809 
‘‘(I) that were committed inside 
of the facility; and 
‘‘(II) with respect to such in-
stances of violations or crimes com-
mitted inside of the facility that were 
the violations or crimes of abuse, ne-
glect, and exploitation, criminal sexual 
abuse, or other violations or crimes 
that resulted in serious bodily injury. 
‘‘(viii) the number of civil monetary 
penalties levied against the facility, em-
ployees, contractors, and other agents. 
‘‘(ix) Any other information that the 
Secretary determines appropriate. 
The facility shall not make available under 
clause (ii) identifying information about com-
plainants or residents. 
‘‘(B) DEADLINE FOR PROVISION OF INFOR-
MATION.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), the Secretary shall en-
sure that the information described in sub-
paragraph (A) is included on such website 
(or a successor website) not later than 1
810 
year after the date of the enactment of this 
subsection. 
‘‘(ii) 
EXCEPTION.—The 
Secretary 
shall ensure that the information described 
in subparagraph (A)(i) and (A)(iii) is in-
cluded on such website (or a successor 
website) not later than 1 year after the 
dates on which the data are submitted to 
the 
Secretary 
pursuant 
to 
section 
1124(c)(4) and subsection (b)(8)(C), re-
spectively. 
‘‘(2) 
REVIEW
AND
MODIFICATION
OF 
WEBSITE.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish a process— 
‘‘(i) to review the accuracy, clarity of 
presentation, timeliness, and comprehen-
siveness of information reported on such 
website as of the day before the date of the 
enactment of this subsection; and 
‘‘(ii) not later than 1 year after the 
date of the enactment of this subsection, to 
modify or revamp such website in accord-
ance with the review conducted under 
clause (i).
811 
‘‘(B) CONSULTATION.—In conducting the 
review under subparagraph (A)(i), the Sec-
retary shall consult with— 
‘‘(i) State long-term care ombudsman 
programs; 
‘‘(ii) consumer advocacy groups; 
‘‘(iii) provider stakeholder groups; 
‘‘(iv) skilled nursing facility employees 
and their representatives; and 
‘‘(v) any other representatives of pro-
grams or groups the Secretary determines 
appropriate.’’. 
(2) TIMELINESS
OF
SUBMISSION
OF
SURVEY 
AND CERTIFICATION INFORMATION.— 
(A) IN GENERAL.—Section 1919(g)(5) of 
the Social Security Act (42 U.S.C. 1396r(g)(5)) 
is amended by adding at the end the following 
new subparagraph: 
‘‘(E) SUBMISSION OF SURVEY AND CER-
TIFICATION
INFORMATION
TO
THE
SEC-
RETARY.—In order to improve the timeliness of 
information made available to the public under 
subparagraph (A) and provided on the Nursing 
Home Compare Medicare website under sub-
section (i), each State shall submit information
812 
respecting any survey or certification rec-
ommendation made respecting a nursing facility 
(including any enforcement actions taken by the 
State or any Federal enforcement action rec-
ommended by the State) to the Secretary not 
later than the date on which the State sends 
such information to the facility. The Secretary 
shall use the information submitted under the 
preceding sentence to update the information 
provided on the Nursing Home Compare Medi-
care website as expeditiously as practicable but 
not less frequently than quarterly.’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by this paragraph shall take effect 1 year 
after the date of the enactment of this Act. 
(3) SPECIAL FOCUS FACILITY PROGRAM.—Sec-
tion 1919(f) of such Act is amended by adding at 
the end of the following new paragraph: 
‘‘(10) SPECIAL FOCUS FACILITY PROGRAM.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
conduct a special focus facility program for en-
forcement of requirements for nursing facilities 
that the Secretary has identified as having a 
poor compliance history or that substantially
813 
failed to meet applicable requirements of this 
Act. 
‘‘(B) PERIODIC
SURVEYS.—Under such 
program the Secretary shall conduct surveys of 
each facility in the program not less often than 
once every 6 months.’’. 
(c) AVAILABILITY OF REPORTS ON SURVEYS, CER-
TIFICATIONS, AND COMPLAINT INVESTIGATIONS.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(d)(1) of the Social Security Act (42 U.S.C. 
1395i–3(d)(1)), as amended by sections 1411 and 
1412, is amended by adding at the end the following 
new subparagraph: 
‘‘(D) AVAILABILITY OF SURVEY, CERTIFI-
CATION, AND COMPLAINT INVESTIGATION RE-
PORTS.—A skilled nursing facility must— 
‘‘(i) have reports with respect to any 
surveys, certifications, and complaint in-
vestigations made respecting the facility 
during the 3 preceding years available for 
any individual to review upon request; and 
‘‘(ii) post notice of the availability of 
such reports in areas of the facility that 
are prominent and accessible to the public.
814 
The facility shall not make available under 
clause (i) identifying information about com-
plainants or residents.’’. 
(2) NURSING FACILITIES.—Section 1919(d)(1) 
of the Social Security Act (42 U.S.C. 1396r(d)(1)), 
as amended by sections 1411 and 1412, is amended 
by adding at the end the following new subpara-
graph: 
‘‘(D) AVAILABILITY OF SURVEY, CERTIFI-
CATION, AND COMPLAINT INVESTIGATION RE-
PORTS.—A nursing facility must— 
‘‘(i) have reports with respect to any 
surveys, certifications, and complaint in-
vestigations made respecting the facility 
during the 3 preceding years available for 
any individual to review upon request; and 
‘‘(ii) post notice of the availability of 
such reports in areas of the facility that 
are prominent and accessible to the public. 
The facility shall not make available under 
clause (i) identifying information about com-
plainants or residents.’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall take effect 1 year after the 
date of the enactment of this Act.
815 
(d) GUIDANCE TO STATES ON FORM 2567 STATE IN-
SPECTION REPORTS AND COMPLAINT INVESTIGATION RE-
PORTS.— 
(1) GUIDANCE.—The Secretary of Health and 
Human Services (in this subtitle referred to as the 
‘‘Secretary’’) shall provide guidance to States on 
how States can establish electronic links to Form 
2567 State inspection reports (or a successor form), 
complaint investigation reports, and a facility’s plan 
of correction or other response to such Form 2567 
State inspection reports (or a successor form) on the 
Internet website of the State that provides informa-
tion on skilled nursing facilities and nursing facili-
ties and the Secretary shall, if possible, include such 
information on Nursing Home Compare. 
(2) REQUIREMENT.—Section 1902(a)(9) of the 
Social Security Act (42 U.S.C. 1396a(a)(9)) is 
amended— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (B); 
(B) by striking the semicolon at the end of 
subparagraph (C) and inserting ‘‘, and’’; and 
(C) by adding at the end the following new 
subparagraph:
816 
‘‘(D) that the State maintain a consumer- 
oriented website providing useful information to 
consumers regarding all skilled nursing facili-
ties and all nursing facilities in the State, in-
cluding for each facility, Form 2567 State in-
spection reports (or a successor form), com-
plaint investigation reports, the facility’s plan of 
correction, and such other information that the 
State or the Secretary considers useful in as-
sisting the public to assess the quality of long 
term care options and the quality of care pro-
vided by individual facilities;’’. 
(3) DEFINITIONS.—In this subsection: 
(A) NURSING FACILITY.—The term ‘‘nurs-
ing facility’’ has the meaning given such term 
in section 1919(a) of the Social Security Act 
(42 U.S.C. 1396r(a)). 
(B) SECRETARY.—The term ‘‘Secretary’’ 
means the Secretary of Health and Human 
Services. 
(C) SKILLED
NURSING
FACILITY.—The 
term ‘‘skilled nursing facility’’ has the meaning 
given such term in section 1819(a) of the Social 
Security Act (42 U.S.C. 1395i–3(a)).
817 
SEC. 1414. REPORTING OF EXPENDITURES. 
Section 1888 of the Social Security Act (42 U.S.C. 
1395yy) is amended by adding at the end the following 
new subsection: 
‘‘(f) REPORTING
OF
DIRECT
CARE
EXPENDI-
TURES.— 
‘‘(1) IN GENERAL.—For cost reports submitted 
under this title for cost reporting periods beginning 
on or after the date that is no more than two years 
after the redesign of the report specified in subpara-
graph (2), skilled nursing facilities shall— 
‘‘(A) separately report expenditures for 
wages and benefits for direct care staff (break-
ing out (at a minimum) registered nurses, li-
censed professional nurses, certified nurse as-
sistants, and other medical and therapy staff); 
and 
‘‘(B) take into account agency and con-
tract staff in a manner to be determined by the 
Administrator. 
‘‘(2) MODIFICATION OF FORM.—The Secretary, 
in consultation with private sector accountants expe-
rienced with skilled nursing facility cost reports, 
shall redesign such reports to meet the requirement 
of paragraph (1) not later than 2 years after the 
date of the enactment of this subsection.
818 
‘‘(3) CATEGORIZATION
BY
FUNCTIONAL
AC-
COUNTS.—Beginning with cost reports submitted 
under paragraph (1), the Secretary, working in con-
sultation with the Medicare Payment Advisory Com-
mission, the Inspector General of the Department of 
Health and Human Services, and other expert par-
ties the Secretary determines appropriate, shall cat-
egorize the expenditures listed on cost reports, as 
modified under paragraph (1), submitted by skilled 
nursing facilities, regardless of any source of pay-
ment for such expenditures, for each skilled nursing 
facility into the following functional accounts on an 
annual basis: 
‘‘(A) Spending on direct care services (in-
cluding nursing, therapy, and medical services). 
‘‘(B) Spending on indirect care (including 
housekeeping and dietary services). 
‘‘(C) Capital assets (including building and 
land costs). 
‘‘(D) Administrative services costs. 
‘‘(4) AVAILABILITY
OF
INFORMATION
SUB-
MITTED.—The Secretary shall establish procedures 
to make information on expenditures submitted 
under this subsection readily available to interested 
parties upon request, subject to such requirements
819 
as the Secretary may specify under the procedures 
established under this paragraph.’’. 
SEC. 1415. STANDARDIZED COMPLAINT FORM. 
(a) SKILLED NURSING FACILITIES.— 
(1) DEVELOPMENT BY THE SECRETARY.—Sec-
tion 1819(f) of the Social Security Act (42 U.S.C. 
1395i–3(f)), as amended by section 1413(a)(3), is 
amended by adding at the end the following new 
paragraph: 
‘‘(9) STANDARDIZED
COMPLAINT
FORM.—The 
Secretary shall develop a standardized complaint 
form for use by a resident (or a person acting on the 
resident’s behalf) in filing a complaint with a State 
survey and certification agency and a State long- 
term care ombudsman program with respect to a 
skilled nursing facility.’’. 
(2) STATE
REQUIREMENTS.—Section 1819(e) 
of the Social Security Act (42 U.S.C. 1395i–3(e)) is 
amended by adding at the end the following new 
paragraph: 
‘‘(6) COMPLAINT
PROCESSES
AND
WHISTLE- 
BLOWER PROTECTION.— 
‘‘(A) COMPLAINT FORMS.—The State must 
make the standardized complaint form devel-
820 
oped under subsection (f)(9) available upon re-
quest to— 
‘‘(i) a resident of a skilled nursing fa-
cility; 
‘‘(ii) any person acting on the resi-
dent’s behalf; and 
‘‘(iii) any person who works at a 
skilled nursing facility or is a representa-
tive of such a worker. 
‘‘(B) COMPLAINT RESOLUTION PROCESS.— 
The State must establish a complaint resolution 
process in order to ensure that a resident, the 
legal representative of a resident of a skilled 
nursing facility, or other responsible party is 
not retaliated against if the resident, legal rep-
resentative, or responsible party has com-
plained, in good faith, about the quality of care 
or other issues relating to the skilled nursing 
facility, that the legal representative of a resi-
dent of a skilled nursing facility or other re-
sponsible party is not denied access to such 
resident or otherwise retaliated against if such 
representative party has complained, in good 
faith, about the quality of care provided by the 
facility or other issues relating to the facility,
821 
and that a person who works at a skilled nurs-
ing facility is not retaliated against if the work-
er has complained, in good faith, about quality 
of care or services or an issue relating to the 
quality of care or services provided at the facil-
ity, whether the resident, legal representative, 
other responsible party, or worker used the 
form developed under subsection (f)(9) or some 
other method for submitting the complaint. 
Such complaint resolution process shall in-
clude— 
‘‘(i) procedures to assure accurate 
tracking of complaints received, including 
notification to the complainant that a com-
plaint has been received; 
‘‘(ii) procedures to determine the like-
ly severity of a complaint and for the in-
vestigation of the complaint; 
‘‘(iii) deadlines for responding to a 
complaint and for notifying the complain-
ant of the outcome of the investigation; 
and 
‘‘(iv) procedures to ensure that the 
identity of the complainant will be kept 
confidential.
822 
‘‘(C) WHISTLEBLOWER PROTECTION.— 
‘‘(i) PROHIBITION AGAINST RETALIA-
TION.—No person who works at a skilled 
nursing facility may be penalized, discrimi-
nated, or retaliated against with respect to 
any aspect of employment, including dis-
charge, promotion, compensation, terms, 
conditions, or privileges of employment, or 
have a contract for services terminated, be-
cause the person (or anyone acting at the 
person’s request) complained, in good 
faith, about the quality of care or services 
provided by a skilled nursing facility or 
about other issues relating to quality of 
care or services, whether using the form 
developed under subsection (f)(9) or some 
other method for submitting the complaint. 
‘‘(ii) RETALIATORY
REPORTING.—A 
skilled nursing facility may not file a com-
plaint or a report against a person who 
works (or has worked at the facility) with 
the appropriate State professional discipli-
nary agency because the person (or anyone 
acting at the person’s request) complained 
in good faith, as described in clause (i).
823 
‘‘(iii) RELIEF.—Any person aggrieved 
by a violation of clause (i) or clause (ii) 
may, in a civil action, obtain all appro-
priate relief, including reinstatement, reim-
bursement of lost wages, compensation, 
and benefits, and exemplary damages 
where warranted, and such other relief as 
the court deems appropriate, as well as 
costs of suit and reasonable attorney and 
expert witness fees. 
‘‘(iv) RIGHTS
NOT
WAIVABLE.—The 
rights protected by this paragraph may not 
be diminished by contract or other agree-
ment, and nothing in this paragraph shall 
be construed to diminish any greater or 
additional protection provided by Federal 
or State law or by contract or other agree-
ment. 
‘‘(v) REQUIREMENT TO POST NOTICE 
OF
EMPLOYEE
RIGHTS.—Each 
skilled 
nursing facility shall post conspicuously in 
an appropriate location a sign (in a form 
specified by the Secretary) specifying the 
rights of persons under this paragraph and 
including a statement that an employee
824 
may file a complaint with the Secretary 
against a skilled nursing facility that vio-
lates the provisions of this paragraph and 
information with respect to the manner of 
filing such a complaint. 
‘‘(D) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as pre-
venting a resident of a skilled nursing facility 
(or a person acting on the resident’s behalf) 
from submitting a complaint in a manner or 
format other than by using the standardized 
complaint form developed under subsection 
(f)(9) (including submitting a complaint orally). 
‘‘(E) GOOD
FAITH
DEFINED.—For pur-
poses of this paragraph, an individual shall be 
deemed to be acting in good faith with respect 
to the filing of a complaint if the individual rea-
sonably believes— 
‘‘(i) the information reported or dis-
closed in the complaint is true; and 
‘‘(ii) the violation of this title has oc-
curred or may occur in relation to such in-
formation.’’. 
