116 S2694 IS: Nursing Home Improvement and Accountability Act of 2021
U.S. Senate
2021-08-10
text/xml
EN
Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.
1.Short title; table of contents(a)This Act may be cited as the Nursing Home Improvement and Accountability Act of 2021
.(b)The table of contents of this Act is as follows:Sec. 1. Short title; table of contents.TITLE I—Transparency and accountabilitySec. 101. Improving the accuracy and reliability of certain skilled nursing facility data.Sec. 102. Ensuring accurate information on cost reports.Sec. 103. Requiring a surety bond for skilled nursing facilities and nursing facilities.Sec. 104. Survey improvements.Sec. 105. Prohibiting pre-dispute arbitration agreements.Sec. 106. Improvements to the special focus facility program.TITLE II—Staffing ImprovementsSec. 201. Nurse staffing requirements.Sec. 202. Improving Nursing Home Compare staffing data.Sec. 203. Ensuring the submission of accurate staffing data.Sec. 204. Requiring 24-hour use of registered professional nurses.Sec. 205. Provision of infection control services.Sec. 206. Enhanced funding to support staffing and quality care in nursing facilities.TITLE III—Building modification and staff investment demonstration programSec. 301. Establishing a skilled nursing facility building modification and staff investment demonstration program.<enum>I</enum><header>Transparency and accountability</header><section id="H410E8AA3864C4B1C8729C913A2F510F1"><enum>101.</enum><header>Improving the accuracy and reliability of certain skilled nursing facility data</header><subsection id="H1D4A61CCF22549E4B44C70EA91E7B89F"><enum>(a)</enum><header>Reduction in payments for inaccurate reporting</header><text>Section 1888(e)(6)(A) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395yy">42 U.S.C. 1395yy(e)(6)(A)</external-xref>) is amended—</text><paragraph id="H59AE1BE2066E4C4C829D8710970607D3"><enum>(1)</enum><text>in the header, by striking <quote><header-in-text level="subparagraph" style="OLC">for failure to report</header-in-text></quote>; and</text></paragraph><paragraph id="HD819CF3BE27F4E629ACC919CC3E4A2DD"><enum>(2)</enum><text>in clause (i)—</text><subparagraph id="H75E38E3A7D3C48E2B56E6E48A5B739FA"><enum>(A)</enum><text>by striking <quote>For fiscal years</quote> and inserting the following: </text><quoted-block style="OLC" display-inline="no-display-inline" id="H9A8E45F219BD482480B909ED292D34FF"><subclause id="H2CE84E260F424C9BAD25DDEF452E2040"><enum>(I)</enum><header>Failure to report</header><text display-inline="yes-display-inline">For fiscal years</text></subclause><after-quoted-block>; and</after-quoted-block></quoted-block></subparagraph><subparagraph id="H48EEB3144D2C414C89ED57DFD11DF891"><enum>(B)</enum><text>by adding at the end the following new subclause:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H87F90F2F185A44848674B744CF30534F"><subclause id="H04CCBE3C71724D51AE3522C5C63FDA82"><enum>(II)</enum><header>Reporting of inaccurate information</header><text display-inline="yes-display-inline">For fiscal years beginning with fiscal year 2025, in the case of a skilled nursing facility that submits data under this paragraph, measures under subsection (h), or resident assessment data described in section 1819(b)(3) with respect to such fiscal year that is inaccurate (as determined by the Secretary through the validation process described in section 1888(h)(12) or otherwise), after determining the percentage described in paragraph (5)(B)(i), and after application of clauses (ii) and (iii) of paragraph (5)(B) and of subclause (I) if this clause (if applicable), the Secretary shall reduce such percentage for payment rates during such fiscal year by 2 percentage points.</text></subclause><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph></subsection><subsection id="H86640E7B24F24CB5AF65893B25BC882D"><enum>(b)</enum><header>Data and measures validation</header><text display-inline="yes-display-inline">Section 1888(h)(12) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395yy">42 U.S.C. 1395yy(h)(12)</external-xref>) is amended—</text><paragraph id="H985F1D93076E49E1815DF8F1795B5F69"><enum>(1)</enum><text>in subparagraph (A), by striking <quote>and the data submitted under subsection (e)(6)</quote> and inserting <quote>, the data submitted under subsection (e)(6), and, beginning with fiscal year 2024, the resident assessment data described in section 1819(b)(3)</quote>; and</text></paragraph><paragraph id="H862EA4984CC145CD943912F8A30E0680"><enum>(2)</enum><text>in subparagraph (B), by striking <quote>of $5,000,000</quote> and all that follows through the period at the end and inserting the following:</text><quoted-block style="OLC" display-inline="yes-display-inline" id="H773D9E50B92149639306AF5DE5408B95"><text>of—</text><clause id="HBB2C5597C2F84084818AB5C9A1AF5D17"><enum>(i)</enum><text display-inline="yes-display-inline">$5,000,000 for each of fiscal years 2023 through 2025; and</text></clause><clause commented="no" id="HEA58522500AD45768C4BB3C5EE4F96D5"><enum>(ii)</enum><text>$50,000,000 for the period of fiscal years 2026 through 2035,</text></clause><quoted-block-continuation-text quoted-block-continuation-text-level="subparagraph">to the Centers for Medicare & Medicaid Services Program Management Account, to remain available until expended.</quoted-block-continuation-text><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="H3A8007E5C1F9426DA9CB3D52866DF76C"><enum>(c)</enum><header>Providing authority To collect data on additional measures</header><text>Section 1888(e)(6)(B)(i)(II) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395yy">42 U.S.C. 1395yy(e)(6)(B)(i)(II)</external-xref>) is amended by inserting <quote>, and data on any other validated measure specified by the Secretary</quote> after <quote>under such subsection (d)(1)</quote>. </text></subsection></section><section id="HCA8C938F95184F7C8D68C86CAF300D8B"><enum>102.</enum><header>Ensuring accurate information on cost reports</header><text display-inline="no-display-inline">Section 1888(f) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395yy">42 U.S.C. 1395yy(f)</external-xref>) is amended by adding at the end the following new paragraphs:</text><quoted-block style="OLC" display-inline="no-display-inline" id="HAFEBCEF8637848B1BA3FAE77245DFC4B"><paragraph id="HA0B7F784CBEC4B16B4A2766C3E8536ED"><enum>(5)</enum><header>Audit of cost reports</header><subparagraph id="H499272526A0D48E6BD31D99404F1870C"><enum>(A)</enum><header>In general</header><text>Beginning in 2022, and annually thereafter, the Secretary shall conduct an audit of cost reports submitted under this title for a representative sample of skilled nursing facilities.</text></subparagraph><subparagraph id="HD45C9752A058412C87E226BD0C649763"><enum>(B)</enum><header>Funding</header><text display-inline="yes-display-inline">The Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 to the Centers for Medicare & Medicaid Services Program Management Account, of $250,000,000 for fiscal year 2023 for purposes of carrying out this paragraph. Amounts transferred pursuant to the previous sentence shall remain available until expended.</text></subparagraph></paragraph><paragraph id="HAB3F904F110A4E1BA485BDA16713B93E"><enum>(6)</enum><header>Review of relationship between cost report data and quality</header><subparagraph id="HC4DBBB550B1041A388D180C636AAE33E"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">Not later than 2 years after the Secretary completes the first audit described in paragraph (5), and not less frequently than once every 2 years thereafter, the Inspector General of the Department of Health and Human Services shall conduct an analysis of, and submit to Congress a report on, the relationship between skilled nursing facility expenditures for functional accounts described in paragraph (3) and skilled nursing facility quality (as specified by the Inspector General).</text></subparagraph><subparagraph id="H42939A38BAEF41FEB90CC8091DD6981D"><enum>(B)</enum><header>Funding</header><text display-inline="yes-display-inline">The Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 to the Inspector General of the Department of Health and Human Services $25,000,000 for fiscal year 2023 for purposes of carrying out this paragraph. Amounts transferred pursuant to the previous sentence shall remain available until expended</text></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></section><section display-inline="no-display-inline" id="H4E34529C0434448A8F6124A4E0B179DD"><enum>103.</enum><header>Requiring a surety bond for skilled nursing facilities and nursing facilities</header><subsection id="HA4937BEDF58E4263810727C47FA43BC7"><enum>(a)</enum><header>Medicare</header><text display-inline="yes-display-inline">Section 1819(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(a)</external-xref>) is amended—</text><paragraph id="HE711147C755D4F5288B88C27BF446631"><enum>(1)</enum><text>in paragraph (2), by striking <quote>and</quote> at the end;</text></paragraph><paragraph id="HAB07A669E997439B9FD9BFF64E876769"><enum>(2)</enum><text>in paragraph (3), by striking the period and inserting <quote>; and</quote>; and</text></paragraph><paragraph id="HF418B5F75B224E5494E80B814158798C"><enum>(3)</enum><text>by adding at the end the following new paragraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H6396694626AA4D9EB847C39797A0882B"><paragraph id="H1BCE57B51DE4413BA5261DC0DD4CA515"><enum>(4)</enum><text display-inline="yes-display-inline">provides the Secretary with a surety bond in a form specified by the Secretary and in an amount that is not less than the minimum of $500,000, unless the Secretary waives the provision of such surety bond due to such facility providing a comparable surety bond under State law.</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="H8E0B0108438E4629B81DC6C91E5C68C3"><enum>(b)</enum><header>Medicaid</header><text display-inline="yes-display-inline">Section 1919(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r">42 U.S.C. 1396r(a)</external-xref>) is amended—</text><paragraph id="H82F2A61075FC4CC1B9D540F3DC5145F8"><enum>(1)</enum><text>in paragraph (2), by striking <quote>and</quote> at the end;</text></paragraph><paragraph id="H457DF380B1C54C50A9FC268CFE4A9F39"><enum>(2)</enum><text>in paragraph (3), by striking the period and inserting <quote>; and</quote>; and</text></paragraph><paragraph id="HE8CD81196AE14FAB87E6A0C2285B6F2D"><enum>(3)</enum><text>by inserting after paragraph (3) the following new paragraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H32CFCA80BEAF49C3A3F061C685D06373"><paragraph id="HEF3FB5E8B3C84B5D98338AEE5CCCAA56"><enum>(4)</enum><text display-inline="yes-display-inline">provides the Secretary with a surety bond in a form specified by the Secretary and in an amount that is not less than the minimum of $500,000, unless the Secretary waives the provision of such surety bond due to such facility providing a comparable surety bond under State law.</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section><section id="HA6C6764E9A904BF5A1B3416E057952EA"><enum>104.