II 

117TH CONGRESS 

1ST SESSION S. 782 

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

Federal nursing home protections and to enhance care quality and transparency for nursing home residents and their families. 

IN THE SENATE OF THE UNITED STATES 

MARCH 16, 2021 

Mr. CASEY (for himself and Mr. TOOMEY) introduced the following bill; which 

was read twice and referred to the Committee on Finance 

A BILL 

To amend titles XVIII and XIX of the Social Security Act 

to modernize Federal nursing home protections and to 

enhance care quality and transparency for nursing home 

residents and their families. 

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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Nursing Home Reform 

5 Modernization Act of 2021’’. 


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1 SEC. 2. IMPROVEMENTS TO NURSING FACILITIES UNDER 

2 THE MEDICARE AND MEDICAID PROGRAMS. 

3 (a) ADVISORY COUNCIL ON SKILLED NURSING FA4 CILITY RANKINGS UNDER MEDICARE AND NURSING FA5 CILITY RANKINGS UNDER MEDICAID.— 

6 (1) ESTABLISHMENT.—Not later than 1 year 

7 after the date of enactment of this Act, the Sec8 retary of Health and Human Services shall establish 

9 the Advisory Council on Skilled Nursing Facility 

10 Rankings under Medicare and Nursing Facility 

11 Rankings under Medicaid (in this subsection re12 ferred to as the ‘‘Advisory Council’’). 

13 (2) MEMBERSHIP.—The Secretary shall ensure 

14 that the membership of the Advisory Council in15 cludes equal representation from the following: 

16 (A) Consumers with nursing home experi17 ence, including adults age 65 and older, individ18 uals with disabilities, family caregivers, and 

19 their advocates. 

20 (B) Skilled nursing facilities and nursing 

21 facilities, including nonprofit facilities. 

22 (C) Academics with expertise in nursing 

23 home oversight. 

24 (D) Health professionals with nursing 

25 home experience, such as physicians, nurses, 


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1 pharmacists, certified nursing assistants, and 

2 direct care professionals. 

3 (E) Professionals with expertise in quality 

4 measurement. 

5 (F) Professionals with expertise in emer6 gency management. 

7 (G) State surveying agencies. 

8 (H) State Long-Term Care Ombudsman 

9 programs. 

10 (I) The Medicare Payment Advisory Com11 mission. 

12 (J) The Medicaid and CHIP Payment and 

13 Access Commission. 

14 (K) The Centers for Medicare & Medicaid 

15 Services. 

16 (L) Other representatives as the Secretary 

17 determines appropriate. 

18 (3) DUTIES.— 

19 (A) STUDY.—The Advisory Council shall 

20 conduct a study of processes for ranking skilled 

21 nursing facilities and nursing facilities under 

22 paragraph (9) of section 1819(f) of the Social 

23 Security Act, as added by subsection (b)(1) and 

24 under paragraph (11) of section 1919(f) of 


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1 such Act, as added by subsection (c)(1). Such 

2 study shall include an analysis of— 

3 (i) which available, verifiable data 

4 sources and measures are best for appro5 priately designating facilities in— 

6 (I) the high-rated facility pro7 gram under paragraph (10) of such 

8 section 1819(f) and under paragraph 

9 (12) of such section 1919(f); and 

10 (II) the low-rated facility pro11 gram under paragraph (8) of such 

12 section 1819(f) and under paragraph 

13 (10) of such section 1919(f); 

14 (ii) the appropriate frequency with 

15 which to update the rankings for the high16 rated and low-rated facility programs de17 scribed in clause (i); 

18 (iii) how best to ensure that skilled 

19 nursing facilities and nursing facilities ap20 propriately report adverse events; 

21 (iv) how surveyors can clearly provide 

22 the rationale for giving deficiencies to such 

23 skilled nursing facilities and nursing facili24 ties and how this can be done in a timely 

25 manner; 


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1 (v) how to manage suspensions from 

2 the high-rated facility program described 

3 in clause (i)(I) and the need for additional 

4 consumer protections to administer such 

5 high-rated facility program; 

6 (vi) the availability or potential devel7 opment of, or modifications to, measures 

8 or verifiable data sources on topics, includ9 ing avoidable hospital readmissions, emer10 gency room visits, risk-adjusted mortality, 

11 discharges to the community, involuntary 

12 discharges, situations involving the inap13 propriate administration of medications by 

14 a facility, and emergency management; and 

15 (vii) the development of, or modifica16 tions to, data collection, verifiable data 

17 sources, and potential measures to assess 

18 the financial stability of a facility. 

19 (B) FINDINGS AND RECOMMENDATIONS.— 

20 (i) IN GENERAL.—Not later than 2 

21 years after the date of enactment of this 

22 Act, the Advisory Council shall submit to 

23 the Secretary the findings of the Advisory 

24 Council under the study conducted under 

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1 ommendations for such legislation and ad2 ministrative action as the Advisory Council 

3 determines appropriate. 

4 (ii) PUBLIC AVAILABILITY.—Upon re5 ceiving the findings and recommendations 

6 under clause (i), the Secretary shall make 

7 the findings and recommendations avail8 able to the public on the internet website 

9 of the Centers for Medicare & Medicaid 

10 Services. 

11 (4) SUNSET.—The Advisory Council shall ter12 minate upon the submission of the report to the Sec13 retary under paragraph (3)(B)(i). 

