
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document affected by Public Law 106-554 Section 1(a)(6)[941(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[941(c)]]
[CITE: 42USC1395i-3]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
        Part A--Hospital Insurance Benefits for Aged and Disabled
 
Sec. 1395i-3. Requirements for, and assuring quality of care in, 
        skilled nursing facilities
        

(a) ``Skilled nursing facility'' defined

    In this subchapter, 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 1395x(l) of this title) with one or more hospitals having 
    agreements in effect under section 1395cc of this title; 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.

        (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. A State or the 
        Secretary may not require disclosure of the records of such 
        committee except insofar as such disclosure is related to the 
        compliance of such committee with the requirements of this 
        subparagraph.

       (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) of this section;
                (iii) uses an instrument which is specified by the State 
            under subsection (e)(5) of this section; and
                (iv) 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 provisions of section 1320a-7a of this title 
            (other than subsections (a) and (b)) shall apply to a civil 
            money penalty under this clause in the same manner as such 
            provisions apply to a penalty or proceeding under section 
            1320a-7a(a) of this title.
            (iii) Use of independent assessors

                If a State determines, under a survey under subsection 
            (g) of this section 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

                Subject to the timeframes prescribed by the Secretary 
            under section 1395yy(e)(6) of this title, such an assessment 
            must be conducted--
                    (I) promptly upon (but no later than 14 days after 
                the date of) admission for each individual admitted on 
                or after October 1, 1990, and by not later than January 
                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.
            (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 preadmission 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;
                (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;
                (vi) routine and emergency dental services to meet the 
            needs of each resident; and
                (vii) treatment and services required by mentally ill 
            and mentally retarded residents not otherwise provided or 
            arranged for (or required to be provided or arranged for) by 
            the State.

        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 licensed nursing service which 
            is sufficient to meet nursing needs of its residents and 
            must use the services of a registered professional nurse at 
            least at least \1\ 8 consecutive hours a day, 7 days a week.
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    \1\ So in original.
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            (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,
                    (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,
                    (IV) the Secretary provides notice of the waiver to 
                the State long-term care ombudsman (established under 
                section 307(a)(12) of the Older Americans Act of 1965 
                [42 U.S.C. 3027(a)(12)]) and the protection and advocacy 
                system in the State for the mentally ill and the 
                mentally retarded, and
                    (V) the facility that is granted such a waiver 
                notifies residents of the facility (or, where 
                appropriate, the guardians or legal representatives of 
                such residents) and members of their immediate families 
                of the waiver.

          A waiver under this subparagraph shall be subject to annual 
            renewal.

                (5) Required training of nurse aides

        (A) In general

            (i) Except as provided in clause (ii), a skilled nursing 
        facility must not use on a full-time basis any individual as a 
        nurse aide in the facility on or after October 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) of this section, and
                (II) is competent to provide nursing or nursing-related 
            services.

            (ii) A skilled nursing facility must not use on a temporary, 
        per diem, leased, or on any basis other than as a permanent 
        employee any individual as a nurse aide in the facility on or 
        after January 1, 1991, unless the individual meets the 
        requirements described in clause (i).

        (B) Offering competency evaluation programs for current 
                employees

            A skilled nursing facility must provide, for individuals 
        used as a nurse aide \2\ by the facility as of January 1, 1990, 
        for a competency evaluation program approved by the State under 
        subsection (e)(1) of this section and such preparation as may be 
        necessary for the individual to complete such a program by 
        October 1, 1990.
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    \2\ So in original. Probably should be ``as nurse aides''.
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        (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 any State registry 
        established under subsection (e)(2)(A) of this section that the 
        facility believes will include information 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 or a new 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 a registered dietician, 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, physical or 
        occupational therapy assistant, registered professional nurse, 
        licensed practical nurse, licensed or certified social worker, 
        registered respiratory therapist, or certified respiratory 
        therapy technician.

           (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
            (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 full-time 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 and to access to current clinical records of the 
            resident upon request by the resident or the resident's 
            legal representative, within 24 hours (excluding hours 
            occurring during a weekend or holiday) after making such a 
            request.
            (v) Accommodation of needs

                The right--
                    (I) to reside and receive services with reasonable 
                accommodation 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 may 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.
            (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.
            (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.
            (x) Refusal of certain transfers

                The right to refuse a transfer to another room within 
            the facility, if a purpose of the transfer is to relocate 
            the resident from a portion of the facility that is a 
            skilled nursing facility (for purposes of this subchapter) 
            to a portion of the facility that is not such a skilled 
            nursing facility.
            (xi) Other rights

                Any other right established by the Secretary.

        Clause (iii) shall not be construed as requiring the provision 
        of a private room. A resident's exercise of a right to refuse 
        transfer under clause (x) shall not affect the resident's 
        eligibility or entitlement to benefits under this subchapter or 
        to medical assistance under subchapter XIX of this chapter.

        (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) including the notice 
            (if any) of the State developed under section 1396r(e)(6) of 
            this title; 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 subchapter 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 
        subchapter 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. In determining whether 
        such a consultant is qualified to conduct reviews under the 
        preceding sentence, the Secretary shall take into account the 
        needs of nursing facilities under this subchapter to have access 
        to the services of such a consultant on a timely basis.

        (E) Information respecting advance directives

            A skilled nursing facility must comply with the requirement 
        of section 1395cc(f) of this title (relating to maintaining 
        written policies and procedures respecting advance directives).

                  (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 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 
            subchapter or subchapter XIX of this chapter on the 
            resident's behalf) for a stay at the facility; 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) of this section; and
                    (II) the name, mailing address, and telephone number 
                of the State long-term care ombudsman (established under 
                title III or VII of the Older Americans Act of 1965 [42 
                U.S.C. 3021 et seq., 3058 et seq.] in accordance with 
                section 712 of the Act [42 U.S.C. 3058g]).

        (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 subchapter 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 subchapter or under a State plan under subchapter 
            XIX of this chapter, (II) not require oral or written 
            assurance that such individuals are not eligible for, or 
            will not apply for, benefits under this subchapter 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 subchapter with respect to admissions practices of 
            skilled 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.

                  (6) Protection of resident funds

        (A) In general

            The skilled nursing facility--
                (i) may not require residents to deposit their personal 
            funds with the facility, and
                (ii) upon 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 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 $100 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 \3\ 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.
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    \3\ So in original. Probably should be ``credit''.
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            (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 subchapter or subchapter XIX of this chapter.

(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 \4\ 
        mental, and psychosocial well-being of each resident (consistent 
        with requirements established under subsection (f)(5) of this 
        section).
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    \4\ So in original. Probably should be followed by a comma.
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        (B) Required notices

            If a change occurs in--
                (i) the persons with an ownership or control interest 
            (as defined in section 1320a-3(a)(3) of this title) in the 
            facility,
                (ii) the persons who are officers, directors, agents, or 
            managing employees (as defined in section 1320a-5(b) of this 
            title) 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) 
        of this section.

                 (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 1320a-3 
        of this title) and with accepted professional standards and 
        principles which apply to professionals providing services in 
        such a facility.

        (B) Other

            A skilled nursing facility must meet such other requirements 
        relating to the health, safety, and well-being 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 1395aa(d) of this title, 
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 January 1, 1989, specify those 
        training and competency evaluation programs, and those 
        competency evaluation programs, that the State approves for 
        purposes of subsection (b)(5) of this section and that meet the 
        requirements established under subsection (f)(2) of this 
        section, and
            (B) by not later than January 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) of this section.

    The failure of the Secretary to establish requirements under 
    subsection (f)(2) of this section 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, or any 
        individual described in subsection (f)(2)(B)(ii) of this section 
        or in subparagraph (B), (C), or (D) of section 6901(b)(4) of the 
        Omnibus Budget Reconciliation Act of 1989.

        (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 this section 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, but shall not include any 
        allegations of resident abuse or neglect or misappropriation of 
        resident property that are not specifically documented by the 
        State under such subsection. The State shall make available to 
        the public information in the registry. 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.

        (C) Prohibition against charges

            A State may not impose any charges on a nurse aide relating 
        to the registry established and maintained under subparagraph 
        (A).

       (3) State appeals process for transfers and discharges

        The State, for transfers and discharges from skilled nursing 
    facilities effected on or after October 1, 1989, must provide for a 
    fair mechanism for hearing appeals on transfers and discharges of 
    residents of such facilities. Such mechanism must meet the 
    guidelines established by the Secretary under subsection (f)(3) of 
    this section; 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) of this section 
    respecting the qualification of administrators of skilled 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) of this section. Such 
    instrument shall be--
            (A) one of the instruments designated under subsection 
        (f)(6)(B) of this section, 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) of this section.

