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Revised Federal Nursing Home Regulations

Final Regulations


On October 4, 2016, the final regulations for nursing homes participating in the Medicare and/or Medicaid programs were published in the Federal Register.

Consumer Voice, along with Justice in Aging and the Center for Medicare Advocacy, created a brief overview of the regulations, including positive and negative effects for nursing home residents.

One of the most notable requirements included in the final regulations is the prohibition of pre-dispute arbitration clauses in nursing home contracts.  Read Consumer Voice's statement commending CMS on this requirement.  This portion of the revised rule has not gone into effect yet pending the outcome of the current lawsuit.  Now, CMS has issued new proposed rules that rescind resident protections against these unfair provisions.  In the proposed rule, CMS removes the requirement preventing facilities from entering into pre-dispute arbitration agreements, and also removes the provision banning facilities from requiring these agreements as a condition of admission.

Take Action


CMS is requesting comments on several items in the final regulations. These items include:

  • Modification or elimination of three (3) parts of the revised federal nursing home regulations- discharge notices to ombudsmen; the grievance process; and the Quality Assurance and Performance Improvement process.
  • Changes to Medicare reimbursement for skilled nursing facilities that would significantly change the financial incentives to facilities for providing therapy. 
  • Ideas for changes to eliminate unnecessary burdens for providers and patients. This solicitation of ideas can be used to advocate for changes related to how hospital time is counted to qualify for Medicare coverage of a skilled nursing facility stay (observation status).

We are providing sample comments for organizations to submit or use to create their own comments. These sample organizational comments can be easily adapted for use by individuals.  Comments are due by 5:00 pm ET on June 26, 2017.

The best way to submit comments is electronically.  Go to www.regulations.gov.  Within the search bar, enter the Regulation Identifier Number associated with this regulation - 0938-AS96 - and then click on the "Comment Now" box.

Rule Resources


Consumer Voice prepared Part I of the Summary of Key Changes in the revised federal nursing home regulations related to Resident Rights; Abuse, Neglect, and Exploitation; and Admission, Transfer and Discharge Rights.  This summary provides an overview of key changes in these three sections that will go into effect in Phase 1 on November 28, 2016.

Consumer Voice also has prepared Part II of the Summary of Key Changes in the revised federal nursing home regulations for the sections on Resident Assessment (§483.20) – Training Requirements (§483.95).  It is designed to highlight what is different between the prior rule and the final rule and includes only those parts of the rule that went into effect in Phase 1 on November 28, 2016.

Consult Consumer Voice's Side-By-Side Comparison of Revised & Previous Federal Nursing Home Regulations for an in-depth look at all the provisions in the revised federal regulations.  The side-by-side classifies which provisions are revised, new, or exactly the same as the previous language.  If the provision is revised, the side-by-side lists the previous language from which it was revised.  In addition, the side-by-side denotes the implementation phase for each provision.

Phase 1 of the revised regulations for nursing homes participating in Medicare and/or Medicaid programs will be implemented on November 28, 2016. A side-by-side chart includes references to the Ombudsman Program comparing the revised regulations and related language from the preamble to the current regulations. The chart shows which requirements are new and indicates whether the regulations are included in Phase 1 or 2 (Phase 2 must be implemented by November 28, 2017). For more information, visit NORC's website.

Presentations


What the Consumer Voice's webinar, A Deeper Dive into the Revised Federal Nursing Home Regulations: Part 3, below.  You will hear experts from Center for Medicare Advocacy, Justice in Aging, and Consumer Voice discuss key changes in: (1) Bedholds, and Return to the Facility, (2) Grievances, (3) Resident/Family Councils, and (4) Quality of Care.

Download the webinar PowerPoint here.

Watch the Consumer Voice's webinar, A Deeper Dive into the Revised Federal Nursing Home Regulations: Part 2, below.  You will hear experts from Center for Medicare Advocacy, Justice in Aging, and Consumer Voice discuss key changes in: (1) Admission, Return, and Bedhold, (2) Visitation Rights, and (3) Specialized Rehabilitative Services.

Download the webinar PowerPoint here.

