1 See References in Text note below.
of the Older Americans Act of 1965) and the protection and advocacy system in the State for the mentally ill and the mentally retarded, and
2 So in original. There are no subpars. (D) to (U).
Availability of survey, certification, and complaint investigation reports
3 So in original. Probably should be followed by a closing parenthesis.
, (II) minimum hours of initial and ongoing training and retraining (including not less than 75 hours in the case of initial training), (III) qualifications of instructors, and (IV) procedures for determination of competency;
4 So in original. Probably should be “clause”.
(i), (iii), or (iv) of subsection (h)(2)(A), clauses 
5 So in original. Probably should be “paragraph”.
(1), (2), or (3) of subsection (h), with respect to a nursing facility in the State.
6 So in original. Probably should be followed by a comma.
shall notify the other of such finding, and the State or the Secretary, respectively, shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in paragraph (2)(A)(iii) or (3)(C)(iii), or terminate the facility’s participation under the State plan. If the facility’s participation in the State plan is terminated by either the State or the Secretary, the State shall provide for the safe and orderly transfer of the residents eligible under the State plan consistent with the requirements of subsection (c)(2).
7 So in original. Cl. (ii) of par. (2)(A) of this subsection does not contain subclauses. Probably means cl. (ii)(IV) of par. (3)(C) of this subsection.
(iii), and (iv) of paragraph (2)(A) may be imposed during the pendency of any hearing. The provisions of this subsection shall apply to a nursing facility (or portion thereof) notwithstanding that the facility (or portion thereof) also is a skilled nursing facility for purposes of subchapter XVIII.
Amendment of Subsection (d)(1)

Puspan. L. 111–148, title VI, § 6101(c)(1)(B), (2), Mar. 23, 2010, 124 Stat. 702, provided that, effective on the date on which the Secretary of Health and Human Services makes certain information available to the public, subsection (d)(1) of this section is amended by striking subparagraph (B) and redesignating subparagraph (C) as subparagraph (B). See 2010 Amendment note and Effective Date of 2010 Amendment note below.

Editorial Notes
References in Text

The Older Americans Act of 1965, referred to in subsecs. (span)(4)(C)(ii)(IV), (c)(2)(B)(iii)(II), and (g)(5)(B), is Puspan. L. 89–73, July 14, 1965, 79 Stat. 218, as amended. Section 307(a)(12) of the Act was repealed by Puspan. L. 106–501, title III, § 306(5), Nov. 13, 2000, 114 Stat. 2244, and provisions formerly appearing in section 307(a)(12) of the Act are now contained in section 307(a)(9) of the Act, which is classified to section 3027(a)(9) of this title. Titles III and VII of the Act are classified generally to subchapters III (§ 3021 et seq.) and XI (§ 3058 et seq.), respectively, of chapter 35 of this title. For complete classification of this Act to the Code, see Short Title note set out under section 3001 of this title and Tables.

The Developmental Disabilities Assistance and Bill of Rights Act of 2000, referred to in subsec. (c)(2)(B)(iii)(III), is Puspan. L. 106–402, Oct. 30, 2000, 114 Stat. 1677. Subtitle C of the Act probably means subtitle C of title I of the Act, which is classified generally to part C (§ 15041 et seq.) of subchapter I of chapter 144 of this title. For complete classification of this Act to the Code, see Short Title note set out under section 15001 of this title and Tables.

The Protection and Advocacy for Mentally Ill Individuals Act [of 1986], referred to in subsec. (c)(2)(B)(iii)(IV), was Puspan. L. 99–319, May 23, 1986, 100 Stat. 478, as amended. Puspan. L. 99–319 was renamed the Protection and Advocacy for Individuals with Mental Illness Act by Puspan. L. 106–310, div. B, title XXXII, § 3206(a), Oct. 17, 2000, 114 Stat. 1193, and is classified generally to chapter 114 (§ 10801 et seq.) of this title. For complete classification of this Act to the Code, see Short Title note set out under section 10801 of this title and Tables.

Section 6901(span)(4)(B)–(D) of the Omnibus Budget Reconciliation Act of 1989, referred to in subsec. (e)(2)(A), is section 6901(span)(4)(B)–(D) of Puspan. L. 101–239, which is set out as a note under section 1395i–3 of this title.

Section 21(span) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, referred to in subsec. (f)(7)(A), probably means section 21(span) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments, Puspan. L. 95–142, which is set out as a note under section 1395x of this title.

Prior Provisions

A prior section 1919 of act Aug. 14, 1935, was renumbered section 1922 and is classified to section 1396r–3 of this title.

Amendments

2021—Subsec. (k). Puspan. L. 117–2 added subsec. (k).

2010—Subsec. (span)(5)(F). Puspan. L. 111–148, § 6121(span)(2), inserted concluding provisions.

Subsec. (d)(1)(B). Puspan. L. 111–148, § 6101(c)(1)(B), redesignated subpar. (C) as (B) and struck out former subpar. (B) which related to required notice to a State licensing agency of change in ownership, control interest, management, or certain positions of responsibility for a nursing facility.

Subsec. (d)(1)(V). Puspan. L. 111–148, § 6103(c)(2), added subpar. (V).

Subsec. (f)(2)(A)(i)(I). Puspan. L. 111–148, § 6121(span)(1), inserted “ (including, in the case of initial training and, if the Secretary determines appropriate, in the case of ongoing training, dementia management training, and patient abuse prevention training” before “, (II)”.

Subsec. (f)(10). Puspan. L. 111–148, § 6103(span)(3), added par. (10).

Subsec. (g)(5)(E). Puspan. L. 111–148, § 6103(span)(2)(A), added subpar. (E).

Subsec. (h)(3)(C)(ii). Puspan. L. 111–148, § 6111(span)(1), designated existing provisions as subcl. (I), inserted span, substituted “Subject to subclause (II), the Secretary” for “The Secretary”, and added subcls. (II) to (IV).

