515 
SEC. 1304. PAYMENT INCENTIVE FOR SELECTED PRIMARY 
CARE SERVICES. 
(a) IN GENERAL.—Section 1833 of the Social Security 
Act is amended by inserting after subsection (o) the fol-
lowing new subsection: 
‘‘(p) PRIMARY CARE PAYMENT INCENTIVES.— 
‘‘(1) IN GENERAL.—In the case of primary care 
services (as defined in paragraph (2)) furnished on or 
after January 1, 2011, by a primary care practi-
tioner (as defined in paragraph (3)) for which 
amounts are payable under section 1848, in addition 
to the amount otherwise paid under this part there 
shall also be paid to the practitioner (or to an em-
ployer or facility in the cases described in clause (A) 
of section 1842(b)(6)) (on a monthly or quarterly 
basis) from the Federal Supplementary Medical In-
surance Trust Fund an amount equal 5 percent (or 
10 percent if the practitioner predominately furnishes 
such services in an area that is designated (under sec-
tion 332(a)(1)(A) of the Public Health Service Act) as 
a primary care health professional shortage area. 
‘‘(2) PRIMARY
CARE
SERVICES
DEFINED.—In 
this subsection, the term ‘primary care services’— 
‘‘(A) means services which are evaluation 
and management services as defined in section 
1848(j)(5)(A); and 
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‘‘(B) includes services furnished by another 
health care professional that would be described 
in subparagraph (A) if furnished by a physician. 
‘‘(3) PRIMARY CARE PRACTITIONER DEFINED.— 
In this subsection, the term ‘primary care practi-
tioner’— 
‘‘(A) means a physician or other health care 
practitioner (including a nurse practitioner) 
who— 
‘‘(i) specializes in family medicine, 
general internal medicine, general pediat-
rics, geriatrics, or obstetrics and gynecology; 
and 
‘‘(ii) has allowed charges for primary 
care services that account for at least 50 
percent of the physician’s or practitioner’s 
total allowed charges under section 1848, as 
determined by the Secretary for the most re-
cent period for which data are available; 
and 
‘‘(B) includes a physician assistant who is 
under the supervision of a physician described in 
subparagraph (A). 
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‘‘(4) LIMITATION ON REVIEW.—There shall be no 
administrative or judicial review under section 1869, 
section 1878, or otherwise, respecting— 
‘‘(A) any determination or designation 
under this subsection; 
‘‘(B) the identification of services as pri-
mary care services under this subsection; and 
‘‘(C) the identification of a practitioner as 
a primary care practitioner under this sub-
section. 
‘‘(5) COORDINATION WITH OTHER PAYMENTS.— 
‘‘(A) WITH OTHER PRIMARY CARE INCEN-
TIVES.—The provisions of this subsection shall 
not be taken into account in applying sub-
sections (m) and (u) and any payment under 
such subsections shall not be taken into account 
in computing payments under this subsection. 
‘‘(B) WITH
QUALITY
INCENTIVES.—Pay-
ments under this subsection shall not be taken 
into account in determining the amounts that 
would otherwise be paid under this part for pur-
poses of section 1834(g)(2)(B).’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 1833(m) of such Act (42 U.S.C. 
1395l(m)) is amended by redesignating paragraph (4) 
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as paragraph (5) and by inserting after paragraph 
(3) the following new paragraph: 
‘‘(4) The provisions of this subsection shall not be taken 
into account in applying subsections (m) or (u) and any 
payment under such subsections shall not be taken into ac-
count in computing payments under this subsection.’’. 
(2) Section 1848(m)(5)(B) of such Act (42 
U.S.C. 1395w–4(m)(5)(B)) is amended by inserting ‘‘, 
(p),’’ after ‘‘(m)’’. 
(3) Section 1848(o)(1)(B)(iv) of such Act (42 
U.S.C. 1395w–4(o)(1)(B)(iv)) is amended by insert-
ing ‘‘primary care’’ before ‘‘health professional short-
age area’’. 
SEC. 1305. INCREASED REIMBURSEMENT RATE FOR CER-
TIFIED NURSE-MIDWIVES. 
(a) IN GENERAL.—Section 1833(a)(1)(K) of the Social 
Security Act (42 U.S.C.1395l(a)(1)(K)) is amended by 
striking ‘‘(but in no event’’ and all that follows through 
‘‘performed by a physician)’’. 
(b) EFFECTIVE DATE.—The amendment made by sub-
section (a) shall apply to services furnished on or after Jan-
uary 1, 2011. 
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SEC. 1306. COVERAGE AND WAIVER OF COST-SHARING FOR 
PREVENTIVE SERVICES. 
(a) MEDICARE COVERED PREVENTIVE SERVICES DE-
FINED.—Section 1861 of the Social Security Act (42 U.S.C. 
1395x), as amended by section 1233(a), is amended by add-
ing at the end the following new subsection: 
‘‘Medicare Covered Preventive Services 
‘‘(iii)(1) Subject to the succeeding provisions of this 
subsection, the term ‘Medicare covered preventive services’ 
means the following: 
‘‘(A) Prostate cancer screening tests (as defined 
in subsection (oo)). 
‘‘(B) Colorectal cancer screening tests (as defined 
in subsection (pp) and when applicable as described 
in section 1305). 
‘‘(C) Diabetes outpatient self-management train-
ing services (as defined in subsection (qq)). 
‘‘(D) Screening for glaucoma for certain individ-
uals (as described in subsection (s)(2)(U)). 
‘‘(E) Medical nutrition therapy services for cer-
tain 
individuals 
(as 
described 
in 
subsection 
(s)(2)(V)). 
‘‘(F) An initial preventive physical examination 
(as defined in subsection (ww)). 
‘‘(G) Cardiovascular screening blood tests (as de-
fined in subsection (xx)(1)). 
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‘‘(H) Diabetes screening tests (as defined in sub-
section (yy)). 
‘‘(I) Ultrasound screening for abdominal aortic 
aneurysm for certain individuals (as described in de-
scribed in subsection (s)(2)(AA)). 
‘‘(J) Pneumococcal and influenza vaccines and 
their administration (as described in subsection 
(s)(10)(A)) and hepatitis B vaccine and its adminis-
tration for certain individuals (as described in sub-
section (s)(10)(B)). 
‘‘(K) Screening mammography (as defined in 
subsection (jj)). 
‘‘(L) Screening pap smear and screening pelvic 
exam (as defined in subsection (nn)). 
‘‘(M) Bone mass measurement (as defined in 
subsection (rr)). 
‘‘(N) Kidney disease education services (as de-
fined in subsection (ggg)). 
‘‘(O) Additional preventive services (as defined 
in subsection (ddd)). 
‘‘(2) With respect to specific Medicare covered preven-
tive services, the limitations and conditions described in the 
provisions referenced in paragraph (1) with respect to such 
services shall apply.’’. 
(b) PAYMENT AND ELIMINATION OF COST-SHARING.— 
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(3) WAIVER
OF
APPLICATION
OF
DEDUCTIBLE 
FOR ALL PREVENTIVE SERVICES.—The first sentence 
of section 1833(b) of the Social Security Act (42 
U.S.C. 1395l(b)) is amended— 
(A) in clause (1), by striking ‘‘items and 
services described in section 1861(s)(10)(A)’’ and 
inserting ‘‘Medicare covered preventive services 
(as defined in section 1861(iii))’’; and 
(B) by striking clause (5) and all that fol-
lows through ‘‘(9)’’ and inserting ‘‘and (5)’’. 
(4) APPLICATION TO PROVIDERS OF SERVICES.— 
Section 1866(a)(2)(A)(ii) of such Act (42 U.S.C. 
1395cc(a)(2)(A)(ii)) is amended by inserting ‘‘other 
than for Medicare covered preventive services and’’ 
after ‘‘for such items and services (’’. 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall apply to services furnished on or after January 
1, 2011. 
(d) REPORT TO CONGRESS ON BARRIERS TO PREVEN-
TIVE SERVICES.—Not later than 12 months after the date 
of the enactment of this Act, the Secretary of Health and 
Human Services shall report to Congress on Medicare bene-
ficiary barriers, such as physician referral requirements or 
being a part of the Welcome to Medicare Physical Exam, 
to abdominal aortic aneurysm screening and other prevent-
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ative services as approved by the U.S. Preventive Services 
Task Force. Furthermore, using existing educational re-
sources, the Secretary shall make educating patients and 
physicians regarding the risk factors for an abdominal aor-
tic aneurysm and when beneficiaries should be screened, a 
priority. 
SEC. 1307. WAIVER OF DEDUCTIBLE FOR COLORECTAL CAN-
CER 
SCREENING 
TESTS 
REGARDLESS 
OF 
CODING, SUBSEQUENT DIAGNOSIS, OR ANCIL-
LARY TISSUE REMOVAL. 
(a) IN GENERAL.—Section 1833(b) of the Social Secu-
rity Act (42 U.S.C. 1395l(b)), as amended by section 
1306(b)(3), is amended by adding at the end the following 
new sentence: ‘‘Clause (1) of the first sentence of this sub-
section shall apply with respect to a colorectal cancer 
screening test regardless of the code that is billed for the 
establishment of a diagnosis as a result of the test, or for 
the removal of tissue or other matter or other procedure that 
is furnished in connection with, as a result of, and in the 
same clinical encounter as, the screening test.’’. 
(b) EFFECTIVE DATE.—The amendment made by sub-
section (a) shall apply to items and services furnished on 
or after January 1, 2011. 
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SEC. 1308. EXCLUDING CLINICAL SOCIAL WORKER SERV-
ICES FROM COVERAGE UNDER THE MEDI-
CARE SKILLED NURSING FACILITY PROSPEC-
TIVE PAYMENT SYSTEM AND CONSOLIDATED 
PAYMENT. 
(a) IN GENERAL.—Section 1888(e)(2)(A)(ii) of the So-
cial Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amend-
ed by inserting ‘‘clinical social worker services,’’ after 
‘‘qualified psychologist services,’’. 
(b) CONFORMING AMENDMENT.—Section 1861(hh)(2) 
of the Social Security Act (42 U.S.C. 1395x(hh)(2)) is 
amended by striking ‘‘and other than services furnished to 
an inpatient of a skilled nursing facility which the facility 
is required to provide as a requirement for participation’’. 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall apply to items and services furnished on or 
after July 1, 2010. 
SEC. 1309. COVERAGE OF MARRIAGE AND FAMILY THERA-
PIST SERVICES AND MENTAL HEALTH COUN-
SELOR SERVICES. 
(a) COVERAGE OF MARRIAGE AND FAMILY THERAPIST 
SERVICES.— 
(1) COVERAGE OF SERVICES.—Section 1861(s)(2) 
of the Social Security Act (42 U.S.C. 1395x(s)(2)), as 
amended by section 1233, is amended— 
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(A) in subparagraph (EE), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (FF), by adding 
‘‘and’’ at the end; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(GG) marriage and family therapist services 
(as defined in subsection (jjj));’’. 
(2) DEFINITION.—Section 1861 of the Social Se-
curity Act (42 U.S.C. 1395x), as amended by sections 
1233 and 1306, is amended by adding at the end the 
following new subsection: 
‘‘Marriage and Family Therapist Services 
‘‘(jjj)(1) The term ‘marriage and family therapist serv-
ices’ means services performed by a marriage and family 
therapist (as defined in paragraph (2)) for the diagnosis 
and treatment of mental illnesses, which the marriage and 
family therapist is legally authorized to perform under 
State law (or the State regulatory mechanism provided by 
State law) of the State in which such services are performed, 
as would otherwise be covered if furnished by a physician 
or as incident to a physician’s professional service, but only 
if no facility or other provider charges or is paid any 
amounts with respect to the furnishing of such services. 
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‘‘(2) The term ‘marriage and family therapist’ means 
an individual who— 
‘‘(A) possesses a master’s or doctoral degree 
which qualifies for licensure or certification as a mar-
riage and family therapist pursuant to State law; 
‘‘(B) after obtaining such degree has performed 
at least 2 years of clinical supervised experience in 
marriage and family therapy; and 
‘‘(C) is licensed or certified as a marriage and 
family therapist in the State in which marriage and 
family therapist services are performed.’’. 
(3) PROVISION FOR PAYMENT UNDER PART B.— 
Section 1832(a)(2)(B) of the Social Security Act (42 
U.S.C. 1395k(a)(2)(B)) is amended by adding at the 
end the following new clause: 
‘‘(v) marriage and family therapist 
services;’’. 
(4) AMOUNT OF PAYMENT.— 
(A) IN GENERAL.—Section 1833(a)(1) of the 
Social Security Act (42 U.S.C. 1395l(a)(1)) is 
amended— 
(i) by striking ‘‘and’’ before ‘‘(W)’’; 
and 
(ii) by inserting before the semicolon at 
the end the following: ‘‘, and (X) with re-
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1308(a), is amended by inserting ‘‘marriage and fam-
ily therapist services (as defined in subsection 
(jjj)(1)),’’ after ‘‘clinical social worker services,’’. 
(6) COVERAGE OF MARRIAGE AND FAMILY THER-
APIST SERVICES PROVIDED IN RURAL HEALTH CLIN-
ICS AND FEDERALLY QUALIFIED HEALTH CENTERS.— 
Section 1861(aa)(1)(B) of the Social Security Act (42 
U.S.C. 1395x(aa)(1)(B)) is amended by striking ‘‘or 
by a clinical social worker (as defined in subsection 
(hh)(1)),’’ and inserting ‘‘, by a clinical social worker 
(as defined in subsection (hh)(1)), or by a marriage 
and family therapist (as defined in subsection 
(jjj)(2)),’’. 
(7) INCLUSION
OF
MARRIAGE
AND
FAMILY 
THERAPISTS AS PRACTITIONERS FOR ASSIGNMENT OF 
CLAIMS.—Section 1842(b)(18)(C) of the Social Secu-
rity Act (42 U.S.C. 1395u(b)(18)(C)) is amended by 
adding at the end the following new clause: 
‘‘(vii) A marriage and family therapist (as de-
fined in section 1861(jjj)(2)).’’. 
(b) COVERAGE
OF MENTAL HEALTH COUNSELOR 
SERVICES.— 
(1) COVERAGE OF SERVICES.—Section 1861(s)(2) 
of the Social Security Act (42 U.S.C. 1395x(s)(2)), as 
previously amended, is further amended— 
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531 
‘‘(2) The term ‘mental health counselor’ means an in-
dividual who— 
‘‘(A) possesses a master’s or doctor’s degree which 
qualifies the individual for licensure or certification 
for the practice of mental health counseling in the 
State in which the services are performed; 
‘‘(B) after obtaining such a degree has performed 
at least 2 years of supervised mental health counselor 
practice; and 
‘‘(C) is licensed or certified as a mental health 
counselor or professional counselor by the State in 
which the services are performed.’’. 
(3) PROVISION FOR PAYMENT UNDER PART B.— 
Section 1832(a)(2)(B) of the Social Security Act (42 
U.S.C. 1395k(a)(2)(B)), as amended by subsection 
(a)(3), is further amended— 
(A) by striking ‘‘and’’ at the end of clause 
(iv); 
(B) by adding ‘‘and’’ at the end of clause 
(v); and 
(C) by adding at the end the following new 
clause: 
‘‘(vi) mental health counselor services; 
and’’. 
(4) AMOUNT OF PAYMENT.— 
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(A) IN GENERAL.—Section 1833(a)(1) of the 
Social Security Act (42 U.S.C. 1395l(a)(1)), as 
amended by subsection (a), is further amended— 
(i) by striking ‘‘and’’ before ‘‘(X)’’; and 
(ii) by inserting before the semicolon at 
the end the following: ‘‘, and (Y) with re-
spect to mental health counselor services 
under section 1861(s)(2)(HH), the amounts 
paid shall be 80 percent of the lesser of the 
actual charge for the services or 75 percent 
of the amount determined for payment of a 
psychologist under clause (L)’’. 
(B) DEVELOPMENT OF CRITERIA WITH RE-
SPECT TO CONSULTATION WITH A PHYSICIAN.— 
The Secretary of Health and Human Services 
shall, taking into consideration concerns for pa-
tient confidentiality, develop criteria with re-
spect to payment for mental health counselor 
services for which payment may be made directly 
to the mental health counselor under part B of 
title XVIII of the Social Security Act (42 U.S.C. 
1395j et seq.) under which such a counselor must 
agree to consult with a patient’s attending or 
primary care physician in accordance with such 
criteria. 
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(5) EXCLUSION OF MENTAL HEALTH COUNSELOR 
SERVICES
FROM
SKILLED
NURSING
FACILITY
PRO-
SPECTIVE
PAYMENT
SYSTEM.—Section 
1888(e)(2)(A)(ii) of the Social Security Act (42 
U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 
1308(a) and subsection (a), is amended by inserting 
‘‘mental health counselor services (as defined in sec-
tion 1861(kkk)(1)),’’ after ‘‘marriage and family ther-
apist services (as defined in subsection (jjj)(1)),’’. 
(6) COVERAGE OF MENTAL HEALTH COUNSELOR 
SERVICES PROVIDED IN RURAL HEALTH CLINICS AND 
FEDERALLY QUALIFIED HEALTH CENTERS.—Section 
1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 
1395x(aa)(1)(B)), as amended by subsection (a), is 
amended by striking ‘‘or by a marriage and family 
therapist (as defined in subsection (jjj)(2)),’’ and in-
serting ‘‘by a marriage and family therapist (as de-
fined in subsection (jjj)(2)), or a mental health coun-
selor (as defined in subsection (kkk)(2)),’’. 
(7) INCLUSION OF MENTAL HEALTH COUNSELORS 
AS PRACTITIONERS FOR ASSIGNMENT OF CLAIMS.— 
Section 1842(b)(18)(C) of the Social Security Act (42 
U.S.C. 1395u(b)(18)(C)), as amended by subsection 
(a)(7), is amended by adding at the end the following 
new clause: 
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‘‘(viii) A mental health counselor (as defined in 
section 1861(kkk)(2)).’’. 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall apply to items and services furnished on or 
after January 1, 2011. 
SEC. 1310. EXTENSION OF PHYSICIAN FEE SCHEDULE MEN-
TAL HEALTH ADD-ON. 
Section 138(a)(1) of the Medicare Improvements for 
Patients and Providers Act of 2008 (Public Law 110–275) 
is amended by striking ‘‘December 31, 2009’’ and inserting 
‘‘December 31, 2011’’. 
SEC. 1311. EXPANDING ACCESS TO VACCINES. 
(a) IN GENERAL.—Paragraph (10) of section 1861(s) 
of the Social Security Act (42 U.S.C. 1395w(s)) is amended 
to read as follows: 
‘‘(10) federally recommended vaccines (as defined 
in subsection (lll)) and their respective administra-
tion;’’. 
(b) 
FEDERALLY
RECOMMENDED
VACCINES
DE-
FINED.—Section 1861 of such Act, as previously amended, 
is further amended by adding at the end the following new 
subsection: 
‘‘Federally Recommended Vaccines 
‘‘(lll) The term ‘federally recommended vaccine’ means 
an approved vaccine recommended by the Advisory Com-
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535 
mittee on Immunization Practices (an advisory committee 
established by the Secretary, acting through the Director of 
the Centers for Disease Control and Prevention).’’. 
(c) CONFORMING AMENDMENTS.— 
(1) Section 1833 of such Act (42 U.S.C. 1395l) 
is amended, in each of subsections (a)(1)(B), 
(a)(2)(G), (a)(3)(A), by striking ‘‘1861(s)(10)(A)’’ 
and inserting ‘‘1861(s)(10)’’ each place it appears. 
(2) Section 1842(o)(1)(A)(iv) of such Act (42 
U.S.C. 1395u(o)(1)(A)(iv)) is amended— 
(A) by striking ‘‘subparagraph (A) or (B) 
of’’; and 
(B) by inserting before the period the fol-
lowing: ‘‘and before January 1, 2011, and influ-
enza vaccines furnished on or after January 1, 
2011’’. 
(3) Section 1847A(c)(6) of such Act (42 U.S.C. 
1395w–3a(c)(6)) is amended by striking subpara-
graph (G) and inserting the following: 
‘‘(G) IMPLEMENTATION.—Chapter 35 of 
title 44, United States Code shall not apply to 
manufacturer provision of information pursuant 
to section 1927(b)(3)(A)(iii) for purposes of im-
plementation of this section.’’. 
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(4) Section 1860D–2(e)(1) of such Act (42 U.S.C. 
1395w–102(e)(1)) is amended by striking ‘‘such term 
includes a vaccine’’ and all that follows through ‘‘its 
administration) and’’. 
(5) Section 1861(ww)(2)(A) of such Act (42 
U.S.C. 1395x(ww)(2)(A))) is amended by striking 
‘‘Pneumococcal, influenza, and hepatitis B vaccine 
and administration’’ and inserting ‘‘Federally rec-
ommended vaccines (as defined in subsection (lll)) 
and their respective administration’’. 
(6) Section 1861(iii)(1) of such Act, as added by 
section 1306(a), is amended by amending subpara-
graph (J) to read as follows: 
‘‘(J) Federally recommended vaccines (as defined 
in subsection (lll)) and their respective administra-
tion.’’. 
