[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[S. 2641 Introduced in Senate (IS)]







110th CONGRESS
  2d Session
                                S. 2641

To amend titles XVIII and XIX of the Social Security Act to improve the 
 transparency of information on skilled nursing facilities and nursing 
facilities and to clarify and improve the targeting of the enforcement 
            of requirements with respect to such facilities.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           February 14, 2008

Mr. Grassley (for himself and Mr. Kohl) introduced the following bill; 
     which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
To amend titles XVIII and XIX of the Social Security Act to improve the 
 transparency of information on skilled nursing facilities and nursing 
facilities and to clarify and improve the targeting of the enforcement 
            of requirements with respect to such facilities.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Nursing Home 
Transparency and Improvement Act of 2008''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
   TITLE I--IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING 
                   FACILITIES AND NURSING FACILITIES

Sec. 101. Required disclosure of ownership and affiliated parties 
                            information.
Sec. 102. Accountability requirements.
Sec. 103. Nursing home compare Medicare website.
Sec. 104. Reporting of expenditures.
Sec. 105. Standardized complaint form.
Sec. 106. Ensuring staffing accountability.
                    TITLE II--TARGETING ENFORCEMENT

Sec. 201. Civil money penalties.
Sec. 202. GAO study and report on the relative financial status and 
                            performance of special focus facilities.
Sec. 203. National independent monitor program.
Sec. 204. GAO studies and reports on temporary management and barriers 
                            to purchasing facilities with a record of 
                            poor care.
Sec. 205. Notification of facility closure.
Sec. 206. National demonstration projects on culture change and use of 
                            information technology in nursing homes.
                  TITLE III--IMPROVING STAFF TRAINING

Sec. 301. Dementia and abuse prevention training.
Sec. 302. Study and report on training required for certified nurse 
                            aides and supervisory staff.

   TITLE I--IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING 
                   FACILITIES AND NURSING FACILITIES

SEC. 101. REQUIRED DISCLOSURE OF OWNERSHIP AND AFFILIATED PARTIES 
              INFORMATION.

    (a) Skilled Nursing Facilities.--Section 1819(d)(1) of the Social 
Security Act (42 U.S.C. 1395i-3(d)(1)) is amended by adding at the end 
the following new subparagraphs:
                    ``(D) Availability of ownership and affiliated 
                parties information.--
                            ``(i) In general.--Beginning on the date of 
                        enactment of this subparagraph, a skilled 
                        nursing facility must have the information 
                        described in clause (ii) available for 
                        submission to the Secretary, the Inspector 
                        General of the Department of Health and Human 
                        Services, the State, the State long-term care 
                        ombudsman, a resident of a facility, and the 
                        legal representative of such a resident or 
                        other responsible party in the case where the 
                        Secretary, the Inspector General, the State, 
                        the State long-term care ombudsman, the 
                        resident, or the legal representative or 
                        responsible party requests such information 
                        (and, beginning on the effective date of the 
                        regulations promulgated under subparagraph 
                        (E)(i), for reporting such information in 
                        accordance with such regulations). The facility 
                        shall certify to the Secretary and the 
                        Inspector General of the Department of Health 
                        and Human Services, as a condition of 
                        participation and payment under the program 
                        under this title, that the information 
                        submitted upon such request is accurate and 
                        current.
                            ``(ii) Information described.--The 
                        following information is described in this 
                        clause:
                                    ``(I) The identity of individuals 
                                with an ownership or control interest 
                                (as defined in section 1124(a)(3)) in 
                                the facility.
                                    ``(II) Information on the members 
                                of the governing body of the skilled 
                                nursing facility, including the names, 
                                titles, and dates of service of such 
                                members.
                                    ``(III) Information describing the 
                                organizational structure of any 
                                affiliated or related parties, 
                                including principal officers and 
                                directors of affiliated or related 
                                companies, or members in the case of a 
                                limited liability company.
                        To the extent that information reported by a 
                        facility to the Internal Revenue Service on 
                        Form 990, information submitted by a facility 
                        to the Securities and Exchange Commission, or 
                        information otherwise submitted to the 
                        Secretary contains the information described in 
                        subclauses (I), (II), and (III), the facility 
                        may provide such Form or such information 
                        submitted to meet the requirements of clause 
                        (i) and subparagraph (E)(i).
                            ``(iii) Definition of affiliated or related 
                        parties.--In this subparagraph, the term 
                        `affiliated or related parties' means companies 
                        or individuals that serve as operators, 
                        landlords, management companies or advisors, 
                        real estate or consulting companies, members of 
                        a limited liability company, administrative 
                        services companies, lenders and companies 
                        providing financial guarantees, captive or 
                        affiliated liability insurance companies, and 
                        such other entities as the Secretary determines 
                        appropriate.
                    ``(E) Reporting.--
                            ``(i) In general.--Not later than 2 years 
                        after the date of enactment of this 
                        subparagraph, the Secretary shall promulgate 
                        regulations requiring skilled nursing 
                        facilities to report the information described 
                        in clause (ii) of subparagraph (D) to the 
                        Secretary in a standardized format, and such 
                        other regulations as are necessary to carry out 
                        such subparagraph. Such regulations shall 
                        ensure that the facility certifies, as a 
                        condition of participation and payment under 
                        the program under this title, that the 
                        information reported is accurate and current.
                            ``(ii) Guidance.--The Secretary shall 
                        provide guidance and technical assistance to 
                        States on how to adopt the standardized format 
                        under clause (i).''.
    (b) Nursing Facilities.--Section 1919(d)(1) of the Social Security 
Act (42 U.S.C. 1396r(d)(1)) is amended by adding at the end the 
following new subparagraph:
                    ``(D) Availability of ownership and affiliated 
                parties information.--
                            ``(i) In general.--Beginning on the date of 
                        enactment of this subparagraph, a nursing 
                        facility must have the information described in 
                        clause (ii) available for submission to the 
                        Secretary, the Inspector General of the 
                        Department of Health and Human Services, the 
                        State, the State long-term care ombudsman, a 
                        resident of a facility, and the legal 
                        representative of such a resident or other 
                        responsible party in the case where the 
                        Secretary, the Inspector General, the State, 
                        the State long-term care ombudsman, the 
                        resident, or the legal representative or 
                        responsible party requests such information 
                        (and, beginning on the effective date of the 
                        regulations promulgated under subparagraph 
                        (E)(i), for reporting such information in 
                        accordance with such regulations). The facility 
                        shall certify to the Secretary and the 
                        Inspector General of the Department of Health 
                        and Human Services, as a condition of 
                        participation and payment under the program 
                        under this title, that the information 
                        submitted upon such request is accurate and 
                        current.
                            ``(ii) Information described.--The 
                        following information is described in this 
                        clause:
                                    ``(I) The identity of individuals 
                                with an ownership or control interest 
                                (as defined in section 1124(a)(3)) in 
                                the facility.
                                    ``(II) Information on the members 
                                of the governing body of the nursing 
                                facility, including the names, titles, 
                                and dates of service of such members.
                                    ``(III) Information describing the 
                                organizational structure of any 
                                affiliated or related parties, 
                                including principal officers and 
                                directors of affiliated or related 
                                companies, or members in the case of a 
                                limited liability company.
                        To the extent that information reported by a 
                        facility to the Internal Revenue Service on 
                        Form 990, information submitted by a facility 
                        to the Securities and Exchange Commission, or 
                        information otherwise submitted to the 
                        Secretary contains the information described in 
                        subclauses (I), (II), and (III), the facility 
                        may provide such Form or such information 
                        submitted to meet the requirements of clause 
                        (i) and subparagraph (E)(i).
                            ``(iii) Definition of affiliated or related 
                        parties.--In this subparagraph, the term 
                        `affiliated or related parties' means companies 
                        or individuals that serve as operators, 
                        landlords, management companies or advisors, 
                        real estate or consulting companies, members of 
                        a limited liability company, administrative 
                        services companies, lenders and companies 
                        providing financial guarantees, captive or 
                        affiliated liability insurance companies, and 
                        such other entities as the Secretary determines 
                        appropriate.
                    ``(E) Reporting.--
                            ``(i) In general.--Not later than 2 years 
                        after the date of enactment of this 
                        subparagraph, the Secretary shall promulgate 
                        regulations requiring nursing facilities to 
                        report the information described in clause (ii) 
                        of subparagraph (D) to the Secretary in a 
                        standardized format, and such other regulations 
                        as are necessary to carry out such 
                        subparagraph. Such regulations shall ensure 
                        that the facility certifies, as a condition of 
                        participation and payment under the program 
                        under this title, that the information reported 
                        is accurate and current.
                            ``(ii) Guidance.--The Secretary shall 
                        provide guidance and technical assistance to 
                        States on how to adopt the standardized format 
                        under clause (i).''.

SEC. 102. ACCOUNTABILITY REQUIREMENTS.

