REQUIREMENTS FOR SKILLED NURSING FACILITIES.

SEC. 4201. REQUIREMENTS FOR SKILLED NURSING FACILITIES. (a) Specification of Facility Requirements.— Title XVIII of the Social Security Act is amended— (1) by amending subsection (j) of section 1861 (42 U.S.C. 1395x) to read as follows: “Skilled Nursing Facility “(j) The term ‘skilled nursing facility’ has the meaning given such term in section 1819(a).”; (2) by adding at the end of section 1864 (42 U.S.C. 1395aa) the following new subsection: “(d) The Secretary may not enter an agreement under this section with a State with respect to determining whether an institution therein is a skilled nursing facility unless the State meets the requirements specified in section 1819(e).”; and (3) by adding at the end of part A the following new section: “requirements for, and assuring quality of care in, skilled nursing facilities “Sec. 1819. (a) Skilled Nursing Facility Defined.— In this title, the term ‘skilled nursing facility’ means an institution (or a distinct part of an institution) which— “(1) is primarily engaged in providing to residents— “(A) skilled nursing care and related services for residents who require medical or nursing care, or “(B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases; “(2) has in effect a transfer agreement (meeting the requirements of section 1861(1)) with one or more hospitals having agreements in effect under section 1866; and “(3) meets the requirements for a skilled nursing facility described in subsections (b), (c), and (d) of this section. “(b) Requirements Relating to Provision of Services.— “(1) Quality of life.— “(A) In general.— A skilled nursing facility must care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident, 101 STAT. 1330–161 “(B) Quality assessment and assurance.— A skilled nursing facility must maintain a quality assessment and assurance committee, consisting of the director of nursing services, a physician designated by the facility, and at least 3 other members of the facility’s staff, which (i) meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary and (ii) develops and implements appropriate plans of action to correct identified quality deficiencies. “(2) Scope of services and activities under plan of care.— A skilled nursing facility must provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with a written plan of care which— “(A) describes the medical, nursing, and psychosocial needs of the resident and how such needs will be met; “(B) is initially prepared, with the participation to the extent practicable of the resident or the resident’s family or legal representative, by a team which includes the resident’s attending physician and a registered professional nurse with responsibility for the resident; and “(C) is periodically reviewed and revised by such team after each assessment under paragraph (3). “(3) Residents’ assessment.— “(A) Requirement.— A skilled nursing facility must conduct a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity, which assessment— “(i) describes the resident’s capability to perform daily life functions and significant impairments in functional capacity; “(ii) is based on a uniform minimum data set specified by the Secretary under subsection (f)(6)(A); “(iii) in the case of a resident eligible for benefits under title XIX, uses an instrument which is specified by the State under subsection (e)(5); and “(iv) in the case of a resident eligible for benefits under part A of this title, includes the identification of medical problems. “(B) Certification.— “(i) In general.— Each such assessment must be conducted or coordinated (with the appropriate participation of health professionals) by a registered professional nurse who signs and certifies the completion of the assessment. Each individual who completes a portion of such an assessment shall sign and certify as to the accuracy of that portion of the assessment. “(ii) Penalty for falsification.— “(I) An individual who willfully and knowingly certifies under clause (i) a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 with respect to each assessment. “(II) An individual who willfully and knowingly causes another individual to certify under clause (i) a material and false statement in a resident assess-101 STAT. 1330–162ment is subject to a civil money penalty of not more than $5,000 with respect to each assessment. “(III) The Secretary shall provide for imposition of civil money penalties under this clause in a manner similar to that for the imposition of civil money penalties under section 1128A. “(iii) Use of independent assessors.— If a State determines, under a survey under subsection (g) or otherwise, that there has been a knowing and willful certification of false assessments under this paragraph, the State may require (for a period specified by the State) that resident assessments under this paragraph be conducted and certified by individuals who are independent of the facility and who are approved by the State. “(C) Frequency.— “(i) In general.— Such an assessment must be conducted— “(I) promptly upon (but no later than 4 days after the date of) admission for each individual admitted on or after October 1, 1990, and by not later than October 1, 1990, for each resident of the facility on that date; “(II) promptly after a significant change in the resident’s physical or mental condition; and “(III) in no case less often than once every 12 months. “(ii) Resident review.