I 

116TH CONGRESS 

1ST SESSION H. R. 5216 

To amend titles XVIII and XIX of the Social Security Act to revise minimum 

nurse staffing requirements for skilled nursing facilities under the Medicare program and for nursing facilities under the Medicaid program, 

and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

NOVEMBER 21, 2019 

Ms. SCHAKOWSKY (for herself, Mrs. HAYES, Mr. GARAMENDI, Mr. RYAN, Mr. 

CARSON of Indiana, Ms. MOORE, Ms. ROYBAL-ALLARD, Mrs. CAROLYN

B. MALONEY of New York, Mrs. DINGELL, Ms. DELAURO, Ms. BASS, 

Ms. JOHNSON of Texas, Mr. DANNY K. DAVIS of Illinois, Mr. HASTINGS, 

Mr. PAYNE, Ms. MATSUI, Ms. UNDERWOOD, Ms. JAYAPAL, Ms. 

PRESSLEY, Ms. JUDY CHU of California, Ms. CLARKE of New York, Mr. 

KHANNA, Mr. DEUTCH, Mr. DESAULNIER, Ms. LEE of California, and 

Mr. TONKO) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend titles XVIII and XIX of the Social Security Act 

to revise minimum nurse staffing requirements for skilled 

nursing facilities under the Medicare program and for 

nursing facilities under the Medicaid program, and for 

other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Quality Care for Nurs3 ing Home Residents Act of 2019’’. 

4 SEC. 2. MINIMUM NURSE STAFFING REQUIREMENTS FOR 

5 SKILLED NURSING FACILITIES UNDER MEDI6 CARE PROGRAM AND NURSING FACILITIES 

7 UNDER MEDICAID PROGRAM. 

8 (a) MEDICARE.— 

9 (1) IN GENERAL.—Subparagraph (C) of section 

10 1819(b)(4) of the Social Security Act (42 U.S.C. 

11 1395i–3(b)(4)) is amended— 

12 (A) in clause (i)— 

13 (i) by amending the clause heading to 

14 read as follows: ‘‘GENERAL REQUIRE15 MENTS BEFORE 2020’’; and 

16 (ii) by striking ‘‘Except as provided in 

17 clause (ii),’’ and inserting ‘‘Except as pro18 vided in clause (iii), with respect to skilled 

19 nursing facility services provided before 

20 January 1, 2020,’’; 

21 (B) by redesignating clause (ii) as clause 

22 (iii); and 

23 (C) by inserting after clause (i) the fol24 lowing new clause: 

25 ‘‘(ii) GENERAL REQUIREMENTS AFTER

26 2019.— 


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1 ‘‘(I) IN GENERAL.—With respect 

2 to skilled nursing facility services pro3 vided on or after January 1, 2020, a 

4 skilled nursing facility must— 

5 ‘‘(aa) provide nursing serv6 ices that are sufficient to meet 

7 the nursing needs of its residents 

8 on a 24-hour basis, to be divided 

9 into day shifts, evening shifts, 

10 and night shifts; 

11 ‘‘(bb) provide for minimum 

12 nurse staffing levels with respect 

13 to each such shift, in accordance 

14 with this clause; and 

15 ‘‘(cc) ensure that, in car16 rying out items (aa) and (bb), a 

17 total minimum of 4.1 hours of 

18 care is provided per resident per 

19 day, with 0.75 hours of care of 

20 such total minimum provided by 

21 a registered professional nurse, 

22 0.54 hours of care of such total 

23 minimum provided by a licensed 

24 practical nurse, and 2.81 hours 

25 of care of such total minimum 


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1 provided by a nurse aide (as de2 fined in paragraph (5)(F)). 

3 ‘‘(II) DAY SHIFTS.—With respect 

4 to a day shift, the skilled nursing fa5 cility must have— 

6 ‘‘(aa) at least 1 registered 

7 professional nurse for every 28 

8 residents, with a minimum of 

9 0.29 hours of care provided per 

10 resident during each such shift; 

11 ‘‘(bb) at least 1 licensed 

12 practical nurse for every 40 resi13 dents, with a minimum of 0.20 

14 hours of care provided per resi15 dent during each such shift; and 

16 ‘‘(cc) at least 1 nurse aide 

17 (as defined in paragraph (5)(F)) 

18 for every 7 residents, with a min19 imum of 1.14 hours of care pro20 vided per resident during each 

21 such shift. 

22 ‘‘(III) EVENING SHIFTS.—With 

23 respect to an evening shift, the skilled 

24 nursing facility must have— 


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1 ‘‘(aa) at least 1 registered 

2 professional nurse for every 30 

3 residents, with a minimum of 

4 0.26 hours of care provided per 

5 resident during each such shift; 

6 ‘‘(bb) at least 1 licensed 

7 practical nurse for every 40 resi8 dents, with a minimum of 0.20 

9 hours of care provided per resi10 dent during each such shift; and 

11 ‘‘(cc) at least 1 nurse aide 

12 (as defined in paragraph (5)(F)) 

13 for every 7 residents, with a min14 imum of 1.14 hours of care pro15 vided per resident during each 

16 such shift. 

17 ‘‘(IV) NIGHT SHIFTS.—With re18 spect to a night shift, the skilled nurs19 ing facility must have— 

20 ‘‘(aa) at least 1 registered 

21 professional nurse for every 40 

22 residents, with a minimum of 

23 0.20 hours of care provided per 

24 resident during such shift; 


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1 ‘‘(bb) at least 1 licensed 

2 practical nurse for every 56 resi3 dents, with a minimum of 0.14 

4 hours of care provided per resi5 dent during such shift; and 

6 ‘‘(cc) at least 1 nurse aide 

7 (as defined in paragraph (5)(F)) 

8 for every 15 residents, with a 

9 minimum of 0.53 hours of care 

10 provided per resident during such 

11 shift. 

12 ‘‘(V) SECRETARIAL AUTHORITY

13 TO ESTABLISH HIGHER MINIMUM

14 NURSE STAFFING LEVELS.—The Sec15 retary may establish and require 

16 skilled nursing facilities (or, at the 

17 Secretary’s discretion, only skilled 

18 nursing facilities that have a higher 

19 percentage of residents with extensive 

20 care needs, as determined by the Sec21 retary) to provide for minimum nurse 

22 staffing levels that are higher than 

23 the levels required under this clause. 

24 ‘‘(VI) RULE OF CONSTRUCTION

25 REGARDING STATE AUTHORITY TO ESVerDate Sep 11 2014 22:02 Dec 10, 2019 Jkt 099200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H5216.IH H5216

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1 TABLISH HIGHER MINIMUM NURSE

2 STAFFING LEVELS.—Nothing in this 

3 clause may be construed as preventing 

4 a State from establishing or requiring 

5 skilled nursing facilities in the State 

6 to provide for minimum nurse staffing 

7 levels that are higher than the levels 

8 required under this clause. 

9 ‘‘(VII) CLARIFICATION WITH RE10 SPECT TO MINIMUM HOURS OF CARE

11 PROVIDED PER RESIDENT REQUIRE12 MENTS.—In complying with the min13 imum hours of care provided per resi14 dent requirements under this clause, a 

15 skilled nursing facility may not count 

16 any time spent by a registered profes17 sional nurse, licensed practical nurse, 

18 or nurse aide on administrative serv19 ices towards compliance with such re20 quirements. 

21 ‘‘(VIII) DEFINITIONS.—In this 

22 clause: 

23 ‘‘(aa) ADMINISTRATIVE

24 SERVICES.—The term ‘adminis25 trative services’ means food prepVerDate Sep 11 2014 22:02 Dec 10, 2019 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H5216.IH H5216

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1 aration, housekeeping, laundry 

2 services, maintenance services, 

3 and other noncaregiving-related 

4 services, as determined by the 

5 Secretary. 

6 ‘‘(bb) DAY SHIFT.—The 

7 term ‘day shift’ means, with re8 spect to a day and a skilled nurs9 ing facility, an assigned work 

10 shift that is a period of 8 con11 secutive hours, beginning not 

12 sooner than 6 a.m. in the time 

13 zone in which such facility is lo14 cated and not later than 8 a.m. 

15 in such time zone. 

16 ‘‘(cc) EVENING SHIFT.—The 

17 term ‘evening shift’ means, with 

18 respect to a day and a skilled 

19 nursing facility, an assigned work 

20 shift that is a period of 8 con21 secutive hours, beginning not 

22 sooner than 2 p.m. in the time 

23 zone in which such facility is lo24 cated and not later than 4 p.m. 

25 in such time zone. 


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1 ‘‘(dd) NIGHT SHIFT.—The 

2 term ‘night shift’ means, with re3 spect to a day and a skilled nurs4 ing facility, an assigned work 

5 shift that is a period of 8 con6 secutive hours, beginning not 

7 sooner than 10 p.m. in the time 

8 zone in which such facility is lo9 cated and not later than mid10 night in such time zone.’’. 

11 (2) ENFORCEMENT.—Section 1819(h) of the 

12 Social Security Act (42 U.S.C. 1395i–3(h)) is 

13 amended— 

14 (A) in paragraph (1), by striking ‘‘If a 

15 State finds, on the basis of a standard’’ and in16 serting ‘‘Subject to paragraph (7), if a State 

17 finds, on the basis of a standard’’; 

18 (B) in paragraph (2), by striking ‘‘With 

19 respect to’’ and inserting ‘‘Subject to paragraph 

20 (7), with respect to’’; and 

21 (C) by adding at the end the following new 

22 paragraph: 

23 ‘‘(7) SPECIAL ENFORCEMENT PROCESS WITH

24 RESPECT TO MINIMUM NURSE STAFFING REQUIRE25 MENTS.— 


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1 ‘‘(A) IN GENERAL.—If a State finds, on 

2 the basis of a standard, extended, or partial ex3 tended survey under subsection (g)(2) or other4 wise, that a skilled nursing facility does not 

5 meet the minimum staffing requirements of 

6 clause (ii) of subsection (b)(4)(C) with respect 

7 to skilled nursing facility services provided on 

8 or after January 1, 2020, the State shall rec9 ommend to the Secretary that the Secretary 

10 take such actions as described in subclauses (I) 

11 and (II) of subparagraph (B)(i). 

12 ‘‘(B) SECRETARIAL AUTHORITY.— 

13 ‘‘(i) IN GENERAL.—With respect to 

14 any skilled nursing facility in a State, if 

15 the Secretary finds, or pursuant to a rec16 ommendation of the State under subpara17 graph (A) finds, that a skilled nursing fa18 cility does not meet the minimum staffing 

19 requirements of clause (ii) of subsection 

20 (b)(4)(C) with respect to skilled nursing 

21 facility services provided on or after Janu22 ary 1, 2020, the Secretary shall— 

23 ‘‘(I) deny any further payments 

24 under this title with respect to all in25 dividuals entitled to benefits under 


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1 this title who are admitted to the fa2 cility after the effective date of the 

3 finding; and 

4 ‘‘(II) impose a civil money pen5 alty in an amount not to exceed 

6 $10,000 for each day of noncompli7 ance. The provisions of section 1128A 

8 (other than subsections (a) and (b)) 

9 shall apply to a civil money penalty 

10 under the previous sentence in the 

11 same manner as such provisions apply 

12 to a penalty or proceeding under sec13 tion 1128A(a). 

