Medicare Rules for Nursing Homes

When looking for a nursing home for your loved one, a certified Medicare or Medicare/Medicaid long-term care facility should be at the top of your list. Certified facilities are federally regulated to ensure that your loved ones are receiving the proper care in well-managed facilities. The certification process is thorough and is designed to ensure quality care is given.

Certification and Compliance

• Surveyors can complete a variety of different surveys.

  More and more nursing homes are becoming both Medicare and Medicaid certified. The state certification for each is similar. In order for a skilled nursing facility to be funded by Medicare, it must be certified. Certification consists of the administration of a Life Safety Code survey and a Standard Survey by a state representative. These surveys are administered unannounced, are usually conducted in two consecutive days and can take place any time of the day. For certification candidates, if substantial issues are found, and the nursing home is not in compliance with federal standards, the state may recommend that the regional office deny certification. Generally for facilities already certified, standard surveys are conducted at least every 15 months to ensure that long-term care is accurately evaluated.

Survey Focus

• The Centers for Medicare & Medicaid Services evaluates nursing homes on specific criteria. Initially there is usually a general observation of the facility. Medication, kitchen and food services are observed. Care is taken to determine that there is no patient abuse. Assurance that residents' quality of life and care is sought. Sanitary conditions are noted. If, through administered surveys, unsatisfactory care is found, a follow-up survey is conducted.

Substandard Care

• When the survey process yields substandard care, an extended or partial extended survey is administered. The attending physician of each resident who received inadequate care is to be notified. The facilities will not be able to provide a nurse aide training and competency evaluation program for two years from the date of the finding of substandard quality of care. If there have been three consecutive findings of substandard care, payment can be denied for all new resident admissions. A state monitor may be assigned to the nursing home. The monitor will periodically visit to make sure the nursing home is functioning in compliance with federal rules. In other cases such as a resident complaint or change in facility administration, alternate, more focused surveys may be administered. Appropriate action is taken to get the facility to comply with Medicare-specific regulations to guarantee quality patient care and patient and staff safety.

Outcomes

• In most instances, several actions are taken to get the nursing home up to par with standard regulations including imposing fines, training and state monitoring. Eventually, if there is not sufficient compliance on the part of the nursing home after several attempts to get the facility to comply with quality assurance standards, the facility's privilege to care for Medicare residents is revoked. In such cases, Medicare-paying residents may be transferred to a new facility. In a worst case scenario, residents will be moved and the facility shut down.