[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 647 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                 S. 647

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

                             March 19, 2009

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 2009''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings.
             TITLE I--IMPROVING TRANSPARENCY OF INFORMATION

Sec. 101. Required disclosure of ownership and additional disclosable 
                            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 pilot program.
Sec. 204. Notification of facility closure.
Sec. 205. 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.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) The Nursing Home Reform Act of 1987 remains one of the 
        strongest laws in the United States to protect the health, 
        safety, and quality of life of elderly people and individuals 
        with disabilities who live in nursing homes.
            (2) The nursing home industry has changed dramatically in 
        the 21 years since the enactment of the Nursing Home Reform Act 
        of 1987, with real estate asset holdings frequently separated 
        from operations in a manner that can frustrate efforts by 
        regulators to hold parent companies accountable for the quality 
        of services that are provided in their facilities.
            (3) Although the Centers for Medicare & Medicaid Services 
        reimburses nursing homes for services each year in an amount in 
        excess of $75,000,000,000, the agency does not always know who 
        the owners and operators of the facilities are.
            (4) Greater transparency and accountability in the nursing 
        home industry can be achieved by simply requiring publicly and 
        privately owned nursing homes to disclose corporate entities 
        that own individual nursing homes, and other entities with 
        which individual nursing homes have key financial, operational, 
        and management relationships.
            (5) Transparency and accountability can be further 
        strengthened by development of an independent monitor pilot 
        program that would allow the Centers for Medicare & Medicaid 
        Services to examine the management of certain nursing home 
        chains that have a record of poor performance and to identify 
        the root causes of quality and safety problems occurring in 
        individual nursing homes.
            (6) The ``Nursing Home Compare'' Medicare website would be 
        significantly improved by the inclusion of timely, auditable 
        information that is derived from payroll data about the direct 
        care staffing levels in all nursing homes across the United 
        States. Inclusion of information about staffing turnover and 
        retention rates in nursing homes, which are closely linked to 
        the quality and consistency of services, would also provide 
        consumers with valuable information.
            (7) According to the Alzheimer's Association, an estimated 
        70 percent of current residents of nursing homes have some 
        degree of cognitive impairment and direct care staff who 
        provide services to such residents would benefit from dementia 
        management and abuse prevention instruction as part of their 
        training.
            (8) When nursing homes elect to close, residents and 
        families generally require help finding another suitable 
        residence and to minimize ``transfer trauma''. Good resident 
        outcomes are achievable when nursing homes provide sufficient 
        written notice and develop a relocation plan for each resident, 
        and when State officials take responsibility for assuring that 
        each resident is transferred to the most appropriate facility 
        or other community setting.

             TITLE I--IMPROVING TRANSPARENCY OF INFORMATION

SEC. 101. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL DISCLOSABLE 
              PARTIES INFORMATION.

    (a) In General.--Section 1124 of the Social Security Act (42 U.S.C. 
1320a-3) is amended by adding at the end the following new subsection:
    ``(c) Required Disclosure of Ownership and Additional Disclosable 
Parties Information.--
            ``(1) Disclosure.--A facility shall have the information 
        described in paragraph (2) available--
                    ``(A) during the period beginning on the date of 
                the enactment of this subsection and ending on the date 
                such information is made available to the public under 
                section 101(b) of the Nursing Home Transparency and 
                Improvement Act of 2009, for submission to the 
                Secretary, the Inspector General of the Department of 
                Health and Human Services, the State in which the 
                facility is located, and the State long-term care 
                ombudsman in the case where the Secretary, the 
                Inspector General, the State, or the State long-term 
                care ombudsman requests such information; and
                    ``(B) beginning on the effective date of the final 
                regulations promulgated under paragraph (3)(A), for 
                reporting such information in accordance with such 
                final regulations.
        Nothing in subparagraph (A) shall be construed as authorizing a 
        facility to dispose of or delete information described in such 
        subparagraph after the effective date of the final regulations 
        promulgated under paragraph (3)(A).
            ``(2) Information described.--
                    ``(A) In general.--The following information is 
                described in this paragraph:
                            ``(i) The information described in 
                        subsections (a) and (b), subject to 
                        subparagraph (C).
                            ``(ii) The identity of and information on--
                                    ``(I) each member of the governing 
                                body of the facility, including the 
                                name, title, and period of service of 
                                each such member;
                                    ``(II) each person or entity who is 
                                an officer, director, member, partner, 
                                trustee, or managing employee of the 
                                facility, including the name, title, 
                                and period of service of each such 
                                person or entity; and
                                    ``(III) each person or entity who 
                                is an additional disclosable party of 
                                the facility.
                            ``(iii) The organizational structure of 
                        each additional disclosable party of the 
                        facility and a description of the relationship 
                        of each such additional disclosable party to 
                        the facility and to one another.
                    ``(B) Special rule where information is already 
                reported or submitted.--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 or any other 
                Federal agency contains the information described in 
                clauses (i), (ii), or (iii) of subparagraph (A), the 
                facility may provide such Form or such information 
                submitted to meet the requirements of paragraph (1).
