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[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[S. 782 Introduced in Senate (IS)]

<DOC>

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.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Nursing Home Reform Modernization 
Act of 2021''.

SEC. 2. IMPROVEMENTS TO NURSING FACILITIES UNDER THE MEDICARE AND 
              MEDICAID PROGRAMS.

    (a) Advisory Council on Skilled Nursing Facility Rankings Under 
Medicare and Nursing Facility Rankings Under Medicaid.--
            (1) Establishment.--Not later than 1 year after the date of 
        enactment of this Act, the Secretary of Health and Human 
        Services shall establish the Advisory Council on Skilled 
        Nursing Facility Rankings under Medicare and Nursing Facility 
        Rankings under Medicaid (in this subsection referred to as the 
        ``Advisory Council'').
            (2) Membership.--The Secretary shall ensure that the 
        membership of the Advisory Council includes equal 
        representation from the following:
                    (A) Consumers with nursing home experience, 
                including adults age 65 and older, individuals with 
                disabilities, family caregivers, and their advocates.
                    (B) Skilled nursing facilities and nursing 
                facilities, including nonprofit facilities.
                    (C) Academics with expertise in nursing home 
                oversight.
                    (D) Health professionals with nursing home 
                experience, such as physicians, nurses, pharmacists, 
                certified nursing assistants, and direct care 
                professionals.
                    (E) Professionals with expertise in quality 
                measurement.
                    (F) Professionals with expertise in emergency 
                management.
                    (G) State surveying agencies.
                    (H) State Long-Term Care Ombudsman programs.
                    (I) The Medicare Payment Advisory Commission.
                    (J) The Medicaid and CHIP Payment and Access 
                Commission.
                    (K) The Centers for Medicare & Medicaid Services.
                    (L) Other representatives as the Secretary 
                determines appropriate.
            (3) Duties.--
                    (A) Study.--The Advisory Council shall conduct a 
                study of processes for ranking skilled nursing 
                facilities and nursing facilities under paragraph (9) 
                of section 1819(f) of the Social Security Act, as added 
                by subsection (b)(1) and under paragraph (11) of 
                section 1919(f) of such Act, as added by subsection 
                (c)(1). Such study shall include an analysis of--
                            (i) which available, verifiable data 
                        sources and measures are best for appropriately 
                        designating facilities in--
                                    (I) the high-rated facility program 
                                under paragraph (10) of such section 
                                1819(f) and under paragraph (12) of 
                                such section 1919(f); and
                                    (II) the low-rated facility program 
                                under paragraph (8) of such section 
                                1819(f) and under paragraph (10) of 
                                such section 1919(f);
                            (ii) the appropriate frequency with which 
                        to update the rankings for the high-rated and 
                        low-rated facility programs described in clause 
                        (i);
                            (iii) how best to ensure that skilled 
                        nursing facilities and nursing facilities 
                        appropriately report adverse events;
                            (iv) how surveyors can clearly provide the 
                        rationale for giving deficiencies to such 
                        skilled nursing facilities and nursing 
                        facilities and how this can be done in a timely 
                        manner;
                            (v) how to manage suspensions from the 
                        high-rated facility program described in clause 
                        (i)(I) and the need for additional consumer 
                        protections to administer such high-rated 
                        facility program;
                            (vi) the availability or potential 
                        development of, or modifications to, measures 
                        or verifiable data sources on topics, including 
                        avoidable hospital readmissions, emergency room 
                        visits, risk-adjusted mortality, discharges to 
                        the community, involuntary discharges, 
                        situations involving the inappropriate 
                        administration of medications by a facility, 
                        and emergency management; and
                            (vii) the development of, or modifications 
                        to, data collection, verifiable data sources, 
                        and potential measures to assess the financial 
                        stability of a facility.
                    (B) Findings and recommendations.--
                            (i) In general.--Not later than 2 years 
                        after the date of enactment of this Act, the 
                        Advisory Council shall submit to the Secretary 
                        the findings of the Advisory Council under the 
                        study conducted under subparagraph (A), 
                        together with recommendations for such 
                        legislation and administrative action as the 
                        Advisory Council determines appropriate.
                            (ii) Public availability.--Upon receiving 
                        the findings and recommendations under clause 
                        (i), the Secretary shall make the findings and 
                        recommendations available to the public on the 
                        internet website of the Centers for Medicare & 
                        Medicaid Services.
            (4) Sunset.--The Advisory Council shall terminate upon the 
        submission of the report to the Secretary under paragraph 
        (3)(B)(i).