14 (b) MEDICARE PROGRAM REVISIONS.— 

15 (1) ESTABLISHMENT OF RANKINGS AND HIGH16 RATED FACILITY PROGRAM.— 

17 (A) IN GENERAL.—Section 1819(f) of the 

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

19 amended by adding at the end the following 

20 new paragraphs: 

21 ‘‘(9) RANKING PROCESS.— 

22 ‘‘(A) PROCESS.— 

23 ‘‘(i) ESTABLISHMENT.—The Secretary 

24 shall establish a process to rank skilled 


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1 nursing facilities based on compliance with 

2 the applicable requirements of this Act. 

3 ‘‘(ii) DATA.—The process established 

4 under clause (i) shall include the use of at 

5 least the preceding 3 years of health in6 spection data, if appropriate, and other 

7 data as determined appropriate by the Sec8 retary. 

9 ‘‘(iii) FINDINGS AND RECOMMENDA10 TIONS OF THE ADVISORY COUNCIL ON

11 SKILLED NURSING FACILITY RANKINGS

12 UNDER MEDICARE AND NURSING FACILITY

13 RANKINGS UNDER MEDICAID.—In estab14 lishing the process under clause (i), the 

15 Secretary shall take into account the find16 ings and recommendations of the Advisory 

17 Council that are submitted to the Sec18 retary under section 2(a)(3)(B)(i) of the 

19 Nursing Home Reform Modernization Act 

20 of 2021. 

21 ‘‘(B) RANKING.— 

22 ‘‘(i) IN GENERAL.—Under the process 

23 established under subparagraph (A), the 

24 Secretary shall use the rankings of skilled 

25 nursing facilities to categorize facilities 


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1 into highest and lowest groups for the pur2 poses specified in clause (ii). 

3 ‘‘(ii) TIMING AND USE OF

4 RANKINGS.—Not later than 2 years after 

5 the date the Secretary receives the findings 

6 and recommendations described in sub7 paragraph (A)(iii), the Secretary shall use 

8 the rankings under clause (i) for purposes 

9 of carrying out— 

10 ‘‘(I) the high-rated facility pro11 gram under paragraph (10); and 

12 ‘‘(II) the low-rated facility pro13 gram under paragraph (8). 

14 ‘‘(10) HIGH-RATED FACILITY PROGRAM.— 

15 ‘‘(A) ESTABLISHMENT.— 

16 ‘‘(i) IN GENERAL.—Not later than 2 

17 years after the date the Secretary receives 

18 the findings and recommendations de19 scribed in paragraph (9)(A)(iii), the Sec20 retary shall establish and implement a 

21 high-rated facility program to encourage 

22 and reward compliance with the require23 ments of this Act. 

24 ‘‘(ii) REPORT.—In establishing the 

25 high-rated facility program, the Secretary 


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1 shall take into account the findings and 

2 recommendations described in paragraph 

3 (9)(A)(iii). 

4 ‘‘(iii) REGULATIONS.—The Secretary 

5 shall establish the high-rated facility pro6 gram under clause (i) through notice and 

7 comment rulemaking. 

8 ‘‘(B) DESIGNATION.—Under the high9 rated facility program, subject to subparagraph 

10 (D), the Secretary shall designate the highest 

11 rated skilled nursing facilities under the 

12 rankings under paragraph (9)(B) as high-rated 

13 skilled nursing facilities. 

14 ‘‘(C) DISTINCTION ON NURSING HOME

15 COMPARE WEBSITE.—A skilled nursing facility 

16 that is designated as a high-rated skilled nurs17 ing facility under subparagraph (B) shall re18 ceive a high-rated distinction on the official 

19 Internet website of the Federal Government for 

20 comparing nursing homes pursuant to sub21 section (i)(1)(C). 

22 ‘‘(D) SUSPENSION OF HIGH-RATED STA23 TUS.— 

24 ‘‘(i) IN GENERAL.—The Secretary 

25 shall suspend a skilled nursing facility’s 


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1 designation under subparagraph (B) if the 

2 Secretary determines that there are cir3 cumstances warranting such suspension. 

4 ‘‘(ii) CIRCUMSTANCES.—In estab5 lishing the circumstances under clause (i), 

6 the Secretary shall take into account— 

7 ‘‘(I) findings from Federal sur8 veys and investigations; 

9 ‘‘(II) findings from State surveys 

10 conducted under subsection (g)(2)(A); 

11 ‘‘(III) findings from State inves12 tigations and surveys conducted under 

13 subsection (g)(4), including a high 

14 number of substantiated complaints, 

15 the frequency and severity of substan16 tiated complaints, and how the com17 plaints are handled by the facility; 

18 ‘‘(IV) situations involving 

19 changes of ownership, administration, 

20 or management of a skilled nursing 

21 facility, or the director of nursing; 

22 ‘‘(V) situations involving the in23 appropriate administration of medica24 tions by a facility; 


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1 ‘‘(VI) situations involving invol2 untary discharges of residents; and 

3 ‘‘(VII) other factors determined 

4 appropriate by the Secretary. 

