Long Term Care Facility Requirements: A Comprehensive Guide

This document outlines the essential requirements for long-term care facilities to participate in Medicare and Medicaid programs. It is based on Subpart B of the Code of Federal Regulations (CFR) and serves as a guide for facilities aiming to provide quality care and maintain regulatory compliance.

I. General Provisions

1. Basis and Scope (§ 483.1)

This section establishes the legal foundation and application of the regulations for long-term care facilities.

• Statutory Basis: Outlines the sections of the Social Security Act that mandate requirements for Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs) participating in Medicare and Medicaid. This includes sections related to:
  • Specific requirements for Medicare SNFs.
  • The Secretary’s authority to impose additional health and safety requirements.
  • Mandated transfer agreements with hospitals.
  • Specific requirements for Medicaid NFs.
  • Operation of compliance and ethics programs in SNFs/NFs.
  • Establishment of Quality Assurance and Performance Improvement (QAPI) programs.
  • Reporting crimes in federally funded LTC facilities.
• Scope: Defines that these regulations are the criteria institutions must meet to qualify as Medicare SNFs and Medicaid NFs. They form the basis for surveys to assess compliance for program participation.

2. Definitions (§ 483.5)

This section provides crucial definitions for terms used throughout the regulations to ensure clarity and consistent interpretation. Key definitions include:

• Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment causing physical harm, pain, or mental anguish. It also encompasses the deprivation of essential goods or services. Includes verbal, sexual, physical, and mental abuse, including technology-enabled abuse.
• Adverse event: An unexpected event that causes death, serious injury, or risk thereof.
• Common area: Facility areas where residents gather, such as living rooms, dining rooms, activity rooms, and outdoor spaces.
• Composite distinct part: A distinct part of a facility comprising non-contiguous components not on the same campus, treated as a single entity with one provider agreement.
• Distinct part: A physically separate and distinguishable SNF or NF within a larger institution, meeting specific ownership, operational, and financial integration criteria.
• Exploitation: Taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion.
• Facility: A SNF or NF meeting specific sections of the Social Security Act requirements, potentially a distinct part of a larger institution, but excluding institutions for individuals with intellectual disabilities.
• Fully sprinklered: A long-term care facility with sprinkler systems in all areas, adhering to NFPA 13 standards without waivers.
• Hours per resident day: A metric for staffing levels, calculated as total staff hours divided by the total number of residents.
• Licensed health professional: A defined list of healthcare professionals including physicians, nurses, therapists, social workers, and respiratory therapists.
• Major modification: Significant alteration of over 50% or 4,500 sq ft of a smoke compartment.
• Misappropriation of resident property: Deliberate misplacement, exploitation, or unauthorized use of a resident’s belongings.
• Mistreatment: Inappropriate treatment or exploitation of a resident.
• Neglect: Failure to provide necessary goods or services to a resident, leading to harm, pain, anguish, or distress.
• Nurse aide: Individuals providing nursing-related services in a facility, excluding licensed professionals, dietitians, or unpaid volunteers, but including paid feeding assistants.
• Person-centered care: Care focused on resident control, supporting their choices and autonomy in daily life.
• Representative of direct care employees: An employee or third party authorized to represent direct care staff expertise in facility assessments.
• Resident representative: Individuals authorized to act on a resident’s behalf, including legal representatives, agents under power of attorney, and court-appointed guardians.
• Sexual abuse: Non-consensual sexual contact of any type with a resident.
• Transfer and discharge: Movement of a resident to a bed outside the certified facility, not within the same certified facility.

II. Resident Rights and Facility Responsibilities

1. Resident Rights (§ 483.10)

This section comprehensively details the rights of residents in long-term care facilities, ensuring dignity, self-determination, and access to services.

• Residents Rights: Every resident has the right to a dignified existence, self-determination, communication, and access to services. Facilities must treat residents with respect and promote their quality of life, regardless of diagnosis, condition severity, or payment source.
• Exercise of Rights: Residents can exercise their rights free from facility interference, coercion, or reprisal. They can designate a representative (legal surrogate) to exercise rights on their behalf, except when legally deemed incompetent. Facilities must respect representative decisions and report concerns about representatives acting against resident interests as per state law.
• Planning and Implementing Care: Residents have the right to be informed and participate in their treatment, including:
  • Full information about their health status.
  • Participation in person-centered care plan development, goal setting, and service decisions.
  • Advance notice of care plan changes.
  • Access to services outlined in the care plan.
  • Review and signing of the care plan after significant changes.
  • Facilities must support resident participation in care planning, assessing strengths and needs, and incorporating personal and cultural preferences.
• Choice of Attending Physician: Residents have the right to choose their physician, provided the physician is licensed and meets facility requirements. Facilities can seek alternate physician participation if the resident’s choice is unable or unwilling to meet requirements, while still honoring resident preferences among options.
• Respect and Dignity: Residents are entitled to be treated with respect and dignity, including:
  • Freedom from physical or chemical restraints for discipline or convenience.
  • Retention and use of personal possessions as space allows.
  • Reasonable accommodation of needs and preferences, unless it endangers safety.
  • Room sharing with a spouse or roommate of choice, with consent.
  • Written notice before room or roommate changes and the right to refuse transfers under specific conditions.
• Self-determination: Facilities must promote resident self-determination by supporting resident choice in:
  • Activities, schedules, healthcare, and providers.
  • Significant life aspects within the facility.
  • Community interaction and activities.
  • Visitation rights, including immediate access for specified individuals and reasonable access for others, subject to resident consent and safety restrictions.
  • Organizing and participating in resident and family groups, with facility support.
  • Choosing to perform services for the facility, with documented need or desire in the care plan, and fair compensation if paid.
  • Managing personal finances, with facility acting as fiduciary if funds are deposited, and providing accounting and safeguarding funds as specified.
• Information and Communication: Residents have the right to be informed and communicate effectively, including:
  • Access to rights information and facility rules.
  • Access to personal and medical records within 24 hours and copies within 2 working days, with reasonable fees.
  • Information provided in accessible formats and languages.
  • Oral and written notices of rights, Medicaid eligibility, contact information for advocacy groups, and complaint filing procedures.
  • Posting of relevant agency and advocacy group information, and complaint procedures.
  • Reasonable access to telephones, internet, and mail, with privacy for communications.
  • Examination of facility survey results and plans of correction.
  • Advance directive information and facility policies.
  • Information on Medicare and Medicaid benefits and refunds.
  • Notification of changes in condition, treatment, transfer/discharge, room/roommate, or resident rights.
• Privacy and Confidentiality: Residents have rights to personal privacy and confidentiality of records, including:
  • Privacy in accommodations, treatment, communications, personal care, and group meetings.
  • Secure and confidential medical records, with refusal rights for release except as legally required.
• Safe Environment: Residents have the right to a safe, clean, comfortable, and homelike environment, including:
  • Safe care and services, a safe physical layout maximizing independence.
  • Housekeeping and maintenance.
  • Clean linens.
  • Private closet space.
  • Adequate lighting and comfortable temperature and sound levels.
• Grievances: Residents have the right to voice grievances without reprisal, with prompt facility efforts to resolve them. Facilities must have a grievance policy including:
  • Notification of grievance rights, contact information for grievance officials and external entities, and expected timeframes.
  • Designation of a Grievance Official to oversee the process, investigate, maintain confidentiality, and issue written decisions.
  • Immediate action to prevent rights violations during investigations.
  • Reporting of abuse, neglect, and misappropriation allegations.
  • Written grievance decisions with specific content and corrective actions.
  • Evidence maintenance of grievance results for at least 3 years.
• Contact with External Entities: Facilities must not discourage resident communication with federal, state, or local officials.