(f) Responsibilities 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 subchapter, 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) of this 
        section, 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, recognition of mental health and social service 
            needs, care of cognitively impaired residents, basic 
            restorative services, and residents' rights) and 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, recognition of mental health and social service 
            needs, care of cognitively impaired residents, basic 
            restorative services, 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; and
                (iv) requirements, under both such programs, that--
                    (I) provide procedures for determining competency 
                that permit a nurse aide, at the nurse aide's option, to 
                establish competency through procedures or methods other 
                than the passing of a written examination and to have 
                the competency evaluation conducted at the nursing 
                facility at which the aide is (or will be) employed 
                (unless the facility is described in subparagraph 
                (B)(iii)(I)),
                    (II) prohibit the imposition on a nurse aide who is 
                employed by (or who has received an offer of employment 
                from) a facility on the date on which the aide begins 
                either such program of any charges (including any 
                charges for textbooks and other required course 
                materials and any charges for the competency evaluation) 
                for either such program, and
                    (III) in the case of a nurse aide not described in 
                subclause (II) who is employed by (or who has received 
                an offer of employment from) a facility not later than 
                12 months after completing either such program, the 
                State shall provide for the reimbursement of costs 
                incurred in completing such program on a prorata \5\ 
                basis during the period in which the nurse aide is so 
                employed.
---------------------------------------------------------------------------
    \5\ So in original. Probably should be ``pro rata''.
---------------------------------------------------------------------------

        (B) Approval of certain programs

            Such requirements--
                (i) may permit approval of programs offered by or in 
            facilities (subject to clause (iii)), as well as outside 
            facilities (including employee organizations), and of 
            programs in effect on December 22, 1987;
                (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 approved under subsection (b)(5) of 
            this section if the State determines that, at the time the 
            program was offered, the program met the requirements for 
            approval under such paragraph; and
                (iii) subject to subparagraph (C), shall prohibit 
            approval of such a program--
                    (I) offered by or in a skilled nursing facility 
                which, within the previous 2 years--
                        (a) has operated under a waiver under subsection 
                    (b)(4)(C)(ii)(II) of this section;
                        (b) has been subject to an extended (or partial 
                    extended) survey under subsection (g)(2)(B)(i) of 
                    this section or section 1396r(g)(2)(B)(i) of this 
                    title, unless the survey shows that the facility is 
                    in compliance with the requirements of subsections 
                    (b), (c), and (d) of this section; or
                        (c) has been assessed a civil money penalty 
                    described in subsection (h)(2)(B)(ii) of this 
                    section or section 1396r(h)(2)(A)(ii) of this title 
                    of not less than $5,000, or has been subject to a 
                    remedy described in clause (i) or (iii) of 
                    subsection (h)(2)(B) of this section, subsection 
                    (h)(4) of this section, section 1396r(h)(1)(B)(i) of 
                    this title, or in clause (i), (iii), or (iv) of 
                    section 1396r(h)(2)(A) of this title, 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 (through subcontract or otherwise) 
            its responsibility under clause (iii)(II) to the skilled 
            nursing facility.

        (C) Waiver authorized

            Clause (iii)(I) of subparagraph (B) shall not apply to a 
        program offered in (but not by) a nursing facility (or skilled 
        nursing facility for purposes of this subchapter) in a State if 
        the State--
                (i) determines that there is no other such program 
            offered within a reasonable distance of the facility,
                (ii) assures, through an oversight effort, that an 
            adequate environment exists for operating the program in the 
            facility, and
                (iii) provides notice of such determination and 
            assurances to the State long-term care ombudsman.

        (3) Federal guidelines for State appeals process for 
                          transfers and discharges

        For purposes of subsections (c)(2)(B)(iii)(I) and (e)(3) of this 
    section, by not later than October 1, 1988, the Secretary shall 
    establish guidelines for minimum standards which State appeals 
    processes under subsection (e)(3) of this section must meet to 
    provide a fair mechanism for hearing appeals on transfers and 
    discharges of residents from skilled nursing facilities.

           (4) Secretarial standards for qualification of 
                               administrators

        For purposes of subsections (d)(1)(C) and (e)(4) of this 
    section, 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) of this section 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 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) of this section, 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) of this section for use by nursing 
        facilities in complying with the requirements of subsection 
        (b)(3)(A)(iii) of this section.

    (7) List of items and services furnished in skilled 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 December 22, 1987, that define 
        those costs which may be charged to the personal funds of 
        residents 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 subchapter 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 subchapter) shall include, at a minimum, the costs for 
        routine personal hygiene items and services furnished by the 
        facility.

(g) Survey and certification process

                (1) State and Federal responsibility

        (A) In general

            Pursuant to an agreement under section 1395aa of this title, 
        each State shall be responsible for certifying, in accordance 
        with surveys conducted under paragraph (2), the compliance of 
        skilled nursing facilities (other than facilities of the State) 
        with the requirements of subsections (b), (c), and (d) of this 
        section. The Secretary shall be responsible for certifying, in 
        accordance with surveys conducted under paragraph (2), the 
        compliance of State skilled nursing facilities with the 
        requirements of such subsections.

        (B) Educational program

            Each State shall conduct periodic educational programs for 
        the staff and residents (and their representatives) of skilled 
        nursing facilities in order to present current regulations, 
        procedures, and policies under this section.

        (C) Investigation of allegations of resident neglect and abuse 
                and misappropriation of resident property

            The State shall provide, through the agency responsible for 
        surveys and certification of nursing facilities under this 
        subsection, for a process for the receipt and timely review and 
        investigation of allegations of neglect and abuse and 
        misappropriation of resident property by a nurse aide of a 
        resident in a nursing facility or by another individual used by 
        the facility in providing services to such a resident. The State 
        shall, after providing the individual involved with a written 
        notice of the allegations (including a statement of the 
        availability of a hearing for the individual to rebut the 
        allegations) and the opportunity for a hearing on the record, 
        make a written finding as to the accuracy of the allegations. If 
        the State finds that a nurse aide has neglected or abused a 
        resident or misappropriated resident property in a facility, the 
        State shall notify the nurse aide and the registry of such 
        finding. If the State finds that any other individual used by 
        the facility has neglected or abused a resident or 
        misappropriated resident property in a facility, the State shall 
        notify the appropriate licensure authority. A State shall not 
        make a finding that an individual has neglected a resident if 
        the individual demonstrates that such neglect was caused by 
        factors beyond the control of the individual.

        (D) Removal of name from nurse aide registry

            (i) In general

                In the case of a finding of neglect under subparagraph 
            (C), the State shall establish a procedure to permit a nurse 
            aide to petition the State to have his or her name removed 
            from the registry upon a determination by the State that--
                    (I) the employment and personal history of the nurse 
                aide does not reflect a pattern of abusive behavior or 
                neglect; and
                    (II) the neglect involved in the original finding 
                was a singular occurrence.
            (ii) Timing of determination

                In no case shall a determination on a petition submitted 
            under clause (i) be made prior to the expiration of the 1-
            year period beginning on the date on which the name of the 
            petitioner was added to the registry under subparagraph (C).

        (E) Construction

            The failure of the Secretary to issue regulations to carry 
        out this subsection shall not relieve a State of its 
        responsibility under this subsection.

                             (2) Surveys

        (A) Standard survey

            (i) In general

                Each skilled nursing facility shall be subject to a 
            standard survey, to be conducted without any prior notice to 
            the facility. Any individual who notifies (or causes to be 
            notified) a skilled nursing facility of the time or date on 
            which such a survey is scheduled to be conducted is subject 
            to a civil money penalty of not to exceed $2,000. The 
            provisions of section 1320a-7a of this title (other than 
            subsections (a) and (b)) shall apply to a civil money 
            penalty under the previous sentence in the same manner as 
            such provisions apply to a penalty or proceeding under 
            section 1320a-7a(a) of this title. The Secretary shall 
            review each State's procedures for the scheduling and 
            conduct of standard surveys to assure that the State has 
            taken all reasonable steps to avoid giving notice of such a 
            survey through the scheduling procedures and the conduct of 
            the surveys themselves.
            (ii) Contents

                Each standard survey shall include, for a case-mix 
            stratified sample of residents--
                    (I) a survey of the quality of care furnished, as 
                measured by indicators of medical, nursing, and 
                rehabilitative care, dietary and nutrition services, 
                activities and social participation, and sanitation, 
                infection control, and the physical environment,
                    (II) written plans of care provided under subsection 
                (b)(2) of this section and an audit of the residents' 
                assessments under subsection (b)(3) of this section to 
                determine the accuracy of such assessments and the 
                adequacy of such plans of care, and
                    (III) a review of compliance with residents' rights 
                under subsection (c) of this section.
            (iii) Frequency

                (I) In general

                    Each skilled nursing facility shall be subject to a 
                standard survey not later than 15 months after the date 
                of the previous standard survey conducted under this 
                subparagraph. The Statewide average interval between 
                standard surveys of skilled nursing facilities under 
                this subsection shall not exceed 12 months.
                (II) Special surveys

                    If not otherwise conducted under subclause (I), a 
                standard survey (or an abbreviated standard survey) may 
                be conducted within 2 months of any change of ownership, 
                administration, management of a skilled nursing 
                facility, or the director of nursing in order to 
                determine whether the change has resulted in any decline 
                in the quality of care furnished in the facility.