                    ``(C) Special rule.--In applying subparagraph 
                (A)(i)--
                            ``(i) with respect to subsections (a) and 
                        (b), `ownership or control interest' shall 
                        include direct or indirect interests, including 
                        such interests in intermediate entities; and
                            ``(ii) subsection (a)(3)(A)(ii) shall 
                        include the owner of a whole or part interest 
                        in any mortgage, deed of trust, note, or other 
                        obligation secured, in whole or in part, by the 
                        entity or any of the property or assets 
                        thereof, if the interest is equal to or exceeds 
                        5 percent of the total property or assets of 
                        the entirety.
            ``(3) Reporting.--
                    ``(A) In general.--Not later than the date that is 
                2 years after the date of the enactment of this 
                subsection, the Secretary shall promulgate final 
                regulations requiring, effective on the date that is 90 
                days after the date on which such final regulations are 
                published in the Federal Register, a facility to report 
                the information described in paragraph (2) to the 
                Secretary in a standardized format, and such other 
                regulations as are necessary to carry out this 
                subsection. Such final regulations shall ensure that 
                the facility certifies, as a condition of participation 
                and payment under the program under title XVIII or XIX, 
                that the information reported by the facility in 
                accordance with such final regulations is, to the 
                maximum extent practicable (as determined by the 
                facility), accurate and current.
                    ``(B) Guidance.--The Secretary shall provide 
                guidance and technical assistance to States on how to 
                adopt the standardized format under subparagraph (A).
            ``(4) No effect on existing reporting requirements.--
        Nothing in this subsection shall reduce, diminish, or alter any 
        reporting requirement for a facility that is in effect as of 
        the date of the enactment of this subsection.
            ``(5) Definitions.--In this subsection:
                    ``(A) Additional disclosable party.--The term 
                `additional disclosable party' means, with respect to a 
                facility, any person or entity who--
                            ``(i) exercises operational, financial, or 
                        managerial control over the facility or a part 
                        thereof, or provides policies or procedures for 
                        any of the operations of the facility, or 
                        provides financial or cash management services 
                        to the facility;
                            ``(ii) leases or subleases real property to 
                        the facility, or owns a whole or part interest 
                        equal to or exceeding 5 percent of the total 
                        value of such real property;
                            ``(iii) lends funds or provides a financial 
                        guarantee to the facility in an amount which is 
                        equal to or exceeds $50,000; or
                            ``(iv) provides management or 
                        administrative services, management or clinical 
                        consulting services, or accounting or financial 
                        services to the facility.
                    ``(B) Facility.--The term `facility' means a 
                disclosing entity which is--
                            ``(i) a skilled nursing facility (as 
                        defined in section 1819(a)); or
                            ``(ii) a nursing facility (as defined in 
                        section 1919(a)).
                    ``(C) Managing employee.--The term `managing 
                employee' means, with respect to a facility, an 
                individual (including a general manager, business 
                manager, administrator, director, or consultant) who 
                directly or indirectly manages, advises, or supervises 
                any element of the practices, finances, or operations 
                of the facility.
                    ``(D) Organizational structure.--The term 
                `organizational structure' means, in the case of--
                            ``(i) a corporation, the officers, 
                        directors, and shareholders of the corporation 
                        who have an ownership interest in the 
                        corporation which is equal to or exceeds 5 
                        percent;
                            ``(ii) a limited liability company, the 
                        members and managers of the limited liability 
                        company (including, as applicable, what 
                        percentage each member and manager has of the 
                        ownership interest in the limited liability 
                        company);
                            ``(iii) a general partnership, the partners 
                        of the general partnership;
                            ``(iv) a limited partnership, the general 
                        partners and any limited partners of the 
                        limited partnership who have an ownership 
                        interest in the limited partnership which is 
                        equal to or exceeds 10 percent;
                            ``(v) a trust, the trustees of the trust;
                            ``(vi) an individual, contact information 
                        for the individual; and
                            ``(vii) any other person or entity, such 
                        information as the Secretary determines 
                        appropriate.''.
    (b) Public Availability of Information.--
            (1) In general.--Not later than the date that is 1 year 
        after the date on which the final regulations promulgated under 
        section 1124(c)(3)(A) of the Social Security Act, as added by 
        subsection (a), are published in the Federal Register, the 
        Secretary shall make the information reported in accordance 
        with such final regulations available to the public in 
        accordance with procedures established by the Secretary.
            (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)).
    (c) Conforming Amendments.--
            (1) In general.--
                    (A) Skilled nursing facilities.--Section 1819(d)(1) 
                of the Social Security Act (42 U.S.C. 1395i-3(d)(1)) is 
                amended by striking subparagraph (B) and redesignating 
                subparagraph (C) as subparagraph (B).
                    (B) Nursing facilities.--Section 1919(d)(1) of the 
                Social Security Act (42 U.S.C. 1396r(d)(1)) is amended 
                by striking subparagraph (B) and redesignating 
                subparagraph (C) as subparagraph (B).