(7) Section 1927(b)(3)(A)(iii) of such Act (42 
U.S.C. 1396r–8(b)(3)(A)(iii)) is amended, in the mat-
ter following subclause (III), by inserting ‘‘(A)(iv) 
(including influenza vaccines furnished on or after 
January 1, 2011),’’ after ‘‘described in subpara-
graph’’ 
(d) EFFECTIVE DATES.—The amendments made by— 
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(1) this section (other than by subsection (c)(7)) 
shall apply to vaccines administered on or after Jan-
uary 1, 2011; and 
(2) by subsection (c)(7) shall apply to calendar 
quarters beginning on or after January 1, 2010. 
SEC. 1312. RECOGNITION OF CERTIFIED DIABETES EDU-
CATORS AS CERTIFIED PROVIDERS FOR PUR-
POSES OF MEDICARE DIABETES OUTPATIENT 
SELF-MANAGEMENT TRAINING SERVICES. 
(a) IN GENERAL.—Section 1861(qq) of the Social Se-
curity Act (42 U.S.C. 1395x(qq)) is amended— 
(1) in paragraph (1), by inserting ‘‘or by a cer-
tified diabetes educator (as defined in paragraph 
(3))’’ after ‘‘paragraph (2)(B)’’; and 
(2) by adding at the end the following new para-
graphs: 
‘‘(3) For purposes of paragraph (1), the term 
‘certified diabetes educator’ means an individual 
who— 
‘‘(A) is licensed or registered by the State in 
which the services are performed as a health care 
professional; 
‘‘(B) specializes in teaching individuals 
with diabetes to develop the necessary skills and 
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knowledge to manage the individual’s diabetic 
condition; and 
‘‘(C) is certified as a diabetes educator by 
a recognized certifying body (as defined in para-
graph (4)). 
‘‘(4)(A) For purposes of paragraph (3)(C), the 
term ‘recognized certifying body’ means— 
‘‘(i) the National Certification Board for 
Diabetes Educators, or 
‘‘(ii) a certifying body for diabetes edu-
cators, which is recognized by the Secretary as 
authorized to grant certification of diabetes edu-
cators for purposes of this subsection pursuant to 
standards established by the Secretary, if the 
Secretary determines such Board or body, respec-
tively, meets the requirement of subparagraph 
(B). 
‘‘(B) The National Certification Board for Dia-
betes Educators or a certifying body for diabetes edu-
cators meets the requirement of this subparagraph, 
with respect to the certification of an individual, if 
the Board or body, respectively, is incorporated and 
registered to do business in the United States and re-
quires as a condition of such certification each of the 
following: 
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‘‘(i) The individual has a qualifying creden-
tial in a specified health care profession. 
‘‘(ii) The individual has professional prac-
tice experience in diabetes self-management 
training that includes a minimum number of 
hours and years of experience in such training. 
‘‘(iii) The individual has successfully com-
pleted a national certification examination of-
fered by such entity. 
‘‘(iv) The individual periodically renews 
certification status following initial certifi-
cation.’’. 
(b) EFFECTIVE DATE.—The amendments made by sub-
section (a) shall apply to diabetes outpatient self-manage-
ment training services furnished on or after the first day 
of the first calendar year that is at least 6 months after 
the date of the enactment of this Act. 
TITLE IV—QUALITY 
Subtitle A—Comparative 
Effectiveness Research 
SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH. 
(a) IN GENERAL.—Title XI of the Social Security Act 
is amended by adding at the end the following new part: 
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‘‘PART D—COMPARATIVE EFFECTIVENESS RESEARCH 
‘‘COMPARATIVE EFFECTIVENESS RESEARCH 
‘‘SEC. 1181. (a) CENTER FOR COMPARATIVE EFFEC-
TIVENESS RESEARCH ESTABLISHED.— 
‘‘(1) IN GENERAL.—The Secretary shall establish 
within the Agency for Healthcare Research and Qual-
ity a Center for Comparative Effectiveness Research 
(in this section referred to as the ‘Center’) to conduct, 
support, and synthesize research (including research 
conducted or supported under section 1013 of the 
Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003) with respect to the outcomes, 
effectiveness, and appropriateness of health care serv-
ices and procedures in order to identify the manner 
in which diseases, disorders, and other health condi-
tions can most effectively and appropriately be pre-
vented, diagnosed, treated, and managed clinically. 
‘‘(2) DUTIES.—The Center shall— 
‘‘(A) conduct, support, and synthesize re-
search relevant to the comparative effectiveness of 
the full spectrum of health care items, services 
and systems, including pharmaceuticals, medical 
devices, medical and surgical procedures, and 
other medical interventions; 
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‘‘(B) conduct and support systematic re-
views of clinical research, including original re-
search conducted subsequent to the date of the en-
actment of this section; 
‘‘(C) continuously develop rigorous scientific 
methodologies for conducting comparative effec-
tiveness studies, and use such methodologies ap-
propriately; 
‘‘(D) submit to the Comparative Effective-
ness Research Commission, the Secretary, and 
Congress appropriate relevant reports described 
in subsection (d)(2); and 
‘‘(E) encourage, as appropriate, the develop-
ment and use of clinical registries and the devel-
opment of clinical effectiveness research data net-
works from electronic health records, post mar-
keting drug and medical device surveillance ef-
forts, and other forms of electronic health data. 
‘‘(3) POWERS.— 
‘‘(A) OBTAINING OFFICIAL DATA.—The Cen-
ter may secure directly from any department or 
agency of the United States information nec-
essary to enable it to carry out this section. 
Upon request of the Center, the head of that de-
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partment or agency shall furnish that informa-
tion to the Center on an agreed upon schedule. 
‘‘(B) DATA COLLECTION.—In order to carry 
out its functions, the Center shall— 
‘‘(i) utilize existing information, both 
published and unpublished, where possible, 
collected and assessed either by its own staff 
or under other arrangements made in ac-
cordance with this section, 
‘‘(ii) carry out, or award grants or 
contracts for, original research and experi-
mentation, where existing information is 
inadequate, and 
‘‘(iii) adopt procedures allowing any 
interested party to submit information for 
the use by the Center and Commission 
under subsection (b) in making reports and 
recommendations. 
‘‘(C) ACCESS OF GAO TO INFORMATION.— 
The Comptroller General shall have unrestricted 
access to all deliberations, records, and non-
proprietary data of the Center and Commission 
under subsection (b), immediately upon request. 
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‘‘(D) PERIODIC
AUDIT.—The Center and 
Commission under subsection (b) shall be subject 
to periodic audit by the Comptroller General. 
‘‘(b) OVERSIGHT BY COMPARATIVE EFFECTIVENESS 
RESEARCH COMMISSION.— 
‘‘(1) IN GENERAL.—The Secretary shall establish 
an independent Comparative Effectiveness Research 
Commission (in this section referred to as the ‘Com-
mission’) to oversee and evaluate the activities carried 
out by the Center under subsection (a), subject to the 
authority of the Secretary, to ensure such activities 
result in highly credible research and information re-
sulting from such research. 
‘‘(2) DUTIES.—The Commission shall— 
‘‘(A) determine national priorities for re-
search described in subsection (a) and in making 
such determinations consult with a broad array 
of public and private stakeholders, including pa-
tients and health care providers and payers; 
‘‘(B) monitor the appropriateness of use of 
the CERTF described in subsection (g) with re-
spect to the timely production of comparative ef-
fectiveness research determined to be a national 
priority under subparagraph (A); 
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‘‘(C) identify highly credible research meth-
ods and standards of evidence for such research 
to be considered by the Center; 
‘‘(D) review the methodologies developed by 
the center under subsection (a)(2)(C); 
‘‘(E) not later than one year after the date 
of the enactment of this section, enter into an ar-
rangement under which the Institute of Medicine 
of the National Academy of Sciences shall con-
duct an evaluation and report on standards of 
evidence for such research; 
‘‘(F) support forums to increase stakeholder 
awareness and permit stakeholder feedback on 
the efforts of the Center to advance methods and 
standards that promote highly credible research; 
‘‘(G) make recommendations for policies 
that would allow for public access of data pro-
duced under this section, in accordance with ap-
propriate privacy and proprietary practices, 
while ensuring that the information produced 
through such data is timely and credible; 
‘‘(H) appoint a clinical perspective advi-
sory panel for each research priority determined 
under subparagraph (A), which shall consult 
with patients and advise the Center on research 
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questions, methods, and evidence gaps in terms 
of clinical outcomes for the specific research in-
quiry to be examined with respect to such pri-
ority to ensure that the information produced 
from such research is clinically relevant to deci-
sions made by clinicians and patients at the 
point of care; 
‘‘(I) make recommendations for the priority 
for periodic reviews of previous comparative ef-
fectiveness research and studies conducted by the 
Center under subsection (a); 
‘‘(J) routinely review processes of the Center 
with respect to such research to confirm that the 
information produced by such research is objec-
tive, credible, consistent with standards of evi-
dence established under this section, and devel-
oped through a transparent process that includes 
consultations with appropriate stakeholders; and 
‘‘(K) make recommendations to the center 
for the broad dissemination of the findings of re-
search conducted and supported under this sec-
tion that enables clinicians, patients, consumers, 
and payers to make more informed health care 
decisions that improve quality and value. 
‘‘(3) COMPOSITION OF COMMISSION.— 
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‘‘(A) IN
GENERAL.—The members of the 
Commission shall consist of— 
‘‘(i) the Director of the Agency for 
Healthcare Research and Quality; 
‘‘(ii) the Chief Medical Officer of the 
Centers for Medicare & Medicaid Services; 
and 
‘‘(iii) 15 additional members who shall 
represent broad constituencies of stake-
holders including clinicians, patients, re-
searchers, third-party payers, consumers of 
Federal and State beneficiary programs. 
Of such members, at least 9 shall be practicing 
physicians, health care practitioners, consumers, 
or patients. 
‘‘(B) QUALIFICATIONS.— 
‘‘(i) DIVERSE
REPRESENTATION
OF 
PERSPECTIVES.—The members of the Com-
mission shall represent a broad range of 
perspectives and shall collectively have expe-
rience in the following areas: 
‘‘(I) Epidemiology. 
‘‘(II) Health services research. 
‘‘(III) Bioethics. 
‘‘(IV) Decision sciences. 
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‘‘(V) Health disparities. 
‘‘(VI) Economics. 
‘‘(ii) DIVERSE
REPRESENTATION
OF 
HEALTH
CARE
COMMUNITY.—At least one 
member shall represent each of the following 
health care communities: 
‘‘(I) Patients. 
‘‘(II) Health care consumers. 
‘‘(III) Practicing Physicians, in-
cluding surgeons. 
‘‘(IV) Other health care practi-
tioners engaged in clinical care. 
‘‘(V) Employers. 
‘‘(VI) Public payers. 
‘‘(VII) Insurance plans. 
‘‘(VIII) Clinical researchers who 
conduct research on behalf of pharma-
ceutical or device manufacturers. 
‘‘(C) LIMITATION.—No more than 3 of the 
Members of the Commission may be representa-
tives of pharmaceutical or device manufacturers 
and such representatives shall be clinical re-
searchers 
described 
under 
subparagraph 
(B)(ii)(VIII). 
‘‘(4) APPOINTMENT.— 
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‘‘(A) IN GENERAL.—The Secretary shall ap-
point the members of the Commission. 
‘‘(B) CONSULTATION.—In considering can-
didates for appointment to the Commission, the 
Secretary may consult with the Government Ac-
countability Office and the Institute of Medicine 
of the National Academy of Sciences. 
‘‘(5) CHAIRMAN; VICE CHAIRMAN.—The Secretary 
shall designate a member of the Commission, at the 
time of appointment of the member, as Chairman and 
a member as Vice Chairman for that term of appoint-
ment, except that in the case of vacancy of the Chair-
manship or Vice Chairmanship, the Secretary may 
designate another member for the remainder of that 
member’s term. The Chairman shall serve as an ex 
officio member of the National Advisory Council of 
the Agency for Health Care Research and Quality 
under section 931(c)(3)(B) of the Public Health Serv-
ice Act. 
‘‘(6) TERMS.— 
‘‘(A) IN GENERAL.—Except as provided in 
subparagraph (B), each member of the Commis-
sion shall be appointed for a term of 4 years. 
‘‘(B) TERMS OF INITIAL APPOINTEES.—Of 
the members first appointed— 
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‘‘(i) 8 shall be appointed for a term of 
4 years; and 
‘‘(ii) 7 shall be appointed for a term of 
3 years. 
‘‘(7) COORDINATION.—To enhance effectiveness 
and coordination, the Secretary is encouraged, to the 
greatest extent possible, to seek coordination between 
the Commission and the National Advisory Council of 
the Agency for Healthcare Research and Quality. 
‘‘(8) CONFLICTS OF INTEREST.— 
‘‘(A) IN
GENERAL.—In appointing the 
members of the Commission or a clinical per-
spective advisory panel described in paragraph 
(2)(H), the Secretary or the Commission, respec-
tively, shall take into consideration any finan-
cial interest (as defined in subparagraph (D)), 
consistent with this paragraph, and develop a 
plan for managing any identified conflicts. 
‘‘(B) EVALUATION
AND
CRITERIA.—When 
considering an appointment to the Commission 
or a clinical perspective advisory panel described 
paragraph (2)(H) the Secretary or the Commis-
sion shall review the expertise of the individual 
and the financial disclosure report filed by the 
individual pursuant to the Ethics in Govern-
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ment Act of 1978 for each individual under con-
sideration for the appointment, so as to reduce 
the likelihood that an appointed individual will 
later require a written determination as referred 
to in section 208(b)(1) of title 18, United States 
Code, a written certification as referred to in sec-
tion 208(b)(3) of title 18, United States Code, or 
a waiver as referred to in subparagraph (D)(iii) 
for service on the Commission at a meeting of 
the Commission. 
‘‘(C) DISCLOSURES; PROHIBITIONS ON PAR-
TICIPATION; WAIVERS.— 
‘‘(i) DISCLOSURE OF FINANCIAL INTER-
EST.—Prior to a meeting of the Commis-
sion or a clinical perspective advisory panel 
described in paragraph (2)(H) regarding a 
‘particular matter’ (as that term is used in 
section 208 of title 18, United States Code), 
each member of the Commission or the clin-
ical perspective advisory panel who is a 
full-time Government employee or special 
Government employee shall disclose to the 
Secretary financial interests in accordance 
with subsection (b) of such section 208. 
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‘‘(ii) PROHIBITIONS
ON
PARTICIPA-
TION.—Except as provided under clause 
(iii), a member of the Commission or a 
clinical perspective advisory panel described 
in paragraph (2)(H) may not participate 
with respect to a particular matter consid-
ered in meeting of the Commission or the 
clinical perspective advisory panel if such 
member (or an immediate family member of 
such member) has a financial interest that 
could be affected by the advice given to the 
Secretary with respect to such matter, ex-
cluding interests exempted in regulations 
issued by the Director of the Office of Gov-
ernment Ethics as too remote or incon-
sequential to affect the integrity of the serv-
ices of the Government officers or employees 
to which such regulations apply. 
‘‘(iii) WAIVER.—If the Secretary deter-
mines it necessary to afford the Commission 
or a clinical perspective advisory panel de-
scribed in paragraph 2(H) essential exper-
tise, the Secretary may grant a waiver of 
the prohibition in clause (ii) to permit a 
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member described in such subparagraph 
to— 
‘‘(I) participate as a non-voting 
member with respect to a particular 
matter considered in a Commission or 
a clinical perspective advisory panel 
meeting; or 
‘‘(II) participate as a voting 
member with respect to a particular 
matter considered in a Commission or 
a clinical perspective advisory panel 
meeting. 
‘‘(iv) LIMITATION
ON
WAIVERS
AND 
OTHER EXCEPTIONS.— 
‘‘(I) DETERMINATION OF ALLOW-
ABLE EXCEPTIONS FOR THE COMMIS-
SION.—The number of waivers granted 
to members of the Commission cannot 
exceed one-half of the total number of 
members for the Commission. 
‘‘(II) PROHIBITION
ON
VOTING 
STATUS ON CLINICAL PERSPECTIVE AD-
VISORY PANELS.—No voting member of 
any clinical perspective advisory panel 
shall be in receipt of a waiver. No 
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more than two nonvoting members of 
any clinical perspective advisory panel 
shall receive a waiver. 
‘‘(D) FINANCIAL INTEREST DEFINED.—For 
purposes of this paragraph, the term ‘financial 
interest’ means a financial interest under section 
208(a) of title 18, United States Code. 
‘‘(9) COMPENSATION.—While serving on the busi-
ness of the Commission (including travel time), a 
member of the Commission shall be entitled to com-
pensation at the per diem equivalent of the rate pro-
vided for level IV of the Executive Schedule under sec-
tion 5315 of title 5, United States Code; and while so 
serving away from home and the member’s regular 
place of business, a member may be allowed travel ex-
penses, as authorized by the Director of the Commis-
sion. 
‘‘(10) AVAILABILITY OF REPORTS.—The Commis-
sion shall transmit to the Secretary a copy of each re-
port submitted under this subsection and shall make 
such reports available to the public. 
‘‘(11) DIRECTOR AND STAFF; EXPERTS AND CON-
SULTANTS.—Subject to such review as the Secretary 
deems necessary to assure the efficient administration 
of the Commission, the Commission may— 
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‘‘(A) appoint an Executive Director (subject 
to the approval of the Secretary) and such other 
personnel as Federal employees under section 
2105 of title 5, United States Code, as may be 
necessary to carry out its duties (without regard 
to the provisions of title 5, United States Code, 
governing appointments in the competitive serv-
ice); 
‘‘(B) seek such assistance and support as 
may be required in the performance of its duties 
from appropriate Federal departments and agen-
cies; 
‘‘(C) enter into contracts or make other ar-
rangements, as may be necessary for the conduct 
of the work of the Commission (without regard 
to section 3709 of the Revised Statutes (41 
U.S.C. 5)); 
‘‘(D) make advance, progress, and other 
payments which relate to the work of the Com-
mission; 
‘‘(E) provide transportation and subsistence 
for persons serving without compensation; and 
‘‘(F) prescribe such rules and regulations as 
it deems necessary with respect to the internal 
organization and operation of the Commission. 
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‘‘(c) RESEARCH REQUIREMENTS.—Any research con-
ducted, supported, or synthesized under this section shall 
meet the following requirements: 
‘‘(1) ENSURING
TRANSPARENCY, CREDIBILITY, 
AND ACCESS.— 
‘‘(A) The establishment of the agenda and 
conduct of the research shall be insulated from 
inappropriate political or stakeholder influence. 
‘‘(B) Methods of conducting such research 
shall be scientifically based. 
‘‘(C) All aspects of the prioritization of re-
search, conduct of the research, and development 
of conclusions based on the research shall be 
transparent to all stakeholders. 
‘‘(D) The process and methods for con-
ducting such research shall be publicly docu-
mented and available to all stakeholders. 
‘‘(E) Throughout the process of such re-
search, the Center shall provide opportunities for 
all stakeholders involved to review and provide 
public comment on the methods and findings of 
such research. 
‘‘(2) USE OF CLINICAL PERSPECTIVE ADVISORY 
PANELS.—The research shall meet a national research 
priority determined under subsection (b)(2)(A) and 
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shall consider advice given to the Center by the clin-
ical perspective advisory panel for the national re-
search priority. 
‘‘(3) STAKEHOLDER INPUT.— 
‘‘(A) IN GENERAL.—The Commission shall 
consult with patients, health care providers, 
health care consumer representatives, and other 
appropriate stakeholders with an interest in the 
research through a transparent process rec-
ommended by the Commission. 
‘‘(B) SPECIFIC AREAS OF CONSULTATION.— 
Consultation shall include where deemed appro-
priate by the Commission— 
‘‘(i) recommending research priorities 
and questions; 
‘‘(ii) recommending research meth-
odologies; and 
‘‘(iii) advising on and assisting with 
efforts to disseminate research findings. 
‘‘(C) OMBUDSMAN.—The Secretary shall 
designate a patient ombudsman. The ombuds-
man shall— 
‘‘(i) serve as an available point of con-
tact for any patients with an interest in 
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proposed comparative effectiveness studies 
by the Center; and 
‘‘(ii) ensure that any comments from 
patients regarding proposed comparative ef-
fectiveness studies are reviewed by the Com-
mission. 
‘‘(4) TAKING
INTO
ACCOUNT
POTENTIAL
DIF-
FERENCES.—Research shall— 
‘‘(A) be designed, as appropriate, to take 
into account the potential for differences in the 
effectiveness of health care items and services 
used with various subpopulations such as racial 
and ethnic minorities, women, different age 
groups (including children, adolescents, adults, 
and seniors), and individuals with different 
comorbidities; and— 
‘‘(B) seek, as feasible and appropriate, to 
include members of such subpopulations as sub-
jects in the research. 
‘‘(d) PUBLIC ACCESS TO COMPARATIVE EFFECTIVE-
NESS INFORMATION.— 
‘‘(1) IN GENERAL.—Not later than 90 days after 
receipt by the Center or Commission, as applicable, of 
a relevant report described in paragraph (2) made by 
the Center, Commission, or clinical perspective advi-
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sory panel under this section, appropriate informa-
tion contained in such report shall be posted on the 
official public Internet site of the Center and of the 
Commission, as applicable. 
