# H.R. 3200/Division B/Title IV/Subtitle B/Part 1
## PART 1 — IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING FACILITIES AND NURSING FACILITIES
### Sec. 1411. Required Disclosure of Ownership and Additional Disclosable Parties Information.

    (a) In General.—
       Section 1124 of the Social Security Act (42 U.S.C. 1320a–3) is amended by adding at the end the following new subsection:
          ``(c) Required Disclosure of Ownership and Additional Disclosable Parties Information.—
             ``(1) Disclosure.—A facility (as defined in paragraph (7)(B)) shall have the information described in paragraph (3) available—
                ``(A) during the period beginning on the date of the enactment of this subsection and ending on the date such information is made available to the public under section 1411(b) of the America’s Affordable Health Choices Act of 2009, for submission to the Secretary, the Inspector General of the Department of Health and Human Services, the State in which the facility is located, and the State long-term care ombudsman in the case where the Secretary, the Inspector General, the State, or the State long-term care ombudsman requests such information; and
                ``(B) beginning on the effective date of the final regulations promulgated under paragraph (4)(A), for reporting such information in accordance with such final regulations.
             ``Nothing in subparagraph (A) shall be construed as authorizing a facility to dispose of or delete information described in such subparagraph after the effective date of the final regulations promulgated under paragraph (4)(A).
             ``(2) Public availability of information.—During the period described in paragraph (1)(A), a facility shall—
                ``(A) make the information described in paragraph (3) available to the public upon request and update such information as may be necessary to reflect changes in such information; and
                ``(B) post a notice of the availability of such information in the lobby of the facility in a prominent manner.
             ``(3) Information described.—
                ``(A) In general.—The following information is described in this paragraph:
                   ``(i) The information described in subsections (a) and (b), subject to subparagraph (C).
                   ``(ii) The identity of and information on—
                      ``(I) each member of the governing body of the facility, including the name, title, and period of service of each such member;
                      ``(II) each person or entity who is an officer, director, member, partner, trustee, or managing employee of the facility, including the name, title, and date of start of service of each such person or entity; and
                      ``(III) each person or entity who is an additional disclosable party of the facility.
                   ``(iii) The organizational structure of each person and entity described in subclauses (II) and (III) of clause (ii) and a description of the relationship of each such person or entity to the facility and to one another.
                ``(B) Special rule where information is already reported or submitted.—To the extent that information reported by a facility to the Internal Revenue Service on Form 990, information submitted by a facility to the Securities and Exchange Commission, or information otherwise submitted to the Secretary or any other Federal agency contains the information described in clauses (i), (ii), or (iii) of subparagraph (A), the Secretary may allow, to the extent practicable, such Form or such information to meet the requirements of paragraph (1) and to be submitted in a manner specified by the Secretary.
                ``(C) Special rule.—In applying subparagraph (A)(i)—
                   ``(i) with respect to subsections (a) and (b), ‘ownership or control interest’ shall include direct or indirect interests, including such interests in intermediate entities; and
                   ``(ii) subsection (a)(3)(A)(ii) shall include the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured, in whole or in part, by the entity or any of the property or assets thereof, if the interest is equal to or exceeds 5 percent of the total property or assets of the entirety.
             ``(4) Reporting.—
                ``(A) In general.—Not later than the date that is 2 years after the date of the enactment of this subsection, the Secretary shall promulgate regulations requiring, effective on the date that is 90 days after the date on which such final regulations are published in the Federal Register, a facility to report the information described in paragraph (3) to the Secretary in a standardized format, and such other regulations as are necessary to carry out this subsection. Such final regulations shall ensure that the facility certifies, as a condition of participation and payment under the program under title XVIII or XIX, that the information reported by the facility in accordance with such final regulations is accurate and current.
                ``(B) Guidance.—The Secretary shall provide guidance and technical assistance to States on how to adopt the standardized format under subparagraph (A).
             ``(5) No effect on existing reporting requirements.—Nothing in this subsection shall reduce, diminish, or alter any reporting requirement for a facility that is in effect as of the date of the enactment of this subsection.
             ``(6) Definitions.—In this subsection:
                ``(A) Additional disclosable party.—The term ‘additional disclosable party’ means, with respect to a facility, any person or entity who—
                   ``(i) exercises operational, financial, or managerial control over the facility or a part thereof, or provides policies or procedures for any of the operations of the facility, or provides financial or cash management services to the facility;
                   ``(ii) leases or subleases real property to the facility, or owns a whole or part interest equal to or exceeding 5 percent of the total value of such real property;
                   ``(iii) lends funds or provides a financial guarantee to the facility in an amount which is equal to or exceeds $50,000; or
                   ``(iv) provides management or administrative services, clinical consulting services, or accounting or financial services to the facility.
                ``(B) Facility.—The term ‘facility’ means a disclosing entity which is—
                   ``(i) a skilled nursing facility (as defined in section 1819(a)); or
                   ``(ii) a nursing facility (as defined in section 1919(a)).
                ``(C) Managing employee.—The term ‘managing employee’ means, with respect to a facility, an individual (including a general manager, business manager, administrator, director, or consultant) who directly or indirectly manages, advises, or supervises any element of the practices, finances, or operations of the facility.
                ``(D) Organizational structure.—The term ‘organizational structure’ means, in the case of—
                   ``(i) a corporation, the officers, directors, and shareholders of the corporation who have an ownership interest in the corporation which is equal to or exceeds 5 percent;
                   ``(ii) a limited liability company, the members and managers of the limited liability company (including, as applicable, what percentage each member and manager has of the ownership interest in the limited liability company);
                   ``(iii) a general partnership, the partners of the general partnership;
                   ``(iv) a limited partnership, the general partners and any limited partners of the limited partnership who have an ownership interest in the limited partnership which is equal to or exceeds 10 percent;
                   ``(v) a trust, the trustees of the trust;
                   ``(vi) an individual, contact information for the individual; and
                   ``(vii) any other person or entity, such information as the Secretary determines appropriate.´´.
