I 
117TH CONGRESS 
1ST SESSION 
H. R. 598 
To amend titles XVIII and XIX of the Social Security Act to improve 
the quality of care in skilled nursing facilities under the Medicare pro-
gram and nursing facilities under the Medicare program during the 
COVID–19 emergency period, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JANUARY 28, 2021 
Ms. SCHAKOWSKY (for herself and Mr. TAKANO) introduced the following bill; 
which was referred to the Committee on Ways and Means, and in addi-
tion to the Committee on Energy and Commerce, for a period to be sub-
sequently determined by the Speaker, in each case for consideration of 
such provisions as fall within the jurisdiction of the committee concerned 
A BILL 
To amend titles XVIII and XIX of the Social Security Act 
to improve the quality of care in skilled nursing facilities 
under the Medicare program and nursing facilities under 
the Medicare program during the COVID–19 emergency 
period, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Quality Care for Nurs-
ing Home Residents and Workers During COVID–19 and 
Beyond Act’’. 
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TITLE I—ADDRESSING COVID–19 
SEC. 101. IMPROVING QUALITY OF CARE IN SKILLED NURS-
ING FACILITIES AND NURSING FACILITIES 
DURING COVID–19 EMERGENCY PERIOD. 
(a) MEDICARE.—Section 1819 of the Social Security 
Act (42 U.S.C. 1395i–3) is amended by adding at the end 
the following new subsection: 
‘‘(k) ADDITIONAL REQUIREMENTS DURING CERTAIN 
PUBLIC HEALTH EMERGENCY.— 
‘‘(1) SKILLED NURSING FACILITIES.— 
‘‘(A) IN GENERAL.—During the portion of 
the emergency period defined in paragraph 
(1)(B) of section 1135(g) beginning on or after 
the date of the enactment of this subsection, a 
skilled nursing facility shall comply with the 
quality of care requirements described in sub-
paragraph (B), the worker safety requirements 
described in subparagraph (C), and the trans-
parency requirements described in subpara-
graph (D). 
‘‘(B) QUALITY OF CARE REQUIREMENTS.— 
The quality of care requirements described in 
this subparagraph are each of the following: 
‘‘(i) Employ, on a full-time basis, an 
onsite infection preventionist who— 
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‘‘(I) has primary professional 
training in nursing, medical tech-
nology, microbiology, epidemiology, or 
other related field; 
‘‘(II) is qualified by education, 
training, experience or certification; 
and 
‘‘(III) has completed specialized 
training in infection prevention and 
control. 
‘‘(ii) In the case of a resident who 
elects to reside with a family member of 
such resident for any portion of the emer-
gency period described in subparagraph 
(A), guarantee the right of such resident to 
resume residency in the facility at any time 
during the 180-day period immediately fol-
lowing the end of such emergency period. 
‘‘(iii) Notwithstanding subparagraphs 
(A) and (B) of subsection (c)(2), permit a 
resident to remain in the facility and not 
discharge or transfer the resident from the 
facility unless— 
‘‘(I) the State survey agency ap-
proves the discharge or transfer; 
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‘‘(II) in the case of a transfer, 
the transfer is to a facility dedicated 
to the care of residents who have been 
diagnosed with COVID–19 if the resi-
dent 
has 
been 
diagnosed 
with 
COVID–19, or a facility dedicated to 
the care of residents who have not 
been diagnosed with COVID–19 if the 
resident has not been diagnosed with 
COVID–19; 
‘‘(III) before effecting the dis-
charge or transfer, the facility records 
the reasons in the resident’s clinical 
record; 
‘‘(IV) at least 72 hours in ad-
vance of the discharge or transfer, the 
facility provides a notice of the dis-
charge or transfer to the resident (or 
legal representative of the resident, if 
applicable), 
including 
the 
reasons 
therefor and the items described in 
clause (iii) of subsection (c)(2)(B); 
and 
‘‘(V) the resident (or legal rep-
resentative of the resident, if applica-
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‘‘(C) WORKER SAFETY REQUIREMENTS.— 
The worker safety requirements described in 
this subparagraph are each of the following: 
‘‘(i) In the case the facility is not oth-
erwise subject to the Occupational Safety 
and Health Act of 1970 (or a State occu-
pational safety and health plan that is ap-
proved under section 18(c) of such Act), 
comply with the Bloodborne Pathogens 
standard under section 1910.1030 of title 
29, Code of Federal Regulations (or a suc-
cessor regulation). 
‘‘(ii) In the case of a predicted short-
age of personal protective equipment, re-
port such predicted shortage to the State 
health department of the State in which 
the facility is located at least 24 hours in 
advance of when such predicted shortage is 
expected to occur. 
‘‘(iii) Educate each employee on the 
transmission of COVID–19. 
‘‘(iv) Notwithstanding any other pro-
vision of law, provide at least two weeks of 
paid sick leave to each employee. 
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‘‘(v) Before each employee’s shift, test 
the employee for COVID–19, or, in the 
case that the facility does not have a suffi-
cient number of testing kits for COVID– 
19, screen each employee for symptoms of 
COVID–19 and report (on a daily basis 
until the facility has a sufficient number of 
such testing kits) to the State survey agen-
cy that the facility does not have a suffi-
cient number of such testing kits and what 
steps the facility is taking to procure a suf-
ficient number of such testing kits. 
‘‘(D) TRANSPARENCY
REQUIREMENTS.— 
The transparency requirements described in 
this subparagraph are each of the following: 
‘‘(i) Report (on a daily basis) to the 
State survey agency, the Centers for Medi-
care & Medicaid Services, and the Centers 
for Disease Control and Prevention each of 
the following: 
‘‘(I) The number of confirmed 
and suspected cases of COVID–19 
among residents and staff, including 
the age and race or ethnicity of such 
residents and staff. 
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‘‘(II) The number of deaths re-
lated to COVID–19 among residents 
and staff, including the age and race 
or ethnicity of such residents and 
staff. 
‘‘(III) The total number of 
deaths (without regard to whether a 
death is related to COVID–19) among 
residents and staff. 
‘‘(IV) The amount of personal 
protective equipment available and 
any projected need regarding such 
equipment. 
‘‘(V) Information on staffing lev-
els that would otherwise be required 
to be submitted through the Payroll- 
Based Journal of the Centers for 
Medicare & Medicaid Services. 
‘‘(VI) The number of residents 
and staff who have been tested for 
COVID–19. 
‘‘(ii) In the case that a resident or 
employee is diagnosed with COVID–19 or 
dies as a result of COVID–19, notify all 
residents, legal representatives of residents, 
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and employees not later than 12 hours 
after such diagnosis is made or such death 
occurs. 
‘‘(iii) At any time three or more resi-
dents or employees have newly onset 
COVID–19 symptoms, notify all residents, 
legal representatives of residents, and em-
ployees not later than 72 hours after such 
three or more residents or employees are 
known to the facility. 
‘‘(iv) In the case that a resident or 
employee is suspected to have or is diag-
nosed with COVID–19, post a notice of 
such suspicion or diagnosis at each en-
trance of the facility for the remaining por-
tion of the emergency period described in 
subparagraph (A). 
‘‘(v) For each day of the portion of 
the emergency period described in subpara-
graph (A), post a notice at each entrance 
of the facility with the information re-
quired under subsection (b)(8) for such 
day. 
‘‘(2) STATES AND FEDERAL GOVERNMENT.— 
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‘‘(A) PUBLIC AVAILABILITY OF INFORMA-
TION.— 
‘‘(i) IN GENERAL.—As soon as pos-
sible, but not later than 24 hours after re-
ceiving any information required under 
paragraph (1)(D)(i), the Administrator of 
the Centers for Medicare & Medicaid Serv-
ices, in coordination with the Director of 
the Centers for Disease Control and Pre-
vention, shall make such information pub-
licly available on the Nursing Home Com-
pare website of the Centers for Medicare & 
Medicaid Services and the COVIDView 
website of the Centers for Disease Control 
and Prevention. 
‘‘(ii) HIPAA COMPLIANT
INFORMA-
TION
ONLY.—Information may only be 
made publicly available under clause (i) if 
the disclosure of such information would 
otherwise be permitted under the Federal 
regulations (concerning the privacy of indi-
vidually identifiable health information) 
promulgated under section 264(c) of the 
Health Insurance Portability and Account-
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ability Act of 1996 (42 U.S.C. 1320d–2 
note). 
‘‘(B) DESIGNATION OF COVID–19 FACILI-
TIES.—For 
purposes 
of 
paragraph 
(1)(B)(iii)(II)— 
‘‘(i) the Administrator of the Centers 
for Medicare & Medicaid Services shall 
specify criteria (which shall include the 
provision of the services of a registered 
nurse on a 24-hour basis) for each State 
survey agency to carry out the designation 
requirement described in clause (ii) with 
respect to skilled nursing facilities; and 
‘‘(ii) each State survey agency shall 
designate a skilled nursing facility in the 
State as a facility dedicated to the care of 
residents who have been diagnosed with 
COVID–19 if such facility meets the cri-
teria specified by the Administrator under 
clause (i). 
‘‘(C) 
MONITORING
AND
SURVEYS.—A 
State survey agency shall— 
‘‘(i) provide onsite monitoring (or, if 
onsite monitoring is not feasible, remote 
monitoring) of all skilled nursing facilities 
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with at least one resident or employee who 
has been diagnosed with COVID–19; 
‘‘(ii) in addition to surveys required 
under subsection (g), conduct a survey of 
a skilled nursing facility, in the same man-
ner and subject to the same requirements 
applicable to standard surveys conducted 
under subsection (g), if the facility has a 
ratio of the number of deaths resulting 
from 
COVID–19 
to 
the 
number 
of 
COVID–19 diagnoses that exceeds 5 per-
cent, or the State survey agency receives a 
COVID–19 or staffing related immediate 
jeopardy complaint regarding the facility; 
and 
‘‘(iii) ensure that each survey team 
that conducts a survey under clause (ii) 
has adequate personal protective equip-
ment while conducting such survey. 
‘‘(3) CIVIL MONEY PENALTIES.—The Secretary 
shall impose a civil money penalty against the opera-
tors of a skilled nursing facility in an amount equal 
to $10,000 per day for each violation of a require-
ment described in subparagraph (B), (C), or (D) of 
paragraph (1) or the reporting of false information 
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under clause (i) of such subparagraph (D). The pro-
visions of section 1128A (other than subsections (a) 
and (b)) shall apply to a civil money penalty under 
the previous sentence in the same manner as such 
provisions apply to a penalty or proceeding under 
section 1128A(a).’’. 
(b) MEDICAID.—Section 1919 of the Social Security 
Act (42 U.S.C. 1396r) is amended by adding at the end 
the following new subsection: 
‘‘(k) ADDITIONAL REQUIREMENTS DURING CERTAIN 
PUBLIC HEALTH EMERGENCY.— 
‘‘(1) NURSING FACILITIES.— 
‘‘(A) IN GENERAL.—During the portion of 
the emergency period defined in paragraph 
(1)(B) of section 1135(g) beginning on or after 
the date of the enactment of this subsection, a 
nursing facility shall comply with the quality of 
care requirements described in subparagraph 
(B), the worker safety requirements described 
in subparagraph (C), and the transparency re-
quirements described in subparagraph (D). 
‘‘(B) QUALITY OF CARE REQUIREMENTS.— 
The quality of care requirements described in 
this subparagraph are each of the following: 
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‘‘(i) Employ, on a full-time basis, an 
onsite infection preventionist who— 
‘‘(I) has primary professional 
training in nursing, medical tech-
nology, microbiology, epidemiology, or 
other related field; 
‘‘(II) is qualified by education, 
training, experience or certification; 
and 
‘‘(III) has completed specialized 
training in infection prevention and 
control. 
‘‘(ii) In the case of a resident who 
elects to reside with a family member of 
such resident for any portion of the emer-
gency period described in subparagraph 
(A), guarantee the right of such resident to 
resume residency in the facility at any time 
during the 180-day period immediately fol-
lowing the end of such emergency period. 