    (a) Skilled Nursing Facilities.--Section 1819(d)(1) of the Social 
Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by section 101, is 
amended by adding at the end the following new subparagraph:
                    ``(F) Accountability requirements.--
                            ``(i) In general.--On or after the date 
                        that is 2 years after the date of enactment of 
                        this subparagraph, any skilled nursing facility 
                        or chain of such facilities must meet standards 
                        for being an accountable entity by complying 
                        with the criteria developed under clause (ii).
                            ``(ii) Criteria.--Not later than the date 
                        that is 2 years after such date of enactment, 
                        the Secretary, in consultation with the General 
                        Counsel of the Department of Health and Human 
                        Services and the Inspector General of the 
                        Department of Health and Human Services, shall 
                        develop criteria to define accountability 
                        requirements applicable to facilities and 
                        chains of such facilities. Such criteria 
                        shall--
                                    ``(I) include standards for 
                                submission of annual independent audits 
                                for facilities that are part of a group 
                                under common ownership or control, 
                                whether publicly or privately held and 
                                which have annual revenues of 
                                $50,000,000 or more in the aggregate as 
                                a group; and
                                    ``(II) require new owners of a 
                                facility to provide proof of financial 
                                ability to operate the facility, 
                                including documentation of projected 
                                revenue and expenses for the first 12 
                                months of operation of the facility.
                            ``(iii) Rule of construction.--The criteria 
                        developed under clause (ii), and any 
                        requirements to submit information under such 
                        criteria, shall be in addition to any 
                        information the Secretary otherwise requires 
                        providers to submit on the ownership and 
                        operation of skilled nursing facilities 
                        (including information required to be submitted 
                        or reported under subparagraph (D) or (E)).''.
    (b) Nursing Facilities.--Section 1919(d)(1) of the Social Security 
Act (42 U.S.C. 1396r(d)(1)), as amended by section 101, is amended by 
adding at the end the following new subparagraph:
                    ``(F) Accountability requirements.--
                            ``(i) In general.--On or after the date 
                        that is 2 years after the date of enactment of 
                        this subparagraph, any nursing facility or 
                        chain of such facilities must meet standards 
                        for being an accountable entity by complying 
                        with the criteria developed under clause (ii).
                            ``(ii) Criteria.--Not later than the date 
                        that is 2 years after such date of enactment, 
                        the Secretary, in consultation with the General 
                        Counsel of the Department of Health and Human 
                        Services and the Inspector General of the 
                        Department of Health and Human Services, shall 
                        develop criteria to define accountability 
                        requirements applicable to facilities and 
                        chains of such facilities. Such criteria 
                        shall--
                                    ``(I) include standards for 
                                submission of annual independent audits 
                                for facilities that are part of a group 
                                under common ownership or control, 
                                whether publicly or privately held and 
                                which have annual revenues of 
                                $50,000,000 or more in the aggregate as 
                                a group; and
                                    ``(II) require new owners of a 
                                facility to provide proof of financial 
                                ability to operate the facility, 
                                including documentation of projected 
                                revenue and expenses for the first 12 
                                months of operation of the facility.
                            ``(iii) Rule of construction.--The criteria 
                        developed under clause (ii), and any 
                        requirements to submit information under such 
                        criteria, shall be in addition to any 
                        information the Secretary otherwise requires 
                        providers to submit on the ownership and 
                        operation of nursing facilities (including 
                        information required to be submitted or 
                        reported under subparagraph (D) or (E)).''.

SEC. 103. NURSING HOME COMPARE MEDICARE WEBSITE.

