II 

118TH CONGRESS 

2D SESSION S. 4280 

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

nursing facilities, nursing facilities, intermediate care facilities for the 

intellectually disabled, and inpatient rehabilitation facilities to permit 

essential caregivers access during any period in which regular visitation 

is restricted. 

IN THE SENATE OF THE UNITED STATES 

MAY 8, 2024 

Mr. BLUMENTHAL (for himself and Mr. CORNYN) 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 require skilled nursing facilities, nursing facilities, intermediate care facilities for the intellectually disabled, 

and inpatient rehabilitation facilities to permit essential 

caregivers access during any period in which regular 

visitation is restricted. 

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 ‘‘Essential Caregivers 

5 Act of 2024’’. 


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1 SEC. 2. FINDINGS. 

2 Congress finds the following: 

3 (1) According to the National Center for Health 

4 Statistics of the Centers for Disease Control and 

5 Prevention, an estimated 1,300,000 individuals re6 sided in nursing homes in 2020 at the onset of the 

7 COVID–19 pandemic and nearly half of all nursing 

8 home residents were living with a diagnosis of Alz9 heimer’s or other related dementia. 

10 (2) Regulations issued pursuant to the Nursing 

11 Home Reform Act of 1987 established basic rights 

12 and services for residents of nursing homes, includ13 ing ‘‘the right to a dignified existence, self-deter14 mination, and communication with and access to 

15 persons and services inside and outside the facility’’. 

16 (3) In March of 2020, the Centers for Medicare 

17 & Medicaid Services instructed nursing facilities to 

18 restrict visitation for all visitors and non-essential 

19 healthcare personnel and cancel communal dining 

20 and group activities. Long-term care ombudsman 

21 program representatives and State surveyors were 

22 among those whose access to long-term care facilities 

23 was prohibited or extremely restricted despite re24 opening guidance released by the Centers for Medi25 care & Medicaid Services in May of 2020. 


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1 (4) Many long-term care residents declined dra2 matically or died prematurely from ‘‘failure to 

3 thrive’’ in isolation. 

4 (5) According to the National Consumer Voice 

5 for Quality Long-Term Care, in the first year of the 

6 COVID–19 pandemic, 1 in 5 healthcare workers re7 signed, retired, or were fired. This exacerbated the 

8 longstanding problem of staff shortages that already 

9 existed. Lack of staff, combined with the forced ab10 sence of families, many of whom provided informal 

11 care and support to residents, resulted in a signifi12 cant decline in residents’ health and well-being. Dur13 ing the pandemic, pressure ulcers in nursing home 

14 residents rose by 31 percent, the number of resi15 dents experiencing significant weight loss rose by 49 

16 percent, the number of residents reporting feeling 

17 down, depressed, or hopeless rose by 40 percent, and 

18 the number of residents prescribed antipsychotic 

19 medications rose by 77.5 percent. 

20 (6) According to the Department of Health and 

21 Human Services, loneliness and isolation, such as 

22 that experienced by long-term care residents during 

23 the COVID–19 pandemic, represent profound 

24 threats to an individual’s health and well-being. 


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1 (7) Essential Caregivers provide supplemental 

2 care for their loved one, regardless of staff short3 ages, staff turnover, or emergencies. Essential Care4 givers support residents and advocate on their be5 half. 

6 SEC. 3. RIGHT TO ESSENTIAL CAREGIVERS; ACCESS TO ES7 SENTIAL CAREGIVERS DURING PERIODS 

8 WHEN VISITATION IS OTHERWISE RE9 STRICTED. 

10 (a) MEDICARE SKILLED NURSING FACILITIES.—Sec11 tion 1819(c)(3) of the Social Security Act (42 U.S.C. 