</enum><header>Survey improvements</header><subsection id="H6D9E09DF06324BC882430A7B6A7D2CA7"><enum>(a)</enum><header>In general</header><text>Section 1128I of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1320a-7j">42 U.S.C. 1320a–7j</external-xref>) is amended—</text><paragraph id="H679FC3A92AD6450CBE53024E10AC3947"><enum>(1)</enum><text>in the section heading, by striking <quote><header-in-text level="section" style="OLC">Accountability requirements for</header-in-text></quote> and inserting <quote><header-in-text level="section" style="OLC">Additional requirements with respect to</header-in-text></quote>; and</text></paragraph><paragraph commented="no" display-inline="no-display-inline" id="HD4C47FD139D7425F99C5A16A10080D08"><enum>(2)</enum><text>by adding at the end the following new subsection:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H70D2BDBC980E41CEA45976F38C91F897"><subsection commented="no" id="HABFA9D6F27904D3E8B9A584352B3AF74"><enum>(i)</enum><header>Survey improvements</header><paragraph commented="no" id="HAEF4D985D46842E397D4F129FEA33F7A"><enum>(1)</enum><header>Review</header><text>The Secretary shall review (and, as appropriate, identify plans to improve) the following: </text><subparagraph commented="no" id="H8467B746DA46418EB853321746A48B7E"><enum>(A)</enum><text>The extent to which surveys conducted under subsection (g) of sections 1819 and 1919 and the enforcement process under subsection (h) of sections 1819 and 1919 result in increased compliance with requirements under sections 1819 and 1919 and subpart B of part 483 of title 42, Code of Federal Regulations, with respect to facilities.</text></subparagraph><subparagraph commented="no" id="HA45FD9D6B95C47C7BAA52E1A8B1AAE6B"><enum>(B)</enum><text>The timeliness and thoroughness of State agency verification of deficiency corrections at facilities.</text></subparagraph><subparagraph commented="no" id="HEB3DD753D9994C34BF9A83BA3D091510"><enum>(C)</enum><text>The appropriateness of the scoping and substantiation of cited deficiencies at facilities.</text></subparagraph><subparagraph commented="no" id="H1A124A093BB7487ABD341456BBCAF4A0"><enum>(D)</enum><text>The accuracy of the identification and appropriateness of the scoping of life safety, infection control, and emergency preparedness deficiencies at facilities.</text></subparagraph><subparagraph commented="no" id="H375331C31F344A33A2CA0FB56F4868DC"><enum>(E)</enum><text>The timeliness of State agency investigations of—</text><clause commented="no" id="HE38EEE7024F848BF99C468EB3C4B30CE"><enum>(i)</enum><text>complaints at facilities; and </text></clause><clause commented="no" id="HFF47E8A71D1D43E6A32BAA0456C89F50"><enum>(ii)</enum><text>reported allegations of abuse, neglect, and exploitation at facilities.</text></clause></subparagraph><subparagraph commented="no" id="HD25F4F51694B46F9A6AFCFBD0CF8A071"><enum>(F)</enum><text>The consistency of facility reporting of substantiated complaints to law enforcement.</text></subparagraph><subparagraph id="H4CCF5C7A15AD4E18BCE7774B2DD10ADE"><enum>(G)</enum><text>The ability of the State agency to sufficiently hire, train, and retain individuals who conduct surveys.</text></subparagraph><subparagraph commented="no" id="H0F75767BD73647ED9D00BFC5C8EB1A51"><enum>(H)</enum><text>Any other area related to surveys of facilities, or the individuals conducting such surveys, determined appropriate by the Secretary.</text></subparagraph></paragraph><paragraph commented="no" id="HD2D4D82FFC3C456A9166239202765487"><enum>(2)</enum><header>Report</header><text>Not later than 3 years after the date of enactment of this subsection, the Secretary shall submit to Congress a report on the review conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Secretary determines to be appropriate. </text></paragraph><paragraph commented="no" id="HCB1DC0B4E7D74DC599F81FD33F2FA6C7"><enum>(3)</enum><header>Support</header><text>If determined appropriate by the Secretary, based on the review under paragraph (1), the Secretary shall provide training, tools, technical assistance, and financial support to State agencies that perform surveys of facilities for the purpose of improving the surveys conducted under subsection (g) and the enforcement process under subsection (h) with respect to the areas reviewed under paragraph (1). </text></paragraph><paragraph commented="no" id="HF2914DE764E74BAE8996E4565B0E25DD"><enum>(4)</enum><header>Funding</header><text display-inline="yes-display-inline">There is appropriated to the Secretary, out of any monies in the Treasury not otherwise appropriated, $570,000,000, to remain available until expended, for purposes of carrying out this subsection.</text></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section><section id="H80A03D24A6954221B669BC20CFA88A88"><enum>105.</enum><header>Prohibiting pre-dispute arbitration agreements</header><subsection id="H52E4D1F6F7204203B76DBDE9EC988DCE"><enum>(a)</enum><header>Medicare</header><text>Section 1819(c) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(c)</external-xref>) is amended by adding at the end the following new paragraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H7F476824D209464FB8EFFA7FAC8F184D"><paragraph id="HAD9577A3D7FE42CFA2B2ABA2EB829D2B"><enum>(7)</enum><header>Prohibition on use of pre-dispute arbitration agreements</header><subparagraph id="HA0D1EB6CE39E4CDBBF7296C50E939C55"><enum>(A)</enum><header>In general</header><text>A skilled nursing facility may not enter into a pre-dispute arbitration agreement with an individual applying to reside or residing in the facility (or a legal representative of such resident), and may not enter into an agreement for services with an entity or individual that enters into a pre-dispute arbitration agreement with an individual applying to reside or residing in the facility (or a legal representative of such resident).</text></subparagraph><subparagraph id="H026C18041F98417AB3F9DEE6709D5C3C"><enum>(B)</enum><header>No validity or enforcement</header><text>A skilled nursing facility shall not enforce a pre-dispute arbitration agreement against a resident or former resident of a skilled nursing facility (or a legal representative of such resident), without regard to whether the agreement was made prior to or after the effective date of this paragraph.</text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="HCA39FE1E1381477C9A6FD0CFD15A7741"><enum>(C)</enum><header>Definition of pre-dispute arbitration agreement</header><text>In this paragraph, the term <term>pre-dispute arbitration agreement</term> means any agreement to arbitrate a potential dispute that, as of the date on which such agreement is entered into, has not yet arisen.</text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="H36C9C2A2767B4CC59346928AC7AAEE5C"><enum>(D)</enum><header>Judicial review</header><text>A determination as to whether and how this paragraph applies to a pre-dispute 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.</text></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></subsection><subsection id="H5937811CEF0343DFB3FE0EC406AABC09"><enum>(b)</enum><header>Medicaid</header><paragraph id="H12187A82F41342BA84DAAB3FBA1DB692"><enum>(1)</enum><header>Home and community-based services and home health care services</header><text>Section 1915 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396n">42 U.S.C. 1396n</external-xref>) is amended by adding at the end the following new subsection:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H575870C9E4B94F308F6B5CD9A836AA4A"><subsection id="HE013DF87423E4F3CA641B54C273E1D55"><enum>(l)</enum><header>Prohibiting pre-Dispute arbitration agreements</header><paragraph id="HFA9437A25A6347D68C8DFEA15F1F9677"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">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) may not enter into a pre-dispute arbitration agreement with an individual receiving such services (or a legal representative of such individual). A provider of such services (and any employee, agent, related entity, or affiliate of such provider) shall not enforce a pre-dispute arbitration agreement against an individual receiving such services, or who formerly received such services (or a legal representative of such individual), without regard to whether such agreement was made prior to the effective date of this subsection.</text></paragraph><paragraph id="H900DA2A0737047E883619308B4BBFE0E"><enum>(2)</enum><header>Definition of pre-dispute arbitration agreement</header><text display-inline="yes-display-inline">In this subsection, the term <term>pre-dispute arbitration agreement</term> means any agreement to arbitrate a potential dispute that, as of the date on which such agreement is entered into, has not yet arisen.</text></paragraph><paragraph id="HAD1FAABC0CCB4AD5A438CD6BE349E18A"><enum>(3)</enum><header>Judicial review</header><text>A determination as to whether and how this subsection applies to a pre-dispute 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.</text></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph><paragraph id="HD8AA8B24530649FDACB1104A64D9C923"><enum>(2)</enum><header>Nursing facilities</header><text>Section 1919(c) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r">42 U.S.C. 1396r(c)</external-xref>) is amended by adding at the end the following new paragraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H59C6BD16BD6943F7BCA971EBF0B7491E"><paragraph id="H251648F7F00F4A66B072A9CF856250B6"><enum>(9)</enum><header>Prohibition on use of pre-dispute arbitration agreements</header><subparagraph id="H3B8FA4426D83497B8959F4A1F15505F7"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">A nursing facility may not enter into a pre-dispute arbitration agreement with an individual applying to reside or residing in the facility (or a legal representative of such resident), and may not enter into an agreement for services with an entity or individual that enters into a pre-dispute arbitration agreement with an individual applying to reside or residing in the facility (or a legal representative of such resident).</text></subparagraph><subparagraph id="H1CBEA95E27A448C69BDF01D85E6FCBB2"><enum>(B)</enum><header>No validity or enforcement</header><text>A nursing facility shall not enforce a pre-dispute arbitration agreement against a resident or former resident of a nursing facility (or a legal representative of such resident), without regard to whether the agreement was made prior to or after the effective date of this paragraph.</text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="HBDE89E7538114A1EA22A5AAB5EDB00DB"><enum>(C)</enum><header>Definition of pre-dispute arbitration agreement</header><text>In this paragraph, the term <term>pre-dispute arbitration agreement</term> means any agreement to arbitrate a potential dispute that, as of the date on which such agreement is entered into, has not yet arisen.</text></subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="HDCDF3D1FF6CF429FBBEE611718B963D5"><enum>(D)</enum><header>Judicial review</header><text>A determination as to whether and how this paragraph applies to a pre-dispute 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.</text></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section><section id="H9FDFB479ED724568A22F1326A06B133D"><enum>106.</enum><header>Improvements to the special focus facility program</header><subsection id="H6336AE0762C54FDAB6B537FFC39C4705"><enum>(a)</enum><header>Appropriate participation</header><paragraph id="H2904E2FE384F43CDA205D0A36FE0FBAC"><enum>(1)</enum><header>Medicare</header><text>Section 1819(f)(8) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(f)(8)</external-xref>) is amended—</text><subparagraph id="H149A9B47A1474D728E2FE9D36DAE5C37"><enum>(A)</enum><text>in subparagraph (A), by striking <quote>The Secretary</quote> and inserting <quote>Subject to the succeeding provisions of this subsection, the Secretary</quote>; and</text></subparagraph><subparagraph id="H36585B494375485C910F647DD28E3E80"><enum>(B)</enum><text>by adding at the end the following new subparagraph:</text><quoted-block style="OLC" id="H4D732B0E611A437CBC193C9C207B8C02"><subparagraph id="HA091174A052B4829BA2BAA1716CA00B8"><enum>(C)</enum><header>Appropriate participation</header><text>Not later than October 1, 2022, the Secretary shall ensure that the number of facilities participating in the special focus facility program is not less than 5 percent of all skilled nursing facilities.