(i) (i)Useofalcohol-basedhandrubdispensersdoesnotconflictwithanyStateorlocalcodesthatprohibitorotherwiserestricttheplacementofalcohol-basedhandrubdispensersinhealthcarefacilities;
1
483.90(a)(6)(ii) (ii)Thedispensersareinstalledinamannerthatminimizesleaksandspillsthatcouldleadtofalls;
1
483.90(a)(6)(iii) (iii)Thedispensersareinstalledinamannerthatadequatelyprotectsagainstinappropriateaccess;
1
483.90(a)(6)(iv) (iv)Thedispensersareinstalledinaccordancewithchapter18.3.2.7orchapter19.3.2.7ofthe2000editionof
1
164
theLifeSafetyCode,asamendedbyNFPATemporaryInterimAmendment00–1(101),issuedbytheStandardsCounciloftheNationalFireProtectionAssociationonApril15,2004.TheDirectoroftheOfficeoftheFederalRegisterhasapprovedNFPATemporaryInterimAmendment00–1(101)forincorporationbyreferenceinaccordancewith5U.S.C.552(a)and1CFRpart51.AcopyoftheamendmentisavailableforinspectionattheCMSInformationResourceCenter,7500SecurityBoulevard,Baltimore,MDandattheOfficeoftheFederalRegister,800NorthCapitolStreetNW.,Suite700,Washington,DC.CopiesmaybeobtainedfromtheNationalFireProtectionAssociation,1BatterymarchPark,Quincy,MA02269;and
483.90(a)(6)(v) (v)Thedispensersaremaintainedinaccordancewithdispensermanufacturerguidelines.
1
483.90(a)(7) (7)Alongtermcarefacilitymust: 1 483.90(a)(7)(i) (i)Install,atleast,battery-operated
singlestationsmokealarmsinaccordancewiththemanufacturer’srecommendationsinresidentsleepingroomsandcommonareas.
1
483.90(a)(7)(ii) (ii)Haveaprogramforinspection,testing,maintenance,andbatteryreplacementthatconformstothemanufacturer’srecommendationsandthatverifiescorrectoperationofthesmokealarms.
1
165
483.90(a)(7)(iii) (iii)Exception: 1 483.90(a)(7)(iii)(A) (A)Thefacilityhassystem-basedsmoke
detectorsinpatientroomsandcommonareasthatareinstalled,tested,andmaintainedinaccordancewithNFPA72,NationalFireAlarmCode,forsystem-basedsmokedetectors;or
1
483.90(a)(7)(iii)(B) (B)ThefacilityisfullysprinkleredinaccordancewithNFPA13,StandardfortheInstallationofSprinklerSystems.
1
483.90(a)(8) (8)Alongtermcarefacilitymust: 1 483.90(a)(8)(i) (i)Installanapproved,supervised
automaticsprinklersysteminaccordancewiththe1999editionofNFPA13,StandardfortheInstallationofSprinklerSystems,asincorporatedbyreference,throughoutthebuildingbyAugust13,2013.TheDirectoroftheOfficeoftheFederalRegisterhasapprovedtheNFPA131999editionoftheStandardfortheInstallationofSprinklerSystems,issuedJuly22,1999forincorporationbyreferenceinaccordancewith5U.S.C.552(a)and1CFRpart51.AcopyoftheCodeisavailableforinspectionattheCMSInformationResourceCenter,7500SecurityBoulevard,Baltimore,MDorattheNationalArchivesandRecordsAdministration(NARA).ForinformationontheavailabilityofthismaterialatNARA,call202–741–6030,orgoto:http://www.archives.gov/federallregister/codeloflfederallregulations/ibrllocations.html.Copiesmaybeobtainedfromthe
1
166
NationalFireProtectionAssociation,1BatterymarchPark,Quincy,MA02269.
483.90(a)(8)(ii) (ii)Test,inspect,andmaintainanapproved,supervisedautomaticsprinklersysteminaccordancewiththe1998editionofNFPA25,StandardfortheInspection,Testing,andMaintenanceofWater-BasedFireProtectionSystems,asincorporatedbyreference.TheDirectoroftheOfficeoftheFederalRegisterhasapprovedtheNFPA25,StandardfortheInspection,Testing,andMaintenanceofWater-BasedFireProtectionSystems,1998edition,issuedJanuary16,1998forincorporationbyreferenceinaccordancewith5U.S.C.552(a)and1CFRpart51.AcopyoftheCodeisavailableforinspectionattheCMSInformationResourceCenter,7500SecurityBoulevard,Baltimore,MDorattheNationalArchivesandRecordsAdministration(NARA).ForinformationontheavailabilityofthismaterialatNARA,call202–741–6030,orgoto:http://www.archives.gov/federallregister/codeloflfederallregulations/ibrllocations.html.CopiesmaybeobtainedfromtheNationalFireProtectionAssociation,1BatterymarchPark,Quincy,MA02269.
