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Nursing HomesAssisted Living/Board & Care Home and Community Based Services

Federal Nursing Home Regulations

Final Regulations

On October 4, 2016, the final regulations for nursing homes participating in the Medicare and/or Medicaid programs were published in the Federal Register. The regulations are effective on November 28, 2016 and will be implemented in three phases. Click here to view the implementation timeframe chart. Additional information regarding the revised regulations will be posted in the coming months. For more information including a summary of the regulations created by Consumer Voice, along with Justice in Aging and the Center for Medicare Advocacy, visit the Consumer Voice website.

Note: The regulations included in Phase 1 were implemented by November 28, 2016, regulations included in Phase 2 were implemented by November 28, 2017, and regulations included in Phase 3 must be implemented by November 28, 2019.

Information from CMS

CMS Website on Nursing Homes
This page from CMS includes information about the background and overview of the final rule, frequently asked questions, and other related resources regarding nursing homes. View the website here.

Revisions to State Operations Manual
CMS released an advance copy of revisions to the State Operations Manual (SOM), Appendix PP with the revised regulations and tags. Visit the CMS website to find the most recent link to the State Operations Manual (SOM).

Online Surveyor Training- Implementation of Revised Requirements
CMS has developed online surveyor training regarding implementation of the revised nursing home requirements. CMS developed the training for Regional Offices, State Survey Agencies, providers, and other stakeholders and it includes information about the regulations, revised surveyor guidance, and the survey process. To access courses visit the CMS Survey and Certification Group Integrated Surveyor Training website. More information about this training is available in this memo.

  • Phase 1 Implementation Training
    Launch the course from this page or visit the CMS Survey and Certification Group Integrated Surveyor Training website, choose “I am a Provider,” select the “Course Catalog” button on the top of the screen, choose “Long-Term Care” in the menu, and click on “Phase 1 Implementation of New Nursing Home Regulations” from the list of courses.
  • Phase 2 Implementation Training 
    Launch the course from this page or visit the CMS Survey and Certification Group Integrated Surveyor Training website, choose “I am a Provider,” select the “Course Catalog” button on the top of the screen, choose “Long-Term Care” in the menu, and click on “LTC Survey Process SME” from the list of courses.

Long-Term Care Facilities: Reform of Requirements Call (October 27, 2016)
CMS provided an overview of the final rule to reform the requirements for long-term care facilities during this MLN (Medicare Learning Network) Provider Call. The slides, audio recording, and transcript are available here.

CMS Suspends Enforcement of Prohibition of Arbitration Agreements (December 9, 2016)
The Centers for Medicare & Medicaid Services (CMS) has released a memorandum "Long-Term Care (LTC) Regulation: Enforcement of Rule Prohibiting Use of Pre-Dispute Binding Arbitration Agreements is Suspended so Long as Court Ordered Injunction Remains in Effect."  The memo, dated December 9, 2016, states that CMS will not enforce the new rule prohibiting skilled nursing facilities, nursing facilities and dually-certified facilities from using pre-dispute binding arbitration agreements while there is a court-ordered injunction in place prohibiting enforcement of this provision. Read the full memo here.

CMS S&C Memo - Explanation of Notice of Transfer-Discharge and SQC (May 12, 2017)
The CMS Survey and Certification memo (17-27-NH) provides clarification regarding copies of transfer and discharge notices to a representative of the Office of the State Long-Term Care Ombudsman and information regarding the new definition of SQC (substandard quality of care) and implementation of the provisions regarding SQC. The memo:

  • Explains facility-initiated transfers and discharges and resident-initiated transfer and discharges.
  • States facilities must provide a copy of facility-initiated discharge notices to the Ombudsman program at the same time the notice is provided to the resident and resident representative.
  • Reinforces the requirement that when a nursing facility decides to discharge the resident while the resident is still hospitalized, the facility must send a notice of discharge to the resident and resident representative and send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman (at the same time they send a notice to the resident and resident representative). 
  • Clarifies the timing and type of notification to the Ombudsman program for emergency transfers.

Read the memo here. Additional CMS S&C memos are posted to their website here.

Revised Interpretive Guidelines (June 29, 2017)
The Centers for Medicare and Medicaid Services (CMS) issued a Survey & Certification Memo announcing the release of several new documents related to the revised federal nursing home regulations, and information about the new survey process and training resources. In the memo, CMS also revealed it will impose a one-year restriction of enforcement remedies for specific Phase 2 requirements and hold constant for one year the Nursing Home Compare health inspection rating for any surveys conducted after November 28, 2017.