</text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph><paragraph id="HAF1C1F026FA946579B1416DFD9E67665"><enum>(2)</enum><header>Medicaid</header><text>Section 1919(f)(10) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395r">42 U.S.C. 1395r(f)(10)</external-xref>) is amended—</text><subparagraph id="HDA3D800AD3C1406399FFEF71DF1E8293"><enum>(A)</enum><text>in subparagraph (A), by striking <quote>The Secretary</quote> and inserting <quote>Subject to the succeeding provisions of this subsection, the Secretary</quote>; and</text></subparagraph><subparagraph id="HF71829070290490BBB6D48760A42CD10"><enum>(B)</enum><text>by adding at the end the following new subparagraph:</text><quoted-block style="OLC" id="H2320F852FBB544308D36C3C67D55733D"><subparagraph id="H4F943DDD8E10420F9661A725BEFE5FFD"><enum>(C)</enum><header>Appropriate participation</header><text>Not later than October 1, 2022, the Secretary shall ensure that the number of facilities participating in the special focus facility program is not less than 5 percent of all nursing facilities.</text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></subparagraph></paragraph></subsection><subsection id="H5B8E1EAA2349459B9049BFD22E5DB538"><enum>(b)</enum><header>Compliance assistance programs</header><paragraph id="H1ACAB7C36B8B4F8B878FBF1D6F1F04BC"><enum>(1)</enum><header>Medicare</header><text>Section 1819(f)(8) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(f)(8)</external-xref>), as amended by subsection (a)(1), is amended by adding at the end the following new subparagraph:</text><quoted-block style="OLC" id="HB02441FF9F44417E866F073C29E125FD"><subparagraph id="HDE027F3DBD45462AA708390FD42EF1B7"><enum>(D)</enum><header>Compliance assistance programs</header><clause id="HFA04EF2D8BAF4BCE939C6B3CF4F3AB9F"><enum>(i)</enum><header>On-site consultation and educational programming</header><subclause id="H5DE4D6B68D1D4E3883A1CEBC273954F9"><enum>(I)</enum><header>In general</header><text>The Secretary shall establish on-site consultation and educational programming for skilled nursing facilities participating in the special focus facility program with respect to compliance with the applicable requirements under this Act.</text></subclause><subclause id="H383EF0E386154ABDB3363F5E4B1490A8"><enum>(II)</enum><header>Entity</header><text>The on-site consultation and educational programming described in subclause (I) shall be carried out by quality improvement organizations under part B of title XI or other independent organizations of a similar type that do not have conflicts of interest and are deemed appropriate by the Secretary.</text></subclause><subclause id="HA1138B67C1FB4ECA846788B114809D76"><enum>(III)</enum><header>Required participation</header><text>A skilled nursing facility participating in the special focus facility program shall participate in any consultations and educational programming described in subclause (I) conducted at the facility.</text></subclause></clause><clause id="H90390FACEA2840F193AD2CB08F478D75"><enum>(ii)</enum><header>Consultation independent of enforcement</header><subclause id="H45616759A5944048AB8A6F3D43D61C7B"><enum>(I)</enum><header>In general</header><text>Subject to subclause (II), on-site consultations and educational programming described in clause (i) shall be conducted independently of any enforcement activity.</text></subclause><subclause id="H9C33AA207EFC4F0E8B35119610928BD0"><enum>(II)</enum><header>Exception</header><text>Subclause (I) shall not apply in the case where a triggering event at the skilled nursing facility is observed in the course of providing on-site consultations and educational programming described in clause (i). In establishing such on-site consultations and educational programming, the Secretary shall determine the triggering events for which the use of necessary enforcement actions is permitted notwithstanding the limitation under subclause (I). Such triggering events shall include events that are required to be reported under State and Federal law and a pattern of deficiencies or problems that the quality improvement organization or other organization has identified for correction but which are consistently not corrected.</text></subclause></clause></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph><paragraph id="HDA16D5BE8C9A49CF9868F49E7C1CD6EA"><enum>(2)</enum><header>Medicaid</header><text>Section 1919(f)(10) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395r">42 U.S.C. 1395r(f)(10)</external-xref>), as amended by subsection (a)(2), is amended by adding at the end the following new subsection:</text><quoted-block style="OLC" id="H15EF980E77B24BB38F12CB61B3773E4F"><subparagraph id="HCADC22ED019F4B228ED0F1A13EC1CA43"><enum>(D)</enum><header>Compliance assistance programs</header><clause id="H4080E716648D4349BF79AFDEC946A36F"><enum>(i)</enum><header>On-site consultation and educational programming</header><subclause id="HAD3AA42E2B124CF1A162E3AF83B9D71F"><enum>(I)</enum><header>In general</header><text>The Secretary shall establish on-site consultation and educational programming for nursing facilities participating in the special focus facility program with respect to compliance with the applicable requirements under this Act.</text></subclause><subclause id="H9E689691B9444A12B7A07DB7B74B645A"><enum>(II)</enum><header>Entity</header><text>The on-site consultation and educational programming described in subclause (I) shall be carried out by quality improvement organizations under part B of title XI or other independent organizations of a similar type that do not have conflicts of interest and are deemed appropriate by the Secretary.</text></subclause><subclause id="HCFE809C8CD06488D85ADA4CFC1CC60AD"><enum>(III)</enum><header>Required participation</header><text>A nursing facility participating in the special focus facility program shall participate in any consultations and educational programming described in subclause (I) conducted at the facility.</text></subclause></clause><clause id="HFEF84261C0C2462BB54CC1C616DB547C"><enum>(ii)</enum><header>Consultation independent of enforcement</header><subclause id="H113015CD09CE4A769ABCE48D6AE3EC5E"><enum>(I)</enum><header>In general</header><text>Subject to subclause (II), on-site consultations and educational programming described in clause (i) shall be conducted independently of any enforcement activity.</text></subclause><subclause id="HE27F11148D12495FA5FE6C52D92A0D75"><enum>(II)</enum><header>Exception</header><text>Subclause (I) shall not apply in the case where a triggering event at the nursing facility is observed in the course of providing on-site consultations and educational programming described in clause (i). In establishing such on-site consultations and educational programming, the Secretary shall determine the triggering events for which the use of necessary enforcement actions is permitted notwithstanding the limitation under subclause (I). Such triggering events shall include events that are required to be reported under State and Federal law and a pattern of deficiencies or problems that the quality improvement organization or other organization has identified for correction but which are consistently not corrected.</text></subclause></clause></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="H6D64A39868884696ADB02FD3204DD573"><enum>(c)</enum><header>Funding for the special focus facility program, including compliance assistance programs</header><text>Section 1819(f)(8) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(f)(8)</external-xref>), as amended by subsections (a)(1) and (b)(1), is amended by adding at the end the following new subparagraph:</text><quoted-block style="OLC" id="HE925E2AE6D604E6C974412B7FB1B4089"><subparagraph id="HF5F5157E03964B69AE2B68B86565395C"><enum>(E)</enum><text>For purposes of carrying out this paragraph and section 1919(f)(10), there is appropriated to the Secretary, out of any monies in the Treasury not otherwise appropriated, $14,800,000 for fiscal year 2022 and each subsequent fiscal year, to remain available until expended. </text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></subsection></section><enum>II</enum><header>Staffing Improvements</header><section id="H39D5F83B54E9487BA51F0AECDD237B7C"><enum>201.</enum><header>Nurse staffing requirements</header><subsection id="H651B11963540433780B6F4E824B8B476"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Title XI of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1301">42 U.S.C. 1301 et seq.</external-xref>) is amended by inserting after section 1128K the following new section:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H98F18D3E822E4F4D92FD7CFAF382555C"><section id="H7CA1D21918794D7BB7E3F2B3455F35FE"><enum>1128L.</enum><header>Nurse staffing requirements for facilities</header><subsection id="H4D50F568C8984F3DAD7A3BCB5A8E0260"><enum>(a)</enum><header>Study</header><text display-inline="yes-display-inline">Not later than 3 years after the date of the enactment of this section, and not less frequently than once every 5 years thereafter, the Secretary shall conduct a study and submit to Congress a report on the appropriateness of establishing minimum staff to resident ratios for nursing staff for skilled nursing facilities (as defined in section 1819(a)) and nursing facilities (as defined in section 1919(a)). Each such report shall include—</text><paragraph id="HA19DD5C364974F87B346A851AFB255B2"><enum>(1)</enum><text>with respect to the first such report, recommendations regarding appropriate minimum ratios of registered nurses (and, if practicable, licensed practical nurses (or licensed vocational nurses) and certified nursing assistants) to residents at such skilled nursing facilities and such nursing facilities; and</text></paragraph><paragraph id="H3F0B21D340AB41D9A8E37898C91D60DD"><enum>(2)</enum><text display-inline="yes-display-inline">with respect to each subsequent such report, recommendations regarding appropriate minimum ratios of registered nurses, licensed practical nurses (or licensed vocational nurses), and certified nursing assistants to residents at such skilled nursing facilities and such nursing facilities.</text></paragraph></subsection><subsection id="HE047AC1877F442E5B3FF7327408F9293"><enum>(b)</enum><header>Promulgation of regulations</header><paragraph id="HC215D77155484802AFECAEE54EC6E6D7"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Not later than 2 years after the Secretary first submits a report under subsection (a), the Secretary shall—</text><subparagraph id="HB31A2B7520C843CA84039D5B46F7390B"><enum>(A)</enum><text display-inline="yes-display-inline">specify through regulations, consistent with such report, appropriate minimum ratios (if any) of registered nurses (and, if practicable, licensed practical nurses (or licensed vocational nurses) and certified nursing assistants) to residents at skilled nursing facilities and nursing facilities; and</text></subparagraph><subparagraph id="HDF42A5E99D1547B1B880B749CB385053"><enum>(B)</enum><text>subject to any waiver in effect under section 1819(b)(9)(B) or 1919(b)(9)(B), require such skilled nursing facilities and such nursing facilities to comply with such ratios.</text></subparagraph></paragraph><paragraph id="H925A15162F064F5BB1FEB3E0976A72D6"><enum>(2)</enum><header>Update</header><text>Not later than 2 years after the submission of each subsequent report under subsection (a), the Secretary shall, consistent with such report, update the regulations described in paragraph (1)(A) to reflect appropriate minimum ratios (if any) of registered nurses, licensed practical nurses (or licensed vocational nurses), and certified nursing assistants to residents at skilled nursing facilities and nursing facilities. </text></paragraph></subsection><subsection id="H1370387949444303B32558D46EE0F765"><enum>(c)</enum><header>Funding</header><text display-inline="yes-display-inline">The Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 to the Centers for Medicare & Medicaid Services Program Management Account, of $50,000,000 for fiscal year 2022 for purposes of carrying out this section. Amounts transferred pursuant to the previous sentence shall remain available until expended.