I 
116TH CONGRESS 
1ST SESSION H. R. 5216 
To amend titles XVIII and XIX of the Social Security Act to revise minimum 
nurse staffing requirements for skilled nursing facilities under the Medi-
care program and for nursing facilities under the Medicaid program, 
and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
NOVEMBER 21, 2019 
Ms. SCHAKOWSKY (for herself, Mrs. HAYES, Mr. GARAMENDI, Mr. RYAN, Mr. 
CARSON of Indiana, Ms. MOORE, Ms. ROYBAL-ALLARD, Mrs. CAROLYN 
B. MALONEY of New York, Mrs. DINGELL, Ms. DELAURO, Ms. BASS, 
Ms. JOHNSON of Texas, Mr. DANNY K. DAVIS of Illinois, Mr. HASTINGS, 
Mr. PAYNE, Ms. MATSUI, Ms. UNDERWOOD, Ms. JAYAPAL, Ms. 
PRESSLEY, Ms. JUDY CHU of California, Ms. CLARKE of New York, Mr. 
KHANNA, Mr. DEUTCH, Mr. DESAULNIER, Ms. LEE of California, and 
Mr. TONKO) introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To amend titles XVIII and XIX of the Social Security Act 
to revise minimum nurse staffing requirements for skilled 
nursing facilities under the Medicare program and for 
nursing facilities under the Medicaid program, and for 
other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Quality Care for Nurs-
ing Home Residents Act of 2019’’. 
SEC. 2. MINIMUM NURSE STAFFING REQUIREMENTS FOR 
SKILLED NURSING FACILITIES UNDER MEDI-
CARE PROGRAM AND NURSING FACILITIES 
UNDER MEDICAID PROGRAM. 
(a) MEDICARE.— 
(1) IN GENERAL.—Subparagraph (C) of section 
1819(b)(4) of the Social Security Act (42 U.S.C. 
1395i–3(b)(4)) is amended— 
(A) in clause (i)— 
(i) by amending the clause heading to 
read as follows: ‘‘GENERAL
REQUIRE-
MENTS BEFORE 2020’’; and 
(ii) by striking ‘‘Except as provided in 
clause (ii),’’ and inserting ‘‘Except as pro-
vided in clause (iii), with respect to skilled 
nursing facility services provided before 
January 1, 2020,’’; 
(B) by redesignating clause (ii) as clause 
(iii); and 
(C) by inserting after clause (i) the fol-
lowing new clause: 
‘‘(ii) GENERAL REQUIREMENTS AFTER 
2019.— 
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‘‘(I) IN GENERAL.—With respect 
to skilled nursing facility services pro-
vided on or after January 1, 2020, a 
skilled nursing facility must— 
‘‘(aa) provide nursing serv-
ices that are sufficient to meet 
the nursing needs of its residents 
on a 24-hour basis, to be divided 
into day shifts, evening shifts, 
and night shifts; 
‘‘(bb) provide for minimum 
nurse staffing levels with respect 
to each such shift, in accordance 
with this clause; and 
‘‘(cc) ensure that, in car-
rying out items (aa) and (bb), a 
total minimum of 4.1 hours of 
care is provided per resident per 
day, with 0.75 hours of care of 
such total minimum provided by 
a registered professional nurse, 
0.54 hours of care of such total 
minimum provided by a licensed 
practical nurse, and 2.81 hours 
of care of such total minimum 
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provided by a nurse aide (as de-
fined in paragraph (5)(F)). 
‘‘(II) DAY SHIFTS.—With respect 
to a day shift, the skilled nursing fa-
cility must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 28 
residents, with a minimum of 
0.29 hours of care provided per 
resident during each such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 40 resi-
dents, with a minimum of 0.20 
hours of care provided per resi-
dent during each such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 7 residents, with a min-
imum of 1.14 hours of care pro-
vided per resident during each 
such shift. 
‘‘(III) EVENING
SHIFTS.—With 
respect to an evening shift, the skilled 
nursing facility must have— 
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‘‘(aa) at least 1 registered 
professional nurse for every 30 
residents, with a minimum of 
0.26 hours of care provided per 
resident during each such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 40 resi-
dents, with a minimum of 0.20 
hours of care provided per resi-
dent during each such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 7 residents, with a min-
imum of 1.14 hours of care pro-
vided per resident during each 
such shift. 
‘‘(IV) NIGHT SHIFTS.—With re-
spect to a night shift, the skilled nurs-
ing facility must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 40 
residents, with a minimum of 
0.20 hours of care provided per 
resident during such shift; 
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‘‘(bb) at least 1 licensed 
practical nurse for every 56 resi-
dents, with a minimum of 0.14 
hours of care provided per resi-
dent during such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 15 residents, with a 
minimum of 0.53 hours of care 
provided per resident during such 
shift. 
‘‘(V) SECRETARIAL
AUTHORITY 
TO
ESTABLISH
HIGHER
MINIMUM 
NURSE STAFFING LEVELS.—The Sec-
retary may establish and require 
skilled nursing facilities (or, at the 
Secretary’s discretion, only skilled 
nursing facilities that have a higher 
percentage of residents with extensive 
care needs, as determined by the Sec-
retary) to provide for minimum nurse 
staffing levels that are higher than 
the levels required under this clause. 
‘‘(VI) RULE
OF
CONSTRUCTION 
REGARDING STATE AUTHORITY TO ES-
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TABLISH
HIGHER
MINIMUM
NURSE 
STAFFING
LEVELS.—Nothing in this 
clause may be construed as preventing 
a State from establishing or requiring 
skilled nursing facilities in the State 
to provide for minimum nurse staffing 
levels that are higher than the levels 
required under this clause. 
‘‘(VII) CLARIFICATION WITH RE-
SPECT TO MINIMUM HOURS OF CARE 
PROVIDED
PER
RESIDENT
REQUIRE-
MENTS.—In complying with the min-
imum hours of care provided per resi-
dent requirements under this clause, a 
skilled nursing facility may not count 
any time spent by a registered profes-
sional nurse, licensed practical nurse, 
or nurse aide on administrative serv-
ices towards compliance with such re-
quirements. 
‘‘(VIII) DEFINITIONS.—In this 
clause: 
‘‘(aa) 
ADMINISTRATIVE 
SERVICES.—The term ‘adminis-
trative services’ means food prep-
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aration, housekeeping, laundry 
services, maintenance services, 
and other noncaregiving-related 
services, as determined by the 
Secretary. 