    (b) Public Availability of Information.—
          (1) In General.—
             Not later than the date that is 1 year after the date on which the final regulations promulgated under section 1124(c)(4)(A) of the Social Security Act, as added by subsection (a), are published in the Federal Register, the information reported in accordance with such final regulations shall be made available to the public in accordance with procedures established by the Secretary.
          (2) Definitions.—
             In this subsection:
                (A) Nursing Facility.—
                   The term ``nursing facility´´ has the meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)).
                (B) Secretary.—
                   The term ``Secretary´´ means the Secretary of Health and Human Services.
                (C) Skilled Nursing Facility.—
                   The term ``skilled nursing facility´´ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395i–3(a)).
    (c) Conforming Amendments.—
          (1) Skilled Nursing Facilities.—
             Section 1819(d)(1) of the Social Security Act (42 U.S.C. 1395i–3(d)(1)) is amended by striking subparagraph (B) and redesignating subparagraph (C) as subparagraph (B).
          (2) Nursing Facilities.—
             Section 1919(d)(1) of the Social Security Act (42 U.S.C. 1396r(d)(1)) is amended by striking subparagraph (B) and redesignating subparagraph (C) as subparagraph (B).

### Sec. 1412. Accountability Requirements.

    (a) Effective Compliance and Ethics Programs.—
          (1) Skilled Nursing Facilities.—
             Section 1819(d)(1) of the Social Security Act (42 U.S.C. 1395i–3(d)(1)), as amended by section 1411(c)(1), is amended by adding at the end the following new subparagraph:
                ``(C) Compliance and ethics programs.—
                   ``(i) Requirement.—On or after the date that is 36 months after the date of the enactment of this subparagraph, a skilled nursing facility shall, with respect to the entity that operates the facility (in this subparagraph referred to as the ‘operating organization’ or ‘organization’), have in operation a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care consistent with regulations developed under clause (ii).
                   ``(ii) Development of regulations.—
                      ``(I) In general.—Not later than the date that is 2 years after such date of the enactment, the Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall promulgate regulations for an effective compliance and ethics program for operating organizations, which may include a model compliance program.
                      ``(II) Design of regulations.—Such regulations with respect to specific elements or formality of a program may vary with the size of the organization, such that larger organizations should have a more formal and rigorous program and include established written policies defining the standards and procedures to be followed by its employees. Such requirements shall specifically apply to the corporate level management of multi-unit nursing home chains.
                      ``(III) Evaluation.—Not later than 3 years after the date of promulgation of regulations under this clause, the Secretary shall complete an evaluation of the compliance and ethics programs required to be established under this subparagraph. Such evaluation shall determine if such programs led to changes in deficiency citations, changes in quality performance, or changes in other metrics of resident quality of care. The Secretary shall submit to Congress a report on such evaluation and shall include in such report such recommendations regarding changes in the requirements for such programs as the Secretary determines appropriate.
                   ``(iii) Requirements for compliance and ethics programs.—In this subparagraph, the term ‘compliance and ethics program’ means, with respect to a skilled nursing facility, a program of the operating organization that—
                      ``(I) has been reasonably designed, implemented, and enforced so that it generally will be effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care; and
                      ``(II) includes at least the required components specified in clause (iv).
                   ``(iv) Required components of program.—The required components of a compliance and ethics program of an organization are the following:
                      ``(I) The organization must have established compliance standards and procedures to be followed by its employees, contractors, and other agents that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under this Act.
                      ``(II) Specific individuals within high-level personnel of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures and have sufficient resources and authority to assure such compliance.
                      ``(III) The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations under this Act.
                      ``(IV) The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, such as by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.
                      ``(V) The organization must have taken reasonable steps to achieve compliance with its standards, such as by utilizing monitoring and auditing systems reasonably designed to detect criminal, civil, and administrative violations under this Act by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents could report violations by others within the organization without fear of retribution.
                      ``(VI) The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense.
                      ``(VII) After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including repayment of any funds to which it was not entitled and any necessary modification to its program to prevent and detect criminal, civil, and administrative violations under this Act.
                      ``(VIII) The organization must periodically undertake reassessment of its compliance program to identify changes necessary to reflect changes within the organization and its facilities.
                   ``(v) Coordination.—The provisions of this subparagraph shall apply with respect to a skilled nursing facility in lieu of section 1874(d).´´.
          (2) Nursing Facilities.—
             Section 1919(d)(1) of the Social Security Act (42 U.S.C. 1396r(d)(1)), as amended by section 1411(c)(2), is amended by adding at the end the following new subparagraph:
                ``(C) Compliance and ethics program.—
                   ``(i) Requirement.—On or after the date that is 36 months after the date of the enactment of this subparagraph, a nursing facility shall, with respect to the entity that operates the facility (in this subparagraph referred to as the ‘operating organization’ or ‘organization’), have in operation a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care consistent with regulations developed under clause (ii).
                   ``(ii) Development of regulations.—
                      ``(I) In general.—Not later than the date that is 2 years after such date of the enactment, the Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall develop regulations for an effective compliance and ethics program for operating organizations, which may include a model compliance program.
                      ``(II) Design of regulations.—Such regulations with respect to specific elements or formality of a program may vary with the size of the organization, such that larger organizations should have a more formal and rigorous program and include established written policies defining the standards and procedures to be followed by its employees. Such requirements may specifically apply to the corporate level management of multi-unit nursing home chains.