‘‘(iii) Notwithstanding subparagraphs 
(A) and (B) of subsection (c)(2), permit a 
resident to remain in the facility and not 
discharge or transfer the resident from the 
facility unless— 
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‘‘(I) the State survey agency ap-
proves the discharge or transfer; 
‘‘(II) in the case of a transfer, 
the transfer is to a facility dedicated 
to the care of residents who have been 
diagnosed with COVID–19 if the resi-
dent 
has 
been 
diagnosed 
with 
COVID–19, or a facility dedicated to 
the care of residents who have not 
been diagnosed with COVID–19 if the 
resident has not been diagnosed with 
COVID–19; 
‘‘(III) before effecting the dis-
charge or transfer, the facility records 
the reasons in the resident’s clinical 
record; 
‘‘(IV) at least 72 hours in ad-
vance of the discharge or transfer, the 
facility provides a notice of the dis-
charge or transfer to the resident (or 
legal representative of the resident, if 
applicable), 
including 
the 
reasons 
therefor and the items described in 
clause (iii) of subsection (c)(2)(B); 
and 
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‘‘(V) the resident (or legal rep-
resentative of the resident, if applica-
ble) acknowledges receipt of the notice 
described in subclause (IV) and pro-
vides written consent to the discharge 
or transfer. 
‘‘(iv) Test (on a weekly basis) each 
resident for COVID–19, or, in the case 
that the facility does not have a sufficient 
number of testing kits for COVID–19, 
screen each resident for symptoms of 
COVID–19 and report (on a daily basis 
until the facility has a sufficient number of 
such testing kits) to the State survey agen-
cy that the facility does not have a suffi-
cient number of such testing kits and what 
steps the facility is taking to procure a suf-
ficient number of such testing kits. 
‘‘(v) Ensure there is an adequate 
number of employees to assist residents in 
communicating with family members and 
friends through phone calls, e-mail, and 
virtual communications on at least a week-
ly basis, without regard to whether a resi-
dent has been diagnosed with COVID–19. 
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‘‘(C) WORKER SAFETY REQUIREMENTS.— 
The worker safety requirements described in 
this subparagraph are each of the following: 
‘‘(i) In the case the facility is not oth-
erwise subject to the Occupational Safety 
and Health Act of 1970 (or a State occu-
pational safety and health plan that is ap-
proved under section 18(c) of such Act), 
comply with the Bloodborne Pathogens 
standard under section 1910.1030 of title 
29, Code of Federal Regulations (or a suc-
cessor regulation). 
‘‘(ii) In the case of a predicted short-
age of personal protective equipment, re-
port such predicted shortage to the State 
health department of the State in which 
the facility is located at least 24 hours in 
advance of when such predicted shortage is 
expected to occur. 
‘‘(iii) Educate each employee on the 
transmission of COVID–19. 
‘‘(iv) Notwithstanding any other pro-
vision of law, provide at least two weeks of 
paid sick leave to each employee. 
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‘‘(v) Before each employee’s shift, test 
the employee for COVID–19, or, in the 
case that the facility does not have a suffi-
cient number of testing kits for COVID– 
19, screen each employee for symptoms of 
COVID–19 and report (on a daily basis 
until the facility has a sufficient number of 
such testing kits) to the State survey agen-
cy that the facility does not have a suffi-
cient number of such testing kits and what 
steps the facility is taking to procure a suf-
ficient number of such testing kits. 
‘‘(D) TRANSPARENCY
REQUIREMENTS.— 
The transparency requirements described in 
this subparagraph are each of the following: 
‘‘(i) Report (on a daily basis) to the 
State survey agency, the Centers for Medi-
care & Medicaid Services, and the Centers 
for Disease Control and Prevention each of 
the following: 
‘‘(I) The number of confirmed 
and suspected cases of COVID–19 
among residents and staff, including 
the age and race or ethnicity of such 
residents and staff. 
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and employees not later than 12 hours 
after such diagnosis is made or such death 
occurs. 
‘‘(iii) At any time three or more resi-
dents or employees have newly onset 
COVID–19 symptoms, notify all residents, 
legal representatives of residents, and em-
ployees not later than 72 hours after such 
three or more residents or employees are 
known to the facility. 
‘‘(iv) In the case that a resident or 
employee is suspected to have or is diag-
nosed with COVID–19, post a notice of 
such suspicion or diagnosis at each en-
trance of the facility for the remaining por-
tion of the emergency period described in 
subparagraph (A). 
‘‘(v) For each day of the portion of 
the emergency period described in subpara-
graph (A), post a notice at each entrance 
of the facility with the information re-
quired under subsection (b)(8) for such 
day. 
‘‘(2) STATES AND FEDERAL GOVERNMENT.— 
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‘‘(A) PUBLIC AVAILABILITY OF INFORMA-
TION.— 
‘‘(i) IN GENERAL.—As soon as pos-
sible, but not later than 24 hours after re-
ceiving any information required under 
paragraph (1)(D)(i), the Administrator of 
the Centers for Medicare & Medicaid Serv-
ices, in coordination with the Director of 
the Centers for Disease Control and Pre-
vention, shall make such information pub-
licly available on the Nursing Home Com-
pare website of the Centers for Medicare & 
Medicaid Services and the COVIDView 
website of the Centers for Disease Control 
and Prevention. 
‘‘(ii) HIPAA COMPLIANT
INFORMA-
TION
ONLY.—Information may only be 
made publicly available under clause (i) if 
the disclosure of such information would 
otherwise be permitted under the Federal 
regulations (concerning the privacy of indi-
vidually identifiable health information) 
promulgated under section 264(c) of the 
Health Insurance Portability and Account-
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ability Act of 1996 (42 U.S.C. 1320d–2 
note). 
‘‘(B) DESIGNATION OF COVID–19 FACILI-
TIES.—For 
purposes 
of 
paragraph 
(1)(B)(iii)(II)— 
‘‘(i) the Administrator of the Centers 
for Medicare & Medicaid Services shall 
specify criteria (which shall include the 
provision of the services of a registered 
nurse on a 24-hour basis) for each State 
survey agency to carry out the designation 
requirement described in clause (ii) with 
respect to nursing facilities; and 
‘‘(ii) each State survey agency shall 
designate a nursing facility in the State as 
a facility dedicated to the care of residents 
who have been diagnosed with COVID–19 
if such facility meets the criteria specified 
by the Administrator under clause (i). 
‘‘(C) 
MONITORING
AND
SURVEYS.—A 
State survey agency shall— 
‘‘(i) provide onsite monitoring (or, if 
onsite monitoring is impractical, remote 
monitoring) of all nursing facilities with at 
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least one resident or employee who has 
been diagnosed with COVID–19; 
‘‘(ii) in addition to surveys required 
under subsection (g), conduct a survey of 
a nursing facility, in the same manner and 
subject to the same requirements applica-
ble to standard surveys conducted under 
subsection (g), if the facility has a ratio of 
the number of deaths resulting from 
COVID–19 to the number of COVID–19 
diagnoses that exceeds 5 percent, or the 
State survey agency receives a COVID–19 
or staffing related immediate jeopardy 
complaint regarding the facility; and 
‘‘(iii) ensure that each survey team 
that conducts a survey under clause (ii) 
has adequate personal protective equip-
ment while conducting such survey. 
‘‘(3) CIVIL MONEY PENALTIES.—The Secretary 
shall impose a civil money penalty against the opera-
tors of a nursing facility in an amount equal to 
$10,000 per day for each violation of a requirement 
described in subparagraph (B), (C), or (D) of para-
graph (1) or the reporting of false information under 
clause (i) of such subparagraph (D). The provisions 
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of section 1128A (other than subsections (a) and 
(b)) shall apply to a civil money penalty under the 
previous sentence in the same manner as such provi-
sions apply to a penalty or proceeding under section 
1128A(a).’’. 
SEC. 102. FUNDING FOR STATE STRIKE TEAMS FOR RESI-
DENT AND EMPLOYEE SAFETY IN SKILLED 
NURSING FACILITIES AND NURSING FACILI-
TIES. 
(a) IN GENERAL.—Of the amounts made available 
under subsection (c), the Secretary of Health and Human 
Services (referred to in this section as the ‘‘Secretary’’) 
shall allocate such amounts among the States, in a man-
ner that takes into account the percentage of skilled nurs-
ing facilities and nursing facilities in each State that have 
residents or employees who have been diagnosed with 
COVID–19, for purposes of establishing and implementing 
strike teams in accordance with subsection (b). 
(b) USE OF FUNDS.—A State that receives funds 
under this section shall use such funds to establish and 
implement a strike team that will be deployed to a skilled 
nursing facility or nursing facility in the State, not later 
than 72 hours after three or more residents or employees 
of the facility are diagnosed with or suspected of having 
COVID–19, to assist the facility in separating residents 
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and employees who have been exposed to COVID–19 from 
those residents and employees who have not been so ex-
posed, supervising testing for COVID–19, ensuring any 
applicable whistleblower protections are being enforced, 
and such other needs as determined necessary by the 
strike team. Such strike team shall include members of 
the National Guard, public health officials from State and 
local health departments, experts in geriatrics and long- 
term care medicine, representatives of residents or con-
sumers, and representatives of workers. 
(c) AUTHORIZATION OF APPROPRIATIONS.—For pur-
poses of carrying out this section, there is authorized to 
be appropriated $500,000,000. 
(d) DEFINITIONS.—In this section: 
(1) NURSING
FACILITY.—The term ‘‘nursing 
facility’’ means a nursing facility under the Medicaid 
program under title XIX of the Social Security Act 
(42 U.S.C. 1396 et seq.). 
(2) SKILLED
NURSING
FACILITY.—The term 
‘‘skilled nursing facility’’ means a skilled nursing fa-
cility under the Medicare program under title XVIII 
of the Social Security Act (42 U.S.C. 1395 et seq.). 
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SEC. 103. REINSTITUTION OF REQUIREMENTS WAIVED FOR 
SKILLED NURSING FACILITIES AND NURSING 
FACILITIES DURING COVID–19 EMERGENCY 
PERIOD. 
(a) IN GENERAL.—With respect to requirements that 
the Administrator of the Centers for Medicare & Medicaid 
Services (referred to in this section as the ‘‘Adminis-
trator’’) waived for skilled nursing facilities and nursing 
facilities under section 1135 or 1812(f) of the Social Secu-
rity Act (42 U.S.C. 1320b–5, 1395d(f)) for the period be-
ginning on March 1, 2020, and ending on the last day 
of the emergency period defined in subsection (g)(1)(B) 
of such section 1135, the Administrator shall terminate 
the waiver of such requirements before the last day of such 
emergency period upon the determination that skilled 
nursing facilities and nursing facilities have the capacity 
to comply with such requirements and that such waiver 
is no longer necessary. 
(b) PLAN FOR CONDUCTING WAIVED OR POSTPONED 
SURVEYS.—With respect to any survey under section 
1819(g) or 1919(g) of the Social Security Act (42 U.S.C. 
1395i–3(g), 1396r(g)) that is waived or postponed during 
the period beginning on March 1, 2020, and ending on 
the last day of the emergency period described in sub-
section (a), the Administrator shall develop a plan for con-
ducting such survey after such last day. 
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(c) TRAINING
AND
CERTIFICATION
OF
NURSE 
AIDES.—With respect to any nurse aide with respect to 
whom the Administrator waived the application of the re-
quirements under section 483.35(d) of title 42, Code of 
Federal Regulations, for the period beginning on March 
1, 2020, and ending on the last day of the emergency pe-
riod described in subsection (a), the Administrator shall 
prohibit the skilled nursing facility or nursing facility em-
ploying such nurse aide from retaining such nurse aide 
after such last day unless such nurse aide satisfies applica-
ble training and certification requirements under such sec-
tion not later than 30 days after such last day. The Ad-
ministrator shall encourage skilled nursing facilities and 
nursing facilities to make available applicable trainings to 
such aides to satisfy such requirements and provide such 
resources as the Administrator determines appropriate to 
such skilled nursing facilities and nursing facilities in 
order to facilitate the provision of such trainings. 
(d) DEFINITIONS.—In this section: 
(1) NURSING
FACILITY.—The term ‘‘nursing 
facility’’ means a nursing facility under the Medicaid 
program under title XIX of the Social Security Act 
(42 U.S.C. 1396 et seq.). 
