[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.''.
                                 <all>