REQUIREMENTS FOR NURSING FACILITIES.

SEC. 4211. REQUIREMENTS FOR NURSING FACILITIES. (a) Specification of Facility Requirements.— Title XIX of the Social Security Act is amended— (1) by redesignating section 1922 as section 1923, (2) by redesignating section 1919 as section 1922 and by transferring and inserting such section after section 1921, and (3) by inserting after section 1918 the following new section: 101 STAT. 1330–183 “requirements for nursing facilities “Sec. 1919. (a) Nursing Facility Defined.— In this title, the term ‘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, “(B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or “(C) on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, 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 nursing facility described in subsections (b), (c), and (d) of this section. Such term also includes any facility which is located in a State on an Indian reservation and is certified by the Secretary as meeting the requirements of paragraph (1) and subsections (b), (c), and (d). “(b) Requirements Relating to Provision of Services.— “(1) Quality of life.— “(A) In general.— A 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. “(B) Quality assessment and assurance.— A 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 nursing facility must provide services and activities 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 nursing facility must conduct a comprehensive, accurate, standardized, reproducible assess—101 STAT. 1330–184ment 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 this title, 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 title XVIII, 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 assessment 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, 1991, 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. 101 STAT. 1330–185 “(ii) Resident review.— The nursing facility must examine each resident no less frequently than once every 3 months and, as appropriate, revise the resident 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. “(F) Requirements relating to pre-admission screening for mentally ill and mentally retarded individuals.— A nursing facility must not admit, on or after January 1, 1989, any new resident who— “(i) is mentally ill (as defined in subsection (e)(7)(G)(i)) unless the State mental health authority has determined (based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority) prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility, and, if the individual requires such level of services, whether the individual requires active treatment for mental illness, or “(ii) is mentally retarded (as defined in subsection (e)(7)(G)(ii)) unless the State mental retardation or developmental disability authority has determined prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility, and, if the individual requires such level of services, whether the individual requires active treatment for mental retardation. “(4) Provision of services and activities.— “(A) In general.— To the extent needed to fulfill all plans of care described in paragraph (2), a nursing facility must provide (or arrange for the provision of)— “(i) nursing and related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing 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; “(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 101 STAT. 1330–186 “(vi) routine dental services (to the extent covered under the State plan) 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. “(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; facility waivers.— “(i) General requirements.— With respect to nursing facility services provided on or after October 1, 1990, a nursing facility— “(I) except as provided in clause (ii), must provide 24-hour licensed nursing services which are sufficient to meet the nursing needs of its residents, and “(II) except as provided in clause (ii), must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, “(ii) Facility waivers.— “(i) Waiver by state.— A State may waive the requirement of subclause (I) or (II) of clause (i) with respect to a facility if— “(I) the facility demonstrates to the satisfaction of the State that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel, “(II) the State determines that a waiver of the requirement will not endanger the health or safety of individuals staying in the facility, and “(III) the State finds that, for any such periods in which licensed nursing services are not available, a registered nurse or a physician is obligated to respond immediately to telephone calls from the facility. A waiver under this clause shall be subject to annual review and to the review of the Secretary and subject to clause (ii) shall be accepted by the Secretary for purposes of this title to the same extent as is the State’s certification of the facility. In granting or renewing a waiver, a State may require the facility to employ other qualified, licensed personnel. “(ii) Assumption of waiver authority by secretary.— If the Secretary determines that a State has shown a clear pattern and practice of allowing waivers in the absence of diligent efforts by facilities to meet the staffing requirements, the Secretary shall assume and excercise the authority of the State to grant waivers. “(5) Required training of nurse aides.— “(A) In general.