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Description of Federal Requirements
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The Federal regulation
on Administration
(483.75), the last of the group of Federal regulations for
nursing-homes, deals with an assortment of topics, loosely related to
administration and management of resources. It is, therefore, one of
the longest of the federal regulations, with 16 main sections, a-p, and
many sub-parts. The umbrella requirement for the entire regulation is
that the nursing home “must be administered in a manner that enables it
to use its resources effectively and efficiently to attain or maintain
the highest practicable physical, mental, and psychosocial well-being of
each resident.”
Part (a)
requires that the nursing home be licensed under any applicable State
and local laws, Part (b) that it offer services in accordance with all
applicable, Federal, State, and local laws, regulations, and codes, and
“accepted professional standards and principles that apply to
professionals working in a nursing home;” and Part (c), that it meet
applicable sections of other Federal Health and Human Services
regulations; specifically cited are HHS rules on nondiscrimination on
the basis of race, color, or national origin, handicap, and age;
protection of human subjects; and prohibition of fraud and abuse. Under
Part (d), a governing body must be established with legal responsibility
for policies governing the facility and appointing an administrator; the
administrator must be licensed by States that so require, and is
responsible for the management of the facility.
Part (e),
called required training of nursing aides, is a lengthy section
referring to training and competency, registry verification, required
retraining, and in-service education. First, a definition section
defines licensed health practitioner to include a physician,
physician assistant, nurse practitioner, physical therapist,
occupational therapist, speech therapist, physical or occupational
therapist assistant, registered professional nurse, licensed practical
nurse, or licensed or certified social worker. By default nurse aide
is defined as any individual “providing nursing or nursing-related
services” to residents in a facility who are not licensed health
professionals (as defined above), a registered dietician, or volunteers
who provide such services without pay. Then the general rule is
enunciated that the facility must not use any person as a nurse’s aide
on a full-time basis for more than four months unless they are trained
in a State-approved training program and competent. Before hiring a
nurse’s aide, the facility must verify that competence through registry
verification or proof that the applicant is currently enrolled in an
approved course or recently completed one. The facility also must check
information about that applicant from all existing State registries. If
for 24 consecutive months since training and competency examination, the
individual has not been employed as a nurse’s aide, a new training and
competency evaluation or a new competency examination must be completed.
Each facility must review the performance of each nurse’s every 12
months, and must provide regular in-service education based on this
review. The in-service education must be sufficient to ensure continuing
competence but at least 12 hours per year. It must address any areas of
weakness as shown in the performance reviews, and it may address special
needs of current residents. If the nurse’s aides are caring for
residents with cognitive impairment, they must receive continuing
education about that topic. A brief Part (f) requires the facility to
ensure that nurse’s aides can demonstrate “competency I skills and
techniques necessary to care or resident’s needs as identified through
resident assessments and described in the plan of care.
Part (g)
requires that the facility employ on a full-time, part-time, or
consultant basis all professionals needed to carry out all the Federal
nursing home regulations and that these professionals be licensed,
certified, or registered as required by the particular State laws. Part
(h), refers to use of outside resources, essentially requiring
that professionals and professional services arranged under contract
must meet prevailing standards, and that, in written contractual
agreements, the facility must undertake responsibility for meeting
professional standards for all those working in the facility and
ensuring the timeliness of services. Part (i) requires that the
facility designate a medical director who is responsible for
implementing resident care policies, and coordinating medical care in
the nursing home. Part (j) sets up standards for providing or obtaining
laboratory services (including blood bank and transfusion
services, if provided in the facility), clarifies that all laboratory
services provided or obtained are under order from the attending
physician, that the facility assist residents as necessary to be
transported for such outside services, and that the facility notify the
physician promptly of results and file the laboratory reports in the
resident’s records. Part (k) specifies parallel standards for providing
or obtaining radiology and diagnostic services under physician
orders. Part (l) relates to clinical records, requiring that
quires the facility maintain records in accordance with professional
standards that are complete, accurate, readily accessible, and
systematically organized. They must be retained for the period required
by the State or for 5 years if the State lacks such standard. The
records must be safeguarded against loss, destruction, or unauthorized
use, and be held confidentially except for specified required releases
for transfer to other facilities, legal, or insurance reasons. This
section states five requirements for the content of the records:
sufficient identifying information to identify the resident, a record of
the resident’s assessments, the plan of car and the services provided,
the results of any preadmission screening conducted by the State, and
progress notes. It should also be noted that in addition to the
discussion in the Administration regulation in Subpart B (which contains
all enumerated Federal Regulations), a separate Subsection D contains
Requirements That Must be met by States and State Agencies: Nurse Aide
Training and Competency Evaluation, and Paid Feeding Assistants
deals specifically with training, evaluation, and curriculum
requirements for CNAs and curriculum requirements for paid feeding
assistants.
