726 
‘‘(C) has 2 or more chronic illnesses, such 
as congestive heart failure, diabetes, other de-
mentias designated by the Secretary, chronic 
obstructive pulmonary disease, ischemic heart 
disease, 
stroke, 
Alzheimer’s 
Disease 
and 
neurodegenerative diseases, and other diseases 
and conditions designated by the Secretary 
which result in high costs under this title; 
‘‘(D) within the past 12 months has had a 
nonelective hospital admission; 
‘‘(E) within the past 12 months has re-
ceived acute or subacute rehabilitation services; 
‘‘(F) has 2 or more functional depend-
encies requiring the assistance of another per-
son (such as bathing, dressing, toileting, walk-
ing, or feeding); and 
‘‘(G) meets such other criteria as the Sec-
retary determines appropriate. 
‘‘(2) PATIENT
ELECTION
TO
PARTICIPATE.— 
The Secretary shall determine an appropriate meth-
od of ensuring that applicable beneficiaries have 
agreed to enroll in an independence at home medical 
practice under the demonstration program. Enroll-
ment in the demonstration program shall be vol-
untary. 
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‘‘(3) BENEFICIARY
ACCESS
TO
SERVICES.— 
Nothing in this section shall be construed as encour-
aging physicians or nurse practitioners to limit ap-
plicable beneficiary access to services covered under 
this title and applicable beneficiaries shall not be re-
quired to relinquish access to any benefit under this 
title as a condition of receiving services from an 
independence at home medical practice. 
‘‘(e) IMPLEMENTATION.— 
‘‘(1) STARTING DATE.—The demonstration pro-
gram shall begin not later than January 1, 2012. An 
agreement with an independence at home medical 
practice under the demonstration program may 
cover not more than a 3-year period. 
‘‘(2) NO
PHYSICIAN
DUPLICATION
IN
DEM-
ONSTRATION PARTICIPATION.—The Secretary shall 
not pay an independence at home medical practice 
under this section that participates in section 1866D 
or section 1866E. 
‘‘(3) NO BENEFICIARY DUPLICATION IN DEM-
ONSTRATION PARTICIPATION.—The Secretary shall 
ensure that no applicable beneficiary enrolled in an 
independence at home medical practice under this 
section is participating in the programs under sec-
tion 1866D or section 1866E. 
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‘‘(4) PREFERENCE.—In approving an independ-
ence at home medical practice, the Secretary shall 
give preference to practices that are— 
‘‘(A) located in high-cost areas of the 
country; 
‘‘(B) have experience in furnishing health 
care services to applicable beneficiaries in the 
home; and 
‘‘(C) use electronic medical records, health 
information technology, and individualized plans 
of care. 
‘‘(5) NUMBER OF PRACTICES.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the Secretary shall enter into agree-
ments with as many independence at home me-
dial practices as practicable and consistent with 
this subsection to test the potential of the inde-
pendence at home medical practice model under 
this section in order to achieve the results de-
scribed in subsection (a) across practices serv-
ing varying numbers of applicable beneficiaries. 
‘‘(B) LIMITATION.—In selecting qualified 
independence at home medial practices to par-
ticipate under the demonstration program, the 
Secretary shall limit the number of applicable 
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beneficiaries that may participate in the dem-
onstration program to 10,000. 
‘‘(6) WAIVER.—The Secretary may waive such 
provisions of this title and title XI as the Secretary 
determines necessary in order to implement the dem-
onstration program. 
‘‘(7) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code, shall not apply to this section. 
‘‘(f) EVALUATION AND MONITORING.— 
‘‘(1) IN GENERAL.—The Secretary shall evalu-
ate each independence at home medical practice 
under the demonstration program to assess whether 
the practice achieved the results described in sub-
section (a). 
‘‘(2) 
FOLLOWING
APPLICABLE
BENE-
FICIARIES.—The Secretary may monitor data on ex-
penditures and quality of services under this title 
after an applicable beneficiary discontinues receiving 
services under this title through a qualifying inde-
pendence at home medical practice. 
‘‘(g) REPORTS TO CONGRESS.—The Secretary shall 
conduct an independent evaluation of the demonstration 
program and submit to Congress a final report, including 
best practices under the demonstration program. Such re-
port shall include an analysis of the demonstration pro-
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gram on coordination of care, expenditures under this 
title, applicable beneficiary access to services, and the 
quality of health care services provided to applicable bene-
ficiaries. 
‘‘(h) FUNDING.—For purposes of administering and 
carrying out the demonstration program, other than for 
payments for items and services furnished under this title 
and shared savings under subsection (c), in addition to 
funds otherwise appropriated, there shall be transferred 
to the Secretary for the Center for Medicare & Medicaid 
Services Program Management Account from the Federal 
Hospital Insurance Trust Fund under section 1817 and 
the Federal Supplementary Medical Insurance Trust 
Fund under section 1841 $5,000,000 for each of fiscal 
years 2010 through 2015. Amounts transferred under this 
subsection for a fiscal year shall be available until ex-
pended. 
‘‘(i) ANTIDISCRIMINATION LIMITATION.—The Sec-
retary shall not enter into an agreement with an entity 
to provide health care items or services under the dem-
onstration program unless such entity guarantees that for 
individuals eligible to be enrolled in such program, the en-
tity will not deny, limit, or condition the coverage or provi-
sion of benefits to which the individual would have other-
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wise been entitled to on the basis of health status if not 
included in this program. 
‘‘(j) TERMINATION.—The Secretary may terminate 
an agreement with an independence at home medical prac-
tice if such practice does not receive incentive payments 
under subsection (c)(2) or consistently fails to meet qual-
ity standards.’’. 
SEC. 1313. RECOGNITION OF CERTIFIED DIABETES EDU-
CATORS AS CERTIFIED PROVIDERS FOR PUR-
POSES OF MEDICARE DIABETES OUTPATIENT 
SELF-MANAGEMENT TRAINING SERVICES. 
(a) IN GENERAL.—Section 1861(qq) of the Social Se-
curity Act (42 U.S.C. 1395x(qq)) is amended— 
(1) in paragraph (1), by inserting ‘‘or by a cer-
tified diabetes educator (as defined in paragraph 
(3))’’ after ‘‘paragraph (2)(B)’’; and 
(2) by adding at the end the following new 
paragraphs: 
‘‘(3) For purposes of paragraph (1), the term 
‘certified diabetes educator’ means an individual 
who— 
‘‘(A) is licensed or registered by the State 
in which the services are performed as a health 
care professional; 
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‘‘(B) specializes in teaching individuals 
with diabetes to develop the necessary skills and 
knowledge to manage the individual’s diabetic 
condition; and 
‘‘(C) is certified as a diabetes educator by 
a recognized certifying body (as defined in 
paragraph (4)). 
‘‘(4)(A) For purposes of paragraph (3)(C), the 
term ‘recognized certifying body’ means— 
‘‘(i) the National Certification Board for 
Diabetes Educators, or 
‘‘(ii) a certifying body for diabetes edu-
cators, which is recognized by the Secretary as 
authorized to grant certification of diabetes 
educators for purposes of this subsection pursu-
ant to standards established by the Secretary, 
if the Secretary determines such Board or body, 
respectively, meets the requirement of subpara-
graph (B). 
‘‘(B) The National Certification Board for Dia-
betes Educators or a certifying body for diabetes 
educators meets the requirement of this subpara-
graph, with respect to the certification of an indi-
vidual, if the Board or body, respectively, is incor-
porated and registered to do business in the United 
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States and requires as a condition of such certifi-
cation each of the following: 
‘‘(i) The individual has a qualifying cre-
dential in a specified health care profession. 
‘‘(ii) The individual has professional prac-
tice experience in diabetes self-management 
training that includes a minimum number of 
hours and years of experience in such training. 
‘‘(iii) The individual has successfully com-
pleted a national certification examination of-
fered by such entity. 
‘‘(iv) The individual periodically renews 
certification status following initial certifi-
cation.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to diabetes outpatient self-man-
agement training services furnished on or after the first 
day of the first calendar year that is at least 6 months 
after the date of the enactment of this Act. 
TITLE IV—QUALITY 
Subtitle A—Comparative 
Effectiveness Research 
SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH. 
(a) IN GENERAL.—Title XI of the Social Security Act 
is amended by adding at the end the following new part: 
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‘‘PART D—COMPARATIVE EFFECTIVENESS RESEARCH 
‘‘COMPARATIVE EFFECTIVENESS RESEARCH 
‘‘SEC. 1181. (a) CENTER FOR COMPARATIVE EFFEC-
TIVENESS RESEARCH ESTABLISHED.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish within the Agency for Healthcare Research and 
Quality a Center for Comparative Effectiveness Re-
search (in this section referred to as the ‘Center’) to 
conduct, support, and synthesize research (including 
research conducted or supported under section 1013 
of the Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003) with respect to the 
outcomes, effectiveness, and appropriateness of 
health care services and procedures in order to iden-
tify the manner in which diseases, disorders, and 
other health conditions can most effectively and ap-
propriately be prevented, diagnosed, treated, and 
managed clinically. 