— A 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 after101 STAT. 1330–187 January 1, 1990, 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 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 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 subparagraph (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 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 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 nursing facility must— “(A) require that the health 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. 1330–188 “(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)), as well as the results of any pre-admission screening conducted under subsection (e)(7). “(7) Required social services.— In the case of a 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 full-time to provide or assure the provision of social services. “(c) Requirements relating to residents’ rights.— “(1) General rights.— “(A) Specified rights.— A 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 roommate 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 may101 STAT. 1330–189 have, including those with respect to the behavior of other residents. “(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. 6161Copy 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. 6262Copy 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. 6363Copy 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.— A 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); “(iii) inform each resident who is entitled to medical assistance under this title— “(I) at the time of admission to the facility or, if later, at the time the resident becomes eligible for such assistance, of the items and services (including those specified under section 1902(a)(28)(B)) that are included in nursing facility services under the State plan and for which the resident may not be charged (except as permitted in section 1916), and of those other items and services that the facility offers and for which the resident may be charged and the amount of the charges for such items and services, and “(II) of changes in the items and services described in subclause (I) and of changes in the charges imposed for items and services described in that subclause; and “(iv) 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 title XVIII 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 a101 STAT. 1330–190 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. “(D) Use of psychopharmacologic drugs.— Psychopharmacologic drugs may be administered only on the orders of a physician and only as part of a plan (included in the written plan of care described in paragraph (2)) designed to eliminate or modify the symptoms for which the drugs are prescribed and only if, at least annually an independent, external consultant reviews the appropriateness of the drug plan of each resident receiving such drugs. “(2) Transfer and discharge rights.— “(A) In general.— A 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 the 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 XVIII 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 XVIII; or “(vi) the facility ceases to operate. In each 6464Copy read “In the each”. of the cases described in clauses (i) through (iv), 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 case described in clause (iv) the documentation must be made by a physician. For purposes of clause (v), in the case of a resident who becomes eligible for assistance under this title after admission to the facility, only charges which may be imposed under this title shall be considered to be allowable. “(B) Pre-transfer and pre-discharge notice.— “(i) In general.— Before effecting a transfer or discharge of a resident, a nursing facility must— 101 STAT. 1330–191 “(I) notify the resident (and, if known, an immediate 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, 1989, notice of the resident’s right to appeal the transfer or discharge under the State process established under subsection (e)(3); “(II) the name, mailing address, and telephone number of the State long-term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965); “(III) in the case of residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy system for developmentally disabled individuals established under part C of the Developmental Disabilities Assistance and Bill of Rights Act; and “(IV) in the case of mentally ill residents (as defined in subsection (e)(7)(G)(i)), the mailing address and telephone number of the agency responsible for the protection and advocacy system for mentally ill individuals established under the Protection and Advocacy for Mentally 111 Individuals Act. “(C) Orientation.— A nursing facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. “(D) Notice on bed-hold policy and readmission.— “(i) Notice before transfer.— Before a resident of a nursing facility is transferred for hospitalization or101 STAT. 1330–192 therapeutic leave, a nursing facility must provide written information to the resident and an immediate family member or legal representative concerning— “(I) the provisions of the State plan under this title regarding the period (if any) during which the resident will be permitted under the State plan to return and resume residence in the facility, and “(II) the policies of the facility regarding such a period, which policies must be consistent with clause (iii). “(ii) Notice upon transfer.