5 ‘‘(iii) NO REINSTATEMENT PRIOR TO

6 NEXT STANDARD SURVEY.—If a skilled 

7 nursing facility’s designation is suspended 

8 under clause (i), such designation shall not 

9 be reinstated prior to a subsequent survey 

10 as specified under subsection 

11 (g)(2)(A)(iii).’’. 

12 (B) ASSESSMENT OF HIGH-RATED DES13 IGNATION IN SPECIAL SURVEYS.—Section 

14 1819(g)(2)(A)(iii)(II) of the Social Security Act 

15 (42 U.S.C. 1395i–3(g)(2)(A)(iii)(II)) is amend16 ed— 

17 (i) by inserting ‘‘(or, in the case of a 

18 facility that is designated as a high-rated 

19 skilled nursing facility under subsection 

20 (f)(10), shall be conducted)’’ after ‘‘may be 

21 conducted’’; and 

22 (ii) by adding at the end the following 

23 new sentence: ‘‘On and after the date the 

24 Secretary implements the high-rated facil25 ity program under subsection (f)(10), any 


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1 survey conducted, pursuant to the pre2 ceding sentence, of a facility that is des3 ignated as a high-rated skilled nursing fa4 cility under such subsection shall include 

5 an assessment of whether such designation 

6 should continue or be suspended under 

7 subparagraph (D) of such subsection.’’. 

8 (2) IMPROVEMENTS TO THE SPECIAL FOCUS

9 FACILITY PROGRAM.— 

10 (A) APPROPRIATE PARTICIPATION.—Sec11 tion 1819(f)(8) of the Social Security Act (42 

12 U.S.C. 1395i–3(f)(8)) is amended— 

13 (i) in subparagraph (A), by striking 

14 ‘‘The Secretary’’ and inserting ‘‘Subject to 

15 the succeeding provisions of this sub16 section, the Secretary’’; and 

17 (ii) by adding at the end the following 

18 new subparagraph: 

19 ‘‘(C) APPROPRIATE PARTICIPATION.—Not 

20 later than 1 year after the date of enactment of 

21 the Nursing Home Reform Modernization Act 

22 of 2021, the Secretary shall ensure that the 

23 number of facilities participating in the special 

24 focus facility program is not less than 3.5 per25 cent of all skilled nursing facilities.’’. 


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1 (B) CONVERSION OF THE SPECIAL FOCUS

2 FACILITY PROGRAM TO THE LOW-RATED FACIL3 ITY PROGRAM AND ADDITIONAL REQUIRE4 MENTS.—Section 1819(f)(8) of the Social Secu5 rity Act (42 U.S.C. 1395i–3(f)(8)), as amended 

6 by subparagraph (A), is amended— 

7 (i) in subparagraph (B), by inserting 

8 the following before the period at the end: 

9 ‘‘(or, on and after the date the Secretary 

10 makes the conversion described in subpara11 graph (D), at a frequency determined ap12 propriate by the Secretary (but in no case 

13 less than once every 6 months))’’; and 

14 (ii) by adding at the end the following 

15 new subparagraphs: 

16 ‘‘(D) CONVERSION TO THE LOW-RATED

17 FACILITY PROGRAM.— 

18 ‘‘(i) IN GENERAL.—On the same date 

19 that the Secretary implements the high20 rated facility program under paragraph 

21 (10), the Secretary shall convert the spe22 cial focus facility program under this sub23 section to the low-rated facility program. 

24 ‘‘(ii) REGULATIONS.—The Secretary 

25 shall carry out the conversion under clause 


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1 (i) through notice and comment rule2 making. 

3 ‘‘(iii) ADDITIONAL REQUIREMENTS

4 FOR THE LOW-RATED FACILITY PRO5 GRAM.—In addition to the provisions that 

6 apply to the low-rated facility program 

7 through the conversion from the special 

8 focus facility program, the succeeding pro9 visions of this subsection shall also apply 

10 to the low-rated facility program. 

11 ‘‘(E) PARTICIPATION.—Subject to the min12 imum participation requirement under subpara13 graph (C), the Secretary shall designate the 

14 lowest rated skilled nursing facilities under the 

15 rankings under paragraph (9)(B) for participa16 tion in the low-rated facility program. 

17 ‘‘(F) PROGRESSIVE ENFORCEMENT AC18 TIONS.—The Secretary, in consultation with 

19 States, shall utilize progressive enforcement ac20 tions, of increasing severity, to ensure facilities 

21 participating in the low-rated facility program 

22 meet the applicable requirements under this 

23 Act. 

24 ‘‘(G) ENFORCEMENT FOR PATTERNS OF

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1 forcement actions specified in subsection (h)(2) 

2 to remedy patterns of deficiencies cited across 

3 multiple surveys. 

4 ‘‘(H) COMPLIANCE ASSISTANCE PRO5 GRAMS.— 

6 ‘‘(i) ON-SITE CONSULTATION AND

7 EDUCATIONAL PROGRAMMING.— 

8 ‘‘(I) IN GENERAL.—The Sec9 retary shall establish on-site consulta10 tion and educational programming for 

11 skilled nursing facilities participating 

12 in the low-rated facility program with 

13 respect to compliance with the appli14 cable requirements under this Act. 

15 ‘‘(II) ENTITY.—The on-site con16 sultation and educational program17 ming described in subclause (I) shall 

18 be carried out by quality improvement 

19 organizations under part B of title XI 

20 or other independent organizations of 

21 a similar type that do not have con22 flicts of interest and are deemed ap23 propriate by the Secretary. 

