Regulations for Skilled Nursing Facilities
Skilled nursing facilities (SNFs) are among the most highly regulated health care entities in the United States. Facilities receiving federal funds to operate as SNFs must comply with strict regulations to ensure that each resident may "...attain or maintain the highest practicable physical, mental, and psychosocial well-being" (42 CFR Part 483).
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History
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The Social Security Act of 1965 created the Medicare (Part §1819) and Medicaid (Part §1919) programs to provide health insurance and/or medical assistance for the aged, disabled and needy. The first nursing home regulations for participating facilities were implemented in 1967 with standards based on the Older Americans Act.
In order to improve care and promote a better quality of life for nursing home residents, Congress passed the comprehensive Omnibus Budget Reconciliation Act of 1987 (known in the industry as OBRA '87), which established strict minimum standards for the 97 percent of nursing homes accepting Medicare and/or Medicaid payment. These regulations are found in the Code of Federal Regulations (42 CFR Part 483) and apply to both SNFs and nursing facilities (NFs).
Types of Facilities
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Although the requirements are virtually the same and can be applied simultaneously, SNFs and NFs differ in the type and duration of care provided and payment received. They are distinct yet interrelated.
SNF: A skilled nursing facility is a hospital unit, nursing home or distinct part of a nursing home that provides skilled nursing care, medical treatments and rehabilitative services. A registered nurse must be on duty at least eight hours each day in an SNF. A patient in an SNF unit has typically been hospitalized recently and is stable but needs some professional medical services to further recover, such as physical therapy for a broken hip, speech therapy following a stroke, or intravenous antibiotics to treat a severe infection. The services in an SNF are paid for by Medicare Part A and are limited to 100 days.
NF: Nursing facilities provide long-term care and assistance with activities of daily living; patients in NFs do not require skilled nursing care on a daily basis. Medicaid or private insurance pays for NF stays with no statutory limits on duration.
SNF/NF: Almost 90 percent of facilities--virtually all of which are nursing homes--are dually certified and participate in both Medicare and Medicaid programs.
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Authority
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The Secretary of the U.S. Department of Health and Human Services (DHHS) delegates administrative authority to the Centers for Medicare and Medicaid Services (CMS). CMS is therefore ultimately responsible for the overall policy-making, funding, supervision and training related to the regulation of SNFs.
CMS in turn delegates most of the survey, certification and enforcement activities to each State Survey Agency (SSA) to be conducted during the state's licensing inspections. Each SSA reports its findings and makes recommendations to CMS, which has final authority over compliance and enforcement decisions in SNFs.
Survey and Certification
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SNFs are fully surveyed for compliance with the regulations every 9 to 15 months. These "standard surveys" are unannounced and include both Health and Life Safety Code (LSC) reviews.
Certain regulations may also be reviewed during "abbreviated surveys," which are conducted in response to complaints or facility-reported incidents. These are unannounced and focus on the area(s) of concern.
Health Surveys
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Health surveys cover more than 150 requirements related to care and life in the facility, including self-determination, privacy, nursing services, nutrition, staffing, infection control, and activities. The survey team may include social workers, dietitians and other disciplines, and at least one registered nurse must be on every survey team.
Life Safety Code Surveys
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LSC surveys are conducted by engineers, architects or other specialty surveyors qualified to ensure the building is safe from fire and other hazards as well as equipped for emergencies, such as power outages and floods. SNF regulations refer to the 2000 edition of the Life Safety Code of the National Fire Protection Association as the authority by which many of LSC surveys are conducted.
Enforcement
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Penalties may be assessed by CMS when an SNF fails to meet regulatory requirements. Depending on the scope and severity of the deficiencies cited, CMS may impose monetary fines, temporarily deny funding, suspend admissions or even terminate the facility's provider agreement. Severe non-compliance can result in placement of a temporary manager or even closure of the facility.
Revisits are conducted after deficiencies have been cited during either standard or abbreviated surveys and the facility alleges to have implemented an acceptable plan of correction. Substantial compliance is achieved when the initial or follow-up visit determines the regulations have been met.
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References
- Centers for Medicare and Medicaid Services, Department of Health and Human Services; Requirements for states and long term care facilities, 42 CFR Part §483; 1987.
- United States Census Bureau; American community survey 3-year estimates 2005-2007; Last Revised: August 26, 2008.
- Agency for Healthcare Research and Quality; AHRQ Publication No. 09-0039-EF; Recommendations for a national mass patient and evacuee movement, regulating, and tracking system. January 2009.