        (B) Extended surveys

            (i) In general

                Each skilled nursing facility which is found, under a 
            standard survey, to have provided substandard quality of 
            care shall be subject to an extended survey. Any other 
            facility may, at the Secretary's or State's discretion, be 
            subject to such an extended survey (or a partial extended 
            survey).
            (ii) Timing

                The extended survey shall be conducted immediately after 
            the standard survey (or, if not practicable, not later than 
            2 weeks after the date of completion of the standard 
            survey).
            (iii) Contents

                In such an extended survey, the survey team shall review 
            and identify the policies and procedures which produced such 
            substandard quality of care and shall determine whether the 
            facility has complied with all the requirements described in 
            subsections (b), (c), and (d) of this section. Such review 
            shall include an expansion of the size of the sample of 
            residents' assessments reviewed and a review of the 
            staffing, of in-service training, and, if appropriate, of 
            contracts with consultants.
            (iv) Construction

                Nothing in this paragraph shall be construed as 
            requiring an extended or partial extended survey as a 
            prerequisite to imposing a sanction against a facility under 
            subsection (h) of this section on the basis of findings in a 
            standard survey.

        (C) Survey protocol

            Standard and extended surveys shall be conducted--
                (i) based upon a protocol which the Secretary has 
            developed, tested, and validated by not later than January 
            1, 1990, and
                (ii) by individuals, of a survey team, who meet such 
            minimum qualifications as the Secretary establishes by not 
            later than such date.

        The failure of the Secretary to develop, test, or validate such 
        protocols or to establish such minimum qualifications shall not 
        relieve any State of its responsibility (or the Secretary of the 
        Secretary's responsibility) to conduct surveys under this 
        subsection.

        (D) Consistency of surveys

            Each State and the Secretary shall implement programs to 
        measure and reduce inconsistency in the application of survey 
        results among surveyors.

        (E) Survey teams

            (i) In general

                Surveys under this subsection shall be conducted by a 
            multidisciplinary team of professionals (including a 
            registered professional nurse).
            (ii) Prohibition of conflicts of interest

                A State may not use as a member of a survey team under 
            this subsection an individual who is serving (or has served 
            within the previous 2 years) as a member of the staff of, or 
            as a consultant to, the facility surveyed respecting 
            compliance with the requirements of subsections (b), (c), 
            and (d) of this section, or who has a personal or familial 
            financial interest in the facility being surveyed.
            (iii) Training

                The Secretary shall provide for the comprehensive 
            training of State and Federal surveyors in the conduct of 
            standard and extended surveys under this subsection, 
            including the auditing of resident assessments and plans of 
            care. No individual shall serve as a member of a survey team 
            unless the individual has successfully completed a training 
            and testing program in survey and certification techniques 
            that has been approved by the Secretary.

                       (3) Validation surveys

        (A) In general

            The Secretary shall conduct onsite surveys of a 
        representative sample of skilled nursing facilities in each 
        State, within 2 months of the date of surveys conducted under 
        paragraph (2) by the State, in a sufficient number to allow 
        inferences about the adequacies of each State's surveys 
        conducted under paragraph (2). In conducting such surveys, the 
        Secretary shall use the same survey protocols as the State is 
        required to use under paragraph (2). If the State has determined 
        that an individual skilled nursing facility meets the 
        requirements of subsections (b), (c), and (d) of this section, 
        but the Secretary determines that the facility does not meet 
        such requirements, the Secretary's determination as to the 
        facility's noncompliance with such requirements is binding and 
        supersedes that of the State survey.

        (B) Scope

            With respect to each State, the Secretary shall conduct 
        surveys under subparagraph (A) each year with respect to at 
        least 5 percent of the number of skilled nursing facilities 
        surveyed by the State in the year, but in no case less than 5 
        skilled nursing facilities in the State.

        (C) Remedies for substandard performance

            If the Secretary finds, on the basis of such surveys, that a 
        State has failed to perform surveys as required under paragraph 
        (2) or that a State's survey and certification performance 
        otherwise is not adequate, the Secretary shall provide for an 
        appropriate remedy, which may include the training of survey 
        teams in the State.

        (D) Special surveys of compliance

            Where the Secretary has reason to question the compliance of 
        a skilled nursing facility with any of the requirements of 
        subsections (b), (c), and (d) of this section, the Secretary may 
        conduct a survey of the facility and, on the basis of that 
        survey, make independent and binding determinations concerning 
        the extent to which the skilled nursing facility meets such 
        requirements.

      (4) Investigation of complaints and monitoring compliance

        Each State shall maintain procedures and adequate staff to--
            (A) investigate complaints of violations of requirements by 
        skilled nursing facilities, and
            (B) monitor, on-site, on a regular, as needed basis, a 
        skilled nursing facility's compliance with the requirements of 
        subsections (b), (c), and (d) of this section, if--
                (i) the facility has been found not to be in compliance 
            with such requirements and is in the process of correcting 
            deficiencies to achieve such compliance;
                (ii) the facility was previously found not to be in 
            compliance with such requirements, has corrected 
            deficiencies to achieve such compliance, and verification of 
            continued compliance is indicated; or
                (iii) the State has reason to question the compliance of 
            the facility with such requirements.

    A State may maintain and utilize a specialized team (including an 
    attorney, an auditor, and appropriate health care professionals) for 
    the purpose of identifying, surveying, gathering and preserving 
    evidence, and carrying out appropriate enforcement actions against 
    substandard skilled nursing facilities.

       (5) Disclosure of results of inspections and activities

        (A) Public information

            Each State, and the Secretary, shall make available to the 
        public--
                (i) information respecting all surveys and 
            certifications made respecting skilled nursing facilities, 
            including statements of deficiencies, within 14 calendar 
            days after such information is made available to those 
            facilities, and approved plans of correction,
                (ii) copies of cost reports of such facilities filed 
            under this subchapter or subchapter XIX of this chapter,
                (iii) copies of statements of ownership under section 
            1320a-3 of this title, and
                (iv) information disclosed under section 1320a-5 of this 
            title.

        (B) Notice to ombudsman

            Each State shall notify the State long-term care ombudsman 
        (established under title III or VII of the Older Americans Act 
        of 1965 [42 U.S.C. 3021 et seq., 3058 et seq.] in accordance 
        with section 712 of the Act [42 U.S.C. 3058g]) of the State's 
        findings of noncompliance with any of the requirements of 
        subsections (b), (c), and (d) of this section, or of any adverse 
        action taken against a skilled nursing facility under paragraph 
        (1), (2), or (4) of subsection (h) of this section, with respect 
        to a skilled nursing facility in the State.

        (C) Notice to physicians and skilled nursing facility 
                administrator licensing board

            If a State finds that a skilled nursing facility has 
        provided substandard quality of care, the State shall notify--
                (i) the attending physician of each resident with 
            respect to which such finding is made, and
                (ii) the State board responsible for the licensing of 
            the skilled nursing facility administrator at the facility.

        (D) Access to fraud control units

            Each State shall provide its State medicaid fraud and abuse 
        control unit (established under section 1396b(q) of this title) 
        with access to all information of the State agency responsible 
        for surveys and certifications under this subsection.

(h) Enforcement process

                           (1) In general

        If a State finds, on the basis of a standard, extended, or 
    partial extended survey under subsection (g)(2) of this section or 
    otherwise, that a skilled nursing facility no longer meets a 
    requirement of subsection (b), (c), or (d) of this section, and 
    further finds that the facility's deficiencies--
            (A) immediately jeopardize the health or safety of its 
        residents, the State shall recommend to the Secretary that the 
        Secretary take such action as described in paragraph (2)(A)(i); 
        or
            (B) do not immediately jeopardize the health or safety of 
        its residents, the State may recommend to the Secretary that the 
        Secretary take such action as described in paragraph (2)(A)(ii).

    If a State finds that a skilled nursing facility meets the 
    requirements of subsections (b), (c), and (d) of this section, but, 
    as of a previous period, did not meet such requirements, the State 
    may recommend a civil money penalty under paragraph (2)(B)(ii) for 
    the days in which it finds that the facility was not in compliance 
    with such requirements.

                      (2) Secretarial authority

        (A) In general

            With respect to any skilled nursing facility in a State, if 
        the Secretary finds, or pursuant to a recommendation of the 
        State under paragraph (1) finds, that a skilled nursing facility 
        no longer meets a requirement of subsection (b), (c), (d), or 
        (e) of this section, and further finds that the facility's 
        deficiencies--
                (i) immediately jeopardize the health or safety of its 
            residents, the Secretary shall take immediate action to 
            remove the jeopardy and correct the deficiencies through the 
            remedy specified in subparagraph (B)(iii), or terminate the 
            facility's participation under this subchapter and may 
            provide, in addition, for one or more of the other remedies 
            described in subparagraph (B); or
                (ii) do not immediately jeopardize the health or safety 
            of its residents, the Secretary may impose any of the 
            remedies described in subparagraph (B).