2. Freedom from Abuse, Neglect, and Exploitation (§ 483.12)

This section emphasizes the right to a safe environment free from mistreatment.

• Residents have the right to be free from abuse, neglect, misappropriation, and exploitation, including corporal punishment, involuntary seclusion, and unauthorized restraints.
• Facility Responsibilities: Facilities must:
  • Prohibit verbal, mental, sexual, or physical abuse, corporal punishment, and involuntary seclusion.
  • Ensure freedom from restraints for discipline or convenience, using the least restrictive methods when medically necessary and documenting re-evaluations.
  • Not employ individuals with records of abuse, neglect, exploitation, or mistreatment.
  • Report employee actions indicating unfitness to state authorities.
• Policies and Procedures: Facilities must develop and implement written policies and procedures to:
  • Prohibit and prevent abuse, neglect, and exploitation.
  • Investigate allegations.
  • Provide required training.
  • Coordinate with QAPI programs.
  • Report crimes as required by law, including annual notifications, conspicuous notices of employee rights, and prohibiting retaliation.
• Response to Allegations: Facilities must:
  • Immediately report alleged violations to the administrator and state authorities (within 2 hours if abuse or serious injury, 24 hours otherwise).
  • Thoroughly investigate all allegations.
  • Prevent further potential mistreatment during investigations.
  • Report investigation results to administrators and state agencies within 5 working days, taking corrective action if violations are verified.

3. Admission, Transfer, and Discharge Rights (§ 483.15)

This section outlines regulations concerning resident admission, transfer, and discharge, ensuring fair and transparent processes.

• Admissions Policy: Facilities must establish and implement a clear admissions policy that:
  • Does not request waivers of resident rights or assurances against applying for Medicare or Medicaid.
  • Does not request waivers of liability for personal property loss.
  • Prohibits third-party guarantees of payment as admission conditions, but allows contracts with representatives managing resident funds.
  • For Medicaid-eligible residents, prohibits extra charges as preconditions for admission, but allows charges for resident-requested non-covered services with proper notice, and allows charitable contributions not tied to admission.
  • Requires disclosure of special characteristics or service limitations before admission.
  • For composite distinct parts, requires disclosure of physical configuration and room change policies.
• Equal Access to Quality Care: Facilities must maintain identical policies for transfer, discharge, and service provision regardless of payment source, and may charge non-Medicaid residents any amount not limited by state law, with proper notice of charges.
• Transfer and Discharge:
  • Facility Requirements: Residents can remain unless transfer or discharge is necessary for:
    • Resident welfare and unmet needs.
    • Improved health negating facility service needs.
    • Safety endangerment to individuals in the facility due to resident clinical or behavioral status.
    • Health endangerment to individuals in the facility.
    • Non-payment after reasonable notice.
    • Facility closure.
  • Transfers/discharges are prohibited while appeals are pending unless remaining endangers health or safety, which must be documented.
  • Documentation: Transfers/discharges must be documented in medical records, including reasons and information communicated to receiving providers. Physician documentation is required for welfare, health improvement, or safety/health endangerment reasons. Information to receiving providers must include practitioner contacts, representative info, advance directives, care instructions, care plan goals, and discharge summaries.
  • Notice Before Transfer: Facilities must provide written notice of transfer/discharge to residents and representatives, including reasons, effective date, location, appeal rights, and ombudsman/advocacy contacts, at least 30 days prior, except in emergencies.
  • Contents of Notice: Written notice must include reason, effective date, location, appeal rights, ombudsman/advocacy contacts, and protection/advocacy agency information.
  • Changes to Notice: Updated information must be provided if notice details change.
  • Orientation for Transfer/Discharge: Facilities must provide sufficient preparation and orientation for safe and orderly transitions.
  • Notice in Advance of Facility Closure: Administrators must provide written closure notification 60 days prior to state agencies, ombudsmen, residents, and representatives, including transfer/relocation plans.
  • Room Changes in a Composite Distinct Part: Room changes are limited to within the resident’s building, unless the resident agrees to move to another location within the composite distinct part.
• Notice of Bed-Hold Policy and Return:
  • Notice Before Transfer: Facilities must provide written information on bed-hold policies and return rights before hospital transfers or therapeutic leave.
  • Bed-hold Notice Upon Transfer: Written notice confirming bed-hold duration must be provided at the time of transfer.
  • Permitting Residents to Return to Facility: Facilities must have written policies allowing residents to return after hospitalization or leave, prioritizing previous rooms or semi-private beds upon availability, if services are still needed and Medicare/Medicaid eligibility continues.

