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Federal Regulations and Guidelines
This page lists the relevant federal regulations covered in the 20 Common Nursing Home Problems guide.Federal Regulations
All regulations listed are from Title 42 of the Code of Federal Regulations.
Section 409.32(c)
“The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. For example, a terminal cancer patient may need some of the skilled services described in [section] 409.33.”
“The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility’s per diem rate.”
“The resident has the right and the facility must provide immediate access to any resident by the following:
“(i) Any representative of the Secretary [of the federal department of Health and Human Services];
“(ii) Any representative of the State:
“(iii) The resident’s individual physician;
“(iv) The State long term care ombudsman [program] . . .;
“(v) The agency responsible for the protection and advocacy system for developmentally disabled individuals . . .;
“(vi) The agency responsible for the protection and advocacy system for mentally ill individuals . . .;
“(vii) Subject to the resident’s right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and
“(viii) Subject to reasonable restrictions and the resident’s right to deny or withdraw consent at any time, others who are visiting with the consent of the resident.”
“ Refusal of certain transfers. (1) An individual has the right to refuse a transfer to another room within the institution, if the purpose of the transfer is to relocate --
“(i) A resident of a [Medicare-certified area] from the distinct part of the institution that is a [Medicare-certified area] to a part of the institution that is not a [Medicare-certified area], or
“(ii) A resident of a [Medicaid-certified area] from the distinct part of the institution that is a [Medicaid-certified area] to a distinct part of the institution that is a [Medicare-certified area].
“(2) A resident’s exercise of the right to refuse transfer under paragraph (o)(1) of this section does not affect the individual’s eligibility or entitlement to Medicare or Medicaid benefits.”
“The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless --
“(i) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility;
“(ii) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility;
“(iii) The safety of individuals in the facility is endangered;
“(iv) The health of individuals in the facility would otherwise be endangered;
“(v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
“(vi) The facility ceases to operate.”
“(3) Permitting resident to return to facility. A nursing facility must establish and follow a written policy under which a resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident --
“(i) Requires the services provided by the facility; and
“(ii) Is eligible for Medicaid nursing facility services.”
“A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all individuals regardless of source of payment.”
“The facility must not require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may require an individual who has legal access to a resident’s income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident’s income or resources.”
“In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility.”
“The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.”
“The resident has the right to--
“(1) Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care;
“(2) Interact with members of the community both inside and outside the facility; and
“(3) Make choices about aspects of his or her life in the facility that are significant to the resident.”
“Participation in resident and family groups.
“(1) A resident has the right to organize and participate in resident groups in the facility;
“(2) A resident’s family has the right to meet in the facility with the families of other residents in the facility;
“(3) The facility must provide a resident or family group, if one exists, with private space;
“(4) Staff or visitors may attend meetings at the group’s invitation;
“(5) The facility must provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings;
“(6) When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility.”
“A comprehensive care plan must be --
“(i) Developed within 7 days after completion of the comprehensive assessment;
“(ii) Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident’s needs, and, to the extent practicable, the participation of the resident, the resident’s family or the resident’s legal representative; and
“(iii) Periodically reviewed and revised by a team of qualified persons after each assessment.”
“Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.”
“Based on the comprehensive assessment of a resident, the facility must ensure that --
“(1) A resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to --
“(i) Bathe, dress, and groom;
“(ii) Transfer and ambulate;
“(iii) Toilet;
“(iv) Eat; and
“(v) Use speech, language, or other functional communication systems.
“(2) A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section; and
“(3) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.”
“Based on the comprehensive assessment of a resident, the facility must ensure that --
“(1) A resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident’s clinical condition demonstrates that use of a naso-gastric tube was unavoidable; and
“(2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.”
“ Part A deductible and coinsurance. The provider may charge the beneficiary or other person on his or her behalf:
“(1) The amount of the inpatient hospital deductible or, if less, the actual charges for the services;
“(2) The amount of inpatient hospital coinsurance applicable for each day the individual is furnished inpatient hospital services after the 60th day, during a benefit period; and
“(3) The posthospital [skilled nursing facility] care coinsurance amount.
“(4) In the case of durable medical equipment (DME) furnished as a home health service, 20 percent of the customary charge for the service.”
Federal Guidelines
Guideline to Section 483.12(a)(2) of Title 42 of the Code of Federal Regulations, Appendix PP to State Operations Manual of Centers for Medicare and Medicaid Services
“Refusal of treatment would not constitute grounds for transfer, unless the [nursing home] is unable to meet the needs of the resident or protect the health and safety of others.”
Guideline to Section 483.45(a) of Title 42 of the Code of Federal Regulations, Appendix PP to State Operations Manual of Centers for Medicare and Medicaid Services
“Specialized rehabilitative services are considered facility services and are, thus, included within the scope of facility services. They must be provided to residents who need them even when the services are not specifically enumerated in the State [Medicaid] plan. No fee can be charged a Medicaid recipient for specialized rehabilitative services because they are covered facility services.”