cost of an attendant may include transportation, meals, lodging, and salary of the attendant, except that no salary may be paid a member of the patient's family.

(ii) Family planning services, including drugs, supplies, and devices, when such services are under the supervision of a physician.

(iii) Services of Christian Science nurses who are listed and certified by the First Church of Christ Scientist, Boston, Mass., when these services have been requested by the patient and are provided (a) by, or under the supervision of, a Christian Science visiting nurse organization listed and certified by the First Church of Christ Scientist, Boston, Mass.; or (b) as private duty services to an individual in his own home or in a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ Scientist, Boston, Mass., when the patient requires individual and continuous care beyond that available from a visiting nurse or that routinely provided by the nursing staff of the sanatorium.

(iv) Care and services provided in Christian Science sanatoria operated by, or listed and certified by, the First Church of Christ Scientist, Boston, Mass.

(v) Skilled nursing home services, as defined in subparagraph (4) (i) of this paragraph, provided to patients under 21 years of age.

(vi) Emergency hospital services which are necessary to prevent the death or serious impairment of the health of the individual and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible hospital available which is equipped to furnish such services, even though the hospital does not currently meet the conditions for participation under title XVIII of the Social Security Act, or definitions of inpatient or outpatient hospital services set forth in subparagraphs (1) and (2) of this paragraph.

(vii) Personal care services in a recipient's home rendered by an individual, not a member of the family, who is qualified to provide such services, where the services are prescribed by a physician in accordance with a plan of treatment and are supervised by a registered nurse.

(c) Limitations. Federal financial participation in expenditures for medical and remedial care and services listed in paragraph (b) of this section is not

available with respect to any individual who is an inmate of a public institution (except as a patient in a medical institution), or any individual who has not attained 65 years of age and who is a patient in an institution for tuberculosis or mental diseases.

(d) General provisions. (1) In all the items listed in paragraph (b) of this section, the following definitions apply, except to the extent the context otherwise requires:

(i) "Patient" is an individual who is in need of and receiving professional services directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health or alleviation of disability or pain.

(ii) "Inpatient" is a patient who has been admitted to a hospital, skilled nursing home, or other medical institution on recommendation of a physician or dentist and is receiving room, board, and professional services in the institution on a continuous 24-hour a day basis.

(iii) "Outpatient" is a patient who is receiving his professional services at an organized medical facility, or distinct part of such facility, which is not providing him with room and board and professional services on a continuous 24hour-a-day basis.

(2) Nothing in the Social Security Act or Federal policies thereunder will be construed to require any State to compel any person to undergo any medical screening, examination, diagnosis, or treatment or to accept any other health care or services provided under its approved State plan if such person objects, or in the case of a child, his parent or guardian objects, to such care on religious grounds. An individual may not be found eligible unless he undergoes such physical examination as is necessary to establish his eligibility, e.g., an examination must be made of an individual applying for medical assistance on the basis of his disability (as disabled under the AFDC, AB, APTD, or AABD program). [34 F.R. 9784, June 24, 1969, as amended at 35 F.R. 3072, Feb. 17, 1970; 35 F.R. 6792, Apr. 29, 1970]

under the plan from any institution, agency, pharmacy, or practitioner, including an organization which provides such services or arranges for their availability on a prepayment basis, which is qualified to perform such services. This provision does not prohibit the State agency from establishing the fees which will be paid to providers for furnishing medical and remedial care available under the plan or from setting reasonable standards relating to the qualifications of providers of such care. In the case of Guam, Puerto Rico, and the Virgin Islands this provision applies only with respect to calendar quarters beginning after June 30, 1972.

[35 F.R. 8732, June 5, 1970]

§ 249.31

Supplementation of payments made to skilled nursing homes; State plan requirements.

A State plan for medical assistance under title XIX of the Social Security Act must provide that participation in the program will be limited to providers of service who accept, as payment in full, the amounts paid in accordance with the fee structure, except that, with respect to payment for care furnished in skilled nursing homes, existing supplementation programs will be permitted until January 1, 1971, where the State has determined and advised the Secretary of Health, Education, and Welfare that its payments for skilled nursing home services furnished under the plan are less than the reasonable cost of such services permitted under Federal regulations, and the State has, prior to 1971, provided the Secretary with a plan for phasing out such supplementation within a reasonable period after January 1, 1971.