12 1395i–3(c)(3)) is amended— 

13 (1) by redesignating subparagraphs (A) through 

14 (E) as clauses (i) through (v), respectively; 

15 (2) by striking ‘‘A skilled nursing facility 

16 must—’’ and inserting the following: 

17 ‘‘(A) IN GENERAL.—A skilled nursing fa18 cility shall—’’; and 

19 (3) by adding at the end the following new sub20 paragraph: 

21 ‘‘(B) ACCESS TO ESSENTIAL CAREGIVERS

22 DURING EMERGENCY PERIODS WHEN VISITA23 TION IS OTHERWISE RESTRICTED.— 

24 ‘‘(i) DESIGNATION OF ESSENTIAL

25 CAREGIVER.—Each skilled nursing facility 


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1 shall recognize the right of each resident of 

2 such facility to— 

3 ‘‘(I) designate and have access to 

4 essential caregivers for such resident 

5 at all times, including during any pe6 riod of emergency in which regular 

7 visitation is restricted by order of a 

8 Federal, State, or local authority or 

9 by other operation of law; and 

10 ‘‘(II) amend such designation at 

11 any time. 

12 ‘‘(ii) PRESUMPTION OF DESIGNA13 TION.—For purposes of clause (i), in the 

14 case of a resident who is unable, by reason 

15 of cognitive or mental disability, to make 

16 an election described in such clause, the 

17 resident representative (as defined in sec18 tion 483.5 of title 42, Code of Federal 

19 Regulations) of such resident shall be per20 mitted to make such designation for such 

21 resident. 

22 ‘‘(iii) ACCESS TO ESSENTIAL CARE23 GIVERS DURING EMERGENCY PERIODS

24 WHEN VISITATION IS OTHERWISE RE25 STRICTED.—During a period of emergency 


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1 in which regular visitation is restricted by 

2 order of a Federal, State, or local author3 ity or by other operation of law, including 

4 any period in which a waiver or modifica5 tion of requirements pursuant to section 

6 1135 is in effect, a skilled nursing facility 

7 shall— 

8 ‘‘(I) not deny in-person access to 

9 a resident by an essential caregiver of 

10 the resident except as provided in this 

11 subparagraph; 

12 ‘‘(II) allow at least 1 essential 

13 caregiver to have access to and pro14 vide assistance to such resident at 

15 such facility every day and at any 

16 time; and 

17 ‘‘(III) enforce the agreement de18 scribed in clause (vii)(III) with respect 

19 to an essential caregiver. 

20 ‘‘(iv) RESTRICTIONS ON ACCESS.— 

21 ‘‘(I) IN GENERAL.—During a pe22 riod of emergency in which regular 

23 visitation is restricted by order of a 

24 Federal, State, or local authority or 

25 by other operation of law, including 


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1 any period in which a waiver or modi2 fication of requirements pursuant to 

3 section 1135 is in effect, a skilled 

4 nursing facility may deny access to a 

5 resident by an essential caregiver of 

6 the resident for— 

7 ‘‘(aa) an initial period of not 

8 longer than 7 days; and 

9 ‘‘(bb) one additional period 

10 of not longer than 7 days (in ad11 dition to the initial period de12 scribed in item (aa)) if the de13 partment of health of the State 

14 in which the facility is located 

15 approves the denial of access for 

16 such additional period. 

17 ‘‘(II) RULE OF APPLICATION.— 

18 For purposes of subclause (I), a pe19 riod of emergency in which regular 

20 visitation is restricted by order of a 

21 Federal, State, or local authority or 

22 by other operation of law shall begin 

23 on the date that such order or other 

24 operation of law takes effect and shall 

25 end on the date that such order or 


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1 other operation of law expires or is 

2 otherwise terminated. During any 

3 such period, the maximum number of 

4 days for which a skilled nursing facil5 ity may deny access to a resident by 

6 an essential caregiver of the resident 

7 is 7 total days (or, subject to the ap8 proval of the department of health of 

9 the State in which the facility is lo10 cated, 14 total days). 

11 ‘‘(v) COMPLIANCE AND NOTIFICA12 TION.— 

13 ‘‘(I) AUTHORITY.—No essential 

14 caregiver who upholds the agreement 

15 described in clause (vii)(III) shall be 

16 denied access to the skilled nursing 

17 facility of the resident involved. 

