SEC. 2. STAFFING REQUIREMENTS FOR MEDICARE- AND
MEDICAID-FUNDED NURSING FACILITIES.
(a) MEDICARE-FUNDED SKILLED NURSING FACILI-
TIES.—
(1) MINIMUM STANDARDS.—Section 1819(b)(4)
of the Social Security Act (42 U.S.C. 1395i–3(b)(4))
is amended by adding at the end the following new
subparagraph:
‘‘(D) MINIMUM
DIRECT
CARE
STAFFING
REQUIREMENTS.—
‘‘(i) LICENSED
NURSES.—Subject to
subsection (f)(8), a skilled nursing facility
must have at least one licensed nurse on
duty on the premises for every—
‘‘(I) 15 residents present during
the day;
‘‘(II) 20 residents present during
the evening; and
‘‘(III) 30 residents present dur-
ing the night.
‘‘(ii) DIRECT
CAREGIVERS.—Subject
to subsection (f)(8), a skilled nursing facil-
ity must have at least one direct caregiver
on duty on the premises for every—
‘‘(I) 5 residents present during
the day;
‘‘(II) 10 residents present during
the evening; and
‘‘(III) 15 residents present dur-
ing the night.
‘‘(iii) 
COUNTING.—In 
determining
compliance with the staffing levels under
this subparagraph:
‘‘(I) 
ADMINISTRATIVE
SERV-
ICES.—In a facility with 60 or more
beds, an individual may not be count-
ed while performing noncaregiving ad-
ministrative services.
‘‘(II) OTHER SERVICES.—An in-
dividual may not be counted while
performing food preparation, house-
keeping, laundry, maintenance serv-
ices, or other noncaregiving-related
activities.
‘‘(iv) CONSTRUCTION.—The staffing
requirements of this subparagraph are in
addition to the requirements of subpara-
graph (C).
‘‘(v) DEFINITIONS.—In this subpara-
graph:
‘‘(I) 
LICENSED
NURSE.—The
term ‘licensed nurse’ means a reg-
istered professional nurse, licensed
practical nurse, or licensed vocational
nurse who meets State licensing re-
quirements and who provides direct
care (including treatment and medica-
tions), who performs resident assess-
ment and observation, who supervises
direct patient care at the unit level, or
who provides planning or coordination
with other resident services.
‘‘(II) DIRECT
CAREGIVER.—The
term ‘direct caregiver’ means a cer-
tified nurse assistant who provides di-
rect care or a licensed nurse who pro-
vides direct care.
‘‘(III) DAY.—The term ‘day’
means an eight-hour period com-
mencing not earlier than 6 a.m. nor
later than 8 a.m.
‘‘(IV) 
EVENING.—The 
term
‘evening’ means an eight-hour period
commencing not earlier than 2 p.m.
nor later than 4 p.m.
‘‘(V) NIGHT.—The term ‘night’
means an eight-hour period com-
mencing not earlier than 10 p.m. nor
later than 12 midnight.’’.
(2) HIGHER STANDARDS.—Section 1819(f) of
such Act (42 U.S.C. 1395i–3(f)) is amended by add-
ing at the end the following new paragraph:
‘‘(8) HIGHER STAFFING STANDARDS FOR RESI-
DENTS WITH HIGHER NURSING CARE NEEDS.—
‘‘(A) IN GENERAL.—The Secretary may es-
tablish higher minimum staffing requirements
than those under subsection (b)(4)(D), includ-
ing for facilities with a higher percentage of
residents with extensive care needs.
‘‘(B) CONSTRUCTION.—Nothing in this
paragraph shall be construed to prohibit a
State from imposing higher minimum staffing
requirements than those under subsection
(b)(4)(D) or subparagraph (A).’’.
(3) 
PAYMENT
MODIFICATION.—Section
1888(e)(4)(G) of such Act is amended by adding at
the end the following new clause:
‘‘(iv) 
ADJUSTMENT
TO
REFLECT
COSTS OF MINIMUM STAFFING.—The Sec-
retary shall provide for an appropriate ad-
justment to account for the costs attrib-
utable to meeting the minimum staffing re-
quirements of subsections (b)(4)(D) and
(f)(8) of section 1819.’’.
(b) MEDICAID-FUNDED NURSING FACILITIES.—
(1) MINIMUM STANDARDS.—Section 1919(b)(4)
of such Act (42 U.S.C. 1396r(b)(4)) is amended by
adding at the end the following new subparagraph:
‘‘(D) MINIMUM
DIRECT
CARE
STAFFING
REQUIREMENTS.—
‘‘(i) LICENSED
NURSES.—Subject to
subsection (f)(8), a nursing facility must
have at least one licensed nurse on duty on
the premises for every—
‘‘(I) 15 residents present during
the day;
‘‘(II) 20 residents present during
the evening; and
‘‘(III) 30 residents present dur-
ing the night.