1
483.90(b) (b)Emergencypower. 1 483.90(b)(1) (1)Anemergencyelectricalpower
systemmustsupplypoweradequateatleastforlightingallentrancesandexits;equipmenttomaintainthefiredetection,alarm,andextinguishingsystems;andlife
1
167
supportsystemsintheeventthenormalelectricalsupplyisinterrupted.
483.90(b)(2) (2)Whenlifesupportsystemsareused,thefacilitymustprovideemergencyelectricalpowerwithanemergencygenerator(asdefinedinNFPA99,HealthCareFacilities)thatislocatedonthepremises.
1
483.90(c) (c)Spaceandequipment.Thefacilitymust—
1 483.90(d) (d)Spaceandequipment.Thefacilitymust—
483.90(c)(1) (1)Providesufficientspaceandequipmentindining,healthservices,recreation,living,andprogramareastoenablestafftoprovideresidentswithneededservicesasrequiredbythesestandardsandasidentifiedineachresident’sassessmentandplanofcare;and
1 483.90(d)(1) (1)Providesufficientspaceandequipmentindining,healthservices,recreation,living,andprogramareastoenablestafftoprovideresidentswithneededservicesasrequiredbythesestandardsandasidentifiedineachresident’sassessmentandplanofcare;and
483.90(c)(2) (2)Maintainallmechanical,electrical,andpatientcareequipmentinsafeoperatingcondition.
1 483.90(d)(2) (2)Maintainallmechanical,electrical,andpatientcareequipmentinsafeoperatingcondition.
483.90(c)(3) (3)Conductregularinspectionofallbedframes,mattresses,andbedrails,ifany,aspartofaregularmaintenanceprogramtoidentifyareasofpossibleentrapment.Whenbedrailsandmattressesareusedandpurchasedseparatelyfromthebedframe,thefacilitymustensurethatthebedrails,mattress,andbedframearecompatible.
1 483.90(d)(3) (3)Conductregularinspectionofallbedframes,mattresses,andbedrails,ifany,aspartofaregularmaintenanceprogramtoidentifyareasofpossibleentrapment.Whenbedrailsandmattressesareusedandpurchasedseparatelyfromthebedframe,thefacilitymustensurethatthebedrails,mattress,andbedframearecompatible.
483.90(d)**Thecrosswalkcites483.90(d),whereasthepublishedrevised
(d)Residentrooms.Residentroomsmustbedesignedandequippedforadequatenursingcare,comfort,andprivacyofresidents.
1
168
regulationscitethissectionas483.90(e).Itisunclearwhichoneiscorrect,sowehaveusedthecrosswalkcitations.483.90(d)(1) (1)Bedroomsmust— 1 483.90(d)(1)(i) (i)Accommodatenomorethanfour
residents.ForfacilitiesthatreceiveapprovalofconstructionorreconstructionplansbyStateandlocalauthoritiesorarenewlycertifiedafterNovember28,2016,bedroomsmustaccommodatenomorethantworesidents.
1 483.90(e)(1)(i) (i)Accommodatenomorethanfourresidents.ForfacilitiesthatreceiveapprovalofconstructionplansbystateandlocalauthoritiesorarenewlycertifiedandhaveneverpreviouslybeenaLTCfacility,afterNovember28,2016,bedroomsmustaccommodatenomorethantworesidents.
483.90(d)(1)(ii) (ii)Measureatleast80squarefeetperresidentinmultipleresidentbedrooms,andatleast100squarefeetinsingleresidentrooms;
1
483.90(d)(1)(iii) (iii)Havedirectaccesstoanexitcorridor; 1 483.90(d)(1)(iv) (iv)Bedesignedorequippedtoassure
fullvisualprivacyforeachresident;1
483.90(d)(1)(v) (v)InfacilitiesinitiallycertifiedafterMarch31,1992,exceptinprivaterooms,eachbedmusthaveceilingsuspendedcurtains,whichextendaroundthebedtoprovidetotalvisualprivacyincombinationwithadjacentwallsandcurtains;
1
483.90(d)(1)(vi) (vi)Haveatleastonewindowtotheoutside;and
1
483.90(d)(1)(vii) (vii)Haveaflooratorabovegradelevel. 1 483.90(d)(2) (2)Thefacilitymustprovideeach 1
169
residentwith—483.90(d)(2)(i) (i)Aseparatebedofpropersizeand
heightforthesafetyandconvenienceoftheresident;
1
483.90(d)(2)(ii) (ii)Aclean,comfortablemattress; 1 483.90(d)(2)(iii) (iii)Beddingappropriatetotheweather
andclimate;and1
483.90(d)(2)(iv) (iv)Functionalfurnitureappropriatetotheresident’sneeds,andindividualclosetspaceintheresident’sbedroomwithclothesracksandshelvesaccessibletotheresident.
