# H.R. 3200/Division B/Title IV/Subtitle B/Part 2
## PART 2 — TARGETING ENFORCEMENT
### Sec. 1421. Civil Money Penalties.

    (a) Skilled Nursing Facilities.—
          (1) In General.—
             Section 1819(h)(2)(B)(ii) of the Social Security Act (42 U.S.C. 1395i–3(h)(2)(B)(ii)) is amended to read as follows:
             ``(ii) Authority with respect to civil money penalties.—
                ``(I) Amount.—The Secretary may impose a civil money penalty in the applicable per instance or per day amount (as defined in subclause (II) and (III)) for each day or instance, respectively, of noncompliance (as determined appropriate by the Secretary).
                ``(II) Applicable per instance amount.—In this clause, the term ‘applicable per instance amount’ means—
                   ``(aa) in the case where the deficiency is found to be a direct proximate cause of death of a resident of the facility, an amount not to exceed $100,000;
                   ``(bb) in each case of a deficiency where the facility is cited for actual harm or immediate jeopardy, an amount not less than $3,050 and not more than $25,000; and
                   ``(cc) in each case of any other deficiency, an amount not less than $250 and not to exceed $3050.
                ``(III) Applicable per day amount.—In this clause, the term ‘applicable per day amount’ means—
                   ``(aa) in each case of a deficiency where the facility is cited for actual harm or immediate jeopardy, an amount not less than $3,050 and not more than $25,000; and
                   ``(bb) in each case of any other deficiency, an amount not less than $250 and not to exceed $3,050.
                ``(IV) Reduction of civil money penalties in certain circumstances.—Subject to subclauses (V) and (VI), in the case where a facility self-reports and promptly corrects a deficiency for which a penalty was imposed under this clause not later than 10 calendar days after the date of such imposition, the Secretary may reduce the amount of the penalty imposed by not more than 50 percent.
                ``(V) Prohibition on reduction for certain deficiencies.—
                   ``(aa) Repeat Deficiencies.—The Secretary may not reduce under subclause (IV) the amount of a penalty if the deficiency is a repeat deficiency.
                   ``(bb) Certain other deficiencies.—The Secretary may not reduce under subclause (IV) the amount of a penalty if the penalty is imposed for a deficiency described in subclause (II)(aa) or (III)(aa) and the actual harm or widespread harm immediately jeopardizes the health or safety of a resident or residents of the facility, or if the penalty is imposed for a deficiency described in subclause (II)(bb).
                ``(VI) Limitation on aggregate reductions.—The aggregate reduction in a penalty under subclause (IV) may not exceed 35 percent on the basis of self-reporting, on the basis of a waiver or an appeal (as provided for under regulations under section 488.436 of title 42, Code of Federal Regulations), or on the basis of both.
                ``(VII) Collection of civil money penalties.—In the case of a civil money penalty imposed under this clause, the Secretary—
                   ``(aa) subject to item (cc), shall, not later than 30 days after the date of imposition of the penalty, provide the opportunity for the facility to participate in an independent informal dispute resolution process which generates a written record prior to the collection of such penalty, but such opportunity shall not affect the responsibility of the State survey agency for making final recommendations for such penalties;
                   ``(bb) in the case where the penalty is imposed for each day of noncompliance, shall not impose a penalty for any day during the period beginning on the initial day of the imposition of the penalty and ending on the day on which the informal dispute resolution process under item (aa) is completed;
                   ``(cc) may provide for the collection of such civil money penalty and the placement of such amounts collected in an escrow account under the direction of the Secretary on the earlier of the date on which the informal dispute resolution process under item (aa) is completed or the date that is 90 days after the date of the imposition of the penalty;
                   ``(dd) may provide that such amounts collected are kept in such account pending the resolution of any subsequent appeals;
                   ``(ee) in the case where the facility successfully appeals the penalty, may provide for the return of such amounts collected (plus interest) to the facility; and
                   ``(ff) in the case where all such appeals are unsuccessful, may provide that some portion of such amounts collected may be used to support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or involuntarily) or is decertified (including offsetting costs of relocating residents to home and community-based settings or another facility), projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by the Secretary (including joint training of facility staff and surveyors, technical assistance for facilities under quality assurance programs, the appointment of temporary management, and other activities approved by the Secretary).