‘‘(bb) 
DAY
SHIFT.—The 
term ‘day shift’ means, with re-
spect to a day and a skilled nurs-
ing facility, an assigned work 
shift that is a period of 8 con-
secutive hours, beginning not 
sooner than 6 a.m. in the time 
zone in which such facility is lo-
cated and not later than 8 a.m. 
in such time zone. 
‘‘(cc) EVENING SHIFT.—The 
term ‘evening shift’ means, with 
respect to a day and a skilled 
nursing facility, an assigned work 
shift that is a period of 8 con-
secutive hours, beginning not 
sooner than 2 p.m. in the time 
zone in which such facility is lo-
cated and not later than 4 p.m. 
in such time zone. 
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‘‘(dd) NIGHT
SHIFT.—The 
term ‘night shift’ means, with re-
spect to a day and a skilled nurs-
ing facility, an assigned work 
shift that is a period of 8 con-
secutive hours, beginning not 
sooner than 10 p.m. in the time 
zone in which such facility is lo-
cated and not later than mid-
night in such time zone.’’. 
(2) ENFORCEMENT.—Section 1819(h) of the 
Social Security Act (42 U.S.C. 1395i–3(h)) is 
amended— 
(A) in paragraph (1), by striking ‘‘If a 
State finds, on the basis of a standard’’ and in-
serting ‘‘Subject to paragraph (7), if a State 
finds, on the basis of a standard’’; 
(B) in paragraph (2), by striking ‘‘With 
respect to’’ and inserting ‘‘Subject to paragraph 
(7), with respect to’’; and 
(C) by adding at the end the following new 
paragraph: 
‘‘(7) SPECIAL
ENFORCEMENT
PROCESS
WITH 
RESPECT TO MINIMUM NURSE STAFFING REQUIRE-
MENTS.— 
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‘‘(A) IN GENERAL.—If a State finds, on 
the basis of a standard, extended, or partial ex-
tended survey under subsection (g)(2) or other-
wise, that a skilled nursing facility does not 
meet the minimum staffing requirements of 
clause (ii) of subsection (b)(4)(C) with respect 
to skilled nursing facility services provided on 
or after January 1, 2020, the State shall rec-
ommend to the Secretary that the Secretary 
take such actions as described in subclauses (I) 
and (II) of subparagraph (B)(i). 
‘‘(B) SECRETARIAL AUTHORITY.— 
‘‘(i) IN
GENERAL.—With respect to 
any skilled nursing facility in a State, if 
the Secretary finds, or pursuant to a rec-
ommendation of the State under subpara-
graph (A) finds, that a skilled nursing fa-
cility does not meet the minimum staffing 
requirements of clause (ii) of subsection 
(b)(4)(C) with respect to skilled nursing 
facility services provided on or after Janu-
ary 1, 2020, the Secretary shall— 
‘‘(I) deny any further payments 
under this title with respect to all in-
dividuals entitled to benefits under 
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this title who are admitted to the fa-
cility after the effective date of the 
finding; and 
‘‘(II) impose a civil money pen-
alty in an amount not to exceed 
$10,000 for each day of noncompli-
ance. The provisions of section 1128A 
(other than subsections (a) and (b)) 
shall apply to a civil money penalty 
under the previous sentence in the 
same manner as such provisions apply 
to a penalty or proceeding under sec-
tion 1128A(a). 
‘‘(ii) REDUCTION
OF
CIVIL
MONEY 
PENALTIES
IN
CERTAIN
CIR-
CUMSTANCES.—Subject to clause (iii), in 
the case where a skilled nursing facility 
self-reports and promptly corrects a defi-
ciency for which a penalty was imposed 
under clause (i)(II) not later than 10 cal-
endar days after the date of such imposi-
tion, the Secretary may reduce the amount 
of the penalty imposed by— 
‘‘(I) not more than 50 percent; or 
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‘‘(II) in the case that the facility 
was penalized under this subsection 
within the three-year period preceding 
the date of such imposition, not more 
than 25 percent. 
‘‘(iii) PROHIBITIONS
ON
REDUCTION 
FOR CERTAIN DEFICIENCIES.— 
‘‘(I) REPEAT
DEFICIENCIES.— 
The Secretary may not reduce the 
amount of a penalty under clause (ii) 
if the Secretary had reduced a penalty 
imposed on the skilled nursing facility 
in the preceding year under such 
clause with respect to a repeat defi-
ciency. 
‘‘(II) CERTAIN
OTHER
DEFI-
CIENCIES.—The Secretary may not 
reduce the amount of a penalty under 
clause (ii) if the penalty is imposed on 
the skilled nursing facility for a defi-
ciency that is found to result in a pat-
tern of harm or widespread harm, im-
mediately jeopardizes the health or 
safety of a resident or residents of the 
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facility, or results in the death of a 
resident of the facility. 
‘‘(iv) REPEATED
NONCOMPLIANCE.— 
In the case of a skilled nursing facility 
which, on three consecutive standard sur-
veys conducted under subsection (g)(2), 
has been found as not meeting the min-
imum staffing requirements of clause (ii) 
of subsection (b)(4)(C) with respect to 
skilled nursing facility services provided on 
or after January 1, 2020, the Secretary 
may (regardless of the remedies provided 
for under clause (i))— 
‘‘(I) appoint temporary manage-
ment to oversee the operation of the 
facility and to assure the health and 
safety of the facility’s residents in ac-
cordance with clause (iii) of para-
graph (2)(B), except that ‘the min-
imum staffing requirements of clause 
(ii) of subsection (b)(4)(C)’ shall be 
substituted for ‘all the requirements 
of subsections (b), (c), and (d)’ under 
such clause; 
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‘‘(II) monitor the facility under 
subsection (g)(4)(B) with respect to 
such minimum staffing requirements 
until the facility has demonstrated to 
the satisfaction of the Secretary that 
the facility is in compliance, and will 
remain in compliance, with such min-
imum staffing requirements; or 
‘‘(III) 
subject 
to 
section 
1128I(h), terminate the facility’s par-
ticipation under this title. 
If the facility’s participation under this 
title is terminated under this clause, the 
State shall provide for the safe and orderly 
transfer of the residents eligible under this 
title, consistent with the requirements of 
subsection (c)(2) and section 1128I(h). 
‘‘(v) 
PUBLIC
NOTICE
OF
VIOLA-
TIONS.— 
‘‘(I) INTERNET
WEBSITE.—The 
Secretary shall publish on the internet 
website of the Department of Health 
and Human Services the names of 
skilled nursing facilities that have vio-
lated the minimum staffing require-
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ments of clause (ii) of subsection 
(b)(4)(C) with respect to skilled nurs-
ing facility services provided on or 
after January 1, 2020. 