‘‘(2) RELEVANT REPORTS DESCRIBED.—For pur-
poses of this section, a relevant report is each of the 
following submitted by the Center or a grantee or con-
tractor of the Center: 
‘‘(A) Any interim or progress reports as 
deemed appropriate by the Secretary. 
‘‘(B) Stakeholder comments. 
‘‘(C) A final report. 
‘‘(e) DISSEMINATION AND INCORPORATION OF COM-
PARATIVE EFFECTIVENESS INFORMATION.— 
‘‘(1) DISSEMINATION.—The Center shall provide 
for the dissemination of appropriate findings pro-
duced by research supported, conducted, or syn-
thesized under this section to health care providers, 
patients, vendors of health information technology fo-
cused on clinical decision support, appropriate profes-
sional associations, and Federal and private health 
plans, and other relevant stakeholders. In dissemi-
nating such findings the Center shall— 
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‘‘(A) convey findings of research so that 
they are comprehensible and useful to patients 
and providers in making health care decisions; 
‘‘(B) discuss findings and other consider-
ations specific to certain sub-populations, risk 
factors, and comorbidities as appropriate; 
‘‘(C) include considerations such as limita-
tions of research and what further research may 
be needed, as appropriate; 
‘‘(D) not include any data that the dissemi-
nation of which would violate the privacy of re-
search participants or violate any confiden-
tiality agreements made with respect to the use 
of data under this section; and 
‘‘(E) assist the users of health information 
technology focused on clinical decision support to 
promote the timely incorporation of such find-
ings into clinical practices and promote the ease 
of use of such incorporation. 
‘‘(2) DISSEMINATION PROTOCOLS AND STRATE-
GIES.—The Center shall develop protocols and strate-
gies for the appropriate dissemination of research 
findings in order to ensure effective communication of 
findings and the use and incorporation of such find-
ings into relevant activities for the purpose of inform-
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ing higher quality and more effective and efficient de-
cisions regarding medical items and services. In de-
veloping and adopting such protocols and strategies, 
the Center shall consult with stakeholders concerning 
the types of dissemination that will be most useful to 
the end users of information and may provide for the 
utilization of multiple formats for conveying findings 
to different audiences, including dissemination to in-
dividuals with limited English proficiency. 
‘‘(f) REPORTS TO CONGRESS.— 
‘‘(1) ANNUAL
REPORTS.—Beginning not later 
than one year after the date of the enactment of this 
section, the Director of the Agency of Healthcare Re-
search and Quality and the Commission shall submit 
to Congress an annual report on the activities of the 
Center and the Commission, as well as the research, 
conducted under this section. Each such report shall 
include a discussion of the Center’s compliance with 
subsection (c)(4)(B), including any reasons for lack of 
complicance with such subsection. 
‘‘(2) RECOMMENDATION FOR FAIR SHARE PER 
CAPITA AMOUNT FOR ALL-PAYER FINANCING.—Begin-
ning not later than December 31, 2011, the Secretary 
shall submit to Congress an annual recommendation 
for a fair share per capita amount described in sub-
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section (c)(1) of section 9511 of the Internal Revenue 
Code of 1986 for purposes of funding the CERTF 
under such section. 
‘‘(3) ANALYSIS AND REVIEW.—Not later than De-
cember 31, 2013, the Secretary, in consultation with 
the Commission, shall submit to Congress a report on 
all activities conducted or supported under this sec-
tion as of such date. Such report shall include an 
evaluation of the overall costs of such activities and 
an analysis of the backlog of any research proposals 
approved by the Commission but not funded. 
‘‘(g) FUNDING OF COMPARATIVE EFFECTIVENESS RE-
SEARCH.—For fiscal year 2010 and each subsequent fiscal 
year, amounts in the Comparative Effectiveness Research 
Trust Fund (referred to in this section as the ‘CERTF’) 
under section 9511 of the Internal Revenue Code of 1986 
shall be available, without the need for further appropria-
tions and without fiscal year limitation, to the Secretary 
to carry out this section. 
‘‘(h) CONSTRUCTION.—Nothing in this section shall be 
construed to permit the Commission or the Center to man-
date coverage, reimbursement, or other policies for any pub-
lic or private payer. 
‘‘(i) RESEARCH NOT TO BE USED TO DENY OR RA-
TION CARE.—In no case may any research conducted, sup-
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ported, or developed by the Center, the Commission, or the 
Federal Coordinating Council for Comparative Effective-
ness Research be used by the federal government to deny 
or ration care. 
‘‘(j) APPLICATION OF FEDERALLY FUNDED CLINICAL 
COMPARATIVE EFFECTIVENESS RESEARCH.—The Centers 
for Medicare & Medicaid Services may not use Federally 
funded clinical comparative effectiveness research data 
under this section to make coverage determinations for med-
ical treatments, services, or items under title XVIII on the 
basis of cost. 
‘‘(k) CONDITIONS ON RECOMMENDATIONS OF STAND-
ARDS OR PROTOCOLS.— 
‘‘(1) IN GENERAL.—The work performed by the 
Commission or the Center shall be based upon con-
sultation with, and review by, the specialty colleges 
and academies of medicine to determine best practices 
within their field of specialty. Any recommendations 
made or best practices developed by the Commission 
or the Center — 
‘‘(A) shall be based upon evidence-based 
medicine; and 
‘‘(B) shall not violate standards and proto-
cols of clinical excellence of the specialty colleges 
and academies. 
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‘‘(2) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) SPECIALTY COLLEGES AND ACADEMIES 
OF MEDICINE.—The term ‘specialty colleges and 
academies of medicine’ means the trade associa-
tions and professional membership societies that 
represent physicians based on the field of medi-
cine in which each such physician practices or 
is board certified. 
‘‘(B) STANDARDS AND PROTOCOLS OF CLIN-
ICAL
EXCELLENCE.—The term ‘standards and 
protocols of clinical excellence’ means clinical or 
practice guidelines that consist of a set of direc-
tions or principles that is based on evidence and 
is designed to assist a health care practitioner 
with decisions about appropriate diagnostic, 
therapeutic, or other clinical procedures for spe-
cific clinical circumstances.’’. 
(b) COMPARATIVE EFFECTIVENESS RESEARCH TRUST 
FUND; FINANCING FOR THE TRUST FUND.—For provision 
establishing a Comparative Effectiveness Research Trust 
Fund and financing such Trust Fund, see section 1802. 
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Subtitle B—Nursing Home 
Transparency 
PART 1—IMPROVING TRANSPARENCY OF INFOR-
MATION ON SKILLED NURSING FACILITIES 
AND NURSING FACILITIES 
SEC. 1411. REQUIRED DISCLOSURE OF OWNERSHIP AND AD-
DITIONAL DISCLOSABLE PARTIES INFORMA-
TION. 
(a) IN GENERAL.—Section 1124 of the Social Security 
Act (42 U.S.C. 1320a–3) is amended by adding at the end 
the following new subsection: 
‘‘(c) REQUIRED DISCLOSURE OF OWNERSHIP AND AD-
DITIONAL DISCLOSABLE PARTIES INFORMATION.— 
‘‘(1) DISCLOSURE.—A facility (as defined in 
paragraph (7)(B)) shall have the information de-
scribed in paragraph (3) available— 
‘‘(A) during the period beginning on the 
date of the enactment of this subsection and end-
ing on the date such information is made avail-
able to the public under section 1411(b) of the 
America’s Affordable Health Choices Act of 2009, 
for submission to the Secretary, the Inspector 
General of the Department of Health and 
Human Services, the State in which the facility 
is located, and the State long-term care ombuds-
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man in the case where the Secretary, the Inspec-
tor General, the State, or the State long-term 
care ombudsman requests such information; and 
‘‘(B) beginning on the effective date of the 
final regulations promulgated under paragraph 
(4)(A), for reporting such information in accord-
ance with such final regulations. 
Nothing in subparagraph (A) shall be construed as 
authorizing a facility to dispose of or delete informa-
tion described in such subparagraph after the effective 
date of the final regulations promulgated under para-
graph (4)(A). 
‘‘(2) PUBLIC AVAILABILITY OF INFORMATION.— 
During the period described in paragraph (1)(A), a 
facility shall— 
‘‘(A) make the information described in 
paragraph (3) available to the public upon re-
quest and update such information as may be 
necessary to reflect changes in such information; 
and 
‘‘(B) post a notice of the availability of such 
information in the lobby of the facility in a 
prominent manner. 
‘‘(3) INFORMATION DESCRIBED.— 
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person or entity to the facility and to one 
another. 
‘‘(B) SPECIAL RULE WHERE INFORMATION 
IS ALREADY REPORTED OR SUBMITTED.—To the 
extent that information reported by a facility to 
the Internal Revenue Service on Form 990, in-
formation submitted by a facility to the Securi-
ties and Exchange Commission, or information 
otherwise submitted to the Secretary or any other 
Federal agency contains the information de-
scribed in clauses (i), (ii), or (iii) of subpara-
graph (A), the Secretary may allow, to the extent 
practicable, such Form or such information to 
meet the requirements of paragraph (1) and to 
be submitted in a manner specified by the Sec-
retary. 
‘‘(C) SPECIAL
RULE.—In applying sub-
paragraph (A)(i)— 
‘‘(i) with respect to subsections (a) and 
(b), ‘ownership or control interest’ shall in-
clude direct or indirect interests, including 
such interests in intermediate entities; and 
‘‘(ii) subsection (a)(3)(A)(ii) shall in-
clude the owner of a whole or part interest 
in any mortgage, deed of trust, note, or 
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other obligation secured, in whole or in 
part, by the entity or any of the property 
or assets thereof, if the interest is equal to 
or exceeds 5 percent of the total property or 
assets of the entirety. 
‘‘(4) REPORTING.— 
‘‘(A) IN GENERAL.—Not later than the date 
that is 2 years after the date of the enactment of 
this subsection, the Secretary shall promulgate 
regulations requiring, effective on the date that is 
90 days after the date on which such final regu-
lations are published in the Federal Register, a 
facility to report the information described in 
paragraph (3) to the Secretary in a standardized 
format, and such other regulations as are nec-
essary to carry out this subsection. Such final 
regulations shall ensure that the facility certifies, 
as a condition of participation and payment 
under the program under title XVIII or XIX, 
that the information reported by the facility in 
accordance with such final regulations is accu-
rate and current. 
‘‘(B) GUIDANCE.—The Secretary shall pro-
vide guidance and technical assistance to States 
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on how to adopt the standardized format under 
subparagraph (A). 
‘‘(5) NO EFFECT ON EXISTING REPORTING RE-
QUIREMENTS.—Nothing in this subsection shall re-
duce, diminish, or alter any reporting requirement 
for a facility that is in effect as of the date of the en-
actment of this subsection. 
‘‘(6) DEFINITIONS.—In this subsection: 
‘‘(A) ADDITIONAL
DISCLOSABLE
PARTY.— 
The term ‘additional disclosable party’ means, 
with respect to a facility, any person or entity 
who— 
‘‘(i) exercises operational, financial, or 
managerial control over the facility or a 
part thereof, or provides policies or proce-
dures for any of the operations of the facil-
ity, or provides financial or cash manage-
ment services to the facility; 
‘‘(ii) leases or subleases real property 
to the facility, or owns a whole or part in-
terest equal to or exceeding 5 percent of the 
total value of such real property; 
‘‘(iii) lends funds or provides a finan-
cial guarantee to the facility in an amount 
which is equal to or exceeds $50,000; or 
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‘‘(iv) provides management or admin-
istrative services, clinical consulting serv-
ices, or accounting or financial services to 
the facility. 
‘‘(B) FACILITY.—The term ‘facility’ means 
a disclosing entity which is— 
‘‘(i) a skilled nursing facility (as de-
fined in section 1819(a)); or 
‘‘(ii) a nursing facility (as defined in 
section 1919(a)). 
‘‘(C) 
MANAGING
EMPLOYEE.—The 
term 
‘managing employee’ means, with respect to a fa-
cility, an individual (including a general man-
ager, business manager, administrator, director, 
or consultant) who directly or indirectly man-
ages, advises, or supervises any element of the 
practices, finances, or operations of the facility. 
‘‘(D) ORGANIZATIONAL
STRUCTURE.—The 
term ‘organizational structure’ means, in the 
case of— 
‘‘(i) a corporation, the officers, direc-
tors, and shareholders of the corporation 
who have an ownership interest in the cor-
poration which is equal to or exceeds 5 per-
cent; 
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‘‘(ii) a limited liability company, the 
members and managers of the limited liabil-
ity company (including, as applicable, what 
percentage each member and manager has 
of the ownership interest in the limited li-
ability company); 
‘‘(iii) a general partnership, the part-
ners of the general partnership; 
‘‘(iv) a limited partnership, the general 
partners and any limited partners of the 
limited partnership who have an ownership 
interest in the limited partnership which is 
equal to or exceeds 10 percent; 
‘‘(v) a trust, the trustees of the trust; 
‘‘(vi) an individual, contact informa-
tion for the individual; and 
‘‘(vii) any other person or entity, such 
information as the Secretary determines ap-
propriate.’’. 
(b) PUBLIC AVAILABILITY OF INFORMATION.— 
(1) IN GENERAL.—Not later than the date that 
is 1 year after the date on which the final regulations 
promulgated under section 1124(c)(4)(A) of the Social 
Security Act, as added by subsection (a), are pub-
lished in the Federal Register, the information re-
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ported in accordance with such final regulations shall 
be made available to the public in accordance with 
procedures established by the Secretary. 
(2) DEFINITIONS.—In this subsection: 
(A) NURSING FACILITY.—The term ‘‘nurs-
ing facility’’ has the meaning given such term in 
section 1919(a) of the Social Security Act (42 
U.S.C. 1396r(a)). 
(B) SECRETARY.—The term ‘‘Secretary’’ 
means the Secretary of Health and Human Serv-
ices. 
(C) SKILLED NURSING FACILITY.—The term 
‘‘skilled nursing facility’’ has the meaning given 
such term in section 1819(a) of the Social Secu-
rity Act (42 U.S.C. 1395i–3(a)). 
(c) CONFORMING AMENDMENTS.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(d)(1) of the Social Security Act (42 U.S.C. 
1395i–3(d)(1)) is amended by striking subparagraph 
(B) and redesignating subparagraph (C) as subpara-
graph (B). 
(2) NURSING FACILITIES.—Section 1919(d)(1) of 
the Social Security Act (42 U.S.C. 1396r(d)(1)) is 
amended by striking subparagraph (B) and redesig-
nating subparagraph (C) as subparagraph (B). 
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573 
SEC. 1412. ACCOUNTABILITY REQUIREMENTS. 
(a) EFFECTIVE
COMPLIANCE
AND
ETHICS
PRO-
GRAMS.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(d)(1) of the Social Security Act (42 U.S.C. 
1395i–3(d)(1)), as amended by section 1411(c)(1), is 
amended by adding at the end the following new sub-
paragraph: 
‘‘(C) 
COMPLIANCE
AND
ETHICS
PRO-
GRAMS.— 
‘‘(i) REQUIREMENT.—On or after the 
date that is 36 months after the date of the 
enactment of this subparagraph, a skilled 
nursing facility shall, with respect to the 
entity that operates the facility (in this sub-
paragraph referred to as the ‘operating or-
ganization’ or ‘organization’), have in oper-
ation a compliance and ethics program that 
is effective in preventing and detecting 
criminal, civil, and administrative viola-
tions under this Act and in promoting qual-
ity of care consistent with regulations devel-
oped under clause (ii). 
‘‘(ii) 
DEVELOPMENT
OF
REGULA-
TIONS.— 
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574 
‘‘(I) IN GENERAL.—Not later than 
the date that is 2 years after such date 
of the enactment, the Secretary, in con-
sultation with the Inspector General of 
the Department of Health and Human 
Services, shall promulgate regulations 
for an effective compliance and ethics 
program for operating organizations, 
which may include a model compliance 
program. 
‘‘(II) DESIGN OF REGULATIONS.— 
Such regulations with respect to spe-
cific elements or formality of a pro-
gram may vary with the size of the or-
ganization, such that larger organiza-
tions should have a more formal and 
rigorous program and include estab-
lished written policies defining the 
standards and procedures to be fol-
lowed by its employees. Such require-
ments shall specifically apply to the 
corporate level management of multi- 
unit nursing home chains. 
‘‘(III) EVALUATION.—Not later 
than 3 years after the date of promul-
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gation of regulations under this clause, 
the Secretary shall complete an evalua-
tion of the compliance and ethics pro-
grams required to be established under 
this subparagraph. Such evaluation 
shall determine if such programs led to 
changes in deficiency citations, changes 
in quality performance, or changes in 
other metrics of resident quality of 
care. The Secretary shall submit to 
Congress a report on such evaluation 
and shall include in such report such 
recommendations regarding changes in 
the requirements for such programs as 
the Secretary determines appropriate. 
‘‘(iii) REQUIREMENTS
FOR
COMPLI-
ANCE AND ETHICS PROGRAMS.—In this sub-
paragraph, the term ‘compliance and ethics 
program’ means, with respect to a skilled 
nursing facility, a program of the operating 
organization that— 
‘‘(I) has been reasonably designed, 
implemented, and enforced so that it 
generally will be effective in preventing 
and detecting criminal, civil, and ad-
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ministrative violations under this Act 
and in promoting quality of care; and 
‘‘(II) includes at least the required 
components specified in clause (iv). 
‘‘(iv) REQUIRED COMPONENTS OF PRO-
GRAM.—The required components of a com-
pliance and ethics program of an organiza-
tion are the following: 
‘‘(I) The organization must have 
established compliance standards and 
procedures to be followed by its em-
ployees, contractors, and other agents 
that are reasonably capable of reducing 
the prospect of criminal, civil, and ad-
ministrative violations under this Act. 
‘‘(II) Specific individuals within 
high-level personnel of the organization 
must have been assigned overall re-
sponsibility to oversee compliance with 
such standards and procedures and 
have sufficient resources and authority 
to assure such compliance. 
‘‘(III) The organization must have 
used due care not to delegate substan-
tial discretionary authority to individ-
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uals whom the organization knew, or 
should have known through the exercise 
of due diligence, had a propensity to 
engage in criminal, civil, and admin-
istrative violations under this Act. 
‘‘(IV) The organization must have 
taken steps to communicate effectively 
its standards and procedures to all em-
ployees and other agents, such as by re-
quiring participation in training pro-
grams or by disseminating publica-
tions that explain in a practical man-
ner what is required. 
‘‘(V) The organization must have 
taken reasonable steps to achieve com-
pliance with its standards, such as by 
utilizing monitoring and auditing sys-
tems reasonably designed to detect 
criminal, civil, and administrative 
violations under this Act by its em-
ployees and other agents and by having 
in place and publicizing a reporting 
system whereby employees and other 
agents could report violations by others 
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within the organization without fear of 
retribution. 
‘‘(VI) The standards must have 
been consistently enforced through ap-
propriate disciplinary mechanisms, in-
cluding, as appropriate, discipline of 
individuals responsible for the failure 
to detect an offense. 
‘‘(VII) After an offense has been 
detected, the organization must have 
taken all reasonable steps to respond 
appropriately to the offense and to pre-
vent further similar offenses, including 
repayment of any funds to which it 
was not entitled and any necessary 
modification to its program to prevent 
and detect criminal, civil, and admin-
istrative violations under this Act. 
‘‘(VIII) The organization must pe-
riodically undertake reassessment of its 
compliance 
program 
to 
identify 
changes necessary to reflect changes 
within the organization and its facili-
ties. 
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‘‘(v) COORDINATION.—The provisions 
of this subparagraph shall apply with re-
spect to a skilled nursing facility in lieu of 
section 1874(d).’’. 
(2) NURSING FACILITIES.—Section 1919(d)(1) of 
the Social Security Act (42 U.S.C. 1396r(d)(1)), as 
amended by section 1411(c)(2), is amended by adding 
at the end the following new subparagraph: 
‘‘(C) COMPLIANCE AND ETHICS PROGRAM.— 
‘‘(i) REQUIREMENT.—On or after the 
date that is 36 months after the date of the 
enactment of this subparagraph, a nursing 
facility shall, with respect to the entity that 
operates the facility (in this subparagraph 
referred to as the ‘operating organization’ 
or ‘organization’), have in operation a com-
pliance and ethics program that is effective 
in preventing and detecting criminal, civil, 
and administrative violations under this 
Act and in promoting quality of care con-
sistent with regulations developed under 
clause (ii). 
‘‘(ii) 
DEVELOPMENT
OF
REGULA-
TIONS.— 
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‘‘(I) IN GENERAL.—Not later than 
the date that is 2 years after such date 
of the enactment, the Secretary, in con-
sultation with the Inspector General of 
the Department of Health and Human 
Services, shall develop regulations for 
an effective compliance and ethics pro-
gram 
for 
operating 
organizations, 
which may include a model compliance 
program. 
