311
State in pursuing, any third party who may be
liable to pay for care and services available
under the plan, unless such individual has good
cause for refusing to cooperate as determined
by the State; and
‘‘(2) provide for entering into cooperative ar-
rangements, including financial arrangements, with
any appropriate agency of any State (including, with
respect to the enforcement and collection of rights of
payment for medical care by or through a parent,
with a State’s agency established or designated
under section 454(3)) and with appropriate courts
and law enforcement officials, to assist the agency or
agencies administering the plan with respect to—
‘‘(A) the enforcement and collection of
rights to support or payment assigned under
this section, and
‘‘(B) any other matters of common con-
cern.
‘‘(b) USE OF AMOUNTS COLLECTED.—Such part of
any amount collected by the State under an assignment
made under the provisions of this section shall be retained
by the State as is necessary to reimburse it for medical
assistance payments made on behalf of an individual with
respect to whom such assignment was executed (with ap-
312
propriate reimbursement of the Federal Government to
the extent of its participation in the financing of such
medical assistance), and the remainder of such amount
collected shall be paid to such individual.
‘‘SEC. 1557. QUALITY ASSURANCE REQUIREMENTS FOR
NURSING FACILITIES.
‘‘(a) NURSING FACILITY DEFINED.—In this title, the
term ‘nursing facility’ means an institution (or a distinct
part of an institution) which—
‘‘(1) is primarily engaged in providing to resi-
dents—
‘‘(A) skilled nursing care and related serv-
ices for residents who require medical or nurs-
ing care,
‘‘(B) rehabilitation services for the reha-
bilitation of injured, disabled, or sick persons,
or
‘‘(C) on a regular basis, health-related care
and services to individuals who because of their
mental or physical condition require care and
services (above the level of room and board)
which can be made available to them only
through institutional facilities,
and is not primarily for the care and treatment of
mental diseases;
313
‘‘(2) has in effect a transfer agreement (meet-
ing the requirements of section 1861(l)) with one or
more hospitals having agreements in effect under
section 1866; and
‘‘(3) meets the requirements for a nursing facil-
ity described in subsections (b), (c), and (d) of this
section.
Such term also includes any facility which is located in
a State on an Indian reservation and is certified by the
Secretary as meeting the requirements of paragraph (1)
and subsections (b), (c), and (d).
‘‘(b) REQUIREMENTS RELATING TO PROVISION OF
SERVICES.—
‘‘(1) QUALITY OF LIFE.—
‘‘(A) IN
GENERAL.—A nursing facility
must care for its residents in such a manner
and in such an environment as will promote
maintenance or enhancement of the quality of
life of each resident.
‘‘(B) QUALITY ASSESSMENT AND ASSUR-
ANCE.—A nursing facility must maintain a
quality assessment and assurance committee,
consisting of the director of nursing services, a
physician designated by the facility, and at least
3 other members of the facility’s staff, which (i)
314
meets at least quarterly to identify issues with
respect to which quality assessment and assur-
ance activities are necessary and (ii) develops
and implements appropriate plans of action to
correct identified quality deficiencies. A State or
the Secretary may not require disclosure of the
records of such committee except insofar as
such disclosure is related to the compliance of
such committee with the requirements of this
subparagraph.
‘‘(2) SCOPE
OF
SERVICES
AND
ACTIVITIES
UNDER
PLAN
OF
CARE.—A nursing facility must
provide services and activities to attain or maintain
the highest practicable physical, mental, and
psychosocial well-being of each resident in accord-
ance with a written plan of care which—
‘‘(A) describes the medical, nursing, and
psychosocial needs of the resident and how such
needs will be met;
‘‘(B) is initially prepared, with the partici-
pation to the extent practicable of the resident
or the resident’s family or legal representative,
by a team which includes the resident’s attend-
ing physician and a registered professional
nurse with responsibility for the resident; and
315
‘‘(C) is periodically reviewed and revised by
such team after each assessment under para-
graph (3).