‘‘(II) CHANGE OF OWNERSHIP.— 
With respect to a skilled nursing facil-
ity whose name is published under 
subclause (I) and has a change of 
ownership, as determined by the Sec-
retary, after the date of such publica-
tion, the Secretary shall remove the 
name of such facility from the website 
described under such subclause after 
the 1-year period beginning on the 
date of such change of ownership.’’. 
(3) CONFORMING
AMENDMENT.—Item (a) of 
section 1819(f)(2)(B)(iii)(I) of the Social Security 
Act (42 U.S.C. 1395i–3(f)(2)(B)(iii)(I)) is amended 
by striking ‘‘subsection (b)(4)(C)(ii)(II)’’ and insert-
ing ‘‘subsection (b)(4)(C)(iii)(II)’’. 
(b) MEDICAID.— 
(1) IN GENERAL.—Subparagraph (C) of section 
1919(b)(4) of the Social Security Act (42 U.S.C. 
1396r(b)(4)) is amended— 
(A) in clause (i)— 
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(i) in the clause heading, by inserting 
after ‘‘GENERAL REQUIREMENTS’’ the fol-
lowing ‘‘BEFORE 2020’’; 
(ii) in the matter preceding subclause 
(I), by inserting after ‘‘October 1, 1990,’’ 
the following: ‘‘and before January 1, 
2020,’’; 
(iii) in subclause (I), by striking 
‘‘clause (ii)’’ and inserting ‘‘clause (iii)’’; 
and 
(iv) in subclause (II), by striking 
‘‘clause (ii)’’ and inserting ‘‘clause (iii)’’; 
(B) by redesignating clauses (ii) and (iii) 
as clauses (iii) and (iv), respectively; and 
(C) by inserting after clause (i) the fol-
lowing new clause: 
‘‘(ii) GENERAL REQUIREMENTS AFTER 
2019.— 
‘‘(I) IN GENERAL.—With respect 
to nursing facility services provided on 
or after January 1, 2020, a nursing 
facility must— 
‘‘(aa) provide nursing serv-
ices that are sufficient to meet 
the nursing needs of its residents 
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on a 24-hour basis, to be divided 
into day shifts, evening shifts, 
and night shifts; 
‘‘(bb) provide for minimum 
nurse staffing levels with respect 
to each such shift, in accordance 
with this clause; and 
‘‘(cc) ensure that, in car-
rying out items (aa) and (bb), a 
total minimum of 4.1 hours of 
care is provided per resident per 
day, with 0.75 hours of care of 
such total minimum provided by 
a registered professional nurse, 
0.54 hours of care of such total 
minimum provided by a licensed 
practical nurse, and 2.81 hours 
of care of such total minimum 
provided by a nurse aide (as de-
fined in paragraph (5)(F)). 
‘‘(II) DAY SHIFTS.—With respect 
to a day shift, the nursing facility 
must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 28 
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residents, with a minimum of 
0.29 hours of care provided per 
resident during each such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 40 resi-
dents, with a minimum of 0.20 
hours of care provided per resi-
dent during each such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 7 residents, with a min-
imum of 1.14 hours of care pro-
vided per resident during each 
such shift. 
‘‘(III) EVENING
SHIFTS.—With 
respect to an evening shift, the nurs-
ing facility must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 30 
residents, with a minimum of 
0.26 hours of care provided per 
resident during each such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 40 resi-
dents, with a minimum of 0.20 
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hours of care provided per resi-
dent during each such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 7 residents, with a min-
imum of 1.14 hours of care pro-
vided per resident during each 
such shift. 
‘‘(IV) NIGHT SHIFTS.—With re-
spect to a night shift, the nursing fa-
cility must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 40 
residents, with a minimum of 
0.20 hours of care provided per 
resident during such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 56 resi-
dents, with a minimum of 0.14 
hours of care provided per resi-
dent during such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 15 residents, with a 
minimum of 0.53 hours of care 
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provided per resident during such 
shift. 
‘‘(V) SECRETARIAL
AUTHORITY 
TO
ESTABLISH
HIGHER
MINIMUM 
NURSE STAFFING LEVELS.—The Sec-
retary may establish and require nurs-
ing facilities (or, at the Secretary’s 
discretion, only nursing facilities that 
have a higher percentage of residents 
with extensive care needs, as deter-
mined by the Secretary) to provide for 
minimum nurse staffing levels that 
are higher than the levels required 
under this clause. 
‘‘(VI) RULE
OF
CONSTRUCTION 
REGARDING STATE AUTHORITY TO ES-
TABLISH
HIGHER
MINIMUM
NURSE 
STAFFING
LEVELS.—Nothing in this 
clause may be construed as preventing 
a State from establishing or requiring 
nursing facilities in the State to pro-
vide for minimum nurse staffing levels 
that are higher than the levels re-
quired under this clause. 
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‘‘(VII) CLARIFICATION WITH RE-
SPECT TO MINIMUM HOURS OF CARE 
PROVIDED
PER
RESIDENT
REQUIRE-
MENTS.—In complying with the min-
imum hours of care provided per resi-
dent requirements under this clause, a 
nursing facility may not count any 
time spent by a registered professional 
nurse, licensed practical nurse, or 
nurse aide on administrative services 
towards compliance with such require-
ments. 
‘‘(VIII) DEFINITIONS.—In this 
clause: 
‘‘(aa) 
ADMINISTRATIVE 
SERVICES.—The term ‘adminis-
trative services’ means food prep-
aration, housekeeping, laundry 
services, maintenance services, 
and other noncaregiving-related 
services, as determined by the 
Secretary. 
‘‘(bb) 
DAY
SHIFT.—The 
term ‘day shift’ means, with re-
spect to a day and a nursing fa-
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cility, an assigned work shift that 
is a period of 8 consecutive 
hours, beginning not sooner than 
6 a.m. in the time zone in which 
such facility is located and not 
later than 8 a.m. in such time 
zone. 
‘‘(cc) EVENING SHIFT.—The 
term ‘evening shift’ means, with 
respect to a day and a nursing 
facility, an assigned work shift 
that is a period of 8 consecutive 
hours, beginning not sooner than 
2 p.m. in the time zone in which 
such facility is located and not 
later than 4 p.m. in such time 
zone. 
