353
ciples which apply to professionals providing
services in such a facility.
‘‘(B) OTHER.—A nursing facility must
meet such other requirements relating to the
health and safety of residents or relating to the
physical facilities thereof as the Secretary may
find necessary.
‘‘(e) STATE REQUIREMENTS RELATING TO NURSING
FACILITY REQUIREMENTS.—A State with a State plan
under this title shall provide for the following:
‘‘(1) SPECIFICATION
AND
REVIEW
OF
NURSE
AIDE
TRAINING
AND
COMPETENCY
EVALUATION
PROGRAMS AND OF NURSE AIDE COMPETENCY EVAL-
UATION PROGRAMS.—The State must—
‘‘(A) specify those training and competency
evaluation programs, and those competency
evaluation programs, that the State approves
for purposes of subsection (b)(5) and that meet
the requirements established under subsection
(f)(2), and
‘‘(B) provide for the review and reapproval
of such programs, at a frequency and using a
methodology consistent with the requirements
established under subsection (f)(2)(A)(iii).
‘‘(2) NURSE AIDE REGISTRY.—
354
‘‘(A) IN GENERAL.—The State shall estab-
lish and maintain a registry of all individuals
who have satisfactorily completed a nurse aide
training and competency evaluation program, or
a nurse aide competency evaluation program,
approved under paragraph (1) in the State, or
any 
individual 
described 
in 
subsection
(f)(2)(B)(ii) or in subparagraph (B), (C), or
(D) of section 6901(b)(4) of the Omnibus
Budget Reconciliation Act of 1989.
‘‘(B) INFORMATION
IN
REGISTRY.—The
registry under subparagraph (A) shall provide
(in accordance with regulations of the Sec-
retary) for the inclusion of specific documented
findings by a State under subsection (g)(1)(C)
of resident neglect or abuse or misappropriation
of resident property involving an individual list-
ed in the registry, as well as any brief state-
ment of the individual disputing the findings.
The State shall make available to the public in-
formation in the registry. In the case of inquir-
ies to the registry concerning an individual list-
ed in the registry, any information disclosed
concerning such a finding shall also include dis-
closure of any such statement in the registry re-
355
lating to the finding or a clear and accurate
summary of such a statement.
‘‘(C) PROHIBITION AGAINST CHARGES.—A
State may not impose any charges on a nurse
aide relating to the registry established and
maintained under subparagraph (A).
‘‘(3) STATE APPEALS PROCESS FOR TRANSFERS
AND DISCHARGES.—The State must provide for a
fair mechanism, meeting the guidelines established
under subsection (f)(3), for hearing appeals on
transfers and discharges of residents of such facili-
ties.
‘‘(4) 
NURSING
FACILITY
ADMINISTRATOR
STANDARDS.—The State must implement and en-
force the nursing facility administrator standards
developed under subsection (f)(4) respecting the
qualification of administrators of nursing facilities.
Any such standards promulgated shall apply to ad-
ministrators of hospital-based facilities as well as ad-
ministrators of freestanding facilities.
‘‘(5) SPECIFICATION OF RESIDENT ASSESSMENT
INSTRUMENT.—The State shall specify the instru-
ment to be used by nursing facilities in the State in
complying with the requirement of subsection
(b)(3)(A)(iii). Such instrument shall be—
356
‘‘(A) one of the instruments designated
under subsection (f)(6)(B), or
‘‘(B) an instrument which the Secretary
has approved as being consistent with the mini-
mum data set of core elements, common defini-
tions, and utilization guidelines specified by the
Secretary under subsection (f)(6)(A).
‘‘(6) NOTICE OF RIGHTS.—Each State shall de-
velop (and periodically update) a written notice of
the rights and obligations of residents of nursing fa-
cilities (and spouses of such residents) under this
title.
‘‘(7) 
STATE
REQUIREMENTS
FOR
PREADMISSION
SCREENING
AND
RESIDENT
RE-
VIEW.—
‘‘(A) PREADMISSION SCREENING.—
‘‘(i) IN
GENERAL.—The State must
have in effect a preadmission screening
program, for identifying mentally ill and
mentally retarded individuals (as defined
in subparagraph (B)) who are admitted to
nursing facilities and for determining
whether they require the level of services of
such a facility.
357
‘‘(ii) STATE REQUIREMENT FOR RESI-
DENT REVIEW.—The State shall notify the
State mental health authority or the State
mental retardation or developmental dis-
ability authority, as appropriate, of the in-
dividuals so identified.
‘‘(B) DEFINITIONS.—In this paragraph:
‘‘(i) An individual is considered to be
‘mentally ill’ if the individual has a serious
mental illness (as defined by the Secretary
in consultation with the National Institute
of Mental Health) and does not have a pri-
mary diagnosis of dementia (including Alz-
heimer’s disease or a related disorder) or a
diagnosis (other than a primary diagnosis)
of dementia and a primary diagnosis that
is not a serious mental illness.
‘‘(ii) An individual is considered to be
‘mentally retarded’ if the individual is
mentally retarded or a person with a relat-
ed condition.
‘‘(f) RESPONSIBILITIES RELATING TO NURSING FA-
CILITY REQUIREMENTS.—
‘‘(1) GENERAL RESPONSIBILITY.—It is the duty
and responsibility of the Secretary to assure that re-
358
quirements which govern the provision of care in
nursing facilities under State plans approved under
this title, and the enforcement of such requirements,
are adequate to protect the health, safety, welfare,
and rights of residents and to promote the effective
and efficient use of public moneys.
