This page provides general information regarding enforcement actions that The Centers for Medicare & Medicaid Services (CMS) may take when a nursing home is not in compliance with Medicare or Medicaid requirements.
Nursing homes, which include Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs), are required to be in compliance with Federal requirements to receive payment under the Medicare or Medicaid programs. The Secretary of the United States Department of Health & Human Services has delegated to the CMS and the State Medicaid Agency the authority to impose enforcement remedies against a nursing home that does not meet Federal requirements.
Each of the 50 States, Puerto Rico and the District of Columbia has an agency that conducts on-site surveys for CMS to determine whether nursing homes are complying with Federal requirements. Surveys are conducted on a 9 to 15 month cycle with a statewide average of 12 months.
Enforcement actions taken against nursing homes that are not in compliance with Federal requirements are called remedies. The statutory and regulatory requirements found in the Social Security Act (SSA) and the Code of Federal Regulations (CFR), provide that CMS or the State may impose one or more remedies when a facility is out of compliance with Federal requirements. The agency that conducts the on-site surveys cites deficiencies that indicate the specific Federal requirements that the facility did not meet.
In order to select the appropriate enforcement remedy(ies), the scope and severity levels of the deficiencies must be assessed. The severity level reflects the impact of the deficiency and is categorized by four levels of harm. The severity harm levels are described as: no actual harm with potential for minimal harm; no actual harm with a potential for more than minimal harm that is not immediate jeopardy; actual harm that is not immediate jeopardy and; immediate jeopardy to resident health or safety. Immediate jeopardy means a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The scope level of a deficiency reflects how many residents were affected by the deficiency. There are three scope levels assigned to a deficiency: isolated, pattern, or widespread. The survey agency determines the scope and severity levels for each deficiency cited at a survey.
The SSA requires any nursing home that does not achieve substantial compliance with the Federal requirements within six months be terminated from participation in Medicare and/or Medicaid. The SSA also requires Denial of Medicare and Medicaid payment for any individual admitted to a nursing home that fails to return to substantial compliance within three months (Mandatory Denial of Payment for New Admissions, or DPNA).
The CMS is committed to improving the quality of care and life for nursing home residents. As part of our commitment, we are working to improve the use and effectiveness of enforcement remedies to assure facility compliance with Federal requirements. The CMS is also maximizing its efforts to improve enforcement activities by focusing on transparency, consistency in application of enforcement remedies and data management to track enforcement actions across the nation.
June 3, 2016 - Update
The Centers for Medicare & Medicaid (CMS) is posting data on nursing home enforcement actions between 2006 and 2014.
The contents supports activities or actions to improve patient or resident safety and increase quality and reliability of care for better outcomes.
Nursing Home enforcement related information can be found in the Downloads section below.