‘‘(dd) NIGHT
SHIFT.—The 
term ‘night shift’ means, with re-
spect to a day and a nursing fa-
cility, an assigned work shift that 
is a period of 8 consecutive 
hours, beginning not sooner than 
10 p.m. in the time zone in which 
such facility is located and not 
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later than midnight in such time 
zone.’’. 
(2) ENFORCEMENT.—Section 1919(h) of the 
Social Security Act (42 U.S.C. 1396r(h)) is amend-
ed— 
(A) in paragraph (1), by striking ‘‘If a 
State finds, on the basis of a standard’’ and in-
serting ‘‘Subject to paragraph (10), if a State 
finds, on the basis of a standard’’; 
(B) in paragraph (2)— 
(i) in subparagraph (C), by striking 
‘‘If a nursing facility’’ and inserting ‘‘Sub-
ject to paragraph (10), if a nursing facil-
ity’’; and 
(ii) in subparagraph (D), by striking 
‘‘In the case of’’ and inserting ‘‘Subject to 
paragraph (10), in the case of’’; 
(C) in paragraph (3)— 
(i) in subparagraph (A), by inserting 
before the period the following: ‘‘and the 
remedies described in paragraph (10)(B)’’; 
and 
(ii) in subparagraph (B), by striking 
‘‘With respect to’’ and inserting ‘‘Subject 
to paragraph (10), with respect to’’; and 
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(D) by adding at the end the following new 
paragraph: 
‘‘(10) SPECIAL ENFORCEMENT PROCESS WITH 
RESPECT TO MINIMUM NURSE STAFFING REQUIRE-
MENTS.— 
‘‘(A) IN GENERAL.—If a State finds, on 
the basis of a standard, extended, or partial ex-
tended survey under subsection (g)(2) or other-
wise, that a nursing facility does not meet the 
minimum staffing requirements of clause (ii) of 
subsection (b)(4)(C) with respect to nursing fa-
cility services provided on or after January 1, 
2020, the State shall— 
‘‘(i) deny any further payments under 
the State plan with respect to all individ-
uals enrolled under such plan who are ad-
mitted to the facility after the effective 
date of the finding; and 
‘‘(ii) recommend to the Secretary that 
the Secretary impose the civil money pen-
alty described in subparagraph (B). 
‘‘(B) SECRETARIAL AUTHORITY.— 
‘‘(i) IN
GENERAL.—With respect to 
any nursing facility in a State other than 
a State nursing facility, if the Secretary 
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finds that such a nursing facility does not 
meet the minimum staffing requirements 
of clause (ii) of subsection (b)(4)(C) with 
respect to nursing facility services provided 
on or after January 1, 2020, the Secretary 
shall— 
‘‘(I) deny any further payments 
to the State for medical assistance 
furnished by the facility to all individ-
uals enrolled under the State plan 
who are admitted to the facility after 
the effective date of the finding; and 
‘‘(II) impose a civil money pen-
alty in an amount not to exceed 
$10,000 for each day of noncompli-
ance. The provisions of section 1128A 
(other than subsections (a) and (b)) 
shall apply to a civil money penalty 
under the previous sentence in the 
same manner as such provisions apply 
to a penalty or proceeding under sec-
tion 1128A(a). 
‘‘(ii) REDUCTION
OF
CIVIL
MONEY 
PENALTIES
IN
CERTAIN
CIR-
CUMSTANCES.—Subject to clause (iii), in 
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the case where a nursing facility self-re-
ports and promptly corrects a deficiency 
for which a penalty was imposed under 
clause (i)(II) not later than 10 calendar 
days after the date of such imposition, the 
Secretary may reduce the amount of the 
penalty imposed by— 
‘‘(I) not more than 50 percent; or 
‘‘(II) in the case that the facility 
was penalized under this subsection 
within the three-year period preceding 
the date of such imposition, not more 
than 25 percent. 
‘‘(iii) PROHIBITIONS
ON
REDUCTION 
FOR CERTAIN DEFICIENCIES.— 
‘‘(I) REPEAT
DEFICIENCIES.— 
The Secretary may not reduce the 
amount of a penalty under clause (ii) 
if the Secretary had reduced a penalty 
imposed on the nursing facility in the 
preceding year under such clause with 
respect to a repeat deficiency. 
‘‘(II) CERTAIN
OTHER
DEFI-
CIENCIES.—The Secretary may not 
reduce the amount of a penalty under 
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clause (ii) if the penalty is imposed on 
the nursing facility for a deficiency 
that is found to result in a pattern of 
harm or widespread harm, imme-
diately jeopardizes the health or safe-
ty of a resident or residents of the fa-
cility, or results in the death of a resi-
dent of the facility. 
‘‘(iv) REPEATED
NONCOMPLIANCE.— 
In the case of a nursing facility which, on 
three consecutive standard surveys con-
ducted under subsection (g)(2), has been 
found as not meeting the minimum staff-
ing requirements of clause (ii) of sub-
section (b)(4)(C) with respect to nursing 
facility services provided on or after Janu-
ary 1, 2020, the Secretary may (regardless 
of the remedies provided for under clause 
(i))— 
‘‘(I) appoint temporary manage-
ment to oversee the operation of the 
facility and to assure the health and 
safety of the facility’s residents in ac-
cordance with clause (iii) of para-
graph (3)(C), except that ‘the min-
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imum staffing requirements of clause 
(ii) of subsection (b)(4)(C)’ shall be 
substituted for ‘all the requirements 
of subsections (b), (c), and (d)’ under 
such clause; 
‘‘(II) monitor the facility under 
subsection (g)(4)(B) with respect to 
such minimum staffing requirements 
until the facility has demonstrated to 
the satisfaction of the Secretary that 
the facility is in compliance, and will 
remain in compliance, with such min-
imum staffing requirements; or 
‘‘(III) 
subject 
to 
section 
1128I(h), terminate the facility’s par-
ticipation under this title. 
If the facility’s participation under this 
title is terminated under this clause, the 
State shall provide for the safe and orderly 
transfer of the residents eligible under this 
title, consistent with the requirements of 
subsection (c)(2) and section 1128I(h). 
‘‘(v) 
PUBLIC
NOTICE
OF
VIOLA-
TIONS.— 
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‘‘(I) INTERNET
WEBSITE.—The 
Secretary shall publish on the internet 
website of the Department of Health 
and Human Services the names of 
nursing facilities that have violated 
the minimum staffing requirements of 
clause (ii) of subsection (b)(4)(C) with 
respect to skilled nursing facility serv-
ices provided on or after January 1, 
2020. 
