; or (ii) a certification in paramedicine. (6) Payment under this title for items and services identified under paragraph (3) or (4) furnished by such qualified group practices at such a facility in amounts determined under subsection (d). (c) Certifications (1) Qualified skilled nursing facilities For purposes of this section, the Secretary shall certify a skilled nursing facility as a qualified skilled nursing facility if the facility submits an application in a time and manner specified by the Secretary and meets the following requirements: (A) The facility has on-site diagnostic equipment necessary for a qualified group practice to furnish items and services under the Program and real-time audio and visual capabilities. (B) The facility has at least one individual who meets the qualifications described in paragraph (5) or a physician present 24 hours a day and 7 days a week to work with the qualified group practice. Such individual may be a member of the staff of the qualified skilled nursing facility or of the qualified group practice. (C) The facility ensures that residents of such facility, upon entering such facility, are allowed to specify in an advanced care directive whether the resident wishes to receive items and services furnished at the facility under the Program in a case where communication with the resident is not possible. (D) The facility ensures that individuals to be furnished such items and services under the Program at such facility have the opportunity, at their request, to instead be transported to a hospital emergency department. (E) The facility is not part of the Special Focus Facility program of the Centers for Medicare & Medicaid Services (although the facility may, at the discretion of the Secretary, be a candidate for selection under such program). Nothing in this paragraph shall affect the requirements under section 1819(b)(4). (2) Qualified group practices For purposes of this section, the Secretary shall certify a group practice as a qualified group practice for a period of 3