‘‘(2) REQUIREMENTS FOR NURSE AIDE TRAIN-
ING AND COMPETENCY EVALUATION PROGRAMS AND
FOR NURSE AIDE COMPETENCY EVALUATION PRO-
GRAMS.—
‘‘(A) IN GENERAL.—For purposes of sub-
sections (b)(5) and (e)(1)(A), the Secretary
shall establish—
‘‘(i) requirements for the approval of
nurse aide training and competency evalua-
tion programs, including requirements re-
lating to (I) the areas to be covered in
such a program (including at least basic
nursing skills, personal care skills, recogni-
tion of mental health and social service
needs, care of cognitively impaired resi-
dents, basic restorative services, and resi-
dents’ rights) and content of the curricu-
lum, (II) minimum hours of initial and on-
going training and retraining (including
359
not less than 75 hours in the case of initial
training), (III) qualifications of instruc-
tors, and (IV) procedures for determina-
tion of competency;
‘‘(ii) requirements for the approval of
nurse aide competency evaluation pro-
grams, including requirement relating to
the areas to be covered in such a program,
including at least basic nursing skills, per-
sonal care skills, recognition of mental
health and social service needs, care of
cognitively impaired residents, basic restor-
ative services, and residents’ rights, and
procedures for determination of com-
petency;
‘‘(iii) requirements respecting the
minimum frequency and methodology to be
used by a State in reviewing such pro-
grams’ compliance with the requirements
for such programs; and
‘‘(iv) requirements, under both such
programs, that—
‘‘(I) provide procedures for deter-
mining competency that permit a
nurse aide, at the nurse aide’s option,
360
to establish competency through pro-
cedures or methods other than the
passing of a written examination and
to have the competency evaluation
conducted at the nursing facility at
which the aide is (or will be) employed
(unless the facility is described in sub-
paragraph (B)(iii)(I)),
‘‘(II) prohibit the imposition on a
nurse aide who is employed by (or
who has received an offer of employ-
ment from) a facility on the date on
which the aide begins either such pro-
gram of any charges (including any
charges for textbooks and other re-
quired course materials and any
charges for the competency evalua-
tion) for either such program, and
‘‘(III) in the case of a nurse aide
not described in subclause (II) who is
employed by (or who has received an
offer of employment from) a facility
not later than 12 months after com-
pleting either such program, the State
shall provide for the reimbursement of
361
costs incurred in completing such pro-
gram on a prorata basis during the
period in which the nurse aide is so
employed.
‘‘(B) APPROVAL OF CERTAIN PROGRAMS.—
Such requirements—
‘‘(i) may permit approval of programs
offered by or in facilities, as well as outside
facilities (including employee organiza-
tions);
‘‘(ii) shall permit a State to find that
an individual who has completed (before
July 1, 1989) a nurse aide training and
competency evaluation program shall be
deemed to have completed such a program
approved under subsection (b)(5) if the
State determines that, at the time the pro-
gram was offered, the program met the re-
quirements for approval under such para-
graph; and
‘‘(iii) subject to subparagraph (C),
shall prohibit approval of such a pro-
gram—
362
‘‘(I) offered by or in a nursing
facility which, within the previous 2
years—
‘‘(a) has operated under a
waiver 
under 
subsection
(b)(4)(C)(ii) that was granted on
the basis of a demonstration that
the facility is unable to provide
the nursing care required under
subsection (b)(4)(C)(i) for a pe-
riod in excess of 48 hours during
a week;
‘‘(b) has been subject to an
extended (or partial extended)
survey 
under 
section
1819(g)(2)(B)(i) or subsection
(g)(2)(B)(i) of this section; or
‘‘(c) has been assessed a
civil money penalty described in
section 1819(h)(2)(B)(ii) or sub-
section (h)(2)(A)(ii) of this sec-
tion of not less than $5,000, or
has been subject to a remedy de-
scribed in subsection (h)(1)(B)(i)
of this section, clauses (i), (iii),
363
or (iv) of subsection (h)(2)(A) of
this section, clauses (i) or (iii) of
section 1819(h)(2)(B), or section
1819(h)(4), or
‘‘(II) offered by or in a nursing
facility unless the State makes the de-
termination, upon an individual’s com-
pletion of the program, that the indi-
vidual is competent to provide nursing
and nursing-related services in nurs-
ing facilities.
A State may not delegate (through sub-
contract or otherwise) its responsibility
under clause (iii)(II) to the nursing facil-
ity.
‘‘(C) WAIVER
AUTHORIZED.—Clause (iii)
of subparagraph (B) shall not apply to a pro-
gram offered in (but not by) a nursing facility
in a State if the State—
‘‘(i) determines that there is no other
such program offered within a reasonable
distance of the facility,
‘‘(ii) assures, through an oversight ef-
fort, that an adequate environment exists
364
for operating the program in the facility,
and
‘‘(iii) provides notice of such deter-
mination and assurances to the State long-
term care ombudsman.
‘‘(3) FEDERAL
GUIDELINES
FOR
STATE
AP-
PEALS
PROCESS
FOR
TRANSFERS
AND
DIS-
CHARGES.—For 
purposes 
of 
subsections
(c)(2)(B)(iii) and (e)(3), the Secretary shall estab-
lish guidelines for minimum standards which State
appeals processes under subsection (e)(3) must meet
to provide a fair mechanism for hearing appeals on
transfers and discharges of residents from nursing
facilities.
‘‘(4) QUALIFICATION
OF
ADMINISTRATORS.—
For purposes of subsections (d)(1)(C) and (e)(4),
the Secretary shall develop standards to be applied
in assuring the qualifications of administrators of
nursing facilities. Any such standards must apply to
administrators of hospital-based facilities as well as
administrators of freestanding facilities.