— The skilled nursing facility must examine each resident no less frequently than once every 3 months and, as appropriate, revise the resident’s assessment to assure the continuing accuracy of the assessment. “(D) Use.— The results of such an assessment shall be used in developing, reviewing, and revising the resident’s plan of care under paragraph (2). “(E) Coordination.— Such assessments shall be coordinated with any State-required pre-admission screening program to the maximum extent practicable in order to avoid duplicative testing and effort. “(4) Provision of services and activities.— “(A) In general.— To the extent needed to fulfill all plans of care described in paragraph (2), a skilled nursing facility must provide, directly or under arrangements (or, with respect to dental services, under agreements) with others for the provision of— “(i) nursing services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; “(ii) medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; “(iii) pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; 101 STAT. 1330–163 “(iv) dietary services that assure that the meals meet the daily nutritional and special dietary needs of each resident; “(v) an on-going program, directed by a qualified professional, of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident; and “(vi) routine and emergency dental services to meet the needs of each resident. The services provided or arranged by the facility must meet professional standards of quality. Nothing in clause (vi) shall be construed as requiring a facility to provide or arrange for dental services described in that clause without additional charge. “(B) Qualified persons providing services.— Services described in clauses (i), (ii), (iii), (iv), and (vi) of subparagraph (A) must be provided by qualified persons in accordance with each resident’s written plan of care. “(C) Required nursing care.— “(i) In general.— Except as provided in clause (ii), a skilled nursing facility must provide 24-hour nursing service which is sufficient to meet nursing needs of its residents and must employ the services of a registered professional nurse at least during the day tour of duty (of at least 8 hours a day) 7 days a week. “(ii) Exception.— To the extent that clause (i) may be deemed to require that a skilled nursing facility engage the services of a registered professional nurse for more than 40 hours a week, the Secretary is authorized to waive such requirement if the Secretary finds that— “(I) the facility is located in a rural area and the supply of skilled nursing facility services in such area is not sufficient to meet the needs of individuals residing therein, “(II) the facility has one full-time registered professional nurse who is regularly on duty at such facility 40 hours a week, and “(III) the facility either has only patients whose physicians have indicated (through physicians’ orders or admission notes) that each such patient does not require the services of a registered nurse or a physician for a 48-hour period, or has made arrangements for a registered professional nurse or a physician to spend such time at such facility as may be indicated as necessary by the physician to provide necessary skilled nursing services on days when the regular full-time registered professional nurse is not on duty. A waiver under this subparagraph shall be subject to annual renewal. “(5) Required training of nurse aides.— “(A) In general.— A skilled nursing facility must not use (on a full-time, temporary, per diem, or other basis) any individual, who is not a licensed health professional (as defined in subparagraph (E)), as a nurse aide in the facility on or after October 1, 1989, (or January 1, 1990, in the case of an individual used by the facility as a nurse aide before101 STAT. 1330–164 July 1, 1989) for more than 4 months unless the individual— “(i) has completed a training and competency evaluation program, or a competency evaluation program, approved by the State under subsection (e)(1)(A), and “(ii) is competent to provide such services. “(B) Offering competency evaluation programs for current employees.— A skilled nursing facility must provide, for individuals used as a nurse aide by the facility as of July 1, 1989, for a competency evaluation program approved by the State under subsection (e)(1) and such preparation as may be necessary for the individual to complete such a program by January 1, 1990. “(C) Competency.— The skilled nursing facility must not permit an individual, other than in a training and competency evaluation program approved by the State, to serve as a nurse aide or provide services of a type for which the individual has not demonstrated competency and must not use such an individual as a nurse aide unless the facility has inquired of the State registry established under subsection (e)(2)(A) as to information in the registry concerning the individual. “(D) Re-training required.— For purposes of subpagraph (A), if, since an individual’s most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual performed nursing or nursing-related services for monetary compensation, such individual shall complete a new training and competency evaluation program. “(E) Regular in-service education.— The skilled nursing facility must provide such regular performance review and regular in-service education as assures that individuals used as nurse aides are competent to perform services as nurse aides, including training for individuals providing nursing and nursing-related services to residents with cognitive impairments. “(F) Nurse aide defined.