[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5216 Introduced in House (IH)]
<DOC>
116th CONGRESS
1st Session
H. R. 5216
To amend titles XVIII and XIX of the Social Security Act to revise
minimum nurse staffing requirements for skilled nursing facilities
under the Medicare program and for nursing facilities under the
Medicaid program, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
November 21, 2019
Ms. Schakowsky (for herself, Mrs. Hayes, Mr. Garamendi, Mr. Ryan, Mr.
Carson of Indiana, Ms. Moore, Ms. Roybal-Allard, Mrs. Carolyn B.
Maloney of New York, Mrs. Dingell, Ms. DeLauro, Ms. Bass, Ms. Johnson
of Texas, Mr. Danny K. Davis of Illinois, Mr. Hastings, Mr. Payne, Ms.
Matsui, Ms. Underwood, Ms. Jayapal, Ms. Pressley, Ms. Judy Chu of
California, Ms. Clarke of New York, Mr. Khanna, Mr. Deutch, Mr.
DeSaulnier, Ms. Lee of California, and Mr. Tonko) introduced the
following bill; which was referred to the Committee on Ways and Means,
and in addition to the Committee on Energy and Commerce, for a period
to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To amend titles XVIII and XIX of the Social Security Act to revise
minimum nurse staffing requirements for skilled nursing facilities
under the Medicare program and for nursing facilities under the
Medicaid program, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Quality Care for Nursing Home
Residents Act of 2019''.
SEC. 2. MINIMUM NURSE STAFFING REQUIREMENTS FOR SKILLED NURSING
FACILITIES UNDER MEDICARE PROGRAM AND NURSING FACILITIES
UNDER MEDICAID PROGRAM.
(a) Medicare.--
(1) In general.--Subparagraph (C) of section 1819(b)(4) of
the Social Security Act (42 U.S.C. 1395i-3(b)(4)) is amended--
(A) in clause (i)--
(i) by amending the clause heading to read
as follows: ``General requirements before
2020''; and
(ii) by striking ``Except as provided in
clause (ii),'' and inserting ``Except as
provided in clause (iii), with respect to
skilled nursing facility services provided
before January 1, 2020,'';
(B) by redesignating clause (ii) as clause (iii);
and
(C) by inserting after clause (i) the following new
clause:
``(ii) General requirements after 2019.--
``(I) In general.--With respect to
skilled nursing facility services
provided on or after January 1, 2020, a
skilled nursing facility must--
``(aa) provide nursing
services that are sufficient to
meet the nursing needs of its
residents on a 24-hour basis,
to be divided into day shifts,
evening shifts, and night
shifts;
``(bb) provide for minimum
nurse staffing levels with
respect to each such shift, in
accordance with this clause;
and
``(cc) ensure that, in
carrying out items (aa) and
(bb), a total minimum of 4.1
hours of care is provided per
resident per day, with 0.75
hours of care of such total
minimum provided by a
registered professional nurse,
0.54 hours of care of such
total minimum provided by a
licensed practical nurse, and
2.81 hours of care of such
total minimum provided by a
nurse aide (as defined in
paragraph (5)(F)).
``(II) Day shifts.--With respect to
a day shift, the skilled nursing
facility must have--
``(aa) at least 1
registered professional nurse
for every 28 residents, with a
minimum of 0.29 hours of care
provided per resident during
each such shift;
``(bb) at least 1 licensed
practical nurse for every 40
residents, with a minimum of
0.20 hours of care provided per
resident during each such
shift; and
``(cc) at least 1 nurse
aide (as defined in paragraph
(5)(F)) for every 7 residents,
with a minimum of 1.14 hours of
care provided per resident
during each such shift.
``(III) Evening shifts.--With
respect to an evening shift, the
skilled nursing facility must have--
``(aa) at least 1
registered professional nurse
for every 30 residents, with a
minimum of 0.26 hours of care
provided per resident during
each such shift;
``(bb) at least 1 licensed
practical nurse for every 40
residents, with a minimum of
0.20 hours of care provided per
resident during each such
shift; and
``(cc) at least 1 nurse
aide (as defined in paragraph
(5)(F)) for every 7 residents,
with a minimum of 1.14 hours of
care provided per resident
during each such shift.
``(IV) Night shifts.--With respect
to a night shift, the skilled nursing
facility must have--
``(aa) at least 1
registered professional nurse
for every 40 residents, with a
minimum of 0.20 hours of care
provided per resident during
such shift;
``(bb) at least 1 licensed
practical nurse for every 56
residents, with a minimum of
0.14 hours of care provided per
resident during such shift; and
``(cc) at least 1 nurse
aide (as defined in paragraph
(5)(F)) for every 15 residents,
with a minimum of 0.53 hours of
care provided per resident
during such shift.
``(V) Secretarial authority to
establish higher minimum nurse staffing
levels.--The Secretary may establish
and require skilled nursing facilities
(or, at the Secretary's discretion,
only skilled nursing facilities that
have a higher percentage of residents
with extensive care needs, as
determined by the Secretary) to provide
for minimum nurse staffing levels that
are higher than the levels required
under this clause.
``(VI) Rule of construction
regarding state authority to establish
higher minimum nurse staffing levels.--
Nothing in this clause may be construed
as preventing a State from establishing
or requiring skilled nursing facilities
in the State to provide for minimum
nurse staffing levels that are higher
than the levels required under this
clause.
``(VII) Clarification with respect
to minimum hours of care provided per
resident requirements.--In complying
with the minimum hours of care provided
per resident requirements under this
clause, a skilled nursing facility may
not count any time spent by a
registered professional nurse, licensed
practical nurse, or nurse aide on
administrative services towards
compliance with such requirements.
``(VIII) Definitions.--In this
clause:
``(aa) Administrative
services.--The term
`administrative services' means
food preparation, housekeeping,
laundry services, maintenance
services, and other
noncaregiving-related services,
as determined by the Secretary.
``(bb) Day shift.--The term
`day shift' means, with respect
to a day and a skilled nursing
facility, an assigned work
shift that is a period of 8
consecutive hours, beginning
not sooner than 6 a.m. in the
time zone in which such
facility is located and not
later than 8 a.m. in such time
zone.
``(cc) Evening shift.--The
term `evening shift' means,
with respect to a day and a
skilled nursing facility, an
assigned work shift that is a
period of 8 consecutive hours,
beginning not sooner than 2
p.m. in the time zone in which
such facility is located and
not later than 4 p.m. in such
time zone.
``(dd) Night shift.--The
term `night shift' means, with
respect to a day and a skilled
nursing facility, an assigned
work shift that is a period of
8 consecutive hours, beginning
not sooner than 10 p.m. in the
time zone in which such
facility is located and not
later than midnight in such
time zone.''.
(2) Enforcement.--Section 1819(h) of the Social Security
Act (42 U.S.C. 1395i-3(h)) is amended--
(A) in paragraph (1), by striking ``If a State
finds, on the basis of a standard'' and inserting
``Subject to paragraph (7), if a State finds, on the
basis of a standard'';
(B) in paragraph (2), by striking ``With respect
to'' and inserting ``Subject to paragraph (7), with
respect to''; and
(C) by adding at the end the following new
paragraph:
``(7) Special enforcement process with respect to minimum
nurse staffing requirements.--
``(A) In general.--If a State finds, on the basis
of a standard, extended, or partial extended survey
under subsection (g)(2) or otherwise, that a skilled
nursing facility does not meet the minimum staffing
requirements of clause (ii) of subsection (b)(4)(C)
with respect to skilled nursing facility services
provided on or after January 1, 2020, the State shall
recommend to the Secretary that the Secretary take such
actions as described in subclauses (I) and (II) of
subparagraph (B)(i).
``(B) Secretarial authority.--
``(i) In general.--With respect to any
skilled nursing facility in a State, if the
Secretary finds, or pursuant to a
recommendation of the State under subparagraph
(A) finds, that a skilled nursing facility does
not meet the minimum staffing requirements of
clause (ii) of subsection (b)(4)(C) with
respect to skilled nursing facility services
provided on or after January 1, 2020, the
Secretary shall--
``(I) deny any further payments
under this title with respect to all
individuals entitled to benefits under
this title who are admitted to the
facility after the effective date of
the finding; and
``(II) impose a civil money penalty
in an amount not to exceed $10,000 for
each day of noncompliance. The
provisions of section 1128A (other than
subsections (a) and (b)) shall apply to
a civil money penalty under the
previous sentence in the same manner as
such provisions apply to a penalty or
proceeding under section 1128A(a).