‘‘(5) CRITERIA
FOR
ADMINISTRATION.—The
Secretary shall establish criteria for assessing a
nursing facility’s compliance with the requirement of
subsection (d)(1) with respect to—
365
‘‘(A) its governing body and management,
‘‘(B) agreements with hospitals regarding
transfers of residents to and from the hospitals
and to and from other nursing facilities,
‘‘(C) disaster preparedness,
‘‘(D) direction of medical care by a physi-
cian,
‘‘(E) laboratory and radiological services,
‘‘(F) clinical records, and
‘‘(G) resident and advocate participation.
‘‘(6) SPECIFICATION OF RESIDENT ASSESSMENT
DATA
SET
AND
INSTRUMENTS.—The Secretary
shall—
‘‘(A) specify a minimum data set of core
elements and common definitions for use by
nursing facilities in conducting the assessments
required under subsection (b)(3), and establish
guidelines for utilization of the data set; and
‘‘(B) designate one or more instruments
which are consistent with the specification made
under subparagraph (A) and which a State may
specify under subsection (e)(5)(A) for use by
nursing facilities in complying with the require-
ments of subsection (b)(3)(A)(iii).
366
‘‘(7) LIST OF ITEMS AND SERVICES FURNISHED
IN NURSING FACILITIES NOT CHARGEABLE TO THE
PERSONAL FUNDS OF A RESIDENT.—The Secretary
shall issue regulations that define those costs which
may be charged to the personal funds of residents
in nursing facilities who are individuals receiving
medical assistance with respect to nursing facility
services under this title and those costs which are to
be included in the payment amount under this title
for nursing facility services.
‘‘(8) CRITERIA FOR MONITORING STATE WAIV-
ERS.—The Secretary shall develop criteria and pro-
cedures for monitoring State performances in grant-
ing waivers pursuant to subsection (b)(4)(C)(ii).
‘‘(g) SURVEY AND CERTIFICATION PROCESS.—
‘‘(1) STATE AND FEDERAL RESPONSIBILITY.—
‘‘(A) IN GENERAL.—Under each State plan
under this title, the State shall be responsible
for certifying, in accordance with surveys con-
ducted under paragraph (2), the compliance of
nursing facilities (other than facilities of the
State) with the requirements of subsections (b),
(c), and (d). The Secretary shall be responsible
for certifying, in accordance with surveys con-
ducted under paragraph (2), the compliance of
367
State nursing facilities with the requirements of
such subsections.
‘‘(B) 
EDUCATIONAL
PROGRAM.—Each
State shall conduct periodic educational pro-
grams for the staff and residents (and their
representatives) of nursing facilities in order to
present current regulations, procedures, and
policies under this section.
‘‘(C) INVESTIGATION OF ALLEGATIONS OF
RESIDENT
NEGLECT
AND
ABUSE
AND
MIS-
APPROPRIATION OF RESIDENT PROPERTY.—The
State shall provide, through the agency respon-
sible for surveys and certification of nursing fa-
cilities under this subsection, for a process for
the receipt and timely review and investigation
of allegations of neglect and abuse and mis-
appropriation of resident property by a nurse
aide of a resident in a nursing facility or by an-
other individual used by the facility in providing
services to such a resident. The State shall,
after notice to the individual involved and a rea-
sonable opportunity for a hearing for the indi-
vidual to rebut allegations, make a finding as to
the accuracy of the allegations. If the State
finds that a nurse aide has neglected or abused
368
a resident or misappropriated resident property
in a facility, the State shall notify the nurse
aide and the registry of such finding. If the
State finds that any other individual used by
the facility has neglected or abused a resident
or misappropriated resident property in a facil-
ity, the State shall notify the appropriate licen-
sure authority. A State shall not make a find-
ing that an individual has neglected a resident
if the individual demonstrates that such neglect
was caused by factors beyond the control of the
individual.
‘‘(2) SURVEYS.—
‘‘(A) ANNUAL STANDARD SURVEY.—
‘‘(i) IN GENERAL.—Each nursing fa-
cility shall be subject to a standard survey,
to be conducted without any prior notice to
the facility. Any individual who notifies (or
causes to be notified) a nursing facility of
the time or date on which such a survey is
scheduled to be conducted is subject to a
civil money penalty of not to exceed
$2,000. The provisions of section 1128A
(other than subsections (a) and (b)) shall
apply to a civil money penalty under the
369
previous sentence in the same manner as
such provisions apply to a penalty or pro-
ceeding under section 1128A(a). The Sec-
retary shall review each State’s procedures
for scheduling and conduct of standard
surveys to assure that the State has taken
all reasonable steps to avoid giving notice
of such a survey through the scheduling
procedures and the conduct of the surveys
themselves.
‘‘(ii) CONTENTS.—Each standard sur-
vey shall include, for a case-mix stratified
sample of residents—
‘‘(I) a survey of the quality of
care furnished, as measured by indica-
tors of medical, nursing, and rehabili-
tative care, dietary and nutrition serv-
ices, activities and social participation,
and sanitation, infection control, and
the physical environment,
‘‘(II) written plans of care pro-
vided under subsection (b)(2) and an
audit of the residents’ assessments
under subsection (b)(3) to determine
the accuracy of such assessments and
370
the adequacy of such plans of care,
and
‘‘(III) a review of compliance
with residents’ rights under sub-
section (c).
