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  Understanding nursing homes can best be done by being aware of the laws, regulations, policies, procedures, accepted practices, and professional standards under which they must deliver care.  It may seem that what happens in a nursing home is only the result of personal decisions made by staff.  Instead, care decisions result from their ongoing interpretation of the broad variety of regulatory constraints and professional guidance under which they work while trying to satisfy the medical needs and personal viewpoints of residents and their families.


            ∆  Legal standards and operating requirements.

            ∆  Federal regulations and standards.

            ∆  Using Appendices P and PP.

            ∆  State nursing home licensing laws and

                 operating regulations.

            ∆  Facility policy and procedure.

            ∆  Standards of professional medical practices.

  ∆  Legal standards and operating requirements.

     Nursing home staff are professionally able and required to make care and related decisions within the limits of the regulatory process and needs of residents.  Their limited scope of decision making could be illustrated by the requirements that walls are to be covered in such a way as to be fire safe, easily cleanable, and provide a pleasing living environment.  The choices of color and acceptable wall finish will be made by staff  or owner within regulatory limits but what ever is chosen must meet mandatory standards.

   There are a variety of State and Federal codes, titles, laws, statutes, and regulatory interpretations of those acts setting standards and boundaries for nursing home operations and quality of care.  Long term care facilities are first established under state licensing laws and, in most cases, a granted  certification that there is a need for nursing home beds in a specific community.  Medical professionals and support services providing care and related functions must also operate in the nursing home under the licensing, regulatory, and standards of practice governing their areas of specialty.  After consideration of all the other functioning guidelines, each long term care facility must establish their own policies and procedures for everyday operation to stay within their operating standards and legal limitations.

∆  Federal regulations and standards.

    Title 42: Public Health, Part 483, Requirements for States and Long Term Care Facilities, Subpart B, Requirements for Long Term Care Facilities, is the most important regulation to someone wanting to understand how Medicare/Medicaid certified nursing homes are supposed to operate. Part 483, Subpart B is used by state inspectors when they conduct a complaint investigation or annual survey of a facility certified for Medicare and Medicaid to judge compliance by the facility in meeting required standards.

    Part 483, Subpart B establishes, under the heading, Requirements for Long Term Facilities, broad service and care standards that are to be met by a certified nursing home. The Centers for Medicare and Medicaid Services (CMS) contracts with the states, usually the state division of health & human services, to conduct surveys or inspections of certified nursing homes to assure they are meeting Part 483 standards and practices.  In the CMS Five Star Quality Rating System, this survey process is called a health inspection but is known to nursing home staff as the survey and the state employees doing the inspection are called surveyors.

    Nursing home investigations and inspections are guided by processes established by CMS to assure consistent inspections.  A description of those procedures are a part of the Medicare State Operations Manual which also regulates other health care processes covered by Medicare and Medicaid.

  There are two appendices to the state operations manual that are important to nursing homes. Appendix P, Survey Protocol for Long-Term Care Facilities, establishes the processes of the survey. Because Part 483 requirements are so broad, Appendix PP, Guidance to Surveyors for Long-Term Facilities, interprets Part 483 into more detailed standards and adds interpretive criteria by which compliance is to be measured.

  ∆  Using appendices P and PP.

    Appendix P is primarily of concern to the surveyors and nursing home staff because it describes how a survey is to take place and other technical details relating to the outcome of a survey.  It may be hard to understand without having experienced a survey or complaint investigation as a nursing home employee and has very little direct connection to actual resident care procedure.  It is an inspection process.

    Appendix PP, on the other hand, can be a significant source of information.  To determine if a facility is in compliance with Part 483, surveyors need more detailed criteria or interpretation of the intent of the law to judge how well the nursing home is meeting requirements.  Appendix PP supplies that detail.

    The more than 600 page document explains what should be in place or done to assure quality care in a Medicare/Medicaid certified nursing home.  If there is any question of proper care not being given to a resident, referring to the appropriate part of Appendix PP will help clarify the issue.  The online version of Appendix PP can be use as an extended checklist of what a certified nursing home should be doing to meet the resident’s needs.

  ∆  State nursing home licensing laws and operating regulations.

  Each state has its own licensing laws and operating regulations defining how a nursing home must operate in that state.  Some are more complicated than others and often refer to or include other state regulations on such related matters as sanitation or safety into their requirements.

    Nursing homes choosing to not be certified for Medicare and Medicaid can often operate under state law and regulatory processes alone. Such non-certified facilities must rely primarily on payment from the resident and to do so, may function as high end health care facilities for those who can afford such.

    In addition, a licensed Administrator is required to manage long term care facilities and each state has their own process for training and licensing Administrators.  A separate license must be acquired to serve as an Administrator in each state.

    The University of Minnesota has an excellent website, NH Regulations Plus, which provides access to nursing home regulations by state and topic as well as to Federal regulations. The website can be accessed at:


  ∆  Standards of professional medical practices.

   Most medical professionals work according to generally accepted practices and standards of quality for their speciality and for medical care in general.  Professional medical associations, governmental regulatory agencies, and state or federal laws can establish professional standards that must be met by nursing home staff. These set behavioral, philosophical, scope of practice, procedural, and other standards and boundaries for those deemed qualified to provide specific medical and medical related services in the nursing home.

    Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. Recommended practices to achieve desired resident outcomes may also be found in clinical literature such as:

   * Current manuals or textbooks on nursing, social work, physical therapy, etc.

   * Standards published by professional organizations such as the American Dietetic Association,

    American Medical Association, American Medical Directors Association, American Nurses

    Association, National Association of Activity Professionals, National Association of Social Work,

     and so forth.

   * Clinical practice guidelines published by the Agency of Health Care Policy and Research.

   * Current professional journal articles.

   An example of accepted practices would be the Infection Control Standard Precautions in Health Care.  These precautions are medical applications, processes, and care practices that have been proven through use and are generally accepted as effective and standard among those who are qualified to deliver professional health care and may be found at:

   Examples of professional standards of practice for administrators and nurses can be found at:

Principles of Excellence for Leaders in Long-Term Care Administration


Standards of Practice for Registered Nurses & Licensed Practical Nurses

∆  Facility policy and procedure.

   Although a great deal of guidance is provided by Part 483 and Appendix PP, each facility is still required to establish their own policy and procedures to directly and indirectly meet those requirements.  Other providers such as an outside pharmacy will have policy and procedures for how they provide services to facility residents.  The facility should have copies of those documents on hand.  With their self generated policy and procedure, those of outside providers, and the requirements of Part 483, a nursing home may have thousands of pages of standards, policy, and procedures to meet.

    An example of
a policy and procedure would be that Part 483 requires residents to be kept safe but does not detail the process necessary to assure that it is adequately done.  A facility specific policy for safety could include securing the building at night with only employees, designated family members, and emergency personnel be allowed entry between 9 p.m. and 7 a.m.  The procedure would then detail how the building is to be secured; how family members, employees and emergency personnel are to gain entry; who is responsible for assuring that required steps are taken to secure the facility; and how compliance with this policy will be measured and monitored.

      Facility policy and procedure may be proprietary documents with each facility creating their own but it is still an operating standard that should be provided upon request for a resident or family member to read.

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