14 ‘‘(ii) REDUCTION OF CIVIL MONEY

15 PENALTIES IN CERTAIN CIR16 CUMSTANCES.—Subject to clause (iii), in 

17 the case where a skilled nursing facility 

18 self-reports and promptly corrects a defi19 ciency for which a penalty was imposed 

20 under clause (i)(II) not later than 10 cal21 endar days after the date of such imposi22 tion, the Secretary may reduce the amount 

23 of the penalty imposed by— 

24 ‘‘(I) not more than 50 percent; or 


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1 ‘‘(II) in the case that the facility 

2 was penalized under this subsection 

3 within the three-year period preceding 

4 the date of such imposition, not more 

5 than 25 percent. 

6 ‘‘(iii) PROHIBITIONS ON REDUCTION

7 FOR CERTAIN DEFICIENCIES.— 

8 ‘‘(I) REPEAT DEFICIENCIES.— 

9 The Secretary may not reduce the 

10 amount of a penalty under clause (ii) 

11 if the Secretary had reduced a penalty 

12 imposed on the skilled nursing facility 

13 in the preceding year under such 

14 clause with respect to a repeat defi15 ciency. 

16 ‘‘(II) CERTAIN OTHER DEFI17 CIENCIES.—The Secretary may not 

18 reduce the amount of a penalty under 

19 clause (ii) if the penalty is imposed on 

20 the skilled nursing facility for a defi21 ciency that is found to result in a pat22 tern of harm or widespread harm, im23 mediately jeopardizes the health or 

24 safety of a resident or residents of the 


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1 facility, or results in the death of a 

2 resident of the facility. 

3 ‘‘(iv) REPEATED NONCOMPLIANCE.— 

4 In the case of a skilled nursing facility 

5 which, on three consecutive standard sur6 veys conducted under subsection (g)(2), 

7 has been found as not meeting the min8 imum staffing requirements of clause (ii) 

9 of subsection (b)(4)(C) with respect to 

10 skilled nursing facility services provided on 

11 or after January 1, 2020, the Secretary 

12 may (regardless of the remedies provided 

13 for under clause (i))— 

14 ‘‘(I) appoint temporary manage15 ment to oversee the operation of the 

16 facility and to assure the health and 

17 safety of the facility’s residents in ac18 cordance with clause (iii) of para19 graph (2)(B), except that ‘the min20 imum staffing requirements of clause 

21 (ii) of subsection (b)(4)(C)’ shall be 

22 substituted for ‘all the requirements 

23 of subsections (b), (c), and (d)’ under 

24 such clause; 


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1 ‘‘(II) monitor the facility under 

2 subsection (g)(4)(B) with respect to 

3 such minimum staffing requirements 

4 until the facility has demonstrated to 

5 the satisfaction of the Secretary that 

6 the facility is in compliance, and will 

7 remain in compliance, with such min8 imum staffing requirements; or 

9 ‘‘(III) subject to section 

10 1128I(h), terminate the facility’s par11 ticipation under this title. 

12 If the facility’s participation under this 

13 title is terminated under this clause, the 

14 State shall provide for the safe and orderly 

15 transfer of the residents eligible under this 

16 title, consistent with the requirements of 

17 subsection (c)(2) and section 1128I(h). 

18 ‘‘(v) PUBLIC NOTICE OF VIOLA19 TIONS.— 

20 ‘‘(I) INTERNET WEBSITE.—The 

21 Secretary shall publish on the internet 

22 website of the Department of Health 

23 and Human Services the names of 

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1 ments of clause (ii) of subsection 

2 (b)(4)(C) with respect to skilled nurs3 ing facility services provided on or 

4 after January 1, 2020. 

5 ‘‘(II) CHANGE OF OWNERSHIP.— 

6 With respect to a skilled nursing facil7 ity whose name is published under 

8 subclause (I) and has a change of 

9 ownership, as determined by the Sec10 retary, after the date of such publica11 tion, the Secretary shall remove the 

12 name of such facility from the website 

13 described under such subclause after 

14 the 1-year period beginning on the 

15 date of such change of ownership.’’. 

16 (3) CONFORMING AMENDMENT.—Item (a) of 

17 section 1819(f)(2)(B)(iii)(I) of the Social Security 

18 Act (42 U.S.C. 1395i–3(f)(2)(B)(iii)(I)) is amended 

19 by striking ‘‘subsection (b)(4)(C)(ii)(II)’’ and insert20 ing ‘‘subsection (b)(4)(C)(iii)(II)’’. 

21 (b) MEDICAID.— 

22 (1) IN GENERAL.—Subparagraph (C) of section 

23 1919(b)(4) of the Social Security Act (42 U.S.C. 

24 1396r(b)(4)) is amended— 

25 (A) in clause (i)— 


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1 (i) in the clause heading, by inserting 

2 after ‘‘GENERAL REQUIREMENTS’’ the fol3 lowing ‘‘BEFORE 2020’’; 

4 (ii) in the matter preceding subclause 

5 (I), by inserting after ‘‘October 1, 1990,’’ 

6 the following: ‘‘and before January 1, 

7 2020,’’; 

8 (iii) in subclause (I), by striking 

9 ‘‘clause (ii)’’ and inserting ‘‘clause (iii)’’; 

10 and 

11 (iv) in subclause (II), by striking 

12 ‘‘clause (ii)’’ and inserting ‘‘clause (iii)’’; 

13 (B) by redesignating clauses (ii) and (iii) 

14 as clauses (iii) and (iv), respectively; and 

15 (C) by inserting after clause (i) the fol16 lowing new clause: 

17 ‘‘(ii) GENERAL REQUIREMENTS AFTER

18 2019.— 

19 ‘‘(I) IN GENERAL.—With respect 

20 to nursing facility services provided on 

21 or after January 1, 2020, a nursing 

22 facility must— 

23 ‘‘(aa) provide nursing serv24 ices that are sufficient to meet 

25 the nursing needs of its residents 


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1 on a 24-hour basis, to be divided 

2 into day shifts, evening shifts, 

3 and night shifts; 

4 ‘‘(bb) provide for minimum 

5 nurse staffing levels with respect 

6 to each such shift, in accordance 

7 with this clause; and 

8 ‘‘(cc) ensure that, in car9 rying out items (aa) and (bb), a 

10 total minimum of 4.1 hours of 

11 care is provided per resident per 

12 day, with 0.75 hours of care of 

13 such total minimum provided by 

14 a registered professional nurse, 

15 0.54 hours of care of such total 

16 minimum provided by a licensed 

17 practical nurse, and 2.81 hours 

18 of care of such total minimum 

19 provided by a nurse aide (as de20 fined in paragraph (5)(F)). 

21 ‘‘(II) DAY SHIFTS.—With respect 

22 to a day shift, the nursing facility 

23 must have— 

24 ‘‘(aa) at least 1 registered 

25 professional nurse for every 28 


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1 residents, with a minimum of 

2 0.29 hours of care provided per 

3 resident during each such shift; 

4 ‘‘(bb) at least 1 licensed 

5 practical nurse for every 40 resi6 dents, with a minimum of 0.20 

7 hours of care provided per resi8 dent during each such shift; and 

9 ‘‘(cc) at least 1 nurse aide 

10 (as defined in paragraph (5)(F)) 

11 for every 7 residents, with a min12 imum of 1.14 hours of care pro13 vided per resident during each 

14 such shift. 

15 ‘‘(III) EVENING SHIFTS.—With 

16 respect to an evening shift, the nurs17 ing facility must have— 

18 ‘‘(aa) at least 1 registered 

19 professional nurse for every 30 

20 residents, with a minimum of 

21 0.26 hours of care provided per 

22 resident during each such shift; 

23 ‘‘(bb) at least 1 licensed 

24 practical nurse for every 40 resi25 dents, with a minimum of 0.20 


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1 hours of care provided per resi2 dent during each such shift; and 

3 ‘‘(cc) at least 1 nurse aide 

4 (as defined in paragraph (5)(F)) 

5 for every 7 residents, with a min6 imum of 1.14 hours of care pro7 vided per resident during each 

8 such shift. 

9 ‘‘(IV) NIGHT SHIFTS.—With re10 spect to a night shift, the nursing fa11 cility must have— 

12 ‘‘(aa) at least 1 registered 

13 professional nurse for every 40 

14 residents, with a minimum of 

15 0.20 hours of care provided per 

16 resident during such shift; 

17 ‘‘(bb) at least 1 licensed 

18 practical nurse for every 56 resi19 dents, with a minimum of 0.14 

20 hours of care provided per resi21 dent during such shift; and 

22 ‘‘(cc) at least 1 nurse aide 

23 (as defined in paragraph (5)(F)) 

24 for every 15 residents, with a 

25 minimum of 0.53 hours of care 


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1 provided per resident during such 

2 shift. 

3 ‘‘(V) SECRETARIAL AUTHORITY

4 TO ESTABLISH HIGHER MINIMUM

5 NURSE STAFFING LEVELS.—The Sec6 retary may establish and require nurs7 ing facilities (or, at the Secretary’s 

8 discretion, only nursing facilities that 

9 have a higher percentage of residents 

10 with extensive care needs, as deter11 mined by the Secretary) to provide for 

12 minimum nurse staffing levels that 

13 are higher than the levels required 

14 under this clause. 

15 ‘‘(VI) RULE OF CONSTRUCTION

16 REGARDING STATE AUTHORITY TO ES17 TABLISH HIGHER MINIMUM NURSE

18 STAFFING LEVELS.—Nothing in this 

19 clause may be construed as preventing 

20 a State from establishing or requiring 

21 nursing facilities in the State to pro22 vide for minimum nurse staffing levels 

23 that are higher than the levels re24 quired under this clause. 


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1 ‘‘(VII) CLARIFICATION WITH RE2 SPECT TO MINIMUM HOURS OF CARE

3 PROVIDED PER RESIDENT REQUIRE4 MENTS.—In complying with the min5 imum hours of care provided per resi6 dent requirements under this clause, a 

7 nursing facility may not count any 

8 time spent by a registered professional 

9 nurse, licensed practical nurse, or 

10 nurse aide on administrative services 

11 towards compliance with such require12 ments. 

13 ‘‘(VIII) DEFINITIONS.—In this 

14 clause: 

15 ‘‘(aa) ADMINISTRATIVE

16 SERVICES.—The term ‘adminis17 trative services’ means food prep18 aration, housekeeping, laundry 

19 services, maintenance services, 

20 and other noncaregiving-related 

21 services, as determined by the 

22 Secretary. 

23 ‘‘(bb) DAY SHIFT.—The 

24 term ‘day shift’ means, with re25 spect to a day and a nursing faVerDate Sep 11 2014 22:02 Dec 10, 2019 Jkt 099200 PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 E:\BILLS\H5216.IH H5216

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1 cility, an assigned work shift that 

2 is a period of 8 consecutive 

3 hours, beginning not sooner than 

4 6 a.m. in the time zone in which 

5 such facility is located and not 

6 later than 8 a.m. in such time 

7 zone. 

8 ‘‘(cc) EVENING SHIFT.—The 

9 term ‘evening shift’ means, with 

10 respect to a day and a nursing 

11 facility, an assigned work shift 

12 that is a period of 8 consecutive 

13 hours, beginning not sooner than 

14 2 p.m. in the time zone in which 

15 such facility is located and not 

16 later than 4 p.m. in such time 

17 zone. 

18 ‘‘(dd) NIGHT SHIFT.—The 

19 term ‘night shift’ means, with re20 spect to a day and a nursing fa21 cility, an assigned work shift that 

22 is a period of 8 consecutive 

23 hours, beginning not sooner than 

24 10 p.m. in the time zone in which 

25 such facility is located and not 


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1 later than midnight in such time 

2 zone.’’. 