‘‘(2) DUTIES.—The Center shall— 
‘‘(A) conduct, support, and synthesize re-
search relevant to the comparative effectiveness 
of the full spectrum of health care items, serv-
ices and systems, including pharmaceuticals, 
medical devices, medical and surgical proce-
dures, and other medical interventions; 
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‘‘(B) conduct and support systematic re-
views of clinical research, including original re-
search conducted subsequent to the date of the 
enactment of this section; 
‘‘(C) continuously develop rigorous sci-
entific methodologies for conducting compara-
tive effectiveness studies, and use such meth-
odologies appropriately; 
‘‘(D) submit to the Comparative Effective-
ness Research Commission, the Secretary, and 
Congress appropriate relevant reports described 
in subsection (d)(2); 
‘‘(E) not later than one year after the date 
of the enactment of this section, enter into an 
arrangement under which the Institute of Medi-
cine of the National Academy of Sciences shall 
conduct an evaluation and report on standards 
of evidence for highly credible research; 
‘‘(F) encourage, as appropriate, the devel-
opment and use of clinical registries and the de-
velopment of clinical effectiveness research data 
networks from electronic health records, post 
marketing drug and medical device surveillance 
efforts, and other forms of electronic health 
data; and 
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‘‘(G) appoint clinical perspective advisory 
panels for research priorities under this section, 
which shall consult with patients and other 
stakeholders and advise the Center on research 
questions, methods, and evidence gaps in terms 
of clinical outcomes for the specific research in-
quiry to be examined with respect to such pri-
ority to ensure that the information produced 
from such research is clinically relevant to deci-
sions made by clinicians and patients at the 
point of care. 
‘‘(3) POWERS.— 
‘‘(A) OBTAINING
OFFICIAL
DATA.—The 
Center may secure directly from any depart-
ment or agency of the United States informa-
tion necessary to enable it to carry out this sec-
tion. Upon request of the Center, the head of 
such department or agency shall furnish that 
information to the Center on an agreed upon 
schedule. 
‘‘(B) DATA
COLLECTION.—In order to 
carry out its functions, the Center shall— 
‘‘(i) utilize existing information, both 
published and unpublished, where possible, 
collected and assessed either by its own 
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staff or under other arrangements made in 
accordance with this section; 
‘‘(ii) carry out, or award grants or 
contracts for, original research and experi-
mentation, where existing information is 
inadequate; and 
‘‘(iii) adopt procedures allowing any 
interested party to submit information for 
the use by the Center in making reports 
and recommendations. 
In carrying out clause (ii), the Center may 
award grants or contracts (or provide for inter-
governmental transfers, as applicable) to pri-
vate entities and governmental agencies with 
experience in conducting comparative effective-
ness research, such as the National Institutes 
of Health and other relevant Federal health 
agencies. 
‘‘(C) ACCESS OF GAO TO INFORMATION.— 
The Comptroller General shall have unrestricted 
access to all deliberations, records, and non-
proprietary data of the Center and Commission 
under subsection (b), immediately upon request. 
‘‘(D) PERIODIC AUDIT.—The Center and 
Commission under subsection (b) shall be sub-
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ject to periodic audit by the Comptroller Gen-
eral. 
‘‘(b) COMPARATIVE
EFFECTIVENESS
RESEARCH 
COMMISSION.— 
‘‘(1) IN
GENERAL.—There is established an 
independent Comparative Effectiveness Research 
Commission (in this section referred to as the ‘Com-
mission’) to advise the Center and evaluate the ac-
tivities carried out by the Center under subsection 
(a) to ensure such activities result in highly credible 
research and information resulting from such re-
search. 
‘‘(2) DUTIES.—The Commission shall— 
‘‘(A)(i) recommend to the Center national 
priorities for research described in subsection 
(a) which shall take into account— 
‘‘(I) disease incidence, prevalence, and 
burden in the United States; 
‘‘(II) evidence gaps in terms of clinical 
outcomes; 
‘‘(III) variations in practice, delivery, 
and outcomes by geography, treatment 
site, provider type, disability, variation in 
age group (including children, adolescents, 
adults, and seniors), racial and ethnic 
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background, gender, genetic and molecular 
subtypes, and other appropriate popu-
lations or subpopulations; and 
‘‘(IV) the potential for new evidence 
concerning certain categories, health care 
services, or treatments to improve patient 
health and well-being, and the quality of 
care; and 
‘‘(ii) in making such recommendations con-
sult with a broad array of public and private 
stakeholders, including patients and health care 
providers and payers; 
‘‘(B) monitor the appropriateness of use of 
the CERTF described in subsection (g) with re-
spect to the timely production of comparative 
effectiveness research recommended to be a na-
tional priority under subparagraph (A); 
‘‘(C) identify highly credible research 
methods and standards of evidence for such re-
search to be considered by the Center; 
‘‘(D) review the methodologies developed 
by the center under subsection (a)(2)(C); 
‘‘(E) support forums to increase stake-
holder awareness and permit stakeholder feed-
back on the efforts of the Center to advance 
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methods and standards that promote highly 
credible research; 
‘‘(F) make recommendations to the Center 
for policies that would allow for public access of 
data produced under this section, in accordance 
with appropriate privacy and proprietary prac-
tices, while ensuring that the information pro-
duced through such data is timely and credible; 
‘‘(G) make recommendations to the Center 
for the priority for periodic reviews of previous 
comparative effectiveness research and studies 
conducted by the Center under subsection (a); 
‘‘(H) at least annually review the processes 
of the Center and make reports to Congress 
and the President regarding research con-
ducted, supported, or synthesized by the Center 
to confirm that the information produced by 
such research is objective, credible, consistent 
with standards of evidence developed under this 
section, and developed through a transparent 
process that includes consultations with appro-
priate stakeholders; 
‘‘(I) make recommendations to the Center 
for the broad dissemination, consistent with 
subsection (e), of the findings of research con-
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ducted and supported under this section that 
enables clinicians, patients, consumers, and 
payers to make more informed health care deci-
sions that improve quality and value; and 
‘‘(J) at least twice each year, hold a public 
meeting with an opportunity for stakeholder 
input. 
The reports under subparagraph (H) shall not be 
submitted to the Office of Management and Budget 
or to any other Federal agency or executive depart-
ment for any purpose prior to transmittal to Con-
gress and the President. Such reports shall be pub-
lished on the public internet website of the Commis-
sion after the date of such transmittal. 
‘‘(3) COMPOSITION OF COMMISSION.— 
‘‘(A) IN GENERAL.—The members of the 
Commission shall consist of— 
‘‘(i) the Director of the Agency for 
Healthcare Research and Quality or their 
designee; 
‘‘(ii) the Chief Medical Officer of the 
Centers for Medicare & Medicaid Services 
or their designee; 
‘‘(iii) the Director of the National In-
stitutes of Health or their designee; and 
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‘‘(iv) 16 additional members who shall 
represent broad constituencies of stake-
holders including clinicians, patients, re-
searchers, third-party payers, and con-
sumers of Federal and State beneficiary 
programs. 
Of such members, at least 10 shall be prac-
ticing physicians, health care practitioners, con-
sumers, or patients. 
‘‘(B) QUALIFICATIONS.— 
‘‘(i) DIVERSE
REPRESENTATION
OF 
PERSPECTIVES.—The 
members 
of 
the 
Commission shall represent a broad range 
of perspectives and shall collectively have 
experience in the following areas: 
‘‘(I) Epidemiology. 
‘‘(II) Health services research. 
‘‘(III) Bioethics. 
‘‘(IV) Decision sciences. 
‘‘(V) Health disparities. 
‘‘(VI) Health economics. 
‘‘(ii) DIVERSE
REPRESENTATION
OF 
HEALTH CARE COMMUNITY.—At least one 
member shall represent each of the fol-
lowing health care communities: 
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‘‘(I) Patients. 
‘‘(II) Health care consumers. 
‘‘(III) Practicing Physicians, in-
cluding surgeons. 
‘‘(IV) Other health care practi-
tioners engaged in clinical care. 
‘‘(V) Organizations with proven 
expertise in racial and ethnic minority 
health research. 
‘‘(VI) Employers. 
‘‘(VII) Public payers. 
‘‘(VIII) Insurance plans. 
‘‘(IX) Clinical researchers who 
conduct research on behalf of pharma-
ceutical or device manufacturers. 
‘‘(C) LIMITATION.—No more than 3 of the 
Members of the Commission may be representa-
tives of pharmaceutical or device manufacturers 
and such representatives shall be clinical re-
searchers 
described 
under 
subparagraph 
(B)(ii)(IX). 
‘‘(4) APPOINTMENT.—The Comptroller General 
shall appoint the members of the Commission. 
‘‘(5) CHAIRMAN; VICE CHAIRMAN.—The Comp-
troller General shall designate a member of the 
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Commission, at the time of appointment of the mem-
ber, as Chairman and a member as Vice Chairman 
for that term of appointment, except that in the case 
of vacancy of the Chairmanship or Vice Chairman-
ship, the Comptroller General may designate another 
member for the remainder of that member’s term. 
The Chairman shall serve as an ex officio member 
of the National Advisory Council of the Agency for 
Health Care Research and Quality under section 
931(c)(3)(B) of the Public Health Service Act. 
‘‘(6) TERMS.— 
‘‘(A) IN GENERAL.—Except as provided in 
subparagraph (B), each member of the Com-
mission shall be appointed for a term of 4 
years. 
‘‘(B) TERMS OF INITIAL APPOINTEES.—Of 
the members first appointed— 
‘‘(i) 8 shall be appointed for a term of 
4 years; and 
‘‘(ii) 8 shall be appointed for a term 
of 3 years. 