Subsec. (h)(8). Puspan. L. 111–148, § 6111(span)(2), which directed insertion of “(ii)(IV),” after “(i),” in subsec. “(h)(5)(8)” of this section, was executed to subsec. (h)(8), to reflect the probable intent of Congress. Subsec. (h)(5) does not contain “(i),”.

Subsecs. (i), (j). Puspan. L. 111–148, § 6103(span)(1), added subsec. (i) and redesignated former subsec. (i) as (j).

2006—Subsec. (c)(5)(A)(i)(II). Puspan. L. 109–432 substituted “subparagraph (B)(v)” for “clause (v)”.

Puspan. L. 109–171, § 6015(a)(1), inserted “subject to clause (v)” after “(II)”.

Subsec. (c)(5)(B)(v). Puspan. L. 109–171, § 6015(a)(2), added cl. (v).

2003—Subsec. (f)(2)(B)(iii). Puspan. L. 108–173, § 932(c)(2)(A), substituted “subparagraphs (C) and (D)” for “subparagraph (C)” in introductory provisions.

Subsec. (f)(2)(D). Puspan. L. 108–173, § 932(c)(2)(B), added subpar. (D).

2000—Subsec. (span)(8). Puspan. L. 106–554 added par. (8).

Subsec. (c)(2)(B)(iii)(III). Puspan. L. 106–402 substituted “subtitle C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000” for “part C of the Developmental Disabilities Assistance and Bill of Rights Act”.

1999—Subsec. (span)(3)(C)(i)(I). Puspan. L. 106–113, § 1000(a)(6) [title VI, § 608(p)(1)], struck out “not later than” before “14 days”.

Subsec. (c)(2)(F). Puspan. L. 106–4 added subpar. (F).

Subsec. (d)(4)(A). Puspan. L. 106–113, § 1000(a)(6) [title VI, § 608(p)(2)], inserted closing parenthesis after “section 1320a–3 of this title”.

1997—Subsec. (f)(2)(B)(iii). Puspan. L. 105–15, § 1(1), inserted “subject to subparagraph (C),” after “(iii)”.

Subsec. (f)(2)(C). Puspan. L. 105–15, § 1(2), added subpar. (C).

Subsec. (g)(1)(D), (E). Puspan. L. 105–33, § 4755(span), added subpar. (D) and redesignated former subpar. (D) as (E).

Subsec. (h)(3)(D). Puspan. L. 105–33, § 4754(a), inserted “and” at end of cl. (i), substituted a period for “, and” at end of cl. (ii), and struck out cl. (iii) which read as follows: “the State agrees to repay to the Federal Government payments received under this subparagraph if the corrective action is not taken in accordance with the approved plan and timetable.”

1996—Subsec. (span)(3)(E). Puspan. L. 104–315, § 2(a), inserted at end “In addition, a nursing facility shall notify the State mental health authority or State mental retardation or developmental disability authority, as applicable, promptly after a significant change in the physical or mental condition of a resident who is mentally ill or mentally retarded.”

Subsec. (e)(7)(B). Puspan. L. 104–315, § 1(a)(1)(A), struck out “annual” before “resident review” in span.

Subsec. (e)(7)(B)(iii). Puspan. L. 104–315, § 2(span), added cl. (iii).

Puspan. L. 104–315, § 1(a)(1)(B), struck out cl. (iii) which related to frequency of reviews as annual, preadmission, and initial.

Subsec. (e)(7)(D)(i). Puspan. L. 104–315, § 1(a)(2), struck out “annual” before “review” in span.

1992—Subsecs. (c)(2)(B)(iii)(II), (g)(5)(B). Puspan. L. 102–375 substituted “title III or VII of the Older Americans Act of 1965 in accordance with section 712 of the Act” for “section 307(a)(12) of the Older Americans Act of 1965”.

1990—Subsec. (span)(1)(B). Puspan. L. 101–508, § 4801(e)(2), inserted at end “A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this subparagraph.”

Subsec. (span)(3)(C)(i)(I). Puspan. L. 101–508, § 4801(e)(3), substituted “not later than 14 days” for “4 days”.

Subsec. (span)(3)(F). Puspan. L. 101–508, § 4801(span)(8), substituted “specialized services” for “active treatment” in cls. (i) and (ii).

Puspan. L. 101–508, § 4801(span)(4)(A), inserted at end “A State mental health authority and a State mental retardation or developmental disability authority may not delegate (by subcontract or otherwise) their responsibilities under this subparagraph to a nursing facility (or to an entity that has a direct or indirect affiliation or relationship with such a facility).”

Puspan. L. 101–508, § 4801(span)(2)(A), substituted “Except as provided in clauses (ii) and (iii) of subsection (e)(7)(A), a nursing facility” for “A nursing facility” in introductory provisions.

Subsec. (span)(4)(A)(vii). Puspan. L. 101–508, § 4801(e)(4), added cl. (vii).

Subsec. (span)(4)(C)(ii). Puspan. L. 101–508, § 4801(e)(5)(A), substituted “To the extent that a facility is unable to meet the requirements of clause (i), a State may waive such requirements with respect to the facility if” for “A State may waive the requirement of subclause (I) or (II) of clause (i) with respect to a facility if” in introductory provisions.

Subsec. (span)(4)(C)(ii)(IV), (V). Puspan. L. 101–508, § 4801(e)(5)(B)–(D), which directed amendment of cl. (ii) by adding subcls. (IV) and (V) at the end, was executed by adding subcls. (IV) and (V) after subcl. (III) and before concluding provisions to reflect the probable intent of Congress.

Subsec. (span)(5)(A). Puspan. L. 101–508, § 4801(a)(2), designated existing provision as cl. (i), substituted “Except as provided in clause (ii), a nursing facility” for “A nursing facility” and “on a full-time basis” for “(on a full-time, temporary, per diem, or other basis)”, redesignated former cls. (i) and (ii) as subcls. (I) and (II), respectively, and added cl. (ii).

