II 

117TH CONGRESS 

1ST SESSION S. 2694 

To improve care furnished and to support the workforce in skilled nursing 

facilities under the Medicare program and in nursing facilities under 

the Medicaid program, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

AUGUST 10, 2021 

Mr. WYDEN (for himself, Mr. CASEY, Mr. BLUMENTHAL, Mr. BENNET, Mr. 

WHITEHOUSE, and Mr. BROWN) introduced the following bill; which was 

read twice and referred to the Committee on Finance 

A BILL 

To improve care furnished and to support the workforce 

in skilled nursing facilities under the Medicare program 

and in nursing facilities under the Medicaid program, 

and for other purposes. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Nursing Home Improvement and Accountability Act of 

6 2021’’. 

7 (b) TABLE OF CONTENTS.—The table of contents of 

8 this Act is as follows: 


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Sec. 1. Short title; table of contents. 

TITLE I—TRANSPARENCY AND ACCOUNTABILITY 

Sec. 101. Improving the accuracy and reliability of certain skilled nursing facility data. 

Sec. 102. Ensuring accurate information on cost reports. 

Sec. 103. Requiring a surety bond for skilled nursing facilities and nursing facilities. 

Sec. 104. Survey improvements. 

Sec. 105. Prohibiting pre-dispute arbitration agreements. 

Sec. 106. Improvements to the special focus facility program. 

TITLE II—STAFFING IMPROVEMENTS 

Sec. 201. Nurse staffing requirements. 

Sec. 202. Improving Nursing Home Compare staffing data. 

Sec. 203. Ensuring the submission of accurate staffing data. 

Sec. 204. Requiring 24-hour use of registered professional nurses. 

Sec. 205. Provision of infection control services. 

Sec. 206. Enhanced funding to support staffing and quality care in nursing facilities. 

TITLE III—BUILDING MODIFICATION AND STAFF INVESTMENT 

DEMONSTRATION PROGRAM 

Sec. 301. Establishing a skilled nursing facility building modification and staff 

investment demonstration program. 

1 TITLE I—TRANSPARENCY AND 

2 ACCOUNTABILITY 

3 SEC. 101. IMPROVING THE ACCURACY AND RELIABILITY OF 

4 CERTAIN SKILLED NURSING FACILITY DATA. 

5 (a) REDUCTION IN PAYMENTS FOR INACCURATE RE6 PORTING.—Section 1888(e)(6)(A) of the Social Security 

7 Act (42 U.S.C. 1395yy(e)(6)(A)) is amended— 

8 (1) in the header, by striking ‘‘FOR FAILURE TO

9 REPORT’’; and 

10 (2) in clause (i)— 

11 (A) by striking ‘‘For fiscal years’’ and in12 serting the following: 


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1 ‘‘(I) FAILURE TO REPORT.—For 

2 fiscal years’’; and 

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

4 subclause: 

5 ‘‘(II) REPORTING OF INAC6 CURATE INFORMATION.—For fiscal 

7 years beginning with fiscal year 2025, 

8 in the case of a skilled nursing facility 

9 that submits data under this para10 graph, measures under subsection (h), 

11 or resident assessment data described 

12 in section 1819(b)(3) with respect to 

13 such fiscal year that is inaccurate (as 

14 determined by the Secretary through 

15 the validation process described in 

16 section 1888(h)(12) or otherwise), 

17 after determining the percentage de18 scribed in paragraph (5)(B)(i), and 

19 after application of clauses (ii) and 

20 (iii) of paragraph (5)(B) and of sub21 clause (I) if this clause (if applicable), 

22 the Secretary shall reduce such per23 centage for payment rates during such 

24 fiscal year by 2 percentage points.’’. 


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1 (b) DATA AND MEASURES VALIDATION.—Section 

2 1888(h)(12) of the Social Security Act (42 U.S.C. 

3 1395yy(h)(12)) is amended— 

4 (1) in subparagraph (A), by striking ‘‘and the 

5 data submitted under subsection (e)(6)’’ and insert6 ing ‘‘, the data submitted under subsection (e)(6), 

7 and, beginning with fiscal year 2024, the resident 

8 assessment data described in section 1819(b)(3)’’; 

9 and 

10 (2) in subparagraph (B), by striking ‘‘of 

11 $5,000,000’’ and all that follows through the period 

12 at the end and inserting the following: ‘‘of— 

13 ‘‘(i) $5,000,000 for each of fiscal 

14 years 2023 through 2025; and 

15 ‘‘(ii) $50,000,000 for the period of fis16 cal years 2026 through 2035, 

17 to the Centers for Medicare & Medicaid Serv18 ices Program Management Account, to remain 

19 available until expended.’’. 

20 (c) PROVIDING AUTHORITY TO COLLECT DATA ON

21 ADDITIONAL MEASURES.—Section 1888(e)(6)(B)(i)(II) of 

22 the Social Security Act (42 U.S.C. 1395yy(e)(6)(B)(i)(II)) 

23 is amended by inserting ‘‘, and data on any other validated 

24 measure specified by the Secretary’’ after ‘‘under such 

25 subsection (d)(1)’’. 


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1 SEC. 102. ENSURING ACCURATE INFORMATION ON COST 

2 REPORTS. 

3 Section 1888(f) of the Social Security Act (42 U.S.C. 

4 1395yy(f)) is amended by adding at the end the following 

5 new paragraphs: 

6 ‘‘(5) AUDIT OF COST REPORTS.— 

7 ‘‘(A) IN GENERAL.—Beginning in 2022, 

8 and annually thereafter, the Secretary shall 

9 conduct an audit of cost reports submitted 

10 under this title for a representative sample of 

11 skilled nursing facilities. 

12 ‘‘(B) FUNDING.—The Secretary shall pro13 vide for the transfer, from the Federal Hospital 

14 Insurance Trust Fund under section 1817 to 

15 the Centers for Medicare & Medicaid Services 

16 Program Management Account, of 

17 $250,000,000 for fiscal year 2023 for purposes 

18 of carrying out this paragraph. Amounts trans19 ferred pursuant to the previous sentence shall 

20 remain available until expended. 

21 ‘‘(6) REVIEW OF RELATIONSHIP BETWEEN

22 COST REPORT DATA AND QUALITY.— 

23 ‘‘(A) IN GENERAL.—Not later than 2 years 

24 after the Secretary completes the first audit de25 scribed in paragraph (5), and not less fre26 quently than once every 2 years thereafter, the 


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1 Inspector General of the Department of Health 

2 and Human Services shall conduct an analysis 

3 of, and submit to Congress a report on, the re4 lationship between skilled nursing facility ex5 penditures for functional accounts described in 

6 paragraph (3) and skilled nursing facility qual7 ity (as specified by the Inspector General). 

8 ‘‘(B) FUNDING.—The Secretary shall pro9 vide for the transfer, from the Federal Hospital 

10 Insurance Trust Fund under section 1817 to 

11 the Inspector General of the Department of 

12 Health and Human Services $25,000,000 for 

13 fiscal year 2023 for purposes of carrying out 

14 this paragraph. Amounts transferred pursuant 

15 to the previous sentence shall remain available 

16 until expended’’. 

17 SEC. 103. REQUIRING A SURETY BOND FOR SKILLED NURS18 ING FACILITIES AND NURSING FACILITIES. 

19 (a) MEDICARE.—Section 1819(a) of the Social Secu20 rity Act (42 U.S.C. 1395i–3(a)) is amended— 

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

22 end; 

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

24 inserting ‘‘; and’’; and 


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

2 paragraph: 

3 ‘‘(4) provides the Secretary with a surety bond 

4 in a form specified by the Secretary and in an 

5 amount that is not less than the minimum of 

6 $500,000, unless the Secretary waives the provision 

7 of such surety bond due to such facility providing a 

8 comparable surety bond under State law.’’. 

9 (b) MEDICAID.—Section 1919(a) of the Social Secu10 rity Act (42 U.S.C. 1396r(a)) is amended— 

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

12 end; 

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

14 inserting ‘‘; and’’; and 

15 (3) by inserting after paragraph (3) the fol16 lowing new paragraph: 

17 ‘‘(4) provides the Secretary with a surety bond 

18 in a form specified by the Secretary and in an 

19 amount that is not less than the minimum of 

20 $500,000, unless the Secretary waives the provision 

21 of such surety bond due to such facility providing a 

22 comparable surety bond under State law.’’. 