‘‘(7) COMPENSATION.—While serving on the 
business of the Commission (including travel time), 
a member of the Commission shall be entitled to 
compensation at the per diem equivalent of the rate 
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provided for level IV of the Executive Schedule 
under section 5315 of title 5, United States Code; 
and while so serving away from home and the mem-
ber’s regular place of business, a member may be al-
lowed travel expenses, as authorized by the Director 
of the Commission. 
‘‘(8) DIRECTOR
AND
STAFF; EXPERTS
AND 
CONSULTANTS.—Subject to such review as the 
Comptroller General deems necessary to assure the 
efficient administration of the Commission, the Com-
mission may— 
‘‘(A) appoint and set the compensation for 
an Executive Director (subject to the approval 
of the Comptroller General) and such other per-
sonnel as Federal employees under section 2105 
of title 5, United States Code, as may be nec-
essary to carry out its duties (without regard to 
the provisions of title 5, United States Code, 
governing appointments in the competitive serv-
ice); 
‘‘(B) seek such assistance and support as 
may be required in the performance of its du-
ties from appropriate Federal departments and 
agencies; 
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‘‘(C) enter into contracts or make other ar-
rangements, as may be necessary for the con-
duct of the work of the Commission (without 
regard to section 3709 of the Revised Statutes 
(41 U.S.C. 5)); 
‘‘(D) make advance, progress, and other 
payments which relate to the work of the Com-
mission; 
‘‘(E) provide transportation and subsist-
ence for persons serving without compensation; 
and 
‘‘(F) prescribe such rules and regulations 
as it deems necessary with respect to the inter-
nal organization and operation of the Commis-
sion. 
‘‘(9) OBTAINING
OFFICIAL
DATA.—The Com-
mission may secure directly from any department or 
agency of the United States information necessary 
to enable the Commission to carry out this section. 
Upon request of the Chairman of the Commission, 
the head of such department or agency shall furnish 
the information to the Commission on an agreed 
upon schedule. 
‘‘(10) AVAILABILITY OF REPORTS.—The Com-
mission shall transmit to the Secretary a copy of 
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each report submitted under this subsection and 
shall make such reports available to the public. 
‘‘(11) COORDINATION.—To enhance effective-
ness and coordination, the Secretary is encouraged, 
to the greatest extent possible, to seek coordination 
between the Commission and the National Advisory 
Council of the Agency for Healthcare Research and 
Quality. 
‘‘(12) CONFLICTS OF INTEREST.— 
‘‘(A) IN
GENERAL.—In appointing the 
members of the Commission or a clinical per-
spective advisory panel described in subsection 
(a)(2)(G), the Comptroller General or the Sec-
retary, respectively, shall take into consider-
ation any financial interest (as defined in sub-
paragraph (D)), consistent with this paragraph, 
and develop a plan for managing any identified 
conflicts. 
‘‘(B) EVALUATION AND CRITERIA.—When 
considering an appointment to the Commission 
or a clinical perspective advisory panel de-
scribed subsection (a)(2)(G), the Comptroller 
General or the Secretary, respectively, shall re-
view the expertise of the individual and the fi-
nancial disclosure report filed by the individual 
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pursuant to the Ethics in Government Act of 
1978 for each individual under consideration 
for the appointment, so as to reduce the likeli-
hood that an appointed individual will later re-
quire a written determination as referred to in 
section 208(b)(1) of title 18, United States 
Code, a written certification as referred to in 
section 208(b)(3) of title 18, United States 
Code, or a waiver as referred to in subpara-
graph (D)(iii) for service on the Commission at 
a meeting of the Commission. 
‘‘(C) DISCLOSURES; 
PROHIBITIONS
ON 
PARTICIPATION; WAIVERS.— 
‘‘(i) DISCLOSURE OF FINANCIAL IN-
TEREST.—Prior to a meeting of the Com-
mission or a clinical perspective advisory 
panel described in subsection (a)(2)(G) re-
garding a ‘particular matter’ (as that term 
is used in section 208 of title 18, United 
States Code), each member of the Commis-
sion or the clinical perspective advisory 
panel who is a full-time Government em-
ployee or special Government employee 
shall disclose to the Comptroller General or 
Secretary, respectively, financial interests 
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in accordance with requiring a waiver 
under section 208(b) of title 18, United 
States Code, or other interests as deemed 
relevant by the Secretary. 
‘‘(ii) PROHIBITIONS
ON
PARTICIPA-
TION.—Except as provided under clause 
(iii), a member of the Commission or a 
clinical perspective advisory panel de-
scribed in subsection (a)(2)(G) may not 
participate with respect to a particular 
matter considered in meeting of the Com-
mission or the clinical perspective advisory 
panel if such member has a financial inter-
est that could be affected by the advice 
given to the Secretary with respect to such 
matter, excluding interests exempted in 
regulations issued by the Director of the 
Office of Government Ethics as too remote 
or inconsequential to affect the integrity of 
the services of the Government officers or 
employees to which such regulations apply. 
‘‘(iii) WAIVER.—If the Comptroller 
General or Secretary, as applicable, deter-
mines it necessary to afford the Commis-
sion or a clinical perspective advisory panel 
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described in subsection (a)(2)(G) essential 
expertise, the Comptroller General or Sec-
retary, respectively, may grant a waiver of 
the prohibition in clause (ii) to permit a 
member described in such subparagraph 
to— 
‘‘(I) participate as a non-voting 
member with respect to a particular 
matter considered in a meeting of the 
Commission or a clinical perspective 
advisory panel, respectively; or 
‘‘(II) participate as a voting 
member with respect to a particular 
matter considered in a meeting of the 
Commission. 
‘‘(iv) LIMITATION
ON
WAIVERS
AND 
OTHER EXCEPTIONS.— 
‘‘(I) DETERMINATION OF ALLOW-
ABLE EXCEPTIONS FOR THE COMMIS-
SION.—The number of waivers grant-
ed to members of the Commission 
cannot exceed one-half of the total 
number of members for the Commis-
sion. 
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‘‘(II) PROHIBITION
ON
VOTING 
STATUS
ON
CLINICAL
PERSPECTIVE 
ADVISORY PANELS.—No voting mem-
ber of any clinical perspective advisory 
panel shall be in receipt of a waiver. 
No more than two nonvoting members 
of any clinical perspective advisory 
panel shall receive a waiver. 
‘‘(D) FINANCIAL
INTEREST
DEFINED.— 
For purposes of this paragraph, the term ‘fi-
nancial interest’ means a financial interest 
under section 208(a) of title 18, United States 
Code. 
‘‘(13) APPLICATION
OF
FACA.—The Federal 
Advisory Committee Act (other than section 14 of 
such Act) shall apply to the Commission to the ex-
tent that the provisions of such Act do not conflict 
with the requirements of this subsection. 
‘‘(c) RESEARCH REQUIREMENTS.—Any research con-
ducted, supported, or synthesized under this section shall 
meet the following requirements: 
‘‘(1) ENSURING TRANSPARENCY, CREDIBILITY, 
AND ACCESS.— 
‘‘(A) The establishment of a research agen-
da by the Center shall be informed by the na-
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tional priorities for research recommended 
under subsection (b)(2)(A). 
‘‘(B) The establishment of the agenda and 
conduct of the research shall be insulated from 
inappropriate political or stakeholder influence. 
‘‘(C) Methods of conducting such research 
shall be scientifically based. 
‘‘(D) Consistent with applicable law, all as-
pects of the prioritization of research, conduct 
of the research, and development of conclusions 
based on the research shall be transparent to 
all stakeholders. 
‘‘(E) Consistent with applicable law, the 
process and methods for conducting such re-
search shall be publicly documented and avail-
able to all stakeholders. 
‘‘(F) Throughout the process of such re-
search, the Center shall provide opportunities 
for all stakeholders involved to review and pro-
vide public comment on the methods and find-
ings of such research. 
‘‘(G) Such research shall consider advice 
given to the Center by the clinical perspective 
advisory panel for the particular national re-
search priority. 
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‘‘(2) STAKEHOLDER INPUT.— 
‘‘(A) IN GENERAL.—The Commission shall 
consult with patients, health care providers, 
health care consumer representatives, and other 
appropriate stakeholders with an interest in the 
research through a transparent process rec-
ommended by the Commission. 
‘‘(B) SPECIFIC
AREAS
OF
CONSULTA-
TION.—Consultation 
shall 
include 
where 
deemed appropriate by the Commission— 
‘‘(i) recommending research priorities 
and questions; 
‘‘(ii) recommending research meth-
odologies; and 
‘‘(iii) advising on and assisting with 
efforts to disseminate research findings. 
‘‘(C) OMBUDSMAN.—The Secretary shall 
designate a patient ombudsman. The ombuds-
man shall— 
‘‘(i) serve as an available point of con-
tact for any patients with an interest in 
proposed comparative effectiveness studies 
by the Center; and 
‘‘(ii) ensure that any comments from 
patients regarding proposed comparative 
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effectiveness studies are reviewed by the 
Center. 
‘‘(3) TAKING INTO ACCOUNT POTENTIAL DIF-
FERENCES.—Research shall— 
‘‘(A) be designed, as appropriate, to take 
into account the potential for differences in the 
effectiveness of health care items, services, and 
systems used with various subpopulations such 
as racial and ethnic minorities, women, dif-
ferent age groups (including children, adoles-
cents, adults, and seniors), individuals with dis-
abilities, 
and 
individuals 
with 
different 
comorbidities 
and 
genetic 
and 
molecular 
subtypes; and— 
‘‘(B) seek, as feasible and appropriate, to 
include members of such subpopulations as sub-
jects in the research. 