Subsec. (span)(5)(C). Puspan. L. 101–508, § 4801(a)(3), substituted “any State registry established under subsection (e)(2)(A) that the facility believes will include information” for “the State registry established under subsection (e)(2)(A) as to information in the registry”.

Subsec. (span)(5)(D). Puspan. L. 101–508, § 4801(a)(4), inserted before period at end “, or a new competency evaluation program”.

Subsec. (span)(5)(F)(i). Puspan. L. 101–508, § 4801(e)(6), substituted “(G)) or a registered dietician” for “(G))”.

Subsec. (span)(6)(A). Puspan. L. 101–508, § 4801(d)(1), inserted before semicolon at end “(or, at the option of a State, under the supervision of a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility but who is working in collaboration with a physician)”.

Subsec. (c)(1)(A). Puspan. L. 101–508, § 4801(e)(8)(B), inserted at end “A resident’s exercise of a right to refuse transfer under clause (x) shall not affect the resident’s eligibility or entitlement to medical assistance under this subchapter or a State’s entitlement to Federal medical assistance under this subchapter with respect to services furnished to such a resident.”

Subsec. (c)(1)(A)(iv). Puspan. L. 101–508, § 4801(e)(9), inserted before period at end “and to access to current clinical records of the resident upon request by the resident or the resident’s legal representative, within 24 hours (excluding hours occurring during a weekend or holiday) after making such a request”.

Subsec. (c)(1)(A)(x), (xi). Puspan. L. 101–508, § 4801(e)(8)(A), added cl. (x) and redesignated former cl. (x) as (xi).

Subsec. (c)(1)(B)(ii). Puspan. L. 101–508, § 4801(e)(10), inserted “including the notice (if any) of the State developed under subsection (e)(6)” after “in such rights)”.

Subsec. (c)(2)(E). Puspan. L. 101–508, § 4751(span)(2), added subpar. (E).

Subsec. (c)(7), (8). Puspan. L. 101–508, § 4801(e)(7)(A), added par. (7) and redesignated former par. (7) as (8).

Subsec. (e)(1)(A). Puspan. L. 101–508, § 4801(e)(18), substituted “under subsection (f)(2)” for “under clause (i) or (ii) of subsection (f)(2)(A)”.

Subsec. (e)(2)(A). Puspan. L. 101–508, § 4801(e)(12)(A), inserted “, or any individual described in subsection (f)(2)(B)(ii) or in subparagraph (B), (C), or (D) of section 6901(span)(4) of the Omnibus Budget Reconciliation Act of 1989” after “in the State”.

Subsec. (e)(2)(C). Puspan. L. 101–508, § 4801(e)(12)(B), added subpar. (C).

Subsec. (e)(7)(A). Puspan. L. 101–508, § 4801(span)(2)(B), designated existing provision as cl. (i), inserted cl. (i) span, and added cls. (ii) and (iii).

Subsec. (e)(7)(B)(i)(II), (ii)(II). Puspan. L. 101–508, § 4801(span)(8), substituted “specialized services” for “active treatment”.

Subsec. (e)(7)(B)(iv). Puspan. L. 101–508, § 4801(span)(4)(B), added cl. (iv).

Subsec. (e)(7)(C)(i) to (iii). Puspan. L. 101–508, § 4801(span)(8), substituted “specialized services” for “active treatment” wherever appearing.

Subsec. (e)(7)(C)(iv). Puspan. L. 101–508, § 4801(span)(5)(A), added cl. (iv).

Subsec. (e)(7)(D). Puspan. L. 101–508, § 4801(span)(3)(A), struck out “where failure to conduct preadmission screening” after “Denial of payment” in span, designated existing provisions as cl. (i), inserted cl. (i) span, and added cl. (ii).

Subsec. (e)(7)(E). Puspan. L. 101–508, § 4801(span)(8), substituted “specialized services” for “active treatment”.

Puspan. L. 101–508, § 4801(span)(6), inserted at end “The State may revise such an agreement, subject to the approval of the Secretary, before October 1, 1991, but only if, under the revised agreement, all residents subject to the agreement who do not require the level of services of such a facility are discharged from the facility by not later than April 1, 1994.”

Puspan. L. 101–508, § 4801(span)(3)(B), substituted “the requirements of subparagraphs (A) through (C) of this paragraph” for “the requirement of this paragraph”.

Subsec. (e)(7)(G)(i). Puspan. L. 101–508, § 4801(span)(7), substituted “serious mental illness (as defined by the Secretary in consultation with the National Institute of Mental Health)” for “primary or secondary diagnosis of mental disorder (as defined in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition)” and inserted before period at end “or a diagnosis (other than a primary diagnosis) of dementia and a primary diagnosis that is not a serious mental illness”.

Subsec. (e)(7)(G)(iii). Puspan. L. 101–508, § 4801(span)(8), substituted “specialized services” for “active treatment”.

Subsec. (f)(2)(A)(iv)(II). Puspan. L. 101–508, § 4801(a)(5)(B), inserted “who is employed by (or who has received an offer of employment from) a facility on the date on which the aide begins either such program” after “nurse aide”.

Subsec. (f)(2)(A)(iv)(III). Puspan. L. 101–508, § 4801(a)(5)(A), (C), (D), added subcl. (III).

Subsec. (f)(2)(B). Puspan. L. 101–508, § 4801(a)(7), inserted “(through subcontract or otherwise)” after “may not delegate” in last sentence.

Subsec. (f)(2)(B)(iii)(I). Puspan. L. 101–508, § 4801(a)(6)(A), amended subcl. (I) generally. Prior to amendment, subcl. (I) read as follows: “offered by or in a nursing facility which has been determined to be out of compliance with the requirements of subsection (span), (c), or (d) of this section, within the previous 2 years, or”.

Subsec. (g)(1)(C). Puspan. L. 101–508, § 4801(e)(13), inserted at end “A State shall not make a finding that an individual has neglected a resident if the individual demonstrates that such neglect was caused by factors beyond the control of the individual.”