— At the time of transfer of a resident to a hospital or for therapeutic leave, a nursing facility must provide written notice to the resident and an immediate family member or legal representative of the duration of any period described in clause (i). “(iii) Permitting resident to return.— A nursing facility must establish and follow a written policy under which a resident— “(I) who is eligible for medical assistance for nursing facility services under a State plan, “(II) who is transferred from the facility for hospitalization or therapeutic leave, and “(III) whose hospitalization or therapeutic leave exceeds a period paid for under the State plan for the holding of a bed in the facility for the resident, will be permitted to be readmitted to the facility immediately upon the first availability of a bed in a semiprivate room in the facility if, at the time of readmission, the resident requires the services provided by the facility. “(3) Access and visitation rights.— A 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 or agency described in subclause (II), (III), or (IV) of paragraph (2)(B)(iii), 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 quauty care.— “(A) In general.— A nursing facility must establish and maintain identical policies and practices regarding trans-101 STAT. 1330–193fer, discharge, and the provision of services required under the State plan for all individuals regardless of source of payment. “(B) Construction.— “(i) Nothing prohibiting any charges for non-medicaid patients.— Subparagraph (A) shall not be construed as prohibiting a nursing facility from charging any amount for services furnished, consistent with the notice in paragraph (1)(B) describing such charges, “(ii) No additional services required.— Subparagraph (A) shall not be construed as requiring a State to offer additional services on behalf of a resident than are otherwise provided under the State plan. “(5) Admissions policy.— “(A) Admissions.— With respect to admissions practices, a 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 title XVIII, (II) not require oral or written assurance that such individuals are not eligible for, or will not apply for, benefits under this title or title XVIII, and (III) prominently display in the facility written information, and provide to such individuals oral and written information, about how to apply for and use such benefits and how to receive refunds for previous payments covered by such benefits; “(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; and “(iii) in the case of an individual who is entitled to medical assistance for nursing facility services, not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan under this title, any gift, money, donation, or other consideration as a precondition of admitting (or expediting the admission of) the individual to the facility or as a requirement for the individual’s 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 the State plan with respect to admissions practices of nursing facilities. “(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. “(iii) Charges for additional services requested.— Subparagraph (A)(iii) shall not be construed as preventing a facility from charging a resident, eligible for101 STAT. 1330–194 medical assistance under the State plan, for items or services the resident has requested and received and that are not specified in the State plan as included in the term ‘nursing facility services’. “(iv) Bona fide contributions.— Subparagraph (A)(iii) shall not be construed as prohibiting a nursing facility from soliciting, accepting, or receiving a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to the resident (or potential resident), but only to the extent that such contribution is not a condition of admission, expediting admission, or continued stay in the facility. “(6) Protection of resident funds.— “(A) In general.— The 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) Notice of certain balances.— The facility must notify each resident receiving medical assistance under the State plan under title XIX when the amount in the resident’s account reaches $200 less than the dollar amount determined under section 1611(a)(3)(B) and the fact that if the amount in the account (in addition to the value of the resident’s other nonexempt resources) reaches the amount determined under such section the resident may lose eligibility for such medical assistance or for benefits under title XVI. “(iv) 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. 101 STAT. 1330–195 “(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 XVIII. “(d) Requirements relating to administration and other matters.— “(1) Administration.— “(A) In general.— A 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-being 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 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) Nursing facility administrator.— The administrator of a nursing facility must meet standards established by the Secretary under subsection (f)(4). “(2) Licensing and life safety code.— “(A) Licensing.— A nursing facility must be licensed under applicable State and local law. “(B) Life safety code.— A 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 nursing facilities. “(3) Sanitary and infection control and physical environment.