[34 F.R. 1397, Jan. 29, 1969]

§ 249.32 Direct payment to certain recipients for physicians' or dentists' services.

a

(a) State plan requirements. If State, under its program of medical assistance under title XIX of the Social Security Act, elects to make direct payments to individuals who are not receiving assistance under the State's plan approved under titles I, X, XIV, XVI, or part A of title IV of the Act for physicians' or dentists' services, the State plan for medical assistance must so provide and must specify the conditions under which payments will be made. Such payments to individuals are in all respect viewed as an alternative to pay

ments made by the State agency directly to the physicians or dentists, and are subject to the same conditions. For example, the payments may not exceed the reasonable charge for such services established by the single State agency.

(b) Federal financial participation. Effective January 2, 1968, Federal financial participation is available for direct payments to individuals who are not receiving assistance under the State's plan approved under titles I, X, XIV, XVI, or part A of title IV of the Act, for physicians' or dentists' services in those States which elect to make such direct payments. Direct payments must be supported by medical bills for services provided under the plan.

[34 F.R. 1397, Jan. 29, 1969]

§ 249.33 Standards for payment skilled nursing home care.

for

(a) State plan requirements. A State plan for medical assistance under title XIX of the Social Security Act must:

(1) Provide that any skilled nursing home (see § 249.10(b) (4) (i) of this part) receiving payments under the plan must:

(i) Supply to the licensing agency of the State full and complete information, and promptly report any changes which would affect the current accuracy of such information, as to the identity

(a) of each person having (directly or indirectly) an ownership interest of 10 percentum or more in such skilled nursing home,

(b) In case a skilled nursing home is organized as a corporation, of each officer and director of the corporation, and

(c) In case a skilled nursing home is organized as a partnership, of each partner;

(ii) Have and maintain an organized nursing service, as defined in paragraph (b) of this section, for its patients which is under the direction of a professional registered nurse who is employed fulltime by such skilled nursing home, and which is composed of sufficient nursing and auxiliary personnel to provide adequate and properly supervised nursing services for such patients during all hours of each day and all days of each week;

(iii) Make satisfactory arrangements, as defined in paragraph (b) of this section, for professional planning and supervision of menus and meal service for patients for whom special diets or dietary restrictions are medically prescribed;

(iv) Have satisfactory policies and procedures, as defined in paragraph (b) of this section;

(a) Relating to the maintenance of medical records on each patient of the skilled nursing home;

(b) Relating to dispensing and administering of drugs and biologicals;

(c) To assure that each patient is under the care of a physician;

(d) To assure that adequate provision is made for medical attention to any patient during emergencies;

(v) Have arrangements, as defined in paragraph (b) of this section, with one or more general hospitals under which such hospital or hospitals will provide needed diagnostic and other services to patients of such skilled nursing home, and under which such hospital or hospitals agree to timely acceptance, as patients thereof, of acutely ill patients of such skilled nursing home who are in need of hospital care. The single State agency, however, may waive this requirement wholly or in part with respect to any skilled nursing home which meets all other requirements and is unable to effect such an arrangement with a hospital, as provided in paragraph (c) of this section;

(vi) Meet conditions relating to environment and sanitation, as specified in paragraph (b) (9) of this section, applicable to extended care facilities under title XVIII of the Social Security Act. The single State agency, however, may waive for such periods and under such conditions as the approved plan provides any requirement imposed by paragraph (b) (9) in accordance with the regulations set forth in paragraph (c) of this section;

(vii) Meet (after December 31, 1969) such provisions of the Life Safety Code of the National Fire Protection Association (21st Edition, 1967) as are applicable to nursing homes; except that the State agency may waive in accordance with regulations set forth in paragraph (c) of this section for such periods as it deems appropriate, specific provisions of such code, which if rigidly applied, would result in unreasonable hardship upon a nursing home, but only if such agency makes a determination (and keeps a written record setting forth the basis of such determination) that such waiver will not adversely affect the health and safety of the patients of such skilled nursing home; and except that the requirements

of this subdivision need 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 patients in nursing homes.