            (2) Effective date.--The amendments made by paragraph (1) 
        shall take effect on the date on which the Secretary makes the 
        information described in subsection (b)(1) available to the 
        public under such subsection.

SEC. 102. ACCOUNTABILITY REQUIREMENTS.

    (a) Effective Compliance and Ethics Programs.--
            (1) 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 subparagraph:
                    ``(D) Compliance and ethics programs.--
                            ``(i) Requirement.--On or after the date 
                        that is 36 months after the date of the 
                        enactment of this subparagraph, a skilled 
                        nursing facility shall, with respect to the 
                        entity that operates the facility (in this 
                        subparagraph referred to as the `operating 
                        organization' or `organization'), have in 
                        operation a compliance and ethics program that 
                        is effective in preventing and detecting 
                        criminal, civil, and administrative violations 
                        under this Act and in promoting quality of care 
                        consistent with regulations developed under 
                        clause (ii).
                            ``(ii) Development of regulations.--
                                    ``(I) In general.--Not later than 
                                the date that is 2 years after such 
                                date of the enactment, the Secretary, 
                                working jointly with the Inspector 
                                General of the Department of Health and 
                                Human Services, shall promulgate 
                                regulations for an effective compliance 
                                and ethics program for operating 
                                organizations, which may include a 
                                model compliance program.
                                    ``(II)  Design of regulations.--
                                Such regulations with respect to 
                                specific elements or formality of a 
                                program may vary with the size of the 
                                organization, such that larger 
                                organizations should have a more formal 
                                program and include established written 
                                policies defining the standards and 
                                procedures to be followed by its 
                                employees. Such requirements may 
                                specifically apply to the corporate 
                                level management of multi unit nursing 
                                home chains.
                                    ``(III) Evaluation.--Not later than 
                                3 years after the date of promulgation 
                                of regulations under this clause, the 
                                Secretary shall complete an evaluation 
                                of the compliance and ethics programs 
                                required to be established under this 
                                subparagraph. Such evaluation shall 
                                determine if such programs led to 
                                changes in deficiency citations, 
                                changes in quality performance, or 
                                changes in other metrics of patient 
                                quality of care. The Secretary shall 
                                submit to Congress a report on such 
                                evaluation and shall include in such 
                                report such recommendations regarding 
                                changes in the requirements for such 
                                programs as the Secretary determines 
                                appropriate.
                            ``(iii) Requirements for compliance and 
                        ethics programs.--In this subparagraph, the 
                        term `compliance and ethics program' means, 
                        with respect to a skilled nursing facility, a 
                        program of the operating organization that--
                                    ``(I) has been reasonably designed, 
                                implemented, and enforced so that it 
                                generally will be effective in 
                                preventing and detecting criminal, 
                                civil, and administrative violations 
                                under this Act and in promoting quality 
                                of care; and
                                    ``(II) includes at least the 
                                required components specified in clause 
                                (iv).
                            ``(iv) Required components of program.--The 
                        required components of a compliance and ethics 
                        program of an organization are the following:
                                    ``(I) The organization must have 
                                established compliance standards and 
                                procedures to be followed by its 
                                employees and other agents that are 
                                reasonably capable of reducing the 
                                prospect of criminal, civil, and 
                                administrative violations under this 
                                Act.
                                    ``(II) Specific individuals within 
                                high-level personnel of the 
                                organization must have been assigned 
                                overall responsibility to oversee 
                                compliance with such standards and 
                                procedures and has sufficient resources 
                                and authority to assure such 
                                compliance.
                                    ``(III) The organization must have 
                                used due care not to delegate 
                                substantial discretionary authority to 
                                individuals whom the organization knew, 
                                or should have known through the 
                                exercise of due diligence, had a 
                                propensity to engage in criminal, 
                                civil, and administrative violations 
                                under this Act.
                                    ``(IV) The organization must have 
                                taken steps to communicate effectively 
                                its standards and procedures to all 
                                employees and other agents, such as by 
                                requiring participation in training 
                                programs or by disseminating 
                                publications that explain in a 
                                practical manner what is required.
                                    ``(V) The organization must have 
                                taken reasonable steps to achieve 
                                compliance with its standards, such as 
                                by utilizing monitoring and auditing 
                                systems reasonably designed to detect 
                                criminal, civil, and administrative 
                                violations under this Act by its 
                                employees and other agents and by 
                                having in place and publicizing a 
                                reporting system whereby employees and 
                                other agents could report violations by 
                                others within the organization without 
                                fear of retribution.
                                    ``(VI) The standards must have been 
                                consistently enforced through 
                                appropriate disciplinary mechanisms, 
                                including, as appropriate, discipline 
                                of individuals responsible for the 
                                failure to detect an offense.
                                    ``(VII) After an offense has been 
                                detected, the organization must have 
                                taken all reasonable steps to respond 
                                appropriately to the offense and to 
                                prevent further similar offenses, 
                                including any necessary modification to 
                                its program to prevent and detect 
                                criminal, civil, and administrative 
                                violations under this Act.