        Nothing in this subparagraph shall be construed as restricting 
        the remedies available to the Secretary to remedy a skilled 
        nursing facility's deficiencies. If the Secretary finds, or 
        pursuant to the recommendation of the State under paragraph (1) 
        finds, that a skilled nursing facility meets such requirements 
        but, as of a previous period, did not meet such requirements, 
        the Secretary may provide for a civil money penalty under 
        subparagraph (B)(ii) for the days on which he finds that the 
        facility was not in compliance with such requirements.

        (B) Specified remedies

            The Secretary may take the following actions with respect to 
        a finding that a facility has not met an applicable requirement:
            (i) Denial of payment

                The Secretary may deny any further payments under this 
            subchapter with respect to all individuals entitled to 
            benefits under this subchapter in the facility or with 
            respect to such individuals admitted to the facility after 
            the effective date of the finding.
            (ii) Authority with respect to civil money penalties

                The Secretary may impose a civil money penalty in an 
            amount not to exceed $10,000 for each day of noncompliance. 
            The provisions of section 1320a-7a of this title (other than 
            subsections (a) and (b)) shall apply to a civil money 
            penalty under the previous sentence in the same manner as 
            such provisions apply to a penalty or proceeding under 
            section 1320a-7a(a) of this title.
            (iii) Appointment of temporary management

                In consultation with the State, the Secretary may 
            appoint temporary management to oversee the operation of the 
            facility and to assure the health and safety of the 
            facility's residents, where there is a need for temporary 
            management while--
                    (I) there is an orderly closure of the facility, or
                    (II) improvements are made in order to bring the 
                facility into compliance with all the requirements of 
                subsections (b), (c), and (d) of this section.

          The temporary management under this clause shall not be 
            terminated under subclause (II) until the Secretary has 
            determined that the facility has the management capability 
            to ensure continued compliance with all the requirements of 
            subsections (b), (c), and (d) of this section.

        The Secretary shall specify criteria, as to when and how each of 
        such remedies is to be applied, the amounts of any fines, and 
        the severity of each of these remedies, to be used in the 
        imposition of such remedies. Such criteria shall be designed so 
        as to minimize the time between the identification of violations 
        and final imposition of the remedies and shall provide for the 
        imposition of incrementally more severe fines for repeated or 
        uncorrected deficiencies. In addition, the Secretary may provide 
        for other specified remedies, such as directed plans of 
        correction.

        (C) Continuation of payments pending remediation

            The Secretary may continue payments, over a period of not 
        longer than 6 months after the effective date of the findings, 
        under this subchapter with respect to a skilled nursing facility 
        not in compliance with a requirement of subsection (b), (c), or 
        (d) of this section, if--
                (i) the State survey agency finds that it is more 
            appropriate to take alternative action to assure compliance 
            of the facility with the requirements than to terminate the 
            certification of the facility,
                (ii) the State has submitted a plan and timetable for 
            corrective action to the Secretary for approval and the 
            Secretary approves the plan of corrective action, and
                (iii) the facility agrees to repay to the Federal 
            Government payments received under this subparagraph if the 
            corrective action is not taken in accordance with the 
            approved plan and timetable.

        The Secretary shall establish guidelines for approval of 
        corrective actions requested by States under this subparagraph.

        (D) Assuring prompt compliance

            If a skilled nursing facility has not complied with any of 
        the requirements of subsections (b), (c), and (d) of this 
        section, within 3 months after the date the facility is found to 
        be out of compliance with such requirements, the Secretary shall 
        impose the remedy described in subparagraph (B)(i) for all 
        individuals who are admitted to the facility after such date.

        (E) Repeated noncompliance

            In the case of a skilled nursing facility which, on 3 
        consecutive standard surveys conducted under subsection (g)(2) 
        of this section, has been found to have provided substandard 
        quality of care, the Secretary shall (regardless of what other 
        remedies are provided)--
                (i) impose the remedy described in subparagraph (B)(i), 
            and
                (ii) monitor the facility under subsection (g)(4)(B) of 
            this section,

        until the facility has demonstrated, to the satisfaction of the 
        Secretary, that it is in compliance with the requirements of 
        subsections (b), (c), and (d) of this section, and that it will 
        remain in compliance with such requirements.

              (3) Effective period of denial of payment

        A finding to deny payment under this subsection shall terminate 
    when the Secretary finds that the facility is in substantial 
    compliance with all the requirements of subsections (b), (c), and 
    (d) of this section.

      (4) Immediate termination of participation for facility 
             where Secretary finds noncompliance and immediate 
                                  jeopardy

        If the Secretary finds that a skilled nursing facility has not 
    met a requirement of subsection (b), (c), or (d) of this section, 
    and finds that the failure immediately jeopardizes the health or 
    safety of its residents, the Secretary shall take immediate action 
    to remove the jeopardy and correct the deficiencies through the 
    remedy specified in paragraph (2)(B)(iii), or the Secretary shall 
    terminate the facility's participation under this subchapter. If the 
    facility's participation under this subchapter is terminated, the 
    State shall provide for the safe and orderly transfer of the 
    residents eligible under this subchapter consistent with the 
    requirements of subsection (c)(2) of this section.

                          (5) Construction

        The remedies provided under this subsection are in addition to 
    those otherwise available under State or Federal law and shall not 
    be construed as limiting such other remedies, including any remedy 
    available to an individual at common law. The remedies described in 
    clauses (i),\6\ and (iii) of paragraph (2)(B) may be imposed during 
    the pendency of any hearing.
---------------------------------------------------------------------------
    \6\ So in original. The comma probably should not appear.
---------------------------------------------------------------------------

                     (6) Sharing of information

        Notwithstanding any other provision of law, all information 
    concerning skilled nursing facilities required by this section to be 
    filed with the Secretary or a State agency shall be made available 
    by such facilities to Federal or State employees for purposes 
    consistent with the effective administration of programs established 
    under this subchapter and subchapter XIX of this chapter, including 
    investigations by State medicaid fraud control units.

(i) Construction

    Where requirements or obligations under this section are identical 
to those provided under section 1396r of this title, the fulfillment of 
those requirements or obligations under section 1396r of this title 
shall be considered to be the fulfillment of the corresponding 
requirements or obligations under this section.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1819, as added and amended 
Pub. L. 100-203, title IV, Secs. 4201(a)(3), 4202(a)(2), 4203(a)(2), 
4206, Dec. 22, 1987, 101 Stat. 1330-160, 1330-175, 1330-179, 1330-182; 
Pub. L. 100-360, title IV, Sec. 411(l)(1)(A), (2)(A)-(D), (F)-(L)(i), 
(4), (5), (7), (11), July 1, 1988, 102 Stat. 800-805, as amended Pub. L. 
100-485, title VI, Sec. 608(d)(27)(A), (C), (D), (I), (L), Oct. 13, 
1988, 102 Stat. 2422, 2423; Pub. L. 101-239, title VI, Sec. 6901(b)(1), 
(3), (d)(4), Dec. 19, 1989, 103 Stat. 2298, 2301; Pub. L. 101-508, title 
IV, Secs. 4008(h)(1)(B)-(F)(i), (G), (2)(B)-(N), (m)(3)(F)[(E)], 
4206(d)(1), Nov. 5, 1990, 104 Stat. 1388-46 to 1388-50, 1388-54, 1388-
116; Pub. L. 102-375, title VII, Sec. 708(a)(1)(A), Sept. 30, 1992, 106 
Stat. 1291; Pub. L. 103-432, title I, Secs. 106(c)(1)(A), (2)(A), 
(3)(A), (4)(A), (B), (d)(1)-(5), 110(b), Oct. 31, 1994, 108 Stat. 4406-
4408; Pub. L. 105-15, Sec. 1, May 15, 1997, 111 Stat. 34; Pub. L. 105-
33, title IV, Secs. 4432(b)(5)(A), 4755(a), Aug. 5, 1997, 111 Stat. 421, 
526.)

                       References in Text

    The Older Americans Act of 1965, referred to in subsecs. 
(c)(2)(B)(iii)(II) and (g)(5)(B), is Pub. L. 89-73, July 14, 1965, 79 
Stat. 218, as amended. Titles III and VII of the Act are classified 
generally to subchapters III (Sec. 3021 et seq.) and XI (Sec. 3058 et 
seq.) of chapter 35 of this title. For complete classification of this 
Act to the Code, see Short Title note set out under section 3001 of this 
title and Tables.
    Subparagraphs (B), (C), and (D) of section 6901(b)(4) of the Omnibus 
Budget Reconciliation Act of 1989 [Pub. L. 101-239], referred to in 
subsec. (e)(2)(A), are set out below.
    Section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse 
Amendments of 1977, referred to in subsec. (f)(7)(A), probably means 
section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments, 
Pub. L. 95-142, which is set out as a note under section 1395x of this 
title.