‘‘(iii) FREQUENCY.—
‘‘(I) IN GENERAL.—Each nursing
facility shall be subject to a standard
survey not later than 15 months after
the date of the previous standard sur-
vey conducted under this subpara-
graph. The statewide average interval
between standard surveys of a nursing
facility shall not exceed 12 months.
‘‘(II) SPECIAL SURVEYS.—If not
otherwise conducted under subclause
(I), a standard survey (or an abbre-
viated standard survey) may be con-
ducted within 2 months of any change
of ownership, administration, manage-
ment of a nursing facility, or director
of nursing in order to determine
whether the change has resulted in
any decline in the quality of care fur-
nished in the facility.
371
‘‘(B) EXTENDED SURVEYS.—
‘‘(i) IN GENERAL.—Each nursing fa-
cility which is found, under a standard sur-
vey, to have provided substandard quality
of care shall be subject to an extended sur-
vey. Any other facility may, at the Sec-
retary’s or State’s discretion, be subject to
such an extended survey (or a partial ex-
tended survey).
‘‘(ii) TIMING.—The extended survey
shall be conducted immediately after the
standard survey (or, if not practicable, not
later than 2 weeks after the date of com-
pletion of the standard survey).
‘‘(iii) CONTENTS.—In such an ex-
tended survey, the survey team shall review
and identify the policies and procedures
which produced such substandard quality
of care and shall determine whether the fa-
cility has complied with all the require-
ments described in subsections (b), (c),
and (d). Such review shall include an ex-
pansion of the size of the sample of resi-
dents’ assessments reviewed and a review
of the staffing, of in-service training, and,
372
if appropriate, of contracts with consult-
ants.
‘‘(iv) 
CONSTRUCTION.—Nothing 
in
this paragraph shall be construed as re-
quiring an extended or partial extended
survey as a prerequisite to imposing a
sanction against a facility under subsection
(h) on the basis of findings in a standard
survey.
‘‘(C) SURVEY
PROTOCOL.—Standard and
extended surveys shall be conducted—
‘‘(i) based upon the protocol which the
Secretary has developed, tested, and vali-
dated, as of the date of the enactment of
this title, and
‘‘(ii) by individuals, of a survey team,
who meet such minimum qualifications as
the Secretary establishes.
‘‘(D) CONSISTENCY
OF
SURVEYS.—Each
State shall implement programs to measure and
reduce inconsistency in the application of sur-
vey results among surveyors.
‘‘(E) SURVEY TEAMS.—
‘‘(i) IN
GENERAL.—Surveys under
this subsection shall be conducted by a
373
multidisciplinary team of professionals (in-
cluding a registered professional nurse).
‘‘(ii) PROHIBITION OF CONFLICTS OF
INTEREST.—A State may not use as a
member of a survey team under this sub-
section an individual who is serving (or has
served within the previous 2 years) as a
member of the staff of, or as a consultant
to, the facility surveyed respecting compli-
ance with the requirements of subsections
(b), (c), and (d), or who has a personal or
familial financial interest in the facility
being surveyed.
‘‘(iii) TRAINING.—The Secretary shall
provide for the comprehensive training of
State and Federal surveyors in the conduct
of standard and extended surveys under
this subsection, including the auditing of
resident assessments and plans of care. No
individual shall serve as a member of a
survey team unless the individual has suc-
cessfully completed a training and testing
program in survey and certification tech-
niques that has been approved by the Sec-
retary.
374
‘‘(3) VALIDATION SURVEYS.—
‘‘(A) IN
GENERAL.—The Secretary shall
conduct onsite surveys of a representative sam-
ple of nursing facilities in each State, within 2
months of the date of surveys conducted under
paragraph (2) by the State, in a sufficient num-
ber to allow inferences about the adequacies of
each State’s surveys conducted under para-
graph (2). In conducting such surveys, the Sec-
retary shall use the same survey protocols as
the State is required to use under paragraph
(2). If the State has determined that an indi-
vidual nursing facility meets the requirements
of subsections (b), (c), and (d), but the Sec-
retary determines that the facility does not
meet such requirements, the Secretary’s deter-
mination as to the facility’s noncompliance with
such requirements is binding and supersedes
that of the State survey.
‘‘(B) SCOPE.—With respect to each State,
the Secretary shall conduct surveys under sub-
paragraph (A) each year with respect to at least
5 percent of the number of nursing facilities
surveyed by the State in the year, but in no
case less than 5 nursing facilities in the State.
375
‘‘(C) 
REDUCTION
IN
ADMINISTRATIVE
COSTS FOR SUBSTANDARD PERFORMANCE.—If
the Secretary finds, on the basis of such sur-
veys, that a State has failed to perform surveys
as required under paragraph (2) or that a
State’s survey and certification performance
otherwise is not adequate, the Secretary may
provide for the training of survey teams in the
State and shall provide for a reduction of the
payment otherwise made to the State under sec-
tion 1512(a)(3)(C) with respect to a quarter
equal to 33 percent multiplied by a fraction, the
denominator of which is equal to the total num-
ber of residents in nursing facilities surveyed by
the Secretary that quarter and the numerator
of which is equal to the total number of resi-
dents in nursing facilities which were found
pursuant to such surveys to be not in compli-
ance with any of the requirements of sub-
sections (b), (c), and (d). A State that is dissat-
isfied with the Secretary’s findings under this
subparagraph may obtain reconsideration and
review of the findings under section 1116 in the
same manner as a State may seek reconsider-
ation and review under that section of the Sec-
377
‘‘(ii) the facility was previously found
not to be in compliance with such require-
ments, has corrected deficiencies to achieve
such compliance, and verification of contin-
ued compliance is indicated; or
‘‘(iii) the State has reason to question
the compliance of the facility with such re-
quirements.