23 SEC. 104. SURVEY IMPROVEMENTS. 

24 (a) IN GENERAL.—Section 1128I of the Social Secu25 rity Act (42 U.S.C. 1320a–7j) is amended— 


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1 (1) in the section heading, by striking ‘‘AC2 COUNTABILITY REQUIREMENTS FOR’’ and in3 serting ‘‘ADDITIONAL REQUIREMENTS WITH RE4 SPECT TO’’; and 

5 (2) by adding at the end the following new sub6 section: 

7 ‘‘(i) SURVEY IMPROVEMENTS.— 

8 ‘‘(1) REVIEW.—The Secretary shall review 

9 (and, as appropriate, identify plans to improve) the 

10 following: 

11 ‘‘(A) The extent to which surveys con12 ducted under subsection (g) of sections 1819 

13 and 1919 and the enforcement process under 

14 subsection (h) of sections 1819 and 1919 result 

15 in increased compliance with requirements 

16 under sections 1819 and 1919 and subpart B 

17 of part 483 of title 42, Code of Federal Regula18 tions, with respect to facilities. 

19 ‘‘(B) The timeliness and thoroughness of 

20 State agency verification of deficiency correc21 tions at facilities. 

22 ‘‘(C) The appropriateness of the scoping 

23 and substantiation of cited deficiencies at facili24 ties. 


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1 ‘‘(D) The accuracy of the identification 

2 and appropriateness of the scoping of life safe3 ty, infection control, and emergency prepared4 ness deficiencies at facilities. 

5 ‘‘(E) The timeliness of State agency inves6 tigations of— 

7 ‘‘(i) complaints at facilities; and 

8 ‘‘(ii) reported allegations of abuse, ne9 glect, and exploitation at facilities. 

10 ‘‘(F) The consistency of facility reporting 

11 of substantiated complaints to law enforcement. 

12 ‘‘(G) The ability of the State agency to 

13 sufficiently hire, train, and retain individuals 

14 who conduct surveys. 

15 ‘‘(H) Any other area related to surveys of 

16 facilities, or the individuals conducting such 

17 surveys, determined appropriate by the Sec18 retary. 

19 ‘‘(2) REPORT.—Not later than 3 years after the 

20 date of enactment of this subsection, the Secretary 

21 shall submit to Congress a report on the review con22 ducted under paragraph (1), together with rec23 ommendations for such legislation and administra24 tive action as the Secretary determines to be appro25 priate. 


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1 ‘‘(3) SUPPORT.—If determined appropriate by 

2 the Secretary, based on the review under paragraph 

3 (1), the Secretary shall provide training, tools, tech4 nical assistance, and financial support to State agen5 cies that perform surveys of facilities for the purpose 

6 of improving the surveys conducted under subsection 

7 (g) and the enforcement process under subsection 

8 (h) with respect to the areas reviewed under para9 graph (1). 

10 ‘‘(4) FUNDING.—There is appropriated to the 

11 Secretary, out of any monies in the Treasury not 

12 otherwise appropriated, $570,000,000, to remain 

13 available until expended, for purposes of carrying 

14 out this subsection.’’. 

15 SEC. 105. PROHIBITING PRE-DISPUTE ARBITRATION 

16 AGREEMENTS. 

17 (a) MEDICARE.—Section 1819(c) of the Social Secu18 rity Act (42 U.S.C. 1395i–3(c)) is amended by adding at 

19 the end the following new paragraph: 

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

21 ARBITRATION AGREEMENTS.— 

22 ‘‘(A) IN GENERAL.—A skilled nursing fa23 cility may not enter into a pre-dispute arbitra24 tion agreement with an individual applying to 

25 reside or residing in the facility (or a legal repVerDate Sep 11 2014 23:31 Aug 13, 2021 Jkt 019200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S2694.IS S2694

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1 resentative of such resident), and may not enter 

2 into an agreement for services with an entity or 

3 individual that enters into a pre-dispute arbitra4 tion agreement with an individual applying to 

5 reside or residing in the facility (or a legal rep6 resentative of such resident). 

7 ‘‘(B) NO VALIDITY OR ENFORCEMENT.—A 

8 skilled nursing facility shall not enforce a pre9 dispute arbitration agreement against a resi10 dent or former resident of a skilled nursing fa11 cility (or a legal representative of such resi12 dent), without regard to whether the agreement 

13 was made prior to or after the effective date of 

14 this paragraph. 

15 ‘‘(C) DEFINITION OF PRE-DISPUTE ARBI16 TRATION AGREEMENT.—In this paragraph, the 

17 term ‘pre-dispute arbitration agreement’ means 

18 any agreement to arbitrate a potential dispute 

19 that, as of the date on which such agreement 

20 is entered into, has not yet arisen. 

21 ‘‘(D) JUDICIAL REVIEW.—A determination 

22 as to whether and how this paragraph applies 

23 to a pre-dispute arbitration agreement shall be 

24 determined under Federal law by a court of 

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1 trator, without regard to whether the party op2 posing arbitration challenges such agreement 

3 specifically or in conjunction with any other 

4 term of the contract containing such agree5 ment.’’. 

6 (b) MEDICAID.— 

7 (1) HOME AND COMMUNITY-BASED SERVICES

8 AND HOME HEALTH CARE SERVICES.—Section 1915 

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

10 amended by adding at the end the following new 

11 subsection: 

12 ‘‘(l) PROHIBITING PRE-DISPUTE ARBITRATION

13 AGREEMENTS.— 

14 ‘‘(1) IN GENERAL.—For home and community15 based services or home health care services provided 

16 under a waiver under this section, section 

17 1902(a)(10)(D), or any other provision authorizing 

18 the provision of home and community-based services 

19 or home health care services under this title, the 

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

21 related entity, or affiliate of such provider) may not 

22 enter into a pre-dispute arbitration agreement with 

23 an individual receiving such services (or a legal rep24 resentative of such individual). A provider of such 

25 services (and any employee, agent, related entity, or 


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1 affiliate of such provider) shall not enforce a pre-dis2 pute arbitration agreement against an individual re3 ceiving such services, or who formerly received such 

4 services (or a legal representative of such indi5 vidual), without regard to whether such agreement 

6 was made prior to the effective date of this sub7 section. 

8 ‘‘(2) DEFINITION OF PRE-DISPUTE ARBITRA9 TION AGREEMENT.—In this subsection, the term 

10 ‘pre-dispute arbitration agreement’ means any 

11 agreement to arbitrate a potential dispute that, as of 

12 the date on which such agreement is entered into, 

13 has not yet arisen. 

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

15 whether and how this subsection applies to a pre-dis16 pute arbitration agreement shall be determined 

17 under Federal law by a court of competent jurisdic18 tion, rather than an arbitrator, without regard to 

19 whether the party opposing arbitration challenges 

20 such agreement specifically or in conjunction with 

21 any other term of the contract containing such 

22 agreement.’’. 

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

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


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1 amended by adding at the end the following new 

2 paragraph: 

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

4 ARBITRATION AGREEMENTS.— 

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

6 not enter into a pre-dispute arbitration agree7 ment with an individual applying to reside or 

8 residing in the facility (or a legal representative 

9 of such resident), and may not enter into an 

10 agreement for services with an entity or indi11 vidual that enters into a pre-dispute arbitration 

12 agreement with an individual applying to reside 

13 or residing in the facility (or a legal representa14 tive of such resident). 

15 ‘‘(B) NO VALIDITY OR ENFORCEMENT.—A 

16 nursing facility shall not enforce a pre-dispute 

17 arbitration agreement against a resident or 

18 former resident of a nursing facility (or a legal 

19 representative of such resident), without regard 

20 to whether the agreement was made prior to or 

21 after the effective date of this paragraph. 

22 ‘‘(C) DEFINITION OF PRE-DISPUTE ARBI23 TRATION AGREEMENT.—In this paragraph, the 

24 term ‘pre-dispute arbitration agreement’ means 

25 any agreement to arbitrate a potential dispute 


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1 that, as of the date on which such agreement 

2 is entered into, has not yet arisen. 

3 ‘‘(D) JUDICIAL REVIEW.—A determination 

4 as to whether and how this paragraph applies 

5 to a pre-dispute arbitration agreement shall be 

6 determined under Federal law by a court of 

7 competent jurisdiction, rather than an arbi8 trator, without regard to whether the party op9 posing arbitration challenges such agreement 

10 specifically or in conjunction with any other 

11 term of the contract containing such agree12 ment.’’. 