Subsec. (g)(5)(A)(i). Puspan. L. 101–508, § 4801(e)(14), substituted “deficiencies, within 14 calendar days after such information is made available to those facilities, and approved plans” for “deficiencies and plans”.

Subsec. (g)(5)(B). Puspan. L. 101–508, § 4801(e)(15), substituted “or of any adverse action taken against a nursing facility under paragraphs (1), (2), or (3) of subsection (h), with respect” for “with respect”.

1989—Subsec. (span)(5)(A). Puspan. L. 101–239, § 6901(span)(1)(A), substituted “October 1, 1990” for “January 1, 1990” in introductory provisions.

Subsec. (span)(5)(B). Puspan. L. 101–239, § 6901(span)(1)(B), substituted “January 1, 1990” and “October 1, 1990” for “July 1, 1989” and “January 1, 1990”, respectively.

Subsec. (c)(1)(A)(ii)(II). Puspan. L. 101–239, § 6901(d)(4)(A), substituted “Secretary until such an order could reasonably be obtained)” for “Secretary) until such an order could reasonably be obtained”.

Subsec. (c)(1)(A)(v)(I). Puspan. L. 101–239, § 6901(d)(4)(B), substituted “accommodation” for “accommodations”.

Subsec. (f)(2)(A)(i)(I). Puspan. L. 101–239, § 6901(d)(4)(C), substituted “and span of the curriculum” for “, span of the curriculum”.

Puspan. L. 101–239, § 6901(span)(3)(A), inserted “care of cognitively impaired residents,” after “social service needs,”.

Subsec. (f)(2)(A)(ii). Puspan. L. 101–239, § 6901(span)(3)(B), substituted “recognition of mental health and social service needs, care of cognitively impaired residents” for “cognitive, behavioral and social care”.

Subsec. (f)(2)(A)(iv). Puspan. L. 101–239, § 6901(span)(3)(C), (D), added cl. (iv).

Subsec. (f)(2)(B)(ii). Puspan. L. 101–239, § 6901(span)(4)(A), substituted “July 1, 1989” for “January 1, 1989”.

Subsec. (h)(3)(D). Puspan. L. 101–239, § 6901(d)(4)(D), substituted “not longer than 6 months after the effective date of the findings” for “not longer than 6 months”.

Subsec. (h)(8). Puspan. L. 101–239, § 6901(d)(1), inserted at end “The provisions of this subsection shall apply to a nursing facility (or portion thereof) notwithstanding that the facility (or portion thereof) also is a skilled nursing facility for purposes of subchapter XVIII.”

1988—Subsec. (span)(3)(A)(iii). Puspan. L. 100–360, § 411(l)(2)(B), struck out “in the case of a resident eligible for benefits under this subchapter,” before “uses an instrument”.

Subsec. (span)(3)(A)(iv). Puspan. L. 100–360, § 411(l)(2)(A), as amended by Puspan. L. 100–485, § 608(d)(27)(C), struck out “in the case of a resident eligible for benefits under part A of subchapter XVIII of this chapter,” before “includes the identification of medical problems”.

Subsec. (span)(3)(B)(ii)(III). Puspan. L. 100–360, § 411(l)(2)(C), amended subcl. (III) generally. Prior to amendment, subcl. (III) read as follows: “The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1320a–7a of this title.”

Subsec. (span)(4)(C)(i)(II). Puspan. L. 100–360, § 411(l)(3)(A)(i), inserted “professional” after “registered”.

Subsec. (span)(4)(C)(ii). Puspan. L. 100–360, § 411(l)(3)(A)(i)–(iv), in span, substituted “(ii) Waiver” for “(ii) Facility waivers.—(i) Waiver”, in subcl. (III), inserted “professional” after “registered”, and in concluding provisions, substituted “clause (iii)” for “clause (ii)” and “use” for “employ”.

Subsec. (span)(4)(C)(iii). Puspan. L. 100–360, § 411(l)(3)(A)(v), (vi), substituted “(iii) Assumption” for “(ii) Assumption” in span and “exercise” for “excercise” in text.

Subsec. (span)(5)(A). Puspan. L. 100–360, § 411(l)(3)(B), which directed amendment of subpar. (A) by striking “subparagraph (E)” and inserting “subparagraph (F)”, could not be executed because of prior amendment by Puspan. L. 100–360, § 411(l)(2)(D)(i), see Amendment note below.

Puspan. L. 100–360, § 411(l)(2)(D)(i), as amended by Puspan. L. 100–485, § 608(d)(27)(D), struck out “, who is not a licensed health professional (as defined in subparagraph (E)),” after “any individual” in introductory provisions.

Subsec. (span)(5)(A)(ii). Puspan. L. 100–360, § 411(l)(2)(D)(ii), substituted “nursing or nursing-related services” for “such services”.

Subsec. (span)(5)(G). Puspan. L. 100–360, § 411(l)(2)(D)(iii), inserted “physical or occupational therapy assistant,” after “occupational therapist,”.

Subsec. (c)(1)(B)(i). Puspan. L. 100–360, § 303(a)(2), inserted before semicolon at end “and of the requirements and procedures for establishing eligibility for medical assistance under this subchapter, including the right to request an assessment under section 1396r–5(c)(1)(B) of this title”.

Subsec. (c)(2)(A)(v). Puspan. L. 100–360, § 411(l)(2)(F), substituted “for a stay at the facility” for “an allowable charge imposed by the facility for an item or service requested by the resident and for which a charge may be imposed consistent with this subchapter and subchapter XVIII of this chapter”.

Subsec. (c)(2)(B)(iii)(III). Puspan. L. 100–360, § 411(l)(3)(C)(iii), as added by Puspan. L. 100–485, § 608(d)(27)(E), substituted “responsible” for “responsibile”.

Subsec. (c)(6). Puspan. L. 100–360, § 411(l)(2)(G), substituted “upon the written” for “once the facility accepts the written” in subpar. (A)(ii) and “Upon written” for “Upon a facility’s acceptance of written” in subpar. (B).