‘‘(3) RESIDENTS’ ASSESSMENT.—
‘‘(A) REQUIREMENT.—A nursing facility
must conduct a comprehensive, accurate, stand-
ardized, reproducible assessment of each resi-
dent’s functional capacity, which assessment—
‘‘(i) describes the resident’s capability
to perform daily life functions and signifi-
cant impairments in functional capacity;
‘‘(ii) is based on a uniform minimum
data set specified by the Secretary under
subsection (f)(6)(A);
‘‘(iii) uses an instrument which is
specified by the State under subsection
(e)(5); and
‘‘(iv) includes the identification of
medical problems.
‘‘(B) CERTIFICATION.—
‘‘(i) IN GENERAL.—Each such assess-
ment must be conducted or coordinated
(with the appropriate participation of
health professionals) by a registered pro-
fessional nurse who signs and certifies the
316
completion of the assessment. Each indi-
vidual who completes a portion of such an
assessment shall sign and certify as to the
accuracy of that portion of the assessment.
‘‘(ii) PENALTY FOR FALSIFICATION.—
‘‘(I) An individual who willfully
and knowingly certifies under clause
(i) a material and false statement in
a resident assessment is subject to a
civil money penalty of not more than
$1,000 with respect to each assess-
ment.
‘‘(II) An individual who willfully
and knowingly causes another individ-
ual to certify under clause (i) a mate-
rial and false statement in a resident
assessment is subject to a civil money
penalty of not more than $5,000 with
respect to each assessment.
‘‘(III) The provisions of section
1128A (other than subsections (a)
and (b)) shall apply to a civil money
penalty under this clause in the same
manner as such provisions apply to a
317
penalty or proceeding under section
1128A(a).
‘‘(iii) USE OF INDEPENDENT ASSES-
SORS.—If a State determines, under a sur-
vey under subsection (g) or otherwise, that
there has been a knowing and willful cer-
tification of false assessments under this
paragraph, the State may require (for a
period specified by the State) that resident
assessments under this paragraph be con-
ducted and certified by individuals who are
independent of the facility and who are ap-
proved by the State.
‘‘(C) FREQUENCY.—
‘‘(i) IN
GENERAL.—Such an assess-
ment must be conducted—
‘‘(I) promptly upon (but no later
than 14 days after the date of) admis-
sion for each individual admitted;
‘‘(II) promptly after a significant
change in the resident’s physical or
mental condition; and
‘‘(III) in no case less often than
once every 12 months.
318
‘‘(ii) RESIDENT REVIEW.—The nurs-
ing facility must examine each resident no
less frequently than once every 3 months
and, as appropriate, revise the resident’s
assessment to assure the continuing accu-
racy of the assessment.
‘‘(D) USE.—The results of such an assess-
ment shall be used in developing, reviewing, and
revising the resident’s plan of care under para-
graph (2).
‘‘(E) COORDINATION.—Such assessments
shall be coordinated with any State-required
preadmission screening program to the maxi-
mum extent practicable in order to avoid dupli-
cative testing and effort. In addition, a nursing
facility shall notify the State mental health au-
thority or State mental retardation or devel-
opmental disability authority, as applicable,
promptly after a significant change in the phys-
ical or mental condition of a resident who is
mentally ill or mentally retarded.