    (a) Skilled Nursing Facilities.--
            (1) In general.--Section 1819 of the Social Security Act 
        (42 U.S.C. 1395i-3) is amended--
                    (A) by redesignating subsection (i) as subsection 
                (j); and
                    (B) by inserting after subsection (h) the following 
                new subsection:
    ``(i) Nursing Home Compare Website.--
            ``(1) Inclusion of additional information.--
                    ``(A) In general.--The Secretary shall ensure that 
                the Department of Health and Human Services includes, 
                as part of the information provided for comparison of 
                nursing homes on the official Internet website of the 
                Federal Government for Medicare beneficiaries (commonly 
                referred to as the `Nursing Home Compare' Medicare 
                website) (or a successor website), the following 
                information in a manner that is prominent, easily 
                accessible, readily understandable to consumers of 
                long-term care services, and searchable:
                            ``(i) Information that is reported to the 
                        Secretary under subparagraph (E) of subsection 
                        (d)(1) and information submitted with respect 
                        to accountability requirements applicable to 
                        facilities and chains of facilities under 
                        subparagraph (F) of such subsection.
                            ``(ii) Information on the `Special Focus 
                        Facility program' (or a successor program) 
                        established by the Centers for Medicare & 
                        Medicaid Services, according to procedures 
                        established by the Secretary. Such procedures 
                        shall provide for the inclusion of information 
                        with respect to, and the names and locations 
                        of, those facilities that--
                                    ``(I) have been enrolled in the 
                                program;
                                    ``(II) are enrolled in the program 
                                and have failed to make significant 
                                progress within 18 months after such 
                                enrollment; and
                                    ``(III) have closed voluntarily or 
                                whose participation under this title 
                                has been terminated by the Secretary.
                            ``(iii) Staffing data for each facility 
                        (including resident census data and data on the 
                        hours of care provided per resident per day) 
                        based on data submitted under subsection 
                        (b)(8)(C)(ii), including information on 
                        staffing turnover and tenure, in a format that 
                        is clearly understandable to consumers of long-
                        term care services and allows such consumers to 
                        compare differences in staffing between 
                        facilities.
                            ``(iv) Links to State Internet websites 
                        with information regarding State survey and 
                        certification programs, links to Form 2567 
                        State inspection reports (or a successor form) 
                        on such websites, information to guide 
                        consumers in how to interpret and understand 
                        such reports, and the facility plan of 
                        correction or other response to such report.
                            ``(v) The standardized complaint form 
                        developed under subsection (f)(8), including 
                        explanatory material on what complaint forms 
                        are, how they are used, and how to file a 
                        complaint with the State survey and 
                        certification program and the State long-term 
                        care ombudsman program.
                            ``(vi) A summary of information on 
                        enforcement that includes remedies proposed and 
                        imposed by the Secretary with respect to a 
                        skilled nursing facility during the preceding 3 
                        years.
                    ``(B) Deadline for provision of information.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), the Secretary shall ensure that 
                        the information described in subparagraph (A) 
                        is included on such website (or a successor 
                        website) not later than 1 year after the date 
                        of enactment of this subsection.
                            ``(ii) Exceptions.--
                                    ``(I) Ownership and affiliated 
                                parties and accountability requirements 
                                information.--The Secretary shall 
                                ensure that the information described 
                                in subparagraph (A)(i) is included on 
                                such website (or a successor website) 
                                not later than the date on which the 
                                requirements under subparagraph (E) and 
                                (F), respectively, of subsection (d)(1) 
                                are implemented.
                                    ``(II) Staffing data.--The 
                                Secretary shall ensure that the 
                                information described in subparagraph 
                                (A)(iii) is included on such website 
                                (or a successor website) not later than 
                                the date on which the requirement under 
                                subsection (b)(8)(C)(ii) is 
                                implemented.
            ``(2) Review and modification of website.--
                    ``(A) In general.--The Secretary shall establish a 
                process--
                            ``(i) to review the accuracy, clarity of 
                        presentation, timeliness, and comprehensiveness 
                        of information reported on such website as of 
                        the day before the date of enactment of this 
                        subsection; and
                            ``(ii) not later than 1 year after the date 
                        of enactment of this subsection, to modify or 
                        revamp such website in accordance with the 
                        review conducted under clause (i).
                    ``(B) Consultation.--In conducting the review under 
                subparagraph (A)(i), the Secretary shall consult with--
                            ``(i) State long-term care ombudsman 
                        programs;
                            ``(ii) consumer advocacy groups;
                            ``(iii) provider stakeholder groups; and
                            ``(iv) any other representatives of 
                        programs or groups the Secretary determines 
                        appropriate.''.
            (2) Timeliness of submission of survey and certification 
        information.--
                    (A) In general.--Section 1819(g)(5) of the Social 
                Security Act (42 U.S.C. 1395i-3(g)(5)) is amended by 
                adding at the end the following new subparagraph:
                    ``(E) Submission of survey and certification 
                information to the secretary.--In order to improve the 
                timeliness of information made available to the public 
                under subparagraph (A) and provided on the Nursing Home 
                Compare Medicare website under subsection (i), each 
                State shall submit information respecting any survey or 
                certification made respecting a skilled nursing 
                facility (including any enforcement actions taken by 
                the State) to the Secretary not later than the date on 
                which the State sends such information to the facility. 
                The Secretary shall use the information submitted under 
                the preceding sentence to update the information 
                provided on the Nursing Home Compare Medicare website 
                as expeditiously as practicable.''.
                    (B) Effective date.--The amendment made by this 
                paragraph shall take effect 1 year after the date of 
                enactment of this Act.
    (b) Nursing Facilities.--
            (1) In general.--Section 1919 of the Social Security Act 
        (42 U.S.C. 1396r) is amended--
                    (A) by redesignating subsection (i) as subsection 
                (j); and
                    (B) by inserting after subsection (h) the following 
                new subsection:
    ``(i) Nursing Home Compare Website.--
            ``(1) Inclusion of additional information.--
                    ``(A) In general.--The Secretary shall ensure that 
                the Department of Health and Human Services includes, 
                as part of the information provided for comparison of 
                nursing homes on the official Internet website of the 
                Federal Government for Medicare beneficiaries (commonly 
                referred to as the `Nursing Home Compare' Medicare 
                website) (or a successor website), the following 
                information in a manner that is prominent, easily 
                accessible, readily understandable to consumers of 
                long-term care services, and searchable:
                            ``(i) Information that is reported to the 
                        Secretary under subparagraph (E) of subsection 
                        (d)(1) and information submitted with respect 
                        to accountability requirements applicable to 
                        facilities and chains of facilities under 
                        subparagraph (F) of such subsection.
                            ``(ii) Information on the `Special Focus 
                        Facility program' (or a successor program) 
                        established by the Centers for Medicare & 
                        Medicaid Services, according to procedures 
                        established by the Secretary. Such procedures 
                        shall provide for the inclusion of information 
                        with respect to, and the names and locations 
                        of, those facilities that--
                                    ``(I) have been enrolled in the 
                                program;
                                    ``(II) are enrolled in the program 
                                and have failed to make significant 
                                progress within 18 months after such 
                                enrollment; and
                                    ``(III) have closed voluntarily or 
                                whose participation under this title 
                                has been terminated by the Secretary.
                            ``(iii) Staffing data for each facility 
                        (including resident census data and data on the 
                        hours of care provided per resident per day) 
                        based on data submitted under subsection 
                        (b)(8)(C)(ii), including information on 
                        staffing turnover and tenure, in a format that 
                        is clearly understandable to consumers of long-
                        term care services and allows such consumers to 
                        compare differences in staffing between 
                        facilities.
                            ``(iv) Links to State Internet websites 
                        with information regarding State survey and 
                        certification programs, links to Form 2567 
                        State inspection reports (or a successor form) 
                        on such websites, information to guide 
                        consumers in how to interpret and understand 
                        such reports, and the facility plan of 
                        correction or other response to such report.
                            ``(v) The standardized complaint form 
                        developed under subsection (f)(10), including 
                        explanatory material on what complaint forms 
                        are, how they are used, and how to file a 
                        complaint with the State survey and 
                        certification program and the State long-term 
                        care ombudsman program.
                            ``(vi) A summary of information on 
                        enforcement that includes remedies proposed and 
                        imposed by the Secretary or a State with 
                        respect to a nursing facility during the 
                        preceding 3 years.
                    ``(B) Deadline for provision of information.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), the Secretary shall ensure that 
                        the information described in subparagraph (A) 
                        is included on such website (or a successor 
                        website) not later than 1 year after the date 
                        of enactment of this subsection.
                            ``(ii) Exceptions.--
                                    ``(I) Ownership and affiliated 
                                parties and accountability requirements 
                                information.--The Secretary shall 
                                ensure that the information described 
                                in subparagraph (A)(i) is included on 
                                such website (or a successor website) 
                                not later than the date on which the 
                                requirements under subparagraph (E) and 
                                (F), respectively, of subsection (d)(1) 
                                are implemented.
                                    ``(II) Staffing data.--The 
                                Secretary shall ensure that the 
                                information described in subparagraph 
                                (A)(iii) is included on such website 
                                (or a successor website) not later than 
                                the date on which the requirement under 
                                subsection (b)(8)(C)(ii) is 
                                implemented.
            ``(2) Review and modification of website.--
                    ``(A) In general.--The Secretary shall establish a 
                process--
                            ``(i) to review the accuracy, clarity of 
                        presentation, timeliness, and comprehensiveness 
                        of information reported on such website as of 
                        the day before the date of enactment of this 
                        subsection; and
                            ``(ii) not later than 1 year after the date 
                        of enactment of this subsection, to modify or 
                        revamp such website in accordance with the 
                        review conducted under clause (i).
                    ``(B) Consultation.--In conducting the review under 
                subparagraph (A)(i), the Secretary shall consult with--
                            ``(i) State long-term care ombudsman 
                        programs;
                            ``(ii) consumer advocacy groups;
                            ``(iii) provider stakeholder groups; and
                            ``(iv) any other representatives of 
                        programs or groups the Secretary determines 
                        appropriate.''.
            (2) Timeliness of submission of survey and certification 
        information.--
                    (A) In general.--Section 1919(g)(5) of the Social 
                Security Act (42 U.S.C. 1396r(g)(5)) is amended by 
                adding at the end the following new subparagraph:
                    ``(E) Submission of survey and certification 
                information to the secretary.--In order to improve the 
                timeliness of information made available to the public 
                under subparagraph (A) and provided on the Nursing Home 
                Compare Medicare website under subsection (i), each 
                State shall submit information respecting any survey or 
                certification made respecting a nursing facility 
                (including any enforcement actions taken by the State) 
                to the Secretary not later than the date on which the 
                State sends such information to the facility. The 
                Secretary shall use the information submitted under the 
                preceding sentence to update the information provided 
                on the Nursing Home Compare Medicare website as 
                expeditiously as practicable.''.
                    (B) Effective date.--The amendment made by this 
                paragraph shall take effect 1 year after the date of 
                enactment of this Act.
    (c) Availability of Reports on Surveys, Certifications, and 
Complaint Investigations.--
            (1) Skilled nursing facilities.--Section 1819(d)(1) of the 
        Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by 
        section 102, is amended by adding at the end the following new 
        subparagraph:
                    ``(G) Availability of survey, certification, and 
                complaint investigation reports.--A skilled nursing 
                facility must--
                            ``(i) have reports with respect to any 
                        surveys, certifications, and complaint 
                        investigations made respecting the facility 
                        during the 3 preceding years available for any 
                        individual to review upon request; and
                            ``(ii) post notice of the availability of 
                        such reports in areas of the facility that are 
                        prominent and accessible to the public.''.
            (2) Nursing facilities.--Section 1919(d)(1) of the Social 
        Security Act (42 U.S.C. 1396r(d)(1)), as amended by section 
        102, is amended by adding at the end the following new 
        subparagraph:
                    ``(G) Availability of survey, certification, and 
                complaint investigation reports.--A nursing facility 
                must--
                            ``(i) have reports with respect to any 
                        surveys, certifications, and complaint 
                        investigations made respecting the facility 
                        during the 3 preceding years available for any 
                        individual to review upon request; and
                            ``(ii) post notice of the availability of 
                        such reports in areas of the facility that are 
                        prominent and accessible to the public.''.
            (3) Effective date.--The amendments made by this subsection 
        shall take effect 1 year after the date of enactment of this 
        Act.
    (d) Guidance to States on Form 2567 State Inspection Reports and 
Complaint Investigation Reports.--
            (1) Guidance.--The Secretary shall provide guidance to 
        States on how States can establish electronic links to Form 
        2567 State inspection reports (or a successor form), complaint 
        investigation reports, and a facility's plan of correction or 
        other response to such Form 2567 State inspection reports (or a 
        successor form) on the Internet website of the State that 
        provides information on skilled nursing facilities and nursing 
        facilities.
            (2) Definitions.--In this subsection:
                    (A) Nursing facility.--The term ``nursing 
                facility'' has the meaning given such term in section 
                1919(a) of the Social Security Act (42 U.S.C. 
                1396r(a)).
                    (B) Secretary.--The term ``Secretary'' means the 
                Secretary of Health and Human Services.
                    (C) Skilled nursing facility.--The term ``skilled 
                nursing facility'' has the meaning given such term in 
                section 1819(a) of the Social Security Act (42 U.S.C. 
                1395i-3(a)).

SEC. 104. REPORTING OF EXPENDITURES.