(b) NURSING FACILITIES.—
825 
(1) DEVELOPMENT BY THE SECRETARY.—Sec-
tion 1919(f) of the Social Security Act (42 U.S.C. 
1395i–3(f)), as amended by section 1413(b), is 
amended by adding at the end the following new 
paragraph: 
‘‘(11) STANDARDIZED COMPLAINT FORM.—The 
Secretary shall develop a standardized complaint 
form for use by a resident (or a person acting on the 
resident’s behalf) in filing a complaint with a State 
survey and certification agency and a State long- 
term care ombudsman program with respect to a 
nursing facility.’’. 
(2) STATE
REQUIREMENTS.—Section 1919(e) 
of the Social Security Act (42 U.S.C. 1395i–3(e)) is 
amended by adding at the end the following new 
paragraph: 
‘‘(8) COMPLAINT
PROCESSES
AND
WHISTLE-
BLOWER PROTECTION.— 
‘‘(A) COMPLAINT FORMS.—The State must 
make the standardized complaint form devel-
oped under subsection (f)(11) available upon re-
quest to— 
‘‘(i) a resident of a nursing facility; 
‘‘(ii) any person acting on the resi-
dent’s behalf; and
826 
‘‘(iii) any person who works at a nurs-
ing facility or a representative of such a 
worker. 
‘‘(B) COMPLAINT RESOLUTION PROCESS.— 
The State must establish a complaint resolution 
process in order to ensure that a resident, the 
legal representative of a resident of a nursing 
facility, or other responsible party is not retali-
ated against if the resident, legal representa-
tive, or responsible party has complained, in 
good faith, about the quality of care or other 
issues relating to the nursing facility, that the 
legal representative of a resident of a nursing 
facility or other responsible party is not denied 
access to such resident or otherwise retaliated 
against if such representative party has com-
plained, in good faith, about the quality of care 
provided by the facility or other issues relating 
to the facility, and that a person who works at 
a nursing facility is not retaliated against if the 
worker has complained, in good faith, about 
quality of care or services or an issue relating 
to the quality of care or services provided at the 
facility, whether the resident, legal representa-
tive, other responsible party, or worker used the
827 
form developed under subsection (f)(11) or 
some other method for submitting the com-
plaint. Such complaint resolution process shall 
include— 
‘‘(i) procedures to assure accurate 
tracking of complaints received, including 
notification to the complainant that a com-
plaint has been received; 
‘‘(ii) procedures to determine the like-
ly severity of a complaint and for the in-
vestigation of the complaint; 
‘‘(iii) deadlines for responding to a 
complaint and for notifying the complain-
ant of the outcome of the investigation; 
and 
‘‘(iv) procedures to ensure that the 
identity of the complainant will be kept 
confidential. 
‘‘(C) WHISTLEBLOWER PROTECTION.— 
‘‘(i) PROHIBITION AGAINST RETALIA-
TION.—No person who works at a nursing 
facility may be penalized, discriminated, or 
retaliated against with respect to any as-
pect of employment, including discharge, 
promotion, compensation, terms, condi-
828 
tions, or privileges of employment, or have 
a contract for services terminated, because 
the person (or anyone acting at the per-
son’s request) complained, in good faith, 
about the quality of care or services pro-
vided by a nursing facility or about other 
issues relating to quality of care or serv-
ices, whether using the form developed 
under subsection (f)(11) or some other 
method for submitting the complaint. 
‘‘(ii) RETALIATORY
REPORTING.—A 
nursing facility may not file a complaint or 
a report against a person who works (or 
has worked at the facility with the appro-
priate State professional disciplinary agen-
cy because the person (or anyone acting at 
the person’s request) complained in good 
faith, as described in clause (i). 
‘‘(iii) RELIEF.—Any person aggrieved 
by a violation of clause (i) or clause (ii) 
may, in a civil action, obtain all appro-
priate relief, including reinstatement, reim-
bursement of lost wages, compensation, 
and benefits, and exemplary damages 
where warranted, and such other relief as
829 
the court deems appropriate, as well as 
costs of suit and reasonable attorney and 
expert witness fees. 
‘‘(iv) RIGHTS
NOT
WAIVABLE.—The 
rights protected by this paragraph may not 
be diminished by contract or other agree-
ment, and nothing in this paragraph shall 
be construed to diminish any greater or 
additional protection provided by Federal 
or State law or by contract or other agree-
ment. 
‘‘(v) REQUIREMENT TO POST NOTICE 
OF EMPLOYEE RIGHTS.—Each nursing fa-
cility shall post conspicuously in an appro-
priate location a sign (in a form specified 
by the Secretary) specifying the rights of 
persons under this paragraph and includ-
ing a statement that an employee may file 
a complaint with the Secretary against a 
nursing facility that violates the provisions 
of this paragraph and information with re-
spect to the manner of filing such a com-
plaint. 
‘‘(D) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as pre-
830 
venting a resident of a nursing facility (or a 
person acting on the resident’s behalf) from 
submitting a complaint in a manner or format 
other than by using the standardized complaint 
form developed under subsection (f)(11) (in-
cluding submitting a complaint orally). 
‘‘(E) GOOD
FAITH
DEFINED.—For pur-
poses of this paragraph, an individual shall be 
deemed to be acting in good faith with respect 
to the filing of a complaint if the individual rea-
sonably believes— 
‘‘(i) the information reported or dis-
closed in the complaint is true; and 
‘‘(ii) the violation of this title has oc-
curred or may occur in relation to such in-
formation.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of the 
enactment of this Act. 
SEC. 1416. ENSURING STAFFING ACCOUNTABILITY. 
(a) 
SKILLED
NURSING
FACILITIES.—Section 
1819(b)(8) of the Social Security Act (42 U.S.C. 1395i– 
3(b)(8)) is amended by adding at the end the following 
new subparagraph:
831 
‘‘(C) SUBMISSION OF STAFFING INFORMA-
TION BASED ON PAYROLL DATA IN A UNIFORM 
FORMAT.—On and after the first day of the 
first calendar quarter beginning after the date 
that is 2 years after the date of enactment of 
this subparagraph, and after consulting with 
State long-term care ombudsman programs, 
consumer advocacy groups, provider stakeholder 
groups, employees and their representatives, 
and other parties the Secretary deems appro-
priate, the Secretary shall require a skilled 
nursing facility to electronically submit to the 
Secretary direct care staffing information (in-
cluding information with respect to agency and 
contract staff) based on payroll and other 
verifiable and auditable data in a uniform for-
mat (according to specifications established by 
the Secretary in consultation with such pro-
grams, groups, and parties). Such specifications 
shall require that the information submitted 
under the preceding sentence— 
‘‘(i) specify the category of work a 
certified employee performs (such as 
whether the employee is a registered nurse, 
licensed practical nurse, licensed vocational
832 
nurse, certified nursing assistant, thera-
pist, or other medical personnel); 
‘‘(ii) include resident census data and 
information on resident case mix; 
‘‘(iii) include a regular reporting 
schedule; and 
‘‘(iv) include information on employee 
turnover and tenure and on the hours of 
care provided by each category of certified 
employees referenced in clause (i) per resi-
dent per day. 
Nothing in this subparagraph shall be con-
strued as preventing the Secretary from requir-
ing submission of such information with respect 
to specific categories, such as nursing staff, be-
fore other categories of certified employees. In-
formation under this subparagraph with respect 
to agency and contract staff shall be kept sepa-
rate from information on employee staffing.’’. 
(b) NURSING FACILITIES.—Section 1919(b)(8) of the 
Social Security Act (42 U.S.C. 1396r(b)(8)) is amended 
by adding at the end the following new subparagraph: 
‘‘(C) SUBMISSION OF STAFFING INFORMA-
TION BASED ON PAYROLL DATA IN A UNIFORM 
FORMAT.—On and after the first day of the
833 
first calendar quarter beginning after the date 
that is 2 years after the date of enactment of 
this subparagraph, and after consulting with 
State long-term care ombudsman programs, 
consumer advocacy groups, provider stakeholder 
groups, employees and their representatives, 
and other parties the Secretary deems appro-
priate, the Secretary shall require a nursing fa-
cility to electronically submit to the Secretary 
direct care staffing information (including in-
formation with respect to agency and contract 
staff) based on payroll and other verifiable and 
auditable data in a uniform format (according 
to specifications established by the Secretary in 
consultation with such programs, groups, and 
parties). Such specifications shall require that 
the information submitted under the preceding 
sentence— 
‘‘(i) specify the category of work a 
certified employee performs (such as 
whether the employee is a registered nurse, 
licensed practical nurse, licensed vocational 
nurse, certified nursing assistant, thera-
pist, or other medical personnel);
834 
‘‘(ii) include resident census data and 
information on resident case mix; 
‘‘(iii) include a regular reporting 
schedule; and 
‘‘(iv) include information on employee 
turnover and tenure and on the hours of 
care provided by each category of certified 
employees referenced in clause (i) per resi-
dent per day. 
Nothing in this subparagraph shall be con-
strued as preventing the Secretary from requir-
ing submission of such information with respect 
to specific categories, such as nursing staff, be-
fore other categories of certified employees. In-
formation under this subparagraph with respect 
to agency and contract staff shall be kept sepa-
rate from information on employee staffing.’’. 
SEC. 1417. NATIONWIDE PROGRAM FOR NATIONAL AND 
STATE BACKGROUND CHECKS ON DIRECT PA-
TIENT ACCESS EMPLOYEES OF LONG-TERM 
CARE FACILITIES AND PROVIDERS. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’), shall establish a program to identify efficient, ef-
fective, and economical procedures for long term care fa-
835 
cilities or providers to conduct background checks on pro-
spective direct patient access employees on a nationwide 
basis (in this subsection, such program shall be referred 
to as the ‘‘nationwide program’’). The Secretary shall 
carry out the nationwide program under similar terms and 
conditions as the pilot program under section 307 of the 
Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (Public Law 108–173; 117 Stat. 
2257), including the prohibition on hiring abusive workers 
and the authorization of the imposition of penalties by a 
participating State under subsections (b)(3)(A) and 
(b)(6), respectively, of such section 307. The program 
under this subsection shall contain the following modifica-
tions to such pilot program: 
(1) AGREEMENTS.— 
(A) NEWLY PARTICIPATING STATES.—The 
Secretary shall enter into agreements with each 
State— 
(i) that the Secretary has not entered 
into an agreement with under subsection 
(c)(1) of such section 307; 
(ii) that agrees to conduct background 
checks under the nationwide program on a 
Statewide basis; and
836 
(iii) that submits an application to the 
Secretary containing such information and 
at such time as the Secretary may specify. 
Under such an agreement a State may 
agree to cover and reimburse each long- 
term care facility or provider for all costs 
attributable to conducting background 
checks and screening described in this sub-
section that were not otherwise required to 
be conducted by such long-term care facil-
ity or provider before the enactment of this 
subsection, except that Federal funding 
with respect to such reimbursement shall 
be limited to the amount made available to 
the State from funds under subsection 
(b)(1). 
(B) CERTAIN PREVIOUSLY PARTICIPATING 
STATES.—The Secretary shall enter into agree-
ments with each State— 
(i) that the Secretary has entered into 
an agreement with under such subsection 
(c)(1); 
(ii) that agrees to conduct background 
checks under the nationwide program on a 
Statewide basis; and
837 
(iii) that submits an application to the 
Secretary containing such information and 
at such time as the Secretary may specify. 
Under such an agreement a State may 
agree to cover and reimburse each long- 
term care facility or provider for all costs 
attributable to conducting background 
checks and screening described in this sub-
section that were not otherwise required to 
be conducted by such long-term care facil-
ity or provider before the enactment of this 
subsection, except that Federal funding 
with respect to such reimbursement shall 
be limited to the amount made available to 
the State from funds under subsection 
(b)(1). 
(2) NONAPPLICATION
OF
SELECTION
CRI-
TERIA.—The selection criteria required under sub-
section (c)(3)(B) of such section 307 shall not apply. 
(3) REQUIRED FINGERPRINT CHECK AS PART 
OF
CRIMINAL
BACKGROUND
CHECK.—The proce-
dures established under subsection (b)(1) of such 
section 307 shall— 
(A) require that the long-term care facility 
or provider (or the designated agent of the
838 
long-term care facility or provider) obtain State 
and national criminal or other background 
checks on the prospective employee through 
such means as the Secretary determines appro-
priate that utilize a search of State-based abuse 
and neglect registries and databases, including 
the abuse and neglect registries of another 
State in the case where a prospective employee 
previously resided in that State, State criminal 
history records, the records of any proceedings 
in the State that may contain disqualifying in-
formation about prospective employees (such as 
proceedings conducted by State professional li-
censing and disciplinary boards and State Med-
icaid Fraud Control Units), and Federal crimi-
nal history records, including a fingerprint 
check using the Integrated Automated Finger-
print Identification System of the Federal Bu-
reau of Investigation; and 
(B) require States to describe and test 
methods that reduce duplicative fingerprinting, 
including providing for the development of ‘‘rap 
back’’ capability by the State such that, if a di-
rect patient access employee of a long-term care 
facility or provider is convicted of a crime fol-
839 
lowing the initial criminal history background 
check conducted with respect to such employee, 
and the employee’s fingerprints match the 
prints on file with the State law enforcement 
department, the department will immediately 
inform the State and the State will immediately 
inform the long-term care facility or provider 
which employs the direct patient access em-
ployee of such conviction. 
(4) STATE REQUIREMENTS.—An agreement en-
tered into under paragraph (1) shall require that a 
participating State— 
(A) be responsible for monitoring compli-
ance with the requirements of the nationwide 
program; 
(B) have procedures in place to— 
(i) conduct screening and criminal or 
other background checks under the nation-
wide program in accordance with the re-
quirements of this section; 
(ii) monitor compliance by long-term 
care facilities and providers with the proce-
dures and requirements of the nationwide 
program;
840 
(iii) as appropriate, provide for a pro-
visional period of employment by a long- 
term care facility or provider of a direct 
patient access employee, not to exceed 60 
days, pending completion of the required 
criminal history background check and, in 
the case where the employee has appealed 
the results of such background check, 
pending completion of the appeals process, 
during which the employee shall be subject 
to direct on-site supervision (in accordance 
with procedures established by the State to 
ensure that a long-term care facility or 
provider furnishes such direct on-site su-
pervision); 
(iv) provide an independent process by 
which a provisional employee or an em-
ployee may appeal or dispute the accuracy 
of the information obtained in a back-
ground check performed under the nation-
wide program, including the specification 
of criteria for appeals for direct patient ac-
cess employees found to have disqualifying 
information which shall include consider-
ation of the passage of time, extenuating
841 
circumstances, demonstration of rehabilita-
tion, and relevancy of the particular dis-
qualifying information with respect to the 
current employment of the individual; 
(v) provide for the designation of a 
single State agency as responsible for— 
(I) overseeing the coordination of 
any State and national criminal his-
tory background checks requested by 
a long-term care facility or provider 
(or the designated agent of the long- 
term care facility or provider) utilizing 
a search of State and Federal crimi-
nal history records, including a finger-
print check of such records; 
(II) overseeing the design of ap-
propriate privacy and security safe-
guards for use in the review of the re-
sults of any State or national criminal 
history background checks conducted 
regarding a prospective direct patient 
access employee to determine whether 
the employee has any conviction for a 
relevant crime;
842 
(III) immediately reporting to 
the long-term care facility or provider 
that requested the criminal history 
background check the results of such 
review; and 
(IV) in the case of an employee 
with a conviction for a relevant crime 
that is subject to reporting under sec-
tion 1128E of the Social Security Act 
(42 U.S.C. 1320a–7e), reporting the 
existence of such conviction to the 
database established under that sec-
tion; 
(vi) determine which individuals are 
direct patient access employees (as defined 
in paragraph (6)(B)) for purposes of the 
nationwide program; 
(vii) as appropriate, specify offenses, 
including convictions for violent crimes, for 
purposes of the nationwide program; and 
(viii) describe and test methods that 
reduce duplicative fingerprinting, including 
providing for the development of ‘‘rap 
back’’ capability such that, if a direct pa-
tient access employee of a long-term care
843 
facility or provider is convicted of a crime 
following the initial criminal history back-
ground check conducted with respect to 
such employee, and the employee’s finger-
prints match the prints on file with the 
State law enforcement department— 
(I) the department will imme-
diately inform the State agency des-
ignated under clause (v) and such 
agency will immediately inform the fa-
cility or provider which employs the 
direct patient access employee of such 
conviction; and 
(II) the State will provide, or will 
require the facility to provide, to the 
employee a copy of the results of the 
criminal history background check 
conducted with respect to the em-
ployee at no charge in the case where 
the individual requests such a copy. 