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></subsection><subsection commented="no" id="HD58FF2F8667B4408BCE34EB48B64896F"><enum>(b)</enum><header>Imposition of requirements</header><paragraph commented="no" id="HC785079377CE4CE4B4933EB6703EEC6F"><enum>(1)</enum><header>Medicare</header><text display-inline="yes-display-inline">Section 1819(b) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(b)</external-xref>) is amended by adding at the end the following new paragraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H46E5F7748B42450B98741847416CD788"><paragraph commented="no" id="H0D99615A8D91442BB8F7CB9E8A8BB1E8"><enum>(9)</enum><header>Nurse staffing requirement</header><subparagraph id="HD44365227159400888C734E180BEDABF"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">Subject to subparagraph (B), a skilled nursing facility shall comply with any minimum staffing ratios for registered nurses, licensed practical nurses (or licensed vocational nurses), or certified nurse assistants specified by the Secretary for such a facility in regulations promulgated under section 1128L(b) or, if greater, as specified by the State involved for such a facility.</text></subparagraph><subparagraph id="HED8D25F7575D452786ECB1F23F993264"><enum>(B)</enum><header>Waiver</header><clause id="HD11FED97C04A4536970FB8A9ECCBF4FA"><enum>(i)</enum><header>In general</header><text>The Secretary may waive the application of subparagraph (A) with respect to a skilled nursing facility if the Secretary finds that—</text><subclause id="HDF71B36EFABD4BBDB30C0FEAAF402799"><enum>(I)</enum><text display-inline="yes-display-inline">the facility is located in a rural area and the supply of skilled nursing facility services in such area is not sufficient to meet the needs of individuals residing therein;</text></subclause><subclause id="H4B8A010F35D646FD8599324B84272527"><enum>(II)</enum><text display-inline="yes-display-inline">the Secretary provides notice of the waiver to the State long-term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965) and the protection and advocacy system in the State for the mentally ill and the mentally retarded; and</text></subclause><subclause id="H65D7D5D73374430F8137B2F9681A200F"><enum>(III)</enum><text display-inline="yes-display-inline">the facility that is granted such a waiver notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver.</text></subclause></clause><clause id="HE61B477CCC064EEB87DCDF17974E3739"><enum>(ii)</enum><header>Renewal</header><text>Any waiver in effect under this subparagraph shall be subject to annual renewal.</text></clause></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph><paragraph commented="no" id="HB1BD0986DABA4B08ABF3B9CA7B814C09"><enum>(2)</enum><header>Medicaid</header><text>Section 1919(b) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r">42 U.S.C. 1396r(b)</external-xref>) is amended by adding at the end the following new paragraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="HB158803E71A14FABBAB27EF9F8D77564"><paragraph commented="no" id="HECD50038790B453BBBD7E91C07DEA7E8"><enum>(9)</enum><header>Nurse staffing requirement</header><subparagraph id="HA491D22567BA4B588A66393C6D51B7CE"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">Subject to subparagraph (B), a nursing facility shall comply with any minimum staffing ratios for registered nurses, licensed practical nurses (or licensed vocational nurses), or certified nurse assistants specified by the Secretary for such a facility in regulations promulgated under section 1128L(b) or, if greater, as specified by the State involved for such a facility.</text></subparagraph><subparagraph id="HFA2B9097BEDE46779516FE7CD474F64E"><enum>(B)</enum><header>Waiver</header><clause id="H458D66DA64F945D49821EB9EE2703343"><enum>(i)</enum><header>In general</header><text>The Secretary may waive the application of subparagraph (A) with respect to a nursing facility if the Secretary finds that—</text><subclause id="H522C278493264BC9A5196FFEF6469B9E"><enum>(I)</enum><text display-inline="yes-display-inline">the facility is located in a rural area and the supply of nursing facility services in such area is not sufficient to meet the needs of individuals residing therein;</text></subclause><subclause id="H11ACD934009941D3B120E9ECADF07595"><enum>(II)</enum><text display-inline="yes-display-inline">the Secretary provides notice of the waiver to the State long-term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965) and the protection and advocacy system in the State for the mentally ill and the mentally retarded; and</text></subclause><subclause id="HB35A7019AB0B4C448C02249A39639253"><enum>(III)</enum><text display-inline="yes-display-inline">the facility that is granted such a waiver notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver.</text></subclause></clause><clause id="H53D7C67E78154A0CB10E830050F5B2D1"><enum>(ii)</enum><header>Renewal</header><text>Any waiver in effect under this subparagraph shall be subject to annual renewal.</text></clause></subparagraph></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section><section id="HC48C62C3CB8C4B8CA145B18470FE0F91"><enum>202.</enum><header>Improving Nursing Home Compare staffing data</header><subsection id="H63B8069C440747A1AEAAB3309584E976"><enum>(a)</enum><header>Medicare</header><text display-inline="yes-display-inline">Section 1819(i)(1)(A)(i) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(i)(1)(A)(i)</external-xref>) is amended by inserting <quote>(excluding, with respect to such data provided on or after October 1, 2022, any hours spent on administrative duties by licensed nurse staff) and, beginning October 1, 2022, data on the hours of care provided per resident per weekend day</quote> after <quote>per resident per day</quote>.</text></subsection><subsection id="HE05DE62A78724C469481E368BA773D4A"><enum>(b)</enum><header>Medicaid</header><text display-inline="yes-display-inline">Section 1919(i)(1)(A)(i) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r">42 U.S.C. 1396r(i)(1)(A)(i)</external-xref>) is amended by inserting <quote>(excluding, with respect to such data provided on or after October 1, 2022, any hours spent on administrative duties by licensed nurse staff) and, beginning October 1, 2022, data on the hours of care provided per resident per weekend day</quote> after <quote>per resident per day</quote>.</text></subsection></section><section id="H20FF9018C50644B0996ABBD635C4092B"><enum>203.</enum><header>Ensuring the submission of accurate staffing data</header><text display-inline="no-display-inline">Section 1128I(g) of the Social Security Act (42 U.S.C. 1320a–7j(g)) is amended—</text><paragraph id="H0B092CEF10E140C0B3ACF957EB9B6AF3"><enum>(1)</enum><text>by redesignating paragraphs (1) through (4) as subparagraphs (A) through (D), respectively, and adjusting the margins accordingly;</text></paragraph><paragraph id="H20E51CBD672A4E37A2CC8CCE5B1D5CE8"><enum>(2)</enum><text>in subparagraph (D), as so redesignated, by striking <quote>paragraph (1)</quote> and inserting <quote>subparagraph (A)</quote>;</text></paragraph><paragraph id="H78FC0ADA500C4C61B4378F2E6966D92C"><enum>(3)</enum><text>by moving the flush matter following subparagraph (D), as so redesignated, 2 ems to the right;</text></paragraph><paragraph id="H2F107F96D9F44B139D0032F0F79534E3"><enum>(4)</enum><text>by striking <quote>Beginning not later than</quote> and inserting the following: </text><quoted-block style="OLC" display-inline="no-display-inline" id="HD30A930FA2D744FD8A7AFF2927077FCB"><paragraph id="HB9C7296336784BE0A20631931569C191"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Beginning not later than</text></paragraph><after-quoted-block>; and</after-quoted-block></quoted-block></paragraph><paragraph id="HB1622F780CC7435AA324736C8B2FA08C"><enum>(5)</enum><text>by adding at the end the following new paragraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="HE3C0551C5E9A49EAA94177978546B0D9"><paragraph id="HFE8D1E703D9A4B6E8F1E464D4E9C5D05"><enum>(2)</enum><header>Penalty for submission of inaccurate information</header><text display-inline="yes-display-inline">Any facility that submits inaccurate information to the Secretary under paragraph (1) may be subject to a civil monetary penalty not to exceed $10,000 for each such submission. The provisions of section 1128A (other than subsections (a) and (b) of such section) shall apply to a civil money penalty under the preceding sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></section><section id="H3F75FADD032F4A8FA883FF624B67ECD8"><enum>204.</enum><header>Requiring 24-hour use of registered professional nurses</header><subsection id="H04C32924098A4EC79317453249B91D3B"><enum>(a)</enum><header>Medicare</header><text display-inline="yes-display-inline">Section 1819(b)(4)(C)(i) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(b)(4)(C)(i)</external-xref>) is amended by striking <quote>registered professional nurse</quote> and all that follows through the period at the end and inserting the following: </text><quoted-block style="OLC" display-inline="yes-display-inline" id="H3A8FF7D3A083452389786B3054B1FFE5"><text>registered professional nurse, with respect to such services furnished—</text><subclause id="H3D26A3311E4D459D8CFBA50A0BB5C1E5"><enum>(I)</enum><text display-inline="yes-display-inline">before October 1, 2023, at least 8 consecutive hours a day, 7 days a week; and</text></subclause><subclause id="H1589DAA53B414BCBABEA52C982FBCF39"><enum>(II)</enum><text>on or after such date, 24 hours a day, 7 days a week.</text></subclause><after-quoted-block>.</after-quoted-block></quoted-block></subsection><subsection id="H36DDA6A02952421DA51DF79221745EDE"><enum>(b)</enum><header>Medicaid</header><text display-inline="yes-display-inline">Section 1919(b)(4)(C)(i)(II) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r">42 U.S.C. 1396r(b)(4)(C)(i)(II)</external-xref>) is amended by striking <quote>registered professional nurse</quote> and all that follows through the period at the end and inserting the following: </text><quoted-block style="OLC" display-inline="yes-display-inline" id="H17C1F146760C4A18813C2FA5C58CD081"><text>registered professional nurse, with respect to such services furnished—</text><item id="HDEEA31C591704C1AB550C7A0D9736199"><enum>(aa)</enum><text display-inline="yes-display-inline">before October 1, 2023, at least 8 consecutive hours a day, 7 days a week; and</text></item><item id="H1EF010E0D3144FCC93B1A050C24F97FE"><enum>(bb)</enum><text>on or after such date, 24 hours a day, 7 days a week.</text></item><after-quoted-block>.</after-quoted-block></quoted-block></subsection></section><section id="H59A2A9B802EA4D77AF9378CBA75D8C29"><enum>205.</enum><header>Provision of infection control services</header><subsection id="HE3556DD1E97A4D88A3D62D92BF25600D"><enum>(a)</enum><header>Medicare</header><text>Section 1819(d)(3) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(d)(3)</external-xref>) is amended—</text><paragraph id="H04CDD2AB1940483B821F7BE797C37085"><enum>(1)</enum><text>by redesignating subparagraphs (A) and (B) as clauses (i) and (ii) respectively, and moving such clauses 2 ems to the right;</text></paragraph><paragraph id="H20FAF3184497485D856E18D4517747A5"><enum>(2)</enum><text>by striking <quote><header-in-text level="paragraph" style="OLC">environment</header-in-text>.