A State may maintain and utilize a specialized team
(including an attorney, an auditor, and appropriate
health care professionals) for the purpose of identi-
fying, surveying, gathering and preserving evidence,
and carrying out appropriate enforcement actions
against substandard nursing facilities.
‘‘(5) DISCLOSURE OF RESULTS OF INSPECTIONS
AND ACTIVITIES.—
‘‘(A) PUBLIC INFORMATION.—Each State,
and the Secretary, shall make available to the
public—
‘‘(i) information respecting all surveys
and certifications made respecting nursing
facilities, including statements of defi-
ciencies, within 14 calendar days after
such information is made available to those
facilities, and approved plans of correction,
378
‘‘(ii) copies of cost reports of such fa-
cilities filed under this title or under title
XVIII,
‘‘(iii) copies of statements of owner-
ship under section 1124, and
‘‘(iv) information disclosed under sec-
tion 1126.
‘‘(B) 
NOTICE
TO
OMBUDSMAN.—Each
State shall notify the State long-term care om-
budsman (established under title III or VII of
the Older Americans Act of 1965 in accordance
with section 712 of the Act) of the State’s find-
ings of noncompliance with any of the require-
ments of subsections (b), (c), and (d), or of any
adverse action taken against a nursing facility
under paragraphs (1), (2), or (3) of subsection
(h), with respect to a nursing facility in the
State.
‘‘(C) NOTICE TO PHYSICIANS AND NURS-
ING
FACILITY
ADMINISTRATOR
LICENSING
BOARD.—If a State finds that a nursing facility
has provided substandard quality of care, the
State shall notify—
379
‘‘(i) the attending physician of each
resident with respect to which such finding
is made, and
‘‘(ii) any State board responsible for
the licensing of the nursing facility admin-
istrator of the facility.
‘‘(D) 
ACCESS
TO
FRAUD
CONTROL
UNITS.—Each State shall provide its State
fraud and abuse control unit (established under
section 1554) with access to all information of
the State agency responsible for surveys and
certifications under this subsection.
‘‘(h) ENFORCEMENT PROCESS.—
‘‘(1) IN GENERAL.—If a State finds, on the
basis of a standard, extended, or partial extended
survey under subsection (g)(2) or otherwise, that a
nursing facility no longer meets a requirement of
subsection (b), (c), or (d)—
‘‘(A) the State shall require the facility to
correct the deficiency involved;
‘‘(B) if the State finds that the facility’s
deficiencies immediately jeopardize the health
or safety of its residents, the State shall take
immediate action to remove the jeopardy and
correct the deficiencies through the remedy
380
specified in paragraph (2)(A)(iii), or terminate
the facility’s participation under the State plan
and may provide, in addition, for one or more
of the other remedies described in paragraph
(2); and
‘‘(C) if the State finds that the facility’s
deficiencies do not immediately jeopardize the
health or safety of its residents, the State
may—
‘‘(i) terminate the facility’s participa-
tion under the State plan,
‘‘(ii) provide for one or more of the
remedies described in paragraph (2), or
‘‘(iii) do both.
Nothing in this paragraph shall be construed as re-
stricting the remedies available to a State to remedy
a nursing facility’s deficiencies. If a State finds that
a nursing facility meets the requirements of sub-
sections (b), (c), and (d), but, as of a previous pe-
riod, did not meet such requirements, the State may
provide for a civil money penalty under paragraph
(2)(A)(ii) for the days in which it finds that the fa-
cility was not in compliance with such requirements.
‘‘(2) SPECIFIED REMEDIES.—
381
‘‘(A) LISTING.—Except as provided in sub-
paragraph (B), each State shall establish by law
(whether statute or regulation) at least the fol-
lowing remedies:
‘‘(i) Denial of payment under the
State plan with respect to any individual
admitted to the nursing facility involved
after such notice to the public and to the
facility as may be provided for by the
State.
‘‘(ii) A civil money penalty assessed
and collected, with interest, for each day in
which the facility is or was out of compli-
ance with a requirement of subsection (b),
(c), or (d). Funds collected by a State as
a result of imposition of such a penalty (or
as a result of the imposition by the State
of a civil money penalty for activities de-
scribed 
in 
subsection 
(b)(3)(B)(ii)(I),
(b)(3)(B)(ii)(II), or (g)(2)(A)(i)) shall be
applied to the protection of the health or
property of residents of nursing facilities
that the State or the Secretary finds defi-
cient, including payment for the costs of
relocation of residents to other facilities,
382
maintenance of operation of a facility
pending correction of deficiencies or clo-
sure, and reimbursement of residents for
personal funds lost.
‘‘(iii) The appointment of temporary
management to oversee the operation of
the facility and to assure the health and
safety of the facility’s residents, where
there is a need for temporary management
while—
‘‘(I) there is an orderly closure of
the facility, or
‘‘(II) improvements are made in
order to bring the facility into compli-
ance with all the requirements of sub-
sections (b), (c), and (d).
The temporary management under this
clause shall not be terminated under sub-
clause (II) until the State has determined
that the facility has the management capa-
bility to ensure continued compliance with
all the requirements of subsections (b), (c),
and (d).
‘‘(iv) The authority, in the case of an
emergency, to close the facility, to transfer
383
residents in that facility to other facilities,
or both.