III. Resident Care Requirements

1. Resident Assessment (§ 483.20)

This section details the requirements for comprehensive and ongoing assessment of residents’ functional capabilities and needs.

• Facilities must conduct initial and periodic comprehensive, accurate, standardized assessments of each resident’s functional capacity using a Resident Assessment Instrument (RAI) specified by CMS.
• Admission Orders: Physician orders for immediate care are required upon admission.
• Comprehensive Assessments:
  • Resident assessment instrument: Must use CMS-specified RAI, including areas like:
    • Identification and demographics.
    • Customary routine.
    • Cognitive, communication, vision, mood, and behavior patterns.
    • Psychosocial well-being, physical functioning, continence, diagnoses, dental and nutritional status, skin condition, activity pursuits, medications, special treatments, discharge planning.
  • When required:
    • Within 14 days of admission (excluding readmissions without significant change).
    • Within 14 days of significant change in condition.
    • At least annually.
• Quarterly Review Assessment: Facilities must use a state-approved quarterly review instrument at least every 3 months.
• Use: Assessments must be maintained for 15 months and used for care plan development and revision.
• Coordination: Assessments must be coordinated with PASARR to avoid duplication and incorporate PASARR recommendations.
• Automated data processing requirement: Facilities must encode and transmit MDS data electronically to CMS within specified timeframes (7-14 days).
• Accuracy of assessments: Assessments must accurately reflect resident status.
• Coordination: Registered nurses must conduct or coordinate assessments with health professionals.
• Certification: Assessments must be signed and certified by registered nurses and contributing individuals.
• Penalty for falsification: Willful falsification of assessments can result in civil money penalties.
• Preadmission screening for individuals with a mental disorder and individuals with intellectual disability:
  • Prohibits admission of new residents with mental disorders or intellectual disabilities (as defined) without prior state authority determination of need for nursing facility level of care and specialized services.
  • Exceptions for hospital transfers and short-term stays (less than 30 days).
  • Requires notification to state authorities upon significant change in condition for residents with mental disorders or intellectual disabilities.

2. Comprehensive Person-Centered Care Planning (§ 483.21)

This section focuses on developing and implementing individualized care plans that are person-centered and address resident needs.

• Baseline care plans:
  • Facilities must develop a baseline care plan within 48 hours of admission, including minimum healthcare information for effective, person-centered care.
  • Can be replaced by a comprehensive care plan if developed within 48 hours and meets comprehensive plan requirements (except timeframe).
  • Summary of baseline plan must be provided to resident/representative, including initial goals, medications, dietary instructions, services, and updated information from the comprehensive plan.
• Comprehensive care plans:
  • Must be person-centered, consistent with resident rights, including measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs identified in assessments.
  • Must describe services for highest practicable well-being and any refused services due to resident rights.
  • Must include specialized services from PASARR, and resident goals, discharge preferences, and plans.
  • A comprehensive care plan must be:
    • Developed within 7 days of assessment completion.
    • Prepared by an interdisciplinary team including physician, RN, nurse aide, food and nutrition staff, resident/representative (if practicable), and other professionals as needed.
    • Reviewed and revised after each assessment.
  • Services provided must:
    • Meet professional quality standards.
    • Be provided by qualified persons according to the care plan.
    • Be culturally competent and trauma-informed.
• Discharge planning:
  • Discharge planning process: Facilities must have an effective discharge planning process focused on resident goals, active partnerships, transition preparation, and readmission reduction, consistent with discharge rights.
    • Must identify discharge needs, develop plans, re-evaluate and modify plans as needed, involve interdisciplinary teams, consider caregiver availability and capability, involve residents/representatives, address care goals and preferences, document community return interest and referrals.
    • Assist residents in selecting post-acute care providers using standardized assessment data, quality measures, and resource use data.
    • Document discharge needs, plans, and evaluations in clinical records, discussed with residents/representatives.
  • Discharge summary: Must include:
    • Recapitulation of stay (diagnoses, treatment, results).
    • Final status summary (items in § 483.20(b)(1)).
    • Medication reconciliation.
    • Post-discharge plan of care with resident/representative participation, including living arrangements, follow-up care, and post-discharge services.

3. Quality of Life (§ 483.24)

This section establishes the principle of quality of life as fundamental to all care and services.

• Facilities must provide necessary care and services to attain or maintain each resident’s highest practicable physical, mental, and psychosocial well-being, based on their assessment and care plan.
• Activities of daily living (ADLs): Facilities must ensure residents’ ADL abilities do not diminish unless clinically unavoidable, including:
  • Appropriate treatment and services to maintain or improve ADL abilities.
  • Necessary services for residents unable to perform ADLs, including nutrition, grooming, and hygiene.
  • Basic life support (CPR) prior to emergency personnel arrival.
• Activities of daily living (ADLs) covered include:
  • Hygiene (bathing, dressing, grooming, oral care).
  • Mobility (transfer, ambulation, walking).
  • Elimination (toileting).
  • Dining (eating, meals, snacks).
  • Communication (speech, language, functional systems).
• Activities:
  • Facilities must provide ongoing programs supporting resident choice of activities (group, individual, independent), designed to meet interests and support well-being, encouraging independence and community interaction.
  • Activities programs must be directed by a qualified professional, such as a therapeutic recreation specialist or activities professional meeting specific licensure, certification, experience, or training requirements.

4. Quality of Care (§ 483.25)

This section defines quality of care as a fundamental principle for all treatment and care provided.