(2) SKILLED
NURSING
FACILITY.—The term 
‘‘skilled nursing facility’’ means a skilled nursing fa-
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cility under the Medicare program under title XVIII 
of the Social Security Act (42 U.S.C. 1395 et seq.). 
SEC. 104. GUIDANCE FOR CERTAIN RESIDENTIAL CARE FA-
CILITIES DURING COVID–19 EMERGENCY PE-
RIOD. 
Not later than 15 days after the date of the enact-
ment of this Act, the Secretary of Health and Human 
Services (referred to in this section as the ‘‘Secretary’’) 
shall issue guidance for long-term health care facilities, 
including assisted living facilities, other residential care fa-
cilities, and such facilities that are temporary during the 
emergency period defined in section 1135(g)(1)(B) of the 
Social Security Act (42 U.S.C. 1320b–5(g)(1)(B)), that 
are not subject to oversight by the Centers for Medicare 
& Medicaid Services on providing access to virtual visita-
tion during any portion of such emergency period in which 
in-person visitation is restricted and ensuring appropriate 
infection control and prevention and employee safety dur-
ing such emergency period. Such guidance shall include— 
(1) steps that health care facilities described in 
this subsection should take to provide residents with 
access to virtual visitation, including through the 
purchase or installation of devices purchased for the 
use or benefit of individual or multiple residents, 
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that allows residents to communicate with their fam-
ilies during such emergency period; 
(2) options for such facilities in notifying resi-
dents and resident representatives of such access to 
virtual visitation and how the facility is addressing 
any operational issues related to such access to vir-
tual visitation; and 
(3) steps that health care facilities described in 
this subsection should take to provide residents and 
employees with appropriate infection control and 
prevention, based on requirements for skilled nurs-
ing facilities under subsection (k) of section 1819 of 
the Social Security Act (42 U.S.C. 1395i–3), as 
added by section 2(a), and requirements for nursing 
facilities under subsection (k) of section 1919 of 
such Act (42 U.S.C. 1396r), as added by section 
2(b). 
TITLE II—STAFFING AND 
SAFETY 
SEC. 201. MINIMUM NURSE STAFFING REQUIREMENTS FOR 
SKILLED NURSING FACILITIES UNDER MEDI-
CARE PROGRAM AND NURSING FACILITIES 
UNDER MEDICAID PROGRAM. 
(a) MEDICARE.— 
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(1) IN GENERAL.—Subparagraph (C) of section 
1819(b)(4) of the Social Security Act (42 U.S.C. 
1395i–3(b)(4)) is amended— 
(A) in clause (i)— 
(i) by amending the clause heading to 
read as follows: ‘‘GENERAL
REQUIRE-
MENTS BEFORE 2023’’; and 
(ii) by striking ‘‘Except as provided in 
clause (ii),’’ and inserting ‘‘Except as pro-
vided in clause (iii), with respect to skilled 
nursing facility services provided before 
January 1, 2023,’’; 
(B) by redesignating clause (ii) as clause 
(iii); and 
(C) by inserting after clause (i) the fol-
lowing new clause: 
‘‘(ii) GENERAL REQUIREMENTS AFTER 
2022.— 
‘‘(I) IN GENERAL.—With respect 
to skilled nursing facility services pro-
vided on or after January 1, 2023, a 
skilled nursing facility must— 
‘‘(aa) provide nursing serv-
ices that are sufficient to meet 
the nursing needs of its residents 
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on a 24-hour basis, to be divided 
into day shifts, evening shifts, 
and night shifts; 
‘‘(bb) provide for minimum 
nurse staffing levels with respect 
to each such shift, in accordance 
with this clause; and 
‘‘(cc) ensure that, in car-
rying out items (aa) and (bb), a 
total minimum of 4.1 hours of 
care is provided per resident per 
day, with 0.75 hours of care of 
such total minimum provided by 
a registered professional nurse, 
0.54 hours of care of such total 
minimum provided by a licensed 
practical nurse, and 2.81 hours 
of care of such total minimum 
provided by a nurse aide (as de-
fined in paragraph (5)(F)). 
‘‘(II) DAY SHIFTS.—With respect 
to a day shift, the skilled nursing fa-
cility must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 28 
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residents, with a minimum of 
0.29 hours of care provided per 
resident during each such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 40 resi-
dents, with a minimum of 0.20 
hours of care provided per resi-
dent during each such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 7 residents, with a min-
imum of 1.14 hours of care pro-
vided per resident during each 
such shift. 
‘‘(III) EVENING
SHIFTS.—With 
respect to an evening shift, the skilled 
nursing facility must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 30 
residents, with a minimum of 
0.26 hours of care provided per 
resident during each such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 40 resi-
dents, with a minimum of 0.20 
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hours of care provided per resi-
dent during each such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 7 residents, with a min-
imum of 1.14 hours of care pro-
vided per resident during each 
such shift. 
‘‘(IV) NIGHT SHIFTS.—With re-
spect to a night shift, the skilled nurs-
ing facility must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 40 
residents, with a minimum of 
0.20 hours of care provided per 
resident during such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 56 resi-
dents, with a minimum of 0.14 
hours of care provided per resi-
dent during such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 15 residents, with a 
minimum of 0.53 hours of care 
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provided per resident during such 
shift. 
‘‘(V) SECRETARIAL
AUTHORITY 
TO
ESTABLISH
HIGHER
MINIMUM 
NURSE STAFFING LEVELS.—The Sec-
retary may establish and require 
skilled nursing facilities (or, at the 
Secretary’s discretion, only skilled 
nursing facilities that have a higher 
percentage of residents with extensive 
care needs, as determined by the Sec-
retary) to provide for minimum nurse 
staffing levels that are higher than 
the levels required under this clause. 
‘‘(VI) RULE
OF
CONSTRUCTION 
REGARDING STATE AUTHORITY TO ES-
TABLISH
HIGHER
MINIMUM
NURSE 
STAFFING
LEVELS.—Nothing in this 
clause may be construed as preventing 
a State from establishing or requiring 
skilled nursing facilities in the State 
to provide for minimum nurse staffing 
levels that are higher than the levels 
required under this clause. 
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‘‘(VII) CLARIFICATION WITH RE-
SPECT TO MINIMUM HOURS OF CARE 
PROVIDED
PER
RESIDENT
REQUIRE-
MENTS.—In complying with the min-
imum hours of care provided per resi-
dent requirements under this clause, a 
skilled nursing facility may not count 
any time spent by a registered profes-
sional nurse, licensed practical nurse, 
or nurse aide on administrative serv-
ices towards compliance with such re-
quirements. 
‘‘(VIII) DEFINITIONS.—In this 
clause: 
‘‘(aa) 
ADMINISTRATIVE 
SERVICES.—The term ‘adminis-
trative services’ means food prep-
aration, housekeeping, laundry 
services, maintenance services, 
and other noncaregiving-related 
services, as determined by the 
Secretary. 
‘‘(bb) 
DAY
SHIFT.—The 
term ‘day shift’ means, with re-
spect to a day and a skilled nurs-
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ing facility, an assigned work 
shift that is a period of 8 con-
secutive hours, beginning not 
sooner than 6 a.m. in the time 
zone in which such facility is lo-
cated and not later than 8 a.m. 
in such time zone. 
‘‘(cc) EVENING SHIFT.—The 
term ‘evening shift’ means, with 
respect to a day and a skilled 
nursing facility, an assigned work 
shift that is a period of 8 con-
secutive hours, beginning not 
sooner than 2 p.m. in the time 
zone in which such facility is lo-
cated and not later than 4 p.m. 
in such time zone. 
‘‘(dd) NIGHT
SHIFT.—The 
term ‘night shift’ means, with re-
spect to a day and a skilled nurs-
ing facility, an assigned work 
shift that is a period of 8 con-
secutive hours, beginning not 
sooner than 10 p.m. in the time 
zone in which such facility is lo-
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cated and not later than mid-
night in such time zone.’’. 
(2) ENFORCEMENT.—Section 1819(h) of the 
Social Security Act (42 U.S.C. 1395i–3(h)) is 
amended— 
(A) in paragraph (1), by striking ‘‘If a 
State finds, on the basis of a standard’’ and in-
serting ‘‘Subject to paragraph (7), if a State 
finds, on the basis of a standard’’; 
(B) in paragraph (2), by striking ‘‘With 
respect to’’ and inserting ‘‘Subject to paragraph 
(7), with respect to’’; and 
(C) by adding at the end the following new 
paragraph: 
‘‘(7) SPECIAL
ENFORCEMENT
PROCESS
WITH 
RESPECT TO MINIMUM NURSE STAFFING REQUIRE-
MENTS.— 
‘‘(A) IN GENERAL.—If a State finds, on 
the basis of a standard, extended, or partial ex-
tended survey under subsection (g)(2) or other-
wise, that a skilled nursing facility does not 
meet the minimum staffing requirements of 
clause (ii) of subsection (b)(4)(C) with respect 
to skilled nursing facility services provided on 
or after January 1, 2023, the State shall rec-
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ommend to the Secretary that the Secretary 
take such actions as described in subclauses (I) 
and (II) of subparagraph (B)(i). 
‘‘(B) SECRETARIAL AUTHORITY.— 
‘‘(i) IN
GENERAL.—With respect to 
any skilled nursing facility in a State, if 
the Secretary finds, or pursuant to a rec-
ommendation of the State under subpara-
graph (A) finds, that a skilled nursing fa-
cility does not meet the minimum staffing 
requirements of clause (ii) of subsection 
(b)(4)(C) with respect to skilled nursing 
facility services provided on or after Janu-
ary 1, 2023, the Secretary shall— 
‘‘(I) deny any further payments 
under this title with respect to all in-
dividuals entitled to benefits under 
this title who are admitted to the fa-
cility after the effective date of the 
finding; and 
‘‘(II) impose a civil money pen-
alty in an amount not to exceed 
$10,000 for each day of noncompli-
ance. The provisions of section 1128A 
(other than subsections (a) and (b)) 
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shall apply to a civil money penalty 
under the previous sentence in the 
same manner as such provisions apply 
to a penalty or proceeding under sec-
tion 1128A(a). 
‘‘(ii) REDUCTION
OF
CIVIL
MONEY 
PENALTIES
IN
CERTAIN
CIR-
CUMSTANCES.—Subject to clause (iii), in 
the case where a skilled nursing facility 
self-reports and promptly corrects a defi-
ciency for which a penalty was imposed 
under clause (i)(II) not later than 10 cal-
endar days after the date of such imposi-
tion, the Secretary may reduce the amount 
of the penalty imposed by— 
‘‘(I) not more than 50 percent; or 
‘‘(II) in the case that the facility 
was penalized under this subsection 
within the three-year period preceding 
the date of such imposition, not more 
than 25 percent. 
‘‘(iii) PROHIBITIONS
ON
REDUCTION 
FOR CERTAIN DEFICIENCIES.— 
‘‘(I) REPEAT
DEFICIENCIES.— 
The Secretary may not reduce the 
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amount of a penalty under clause (ii) 
if the Secretary had reduced a penalty 
imposed on the skilled nursing facility 
in the preceding year under such 
clause with respect to a repeat defi-
ciency. 
‘‘(II) CERTAIN
OTHER
DEFI-
CIENCIES.—The Secretary may not 
reduce the amount of a penalty under 
clause (ii) if the penalty is imposed on 
the skilled nursing facility for a defi-
ciency that is found to result in a pat-
tern of harm or widespread harm, im-
mediately jeopardizes the health or 
safety of a resident or residents of the 
facility, or results in the death of a 
resident of the facility. 
‘‘(iv) REPEATED
NONCOMPLIANCE.— 
In the case of a skilled nursing facility 
which, on three consecutive standard sur-
veys conducted under subsection (g)(2), 
has been found as not meeting the min-
imum staffing requirements of clause (ii) 
of subsection (b)(4)(C) with respect to 
skilled nursing facility services provided on 
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or after January 1, 2023, the Secretary 
may (regardless of the remedies provided 
for under clause (i))— 
‘‘(I) appoint temporary manage-
ment to oversee the operation of the 
facility and to assure the health and 
safety of the facility’s residents in ac-
cordance with clause (iii) of para-
graph (2)(B), except that ‘the min-
imum staffing requirements of clause 
(ii) of subsection (b)(4)(C)’ shall be 
substituted for ‘all the requirements 
of subsections (b), (c), and (d)’ under 
such clause; 
‘‘(II) monitor the facility under 
subsection (g)(4)(B) with respect to 
such minimum staffing requirements 
until the facility has demonstrated to 
the satisfaction of the Secretary that 
the facility is in compliance, and will 
remain in compliance, with such min-
imum staffing requirements; or 
‘‘(III) 
subject 
to 
section 
1128I(h), terminate the facility’s par-
ticipation under this title. 