13 SEC. 106. IMPROVEMENTS TO THE SPECIAL FOCUS FACIL14 ITY PROGRAM. 

15 (a) APPROPRIATE PARTICIPATION.— 

16 (1) MEDICARE.—Section 1819(f)(8) of the So17 cial Security Act (42 U.S.C. 1395i–3(f)(8)) is 

18 amended— 

19 (A) in subparagraph (A), by striking ‘‘The 

20 Secretary’’ and inserting ‘‘Subject to the suc21 ceeding provisions of this subsection, the Sec22 retary’’; and 

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

24 subparagraph: 


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1 ‘‘(C) APPROPRIATE PARTICIPATION.—Not 

2 later than October 1, 2022, the Secretary shall 

3 ensure that the number of facilities partici4 pating in the special focus facility program is 

5 not less than 5 percent of all skilled nursing fa6 cilities.’’. 

7 (2) MEDICAID.—Section 1919(f)(10) of the So8 cial Security Act (42 U.S.C. 1395r(f)(10)) is amend9 ed— 

10 (A) in subparagraph (A), by striking ‘‘The 

11 Secretary’’ and inserting ‘‘Subject to the suc12 ceeding provisions of this subsection, the Sec13 retary’’; and 

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

15 subparagraph: 

16 ‘‘(C) APPROPRIATE PARTICIPATION.—Not 

17 later than October 1, 2022, the Secretary shall 

18 ensure that the number of facilities partici19 pating in the special focus facility program is 

20 not less than 5 percent of all nursing facili21 ties.’’. 

22 (b) COMPLIANCE ASSISTANCE PROGRAMS.— 

23 (1) MEDICARE.—Section 1819(f)(8) of the So24 cial Security Act (42 U.S.C. 1395i–3(f)(8)), as 


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1 amended by subsection (a)(1), is amended by adding 

2 at the end the following new subparagraph: 

3 ‘‘(D) 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 skilled nursing facilities participating 

11 in the special focus facility program 

12 with respect to compliance with the 

13 applicable requirements under this 

14 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 special focus facility 

2 program 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 (2) MEDICAID.—Section 1919(f)(10) of the So11 cial Security Act (42 U.S.C. 1395r(f)(10)), as 

12 amended by subsection (a)(2), is amended by adding 

13 at the end the following new subsection: 

14 ‘‘(D) COMPLIANCE ASSISTANCE PRO15 GRAMS.— 

16 ‘‘(i) ON-SITE CONSULTATION AND

17 EDUCATIONAL PROGRAMMING.— 

18 ‘‘(I) IN GENERAL.—The Sec19 retary shall establish on-site consulta20 tion and educational programming for 

21 nursing facilities participating in the 

22 special focus facility program with re23 spect to compliance with the applica24 ble requirements under this Act. 


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1 ‘‘(II) ENTITY.—The on-site con2 sultation and educational program3 ming described in subclause (I) shall 

4 be carried out by quality improvement 

5 organizations under part B of title XI 

6 or other independent organizations of 

7 a similar type that do not have con8 flicts of interest and are deemed ap9 propriate by the Secretary. 

10 ‘‘(III) REQUIRED PARTICIPA11 TION.—A nursing facility partici12 pating in the special focus facility pro13 gram shall participate in any con14 sultations and educational program15 ming described in subclause (I) con16 ducted at the facility. 

17 ‘‘(ii) CONSULTATION INDEPENDENT

18 OF ENFORCEMENT.— 

19 ‘‘(I) IN GENERAL.—Subject to 

20 subclause (II), on-site consultations 

21 and educational programming de22 scribed in clause (i) shall be con23 ducted independently of any enforce24 ment activity. 


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1 ‘‘(II) EXCEPTION.—Subclause (I) 

2 shall not apply in the case where a 

3 triggering event at the nursing facility 

4 is observed in the course of providing 

5 on-site consultations and educational 

6 programming described in clause (i). 

7 In establishing such on-site consulta8 tions and educational programming, 

9 the Secretary shall determine the trig10 gering events for which the use of 

11 necessary enforcement actions is per12 mitted notwithstanding the limitation 

13 under subclause (I). Such triggering 

14 events shall include events that are re15 quired to be reported under State and 

16 Federal law and a pattern of defi17 ciencies or problems that the quality 

18 improvement organization or other or19 ganization has identified for correc20 tion but which are consistently not 

21 corrected.’’. 

22 (c) FUNDING FOR THE SPECIAL FOCUS FACILITY

23 PROGRAM, INCLUDING COMPLIANCE ASSISTANCE PRO24 GRAMS.—Section 1819(f)(8) of the Social Security Act (42 

25 U.S.C. 1395i–3(f)(8)), as amended by subsections (a)(1) 


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1 and (b)(1), is amended by adding at the end the following 

2 new subparagraph: 

3 ‘‘(E) For purposes of carrying out this 

4 paragraph and section 1919(f)(10), there is ap5 propriated to the Secretary, out of any monies 

6 in the Treasury not otherwise appropriated, 

7 $14,800,000 for fiscal year 2022 and each sub8 sequent fiscal year, to remain available until ex9 pended.’’. 

10 TITLE II—STAFFING 

11 IMPROVEMENTS 

12 SEC. 201. NURSE STAFFING REQUIREMENTS. 

13 (a) IN GENERAL.—Title XI of the Social Security Act 

14 (42 U.S.C. 1301 et seq.) is amended by inserting after 

15 section 1128K the following new section: 

16 ‘‘SEC. 1128L. NURSE STAFFING REQUIREMENTS FOR FA17 CILITIES. 

18 ‘‘(a) STUDY.—Not later than 3 years after the date 

19 of the enactment of this section, and not less frequently 

20 than once every 5 years thereafter, the Secretary shall 

21 conduct a study and submit to Congress a report on the 

22 appropriateness of establishing minimum staff to resident 

23 ratios for nursing staff for skilled nursing facilities (as de24 fined in section 1819(a)) and nursing facilities (as defined 

25 in section 1919(a)). Each such report shall include— 


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1 ‘‘(1) with respect to the first such report, rec2 ommendations regarding appropriate minimum ra3 tios of registered nurses (and, if practicable, licensed 

4 practical nurses (or licensed vocational nurses) and 

5 certified nursing assistants) to residents at such 

6 skilled nursing facilities and such nursing facilities; 

7 and 

8 ‘‘(2) with respect to each subsequent such re9 port, recommendations regarding appropriate min10 imum ratios of registered nurses, licensed practical 

11 nurses (or licensed vocational nurses), and certified 

12 nursing assistants to residents at such skilled nurs13 ing facilities and such nursing facilities. 

14 ‘‘(b) PROMULGATION OF REGULATIONS.— 

15 ‘‘(1) IN GENERAL.—Not later than 2 years 

16 after the Secretary first submits a report under sub17 section (a), the Secretary shall— 

18 ‘‘(A) specify through regulations, con19 sistent with such report, appropriate minimum 

20 ratios (if any) of registered nurses (and, if 

21 practicable, licensed practical nurses (or li22 censed vocational nurses) and certified nursing 

23 assistants) to residents at skilled nursing facili24 ties and nursing facilities; and 


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1 ‘‘(B) subject to any waiver in effect under 

2 section 1819(b)(9)(B) or 1919(b)(9)(B), re3 quire such skilled nursing facilities and such 

4 nursing facilities to comply with such ratios. 

5 ‘‘(2) UPDATE.—Not later than 2 years after the 

6 submission of each subsequent report under sub7 section (a), the Secretary shall, consistent with such 

8 report, update the regulations described in para9 graph (1)(A) to reflect appropriate minimum ratios 

10 (if any) of registered nurses, licensed practical 

11 nurses (or licensed vocational nurses), and certified 

12 nursing assistants to residents at skilled nursing fa13 cilities and nursing facilities. 

14 ‘‘(c) FUNDING.—The Secretary shall provide for the 

15 transfer, from the Federal Hospital Insurance Trust Fund 

16 under section 1817 to the Centers for Medicare & Med17 icaid Services Program Management Account, of 

18 $50,000,000 for fiscal year 2022 for purposes of carrying 

19 out this section. Amounts transferred pursuant to the pre20 vious sentence shall remain available until expended.’’. 

