Government Regulation of Nursing Homes

Scott Smith

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The Center for Medicare & Medicaid (CMS) is the component of the Federal Government's Department of Health and Human Services that oversees the Medicare and Medicaid programs. A large portion of Medicaid and Medicare dollars is used each year to cover nursing home care and services for the elderly and disabled. State governments oversee the licensing of nursing homes. In addition, State have a contract with CMS to monitor those nursing homes that want to be eligible to provider care to Medicare and Medicaid beneficiaries. Congress established minimum requirements for nursing homes that want to provide services under Medicare and Medicaid. These requirements are broadly outlined in the Social Security Act (the Act). The Act also entrusts the Secretary of Health and Human Services (DHHS) with CMS, a DHHS Agency, is also charged with the responsibility of working out details of the law and how it will be implemented, which it does by writing regulations and manuals.

CMS contracts with each State to conduct onsite inspections that determine whether its nursing homes meet the minimum Medicare and Medicaid quality and performance standards. Typically, the part of State government that takes care of this duty is the health department or department of human services. In Ohio, Public Health Council within the Department of Health Services is responsible favor protecting the health and safety of nursing care institutions. The State conducts inspections of each nursing home that participates in Medicare and/or Medicaid on average about once a year. Nursing homes pursuant to the social security act are required to cooperate with the Ohio Department of health in mandatory annual inspection under the Omnibus Budget Reconciliation Act O.R.C. Ann. §3721.04. If the nursing home is performing poorly, however, the State inspectors may have to go in more frequently. The State also investigates complaints about nursing home care. During the nursing home inspection, the State looks at many aspects of quality. The inspection team observes resident care processes, staff/resident interaction, and environment. Using an established protocol of residential rights, the team interview a sample of residents and family members bout their life within the nursing home, and interview caregivers and administrative staff. O.R.C. Ann. §3721.04.

Depending on the nature of the problem, the law permits CMS to take a variety of actions; for example, CMS may fine the nursing home, deny payment to the nursing home, assign a temporary manager, or install a State monitor. CMS considers the extent of harm caused by the failure to meet requirements when it taken an enforcement action. If the nursing home does not correct its problems, CMS terminates its agreement with the nursing home. As a result, the nursing home is no longer certified to provide care to Medicare and Medicaid beneficiaries. Any beneficiary residing in the home at the time of the termination are transferred to certified facilities.

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