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If the facility’s participation under this 
title is terminated under this clause, the 
State shall provide for the safe and orderly 
transfer of the residents eligible under this 
title, consistent with the requirements of 
subsection (c)(2) and section 1128I(h). 
‘‘(v) 
PUBLIC
NOTICE
OF
VIOLA-
TIONS.— 
‘‘(I) INTERNET
WEBSITE.—The 
Secretary shall publish on the internet 
website of the Department of Health 
and Human Services the names of 
skilled nursing facilities that have vio-
lated the minimum staffing require-
ments of clause (ii) of subsection 
(b)(4)(C) with respect to skilled nurs-
ing facility services provided on or 
after January 1, 2023. 
‘‘(II) CHANGE OF OWNERSHIP.— 
With respect to a skilled nursing facil-
ity whose name is published under 
subclause (I) and has a change of 
ownership, as determined by the Sec-
retary, after the date of such publica-
tion, the Secretary shall remove the 
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(iv) in subclause (II), by striking 
‘‘clause (ii)’’ and inserting ‘‘clause (iii)’’; 
(B) by redesignating clauses (ii) and (iii) 
as clauses (iii) and (iv), respectively; and 
(C) by inserting after clause (i) the fol-
lowing new clause: 
‘‘(ii) GENERAL REQUIREMENTS AFTER 
2022.— 
‘‘(I) IN GENERAL.—With respect 
to nursing facility services provided on 
or after January 1, 2023, a nursing 
facility must— 
‘‘(aa) provide nursing serv-
ices that are sufficient to meet 
the nursing needs of its residents 
on a 24-hour basis, to be divided 
into day shifts, evening shifts, 
and night shifts; 
‘‘(bb) provide for minimum 
nurse staffing levels with respect 
to each such shift, in accordance 
with this clause; and 
‘‘(cc) ensure that, in car-
rying out items (aa) and (bb), a 
total minimum of 4.1 hours of 
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care is provided per resident per 
day, with 0.75 hours of care of 
such total minimum provided by 
a registered professional nurse, 
0.54 hours of care of such total 
minimum provided by a licensed 
practical nurse, and 2.81 hours 
of care of such total minimum 
provided by a nurse aide (as de-
fined in paragraph (5)(F)). 
‘‘(II) DAY SHIFTS.—With respect 
to a day shift, the nursing facility 
must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 28 
residents, with a minimum of 
0.29 hours of care provided per 
resident during each such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 40 resi-
dents, with a minimum of 0.20 
hours of care provided per resi-
dent during each such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
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for every 7 residents, with a min-
imum of 1.14 hours of care pro-
vided per resident during each 
such shift. 
‘‘(III) EVENING
SHIFTS.—With 
respect to an evening shift, the nurs-
ing facility must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 30 
residents, with a minimum of 
0.26 hours of care provided per 
resident during each such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 40 resi-
dents, with a minimum of 0.20 
hours of care provided per resi-
dent during each such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 7 residents, with a min-
imum of 1.14 hours of care pro-
vided per resident during each 
such shift. 
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‘‘(IV) NIGHT SHIFTS.—With re-
spect to a night shift, the nursing fa-
cility must have— 
‘‘(aa) at least 1 registered 
professional nurse for every 40 
residents, with a minimum of 
0.20 hours of care provided per 
resident during such shift; 
‘‘(bb) at least 1 licensed 
practical nurse for every 56 resi-
dents, with a minimum of 0.14 
hours of care provided per resi-
dent during such shift; and 
‘‘(cc) at least 1 nurse aide 
(as defined in paragraph (5)(F)) 
for every 15 residents, with a 
minimum of 0.53 hours of care 
provided per resident during such 
shift. 
‘‘(V) SECRETARIAL
AUTHORITY 
TO
ESTABLISH
HIGHER
MINIMUM 
NURSE STAFFING LEVELS.—The Sec-
retary may establish and require nurs-
ing facilities (or, at the Secretary’s 
discretion, only nursing facilities that 
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have a higher percentage of residents 
with extensive care needs, as deter-
mined by the Secretary) to provide for 
minimum nurse staffing levels that 
are higher than the levels required 
under this clause. 
‘‘(VI) RULE
OF
CONSTRUCTION 
REGARDING STATE AUTHORITY TO ES-
TABLISH
HIGHER
MINIMUM
NURSE 
STAFFING
LEVELS.—Nothing in this 
clause may be construed as preventing 
a State from establishing or requiring 
nursing facilities in the State to pro-
vide for minimum nurse staffing levels 
that are higher than the levels re-
quired under this clause. 
‘‘(VII) CLARIFICATION WITH RE-
SPECT TO MINIMUM HOURS OF CARE 
PROVIDED
PER
RESIDENT
REQUIRE-
MENTS.—In complying with the min-
imum hours of care provided per resi-
dent requirements under this clause, a 
nursing facility may not count any 
time spent by a registered professional 
nurse, licensed practical nurse, or 
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nurse aide on administrative services 
towards compliance with such require-
ments. 
‘‘(VIII) DEFINITIONS.—In this 
clause: 
‘‘(aa) 
ADMINISTRATIVE 
SERVICES.—The term ‘adminis-
trative services’ means food prep-
aration, housekeeping, laundry 
services, maintenance services, 
and other noncaregiving-related 
services, as determined by the 
Secretary. 
‘‘(bb) 
DAY
SHIFT.—The 
term ‘day shift’ means, with re-
spect to a day and a nursing fa-
cility, an assigned work shift that 
is a period of 8 consecutive 
hours, beginning not sooner than 
6 a.m. in the time zone in which 
such facility is located and not 
later than 8 a.m. in such time 
zone. 
‘‘(cc) EVENING SHIFT.—The 
term ‘evening shift’ means, with 
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respect to a day and a nursing 
facility, an assigned work shift 
that is a period of 8 consecutive 
hours, beginning not sooner than 
2 p.m. in the time zone in which 
such facility is located and not 
later than 4 p.m. in such time 
zone. 
‘‘(dd) NIGHT
SHIFT.—The 
term ‘night shift’ means, with re-
spect to a day and a nursing fa-
cility, an assigned work shift that 
is a period of 8 consecutive 
hours, beginning not sooner than 
10 p.m. in the time zone in which 
such facility is located and not 
later than midnight in such time 
zone.’’. 
(2) ENFORCEMENT.—Section 1919(h) of the 
Social Security Act (42 U.S.C. 1396r(h)) is amend-
ed— 
(A) in paragraph (1), by striking ‘‘If a 
State finds, on the basis of a standard’’ and in-
serting ‘‘Subject to paragraph (10), if a State 
finds, on the basis of a standard’’; 
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(B) in paragraph (2)— 
(i) in subparagraph (C), by striking 
‘‘If a nursing facility’’ and inserting ‘‘Sub-
ject to paragraph (10), if a nursing facil-
ity’’; and 
(ii) in subparagraph (D), by striking 
‘‘In the case of’’ and inserting ‘‘Subject to 
paragraph (10), in the case of’’; 
(C) in paragraph (3)— 
(i) in subparagraph (A), by inserting 
before the period the following: ‘‘and the 
remedies described in paragraph (10)(B)’’; 
and 
(ii) in subparagraph (B), by striking 
‘‘With respect to’’ and inserting ‘‘Subject 
to paragraph (10), with respect to’’; and 
(D) by adding at the end the following new 
paragraph: 
‘‘(10) SPECIAL ENFORCEMENT PROCESS WITH 
RESPECT TO MINIMUM NURSE STAFFING REQUIRE-
MENTS.— 
‘‘(A) IN GENERAL.—If a State finds, on 
the basis of a standard, extended, or partial ex-
tended survey under subsection (g)(2) or other-
wise, that a nursing facility does not meet the 
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minimum staffing requirements of clause (ii) of 
subsection (b)(4)(C) with respect to nursing fa-
cility services provided on or after January 1, 
2023, the State shall— 
‘‘(i) deny any further payments under 
the State plan with respect to all individ-
uals enrolled under such plan who are ad-
mitted to the facility after the effective 
date of the finding; and 
‘‘(ii) recommend to the Secretary that 
the Secretary impose the civil money pen-
alty described in subparagraph (B). 
‘‘(B) SECRETARIAL AUTHORITY.— 
‘‘(i) IN
GENERAL.—With respect to 
any nursing facility in a State other than 
a State nursing facility, if the Secretary 
finds that such a nursing facility does not 
meet the minimum staffing requirements 
of clause (ii) of subsection (b)(4)(C) with 
respect to nursing facility services provided 
on or after January 1, 2023, the Secretary 
shall— 
‘‘(I) deny any further payments 
to the State for medical assistance 
furnished by the facility to all individ-
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uals enrolled under the State plan 
who are admitted to the facility after 
the effective date of the finding; and 
‘‘(II) impose a civil money pen-
alty in an amount not to exceed 
$10,000 for each day of noncompli-
ance. The provisions of section 1128A 
(other than subsections (a) and (b)) 
shall apply to a civil money penalty 
under the previous sentence in the 
same manner as such provisions apply 
to a penalty or proceeding under sec-
tion 1128A(a). 
‘‘(ii) REDUCTION
OF
CIVIL
MONEY 
PENALTIES
IN
CERTAIN
CIR-
CUMSTANCES.—Subject to clause (iii), in 
the case where a nursing facility self-re-
ports and promptly corrects a deficiency 
for which a penalty was imposed under 
clause (i)(II) not later than 10 calendar 
days after the date of such imposition, the 
Secretary may reduce the amount of the 
penalty imposed by— 
‘‘(I) not more than 50 percent; or 
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‘‘(II) in the case that the facility 
was penalized under this subsection 
within the three-year period preceding 
the date of such imposition, not more 
than 25 percent. 
‘‘(iii) PROHIBITIONS
ON
REDUCTION 
FOR CERTAIN DEFICIENCIES.— 
‘‘(I) REPEAT
DEFICIENCIES.— 
The Secretary may not reduce the 
amount of a penalty under clause (ii) 
if the Secretary had reduced a penalty 
imposed on the nursing facility in the 
preceding year under such clause with 
respect to a repeat deficiency. 
‘‘(II) CERTAIN
OTHER
DEFI-
CIENCIES.—The Secretary may not 
reduce the amount of a penalty under 
clause (ii) if the penalty is imposed on 
the nursing facility for a deficiency 
that is found to result in a pattern of 
harm or widespread harm, imme-
diately jeopardizes the health or safe-
ty of a resident or residents of the fa-
cility, or results in the death of a resi-
dent of the facility. 
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‘‘(iv) REPEATED
NONCOMPLIANCE.— 
In the case of a nursing facility which, on 
three consecutive standard surveys con-
ducted under subsection (g)(2), has been 
found as not meeting the minimum staff-
ing requirements of clause (ii) of sub-
section (b)(4)(C) with respect to nursing 
facility services provided on or after Janu-
ary 1, 2023, the Secretary may (regardless 
of the remedies provided for under clause 
(i))— 
‘‘(I) appoint temporary manage-
ment to oversee the operation of the 
facility and to assure the health and 
safety of the facility’s residents in ac-
cordance with clause (iii) of para-
graph (3)(C), except that ‘the min-
imum staffing requirements of clause 
(ii) of subsection (b)(4)(C)’ shall be 
substituted for ‘all the requirements 
of subsections (b), (c), and (d)’ under 
such clause; 
‘‘(II) monitor the facility under 
subsection (g)(4)(B) with respect to 
such minimum staffing requirements 
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until the facility has demonstrated to 
the satisfaction of the Secretary that 
the facility is in compliance, and will 
remain in compliance, with such min-
imum staffing requirements; or 
‘‘(III) 
subject 
to 
section 
1128I(h), terminate the facility’s par-
ticipation under this title. 