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1 ticipating in the low-rated facility pro2 gram shall participate in any con3 sultations and educational program4 ming described in subclause (I) con5 ducted at the facility. 

6 ‘‘(ii) CONSULTATION INDEPENDENT

7 OF ENFORCEMENT.— 

8 ‘‘(I) IN GENERAL.—Subject to 

9 subclause (II), on-site consultations 

10 and educational programming de11 scribed in clause (i) shall be con12 ducted independently of any enforce13 ment activity. 

14 ‘‘(II) EXCEPTION.—Subclause (I) 

15 shall not apply in the case where a 

16 triggering event at the skilled nursing 

17 facility is observed in the course of 

18 providing on-site consultations and 

19 educational programming described in 

20 clause (i). In establishing such on-site 

21 consultations and educational pro22 gramming, the Secretary shall deter23 mine the triggering events for which 

24 the use of necessary enforcement ac25 tions is permitted notwithstanding the 


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1 limitation under subclause (I). Such 

2 triggering events shall include events 

3 that are required to be reported under 

4 State and Federal law and a pattern 

5 of deficiencies or problems that the 

6 quality improvement organization or 

7 other organization has identified for 

8 correction but which are consistently 

9 not corrected. 

10 ‘‘(I) PUBLIC AVAILABILITY.— 

11 ‘‘(i) IN GENERAL.—The Secretary 

12 shall ensure that a skilled nursing facility’s 

13 participation in the low-rated facility pro14 gram is publicly announced, including to— 

15 ‘‘(I) resident family councils; 

16 ‘‘(II) resident attending physi17 cians; 

18 ‘‘(III) the State board respon19 sible for the licensing of the skilled 

20 nursing facility administrator at the 

21 facility; 

22 ‘‘(IV) State Long-Term Care 

23 Ombudsman programs (as described 

24 in section 712(a)(1) of the Older 

25 Americans Act of 1965); and 


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1 ‘‘(V) the community at large. 

2 ‘‘(ii) WRITTEN NOTIFICATION.—The 

3 Secretary shall ensure that, in the case of 

4 a skilled nursing facility that is partici5 pating in the low-rated facility program, 

6 residents of such facility and family or 

7 legal representatives are furnished with in8 dividualized written notice of such partici9 pation. Such notice shall be provided to 

10 current residents and to new residents 

11 prior to admission. 

12 ‘‘(J) REQUIREMENT FOR REMOVAL.—The 

13 Secretary shall require that a skilled nursing fa14 cility show improvement prior to removal from 

15 the low-rated facility program.’’. 

16 (C) USE OF CIVIL MONEY PENALTIES.— 

17 Section 1819(h)(2)(B)(ii)(IV)(ff) of the Social 

18 Security Act (42 U.S.C. 1395i– 

19 3(h)(2)(B)(ii)(IV)(ff)) is amended— 

20 (i) by striking ‘‘and facility improve21 ment initiatives’’ and inserting ‘‘facility 

22 improvement initiatives’’; and 

23 (ii) by inserting the following before 

24 the period at the end: ‘‘, and, on and after 

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1 sion described in subsection (f)(8)(D), con2 sultation, education, and other activities to 

3 foster improvement and remedy root 

4 causes contributing to deficiencies cited 

5 across multiple surveys among facilities in 

6 the low-rated facility program under sub7 section (f)(8)’’. 

8 (3) INFORMATION ON HIGH-RATED AND LOW9 RATED FACILITIES ON NURSING HOME COMPARE

10 MEDICARE WEBSITE.—Section 1819(i)(1) of the So11 cial Security Act (42 U.S.C. 1395i–3(i)(1)) is 

12 amended— 

13 (A) in subparagraph (A), by adding at the 

14 end the following new clause: 

15 ‘‘(vi) On and after the date the Sec16 retary implements the high-rated facility 

17 program under subsection (f)(10) and 

18 makes the conversion under subsection 

19 (f)(8)(D), consistent with subparagraph 

20 (C)— 

21 ‘‘(I) for each skilled nursing fa22 cility that is designated as a high23 rated skilled nursing facility under 

24 subsection (f)(10), the date the facil25 ity was so designated; and 


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1 ‘‘(II) for each skilled nursing fa2 cility participating in the low-rated fa3 cility program under subsection (f)(8), 

4 the date the facility was identified for 

5 inclusion in such program.’’; and 

6 (B) by adding at the end the following new 

7 subparagraphs: 

8 ‘‘(C) DISTINCTIONS FOR HIGH-RATED AND

9 LOW-RATED FACILITIES.—On and after the 

10 date the Secretary implements the high-rated 

11 facility program under subsection (f)(10) and 

12 makes the conversion under subsection 

13 (f)(8)(D), the Secretary shall ensure that 

14 graphics, including an appropriate explanation 

15 of such graphics, are prominently displayed on 

16 the website described in subparagraph (A) in 

17 order to distinguish each of the following: 

18 ‘‘(i) Skilled nursing facilities that are 

19 designated as high-rated skilled nursing fa20 cilities under subsection (f)(10). 