— In this paragraph, the term ‘nurse aide’ means any individual providing nursing or nursing-related services to residents in a skilled nursing facility, but does not include an individual— “(i) who is a licensed health professional (as defined in subparagraph (G)), or “(ii) who volunteers to provide such services without monetary compensation. “(G) Licensed health professional defined.— In this paragraph, the term ‘licensed health professional’ means a physician, physician assistant, nurse practitioner, physical, speech, or occupational therapist, registered professional nurse, licensed practical nurse, or licensed or certified social worker. “(6) Physician supervision and clinical records.— A skilled nursing facility must— “(A) require that the medical care of every resident be provided under the supervision of a physician; “(B) provide for having a physician available to furnish necessary medical care in case of emergency; and 101 STAT. 1330–165 “(C) maintain clinical records on all residents, which records include the plans of care (described in paragraph (2)) and the residents’ assessments (described in paragraph (3)). “(7) Required social services.— In the case of a skilled nursing facility with more than 120 beds, the facility must have at least one social worker (with at least a bachelor’s degree in social work or similar professional qualifications) employed fulltime to provide or assure the provision of social services. “(c) Requirements Relating to Residents’ Rights.— “(1) General rights.— “(A) Specified rights.— A skilled nursing facility must protect and promote the rights of each resident, including each of the following rights: “(i) Free choice.— The right to choose a personal attending physician, to be fully informed in advance about care and treatment, to be fully informed in advance of any changes in care or treatment that may affect the resident’s well-being, and (except with respect to a resident adjudged incompetent) to participate in planning care and treatment or changes in care and treatment. “(ii) Free from restraints.— The right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms. Restraints may only be imposed— “(I) to ensure the physical safety of the resident or other residents, and “(II) only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used (except in emergency circumstances specified by the Secretary) until such an order could reasonably be obtained. “(iii) Privacy.— The right to privacy with regard to accommodations, medical treatment, written and telephonic communications, visits, and meetings of family and of resident groups. “(iv) Confidentiality.— The right to confidentiality of personal and clinical records. “(v) Accommodation of needs.— The right— “(I) to reside and receive services with reasonable accommodations of individual needs and preferences, except where the health or safety of the individual or other residents would be endangered, and “(II) to receive notice before the room or room-mate of the resident in the facility is changed, “(vi) Grievances.— The right to voice grievances with respect to treatment or care that is (or fails to be) furnished, without discrimination or reprisal for voicing the grievances and the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents. 101 STAT. 1330–166 “(vii) Participation in resident and family groups.— The right of the resident to organize and participate in resident groups in the facility and the right of the resident’s family to meet in the facility with the families of other residents in the facility. 5757Copy read “ “(ix)”.“(viii) Participation in other activities.— The right of the resident to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. 5858Copy read “ “(x)”.“(ix) Examination of survey results.— The right to examine, upon reasonable request, the results of the most recent survey of the facility conducted by the Secretary or a State with respect to the facility and any plan of correction in effect with respect to the facility. 5959Copy read “ “(xi)”.“(x) Other rights.— Any other right established by the Secretary. Clause (iii) shall not be construed as requiring the provision of a private room. “(B) Notice of rights and services.— A skilled nursing facility must— “(i) inform each resident, orally and in writing at the time of admission to the facility, of the resident’s legal rights during the stay at the facility; “(ii) make available to each resident, upon reasonable request, a written statement of such rights (which statement is updated upon changes in such rights); and “(iii) inform each other resident, in writing before or at the time of admission and periodically during the resident’s stay, of services available in the facility and of related charges for such services, including any charges for services not covered under this title or by the facility’s basic per diem charge. The written description of legal rights under this subparagraph shall include a description of the protection of personal funds under paragraph (6) and a statement that a resident may file a complaint with a State survey and certification agency respecting resident abuse and neglect and misappropriation of resident property in the facility. “(C) Rights of incompetent residents.— In the case of a resident adjudged incompetent under the laws of a State, the rights of the resident under this title shall devolve upon, and, to the extent judged necessary by a court of competent jurisdiction, be exercised by, the person appointed under State law to act on the resident’s behalf. “(2) Transfer and discharge rights.