                               Amendments

    1997--Subsec. (b)(3)(C)(i). Pub. L. 105-33, Sec. 4432(b)(5)(A), 
substituted ``Subject to the timeframes prescribed by the Secretary 
under section 1395yy(e)(6) of this title, such'' for ``Such'' in 
introductory provisions.
    Subsec. (f)(2)(B)(iii). Pub. L. 105-15, Sec. 1(1), inserted 
``subject to subparagraph (C),'' after ``(iii)''.
    Subsec. (f)(2)(C). Pub. L. 105-15, Sec. 1(2), added subpar. (C).
    Subsec. (g)(1)(D), (E). Pub. L. 105-33, Sec. 4755(a), added subpar. 
(D) and redesignated former subpar. (D) as (E).
    1994--Subsec. (b)(3)(C)(i)(I). Pub. L. 103-432, Sec. 110(b), 
substituted ``but no later than 14 days'' for ``but no later than not 
later than 14 days''.
    Subsec. (b)(5)(D). Pub. L. 103-432, Sec. 106(d)(1), struck out comma 
before ``or a new competency evaluation program''.
    Subsec. (b)(5)(G). Pub. L. 103-432, Sec. 106(d)(2), substituted 
``licensed or certified social worker, registered respiratory therapist, 
or certified respiratory therapy technician'' for ``or licensed or 
certified social worker''.
    Subsec. (c)(1)(D). Pub. L. 103-432, Sec. 106(c)(2)(A), inserted at 
end ``In determining whether such a consultant is qualified to conduct 
reviews under the preceding sentence, the Secretary shall take into 
account the needs of nursing facilities under this subchapter to have 
access to the services of such a consultant on a timely basis.''
    Subsec. (c)(6)(B)(i). Pub. L. 103-432, Sec. 106(c)(3)(A), 
substituted ``$100'' for ``$50''.
    Subsec. (e)(2)(B). Pub. L. 103-432, Sec. 106(c)(4)(A), inserted ``, 
but shall not include any allegations of resident abuse or neglect or 
misappropriation of resident property that are not specifically 
documented by the State under such subsection'' after ``individual 
disputing the findings'' in first sentence.
    Subsec. (f)(2)(B)(i). Pub. L. 103-432, Sec. 106(d)(3), substituted 
``facilities (subject to clause (iii)),'' for ``facilities,''.
    Subsec. (f)(2)(B)(iii)(I)(b). Pub. L. 103-432, Sec. 106(c)(1)(A), 
inserted before semicolon at end ``, unless the survey shows that the 
facility is in compliance with the requirements of subsections (b), (c), 
and (d) of this section''.
    Subsec. (f)(2)(B)(iii)(I)(c). Pub. L. 103-432, Sec. 106(d)(4), 
substituted ``clause'' for ``clauses'' in two places.
    Subsec. (g)(1)(C). Pub. L. 103-432, Sec. 106(c)(4)(B), substituted 
second sentence for former second sentence which read as follows: ``The 
State shall, after notice to the individual involved and a reasonable 
opportunity for a hearing for the individual to rebut allegations, make 
a finding as to the accuracy of the allegations.''
    Subsec. (g)(5)(B). Pub. L. 103-432, Sec. 106(d)(5), substituted 
``paragraph'' for ``paragraphs'' before ``(1), (2), or (4) of subsection 
(h)''.
    1992--Subsecs. (c)(2)(B)(iii)(II), (g)(5)(B). Pub. L. 102-375 
substituted ``title III or VII of the Older Americans Act of 1965 in 
accordance with section 712 of the Act'' for ``section 307(a)(12) of the 
Older Americans Act of 1965''.
    1990--Subsec. (b)(1)(B). Pub. L. 101-508, Sec. 4008(h)(2)(B), 
inserted at end ``A State or the Secretary may not require disclosure of 
the records of such committee except insofar as such disclosure is 
related to the compliance of such committee with the requirements of 
this subparagraph.''
    Subsec. (b)(3)(C)(i)(I). Pub. L. 101-508, Sec. 4008(h)(2)(C), 
substituted ``not later than 14 days'' for ``4 days''.
    Subsec. (b)(4)(A)(vii). Pub. L. 101-508, Sec. 4008(h)(2)(D), added 
cl. (vii).
    Subsec. (b)(4)(C)(ii)(IV), (V). Pub. L. 101-508, Sec. 4008(h)(2)(E), 
added subcls. (IV) and (V).
    Subsec. (b)(5)(A). Pub. L. 101-508, Sec. 4008(h)(1)(B), designated 
existing provisions as cl. (i), in introductory provisions substituted 
``Except as provided in clause (ii), a skilled nursing facility'' for 
``A skilled nursing facility'' and ``on a full-time basis'' for ``(on a 
full-time, temporary, per diem, or other basis)'', redesignated former 
cls. (i) and (ii) as subcls. (I) and (II), respectively, and added cl. 
(ii).
    Subsec. (b)(5)(C). Pub. L. 101-508, Sec. 4008(h)(1)(C), substituted 
``any State registry established under subsection (e)(2)(A) of this 
section that the facility believes will include information'' for ``the 
State registry established under subsection (e)(2)(A) of this section as 
to information in the registry''.
    Subsec. (b)(5)(D). Pub. L. 101-508, Sec. 4008(h)(1)(D), inserted 
before period at end ``, or a new competency evaluation program'' after 
``and competency evaluation program''.
    Subsec. (b)(5)(F)(i). Pub. L. 101-508, Sec. 4008(h)(2)(F), 
substituted ``(G)) or a registered dietician,'' for ``(G)),''.
    Subsec. (c)(1)(A). Pub. L. 101-508, Sec. 4008(h)(2)(G)(B)[(ii)], 
inserted at end ``A resident's exercise of a right to refuse transfer 
under clause (x) shall not affect the resident's eligibility or 
entitlement to benefits under this subchapter or to medical assistance 
under subchapter XIX of this chapter.''
    Subsec. (c)(1)(A)(iv). Pub. L. 101-508, Sec. 4008(h)(2)(H), inserted 
before period at end ``and to access to current clinical records of the 
resident upon request by the resident or the resident's legal 
representative, within 24 hours (excluding hours occurring during a 
weekend or holiday) after making such a request''.
    Subsec. (c)(1)(A)(x), (xi). Pub. L. 101-508, Sec. 4008(h)(2)(G)(i), 
added cl. (x) and redesignated former cl. (x) as (xi).
    Subsec. (c)(1)(B)(ii). Pub. L. 101-508, Sec. 4008(h)(2)(I), inserted 
``including the notice (if any) of the State developed under section 
1396r(e)(6) of this title'' after ``in such rights)''.
    Subsec. (c)(1)(E). Pub. L. 101-508, Sec. 4206(d)(1), added subpar. 
(E).
    Subsec. (e)(1)(A). Pub. L. 101-508, Sec. 4008(h)(2)(J), substituted 
``subsection (f)(2) of this section'' for ``clause (i) or (ii) of 
subsection (f)(2)(A) of this section''.
    Subsec. (e)(2)(A). Pub. L. 101-508, Sec. 4008(h)(2)(K)(i), inserted 
before period at end ``, or any individual described in subsection 
(f)(2)(B)(ii) of this section or in subparagraph (B), (C), or (D) of 
section 6901(b)(4) of the Omnibus Budget Reconciliation Act of 1989''.
    Subsec. (e)(2)(C). Pub. L. 101-508, Sec. 4008(h)(2)(K)(ii), added 
subpar. (C).
    Subsec. (f)(2)(A)(ii). Pub. L. 101-508, Sec. 4008(m)(3)(F)[(E)], 
struck out ``and'' after semicolon at end.
    Subsec. (f)(2)(A)(iv). Pub. L. 101-508, Sec. 4008(h)(1)(E), struck 
out ``and'' at end of subcl. (I), inserted ``who is employed by (or who 
has received an offer of employment from) a facility on the date on 
which the aide begins either such program'' after ``nurse aide'' and 
substituted ``, and'' for period at end of subcl. (II), and added subcl. 
(III).
    Subsec. (f)(2)(B). Pub. L. 101-508, Sec. 4008(h)(1)(G), inserted 
``(through subcontract or otherwise)'' after ``may not delegate'' in 
second sentence.
    Subsec. (f)(2)(B)(iii)(I). Pub. L. 101-508, Sec. 4008(h)(1)(F)(i), 
amended subcl. (I) generally. Prior to amendment, subcl. (I) read as 
follows: ``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) of this section, within the previous 2 years, or''.
    Subsec. (g)(1)(C). Pub. L. 101-508, Sec. 4008(h)(2)(L), inserted at 
end ``A State shall not make a finding that an individual has neglected 
a resident if the individual demonstrates that such neglect was caused 
by factors beyond the control of the individual.''
    Subsec. (g)(5)(A)(i). Pub. L. 101-508, Sec. 4008(h)(2)(M), 
substituted ``deficiencies, within 14 calendar days after such 
information is made available to those facilities, and approved plans'' 
for ``deficiencies and plans''.
    Subsec. (g)(5)(B). Pub. L. 101-508, Sec. 4008(h)(2)(N), substituted 
``or of any adverse action taken against a skilled nursing facility 
under paragraphs (1), (2), or (4) of subsection (h) of this section, 
with respect'' for ``with respect''.
    1989--Subsec. (b)(5)(A). Pub. L. 101-239, Sec. 6901(b)(1)(A), 
substituted ``October 1, 1990'' for ``January 1, 1990'' in introductory 
provisions.
    Subsec. (b)(5)(B). Pub. L. 101-239, Sec. 6901(b)(1)(B), substituted 
``January 1, 1990'' and ``October 1, 1990'' for ``July 1, 1989'' and 
``January 1, 1990'', respectively.
    Subsec. (c)(1)(A)(ii)(II). Pub. L. 101-239, Sec. 6901(d)(4)(A), 
substituted ``Secretary until such an order could reasonably be 
obtained)'' for ``Secretary) until such an order could reasonably be 
obtained''.
    Subsec. (c)(1)(A)(v)(I). Pub. L. 101-239, Sec. 6901(d)(4)(B), 
substituted ``accommodation'' for ``accommodations''.
    Subsec. (f)(2)(A)(i)(I). Pub. L. 101-239, Sec. 6901(d)(4)(C), 
substituted ``and content of the curriculum'' for ``, content of the 
