I 
116TH CONGRESS 
2D SESSION 
H. R. 9021 
To amend titles XVIII and XIX of the Social Security Act to modernize 
Federal nursing home protections and to enhance care quality and trans-
parency for nursing home residents and their families. 
IN THE HOUSE OF REPRESENTATIVES 
DECEMBER 17, 2020 
Mr. PASCRELL (for himself, Mr. KELLY of Pennsylvania, Ms. ESHOO, and Mr. 
MCKINLEY) 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 modernize Federal nursing home protections and to 
enhance care quality and transparency for nursing home 
residents and their families. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Nursing Home Reform 
Modernization Act of 2020’’. 
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SEC. 2. IMPROVEMENTS TO NURSING FACILITIES UNDER 
THE MEDICARE AND MEDICAID PROGRAMS. 
(a) ADVISORY COUNCIL ON SKILLED NURSING FA-
CILITY RANKINGS UNDER MEDICARE AND NURSING FA-
CILITY RANKINGS UNDER MEDICAID.— 
(1) ESTABLISHMENT.—Not later than 1 year 
after the date of enactment of this Act, the Sec-
retary of Health and Human Services shall establish 
the Advisory Council on Skilled Nursing Facility 
Rankings under Medicare and Nursing Facility 
Rankings under Medicaid (in this subsection re-
ferred to as the ‘‘Advisory Council’’). 
(2) MEMBERSHIP.—The Secretary shall ensure 
that the membership of the Advisory Council in-
cludes equal representation from the following: 
(A) Consumers with nursing home experi-
ence, including adults age 65 and older, individ-
uals with disabilities, family caregivers, and 
their advocates. 
(B) Skilled nursing facilities and nursing 
facilities, including non-profit facilities. 
(C) Academics with expertise in nursing 
home oversight. 
(D) Health professionals with nursing 
home experience, such as physicians, nurses, 
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pharmacists, certified nursing assistants, and 
direct care professionals. 
(E) Professionals with expertise in quality 
measurement. 
(F) Professionals with expertise in emer-
gency management. 
(G) State surveying agencies. 
(H) State long-term care ombudsman pro-
grams. 
(I) The Medicare Payment Advisory Com-
mission. 
(J) The Medicaid and CHIP Payment and 
Access Commission. 
(K) The Centers for Medicare & Medicaid 
Services. 
(L) Other representatives as the Secretary 
determines appropriate. 
(3) DUTIES.— 
(A) STUDY.—The Advisory Council shall 
conduct a study of processes for ranking skilled 
nursing facilities and nursing facilities under 
paragraph (9) of section 1819(f) of the Social 
Security Act, as added by subsection (b)(1) and 
under paragraph (11) of section 1919(f) of 
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such Act, as added by subsection (c)(1). Such 
study shall include an analysis of— 
(i) which available, verifiable data 
sources and measures are best for appro-
priately designating facilities in— 
(I) the high-rated facility pro-
gram under paragraph (10) of such 
section 1819(f) and under paragraph 
(12) of such section 1919(f); and 
(II) the low-rated facility pro-
gram under paragraph (8) of such 
section 1819(f) and under paragraph 
(10) of such section 1919(f); 
(ii) the appropriate frequency with 
which to update the rankings for the high- 
rated and low-rated facility programs de-
scribed in clause (i); 
(iii) how best to ensure that skilled 
nursing facilities and nursing facilities ap-
propriately report adverse events; 
(iv) how surveyors can clearly provide 
the rationale for giving deficiencies to such 
skilled nursing facilities and nursing facili-
ties and how this can be done in a timely 
manner; 
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(v) how to manage suspensions from 
the high-rated facility program described 
in clause (i)(I) and the need for additional 
consumer protections to administer such 
high-rated facility program; 
(vi) the availability or potential devel-
opment of, or modifications to, measures 
or verifiable data sources on topics, includ-
ing avoidable hospital readmissions, emer-
gency room visits, risk-adjusted mortality, 
discharges to the community, involuntary 
discharges, situations involving the inap-
propriate administration of medications by 
a facility, and emergency management; and 
(vii) the development of, or modifica-
tions to, data collection, verifiable data 
sources, and potential measures to assess 
the financial stability of a facility. 
(B) FINDINGS AND RECOMMENDATIONS.— 
(i) IN GENERAL.—Not later than 2 
years after the date of enactment of this 
Act, the Advisory Council shall submit to 
the Secretary the findings of the Advisory 
Council under the study conducted under 
subparagraph (A), together with rec-
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ommendations for such legislation and ad-
ministrative action as the Advisory Council 
determines appropriate. 