21 ‘‘(ii) Skilled nursing facilities that are 

22 participating in the low-rated facility pro23 gram under subsection (f)(8), with infor24 mation on facilities that have been placed 

25 in such program more than one time over 


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1 the course of the last 10 years (including 

2 the number of times such skilled nursing 

3 facilities have been placed in the program). 

4 ‘‘(D) FOCUS GROUPS AND CONSUMER

5 TESTING.—In order to help limit confusion, 

6 particularly among older adults, individuals 

7 with disabilities, and family caregivers, the Sec8 retary shall utilize focus groups and other con9 sumer testing methods prior to including the 

10 additional information under subparagraph 

11 (A)(vi) and implementing the distinctions under 

12 subparagraph (C).’’. 

13 (c) MEDICAID PROGRAM REVISIONS.— 

14 (1) ESTABLISHMENT OF RANKINGS AND HIGH15 RATED FACILITY PROGRAM.— 

16 (A) IN GENERAL.—Section 1919(f) of the 

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

18 amended by adding at the end the following 

19 new paragraphs: 

20 ‘‘(11) RANKING PROCESS.— 

21 ‘‘(A) PROCESS.— 

22 ‘‘(i) ESTABLISHMENT.—The Secretary 

23 shall establish a process to rank nursing 

24 facilities based on compliance with the ap25 plicable requirements of this Act. 


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1 ‘‘(ii) DATA.—The process established 

2 under clause (i) shall include the use of at 

3 least the preceding 3 years of health in4 spection data, if appropriate, and other 

5 data as determined appropriate by the Sec6 retary. 

7 ‘‘(iii) FINDINGS AND RECOMMENDA8 TIONS OF THE ADVISORY COUNCIL ON

9 SKILLED NURSING FACILITY RANKINGS

10 UNDER MEDICARE AND NURSING FACILITY

11 RANKINGS UNDER MEDICAID.—In estab12 lishing the process under clause (i), the 

13 Secretary shall take into account the find14 ings and recommendations of the Advisory 

15 Council that are submitted to the Sec16 retary under section 2(a)(3)(B)(i) of the 

17 Nursing Home Reform Modernization Act 

18 of 2021. 

19 ‘‘(B) RANKING.— 

20 ‘‘(i) IN GENERAL.—Under the process 

21 established under subparagraph (A), the 

22 Secretary shall use the rankings of nursing 

23 facilities to categorize facilities into highest 

24 and lowest groups for the purposes speci25 fied in clause (ii). 


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1 ‘‘(ii) TIMING AND USE OF

2 RANKINGS.—Not later than 2 years after 

3 the date the Secretary receives the findings 

4 and recommendations described in sub5 paragraph (A)(iii), the Secretary shall use 

6 the rankings under clause (i) for purposes 

7 of carrying out— 

8 ‘‘(I) the high-rated facility pro9 gram under paragraph (12); and 

10 ‘‘(II) the low-rated facility pro11 gram under paragraph (10). 

12 ‘‘(12) HIGH-RATED FACILITY PROGRAM.— 

13 ‘‘(A) ESTABLISHMENT.— 

14 ‘‘(i) IN GENERAL.—Not later than 2 

15 years after the date the Secretary receives 

16 the findings and recommendations de17 scribed in paragraph (11)(A)(iii), the Sec18 retary shall establish and implement a 

19 high-rated facility program to encourage 

20 and reward compliance with the require21 ments of this Act. 

22 ‘‘(ii) REPORT.—In establishing the 

23 high-rated facility program, the Secretary 

24 shall take into account the findings and 


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1 recommendations described in paragraph 

2 (11)(A)(iii). 

3 ‘‘(iii) REGULATIONS.—The Secretary 

4 shall establish the high-rated facility pro5 gram under clause (i) through notice and 

6 comment rulemaking. 

7 ‘‘(B) DESIGNATION.—Under the high8 rated facility program, subject to subparagraph 

9 (D), the Secretary shall designate the highest 

10 rated nursing facilities under the rankings 

11 under paragraph (11)(B) as high-rated nursing 

12 facilities. 

13 ‘‘(C) DISTINCTION ON NURSING HOME

14 COMPARE WEBSITE.—A nursing facility that is 

15 designated as a high-rated nursing facility 

16 under subparagraph (B) shall receive a high17 rated distinction on the official Internet website 

18 of the Federal Government for comparing nurs19 ing homes pursuant to subsection (i)(1)(C). 

20 ‘‘(D) SUSPENSION OF HIGH-RATED STA21 TUS.— 

22 ‘‘(i) IN GENERAL.—The Secretary 

23 shall suspend a nursing facility’s designa24 tion under subparagraph (B) if the SecVerDate Sep 11 2014 19:11 Apr 11, 2021 Jkt 019200 PO 00000 Frm 00024 Fmt 6652 Sfmt 6201 E:\BILLS\S782.IS S782

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1 retary determines that there are cir2 cumstances warranting such suspension. 

3 ‘‘(ii) CIRCUMSTANCES.—In estab4 lishing the circumstances under clause (i), 

5 the Secretary shall take into account— 

6 ‘‘(I) findings from Federal sur7 veys and investigations; 

8 ‘‘(II) findings from State surveys 

9 conducted under subsection (g)(2)(A); 

10 ‘‘(III) findings from State inves11 tigations and surveys conducted under 

12 subsection (g)(4), including a high 

13 number of substantiated complaints, 

14 the frequency and severity of substan15 tiated complaints, and how the com16 plaints are handled by the facility; 

17 ‘‘(IV) situations involving 

18 changes of ownership, administration, 

19 or management of a nursing facility, 

20 or the director of nursing; 

21 ‘‘(V) situations involving the in22 appropriate administration of medica23 tions by a facility; 

24 ‘‘(VI) situations involving invol25 untary discharges of residents; and 


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1 ‘‘(VII) other factors determined 

2 appropriate by the Secretary. 