21 (b) IMPOSITION OF REQUIREMENTS.— 

22 (1) MEDICARE.—Section 1819(b) of the Social 

23 Security Act (42 U.S.C. 1395i–3(b)) is amended by 

24 adding at the end the following new paragraph: 

25 ‘‘(9) NURSE STAFFING REQUIREMENT.— 


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1 ‘‘(A) IN GENERAL.—Subject to subpara2 graph (B), a skilled nursing facility shall com3 ply with any minimum staffing ratios for reg4 istered nurses, licensed practical nurses (or li5 censed vocational nurses), or certified nurse as6 sistants specified by the Secretary for such a 

7 facility in regulations promulgated under sec8 tion 1128L(b) or, if greater, as specified by the 

9 State involved for such a facility. 

10 ‘‘(B) WAIVER.— 

11 ‘‘(i) IN GENERAL.—The Secretary 

12 may waive the application of subparagraph 

13 (A) with respect to a skilled nursing facil14 ity if the Secretary finds that— 

15 ‘‘(I) the facility is located in a 

16 rural area and the supply of skilled 

17 nursing facility services in such area 

18 is not sufficient to meet the needs of 

19 individuals residing therein; 

20 ‘‘(II) the Secretary provides no21 tice of the waiver to the State long22 term care ombudsman (established 

23 under section 307(a)(12) of the Older 

24 Americans Act of 1965) and the pro25 tection and advocacy system in the 


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•S 2694 IS

1 State for the mentally ill and the 

2 mentally retarded; and 

3 ‘‘(III) the facility that is granted 

4 such a waiver notifies residents of the 

5 facility (or, where appropriate, the 

6 guardians or legal representatives of 

7 such residents) and members of their 

8 immediate families of the waiver. 

9 ‘‘(ii) RENEWAL.—Any waiver in effect 

10 under this subparagraph shall be subject to 

11 annual renewal.’’. 

12 (2) MEDICAID.—Section 1919(b) of the Social 

13 Security Act (42 U.S.C. 1396r(b)) is amended by 

14 adding at the end the following new paragraph: 

15 ‘‘(9) NURSE STAFFING REQUIREMENT.— 

16 ‘‘(A) IN GENERAL.—Subject to subpara17 graph (B), a nursing facility shall comply with 

18 any minimum staffing ratios for registered 

19 nurses, licensed practical nurses (or licensed vo20 cational nurses), or certified nurse assistants 

21 specified by the Secretary for such a facility in 

22 regulations promulgated under section 

23 1128L(b) or, if greater, as specified by the 

24 State involved for such a facility. 

25 ‘‘(B) WAIVER.— 


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1 ‘‘(i) IN GENERAL.—The Secretary 

2 may waive the application of subparagraph 

3 (A) with respect to a nursing facility if the 

4 Secretary finds that— 

5 ‘‘(I) the facility is located in a 

6 rural area and the supply of nursing 

7 facility services in such area is not 

8 sufficient to meet the needs of individ9 uals residing therein; 

10 ‘‘(II) the Secretary provides no11 tice of the waiver to the State long12 term care ombudsman (established 

13 under section 307(a)(12) of the Older 

14 Americans Act of 1965) and the pro15 tection and advocacy system in the 

16 State for the mentally ill and the 

17 mentally retarded; and 

18 ‘‘(III) the facility that is granted 

19 such a waiver notifies residents of the 

20 facility (or, where appropriate, the 

21 guardians or legal representatives of 

22 such residents) and members of their 

23 immediate families of the waiver. 


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•S 2694 IS

1 ‘‘(ii) RENEWAL.—Any waiver in effect 

2 under this subparagraph shall be subject to 

3 annual renewal.’’. 

4 SEC. 202. IMPROVING NURSING HOME COMPARE STAFFING 

5 DATA. 

6 (a) MEDICARE.—Section 1819(i)(1)(A)(i) of the So7 cial Security Act (42 U.S.C. 1395i–3(i)(1)(A)(i)) is 

8 amended by inserting ‘‘(excluding, with respect to such 

9 data provided on or after October 1, 2022, any hours 

10 spent on administrative duties by licensed nurse staff) 

11 and, beginning October 1, 2022, data on the hours of care 

12 provided per resident per weekend day’’ after ‘‘per resi13 dent per day’’. 

14 (b) MEDICAID.—Section 1919(i)(1)(A)(i) of the So15 cial Security Act (42 U.S.C. 1396r(i)(1)(A)(i)) is amended 

16 by inserting ‘‘(excluding, with respect to such data pro17 vided on or after October 1, 2022, any hours spent on 

18 administrative duties by licensed nurse staff) and, begin19 ning October 1, 2022, data on the hours of care provided 

20 per resident per weekend day’’ after ‘‘per resident per 

21 day’’. 

22 SEC. 203. ENSURING THE SUBMISSION OF ACCURATE 

23 STAFFING DATA. 

24 Section 1128I(g) of the Social Security Act (42 

25 U.S.C. 1320a–7j(g)) is amended— 


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1 (1) by redesignating paragraphs (1) through 

2 (4) as subparagraphs (A) through (D), respectively, 

3 and adjusting the margins accordingly; 

4 (2) in subparagraph (D), as so redesignated, by 

5 striking ‘‘paragraph (1)’’ and inserting ‘‘subpara6 graph (A)’’; 

7 (3) by moving the flush matter following sub8 paragraph (D), as so redesignated, 2 ems to the 

9 right; 

10 (4) by striking ‘‘Beginning not later than’’ and 

11 inserting the following: 

12 ‘‘(1) IN GENERAL.—Beginning not later than’’; 

13 and 

14 (5) by adding at the end the following new 

15 paragraph: 

16 ‘‘(2) PENALTY FOR SUBMISSION OF INAC17 CURATE INFORMATION.—Any facility that submits 

18 inaccurate information to the Secretary under para19 graph (1) may be subject to a civil monetary penalty 

20 not to exceed $10,000 for each such submission. The 

21 provisions of section 1128A (other than subsections 

22 (a) and (b) of such section) shall apply to a civil 

23 money penalty under the preceding sentence in the 

24 same manner as such provisions apply to a penalty 

25 or proceeding under section 1128A(a).’’. 


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1 SEC. 204. REQUIRING 24-HOUR USE OF REGISTERED PRO2 FESSIONAL NURSES. 

3 (a) MEDICARE.—Section 1819(b)(4)(C)(i) of the So4 cial Security Act (42 U.S.C. 1395i–3(b)(4)(C)(i)) is 

5 amended by striking ‘‘registered professional nurse’’ and 

6 all that follows through the period at the end and inserting 

7 the following: ‘‘registered professional nurse, with respect 

8 to such services furnished— 

9 ‘‘(I) before October 1, 2023, at 

10 least 8 consecutive hours a day, 7 

11 days a week; and 

12 ‘‘(II) on or after such date, 24 

13 hours a day, 7 days a week.’’. 

14 (b) MEDICAID.—Section 1919(b)(4)(C)(i)(II) of the 

15 Social Security Act (42 U.S.C. 1396r(b)(4)(C)(i)(II)) is 

16 amended by striking ‘‘registered professional nurse’’ and 

17 all that follows through the period at the end and inserting 

18 the following: ‘‘registered professional nurse, with respect 

19 to such services furnished— 

20 ‘‘(aa) before October 1, 

21 2023, at least 8 consecutive 

22 hours a day, 7 days a week; and 

23 ‘‘(bb) on or after such date, 

24 24 hours a day, 7 days a week.’’. 


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1 SEC. 205. PROVISION OF INFECTION CONTROL SERVICES. 

