I 

111TH CONGRESS 

2D SESSION H. R. 6074 

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

quality under the Medicaid Program through nursing facility survey 

system improvements. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 30, 2010 

Mr. STUPAK introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend titles XVIII and XIX of the Social Security Act 

to enhance quality under the Medicaid Program through 

nursing facility survey system improvements. 

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 ‘‘Enhancing Quality 

5 through Survey System Improvements Act of 2010’’. 


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1 SEC. 2. DATA DRIVEN MODERNIZATION OF THE SURVEY 

2 PROCESS. 

3 (a) REVIEW OF STATE AND CONTRACTOR SURVEY

4 PROCEDURES.— 

5 (1) MEDICARE.—Section 1819(g)(2)(A)(i) of 

6 the Social Security Act (42 U.S.C. 1395i– 

7 3(g)(2)(A)(i)) is amended— 

8 (A) by striking ‘‘of’’ before ‘‘not to exceed’’ 

9 in the second sentence; and 

10 (B) by striking ‘‘each State’s procedures 

11 for the scheduling and conduct of standard sur12 veys to assure that the State’’ and inserting 

13 ‘‘the procedures of each State, or other con14 tractor as chosen by the Secretary, for sched15 uling and conducting standard surveys to as16 sure that the State, or other contractor,’’. 

17 (2) MEDICAID.—Section 1919(g)(2)(A)(i) of the 

18 Social Security Act (42 U.S.C. 1396r(g)(2)(A)(i)) is 

19 amended— 

20 (A) by striking ‘‘of’’ before ‘‘not to exceed’’ 

21 in the second sentence; and 

22 (B) by striking ‘‘each State’s procedures 

23 for the scheduling and conduct of standard sur24 veys to assure that the State’’ and inserting 

25 ‘‘the procedures of each State, or other con26 tractor as chosen by the Secretary, for schedVerDate Mar 15 2010 01:21 Aug 05, 2010 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H6074.IH H6074

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1 uling and conducting standard surveys to as2 sure that the State, or other contractor,’’. 

3 (b) FREQUENCY OF SURVEYS OF TOP TIER AND

4 OTHER FACILITIES.— 

5 (1) MEDICARE.—Section 1819(g)(2)(A)(iii) of 

6 the Social Security Act (42 U.S.C. 1395i– 

7 3(g)(2)(A)(iii)) is amended— 

8 (A) by striking subclause (I); 

9 (B) by redesignating subclause (II) as sub10 clause (III); 

11 (C) in subclause (III), as so redesignated, 

12 by striking ‘‘subclause (I)’’ and inserting ‘‘sub13 clauses (I) and (II)’’; and 

14 (D) by inserting before subclause (III), as 

15 so redesignated, the following subclauses: 

16 ‘‘(I) SURVEYS OF TOP TIER FA17 CILITIES.—Each skilled nursing facil18 ity in the top tier (as defined by the 

19 Secretary in regulations) shall be sub20 ject to a complete on-site standard 

21 survey not later than 36 months after 

22 the date of the previous standard sur23 vey of such facility conducted under 

24 this subparagraph. The statewide av25 erage interval between standard surVerDate Mar 15 2010 01:21 Aug 05, 2010 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H6074.IH H6074

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1 veys of top tier skilled nursing facili2 ties under this subclause shall not ex3 ceed 39 months. Such facilities will 

4 also be subject to quarterly off-site re5 view of acuity-adjusted quality indica6 tors (as identified by the Secretary). 

7 During any year in which a top tier 

8 skilled nursing facility does not re9 ceive a complete on-site standard sur10 vey, such facility will also be subject 

11 to an annual half-day on-site review of 

12 quality of life and safety issues. All 

13 necessary data in connection with 

14 such surveys shall be submitted to the 

15 Secretary by each such top tier skilled 

16 nursing facility at a time and in such 

17 a manner as determined by the Sec18 retary. 

19 ‘‘(II) SURVEYS OF OTHER FA20 CILITIES.—Skilled nursing facilities 

21 not identified in subclause (I) shall be 

22 subject to a complete standard on-site 

23 survey not later than 12 months after 

24 the date of the previous standard sur25 vey of such facility conducted under 


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1 this subparagraph. The statewide av2 erage interval between standard sur3 veys of such facilities shall not exceed 

4 15 months. Such facilities also will be 

5 subject to quarterly off-site review of 

6 acuity-adjusted quality indicators (as 

7 identified by the Secretary). All nec8 essary data in connection with such 

9 surveys shall be submitted to the Sec10 retary by each such facility at a time 

11 and in such a manner as determined 

12 by the Secretary.’’. 