—A skilled</quote> and inserting “<header-in-text level="paragraph" style="OLC">environment</header-in-text>.—</text><quoted-block style="OLC" display-inline="no-display-inline" id="HB24844CEB09542A69C06CB3FD29F7BF7"><subparagraph id="HE2CDBB8133FF4EC996663C9CD5AF44C3"><enum>(A)</enum><header>In general</header><text>A skilled</text></subparagraph><after-quoted-block>;</after-quoted-block></quoted-block></paragraph><paragraph id="H634B821C639044E68CFB8923562F7ECF"><enum>(3)</enum><text>in subparagraph (A), as amended by paragraphs (1) and (2)—</text><subparagraph id="H40807CAB542E454E8184F99B958CFFF2"><enum>(A)</enum><text>in clause (i), by striking <quote>, and</quote> at the end and inserting a semicolon;</text></subparagraph><subparagraph id="H2E3A9CB3A0134421BBD3976D0D2F9A49"><enum>(B)</enum><text>in clause (ii), by striking the period at the end and inserting <quote>; and</quote>; and</text></subparagraph><subparagraph id="HB7369F65CCEB47E89FDB350900DA06A9"><enum>(C)</enum><text>by adding at the end the following new clause:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H23292FE690B84020B3FDFB5253DE33D3"><clause id="HFBCD23DF51D6409F910B753C86338307"><enum>(iii)</enum><text>provide, directly or under arrangements with others, for infection control services overseen by an infection preventionist for a minimum number of hours per week as determined appropriate by the Secretary (but, subject to subparagraph (B), not less than 40 hours per week).</text></clause><after-quoted-block>; and</after-quoted-block></quoted-block></subparagraph></paragraph><paragraph id="HFA74A9943C2642C4BFC1E1A71F6D3B03"><enum>(4)</enum><text>by adding at the end the following new subparagraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H0DC44DCE5D7D46B4A5E2BBA39F85056F"><subparagraph id="HBB5B6AB9D5BF4172BCEA480697561362"><enum>(B)</enum><header>Reduction in required number of hours for infection control services overseen by an infection preventionist</header><clause id="HD5DA01E1E6B2403FB8E8A3A1EFE6C225"><enum>(i)</enum><header>In general</header><text>The Secretary may grant a waiver to a skilled nursing facility under which the number of hours per week that infection control services overseen by an infection preventionist at the facility are required under subparagraph (A)(iii) are reduced if the Secretary finds that—</text><subclause id="H7C63E570C1D54881B2AC0CAA12785E1A"><enum>(I)</enum><text>the facility—</text><item id="HD389458BACAC4F2FA1B2B9879D9D962A"><enum>(aa)</enum><text>is located in a rural area and the supply of skilled nursing facility services in such area is not sufficient to meet the needs of individuals residing therein; or</text></item><item id="H727EC1F24830453B86FA0EBEDD165EAC"><enum>(bb)</enum><text>is of a size that necessitates a lower requirement;</text></item></subclause><subclause id="H0F41ABE5F4EC4CA888648810386C40EE"><enum>(II)</enum><text>the Secretary provides notice of the waiver to the State Long-Term Care Ombudsman (supported under title III or chapter 2 of subtitle A of title VII of the Older Americans Act of 1965) and the protection and advocacy system (as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000) in the State; and </text></subclause><subclause id="H4E053875D8764D43AB0C4D2064D96D23"><enum>(III)</enum><text>the facility that is granted the waiver notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver. </text></subclause></clause><clause id="H99C93DB7D7374D2D9D668BA7A7980255"><enum>(ii)</enum><header>Annual review</header><text>A waiver under this subparagraph shall be subject to annual review by the Secretary.</text></clause></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="H0173A5D4A71244C2958968CAF5B1CAAD"><enum>(b)</enum><header>Medicaid</header><text>Section 1919(d)(3) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r">42 U.S.C. 1396r(d)(3)</external-xref>) is amended—</text><paragraph id="H5F14628177A14AC8BF23672FD683DEDB"><enum>(1)</enum><text>by redesignating subparagraphs (A) and (B) as clauses (i) and (ii) respectively, and moving such clauses 2 ems to the right;</text></paragraph><paragraph id="H4577522DE4574131B3813967B4314098"><enum>(2)</enum><text>by striking <quote><header-in-text level="paragraph" style="OLC">environment</header-in-text>.—A nursing facility</quote> and inserting “<header-in-text level="paragraph" style="OLC">environment</header-in-text>.—</text><quoted-block style="OLC" display-inline="no-display-inline" id="H571F1BED24A44DD68F4943F0184BB135"><subparagraph id="H6258A0072BEC4EBD87FE5C545FECFC16"><enum>(A)</enum><header>In general</header><text>A nursing facility</text></subparagraph><after-quoted-block>;</after-quoted-block></quoted-block></paragraph><paragraph id="H93CC137497D14E6799F9CC67472EE657"><enum>(3)</enum><text>in subparagraph (A), as amended by paragraphs (1) and (2)—</text><subparagraph id="HBF7DA9433AD743D4AE39B8596882FADD"><enum>(A)</enum><text>in clause (i), by striking <quote>, and</quote> at the end and inserting a semicolon;</text></subparagraph><subparagraph id="H29B04038EDC84227B51238EDCA60F3CC"><enum>(B)</enum><text>in clause (ii), by striking the period at the end and inserting <quote>; and</quote>; and</text></subparagraph><subparagraph id="H5A1BFB1CBE704F9985EA90329A055AB8"><enum>(C)</enum><text>by adding at the end the following new clause:</text><quoted-block style="OLC" display-inline="no-display-inline" id="HB160AB82047545C189B6AC8FB7997001"><clause id="H7147C5A824D542C69D0BF041B598023A"><enum>(iii)</enum><text>provide, directly or under arrangements with others, for infection control services overseen by an infection preventionist for a minimum number of hours per week as determined appropriate by the Secretary (but, subject to subparagraph (B), not less than 40 hours per week). </text></clause><after-quoted-block>; and</after-quoted-block></quoted-block></subparagraph></paragraph><paragraph commented="no" display-inline="no-display-inline" id="HE2E3FC3180184296BB627AD24BCFAD05"><enum>(4)</enum><text>by adding at the end the following new subparagraph:</text><quoted-block style="OLC" display-inline="no-display-inline" id="H632E4293480B40E0853B32E186F6C6AA"><subparagraph id="H600ED74772054ECF990037A657112ADF"><enum>(B)</enum><header>Reduction in required number of hours for infection control services overseen by an infection preventionist</header><clause id="H47296FCB78E94B1C81342B32AFEA6FE3"><enum>(i)</enum><header>In general</header><text>A State may grant a waiver to a nursing facility under which the number of hours per week that infection control services overseen by an infection preventionist at the facility are required under subparagraph (A)(iii) are reduced if—</text><subclause id="H80B843131E7943FA908BC81E5F3FE790"><enum>(I)</enum><text>the facility demonstrates to the satisfaction of the State that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel;</text></subclause><subclause id="HCA3FD7A779D94E61975B24AA2BF4ADBB"><enum>(II)</enum><text>the State determines that the waiver will not endanger the health or safety of individuals staying in the facility;</text></subclause><subclause id="HE122C4678BF2403BA574ED969830902B"><enum>(III)</enum><text>the State agency granting the waiver provides notice of the waiver to the State Long-Term Care Ombudsman (supported under title III or chapter 2 of subtitle A of title VII of the Older Americans Act of 1965) and the protection and advocacy system (as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000); and</text></subclause><subclause id="H5BEA87B6511242D8A2900DCEB7A9C6B7"><enum>(IV)</enum><text>the nursing facility that is granted the waiver by a State notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver. </text></subclause></clause><clause id="H90DECC977D9C4FCFAD733AC0986B2271"><enum>(ii)</enum><header>Annual review</header><text>A waiver under this subparagraph shall be subject to annual review by the State agency and to the review of the Secretary and subject to clause (iii) shall be accepted by the Secretary for purposes of this title to the same extent as is the State’s certification of the facility. In granting or renewing a waiver, a State may require the facility to use other qualified, licensed personnel to meet the staffing requirements under subparagraph (A)(iii). </text></clause><clause id="HD5EBDEB53FCE4B37AF6714DD365B6DF1"><enum>(iii)</enum><header>Assumption of waiver authority by Secretary</header><text>If the Secretary determines that a State has shown a clear pattern and practice of allowing waivers in the absence of diligent efforts by facilities to meet the staffing requirements under subparagraph (A)(iii), the Secretary shall assume and exercise the authority of the State to grant waivers.</text></clause></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection><subsection id="H3B4CBD24E1524A538617B1FE0BC4F7B4"><enum>(c)</enum><header>Effective date</header><text>The amendments made by this section shall take effect on October 1, 2022. </text></subsection></section><section id="H507EB32FF5144541B0B5A690F6F0734C"><enum>206.</enum><header>Enhanced funding to support staffing and quality care in nursing facilities</header><subsection id="H9681D256C4564B6E853FC3898B9FB979"><enum>(a)</enum><header>FMAP increase</header><paragraph id="H8278CAE3133541828A88DBD8E2E4B648"><enum>(1)</enum><header>In general</header><text>Notwithstanding subsection (b) or (ff) of section 1905 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396d">42 U.S.C. 1396d</external-xref>), in the case of a State that meets the requirements described in subsection (c), the Federal medical assistance percentage determined for the State under subsection (b) of section 1905 of such Act (or subsection (ff) of such section, if applicable) and, if applicable, as increased under subsection (y), (z), (aa), or (ii) of such section or section 6008 of the Families First Coronavirus Response Act (<external-xref legal-doc="public-law" parsable-cite="pl/116/127">Public Law 116–127</external-xref>), or any other provision of law, shall be increased by the applicable number of percentage points specified in paragraph (2) (but not to exceed 95 percent) with respect to amounts expended by the State Medicaid program for medical assistance for nursing facility services provided for each calendar quarter that occurs during the applicable period and for which the Secretary determines that the State meets such requirements. Any payment made to Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa for expenditures on medical assistance that are subject to the Federal medical assistance percentage increase specified under the first sentence of this paragraph shall not be taken into account for purposes of applying payment limits under subsections (f) and (g) of section 1108 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1308">42 U.S.C. 1308</external-xref>).</text></paragraph><paragraph id="H7AE50187027A430C826B7CD1F14ADA27"><enum>(2)</enum><header>Applicable number of percentage points</header><text>For purposes of paragraph (1), the applicable number of percentage points specified in this paragraph is—</text><subparagraph id="H2AA2CDBF151541DEB41CC1F4C08F09EF"><enum>(A)</enum><text>in the case of a calendar quarter that occurs within the 16-quarter period that begins on the 1st day of the applicable period, 3 percentage points;</text></subparagraph><subparagraph id="HB4E61B74547A46A19C30969D753182F3"><enum>(B)</enum><text>in the case of a calendar quarter that occurs within the 4-quarter period immediately succeeding such 16-quarter period, 2 percentage points; and</text></subparagraph><subparagraph id="H459491897D74415D94C30D5669E39E56"><enum>(C)</enum><text>in the case of a calendar quarter that occurs within the 4-quarter period immediately succeeding the 4-quarter period described in subparagraph (B), 1 percentage point.