This letter outlines the requirements for nursing homes and other healthcare facilities to obtain a waiver of the requirement to provide a licensed nurse on a 24-hour basis, or for SNFs, to provide services of a registered nurse for more than 40 hours a week. It also provides guidance on how to conduct a survey of nursing services if a waiver has been granted or requested. Nursing homes and other healthcare facilities must demonstrate to the satisfaction of the state that they have been unable to recruit appropriate personnel, and that the waiver will not endanger the health or safety of individuals staying in the facility. The facility must also make arrangements for a registered nurse or physician to spend time at the facility, as determined necessary by the physician, to provide necessary skilled nursing services on days when the regular full-time registered nurse is not on duty. In addition, the facility must notify the Office of the State Long-Term Care Ombudsman and the protection and advocacy system in the state of the waiver, and notify residents of the facility and their representatives of the waiver. Nursing homes and healthcare facilities must also conduct a survey of nursing services during each certification survey if a waiver has been granted or requested. The survey team must determine, among other things, the facility's recruitment efforts, how resident needs are being met in the absence of a licensed nurse, and whether there is evidence that preventive measures are being taken to avoid poor quality of care outcomes.

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