curriculum''.
    Pub. L. 101-239, Sec. 6901(b)(3)(A), inserted ``care of cognitively 
impaired residents,'' after ``social service needs,''.
    Subsec. (f)(2)(A)(ii). Pub. L. 101-239, Sec. 6901(b)(3)(B), 
substituted ``recognition of mental health and social service needs, 
care of cognitively impaired residents'' for ``cognitive, behavioral and 
social care''.
    Subsec. (f)(2)(A)(iv). Pub. L. 101-239, Sec. 6901(b)(3)(C), (D), 
added cl. (iv).
    Subsec. (h)(2)(C). Pub. L. 101-239, Sec. 6901(d)(4)(D), inserted 
``after the effective date of the findings'' after ``6 months'' in 
introductory provisions.
    1988--Subsec. (b)(3)(A)(iii). Pub. L. 100-360, Sec. 411(l)(2)(B), 
struck out ``in the case of a resident eligible for benefits under 
subchapter XIX of this chapter,'' before ``uses an instrument''.
    Subsec. (b)(3)(A)(iv). Pub. L. 100-360, Sec. 411(l)(2)(A), as 
amended by Pub. L. 100-485, Sec. 608(d)(27)(C), struck out ``in the case 
of a resident eligible for benefits under this part,'' before ``includes 
the identification''.
    Subsec. (b)(3)(B)(ii)(III). Pub. L. 100-360, Sec. 411(l)(2)(C), 
amended subcl. (III) generally. Prior to amendment, subcl. (III) read as 
follows: ``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 1320a-7a of this 
title.''
    Subsec. (b)(3)(C)(i)(I). Pub. L. 100-360, Sec. 411(l)(1)(A)(i), 
substituted ``than January 1, 1991'' for ``than October 1, 1990''.
    Subsec. (b)(4)(C)(i). Pub. L. 100-360, Sec. 411(l)(1)(A)(ii), 
substituted ``24-hour licensed nursing'' for ``24-hour nursing'', ``must 
use'' for ``must employ'', and ``at least 8 consecutive hours a day,'' 
for ``during the day tour of duty (of at least 8 hours a day)''.
    Subsec. (b)(5)(A). Pub. L. 100-360, Sec. 411(l)(2)(D)(i), as amended 
by Pub. L. 100-485, Sec. 608(d)(27)(D), struck out ``, who is not a 
licensed health professional (as defined in subparagraph (E)),'' after 
``any individual''.
    Pub. L. 100-360, Sec. 411(l)(1)(A)(iii), substituted ``January 1, 
1990'' for ``October 1, 1989, (or January 1, 1990, in the case of an 
individual used by the facility as a nurse aide before July 1, 1989)''.
    Subsec. (b)(5)(A)(ii). Pub. L. 100-360, Sec. 411(l)(2)(D)(ii), 
substituted ``nursing or nursing-related services'' for ``such 
services''.
    Subsec. (b)(5)(G). Pub. L. 100-360, Sec. 411(l)(2)(D)(iii), inserted 
``physical or occupational therapy assistant,'' after ``occupational 
therapist,''.
    Subsec. (c)(1)(D). Pub. L. 100-360, Sec. 411(l)(1)(A)(iv), as added 
by Pub. L. 100-485, Sec. 608(d)(27)(A), added subpar. (D).
    Subsec. (c)(2)(A)(v). Pub. L. 100-360, Sec. 411(l)(2)(F), 
substituted ``for a stay at the facility'' for ``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 subchapter 
and subchapter XIX of this chapter''.
    Subsec. (c)(6). Pub. L. 100-360, Sec. 411(l)(2)(G), substituted 
``upon the written'' for ``once the facility accepts the written'' in 
subpar. (A)(ii), and ``Upon written'' for ``Upon a facility's acceptance 
of written'' in subpar. (B).
    Subsec. (e)(1)(A). Pub. L. 100-360, Sec. 411(l)(1)(A)(v), formerly 
Sec. 411(l)(1)(A)(iv), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(A), substituted ``January'' for ``March''.
    Subsec. (e)(1)(B). Pub. L. 100-360, Sec. 411(l)(1)(A)(vi), formerly 
Sec. 411(l)(1)(A)(v), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(A), substituted ``January'' for ``March''.
    Subsec. (e)(2)(A). Pub. L. 100-360, Sec. 411(l)(1)(A)(vii), formerly 
Sec. 411(l)(1)(A)(vi), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(A), substituted ``January'' for ``March''.
    Subsec. (e)(2)(B). Pub. L. 100-360, Sec. 411(l)(2)(H), inserted 
after first sentence ``The State shall make available to the public 
information in the registry.''
    Subsec. (e)(3). Pub. L. 100-360, Sec. 411(l)(2)(I), inserted ``and 
discharges'' after ``transfers'' in heading and in two places in text.
    Pub. L. 100-360, Sec. 411(l)(1)(A)(viii), formerly 
Sec. 411(l)(1)(A)(vii), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(A), substituted ``1989'' for ``1990''.
    Subsec. (e)(5). Pub. L. 100-360, Sec. 411(l)(1)(A)(ix), formerly 
Sec. 411(l)(1)(A)(viii), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(A), substituted ``1990'' for ``1989'' in introductory 
provisions.
    Subsec. (f)(2)(A)(i)(I). Pub. L. 100-360, Sec. 411(l)(2)(J), 
substituted ``recognition of mental health and social service needs'' 
for ``cognitive, behavioral and social care''.
    Subsec. (f)(3). Pub. L. 100-360, Sec. 411(l)(2)(I), inserted ``and 
discharges'' after ``transfers'' in heading and in text.
    Pub. L. 100-360, Sec. 411(l)(1)(A)(x), formerly 
Sec. 411(l)(1)(A)(ix), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(A), substituted ``1988'' for ``1989''.
    Subsec. (f)(6)(A). Pub. L. 100-360, Sec. 411(l)(1)(A)(xi), formerly 
Sec. 411(l)(1)(A)(x), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(A), substituted ``January'' for ``July''.
    Subsec. (f)(6)(B). Pub. L. 100-360, Sec. 411(l)(1)(A)(xii), formerly 
Sec. 411(l)(1)(A)(xi), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(A), substituted ``April'' for ``October''.
    Subsec. (f)(7)(A). Pub. L. 100-360, Sec. 411(l)(2)(K), substituted 
``residents'' for ``patients''.
    Subsec. (f)(7)(B). Pub. L. 100-360, Sec. 411(l)(2)(L)(i), 
substituted ``shall include'' for ``shall not include''.
    Subsec. (g)(1)(C). Pub. L. 100-360, Sec. 411(l)(5)(A)-(C), 
substituted ``and timely review'' for ``, review,'', inserted ``or by 
another individual used by the facility in providing services to such a 
resident'' after ``a nursing facility'', and substituted ``The State 
shall, after notice to the individual involved and a reasonable 
opportunity for a hearing for the individual to rebut allegations, make 
a finding as to the accuracy of the allegations. If the State finds that 
a nurse aide has neglected or abused a resident or misappropriated 
resident property in a facility, the State shall notify the nurse aide 
and the registry of such finding. If the State finds that any other 
individual used by the facility has neglected or abused a resident or 
misappropriated resident property in a facility, the State shall notify 
the appropriate licensure authority.'' for ``If the State finds, after 
notice to the nurse aide involved and a reasonable opportunity for a 
hearing for the nurse aide to rebut allegations, that a nurse aide whose 
name is contained in a nurse aide registry has neglected or abused a 
resident or misappropriated resident property in a facility, the State 
shall notify the nurse aide and the registry of such finding.''
    Subsec. (g)(1)(D). Pub. L. 100-360, Sec. 411(l)(5)(D), substituted 
``to issue regulations to carry out this subsection'' for ``to establish 
standards under subsection (f) of this section''.
    Subsec. (g)(2)(A)(i). Pub. L. 100-360, Sec. 411(l)(5)(E), amended 
third sentence generally. Prior to amendment, third sentence read as 
follows: ``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 1320a-7a of this 
title.''
    Subsec. (g)(2)(B)(ii). Pub. L. 100-360, Sec. 411(l)(5)(F), as added 
by Pub. L. 100-485, Sec. 608(d)(27)(I), substituted ``practicable'' for 
``practical''.
    Subsec. (g)(2)(C)(i). Pub. L. 100-360, Sec. 411(l)(4), substituted 
``January'' for ``October''.
    Subsec. (g)(3)(D). Pub. L. 100-360, Sec. 411(l)(5)(G), formerly 
Sec. 411(l)(5)(F), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(I), substituted ``on the basis of that survey'' for ``on 
that basis''.
    Subsec. (g)(4). Pub. L. 100-360, Sec. 411(l)(5)(H), formerly 
Sec. 411(l)(5)(G), as redesignated by Pub. L. 100-485, 
Sec. 608(d)(27)(I), struck out ``chronically'' after ``enforcement 
actions against'' in last sentence.
    Subsec. (h)(2)(B)(ii). Pub. L. 100-360, Sec. 411(l)(7)(A), 
substituted ``. The provisions of section 1320a-7a of this title (other 
than subsections (a) and (b)) shall apply to a civil money penalty under 
the previous sentence in the same manner as such provisions apply to a 
penalty or proceeding under section 1320a-7a(a) of this title.'' for 
``and the Secretary shall impose and collect such a penalty in the same 
manner as civil money penalties are imposed and collected under section 
1320a-7a of this title.''
    Subsec. (h)(5). Pub. L. 100-360, Sec. 411(l)(11), as added by Pub. 
L. 100-485, Sec. 608(d)(27)(L), substituted ``clauses (i), and (iii) of 
paragraph (2)(B)'' for ``clauses (i), (iii), and (iv) of paragraph 
(2)(A)''.
    Subsec. (h)(6). Pub. L. 100-360, Sec. 411(l)(7)(B), inserted ``by 
such facilities'' after ``be made available''.
    1987--Subsecs. (g) to (i). Pub. L. 100-203, Secs. 4202(a)(2), 
4203(a)(2), 4206, added subsecs. (g), (h), and (i), respectively.