1
483.90(d)(3) (3)CMS,orinthecaseofanursingfacilitythesurveyagency,maypermitvariationsinrequirementsspecifiedinparagraphs(d)(1)(i)and(ii)ofthissectionrelatingtoroomsinindividualcaseswhenthefacilitydemonstratesinwritingthatthevariations—
1
483.90(d)(3)(i) (i)Areinaccordancewiththespecialneedsoftheresidents;and
1
483.90(d)(3)(ii) (ii)Willnotadverselyaffectresidents’healthandsafety.
1
483.90(e)**Thecrosswalkcites483.90(e),whereasthepublishedrevisedregulationscitethissectionas483.90(f).Itisunclearwhichoneiscorrect,sowehaveusedthecrosswalk
(e)Bathroomfacilities.Eachresidentroommustbeequippedwithorlocatedneartoiletandbathingfacilities.ForfacilitiesthatreceiveapprovalofconstructionfromStateandlocalauthoritiesorarenewlycertifiedafterNovember28,2016,eachresidentroommusthaveitsownbathroomequippedwithatleastacommodeandsink.
1 483.90(f)
(f)Bathroomfacilities.Eachresidentroommustbeequippedwithorlocatedneartoiletandbathingfacilities.ForfacilitiesthatreceiveapprovalofconstructionfromstateandlocalauthoritiesorarenewlycertifiedandhaveneverpreviouslybeenaLTCfacility,afterNovember28,2016,eachresidentroommusthaveitsownbathroomequippedwithatleastacommodeandsink.
170
citations.483.90(f)**TheCMScrosswalkcites483.90(f),whereasthepublishedrevisedregulationscitethissectionas483.90(g).Itisunclearwhichoneiscorrect,sowehaveusedthecrosswalkcitations.
(f)Residentcallsystem.Thefacilitymustbeadequatelyequippedtoallowresidentstocallforstaffassistancethroughacommunicationsystemwhichrelaysthecalldirectlytoastaffmemberortoacentralizedstaffworkareafrom—
1
483.90(f)(1) (1)Eachresident’sbedside;and 3 483.90(f)(2) (2)Toiletandbathingfacilities. 1 483.90(g)**TheCMScrosswalkcites483.90(g),whereasthepublishedrevisedregulationscitethissectionas483.90(h).Itisunclearwhichoneiscorrect,sowehaveusedthecrosswalkcitations.
(g)Diningandresidentactivities.Thefacilitymustprovideoneormoreroomsdesignatedforresidentdiningandactivities.Theseroomsmust—
1
483.90(g)(2) (2)Bewellventilated; 1 483.90(g)(3) (3)Beadequatelyfurnished;and 1 483.90(g)(4) (4)Havesufficientspaceto
accommodateallactivities.1
483.90(h)**TheCMS
(h)Otherenvironmentalconditions.
1
171
crosswalkcites483.90(h),whereasthepublishedrevisedregulationscitethissectionas483.90(i).Itisunclearwhichoneiscorrect,sowehaveusedthecrosswalkcitations.483.90(h) Thefacilitymustprovideasafe,
functional,sanitary,andcomfortableenvironmentfortheresidents,staffandthepublic.Thefacilitymust—
483.90(h)(1) (1)Establishprocedurestoensurethatwaterisavailabletoessentialareaswhenthereisalossofnormalwatersupply;
1
483.90(h)(2) (2)Haveadequateoutsideventilationbymeansofwindows,ormechanicalventilation,oracombinationofthetwo;
1
483.90(h)(3) (3)Equipcorridorswithfirmlysecuredhandrailsoneachside;and
1
483.90(h)(4) (4)Maintainaneffectivepestcontrolprogramsothatthefacilityisfreeofpestsandrodents.
1
483.90(h)(5) (5)Establishpolicies,inaccordancewithapplicableFederal,State,andlocallawsandregulations,regardingsmoking,smokingareas,andsmokingsafetythatalsotakeintoaccountnon-smokingresidents.
2
§483.95 Trainingrequirements. Thisentiresectionwillbe
172
implementedinPhase3,withthe
followingexceptions:§483.95(c),
§483.95(g)(1),§483.95(g)(2),§483.95(g)(4),and§483.95(h),whichwere
implementedinPhase1.