• Facilities must ensure residents receive treatment and care according to professional standards, person-centered care plans, and resident choices.
• Vision and hearing: Facilities must assist residents in obtaining proper treatment and assistive devices for vision and hearing, including appointment scheduling and transportation.
• Skin integrity:
  • Pressure ulcers: Facilities must ensure care to prevent pressure ulcers unless clinically unavoidable, and provide necessary treatment for existing ulcers to promote healing and prevent new ones.
  • Foot care: Facilities must provide foot care and treatment to maintain mobility and foot health, and assist with appointments with qualified professionals when needed.
• Mobility: Facilities must ensure residents without limited motion upon entry do not experience motion reduction unless clinically unavoidable, and provide treatment to increase or maintain motion. Residents with limited mobility must receive services, equipment, and assistance to maximize independence.
• Accidents: Facilities must ensure environments remain as hazard-free as possible and provide supervision and assistive devices to prevent accidents.
• Incontinence:
  • Facilities must maintain continence for residents continent upon admission unless clinically impossible.
  • For urinary incontinence: limit catheterization to clinically necessary conditions, assess for catheter removal, and provide treatment to prevent UTIs and restore continence.
  • For fecal incontinence: provide treatment to restore normal bowel function as much as possible.
• Colostomy, urostomy, or ileostomy care: Facilities must provide care consistent with professional standards and resident care plans.
• Assisted nutrition and hydration: Facilities must ensure residents maintain acceptable nutritional status and hydration, are offered therapeutic diets when needed, and enteral feeding is only used when clinically indicated and consented to. Residents enterally fed must receive services to restore oral skills and prevent complications.
• Parenteral fluids: Must be administered per professional standards, physician orders, and care plans.
• Respiratory care: Facilities must provide respiratory care, including tracheostomy and suctioning, per professional standards, care plans, and regulations.
• Prostheses: Facilities must assist residents in using and wearing prostheses per professional standards and care plans.
• Pain management: Facilities must ensure pain management services are provided per professional standards and care plans.
• Dialysis: Facilities must ensure dialysis services are provided per professional standards and care plans.
• Trauma-informed care: Facilities must provide culturally competent, trauma-informed care, accounting for resident experiences to mitigate re-traumatization triggers.
• Bed rails: Facilities must attempt alternatives before bed rails, assess entrapment risk before installation, review risks/benefits with residents, ensure bed compatibility, and follow manufacturer guidelines for installation and maintenance.

5. Physician Services (§ 483.30)

This section outlines requirements for physician involvement in resident care.

• Physicians must personally approve admissions in writing and residents must remain under physician care. Physician, PA, NP, or CNS orders are needed for immediate care and needs.
• Physician supervision: Medical care must be supervised by a physician, with another physician available when the attending physician is unavailable.
• Physician visits: Physicians must:
  • Review care programs, medications, and treatments at each visit.
  • Write, sign, and date progress notes.
  • Sign and date all orders (except flu/pneumococcal vaccines under policy).
• Frequency of physician visits:
  • Visits required every 30 days for the first 90 days post-admission, then every 60 days.
  • Visits are timely if within 10 days of the required date.
  • Personal physician visits are generally required, but after the initial visit, visits can alternate with PA, NP, or CNS visits in SNFs.
• Availability of physicians for emergency care: Facilities must provide or arrange for 24/7 physician services for emergencies.
• Physician delegation of tasks in SNFs: Physicians can delegate tasks to PAs, NPs, or CNSs under their supervision and within state scope of practice (except when regulations mandate physician-only tasks or delegation is prohibited by state law/facility policy). Dietary and therapy order writing can be delegated to qualified professionals.
• Performance of physician tasks in NFs: States may allow NPs, CNSs, or PAs (not facility employees, but collaborating with a physician) to perform any required physician task in NFs.

6. Nursing Services (§ 483.35)

This section details requirements for nursing staff and services in long-term care facilities.

• Facilities must have sufficient nursing staff with appropriate competencies to ensure resident safety and well-being, considering resident assessments, care plans, and facility resident population characteristics.
• Sufficient staff:
  • Facilities must provide 24/7 services by sufficient licensed nurses and other nursing personnel (nurse aides).
  • Except when waived, a licensed nurse must be designated as charge nurse per shift.
  • Licensed nurses must have competencies for resident needs.
  • Providing care includes assessment, planning, implementation, and response to needs.
• Total nurse staffing: Facilities must meet or exceed minimum staffing hours per resident day:
  • Minimum 3.48 hours total nurse staffing, including 0.55 RN hours and 2.45 nurse aide hours.
  • Exemptions possible for non-compliant facilities meeting eligibility criteria.
  • Minimum staffing hours are not approval for facilities to staff only to these minimums; sufficient staff with appropriate skills for resident needs is mandatory.
• Registered nurse (RN):
  • Except when waived/exempted, facilities must have an RN onsite 24/7 for direct resident care.
  • During RN onsite requirement exemptions, facilities must have RN, NP, PA, or physician available for immediate telephone response.
  • Except when waived, facilities must have a full-time RN director of nursing (DON).
  • DON can be charge nurse only if facility occupancy is 60 or fewer residents.
• Proficiency of nurse aides: Facilities must ensure nurse aides demonstrate competency in skills to meet resident needs.
• Requirements for facility hiring and use of nursing aides:
  • Facilities cannot use individuals as nurse aides for over 4 months full-time unless they are competent and have completed required training/evaluation programs or are deemed competent.
  • Temporary/agency nurse aides must meet the same requirements.
  • New nurse aides (less than 4 months’ experience) must be in training programs or have demonstrated competence.
  • Registry verification of competency is required before allowing individuals to serve as nurse aides.
  • Multi-state registry verification is required.
  • Retraining is needed if there is a 24-month gap in compensated nursing-related services.
  • Annual performance reviews and regular in-service education are required.
• Nursing facilities: Waiver of requirement to provide licensed nurses and a registered nurse on a 24-hour basis: States may waive licensed nurse/24-hour RN requirements if facilities demonstrate recruitment difficulties despite diligent efforts and prevailing wages, and waivers will not endanger resident health/safety. Waivers are subject to annual state review and require RN or physician availability for telephone calls.
• SNFs: Waiver of the requirement to provide services of a registered nurse for at least 112 hours a week: Secretary may waive RN service hour requirements for rural SNFs with RN staffing shortages, one full-time RN, and arrangements for RN/physician services when the regular RN is off-duty. Waivers are subject to annual renewal.
• Hardship exemptions from the minimum hours per resident day and registered nurse onsite 24 hours per day, for 7 days a week requirements: Secretary may grant hardship exemptions from minimum staffing hours and 24/7 RN requirements if verifiable hardship exists due to workforce shortages. Facilities must meet location, good faith hiring efforts, financial commitment, and disclosure criteria, and cannot be Special Focus Facilities or have recent staffing-related deficiencies. Exemptions last until the next standard survey.
• Nurse staffing information: Facilities must post daily nurse staffing information including facility name, date, staffing numbers by category (RN, LPN/LVN, CNA), resident census, and make data publicly available upon request. Data must be retained for 18 months minimum.