18 ‘‘(II) NOTIFICATION.— If an es19 sential caregiver fails to comply with 

20 an agreement with a skilled nursing 

21 facility described in clause (vii)(III), 

22 the facility must first provide a warn23 ing to the essential caregiver and resi24 dent in writing citing specific issues of 


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1 non-compliance and providing clear 

2 guidance for corrective measures. 

3 ‘‘(III) ENFORCEMENT.—If an es4 sential caregiver or resident, after re5 ceiving a notification of noncompli6 ance described in subclause (II), fails 

7 to take corrective action, the essential 

8 caregiver may subsequently be denied 

9 access to the resident. In such cases, 

10 the facility shall provide to such care11 giver and such resident (or health 

12 care proxy of such resident), not later 

13 than 24 hours after such denial of ac14 cess occurs, a written explanation as 

15 to why such caregiver was denied ac16 cess to such resident. Such expla17 nation must include the resident’s and 

18 caregiver’s options for appeal under 

19 the processes established under clause 

20 (vi). 

21 ‘‘(vi) OPTIONS FOR RESIDENTS AND

22 CAREGIVERS TO APPEAL DENIALS OF AC23 CESS.— 

24 ‘‘(I) IN GENERAL.—Not later 

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1 ment of this subparagraph, the Sec2 retary shall issue a final rule estab3 lishing a process for residents and 

4 caregivers to appeal denials of access. 

5 ‘‘(II) APPEALS PROCESS.—The 

6 agency responsible for overseeing the 

7 appeals process established under sub8 clause (I) shall— 

9 ‘‘(aa) receive appeals from 

10 residents and essential caregivers 

11 challenging a decision by a 

12 skilled nursing facility to deny 

13 access under clause (v); and 

14 ‘‘(bb) investigate all such 

15 appeals within 48 hours of re16 ceipt. 

17 ‘‘(III) BURDEN OF PROOF.— 

18 During an appeal received under the 

19 appeals process established under sub20 clause (I), if a skilled nursing facility 

21 defends a decision to deny access to 

22 an essential caregiver under clause (v) 

23 on the basis that the essential care24 giver violated the agreement described 

25 in clause (vii)(III), the skilled nursing 


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1 facility shall have the burden of proof 

2 in demonstrating that the essential 

3 caregiver violated such agreement. 

4 ‘‘(IV) RESOLUTION OF AP5 PEAL.—With respect to an appeal re6 ceived under the appeals process es7 tablished under subclause (I), the 

8 agency responsible for overseeing the 

9 appeal shall make a determination as 

10 to whether a skilled nursing facility 

11 violated a requirement or prohibition 

12 of this subparagraph within 48 hours 

13 of commencing its investigation. If the 

14 agency determines that a facility has 

15 violated such a requirement or prohi16 bition the agency shall— 

17 ‘‘(aa) require the facility to 

18 allow immediate access to the es19 sential caregiver in question; 

20 ‘‘(bb) require the facility to 

21 establish a corrective action plan 

22 to prevent the recurrence of such 

23 violation within a 7-day period of 

24 receiving notice from the agency; 

25 and 


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1 ‘‘(cc) impose a civil money 

2 penalty in an amount to be deter3 mined by the agency (not to ex4 ceed $5,000) if such facility fails 

5 to implement the corrective ac6 tion plan with the 7-day period 

7 specified in item (bb). 

8 ‘‘(vii) DEFINITION OF ESSENTIAL

9 CAREGIVER.—For purposes of this sub10 paragraph, the term ‘essential caregiver’ 

11 means, with respect to a resident of a 

12 skilled nursing facility, an individual 

13 who— 

14 ‘‘(I) is designated by or on behalf 

15 of the resident pursuant to clause (i) 

16 or clause (ii); 

17 ‘‘(II) will provide assistance to 

18 such resident, which may include as19 sistance with activities of daily living 

20 or providing emotional support or 

21 companionship to such resident; and 

22 ‘‘(III) agrees to follow all safety 

23 protocols established by such facility, 

24 which shall be clearly specified in 

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1 tive than the safety protocols (includ2 ing safety standards and entry re3 quirements) applicable to staff of such 

4 facility.’’. 