                    Effective Date of 1997 Amendment

    Section 4432(d) of Pub. L. 105-33 provided that: ``The amendments 
made by this section [amending this section and sections 1395k, 1395l, 
1395u, 1395x, 1395y, 1395cc, 1395tt, and 1395yy of this title] are 
effective for cost reporting periods beginning on or after July 1, 1998; 
except that the amendments made by subsection (b) [amending this section 
and sections 1395k, 1395l, 1395u, 1395x, 1395y, 1395cc, 1395tt, and 
1395yy of this title] shall apply to items and services furnished on or 
after July 1, 1998.''


                    Effective Date of 1994 Amendment

    Section 106(c)(1)(B) of Pub. L. 103-432 provided that: ``The 
amendment made by subparagraph (A) [amending this section] shall take 
effect as if included in the enactment of OBRA-1990 [Pub. L. 101-508].''
    Section 106(c)(2)(B) of Pub. L. 103-432 provided that: ``The 
amendment made by subparagraph (A) [amending this section] shall take 
effect as if included in the enactment of OBRA-1987 [Pub. L. 100-203].''
    Section 106(c)(3)(B) of Pub. L. 103-432 provided that: ``The 
amendment made by subparagraph (A) [amending this section] shall take 
effect January 1, 1995.''
    Section 106(c)(4)(C) of Pub. L. 103-432 provided that: ``The 
amendments made by this paragraph [amending this section] shall take 
effect January 1, 1995.''
    Section 106(d)(7) of Pub. L. 103-432 provided that: ``The amendments 
made by this subsection [amending this section and provisions set out as 
a note below] shall take effect as if included in the enactment of OBRA-
1990 [Pub. L. 101-508].''


                    Effective Date of 1992 Amendment

    Amendment by Pub. L. 102-375 inapplicable with respect to fiscal 
year 1993, see section 4(b) of Pub. L. 103-171, set out as a note under 
section 3001 of this title.
    Amendment by Pub. L. 102-375 inapplicable with respect to fiscal 
year 1992, see section 905(b)(6) of Pub. L. 102-375, set out as a note 
under section 3001 of this title.


                    Effective Date of 1990 Amendment

    Section 4008(h)(1)(F)(ii) of Pub. L. 101-508, as amended by Pub. L. 
103-432, title I, Sec. 106(d)(6), Oct. 31, 1994, 108 Stat. 4407, 
provided that:
    ``(I) The amendments made by clause (i) [amending this section] 
shall take effect as if included in the enactment of the Omnibus Budget 
Reconciliation Act of 1987 [Pub. L. 100-203], except that a State may 
not approve a training and competency evaluation program or a competency 
evaluation program offered by or in a skilled nursing facility which, 
pursuant to any Federal or State law within the 2-year period beginning 
on October 1, 1988--
        ``(aa) had its participation terminated under title XVIII of the 
    Social Security Act [this subchapter] or under the State plan under 
    title XIX of such Act [subchapter XIX of this chapter];
        ``(bb) was subject to a denial of payment under either such 
    title;
        ``(cc) was assessed a civil money penalty not less than $5,000 
    for deficiencies in skilled nursing facility standards;
        ``(dd) operated under a temporary management appointed to 
    oversee the operation of the facility and to ensure the health and 
    safety of the facility's residents; or
        ``(ee) pursuant to State action, was closed or had its residents 
    transferred.
    ``(II) Notwithstanding subclause (I) and subject to section 
1819(f)(2)(B)(iii)(I) of the Social Security Act [subsec. 
(f)(2)(B)(iii)(I) of this section] (as amended by clause (i)), a State 
may approve a training and competency evaluation program or a competency 
evaluation program offered by or in a skilled nursing facility described 
in subclause (I) if, during the previous 2 years, item (aa), (bb), (cc), 
(dd), or (ee) of subclause (I) did not apply to the facility.''
    Section 4008(h)(1)(H) of Pub. L. 101-508 provided that: ``Except as 
provided in subparagraph (F) [amending this section and enacting 
provisions set out as a note above], the amendments made by this 
subsection [probably means this paragraph, amending this section] shall 
take effect as if they were included in the enactment of the Omnibus 
Budget Reconciliation Act of 1987 [Pub. L. 100-203].''
    Section 4008(h)(2)(P) of Pub. L. 101-508 provided that: ``The 
amendments made by this paragraph [amending this section and sections 
1395x and 1395yy of this title] shall take effect as if they were 
included in the enactment of the Omnibus Budget Reconciliation Act of 
1987 [Pub. L. 100-203].''
    Section 4206(e)(1) of Pub. L. 101-508 provided that: ``The 
amendments made by subsections (a) and (d) [amending this section and 
sections 1395cc and 1395bbb of this title] shall apply with respect to 
services furnished on or after the first day of the first month 
beginning more than 1 year after the date of the enactment of this Act 
[Nov. 5, 1990].''


                    Effective Date of 1989 Amendment

    Section 6901(b)(6) of Pub. L. 101-239 provided that:
    ``(A) In general.--Except as provided in subparagraph (B), the 
amendments made by this subsection [amending this section and sections 
1396b and 1396r of this title] shall take effect as if they were 
included in the enactment of the Omnibus Budget Reconciliation Act of 
1987 [Pub. L. 100-203].
    ``(B) Exception.--The amendments made by paragraph (3) [amending 
this section and section 1396r of this title] shall apply to nurse aide 
training and competency evaluation programs, and nurse aide competency 
evaluation programs, offered on or after the end of the 90-day period 
beginning on the date of the enactment of this Act [Dec. 19, 1989], but 
shall not affect competency evaluations conducted under programs offered 
before the end of such period.''
    Section 6901(d)(6) of Pub. L. 101-239 provided that:
    ``(A) In general.--Except as provided in subparagraph (B), the 
amendments made by this subsection [amending this section and sections 
1396i and 1396r of this title] shall take effect as if they were 
included in the enactment of the Omnibus Budget Reconciliation Act of 
1987 [Pub. L. 100-203].
    ``(B) Exception.--The amendment made by paragraph (1) [amending 
section 1396r of this title] shall take effect on the date of the 
enactment of this Act [Dec. 19, 1989].''


                    Effective Date of 1988 Amendments

    Amendment by Pub. L. 100-485 effective as if originally included in 
the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100-360, see 
section 608(g)(1) of Pub. L. 100-485, set out as a note under section 
704 of this title.
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by Pub. L. 100-360, as it relates to a provision in the 
Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203, effective as 
if included in the enactment of that provision in Pub. L. 100-203, see 
section 411(a) of Pub. L. 100-360, set out as a Reference to OBRA; 
Effective Date note under section 106 of Title 1, General Provisions.