(ii) PUBLIC AVAILABILITY.—Upon re-
ceiving the findings and recommendations 
under clause (i), the Secretary shall make 
the findings and recommendations avail-
able to the public on the internet website 
of the Centers for Medicare & Medicaid 
Services. 
(4) SUNSET.—The Advisory Council shall ter-
minate upon the submission of the report to the Sec-
retary under paragraph (3)(B)(i). 
(b) MEDICARE PROGRAM REVISIONS.— 
(1) ESTABLISHMENT OF RANKINGS AND HIGH- 
RATED FACILITY PROGRAM.— 
(A) IN GENERAL.—Section 1819(f) of the 
Social Security Act (42 U.S.C. 1395i–3(f)) is 
amended by adding at the end the following 
new paragraphs: 
‘‘(9) RANKING PROCESS.— 
‘‘(A) PROCESS.— 
‘‘(i) ESTABLISHMENT.—The Secretary 
shall establish a process to rank skilled 
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nursing facilities based on compliance with 
the applicable requirements of this Act. 
‘‘(ii) DATA.—The process established 
under clause (i) shall include the use of at 
least the preceding 3 years of health in-
spection data, if appropriate, and other 
data as determined appropriate by the Sec-
retary. 
‘‘(iii) FINDINGS
AND
RECOMMENDA-
TIONS
OF
THE
ADVISORY
COUNCIL
ON 
SKILLED
NURSING
FACILITY
RANKINGS 
UNDER MEDICARE AND NURSING FACILITY 
RANKINGS
UNDER
MEDICAID.—In estab-
lishing the process under clause (i), the 
Secretary shall take into account the find-
ings and recommendations of the Advisory 
Council that are submitted to the Sec-
retary under section 2(a)(3)(B)(i) of the 
Nursing Home Reform Modernization Act 
of 2020. 
‘‘(B) RANKING.— 
‘‘(i) IN GENERAL.—Under the process 
established under subparagraph (A), the 
Secretary shall use the rankings of skilled 
nursing facilities to categorize facilities 
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shall take into account the findings and 
recommendations described in paragraph 
(9)(A)(iii). 
‘‘(iii) REGULATIONS.—The Secretary 
shall establish the high-rated facility pro-
gram under clause (i) through notice and 
comment rulemaking. 
‘‘(B) DESIGNATION.—Under the high- 
rated facility program, subject to subparagraph 
(D), the Secretary shall designate the highest 
rated skilled nursing facilities under the 
rankings under paragraph (9)(B) as high-rated 
skilled nursing facilities. 
‘‘(C) DISTINCTION
ON
NURSING
HOME 
COMPARE WEBSITE.—A skilled nursing facility 
that is designated as a high-rated skilled nurs-
ing facility under subparagraph (B) shall re-
ceive a high-rated distinction on the official 
Internet website of the Federal Government for 
comparing nursing homes pursuant to sub-
section (i)(1)(C). 
‘‘(D) SUSPENSION
OF
HIGH-RATED
STA-
TUS.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall suspend a skilled nursing facility’s 
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designation under subparagraph (B) if the 
Secretary determines that there are cir-
cumstances warranting such suspension. 
‘‘(ii) 
CIRCUMSTANCES.—In 
estab-
lishing the circumstances under clause (i), 
the Secretary shall take into account— 
‘‘(I) findings from Federal sur-
veys and investigations; 
‘‘(II) findings from State surveys 
conducted under subsection (g)(2)(A); 
‘‘(III) findings from State inves-
tigations and surveys conducted under 
subsection (g)(4), including a high 
number of substantiated complaints, 
the frequency and severity of substan-
tiated complaints, and how the com-
plaints are handled by the facility; 
‘‘(IV) 
situations 
involving 
changes of ownership, administration, 
or management of a skilled nursing 
facility, or the director of nursing; 
‘‘(V) situations involving the in-
appropriate administration of medica-
tions by a facility; 
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‘‘(VI) situations involving invol-
untary discharges of residents; and 
‘‘(VII) other factors determined 
appropriate by the Secretary. 
‘‘(iii) NO REINSTATEMENT PRIOR TO 
NEXT
STANDARD
SURVEY.—If a skilled 
nursing facility’s designation is suspended 
under clause (i), such designation shall not 
be reinstated prior to a subsequent survey 
as 
specified 
under 
subsection 
(g)(2)(A)(iii).’’. 
