II 

117TH CONGRESS 

1ST SESSION S. 315 

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

care for residents of skilled nursing facilities and nursing facilities, and 

for other purposes. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 12, 2021 

Mr. BLUMENTHAL (for himself and Mr. BOOKER) 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 ensure quality care for residents of skilled nursing 

facilities and nursing facilities, 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. 

4 This Act may be cited as the ‘‘Quality Care for Nurs5 ing Home Residents Act’’. 


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1 SEC. 2. MINIMUM NURSE STAFFING REQUIREMENTS FOR 

2 SKILLED NURSING FACILITIES UNDER MEDI3 CARE PROGRAM AND NURSING FACILITIES 

4 UNDER MEDICAID PROGRAM. 

5 (a) MEDICARE.— 

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

7 1819(b)(4) of the Social Security Act (42 U.S.C. 

8 1395i–3(b)(4)) is amended— 

9 (A) in clause (i)— 

10 (i) by amending the clause heading to 

11 read as follows: ‘‘GENERAL REQUIRE12 MENTS BEFORE 2022’’; and 

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

14 clause (ii),’’ and inserting ‘‘Except as pro15 vided in clause (iii), with respect to skilled 

16 nursing facility services provided before 

17 January 1, 2022,’’; 

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

19 (iii); and 

20 (C) by inserting after clause (i) the fol21 lowing new clause: 

22 ‘‘(ii) GENERAL REQUIREMENTS AFTER

23 2021.— 

24 ‘‘(I) IN GENERAL.—With respect 

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1 vided on or after January 1, 2022, a 

2 skilled nursing facility must— 

3 ‘‘(aa) provide nursing serv4 ices that are sufficient to meet 

5 the nursing needs of its residents 

6 on a 24-hour basis, to be divided 

7 into day shifts, evening shifts, 

8 and night shifts; 

9 ‘‘(bb) provide for minimum 

10 nurse staffing levels with respect 

11 to each such shift, in accordance 

12 with this clause; and 

13 ‘‘(cc) ensure that, in car14 rying out items (aa) and (bb), a 

15 total minimum of 4.1 hours of 

16 care is provided per resident per 

17 day, with 0.75 hours of care of 

18 such total minimum provided by 

19 a registered professional nurse, 

20 0.54 hours of care of such total 

21 minimum provided by a licensed 

22 practical nurse, and 2.81 hours 

23 of care of such total minimum 

24 provided by a nurse aide (as de25 fined in paragraph (5)(F)). 


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1 ‘‘(II) DAY SHIFTS.—With respect 

2 to a day shift, the skilled nursing fa3 cility must have— 

4 ‘‘(aa) at least 1 registered 

5 professional nurse for every 28 

6 residents, with a minimum of 

7 0.29 hours of care provided per 

8 resident during each such shift; 

9 ‘‘(bb) at least 1 licensed 

10 practical nurse for every 40 resi11 dents, with a minimum of 0.20 

12 hours of care provided per resi13 dent during each such shift; and 

14 ‘‘(cc) at least 1 nurse aide 

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

16 for every 7 residents, with a min17 imum of 1.14 hours of care pro18 vided per resident during each 

19 such shift. 

20 ‘‘(III) EVENING SHIFTS.—With 

21 respect to an evening shift, the skilled 

22 nursing facility must have— 

23 ‘‘(aa) at least 1 registered 

24 professional nurse for every 30 

25 residents, with a minimum of 


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1 0.26 hours of care provided per 

2 resident during each such shift; 

3 ‘‘(bb) at least 1 licensed 

4 practical nurse for every 40 resi5 dents, with a minimum of 0.20 

6 hours of care provided per resi7 dent during each such shift; and 

8 ‘‘(cc) at least 1 nurse aide 

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

10 for every 7 residents, with a min11 imum of 1.14 hours of care pro12 vided per resident during each 

13 such shift. 

14 ‘‘(IV) NIGHT SHIFTS.—With re15 spect to a night shift, the skilled nurs16 ing facility must have— 

17 ‘‘(aa) at least 1 registered 

18 professional nurse for every 40 

19 residents, with a minimum of 

20 0.20 hours of care provided per 

21 resident during such shift; 

22 ‘‘(bb) at least 1 licensed 

23 practical nurse for every 56 resi24 dents, with a minimum of 0.14 


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

3 ‘‘(cc) at least 1 nurse aide 

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

5 for every 15 residents, with a 

6 minimum of 0.53 hours of care 

7 provided per resident during such 

8 shift. 

9 ‘‘(V) SECRETARIAL AUTHORITY

10 TO ESTABLISH HIGHER MINIMUM

11 NURSE STAFFING LEVELS.—The Sec12 retary may establish and require 

13 skilled nursing facilities (or, at the 

14 Secretary’s discretion, only skilled 

15 nursing facilities that have a higher 

16 percentage of residents with extensive 

17 care needs, as determined by the Sec18 retary) to provide for minimum nurse 

19 staffing levels that are higher than 

20 the levels required under this clause. 

21 ‘‘(VI) RULE OF CONSTRUCTION

22 REGARDING STATE AUTHORITY TO ES23 TABLISH HIGHER MINIMUM NURSE

24 STAFFING LEVELS.—Nothing in this 

25 clause may be construed as preventing 


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1 a State from establishing or requiring 

2 skilled nursing facilities in the State 

3 to provide for minimum nurse staffing 

4 levels that are higher than the levels 

5 required under this clause. 

6 ‘‘(VII) CLARIFICATION WITH RE7 SPECT TO MINIMUM HOURS OF CARE

8 PROVIDED PER RESIDENT REQUIRE9 MENTS.—In complying with the min10 imum hours of care provided per resi11 dent requirements under this clause, a 

12 skilled nursing facility may not count 

13 any time spent by a registered profes14 sional nurse, licensed practical nurse, 

15 or nurse aide on administrative serv16 ices towards compliance with such re17 quirements. 

18 ‘‘(VIII) DEFINITIONS.—In this 

19 clause: 

20 ‘‘(aa) ADMINISTRATIVE

21 SERVICES.—The term ‘adminis22 trative services’ means food prep23 aration, housekeeping, laundry 

24 services, maintenance services, 

25 and other noncaregiving-related 


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1 services, as determined by the 

2 Secretary. 

3 ‘‘(bb) DAY SHIFT.—The 

4 term ‘day shift’ means, with re5 spect to a day and a skilled nurs6 ing facility, an assigned work 

7 shift that is a period of 8 con8 secutive hours, beginning not 

9 sooner than 6 a.m. in the time 

10 zone in which such facility is lo11 cated and not later than 8 a.m. 

12 in such time zone. 

13 ‘‘(cc) EVENING SHIFT.—The 

14 term ‘evening shift’ means, with 

15 respect to a day and a skilled 

16 nursing facility, an assigned work 

17 shift that is a period of 8 con18 secutive hours, beginning not 

19 sooner than 2 p.m. in the time 

20 zone in which such facility is lo21 cated and not later than 4 p.m. 

22 in such time zone. 

23 ‘‘(dd) NIGHT SHIFT.—The 

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1 ing facility, an assigned work 

2 shift that is a period of 8 con3 secutive hours, beginning not 

4 sooner than 10 p.m. in the time 

5 zone in which such facility is lo6 cated and not later than mid7 night in such time zone.’’. 