‘‘(II) DESIGN OF REGULATIONS.— 
Such regulations with respect to spe-
cific elements or formality of a pro-
gram may vary with the size of the or-
ganization, such that larger organiza-
tions should have a more formal and 
rigorous program and include estab-
lished written policies defining the 
standards and procedures to be fol-
lowed by its employees. Such require-
ments may specifically apply to the 
corporate level management of multi- 
unit nursing home chains. 
‘‘(III) EVALUATION.—Not later 
than 3 years after the date of promul-
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bajohnson on DSK2BSOYB1PROD with BILLS
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gation of regulations under this clause 
the Secretary shall complete an evalua-
tion of the compliance and ethics pro-
grams required to be established under 
this subparagraph. Such evaluation 
shall determine if such programs led to 
changes in deficiency citations, changes 
in quality performance, or changes in 
other metrics of resident quality of 
care. The Secretary shall submit to 
Congress a report on such evaluation 
and shall include in such report such 
recommendations regarding changes in 
the requirements for such programs as 
the Secretary determines appropriate. 
‘‘(iii) REQUIREMENTS
FOR
COMPLI-
ANCE AND ETHICS PROGRAMS.—In this sub-
paragraph, the term ‘compliance and ethics 
program’ means, with respect to a nursing 
facility, a program of the operating organi-
zation that— 
‘‘(I) has been reasonably designed, 
implemented, and enforced so that it 
generally will be effective in preventing 
and detecting criminal, civil, and ad-
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ministrative violations under this Act 
and in promoting quality of care; and 
‘‘(II) includes at least the required 
components specified in clause (iv). 
‘‘(iv) REQUIRED COMPONENTS OF PRO-
GRAM.—The required components of a com-
pliance and ethics program of an organiza-
tion are the following: 
‘‘(I) The organization must have 
established compliance standards and 
procedures to be followed by its em-
ployees and other agents that are rea-
sonably capable of reducing the pros-
pect of criminal, civil, and adminis-
trative violations under this Act. 
‘‘(II) Specific individuals within 
high-level personnel of the organization 
must have been assigned overall re-
sponsibility to oversee compliance with 
such standards and procedures and has 
sufficient resources and authority to 
assure such compliance. 
‘‘(III) The organization must have 
used due care not to delegate substan-
tial discretionary authority to individ-
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uals whom the organization knew, or 
should have known through the exercise 
of due diligence, had a propensity to 
engage in criminal, civil, and admin-
istrative violations under this Act. 
‘‘(IV) The organization must have 
taken steps to communicate effectively 
its standards and procedures to all em-
ployees and other agents, such as by re-
quiring participation in training pro-
grams or by disseminating publica-
tions that explain in a practical man-
ner what is required. 
‘‘(V) The organization must have 
taken reasonable steps to achieve com-
pliance with its standards, such as by 
utilizing monitoring and auditing sys-
tems reasonably designed to detect 
criminal, civil, and administrative 
violations under this Act by its em-
ployees and other agents and by having 
in place and publicizing a reporting 
system whereby employees and other 
agents could report violations by others 
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within the organization without fear of 
retribution. 
‘‘(VI) The standards must have 
been consistently enforced through ap-
propriate disciplinary mechanisms, in-
cluding, as appropriate, discipline of 
individuals responsible for the failure 
to detect an offense. 
‘‘(VII) After an offense has been 
detected, the organization must have 
taken all reasonable steps to respond 
appropriately to the offense and to pre-
vent further similar offenses, including 
repayment of any funds to which it 
was not entitled and any necessary 
modification to its program to prevent 
and detect criminal, civil, and admin-
istrative violations under this Act. 
‘‘(VIII) The organization must pe-
riodically undertake reassessment of its 
compliance 
program 
to 
identify 
changes necessary to reflect changes 
within the organization and its facili-
ties. 
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585 
‘‘(v) COORDINATION.—The provisions 
of this subparagraph shall apply with re-
spect to a nursing facility in lieu of section 
1902(a)(77).’’. 
(b) QUALITY ASSURANCE
AND PERFORMANCE IM-
PROVEMENT PROGRAM.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(b)(1)(B) of the Social Security Act (42 U.S.C. 
1396r(b)(1)(B)) is amended— 
(A) by striking ‘‘ASSURANCE’’ and inserting 
‘‘ASSURANCE AND QUALITY ASSURANCE AND PER-
FORMANCE IMPROVEMENT PROGRAM’’; 
(B) by designating the matter beginning 
with ‘‘A skilled nursing facility’’ as a clause (i) 
with the heading ‘‘IN GENERAL.—’’ and the ap-
propriate indentation; 
(C) in clause (i) (as so designated by sub-
paragraph (B)), by redesignating clauses (i) and 
(ii) as subclauses (I) and (II), respectively; and 
(D) by adding at the end the following new 
clause: 
‘‘(ii) QUALITY ASSURANCE AND PER-
FORMANCE IMPROVEMENT PROGRAM.— 
‘‘(I) IN GENERAL.—Not later than 
December 31, 2011, the Secretary shall 
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586 
establish and implement a quality as-
surance and performance improvement 
program (in this clause referred to as 
the ‘QAPI program’) for skilled nurs-
ing facilities, including multi-unit 
chains of such facilities. Under the 
QAPI program, the Secretary shall es-
tablish standards relating to such fa-
cilities and provide technical assist-
ance to such facilities on the develop-
ment of best practices in order to meet 
such standards. Not later than 1 year 
after the date on which the regulations 
are promulgated under subclause (II), 
a skilled nursing facility must submit 
to the Secretary a plan for the facility 
to meet such standards and implement 
such best practices, including how to 
coordinate the implementation of such 
plan with quality assessment and as-
surance activities conducted under 
clause (i). 
‘‘(II) REGULATIONS.—The Sec-
retary shall promulgate regulations to 
carry out this clause.’’. 
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(2) 
NURSING
FACILITIES.—Section 
1919(b)(1)(B) of the Social Security Act (42 U.S.C. 
1396r(b)(1)(B)) is amended— 
(A) by striking ‘‘ASSURANCE’’ and inserting 
‘‘ASSURANCE AND QUALITY ASSURANCE AND PER-
FORMANCE IMPROVEMENT PROGRAM’’; 
(B) by designating the matter beginning 
with ‘‘A nursing facility’’ as a clause (i) with 
the heading ‘‘IN GENERAL.—’’ and the appro-
priate indentation; and 
(C) by adding at the end the following new 
clause: 
‘‘(ii) QUALITY ASSURANCE AND PER-
FORMANCE IMPROVEMENT PROGRAM.— 
‘‘(I) IN GENERAL.—Not later than 
December 31, 2011, the Secretary shall 
establish and implement a quality as-
surance and performance improvement 
program (in this clause referred to as 
the ‘QAPI program’) for nursing facili-
ties, including multi-unit chains of 
such facilities. Under the QAPI pro-
gram, the Secretary shall establish 
standards relating to such facilities 
and provide technical assistance to 
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588 
such facilities on the development of 
best practices in order to meet such 
standards. Not later than 1 year after 
the date on which the regulations are 
promulgated under subclause (II), a 
nursing facility must submit to the 
Secretary a plan for the facility to 
meet such standards and implement 
such best practices, including how to 
coordinate the implementation of such 
plan with quality assessment and as-
surance activities conducted under 
clause (i). 
‘‘(II) REGULATIONS.—The Sec-
retary shall promulgate regulations to 
carry out this clause.’’. 
(3) PROPOSAL TO REVISE QUALITY ASSURANCE 
AND PERFORMANCE IMPROVEMENT PROGRAMS.—The 
Secretary shall include in the proposed rule published 
under section 1888(e) of the Social Security Act (42 
U.S.C. 1395yy(e)(5)(A)) for the subsequent fiscal year 
to the extent otherwise authorized under section 
1819(b)(1)(B) or 1819(d)(1)(C) of the Social Security 
Act or other statutory or regulatory authority, one or 
more proposals for skilled nursing facilities to modify 
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and strengthen quality assurance and performance 
improvement programs in such facilities. At the time 
of publication of such proposed rule and to the extent 
otherwise authorized under section 1919(b)(1)(B) or 
1919(d)(1)(C) of such Act or other regulatory author-
ity. 
(4) FACILITY PLAN.—Not later than 1 year after 
the date on which the regulations are promulgated 
under subclause (II) of clause (ii) of sections 
1819(b)(1)(B) and 1919(b)(1)(B) of the Social Secu-
rity Act, as added by paragraphs (1) and (2), a 
skilled nursing facility and a nursing facility must 
submit to the Secretary a plan for the facility to meet 
the standards under such regulations and implement 
such best practices, including how to coordinate the 
implementation of such plan with quality assessment 
and assurance activities conducted under clause (i) of 
such sections. 
(c) GAO STUDY
ON NURSING FACILITY UNDER-
CAPITALIZATION.— 
(1) IN GENERAL.—The Comptroller General of 
the United States shall conduct a study that examines 
the following: 
(A) The extent to which corporations that 
own or operate large numbers of nursing facili-
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ties, taking into account ownership type (includ-
ing private equity and control interests), are 
undercapitalizing such facilities. 
(B) The effects of such undercapitalization 
on quality of care, including staffing and food 
costs, at such facilities. 
(C) Options to address such undercapital-
ization, such as requirements relating to surety 
bonds, liability insurance, or minimum capital-
ization. 
(2) REPORT.—Not later than 18 months after the 
date of the enactment of this Act, the Comptroller 
General shall submit to Congress a report on the 
study conducted under paragraph (1). 
(3) NURSING FACILITY.—In this subsection, the 
term ‘‘nursing facility’’ includes a skilled nursing fa-
cility. 
SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819 of the Social Se-
curity Act (42 U.S.C. 1395i–3) is amended— 
(A) by redesignating subsection (i) as sub-
section (j); and 
(B) by inserting after subsection (h) the fol-
lowing new subsection: 
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591 
‘‘(i) NURSING HOME COMPARE WEBSITE.— 
‘‘(1) INCLUSION OF ADDITIONAL INFORMATION.— 
‘‘(A) IN GENERAL.—The Secretary shall en-
sure that the Department of Health and Human 
Services includes, as part of the information pro-
vided for comparison of nursing homes on the of-
ficial Internet website of the Federal Government 
for Medicare beneficiaries (commonly referred to 
as the ‘Nursing Home Compare’ Medicare 
website) (or a successor website), the following 
information in a manner that is prominent, eas-
ily accessible, readily understandable to con-
sumers of long-term care services, and searchable: 
‘‘(i) Information that is reported to the 
Secretary under section 1124(c)(4). 
‘‘(ii) Information on the ‘Special Focus 
Facility program’ (or a successor program) 
established by the Centers for Medicare and 
Medicaid Services, according to procedures 
established by the Secretary. Such proce-
dures shall provide for the inclusion of in-
formation with respect to, and the names 
and locations of, those facilities that, since 
the previous quarter— 
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‘‘(I) were newly enrolled in the 
program; 
‘‘(II) are enrolled in the program 
and have failed to significantly im-
prove; 
‘‘(III) are enrolled in the program 
and have significantly improved; 
‘‘(IV) have graduated from the 
program; and 
‘‘(V) have closed voluntarily or no 
longer participate under this title. 
‘‘(iii) Staffing data for each facility 
(including resident census data and data on 
the hours of care provided per resident per 
day) based on data submitted under sub-
section (b)(8)(C), including information on 
staffing turnover and tenure, in a format 
that is clearly understandable to consumers 
of long-term care services and allows such 
consumers to compare differences in staffing 
between facilities and State and national 
averages for the facilities. Such format shall 
include— 
‘‘(I) concise explanations of how 
to interpret the data (such as a plain 
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593 
English explanation of data reflecting 
‘nursing home staff hours per resident 
day’); 
‘‘(II) differences in types of staff 
(such as training associated with dif-
ferent categories of staff); 
‘‘(III) the relationship between 
nurse staffing levels and quality of 
care; and 
‘‘(IV) an explanation that appro-
priate staffing levels vary based on pa-
tient case mix. 
‘‘(iv) Links to State Internet websites 
with information regarding State survey 
and certification programs, links to Form 
2567 State inspection reports (or a suc-
cessor form) on such websites, information 
to guide consumers in how to interpret and 
understand such reports, and the facility 
plan of correction or other response to such 
report. 
‘‘(v) The standardized complaint form 
developed under subsection (f)(8), including 
explanatory material on what complaint 
forms are, how they are used, and how to 
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file a complaint with the State survey and 
certification program and the State long- 
term care ombudsman program. 
‘‘(vi) Summary information on the 
number, type, severity, and outcome of sub-
stantiated complaints. 
‘‘(vii) The number of adjudicated in-
stances of criminal violations by employees 
of a a nursing facility— 
‘‘(I) that were committed inside 
the facility; 
‘‘(II) with respect to such in-
stances of violations or crimes com-
mitted inside of the facility that were 
the violations or crimes of abuse, ne-
glect, and exploitation, criminal sexual 
abuse, or other violations or crimes 
that resulted in serious bodily injury; 
and 
‘‘(III) the number of civil mone-
tary penalties levied against the facil-
ity, employees, contractors, and other 
agents. 
‘‘(B) DEADLINE FOR PROVISION OF INFOR-
MATION.— 
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595 
‘‘(i) IN GENERAL.—Except as provided 
in clause (ii), the Secretary shall ensure 
that the information described in subpara-
graph (A) is included on such website (or a 
successor website) not later than 1 year 
after the date of the enactment of this sub-
section. 
‘‘(ii) EXCEPTION.—The Secretary shall 
ensure that the information described in 
subparagraph (A)(i) and (A)(iii) is in-
cluded on such website (or a successor 
website) not later than the date on which 
the requirements under section 1124(c)(4) 
and subsection (b)(8)(C)(ii) are imple-
mented. 
‘‘(2) REVIEW AND MODIFICATION OF WEBSITE.— 
‘‘(A) IN GENERAL.—The Secretary shall es-
tablish a process— 
‘‘(i) to review the accuracy, clarity of 
presentation, timeliness, and comprehensive-
ness of information reported on such website 
as of the day before the date of the enact-
ment of this subsection; and 
‘‘(ii) not later than 1 year after the 
date of the enactment of this subsection, to 
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596 
modify or revamp such website in accord-
ance with the review conducted under clause 
(i). 
‘‘(B) CONSULTATION.—In conducting the 
review under subparagraph (A)(i), the Secretary 
shall consult with— 
‘‘(i) State long-term care ombudsman 
programs; 
‘‘(ii) consumer advocacy groups; 
‘‘(iii) provider stakeholder groups; and 
‘‘(iv) any other representatives of pro-
grams or groups the Secretary determines 
appropriate.’’. 
(2) TIMELINESS OF SUBMISSION OF SURVEY AND 
CERTIFICATION INFORMATION.— 
(A) IN GENERAL.—Section 1819(g)(5) of the 
Social Security Act (42 U.S.C. 1395i–3(g)(5)) is 
amended by adding at the end the following new 
subparagraph: 
‘‘(E) SUBMISSION OF SURVEY AND CERTIFI-
CATION INFORMATION TO THE SECRETARY.—In 
order to improve the timeliness of information 
made available to the public under subparagraph 
(A) and provided on the Nursing Home Compare 
Medicare website under subsection (i), each State 
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597 
shall submit information respecting any survey 
or certification made respecting a skilled nursing 
facility (including any enforcement actions taken 
by the State) to the Secretary not later than the 
date on which the State sends such information 
to the facility. The Secretary shall use the infor-
mation submitted under the preceding sentence 
to update the information provided on the Nurs-
ing Home Compare Medicare website as expedi-
tiously as practicable but not less frequently 
than quarterly.’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by this paragraph shall take effect 1 year 
after the date of the enactment of this Act. 
(3) SPECIAL
FOCUS
FACILITY
PROGRAM.—Sec-
tion 1819(f) of such Act is amended by adding at the 
end the following new paragraph: 
‘‘(8) SPECIAL FOCUS FACILITY PROGRAM.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
conduct a special focus facility program for en-
forcement of requirements for skilled nursing fa-
cilities that the Secretary has identified as hav-
ing substantially failed to meet applicable re-
quirement of this Act. 
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598 
‘‘(B) PERIODIC SURVEYS.—Under such pro-
gram the Secretary shall conduct surveys of each 
facility in the program not less than once every 
6 months.’’. 
(b) NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1919 of the Social Se-
curity Act (42 U.S.C. 1396r) is amended— 
(A) by redesignating subsection (i) as sub-
section (j); and 
(B) by inserting after subsection (h) the fol-
lowing new subsection: 
‘‘(i) NURSING HOME COMPARE WEBSITE.— 
‘‘(1) INCLUSION OF ADDITIONAL INFORMATION.— 
‘‘(A) IN GENERAL.—The Secretary shall en-
sure that the Department of Health and Human 
Services includes, as part of the information pro-
vided for comparison of nursing homes on the of-
ficial Internet website of the Federal Government 
for Medicare beneficiaries (commonly referred to 
as the ‘Nursing Home Compare’ Medicare 
website) (or a successor website), the following 
information in a manner that is prominent, eas-
ily accessible, readily understandable to con-
sumers of long-term care services, and searchable: 
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599 
‘‘(i) Staffing data for each facility (in-
cluding resident census data and data on 
the hours of care provided per resident per 
day) based on data submitted under sub-
section (b)(8)(C)(ii), including information 
on staffing turnover and tenure, in a for-
mat that is clearly understandable to con-
sumers of long-term care services and allows 
such consumers to compare differences in 
staffing between facilities and State and na-
tional averages for the facilities. Such for-
mat shall include— 
‘‘(I) concise explanations of how 
to interpret the data (such as plain 
English explanation of data reflecting 
‘nursing home staff hours per resident 
day’); 
‘‘(II) differences in types of staff 
(such as training associated with dif-
ferent categories of staff); 
‘‘(III) the relationship between 
nurse staffing levels and quality of 
care; and 
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600 
‘‘(IV) an explanation that appro-
priate staffing levels vary based on pa-
tient case mix. 
‘‘(ii) Links to State Internet websites 
with information regarding State survey 
and certification programs, links to Form 
2567 State inspection reports (or a suc-
cessor form) on such websites, information 
to guide consumers in how to interpret and 
understand such reports, and the facility 
plan of correction or other response to such 
report. 
‘‘(iii) The standardized complaint form 
developed under subsection (f)(10), includ-
ing explanatory material on what com-
plaint forms are, how they are used, and 
how to file a complaint with the State sur-
vey and certification program and the State 
long-term care ombudsman program. 
‘‘(iv) Summary information on the 
number, type, severity, and outcome of sub-
stantiated complaints. 
‘‘(v) The number of adjudicated in-
stances of criminal violations by employees 
of a nursing facility— 
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‘‘(I) that were committed inside of 
the facility; and 
‘‘(II) with respect to such in-
stances of violations or crimes com-
mitted outside of the facility, that were 
the violations or crimes that resulted 
in the serious bodily injury of an elder. 
‘‘(B) DEADLINE FOR PROVISION OF INFOR-
MATION.— 
‘‘(i) IN GENERAL.—Except as provided 
in clause (ii), the Secretary shall ensure 
that the information described in subpara-
graph (A) is included on such website (or a 
successor website) not later than 1 year 
after the date of the enactment of this sub-
section. 
‘‘(ii) EXCEPTION.—The Secretary shall 
ensure that the information described in 
subparagraph (A)(i) and (A)(iii) is in-
cluded on such website (or a successor 
website) not later than the date on which 
the requirements under section 1124(c)(4) 
and subsection (b)(8)(C)(ii) are imple-
mented. 
‘‘(2) REVIEW AND MODIFICATION OF WEBSITE.— 
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602 
‘‘(A) IN GENERAL.—The Secretary shall es-
tablish a process— 
‘‘(i) to review the accuracy, clarity of 
presentation, timeliness, and comprehensive-
ness of information reported on such website 
as of the day before the date of the enact-
ment of this subsection; and 
‘‘(ii) not later than 1 year after the 
date of the enactment of this subsection, to 
modify or revamp such website in accord-
ance with the review conducted under clause 
(i). 
‘‘(B) CONSULTATION.—In conducting the 
review under subparagraph (A)(i), the Secretary 
shall consult with— 
‘‘(i) State long-term care ombudsman 
programs; 
‘‘(ii) consumer advocacy groups; 
‘‘(iii) provider stakeholder groups; 
‘‘(iv) skilled nursing facility employees 
and their representatives; and 
‘‘(v) any other representatives of pro-
grams or groups the Secretary determines 
appropriate.’’. 
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603 
(2) TIMELINESS OF SUBMISSION OF SURVEY AND 
CERTIFICATION INFORMATION.— 
(A) IN GENERAL.—Section 1919(g)(5) of the 
Social Security Act (42 U.S.C. 1396r(g)(5)) is 
amended by adding at the end the following new 
subparagraph: 
‘‘(E) SUBMISSION OF SURVEY AND CERTIFI-
CATION INFORMATION TO THE SECRETARY.—In 
order to improve the timeliness of information 
made available to the public under subparagraph 
(A) and provided on the Nursing Home Compare 
Medicare website under subsection (i), each State 
shall submit information respecting any survey 
or certification made respecting a nursing facil-
ity (including any enforcement actions taken by 
the State) to the Secretary not later than the 
date on which the State sends such information 
to the facility. The Secretary shall use the infor-
mation submitted under the preceding sentence 
to update the information provided on the Nurs-
ing Home Compare Medicare website as expedi-
tiously as practicable but not less frequently 
than quarterly.’’. 