                             Effective Date

    Section 4204 of title IV of Pub. L. 100-203, as amended by Pub. L. 
100-360, title IV, Sec. 411(l)(9), July 1, 1988, 102 Stat. 805; Pub. L. 
100-485, title VI, Sec. 608(d)(27)(K), Oct. 13, 1988, 102 Stat. 2423, 
provided that:
    ``(a) New Requirements and Survey and Certification Process.--Except 
as otherwise specifically provided in section 1819 of the Social 
Security Act [this section], the amendments made by sections 4201 and 
4202 [enacting and amending this section and amending sections 1395x, 
1395aa, 1395tt, and 1395yy of this title] (relating to skilled nursing 
facility requirements and survey and certification requirements) shall 
apply to services furnished on or after October 1, 1990, without regard 
to whether regulations to implement such amendments are promulgated by 
such date.
    ``(b) Enforcement.--(1) Except as otherwise specifically provided in 
section 1819 of the Social Security Act [this section], the amendments 
made by section 4203 of this Act [amending this section and section 
1395aa of this title] apply January 1, 1988, without regard to whether 
regulations to implement such amendments are promulgated by such date.
    ``(2) In applying the amendments made by section 4203 of this Act 
for services furnished by a skilled nursing facility before October 1, 
1990, any reference to a requirement of subsection (b), (c), or (d), of 
section 1819 of the Social Security Act is deemed a reference to the 
provisions of section 1861(j) of such Act [section 1395x(j) of this 
title].
    ``(c) Waiver of Paperwork Reduction.--Chapter 35 of title 44, United 
States Code, shall not apply to information required for purposes of 
carrying out this part [part 1 of subtitle C (Secs. 4201-4206), enacting 
this section, amending this section and sections 1395x, 1395aa, 1395tt, 
and 1395yy of this title, and enacting provisions set out as notes under 
this section] and implementing the amendments made by this part.''


 Study and Report Regarding State Licensure and Certification Standards 
             and Respiratory Therapy Competency Examinations

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title I, Sec. 107], Nov. 
29, 1999, 113 Stat. 1536, 1501A-328, provided that:
    ``(a) Study.--The Secretary of Health and Human Services shall 
conduct a study that--
        ``(1) identifies variations in State licensure and certification 
    standards for health care providers (including nursing and allied 
    health professionals) and other individuals providing respiratory 
    therapy in skilled nursing facilities;
        ``(2) examines State requirements relating to respiratory 
    therapy competency examinations for such providers and individuals; 
    and
        ``(3) determines whether regular respiratory therapy competency 
    examinations or certifications should be required under the medicare 
    program under title XVIII of the Social Security Act (42 U.S.C. 1395 
    et seq.) for such providers and individuals.
    ``(b) Report.--Not later than 18 months after the date of enactment 
of this Act [Nov. 29, 1999], the Secretary of Health and Human Services 
shall submit to Congress a report on the results of the study conducted 
under this section, together with any recommendations for legislation 
that the Secretary determines to be appropriate as a result of such 
study.''


                           Retroactive Review

    Section 4755(c) of Pub. L. 105-33 provided that: ``The procedures 
developed by a State under the amendments made by subsection[s] (a) and 
(b) [amending this section and section 1396r of this title] shall permit 
an individual to petition for a review of any finding made by a State 
under section 1819(g)(1)(C) or 1919(g)(1)(C) of the Social Security Act 
(42 U.S.C. 1395i-3(g)(1)(C) or 1396r(g)(1)(C)) after January 1, 1995.''


 Study and Report on Deeming for Nursing Facilities and Renal Dialysis 
                               Facilities

    Pub. L. 104-134, title I, Sec. 101(d) [title V, Sec. 516(d)], Apr. 
26, 1996, 110 Stat. 1321-211, 1321-248; renumbered title I, Pub. L. 104-
140, Sec. 1(a), May 2, 1996, 110 Stat. 1327, provided that:
    ``(1) Study.--The Secretary of Health and Human Services shall 
provide for--
        ``(A) a study concerning the effectiveness and appropriateness 
    of the current mechanisms for surveying and certifying skilled 
    nursing facilities for compliance with the conditions and 
    requirements of sections 1819 and 1861(j) of the Social Security Act 
    [this section and section 1395x(j) of this title] and nursing 
    facilities for compliance with the conditions of section 1919 of 
    such Act [section 1396r of this title], and
        ``(B) a study concerning the effectiveness and appropriateness 
    of the current mechanisms for surveying and certifying renal 
    dialysis facilities for compliance with the conditions and 
    requirements of section 1881(b) of the Social Security Act [section 
    1395rr(b) of this title].
    ``(2) Report.--Not later than July 1, 1997, the Secretary shall 
transmit to Congress a report on each of the studies provided for under 
paragraph (1). The report on the study under paragraph (1)(A) shall 
include (and the report on the study under paragraph (1)(B) may include) 
a specific framework, where appropriate, for implementing a process 
under which facilities covered under the respective study may be deemed 
to meet applicable medicare conditions and requirements if they are 
accredited by a national accreditation body.''


          Maintaining Regulatory Standards for Certain Services

    Section 4008(h)(2)(O) of Pub. L. 101-508 provided that: ``Any 
regulations promulgated and applied by the Secretary of Health and Human 
Services after the date of the enactment of the Omnibus Budget 
Reconciliation Act of 1987 [Dec. 22, 1987] with respect to services 
described in clauses (ii), (iv), and (v) of section 1819(b)(4)(A) of the 
Social Security Act [subsec. (b)(4)(A)(ii), (iv), and (v) of this 
section] shall include requirements for providers of such services that 
are at least as strict as the requirements applicable to providers of 
such services prior to the enactment of the Omnibus Budget 
Reconciliation Act of 1987.''


 Nurse Aide Training and Competency Evaluation Programs; Publication of 
                          Proposed Regulations

    Section 6901(b)(2) of Pub. L. 101-239 provided that: ``The Secretary 
of Health and Human Services shall issue proposed regulations to 
establish the requirements described in sections 1819(f)(2) and 
1919(f)(2) of the Social Security Act [subsec. (f)(2) of this section 
and section 1396r(f)(2) of this title] by not later than 90 days after 
the date of the enactment of this Act [Dec. 19, 1989].''


     Nurse Aide Training and Competency Evaluation; Satisfaction of 
                          Requirements; Waiver

    Section 6901(b)(4)(B)-(D) of Pub. L. 101-239 provided that:
    ``(B) A nurse aide shall be considered to satisfy the requirement of 
sections 1819(b)(5)(A) and 1919(b)(5)(A) of the Social Security Act 
[subsec. (b)(5)(A) of this section and section 1396r(b)(5)(A) of this 
title] (of having completed a training and competency evaluation program 
approved by a State under section 1819(e)(1)(A) or 1919(e)(1)(A) of such 
Act [subsec. (e)(1)(A) of this section and section 1396r(e)(1)(A) of 
this title]), if such aide would have satisfied such requirement as of 
July 1, 1989, if a number of hours (not less than 60 hours) were 
substituted for `75 hours' in sections 1819(f)(2) and 1919(f)(2) of such 
Act [subsec. (f)(2) of this section and section 1396r(f)(2) of this 
title], respectively, and if such aide had received, before July 1, 
1989, at least the difference in the number of such hours in supervised 
practical nurse aide training or in regular in-service nurse aide 
education.
    ``(C) A nurse aide shall be considered to satisfy the requirement of 
sections 1819(b)(5)(A) and 1919(b)(5)(A) of the Social Security Act (of 
having completed a training and competency evaluation program approved 
by a State under section 1819(e)(1)(A) or 1919(e)(1)(A) of such Act), if 
such aide was found competent (whether or not by the State), before July 
1, 1989, after the completion of a course of nurse aide training of at 
least 100 hours duration.
    ``(D) With respect to the nurse aide competency evaluation 
requirements described in sections 1819(b)(5)(A) and 1919(b)(5)(A) of 
the Social Security Act, a State may waive such requirements with 
respect to an individual who can demonstrate to the satisfaction of the 
State that such individual has served as a nurse aide at one or more 
facilities of the same employer in the State for at least 24 consecutive 
months before the date of the enactment of this Act [Dec. 19, 1989].''


 Evaluation and Report on Implementation of Resident Assessment Process

    Section 4201(c) of Pub. L. 100-203 provided that: ``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 [enacting this section and amending 
sections 1395x, 1395aa, 1395tt, and 1395yy of this title].''


      Annual Report on Statutory Compliance and Enforcement Actions

    Section 4205 of Pub. L. 100-203 provided that: ``The Secretary of 
Health and Human Services shall report to the Congress annually on the 
extent to which skilled nursing facilities are complying with the 
requirements of subsections (b), (c), and (d) of section 1819 of the 
Social Security Act [subsecs. (b), (c), and (d) of this section] (as 
added by the amendments made by this part) and the number and type of 
enforcement actions taken by States and the Secretary under section 
1819(h) of such Act (as added by section 4203 of this Act).''

                  Section Referred to in Other Sections

    This section is referred to in sections 1395x, 1395aa, 1395bb, 
1395cc, 1395tt, 1395yy, 1396r, 3002 of this title; title 38 section 
3675.