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

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

10 amended— 

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

12 State finds, on the basis of a standard’’ and in13 serting ‘‘Subject to paragraph (7), if a State 

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

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

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

17 (7), with respect to’’; and 

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

19 paragraph: 

20 ‘‘(7) SPECIAL ENFORCEMENT PROCESS WITH

21 RESPECT TO MINIMUM NURSE STAFFING REQUIRE22 MENTS.— 

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

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1 wise, that a skilled nursing facility does not 

2 meet the minimum staffing requirements of 

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

4 to skilled nursing facility services provided on 

5 or after January 1, 2022, the State shall rec6 ommend to the Secretary that the Secretary 

7 take such actions as described in subclauses (I) 

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

9 ‘‘(B) SECRETARIAL AUTHORITY.— 

10 ‘‘(i) IN GENERAL.—With respect to 

11 any skilled nursing facility in a State, if 

12 the Secretary finds, or pursuant to a rec13 ommendation of the State under subpara14 graph (A) finds, that a skilled nursing fa15 cility does not meet the minimum staffing 

16 requirements of clause (ii) of subsection 

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

18 facility services provided on or after Janu19 ary 1, 2022, the Secretary shall— 

20 ‘‘(I) deny any further payments 

21 under this title with respect to all in22 dividuals entitled to benefits under 

23 this title who are admitted to the fa24 cility after the effective date of the 

25 finding; and 


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1 ‘‘(II) impose a civil money pen2 alty in an amount not to exceed 

3 $10,000 for each day of noncompli4 ance. The provisions of section 1128A 

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

6 shall apply to a civil money penalty 

7 under the previous sentence in the 

8 same manner as such provisions apply 

9 to a penalty or proceeding under sec10 tion 1128A(a). 

11 ‘‘(ii) REDUCTION OF CIVIL MONEY

12 PENALTIES IN CERTAIN CIR13 CUMSTANCES.—Subject to clause (iii), in 

14 the case where a skilled nursing facility 

15 self-reports and promptly corrects a defi16 ciency for which a penalty was imposed 

17 under clause (i)(II) not later than 10 cal18 endar days after the date of such imposi19 tion, the Secretary may reduce the amount 

20 of the penalty imposed by— 

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

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

23 was penalized under this subsection 

24 within the three-year period preceding 


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1 the date of such imposition, not more 

2 than 25 percent. 

3 ‘‘(iii) PROHIBITIONS ON REDUCTION

4 FOR CERTAIN DEFICIENCIES.— 

5 ‘‘(I) REPEAT DEFICIENCIES.— 

6 The Secretary may not reduce the 

7 amount of a penalty under clause (ii) 

8 if the Secretary had reduced a penalty 

9 imposed on the skilled nursing facility 

10 in the preceding year under such 

11 clause with respect to a repeat defi12 ciency. 

13 ‘‘(II) CERTAIN OTHER DEFI14 CIENCIES.—The Secretary may not 

15 reduce the amount of a penalty under 

16 clause (ii) if the penalty is imposed on 

17 the skilled nursing facility for a defi18 ciency that is found to result in a pat19 tern of harm or widespread harm, im20 mediately jeopardizes the health or 

21 safety of a resident or residents of the 

22 facility, or results in the death of a 

23 resident of the facility. 

24 ‘‘(iv) REPEATED NONCOMPLIANCE.— 

25 In the case of a skilled nursing facility 


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1 which, on three consecutive standard sur2 veys conducted under subsection (g)(2), 

3 has been found as not meeting the min4 imum staffing requirements of clause (ii) 

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

6 skilled nursing facility services provided on 

7 or after January 1, 2022, the Secretary 

8 may (regardless of the remedies provided 

9 for under clause (i))— 

10 ‘‘(I) appoint temporary manage11 ment to oversee the operation of the 

12 facility and to assure the health and 

13 safety of the facility’s residents in ac14 cordance with clause (iii) of para15 graph (2)(B), except that ‘the min16 imum staffing requirements of clause 

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

18 substituted for ‘all the requirements 

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

20 such clause; 

21 ‘‘(II) monitor the facility under 

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

23 such minimum staffing requirements 

24 until the facility has demonstrated to 

25 the satisfaction of the Secretary that 


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1 the facility is in compliance, and will 

2 remain in compliance, with such min3 imum staffing requirements; or 

4 ‘‘(III) subject to section 

5 1128I(h), terminate the facility’s par6 ticipation under this title. 

7 If the facility’s participation under this 

8 title is terminated under this clause, the 

9 State shall provide for the safe and orderly 

10 transfer of the residents eligible under this 

11 title, consistent with the requirements of 

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

13 ‘‘(v) PUBLIC NOTICE OF VIOLA14 TIONS.— 

15 ‘‘(I) INTERNET WEBSITE.—The 

16 Secretary shall publish on the internet 

17 website of the Department of Health 

18 and Human Services the names of 

19 skilled nursing facilities that have vio20 lated the minimum staffing require21 ments of clause (ii) of subsection 

22 (b)(4)(C) with respect to skilled nurs23 ing facility services provided on or 

24 after January 1, 2022. 


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1 ‘‘(II) CHANGE OF OWNERSHIP.— 

2 With respect to a skilled nursing facil3 ity whose name is published under 

4 subclause (I) and has a change of 

5 ownership, as determined by the Sec6 retary, after the date of such publica7 tion, the Secretary shall remove the 

8 name of such facility from the website 

9 described under such subclause after 

10 the 1-year period beginning on the 

11 date of such change of ownership.’’. 

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

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

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

15 by striking ‘‘subsection (b)(4)(C)(ii)(II)’’ and insert16 ing ‘‘subsection (b)(4)(C)(iii)(II)’’. 

17 (b) MEDICAID.— 

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

19 1919(b)(4) of the Social Security Act (42 U.S.C. 

20 1396r(b)(4)) is amended— 

21 (A) in clause (i)— 

22 (i) in the clause heading, by inserting 

23 after ‘‘GENERAL REQUIREMENTS’’ the fol24 lowing ‘‘BEFORE 2022’’; 


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1 (ii) in the matter preceding subclause 

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

3 the following: ‘‘and before January 1, 

4 2022,’’; 

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

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

7 and 

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

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

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

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

12 (C) by inserting after clause (i) the fol13 lowing new clause: 

14 ‘‘(ii) GENERAL REQUIREMENTS AFTER

15 2021.— 

16 ‘‘(I) IN GENERAL.—With respect 

17 to nursing facility services provided on 

18 or after January 1, 2022, a nursing 

19 facility must— 

20 ‘‘(aa) provide nursing serv21 ices that are sufficient to meet 

22 the nursing needs of its residents 

23 on a 24-hour basis, to be divided 

24 into day shifts, evening shifts, 

25 and night shifts; 


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1 ‘‘(bb) provide for minimum 

2 nurse staffing levels with respect 

3 to each such shift, in accordance 

4 with this clause; and 

5 ‘‘(cc) ensure that, in car6 rying out items (aa) and (bb), a 

7 total minimum of 4.1 hours of 

8 care is provided per resident per 

9 day, with 0.75 hours of care of 

10 such total minimum provided by 

11 a registered professional nurse, 

12 0.54 hours of care of such total 

13 minimum provided by a licensed 

14 practical nurse, and 2.81 hours 

15 of care of such total minimum 

16 provided by a nurse aide (as de17 fined in paragraph (5)(F)). 