  • Revised Interpretive Guidelines
    These are contained in Revised State Operations Manual (SOM) Appendix PP.  The guidelines are effective November 28, 2017.  They include clarification to existing unchanged requirements, guidance for new requirements implemented in Phase 1, as well as guidance for the new Phase 2 regulations. CMS notes that it has added a section in some areas to the Interpretive Guidance titled “Key Elements of Noncompliance.” This is intended to provide guidance about the key behaviors and practices identified in the regulation.  Note that Appendix PP uses newly designated F-Tags 
  • A Crosswalk of Old F-Tags to New F-Tags
    Since the regulatory sections in the revised rules were re-structured, CMS renumbered the F-Tags. Some tags were combined, and some tags were split into multiple subparts.  These new F-Tags will be used after November 28, 2017.  The crosswalk shows you old F-Tags and the corresponding new F-Tag(s).
  • Survey Process
    CMS is launching a new, computer-based Long Term Care survey system at the same time that Phase 2 is implemented. Information about the survey process is available here, which includes a slide deck outlining the survey process.
  • List of Revised F-Tags
    Read the list of revised F-Tags here

CMS's Revised Interpretive Guidelines with Clickable Table of Contents (July 21, 2017)
At nearly 700 pages, the new Interpretive Guidelines released by the Centers of Medicare and Medicaid Services (CMS) is a large document. The clickable table of contents makes it easier to navigate the different sections. The table of contents is on page 2, view the document here.

CMS Memo - An Initiative to Address Facility Initiated Discharges that Violate Federal Regulations (December 22, 2017)
This memo is from CMS to State Survey Agency Directors. Federal regulations allow facilities to initiate discharges of residents only in specific instances. Despite these protections, discharges which violate Federal regulations continue to be one of the most frequent complaints made to State Long-Term Care Ombudsman Programs. CMS has begun an initiative to examine and mitigate facility-initiated discharges that violate federal regulations. CMS is examining State survey agency’s intake and triage practices for these type of discharge complaints, developing examples of inappropriate and appropriate discharges for surveyors, identifying best practices for nursing homes, developing training and evaluating enforcement options for these types violations. Civil Money Penalty (CMP) Reinvestment Projects Assistance. CMS is encouraging States to pursue CMP-funded projects that may help prevent facility initiated discharges that violate federal regulations. Read the memo here.


Resources by NORC


Side-by-Side Comparison of Ombudsman References in Revised and Previous Federal Nursing Home Regulations  (2016)
This side-by-side chart includes references to the Long-Term Care Ombudsman Program (LTCOP) in the revised regulations and related language from the preamble compared to current regulations. The revised regulations are effective November 28, 2016 and will be implemented in three phases (regulations in Phase 1 must be implemented by November 28, 2016).

Resources by Consumer Voice

Rule Resources

Reference Guide: Summary of CMS's Updated Nursing Home Guidance (July 2022)
On June 29, 2022, CMS released Phase 3 guidance along with updated Phase 2 guidance. The guidance was issued as the result of 2016 revisions to the Medicare Requirements for Participation for Nursing Homes. Due to delays caused by the COVID-19 pandemic, CMS is only now releasing the last set of guidance, which was originally scheduled to be released in 2019. The Phase 3 Guidance offers significant updates to the requirements state oversight agencies must follow when surveying and assessing a nursing home’s compliance with the federal regulations. These areas include visitation; staffing; abuse and neglect of residents; transfer and discharge rights; infection control; and resident assessments. CMS has highlighted the updated text in red. Consumer Voice has created a Reference Guide and summary to help consumers understand and access this updated guidance.

Summary of Key Changes in the Rule – Phase 2 (December 2017)
This summary sheet is designed to provide an overview of key changes in the revised federal nursing home regulations that went into effect November 28, 2017 as part of Phase 2.  The purpose of the summary is to highlight what is different (new or modified) between the prior rule and the final rule.  For more information about the nursing home requirements, including Summary of Key Changes – Parts I and II, click here.

The Revised Federal Nursing Home Regulations: Summary of Key Changes - Part I (November 2016)
This summary provides a brief overview of key changes in the revised federal nursing home regulations related to Resident Rights; Abuse, Neglect, and Exploitation; and Admission, Transfer and Discharge Rights. This chart is designed to highlight what is different between the prior rule and the final rule.