    Section 1888 of the Social Security Act (42 U.S.C. 1395yy) is 
amended by adding at the end the following new subsection:
    ``(f) Reporting of Expenditures.--
            ``(1) In general.--For cost reports submitted for cost 
        reporting periods beginning on or after the date that is 1 year 
        after the date of enactment of this subsection, skilled nursing 
        facilities shall separately report expenditures for wages and 
        benefits for nursing staff (by staff level, breaking out (at a 
        minimum) registered nurses, licensed professional nurses, and 
        certified nurse assistants).
            ``(2) Modification of form.--The Secretary, in consultation 
        with private sector accountants experienced with medicare and 
        medicaid nursing facility home cost reports, shall redesign 
        such reports to meet the requirement of paragraph (1).
            ``(3) Categorization.--The Secretary, working in 
        consultation with the Medicare Payment Advisory Commission, the 
        Inspector General of the Department of Health and Human 
        Services, and other expert parties the Secretary determines 
        appropriate, shall take the expenditures listed on cost reports 
        submitted by skilled nursing facilities and categorize such 
        expenditures into the following categories on an annual basis:
                    ``(A) Spending on direct care services (including 
                nursing, therapy, and non-ancillary therapy services).
                    ``(B) Spending on indirect care (including 
                housekeeping, dietary, and other related services).
                    ``(C) Capital costs (including building and land 
                costs).
                    ``(D) Administrative costs.
            ``(4) Availability of information submitted.--The Secretary 
        shall establish procedures to make information on expenditures 
        submitted under this subsection readily available to interested 
        parties upon request, subject to such requirements as the 
        Secretary may specify under the procedures established under 
        this paragraph.''.

SEC. 105. STANDARDIZED COMPLAINT FORM.

    (a) Skilled Nursing Facilities.--
            (1) Development by the secretary.--Section 1819(f) of the 
        Social Security Act (42 U.S.C. 1395i-3(f)) is amended by adding 
        at the end the following new paragraph:
            ``(8) Standardized complaint form.--The Secretary shall 
        develop a standardized complaint form for use by a resident (or 
        a person acting on the resident's behalf) in filing a complaint 
        with a State survey and certification agency and a State long-
        term care ombudsman program with respect to a skilled nursing 
        facility.''.
            (2) State requirements.--Section 1819(e) of the Social 
        Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the 
        end the following new paragraph:
            ``(6) Complaint forms and resolution processes.--
                    ``(A) Complaint forms.--The State must make the 
                standardized complaint form developed under subsection 
                (f)(8) available upon request to--
                            ``(i) a resident of a skilled nursing 
                        facility; and
                            ``(ii) any person acting on the resident's 
                        behalf.
                    ``(B) Complaint resolution process.--The State must 
                establish a complaint resolution process in order to 
                ensure that the legal representative of a resident of a 
                skilled nursing facility or other responsible party is 
                not denied access to such resident or otherwise 
                retaliated against if they have complained about the 
                quality of care provided by the facility or other 
                issues relating to the facility. Such complaint 
                resolution process shall include--
                            ``(i) procedures to assure accurate 
                        tracking of complaints received, including 
                        notification to the complainant that a 
                        complaint has been received;
                            ``(ii) procedures to determine the likely 
                        severity of a complaint and for the 
                        investigation of the complaint; and
                            ``(iii) deadlines for responding to a 
                        complaint and for notifying the complainant of 
                        the outcome of the investigation.
                    ``(C) Rule of construction.--Nothing in this 
                paragraph shall be construed as preventing a resident 
                of a skilled nursing facility (or a person acting on 
                the resident's behalf) from submitting a complaint in a 
                manner or format other than by using the standardized 
                complaint form developed under subsection (f)(8) 
                (including submitting a complaint orally).''.
    (b) Nursing Facilities.--
            (1) Development by the secretary.--Section 1919(f) of the 
        Social Security Act (42 U.S.C. 1395i-3(f)) is amended by adding 
        at the end the following new paragraph:
            ``(10) Standardized complaint form.--The Secretary shall 
        develop a standardized complaint form for use by a resident (or 
        a person acting on the resident's behalf) in filing a complaint 
        with a State survey and certification agency and a State long-
        term care ombudsman program with respect to a nursing 
        facility.''.
            (2) State requirements.--Section 1919(e) of the Social 
        Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the 
        end the following new paragraph:
            ``(8) Complaint forms and resolution processes.--
                    ``(A) Complaint forms.--The State must make the 
                standardized complaint form developed under subsection 
                (f)(10) available upon request to--
                            ``(i) a resident of a nursing facility; and
                            ``(ii) any person acting on the resident's 
                        behalf.
                    ``(B) Complaint resolution process.--The State must 
                establish a complaint resolution process in order to 
                ensure that the legal representative of a resident of a 
                nursing facility or other responsible party is not 
                denied access to such resident or otherwise retaliated 
                against if they have complained about the quality of 
                care provided by the facility or other issues relating 
                to the facility. Such complaint resolution process 
                shall include--
                            ``(i) procedures to assure accurate 
                        tracking of complaints received, including 
                        notification to the complainant that a 
                        complaint has been received;
                            ``(ii) procedures to determine the likely 
                        severity of a complaint and for the 
                        investigation of the complaint; and
                            ``(iii) deadlines for responding to a 
                        complaint and for notifying the complainant of 
                        the outcome of the investigation.
                    ``(C) Rule of construction.--Nothing in this 
                paragraph shall be construed as preventing a resident 
                of a nursing facility (or a person acting on the 
                resident's behalf) from submitting a complaint in a 
                manner or format other than by using the standardized 
                complaint form developed under subsection (f)(10) 
                (including submitting a complaint orally).''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of enactment of this Act.

SEC. 106. ENSURING STAFFING ACCOUNTABILITY.

    (a) Skilled Nursing Facilities.--Section 1819(b)(8) of the Social 
Security Act (42 U.S.C. 1395i-3(b)(8)) is amended by adding at the end 
the following new subparagraph:
                    ``(C) Submission of staffing information based on 
                payroll data in a uniform format.--
                            ``(i) Design phase.--
                                    ``(I) In general.--The Secretary 
                                shall establish a program for skilled 
                                nursing facilities to report staffing 
                                information (including information with 
                                respect to agency and contract staff) 
                                based on payroll data. Such program 
                                shall be conducted for a 1-year period 
                                beginning on the date of enactment of 
                                this subparagraph.
                                    ``(II) Report.--Not later than 6 
                                months after the completion of the 
                                program established under subclause 
                                (I), the Secretary shall submit a 
                                report to Congress containing the 
                                results of the program.
                            ``(ii) Submission of staffing 
                        information.--Beginning not later than 1 year 
                        after the completion of the program established 
                        under clause (i)(I), the Secretary shall 
                        require a skilled nursing facility to 
                        electronically submit to the Secretary nurse 
                        staffing information (including information 
                        with respect to agency and contract staff) 
                        based on payroll data in a uniform format 
                        (according to specifications established by the 
                        Secretary). Such specifications shall require 
                        that the information submitted under the 
                        preceding sentence--
                                    ``(I) specify the category of work 
                                a certified employee performs (such as 
                                whether the employee is a registered 
                                nurse, licensed practical nurse, 
                                licensed vocational nurse, or certified 
                                nursing assistant);
                                    ``(II) include resident census 
                                data;
                                    ``(III) include a regular reporting 
                                schedule; and
                                    ``(IV) include information on 
                                employee turnover and tenure and on the 
                                hours of care provided by each category 
                                of certified employees referenced in 
                                subclause (I) per resident per day.''
    (b) Nursing Facilities.--Section 1919(b)(8) of the Social Security 
Act (42 U.S.C. 1396r(b)(8)) is amended by adding at the end the 
following new subparagraph:
                    ``(C) Submission of staffing information based on 
                payroll data in a uniform format.--
                            ``(i) Design phase.--
                                    ``(I) In general.--The Secretary 
                                shall establish a program for nursing 
                                facilities to report staffing 
                                information (including information with 
                                respect to agency and contract staff) 
                                based on payroll data. Such program 
                                shall be conducted for a 1-year period 
                                beginning on the date of enactment of 
                                this subparagraph.
                                    ``(II) Report.--Not later than 6 
                                months after the completion of the 
                                program established under subclause 
                                (I), the Secretary shall submit a 
                                report to Congress containing the 
                                results of the program.
                            ``(ii) Submission of staffing 
                        information.--Beginning not later than 1 year 
                        after the completion of the program established 
                        under clause (i)(I), the Secretary shall 
                        require a nursing facility to electronically 
                        submit to the Secretary nurse staffing 
                        information (including information with respect 
                        to agency and contract staff) based on payroll 
                        data in a uniform format (according to 
                        specifications established by the Secretary). 
                        Such specifications shall require that the 
                        information submitted under the preceding 
                        sentence--
                                    ``(I) specify the category of work 
                                a certified employee performs (such as 
                                whether the employee is a registered 
                                nurse, licensed practical nurse, 
                                licensed vocational nurse, or certified 
                                nursing assistant);
                                    ``(II) include resident census 
                                data;
                                    ``(III) include a regular reporting 
                                schedule; and
                                    ``(IV) include information on 
                                employee turnover and tenure and on the 
                                hours of care provided by each category 
                                of certified employees referenced in 
                                subclause (I) per resident per day.''

                    TITLE II--TARGETING ENFORCEMENT

SEC. 201. CIVIL MONEY PENALTIES.