3 ‘‘(iii) NO REINSTATEMENT PRIOR TO

4 NEXT STANDARD SURVEY.—If a nursing 

5 facility’s designation is suspended under 

6 clause (i), such designation shall not be re7 instated prior to a subsequent survey as 

8 specified under subsection (g)(2)(A)(iii).’’. 

9 (B) ASSESSMENT OF HIGH-RATED DES10 IGNATION IN SPECIAL SURVEYS.—Section 

11 1919(g)(2)(A)(iii)(II) of the Social Security Act 

12 (42 U.S.C. 1396r(g)(2)(A)(iii)(II)) is amend13 ed— 

14 (i) by inserting ‘‘(or, in the case of a 

15 facility that is designated as a high-rated 

16 nursing facility under subsection (f)(12), 

17 shall be conducted)’’ after ‘‘may be con18 ducted’’; and 

19 (ii) by adding at the end the following 

20 new sentence: ‘‘On and after the date the 

21 Secretary implements the high-rated facil22 ity program under subsection (f)(12), any 

23 survey conducted, pursuant to the pre24 ceding sentence, of a facility that is des25 ignated as a high-rated nursing facility 


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1 under such subsection shall include an as2 sessment of whether such designation 

3 should continue or be suspended under 

4 subparagraph (D) of such subsection.’’. 

5 (2) IMPROVEMENTS TO THE SPECIAL FOCUS

6 FACILITY PROGRAM.— 

7 (A) APPROPRIATE PARTICIPATION.—Sec8 tion 1919(f)(10) of the Social Security Act (42 

9 U.S.C. 1395r(f)(10)) is amended— 

10 (i) in subparagraph (A), by striking 

11 ‘‘The Secretary’’ and inserting ‘‘Subject to 

12 the succeeding provisions of this sub13 section, the Secretary’’; and 

14 (ii) by adding at the end the following 

15 new subparagraph: 

16 ‘‘(C) APPROPRIATE PARTICIPATION.—Not 

17 later than 1 year after the date of enactment of 

18 the Nursing Home Reform Modernization Act 

19 of 2021, the Secretary shall ensure that the 

20 number of facilities participating in the special 

21 focus facility program is not less than 3.5 per22 cent of all nursing facilities.’’. 

23 (B) CONVERSION OF THE SPECIAL FOCUS

24 FACILITY PROGRAM TO THE LOW-RATED FACIL25 ITY PROGRAM AND ADDITIONAL REQUIREVerDate Sep 11 2014 19:11 Apr 11, 2021 Jkt 019200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\S782.IS S782

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1 MENTS.—Section 1919(f)(10) of the Social Se2 curity Act (42 U.S.C. 1395i–3(f)(10)), as 

3 amended by subparagraph (A), is amended— 

4 (i) in subparagraph (B), by inserting 

5 the following before the period at the end: 

6 ‘‘(or, on and after the date the Secretary 

7 makes the conversion described in subpara8 graph (D), at a frequency determined ap9 propriate by the Secretary (but in no case 

10 less than once every 6 months))’’; and 

11 (ii) by adding at the end the following 

12 new subparagraphs: 

13 ‘‘(D) CONVERSION TO THE LOW-RATED

14 FACILITY PROGRAM.— 

15 ‘‘(i) IN GENERAL.—On the same date 

16 that the Secretary implements the high17 rated facility program under paragraph 

18 (12), the Secretary shall convert the spe19 cial focus facility program under this sub20 section to the low-rated facility program. 

21 ‘‘(ii) REGULATIONS.—The Secretary 

22 shall carry out the conversion under clause 

23 (i) through notice and comment rule24 making. 


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1 ‘‘(iii) ADDITIONAL REQUIREMENTS

2 FOR THE LOW-RATED FACILITY PRO3 GRAM.—In addition to the provisions that 

4 apply to the low-rated facility program 

5 through the conversion from the special 

6 focus facility program, the succeeding pro7 visions of this subsection shall also apply 

8 to the low-rated facility program. 

9 ‘‘(E) PARTICIPATION.—Subject to the min10 imum participation requirement under subpara11 graph (C), the Secretary shall designate the 

12 lowest rated nursing facilities under the 

13 rankings under paragraph (11)(B) for partici14 pation in the low-rated facility program. 

15 ‘‘(F) PROGRESSIVE ENFORCEMENT AC16 TIONS.—The Secretary, in consultation with 

17 States, shall utilize progressive enforcement ac18 tions, of increasing severity, to ensure facilities 

19 participating in the low-rated facility program 

20 meet the applicable requirements under this 

21 Act. 

22 ‘‘(G) ENFORCEMENT FOR PATTERNS OF

23 DEFICIENCY.—The Secretary may utilize en24 forcement actions specified in subsection (h)(2) 


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1 to remedy patterns of deficiencies cited across 

2 multiple surveys. 