2 (a) MEDICARE.—Section 1819(d)(3) of the Social Se3 curity Act (42 U.S.C. 1395i–3(d)(3)) is amended— 

4 (1) by redesignating subparagraphs (A) and 

5 (B) as clauses (i) and (ii) respectively, and moving 

6 such clauses 2 ems to the right; 

7 (2) by striking ‘‘ENVIRONMENT.—A skilled’’ 

8 and inserting ‘‘ENVIRONMENT.— 

9 ‘‘(A) IN GENERAL.—A skilled’’; 

10 (3) in subparagraph (A), as amended by para11 graphs (1) and (2)— 

12 (A) in clause (i), by striking ‘‘, and’’ at the 

13 end and inserting a semicolon; 

14 (B) in clause (ii), by striking the period at 

15 the end and inserting ‘‘; and’’; and 

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

17 clause: 

18 ‘‘(iii) provide, directly or under ar19 rangements with others, for infection con20 trol services overseen by an infection 

21 preventionist for a minimum number of 

22 hours per week as determined appropriate 

23 by the Secretary (but, subject to subpara24 graph (B), not less than 40 hours per 

25 week).’’; and 


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1 (4) by adding at the end the following new sub2 paragraph: 

3 ‘‘(B) REDUCTION IN REQUIRED NUMBER

4 OF HOURS FOR INFECTION CONTROL SERVICES

5 OVERSEEN BY AN INFECTION

6 PREVENTIONIST.— 

7 ‘‘(i) IN GENERAL.—The Secretary 

8 may grant a waiver to a skilled nursing fa9 cility under which the number of hours per 

10 week that infection control services over11 seen by an infection preventionist at the 

12 facility are required under subparagraph 

13 (A)(iii) are reduced if the Secretary finds 

14 that— 

15 ‘‘(I) the facility— 

16 ‘‘(aa) is located in a rural 

17 area and the supply of skilled 

18 nursing facility services in such 

19 area is not sufficient to meet the 

20 needs of individuals residing 

21 therein; or 

22 ‘‘(bb) is of a size that neces23 sitates a lower requirement; 

24 ‘‘(II) the Secretary provides no25 tice of the waiver to the State LongVerDate Sep 11 2014 23:31 Aug 13, 2021 Jkt 019200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\S2694.IS S2694

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1 Term Care Ombudsman (supported 

2 under title III or chapter 2 of subtitle 

3 A of title VII of the Older Americans 

4 Act of 1965) and the protection and 

5 advocacy system (as defined in section 

6 102 of the Developmental Disabilities 

7 Assistance and Bill of Rights Act of 

8 2000) in the State; and 

9 ‘‘(III) the facility that is granted 

10 the waiver notifies residents of the fa11 cility (or, where appropriate, the 

12 guardians or legal representatives of 

13 such residents) and members of their 

14 immediate families of the waiver. 

15 ‘‘(ii) ANNUAL REVIEW.—A waiver 

16 under this subparagraph shall be subject to 

17 annual review by the Secretary.’’. 

18 (b) MEDICAID.—Section 1919(d)(3) of the Social Se19 curity Act (42 U.S.C. 1396r(d)(3)) is amended— 

20 (1) by redesignating subparagraphs (A) and 

21 (B) as clauses (i) and (ii) respectively, and moving 

22 such clauses 2 ems to the right; 

23 (2) by striking ‘‘ENVIRONMENT.—A nursing fa24 cility’’ and inserting ‘‘ENVIRONMENT.— 

25 ‘‘(A) IN GENERAL.—A nursing facility’’; 


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•S 2694 IS

1 (3) in subparagraph (A), as amended by para2 graphs (1) and (2)— 

3 (A) in clause (i), by striking ‘‘, and’’ at the 

4 end and inserting a semicolon; 

5 (B) in clause (ii), by striking the period at 

6 the end and inserting ‘‘; and’’; and 

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

8 clause: 

9 ‘‘(iii) provide, directly or under ar10 rangements with others, for infection con11 trol services overseen by an infection 

12 preventionist for a minimum number of 

13 hours per week as determined appropriate 

14 by the Secretary (but, subject to subpara15 graph (B), not less than 40 hours per 

16 week).’’; and 

17 (4) by adding at the end the following new sub18 paragraph: 

19 ‘‘(B) REDUCTION IN REQUIRED NUMBER

20 OF HOURS FOR INFECTION CONTROL SERVICES

21 OVERSEEN BY AN INFECTION

22 PREVENTIONIST.— 

23 ‘‘(i) IN GENERAL.—A State may 

24 grant a waiver to a nursing facility under 

25 which the number of hours per week that 


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•S 2694 IS

1 infection control services overseen by an in2 fection preventionist at the facility are re3 quired under subparagraph (A)(iii) are re4 duced if— 

5 ‘‘(I) the facility demonstrates to 

6 the satisfaction of the State that the 

7 facility has been unable, despite dili8 gent efforts (including offering wages 

9 at the community prevailing rate for 

10 nursing facilities), to recruit appro11 priate personnel; 

12 ‘‘(II) the State determines that 

13 the waiver will not endanger the 

14 health or safety of individuals staying 

15 in the facility; 

16 ‘‘(III) the State agency granting 

17 the waiver provides notice of the waiv18 er to the State Long-Term Care Om19 budsman (supported under title III or 

20 chapter 2 of subtitle A of title VII of 

21 the Older Americans Act of 1965) and 

22 the protection and advocacy system 

23 (as defined in section 102 of the De24 velopmental Disabilities Assistance 

25 and Bill of Rights Act of 2000); and 


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1 ‘‘(IV) the nursing facility that is 

2 granted the waiver by a State notifies 

3 residents of the facility (or, where ap4 propriate, the guardians or legal rep5 resentatives of such residents) and 

6 members of their immediate families 

7 of the waiver. 

8 ‘‘(ii) ANNUAL REVIEW.—A waiver 

9 under this subparagraph shall be subject to 

10 annual review by the State agency and to 

11 the review of the Secretary and subject to 

12 clause (iii) shall be accepted by the Sec13 retary for purposes of this title to the same 

14 extent as is the State’s certification of the 

15 facility. In granting or renewing a waiver, 

16 a State may require the facility to use 

17 other qualified, licensed personnel to meet 

18 the staffing requirements under subpara19 graph (A)(iii). 

20 ‘‘(iii) ASSUMPTION OF WAIVER AU21 THORITY BY SECRETARY.—If the Secretary 

22 determines that a State has shown a clear 

23 pattern and practice of allowing waivers in 

24 the absence of diligent efforts by facilities 

25 to meet the staffing requirements under 


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•S 2694 IS

1 subparagraph (A)(iii), the Secretary shall 

2 assume and exercise the authority of the 

3 State to grant waivers.’’. 

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

5 this section shall take effect on October 1, 2022. 

6 SEC. 206. ENHANCED FUNDING TO SUPPORT STAFFING 

7 AND QUALITY CARE IN NURSING FACILITIES. 

8 (a) FMAP INCREASE.— 

9 (1) IN GENERAL.—Notwithstanding subsection 

10 (b) or (ff) of section 1905 of the Social Security Act 

11 (42 U.S.C. 1396d), in the case of a State that meets 

12 the requirements described in subsection (c), the 

13 Federal medical assistance percentage determined 

14 for the State under subsection (b) of section 1905 

15 of such Act (or subsection (ff) of such section, if ap16 plicable) and, if applicable, as increased under sub17 section (y), (z), (aa), or (ii) of such section or sec18 tion 6008 of the Families First Coronavirus Re19 sponse Act (Public Law 116–127), or any other pro20 vision of law, shall be increased by the applicable 

21 number of percentage points specified in paragraph 

22 (2) (but not to exceed 95 percent) with respect to 

23 amounts expended by the State Medicaid program 

24 for medical assistance for nursing facility services 

25 provided for each calendar quarter that occurs durVerDate Sep 11 2014 23:31 Aug 13, 2021 Jkt 019200 PO 00000 Frm 00037 Fmt 6652 Sfmt 6201 E:\BILLS\S2694.IS S2694

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1 ing the applicable period and for which the Secretary 

2 determines that the State meets such requirements. 

3 Any payment made to Puerto Rico, the Virgin Is4 lands, Guam, the Northern Mariana Islands, or 

5 American Samoa for expenditures on medical assist6 ance that are subject to the Federal medical assist7 ance percentage increase specified under the first 

8 sentence of this paragraph shall not be taken into 

9 account for purposes of applying payment limits 

10 under subsections (f) and (g) of section 1108 of the 

11 Social Security Act (42 U.S.C. 1308). 

12 (2) APPLICABLE NUMBER OF PERCENTAGE

13 POINTS.—For purposes of paragraph (1), the appli14 cable number of percentage points specified in this 

15 paragraph is— 

16 (A) in the case of a calendar quarter that 

17 occurs within the 16-quarter period that begins 

18 on the 1st day of the applicable period, 3 per19 centage points; 

20 (B) in the case of a calendar quarter that 

21 occurs within the 4-quarter period immediately 

22 succeeding such 16-quarter period, 2 percentage 

23 points; and 

24 (C) in the case of a calendar quarter that 

25 occurs within the 4-quarter period immediately 


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1 succeeding the 4-quarter period described in 

2 subparagraph (B), 1 percentage point. 