483.95 Afacilitymustdevelop,implement,andmaintainaneffectivetrainingprogramforallnewandexistingstaff;individualsprovidingservicesunderacontractualarrangement;andvolunteers,consistentwiththeirexpectedroles.Afacilitymustdeterminetheamountandtypesoftrainingnecessarybasedonafacilityassessmentasspecifiedat§483.70(e).Trainingtopicsmustincludebutarenotlimitedto—
3
483.95(a) (a)Communication.Afacilitymustincludeeffectivecommunicationsasmandatorytrainingfordirectcarestaff.
3
483.95(b) (b)Resident’srightsandfacilityresponsibilities.Afacilitymustensurethatstaffmembersareeducatedontherightsoftheresidentandtheresponsibilitiesofafacilitytoproperlycareforitsresidentsassetforthat§483.10,respectively.
3
483.95(c) (c)Abuse,neglect,andexploitation.Inadditiontothefreedomfromabuse,
1
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neglect,andexploitationrequirementsin§483.12,facilitiesmustalsoprovidetrainingtotheirstaffthatataminimumeducatesstaffon—
483.95(c)(1) (1)Activitiesthatconstituteabuse,neglect,exploitation,andmisappropriationofresidentpropertyassetforthat§483.12.
1
483.95(c)(2) (2)Proceduresforreportingincidentsofabuse,neglect,exploitation,orthemisappropriationofresidentproperty.
1
483.95(c)(3) (3)Dementiamanagementandresidentabuseprevention.
1
483.95(d) (d)Qualityassuranceandperformanceimprovement.AfacilitymustincludeaspartofitsQAPIprogrammandatorytrainingthatoutlinesandinformsstaffoftheelementsandgoalsofthefacility’sQAPIprogramassetforthat§483.75.
3
483.95(e) (e)Infectioncontrol.Afacilitymustincludeaspartofitsinfectionpreventionandcontrolprogrammandatorytrainingthatincludesthewrittenstandards,policies,andproceduresfortheprogramasdescribedat§483.80(a)(2).
3
483.95(f) (f)Complianceandethics.Theoperatingorganizationforeachfacilitymustincludeaspartofitscomplianceandethicsprogram,assetforthat§483.85—
3 483.95(f) (f)Complianceandethics.Theoperatingorganizationforeachfacilitymustincludeaspartofitscomplianceandethicsprogram,assetforthat§483.85,aneffectivewaytocommunicatethatprogram’sstandards,policies,andproceduresthroughatrainingprogramorinanotherpracticalmannerwhichexplainstherequirementsundertheprogram.
483.95(f)(1) (1)Aneffectivewaytocommunicatethatprogram’sstandards,policies,andproceduresthroughatrainingprogram
3 483.95(f)(1) (1)Aneffectivewaytocommunicatethatprogram’sstandards,policies,andproceduresthroughatrainingprogramorinanotherpracticalmannerwhichexplains
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orinanotherpracticalmannerwhichexplainstherequirementsundertheprogram.
therequirementsundertheprogram.
483.95(f)(2) (2)Annualtrainingiftheoperatingorganizationoperatesfiveormorefacilities.
3 483.95(f)(2) (2)Annualtrainingiftheoperatingorganizationoperatesfiveormorefacilities.
483.95(g) (g)Requiredin-servicetrainingfornurseaides.In-servicetrainingmust—
1
483.95(g)(1) (1)Besufficienttoensurethecontinuingcompetenceofnurseaides,butmustbenolessthan12hoursperyear.
1
483.95(g)(2) (2)Includedementiamanagementtrainingandresidentabusepreventiontraining.
1
483.95(g)(3) (3)Addressareasofweaknessasdeterminedinnurseaides’performancereviewsandfacilityassessmentat§483.70(e)andmayaddressthespecialneedsofresidentsasdeterminedbythefacilitystaff.
3
483.95(g)(4) (4)Fornurseaidesprovidingservicestoindividualswithcognitiveimpairments,alsoaddressthecareofthecognitivelyimpaired.
1
483.95(h)
(h)Requiredtrainingoffeedingassistants.AfacilitymustnotuseanyindividualworkinginthefacilityasapaidfeedingassistantunlessthatindividualhassuccessfullycompletedaState-approvedtrainingprogramforfeedingassistants,asspecifiedin§483.160.
1
483.95(i) (i)Behavioralhealth.Afacilitymustprovidebehavioralhealthtrainingconsistentwiththerequirementsat§483.40andasdeterminedbythefacility
3
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assessmentat§483.70(e). PART488–SURVEY,CERTIFICATIONANDENFORCEMENTPROCEDURES488.331 InformalDisputeResolution 488.331 InformalDisputeResolution488.331(a)(1) (a)Opportunitytorefutesurveyfindings.