‘‘(II) CHANGE OF OWNERSHIP.— 
With respect to a nursing facility 
whose name is published under sub-
clause (I) and has a change of owner-
ship, as determined by the Secretary, 
after the date of such publication, the 
Secretary shall remove the name of 
such facility from the website de-
scribed under such subclause after the 
1-year period beginning on the date of 
such change of ownership.’’. 
(3) CONFORMING AMENDMENTS.— 
(A) Clause (iii) of section 1919(b)(4)(C) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396r(b)(4)(C)), as redesignated by paragraph 
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(1)(B), is amended by striking ‘‘subject to 
clause (iii)’’ and inserting ‘‘subject to clause 
(iv)’’. 
(B) 
Item 
(a) 
of 
section 
1919(f)(2)(B)(iii)(I) of the Social Security Act 
(42 U.S.C. 1396r(f)(2)(B)(iii)(I)) is amended 
by striking ‘‘subsection (b)(4)(C)(ii)’’ and in-
serting ‘‘subsection (b)(4)(C)(iii)’’. 
(C) Paragraph (9) of section 1919(f) of 
the Social Security Act (42 U.S.C. 1396r(f)) is 
amended by striking ‘‘subsection (b)(4)(C)(ii)’’ 
and inserting ‘‘subsection (b)(4)(C)(iii)’’. 
(c) STUDIES AND REPORTS REGARDING IMPACT OF 
MINIMUM NURSE STAFFING REQUIREMENTS.— 
(1) INITIAL STUDY AND REPORT.— 
(A) IN GENERAL.—Not later than June 1, 
2021, the Secretary of Health and Human 
Services shall study and submit to the Com-
mittee on Energy and Commerce and the Com-
mittee on Ways and Means of the House of 
Representatives and the Committee on Finance 
of the Senate a publicly available report— 
(i) on the impact of the minimum 
nurse staffing requirements added by sub-
section (a) on the reimbursement levels of 
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ing methods for attracting and retaining 
such personnel. 
(B) CONSIDERATIONS.—In conducting the 
study required under subparagraph (A), the 
Secretary of Health and Human Services shall 
take into consideration— 
(i) the benefits of any increase in 
nurse staffing levels, including with respect 
to workforce training and retention; 
(ii) any decrease in the rate of work-
place injuries; 
(iii) any changes in medical care costs 
for residents of skilled nursing facilities 
and nursing facilities; 
(iv) any decrease in hospitalization 
rates for such residents; 
(v) any changes in personnel and ad-
ministrative costs for skilled nursing facili-
ties and nursing facilities; and 
(vi) any changes in recruiting and 
training costs. 
(2) SUBSEQUENT
STUDY
AND
REPORT.—Not 
later than January 1, 2023, the Secretary of Health 
and Human Services shall conduct a follow-up study 
to the study conducted under paragraph (1)(A) and 
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submit to the Committee on Energy and Commerce 
and the Committee on Ways and Means of the 
House of Representatives and the Committee on Fi-
nance of the Senate a publicly available report on 
such follow-up study. 
SEC. 3. DISCLOSURE OF NURSE STAFFING LEVELS AT 
SKILLED NURSING FACILITIES UNDER MEDI-
CARE PROGRAM AND NURSING FACILITIES 
UNDER MEDICAID PROGRAM. 
(a) MEDICARE.—Paragraph (8) of section 1819(b) of 
the Social Security Act (42 U.S.C. 1395i–3(b)) is amend-
ed to read as follows: 
‘‘(8) INFORMATION ON NURSE STAFFING.— 
‘‘(A) IN
GENERAL.—Each day, a skilled 
nursing facility shall post for each shift notices 
with— 
‘‘(i) a description of the nurse staffing 
requirements applicable with respect to the 
facility and day under paragraph (4)(C); 
‘‘(ii) information on the number of 
registered professional nurses, licensed 
practical nurses, and nurse aides (as de-
fined in paragraph (5)(F)) assigned to pro-
vide direct care services to residents in the 
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facility during the shift, disaggregated by 
units in the facility; and 
‘‘(iii) a statement that the facility is 
required, upon request, to provide any 
nurse staffing information (as described in 
this subparagraph) of the facility from the 
preceding 12-month period. 
The information in such notices shall be written 
in a uniform manner, printed in an easily read-
able 14-point type font, and made available in 
appropriate languages, as determined by the 
Secretary. The skilled nursing facility shall 
make such notices available at each nurses’ sta-
tion in the facility and other areas in each unit 
of the facility, as determined appropriate by the 
facility, and shall keep and maintain each such 
notice for at least three years after the date on 
which each such notice is posted in the facility. 
‘‘(B) PUBLIC AVAILABILITY OF INFORMA-
TION.—A skilled nursing facility shall, upon re-
quest, make available to the public any nurse 
staffing information (as described in subpara-
graph (A)) of the facility from the preceding 
12-month period. In the case that the facility 
makes such information available as a paper 
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copy, such facility may not charge for such copy 
an amount greater than the cost of making 
such copy.’’. 
(b) MEDICAID.—Paragraph (8) of section 1919(b) of 
the Social Security Act (42 U.S.C. 1396r(b)) is amended 
to read as follows: 
‘‘(8) INFORMATION ON NURSE STAFFING.— 
‘‘(A) IN
GENERAL.—Each day, a skilled 
nursing facility shall post for each shift notices 
with— 
‘‘(i) a description of the nurse staffing 
requirements applicable with respect to the 
facility and day under paragraph (4)(C); 
‘‘(ii) information on the number of 
registered professional nurses, licensed 
practical nurses, and nurse aides (as de-
fined in paragraph (5)(F)) assigned to pro-
vide direct care services to residents in the 
facility during the shift, disaggregated by 
units in the facility; and 
‘‘(iii) a statement that the facility is 
required, upon request, to provide any 
nurse staffing information (as described in 
this subparagraph) of the facility from the 
preceding 12-month period. 
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The information in such notices shall be written 
in a uniform manner, printed in an easily read-
able 14-point type font, and made available in 
appropriate languages, as determined by the 
Secretary. The skilled nursing facility shall 
make such notices available at each nurses’ sta-
tion in the facility and other areas in each unit 
of the facility, as determined appropriate by the 
facility, and shall keep and maintain each such 
notice for at least three years after the date on 
which each such notice is posted in the facility. 
‘‘(B) PUBLIC AVAILABILITY OF INFORMA-
TION.—A skilled nursing facility shall, upon re-
quest, make available to the public any nurse 
staffing information (as described in subpara-
graph (A)) of the facility from the preceding 
12-month period.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on the date of enactment of this 
Act and apply with respect to nurse staffing information 
posted or requested on or after the date that is one year 
after such date of enactment. 