5 (b) MEDICAID NURSING FACILITIES.—Section 

6 1919(c)(3) of the Social Security Act (42 U.S.C. 

7 1396r(c)(3)) is amended— 

8 (1) by redesignating subparagraphs (A) through 

9 (E) as clauses (i) through (v), respectively; 

10 (2) by striking ‘‘A nursing facility must—’’ and 

11 inserting the following: 

12 ‘‘(A) IN GENERAL.—A nursing facility 

13 shall—’’; and 

14 (3) by adding at the end the following new sub15 paragraph: 

16 ‘‘(B) ACCESS TO ESSENTIAL CAREGIVERS

17 DURING EMERGENCY PERIODS WHEN VISITA18 TION IS OTHERWISE RESTRICTED.— 

19 ‘‘(i) DESIGNATION OF ESSENTIAL

20 CAREGIVER.—Each nursing facility shall 

21 recognize the right of each resident of such 

22 facility to— 

23 ‘‘(I) designate and have access to 

24 essential caregivers for such resident 

25 at all times, including during any peVerDate Sep 11 2014 01:57 Jun 08, 2024 Jkt 049200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\S4280.IS S4280

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1 riod of emergency in which regular 

2 visitation is restricted by order of a 

3 Federal, State, or local authority or 

4 by other operation of law; and 

5 ‘‘(II) amend such designation at 

6 any time. 

7 ‘‘(ii) PRESUMPTION OF DESIGNA8 TION.—For purposes of clause (i), in the 

9 case of a resident who is unable, by reason 

10 of cognitive or mental disability, to make 

11 an election described in such clause, the 

12 resident representative (as defined in sec13 tion 483.5 of title 42, Code of Federal 

14 Regulations) of such resident shall be per15 mitted to make such designation for such 

16 resident. 

17 ‘‘(iii) ACCESS TO ESSENTIAL CARE18 GIVERS DURING EMERGENCY PERIODS

19 WHEN VISITATION IS OTHERWISE RE20 STRICTED.—During a period of emergency 

21 in which regular visitation is restricted by 

22 order of a Federal, State, or local author23 ity or by other operation of law, including 

24 any period in which a waiver or modificaVerDate Sep 11 2014 01:57 Jun 08, 2024 Jkt 049200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S4280.IS S4280

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1 tion of requirements pursuant to section 

2 1135 is in effect, a nursing facility shall— 

3 ‘‘(I) not deny in-person access to 

4 a resident by an essential caregiver of 

5 the resident except as provided in this 

6 subparagraph; 

7 ‘‘(II) allow at least 1 essential 

8 caregiver to have access to and pro9 vide assistance to such resident at 

10 such facility every day and at any 

11 time; and 

12 ‘‘(III) enforce the agreement de13 scribed in clause (vii)(III) with respect 

14 to an essential caregiver. 

15 ‘‘(iv) RESTRICTIONS ON ACCESS.— 

16 ‘‘(I) IN GENERAL.—During a pe17 riod of emergency in which regular 

18 visitation is restricted by order of a 

19 Federal, State, or local authority or 

20 by other operation of law, including 

21 any period in which a waiver or modi22 fication of requirements pursuant to 

23 section 1135 is in effect, a nursing fa24 cility may deny access to a resident by 


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1 an essential caregiver of the resident 

2 for— 

3 ‘‘(aa) an initial period of not 

4 longer than 7 days; and 

5 ‘‘(bb) one additional period 

6 of not longer than 7 days (in ad7 dition to the initial period de8 scribed in item (aa)) if the de9 partment of health of the State 

10 in which the facility is located 

11 approves the denial of access for 

12 such additional period. 

13 ‘‘(II) RULE OF APPLICATION.— 

14 For purposes of subclause (I), a pe15 riod of emergency in which regular 

16 visitation is restricted by order of a 

17 Federal, State, or local authority or 

18 by other operation of law shall begin 

19 on the date that such order or other 

20 operation of law takes effect and shall 

21 end on the date that such order or 

22 other operation of law expires or is 

23 otherwise terminated. During any 

24 such period, the maximum number of 

25 days for which a nursing facility may 


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1 deny access to a resident by an essen2 tial caregiver of the resident is 7 total 

3 days (or, subject to the approval of 

4 the department of health of the State 

5 in which the facility is located, 14 

6 total days). 

