983
‘‘(ii) the transfer or discharge is ap-
propriate 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 rea-
sonable and appropriate notice, to pay (or
to have paid under this title or title XVIII
on the resident’s behalf) for a stay at the
facility; or
‘‘(vi) the facility ceases to operate.
In each of the cases described in clauses (i)
through (iv), the basis for the transfer or dis-
charge must be documented in the resident’s
clinical record. In the cases described in clauses
(i) and (ii), the documentation must be made
by the resident’s physician, and in the case de-
scribed in clause (iv) the documentation must
be made by a physician. For purposes of clause
(v), in the case of a resident who becomes eligi-
ble for assistance under this title after admis-
984
sion to the facility, only charges which may be
imposed under this title shall be considered to
be allowable.
‘‘(B) PRE-TRANSFER AND PRE-DISCHARGE
NOTICE.—
‘‘(i) IN GENERAL.—Before effecting a
transfer or discharge of a resident, a nurs-
ing facility must—
‘‘(I) notify the resident (and, if
known, an immediate family member
of the resident or legal representative)
of the transfer or discharge and the
reasons therefor,
‘‘(II) record the reasons in the
resident’s clinical record (including
any documentation required under
subparagraph (A)), and
‘‘(III) include in the notice the
items described in clause (iii).
‘‘(ii) TIMING OF NOTICE.—The notice
under clause (i)(I) must be made at least
30 days in advance of the resident’s trans-
fer or discharge except—
‘‘(I) in a case described in clause
(iii) or (iv) of subparagraph (A);
985
‘‘(II) in a case described in
clause (ii) of subparagraph (A), where
the resident’s health improves suffi-
ciently to allow a more immediate
transfer or discharge;
‘‘(III) in a case described in
clause (i) of subparagraph (A), where
a more immediate transfer or dis-
charge is necessitated by the resi-
dent’s urgent medical needs; or
‘‘(IV) in a case where a resident
has not resided in the facility for 30
days.
In the case of such exceptions, notice must
be given as many days before the date of
the transfer or discharge as is practicable.
‘‘(iii) ITEMS INCLUDED IN NOTICE.—
Each notice under clause (i) must in-
clude—
‘‘(I) notice of the resident’s right
to appeal the transfer or discharge
under the State process established
under subsection (e)(3);
‘‘(II) the name, mailing address,
and telephone number of the State
986
long-term care ombudsman (estab-
lished under title III or VII of the
Older Americans Act of 1965);
‘‘(III) in the case of residents
with developmental disabilities, the
mailing address and telephone number
of the agency responsible for the pro-
tection and advocacy system for devel-
opmentally disabled individuals estab-
lished under part C of the Devel-
opmental Disabilities Assistance and
Bill of Rights Act; and
‘‘(IV) in the case of mentally ill
residents (as defined in subsection
(e)(7)(G)(i)), the mailing address and
telephone number of the agency re-
sponsible for the protection and advo-
cacy system for mentally ill individ-
uals established under the Protection
and Advocacy for Mentally Ill Individ-
uals Act.
‘‘(C) ORIENTATION.—A nursing facility
must provide sufficient preparation and orienta-
tion to residents to ensure safe and orderly
transfer or discharge from the facility.
987
‘‘(D) NOTICE ON BED-HOLD POLICY AND
READMISSION.—
‘‘(i) NOTICE
BEFORE
TRANSFER.—
Before a resident of a nursing facility is
transferred for hospitalization or thera-
peutic leave, a nursing facility must pro-
vide written information to the resident
and an immediate family member or legal
representative concerning—
‘‘(I) the provisions of the State
plan under this title regarding the pe-
riod (if any) during which the resident
will be permitted under the State plan
to return and resume residence in the
facility, and
‘‘(II) the policies of the facility
regarding such a period, which poli-
cies must be consistent with clause
(iii).
‘‘(ii) NOTICE
UPON
TRANSFER.—At
the time of transfer of a resident to a hos-
pital or for therapeutic leave, a nursing fa-
cility must provide written notice to the
resident and an immediate family member
988
or legal representative of the duration of
any period described in clause (i).