    (a) Skilled Nursing Facilities.--
            (1) In general.--Section 1819(h)(2)(B)(ii) of the Social 
        Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended to 
        read as follows:
                            ``(ii) Authority with respect to civil 
                        money penalties.--
                                    ``(I) Amount.--Subject to subclause 
                                (III), the Secretary may impose a civil 
                                money penalty in the applicable amount 
                                (as defined in subclause (II)) for each 
                                day or each instance of noncompliance 
                                (as determined appropriate by the 
                                Secretary).
                                    ``(II) Applicable amount.--In this 
                                clause, the term `applicable amount' 
                                means--
                                            ``(aa) in the case where 
                                        the deficiency results in the 
                                        death of a resident of the 
                                        facility, an amount not to 
                                        exceed $100,000;
                                            ``(bb) in the case of a 
                                        deficiency where the facility 
                                        is cited for actual harm or 
                                        immediate jeopardy, an amount 
                                        not less than $3,000 and not 
                                        more than $25,000; and
                                            ``(cc) in the case of any 
                                        other deficiency, an amount not 
                                        to exceed $3,000.
                                    ``(III) Reduction of civil money 
                                penalties in certain circumstances.--
                                Subject to subclause (IV), in the case 
                                where a facility self-reports and 
                                promptly corrects a deficiency for 
                                which a penalty was imposed under this 
                                clause not later than 10 calendar days 
                                after the date of such imposition, the 
                                Secretary may reduce the amount of the 
                                penalty imposed by not more than 50 
                                percent.
                                    ``(IV) Prohibitions on reduction 
                                for certain deficiencies.--
                                            ``(aa) Repeat 
                                        deficiencies.--The Secretary 
                                        may not reduce the amount of a 
                                        penalty under subclause (III) 
                                        if the Secretary had reduced a 
                                        penalty imposed on the facility 
                                        in the preceding year under 
                                        such subclause with respect to 
                                        a repeat deficiency.
                                            ``(bb) Certain other 
                                        deficiencies.--The Secretary 
                                        may not reduce the amount of a 
                                        penalty under subclause (III) 
                                        if the penalty is imposed for a 
                                        deficiency described in 
                                        subclause (II)(bb) and the 
                                        actual harm is found to result 
                                        in a pattern of harm or 
                                        widespread harm that 
                                        immediately jeopardizes the 
                                        health or safety of a resident 
                                        or residents of the facility, 
                                        or if the penalty is imposed 
                                        for a deficiency described in 
                                        subclause (II)(aa).
                                    ``(V) Collection of civil money 
                                penalties.--In the case of a civil 
                                money penalty imposed under this clause 
                                for a deficiency described in item (aa) 
                                or (bb) of subclause (II), the 
                                Secretary--
                                            ``(aa) subject to item 
                                        (bb), shall provide the 
                                        opportunity for the facility to 
                                        participate in an informal 
                                        dispute resolution process 
                                        prior to the collection of such 
                                        penalty;
                                            ``(bb) may provide for the 
                                        collection of such civil money 
                                        penalty and the placement of 
                                        such amounts collected in an 
                                        escrow account on the earlier 
                                        of the date on which the 
                                        informal dispute resolution 
                                        process under item (aa) is 
                                        completed or the date that is 
                                        90 days after the date of the 
                                        imposition of the penalty;
                                            ``(cc) may provide that 
                                        such amounts collected are kept 
                                        in such account pending the 
                                        resolution of any appeals;
                                            ``(dd) in the case where 
                                        the facility successfully 
                                        appeals the penalty, may 
                                        provide for the return of such 
                                        amounts collected (plus 
                                        interest) to the facility; and
                                            ``(ee) in the case where 
                                        all such appeals are 
                                        unsuccessful, may provide that 
                                        some portion of such amounts 
                                        collected may be used to 
                                        support activities that benefit 
                                        residents, including assistance 
                                        to support and protect 
                                        residents who reside in a 
                                        facility that closes 
                                        (voluntarily or involuntarily) 
                                        or is decertified (including 
                                        offsetting costs of relocating 
                                        residents to home and 
                                        community-based settings or 
                                        another facility), and projects 
                                        that support resident and 
                                        family councils and other 
                                        consumer involvement in 
                                        assuring quality care in 
                                        facilities.
                                    ``(VI) Procedure.--The provisions 
                                of section 1128A (other than 
                                subsections (a) and (b) and except to 
                                the extent that such provisions require 
                                a hearing prior to the imposition of a 
                                civil money penalty in the case 
                                described in subclause (V)) shall apply 
                                to a civil money penalty under this 
                                clause in the same manner as such 
                                provisions apply to a penalty or 
                                proceeding under section 1128A(a).''.
            (2) Conforming amendment.--The second sentence of section 
        1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-3(h)(5)) 
        is amended by inserting ``(ii)(V),'' after ``(i),''.
    (b) Nursing Facilities.--
            (1) Penalties imposed by the state.--
                    (A) In general.--Section 1919(h)(2) of the Social 
                Security Act (42 U.S.C. 1396r(h)(2)) is amended--
                            (i) in subparagraph (A)(ii), by striking 
                        the first sentence and inserting the following: 
                        ``A civil money penalty in accordance with 
                        subparagraph (G).''; and
                            (ii) by adding at the end the following new 
                        subparagraph:
                    ``(G) Civil money penalties.--
                            ``(i) In general.--Subject to clause (iii), 
                        the State may impose a civil money penalty 
                        under subparagraph (A)(ii) in the applicable 
                        amount for each day or each instance of 
                        noncompliance (as determined appropriate by the 
                        State).
                            ``(ii) Definition of applicable amount.--In 
                        this subparagraph, the term `applicable amount' 
                        means--
                                    ``(I) in the case where the 
                                deficiency results in the death of a 
                                resident of the facility, an amount not 
                                to exceed $100,000;
                                    ``(II) in the case of a deficiency 
                                where the facility is cited for actual 
                                harm or immediate jeopardy, an amount 
                                not less than $3,000 and not more than 
                                $25,000; and
                                    ``(III) in the case of any other 
                                deficiency, an amount not to exceed 
                                $3,000.
                            ``(iii) Reduction of civil money penalties 
                        in certain circumstances.--Subject to clause 
                        (iv), in the case where a facility self-reports 
                        and promptly corrects a deficiency for which a 
                        penalty was imposed under subparagraph (A)(ii) 
                        not later than 10 calendar days after the date 
                        of such imposition, the State may reduce the 
                        amount of the penalty imposed by not more than 
                        50 percent.
                            ``(iv) Prohibition on reduction for certain 
                        deficiencies.--
                                    ``(I) Repeat deficiencies.--The 
                                State may not reduce the amount of a 
                                penalty under clause (iii) if the State 
                                had reduced a penalty imposed on the 
                                facility in the preceding year under 
                                such clause with respect to a repeat 
                                deficiency.
                                    ``(II) Certain other 
                                deficiencies.--The State may not reduce 
                                the amount of a penalty under clause 
                                (iii) if the penalty is imposed for a 
                                deficiency described in clause (ii)(II) 
                                and the actual harm is found to result 
                                in a pattern of harm or widespread harm 
                                that immediately jeopardizes the health 
                                or safety of a resident or residents of 
                                the facility, or if the penalty is 
                                imposed for a deficiency described in 
                                clause (ii)(I).
                            ``(v) Collection of civil money 
                        penalties.--In the case of a civil money 
                        penalty imposed under subparagraph (A)(ii) for 
                        a deficiency described in subclause (I) or (II) 
                        of clause (ii), the State--
                                    ``(I) subject to subclause (II), 
                                shall provide the opportunity for the 
                                facility to participate in an informal 
                                dispute resolution process prior to the 
                                collection of such penalty;
                                    ``(II) may provide for the 
                                collection of such civil money penalty 
                                and the placement of such amounts 
                                collected in an escrow account on the 
                                earlier of the date on which the 
                                informal dispute resolution process 
                                under subclause (I) is completed or the 
                                date that is 90 days after the date of 
                                the imposition of the penalty;
                                    ``(III) may provide that such 
                                amounts collected are kept in such 
                                account pending the resolution of any 
                                appeals;
                                    ``(IV) in the case where the 
                                facility successfully appeals the 
                                penalty, may provide for the return of 
                                such amounts collected (plus interest) 
                                to the facility; and
                                    ``(V) in the case where all such 
                                appeals are unsuccessful, may provide 
                                that such funds collected shall be used 
                                for the purposes described in the 
                                second sentence of subparagraph 
                                (A)(ii).''.
                    (B) Conforming amendment.--The second sentence of 
                section 1919(h)(2)(A)(ii) is amended by inserting ``, 
                and some portion of such funds may be used to support 
                activities that benefit residents, including assistance 
                to support and protect residents who reside in a 
                facility that closes (voluntarily or involuntarily) or 
                is decertified (including offsetting costs of 
                relocating residents to home and community-based 
                settings or another facility), and projects that 
                support resident and family councils and other consumer 
                involvement in assuring quality care in facilities'' 
                before the period at the end.
            (2) Penalties imposed by the secretary.--
                    (A) In general.--Section 1919(h)(3)(C)(ii) of the 
                Social Security Act (42 U.S.C. 1396r(h)(3)(C)) is 
                amended to read as follows:
                            ``(ii) Authority with respect to civil 
                        money penalties.--
                                    ``(I) Amount.--Subject to subclause 
                                (III), the Secretary may impose a civil 
                                money penalty in the applicable amount 
                                (as defined in subclause (II)) for each 
                                day or each instance of noncompliance 
                                (as determined appropriate by the 
                                Secretary).
                                    ``(II) Applicable amount.--In this 
                                clause, the term `applicable amount' 
                                means--
                                            ``(aa) in the case where 
                                        the deficiency results in the 
                                        death of a resident of the 
                                        facility, an amount not to 
                                        exceed $100,000;
                                            ``(bb) in the case of a 
                                        deficiency where the facility 
                                        is cited for actual harm or 
                                        immediate jeopardy, an amount 
                                        not less than $3,000 and not 
                                        more than $25,000; and
                                            ``(cc) in the case of any 
                                        other deficiency, an amount not 
                                        to exceed $3,000.
                                    ``(III) Reduction of civil money 
                                penalties in certain circumstances.--
                                Subject to subclause (IV), in the case 
                                where a facility self-reports and 
                                promptly corrects a deficiency for 
                                which a penalty was imposed under this 
                                clause not later than 10 calendar days 
                                after the date of such imposition, the 
                                Secretary may reduce the amount of the 
                                penalty imposed by not more than 50 
                                percent.
                                    ``(IV) Prohibitions on reduction 
                                for certain deficiencies.--
                                            ``(aa) Repeat 
                                        deficiencies.--The Secretary 
                                        may not reduce the amount of a 
                                        penalty under subclause (III) 
                                        if the Secretary had reduced a 
                                        penalty imposed on the facility 
                                        in the preceding year under 
                                        such subclause with respect to 
                                        a repeat deficiency.
                                            ``(bb) Certain other 
                                        deficiencies.--The Secretary 
                                        may not reduce the amount of a 
                                        penalty under subclause (III) 
                                        if the penalty is imposed for a 
                                        deficiency described in 
                                        subclause (II)(bb) and the 
                                        actual harm is found to result 
                                        in a pattern of harm or 
                                        widespread harm that 
                                        immediately jeopardizes the 
                                        health or safety of a resident 
                                        or residents of the facility, 
                                        or if the penalty is imposed 
                                        for a deficiency described in 
                                        subclause (II)(aa).
                                    ``(V) Collection of civil money 
                                penalties.--In the case of a civil 
                                money penalty imposed under this clause 
                                for a deficiency described in item (aa) 
                                or (bb) of subclause (II), the 
                                Secretary--
                                            ``(aa) subject to item 
                                        (bb), shall provide the 
                                        opportunity for the facility to 
                                        participate in an informal 
                                        dispute resolution process 
                                        prior to the collection of such 
                                        penalty;
                                            ``(bb) may provide for the 
                                        collection of such civil money 
                                        penalty and the placement of 
                                        such amounts collected in an 
                                        escrow account on the earlier 
                                        of the date on which the 
                                        informal dispute resolution 
                                        process under item (aa) is 
                                        completed or the date that is 
                                        90 days after the date of the 
                                        imposition of the penalty;
                                            ``(cc) may provide that 
                                        such amounts collected are kept 
                                        in such account pending the 
                                        resolution of any appeals;
                                            ``(dd) in the case where 
                                        the facility successfully 
                                        appeals the penalty, may 
                                        provide for the return of such 
                                        amounts collected (plus 
                                        interest) to the facility; and
                                            ``(ee) in the case where 
                                        all such appeals are 
                                        unsuccessful, may provide that 
                                        some portion of such amounts 
                                        collected may be used to 
                                        support activities that benefit 
                                        residents, including assistance 
                                        to support and protect 
                                        residents who reside in a 
                                        facility that closes 
                                        (voluntarily or involuntarily) 
                                        or is decertified (including 
                                        offsetting costs of relocating 
                                        residents to home and 
                                        community-based settings or 
                                        another facility), and projects 
                                        that support resident and 
                                        family councils and other 
                                        consumer involvement in 
                                        assuring quality care in 
                                        facilities.
                                    ``(VI) Procedure.--The provisions 
                                of section 1128A (other than 
                                subsections (a) and (b) and except to 
                                the extent that such provisions require 
                                a hearing prior to the imposition of a 
                                civil money penalty in the case 
                                described in subclause (V)) shall apply 
                                to a civil money penalty under this 
                                clause in the same manner as such 
                                provisions apply to a penalty or 
                                proceeding under section 1128A(a).''.
                    (B) Conforming amendment.--Section 1919(h)(5)(8) of 
                the Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is 
                amended by inserting ``(ii)(V),'' after ``(i),''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of enactment of this Act.