‘‘(d) PUBLIC ACCESS TO COMPARATIVE EFFECTIVE-
NESS INFORMATION.— 
‘‘(1) IN
GENERAL.—Not later than 90 days 
after receipt by the Center or Commission, as appli-
cable, of a relevant report described in paragraph 
(2) made by the Center, Commission, or clinical per-
spective advisory panel under this section, appro-
priate information contained in such report shall be 
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posted on the official public Internet site of the Cen-
ter and of the Commission, as applicable. 
‘‘(2) RELEVANT
REPORTS
DESCRIBED.—For 
purposes of this section, a relevant report is each of 
the following submitted by the Center or a grantee 
or contractor of the Center: 
‘‘(A) Any interim or progress reports as 
deemed appropriate by the Secretary. 
‘‘(B) Stakeholder comments. 
‘‘(C) A final report. 
‘‘(e) DISSEMINATION AND INCORPORATION OF COM-
PARATIVE EFFECTIVENESS INFORMATION.— 
‘‘(1) DISSEMINATION.—The Center shall pro-
vide for the dissemination of appropriate findings 
produced by research supported, conducted, or syn-
thesized under this section to health care providers, 
patients, vendors of health information technology 
focused on clinical decision support, relevant expert 
organizations (as defined in subsection (i)(3)(A)), 
and Federal and private health plans, and other rel-
evant stakeholders. In disseminating such findings 
the Center shall— 
‘‘(A) convey findings of research so that 
they are comprehensible and useful to patients 
and providers in making health care decisions; 
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‘‘(B) discuss findings and other consider-
ations specific to certain sub-populations, risk 
factors, and comorbidities as appropriate; 
‘‘(C) include considerations such as limita-
tions of research and what further research 
may be needed, as appropriate; 
‘‘(D) not include any data that the dis-
semination of which would violate the privacy of 
research participants or violate any confiden-
tiality agreements made with respect to the use 
of data under this section; and 
‘‘(E) assist the users of health information 
technology focused on clinical decision support 
to promote the timely incorporation of such 
findings into clinical practices and promote the 
ease of use of such incorporation. 
‘‘(2) DISSEMINATION PROTOCOLS AND STRATE-
GIES.—The Center shall develop protocols and strat-
egies for the appropriate dissemination of research 
findings in order to ensure effective communication 
of findings and the use and incorporation of such 
findings into relevant activities for the purpose of in-
forming higher quality and more effective and effi-
cient decisions regarding medical items and services. 
In developing and adopting such protocols and strat-
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egies, the Center shall consult with stakeholders con-
cerning the types of dissemination that will be most 
useful to the end users of information and may pro-
vide for the utilization of multiple formats for con-
veying findings to different audiences, including dis-
semination to individuals with limited English pro-
ficiency. 
‘‘(f) REPORTS TO CONGRESS.— 
‘‘(1) ANNUAL REPORTS.—Beginning not later 
than one year after the date of the enactment of this 
section, the Director of the Agency of Healthcare 
Research and Quality shall submit to Congress an 
annual report on the activities of the Center, as well 
as the research, conducted under this section. Each 
such report shall include a discussion of the Center’s 
compliance with subsection (c)(3)(B), including any 
reasons for lack of compliance with such subsection. 
‘‘(2) RECOMMENDATION FOR FAIR SHARE PER 
CAPITA AMOUNT FOR ALL-PAYER FINANCING.—Be-
ginning not later than December 31, 2011, the Sec-
retary shall submit to Congress an annual rec-
ommendation for a fair share per capita amount de-
scribed in subsection (c)(1) of section 9511 of the 
Internal Revenue Code of 1986 for purposes of 
funding the CERTF under such section. 
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‘‘(3) ANALYSIS AND REVIEW.—Not later than 
December 31, 2013, the Secretary, in consultation 
with the Commission, shall submit to Congress a re-
port on all activities conducted or supported under 
this section as of such date. Such report shall in-
clude an evaluation of the overall costs of such ac-
tivities and an analysis of the backlog of any re-
search proposals approved by the Center but not 
funded. 
‘‘(g) FUNDING
OF COMPARATIVE EFFECTIVENESS 
RESEARCH.—For fiscal year 2010 and each subsequent 
fiscal year, amounts in the Comparative Effectiveness Re-
search Trust Fund (referred to in this section as the 
‘CERTF’) under section 9511 of the Internal Revenue 
Code of 1986 shall be available in accordance with such 
section, without the need for further appropriations and 
without fiscal year limitation, to carry out this section. 
‘‘(h) CONSTRUCTION.— 
‘‘(1) COVERAGE.—Nothing in this section shall 
be construed— 
‘‘(A) to permit the Center or Commission 
to mandate coverage, reimbursement, or other 
policies for any public or private payer; or 
‘‘(B) as preventing the Secretary from cov-
ering the routine costs of clinical care received 
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by an individual entitled to, or enrolled for, ben-
efits under title XVIII, XIX, or XXI in the case 
where such individual is participating in a clin-
ical trial and such costs would otherwise be cov-
ered under such title with respect to the bene-
ficiary. 
‘‘(2) REPORTS AND FINDINGS.—None of the re-
ports submitted under this section or research find-
ings disseminated by the Center or Commission shall 
be construed as mandates, for payment, coverage, or 
treatment. 
‘‘(3) PROTECTING THE PHYSICIAN-PATIENT RE-
LATIONSHIP.—Nothing in this section shall be con-
strued to authorize any Federal officer or employee 
to exercise any supervision or control over the prac-
tice of medicine. 
‘‘(i) CONSULTATION WITH RELEVANT EXPERT OR-
GANIZATIONS.— 
‘‘(1) CONSULTATION PRIOR TO INITIATION OF 
RESEARCH.—Prior to recommending priorities or 
initiating research described in this section, the 
Commission or the Center shall consult with the rel-
evant expert organizations responsible for standards 
and protocols of clinical excellence. Such consulta-
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tion shall be consistent with the processes estab-
lished under subsection (c)(2). 
‘‘(2) CONSULTATION IN DISSEMINATION OF RE-
SEARCH.—Any dissemination of research from the 
Commission or the Center and findings made by the 
Commission or the Center shall be consistent with 
processes established under subsection (e) and 
shall— 
‘‘(A) be based upon evidence-based medi-
cine; and 
‘‘(B) take into consideration standards and 
protocols of clinical excellence developed by rel-
evant expert organizations. 
‘‘(3) DEFINITIONS.—For purposes of this sub-
section: 
‘‘(A) 
RELEVANT
EXPERT
ORGANIZA-
TIONS.—The term ‘relevant expert organization’ 
means an organization with expertise in the rig-
orous application of evidence-based scientific 
methods for the design of clinical studies, the 
interpretation of clinical data, and the develop-
ment of national clinical practice guidelines, in-
cluding a voluntary health organization, clinical 
specialty, or other professional organization 
that represents physicians based on the field of 
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medicine in which each such physician practices 
or is board certified. 
‘‘(B) STANDARDS
AND
PROTOCOLS
OF 
CLINICAL EXCELLENCE.—The term ‘standards 
and protocols of clinical excellence’ means clin-
ical or practice guidelines that consist of a set 
of directions or principles that is based on evi-
dence and is designed to assist a health care 
practitioner with decisions about appropriate di-
agnostic, therapeutic, or other clinical proce-
dures for specific clinical circumstances. 
‘‘(j) RESEARCH MAY NOT BE USED TO DENY OR RA-
TION CARE.—Nothing in this section shall be construed 
to make more stringent or otherwise change the standards 
or requirements for coverage of items and services under 
this Act.’’. 
(b) 
COMPARATIVE
EFFECTIVENESS
RESEARCH 
TRUST FUND; FINANCING FOR THE TRUST FUND.—For 
the provision establishing a Comparative Effectiveness Re-
search Trust Fund and financing such Trust Fund, see 
section 1802. 
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Subtitle B—Nursing Home 
Transparency 
PART 1—IMPROVING TRANSPARENCY OF INFOR-
MATION ON SKILLED NURSING FACILITIES, 
NURSING FACILITIES, AND OTHER LONG- 
TERM CARE FACILITIES 
SEC. 1411. REQUIRED DISCLOSURE OF OWNERSHIP AND 
ADDITIONAL DISCLOSABLE PARTIES INFOR-
MATION. 
(a) IN GENERAL.—Section 1124 of the Social Secu-
rity Act (42 U.S.C. 1320a–3) is amended by adding at 
the end the following new subsection: 
‘‘(c) REQUIRED DISCLOSURE OF OWNERSHIP AND 
ADDITIONAL DISCLOSABLE PARTIES INFORMATION.— 
‘‘(1) DISCLOSURE.—A facility (as defined in 
paragraph (6)(B)) shall have the information de-
scribed in paragraph (3) available— 
‘‘(A) during the period beginning on the 
date of the enactment of this subsection and 
ending on the date such information is made 
available to the public under section 1411(b) of 
the Affordable Health Care for America Act, 
for submission to the Secretary, the Inspector 
General of the Department of Health and 
Human Services, the State in which the facility 
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is located, and the State long-term care om-
budsman in the case where the Secretary, the 
Inspector General, the State, or the State long- 
term care ombudsman requests such informa-
tion; and 
‘‘(B) beginning on the effective date of the 
final regulations promulgated under paragraph 
(4)(A), for reporting such information in ac-
cordance with such final regulations. 