3 (2) ENFORCEMENT.—Section 1919(h) of the 

4 Social Security Act (42 U.S.C. 1396r(h)) is amend5 ed— 

6 (A) in paragraph (1), by striking ‘‘If a 

7 State finds, on the basis of a standard’’ and in8 serting ‘‘Subject to paragraph (10), if a State 

9 finds, on the basis of a standard’’; 

10 (B) in paragraph (2)— 

11 (i) in subparagraph (C), by striking 

12 ‘‘If a nursing facility’’ and inserting ‘‘Sub13 ject to paragraph (10), if a nursing facil14 ity’’; and 

15 (ii) in subparagraph (D), by striking 

16 ‘‘In the case of’’ and inserting ‘‘Subject to 

17 paragraph (10), in the case of’’; 

18 (C) in paragraph (3)— 

19 (i) in subparagraph (A), by inserting 

20 before the period the following: ‘‘and the 

21 remedies described in paragraph (10)(B)’’; 

22 and 

23 (ii) in subparagraph (B), by striking 

24 ‘‘With respect to’’ and inserting ‘‘Subject 

25 to paragraph (10), with respect to’’; and 


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1 (D) by adding at the end the following new 

2 paragraph: 

3 ‘‘(10) SPECIAL ENFORCEMENT PROCESS WITH

4 RESPECT TO MINIMUM NURSE STAFFING REQUIRE5 MENTS.— 

6 ‘‘(A) IN GENERAL.—If a State finds, on 

7 the basis of a standard, extended, or partial ex8 tended survey under subsection (g)(2) or other9 wise, that a nursing facility does not meet the 

10 minimum staffing requirements of clause (ii) of 

11 subsection (b)(4)(C) with respect to nursing fa12 cility services provided on or after January 1, 

13 2020, the State shall— 

14 ‘‘(i) deny any further payments under 

15 the State plan with respect to all individ16 uals enrolled under such plan who are ad17 mitted to the facility after the effective 

18 date of the finding; and 

19 ‘‘(ii) recommend to the Secretary that 

20 the Secretary impose the civil money pen21 alty described in subparagraph (B). 

22 ‘‘(B) SECRETARIAL AUTHORITY.— 

23 ‘‘(i) IN GENERAL.—With respect to 

24 any nursing facility in a State other than 

25 a State nursing facility, if the Secretary 


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1 finds that such a nursing facility does not 

2 meet the minimum staffing requirements 

3 of clause (ii) of subsection (b)(4)(C) with 

4 respect to nursing facility services provided 

5 on or after January 1, 2020, the Secretary 

6 shall— 

7 ‘‘(I) deny any further payments 

8 to the State for medical assistance 

9 furnished by the facility to all individ10 uals enrolled under the State plan 

11 who are admitted to the facility after 

12 the effective date of the finding; and 

13 ‘‘(II) impose a civil money pen14 alty in an amount not to exceed 

15 $10,000 for each day of noncompli16 ance. The provisions of section 1128A 

17 (other than subsections (a) and (b)) 

18 shall apply to a civil money penalty 

19 under the previous sentence in the 

20 same manner as such provisions apply 

21 to a penalty or proceeding under sec22 tion 1128A(a). 

23 ‘‘(ii) REDUCTION OF CIVIL MONEY

24 PENALTIES IN CERTAIN CIR25 CUMSTANCES.—Subject to clause (iii), in 


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1 the case where a nursing facility self-re2 ports and promptly corrects a deficiency 

3 for which a penalty was imposed under 

4 clause (i)(II) not later than 10 calendar 

5 days after the date of such imposition, the 

6 Secretary may reduce the amount of the 

7 penalty imposed by— 

8 ‘‘(I) not more than 50 percent; or 

9 ‘‘(II) in the case that the facility 

10 was penalized under this subsection 

11 within the three-year period preceding 

12 the date of such imposition, not more 

13 than 25 percent. 

14 ‘‘(iii) PROHIBITIONS ON REDUCTION

15 FOR CERTAIN DEFICIENCIES.— 

16 ‘‘(I) REPEAT DEFICIENCIES.— 

17 The Secretary may not reduce the 

18 amount of a penalty under clause (ii) 

19 if the Secretary had reduced a penalty 

20 imposed on the nursing facility in the 

21 preceding year under such clause with 

22 respect to a repeat deficiency. 

23 ‘‘(II) CERTAIN OTHER DEFI24 CIENCIES.—The Secretary may not 

25 reduce the amount of a penalty under 


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1 clause (ii) if the penalty is imposed on 

2 the nursing facility for a deficiency 

3 that is found to result in a pattern of 

4 harm or widespread harm, imme5 diately jeopardizes the health or safe6 ty of a resident or residents of the fa7 cility, or results in the death of a resi8 dent of the facility. 

9 ‘‘(iv) REPEATED NONCOMPLIANCE.— 

10 In the case of a nursing facility which, on 

11 three consecutive standard surveys con12 ducted under subsection (g)(2), has been 

13 found as not meeting the minimum staff14 ing requirements of clause (ii) of sub15 section (b)(4)(C) with respect to nursing 

16 facility services provided on or after Janu17 ary 1, 2020, the Secretary may (regardless 

18 of the remedies provided for under clause 

19 (i))— 

20 ‘‘(I) appoint temporary manage21 ment to oversee the operation of the 

22 facility and to assure the health and 

23 safety of the facility’s residents in ac24 cordance with clause (iii) of para25 graph (3)(C), except that ‘the minVerDate Sep 11 2014 22:02 Dec 10, 2019 Jkt 099200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\H5216.IH H5216

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1 imum staffing requirements of clause 

2 (ii) of subsection (b)(4)(C)’ shall be 

3 substituted for ‘all the requirements 

4 of subsections (b), (c), and (d)’ under 

5 such clause; 

6 ‘‘(II) monitor the facility under 

7 subsection (g)(4)(B) with respect to 

8 such minimum staffing requirements 

9 until the facility has demonstrated to 

10 the satisfaction of the Secretary that 

11 the facility is in compliance, and will 

12 remain in compliance, with such min13 imum staffing requirements; or 

14 ‘‘(III) subject to section 

15 1128I(h), terminate the facility’s par16 ticipation under this title. 

17 If the facility’s participation under this 

18 title is terminated under this clause, the 

19 State shall provide for the safe and orderly 

20 transfer of the residents eligible under this 

21 title, consistent with the requirements of 

22 subsection (c)(2) and section 1128I(h). 

23 ‘‘(v) PUBLIC NOTICE OF VIOLA24 TIONS.— 


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1 ‘‘(I) INTERNET WEBSITE.—The 

2 Secretary shall publish on the internet 

3 website of the Department of Health 

4 and Human Services the names of 

5 nursing facilities that have violated 

6 the minimum staffing requirements of 

7 clause (ii) of subsection (b)(4)(C) with 

8 respect to skilled nursing facility serv9 ices provided on or after January 1, 

10 2020. 

11 ‘‘(II) CHANGE OF OWNERSHIP.— 

12 With respect to a nursing facility 

13 whose name is published under sub14 clause (I) and has a change of owner15 ship, as determined by the Secretary, 

16 after the date of such publication, the 

17 Secretary shall remove the name of 

18 such facility from the website de19 scribed under such subclause after the 

20 1-year period beginning on the date of 

21 such change of ownership.’’. 

22 (3) CONFORMING AMENDMENTS.— 

23 (A) Clause (iii) of section 1919(b)(4)(C) of 

24 the Social Security Act (42 U.S.C. 

25 1396r(b)(4)(C)), as redesignated by paragraph 


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1 (1)(B), is amended by striking ‘‘subject to 

2 clause (iii)’’ and inserting ‘‘subject to clause 

3 (iv)’’. 

4 (B) Item (a) of section 

5 1919(f)(2)(B)(iii)(I) of the Social Security Act 

6 (42 U.S.C. 1396r(f)(2)(B)(iii)(I)) is amended 

7 by striking ‘‘subsection (b)(4)(C)(ii)’’ and in8 serting ‘‘subsection (b)(4)(C)(iii)’’. 

9 (C) Paragraph (9) of section 1919(f) of 

10 the Social Security Act (42 U.S.C. 1396r(f)) is 

11 amended by striking ‘‘subsection (b)(4)(C)(ii)’’ 

12 and inserting ‘‘subsection (b)(4)(C)(iii)’’. 

13 (c) STUDIES AND REPORTS REGARDING IMPACT OF

14 MINIMUM NURSE STAFFING REQUIREMENTS.— 

15 (1) INITIAL STUDY AND REPORT.— 

16 (A) IN GENERAL.—Not later than June 1, 

17 2021, the Secretary of Health and Human 

18 Services shall study and submit to the Com19 mittee on Energy and Commerce and the Com20 mittee on Ways and Means of the House of 

21 Representatives and the Committee on Finance 

22 of the Senate a publicly available report— 

23 (i) on the impact of the minimum 

24 nurse staffing requirements added by sub25 section (a) on the reimbursement levels of 


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1 skilled nursing facilities under the Medi2 care program under title XVIII of the So3 cial Security Act (42 U.S.C. 1395 et seq.) 

4 and the adequacy of personnel numbers in 

5 such skilled nursing facilities to meet such 

6 minimum nurse staffing requirements; 

7 (ii) on the impact of the minimum 

8 nurse staffing requirements added by sub9 section (b) on the reimbursement levels of 

10 nursing facilities under the Medicaid pro11 gram under title XIX of the Social Secu12 rity Act (42 U.S.C. 1396 et seq.) and the 

13 adequacy of personnel numbers in such 

14 nursing facilities to meet such minimum 

15 nurse staffing requirements; and 

16 (iii) including recommendations on the 

17 steps that such skilled nursing facilities 

18 and nursing facilities can take to ensure 

19 that adequate personnel are available in 

20 such skilled nursing facilities and nursing 

21 facilities to meet the minimum nurse staff22 ing requirements added by subsections (a) 

23 and (b) for such skilled nursing facilities 

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1 ing methods for attracting and retaining 

2 such personnel. 

3 (B) CONSIDERATIONS.—In conducting the 

4 study required under subparagraph (A), the 

5 Secretary of Health and Human Services shall 

6 take into consideration— 

7 (i) the benefits of any increase in 

8 nurse staffing levels, including with respect 

9 to workforce training and retention; 

10 (ii) any decrease in the rate of work11 place injuries; 

12 (iii) any changes in medical care costs 

13 for residents of skilled nursing facilities 

14 and nursing facilities; 

15 (iv) any decrease in hospitalization 

16 rates for such residents; 

17 (v) any changes in personnel and ad18 ministrative costs for skilled nursing facili19 ties and nursing facilities; and 

20 (vi) any changes in recruiting and 

21 training costs. 

22 (2) SUBSEQUENT STUDY AND REPORT.—Not 

23 later than January 1, 2023, the Secretary of Health 

24 and Human Services shall conduct a follow-up study 

25 to the study conducted under paragraph (1)(A) and 


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1 submit to the Committee on Energy and Commerce 

2 and the Committee on Ways and Means of the 

3 House of Representatives and the Committee on Fi4 nance of the Senate a publicly available report on 

5 such follow-up study. 