3 (b) DEFINITIONS.—In this section: 

4 (1) APPLICABLE PERIOD.—The term ‘‘applica5 ble period’’ means the period that— 

6 (A) begins on the 1st day of the 1st cal7 endar quarter that begins on or after the date 

8 that is 1 year after the date of enactment of 

9 this section; and 

10 (B) ends on the last day of the succeeding 

11 24th calendar quarter. 

12 (2) NURSING FACILITY STAFF.—The term 

13 ‘‘nursing facility staff’’ includes a registered nurse, 

14 licensed practical nurse, licensed nursing assistant, 

15 certified nursing assistant, nursing assistant, and 

16 any other relevant staff, as determined by the Sec17 retary, who provide care to Medicaid beneficiaries 

18 who are residents in a nursing facility. 

19 (3) MEDICAID BENEFICIARY.—The term ‘‘Med20 icaid beneficiary’’ means an individual who is eligible 

21 for, and enrolled in, a State Medicaid program. 

22 (4) MEDICAID PROGRAM.—The term ‘‘Medicaid 

23 program’’ means, with respect to a State, the State 

24 program under title XIX of the Social Security Act 

25 (42 U.S.C. 1396 et seq.) (including any waiver or 


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1 demonstration under such title or under section 

2 1115 of such Act (42 U.S.C. 1315) relating to such 

3 title). 

4 (5) NURSING FACILITY.—The term ‘‘nursing 

5 facility’’— 

6 (A) has the meaning given such term in 

7 section 1919(a) of the Social Security Act (42 

8 U.S.C. 1396r(a)); and 

9 (B) includes a skilled nursing facility, as 

10 defined in section 1819(a) of the Social Secu11 rity Act (42 U.S.C. 1395i–3(a)), that is a par12 ticipating provider in the Medicaid program of 

13 the State in which the facility is located or oth14 erwise furnishes items or services for which 

15 medical assistance is available under the Med16 icaid program of the State in which the facility 

17 is located. 

18 (6) NURSING FACILITY SERVICES.— 

19 (A) IN GENERAL.—Subject to subpara20 graphs (B) and (C), the term ‘‘nursing facility 

21 services’’ has the meaning given such term 

22 under section 1905(f) of the Social Security Act 

23 (42 U.S.C. 1396d(f)). 

24 (B) STATE MEDICAID PROGRAM.—With re25 spect to a State, such term includes those servVerDate Sep 11 2014 23:31 Aug 13, 2021 Jkt 019200 PO 00000 Frm 00040 Fmt 6652 Sfmt 6201 E:\BILLS\S2694.IS S2694

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1 ices (including any limitations on the provision 

2 of, or payment for, such services) that are spec3 ified as nursing facility services for purposes of 

4 the Medicaid program of the State in which the 

5 nursing facility furnishing such services is lo6 cated. 

7 (C) INDIVIDUAL PLAN OF CARE.—Notwith8 standing subparagraph (A) or (B), such term 

9 includes items or services that are specified in 

10 the individual plan of care for a resident of a 

11 nursing facility and are furnished to the resi12 dent in accordance with the requirements of 

13 such plan. 

14 (7) SECRETARY.—The term ‘‘Secretary’’ means 

15 the Secretary of Health and Human Services. 

16 (8) STATE.—The term ‘‘State’’ has the mean17 ing given such term for purposes of title XIX of the 

18 Social Security Act (42 U.S.C. 1396 et seq.). 

19 (c) REQUIREMENTS.—As a condition for receipt of 

20 the increase under subsection (a) to the Federal medical 

21 assistance percentage determined for a State under sub22 section (b) of section 1905 of the Social Security Act (42 

23 U.S.C. 1396d) for a calendar quarter, the State shall dem24 onstrate to the satisfaction of the Secretary the following: 


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1 (1) USE OF ADDITIONAL FEDERAL FUNDS.— 

2 The State agrees to— 

3 (A) use the Federal funds attributable to 

4 the increase under subsection (a) only for the 

5 purposes specified in subsection (d); and 

6 (B) not use such Federal funds to satisfy 

7 any State contribution required under the State 

8 Medicaid program. 

9 (2) PLAN FOR STAFFING AND SERVICE IM10 PROVEMENTS AND REPORTING.—The State has a 

11 reasonable plan for achieving the purposes specified 

12 in subsection (d), including with respect to— 

13 (A) carrying out the staffing and service 

14 improvements specified in subsection (e) to 

15 strengthen nursing facility staff workforce and 

16 improve the quality and safety of care for Med17 icaid beneficiaries; and 

18 (B) collecting and reporting the informa19 tion required under subsection (f). 

20 (3) SUPPLEMENT, NOT SUPPLANT.—The State 

21 agrees to use the Federal funds attributable to the 

22 increase under subsection (a) to supplement, and not 

23 supplant, the level of State funds expended as of Oc24 tober 1, 2021, for nursing facility services, including 

25 with respect to efforts to strengthen the nursing faVerDate Sep 11 2014 23:31 Aug 13, 2021 Jkt 019200 PO 00000 Frm 00042 Fmt 6652 Sfmt 6201 E:\BILLS\S2694.IS S2694

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1 cility staff workforce and improve the quality and 

2 safety of care for Medicaid beneficiaries, under the 

3 State Medicaid program. 

4 (4) REPORTING AND OVERSIGHT.—The State 

5 agrees to— 

6 (A) annually report the information speci7 fied in subsection (f) to the Secretary in such 

8 form and manner as the Secretary shall require; 

9 and 

10 (B) provide such data and information as 

11 is necessary for the evaluation required under 

12 subsection (g). 

13 (d) USE OF FUNDS.—A State may use the Federal 

14 funds attributable to the increase under subsection (a) 

15 only for expenditures eligible for payment under the State 

16 Medicaid program that are attributable to State efforts 

17 to achieve both of the following purposes: 

18 (1) To expand and improve nursing facility 

19 staffing, including by increasing payments for nurs20 ing facility services to improve staff wages and bene21 fits, support retention and recruitment, and reduce 

22 staff turnover, consistent with the improvements 

23 specified in paragraphs (1) and (2) of subsection (e). 

24 (2) To support and improve the quality and 

25 safety of care provided to Medicaid beneficiaries in 


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1 nursing facilities, including through efforts to ex2 pand the use of person-centered models of care, and 

3 incentives or payments related to the provision of 

4 care for Medicaid beneficiaries in private rooms. 

5 (e) STAFFING AND SERVICE IMPROVEMENTS.—The 

6 staffing and service improvements specified in this sub7 section are the following: 

8 (1) The State makes such changes to processes 

9 for determining payment rates for nursing facility 

10 services as are necessary to ensure that— 

11 (A) such payment rates are reviewed and 

12 updated every 2 years during the applicable pe13 riod to support the recruitment and retention of 

14 nursing facility staff, and reduce turnover in 

15 such staff through a transparent process that 

16 involves meaningful input from stakeholders; 

17 and 

18 (B) increases to such payment rates are, at 

19 a minimum, used to proportionally increase 

20 wages and benefits for nursing facility staff. 

21 (2) The State updates, develops, and adopts 

22 training opportunities and resources for nursing fa23 cility staff, including training for providing person24 centered care. 


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•S 2694 IS

1 (3) The State improves and streamlines edu2 cation and options counseling services for Medicaid 

3 beneficiaries, potential Medicaid beneficiaries, and 

4 family members of such beneficiaries and potential 

5 beneficiaries, with respect to eligibility and options 

6 for institutional and non-institutional long term 

7 care. 

8 (f) ANNUALLY REPORTED INFORMATION.—The in9 formation required to be annually reported to the Sec10 retary by a State with respect to such reporting periods 

11 as the Secretary shall specify is the following: 

12 (1) The number of Medicaid beneficiaries who 

13 received during the reporting period or, as of the 

14 date of the report, are receiving, nursing facility 

15 services in the State, disaggregated by race, eth16 nicity, gender, geography, age, and income. 

17 (2) A description of how the State spent the 

18 Federal funds attributable to the increase under 

19 subsection (a) during the reporting period. 

20 (3) Changes to payment rates for nursing facil21 ity services under the State Medicaid program dur22 ing the reporting period. 