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604 
(B) EFFECTIVE
DATE.—The amendment 
made by this paragraph shall take effect 1 year 
after the date of the enactment of this Act. 
(3) SPECIAL
FOCUS
FACILITY
PROGRAM.—Sec-
tion 1919(f) of such Act is amended by adding at the 
end of the following new paragraph: 
‘‘(10) SPECIAL FOCUS FACILITY PROGRAM.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
conduct a special focus facility program for en-
forcement of requirements for nursing facilities 
that the Secretary has identified as having sub-
stantially failed to meet applicable requirements 
of this Act. 
‘‘(B) PERIODIC SURVEYS.—Under such pro-
gram the Secretary shall conduct surveys of each 
facility in the program not less often than once 
every 6 months.’’. 
(c) AVAILABILITY OF REPORTS ON SURVEYS, CERTIFI-
CATIONS, AND COMPLAINT INVESTIGATIONS.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(d)(1) of the Social Security Act (42 U.S.C. 
1395i–3(d)(1)), as amended by sections 1411 and 
1412, is amended by adding at the end the following 
new subparagraph: 
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605 
‘‘(D) AVAILABILITY
OF
SURVEY, CERTIFI-
CATION, AND
COMPLAINT
INVESTIGATION
RE-
PORTS.—A skilled nursing facility must— 
‘‘(i) have reports with respect to any 
surveys, certifications, and complaint inves-
tigations made respecting the facility dur-
ing the 3 preceding years available for any 
individual to review upon request; and 
‘‘(ii) post notice of the availability of 
such reports in areas of the facility that are 
prominent and accessible to the public. 
The facility shall not make available under 
clause (i) identifying information about com-
plainants or residents.’’. 
(2) NURSING FACILITIES.—Section 1919(d)(1) of 
the Social Security Act (42 U.S.C. 1396r(d)(1)), as 
amended by sections 1411 and 1412, is amended by 
adding at the end the following new subparagraph: 
‘‘(D) AVAILABILITY
OF
SURVEY, CERTIFI-
CATION, AND
COMPLAINT
INVESTIGATION
RE-
PORTS.—A nursing facility must— 
‘‘(i) have reports with respect to any 
surveys, certifications, and complaint inves-
tigations made respecting the facility dur-
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606 
ing the 3 preceding years available for any 
individual to review upon request; and 
‘‘(ii) post notice of the availability of 
such reports in areas of the facility that are 
prominent and accessible to the public. 
The facility shall not make available under 
clause (i) identifying information about com-
plainants or residents.’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall take effect 1 year after the 
date of the enactment of this Act. 
(d) GUIDANCE TO STATES ON FORM 2567 STATE IN-
SPECTION REPORTS AND COMPLAINT INVESTIGATION RE-
PORTS.— 
(1) GUIDANCE.—The Secretary of Health and 
Human Services (in this subtitle referred to as the 
‘‘Secretary’’) shall provide guidance to States on how 
States can establish electronic links to Form 2567 
State inspection reports (or a successor form), com-
plaint investigation reports, and a facility’s plan of 
correction or other response to such Form 2567 State 
inspection reports (or a successor form) on the Inter-
net website of the State that provides information on 
skilled nursing facilities and nursing facilities and 
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607 
the Secretary shall, if possible, include such informa-
tion on Nursing Home Compare. 
(2) REQUIREMENT.—Section 1902(a)(9) of the 
Social Security Act (42 U.S.C. 1396a(a)(9)) is 
amended— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (B); 
(B) by striking the semicolon at the end of 
subparagraph (C) and inserting ‘‘, and’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(D) that the State maintain a consumer- 
oriented website providing useful information to 
consumers regarding all skilled nursing facilities 
and all nursing facilities in the State, including 
for each facility, Form 2567 State inspection re-
ports (or a successor form), complaint investiga-
tion reports, the facility’s plan of correction, and 
such other information that the State or the Sec-
retary considers useful in assisting the public to 
assess the quality of long term care options and 
the quality of care provided by individual facili-
ties;’’. 
(3) DEFINITIONS.—In this subsection: 
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608 
(A) NURSING FACILITY.—The term ‘‘nurs-
ing facility’’ has the meaning given such term in 
section 1919(a) of the Social Security Act (42 
U.S.C. 1396r(a)). 
(B) SECRETARY.—The term ‘‘Secretary’’ 
means the Secretary of Health and Human Serv-
ices. 
(C) SKILLED NURSING FACILITY.—The term 
‘‘skilled nursing facility’’ has the meaning given 
such term in section 1819(a) of the Social Secu-
rity Act (42 U.S.C. 1395i–3(a)). 
SEC. 1414. REPORTING OF EXPENDITURES. 
Section 1888 of the Social Security Act (42 U.S.C. 
1395yy) is amended by adding at the end the following new 
subsection: 
‘‘(f) REPORTING OF DIRECT CARE EXPENDITURES.— 
‘‘(1) IN GENERAL.—For cost reports submitted 
under this title for cost reporting periods beginning 
on or after the date that is 3 years after the date of 
the enactment of this subsection, skilled nursing fa-
cilities shall separately report expenditures for wages 
and benefits for direct care staff (breaking out (at a 
minimum) registered nurses, licensed professional 
nurses, certified nurse assistants, and other medical 
and therapy staff). 
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609 
‘‘(2) MODIFICATION OF FORM.—The Secretary, 
in consultation with private sector accountants expe-
rienced with skilled nursing facility cost reports, shall 
redesign such reports to meet the requirement of para-
graph (1) not later than 1 year after the date of the 
enactment of this subsection. 
‘‘(3) CATEGORIZATION
BY
FUNCTIONAL
AC-
COUNTS.—Not later than 30 months after the date of 
the enactment of this subsection, the Secretary, work-
ing in consultation with the Medicare Payment Advi-
sory Commission, the Inspector General of the De-
partment of Health and Human Services, and other 
expert parties the Secretary determines appropriate, 
shall take the expenditures listed on cost reports, as 
modified under paragraph (1), submitted by skilled 
nursing facilities and categorize such expenditures, 
regardless of any source of payment for such expendi-
tures, for each skilled nursing facility into the fol-
lowing functional accounts on an annual basis: 
‘‘(A) Spending on direct care services (in-
cluding nursing, therapy, and medical services). 
‘‘(B) Spending on indirect care (including 
housekeeping and dietary services). 
‘‘(C) Capital assets (including building and 
land costs). 
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‘‘(D) Administrative services costs. 
‘‘(4) 
AVAILABILITY
OF
INFORMATION
SUB-
MITTED.—The Secretary shall establish procedures to 
make information on expenditures submitted under 
this subsection readily available to interested parties 
upon request, subject to such requirements as the Sec-
retary may specify under the procedures established 
under this paragraph.’’. 
SEC. 1415. STANDARDIZED COMPLAINT FORM. 
(a) SKILLED NURSING FACILITIES.— 
(1) DEVELOPMENT BY THE SECRETARY.—Section 
1819(f) of the Social Security Act (42 U.S.C. 1395i– 
3(f)), as amended by section 1413(a)(3), is amended 
by adding at the end the following new paragraph: 
‘‘(9) STANDARDIZED
COMPLAINT
FORM.—The 
Secretary shall develop a standardized complaint 
form for use by a resident (or a person acting on the 
resident’s behalf) in filing a complaint with a State 
survey and certification agency and a State long-term 
care ombudsman program with respect to a skilled 
nursing facility.’’. 
(2) STATE REQUIREMENTS.—Section 1819(e) of 
the Social Security Act (42 U.S.C. 1395i–3(e)) is 
amended by adding at the end the following new 
paragraph: 
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‘‘(6) COMPLAINT
PROCESSES
AND
WHISTLE- 
BLOWER PROTECTION.— 
‘‘(A) COMPLAINT FORMS.—The State must 
make the standardized complaint form developed 
under subsection (f)(9) available upon request 
to— 
‘‘(i) a resident of a skilled nursing fa-
cility; 
‘‘(ii) any person acting on the resi-
dent’s behalf; and 
‘‘(iii) any person who works at a 
skilled nursing facility or is a representa-
tive of such a worker. 
‘‘(B) COMPLAINT RESOLUTION PROCESS.— 
The State must establish a complaint resolution 
process in order to ensure that a resident, the 
legal representative of a resident of a skilled 
nursing facility, or other responsible party is not 
retaliated against if the resident, legal represent-
ative, or responsible party has complained, in 
good faith, about the quality of care or other 
issues relating to the skilled nursing facility, 
that the legal representative of a resident of a 
skilled nursing facility or other responsible party 
is not denied access to such resident or otherwise 
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retaliated against if such representative party 
has complained, in good faith, about the quality 
of care provided by the facility or other issues re-
lating to the facility, and that a person who 
works at a skilled nursing facility is not retali-
ated against if the worker has complained, in 
good faith, about quality of care or services or an 
issue relating to the quality of care or services 
provided at the facility, whether the resident, 
legal representative, other responsible party, or 
worker used the form developed under subsection 
(f)(9) or some other method for submitting the 
complaint. Such complaint resolution process 
shall include— 
‘‘(i) procedures to assure accurate 
tracking of complaints received, including 
notification to the complainant that a com-
plaint has been received; 
‘‘(ii) procedures to determine the likely 
severity of a complaint and for the inves-
tigation of the complaint; 
‘‘(iii) deadlines for responding to a 
complaint and for notifying the complain-
ant of the outcome of the investigation; and 
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‘‘(iv) procedures to ensure that the 
identity of the complainant will be kept 
confidential. 
‘‘(C) WHISTLEBLOWER PROTECTION.— 
‘‘(i) PROHIBITION
AGAINST
RETALIA-
TION.—No person who works at a skilled 
nursing facility may be penalized, discrimi-
nated, or retaliated against with respect to 
any aspect of employment, including dis-
charge, promotion, compensation, terms, 
conditions, or privileges of employment, or 
have a contract for services terminated, be-
cause the person (or anyone acting at the 
person’s request) complained, in good faith, 
about the quality of care or services pro-
vided by a nursing facility or about other 
issues relating to quality of care or services, 
whether using the form developed under sub-
section (f)(9) or some other method for sub-
mitting the complaint. 
‘‘(ii) 
RETALIATORY
REPORTING.—A 
skilled nursing facility may not file a com-
plaint or a report against a person who 
works (or has worked at the facility with 
the appropriate State professional discipli-
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nary agency because the person (or anyone 
acting at the person’s request) complained 
in good faith, as described in clause (i). 
‘‘(iii) COMMENCEMENT
OF
ACTION.— 
Any person who believes the person has been 
penalized, discriminated , or retaliated 
against or had a contract for services termi-
nated in violation of clause (i) or against 
whom a complaint has been filed in viola-
tion of clause (ii) may bring an action at 
law or equity in the appropriate district 
court of the United States, which shall have 
jurisdiction over such action without regard 
to the amount in controversy or the citizen-
ship of the parties, and which shall have ju-
risdiction to grant complete relief, includ-
ing, but not limited to, injunctive relief 
(such as reinstatement, compensatory dam-
ages (which may include reimbursement of 
lost wages, compensation, and benefits), 
costs of litigation (including reasonable at-
torney and expert witness fees), exemplary 
damages where appropriate, and such other 
relief as the court deems just and proper. 
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615 
‘‘(iv) RIGHTS
NOT
WAIVABLE.—The 
rights protected by this paragraph may not 
be diminished by contract or other agree-
ment, and nothing in this paragraph shall 
be construed to diminish any greater or ad-
ditional protection provided by Federal or 
State law or by contract or other agreement. 
‘‘(v) REQUIREMENT TO POST NOTICE 
OF EMPLOYEE RIGHTS.—Each skilled nurs-
ing facility shall post conspicuously in an 
appropriate location a sign (in a form spec-
ified by the Secretary) specifying the rights 
of persons under this paragraph and in-
cluding a statement that an employee may 
file a complaint with the Secretary against 
a skilled nursing facility that violates the 
provisions of this paragraph and informa-
tion with respect to the manner of filing 
such a complaint. 
‘‘(D) RULE OF CONSTRUCTION.—Nothing in 
this paragraph shall be construed as preventing 
a resident of a skilled nursing facility (or a per-
son acting on the resident’s behalf) from submit-
ting a complaint in a manner or format other 
than by using the standardized complaint form 
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616 
developed under subsection (f)(9) (including sub-
mitting a complaint orally). 
‘‘(E) GOOD FAITH DEFINED.—For purposes 
of this paragraph, an individual shall be deemed 
to be acting in good faith with respect to the fil-
ing of a complaint if the individual reasonably 
believes— 
‘‘(i) the information reported or dis-
closed in the complaint is true; and 
‘‘(ii) the violation of this title has oc-
curred or may occur in relation to such in-
formation.’’. 
(b) NURSING FACILITIES.— 
(1) DEVELOPMENT BY THE SECRETARY.—Section 
1919(f) of the Social Security Act (42 U.S.C. 1395i– 
3(f)), as amended by section 1413(b), is amended by 
adding at the end the following new paragraph: 
‘‘(11) STANDARDIZED
COMPLAINT
FORM.—The 
Secretary shall develop a standardized complaint 
form for use by a resident (or a person acting on the 
resident’s behalf) in filing a complaint with a State 
survey and certification agency and a State long-term 
care ombudsman program with respect to a nursing 
facility.’’. 
VerDate Nov 24 2008 
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617 
(2) STATE REQUIREMENTS.—Section 1919(e) of 
the Social Security Act (42 U.S.C. 1395i–3(e)) is 
amended by adding at the end the following new 
paragraph: 
‘‘(8) COMPLAINT
PROCESSES
AND
WHISTLE-
BLOWER PROTECTION.— 
‘‘(A) COMPLAINT FORMS.—The State must 
make the standardized complaint form developed 
under subsection (f)(11) available upon request 
to— 
‘‘(i) a resident of a nursing facility; 
‘‘(ii) any person acting on the resi-
dent’s behalf; and 
‘‘(iii) any person who works at a nurs-
ing facility or a representative of such a 
worker. 
‘‘(B) COMPLAINT RESOLUTION PROCESS.— 
The State must establish a complaint resolution 
process in order to ensure that a resident, the 
legal representative of a resident of a nursing fa-
cility, or other responsible party is not retaliated 
against if the resident, legal representative, or re-
sponsible party has complained, in good faith, 
about the quality of care or other issues relating 
to the nursing facility, that the legal representa-
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618 
tive of a resident of a nursing facility or other 
responsible party is not denied access to such 
resident or otherwise retaliated against if such 
representative party has complained, in good 
faith, about the quality of care provided by the 
facility or other issues relating to the facility, 
and that a person who works at a nursing facil-
ity is not retaliated against if the worker has 
complained, in good faith, about quality of care 
or services or an issue relating to the quality of 
care or services provided at the facility, whether 
the resident, legal representative, other respon-
sible party, or worker used the form developed 
under subsection (f)(11) or some other method for 
submitting the complaint. Such complaint reso-
lution process shall include— 
‘‘(i) procedures to assure accurate 
tracking of complaints received, including 
notification to the complainant that a com-
plaint has been received; 
‘‘(ii) procedures to determine the likely 
severity of a complaint and for the inves-
tigation of the complaint; 
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619 
‘‘(iii) deadlines for responding to a 
complaint and for notifying the complain-
ant of the outcome of the investigation; and 
‘‘(iv) procedures to ensure that the 
identity of the complainant will be kept 
confidential. 
‘‘(C) WHISTLEBLOWER PROTECTION.— 
‘‘(i) PROHIBITION
AGAINST
RETALIA-
TION.—No person who works at a nursing 
facility may be penalized, discriminated, or 
retaliated against with respect to any as-
pect of employment, including discharge, 
promotion, compensation, terms, conditions, 
or privileges of employment, or have a con-
tract for services terminated, because the 
person (or anyone acting at the person’s re-
quest) complained, in good faith, about the 
quality of care or services provided by a 
nursing facility or about other issues relat-
ing to quality of care or services, whether 
using the form developed under subsection 
(f)(11) or some other method for submitting 
the complaint. 
‘‘(ii) 
RETALIATORY
REPORTING.—A 
nursing facility may not file a complaint or 
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620 
a report against a person who works (or has 
worked at the facility with the appropriate 
State professional disciplinary agency be-
cause the person (or anyone acting at the 
person’s request) complained in good faith, 
as described in clause (i). 
‘‘(iii) COMMENCEMENT
OF
ACTION.— 
Any person who believes the person has been 
penalized, 
discriminated, 
or 
retaliated 
against or had a contract for services termi-
nated in violation of clause (i) or against 
whom a complaint has been filed in viola-
tion of clause (ii) may bring an action at 
law or equity in the appropriate district 
court of the United States, which shall have 
jurisdiction over such action without regard 
to the amount in controversy or the citizen-
ship of the parties, and which shall have ju-
risdiction to grant complete relief, includ-
ing, but not limited to, injunctive relief 
(such as reinstatement, compensatory dam-
ages (which may include reimbursement of 
lost wages, compensation, and benefits), 
costs of litigation (including reasonable at-
torney and expert witness fees), exemplary 
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621 
damages where appropriate, and such other 
relief as the court deems just and proper. 
‘‘(iv) RIGHTS
NOT
WAIVABLE.—The 
rights protected by this paragraph may not 
be diminished by contract or other agree-
ment, and nothing in this paragraph shall 
be construed to diminish any greater or ad-
ditional protection provided by Federal or 
State law or by contract or other agreement. 
‘‘(v) REQUIREMENT TO POST NOTICE 
OF EMPLOYEE RIGHTS.—Each nursing fa-
cility shall post conspicuously in an appro-
priate location a sign (in a form specified 
by the Secretary) specifying the rights of 
persons under this paragraph and includ-
ing a statement that an employee may file 
a complaint with the Secretary against a 
nursing facility that violates the provisions 
of this paragraph and information with re-
spect to the manner of filing such a com-
plaint. 
‘‘(D) RULE OF CONSTRUCTION.—Nothing in 
this paragraph shall be construed as preventing 
a resident of a nursing facility (or a person act-
ing on the resident’s behalf) from submitting a 
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622 
complaint in a manner or format other than by 
using the standardized complaint form developed 
under subsection (f)(11) (including submitting a 
complaint orally). 
‘‘(E) GOOD FAITH DEFINED.—For purposes 
of this paragraph, an individual shall be deemed 
to be acting in good faith with respect to the fil-
ing of a complaint if the individual reasonably 
believes— 
‘‘(i) the information reported or dis-
closed in the complaint is true; and 
‘‘(ii) the violation of this title has oc-
curred or may occur in relation to such in-
formation.’’. 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall take effect 1 year after the date of the enact-
ment of this Act. 
SEC. 1416. ENSURING STAFFING ACCOUNTABILITY. 
(a) 
SKILLED
NURSING
FACILITIES.—Section 
1819(b)(8) of the Social Security Act (42 U.S.C. 1395i– 
3(b)(8)) is amended by adding at the end the following new 
subparagraph: 
‘‘(C) SUBMISSION OF STAFFING INFORMA-
TION BASED ON PAYROLL DATA IN A UNIFORM 
FORMAT.—Beginning not later than 2 years 
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after the date of the enactment of this subpara-
graph, and after consulting with State long-term 
care ombudsman programs, consumer advocacy 
groups, provider stakeholder groups, employees 
and their representatives, and other parties the 
Secretary deems appropriate, the Secretary shall 
require a skilled nursing facility to electronically 
submit to the Secretary direct care staffing infor-
mation (including information with respect to 
agency and contract staff) based on payroll and 
other verifiable and auditable data in a uniform 
format (according to specifications established by 
the Secretary in consultation with such pro-
grams, groups, and parties). Such specifications 
shall require that the information submitted 
under the preceding sentence— 
‘‘(i) specify the category of work a cer-
tified employee performs (such as whether 
the employee is a registered nurse, licensed 
practical nurse, licensed vocational nurse, 
certified nursing assistant, therapist, or 
other medical personnel); 
‘‘(ii) include resident census data and 
information on resident case mix; 
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624 
‘‘(iii) include a regular reporting 
schedule; and 
‘‘(iv) include information on employee 
turnover and tenure and on the hours of 
care provided by each category of certified 
employees referenced in clause (i) per resi-
dent per day. 
Nothing in this subparagraph shall be construed 
as preventing the Secretary from requiring sub-
mission of such information with respect to spe-
cific categories, such as nursing staff, before 
other categories of certified employees. Informa-
tion under this subparagraph with respect to 
agency and contract staff shall be kept separate 
from information on employee staffing.’’. 