‘‘(ii) DIRECT
CAREGIVERS.—Subject
to subsection (f)(8), a nursing facility must
have at least one direct caregiver on duty
on the premises for every—
‘‘(I) 5 residents present during
the day;
‘‘(II) 10 residents present during
the evening; and
‘‘(III) 15 residents present dur-
ing the night.
‘‘(iii) 
COUNTING.—In 
determining
compliance with the staffing levels under
this subparagraph:
‘‘(I) 
ADMINISTRATIVE
SERV-
ICES.—In a facility with 60 or more
beds, an individual may not be count-
ed while performing noncaregiving ad-
ministrative services.
‘‘(II) OTHER SERVICES.—An in-
dividual may not be counted while
performing food preparation, house-
keeping, laundry, maintenance serv-
ices, or other noncaregiving-related
activities.
‘‘(iv) CONSTRUCTION.—The staffing
requirements of this subparagraph are in
addition to the requirements of subpara-
graph (C).
‘‘(v) DEFINITIONS.—In this subpara-
graph:
‘‘(I) 
LICENSED
NURSE.—The
term ‘licensed nurse’ means a reg-
istered professional nurse, licensed
practical nurse, or licensed vocational
nurse who meets State licensing re-
quirements and who provides direct
care (including treatment and medica-
tions), who performs resident assess-
ment and observation, who supervises
direct patient care at the unit level, or
who provides planning or coordination
with other resident services.
‘‘(II) DIRECT
CAREGIVER.—The
term ‘direct caregiver’ means a cer-
tified nurse assistant who provides di-
rect care or a licensed nurse who pro-
vides direct care.
‘‘(III) DAY.—The term ‘day’
means an eight-hour period com-
mencing not earlier than 6 a.m. nor
later than 8 a.m.
‘‘(IV) 
EVENING.—The 
term
‘evening’ means an eight-hour period
commencing not earlier than 2 p.m.
nor later than 4 p.m.
‘‘(V) NIGHT.—The term ‘night’
means an eight-hour period com-
mencing not earlier than 10 p.m. nor
later than 12 midnight.’’.
(2) HIGHER STANDARDS.—Section 1919(f) of
such Act (42 U.S.C. 1396r(f)) is amended by adding
at the end the following new paragraph:
‘‘(8) HIGHER STAFFING STANDARDS FOR RESI-
DENTS WITH HIGHER NURSING CARE NEEDS.—
‘‘(A) IN GENERAL.—The Secretary may es-
tablish higher minimum staffing requirements
than those under subsection (b)(4)(D), includ-
ing for facilities with a higher percentage of
residents with extensive care needs.
‘‘(B) CONSTRUCTION.—Nothing in this
paragraph shall be construed to prohibit a
State from imposing higher minimum staffing
requirements than those under subsection
(b)(4)(D) or subparagraph (A).’’.
(3) 
PAYMENT
MODIFICATION.—Section
1902(a)(13)(A) of such Act is amended—
(A) in clause (iii), by striking the final
‘‘and’’;
(B) in clause (iv), by striking the semi-
colon and inserting ‘‘, and’’; and
(C) by inserting after clause (iv) the fol-
lowing new clause:
‘‘(v) in the case of nursing facilities,
such rates take into account the costs at-
tributable to the requirements of section
1919(b)(4)(D).’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to services provided on or after
the date that is two years after the date of enactment of
this Act.
(d) REPORT TO CONGRESS ON ADEQUACY OF PER-
SONNEL TO MEET STAFFING REQUIREMENTS.—Not later
than one year after the date of enactment of this Act, the
Secretary of Health and Human Services shall submit to
the Congress a report regarding the adequacy of personnel
in nursing facilities covered under titles XVIII and XIX
of the Social Security Act to meet the direct care staffing
requirements required under the amendments made by
this Act to sections 1819(b)(4)(D) and 1919(b)(4)(D) of
the Social Security Act (42 U.S.C. 1395i–3(b)(4)(D) and
1396r(b)(4)(D)) and, if inadequate, recommendations on
steps that should be taken to ensure that adequate num-
bers of trained staff are available to meet such require-
ments, including ways to attract and retain such direct
caregiving personnel.
SEC. 3. DISCLOSURE OF STAFFING LEVELS AT MEDICARE-
AND MEDICAID-FUNDED NURSING FACILI-
TIES.
(a) MEDICARE-FUNDED SKILLED NURSING FACILI-
TIES.—
(1) IN GENERAL.—Section 1819(b)(4) of the
Social Security Act (42 U.S.C. 1395i–3(b)(4)), as
amended by section 2(a)(1) of this Act, is further
amended by adding at the end the following new
subparagraph:
‘‘(E) DISCLOSURE
OF
STAFFING
LEV-
ELS.—A skilled nursing facility must conspicu-
ously post the following notices adjacent to each
other in each area or unit to which such notices
apply in the facility in a manner visible and ac-
cessible to residents, their families, caregivers,
and prospective residents of such facility and in
such a uniform format as the Secretary may
prescribe and must retain the information on
such notices for at least one year after posting
and make such information available upon re-
quest:
‘‘(i) MINIMUM
STAFFING
REQUIRE-
MENTS.—A notice describing the minimum
staffing requirements set forth in subpara-
graph (D) and, if applicable, subsection
(f)(8).