(1)Fornon-Federalsurveys,theStatemustofferafacilityaninformalopportunity,atthefacility’srequest,todisputesurveyfindingsuponthefacility’sreceiptoftheofficialstatementofdeficiencies.
488.331(a)(2) (2)ForFederalsurveys,CMSoffersafacilityaninformalopportunity,atthefacility’srequest,todisputesurveyfindingsuponthefacility’sreceiptoftheofficialstatementofdeficiencies.
488.331(a)(3) (3)ForSNFs,dually-participatingSNF/NFs,andNF-onlyfacilitiesthathavecivilmoneypenaltiesimposedbyCMSthatwillbeplacedinaCMSescrowaccount,CMSalsooffersthefacilityanopportunityforindependentinformaldisputeresolution,subjecttothetermsofparagraphs(b),(c),and(d)ofthissectionandof488.431.Thefacilitymustrequestindependentinformaldisputeresolutioninwritingwithin10daysofreceiptofCMS’soffer.However,afacilitymaynotsuethedisputeresolutionprocessatboth488.331and488.431forthesamedeficiencycitationarisingfromthesamesurveyunlesstheinformaldisputeresolutionprocessat488.331wascompletedpriortotheimpositionof
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thecivilmoneypenalty.488.331(b)(1) (b)(1)FailureoftheStateorCMS,as
appropriate,tocompleteinformaldisputeresolutiontimelycannotdelaytheeffectivedateofanyenforcementactionagainstthefacility.
488.331(b)(1) (b)(1)Informaldisputeresolutionwillbecompletedwithin60daysofthefacility’srequesttodisputethesurveyfindingsiftherequestbythefacilityistimely.FailureofthestateorCMS,asappropriatetocompleteinformaldisputeresolutiontimelycannotdelaytheeffectivedateofanyenforcementactionagainstthefacility.
488.331(b)(2) (b)(2)Afacilitymaynotseekadelayofanyenforcementactionagainstitonthegroundsthatinformaldisputeresolutionhasnotbeencompletedbeforetheeffectivedateoftheenforcementaction.
488.331(b)(2) (b)(2)Afacilitymaynotseekadelayofanyenforcementactionagainstitonthegroundsthatinformaldisputeresolutionhasnotbeencompletedbeforetheeffectivedateoftheenforcementaction,exceptthattheresultsofthesurveywillnotbeuploadedintotheCMSnursinghomesurveyandcertificationdatabaseand/orusedforthepurposesoftheCMS“NursingHomeCompare”websitetocalculatethefacility’s5-starratinguntiltheinformaldisputeresolutionortheindependentinformaldisputeresolutionprocessiscomplete.
488.331(c) (c)Ifaproviderissubsequentlysuccessful,duringtheinformaldisputeresolutionprocess,atdemonstratingthatdeficienciesshouldnothavebeencited,thedeficienciesareremovedfromthestatementofdeficienciesandanyenforcementactionsimposedsolelyasaresultofthoseciteddeficienciesarerescinded.
488.331(d) (d)Notification.Uponrequest,CMSdoesandtheStatemustprovidethefacilitywithwrittennotificationoftheinformaldisputeresolutionprocess.
488.431 CivilMoneyPenaltiesImposedbyCMS
andIndependentInformalDisputeResolution:forSNFs,dually–
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participatingSNF/NFs,andNF-onlyfacilities.
488.431(a) (a)Opportunityforindependentreview.CMSretainsultimateauthorityforthesurveyfindingsandimpositionofcivilmoneypenalties,butprovidesanopportunityforindependentinformaldisputeresolutionwithin30daysofnoticeofimpositionofacivilmoneypenaltythatwillbeplacedinescrowinaccordancewithparagraph(b)ofthissection.Anindependentinformaldisputeresolutionwill—
488.431(a)(1) (1)Becompletedwithin60daysoffacility'srequestifanindependentinformaldisputeresolutionistimelyrequestedbythefacility.
488.431(a)(2) (2)Generateawrittenrecordpriortothecollectionofthepenalty.
(2)Generateawrittenrecordpriortothecollectionofthepenalty.Thestate,orCMS,asapplicable,willprovidethefacilitywithawrittennotificationoftheindependentreviewer’srecommendationandthefinaldecision,includingarationaleforthatdecision.
488.431(a)(3) (3)Includenotificationtoaninvolvedresidentorresidentrepresentative,aswellastheState'slongtermcareombudsman,toprovideopportunityforwrittencomment.