Watch the Consumer Voice's webinar, A Deeper Dive into the Revised Federal Nursing Home Regulations: Part 1, below.  You will hear experts from Center for Medicare Advocacy, Justice in Aging and Consumer Voice discuss key changes in: (1) Assessment, Care Planning & Discharge Planning, (2) Nursing Services, (3), Unnecessary and Antipsychotic Drugs, and (4) Transfer/Discharge.

Download the webinar PowerPoint here.

Watch the Consumer Voice's webinar,  Introduction to the Revised Federal Nursing Home Regulations: What's In, What's Not,  below.  You will hear CMS provide an overview of the revised rule and experts from the Center for Medicare Advocacy, Justice in Aging and Consumer Voice discuss changes in key areas.

Download the webinar PowerPoint here.  You may download a rough draft of the closed captions for this webinar here.

Presentation on the Revised Final Nursing Home Regulations at the National Health Law Program Annual Conference, 12-5-16 by Lori Smetanka and Toby Edelman

Issue Briefs


Consumer Voice, in partnership with Justice in Aging and the Center for Medicare Advocacy, is developing a series of briefs entitled "A Closer Look at the Revised Nursing Facility Regulations."  

  • Why the Recently-Revised Nursing Home Regulations are Vital for Nursing Home Residents - This fact sheet provides a quick overview of some of the important new provisions, so that stakeholders and policymakers can better understand the revised regulations’ important role in improving nursing facility care. The revised regulations provide many benefits to nursing facility residents, including an increased focus on addressing a resident’s needs and preferences. 
  • Assessments, Care Planning, and Discharge Planning - This brief provides an overview of the regulations in these areas and highlights provisions that can be useful in advocating for improved quality of care and quality of life.  For instance, the revised assessment process must now gather information about a resident's preferences, goals, and there is greater emphasis on the participation of the resident and resident’s representative participate in the care planning team.  Also, care planning must include planning for discharge, to give residents an increased ability to move out of the facility into the community. The brief gives information on effective dates, how to find the regulations, and concludes with practical tips for residents and advocates.
  • Unnecessary Drugs and Antipsychotic Medications - This brief outlines the recent changes in unnecessary drug regulations, including a discussion of a broader category of psychotropic drugs, along with new controls over “as needed” (PRN) psychotropic drugs. The revised regulations also expand requirements for drug regimen reviews.
  • Involuntary Transfer and Discharge - This brief explains the minor changes in transfer and discharge regulations, which include narrowing the facility’s ability to base a transfer/discharge on a supposed inability to meet the resident’s needs, by requiring increased documentation by the resident’s physician. The regulations also limit transfer/discharge for nonpayment.
  • Nursing Services - This brief explains the recent changes in nursing services regulations, which include placing a greater emphasis on establishing minimum comptencies and skill sets for all nursing personnel.  In addition, the regulations have increased requirements for in-service training of nursing personnel.
  • Admission - This brief explains the changes in admission, bedhold and return regulations, which include broadly prohibiting facilities from using admission agreements or other documents that waive a resident's rights.  The revised regulations also prohibit pre-dispute arbitration agreements, but this consumer protection is currently blocked by a court order.
  • Visitation Rights - This brief explains changes in visitation rights including the right to receive visitors, written policies and procedures and other facility requirements, notice requirements, and visitation privileges.
  • Rehabilitation Services - This brief covers how the substantive requirements for specialized rehabilitative services are largely unchanged from the prior version of the regulations, with the exception of "respiratory therapy," which is added to the list of services that a facility must provide to its residents who need them.
  • Return to Facility After Hospitalization - This brief explains bed hold rights when a resident returns to a facility after a hospitalization.  The brief provides information on advance notification of bed hold rights and residents' rights if they return to a facility after a bed hold period has been exceeded.
  • Grievances and Resident/Family Councils - This brief covers the resident's right to file grievances and the facility's requirement to work to resolve those concerns promptly.  Each facility must have a grievance policy and provide residents with information on how to file a grievance.  Also, residents have a right to form a resident council, and family members and resident representatives have the right to form a family council.  The facility must act upon council concerns and recommendations.
  • Quality of Care - The substantive requirements for quality of care are retained in the revised regulations and CMS has affirmed the regulations' goals of supporting person-centered care and enabling each resident to attain his or her highest level of well-being.  This brief covers those regulations as well as providing information on how the quality of care provisions have been reorganized in the revised regulations.