    (b) Medicare Program Revisions.--
            (1) Establishment of rankings and high-rated facility 
        program.--
                    (A) In general.--Section 1819(f) of the Social 
                Security Act (42 U.S.C. 1395i-3(f)) is amended by 
                adding at the end the following new paragraphs:
            ``(9) Ranking process.--
                    ``(A) Process.--
                            ``(i) Establishment.--The Secretary shall 
                        establish a process to rank skilled nursing 
                        facilities based on compliance with the 
                        applicable requirements of this Act.
                            ``(ii) Data.--The process established under 
                        clause (i) shall include the use of at least 
                        the preceding 3 years of health inspection 
                        data, if appropriate, and other data as 
                        determined appropriate by the Secretary.
                            ``(iii) Findings and recommendations of the 
                        advisory council on skilled nursing facility 
                        rankings under medicare and nursing facility 
                        rankings under medicaid.--In establishing the 
                        process under clause (i), the Secretary shall 
                        take into account the findings and 
                        recommendations of the Advisory Council that 
                        are submitted to the Secretary under section 
                        2(a)(3)(B)(i) of the Nursing Home Reform 
                        Modernization Act of 2021.
                    ``(B) Ranking.--
                            ``(i) In general.--Under the process 
                        established under subparagraph (A), the 
                        Secretary shall use the rankings of skilled 
                        nursing facilities to categorize facilities 
                        into highest and lowest groups for the purposes 
                        specified in clause (ii).
                            ``(ii) Timing and use of rankings.--Not 
                        later than 2 years after the date the Secretary 
                        receives the findings and recommendations 
                        described in subparagraph (A)(iii), the 
                        Secretary shall use the rankings under clause 
                        (i) for purposes of carrying out--
                                    ``(I) the high-rated facility 
                                program under paragraph (10); and
                                    ``(II) the low-rated facility 
                                program under paragraph (8).
            ``(10) High-rated facility program.--
                    ``(A) Establishment.--
                            ``(i) In general.--Not later than 2 years 
                        after the date the Secretary receives the 
                        findings and recommendations described in 
                        paragraph (9)(A)(iii), the Secretary shall 
                        establish and implement a high-rated facility 
                        program to encourage and reward compliance with 
                        the requirements of this Act.
                            ``(ii) Report.--In establishing the high-
                        rated facility program, the Secretary shall 
                        take into account the findings and 
                        recommendations described in paragraph 
                        (9)(A)(iii).
                            ``(iii) Regulations.--The Secretary shall 
                        establish the high-rated facility program under 
                        clause (i) through notice and comment 
                        rulemaking.
                    ``(B) Designation.--Under the high-rated facility 
                program, subject to subparagraph (D), the Secretary 
                shall designate the highest rated skilled nursing 
                facilities under the rankings under paragraph (9)(B) as 
                high-rated skilled nursing facilities.
                    ``(C) Distinction on nursing home compare 
                website.--A skilled nursing facility that is designated 
                as a high-rated skilled nursing facility under 
                subparagraph (B) shall receive a high-rated distinction 
                on the official Internet website of the Federal 
                Government for comparing nursing homes pursuant to 
                subsection (i)(1)(C).
                    ``(D) Suspension of high-rated status.--
                            ``(i) In general.--The Secretary shall 
                        suspend a skilled nursing facility's 
                        designation under subparagraph (B) if the 
                        Secretary determines that there are 
                        circumstances warranting such suspension.
                            ``(ii) Circumstances.--In establishing the 
                        circumstances under clause (i), the Secretary 
                        shall take into account--
                                    ``(I) findings from Federal surveys 
                                and investigations;
                                    ``(II) findings from State surveys 
                                conducted under subsection (g)(2)(A);
                                    ``(III) findings from State 
                                investigations and surveys conducted 
                                under subsection (g)(4), including a 
                                high number of substantiated 
                                complaints, the frequency and severity 
                                of substantiated complaints, and how 
                                the complaints are handled by the 
                                facility;
                                    ``(IV) situations involving changes 
                                of ownership, administration, or 
                                management of a skilled nursing 
                                facility, or the director of nursing;
                                    ``(V) situations involving the 
                                inappropriate administration of 
                                medications by a facility;
                                    ``(VI) situations involving 
                                involuntary discharges of residents; 
                                and
                                    ``(VII) other factors determined 
                                appropriate by the Secretary.