SEC. 202. GAO STUDY AND REPORT ON THE RELATIVE FINANCIAL STATUS AND 
              PERFORMANCE OF SPECIAL FOCUS FACILITIES.

    (a) Study.--
            (1) In general.--The Comptroller General of the United 
        States shall conduct a study on the financial status, resident 
        care, and performance of skilled nursing facilities and nursing 
        facilities in the Special Focus Facility program (or a 
        successor program) established by the Centers for Medicare & 
        Medicaid Services relative to a comparable sample of facilities 
        that are not in such program. Such study shall include an 
        examination of the ownership and control interests, and any 
        affiliated parties, of the facilities studied (as applicable).
            (2) Definitions.--In this section:
                    (A) Nursing facility.--The term ``nursing 
                facility'' has the meaning given such term in section 
                1919(a) of the Social Security Act (42 U.S.C. 
                1396r(a)).
                    (B) Secretary.--The term ``Secretary'' means the 
                Secretary of Health and Human Services.
                    (C) Skilled nursing facility.--The term ``skilled 
                nursing facility'' has the meaning given such term in 
                section 1819(a) of the Social Security Act (42 U.S.C. 
                1395(a)).
    (b) Report.--Not later than 1 year after the date of enactment of 
this Act, the Comptroller General of the United States shall submit a 
report to Congress and the Secretary containing the results of the 
study conducted under subsection (a), together with recommendations for 
such legislation and administrative action as the Comptroller General 
determines appropriate.

SEC. 203. NATIONAL INDEPENDENT MONITOR PROGRAM.

