Quality improvement for nursing facilities under the medicare and medicaid programs

(a)

Incentives for immediate improvement and protection of needed training programs

(1)

Medicare program

Section 1819(f)(2) of the Social Security Act (42 U.S.C. 1395i–3(f)(2)) is amended— (A)in subparagraph (B)— (i)by adding and at the end of clause (i); (ii)by striking ; and at the end of clause (ii) and inserting a period; and (iii)by striking clause (iii); and (B)by striking subparagraphs (C) and (D). (2)

Medicaid program

Section 1919(f)(2) of such Act (42 U.S.C.1396r(f)(2)) is amended— (A)in subparagraph (B)— (i)by adding and at the end of clause (i); (ii)by striking ; and at the end of clause (ii) and inserting a period; and (iii)by striking clause (iii); and (B)by striking subparagraphs (C) and (D). (b)

Specified remedies

(1)

Medicare program

Section 1819(h)(2)(B) of such Act (42 U.S.C. 1395i–3(h)(2)(B)) is amended— (A)by redesignating clause (iii) as clause (iv); and (B)by inserting after clause (ii) the following new clause:

(iii)

Disapproval of nurse aide training and competency evaluation programs

In consultation with the State, the Secretary may disapprove nurse aide training and competency evaluation programs offered by the facility.

(2)

Medicaid program

Section 1919(h)(2)(A) of such Act (42 U.S.C. 1396r(h)(2)(A)) is amended— (A)by redesignating clauses (iii) and (iv) as clauses (iv) and (v), respectively; and (B)by inserting after clause (ii) the following new clause:

(iii)In consultation with the State, the Secretary may disapprove nurse aide training and competency evaluation programs offered by the facility.

(c)

Promoting innovation and quality improvement through state waivers

(1)

Medicare program

Section 1819(g) of such Act (42 U.S.C. 1395i–3(g)) is amended by adding at the end the following new paragraph:

(6)

Waiver demonstration authority to promote innovation and quality improvement

(A)

In general

At the request of a State, but not to exceed a total of 3 States, the Secretary may waive provisions of this subsection relating to survey and certification procedures in order to test and implement innovative alternatives to the survey process otherwise applicable. The Secretary shall provide special consideration to the application of alternative procedures that increase the use of outcome measures, the incorporation of quality of life measures, and improve consistency and accuracy in deficiency determinations and survey results. The Secretary shall approve a waiver request if applicant demonstrates significant potential for improving the quality of care, quality of life, and safety of residents. (B)

Consideration of views of stakeholders

The Secretary shall only consider waiver applications under this paragraph from a State under this paragraph if the State has convened and consulted with appropriate stakeholders in the State, including representatives of nursing facilities, consumers groups, the State long term care ombudsman, labor organizations (and where such organizations are not present in the industry, other employee representatives), and licensed health care providers, to assist in developing their alternative system. In determining whether to grant such waivers the Secretary shall take into consideration the views of the stakeholders convened by the State.

(2)

Medicaid program

Section 1919(g) of such Act (42 U.S.C. 1396r(g)) is amended by adding at the end the following new paragraph:

(6)

Waiver demonstration authority to promote innovation and quality improvement

(A)

In general

At the request of a State, but not to exceed a total of 3 States, the Secretary may waive provisions of this subsection relating to survey and certification procedures in order to test and implement innovative alternatives to the survey process otherwise applicable. The Secretary shall provide special consideration to the application of alternative procedures that increase the use of outcome measures, the incorporation of quality of life measures, and improve consistency and accuracy in deficiency determinations and survey results. The Secretary shall approve a waiver request if it demonstrates significant potential for improving the quality of care, quality of life, and safety of residents. (B)

Consideration of views of stakeholders

(d)

Removal of inflexibility in provider termination

(1)

Medicare program

Section 1819(h)(2) of such Act (42 U.S.C. 1395i–3(h)(2)) is amended— (A)in subparagraph (D), by striking If and inserting Subject to subparagraph (F), if; (B)in subparagraph (E), by striking In and inserting Subject to subparagraph (F), in; and (C)by adding at the end the following new subparagraph:

(F)

Continuation of payments pending remediation when flexibility needed to protect residents

The Secretary may continue payments, over a period not longer than 12 months after the effective date of the findings, under this title with respect to a nursing facility not in compliance with a requirement of subsection (b), (c), or (d), if— (i)the State survey agency finds that ceasing payments is not in the best interests of residents and that continuation of payments would not jeopardize residents’ health and safety; (ii)the State survey agency finds that it is more appropriate to take alternative action to assure compliance of the facility with the requirements than to terminate the certification of the facility; and (iii)the State has submitted a plan and timetable for corrective action to the Secretary for approval and the Secretary approves the plan of corrective action.

