Elder Law

State Inspections and Licensing of Nursing Homes

Your mother is a resident in a nursing facility and you want the comfort of knowing that the facility is adequately providing for her care and needs. All nursing facilities must meet certain criteria and standards to be licensed and certified under state and federal regulations. And, the facility will be inspected at least once a year to ensure continued compliance with those regulations.

Licensing

Nursing facilities are required to be licensed by the state in order to provide services to residents. In order to receive a license, a facility must meet certain criteria and conditions including compliance with:

  • Minimum standards for medical care, nursing care, and financial condition
  • Safety and security standards
  • Facility construction and building standards
  • Operation standards
  • Additional state and federal standards and regulations

The state survey agency will send a team of experts to inspect the facility and its plans, programs, services and operations to ensure that it meets with licensing criteria and with Medicare and Medicaid certification requirements established by the Centers for Medicare and Medicaid Services (CMS).

Surveys and Inspections

In addition to being licensed, nursing facilities must be surveyed or inspected every 12 to 15 months in order to remain certified to receive Medicare and Medicaid payments and to retain their licenses. Again, a team of exerts from the state survey agency will examine the facility for the following:

  • Substantial compliance with quality of care standards including accuracy in resident assessments and the adequacy of resident care plans
  • Compliance with residents' rights to privacy, security and safety, the right to participate in care and quality of life decisions and the right to report instances of abuse and neglect
  • Staffing plans including staff to resident ratios, staff skills and expertise, written standards of conduct, documentation of criminal background checks and training and development programs
  • The establishment and execution of an adequate accounting system and billing procedures
  • The establishment of a compliance program that includes the designation of a compliance officer and compliance committee, the establishment of internal audit procedures and reporting and correction action procedures

Whenever a substandard quality of care is found, the survey team must complete an extended survey within two weeks after the annual survey revealed the substandard care and must report the finding to each resident's physician and the state agency that licensed the facility's administrator.

A substandard quality of care occurs whenever a facility's failure to comply with certain quality of care requirements causes any of the following:

  • Immediate jeopardy to resident health or safety
  • A pattern of actual harm or widespread actual harm, or
  • The widespread potential for more than minimal harm, but no actual harm

Further, any violation of federal law must be reported as deficiency to the CMS. Examples of deficiencies include:

  • Failure to monitor or provide adequate care and treatment to residents
  • Failure to provide sufficient trained staff
  • Failure to report instances of abuse and neglect of residents
  • Submission of inaccurate or unauthorized billing statements or claims

When deficiencies and substandard care are reported in the surveys, the facility must submit a detailed correction plan stating how and when each finding will be corrected. The continuation of substandard care and deficiencies may result in money penalties, the transfer of residents, the termination of the facility's participation in the Medicare or Medicaid programs or the loss of its license.

Complaint Investigations

State agencies are also responsible for investigating complaints that involve the safety of residents including claims of abuse or neglect. Most state laws protect residents and facility employees from retaliation for making complaints to a state agency or a supervisor.

A resident or individual wanting to report an instance of resident abuse, neglect or exploitation may call the state long term care ombudsman or the state survey agency.

Questions for Your Attorney

  • What kinds of criteria do nursing facilities have to meet to be licensed by the state?
  • Are licensing requirements different from inspection requirements?
  • What happens if a survey team finds substandard care in a nursing facility?
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