Government Regulation of Nursing Homes

The Center for Medicare & Medicaid Services (CMS) is the component of the Federal Government's Department of Health and Human Services that oversees the nation's Medicare and Medicaid programs. A large portion of Medicare and Medicaid dollars is used each year to cover nursing home care and services for the elderly and disabled. State governments oversee the licensing of nursing homes. In addition, States have a contract with CMS to monitor those nursing homes that want to be eligible to provide care to Medicare and Medicaid beneficiaries. Congress established minimum requirements for nursing homes that want to provide services under Medicare and Medicaid. These requirements are broadly outlined in the Social Security Act (the Act). The Act also entrusts the Secretary of Health and Human Services (DHHS) with the responsibility of monitoring and enforcing these requirements. CMS, a DHHS Agency, is also charged with the responsibility of working out the details of the law and how it will be implemented, which it does by writing regulations and manuals.

CMS contracts with each State to conduct onsite inspections that determine whether its nursing homes meet the minimum Medicare and Medicaid quality and performance standards. Typically, the part of State government that takes care of this duty is the health department or department of human services. In Virginia, the Office of Long Term Care within the Department of Health is responsible for protecting the health and safety of nursing care institutions. The State conducts inspections of each nursing home that participates in Medicare and/or Medicaid no less than twice per year. Nursing homes, pursuant to the social security act, are required to cooperate with the Virginia Department of Health in mandatory biennial inspections. Va. Code § 32.1-126. If the nursing home is performing poorly, however, the State inspectors may go in more frequently. Va. Code § 32.1-25. The State also investigates complaints about nursing home care. Va. Code § 2.2-704. The Office of Long Term Care Ombudsman has access to nursing home facilities, staff, and records to investigate any such complaints. Va. Code § 2.2-705. When an inspection team finds that a home does not meet a specific regulation, it issues a deficiency citation. After each inspection the Department of Health issues a quality rating based on the quality of service provided by the facility. If the State finds any violations of nursing home regulations, it may, through a court proceeding, impose a civil penalty, or have an injunction imposed against the deficient nursing home until the nursing home complies with the regulations. Va. Code § 32.1-27.

Depending on the nature of the problem, the law permits CMS to take a variety of actions; for example, CMS may fine the nursing home, deny payment to the nursing home, assign a temporary manager, or install a State monitor. CMS considers the extent of harm caused by the failure to meet requirements when it takes an enforcement action. If the nursing home does not correct its problems, CMS terminates its agreement with the nursing home. As a result, the nursing home is no longer certified to provide care to Medicare and Medicaid beneficiaries. Any beneficiaries residing in the home at the time of the termination are transferred to certified facilities.

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