What federal regulations relate to nursing home safety?

More than 15,000 nursing homes across the country care for millions of residents. These facilities are governed by federal regulations designed to maintain a quality standard of care and protect residents.

If you or a family member lives in a nursing home, knowing these laws can help you understand your rights and what can happen if federal regulations are violated.

Key federal regulations to know

Over the past several decades, concerns over the quality of care in nursing homes have risen.

In response, the federal government has enacted a number of different laws to protect elderly residents and hold these facilities accountable. Some of the major laws to know are:

1987 Nursing Home Reform Act (NHRA)

In 1986, the Institute of Medicine (IOM), now called the National Academy of Medicine, published a report that would lay the groundwork for legislation that still applies to nursing homes today.

The IOM report found significant evidence of poor quality of care, neglect, and abuse in nursing homes. As a result, the Nursing Home Reform Act (NHRA) was passed in 1987.

The NHRA outlines a minimum standard of care all nursing homes across the US must meet. Nursing home services mandated by the NHRA include:

• Nursing
• Pharmacy
• Dietary support
• Rehabilitation
• Social services, including a full-time social worker in facilities with more than 120 beds
• Individual care plans for residents
• Regular resident assessments

The nursing home must also be adequately staffed and keep accurate medical records for all residents.

Additionally, the NHRA includes a bill of rights for all nursing home residents, which guarantees the right to:

• Adequate medical care
• Respect and privacy
• Be free of abuse, neglect, and discrimination
• Be free of restraints
• Manage your money or choose someone you trust to do so
• Outside advocacy; your doctor and family should be notified if you injured or need any changes to your care plan
• Voice complaints
• Spend time with visitors
• Participate in activities

2010 Elder Justice Act (EJA)

In 2010, the Elder Justice Act (EJA) became law as part of the Patient Protection and Affordable Care Act (PPACA).

The EJA was specifically written to combat elder abuse, neglect, and exploitation and protects people aged 60 or older. It aims to do this by improving the prevention and detection of elder abuse through the coordination of reporting of such crimes.

Any nursing homes that receive $10,000 or more in federal funds are subject to EJA reporting requirements. The facility’s owners, managers, employees, and contractors are held responsible to the reporting requirements.

What needs to be reported?

Under EJA rules the following must be formally reported:

• Suspicion of a crime. Anyone subject to the reporting requirements under the EJA is required to report suspicions of any crime committed against an elderly resident. The report should be made to the Arizona Department of Health Services and local law enforcement. If serious physical harm comes to the victim of abuse, a report must be made within two hours of discovery. If the crime does not cause serious physical harm, it must be reported within 24 hours.
• Facility closure. The EJA also includes a 60-day closure window provision, which relates to reporting requirements for any facility that is closing. The facility must inform the state and the Secretary of the U.S. Department of Health and Human Services (HHS). When reporting the closure, the facility must provide information on how residents will be placed in new homes.
• Funding. The EJA provides funding for state Adult Protective Service (APS) programs. Arizona’s APS program is a part of the Division of Aging and Adult Services. This law also supports elder abuse forensic centers, which helps the victims of elder abuse.

The EJA also created the Elder Justice Coordinating Council and advisory board and an employee database.

The Elder Justice Coordinating Council is a federal entity that helps coordinate the federal government’s response to elder abuse, neglect, and exploitation.

The Secretary of HHS and the Attorney General are members of the council. The Advisory Board on Elder Abuse, Neglect, and Exploitation, also created under the EJA, provides support to the council.

How are federal regulations enforced?

Legislation like the NHRA and EJA were enacted at the federal level, but they are enforced in a few different ways.

State Agencies

Federal oversight outlines mandatory measures that all nursing homes must meet, but state agencies are largely responsible for regulatory enforcement. These agencies include:

• The Arizona Department of Health Services oversees licensing for long-term care facilities in the state.
• The Bureau of Long Term Care Licensing enforces compliance with both state and federal regulations. This body investigates complaints and surveys nursing homes.

Centers for Medicare and Medicaid

Nearly all nursing homes are certified by Medicare and Medicaid.

Only 4% are not certified by Medicare or Medicaid; the rest are certified by one or both.