                            ``(iii) No reinstatement prior to next 
                        standard survey.--If a skilled nursing 
                        facility's designation is suspended under 
                        clause (i), such designation shall not be 
                        reinstated prior to a subsequent survey as 
                        specified under subsection (g)(2)(A)(iii).''.
                    (B) Assessment of high-rated designation in special 
                surveys.--Section 1819(g)(2)(A)(iii)(II) of the Social 
                Security Act (42 U.S.C. 1395i-3(g)(2)(A)(iii)(II)) is 
                amended--
                            (i) by inserting ``(or, in the case of a 
                        facility that is designated as a high-rated 
                        skilled nursing facility under subsection 
                        (f)(10), shall be conducted)'' after ``may be 
                        conducted''; and
                            (ii) by adding at the end the following new 
                        sentence: ``On and after the date the Secretary 
                        implements the high-rated facility program 
                        under subsection (f)(10), any survey conducted, 
                        pursuant to the preceding sentence, of a 
                        facility that is designated as a high-rated 
                        skilled nursing facility under such subsection 
                        shall include an assessment of whether such 
                        designation should continue or be suspended 
                        under subparagraph (D) of such subsection.''.
            (2) Improvements to the special focus facility program.--
                    (A) Appropriate participation.--Section 1819(f)(8) 
                of the Social Security Act (42 U.S.C. 1395i-3(f)(8)) is 
                amended--
                            (i) in subparagraph (A), by striking ``The 
                        Secretary'' and inserting ``Subject to the 
                        succeeding provisions of this subsection, the 
                        Secretary''; and
                            (ii) by adding at the end the following new 
                        subparagraph:
                    ``(C) Appropriate participation.--Not later than 1 
                year after the date of enactment of the Nursing Home 
                Reform Modernization Act of 2021, the Secretary shall 
                ensure that the number of facilities participating in 
                the special focus facility program is not less than 3.5 
                percent of all skilled nursing facilities.''.
                    (B) Conversion of the special focus facility 
                program to the low-rated facility program and 
                additional requirements.--Section 1819(f)(8) of the 
                Social Security Act (42 U.S.C. 1395i-3(f)(8)), as 
                amended by subparagraph (A), is amended--
                            (i) in subparagraph (B), by inserting the 
                        following before the period at the end: ``(or, 
                        on and after the date the Secretary makes the 
                        conversion described in subparagraph (D), at a 
                        frequency determined appropriate by the 
                        Secretary (but in no case less than once every 
                        6 months))''; and
                            (ii) by adding at the end the following new 
                        subparagraphs:
                    ``(D) Conversion to the low-rated facility 
                program.--
                            ``(i) In general.--On the same date that 
                        the Secretary implements the high-rated 
                        facility program under paragraph (10), the 
                        Secretary shall convert the special focus 
                        facility program under this subsection to the 
                        low-rated facility program.
                            ``(ii) Regulations.--The Secretary shall 
                        carry out the conversion under clause (i) 
                        through notice and comment rulemaking.
                            ``(iii) Additional requirements for the 
                        low-rated facility program.--In addition to the 
                        provisions that apply to the low-rated facility 
                        program through the conversion from the special 
                        focus facility program, the succeeding 
                        provisions of this subsection shall also apply 
                        to the low-rated facility program.
                    ``(E) Participation.--Subject to the minimum 
                participation requirement under subparagraph (C), the 
                Secretary shall designate the lowest rated skilled 
                nursing facilities under the rankings under paragraph 
                (9)(B) for participation in the low-rated facility 
                program.
                    ``(F) Progressive enforcement actions.--The 
                Secretary, in consultation with States, shall utilize 
                progressive enforcement actions, of increasing 
                severity, to ensure facilities participating in the 
                low-rated facility program meet the applicable 
                requirements under this Act.
                    ``(G) Enforcement for patterns of deficiency.--The 
                Secretary may utilize enforcement actions specified in 
                subsection (h)(2) to remedy patterns of deficiencies 
                cited across multiple surveys.
                    ``(H) Compliance assistance programs.--
                            ``(i) On-site consultation and educational 
                        programming.--
                                    ``(I) In general.--The Secretary 
                                shall establish on-site consultation 
                                and educational programming for skilled 
                                nursing facilities participating in the 
                                low-rated facility program with respect 
                                to compliance with the applicable 
                                requirements under this Act.
                                    ``(II) Entity.--The on-site 
                                consultation and educational 
                                programming described in subclause (I) 
                                shall be carried out by quality 
                                improvement organizations under part B 
                                of title XI or other independent 
                                organizations of a similar type that do 
                                not have conflicts of interest and are 
                                deemed appropriate by the Secretary.