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SEC. 4. ADMINISTRATIVE STAFFING REQUIREMENTS FOR 
SKILLED NURSING FACILITIES UNDER MEDI-
CARE PROGRAM AND NURSING FACILITIES 
UNDER MEDICAID PROGRAM. 
(a) MEDICARE.—Paragraph (1) of section 1819(d) of 
the Social Security Act (42 U.S.C. 1395i–3(d)) is amend-
ed— 
(1) by redesignating the second subparagraph 
(C) as subparagraph (E); and 
(2) by inserting after the first subparagraph 
(C) the following new subparagraph: 
‘‘(D) 
NURSING
MANAGEMENT
PER-
SONNEL.— 
‘‘(i) IN GENERAL.—A skilled nursing 
facility must employ nursing management 
personnel in accordance with this subpara-
graph. 
‘‘(ii) DIRECTOR
OF
NURSING
SERV-
ICES.—A skilled nursing facility must em-
ploy a registered professional nurse to 
serve full-time as the director of nursing 
services of the facility. Such director of 
nursing services shall be responsible for de-
termining the number and types of nursing 
personnel needed to sufficiently meet the 
nursing needs of the residents of the facil-
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serve part-time as the director of in-service 
education of the facility. In carrying out 
the previous sentence, a skilled nursing fa-
cility must, to the extent practicable and 
appropriate, employ a registered profes-
sional nurse who has received training in 
adult education and gerontology.’’. 
(b) MEDICAID.— 
(1) IN
GENERAL.—Paragraph (1) of section 
1919(d) of the Social Security Act (42 U.S.C. 
1396r(d)) is amended by inserting after subpara-
graph (C) the following new subparagraph: 
‘‘(D) 
NURSING
MANAGEMENT
PER-
SONNEL.— 
‘‘(i) IN GENERAL.—A nursing facility 
must employ nursing management per-
sonnel in accordance with this subpara-
graph. 
‘‘(ii) DIRECTOR
OF
NURSING
SERV-
ICES.—A nursing facility must employ a 
registered professional nurse to serve full- 
time as the director of nursing services of 
the facility. Such director of nursing serv-
ices shall be responsible for determining 
the number and types of nursing personnel 
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needed to sufficiently meet the nursing 
needs of the residents of the facility (as re-
quired under subsection (b)(4)(C)). 
‘‘(iii) ASSISTANT DIRECTOR OF NURS-
ING
SERVICES.—A nursing facility must 
employ a registered professional nurse to 
serve full-time as the assistant director of 
nursing services of the facility, except that 
in the case of a nursing facility that has 
fewer than 100 beds, such facility may em-
ploy a registered professional nurse to 
serve part-time as the assistant director of 
nursing services of the facility. A reg-
istered professional nurse who serves as 
the assistant director of nursing services of 
a nursing facility may also serve as a su-
pervisor for direct clinical nursing care for 
such facility. 
‘‘(iv) DIRECTOR OF IN-SERVICE EDU-
CATION.—A nursing facility must employ a 
registered professional nurse to serve full- 
time as the director of in-service education 
of the facility, except that in the case of a 
nursing facility that has fewer than 100 
beds, such facility may employ a registered 
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professional nurse to serve part-time as the 
director of in-service education of the facil-
ity. In carrying out the previous sentence, 
a nursing facility must, to the extent prac-
ticable and appropriate, employ a reg-
istered professional nurse who has received 
training in adult education and geron-
tology.’’. 
(2) TECHNICAL AMENDMENT.—Paragraph (1) 
of section 1919(d) of the Social Security Act (42 
U.S.C. 1396r(d)) is amended by redesignating sub-
paragraph (V) as subparagraph (E). 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on the date of enactment of this 
Act and apply with respect to the administration of skilled 
nursing facilities and nursing facilities on or after the date 
that is one year after such date of enactment. 
SEC. 5. NURSE TRAINING REQUIREMENTS WITH RESPECT 
TO SKILLED NURSING FACILITIES UNDER 
MEDICARE PROGRAM AND NURSING FACILI-
TIES UNDER MEDICAID PROGRAM. 
(a) MEDICARE.— 
(1) ORIENTATION
FOR
REGISTERED
PROFES-
SIONAL NURSES, LICENSED PRACTICAL NURSES, AND 
NURSE AIDES.—Section 1819(d) of the Social Secu-
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rity Act (42 U.S.C. 1395i–3(d)) is amended by add-
ing at the end the following new paragraph: 
‘‘(5) ORIENTATIONS.—A skilled nursing facility 
must provide to registered professional nurses, li-
censed practical nurses, and nurse aides, before such 
registered professional nurses, licensed practical 
nurses, and nurse aides are assigned to provide di-
rect care services to residents in the facility, orienta-
tions providing education on the policies and emer-
gency procedures of the facility and on residents’ 
rights under this section.’’. 
(2) REQUIREMENTS FOR NURSE AIDE TRAINING 
AND COMPETENCY EVALUATION PROGRAMS AND FOR 
NURSE
AIDE
COMPETENCY
EVALUATION
PRO-
GRAMS.—Subparagraph (A) of section 1819(f)(2) of 
the Social Security Act (42 U.S.C. 1395i–3(f)(2)) is 
amended— 
(A) in the matter preceding clause (i), by 
inserting after ‘‘1988’’ the following: ‘‘, and up-
date, as determined necessary by the Sec-
retary’’; 
(B) in clause (i)— 
(i) by inserting after ‘‘care of cog-
nitively impaired residents,’’ the following: 
‘‘care of older adults,’’; 
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(ii) by striking ‘‘patient abuse preven-
tion training,’’ and inserting ‘‘patient 
abuse prevention training),’’; and 
(iii) by striking ‘‘75 hours’’ and in-
serting ‘‘120 hours’’; and 
(C) in clause (ii)— 
(i) by striking ‘‘requirement relating 
to’’ and inserting ‘‘requirements relating to 
(I)’’; 
(ii) by inserting after ‘‘care of cog-
nitively impaired residents,’’ the following: 
‘‘care of older adults,’’; and 
(iii) by striking ‘‘and procedures’’ and 
inserting ‘‘(II) minimum hours of initial 
and ongoing training and retraining (in-
cluding not less than 120 hours in the case 
of initial training), and (III) procedures’’. 