                ``(VIII) Procedure.—The provisions of section 1128A (other than subsections (a) and (b) and except to the extent that such provisions require a hearing prior to the imposition of a civil money penalty) shall apply to a civil money penalty under this clause in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).´´.
          (2) Conforming Amendment.—
          The second sentence of section 1819(h)(5) of the Social Security Act (42 U.S.C. 1395i–3(h)(5)) is amended by inserting ``(ii),´´ after ``(i),´´.
    (b) Nursing Facilities.—
          (1) Penalties imposed by the state.—
                (A) In General.—
                   Section 1919(h)(2) of the Social Security Act (42 U.S.C. 1396r(h)(2)) is amended—
                      (i) in subparagraph (A)(ii), by striking the first sentence and inserting the following: ``A civil money penalty in accordance with subparagraph (G).´´; and
                      (ii) by adding at the end the following new subparagraph:
                      ``(G) Civil money penalties.—
                         ``(i) In general.—The State may impose a civil money penalty under subparagraph (A)(ii) in the applicable per instance or per day amount (as defined in subclause (II) and (III)) for each day or instance, respectively, of noncompliance (as determined appropriate by the Secretary).
                         ``(ii) Applicable per instance amount.—In this subparagraph, the term ‘applicable per instance amount’ means—
                            ``(I) in the case where the deficiency is found to be a direct proximate cause of death of a resident of the facility, an amount not to exceed $100,000;
                            ``(II) in each case of a deficiency where the facility is cited for actual harm or immediate jeopardy, an amount not less than $3,050 and not more than $25,000; and
                            ``(III) in each case of any other deficiency, an amount not less than $250 and not to exceed $3,050.
                         ``(iii) Applicable per day amount.—In this subparagraph, the term ‘applicable per day amount’ means—
                            ``(I) in each case of a deficiency where the facility is cited for actual harm or immediate jeopardy, an amount not less than $3,050 and not more than $25,000; and
                            ``(II) in each case of any other deficiency, an amount not less than $250 and not to exceed $3,050.
                         ``(iv) Reduction of civil money penalties in certain circumstances.—Subject to clauses (v) and (vi), in the case where a facility self-reports and promptly corrects a deficiency for which a penalty was imposed under subparagraph (A)(ii) not later than 10 calendar days after the date of such imposition, the State may reduce the amount of the penalty imposed by not more than 50 percent.
                         ``(v) Prohibition on reduction for certain deficiencies.—
                            ``(I) Repeat deficiencies.—The State may not reduce under clause (iv) the amount of a penalty if the State had reduced a penalty imposed on the facility in the preceding year under such clause with respect to a repeat deficiency.
                            ``(II) Certain other deficiencies.—The State may not reduce under clause (iv) the amount of a penalty if the penalty is imposed for a deficiency described in clause (ii)(II) or (iii)(I) and the actual harm or widespread harm that immediately jeopardizes the health or safety of a resident or residents of the facility, or if the penalty is imposed for a deficiency described in clause (ii)(I).
                            ``(III) Limitation on Aggregate Reductions.—The aggregate reduction in a penalty under clause (iv) may not exceed 35 percent on the basis of self-reporting, on the basis of a waiver or an appeal (as provided for under regulations under section 488.436 of title 42, Code of Federal Regulations), or on the basis of both.