(B) ASSESSMENT
OF
HIGH-RATED
DES-
IGNATION
IN
SPECIAL
SURVEYS.—Section 
1819(g)(2)(A)(iii)(II) of the Social Security Act 
(42 U.S.C. 1395i–3(g)(2)(A)(iii)(II)) is amend-
ed— 
(i) by inserting ‘‘(or, in the case of a 
facility that is designated as a high-rated 
skilled nursing facility under subsection 
(f)(10), shall be conducted)’’ after ‘‘may be 
conducted’’; and 
(ii) by adding at the end the following 
new sentence: ‘‘On and after the date the 
Secretary implements the high-rated facil-
ity program under subsection (f)(10), any 
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survey conducted, pursuant to the pre-
ceding sentence, of a facility that is des-
ignated as a high-rated skilled nursing fa-
cility under such subsection shall include 
an assessment of whether such designation 
should continue or be suspended under 
subparagraph (D) of such subsection.’’. 
(2) IMPROVEMENTS
TO
THE
SPECIAL
FOCUS 
FACILITY PROGRAM.— 
(A) APPROPRIATE
PARTICIPATION.—Sec-
tion 1819(f)(8) of the Social Security Act (42 
U.S.C. 1395i–3(f)(8)) is amended— 
(i) in subparagraph (A), by striking 
‘‘The Secretary’’ and inserting ‘‘Subject to 
the succeeding provisions of this sub-
section, the Secretary’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(C) APPROPRIATE
PARTICIPATION.—Not 
later than 1 year after the date of enactment of 
the Nursing Home Reform Modernization Act 
of 2020, the Secretary shall ensure that the 
number of facilities participating in the special 
focus facility program is not less than 3.5 per-
cent of all skilled nursing facilities.’’. 
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(B) CONVERSION OF THE SPECIAL FOCUS 
FACILITY PROGRAM TO THE LOW-RATED FACIL-
ITY
PROGRAM
AND
ADDITIONAL
REQUIRE-
MENTS.—Section 1819(f)(8) of the Social Secu-
rity Act (42 U.S.C. 1395i–3(f)(8)), as amended 
by subparagraph (A), is amended— 
(i) in subparagraph (B), by inserting 
the following before the period at the end: 
‘‘(or, on and after the date the Secretary 
makes the conversion described in subpara-
graph (D), at a frequency determined ap-
propriate by the Secretary (but in no case 
less than once every 6 months))’’; and 
(ii) by adding at the end the following 
new subparagraphs: 
‘‘(D) CONVERSION
TO
THE
LOW-RATED 
FACILITY PROGRAM.— 
‘‘(i) IN GENERAL.—On the same date 
that the Secretary implements the high- 
rated facility program under paragraph 
(10), the Secretary shall convert the spe-
cial focus facility program under this sub-
section to the low-rated facility program. 
‘‘(ii) REGULATIONS.—The Secretary 
shall carry out the conversion under clause 
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(i) through notice and comment rule-
making. 
‘‘(iii) 
ADDITIONAL
REQUIREMENTS 
FOR
THE
LOW-RATED
FACILITY
PRO-
GRAM.—In addition to the provisions that 
apply to the low-rated facility program 
through the conversion from the special 
focus facility program, the succeeding pro-
visions of this subsection shall also apply 
to the low-rated facility program. 
‘‘(E) PARTICIPATION.—Subject to the min-
imum participation requirement under subpara-
graph (C), the Secretary shall designate the 
lowest rated skilled nursing facilities under the 
rankings under paragraph (9)(B) for participa-
tion in the low-rated facility program. 
‘‘(F) PROGRESSIVE
ENFORCEMENT
AC-
TIONS.—The Secretary, in consultation with 
States, shall utilize progressive enforcement ac-
tions, of increasing severity, to ensure facilities 
participating in the low-rated facility program 
meet the applicable requirements under this 
Act. 
‘‘(G) ENFORCEMENT
FOR
PATTERNS
OF 
DEFICIENCY.—The Secretary may utilize en-
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forcement actions specified in subsection (h)(2) 
to remedy patterns of deficiencies cited across 
multiple surveys. 
‘‘(H) 
COMPLIANCE
ASSISTANCE
PRO-
GRAMS.— 
‘‘(i) ON-SITE
CONSULTATION
AND 
EDUCATIONAL PROGRAMMING.— 
‘‘(I) IN
GENERAL.—The Sec-
retary shall establish on-site consulta-
tion and educational programming for 
skilled nursing facilities participating 
in the low-rated facility program with 
respect to compliance with the appli-
cable requirements under this Act. 
‘‘(II) ENTITY.—The on-site con-
sultation and educational program-
ming described in subclause (I) shall 
be carried out by quality improvement 
organizations under part B of title XI 
or other independent organizations of 
a similar type that do not have con-
flicts of interest and are deemed ap-
propriate by the Secretary. 
‘‘(III) 
REQUIRED
PARTICIPA-
TION.—A skilled nursing facility par-
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ticipating in the low-rated facility pro-
gram shall participate in any con-
sultations and educational program-
ming described in subclause (I) con-
ducted at the facility. 