CMS Resources


  • CMS released an advance copy of revisions to the State Operations Manual (SOM), Appendix PP with the revised regulations and tags (see this memo for more details).
  • The Centers for Medicare and Medicaid Services published on-demand, online training related to the Phase 1 requirements available for providers on the CMS website. CMS developed online training for regional offices, state survey agencies, providers and other stakeholders on the new Nursing Home Regulations, including information about Phase 1 of the new regulations.  All Long Term Care surveyors are required to complete the training in order to be able to conduct any LTC surveys after November 28, 2016.  Read the memo from CMS here.

Implementation Timeframes


On October 4, 2016, the final regulations for nursing homes participating in the Medicare and/or Medicaid programs were published in the Federal Register. The regulations are effective on November 28, 2016 and will be implemented in three phases. The chart below shows the implementation timeframes. Additional details regarding the revised regulations will be posted in the coming months.

This summary provides an overview of key changes in the revised federal regulations related to Resident Rights; Abuse, Neglect, and Exploitation; and Admission, Transfer and Discharge Rights that will go into effect in Phase 1 on November 28, 2016.

Note: The regulations included in Phase 1 must be implemented by November 28, 2016, regulations included in Phase 2 must be implemented by November 28, 2017, and regulations included in Phase 3 must be implemented by November 28, 2019.

Regulatory section

Implementation deadline

§ 483.1 Basis and scope

This entire section will be implemented in Phase 1.

§ 483.5 Definitions

This entire section will be implemented in Phase 1.

§ 483.10 Resident rights

The section will be implemented in Phase 1 with the following exception:

(g)(4)(ii)–(v) Providing contact information for State and local advocacy organizations, Medicare and Medicaid eligibility information, Aging and Disability Resources Center and Medicaid Fraud Control Unit—Implemented in Phase 2.

§ 483.12 Freedom from abuse, neglect, and exploitation

This section will be implemented in Phase 1 with the following exceptions:

(b)(4) Coordination with QAPI Plan—Implemented in Phase 3.

(b)(5) Reporting crimes/1150B—Implemented in Phase 2.

§ 483.15 Admission, transfer, and discharge rights

This section will be implemented in Phase 1 with the following exceptions:

(c)(2) Transfer/Discharge Documentation—Implemented in Phase 2.

§ 483.20 Resident assessment

This entire section will be implemented in Phase 1.

§ 483.21 Comprehensive person-centered care planning

This section will be implemented in Phase 1 with the following exceptions:

(a) Baseline care plan—Implemented in Phase 2.

(b)(3)(iii) Trauma informed care—Implemented in Phase 3.

§ 483.24 Quality of life

This entire section will be implemented in Phase 1.

§ 483.25 Quality of care

This section will be implemented in Phase 1 with the following exception:

(m) Trauma-informed care—Implemented in Phase 3.

§ 483.30 Physician services

This entire section will be implemented in Phase 1.

§ 483.35 Nursing services

This section will be implemented in Phase 1 with the following exception:

Specific usage of the Facility Assessment at § 483.70(e) in the determination of sufficient number and competencies for staff— Implemented in Phase 2.

§ 483.40 Behavioral health services

This section will be implemented in Phase 2 with the following exceptions:

(a)(1) As related to residents with a history of trauma and/or post-traumatic stress disorder—Implemented in Phase 3.

(b)(1), (b)(2), and (d) Comprehensive assessment and medically related social services—Implemented in Phase 1.

§ 483.45 Pharmacy services

This section will be implemented in Phase 1 with the following exceptions:

(c)(2) Medical chart review—Implemented in Phase 2.

(e) Psychotropic drugs—Implemented in Phase 2.

§ 483.50 Laboratory, radiology, and other diagnostic services

This entire section will be implemented in Phase 1.