6 SEC. 3. DISCLOSURE OF NURSE STAFFING LEVELS AT 

7 SKILLED NURSING FACILITIES UNDER MEDI8 CARE PROGRAM AND NURSING FACILITIES 

9 UNDER MEDICAID PROGRAM. 

10 (a) MEDICARE.—Paragraph (8) of section 1819(b) of 

11 the Social Security Act (42 U.S.C. 1395i–3(b)) is amend12 ed to read as follows: 

13 ‘‘(8) INFORMATION ON NURSE STAFFING.— 

14 ‘‘(A) IN GENERAL.—Each day, a skilled 

15 nursing facility shall post for each shift notices 

16 with— 

17 ‘‘(i) a description of the nurse staffing 

18 requirements applicable with respect to the 

19 facility and day under paragraph (4)(C); 

20 ‘‘(ii) information on the number of 

21 registered professional nurses, licensed 

22 practical nurses, and nurse aides (as de23 fined in paragraph (5)(F)) assigned to pro24 vide direct care services to residents in the 


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1 facility during the shift, disaggregated by 

2 units in the facility; and 

3 ‘‘(iii) a statement that the facility is 

4 required, upon request, to provide any 

5 nurse staffing information (as described in 

6 this subparagraph) of the facility from the 

7 preceding 12-month period. 

8 The information in such notices shall be written 

9 in a uniform manner, printed in an easily read10 able 14-point type font, and made available in 

11 appropriate languages, as determined by the 

12 Secretary. The skilled nursing facility shall 

13 make such notices available at each nurses’ sta14 tion in the facility and other areas in each unit 

15 of the facility, as determined appropriate by the 

16 facility, and shall keep and maintain each such 

17 notice for at least three years after the date on 

18 which each such notice is posted in the facility. 

19 ‘‘(B) PUBLIC AVAILABILITY OF INFORMA20 TION.—A skilled nursing facility shall, upon re21 quest, make available to the public any nurse 

22 staffing information (as described in subpara23 graph (A)) of the facility from the preceding 

24 12-month period. In the case that the facility 

25 makes such information available as a paper 


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1 copy, such facility may not charge for such copy 

2 an amount greater than the cost of making 

3 such copy.’’. 

4 (b) MEDICAID.—Paragraph (8) of section 1919(b) of 

5 the Social Security Act (42 U.S.C. 1396r(b)) is amended 

6 to read as follows: 

7 ‘‘(8) INFORMATION ON NURSE STAFFING.— 

8 ‘‘(A) IN GENERAL.—Each day, a skilled 

9 nursing facility shall post for each shift notices 

10 with— 

11 ‘‘(i) a description of the nurse staffing 

12 requirements applicable with respect to the 

13 facility and day under paragraph (4)(C); 

14 ‘‘(ii) information on the number of 

15 registered professional nurses, licensed 

16 practical nurses, and nurse aides (as de17 fined in paragraph (5)(F)) assigned to pro18 vide direct care services to residents in the 

19 facility during the shift, disaggregated by 

20 units in the facility; and 

21 ‘‘(iii) a statement that the facility is 

22 required, upon request, to provide any 

23 nurse staffing information (as described in 

24 this subparagraph) of the facility from the 

25 preceding 12-month period. 


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1 The information in such notices shall be written 

2 in a uniform manner, printed in an easily read3 able 14-point type font, and made available in 

4 appropriate languages, as determined by the 

5 Secretary. The skilled nursing facility shall 

6 make such notices available at each nurses’ sta7 tion in the facility and other areas in each unit 

8 of the facility, as determined appropriate by the 

9 facility, and shall keep and maintain each such 

10 notice for at least three years after the date on 

11 which each such notice is posted in the facility. 

12 ‘‘(B) PUBLIC AVAILABILITY OF INFORMA13 TION.—A skilled nursing facility shall, upon re14 quest, make available to the public any nurse 

15 staffing information (as described in subpara16 graph (A)) of the facility from the preceding 

17 12-month period.’’. 

18 (c) EFFECTIVE DATE.—The amendments made by 

19 this section take effect on the date of enactment of this 

20 Act and apply with respect to nurse staffing information 

21 posted or requested on or after the date that is one year 

22 after such date of enactment. 


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1 SEC. 4. ADMINISTRATIVE STAFFING REQUIREMENTS FOR 

2 SKILLED NURSING FACILITIES UNDER MEDI3 CARE PROGRAM AND NURSING FACILITIES 

4 UNDER MEDICAID PROGRAM. 

5 (a) MEDICARE.—Paragraph (1) of section 1819(d) of 

6 the Social Security Act (42 U.S.C. 1395i–3(d)) is amend7 ed— 

8 (1) by redesignating the second subparagraph 

9 (C) as subparagraph (E); and 

10 (2) by inserting after the first subparagraph 

11 (C) the following new subparagraph: 

12 ‘‘(D) NURSING MANAGEMENT PER13 SONNEL.— 

14 ‘‘(i) IN GENERAL.—A skilled nursing 

15 facility must employ nursing management 

16 personnel in accordance with this subpara17 graph. 

18 ‘‘(ii) DIRECTOR OF NURSING SERV19 ICES.—A skilled nursing facility must em20 ploy a registered professional nurse to 

21 serve full-time as the director of nursing 

22 services of the facility. Such director of 

23 nursing services shall be responsible for de24 termining the number and types of nursing 

25 personnel needed to sufficiently meet the 

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1 ity (as required under subsection 

2 (b)(4)(C)). 

3 ‘‘(iii) ASSISTANT DIRECTOR OF NURS4 ING SERVICES.—A skilled nursing facility 

5 must employ a registered professional 

6 nurse to serve full-time as the assistant di7 rector of nursing services of the facility, 

8 except that in the case of a skilled nursing 

9 facility that has fewer than 100 beds, such 

10 facility may employ a registered profes11 sional nurse to serve part-time as the as12 sistant director of nursing services of the 

13 facility. A registered professional nurse 

14 who serves as the assistant director of 

15 nursing services of a skilled nursing facility 

16 may also serve as a supervisor for direct 

17 clinical nursing care for such facility. 

18 ‘‘(iv) DIRECTOR OF IN-SERVICE EDU19 CATION.—A skilled nursing facility must 

20 employ a registered professional nurse to 

21 serve full-time as the director of in-service 

22 education of the facility, except that in the 

23 case of a skilled nursing facility that has 

24 fewer than 100 beds, such facility may em25 ploy a registered professional nurse to 


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1 serve part-time as the director of in-service 

2 education of the facility. In carrying out 

3 the previous sentence, a skilled nursing fa4 cility must, to the extent practicable and 

5 appropriate, employ a registered profes6 sional nurse who has received training in 

7 adult education and gerontology.’’. 

8 (b) MEDICAID.— 

9 (1) IN GENERAL.—Paragraph (1) of section 

10 1919(d) of the Social Security Act (42 U.S.C. 

11 1396r(d)) is amended by inserting after subpara12 graph (C) the following new subparagraph: 

13 ‘‘(D) NURSING MANAGEMENT PER14 SONNEL.— 

15 ‘‘(i) IN GENERAL.—A nursing facility 

16 must employ nursing management per17 sonnel in accordance with this subpara18 graph. 

19 ‘‘(ii) DIRECTOR OF NURSING SERV20 ICES.—A nursing facility must employ a 

21 registered professional nurse to serve full22 time as the director of nursing services of 

23 the facility. Such director of nursing serv24 ices shall be responsible for determining 

25 the number and types of nursing personnel 


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1 needed to sufficiently meet the nursing 

2 needs of the residents of the facility (as re3 quired under subsection (b)(4)(C)). 

4 ‘‘(iii) ASSISTANT DIRECTOR OF NURS5 ING SERVICES.—A nursing facility must 

6 employ a registered professional nurse to 

7 serve full-time as the assistant director of 

8 nursing services of the facility, except that 

9 in the case of a nursing facility that has 

10 fewer than 100 beds, such facility may em11 ploy a registered professional nurse to 

12 serve part-time as the assistant director of 

13 nursing services of the facility. A reg14 istered professional nurse who serves as 

15 the assistant director of nursing services of 

16 a nursing facility may also serve as a su17 pervisor for direct clinical nursing care for 

18 such facility. 

19 ‘‘(iv) DIRECTOR OF IN-SERVICE EDU20 CATION.—A nursing facility must employ a 

21 registered professional nurse to serve full22 time as the director of in-service education 

23 of the facility, except that in the case of a 

24 nursing facility that has fewer than 100 

25 beds, such facility may employ a registered 


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•HR 5216 IH

1 professional nurse to serve part-time as the 

2 director of in-service education of the facil3 ity. In carrying out the previous sentence, 

4 a nursing facility must, to the extent prac5 ticable and appropriate, employ a reg6 istered professional nurse who has received 

7 training in adult education and geron8 tology.’’. 

9 (2) TECHNICAL AMENDMENT.—Paragraph (1) 

10 of section 1919(d) of the Social Security Act (42 

11 U.S.C. 1396r(d)) is amended by redesignating sub12 paragraph (V) as subparagraph (E). 

13 (c) EFFECTIVE DATE.—The amendments made by 

14 this section take effect on the date of enactment of this 

15 Act and apply with respect to the administration of skilled 

16 nursing facilities and nursing facilities on or after the date 

17 that is one year after such date of enactment. 

18 SEC. 5. NURSE TRAINING REQUIREMENTS WITH RESPECT 

19 TO SKILLED NURSING FACILITIES UNDER 

20 MEDICARE PROGRAM AND NURSING FACILI21 TIES UNDER MEDICAID PROGRAM. 

22 (a) MEDICARE.— 

23 (1) ORIENTATION FOR REGISTERED PROFES24 SIONAL NURSES, LICENSED PRACTICAL NURSES, AND

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1 rity Act (42 U.S.C. 1395i–3(d)) is amended by add2 ing at the end the following new paragraph: 

3 ‘‘(5) ORIENTATIONS.—A skilled nursing facility 

4 must provide to registered professional nurses, li5 censed practical nurses, and nurse aides, before such 

6 registered professional nurses, licensed practical 

7 nurses, and nurse aides are assigned to provide di8 rect care services to residents in the facility, orienta9 tions providing education on the policies and emer10 gency procedures of the facility and on residents’ 

11 rights under this section.’’. 

12 (2) REQUIREMENTS FOR NURSE AIDE TRAINING

13 AND COMPETENCY EVALUATION PROGRAMS AND FOR

14 NURSE AIDE COMPETENCY EVALUATION PRO15 GRAMS.—Subparagraph (A) of section 1819(f)(2) of 

16 the Social Security Act (42 U.S.C. 1395i–3(f)(2)) is 

17 amended— 

18 (A) in the matter preceding clause (i), by 

19 inserting after ‘‘1988’’ the following: ‘‘, and up20 date, as determined necessary by the Sec21 retary’’; 

22 (B) in clause (i)— 

23 (i) by inserting after ‘‘care of cog24 nitively impaired residents,’’ the following: 

25 ‘‘care of older adults,’’; 


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1 (ii) by striking ‘‘patient abuse preven2 tion training,’’ and inserting ‘‘patient 

3 abuse prevention training),’’; and 

4 (iii) by striking ‘‘75 hours’’ and in5 serting ‘‘120 hours’’; and 

6 (C) in clause (ii)— 

7 (i) by striking ‘‘requirement relating 

8 to’’ and inserting ‘‘requirements relating to 

9 (I)’’; 

10 (ii) by inserting after ‘‘care of cog11 nitively impaired residents,’’ the following: 

12 ‘‘care of older adults,’’; and 

13 (iii) by striking ‘‘and procedures’’ and 

14 inserting ‘‘(II) minimum hours of initial 

15 and ongoing training and retraining (in16 cluding not less than 120 hours in the case 

17 of initial training), and (III) procedures’’. 