Nothing in subparagraph (A) shall be construed as 
authorizing a facility to dispose of or delete informa-
tion described in such subparagraph after the effec-
tive date of the final regulations promulgated under 
paragraph (4)(A). 
‘‘(2) PUBLIC AVAILABILITY OF INFORMATION.— 
During the period described in paragraph (1)(A), a 
facility shall— 
‘‘(A) make the information described in 
paragraph (3) available to the public upon re-
quest and update such information as may be 
necessary to reflect changes in such informa-
tion; and 
‘‘(B) post a notice of the availability of 
such information in the lobby of the facility in 
a prominent manner. 
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‘‘(3) INFORMATION DESCRIBED.— 
‘‘(A) IN GENERAL.—The following infor-
mation is described in this paragraph: 
‘‘(i) The information described in sub-
sections (a) and (b), subject to subpara-
graph (C). 
‘‘(ii) The identity of and information 
on— 
‘‘(I) each member of the gov-
erning body of the facility, including 
the name, title, and period of service 
of each such member; 
‘‘(II) each person or entity who is 
an officer, director, member, partner, 
trustee, or managing employee of the 
facility, including the name, title, and 
date of start of service of each such 
person or entity; and 
‘‘(III) each person or entity who 
is an additional disclosable party of 
the facility. 
‘‘(iii) A description of the organiza-
tional structure and the relationship of 
each person and entity described in sub-
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clauses (II) and (III) of clause (ii) to the 
facility and to one another. 
‘‘(B) SPECIAL RULE WHERE INFORMATION 
IS
ALREADY
REPORTED
OR
SUBMITTED.—To 
the extent that information reported by a facil-
ity to the Internal Revenue Service on Form 
990, information submitted by a facility to the 
Securities and Exchange Commission, or infor-
mation otherwise submitted to the Secretary or 
any other Federal agency contains the informa-
tion described in clauses (i), (ii), or (iii) of sub-
paragraph (A), the Secretary may allow, to the 
extent practicable, such Form or such informa-
tion to meet the requirements of paragraph (1) 
and to be submitted in a manner specified by 
the Secretary. 
‘‘(C) SPECIAL
RULE.—In applying sub-
paragraph (A)(i)— 
‘‘(i) with respect to subsections (a) 
and (b), ‘ownership or control interest’ 
shall include direct or indirect interests, in-
cluding such interests in intermediate enti-
ties; and 
‘‘(ii) subsection (a)(3)(A)(ii) shall in-
clude the owner of a whole or part interest 
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in any mortgage, deed of trust, note, or 
other obligation secured, in whole or in 
part, by the entity or any of the property 
or assets thereof, if the interest is equal to 
or exceeds 5 percent of the total property 
or assets of the entirety. 
‘‘(4) REPORTING.— 
‘‘(A) IN
GENERAL.—Not later than the 
date that is 2 years after the date of the enact-
ment of this subsection, the Secretary shall pro-
mulgate regulations requiring a facility to re-
port the information described in paragraph (3) 
to the Secretary in a standardized format, and 
such other regulations as are necessary to carry 
out this subsection. Such regulations shall 
specify the frequency of reporting, as deter-
mined by the Secretary. Such final regulations 
shall also require— 
‘‘(i) the reporting of such information 
on or after the first day of the first cal-
endar quarter beginning after the date 
that is 90 days after the date on which 
such final regulations are published in the 
Federal Register; and— 
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‘‘(ii) the certification, as a condition 
of participation under the program under 
title XVIII or XIX, that such information 
is accurate and current. 
‘‘(B) GUIDANCE.—The Secretary shall pro-
vide guidance and technical assistance to States 
on how to adopt the standardized format under 
subparagraph (A). 
‘‘(5) NO EFFECT ON EXISTING REPORTING RE-
QUIREMENTS.—Nothing in this subsection shall re-
duce, diminish, or alter any reporting requirement 
for a facility that is in effect as of the date of the 
enactment of this subsection. 
‘‘(6) DEFINITIONS.—In this subsection: 
‘‘(A) ADDITIONAL DISCLOSABLE PARTY.— 
The term ‘additional disclosable party’ means, 
with respect to a facility, any person or entity 
who, through ownership interest, partnership 
interest, contract, or otherwise— 
‘‘(i) directly or indirectly exercises 
operational, financial, administrative, or 
managerial control or direction over the fa-
cility or a part thereof, or provides policies 
or procedures for any of the operations of 
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the facility, or provides financial or cash 
management services to the facility; 
‘‘(ii) leases or subleases real property 
to the facility, or owns a whole or part in-
terest equal to or exceeding 5 percent of 
the total value of such real property; 
‘‘(iii) lends funds or provides a finan-
cial guarantee to the facility in an amount 
which is equal to or exceeds $50,000; or 
‘‘(iv) provides management or admin-
istrative services, clinical consulting serv-
ices, or accounting or financial services to 
the facility. 
‘‘(B) FACILITY.—The term ‘facility’ means 
a disclosing entity which is— 
‘‘(i) a skilled nursing facility (as de-
fined in section 1819(a)); or 
‘‘(ii) a nursing facility (as defined in 
section 1919(a)). 
‘‘(C) MANAGING
EMPLOYEE.—The term 
‘managing employee’ means, with respect to a 
facility, an individual (including a general man-
ager, business manager, administrator, director, 
or consultant) who directly or indirectly man-
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ages, advises, or supervises any element of the 
practices, finances, or operations of the facility. 
‘‘(D) ORGANIZATIONAL STRUCTURE.—The 
term ‘organizational structure’ means, in the 
case of— 
‘‘(i) a corporation, the officers, direc-
tors, and shareholders of the corporation 
who have an ownership interest in the cor-
poration which is equal to or exceeds 5 
percent; 
‘‘(ii) a limited liability company, the 
members and managers of the limited li-
ability company (including, as applicable, 
what percentage each member and man-
ager has of the ownership interest in the 
limited liability company); 
‘‘(iii) a general partnership, the part-
ners of the general partnership; 
‘‘(iv) a limited partnership, the gen-
eral partners and any limited partners of 
the limited partnership who have an own-
ership interest in the limited partnership 
which is equal to or exceeds 10 percent; 
‘‘(v) a trust, the trustees of the trust; 
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‘‘(vi) an individual, contact informa-
tion for the individual; and 
‘‘(vii) any other person or entity, such 
information as the Secretary determines 
appropriate.’’. 
(b) PUBLIC AVAILABILITY OF INFORMATION.—Not 
later than the date that is 1 year after the date on which 
the 
final 
regulations 
promulgated 
under 
section 
1124(c)(4)(A) of the Social Security Act, as added by sub-
section (a), are published in the Federal Register, the in-
formation reported in accordance with such final regula-
tions shall be made available to the public in accordance 
with procedures established by the Secretary of Health 
and Human Services. 
(a) CONFORMING AMENDMENTS.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(d)(1) of the Social Security Act (42 U.S.C. 
1395i–3(d)(1)) is amended by striking subparagraph 
(B) and redesignating subparagraph (C) as subpara-
graph (B). 
(2) NURSING FACILITIES.—Section 1919(d)(1) 
of the Social Security Act (42 U.S.C. 1396r(d)(1)) 
is amended by striking subparagraph (B) and redes-
ignating subparagraph (C) as subparagraph (B). 
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SEC. 1412. ACCOUNTABILITY REQUIREMENTS. 
(a) EFFECTIVE COMPLIANCE
AND ETHICS PRO-
GRAMS.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(d)(1) of the Social Security Act (42 U.S.C. 
1395i–3(d)(1)), as amended by section 1411(c)(1), 
is amended by adding at the end the following new 
subparagraph: 
‘‘(C) COMPLIANCE
AND
ETHICS
PRO-
GRAMS.— 
‘‘(i) REQUIREMENT.—On or after the 
first day of the first calendar quarter be-
ginning after the date that is 1 year after 
the date on which regulations developed 
under clause (ii) are published in the Fed-
eral Register, a skilled nursing facility 
shall, with respect to the entity that oper-
ates or controls the facility (in this sub-
paragraph referred to as the ‘operating or-
ganization’ or ‘organization’), have in oper-
ation a compliance and ethics program 
that is effective in preventing and detect-
ing criminal, civil, and administrative viola-
tions under this Act and in promoting 
quality of care consistent with such regula-
tions. 
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‘‘(ii) 
DEVELOPMENT
OF
REGULA-
TIONS.— 
‘‘(I) IN
GENERAL.—Not later 
than the date that is 2 years after the 
date of the enactment of this subpara-
graph, the Secretary, in consultation 
with the Inspector General of the De-
partment of Health and Human Serv-
ices, shall promulgate regulations for 
an effective compliance and ethics 
program for operating organizations, 
which may include a model compliance 
program. 
‘‘(II) 
DESIGN
OF
REGULA-
TIONS.—Such regulations with respect 
to specific elements or formality of a 
program may vary with the size of the 
organization, such that larger organi-
zations should have a more formal 
and rigorous program and include es-
tablished written policies defining the 
standards and procedures to be fol-
lowed by its employees. Such require-
ments shall specifically apply to the 
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corporate level management of multi- 
unit nursing home chains. 