‘‘(4) PROVISION
OF
SERVICES
AND
ACTIVI-
TIES.—
‘‘(A) IN GENERAL.—To the extent needed
to fulfill all plans of care described in para-
319
graph (2), a nursing facility must provide (or
arrange for the provision of)—
‘‘(i) nursing and related services and
specialized rehabilitative services to attain
or maintain the highest practicable phys-
ical, mental, and psychosocial well-being of
each resident;
‘‘(ii) medically-related social services
to attain or maintain the highest prac-
ticable physical, mental, and psychosocial
well-being of each resident;
‘‘(iii) pharmaceutical services (includ-
ing procedures that assure the accurate ac-
quiring, receiving, dispensing, and admin-
istering of all drugs and biologicals) to
meet the needs of each resident;
‘‘(iv) dietary services that assure that
the meals meet the daily nutritional and
special dietary needs of each resident;
‘‘(v) an on-going program, directed by
a qualified professional, of activities de-
signed to meet the interests and the phys-
ical, mental, and psychosocial well-being of
each resident;
320
‘‘(vi) routine dental services (to the
extent covered under the State plan) and
emergency dental services to meet the
needs of each resident; and
‘‘(vii) treatment and services required
by mentally ill and mentally retarded resi-
dents not otherwise provided or arranged
for (or required to be provided or arranged
for) by the State.
The services provided or arranged by the facil-
ity must meet professional standards of quality.
‘‘(B) 
QUALIFIED
PERSONS
PROVIDING
SERVICES.—Services described in clauses (i),
(ii), (iii), (iv), and (vi) of subparagraph (A)
must be provided by qualified persons in ac-
cordance with each resident’s written plan of
care.
‘‘(C) REQUIRED NURSING CARE; FACILITY
WAIVERS.—
‘‘(i) GENERAL
REQUIREMENTS.—A
nursing facility—
‘‘(I) except as provided in clause
(ii), must provide 24-hour licensed
nursing services which are sufficient
321
to meet the nursing needs of its resi-
dents, and
‘‘(II) except as provided in clause
(ii), must use the services of a reg-
istered professional nurse for at least
8 consecutive hours a day, 7 days a
week.
‘‘(ii) WAIVER BY STATE.—To the ex-
tent that a facility is unable to meet the
requirements of clause (i), a State may
waive such requirements with respect to
the facility if—
‘‘(I) the facility demonstrates to
the satisfaction of the State that the
facility has been unable, despite dili-
gent efforts (including offering wages
at the community prevailing rate for
nursing facilities), to recruit appro-
priate personnel,
‘‘(II) the State determines that a
waiver of the requirement will not en-
danger the health or safety of individ-
uals staying in the facility,
‘‘(III) the State finds that, for
any such periods in which licensed
322
nursing services are not available, a
registered professional nurse or a phy-
sician is obligated to respond imme-
diately to telephone calls from the fa-
cility,
‘‘(IV) the State agency granting
a waiver of such requirements pro-
vides notice of the waiver to the State
long-term care ombudsman (estab-
lished under section 307(a)(12) of the
Older Americans Act of 1965) and the
protection and advocacy system in the
State for the mentally ill and the
mentally retarded, and
‘‘(V) the nursing facility that is
granted such a waiver by a State noti-
fies residents of the facility (or, where
appropriate, the guardians or legal
representatives of such residents) and
members of their immediate families
of the waiver.
A waiver under this clause shall be subject
to annual review and to the review of the
Secretary and subject to clause (iii) shall
be accepted by the Secretary for purposes
323
of this title to the same extent as is the
State’s certification of the facility. In
granting or renewing a waiver, a State
may require the facility to use other quali-
fied, licensed personnel.
‘‘(iii) ASSUMPTION
OF
WAIVER
AU-
THORITY BY SECRETARY.—If the Secretary
determines that a State has shown a clear
pattern and practice of allowing waivers in
the absence of diligent efforts by facilities
to meet the staffing requirements, the Sec-
retary shall assume and exercise the au-
thority of the State to grant waivers.
‘‘(5) REQUIRED TRAINING OF NURSE AIDES.—
‘‘(A) IN GENERAL.—(i) Except as provided
in clause (ii), a nursing facility must not use on
a full-time basis any individual as a nurse aide
in the facility, for more than 4 months unless
the individual—
‘‘(I) has completed a training and
competency evaluation program, or a com-
petency evaluation program, approved by
the State under subsection (e)(1)(A), and
‘‘(II) is competent to provide nursing
or nursing-related services.