``(ii) Reduction of civil money penalties
in certain circumstances.--Subject to clause
(iii), in the case where a skilled nursing
facility self-reports and promptly corrects a
deficiency for which a penalty was imposed
under clause (i)(II) not later than 10 calendar
days after the date of such imposition, the
Secretary may reduce the amount of the penalty
imposed by--
``(I) not more than 50 percent; or
``(II) in the case that the
facility was penalized under this
subsection within the three-year period
preceding the date of such imposition,
not more than 25 percent.
``(iii) Prohibitions on reduction for
certain deficiencies.--
``(I) Repeat deficiencies.--The
Secretary may not reduce the amount of
a penalty under clause (ii) if the
Secretary had reduced a penalty imposed
on the skilled nursing facility in the
preceding year under such clause with
respect to a repeat deficiency.
``(II) Certain other
deficiencies.--The Secretary may not
reduce the amount of a penalty under
clause (ii) if the penalty is imposed
on the skilled nursing 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) Repeated noncompliance.--In the case
of a skilled nursing facility which, on three
consecutive standard surveys conducted under
subsection (g)(2), has been found as not
meeting the minimum staffing requirements of
clause (ii) of subsection (b)(4)(C) with
respect to skilled nursing facility services
provided on or after January 1, 2020, the
Secretary may (regardless of the remedies
provided for under clause (i))--
``(I) appoint temporary management
to oversee the operation of the
facility and to assure the health and
safety of the facility's residents in
accordance with clause (iii) of
paragraph (2)(B), except that `the
minimum staffing requirements of clause
(ii) of subsection (b)(4)(C)' shall be
substituted for `all the requirements
of subsections (b), (c), and (d)' under
such clause;
``(II) monitor the facility under
subsection (g)(4)(B) with respect to
such minimum staffing requirements
until the facility has demonstrated to
the satisfaction of the Secretary that
the facility is in compliance, and will
remain in compliance, with such minimum
staffing requirements; or
``(III) subject to section
1128I(h), terminate the facility's
participation under this title.
If the facility's participation under this
title is terminated under this clause, the
State shall provide for the safe and orderly
transfer of the residents eligible under this
title, consistent with the requirements of
subsection (c)(2) and section 1128I(h).
``(v) Public notice of violations.--
``(I) Internet website.--The
Secretary shall publish on the internet
website of the Department of Health and
Human Services the names of skilled
nursing facilities that have violated
the minimum staffing requirements of
clause (ii) of subsection (b)(4)(C)
with respect to skilled nursing
facility services provided on or after
January 1, 2020.
``(II) Change of ownership.--With
respect to a skilled nursing facility
whose name is published under subclause
(I) and has a change of ownership, as
determined by the Secretary, after the
date of such publication, the Secretary
shall remove the name of such facility
from the website described under such
subclause after the 1-year period
beginning on the date of such change of
ownership.''.
(3) Conforming amendment.--Item (a) of section
1819(f)(2)(B)(iii)(I) of the Social Security Act (42 U.S.C.
1395i-3(f)(2)(B)(iii)(I)) is amended by striking ``subsection
(b)(4)(C)(ii)(II)'' and inserting ``subsection
(b)(4)(C)(iii)(II)''.
(b) Medicaid.--
(1) In general.--Subparagraph (C) of section 1919(b)(4) of
the Social Security Act (42 U.S.C. 1396r(b)(4)) is amended--
(A) in clause (i)--
(i) in the clause heading, by inserting
after ``General requirements'' the following
``before 2020'';
(ii) in the matter preceding subclause (I),
by inserting after ``October 1, 1990,'' the
following: ``and before January 1, 2020,'';
(iii) in subclause (I), by striking
``clause (ii)'' and inserting ``clause (iii)'';
and
(iv) in subclause (II), by striking
``clause (ii)'' and inserting ``clause (iii)'';
(B) by redesignating clauses (ii) and (iii) as
clauses (iii) and (iv), respectively; and
(C) by inserting after clause (i) the following new
clause:
``(ii) General requirements after 2019.--
``(I) In general.--With respect to
nursing facility services provided on
or after January 1, 2020, a nursing
facility must--
``(aa) provide nursing
services that are sufficient to
meet the nursing needs of its
residents on a 24-hour basis,
to be divided into day shifts,
evening shifts, and night
shifts;
``(bb) provide for minimum
nurse staffing levels with
respect to each such shift, in
accordance with this clause;
and
``(cc) ensure that, in
carrying out items (aa) and
(bb), a total minimum of 4.1
hours of care is provided per
resident per day, with 0.75
hours of care of such total
minimum provided by a
registered professional nurse,
0.54 hours of care of such
total minimum provided by a
licensed practical nurse, and
2.81 hours of care of such
total minimum provided by a
nurse aide (as defined in
paragraph (5)(F)).
``(II) Day shifts.--With respect to
a day shift, the nursing facility must
have--
``(aa) at least 1
registered professional nurse
for every 28 residents, with a
minimum of 0.29 hours of care
provided per resident during
each such shift;
``(bb) at least 1 licensed
practical nurse for every 40
residents, with a minimum of
0.20 hours of care provided per
resident during each such
shift; and
``(cc) at least 1 nurse
aide (as defined in paragraph
(5)(F)) for every 7 residents,
with a minimum of 1.14 hours of
care provided per resident
during each such shift.
``(III) Evening shifts.--With
respect to an evening shift, the
nursing facility must have--
``(aa) at least 1
registered professional nurse
for every 30 residents, with a
minimum of 0.26 hours of care
provided per resident during
each such shift;
``(bb) at least 1 licensed
practical nurse for every 40
residents, with a minimum of
0.20 hours of care provided per
resident during each such
shift; and
``(cc) at least 1 nurse
aide (as defined in paragraph
(5)(F)) for every 7 residents,
with a minimum of 1.14 hours of
care provided per resident
during each such shift.
``(IV) Night shifts.--With respect
to a night shift, the nursing facility
must have--
``(aa) at least 1
registered professional nurse
for every 40 residents, with a
minimum of 0.20 hours of care
provided per resident during
such shift;
``(bb) at least 1 licensed
practical nurse for every 56
residents, with a minimum of
0.14 hours of care provided per
resident during such shift; and
``(cc) at least 1 nurse
aide (as defined in paragraph
(5)(F)) for every 15 residents,
with a minimum of 0.53 hours of
care provided per resident
during such shift.
``(V) Secretarial authority to
establish higher minimum nurse staffing
levels.--The Secretary may establish
and require nursing facilities (or, at
the Secretary's discretion, only
nursing facilities that have a higher
percentage of residents with extensive
care needs, as determined by the
Secretary) to provide for minimum nurse
staffing levels that are higher than
the levels required under this clause.
``(VI) Rule of construction
regarding state authority to establish
higher minimum nurse staffing levels.--
Nothing in this clause may be construed
as preventing a State from establishing
or requiring nursing facilities in the
State to provide for minimum nurse
staffing levels that are higher than
the levels required under this clause.
``(VII) Clarification with respect
to minimum hours of care provided per
resident requirements.--In complying
with the minimum hours of care provided
per resident requirements under this
clause, a nursing facility may not
count any time spent by a registered
professional nurse, licensed practical
nurse, or nurse aide on administrative
services towards compliance with such
requirements.
``(VIII) Definitions.--In this
clause:
``(aa) Administrative
services.--The term
`administrative services' means
food preparation, housekeeping,
laundry services, maintenance
services, and other
noncaregiving-related services,
as determined by the Secretary.
``(bb) Day shift.--The term
`day shift' means, with respect
to a day and a nursing
facility, an assigned work
shift that is a period of 8
consecutive hours, beginning
not sooner than 6 a.m. in the
time zone in which such
facility is located and not
later than 8 a.m. in such time
zone.
``(cc) Evening shift.--The
term `evening shift' means,
with respect to a day and a
nursing facility, an assigned
work shift that is a period of
8 consecutive hours, beginning
not sooner than 2 p.m. in the
time zone in which such
facility is located and not
later than 4 p.m. in such time
zone.
``(dd) Night shift.--The
term `night shift' means, with
respect to a day and a nursing
facility, an assigned work
shift that is a period of 8
consecutive hours, beginning
not sooner than 10 p.m. in the
time zone in which such
facility is located and not
later than midnight in such
time zone.''.