                                    ``(VIII) The organization must 
                                periodically undertake reassessment of 
                                its compliance program to identify 
                                changes necessary to reflect changes 
                                within the organization and its 
                                facilities.''.
            (2) 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) Compliance and ethics program.--
                            ``(i) Requirement.--On or after the date 
                        that is 36 months after the date of the 
                        enactment of this subparagraph, a nursing 
                        facility shall, with respect to the entity that 
                        operates the facility (in this subparagraph 
                        referred to as the `operating organization' or 
                        `organization'), have in operation a compliance 
                        and ethics program that is effective in 
                        preventing and detecting criminal, civil, and 
                        administrative violations under this Act and in 
                        promoting quality of care consistent with 
                        regulations developed under clause (ii).
                            ``(ii) Development of regulations.--
                                    ``(I) In general.--Not later than 
                                the date that is 2 years after such 
                                date of the enactment, the Secretary, 
                                in consultation with the Inspector 
                                General of the Department of Health and 
                                Human Services, shall develop 
                                regulations for an effective compliance 
                                and ethics program for operating 
                                organizations, which may include a 
                                model compliance program.
                                    ``(II)  Design of regulations.--
                                Such regulations with respect to 
                                specific elements or formality of a 
                                program may vary with the size of the 
                                organization, such that larger 
                                organizations should have a more formal 
                                program and include established written 
                                policies defining the standards and 
                                procedures to be followed by its 
                                employees. Such requirements may 
                                specifically apply to the corporate 
                                level management of multi unit nursing 
                                home chains.
                                    ``(III) Evaluation.--Not later than 
                                3 years after the date of promulgation 
                                of regulations under this clause the 
                                Secretary shall complete an evaluation 
                                of the compliance and ethics programs 
                                required to be established under this 
                                subparagraph. Such evaluation shall 
                                determine if such programs led to 
                                changes in deficiency citations, 
                                changes in quality performance, or 
                                changes in other metrics of patient 
                                quality of care. The Secretary shall 
                                submit to Congress a report on such 
                                evaluation and shall include in such 
                                report such recommendations regarding 
                                changes in the requirements for such 
                                programs as the Secretary determines 
                                appropriate.
                            ``(iii) Requirements for compliance and 
                        ethics programs.--In this subparagraph, the 
                        term `compliance and ethics program' means, 
                        with respect to a nursing facility, a program 
                        of the operating organization that--
                                    ``(I) has been reasonably designed, 
                                implemented, and enforced so that it 
                                generally will be effective in 
                                preventing and detecting criminal, 
                                civil, and administrative violations 
                                under this Act and in promoting quality 
                                of care; and
                                    ``(II) includes at least the 
                                required components specified in clause 
                                (iv).
                            ``(iv) Required components of program.--The 
                        required components of a compliance and ethics 
                        program of an organization are the following:
                                    ``(I) The organization must have 
                                established compliance standards and 
                                procedures to be followed by its 
                                employees and other agents that are 
                                reasonably capable of reducing the 
                                prospect of criminal, civil, and 
                                administrative violations under this 
                                Act.
                                    ``(II) Specific individuals within 
                                high-level personnel of the 
                                organization must have been assigned 
                                overall responsibility to oversee 
                                compliance with such standards and 
                                procedures and has sufficient resources 
                                and authority to assure such 
                                compliance.
                                    ``(III) The organization must have 
                                used due care not to delegate 
                                substantial discretionary authority to 
                                individuals whom the organization knew, 
                                or should have known through the 
                                exercise of due diligence, had a 
                                propensity to engage in criminal, 
                                civil, and administrative violations 
                                under this Act.
                                    ``(IV) The organization must have 
                                taken steps to communicate effectively 
                                its standards and procedures to all 
                                employees and other agents, such as by 
                                requiring participation in training 
                                programs or by disseminating 
                                publications that explain in a 
                                practical manner what is required.
                                    ``(V) The organization must have 
                                taken reasonable steps to achieve 
                                compliance with its standards, such as 
                                by utilizing monitoring and auditing 
                                systems reasonably designed to detect 
                                criminal, civil, and administrative 
                                violations under this Act by its 
                                employees and other agents and by 
                                having in place and publicizing a 
                                reporting system whereby employees and 
                                other agents could report violations by 
                                others within the organization without 
                                fear of retribution.
                                    ``(VI) The standards must have been 
                                consistently enforced through 
                                appropriate disciplinary mechanisms, 
                                including, as appropriate, discipline 
                                of individuals responsible for the 
                                failure to detect an offense.
                                    ``(VII) After an offense has been 
                                detected, the organization must have 
                                taken all reasonable steps to respond 
                                appropriately to the offense and to 
                                prevent further similar offenses, 
                                including any necessary modification to 
                                its program to prevent and detect 
                                criminal, civil, and administrative 
                                violations under this Act.