‘‘(III) EVALUATION.—Not later 
than 3 years after the date on which 
compliance and ethics programs estab-
lished under this subparagraph are in 
operation pursuant to clause (i), the 
Secretary shall complete an evaluation 
of such programs. Such evaluation 
shall determine if such programs led 
to changes in deficiency citations, 
changes in quality performance, or 
changes in other metrics of resident 
quality of care. The Secretary shall 
submit to Congress a report on such 
evaluation and shall include in such 
report such recommendations regard-
ing changes in the requirements for 
such programs as the Secretary deter-
mines appropriate. 
‘‘(iii) REQUIREMENTS
FOR
COMPLI-
ANCE
AND
ETHICS
PROGRAMS.—In this 
subparagraph, the term ‘compliance and 
ethics program’ means, with respect to a 
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skilled nursing facility, a program of the 
operating organization that— 
‘‘(I) has been reasonably de-
signed, implemented, and enforced so 
that it generally will be effective in 
preventing and detecting criminal, 
civil, and administrative violations 
under this Act and in promoting qual-
ity of care; and 
‘‘(II) includes at least the re-
quired components specified in clause 
(iv). 
‘‘(iv) REQUIRED
COMPONENTS
OF 
PROGRAM.—The required components of a 
compliance and ethics program of an orga-
nization are the following: 
‘‘(I) The organization must have 
established compliance standards and 
procedures to be followed by its em-
ployees, contractors, and other agents 
that are reasonably capable of reduc-
ing the prospect of criminal, civil, and 
administrative violations under this 
Act. 
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‘‘(II) Specific individuals within 
high-level personnel of the organiza-
tion must have been assigned overall 
responsibility to oversee compliance 
with such standards and procedures 
and have sufficient resources and au-
thority to assure such compliance. 
‘‘(III) The organization must 
have used due care not to delegate 
substantial discretionary authority to 
individuals whom the organization 
knew, or should have known through 
the exercise of due diligence, had a 
propensity to engage in criminal, civil, 
and administrative violations under 
this Act. 
‘‘(IV) The organization must 
have taken steps to communicate ef-
fectively its standards and procedures 
to all employees and other agents, 
such as by requiring participation in 
training programs or by disseminating 
publications that explain in a practical 
manner what is required. 
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‘‘(V) The organization must have 
taken reasonable steps to achieve com-
pliance with its standards, such as by 
utilizing monitoring and auditing sys-
tems reasonably designed to detect 
criminal, civil, and administrative vio-
lations under this Act by its employ-
ees and other agents and by having in 
place and publicizing a reporting sys-
tem whereby employees and other 
agents could report violations by oth-
ers within the organization without 
fear of retribution. 
‘‘(VI) The standards must have 
been consistently enforced through ap-
propriate disciplinary mechanisms, in-
cluding, as appropriate, discipline of 
individuals responsible for the failure 
to detect an offense. 
‘‘(VII) After an offense has been 
detected, the organization must have 
taken all reasonable steps to respond 
appropriately to the offense and to 
prevent further similar offenses, in-
cluding repayment of any funds to 
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which it was not entitled and any nec-
essary modification to its program to 
prevent and detect criminal, civil, and 
administrative violations under this 
Act. 
‘‘(VIII) The organization must 
periodically undertake reassessment of 
its compliance program to identify 
changes necessary to reflect changes 
within the organization and its facili-
ties. 
‘‘(v) COORDINATION.—The provisions 
of this subparagraph shall apply with re-
spect to a skilled nursing facility in lieu of 
section 1874(d).’’. 
(2) NURSING FACILITIES.—Section 1919(d)(1) 
of the Social Security Act (42 U.S.C. 1396r(d)(1)), 
as amended by section 1411(c)(2), is amended by 
adding at the end the following new subparagraph: 
‘‘(C) COMPLIANCE
AND
ETHICS
PRO-
GRAM.— 
‘‘(i) REQUIREMENT.—On or after the 
first day of the first calendar quarter be-
ginning after the date that is 1 year after 
the date on which regulations developed 
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under clause (ii) are published in the Fed-
eral Register, a skilled nursing facility 
shall, with respect to the entity that oper-
ates or controls the facility (in this sub-
paragraph referred to as the ‘operating or-
ganization’ or ‘organization’), have in oper-
ation a compliance and ethics program 
that is effective in preventing and detect-
ing criminal, civil, and administrative viola-
tions under this Act and in promoting 
quality of care consistent with such regula-
tions. 
‘‘(iii) DEVELOPMENT
OF
REGULA-
TIONS.— 
‘‘(I) IN
GENERAL.—Not later 
than the date that is 2 years after the 
date of the enactment of this subpara-
graph, the Secretary, in consultation 
with the Inspector General of the De-
partment of Health and Human Serv-
ices, shall promulgate regulations for 
an effective compliance and ethics 
program for operating organizations, 
which may include a model compliance 
program. 
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‘‘(II) 
DESIGN
OF
REGULA-
TIONS.—Such regulations with respect 
to specific elements or formality of a 
program may vary with the size of the 
organization, such that larger organi-
zations should have a more formal 
and rigorous program and include es-
tablished written policies defining the 
standards and procedures to be fol-
lowed by its employees. Such require-
ments shall specifically apply to the 
corporate level management of multi- 
unit nursing home chains. 
‘‘(III) EVALUATION.—Not later 
than 3 years after the date on which 
compliance and ethics programs estab-
lished under this subparagraph are in 
operation pursuant to clause (i), the 
Secretary shall complete an evaluation 
of such programs. Such evaluation 
shall determine if such programs led 
to changes in deficiency citations, 
changes in quality performance, or 
changes in other metrics of resident 
quality of care. The Secretary shall 
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submit to Congress a report on such 
evaluation and shall include in such 
report such recommendations regard-
ing changes in the requirements for 
such programs as the Secretary deter-
mines appropriate. 
‘‘(v) REQUIREMENTS
FOR
COMPLI-
ANCE
AND
ETHICS
PROGRAMS.—In this 
subparagraph, the term ‘compliance and 
ethics program’ means, with respect to a 
nursing facility, a program of the oper-
ating organization that— 
‘‘(I) has been reasonably de-
signed, implemented, and enforced so 
that it generally will be effective in 
preventing and detecting criminal, 
civil, and administrative violations 
under this Act and in promoting qual-
ity of care; and 
‘‘(II) includes at least the re-
quired components specified in clause 
(iv). 
‘‘(vi) REQUIRED
COMPONENTS
OF 
PROGRAM.—The required components of a 
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compliance and ethics program of an orga-
nization are the following: 
‘‘(I) The organization must have 
established compliance standards and 
procedures to be followed by its em-
ployees and other agents that are rea-
sonably capable of reducing the pros-
pect of criminal, civil, and administra-
tive violations under this Act. 
‘‘(II) Specific individuals within 
high-level personnel of the organiza-
tion must have been assigned overall 
responsibility to oversee compliance 
with such standards and procedures 
and has sufficient resources and au-
thority to assure such compliance. 
‘‘(III) The organization must 
have used due care not to delegate 
substantial discretionary authority to 
individuals whom the organization 
knew, or should have known through 
the exercise of due diligence, had a 
propensity to engage in criminal, civil, 
and administrative violations under 
this Act. 
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‘‘(IV) The organization must 
have taken steps to communicate ef-
fectively its standards and procedures 
to all employees and other agents, 
such as by requiring participation in 
training programs or by disseminating 
publications that explain in a practical 
manner what is required. 
‘‘(V) The organization must have 
taken reasonable steps to achieve com-
pliance with its standards, such as by 
utilizing monitoring and auditing sys-
tems reasonably designed to detect 
criminal, civil, and administrative vio-
lations under this Act by its employ-
ees and other agents and by having in 
place and publicizing a reporting sys-
tem whereby employees and other 
agents could report violations by oth-
ers within the organization without 
fear of retribution. 
‘‘(VI) The standards must have 
been consistently enforced through ap-
propriate disciplinary mechanisms, in-
cluding, as appropriate, discipline of 
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individuals responsible for the failure 
to detect an offense. 
‘‘(VII) After an offense has been 
detected, the organization must have 
taken all reasonable steps to respond 
appropriately to the offense and to 
prevent further similar offenses, in-
cluding repayment of any funds to 
which it was not entitled and any nec-
essary modification to its program to 
prevent and detect criminal, civil, and 
administrative violations under this 
Act. 
‘‘(VIII) The organization must 
periodically undertake reassessment of 
its compliance program to identify 
changes necessary to reflect changes 
within the organization and its facili-
ties. 
‘‘(vii) 
COORDINATION.—The 
provi-
sions of this subparagraph shall apply with 
respect to a nursing facility in lieu of sec-
tion 1902(a)(77).’’. 
(b) QUALITY ASSURANCE AND PERFORMANCE IM-
PROVEMENT PROGRAM.— 
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(1) SKILLED
NURSING
FACILITIES.—Section 
1819(b)(1)(B) of the Social Security Act (42 U.S.C. 
1396r(b)(1)(B)) is amended— 
(A) by striking ‘‘ASSURANCE’’ and insert-
ing ‘‘ASSURANCE
AND
QUALITY
ASSURANCE 
AND PERFORMANCE IMPROVEMENT PROGRAM’’; 
(B) by designating the matter beginning 
with ‘‘A skilled nursing facility’’ as a clause (i) 
with the heading ‘‘IN GENERAL.—’’ and the ap-
propriate indentation; 
(C) in clause (i) (as so designated by sub-
paragraph (B)), by redesignating clauses (i) 
and (ii) as subclauses (I) and (II), respectively; 
and 
(D) by adding at the end the following new 
clause: 
‘‘(ii) QUALITY ASSURANCE AND PER-
FORMANCE IMPROVEMENT PROGRAM.— 
‘‘(I) IN
GENERAL.—Not later 
than December 31, 2011, the Sec-
retary shall establish and implement a 
quality assurance and performance 
improvement program (in this clause 
referred to as the ‘QAPI program’) 
for skilled nursing facilities, including 
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multi-unit chains of such facilities. 