18 ‘‘(II) DAY SHIFTS.—With respect 

19 to a day shift, the nursing facility 

20 must have— 

21 ‘‘(aa) at least 1 registered 

22 professional nurse for every 28 

23 residents, with a minimum of 

24 0.29 hours of care provided per 

25 resident during each such shift; 


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1 ‘‘(bb) at least 1 licensed 

2 practical nurse for every 40 resi3 dents, with a minimum of 0.20 

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

6 ‘‘(cc) at least 1 nurse aide 

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

8 for every 7 residents, with a min9 imum of 1.14 hours of care pro10 vided per resident during each 

11 such shift. 

12 ‘‘(III) EVENING SHIFTS.—With 

13 respect to an evening shift, the nurs14 ing facility must have— 

15 ‘‘(aa) at least 1 registered 

16 professional nurse for every 30 

17 residents, with a minimum of 

18 0.26 hours of care provided per 

19 resident during each such shift; 

20 ‘‘(bb) at least 1 licensed 

21 practical nurse for every 40 resi22 dents, with a minimum of 0.20 

23 hours of care provided per resi24 dent during each such shift; and 


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1 ‘‘(cc) at least 1 nurse aide 

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

3 for every 7 residents, with a min4 imum of 1.14 hours of care pro5 vided per resident during each 

6 such shift. 

7 ‘‘(IV) NIGHT SHIFTS.—With re8 spect to a night shift, the nursing fa9 cility must have— 

10 ‘‘(aa) at least 1 registered 

11 professional nurse for every 40 

12 residents, with a minimum of 

13 0.20 hours of care provided per 

14 resident during such shift; 

15 ‘‘(bb) at least 1 licensed 

16 practical nurse for every 56 resi17 dents, with a minimum of 0.14 

18 hours of care provided per resi19 dent during such shift; and 

20 ‘‘(cc) at least 1 nurse aide 

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

22 for every 15 residents, with a 

23 minimum of 0.53 hours of care 

24 provided per resident during such 

25 shift. 


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1 ‘‘(V) SECRETARIAL AUTHORITY

2 TO ESTABLISH HIGHER MINIMUM

3 NURSE STAFFING LEVELS.—The Sec4 retary may establish and require nurs5 ing facilities (or, at the Secretary’s 

6 discretion, only nursing facilities that 

7 have a higher percentage of residents 

8 with extensive care needs, as deter9 mined by the Secretary) to provide for 

10 minimum nurse staffing levels that 

11 are higher than the levels required 

12 under this clause. 

13 ‘‘(VI) RULE OF CONSTRUCTION

14 REGARDING STATE AUTHORITY TO ES15 TABLISH HIGHER MINIMUM NURSE

16 STAFFING LEVELS.—Nothing in this 

17 clause may be construed as preventing 

18 a State from establishing or requiring 

19 nursing facilities in the State to pro20 vide for minimum nurse staffing levels 

21 that are higher than the levels re22 quired under this clause. 

23 ‘‘(VII) CLARIFICATION WITH RE24 SPECT TO MINIMUM HOURS OF CARE

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1 MENTS.—In complying with the min2 imum hours of care provided per resi3 dent requirements under this clause, a 

4 nursing facility may not count any 

5 time spent by a registered professional 

6 nurse, licensed practical nurse, or 

7 nurse aide on administrative services 

8 towards compliance with such require9 ments. 

10 ‘‘(VIII) DEFINITIONS.—In this 

11 clause: 

12 ‘‘(aa) ADMINISTRATIVE

13 SERVICES.—The term ‘adminis14 trative services’ means food prep15 aration, housekeeping, laundry 

16 services, maintenance services, 

17 and other noncaregiving-related 

18 services, as determined by the 

19 Secretary. 

20 ‘‘(bb) DAY SHIFT.—The 

21 term ‘day shift’ means, with re22 spect to a day and a nursing fa23 cility, an assigned work shift that 

24 is a period of 8 consecutive 

25 hours, beginning not sooner than 


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1 6 a.m. in the time zone in which 

2 such facility is located and not 

3 later than 8 a.m. in such time 

4 zone. 

5 ‘‘(cc) EVENING SHIFT.—The 

6 term ‘evening shift’ means, with 

7 respect to a day and a nursing 

8 facility, an assigned work shift 

9 that is a period of 8 consecutive 

10 hours, beginning not sooner than 

11 2 p.m. in the time zone in which 

12 such facility is located and not 

13 later than 4 p.m. in such time 

14 zone. 

15 ‘‘(dd) NIGHT SHIFT.—The 

16 term ‘night shift’ means, with re17 spect to a day and a nursing fa18 cility, an assigned work shift that 

19 is a period of 8 consecutive 

20 hours, beginning not sooner than 

21 10 p.m. in the time zone in which 

22 such facility is located and not 

23 later than midnight in such time 

24 zone.’’. 


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

2 Social Security Act (42 U.S.C. 1396r(h)) is amend3 ed— 

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

5 State finds, on the basis of a standard’’ and in6 serting ‘‘Subject to paragraph (10), if a State 

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

8 (B) in paragraph (2)— 

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

10 ‘‘If a nursing facility’’ and inserting ‘‘Sub11 ject to paragraph (10), if a nursing facil12 ity’’; and 

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

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

15 paragraph (10), in the case of’’; 

16 (C) in paragraph (3)— 

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

18 before the period the following: ‘‘and the 

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

20 and 

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

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

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

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

25 paragraph: 


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1 ‘‘(10) SPECIAL ENFORCEMENT PROCESS WITH

2 RESPECT TO MINIMUM NURSE STAFFING REQUIRE3 MENTS.— 

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

5 the basis of a standard, extended, or partial ex6 tended survey under subsection (g)(2) or other7 wise, that a nursing facility does not meet the 

8 minimum staffing requirements of clause (ii) of 

9 subsection (b)(4)(C) with respect to nursing fa10 cility services provided on or after January 1, 

11 2022, the State shall— 

12 ‘‘(i) deny any further payments under 

13 the State plan with respect to all individ14 uals enrolled under such plan who are ad15 mitted to the facility after the effective 

16 date of the finding; and 

17 ‘‘(ii) recommend to the Secretary that 

18 the Secretary impose the civil money pen19 alty described in subparagraph (B). 

20 ‘‘(B) SECRETARIAL AUTHORITY.— 

21 ‘‘(i) IN GENERAL.—With respect to 

22 any nursing facility in a State other than 

23 a State nursing facility, if the Secretary 

24 finds that such a nursing facility does not 

25 meet the minimum staffing requirements 


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

2 respect to nursing facility services provided 

3 on or after January 1, 2022, the Secretary 

4 shall— 

5 ‘‘(I) deny any further payments 

6 to the State for medical assistance 

7 furnished by the facility to all individ8 uals enrolled under the State plan 

9 who are admitted to the facility after 

10 the effective date of the finding; and 

11 ‘‘(II) impose a civil money pen12 alty in an amount not to exceed 

13 $10,000 for each day of noncompli14 ance. The provisions of section 1128A 

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

16 shall apply to a civil money penalty 

17 under the previous sentence in the 

18 same manner as such provisions apply 

19 to a penalty or proceeding under sec20 tion 1128A(a). 