                                    ``(VIII) The organization must 
                                periodically undertake reassessment of 
                                its compliance program to identify 
                                changes necessary to reflect changes 
                                within the organization and its 
                                facilities.''.
    (b) Quality Assurance and Performance Improvement Program.--
            (1) Skilled nursing facilities.--Section 1819(b)(1)(B) of 
        the Social Security Act (42 U.S.C. 1395i-3(b)(1)(B)) is 
        amended--
                    (A) by striking ``Assurance.--A skilled nursing 
                facility'' and inserting ``Assurance and quality 
                assurance and performance improvement program.--
                            ``(i) In general.--A skilled nursing 
                        facility''; and
                    (B) by adding at the end the following new clause:
                            ``(ii) Quality assurance and performance 
                        improvement program.--
                                    ``(I) In general.--Not later than 
                                December 31, 2011, the Secretary shall 
                                establish and implement a quality 
                                assurance and performance improvement 
                                program (in this subparagraph referred 
                                to as the `QAPI program') for skilled 
                                nursing facilities, including multi 
                                unit chains of such facilities. Under 
                                the QAPI program, the Secretary shall 
                                establish standards relating to quality 
                                assurance and performance improvement 
                                with respect to such facilities and 
                                provide technical assistance to such 
                                facilities on the development of best 
                                practices in order to meet such 
                                standards. Not later than 1 year after 
                                the date on which the regulations are 
                                promulgated under subclause (II), a 
                                skilled nursing facility must submit to 
                                the Secretary a plan for the facility 
                                to meet such standards and implement 
                                such best practices, including how to 
                                coordinate the implementation of such 
                                plan with quality assessment and 
                                assurance activities conducted under 
                                clause (i).
                                    ``(II) Regulations.--The Secretary 
                                shall promulgate regulations to carry 
                                out this clause.''.
            (2) Nursing facilities.--Section 1919(b)(1)(B) of the 
        Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended--
                    (A) by striking ``Assurance.--A nursing facility'' 
                and inserting ``Assurance and quality assurance and 
                performance improvement program.--
                            ``(i) In general.--A nursing facility''; 
                        and
                    (B) by adding at the end the following new clause:
                            ``(ii) Quality assurance and performance 
                        improvement program.--
                                    ``(I) In general.--Not later than 
                                December 31, 2011, the Secretary shall 
                                establish and implement a quality 
                                assurance and performance improvement 
                                program (in this subparagraph referred 
                                to as the `QAPI program') for nursing 
                                facilities, including multi unit chains 
                                of such facilities. Under the QAPI 
                                program, the Secretary shall establish 
                                standards relating to quality assurance 
                                and performance improvement with 
                                respect to such facilities and provide 
                                technical assistance to such facilities 
                                on the development of best practices in 
                                order to meet such standards. Not later 
                                than 1 year after the date on which the 
                                regulations are promulgated under 
                                subclause (II), a nursing facility must 
                                submit to the Secretary a plan for the 
                                facility to meet such standards and 
                                implement such best practices, 
                                including how to coordinate the 
                                implementation of such plan with 
                                quality assessment and assurance 
                                activities conducted under clause (i).
                                    ``(II) Regulations.--The Secretary 
                                shall promulgate regulations to carry 
                                out this clause.''.

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) 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.
                            ``(ii) 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 links to the facility plan of 
                        correction or other response to such report.
                            ``(iii) 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.
                            ``(iv) A summary of information on 
                        enforcement that includes the number of 
                        complaints, including the number of such 
                        complaints which the Secretary finds are 
                        substantiated, and remedies proposed and 
                        imposed by the Secretary or a State with 
                        respect to a skilled nursing facility during 
                        the preceding 3 years.
                            ``(v) A summary of expenditures by skilled 
                        nursing facilities for wages and benefits of 
                        direct care staff (based on information 
                        submitted under section 1888(f)).
                    ``(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 the enactment of this subsection.
                            ``(ii) Exception.--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 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 the enactment of 
                        this subsection; and
                            ``(ii) not later than 1 year after the date 
                        of the 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 
                the 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) 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.
                            ``(ii) 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 links to the facility plan of 
                        correction or other response to such report.
                            ``(iii) 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.
                            ``(iv) A summary of information on 
                        enforcement that includes the number of 
                        complaints, including the number of such 
                        complaints which the Secretary finds are 
                        substantiated, and 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 the enactment of this subsection.
                            ``(ii) Exception.--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 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 the enactment of 
                        this subsection; and
                            ``(ii) not later than 1 year after the date 
                        of the 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 
                the 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:
                    ``(E) 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:
                    ``(E) 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 the 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 Direct Care Expenditures.--
            ``(1) In general.--For cost reports submitted under this 
        title for cost reporting periods beginning on or after the date 
        that is 2 years after the date of the enactment of this 
        subsection, skilled nursing facilities shall separately report 
        expenditures for wages and benefits for direct care staff 
        (breaking out (at a minimum) registered nurses, licensed 
        professional nurses, certified nurse assistants, and other 
        medical and therapy staff).