324
‘‘(ii) A nursing facility must not use on a
temporary, per diem, leased, or on any other
basis other than as a permanent employee any
individual as a nurse aide in the facility, unless
the individual meets the requirements described
in clause (i).
‘‘(B) OFFERING
COMPETENCY
EVALUA-
TION PROGRAMS FOR CURRENT EMPLOYEES.—
A nursing facility must provide, for individuals
used as a nurse aide by the facility, for a com-
petency evaluation program approved by the
State under subsection (e)(1) and such prepara-
tion as may be necessary for the individual to
complete such a program.
‘‘(C) COMPETENCY.—The nursing facility
must not permit an individual, other than in a
training and competency evaluation program
approved by the State, to serve as a nurse aide
or provide services of a type for which the indi-
vidual has not demonstrated competency and
must not use such an individual as a nurse aide
unless the facility has inquired of any State
registry established under subsection (e)(2)(A)
that the facility believes will include information
concerning the individual.
325
‘‘(D) RE-TRAINING REQUIRED.—For pur-
poses of subparagraph (A), if, since an individ-
ual’s most recent completion of a training and
competency evaluation program, there has been
a continuous period of 24 consecutive months
during none of which the individual performed
nursing or nursing-related services for monetary
compensation, such individual shall complete a
new training and competency evaluation pro-
gram, or a new competency evaluation program.
‘‘(E) REGULAR IN-SERVICE EDUCATION.—
The nursing facility must provide such regular
performance review and regular in-service edu-
cation as assures that individuals used as nurse
aides are competent to perform services as
nurse aides, including training for individuals
providing nursing and nursing-related services
to residents with cognitive impairments.
‘‘(F) NURSE
AIDE
DEFINED.—In this
paragraph, the term ‘nurse aide’ means any in-
dividual providing nursing or nursing-related
services to residents in a nursing facility, but
does not include an individual—
326
‘‘(i) who is a licensed health profes-
sional (as defined in subparagraph (G)) or
a registered dietitian, or
‘‘(ii) who volunteers to provide such
services without monetary compensation.
‘‘(G) LICENSED
HEALTH
PROFESSIONAL
DEFINED.—In this paragraph, the term ‘li-
censed health professional’ means a physician,
physician assistant, nurse practitioner, physical,
speech, or occupational therapist, physical or
occupational therapy assistant, registered pro-
fessional nurse, licensed practical nurse, or li-
censed or certified social worker.
‘‘(6) PHYSICIAN
SUPERVISION
AND
CLINICAL
RECORDS.—A nursing facility must—
‘‘(A) require that the health care of every
resident be provided under the supervision of a
physician (or, at the option of a State, under
the supervision of a nurse practitioner, clinical
nurse specialist, or physician assistant who is
not an employee of the facility but who is work-
ing in collaboration with a physician);
‘‘(B) provide for having a physician avail-
able to furnish necessary medical care in case
of emergency; and
327
‘‘(C) maintain clinical records on all resi-
dents, which records include the plans of care
(described in paragraph (2)) and the residents’
assessments (described in paragraph (3)), as
well as the results of any pre-admission screen-
ing conducted under subsection (e)(7).
‘‘(7) REQUIRED SOCIAL SERVICES.—In the case
of a nursing facility with more than 120 beds, the
facility must have at least one social worker (with at
least a bachelor’s degree in social work or similar
professional qualifications) employed full-time to
provide or assure the provision of social services.
‘‘(c) REQUIREMENTS
RELATING
TO
RESIDENTS’
RIGHTS.—
‘‘(1) GENERAL RIGHTS.—
‘‘(A) SPECIFIED RIGHTS.—A nursing facil-
ity must protect and promote the rights of each
resident, including each of the following rights:
‘‘(i) FREE
CHOICE.—The right to
choose a personal attending physician, to
be fully informed in advance about care
and treatment, to be fully informed in ad-
vance of any changes in care or treatment
that may affect the resident’s well-being,
and (except with respect to a resident ad-
328
judged incompetent) to participate in plan-
ning care and treatment or changes in care
and treatment.