— A nursing facility must— 101 STAT. 1330–196 “(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 nursing facility must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations (including the requirements of section 1124 and with accepted professional standards and principles which apply to professionals providing services in such a facility. “(B) Other.— A nursing facility must meet such other requirements relating to the health and safety of residents or relating to the physical facilities thereof as the Secretary may find necessary.”. (c) State Requirements Relating to Nursing Facility Requirements.— Section 1919 of such Act is further amended by adding at the end the following new subsection: “(e) State Requirements Relating to Nursing Facility Requirements.— As a condition of approval of 6565Copy read “approval its”. its plan under this title, a State must provide for the following: “(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 September 1, 1988, 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 September 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 January 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 resident101 STAT. 1330–197 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 nursing facilities effected on or after October 1, 1989, must provide for a fair mechanism, meeting the guidelines established under subsection (f)(3), for hearing appeals on transfers of residents of such facilities; but the failure of the Secretary to establish such guidelines under such subsection shall not relieve any State of its responsibility under this paragraph. “(4) Nursing facility administrator standards.— By not later than July 1, 1989, the State must have implemented and enforced the nursing facility administrator standards developed under subsection (f)(4) respecting the qualification of administrators of nursing facilities. “(5) Specification of resident assessment instrument.— Effective July 1, 1990, 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). “(6) Notice of medicaid rights.— Each State, as a condition of approval of its plan under this title, effective April 1, 1988, must develop (and periodically update) a written notice of the rights and obligations of residents of nursing facilities (and spouses of such residents) under this title. “(7) State requirements for pre-admission screening and resident review.— “(A) Pre-admission screening.— Effective January 1, 1989, the State must have in effect a pre-admission screening program, for making determinations (using any criteria developed under subsection (f)(8)) described in subsection (b)(3)(F) for mentally ill and mentally retarded individuals (as defined in subparagraph (G)) who are admitted to nursing facilities on or after January 1, 1989. The failure of the Secretary to develop minimum criteria under subsection (f)(8) shall not relieve any State of its responsibility to have a pre-admission screening program under this subparagraph or to perform resident reviews under subparagraph (B). “(B) State requirement for annual resident review.— “(i) For mentally ill residents.— As of April 1, 1990, in the case of each resident of a nursing facility who is mentally ill, the State mental health authority must review and determine (using any criteria developed under subsection (f)(8) and based on an independent physical and mental evaluation performed by a101 STAT. 1330–198 person or entity other than the State mental health authority)— “(I) whether or not the resident, because of the resident’s physical and mental condition, requires the level of services provided by a nursing facility or requires the level of services of an inpatient psychiatric hospital for individuals under age 21 (as described in section 1905(h)) or of an institution for mental diseases providing medical assistance to individuals 65 years of age or older; and “(II) whether or not the resident requires active treatment for mental illness, “(ii) For mentally retarded residents.— As of April 1, 1990, in the case of each resident of a nursing facility who is mentally retarded, the State mental retardation or developmental disability authority must review and determine (using any criteria developed under subsection (f)(8))— “(I) whether or not the resident, because of the resident’s physical and mental condition, requires the level of services provided by a nursing facility or requires the level of services of an intermediate care facility described under section 1905(d); and “(II) whether or not the resident requires active treatment for mental retardation, “(iii) Frequency of reviews.— “(I) Annual.— Except as provided in subclauses (II) and (III), the reviews and determinations under clauses (i) and (ii) must be conducted with respect to each mentally ill or mentally retarded resident not less often than annually. “(II) Pre-admission review cases.— In the case of a resident subject to a pre-admission review under subsection (b)(3)(F), the review and determination under clause (i) or (ii) need not be done until the resident has resided in the nursing facility for 1 year. “(III) Initial review.— The reviews and determinations under clauses (i) and (ii) must first be conducted (for each resident not subject to pre-admission review under subsection (b)(3)(F)) by not later than April 1, 1990. “(C) Response to pre-admission screening and resident review.— AS of April 1, 1990, the State must meet the following requirements: “(i) Long-term residents not requiring nursing facility services, but requiring active treatment.