§ 483.55 Dental services

This section will be implemented in Phase 1 with the following exceptions:

 • (a)(3) and (a)(5) Loss or damage of dentures and policy for referral—Implemented in Phase 2.

(b)(3) and (b)(4) Referral for dental services regarding loss or damaged dentures—Implemented in Phase 2.

§ 483.60 Food and nutrition services

This section will be implemented in Phase 1 with the following exceptions:

(a) As linked to Facility Assessment at § 483.70(e)—Implemented in Phase 2.

(a)(1)(iv) Dietitians hired or contracted with prior to effective date—Built in implementation date of 5 years following effective date of the final rule.

(a)(2)(i) Director of food & nutrition services designated to serve prior to effective—Built in implementation date of 5 years following the effective date of the final rule.

(a)(2)(i) Dietitians designated to after the effective date—Built in implementation date of 1 year following the effective date of the final rule.

§ 483.65 Specialized rehabilitative services

This entire section will be implemented in Phase 1.

§ 483.70 Administration

This section will be implemented in Phase 1 with the following exceptions:

(d)(3) Governing body responsibility of QAPI program—Implemented in Phase 3.

 • (e) Facility assessment—Implemented in Phase 2.

§ 483.75 Quality assurance and performance improvement

This section will be implemented in Phase 3 with the following exceptions:

(a)(2) Initial QAPI Plan must be provided to State Agency Surveyor at annual survey—Implemented in Phase 2.

(g)(1) QAA committee—All requirements of this section will be implemented in Phase 1 with the exception of subparagraph (iv), the addition of the ICPO, which will be implemented in Phase 3.

(h) Disclosure of information—Implemented in Phase 1.

(i) Sanctions—Implemented in Phase 1.

§ 483.80 Infection control

This section will be implemented in Phase 1 with the following exceptions:

(a) As linked to Facility Assessment at § 483.70(e)—Implemented in Phase 2.

(a)(3) Antibiotic stewardship—Implemented in Phase 2.

(b) Infection preventionist (IP)—Implemented in Phase 3.

(c) IP participation on QAA committee—Implemented in Phase 3.

§ 483.85 Compliance and ethics program

This entire section will be implemented in Phase 3. 

§ 483.90 Physical environment

This section will be implemented in Phase 1 with the following exceptions:

(f)(1) Call system from each resident’s bedside—Implemented in Phase 3.

(h)(5) Policies regarding smoking—Implemented in Phase 2.

§ 483.95 Training requirements

This entire section will be implemented in Phase 3 with the following exceptions:

(c) Abuse, neglect, and exploitation training—Implemented in Phase 1.

(g)(1) Regarding in-service training, (g)(2) dementia management & abuse prevention training, (g)(4) care of the cognitively impaired—Implemented in Phase 1.

(h) Training of feeding assistants—Implemented in Phase 1.

Proposed Regulations


The Centers for Medicare and Medicaid Services (CMS) has officially published its proposed revisions to the current regulations (also known as the Requirements of Participation) for nursing homes participating in the Medicare and/or Medicaid programs. This proposed rule is available to view in full at the Federal Register website here

As you may recall, CMS announced that it would be revising the Requirements of Participation for nursing homes in 2012; at that time, Consumer Voice, other advocates, and stakeholders submitted detailed recommendations to the agency on ways the current rules could be updated and strengthened (click here to see recommendations made by Consumer Voice in 2012 and here to view additional recommendations submitted in 2014.).

Consumer Voice has developed a comparison of the proposed and current regulations. To view this side-by-side comparison in PDF format, click here. The side-by-side in Excel format can be accessed here.

In addition, the non-profit, citizen advocacy group Public Citizen has put together a petition individuals can sign asking CMS to ban forced, pre-dispute arbitration in nursing home contracts as part of the proposed revisions to the nursing home regulations. Click here to sign their petition and here to learn more about this issue. 

The Requirements of Participation set critical standards for the quality of life and quality of care for nursing home residents. CMS must receive feedback from advocates like yourselves on the proposed revisions to ensure that any changes to the existing regulations would benefit, and not harm, residents.

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