Background checks and screenings under 
this subsection shall be valid for a period 
of no longer than 2 years, as determined 
by the State and approved by the Sec-
retary.
844 
(5) PAYMENTS.— 
(A) NEWLY PARTICIPATING STATES.— 
(i) IN GENERAL.—As part of the ap-
plication submitted by a State under para-
graph (1)(A)(iii), the State shall guar-
antee, with respect to the costs to be in-
curred by the State in carrying out the na-
tionwide program, that the State will make 
available (directly or through donations 
from public or private entities) a particular 
amount of non-Federal contributions, as a 
condition of receiving the Federal match 
under clause (ii). 
(ii) FEDERAL MATCH.—The payment 
amount to each State that the Secretary 
enters into an agreement with under para-
graph (1)(A) shall be 3 times the amount 
that the State guarantees to make avail-
able under clause (i). 
(B) 
PREVIOUSLY
PARTICIPATING 
STATES.— 
(i) IN GENERAL.—As part of the ap-
plication submitted by a State under para-
graph (1)(B)(iii), the State shall guar-
antee, with respect to the costs to be in-
845 
curred by the State in carrying out the na-
tionwide program, that the State will make 
available (directly or through donations 
from public or private entities) a particular 
amount of non-Federal contributions, as a 
condition of receiving the Federal match 
under clause (ii). 
(ii) FEDERAL MATCH.—The payment 
amount to each State that the Secretary 
enters into an agreement with under para-
graph (1)(B) shall be 3 times the amount 
that the State guarantees to make avail-
able under clause (i). 
(6) DEFINITIONS.—Under the nationwide pro-
gram: 
(A) LONG-TERM CARE FACILITY OR PRO-
VIDER.—The term ‘‘long-term care facility or 
provider’’ means the following facilities or pro-
viders which receive payment for services under 
title XVIII or XIX of the Social Security Act: 
(i) A skilled nursing facility (as de-
fined in section 1819(a) of the Social Secu-
rity Act (42 U.S.C. 1395i–3(a))).
846 
(ii) A nursing facility (as defined in 
section 1919(a) of such Act (42 U.S.C. 
1396r(a))). 
(iii) A home health agency. 
(iv) A provider of hospice care (as de-
fined in section 1861(dd)(1) of such Act 
(42 U.S.C. 1395x(dd)(1))). 
(v) A long-term care hospital (as de-
scribed in section 1886(d)(1)(B)(iv) of 
such 
Act 
(42 
U.S.C. 
1395ww(d)(1)(B)(iv))). 
(vi) A provider of personal care serv-
ices. 
(vii) A provider of adult day care. 
(viii) A residential care provider that 
arranges for, or directly provides, long- 
term care services, including an assisted 
living facility that provides a nursing home 
level of care conveyed by State licensure or 
State definition. 
(ix) An intermediate care facility for 
the mentally retarded (as defined in sec-
tion 1905(d) of such Act (42 U.S.C. 
1396d(d))).
848 
(i) a review of the various procedures 
implemented by participating States for 
long-term care facilities or providers, in-
cluding staffing agencies, to conduct back-
ground checks of direct patient access em-
ployees and identify the most efficient, ef-
fective, and economical procedures for con-
ducting such background checks; 
(ii) an assessment of the costs of con-
ducting such background checks (including 
start-up and administrative costs); 
(iii) a determination of the extent to 
which conducting such background checks 
leads to any unintended consequences, in-
cluding a reduction in the available work-
force for such facilities or providers; 
(iv) an assessment of the impact of 
the program on reducing the number of in-
cidents of neglect, abuse, and misappro-
priation of resident property to the extent 
practicable; and 
(v) an evaluation of other aspects of 
the program, as determined appropriate by 
the Secretary.
849 
(B) REPORT.—Not later than 180 days 
after the completion of the nationwide program, 
the Inspector General of the Department of 
Health and Human Services shall submit a re-
port to Congress containing the results of the 
evaluation conducted under subparagraph (A). 
(b) FUNDING.— 
(1) NOTIFICATION.—The Secretary of Health 
and Human Services shall notify the Secretary of 
the Treasury of the amount necessary to carry out 
the nationwide program under this section, including 
costs for the Department of Health and Human 
Services to administer and evaluate the program, for 
the period of fiscal years 2010 through 2012, except 
that in no case shall such amount exceed 
$160,000,000. 
(2) TRANSFER OF FUNDS.—Out of any funds 
in the Treasury not otherwise appropriated, the Sec-
retary of the Treasury shall provide for the transfer 
to the Secretary of Health and Human Services of 
the amount specified as necessary to carry out the 
nationwide program under paragraph (1). Such 
amount shall remain available until expended.
850 
PART 2—TARGETING ENFORCEMENT 
SEC. 1421. CIVIL MONEY PENALTIES. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819(h)(2)(B)(ii) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395i– 
3(h)(2)(B)(ii)) is amended to read as follows: 
‘‘(ii) AUTHORITY WITH RESPECT TO 
CIVIL MONEY PENALTIES.— 
‘‘(I) AMOUNT.—The Secretary 
may impose a civil money penalty in 
the applicable per instance or per day 
amount (as defined in subclause (II) 
and (III)) for each day or instance, 
respectively, of noncompliance (as de-
termined appropriate by the Sec-
retary). 
‘‘(II) APPLICABLE PER INSTANCE 
AMOUNT.—In this clause, the term 
‘applicable 
per 
instance 
amount’ 
means— 
‘‘(aa) in the case where the 
deficiency is found to be a direct 
proximate cause of death of a 
resident 
of 
the 
facility, 
an 
amount not to exceed $100,000.
851 
‘‘(bb) in each case of a defi-
ciency where the facility is cited 
for actual harm or immediate 
jeopardy, an amount not less 
than $3,050 and not more than 
$25,000; and 
‘‘(cc) in each case of any 
other deficiency, an amount not 
less than $250 and not to exceed 
$3050. 
‘‘(III) APPLICABLE
PER
DAY 
AMOUNT.—In this clause, the term 
‘applicable per day amount’ means— 
‘‘(aa) in each case of a defi-
ciency where the facility is cited 
for actual harm or immediate 
jeopardy, an amount not less 
than $3,050 and not more than 
$25,000; and 
‘‘(bb) in each case of any 
other deficiency, an amount not 
less than $250 and not to exceed 
$3,050. 
‘‘(IV) 
REDUCTION
OF
CIVIL 
MONEY PENALTIES IN CERTAIN CIR-
852 
CUMSTANCES.—Subject to subclauses 
(V) and (VI), in the case where a fa-
cility self-reports and promptly cor-
rects a deficiency for which a penalty 
was imposed under this clause not 
later than 10 calendar days after the 
date of such imposition, the Secretary 
may reduce the amount of the penalty 
imposed by not more than 50 percent. 
‘‘(V) PROHIBITION
ON
REDUC-
TION FOR CERTAIN DEFICIENCIES.— 
‘‘(aa) 
REPEAT
DEFI-
CIENCIES.—The Secretary may 
not reduce under subclause (IV) 
the amount of a penalty if the 
deficiency is a repeat deficiency. 
‘‘(bb) CERTAIN OTHER DE-
FICIENCIES.—The Secretary may 
not reduce under subclause (IV) 
the amount of a penalty if the 
penalty is imposed for a defi-
ciency described in subclause 
(II)(aa) or (III)(aa) and the ac-
tual harm or widespread harm 
immediately 
jeopardizes 
the
853 
health or safety of a resident or 
residents of the facility, or if the 
penalty is imposed for a defi-
ciency described in subclause 
(II)(bb). 
‘‘(VI) LIMITATION
ON
AGGRE-
GATE
REDUCTIONS.—The aggregate 
reduction in a penalty under sub-
clause (IV) may not exceed 35 percent 
on the basis of self-reporting, on the 
basis of a waiver of an appeal (as pro-
vided for under regulations under sec-
tion 488.436 of title 42, Code of Fed-
eral Regulations), or on the basis of 
both. 
‘‘(VII) COLLECTION
OF
CIVIL 
MONEY PENALTIES.—In the case of a 
civil money penalty imposed under 
this clause, the Secretary— 
‘‘(aa) subject to item (cc), 
shall, not later than 30 days 
after the date of imposition of 
the penalty, provide the oppor-
tunity for the facility to partici-
pate in an independent informal
854 
dispute resolution process, estab-
lished by the State survey agen-
cy, which generates a written 
record prior to the collection of 
such penalty, but such oppor-
tunity shall not affect the respon-
sibility of the State survey agen-
cy for making final recommenda-
tions for such penalties; 
‘‘(bb) in the case where the 
penalty is imposed for each day 
of noncompliance, shall not im-
pose a penalty for any day during 
the period beginning on the ini-
tial day of the imposition of the 
penalty and ending on the day on 
which the informal dispute reso-
lution process under item (aa) is 
completed; 
‘‘(cc) may provide for the 
collection of such civil money 
penalty and the placement of 
such amounts collected in an es-
crow account under the direction 
of the Secretary on the earlier of
855 
the date on which the informal 
dispute resolution process under 
item (aa) is completed or the 
date that is 90 days after the 
date of the imposition of the pen-
alty; 
‘‘(dd) may provide that such 
amounts collected are kept in 
such account pending the resolu-
tion of any subsequent appeals; 
‘‘(ee) in the case where the 
facility successfully appeals the 
penalty, may provide for the re-
turn of such amounts collected 
(plus interest) to the facility; and 
‘‘(ff) in the case where all 
such appeals are unsuccessful, 
may provide that some portion of 
such amounts collected may be 
used to support activities that 
benefit residents, including as-
sistance to support and protect 
residents of a facility that closes 
(voluntarily or involuntarily) or is 
decertified (including offsetting
856 
costs of relocating residents to 
home and community-based set-
tings or another facility), projects 
that support resident and family 
councils and other consumer in-
volvement in assuring quality 
care in facilities, and facility im-
provement initiatives approved by 
the Secretary (including joint 
training of facility staff and sur-
veyors, technical assistance for 
facilities under quality assurance 
programs, the appointment of 
temporary 
management, 
and 
other activities approved by the 
Secretary). 
‘‘(VIII) PROCEDURE.—The pro-
visions of section 1128A (other than 
subsections (a) and (b) and except to 
the extent that such provisions require 
a hearing prior to the imposition of a 
civil money penalty) shall apply to a 
civil money penalty under this clause 
in the same manner as such provi-
857 
sions apply to a penalty or proceeding 
under section 1128A(a).’’. 
(2) CONFORMING
AMENDMENT.—The second 
sentence of section 1819(h)(5) of the Social Security 
Act (42 U.S.C. 1395i–3(h)(5)) is amended by insert-
ing ‘‘(ii),’’after ‘‘(i),’’. 
(b) NURSING FACILITIES.— 
(1) PENALTIES IMPOSED BY THE STATE.— 
(A) IN GENERAL.—Section 1919(h)(2) of 
the Social Security Act (42 U.S.C. 1396r(h)(2)) 
is amended— 
(i) in subparagraph (A)(ii), by strik-
ing the first sentence and inserting the fol-
lowing: ‘‘A civil money penalty in accord-
ance with subparagraph (G).’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(G) CIVIL MONEY PENALTIES.— 
‘‘(i) IN
GENERAL.—The State may 
impose a civil money penalty under sub-
paragraph (A)(ii) in the applicable per in-
stance or per day amount (as defined in 
subclauses (II) and (III)) for each day or 
instance, respectively, of noncompliance (as 
determined appropriate by the Secretary).
858 
‘‘(ii) 
APPLICABLE
PER
INSTANCE 
AMOUNT.—In this subparagraph, the term 
‘applicable per instance amount’ means— 
‘‘(I) in the case where the defi-
ciency is found to be a direct proxi-
mate cause of death of a resident of 
the facility, an amount not to exceed 
$100,000. 
‘‘(II) in each case of a deficiency 
where the facility is cited for actual 
harm or immediate jeopardy, an 
amount not less than $3,050 and not 
more than $25,000; and 
‘‘(III) in each case of any other 
deficiency, an amount not less than 
$250 and not to exceed $3,050. 
‘‘(iii) 
APPLICABLE
PER
DAY 
AMOUNT.—In this subparagraph, the term 
‘applicable per day amount’ means— 
‘‘(I) in each case of a deficiency 
where the facility is cited for actual 
harm or immediate jeopardy, an 
amount not less than $3,050 and not 
more than $25,000; and
859 
‘‘(II) in each case of any other 
deficiency, an amount not less than 
$250 and not to exceed $3,050. 
‘‘(iv) REDUCTION
OF
CIVIL
MONEY 
PENALTIES
IN
CERTAIN
CIR-
CUMSTANCES.—Subject to clauses (v) and 
(vi), in the case where a facility self-re-
ports and promptly corrects a deficiency 
for which a penalty was imposed under 
subparagraph (A)(ii) not later than 10 cal-
endar days after the date of such imposi-
tion, the State may reduce the amount of 
the penalty imposed by not more than 50 
percent. 
‘‘(v) PROHIBITION
ON
REDUCTION 
FOR CERTAIN DEFICIENCIES.— 
‘‘(I) REPEAT
DEFICIENCIES.— 
The State may not reduce under 
clause (iv) the amount of a penalty if 
the State had reduced a penalty im-
posed on the facility in the preceding 
year under such clause with respect to 
a repeat deficiency. 
‘‘(II) CERTAIN
OTHER
DEFI-
CIENCIES.—The State may not reduce
860 
under clause (iv) the amount of a pen-
alty if the penalty is imposed for a de-
ficiency described in clause (ii)(II) or 
(iii)(I) and the actual harm or wide-
spread harm that immediately jeop-
ardizes the health or safety of a resi-
dent or residents of the facility, or if 
the penalty is imposed for a deficiency 
described in clause (ii)(I). 