— In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility, but to require active treatment for mental illness or mental retardation, and who has continuously resided in a nursing facility for at least 30 months before the date of the determination, the State must, in consultation with the resident’s family or legal representative and care-givers— 101 STAT. 1330–199 “(I) inform the resident of the institutional and noninstitutional alternatives covered under the State plan for the resident, “(II) offer the resident the choice of remaining in the facility or of receiving covered services in an alternative appropriate institutional or noninstitutional setting, “(III) clarify the effect on eligibility for services under the State plan if the resident chooses to leave the facility (including its effect on readmission to the facility), and “(IV) regardless of the resident’s choice, provide for (or arrange for the provision of) such active treatment for the mental illness or mental retardation. A State shall not be denied payment under this title for nursing facility services for a resident described in this clause because the resident does not require the level of services provided by such a facility, if the resident chooses to remain in such a facility. “(ii) Other residents not requiring nursing facility services, but requiring active treatment.— In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility, but to require active treatment for mental illness or mental retardation, and who has not continuously resided in a nursing facility for at least 30 months before the date of the determination, the State must, in consultation with the resident’s family or legal representative and care-givers— “(I) arrange for the safe and orderly discharge of the resident from the facility, consistent with the requirements of subsection (c)(2), “(II) prepare and orient the resident for such discharge, and “(III) provide for (or arrange for the provision of) such active treatment for the mental illness or mental retardation, “(iii) Residents not requiring nursing facility services and not requiring active treatment.— In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility and not to require active treatment for mental illness or mental retardation, the State must— “(I) arrange for the safe and orderly discharge of the resident from the facility, consistent with the requirements of subsection (c)(2), and “(II) prepare and orient the resident for such discharge. “(D) Denial of payment where failure to conduct pre-admission screening.— No payment may be made under section 1903(a) with respect to nursing facility services furnished to an individual for whom a determination is required under subsection (b)(3)(F) or subparagraph (B) but for whom the determination is not made. 101 STAT. 1330–200 “(E) Permitting alternative disposition plans.— With respect to residents of a nursing facility who are mentally retarded or mentally ill and who are determined under subparagraph (B) not to require the level of services of such a facility, but who require active treatment for mental illness or mental retardation, a State and the nursing facility shall be considered to be in compliance with the requirement of this paragraph if, before October 1, 1988, the State and the Secretary have entered into an agreement relating to the disposition of such residents of the facility and the State is in compliance with such agreement. Such an agreement may provide for the disposition of the residents after the date specified in subparagraph (C). “(F) Appeals procedures.— Each State, as a condition of approval of its plan under this title, effective January 1, 1989, must have in effect an appeals process for individuals adversely affected by determinations under subparagraph (A) or (B). “(G) Definitions.— In this paragraph and in subsection (b)(3)(F): “(i) An individual is considered to be ‘mentally ill’ if the individual has a primary or secondary diagnosis of mental disorder (as defined in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition) and does not have a primary diagnosis of dementia (including Alzheimer’s disease or a related disorder), “(ii) An individual is considered to be ‘mentally retarded’ if the individual is mentally retarded or a person with a related condition (as described in section 1905(d)). “(iii) The term ‘active treatment’ has the meaning given such term by the Secretary in regulations, but does not include, in the case of a resident of a nursing facility, services within the scope of services which the facility must provide or arrange for its residents under subsection (b)(4). “(f) Responsibilities of Secretary Relating to 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 nursing facilities under State plans approved 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 July 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’101 STAT. 1330–201 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, and residents’ rights, and procedures for determination of competency; “(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 January 1, 1989) a nurse aide training and competency evaluation program shall be deemed to have completed such a program approved 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 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 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 nursing facilities. A State may not delegate its responsibility under clause (iii)(II) to the nursing facility. “(3) Federal guidelines for state appeals process for transfers.