18 (b) MEDICAID.— 

19 (1) ORIENTATION FOR REGISTERED PROFES20 SIONAL NURSES, LICENSED PRACTICAL NURSES, AND

21 NURSE AIDES.—Section 1919(d) of the Social Secu22 rity Act (42 U.S.C. 1396r(d)) is amended by adding 

23 at the end the following new paragraph: 

24 ‘‘(5) ORIENTATIONS.—A nursing facility must 

25 provide to registered professional nurses, licensed 


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•HR 5216 IH

1 practical nurses, and nurse aides, before such reg2 istered professional nurses, licensed practical nurses, 

3 and nurse aides are assigned to provide direct care 

4 services to residents in the facility, orientations pro5 viding education on the policies and emergency pro6 cedures of the facility and on residents’ rights under 

7 this section.’’. 

8 (2) REQUIREMENTS FOR NURSE AIDE TRAINING

9 AND COMPETENCY EVALUATION PROGRAMS AND FOR

10 NURSE AIDE COMPETENCY EVALUATION PRO11 GRAMS.—Subparagraph (A) of section 1919(f)(2) of 

12 the Social Security Act (42 U.S.C. 1396r(f)(2)) is 

13 amended— 

14 (A) in the matter preceding clause (i), by 

15 inserting after ‘‘1988’’ the following: ‘‘, and up16 date, as determined necessary by the Sec17 retary’’; 

18 (B) in clause (i)— 

19 (i) by inserting after ‘‘care of cog20 nitively impaired residents,’’ the following: 

21 ‘‘care of older adults,’’; 

22 (ii) by striking ‘‘patient abuse preven23 tion training,’’ and inserting ‘‘patient 

24 abuse prevention training),’’; and 


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•HR 5216 IH

1 (iii) by striking ‘‘75 hours’’ and in2 serting ‘‘120 hours’’; and 

3 (C) in clause (ii)— 

4 (i) by striking ‘‘requirement relating 

5 to’’ and inserting ‘‘requirements relating to 

6 (I)’’; 

7 (ii) by inserting after ‘‘care of cog8 nitively impaired residents,’’ the following: 

9 ‘‘care of older adults,’’; and 

10 (iii) by striking ‘‘and procedures’’ and 

11 inserting ‘‘(II) minimum hours of initial 

12 and ongoing training and retraining (in13 cluding not less than 120 hours in the case 

14 of initial training), and (III) procedures’’. 

15 (c) EFFECTIVE DATE.—The amendments made by 

16 this section take effect on the date of enactment of this 

17 Act and shall apply with respect to nurse aide training 

18 and competency evaluation programs, nurse aide com19 petency evaluation programs, and nurse orientations con20 ducted on or after the date that is one year after such 

21 date of enactment. 

22 SEC. 6. WHISTLEBLOWER AND RESIDENT PROTECTIONS. 

23 (a) MEDICARE.—Section 1819 of the Social Security 

24 Act (42 U.S.C. 1395i–3) is amended by adding at the end 

25 the following new subsection: 


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1 ‘‘(k) WHISTLEBLOWER AND RESIDENT PROTEC2 TIONS.— 

3 ‘‘(1) STATEMENT REGARDING PROFESSIONAL

4 OBLIGATION AND RIGHTS.—All nurses employed by 

5 a skilled nursing facility have a duty and right to act 

6 based on their professional judgment in accordance 

7 with the nursing laws and regulations of the State 

8 in which such facility is located, to provide nursing 

9 care in the exclusive interests of the residents of the 

10 facility, and to act as the residents’ advocate. 

11 ‘‘(2) OBJECTION TO OR REFUSAL OF WORK AS12 SIGNMENT.—A nurse may object to, or refuse to 

13 participate in, any activity, policy, practice, assign14 ment, or task (referred to in this subsection as a 

15 ‘work assignment’) if— 

16 ‘‘(A) the nurse reasonably believes such 

17 work assignment to be in violation of the min18 imum nurse staffing requirements of clause (ii) 

19 of subsection (b)(4)(C); or 

20 ‘‘(B) the nurse reasonably believes that the 

21 nurse is not prepared by education, training, or 

22 experience to perform or comply with such work 

23 assignment without compromising the safety of 

24 a resident or jeopardizing the license of the 

25 nurse. 


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1 ‘‘(3) RETALIATION FOR OBJECTION TO OR RE2 FUSAL OF WORK ASSIGNMENT BARRED.— 

3 ‘‘(A) NO DISCHARGE, DISCRIMINATION, OR

4 RETALIATION.—No skilled nursing facility may 

5 discharge, retaliate, discriminate, or otherwise 

6 take adverse action in any manner with respect 

7 to any aspect of a nurse’s employment with the 

8 facility, including discharge, promotion, com9 pensation, or terms, conditions, or privileges of 

10 employment, based on the nurse’s objection to, 

11 or refusal of, a work assignment under para12 graph (2). 

13 ‘‘(B) NO FILING OF COMPLAINT.—No 

14 skilled nursing facility may file a complaint or 

15 a report against a nurse with a State profes16 sional disciplinary agency because of the nurse’s 

17 objection to, or refusal of, a work assignment 

18 under paragraph (2). 

19 ‘‘(4) CAUSE OF ACTION.—Any nurse (or a col20 lective bargaining representative or legal representa21 tive of such nurse) against whom a skilled nursing 

22 facility has taken an adverse action in violation of 

23 paragraph (3)(A), or against whom such facility has 

24 filed a complaint or report in violation of paragraph 

25 (3)(B), may (without regard to whether a complaint 


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1 has been filed under paragraph (5) or (10)(B)) 

2 bring a cause of action in an appropriate district 

3 court of the United States. The legal burdens of 

4 proof specified in section 1221(e) of title 5, United 

5 States Code, shall be controlling for the purposes of 

6 any cause of action brought under this paragraph. 

7 A nurse who prevails on the cause of action may be 

8 entitled to one or more of the following: 

9 ‘‘(A) Reinstatement. 

10 ‘‘(B) Reimbursement of lost wages, com11 pensation, and benefits. 

12 ‘‘(C) Attorneys’ fees. 

13 ‘‘(D) Court costs. 

14 ‘‘(E) Other damages. 

15 ‘‘(5) COMPLAINT TO SECRETARY.—Any indi16 vidual may file a complaint with the Secretary 

17 against a skilled nursing facility that violates a re18 quirement described in paragraph (3). For any com19 plaint filed, the Secretary shall— 

20 ‘‘(A) receive and investigate the complaint; 

21 ‘‘(B) determine whether a violation of such 

22 paragraph, as alleged in the complaint, has oc23 curred; and 

24 ‘‘(C) in the case that the Secretary deter25 mines that such a violation has occurred, issue 


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•HR 5216 IH

1 an order that the complaining individual may 

2 not suffer any adverse action prohibited by 

3 paragraph (3) or (7). 

4 ‘‘(6) TOLL-FREE TELEPHONE NUMBER.— 

5 ‘‘(A) IN GENERAL.—The Secretary shall 

6 provide for the establishment of a toll-free tele7 phone hotline to provide information regarding 

8 the minimum nurse staffing requirements of 

9 clause (ii) of subsection (b)(4)(C) and to receive 

10 reports of violations of such requirements. 

11 ‘‘(B) NOTICE TO RESIDENTS.—A skilled 

12 nursing facility shall provide each resident ad13 mitted to the facility with the telephone number 

14 of the hotline described in subparagraph (A) 

15 and give notice to each such resident that such 

16 hotline may be used to report inadequate staff17 ing. 

18 ‘‘(7) PROTECTION FOR REPORTING.— 

19 ‘‘(A) PROHIBITION ON RETALIATION OR

20 DISCRIMINATION.—A skilled nursing facility 

21 may not retaliate or discriminate in any manner 

22 against any resident, employee, or contract em23 ployee of the facility, or any other individual, on 

24 the basis that such resident, employee, contract 

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1 junction with another individual) has, in good 

2 faith— 

3 ‘‘(i) presented a grievance or com4 plaint; 

5 ‘‘(ii) initiated or cooperated in any in6 vestigation or proceeding of any govern7 mental entity, regulatory agency, or private 

8 accreditation body; 

9 ‘‘(iii) made a civil claim or demand; or 

10 ‘‘(iv) filed an action relating to the 

11 care, services, or conditions of the facility. 

12 ‘‘(B) GOOD FAITH DEFINED.—For pur13 poses of this paragraph, an individual shall be 

14 deemed to be acting in good faith if the indi15 vidual reasonably believes— 

16 ‘‘(i) the information reported or dis17 closed is true; and 

18 ‘‘(ii) a violation of the minimum nurse 

19 staffing requirements of clause (ii) of sub20 section (b)(4)(C) has occurred or may 

21 occur. 

22 ‘‘(8) PROHIBITION ON INTERFERENCE WITH

23 RIGHTS.— 

24 ‘‘(A) EXERCISE OF RIGHTS.—A skilled 

25 nursing facility may not— 


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1 ‘‘(i) interfere with, restrain, or deny 

2 the exercise, or attempt to exercise, by any 

3 individual of any right, procedure, or rem4 edy provided or protected under this sub5 section; or 

6 ‘‘(ii) coerce or intimidate any indi7 vidual regarding the exercise, or attempt to 

8 exercise, such right. 

9 ‘‘(B) OPPOSITION TO UNLAWFUL POLICIES

10 OR PRACTICES.—A skilled nursing facility may 

11 not retaliate or discriminate against any indi12 vidual for opposing any policy, practice, or ac13 tion of the facility which is alleged to violate, 

14 breach, or fail to comply with any provision of 

15 the minimum nurse staffing requirements of 

16 clause (ii) of subsection (b)(4)(C). 

17 ‘‘(C) PROHIBITION ON INTERFERENCE

18 WITH PROTECTED COMMUNICATIONS.—A skilled 

19 nursing facility may not make, adopt, or en20 force any rule, regulation, policy, or practice 

21 which in any manner directly or indirectly pro22 hibits, impedes, or discourages a nurse from, or 

23 intimidates, coerces, or induces a nurse regard24 ing, engaging in free speech activities or disVerDate Sep 11 2014 22:02 Dec 10, 2019 Jkt 099200 PO 00000 Frm 00051 Fmt 6652 Sfmt 6201 E:\BILLS\H5216.IH H5216

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1 closing information as provided under this sub2 section. 

3 ‘‘(D) PROHIBITION ON INTERFERENCE

4 WITH COLLECTIVE ACTION.—A skilled nursing 

5 facility may not in any way interfere with the 

6 rights of nurses to organize, bargain collec7 tively, and engage in concerted activity under 

8 section 7 of the National Labor Relations Act 

9 (29 U.S.C. 157). 

10 ‘‘(9) NOTICE.—A skilled nursing facility shall 

11 post in an appropriate location in each unit a con12 spicuous notice, in a form specified by the Secretary, 

13 that— 

14 ‘‘(A) explains the rights of nurses, resi15 dents, and other individuals under this sub16 section; 

17 ‘‘(B) includes a statement that a nurse, 

18 resident, or other individual may file a com19 plaint with the Secretary against the facility for 

20 a violation of a requirement or a prohibition of 

21 this subsection; and 

22 ‘‘(C) provides instructions on how to file 

23 such a complaint. 

24 ‘‘(10) ENFORCEMENT.— 


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1 ‘‘(A) IN GENERAL.—The Secretary shall 

2 enforce the requirements and prohibitions of 

3 this subsection in accordance with this para4 graph. 

5 ‘‘(B) PROCEDURES FOR RECEIVING AND

6 INVESTIGATING COMPLAINTS.—The Secretary 

7 shall establish procedures under which— 

8 ‘‘(i) any individual may file a com9 plaint alleging that a skilled nursing facil10 ity has violated a requirement or a prohibi11 tion of this subsection; and 

12 ‘‘(ii) any such complaint shall be in13 vestigated by the Secretary. 