13 (2) MEDICAID.—Section 1919(g)(2)(A)(iii) of 

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

15 1396r(g)(2)(A)(iii)) is amended— 

16 (A) by striking subclause (I); 

17 (B) by redesignating subclause (II) as sub18 clause (III); 

19 (C) in subclause (III), as so redesignated, 

20 by striking ‘‘subclause (I)’’ and inserting ‘‘sub21 clauses (I) and (II)’’; and 

22 (D) by inserting before subclause (III), as 

23 so redesignated, the following subclauses: 

24 ‘‘(I) SURVEYS OF TOP TIER FA25 CILITIES.—Each nursing facility in 


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1 the top tier (as defined by the Sec2 retary in regulations) shall be subject 

3 to a complete on-site standard survey 

4 not later than 36 months after the 

5 date of the previous standard survey 

6 of such facility conducted under this 

7 subparagraph. The statewide average 

8 interval between standard surveys of 

9 top tier nursing facilities under this 

10 subclause shall not exceed 39 months. 

11 Such facilities will also be subject to 

12 quarterly off-site review of acuity-ad13 justed quality indicators (as identified 

14 by the Secretary). During any year in 

15 which a top tier nursing facility does 

16 not receive a complete on-site stand17 ard survey, such facility will also be 

18 subject to an annual half-day on-site 

19 review of quality of life and safety 

20 issues. All necessary data in connec21 tion with such surveys shall be sub22 mitted to the Secretary by each such 

23 top tier nursing facility at a time and 

24 in such a manner as determined by 

25 the Secretary. 


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1 ‘‘(II) SURVEYS OF OTHER FA2 CILITIES.—Nursing facilities not iden3 tified in subclause (I) shall be subject 

4 to a complete standard on-site survey 

5 not later than 12 months after the 

6 date of the previous standard survey 

7 of such facility conducted under this 

8 subparagraph. The statewide average 

9 interval between standard surveys of 

10 such facilities shall not exceed 15 

11 months. Such facilities also will be 

12 subject to quarterly off-site review of 

13 acuity-adjusted quality indicators (as 

14 identified by the Secretary). All nec15 essary data in connection with such 

16 surveys shall be submitted to the Sec17 retary by each such facility at a time 

18 and in such a manner as determined 

19 by the Secretary.’’. 

20 (c) CHANGE IN EFFECTIVE DATES.— 

21 (1) MEDICARE.—Section 1819(g)(2)(C) of the 

22 Social Security Act (42 U.S.C. 1395i–3(g)(2)(C)) is 

23 amended— 

24 (A) in clause (i)— 


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1 (i) by inserting ‘‘(I)’’ before ‘‘based on 

2 a protocol’’; and 

3 (ii) by striking ‘‘, and’’ and inserting 

4 ‘‘; or 

5 ‘‘(II) with respect to surveys con6 ducted on or after the last day of the 24- 

7 month period beginning on the date of the 

8 enactment of the Enhancing Quality 

9 through Survey System Improvements Act 

10 of 2010, based on a revision of protocol 

11 under subclause (I) that has been tested 

12 and validated not later than such last day; 

13 and’’; and 

14 (B) in clause (ii), by striking ‘‘such date’’ 

15 and inserting ‘‘January 1, 1990, or, with re16 spect to surveys conducted on or after the last 

17 day of the 24-month period beginning on the 

18 date of the enactment of the Enhancing Quality 

19 through Survey System Improvements Act of 

20 2010, by such last day.’’. 

21 (2) MEDICAID.—Section 1919(g)(2)(C) of the 

22 Social Security Act (42 U.S.C. 1396r(g)(2)(C)) is 

23 amended— 

24 (A) in clause (i)— 


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1 (i) by inserting ‘‘(I)’’ before ‘‘based on 

2 a protocol’’; and 

3 (ii) by striking ‘‘, and’’ and inserting 

4 ‘‘; or 

5 ‘‘(II) with respect to surveys con6 ducted on or after the last day of the 24- 

7 month period beginning on the date of the 

8 enactment of the Enhancing Quality 

9 through Survey System Improvements Act 

10 of 2010, based on a revision of protocol 

11 under subclause (I) that has been tested 

12 and validated not later than such last day; 

13 and’’; and 

14 (B) in clause (ii), by striking ‘‘such date’’ 

15 and inserting ‘‘January 1, 1990, or, with re16 spect to surveys conducted on or after the last 

17 day of the 24-month period beginning on the 

18 date of the enactment of the Enhancing Quality 

19 through Survey System Improvements Act of 

20 2010, by such last day.’’. 