                      ``(III) Evaluation.—Not later than 3 years after the date of promulgation of regulations under this clause the Secretary shall complete an evaluation of the compliance and ethics programs required to be established under this subparagraph. Such evaluation shall determine if such programs led to changes in deficiency citations, changes in quality performance, or changes in other metrics of resident quality of care. The Secretary shall submit to Congress a report on such evaluation and shall include in such report such recommendations regarding changes in the requirements for such programs as the Secretary determines appropriate.
                   ``(iii) Requirements for compliance and ethics programs.—In this subparagraph, the term ‘compliance and ethics program’ means, with respect to a nursing facility, a program of the operating organization that—
                      ``(I) has been reasonably designed, implemented, and enforced so that it generally will be effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care; and
                      ``(II) includes at least the required components specified in clause (iv).
                   ``(iv) Required components of program.—The required components of a compliance and ethics program of an organization are the following:
                      ``(I) The organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under this Act.
                      ``(II) Specific individuals within high-level personnel of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures and has sufficient resources and authority to assure such compliance.
                      ``(III) The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations under this Act.
                      ``(IV) The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, such as by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.
                      ``(V) The organization must have taken reasonable steps to achieve compliance with its standards, such as by utilizing monitoring and auditing systems reasonably designed to detect criminal, civil, and administrative violations under this Act by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents could report violations by others within the organization without fear of retribution.
                      ``(VI) The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense.
                      ``(VII) After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including repayment of any funds to which it was not entitled and any necessary modification to its program to prevent and detect criminal, civil, and administrative violations under this Act.
                      ``(VIII) The organization must periodically undertake reassessment of its compliance program to identify changes necessary to reflect changes within the organization and its facilities.
                   ``(v) Coordination.—The provisions of this subparagraph shall apply with respect to a nursing facility in lieu of section 1902(a)(77).´´.
    (b) Quality Assurance and Performance Improvement Program.—
          (1) Skilled Nursing Facilities.—
             Section 1819(b)(1)(B) of the Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended—
                (A) by striking ``assurance´´ and inserting ``assurance and quality assurance and performance improvement program´´;
                (B) by designating the matter beginning with ``A nursing facility´´ as a clause (i) with the heading ``In general.—´´ and the appropriate indentation; and
                (C) by adding at the end the following new clause:
                   ``(ii) Quality assurance and performance improvement program.—
                      ``(I) In general.—Not later than December 31, 2011, the Secretary shall establish and implement a quality assurance and performance improvement program (in this clause referred to as the ‘QAPI program’) for skilled nursing facilities, including multi-unit chains of such facilities. Under the QAPI program, the Secretary shall establish standards relating to such facilities and provide technical assistance to such facilities on the development of best practices in order to meet such standards. Not later than 1 year after the date on which the regulations are promulgated under subclause (II), a skilled nursing facility must submit to the Secretary a plan for the facility to meet such standards and implement such best practices, including how to coordinate the implementation of such plan with quality assessment and assurance activities conducted under clause (i).
                      ``(II) Regulations.—The Secretary shall promulgate regulations to carry out this clause.´´.
          (2) Nursing Facilities.—
             Section 1919(b)(1)(B) of the Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended—
                (A) by striking ``assurance´´ and inserting ``assurance and quality assurance and performance improvement program´´;
                (B) by designating the matter beginning with ``A nursing facility´´ as a clause (i) with the heading ``In general.—´´ and the appropriate indentation; and
                (C) by adding at the end the following new clause:
                   ``(ii) Quality assurance and performance improvement program.—
                      ``(I) In general.—Not later than December 31, 2011, the Secretary shall establish and implement a quality assurance and performance improvement program (in this clause referred to as the ‘QAPI program’) for nursing facilities, including multi-unit chains of such facilities. Under the QAPI program, the Secretary shall establish standards relating to such facilities and provide technical assistance to such facilities on the development of best practices in order to meet such standards. Not later than 1 year after the date on which the regulations are promulgated under subclause (II), a nursing facility must submit to the Secretary a plan for the facility to meet such standards and implement such best practices, including how to coordinate the implementation of such plan with quality assessment and assurance activities conducted under clause (i).
                      ``(II) Regulations.—The Secretary shall promulgate regulations to carry out this clause.´´.
          (3) Proposal to Revise Quality Assurance and Performance Improvement Programs.—
             The Secretary shall include in the proposed rule published under section 1888(e) of the Social Security Act (42 U.S.C. 1395yy(e)(5)(A)) for the subsequent fiscal year to the extent otherwise authorized under section 1819(b)(1)(B) or 1819(d)(1)(C) of the Social Security Act or other statutory or regulatory authority, one or more proposals for skilled nursing facilities to modify and strengthen quality assurance and performance improvement programs in such facilities. At the time of publication of such proposed rule and to the extent otherwise authorized under section 1919(b)(1)(B) or 1919(d)(1)(C) of such Act or other regulatory authority.
          (4) Facility Plan.—
             Not later than 1 year after the date on which the regulations are promulgated under subclause (II) of clause (ii) of sections 1819(b)(1)(B) and 1919(b)(1)(B) of the Social Security Act, as added by paragraphs (1) and (2), a skilled nursing facility and a nursing facility must submit to the Secretary a plan for the facility to meet the standards under such regulations and implement such best practices, including how to coordinate the implementation of such plan with quality assessment and assurance activities conducted under clause (i) of such sections.
    (c) GAO Study on Nursing Facility Undercapitalization.—
          (1) In General.—
             The Comptroller General of the United States shall conduct a study that examines the following:
                (A) The extent to which corporations that own or operate large numbers of nursing facilities, taking into account ownership type (including private equity and control interests), are undercapitalizing such facilities.