‘‘(ii) CONSULTATION
INDEPENDENT 
OF ENFORCEMENT.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), on-site consultations 
and educational programming de-
scribed in clause (i) shall be con-
ducted independently of any enforce-
ment activity. 
‘‘(II) EXCEPTION.—Subclause (I) 
shall not apply in the case where a 
triggering event at the skilled nursing 
facility is observed in the course of 
providing on-site consultations and 
educational programming described in 
clause (i). In establishing such on-site 
consultations and educational pro-
gramming, the Secretary shall deter-
mine the triggering events for which 
the use of necessary enforcement ac-
tions is permitted notwithstanding the 
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limitation under subclause (I). Such 
triggering events shall include events 
that are required to be reported under 
State and Federal law and a pattern 
of deficiencies or problems that the 
quality improvement organization or 
other organization has identified for 
correction but which are consistently 
not corrected. 
‘‘(I) PUBLIC AVAILABILITY.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall ensure that a skilled nursing facility’s 
participation in the low-rated facility pro-
gram is publicly announced, including to— 
‘‘(I) resident family councils; 
‘‘(II) resident attending physi-
cians; 
‘‘(III) the State board respon-
sible for the licensing of the skilled 
nursing facility administrator at the 
facility; 
‘‘(IV) State Long-Term Care 
Ombudsman programs (as described 
in section 712(a)(1) of the Older 
Americans Act of 1965); and 
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‘‘(V) the community at large. 
‘‘(ii) WRITTEN
NOTIFICATION.—The 
Secretary shall ensure that, in the case of 
a skilled nursing facility that is partici-
pating in the low-rated facility program, 
residents of such facility and family or 
legal representatives are furnished with in-
dividualized written notice of such partici-
pation. Such notice shall be provided to 
current residents and to new residents 
prior to admission. 
‘‘(J) REQUIREMENT FOR REMOVAL.—The 
Secretary shall require that a skilled nursing fa-
cility show improvement prior to removal from 
the low-rated facility program.’’. 
(C) USE OF CIVIL MONEY PENALTIES.— 
Section 1819(h)(2)(B)(ii)(IV)(ff) of the Social 
Security 
Act 
(42 
U.S.C. 
1395i– 
3(h)(2)(B)(ii)(IV)(ff)) is amended— 
(i) by striking ‘‘and facility improve-
ment initiatives’’ and inserting ‘‘facility 
improvement initiatives’’; and 
(ii) by inserting the following before 
the period at the end: ‘‘, and, on and after 
the date the Secretary makes the conver-
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sion described in subsection (f)(8)(D), con-
sultation, education, and other activities to 
foster 
improvement 
and 
remedy 
root 
causes contributing to deficiencies cited 
across multiple surveys among facilities in 
the low-rated facility program under sub-
section (f)(8)’’. 
(3) INFORMATION ON HIGH-RATED AND LOW- 
RATED
FACILITIES
ON
NURSING
HOME
COMPARE 
MEDICARE WEBSITE.—Section 1819(i)(1) of the So-
cial Security Act (42 U.S.C. 1395i–3(i)(1)) is 
amended— 
(A) in subparagraph (A), by adding at the 
end the following new clause: 
‘‘(vi) On and after the date the Sec-
retary implements the high-rated facility 
program under subsection (f)(10) and 
makes the conversion under subsection 
(f)(8)(D), consistent with subparagraph 
(C)— 
‘‘(I) for each skilled nursing fa-
cility that is designated as a high- 
rated skilled nursing facility under 
subsection (f)(10), the date the facil-
ity was so designated; and 
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‘‘(II) for each skilled nursing fa-
cility participating in the low-rated fa-
cility program under subsection (f)(8), 
the date the facility was identified for 
inclusion in such program.’’; and 
(B) by adding at the end the following new 
subparagraphs: 
‘‘(C) DISTINCTIONS FOR HIGH-RATED AND 
LOW-RATED
FACILITIES.—On and after the 
date the Secretary implements the high-rated 
facility program under subsection (f)(10) and 
makes 
the 
conversion 
under 
subsection 
(f)(8)(D), the Secretary shall ensure that 
graphics, including an appropriate explanation 
of such graphics, are prominently displayed on 
the website described in subparagraph (A) in 
order to distinguish each of the following: 
‘‘(i) Skilled nursing facilities that are 
designated as high-rated skilled nursing fa-
cilities under subsection (f)(10). 
‘‘(ii) Skilled nursing facilities that are 
participating in the low-rated facility pro-
gram under subsection (f)(8), with infor-
mation on facilities that have been placed 
in such program more than one time over 
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the course of the last 10 years (including 
the number of times such skilled nursing 
facilities have been placed in the program). 