                                    ``(III) Required participation.--A 
                                skilled nursing facility participating 
                                in the low-rated facility program shall 
                                participate in any consultations and 
                                educational programming described in 
                                subclause (I) conducted at the 
                                facility.
                            ``(ii) Consultation independent of 
                        enforcement.--
                                    ``(I) In general.--Subject to 
                                subclause (II), on-site consultations 
                                and educational programming described 
                                in clause (i) shall be conducted 
                                independently of any enforcement 
                                activity.
                                    ``(II) Exception.--Subclause (I) 
                                shall not apply in the case where a 
                                triggering event at the skilled nursing 
                                facility is observed in the course of 
                                providing on-site consultations and 
                                educational programming described in 
                                clause (i). In establishing such on-
                                site consultations and educational 
                                programming, the Secretary shall 
                                determine the triggering events for 
                                which the use of necessary enforcement 
                                actions is permitted notwithstanding 
                                the limitation under subclause (I). 
                                Such triggering events shall include 
                                events that are required to be reported 
                                under State and Federal law and a 
                                pattern of deficiencies or problems 
                                that the quality improvement 
                                organization or other organization has 
                                identified for correction but which are 
                                consistently not corrected.
                    ``(I) Public availability.--
                            ``(i) In general.--The Secretary shall 
                        ensure that a skilled nursing facility's 
                        participation in the low-rated facility program 
                        is publicly announced, including to--
                                    ``(I) resident family councils;
                                    ``(II) resident attending 
                                physicians;
                                    ``(III) the State board responsible 
                                for the licensing of the skilled 
                                nursing facility administrator at the 
                                facility;
                                    ``(IV) State Long-Term Care 
                                Ombudsman programs (as described in 
                                section 712(a)(1) of the Older 
                                Americans Act of 1965); and
                                    ``(V) the community at large.
                            ``(ii) Written notification.--The Secretary 
                        shall ensure that, in the case of a skilled 
                        nursing facility that is participating in the 
                        low-rated facility program, residents of such 
                        facility and family or legal representatives 
                        are furnished with individualized written 
                        notice of such participation. Such notice shall 
                        be provided to current residents and to new 
                        residents prior to admission.
                    ``(J) Requirement for removal.--The Secretary shall 
                require that a skilled nursing facility show 
                improvement prior to removal from the low-rated 
                facility program.''.
                    (C) Use of civil money penalties.--Section 
                1819(h)(2)(B)(ii)(IV)(ff) of the Social Security Act 
                (42 U.S.C. 1395i-3(h)(2)(B)(ii)(IV)(ff)) is amended--
                            (i) by striking ``and facility improvement 
                        initiatives'' and inserting ``facility 
                        improvement initiatives''; and
                            (ii) by inserting the following before the 
                        period at the end: ``, and, on and after the 
                        date the Secretary makes the conversion 
                        described in subsection (f)(8)(D), 
                        consultation, education, and other activities 
                        to foster improvement and remedy root causes 
                        contributing to deficiencies cited across 
                        multiple surveys among facilities in the low-
                        rated facility program under subsection 
                        (f)(8)''.
            (3) Information on high-rated and low-rated facilities on 
        nursing home compare medicare website.--Section 1819(i)(1) of 
        the Social Security Act (42 U.S.C. 1395i-3(i)(1)) is amended--
                    (A) in subparagraph (A), by adding at the end the 
                following new clause:
                            ``(vi) On and after the date the Secretary 
                        implements the high-rated facility program 
                        under subsection (f)(10) and makes the 
                        conversion under subsection (f)(8)(D), 
                        consistent with subparagraph (C)--
                                    ``(I) for each skilled nursing 
                                facility that is designated as a high-
                                rated skilled nursing facility under 
                                subsection (f)(10), the date the 
                                facility was so designated; and
                                    ``(II) for each skilled nursing 
                                facility participating in the low-rated 
                                facility program under subsection 
                                (f)(8), the date the facility was 
                                identified for inclusion in such 
                                program.''; and
                    (B) by adding at the end the following new 
                subparagraphs:
                    ``(C) Distinctions for high-rated and low-rated 
                facilities.--On and after the date the Secretary 
                implements the high-rated facility program under 
                subsection (f)(10) and makes the conversion under 
                subsection (f)(8)(D), the Secretary shall ensure that 
                graphics, including an appropriate explanation of such 
                graphics, are prominently displayed on the website 
                described in subparagraph (A) in order to distinguish 
                each of the following:
                            ``(i) Skilled nursing facilities that are 
                        designated as high-rated skilled nursing 
                        facilities under subsection (f)(10).