Under the QAPI program, the Sec-
retary shall establish standards relat-
ing to such facilities and provide tech-
nical assistance to such facilities on 
the development of best practices in 
order to meet such standards. Not 
later than 1 year after the date on 
which the regulations are promulgated 
under subclause (II), a skilled nursing 
facility must submit to the Secretary 
a plan for the facility to meet such 
standards and implement such best 
practices, including how to coordinate 
the implementation of such plan with 
quality assessment and assurance ac-
tivities conducted under clause (i). 
‘‘(II) REGULATIONS.—The Sec-
retary shall promulgate regulations to 
carry out this clause.’’. 
(2) 
NURSING
FACILITIES.—Section 
1919(b)(1)(B) of the Social Security Act (42 U.S.C. 
1396r(b)(1)(B)) is amended— 
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(A) by striking ‘‘ASSURANCE’’ and insert-
ing ‘‘ASSURANCE
AND
QUALITY
ASSURANCE 
AND PERFORMANCE IMPROVEMENT PROGRAM’’; 
(B) by designating the matter beginning 
with ‘‘A nursing facility’’ as a clause (i) with 
the heading ‘‘IN GENERAL.—’’ and the appro-
priate indentation; and 
(C) by adding at the end the following new 
clause: 
‘‘(ii) QUALITY ASSURANCE AND PER-
FORMANCE IMPROVEMENT PROGRAM.— 
‘‘(I) IN
GENERAL.—Not later 
than December 31, 2011, the Sec-
retary shall establish and implement a 
quality assurance and performance 
improvement program (in this clause 
referred to as the ‘QAPI program’) 
for nursing facilities, including multi- 
unit chains of such facilities. Under 
the QAPI program, the Secretary 
shall establish standards relating to 
such facilities and provide technical 
assistance to such facilities on the de-
velopment of best practices in order to 
meet such standards. Not later than 1 
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year after the date on which the regu-
lations are promulgated under sub-
clause (II), a nursing facility must 
submit to the Secretary a plan for the 
facility to meet such standards and 
implement such best practices, includ-
ing how to coordinate the implementa-
tion of such plan with quality assess-
ment and assurance activities con-
ducted under clause (i). 
‘‘(II) REGULATIONS.—The Sec-
retary shall promulgate regulations to 
carry out this clause.’’. 
(3) PROPOSAL TO REVISE QUALITY ASSURANCE 
AND
PERFORMANCE
IMPROVEMENT
PROGRAMS.— 
The Secretary shall implement policies that modify 
and strengthen quality assurance and performance 
improvement programs in skilled nursing facilities 
and nursing facilities on a periodic basis, as deter-
mined by the Secretary. 
(4) FACILITY
PLAN.—Not later than 1 year 
after the date on which the regulations are promul-
gated under subclause (II) of clause (ii) of sections 
1819(b)(1)(B) and 1919(b)(1)(B) of the Social Se-
curity Act, as added by paragraphs (1) and (2), a 
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skilled nursing facility and a nursing facility must 
submit to the Secretary a plan for the facility to 
meet the standards under such regulations and im-
plement such best practices, including how to coordi-
nate the implementation of such plan with quality 
assessment and assurance activities conducted under 
clause (i) of such sections. 
(c) GAO STUDY
ON NURSING FACILITY UNDER-
CAPITALIZATION.— 
(1) IN GENERAL.—The Comptroller General of 
the United States shall conduct a study that exam-
ines the following: 
(A) The extent to which corporations that 
own or operate large numbers of nursing facili-
ties, taking into account ownership type (includ-
ing private equity and control interests), are 
undercapitalizing such facilities. 
(B) The effects of such undercapitalization 
on quality of care, including staffing and food 
costs, at such facilities. 
(C) Options to address such undercapital-
ization, such as requirements relating to surety 
bonds, liability insurance, or minimum capital-
ization. 
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(2) REPORT.—Not later than 18 months after 
the date of the enactment of this Act, the Comp-
troller General shall submit to Congress a report on 
the study conducted under paragraph (1). 
(3) NURSING FACILITY.—In this subsection, the 
term ‘‘nursing facility’’ includes a skilled nursing fa-
cility. 
SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819 of the Social 
Security Act (42 U.S.C. 1395i–3) is amended— 
(A) by redesignating subsection (i) as sub-
section (j); and 
(B) by inserting after subsection (h) the 
following new subsection: 
‘‘(i) NURSING HOME COMPARE WEBSITE.— 
‘‘(1) INCLUSION
OF
ADDITIONAL
INFORMA-
TION.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
ensure that the Department of Health and 
Human Services includes, as part of the infor-
mation provided for comparison of nursing 
homes on the official Internet website of the 
Federal Government for Medicare beneficiaries 
(commonly referred to as the ‘Nursing Home 
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Compare’ Medicare website) (or a successor 
website), the following information in a manner 
that is prominent, easily accessible, readily un-
derstandable to consumers of long-term care 
services, and searchable: 
‘‘(i) Information that is reported to 
the Secretary under section 1124(c)(4). 
‘‘(ii) Information on the ‘Special 
Focus Facility program’ (or a successor 
program) established by the Centers for 
Medicare and Medicaid Services, according 
to procedures established by the Secretary. 
Such procedures shall provide for the in-
clusion of information with respect to, and 
the names and locations of, those facilities 
that, since the previous quarter— 
‘‘(I) were newly enrolled in the 
program; 
‘‘(II) are enrolled in the program 
and have failed to significantly im-
prove; 
‘‘(III) are enrolled in the pro-
gram and have significantly improved; 
‘‘(IV) have graduated from the 
program; and 
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‘‘(V) have closed voluntarily or 
no longer participate under this title. 
‘‘(iii) Staffing data for each facility 
(including resident census data and data 
on the hours of care provided per resident 
per day) based on data submitted under 
subsection (b)(8)(C), including information 
on staffing turnover and tenure, in a for-
mat that is clearly understandable to con-
sumers of long-term care services and al-
lows such consumers to compare dif-
ferences in staffing between facilities and 
State and national averages for the facili-
ties. Such format shall include— 
‘‘(I) concise explanations of how 
to interpret the data (such as a plain 
English explanation of data reflecting 
‘nursing home staff hours per resident 
day’); 
‘‘(II) differences in types of staff 
(such as training associated with dif-
ferent categories of staff); 
‘‘(III) the relationship between 
nurse staffing levels and quality of 
care; and 
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‘‘(IV) an explanation that appro-
priate staffing levels vary based on 
patient case mix. 
‘‘(iv) Links to State internet websites 
with information regarding State survey 
and certification programs, links to Form 
2567 State inspection reports (or a suc-
cessor form) on such websites, information 
to guide consumers in how to interpret and 
understand such reports, and the facility 
plan of correction or other response to 
such report. 
‘‘(v) The standardized complaint form 
developed under subsection (f)(8), includ-
ing explanatory material on what com-
plaint forms are, how they are used, and 
how to file a complaint with the State sur-
vey and certification program and the 
State long-term care ombudsman program. 
‘‘(vi) Summary information on the 
number, type, severity, and outcome of 
substantiated complaints. 
‘‘(vii) The number of adjudicated in-
stances of criminal violations by employees 
of a nursing facility— 
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‘‘(I) that were committed inside 
the facility; 
‘‘(II) with respect to such in-
stances of violations or crimes com-
mitted inside of the facility that were 
the violations or crimes of abuse, ne-
glect, and exploitation, criminal sexual 
abuse, or other violations or crimes 
that resulted in serious bodily injury; 
and 
‘‘(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 (iv) identifying information on complain-
ants 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 
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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). 
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‘‘(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; and 
‘‘(iv) any other representatives of pro-
grams or groups the Secretary determines 
appropriate.’’. 
(2) TIMELINESS
OF
SUBMISSION
OF
SURVEY 
AND CERTIFICATION INFORMATION.— 
(A) IN GENERAL.—Section 1819(g)(5) of 
the Social Security Act (42 U.S.C. 1395i– 
3(g)(5)) is amended by adding at the end the 
following new subparagraph: 
‘‘(E) SUBMISSION OF SURVEY AND 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 
respecting any survey or certification rec-
ommendation made respecting a skilled nursing 
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facility (including any enforcement actions 
taken by the State or any Federal enforcement 
action recommended by the State) to the Sec-
retary not later than the date on which the 
State sends such information to the facility. 
The Secretary shall use the information sub-
mitted under the preceding sentence to update 
the information provided on the Nursing Home 
Compare Medicare website as expeditiously as 
practicable but not less frequently than quar-
terly.’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by this paragraph shall take effect 1 year 
after the date of the enactment of this Act. 