If the facility’s participation under this 
title is terminated under this clause, the 
State shall provide for the safe and orderly 
transfer of the residents eligible under this 
title, consistent with the requirements of 
subsection (c)(2) and section 1128I(h). 
‘‘(v) 
PUBLIC
NOTICE
OF
VIOLA-
TIONS.— 
‘‘(I) INTERNET
WEBSITE.—The 
Secretary shall publish on the internet 
website of the Department of Health 
and Human Services the names of 
nursing facilities that have violated 
the minimum staffing requirements of 
clause (ii) of subsection (b)(4)(C) with 
respect to skilled nursing facility serv-
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ices provided on or after January 1, 
2023. 
‘‘(II) CHANGE OF OWNERSHIP.— 
With respect to a nursing facility 
whose name is published under sub-
clause (I) and has a change of owner-
ship, as determined by the Secretary, 
after the date of such publication, the 
Secretary shall remove the name of 
such facility from the website de-
scribed under such subclause after the 
1-year period beginning on the date of 
such change of ownership.’’. 
(3) CONFORMING AMENDMENTS.— 
(A) Clause (iii) of section 1919(b)(4)(C) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396r(b)(4)(C)), as redesignated by paragraph 
(1)(B), is amended by striking ‘‘subject to 
clause (iii)’’ and inserting ‘‘subject to clause 
(iv)’’. 
(B) 
Item 
(a) 
of 
section 
1919(f)(2)(B)(iii)(I) of the Social Security Act 
(42 U.S.C. 1396r(f)(2)(B)(iii)(I)) is amended 
by striking ‘‘subsection (b)(4)(C)(ii)’’ and in-
serting ‘‘subsection (b)(4)(C)(iii)’’. 
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(C) Paragraph (9) of section 1919(f) of 
the Social Security Act (42 U.S.C. 1396r(f)) is 
amended by striking ‘‘subsection (b)(4)(C)(ii)’’ 
and inserting ‘‘subsection (b)(4)(C)(iii)’’. 
(c) STUDIES AND REPORTS REGARDING IMPACT OF 
MINIMUM NURSE STAFFING REQUIREMENTS.— 
(1) INITIAL STUDY AND REPORT.— 
(A) IN GENERAL.—Not later than June 1, 
2023, the Secretary of Health and Human 
Services shall study and submit to the Com-
mittee on Energy and Commerce and the Com-
mittee on Ways and Means of the House of 
Representatives and the Committee on Finance 
of the Senate a publicly available report— 
(i) on the impact of the minimum 
nurse staffing requirements added by sub-
section (a) on the reimbursement levels of 
skilled nursing facilities under the Medi-
care program under title XVIII of the So-
cial Security Act (42 U.S.C. 1395 et seq.) 
and the adequacy of personnel numbers in 
such skilled nursing facilities to meet such 
minimum nurse staffing requirements; 
(ii) on the impact of the minimum 
nurse staffing requirements added by sub-
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section (b) on the reimbursement levels of 
nursing facilities under the Medicaid pro-
gram under title XIX of the Social Secu-
rity Act (42 U.S.C. 1396 et seq.) and the 
adequacy of personnel numbers in such 
nursing facilities to meet such minimum 
nurse staffing requirements; and 
(iii) including recommendations on the 
steps that such skilled nursing facilities 
and nursing facilities can take to ensure 
that adequate personnel are available in 
such skilled nursing facilities and nursing 
facilities to meet the minimum nurse staff-
ing requirements added by subsections (a) 
and (b) for such skilled nursing facilities 
and nursing facilities, respectively, includ-
ing methods for attracting and retaining 
such personnel. 
(B) CONSIDERATIONS.—In conducting the 
study required under subparagraph (A), the 
Secretary of Health and Human Services shall 
take into consideration— 
(i) the benefits of any increase in 
nurse staffing levels, including with respect 
to workforce training and retention; 
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(ii) any decrease in the rate of work-
place injuries; 
(iii) any changes in medical care costs 
for residents of skilled nursing facilities 
and nursing facilities; 
(iv) any decrease in hospitalization 
rates for such residents; 
(v) any changes in personnel and ad-
ministrative costs for skilled nursing facili-
ties and nursing facilities; and 
(vi) any changes in recruiting and 
training costs. 
(2) SUBSEQUENT
STUDY
AND
REPORT.—Not 
later than January 1, 2025, the Secretary of Health 
and Human Services shall conduct a follow-up study 
to the study conducted under paragraph (1)(A) and 
submit to the Committee on Energy and Commerce 
and the Committee on Ways and Means of the 
House of Representatives and the Committee on Fi-
nance of the Senate a publicly available report on 
such follow-up study. 
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SEC. 202. DISCLOSURE OF NURSE STAFFING LEVELS AT 
SKILLED NURSING FACILITIES UNDER MEDI-
CARE PROGRAM AND NURSING FACILITIES 
UNDER MEDICAID PROGRAM. 
(a) MEDICARE.—Paragraph (8) of section 1819(b) of 
the Social Security Act (42 U.S.C. 1395i–3(b)) is amend-
ed to read as follows: 
‘‘(8) INFORMATION ON NURSE STAFFING.— 
‘‘(A) IN
GENERAL.—Each day, a skilled 
nursing facility shall post for each shift notices 
with— 
‘‘(i) a description of the nurse staffing 
requirements applicable with respect to the 
facility and day under paragraph (4)(C); 
‘‘(ii) information on the number of 
registered professional nurses, licensed 
practical nurses, and nurse aides (as de-
fined in paragraph (5)(F)) assigned to pro-
vide direct care services to residents in the 
facility during the shift, disaggregated by 
units in the facility; and 
‘‘(iii) a statement that the facility is 
required, upon request, to provide any 
nurse staffing information (as described in 
this subparagraph) of the facility from the 
preceding 12-month period. 
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The information in such notices shall be written 
in a uniform manner, printed in an easily read-
able 14-point type font, and made available in 
appropriate languages, as determined by the 
Secretary. The skilled nursing facility shall 
make such notices available at each nurses’ sta-
tion in the facility and other areas in each unit 
of the facility, as determined appropriate by the 
facility, and shall keep and maintain each such 
notice for at least three years after the date on 
which each such notice is posted in the facility. 
‘‘(B) PUBLIC AVAILABILITY OF INFORMA-
TION.—A skilled nursing facility shall, upon re-
quest, make available to the public any nurse 
staffing information (as described in subpara-
graph (A)) of the facility from the preceding 
12-month period. In the case that the facility 
makes such information available as a paper 
copy, such facility may not charge for such copy 
an amount greater than the cost of making 
such copy.’’. 
(b) MEDICAID.—Paragraph (8) of section 1919(b) of 
the Social Security Act (42 U.S.C. 1396r(b)) is amended 
to read as follows: 
‘‘(8) INFORMATION ON NURSE STAFFING.— 
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‘‘(A) IN
GENERAL.—Each day, a skilled 
nursing facility shall post for each shift notices 
with— 
‘‘(i) a description of the nurse staffing 
requirements applicable with respect to the 
facility and day under paragraph (4)(C); 
‘‘(ii) information on the number of 
registered professional nurses, licensed 
practical nurses, and nurse aides (as de-
fined in paragraph (5)(F)) assigned to pro-
vide direct care services to residents in the 
facility during the shift, disaggregated by 
units in the facility; and 
‘‘(iii) a statement that the facility is 
required, upon request, to provide any 
nurse staffing information (as described in 
this subparagraph) of the facility from the 
preceding 12-month period. 
The information in such notices shall be written 
in a uniform manner, printed in an easily read-
able 14-point type font, and made available in 
appropriate languages, as determined by the 
Secretary. The skilled nursing facility shall 
make such notices available at each nurses’ sta-
tion in the facility and other areas in each unit 
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of the facility, as determined appropriate by the 
facility, and shall keep and maintain each such 
notice for at least three years after the date on 
which each such notice is posted in the facility. 
‘‘(B) PUBLIC AVAILABILITY OF INFORMA-
TION.—A skilled nursing facility shall, upon re-
quest, make available to the public any nurse 
staffing information (as described in subpara-
graph (A)) of the facility from the preceding 
12-month period.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on the date of enactment of this 
Act and apply with respect to nurse staffing information 
posted or requested on or after the date that is one year 
after such date of enactment. 
SEC. 203. ADMINISTRATIVE STAFFING REQUIREMENTS FOR 
SKILLED NURSING FACILITIES UNDER MEDI-
CARE PROGRAM AND NURSING FACILITIES 
UNDER MEDICAID PROGRAM. 
(a) MEDICARE.—Paragraph (1) of section 1819(d) of 
the Social Security Act (42 U.S.C. 1395i–3(d)) is amend-
ed— 
(1) by redesignating the second subparagraph 
(C) as subparagraph (E); and 
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(2) by inserting after the first subparagraph 
(C) the following new subparagraph: 
‘‘(D) 
NURSING
MANAGEMENT
PER-
SONNEL.— 
‘‘(i) IN GENERAL.—A skilled nursing 
facility must employ nursing management 
personnel in accordance with this subpara-
graph. 
‘‘(ii) DIRECTOR
OF
NURSING
SERV-
ICES.—A skilled nursing facility must em-
ploy a registered professional nurse to 
serve full-time as the director of nursing 
services of the facility. Such director of 
nursing services shall be responsible for de-
termining the number and types of nursing 
personnel needed to sufficiently meet the 
nursing needs of the residents of the facil-
ity 
(as 
required 
under 
subsection 
(b)(4)(C)). 
‘‘(iii) ASSISTANT DIRECTOR OF NURS-
ING SERVICES.—A skilled nursing facility 
must employ a registered professional 
nurse to serve full-time as the assistant di-
rector of nursing services of the facility, 
except that in the case of a skilled nursing 
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facility that has fewer than 100 beds, such 
facility may employ a registered profes-
sional nurse to serve part-time as the as-
sistant director of nursing services of the 
facility. A registered professional nurse 
who serves as the assistant director of 
nursing services of a skilled nursing facility 
may also serve as a supervisor for direct 
clinical nursing care for such facility. 
‘‘(iv) DIRECTOR OF IN-SERVICE EDU-
CATION.—A skilled nursing facility must 
employ a registered professional nurse to 
serve full-time as the director of in-service 
education of the facility, except that in the 
case of a skilled nursing facility that has 
fewer than 100 beds, such facility may em-
ploy a registered professional nurse to 
serve part-time as the director of in-service 
education of the facility. In carrying out 
the previous sentence, a skilled nursing fa-
cility must, to the extent practicable and 
appropriate, employ a registered profes-
sional nurse who has received training in 
adult education and gerontology.’’. 
(b) MEDICAID.— 
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(1) IN
GENERAL.—Paragraph (1) of section 
1919(d) of the Social Security Act (42 U.S.C. 
1396r(d)) is amended by inserting after subpara-
graph (C) the following new subparagraph: 
‘‘(D) 
NURSING
MANAGEMENT
PER-
SONNEL.— 
‘‘(i) IN GENERAL.—A nursing facility 
must employ nursing management per-
sonnel in accordance with this subpara-
graph. 
‘‘(ii) DIRECTOR
OF
NURSING
SERV-
ICES.—A nursing facility must employ a 
registered professional nurse to serve full- 
time as the director of nursing services of 
the facility. Such director of nursing serv-
ices shall be responsible for determining 
the number and types of nursing personnel 
needed to sufficiently meet the nursing 
needs of the residents of the facility (as re-
quired under subsection (b)(4)(C)). 
‘‘(iii) ASSISTANT DIRECTOR OF NURS-
ING
SERVICES.—A nursing facility must 
employ a registered professional nurse to 
serve full-time as the assistant director of 
nursing services of the facility, except that 
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(2) TECHNICAL AMENDMENT.—Paragraph (1) 
of section 1919(d) of the Social Security Act (42 
U.S.C. 1396r(d)) is amended by redesignating sub-
paragraph (V) as subparagraph (E). 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on the date of enactment of this 
Act and apply with respect to the administration of skilled 
nursing facilities and nursing facilities on or after the date 
that is one year after such date of enactment. 
SEC. 204. NURSE TRAINING REQUIREMENTS WITH RESPECT 
TO SKILLED NURSING FACILITIES UNDER 
MEDICARE PROGRAM AND NURSING FACILI-
TIES UNDER MEDICAID PROGRAM. 