‘‘(D) FOCUS
GROUPS
AND
CONSUMER 
TESTING.—In order to help limit confusion, 
particularly among older adults, individuals 
with disabilities, and family caregivers, the Sec-
retary shall utilize focus groups and other con-
sumer testing methods prior to including the 
additional information under subparagraph 
(A)(vi) and implementing the distinctions under 
subparagraph (C).’’. 
(c) MEDICAID PROGRAM REVISIONS.— 
(1) ESTABLISHMENT OF RANKINGS AND HIGH- 
RATED FACILITY PROGRAM.— 
(A) IN GENERAL.—Section 1919(f) of the 
Social Security Act (42 U.S.C. 1396r(f)) is 
amended by adding at the end the following 
new paragraphs: 
‘‘(11) RANKING PROCESS.— 
‘‘(A) PROCESS.— 
‘‘(i) ESTABLISHMENT.—The Secretary 
shall establish a process to rank nursing 
facilities based on compliance with the ap-
plicable requirements of this Act. 
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‘‘(ii) DATA.—The process established 
under clause (i) shall include the use of at 
least the preceding 3 years of health in-
spection data, if appropriate, and other 
data as determined appropriate by the Sec-
retary. 
‘‘(iii) FINDINGS
AND
RECOMMENDA-
TIONS
OF
THE
ADVISORY
COUNCIL
ON 
SKILLED
NURSING
FACILITY
RANKINGS 
UNDER MEDICARE AND NURSING FACILITY 
RANKINGS
UNDER
MEDICAID.—In estab-
lishing the process under clause (i), the 
Secretary shall take into account the find-
ings and recommendations of the Advisory 
Council that are submitted to the Sec-
retary under section 2(a)(3)(B)(i) of the 
Nursing Home Reform Modernization Act 
of 2020. 
‘‘(B) RANKING.— 
‘‘(i) IN GENERAL.—Under the process 
established under subparagraph (A), the 
Secretary shall use the rankings of nursing 
facilities to categorize facilities into highest 
and lowest groups for the purposes speci-
fied in clause (ii). 
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‘‘(ii) 
TIMING
AND
USE
OF 
RANKINGS.—Not later than 2 years after 
the date the Secretary receives the findings 
and recommendations described in sub-
paragraph (A)(iii), the Secretary shall use 
the rankings under clause (i) for purposes 
of carrying out— 
‘‘(I) the high-rated facility pro-
gram under paragraph (12); and 
‘‘(II) the low-rated facility pro-
gram under paragraph (10). 
‘‘(12) HIGH-RATED FACILITY PROGRAM.— 
‘‘(A) ESTABLISHMENT.— 
‘‘(i) IN GENERAL.—Not later than 2 
years after the date the Secretary receives 
the findings and recommendations de-
scribed in paragraph (11)(A)(iii), the Sec-
retary shall establish and implement a 
high-rated facility program to encourage 
and reward compliance with the require-
ments of this Act. 
‘‘(ii) REPORT.—In establishing the 
high-rated facility program, the Secretary 
shall take into account the findings and 
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recommendations described in paragraph 
(11)(A)(iii). 
‘‘(iii) REGULATIONS.—The Secretary 
shall establish the high-rated facility pro-
gram under clause (i) through notice and 
comment rulemaking. 
‘‘(B) DESIGNATION.—Under the high- 
rated facility program, subject to subparagraph 
(D), the Secretary shall designate the highest 
rated nursing facilities under the rankings 
under paragraph (11)(B) as high-rated nursing 
facilities. 
‘‘(C) DISTINCTION
ON
NURSING
HOME 
COMPARE WEBSITE.—A nursing facility that is 
designated as a high-rated nursing facility 
under subparagraph (B) shall receive a high- 
rated distinction on the official Internet website 
of the Federal Government for comparing nurs-
ing homes pursuant to subsection (i)(1)(C). 
‘‘(D) SUSPENSION
OF
HIGH-RATED
STA-
TUS.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall suspend a nursing facility’s designa-
tion under subparagraph (B) if the Sec-
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retary determines that there are cir-
cumstances warranting such suspension. 
‘‘(ii) 
CIRCUMSTANCES.—In 
estab-
lishing the circumstances under clause (i), 
the Secretary shall take into account— 
‘‘(I) findings from Federal sur-
veys and investigations; 
‘‘(II) findings from State surveys 
conducted under subsection (g)(2)(A); 
‘‘(III) findings from State inves-
tigations and surveys conducted under 
subsection (g)(4), including a high 
number of substantiated complaints, 
the frequency and severity of substan-
tiated complaints, and how the com-
plaints are handled by the facility; 
‘‘(IV) 
situations 
involving 
changes of ownership, administration, 
or management of a nursing facility, 
or the director of nursing; 
‘‘(V) situations involving the in-
appropriate administration of medica-
tions by a facility; 
‘‘(VI) situations involving invol-
untary discharges of residents; and 
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‘‘(VII) other factors determined 
appropriate by the Secretary. 