The Centers for Medicare and Medicaid (CMS) work with the state agencies responsible for licensing to ensure nursing homes meet federal requirements.

CMS provides a State Operations Manual (SOM), which helps state surveyors complete their reviews of nursing homes. Nursing homes need to achieve CMS certification to receive reimbursement from Medicare and/or Medicaid. The state agency responsible conducts surveys of nursing homes at least once a year.

The National Nursing Home Initiative

The National Nursing Home Initiative is the federal government’s latest effort to enforce quality care in nursing homes.

In 2020, the Department of Justice launched the program to investigate the worst facilities in the country. As of March 2020, the initiative was investigating 30 different facilities across nine states.

Investigation through the initiative is being coordinated with the Elder Justice Initiative and the U.S. Attorney’s Office.

What are the consequences of violating federal regulations?

If a nursing home is found to be in violation of federal regulations, it faces a number of potential consequences, including:

• Corrections. CMS and state agencies can implement changes within a nursing home in response to violation of federal regulations. A nursing home may be subject to training, a plan of correction, temporary management changes, and removal of residents.
• Financial penalties. Under the EJA, both individuals and facilities are potentially subject to penalties. Individuals who fail to report within the required timeframe can face financial penalties up to $300,000. Facilities that retaliate against an individual who reports under EJA requirements face a fine of up to $200,000 and the possibility of losing federal funding.

Failure to comply with regulations like the EJA and NHRA can also result in loss of Medicare and Medicaid certification, which means the facility in question cannot receive reimbursement from CMS.

• Criminal charges. Individuals responsible for intentional abuse and neglect may be subject to criminal charges. For example, employees of a Florida nursing home were charged with manslaughter after 12 residents died due to overheating.
• Closure. A state agency may determine a nursing home is required to close due to regulatory violations. If this happens, residents will be given 30-day notice.
• Litigation. Violation of federal regulations can result in the harm or death of nursing home residents. The victims and their families can pursue a civil case against the facility. It is up to the state or federal government whether or not to pursue a criminal case against a facility or individuals.

Federal regulation exists to protect nursing home residents, but families still need to be vigilant. Only one in 23 cases of abuse is reported as mandated. If you suspect your family member is the victim of abuse in a nursing home, you do not have to wait for the facility to act.

FAQs about federal regulations for nursing homes

Understanding the basics of the regulations that guarantee nursing home residents can help you advocate for your loved ones. But, it can be confusing when a facility violates these regulations.

What do I do if I suspect a nursing home is violating federal regulations?

Federal regulations mandate nursing homes report any instances of abuse, neglect, or exploitation, but this does not always happen.

If you suspect your rights or the rights of your loved one guaranteed by federal law are being violated, you can file a complaint with the facility’s administration and the Arizona Department of Health. That state agency is required to investigate the complaint.

Can federal regulations help me pursue an abuse case against a nursing home?

Violating federal regulations opens a nursing home up to the possibility of civil and criminal action. If a nursing home is found to be non-compliant with any federal regulations designed to protect its residents, you and your family may be able to pursue a civil case.

A civil case can help you or your loved one receive a settlement as compensation for any abuse or neglect suffered.

Can I find out if a nursing home has disregarded federal regulations in the past?

Enforcement of federal regulations is meant to push facilities to reach compliance. As such nursing homes still operating today may have violated regulations in the past. If you are deciding on a nursing home or researching your loved one’s current facility, you can find out which facilities have faced regulatory action.

AZ Care Check is Arizona’s database. You can search a nursing home and find if the Arizona Department of Health Services has ever found it deficient. You can also use the federal government’s Nursing Home Compare tool to compare the quality of any nursing home certified by Medicare or Medicaid.

How could deregulation affect nursing homes?

The Trump administration has proposed measures that could roll back some federal regulations overseeing nursing homes.

The “Medicare & Medicaid Programs; Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency and Transparency” rule proposed by CMS would reduce standards for facility assessments and infection control, among other changes.

The changes are being made in an effort to reduce burden on long-term care facilities. Organizations, like the Center for Medicare Advocacy, argue that this type of deregulation is dangerous for the residents of nursing homes.