(2) Enforcement.--Section 1919(h) of the Social Security
Act (42 U.S.C. 1396r(h)) is amended--
(A) in paragraph (1), by striking ``If a State
finds, on the basis of a standard'' and inserting
``Subject to paragraph (10), if a State finds, on the
basis of a standard'';
(B) in paragraph (2)--
(i) in subparagraph (C), by striking ``If a
nursing facility'' and inserting ``Subject to
paragraph (10), if a nursing facility''; and
(ii) in subparagraph (D), by striking ``In
the case of'' and inserting ``Subject to
paragraph (10), in the case of'';
(C) in paragraph (3)--
(i) in subparagraph (A), by inserting
before the period the following: ``and the
remedies described in paragraph (10)(B)''; and
(ii) in subparagraph (B), by striking
``With respect to'' and inserting ``Subject to
paragraph (10), with respect to''; and
(D) by adding at the end the following new
paragraph:
``(10) Special enforcement process with respect to minimum
nurse staffing requirements.--
``(A) In general.--If a State finds, on the basis
of a standard, extended, or partial extended survey
under subsection (g)(2) or otherwise, that a nursing
facility does not meet the minimum staffing
requirements of clause (ii) of subsection (b)(4)(C)
with respect to nursing facility services provided on
or after January 1, 2020, the State shall--
``(i) deny any further payments under the
State plan with respect to all individuals
enrolled under such plan who are admitted to
the facility after the effective date of the
finding; and
``(ii) recommend to the Secretary that the
Secretary impose the civil money penalty
described in subparagraph (B).
``(B) Secretarial authority.--
``(i) In general.--With respect to any
nursing facility in a State other than a State
nursing facility, if the Secretary finds that
such a nursing facility does not meet the
minimum staffing requirements of clause (ii) of
subsection (b)(4)(C) with respect to nursing
facility services provided on or after January
1, 2020, the Secretary shall--
``(I) deny any further payments to
the State for medical assistance
furnished by the facility to all
individuals enrolled under the State
plan who are admitted to the facility
after the effective date of the
finding; and
``(II) impose a civil money penalty
in an amount not to exceed $10,000 for
each day of noncompliance. The
provisions of section 1128A (other than
subsections (a) and (b)) shall apply to
a civil money penalty under the
previous sentence in the same manner as
such provisions apply to a penalty or
proceeding under section 1128A(a).
``(ii) Reduction of civil money penalties
in certain circumstances.--Subject to clause
(iii), in the case where a nursing facility
self-reports and promptly corrects a deficiency
for which a penalty was imposed under clause
(i)(II) not later than 10 calendar days after
the date of such imposition, the Secretary may
reduce the amount of the penalty imposed by--
``(I) not more than 50 percent; or
``(II) in the case that the
facility was penalized under this
subsection within the three-year period
preceding the date of such imposition,
not more than 25 percent.
``(iii) Prohibitions on reduction for
certain deficiencies.--
``(I) Repeat deficiencies.--The
Secretary may not reduce the amount of
a penalty under clause (ii) if the
Secretary had reduced a penalty imposed
on the nursing facility in the
preceding year under such clause with
respect to a repeat deficiency.
``(II) Certain other
deficiencies.--The Secretary may not
reduce the amount of a penalty under
clause (ii) if the penalty is imposed
on the nursing 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) Repeated noncompliance.--In the case
of a nursing facility which, on three
consecutive standard surveys conducted under
subsection (g)(2), has been found as not
meeting the minimum staffing requirements of
clause (ii) of subsection (b)(4)(C) with
respect to nursing facility services provided
on or after January 1, 2020, the Secretary may
(regardless of the remedies provided for under
clause (i))--
``(I) appoint temporary management
to oversee the operation of the
facility and to assure the health and
safety of the facility's residents in
accordance with clause (iii) of
paragraph (3)(C), except that `the
minimum staffing requirements of clause
(ii) of subsection (b)(4)(C)' shall be
substituted for `all the requirements
of subsections (b), (c), and (d)' under
such clause;
``(II) monitor the facility under
subsection (g)(4)(B) with respect to
such minimum staffing requirements
until the facility has demonstrated to
the satisfaction of the Secretary that
the facility is in compliance, and will
remain in compliance, with such minimum
staffing requirements; or
``(III) subject to section
1128I(h), terminate the facility's
participation under this title.
If the facility's participation under this
title is terminated under this clause, the
State shall provide for the safe and orderly
transfer of the residents eligible under this
title, consistent with the requirements of
subsection (c)(2) and section 1128I(h).
``(v) Public notice of violations.--
``(I) Internet website.--The
Secretary shall publish on the internet
website of the Department of Health and
Human Services the names of nursing
facilities that have violated the
minimum staffing requirements of clause
(ii) of subsection (b)(4)(C) with
respect to skilled nursing facility
services provided on or after January
1, 2020.
``(II) Change of ownership.--With
respect to a nursing facility whose
name is published under subclause (I)
and has a change of ownership, as
determined by the Secretary, after the
date of such publication, the Secretary
shall remove the name of such facility
from the website described under such
subclause after the 1-year period
beginning on the date of such change of
ownership.''.
(3) Conforming amendments.--
(A) Clause (iii) of section 1919(b)(4)(C) of the
Social Security Act (42 U.S.C. 1396r(b)(4)(C)), as
redesignated by paragraph (1)(B), is amended by
striking ``subject to clause (iii)'' and inserting
``subject to clause (iv)''.
(B) Item (a) of section 1919(f)(2)(B)(iii)(I) of
the Social Security Act (42 U.S.C.
1396r(f)(2)(B)(iii)(I)) is amended by striking
``subsection (b)(4)(C)(ii)'' and inserting ``subsection
(b)(4)(C)(iii)''.
(C) Paragraph (9) of section 1919(f) of the Social
Security Act (42 U.S.C. 1396r(f)) is amended by
striking ``subsection (b)(4)(C)(ii)'' and inserting
``subsection (b)(4)(C)(iii)''.
(c) Studies and Reports Regarding Impact of Minimum Nurse Staffing
Requirements.--
(1) Initial study and report.--
(A) In general.--Not later than June 1, 2021, the
Secretary of Health and Human Services shall study and
submit to the Committee on Energy and Commerce and the
Committee on Ways and Means of the House of
Representatives and the Committee on Finance of the
Senate a publicly available report--
(i) on the impact of the minimum nurse
staffing requirements added by subsection (a)
on the reimbursement levels of skilled nursing
facilities under the Medicare program under
title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) and the adequacy of
personnel numbers in such skilled nursing
facilities to meet such minimum nurse staffing
requirements;
(ii) on the impact of the minimum nurse
staffing requirements added by subsection (b)
on the reimbursement levels of nursing
facilities under the Medicaid program under
title XIX of the Social Security Act (42 U.S.C.
1396 et seq.) and the adequacy of personnel
numbers in such nursing facilities to meet such
minimum nurse staffing requirements; and
(iii) including recommendations on the
steps that such skilled nursing facilities and
nursing facilities can take to ensure that
adequate personnel are available in such
skilled nursing facilities and nursing
facilities to meet the minimum nurse staffing
requirements added by subsections (a) and (b)
for such skilled nursing facilities and nursing
facilities, respectively, including methods for
attracting and retaining such personnel.
(B) Considerations.--In conducting the study
required under subparagraph (A), the Secretary of
Health and Human Services shall take into
consideration--
(i) the benefits of any increase in nurse
staffing levels, including with respect to
workforce training and retention;
(ii) any decrease in the rate of workplace
injuries;
(iii) any changes in medical care costs for
residents of skilled nursing facilities and
nursing facilities;
(iv) any decrease in hospitalization rates
for such residents;
(v) any changes in personnel and
administrative costs for skilled nursing
facilities and nursing facilities; and
(vi) any changes in recruiting and training
costs.
(2) Subsequent study and report.--Not later than January 1,
2023, the Secretary of Health and Human Services shall conduct
a follow-up study to the study conducted under paragraph (1)(A)
and submit to the Committee on Energy and Commerce and the
Committee on Ways and Means of the House of Representatives and
the Committee on Finance of the Senate a publicly available
report on such follow-up study.
SEC. 3. DISCLOSURE OF NURSE STAFFING LEVELS AT SKILLED NURSING
FACILITIES UNDER MEDICARE PROGRAM AND NURSING FACILITIES
UNDER MEDICAID PROGRAM.