‘‘(III) LIMITATION
ON
AGGRE-
GATE
REDUCTIONS.—The aggregate 
reduction in a penalty under clause 
(iv) may not exceed 35 percent on the 
basis of self-reporting, on the basis of 
a waiver of an appeal (as provided for 
under 
regulations 
under 
section 
488.436 of title 42, Code of Federal 
Regulations), or on the basis of both. 
‘‘(vi) COLLECTION
OF
CIVIL
MONEY 
PENALTIES.—In the case of a civil money 
penalty 
imposed 
under 
subparagraph 
(A)(ii), the State— 
‘‘(I) subject to subclause (III), 
shall, not later than 30 days after the 
date of imposition of the penalty, pro-
861 
vide the opportunity for the facility to 
participate in an independent informal 
dispute resolution process, established 
by the State survey agency, which 
generates a written record prior to the 
collection of such penalty, but such 
opportunity shall not affect the re-
sponsibility of the State survey agency 
for making final recommendations for 
such penalties; 
‘‘(II) in the case where the pen-
alty is imposed for each day of non-
compliance, shall not impose a penalty 
for any day during the period begin-
ning on the initial day of the imposi-
tion of the penalty and ending on the 
day on which the informal dispute res-
olution process under subclause (I) is 
completed; 
‘‘(III) may provide for the collec-
tion of such civil money penalty and 
the placement of such amounts col-
lected in an escrow account under the 
direction of the State on the earlier of 
the date on which the informal dis-
862 
pute resolution process under sub-
clause (I) is completed or the date 
that is 90 days after the date of the 
imposition of the penalty; 
‘‘(IV) may provide that such 
amounts collected are kept in such ac-
count pending the resolution of any 
subsequent appeals; 
‘‘(V) in the case where the facil-
ity successfully appeals the penalty, 
may provide for the return of such 
amounts collected (plus interest) to 
the facility; and 
‘‘(VI) in the case where all such 
appeals are unsuccessful, may provide 
that such funds collected shall be used 
for the purposes described in the sec-
ond 
sentence 
of 
subparagraph 
(A)(ii).’’. 
(B) CONFORMING AMENDMENT.—The sec-
ond sentence of section 1919(h)(2)(A)(ii) of the 
Social 
Security 
Act 
(42 
U.S.C. 
1396r(h)(2)(A)(ii)) is amended by inserting be-
fore the period at the end the following: ‘‘, and 
some portion of such funds may be used to sup-
863 
port activities that benefit residents, including 
assistance to support and protect residents of a 
facility that closes (voluntarily or involuntarily) 
or is decertified (including offsetting costs of re-
locating residents to home and community- 
based settings or another facility), projects that 
support resident and family councils and other 
consumer involvement in assuring quality care 
in facilities, and facility improvement initiatives 
approved by the Secretary (including joint 
training of facility staff and surveyors, pro-
viding technical assistance to facilities under 
quality assurance programs, the appointment of 
temporary management, and other activities ap-
proved by the Secretary)’’. 
(2) 
PENALTIES
IMPOSED
BY
THE
SEC-
RETARY.— 
(A) 
IN
GENERAL.—Section 
1919(h)(3)(C)(ii) of the Social Security Act (42 
U.S.C. 1396r(h)(3)(C)) is amended to read as 
follows: 
‘‘(ii) AUTHORITY WITH RESPECT TO 
CIVIL MONEY PENALTIES.— 
‘‘(I) AMOUNT.—Subject to sub-
clause (II), the Secretary may impose
864 
a civil money penalty in an amount 
not to exceed $10,000 for each day or 
each instance of noncompliance (as 
determined appropriate by the Sec-
retary). 
‘‘(II) 
REDUCTION
OF
CIVIL 
MONEY PENALTIES IN CERTAIN CIR-
CUMSTANCES.—Subject to subclause 
(III), in the case where a facility self- 
reports and promptly corrects a defi-
ciency for which a penalty was im-
posed under this clause not later than 
10 calendar days after the date of 
such imposition, the Secretary may 
reduce the amount of the penalty im-
posed by not more than 50 percent. 
‘‘(III) PROHIBITION ON REDUC-
TION
FOR
REPEAT
DEFICIENCIES.— 
The Secretary may not reduce the 
amount of a penalty under subclause 
(II) if the Secretary had reduced a 
penalty imposed on the facility in the 
preceding year under such subclause 
with respect to a repeat deficiency.
865 
‘‘(IV) COLLECTION
OF
CIVIL 
MONEY PENALTIES.—In the case of a 
civil money penalty imposed under 
this clause, the Secretary— 
‘‘(aa) subject to item (bb), 
shall, not later than 30 days 
after the date of imposition of 
the penalty, provide the oppor-
tunity for the facility to partici-
pate in an independent informal 
dispute resolution process which 
generates a written record prior 
to the collection of such penalty; 
‘‘(bb) in the case where the 
penalty is imposed for each day 
of noncompliance, shall not im-
pose a penalty for any day during 
the period beginning on the ini-
tial day of the imposition of the 
penalty and ending on the day on 
which the informal dispute reso-
lution process under item (aa) is 
completed; 
‘‘(cc) may provide for the 
collection of such civil money
866 
penalty and the placement of 
such amounts collected in an es-
crow account under the direction 
of the Secretary on the earlier of 
the date on which the informal 
dispute resolution process under 
item (aa) is completed or the 
date that is 90 days after the 
date of the imposition of the pen-
alty; 
‘‘(dd) may provide that such 
amounts collected are kept in 
such account pending the resolu-
tion of any subsequent appeals; 
‘‘(ee) in the case where the 
facility successfully appeals the 
penalty, may provide for the re-
turn of such amounts collected 
(plus interest) to the facility; and 
‘‘(ff) in the case where all 
such appeals are unsuccessful, 
may provide that some portion of 
such amounts collected may be 
used to support activities that 
benefit residents, including as-
867 
sistance to support and protect 
residents of a facility that closes 
(voluntarily or involuntarily) or is 
decertified (including offsetting 
costs of relocating residents to 
home and community-based set-
tings or another facility), projects 
that support resident and family 
councils and other consumer in-
volvement in assuring quality 
care in facilities, and facility im-
provement initiatives approved by 
the Secretary (including joint 
training of facility staff and sur-
veyors, technical assistance for 
facilities under quality assurance 
programs, the appointment of 
temporary 
management, 
and 
other activities approved by the 
Secretary). 
‘‘(V) PROCEDURE.—The provi-
sions of section 1128A (other than 
subsections (a) and (b) and except to 
the extent that such provisions require 
a hearing prior to the imposition of a
868 
civil money penalty) shall apply to a 
civil money penalty under this clause 
in the same manner as such provi-
sions apply to a penalty or proceeding 
under section 1128A(a).’’. 
(B) CONFORMING
AMENDMENT.—Section 
1919(h)(8) of the Social Security Act (42 
U.S.C. 1396r(h)(5)(8)) is amended by inserting 
‘‘and in paragraph (3)(C)(ii)’’ after ‘‘paragraph 
(2)(A)’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of the 
enactment of this Act. 
SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PRO-
GRAM. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—The Secretary, in consulta-
tion with the Inspector General of the Department 
of Health and Human Services, shall establish a 
pilot program (in this section referred to as the 
‘‘pilot program’’) to develop, test, and implement use 
of an independent monitor to oversee interstate and 
large intrastate chains of skilled nursing facilities 
and nursing facilities.
869 
(2) SELECTION.—The Secretary shall select 
chains of skilled nursing facilities and nursing facili-
ties described in paragraph (1) to participate in the 
pilot program from among those chains that submit 
an application to the Secretary at such time, in such 
manner, and containing such information as the Sec-
retary may require. 
(3) DURATION.—The Secretary shall conduct 
the pilot program for a 2-year period. 
(4) IMPLEMENTATION.—The Secretary shall 
implement the pilot program not later than one year 
after the date of the enactment of this Act. 
(b) REQUIREMENTS.—The Secretary shall evaluate 
chains selected to participate in the pilot program based 
on criteria selected by the Secretary, including where evi-
dence suggests that one or more facilities of the chain are 
experiencing serious safety and quality of care problems. 
Such criteria may include the evaluation of a chain that 
includes one or more facilities participating in the ‘‘Special 
Focus Facility’’ program (or a successor program) or one 
or more facilities with a record of repeated serious safety 
and quality of care deficiencies. 
(c) RESPONSIBILITIES OF THE INDEPENDENT MON-
ITOR.—An independent monitor that enters into a con-
870 
tract with the Secretary to participate in the conduct of 
such program shall— 
(1) conduct periodic reviews and prepare root- 
cause quality and deficiency analyses of a chain to 
assess if facilities of the chain are in compliance 
with State and Federal laws and regulations applica-
ble to the facilities; 
(2) undertake sustained oversight of the chain, 
whether publicly or privately held, to involve the 
owners of the chain and the principal business part-
ners of such owners in facilitating compliance by fa-
cilities of the chain with State and Federal laws and 
regulations applicable to the facilities; 
(3) analyze the management structure, distribu-
tion of expenditures, and nurse staffing levels of fa-
cilities of the chain in relation to resident census, 
staff turnover rates, and tenure; 
(4) report findings and recommendations with 
respect to such reviews, analyses, and oversight to 
the chain and facilities of the chain, to the Secretary 
and to relevant States; and 
(5) publish the results of such reviews, anal-
yses, and oversight. 
(d) IMPLEMENTATION OF RECOMMENDATIONS.—
871 
(1) RECEIPT OF FINDING BY CHAIN.—Not later 
than 10 days after receipt of a finding of an inde-
pendent monitor under subsection (c)(4), a chain 
participating in the pilot program shall submit to 
the independent monitor a report— 
(A) outlining corrective actions the chain 
will take to implement the recommendations in 
such report; or 
(B) indicating that the chain will not im-
plement such recommendations and why it will 
not do so. 
(2) RECEIPT
OF
REPORT
BY
INDEPENDENT 
MONITOR.—Not later than 10 days after the date of 
receipt of a report submitted by a chain under para-
graph (1), an independent monitor shall finalize its 
recommendations and submit a report to the chain 
and facilities of the chain, the Secretary, and the 
State (or States) involved, as appropriate, containing 
such final recommendations. 
(e) COST OF APPOINTMENT.—A chain shall be re-
sponsible for a portion of the costs associated with the 
appointment of independent monitors under the pilot pro-
gram. The chain shall pay such portion to the Secretary 
(in an amount and in accordance with procedures estab-
lished by the Secretary).
872 
(f) WAIVER AUTHORITY.—The Secretary may waive 
such requirements of titles XVIII and XIX of the Social 
Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as 
may be necessary for the purpose of carrying out the pilot 
program. 
(g) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as may be 
necessary to carry out this section. 
(h) DEFINITIONS.—In this section: 
(1) FACILITY.—The term ‘‘facility’’ means a 
skilled nursing facility or a nursing facility. 
(2) NURSING
FACILITY.—The term ‘‘nursing 
facility’’ has the meaning given such term in section 
1919(a) of the Social Security Act (42 U.S.C. 
1396r(a)). 
(3) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services, acting 
through the Assistant Secretary for Planning and 
Evaluation. 
(4) SKILLED
NURSING
FACILITY.—The term 
‘‘skilled nursing facility’’ has the meaning given such 
term in section 1819(a) of the Social Security Act 
(42 U.S.C. 1395(a)). 
(i) EVALUATION AND REPORT.—
873 
(1) EVALUATION.—The Inspector General of 
the Department of Health and Human Services shall 
evaluate the pilot program. Such evaluation shall— 
(A) determine whether the independent 
monitor program should be established on a 
permanent basis; and 
(B) if the Inspector General determines 
that the independent monitor program should 
be established on a permanent basis, rec-
ommend appropriate procedures and mecha-
nisms for such establishment. 
(2) REPORT.—Not later than 180 days after 
the completion of the pilot program, the Inspector 
General shall submit to Congress and the Secretary 
a report containing the results of the evaluation con-
ducted under paragraph (1), together with rec-
ommendations for such legislation and administra-
tive action as the Inspector General determines ap-
propriate. 
SEC. 1423. NOTIFICATION OF FACILITY CLOSURE. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819(c) of the So-
cial Security Act (42 U.S.C. 1395i–3(c)) is amended 
by adding at the end the following new paragraph: 
‘‘(7) NOTIFICATION OF FACILITY CLOSURE.—
874 
‘‘(A) IN GENERAL.—Any individual who is 
the administrator of a skilled nursing facility 
must— 
‘‘(i) submit to the Secretary, the State 
long-term care ombudsman, residents of 
the facility, and the legal representatives of 
such residents or other responsible parties, 
written notification of an impending clo-
sure— 
‘‘(I) subject to subclause (II), not 
later than the date that is 60 days 
prior to the date of such closure; and 
‘‘(II) in the case of a facility 
where the Secretary terminates the fa-
cility’s participation under this title, 
not later than the date that the Sec-
retary determines appropriate; 
‘‘(ii) ensure that the facility does not 
admit any new residents on or after the 
date on which such written notification is 
submitted; and 
‘‘(iii) include in the notice a plan for 
the transfer and adequate relocation of the 
residents of the facility by a specified date 
prior to closure that has been approved by
875 
the State, including assurances that the 
residents will be transferred to the most 
appropriate facility or other setting in 
terms of quality, services, and location, 
taking into consideration the needs and 
best interests of each resident. 
‘‘(B) RELOCATION.— 
‘‘(i) IN
GENERAL.—The State shall 
ensure that, before a facility closes, all 
residents of the facility have been success-
fully relocated to another facility or an al-
ternative home and community-based set-
ting. 
‘‘(ii) CONTINUATION
OF
PAYMENTS 
UNTIL RESIDENTS RELOCATED.—The Sec-
retary may, as the Secretary determines 
appropriate, continue to make payments 
under this title with respect to residents of 
a facility that has submitted a notification 
under subparagraph (A) during the period 
beginning on the date such notification is 
submitted and ending on the date on which 
the resident is successfully relocated.’’.
876 
(2) 
CONFORMING
AMENDMENTS.—Section 
1819(h)(4) of the Social Security Act (42 U.S.C. 
1395i–3(h)(4)) is amended— 
(A) in the first sentence, by striking ‘‘the 
Secretary shall terminate’’ and inserting ‘‘the 
Secretary, subject to subsection (c)(7), shall 
terminate’’; and 
(B) in the second sentence, by striking 
‘‘subsection (c)(2)’’ and inserting ‘‘paragraphs 
(2) and (7) of subsection (c)’’. 
(b) NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1919(c) of the So-
cial Security Act (42 U.S.C. 1396r(c)) is amended 
by adding at the end the following new paragraph: 
‘‘(9) NOTIFICATION OF FACILITY CLOSURE.— 
‘‘(A) IN GENERAL.—Any individual who is 
an administrator of a nursing facility must— 
‘‘(i) submit to the Secretary, the State 
long-term care ombudsman, residents of 
the facility, and the legal representatives of 
such residents or other responsible parties, 
written notification of an impending clo-
sure—
877 
‘‘(I) subject to subclause (II), not 
later than the date that is 60 days 
prior to the date of such closure; and 
‘‘(II) in the case of a facility 
where the Secretary terminates the fa-
cility’s participation under this title, 
not later than the date that the Sec-
retary determines appropriate; 
‘‘(ii) ensure that the facility does not 
admit any new residents on or after the 
date on which such written notification is 
submitted; and 
‘‘(iii) include in the notice a plan for 
the transfer and adequate relocation of the 
residents of the facility by a specified date 
prior to closure that has been approved by 
the State, including assurances that the 
residents will be transferred to the most 
appropriate facility or other setting in 
terms of quality, services, and location, 
taking into consideration the needs and 
best interests of each resident. 