7. Behavioral Health Services (§ 483.40)

This section addresses the provision of behavioral health care to residents.

• Facilities must provide necessary behavioral health care and services to attain or maintain residents’ highest practicable well-being, based on assessments and care plans. Behavioral health includes mental and emotional well-being, prevention and treatment of mental and substance use disorders.
• Facilities must have sufficient staff with competencies and skills to provide services to residents with mental and psychosocial disorders, trauma histories, and implement non-pharmacological interventions.
• Based on assessments, facilities must ensure:
  • Residents with mental disorders, psychosocial difficulties, or trauma histories receive appropriate treatment.
  • Residents without these diagnoses do not exhibit decreased social interaction or increased withdrawn/depressive behaviors unless clinically unavoidable.
  • Residents with dementia receive appropriate treatment to maintain their well-being.
• If rehabilitative services for mental disorders or intellectual disabilities are required in the care plan, facilities must provide or obtain them from outside resources.
• Facilities must provide medically-related social services to maintain residents’ highest practicable well-being.

8. Pharmacy Services (§ 483.45)

This section outlines requirements for pharmaceutical services in long-term care facilities.

• Facilities must provide routine and emergency drugs and biologicals to residents, or obtain them through agreements. Unlicensed staff may administer drugs if state law permits, under licensed nurse supervision.
• Procedures: Facilities must provide pharmaceutical services ensuring accurate acquisition, dispensing, and administration of drugs.
• Service consultation: Facilities must employ or obtain services of a licensed pharmacist for consultation on pharmacy services, controlled drug record systems, and drug record reviews.
• Drug regimen review:
  • Licensed pharmacists must review each resident’s drug regimen monthly, including medical chart review.
  • Review must include psychotropic drugs (antipsychotics, antidepressants, anti-anxiety, hypnotics).
  • Pharmacists must report irregularities (including unnecessary drug criteria) to physicians, medical director, and DON.
  • Physicians must document review and action taken, or rationale for no change.
  • Facilities must have policies for monthly drug regimen reviews, including timeframes and urgent action protocols.
• Unnecessary drugs—General: Each resident’s drug regimen must be free from unnecessary drugs, defined as use in excessive dose, duration, without monitoring or indications, with adverse consequences, or combinations thereof.
• Psychotropic drugs: Facilities must ensure:
  • Residents not using psychotropic drugs are not given them unless necessary for a diagnosed condition.
  • Residents using psychotropic drugs receive gradual dose reductions and behavioral interventions to discontinue use, unless contraindicated.
  • PRN psychotropic drug orders are only for diagnosed conditions, limited to 14 days (renewable with physician rationale, except antipsychotics).
  • PRN antipsychotic orders are limited to 14 days and non-renewable without physician re-evaluation.
• Medication errors: Facilities must ensure medication error rates are below 5% and residents are free of significant errors.
• Labeling of drugs and biologicals: Must be labeled professionally with instructions and expiration dates.
• Storage of drugs and biologicals: Must be stored in locked compartments under proper temperature control, accessible only to authorized personnel. Schedule II controlled drugs must be stored in separately locked, permanently affixed compartments, unless using single-unit dose systems.

9. Laboratory, Radiology, and Other Diagnostic Services (§ 483.50)

This section details requirements for providing diagnostic services to residents.

• Facilities must provide or obtain laboratory services to meet resident needs, ensuring quality and timeliness.
• Laboratory services:
  • On-site lab services must meet Part 493 requirements.
  • Referral labs must be certified in relevant specialties.
  • Facilities must have agreements with certified labs if on-site services aren’t provided.
  • Lab services must be ordered by physicians, PAs, NPs, or CNSs.
  • Facilities must promptly notify ordering practitioners of out-of-range results, assist with transportation, and file dated lab reports in resident records.
• Radiology and other diagnostic services:
  • Facilities must provide or obtain radiology and diagnostic services, ensuring quality and timeliness.
  • On-site diagnostic services must meet hospital conditions of participation (§ 482.26).
  • Facilities must have agreements with Medicare-approved providers if on-site services aren’t provided.
  • Diagnostic services must be ordered by physicians, PAs, NPs, or CNSs.
  • Facilities must promptly notify ordering practitioners of out-of-range results, assist with transportation, and file signed, dated reports in resident records.

10. Dental Services (§ 483.55)

This section addresses the provision of dental care to residents.

• Facilities must assist residents in obtaining routine and 24-hour emergency dental care.
• Skilled nursing facilities:
  • Must provide or obtain routine and emergency dental services.
  • May charge Medicare residents for dental services.
  • Must have a policy on facility responsibility for denture loss/damage.
  • Must assist residents with appointments and transportation.
  • Must refer residents with lost/damaged dentures within 3 days (or document reasons for delay and interim measures).
• Nursing facilities:
  • Must provide or obtain routine (to the extent covered by state plans) and emergency dental services.
  • Must assist residents with appointments and transportation.
  • Must refer residents with lost/damaged dentures within 3 days (or document reasons for delay and interim measures).
  • Must have a policy on facility responsibility for denture loss/damage.
  • Must assist eligible residents in applying for dental service reimbursement under state plans.

11. Food and Nutrition Services (§ 483.60)

This section details requirements for providing adequate food and nutrition to residents.

