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,oremailinfo@theconsumervoice.org

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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

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483.1(a)(1)(ii) (ii)TheSecretarymayimposeadditionalrequirements(seesection1819(d)(4)(B))iftheyarenecessaryforthehealthandsafetyofindividualstowhomservicesarefurnishedinthefacilities.

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483.1(a)(2) (2)Section1861(l)oftheActrequiresthefacilitytohaveineffectatransferagreementwithahospital.

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483.1(a)(3) (3)Sections1919(a),(b),(c),(d),and(f)oftheActprovidethatnursingfacilitiesparticipatinginMedicaidmustmeetcertainspecificrequirements.

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483.1(a)(4) (4)Sections1128I(b)and(c)requirethat--

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483.1(a)(4)(i) (i)Skillednursingfacilitiesornursingfacilityhaveinoperationacompliance

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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.

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483.1(b) (b)Scope.TheprovisionsofthispartcontaintherequirementsthataninstitutionmustmeetinordertoqualifytoparticipateasaSkilledNursingFacilityintheMedicareprogram,andasanursingfacilityintheMedicaidprogram.TheyserveasthebasisforsurveyactivitiesforthepurposeofdeterminingwhetherafacilitymeetstherequirementsforparticipationinMedicareandMedicaid.

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§483.5 Definitions. Thisentiresectionwas

implementedinPhase1.

483.5 Asusedinthissubpart,thefollowingdefinitionsapply:

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483.5inalphabeticalorder.

Abuse.Abuseisthewillfulinflictionofinjury,unreasonableconfinement,intimidation,orpunishmentwithresultingphysicalharm,painormentalanguish.Abusealsoincludesthedeprivationbyanindividual,includinga

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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.

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483.5inalphabeticalorder.

Commonarea.Commonareasareareasinthefacilitywhereresidentsmaygathertogetherwithotherresidents,visitors,andstafforengageinindividualpursuits,apartfromtheirresidentialrooms.Thisincludesbutisnotlimitedtolivingrooms,diningrooms,activityrooms,outdoorareas,andmeetingroomswhereresidentsarelocatedonaregularbasis.

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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

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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

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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.

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(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.

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483.5inalphabeticalorder.

Compositedistinctpart. 1

(1)Definition.Acompositedistinctpartisadistinctpartconsistingoftwoormorenoncontiguouscomponentsthatarenotlocatedwithinthesamecampus,asdefinedin§413.65(a)(2)ofthischapter.

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(2)Requirements.Inadditiontomeetingtherequirementsofparagraph(b)ofthissection,acompositedistinctpartmustmeetallofthefollowingrequirements:

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(i)ASNForNFthatisacompositeofmorethanonelocationwillbetreatedasasingledistinctpartoftheinstitutionofwhichitisadistinctpart.Assuch,thecompositedistinctpartwillhaveonlyoneprovideragreementandonlyoneprovidernumber.

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(ii)Iftwoormoreinstitutions(eachwithadistinctpartSNForNF)undergoachangeofownership,CMSmustapprovetheexistingSNFsorNFsasmeetingtherequirementsbeforetheyareconsideredacompositedistinctpartofasingleinstitution.Inmakingsuchadetermination,CMSconsiderswhether

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itsapprovalordisapprovalofacompositedistinctpartpromotestheeffectiveandefficientuseofpublicmonieswithoutsacrificingthequalityofcare.

(iii)IfthereisachangeofownershipofacompositedistinctpartSNForNF,theassignmentoftheprovideragreementtothenewownerwillapplytoalloftheapprovedlocationsthatcomprisethecompositedistinctpartSNForNF.

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(iv)Toensurequalityofcareandqualityoflifeforallresidents,thevariouscomponentsofacompositedistinctpartmustmeetalloftherequirementsforparticipationindependentlyineachlocation.

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(v)Useofcompositedistinctpartstosegregateresidentsbypaymentsourceoronabasisotherthancareneedsisprohibited.

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483.5inalphabeticalorder.

Exploitation.Exploitationmeanstakingadvantageofaresidentforpersonalgainthroughtheuseofmanipulation,intimidation,threats,orcoercion.

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483.5inalphabeticalorder.

Fullysprinklered.AfullysprinkleredlongtermcarefacilityisonethathasallareassprinkleredinaccordancewithNationalFireProtectionAssociation13“StandardfortheInstallationofSprinklerSystems”withouttheuseofwaiversortheFireSafetyEvaluationSystem.

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483.5inalphabeticalorder.

Licensedhealthprofessional.Alicensedhealthprofessionalisaphysician;physicianassistant;nursepractitioner;

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physical,speech,oroccupationaltherapist;physicaloroccupationaltherapyassistant;registeredprofessionalnurse;licensedpracticalnurse;orlicensedorcertifiedsocialworker;orregisteredrespiratorytherapytechnician.

483.5inalphabeticalorder.

Majormodificationmeansthemodificationofmorethan50percent,ormorethan4,500squarefeet,ofthesmokecompartment.

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483.5inalphabeticalorder.

