This regulation requires nursing facilities to ensure Medicaid residents receive routine dental services (to the extent covered under the State plan) and emergency dental services, assist residents with scheduling appointments and arranging transportation, refer residents with lost or damaged dentures to a dentist within three business days, maintain a policy on facility responsibility for denture loss or damage, and assist eligible residents in applying for reimbursement of dental services as an incurred medical expense. Facilities must document extenuating circumstances if a referral is delayed beyond three business days and demonstrate steps taken to ensure the resident could eat and drink adequately in the interim. Facilities may not charge Medicaid residents for routine dental services covered by the State plan or for emergency dental services, nor charge residents for denture loss or damage determined to be the facility's responsibility.
View official sourceF791 (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility— §483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; §483.55(b)(2) Must, if necessary or if requested, assist the resident— (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. INTENT of §483.55(a)[F790] & (b) [F791] To ensure that residents obtain needed dental services, including routine dental services; to ensure the facility provides the assistance needed or requested to obtain these services; to ensure the resident is not inappropriately charged for these services; and if a referral does not occur within three business days, documentation of the facility’s to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. DEFINITIONS for §483.55(a)[F790] & (b) [F791] “Emergency dental services” includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. “Promptly” means within 3 business days or less from the time the loss or damage to dentures is identified unless the facility can provide documentation of extenuating circumstances that resulted in the delay. “Routine dental services” means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. GUIDANCE for §483.55(a)[F790] & (b) [F791] A dentist must be available for each resident. The dentist can be directly employed by the facility or the facility can have a written contractual agreement with a dentist. The facility may also choose to have a written agreement for dentist services from a dental clinic, dental school or a dental hygienist all of whom are working within Federal and State laws and under the direct supervision of a dentist. For Medicare and private pay residents, facilities are responsible for having the services available, but may bill an additional charge for the services. For Medicaid residents, the facility must provide all emergency dental services and those routine dental services to the extent covered under the Medicaid state plan. The facility must inform the resident of the deduction for the incurred medical expense available under the Medicaid State plan and must assist the resident in applying for the deduction. If any resident is unable to pay for dental services, the facility should attempt to find alternative funding sources or delivery systems so that the resident may receive the services needed to meet their dental needs and maintain his/her highest practicable level of well-being. This can include finding other providers of dental services, such as a dental school or the provision of dental hygiene services on site at a facility. The facility must assist residents in making arrangements for transportation to their dental appointments when necessary or requested. The facility should attempt to minimize the financial burden on the resident by finding the lowest cost or no cost transportation option to dental health care appointments. The facility must have a policy identifying those instances when the loss or damage of partial or full dentures is the facility’s responsibility, such as when facility staff discards dentures placed on a meal tray. A blanket policy of facility non-responsibility for the loss or damage of dentures or a policy stating the facility is only responsible when the dentures are in actual physical possession of facility staff would not meet the requirement. In addition, the facility is prohibited from requesting or requiring residents or potential residents to waive any potential facility liability for losses of personal property. See §483.15(a)(2)(iii), F620, Admissions Policy. Prompt referral means no later than three (3) business days from the time the partial or full dentures are lost or damaged. Referral does not mean that the resident must see the dentist at that time. It does mean that an earliest possible appointment (referral) is made, or that the facility is aggressively working to have the dentures repaired or replaced if the dentist was contacted timely and determined the dentures could be repaired or replaced without a dental visit. If there is a delay in making the referral, the facility must document the circumstances that led to the delay. The facility must also be able to provide documentation demonstrating what they did to ensure the resident could still adequately eat and drink while waiting for the issue with their dentures to be addressed. If concerns are identified regarding providing ADL assistance for oral hygiene (such as assistance with brushing, flossing, denture cleaning), do not cite here. See guidance under §483.24(a), F677, Activities of Daily Living. Summary of Procedures for §483.55(a)[F790] & (b) [F791] The process to review concerns are outlined in the Dental Care Area Pathway. Record Review Review the resident’s records for identification of the resident’s dental needs and the resident’s responsiveness to dental services. The information found in the resident’s assessment and care plans should be used to guide resident observations, and to determine whether the facility has met or is meeting related regulatory requirements including, but not limited to, person- centered care planning, resident assessment, and dental services. Finally, determine the resident’s