‘‘(ii) FREE FROM RESTRAINTS.—The
right to be free from physical or mental
abuse, corporal punishment, involuntary
seclusion, and any physical or chemical re-
straints imposed for purposes of discipline
or convenience and not required to treat
the resident’s medical symptoms. Re-
straints may only be imposed—
‘‘(I) to ensure the physical safety
of the resident or other residents, and
‘‘(II) only upon the written order
of a physician that specifies the dura-
tion and circumstances under which
the restraints are to be used (except
in emergency circumstances specified
by the Secretary until such an order
could reasonably be obtained).
‘‘(iii) PRIVACY.—The right to privacy
with regard to accommodations, medical
treatment, written and telephonic commu-
nications, visits, and meetings of family
and of resident groups.
329
‘‘(iv) CONFIDENTIALITY.—The right
to confidentiality of personal and clinical
records and to access to current clinical
records of the resident upon request by the
resident or the resident’s legal representa-
tive, within 24 hours (excluding hours oc-
curring during a weekend or holiday) after
making such a request.
‘‘(v) ACCOMMODATION
OF
NEEDS.—
The right—
‘‘(I) to reside and receive services
with reasonable accommodation of in-
dividual needs and preferences, except
where the health or safety of the indi-
vidual or other residents would be en-
dangered, and
‘‘(II) to receive notice before the
room or roommate of the resident in
the facility is changed.
‘‘(vi) GRIEVANCES.—The right to
voice grievances with respect to treatment
or care that is (or fails to be) furnished,
without discrimination or reprisal for voic-
ing the grievances and the right to prompt
efforts by the facility to resolve grievances
330
the resident may have, including those with
respect to the behavior of other residents.
‘‘(vii) PARTICIPATION
IN
RESIDENT
AND FAMILY GROUPS.—The right of the
resident to organize and participate in resi-
dent groups in the facility and the right of
the resident’s family to meet in the facility
with the families of other residents in the
facility.
‘‘(viii) PARTICIPATION IN OTHER AC-
TIVITIES.—The right of the resident to
participate in social, religious, and commu-
nity activities that do not interfere with
the rights of other residents in the facility.
‘‘(ix) EXAMINATION OF SURVEY RE-
SULTS.—The right to examine, upon rea-
sonable request, the results of the most re-
cent survey of the facility conducted by the
Secretary or a State with respect to the fa-
cility and any plan of correction in effect
with respect to the facility.
‘‘(x) REFUSAL
OF
CERTAIN
TRANS-
FERS.—The right to refuse a transfer to
another room within the facility, if a pur-
poses of the transfer is to relocate the resi-
331
dent from a portion of the facility that is
not a skilled nursing facility (for purposes
of title XVIII) to a portion of the facility
that is such a skilled nursing facility.
‘‘(xi) OTHER
RIGHTS.—Any other
right established by the Secretary.
Clause (i) shall not be construed as precluding
a State from requiring a resident of a nursing
facility to choose a personal attending physician
who participates in a managed care network
under a contract with the State to provide med-
ical assistance under this title. Clause (iii) shall
not be construed as requiring the provision of
a private room. A resident’s exercise of a right
to refuse transfer under clause (x) shall not af-
fect the resident’s eligibility or entitlement to
medical assistance under this title or a State’s
entitlement to Federal medical assistance under
this title with respect to services furnished to
such a resident.
