Medicare (Title XVIII of the Social Security Act)
Requirements for, and assuring quality of care in, Skilled Nursing Facilities

Requirements for, and assuring quality of care in, Skilled Nursing Facilities99

Requirements related to provision of services

Quality Assessment and Assurance

Every nursing facility must maintain a quality assessment and assurance committee that meets quarterly to identify issues needing quality improvement100 and to develop and implement appropriate plans of action to correct identified quality deficiencies.101

Clinical Records

Skilled nursing facilities must, with the patient’s permission, permit representatives of the state ombudsman to examine such patient’s clinical records.102  The record must contain an assessment of each patient’s functional capacity and a plan of care for each patient,103 and documentation of the reasons for any discharge or transfer.104

Residents’ Assessments

Assessments must be conducted upon admission105 and at least once every 12 months.106  The facility must examine each resident at least once every three months and revise the assessment as necessary;107 if a significant change in the resident’s condition has occurred, a new assessment must be conducted.108  A registered professional nurse must conduct, coordinate, sign and certify the completeness of assessments; any other health professional completing a portion of the assessment must sign that portion and certify its accuracy.109  The assessment must describe the resident’s ability to perform daily life functions and identify any significant impairment in the resident’s functional capacity110 or any medical problems.111

Plans of Care

A team including the resident’s physician and a registered nurse must prepare the plan of care112 based on the results of the patient assessment.113  The plan must identify the medical, nursing and psychosocial needs of the resident and describe how such needs will be met.114  The team must review and revise the plan after every resident assessment.115

Requirements Relating to Residents’ Rights

General Rights

The facility must protect and promote the rights of every resident, which include:

• The right to participate in planning care and treatment;116
• The right to privacy with regard to medical treatment;117
• The right to confidentiality of personal and clinical records and to access to current clinical records upon request, within 24 hours of making such request;118
• The right to request and receive access to current clinical records;119
• The right to voice grievances with respect to treatment or care that is (or fails to be) furnished, without discrimination or reprisal, and to prompt efforts by the facility to resolve these grievances and;120
• The right to review the results of the most recent survey of the facility conducted by the Secretary or a state and any plan of correction in effect.121

Provision of Care

In dispensing psychopharmacologic drugs, the facility must maintain plans written by a physician that indicate the need for and proper administration of such drugs; these plans must be annually reviewed for appropriateness by an external consultant.122    In using restraints, the facility must maintain written orders of a physician specifying the duration and circumstances under which restraints are to be used.123

Transfers and Discharges

When transferring or discharging patients, the facility must notify the resident and an immediate family member or legal representative of the impending occurrence of and reasons for the transfer or discharge at least 30 days prior to the transfer or discharge, unless otherwise indicated.124 The basis for a transfer or discharge must be documented in the resident’s clinical record125 by an appropriate provider.126

Requirements Relating to Administration

The facility must have reports with respect to any surveys, certifications, and complaint investigations respecting the facility during the preceding three years available for any individual to review upon request,127 and may not make available any identifying information about the complainants or residents.128  The facility must post the results of its most recent survey in an accessible location.129

A public nurse aide registry must be established130 that includes all documented findings of resident neglect, abuse or misappropriation of property by a nurse aide, and any statement of the aide disputing the findings.131

Definitions of Services, Institutions, Etc.132

A utilization review plan of a skilled nursing facility is sufficient if it provides for review of admissions to the institution, the duration of stays therein, and the professional services furnished with respect to the medical necessity of the services133 and for the purpose of promoting the most efficient use of available health facilities and services.134  The plan must provide for prompt notification to the institution, the individual and his attending physician of any finding that further stay in the institution is not medically necessary.135