— For purposes of subsections (c)(2)(B)(iii) and (e)(3), by not later than October 1, 1988, 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 nursing facilities. “(4) Secretarial standards qualification of administrators.— For purposes of subsections (d)(1)(C) and (e)(4), the Secretary shall develop, by not later than March 1, 1988, standards to be applied in assuring the qualifications of administrators of nursing facilities. “(5) Criteria for administration.— The Secretary shall establish criteria for assessing a nursing facility’s compliance with the requirement of subsection (d)(1) with respect to— “(A) its governing body and management, 101 STAT. 1330–202 “(B) agreements with hospitals regarding transfers of residents to and from the hospitals and to and from other 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 January 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 April 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 nursing facilities not chargeable to the personal funds of a resident.— “(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 nursing facilities who are individuals receiving medical assistance with respect to nursing facility services under this title and those costs which are to be included in the payment amount under this title for nursing facility 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 that subparagraph, in the case of a resident of a nursing facility who is eligible to receive benefits for nursing facility services under this title, for purposes of section 1902(a)(28)(B), the Secretary shall be deemed to have promulgated regulations under this paragraph which provide that 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) do not include, at a minimum, the costs for routine personal hygiene items and services furnished by the facility. “(8) Federal minimum criteria and monitoring for pre-admission screening and resident review.— “(A) Minimum criteria.— The Secretary shall develop, by not later than October 1, 1988, minimum criteria for States to use in making determinations under subsections (b)(3)(F) and (e)(7)(B) and in permitting individuals adversely affected to appeal such determinations, and shall notify the States of such criteria. “(B) Monitoring compliance.— The Secretary shall review, in a sufficient number of cases to allow reasonable101 STAT. 1330–203 inferences, each State’s compliance with the requirements of subsection (e)(7)(C)(ii) (relating to discharge and placement for active treatment of certain residents). “(9) 6666Copy read “ “(8)”. Criteria for monitoring state waivers.— The Secretary shall develop, by not later than October 1, 1988, criteria and procedures for monitoring State performances in granting waivers pursuant to subsection (b)(4)(C)(ii).”. (b) Incorporating Requirements into State Plan.— (1) In general.— Section 1902(a) of such Act (42 U.S.C. 1396a(a)) is amended— (A) in paragraph (13)(A), by inserting “which, in the case of nursing facilities, take into account the costs of complying with subsections (b) (other than paragraph (3)(F) thereof), (c), and (d) of section 1919 and provide (in the case of a nursing facility with a waiver under section 1919(b)(4)(C)(ii)) for an appropriate reduction to take into account the lower costs (if any) of the facility for nursing care,” after “State” the second place it appears; and (B) by amending paragraph (28) to read as follows: “(28) provide— “(A) that any nursing facility receiving payments under such plan must satisfy all the requirements of subsections (b) through (d) of section 1919 as they apply to such facilities; “(B) for including in ‘nursing facility services’ at least the items and services specified (or deemed to be specified) by the Secretary under section 1919(f)(7) and making available upon request a description of the items and services so included; “(C) for procedures to make available to the public the data and methodology used in establishing payment rates for nursing facilities under this title; and “(D) for compliance (by the date specified in the respective sections) with the requirements of— “(i) section 1919(f) (relating to implementation of, nursing facility requirements, including paragraph (6)(B), relating to specification of resident assessment instrument); “(ii) section 1919(g) (relating to responsibility for survey and certification of nursing facilities); and “(iii) sections 1919(h)(2)(B) and 1919(h)(2)(D) (relating to establishment and application of remedies);”. (2) State plan amendment required.— A plan of a State under title XIX of the Social Security Act shall not be considered to have met the requirement of section 1902(a)(13)(A) of the Social Security Act (as amended by paragraph (1)(A) of this subsection), as of the first day of a Federal fiscal year (beginning on or after October 1, 1990), unless the State has submitted to the Secretary of Health and Human Services, as of April 1 before the fiscal year, an amendment to such State plan to provide for an appropriate adjustment in payment amounts for nursing facility services furnished during the Federal fiscal year. The Secretary shall, not later than September 80 before the fiscal year concerned, review each such plan amendment for101 STAT. 1330–204 compliance with such requirement and by such date shall approve or disapprove each such amendment. If the Secretary disapproves such an amendment, the State shall immediately submit a revised amendment which meets such requirement. The absence of approval of such a plan amendment does not relieve the State or any nursing facility of any obligation or requirement under title XIX of the Social Security Act (as amended by this Act). (c) Evaluation.