                (B) The effects of such undercapitalization on quality of care, including staffing and food costs, at such facilities.
                (C) Options to address such undercapitalization, such as requirements relating to surety bonds, liability insurance, or minimum capitalization.
          (2) Report.—
             Not later than 18 months after the date of the enactment of this Act, the Comptroller General shall submit to Congress a report on the study conducted under paragraph (1).
          (3) Nursing Facility.—
             In this subsection, the term ``nursing facility´´ includes a skilled nursing facility.

### Sec. 1413. Nursing Home Compare Medicare Website.

    (a) Skilled Nursing Facilities.—
          (1) In General.—
             Section 1819 of the Social Security Act (42 U.S.C. 1395i–3) is amended—
                (A) by redesignating subsection (i) as subsection (j); and
                (B) by inserting after subsection (h) the following new subsection:
                   ``(i) Nursing Home Compare Website.—
                      ``(1) Inclusion of additional information.—
                         ``(A) In general.—The Secretary shall ensure that the Department of Health and Human Services includes, as part of the information provided for comparison of nursing homes on the official Internet website of the Federal Government for Medicare beneficiaries (commonly referred to as the ‘Nursing Home Compare’ Medicare website) (or a successor website), the following information in a manner that is prominent, easily accessible, readily understandable to consumers of long-term care services, and searchable:
                            ``(i) Information that is reported to the Secretary under section 1124(c)(4).
                            ``(ii) Information on the ‘Special Focus Facility program’ (or a successor program) established by the Centers for Medicare and Medicaid Services, according to procedures established by the Secretary. Such procedures shall provide for the inclusion of information with respect to, and the names and locations of, those facilities that, since the previous quarter—
                               ``(I) were newly enrolled in the program;
                               ``(II) are enrolled in the program and have failed to significantly improve;
                               ``(III) are enrolled in the program and have significantly improved;
                               ``(IV) have graduated from the program; and
                               ``(V) have closed voluntarily or no longer participate under this title.
                            ``(iii) Staffing data for each facility (including resident census data and data on the hours of care provided per resident per day) based on data submitted under subsection (b)(8)(C), including information on staffing turnover and tenure, in a format that is clearly understandable to consumers of long-term care services and allows such consumers to compare differences in staffing between facilities and State and national averages for the facilities. Such format shall include—
                               ``(I) concise explanations of how to interpret the data (such as a plain English explanation of data reflecting ‘nursing home staff hours per resident day’);
                               ``(II) differences in types of staff (such as training associated with different categories of staff);
                               ``(III) the relationship between nurse staffing levels and quality of care; and
                               ``(IV) an explanation that appropriate staffing levels vary based on patient case mix.
                            ``(iv) Links to State Internet websites with information regarding State survey and certification programs, links to Form 2567 State inspection reports (or a successor form) on such websites, information to guide consumers in how to interpret and understand such reports, and the facility plan of correction or other response to such report.
                            ``(v) The standardized complaint form developed under subsection (f)(8), including explanatory material on what complaint forms are, how they are used, and how to file a complaint with the State survey and certification program and the State long-term care ombudsman program.
                            ``(vi) Summary information on the number, type, severity, and outcome of substantiated complaints.
                            ``(vii) The number of adjudicated instances of criminal violations by employees of a a nursing facility—
                               ``(I) that were committed inside the facility;
                               ``(II) with respect to such instances of violations or crimes committed inside of the facility that were the violations or crimes of abuse, neglect, and exploitation, criminal sexual abuse, or other violations or crimes that resulted in serious bodily injury; and
                               ``(III) the number of civil monetary penalties levied against the facility, employees, contractors, and other agents.
                         ``(B) Deadline for provision of information.—
                            ``(i) In general.—Except as provided in clause (ii), the Secretary shall ensure that the information described in subparagraph (A) is included on such website (or a successor website) not later than 1 year after the date of the enactment of this subsection.
                            ``(ii) Exception.—The Secretary shall ensure that the information described in subparagraph (A)(i) and (A)(iii) is included on such website (or a successor website) not later than the date on which the requirements under section 1124(c)(4) and subsection (b)(8)(C)(ii) are implemented.
                      ``(2) Review and modification of website.—
                         ``(A) In general.—The Secretary shall establish a process—
                            ``(i) to review the accuracy, clarity of presentation, timeliness, and comprehensiveness of information reported on such website as of the day before the date of the enactment of this subsection; and
                            ``(ii) not later than 1 year after the date of the enactment of this subsection, to modify or revamp such website in accordance with the review conducted under clause (i).
                         ``(B) Consultation.—In conducting the review under subparagraph (A)(i), the Secretary shall consult with—
                            ``(i) State long-term care ombudsman programs;
                            ``(ii) consumer advocacy groups;
                            ``(iii) provider stakeholder groups; and
                            ``(iv) any other representatives of programs or groups the Secretary determines appropriate.´´.
          (2) Timeliness of Submission of Survey and Certification Information.—
                (A) In General.—
                   Section 1819(g)(5) of the Social Security Act (42 U.S.C. 1395i–3(g)(5)) is amended by adding at the end the following new subparagraph:
                      ``(E) Submission of survey and certification information to the secretary.—In order to improve the timeliness of information made available to the public under subparagraph (A) and provided on the Nursing Home Compare Medicare website under subsection (i), each State shall submit information respecting any survey or certification made respecting a skilled nursing facility (including any enforcement actions taken by the State) to the Secretary not later than the date on which the State sends such information to the facility. The Secretary shall use the information submitted under the preceding sentence to update the information provided on the Nursing Home Compare Medicare website as expeditiously as practicable but not less frequently than quarterly.´´.