The State also shall specify criteria, as to when
and how each of such remedies is to be applied,
the amounts of any fines, and the severity of
each of these remedies, to be used in the impo-
sition of such remedies. Such criteria shall be
designed so as to minimize the time between
the identification of violations and final imposi-
tion of the remedies and shall provide for the
imposition of incrementally more severe fines
for repeated or uncorrected deficiencies. In ad-
dition, the State may provide for other specified
remedies, such as directed plans of correction.
‘‘(B) GUIDANCE AND ALTERNATIVE REM-
EDIES.—(i) The Secretary shall provide through
regulations guidance to States in establishing
remedies under clauses (i) through (iv) of sub-
paragraph (A).
‘‘(ii) A State may establish alternative
remedies (other than termination of participa-
tion) other than those described in clauses (i)
through (iv) of subparagraph (A), if the State
demonstrates to the Secretary’s satisfaction
that the alternative remedies are as effective in
384
deterring noncompliance and correcting defi-
ciencies as those described in such subpara-
graph.
‘‘(C) ASSURING PROMPT COMPLIANCE.—If
a nursing facility has not complied with any of
the requirements of subsections (b), (c), and
(d), within 3 months after the date the facility
is found to be out of compliance with such re-
quirements, the State shall impose the remedy
described in subparagraph (A)(i) for all individ-
uals who are admitted to the facility after such
date.
‘‘(D) REPEATED NONCOMPLIANCE.—In the
case of a nursing facility which, on 3 consecu-
tive standard surveys conducted under sub-
section (g)(2), has been found to have provided
substandard quality of care, the State shall (re-
gardless of what other remedies are provided)—
‘‘(i) impose the remedy described in
subparagraph (A)(i), and
‘‘(ii) monitor the facility under sub-
section (g)(4)(B),
until the facility has demonstrated, to the satis-
faction of the State, that it is in compliance
with the requirements of subsections (b), (c),
385
and (d), and that it will remain in compliance
with such requirements.
‘‘(E) FUNDING.—The reasonable expendi-
tures of a State to provide for temporary man-
agement and other expenses associated with im-
plementing the remedies described in clauses
(iii) and (iv) of subparagraph (A) shall be con-
sidered, for purposes of section 1512(a)(3)(C),
to be necessary for the proper and efficient ad-
ministration of the State plan.
‘‘(F) INCENTIVES
FOR
HIGH
QUALITY
CARE.—In addition to the remedies specified in
this paragraph, a State may establish a pro-
gram to reward, through public recognition, in-
centive payments, or both, nursing facilities
that provide the highest quality care to resi-
dents who are entitled to medical assistance
under this title. For purposes of section
1512(a)(3)(C), proper expenses incurred by a
State in carrying out such a program shall be
considered to be expenses necessary for the
proper and efficient administration of the State
plan.
‘‘(3) SECRETARIAL AUTHORITY.—
386
‘‘(A) FOR STATE NURSING FACILITIES.—
With respect to a State nursing facility, the
Secretary shall have the authority and duties of
a State under this subsection, including the au-
thority to impose remedies described in clauses
(i), (ii), and (iii) of paragraph (2)(A). Nothing
in this subparagraph shall be construed as re-
stricting the remedies available to the Secretary
to remedy a nursing facility’s deficiencies.
‘‘(B) OTHER NURSING FACILITIES.—With
respect to any other nursing facility in a State,
if the Secretary finds that a nursing facility no
longer meets a requirement of subsection (b),
(c), (d), or (e), and further finds that the facili-
ty’s deficiencies—
‘‘(i) immediately jeopardize the health
or safety of its residents, the Secretary
shall take immediate action to remove the
jeopardy 
and 
correct 
the 
deficiencies
through the remedy specified in subpara-
graph (C)(iii), or terminate the facility’s
participation under the State plan and
may provide, in addition, for one or more
of the other remedies described in subpara-
graph (C); or
387
‘‘(ii) do not immediately jeopardize
the health or safety of its residents, the
Secretary may impose any of the remedies
described in subparagraph (C).
Nothing in this subparagraph shall be con-
strued as restricting the remedies available to
the Secretary to remedy a nursing facility’s de-
ficiencies. If the Secretary finds that a nursing
facility meets such requirements but, as of a
previous period, did not meet such require-
ments, the Secretary may provide for a civil
money penalty under subparagraph (C)(ii) for
the days on which he finds that the facility was
not in compliance with such requirements.
‘‘(C) SPECIFIED
REMEDIES.—The rem-
edies specified in this subparagraph are as fol-
lows:
‘‘(i) DENIAL OF PAYMENT.—Denial of
any further payments to the State in ac-
cordance with section 1529(f) for medical
assistance furnished by the facility to all
individuals in the facility or to individuals
admitted to the facility after the effective
date of the finding.
388
‘‘(ii) AUTHORITY WITH RESPECT TO
CIVIL MONEY PENALTIES.—Imposition of a
civil money penalty against the facility in
an amount not to exceed $10,000 for each
day of noncompliance. The provisions of
section 1128A (other than subsections (a)
and (b)) shall apply to a civil money pen-
alty under the previous sentence in the
same manner as such provisions apply to a
penalty 
or 
proceeding 
under 
section
1128A(a).
‘‘(iii) APPOINTMENT
OF
TEMPORARY
MANAGEMENT.—Appointment 
of 
tem-
porary management to oversee the oper-
ation of the facility and to assure the
health and safety of the facility’s residents,
where there is a need for temporary man-
agement while—
‘‘(I) there is an orderly closure of
the facility, or
‘‘(II) improvements are made in
order to bring the facility into compli-
ance with all the requirements of sub-
sections (b), (c), and (d).
