About Us-Licensing & Certification
Who Regulates Nursing Homes?
"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
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 126,800 nursing home beds, on
any given day approximately 68 percent are occupied by a Medi-Cal beneficiary.
Each year, CDPH L&C staff conducts approximately 1,350 on-site inspections of nursing
homes and responds to approximately 5,000 complaints and 5,300 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.
In addition to inspection by CDPH, some California nursing homes are members of
a private national accrediting organization called the Joint Commission, which independently
inspects member facilities to assess performance.
CDPH L&C has over 500 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
Federal certification inspections are generally conducted on-site over a three-
to four-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 or 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 6 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.
If CDPH determines that the nursing home failed to comply with any applicable state
and federal licensure standards, CDPH cites the facility deficient practice(s).
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. "
Deficiencies and Plans of Correction
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 cite a deficiency as a result of
an on-site inspection that substantiates a violation of requirements. If CDPH cites
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 of statutes 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.
Designation of Penalty Monies
CDPH deposits all penalty monies collected for violations of state standards into
a special fund (Citation Penalty Account) to support or operate health care facilities
that violate state laws and regulations and are unable or unwilling to make necessary
corrections. 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://ccr.oal.ca.gov/linkedslice/default.asp?SP=CCR-1000&Action=Welcome
Federal requirements for certification as a provider for Medicare/Medi-Cal are found
in the Code of Federal Regulations: 42CFR 483.00 at http://www.cms.gov/Center/Provider-Type/Skilled-Nursing-Facility-Center.html .
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.
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