• Facilities must provide nourishing, palatable, balanced diets meeting residents’ nutritional and dietary needs and preferences.
• Staffing: Facilities must employ sufficient staff with appropriate competencies for food and nutrition services, considering resident needs and facility assessment.
  • Requires a qualified dietitian or clinically qualified nutrition professional (full-time, part-time, or consultant) meeting specific degree, practice, licensure, or certification requirements.
  • If no full-time dietitian, a designated food and nutrition services director is required, meeting specific certification, degree, or experience/training criteria, and receiving dietitian consultations.
  • Sufficient support personnel are needed for food and nutrition services.
• Food and Nutrition Services staff member must participate in interdisciplinary care teams.
• Menus and nutritional adequacy: Menus must:
  • Meet nutritional needs per national guidelines.
  • Be prepared in advance and followed.
  • Reflect resident religious, cultural, and ethnic needs and resident input.
  • Be updated periodically and reviewed by dietitians for adequacy.
  • Not limit resident dietary choices.
• Food and drink: Facilities must provide:
  • Food prepared to conserve nutrition, flavor, and appearance.
  • Palatable, attractive food at safe temperatures.
  • Food in forms meeting individual needs.
  • Food accommodating allergies, intolerances, and preferences.
  • Appealing alternatives if residents refuse initial servings.
  • Drinks, including water, adequate for hydration.
• Therapeutic diets: Must be prescribed by physicians (physicians can delegate diet prescription to registered dietitians as state law allows).
• Frequency of meals:
  • At least three meals daily at regular community-comparable times or resident-preference times.
  • No more than 14 hours between substantial evening meals and breakfast (16 hours if bedtime snack and resident group agreement).
  • Nourishing alternative meals and snacks provided outside scheduled times.
• Assistive devices: Facilities must provide special eating equipment and assistance for residents needing them.
• Paid feeding assistants: Facilities may use paid feeding assistants if they complete state-approved training and work under RN/LPN supervision, only for residents without complicated feeding problems.
• Food safety requirements: Facilities must:
  • Procure food from approved sources (including local producers and facility gardens, if safe).
  • Store, prepare, serve food according to food safety standards.
  • Have policies for safe handling of food brought by visitors.
  • Properly dispose of garbage and refuse.

12. Specialized Rehabilitative Services (§ 483.65)

This section addresses the provision of specialized rehabilitative services.

• If specialized rehabilitative services (PT, SLP, OT, respiratory therapy, mental health/ID rehab) are required in care plans, facilities must provide or obtain them from outside resources that are Medicare/Medicaid providers and not excluded from federal/state healthcare programs.
• Specialized services must be provided under physician orders by qualified personnel.

IV. Facility Administration and Management

1. Administration (§ 483.70)

This section outlines administrative and management requirements for long-term care facilities.

• Facilities must be administered effectively and efficiently to maintain residents’ highest practicable well-being.
• Licensure: Facilities must be licensed under state and local law.
• Compliance with Federal, State, and local laws and professional standards: Facilities must operate in compliance with all applicable laws, regulations, codes, and professional standards.
• Relationship to other HHS regulations: Facilities must also comply with other HHS regulations, including non-discrimination, research subject protection, fraud and abuse, and health information privacy.
• Governing body: Facilities must have a legally responsible governing body that establishes management and operation policies, appoints a licensed administrator who reports to them, and is accountable for the QAPI program.
• Staff qualifications: Facilities must employ necessary professionals (full-time, part-time, consultant) who are licensed/certified as per state law.
• Use of outside resources: If facilities don’t employ qualified professionals for specific services, they must obtain services from outside agencies under written agreements ensuring professional standards and timely services.
• Medical director: Facilities must designate a medical director responsible for care policies and medical care coordination.
• Medical records:
  • Must maintain complete, accurate, accessible, and organized medical records for each resident, kept confidential except for authorized releases (to resident, legal requirements, treatment/payment/operations, public health, etc.).
  • Must safeguard records against loss, destruction, or unauthorized use, and retain records for state-required periods or 5 years post-discharge (3 years after minor reaches legal age).
  • Medical records must contain identification, assessments, care plans, PASARR evaluations, physician/nurse notes, and diagnostic reports.
• Transfer agreement: Facilities (except those on Indian reservations) must have written transfer agreements with hospitals ensuring timely resident transfers when medically appropriate and exchange of necessary medical information. Good faith efforts to establish agreements are sufficient.
• Disclosure of ownership: Facilities must comply with disclosure requirements of §§ 420.206 and 455.104 and notify state licensing agencies of changes in ownership, officers, management, or administrators/DONs.
• Facility closure-Administrator: Administrators must provide written closure notification 60 days prior to state agencies, ombudsmen, residents, and representatives, and ensure no new admissions after notification, including a state-approved transfer plan.
• Facility closure: Facilities must have policies ensuring administrator duties for closure notifications are fulfilled.
• Binding arbitration agreements: If facilities use binding arbitration agreements, they must not be mandatory for admission/continued care, must be explained clearly, understood and acknowledged by resident/representative, allow rescission within 30 days, and not restrict communication with officials. Arbitration agreements and decisions must be retained for 5 years.
• Hospice services:
  • LTC facilities may arrange hospice services through agreements with Medicare-certified hospices or assist residents in transferring to facilities that do.
  • Hospice agreements must be written and detail services, responsibilities, communication processes, notification procedures, and hospice responsibilities (medical direction, nursing, counseling, supplies, etc.) and LTC facility responsibilities (room/board, personal/nursing care).
  • LTC facilities must designate an interdisciplinary team member to coordinate hospice care, collaborate with hospice representatives, communicate with hospice/physician teams, and obtain hospice care information. Resident care plans must include both hospice plans and LTC facility services.
• Social worker: Facilities with over 120 beds must employ a full-time qualified social worker with a bachelor’s degree in social work or related field and one year of supervised healthcare social work experience.
• Mandatory submission of staffing information based on payroll data in a uniform format: Facilities must electronically submit direct care staffing information to CMS based on payroll data, including staff category, census, turnover/tenure, and hours per resident day, differentiating employees from agency/contract staff, in a CMS-specified format, no less than quarterly.

2. Facility Assessment (§ 483.71)

This section mandates facility-wide assessments to determine necessary resources for competent resident care.

