Medicare Conditions of Participation
Long Term Care Facilities

4.) Long Term Care Facilities

        a.) Requirements for Long Term Care Facilities

Skilled nursing facilities and nursing facilities participating in Medicare must meet federal requirements for participation in the Medicare and Medicaid programs.100

A facility must be licensed under applicable state law and comply with federal and state laws.101 The facility must have a governing body that is legally responsible for establishing policies regarding the management and operation of the facility. The facility must maintain clinical records on each resident. The facility must have detailed written plans and procedures related to potential emergencies and disasters. The facility must a written transfer agreement with one or more hospitals. A facility must maintain a quality assessment and assurance committee.

                i.) Residents’ rights

A resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.102 A facility must protect and promote the rights of each resident. The facility must inform the resident of his or her rights both orally and in writing in a language that the resident understands.

A facility must permit each resident to remain in the facility unless the transfer or discharge is medically necessary, necessary to protect a resident’s health and safety, the resident failed to pay for services, or the facility ceases to operate.103 When the facility transfers or discharges a resident, it must be documented in the resident's clinical record. Before a facility transfers or discharges a resident, the facility must notify the resident and a family member or legal representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.

A facility must care for its residents in a manner and in an environment that promotes each resident’s quality of life.104 Each resident has the right to self-determination and participation, engage in activities, and care in a safe and clean environment.

                ii.) Long Term Care Facility Services

A facility must conduct initial and periodic assessments of each resident’s functional capacity.105 Each resident must receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being.106

        b.) Preadmission Screening and Annual Resident Review (PASARR) of Mentally Ill and Mentally Retarded Individuals

The following regulatory requirements apply to the screening of all individuals with mental illness or mental retardation who apply to or reside in Medicaid certified nursing facilities.107

The states must operate preadmission screening and annual resident review (PASARR) programs as a condition of approval of the states’ plan.108 PASARR determinations made by state mental health or mental retardation authorities cannot be revoked by the state’s Medicaid agency.109 The PASARR must be coordinated with routine resident assessment to avoid duplicative testing and effort.

For each nursing facility applicant with mental illness or mental retardation, the state mental health or mental retardation authority must determine whether the individual requires the level of services provided by the nursing facility or requires specialized services.110 For each resident of a nursing facility who has a mental illness or intellectual disability, state authorities must annually review whether the resident requires the level of services provided by the nursing facility and specialized services for mental illness or intellectual disability.111 If the state mental health or mental retardation authority determines that a resident or applicant for admission to a NF requires a nursing facility level of services, the nursing facility may admit or retain the individual.112 If the resident or applicant needs specialized services, then the state must provide or arrange for the provision of the specialized services needed by the individual while he resides in the nursing facility.113 If state mental health or intellectual disability authority determines that an applicant for admission to a NF does not require NF services, the applicant cannot be admitted to a nursing facility. 114

        c.) Resident Assessment

States must specify the resident assessment instrument (RAI) that will be used by long-term care facilities when conducting initial and periodic assessments of each resident’s function capacity.115 The RAI must be approved by CMS.  

        d.) The Use of Restraint or Seclusion in Psychiatric Residential Treatment Facilities Providing Inpatient Psychiatric Residential Treatment Facilities for Individuals Under Age 21

A psychiatric residential treatment facility must meet regulatory requirements regarding the use of restraint or seclusion to patients under age 21.116  Orders for restraint or seclusion must only be made by a physician permitted by a state and the facility.117 If a physician orders restraint or seclusion, that person must contact the resident’s treatment team physician and document in the resident’s record the date and time the team physician was consulted.118  Injuries must be documented in the resident’s chart.119 If the resident is a minor, the facility must notify the resident’s parent(s) or legal guardian that the resident has been restrained or placed in seclusion as soon as possible after the initiation of each emergency safety intervention.120

Each psychiatric residential treatment facility that provides inpatient psychiatric services to individuals under age 21 must attest in writing that the facility is in compliance with CMS’ standards governing the use of restraint and seclusion.121 The facility must report each serious occurrence to both the state Medicaid agency and the state-designated protection and advocacy system. Serious occurrences include a resident’s death, a serious injury, and a resident’s suicide attempt.

        e.) Conditions of Participation for Intermediate Care Facilities for the Mentally Retarded

The Secretary of the Department of Health and Human Services has the authority to prescribe regulations for intermediate care facility services in facilities for the mentally retarded and related conditions.122 Facilities must comply with other HHS regulations, including those pertaining to nondiscrimination requirements.123 Violations of these regulations may result in the termination or suspension of federal financial assistance.

Intermediate care facilities must comply with the following conditions of participation:

• Facilities must have governing bodies, comply with applicable federal and state laws, protect client records, and have agreements with outside programs or services to provide for services not provided, including emergency and other health care.124
• The facility must ensure the rights of all clients. Therefore, the facility must inform each client or the client’s parent or legal guardian of the client’s rights and the rules of the facility and of the client’s medical condition, risks of treatment, and the right to refuse treatment. The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, or abuse of the client.125
• Each client’s active treatment program must be coordinated and monitored by a qualified mental retardation professional. Each client must receive the professional program services needed to implement the active treatment program defined by the client’s individual program plan.126
• Each client must receive a continuous active treatment program that is developed by an interdisciplinary team. Each facility must comply with standards related to admissions, transfers, and discharge. The client’s progress must be documented in his or her records.127
• The facility must develop and implement written policies for the management of conduct between staff and clients and the management of inappropriate client behavior. 128
• The facility must meet standards relating to physician services, physician participation in the individual program plan, nursing services, nursing staff, dental services, drug regimens, drug storage and recordkeeping, drug labeling, and laboratory services.129