‘‘(iii) NO REINSTATEMENT PRIOR TO 
NEXT
STANDARD
SURVEY.—If a nursing 
facility’s designation is suspended under 
clause (i), such designation shall not be re-
instated prior to a subsequent survey as 
specified under subsection (g)(2)(A)(iii).’’. 
(B) ASSESSMENT
OF
HIGH-RATED
DES-
IGNATION
IN
SPECIAL
SURVEYS.—Section 
1919(g)(2)(A)(iii)(II) of the Social Security Act 
(42 U.S.C. 1396r(g)(2)(A)(iii)(II)) is amend-
ed— 
(i) by inserting ‘‘(or, in the case of a 
facility that is designated as a high-rated 
nursing facility under subsection (f)(12), 
shall be conducted)’’ after ‘‘may be con-
ducted’’; and 
(ii) by adding at the end the following 
new sentence: ‘‘On and after the date the 
Secretary implements the high-rated facil-
ity program under subsection (f)(12), any 
survey conducted, pursuant to the pre-
ceding sentence, of a facility that is des-
ignated as a high-rated nursing facility 
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under such subsection shall include an as-
sessment of whether such designation 
should continue or be suspended under 
subparagraph (D) of such subsection.’’. 
(2) IMPROVEMENTS
TO
THE
SPECIAL
FOCUS 
FACILITY PROGRAM.— 
(A) APPROPRIATE
PARTICIPATION.—Sec-
tion 1919(f)(10) of the Social Security Act (42 
U.S.C. 1395r(f)(10)) is amended— 
(i) in subparagraph (A), by striking 
‘‘The Secretary’’ and inserting ‘‘Subject to 
the succeeding provisions of this sub-
section, the Secretary’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(C) APPROPRIATE
PARTICIPATION.—Not 
later than 1 year after the date of enactment of 
the Nursing Home Reform Modernization Act 
of 2020, the Secretary shall ensure that the 
number of facilities participating in the special 
focus facility program is not less than 3.5 per-
cent of all nursing facilities.’’. 
(B) CONVERSION OF THE SPECIAL FOCUS 
FACILITY PROGRAM TO THE LOW-RATED FACIL-
ITY
PROGRAM
AND
ADDITIONAL
REQUIRE-
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MENTS.—Section 1919(f)(10) of the Social Se-
curity Act (42 U.S.C. 1395i–3(f)(10)), as 
amended by subparagraph (A), is amended— 
(i) in subparagraph (B), by inserting 
the following before the period at the end: 
‘‘(or, on and after the date the Secretary 
makes the conversion described in subpara-
graph (D), at a frequency determined ap-
propriate by the Secretary (but in no case 
less than once every 6 months))’’; and 
(ii) by adding at the end the following 
new subparagraphs: 
‘‘(D) CONVERSION
TO
THE
LOW-RATED 
FACILITY PROGRAM.— 
‘‘(i) IN GENERAL.—On the same date 
that the Secretary implements the high- 
rated facility program under paragraph 
(12), the Secretary shall convert the spe-
cial focus facility program under this sub-
section to the low-rated facility program. 
‘‘(ii) REGULATIONS.—The Secretary 
shall carry out the conversion under clause 
(i) through notice and comment rule-
making. 
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‘‘(iii) 
ADDITIONAL
REQUIREMENTS 
FOR
THE
LOW-RATED
FACILITY
PRO-
GRAM.—In addition to the provisions that 
apply to the low-rated facility program 
through the conversion from the special 
focus facility program, the succeeding pro-
visions of this subsection shall also apply 
to the low-rated facility program. 
‘‘(E) PARTICIPATION.—Subject to the min-
imum participation requirement under subpara-
graph (C), the Secretary shall designate the 
lowest rated nursing facilities under the 
rankings under paragraph (11)(B) for partici-
pation in the low-rated facility program. 
‘‘(F) PROGRESSIVE
ENFORCEMENT
AC-
TIONS.—The Secretary, in consultation with 
States, shall utilize progressive enforcement ac-
tions, of increasing severity, to ensure facilities 
participating in the low-rated facility program 
meet the applicable requirements under this 
Act. 
‘‘(G) ENFORCEMENT
FOR
PATTERNS
OF 
DEFICIENCY.—The Secretary may utilize en-
forcement actions specified in subsection (h)(2) 
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to remedy patterns of deficiencies cited across 
multiple surveys. 