3 ‘‘(H) COMPLIANCE ASSISTANCE PRO4 GRAMS.— 

5 ‘‘(i) ON-SITE CONSULTATION AND

6 EDUCATIONAL PROGRAMMING.— 

7 ‘‘(I) IN GENERAL.—The Sec8 retary shall establish on-site consulta9 tion and educational programming for 

10 nursing facilities participating in the 

11 low-rated facility program with re12 spect to compliance with the applica13 ble requirements under this Act. 

14 ‘‘(II) ENTITY.—The on-site con15 sultation and educational program16 ming described in subclause (I) shall 

17 be carried out by quality improvement 

18 organizations under part B of title XI 

19 or other independent organizations of 

20 a similar type that do not have con21 flicts of interest and are deemed ap22 propriate by the Secretary. 

23 ‘‘(III) REQUIRED PARTICIPA24 TION.—A nursing facility partici25 pating in the low-rated facility proVerDate Sep 11 2014 19:11 Apr 11, 2021 Jkt 019200 PO 00000 Frm 00030 Fmt 6652 Sfmt 6201 E:\BILLS\S782.IS S782

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1 gram shall participate in any con2 sultations and educational program3 ming described in subclause (I) con4 ducted at the facility. 

5 ‘‘(ii) CONSULTATION INDEPENDENT

6 OF ENFORCEMENT.— 

7 ‘‘(I) IN GENERAL.—Subject to 

8 subclause (II), on-site consultations 

9 and educational programming de10 scribed in clause (i) shall be con11 ducted independently of any enforce12 ment activity. 

13 ‘‘(II) EXCEPTION.—Subclause (I) 

14 shall not apply in the case where a 

15 triggering event at the nursing facility 

16 is observed in the course of providing 

17 on-site consultations and educational 

18 programming described in clause (i). 

19 In establishing such on-site consulta20 tions and educational programming, 

21 the Secretary shall determine the trig22 gering events for which the use of 

23 necessary enforcement actions is per24 mitted notwithstanding the limitation 

25 under subclause (I). Such triggering 


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1 events shall include events that are re2 quired to be reported under State and 

3 Federal law and a pattern of defi4 ciencies or problems that the quality 

5 improvement organization or other or6 ganization has identified for correc7 tion but which are consistently not 

8 corrected. 

9 ‘‘(I) PUBLIC AVAILABILITY.— 

10 ‘‘(i) IN GENERAL.—The Secretary 

11 shall ensure that a nursing facility’s par12 ticipation in the low-rated facility program 

13 is publicly announced, including to— 

14 ‘‘(I) resident family councils; 

15 ‘‘(II) resident attending physi16 cians; 

17 ‘‘(III) the State board respon18 sible for the licensing of the nursing 

19 facility administrator at the facility; 

20 ‘‘(IV) State Long-Term Care 

21 Ombudsman programs (as described 

22 in section 712(a)(1) of the Older 

23 Americans Act of 1965); and 

24 ‘‘(V) the community at large. 


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1 ‘‘(ii) WRITTEN NOTIFICATION.—The 

2 Secretary shall ensure that, in the case of 

3 a nursing facility that is participating in 

4 the low-rated facility program, residents of 

5 such facility and family or legal represent6 atives are furnished with individualized 

7 written notice of such participation. Such 

8 notice shall be provided to current resi9 dents and to new residents prior to admis10 sion. 

11 ‘‘(J) REQUIREMENT FOR REMOVAL.—The 

12 Secretary shall require that a nursing facility 

13 show improvement prior to removal from the 

14 low-rated facility program.’’. 

15 (C) USE OF CIVIL MONEY PENALTIES.— 

16 Section 1919(h)(3)(C)(ii)(IV)(ff) of the Social 

17 Security Act (42 U.S.C. 

18 1396r(h)(3)(C)(ii)(IV)(ff)) is amended— 

19 (i) by striking ‘‘and facility improve20 ment initiatives’’ and inserting ‘‘facility 

21 improvement initiatives’’; and 

22 (ii) by inserting the following before 

23 the period at the end: ‘‘, and, on and after 

24 the date the Secretary makes the conver25 sion described in subsection (f)(10)(D), 


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1 consultation, education, and other activities 

2 to foster improvement and remedy root 

3 causes contributing to deficiencies cited 

4 across multiple surveys among facilities in 

5 the low-rated facility program under sub6 section (f)(10)’’. 

7 (3) INFORMATION ON HIGH-RATED AND LOW8 RATED FACILITIES ON NURSING HOME COMPARE

9 MEDICARE WEBSITE.—Section 1919(i)(1) of the So10 cial Security Act (42 U.S.C. 1396r(i)(1)) is amend11 ed— 

12 (A) in subparagraph (A), by adding at the 

13 end the following new clause: 

14 ‘‘(vi) On and after the date the Sec15 retary implements the high-rated facility 

16 program under subsection (f)(12) and 

17 makes the conversion under subsection 

18 (f)(10)(D), consistent with subparagraph 

19 (C)— 

20 ‘‘(I) for each nursing facility that 

21 is designated as a high-rated nursing 

22 facility under subsection (f)(12), the 

23 date the facility was so designated; 

24 and 


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1 ‘‘(II) for each nursing facility 

2 participating in the low-rated facility 

3 program under subsection (f)(10), the 

4 date the facility was identified for in5 clusion in such program.’’; and 

6 (B) by adding at the end the following new 

7 subparagraphs: 

8 ‘‘(C) DISTINCTIONS FOR HIGH-RATED AND

9 LOW-RATED FACILITIES.—On and after the 

10 date the Secretary implements the high-rated 

11 facility program under subsection (f)(12) and 

12 makes the conversion under subsection 

13 (f)(10)(D), the Secretary shall ensure that 

14 graphics, including an appropriate explanation 

15 of such graphics, are prominently displayed on 

16 the website described in subparagraph (A) in 

17 order to distinguish each of the following: 

18 ‘‘(i) Nursing facilities that are des19 ignated as high-rated nursing facilities 

20 under subsection (f)(12). 