                (B) Effective Date.—
                   The amendment made by this paragraph shall take effect 1 year after the date of the enactment of this Act.
          (3) Special Focus Facility Program.—
             Section 1819(f) of such Act is amended by adding at the end the following new paragraph:
                ``(8) Special focus facility program.—
                   ``(A) In general.—The Secretary shall conduct a special focus facility program for enforcement of requirements for skilled nursing facilities that the Secretary has identified as having substantially failed to meet applicable requirement of this Act.
                   ``(B) Periodic surveys.—Under such program the Secretary shall conduct surveys of each facility in the program not less than once every 6 months.´´.
    (b) Nursing Facilities.—
          (1) In General.—
             Section 1919 of the Social Security Act (42 U.S.C. 1396r) is amended—
                (A) by redesignating subsection (i) as subsection (j); and
                (B) by inserting after subsection (h) the following new subsection:
                   ``(i) Nursing Home Compare Website.—
                      ``(1) Inclusion of additional information.—
                         ``(A) In general.—The Secretary shall ensure that the Department of Health and Human Services includes, as part of the information provided for comparison of nursing homes on the official Internet website of the Federal Government for Medicare beneficiaries (commonly referred to as the ‘Nursing Home Compare’ Medicare website) (or a successor website), the following information in a manner that is prominent, easily accessible, readily understandable to consumers of long-term care services, and searchable:
                            ``(i) Staffing data for each facility (including resident census data and data on the hours of care provided per resident per day) based on data submitted under subsection (b)(8)(C)(ii), including information on staffing turnover and tenure, in a format that is clearly understandable to consumers of long-term care services and allows such consumers to compare differences in staffing between facilities and State and national averages for the facilities. Such format shall include—
                               ``(I) concise explanations of how to interpret the data (such as plain English explanation of data reflecting ‘nursing home staff hours per resident day’);
                               ``(II) differences in types of staff (such as training associated with different categories of staff);
                               ``(III) the relationship between nurse staffing levels and quality of care; and
                               ``(IV) an explanation that appropriate staffing levels vary based on patient case mix.
                            ``(ii) Links to State Internet websites with information regarding State survey and certification programs, links to Form 2567 State inspection reports (or a successor form) on such websites, information to guide consumers in how to interpret and understand such reports, and the facility plan of correction or other response to such report.
                            ``(iii) The standardized complaint form developed under subsection (f)(10), including explanatory material on what complaint forms are, how they are used, and how to file a complaint with the State survey and certification program and the State long-term care ombudsman program.
                            ``(iv) Summary information on the number, type, severity, and outcome of substantiated complaints.
                            ``(v) The number of adjudicated instances of criminal violations by employees of a nursing facility—
                               ``(I) that were committed inside of the facility; and
                               ``(II) with respect to such instances of violations or crimes committed outside of the facility, that were the violations or crimes that resulted in the serious bodily injury of an elder.
                         ``(B) Deadline for provision of information.—
                            ``(i) In general.—Except as provided in clause (ii), the Secretary shall ensure that the information described in subparagraph (A) is included on such website (or a successor website) not later than 1 year after the date of the enactment of this subsection.
                            ``(ii) Exception.—The Secretary shall ensure that the information described in subparagraph (A)(i) and (A)(iii) is included on such website (or a successor website) not later than the date on which the requirements under section 1124(c)(4) and subsection (b)(8)(C)(ii) are implemented.
                      ``(2) Review and modification of website.—
                         ``(A) In general.—The Secretary shall establish a process—
                            ``(i) to review the accuracy, clarity of presentation, timeliness, and comprehensiveness of information reported on such website as of the day before the date of the enactment of this subsection; and
                            ``(ii) not later than 1 year after the date of the enactment of this subsection, to modify or revamp such website in accordance with the review conducted under clause (i).
                         ``(B) Consultation.—In conducting the review under subparagraph (A)(i), the Secretary shall consult with—
                            ``(i) State long-term care ombudsman programs;
                            ``(ii) consumer advocacy groups;
                            ``(iii) provider stakeholder groups;
                            ``(iv) skilled nursing facility employees and their representatives; and
                            ``(v) any other representatives of programs or groups the Secretary determines appropriate.´´.
          (2) Timeliness of Submission of Survey and Certification Information.—
                (A) In General.—
                   Section 1919(g)(5) of the Social Security Act (42 U.S.C. 1396r(g)(5)) is amended by adding at the end the following new subparagraph:
                      ``(E) Submission of survey and certification information to the secretary.—In order to improve the timeliness of information made available to the public under subparagraph (A) and provided on the Nursing Home Compare Medicare website under subsection (i), each State shall submit information respecting any survey or certification made respecting a nursing facility (including any enforcement actions taken by the State) to the Secretary not later than the date on which the State sends such information to the facility. The Secretary shall use the information submitted under the preceding sentence to update the information provided on the Nursing Home Compare Medicare website as expeditiously as practicable but not less frequently than quarterly.´´.
                (B) Effective Date.—
                   The amendment made by this paragraph shall take effect 1 year after the date of the enactment of this Act.
          (3) Special Focus Facility Program.—
             Section 1919(f) of such Act is amended by adding at the end of the following new paragraph:
                ``(10) Special focus facility program.—
                   ``(A) In general.—The Secretary shall conduct a special focus facility program for enforcement of requirements for nursing facilities that the Secretary has identified as having substantially failed to meet applicable requirements of this Act.
                   ``(B) Periodic surveys.—Under such program the Secretary shall conduct surveys of each facility in the program not less often than once every 6 months.´´.