            ``(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) not later 
        than 1 year after the date of the enactment of this subsection.
            ``(3) Categorization by functional accounts.--Not later 
        than 30 months after the date of the enactment of this 
        subsection, the Secretary, working in consultation with the 
        Medicare Payment Advisory Commission, the Medicaid and CHIP 
        Payment and Access 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, as modified under 
        paragraph (1), submitted by skilled nursing facilities and 
        categorize such expenditures, regardless of any source of 
        payment for such expenditures, for each skilled nursing 
        facility into the following functional accounts on an annual 
        basis:
                    ``(A) Spending on direct care services (including 
                nursing, therapy, and medical services).
                    ``(B) Spending on indirect care (including 
                housekeeping and dietary services).
                    ``(C) Capital assets (including building and land 
                costs).
                    ``(D) Administrative services 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 the 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.--Beginning not later 
                than 2 years after the date of the enactment of this 
                subparagraph, and after consulting with State long-term 
                care ombudsman programs, consumer advocacy groups, 
                provider stakeholder groups, employees and their 
                representatives, and other parties the Secretary deems 
                appropriate, the Secretary shall require a skilled 
                nursing facility to electronically submit to the 
                Secretary direct care staffing information (including 
                information with respect to agency and contract staff) 
                based on payroll and other verifiable and auditable 
                data in a uniform format (according to specifications 
                established by the Secretary in consultation with such 
                programs, groups, and parties). 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, 
                        certified nursing assistant, therapist, or 
                        other medical personnel);
                            ``(ii) include resident census data and 
                        information on resident case mix;
                            ``(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 clause (i) per resident 
                        per day.
                Nothing in this subparagraph shall be construed as 
                preventing the Secretary from requiring submission of 
                such information with respect to specific categories, 
                such as nursing staff, before other categories of 
                certified employees. Information under this 
                subparagraph with respect to agency and contract staff 
                shall be kept separate from information on employee 
                staffing.''.
    (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.--Beginning not later 
                than 2 years after the date of the enactment of this 
                subparagraph, and after consulting with State long-term 
                care ombudsman programs, consumer advocacy groups, 
                provider stakeholder groups, employees and their 
                representatives, and other parties the Secretary deems 
                appropriate, the Secretary shall require a nursing 
                facility to electronically submit to the Secretary 
                direct care staffing information (including information 
                with respect to agency and contract staff) based on 
                payroll and other verifiable and auditable data in a 
                uniform format (according to specifications established 
                by the Secretary in consultation with such programs, 
                groups, and parties). 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, 
                        certified nursing assistant, therapist, or 
                        other medical personnel);
                            ``(ii) include resident census data and 
                        information on resident case mix;
                            ``(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 clause (i) per resident 
                        per day.
                Nothing in this subparagraph shall be construed as 
                preventing the Secretary from requiring submission of 
                such information with respect to specific categories, 
                such as nursing staff, before other categories of 
                certified employees. Information under this 
                subparagraph with respect to agency and contract staff 
                shall be kept separate from information on employee 
                staffing.''.

                    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--
                    (A) by striking ``Penalties.--The Secretary'' and 
                inserting ``penalties.--
                                    ``(I) In general.--Subject to 
                                subclause (II), the Secretary''; and
                    (B) by adding at the end the following new 
                subclauses:
                                    ``(II) Reduction of civil money 
                                penalties in certain circumstances.--
                                Subject to subclause (III), 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.
                                    ``(III) Prohibitions on reduction 
                                for certain deficiencies.--
                                            ``(aa) Repeat 
                                        deficiencies.--The Secretary 
                                        may not reduce the amount of a 
                                        penalty under subclause (II) 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 (II) if 
                                        the penalty is imposed on the 
                                        facility for a deficiency that 
                                        is found to result in a pattern 
                                        of harm or widespread harm, 
                                        immediately jeopardizes the 
                                        health or safety of a resident 
                                        or residents of the facility, 
                                        or results in the death of a 
                                        resident of the facility.
                                    ``(IV) Collection of civil money 
                                penalties.--In the case of a civil 
                                money penalty imposed under this 
                                clause, the Secretary shall issue 
                                regulations that--
                                            ``(aa) subject to item 
                                        (cc), not later than 30 days 
                                        after the imposition of the 
                                        penalty, provide for the 
                                        facility to have the 
                                        opportunity to participate in 
                                        an independent informal dispute 
                                        resolution process which 
                                        generates a written record 
                                        prior to the collection of such 
                                        penalty;
                                            ``(bb) in the case where 
                                        the penalty is imposed for each 
                                        day of noncompliance, provide 
                                        that a penalty may not be 
                                        imposed for any day during the 
                                        period beginning on the initial 
                                        day of the imposition of the 
                                        penalty and ending on the day 
                                        on which the informal dispute 
                                        resolution process under item 
                                        (aa) is completed;
                                            ``(cc) may provide for the 
                                        collection of such civil money 
                                        penalty and the placement of 
                                        such amounts collected in an 
                                        escrow account under the 
                                        direction of the Secretary 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;
                                            ``(dd) may provide that 
                                        such amounts collected are kept 
                                        in such account pending the 
                                        resolution of any subsequent 
                                        appeals;
                                            ``(ee) 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
                                            ``(ff) 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 of 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), projects 
                                        that support resident and 
                                        family councils and other 
                                        consumer involvement in 
                                        assuring quality care in 
                                        facilities, and facility 
                                        improvement initiatives 
                                        approved by the Secretary 
                                        (including joint training of 
                                        facility staff and surveyors, 
                                        technical assistance for 
                                        facilities implementing quality 
                                        assurance programs, the 
                                        appointment of temporary 
                                        management firms, and other 
                                        activities approved by the 
                                        Secretary).''.