488.431(a)(4) (4)BeapprovedbyCMSandconductedbytheStateundersection1864oftheAct,orbyanentityapprovedbytheStateandCMS,orbyCMSoritsagentinthecaseofsurveysconductedonlybyfederalsurveyorswheretheStateindependentdisputeresolutionprocessisnotused,andwhichhasnoconflictofinterest,
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suchas:488.431(a)(4)(i) (i)AcomponentofanumbrellaState
agencyprovidedthatthecomponentisorganizationallyseparatefromtheStatesurveyagency.
(i)AcomponentofanumbrellaStateagencyprovidedthatthecomponentisorganizationallyseparatefromtheStatesurveyagencyandhasaspecificunderstandingofMedicareandMedicaidrequirements.
488.431(a)(4)(ii) (ii)AnindependententitywithaspecificunderstandingofMedicareandMedicaidprogramrequirementsselectedbytheStateandapprovedbyCMS.
488.431(a)(5) (5)Notincludethesurveyfindingsthathavealreadybeenthesubjectofaninformaldisputeresolutionunder§488.331fortheparticulardeficiencycitationsatissueintheindependentprocessunder§488.431,unlesstheinformaldisputeresolutionunder§488.331wascompletedpriortotheimpositionofthecivilmoneypenalty.
488.431(b)(1) (b)Collectionandplacementinescrowaccount.(1)Forbothperdayandperinstancecivilmoneypenalties,CMSmaycollectandplacetheimposedcivilmoneypenaltiesinanescrowaccountonwhicheverofthefollowingoccursfirst:
488.431(b)(1)(i) (i)Thedateonwhichtheindependentinformaldisputeresolutionprocessiscompletedunderparagraph(a)ofthissection.
488.431(b)(1)(ii) (ii)Thedatethatis90daysafterthedateofthenoticeofimpositionofthepenalty.
488.431(b)(2) (2)Forcollectionandplacementinescrowaccountsofperdaycivilmoneypenalties,CMSmaycollecttheportionoftheperdaycivilmoneypenaltythathasaccrueduptothetimeofcollectionas
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specifiedinparagraph(b)(1)ofthissection.CMSmaymakeadditionalcollectionsperiodicallyuntilthefullamountiscollected,exceptthatthefullbalancemustbecollectedoncethefacilityachievessubstantialcomplianceoristerminatedfromtheprogramandCMSdeterminesthefinalamountofthecivilmoneypenaltyimposed.
488.431(b)(3) (3)CMSmayprovideforanescrowpaymentschedulethatdiffersfromthecollectiontimesofparagraph(1)ofthissubsectioninanycaseinwhichCMSdeterminesthatmoretimeisnecessaryfordepositofthetotalcivilmoneypenaltyintoanescrowaccount,nottoexceed12months,ifCMSfindsthatimmediatepaymentwouldcreatesubstantialandunduefinancialhardshiponthefacility.
488.431(b)(4) (4)Ifthefullcivilmoneypenaltyisnotplacedinanescrowaccountwithin30calendardaysfromthedatetheproviderreceivesnoticeofcollection,orwithin30calendardaysofanyduedateestablishedpursuanttoahardshipfindingunderparagraph(b)(3),CMSmaydeducttheamountofthecivilmoneypenaltyfromanysumthenorlaterowedbyCMSortheStatetothefacilityinaccordancewith§488.442(c).
488.431(b)(5) (5)Foranycivilmoneypenaltiesthatarenotcollectedandplacedintoanescrowaccountunderthissection,CMSwillcollectsuchcivilmoneypenaltiesinthesamemannerastheStateinaccordance
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with§488.432.488.431(c) (c)Maintenanceofescrowedfunds.CMS
willmaintaincollectedcivilmoneypenaltiesinanescrowaccountpendingtheresolutionofanyadministrativeappealofthedeficiencyfindingsthatcomprisethebasisforthecivilmonetarypenaltyimposition.CMSwillretaintheescrowedfundsonanon-goingbasisand,uponafinaladministrativedecision,willeitherreturnapplicablefundsinaccordancewithparagraph(d)(2)ofthissectionor,inthecaseofanunsuccessfuladministrativeappeal,willperiodicallydisbursethefundstoStatesorotherentitiesinaccordancewith§488.433.
488.431(d)(1) (d)Whenafacilityrequestsahearing.(1)Afacilitymustrequestahearingonthedeterminationofthenoncompliancethatisthebasisforimpositionofthecivilmoneypenaltyasspecifiedin§498.40ofthischapter.