</text></subparagraph></paragraph></subsection><subsection id="HE750A1480A9F4E60A2EAB73CF514058C"><enum>(b)</enum><header>Definitions</header><text>In this section:</text><paragraph id="HBA8E71CBCDBD47B592A058C5B3EAA3AD"><enum>(1)</enum><header>Applicable period</header><text>The term <term>applicable period</term> means the period that—</text><subparagraph id="HCC79970EE5B24E80B4DA9EA495A0E6A9"><enum>(A)</enum><text>begins on the 1st day of the 1st calendar quarter that begins on or after the date that is 1 year after the date of enactment of this section; and</text></subparagraph><subparagraph id="HB3C45BF28C754B609AA34DD1B4A963AD"><enum>(B)</enum><text>ends on the last day of the succeeding 24th calendar quarter.</text></subparagraph></paragraph><paragraph id="HD751C55AB8CB4EEAAD1A8F49EA7D5B75"><enum>(2)</enum><header>Nursing facility staff</header><text>The term <term>nursing facility staff</term> includes a registered nurse, licensed practical nurse, licensed nursing assistant, certified nursing assistant, nursing assistant, and any other relevant staff, as determined by the Secretary, who provide care to Medicaid beneficiaries who are residents in a nursing facility.</text></paragraph><paragraph id="H86416B6F7B874BC386F2876DB2F32431"><enum>(3)</enum><header>Medicaid beneficiary</header><text>The term <term>Medicaid beneficiary</term> means an individual who is eligible for, and enrolled in, a State Medicaid program.</text></paragraph><paragraph commented="no" id="H0453FF83E59C4A1C8C96211941A9126E"><enum>(4)</enum><header>Medicaid program</header><text>The term <term>Medicaid program</term> means, with respect to a State, the State program under title XIX of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396">42 U.S.C. 1396 et seq.</external-xref>) (including any waiver or demonstration under such title or under section 1115 of such Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1315">42 U.S.C. 1315</external-xref>) relating to such title).</text></paragraph><paragraph commented="no" id="HB86822356DF5400A98DBA39158331D13"><enum>(5)</enum><header>Nursing facility</header><text>The term <term>nursing facility</term>—</text><subparagraph commented="no" id="HB989739B231948E2BFF5C8A82FA4B3FD"><enum>(A)</enum><text>has the meaning given such term in section 1919(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396r">42 U.S.C. 1396r(a)</external-xref>); and</text></subparagraph><subparagraph commented="no" id="H7BA09EB409E640DDABA9800DF466B9D8"><enum>(B)</enum><text>includes a skilled nursing facility, as defined in section 1819(a) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395i-3">42 U.S.C. 1395i–3(a)</external-xref>), that is a participating provider in the Medicaid program of the State in which the facility is located or otherwise furnishes items or services for which medical assistance is available under the Medicaid program of the State in which the facility is located.</text></subparagraph></paragraph><paragraph commented="no" id="HFA9D1084C953430AA6FFEC48891C609A"><enum>(6)</enum><header>Nursing facility services</header><subparagraph commented="no" id="H69B5D60AB1984BABBD38C1582F15E38D"><enum>(A)</enum><header>In general</header><text>Subject to subparagraphs (B) and (C), the term <term>nursing facility services</term> has the meaning given such term under section 1905(f) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396d">42 U.S.C. 1396d(f)</external-xref>).</text></subparagraph><subparagraph commented="no" id="H9330758C90C04326B434C91129605356"><enum>(B)</enum><header>State medicaid program</header><text>With respect to a State, such term includes those services (including any limitations on the provision of, or payment for, such services) that are specified as nursing facility services for purposes of the Medicaid program of the State in which the nursing facility furnishing such services is located.</text></subparagraph><subparagraph commented="no" id="H14D4C9EB81EB4BE08E59F80BC3C61608"><enum>(C)</enum><header>Individual plan of care</header><text>Notwithstanding subparagraph (A) or (B), such term includes items or services that are specified in the individual plan of care for a resident of a nursing facility and are furnished to the resident in accordance with the requirements of such plan.</text></subparagraph></paragraph><paragraph commented="no" id="H10DD4133FED149E693BF67BF4DE05314"><enum>(7)</enum><header>Secretary</header><text>The term <term>Secretary</term> means the Secretary of Health and Human Services.</text></paragraph><paragraph commented="no" id="H14450D2922194414900537582187D06C"><enum>(8)</enum><header>State</header><text>The term <term>State</term> has the meaning given such term for purposes of title XIX of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396">42 U.S.C. 1396 et seq.</external-xref>).</text></paragraph></subsection><subsection commented="no" id="H0978CA37F7A14BA8A08B121C11B2A536"><enum>(c)</enum><header>Requirements</header><text>As a condition for receipt of the increase under subsection (a) to the Federal medical assistance percentage determined for a State under subsection (b) of section 1905 of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1396d">42 U.S.C. 1396d</external-xref>) for a calendar quarter, the State shall demonstrate to the satisfaction of the Secretary the following:</text><paragraph commented="no" id="H7E4F39413B634E6FAA5497BB919B62E4"><enum>(1)</enum><header>Use of additional federal funds</header><text>The State agrees to—</text><subparagraph commented="no" id="H7BBD653397A14967B716E10BD36D3CEA"><enum>(A)</enum><text>use the Federal funds attributable to the increase under subsection (a) only for the purposes specified in subsection (d); and</text></subparagraph><subparagraph commented="no" id="H70FA54D1A6684CDAA3CDD39FA29E1121"><enum>(B)</enum><text>not use such Federal funds to satisfy any State contribution required under the State Medicaid program.</text></subparagraph></paragraph><paragraph commented="no" id="H4E18F1F1BBDF47C9B3115B64AD4E0FB8"><enum>(2)</enum><header>Plan for staffing and service improvements and reporting</header><text>The State has a reasonable plan for achieving the purposes specified in subsection (d), including with respect to—</text><subparagraph commented="no" id="HF16AD7E42CCE431C91E6B3BA2576E050"><enum>(A)</enum><text>carrying out the staffing and service improvements specified in subsection (e) to strengthen nursing facility staff workforce and improve the quality and safety of care for Medicaid beneficiaries; and</text></subparagraph><subparagraph commented="no" id="H468926ACC6894F8EBF62904D430B274F"><enum>(B)</enum><text>collecting and reporting the information required under subsection (f).</text></subparagraph></paragraph><paragraph id="H29EC98DEA64F418CA2AFDEAC12C9C714"><enum>(3)</enum><header>Supplement, not supplant</header><text>The State agrees to use the Federal funds attributable to the increase under subsection (a) to supplement, and not supplant, the level of State funds expended as of October 1, 2021, for nursing facility services, including with respect to efforts to strengthen the nursing facility staff workforce and improve the quality and safety of care for Medicaid beneficiaries, under the State Medicaid program.</text></paragraph><paragraph commented="no" id="HA2871EA1E7FA497CB3C2D76C2889384E"><enum>(4)</enum><header>Reporting and oversight</header><text>The State agrees to—</text><subparagraph commented="no" id="H96F348AA785E42C4B78DAB289E604E5A"><enum>(A)</enum><text>annually report the information specified in subsection (f) to the Secretary in such form and manner as the Secretary shall require; and</text></subparagraph><subparagraph commented="no" id="HDE0BA4F140ED41D6BAB8F6DAD17F5384"><enum>(B)</enum><text>provide such data and information as is necessary for the evaluation required under subsection (g).</text></subparagraph></paragraph></subsection><subsection commented="no" id="HED5D7336870540CEB08C166A31B53DB1"><enum>(d)</enum><header>Use of funds</header><text>A State may use the Federal funds attributable to the increase under subsection (a) only for expenditures eligible for payment under the State Medicaid program that are attributable to State efforts to achieve both of the following purposes:</text><paragraph commented="no" id="H26DB7891192E4CF295AD74927C195226"><enum>(1)</enum><text>To expand and improve nursing facility staffing, including by increasing payments for nursing facility services to improve staff wages and benefits, support retention and recruitment, and reduce staff turnover, consistent with the improvements specified in paragraphs (1) and (2) of subsection (e). </text></paragraph><paragraph commented="no" id="H00C578115B814DD396F2C2C642A9C767"><enum>(2)</enum><text>To support and improve the quality and safety of care provided to Medicaid beneficiaries in nursing facilities, including through efforts to expand the use of person-centered models of care, and incentives or payments related to the provision of care for Medicaid beneficiaries in private rooms. </text></paragraph></subsection><subsection commented="no" id="H058378D8B0BC4C10AC53EC1BD94679E7"><enum>(e)</enum><header>Staffing and service improvements</header><text>The staffing and service improvements specified in this subsection are the following:</text><paragraph id="H6269CDACB7874555B8CE9F08545EA175"><enum>(1)</enum><text>The State makes such changes to processes for determining payment rates for nursing facility services as are necessary to ensure that—</text><subparagraph id="HEF01835B11114C17850D0827B1182363"><enum>(A)</enum><text>such payment rates are reviewed and updated every 2 years during the applicable period to support the recruitment and retention of nursing facility staff, and reduce turnover in such staff through a transparent process that involves meaningful input from stakeholders; and</text></subparagraph><subparagraph id="HD8535EF430084A958EE65838D84C9694"><enum>(B)</enum><text>increases to such payment rates are, at a minimum, used to proportionally increase wages and benefits for nursing facility staff.</text></subparagraph></paragraph><paragraph id="H548A2426542F4871A7B4C35CE77DE915"><enum>(2)</enum><text>The State updates, develops, and adopts training opportunities and resources for nursing facility staff, including training for providing person-centered care.</text></paragraph><paragraph id="HC685780B5EBA40FFA0168440B9515243"><enum>(3)</enum><text>The State improves and streamlines education and options counseling services for Medicaid beneficiaries, potential Medicaid beneficiaries, and family members of such beneficiaries and potential beneficiaries, with respect to eligibility and options for institutional and non-institutional long term care. </text></paragraph></subsection><subsection id="H941BB1170B454A32B83656D5A418D55B"><enum>(f)</enum><header>Annually reported information</header><text>The information required to be annually reported to the Secretary by a State with respect to such reporting periods as the Secretary shall specify is the following:</text><paragraph id="H918496BA99494381820F9651BE280A46"><enum>(1)</enum><text>The number of Medicaid beneficiaries who received during the reporting period or, as of the date of the report, are receiving, nursing facility services in the State, disaggregated by race, ethnicity, gender, geography, age, and income.</text></paragraph><paragraph id="HFC52E0C99B8249B19D5E0C42971471E7"><enum>(2)</enum><text>A description of how the State spent the Federal funds attributable to the increase under subsection (a) during the reporting period.</text></paragraph><paragraph commented="no" id="H52DF92594937431BBFC8593ADF52C2F9"><enum>(3)</enum><text>Changes to payment rates for nursing facility services under the State Medicaid program during the reporting period.