14 ‘‘(C) REMEDIES.—If the Secretary deter15 mines that a skilled nursing facility has violated 

16 a requirement or prohibition of this subsection, 

17 the Secretary— 

18 ‘‘(i) shall require the facility to estab19 lish a corrective action plan to prevent the 

20 recurrence of such violation; and 

21 ‘‘(ii) may impose civil money penalties 

22 as described in subparagraph (D). 

23 ‘‘(D) CIVIL PENALTIES.— 

24 ‘‘(i) IN GENERAL.—In addition to any 

25 other penalties prescribed by law, the SecVerDate Sep 11 2014 22:02 Dec 10, 2019 Jkt 099200 PO 00000 Frm 00053 Fmt 6652 Sfmt 6201 E:\BILLS\H5216.IH H5216

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1 retary may impose civil penalties as fol2 lows: 

3 ‘‘(I) SKILLED NURSING FACILITY

4 LIABILITY.—The Secretary may im5 pose on a skilled nursing facility 

6 found to be in violation of this sub7 section a civil money penalty of— 

8 ‘‘(aa) not more than 

9 $25,000 for the first knowing 

10 violation of this subsection by 

11 such facility; and 

12 ‘‘(bb) not more than 

13 $50,000 for any subsequent 

14 knowing violation of this sub15 section by such facility. 

16 ‘‘(II) INDIVIDUAL LIABILITY.— 

17 The Secretary may impose on an indi18 vidual who— 

19 ‘‘(aa) is employed by a 

20 skilled nursing facility; and 

21 ‘‘(bb) is found by the Sec22 retary to have knowingly violated 

23 this subsection on behalf of the 

24 facility, 


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1 a civil money penalty of not more 

2 than $20,000 for each such violation 

3 by the individual. 

4 ‘‘(ii) PROCEDURES.—The provisions 

5 of section 1128A of the Social Security Act 

6 (other than subsections (a) and (b)) shall 

7 apply with respect to a civil money penalty 

8 or proceeding under this subparagraph in 

9 the same manner as such provisions apply 

10 with respect to a civil money penalty or 

11 proceeding under such section 1128A. 

12 ‘‘(E) PUBLIC NOTICE OF VIOLATIONS.— 

13 ‘‘(i) INTERNET WEBSITE.—The Sec14 retary shall publish on the internet website 

15 of the Department of Health and Human 

16 Services the names of skilled nursing facili17 ties on which a civil money penalty has 

18 been imposed under this subsection, the 

19 violation for which such penalty was im20 posed, and such additional information as 

21 the Secretary determines appropriate. 

22 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

23 respect to a skilled nursing facility that 

24 had a change of ownership, as determined 

25 by the Secretary, penalties imposed on the 


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1 facility while under previous ownership 

2 shall no longer be published by the Sec3 retary pursuant to clause (i) after the 1- 

4 year period beginning on the date of such 

5 change of ownership. 

6 ‘‘(F) USE OF FUNDS.—Funds collected by 

7 the Secretary pursuant to this subsection are 

8 authorized to be appropriated to implement the 

9 minimum nurse staffing requirements of clause 

10 (ii) of subsection (b)(4)(C). 

11 ‘‘(11) NURSE DEFINED.—In this subsection, 

12 the term ‘nurse’ means a registered professional 

13 nurse, a licensed practical nurse, and a nurse aide.’’. 

14 (b) MEDICAID.—Section 1919 of the Social Security 

15 Act (42 U.S.C. 1396r) is amended by adding at the end 

16 the following new subsection: 

17 ‘‘(k) WHISTLEBLOWER AND RESIDENT PROTEC18 TIONS.— 

19 ‘‘(1) STATEMENT REGARDING PROFESSIONAL

20 OBLIGATION AND RIGHTS.—All nurses employed by 

21 a nursing facility have a duty and right to act based 

22 on their professional judgment in accordance with 

23 the nursing laws and regulations of the State in 

24 which such facility is located, to provide nursing care 


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1 in the exclusive interests of the residents of the facil2 ity, and to act as the residents’ advocate. 

3 ‘‘(2) OBJECTION TO OR REFUSAL OF WORK AS4 SIGNMENT.—A nurse may object to, or refuse to 

5 participate in, any activity, policy, practice, assign6 ment, or task (referred to in this subsection as a 

7 ‘work assignment’) if— 

8 ‘‘(A) the nurse reasonably believes such 

9 work assignment to be in violation of the min10 imum nurse staffing requirements of clause (ii) 

11 of subsection (b)(4)(C); or 

12 ‘‘(B) the nurse reasonably believes that the 

13 nurse is not prepared by education, training, or 

14 experience to perform or comply with such work 

15 assignment without compromising the safety of 

16 a resident or jeopardizing the license of the 

17 nurse. 

18 ‘‘(3) RETALIATION FOR OBJECTION TO OR RE19 FUSAL OF WORK ASSIGNMENT BARRED.— 

20 ‘‘(A) NO DISCHARGE, DISCRIMINATION, OR

21 RETALIATION.—No nursing facility may dis22 charge, retaliate, discriminate, or otherwise take 

23 adverse action in any manner with respect to 

24 any aspect of a nurse’s employment with the fa25 cility, including discharge, promotion, comVerDate Sep 11 2014 22:02 Dec 10, 2019 Jkt 099200 PO 00000 Frm 00057 Fmt 6652 Sfmt 6201 E:\BILLS\H5216.IH H5216

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1 pensation, or terms, conditions, or privileges of 

2 employment, based on the nurse’s objection to, 

3 or refusal of, a work assignment under para4 graph (2). 

5 ‘‘(B) NO FILING OF COMPLAINT.—No 

6 nursing facility may file a complaint or a report 

7 against a nurse with a State professional dis8 ciplinary agency because of the nurse’s objec9 tion to, or refusal of, a work assignment under 

10 paragraph (2). 

11 ‘‘(4) CAUSE OF ACTION.—Any nurse (or a col12 lective bargaining representative or legal representa13 tive of such nurse) against whom a nursing facility 

14 has taken an adverse action in violation of para15 graph (3)(A), or against whom such facility has filed 

16 a complaint or report in violation of paragraph 

17 (3)(B), may (without regard to whether a complaint 

18 has been filed under paragraph (5) or (10)(B)) 

19 bring a cause of action in an appropriate district 

20 court of the United States. The legal burdens of 

21 proof specified in section 1221(e) of title 5, United 

22 States Code, shall be controlling for the purposes of 

23 any cause of action brought under this paragraph. 

24 A nurse who prevails on the cause of action may be 

25 entitled to one or more of the following: 


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1 ‘‘(A) Reinstatement. 

2 ‘‘(B) Reimbursement of lost wages, com3 pensation, and benefits. 

4 ‘‘(C) Attorneys’ fees. 

5 ‘‘(D) Court costs. 

6 ‘‘(E) Other damages. 

7 ‘‘(5) COMPLAINT TO SECRETARY.—Any indi8 vidual may file a complaint with the Secretary 

9 against a nursing facility that violates a requirement 

10 described in paragraph (3). For any complaint filed, 

11 the Secretary shall— 

12 ‘‘(A) receive and investigate the complaint; 

13 ‘‘(B) determine whether a violation of such 

14 paragraph, as alleged in the complaint, has oc15 curred; and 

16 ‘‘(C) in the case that the Secretary deter17 mines that such a violation has occurred, issue 

18 an order that the complaining individual may 

19 not suffer any adverse action prohibited by 

20 paragraph (3) or (7). 

21 ‘‘(6) TOLL-FREE TELEPHONE NUMBER.— 

22 ‘‘(A) IN GENERAL.—The Secretary shall 

23 provide for the establishment of a toll-free tele24 phone hotline to provide information regarding 

25 the minimum nurse staffing requirements of 


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1 clause (ii) of subsection (b)(4)(C) and to receive 

2 reports of violations of such requirements. 

3 ‘‘(B) NOTICE TO RESIDENTS.—A nursing 

4 facility shall provide each resident admitted to 

5 the facility with the telephone number of the 

6 hotline described in subparagraph (A) and give 

7 notice to each such resident that such hotline 

8 may be used to report inadequate staffing or 

9 care. 

10 ‘‘(7) PROTECTION FOR REPORTING.— 

11 ‘‘(A) PROHIBITION ON RETALIATION OR

12 DISCRIMINATION.—A nursing facility may not 

13 retaliate or discriminate in any manner against 

14 any resident, employee, or contract employee of 

15 the facility, or any other individual, on the basis 

16 that such resident, employee, contract employee, 

17 or individual (individually or in conjunction 

18 with another individual) has, in good faith— 

19 ‘‘(i) presented a grievance or com20 plaint; 

21 ‘‘(ii) initiated or cooperated in any in22 vestigation or proceeding of any govern23 mental entity, regulatory agency, or private 

24 accreditation body; 

25 ‘‘(iii) made a civil claim or demand; or 


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1 ‘‘(iv) filed an action relating to the 

2 care, services, or conditions of the facility. 

3 ‘‘(B) GOOD FAITH DEFINED.—For pur4 poses of this paragraph, an individual shall be 

5 deemed to be acting in good faith if the indi6 vidual reasonably believes— 

7 ‘‘(i) the information reported or dis8 closed is true; and 

9 ‘‘(ii) a violation of the minimum nurse 

10 staffing requirements of clause (ii) of sub11 section (b)(4)(C) has occurred or may 

12 occur. 

13 ‘‘(8) PROHIBITION ON INTERFERENCE WITH

14 RIGHTS.— 

15 ‘‘(A) EXERCISE OF RIGHTS.—A nursing 

16 facility may not— 

17 ‘‘(i) interfere with, restrain, or deny 

18 the exercise, or attempt to exercise, by any 

19 individual of any right, procedure, or rem20 edy provided or protected under this sub21 section; or 

22 ‘‘(ii) coerce or intimidate any indi23 vidual regarding the exercise, or attempt to 

24 exercise, such right. 


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1 ‘‘(B) OPPOSITION TO UNLAWFUL POLICIES

2 OR PRACTICES.—A nursing facility may not re3 taliate or discriminate against any individual 

4 for opposing any policy, practice, or action of 

5 the facility which is alleged to violate, breach, 

6 or fail to comply with any provision of the min7 imum nurse staffing requirements of clause (ii) 

8 of subsection (b)(4)(C). 

9 ‘‘(C) PROHIBITION ON INTERFERENCE

10 WITH PROTECTED COMMUNICATIONS.—A nurs11 ing facility may not make, adopt, or enforce any 

12 rule, regulation, policy, or practice which in any 

13 manner directly or indirectly prohibits, impedes, 

14 or discourages a nurse from, or intimidates, co15 erces, or induces a nurse regarding, engaging in 

16 free speech activities or disclosing information 

17 as provided under this subsection. 

18 ‘‘(D) PROHIBITION ON INTERFERENCE

19 WITH COLLECTIVE ACTION.—A nursing facility 

20 may not in any way interfere with the rights of 

21 nurses to organize, bargain collectively, and en22 gage in concerted activity under section 7 of the 

23 National Labor Relations Act (29 U.S.C. 157). 


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1 ‘‘(9) NOTICE.—A nursing facility shall post in 

2 an appropriate location in each unit a conspicuous 

3 notice, in a form specified by the Secretary, that— 

4 ‘‘(A) explains the rights of nurses, resi5 dents, and other individuals under this sub6 section; 

7 ‘‘(B) includes a statement that a nurse, 

8 resident, or other individual may file a com9 plaint with the Secretary against the facility for 

10 a violation of a requirement or a prohibition of 

11 this subsection; and 

12 ‘‘(C) provides instructions on how to file 

13 such a complaint. 