(a) Medicare.--Paragraph (8) of section 1819(b) of the Social
Security Act (42 U.S.C. 1395i-3(b)) is amended to read as follows:
``(8) Information on nurse staffing.--
``(A) In general.--Each day, a skilled nursing
facility shall post for each shift notices with--
``(i) a description of the nurse staffing
requirements applicable with respect to the
facility and day under paragraph (4)(C);
``(ii) information on the number of
registered professional nurses, licensed
practical nurses, and nurse aides (as defined
in paragraph (5)(F)) assigned to provide direct
care services to residents in the facility
during the shift, disaggregated by units in the
facility; and
``(iii) a statement that the facility is
required, upon request, to provide any nurse
staffing information (as described in this
subparagraph) of the facility from the
preceding 12-month period.
The information in such notices shall be written in a
uniform manner, printed in an easily readable 14-point
type font, and made available in appropriate languages,
as determined by the Secretary. The skilled nursing
facility shall make such notices available at each
nurses' station in the facility and other areas in each
unit of the facility, as determined appropriate by the
facility, and shall keep and maintain each such notice
for at least three years after the date on which each
such notice is posted in the facility.
``(B) Public availability of information.--A
skilled nursing facility shall, upon request, make
available to the public any nurse staffing information
(as described in subparagraph (A)) of the facility from
the preceding 12-month period. In the case that the
facility makes such information available as a paper
copy, such facility may not charge for such copy an
amount greater than the cost of making such copy.''.
(b) Medicaid.--Paragraph (8) of section 1919(b) of the Social
Security Act (42 U.S.C. 1396r(b)) is amended to read as follows:
``(8) Information on nurse staffing.--
``(A) In general.--Each day, a skilled nursing
facility shall post for each shift notices with--
``(i) a description of the nurse staffing
requirements applicable with respect to the
facility and day under paragraph (4)(C);
``(ii) information on the number of
registered professional nurses, licensed
practical nurses, and nurse aides (as defined
in paragraph (5)(F)) assigned to provide direct
care services to residents in the facility
during the shift, disaggregated by units in the
facility; and
``(iii) a statement that the facility is
required, upon request, to provide any nurse
staffing information (as described in this
subparagraph) of the facility from the
preceding 12-month period.
The information in such notices shall be written in a
uniform manner, printed in an easily readable 14-point
type font, and made available in appropriate languages,
as determined by the Secretary. The skilled nursing
facility shall make such notices available at each
nurses' station in the facility and other areas in each
unit of the facility, as determined appropriate by the
facility, and shall keep and maintain each such notice
for at least three years after the date on which each
such notice is posted in the facility.
``(B) Public availability of information.--A
skilled nursing facility shall, upon request, make
available to the public any nurse staffing information
(as described in subparagraph (A)) of the facility from
the preceding 12-month period.''.
(c) Effective Date.--The amendments made by this section take
effect on the date of enactment of this Act and apply with respect to
nurse staffing information posted or requested on or after the date
that is one year after such date of enactment.
SEC. 4. ADMINISTRATIVE STAFFING REQUIREMENTS FOR SKILLED NURSING
FACILITIES UNDER MEDICARE PROGRAM AND NURSING FACILITIES
UNDER MEDICAID PROGRAM.
(a) Medicare.--Paragraph (1) of section 1819(d) of the Social
Security Act (42 U.S.C. 1395i-3(d)) is amended--
(1) by redesignating the second subparagraph (C) as
subparagraph (E); and
(2) by inserting after the first subparagraph (C) the
following new subparagraph:
``(D) Nursing management personnel.--
``(i) In general.--A skilled nursing
facility must employ nursing management
personnel in accordance with this subparagraph.
``(ii) Director of nursing services.--A
skilled nursing facility must employ a
registered professional nurse to serve full-
time as the director of nursing services of the
facility. Such director of nursing services
shall be responsible for determining the number
and types of nursing personnel needed to
sufficiently meet the nursing needs of the
residents of the facility (as required under
subsection (b)(4)(C)).
``(iii) Assistant director of nursing
services.--A skilled nursing facility must
employ a registered professional nurse to serve
full-time as the assistant director of nursing
services of the facility, except that in the
case of a skilled nursing facility that has
fewer than 100 beds, such facility may employ a
registered professional nurse to serve part-
time as the assistant director of nursing
services of the facility. A registered
professional nurse who serves as the assistant
director of nursing services of a skilled
nursing facility may also serve as a supervisor
for direct clinical nursing care for such
facility.
``(iv) Director of in-service education.--A
skilled nursing facility must employ a
registered professional nurse to serve full-
time as the director of in-service education of
the facility, except that in the case of a
skilled nursing facility that has fewer than
100 beds, such facility may employ a registered
professional nurse to serve part-time as the
director of in-service education of the
facility. In carrying out the previous
sentence, a skilled nursing facility must, to
the extent practicable and appropriate, employ
a registered professional nurse who has
received training in adult education and
gerontology.''.
(b) Medicaid.--
(1) In general.--Paragraph (1) of section 1919(d) of the
Social Security Act (42 U.S.C. 1396r(d)) is amended by
inserting after subparagraph (C) the following new
subparagraph:
``(D) Nursing management personnel.--
``(i) In general.--A nursing facility must
employ nursing management personnel in
accordance with this subparagraph.
``(ii) Director of nursing services.--A
nursing facility must employ a registered
professional nurse to serve full-time as the
director of nursing services of the facility.
Such director of nursing services shall be
responsible for determining the number and
types of nursing personnel needed to
sufficiently meet the nursing needs of the
residents of the facility (as required under
subsection (b)(4)(C)).
``(iii) Assistant director of nursing
services.--A nursing facility must employ a
registered professional nurse to serve full-
time as the assistant director of nursing
services of the facility, except that in the
case of a nursing facility that has fewer than
100 beds, such facility may employ a registered
professional nurse to serve part-time as the
assistant director of nursing services of the
facility. A registered professional nurse who
serves as the assistant director of nursing
services of a nursing facility may also serve
as a supervisor for direct clinical nursing
care for such facility.
``(iv) Director of in-service education.--A
nursing facility must employ a registered
professional nurse to serve full-time as the
director of in-service education of the
facility, except that in the case of a nursing
facility that has fewer than 100 beds, such
facility may employ a registered professional
nurse to serve part-time as the director of in-
service education of the facility. In carrying
out the previous sentence, a nursing facility
must, to the extent practicable and
appropriate, employ a registered professional
nurse who has received training in adult
education and gerontology.''.
(2) Technical amendment.--Paragraph (1) of section 1919(d)
of the Social Security Act (42 U.S.C. 1396r(d)) is amended by
redesignating subparagraph (V) as subparagraph (E).
(c) Effective Date.--The amendments made by this section take
effect on the date of enactment of this Act and apply with respect to
the administration of skilled nursing facilities and nursing facilities
on or after the date that is one year after such date of enactment.
SEC. 5. NURSE TRAINING REQUIREMENTS WITH RESPECT TO SKILLED NURSING
FACILITIES UNDER MEDICARE PROGRAM AND NURSING FACILITIES
UNDER MEDICAID PROGRAM.
(a) Medicare.--
(1) Orientation for registered professional nurses,
licensed practical nurses, and nurse aides.--Section 1819(d) of
the Social Security Act (42 U.S.C. 1395i-3(d)) is amended by
adding at the end the following new paragraph:
``(5) Orientations.--A skilled nursing facility must
provide to registered professional nurses, licensed practical
nurses, and nurse aides, before such registered professional
nurses, licensed practical nurses, and nurse aides are assigned
to provide direct care services to residents in the facility,
orientations providing education on the policies and emergency
procedures of the facility and on residents' rights under this
section.''.
(2) Requirements for nurse aide training and competency
evaluation programs and for nurse aide competency evaluation
programs.--Subparagraph (A) of section 1819(f)(2) of the Social
Security Act (42 U.S.C. 1395i-3(f)(2)) is amended--
(A) in the matter preceding clause (i), by
inserting after ``1988'' the following: ``, and update,
as determined necessary by the Secretary'';
(B) in clause (i)--
(i) by inserting after ``care of
cognitively impaired residents,'' the
following: ``care of older adults,'';
(ii) by striking ``patient abuse prevention
training,'' and inserting ``patient abuse
prevention training),''; and
(iii) by striking ``75 hours'' and
inserting ``120 hours''; and
(C) in clause (ii)--
(i) by striking ``requirement relating to''
and inserting ``requirements relating to (I)'';
(ii) by inserting after ``care of
cognitively impaired residents,'' the
following: ``care of older adults,''; and
(iii) by striking ``and procedures'' and
inserting ``(II) minimum hours of initial and
ongoing training and retraining (including not
less than 120 hours in the case of initial
training), and (III) procedures''.