• Facilities must conduct and document facility-wide assessments annually and when changes occur that substantially modify the assessment. Assessments must address:
  • Resident population: Number and capacity, care needs (diseases, conditions, acuity), staff competencies, physical environment needs, and cultural/religious factors.
  • Facility resources: Buildings, equipment, services (therapy, pharmacy, behavioral health), personnel (staff, contractors, volunteers), contracts, and health IT.
  • Risk assessment: Facility-based and community-based all-hazards risk assessment.
• Conducting the facility assessment: Facilities must ensure active involvement of leadership/management (governing body, medical director, administrator, DON), direct care staff (RNs, LPNs/LVNs, NAs, representatives), and consider input from residents, representatives, and families.
• Use of facility assessment: Facilities must use assessments to:
  • Inform staffing decisions to ensure sufficient staff with appropriate competencies.
  • Consider unit-specific and shift-specific staffing needs.
  • Develop recruitment and retention plans for direct care staff.
  • Inform contingency planning for events impacting resident care.

3. Emergency Preparedness (§ 483.73)

This section outlines comprehensive emergency preparedness program requirements.

• Facilities must comply with federal, state, and local emergency preparedness requirements and maintain an emergency preparedness program including:
  • Emergency plan: Annually reviewed and updated, based on facility and community-based all-hazards risk assessment (including missing residents), strategies for identified events, resident population considerations, continuity of operations, and collaboration with emergency officials.
  • Policies and procedures: Annually reviewed and updated, based on the emergency plan and risk assessment, addressing:
    • Subsistence needs (food, water, supplies, alternate energy for temperature, lighting, alarms, waste disposal).
    • Staff and resident tracking.
    • Safe evacuation (care needs, staff roles, transport, locations, communication).
    • Shelter-in-place plans.
    • Medical record preservation and confidentiality.
    • Volunteer use and emergency staffing.
    • Arrangements with other facilities for resident reception.
    • Facility roles under Secretary-declared waivers at alternate care sites.
  • Communication plan: Annually reviewed and updated, complying with laws, including contact information for staff, service entities, physicians, other facilities, volunteers, emergency agencies, licensing/ombudsman, communication methods, information sharing for continuity of care, evacuation information release, and facility status reporting.
  • Training and testing: Annually reviewed and updated program based on plan, risk assessment, policies, and communication plan, including:
    • Initial and annual training on emergency procedures for staff, contractors, and volunteers, documented and demonstrating staff knowledge.
    • Biannual testing: annual full-scale community-based exercise (or facility-based functional exercise if community exercise inaccessible), plus a second annual exercise (full-scale, functional, mock drill, or tabletop). Actual emergencies exempt facilities from the next full-scale exercise. Documentation and analysis of exercises and events are required, with plan revisions as needed.
  • Emergency and standby power systems: Facilities must implement systems per emergency plans, with generators located, inspected, tested, maintained, and fueled according to NFPA standards.
  • Integrated healthcare systems: Facilities in multi-facility systems may participate in unified emergency programs if each facility actively participates in development, programs address unique facility circumstances, and each facility can use and comply with the unified program. Unified programs must include unified emergency plans based on community and individual facility risk assessments, integrated policies, communication plans, and training/testing programs.

4. Quality Assurance and Performance Improvement (§ 483.75)

This section mandates comprehensive QAPI programs to improve care and quality of life.

• Facilities must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program focusing on care outcomes and quality of life, documenting ongoing program evidence and presenting plans to state agencies annually and to CMS upon request.
• Program design and scope: QAPI programs must be ongoing, comprehensive, address all care systems and management practices, include clinical care, quality of life, and resident choice, use best evidence for quality indicators, and reflect facility complexities.
• Program feedback, data systems and monitoring: Facilities must have written policies for feedback, data collection, and monitoring, including adverse event monitoring, using staff/resident feedback, data from all departments (including facility assessments), developing and monitoring performance indicators, and systematically monitoring adverse events.
• Program systematic analysis and systemic action: Facilities must take performance improvement actions, measure success, and track performance to sustain improvements, developing policies for systematic cause analysis, corrective actions at system levels, and monitoring effectiveness.
• Program activities: Facilities must prioritize performance improvement activities in high-risk, high-volume, or problem-prone areas, tracking medical errors and adverse events, implementing preventive actions with facility-wide feedback, and conducting annual improvement projects focused on high-risk areas.
• Governance and leadership: Governing bodies/executive leadership are responsible for QAPI programs being defined, implemented, maintained, resourced, sustained, prioritizing problems, ensuring corrective actions, and setting clear expectations for safety, quality, rights, choice, and respect.
• Quality assessment and assurance: Facilities must maintain a QA committee including DON, medical director, administrator/leader, and infection preventionist, reporting to the governing body, meeting quarterly to coordinate QAPI activities, develop action plans, and review/analyze data for improvement.
• Disclosure of information: Committee records are protected from disclosure except for compliance verification.
• Sanctions: Good faith QAPI efforts are not basis for sanctions.

5. Infection Control (§ 483.80)

This section mandates infection prevention and control programs in long-term care facilities.