— “(A) In general.— A skilled nursing facility must permit each resident to remain in the facility and must not transfer or discharge the resident from the facility unless— “(i) the transfer or discharge is necessary to meet the resident’s welfare and the resident’s welfare cannot be met in the facility; “(ii) the transfer or discharge is appropriate because the resident’s health has improved sufficiently so the101 STAT. 1330–167 resident no longer needs the services provided by the facility; “(iii) the safety of individuals in the facility is endangered; “(iv) the health of individuals in the facility would otherwise be endangered; “(v) the resident has failed, after reasonable and appropriate notice, to pay (or to have paid under this title or title XIX on the resident’s behalf) an allowable charge imposed by the facility for an item or service requested by the resident and for which a charge may be imposed consistent with this title and title XIX; or “(vi) the facility ceases to operate. In each of the cases described in clauses (i) through (v), the basis for the transfer or discharge must be documented in the resident’s clinical record. In the cases described in clauses (i) and (ii), the documentation must be made by the resident’s physician, and in the cases described in clauses (iii) and (iv) the documentation must be made by a physician. “(B) Pre-transfer and pre-discharge notice.— “(i) In general.— Before effecting a transfer or discharge of a resident, a skilled nursing facility must— “(I) notify the resident (and, if known, a family member of the resident or legal representative) of the transfer or discharge and the reasons therefor, “(II) record the reasons in the resident’s clinical record (including any documentation required under subparagraph (A)), and “(III) include in the notice the items described in clause (iii). “(ii) Timing of notice.— The notice under clause (i)(I) must be made at least 30 days in advance of the resident’s transfer or discharge except— “(I) in a case described in clause (iii) or (iv) of subparagraph (A); “(II) in a case described in clause (ii) of subparagraph (A), where the resident’s health improves sufficiently to allow a more immediate transfer or discharge; “(III) in a case described in clause (i) of subparagraph (A), where a more immediate transfer or discharge is necessitated by the resident’s urgent medical needs; or “(IV) in a case where a resident has not resided in the facility for 30 days. In the case of such exceptions, notice must be given as many days before the date of the transfer or discharge as is practicable. “(iii) Items included in notice.— Each notice under clause (i) must include— “(I) for transfers or discharges effected on or after October 1, 1990, notice of the resident’s right to appeal the transfer or discharge under the State process established under subsection (e)(3); and “(II) the name, mailing address, and telephone number of the State long-term care ombudsman101 STAT. 1330–168(established under section 307(a)(12) of the Older Americans Act of 1965). “(C) Orientation.— A skilled nursing facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. “(3) Access and visitation rights.— A skilled nursing facility must— “(A) permit immediate access to any resident by any representative of the Secretary, by any representative of the State, by an ombudsman described in paragraph (2)(B)(iii)(II), or by the resident’s individual physician; “(B) permit immediate access to a resident, subject to the resident’s right to deny or withdraw consent at any time, by immediate family or other relatives of the resident; “(C) permit immediate access to a resident, subject to reasonable restrictions and the resident’s right to deny or withdraw consent at any time, by others who are visiting with the consent of the resident; “(D) permit reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident’s right to deny or withdraw consent at any time; and “(E) permit representatives of the State ombudsman (described in paragraph (2)(B)(iii)(II)), with the permission of the resident (or the resident’s legal representative) and consistent with State law, to examine a resident’s clinical records. “(4) Equal access to quality care.— A skilled nursing facility must establish and maintain identical policies and practices regarding transfer, discharge, and covered services under this title for all individuals regardless of source of payment. “(5) Admissions policy.— “(A) Admissions.— With respect to admissions practices, a skilled nursing facility must— “(i) (I) not require individuals applying to reside or residing in the facility to waive their rights to benefits under this title or under a State plan under title XIX, (II) not require oral or written assurance that such individuals are not eligible for, or will not apply for, benefits under this title or such a State plan, and (III) prominently display in the facility and provide to such individuals written information about how to apply for and use such benefits and how to receive refunds for previous payments covered by such benefits; and “(ii) not require a third party guarantee of payment to the facility as a condition of admission (or expedited admission) to, or continued stay in, the facility. “(B) Construction.— “(i) No preemption of stricter standards.— Subparagraph (A) shall not be construed as preventing States or political subdivisions therein from prohibiting, under State or local law, the discrimination against individuals who are entitled to medical assistance under this title with respect to admissions practices of skilled nursing facilities. 