About Us - Licensing & Certification
Who Regulates Nursing Homes? | Deficiencies and Plans of Correction | Enforcement Remedies | Penalty Letter | Alternate Resolutions | Designation of Penalty Monies | Nursing Home Regulations | Information About Enforcement Actions
Nursing homes in California are licensed, regulated, inspected, and/or certified by a number of public and private agencies at the state and federal levels, including the California Department of Public Health (CDPH) Licensing and Certification Division (L&C) and the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS). These agencies have separate -- yet sometimes overlapping -- jurisdictions.
CDPH is responsible for ensuring nursing homes comply with state laws and regulations. In addition, CDPH has a cooperative agreement with CMS to ensure that facilities accepting Medicare and Medi-Cal (in California, Medicaid is referred to as Medi-Cal) payments meet federal requirements. Of California’s 139,390 skilled nursing beds, on any given day approximately 68 percent are occupied by a Medi-Cal beneficiary.
Each year, CDPH L&C staff conducts approximately 1,320 on-site inspections of nursing homes and responds to approximately 6,650 complaints and 19,300 events reported by facilities. Events that facilities are required to report to CDPH (“reportable events”) include interruptions of services essential to the health and safety of residents; alleged or suspected abuse; all fires, disasters, and other risks to resident life or health resulting from accidents or incidents at the facility; and administrator or director of nursing personnel changes. Investigation of complaints and reportable events also requires on-site inspections. These inspections, called surveys, evaluate compliance with both state and federal requirements.
CDPH L&C has over 600 surveyors and uses teams to inspect nursing homes. Teams consist primarily of registered nurses (RN) and life safety code surveyors. On some inspections, the teams may be joined by other professionals, such as pharmacists, nutritionists, physical and occupational therapists, infection control experts and physician consultants. RNs are the primary surveyors for complaint inspections, with consultant staff participation as needed.
Federal certification inspections are generally conducted on-site over a four to five day period, during which the inspection team evaluates all aspects of resident care and nursing home procedures and practices, and assesses facility compliance with state and federal standards. Areas of care reviewed during a federal certification inspection include residents’ rights, facility practices, quality of life, activities, assessment and care plans, quality of care provided for specific needs, dietary services, housekeeping, staffing, pharmacy, physician services, environment, disaster preparedness, and quality assurance. Surveyors review compliance with state licensing requirements during the federal certification inspection or during a separate licensing inspection and during on-site complaint investigations.
Inspections include observations of resident care; inspection of all areas of the nursing home; interviews of residents, family members, staff or other individuals; and inspection of medical records and other documents. The inspection team also evaluates the quality of resident care through an analysis of statistical data reported by nursing homes and by a review of reportable event information or other notices filed with CDPH.
Inspections in response to complaints or reportable events are generally shorter than certification inspections and focus on those areas of resident care or services alleged to be violated. If during the course of a complaint investigation CDPH uncovers additional problems, a full on-site inspection may be initiated.
CDPH inspects nursing homes at least once every 9 to 15.9 months. The statewide average is once every 12 months, but is more frequent for facilities with poor inspection results and numerous verified complaints. CDPH conducts inspections without prior notice and changes inspection schedules annually to make it difficult for facilities to anticipate surveys. CDPH typically inspects nursing homes on weekdays, but survey teams also conduct inspections at night, on weekends, and during holidays.
At the conclusion of each inspection, CDPH shares its findings with nursing home administrative staff in an exit interview and in a survey report to the facility. Following each inspection, CDPH issues a written Statement of Deficiencies to the facility, listing each deficient practice identified during the inspection.
All nursing facilities in California must meet mandatory state standards that set the minimum and essential requirements of care for continued licensure. Survey teams also evaluate whether facilities meet federal requirements and certify their compliance with federal care standards. Facilities failing to meet the state or federal standards are subject to fines or other enforcement actions.