(2) Provide and specify the methods and procedures which assure that:

(i) The single State agency will, prior to execution of an agreement with any facility for provision of skilled nursing home care and making payments under the plan,

(a) Obtain sufficient evidence through survey arrangements with the State licensing authority or with the agency of the State designated pursuant to section 1864 of the Social Security Act, that the facility

(1) Meets the requirement of subparagraph (1) of this paragraph; or

(2) Is a participating provider of extended care under title XVIII of the Social Security Act, and in addition meets the requirements of subdivisions (i), (v) and (vii) of such subparagraph (1); or

(b) Otherwise obtain sufficient evidence that the facility meets the requirements of such subparagraph (1); Provided, however, That if the single State agency elects not to use the services of the State licensing authority or the agency of the State designated pursuant to section 1864 of the Social Security Act, a written justification is submitted to the Administrator, Social and Rehabilitation Service that such election is not inconsistent with efficiency and economy of administration.

(ii) The single State agency will:

(a) Review information contained in reports of medical review teams on inspections made pursuant to State plan provisions under section 1902 (a) (26) of the Social Security Act;

(b) Review statements obtained by the appropriate State agency from each skilled nursing home, on forms provided by such agency, setting forth (from payroll records) the average numbers and types of personnel (in full-time equivalents) on each shift during at least 1 week of each quarter, such week to be selected by the survey agency and to occur irregularly in each quarter of the year;

(c) Evaluate such statements to determine that requirements relating to personnel were or were not met during any quarter in which payment is being requested;

(iii) Beginning January 1, 1970, onsite inspection by qualified personnel will be made at least once during the term of an agreement, or more frequently if there is a question of compliance, and the single State agency will review the information thus obtained, except that this requirement may be deemed to be met for skilled nursing homes also certified to participate as extended care facilities under title XVIII of the Social Security Act;

(iv) The single State agency agreement with a facility for payments under the plan may not exceed a period of 1 year. Execution of a new agreement shall be contingent upon a determination of compliance with the provisions of subparagraph (1) of this paragraph except that:

(a) In the case of any skilled nursing home determined or certified to be in substantial compliance (i.e., is in compliance except for deficiencies) with the requirements of such subparagraph (1), the single State agency may enter into an agreement with such skilled nursing home for the provision of services and making of payments under the plan for a period not to exceed 6 months provided that on the basis of documented evidence derived from a survey the single State agency finds that:

(1) There is a reasonable prospect that the deficiencies can be corrected within 6 months and the skilled nursing home provides in writing a plan acceptable to the single State agency for so doing;

(2) The deficiencies noted individually or in combination, do not jeopardize the health and safety of the patients and a written justification of such a finding is maintained on file by the appropriate State agency;

And provided further, That

(3) No more than two successive agreements for 6 months are executed with any skilled nursing home having deficiencies, and no second agreement is executed if any of the deficiencies existing are the same as those which occasioned the prior agreement unless the single State agency finds on the basis of documented evidence derived from a survey that the facility has made substantial effort and progress in correcting such deficiencies;

(b) Notwithstanding the foregoing provisions, in the case of skilled nursing homes certified with deficiencies as extended care facilities under the provi

sions of title XVIII of the Social Security Act, the term of agreements may extend until 90 days after the next inspection scheduled, as required, for extended care facility certification.

For the purposes of this subdivision (iv), waivers granted pursuant to paragraph (a) (1) (v)-(vii) and paragraph (c) of this section are not considered deficiencies.