21 ‘‘(ii) REDUCTION OF CIVIL MONEY

22 PENALTIES IN CERTAIN CIR23 CUMSTANCES.—Subject to clause (iii), in 

24 the case where a nursing facility self-re25 ports and promptly corrects a deficiency 


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1 for which a penalty was imposed under 

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

3 days after the date of such imposition, the 

4 Secretary may reduce the amount of the 

5 penalty imposed by— 

6 ‘‘(I) not more than 50 percent; or 

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

8 was penalized under this subsection 

9 within the three-year period preceding 

10 the date of such imposition, not more 

11 than 25 percent. 

12 ‘‘(iii) PROHIBITIONS ON REDUCTION

13 FOR CERTAIN DEFICIENCIES.— 

14 ‘‘(I) REPEAT DEFICIENCIES.— 

15 The Secretary may not reduce the 

16 amount of a penalty under clause (ii) 

17 if the Secretary had reduced a penalty 

18 imposed on the nursing facility in the 

19 preceding year under such clause with 

20 respect to a repeat deficiency. 

21 ‘‘(II) CERTAIN OTHER DEFI22 CIENCIES.—The Secretary may not 

23 reduce the amount of a penalty under 

24 clause (ii) if the penalty is imposed on 

25 the nursing facility for a deficiency 


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1 that is found to result in a pattern of 

2 harm or widespread harm, imme3 diately jeopardizes the health or safe4 ty of a resident or residents of the fa5 cility, or results in the death of a resi6 dent of the facility. 

7 ‘‘(iv) REPEATED NONCOMPLIANCE.— 

8 In the case of a nursing facility which, on 

9 three consecutive standard surveys con10 ducted under subsection (g)(2), has been 

11 found as not meeting the minimum staff12 ing requirements of clause (ii) of sub13 section (b)(4)(C) with respect to nursing 

14 facility services provided on or after Janu15 ary 1, 2022, the Secretary may (regardless 

16 of the remedies provided for under clause 

17 (i))— 

18 ‘‘(I) appoint temporary manage19 ment to oversee the operation of the 

20 facility and to assure the health and 

21 safety of the facility’s residents in ac22 cordance with clause (iii) of para23 graph (3)(C), except that ‘the min24 imum staffing requirements of clause 

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


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1 substituted for ‘all the requirements 

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

3 such clause; 

4 ‘‘(II) monitor the facility under 

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

6 such minimum staffing requirements 

7 until the facility has demonstrated to 

8 the satisfaction of the Secretary that 

9 the facility is in compliance, and will 

10 remain in compliance, with such min11 imum staffing requirements; or 

12 ‘‘(III) subject to section 

13 1128I(h), terminate the facility’s par14 ticipation under this title. 

15 If the facility’s participation under this 

16 title is terminated under this clause, the 

17 State shall provide for the safe and orderly 

18 transfer of the residents eligible under this 

19 title, consistent with the requirements of 

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

21 ‘‘(v) PUBLIC NOTICE OF VIOLA22 TIONS.— 

23 ‘‘(I) INTERNET WEBSITE.—The 

24 Secretary shall publish on the internet 

25 website of the Department of Health 


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1 and Human Services the names of 

2 nursing facilities that have violated 

3 the minimum staffing requirements of 

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

5 respect to skilled nursing facility serv6 ices provided on or after January 1, 

7 2022. 

8 ‘‘(II) CHANGE OF OWNERSHIP.— 

9 With respect to a nursing facility 

10 whose name is published under sub11 clause (I) and has a change of owner12 ship, as determined by the Secretary, 

13 after the date of such publication, the 

14 Secretary shall remove the name of 

15 such facility from the website de16 scribed under such subclause after the 

17 1-year period beginning on the date of 

18 such change of ownership.’’. 

19 (3) CONFORMING AMENDMENTS.— 

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

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

22 1396r(b)(4)(C)), as redesignated by paragraph 

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

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

25 (iv)’’. 


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1 (B) Item (a) of section 

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

3 (42 U.S.C. 1396r(f)(2)(B)(iii)(I)) is amended 

4 by striking ‘‘subsection (b)(4)(C)(ii)’’ and in5 serting ‘‘subsection (b)(4)(C)(iii)’’. 

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

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

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

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

10 (c) STUDIES AND REPORTS REGARDING IMPACT OF

11 MINIMUM NURSE STAFFING REQUIREMENTS.— 

12 (1) INITIAL STUDY AND REPORT.— 

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

14 2023, the Secretary of Health and Human 

15 Services shall study and submit to the Com16 mittee on Energy and Commerce and the Com17 mittee on Ways and Means of the House of 

18 Representatives and the Committee on Finance 

19 of the Senate a publicly available report— 

20 (i) on the impact of the minimum 

21 nurse staffing requirements added by sub22 section (a) on the reimbursement levels of 

23 skilled nursing facilities under the Medi24 care program under title XVIII of the So25 cial Security Act (42 U.S.C. 1395 et seq.) 


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1 and the adequacy of personnel numbers in 

2 such skilled nursing facilities to meet such 

3 minimum nurse staffing requirements; 

4 (ii) on the impact of the minimum 

5 nurse staffing requirements added by sub6 section (b) on the reimbursement levels of 

7 nursing facilities under the Medicaid pro8 gram under title XIX of the Social Secu9 rity Act (42 U.S.C. 1396 et seq.) and the 

10 adequacy of personnel numbers in such 

11 nursing facilities to meet such minimum 

12 nurse staffing requirements; and 

13 (iii) including recommendations on the 

14 steps that such skilled nursing facilities 

15 and nursing facilities can take to ensure 

16 that adequate personnel are available in 

17 such skilled nursing facilities and nursing 

18 facilities to meet the minimum nurse staff19 ing requirements added by subsections (a) 

20 and (b) for such skilled nursing facilities 

21 and nursing facilities, respectively, includ22 ing methods for attracting and retaining 

23 such personnel. 

24 (B) CONSIDERATIONS.—In conducting the 

25 study required under subparagraph (A), the 


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1 Secretary of Health and Human Services shall 

2 take into consideration— 

3 (i) the benefits of any increase in 

4 nurse staffing levels, including with respect 

5 to workforce training and retention; 

6 (ii) any decrease in the rate of work7 place injuries; 

8 (iii) any changes in medical care costs 

9 for residents of skilled nursing facilities 

10 and nursing facilities; 

11 (iv) any decrease in hospitalization 

12 rates for such residents; 

13 (v) any changes in personnel and ad14 ministrative costs for skilled nursing facili15 ties and nursing facilities; and 

16 (vi) any changes in recruiting and 

17 training costs. 

18 (2) SUBSEQUENT STUDY AND REPORT.—Not 

19 later than January 1, 2025, the Secretary of Health 

20 and Human Services shall conduct a follow-up study 

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

22 submit to the Committee on Energy and Commerce 

23 and the Committee on Ways and Means of the 

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1 nance of the Senate a publicly available report on 

2 such follow-up study. 

