Who Regulates Nursing Homes?

A. Nursing homes are regulated by both the federal government and the government of the state in which they operate.

Nursing homes are one of the most heavily regulated industries that there are. This is for good reason because they care for the most vulnerable in society. Skilled nursing facilities have detailed regulations that they must follow and any failure to follow these rules could lead to some sort of sanctions for the nursing home.

There are multiple levels of regulations for nursing home. They are subject to both state and federal regulations, and each regulator has the ability to punish the facility in some way. It is not uncommon for each regulator to take some sort of action against the nursing home for egregious violations of rules of care.

In order to operate in the boundaries of a state, nursing homes are subject to state regulation. They are required to be licensed by the state in which the nursing home is physically located, even if the corporate parent is located elsewhere. In order to provide services to residents in a state, the nursing home will have to follow the state’s regulations.

The state will have health inspectors that may be a regular presence at the nursing homes. They are the “boots on the ground” that observe the daily care that is provided at a nursing home. Oftentimes, when residents and their families file a complaint, it is with the state, who then initiates the investigation. These regulators will carry out licensing inspections and have the ability to issue fines to nursing home. States can ultimately revoke the nursing home’s license if the violations are serious and sustained enough to merit it. In addition, states also can control funding that comes from state programs to aid low-income nursing home residents. If a nursing home has repeated noncompliance with state rules, it can be removed from this program.

Nursing homes are also subject to co-extensive federal government regulation. It is rare to have a complementary, yet overlapping system of regulation for an industry, but each level of regulation serves its own purpose. For the federal government, it is the Department of Health and Human Services that is the applicable regulator. HHS’ interest in nursing home care comes from the fact that it is the administrator of both the Medicare and Medicaid programs.

In order to receive Medicare and Medicaid funding, nursing homes must follow detailed federal rules as well. These regulations are incredibly prescriptive and govern practically every aspect of care at the facility. Compliance with these rules is a condition of participation in the program.

The federal government will oversee nursing homes in several ways. First, nursing homes must undergo an annual inspection. Inspectors will show up unannounced in order to gain a view of the daily care at the facility. They will select a sample of the residents of the nursing home and scrutinize their entire regimen of care. The inspectors will also scrutinize the physical environment and many other topics of care at the facility. When they are finished with their inspection, the regulators will issue an inspection report detailing the deficiencies that they found on their visit. In addition, there will also be inspections carried out in response to a particular complaint filed by a resident or their families. When there is a deficiency, nursing homes must show the government by a certain point in time that the deficiency has been corrected.

Of course, the federal regulators do not carry out the actual inspection since they have a large amount of nursing homes under their purview. The federal government will contract with the states, who provide the inspectors that visit the nursing homes. The state inspectors will make their recommendations to the federal government about the violations that they observed and the appropriate action. The federal regulators will then decide whether to adopt the advice given to them by their state colleagues.

The federal government has the power to issue fines to a nursing home for noncompliance with its regulations. They will generally give a penalty to a facility when there is actual harm done to a resident as a result of the violation. If the deficiency is particularly bad or results from longstanding uncorrected violations, the federal government can issue a payment denial from Medicare and Medicaid. This means that the nursing home cannot receive reimbursement from the federal government for new residents, effectively barring them from taking in new residents so long as the payment denial remains in place.

If the nursing home still cannot remedy the serious deficiencies after a prolonged period of time, they can be suspended from the Medicare and Medicaid programs. This is effectively a death knell for the nursing home. The government will usually try to work with a nursing home for an extended period before it takes this drastic step.