‘‘(B) RELOCATION.— 
‘‘(i) IN
GENERAL.—The State shall 
ensure that, before a facility closes, all
878 
residents of the facility have been success-
fully relocated to another facility or an al-
ternative home and community-based set-
ting. 
‘‘(ii) CONTINUATION
OF
PAYMENTS 
UNTIL RESIDENTS RELOCATED.—The Sec-
retary may, as the Secretary determines 
appropriate, continue to make payments 
under this title with respect to residents of 
a facility that has submitted a notification 
under subparagraph (A) during the period 
beginning on the date such notification is 
submitted and ending on the date on which 
the resident is successfully relocated.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of the 
enactment of this Act. 
PART 3—IMPROVING STAFF TRAINING 
SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING. 
(a) 
SKILLED
NURSING
FACILITIES.—Section 
1819(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 
1395i–3(f)(2)(A)(i)(I)) is amended by inserting ‘‘(includ-
ing, in the case of initial training and, if the Secretary 
determines appropriate, in the case of ongoing training,
879 
dementia management training and resident abuse preven-
tion training)’’ after ‘‘curriculum’’. 
(b) 
NURSING
FACILITIES.—Section 
1919(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 
1396r(f)(2)(A)(i)(I)) is amended by inserting ‘‘(including, 
in the case of initial training and, if the Secretary deter-
mines appropriate, in the case of ongoing training, demen-
tia management training and resident abuse prevention 
training)’’ after ‘‘curriculum’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of the 
enactment of this Act. 
SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED 
FOR CERTIFIED NURSE AIDES AND SUPER-
VISORY STAFF. 
(a) STUDY.— 
(1) IN GENERAL.—The Secretary shall conduct 
a study on the content of training for certified nurse 
aides and supervisory staff of skilled nursing facili-
ties and nursing facilities. The study shall include an 
analysis of the following: 
(A) Whether the number of initial training 
hours for certified nurse aides required under 
sections 
1819(f)(2)(A)(i)(II) 
and 
1919(f)(2)(A)(i)(II) of the Social Security Act
880 
(42 
U.S.C. 
1395i–3(f)(2)(A)(i)(II); 
1396r(f)(2)(A)(i)(II)) should be increased from 
75 and, if so, what the required number of ini-
tial training hours should be, including any rec-
ommendations for the content of such training 
(including training related to dementia). 
(B) Whether requirements for ongoing 
training 
under 
such 
sections 
1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) 
should be increased from 12 hours per year, in-
cluding any recommendations for the content of 
such training. 
(2) CONSULTATION.—In conducting the anal-
ysis under paragraph (1)(A), the Secretary shall 
consult with States that, as of the date of the enact-
ment of this Act, require more than 75 hours of 
training for certified nurse aides. 
(3) DEFINITIONS.—In this section: 
(A) NURSING FACILITY.—The term ‘‘nurs-
ing facility’’ has the meaning given such term 
in section 1919(a) of the Social Security Act 
(42 U.S.C. 1396r(a)). 
(B) SECRETARY.—The term ‘‘Secretary’’ 
means the Secretary of Health and Human
881 
Services, acting through the Assistant Secretary 
for Planning and Evaluation. 
(C) SKILLED
NURSING
FACILITY.—The 
term ‘‘skilled nursing facility’’ has the meaning 
given such term in section 1819(a) of the Social 
Security Act (42 U.S.C. 1395(a)). 
(b) REPORT.—Not later than 2 years after the date 
of the enactment of this Act, the Secretary shall submit 
to Congress a report containing the results of the study 
conducted under subsection (a), together with rec-
ommendations for such legislation and administrative ac-
tion as the Secretary determines appropriate. 
SEC. 1433. QUALIFICATION OF DIRECTOR OF FOOD SERV-
ICES OF A SKILLED NURSING FACILITY OR 
NURSING FACILITY. 
(a) MEDICARE.—Section 1819(b)(4)(A) of the Social 
Security Act (42 U.S.C. 1395i–3(b)(4)(A)) is amended by 
adding at the end the following: ‘‘With respect to meeting 
the staffing requirement imposed by the Secretary to carry 
out clause (iv), the full-time director of food services of 
the facility, if not a qualified dietitian (as defined in sec-
tion 483.35(a)(2) of title 42, Code of Federal Regulations, 
as in effect as of the date of the enactment of this sen-
tence), shall be a Certified Dietary Manager meeting the 
requirements of the Certifying Board for Dietary Man-
883 
Subtitle C—Quality Measurements 
SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR 
QUALITY IMPROVEMENT. 
Title XI of the Social Security Act, as amended by 
section 1401(a), is further amended by adding at the end 
the following new part: 
‘‘PART E—QUALITY IMPROVEMENT 
‘‘ESTABLISHMENT OF NATIONAL PRIORITIES FOR 
PERFORMANCE IMPROVEMENT 
‘‘SEC. 1191. (a) ESTABLISHMENT OF NATIONAL PRI-
ORITIES BY THE SECRETARY.—The Secretary shall estab-
lish and periodically update, not less frequently than tri-
ennially, national priorities for performance improvement. 
‘‘(b) RECOMMENDATIONS
FOR NATIONAL PRIOR-
ITIES.—In establishing and updating national priorities 
under subsection (a), the Secretary shall solicit and con-
sider recommendations from multiple outside stake-
holders. 
‘‘(c) CONSIDERATIONS IN SETTING NATIONAL PRI-
ORITIES.—With respect to such priorities, the Secretary 
shall ensure that priority is given to areas in the delivery 
of health care services in the United States that— 
‘‘(1) contribute to a large burden of disease, in-
cluding those that address the health care provided
884 
to patients with prevalent, high-cost chronic dis-
eases; 
‘‘(2) have the greatest potential to decrease 
morbidity and mortality in this country, including 
those that are designed to eliminate harm to pa-
tients; 
‘‘(3) have the greatest potential for improving 
the 
performance, 
affordability, 
and 
patient- 
centeredness of health care, including those due to 
variations in care; 
‘‘(4) address health disparities across groups 
and areas; and 
‘‘(5) have the potential for rapid improvement 
due to existing evidence, standards of care or other 
reasons. 
‘‘(d) DEFINITIONS.—In this part: 
‘‘(1) CONSENSUS-BASED
ENTITY.—The term 
‘consensus-based entity’ means an entity with a con-
tract with the Secretary under section 1890. 
‘‘(2) QUALITY
MEASURE.—The term ‘quality 
measure’ means a national consensus standard for 
measuring the performance and improvement of pop-
ulation health, or of institutional providers of serv-
ices, physicians, and other health care practitioners 
in the delivery of health care services.
885 
‘‘(e) FUNDING.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
for the transfer, from the Federal Hospital Insur-
ance Trust Fund under section 1817 and the Fed-
eral Supplementary Medical Insurance Trust Fund 
under section 1841 (in such proportion as the Sec-
retary determines appropriate), of $2,000,000, for 
the activities under this section for each of the fiscal 
years 2010 through 2014. 
‘‘(2) AUTHORIZATION
OF
APPROPRIATIONS.— 
For purposes of carrying out the provisions of this 
section, in addition to funds otherwise available, out 
of any funds in the Treasury not otherwise appro-
priated, there are appropriated to the Secretary of 
Health and Human Services $2,000,000 for each of 
the fiscal years 2010 through 2014.’’. 
SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; 
GAO EVALUATION OF DATA COLLECTION 
PROCESS FOR QUALITY MEASUREMENT. 
Part E of title XI of the Social Security Act, as added 
by section 1441, is amended by adding at the end the fol-
lowing new sections: 
‘‘SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES. 
‘‘(a) AGREEMENTS WITH QUALIFIED ENTITIES.—
886 
‘‘(1) IN GENERAL.—The Secretary shall enter 
into agreements with qualified entities to develop 
quality measures for the delivery of health care serv-
ices in the United States. 
‘‘(2) FORM OF AGREEMENTS.—The Secretary 
may carry out paragraph (1) by contract, grant, or 
otherwise. 
‘‘(3) 
RECOMMENDATIONS
OF
CONSENSUS- 
BASED ENTITY.—In carrying out this section, the 
Secretary shall— 
‘‘(A) seek public input; and 
‘‘(B) take into consideration recommenda-
tions of the consensus-based entity with a con-
tract with the Secretary under section 1890(a). 
‘‘(b) DETERMINATION OF AREAS WHERE QUALITY 
MEASURES ARE REQUIRED.—Consistent with the na-
tional priorities established under this part and with the 
programs administered by the Centers for Medicare & 
Medicaid Services and in consultation with other relevant 
Federal agencies, the Secretary shall determine areas in 
which quality measures for assessing health care services 
in the United States are needed. 
‘‘(c) DEVELOPMENT OF QUALITY MEASURES.— 
‘‘(1) PATIENT-CENTERED
AND
POPULATION- 
BASED
MEASURES.—In entering into agreements
887 
under subsection (a), the Secretary shall give pri-
ority to the development of quality measures that 
allow the assessment of— 
‘‘(A) health outcomes, presence of impair-
ment, and functional status of patients; 
‘‘(B) the continuity and coordination of 
care and care transitions for patients across 
providers and health care settings, including 
end of life care; 
‘‘(C) patient experience and patient en-
gagement; 
‘‘(D) the safety, effectiveness, and timeli-
ness of care; 
‘‘(E) health disparities including those as-
sociated with individual race, ethnicity, age, 
gender, place of residence or language; and 
‘‘(F) the efficiency and resource use in the 
provision of care. 
‘‘(2) USE OF FUNDS.—An entity that enters 
into an agreement under subsection (a) shall develop 
quality measures that— 
‘‘(A) to the extent feasible, have the ability 
to be collected through the use of health infor-
mation technologies supporting better delivery 
of health care services; and
888 
‘‘(B) are available free of charge to users 
for the use of such measures. 
‘‘(3) AVAILABILITY OF MEASURES.—The Sec-
retary shall make quality measures developed under 
this section available to the public. 
‘‘(4) TESTING OF PROPOSED MEASURES.—The 
Secretary may use amounts made available under 
subsection (f) to fund the testing of proposed quality 
measures by qualified entities. Testing funded under 
this paragraph shall include testing of the feasibility 
and usability of proposed measures. 
‘‘(5) UPDATING
OF
ENDORSED
MEASURES.— 
The Secretary may use amounts made available 
under subsection (f) to fund the updating (and test-
ing, if applicable) by consensus-based entities of 
quality measures that have been previously endorsed 
by such an entity as new evidence is developed, in 
a manner consistent with section 1890(b)(3). 
‘‘(d) QUALIFIED ENTITIES.—Before entering into 
agreements with a qualified entity, the Secretary shall en-
sure that the entity is a public, private, or academic insti-
tution with technical expertise in the area of health quality 
measurement. 
‘‘(e) APPLICATION FOR GRANT.—A grant may be 
made under this section only if an application for the
889 
grant is submitted to the Secretary and the application 
is in such form, is made in such manner, and contains 
such agreements, assurances, and information as the Sec-
retary determines to be necessary to carry out this section. 
‘‘(f) FUNDING.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
for the transfer, from the Federal Hospital Insur-
ance Trust Fund under section 1817 and the Fed-
eral Supplementary Medical Insurance Trust Fund 
under section 1841 (in such proportion as the Sec-
retary determines appropriate), of $25,000,000, to 
the Secretary for purposes of carrying out this sec-
tion for each of the fiscal years 2010 through 2014. 
‘‘(2) AUTHORIZATION
OF
APPROPRIATIONS.— 
For purposes of carrying out the provisions of this 
section, in addition to funds otherwise available, out 
of any funds in the Treasury not otherwise appro-
priated, there are appropriated to the Secretary of 
Health and Human Services $25,000,000 for each 
of the fiscal years 2010 through 2014. 
‘‘SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROC-
ESS FOR QUALITY MEASUREMENT. 
‘‘(a) GAO EVALUATIONS.—The Comptroller General 
of the United States shall conduct periodic evaluations of
890 
the implementation of the data collection processes for 
quality measures used by the Secretary. 
‘‘(b) CONSIDERATIONS.—In carrying out the evalua-
tion under subsection (a), the Comptroller General shall 
determine— 
‘‘(1) whether the system for the collection of 
data for quality measures provides for validation of 
data as relevant and scientifically credible; 
‘‘(2) whether data collection efforts under the 
system use the most efficient and cost-effective 
means in a manner that minimizes administrative 
burden on persons required to collect data and that 
adequately protects the privacy of patients’ personal 
health information and provides data security; 
‘‘(3) whether standards under the system pro-
vide for an appropriate opportunity for physicians 
and other clinicians and institutional providers of 
services to review and correct findings; and 
‘‘(4) the extent to which quality measures are 
consistent with section 1192(c)(1) or result in direct 
or indirect costs to users of such measures. 
‘‘(c) REPORT.—The Comptroller General shall sub-
mit reports to Congress and to the Secretary containing 
a description of the findings and conclusions of the results 
of each such evaluation.’’.
891 
SEC. 1443. MULTI-STAKEHOLDER PRE-RULEMAKING INPUT 
INTO SELECTION OF QUALITY MEASURES. 
Section 1808 of the Social Security Act (42 U.S.C. 
1395b–9) is amended by adding at the end the following 
new subsection: 
‘‘(d) MULTI-STAKEHOLDER PRE-RULEMAKING INPUT 
INTO SELECTION OF QUALITY MEASURES.— 
‘‘(1) LIST OF MEASURES.—Not later than De-
cember 1 before each year (beginning with 2011), 
the Secretary shall make public a list of measures 
being considered for selection for quality measure-
ment by the Secretary in rulemaking with respect to 
payment systems under this title beginning in the 
payment year beginning in such year and for pay-
ment systems beginning in the calendar year fol-
lowing such year, as the case may be. 
‘‘(2) CONSULTATION
ON
SELECTION
OF
EN-
DORSED
QUALITY
MEASURES.—A consensus-based 
entity that has entered into a contract under section 
1890 shall, as part of such contract, convene multi- 
stakeholder groups to provide recommendations on 
the selection of individual or composite quality meas-
ures, for use in reporting performance information 
to the public or for use in public health care pro-
grams.
892 
‘‘(3) MULTI-STAKEHOLDER INPUT.—Not later 
than February 1 of each year (beginning with 
2011), the consensus-based entity described in para-
graph (2) shall transmit to the Secretary the rec-
ommendations of multi-stakeholder groups provided 
under paragraph (2). Such recommendations shall 
be included in the transmissions the consensus-based 
entity makes to the Secretary under the contract 
provided for under section 1890. 
‘‘(4) REQUIREMENT
FOR
TRANSPARENCY
IN 
PROCESS.— 
‘‘(A) IN
GENERAL.—In convening multi- 
stakeholder groups under paragraph (2) with 
respect to the selection of quality measures, the 
consensus-based entity described in such para-
graph shall provide for an open and transparent 
process for the activities conducted pursuant to 
such convening. 