3 SEC. 3. DISCLOSURE OF NURSE STAFFING LEVELS AT 

4 SKILLED NURSING FACILITIES UNDER MEDI5 CARE PROGRAM AND NURSING FACILITIES 

6 UNDER MEDICAID PROGRAM. 

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

8 the Social Security Act (42 U.S.C. 1395i–3(b)) is amend9 ed to read as follows: 

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

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

12 nursing facility shall post for each shift notices 

13 with— 

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

15 requirements applicable with respect to the 

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

17 ‘‘(ii) information on the number of 

18 registered professional nurses, licensed 

19 practical nurses, and nurse aides (as de20 fined in paragraph (5)(F)) assigned to pro21 vide direct care services to residents in the 

22 facility during the shift, disaggregated by 

23 units in the facility; and 

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

25 required, upon request, to provide any 


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1 nurse staffing information (as described in 

2 this subparagraph) of the facility from the 

3 preceding 12-month period. 

4 The information in such notices shall be written 

5 in a uniform manner, printed in an easily read6 able 14-point type font, and made available in 

7 appropriate languages, as determined by the 

8 Secretary. The skilled nursing facility shall 

9 make such notices available at each nurses’ sta10 tion in the facility and other areas in each unit 

11 of the facility, as determined appropriate by the 

12 facility, and shall keep and maintain each such 

13 notice for at least three years after the date on 

14 which each such notice is posted in the facility. 

15 ‘‘(B) PUBLIC AVAILABILITY OF INFORMA16 TION.—A skilled nursing facility shall, upon re17 quest, make available to the public any nurse 

18 staffing information (as described in subpara19 graph (A)) of the facility from the preceding 

20 12-month period. In the case that the facility 

21 makes such information available as a paper 

22 copy, such facility may not charge for such copy 

23 an amount greater than the cost of making 

24 such copy.’’. 


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

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

3 to read as follows: 

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

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

6 nursing facility shall post for each shift notices 

7 with— 

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

9 requirements applicable with respect to the 

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

11 ‘‘(ii) information on the number of 

12 registered professional nurses, licensed 

13 practical nurses, and nurse aides (as de14 fined in paragraph (5)(F)) assigned to pro15 vide direct care services to residents in the 

16 facility during the shift, disaggregated by 

17 units in the facility; and 

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

19 required, upon request, to provide any 

20 nurse staffing information (as described in 

21 this subparagraph) of the facility from the 

22 preceding 12-month period. 

23 The information in such notices shall be written 

24 in a uniform manner, printed in an easily read25 able 14-point type font, and made available in 


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1 appropriate languages, as determined by the 

2 Secretary. The skilled nursing facility shall 

3 make such notices available at each nurses’ sta4 tion in the facility and other areas in each unit 

5 of the facility, as determined appropriate by the 

6 facility, and shall keep and maintain each such 

7 notice for at least three years after the date on 

8 which each such notice is posted in the facility. 

9 ‘‘(B) PUBLIC AVAILABILITY OF INFORMA10 TION.—A skilled nursing facility shall, upon re11 quest, make available to the public any nurse 

12 staffing information (as described in subpara13 graph (A)) of the facility from the preceding 

14 12-month period.’’. 

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

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

17 Act and apply with respect to nurse staffing information 

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

19 after such date of enactment. 


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1 SEC. 4. ADMINISTRATIVE STAFFING REQUIREMENTS FOR 

2 SKILLED NURSING FACILITIES UNDER MEDI3 CARE PROGRAM AND NURSING FACILITIES 

4 UNDER MEDICAID PROGRAM. 

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

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

8 (1) by redesignating the second subparagraph 

9 (C) as subparagraph (E); and 

10 (2) by inserting after the first subparagraph 

11 (C) the following new subparagraph: 

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

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

15 facility must employ nursing management 

16 personnel in accordance with this subpara17 graph. 

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

21 serve full-time as the director of nursing 

22 services of the facility. Such director of 

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

25 personnel needed to sufficiently meet the 

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1 ity (as required under subsection 

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

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

5 must employ a registered professional 

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

8 except that in the case of a skilled nursing 

9 facility that has fewer than 100 beds, such 

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

13 facility. A registered professional nurse 

14 who serves as the assistant director of 

15 nursing services of a skilled nursing facility 

16 may also serve as a supervisor for direct 

17 clinical nursing care for such facility. 

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

20 employ a registered professional nurse to 

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

22 education of the facility, except that in the 

23 case of a skilled nursing facility that has 

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


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

2 education of the facility. In carrying out 

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

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

7 adult education and gerontology.’’. 

8 (b) MEDICAID.— 

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

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

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

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

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

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

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

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

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

25 the number and types of nursing personnel 


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1 needed to sufficiently meet the nursing 

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

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

6 employ a registered professional nurse to 

7 serve full-time as the assistant director of 

8 nursing services of the facility, except that 

9 in the case of a nursing facility that has 

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

12 serve part-time as the assistant director of 

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

15 the assistant director of nursing services of 

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

18 such facility. 

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

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

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

24 nursing facility that has fewer than 100 

25 beds, such facility may employ a registered 


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1 professional nurse to serve part-time as the 

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

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

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

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

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

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

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

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

15 Act and apply with respect to the administration of skilled 

16 nursing facilities and nursing facilities on or after the date 

17 that is one year after such date of enactment. 

18 SEC. 5. NURSE TRAINING REQUIREMENTS WITH RESPECT 

19 TO SKILLED NURSING FACILITIES UNDER 

20 MEDICARE PROGRAM AND NURSING FACILI21 TIES UNDER MEDICAID PROGRAM. 

22 (a) MEDICARE.— 

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

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

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

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

6 registered professional nurses, licensed practical 

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

11 rights under this section.’’. 

12 (2) REQUIREMENTS FOR NURSE AIDE TRAINING

13 AND COMPETENCY EVALUATION PROGRAMS AND FOR

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

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

17 amended— 

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

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

22 (B) in clause (i)— 

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

25 ‘‘care of older adults,’’; 


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

3 abuse prevention training),’’; and 

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

6 (C) in clause (ii)— 

7 (i) by striking ‘‘requirement relating 

8 to’’ and inserting ‘‘requirements relating to 

9 (I)’’; 

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

12 ‘‘care of older adults,’’; and 

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

14 inserting ‘‘(II) minimum hours of initial 

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

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

18 (b) MEDICAID.— 

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

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

23 at the end the following new paragraph: 

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

25 provide to registered professional nurses, licensed 


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

3 and nurse aides are assigned to provide direct care 

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

7 this section.’’. 

8 (2) REQUIREMENTS FOR NURSE AIDE TRAINING

9 AND COMPETENCY EVALUATION PROGRAMS AND FOR

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

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

13 amended— 

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

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

18 (B) in clause (i)— 

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

21 ‘‘care of older adults,’’; 

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

24 abuse prevention training),’’; and 


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

3 (C) in clause (ii)— 

4 (i) by striking ‘‘requirement relating 

5 to’’ and inserting ‘‘requirements relating to 

6 (I)’’; 

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

9 ‘‘care of older adults,’’; and 

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

11 inserting ‘‘(II) minimum hours of initial 

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

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

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

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

17 Act and shall apply with respect to nurse aide training 

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

21 date of enactment. 