488.431(d)(2) (2)Iftheadministrativelawjudgereversesdeficiencyfindingsthatcomprisethebasisofacivilmoneypenaltyinwholeorinpart,theescrowedamountscontinuetobeheldpendingexpirationofthetimeforCMStoappealthedecisionor,whereCMSdoesappeal,aDepartmentalAppealsBoarddecisionaffirmingthereversalofthepertinentdeficiencyfindings.Anycollectedcivilmoneypenaltyamountowedtothefacilitybasedonafinaladministrativedecisionwillbereturnedtothefacilitywithapplicableinterestasspecifiedin
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section1878(f)(2)oftheAct. 488.432 CivilMoneyPenaltiesImposedbythe
State:NF-only
488.432(a)(1) (a)Whenafacilityrequestsahearing.(1)WhentheStateimposesacivilmoneypenaltyagainstanon-StateoperatedNFthatisnotsubjecttoimpositionofremediesbyCMS,thefacilitymustrequestahearingonthedeterminationofnoncompliancethatisthebasisforimpositionofthecivilmoneypenaltywithinthetimespecifiedin§431.153ofthischapter.
488.432(a)(2)(i) (2)(i)Ifafacilityrequestsahearingwithinthetimeframespecifiedinparagraph(a)(1)ofthissection,foracivilmoneypenaltyimposedperday,theStateinitiatescollectionofthepenaltywhenthereisafinaladministrativedecisionthatupholdstheState'sdeterminationofnoncomplianceafterthefacilityachievessubstantialcomplianceoristerminated.
488.432(a)(2)(ii) (ii)Ifafacilityrequestsahearingforacivilmoneypenaltyimposedperinstanceofnoncompliancewithinthetimespecifiedinparagraph(a)(1)ofthissection,theStateinitiatescollectionofthepenaltywhenthereisafinaladministrativedecisionthatupholdstheState'sdeterminationofnoncompliance.
488.432(b)(1) (b)Whenafacilitydoesnotrequestahearingforacivilmoneypenaltyimposedperday.(1)Ifafacilitydoesnotrequestahearinginaccordancewith
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paragraph(a)ofthissection,theStateinitiatescollectionofthepenaltywhenthefacility—
488.432(b)(1)(i) (i)Achievessubstantialcompliance;or 488.432(b)(1)(ii) (ii)Isterminated. 488.432(b)(2) (2)Whenafacilitydoesnotrequesta
hearingforacivilmoneypenaltyimposedperinstanceofnoncompliance.Ifafacilitydoesnotrequestahearinginaccordancewithparagraph(a)ofthissection,theStateinitiatescollectionofthepenaltywhenthetimeframeforrequestingahearingexpires.
488.432(c)(1) (c)Whenafacilitywaivesahearing.(1)Ifafacilitywaives,inwriting,itsrighttoahearingasspecifiedin§488.436,foracivilmoneypenaltyimposedperday,theStateinitiatescollectionofthepenaltywhenthefacility—
488.432(c)(1)(i)-(ii) (i)Achievessubstantialcompliance;or(ii)Isterminated.
488.432(c)(2) (2)Ifafacilitywaives,inwriting,itsrighttoahearingasspecifiedin§488.436,theStateinitiatescollectionofcivilmoneypenaltyimposedperinstanceofnoncomplianceuponreceiptofthefacility'snotification.
488.432(c)(2) (2)Ifafacilitywaives,inwriting,itsrighttoahearingasspecifiedin§488.436,theStateinitiatescollectionofcivilmoneypenaltyimposedperinstanceofnoncomplianceafter60daysandthestatehasnotreceivedatimelyrequestforahearing.
488.432(d) (d)Accrualandcomputationofpenaltiesforafacilitythat—
488.432(d)(1) (1)Requestsahearingordoesnotrequestahearingarespecifiedin§488.440;
488.432(d)(2) (2)Waivesitsrighttoahearinginwriting,arespecifiedin§§488.436(b)and488.440.
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488.436 CivilMoneyPenalties:Waiverof
hearing,reductionofpenaltyamount
488.436(a) (a)Waiverofahearing.Thefacilitymaywaivetherighttoahearing,inwriting,within60daysfromthedateofthenoticeimposingthecivilmoneypenalty.
488.436(a) (a)ConstructiveWaiverofahearing.Afacilityisdeemedtohavewaiveditsrighttoahearingafter60daysifCMShasnotreceivedarequestforahearingfromthefacility.
488.436(b)(1) (b)Reductionofpenaltyamount.(1)Ifthefacilitywaivesitsrighttoahearinginaccordancewiththeproceduresspecifiedinparagraph(a)ofthissection,CMSortheStatereducesthecivilmoneypenaltyby35percent,aslongasthecivilmoneypenaltyhasnotalsobeenreducedby50percentunder§488.438.