(b) MEDICAID.— 
(1) ORIENTATION
FOR
REGISTERED
PROFES-
SIONAL NURSES, LICENSED PRACTICAL NURSES, AND 
NURSE AIDES.—Section 1919(d) of the Social Secu-
rity Act (42 U.S.C. 1396r(d)) is amended by adding 
at the end the following new paragraph: 
‘‘(5) ORIENTATIONS.—A nursing facility must 
provide to registered professional nurses, licensed 
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practical nurses, and nurse aides, before such reg-
istered professional nurses, licensed practical nurses, 
and nurse aides are assigned to provide direct care 
services to residents in the facility, orientations pro-
viding education on the policies and emergency pro-
cedures of the facility and on residents’ rights under 
this section.’’. 
(2) REQUIREMENTS FOR NURSE AIDE TRAINING 
AND COMPETENCY EVALUATION PROGRAMS AND FOR 
NURSE
AIDE
COMPETENCY
EVALUATION
PRO-
GRAMS.—Subparagraph (A) of section 1919(f)(2) of 
the Social Security Act (42 U.S.C. 1396r(f)(2)) is 
amended— 
(A) in the matter preceding clause (i), by 
inserting after ‘‘1988’’ the following: ‘‘, and up-
date, as determined necessary by the Sec-
retary’’; 
(B) in clause (i)— 
(i) by inserting after ‘‘care of cog-
nitively impaired residents,’’ the following: 
‘‘care of older adults,’’; 
(ii) by striking ‘‘patient abuse preven-
tion training,’’ and inserting ‘‘patient 
abuse prevention training),’’; and 
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(iii) by striking ‘‘75 hours’’ and in-
serting ‘‘120 hours’’; and 
(C) in clause (ii)— 
(i) by striking ‘‘requirement relating 
to’’ and inserting ‘‘requirements relating to 
(I)’’; 
(ii) by inserting after ‘‘care of cog-
nitively impaired residents,’’ the following: 
‘‘care of older adults,’’; and 
(iii) by striking ‘‘and procedures’’ and 
inserting ‘‘(II) minimum hours of initial 
and ongoing training and retraining (in-
cluding not less than 120 hours in the case 
of initial training), and (III) procedures’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on the date of enactment of this 
Act and shall apply with respect to nurse aide training 
and competency evaluation programs, nurse aide com-
petency evaluation programs, and nurse orientations con-
ducted on or after the date that is one year after such 
date of enactment. 
SEC. 6. WHISTLEBLOWER AND RESIDENT PROTECTIONS. 
(a) MEDICARE.—Section 1819 of the Social Security 
Act (42 U.S.C. 1395i–3) is amended by adding at the end 
the following new subsection: 
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‘‘(k) WHISTLEBLOWER
AND
RESIDENT
PROTEC-
TIONS.— 
‘‘(1) STATEMENT
REGARDING
PROFESSIONAL 
OBLIGATION AND RIGHTS.—All nurses employed by 
a skilled nursing facility have a duty and right to act 
based on their professional judgment in accordance 
with the nursing laws and regulations of the State 
in which such facility is located, to provide nursing 
care in the exclusive interests of the residents of the 
facility, and to act as the residents’ advocate. 
‘‘(2) OBJECTION TO OR REFUSAL OF WORK AS-
SIGNMENT.—A nurse may object to, or refuse to 
participate in, any activity, policy, practice, assign-
ment, or task (referred to in this subsection as a 
‘work assignment’) if— 
‘‘(A) the nurse reasonably believes such 
work assignment to be in violation of the min-
imum nurse staffing requirements of clause (ii) 
of subsection (b)(4)(C); or 
‘‘(B) the nurse reasonably believes that the 
nurse is not prepared by education, training, or 
experience to perform or comply with such work 
assignment without compromising the safety of 
a resident or jeopardizing the license of the 
nurse. 
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‘‘(3) RETALIATION FOR OBJECTION TO OR RE-
FUSAL OF WORK ASSIGNMENT BARRED.— 
‘‘(A) NO DISCHARGE, DISCRIMINATION, OR 
RETALIATION.—No skilled nursing facility may 
discharge, retaliate, discriminate, or otherwise 
take adverse action in any manner with respect 
to any aspect of a nurse’s employment with the 
facility, including discharge, promotion, com-
pensation, or terms, conditions, or privileges of 
employment, based on the nurse’s objection to, 
or refusal of, a work assignment under para-
graph (2). 
‘‘(B) NO
FILING
OF
COMPLAINT.—No 
skilled nursing facility may file a complaint or 
a report against a nurse with a State profes-
sional disciplinary agency because of the nurse’s 
objection to, or refusal of, a work assignment 
under paragraph (2). 
‘‘(4) CAUSE OF ACTION.—Any nurse (or a col-
lective bargaining representative or legal representa-
tive of such nurse) against whom a skilled nursing 
facility has taken an adverse action in violation of 
paragraph (3)(A), or against whom such facility has 
filed a complaint or report in violation of paragraph 
(3)(B), may (without regard to whether a complaint 
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has been filed under paragraph (5) or (10)(B)) 
bring a cause of action in an appropriate district 
court of the United States. The legal burdens of 
proof specified in section 1221(e) of title 5, United 
States Code, shall be controlling for the purposes of 
any cause of action brought under this paragraph. 
A nurse who prevails on the cause of action may be 
entitled to one or more of the following: 
‘‘(A) Reinstatement. 
‘‘(B) Reimbursement of lost wages, com-
pensation, and benefits. 
‘‘(C) Attorneys’ fees. 
‘‘(D) Court costs. 
‘‘(E) Other damages. 
‘‘(5) COMPLAINT
TO
SECRETARY.—Any indi-
vidual may file a complaint with the Secretary 
against a skilled nursing facility that violates a re-
quirement described in paragraph (3). For any com-
plaint filed, the Secretary shall— 
‘‘(A) receive and investigate the complaint; 
‘‘(B) determine whether a violation of such 
paragraph, as alleged in the complaint, has oc-
curred; and 
‘‘(C) in the case that the Secretary deter-
mines that such a violation has occurred, issue 
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an order that the complaining individual may 
not suffer any adverse action prohibited by 
paragraph (3) or (7). 
‘‘(6) TOLL-FREE TELEPHONE NUMBER.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
provide for the establishment of a toll-free tele-
phone hotline to provide information regarding 
the minimum nurse staffing requirements of 
clause (ii) of subsection (b)(4)(C) and to receive 
reports of violations of such requirements. 