Subsec. (c)(7). Puspan. L. 100–360, § 411(l)(6)(B), amended Puspan. L. 100–203, § 4212(span), see 1987 Amendment note below.

Subsec. (e). Puspan. L. 100–360, § 411(l)(3)(C)(ii), as added by Puspan. L. 100–485, § 608(d)(27)(E), amended Puspan. L. 100–203, § 4211, see 1987 Amendment note below.

Subsec. (e)(1). Puspan. L. 100–360, § 411(l)(3)(D)(i), (ii), substituted “January 1, 1989” for “September 1, 1988” in subpar. (A) and “January” for “September” in subpar. (B).

Subsec. (e)(2)(B). Puspan. L. 100–360, § 411(l)(2)(H), inserted after first sentence “The State shall make available to the public information in the registry.”

Subsec. (e)(3). Puspan. L. 100–360, § 411(l)(2)(I), inserted “and discharges” after “transfers” in span and two places in text.

Subsec. (e)(7)(E). Puspan. L. 100–360, § 411(l)(3)(D)(iii), substituted “April 1, 1989” for “October 1, 1988”.

Subsec. (f). Puspan. L. 100–360, § 411(l)(3)(C)(ii), as added by Puspan. L. 100–485, § 608(d)(27)(E), amended Puspan. L. 100–203, § 4211, see 1987 Amendment note below.

Subsec. (f)(2)(A). Puspan. L. 100–360, § 411(l)(3)(D)(iv), substituted “September” for “July” in introductory provisions.

Subsec. (f)(2)(A)(i)(I). Puspan. L. 100–360, § 411(l)(2)(J), substituted “recognition of mental health and social service needs” for “cognitive, behavioral and social care”.

Subsec. (f)(3). Puspan. L. 100–360, § 411(l)(2)(I), inserted “and discharges” after “transfers” in span and in text.

Subsec. (f)(7)(A). Puspan. L. 100–360, § 411(l)(2)(K), substituted “residents” for “patients”.

Subsec. (f)(7)(B). Puspan. L. 100–360, § 411(l)(2)(L)(ii), substituted “include” for “do not include”.

Subsec. (g)(1)(C). Puspan. L. 100–360, § 411(l)(5)(A)–(C), substituted “and timely review” for “, review,”, inserted “or by another individual used by the facility in providing services to such a resident” after “a nursing facility”, and substituted “The State shall, after notice to the individual involved and a reasonable opportunity for a hearing for the individual to rebut allegations, make a finding as to the accuracy of the allegations. If the State finds that a nurse aide has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the nurse aide and the registry of such finding. If the State finds that any other individual used by the facility has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the appropriate licensure authority” for “If the State finds, after notice to the nurse aide involved and a reasonable opportunity for a hearing for the nurse aide to rebut allegations, that a nurse aide whose name is contained in a nurse aide registry has neglected or abused a resident or misappropriated resident property in a facility, the State shall notify the nurse aide and the registry of such finding”.

Subsec. (g)(1)(D). Puspan. L. 100–360, § 411(l)(5)(D), substituted “to issue regulations to carry out this subsection” for “to establish standards under subsection (f) of this section”.

Subsec. (g)(2)(A)(i). Puspan. L. 100–360, § 411(l)(5)(E), amended third sentence generally. Prior to amendment, third sentence read as follows: “The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1320a–7a of this title.”

Subsec. (g)(2)(B)(ii). Puspan. L. 100–360, § 411(l)(5)(F), as added by Puspan. L. 100–485, § 608(d)(27)(I), substituted “practicable” for “practical”.

Subsec. (g)(3)(C). Puspan. L. 100–360, § 411(l)(6)(A), redesignated subpar. (C), relating to special surveys of compliance, as (D).

Subsec. (g)(3)(D). Puspan. L. 100–360, § 411(l)(5)(G), formerly § 411(l)(5)(F), as redesignated by Puspan. L. 100–485, § 608(d)(27)(I), substituted “on the basis of that survey” for “on that basis”.

Subsec. (g)(4). Puspan. L. 100–360, § 411(l)(5)(H), formerly § 411(l)(5)(G), as redesignated by Puspan. L. 100–485, § 608(d)(27)(I), struck out “chronically” after “enforcement actions against” in last sentence.

Subsec. (h). Puspan. L. 100–360, § 411(l)(8)(A), made technical correction to directory language of Puspan. L. 100–203, § 4213(a), see 1987 Amendment note below.

Subsec. (h)(1). Puspan. L. 100–360, § 411(l)(8)(B)(i), substituted “paragraph (2)(A)(ii)”for “paragraph (2)(A)(i)” in last sentence.

Subsec. (h)(2)(B)(i). Puspan. L. 100–360, § 411(l)(8)(B)(ii), struck out “or otherwise” after “regulations”.

Subsec. (h)(3)(C)(ii). Puspan. L. 100–360, § 411(l)(7)(A), substituted “. The provisions of section 1320a–7a of this title (other than subsections (a) and (span)) shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1320a–7a(a) of this title” for “and the Secretary shall impose and collect such a penalty in the same manner as civil money penalties are imposed and collected under section 1320a–7a of this title”.

Subsec. (h)(5). Puspan. L. 100–360, § 411(l)(8)(B)(iii), substituted “State or the Secretary, respectively” for “State and the Secretary”.

Subsec. (h)(9). Puspan. L. 100–360, § 411(l)(7)(B), inserted “by such facilities” after “be made available”.

1987—Subsec. (c)(7). Puspan. L. 100–203, § 4212(span), as amended by Puspan. L. 100–360, § 411(l)(6)(B), added par. (7).

Subsecs. (e), (f). Puspan. L. 100–203, § 4211, which contained two subsecs. (c), the first of which amended this section and the second of which enacted provisions set out as a note below, was amended by Puspan. L. 100–360, § 411(l)(3)(C)(ii), to delete the designation, span, and directory language of the first subsec. (c), resulting in subsecs. (e) and (f) being added by section 4211(a)(3) of Puspan. L. 100–203, which enacted subsecs. (a) to (d) of this section.