— The Secretary of Health and Human Services shall evaluate, and report to Congress by not later than January 1, 1993, on the implementation of the resident assessment process for residents of nursing facilities under the amendments made by this section. (d) Funding.— (1) In general.— Section 1903(a)(2) of such Act (42 U.S.C. 1396b(a)(2)) is amended— (A) by inserting “(A)” after “(2)”, and (B) by adding at the end the following new subparagraphs: “(B) notwithstanding paragraph (1) or subparagraph (A), with respect to amounts expended for nursing aide training and competency evaluation programs, and competency evaluation programs, described in section 1919(e)(1), regardless of whether the programs are provided in or outside nursing facilities or of the skill of the personnel involved in such programs, an amount equal to 50 percent of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to such programs; plus “(C) an amount equal to 75 percent of so much of the sums expended during such quarter (as found necessary by the Secretary for the proper and efficient administration of the State plan) as are attributable to pre-admission screening and resident review activities conducted by the State under section 1919(e)(7); plus”. (2) Enhanced funding for nurse aide training.— For Calendar quarters during fiscal years 1988 and 1989, with respect to payment under section 1903(a)(2)(B) of the Social Security Act to a State for additional amounts expended by the State under its plan approved under title XIX of such Act for nursing aide training and competency evaluation programs, and competency evaluation programs, described in section 1919(e)(1) of such title, any reference to “50 percent” is deemed a reference to the sum of the Federal medical assistance percentage (determined under section 1905(b) of such Act) plus 25 percentage points, but not to exceed 90 percent. (e) Revision of Previous Definitions.— Section 1905 of such Act (42 U.S.C. 1396d) is amended— (1) by amending subsection (c) to read as follows: “(c) For definition of the term ‘nursing facility’, see section 1919(a).”; (2) in subsection (d)— (A) by striking “intermediate care facility services” and inserting “intermediate care facility for the mentally retarded”, (B) by striking “may include services in a public” and inserting “means an”, 101 STAT. 1330–205 (C) in paragraph (3), by inserting “in the case of a public institution,” after “(3)”; (3) in subsection (f), by striking “skilled” each place it appears; and (4) by striking subsection (i). (f) Making Coverage of Nursing Facility Services Mandatory for Adults.— Section 1905(a)(4)(A) of such Act (42 U.S.C. 1396d(a)(4)(A)) is amended by striking “skilled”. (g) Elimination of Payment Differential.— Section 1903 of such Act (42 U.S.C. 1396b) is amended— (1) by striking subsection (h), and (2) in subsection (a)(1), by striking “, (h), and” and inserting “and”. (h) Clarifying Terminology.— (1) Section 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)) is amended— (A) in subparagraph (A)(ii)(VI), by striking “skilled” and by inserting “for the mentally retarded” after “intermediate care facility”; (B) in subparagraph (C)(iv), by striking “intermediate care facility services” and inserting “in an intermediate care facility”; and (C) in subparagraph (D), by striking “skilled”. (2) Section 1902(a)(13) of such Act (42 U.S.C. 1396a(a)(13)) is amended— (A) in subparagraph (A), by striking “, skilled nursing facility, and intermediate care facility services” and inserting “services, nursing facility services, and services in an intermediate care facility for the mentally retarded”;6767Copy read “retarded”,”. (B) in subparagraph (A), by striking “, skilled nursing facility, and intermediate care facility and” and inserting “nursing facility, and intermediate care facility for the mentally retarded and”; (C) in subparagraph (C), by striking “skilled nursing facilities and intermediate care facilities” and inserting “nursing facilities”; and (D) in subparagraph (D)— (i) by striking “skilled nursing facility or intermediate care facility” and inserting “nursing facility”, and (ii) by striking “skilled nursing facility services or intermediate care facility services” and inserting “nursing facility services” (3) Section 1902(a)(30)(B) of such Act (42 U.S.C. 1396a(a)(30)(B)) is amended by striking “skilled nursing facility, intermediate care facility,” each place it appears and inserting “intermediate care facility for the mentally retarded,”. (4) Section 1902(e)(3)(B)(i) of such Act (42 U.S.C. 1396a(e)(3)(B)(i)) is amended by striking “skilled nursing facility, or intermediate care facility” and inserting “nursing facility, or intermediate care facility for the mentally retarded”. (5) Section 1902(e)(9) of such Act (42 U.S.C. 1396a(e)(9)) is amended— (A) in subparagraph (A)(iii), by striking “skilled nursing facility, or intermediate care facility,” and inserting “nursing facility, or intermediate care facility for the mentally retarded” and 101 STAT. 1330–206 (B) in