            (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)(IV),'' after ``(i),''.
    (b) Nursing Facilities.--
            (1) In general.--Section 1919(h)(3)(C)(ii) of the Social 
        Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended--
                    (A) by striking ``Penalties.--The Secretary'' and 
                inserting ``penalties.--
                                    ``(I) In general.--Subject to 
                                subclause (II), the Secretary''; and
                    (B) by adding at the end the following new 
                subclauses:
                                    ``(II) Reduction of civil money 
                                penalties in certain circumstances.--
                                Subject to subclause (III), 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.
                                    ``(III) Prohibitions on reduction 
                                for certain deficiencies.--
                                            ``(aa) Repeat 
                                        deficiencies.--The Secretary 
                                        may not reduce the amount of a 
                                        penalty under subclause (II) 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 (II) if 
                                        the penalty is imposed on the 
                                        facility for a deficiency that 
                                        is found to result in a pattern 
                                        of harm or widespread harm, 
                                        immediately jeopardizes the 
                                        health or safety of a resident 
                                        or residents of the facility, 
                                        or results in the death of a 
                                        resident of the facility.
                                    ``(IV) Collection of civil money 
                                penalties.--In the case of a civil 
                                money penalty imposed under this 
                                clause, the Secretary shall issue 
                                regulations that--
                                            ``(aa) subject to item 
                                        (cc), not later than 30 days 
                                        after the imposition of the 
                                        penalty, provide for the 
                                        facility to have the 
                                        opportunity to participate in 
                                        an independent informal dispute 
                                        resolution process which 
                                        generates a written record 
                                        prior to the collection of such 
                                        penalty;
                                            ``(bb) in the case where 
                                        the penalty is imposed for each 
                                        day of noncompliance, provide 
                                        that a penalty may not be 
                                        imposed for any day during the 
                                        period beginning on the initial 
                                        day of the imposition of the 
                                        penalty and ending on the day 
                                        on which the informal dispute 
                                        resolution process under item 
                                        (aa) is completed;
                                            ``(cc) may provide for the 
                                        collection of such civil money 
                                        penalty and the placement of 
                                        such amounts collected in an 
                                        escrow account under the 
                                        direction of the Secretary 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;
                                            ``(dd) may provide that 
                                        such amounts collected are kept 
                                        in such account pending the 
                                        resolution of any subsequent 
                                        appeals;
                                            ``(ee) 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
                                            ``(ff) 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 of 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), projects 
                                        that support resident and 
                                        family councils and other 
                                        consumer involvement in 
                                        assuring quality care in 
                                        facilities, and facility 
                                        improvement initiatives 
                                        approved by the Secretary 
                                        (including joint training of 
                                        facility staff and surveyors, 
                                        technical assistance for 
                                        facilities implementing quality 
                                        assurance programs, the 
                                        appointment of temporary 
                                        management firms, and other 
                                        activities approved by the 
                                        Secretary).''.
            (2) 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)(IV),'' after ``(i),''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of the 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 the enactment 
of this Act, the Comptroller General of the United States shall submit 
to Congress and the Secretary a report 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 PILOT PROGRAM.

    (a) Establishment.--
            (1) In general.--The Secretary shall establish a pilot 
        program to develop, test, and implement an independent monitor 
        program to oversee interstate and large intrastate chains of 
        skilled nursing facilities and nursing facilities.
            (2) Selection.--The Secretary shall select chains of 
        skilled nursing facilities and nursing facilities described in 
        paragraph (1) to participate in the pilot program under this 
        section from among those chains that submit an application to 
        the Secretary at such time, in such manner, and containing such 
        information as the Secretary may require.
            (3) Duration.--The Secretary shall conduct the pilot 
        program under this section for a 2-year period.
            (4) Implementation.--The Secretary shall implement the 
        pilot program under this section not later than 1 year after 
        the date of the enactment of this Act.
    (b) Requirements.--The Secretary shall evaluate chains selected to 
participate in the pilot program under this section based on criteria 
selected by the Secretary, including where evidence suggests that 1 or 
more facilities of the chain are experiencing serious safety and 
quality of care problems. Such criteria may include the evaluation of a 
chain that includes 1 or more facilities participating in the ``Special 
Focus Facility'' program (or a successor program) or 1 or more 
facilities with a record of repeated serious safety and quality of care 
deficiencies.