‘‘(B) NOTICE OF RIGHTS.—A nursing fa-
cility must—
‘‘(i) inform each resident, orally and
in writing at the time of admission to the
facility, of the resident’s legal rights dur-
332
ing the stay at the facility and of the re-
quirements and procedures for establishing
eligibility for medical assistance under this
title, including the right to request an as-
sessment under section 1505(c)(1)(B);
‘‘(ii) make available to each resident,
upon reasonable request, a written state-
ment of such rights (which statement is
updated upon changes in such rights) in-
cluding the notice (if any) of the State de-
veloped under subsection (e)(6);
‘‘(iii) inform each resident who is enti-
tled to medical assistance under this
title—
‘‘(I) at the time of admission to
the facility or, if later, at the time the
resident becomes eligible for such as-
sistance, of the items and services
that are included in nursing facility
services under the State plan and for
which the resident may not be
charged, and of those other items and
services that the facility offers and for
which the resident may be charged
333
and the amount of the charges for
such items and services, and
‘‘(II) of changes in the items and
services described in subclause (I) and
of changes in the charges imposed for
items and services described in that
subclause; and
‘‘(iv) inform each other resident, in
writing before or at the time of admission
and periodically during the resident’s stay,
of services available in the facility and of
related charges for such services, including
any charges for services not covered under
title XVIII or by the facility’s basic per
diem charge.
The written description of legal rights under
this subparagraph shall include a description of
the protection of personal funds under para-
graph (6) and a statement that a resident may
file a complaint with a State survey and certifi-
cation agency respecting resident abuse and ne-
glect and misappropriation of resident property
in the facility.
‘‘(C) RIGHTS
OF
INCOMPETENT
RESI-
DENTS.—In the case of a resident adjudged in-
334
competent under the laws of a State, the rights
of the resident under this title shall devolve
upon, and, to the extent judged necessary by a
court of competent jurisdiction, be exercised by,
the person appointed under State law to act on
the resident’s behalf.
‘‘(D) USE
OF
PSYCHOPHARMACOLOGIC
DRUGS.—Psychopharmacologic drugs may be
administered only on the orders of a physician
and only as part of a plan (included in the writ-
ten plan of care described in paragraph (2)) de-
signed to eliminate or modify the symptoms for
which the drugs are prescribed and only if, at
least annually an independent, external consult-
ant reviews the appropriateness of the drug
plan of each resident receiving such drugs.
‘‘(2) TRANSFER AND DISCHARGE RIGHTS.—
‘‘(A) IN
GENERAL.—A nursing facility
must permit each resident to remain in the fa-
cility and must not transfer or discharge the
resident from the facility unless—
‘‘(i) the transfer or discharge is nec-
essary to meet the resident’s welfare and
the resident’s welfare cannot be met in the
facility;
335
‘‘(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-
336
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);
337
‘‘(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
338
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.
339
‘‘(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
340
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—
341
‘‘(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
342
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.—
343
‘‘(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
344
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-
345
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—
346
‘‘(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.
347
‘‘(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
348
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
349
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
350
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.
351
‘‘(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
352
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-
376
retary’s 
determination 
under 
section
1116(a)(1).
‘‘(D) 
SPECIAL
SURVEYS
OF
COMPLI-
ANCE.—Where the Secretary has reason to
question the compliance of a nursing facility
with any of the requirements of subsections (b),
(c), and (d), the Secretary may conduct a sur-
vey of the facility and, on the basis of that sur-
vey, make independent and binding determina-
tions concerning the extent to which the nurs-
ing facility meets such requirements.
‘‘(4) INVESTIGATION OF COMPLAINTS AND MON-
ITORING
NURSING
FACILITY
COMPLIANCE.—Each
State shall maintain procedures and adequate staff
to—
‘‘(A) investigate complaints of violations of
requirements by nursing facilities, and
‘‘(B) monitor, on-site, on a regular, as
needed basis, a nursing facility’s compliance
with the requirements of subsections (b), (c),
and (d), if—
‘‘(i) the facility has been found not to
be in compliance with such requirements
and is in the process of correcting defi-
ciencies to achieve such compliance;