101 STAT. 1330–169 “(ii) Contracts with legal representatives.— Subparagraph (A)(ii) shall not be construed as preventing a facility from requiring an individual, who has legal access to a resident’s income or resources available to pay for care in the facility, to sign a contract (without incurring personal financial liability) to provide payment from the resident’s income or resources for such care. “(6) Protection op resident funds.— “(A) In general.— The skilled nursing facility— “(i) may not require residents to deposit their personal funds with the facility, and “(ii) once the facility accepts the written authorization of the resident, must hold, safeguard, and account for such personal funds under a system established and maintained by the facility in accordance with this paragraph. “(B) Management of personal funds.— Upon a facility’s acceptance of written authorization of a resident under subparagraph (A)(ii), the facility must manage and account for the personal funds of the resident deposited with the facility as follows: “(i) Deposit.— The facility must deposit any amount of personal funds in excess of $50 with respect to a resident in an interest bearing account (or accounts) that is separate from any of the facility’s operating accounts and credits all interest earned on such separate account to such account. With respect to any other personal funds, the facility must maintain such funds in a non-interest bearing account or petty cash fund. “(ii) Accounting and records.— The facility must assure a full and complete separate accounting of each such resident’s personal funds, maintain a written record of all financial transactions involving the personal funds of a resident deposited with the facility, and afford the resident (or a legal representative of the resident) reasonable access to such record. “(iii) Conveyance upon death.— Upon the death of a resident with such an account, the facility must convey promptly the resident’s personal funds (and a final accounting of such funds) to the individual administering the resident’s estate. “(C) Assurance of financial security.— The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. “(D) Limitation on charges to personal funds.— The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under this title or title XIX. “(d) Requirements Relating to Administration and Other Matters.— “(1) Administration.— “(A) In general.— A skilled nursing facility 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-101 STAT. 1330–170being of each resident (consistent with requirements established under subsection (f)(5)). “(B) Required notices.— If a change occurs in— “(i) the persons with an ownership or control interest (as defined in section 1124(a)(3)) in the facility, “(ii) the persons who are officers, directors, agents, or managing employees (as defined in section 1126(b)) of the facility, “(iii) the corporation, association, or other company responsible for the management of the facility, or “(iv) the individual who is the administrator or director of nursing of the facility, the skilled nursing facility must provide notice to the State agency responsible for the licensing of the facility, at the time of the change, of the change and of the identity of each new person, company, or individual described in the respective clause. “(C) Skilled nursing facility administrator.— The administrator of a skilled nursing facility must meet standards established by the Secretary under subsection (f)(4). “(2) Licensing and life safety code.— “(A) Licensing.— A skilled nursing facility must be licensed under applicable State and local law. “(B) Life safety code.— A skilled nursing facility must meet such provisions of such edition (as specified by the Secretary in regulation) of the Life Safety Code of the National Fire Protection Association as are applicable to nursing homes; except that— “(i) the Secretary may waive, for such periods as he deems appropriate, specific provisions of such Code which if rigidly applied would result in unreasonable hardship upon a facility, but only if such waiver would not adversely affect the health and safety of residents or personnel, and “(ii) the provisions of such Code shall not apply in any State if the Secretary finds that in such State there is in effect a fire and safety code, imposed by State law, which adequately protects residents of and personnel in skilled nursing facilities. “(3) Sanitary and infection control and physical environment.— A skilled nursing facility must— “(A) establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection, and “(B) be designed, constructed, equipped, and maintained in a manner to protect the health and safety of residents, personnel, and the general public. “(4) Miscellaneous.— “(A) Compliance with federal, state, and local laws and professional standards.— A skilled nursing facility must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations (including the requirements of section 59a59aCopy read “sections”. 1124) and with accepted professional standards and principles which apply to professionals providing services in such a facility. 101 STAT. 1330–171 “(B) Other.— A skilled nursing facility must meet such other requirements relating to the health, safety, and wellbeing of residents or relating to the physical facilities thereof as the Secretary may find necessary. “(e) State Requirements Relating to Skilled Nursing Facility Requirements.