    (a) Skilled Nursing Facilities.--Section 1819(h) of the Social 
Security Act (42 U.S.C. 1395i-3(h)(2) is amended--
            (1) by redesignating paragraphs (5) and (6) as paragraphs 
        (6) and (7), respectively; and
            (2) by inserting after paragraph (4) the following new 
        paragraph:
            ``(5) National independent monitor program.--
                    ``(A) In general.--Not later than 1 year after the 
                date of enactment of this paragraph, the Secretary, in 
                consultation with the Inspector General of the 
                Department of Health and Human Services, shall develop, 
                test, and implement a protocol for the establishment of 
                an independent monitoring program to oversee interstate 
                and large intrastate chains of skilled nursing 
                facilities. Such program shall be designed to analyze 
                such chains in 1 or more of the following instances:
                            ``(i) Where 3 or more facilities of the 
                        chain were enrolled in the `Special Focus 
                        Facility program' (or a successor program) 
                        established by the Centers for Medicare & 
                        Medicaid Services during the preceding 3 years.
                            ``(ii) Where the chain has been 
                        experiencing financial problems that may be 
                        linked to serious quality deficiencies.
                            ``(iii) Where the chain has a record of 
                        chronic poor performance.
                    ``(B) Responsibilities.--The independent monitoring 
                program established under subparagraph (A) shall 
                include the following responsibilities:
                            ``(i) Conducting periodic reviews and 
                        preparing root-cause quality and deficiency 
                        analyses of a chain described in such 
                        subparagraph to assess compliance by the chain 
                        with State and Federal laws and regulations.
                            ``(ii) Conducting oversight of efforts by 
                        such a chain, whether publicly or privately 
                        held, to achieve compliance with State and 
                        Federal laws and regulations.
                            ``(iii) Analyzing the management structure, 
                        distribution of expenditures, and nurse 
                        staffing levels of facilities of such a chain 
                        in relation to resident census, staff turnover 
                        rates, and tenure.
                            ``(iv) Reporting findings and 
                        recommendations with respect to such reviews, 
                        analyses, and oversight to the chain and 
                        facilities of the chain, to the Secretary, and 
                        to relevant States.
                            ``(v) Publishing the results of such 
                        reviews, analyses, and oversight.
                    ``(C) Implementation of recommendations.--
                            ``(i) Receipt of finding by chain.--Not 
                        later than 10 days after receipt of a finding 
                        reported under subparagraph (B)(iv), the chain 
                        shall submit a report to the independent 
                        monitor--
                                    ``(I) outlining corrective actions 
                                to be taken by the chain to implement 
                                the recommendations in such report; or
                                    ``(II) indicating that the chain 
                                will not implement such 
                                recommendations, and why it will not do 
                                so.
                            ``(ii) Receipt of report by independent 
                        monitor.--Not later than 10 days after receipt 
                        of the report submitted by the chain under 
                        clause (i), the independent monitor shall 
                        finalize its recommendations and submit a 
                        report to the chain and facilities of the 
                        chain, the Secretary, and the State or States, 
                        as appropriate, containing such final 
                        recommendations.
                            ``(iii) Civil money penalty.--The Secretary 
                        may impose a civil money penalty under 
                        subsection (h)(2)(B)(ii) on a chain that fails 
                        to respond to or to take corrective actions to 
                        implement the recommendations of the 
                        independent monitor in accordance with this 
                        subparagraph.
                    ``(D) Cost of appointment.--A chain shall be 
                responsible for all costs associated with the 
                appointment of independent monitors under the program 
                under this paragraph. The chain shall pay such costs to 
                the Secretary (in accordance with procedures 
                established by the Secretary).
                    ``(E) Evaluation and report.--
                            ``(i) Evaluation.--The Inspector General of 
                        the Department of Health and Human Services 
                        shall evaluate the independent monitoring 
                        program under this paragraph.
                            ``(ii) Report.--Not later than 2 years 
                        after the implementation of such program under 
                        subparagraph (A), the Inspector General shall 
                        submit a report to Congress containing the 
                        results of the evaluation conducted under 
                        clause (i), together with recommendations for 
                        such legislation and administrative action as 
                        the Inspector General determines appropriate.
                    ``(F) Intermediate remedy.--The appointment of an 
                independent monitor shall be an intermediate remedy 
                that may be in addition to or in lieu of other remedies 
                under this subsection.''.
    (b) Nursing Facilities.--Section 1919(h) of the Social Security Act 
(42 U.S.C. 1396r(h)) is amended--
            (1) by redesignating paragraphs (8) and (9) as paragraphs 
        (9) and (10), respectively; and
            (2) by inserting after paragraph (7) the following new 
        paragraph:
            ``(8) National independent monitor program.--
                    ``(A) In general.--Not later than 1 year after the 
                date of enactment of this paragraph, the Secretary, in 
                consultation with the Inspector General of the 
                Department of Health and Human Services, shall develop, 
                test, and implement a protocol for the establishment of 
                an independent monitoring program to oversee interstate 
                and large intrastate chains of nursing facilities. Such 
                program shall be designed to analyze such chains in 1 
                or more of the following instances:
                            ``(i) Where 3 or more facilities of the 
                        chain were enrolled in the `Special Focus 
                        Facility program' (or a successor program) 
                        established by the Centers for Medicare & 
                        Medicaid Services during the preceding 3 years.
                            ``(ii) Where the chain has been 
                        experiencing financial problems that may be 
                        linked to serious quality deficiencies.
                            ``(iii) Where the chain has a record of 
                        chronic poor performance.
                    ``(B) Responsibilities.--The independent monitoring 
                program established under subparagraph (A) shall 
                include the following responsibilities:
                            ``(i) Conducting periodic reviews and 
                        preparing root-cause quality and deficiency 
                        analyses of a chain described in such 
                        subparagraph to assess compliance by the chain 
                        with State and Federal laws and regulations.
                            ``(ii) Conducting oversight of efforts by 
                        such a chain, whether publicly or privately 
                        held, to achieve compliance with State and 
                        Federal laws and regulations.
                            ``(iii) Analyzing the management structure, 
                        distribution of expenditures, and nurse 
                        staffing levels of facilities of such a chain 
                        in relation to resident census, staff turnover 
                        rates, and tenure.
                            ``(iv) Reporting findings and 
                        recommendations with respect to such reviews, 
                        analyses, and oversight to the chain and 
                        facilities of the chain, to the Secretary, and 
                        to relevant States.
                            ``(v) Publishing the results of such 
                        reviews, analyses, and oversight.
                    ``(C) Implementation of recommendations.--
                            ``(i) Receipt of finding by chain.--Not 
                        later than 10 days after receipt of a finding 
                        reported under subparagraph (B)(iv), the chain 
                        shall submit a report to the independent 
                        monitor--
                                    ``(I) outlining corrective actions 
                                to be taken by the chain to implement 
                                the recommendations in such report; or
                                    ``(II) indicating that the chain 
                                will not implement such 
                                recommendations, and why it will not do 
                                so.
                            ``(ii) Receipt of report by independent 
                        monitor.--Not later than 10 days after receipt 
                        of the report submitted by the chain under 
                        clause (i), the independent monitor shall 
                        finalize its recommendations and submit a 
                        report to the chain and facilities of the 
                        chain, the Secretary, and the State or States, 
                        as appropriate, containing such final 
                        recommendations.
                            ``(iii) Civil money penalty.--A State or 
                        the Secretary may impose a civil money penalty 
                        under subsection (h)(2)(A)(ii), or 
                        (h)(3)(C)(ii), respectively, on a chain that 
                        fails to respond to or to take corrective 
                        actions to implement the recommendations of the 
                        independent monitor in accordance with this 
                        subparagraph.
                    ``(D) Cost of appointment.--A chain shall be 
                responsible for all costs associated with the 
                appointment of independent monitors under the program 
                under this paragraph. The chain shall pay such costs to 
                the Secretary (in accordance with procedures 
                established by the Secretary).
                    ``(E) Evaluation and report.--
                            ``(i) Evaluation.--The Inspector General of 
                        the Department of Health and Human Services 
                        shall evaluate the independent monitoring 
                        program under this paragraph.
                            ``(ii) Report.--Not later than 2 years 
                        after the implementation of such program under 
                        subparagraph (A), the Inspector General shall 
                        submit a report to Congress containing the 
                        results of the evaluation conducted under 
                        clause (i), together with recommendations for 
                        such legislation and administrative action as 
                        the Inspector General determines appropriate.
                    ``(F) Intermediate remedy.--The appointment of an 
                independent monitor shall be an intermediate remedy 
                that may be in addition to or in lieu of other remedies 
                under this subsection.''.

SEC. 204. GAO STUDIES AND REPORTS ON TEMPORARY MANAGEMENT AND BARRIERS 
              TO PURCHASING FACILITIES WITH A RECORD OF POOR CARE.

    (a) Study and Report on Temporary Management.--
            (1) In general.--The Comptroller General of the United 
        States (in this section referred to as the ``Comptroller 
        General'') shall conduct a study on--
                    (A) best practices for the appointment of temporary 
                management under sections 1819(h)(2)(B)(iii), 
                1919(h)(2)(A)(iii), and 1919(h)(3)(C)(iii) of the 
                Social Security Act (42 U.S.C. 1395i-3(h)(2)(B)(iii); 
                1396r(h)(2)(A)(iii); 1396r(h)(3)(C)(iii)); and
                    (B) barriers to the appointment of such temporary 
                management.
            (2) Report.--Not later than 1 year after the date of 
        enactment of this Act, the Comptroller General shall submit a 
        report to Congress containing the results of the study 
        conducted under paragraph (1), together with recommendations 
        for such legislation and administrative action as the 
        Comptroller General determines appropriate.
            (3) Guidance to states.--The Secretary of Health and Human 
        Services shall issue guidance to States based on the 
        recommendations contained in the report submitted under 
        paragraph (2).
    (b) Study and Report on Barriers to Purchasing Facilities With a 
Record of Poor Care.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study on the extent and the nature of any 
        barriers for new owners who purchase, and potential owners who 
        wish to purchase, skilled nursing facilities and nursing 
        facilities with a record of poor care.
            (2) Report.--Not later than 1 year after the date of 
        enactment of this Act, the Comptroller General shall submit a 
        report to Congress containing the results of the study 
        conducted under paragraph (1), together with recommendations 
        for such legislation and administrative action as the 
        Comptroller General determines appropriate to address any 
        barriers identified in such study.
            (3) Definitions.--In this subsection:
                    (A) Nursing facility.--The term ``nursing 
                facility'' has the meaning given such term in section 
                1919(a) of the Social Security Act (42 U.S.C. 
                1396r(a)).
                    (B) Skilled nursing facility.--The term ``skilled 
                nursing facility'' has the meaning given such term in 
                section 1819(a) of the Social Security Act (42 U.S.C. 
                1395(a)).

SEC. 205. NOTIFICATION OF FACILITY CLOSURE.