22 SEC. 6. WHISTLEBLOWER AND RESIDENT PROTECTIONS. 

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

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

25 the following new subsection: 


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

3 ‘‘(1) STATEMENT REGARDING PROFESSIONAL

4 OBLIGATION AND RIGHTS.—All nurses employed by 

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

6 based on their professional judgment in accordance 

7 with the nursing laws and regulations of the State 

8 in which such facility is located, to provide nursing 

9 care in the exclusive interests of the residents of the 

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

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

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

15 ‘work assignment’) if— 

16 ‘‘(A) the nurse reasonably believes such 

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

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

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

21 nurse is not prepared by education, training, or 

22 experience to perform or comply with such work 

23 assignment without compromising the safety of 

24 a resident or jeopardizing the license of the 

25 nurse. 


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

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

4 RETALIATION.—No skilled nursing facility may 

5 discharge, retaliate, discriminate, or otherwise 

6 take adverse action in any manner with respect 

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

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

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

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

13 ‘‘(B) NO FILING OF COMPLAINT.—No 

14 skilled nursing facility may file a complaint or 

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

17 objection to, or refusal of, a work assignment 

18 under paragraph (2). 

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

22 facility has taken an adverse action in violation of 

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

24 filed a complaint or report in violation of paragraph 

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


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

2 bring a cause of action in an appropriate district 

3 court of the United States. The legal burdens of 

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

5 States Code, shall be controlling for the purposes of 

6 any cause of action brought under this paragraph. 

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

8 entitled to one or more of the following: 

9 ‘‘(A) Reinstatement. 

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

12 ‘‘(C) Attorneys’ fees. 

13 ‘‘(D) Court costs. 

14 ‘‘(E) Other damages. 

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

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

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

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

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

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


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1 an order that the complaining individual may 

2 not suffer any adverse action prohibited by 

3 paragraph (3) or (7). 

4 ‘‘(6) TOLL-FREE TELEPHONE NUMBER.— 

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

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

8 the minimum nurse staffing requirements of 

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

10 reports of violations of such requirements. 

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

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

14 of the hotline described in subparagraph (A) 

15 and give notice to each such resident that such 

16 hotline may be used to report inadequate staff17 ing. 

18 ‘‘(7) PROTECTION FOR REPORTING.— 

19 ‘‘(A) PROHIBITION ON RETALIATION OR

20 DISCRIMINATION.—A skilled nursing facility 

21 may not retaliate or discriminate in any manner 

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

24 the basis that such resident, employee, contract 

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1 junction with another individual) has, in good 

2 faith— 

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

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

8 accreditation body; 

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

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

11 care, services, or conditions of the facility. 

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

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

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

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

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

21 occur. 

22 ‘‘(8) PROHIBITION ON INTERFERENCE WITH

23 RIGHTS.— 

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

25 nursing facility may not— 


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

2 the exercise, or attempt to exercise, by any 

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

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

8 exercise, such right. 

9 ‘‘(B) OPPOSITION TO UNLAWFUL POLICIES

10 OR PRACTICES.—A skilled nursing facility may 

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

14 breach, or fail to comply with any provision of 

15 the minimum nurse staffing requirements of 

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

17 ‘‘(C) PROHIBITION ON INTERFERENCE

18 WITH PROTECTED COMMUNICATIONS.—A skilled 

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

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

23 intimidates, coerces, or induces a nurse regard24 ing, engaging in free speech activities or disVerDate Sep 11 2014 19:09 Feb 27, 2021 Jkt 019200 PO 00000 Frm 00051 Fmt 6652 Sfmt 6201 E:\BILLS\S315.IS S315

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1 closing information as provided under this sub2 section. 

3 ‘‘(D) PROHIBITION ON INTERFERENCE

4 WITH COLLECTIVE ACTION.—A skilled nursing 

5 facility may not in any way interfere with the 

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

8 section 7 of the National Labor Relations Act 

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

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

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

13 that— 

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

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

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

20 a violation of a requirement or a prohibition of 

21 this subsection; and 

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

23 such a complaint. 

24 ‘‘(10) ENFORCEMENT.— 


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

2 enforce the requirements and prohibitions of 

3 this subsection in accordance with this para4 graph. 

5 ‘‘(B) PROCEDURES FOR RECEIVING AND

6 INVESTIGATING COMPLAINTS.—The Secretary 

7 shall establish procedures under which— 

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

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

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

16 a requirement or prohibition of this subsection, 

17 the Secretary— 

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

20 recurrence of such violation; and 

21 ‘‘(ii) may impose civil money penalties 

22 as described in subparagraph (D). 

23 ‘‘(D) CIVIL PENALTIES.— 

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

25 other penalties prescribed by law, the SecVerDate Sep 11 2014 19:09 Feb 27, 2021 Jkt 019200 PO 00000 Frm 00053 Fmt 6652 Sfmt 6201 E:\BILLS\S315.IS S315

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1 retary may impose civil penalties as fol2 lows: 

3 ‘‘(I) SKILLED NURSING FACILITY

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

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

8 ‘‘(aa) not more than 

9 $25,000 for the first knowing 

10 violation of this subsection by 

11 such facility; and 

12 ‘‘(bb) not more than 

13 $50,000 for any subsequent 

14 knowing violation of this sub15 section by such facility. 

16 ‘‘(II) INDIVIDUAL LIABILITY.— 

17 The Secretary may impose on an indi18 vidual who— 

19 ‘‘(aa) is employed by a 

20 skilled nursing facility; and 

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

23 this subsection on behalf of the 

24 facility, 


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1 a civil money penalty of not more 

2 than $20,000 for each such violation 

3 by the individual. 

4 ‘‘(ii) PROCEDURES.—The provisions 

5 of section 1128A of the Social Security Act 

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

7 apply with respect to a civil money penalty 

8 or proceeding under this subparagraph in 

9 the same manner as such provisions apply 

10 with respect to a civil money penalty or 

11 proceeding under such section 1128A. 

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

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

15 of the Department of Health and Human 

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

18 been imposed under this subsection, the 

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

21 the Secretary determines appropriate. 

22 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

23 respect to a skilled nursing facility that 

24 had a change of ownership, as determined 

25 by the Secretary, penalties imposed on the 


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1 facility while under previous ownership 

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

4 year period beginning on the date of such 

5 change of ownership. 

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

7 the Secretary pursuant to this subsection are 

8 authorized to be appropriated to implement the 

9 minimum nurse staffing requirements of clause 

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

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

12 the term ‘nurse’ means a registered professional 

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

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

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

16 the following new subsection: 

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

19 ‘‘(1) STATEMENT REGARDING PROFESSIONAL

20 OBLIGATION AND RIGHTS.—All nurses employed by 

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

22 on their professional judgment in accordance with 

23 the nursing laws and regulations of the State in 

24 which such facility is located, to provide nursing care 


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

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

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

7 ‘work assignment’) if— 

8 ‘‘(A) the nurse reasonably believes such 

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

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

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

13 nurse is not prepared by education, training, or 

14 experience to perform or comply with such work 

15 assignment without compromising the safety of 

16 a resident or jeopardizing the license of the 

17 nurse. 

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

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

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

23 adverse action in any manner with respect to 

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1 pensation, or terms, conditions, or privileges of 

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

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

5 ‘‘(B) NO FILING OF COMPLAINT.—No 

6 nursing facility may file a complaint or a report 

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

10 paragraph (2). 