                            ``(ii) Skilled nursing facilities that are 
                        participating in the low-rated facility program 
                        under subsection (f)(8), with information on 
                        facilities that have been placed in such 
                        program more than one time over the course of 
                        the last 10 years (including the number of 
                        times such skilled nursing facilities have been 
                        placed in the program).
                    ``(D) Focus groups and consumer testing.--In order 
                to help limit confusion, particularly among older 
                adults, individuals with disabilities, and family 
                caregivers, the Secretary shall utilize focus groups 
                and other consumer testing methods prior to including 
                the additional information under subparagraph (A)(vi) 
                and implementing the distinctions under subparagraph 
                (C).''.
    (c) Medicaid Program Revisions.--
            (1) Establishment of rankings and high-rated facility 
        program.--
                    (A) In general.--Section 1919(f) of the Social 
                Security Act (42 U.S.C. 1396r(f)) is amended by adding 
                at the end the following new paragraphs:
            ``(11) Ranking process.--
                    ``(A) Process.--
                            ``(i) Establishment.--The Secretary shall 
                        establish a process to rank nursing facilities 
                        based on compliance with the applicable 
                        requirements of this Act.
                            ``(ii) Data.--The process established under 
                        clause (i) shall include the use of at least 
                        the preceding 3 years of health inspection 
                        data, if appropriate, and other data as 
                        determined appropriate by the Secretary.
                            ``(iii) Findings and recommendations of the 
                        advisory council on skilled nursing facility 
                        rankings under medicare and nursing facility 
                        rankings under medicaid.--In establishing the 
                        process under clause (i), the Secretary shall 
                        take into account the findings and 
                        recommendations of the Advisory Council that 
                        are submitted to the Secretary under section 
                        2(a)(3)(B)(i) of the Nursing Home Reform 
                        Modernization Act of 2021.
                    ``(B) Ranking.--
                            ``(i) In general.--Under the process 
                        established under subparagraph (A), the 
                        Secretary shall use the rankings of nursing 
                        facilities to categorize facilities into 
                        highest and lowest groups for the purposes 
                        specified in clause (ii).
                            ``(ii) Timing and use of rankings.--Not 
                        later than 2 years after the date the Secretary 
                        receives the findings and recommendations 
                        described in subparagraph (A)(iii), the 
                        Secretary shall use the rankings under clause 
                        (i) for purposes of carrying out--
                                    ``(I) the high-rated facility 
                                program under paragraph (12); and
                                    ``(II) the low-rated facility 
                                program under paragraph (10).
            ``(12) High-rated facility program.--
                    ``(A) Establishment.--
                            ``(i) In general.--Not later than 2 years 
                        after the date the Secretary receives the 
                        findings and recommendations described in 
                        paragraph (11)(A)(iii), the Secretary shall 
                        establish and implement a high-rated facility 
                        program to encourage and reward compliance with 
                        the requirements of this Act.
                            ``(ii) Report.--In establishing the high-
                        rated facility program, the Secretary shall 
                        take into account the findings and 
                        recommendations described in paragraph 
                        (11)(A)(iii).
                            ``(iii) Regulations.--The Secretary shall 
                        establish the high-rated facility program under 
                        clause (i) through notice and comment 
                        rulemaking.
                    ``(B) Designation.--Under the high-rated facility 
                program, subject to subparagraph (D), the Secretary 
                shall designate the highest rated nursing facilities 
                under the rankings under paragraph (11)(B) as high-
                rated nursing facilities.
                    ``(C) Distinction on nursing home compare 
                website.--A nursing facility that is designated as a 
                high-rated nursing facility under subparagraph (B) 
                shall receive a high-rated distinction on the official 
                Internet website of the Federal Government for 
                comparing nursing homes pursuant to subsection 
                (i)(1)(C).
                    ``(D) Suspension of high-rated status.--
                            ``(i) In general.--The Secretary shall 
                        suspend a nursing facility's designation under 
                        subparagraph (B) if the Secretary determines 
                        that there are circumstances warranting such 
                        suspension.