                         ``(vi) Collection of civil money penalties.—In the case of a civil money penalty imposed under subparagraph (A)(ii), the State—
                            ``(I) subject to subclause (III), shall, not later than 30 days after the date of imposition of the penalty, provide the opportunity for the facility to participate in an independent informal dispute resolution process which generates a written record prior to the collection of such penalty, but such opportunity shall not affect the responsibility of the State survey agency for making final recommendations for such penalties;
                            ``(II) in the case where the penalty is imposed for each day of noncompliance, shall not impose a penalty for any day during the period beginning on the initial day of the imposition of the penalty and ending on the day on which the informal dispute resolution process under subclause (I) is completed;
                            ``(III) may provide for the collection of such civil money penalty and the placement of such amounts collected in an escrow account under the direction of the State on the earlier of the date on which the informal dispute resolution process under subclause (I) is completed or the date that is 90 days after the date of the imposition of the penalty;
                            ``(IV) may provide that such amounts collected are kept in such account pending the resolution of any subsequent appeals;
                            ``(V) in the case where the facility successfully appeals the penalty, may provide for the return of such amounts collected (plus interest) to the facility; and
                            ``(VI) in the case where all such appeals are unsuccessful, may provide that such funds collected shall be used for the purposes described in the second sentence of subparagraph (A)(ii).´´.
                (B) Conforming Amendment.—
                   The second sentence of section 1919(h)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1396r(h)(2)(A)(ii)) is amended by inserting before the period at the end the following: ``, and some portion of such funds may be used to support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or involuntarily) or is decertified (including offsetting costs of relocating residents to home and community-based settings or another facility), projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by the Secretary (including joint training of facility staff and surveyors, providing technical assistance to facilities under quality assurance programs, the appointment of temporary management, and other activities approved by the Secretary)´´.
          (2) Penalties Imposed by the Secretary.—
                (A) In General.—
                   Section 1919(h)(3)(C)(ii) of the Social Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended to read as follows:
                      ``(ii) Authority with respect to civil money penalties.—
                         ``(I) Amount.—Subject to subclause (II), the Secretary may impose a civil money penalty in an amount not to exceed $10,000 for each day or each instance of noncompliance (as determined appropriate by the Secretary).
                         ``(II) Reduction of civil money penalties in certain circumstances.—Subject to subclause (III), in the case where a facility self-reports and promptly corrects a deficiency for which a penalty was imposed under this clause not later than 10 calendar days after the date of such imposition, the Secretary may reduce the amount of the penalty imposed by not more than 50 percent.
                         ``(III) Prohibition on reduction for repeat deficiencies.—The Secretary may not reduce the amount of a penalty under subclause (II) if the Secretary had reduced a penalty imposed on the facility in the preceding year under such subclause with respect to a repeat deficiency.
                         ``(IV) Collection of civil money penalties.—In the case of a civil money penalty imposed under this clause, the Secretary—
                            ``(aa) subject to item (bb), shall, not later than 30 days after the date of imposition of the penalty, provide the opportunity for the facility to participate in an independent informal dispute resolution process which generates a written record prior to the collection of such penalty;
                            ``(bb) in the case where the penalty is imposed for each day of noncompliance, shall not impose a penalty for any day during the period beginning on the initial day of the imposition of the penalty and ending on the day on which the informal dispute resolution process under item (aa) is completed;
                            ``(cc) may provide for the collection of such civil money penalty and the placement of such amounts collected in an escrow account under the direction of the Secretary on the earlier of the date on which the informal dispute resolution process under item (aa) is completed or the date that is 90 days after the date of the imposition of the penalty;
                            ``(dd) may provide that such amounts collected are kept in such account pending the resolution of any subsequent appeals;
                            ``(ee) in the case where the facility successfully appeals the penalty, may provide for the return of such amounts collected (plus interest) to the facility; and
                            ``(ff) in the case where all such appeals are unsuccessful, may provide that some portion of such amounts collected may be used to support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or involuntarily) or is decertified (including offsetting costs of relocating residents to home and community-based settings or another facility), projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by the Secretary (including joint training of facility staff and surveyors, technical assistance for facilities under quality assurance programs, the appointment of temporary management, and other activities approved by the Secretary).
                         ``(V) Procedure.—The provisions of section 1128A (other than subsections (a) and (b) and except to the extent that such provisions require a hearing prior to the imposition of a civil money penalty) shall apply to a civil money penalty under this clause in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).´´.