    (c) Availability of Reports on Surveys, Certifications, and Complaint Investigations.—
          (1) Skilled Nursing Facilities.—
             Section 1819(d)(1) of the Social Security Act (42 U.S.C. 1395i–3(d)(1)), as amended by sections 1411 and 1412, is amended by adding at the end the following new subparagraph:
                ``(D) Availability of survey, certification, and complaint investigation reports.—A skilled nursing facility must—
                   ``(i) have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years available for any individual to review upon request; and
                   ``(ii) post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
                ``The facility shall not make available under clause (i) identifying information about complainants or residents.´´.
          (2) Nursing Facilities.—
             Section 1919(d)(1) of the Social Security Act (42 U.S.C. 1396r(d)(1)), as amended by sections 1411 and 1412, is amended by adding at the end the following new subparagraph:
                ``(D) Availability of survey, certification, and complaint investigation reports.—A nursing facility must—
                   ``(i) have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years available for any individual to review upon request; and
                   ``(ii) post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
                ``The facility shall not make available under clause (i) identifying information about complainants or residents.´´.
          (3) Effective date.—
             The amendments made by this subsection shall take effect 1 year after the date of the enactment of this Act.
    (d) Guidance to States on Form 2567 State Inspection Reports and Complaint Investigation Reports.—
          (1) Guidance.—
             The Secretary of Health and Human Services (in this subtitle referred to as the ``Secretary´´) shall provide guidance to States on how States can establish electronic links to Form 2567 State inspection reports (or a successor form), complaint investigation reports, and a facility’s plan of correction or other response to such Form 2567 State inspection reports (or a successor form) on the Internet website of the State that provides information on skilled nursing facilities and nursing facilities and the Secretary shall, if possible, include such information on Nursing Home Compare.
          (2) Requirement.—
             Section 1902(a)(9) of the Social Security Act (42 U.S.C. 1396a(a)(9)) is amended—
                (A) by striking ``and´´ at the end of subparagraph (B);
                (B) by striking the semicolon at the end of subparagraph (C) and inserting ``, and´´; and
                (C) by adding at the end the following new subparagraph:
                   ``(D) that the State maintain a consumer-oriented website providing useful information to consumers regarding all skilled nursing facilities and all nursing facilities in the State, including for each facility, Form 2567 State inspection reports (or a successor form), complaint investigation reports, the facility’s plan of correction, and such other information that the State or the Secretary considers useful in assisting the public to assess the quality of long term care options and the quality of care provided by individual facilities;´´.
          (3) Definitions.—
             In this subsection:
                (A) Nursing Facility.—
                   The term ``nursing facility´´ has the meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)).
                (B) Secretary.—
                   The term ``Secretary´´ means the Secretary of Health and Human Services.
                (C) Skilled Nursing Facility.—
                   The term ``skilled nursing facility´´ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395i–3(a)).

### Sec. 1414. Reporting of Expenditures.

    Section 1888 of the Social Security Act (42 U.S.C. 1395yy) is amended by adding at the end the following new subsection:
          ``(f) Reporting of Direct Care Expenditures.—
             ``(1) In general.—For cost reports submitted under this title for cost reporting periods beginning on or after the date that is 3 years after the date of the enactment of this subsection, skilled nursing facilities shall separately report expenditures for wages and benefits for direct care staff (breaking out (at a minimum) registered nurses, licensed professional nurses, certified nurse assistants, and other medical and therapy staff).
             ``(2) Modification of form.—The Secretary, in consultation with private sector accountants experienced with skilled nursing facility cost reports, shall redesign such reports to meet the requirement of paragraph (1) not later than 1 year after the date of the enactment of this subsection.
             ``(3) Categorization by functional accounts.—Not later than 30 months after the date of the enactment of this subsection, the Secretary, working in consultation with the Medicare Payment Advisory Commission, the Inspector General of the Department of Health and Human Services, and other expert parties the Secretary determines appropriate, shall take the expenditures listed on cost reports, as modified under paragraph (1), submitted by skilled nursing facilities and categorize such expenditures, regardless of any source of payment for such expenditures, for each skilled nursing facility into the following functional accounts on an annual basis:
                ``(A) Spending on direct care services (including nursing, therapy, and medical services).
                ``(B) Spending on indirect care (including housekeeping and dietary services).
                ``(C) Capital assets (including building and land costs).
                ``(D) Administrative services costs.
             ``(4) Availability of information submitted.—The Secretary shall establish procedures to make information on expenditures submitted under this subsection readily available to interested parties upon request, subject to such requirements as the Secretary may specify under the procedures established under this paragraph.´´.

### Sec. 1415. Standardized Complaint Form.

    (a) Skilled Nursing Facilities.—
          (1) Development by the secretary.—
             Section 1819(f) of the Social Security Act (42 U.S.C. 1395i–3(f)), as amended by section 1413(a)(3), is amended by adding at the end the following new paragraph:
                ``(9) Standardized complaint form.—The Secretary shall develop a standardized complaint form for use by a resident (or a person acting on the resident’s behalf) in filing a complaint with a State survey and certification agency and a State long-term care ombudsman program with respect to a skilled nursing facility.´´.
          (2) State Requirements.—
             Section 1819(e) of the Social Security Act (42 U.S.C. 1395i–3(e)) is amended by adding at the end the following new paragraph:
                ``(6) Complaint processes and whistle-blower protection.—
                   ``(A) Complaint forms.—The State must make the standardized complaint form developed under subsection (f)(9) available upon request to—
                      ``(i) a resident of a skilled nursing facility;
                      ``(ii) any person acting on the resident’s behalf; and
                      ``(iii) any person who works at a skilled nursing facility or is a representative of such a worker.