‘‘(B) SELECTION OF ORGANIZATIONS PAR-
TICIPATING
IN
MULTI-STAKEHOLDER 
GROUPS.—The process under paragraph (2) 
shall ensure that the selection of representatives 
of multi-stakeholder groups includes provision 
for public nominations for, and the opportunity 
for public comment on, such selection.
893 
‘‘(5) USE OF INPUT.—The respective proposed 
rule shall contain a summary of the recommenda-
tions made by the multi-stakeholder groups under 
paragraph (2), as well as other comments received 
regarding the proposed measures, and the extent to 
which such proposed rule follows such recommenda-
tions and the rationale for not following such rec-
ommendations. 
‘‘(6) MULTI-STAKEHOLDER GROUPS.—For pur-
poses of this subsection, the term ‘multi-stakeholder 
groups’ means, with respect to a quality measure, a 
voluntary collaborative of organizations representing 
persons interested in or affected by the use of such 
quality measure, such as the following: 
‘‘(A) Hospitals and other institutional pro-
viders. 
‘‘(B) Physicians. 
‘‘(C) Health care quality alliances. 
‘‘(D) Nurses and other health care practi-
tioners. 
‘‘(E) Health plans. 
‘‘(F) Patient advocates and consumer 
groups. 
‘‘(G) Employers.
894 
‘‘(H) Public and private purchasers of 
health care items and services. 
‘‘(I) Labor organizations. 
‘‘(J) Relevant departments or agencies of 
the United States. 
‘‘(K) Biopharmaceutical companies and 
manufacturers of medical devices. 
‘‘(L) Licensing, credentialing, and accred-
iting bodies. 
‘‘(7) FUNDING.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
provide for the transfer, from the Federal Hos-
pital Insurance Trust Fund under section 1817 
and the Federal Supplementary Medical Insur-
ance Trust Fund under section 1841 (in such 
proportion as the Secretary determines appro-
priate), of $1,000,000, to the Secretary for pur-
poses of carrying out this subsection for each of 
the fiscal years 2010 through 2014. 
‘‘(B) 
AUTHORIZATION
OF
APPROPRIA-
TIONS.—For purposes of carrying out the provi-
sions of this subsection, in addition to funds 
otherwise available, out of any funds in the 
Treasury not otherwise appropriated, there are 
appropriated to the Secretary of Health and
895 
Human Services $1,000,000 for each of the fis-
cal years 2010 through 2014.’’. 
SEC. 1444. APPLICATION OF QUALITY MEASURES. 
(a) 
INPATIENT
HOSPITAL
SERVICES.—Section 
1886(b)(3)(B) of such Act (42 U.S.C. 1395ww(b)(3)(B)) 
is amended by adding at the end the following new clause: 
‘‘(x)(I) Subject to subclause (II), for purposes of re-
porting data on quality measures for inpatient hospital 
services furnished during fiscal year 2012 and each subse-
quent fiscal year, the quality measures specified under 
clause (viii) shall be measures selected by the Secretary 
from measures that have been endorsed by the entity with 
a contract with the Secretary under section 1890(a). 
‘‘(II) In the case of a specified area or medical topic 
determined appropriate by the Secretary for which a fea-
sible and practical quality measure has not been endorsed 
by the entity with a contract under section 1890(a), the 
Secretary may specify a measure that is not so endorsed 
as long as due consideration is given to measures that 
have been endorsed or adopted by a consensus organiza-
tion identified by the Secretary. The Secretary shall sub-
mit such a non-endorsed measure to the entity for consid-
eration for endorsement. If the entity considers but does 
not endorse such a measure and if the Secretary does not 
phase-out use of such measure, the Secretary shall include
897 
following: ‘‘The Secretary shall submit such a non-en-
dorsed measure to the entity for consideration for endorse-
ment. If the entity considers but does not endorse such 
a measure and if the Secretary does not phase-out use 
of such measure, the Secretary shall include the rationale 
for continued use of such a measure in rulemaking.’’. 
(e) 
ENDORSEMENT
OF
STANDARDS.—Section 
1890(b)(2) of the Social Security Act (42 U.S.C. 
1395aaa(b)(2)) is amended by adding after and below sub-
paragraph (B) the following: 
‘‘If the entity does not endorse a measure, such enti-
ty shall explain the reasons and provide suggestions 
about changes to such measure that might make it 
a potentially endorsable measure.’’. 
(f) EFFECTIVE DATE.—Except as otherwise pro-
vided, the amendments made by this section shall apply 
to quality measures applied for payment years beginning 
with 2012 or fiscal year 2012, as the case may be. 
SEC. 1445. CONSENSUS-BASED ENTITY FUNDING. 
Section 1890(d) of the Social Security Act (42 U.S.C. 
1395aaa(d)) is amended by striking ‘‘for each of fiscal 
years 2009 through 2012’’ and inserting ‘‘for fiscal year 
2009, and $12,000,000 for each of the fiscal years 2010 
through 2012’’.
898 
SEC. 1446. QUALITY INDICATORS FOR CARE OF PEOPLE 
WITH ALZHEIMER’S DISEASE. 
(a) QUALITY INDICATORS.—The Secretary of Health 
and Human Services shall develop quality indicators for 
the provision of medical services to people with Alz-
heimer’s disease and other dementias and a plan for im-
plementing the indicators to measure the quality of care 
provided for people with these conditions by physicians, 
hospitals, and other appropriate providers of services and 
suppliers. 
(b) REPORT.—The Secretary shall submit a report to 
the Committees on Energy and Commerce and Ways and 
Means of the United States House of Representatives and 
to the Committees on Finance and Health, Education, 
Labor, and Pensions of the United States Senate not later 
than 24 months after the date of the enactment of this 
Act setting forth the status of their efforts to implement 
the requirements of subsection (a).
899 
Subtitle D—Physician Payments 
Sunshine Provision 
SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BE-
TWEEN 
MANUFACTURERS 
AND 
DISTRIBU-
TORS 
OF 
COVERED 
DRUGS, 
DEVICES, 
BIOLOGICALS, 
OR 
MEDICAL 
SUPPLIES 
UNDER MEDICARE, MEDICAID, OR CHIP AND 
PHYSICIANS AND OTHER HEALTH CARE ENTI-
TIES AND BETWEEN PHYSICIANS AND OTHER 
HEALTH CARE ENTITIES. 
(a) IN GENERAL.—Part A of title XI of the Social 
Security Act (42 U.S.C. 1301 et seq.), as amended by sec-
tion 1631(a), is further amended by inserting after section 
1128G the following new section: 
‘‘SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS’ FINAN-
CIAL RELATIONSHIPS WITH MANUFACTUR-
ERS 
AND 
DISTRIBUTORS 
OF 
COVERED 
DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL 
SUPPLIES UNDER MEDICARE, MEDICAID, OR 
CHIP AND WITH ENTITIES THAT BILL FOR 
SERVICES UNDER MEDICARE. 
‘‘(a) REPORTING OF PAYMENTS OR OTHER TRANS-
FERS OF VALUE.— 
‘‘(1) IN GENERAL.—Except as provided in this 
subsection, not later than March 31, 2011, and an-
900 
nually thereafter, each applicable manufacturer or 
distributor that provides a payment or other transfer 
of value to a covered recipient, or to an entity or in-
dividual at the request of or designated on behalf of 
a covered recipient, shall submit to the Secretary, in 
such electronic form as the Secretary shall require, 
the following information with respect to the pre-
ceding calendar year: 
‘‘(A) With respect to the covered recipient, 
the recipient’s name, business address, physi-
cian specialty, and national provider identifier. 
‘‘(B) With respect to the payment or other 
transfer of value, other than a drug sample— 
‘‘(i) its value and date; 
‘‘(ii) the name of the related drug, de-
vice, or supply, if available, to the level of 
specificity available; and 
‘‘(iii) a description of its form, indi-
cated (as appropriate for all that apply) 
as— 
‘‘(I) cash or a cash equivalent; 
‘‘(II) in-kind items or services; 
‘‘(III) stock, a stock option, or 
any other ownership interest, divi-
901 
dend, profit, or other return on invest-
ment; or 
‘‘(IV) any other form (as defined 
by the Secretary). 
‘‘(C) With respect to a drug sample, the 
name, number, date, and dosage units of the 
sample. 
‘‘(2) 
AGGREGATE
REPORTING.—Information 
submitted by an applicable manufacturer or dis-
tributor under paragraph (1) shall include the ag-
gregate amount of all payments or other transfers of 
value provided by the manufacturer or distributor to 
covered recipients (and to entities or individuals at 
the request of or designated on behalf of a covered 
recipient) during the year involved, including all pay-
ments and transfers of value regardless of whether 
such payments or transfer of value were individually 
disclosed. 
‘‘(3) SPECIAL RULE FOR CERTAIN PAYMENTS 
OR
OTHER
TRANSFERS
OF
VALUE.—In the case 
where an applicable manufacturer or distributor pro-
vides a payment or other transfer of value to an en-
tity or individual at the request of or designated on 
behalf of a covered recipient, the manufacturer or 
distributor shall disclose that payment or other
902 
transfer of value under the name of the covered re-
cipient. 
‘‘(4) DELAYED
REPORTING
FOR
PAYMENTS 
MADE
PURSUANT
TO
PRODUCT
DEVELOPMENT 
AGREEMENTS.—In the case of a payment or other 
transfer of value made to a covered recipient by an 
applicable manufacturer or distributor pursuant to a 
product development agreement for services fur-
nished in connection with the development of a new 
drug, device, biological, or medical supply, the appli-
cable manufacturer or distributor may report the 
value and recipient of such payment or other trans-
fer of value in the first reporting period under this 
subsection in the next reporting deadline after the 
earlier of the following: 
‘‘(A) The date of the approval or clearance 
of the covered drug, device, biological, or med-
ical supply by the Food and Drug Administra-
tion. 
‘‘(B) Two calendar years after the date 
such payment or other transfer of value was 
made. 
‘‘(5) DELAYED
REPORTING
FOR
PAYMENTS 
MADE PURSUANT TO CLINICAL INVESTIGATIONS.—In 
the case of a payment or other transfer of value
903 
made to a covered recipient by an applicable manu-
facturer or distributor in connection with a clinical 
investigation regarding a new drug, device, biologi-
cal, or medical supply, the applicable manufacturer 
or distributor may report as required under this sec-
tion in the next reporting period under this sub-
section after the earlier of the following: 
‘‘(A) The date that the clinical investiga-
tion is registered on the website maintained by 
the National Institutes of Health pursuant to 
section 671 of the Food and Drug Administra-
tion Amendments Act of 2007. 
‘‘(B) Two calendar years after the date 
such payment or other transfer of value was 
made. 
‘‘(6) 
CONFIDENTIALITY.—Information 
de-
scribed in paragraph (4) or (5) shall be considered 
confidential and shall not be subject to disclosure 
under section 552 of title 5, United States Code, or 
any other similar Federal, State, or local law, until 
or after the date on which the information is made 
available to the public under such paragraph. 
‘‘(7) PHYSICIANS
IN
SELF-INSURED
HEALTH 
PLANS.—Nothing in this subsection shall be con-
strued to require the disclosure of a payment or
904 
other transfer of value to a physician by a self-in-
sured health plan. 
‘‘(b) REPORTING OF OWNERSHIP INTEREST BY PHY-
SICIANS.— 
‘‘(1) HOSPITALS AND OTHER ENTITIES THAT 
BILL MEDICARE.—Not later than March 31 of each 
year (beginning with 2011), each hospital or other 
health care entity (not including a Medicare Advan-
tage organization) that bills the Secretary under 
part A or part B of title XVIII for services shall re-
port on the ownership shares (other than ownership 
shares described in section 1877(c)) of each physi-
cian who, directly or indirectly, owns an interest in 
the entity. 
‘‘(2) ADDITIONAL
PHYSICIAN
OWNERSHIP.— 
Not later than March 31 of each year (beginning 
with 2011), in addition to the requirement under 
subsection (a)(1), any applicable manufacturer, ap-
plicable group purchasing organization, or applicable 
distributor shall submit to the Secretary, in such 
electronic form as the Secretary shall require, the 
following information regarding any ownership or in-
vestment interest (other than an ownership or in-
vestment interest in a publicly traded security and 
mutual fund, as described in section 1877(c)) held
905 
by a physician (or an immediate family member of 
such physician (as defined for purposes of section 
1877(a))) in the applicable manufacturer, applicable 
group purchasing organization or applicable dis-
tributor during the preceding year: 
‘‘(A) The dollar amount invested by each 
physician holding such an ownership or invest-
ment interest. 
‘‘(B) The value and terms of each such 
ownership or investment interest. 
‘‘(C) Any payment or other transfer of 
value provided to a physician holding such an 
ownership or investment interest (or to an enti-
ty or individual at the request of or designated 
on behalf of a physician holding such an owner-
ship or investment interest), including the infor-
mation described in clauses (i) through (iii) of 
paragraph (a)(1)(B), and information described 
in subsection (f)(8)(A) and (f)(8)(B). 
‘‘(D) Any other information regarding the 
ownership or investment interest the Secretary 
determines appropriate. 
‘‘(3) DEFINITIONS.—In this subsection:
906 
‘‘(A) PHYSICIAN.—The term ‘physician’ in-
cludes a physician’s immediate family members 
(as defined for purposes of section 1877(a)). 
‘‘(B) APPLICABLE GROUP PURCHASING OR-
GANIZATION.—The term ‘applicable group pur-
chasing organization’ means any organization 
or other entity (as defined by the Secretary) 
that purchases, arranges for, or negotiates the 
purchase of a covered drug, device, biological, 
or medical supply. 
‘‘(4) STUDY OF PRACTICE PATTERNS IN AD-
VANCED DIAGNOSTIC IMAGING AND RADIATION ON-
COLOGY SERVICES.—The Comptroller General of the 
United States shall conduct a study to evaluate the 
extent of use of physician self-referral arrangements 
and the effects of such arrangements on the cost of 
providing advanced diagnostic imaging and radiation 
oncology services to Medicare beneficiaries under 
title XVIII. The study shall be completed and sub-
mitted to Congress not later than July 1, 2011. 
‘‘(c) PUBLIC AVAILABILITY.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish procedures to ensure that, not later than Sep-
tember 30, 2011, and on June 30 of each year be-
ginning thereafter, the information submitted under
907 
subsections (a) and (b), other than information re-
gard drug samples, with respect to the preceding 
calendar year is made available through an Internet 
website that— 
‘‘(A) is searchable and is in a format that 
is clear and understandable; 
‘‘(B) contains information that is pre-
sented by the name of the applicable manufac-
turer or distributor, the name of the covered re-
cipient, the business address of the covered re-
cipient, the specialty (if applicable) of the cov-
ered recipient, the value of the payment or 
other transfer of value, the date on which the 
payment or other transfer of value was provided 
to the covered recipient, the form of the pay-
ment or other transfer of value, indicated (as 
appropriate) under subsection (a)(1)(B)(ii), the 
nature of the payment or other transfer of 
value, indicated (as appropriate) under sub-
section (a)(1)(B)(iii), and the name of the cov-
ered drug, device, biological, or medical supply, 
as applicable; 
‘‘(C) contains information that is able to 
be easily aggregated and downloaded;
908 
‘‘(D) contains a description of any enforce-
ment actions taken to carry out this section, in-
cluding any penalties imposed under subsection 
(d), during the preceding year; 
‘‘(E) contains background information on 
industry-physician relationships; 
‘‘(F) in the case of information submitted 
with respect to a payment or other transfer of 
value described in subsection (a)(5), lists such 
information separately from the other informa-
tion submitted under subsection (a) and des-
ignates such separately listed information as 
funding for clinical research; 
‘‘(G) contains any other information the 
Secretary determines would be helpful to the 
average consumer; and 
‘‘(H) provides the covered recipient an op-
portunity to submit corrections to the informa-
tion made available to the public with respect to 
the covered recipient. 