‘‘(iii) PERMITTING RESIDENT TO RE-
TURN.—A nursing facility must establish
and follow a written policy under which a
resident—
‘‘(I) who is eligible for medical
assistance for nursing facility services
under a State plan,
‘‘(II) who is transferred from the
facility for hospitalization or thera-
peutic leave, and
‘‘(III) whose hospitalization or
therapeutic leave exceeds a period
paid for under the State plan for the
holding of a bed in the facility for the
resident,
will be permitted to be readmitted to the
facility immediately upon the first avail-
ability of a bed in a room (not including a
private room) in the facility if, at the time
of readmission, the resident requires the
services provided by the facility.
‘‘(3) ACCESS
AND
VISITATION
RIGHTS.—A
nursing facility must—
989
‘‘(A) permit immediate access to any resi-
dent by any representative of the Secretary, by
any representative of the State, by an ombuds-
man or agency described in subclause (II),
(III), or (IV) of paragraph (2)(B)(iii), or by the
resident’s individual physician;
‘‘(B) permit immediate access to a resi-
dent, subject to the resident’s right to deny or
withdraw consent at any time, by immediate
family or other relatives of the resident;
‘‘(C) permit immediate access to a resi-
dent, subject to reasonable restrictions and the
resident’s right to deny or withdraw consent at
any time, by others who are visiting with the
consent of the resident;
‘‘(D) permit reasonable access to a resi-
dent by any entity or individual that provides
health, social, legal, or other services to the
resident, subject to the resident’s right to deny
or withdraw consent at any time; and
‘‘(E) permit representatives of the State
ombudsman 
(described 
in 
paragraph
(2)(B)(iii)(II)), with the permission of the resi-
dent (or the resident’s legal representative) and
990
consistent with State law, to examine a resi-
dent’s clinical records.
‘‘(4) EQUAL ACCESS TO QUALITY CARE.—
‘‘(A) IN
GENERAL.—A nursing facility
must establish and maintain identical policies
and practices regarding transfer, discharge, and
the provision of services required under the
State plan for all individuals regardless of
source of payment.
‘‘(B) CONSTRUCTION.—
‘‘(i) 
NOTHING
PROHIBITING
ANY
CHARGES FOR NON-MEDICAL ASSISTANCE
PATIENTS.—Subparagraph (A) shall not be
construed as prohibiting a nursing facility
from charging any amount for services fur-
nished, consistent with the notice in para-
graph (1)(B) describing such charges.
‘‘(ii) NO
ADDITIONAL
SERVICES
RE-
QUIRED.—Subparagraph (A) shall not be
construed as requiring a State to offer ad-
ditional services on behalf of a resident
than are otherwise provided under the
State plan.
‘‘(5) ADMISSIONS POLICY.—
991
‘‘(A) ADMISSIONS.—With respect to admis-
sions practices, a nursing facility must—
‘‘(i)(I) not require individuals apply-
ing to reside or residing in the facility to
waive their rights to benefits under a State
plan under this title or title XVIII, (II) not
require oral or written assurance that such
individuals are not eligible for, or will not
apply for, benefits under a State plan
under this title or title XVIII, and (III)
prominently display in the facility written
information, and provide to such individ-
uals oral and written information, about
how to apply for and use such benefits and
how to receive refunds for previous pay-
ments covered by such benefits;
‘‘(ii) not require a third party guaran-
tee of payment to the facility as a condi-
tion of admission (or expedited admission)
to, or continued stay in, the facility; and
‘‘(iii) in the case of an individual who
is provided medical assistance for nursing
facility services, not charge, solicit, accept,
or receive, in addition to any amount oth-
erwise required to be paid under the State
992
plan under this title, any gift, money, do-
nation, or other consideration as a pre-
condition of admitting (or expediting the
admission of) the individual to the facility
or as a requirement for the individual’s
continued stay in the facility.
‘‘(B) CONSTRUCTION.—
‘‘(i) NO
PREEMPTION
OF
STRICTER
STANDARDS.—Subparagraph (A) shall not
be construed as preventing States or politi-
cal subdivisions therein from prohibiting,
under State or local law, the discrimination
against individuals who are provided medi-
cal assistance under the State plan with
respect to admissions practices of nursing
facilities.