A deficiency is a nursing home violation of one or more specific licensure or certification requirement. Deficiencies range in scope and severity from isolated violations with no harm to residents to widespread violations that cause injuries or put residents in immediate jeopardy of harm or death. CDPH may identify a deficiency as a result of an on-site inspection that substantiates a violation of requirements. If CDPH identifies a deficiency, the nursing home must submit a written plan of correction detailing how and when the facility will correct each deficiency. CDPH may direct specific corrective measures. When conditions at a facility pose a serious risk to the health and safety of residents, CDPH declares an immediate jeopardy status. The facility must take immediate corrective action and if correction is not achieved, the facility may be terminated from receiving Medicare and/or Medi-Cal funding. If improvement does not occur, CDPH may need to find a new owner or relocate the residents.
In many cases, nursing homes correct less serious deficiencies by implementing a written plan of correction without incurring fines or other penalties. If warranted, CDPH may impose a fine, appoint a temporary manager or receiver, suspend or revoke the nursing home’s license, or use other remedies for violations as provided by state or federal law. State statute categorizes citations that impose a civil monetary penalty as Class B, A, or AA. The associated fines range from $100 to $1,000 for Class B, $5,000 to $20,000 for Class A and $25,000 to $100,000 for Class AA. The citation class and amount of the fine depends upon the significance and severity of the substantiated violation, as defined in California law. Federal enforcement remedies include a written plan of correction, directed training, state monitoring, denial of payment for new admissions, ban on admissions, and fines ranging from $50 to $10,000 per day for survey violations and $1,000 to $10,000 for specific instance violations, such as a determination of immediate jeopardy or significant harm to the patient. The amount of the fine depends upon the scope and the severity of the substantiated violation(s).These actions are prescribed and defined in federal law. While CDPH can impose state fines, it can only recommend to CMS that a federal remedy other than a written plan of correction be imposed. CMS may impose, modify, or waive CDPH’ recommended remedy.
When CDPH cites a nursing home for violation of a regulation or law, the Department issues a notice letter and a document (Form 2567 – Statement of Deficiencies) identifying the specific violations. These are public documents available from the CDPH L&C local district office.
Nursing homes can dispute survey findings and penalties. Facilities may ask to discuss the accuracy of inspection findings during the course of an inspection visit or during the exit interview. Nursing homes also may request a formal appeal depending upon the seriousness of the violations and whether the violations are state or federal requirements. State and federal law offer/provide different appeal processes.
CDPH deposits all penalty monies collected for violations of state standards into a special fund (Citation Penalty Account) which can be used for purposes related to the care and protection of facility residents. The Citation Penalty Account allows CDPH to safeguard facility residents and avoid closure of a facility whenever possible.
Nursing Home Regulations
California licensing requirements are found in the California Code of Regulations, Title 22, Division 5 Chapter 3 – Skilled Nursing Facilities Section at http://www.leginfo.ca.gov.
Federal requirements for certification as a provider for Medicare/Medi-Cal are found in the Code of Federal Regulations: 42CFR 483.00 at www.cms.hhs.gov.
Information About Enforcement Actions
Information on state and federal inspections and complaint investigations is available from CDPH. As you review an inspection report, it is important to remember that nursing homes have the right to appeal survey findings and penalties. Such appeals may be pending at the time the report is issued. On appeal, CDPH’ decision may be upheld or reversed, or a settlement may be reached in which fines are reduced.
Inspection reports show only a one-time “snap-shot” of nursing home compliance with established standards. To assess more fully the quality of care provided by a facility, it is important to review current and past survey reports. You may also wish to discuss services and performance levels with your doctor and with family members or friends who have used a facility. A visit to the facility may also be appropriate.
Complete inspection reports and nursing home plans of correction, edited to ensure patient confidentiality, are available at each nursing home as well as at the CDPH L&C local district office. Recent federal inspection surveys are posted on the web at www.medicare.gov/NHCompare/home.asp.
Heath Facilities Consumer Information
The Health Facilities Consumer Information System (HFCIS) website provides health care consumers and general public with information about licensed long-term care facilities and hospitals throughout California. A nursing home or hospital can be located by entering a zip code, city, or county. A map will appear displaying the facilities located within the look-up area.
In addition to numerous links to other governmental, advocate and provider organizations, HFCIS also provides consumers and general public with an on-line complaint form to file a complaint regarding a specific facility. Upon submission, the complaint is forwarded to the appropriate Licensing and Certification District Office for investigation.