‘‘(ii) 
CURRENT
STAFF
INFORMA-
TION.—A notice showing, separately for
each shift in the area or unit of the facility
in which it is posted—
‘‘(I) the current number of direct
caregivers (including licensed nurses)
present on the premises who perform
resident care and the name and pro-
fessional title of each such caregiver;
‘‘(II) the current ratio of resi-
dents to licensed nurses present on
the premises;
‘‘(III) the current ratio of resi-
dents to direct caregivers (including
licensed nurses) present on the prem-
ises; and
‘‘(IV) the current number of resi-
dents of such area or unit.’’.
(2) 
CONFORMING
AMENDMENT.—Section
1819(b)(4)(D)(v) of such Act (42 U.S.C. 1395i–
3(b)(4)(D)(v)), as added by section 2(a)(1) of this
Act, is amended by inserting ‘‘and subparagraph
(E)’’ after ‘‘this subparagraph’’.
(b) MEDICAID-FUNDED NURSING FACILITIES.—
(1) IN GENERAL.—Section 1919(b)(4) of such
Act (42 U.S.C. 1396r(b)(4)), as amended by section
2(b)(1) of this Act, is further amended by adding at
the end the following new subparagraph:
‘‘(E) DISCLOSURE
OF
STAFFING
LEV-
ELS.—A nursing facility must conspicuously
post the following notices adjacent to each other
in each area or unit to which such notices apply
in the facility in a manner visible and accessible
to residents, their families, caregivers, and pro-
spective residents of such facility and in such a
uniform format as the Secretary may prescribe
and must retain the information on such no-
tices for at least one year after posting and
make such information available upon request:
‘‘(i) MINIMUM
STAFFING
REQUIRE-
MENTS.—A notice describing the minimum
staffing requirements set forth in subpara-
graph (D) and, if applicable, subsection
(f)(8).
‘‘(ii) 
CURRENT
STAFF
INFORMA-
TION.—A notice showing, separately for
each shift in the area or unit of the facility
in which it is posted—
‘‘(I) the current number of direct
caregivers (including licensed nurses)
present on the premises who perform
resident care and the name and pro-
fessional title of each such caregiver;
‘‘(II) the current ratio of resi-
dents to licensed nurses present on
the premises;
‘‘(III) the current ratio of resi-
dents to direct caregivers (including
licensed nurses) present on the prem-
ises; and
‘‘(IV) the current number of resi-
dents of such area or unit.’’.
(2) 
CONFORMING
AMENDMENT.—Section
1919(b)(4)(D)(v) 
of 
such 
Act 
(42 
U.S.C.
1396r(b)(4)(D)(v)), as added by section 2(b)(1) of
this Act, is amended by inserting ‘‘and subpara-
graph (E)’’ after ‘‘this subparagraph’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to services provided on or after
the date that is two years after the date of enactment of
this Act.
SEC. 4. ADMINISTRATIVE STAFFING REQUIREMENTS FOR
MEDICARE- AND MEDICAID-FUNDED NURS-
ING FACILITIES.
(a) MEDICARE-FUNDED SKILLED NURSING FACILI-
TIES.—
(1) MINIMUM STANDARDS.—
(A) IN GENERAL.—Section 1819(d)(1) of
the Social Security Act (42 U.S.C. 1395i–
3(d)(1)) is amended by adding at the end the
following new subparagraph:
‘‘(D) 
ADMINISTRATIVE
STAFFING.—A
skilled nursing facility must maintain at least
the administrative staff described in the fol-
lowing clauses (i) through (iv):
‘‘(i) DIRECTOR
OF
NURSING
SERV-
ICES.—An individual who serves full time
as a director of nursing services and who
is a registered professional nurse.
‘‘(ii) ASSISTANT DIRECTOR OF NURS-
ING SERVICES.—An individual who serves
full time as an assistant director of nurs-
ing services and who is a registered profes-
sional nurse, except that in a facility with
fewer than 100 beds, such individual may
serve part time and may also serve as a di-
rect care clinical nursing supervisor.
‘‘(iii) DIRECTOR OF IN-SERVICE EDU-
CATION.—An individual who serves full
time as a director of in-service education,
who is a registered professional nurse, and
who has, to the extent practicable and ap-
propriate, training in adult education and
gerontology, except that in a facility with
fewer than 100 beds, such individual may
serve part time.
‘‘(iv) DIRECT CARE CLINICAL NURS-
ING
SUPERVISOR.—For each shift each
day, an individual who serves full time as
a direct care clinical nursing supervisor
and who is a registered professional nurse,
except that in a facility with fewer than
100 beds, such an individual may serve
part time and may also serve as an assist-
ant director of nursing.
‘‘(v) LIMITATION
ON
FULFILLMENT
OF ADMINISTRATIVE PERSONNEL REQUIRE-
MENTS.—An 
individual 
cannot 
satisfy
more than one requirement of clauses (i)