(a) MEDICARE.— 
(1) ORIENTATION
FOR
REGISTERED
PROFES-
SIONAL NURSES, LICENSED PRACTICAL NURSES, AND 
NURSE AIDES.—Section 1819(d) of the Social Secu-
rity Act (42 U.S.C. 1395i–3(d)) is amended by add-
ing at the end the following new paragraph: 
‘‘(5) ORIENTATIONS.—A skilled nursing facility 
must provide to registered professional nurses, li-
censed practical nurses, and nurse aides, before such 
registered professional nurses, licensed practical 
nurses, and nurse aides are assigned to provide di-
rect care services to residents in the facility, orienta-
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tions providing education on the policies and emer-
gency procedures of the facility and on residents’ 
rights under this section.’’. 
(2) REQUIREMENTS FOR NURSE AIDE TRAINING 
AND COMPETENCY EVALUATION PROGRAMS AND FOR 
NURSE
AIDE
COMPETENCY
EVALUATION
PRO-
GRAMS.—Subparagraph (A) of section 1819(f)(2) of 
the Social Security Act (42 U.S.C. 1395i–3(f)(2)) is 
amended— 
(A) in the matter preceding clause (i), by 
inserting after ‘‘1988’’ the following: ‘‘, and up-
date, as determined necessary by the Sec-
retary’’; 
(B) in clause (i)— 
(i) by inserting after ‘‘care of cog-
nitively impaired residents,’’ the following: 
‘‘care of older adults,’’; 
(ii) by striking ‘‘patient abuse preven-
tion training,’’ and inserting ‘‘patient 
abuse prevention training),’’; and 
(iii) by striking ‘‘75 hours’’ and in-
serting ‘‘120 hours’’; and 
(C) in clause (ii)— 
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(i) by striking ‘‘requirement relating 
to’’ and inserting ‘‘requirements relating to 
(I)’’; 
(ii) by inserting after ‘‘care of cog-
nitively impaired residents,’’ the following: 
‘‘care of older adults,’’; and 
(iii) by striking ‘‘and procedures’’ and 
inserting ‘‘(II) minimum hours of initial 
and ongoing training and retraining (in-
cluding not less than 120 hours in the case 
of initial training), and (III) procedures’’. 
(b) MEDICAID.— 
(1) ORIENTATION
FOR
REGISTERED
PROFES-
SIONAL NURSES, LICENSED PRACTICAL NURSES, AND 
NURSE AIDES.—Section 1919(d) of the Social Secu-
rity Act (42 U.S.C. 1396r(d)) is amended by adding 
at the end the following new paragraph: 
‘‘(5) ORIENTATIONS.—A nursing facility must 
provide to registered professional nurses, licensed 
practical nurses, and nurse aides, before such reg-
istered professional nurses, licensed practical nurses, 
and nurse aides are assigned to provide direct care 
services to residents in the facility, orientations pro-
viding education on the policies and emergency pro-
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pamtmann on DSKBC07HB2PROD with BILLS
cedures of the facility and on residents’ rights under 
this section.’’. 
(2) REQUIREMENTS FOR NURSE AIDE TRAINING 
AND COMPETENCY EVALUATION PROGRAMS AND FOR 
NURSE
AIDE
COMPETENCY
EVALUATION
PRO-
GRAMS.—Subparagraph (A) of section 1919(f)(2) of 
the Social Security Act (42 U.S.C. 1396r(f)(2)) is 
amended— 
(A) in the matter preceding clause (i), by 
inserting after ‘‘1988’’ the following: ‘‘, and up-
date, as determined necessary by the Sec-
retary’’; 
(B) in clause (i)— 
(i) by inserting after ‘‘care of cog-
nitively impaired residents,’’ the following: 
‘‘care of older adults,’’; 
(ii) by striking ‘‘patient abuse preven-
tion training,’’ and inserting ‘‘patient 
abuse prevention training),’’; and 
(iii) by striking ‘‘75 hours’’ and in-
serting ‘‘120 hours’’; and 
(C) in clause (ii)— 
(i) by striking ‘‘requirement relating 
to’’ and inserting ‘‘requirements relating to 
(I)’’; 
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(ii) by inserting after ‘‘care of cog-
nitively impaired residents,’’ the following: 
‘‘care of older adults,’’; and 
(iii) by striking ‘‘and procedures’’ and 
inserting ‘‘(II) minimum hours of initial 
and ongoing training and retraining (in-
cluding not less than 120 hours in the case 
of initial training), and (III) procedures’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on the date of enactment of this 
Act and shall apply with respect to nurse aide training 
and competency evaluation programs, nurse aide com-
petency evaluation programs, and nurse orientations con-
ducted on or after the date that is one year after such 
date of enactment. 
SEC. 205. WHISTLEBLOWER AND RESIDENT PROTECTIONS. 
(a) MEDICARE.—Section 1819 of the Social Security 
Act (42 U.S.C. 1395i–3) is amended by adding at the end 
the following new subsection: 
‘‘(l) WHISTLEBLOWER
AND
RESIDENT
PROTEC-
TIONS.— 
‘‘(1) STATEMENT
REGARDING
PROFESSIONAL 
OBLIGATION AND RIGHTS.—All nurses employed by 
a skilled nursing facility have a duty and right to act 
based on their professional judgment in accordance 
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with the nursing laws and regulations of the State 
in which such facility is located, to provide nursing 
care in the exclusive interests of the residents of the 
facility, and to act as the residents’ advocate. 
‘‘(2) OBJECTION TO OR REFUSAL OF WORK AS-
SIGNMENT.—A nurse may object to, or refuse to 
participate in, any activity, policy, practice, assign-
ment, or task (referred to in this subsection as a 
‘work assignment’) if— 
‘‘(A) the nurse reasonably believes such 
work assignment to be in violation of the min-
imum nurse staffing requirements of clause (ii) 
of subsection (b)(4)(C); or 
‘‘(B) the nurse reasonably believes that the 
nurse is not prepared by education, training, or 
experience to perform or comply with such work 
assignment without compromising the safety of 
a resident or jeopardizing the license of the 
nurse. 
‘‘(3) RETALIATION FOR OBJECTION TO OR RE-
FUSAL OF WORK ASSIGNMENT BARRED.— 
‘‘(A) NO DISCHARGE, DISCRIMINATION, OR 
RETALIATION.—No skilled nursing facility may 
discharge, retaliate, discriminate, or otherwise 
take adverse action in any manner with respect 
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to any aspect of a nurse’s employment with the 
facility, including discharge, promotion, com-
pensation, or terms, conditions, or privileges of 
employment, based on the nurse’s objection to, 
or refusal of, a work assignment under para-
graph (2). 
‘‘(B) NO
FILING
OF
COMPLAINT.—No 
skilled nursing facility may file a complaint or 
a report against a nurse with a State profes-
sional disciplinary agency because of the nurse’s 
objection to, or refusal of, a work assignment 
under paragraph (2). 
‘‘(4) CAUSE OF ACTION.—Any nurse (or a col-
lective bargaining representative or legal representa-
tive of such nurse) against whom a skilled nursing 
facility has taken an adverse action in violation of 
paragraph (3)(A), or against whom such facility has 
filed a complaint or report in violation of paragraph 
(3)(B), may (without regard to whether a complaint 
has been filed under paragraph (5) or (10)(B)) 
bring a cause of action in an appropriate district 
court of the United States. The legal burdens of 
proof specified in section 1221(e) of title 5, United 
States Code, shall be controlling for the purposes of 
any cause of action brought under this paragraph. 
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A nurse who prevails on the cause of action may be 
entitled to one or more of the following: 
‘‘(A) Reinstatement. 
‘‘(B) Reimbursement of lost wages, com-
pensation, and benefits. 
‘‘(C) Attorneys’ fees. 
‘‘(D) Court costs. 
‘‘(E) Other damages. 
‘‘(5) COMPLAINT
TO
SECRETARY.—Any indi-
vidual may file a complaint with the Secretary 
against a skilled nursing facility that violates a re-
quirement described in paragraph (3). For any com-
plaint filed, the Secretary shall— 
‘‘(A) receive and investigate the complaint; 
‘‘(B) determine whether a violation of such 
paragraph, as alleged in the complaint, has oc-
curred; and 
‘‘(C) in the case that the Secretary deter-
mines that such a violation has occurred, issue 
an order that the complaining individual may 
not suffer any adverse action prohibited by 
paragraph (3) or (7). 
‘‘(6) TOLL-FREE TELEPHONE NUMBER.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
provide for the establishment of a toll-free tele-
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phone hotline to provide information regarding 
the minimum nurse staffing requirements of 
clause (ii) of subsection (b)(4)(C) and to receive 
reports of violations of such requirements. 
‘‘(B) NOTICE
TO
RESIDENTS.—A skilled 
nursing facility shall provide each resident ad-
mitted to the facility with the telephone number 
of the hotline described in subparagraph (A) 
and give notice to each such resident that such 
hotline may be used to report inadequate staff-
ing. 
‘‘(7) PROTECTION FOR REPORTING.— 
‘‘(A) PROHIBITION
ON
RETALIATION
OR 
DISCRIMINATION.—A skilled nursing facility 
may not retaliate or discriminate in any manner 
against any resident, employee, or contract em-
ployee of the facility, or any other individual, on 
the basis that such resident, employee, contract 
employee, or individual (individually or in con-
junction with another individual) has, in good 
faith— 
‘‘(i) presented a grievance or com-
plaint; 
‘‘(ii) initiated or cooperated in any in-
vestigation or proceeding of any govern-
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mental entity, regulatory agency, or private 
accreditation body; 
‘‘(iii) made a civil claim or demand; or 
‘‘(iv) filed an action relating to the 
care, services, or conditions of the facility. 
‘‘(B) GOOD
FAITH
DEFINED.—For pur-
poses of this paragraph, an individual shall be 
deemed to be acting in good faith if the indi-
vidual reasonably believes— 
‘‘(i) the information reported or dis-
closed is true; and 
‘‘(ii) a violation of the minimum nurse 
staffing requirements of clause (ii) of sub-
section (b)(4)(C) has occurred or may 
occur. 
‘‘(8) PROHIBITION
ON
INTERFERENCE
WITH 
RIGHTS.— 
‘‘(A) EXERCISE
OF
RIGHTS.—A skilled 
nursing facility may not— 
‘‘(i) interfere with, restrain, or deny 
the exercise, or attempt to exercise, by any 
individual of any right, procedure, or rem-
edy provided or protected under this sub-
section; or 
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‘‘(ii) coerce or intimidate any indi-
vidual regarding the exercise, or attempt to 
exercise, such right. 
‘‘(B) OPPOSITION TO UNLAWFUL POLICIES 
OR PRACTICES.—A skilled nursing facility may 
not retaliate or discriminate against any indi-
vidual for opposing any policy, practice, or ac-
tion of the facility which is alleged to violate, 
breach, or fail to comply with any provision of 
the minimum nurse staffing requirements of 
clause (ii) of subsection (b)(4)(C). 
‘‘(C) PROHIBITION
ON
INTERFERENCE 
WITH PROTECTED COMMUNICATIONS.—A skilled 
nursing facility may not make, adopt, or en-
force any rule, regulation, policy, or practice 
which in any manner directly or indirectly pro-
hibits, impedes, or discourages a nurse from, or 
intimidates, coerces, or induces a nurse regard-
ing, engaging in free speech activities or dis-
closing information as provided under this sub-
section. 
‘‘(D) PROHIBITION
ON
INTERFERENCE 
WITH COLLECTIVE ACTION.—A skilled nursing 
facility may not in any way interfere with the 
rights of nurses to organize, bargain collec-
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pamtmann on DSKBC07HB2PROD with BILLS
tively, and engage in concerted activity under 
section 7 of the National Labor Relations Act 
(29 U.S.C. 157). 
‘‘(9) NOTICE.—A skilled nursing facility shall 
post in an appropriate location in each unit a con-
spicuous notice, in a form specified by the Secretary, 
that— 
‘‘(A) explains the rights of nurses, resi-
dents, and other individuals under this sub-
section; 
‘‘(B) includes a statement that a nurse, 
resident, or other individual may file a com-
plaint with the Secretary against the facility for 
a violation of a requirement or a prohibition of 
this subsection; and 
‘‘(C) provides instructions on how to file 
such a complaint. 