‘‘(H) 
COMPLIANCE
ASSISTANCE
PRO-
GRAMS.— 
‘‘(i) ON-SITE
CONSULTATION
AND 
EDUCATIONAL PROGRAMMING.— 
‘‘(I) IN
GENERAL.—The Sec-
retary shall establish on-site consulta-
tion and educational programming for 
nursing facilities participating in the 
low-rated facility program with re-
spect to compliance with the applica-
ble requirements under this Act. 
‘‘(II) ENTITY.—The on-site con-
sultation and educational program-
ming described in subclause (I) shall 
be carried out by quality improvement 
organizations under part B of title XI 
or other independent organizations of 
a similar type that do not have con-
flicts of interest and are deemed ap-
propriate by the Secretary. 
‘‘(III) 
REQUIRED
PARTICIPA-
TION.—A 
nursing 
facility 
partici-
pating in the low-rated facility pro-
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gram shall participate in any con-
sultations and educational program-
ming described in subclause (I) con-
ducted at the facility. 
‘‘(ii) CONSULTATION
INDEPENDENT 
OF ENFORCEMENT.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), on-site consultations 
and educational programming de-
scribed in clause (i) shall be con-
ducted independently of any enforce-
ment activity. 
‘‘(II) EXCEPTION.—Subclause (I) 
shall not apply in the case where a 
triggering event at the nursing facility 
is observed in the course of providing 
on-site consultations and educational 
programming described in clause (i). 
In establishing such on-site consulta-
tions and educational programming, 
the Secretary shall determine the trig-
gering events for which the use of 
necessary enforcement actions is per-
mitted notwithstanding the limitation 
under subclause (I). Such triggering 
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events shall include events that are re-
quired to be reported under State and 
Federal law and a pattern of defi-
ciencies or problems that the quality 
improvement organization or other or-
ganization has identified for correc-
tion but which are consistently not 
corrected. 
‘‘(I) PUBLIC AVAILABILITY.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall ensure that a nursing facility’s par-
ticipation in the low-rated facility program 
is publicly announced, including to— 
‘‘(I) resident family councils; 
‘‘(II) resident attending physi-
cians; 
‘‘(III) the State board respon-
sible for the licensing of the nursing 
facility administrator at the facility; 
‘‘(IV) State Long-Term Care 
Ombudsman programs (as described 
in section 712(a)(1) of the Older 
Americans Act of 1965); and 
‘‘(V) the community at large. 
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‘‘(ii) WRITTEN
NOTIFICATION.—The 
Secretary shall ensure that, in the case of 
a nursing facility that is participating in 
the low-rated facility program, residents of 
such facility and family or legal represent-
atives are furnished with individualized 
written notice of such participation. Such 
notice shall be provided to current resi-
dents and to new residents prior to admis-
sion. 
‘‘(J) REQUIREMENT FOR REMOVAL.—The 
Secretary shall require that a nursing facility 
show improvement prior to removal from the 
low-rated facility program.’’. 
(C) USE OF CIVIL MONEY PENALTIES.— 
Section 1919(h)(3)(C)(ii)(IV)(ff) of the Social 
Security 
Act 
(42 
U.S.C. 
1396r(h)(3)(C)(ii)(IV)(ff)) is amended— 
(i) by striking ‘‘and facility improve-
ment initiatives’’ and inserting ‘‘facility 
improvement initiatives’’; and 
(ii) by inserting the following before 
the period at the end: ‘‘, and, on and after 
the date the Secretary makes the conver-
sion described in subsection (f)(10)(D), 
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consultation, education, and other activities 
to foster improvement and remedy root 
causes contributing to deficiencies cited 
across multiple surveys among facilities in 
the low-rated facility program under sub-
section (f)(10)’’. 
(3) INFORMATION ON HIGH-RATED AND LOW- 
RATED
FACILITIES
ON
NURSING
HOME
COMPARE 
MEDICARE WEBSITE.—Section 1919(i)(1) of the So-
cial Security Act (42 U.S.C. 1396r(i)(1)) is amend-
ed— 
(A) in subparagraph (A), by adding at the 
end the following new clause: 
‘‘(vi) On and after the date the Sec-
retary implements the high-rated facility 
program under subsection (f)(12) and 
makes the conversion under subsection 
(f)(10)(D), consistent with subparagraph 
(C)— 
‘‘(I) for each nursing facility that 
is designated as a high-rated nursing 
facility under subsection (f)(12), the 
date the facility was so designated; 
and 
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‘‘(II) for each nursing facility 
participating in the low-rated facility 
program under subsection (f)(10), the 
date the facility was identified for in-
clusion in such program.’’; and 
(B) by adding at the end the following new 
subparagraphs: 
‘‘(C) DISTINCTIONS FOR HIGH-RATED AND 
LOW-RATED
FACILITIES.—On and after the 
date the Secretary implements the high-rated 
facility program under subsection (f)(12) and 
makes 
the 
conversion 
under 
subsection 
(f)(10)(D), the Secretary shall ensure that 
graphics, including an appropriate explanation 
of such graphics, are prominently displayed on 
the website described in subparagraph (A) in 
order to distinguish each of the following: 
‘‘(i) Nursing facilities that are des-
ignated as high-rated nursing facilities 
under subsection (f)(12). 
