Nursing Homes

Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities

Nursing home surveys are conducted in accordance with survey protocols and Federal requirements to determine whether a citation of non-compliance appropriate.  Consolidated Medicare and Medicaid requirements for participation (requirements) for Long Term Care (LTC) facilities (42 CFR part 483, subpart B) were first published in the Federal Register on February 2, 1989 (54 FR 5316). The requirements for participation were recently revised to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety. The revisions were published in a final rule that became effective on November 28, 2016.

The survey protocols and interpretive guidelines serve to clarify and/or explain the intent of the regulations. All surveyors are required to use them in assessing compliance with Federal requirements.  Deficiencies are based on violations of the regulations, which are to be based on observations of the nursing home’s performance or practices.

The items in the downloads section below provide additional information about the background and overview of the final rule, frequently asked questions, and other related resources.

Update: April, 2024

CMS consistently strives to improve the effectiveness and efficiency of our nursing home oversight and compliance programs to protect residents’ health and safety. In 2017, CMS implemented a new nursing home survey process across all states, in conjunction with the implementation of revised Requirements for Participation for Long Term Care Facilities.  Over the last few years, we have continued to improve the consistency, accuracy, and efficiency of the nursing home survey process. We believe it is important to prioritize limited resources toward those areas that pose an increased risk to individuals’ health and safety. By modifying some surveys based on compliance and quality history, we will be able to devote more time and resources to nursing homes with lower quality whose residents are at higher risk of harm. This effort to prioritize resources for nursing home surveys has become more pressing as the budget for survey and certification has remained flatlined at $397 million since 2015. Please see the President’s Budget for additional information about the President's proposals to shift funding for nursing home surveys from discretionary to mandatory and increase funding to cover 100 percent of statutorily-mandated surveys.

CMS is testing a risk-based survey (RBS) approach that allows consistently higher-quality facilities to receive a more focused survey that takes less time and resources than the traditional standard recertification survey, while ensuring compliance with health and safety standards. Higher quality could be indicated by a history of fewer citations for noncompliance, higher staffing, fewer hospitalizations, and other characteristics (e.g., no citations related to resident harm or abuse, no pending investigations for residents at immediate jeopardy for serious harm, compliance with staffing and data submission requirements). The number of nursing homes that could meet these criteria would be limited, such as up to 10 percent of nursing homes within a state. The survey resources saved by performing a more focused review of the required areas of a standard survey in these higher quality facilities would then be available to perform more timely oversight of facilities where the risks to residents’ health and safety are greater. If any concerns about resident safety were encountered during the RBS, it would immediately be expanded. Resident safety will always be prioritized, regardless of the type of survey process. The RBS process would not apply to complaint surveys.

CMS is working with states to test this process over the next several months. We will provide updates as we progress, and any official or formal memoranda will be posted to the CMS website for Policy & Memos to States and CMS Locations.