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

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

16 a complaint or report in violation of paragraph 

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

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

19 bring a cause of action in an appropriate district 

20 court of the United States. The legal burdens of 

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

22 States Code, shall be controlling for the purposes of 

23 any cause of action brought under this paragraph. 

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

25 entitled to one or more of the following: 


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1 ‘‘(A) Reinstatement. 

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

4 ‘‘(C) Attorneys’ fees. 

5 ‘‘(D) Court costs. 

6 ‘‘(E) Other damages. 

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

9 against a nursing facility that violates a requirement 

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

11 the Secretary shall— 

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

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

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

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

18 an order that the complaining individual may 

19 not suffer any adverse action prohibited by 

20 paragraph (3) or (7). 

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

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

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

25 the minimum nurse staffing requirements of 


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

2 reports of violations of such requirements. 

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

4 facility shall provide each resident admitted to 

5 the facility with the telephone number of the 

6 hotline described in subparagraph (A) and give 

7 notice to each such resident that such hotline 

8 may be used to report inadequate staffing or 

9 care. 

10 ‘‘(7) PROTECTION FOR REPORTING.— 

11 ‘‘(A) PROHIBITION ON RETALIATION OR

12 DISCRIMINATION.—A nursing facility may not 

13 retaliate or discriminate in any manner against 

14 any resident, employee, or contract employee of 

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

16 that such resident, employee, contract employee, 

17 or individual (individually or in conjunction 

18 with another individual) has, in good faith— 

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

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

24 accreditation body; 

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


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

2 care, services, or conditions of the facility. 

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

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

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

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

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

12 occur. 

13 ‘‘(8) PROHIBITION ON INTERFERENCE WITH

14 RIGHTS.— 

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

16 facility may not— 

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

18 the exercise, or attempt to exercise, by any 

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

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

24 exercise, such right. 


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1 ‘‘(B) OPPOSITION TO UNLAWFUL POLICIES

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

4 for opposing any policy, practice, or action of 

5 the facility which is alleged to violate, breach, 

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

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

9 ‘‘(C) PROHIBITION ON INTERFERENCE

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

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

13 manner directly or indirectly prohibits, impedes, 

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

16 free speech activities or disclosing information 

17 as provided under this subsection. 

18 ‘‘(D) PROHIBITION ON INTERFERENCE

19 WITH COLLECTIVE ACTION.—A nursing facility 

20 may not in any way interfere with the rights of 

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

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


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

2 an appropriate location in each unit a conspicuous 

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

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

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

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

10 a violation of a requirement or a prohibition of 

11 this subsection; and 

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

13 such a complaint. 

14 ‘‘(10) ENFORCEMENT.— 

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

16 enforce the requirements and prohibitions of 

17 this subsection in accordance with this para18 graph. 

19 ‘‘(B) PROCEDURES FOR RECEIVING AND

20 INVESTIGATING COMPLAINTS.—The Secretary 

21 shall establish procedures under which— 

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

24 violated a requirement or a prohibition of 

25 this subsection; and 


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

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

6 Secretary— 

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

9 recurrence of such violation; and 

10 ‘‘(ii) may impose civil money penalties 

11 as described in subparagraph (D). 

12 ‘‘(D) CIVIL PENALTIES.— 

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

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

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

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

21 penalty of— 

22 ‘‘(aa) not more than 

23 $25,000 for the first knowing 

24 violation of this subsection by 

25 such facility; and 


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1 ‘‘(bb) not more than 

2 $50,000 for any subsequent 

3 knowing violation of this sub4 section by such facility. 

5 ‘‘(II) INDIVIDUAL LIABILITY.— 

6 The Secretary may impose on an indi7 vidual who— 

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

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

12 this subsection on behalf of the 

13 facility, 

14 a civil money penalty of not more 

15 than $20,000 for each such violation 

16 by the individual. 

17 ‘‘(ii) PROCEDURES.—The provisions 

18 of section 1128A of the Social Security Act 

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

20 apply with respect to a civil money penalty 

21 or proceeding under this subparagraph in 

22 the same manner as such provisions apply 

23 with respect to a civil money penalty or 

24 proceeding under such section 1128A. 

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


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

3 of the Department of Health and Human 

4 Services the names of nursing facilities on 

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

7 for which such penalty was imposed, and 

8 such additional information as the Sec9 retary determines appropriate. 

10 ‘‘(ii) CHANGE OF OWNERSHIP.—With 

11 respect to a nursing facility that had a 

12 change of ownership, as determined by the 

13 Secretary, penalties imposed on the facility 

14 while under previous ownership shall no 

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

17 beginning on the date of such change of 

18 ownership. 

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

20 the Secretary pursuant to this subsection are 

21 authorized to be appropriated to implement the 

22 minimum nurse staffing requirements of clause 

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


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

2 the term ‘nurse’ means a registered professional 

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

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

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

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

8 other adverse actions, and interferences with rights that 

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

10 of enactment and with respect to notices provided on or 

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

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

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

17 the end the following new paragraph: 

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

19 ARBITRATION AGREEMENTS.— 

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

22 to enforce a pre-dispute arbitration agreement 

23 from or on behalf of any resident, whether the 

24 agreement is made before, during, or after the 

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


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1 on behalf of any employee, or contract employee 

2 of the facility, or any other individual if such 

3 individual is alleged to be engaged in conduct 

4 protected under subsection (k). 

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

6 apply to the skilled nursing facility and to any 

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

9 the resident. 

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

11 pre-dispute arbitration agreement shall not be 

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

15 was made prior to or after the effective date of 

16 this paragraph. 

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

19 term ‘pre-dispute arbitration agreement’ means 

20 any agreement to arbitrate a dispute when the 

21 dispute has arisen after such agreement has 

22 been made. 

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

24 as to whether and how this paragraph applies 

25 to an arbitration agreement shall be determined 


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•S 315 IS

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

4 challenges such agreement specifically or in 

5 conjunction with any other term of the contract 

6 containing such agreement.’’. 

7 (b) MEDICAID.— 

8 (1) HOME AND COMMUNITY-BASED SERVICES

9 AND HOME HEALTH CARE SERVICES.—Section 1915 

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

11 amended by adding at the end the following new 

12 subsection: 

13 ‘‘(m) PROHIBITING PRE-DISPUTE ARBITRATION

14 AGREEMENTS.— 

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

17 under a waiver under this section, section 

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

19 the provision of home and community-based services 

20 or home health care services under this title, the 

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

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

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

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


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

4 other individual if such individual is alleged to be 

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

6 A pre-dispute arbitration agreement between such a 

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

9 shall not be valid or enforceable, without regard to 

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

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

15 dispute when the dispute has arisen after such 

16 agreement has been made. 

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

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

20 law by a court of competent jurisdiction, rather than 

21 an arbitrator, without regard to whether the party 

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

24 contract containing such agreement.’’. 


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

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

3 amended by adding at the end the following new 

4 paragraph: 

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

6 ARBITRATION AGREEMENTS.— 

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

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

9 a pre-dispute arbitration agreement from or on 

10 behalf of any resident, whether the agreement 

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

12 admission to the facility, or from or on behalf 

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

15 is alleged to be engaged in conduct protected 

16 under subsection (k). 