(3) SPECIAL FOCUS FACILITY PROGRAM.—Sec-
tion 1819(f) of such Act is amended by adding at 
the end the following new paragraph: 
‘‘(8) SPECIAL FOCUS FACILITY PROGRAM.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
conduct a special focus facility program for en-
forcement of requirements for skilled nursing 
facilities that the Secretary has identified as 
having a poor compliance history or that sub-
stantially failed to meet applicable requirements 
of this Act 
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‘‘(B) PERIODIC
SURVEYS.—Under such 
program the Secretary shall conduct surveys of 
each facility in the program not less than once 
every 6 months.’’. 
(b) NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1919 of the Social 
Security Act (42 U.S.C. 1396r) is amended— 
(A) by redesignating subsection (i) as sub-
section (j); and 
(B) by inserting after subsection (h) the 
following new subsection: 
‘‘(i) NURSING HOME COMPARE WEBSITE.— 
‘‘(1) INCLUSION
OF
ADDITIONAL
INFORMA-
TION.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
ensure that the Department of Health and 
Human Services includes, as part of the infor-
mation provided for comparison of nursing 
homes on the official internet website of the 
Federal Government for Medicare beneficiaries 
(commonly referred to as the ‘Nursing Home 
Compare’ Medicare website) (or a successor 
website), the following information in a manner 
that is prominent, easily accessible, readily un-
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derstandable to consumers of long-term care 
services, and searchable: 
‘‘(i) Information that is reported to 
the Secretary under section 1124(c)(4) 
‘‘(ii) Information on the ‘Special 
Focus Facility program’ (or a successor 
program) established by the Centers for 
Medicare & Medicaid Services, according to 
procedures established by the Secretary. 
Such procedures shall provide for the in-
clusion of information with respect to, and 
the names and locations of, those facilities 
that, since the previous quarter— 
‘‘(I) were newly enrolled in the 
program; 
‘‘(II) are enrolled in the program 
and have failed to significantly im-
prove; 
‘‘(III) are enrolled in the pro-
gram and have significantly improved; 
‘‘(IV) have graduated from the 
program; and 
‘‘(V) have closed voluntarily or 
no longer participate under this title. 
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‘‘(iii) Staffing data for each facility 
(including resident census data and data 
on the hours of care provided per resident 
per day) based on data submitted under 
subsection (b)(8)(C)(ii), including informa-
tion on staffing turnover and tenure, in a 
format that is clearly understandable to 
consumers of long-term care services and 
allows such consumers to compare dif-
ferences in staffing between facilities and 
State and national averages for the facili-
ties. Such format shall include— 
‘‘(I) concise explanations of how 
to interpret the data (such as plain 
English explanation of data reflecting 
‘nursing home staff hours per resident 
day’); 
‘‘(II) differences in types of staff 
(such as training associated with dif-
ferent categories of staff); 
‘‘(III) the relationship between 
nurse staffing levels and quality of 
care; and 
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‘‘(IV) an explanation that appro-
priate staffing levels vary based on 
patient case mix. 
‘‘(iv) Links to State internet websites 
with information regarding State survey 
and certification programs, links to Form 
2567 State inspection reports (or a suc-
cessor form) on such websites, information 
to guide consumers in how to interpret and 
understand such reports, and the facility 
plan of correction or other response to 
such report. 
‘‘(v) The standardized complaint form 
developed under subsection (f)(10), includ-
ing explanatory material on what com-
plaint forms are, how they are used, and 
how to file a complaint with the State sur-
vey and certification program and the 
State long-term care ombudsman program. 
‘‘(vi) Summary information on the 
number, type, severity, and outcome of 
substantiated complaints. 
‘‘(vii) The number of adjudicated in-
stances of criminal violations by employees 
of a nursing facility— 
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‘‘(I) that were committed inside 
of the facility; and 
‘‘(II) with respect to such in-
stances of violations or crimes com-
mitted 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 
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802 
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). 
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803 
‘‘(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 
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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 
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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. 
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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. 
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(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: 
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‘‘(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)). 
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809 
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. 
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‘‘(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 
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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-
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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, 
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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. 
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‘‘(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). 
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‘‘(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 
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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.— 
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(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 
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‘‘(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 
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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-
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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 
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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-
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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: 
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‘‘(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 
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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 
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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); 
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‘‘(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-
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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 
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(iii) that submits an application to the 
Secretary containing such information and 
at such time as the Secretary may specify. 
(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 
(iii) that submits an application to the 
Secretary containing such information and 
at such time as the Secretary may specify. 
(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 
long-term care facility or provider) obtain State 
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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-
lowing the initial criminal history background 
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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; 
(iii) as appropriate, provide for a pro-
visional period of employment by a long- 
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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 
circumstances, demonstration of rehabilita-
tion, and relevancy of the particular dis-
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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; 
(III) immediately reporting to 
the long-term care facility or provider 
that requested the criminal history 
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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 
facility or provider is convicted of a crime 
following the initial criminal history back-
ground check conducted with respect to 
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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. 
(5) PAYMENTS.— 
(A) NEWLY PARTICIPATING STATES.— 
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(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-
curred by the State in carrying out the na-
tionwide program, that the State will make 
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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))). 
(ii) A nursing facility (as defined in 
section 1919(a) of such Act (42 U.S.C. 
1396r(a))). 
(iii) A home health agency. 
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(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))). 
(x) Any other facility or provider of 
long-term care services under such titles as 
the participating State determines appro-
priate. 
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(B) 
DIRECT
PATIENT
ACCESS
EM-
PLOYEE.—The term ‘‘direct patient access em-
ployee’’ means any individual who has access to 
a patient or resident of a long-term care facility 
or provider through employment or through a 
contract with such facility or provider and has 
duties that involve (or may involve) one-on-one 
contact with a patient or resident of the facility 
or provider, as determined by the State for pur-
poses of the nationwide program. Such term 
does not include a volunteer unless the volun-
teer has duties that are equivalent to the duties 
of a direct patient access employee and those 
duties involve (or may involve) one-on-one con-
tact with a patient or resident of the long-term 
care facility or provider. 
(7) EVALUATION AND REPORT.— 
(A) EVALUATION.—The Inspector General 
of the Department of Health and Human Serv-
ices shall conduct an evaluation of the nation-
wide program. Such evaluation shall include— 
(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-
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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. 
(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-
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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. 
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: 
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‘‘(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. 
‘‘(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 
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‘‘(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-
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 
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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 
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). 
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‘‘(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 
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-
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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 
the date on which the informal 
dispute resolution process under 
item (aa) is completed or the 
date that is 90 days after the 
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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 
costs of relocating residents to 
home and community-based set-
tings or another facility), projects 
that support resident and family 
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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-
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 
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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 
subclause (II) and (III)) for each day or 
instance, respectively, of noncompliance (as 
determined appropriate by the Secretary). 
‘‘(ii) 
APPLICABLE
PER
INSTANCE 
AMOUNT.—In this subparagraph, the term 
‘applicable per instance amount’ means— 
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‘‘(I) in the case where the defi-
ciency is found to be a direct proxi-
mate cause of death of a resident of 
the facility, an amount not to exceed 
$100,000. 
‘‘(II) in each case of a deficiency 
where the facility is cited for actual 
harm or immediate jeopardy, an 
amount not less than $3,050 and not 
more than $25,000; and 
‘‘(III) in each case of any other 
deficiency, an amount not less than 
$250 and not to exceed $3050. 
‘‘(iii) 
APPLICABLE
PER
DAY 
AMOUNT.—In this subparagraph, the term 
‘applicable per day amount’ means— 
‘‘(I) in each case of a deficiency 
where the facility is cited for actual 
harm or immediate jeopardy, an 
amount not less than $3,050 and not 
more than $25,000 and 
‘‘(II) in each case of any other 
deficiency, an amount not less than 
$250 and not to exceed $3,050. 
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‘‘(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 
under clause (iv) the amount of a pen-
alty if the penalty is imposed for a de-
ficiency described in clause (ii)(II) or 
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(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-
vide the opportunity for the facility to 
participate in an independent informal 
dispute resolution process, established 
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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-
pute resolution process under sub-
clause (I) is completed or the date 
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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-
port activities that benefit residents, including 
assistance to support and protect residents of a 
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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 
a civil money penalty in an amount 
not to exceed $10,000 for each day or 
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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. 
‘‘(IV) COLLECTION
OF
CIVIL 
MONEY PENALTIES.—In the case of a 
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civil money penalty imposed under 
this clause, the Secretary— 
‘‘(aa) subject to item (bb), 
shall, not later than 30 days 
after the date of imposition of 
the 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 
penalty and the placement of 
such amounts collected in an es-
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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-
sistance to support and protect 
residents of a facility that closes 
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‘‘(5) A general audit report of the Secretary on 
the Health Care Educational Loan Repayment Pro-
gram as required by section 110(m). 
‘‘(6) A report of the findings and conclusions of 
demonstration programs on development of edu-
cational curricula for substance abuse counseling as 
required in section 125(f). 
‘‘(7) A separate statement which specifies the 
amount of funds requested to carry out the provi-
sions of section 201. 
‘‘(8) A report of the evaluations of health pro-
motion and disease prevention as required in section 
203(c). 
‘‘(9) A biennial report to Congress on infectious 
diseases as required by section 212. 
‘‘(10) A report on environmental and nuclear 
health hazards as required by section 215. 
‘‘(11) An annual report on the status of all 
health care facilities needs as required by section 
301(c)(2)(B) and 301(d). 
‘‘(12) Reports on safe water and sanitary waste 
disposal facilities as required by section 302(h). 
‘‘(13) An annual report on the expenditure of 
non-Service funds for renovation as required by sec-
tions 304(b)(2). 
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