14 ‘‘(10) ENFORCEMENT.— 

15 ‘‘(A) IN GENERAL.—The Secretary shall 

16 enforce the requirements and prohibitions of 

17 this subsection in accordance with this para18 graph. 

19 ‘‘(B) PROCEDURES FOR RECEIVING AND

20 INVESTIGATING COMPLAINTS.—The Secretary 

21 shall establish procedures under which— 

22 ‘‘(i) any individual may file a com23 plaint alleging that a nursing facility has 

24 violated a requirement or a prohibition of 

25 this subsection; and 


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1 ‘‘(ii) any such complaint shall be in2 vestigated by the Secretary. 

3 ‘‘(C) REMEDIES.—If the Secretary deter4 mines that a nursing facility has violated a re5 quirement or prohibition of this subsection, the 

6 Secretary— 

7 ‘‘(i) shall require the facility to estab8 lish a corrective action plan to prevent the 

9 recurrence of such violation; and 

10 ‘‘(ii) may impose civil money penalties 

11 as described in subparagraph (D). 

12 ‘‘(D) CIVIL PENALTIES.— 

13 ‘‘(i) IN GENERAL.—In addition to any 

14 other penalties prescribed by law, the Sec15 retary may impose civil penalties as fol16 lows: 

17 ‘‘(I) NURSING FACILITY LIABIL18 ITY.—The Secretary may impose on a 

19 nursing facility found to be in viola20 tion of this subsection a civil money 

21 penalty of— 

22 ‘‘(aa) not more than 

23 $25,000 for the first knowing 

24 violation of this subsection by 

25 such facility; and 


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•HR 5216 IH

1 ‘‘(bb) not more than 

2 $50,000 for any subsequent 

3 knowing violation of this sub4 section by such facility. 

5 ‘‘(II) INDIVIDUAL LIABILITY.— 

6 The Secretary may impose on an indi7 vidual who— 

8 ‘‘(aa) is employed by a nurs9 ing facility; and 

10 ‘‘(bb) is found by the Sec11 retary to have knowingly violated 

12 this subsection on behalf of the 

13 facility, 

14 a civil money penalty of not more 

15 than $20,000 for each such violation 

16 by the individual. 

17 ‘‘(ii) PROCEDURES.—The provisions 

18 of section 1128A of the Social Security Act 

19 (other than subsections (a) and (b)) shall 

20 apply with respect to a civil money penalty 

21 or proceeding under this subparagraph in 

22 the same manner as such provisions apply 

23 with respect to a civil money penalty or 

24 proceeding under such section 1128A. 

25 ‘‘(E) PUBLIC NOTICE OF VIOLATIONS.— 


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1 ‘‘(i) INTERNET WEBSITE.—The Sec2 retary shall publish on the internet website 

3 of the Department of Health and Human 

4 Services the names of nursing facilities on 

5 which a civil money penalty has been im6 posed under this subsection, the violation 

7 for which such penalty was imposed, and 

8 such additional information as the Sec9 retary determines appropriate. 

10 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

11 respect to a nursing facility that had a 

12 change of ownership, as determined by the 

13 Secretary, penalties imposed on the facility 

14 while under previous ownership shall no 

15 longer be published by the Secretary pur16 suant to clause (i) after the 1-year period 

17 beginning on the date of such change of 

18 ownership. 

19 ‘‘(F) USE OF FUNDS.—Funds collected by 

20 the Secretary pursuant to this subsection are 

21 authorized to be appropriated to implement the 

22 minimum nurse staffing requirements of clause 

23 (ii) of subsection (b)(4)(C). 


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1 ‘‘(11) NURSE DEFINED.—In this subsection, 

2 the term ‘nurse’ means a registered professional 

3 nurse, a licensed practical nurse, and a nurse aide.’’. 

4 (c) EFFECTIVE DATE.—The amendments made by 

5 this section take effect on the date of enactment of this 

6 Act and shall apply with respect to objections to or refus7 als of work assignments, complaints, retaliations and 

8 other adverse actions, and interferences with rights that 

9 occur on or after the date that is one year after such date 

10 of enactment and with respect to notices provided on or 

11 after the date that is one year after such date of enact12 ment. 

13 SEC. 7. PROHIBITING PRE-DISPUTE ARBITRATION AGREE14 MENTS. 

15 (a) MEDICARE.—Section 1819(c) of the Social Secu16 rity Act (42 U.S.C. 1395i–3(c)) is amended by adding at 

17 the end the following new paragraph: 

18 ‘‘(7) PROHIBITION ON USE OF PRE-DISPUTE

19 ARBITRATION AGREEMENTS.— 

20 ‘‘(A) IN GENERAL.—A skilled nursing fa21 cility may not require, solicit, accept, or move 

22 to enforce a pre-dispute arbitration agreement 

23 from or on behalf of any resident, whether the 

24 agreement is made before, during, or after the 

25 resident’s admission to the facility, or from or 


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1 on behalf of any employee, or contract employee 

2 of the facility, or any other individual if such 

3 individual is alleged to be engaged in conduct 

4 protected under subsection (k). 

5 ‘‘(B) APPLICATION.—This paragraph shall 

6 apply to the skilled nursing facility and to any 

7 other business or person providing or respon8 sible for providing skilled nursing services to 

9 the resident. 

10 ‘‘(C) NO VALIDITY OR ENFORCEMENT.—A 

11 pre-dispute arbitration agreement shall not be 

12 valid or specifically enforceable against a resi13 dent or former resident of a skilled nursing fa14 cility, without regard to whether the agreement 

15 was made prior to or after the effective date of 

16 this paragraph. 

17 ‘‘(D) DEFINITION OF PRE-DISPUTE ARBI18 TRATION AGREEMENT.—In this paragraph, the 

19 term ‘pre-dispute arbitration agreement’ means 

20 any agreement to arbitrate a dispute when the 

21 dispute has arisen after such agreement has 

22 been made. 

23 ‘‘(E) JUDICIAL REVIEW.—A determination 

24 as to whether and how this paragraph applies 

25 to an arbitration agreement shall be determined 


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1 under Federal law by a court of competent ju2 risdiction, rather than an arbitrator, without re3 gard to whether the party opposing arbitration 

4 challenges such agreement specifically or in 

5 conjunction with any other term of the contract 

6 containing such agreement.’’. 

7 (b) MEDICAID.— 

8 (1) HOME AND COMMUNITY-BASED SERVICES

9 AND HOME HEALTH CARE SERVICES.—Section 1915 

10 of the Social Security Act (42 U.S.C. 1396n) is 

11 amended by adding at the end the following new 

12 subsection: 

13 ‘‘(m) PROHIBITING PRE-DISPUTE ARBITRATION

14 AGREEMENTS.— 

15 ‘‘(1) IN GENERAL.—For home and community16 based services or home health care services provided 

17 under a waiver under this section, section 

18 1902(a)(10)(D), or any other provision authorizing 

19 the provision of home and community-based services 

20 or home health care services under this title, the 

21 provider of such services (and any employee, agent, 

22 related entity, or affiliate of such provider) shall not 

23 require, solicit, or accept a pre-dispute arbitration 

24 agreement from or on behalf of any individual re25 ceiving such services, whether the agreement is made 


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1 before, during, or after the first date on which serv2 ices are received, or from or on behalf of any em3 ployee, or contract employee of the provider, or any 

4 other individual if such individual is alleged to be 

5 engaged in conduct protected under section 1919(k). 

6 A pre-dispute arbitration agreement between such a 

7 provider (or entity or person) and an individual re8 ceiving services (or who formerly received services) 

9 shall not be valid or enforceable, without regard to 

10 whether such agreement was made prior to the effec11 tive date of this subsection. 

12 ‘‘(2) DEFINITION OF PRE-DISPUTE ARBITRA13 TION AGREEMENT.—The term ‘pre-dispute arbitra14 tion agreement’ means any agreement to arbitrate a 

15 dispute when the dispute has arisen after such 

16 agreement has been made. 

17 ‘‘(3) JUDICIAL REVIEW.—A determination as to 

18 whether and how this subsection applies to an arbi19 tration agreement shall be determined under Federal 

20 law by a court of competent jurisdiction, rather than 

21 an arbitrator, without regard to whether the party 

22 opposing arbitration challenges such agreement spe23 cifically or in conjunction with any other term of the 

24 contract containing such agreement.’’. 


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1 (2) NURSING FACILITIES.—Section 1919(c) of 

2 the Social Security Act (42 U.S.C. 1396r(c)) is 

3 amended by adding at the end the following new 

4 paragraph: 

5 ‘‘(9) PROHIBITION ON USE OF PRE-DISPUTE

6 ARBITRATION AGREEMENTS.— 

7 ‘‘(A) IN GENERAL.—A nursing facility may 

8 not require, solicit, accept, or move to enforce 

9 a pre-dispute arbitration agreement from or on 

10 behalf of any resident, whether the agreement 

11 is made before, during, or after the resident’s 

12 admission to the facility, or from or on behalf 

13 of any employee, or contract employee of the fa14 cility, or any other individual if such individual 

15 is alleged to be engaged in conduct protected 

16 under subsection (k). 

17 ‘‘(B) APPLICATION.—This paragraph shall 

18 apply to the nursing facility and to any other 

19 business or person providing or responsible for 

20 providing nursing services to the resident. 

21 ‘‘(C) NO VALIDITY OR ENFORCEMENT.—A 

22 pre-dispute arbitration agreement shall not be 

23 valid or specifically enforceable against a resi24 dent or former resident of a nursing facility, 

25 without regard to whether the agreement was 


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1 made prior to or after the effective date of this 

2 paragraph. 

3 ‘‘(D) DEFINITION OF PRE-DISPUTE ARBI4 TRATION AGREEMENT.—In this paragraph, the 

5 term ‘pre-dispute arbitration agreement’ means 

6 any agreement to arbitrate a dispute when the 

7 dispute has arisen after such agreement has 

8 been made. 

9 ‘‘(E) JUDICIAL REVIEW.—A determination 

10 as to whether and how this paragraph applies 

11 to an arbitration agreement shall be determined 

12 under Federal law by a court of competent ju13 risdiction, rather than an arbitrator, without re14 gard to whether the party opposing arbitration 

15 challenges such agreement specifically or in 

16 conjunction with any other term of the contract 

17 containing such agreement.’’. 

18 SEC. 8. STANDARDIZED PROTOCOL FOR OBTAINING IN19 FORMED CONSENT FROM RESIDENTS PRIOR 

20 TO PRESCRIBING PSYCHOTROPIC DRUGS. 

21 (a) STANDARDIZED PROTOCOL.— 

22 (1) SKILLED NURSING FACILITIES.—Section 

23 1819(b) of the Social Security Act (42 U.S.C. 