• Facilities must establish and maintain an Infection Prevention and Control Program (IPCP) to provide a safe, sanitary environment and prevent communicable disease transmission.
• Infection prevention and control program: IPCPs must include:
  • Systems for preventing, identifying, reporting, investigating, and controlling infections for residents, staff, and visitors, based on facility assessments and national standards.
  • Written standards, policies, and procedures for:
    • Surveillance systems for communicable diseases.
    • Reporting procedures for infections.
    • Standard and transmission-based precautions.
    • Isolation protocols (type, duration, least restrictive methods).
    • Employee restrictions with communicable diseases/lesions.
    • Hand hygiene procedures.
  • Antibiotic stewardship programs with use protocols and monitoring systems.
  • Systems for recording incidents and corrective actions.
• Infection preventionist: Facilities must designate one or more IPs responsible for the IPCP, who must have relevant training/experience in nursing, medical technology, microbiology, epidemiology, or related fields, be qualified by education/training/certification, work part-time at the facility, and have specialized IPC training.
• IP participation on quality assessment and assurance committee: At least one IP must be a QA committee member and regularly report on the IPCP.
• Influenza, pneumococcal, and COVID-19 immunizations: Facilities must have policies to ensure:
  • Residents/representatives receive education on vaccine benefits and side effects before immunization offers.
  • Annual influenza immunization offers (October 1-March 31) unless contraindicated or already immunized.
  • Pneumococcal immunization offers unless contraindicated or already immunized.
  • COVID-19 vaccine offers to residents and staff when available, with education on benefits and risks, and information updates for multi-dose regimens.
  • Resident/representative and staff opportunity to accept or refuse immunizations.
  • Medical record documentation of education, immunization status, or reasons for non-immunization for residents.
  • Staff vaccination documentation including education, vaccine offer, and vaccination status.
• Linens: Personnel must handle, store, process, and transport linens to prevent infection spread.
• Annual review: Facilities must annually review and update their IPCP.
• Respiratory illness reporting: Facilities must electronically report information on acute respiratory illnesses, including influenza, COVID-19, and RSV, in a standardized format specified by the Secretary, including facility census, resident vaccination status, confirmed cases, and hospitalizations. During PHEs, reporting must also include staff infections, supply/staffing shortages, and medical countermeasure/therapeutic inventories.

6. Compliance and Ethics Program (§ 483.85)

This section mandates compliance and ethics programs for long-term care facilities.

• Operating organizations for each facility must have a compliance and ethics program designed, implemented, and enforced to prevent/detect violations and promote quality care.
• Required components for all facilities: Programs must include:
  • Written compliance and ethics standards, policies, and procedures (contact person for reporting, anonymous reporting methods, disciplinary standards).
  • Assignment of high-level personnel to oversee compliance.
  • Sufficient resources and authority for designated personnel.
  • Due care in delegating authority to individuals without propensity for violations.
  • Effective communication of program standards through training/orientation.
  • Reasonable steps to achieve compliance, including monitoring/auditing systems, reporting systems, and data integrity processes.
  • Consistent enforcement through disciplinary mechanisms.
  • Response and prevention measures after violation detection, including program modification.
• Additional required components for operating organizations with five or more facilities: In addition to above, these programs must include:
  • Mandatory annual training program on compliance and ethics.
  • Designated compliance officer reporting directly to the governing body.
  • Designated compliance liaisons at each facility.
• Annual review: Operating organizations must review and revise programs annually to reflect legal/regulatory changes and improve performance.

7. Physical Environment (§ 483.90)

This section details requirements for the physical environment of long-term care facilities.

• Facilities must be designed, constructed, equipped, and maintained to protect resident, personnel, and public health and safety.
• Life safety from fire: Facilities must meet Life Safety Code (NFPA 101) and Health Care Facilities Code (NFPA 99) provisions, including sprinkler systems, smoke alarms, and emergency power, with waivers possible for unreasonable hardship if safety is not compromised.
• Building safety: Facilities must meet applicable Health Care Facilities Code (NFPA 99) provisions, with waivers possible for unreasonable hardship if safety is not compromised.
• Emergency power: Facilities must have emergency electrical systems for lighting, fire safety systems, and life support, using on-premises emergency generators for life support systems.
• Space and equipment: Facilities must provide sufficient space and equipment for dining, health services, recreation, living, and programs, maintain equipment in safe condition, and regularly inspect beds and bed rails for entrapment risks.
• Resident rooms:
  • Bedrooms must accommodate no more than four residents (two for new/reconstructed/newly certified facilities), measure at least 80 sq ft per resident in multi-bed rooms (100 sq ft single), have direct exit access, visual privacy, windows to the outside, and be at or above grade level.
  • Each resident must have a separate bed, mattress, bedding, functional furniture, and individual closet space.
  • CMS/state agencies may permit room variations for special resident needs without compromising safety.
• Bathroom facilities: Each room must have or be near toilet and bathing facilities (new/reconstructed/newly certified facilities must have in-room bathrooms with commode and sink).
• Resident call system: Facilities must have call systems from bedside and bathrooms to staff.
• Dining and resident activities: Rooms must be well-lit, ventilated, furnished, and spacious.
• Other environmental conditions: Facilities must:
  • Have procedures for water availability during supply loss.
  • Have adequate ventilation (windows or mechanical).
  • Equip corridors with handrails.
  • Maintain effective pest control programs.
  • Establish smoking policies compliant with laws and considering non-smokers.

8. Training Requirements (§ 483.95)

This section outlines mandatory training program requirements for facility staff.

• Facilities must develop, implement, and maintain effective training programs for staff, contractors, and volunteers, based on facility assessments, covering:
  • Communication: Effective communication mandatory for direct care staff.
  • Resident’s rights and facility responsibilities: Education on resident rights and facility obligations (§ 483.10).
  • Abuse, neglect, and exploitation: Training on abuse, neglect, exploitation, misappropriation (§ 483.12), reporting procedures, dementia management, and abuse prevention.
  • Quality assurance and performance improvement: Training on QAPI program elements and goals (§ 483.75).
  • Infection control: Training on IPCP standards, policies, and procedures (§ 483.80(a)(2)).
  • Compliance and ethics: Training on compliance and ethics program standards, policies, and procedures (§ 483.85), with annual training for organizations with 5+ facilities.
  • Required in-service training for nurse aides: At least 12 hours annually, including dementia management, abuse prevention, addressing performance weaknesses and resident needs, and cognitive impairment care.
  • Required training of feeding assistants: State-approved feeding assistant training program completion (§ 483.160).
  • Behavioral health: Behavioral health training consistent with § 483.40 and facility assessments.

This comprehensive guide provides an overview of the requirements for long-term care facilities as outlined in Subpart B of the CFR. Adherence to these regulations is crucial for facilities participating in Medicare and Medicaid, ensuring they provide high-quality, safe, and person-centered care to their residents. Understanding these regulations, particularly concerning aspects like resident assessment and care planning, is essential for accurate Long Term Care Adl Coding and overall compliance.