</text></paragraph><paragraph id="H2EF2B8C68D4941A4ADE67AC067BCC35F"><enum>(4)</enum><text>The staffing information and employee turnover and tenure information in nursing facilities in the State during the reporting period, based on submissions to the Payroll-Based Journal system of the Centers for Medicare & Medicaid Services under section 1128I(g) of the Social Security Act (42 U.S.C. 1320a–7j(g)). </text></paragraph><paragraph id="H4A175788EB954FA4A83A802F5F5A4381"><enum>(5)</enum><text>The wages and benefits provided to nursing facility staff in nursing facilities in the State during the reporting period.</text></paragraph><paragraph id="HD685B46CC71948E0895AD7074B1682F6"><enum>(6)</enum><text>A description of the health status of, and quality of care provided to, Medicaid beneficiaries who are residents of nursing facilities in the State during the reporting period, in the manner determined by the Secretary.</text></paragraph></subsection><subsection commented="no" id="HA44BDCAFB25B4913A3E8ABCE8D46F236"><enum>(g)</enum><header>Evaluation</header><text>The Secretary shall engage an external contractor to conduct an independent evaluation of the impact of this section on— </text><paragraph commented="no" id="HF0D9B63060B747BAA5814DE8C23A6F4D"><enum>(1)</enum><text>the quality and safety of care provided in nursing facilities to Medicaid beneficiaries who are residents of nursing facilities;</text></paragraph><paragraph commented="no" id="HC0C1A4C1B780417CA0B5686C69B4243E"><enum>(2)</enum><text>the capacity of the nursing facility staff workforce to provide quality, safe care for Medicaid beneficiaries who are residents of nursing facilities; and</text></paragraph><paragraph commented="no" id="H9133F45EBB3E4CE7B4C2838ACFB1B65E"><enum>(3)</enum><text>the wages, benefits, and turnover of nursing facility staff.</text></paragraph></subsection><subsection commented="no" id="HA74F6D0519F44617815DAAF673AB3357"><enum>(h)</enum><header>Interim and final reports to Congress</header><paragraph commented="no" id="H380A495A851E4C4EB6D2EBF4B26AF0DF"><enum>(1)</enum><header>In general</header><text>The Secretary shall submit an interim report to Congress on the implementation of this section 4 years after the date of enactment of this section, and a final report on the implementation of this section 8 years after such date.</text></paragraph><paragraph commented="no" id="H350CE129DE3C4127BF44418F97A67E4B"><enum>(2)</enum><header>Required information</header><subparagraph commented="no" id="HBEC1C4EE964F4B5CA8EBB10153D653FE"><enum>(A)</enum><header>Interim and final reports</header><text>The interim and final reports submitted under this subsection shall include the following information:</text><clause commented="no" id="H4CF18680FDC64863B575A93C75EBCD56"><enum>(i)</enum><text>The number of States that received an increase to the Federal medical assistance percentage of the State under subsection (a) during the applicable period.</text></clause><clause commented="no" id="HD043A1CB29014A3994FCFECD87B53221"><enum>(ii)</enum><text>The State activities funded by the Federal funds attributable to the increase under subsection (a).</text></clause></subparagraph><subparagraph commented="no" id="H6B23DBA86FAD4210972C475CADE4872D"><enum>(B)</enum><header>Final report</header><text>The final report submitted under this section shall include, in addition to the information required under subparagraph (A), the results of the independent evaluation conducted pursuant to subsection (g).</text></subparagraph></paragraph></subsection></section><enum>III</enum><header>Building modification and staff investment demonstration program</header><section id="HAC20C51782424292BC7823224E72912A"><enum>301.</enum><header>Establishing a skilled nursing facility building modification and staff investment demonstration program</header><text display-inline="no-display-inline">Part A of title XVIII of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395c">42 U.S.C. 1395c et seq.</external-xref>) is amended by inserting after section 1819 the following new section: </text><quoted-block style="OLC" display-inline="no-display-inline" id="H384A7EB43084405EA74911FBA830B1EA"><section section-type="subsequent-section" id="H60C2666040EE496CA0A04A44C73E45D9"><enum>1819A.</enum><header>Community-based living modifications and staff investment demonstration program</header><subsection id="HC0DFDF7A480047DDBB50A3997D4B30CF"><enum>(a)</enum><header>Establishment</header><text>Not later than January 1, 2023, the Secretary shall establish a demonstration program to test the impact of providing skilled nursing facilities (as defined in section 1819(a)) selected by the Secretary under subsection (b) funding to modify the built environments of such facilities (or portions of such facilities) and invest in individuals providing resident care in such facilities (or in portions of such facilities) in order to, with respect to residents of such facilities, improve health outcomes relative to residents of facilities not so selected.</text></subsection><subsection id="HEAB7A111CF424812A26341912BE5FC17"><enum>(b)</enum><header>Application and selection of facilities</header><paragraph id="H527E6A6D21B24480813475F8FDA3B9A8"><enum>(1)</enum><header>Application</header><subparagraph id="H6E4C51D331BB42E89F27928C478A63FC"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">A skilled nursing facility shall only be eligible to receive funding under the demonstration program established under subsection (a) if such facility submits an application at such time and in such manner as specified by the Secretary that contains—</text><clause id="H76A46FEAD94C42F3A2751CB060A0CF62"><enum>(i)</enum><text>a description of modifications and investments described in subsection (a) that will be made by the facility using such funds, including the estimated costs of such modifications and investments;</text></clause><clause id="H584EBFDDC7F24B9A99B265D68834CC3E"><enum>(ii)</enum><text>an agreement that such facility (or, in the case such modifications and investments are to be made only with respect to a portion of such facility, such portion of such facility)—</text><subclause id="HFA6572F2645142B0A4FAB1A382D670A4"><enum>(I)</enum><text>will meet the requirements described in subparagraph (B) not later than the date that is 2 years after such facility first receives funds for such modifications and investments under such program; and</text></subclause><subclause id="H1E8F530BD068441897B5F1B481DBA03C"><enum>(II)</enum><text>will continue to meet such requirements for the 5-year period beginning on the date that is 2 years after such facilities first receives such funds;</text></subclause></clause><clause id="H47EFCCE4CC09461E958D3E86E27965B8"><enum>(iii)</enum><text>an agreement that, in the case such facility (or such portion of such facility, as applicable) fails to meet such requirements in accordance with clause (ii), such facility will—</text><subclause id="H29D6D0DF09764D299F5AC7ED912AAC22"><enum>(I)</enum><text>repay such funds to the Secretary in an amount determined appropriate by the Secretary under subsection (d); and</text></subclause><subclause id="H851529B5E6364298880FF8F5507737C5"><enum>(II)</enum><text>notify each resident of such facility (or each resident of such portion of such facility, as applicable) of the failure of such facility or such portion, as applicable, to meet such requirements;</text></subclause></clause><clause id="H860686E14CDA4A58B6EABD3050C3E088"><enum>(iv)</enum><text>an agreement that, if such facility is selected by the Secretary under paragraph (2), the facility will notify each resident of such facility (or each resident of such portion of such facility, as applicable), of such selection and include in such notification a description of the program established under subsection (a), including any modifications and investments to be made with respect to such facility (or with respect to such portion of such facility, as applicable); and</text></clause><clause id="HBD6252EF521D4ABE8C06712848C54AEF"><enum>(v)</enum><text display-inline="yes-display-inline">in the case such modifications and investments are to be made only with respect to a portion of such facility, an agreement that such facility will not discriminate in the selection of residents who may reside in such portion based on whether payment is being made to such facility with respect to such resident under this title, a State plan (or waiver of such plan) under title XIX, or otherwise.</text></clause></subparagraph><subparagraph display-inline="no-display-inline" id="HC2D1366B45124861BC6473B33F6211F6"><enum>(B)</enum><header>Requirements</header><text>For purposes of subparagraph (A), the requirements described in this subparagraph with respect to a skilled nursing facility (or a portion of such facility) are the following:</text><clause id="H7E2D9BE3BCEE45B4AF2A4397D0C42F9D"><enum>(i)</enum><text>The facility (or portion) maintains beds for no less than 5 and no more than 14 residents.</text></clause><clause id="H72AB206F31A149A19052E80508527357"><enum>(ii)</enum><text display-inline="yes-display-inline">The facility (or portion) incorporates universal design (defined in section 3(19) of the Assistive Technology Act of 1998)) to ensure such facility (or portion) is accessible to all residents, regardless of age or disability, including by providing for the following:</text><subclause id="H42F744D64C32421A822EACE76F3DD327"><enum>(I)</enum><text display-inline="yes-display-inline">Private rooms and bathrooms (unless such facility determines that the provision of private rooms and bathrooms at such facility would adversely affect the availability of skilled nursing facility services in the area in which such facility is located and the Secretary concurs with such determination).</text></subclause><subclause id="H37C24552B0D74DF195BE2CE830DACE47"><enum>(II)</enum><text display-inline="yes-display-inline">Shared space, including a central living area, as defined by the Secretary, with a communal dining table and accessible kitchen.</text></subclause><subclause id="H7D8BBB85FECD4F30A97528C5B0A5C99F"><enum>(III)</enum><text display-inline="yes-display-inline">Accessible outdoor space, including a protected garden space for use by residents and their visitors.</text></subclause></clause><clause id="HEBBCE5634D334A34A50B69AFB7BB9AC2"><enum>(iii)</enum><text>The facility (or portion) provides a clinical team that consists of a full-time registered professional nurse or licensed practical nurse (or licensed vocational nurse) who works in partnership with certified nursing assistants in a team-based, collaborative model.</text></clause><clause id="HF9E00F77C2764655A6C5D8E2C420B3F3"><enum>(iv)</enum><text>The facility (or portion) has a licensed practical nurse (or licensed vocational nurse) on site at all times.</text></clause><clause id="H119A77E3FD8644A49EDF36F60DD3BB5C"><enum>(v)</enum><text display-inline="yes-display-inline">The facility (or portion) facilitates a standing resident council run by residents, and a standing family council run by family members of residents, that meets such requirements as may be specified by the Secretary.</text></clause><clause id="H79B7105F876A4A9E9C28B5F0D8A13586"><enum>(vi)</enum><text>The facility (or portion) solicits resident input on facility policies (or policies relating to such portion of such facility), including with respect to programs and scheduling, and, in the case of an incapacitated resident, solicits such input from an individual recognized by State law to act on behalf of such resident.