23 (4) The staffing information and employee 

24 turnover and tenure information in nursing facilities 

25 in the State during the reporting period, based on 


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1 submissions to the Payroll-Based Journal system of 

2 the Centers for Medicare & Medicaid Services under 

3 section 1128I(g) of the Social Security Act (42 

4 U.S.C. 1320a–7j(g)). 

5 (5) The wages and benefits provided to nursing 

6 facility staff in nursing facilities in the State during 

7 the reporting period. 

8 (6) A description of the health status of, and 

9 quality of care provided to, Medicaid beneficiaries 

10 who are residents of nursing facilities in the State 

11 during the reporting period, in the manner deter12 mined by the Secretary. 

13 (g) EVALUATION.—The Secretary shall engage an ex14 ternal contractor to conduct an independent evaluation of 

15 the impact of this section on— 

16 (1) the quality and safety of care provided in 

17 nursing facilities to Medicaid beneficiaries who are 

18 residents of nursing facilities; 

19 (2) the capacity of the nursing facility staff 

20 workforce to provide quality, safe care for Medicaid 

21 beneficiaries who are residents of nursing facilities; 

22 and 

23 (3) the wages, benefits, and turnover of nursing 

24 facility staff. 

25 (h) INTERIM AND FINAL REPORTS TO CONGRESS.— 


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1 (1) IN GENERAL.—The Secretary shall submit 

2 an interim report to Congress on the implementation 

3 of this section 4 years after the date of enactment 

4 of this section, and a final report on the implemen5 tation of this section 8 years after such date. 

6 (2) REQUIRED INFORMATION.— 

7 (A) INTERIM AND FINAL REPORTS.—The 

8 interim and final reports submitted under this 

9 subsection shall include the following informa10 tion: 

11 (i) The number of States that received 

12 an increase to the Federal medical assist13 ance percentage of the State under sub14 section (a) during the applicable period. 

15 (ii) The State activities funded by the 

16 Federal funds attributable to the increase 

17 under subsection (a). 

18 (B) FINAL REPORT.—The final report sub19 mitted under this section shall include, in addi20 tion to the information required under subpara21 graph (A), the results of the independent eval22 uation conducted pursuant to subsection (g). 


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1 TITLE III—BUILDING MODIFICA2 TION AND STAFF INVEST3 MENT DEMONSTRATION PRO4 GRAM 

5 SEC. 301. ESTABLISHING A SKILLED NURSING FACILITY 

6 BUILDING MODIFICATION AND STAFF IN7 VESTMENT DEMONSTRATION PROGRAM. 

8 Part A of title XVIII of the Social Security Act (42 

9 U.S.C. 1395c et seq.) is amended by inserting after sec10 tion 1819 the following new section: 

11 ‘‘SEC. 1819A. COMMUNITY-BASED LIVING MODIFICATIONS 

12 AND STAFF INVESTMENT DEMONSTRATION 

13 PROGRAM. 

14 ‘‘(a) ESTABLISHMENT.—Not later than January 1, 

15 2023, the Secretary shall establish a demonstration pro16 gram to test the impact of providing skilled nursing facili17 ties (as defined in section 1819(a)) selected by the Sec18 retary under subsection (b) funding to modify the built 

19 environments of such facilities (or portions of such facili20 ties) and invest in individuals providing resident care in 

21 such facilities (or in portions of such facilities) in order 

22 to, with respect to residents of such facilities, improve 

23 health outcomes relative to residents of facilities not so 

24 selected. 


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1 ‘‘(b) APPLICATION AND SELECTION OF FACILI2 TIES.— 

3 ‘‘(1) APPLICATION.— 

4 ‘‘(A) IN GENERAL.—A skilled nursing fa5 cility shall only be eligible to receive funding 

6 under the demonstration program established 

7 under subsection (a) if such facility submits an 

8 application at such time and in such manner as 

9 specified by the Secretary that contains— 

10 ‘‘(i) a description of modifications and 

11 investments described in subsection (a) 

12 that will be made by the facility using such 

13 funds, including the estimated costs of 

14 such modifications and investments; 

15 ‘‘(ii) an agreement that such facility 

16 (or, in the case such modifications and in17 vestments are to be made only with respect 

18 to a portion of such facility, such portion 

19 of such facility)— 

20 ‘‘(I) will meet the requirements 

21 described in subparagraph (B) not 

22 later than the date that is 2 years 

23 after such facility first receives funds 

24 for such modifications and invest25 ments under such program; and 


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1 ‘‘(II) will continue to meet such 

2 requirements for the 5-year period be3 ginning on the date that is 2 years 

4 after such facilities first receives such 

5 funds; 

6 ‘‘(iii) an agreement that, in the case 

7 such facility (or such portion of such facil8 ity, as applicable) fails to meet such re9 quirements in accordance with clause (ii), 

10 such facility will— 

11 ‘‘(I) repay such funds to the Sec12 retary in an amount determined ap13 propriate by the Secretary under sub14 section (d); and 

15 ‘‘(II) notify each resident of such 

16 facility (or each resident of such por17 tion of such facility, as applicable) of 

18 the failure of such facility or such 

19 portion, as applicable, to meet such 

20 requirements; 

21 ‘‘(iv) an agreement that, if such facil22 ity is selected by the Secretary under para23 graph (2), the facility will notify each resi24 dent of such facility (or each resident of 

25 such portion of such facility, as applicable), 


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1 of such selection and include in such notifi2 cation a description of the program estab3 lished under subsection (a), including any 

4 modifications and investments to be made 

5 with respect to such facility (or with re6 spect to such portion of such facility, as 

7 applicable); and 

8 ‘‘(v) in the case such modifications 

9 and investments are to be made only with 

10 respect to a portion of such facility, an 

11 agreement that such facility will not dis12 criminate in the selection of residents who 

13 may reside in such portion based on 

14 whether payment is being made to such fa15 cility with respect to such resident under 

16 this title, a State plan (or waiver of such 

17 plan) under title XIX, or otherwise. 

18 ‘‘(B) REQUIREMENTS.—For purposes of 

19 subparagraph (A), the requirements described 

20 in this subparagraph with respect to a skilled 

21 nursing facility (or a portion of such facility) 

22 are the following: 

23 ‘‘(i) The facility (or portion) main24 tains beds for no less than 5 and no more 

25 than 14 residents. 


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1 ‘‘(ii) The facility (or portion) incor2 porates universal design (defined in section 

3 3(19) of the Assistive Technology Act of 

4 1998)) to ensure such facility (or portion) 

5 is accessible to all residents, regardless of 

6 age or disability, including by providing for 

7 the following: 

8 ‘‘(I) Private rooms and bath9 rooms (unless such facility determines 

10 that the provision of private rooms 

11 and bathrooms at such facility would 

12 adversely affect the availability of 

13 skilled nursing facility services in the 

14 area in which such facility is located 

15 and the Secretary concurs with such 

16 determination). 

17 ‘‘(II) Shared space, including a 

18 central living area, as defined by the 

19 Secretary, with a communal dining 

20 table and accessible kitchen. 

21 ‘‘(III) Accessible outdoor space, 

22 including a protected garden space for 

23 use by residents and their visitors. 

24 ‘‘(iii) The facility (or portion) provides 

25 a clinical team that consists of a full-time 


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1 registered professional nurse or licensed 

2 practical nurse (or licensed vocational 

3 nurse) who works in partnership with cer4 tified nursing assistants in a team-based, 

5 collaborative model. 

6 ‘‘(iv) The facility (or portion) has a li7 censed practical nurse (or licensed voca8 tional nurse) on site at all times. 

9 ‘‘(v) The facility (or portion) facili10 tates a standing resident council run by 

11 residents, and a standing family council 

12 run by family members of residents, that 

13 meets such requirements as may be speci14 fied by the Secretary. 

15 ‘‘(vi) The facility (or portion) solicits 

16 resident input on facility policies (or poli17 cies relating to such portion of such facil18 ity), including with respect to programs 

19 and scheduling, and, in the case of an in20 capacitated resident, solicits such input 

21 from an individual recognized by State law 

22 to act on behalf of such resident. 

23 ‘‘(vii) In addition to the resident as24 sessment under section 1819(b)(3), the fa25 cility (or portion) conducts an assessment 


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1 of residents’ care preferences (or, in the 

2 case of an incapacitated resident, such 

3 preferences as expressed by an individual 

4 recognized by State law to act on behalf of 

5 such resident) not later than 14 days after 

6 the resident is admitted to such facility or 

7 portion of such facility (or, in the case of 

8 a resident residing at such facility at the 

9 time such facility receives funding under 

10 the program established under paragraph 

11 (1), not later than 14 days after the date 

12 of such receipt) to ensure care is person13 directed. 