— The requirements, referred to in section 1864(d), with respect to a State are as follows: “(1) Specification and review of nurse aide training and competency evaluation programs and of nurse aide competency evaluation programs.— The State must— “(A) by not later than March 1, 1989, specify those training and competency evaluation programs, and those competency evaluation programs, that the State approves for purposes of subsection (b)(5) and that meet the requirements established under clause (i) or (ii) of subsection (f)(2)(A), and “(B) by not later than March 1, 1990, provide for the review and reapproval of such programs, at a frequency and using a methodology consistent with the requirements established under subsection (f)(2)(A)(iii). The failure of the Secretary to establish requirements under subsection (f)(2) shall not relieve any State of its responsibility under this paragraph. “(2) Nurse aide registry.— “(A) In general.— By not later than March 1, 1989, the State shall establish and maintain a registry of all individuals who have satisfactorily completed a nurse aide training and competency evaluation program, or a nurse aide competency evaluation program, approved under paragraph (1) in the State. “(B) Information in registry.— The registry under subparagraph (A) shall provide (in accordance with regulations of the Secretary) for the inclusion of specific documented findings by a State under subsection (g)(1)(C) of resident neglect or abuse or misappropriation of resident property involving an individual listed in the registry, as well as any brief statement of the individual disputing the findings. In the case of inquiries to the registry concerning an individual listed in the registry, any information disclosed concerning such a finding shall also include disclosure of any such statement in the registry relating to the finding or a clear and accurate summary of such a statement. “(3) State appeals process for transfers.— The State, for transfers from skilled nursing facilities effected on or after October 1, 1990, must provide for a fair mechanism for hearing appeals on transfers of residents of such facilities. Such mechanism must meet the guidelines established by the Secretary under subsection (f)(3); but the failure of the Secretary to establish such guidelines shall not relieve any State of its responsibility to provide for such a fair mechanism. “(4) Skilled nursing facility administrator standards.— By not later than January 1, 1990, the State must have implemented and enforced the skilled nursing facility administrator standards developed under subsection (f)(4) respecting the qualification of administrators of skilled nursing facilities. 101 STAT. 1330–172 “(5) Specification of resident assessment instrument.— Effective July 1, 1989, the State shall specify the instrument to be used by nursing facilities in the State in complying with the requirement of subsection (b)(3)(A)(iii). Such instrument shall be— “(A) one of the instruments designated under subsection (f)(6)(B), or “(B) an instrument which the Secretary has approved as being consistent with the minimum data set of core elements, common definitions, and utilization guidelines specified by the Secretary under subsection (f)(6)(A). “(f) Responsibiuties of Secretary Relating to Skilled Nursing Facility Requirements.— “(1) General responsibility.— It is the duty and responsibility of the Secretary to assure that requirements which govern the provision of care in skilled nursing facilities under this title, and the enforcement of such requirements, are adequate to protect the health, safety, welfare, and rights of residents and to promote the effective and efficient use of public moneys. “(2) Requirements for nurse aide training and competency evaluation programs and for nurse aide competency evaluation programs.— “(A) In general.— For purposes of subsections (b)(5) and (e)(1)(A), the Secretary shall establish, by not later than September 1, 1988— “(i) requirements for the approval of nurse aide training and competency evaluation programs, including requirements relating to (I) the areas to be covered in such a program (including at least basic nursing skills, personal care skills, cognitive, behavioral and social care, basic restorative services, and residents’ rights), content of the curriculum, (II) minimum hours of initial and ongoing training and retraining (including not less than 75 hours in the case of initial training), (III) qualifications of instructors, and (IV) procedures for determination of competency; “(ii) requirements for the approval of nurse aide competency evaluation programs, including requirement relating to the areas to be covered in such a program, including at least basic nursing skills, personal care skills, cognitive, behavioral and social care, basic restorative services, residents’ rights, and procedures for determination of competency; and “(iii) requirements respecting the minimum frequency and methodology to be used by a State in reviewing such programs compliance with the requirements for such programs. “(B) Approval of certain programs.