(b) NURSING FACILITIES.—Section 1919(b)(8) of the 
Social Security Act (42 U.S.C. 1396r(b)(8)) is amended by 
adding at the end the following new subparagraph: 
‘‘(C) SUBMISSION OF STAFFING INFORMA-
TION BASED ON PAYROLL DATA IN A UNIFORM 
FORMAT.—Beginning not later than 2 years 
after the date of the enactment of this subpara-
graph, and after consulting with State long-term 
care ombudsman programs, consumer advocacy 
groups, provider stakeholder groups, employees 
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625 
and their representatives, and other parties the 
Secretary deems appropriate, the Secretary shall 
require a nursing facility to electronically sub-
mit to the Secretary direct care staffing informa-
tion (including information with respect to agen-
cy and contract staff) based on payroll and other 
verifiable and auditable data in a uniform for-
mat (according to specifications established by 
the Secretary in consultation with such pro-
grams, groups, and parties). Such specifications 
shall require that the information submitted 
under the preceding sentence— 
‘‘(i) specify the category of work a cer-
tified employee performs (such as whether 
the employee is a registered nurse, licensed 
practical nurse, licensed vocational nurse, 
certified nursing assistant, therapist, or 
other medical personnel); 
‘‘(ii) include resident census data and 
information on resident case mix; 
‘‘(iii) include a regular reporting 
schedule; and 
‘‘(iv) include information on employee 
turnover and tenure and on the hours of 
care provided by each category of certified 
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bajohnson on DSK2BSOYB1PROD with BILLS
626 
employees referenced in clause (i) per resi-
dent per day. 
Nothing in this subparagraph shall be construed 
as preventing the Secretary from requiring sub-
mission of such information with respect to spe-
cific categories, such as nursing staff, before 
other categories of certified employees. Informa-
tion under this subparagraph with respect to 
agency and contract staff shall be kept separate 
from information on employee staffing.’’. 
PART 2—TARGETING ENFORCEMENT 
SEC. 1421. CIVIL MONEY PENALTIES. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819(h)(2)(B)(ii) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395i– 
3(h)(2)(B)(ii)) is amended to read as follows: 
‘‘(ii) AUTHORITY
WITH
RESPECT
TO 
CIVIL MONEY PENALTIES.— 
‘‘(I) 
AMOUNT.—The 
Secretary 
may impose a civil money penalty in 
the applicable per instance or per day 
amount (as defined in subclause (II) 
and (III)) for each day or instance, re-
spectively, of noncompliance (as deter-
mined appropriate by the Secretary). 
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‘‘(II) APPLICABLE PER INSTANCE 
AMOUNT.—In this clause, the term ‘ap-
plicable per instance amount’ means— 
‘‘(aa) in the case where the 
deficiency is found to be a direct 
proximate cause of death of a resi-
dent of the facility, an amount 
not to exceed $100,000; 
‘‘(bb) in each case of a defi-
ciency where the facility is cited 
for actual harm or immediate 
jeopardy, an amount not less than 
$3,050 
and 
not 
more 
than 
$25,000; and 
‘‘(cc) in each case of any 
other deficiency, an amount not 
less than $250 and not to exceed 
$3050. 
‘‘(III) 
APPLICABLE
PER
DAY 
AMOUNT.—In this clause, the term ‘ap-
plicable per day amount’ means— 
‘‘(aa) in each case of a defi-
ciency where the facility is cited 
for actual harm or immediate 
jeopardy, an amount not less than 
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$3,050 
and 
not 
more 
than 
$25,000, and 
‘‘(bb) in each case of any 
other deficiency, an amount not 
less than $250 and not to exceed 
$3,050. 
‘‘(IV) 
REDUCTION
OF
CIVIL 
MONEY
PENALTIES
IN
CERTAIN
CIR-
CUMSTANCES.—Subject to subclauses 
(V) and (VI), in the case where a facil-
ity self-reports and promptly corrects a 
deficiency for which a penalty was im-
posed under this clause not later than 
10 calendar days after the date of such 
imposition, the Secretary may reduce 
the amount of the penalty imposed by 
not more than 50 percent. 
‘‘(V) PROHIBITION ON REDUCTION 
FOR CERTAIN DEFICIENCIES.— 
‘‘(aa) 
REPEAT
DEFI-
CIENCIES.—The Secretary may 
not reduce under subclause (IV) 
the amount of a penalty if the de-
ficiency is a repeat deficiency. 
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‘‘(bb) CERTAIN OTHER DEFI-
CIENCIES.—The Secretary may 
not reduce under subclause (IV) 
the amount of a penalty if the 
penalty is imposed for a defi-
ciency 
described 
in 
subclause 
(II)(aa) or (III)(aa) and the ac-
tual harm or widespread harm 
immediately jeopardizes the health 
or safety of a resident or residents 
of the facility, or if the penalty is 
imposed for a deficiency described 
in subclause (II)(bb). 
‘‘(VI) LIMITATION ON AGGREGATE 
REDUCTIONS.—The aggregate reduction 
in a penalty under subclause (IV) may 
not exceed 35 percent on the basis of 
self-reporting, on the basis of a waiver 
or an appeal (as provided for under 
regulations under section 488.436 of 
title 42, Code of Federal Regulations), 
or on the basis of both. 
‘‘(VII) 
COLLECTION
OF
CIVIL 
MONEY PENALTIES.—In the case of a 
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civil money penalty imposed under 
this clause, the Secretary— 
‘‘(aa) subject to item (cc), 
shall, not later than 30 days after 
the date of imposition of the pen-
alty, provide the opportunity for 
the facility to participate in an 
independent informal dispute res-
olution process which generates a 
written record prior to the collec-
tion of such penalty, but such op-
portunity shall not affect the re-
sponsibility of the State survey 
agency for making final rec-
ommendations for such penalties; 
‘‘(bb) in the case where the 
penalty is imposed for each day of 
noncompliance, shall not impose a 
penalty for any day during the 
period beginning on the initial 
day of the imposition of the pen-
alty and ending on the day on 
which the informal dispute resolu-
tion process under item (aa) is 
completed; 
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631 
‘‘(cc) may provide for the col-
lection of such civil money pen-
alty and the placement of such 
amounts collected in an escrow 
account under the direction of the 
Secretary on the earlier of the 
date on which the informal dis-
pute resolution process under item 
(aa) is completed or the date that 
is 90 days after the date of the 
imposition of the penalty; 
‘‘(dd) may provide that such 
amounts collected are kept in such 
account pending the resolution of 
any subsequent appeals; 
‘‘(ee) in the case where the 
facility successfully appeals the 
penalty, may provide for the re-
turn of such amounts collected 
(plus interest) to the facility; and 
‘‘(ff) in the case where all 
such appeals are unsuccessful, 
may provide that some portion of 
such amounts collected may be 
used to support activities that 
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benefit residents, including assist-
ance to support and protect resi-
dents of a facility that closes (vol-
untarily or involuntarily) or is 
decertified (including offsetting 
costs of relocating residents to 
home and community-based set-
tings or another facility), projects 
that support resident and family 
councils and other consumer in-
volvement in assuring quality 
care in facilities, and facility im-
provement initiatives approved by 
the Secretary (including joint 
training of facility staff and sur-
veyors, technical assistance for fa-
cilities under quality assurance 
programs, the appointment of 
temporary 
management, 
and 
other activities approved by the 
Secretary). 
‘‘(VIII) PROCEDURE.—The provi-
sions of section 1128A (other than sub-
sections (a) and (b) and except to the 
extent that such provisions require a 
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hearing prior to the imposition of a 
civil money penalty) shall apply to a 
civil money penalty under this clause 
in the same manner as such provisions 
apply to a penalty or proceeding under 
section 1128A(a).’’. 
(2) CONFORMING AMENDMENT.—The second sen-
tence of section 1819(h)(5) of the Social Security Act 
(42 U.S.C. 1395i–3(h)(5)) is amended by inserting 
‘‘(ii),’’after ‘‘(i),’’. 
(b) NURSING FACILITIES.— 
(1) PENALTIES IMPOSED BY THE STATE.— 
(A) IN GENERAL.—Section 1919(h)(2) of the 
Social Security Act (42 U.S.C. 1396r(h)(2)) is 
amended— 
(i) in subparagraph (A)(ii), by strik-
ing the first sentence and inserting the fol-
lowing: ‘‘A civil money penalty in accord-
ance with subparagraph (G).’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(G) CIVIL MONEY PENALTIES.— 
‘‘(i) IN GENERAL.—The State may im-
pose a civil money penalty under subpara-
graph (A)(ii) in the applicable per instance 
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or per day amount (as defined in subclause 
(II) and (III)) for each day or instance, re-
spectively, of noncompliance (as determined 
appropriate by the Secretary). 
‘‘(ii) 
APPLICABLE
PER
INSTANCE 
AMOUNT.—In this subparagraph, the term 
‘applicable per instance amount’ means— 
‘‘(I) in the case where the defi-
ciency is found to be a direct proxi-
mate cause of death of a resident of the 
facility, an amount not to exceed 
$100,000. 
‘‘(II) in each case of a deficiency 
where the facility is cited for actual 
harm or immediate jeopardy, an 
amount not less than $3,050 and not 
more than $25,000; and 
‘‘(III) in each case of any other 
deficiency, an amount not less than 
$250 and not to exceed $3050. 
‘‘(iii) 
APPLICABLE
PER
DAY 
AMOUNT.—In this subparagraph, the term 
‘applicable per day amount’ means— 
‘‘(I) in each case of a deficiency 
where the facility is cited for actual 
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harm or immediate jeopardy, an 
amount not less than $3,050 and not 
more than $25,000 and 
‘‘(II) in each case of any other de-
ficiency, an amount not less than $250 
and not to exceed $3,050. 
‘‘(iv) REDUCTION
OF
CIVIL
MONEY 
PENALTIES IN CERTAIN CIRCUMSTANCES.— 
Subject to clauses (v) and (vi), in the case 
where a facility self-reports and promptly 
corrects a deficiency for which a penalty 
was imposed under subparagraph (A)(ii) 
not later than 10 calendar days after the 
date of such imposition, the State may re-
duce the amount of the penalty imposed by 
not more than 50 percent. 
‘‘(v) PROHIBITION ON REDUCTION FOR 
CERTAIN DEFICIENCIES.— 
‘‘(I) REPEAT DEFICIENCIES.—The 
State may not reduce under clause (iv) 
the amount of a penalty if the State 
had reduced a penalty imposed on the 
facility in the preceding year under 
such clause with respect to a repeat de-
ficiency. 
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‘‘(II) 
CERTAIN
OTHER
DEFI-
CIENCIES.—The State may not reduce 
under clause (iv) the amount of a pen-
alty if the penalty is imposed for a de-
ficiency described in clause (ii)(II) or 
(iii)(I) and the actual harm or wide-
spread harm that immediately jeopard-
izes the health or safety of a resident or 
residents of the facility, or if the pen-
alty is imposed for a deficiency de-
scribed in clause (ii)(I). 
‘‘(III) LIMITATION ON AGGREGATE 
REDUCTIONS.—The aggregate reduction 
in a penalty under clause (iv) may not 
exceed 35 percent on the basis of self- 
reporting, on the basis of a waiver or 
an appeal (as provided for under regu-
lations under section 488.436 of title 
42, Code of Federal Regulations), or on 
the basis of both. 
‘‘(vi) COLLECTION
OF
CIVIL
MONEY 
PENALTIES.—In the case of a civil money 
penalty 
imposed 
under 
subparagraph 
(A)(ii), the State— 
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‘‘(I) subject to subclause (III), 
shall, not later than 30 days after the 
date of imposition of the penalty, pro-
vide the opportunity for the facility to 
participate in an independent infor-
mal dispute resolution process which 
generates a written record prior to the 
collection of such penalty, but such op-
portunity shall not affect the responsi-
bility of the State survey agency for 
making final recommendations for 
such penalties; 
‘‘(II) in the case where the pen-
alty is imposed for each day of non-
compliance, shall not impose a penalty 
for any day during the period begin-
ning on the initial day of the imposi-
tion of the penalty and ending on the 
day on which the informal dispute res-
olution process under subclause (I) is 
completed; 
‘‘(III) may provide for the collec-
tion of such civil money penalty and 
the placement of such amounts collected 
in an escrow account under the direc-
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tion of the State on the earlier of the 
date on which the informal dispute res-
olution process under subclause (I) is 
completed or the date that is 90 days 
after the date of the imposition of the 
penalty; 
‘‘(IV) may provide that such 
amounts collected are kept in such ac-
count pending the resolution of any 
subsequent appeals; 
‘‘(V) in the case where the facility 
successfully appeals the penalty, may 
provide for the return of such amounts 
collected (plus interest) to the facility; 
and 
‘‘(VI) in the case where all such 
appeals are unsuccessful, may provide 
that such funds collected shall be used 
for the purposes described in the second 
sentence of subparagraph (A)(ii).’’. 
(B) CONFORMING AMENDMENT.—The second 
sentence of section 1919(h)(2)(A)(ii) of the Social 
Security Act (42 U.S.C. 1396r(h)(2)(A)(ii)) is 
amended by inserting before the period at the 
end the following: ‘‘, and some portion of such 
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funds may be used to support activities that ben-
efit residents, including assistance to support 
and protect residents of a facility that closes 
(voluntarily or involuntarily) or is decertified 
(including offsetting costs of relocating residents 
to home and community-based settings or an-
other facility), projects that support resident and 
family councils and other consumer involvement 
in assuring quality care in facilities, and facil-
ity improvement initiatives approved by the Sec-
retary (including joint training of facility staff 
and surveyors, providing technical assistance to 
facilities under quality assurance programs, the 
appointment of temporary management, and 
other activities approved by the Secretary)’’. 
(2) PENALTIES IMPOSED BY THE SECRETARY.— 
(A) 
IN
GENERAL.—Section 
1919(h)(3)(C)(ii) of the Social Security Act (42 
U.S.C. 1396r(h)(3)(C)) is amended to read as 
follows: 
‘‘(ii) AUTHORITY
WITH
RESPECT
TO 
CIVIL MONEY PENALTIES.— 
‘‘(I) AMOUNT.—Subject to sub-
clause (II), the Secretary may impose 
a civil money penalty in an amount 
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not to exceed $10,000 for each day or 
each instance of noncompliance (as de-
termined appropriate by the Sec-
retary). 
‘‘(II) REDUCTION OF CIVIL MONEY 
PENALTIES
IN
CERTAIN
CIR-
CUMSTANCES.—Subject 
to 
subclause 
(III), in the case where a facility self- 
reports and promptly corrects a defi-
ciency for which a penalty was im-
posed under this clause not later than 
10 calendar days after the date of such 
imposition, the Secretary may reduce 
the amount of the penalty imposed by 
not more than 50 percent. 
‘‘(III) PROHIBITION
ON
REDUC-
TION FOR REPEAT DEFICIENCIES.—The 
Secretary may not reduce the amount 
of a penalty under subclause (II) if the 
Secretary had reduced a penalty im-
posed on the facility in the preceding 
year under such subclause with respect 
to a repeat deficiency. 
‘‘(IV) 
COLLECTION
OF
CIVIL 
MONEY PENALTIES.—In the case of a 
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civil money penalty imposed under 
this clause, the Secretary— 
‘‘(aa) subject to item (bb), 
shall, not later than 30 days after 
the date of imposition of the pen-
alty, provide the opportunity for 
the facility to participate in an 
independent informal dispute res-
olution process which generates a 
written record prior to the collec-
tion of such penalty; 
‘‘(bb) in the case where the 
penalty is imposed for each day of 
noncompliance, shall not impose a 
penalty for any day during the 
period beginning on the initial 
day of the imposition of the pen-
alty and ending on the day on 
which the informal dispute resolu-
tion process under item (aa) is 
completed; 
‘‘(cc) may provide for the col-
lection of such civil money pen-
alty and the placement of such 
amounts collected in an escrow 
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642 
account under the direction of the 
Secretary on the earlier of the 
date on which the informal dis-
pute resolution process under item 
(aa) is completed or the date that 
is 90 days after the date of the 
imposition of the penalty; 
‘‘(dd) may provide that such 
amounts collected are kept in such 
account pending the resolution of 
any subsequent appeals; 
‘‘(ee) in the case where the 
facility successfully appeals the 
penalty, may provide for the re-
turn of such amounts collected 
(plus interest) to the facility; and 
‘‘(ff) in the case where all 
such appeals are unsuccessful, 
may provide that some portion of 
such amounts collected may be 
used to support activities that 
benefit residents, including assist-
ance to support and protect resi-
dents of a facility that closes (vol-
untarily or involuntarily) or is 
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643 
decertified (including offsetting 
costs of relocating residents to 
home and community-based set-
tings or another facility), projects 
that support resident and family 
councils and other consumer in-
volvement in assuring quality 
care in facilities, and facility im-
provement initiatives approved by 
the Secretary (including joint 
training of facility staff and sur-
veyors, technical assistance for fa-
cilities under quality assurance 
programs, the appointment of 
temporary 
management, 
and 
other activities approved by the 
Secretary). 
‘‘(V) 
PROCEDURE.—The 
provi-
sions of section 1128A (other than sub-
sections (a) and (b) and except to the 
extent that such provisions require a 
hearing prior to the imposition of a 
civil money penalty) shall apply to a 
civil money penalty under this clause 
in the same manner as such provisions 
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644 
apply to a penalty or proceeding under 
section 1128A(a).’’. 
(B) 
CONFORMING
AMENDMENT.—Section 
1919(h)(8) of the Social Security Act (42 U.S.C. 
1396r(h)(5)(8)) is amended by inserting ‘‘and in 
paragraph (3)(C)(ii)’’ after ‘‘paragraph (2)(A)’’. 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall take effect 1 year after the date of the enact-
ment of this Act. 
SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PRO-
GRAM. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—The Secretary, in consultation 
with the Inspector General of the Department of 
Health and Human Services, shall establish a pilot 
program (in this section referred to as the ‘‘pilot pro-
gram’’) to develop, test, and implement use of an 
independent monitor to oversee interstate and large 
intrastate chains of skilled nursing facilities and 
nursing facilities. 
(2) SELECTION.—The Secretary shall select 
chains of skilled nursing facilities and nursing facili-
ties described in paragraph (1) to participate in the 
pilot program from among those chains that submit 
an application to the Secretary at such time, in such 
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645 
manner, and containing such information as the Sec-
retary may require. 
(3) DURATION.—The Secretary shall conduct the 
pilot program for a two-year period. 
(4) IMPLEMENTATION.—The Secretary shall im-
plement the pilot program not later than one year 
after the date of the enactment of this Act. 
(b) REQUIREMENTS.—The Secretary shall evaluate 
chains selected to participate in the pilot program based 
on criteria selected by the Secretary, including where evi-
dence suggests that one or more facilities of the chain are 
experiencing serious safety and quality of care problems. 
Such criteria may include the evaluation of a chain that 
includes one or more facilities participating in the ‘‘Special 
Focus Facility’’ program (or a successor program) or one 
or more facilities with a record of repeated serious safety 
and quality of care deficiencies. 
(c) RESPONSIBILITIES OF THE INDEPENDENT MON-
ITOR.—An independent monitor that enters into a contract 
with the Secretary to participate in the conduct of such pro-
gram shall— 
(1) conduct periodic reviews and prepare root- 
cause quality and deficiency analyses of a chain to 
assess if facilities of the chain are in compliance with 
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646 
State and Federal laws and regulations applicable to 
the facilities; 
(2) undertake sustained oversight of the chain, 
whether publicly or privately held, to involve the own-
ers of the chain and the principal business partners 
of such owners in facilitating compliance by facilities 
of the chain with State and Federal laws and regula-
tions applicable to the facilities; 
(3) analyze the management structure, distribu-
tion of expenditures, and nurse staffing levels of fa-
cilities of the chain in relation to resident census, 
staff turnover rates, and tenure; 
(4) report findings and recommendations with 
respect to such reviews, analyses, and oversight to the 
chain and facilities of the chain, to the Secretary and 
to relevant States; and 
(5) publish the results of such reviews, analyses, 
and oversight. 
(d) IMPLEMENTATION OF RECOMMENDATIONS.— 
(1) RECEIPT OF FINDING BY CHAIN.—Not later 
than 10 days after receipt of a finding of an inde-
pendent monitor under subsection (c)(4), a chain par-
ticipating in the pilot program shall submit to the 
independent monitor a report— 
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647 
(A) outlining corrective actions the chain 
will take to implement the recommendations in 
such report; or 
(B) indicating that the chain will not im-
plement such recommendations and why it will 
not do so. 
(2) RECEIPT OF REPORT BY INDEPENDENT MON-
ITOR.—Not later than 10 days after the date of re-
ceipt of a report submitted by a chain under para-
graph (1), an independent monitor shall finalize its 
recommendations and submit a report to the chain 
and facilities of the chain, the Secretary, and the 
State (or States) involved, as appropriate, containing 
such final recommendations. 
(e) COST OF APPOINTMENT.—A chain shall be respon-
sible for a portion of the costs associated with the appoint-
ment of independent monitors under the pilot program. The 
chain shall pay such portion to the Secretary (in an 
amount and in accordance with procedures established by 
the Secretary). 
(f) WAIVER AUTHORITY.—The Secretary may waive 
such requirements of titles XVIII and XIX of the Social Se-
curity Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as may 
be necessary for the purpose of carrying out the pilot pro-
gram. 
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(g) AUTHORIZATION OF APPROPRIATIONS.—There are 
authorized to be appropriated such sums as may be nec-
essary to carry out this section. 
(h) DEFINITIONS.—In this section: 
(1) FACILITY.—The term ‘‘facility’’ means a 
skilled nursing facility or a nursing facility. 