‘‘(B) NOTICE
TO
RESIDENTS.—A skilled 
nursing facility shall provide each resident ad-
mitted to the facility with the telephone number 
of the hotline described in subparagraph (A) 
and give notice to each such resident that such 
hotline may be used to report inadequate staff-
ing. 
‘‘(7) PROTECTION FOR REPORTING.— 
‘‘(A) PROHIBITION
ON
RETALIATION
OR 
DISCRIMINATION.—A skilled nursing facility 
may not retaliate or discriminate in any manner 
against any resident, employee, or contract em-
ployee of the facility, or any other individual, on 
the basis that such resident, employee, contract 
employee, or individual (individually or in con-
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junction with another individual) has, in good 
faith— 
‘‘(i) presented a grievance or com-
plaint; 
‘‘(ii) initiated or cooperated in any in-
vestigation or proceeding of any govern-
mental entity, regulatory agency, or private 
accreditation body; 
‘‘(iii) made a civil claim or demand; or 
‘‘(iv) filed an action relating to the 
care, services, or conditions of the facility. 
‘‘(B) GOOD
FAITH
DEFINED.—For pur-
poses of this paragraph, an individual shall be 
deemed to be acting in good faith if the indi-
vidual reasonably believes— 
‘‘(i) the information reported or dis-
closed is true; and 
‘‘(ii) a violation of the minimum nurse 
staffing requirements of clause (ii) of sub-
section (b)(4)(C) has occurred or may 
occur. 
‘‘(8) PROHIBITION
ON
INTERFERENCE
WITH 
RIGHTS.— 
‘‘(A) EXERCISE
OF
RIGHTS.—A skilled 
nursing facility may not— 
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‘‘(i) interfere with, restrain, or deny 
the exercise, or attempt to exercise, by any 
individual of any right, procedure, or rem-
edy provided or protected under this sub-
section; or 
‘‘(ii) coerce or intimidate any indi-
vidual regarding the exercise, or attempt to 
exercise, such right. 
‘‘(B) OPPOSITION TO UNLAWFUL POLICIES 
OR PRACTICES.—A skilled nursing facility may 
not retaliate or discriminate against any indi-
vidual for opposing any policy, practice, or ac-
tion of the facility which is alleged to violate, 
breach, or fail to comply with any provision of 
the minimum nurse staffing requirements of 
clause (ii) of subsection (b)(4)(C). 
‘‘(C) PROHIBITION
ON
INTERFERENCE 
WITH PROTECTED COMMUNICATIONS.—A skilled 
nursing facility may not make, adopt, or en-
force any rule, regulation, policy, or practice 
which in any manner directly or indirectly pro-
hibits, impedes, or discourages a nurse from, or 
intimidates, coerces, or induces a nurse regard-
ing, engaging in free speech activities or dis-
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closing information as provided under this sub-
section. 
‘‘(D) PROHIBITION
ON
INTERFERENCE 
WITH COLLECTIVE ACTION.—A skilled nursing 
facility may not in any way interfere with the 
rights of nurses to organize, bargain collec-
tively, and engage in concerted activity under 
section 7 of the National Labor Relations Act 
(29 U.S.C. 157). 
‘‘(9) NOTICE.—A skilled nursing facility shall 
post in an appropriate location in each unit a con-
spicuous notice, in a form specified by the Secretary, 
that— 
‘‘(A) explains the rights of nurses, resi-
dents, and other individuals under this sub-
section; 
‘‘(B) includes a statement that a nurse, 
resident, or other individual may file a com-
plaint with the Secretary against the facility for 
a violation of a requirement or a prohibition of 
this subsection; and 
‘‘(C) provides instructions on how to file 
such a complaint. 
‘‘(10) ENFORCEMENT.— 
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‘‘(A) IN
GENERAL.—The Secretary shall 
enforce the requirements and prohibitions of 
this subsection in accordance with this para-
graph. 
‘‘(B) PROCEDURES
FOR
RECEIVING
AND 
INVESTIGATING
COMPLAINTS.—The Secretary 
shall establish procedures under which— 
‘‘(i) any individual may file a com-
plaint alleging that a skilled nursing facil-
ity has violated a requirement or a prohibi-
tion of this subsection; and 
‘‘(ii) any such complaint shall be in-
vestigated by the Secretary. 
‘‘(C) REMEDIES.—If the Secretary deter-
mines that a skilled nursing facility has violated 
a requirement or prohibition of this subsection, 
the Secretary— 
‘‘(i) shall require the facility to estab-
lish a corrective action plan to prevent the 
recurrence of such violation; and 
‘‘(ii) may impose civil money penalties 
as described in subparagraph (D). 
‘‘(D) CIVIL PENALTIES.— 
‘‘(i) IN GENERAL.—In addition to any 
other penalties prescribed by law, the Sec-
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retary may impose civil penalties as fol-
lows: 
‘‘(I) SKILLED NURSING FACILITY 
LIABILITY.—The Secretary may im-
pose on a skilled nursing facility 
found to be in violation of this sub-
section a civil money penalty of— 
‘‘(aa) 
not 
more 
than 
$25,000 for the first knowing 
violation of this subsection by 
such facility; and 
‘‘(bb) 
not 
more 
than 
$50,000 
for 
any 
subsequent 
knowing violation of this sub-
section by such facility. 
‘‘(II) INDIVIDUAL
LIABILITY.— 
The Secretary may impose on an indi-
vidual who— 
‘‘(aa) is employed by a 
skilled nursing facility; and 
‘‘(bb) is found by the Sec-
retary to have knowingly violated 
this subsection on behalf of the 
facility, 
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a civil money penalty of not more 
than $20,000 for each such violation 
by the individual. 
‘‘(ii) PROCEDURES.—The provisions 
of section 1128A of the Social Security Act 
(other than subsections (a) and (b)) shall 
apply with respect to a civil money penalty 
or proceeding under this subparagraph in 
the same manner as such provisions apply 
with respect to a civil money penalty or 
proceeding under such section 1128A. 
‘‘(E) PUBLIC NOTICE OF VIOLATIONS.— 
‘‘(i) INTERNET
WEBSITE.—The Sec-
retary shall publish on the internet website 
of the Department of Health and Human 
Services the names of skilled nursing facili-
ties on which a civil money penalty has 
been imposed under this subsection, the 
violation for which such penalty was im-
posed, and such additional information as 
the Secretary determines appropriate. 
‘‘(ii) CHANGE OF OWNERSHIP.—With 
respect to a skilled nursing facility that 
had a change of ownership, as determined 
by the Secretary, penalties imposed on the 
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