Summary of Key Changes in Revised Federal Nursing Home Regulations – Part II (December 2016)
This summary presents an overview of key changes in the revised federal nursing home regulations for the sections on Resident Assessment (§483.20) – Training Requirements (§483.95).  It is designed to highlight what is different between the prior rule and the final rule and includes only those parts of the rule that went into effect in Phase 1 on November 28, 2016. Part II, combined with Part I, cover all sections of the regulations. For more information about the nursing home requirements and to access Summary of Key Changes - Part I, click here

Side-by-Side Comparison of Revised and Previous Federal Nursing Home Regulations (January 2017)
The side-by-side comparison shows each provision of the revised federal nursing home regulations and traces it back to provisions from the previous regulations.  With the side-by-side comparison, you will be able to locate which provision in the revised regulations is new or revised.  If it is revised, you will be able to see the previous language from which it was revised.  The side-by-side comparison denotes the implementation phase for each provision in the revised regulations. The side-by-side comparison was created utilizing the Centers for Medicare & Medicaid Services (CMS) information provided in its Long-Term Care Facilities Crosswalk found in the Federal Register, Vol. 81, No. 192, October 4, 2016 (p. 68825) here.  

Issue Briefs

Issue Brief: Why the Recently-Revised Nursing Home Regulations are Vital for Nursing Home Residents (December 2016)
This fact sheet provides an overview of some important new revisions and how they protect long-term care consumers.  Stakeholders and policymakers can use the fact sheet to better understand the role the revised regulations have in improving nursing care, including an increased focus on addressing a resident's needs and preferences. This fact sheet was released by Consumer Voice, in partnership with Justice in Aging.

Issue Brief: Assessments, Care Planning, and Discharge Planning (December 2016)
This brief provides an overview of the regulations in these areas and highlights provisions that can be useful in advocating for improved quality of care and quality of life.  For instance, the revised assessment process must now gather information about a resident's preferences, goals, and there is greater emphasis on the participation of the resident and resident’s representative participate in the care planning team.  Also, care planning must include planning for discharge, to give residents an increased ability to move out of the facility into the community. The brief gives information on effective dates, how to find the regulations, and concludes with practical tips for residents and advocates.

Issue Brief: Unnecessary Drugs and Antipsychotic Medications (February 2017)
This brief outlines the recent changes in unnecessary drug regulations, including a discussion of a broader category of psychotropic drugs, along with new controls over “as needed” (PRN) psychotropic drugs. The revised regulations also expand requirements for drug regimen reviews.

Issue Brief: Involuntary Transfer and Discharge (February 2017)
This brief explains the minor changes in transfer and discharge regulations, which include narrowing the facility’s ability to base a transfer/discharge on a supposed inability to meet the resident’s needs, by requiring increased documentation by the resident’s physician. The regulations also limit transfer/discharge for nonpayment.

Issue Brief: Nursing Services (February 2017)
This brief explains the recent changes in nursing services regulations, which include placing a greater emphasis on establishing minimum competencies and skill sets for all nursing personnel.  In addition, the regulations have increased requirements for in-service training of nursing personnel.

Issue Brief: Admission (March 2017)
This brief explains the changes in admission, bedhold and return regulations, which include broadly prohibiting facilities from using admission agreements or other documents that waive a resident's rights.  The revised regulations also prohibit pre-dispute arbitration agreements, but this consumer protection is currently blocked by a court order.

Issue Brief: Visitation Rights (March 2017)
This brief explains changes in visitation rights including the right to receive visitors, written policies and procedures and other facility requirements, notice requirements, and visitation privileges.

Issue Brief: Rehabilitation Services (March 2017)
This brief covers how the substantive requirements for specialized rehabilitative services are largely unchanged from the prior version of the regulations, with the exception of "respiratory therapy," which is added to the list of services that a facility must provide to its residents who need them.  In responding to a question regarding whether respiratory therapy would include ventilator care, CMS emphasized that a nursing facility is obligated to meet residents' needs.

Issue Brief: Return to Facility After Hospitalization (April 2017)
This brief explains bed hold rights when a resident returns to a facility after a hospitalization.  The brief provides information on advance notification of bed hold rights and residents' rights if they return to a facility after a bed hold period has been exceeded.

Issue Brief: Grievances and Resident/Family Councils (May 2017)
This brief covers the resident's right to file grievances and the facility's requirement to work to resolve those concerns promptly.  Each facility must have a grievance policy and provide residents with information on how to file a grievance.  Also, residents have a right to form a resident council, and family members and resident representatives have the right to form a family council.  The facility must act upon council concerns and recommendations.