                (B) Conforming Amendment.—
                   Section 1919(h)(8) of the Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by inserting ``and in paragraph (3)(C)(ii)´´ after ``paragraph (2)(A)´´.
    (c) Effective Date.—
       The amendments made by this section shall take effect 1 year after the date of the enactment of this Act.

### Sec. 1422. National Independent Monitor Pilot Program.

    (a) Establishment.—
          (1) In General.—
             The Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall establish a pilot program (in this section referred to as the ``pilot program´´) to develop, test, and implement use of an independent monitor to oversee interstate and large intrastate chains of skilled nursing facilities and nursing facilities.
          (2) Selection.—
             The Secretary shall select chains of skilled nursing facilities and nursing facilities described in paragraph (1) to participate in the pilot program from among those chains that submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require.
          (3) Duration.—
             The Secretary shall conduct the pilot program for a two-year period.
          (4) Implementation.—
             The Secretary shall implement the pilot program not later than one year after the date of the enactment of this Act.
    (b) Requirements.—
       The Secretary shall evaluate chains selected to participate in the pilot program based on criteria selected by the Secretary, including where evidence suggests that one or more facilities of the chain are experiencing serious safety and quality of care problems. Such criteria may include the evaluation of a chain that includes one or more facilities participating in the ``Special Focus Facility´´ program (or a successor program) or one or more facilities with a record of repeated serious safety and quality of care deficiencies.
    (c) Responsibilities of the Independent Monitor.—
       An independent monitor that enters into a contract with the Secretary to participate in the conduct of such program shall—
          (1) conduct periodic reviews and prepare root-cause quality and deficiency analyses of a chain to assess if facilities of the chain are in compliance with State and Federal laws and regulations applicable to the facilities;
          (2) undertake sustained oversight of the chain, whether publicly or privately held, to involve the owners of the chain and the principal business partners of such owners in facilitating compliance by facilities of the chain with State and Federal laws and regulations applicable to the facilities;
          (3) analyze the management structure, distribution of expenditures, and nurse staffing levels of facilities of the chain in relation to resident census, staff turnover rates, and tenure;
          (4) report findings and recommendations with respect to such reviews, analyses, and oversight to the chain and facilities of the chain, to the Secretary and to relevant States; and
          (5) publish the results of such reviews, analyses, and oversight.
    (d) Implementation of Recommendations.—
          (1) Receipt of Finding by Chain.—
             Not later than 10 days after receipt of a finding of an independent monitor under subsection (c)(4), a chain participating in the pilot program shall submit to the independent monitor a report—
                (A) outlining corrective actions the chain will take to implement the recommendations in such report; or
                (B) indicating that the chain will not implement such recommendations and why it will not do so.
          (2) Receipt of Report by Independent Monitor.—
             Not later than 10 days after the date of receipt of a report submitted by a chain under paragraph (1), an independent monitor shall finalize its recommendations and submit a report to the chain and facilities of the chain, the Secretary, and the State (or States) involved, as appropriate, containing such final recommendations.
    (e) Cost of Appointment.—
       A chain shall be responsible for a portion of the costs associated with the appointment of independent monitors under the pilot program. The chain shall pay such portion to the Secretary (in an amount and in accordance with procedures established by the Secretary).
    (f) Waiver Authority.—
       The Secretary may waive such requirements of titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as may be necessary for the purpose of carrying out the pilot program.
    (g) Authorization of Appropriations.—
       There are authorized to be appropriated such sums as may be necessary to carry out this section.
    (h) Definitions.—
       In this section:
          (1) Facility.—
             The term ``facility´´ means a skilled nursing facility or a nursing facility.
          (2) 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)).
          (3) Secretary.—
             The term ``Secretary´´ means the Secretary of Health and Human Services, acting through the Assistant Secretary for Planning and Evaluation.
          (4) Skilled Nursing Facility.—
             The term ``skilled nursing facility´´ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395(a)).
    (i) Evaluation and Report.—
          (1) Evaluation.—
             The Inspector General of the Department of Health and Human Services shall evaluate the pilot program. Such evaluation shall—
                (A) determine whether the independent monitor program should be established on a permanent basis; and
                (B) if the Inspector General determines that the independent monitor program should be established on a permanent basis, recommend appropriate procedures and mechanisms for such establishment.