24 1395i–3(b)) is amended by adding at the end the 

25 following new paragraph: 


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1 ‘‘(9) STANDARDIZED PROTOCOL FOR OBTAIN2 ING INFORMED CONSENT FROM A RESIDENT PRIOR

3 TO PRESCRIBING PSYCHOTROPIC DRUGS FOR A USE

4 NOT APPROVED BY THE FOOD AND DRUG ADMINIS5 TRATION.— 

6 ‘‘(A) PROTOCOL.—Not later than the date 

7 that is one year after the date of the enactment 

8 of this paragraph, the Secretary, taking into ac9 count the results of the study conducted by the 

10 Comptroller General of the United States under 

11 section 8(a)(3) of the Quality Care for Nursing 

12 Home Residents Act of 2019 and in consulta13 tion with stakeholder groups (including resi14 dents of skilled nursing facilities, family mem15 bers of such residents, advocates for such resi16 dents, long-term care ombudsmen, and pro17 viders), shall develop a standardized protocol 

18 for skilled nursing facilities to obtain written in19 formed consent, in accordance with this para20 graph, from a resident (or, if applicable, the 

21 resident’s designated health care agent or other 

22 surrogate under State law or regulation) prior 

23 to prescribing a psychotropic drug to the resi24 dent for a use not approved by the Food and 

25 Drug Administration. 


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1 ‘‘(B) REQUIREMENTS.—The standardized 

2 protocol developed under subparagraph (A) 

3 shall include the following: 

4 ‘‘(i) A requirement, with respect to a 

5 resident, that— 

6 ‘‘(I) the facility, with the involve7 ment of the prescriber, inform the 

8 resident (or, if applicable, the resi9 dent’s designated health care agent or 

10 other surrogate under State law or 

11 regulation) of— 

12 ‘‘(aa) possible side effects 

13 and risks associated with the psy14 chotropic drug, including the 

15 mention of any ‘black box warn16 ing’; 

17 ‘‘(bb) treatment modalities 

18 that were attempted prior to the 

19 use of the psychotropic drug; and 

20 ‘‘(cc) any other information 

21 the Secretary determines appro22 priate; 

23 ‘‘(II) the resident (or, if applica24 ble, the resident’s designated health 

25 care agent or other surrogate under 


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1 State law or regulation) provide writ2 ten informed consent to the adminis3 tration of the psychotropic drug; and 

4 ‘‘(III) the administration of the 

5 psychotropic drug is in accordance 

6 with any plan of care that the resi7 dent has in place, including non-phar8 macological interventions as appro9 priate that can effectively address un10 derlying medical and environmental 

11 causes of behavioral disorders. 

12 ‘‘(ii) An alternative protocol for ob13 taining such written informed consent— 

14 ‘‘(I) in the case of emergencies; 

15 and 

16 ‘‘(II) in the absence of a clearly 

17 identified designated health care agent 

18 or other surrogate under State law or 

19 regulation. 

20 ‘‘(iii) Other items determined appro21 priate by the Secretary. 

22 ‘‘(C) TIMING OF INFORMED CONSENT.— 

23 Under the standardized protocol, a skilled nurs24 ing facility shall obtain the written informed 

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1 spect to a psychotropic drug and a resident of 

2 the facility— 

3 ‘‘(i) prior to the initial prescribing of 

4 such psychotropic drug to such resident if 

5 such resident does not have a current pre6 scription for such psychotropic drug at the 

7 time such resident is admitted to the facil8 ity; and 

9 ‘‘(ii) at least once a month to the ex10 tent that the administration of such psy11 chotropic drug to such resident is in ac12 cordance with the plan of care that the 

13 resident has in place. 

14 ‘‘(D) COMPLIANCE.—Effective beginning 

15 on the date that is one year and 180 days after 

16 the date of the enactment of this paragraph, a 

17 skilled nursing facility shall comply with the 

18 standardized protocol developed under subpara19 graph (A). 

20 ‘‘(E) NO PREEMPTION.—Nothing in this 

21 paragraph shall preempt any provision of State 

22 or Federal law that provides broader rights 

23 with respect to written informed consent for 

24 residents of facilities.’’. 


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1 (2) NURSING FACILITIES.—Section 1919(b) of 

2 the Social Security Act (42 U.S.C. 1396r(b)) is 

3 amended by adding at the end the following new 

4 paragraph: 

5 ‘‘(9) STANDARDIZED PROTOCOL FOR OBTAIN6 ING INFORMED CONSENT FROM A RESIDENT PRIOR

7 TO PRESCRIBING PSYCHOTROPIC DRUGS FOR A USE

8 NOT APPROVED BY THE FOOD AND DRUG ADMINIS9 TRATION.— 

10 ‘‘(A) PROTOCOL.—Not later than the date 

11 that is one year after the date of the enactment 

12 of this paragraph, the Secretary, taking into ac13 count the results of the study conducted by the 

14 Comptroller General of the United States under 

15 section 8(a)(3) of the Quality Care for Nursing 

16 Home Residents Act of 2019 and in consulta17 tion with stakeholder groups (including resi18 dents of skilled nursing facilities, family mem19 bers of such residents, advocates for such resi20 dents, long-term care ombudsmen, and pro21 viders), shall develop a standardized protocol 

22 for nursing facilities to obtain written informed 

23 consent, in accordance with this paragraph, 

24 from a resident (or, if applicable, the resident’s 

25 designated health care agent or other surrogate 


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1 under State law or regulation) prior to pre2 scribing a psychotropic drug to the resident for 

3 a use not approved by the Food and Drug Ad4 ministration. 

5 ‘‘(B) REQUIREMENTS.—The standardized 

6 protocol developed under subparagraph (A) 

7 shall include the following: 

8 ‘‘(i) A requirement, with respect to a 

9 resident, that— 

10 ‘‘(I) the facility, with the involve11 ment of the prescriber, inform the 

12 resident (or, if applicable, the resi13 dent’s designated health care agent or 

14 other surrogate under State law or 

15 regulation) of— 

16 ‘‘(aa) possible side effects 

17 and risks associated with the psy18 chotropic drug, including the 

19 mention of any ‘black box warn20 ing’; 

21 ‘‘(bb) treatment modalities 

22 that were attempted prior to the 

23 use of the psychotropic drug; and 


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1 ‘‘(cc) any other information 

2 the Secretary determines appro3 priate; 

4 ‘‘(II) the resident (or, if applica5 ble, the resident’s designated health 

6 care agent or other surrogate under 

7 State law or regulation) provide writ8 ten informed consent to the adminis9 tration of the psychotropic drug; and 

10 ‘‘(III) the administration of the 

11 psychotropic drug is in accordance 

12 with any plan of care that the resi13 dent has in place, including non-phar14 macological interventions as appro15 priate that can effectively address un16 derlying medical and environmental 

17 causes of behavioral disorders. 

18 ‘‘(ii) An alternative protocol for ob19 taining such written informed consent— 

20 ‘‘(I) in the case of emergencies; 

21 and 

22 ‘‘(II) in the absence of a clearly 

23 identified designated health care agent 

24 or other surrogate under State law or 

25 regulation. 


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1 ‘‘(iii) Other items determined appro2 priate by the Secretary. 

3 ‘‘(C) TIMING OF INFORMED CONSENT.— 

4 Under the standardized protocol, a nursing fa5 cility shall obtain the written informed consent 

6 described in subparagraph (A), with respect to 

7 a psychotropic drug and a resident of the facil8 ity— 

9 ‘‘(i) prior to the initial prescribing of 

10 such psychotropic drug to such resident if 

11 such resident does not have a current pre12 scription for such psychotropic drug at the 

13 time such resident is admitted to the facil14 ity; and 

15 ‘‘(ii) at least once a month to the ex16 tent that the administration of such psy17 chotropic drug to such resident is in ac18 cordance with the plan of care that the 

19 resident has in place. 

20 ‘‘(D) COMPLIANCE.—Effective beginning 

21 on the date that is one year and 180 days after 

22 the date of the enactment of this paragraph, a 

23 nursing facility shall comply with the standard24 ized protocol developed under subparagraph 

25 (A). 


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1 ‘‘(E) NO PREEMPTION.—Nothing in this 

2 paragraph shall preempt any provision of State 

3 or Federal law that provides broader rights 

4 with respect to written informed consent for 

5 residents of facilities.’’. 

6 (3) GAO STUDY AND REPORT ON INFORMED

7 CONSENT LAWS WITH RESPECT TO PRESCRIBING OF

8 PSYCHOTROPIC DRUGS.— 

9 (A) STUDY.—The Comptroller General of 

10 the United States (in this paragraph referred to 

11 as the ‘‘Comptroller General’’) shall conduct a 

12 study of State laws and regulations concerning 

13 informed consent with respect to the adminis14 tration of a psychotropic drug with regard to 

15 the effectiveness of such laws and practices in 

16 changing the frequency of prescribing of psy17 chotropic drugs to older adults. The study shall 

18 include an analysis as to whether in the case of 

19 States that have not enacted such informed 

20 consent laws, such States have developed other 

21 mechanisms to guide appropriate prescribing of 

22 psychotropic drugs in older adults with demen23 tia. 

24 (B) REPORT.—Not later than 180 days 

25 after the date of enactment of this Act, the 


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1 Comptroller General shall submit to the Sec2 retary of Health and Human Services, the 

3 Committees on Energy and Commerce and 

4 Ways and Means of the House of Representa5 tives, and the Committee on Finance of the 

6 Senate a report containing the results of the 

7 study conducted under subparagraph (A), to8 gether with such recommendations as the 

9 Comptroller General determines appropriate. 

10 (b) DEVELOPMENT OF MEASURE OF UTILIZATION OF

11 PSYCHOTROPIC DRUGS FOR INCLUSION ON NURSING

12 HOME COMPARE WEBSITE.— 

13 (1) MEDICARE.—Section 1819(i) of the Social 

14 Security Act (42 U.S.C. 1395i–3(i)) is amended— 

15 (A) by redesignating paragraph (3) as 

16 paragraph (4); and 

17 (B) by inserting after paragraph (2) the 

18 following new paragraph: 

19 ‘‘(3) DEVELOPMENT OF MEASURE OF UTILIZA20 TION OF PSYCHOTROPIC DRUGS.— 

21 ‘‘(A) IN GENERAL.—Not later than the 

22 date that is one year after the date of the en23 actment of this paragraph, the Secretary shall 

24 include a measure of the utilization of psycho25 tropic drugs for each skilled nursing facility for 


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1 inclusion on such website (or a successor 

2 website) as part of the quality measures or 

3 health inspections measures, or both such meas4 ures, under the Five-Star Quality Rating Sys5 tem established by the Administrator of the 

6 Centers for Medicare & Medicaid Services. 

7 ‘‘(B) CONSIDERATIONS.—In developing the 

8 measure under subparagraph (A), the Secretary 

9 shall take into account special patient popu10 lations, special care units, appropriate diag11 noses, and other factors, as determined appro12 priate by the Secretary.’’. 

13 (2) MEDICAID.—Section 1919(i) of the Social 

14 Security Act (42 U.S.C. 1396r(i)) is amended— 

15 (A) by redesignating paragraph (3) as 

16 paragraph (4); and 

17 (B) by inserting after paragraph (2) the 

18 following new paragraph: 

19 ‘‘(3) DEVELOPMENT OF MEASURE OF UTILIZA20 TION OF PSYCHOTROPIC DRUGS.— 

21 ‘‘(A) IN GENERAL.—Not later than the 

22 date that is one year after the date of the en23 actment of this paragraph, the Secretary shall 

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1 sion on such website (or a successor website) as 

2 part of the quality measures or health inspec3 tions measures, or both such measures, under 

4 the Five-Star Quality Rating System estab5 lished by the Administrator of the Centers for 

6 Medicare & Medicaid Services. 

7 ‘‘(B) CONSIDERATIONS.—In developing the 

8 measure under subparagraph (A), the Secretary 

9 shall take into account special patient popu10 lations, special care units, appropriate diag11 noses, and other factors, as determined appro12 priate by the Secretary.’’. 

Æ 


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