Part (m)
requires disaster and emergency preparedness. First, the facility must
have “detailed written plans and procedures to meet all potential
emergencies and disasters, such as fire, severe weather, and missing
residents;” and, second, the facility must train all employees in
emergency procedures upon employment, periodically review the procedures
with existing staff, and carry out unannounced staff fire drills using
these procedures.
Part (n)
requires that the facility have written transfer agreements with one or
more hospitals in the area approved for Medicare and Medicaid to
reasonably assure that residents in need of care will have timely
transfer to hospital accompanied by appropriate information. A facility
will have met this requirement if it has made good faith attempts to
enter into agreement with a hospital close enough to the facility to
make transfer feasible.
Part (o)
requires that the facility maintain a quality assessment and assurance
committee that consists of the director of nursing services, a physician
designated by the facility, and at least 3 other facility staff members;
that the committee meet at least quarterly to determine which quality
assessment and assurance activities are needed, and develop plans of
actions related to correct identified deficits in quality. Information
derived from quality assurance activities are explicitly protected from
use against the facility in legal or regulatory activity. Neither State
nor the Secretary of the U.S. Department of Health and Human Services
may require disclosure of the records of the committee (except as proof
of compliance with the quality assurance regulation) nor may they use
good faith efforts to correct quality deficits as a basis for
sanctioning the facility.
Finally,
Part (p) requires that the facility disclose its ownership, and provide
the State licensing agency with information about the following changes:
controlling ownership; officers, directors, agents, or managing
employees; the corporation, association, or other company responsible
for the facility management; and the facility administrator or director
of nursing. Such notice must include the names of the new individuals
or companies assuming the roles after the change.
Comparison of State Requirements
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|
483.70 Administration |
|
State |
Goes beyond
Federal
Regulations? |
Subjects addressed: How State differs from
or expands on Federal Regulations |
|
Alabama |
Yes |
Ownership disclosure amplification (including
time period for reporting); accounting standards; acting
administrator during latter’s absence; person to laboratory
(reference to bedside glucose testing); 24 hour time period
for reporting fires or disasters. |
|
Alaska |
Yes |
Medical director (experimental drug
protocols); duties of administrator. |
|
Arizona |
Yes |
Duties of administrator; limitations in
serving as both hospital and NH administrator; ownership
changes (timing of reporting); disaster and emergency
preparedness (map of evacuation posted at nursing stations);
medical director role; quality assurance.
|
|
Arkansas |
Yes |
Administrator hours on premises and
substitution plans; Administrators-in-Training; Written
policies maintained by administrator. |
|
California |
Yes |
Administrator role; administrator
responsibility for multiple facilities; administrator
coverage; governance structure (3 required
committees). |
|
Colorado |
Yes |
Quality assurance; administrator
responsibility; facility plan of organization; staffing
plan; department structure; staff development (coordinator,
program, documentation); records on employees; staff
identification badges; medical director duties. |
|
Connecticut |
Yes |
Duties of governing body; Administrator
(credentials, application process & references; duties;
coverage based on size of facility; prohibitions against
serving as DON); Medical director (role, organized medical
staff); Nurse’s Aide training and competency (including
instructor credentials); Registries (foreign training);
Clinical records (contents, format details, retaining 10
years). |
|
Delaware |
Yes |
Nurse aides trained outside of Delaware;
Nurse aide role and function; nurse aide competencies;
detailed curriculum; instructor credentials. |
|
District of
Columbia |
Yes |
Administrative management, requirements, fees
and policies for personnel and resident care. |
|
Florida |
Yes |
License to provide adult day care or respite
(part of Gold Seal program); Gold Seal quality recognition
program, in general; Clinical Records (includes records of
all services provided by nurse’s aides; Fiscal records;
Reporting requirements on turnover, & vacant beds; Internal
quality assurance and risk management program; State program
of nurse quality monitors (includes quality assurance early
warning system; Nurse aide training and competency;
Confidentiality and conditions of disclosure of QA
activities, risk management, and State monitoring. |
|
Georgia |
Yes |
Administrator (multiple facilities);
Policies; Personnel folders; Home and premises only used for
purposes permitted. |
|
Hawaii |
Yes |
Disaster preparedness; Clinical records;
Other records that facility must keep. |
|
Idaho |
Yes |
Disclosures of ownership; Administrator
(hospital administrators as NH administrator; backup;