‘‘(10) ENFORCEMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
enforce the requirements and prohibitions of 
this subsection in accordance with this para-
graph. 
‘‘(B) PROCEDURES
FOR
RECEIVING
AND 
INVESTIGATING
COMPLAINTS.—The Secretary 
shall establish procedures under which— 
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‘‘(i) any individual may file a com-
plaint alleging that a skilled nursing facil-
ity has violated a requirement or a prohibi-
tion of this subsection; and 
‘‘(ii) any such complaint shall be in-
vestigated by the Secretary. 
‘‘(C) REMEDIES.—If the Secretary deter-
mines that a skilled nursing facility has violated 
a requirement or prohibition of this subsection, 
the Secretary— 
‘‘(i) shall require the facility to estab-
lish a corrective action plan to prevent the 
recurrence of such violation; and 
‘‘(ii) may impose civil money penalties 
as described in subparagraph (D). 
‘‘(D) CIVIL PENALTIES.— 
‘‘(i) IN GENERAL.—In addition to any 
other penalties prescribed by law, the Sec-
retary may impose civil penalties as fol-
lows: 
‘‘(I) SKILLED NURSING FACILITY 
LIABILITY.—The Secretary may im-
pose on a skilled nursing facility 
found to be in violation of this sub-
section a civil money penalty of— 
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‘‘(aa) 
not 
more 
than 
$25,000 for the first knowing 
violation of this subsection by 
such facility; and 
‘‘(bb) 
not 
more 
than 
$50,000 
for 
any 
subsequent 
knowing violation of this sub-
section by such facility. 
‘‘(II) INDIVIDUAL
LIABILITY.— 
The Secretary may impose on an indi-
vidual who— 
‘‘(aa) is employed by a 
skilled nursing facility; and 
‘‘(bb) is found by the Sec-
retary to have knowingly violated 
this subsection on behalf of the 
facility, 
a civil money penalty of not more 
than $20,000 for each such violation 
by the individual. 
‘‘(ii) PROCEDURES.—The provisions 
of section 1128A of the Social Security Act 
(other than subsections (a) and (b)) shall 
apply with respect to a civil money penalty 
or proceeding under this subparagraph in 
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the same manner as such provisions apply 
with respect to a civil money penalty or 
proceeding under such section 1128A. 
‘‘(E) PUBLIC NOTICE OF VIOLATIONS.— 
‘‘(i) INTERNET
WEBSITE.—The Sec-
retary shall publish on the internet website 
of the Department of Health and Human 
Services the names of skilled nursing facili-
ties on which a civil money penalty has 
been imposed under this subsection, the 
violation for which such penalty was im-
posed, and such additional information as 
the Secretary determines appropriate. 
‘‘(ii) CHANGE OF OWNERSHIP.—With 
respect to a skilled nursing facility that 
had a change of ownership, as determined 
by the Secretary, penalties imposed on the 
facility while under previous ownership 
shall no longer be published by the Sec-
retary pursuant to clause (i) after the 1- 
year period beginning on the date of such 
change of ownership. 
‘‘(F) USE OF FUNDS.—Funds collected by 
the Secretary pursuant to this subsection are 
authorized to be appropriated to implement the 
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minimum nurse staffing requirements of clause 
(ii) of subsection (b)(4)(C). 
‘‘(11) NURSE
DEFINED.—In this subsection, 
the term ‘nurse’ means a registered professional 
nurse, a licensed practical nurse, and a nurse aide.’’. 
(b) MEDICAID.—Section 1919 of the Social Security 
Act (42 U.S.C. 1396r) is amended by adding at the end 
the following new subsection: 
‘‘(l) WHISTLEBLOWER
AND
RESIDENT
PROTEC-
TIONS.— 
‘‘(1) STATEMENT
REGARDING
PROFESSIONAL 
OBLIGATION AND RIGHTS.—All nurses employed by 
a nursing facility have a duty and right to act based 
on their professional judgment in accordance with 
the nursing laws and regulations of the State in 
which such facility is located, to provide nursing care 
in the exclusive interests of the residents of the facil-
ity, and to act as the residents’ advocate. 
‘‘(2) OBJECTION TO OR REFUSAL OF WORK AS-
SIGNMENT.—A nurse may object to, or refuse to 
participate in, any activity, policy, practice, assign-
ment, or task (referred to in this subsection as a 
‘work assignment’) if— 
‘‘(A) the nurse reasonably believes such 
work assignment to be in violation of the min-
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imum nurse staffing requirements of clause (ii) 
of subsection (b)(4)(C); or 
‘‘(B) the nurse reasonably believes that the 
nurse is not prepared by education, training, or 
experience to perform or comply with such work 
assignment without compromising the safety of 
a resident or jeopardizing the license of the 
nurse. 
‘‘(3) RETALIATION FOR OBJECTION TO OR RE-
FUSAL OF WORK ASSIGNMENT BARRED.— 
‘‘(A) NO DISCHARGE, DISCRIMINATION, OR 
RETALIATION.—No nursing facility may dis-
charge, retaliate, discriminate, or otherwise take 
adverse action in any manner with respect to 
any aspect of a nurse’s employment with the fa-
cility, including discharge, promotion, com-
pensation, or terms, conditions, or privileges of 
employment, based on the nurse’s objection to, 
or refusal of, a work assignment under para-
graph (2). 
‘‘(B) NO
FILING
OF
COMPLAINT.—No 
nursing facility may file a complaint or a report 
against a nurse with a State professional dis-
ciplinary agency because of the nurse’s objec-
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tion to, or refusal of, a work assignment under 
paragraph (2). 
‘‘(4) CAUSE OF ACTION.—Any nurse (or a col-
lective bargaining representative or legal representa-
tive of such nurse) against whom a nursing facility 
has taken an adverse action in violation of para-
graph (3)(A), or against whom such facility has filed 
a complaint or report in violation of paragraph 
(3)(B), may (without regard to whether a complaint 
has been filed under paragraph (5) or (10)(B)) 
bring a cause of action in an appropriate district 
court of the United States. The legal burdens of 
proof specified in section 1221(e) of title 5, United 
States Code, shall be controlling for the purposes of 
any cause of action brought under this paragraph. 
A nurse who prevails on the cause of action may be 
entitled to one or more of the following: 
‘‘(A) Reinstatement. 
‘‘(B) Reimbursement of lost wages, com-
pensation, and benefits. 
‘‘(C) Attorneys’ fees. 
‘‘(D) Court costs. 
‘‘(E) Other damages. 
‘‘(5) COMPLAINT
TO
SECRETARY.—Any indi-
vidual may file a complaint with the Secretary 
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against a nursing facility that violates a requirement 
described in paragraph (3). For any complaint filed, 
the Secretary shall— 
‘‘(A) receive and investigate the complaint; 
‘‘(B) determine whether a violation of such 
paragraph, as alleged in the complaint, has oc-
curred; and 
‘‘(C) in the case that the Secretary deter-
mines that such a violation has occurred, issue 
an order that the complaining individual may 
not suffer any adverse action prohibited by 
paragraph (3) or (7). 
‘‘(6) TOLL-FREE TELEPHONE NUMBER.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
provide for the establishment of a toll-free tele-
phone hotline to provide information regarding 
the minimum nurse staffing requirements of 
clause (ii) of subsection (b)(4)(C) and to receive 
reports of violations of such requirements. 
‘‘(B) NOTICE TO RESIDENTS.—A nursing 
facility shall provide each resident admitted to 
the facility with the telephone number of the 
hotline described in subparagraph (A) and give 
notice to each such resident that such hotline 
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may be used to report inadequate staffing or 
care. 
‘‘(7) PROTECTION FOR REPORTING.— 
‘‘(A) PROHIBITION
ON
RETALIATION
OR 
DISCRIMINATION.—A nursing facility may not 
retaliate or discriminate in any manner against 
any resident, employee, or contract employee of 
the facility, or any other individual, on the basis 
that such resident, employee, contract employee, 
or individual (individually or in conjunction 
with another individual) has, in good faith— 
‘‘(i) presented a grievance or com-
plaint; 
‘‘(ii) initiated or cooperated in any in-
vestigation or proceeding of any govern-
mental entity, regulatory agency, or private 
accreditation body; 
‘‘(iii) made a civil claim or demand; or 
‘‘(iv) filed an action relating to the 
care, services, or conditions of the facility. 
‘‘(B) GOOD
FAITH
DEFINED.—For pur-
poses of this paragraph, an individual shall be 
deemed to be acting in good faith if the indi-
vidual reasonably believes— 
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‘‘(i) the information reported or dis-
closed is true; and 
‘‘(ii) a violation of the minimum nurse 
staffing requirements of clause (ii) of sub-
section (b)(4)(C) has occurred or may 
occur. 
‘‘(8) PROHIBITION
ON
INTERFERENCE
WITH 
RIGHTS.— 
‘‘(A) EXERCISE
OF
RIGHTS.—A nursing 
facility may not— 
‘‘(i) interfere with, restrain, or deny 
the exercise, or attempt to exercise, by any 
individual of any right, procedure, or rem-
edy provided or protected under this sub-
section; or 
‘‘(ii) coerce or intimidate any indi-
vidual regarding the exercise, or attempt to 
exercise, such right. 
‘‘(B) OPPOSITION TO UNLAWFUL POLICIES 
OR PRACTICES.—A nursing facility may not re-
taliate or discriminate against any individual 
for opposing any policy, practice, or action of 
the facility which is alleged to violate, breach, 
or fail to comply with any provision of the min-
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pamtmann on DSKBC07HB2PROD with BILLS
imum nurse staffing requirements of clause (ii) 
of subsection (b)(4)(C). 
‘‘(C) PROHIBITION
ON
INTERFERENCE 
WITH PROTECTED COMMUNICATIONS.—A nurs-
ing facility may not make, adopt, or enforce any 
rule, regulation, policy, or practice which in any 
manner directly or indirectly prohibits, impedes, 
or discourages a nurse from, or intimidates, co-
erces, or induces a nurse regarding, engaging in 
free speech activities or disclosing information 
as provided under this subsection. 
‘‘(D) PROHIBITION
ON
INTERFERENCE 
WITH COLLECTIVE ACTION.—A nursing facility 
may not in any way interfere with the rights of 
nurses to organize, bargain collectively, and en-
gage in concerted activity under section 7 of the 
National Labor Relations Act (29 U.S.C. 157). 
‘‘(9) NOTICE.—A nursing facility shall post in 
an appropriate location in each unit a conspicuous 
notice, in a form specified by the Secretary, that— 
‘‘(A) explains the rights of nurses, resi-
dents, and other individuals under this sub-
section; 
‘‘(B) includes a statement that a nurse, 
resident, or other individual may file a com-
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pamtmann on DSKBC07HB2PROD with BILLS
plaint with the Secretary against the facility for 
a violation of a requirement or a prohibition of 
this subsection; and 
‘‘(C) provides instructions on how to file 
such a complaint. 
‘‘(10) ENFORCEMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
enforce the requirements and prohibitions of 
this subsection in accordance with this para-
graph. 
‘‘(B) PROCEDURES
FOR
RECEIVING
AND 
INVESTIGATING
COMPLAINTS.—The Secretary 
shall establish procedures under which— 
‘‘(i) any individual may file a com-
plaint alleging that a nursing facility has 
violated a requirement or a prohibition of 
this subsection; and 
‘‘(ii) any such complaint shall be in-
vestigated by the Secretary. 
‘‘(C) REMEDIES.—If the Secretary deter-
mines that a nursing facility has violated a re-
quirement or prohibition of this subsection, the 
Secretary— 
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‘‘(i) shall require the facility to estab-
lish a corrective action plan to prevent the 
recurrence of such violation; and 
‘‘(ii) may impose civil money penalties 
as described in subparagraph (D). 