‘‘(2) ACCURACY OF REPORTING.—The accuracy 
of the information that is submitted under sub-
sections (a) and (b) and made available under para-
graph (1) shall be the responsibility of the reporting 
entity reporting under subsection (a) or (b), as ap-
909 
plicable. The Secretary shall establish procedures to 
ensure that the covered recipient is provided with an 
opportunity to submit corrections to the applicable 
reporting entity with regard to information made 
public with respect to the covered recipient and, 
under such procedures, the corrections shall be 
transmitted to the Secretary. 
‘‘(3) SPECIAL RULE FOR DRUG SAMPLES.—In-
formation relating to drug samples provided under 
subsection (a) shall not be made available to the 
public by the Secretary but may be made available 
outside the Department of Health and Human Serv-
ices by the Secretary for research or legitimate busi-
ness purposes pursuant to data use agreements. 
‘‘(4) SPECIAL RULE FOR NATIONAL PROVIDER 
IDENTIFIERS.—Information relating to national pro-
vider identifiers provided under subsection (a) shall 
not be made available to the public by the Secretary 
but may be made available outside the Department 
of Health and Human Services by the Secretary for 
research or legitimate business purposes pursuant to 
data use agreements. 
‘‘(d) PENALTIES FOR NONCOMPLIANCE.— 
‘‘(1) FAILURE TO REPORT.—
910 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), except as provided in paragraph (2), 
any reporting entity that fails to submit infor-
mation required under subsection (a) or (b), as 
applicable, in a timely manner in accordance 
with regulations promulgated to carry out such 
applicable subsection shall be subject to a civil 
money penalty of not less than $1,000, but not 
more than $10,000, for each payment or other 
transfer of value or ownership or investment in-
terest not reported as required under such sub-
section. Such penalty shall be imposed and col-
lected in the same manner as civil money pen-
alties under subsection (a) of section 1128A are 
imposed and collected under that section. 
‘‘(B) LIMITATION.—The total amount of 
civil money penalties imposed under subpara-
graph (A), with respect to each annual submis-
sion of information under subsection (a) by a 
reporting entity, shall not exceed $150,000. 
‘‘(2) KNOWING FAILURE TO REPORT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), any reporting entity that knowingly 
fails to submit information required under sub-
section (a) or (b), as applicable, in a timely
911 
manner in accordance with regulations promul-
gated to carry out such applicable subsection, 
shall be subject to a civil money penalty of not 
less 
than 
$10,000, 
but 
not 
more 
than 
$100,000, for each payment or other transfer of 
value or ownership or investment interest not 
reported as required under such subsection. 
Such penalty shall be imposed and collected in 
the same manner as civil money penalties under 
subsection (a) of section 1128A are imposed 
and collected under that section. 
‘‘(B) LIMITATION.—The total amount of 
civil money penalties imposed under subpara-
graph (A) with respect to each annual submis-
sion of information under subsection (a) or (b) 
by an applicable reporting entity shall not ex-
ceed $1,000,000, or, if greater, 0.1 percentage 
of the total annual revenues of the reporting en-
tity. 
‘‘(3) USE OF FUNDS.—Funds collected by the 
Secretary as a result of the imposition of a civil 
money penalty under this subsection shall be used to 
carry out this section. 
‘‘(4) ENFORCEMENT THROUGH STATE ATTOR-
NEYS GENERAL.—The attorney general of a State,
912 
after providing notice to the Secretary of an intent 
to proceed under this paragraph in a specific case 
and providing the Secretary with an opportunity to 
bring an action under this subsection and the Sec-
retary declining such opportunity, may proceed 
under this subsection against an applicable manufac-
turer or distributor in the State. 
‘‘(e) ANNUAL REPORT
TO CONGRESS.—Not later 
than April 1 of each year beginning with 2011, the Sec-
retary shall submit to Congress a report that includes the 
following: 
‘‘(1) The information submitted under this sec-
tion during the preceding year, aggregated for each 
applicable reporting entity that submitted such in-
formation during such year. 
‘‘(2) A description of any enforcement actions 
taken to carry out this section, including any pen-
alties imposed under subsection (d), during the pre-
ceding year. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) APPLICABLE
DISTRIBUTOR.—The term 
‘applicable distributor’ means— 
‘‘(A) any entity, other than an applicable 
group purchasing organization, that buys and 
resells, or receives a commission or other simi-
913 
lar form of payment, from another seller, for 
selling or arranging for the sale of a covered 
drug, device, biological, or medical supply; or 
‘‘(B) any entity under common ownership 
with such an entity described in subparagraph 
(A) and which provides assistance or support to 
such entity so described with respect to the pro-
duction, 
preparation, 
propagation, 
compounding, 
conversion, 
processing, 
mar-
keting, or distribution of a covered drug, device, 
biological, or medical supply. 
Such term does not include a wholesale pharma-
ceutical distributor. 
‘‘(2) APPLICABLE MANUFACTURER.—The term 
‘applicable manufacturer’ means any entity which is 
engaged in the production, preparation, propagation, 
compounding, conversion, processing, marketing, or 
manufacturer-direct distribution of a covered drug, 
device, biological, or medical supply (or any entity 
under common ownership with such entity and which 
provides assistance or support to such entity with re-
spect to the production, preparation, propagation, 
compounding, conversion, processing, marketing, or 
distribution or a covered drug, device, biological, or 
medical supply). For purposes of this section only,
914 
such term does not include a retail pharmacy li-
censed under State law. 
‘‘(3) CLINICAL
INVESTIGATION.—The term 
‘clinical investigation’ means any experiment involv-
ing one or more human subjects, or materials de-
rived from human subjects, in which a drug or de-
vice is administered, dispensed, or used. 
‘‘(4) COVERED DRUG, DEVICE, BIOLOGICAL, OR 
MEDICAL SUPPLY.—The term ‘covered’ means, with 
respect to a drug, device, biological, or medical sup-
ply, such a drug, device, biological, or medical supply 
for which payment is available under title XVIII or 
a State plan under title XIX or XXI (or a waiver 
of such a plan). 
‘‘(5) COVERED RECIPIENT.—The term ‘covered 
recipient’ means the following: 
‘‘(A) A physician. 
‘‘(B) A physician group practice. 
‘‘(C) Any other prescriber of a covered 
drug, device, biological, or medical supply. 
‘‘(D) A pharmacy or pharmacist. 
‘‘(E) A health insurance issuer, group 
health plan, or other entity offering a health 
benefits plan, including any employee of such 
an issuer, plan, or entity.
915 
‘‘(F) A pharmacy benefit manager, includ-
ing any employee of such a manager. 
‘‘(G) A hospital. 
‘‘(H) A medical school. 
‘‘(I) A sponsor of a continuing medical 
education program. 
‘‘(J) A patient advocacy or disease specific 
group. 
‘‘(K) A organization of health care profes-
sionals. 
‘‘(L) A biomedical researcher. 
‘‘(M) A group purchasing organization. 
‘‘(6) EMPLOYEE.—The term ‘employee’ has the 
meaning given such term in section 1877(h)(2). 
‘‘(7) KNOWINGLY.—The term ‘knowingly’ has 
the meaning given such term in section 3729(b) of 
title 31, United States Code. 
‘‘(8) PAYMENT
OR
OTHER
TRANSFER
OF 
VALUE.— 
‘‘(A) IN GENERAL.—The term ‘payment or 
other transfer of value’ means a transfer of 
anything of value for or of any of the following: 
‘‘(i) Gift, food, or entertainment. 
‘‘(ii) Travel or trip. 
‘‘(iii) Honoraria.
916 
‘‘(iv) Research funding or grant. 
‘‘(v) Education or conference funding. 
‘‘(vi) Consulting fees. 
‘‘(vii) Ownership or investment inter-
est and royalties or license fee. 
‘‘(B) INCLUSIONS.—Subject to subpara-
graph (C), the term ‘payment or other transfer 
of value’ includes any compensation, gift, hono-
rarium, speaking fee, consulting fee, travel, 
services, dividend, profit distribution, stock or 
stock option grant, or any ownership or invest-
ment interest held by a physician in a manufac-
turer (excluding a dividend or other profit dis-
tribution from, or ownership or investment in-
terest in, a publicly traded security or mutual 
fund (as described in section 1877(c))). 
‘‘(C) EXCLUSIONS.—The term ‘payment or 
other transfer of value’ does not include the fol-
lowing: 
‘‘(i) Any payment or other transfer of 
value provided by an applicable manufac-
turer or distributor to a covered recipient 
where the amount transferred to, requested 
by, or designated on behalf of the covered 
recipient does not exceed $5.
917 
‘‘(ii) The loan of a covered device for 
a short-term trial period, not to exceed 90 
days, to permit evaluation of the covered 
device by the covered recipient. 
‘‘(iii) Items or services provided under 
a contractual warranty, including the re-
placement of a covered device, where the 
terms of the warranty are set forth in the 
purchase or lease agreement for the cov-
ered device. 
‘‘(iv) A transfer of anything of value 
to a covered recipient when the covered re-
cipient is a patient and not acting in the 
professional capacity of a covered recipient. 
‘‘(v) In-kind items used for the provi-
sion of charity care. 
‘‘(vi) A dividend or other profit dis-
tribution from, or ownership or investment 
interest in, a publicly traded security and 
mutual fund (as described in section 
1877(c)). 
‘‘(vii) Compensation paid by an appli-
cable manufacturer or distributor to a cov-
ered recipient who is directly employed by
918 
and works solely for such manufacturer or 
distributor. 
‘‘(viii) Payments made to a covered 
recipient by an applicable manufacturer or 
by a health plan affiliated with an applica-
ble manufacturer for medical care provided 
to employees of such manufacturer or their 
dependents. 
‘‘(ix) Any discount (including a re-
bate). 
‘‘(x) Any payment or other transfer of 
value that is made to a covered recipient 
indirectly through an entity other than the 
applicable manufacturer in connection with 
an activity or service— 
‘‘(I) in which the applicable man-
ufacturer is unaware of the identity of 
the covered recipient and is not using 
such activity or service to market its 
product to the covered recipient; and 
‘‘(II) that is not designed to mar-
ket or promote the product to the cov-
ered recipient. 
‘‘(xi) In the case of an applicable 
manufacturer who offers a self-insured
919 
plan, payments for the provision of health 
care to employees under the plan. 
‘‘(9) PHYSICIAN.—The term ‘physician’ has the 
meaning given that term in section 1861(r). For 
purposes of this section, such term does not include 
a physician who is an employee of the applicable 
manufacturer that is required to submit information 
under subsection (a). 
‘‘(10) REPORTING ENTITY.—The term ‘report-
ing entity’ means— 
‘‘(A) with respect to the reporting require-
ment under subsection (a), an applicable manu-
facturer or distributor of a covered drug, device, 
biological, or medical supply required to report 
under such subsection; and 
‘‘(B) with respect to the reporting require-
ment under subsection (b), a hospital, other 
health care entity, applicable manufacturer, ap-
plicable distributor, or applicable group pur-
chasing organization required to report physi-
cian ownership under such subsection. 
‘‘(g) ANNUAL REPORTS TO STATES.—Not later than 
April 1 of each year beginning with 2011, the Secretary 
shall submit to States a report that includes a summary 
of the information submitted under subsections (a), (b),
920 
and (e) during the preceding year with respect to covered 
recipients or other hospitals and entities in the State. 
‘‘(h) RELATION TO STATE LAWS.— 
‘‘(1) IN
GENERAL.—Effective on January 1, 
2011, subject to paragraph (2), the provisions of 
this section shall preempt any law or regulation of 
a State or of a political subdivision of a State that 
requires an applicable manufacturer and applicable 
distributor (as such terms are defined in subsection 
(f)) to disclose or report, in any format, the type of 
information (described in subsection (a)) regarding a 
payment or other transfer of value provided by the 
manufacturer to a covered recipient (as so defined). 
‘‘(2) NO
PREEMPTION
OF
ADDITIONAL
RE-
QUIREMENTS.—Paragraph (1) shall not preempt any 
statute or regulation of a State or political subdivi-
sion of a State that requires any of the following: 
‘‘(A) The disclosure or reporting of infor-
mation not of the type required to be disclosed 
or reported under this section. 
‘‘(B) The disclosure or reporting, in any 
format, of information described in subsection 
(f)(8)(C), except in the case of information de-
scribed in clause (i) of subsection (f)(8)(C).
921 
‘‘(C) The disclosure or reporting, in any 
format, of the type of information by any per-
son or entity other than an applicable manufac-
turer (as so defined) or a covered recipient (as 
defined in subsection (f)). 
‘‘(D) The disclosure or reporting, in any 
format, of the type of information required to 
be disclosed or reported under this section to a 
Federal, State, or local governmental agency for 
public health surveillance, investigation, or 
other public health purposes or health oversight 
purposes. 
Nothing in paragraph (1) shall be construed to limit 
the discovery or admissibility of information de-
scribed in this paragraph in a criminal, civil, or ad-
ministrative proceeding.’’. 
(b) AVAILABILITY OF INFORMATION FROM THE DIS-
CLOSURE
OF
FINANCIAL
RELATIONSHIP
REPORT 
(DFRR).—The Secretary of Health and Human Services 
shall submit to Congress a report on the full results of 
the Disclosure of Physician Financial Relationships sur-
veys required pursuant to section 5006 of the Deficit Re-
duction Act of 2005. Such report shall be submitted to 
Congress not later than the date that is 6 months after 
the date such surveys are collected and shall be made pub-
922 
licly available on an Internet website of the Department 
of Health and Human Services. 
(c) GAO REPORT.—Not later than December 31, 
2012, the Comptroller General of the United States shall 
submit to Congress a report on section 1128H of the So-
cial Security Act, as added by subsection (a). Such report 
shall address the extent to which important transfers of 
value are being adequately reported under such section 
(including unreported transfers required by such section 
as well as transfers not required to be reported by such 
section), the impact on States of the Federal preemption 
provision under subsection (h) of such section, whether 
changes have occurred in the pattern of payments as a 
result of efforts to evade reporting requirements, a de-
scription of the financial relationships subject to delayed 
reporting under subsection (a) of such section, and any 
recommended improvements to the collection or the anal-
ysis of data reported under such section.
923 
Subtitle E—Public Reporting on 
Health Care-Associated Infections 
SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY 
HOSPITALS 
AND 
AMBULATORY 
SURGICAL 
CENTERS ON HEALTH CARE-ASSOCIATED IN-
FECTIONS. 
(a) IN GENERAL.—Title XI of the Social Security Act 
is amended by inserting after section 1138 the following 
section: 
‘‘SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY 
HOSPITALS 
AND 
AMBULATORY 
SURGICAL 
CENTERS ON HEALTH CARE-ASSOCIATED IN-
FECTIONS. 