(2)

Medicaid program

Section 1919(h)(2) of such Act (42 U.S.C. 1396r(h)(2)) is amended— (A)in subparagraph (C), by striking If and inserting Subject to subparagraph (G), if; (B)in subparagraph (D), by striking In and inserting Subject to subparagraph (G), in; and (C)by adding at the end the following new subparagraph:

(G)

Continuation of payments pending remediation when flexibility needed to protect residents

(e)

Access to informal dispute resolution process

(1)

Medicare program

Section 1819(g)(1) of such Act (42 U.S.C. 1395i–3(g)(1)) is amended by adding at the end the following new subparagraph:

(F)

Establishment of informal, independent dispute resolution process

Each State shall establish an informal dispute resolution process that allows facilities to settle disputes involving compliance with the standards established under this section. Such process shall rely on independent third parties, not related to the State survey agency or the facilities, in resolving disputes.

(2)

Medicaid program

Section 1919(g)(1) of such Act (42 U.S.C. 1396r(g)(1)) is amended by adding at the end the following new subparagraph:

(F)

Establishment of informal, independent dispute resolution process

(f)

Removing barriers that deter new management from taking over and improving problem facilities

(1)

Medicare program

Section 1819(h) of such Act (42 U.S.C. 1395i–3(h)) is amended by adding at the end the following new paragraph:

(7)

Fostering improvement of facilities with poor compliance histories

The Secretary shall provide incentives for operators with histories of good compliance to acquire facilities with poor compliance histories. Such incentives shall be designed to promote the sustained provision of high-quality care and shall only be made available in the case of bona fide, arm’s-length sale of facilities with poor compliance histories.

(2)

Medicaid program

Section 1919(h) of such Act (42 U.S.C. 1396r(h)) is amended by adding at the end the following new paragraph:

(10)

Fostering improvement of facilities with poor compliance histories

(g)

Allowing appeals of all deficiencies

(1)

Medicare program

Section 1819(h) of such Act, as amended by subsection (f)(1), is further amended by adding at the end the following new paragraph:

(8)

Right to appeal all deficiency citations

Notwithstanding any other provision of law, a facility may appeal any deficiency determination under this section with respect to which a penalty has not been imposed in the same manner as the facility may appeal such determination if a penalty had been imposed.

(2)

Medicaid program

Section 1919(h) of such Act, as amended by subsection (f)(2), is further amended by adding at the end the following new paragraph:

(11)

Right to appeal all deficiency citations

(h)

Joint providers/Surveyor training

(1)

Medicare program

Section 1819(e) of such Act (42 U.S.C. 1395i–3(e)) is amended by adding at the end the following new paragraph:

(6)

Joint provider/surveyor training

The Secretary shall require the State to establish a process for joint training and education of surveyors and providers at least annually and periodically as changes to regulations, guidelines, and policy governing nursing facility operations are implemented and used in surveys of participating facilities.

(2)

Medicaid program

Section 1919(e) of such Act (42 U.S.C. 1396r(e)) is amended by adding at the end the following new paragraph:

(8)

Joint provider/surveyor training

The State shall establish a process for joint training and education to surveyors and providers at least annually and periodically as changes to regulations, guidelines, and policy governing nursing facility operations are implemented and used in surveys of participating facilities.

(i)

Facility-based training for new surveyors

(1)

Medicare program

Section 1819(e) of such Act (42 U.S.C. 1395i–3(e)), as amended by subsection (h)(1), is amended by adding at the end the following new paragraph:

(7)

Facility-based training for new surveyors

The Secretary shall require the State to establish a process for assuring that— (A)each individual newly hired as a nursing home surveyor, as part of the individual’s basic training, is assigned full-time to a participating nursing facility for at least 5 days within a 7-day period to observe actual operations outside of the survey process before the individual begins oversight responsibilities; (B)such individual shall not assume oversight responsibility during this training period and such observations may not be the sole basis of a deficiency citation against the facility; and (C)such individual shall not be assigned as a member of a survey team for the facility in which the individual received training for two standard surveys following the training period in the facility.

(2)

Medicaid program

Section 1919(e) of such Act (42 U.S.C. 1396r(e)), as amended by subsection (h)(2), is amended by adding at the end the following new paragraph:

(9)

Facility-based training for new surveyors

The State shall establish a process for assuring that— (A)each individual newly hired as a nursing home surveyor, as part of the individual’s basic training, is assigned full-time to a participating nursing facility for at least 5 days within a 7-day period to observe actual operations outside of the survey process before the individual begins oversight responsibilities; (B)such individual shall not assume oversight responsibility during this training period and such observations may not be the sole basis of a deficiency citation against the facility; and (C)such individual shall not be assigned as a member of a survey team for the facility in which the individual received training for two standard surveys following the training period in the facility.

(j)

Effective date

The amendments made by this section shall take effect one month after the date of the enactment of this Act, except in cases where regulations are needed to implement these amendments and in such cases shall be effective 6 months after such enactment date.