                   ``(B) Complaint resolution process.—The State must establish a complaint resolution process in order to ensure that a resident, the legal representative of a resident of a skilled nursing facility, or other responsible party is not retaliated against if the resident, legal representative, or responsible party has complained, in good faith, about the quality of care or other issues relating to the skilled nursing facility, that the legal representative of a resident of a skilled nursing facility or other responsible party is not denied access to such resident or otherwise retaliated against if such representative party has complained, in good faith, about the quality of care provided by the facility or other issues relating to the facility, and that a person who works at a skilled nursing facility is not retaliated against if the worker has complained, in good faith, about quality of care or services or an issue relating to the quality of care or services provided at the facility, whether the resident, legal representative, other responsible party, or worker used the form developed under subsection (f)(9) or some other method for submitting the complaint. Such complaint resolution process shall include—
                      ``(i) procedures to assure accurate tracking of complaints received, including notification to the complainant that a complaint has been received;
                      ``(ii) procedures to determine the likely severity of a complaint and for the investigation of the complaint;
                      ``(iii) deadlines for responding to a complaint and for notifying the complainant of the outcome of the investigation; and
                      ``(iv) procedures to ensure that the identity of the complainant will be kept confidential.
                   ``(C) Whistleblower protection.—
                      ``(i) Prohibition against retaliation.—No person who works at a skilled nursing facility may be penalized, discriminated, or retaliated against with respect to any aspect of employment, including discharge, promotion, compensation, terms, conditions, or privileges of employment, or have a contract for services terminated, because the person (or anyone acting at the person’s request) complained, in good faith, about the quality of care or services provided by a nursing facility or about other issues relating to quality of care or services, whether using the form developed under subsection (f)(9) or some other method for submitting the complaint.
                      ``(ii) Retaliatory reporting.—A skilled nursing facility may not file a complaint or a report against a person who works (or has worked at the facility with the appropriate State professional disciplinary agency because the person (or anyone acting at the person’s request) complained in good faith, as described in clause (i).
                      ``(iii) Commencement of action.—Any person who believes the person has been penalized, discriminated, or retaliated against or had a contract for services terminated in violation of clause (i) or against whom a complaint has been filed in violation of clause (ii) may bring an action at law or equity in the appropriate district court of the United States, which shall have jurisdiction over such action without regard to the amount in controversy or the citizenship of the parties, and which shall have jurisdiction to grant complete relief, including, but not limited to, injunctive relief (such as reinstatement, compensatory damages (which may include reimbursement of lost wages, compensation, and benefits), costs of litigation (including reasonable attorney and expert witness fees), exemplary damages where appropriate, and such other relief as the court deems just and proper.
                      ``(iv) Rights not waivable.—The rights protected by this paragraph may not be diminished by contract or other agreement, and nothing in this paragraph shall be construed to diminish any greater or additional protection provided by Federal or State law or by contract or other agreement.
                      ``(v) Requirement to post notice of employee rights.—Each skilled nursing facility shall post conspicuously in an appropriate location a sign (in a form specified by the Secretary) specifying the rights of persons under this paragraph and including a statement that an employee may file a complaint with the Secretary against a skilled nursing facility that violates the provisions of this paragraph and information with respect to the manner of filing such a complaint.
                   ``(D) Rule of construction.—Nothing in this paragraph shall be construed as preventing a resident of a skilled nursing facility (or a person acting on the resident’s behalf) from submitting a complaint in a manner or format other than by using the standardized complaint form developed under subsection (f)(9) (including submitting a complaint orally).
                   ``(E) Good faith defined.—For purposes of this paragraph, an individual shall be deemed to be acting in good faith with respect to the filing of a complaint if the individual reasonably believes—
                      ``(i) the information reported or disclosed in the complaint is true; and
                      ``(ii) the violation of this title has occurred or may occur in relation to such information.´´.
    (b) Nursing Facilities.—
          (1) Development by the Secretary.—
             Section 1919(f) of the Social Security Act (42 U.S.C. 1395i–3(f)), as amended by section 1413(b), is amended by adding at the end the following new paragraph:
                ``(11) Standardized complaint form.—The Secretary shall develop a standardized complaint form for use by a resident (or a person acting on the resident’s behalf) in filing a complaint with a State survey and certification agency and a State long-term care ombudsman program with respect to a nursing facility.´´.
          (2) State Requirements.—
             Section 1919(e) of the Social Security Act (42 U.S.C. 1395i–3(e)) is amended by adding at the end the following new paragraph:
                ``(8) Complaint processes and whistleblower protection.—
                   ``(A) Complaint forms.—The State must make the standardized complaint form developed under subsection (f)(11) available upon request to—
                      ``(i) a resident of a nursing facility;
                      ``(ii) any person acting on the resident’s behalf; and
                      ``(iii) any person who works at a nursing facility or a representative of such a worker.
                   ``(B) Complaint resolution process.—The State must establish a complaint resolution process in order to ensure that a resident, the legal representative of a resident of a nursing facility, or other responsible party is not retaliated against if the resident, legal representative, or responsible party has complained, in good faith, about the quality of care or other issues relating to the nursing facility, that the legal representative of a resident of a nursing facility or other responsible party is not denied access to such resident or otherwise retaliated against if such representative party has complained, in good faith, about the quality of care provided by the facility or other issues relating to the facility, and that a person who works at a nursing facility is not retaliated against if the worker has complained, in good faith, about quality of care or services or an issue relating to the quality of care or services provided at the facility, whether the resident, legal representative, other responsible party, or worker used the form developed under subsection (f)(11) or some other method for submitting the complaint. Such complaint resolution process shall include—
                      ``(i) procedures to assure accurate tracking of complaints received, including notification to the complainant that a complaint has been received;
                      ``(ii) procedures to determine the likely severity of a complaint and for the investigation of the complaint;
                      ``(iii) deadlines for responding to a complaint and for notifying the complainant of the outcome of the investigation; and
                      ``(iv) procedures to ensure that the identity of the complainant will be kept confidential.