(v) All information and reports used in determining whether a skilled nursing home meets the requirements set forth in subparagraph (1) of this paragraph are maintained on file for a period of at least 3 years by the appropriate State agency for ready access by the Department of Health, Education, and Welfare; and

(a) Copies of reports of inspection made on or after January 1, 1970, are completed by the inspector(s) surveying the premises with notations indicating whether each requirement for which inspection is made, is or is not satisfied, with documentation of deficiencies;

(b) Copies of official notices of waiver of any requirement imposed pursuant to subparagraph (1)(vii) of this paragraph and regulations pertaining thereto are on file;

(vi) Facilities which do not qualify under this section are not recognized as skilled nursing homes for purposes of payment under title XIX of the Act.

(b) Definition of terms. For purposes of paragraph (a)(1) of this section the following definitions apply:

(1) Organized nursing service. The term "organized nursing service" means that:

(i) Nursing services are under the direction of a director of nursing service who is a professional registered nurse and who:

(a) Is employed full-time in the facility, devotes her full-time to supervising the nursing service, and is on duty during the day shift;

(b) Is qualified by education, training or experience for supervisory duties;

(c) Is responsible to the administrator for the selection, assignment, and direction of the activities of nursing service personnel;

(d) Is responsible to the administrator for development of standards, policies, and procedures governing skilled nursing care and for assuring that such standards, policies and procedures are observed;

(ii) There is on duty at all times and in charge of nursing activities at least one

professional registered nurse or licensed practical (or vocational) nurse who is a graduate of a State-approved school of practical nursing, or who is found by the appropriate State licensing authority for nurses on the basis of the individual's education and formal training to have background considered to be equivalent to graduation from a State's approved school of practical nursing except that:

(a) In those instances in which a licensed practical nurse serving as charge nurse is not a graduate of an approved school and does not possess background determined to be equivalent but was successfully discharging the responsibilities of a charge nurse on July 1, 1967, such nurse may continue to be employed in this capacity until July 1, 1970, but after that date only if she has been found by the appropriate State licensing authority to have completed training equivalent to graduation from a State-approved school of practical nursing; and

(b) In the case of institutions for the mentally retarded or distinct parts of such institutions which are certified as skilled nursing homes, other categories of licensed personnel with special training in the care of such patients may serve as charge nurse: Provided, That such person is licensed by the State in such category following completion of a course of training which includes at least the number of classroom and practice hours in all of the nursing subjects included in the program of a State approved school of practical (or vocational) nursing as evidenced by a report to the single State agency by the agency or agencies of the State responsible for the licensure of such personnel comparing the courses in the respective curricula.

(iii) Lines of administrative and supervisory responsibility are clearly established in writing, and are known to all members of the nursing staff and to appropriate personnel in other units of the facility;

(iv) Duties are clearly defined and assigned to staff members consistent with the level of education, preparation, experience, and licensing of each.

(v) There are written patient-care policies and procedures governing skilled nursing care and related services, including restorative services, and staff members are familiar with them.

(2) Nursing and auxiliary personnel.

(i) Numbers and categories of personnel are determined by the number of patients and their particular needs in accordance with accepted policies of effective nursing care and guidelines issued by the Social and Rehabilitation Service;

(ii) Nursing and auxiliary personnel are employed and assigned on the basis of their experience or qualifications to perform designated duties;

(iii) The amount of nursing time is sufficient to assure that each patient:

(a) Receives treatments, medications, and diet as prescribed;

(b) Receives proper care to prevent decubiti and is kept comfortable, clean, and well-groomed;

(c) Is protected from accident and injury by the adoption of appropriate safety measures;

(d) Is encouraged to perform out-ofbed activities as permitted;

(e) Receives assistance to maintain optimal physical and mental function.

(4) Professional planning and supervision of menus and meal service. The phrase "professional planning and supervision," when used in relation to menus and meal service for patients for whom special diets or dietary restrictions are medically prescribed means that:

(i) Menus are planned and supervised by professional personnel meeting the following qualifications:

(a) A dietitian who meets the American Dietetic Association's standards for qualification as a dietitian; or

(b) A graduate holding at least a bachelor's degree from a university program with major study in food and nutrition; or

(c) A trained food service supervisor, an associate degree dietary technician, or a professional registered nurse, with frequent and regularly scheduled consultation from a dietitian or nutritionist meeting the qualifications stated in sub