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

18 apply to the nursing facility and to any other 

19 business or person providing or responsible for 

20 providing nursing services to the resident. 

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

22 pre-dispute arbitration agreement shall not be 

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

25 without regard to whether the agreement was 


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1 made prior to or after the effective date of this 

2 paragraph. 

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

5 term ‘pre-dispute arbitration agreement’ means 

6 any agreement to arbitrate a dispute when the 

7 dispute has arisen after such agreement has 

8 been made. 

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

10 as to whether and how this paragraph applies 

11 to an arbitration agreement shall be determined 

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

15 challenges such agreement specifically or in 

16 conjunction with any other term of the contract 

17 containing such agreement.’’. 

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

20 TO PRESCRIBING PSYCHOTROPIC DRUGS. 

21 (a) STANDARDIZED PROTOCOL.— 

22 (1) SKILLED NURSING FACILITIES.—Section 

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

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

25 following new paragraph: 


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

3 TO PRESCRIBING PSYCHOTROPIC DRUGS FOR A USE

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

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

7 that is one year after the date of the enactment 

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

10 Comptroller General of the United States under 

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

12 Home Residents Act and in consultation with 

13 stakeholder groups (including residents of 

14 skilled nursing facilities, family members of 

15 such residents, advocates for such residents, 

16 long-term care ombudsmen, and providers), 

17 shall develop a standardized protocol for skilled 

18 nursing facilities to obtain written informed 

19 consent, in accordance with this paragraph, 

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

21 designated health care agent or other surrogate 

22 under State law or regulation) prior to pre23 scribing a psychotropic drug to the resident for 

24 a use not approved by the Food and Drug Ad25 ministration. 


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1 ‘‘(B) REQUIREMENTS.—The standardized 

2 protocol developed under subparagraph (A) 

3 shall include the following: 

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

5 resident, that— 

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

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

10 other surrogate under State law or 

11 regulation) of— 

12 ‘‘(aa) possible side effects 

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

15 mention of any ‘black box warn16 ing’; 

17 ‘‘(bb) treatment modalities 

18 that were attempted prior to the 

19 use of the psychotropic drug; and 

20 ‘‘(cc) any other information 

21 the Secretary determines appro22 priate; 

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

25 care agent or other surrogate under 


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

4 ‘‘(III) the administration of the 

5 psychotropic drug is in accordance 

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

11 causes of behavioral disorders. 

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

14 ‘‘(I) in the case of emergencies; 

15 and 

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

17 identified designated health care agent 

18 or other surrogate under State law or 

19 regulation. 

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

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

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

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1 spect to a psychotropic drug and a resident of 

2 the facility— 

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

4 such psychotropic drug to such resident if 

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

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

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

13 resident has in place. 

14 ‘‘(D) COMPLIANCE.—Effective beginning 

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

16 the date of the enactment of this paragraph, a 

17 skilled nursing facility shall comply with the 

18 standardized protocol developed under subpara19 graph (A). 

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

21 paragraph shall preempt any provision of State 

22 or Federal law that provides broader rights 

23 with respect to written informed consent for 

24 residents of facilities.’’. 


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

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

3 amended by adding at the end the following new 

4 paragraph: 

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

7 TO PRESCRIBING PSYCHOTROPIC DRUGS FOR A USE

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

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

11 that is one year after the date of the enactment 

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

14 Comptroller General of the United States under 

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

16 Home Residents Act and in consultation with 

17 stakeholder groups (including residents of 

18 skilled nursing facilities, family members of 

19 such residents, advocates for such residents, 

20 long-term care ombudsmen, and providers), 

21 shall develop a standardized protocol for nurs22 ing facilities to obtain written informed consent, 

23 in accordance with this paragraph, from a resi24 dent (or, if applicable, the resident’s designated 

25 health care agent or other surrogate under 


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1 State law or regulation) prior to prescribing a 

2 psychotropic drug to the resident for a use not 

3 approved by the Food and Drug Administra4 tion. 

5 ‘‘(B) REQUIREMENTS.—The standardized 

6 protocol developed under subparagraph (A) 

7 shall include the following: 

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

9 resident, that— 

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

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

14 other surrogate under State law or 

15 regulation) of— 

16 ‘‘(aa) possible side effects 

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

19 mention of any ‘black box warn20 ing’; 

21 ‘‘(bb) treatment modalities 

22 that were attempted prior to the 

23 use of the psychotropic drug; and 


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1 ‘‘(cc) any other information 

2 the Secretary determines appro3 priate; 

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

6 care agent or other surrogate under 

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

10 ‘‘(III) the administration of the 

11 psychotropic drug is in accordance 

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

17 causes of behavioral disorders. 

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

20 ‘‘(I) in the case of emergencies; 

21 and 

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

23 identified designated health care agent 

24 or other surrogate under State law or 

25 regulation. 


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

3 ‘‘(C) TIMING OF INFORMED CONSENT.— 

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

6 described in subparagraph (A), with respect to 

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

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

10 such psychotropic drug to such resident if 

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

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

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

19 resident has in place. 

20 ‘‘(D) COMPLIANCE.—Effective beginning 

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

22 the date of the enactment of this paragraph, a 

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

25 (A). 


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

2 paragraph shall preempt any provision of State 

3 or Federal law that provides broader rights 

4 with respect to written informed consent for 

5 residents of facilities.’’. 

6 (3) GAO STUDY AND REPORT ON INFORMED

7 CONSENT LAWS WITH RESPECT TO PRESCRIBING OF

8 PSYCHOTROPIC DRUGS.— 

9 (A) STUDY.—The Comptroller General of 

10 the United States (in this paragraph referred to 

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

12 study of State laws and regulations concerning 

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

15 the effectiveness of such laws and practices in 

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

18 include an analysis as to whether in the case of 

19 States that have not enacted such informed 

20 consent laws, such States have developed other 

21 mechanisms to guide appropriate prescribing of 

22 psychotropic drugs in older adults with demen23 tia. 

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

25 after the date of enactment of this Act, the 


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

3 Committees on Energy and Commerce and 

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

6 Senate a report containing the results of the 

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

9 Comptroller General determines appropriate. 

10 (b) DEVELOPMENT OF MEASURE OF UTILIZATION OF

11 PSYCHOTROPIC DRUGS FOR INCLUSION ON NURSING

12 HOME COMPARE WEBSITE.— 

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

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

15 (A) by redesignating paragraph (3) as 

16 paragraph (4); and 

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

18 following new paragraph: 

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

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

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

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


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1 inclusion on such website (or a successor 

2 website) as part of the quality measures or 

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

6 Centers for Medicare & Medicaid Services. 

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

8 measure under subparagraph (A), the Secretary 

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

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

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

15 (A) by redesignating paragraph (3) as 

16 paragraph (4); and 

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

18 following new paragraph: 

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

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

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

24 include a measure of the utilization of psycho25 tropic drugs for each nursing facility for incluVerDate Sep 11 2014 19:09 Feb 27, 2021 Jkt 019200 PO 00000 Frm 00083 Fmt 6652 Sfmt 6201 E:\BILLS\S315.IS S315

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

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

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

6 Medicare & Medicaid Services. 

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

8 measure under subparagraph (A), the Secretary 

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

Æ 


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