7 ‘‘(v) COMPLIANCE AND NOTIFICA8 TION.— 

9 ‘‘(I) AUTHORITY.—No essential 

10 caregiver who upholds the agreement 

11 described in clause (vii)(III) shall be 

12 denied access to the nursing facility of 

13 the resident involved. 

14 ‘‘(II) NOTIFICATION.— If an es15 sential caregiver fails to comply with 

16 an agreement with a nursing facility 

17 described in clause (vii)(III), the facil18 ity must first provide a warning to the 

19 essential caregiver and resident in 

20 writing citing specific issues of non21 compliance and providing clear guid22 ance for corrective measures. 

23 ‘‘(III) ENFORCEMENT.—If an es24 sential caregiver or resident, after re25 ceiving a notification of noncompliVerDate Sep 11 2014 01:57 Jun 08, 2024 Jkt 049200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\S4280.IS S4280

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1 ance described in subclause (II), fails 

2 to take corrective action, the essential 

3 caregiver may subsequently be denied 

4 access to the resident. In such cases, 

5 the facility shall provide to such care6 giver and such resident (or health 

7 care proxy of such resident), not later 

8 than 24 hours after such denial of ac9 cess occurs, a written explanation as 

10 to why such caregiver was denied ac11 cess to such resident. Such expla12 nation must include the resident’s and 

13 caregiver’s options for appeal under 

14 the processes established under clause 

15 (vi). 

16 ‘‘(vi) OPTIONS FOR RESIDENTS AND

17 CAREGIVERS TO APPEAL DENIALS OF AC18 CESS.— 

19 ‘‘(I) IN GENERAL.—Not later 

20 than 2 years after the date of enact21 ment of this subparagraph, the Sec22 retary shall issue a final rule estab23 lishing a process for residents and 

24 caregivers to appeal denials of access. 


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1 ‘‘(II) APPEALS PROCESS.—The 

2 agency responsible for overseeing the 

3 appeals process established under sub4 clause (I) shall— 

5 ‘‘(aa) receive appeals from 

6 residents and essential caregivers 

7 challenging a decision by a nurs8 ing facility to deny access under 

9 clause (v); and 

10 ‘‘(bb) investigate all such 

11 appeals within 48 hours of re12 ceipt. 

13 ‘‘(III) BURDEN OF PROOF.— 

14 During an appeal received under the 

15 appeals process established under sub16 clause (I), if a nursing facility defends 

17 a decision to deny access to an essen18 tial caregiver under clause (v) on the 

19 basis that the essential caregiver vio20 lated the agreement described in 

21 clause (vii)(III), the nursing facility 

22 shall have the burden of proof in dem23 onstrating that the essential caregiver 

24 violated such agreement. 


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1 ‘‘(IV) RESOLUTION OF AP2 PEAL.—With respect to an appeal re3 ceived under the appeals process es4 tablished under subclause (I), the 

5 agency responsible for overseeing the 

6 appeal shall make a determination as 

7 to whether a nursing facility violated 

8 a requirement or prohibition of this 

9 subparagraph within 48 hours of com10 mencing its investigation. If the agen11 cy determines that a facility has vio12 lated such a requirement or prohibi13 tion the agency shall— 

14 ‘‘(aa) require the facility to 

15 allow immediate access to the es16 sential caregiver in question; 

17 ‘‘(bb) require the facility to 

18 establish a corrective action plan 

19 to prevent the recurrence of such 

20 violation within a 7-day period of 

21 receiving notice from the agency; 

22 and 

23 ‘‘(cc) impose a civil money 

24 penalty in an amount to be deter25 mined by the agency (not to exVerDate Sep 11 2014 01:57 Jun 08, 2024 Jkt 049200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\S4280.IS S4280

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1 ceed $5,000) if such facility fails 

2 to implement the corrective ac3 tion plan with the 7-day period 

4 specified in item (bb). 