21 ‘‘(ii) Nursing facilities that are par22 ticipating in the low-rated facility program 

23 under subsection (f)(10), with information 

24 on facilities that have been placed in such 

25 program more than one time over the 


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1 course of the last 10 years (including the 

2 number of times such nursing facilities 

3 have been placed in the program). 

4 ‘‘(D) FOCUS GROUPS AND CONSUMER

5 TESTING.—In order to help limit confusion, 

6 particularly among older adults, individuals 

7 with disabilities, and family caregivers, the Sec8 retary shall utilize focus groups and other con9 sumer testing methods prior to including the 

10 additional information under subparagraph 

11 (A)(vi) and implementing the distinctions under 

12 subparagraph (C).’’. 

13 (d) GAO STUDY AND REPORT.— 

14 (1) STUDY.—The Comptroller General of the 

15 United States (in this section referred to as the 

16 ‘‘Comptroller General’’) shall conduct a study on the 

17 quality of items and services furnished by skilled 

18 nursing facilities under title XVIII of the Social Se19 curity Act and nursing facilities under title XIX of 

20 such Act, and such facilities’ compliance with the 

21 applicable requirements under such titles. Such 

22 study shall include analysis of the following: 

23 (A) The effectiveness of the low-rated facil24 ity program established under paragraph (8) of 

25 section 1819(f) of the Social Security Act (42 


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1 U.S.C. 1395i–3(f)), as amended by subsection 

2 (b)(2), and under paragraph (10) of section 

3 1919(f) of such Act (42 U.S.C. 1396r(f)), as 

4 amended by subsection (c)(2). 

5 (B) Other areas determined appropriate by 

6 the Comptroller General. 

7 (2) REPORT.—Not later than 6 years after the 

8 date of enactment of this Act, the Comptroller Gen9 eral shall submit to the appropriate Committees of 

10 Congress a report containing the results of the study 

11 conducted under paragraph (1), together with rec12 ommendations for such legislation and administra13 tive action as the Comptroller General determines 

14 appropriate. 

15 (e) RULES OF CONSTRUCTION.— 

16 (1) SURVEYS.—Nothing in the provisions of, or 

17 the amendments made by, this section shall be con18 strued to allow the Secretary to modify or deviate 

19 from— 

20 (A) a survey schedule that requires unan21 nounced and unanticipated surveying of skilled 

22 nursing facilities under subsection (g)(2)(A)(i) 

23 of section 1819 of the Social Security Act (42 

24 U.S.C. 1395i–3(g)) or under subsection 


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1 (g)(2)(A)(i) of section 1919 of the Social Secu2 rity Act (42 U.S.C. 1396r(g)); 

3 (B) the surveying frequency specified 

4 under subsection (g)(2)(A)(iii) of such section 

5 1819 or under subsection (g)(2)(A)(iii) of such 

6 section 1919; or 

7 (C) surveys and investigations as required 

8 under subsection (g)(4) of such section 1819 or 

9 under subsection (g)(4) of such section 1919. 

10 (2) ACCOUNTABILITY AND STATE LAW.—Noth11 ing in the provisions of, or the amendments made 

12 by, this section shall be construed to impact the abil13 ity of a resident, the family of a resident, or a suc14 cessor in interest to hold a skilled nursing facility or 

15 nursing facility accountable or change protections 

16 granted under State law. 

17 SEC. 3. DEFINITIONS. 

18 In this Act: 

19 (1) APPROPRIATE COMMITTEES OF CON20 GRESS.—The term ‘‘appropriate Committee of Con21 gress’’ means— 

22 (A) the Committee on Finance of the Sen23 ate; 

24 (B) the Committee on Health, Education, 

25 Labor, and Pensions of the Senate; 


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1 (C) the Special Committee on Aging of the 

2 Senate; 

3 (D) the Committee on Ways and Means of 

4 the House of Representatives; and 

5 (E) the Committee on Energy and Com6 merce of the House of Representatives. 

7 (2) NURSING FACILITY.—The term ‘‘nursing 

8 facility’’ has the meaning given that term in section 

9 1919(a) of the Social Security Act (42 U.S.C. 

10 1396r(a)). 

11 (3) SKILLED NURSING FACILITY.—The term 

12 ‘‘skilled nursing facility’’ has the meaning given that 

13 term in section 1819(a) of the Social Security Act 

14 (42 U.S.C. 1395i–3(a)). 

15 (4) SECRETARY.—The term ‘‘Secretary’’ means 

16 the Secretary of Health and Human Services. 

Æ 


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