(2) NURSING FACILITY.—The term ‘‘nursing fa-
cility’’ has the meaning given such term in section 
1919(a) of the Social Security Act (42 U.S.C. 
1396r(a)). 
(3) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services, acting 
through the Assistant Secretary for Planning and 
Evaluation. 
(4) SKILLED
NURSING
FACILITY.—The term 
‘‘skilled nursing facility’’ has the meaning given such 
term in section 1819(a) of the Social Security Act (42 
U.S.C. 1395(a)). 
(i) EVALUATION AND REPORT.— 
(1) EVALUATION.—The Inspector General of the 
Department of Health and Human Services shall 
evaluate the pilot program. Such evaluation shall— 
(A) determine whether the independent 
monitor program should be established on a per-
manent basis; and 
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(B) if the Inspector General determines that 
the independent monitor program should be es-
tablished on a permanent basis, recommend ap-
propriate procedures and mechanisms for such 
establishment. 
(2) REPORT.—Not later than 180 days after the 
completion of the pilot program, the Inspector Gen-
eral shall submit to Congress and the Secretary a re-
port containing the results of the evaluation con-
ducted under paragraph (1), together with rec-
ommendations for such legislation and administrative 
action as the Inspector General determines appro-
priate. 
SEC. 1423. NOTIFICATION OF FACILITY CLOSURE. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819(c) of the Social 
Security Act (42 U.S.C. 1395i–3(c)) is amended by 
adding at the end the following new paragraph: 
‘‘(7) NOTIFICATION OF FACILITY CLOSURE.— 
‘‘(A) IN GENERAL.—Any individual who is 
the administrator of a skilled nursing facility 
must— 
‘‘(i) submit to the Secretary, the State 
long-term care ombudsman, residents of the 
facility, and the legal representatives of 
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such residents or other responsible parties, 
written notification of an impending clo-
sure— 
‘‘(I) subject to subclause (II), not 
later than the date that is 60 days 
prior to the date of such closure; and 
‘‘(II) in the case of a facility 
where the Secretary terminates the fa-
cility’s participation under this title, 
not later than the date that the Sec-
retary determines appropriate; 
‘‘(ii) ensure that the facility does not 
admit any new residents on or after the 
date on which such written notification is 
submitted; and 
‘‘(iii) include in the notice a plan for 
the transfer and adequate relocation of the 
residents of the facility by a specified date 
prior to closure that has been approved by 
the State, including assurances that the 
residents will be transferred to the most ap-
propriate facility or other setting in terms 
of quality, services, and location, taking 
into consideration the needs and best inter-
ests of each resident. 
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‘‘(B) RELOCATION.— 
‘‘(i) IN GENERAL.—The State shall en-
sure that, before a facility closes, all resi-
dents of the facility have been successfully 
relocated to another facility or an alter-
native home and community-based setting. 
‘‘(ii) CONTINUATION
OF
PAYMENTS 
UNTIL
RESIDENTS
RELOCATED.—The Sec-
retary may, as the Secretary determines ap-
propriate, continue to make payments 
under this title with respect to residents of 
a facility that has submitted a notification 
under subparagraph (A) during the period 
beginning on the date such notification is 
submitted and ending on the date on which 
the resident is successfully relocated.’’. 
(2) 
CONFORMING
AMENDMENTS.—Section 
1819(h)(4) of the Social Security Act (42 U.S.C. 
1395i–3(h)(4)) is amended— 
(A) in the first sentence, by striking ‘‘the 
Secretary shall terminate’’ and inserting ‘‘the 
Secretary, subject to subsection (c)(7), shall ter-
minate’’; and 
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(B) in the second sentence, by striking ‘‘sub-
section (c)(2)’’ and inserting ‘‘paragraphs (2) 
and (7) of subsection (c)’’. 
(b) NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1919(c) of the Social 
Security Act (42 U.S.C. 1396r(c)) is amended by 
adding at the end the following new paragraph: 
‘‘(9) NOTIFICATION OF FACILITY CLOSURE.— 
‘‘(A) IN GENERAL.—Any individual who is 
an administrator of a nursing facility must— 
‘‘(i) submit to the Secretary, the State 
long-term care ombudsman, residents of the 
facility, and the legal representatives of 
such residents or other responsible parties, 
written notification of an impending clo-
sure— 
‘‘(I) subject to subclause (II), not 
later than the date that is 60 days 
prior to the date of such closure; and 
‘‘(II) in the case of a facility 
where the Secretary terminates the fa-
cility’s participation under this title, 
not later than the date that the Sec-
retary determines appropriate; 
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‘‘(ii) ensure that the facility does not 
admit any new residents on or after the 
date on which such written notification is 
submitted; and 
‘‘(iii) include in the notice a plan for 
the transfer and adequate relocation of the 
residents of the facility by a specified date 
prior to closure that has been approved by 
the State, including assurances that the 
residents will be transferred to the most ap-
propriate facility or other setting in terms 
of quality, services, and location, taking 
into consideration the needs and best inter-
ests of each resident. 
‘‘(B) RELOCATION.— 
‘‘(i) IN GENERAL.—The State shall en-
sure that, before a facility closes, all resi-
dents of the facility have been successfully 
relocated to another facility or an alter-
native home and community-based setting. 
‘‘(ii) CONTINUATION
OF
PAYMENTS 
UNTIL
RESIDENTS
RELOCATED.—The Sec-
retary may, as the Secretary determines ap-
propriate, continue to make payments 
under this title with respect to residents of 
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a facility that has submitted a notification 
under subparagraph (A) during the period 
beginning on the date such notification is 
submitted and ending on the date on which 
the resident is successfully relocated.’’. 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall take effect 1 year after the date of the enact-
ment of this Act. 
PART 3—IMPROVING STAFF TRAINING 
SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING. 
(a) 
SKILLED
NURSING
FACILITIES.—Section 
1819(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 
1395i–3(f)(2)(A)(i)(I)) is amended by inserting ‘‘(includ-
ing, in the case of initial training and, if the Secretary 
determines appropriate, in the case of ongoing training, de-
mentia management training and resident abuse preven-
tion training)’’ after ‘‘curriculum’’. 
(b) NURSING FACILITIES.—Section 1919(f)(2)(A)(i)(I) 
of the Social Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) 
is amended by inserting ‘‘(including, in the case of initial 
training and, if the Secretary determines appropriate, in 
the case of ongoing training, dementia management train-
ing and resident abuse prevention training)’’ after ‘‘cur-
riculum’’. 
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(c) EFFECTIVE DATE.—The amendments made by this 
section shall take effect 1 year after the date of the enact-
ment of this Act. 
SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED 
FOR CERTIFIED NURSE AIDES AND SUPER-
VISORY STAFF. 
(a) STUDY.— 
(1) IN GENERAL.—The Secretary shall conduct a 
study on the content of training for certified nurse 
aides and supervisory staff of skilled nursing facilities 
and nursing facilities. The study shall include an 
analysis of the following: 
(A) Whether the number of initial training 
hours for certified nurse aides required under 
sections 
1819(f)(2)(A)(i)(II) 
and 
1919(f)(2)(A)(i)(II) of the Social Security Act 
(42 
U.S.C. 
1395i–3(f)(2)(A)(i)(II); 
1396r(f)(2)(A)(i)(II)) should be increased from 
75 and, if so, what the required number of ini-
tial training hours should be, including any rec-
ommendations for the content of such training 
(including training related to dementia). 
(B) Whether requirements for ongoing 
training under such sections 1819(f)(2)(A)(i)(II) 
and 1919(f)(2)(A)(i)(II) should be increased from 
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12 hours per year, including any recommenda-
tions for the content of such training. 
(2) CONSULTATION.—In conducting the analysis 
under paragraph (1)(A), the Secretary shall consult 
with States that, as of the date of the enactment of 
this Act, require more than 75 hours of training for 
certified nurse aides. 
(3) DEFINITIONS.—In this section: 
(A) NURSING FACILITY.—The term ‘‘nurs-
ing facility’’ has the meaning given such term in 
section 1919(a) of the Social Security Act (42 
U.S.C. 1396r(a)). 
(B) SECRETARY.—The term ‘‘Secretary’’ 
means the Secretary of Health and Human Serv-
ices, acting through the Assistant Secretary for 
Planning and Evaluation. 
(C) SKILLED NURSING FACILITY.—The term 
‘‘skilled nursing facility’’ has the meaning given 
such term in section 1819(a) of the Social Secu-
rity Act (42 U.S.C. 1395(a)). 
(b) REPORT.—Not later than 2 years after the date 
of the enactment of this Act, the Secretary shall submit to 
Congress a report containing the results of the study con-
ducted under subsection (a), together with recommendations 
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for such legislation and administrative action as the Sec-
retary determines appropriate. 
SEC. 1433. QUALIFICATION OF DIRECTOR OF FOOD SERV-
ICES OF A MEDICAID NURSING FACILITY. 
(a) IN GENERAL.—Section 1919(b)(4)(A) of the Social 
Security Act (42 U.S.C. 1396r(b)(4)(A)) is amended by 
adding at the end the following: ‘‘With respect to meeting 
the staffing requirement imposed by the Secretary to carry 
out clause (iv), the full-time director of food services of the 
facility, if not a qualified dietitian (as defined in section 
483.35(a)(2) of title 42, Code of Federal Regulations, as in 
effect as of the date of the enactment of this section), shall 
be a Certified Dietary Manager meeting the requirements 
of the Certifying Board for Dietary Managers, or a Dietetic 
Technician, Registered meeting the requirements of the 
Commission on Dietetic Registration or have equivalent 
military or academic qualifications (as specified by the Sec-
retary).’’. 
(b) EFFECTIVE DATE.—The amendment made by sub-
section (a) shall take effect on the date that is 180 days 
after the date of enactment of this Act. 
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Subtitle C—Quality Measurements 
SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR 
QUALITY IMPROVEMENT. 
Title XI of the Social Security Act, as amended by 
section 1401(a), is further amended by adding at the end 
the following new part: 
‘‘PART E—QUALITY IMPROVEMENT 
‘‘ESTABLISHMENT OF NATIONAL PRIORITIES FOR 
PERFORMANCE IMPROVEMENT 
‘‘SEC. 1191. (a) ESTABLISHMENT OF NATIONAL PRI-
ORITIES BY THE SECRETARY.—The Secretary shall estab-
lish and periodically update, not less frequently than tri-
ennially, national priorities for performance improvement. 
‘‘(b) RECOMMENDATIONS
FOR
NATIONAL
PRIOR-
ITIES.—In establishing and updating national priorities 
under subsection (a), the Secretary shall solicit and con-
sider recommendations from multiple outside stakeholders. 
‘‘(c) CONSIDERATIONS IN SETTING NATIONAL PRIOR-
ITIES.—With respect to such priorities, the Secretary shall 
ensure that priority is given to areas in the delivery of 
health care services in the United States that— 
‘‘(1) contribute to a large burden of disease, in-
cluding those that address the health care provided to 
patients with prevalent, high-cost chronic diseases; 
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‘‘(2) have the greatest potential to decrease mor-
bidity and mortality in this country, including those 
that are designed to eliminate harm to patients; 
‘‘(3) have the greatest potential for improving 
the 
performance, 
affordability, 
and 
patient- 
centeredness of health care, including those due to 
variations in care; 
‘‘(4) address health disparities across groups and 
areas; and 
‘‘(5) have the potential for rapid improvement 
due to existing evidence, standards of care or other 
reasons. 
‘‘(d) DEFINITIONS.—In this part: 
‘‘(1) CONSENSUS-BASED ENTITY.—The term ‘con-
sensus-based entity’ means an entity with a contract 
with the Secretary under section 1890. 
‘‘(2) QUALITY
MEASURE.—The term ‘quality 
measure’ means a national consensus standard for 
measuring the performance and improvement of pop-
ulation health, or of institutional providers of serv-
ices, physicians, and other health care practitioners 
in the delivery of health care services. 
‘‘(e) FUNDING.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
for the transfer, from the Federal Hospital Insurance 
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Trust Fund under section 1817 and the Federal Sup-
plementary Medical Insurance Trust Fund under sec-
tion 1841 (in such proportion as the Secretary deter-
mines appropriate), of $2,000,000, for the activities 
under this section for each of the fiscal years 2010 
through 2014. 
‘‘(2) AUTHORIZATION OF APPROPRIATIONS.—For 
purposes of carrying out the provisions of this section, 
in addition to funds otherwise available, out of any 
funds in the Treasury not otherwise appropriated, 
there are appropriated to the Secretary of Health and 
Human Services $2,000,000 for each of the fiscal 
years 2010 through 2014.’’. 
SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; 
GAO EVALUATION OF DATA COLLECTION 
PROCESS FOR QUALITY MEASUREMENT. 
Part E of title XI of the Social Security Act, as added 
by section 1441, is amended by adding at the end the fol-
lowing new sections: 
‘‘SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES. 
‘‘(a) AGREEMENTS WITH QUALIFIED ENTITIES.— 
‘‘(1) IN
GENERAL.—The Secretary shall enter 
into agreements with qualified entities to develop 
quality measures for the delivery of health care serv-
ices in the United States. 
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‘‘(2) FORM
OF
AGREEMENTS.—The Secretary 
may carry out paragraph (1) by contract, grant, or 
otherwise. 
‘‘(3) RECOMMENDATIONS OF CONSENSUS-BASED 
ENTITY.—In carrying out this section, the Secretary 
shall— 
‘‘(A) seek public input; and 
‘‘(B) take into consideration recommenda-
tions of the consensus-based entity with a con-
tract with the Secretary under section 1890(a). 
‘‘(b) DETERMINATION
OF AREAS WHERE QUALITY 
MEASURES ARE REQUIRED.—Consistent with the national 
priorities established under this part and with the pro-
grams administered by the Centers for Medicare & Med-
icaid Services and in consultation with other relevant Fed-
eral agencies, the Secretary shall determine areas in which 
quality measures for assessing health care services in the 
United States are needed. 
‘‘(c) DEVELOPMENT OF QUALITY MEASURES.— 
‘‘(1) 
PATIENT-CENTERED
AND
POPULATION- 
BASED
MEASURES.—Quality 
measures 
developed 
under agreements under subsection (a) shall be de-
signed— 
‘‘(A) to assess outcomes, presence of impair-
ment, and functional status of patients; 
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‘‘(B) to assess the continuity and coordina-
tion of care and care transitions for patients 
across providers and health care settings, includ-
ing end of life care; 
‘‘(C) to assess patient experience and pa-
tient engagement; 
‘‘(D) to assess the safety, effectiveness, and 
timeliness of care; 
‘‘(E) to assess health disparities including 
those associated with individual race, ethnicity, 
age, gender, place of residence or language; 
‘‘(F) to assess the efficiency and resource use 
in the provision of care; 
‘‘(G) to the extent feasible, to be collected as 
part of health information technologies sup-
porting better delivery of health care services; 
‘‘(H) to be available free of charge to users 
for the use of such measures; and 
‘‘(I) to assess delivery of health care services 
to individuals regardless of age. 
‘‘(2) AVAILABILITY
OF
MEASURES.—The Sec-
retary shall make quality measures developed under 
this section available to the public. 
‘‘(3) TESTING
OF
PROPOSED
MEASURES.—The 
Secretary may use amounts made available under 
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subsection (f) to fund the testing of proposed quality 
measures by qualified entities. Testing funded under 
this paragraph shall include testing of the feasibility 
and usability of proposed measures. 
‘‘(4) UPDATING OF ENDORSED MEASURES.—The 
Secretary may use amounts made available under 
subsection (f) to fund the updating (and testing, if 
applicable) by consensus-based entities of quality 
measures that have been previously endorsed by such 
an entity as new evidence is developed, in a manner 
consistent with section 1890(b)(3). 
‘‘(d) QUALIFIED
ENTITIES.—Before entering into 
agreements with a qualified entity, the Secretary shall en-
sure that the entity is a public, nonprofit or academic insti-
tution with technical expertise in the area of health quality 
measurement. 
‘‘(e) APPLICATION FOR GRANT.—A grant may be made 
under this section only if an application for the grant is 
submitted to the Secretary and the application is in such 
form, is made in such manner, and contains such agree-
ments, assurances, and information as the Secretary deter-
mines to be necessary to carry out this section. 
‘‘(f) FUNDING.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
for the transfer, from the Federal Hospital Insurance 
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Trust Fund under section 1817 and the Federal Sup-
plementary Medical Insurance Trust Fund under sec-
tion 1841 (in such proportion as the Secretary deter-
mines appropriate), of $25,000,000, to the Secretary 
for purposes of carrying out this section for each of 
the fiscal years 2010 through 2014. 
‘‘(2) AUTHORIZATION OF APPROPRIATIONS.—For 
purposes of carrying out the provisions of this section, 
in addition to funds otherwise available, out of any 
funds in the Treasury not otherwise appropriated, 
there are appropriated to the Secretary of Health and 
Human Services $25,000,000 for each of the fiscal 
years 2010 through 2014. 
‘‘SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROC-
ESS FOR QUALITY MEASUREMENT. 
‘‘(a) GAO EVALUATIONS.—The Comptroller General of 
the United States shall conduct periodic evaluations of the 
implementation of the data collection processes for quality 
measures used by the Secretary. 
‘‘(b) CONSIDERATIONS.—In carrying out the evalua-
tion under subsection (a), the Comptroller General shall de-
termine— 
‘‘(1) whether the system for the collection of data 
for quality measures provides for validation of data 
as relevant and scientifically credible; 
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‘‘(2) whether data collection efforts under the sys-
tem use the most efficient and cost-effective means in 
a manner that minimizes administrative burden on 
persons required to collect data and that adequately 
protects the privacy of patients’ personal health infor-
mation and provides data security; 
‘‘(3) whether standards under the system provide 
for an appropriate opportunity for physicians and 
other clinicians and institutional providers of services 
to review and correct findings; and 
‘‘(4) the extent to which quality measures are 
consistent with section 1192(c)(1) or result in direct 
or indirect costs to users of such measures. 
‘‘(c) REPORT.—The Comptroller General shall submit 
reports to Congress and to the Secretary containing a de-
scription of the findings and conclusions of the results of 
each such evaluation.’’. 
SEC. 1443. MULTISTAKEHOLDER PRERULEMAKING INPUT 
INTO SELECTION OF QUALITY MEASURES. 
Section 1808 of the Social Security Act (42 U.S.C. 
1395b–9) is amended by adding at the end the following 
new subsection: 
‘‘(d) MULTI-STAKEHOLDER PRE-RULEMAKING INPUT 
INTO SELECTION OF QUALITY MEASURES.— 
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‘‘(1) LIST OF MEASURES.—Not later than De-
cember 1 before each year (beginning with 2011), the 
Secretary shall make public a list of measures being 
considered for selection for quality measurement by 
the Secretary in rulemaking with respect to payment 
systems under this title beginning in the payment 
year beginning in such year and for payment systems 
beginning in the calendar year following such year, 
as the case may be. 
‘‘(2) CONSULTATION
ON
SELECTION
OF
EN-
DORSED QUALITY MEASURES.—A consensus-based en-
tity that has entered into a contract under section 
1890 shall, as part of such contract, convene multi- 
stakeholder groups to provide recommendations on the 
selection of individual or composite quality measures, 
for use in reporting performance information to the 
public or for use in public health care programs. 
‘‘(3) MULTI-STAKEHOLDER
INPUT.—Not later 
than February 1 of each year (beginning with 2011), 
the consensus-based entity described in paragraph (2) 
shall transmit to the Secretary the recommendations 
of multi-stakeholder groups provided under paragraph 
(2). Such recommendations shall be included in the 
transmissions the consensus-based entity makes to the 
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Secretary under the contract provided for under sec-
tion 1890. 
‘‘(4) REQUIREMENT
FOR
TRANSPARENCY
IN 
PROCESS.— 
‘‘(A) IN
GENERAL.—In convening multi- 
stakeholder groups under paragraph (2) with re-
spect to the selection of quality measures, the 
consensus-based entity described in such para-
graph shall provide for an open and transparent 
process for the activities conducted pursuant to 
such convening. 
‘‘(B) SELECTION OF ORGANIZATIONS PAR-
TICIPATING IN MULTI-STAKEHOLDER GROUPS.— 
The process under paragraph (2) shall ensure 
that the selection of representatives of multi- 
stakeholder groups includes provision for public 
nominations for, and the opportunity for public 
comment on, such selection. 
‘‘(5) USE OF INPUT.—The respective proposed 
rule shall contain a summary of the recommendations 
made by the multi-stakeholder groups under para-
graph (2), as well as other comments received regard-
ing the proposed measures, and the extent to which 
such proposed rule follows such recommendations and 
the rationale for not following such recommendations. 
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‘‘(6) MULTI-STAKEHOLDER GROUPS.—For pur-
poses of this subsection, the term ‘multi-stakeholder 
groups’ means, with respect to a quality measure, a 
voluntary collaborative of organizations representing 
persons interested in or affected by the use of such 
quality measure, such as the following: 
‘‘(A) Hospitals and other institutional pro-
viders. 
‘‘(B) Physicians. 
‘‘(C) Health care quality alliances. 