</text></clause><clause id="HD9AC791757854016852E6365ADEDDA98"><enum>(vii)</enum><text>In addition to the resident assessment under section 1819(b)(3), the facility (or portion) conducts an assessment of residents’ care preferences (or, in the case of an incapacitated resident, such preferences as expressed by an individual recognized by State law to act on behalf of such resident) not later than 14 days after the resident is admitted to such facility or portion of such facility (or, in the case of a resident residing at such facility at the time such facility receives funding under the program established under paragraph (1), not later than 14 days after the date of such receipt) to ensure care is person-directed.</text></clause><clause id="H9174CB0EEE294F0CBE629B2EDB1E74BD"><enum>(viii)</enum><text>The facility (or portion) offers daily activities, such as art, music, educational activities, or other activities based on resident preferences.</text></clause></subparagraph><subparagraph id="HA1709AEAE68B44C085653D526AF3C03D"><enum>(C)</enum><header>Timeframe</header><text display-inline="yes-display-inline">The Secretary shall develop the application described in subparagraph (A) and begin accepting such applications not later than July 1, 2023. The Secretary shall accept such applications during the 2-year period beginning on the date such applications are first accepted.</text></subparagraph></paragraph><paragraph id="H5FE1D2DBF40046DCA498C4D4BB64354D"><enum>(2)</enum><header>Selection</header><subparagraph id="HAE7AE164E8174CDF8E77F927453858EB"><enum>(A)</enum><header>In general</header><text display-inline="yes-display-inline">Not later than 2 years after the date the Secretary first accepts applications under paragraph (1), the Secretary shall select a number of skilled nursing facilities determined appropriate by the Secretary to receive funding under the program established under subsection (a).</text></subparagraph><subparagraph id="H09EA888E10D2495E947804DFFF9F9D97"><enum>(B)</enum><header>Preference</header><text>In selecting skilled nursing facilities under this paragraph, the Secretary shall—</text><clause id="HB90D9E1655784197A8E8CCF5EFD78039"><enum>(i)</enum><text>give preference to facilities that—</text><subclause id="H2D742F365DE34BAAB06C8A59A972B2F1"><enum>(I)</enum><text>are located in medically underserved areas (as defined in section 330(b)(3)(A) of the Public Health Service Act); and</text></subclause><subclause id="H1DF050A8E45442FFB6A0B281CE63079A"><enum>(II)</enum><text display-inline="yes-display-inline">house a majority of residents who are receiving medical assistance consisting of nursing facility services under a State plan (or waiver of such plan) under title XIX;</text></subclause></clause><clause id="H60FB79B0BB0F47B6922710A3E373A3FD"><enum>(ii)</enum><text>give preference to facilities that demonstrate the greatest likelihood of meeting the requirements described in paragraph (1)(B) within 2 years of receiving funding under the program established under subsection (a);</text></clause><clause id="H7CEDCB32A55D4E5BAA45A66908649F5B"><enum>(iii)</enum><text>give preference to facilities that offer staff training beyond such training required under section 1819 (as determined through payroll based journal data); and</text></clause><clause id="H7C6F3046EB374FD08DBC0D4BEFDD9F66"><enum>(iv)</enum><text>so select such facilities in a manner that ensures geographic diversity, to the extent practicable.</text></clause></subparagraph></paragraph></subsection><subsection id="HFAC91F3DEBFA4C35B45480CE911E3C03"><enum>(c)</enum><header>Funds</header><paragraph id="H52F4C61052D640B3A90B94CF8EAAEC07"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Subject to paragraph (3) and subsection (h), the Secretary shall provide funds to each skilled nursing facility selected under subsection (b)(2) in an amount equal to not more than the costs specified by such facility pursuant to subsection (b)(1)(A)(i).</text></paragraph><paragraph id="H9AB448E86DE94926B10DDF24CD95B5D7"><enum>(2)</enum><header>Use of funds</header><subparagraph id="H46DE3F5E7A8E4B61AF144D29C665ABF2"><enum>(A)</enum><header>In general</header><text>Subject to subparagraph (B), funds provided under paragraph (1) may only be used by a skilled nursing facility for modifications and investments specified by such facility pursuant to subsection (b)(1)(A)(i).</text></subparagraph><subparagraph id="H6BCCCDA7D9D143A8AE431F3610D08F92"><enum>(B)</enum><header>Exception</header><text>A skilled nursing facility may use funds provided under paragraph (1) for modifications and investments described in subsection (a) but not specified by such facility pursuant to subsection (b)(1)(A)(i) if—</text><clause id="H38ADFFC4AA214034A152C7C3E8B87D56"><enum>(i)</enum><text>such facility submits a request to the Secretary containing a description of such modifications and investments; and</text></clause><clause id="H38D612A5F86D445AA9D5F72A25F26DD5"><enum>(ii)</enum><text>the Secretary determines that such modifications and investments will assist such facility (or a portion of such facility, as applicable) in complying with the requirements specified in subsection (b)(1)(B).</text></clause></subparagraph></paragraph><paragraph id="H30A8A7B9171B44958E93F9D37A0C709D"><enum>(3)</enum><header>Form of provision of funds</header><text display-inline="yes-display-inline">The Secretary may provide funding under paragraph (1) in the form of a single upfront payment or in up to 3 installment payments, spaced out across the first 3 fiscal years beginning with the fiscal year in which the first such payment is made.</text></paragraph><paragraph id="H5E0A964929EA413EB92B87124D5C797B"><enum>(4)</enum><header>Limitation of provision of funding</header><text>No skilled nursing facility may receive more than 3 percent of the total monies appropriated under paragraph (5).</text></paragraph><paragraph id="H901F19E83B9849F782B0D1C1B7E5489E"><enum>(5)</enum><header>Appropriation</header><text>In addition to any amounts otherwise available, there is appropriated to the Secretary, out of any monies in the Treasury not otherwise appropriated, $1,300,000,000, to remain available until expended, for purposes of providing funds to skilled nursing facilities under paragraph (1).</text></paragraph></subsection><subsection id="HB73C84F4660F448AAED1B53F9405025A"><enum>(d)</enum><header>Failure To meet requirements</header><paragraph commented="no" id="H43C846AC69DB40C4AC6B305EEE5A2F7C"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">Subject to paragraph (2), in the case of a facility (or a portion of such facility, as applicable) that fails to meet the requirements described in subsection (b)(1)(B) in accordance with the agreement described in subsection (b)(1)(A)(ii), the Secretary may recoup any funds provided to such facility under subsection (c)(1) in an amount determined appropriate by the Secretary. In determining such amount, the Secretary shall take into account the extent of the compliance of such facility (or portion of such facility, as applicable) with such requirements.</text></paragraph><paragraph id="H83D10664636445E4B1651FC38F0CD297"><enum>(2)</enum><header>Exception</header><text>The Secretary may suspend any recoupment described in paragraph (1) with respect to a facility (or a portion of such facility, as applicable) described in such paragraph for a period of time determined appropriate by the Secretary if the Secretary finds that such facility (or such portion) will likely be in compliance with the requirements described in such paragraph within a reasonable time specified by the Secretary. </text></paragraph></subsection><subsection id="H67A2897158984EBCAF91DAD1C5DB0955"><enum>(e)</enum><header>Evaluation of program</header><paragraph id="HF95DE1EC76C94E0BBA3C01FE5766B194"><enum>(1)</enum><header>In general</header><text display-inline="yes-display-inline">The Secretary shall evaluate each skilled nursing facility receiving funds under the program established under subsection (a) to assess whether, relative to similarly situated skilled nursing facilities not receiving funds under such program and residents of such facilities, modifications and investments described in subsection (a) made at skilled nursing facilities using such funds resulted in, with respect to residents of such facilities (or, in the case such modifications and investments are made only with respect to a portion of such facility, residents of such portion of such facility)—</text><subparagraph display-inline="no-display-inline" id="H38B0FBE051F548FFB4C07DA9064638B7"><enum>(A)</enum><text>a reduction in preventable hospitalizations;</text></subparagraph><subparagraph id="HF4A58F9AC029435992259E0CF3ED309C"><enum>(B)</enum><text>a reduction in hospital readmissions;</text></subparagraph><subparagraph id="H06D8A331CC0B442EAA9D56539C9D3309"><enum>(C)</enum><text>a reduction in emergency room visits; </text></subparagraph><subparagraph id="HDED187EC16A84FBFA9528D529FE21F9B"><enum>(D)</enum><text>greater improvement in functional status;</text></subparagraph><subparagraph id="H2207F49CDD2B4B04BF9E7DF1A0398A01"><enum>(E)</enum><text>an improvement in infection control;</text></subparagraph><subparagraph id="HC9F0911C5D1441CE9B899408C24DB8EF"><enum>(F)</enum><text>a reduction in nursing staff turnover rates;</text></subparagraph><subparagraph id="H8FEB1A8BFE96454C83F631335A2056F2"><enum>(G)</enum><text>an increase in resident and family caregiver satisfaction;</text></subparagraph><subparagraph id="H3C40A94C707B4E328F170D87C296D2A4"><enum>(H)</enum><text>other improvements in resident quality of life as may be specified by the Secretary;</text></subparagraph><subparagraph id="H9DDE300ADE8640D9AA4446DD84ACA316"><enum>(I)</enum><text>a reduction in expenditures under this part (excluding funds provided under subsection (c)(1)); or</text></subparagraph><subparagraph id="H31895E06FE9B4239856A272A378E660F"><enum>(J)</enum><text>any other outcomes specified by the Secretary.</text></subparagraph></paragraph><paragraph id="H4D11F7D77254484E9D1002CE7C97AFF3"><enum>(2)</enum><header>Reports to congress</header><text>Based on evaluations described in paragraph (1), the Secretary shall, not later than July 1, 2031, and again not later than July 1, 2035, submit to Congress a report on such program. Each such report shall include an analysis of the demonstration program’s effect on the outcomes described in paragraph (1).</text></paragraph></subsection><subsection id="H028A3C1EF8284F77A9115F2A68DCA93E"><enum>(f)</enum><header>Implementation</header><text display-inline="yes-display-inline"><external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/44/35">Chapter 35</external-xref> of title 44, United States Code, shall not apply to this section.</text></subsection><subsection id="HAA7662B5AED34F408C93AC4F0F7E608C"><enum>(g)</enum><header>Authority To expand to certain nursing facilities</header><text display-inline="yes-display-inline">The Secretary may, subject to subsection (h), enter into agreements with States to include nursing facilities (as defined in section 1919(a)) that are not skilled nursing facilities (as defined in section 1819(a)) in the demonstration program established under subsection (a) and may modify the requirements of the previous provisions of this section as appropriate to be applicable to such facilities.</text></subsection><subsection commented="no" id="HC0D85EB64E7449D693D5AC2AAEBBE8FB"><enum>(h)</enum><header>Funding</header><text>The Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under 1817 to the Centers for Medicare & Medicaid Services Program Management Account, of $30,000,000 for fiscal year 2023 for purposes of carrying out this section (other than for purposes of making payments under subsection (c)(1)). Amounts transferred pursuant to the previous sentence shall remain available until expended.</text></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></section>