(b) Medicaid.--
(1) Orientation for registered professional nurses,
licensed practical nurses, and nurse aides.--Section 1919(d) of
the Social Security Act (42 U.S.C. 1396r(d)) is amended by
adding at the end the following new paragraph:
``(5) Orientations.--A nursing facility must provide to
registered professional nurses, licensed practical nurses, and
nurse aides, before such registered professional nurses,
licensed practical nurses, and nurse aides are assigned to
provide direct care services to residents in the facility,
orientations providing education on the policies and emergency
procedures of the facility and on residents' rights under this
section.''.
(2) Requirements for nurse aide training and competency
evaluation programs and for nurse aide competency evaluation
programs.--Subparagraph (A) of section 1919(f)(2) of the Social
Security Act (42 U.S.C. 1396r(f)(2)) is amended--
(A) in the matter preceding clause (i), by
inserting after ``1988'' the following: ``, and update,
as determined necessary by the Secretary'';
(B) in clause (i)--
(i) by inserting after ``care of
cognitively impaired residents,'' the
following: ``care of older adults,'';
(ii) by striking ``patient abuse prevention
training,'' and inserting ``patient abuse
prevention training),''; and
(iii) by striking ``75 hours'' and
inserting ``120 hours''; and
(C) in clause (ii)--
(i) by striking ``requirement relating to''
and inserting ``requirements relating to (I)'';
(ii) by inserting after ``care of
cognitively impaired residents,'' the
following: ``care of older adults,''; and
(iii) by striking ``and procedures'' and
inserting ``(II) minimum hours of initial and
ongoing training and retraining (including not
less than 120 hours in the case of initial
training), and (III) procedures''.
(c) Effective Date.--The amendments made by this section take
effect on the date of enactment of this Act and shall apply with
respect to nurse aide training and competency evaluation programs,
nurse aide competency evaluation programs, and nurse orientations
conducted on or after the date that is one year after such date of
enactment.
SEC. 6. WHISTLEBLOWER AND RESIDENT PROTECTIONS.
(a) Medicare.--Section 1819 of the Social Security Act (42 U.S.C.
1395i-3) is amended by adding at the end the following new subsection:
``(k) Whistleblower and Resident Protections.--
``(1) Statement regarding professional obligation and
rights.--All nurses employed by a skilled nursing facility have
a duty and right to act based on their professional judgment in
accordance with the nursing laws and regulations of the State
in which such facility is located, to provide nursing care in
the exclusive interests of the residents of the facility, and
to act as the residents' advocate.
``(2) Objection to or refusal of work assignment.--A nurse
may object to, or refuse to participate in, any activity,
policy, practice, assignment, or task (referred to in this
subsection as a `work assignment') if--
``(A) the nurse reasonably believes such work
assignment to be in violation of the minimum nurse
staffing requirements of clause (ii) of subsection
(b)(4)(C); or
``(B) the nurse reasonably believes that the nurse
is not prepared by education, training, or experience
to perform or comply with such work assignment without
compromising the safety of a resident or jeopardizing
the license of the nurse.
``(3) Retaliation for objection to or refusal of work
assignment barred.--
``(A) No discharge, discrimination, or
retaliation.--No skilled nursing facility may
discharge, retaliate, discriminate, or otherwise take
adverse action in any manner with respect to any aspect
of a nurse's employment with the facility, including
discharge, promotion, compensation, or terms,
conditions, or privileges of employment, based on the
nurse's objection to, or refusal of, a work assignment
under paragraph (2).
``(B) No filing of complaint.--No skilled nursing
facility may file a complaint or a report against a
nurse with a State professional disciplinary agency
because of the nurse's objection to, or refusal of, a
work assignment under paragraph (2).
``(4) Cause of action.--Any nurse (or a collective
bargaining representative or legal representative of such
nurse) against whom a skilled nursing facility has taken an
adverse action in violation of paragraph (3)(A), or against
whom such facility has filed a complaint or report in violation
of paragraph (3)(B), may (without regard to whether a complaint
has been filed under paragraph (5) or (10)(B)) bring a cause of
action in an appropriate district court of the United States.
The legal burdens of proof specified in section 1221(e) of
title 5, United States Code, shall be controlling for the
purposes of any cause of action brought under this paragraph. A
nurse who prevails on the cause of action may be entitled to
one or more of the following:
``(A) Reinstatement.
``(B) Reimbursement of lost wages, compensation,
and benefits.
``(C) Attorneys' fees.
``(D) Court costs.
``(E) Other damages.
``(5) Complaint to secretary.--Any individual may file a
complaint with the Secretary against a skilled nursing facility
that violates a requirement described in paragraph (3). For any
complaint filed, the Secretary shall--
``(A) receive and investigate the complaint;
``(B) determine whether a violation of such
paragraph, as alleged in the complaint, has occurred;
and
``(C) in the case that the Secretary determines
that such a violation has occurred, issue an order that
the complaining individual may not suffer any adverse
action prohibited by paragraph (3) or (7).
``(6) Toll-free telephone number.--
``(A) In general.--The Secretary shall provide for
the establishment of a toll-free telephone hotline to
provide information regarding the minimum nurse
staffing requirements of clause (ii) of subsection
(b)(4)(C) and to receive reports of violations of such
requirements.
``(B) Notice to residents.--A skilled nursing
facility shall provide each resident admitted to the
facility with the telephone number of the hotline
described in subparagraph (A) and give notice to each
such resident that such hotline may be used to report
inadequate staffing.
``(7) Protection for reporting.--
``(A) Prohibition on retaliation or
discrimination.--A skilled nursing facility may not
retaliate or discriminate in any manner against any
resident, employee, or contract employee of the
facility, or any other individual, on the basis that
such resident, employee, contract employee, or
individual (individually or in conjunction with another
individual) has, in good faith--
``(i) presented a grievance or complaint;
``(ii) initiated or cooperated in any
investigation or proceeding of any governmental
entity, regulatory agency, or private
accreditation body;
``(iii) made a civil claim or demand; or
``(iv) filed an action relating to the
care, services, or conditions of the facility.
``(B) Good faith defined.--For purposes of this
paragraph, an individual shall be deemed to be acting
in good faith if the individual reasonably believes--
``(i) the information reported or disclosed
is true; and
``(ii) a violation of the minimum nurse
staffing requirements of clause (ii) of
subsection (b)(4)(C) has occurred or may occur.
``(8) Prohibition on interference with rights.--
``(A) Exercise of rights.--A skilled nursing
facility may not--
``(i) interfere with, restrain, or deny the
exercise, or attempt to exercise, by any
individual of any right, procedure, or remedy
provided or protected under this subsection; or
``(ii) coerce or intimidate any individual
regarding the exercise, or attempt to exercise,
such right.
``(B) Opposition to unlawful policies or
practices.--A skilled nursing facility may not
retaliate or discriminate against any individual for
opposing any policy, practice, or action of the
facility which is alleged to violate, breach, or fail
to comply with any provision of the minimum nurse
staffing requirements of clause (ii) of subsection
(b)(4)(C).
``(C) Prohibition on interference with protected
communications.--A skilled nursing facility may not
make, adopt, or enforce any rule, regulation, policy,
or practice which in any manner directly or indirectly
prohibits, impedes, or discourages a nurse from, or
intimidates, coerces, or induces a nurse regarding,
engaging in free speech activities or disclosing
information as provided under this subsection.
``(D) Prohibition on interference with collective
action.--A skilled nursing facility may not in any way
interfere with the rights of nurses to organize,
bargain collectively, and engage in concerted activity
under section 7 of the National Labor Relations Act (29
U.S.C. 157).
``(9) Notice.--A skilled nursing facility shall post in an
appropriate location in each unit a conspicuous notice, in a
form specified by the Secretary, that--
``(A) explains the rights of nurses, residents, and
other individuals under this subsection;
``(B) includes a statement that a nurse, resident,
or other individual may file a complaint with the
Secretary against the facility for a violation of a
requirement or a prohibition of this subsection; and
``(C) provides instructions on how to file such a
complaint.