389
The temporary management under this
clause shall not be terminated under sub-
clause (II) until the Secretary has deter-
mined that the facility has the manage-
ment capability to ensure continued com-
pliance with all the requirements of sub-
sections (b), (c), and (d).
The Secretary shall specify criteria, as to when
and how each of such remedies is to be applied,
the amounts of any fines, and the severity of
each of these remedies, to be used in the impo-
sition of such remedies. Such criteria shall be
designed so as to minimize the time between
the identification of violations and final imposi-
tion of the remedies and shall provide for the
imposition of incrementally more severe fines
for repeated or uncorrected deficiencies. In ad-
dition, the Secretary may provide for other
specified remedies, such as directed plans of
correction.
‘‘(D) CONTINUATION OF PAYMENTS PEND-
ING
REMEDIATION.—The Secretary may con-
tinue payments, over a period of not longer
than 6 months after the effective date of the
findings, under this title with respect to a nurs-
390
ing facility not in compliance with a require-
ment of subsection (b), (c), or (d), if—
‘‘(i) the State survey agency finds
that it is more appropriate to take alter-
native action to assure compliance of the
facility with the requirements than to ter-
minate the certification of the facility,
‘‘(ii) the State has submitted a plan
and timetable for corrective action to the
Secretary for approval and the Secretary
approves the plan of corrective action, and
‘‘(iii) the State agrees to repay to the
Federal Government payments received
under this subparagraph if the corrective
action is not taken in accordance with the
approved plan and timetable.
The Secretary shall establish guidelines for ap-
proval of corrective actions requested by States
under this subparagraph.
‘‘(4) SPECIAL RULES REGARDING PAYMENTS TO
FACILITIES.—
‘‘(A) CONTINUATION OF PAYMENTS PEND-
ING
REMEDIATION.—The State or the Sec-
retary, as appropriate, may continue payments,
over a period of not longer than 6 months after
391
the effective date of the findings, under this
title with respect to a nursing facility not in
compliance with a requirement of subsection
(b), (c), or (d). The State may continue such
payments only if—
‘‘(i) the State survey agency finds
that it is more appropriate to take alter-
native action to assure compliance of the
facility with the requirements than to ter-
minate the certification of the facility,
‘‘(ii) the State has submitted a plan
and timetable for corrective action to the
Secretary for approval and the Secretary
approves the plan of corrective action, and
‘‘(iii) the State agrees to repay to the
Federal Government payments received
under this subparagraph if the corrective
action is not taken in accordance with the
approved plan and timetable.
The Secretary shall establish guidelines for ap-
proval of corrective actions requested by States
under this subparagraph.
‘‘(B) EFFECTIVE PERIOD OF DENIAL OF
PAYMENT.—A finding to deny payment under
this subsection shall terminate when the State
392
or Secretary (as the case may be) finds that the
facility is in substantial compliance with all the
requirements of subsections (b), (c), and (d).
‘‘(5) IMMEDIATE TERMINATION OF PARTICIPA-
TION FOR FACILITY WHERE STATE OR SECRETARY
FINDS
NONCOMPLIANCE
AND
IMMEDIATE
JEOP-
ARDY.—If either the State or the Secretary finds
that a nursing facility has not met a requirement of
subsection (b), (c), or (d), and finds that the failure
immediately jeopardizes the health or safety of its
residents, the State or the Secretary, respectively
shall notify the other of such finding, and the State
or the Secretary, respectively, shall take immediate
action to remove the jeopardy and correct the defi-
ciencies through the remedy specified in paragraph
(2)(A)(iii) or (3)(C)(iii), or terminate the facility’s
participation under the State plan. If the facility’s
participation in the State plan is terminated by ei-
ther the State or the Secretary, the State shall pro-
vide for the safe and orderly transfer of the resi-
dents eligible under the State plan consistent with
the requirements of subsection (c)(2).
‘‘(6) SPECIAL RULES WHERE STATE AND SEC-
RETARY
DO
NOT
AGREE
ON
FINDING
OF
NON-
COMPLIANCE.—
393
‘‘(A) STATE FINDING OF NONCOMPLIANCE
AND NO SECRETARIAL FINDING OF NONCOMPLI-
ANCE.—If the Secretary finds that a nursing
facility has met all the requirements of sub-
sections (b), (c), and (d), but a State finds that
the facility has not met such requirements and
the failure does not immediately jeopardize the
health or safety of its residents, the State’s
findings shall control and the remedies imposed
by the State shall be applied.
‘‘(B) SECRETARIAL
FINDING
OF
NON-
COMPLIANCE AND NO STATE FINDING OF NON-
COMPLIANCE.—If the Secretary finds that a
nursing facility has not met all the require-
ments of subsections (b), (c), and (d), and that
the failure does not immediately jeopardize the
health or safety of its residents, but the State
has not made such a finding, the Secretary—
‘‘(i) may impose any remedies speci-
fied in paragraph (3)(C) with respect to
the facility, and
‘‘(ii) shall (pending any termination
by the Secretary) permit continuation of
payments in accordance with paragraph
(3)(D).