‘‘(ii) Nursing facilities that are par-
ticipating in the low-rated facility program 
under subsection (f)(10), with information 
on facilities that have been placed in such 
program more than one time over the 
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course of the last 10 years (including the 
number of times such nursing facilities 
have been placed in the program). 
‘‘(D) FOCUS
GROUPS
AND
CONSUMER 
TESTING.—In order to help limit confusion, 
particularly among older adults, individuals 
with disabilities, and family caregivers, the Sec-
retary shall utilize focus groups and other con-
sumer testing methods prior to including the 
additional information under subparagraph 
(A)(vi) and implementing the distinctions under 
subparagraph (C).’’. 
(d) GAO STUDY AND REPORT.— 
(1) STUDY.—The Comptroller General of the 
United States (in this section referred to as the 
‘‘Comptroller General’’) shall conduct a study on the 
quality of items and services furnished by skilled 
nursing facilities under title XVIII of the Social Se-
curity Act and nursing facilities under title XIX of 
such Act, and such facilities’ compliance with the 
applicable requirements under such titles. Such 
study shall include analysis of the following: 
(A) The effectiveness of the low-rated facil-
ity program established under paragraph (8) of 
section 1819(f) of the Social Security Act (42 
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U.S.C. 1395i–3(f)), as amended by subsection 
(b)(2), and under paragraph (10) of section 
1919(f) of such Act (42 U.S.C. 1396r(f)), as 
amended by subsection (c)(2). 
(B) Other areas determined appropriate by 
the Comptroller General. 
(2) REPORT.—Not later than 6 years after the 
date of enactment of this Act, the Comptroller Gen-
eral shall submit to the appropriate Committees of 
Congress a report containing the results of the study 
conducted under paragraph (1), together with rec-
ommendations for such legislation and administra-
tive action as the Comptroller General determines 
appropriate. 
(e) RULES OF CONSTRUCTION.— 
(1) SURVEYS.—Nothing in the provisions of, or 
the amendments made by, this section shall be con-
strued to allow the Secretary to modify or deviate 
from— 
(A) a survey schedule that requires unan-
nounced and unanticipated surveying of skilled 
nursing facilities under subsection (g)(2)(A)(i) 
of section 1819 of the Social Security Act (42 
U.S.C. 
1395i–3(g)) 
or 
under 
subsection 
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(g)(2)(A)(i) of section 1919 of the Social Secu-
rity Act (42 U.S.C. 1396r(g)); 
(B) the surveying frequency specified 
under subsection (g)(2)(A)(iii) of such section 
1819 or under subsection (g)(2)(A)(iii) of such 
section 1919; or 
(C) surveys and investigations as required 
under subsection (g)(4) of such section 1819 or 
under subsection (g)(4) of such section 1919. 
(2) ACCOUNTABILITY AND STATE LAW.—Noth-
ing in the provisions of, or the amendments made 
by, this section shall be construed to impact the abil-
ity of a resident, the family of a resident, or a suc-
cessor in interest to hold a skilled nursing facility or 
nursing facility accountable or change protections 
granted under State law. 
SEC. 3. DEFINITIONS. 
In this Act: 
(1) 
APPROPRIATE
COMMITTEES
OF
CON-
GRESS.—The term ‘‘appropriate Committee of Con-
gress’’ means— 
(A) the Committee on Finance of the Sen-
ate; 
(B) the Committee on Health, Education, 
Labor, and Pensions of the Senate; 
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(C) the Special Committee on Aging of the 
Senate; 
(D) the Committee on Ways and Means of 
the House of Representatives; and 
(E) the Committee on Energy and Com-
merce of the House of Representatives. 
(2) NURSING
FACILITY.—The term ‘‘nursing 
facility’’ has the meaning given that term in section 
1919(a) of the Social Security Act (42 U.S.C. 
1396r(a)). 
(3) SKILLED
NURSING
FACILITY.—The term 
‘‘skilled nursing facility’’ has the meaning given that 
term in section 1819(a) of the Social Security Act 
(42 U.S.C. 1395i–3(a)). 
(4) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
Æ 
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