Misappropriationofresidentpropertymeansthedeliberatemisplacement,exploitation,orwrongful,temporary,orpermanentuseofaresident’sbelongingsormoneywithouttheresident’sconsent.

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483.5inalphabeticalorder.

Mistreatmentmeansinappropriatetreatmentorexploitationofaresident.

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483.5inalphabeticalorder.

Neglectisthefailureofthefacility,itsemployeesorserviceproviderstoprovidegoodsandservicestoaresidentthatarenecessarytoavoidphysicalharm,pain,mentalanguishoremotionaldistress.

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483.5inalphabeticalorder.

Nurseaide.Anurseaideisanyindividualprovidingnursingornursing-relatedservicestoresidentsinafacility.Thistermmayalsoincludeanindividualwhoprovidestheseservicesthroughanagencyorunderacontractwiththefacility,butisnotalicensedhealthprofessional,aregistereddietitian,orsomeonewhovolunteerstoprovidesuchserviceswithoutpay.Nurseaidesdonotincludethoseindividualswhofurnish

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servicestoresidentsonlyaspaidfeedingassistantsasdefinedin§488.301ofthischapter.

483.5inalphabeticalorder.

Person-centeredcare.Forpurposesofthissubpart,person-centeredcaremeanstofocusontheresidentasthelocusofcontrolandsupporttheresidentinmakingtheirownchoicesandhavingcontrolovertheirdailylives.

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483.5inalphabeticalorder.

Residentrepresentative.Forpurposesofthissubpart,thetermresidentrepresentativemeansanyofthefollowing:

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(1)Anindividualchosenbytheresidenttoactonbehalfoftheresidentinordertosupporttheresidentindecision-making;accessmedical,socialorotherpersonalinformationoftheresident;managefinancialmatters;orreceivenotifications;

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(2)ApersonauthorizedbyStateorFederallaw(includingbutnotlimitedtoagentsunderpowerofattorney,representativepayees,andotherfiduciaries)toactonbehalfoftheresidentinordertosupporttheresidentindecision-making;accessmedical,socialorotherpersonalinformationoftheresident;managefinancialmatters;orreceivenotifications;

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(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.

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483.5inalphabeticalorder.

Transferanddischargeincludesmovementofaresidenttoabedoutsideofthecertifiedfacilitywhetherthatbedisinthesamephysicalplantornot.Transferanddischargedoesnotrefertomovementofaresidenttoabedwithinthesamecertifiedfacility.

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§483.10 Residentrights. ThissectionwasimplementedinPhase1,withthe

followingexception:

§483.10(g)(4)(ii)-(v),whichwasimplementedin

Phase2.

483.10(a) (a)ResidentsRights.Theresidenthasarighttoadignifiedexistence,self-determination,andcommunicationwithandaccesstopersonsandservicesinsideandoutsidethefacility,includingthosespecifiedinthissection.

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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.

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483.10(b)(1) (1)Thefacilitymustensurethattheresidentcanexercisehisorherrightswithoutinterference,coercion,discrimination,orreprisalfromthefacility

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483.10(b)(2) (2)Theresidenthastherighttobefreeofinterference,coercion,discrimination,andreprisalfromthefacilityinexercisinghisorherrightsandtobesupportedbythefacilityintheexerciseofhisorherrightsasrequiredunderthissubpart.

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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.

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483.10(b)(3)(ii) (ii)Theresidentretainstherighttoexercisethoserightsnotdelegatedtoaresidentrepresentative,includingtherighttorevokeadelegationofrights,exceptaslimitedbyStatelaw.

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483.10(b)(4) (4)Thefacilitymusttreatthedecisionsofaresidentrepresentativeasthedecisionsoftheresidenttotheextentrequiredbythecourtordelegatedbytheresident,inaccordancewithapplicablelaw.

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483.10(b)(5) (5)Thefacilityshallnotextendtheresidentrepresentativetherighttomakedecisionsonbehalfoftheresidentbeyondtheextentrequiredbythecourtordelegatedbytheresident,inaccordancewithapplicablelaw.

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483.10(b)(6) (6)Ifthefacilityhasreasontobelievethataresidentrepresentativeismakingdecisionsortakingactionsthatarenotinthebestinterestsofaresident,thefacilityshallreportsuchconcernsinthemannerrequiredunderStatelaw.

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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.

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483.10(b)(7)(ii) (ii)Theresident’swishesandpreferencesmustbeconsideredintheexerciseofrightsbytherepresentative.

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483.10(b)(7)(iii) (iii)Totheextentpracticable,theresidentmustbeprovidedwithopportunitiestoparticipateinthecareplanningprocess.

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483.10(c) (c)Planningandimplementingcare.Theresidenthastherighttobeinformedof,andparticipatein,hisorhertreatment,including:

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483.10(c)(1) (1)Therighttobefullyinformedinlanguagethatheorshecanunderstandofhisorhertotalhealthstatus,includingbutnotlimitedto,hisorhermedicalcondition.

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483.10(c)(2) (2)Therighttoparticipateinthedevelopmentandimplementationofhisorherperson-centeredplanofcare,includingbutnotlimitedto:

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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.