488.436(b)(2) (2)Ifthefacilitydoesnotwaiveitsrighttoahearinginaccordancewiththeproceduresspecifiedinparagraph(a)ofthissection,thecivilmoneypenaltyisnotreducedby35percent.
488.442 CivilMoneyPenalties:DueDatefor
PaymentofPenalty
488.442(a)(1) (a)Whenpaymentsaredueforacivilmoneypenalty.(1)Paymentforacivilmoneypenaltyisdueinaccordancewith§488.431ofthischapterforCMS-imposedpenaltiesand15daysaftertheStateinitiatescollectionpursuantto§488.432ofthischapterforState-imposedpenalties,exceptasprovidedinparagraphs(a)(2)and(3)ofthissection.
488.442(a)(2) (2)Afterarequesttowaiveahearingorwhenahearingwasnotrequested.Exceptasprovidedforin
488.442(a)(2) (2)Afterthefacilitywaivesitsrighttoahearinginaccordancewith488.436(a).Exceptasprovidedforin§488.431,acivilmoneypenaltyisdue75daysafterthe
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§488.431,acivilmoneypenaltyisdue15daysafterreceiptofawrittenrequesttowaiveahearinginaccordancewith§488.436or15daysafterthetimeperiodforrequestingahearinghasexpiredandahearingrequestwasnotreceivedwhen:
noticeofthepenaltyandahearingrequestwasnotreceivedwhen:
488.442(a)(2)(i) (i)Thefacilityachievedsubstantialcompliancebeforethehearingrequestwasdue;or
488.442(a)(2)(ii) (ii)Theeffectivedateofterminationoccursbeforethehearingrequestwasdue.
488.442(a)(3) (3)Aftertheeffectivedateoftermination.Acivilmoneypenaltypaymentisdue15daysaftertheeffectivedateoftermination,ifthatdateisearlierthanthedatespecifiedinparagraph(a)(1)ofthissection.
488.442(b) [Reserved] 488.442(c) (c)Deductionofpenaltyfromamount
owed.Theamountofthepenalty,whendetermined,maybedeductedfromanysumthenorlaterowingbyCMSortheStatetothefacility.
488.442(d)(1) (d)Interest—(1)Assessment.Interestisassessedontheunpaidbalanceofthepenalty,beginningontheduedate.
488.442(d)(2) (2)Medicareinterest.Medicarerateofinterestisthehigherof—
488.442(d)(2)(i) (i)TheratefixedbytheSecretaryoftheTreasuryaftertakingintoconsiderationprivateconsumerratesofinterestprevailingonthedateofthenoticeofthepenaltyamountdue(publishedquarterly
185
intheFEDERALREGISTERbyHHSunder45CFR30.13(a));or
488.442(d)(2)(ii) (ii)Thecurrentvalueoffunds(publishedannuallyintheFEDERALREGISTERbytheSecretaryoftheTreasury,subjecttoquarterlyrevisions).
488.442(d)(3) (3)Medicaidinterest.TheinterestrateforMedicaidisdeterminedbytheState.
488.442(e) (e)PenaltiescollectedbyCMS.CivilmoneypenaltiesandcorrespondinginterestcollectedbyCMSfrom—
488.442(e)(1) (1)Medicare-participatingfacilitiesaredepositedanddisbursedinaccordancewith§488.433;and
488.442(e)(2) (2)Medicaid-participatingfacilitiesarereturnedtotheState.
488.442(f) (f)Collectionfromduallyparticipatingfacilities.Civilmoneypenaltiescollectedfromduallyparticipatingfacilitiesaredepositedanddisbursedinaccordancewith§488.433andreturnedtotheStateinproportioncommensuratewiththerelativeproportionsofMedicareandMedicaidbedsatthefacilityactuallyinusebyresidentscoveredbytherespectiveprogramsonthedatethecivilmoneypenaltybeginstoaccrue.
488.442(g) (g)PenaltiescollectedbytheState.CivilmoneypenaltiescollectedbytheStatemustbeappliedtotheprotectionofthehealthorpropertyofresidentsoffacilitiesthattheStateorCMSfindsnoncompliant,suchas—
488.442(g)(1) (1)Paymentforthecostofrelocatingresidentstootherfacilities;
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488.442(g)(2) (2)Statecostsrelatedtotheoperationofafacilitypendingcorrectionofdeficienciesorclosure;and
488.442(g)(3) (3)Reimbursementofresidentsforpersonalfundsorpropertylostatafacilityasaresultofactionsbythefacilityorbyindividualsusedbythefacilitytoprovideservicestoresidents.