duties); |
|
Illinois |
Yes |
Disclosure of ownership (change of
administrator disclosed in 5
days); Administrator (backup,
duties of administrator); nurse’s aide registry and
employment requirements; Nurse’s aide training; Disaster
preparedness; Medical director. |
|
Indiana |
Yes |
Administrator (notification of change,
substitute, role); Policies; Notifications; Disaster
preparedness; Transfer agreements with hospitals; Medical
Director role; Screening of prospective employees; Nurse’s
aide training and competency (curriculum); in-service
training. |
|
Iowa |
Yes |
Administrator (more than one facility,
provision administrator, temporary backup, assistant
administrator, roles); Medical director (roles). |
|
Kansas |
Yes |
Licensure (detailed instructions and criteria
for applications); disclosures of ownership; disclosures on
construction plans and alterations thereto; Administrator
(written job description; criteria for more than one
facility; backup during absences); Required reports on staff
and residents; Smoking policy; Clinical Records (contents,
clinical record staff); Disaster preparedness. |
|
Kentucky |
Yes |
Governance (policies); Personnel job
descriptions; In-service education. |
|
Louisiana |
Yes |
Disclosures of change in administrator;
Administrator backup; Personnel records; Outside services
(annual verification of credentials); Written policies;
In-service training; disaster preparedness. |
|
Maine |
Yes |
Administrator (exemption of hospital-based,
substitute for absence; emergency administrator, coverage;
shared administrator, quality assurance (reporting,
utilization review requirements), Professional policies;
Employment conditions (including grievances, employee
records, time schedule); In-service training. |
|
Maryland |
Yes |
Administrator (multiple facilities, relief,
absenteeism, character); Voluntary admission ceiling
policies; Employee records; Orientation (supportive
personnel orientation); Medical director (a very detailed
section on credentials, role, reporting, QA; duties of
others in relationship to medical director, among other
elements); Training (curriculum); Registry; Quality
assurance (committee composition, duties, elements of QA
plan, including incident reporting). |
|
Massachusetts |
Yes |
Administrator (coverage, alternate, role);
Policy responsibility of administrator and licensee;
Employee records and employee health; incidence reporting;
licensure (voluminous material regarding license
applications, renewals, denial or loss of license, appeals;
non-transferability of license, posting of license, name of
facility, transfer of ownership; intent to close). |
|
Michigan |
Yes |
Administrator (coverage); Nurse aide
competency (random competency exams by surveyors). |
|
Minnesota |
Yes |
Administrator, (absence requirements, roles,
medical director). |
|
Mississippi |
Yes |
Administrator (alternative in his/her
absence, responsibilities); Criminal checks (definition of
employee for purpose; exemption of students on signing
affidavit); Organizational chart; Administrator (alternative
for absences, age, character); after 2001, a mandatory 2-day
mentoring by the Survey & Certification agency. |
|
Missouri |
No |
Echoes federal requirements. |
|
Montana |
Yes |
CNA competence and testing; Allowable costs;
Reimbursable services under Medicaid; License (application
and renewal, licensing food establishment); Nurse aide
training (curriculum). |
|
Nebraska |
Yes |
Licensee responsibility; Administrator
(coverage; multiple facility; notification of changes;
responsibility; Staff credentials; Employee health; disaster
preparedness. |
|
Nevada |
Yes |
Quality assurance; Incident reporting;
Administrator (coverage, alternate for absences,
responsibilities); quality assurance (core team to
participate, responsibility, procedures, reporting and
records). |
|
New Hampshire |
Yes |
Administrator (coverage, alternate in
absence, responsibility); Personnel and staffing records;
Employee health; Nurse aide registry. |
|
New Jersey |
Yes |
Administrator (coverage, multiple, vacancy,
qualifications); Mandatory job descriptions; Advisory staff;
Mandatory resident communications; Staff development
(curriculum on communication, topics, frequency, Medical
director; Emergency preparedness (smoking policies, fire
drills, evacuation procedures, emergency supplies); Quality
assurance (monitoring of QIs, source of information includes
gathering information from residents and visitors); Periodic
satisfaction surveys of families; Clinical records. |
|
New Mexico |
Yes |
Administrator (coverage, multiple facilities,
temporary replacement). |
|
New
York |
Yes |
Radiology services; Clinical records;
Administrator (role, setting an example for accessibility
and communication, coverage, multiple facilities, vacancy;
temporary acting administrator, responsibilities); RUGS
classification system (informing residents of it); Governing
body available to meet with resident council at least 3
times a year; Orientation (includes volunteers, private duty
personnel and consultants; content of orientation); Employee
health; Organization chart and policy manual; Nurse aide
training (instructors, curriculum, competency testing);
Quality assurance (committee composition, procedures;
selection of topics and residents for review.