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483.10(c)(2)(iii) (iii)Therighttobeinformed,inadvance,ofchangestotheplanofcare.

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483.10(c)(2)(iv) (iv)Therighttoreceivetheservicesand/oritemsincludedintheplanofcare.

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483.10(c)(2)(v) (v)Therighttoseethecareplan,includingtherighttosignaftersignificantchangestotheplanofcare.

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483.10(c)(3) (3)Thefacilityshallinformtheresidentoftherighttoparticipateinhisorhertreatmentandshallsupporttheresidentinthisright.Theplanningprocessmust—

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483.10(c)(3)(i) (i)Facilitatetheinclusionoftheresidentand/orresidentrepresentative.

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483.10(c)(3)(ii) (ii)Includeanassessmentoftheresident’sstrengthsandneeds.

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483.10(c)(3)(iii) (iii)Incorporatetheresident’spersonalandculturalpreferencesindevelopinggoalsofcare.

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483.10(c)(4) (4)Therighttobeinformed,inadvance,ofthecaretobefurnishedandthetypeofcaregiverorprofessionalthatwillfurnishcare.

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483.10(c)(5) (5)Therighttobeinformedinadvance,bythephysicianorotherpractitionerorprofessional,oftherisksandbenefitsofproposedcare,oftreatmentand

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treatmentalternativesortreatmentoptionsandtochoosethealternativeoroptionheorsheprefers.

483.10(c)(6) (6)Therighttorequest,refuse,and/ordiscontinuetreatment,toparticipateinorrefusetoparticipateinexperimentalresearch,andtoformulateanadvancedirective.

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483.10(c)(7) (7)Therighttoself-administermedicationsiftheinterdisciplinaryteam,asdefinedby§483.21(b)(2)(ii),hasdeterminedthatthispracticeisclinicallyappropriate.

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483.10(c)(8) (8)Nothinginthisparagraphshouldbeconstruedastherightoftheresidenttoreceivetheprovisionofmedicaltreatmentormedicalservicesdeemedmedicallyunnecessaryorinappropriate.

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483.10(d) (d)Choiceofattendingphysician.Theresidenthastherighttochoosehisorherattendingphysician.

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483.10(d)(1) (1)Thephysicianmustbelicensedtopractice,and

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483.10(d)(2) (2)Ifthephysicianchosenbytheresidentrefusestoordoesnotmeetrequirementsspecifiedinthispart,thefacilitymayseekalternatephysicianparticipationasspecifiedinparagraphs(d)(4)and(5)ofthissectiontoassureprovisionofappropriateandadequatecareandtreatment.

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483.10(d)(3)

(3)Thefacilitymustensurethateachresidentremainsinformedofthename,specialty,andwayofcontactingthephysicianandotherprimarycare

1 483.10(d)(3) (3)Thefacilitymustprovidetheprimarycarephysician’snameandcontactinformationuponadmission,withanychangeofsuchinformationorupontheresident’srequest.

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professionalsresponsibleforhisorhercare.

483.10(d)(4) (4)Thefacilitymustinformtheresidentifthefacilitydeterminesthatthephysicianchosenbytheresidentisunableorunwillingtomeetrequirementsspecifiedinthispartandthefacilityseeksalternatephysicianparticipationtoassureprovisionofappropriateandadequatecareandtreatment.Thefacilitymustdiscussthealternativephysicianparticipationwiththeresidentandhonortheresident’spreferences,ifany,amongoptions.

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483.10(d)(5) (5)Iftheresidentsubsequentlyselectsanotherattendingphysicianwhomeetstherequirementsspecifiedinthispart,thefacilitymusthonorthatchoice.

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483.10(e) (e)Respectanddignity.Theresidenthasarighttobetreatedwithrespectanddignity,including:

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483.10(e)(1) (1)Therighttobefreefromanyphysicalorchemicalrestraintsimposedforpurposesofdisciplineorconvenience,andnotrequiredtotreattheresident’smedicalsymptoms,consistentwith§483.12(a)(2).

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483.10(e)(2) (2)Therighttoretainandusepersonalpossession,includingfurnishings,andclothing,asspacepermits,unlesstodosowouldinfringeupontherightsorhealthandsafetyofotherresidents.

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483.10(e)(3) (3)Therighttoresideandreceiveservicesinthefacilitywithreasonableaccommodationofresidentneedsand

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preferencesexceptwhentodosowouldendangerthehealthorsafetyoftheresidentorotherresidents.

483.10(e)(4) (4)Therighttosharearoomwithhisorherspousewhenmarriedresidentsliveinthesamefacilityandbothspousesconsenttothearrangement.

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483.10(e)(5) (5)Therighttosharearoomwithhisorherroommateofchoicewhenpracticable,whenbothresidentsliveinthesamefacilityandbothresidentsconsenttothearrangement.

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483.10(e)(6) (6)Therighttoreceivewrittennotice,includingthereasonforthechange,beforetheresident’sroomorroommateinthefacilityischanged.

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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

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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

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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

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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

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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

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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.

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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

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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;

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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

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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

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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

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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:

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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

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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:

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§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

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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

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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

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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

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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

120

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

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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

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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.

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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.