Issue Brief: Quality of Care (May 2017)
The substantive requirements for quality of care are retained in the revised regulations, and CMS has affirmed the regulations' goals of supporting person-centered care and enabling each resident to attain his or her highest level of well-being.  This brief covers those regulations as well as providing information on how the quality of care provisions have been reorganized in the revised regulations.


Introduction to the Revised Federal Nursing Home Regulations: What’s In, What’s Not Webinar (October 2016)
During this webinar hosted by Consumer Voice, Karen Tritz, Director, Division of Nursing Homes, Survey and Certification Group, Centers for Medicare & Medicaid Services, provided an overview of the revised rule and Eric Carlson, Directing Attorney, Justice in Aging; Toby Edelman, Senior Policy Attorney, Center for Medicare Advocacy; and Robyn Grant, Director of Public Policy and Advocacy, Consumer Voice discussed changes in key areas.

A Deeper Dive into the Revised Federal Nursing Home Regulations: Part 1 (February 2017)

This webinar lets you hear from the experts at the Center for Medicare Advocacy, Justice in Aging and Consumer Voice discussing key changes in: (1) Assessment, Care Planning & Discharge Planning, (2) Nursing Services, (3), Unnecessary and Antipsychotic Drugs, and (4) Transfer/Discharge. View the slides.

A Deeper Dive into the Revised Federal Nursing Home Regulations: Part 2 (March 2017)
In this webinar you will hear experts from Center for Medicare Advocacy, Justice in Aging, and Consumer Voice discuss key changes in: (1) Admission, Return, and Bedhold, (2) Visitation Rights, and (3) Specialized Rehabilitative Services.

A Deeper Dive into the Revised Federal Nursing Home Regulations: Part 3 (April 2017)
You will hear experts from Center for Medicare Advocacy, Justice in Aging, and Consumer Voice discuss key changes in: (1) Bedholds, and Return to the Facility, (2) Grievances, (3) Resident/Family Councils, and (4) Quality of Care.

A Deeper Dive into the Revised Federal Nursing Home Regulations: Taking Another Look at Key Sections (June 2017)
You will hear experts from Center for Medicare Advocacy, Justice in Aging, and Consumer Voice answer your questions in key sections: (1) Rehabilitation Services, (2) Visitation, (3) Transfer-Discharge, and (4) Return to the Facility.

Making it Real: Using the Revised Federal Nursing Home Regulations in Your Advocacy (January 2018)
In this webinar, you will hear from experts from Center for Medicare Advocacy and Justice in Aging discuss how to address common problems and promote quality person-centered care and residents' rights by using the revised federal nursing home regulations.  Topics covered include: admission; comprehensive and baseline care plans; visitation; rehab services; transfer/discharge; return to the facility; and facility assessment.

Overview of Phase 3 Nursing Home Regulations: A Look Ahead (April 9, 2019)
On November 28, 2019 - 3 years after the revised federal nursing home rules were issued - “Phase 3” requirements will go into effect.  These include a number of new requirements that nursing homes must implement, and in some cases, new systems that must be put in place. The  webinar includes presentations from experts from the Center for Medicare Advocacy, Justice in Aging and Consumer Voice on the following topics and more: compliance and ethics program; infection preventionist; trauma-informed care; quality assurance and performance improvement program; and training.

Download the webinar Powerpoint here. Access the Summary of Key Changes handout here.


Training and Consumer Education Materials

These materials can be used in training by and for Ombudsman program representatives, for members of resident and family councils, and community education.  

Transfers and Discharges

Abuse, Neglect, Exploitation and Misappropriation of Property

Residents' Rights: Your Life, Your Care, Your Choices

Additional Resources

Survey and Enforcement Regulations



View archive here

Proposed Revisions to the Federal Nursing Home Regulations
The Centers for Medicare and Medicaid Services (CMS) has officially published its proposed revisions to the current regulations (also known as the Requirements of Participation) for nursing homes participating in the Medicare and/or Medicaid programs. This proposed rule is available to view in full at the Federal Register website. Interested individuals, groups and organizations will be able to submit formal comments on the rule from now until September 14th, 2015 through the Federal Register site.

Ombudsman References in Proposed Federal Nursing Home Regulations 
This chart includes references of the Long-Term Care Ombudsman Program (LTCOP) in the current and proposed regulations and related language from the preamble of the proposed rule.

Side-by-Side Comparison of CMS Proposed and Current Federal Nursing Home Regulations
Developed by the National Consumer Voice for Quality Long-Term Care, this chart provides a side-by-side comparison of the CMS proposed rule to the current federal nursing home regulations.  The chart is also available in Excel form.

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