21 (d) CONSISTENCY OF SURVEYS.— 

22 (1) MEDICARE.—Section 1819(g)(2) of the So23 cial Security Act (42 U.S.C. 1395i–3(g)(2)) is 

24 amended by striking subparagraph (D) and inserting 

25 the following: 


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1 ‘‘(D) CONSISTENCY OF SURVEYS.— 

2 ‘‘(i) IN GENERAL.—Each State shall 

3 implement programs to measure and re4 duce inconsistency in the application of 

5 survey results (including the results of 

6 both health surveys and life safety surveys) 

7 among surveyors. 

8 ‘‘(ii) SECRETARY PROVIDES OVER9 SIGHT.—The Secretary shall take such ac10 tions as necessary to assure that there is 

11 consistent application, both within States 

12 and across States, of the survey process 

13 under this subsection (including the proc14 ess for both health surveys and life safety 

15 surveys). 

16 ‘‘(iii) APPEALS.—The Secretary will 

17 assure that there is a fair and timely ap18 peals process for surveys under this sub19 section (including both health surveys and 

20 life safety surveys) in which each State of21 fice and regional office provides a timely 

22 resolution of disputes. 

23 ‘‘(iv) REPORT.—The Secretary shall 

24 report to the Congress annually, by Octo25 ber 30, on the actions taken to ensure the 


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1 consistency of the survey process within 

2 and across states. Such report shall in3 clude data that assesses the consistency of 

4 the survey process. Such report also shall 

5 provide a summary of the status of appeals 

6 process, including data that assesses the 

7 timeliness of the resolution of disputes.’’. 

8 (2) MEDICAID.—Section 1919(g)(2) of the So9 cial Security Act (42 U.S.C. 1396r(g)(2)) is amend10 ed by striking subparagraph (D) and inserting the 

11 following: 

12 ‘‘(D) CONSISTENCY OF SURVEYS.— 

13 ‘‘(i) IN GENERAL.—Each State shall 

14 implement programs to measure and re15 duce inconsistency in the application of 

16 survey results (including the results of 

17 both health surveys and life safety surveys) 

18 among surveyors. 

19 ‘‘(ii) SECRETARY PROVIDES OVER20 SIGHT.—The Secretary shall take such ac21 tions as necessary to assure that there is 

22 consistent application, both within States 

23 and across States, of the survey process 

24 under this subsection (including the procVerDate Mar 15 2010 01:21 Aug 05, 2010 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H6074.IH H6074

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1 ess for both health surveys and life safety 

2 surveys). 

3 ‘‘(iii) APPEALS.—The Secretary will 

4 assure that there is a fair and timely ap5 peals process for surveys under this sub6 section (including both health surveys and 

7 life safety surveys) in which each State of8 fice and regional office provides a timely 

9 resolution of disputes. 

10 ‘‘(iv) REPORT.—The Secretary shall 

11 report to the Congress annually, by Octo12 ber 30, on the actions taken to ensure the 

13 consistency of the survey process within 

14 and across states. Such report shall in15 clude data that assesses the consistency of 

16 the survey process. Such report also shall 

17 provide a summary of the status of appeals 

18 process, including data that assesses the 

19 timeliness of the resolution of disputes.’’. 

20 (e) CIRCUMSTANCES FOR SPECIAL SURVEYS OF COM21 PLIANCE.— 

22 (1) MEDICARE.—Section 1819(g)(3)(D) of the 

23 Social Security Act (42 U.S.C. 1395i–3(g)(3)(D)) is 

24 amended by striking subparagraph (D) and inserting 

25 the following: 


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1 (A) By inserting ‘‘(I) IN GENERAL.—’’ be2 fore ‘‘Where the Secretary has’’ and adjusting 

3 the indentation appropriately. 

4 (B) By adding at the end the following 

5 new subclause: 

6 ‘‘(II) CIRCUMSTANCES FOR SPE7 CIAL SURVEYS.—The Secretary shall 

8 conduct a survey under subclause (I) 

9 of a skilled nursing facility if, with re10 spect to such facility, any of the fol11 lowing events occurs: 

12 ‘‘(aa) A complaint is made 

13 by a resident or family member 

14 of a resident of such facility. 