                   ``(C) Whistleblower protection.—
                      ``(i) Prohibition against retaliation.—No person who works at a nursing facility may be penalized, discriminated, or retaliated against with respect to any aspect of employment, including discharge, promotion, compensation, terms, conditions, or privileges of employment, or have a contract for services terminated, because the person (or anyone acting at the person’s request) complained, in good faith, about the quality of care or services provided by a nursing facility or about other issues relating to quality of care or services, whether using the form developed under subsection (f)(11) or some other method for submitting the complaint.
                      ``(ii) Retaliatory reporting.—A nursing facility may not file a complaint or a report against a person who works (or has worked at the facility with the appropriate State professional disciplinary agency because the person (or anyone acting at the person’s request) complained in good faith, as described in clause (i).
                      ``(iii) Commencement of action.—Any person who believes the person has been penalized, discriminated, or retaliated against or had a contract for services terminated in violation of clause (i) or against whom a complaint has been filed in violation of clause (ii) may bring an action at law or equity in the appropriate district court of the United States, which shall have jurisdiction over such action without regard to the amount in controversy or the citizenship of the parties, and which shall have jurisdiction to grant complete relief, including, but not limited to, injunctive relief (such as reinstatement, compensatory damages (which may include reimbursement of lost wages, compensation, and benefits), costs of litigation (including reasonable attorney and expert witness fees), exemplary damages where appropriate, and such other relief as the court deems just and proper.
                      ``(iv) Rights not waivable.—The rights protected by this paragraph may not be diminished by contract or other agreement, and nothing in this paragraph shall be construed to diminish any greater or additional protection provided by Federal or State law or by contract or other agreement.
                      ``(v) Requirement to post notice of employee rights.—Each nursing facility shall post conspicuously in an appropriate location a sign (in a form specified by the Secretary) specifying the rights of persons under this paragraph and including a statement that an employee may file a complaint with the Secretary against a nursing facility that violates the provisions of this paragraph and information with respect to the manner of filing such a complaint.
                   ``(D) Rule of construction.—Nothing in this paragraph shall be construed as preventing a resident of a nursing facility (or a person acting on the resident’s behalf) from submitting a complaint in a manner or format other than by using the standardized complaint form developed under subsection (f)(11) (including submitting a complaint orally).
                   ``(E) Good faith defined.—For purposes of this paragraph, an individual shall be deemed to be acting in good faith with respect to the filing of a complaint if the individual reasonably believes—
                      ``(i) the information reported or disclosed in the complaint is true; and
                      ``(ii) the violation of this title has occurred or may occur in relation to such information.´´.
    (c) Effective Date.—
       The amendments made by this section shall take effect 1 year after the date of the enactment of this Act.

### Sec. 1416. Ensuring Staffing Accountability.

    (a) Skilled Nursing Facilities.—
       Section 1819(b)(8) of the Social Security Act (42 U.S.C. 1395i–3(b)(8)) is amended by adding at the end the following new subparagraph:
             ``(C) Submission of staffing information based on payroll data in a uniform format.—Beginning not later than 2 years after the date of the enactment of this subparagraph, and after consulting with State long-term care ombudsman programs, consumer advocacy groups, provider stakeholder groups, employees and their representatives, and other parties the Secretary deems appropriate, the Secretary shall require a skilled nursing facility to electronically submit to the Secretary direct care staffing information (including information with respect to agency and contract staff) based on payroll and other verifiable and auditable data in a uniform format (according to specifications established by the Secretary in consultation with such programs, groups, and parties). Such specifications shall require that the information submitted under the preceding sentence—
                ``(i) specify the category of work a certified employee performs (such as whether the employee is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other medical personnel);
                ``(ii) include resident census data and information on resident case mix;
                ``(iii) include a regular reporting schedule; and
                ``(iv) include information on employee turnover and tenure and on the hours of care provided by each category of certified employees referenced in clause (i) per resident per day.
             ``Nothing in this subparagraph shall be construed as preventing the Secretary from requiring submission of such information with respect to specific categories, such as nursing staff, before other categories of certified employees. Information under this subparagraph with respect to agency and contract staff shall be kept separate from information on employee staffing.´´.
    (b) Nursing Facilities.—
       Section 1919(b)(8) of the Social Security Act (42 U.S.C. 1396r(b)(8)) is amended by adding at the end the following new subparagraph:
             ``(C) Submission of staffing information based on payroll data in a uniform format.—Beginning not later than 2 years after the date of the enactment of this subparagraph, and after consulting with State long-term care ombudsman programs, consumer advocacy groups, provider stakeholder groups, employees and their representatives, and other parties the Secretary deems appropriate, the Secretary shall require a nursing facility to electronically submit to the Secretary direct care staffing information (including information with respect to agency and contract staff) based on payroll and other verifiable and auditable data in a uniform format (according to specifications established by the Secretary in consultation with such programs, groups, and parties). Such specifications shall require that the information submitted under the preceding sentence—
                ``(i) specify the category of work a certified employee performs (such as whether the employee is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other medical personnel);
                ``(ii) include resident census data and information on resident case mix;
                ``(iii) include a regular reporting schedule; and
                ``(iv) include information on employee turnover and tenure and on the hours of care provided by each category of certified employees referenced in clause (i) per resident per day.
             ``Nothing in this subparagraph shall be construed as preventing the Secretary from requiring submission of such information with respect to specific categories, such as nursing staff, before other categories of certified employees. Information under this subparagraph with respect to agency and contract staff shall be kept separate from information on employee staffing.´´.