payer status (Medicare, Medicaid or private pay) for service eligibility determinations. Observation Observe the resident to determine if his or her dental status is consistent with the comprehensive assessment or if the resident exhibited signs of dental health concerns that may not have been identified. Resident/Resident Representative Interview Interview the resident and/or resident representative to determine if any concerns identified since the last survey were promptly addressed to the resident’s or the resident representative’s satisfaction. This includes determining if the facility provided the assistance to obtain dental services needed or requested by the resident or resident representative and whether the facility assisted the resident with arranging transportation to the dental appointment. If the identified concern is related to missing or damaged dentures, interview the resident and family/resident representative to determine if a referral was promptly (within three business days) made, if an explanation was provided if a referral was not promptly made, and if the facility took measures to ensure the resident was able to continue to eat or drink adequately while awaiting dental services. KEY ELEMENTS OF NONCOMPLIANCE To cite deficient practice, the surveyor’s investigation will generally show that the facility any of the following: For residents receiving Medicare and private pay residents, F790: • Failed to provide or obtain from an outside resource, in accordance with §483.70(f), routine and emergency dental services to meet the needs of each resident; or • Did not assist the resident as necessary or requested to make appointments for dental services and/or arrange for transportation to and from the dental service location; or • Did not promptly, within three business days, refer a resident with lost or damaged partial or full dentures and/or documented the extenuating circumstances that led to a delay; or • Did not document what the facility did to ensure a resident with missing or damaged dentures could still eat and drink adequately while awaiting dental services; or • Charged a resident for the loss or damage of partial or full dentures determined to by facility policy to be the facility’s responsibility. For residents receiving Medicaid, F791: • Failed to provide or obtain from an outside resource, in accordance with §483.70(f), routine (to the extent covered by the State plan) and emergency dental services for each resident; or • Did not assist the resident as necessary or requested to make appointments for dental services or arrange for transportation to and from dental services locations; or • Did not promptly, within three days, refer a resident with lost or damaged partial or full dentures and/or documented the extenuating circumstances that led to a delay; or • Did not document what the facility did to ensure a resident with missing or damaged partial or full dentures could still eat and drink adequately while awaiting dental services; or • Charged a resident for the loss or damage of partial or full dentures determined to by facility policy to be the facility’s responsibility; or • Failed to assist a resident(s) who are eligible to participate and/or wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan; or • Charged a Medicaid resident an added fee for routine dental services covered by the State plan or for emergency dental services. ADDITIONAL TAGS FOR CONSIDERATION MAY INCLUDE, BUT ARE NOT LIMITED TO: • §483.10(g)(14), F580, Notification of Change o Determine whether staff notified all necessary care providers and resident representatives of change in dental/oral condition when required. • §483.20(b)(i), (iii), F636, Comprehensive Assessment o Determine if the facility comprehensively assessed the resident’s risk and/or underlying causes (to the extent possible) of the resident’s dental/oral condition and the impact upon the resident’s function, mood and cognition. • §483.20(g), F641, Accuracy of Assessments o Determine whether the assessment accurately reflected the dental condition of the resident at the time of the assessment. • §483.21(b)(1), F656, Comprehensive Care Plan o Determine if the facility developed a care plan based on the comprehensive assessment to address the resident’s dental/oral condition. • §483.25(g)(1)-(3), F692, Assisted Nutrition and Hydration o Determine if the staff ensured the resident maintained or did not experience an avoidable decline in nutritional status related to the resident’s oral/dental condition. • §483.25(k), F697, Pain Management o Determine whether staff have assessed, care-planned, and provided services to manage a resident’s oral/dental pain. • §483.35(a), F725, Sufficient and Competent Nursing Staff o Determine whether based on the resident’s needs the facility had qualified staff in sufficient numbers and with the required competencies to identify dental concerns and provide necessary routine resident dental care. • §483.40(d), F745, Social Services o Determine whether the facility provided medically-related social services by addressing any unmet needs related to dental/denture or oral care. • §483.45(d), F757, Unnecessary Medications o Determine if the resident is experiencing an adverse dental/oral consequence of a medication which indicated the dose should have been reduced or discontinued, or any combination of the reasons stated in §§483.45(d)(1)-(5). • §483.70(h)(5), F842, Medical Records o Determine whether the resident’s records accurately and completely document the resident’s dental/oral status and the care and services provided in accordance with current professional standards and practices. • §483.70(f), F840, Use of Outside Resources o Determine whether dental services provided met professional standards and principles and the timeliness of those services. • §483.70(g), F841, Medical Director o Determine if the medical director was involved in the development of dental/oral health policies/procedures and the coordination of care both on-site as well as availability of off-site providers and addressed any quality concerns.