          (2) Report.—
             Not later than 180 days after the completion of the pilot program, the Inspector General shall submit to Congress and the Secretary a report containing the results of the evaluation conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Inspector General determines appropriate.

### Sec. 1423. Notification of Facility Closure.

    (a) Skilled Nursing Facilities.—
          (1) In General.—
             Section 1819(c) of the Social Security Act (42 U.S.C. 1395i–3(c)) is amended by adding at the end the following new paragraph:
                ``(7) Notification of facility closure.—
                   ``(A) In general.—Any individual who is the administrator of a skilled nursing facility must—
                      ``(i) submit to the Secretary, the State long-term care ombudsman, residents of the facility, and the legal representatives of such residents or other responsible parties, written notification of an impending closure—
                         ``(I) subject to subclause (II), not later than the date that is 60 days prior to the date of such closure; and
                         ``(II) in the case of a facility where the Secretary terminates the facility’s participation under this title, not later than the date that the Secretary determines appropriate;
                      ``(ii) ensure that the facility does not admit any new residents on or after the date on which such written notification is submitted; and
                      ``(iii) include in the notice a plan for the transfer and adequate relocation of the residents of the facility by a specified date prior to closure that has been approved by the State, including assurances that the residents will be transferred to the most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs and best interests of each resident.
                   ``(B) Relocation.—
                      ``(i) In general.—The State shall ensure that, before a facility closes, all residents of the facility have been successfully relocated to another facility or an alternative home and community-based setting.
                      ``(ii) Continuation of payments until residents relocated.—The Secretary may, as the Secretary determines appropriate, continue to make payments under this title with respect to residents of a facility that has submitted a notification under subparagraph (A) during the period beginning on the date such notification is submitted and ending on the date on which the resident is successfully relocated.´´.
          (2) Conforming Amendments.—
             Section 1819(h)(4) of the Social Security Act (42 U.S.C. 1395i–3(h)(4)) is amended—
                (A) in the first sentence, by striking ``the Secretary shall terminate´´ and inserting ``the Secretary, subject to subsection (c)(7), shall terminate´´; and
                (B) in the second sentence, by striking ``subsection (c)(2)´´ and inserting ``paragraphs (2) and (7) of subsection (c)´´.
    (b) Nursing Facilities.—
          (1) In General.—
             Section 1919(c) of the Social Security Act (42 U.S.C. 1396r(c)) is amended by adding at the end the following new paragraph:
                ``(9) Notification of facility closure.—
                   ``(A) In general.—Any individual who is an administrator of a nursing facility must—
                      ``(i) submit to the Secretary, the State long-term care ombudsman, residents of the facility, and the legal representatives of such residents or other responsible parties, written notification of an impending closure—
                         ``(I) subject to subclause (II), not later than the date that is 60 days prior to the date of such closure; and
                         ``(II) in the case of a facility where the Secretary terminates the facility’s participation under this title, not later than the date that the Secretary determines appropriate;
                      ``(ii) ensure that the facility does not admit any new residents on or after the date on which such written notification is submitted; and
                      ``(iii) include in the notice a plan for the transfer and adequate relocation of the residents of the facility by a specified date prior to closure that has been approved by the State, including assurances that the residents will be transferred to the most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs and best interests of each resident.
                   ``(B) Relocation.—
                      ``(i) In general.—The State shall ensure that, before a facility closes, all residents of the facility have been successfully relocated to another facility or an alternative home and community-based setting.
                      ``(ii) Continuation of payments until residents relocated.—The Secretary may, as the Secretary determines appropriate, continue to make payments under this title with respect to residents of a facility that has submitted a notification under subparagraph (A) during the period beginning on the date such notification is submitted and ending on the date on which the resident is successfully relocated.´´.
    (c) Effective Date.—
       The amendments made by this section shall take effect 1 year after the date of the enactment of this Act.