                            ``(ii) Circumstances.--In establishing the 
                        circumstances under clause (i), the Secretary 
                        shall take into account--
                                    ``(I) findings from Federal surveys 
                                and investigations;
                                    ``(II) findings from State surveys 
                                conducted under subsection (g)(2)(A);
                                    ``(III) findings from State 
                                investigations and surveys conducted 
                                under subsection (g)(4), including a 
                                high number of substantiated 
                                complaints, the frequency and severity 
                                of substantiated complaints, and how 
                                the complaints are handled by the 
                                facility;
                                    ``(IV) situations involving changes 
                                of ownership, administration, or 
                                management of a nursing facility, or 
                                the director of nursing;
                                    ``(V) situations involving the 
                                inappropriate administration of 
                                medications by a facility;
                                    ``(VI) situations involving 
                                involuntary discharges of residents; 
                                and
                                    ``(VII) other factors determined 
                                appropriate by the Secretary.
                            ``(iii) No reinstatement prior to next 
                        standard survey.--If a nursing facility's 
                        designation is suspended under clause (i), such 
                        designation shall not be reinstated prior to a 
                        subsequent survey as specified under subsection 
                        (g)(2)(A)(iii).''.
                    (B) Assessment of high-rated designation in special 
                surveys.--Section 1919(g)(2)(A)(iii)(II) of the Social 
                Security Act (42 U.S.C. 1396r(g)(2)(A)(iii)(II)) is 
                amended--
                            (i) by inserting ``(or, in the case of a 
                        facility that is designated as a high-rated 
                        nursing facility under subsection (f)(12), 
                        shall be conducted)'' after ``may be 
                        conducted''; and
                            (ii) by adding at the end the following new 
                        sentence: ``On and after the date the Secretary 
                        implements the high-rated facility program 
                        under subsection (f)(12), any survey conducted, 
                        pursuant to the preceding sentence, of a 
                        facility that is designated as a high-rated 
                        nursing facility under such subsection shall 
                        include an assessment of whether such 
                        designation should continue or be suspended 
                        under subparagraph (D) of such subsection.''.
            (2) Improvements to the special focus facility program.--
                    (A) Appropriate participation.--Section 1919(f)(10) 
                of the Social Security Act (42 U.S.C. 1395r(f)(10)) is 
                amended--
                            (i) in subparagraph (A), by striking ``The 
                        Secretary'' and inserting ``Subject to the 
                        succeeding provisions of this subsection, the 
                        Secretary''; and
                            (ii) by adding at the end the following new 
                        subparagraph:
                    ``(C) Appropriate participation.--Not later than 1 
                year after the date of enactment of the Nursing Home 
                Reform Modernization Act of 2021, the Secretary shall 
                ensure that the number of facilities participating in 
                the special focus facility program is not less than 3.5 
                percent of all nursing facilities.''.
                    (B) Conversion of the special focus facility 
                program to the low-rated facility program and 
                additional requirements.--Section 1919(f)(10) of the 
                Social Security Act (42 U.S.C. 1395i-3(f)(10)), as 
                amended by subparagraph (A), is amended--
                            (i) in subparagraph (B), by inserting the 
                        following before the period at the end: ``(or, 
                        on and after the date the Secretary makes the 
                        conversion described in subparagraph (D), at a 
                        frequency determined appropriate by the 
                        Secretary (but in no case less than once every 
                        6 months))''; and
                            (ii) by adding at the end the following new 
                        subparagraphs:
                    ``(D) Conversion to the low-rated facility 
                program.--
                            ``(i) In general.--On the same date that 
                        the Secretary implements the high-rated 
                        facility program under paragraph (12), the 
                        Secretary shall convert the special focus 
                        facility program under this subsection to the 
                        low-rated facility program.
                            ``(ii) Regulations.--The Secretary shall 
                        carry out the conversion under clause (i) 
                        through notice and comment rulemaking.
                            ``(iii) Additional requirements for the 
                        low-rated facility program.--In addition to the 
                        provisions that apply to the low-rated facility 
                        program through the conversion from the special 
                        focus facility program, the succeeding 
                        provisions of this subsection shall also apply 
                        to the low-rated facility program.
                    ``(E) Participation.--Subject to the minimum 
                participation requirement under subparagraph (C), the 
                Secretary shall designate the lowest rated nursing 
                facilities under the rankings under paragraph (11)(B) 
                for participation in the low-rated facility program.
                    ``(F) Progressive enforcement actions.--The 
                Secretary, in consultation with States, shall utilize 
                progressive enforcement actions, of increasing 
                severity, to ensure facilities participating in the 
                low-rated facility program meet the applicable 
                requirements under this Act.
                    ``(G) Enforcement for patterns of deficiency.--The 
                Secretary may utilize enforcement actions specified in 
                subsection (h)(2) to remedy patterns of deficiencies 
                cited across multiple surveys.