5 ‘‘(vii) DEFINITION OF ESSENTIAL

6 CAREGIVER.—For purposes of this sub7 paragraph, the term ‘essential caregiver’ 

8 means, with respect to a resident of a 

9 nursing facility, an individual who— 

10 ‘‘(I) is designated by or on behalf 

11 of the resident pursuant to clause (i) 

12 or clause (ii); 

13 ‘‘(II) will provide assistance to 

14 such resident, which may include as15 sistance with of activities of daily liv16 ing or providing emotional support or 

17 companionship to such resident; and 

18 ‘‘(III) agrees to follow all safety 

19 protocols established by such facility, 

20 which shall be clearly specified in 

21 writing and may be no more restric22 tive than the safety protocols (includ23 ing safety standards and entry re24 quirements) applicable to staff of such 

25 facility.’’. 


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1 (c) INTERMEDIATE CARE FACILITIES FOR THE IN2 TELLECTUALLY DISABLED.—Section 1905(d) of the So3 cial Security Act (42 U.S.C. 1396d(d)) is amended— 

4 (1) in paragraph (2), by striking ‘‘and’’ at the 

5 end; 

6 (2) in paragraph (3), by striking the period and 

7 inserting ‘‘; and’’; and 

8 (3) by adding at the end the following new 

9 paragraph: 

10 ‘‘(4) the institution complies with the require11 ments relating to the designation of, and access to 

12 residents by, essential caregivers described in section 

13 1919(c)(3)(B) in the same manner as if such insti14 tution were a nursing facility.’’. 

15 (d) INPATIENT REHABILITATION FACILITIES.—Sec16 tion 1866(a)(1) of the Social Security Act (42 U.S.C. 

17 1395cc(a)(1)) is amended— 

18 (1) in subparagraph (X), by striking ‘‘and’’ at 

19 the end; 

20 (2) in subparagraph (Y), by striking the period 

21 at the end and inserting ‘‘, and’’; and 

22 (3) by inserting after subparagraph (Y) the fol23 lowing new subparagraph: 

24 ‘‘(Z) in the case of an inpatient rehabilitation 

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1 fined by the Secretary) as a skilled nursing facility, 

2 nursing facility (as defined in section 1919(a)), or 

3 intermediate care facility for the intellectually dis4 abled (as described in section 1905(d)), to comply 

5 with the requirements relating to the designation of, 

6 and access to residents by, essential caregivers de7 scribed in section 1819(c)(3)(B) in the same manner 

8 as if such institution were a skilled nursing facil9 ity.’’. 

10 (e) REGULATIONS.—The Secretary of Health and 

11 Human Services shall, after consultation with stakeholders 

12 (including residents, family members, long-term care om13 budsmen, other advocates of nursing home residents, and 

14 nursing home providers), promulgate regulations to carry 

15 out this Act and the amendments made by this Act. 

16 (f) RULES OF CONSTRUCTION.— 

17 (1) NO NEW AUTHORITY FOR STATE AND

18 LOCAL OFFICIALS TO RESTRICT VISITATION AT

19 NURSING FACILITIES.—Nothing in this section or 

20 the amendments made by this section shall be con21 strued as creating any new authority for State or 

22 local officials to restrict visitation at nursing facili23 ties. 

24 (2) NO NEW AUTHORITY FOR NURSING FACILI25 TIES TO UNILATERALLY RESTRICT VISITATION.— 


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1 Nothing in this section or the amendments made by 

2 this section shall be construed as creating any new 

3 authority for a skilled nursing facility or nursing fa4 cility (as such terms are defined in sections 1819 

5 and 1919 of the Social Security Act, respectively (42 

6 U.S.C. 1395i–3, 1396r)) to restrict visitation. 

7 (g) EFFECTIVE DATE.—The amendments made by 

8 this Act shall take effect on the date that is 2 years after 

9 the date of enactment of this Act, and shall apply with 

10 respect to periods beginning on or after such date in which 

11 regular visitation at nursing facilities is restricted by order 

12 of a Federal, State, or local authority or by other oper13 ation of law. 

Æ 


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