Subsec. (g). Puspan. L. 100–203, § 4212(a), added subsec. (g).

Subsec. (h). Puspan. L. 100–203, § 4213(a), as amended by Puspan. L. 100–360, § 411(l)(8)(A), added subsec. (h).

Subsec. (i). Puspan. L. 100–203, § 4216, added subsec. (i).

Statutory Notes and Related Subsidiaries
Effective Date of 2010 Amendment

Amendment by section 6101(c)(1)(B) of Puspan. L. 111–148 effective on the date on which the Secretary of Health and Human Services makes the information described in section 6101(span) of Puspan. L. 111–148, set out as a note under section 1320a–3 of this title, available to the public, see section 6101(c)(2) of Puspan. L. 111–148, set out as a note under section 1395i–3 of this title.

Puspan. L. 111–148, title VI, § 6103(span)(2)(B), Mar. 23, 2010, 124 Stat. 709, provided that: “The amendment made by this paragraph [amending this section] shall take effect 1 year after the date of the enactment of this Act [Mar. 23, 2010].”

Amendment by section 6103(c)(2) of Puspan. L. 111–148 effective 1 year after Mar. 23, 2010, see section 6103(c)(3) of Puspan. L. 111–148, set out as a note under section 1395i–3 of this title.

Amendment by section 6111(span) of Puspan. L. 111–148 effective 1 year after Mar. 23, 2010, see section 6111(c) of Puspan. L. 111–148, set out as a note under section 1395i–3 of this title.

Amendment by section 6121(span) of Puspan. L. 111–148 effective 1 year after Mar. 23, 2010, see section 6121(c) of Puspan. L. 111–148, set out as a note under section 1395i–3 of this title.

Effective Date of 2006 Amendment

Puspan. L. 109–432, div. B, title IV, § 405(c)(2)(B), Dec. 20, 2006, 120 Stat. 3000, provided that the amendment made by section 405(c)(2)(B) is effective as if included in the amendment made by section 6015(a)(1) of the Deficit Reduction Act of 2005 [Puspan. L. 109–171].

Effective Date of 2003 Amendment

Amendment by Puspan. L. 108–173 applicable to appeals filed on or after Oct. 1, 2004, see section 932(d) of Puspan. L. 108–173, set out as a note under section 1395i–3 of this title.

Effective Date of 2000 Amendment

Amendment by Puspan. L. 106–554 effective Jan. 1, 2003, see section 1(a)(6) [title IX, § 941(c)] of Puspan. L. 106–554, set out as a note under section 1395i–3 of this title.

Effective Date of 1999 Amendment

Puspan. L. 106–4, § 2(span), Mar. 25, 1999, 113 Stat. 8, provided that: “The amendment made by subsection (a) [amending this section] applies to voluntary withdrawals from participation occurring on or after the date of the enactment of this Act [Mar. 25, 1999].”

Effective Date of 1997 Amendment

Puspan. L. 105–33, title IV, § 4754(span), Aug. 5, 1997, 111 Stat. 526, provided that: “The amendments made by subsection (a) [amending this section] take effect on the date of the enactment of this Act [Aug. 5, 1997].”

Effective Date of 1996 Amendment

Puspan. L. 104–315, § 1(span), Oct. 19, 1996, 110 Stat. 3824, provided that: “The amendments made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [Oct. 19, 1996].”

Puspan. L. 104–315, § 2(c), Oct. 19, 1996, 110 Stat. 3825, provided that: “The amendments made by this section [amending this section] shall apply to changes in physical or mental condition occurring on or after the date of the enactment of this Act [Oct. 19, 1996].”

Effective Date of 1992 Amendment

Amendment by Puspan. L. 102–375 inapplicable with respect to fiscal year 1993, see section 4(span) of Puspan. L. 103–171, set out as a note under section 3001 of this title.

Amendment by Puspan. L. 102–375 inapplicable with respect to fiscal year 1992, see section 905(span)(6) of Puspan. L. 102–375, set out as a note under section 3001 of this title.

Effective Date of 1990 Amendment

Amendment by section 4751(span)(2) of Puspan. L. 101–508 applicable with respect to services furnished on or after the first day of the first month beginning more than 1 year after Nov. 5, 1990, see section 4751(c) of Puspan. L. 101–508, set out as a note under section 1396a of this title.

Puspan. L. 101–508, title IV, § 4801(a)(6)(B), Nov. 5, 1990, 104 Stat. 1388–212, provided that: “The amendments made by subparagraph (A) [amending this section] shall take effect as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987 [Puspan. L. 100–203], except that a State may not approve a training and competency evaluation program or a competency evaluation program offered by or in a nursing facility which, pursuant to any Federal or State law within the 2-year period beginning on October 1, 1988

“(i) had its participation terminated under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] or under the State plan under title XIX of such Act [42 U.S.C. 1396 et seq.];
“(ii) was subject to a denial of payment under either such title;
“(iii) was assessed a civil money penalty not less than $5,000 for deficiencies in nursing facility standards;
“(iv) operated under a temporary management appointed to oversee the operation of the facility and to ensure the health and safety of the facility’s residents; or
“(v) pursuant to State action, was closed or had its residents transferred.”

Amendment by section 4801(a)(2)–(5), (7) of Puspan. L. 101–508 effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, Puspan. L. 100–203, see section 4801(a)(9) of Puspan. L. 101–508, set out as a note under section 1396span of this title.

Puspan. L. 101–508, title IV, § 4801(span)(9), Nov. 5, 1990, 104 Stat. 1388–215, provided that:

“(A)In general.—Except as provided in subparagraph (B), the amendments made by this subsection [amending this section] shall take effect as if they were included in the enactment of the Omnibus Budget Reconciliation Act of 1987 [Puspan. L. 100–203].
“(B)Exception.—The amendments made by paragraphs (4), (6), and (8) [amending this section] shall take effect on the date of the enactment of this Act [Nov. 5, 1990], without regard to whether or not regulations to implement such amendments have been promulgated.”