‘‘(ii) CONTRACTS
WITH
LEGAL
REP-
RESENTATIVES.—Subparagraph 
(A)(ii)
shall not be construed as preventing a fa-
cility from requiring an individual, who has
legal access to a resident’s income or re-
sources available to pay for care in the fa-
cility, to sign a contract (without incurring
personal financial liability) to provide pay-
993
ment from the resident’s income or re-
sources for such care.
‘‘(iii) 
CHARGES
FOR
ADDITIONAL
SERVICES
REQUESTED.—Subparagraph
(A)(iii) shall not be construed as prevent-
ing a facility from charging a resident, eli-
gible for medical assistance under the
State plan, for items or services the resi-
dent has requested and received and that
are not specified in the State plan as in-
cluded in covered nursing facility services.
‘‘(iv) BONA FIDE CONTRIBUTIONS.—
Subparagraph (A)(iii) shall not be con-
strued as prohibiting a nursing facility
from soliciting, accepting, or receiving a
charitable, religious, or philanthropic con-
tribution from an organization or from a
person unrelated to the resident (or poten-
tial resident), but only to the extent that
such contribution is not a condition of ad-
mission, expediting admission, or continued
stay in the facility.
‘‘(6) PROTECTION OF RESIDENT FUNDS.—
‘‘(A) IN GENERAL.—The nursing facility—
994
‘‘(i) may not require residents to de-
posit their personal funds with the facility,
and
‘‘(ii) upon the written authorization of
the resident, must hold, safeguard, and ac-
count for such personal funds under a sys-
tem established and maintained by the fa-
cility in accordance with this paragraph.
‘‘(B) 
MANAGEMENT
OF
PERSONAL
FUNDS.—Upon written authorization of a resi-
dent under subparagraph (A)(ii), the facility
must manage and account for the personal
funds of the resident deposited with the facility
as follows:
‘‘(i) DEPOSIT.—The facility must de-
posit any amount of personal funds in ex-
cess of $50 with respect to a resident in an
interest bearing account (or accounts) that
is separate from any of the facility’s oper-
ating accounts and credits all interest
earned on such separate account to such
account. With respect to any other per-
sonal funds, the facility must maintain
such funds in a non-interest bearing ac-
count or petty cash fund.
995
‘‘(ii) ACCOUNTING
AND
RECORDS.—
The facility must assure a full and com-
plete separate accounting of each such
resident’s personal funds, maintain a writ-
ten record of all financial transactions in-
volving the personal funds of a resident de-
posited with the facility, and afford the
resident (or a legal representative of the
resident) reasonable access to such record.
‘‘(iii) NOTICE
OF
CERTAIN
BAL-
ANCES.—The facility must notify each resi-
dent receiving medical assistance under the
State plan when the amount in the resi-
dent’s account reaches $200 less than the
dollar amount determined under section
1611(a)(3)(B) and the fact that if the
amount in the account (in addition to the
value of the resident’s other nonexempt re-
sources) reaches the amount determined
under such section the resident may lose
eligibility for such medical assistance or for
benefits under title XVI.
‘‘(iv) CONVEYANCE
UPON
DEATH.—
Upon the death of a resident with such an
account, the facility must convey promptly
996
the resident’s personal funds (and a final
accounting of such funds) to the individual
administering the resident’s estate. All
other personal property, including medical
records, shall be considered part of the
resident’s estate and shall only be released
to the administrator of the estate.
‘‘(C) ASSURANCE
OF
FINANCIAL
SECU-
RITY.—The facility must purchase a surety
bond, or otherwise provide assurance satisfac-
tory to the State, to assure the security of all
personal funds of residents deposited with the
facility.
‘‘(D) LIMITATION ON CHARGES TO PER-
SONAL FUNDS.—The facility may not impose a
charge against the personal funds of a resident
for any item or service for which payment is
made under this title or title XVIII.
‘‘(7) LIMITATION
ON
CHARGES
IN
CASE
OF
MEDICAL-ASSISTANCE-ELIGIBLE INDIVIDUALS.—
‘‘(A) IN GENERAL.—A nursing facility may
not impose charges, for certain medical-assist-
ance-eligible individuals for nursing facility
services covered by the State under its plan
under this title, that exceed the payment
997
amounts established by the State for such serv-
ices under this title.