|
|
North Carolina |
Yes |
Administrator (full-time). |
|
North Dakota |
Yes |
Administrator (alternatives in absence),
Personnel policies (job descriptions); Quality improvement.
|
|
Ohio |
Yes |
Nursing-related services (definition);
Nurse’s aide training; Competency exam (prohibition of
charging aide for it); Orientation; In-service (including
for specialty units); Medical director; Disaster
preparedness (training, evacuation, fire drills; Quality
assurance (monitoring trends). |
|
Oklahoma |
Yes |
Administrator (alternative in absence);
Administrative records (includes copies of all contracts,
resident council records, transfer agreement, transportation
agreements, etc); Job descriptions; Nursing policy and
procedure manual; Employee health; Inventory of residents
possessions; Quality assurance (committee composition);
Medical director; .Quality assurance. |
|
Oregon |
Yes |
Employment (reference check, rules for
prohibition of employment; Consultant report; Quality
assurance (policies required, procedures for audits;
Administrator (multiple facilities; alternative for
absences; Medical director; Clinical records (filing,
content, format); Orientation (topics); In-services
training. |
|
Pennsylvania |
Yes |
Governance (by-laws); Administrator (multiple
facilities, coverage, alternative for absences;
responsibilities); Clinical Records (retention for 7 years,
record content). |
|
Rhode Island |
Yes |
Governing body (conflict of interest policy);
Quality assurance; Administrator (coverage, alternative for
absences, responsibilities); Notification of labor actions;
Medical director; Criminal records checks (disqualifying
offenses); Employees (job descriptions, employee health,
employee records); In-service training (content); employee
photo IDs; Professional license verification; Clinical
records (content); Resident care policies; Disaster
preparation. |
|
South Carolina |
Yes |
Administrator (coverage, hours, alternative
in absence; Employee health records; Voluntary workers and
private sitters. |
|
South Dakota |
Yes |
Administrator (credentials, alternative
during absences, Personnel policies; Employee health;
Emergency preparedness. |
|
Tennessee |
Yes |
Administrator (hours and coverage; hospital
based administrator; unexpected loss of administrator;
notification of loss, temporary replacement policies);
replacement notice and policies; Criminal checks; Policies
and procedures (including pain assessment and end-of-life
care; Quality improvement; Medical director; Disaster
preparedness (extremely detailed section); Nurse aide
training and competency testing. |
|
Texas |
Yes |
Licensure (application, building approval,
ownership changes; Alzheimer’s programs; disclosures,
renewal, revocation); Governing body; Administrator
(coverage). |
|
Utah |
Yes |
Administrator (only one facility; alternative
in absence, responsibilities); Contracts; Policies; Employee
records and employee health; Volunteers; Quality assurance;
Clinical and other records; Emergency preparedness. |
|
Vermont |
Yes |
Licensure; Quality assurance (committee
composition). |
|
Virginia |
Yes |
Bed capacity; Employee records and employee
health; Administrator (full time; changes and notifications,
alternative for absences); Administrative policies; Quality
assurance (committee composition, procedures); Medical
director; Disaster preparedness; In-service training
(content, recording. |
|
Washington |
Yes |
Administrator (coverage, alternate for
absences, multiple facilities); Policies (written policies,
whistle blower protection); Notifications and mandated
reports; Name badges (residents have sufficient information
to distinguish types of nurses(; Staff development program;
Clinical and other records (content, retain 8 years;
qualifications of record personnel, index system,
legibility); Disaster preparedness; Quality assurance (must
seek out input from resident and family groups); Criminal
checks (disqualifying offences, disclosure to staff member
or applicant). |
|
West Virginia |
Yes |
Disaster training; Quality assurance.
|
|
Wisconsin |
Yes |
Administrator (multiple facilities, alternate
in absence, termination, notice of changes, temporary
replacement); Employee and volunteer health; Orientation;
In-service (nursing, dietary); Employee records; Clinical
records; Social work and activity records; Administrative
records; Disaster preparedness. |
|
Wyoming |
Yes |
Administrator (coverage, multiple facilities,
alternate for absences; changes and temporary administrator,
notification of changes); Policies; Employee health; Staff
development. |
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