Skilled Nursing Facility (SNF)-Waiver of Requirement for a

7014.1.1 - Skilled Nursing Facility (SNF)-Waiver of Requirement for a Registered Nurse (RN) More than 40 Hours a Week (Rev. 244; Issued: 06-26-26; Effective: 06-26-26; Implementation: 06-26-26) §483.35(f) Waiver of the requirement to provide services of a registered nurse for more than 40 hours a week. (1) The Secretary may waive the requirement that a SNF provide the services of a registered nurse for more than 40 hours a week, including a director of nursing specified in paragraph (b) of this section, if the Secretary finds that— (i) The facility is located in a rural area and the supply of skilled nursing facility services in the area is not sufficient to meet the needs of individuals residing in the area; (ii) The facility has one full-time registered nurse who is regularly on duty at the facility 40 hours a week; and (iii) The facility either— (A) Has only patients whose physicians have indicated (through physicians’ orders or admission notes) that they do not require the services of a registered nurse or a physician for a 48-hours period or; (B) Has made arrangements for a registered nurse or a physician to spend time at the facility, as determined necessary by the physician, to provide necessary skilled nursing services on days when the regular full-time registered nurse is not on duty; (iv) The Secretary provides notice of the waiver to the Office of the State Long- Term Care Ombudsman (established under section 712 of the Older Americans Act of 1965) and the protection and advocacy system in the State for individuals with developmental disabilities or mental disorders; and (v) The facility that is granted such a waiver notifies residents of the facility and their resident representatives of the waiver. (2) A waiver of the registered nurse requirement under paragraph (f)(1) of this section is subject to annual renewal by the Secretary. The CMS Location, acting on behalf of the Secretary, may waive the requirement for services of an RN 8 consecutive hours a day, 7 days a week. However, the facility must still have an RN 40 hours a week (i.e., the waiver only permits the facility to not have an RN for a period of two days (48 hours). Also, CMS may waive the other requirement that the facility must designate an RN to serve as the director of nursing on a full-time basis. To grant a waiver on these requirements, the state agency obtains the following information below, which is then forwarded to the CMS Location: a) The facility is located in a rural area and the supply of skilled nursing facility services is not sufficient to meet area needs. Rural means all areas not delineated as “urban” by the Bureau of Census, based on the most recent census. b) The facility has one full-time registered nurse regularly on duty 40 hours a week. This may be the same individual or part-time individuals. This nurse may or may not be the Director of Nursing and may perform some Director of Nursing and some clinical duties if the facility so desires. The facility must provide evidence of this, which may be in the form of a time- sheet/card or salary information showing an RN onsite for 40 hours a week (schedule of when an RN is supposed to work is not acceptable). c) The facility meets either of the following conditions: i. The facility has residents whose physicians have indicated, through admission notes or physicians’ orders, that the residents do not need RN or physician care for a 48-hour period; or ii. A physician or RN will spend the necessary time at the facility to provide the care that residents need during the days that an RN is not on duty. This requirement refers to clinical care of the residents who need skilled nursing services. For facilities that were granted a waiver under section 483.35(f) the prior year: the facility must provide evidence that they notified the residents of the facility, their guardians or their resident representatives (where appropriate), and members of their immediate families of the waiver. If a facility does not have evidence of this, they may be granted another waiver if they meet all other requirements, as long as the facility provides evidence that the residents and their representatives have been notified of the waiver (e.g., within 30 days). If the facility does not provide this evidence, the waiver is rescinded. The state agency forwards the above information to the CMS Location for review, and the CMS Location grants the waiver after confirming all of the requirements are met. If a waiver is granted, the CMS Location, must provide notice of the waiver to the State long- term care ombudsman and to the State protection and advocacy system for the mentally ill and intellectually disabled. The facility granted such a waiver must notify residents of the facility (or responsible guardians) and members of their immediate families of the waiver. A waiver of the RN requirement is subject to annual renewal by the Secretary.