Puspan. L. 101–508, title IV, § 4801(d)(2), Nov. 5, 1990, 104 Stat. 1388–215, provided that: “The amendment made by paragraph (1) [amending this section] applies with respect to nursing facility services furnished on or after October 1, 1990, without regard to whether or not final regulations to carry out such amendment have been promulgated by such date.”

Puspan. L. 101–508, title IV, § 4801(e)(7)(B), Nov. 5, 1990, 104 Stat. 1388–217, provided that: “The amendments made by subparagraph (A) [amending this section] shall take effect on the date of the enactment of this Act [Nov. 5, 1990], without regard to whether or not regulations to implement such amendments have been promulgated.”

Amendment by section 4801(e)(2)–(6), (8)–(10), (12)–(15), and (18) of Puspan. L. 101–508 effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, Puspan. L. 100–203, see section 4801(e)(19) of Puspan. L. 101–508, set out as a note under section 1396a of this title.

Effective Date of 1989 Amendment

Amendment by section 6901(span)(1), (4)(A) of Puspan. L. 101–239 effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, Puspan. L. 100–203, and amendment by section 6901(span)(3) of Puspan. L. 101–239 applicable to nurse aide training and competency evaluation programs, and nurse aide competency evaluation programs, offered on or after end of 90-day period beginning on Dec. 19, 1989, but not to affect competency evaluations conducted under programs offered before end of that period, see section 6901(span)(6) of Puspan. L. 101–239, set out as a note under section 1395i–3 of this title.

Amendment by section 6901(d)(1) of Puspan. L. 101–239 effective Dec. 19, 1989, and amendment by section 6901(d)(4) of Puspan. L. 101–239 effective as if included in the enactment of the Omnibus Budget Reconciliation Act of 1987, Puspan. L. 100–203, see section 6901(d)(6) of Puspan. L. 101–239, set out as a note under section 1395i–3 of this title.

Effective Date of 1988 Amendment

Amendment by Puspan. L. 100–485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Puspan. L. 100–360, see section 608(g)(1) of Puspan. L. 100–485, set out as a note under section 704 of this title.

Amendment by section 303(a)(2) of Puspan. L. 100–360 applicable, except as otherwise provided, to payments under this subchapter for calendar quarters beginning on or after Sept. 30, 1989, without regard to whether or not final regulations to carry out such amendment has been promulgated by such date, see section 303(g)(1)(A), (5) of Puspan. L. 100–360, set out as an Effective Date note under section 1396r–5 of this title.

Except as specifically provided in section 411 of Puspan. L. 100–360, amendment by section 411(l)(2)(A)–(D), (F)–(K), (L)(ii), (3)(A), (B), (C)(ii), (iii), (D), (5), (6)(A), (B), (7), and (8)(A), (B) of Puspan. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Puspan. L. 100–203, effective as if included in the enactment of that provision in Puspan. L. 100–203, see section 411(a) of Puspan. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.

Effective Date

Puspan. L. 100–203, title IV, § 4214, Dec. 22, 1987, 101 Stat. 1330–219, as amended by Puspan. L. 100–360, title IV, § 411(l)(10), July 1, 1988, 102 Stat. 806, provided that:

“(a)New Requirements and Survey and Certification Process.—Except as otherwise specifically provided in section 1919 of the Social Security Act [42 U.S.C. 1396r], the amendments made by sections 4211 [enacting this section, amending sections 1320a–7span, 1396a, 1396span, 1396d, 1396j, 1396l, 1396n, 1396o, 1396p, 1396r, and 1396s of this title, redesignating section 1396r of this title as section 1396r–3 of this title, and amending provisions set out as a note under section 1396r–3 of this title] and 4212 [amending sections 1395cc, 1396a, 1396span, 1396i, and 1396r of this title] (relating to nursing facility requirements and survey and certification requirements) shall apply to nursing facility services furnished on or after October 1, 1990, without regard to whether regulations to implement such amendments are promulgated by such date; except that section 1902(a)(28)(B) of the Social Security Act [42 U.S.C. 1396a(a)(28)(B)] (as amended by section 4211(span) of this Act), relating to requiring State medical assistance plans to specify the services included in nursing facility services, shall apply to calendar quarters beginning more than 6 months after the date of the enactment of this Act [Dec. 22, 1987], without regard to whether regulations to implement such section are promulgated by such date.
“(span)Enforcement.—
(1) Except as otherwise specifically provided in section 1919 of the Social Security Act [42 U.S.C. 1396r], the amendments made by section 4213 of this Act [amending this section and sections 1396a and 1396span of this title] apply to payments under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] for calendar quarters beginning on or after the date of the enactment of this Act [Dec. 22, 1987], without regard to whether regulations to implement such amendments are promulgated by such date.
“(2) In applying the amendments made by this part [part 2 of subtitle C (§§ 4211–4218) of title IV of Puspan. L. 100–203, see Tables for classification] for services furnished before October 1, 1990
“(A) any reference to a nursing facility is deemed a reference to a skilled nursing facility or intermediate care facility (other than an intermediate care facility for the mentally retarded), and
“(B) with respect to such a skilled nursing facility or intermediate care facility, any reference to a requirement of subsection (span), (c), or (d) of section 1919 of the Social Security Act [42 U.S.C. 1396r(span), (c), (d)], is deemed a reference to the provisions of section 1861(j) or section 1905(c), respectively, of the Social Security Act [42 U.S.C. 1395x(j), 1396d(c)].
“(c)Waiver of Paperwork Reduction.—Chapter 35 of title 44, United States Code, shall not apply to information required for purposes of carrying out this part and implementing the amendments made by this part.”

Retroactive Review

For requirement that procedures developed by a State permit individual to petition for review of any finding made by a State under subsec. (g)(1)(C) of this section or section 1395i–3(g)(1)(C) of this title after Jan. 1, 1995, see section 4755(c) of Puspan. L. 105–33, set out as a note under section 1395i–3 of this title.