    (a) Skilled Nursing Facilities.--
            (1) In general.--Section 1819(c) of the Social Security Act 
        (42 U.S.C. 1395i-3(c)) is amended by adding at the end the 
        following new paragraph:
            ``(7) Notification of facility closure.--
                    ``(A) In general.--Any individual who is the 
                administrator of a skilled nursing facility must--
                            ``(i) submit to the Secretary, the State 
                        long-term care ombudsman, residents of the 
                        facility, and the legal representatives of such 
                        residents or other responsible parties, written 
                        notification of an impending closure--
                                    ``(I) subject to subclause (II), 
                                not later than the date that is 60 days 
                                prior to the date of such closure; and
                                    ``(II) in the case of a facility 
                                where the Secretary terminates the 
                                facility's participation under this 
                                title, not later than the date that the 
                                Secretary determines appropriate;
                            ``(ii) ensure that the facility does not 
                        admit any new residents on or after the date on 
                        which such written notification is submitted; 
                        and
                            ``(iii) include in the notice a plan for 
                        the transfer and adequate relocation of the 
                        residents of the facility by a specified date 
                        prior to closure that has been approved by the 
                        State, including assurances that the residents 
                        will be transferred to the most appropriate 
                        facility or other setting in terms of quality, 
                        services, and location, taking into 
                        consideration the needs and best interests of 
                        each resident.
                    ``(B) Relocation.--
                            ``(i) In general.--The State shall ensure 
                        that, before a facility closes, all residents 
                        of the facility have been successfully 
                        relocated to another facility or an alternative 
                        home and community-based setting.
                            ``(ii) Continuation of payments until 
                        residents relocated.--The Secretary may, as the 
                        Secretary determines appropriate, continue to 
                        make payments under this title with respect to 
                        residents of a facility that has submitted a 
                        notification under subparagraph (A) during the 
                        period beginning on the date such notification 
                        is submitted and ending on the date on which 
                        the resident is successfully relocated.''.
            (2) Conforming amendments.--Section 1819(h)(4) of the 
        Social Security Act (42 U.S.C. 1395i-3(h)(4)) is amended--
                    (A) in the first sentence, by striking ``the 
                Secretary shall terminate'' and inserting ``the 
                Secretary, subject to subsection (c)(7), shall 
                terminate''; and
                    (B) in the second sentence, by striking 
                ``subsection (c)(2)'' and inserting ``paragraphs (2) 
                and (7) of subsection (c)''.
    (b) Nursing Facilities.--
            (1) In general.--Section 1919(c) of the Social Security Act 
        (42 U.S.C. 1396r(c)) is amended by adding at the end the 
        following new paragraph:
            ``(9) Notification of facility closure.--
                    ``(A) In general.--Any individual who is an 
                administrator of a nursing facility must--
                            ``(i) submit to the Secretary, the State 
                        long-term care ombudsman, residents of the 
                        facility, and the legal representatives of such 
                        residents or other responsible parties, written 
                        notification of an impending closure--
                                    ``(I) subject to subclause (II), 
                                not later than the date that is 60 days 
                                prior to the date of such closure; and
                                    ``(II) in the case of a facility 
                                where the Secretary terminates the 
                                facility's participation under this 
                                title, not later than the date that the 
                                Secretary determines appropriate;
                            ``(ii) ensure that the facility does not 
                        admit any new residents on or after the date on 
                        which such written notification is submitted; 
                        and
                            ``(iii) include in the notice a plan for 
                        the transfer and adequate relocation of the 
                        residents of the facility by a specified date 
                        prior to closure that has been approved by the 
                        State, including assurances that the residents 
                        will be transferred to the most appropriate 
                        facility or other setting in terms of quality, 
                        services, and location, taking into 
                        consideration the needs and best interests of 
                        each resident.
                    ``(B) Relocation.--
                            ``(i) In general.--The State shall ensure 
                        that, before a facility closes, all residents 
                        of the facility have been successfully 
                        relocated to another facility or an alternative 
                        home and community-based setting.
                            ``(ii) Continuation of payments until 
                        residents relocated.--The Secretary may, as the 
                        Secretary determines appropriate, continue to 
                        make payments under this title with respect to 
                        residents of a facility that has submitted a 
                        notification under subparagraph (A) during the 
                        period beginning on the date such notification 
                        is submitted and ending on the date on which 
                        the resident is successfully relocated.''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of enactment of this Act.

SEC. 206. NATIONAL DEMONSTRATION PROJECTS ON CULTURE CHANGE AND USE OF 
              INFORMATION TECHNOLOGY IN NURSING HOMES.

    (a) In General.--The Secretary shall conduct 2 demonstration 
projects, 1 for the development of best practices in skilled nursing 
facilities and nursing facilities that are involved in the culture 
change movement (including the development of resources for facilities 
to find and access funding in order to undertake culture change) and 1 
for the development of best practices in skilled nursing facilities and 
nursing facilities for the use of information technology to improve 
resident care.
    (b) Conduct of Demonstration Projects.--
            (1) Grant award.--Under each demonstration project 
        conducted under this section, the Secretary shall award 1 or 
        more grants to facility-based settings for the development of 
        best practices described in subsection (a) with respect to the 
        demonstration project involved. Such award shall be made on a 
        competitive basis and may be allocated in 1 lump-sum payment.
            (2) Consideration of special needs of residents.--Each 
        demonstration project conducted under this section shall take 
        into consideration the special needs of residents of skilled 
        nursing facilities and nursing facilities who have cognitive 
        impairment, including dementia.
    (c) Implementation and Duration.--
            (1) Implementation.--The demonstration projects shall each 
        be implemented not later than 1 year after the date of 
        enactment of this Act.
            (2) In general.--The demonstration projects shall each be 
        conducted for a period not to exceed 3 years.
    (d) Definitions.--In this section:
            (1) Nursing facility.--The term ``nursing facility'' has 
        the meaning given such term in section 1919(a) of the Social 
        Security Act (42 U.S.C. 1396r(a)).
            (2) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (3) Skilled nursing facility.--The term ``skilled nursing 
        facility'' has the meaning given such term in section 1819(a) 
        of the Social Security Act (42 U.S.C. 1395(a)).
    (e) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as are necessary to carry out this section.
    (f) Report.--Not later than 9 months after the completion of the 
demonstration project, the Secretary shall submit a report to Congress 
on such project, together with recommendations for such legislation and 
administrative action as the Secretary determines appropriate.

                  TITLE III--IMPROVING STAFF TRAINING

SEC. 301. DEMENTIA AND ABUSE PREVENTION TRAINING.

    (a) Skilled Nursing Facilities.--Section 1819(f)(2)(A)(i)(I) of the 
Social Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(I)) is amended by 
inserting ``(including, in the case of initial training and, if the 
Secretary determines appropriate, in the case of ongoing training, 
dementia management training, and patient abuse prevention training'' 
before ``, (II)''.
    (b) Nursing Facilities.--Section 1919(f)(2)(A)(i)(I) of the Social 
Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is amended by inserting 
``(including, in the case of initial training and, if the Secretary 
determines appropriate, in the case of ongoing training, dementia 
management training, and patient abuse prevention'' before ``, (II)''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of enactment of this Act.

SEC. 302. STUDY AND REPORT ON TRAINING REQUIRED FOR CERTIFIED NURSE 
              AIDES AND SUPERVISORY STAFF.

    (a) Study.--
            (1) In general.--The Secretary shall conduct a study on the 
        content of training for certified nurse aides and supervisory 
        staff of skilled nursing facilities and nursing facilities. The 
        study shall include an analysis of the following:
                    (A) Whether the number of initial training hours 
                for certified nurse aides required under sections 
                1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) of the 
                Social Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(II); 
                1396r(f)(2)(A)(i)(II)) should be increased from 75 and, 
                if so, what the required number of initial training 
                hours should be, including any recommendations for the 
                content of such training (including training related to 
                dementia).
                    (B) Whether requirements for ongoing training under 
                such sections 1819(f)(2)(A)(i)(II) and 
                1919(f)(2)(A)(i)(II) should be increased from 12 hours 
                per year, including any recommendations for the content 
                of such training.
            (2) Consultation.--In conducting the analysis under 
        paragraph (1)(A), the Secretary shall consult with States that 
        currently (as of the date of enactment of this Act) require 
        more than 75 hours of training for certified nurse aides.
            (3) Definitions.--In this section:
                    (A) Nursing facility.--The term ``nursing 
                facility'' has the meaning given such term in section 
                1919(a) of the Social Security Act (42 U.S.C. 
                1396r(a)).
                    (B) Secretary.--The term ``Secretary'' means the 
                Secretary of Health and Human Services, acting through 
                the Assistant Secretary for Planning and Evaluation.
                    (C) Skilled nursing facility.--The term ``skilled 
                nursing facility'' has the meaning given such term in 
                section 1819(a) of the Social Security Act (42 U.S.C. 
                1395(a)).
    (b) Report.--Not later than 2 years after the date of enactment of 
this Act, the Secretary shall submit a report to Congress containing 
the results of the study conducted under subsection (a), together with 
recommendations for such legislation and administrative action as the 
Secretary determines appropriate.
                                 <all>