15 ‘‘(bb) The skilled nursing fa16 cility self-reports a reportable in17 cident to the State agency re18 sponsible for surveys and certifi19 cations under this subsection. 

20 ‘‘(cc) A quarterly review of 

21 quality indicator data from such 

22 facility suggests a potential prob23 lem at such facility.’’. 


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1 (2) MEDICAID.—Section 1919(g)(3)(D) of the 

2 Social Security Act (42 U.S.C. 1396r(g)(3)(D)) is 

3 amended— 

4 (A) by inserting ‘‘(I) IN GENERAL.—’’ be5 fore ‘‘Where the Secretary has’’ and adjusting 

6 the indentation appropriately; and 

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

8 subclause: 

9 ‘‘(II) CIRCUMSTANCES FOR SPE10 CIAL SURVEYS.—The Secretary shall 

11 conduct a survey under subclause (I) 

12 of a nursing facility if, with respect to 

13 such facility, any of the following 

14 events occurs: 

15 ‘‘(aa) A complaint is made 

16 by a resident or family member 

17 of a resident of such facility. 

18 ‘‘(bb) The nursing facility 

19 self-reports a reportable incident 

20 to the State agency responsible 

21 for surveys and certifications 

22 under this subsection. 

23 ‘‘(cc) A quarterly review of 

24 quality indicator data from such 


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1 facility suggests a potential prob2 lem at such facility.’’. 

3 (f) NOTICE TO FACILITIES AND THE PUBLIC.— 

4 (1) MEDICARE.—Section 1819(g)(5) of the So5 cial Security Act (42 U.S.C. 1395i–3(g)(5)) is 

6 amended— 

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

8 ‘‘statements of deficiencies’’ and inserting ‘‘re9 ports of surveys under subparagraph (F)’’; and 

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

11 subparagraph: 

12 ‘‘(F) NOTICE TO FACILITY.—A written re13 port of the survey must be given to the skilled 

14 nursing facility within 15 calendar days fol15 lowing the date the survey team exited the facil16 ity. The report of the survey must include all 

17 the positive aspects of care and facility life as 

18 well as the aspects of care that may need im19 provement.’’. 

20 (2) MEDICAID.—Section 1919(g)(5) of the So21 cial Security Act (42 U.S.C. 1396r(g)(5)) is amend22 ed— 

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

24 ‘‘statements of deficiencies’’ and inserting ‘‘re25 ports of surveys under subparagraph (F)’’; and 


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

2 subparagraph: 

3 ‘‘(F) NOTICE TO FACILITY.—A written re4 port of the survey must be given to the nursing 

5 facility within 15 calendar days following the 

6 date the survey team exited the facility. The re7 port of the survey must include all the positive 

8 aspects of care and facility life as well as the 

9 aspects of care that may need improvement.’’. 

10 (g) TREATMENT OF FUNDS COLLECTED FROM CIVIL

11 MONETARY PENALTIES.— 

12 (1) MEDICARE.—Section 1819(h)(2)(A) of the 

13 Social Security Act (42 U.S.C. 1395i–3(h)(2)(A)) is 

14 amended by adding at the end (in the flush matter 

15 following clause (ii)) the following sentence: ‘‘Not16 withstanding the previous sentence, any funds col17 lected by a State as a result of the imposition of 

18 such a penalty (or as a result of the imposition by 

19 the State of a civil money penalty for activities de20 scribed in subsections (b)(3)(B)(ii)(I), 

21 (b)(3)(B)(ii)(II), or (g)(2)(A)(i)) shall be used for 

22 development of acuity adjusters that will provide 

23 more accurate information to the public, skilled 

24 nursing facilities, and the residents of such facilities, 


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1 about the quality of care that is provided by each 

2 such facility.’’. 

3 (2) MEDICAID.—Section 1919(h)(2)(A)(ii) of 

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

5 1396r(h)(2)(A)(ii)) is amended by adding at the end 

6 (in the flush matter following clause (ii)) the fol7 lowing sentence: ‘‘Notwithstanding the previous sen8 tence, any funds collected by a State as a result of 

9 the imposition of such a penalty (or as a result of 

10 the imposition by the State of a civil money penalty 

11 for activities described in subsections 

12 (b)(3)(B)(ii)(I), (b)(3)(B)(ii)(II), or (g)(2)(A)(i)) 

13 shall be used for development of acuity adjusters 

14 that will provide more accurate information to the 

15 public, nursing facilities, and the residents of such 

16 facilities, about the quality of care that is provided 

17 by each such facility.’’. 

Æ 


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