‘‘(D) Nurses and other health care practi-
tioners. 
‘‘(E) Health plans. 
‘‘(F) 
Patient 
advocates 
and 
consumer 
groups. 
‘‘(G) Employers. 
‘‘(H) Public and private purchasers of 
health care items and services. 
‘‘(I) Labor organizations. 
‘‘(J) Relevant departments or agencies of 
the United States. 
‘‘(K) Biopharmaceutical companies and 
manufacturers of medical devices. 
‘‘(L) Licensing, credentialing, and accred-
iting bodies. 
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‘‘(7) FUNDING.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
provide for the transfer, from the Federal Hos-
pital Insurance Trust Fund under section 1817 
and the Federal Supplementary Medical Insur-
ance Trust Fund under section 1841 (in such 
proportion as the Secretary determines appro-
priate), of $1,000,000, to the Secretary for pur-
poses of carrying out this subsection for each of 
the fiscal years 2010 through 2014. 
‘‘(B) 
AUTHORIZATION
OF
APPROPRIA-
TIONS.—For purposes of carrying out the provi-
sions of this subsection, in addition to funds oth-
erwise available, out of any funds in the Treas-
ury not otherwise appropriated, there are appro-
priated to the Secretary of Health and Human 
Services $1,000,000 for each of the fiscal years 
2010 through 2014.’’. 
SEC. 1444. APPLICATION OF QUALITY MEASURES. 
(a) 
INPATIENT
HOSPITAL
SERVICES.—Section 
1886(b)(3)(B) of such Act (42 U.S.C. 1395ww(b)(3)(B)) is 
amended by adding at the end the following new clause: 
‘‘(x)(I) Subject to subclause (II), for purposes of report-
ing data on quality measures for inpatient hospital services 
furnished during fiscal year 2012 and each subsequent fis-
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cal year, the quality measures specified under clause (viii) 
shall be measures selected by the Secretary from measures 
that have been endorsed by the entity with a contract with 
the Secretary under section 1890(a). 
‘‘(II) In the case of a specified area or medical topic 
determined appropriate by the Secretary for which a fea-
sible and practical quality measure has not been endorsed 
by the entity with a contract under section 1890(a), the 
Secretary may specify a measure that is not so endorsed 
as long as due consideration is given to measures that have 
been endorsed or adopted by a consensus organization iden-
tified by the Secretary. The Secretary shall submit such a 
non-endorsed measure to the entity for consideration for en-
dorsement. If the entity considers but does not endorse such 
a measure and if the Secretary does not phase-out use of 
such measure, the Secretary shall include the rationale for 
continued use of such a measure in rulemaking.’’. 
(b) 
OUTPATIENT
HOSPITAL
SERVICES.—Section 
1833(t)(17) of such Act (42 U.S.C. 1395l(t)(17)) is amended 
by adding at the end the following new subparagraph: 
‘‘(F) USE
OF
ENDORSED
QUALITY
MEAS-
URES.—The provisions of clause (x) of section 
1886(b)(3)(C) shall apply to quality measures 
for covered OPD services under this paragraph 
in the same manner as such provisions apply to 
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671 
quality measures for inpatient hospital serv-
ices.’’. 
(c) PHYSICIANS’ SERVICES.—Section 1848(k)(2)(C)(ii) 
of such Act (42 U.S.C. 1395w-4(k)(2)(C)(ii)) is amended 
by adding at the end the following: ‘‘The Secretary shall 
submit such a non-endorsed measure to the entity for con-
sideration for endorsement. If the entity considers but does 
not endorse such a measure and if the Secretary does not 
phase-out use of such measure, the Secretary shall include 
the rationale for continued use of such a measure in rule-
making.’’. 
(d) 
RENAL
DIALYSIS
SERVICES.—Section 
1881(h)(2)(B)(ii) 
of 
such 
Act 
(42 
U.S.C. 
1395rr(h)(2)(B)(ii)) is amended by adding at the end the 
following: ‘‘The Secretary shall submit such a non-endorsed 
measure to the entity for consideration for endorsement. If 
the entity considers but does not endorse such a measure 
and if the Secretary does not phase-out use of such measure, 
the Secretary shall include the rationale for continued use 
of such a measure in rulemaking.’’. 
(e) 
ENDORSEMENT
OF
STANDARDS.—Section 
1890(b)(2) of the Social Security Act (42 U.S.C. 
1395aaa(b)(2)) is amended by adding after and below sub-
paragraph (B) the following: 
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‘‘If the entity does not endorse a measure, such entity 
shall explain the reasons and provide suggestions 
about changes to such measure that might make it a 
potentially endorsable measure.’’. 
(f) EFFECTIVE DATE.—Except as otherwise provided, 
the amendments made by this section shall apply to quality 
measures applied for payment years beginning with 2012 
or fiscal year 2012, as the case may be. 
SEC. 1445. CONSENSUS-BASED ENTITY FUNDING. 
Section 1890(d) of the Social Security Act (42 U.S.C. 
1395aaa(d)) is amended by striking ‘‘for each of fiscal years 
2009 through 2012’’ and inserting ‘‘for fiscal year 2009, 
and $12,000,000 for each of the fiscal years 2010 through 
2012’’. 
SEC. 1446. QUALITY INDICATORS FOR CARE OF PEOPLE 
WITH ALZHEIMER’S DISEASE. 
(a) QUALITY INDICATORS.—The Secretary of Health 
and Human Services, acting through the Agency for 
Healthcare Research and Quality (AHRQ), shall develop, 
either directly or with commissioned projects, a core set of 
quality indicators for the provision of medical services to 
people with Alzheimer’s disease and other dementias and 
a plan for implementing the indicators to measure the qual-
ity of care provided for people with these conditions by phy-
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673 
sicians, hospitals, and other medical, residential and home 
care agencies and providers. 
(b) REPORT.—The Secretary shall submit a report to 
the Committees on Energy and Commerce and Ways and 
Means of the United States House of Representatives and 
to the Committees on Finance and Health, Education, and 
Pensions of the United States Senate not later than 12 
months after the date of the enactment of this Act setting 
forth the status of their efforts to implement the require-
ments of subsection (a). 
SEC. 1447. STUDY ON FIVE STAR QUALITY RATING SYSTEM. 
(a) STUDY.—The Comptroller General of the United 
States shall conduct a study on the Five-Star Quality Rat-
ing System
(or a
successor program)
established by the 
Centers for Medicare & Medicaid Services.
The study 
shall— 
(1) determine whether the composite star rating 
should be eliminated in favor of a multi-dimensional 
system under which a star rating is assigned to each 
individual domain; 
(2) determine whether an appeals process should 
be implemented for the Five Star Rating System to 
address situations in which questionable, inaccurate, 
or incomplete data has been identified; 
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(3) 
evaluate 
the 
appropriateness 
of 
any 
weighting methodology used to adjust quality meas-
ures, including an assessment of whether such method-
ology is validated, whether it takes into account resi-
dent characteristics, the appropriateness of the 
weighting of individual quality measures, and wheth-
er the accuracy of information to consumers would be 
enhanced if the standard survey were weighted more 
heavily than the complaint survey; 
(4) assess the appropriateness of the case-mix ad-
justment methodology used to evaluate staffing levels, 
along with the appropriateness of the staffing levels 
established by the Centers for Medicare & Medicaid 
Services to achieve a 5-star rating given
the absence 
of any existing Federal nursing home
staffing
guidelines or Medicare funding to support these staff-
ing levels; 
(5)
if the Comptroller General determines that 
such target staffing levels are appropriate, evaluate, 
in consultation with the Secretary of Health and 
Human Services,
the cost of modifying the Medicare 
Skilled Nursing Facility Resource Utilization Groups 
to reflect the costs to facilities of providing staffing at 
these target levels; 
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(6) evaluate how best to represent resident/con-
sumer satisfaction under the rating system, and re-
view approaches to report other facility-specific char-
acteristics to enable consumers to better identify fa-
cilities that will meet their individual needs; 
(7) evaluate the impact of the rating system on
Medicare skilled nursing facilities and Medicaid nurs-
ing facilities, including a review of potential prob-
lems associated with inaccurate or incomplete data 
and other unanticipated consequences reported by fa-
cilities; and 
(8) assess whether the national program should 
be suspended and replaced with a pilot program test-
ing potential nursing home quality rating systems in 
a limited number of States. 
(b) REPORT.—Not later than 1 year after the date of 
the enactment of this Act, the Comptroller General of the 
United States shall submit to Congress and the Secretary 
of Health and Human Services a report containing the re-
sults of the study conducted under subsection (a), together 
with recommendations for such modifications to the Five- 
Star Quality Rating System as the Comptroller General de-
termines appropriate. 
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Subtitle D—Physician Payments 
Sunshine Provision 
SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BE-
TWEEN 
MANUFACTURERS 
AND 
DISTRIBU-
TORS 
OF 
COVERED 
DRUGS, 
DEVICES, 
BIOLOGICALS, OR MEDICAL SUPPLIES UNDER 
MEDICARE, MEDICAID, OR CHIP AND PHYSI-
CIANS AND OTHER HEALTH CARE ENTITIES 
AND 
BETWEEN 
PHYSICIANS 
AND 
OTHER 
HEALTH CARE ENTITIES. 
(a) IN GENERAL.—Part A of title XI of the Social Se-
curity Act (42 U.S.C. 1301 et seq.), as amended by section 
1631(a), is further amended by inserting after section 
1128G the following new section: 
‘‘SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS’ FINAN-
CIAL RELATIONSHIPS WITH MANUFACTUR-
ERS 
AND 
DISTRIBUTORS 
OF 
COVERED 
DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL 
SUPPLIES UNDER MEDICARE, MEDICAID, OR 
CHIP AND WITH ENTITIES THAT BILL FOR 
SERVICES UNDER MEDICARE. 
‘‘(a) REPORTING OF PAYMENTS OR OTHER TRANS-
FERS OF VALUE.— 
‘‘(1) IN GENERAL.—Except as provided in this 
subsection, not later than March 31, 2011 and annu-
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677 
ally thereafter, each applicable manufacturer or dis-
tributor that provides a payment or other transfer of 
value to a covered recipient, or to an entity or indi-
vidual at the request of or designated on behalf of a 
covered recipient, shall submit to the Secretary, in 
such electronic form as the Secretary shall require, the 
following information with respect to the preceding 
calendar year: 
‘‘(A) With respect to the covered recipient, 
the recipient’s name, business address, physician 
specialty, and national provider identifier. 
‘‘(B) With respect to the payment or other 
transfer of value, other than a drug sample— 
‘‘(i) its value and date; 
‘‘(ii) the name of the related drug, de-
vice, or supply, if available; and 
‘‘(iii) a description of its form, indi-
cated (as appropriate for all that apply) 
as— 
‘‘(I) cash or a cash equivalent; 
‘‘(II) in-kind items or services; 
‘‘(III) stock, a stock option, or 
any other ownership interest, dividend, 
profit, or other return on investment; 
or 
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‘‘(IV) any other form (as defined 
by the Secretary). 
‘‘(C) With respect to a drug sample, the 
name, number, date, and dosage units of the 
sample. 
‘‘(2) AGGREGATE REPORTING.—Information sub-
mitted by an applicable manufacturer or distributor 
under paragraph (1) shall include the aggregate 
amount of all payments or other transfers of value 
provided by the manufacturer or distributor to cov-
ered recipients (and to entities or individuals at the 
request of or designated on behalf of a covered recipi-
ent) during the year involved, including all payments 
and transfers of value regardless of whether such pay-
ments or transfer of value were individually disclosed. 
‘‘(3) SPECIAL RULE FOR CERTAIN PAYMENTS OR 
OTHER TRANSFERS OF VALUE.—In the case where an 
applicable manufacturer or distributor provides a 
payment or other transfer of value to an entity or in-
dividual at the request of or designated on behalf of 
a covered recipient, the manufacturer or distributor 
shall disclose that payment or other transfer of value 
under the name of the covered recipient. 
‘‘(4) DELAYED REPORTING FOR PAYMENTS MADE 
PURSUANT
TO
PRODUCT
DEVELOPMENT
AGREE-
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MENTS.—In the case of a payment or other transfer 
of value made to a covered recipient by an applicable 
manufacturer or distributor pursuant to a product 
development agreement for services furnished in con-
nection with the development of a new drug, device, 
biological, or medical supply, the applicable manufac-
turer or distributor may report the value and recipi-
ent of such payment or other transfer of value in the 
first reporting period under this subsection in the 
next reporting deadline after the earlier of the fol-
lowing: 
‘‘(A) The date of the approval or clearance 
of the covered drug, device, biological, or medical 
supply by the Food and Drug Administration. 
‘‘(B) Two calendar years after the date such 
payment or other transfer of value was made. 
‘‘(5) DELAYED REPORTING FOR PAYMENTS MADE 
PURSUANT TO CLINICAL INVESTIGATIONS.—In the case 
of a payment or other transfer of value made to a 
covered recipient by an applicable manufacturer or 
distributor in connection with a clinical investigation 
regarding a new drug, device, biological, or medical 
supply, the applicable manufacturer or distributor 
may report as required under this section in the next 
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reporting period under this subsection after the ear-
lier of the following: 
‘‘(A) The date that the clinical investigation 
is registered on the website maintained by the 
National Institutes of Health pursuant to section 
671 of the Food and Drug Administration 
Amendments Act of 2007. 
‘‘(B) Two calendar years after the date such 
payment or other transfer of value was made. 
‘‘(6) CONFIDENTIALITY.—Information described 
in paragraph (4) or (5) shall be considered confiden-
tial and shall not be subject to disclosure under sec-
tion 552 of title 5, United States Code, or any other 
similar Federal, State, or local law, until or after the 
date on which the information is made available to 
the public under such paragraph. 
‘‘(b) REPORTING OF OWNERSHIP INTEREST BY PHYSI-
CIANS IN HOSPITALS AND OTHER ENTITIES THAT BILL 
MEDICARE.—Not later than March 31 of each year (begin-
ning with 2011), each hospital or other health care entity 
(not including a Medicare Advantage organization) that 
bills the Secretary under part A or part B of title XVIII 
for services shall report on the ownership shares (other than 
ownership shares described in section 1877(c)) of each phy-
sician who, directly or indirectly, owns an interest in the 
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entity. In this subsection, the term ‘physician’ includes a 
physician’s immediate family members (as defined for pur-
poses of section 1877(a)). 
‘‘(c) PUBLIC AVAILABILITY.— 
‘‘(1) IN GENERAL.—The Secretary shall establish 
procedures to ensure that, not later than September 
30, 2011, and on June 30 of each year beginning 
thereafter, the information submitted under sub-
sections (a) and (b), other than information regard 
drug samples, with respect to the preceding calendar 
year is made available through an Internet website 
that— 
‘‘(A) is searchable and is in a format that 
is clear and understandable; 
‘‘(B) contains information that is presented 
by the name of the applicable manufacturer or 
distributor, the name of the covered recipient, the 
business address of the covered recipient, the spe-
cialty (if applicable) of the covered recipient, the 
value of the payment or other transfer of value, 
the date on which the payment or other transfer 
of value was provided to the covered recipient, 
the form of the payment or other transfer of 
value, indicated (as appropriate) under sub-
section (a)(1)(B)(ii), the nature of the payment 
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or other transfer of value, indicated (as appro-
priate) under subsection (a)(1)(B)(iii), and the 
name of the covered drug, device, biological, or 
medical supply, as applicable; 
‘‘(C) contains information that is able to be 
easily aggregated and downloaded; 
‘‘(D) contains a description of any enforce-
ment actions taken to carry out this section, in-
cluding any penalties imposed under subsection 
(d), during the preceding year; 
‘‘(E) contains background information on 
industry-physician relationships; 
‘‘(F) in the case of information submitted 
with respect to a payment or other transfer of 
value described in subsection (a)(5), lists such 
information separately from the other informa-
tion submitted under subsection (a) and des-
ignates such separately listed information as 
funding for clinical research; 
‘‘(G) contains any other information the 
Secretary determines would be helpful to the av-
erage consumer; and 
‘‘(H) provides the covered recipient an op-
portunity to submit corrections to the informa-
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683 
tion made available to the public with respect to 
the covered recipient. 
‘‘(2) ACCURACY OF REPORTING.—The accuracy 
of the information that is submitted under subsections 
(a) and (b) and made available under paragraph (1) 
shall be the responsibility of the applicable manufac-
turer or distributor of a covered drug, device, biologi-
cal, or medical supply reporting under subsection (a) 
or hospital or other health care entity reporting phy-
sician ownership under subsection (b). The Secretary 
shall establish procedures to ensure that the covered 
recipient is provided with an opportunity to submit 
corrections to the manufacturer, distributor, hospital, 
or other entity reporting under subsection (a) or (b) 
with regard to information made public with respect 
to the covered recipient and, under such procedures, 
the corrections shall be transmitted to the Secretary. 
‘‘(3) SPECIAL RULE FOR DRUG SAMPLES.—Infor-
mation relating to drug samples provided under sub-
section (a) shall not be made available to the public 
by the Secretary but may be made available outside 
the Department of Health and Human Services by 
the Secretary for research or legitimate business pur-
poses pursuant to data use agreements. 
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684 
‘‘(4) SPECIAL
RULE
FOR
NATIONAL
PROVIDER 
IDENTIFIERS.—Information relating to national pro-
vider identifiers provided under subsection (a) shall 
not be made available to the public by the Secretary 
but may be made available outside the Department of 
Health and Human Services by the Secretary for re-
search or legitimate business purposes pursuant to 
data use agreements. 
‘‘(d) PENALTIES FOR NONCOMPLIANCE.— 
‘‘(1) FAILURE TO REPORT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), except as provided in paragraph (2), 
any applicable manufacturer or distributor that 
fails to submit information required under sub-
section (a) in a timely manner in accordance 
with regulations promulgated to carry out such 
subsection, and any hospital or other entity that 
fails to submit information required under sub-
section (b) in a timely manner in accordance 
with regulations promulgated to carry out such 
subsection shall be subject to a civil money pen-
alty of not less than $1,000, but not more than 
$10,000, for each payment or other transfer of 
value or ownership or investment interest not re-
ported as required under such subsection. Such 
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685 
penalty shall be imposed and collected in the 
same manner as civil money penalties under 
subsection (a) of section 1128A are imposed and 
collected under that section. 
‘‘(B) LIMITATION.—The total amount of 
civil money penalties imposed under subpara-
graph (A) with respect to each annual submis-
sion of information under subsection (a) by an 
applicable manufacturer or distributor or other 
entity shall not exceed $150,000. 
‘‘(2) KNOWING FAILURE TO REPORT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), any applicable manufacturer or dis-
tributor that knowingly fails to submit informa-
tion required under subsection (a) in a timely 
manner in accordance with regulations promul-
gated to carry out such subsection and any hos-
pital or other entity that fails to submit infor-
mation required under subsection (b) in a timely 
manner in accordance with regulations promul-
gated to carry out such subsection, shall be sub-
ject to a civil money penalty of not less than 
$10,000, but not more than $100,000, for each 
payment or other transfer of value or ownership 
or investment interest not reported as required 
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686 
under such subsection. Such penalty shall be im-
posed and collected in the same manner as civil 
money penalties under subsection (a) of section 
1128A are imposed and collected under that sec-
tion. 
‘‘(B) LIMITATION.—The total amount of 
civil money penalties imposed under subpara-
graph (A) with respect to each annual submis-
sion of information under subsection (a) or (b) 
by an applicable manufacturer, distributor, or 
entity shall not exceed $1,000,000, or, if greater, 
0.1 percentage of the total annual revenues of the 
manufacturer, distributor, or entity. 
‘‘(3) USE
OF
FUNDS.—Funds collected by the 
Secretary as a result of the imposition of a civil 
money penalty under this subsection shall be used to 
carry out this section. 
‘‘(4) ENFORCEMENT
THROUGH
STATE
ATTOR-
NEYS
GENERAL.—The attorney general of a State, 
after providing notice to the Secretary of an intent to 
proceed under this paragraph in a specific case and 
providing the Secretary with an opportunity to bring 
an action under this subsection and the Secretary de-
clining such opportunity, may proceed under this 
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687 
subsection against a manufacturer or distributor in 
the State. 
‘‘(e) ANNUAL REPORT TO CONGRESS.—Not later than 
April 1 of each year beginning with 2011, the Secretary 
shall submit to Congress a report that includes the fol-
lowing: 
‘‘(1) The information submitted under this sec-
tion during the preceding year, aggregated for each 
applicable manufacturer or distributor of a covered 
drug, device, biological, or medical supply that sub-
mitted such information during such year. 
‘‘(2) A description of any enforcement actions 
taken to carry out this section, including any pen-
alties imposed under subsection (d), during the pre-
ceding year. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) APPLICABLE MANUFACTURER; APPLICABLE 
DISTRIBUTOR.—The term ‘applicable manufacturer’ 
means a manufacturer of a covered drug, device, bio-
logical, or medical supply, and the term ‘applicable 
distributor’ means a distributor of a covered drug, de-
vice, or medical supply. 
‘‘(2) CLINICAL INVESTIGATION.—The term ‘clin-
ical investigation’ means any experiment involving 
one or more human subjects, or materials derived 
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