14 ‘‘(viii) The facility (or portion) offers 

15 daily activities, such as art, music, edu16 cational activities, or other activities based 

17 on resident preferences. 

18 ‘‘(C) TIMEFRAME.—The Secretary shall 

19 develop the application described in subpara20 graph (A) and begin accepting such applica21 tions not later than July 1, 2023. The Sec22 retary shall accept such applications during the 

23 2-year period beginning on the date such appli24 cations are first accepted. 

25 ‘‘(2) SELECTION.— 


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1 ‘‘(A) IN GENERAL.—Not later than 2 years 

2 after the date the Secretary first accepts appli3 cations under paragraph (1), the Secretary 

4 shall select a number of skilled nursing facilities 

5 determined appropriate by the Secretary to re6 ceive funding under the program established 

7 under subsection (a). 

8 ‘‘(B) PREFERENCE.—In selecting skilled 

9 nursing facilities under this paragraph, the Sec10 retary shall— 

11 ‘‘(i) give preference to facilities that— 

12 ‘‘(I) are located in medically un13 derserved areas (as defined in section 

14 330(b)(3)(A) of the Public Health 

15 Service Act); and 

16 ‘‘(II) house a majority of resi17 dents who are receiving medical as18 sistance consisting of nursing facility 

19 services under a State plan (or waiver 

20 of such plan) under title XIX; 

21 ‘‘(ii) give preference to facilities that 

22 demonstrate the greatest likelihood of 

23 meeting the requirements described in 

24 paragraph (1)(B) within 2 years of receivVerDate Sep 11 2014 23:31 Aug 13, 2021 Jkt 019200 PO 00000 Frm 00055 Fmt 6652 Sfmt 6201 E:\BILLS\S2694.IS S2694

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1 ing funding under the program established 

2 under subsection (a); 

3 ‘‘(iii) give preference to facilities that 

4 offer staff training beyond such training 

5 required under section 1819 (as deter6 mined through payroll based journal data); 

7 and 

8 ‘‘(iv) so select such facilities in a man9 ner that ensures geographic diversity, to 

10 the extent practicable. 

11 ‘‘(c) FUNDS.— 

12 ‘‘(1) IN GENERAL.—Subject to paragraph (3) 

13 and subsection (h), the Secretary shall provide funds 

14 to each skilled nursing facility selected under sub15 section (b)(2) in an amount equal to not more than 

16 the costs specified by such facility pursuant to sub17 section (b)(1)(A)(i). 

18 ‘‘(2) USE OF FUNDS.— 

19 ‘‘(A) IN GENERAL.—Subject to subpara20 graph (B), funds provided under paragraph (1) 

21 may only be used by a skilled nursing facility 

22 for modifications and investments specified by 

23 such facility pursuant to subsection 

24 (b)(1)(A)(i). 


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1 ‘‘(B) EXCEPTION.—A skilled nursing facil2 ity may use funds provided under paragraph 

3 (1) for modifications and investments described 

4 in subsection (a) but not specified by such facil5 ity pursuant to subsection (b)(1)(A)(i) if— 

6 ‘‘(i) such facility submits a request to 

7 the Secretary containing a description of 

8 such modifications and investments; and 

9 ‘‘(ii) the Secretary determines that 

10 such modifications and investments will as11 sist such facility (or a portion of such facil12 ity, as applicable) in complying with the 

13 requirements specified in subsection 

14 (b)(1)(B). 

15 ‘‘(3) FORM OF PROVISION OF FUNDS.—The 

16 Secretary may provide funding under paragraph (1) 

17 in the form of a single upfront payment or in up to 

18 3 installment payments, spaced out across the first 

19 3 fiscal years beginning with the fiscal year in which 

20 the first such payment is made. 

21 ‘‘(4) LIMITATION OF PROVISION OF FUND22 ING.—No skilled nursing facility may receive more 

23 than 3 percent of the total monies appropriated 

24 under paragraph (5). 


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1 ‘‘(5) APPROPRIATION.—In addition to any 

2 amounts otherwise available, there is appropriated to 

3 the Secretary, out of any monies in the Treasury not 

4 otherwise appropriated, $1,300,000,000, to remain 

5 available until expended, for purposes of providing 

6 funds to skilled nursing facilities under paragraph 

7 (1). 

8 ‘‘(d) FAILURE TO MEET REQUIREMENTS.— 

9 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

10 in the case of a facility (or a portion of such facility, 

11 as applicable) that fails to meet the requirements de12 scribed in subsection (b)(1)(B) in accordance with 

13 the agreement described in subsection (b)(1)(A)(ii), 

14 the Secretary may recoup any funds provided to 

15 such facility under subsection (c)(1) in an amount 

16 determined appropriate by the Secretary. In deter17 mining such amount, the Secretary shall take into 

18 account the extent of the compliance of such facility 

19 (or portion of such facility, as applicable) with such 

20 requirements. 

21 ‘‘(2) EXCEPTION.—The Secretary may suspend 

22 any recoupment described in paragraph (1) with re23 spect to a facility (or a portion of such facility, as 

24 applicable) described in such paragraph for a period 

25 of time determined appropriate by the Secretary if 


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1 the Secretary finds that such facility (or such por2 tion) will likely be in compliance with the require3 ments described in such paragraph within a reason4 able time specified by the Secretary. 

5 ‘‘(e) EVALUATION OF PROGRAM.— 

6 ‘‘(1) IN GENERAL.—The Secretary shall evalu7 ate each skilled nursing facility receiving funds 

8 under the program established under subsection (a) 

9 to assess whether, relative to similarly situated 

10 skilled nursing facilities not receiving funds under 

11 such program and residents of such facilities, modi12 fications and investments described in subsection (a) 

13 made at skilled nursing facilities using such funds 

14 resulted in, with respect to residents of such facili15 ties (or, in the case such modifications and invest16 ments are made only with respect to a portion of 

17 such facility, residents of such portion of such facil18 ity)— 

19 ‘‘(A) a reduction in preventable hos20 pitalizations; 

21 ‘‘(B) a reduction in hospital readmissions; 

22 ‘‘(C) a reduction in emergency room visits; 

23 ‘‘(D) greater improvement in functional 

24 status; 

25 ‘‘(E) an improvement in infection control; 


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1 ‘‘(F) a reduction in nursing staff turnover 

2 rates; 

3 ‘‘(G) an increase in resident and family 

4 caregiver satisfaction; 

5 ‘‘(H) other improvements in resident qual6 ity of life as may be specified by the Secretary; 

7 ‘‘(I) a reduction in expenditures under this 

8 part (excluding funds provided under subsection 

9 (c)(1)); or 

10 ‘‘(J) any other outcomes specified by the 

11 Secretary. 

12 ‘‘(2) REPORTS TO CONGRESS.—Based on eval13 uations described in paragraph (1), the Secretary 

14 shall, not later than July 1, 2031, and again not 

15 later than July 1, 2035, submit to Congress a report 

16 on such program. Each such report shall include an 

17 analysis of the demonstration program’s effect on 

18 the outcomes described in paragraph (1). 

19 ‘‘(f) IMPLEMENTATION.—Chapter 35 of title 44, 

20 United States Code, shall not apply to this section. 

21 ‘‘(g) AUTHORITY TO EXPAND TO CERTAIN NURSING

22 FACILITIES.—The Secretary may, subject to subsection 

23 (h), enter into agreements with States to include nursing 

24 facilities (as defined in section 1919(a)) that are not 

25 skilled nursing facilities (as defined in section 1819(a)) 


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1 in the demonstration program established under sub2 section (a) and may modify the requirements of the pre3 vious provisions of this section as appropriate to be appli4 cable to such facilities. 

5 ‘‘(h) FUNDING.—The Secretary shall provide for the 

6 transfer, from the Federal Hospital Insurance Trust Fund 

7 under 1817 to the Centers for Medicare & Medicaid Serv8 ices Program Management Account, of $30,000,000 for 

9 fiscal year 2023 for purposes of carrying out this section 

10 (other than for purposes of making payments under sub11 section (c)(1)). Amounts transferred pursuant to the pre12 vious sentence shall remain available until expended.’’. 

Æ 


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