``(10) Enforcement.--
``(A) In general.--The Secretary shall enforce the
requirements and prohibitions of this subsection in
accordance with this paragraph.
``(B) Procedures for receiving and investigating
complaints.--The Secretary shall establish procedures
under which--
``(i) any individual may file a complaint
alleging that a skilled nursing facility has
violated a requirement or a prohibition of this
subsection; and
``(ii) any such complaint shall be
investigated by the Secretary.
``(C) Remedies.--If the Secretary determines that a
skilled nursing facility has violated a requirement or
prohibition of this subsection, the Secretary--
``(i) shall require the facility to
establish a corrective action plan to prevent
the recurrence of such violation; and
``(ii) may impose civil money penalties as
described in subparagraph (D).
``(D) Civil penalties.--
``(i) In general.--In addition to any other
penalties prescribed by law, the Secretary may
impose civil penalties as follows:
``(I) Skilled nursing facility
liability.--The Secretary may impose on
a skilled nursing facility found to be
in violation of this subsection a civil
money penalty of--
``(aa) not more than
$25,000 for the first knowing
violation of this subsection by
such facility; and
``(bb) not more than
$50,000 for any subsequent
knowing violation of this
subsection by such facility.
``(II) Individual liability.--The
Secretary may impose on an individual
who--
``(aa) is employed by a
skilled nursing facility; and
``(bb) is found by the
Secretary to have knowingly
violated this subsection on
behalf of the facility,
a civil money penalty of not more than
$20,000 for each such violation by the
individual.
``(ii) Procedures.--The provisions of
section 1128A of the Social Security Act (other
than subsections (a) and (b)) shall apply with
respect to a civil money penalty or proceeding
under this subparagraph in the same manner as
such provisions apply with respect to a civil
money penalty or proceeding under such section
1128A.
``(E) Public notice of violations.--
``(i) Internet website.--The Secretary
shall publish on the internet website of the
Department of Health and Human Services the
names of skilled nursing facilities on which a
civil money penalty has been imposed under this
subsection, the violation for which such
penalty was imposed, and such additional
information as the Secretary determines
appropriate.
``(ii) Change of ownership.--With respect
to a skilled nursing facility that had a change
of ownership, as determined by the Secretary,
penalties imposed on the facility while under
previous ownership shall no longer be published
by the Secretary pursuant to clause (i) after
the 1-year period beginning on the date of such
change of ownership.
``(F) Use of funds.--Funds collected by the
Secretary pursuant to this subsection are authorized to
be appropriated to implement the minimum nurse staffing
requirements of clause (ii) of subsection (b)(4)(C).
``(11) Nurse defined.--In this subsection, the term `nurse'
means a registered professional nurse, a licensed practical
nurse, and a nurse aide.''.
(b) Medicaid.--Section 1919 of the Social Security Act (42 U.S.C.
1396r) is amended by adding at the end the following new subsection:
``(k) Whistleblower and Resident Protections.--
``(1) Statement regarding professional obligation and
rights.--All nurses employed by a nursing facility have a duty
and right to act based on their professional judgment in
accordance with the nursing laws and regulations of the State
in which such facility is located, to provide nursing care in
the exclusive interests of the residents of the facility, and
to act as the residents' advocate.
``(2) Objection to or refusal of work assignment.--A nurse
may object to, or refuse to participate in, any activity,
policy, practice, assignment, or task (referred to in this
subsection as a `work assignment') if--
``(A) the nurse reasonably believes such work
assignment to be in violation of the minimum nurse
staffing requirements of clause (ii) of subsection
(b)(4)(C); or
``(B) the nurse reasonably believes that the nurse
is not prepared by education, training, or experience
to perform or comply with such work assignment without
compromising the safety of a resident or jeopardizing
the license of the nurse.
``(3) Retaliation for objection to or refusal of work
assignment barred.--
``(A) No discharge, discrimination, or
retaliation.--No nursing facility may discharge,
retaliate, discriminate, or otherwise take adverse
action in any manner with respect to any aspect of a
nurse's employment with the facility, including
discharge, promotion, compensation, or terms,
conditions, or privileges of employment, based on the
nurse's objection to, or refusal of, a work assignment
under paragraph (2).
``(B) No filing of complaint.--No nursing facility
may file a complaint or a report against a nurse with a
State professional disciplinary agency because of the
nurse's objection to, or refusal of, a work assignment
under paragraph (2).
``(4) Cause of action.--Any nurse (or a collective
bargaining representative or legal representative of such
nurse) against whom a nursing facility has taken an adverse
action in violation of paragraph (3)(A), or against whom such
facility has filed a complaint or report in violation of
paragraph (3)(B), may (without regard to whether a complaint
has been filed under paragraph (5) or (10)(B)) bring a cause of
action in an appropriate district court of the United States.
The legal burdens of proof specified in section 1221(e) of
title 5, United States Code, shall be controlling for the
purposes of any cause of action brought under this paragraph. A
nurse who prevails on the cause of action may be entitled to
one or more of the following:
``(A) Reinstatement.
``(B) Reimbursement of lost wages, compensation,
and benefits.
``(C) Attorneys' fees.
``(D) Court costs.
``(E) Other damages.
``(5) Complaint to secretary.--Any individual may file a
complaint with the Secretary against a nursing facility that
violates a requirement described in paragraph (3). For any
complaint filed, the Secretary shall--
``(A) receive and investigate the complaint;
``(B) determine whether a violation of such
paragraph, as alleged in the complaint, has occurred;
and
``(C) in the case that the Secretary determines
that such a violation has occurred, issue an order that
the complaining individual may not suffer any adverse
action prohibited by paragraph (3) or (7).
``(6) Toll-free telephone number.--
``(A) In general.--The Secretary shall provide for
the establishment of a toll-free telephone hotline to
provide information regarding the minimum nurse
staffing requirements of clause (ii) of subsection
(b)(4)(C) and to receive reports of violations of such
requirements.
``(B) Notice to residents.--A nursing facility
shall provide each resident admitted to the facility
with the telephone number of the hotline described in
subparagraph (A) and give notice to each such resident
that such hotline may be used to report inadequate
staffing or care.
``(7) Protection for reporting.--
``(A) Prohibition on retaliation or
discrimination.--A nursing facility may not retaliate
or discriminate in any manner against any resident,
employee, or contract employee of the facility, or any
other individual, on the basis that such resident,
employee, contract employee, or individual
(individually or in conjunction with another
individual) has, in good faith--
``(i) presented a grievance or complaint;
``(ii) initiated or cooperated in any
investigation or proceeding of any governmental
entity, regulatory agency, or private
accreditation body;
``(iii) made a civil claim or demand; or
``(iv) filed an action relating to the
care, services, or conditions of the facility.
``(B) Good faith defined.--For purposes of this
paragraph, an individual shall be deemed to be acting
in good faith if the individual reasonably believes--
``(i) the information reported or disclosed
is true; and
``(ii) a violation of the minimum nurse
staffing requirements of clause (ii) of
subsection (b)(4)(C) has occurred or may occur.
``(8) Prohibition on interference with rights.--
``(A) Exercise of rights.--A nursing facility may
not--
``(i) interfere with, restrain, or deny the
exercise, or attempt to exercise, by any
individual of any right, procedure, or remedy
provided or protected under this subsection; or
``(ii) coerce or intimidate any individual
regarding the exercise, or attempt to exercise,
such right.
``(B) Opposition to unlawful policies or
practices.--A nursing facility may not retaliate or
discriminate against any individual for opposing any
policy, practice, or action of the facility which is
alleged to violate, breach, or fail to comply with any
provision of the minimum nurse staffing requirements of
clause (ii) of subsection (b)(4)(C).
``(C) Prohibition on interference with protected
communications.--A nursing facility may not make,
adopt, or enforce any rule, regulation, policy, or
practice which in any manner directly or indirectly
prohibits, impedes, or discourages a nurse from, or
intimidates, coerces, or induces a nurse regarding,
engaging in free speech activities or disclosing
information as provided under this subsection.
``(D) Prohibition on interference with collective
action.--A nursing facility may not in any way
interfere with the rights of nurses to organize,
bargain collectively, and engage in concerted activity
under section 7 of the National Labor Relations Act (29
U.S.C. 157).