‘‘(a) REPORTING REQUIREMENT.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
that a hospital (as defined in subsection (g)) or am-
bulatory surgical center meeting the requirements of 
titles XVIII or XIX may participate in the programs 
established under such titles only if, in accordance 
with this section, the hospital or center reports such 
information on health care-associated infections that 
develop in the hospital or center (and such demo-
graphic information associated with such infections) 
as the Secretary specifies.
924 
‘‘(2) REPORTING PROTOCOLS.— Such informa-
tion shall be reported in accordance with reporting 
protocols established by the Secretary through the 
Director of the Centers for Disease Control and Pre-
vention (in this section referred to as the ‘CDC’) 
and to the National Healthcare Safety Network of 
the CDC or under such another reporting system of 
such Centers as determined appropriate by the Sec-
retary in consultation with such Director. 
‘‘(3) COORDINATION
WITH
HIT.—The Sec-
retary, through the Director of the CDC and the Of-
fice of the National Coordinator for Health Informa-
tion Technology, shall ensure that the transmission 
of information under this subsection is coordinated 
with systems established under the HITECH Act, 
where appropriate. 
‘‘(4) PROCEDURES TO ENSURE THE VALIDITY 
OF
INFORMATION.—The Secretary shall establish 
procedures regarding the validity of the information 
submitted under this subsection in order to ensure 
that such information is appropriately compared 
across hospitals and centers. Such procedures shall 
address failures to report as well as errors in report-
ing.
925 
‘‘(5) IMPLEMENTATION.—Not later than 1 year 
after the date of enactment of this section, the Sec-
retary, through the Director of CDC, shall promul-
gate regulations to carry out this section. 
‘‘(b) PUBLIC POSTING OF INFORMATION.—The Sec-
retary shall promptly post, on the official public Internet 
site of the Department of Health and Human Services, 
the information reported under subsection (a). Such infor-
mation shall be set forth in a manner that allows for the 
comparison of information on health care-associated infec-
tions— 
‘‘(1) among hospitals and ambulatory surgical 
centers; and 
‘‘(2) by demographic information. 
‘‘(c) ANNUAL REPORT TO CONGRESS.—On an annual 
basis the Secretary shall submit to the Congress a report 
that summarizes each of the following: 
‘‘(1) The number and types of health care-asso-
ciated infections reported under subsection (a) in 
hospitals and ambulatory surgical centers during 
such year. 
‘‘(2) Factors that contribute to the occurrence 
of such infections, including health care worker im-
munization rates.
926 
‘‘(3) Based on the most recent information 
available to the Secretary on the composition of the 
professional staff of hospitals and ambulatory sur-
gical centers, the number of certified infection con-
trol professionals on the staff of hospitals and ambu-
latory surgical centers. 
‘‘(4) The total increases or decreases in health 
care costs that resulted from increases or decreases 
in the rates of occurrence of each such type of infec-
tion during such year. 
‘‘(5) Recommendations, in coordination with the 
Center for Quality Improvement established under 
section 931 of the Public Health Service Act, for 
best practices to eliminate the rates of occurrence of 
each such type of infection in hospitals and ambula-
tory surgical centers. 
‘‘(d) NON-PREEMPTION OF STATE LAWS.—Nothing 
in this section shall be construed as preempting or other-
wise affecting any provision of State law relating to the 
disclosure of information on health care-associated infec-
tions or patient safety procedures for a hospital or ambu-
latory surgical center. 
‘‘(e) HEALTH CARE-ASSOCIATED INFECTION.—For 
purposes of this section:
927 
‘‘(1) IN GENERAL.—The term ‘health care-asso-
ciated infection’ means an infection that develops in 
a patient who has received care in any institutional 
setting where health care is delivered and is related 
to receiving health care. 
‘‘(2) RELATED TO RECEIVING HEALTH CARE.— 
The term ‘related to receiving health care’, with re-
spect to an infection, means that the infection was 
not incubating or present at the time health care 
was provided. 
‘‘(f) APPLICATION
TO
CRITICAL
ACCESS
HOS-
PITALS.—For purposes of this section, the term ‘hospital’ 
includes a critical access hospital, as defined in section 
1861(mm)(1).’’. 
(b) EFFECTIVE DATE.—With respect to section 
1138A of the Social Security Act (as inserted by sub-
section (a) of this section), the requirement under such 
section that hospitals and ambulatory surgical centers 
submit reports takes effect on such date (not later than 
2 years after the date of the enactment of this Act) as 
the Secretary of Health and Human Services shall specify. 
In order to meet such deadline, the Secretary may imple-
ment such section through guidance or other instructions. 
(c) GAO REPORT.—Not later than 18 months after 
the date of the enactment of this Act, the Comptroller
928 
General of the United States shall submit to Congress a 
report on the program established under section 1138A 
of the Social Security Act, as inserted by subsection (a). 
Such report shall include an analysis of the appropriate-
ness of the types of information required for submission, 
compliance with reporting requirements, the success of the 
validity procedures established, and any conflict or overlap 
between the reporting required under such section and any 
other reporting systems mandated by either the States or 
the Federal Government. 
(d) REPORT ON ADDITIONAL DATA.—Not later than 
18 months after the date of the enactment of this Act, 
the Secretary of Health and Human Services shall submit 
to the Congress a report on the appropriateness of expand-
ing the requirements under such section to include addi-
tional information (such as health care worker immuniza-
tion rates), in order to improve health care quality and 
patient safety. 
TITLE V—MEDICARE GRADUATE 
MEDICAL EDUCATION 
SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSI-
TIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Se-
curity Act (42 U.S.C. 1395ww(h)) is amended—
929 
(1) in paragraph (4)(F)(i), by striking ‘‘para-
graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 
(2) in paragraph (4)(H)(i), by striking ‘‘para-
graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 
(3) in paragraph (7)(E), by inserting ‘‘and 
paragraph (8)’’ after ‘‘this paragraph’’; and 
(4) by adding at the end the following new 
paragraph: 
‘‘(8) ADDITIONAL REDISTRIBUTION OF UNUSED 
RESIDENCY POSITIONS.— 
‘‘(A) REDUCTIONS IN LIMIT BASED ON UN-
USED POSITIONS.— 
‘‘(i) PROGRAMS SUBJECT TO REDUC-
TION.—If a hospital’s reference resident 
level (specified in clause (ii)) is less than 
the otherwise applicable resident limit (as 
defined in subparagraph (C)(ii)), effective 
for portions of cost reporting periods oc-
curring on or after July 1, 2011, the oth-
erwise applicable resident limit shall be re-
duced by 90 percent of the difference be-
tween such otherwise applicable resident 
limit and such reference resident level. 
‘‘(ii) REFERENCE RESIDENT LEVEL.—
930 
‘‘(I) IN
GENERAL.—Except as 
otherwise provided in a subsequent 
subclause, the reference resident level 
specified in this clause for a hospital 
is the highest resident level for any of 
the 3 most recent cost reporting peri-
ods (ending before the date of the en-
actment of this paragraph) of the hos-
pital for which a cost report has been 
settled (or, if not, submitted (subject 
to audit)), as determined by the Sec-
retary. 
‘‘(II) USE OF MOST RECENT AC-
COUNTING PERIOD TO RECOGNIZE EX-
PANSION OF EXISTING PROGRAMS.—If 
a hospital submits a timely request to 
increase its resident level due to an 
expansion, or planned expansion, of 
an existing residency training pro-
gram that is not reflected on the most 
recent settled or submitted cost re-
port, after audit and subject to the 
discretion of the Secretary, subject to 
subclause (IV), the reference resident 
level for such hospital is the resident
931 
level that includes the additional resi-
dents attributable to such expansion 
or establishment, as determined by 
the Secretary. The Secretary is au-
thorized to determine an alternative 
reference resident level for a hospital 
that submitted to the Secretary a 
timely request, before the start of the 
2009–2010 academic year, for an in-
crease in its reference resident level 
due to a planned expansion. 
‘‘(III) 
SPECIAL
PROVIDER 
AGREEMENT.—In the case of a hos-
pital 
described 
in 
paragraph 
(4)(H)(v), the reference resident level 
specified in this clause is the limita-
tion applicable under subclause (I) of 
such paragraph. 
‘‘(IV) 
PREVIOUS
REDISTRIBU-
TION.—The reference resident level 
specified in this clause for a hospital 
shall be increased to the extent re-
quired to take into account an in-
crease in resident positions made 
available to the hospital under para-
932 
graph (7)(B) that are not otherwise 
taken into account under a previous 
subclause. 
‘‘(iii) AFFILIATION.—The provisions 
of clause (i) shall be applied to hospitals 
which are members of the same affiliated 
group (as defined by the Secretary under 
paragraph (4)(H)(ii)) and to the extent the 
hospitals can demonstrate that they are 
filling any additional
resident slots allo-
cated to other hospitals through an affili-
ation agreement, the Secretary shall adjust 
the determination of available slots accord-
ingly, or which the Secretary otherwise has 
permitted the resident positions (under 
section 402 of the Social Security Amend-
ments of 1967) to be aggregated for pur-
poses of applying the resident position lim-
itations under this subsection. 
‘‘(B) REDISTRIBUTION.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall increase the otherwise applicable resi-
dent limit for each qualifying hospital that 
submits an application under this subpara-
graph by such number as the Secretary
933 
may approve for portions of cost reporting 
periods occurring on or after July 1, 2011. 
The estimated aggregate number of in-
creases in the otherwise applicable resident 
limit under this subparagraph may not ex-
ceed the Secretary’s estimate of the aggre-
gate reduction in such limits attributable 
to subparagraph (A). 
‘‘(ii) REQUIREMENTS
FOR
QUALI-
FYING
HOSPITALS.—A hospital is not a 
qualifying hospital for purposes of this 
paragraph unless the following require-
ments are met: 
‘‘(I) MAINTENANCE OF PRIMARY 
CARE
RESIDENT
LEVEL.—The hos-
pital maintains the number of primary 
care residents at a level that is not 
less than the base level of primary 
care residents increased by the num-
ber of additional primary care resi-
dent positions provided to the hospital 
under this subparagraph. For pur-
poses of this subparagraph, the ‘base 
level of primary care residents’ for a 
hospital is the level of such residents
934 
as of a base period (specified by the 
Secretary), determined without regard 
to whether such positions were in ex-
cess of the otherwise applicable resi-
dent limit for such period but taking 
into account the application of sub-
clauses (II) and (III) of subparagraph 
(A)(ii). 
‘‘(II) DEDICATED
ASSIGNMENT 
OF ADDITIONAL RESIDENT POSITIONS 
TO PRIMARY CARE.—The hospital as-
signs all such additional resident posi-
tions for primary care residents. 
‘‘(III) 
ACCREDITATION.—The 
hospital’s residency programs in pri-
mary care are fully accredited or, in 
the case of a residency training pro-
gram not in operation as of the base 
year, the hospital is actively applying 
for such accreditation for the program 
for such additional resident positions 
(as determined by the Secretary). 
‘‘(iii) CONSIDERATIONS
IN
REDIS-
TRIBUTION.—In determining for which 
qualifying hospitals the increase in the oth-
935 
erwise applicable resident limit is provided 
under this subparagraph, the Secretary 
shall take into account the demonstrated 
likelihood of the hospital filling the posi-
tions within the first 3 cost reporting peri-
ods beginning on or after July 1, 2011, 
made available under this subparagraph, 
as determined by the Secretary. 
‘‘(iv) PRIORITY
FOR
CERTAIN
HOS-
PITALS.—In determining for which quali-
fying hospitals the increase in the other-
wise applicable resident limit is provided 
under this subparagraph, the Secretary 
shall distribute the increase to qualifying 
hospitals based on the following criteria: 
‘‘(I) The Secretary shall give 
preference to hospitals that had a re-
duction in resident training positions 
under subparagraph (A). 
‘‘(II) The Secretary shall give 
preference to hospitals with 3-year 
primary care residency training pro-
grams, such as family practice and 
general internal medicine.
936 
‘‘(III) The Secretary shall give 
preference to hospitals insofar as they 
have in effect formal arrangements 
(as determined by the Secretary) that 
place greater emphasis upon training 
in Federally qualified health centers, 
rural health clinics, and other nonpro-
vider settings, and to hospitals that 
receive additional payments under 
subsection (d)(5)(F) and emphasize 
training in an outpatient department. 
‘‘(IV) The Secretary shall give 
preference to hospitals with a number 
of positions (as of July 1, 2009) in 
excess of the otherwise applicable resi-
dent limit for such period. 
‘‘(V) The Secretary shall give 
preference to hospitals that place 
greater emphasis upon training in a 
health professional shortage area (des-
ignated under section 332 of the Pub-
lic Health Service Act) or a health 
professional needs area (designated 
under section 2211 of such Act).
937 
‘‘(VI) The Secretary shall give 
preference to hospitals in States that 
have low resident-to-population ratios 
(including a greater preference for 
those States with lower resident-to- 
population ratios). 
‘‘(v) LIMITATION.—In no case shall 
more than 20 full-time equivalent addi-
tional residency positions be made available 
under this subparagraph with respect to 
any hospital. 
‘‘(vi) APPLICATION OF PER RESIDENT 
AMOUNTS FOR PRIMARY CARE.—With re-
spect to additional residency positions in a 
hospital attributable to the increase pro-
vided under this subparagraph, the ap-
proved FTE resident amounts are deemed 
to be equal to the hospital per resident 
amounts for primary care and nonprimary 
care computed under paragraph (2)(D) for 
that hospital. 
‘‘(vii) DISTRIBUTION.—The Secretary 
shall distribute the increase in resident 
training positions to qualifying hospitals
938 
under this subparagraph not later than 
July 1, 2011. 
‘‘(C) RESIDENT
LEVEL
AND
LIMIT
DE-
FINED.—In this paragraph: 
‘‘(i) The term ‘resident level’ has the 
meaning given such term in paragraph 
(7)(C)(i). 
‘‘(ii) The term ‘otherwise applicable 
resident limit’ means, with respect to a 
hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of 
paragraph (4) on the resident level for the 
hospital determined without regard to this 
paragraph but taking into account para-
graph (7)(A). 
‘‘(D) MAINTENANCE
OF
PRIMARY
CARE 
RESIDENT LEVEL.—In carrying out this para-
graph, the Secretary shall require hospitals that 
receive additional resident positions under sub-
paragraph (B)— 
‘‘(i) to maintain records, and periodi-
cally report to the Secretary, on the num-
ber of primary care residents in its resi-
dency training programs; and
944 
(A) an approved teaching health center 
shall contract with an accredited teaching hos-
pital to carry out the inpatient responsibilities 
of the primary care residency program of the 
hospital involved and is responsible for payment 
to the hospital for the hospital’s costs of the 
salary and fringe benefits for residents in the 
program; 
(B) the number of primary care residents 
of the center shall not count against the con-
tracting hospital’s resident limit; and 
(C) the contracting hospital shall agree not 
to diminish the number of residents in its pri-
mary care residency training program. 
(3) APPROVED TEACHING HEALTH CENTER DE-
FINED.—In this subsection, the term ‘‘approved 
teaching health center’’ means a nonprovider setting, 
such as a Federally qualified health center or rural 
health clinic (as defined in section 1861(aa) of the 
Social Security Act), that develops and operates an 
accredited primary care residency program for which 
funding would be available if it were operated by a 
hospital.