subparagraph (B), by striking “skilled nursing facilities, or intermediate care facilities” and inserting “nursing facilities, or intermediate care facilities for the mentally retarded”. (6) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is amended— (A) in paragraph (5), by striking “skilled”, (B) in paragraph (14), by striking “, skilled nursing facility services, and intermediate care facility services” and inserting “and nursing facility services”, and (C) in paragraph (15), by striking “intermediate care facility services (other than such services” and inserting “services in an intermediate care facility for the mentally retarded (other than”. (7) Section 1128B of such Act (42 U.S.C. 1320a–7b) is amended— (A) in subsection (c), by striking “intermediate care facility” and inserting “nursing facility, intermediate care facility for the mentally retarded”, and (B) in subsection (d)(2)(A), by striking “skilled nursing facility, or intermediate care facility” and inserting “nursing facility, or intermediate care facility for the mentally retarded”. (8) Section 1911 of such Act (42 U.S.C. 1396j) is amended by striking “, intermediate care facility, or skilled nursing facility” each place it appears and inserting “or nursing facility”. (9) Section 1913 of such Act (42 U.S.C. 13961) is amended— (A) in the heading, by striking “skilled nursing and intermediate care services” and inserting “nursing facility services”; (B) in subsection (a)— (i) by striking “skilled nursing facility services and intermediate care facility services” and inserting “nursing facility services”, and (ii) by inserting before the period at the end the following: “and which, with respect to the provision of such services, meets the requirements of subsections (b) through (d) of section 1919”; (C) in subsection (b)(1)— (i) by striking “skilled nursing or intermediate care facility services” and inserting “nursing facility services”, and (ii) by striking “skilled nursing and intermediate care facilities” and inserting “nursing facilities”; and (D) in subsection (b)(3), by striking “skilled nursing or intermediate care facility services” and inserting “nursing facility services”. (10) Section 1915(c) of such Act (42 U.S.C. 1396n(c)) is amended— (A) in paragraph (1), by striking “skilled nursing facility or intermediate care facility” and inserting “nursing facility or intermediate care facility for the mentally retarded”; (B) in paragraph (2)(B)(i), by striking “, skilled nursing facility, or intermediate care facility services” and inserting “services, nursing facility services, or services in an intermediate care facility for the mentally retarded”; (C) in paragraph (2)(B), by striking “need” and all that follows up to the semicolon and inserting “need for inpatient hospital services, nursing facility services, or services in an intermediate care facility for the mentally retarded”; (D) in paragraph (2)(C), by striking “or skilled nursing facility or intermediate care facility” and inserting “, nursing facility, or intermediate care facility for the mentally retarded”; 101 STAT. 1330–207 (E) in paragraph (2)(C), by striking “or skilled nursing facility or intermediate care facility services” and inserting “, nursing facility services, or services in an intermediate care facility for the mentally retarded”; (F) in paragraph (5), by striking “skilled nursing facility or intermediate care facility” and inserting “nursing facility or intermediate care facility for the mentally retarded”; and (G) in paragraph (7), by striking “or in skilled nursing or intermediate care facilities” and inserting “, nursing facilities, or intermediate care facilities for the mentally retarded”. (11) Section 1916 of such Act (42 U.S.C. 1396m) is amended, in subsections (a)(2)(C) and (b)(2)(C), by striking “skilled nursing facility, intermediate care facility” and inserting “nursing facility, intermediate care facility for the mentally retarded”. (12) Section 1917 of such Act (42 U.S.C. 1396p), as amended by this title, is further amended— (A) in subsections (a)(1)(B)(i) and (c)(2)(B)(i), by striking “skilled nursing facility, intermediate care facility” and inserting “nursing facility, intermediate care facility for the mentally retarded”, and (B) in subsection (c)(3)(A), by striking “skilled”. (i) Utilization Review.— Section 1903(i)(4) of such Act (42 U.S.C. 1396b(i)(4)) is amended by striking “or skilled nursing facility” each place it appears. (j) Technical Assistance.— The Secretary of Health and Human Services shall, upon request by a State, furnish technical assistance with respect to the development and implementation of reimbursement methods for nursing facilities that take into account the case mix of residents in the different facilities. (k) Report on Staffing Requirements.— The Secretary of Health and Human Services shall report to Congress, by not later than January 1, 1993, on the progress made in implementing the nursing facility staffing requirements of subparagraph (C) of section 1919(b)(4) of the Social Security Act (as amended by subsection (a) of this section), including the number and types of waivers approved under subparagraph (C)(ii) of such section and the number of facilities which have received waivers. (l) Conforming Amendment.— Section 9516(c) of the Consolidated Omnibus Budget Reconciliation Act of 1985 is amended by striking “section 1919” and inserting “section 1922”.