``(9) Notice.--A nursing facility shall post in an
appropriate location in each unit a conspicuous notice, in a
form specified by the Secretary, that--
``(A) explains the rights of nurses, residents, and
other individuals under this subsection;
``(B) includes a statement that a nurse, resident,
or other individual may file a complaint with the
Secretary against the facility for a violation of a
requirement or a prohibition of this subsection; and
``(C) provides instructions on how to file such a
complaint.
``(10) Enforcement.--
``(A) In general.--The Secretary shall enforce the
requirements and prohibitions of this subsection in
accordance with this paragraph.
``(B) Procedures for receiving and investigating
complaints.--The Secretary shall establish procedures
under which--
``(i) any individual may file a complaint
alleging that a nursing facility has violated a
requirement or a prohibition of this
subsection; and
``(ii) any such complaint shall be
investigated by the Secretary.
``(C) Remedies.--If the Secretary determines that a
nursing facility has violated a requirement or
prohibition of this subsection, the Secretary--
``(i) shall require the facility to
establish a corrective action plan to prevent
the recurrence of such violation; and
``(ii) may impose civil money penalties as
described in subparagraph (D).
``(D) Civil penalties.--
``(i) In general.--In addition to any other
penalties prescribed by law, the Secretary may
impose civil penalties as follows:
``(I) Nursing facility liability.--
The Secretary may impose on a nursing
facility found to be in violation of
this subsection a civil money penalty
of--
``(aa) not more than
$25,000 for the first knowing
violation of this subsection by
such facility; and
``(bb) not more than
$50,000 for any subsequent
knowing violation of this
subsection by such facility.
``(II) Individual liability.--The
Secretary may impose on an individual
who--
``(aa) is employed by a
nursing facility; and
``(bb) is found by the
Secretary to have knowingly
violated this subsection on
behalf of the facility,
a civil money penalty of not more than
$20,000 for each such violation by the
individual.
``(ii) Procedures.--The provisions of
section 1128A of the Social Security Act (other
than subsections (a) and (b)) shall apply with
respect to a civil money penalty or proceeding
under this subparagraph in the same manner as
such provisions apply with respect to a civil
money penalty or proceeding under such section
1128A.
``(E) Public notice of violations.--
``(i) Internet website.--The Secretary
shall publish on the internet website of the
Department of Health and Human Services the
names of nursing facilities on which a civil
money penalty has been imposed under this
subsection, the violation for which such
penalty was imposed, and such additional
information as the Secretary determines
appropriate.
``(ii) Change of ownership.--With respect
to a nursing facility that had a change of
ownership, as determined by the Secretary,
penalties imposed on the facility while under
previous ownership shall no longer be published
by the Secretary pursuant to clause (i) after
the 1-year period beginning on the date of such
change of ownership.
``(F) Use of funds.--Funds collected by the
Secretary pursuant to this subsection are authorized to
be appropriated to implement the minimum nurse staffing
requirements of clause (ii) of subsection (b)(4)(C).
``(11) Nurse defined.--In this subsection, the term `nurse'
means a registered professional nurse, a licensed practical
nurse, and a nurse aide.''.
(c) Effective Date.--The amendments made by this section take
effect on the date of enactment of this Act and shall apply with
respect to objections to or refusals of work assignments, complaints,
retaliations and other adverse actions, and interferences with rights
that occur on or after the date that is one year after such date of
enactment and with respect to notices provided on or after the date
that is one year after such date of enactment.
SEC. 7. PROHIBITING PRE-DISPUTE ARBITRATION AGREEMENTS.
(a) Medicare.--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) Prohibition on use of pre-dispute arbitration
agreements.--
``(A) In general.--A skilled nursing facility may
not require, solicit, accept, or move to enforce a pre-
dispute arbitration agreement from or on behalf of any
resident, whether the agreement is made before, during,
or after the resident's admission to the facility, or
from or on behalf of any employee, or contract employee
of the facility, or any other individual if such
individual is alleged to be engaged in conduct
protected under subsection (k).
``(B) Application.--This paragraph shall apply to
the skilled nursing facility and to any other business
or person providing or responsible for providing
skilled nursing services to the resident.
``(C) No validity or enforcement.--A pre-dispute
arbitration agreement shall not be valid or
specifically enforceable against a resident or former
resident of a skilled nursing facility, without regard
to whether the agreement was made prior to or after the
effective date of this paragraph.
``(D) Definition of pre-dispute arbitration
agreement.--In this paragraph, the term `pre-dispute
arbitration agreement' means any agreement to arbitrate
a dispute when the dispute has arisen after such
agreement has been made.
``(E) Judicial review.--A determination as to
whether and how this paragraph applies to an
arbitration agreement shall be determined under Federal
law by a court of competent jurisdiction, rather than
an arbitrator, without regard to whether the party
opposing arbitration challenges such agreement
specifically or in conjunction with any other term of
the contract containing such agreement.''.
(b) Medicaid.--
(1) Home and community-based services and home health care
services.--Section 1915 of the Social Security Act (42 U.S.C.
1396n) is amended by adding at the end the following new
subsection:
``(m) Prohibiting Pre-Dispute Arbitration Agreements.--
``(1) In general.--For home and community-based services or
home health care services provided under a waiver under this
section, section 1902(a)(10)(D), or any other provision
authorizing the provision of home and community-based services
or home health care services under this title, the provider of
such services (and any employee, agent, related entity, or
affiliate of such provider) shall not require, solicit, or
accept a pre-dispute arbitration agreement from or on behalf of
any individual receiving such services, whether the agreement
is made before, during, or after the first date on which
services are received, or from or on behalf of any employee, or
contract employee of the provider, or any other individual if
such individual is alleged to be engaged in conduct protected
under section 1919(k). A pre-dispute arbitration agreement
between such a provider (or entity or person) and an individual
receiving services (or who formerly received services) shall
not be valid or enforceable, without regard to whether such
agreement was made prior to the effective date of this
subsection.
``(2) Definition of pre-dispute arbitration agreement.--The
term `pre-dispute arbitration agreement' means any agreement to
arbitrate a dispute when the dispute has arisen after such
agreement has been made.
``(3) Judicial review.--A determination as to whether and
how this subsection applies to an arbitration agreement shall
be determined under Federal law by a court of competent
jurisdiction, rather than an arbitrator, without regard to
whether the party opposing arbitration challenges such
agreement specifically or in conjunction with any other term of
the contract containing such agreement.''.
(2) Nursing facilities.--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) Prohibition on use of pre-dispute arbitration
agreements.--
``(A) In general.--A nursing facility may not
require, solicit, accept, or move to enforce a pre-
dispute arbitration agreement from or on behalf of any
resident, whether the agreement is made before, during,
or after the resident's admission to the facility, or
from or on behalf of any employee, or contract employee
of the facility, or any other individual if such
individual is alleged to be engaged in conduct
protected under subsection (k).
``(B) Application.--This paragraph shall apply to
the nursing facility and to any other business or
person providing or responsible for providing nursing
services to the resident.
``(C) No validity or enforcement.--A pre-dispute
arbitration agreement shall not be valid or
specifically enforceable against a resident or former
resident of a nursing facility, without regard to
whether the agreement was made prior to or after the
effective date of this paragraph.
``(D) Definition of pre-dispute arbitration
agreement.--In this paragraph, the term `pre-dispute
arbitration agreement' means any agreement to arbitrate
a dispute when the dispute has arisen after such
agreement has been made.
``(E) Judicial review.--A determination as to
whether and how this paragraph applies to an
arbitration agreement shall be determined under Federal
law by a court of competent jurisdiction, rather than
an arbitrator, without regard to whether the party
opposing arbitration challenges such agreement
specifically or in conjunction with any other term of
the contract containing such agreement.''.
SEC. 8. STANDARDIZED PROTOCOL FOR OBTAINING INFORMED CONSENT FROM
RESIDENTS PRIOR TO PRESCRIBING PSYCHOTROPIC DRUGS.
(a) Standardized Protocol.--
(1) Skilled nursing facilities.--Section 1819(b) of the
Social Security Act (42 U.S.C. 1395i-3(b)) is amended by adding
at the end the following new paragraph:
``(9) Standardized protocol for obtaining informed consent
from a resident prior to prescribing psychotropic drugs for a
use not approved by the food and drug administration.--
``(A) Protocol.--Not later than the date that is
one year after the date of the enactment of this
paragraph, the Secretary, taking into account the
results of the study conducted by the Comptroller
General of the United States under section 8(a)(3) of
the Quality Care for Nursing Home Residents Act of 2019
and in consultation with stakeholder groups (including
residents of skilled nursing facilities, family members
of such residents, advocates for such residents, long-
term care ombudsmen, and providers), shall develop a
standardized protocol for skilled nursing facilities to
obtain written informed consent, in accordance with
this paragraph, from a resident (or, if applicable, the
resident's designated health care agent or other
surrogate under State law or regulation) prior to
prescribing a psychotropic drug to the resident for a
use not approved by the Food and Drug Administration.