                    ``(H) Compliance assistance programs.--
                            ``(i) On-site consultation and educational 
                        programming.--
                                    ``(I) In general.--The Secretary 
                                shall establish on-site consultation 
                                and educational programming for nursing 
                                facilities participating in the low-
                                rated facility program with respect to 
                                compliance with the applicable 
                                requirements under this Act.
                                    ``(II) Entity.--The on-site 
                                consultation and educational 
                                programming described in subclause (I) 
                                shall be carried out by quality 
                                improvement organizations under part B 
                                of title XI or other independent 
                                organizations of a similar type that do 
                                not have conflicts of interest and are 
                                deemed appropriate by the Secretary.
                                    ``(III) Required participation.--A 
                                nursing facility participating in the 
                                low-rated facility program shall 
                                participate in any consultations and 
                                educational programming described in 
                                subclause (I) conducted at the 
                                facility.
                            ``(ii) Consultation independent of 
                        enforcement.--
                                    ``(I) In general.--Subject to 
                                subclause (II), on-site consultations 
                                and educational programming described 
                                in clause (i) shall be conducted 
                                independently of any enforcement 
                                activity.
                                    ``(II) Exception.--Subclause (I) 
                                shall not apply in the case where a 
                                triggering event at the nursing 
                                facility is observed in the course of 
                                providing on-site consultations and 
                                educational programming described in 
                                clause (i). In establishing such on-
                                site consultations and educational 
                                programming, the Secretary shall 
                                determine the triggering events for 
                                which the use of necessary enforcement 
                                actions is permitted notwithstanding 
                                the limitation under subclause (I). 
                                Such triggering events shall include 
                                events that are required to be reported 
                                under State and Federal law and a 
                                pattern of deficiencies or problems 
                                that the quality improvement 
                                organization or other organization has 
                                identified for correction but which are 
                                consistently not corrected.
                    ``(I) Public availability.--
                            ``(i) In general.--The Secretary shall 
                        ensure that a nursing facility's participation 
                        in the low-rated facility program is publicly 
                        announced, including to--
                                    ``(I) resident family councils;
                                    ``(II) resident attending 
                                physicians;
                                    ``(III) the State board responsible 
                                for the licensing of the nursing 
                                facility administrator at the facility;
                                    ``(IV) State Long-Term Care 
                                Ombudsman programs (as described in 
                                section 712(a)(1) of the Older 
                                Americans Act of 1965); and
                                    ``(V) the community at large.
                            ``(ii) Written notification.--The Secretary 
                        shall ensure that, in the case of a nursing 
                        facility that is participating in the low-rated 
                        facility program, residents of such facility 
                        and family or legal representatives are 
                        furnished with individualized written notice of 
                        such participation. Such notice shall be 
                        provided to current residents and to new 
                        residents prior to admission.
                    ``(J) Requirement for removal.--The Secretary shall 
                require that a nursing facility show improvement prior 
                to removal from the low-rated facility program.''.
                    (C) Use of civil money penalties.--Section 
                1919(h)(3)(C)(ii)(IV)(ff) of the Social Security Act 
                (42 U.S.C. 1396r(h)(3)(C)(ii)(IV)(ff)) is amended--
                            (i) by striking ``and facility improvement 
                        initiatives'' and inserting ``facility 
                        improvement initiatives''; and
                            (ii) by inserting the following before the 
                        period at the end: ``, and, on and after the 
                        date the Secretary makes the conversion 
                        described in subsection (f)(10)(D), 
                        consultation, education, and other activities 
                        to foster improvement and remedy root causes 
                        contributing to deficiencies cited across 
                        multiple surveys among facilities in the low-
                        rated facility program under subsection 
                        (f)(10)''.
            (3) Information on high-rated and low-rated facilities on 
        nursing home compare medicare website.--Section 1919(i)(1) of 
        the Social Security Act (42 U.S.C. 1396r(i)(1)) is amended--
                    (A) in subparagraph (A), by adding at the end the 
                following new clause:
                            ``(vi) On and after the date the Secretary 
                        implements the high-rated facility program 
                        under subsection (f)(12) and makes the 
                        conversion under subsection (f)(10)(D), 
                        consistent with subparagraph (C)--
                                    ``(I) for each nursing facility 
                                that is designated as a high-rated 
                                nursing facility under subsection 
                                (f)(12), the date the facility was so 
                                designated; and
                                    ``(II) for each nursing facility 
                                participating in the low-rated facility 
                                program under subsection (f)(10), the 
                                date the facility was identified for 
                                inclusion in such program.''; and
                    (B) by adding at the end the following new 
                subparagraphs:
                    ``(C) Distinctions for high-rated and low-rated 
                facilities.--On and after the date the Secretary 
                implements the high-rated facility program under 
                subsection (f)(12) and makes the conversion under 
                subsection (f)(10)(D), the Secretary shall ensure that 
                graphics, including an appropriate explanation of such 
                graphics, are prominently displayed on the website 
                described in subparagraph (A) in order to distinguish 
                each of the following:
                            ``(i) Nursing facilities that are 
                        designated as high-rated nursing facilities 
                        under subsection (f)(12).