‘‘(B) CERTAIN
MEDICAL-ASSISTANCE-ELI-
GIBLE
INDIVIDUALS
DEFINED.—In subpara-
graph (A), the term ‘certain medical-assistance-
eligible individual’ means an individual who is
entitled to medical assistance for nursing facil-
ity services in the facility under this title but
with respect to whom such benefits are not
being paid because, in determining the amount
of the individual’s income to be applied monthly
to payment for the costs of such services, the
amount of such income exceeds the payment
amounts established by the State for such serv-
ices under this title.
‘‘(8) POSTING OF SURVEY RESULTS.—A nurs-
ing facility must post in a place readily accessible to
residents, and family members and legal representa-
tives of residents, the results of the most recent sur-
vey of the facility conducted under subsection (g).
‘‘(d) REQUIREMENTS RELATING
TO ADMINISTRA-
TION AND OTHER MATTERS.—
‘‘(1) ADMINISTRATION.—
‘‘(A) IN
GENERAL.—A nursing facility
must be administered in a manner that enables
998
it to use its resources effectively and efficiently
to attain or maintain the highest practicable
physical, mental, and psychosocial well-being of
each resident (consistent with requirements es-
tablished under subsection (f)(5)).
‘‘(B) REQUIRED NOTICES.—If a change oc-
curs in—
‘‘(i) the persons with an ownership or
control interest (as defined in section
1124(a)(3)) in the facility,
‘‘(ii) the persons who are officers, di-
rectors, agents, or managing employees (as
defined in section 1126(b)) of the facility,
‘‘(iii) the corporation, association, or
other company responsible for the manage-
ment of the facility, or
‘‘(iv) the individual who is the admin-
istrator or director of nursing of the facil-
ity,
the nursing facility must provide notice to the
State agency responsible for the licensing of the
facility, at the time of the change, of the change
and of the identity of each new person, com-
pany, or individual described in the respective
clause.
999
‘‘(C) 
NURSING
FACILITY
ADMINIS-
TRATOR.—The administrator of a nursing facil-
ity, whether freestanding or hospital-based,
must meet such standards as are established by
the Secretary under subsection (f)(4).
‘‘(2) LICENSING AND LIFE SAFETY CODE.—
‘‘(A) LICENSING.—A nursing facility must
be licensed under applicable State and local law.
‘‘(B) LIFE SAFETY CODE.—A nursing fa-
cility must meet such provisions of such edition
(as specified by the Secretary in regulation) of
the Life Safety Code of the National Fire Pro-
tection Association as are applicable to nursing
homes; except that—
‘‘(i) the Secretary may waive, for such
periods as he deems appropriate, specific
provisions of such Code which if rigidly ap-
plied would result in unreasonable hard-
ship upon a facility, but only if such waiver
would not adversely affect the health and
safety of residents or personnel, and
‘‘(ii) the provisions of such Code shall
not apply in any State if the Secretary
finds that in such State there is in effect
a fire and safety code, imposed by State
1000
law, which adequately protects residents of
and personnel in nursing facilities.
‘‘(3) SANITARY AND INFECTION CONTROL AND
PHYSICAL
ENVIRONMENT.—A 
nursing 
facility
must—
‘‘(A) establish and maintain an infection
control program designed to provide a safe, san-
itary, and comfortable environment in which
residents reside and to help prevent the devel-
opment and transmission of disease and infec-
tion, and
‘‘(B) be designed, constructed, equipped,
and maintained in a manner to protect the
health and safety of residents, personnel, and
the general public.
‘‘(4) MISCELLANEOUS.—
‘‘(A) COMPLIANCE WITH FEDERAL, STATE,
AND LOCAL LAWS AND PROFESSIONAL STAND-
ARDS.—A nursing facility, whether freestanding
or hospital-based, must operate and provide
services in compliance with all applicable Fed-
eral, State, and local laws and regulations (in-
cluding the requirements of section 1124) and
with accepted professional standards and prin-