— Such requirements— “(i) may permit approval of programs offered by or in facilities, as well as outside facilities (including employee organizations), and of programs in effect on the date of the enactment of this section; “(ii) shall permit a State to find that an individual who has completed (before July 1, 1989) a nurse aide training and competency evaluation program shall be deemed to have completed such a program approved101 STAT. 1330–173 under subsection (b)(5) if the State determines that, at the time the program was offered, the program met the requirements for approval under such paragraph; and “(iii) shall prohibit approval of such a program— “(I) offered by or in a skilled nursing facility which has been determined to be out of compliance with the requirements of subsection (b), (c), or (d), within the previous 2 years, or “(II) offered by or in a skilled nursing facility unless the State makes the determination, upon an individual’s completion of the program, that the individual is competent to provide nursing and nursing-related services in skilled nursing facilities. A State may not delegate its responsibility under clause (iii)(II) to the skilled nursing facility. “(3) Federal guidelines for state appeals process for transfers.— For purposes of subsections (c)(2)(B)(iii)(I) and (e)(3), by not later than October 1, 1989, the Secretary shall establish guidelines for minimum standards which State appeals processes under subsection (e)(3) must meet to provide a fair mechanism for hearing appeals on transfers of residents from skilled nursing facilities. “(4) Secretarial standards for qualification of administrators.— For purposes of subsections (d)(1)(C) and (e)(4), the Secretary shall develop, by not later than March 1, 1989, standards to be applied in assuring the qualifications of administrators of skilled nursing facilities. “(5) Criteria for administration.— The Secretary shall establish criteria for assessing a skilled nursing facility’s compliance with the requirement of subsection (d)(1) with respect to— “(A) its governing body and management, “(B) agreements with hospitals regarding transfers of residents to and from the hospitals and to and from other skilled nursing facilities, “(C) disaster preparedness, “(D) direction of medical care by a physician, “(E) laboratory and radiological services, “(F) clinical records, and “(G) resident and advocate participation. “(6) Specification of resident assessment data set and instruments.— The Secretary shall— “(A) not later than July 1, 1989, specify a minimum data set of core elements and common definitions for use by nursing facilities in conducting the assessments required under subsection (b)(3), and establish guidelines for utilization of the data set; and “(B) by not later than October 1, 1990, designate one or more instruments which are consistent with the specification made under subparagraph (A) and which a State may specify under subsection (e)(5)(A) for use by nursing facilities in complying with the requirements of subsection (b)(3)(A)(iii). “(7) List of items and services furnished in skilled nursing facilities not chargeable to the personal funds of a resident.— 101 STAT. 1330–174 “(A) Regulations required.— Pursuant to the requirement of section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977, the Secretary shall issue regulations, on or before the first day of the seventh month to begin after the date of enactment of this section, that define those costs which may be charged to the personal funds of patients in skilled nursing facilities who are individuals receiving benefits under this part and those costs which are to be included in the reasonable cost (or other payment amount) under this title for extended care services. “(B) Rule if failure to publish regulations.— If the Secretary does not issue the regulations under subparagraph (A) on or before the date required in such subparagraph, in the case of a resident of a skilled nursing facility who is eligible to receive benefits under this part, the costs which may not be charged to the personal funds of such resident (and for which payment is considered to be made under this title) shall not include, at a minimum, the costs for routine personal hygiene items and services furnished by the facility.”. (b) Costs of Meeting Requirements.— (1) Under reasonable cost.— Section 1861(v)(1)(E) of such Act (42 U.S.C. 1395s(v)(1)(E)) is amended by adding at the end the following new sentence: “Notwithstanding the previous sentence, such regulations with respect to skilled nursing facilities shall take into account (in a manner consistent with subparagraph (A) and based on patient-days of services furnished) the costs of such facilities complying with the requirements of subsections (b), (c), and (d) of section 1819 (including the costs of conducting nurse aide training and competency evaluation programs and competency evaluation programs).”. (2) Adjustment in prospective payments.— Section 1888(d) of such Act (42 U.S.C. 1395yy(d)) is amended by adding at the end the following new paragraph: “(7) In computing the rates of payment to be made under this subsection, there shall be taken into account the costs described in the last sentence of section 1861(v)(1)(E) (relating to compliance with nursing facility requirements and of conducting nurse aide training and competency evaluation programs and competency evaluation programs).”. (c) Evaluation.— The Secretary of Health and Human Services shall evaluate, and report to Congress by not later than January 1, 1992, on the implementation of the resident assessment process for residents of skilled nursing facilities under the amendments made by this section. (d) Conforming Amendment.— Section 1861(a)(2) of the Social Security Act (42 U.S.C. 1395x(a)(2)) is amended by striking “skilled nursing facility” and inserting “facility described in section 1919(a)(2) or subsection (y)(1)”.