                            ``(ii) Nursing facilities that are 
                        participating in the low-rated facility program 
                        under subsection (f)(10), with information on 
                        facilities that have been placed in such 
                        program more than one time over the course of 
                        the last 10 years (including the number of 
                        times such nursing facilities have been placed 
                        in the program).
                    ``(D) Focus groups and consumer testing.--In order 
                to help limit confusion, particularly among older 
                adults, individuals with disabilities, and family 
                caregivers, the Secretary shall utilize focus groups 
                and other consumer testing methods prior to including 
                the additional information under subparagraph (A)(vi) 
                and implementing the distinctions under subparagraph 
                (C).''.
    (d) GAO Study and Report.--
            (1) Study.--The Comptroller General of the United States 
        (in this section referred to as the ``Comptroller General'') 
        shall conduct a study on the quality of items and services 
        furnished by skilled nursing facilities under title XVIII of 
        the Social Security Act and nursing facilities under title XIX 
        of such Act, and such facilities' compliance with the 
        applicable requirements under such titles. Such study shall 
        include analysis of the following:
                    (A) The effectiveness of the low-rated facility 
                program established under paragraph (8) of section 
                1819(f) of the Social Security Act (42 U.S.C. 1395i-
                3(f)), as amended by subsection (b)(2), and under 
                paragraph (10) of section 1919(f) of such Act (42 
                U.S.C. 1396r(f)), as amended by subsection (c)(2).
                    (B) Other areas determined appropriate by the 
                Comptroller General.
            (2) Report.--Not later than 6 years after the date of 
        enactment of this Act, the Comptroller General shall submit to 
        the appropriate Committees of Congress a report containing the 
        results of the study conducted under paragraph (1), together 
        with recommendations for such legislation and administrative 
        action as the Comptroller General determines appropriate.
    (e) Rules of Construction.--
            (1) Surveys.--Nothing in the provisions of, or the 
        amendments made by, this section shall be construed to allow 
        the Secretary to modify or deviate from--
                    (A) a survey schedule that requires unannounced and 
                unanticipated surveying of skilled nursing facilities 
                under subsection (g)(2)(A)(i) of section 1819 of the 
                Social Security Act (42 U.S.C. 1395i-3(g)) or under 
                subsection (g)(2)(A)(i) of section 1919 of the Social 
                Security Act (42 U.S.C. 1396r(g));
                    (B) the surveying frequency specified under 
                subsection (g)(2)(A)(iii) of such section 1819 or under 
                subsection (g)(2)(A)(iii) of such section 1919; or
                    (C) surveys and investigations as required under 
                subsection (g)(4) of such section 1819 or under 
                subsection (g)(4) of such section 1919.
            (2) Accountability and state law.--Nothing in the 
        provisions of, or the amendments made by, this section shall be 
        construed to impact the ability of a resident, the family of a 
        resident, or a successor in interest to hold a skilled nursing 
        facility or nursing facility accountable or change protections 
        granted under State law.

SEC. 3. DEFINITIONS.

    In this Act:
            (1) Appropriate committees of congress.--The term 
        ``appropriate Committee of Congress'' means--
                    (A) the Committee on Finance of the Senate;
                    (B) the Committee on Health, Education, Labor, and 
                Pensions of the Senate;
                    (C) the Special Committee on Aging of the Senate;
                    (D) the Committee on Ways and Means of the House of 
                Representatives; and
                    (E) the Committee on Energy and Commerce of the 
                House of Representatives.
            (2) Nursing facility.--The term ``nursing facility'' has 
        the meaning given that term in section 1919(a) of the Social 
        Security Act (42 U.S.C. 1396r(a)).
            (3) Skilled nursing facility.--The term ``skilled nursing 
        facility'' has the meaning given that term in section 1819(a) 
        of the Social Security Act (42 U.S.C. 1395i-3(a)).
            (4) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
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