Nurse Aide Training and Competency Evaluation; Compliance Actions

Puspan. L. 101–508, title IV, § 4801(a)(1), Nov. 5, 1990, 104 Stat. 1388–211, provided that: “The Secretary of Health and Human Services shall not take (and shall not continue) any action against a State under section 1904 of the Social Security Act [42 U.S.C. 1396c] on the basis of the State’s failure to meet the requirement of section 1919(e)(1)(A) of such Act [42 U.S.C. 1396r(e)(1)(A)] before the effective date of guidelines, issued by the Secretary, establishing requirements under section 1919(f)(2)(A) of such Act, if the State demonstrates to the satisfaction of the Secretary that it has made a good faith effort to meet such requirement before such effective date.”

Preadmission Screening and Annual Resident Review; Compliance Actions

Puspan. L. 101–508, title IV, § 4801(span)(1), Nov. 5, 1990, 104 Stat. 1388–213, provided that: “The Secretary of Health and Human Services shall not take (and shall not continue) any action against a State under section 1904 or section 1919(e)(7)(D) of the Social Security Act [42 U.S.C. 1396c, 1396r(e)(7)(D)] on the basis of the State’s failure to meet the requirement of section 1919(e)(7)(A) of such Act before the effective date of guidelines, issued by the Secretary, establishing minimum criteria under section 1919(f)(8)(A) of such Act, if the State demonstrates to the satisfaction of the Secretary that it has made a good faith effort to meet such requirement before such effective date.”

Restriction on Enforcement Process

Puspan. L. 101–508, title IV, § 4801(c), Nov. 5, 1990, 104 Stat. 1388–215, provided that: “The Secretary of Health and Human Services shall not take (and shall not continue) any action against a State under section 1904 of the Social Security Act [42 U.S.C. 1396c] on the basis of the State’s failure to meet the requirements of section 1919(h)(2) of such Act [42 U.S.C. 1396r(h)(2)] before the effective date of guidelines, issued by the Secretary, regarding the establishment of remedies by the State under such section, if the State demonstrates to the satisfaction of the Secretary that it has made a good faith effort to meet such requirements before such effective date.”

Staffing Requirements

Puspan. L. 101–508, title IV, § 4801(e)(17), Nov. 5, 1990, 104 Stat. 1388–218, as amended by Puspan. L. 105–362, title VI, § 602(span)(1), Nov. 10, 1998, 112 Stat. 3286, provided that:

“(A)Maintaining regulatory standards for certain services.—Any regulations promulgated and applied by the Secretary of Health and Human Services after the date of the enactment of the Omnibus Budget Reconciliation Act of 1987 [Dec. 22, 1987] with respect to services described in clauses (ii), (iv), and (v) of section 1919(span)(4)(A) of the Social Security Act [42 U.S.C. 1396r(span)(4)(A)(ii), (iv), (v)] shall include requirements for providers of such services that are at least as strict as the requirements applicable to providers of such services prior to the enactment of the Omnibus Budget Reconciliation Act of 1987.
“(B)Study on staffing requirements in nursing facilities.—The Secretary shall conduct a study and report to Congress no later than January 1, 1999, on the appropriateness of establishing minimum caregiver to resident ratios and minimum supervisor to caregiver ratios for skilled nursing facilities serving as providers of services under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] and nursing facilities receiving payments under a State plan under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], and shall include in such study recommendations regarding appropriate minimum ratios.”

Nurse Aide Training and Competency Evaluation; Satisfaction of Requirements; Waiver

For satisfaction of training and competency evaluation requirements of subsec. (span)(5)(A) of this section and section 1395i–3(span)(5)(A) of this title and authorization for a State to waive such competency evaluation requirements, see section 6901(span)(4)(B)–(D) of Puspan. L. 101–239, set out as a note under section 1395i–3 of this title.

Publication of Proposed Regulations Respecting Preadmission Screening and Annual Resident Review

Puspan. L. 101–239, title VI, § 6901(c), Dec. 19, 1989, 103 Stat. 2300, provided that: “The Secretary of Health and Human Services shall issue proposed regulations to establish the criteria described in section 1919(f)(8)(A) of the Social Security Act [42 U.S.C. 1396r(f)(8)(A)] by not later than 90 days after the date of the enactment of this Act [Dec. 19, 1989].”

Evaluation and Report on Implementation of Resident Assessment Process

Puspan. L. 100–203, title IV, § 4211(c), Dec. 22, 1987, 101 Stat. 1330–196, directed Secretary of Health and Human Services to evaluate and report to Congress by not later than Jan. 1, 1993, on implementation of resident assessment process for residents of nursing facilities under amendments made by section 4211(c).

Report on Staffing Requirements

Puspan. L. 100–203, title IV, § 4211(k), Dec. 22, 1987, 101 Stat. 1330–207, directed Secretary of Health and Human Services to report to Congress, by not later than Jan. 1, 1993, on progress made in implementing the nursing facility staffing requirements of 42 U.S.C. 1396r(span)(4)(C), including the number and types of waivers approved under subparagraph (C)(ii) of such section and the number of facilities which received waivers.

Annual Report on Statutory Compliance and Enforcement Actions

Puspan. L. 100–203, title IV, § 4215, Dec. 22, 1987, 101 Stat. 1330–220, as amended by Puspan. L. 101–508, title IV, § 4801(span)(5)(B), Nov. 5, 1990, 104 Stat. 1388–214, provided that: “The Secretary of Health and Human Services shall report to the Congress annually on the extent to which nursing facilities are complying with the requirements of subsections (span), (c), and (d) of section 1919 of the Social Security Act [42 U.S.C. 1396r(span), (c), (d)] (as added by the amendments made by this part) and the number and type of enforcement actions taken by States and the Secretary under section 1919(h) of such Act (as added by section 4213 of this Act). Each such report shall also include a summary of the information reported by States under section 1919(e)(7)(C)(iv) of such Act.”