    (c) Responsibilities.--An independent monitor that enters into a 
contract with the Secretary to participate in the conduct of the pilot 
program under this section shall--
            (1) conduct periodic reviews and prepare root-cause quality 
        and deficiency analyses of a chain to assess if facilities of 
        the chain are in compliance with State and Federal laws and 
        regulations applicable to the facilities;
            (2) undertake sustained oversight of the chain, whether 
        publicly or privately held, to involve the owners of, and any 
        additional disclosable party with respect to a facility of, the 
        chain in facilitating compliance by facilities of the chain 
        with State and Federal laws and regulations applicable to the 
        facilities;
            (3) analyze the management structure, distribution of 
        expenditures, and nurse staffing levels of facilities of the 
        chain in relation to resident census, staff turnover rates, and 
        tenure;
            (4) report 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; and
            (5) publish the results of such reviews, analyses, and 
        oversight.
    (d) Implementation of Recommendations.--
            (1) Receipt of finding by chain.--Not later than 10 days 
        after receipt of a finding of an independent monitor under 
        subsection (c)(4), a chain participating in the pilot program 
        shall submit to the independent monitor a report--
                    (A) outlining corrective actions the chain will 
                take to implement the recommendations in such report; 
                or
                    (B) indicating that the chain will not implement 
                such recommendations, and why it will not do so.
            (2) Receipt of report by independent monitor.--Not later 
        than 10 days after receipt of a report submitted by a chain 
        under paragraph (1), an 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.
    (e) Cost of Appointment.--A chain shall be responsible for a 
portion of the costs associated with the appointment of independent 
monitors under the pilot program under this section. The chain shall 
pay such portion to the Secretary (in an amount and in accordance with 
procedures established by the Secretary).
    (f) Waiver Authority.--The Secretary may waive such requirements of 
titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et 
seq.; 1396 et seq.) as may be necessary for the purpose of carrying out 
the pilot program under this section.
    (g) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as may be necessary to carry out this section.
    (h) Definitions.--In this section:
            (1) Additional disclosable party.--The term ``additional 
        disclosable party'' has the meaning given such term in section 
        1124(c)(5)(A) of the Social Security Act, as added by section 
        101(a).
            (2) Facility.--The term ``facility'' means a skilled 
        nursing facility or a nursing facility.
            (3) 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)).
            (4) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services, acting through the Assistant 
        Secretary for Planning and Evaluation.
            (5) 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)).
    (i) Evaluation and Report.--
            (1) Evaluation.--The Inspector General of the Department of 
        Health and Human Services shall evaluate the pilot program 
        conducted under this subsection. Such evaluation shall--
                    (A) determine whether the independent monitor 
                program should be established on a permanent basis; and
                    (B) if the Inspector General determines that such 
                program should be established on a permanent basis, 
                recommend appropriate procedures and mechanisms for 
                such establishment.
            (2) Report.--Not later than 180 days after the completion 
        of the pilot program under this section, the Inspector General 
        shall submit to Congress and the Secretary a report containing 
        the results of the evaluation conducted under paragraph (1), 
        together with recommendations for such legislation and 
        administrative action as the Inspector General determines 
        appropriate.

SEC. 204. 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 the enactment of this Act.

SEC. 205. 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) Duration and Implementation.--
            (1) Duration.--The demonstration projects shall each be 
        conducted for a period not to exceed 3 years.
            (2) Implementation.--The demonstration projects shall each 
        be implemented not later than 1 year after the date of the 
        enactment of this Act.
    (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 may be necessary to carry out this section.
    (f) Report.--Not later than 9 months after the completion of the 
demonstration project, the Secretary shall submit to Congress a report 
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.--
            (1) In general.--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)''.
            (2) Clarification of definition of nurse aide.--Section 
        1819(b)(5)(F) of the Social Security Act (42 U.S.C. 1395i-
        3(b)(5)(F)) is amended by adding at the end the following flush 
        sentence:
                ``Such term includes an individual who provides such 
                services through an agency or under a contract with the 
                facility.''.
    (b) Nursing Facilities.--
            (1) In general.--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 training'' before ``, (II)''.
            (2) Clarification of definition of nurse aide.--Section 
        1919(b)(5)(F) of the Social Security Act (42 U.S.C. 
        1396r(b)(5)(F)) is amended by adding at the end the following 
        flush sentence:
                ``Such term includes an individual who provides such 
                services through an agency or under a contract with the 
                facility.''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of the 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) Nurse aide.--The term ``nurse aide'' has the 
                meaning given such term in sections 1819(b)(5)(F) and 
                1919(b)(5)(F) of the Social Security Act (42 U.S.C. 
                1395i-3(b)(5)(F); 1396r(b)(5)(F)), as amended by 
                section 301.
                    (B) 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)).
                    (C) Secretary.--The term ``Secretary'' means the 
                Secretary of Health and Human Services, acting through 
                the Assistant Secretary for Planning and Evaluation.
                    (D) 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>