394
‘‘(7) SPECIAL RULES FOR TIMING OF TERMI-
NATION OF PARTICIPATION WHERE REMEDIES OVER-
LAP.—If both the Secretary and the State find that
a nursing facility has not met all the requirements
of subsections (b), (c), and (d), and neither finds
that the failure immediately jeopardizes the health
or safety of its residents—
‘‘(A)(i) if both find that the facility’s par-
ticipation under the State plan should be termi-
nated, the State’s timing of any termination
shall control so long as the termination date
does not occur later than 6 months after the
date of the finding to terminate;
‘‘(ii) if the Secretary, but not the State,
finds that the facility’s participation under the
State plan should be terminated, the Secretary
shall (pending any termination by the Sec-
retary) permit continuation of payments in ac-
cordance with paragraph (3)(D); or
‘‘(iii) if the State, but not the Secretary,
finds that the facility’s participation under the
State plan should be terminated, the State’s de-
cision to terminate, and timing of such termi-
nation, shall control; and
395
‘‘(B)(i) if the Secretary or the State, but
not both, establishes one or more remedies
which are additional or alternative to the rem-
edy of terminating the facility’s participation
under the State plan, such additional or alter-
native remedies shall also be applied, or
‘‘(ii) if both the Secretary and the State
establish one or more remedies which are addi-
tional or alternative to the remedy of terminat-
ing the facility’s participation under the State
plan, only the additional or alternative remedies
of the Secretary shall apply.
‘‘(8) CONSTRUCTION.—The remedies provided
under this subsection are in addition to those other-
wise available under Federal or State law and shall
not be construed as limiting such other remedies, in-
cluding any remedy available to an individual at
common law. The remedies described in clauses (i),
(iii), and (iv) of paragraph (2)(A) may be imposed
during the pendency of any hearing. The provisions
of this subsection shall apply to a nursing facility (or
portion thereof) notwithstanding that the facility (or
portion thereof) also is a skilled nursing facility for
purposes of title XVIII.
396
‘‘(9) SHARING
OF
INFORMATION.—Notwith-
standing any other provision of law, all information
concerning nursing facilities required by this section
to be filed with the Secretary or a State agency shall
be made available by such facilities to Federal or
State employees for purposes consistent with the ef-
fective administration of programs established under
this title and title XVIII, including investigations by
State fraud control units.
‘‘(i) CONSTRUCTION.—Where requirements or obliga-
tions under this section are identical to those provided
under section 1819 of this Act, the fulfillment of those
requirements or obligations under section 1819 shall be
considered to be the fulfillment of the corresponding re-
quirements or obligations under this section.
‘‘SEC. 1558. OTHER PROVISIONS PROMOTING PROGRAM IN-
TEGRITY.
‘‘(a) PUBLIC ACCESS TO SURVEY RESULTS.—Each
State plan shall provide that upon completion of a survey
of any health care facility or organization by a State agen-
cy to carry out the plan, the agency shall make public in
readily available form and place the pertinent findings of
the survey relating to the compliance of the facility or or-
ganization with requirements of law.
397
‘‘(b) RECORD KEEPING.—Each State plan shall pro-
vide for agreements with persons or institutions providing
services under the plan under which the person or institu-
tion agrees—
‘‘(1) to keep such records, including ledgers,
books, and original evidence of costs, as are nec-
essary to fully disclose the extent of the services pro-
vided to individuals receiving assistance under the
plan, and
‘‘(2) to furnish the State agency with such in-
formation regarding any payments claimed by such
person or institution for providing services under the
plan, as the State agency may from time to time re-
quest.
‘‘(c) QUALITY ASSURANCE.—Each State plan shall
provide a program to assure the quality of services pro-
vided under the plan, including such services provided to
individuals with chronic mental or physical illness.
‘‘PART E—GENERAL PROVISIONS
‘‘SEC. 1571. DEFINITIONS.
‘‘(a) MEDICAL ASSISTANCE.—For purposes of this
title, the term ‘medical assistance’ means payment of part
or all of the cost of any of the following, or assistance
in the purchase, in whole or in part, of health benefit cov-
erage that includes any of the following, for eligible low-
398
income individuals (as defined in subsection (b)) as speci-
fied under the State plan:
‘‘(1) Inpatient hospital services.
‘‘(2) Outpatient hospital services.
‘‘(3) Physician services.
‘‘(4) Surgical services.
‘‘(5) Clinic services and other ambulatory
health care services.
‘‘(6) Nursing facility services.
‘‘(7) Intermediate care facility services for the
mentally retarded.
‘‘(8) Prescription drugs and biologicals and the
administration of such drugs and biologicals, only if
such drugs and biologicals are not furnished for the
purpose of causing, or assisting in causing, the
death, suicide, euthanasia, or mercy killing of a per-
son.
‘‘(9) Over-the-counter medications.
‘‘(10) Laboratory and radiological services.
‘‘(11) Prepregnancy family planning services
and supplies.
‘‘(12) Inpatient mental health services, includ-
ing services furnished in a State-operated mental
hospital and including residential or other 24-hour
therapeutically planned structured services.
399
‘‘(13) Outpatient mental health services, includ-
ing services furnished in a State-operated mental
hospital and including community-based services.
‘‘(14) Durable medical equipment and other
medically-related or remedial devices (such as pros-
thetic devices, implants, eyeglasses, hearing aids,
dental devices, and adaptive devices).
‘‘(15) Disposable medical supplies.
‘‘(16) Home and community-based health care
services and related supportive services (such as
home health nursing services, home health aide serv-
ices, personal care, assistance with activities of daily
living, chore services, day care services, respite care
services, training for family members, and minor
modifications to the home).
‘‘(17) Community supported living arrange-
ments, assisted living arrangements, and transitional
living arrangements in the community.
‘‘(18) Nursing care services (such as nurse
practitioner services, nurse midwife services, ad-
vanced practice nurse services, private duty nursing
care, pediatric nurse services, and respiratory care
services) in a home, school, or other setting.