``(B) Requirements.--The standardized protocol
developed under subparagraph (A) shall include the
following:
``(i) A requirement, with respect to a
resident, that--
``(I) the facility, with the
involvement of the prescriber, inform
the resident (or, if applicable, the
resident's designated health care agent
or other surrogate under State law or
regulation) of--
``(aa) possible side
effects and risks associated
with the psychotropic drug,
including the mention of any
`black box warning';
``(bb) treatment modalities
that were attempted prior to
the use of the psychotropic
drug; and
``(cc) any other
information the Secretary
determines appropriate;
``(II) the resident (or, if
applicable, the resident's designated
health care agent or other surrogate
under State law or regulation) provide
written informed consent to the
administration of the psychotropic
drug; and
``(III) the administration of the
psychotropic drug is in accordance with
any plan of care that the resident has
in place, including non-pharmacological
interventions as appropriate that can
effectively address underlying medical
and environmental causes of behavioral
disorders.
``(ii) An alternative protocol for
obtaining such written informed consent--
``(I) in the case of emergencies;
and
``(II) in the absence of a clearly
identified designated health care agent
or other surrogate under State law or
regulation.
``(iii) Other items determined appropriate
by the Secretary.
``(C) Timing of informed consent.--Under the
standardized protocol, a skilled nursing facility shall
obtain the written informed consent described in
subparagraph (A), with respect to a psychotropic drug
and a resident of the facility--
``(i) prior to the initial prescribing of
such psychotropic drug to such resident if such
resident does not have a current prescription
for such psychotropic drug at the time such
resident is admitted to the facility; and
``(ii) at least once a month to the extent
that the administration of such psychotropic
drug to such resident is in accordance with the
plan of care that the resident has in place.
``(D) Compliance.--Effective beginning on the date
that is one year and 180 days after the date of the
enactment of this paragraph, a skilled nursing facility
shall comply with the standardized protocol developed
under subparagraph (A).
``(E) No preemption.--Nothing in this paragraph
shall preempt any provision of State or Federal law
that provides broader rights with respect to written
informed consent for residents of facilities.''.
(2) Nursing facilities.--Section 1919(b) of the Social
Security Act (42 U.S.C. 1396r(b)) is amended by adding at the
end the following new paragraph:
``(9) Standardized protocol for obtaining informed consent
from a resident prior to prescribing psychotropic drugs for a
use not approved by the food and drug administration.--
``(A) Protocol.--Not later than the date that is
one year after the date of the enactment of this
paragraph, the Secretary, taking into account the
results of the study conducted by the Comptroller
General of the United States under section 8(a)(3) of
the Quality Care for Nursing Home Residents Act of 2019
and in consultation with stakeholder groups (including
residents of skilled nursing facilities, family members
of such residents, advocates for such residents, long-
term care ombudsmen, and providers), shall develop a
standardized protocol for nursing facilities to obtain
written informed consent, in accordance with this
paragraph, from a resident (or, if applicable, the
resident's designated health care agent or other
surrogate under State law or regulation) prior to
prescribing a psychotropic drug to the resident for a
use not approved by the Food and Drug Administration.
``(B) Requirements.--The standardized protocol
developed under subparagraph (A) shall include the
following:
``(i) A requirement, with respect to a
resident, that--
``(I) the facility, with the
involvement of the prescriber, inform
the resident (or, if applicable, the
resident's designated health care agent
or other surrogate under State law or
regulation) of--
``(aa) possible side
effects and risks associated
with the psychotropic drug,
including the mention of any
`black box warning';
``(bb) treatment modalities
that were attempted prior to
the use of the psychotropic
drug; and
``(cc) any other
information the Secretary
determines appropriate;
``(II) the resident (or, if
applicable, the resident's designated
health care agent or other surrogate
under State law or regulation) provide
written informed consent to the
administration of the psychotropic
drug; and
``(III) the administration of the
psychotropic drug is in accordance with
any plan of care that the resident has
in place, including non-pharmacological
interventions as appropriate that can
effectively address underlying medical
and environmental causes of behavioral
disorders.
``(ii) An alternative protocol for
obtaining such written informed consent--
``(I) in the case of emergencies;
and
``(II) in the absence of a clearly
identified designated health care agent
or other surrogate under State law or
regulation.
``(iii) Other items determined appropriate
by the Secretary.
``(C) Timing of informed consent.--Under the
standardized protocol, a nursing facility shall obtain
the written informed consent described in subparagraph
(A), with respect to a psychotropic drug and a resident
of the facility--
``(i) prior to the initial prescribing of
such psychotropic drug to such resident if such
resident does not have a current prescription
for such psychotropic drug at the time such
resident is admitted to the facility; and
``(ii) at least once a month to the extent
that the administration of such psychotropic
drug to such resident is in accordance with the
plan of care that the resident has in place.
``(D) Compliance.--Effective beginning on the date
that is one year and 180 days after the date of the
enactment of this paragraph, a nursing facility shall
comply with the standardized protocol developed under
subparagraph (A).
``(E) No preemption.--Nothing in this paragraph
shall preempt any provision of State or Federal law
that provides broader rights with respect to written
informed consent for residents of facilities.''.
(3) GAO study and report on informed consent laws with
respect to prescribing of psychotropic drugs.--
(A) Study.--The Comptroller General of the United
States (in this paragraph referred to as the
``Comptroller General'') shall conduct a study of State
laws and regulations concerning informed consent with
respect to the administration of a psychotropic drug
with regard to the effectiveness of such laws and
practices in changing the frequency of prescribing of
psychotropic drugs to older adults. The study shall
include an analysis as to whether in the case of States
that have not enacted such informed consent laws, such
States have developed other mechanisms to guide
appropriate prescribing of psychotropic drugs in older
adults with dementia.
(B) Report.--Not later than 180 days after the date
of enactment of this Act, the Comptroller General shall
submit to the Secretary of Health and Human Services,
the Committees on Energy and Commerce and Ways and
Means of the House of Representatives, and the
Committee on Finance of the Senate a report containing
the results of the study conducted under subparagraph
(A), together with such recommendations as the
Comptroller General determines appropriate.
(b) Development of Measure of Utilization of Psychotropic Drugs for
Inclusion on Nursing Home Compare Website.--
(1) Medicare.--Section 1819(i) of the Social Security Act
(42 U.S.C. 1395i-3(i)) is amended--
(A) by redesignating paragraph (3) as paragraph
(4); and
(B) by inserting after paragraph (2) the following
new paragraph:
``(3) Development of measure of utilization of psychotropic
drugs.--
``(A) In general.--Not later than the date that is
one year after the date of the enactment of this
paragraph, the Secretary shall include a measure of the
utilization of psychotropic drugs for each skilled
nursing facility for inclusion on such website (or a
successor website) as part of the quality measures or
health inspections measures, or both such measures,
under the Five-Star Quality Rating System established
by the Administrator of the Centers for Medicare &
Medicaid Services.
``(B) Considerations.--In developing the measure
under subparagraph (A), the Secretary shall take into
account special patient populations, special care
units, appropriate diagnoses, and other factors, as
determined appropriate by the Secretary.''.
(2) Medicaid.--Section 1919(i) of the Social Security Act
(42 U.S.C. 1396r(i)) is amended--
(A) by redesignating paragraph (3) as paragraph
(4); and
(B) by inserting after paragraph (2) the following
new paragraph:
``(3) Development of measure of utilization of psychotropic
drugs.--
``(A) In general.--Not later than the date that is
one year after the date of the enactment of this
paragraph, the Secretary shall include a measure of the
utilization of psychotropic drugs for each nursing
facility for inclusion on such website (or a successor
website) as part of the quality measures or health
inspections measures, or both such measures, under the
Five-Star Quality Rating System established by the
Administrator of the Centers for Medicare & Medicaid
Services.
``(B) Considerations.--In developing the measure
under subparagraph (A), the Secretary shall take into
account special patient populations, special care
units, appropriate diagnoses, and other factors, as
determined appropriate by the Secretary.''.
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