‘‘(D) CIVIL PENALTIES.— 
‘‘(i) IN GENERAL.—In addition to any 
other penalties prescribed by law, the Sec-
retary may impose civil penalties as fol-
lows: 
‘‘(I) NURSING FACILITY LIABIL-
ITY.—The Secretary may impose on a 
nursing facility found to be in viola-
tion of this subsection a civil money 
penalty of— 
‘‘(aa) 
not 
more 
than 
$25,000 for the first knowing 
violation of this subsection by 
such facility; and 
‘‘(bb) 
not 
more 
than 
$50,000 
for 
any 
subsequent 
knowing violation of this sub-
section by such facility. 
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‘‘(II) INDIVIDUAL
LIABILITY.— 
The Secretary may impose on an indi-
vidual who— 
‘‘(aa) is employed by a nurs-
ing facility; and 
‘‘(bb) is found by the Sec-
retary to have knowingly violated 
this subsection on behalf of the 
facility, 
a civil money penalty of not more 
than $20,000 for each such violation 
by the individual. 
‘‘(ii) PROCEDURES.—The provisions 
of section 1128A of the Social Security Act 
(other than subsections (a) and (b)) shall 
apply with respect to a civil money penalty 
or proceeding under this subparagraph in 
the same manner as such provisions apply 
with respect to a civil money penalty or 
proceeding under such section 1128A. 
‘‘(E) PUBLIC NOTICE OF VIOLATIONS.— 
‘‘(i) INTERNET
WEBSITE.—The Sec-
retary shall publish on the internet website 
of the Department of Health and Human 
Services the names of nursing facilities on 
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which a civil money penalty has been im-
posed under this subsection, the violation 
for which such penalty was imposed, and 
such additional information as the Sec-
retary determines appropriate. 
‘‘(ii) CHANGE OF OWNERSHIP.—With 
respect to a nursing facility that had a 
change of ownership, as determined by the 
Secretary, penalties imposed on the facility 
while under previous ownership shall no 
longer be published by the Secretary pur-
suant to clause (i) after the 1-year period 
beginning on the date of such change of 
ownership. 
‘‘(F) USE OF FUNDS.—Funds collected by 
the Secretary pursuant to this subsection are 
authorized to be appropriated to implement the 
minimum nurse staffing requirements of clause 
(ii) of subsection (b)(4)(C). 
‘‘(11) NURSE
DEFINED.—In this subsection, 
the term ‘nurse’ means a registered professional 
nurse, a licensed practical nurse, and a nurse aide.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section take effect on the date of enactment of this 
Act and shall apply with respect to objections to or refus-
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als of work assignments, complaints, retaliations and 
other adverse actions, and interferences with rights that 
occur on or after the date that is one year after such date 
of enactment and with respect to notices provided on or 
after the date that is one year after such date of enact-
ment. 
SEC. 
206. 
PROHIBITING 
PRE-DISPUTE 
ARBITRATION 
AGREEMENTS. 
(a) MEDICARE.—Section 1819(c) of the Social Secu-
rity Act (42 U.S.C. 1395i–3(c)) is amended by adding at 
the end the following new paragraph: 
‘‘(7) PROHIBITION
ON
USE
OF
PRE-DISPUTE 
ARBITRATION AGREEMENTS.— 
‘‘(A) IN GENERAL.—A skilled nursing fa-
cility may not require, solicit, accept, or move 
to enforce a pre-dispute arbitration agreement 
from or on behalf of any resident, whether the 
agreement is made before, during, or after the 
resident’s admission to the facility, or from or 
on behalf of any employee, or contract employee 
of the facility, or any other individual if such 
individual is alleged to be engaged in conduct 
protected under subsection (l). 
‘‘(B) APPLICATION.—This paragraph shall 
apply to the skilled nursing facility and to any 
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other business or person providing or respon-
sible for providing skilled nursing services to 
the resident. 
‘‘(C) NO VALIDITY OR ENFORCEMENT.—A 
pre-dispute arbitration agreement shall not be 
valid or specifically enforceable against a resi-
dent or former resident of a skilled nursing fa-
cility, without regard to whether the agreement 
was made prior to or after the effective date of 
this paragraph. 
‘‘(D) DEFINITION OF PRE-DISPUTE ARBI-
TRATION AGREEMENT.—In this paragraph, the 
term ‘pre-dispute arbitration agreement’ means 
any agreement to arbitrate a dispute when the 
dispute has arisen after such agreement has 
been made. 
‘‘(E) JUDICIAL REVIEW.—A determination 
as to whether and how this paragraph applies 
to an arbitration agreement shall be determined 
under Federal law by a court of competent ju-
risdiction, rather than an arbitrator, without re-
gard to whether the party opposing arbitration 
challenges such agreement specifically or in 
conjunction with any other term of the contract 
containing such agreement.’’. 
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(b) MEDICAID.— 
(1) HOME
AND
COMMUNITY-BASED
SERVICES 
AND HOME HEALTH CARE SERVICES.—Section 1915 
of the Social Security Act (42 U.S.C. 1396n) is 
amended by adding at the end the following new 
subsection: 
‘‘(m) PROHIBITING
PRE-DISPUTE
ARBITRATION 
AGREEMENTS.— 
‘‘(1) IN GENERAL.—For home and community- 
based services or home health care services provided 
under 
a 
waiver 
under 
this 
section, 
section 
1902(a)(10)(D), or any other provision authorizing 
the provision of home and community-based services 
or home health care services under this title, the 
provider of such services (and any employee, agent, 
related entity, or affiliate of such provider) shall not 
require, solicit, or accept a pre-dispute arbitration 
agreement from or on behalf of any individual re-
ceiving such services, whether the agreement is made 
before, during, or after the first date on which serv-
ices are received, or from or on behalf of any em-
ployee, or contract employee of the provider, or any 
other individual if such individual is alleged to be 
engaged in conduct protected under section 1919(l). 
A pre-dispute arbitration agreement between such a 
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provider (or entity or person) and an individual re-
ceiving services (or who formerly received services) 
shall not be valid or enforceable, without regard to 
whether such agreement was made prior to the effec-
tive date of this subsection. 
‘‘(2) DEFINITION
OF
PRE-DISPUTE
ARBITRA-
TION AGREEMENT.—The term ‘pre-dispute arbitra-
tion agreement’ means any agreement to arbitrate a 
dispute when the dispute has arisen after such 
agreement has been made. 
‘‘(3) JUDICIAL REVIEW.—A determination as to 
whether and how this subsection applies to an arbi-
tration agreement shall be determined under Federal 
law by a court of competent jurisdiction, rather than 
an arbitrator, without regard to whether the party 
opposing arbitration challenges such agreement spe-
cifically or in conjunction with any other term of the 
contract containing such agreement.’’. 
(2) NURSING FACILITIES.—Section 1919(c) of 
the Social Security Act (42 U.S.C. 1396r(c)) is 
amended by adding at the end the following new 
paragraph: 
‘‘(9) PROHIBITION
ON
USE
OF
PRE-DISPUTE 
ARBITRATION AGREEMENTS.— 
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‘‘(A) IN GENERAL.—A nursing facility may 
not require, solicit, accept, or move to enforce 
a pre-dispute arbitration agreement from or on 
behalf of any resident, whether the agreement 
is made before, during, or after the resident’s 
admission to the facility, or from or on behalf 
of any employee, or contract employee of the fa-
cility, or any other individual if such individual 
is alleged to be engaged in conduct protected 
under subsection (l). 
‘‘(B) APPLICATION.—This paragraph shall 
apply to the nursing facility and to any other 
business or person providing or responsible for 
providing nursing services to the resident. 
‘‘(C) NO VALIDITY OR ENFORCEMENT.—A 
pre-dispute arbitration agreement shall not be 
valid or specifically enforceable against a resi-
dent or former resident of a nursing facility, 
without regard to whether the agreement was 
made prior to or after the effective date of this 
paragraph. 
‘‘(D) DEFINITION OF PRE-DISPUTE ARBI-
TRATION AGREEMENT.—In this paragraph, the 
term ‘pre-dispute arbitration agreement’ means 
any agreement to arbitrate a dispute when the 
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100 
dispute has arisen after such agreement has 
been made. 
‘‘(E) JUDICIAL REVIEW.—A determination 
as to whether and how this paragraph applies 
to an arbitration agreement shall be determined 
under Federal law by a court of competent ju-
risdiction, rather than an arbitrator, without re-
gard to whether the party opposing arbitration 
challenges such agreement specifically or in 
conjunction with any other term of the contract 
containing such agreement.’’. 
SEC. 207. STANDARDIZED PROTOCOL FOR OBTAINING IN-
FORMED CONSENT FROM RESIDENTS PRIOR 
TO PRESCRIBING PSYCHOTROPIC DRUGS. 
(a) STANDARDIZED PROTOCOL.— 
(1) SKILLED
NURSING
FACILITIES.—Section 
1819(b) of the Social Security Act (42 U.S.C. 
1395i–3(b)) is amended by adding at the end the 
following new paragraph: 
‘‘(9) STANDARDIZED PROTOCOL FOR OBTAIN-
ING INFORMED CONSENT FROM A RESIDENT PRIOR 
TO PRESCRIBING PSYCHOTROPIC DRUGS FOR A USE 
NOT APPROVED BY THE FOOD AND DRUG ADMINIS-
TRATION.— 
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101 
‘‘(A) PROTOCOL.—Not later than the date 
that is one year after the date of the enactment 
of this paragraph, the Secretary, taking into ac-
count the results of the study conducted by the 
Comptroller General of the United States under 
section 8(a)(3) of the Quality Care for Nursing 
Home Residents and Workers During COVID– 
19 and Beyond Act and in consultation with 
stakeholder groups (including residents of 
skilled nursing facilities, family members of 
such residents, advocates for such residents, 
long-term care ombudsmen, and providers), 
shall develop a standardized protocol for skilled 
nursing facilities to obtain written informed 
consent, in accordance with this paragraph, 
from a resident (or, if applicable, the resident’s 
designated health care agent or other surrogate 
under State law or regulation) prior to pre-
scribing a psychotropic drug to the resident for 
a use not approved by the Food and Drug Ad-
ministration. 
‘‘(B) REQUIREMENTS.—The standardized 
protocol developed under subparagraph (A) 
shall include the following: 
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102 
‘‘(i) A requirement, with respect to a 
resident, that— 
‘‘(I) the facility, with the involve-
ment of the prescriber, inform the 
resident (or, if applicable, the resi-
dent’s designated health care agent or 
other surrogate under State law or 
regulation) of— 
‘‘(aa) possible side effects 
and risks associated with the psy-
chotropic drug, including the 
mention of any ‘black box warn-
ing’; 
‘‘(bb) treatment modalities 
that were attempted prior to the 
use of the psychotropic drug; and 
‘‘(cc) any other information 
the Secretary determines appro-
priate; 
‘‘(II) the resident (or, if applica-
ble, the resident’s designated health 
care agent or other surrogate under 
State law or regulation) provide writ-
ten informed consent to the adminis-
tration of the psychotropic drug; and 
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103 
‘‘(III) the administration of the 
psychotropic drug is in accordance 
with any plan of care that the resi-
dent has in place, including non-phar-
macological interventions as appro-
priate that can effectively address un-
derlying medical and environmental 
causes of behavioral disorders. 
‘‘(ii) An alternative protocol for ob-
taining such written informed consent— 
‘‘(I) in the case of emergencies; 
and 
‘‘(II) in the absence of a clearly 
identified designated health care agent 
or other surrogate under State law or 
regulation. 
‘‘(iii) Other items determined appro-
priate by the Secretary. 
‘‘(C) TIMING OF INFORMED CONSENT.— 
Under the standardized protocol, a skilled nurs-
ing facility shall obtain the written informed 
consent described in subparagraph (A), with re-
spect to a psychotropic drug and a resident of 
the facility— 
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104 
‘‘(i) prior to the initial prescribing of 
such psychotropic drug to such resident if 
such resident does not have a current pre-
scription for such psychotropic drug at the 
time such resident is admitted to the facil-
ity; and 
‘‘(ii) at least once a month to the ex-
tent that the administration of such psy-
chotropic drug to such resident is in ac-
cordance with the plan of care that the 
resident has in place. 
‘‘(D) COMPLIANCE.—Effective beginning 
on the date that is one year and 180 days after 
the date of the enactment of this paragraph, a 
skilled nursing facility shall comply with the 
standardized protocol developed under subpara-
graph (A). 
‘‘(E) NO
PREEMPTION.—Nothing in this 
paragraph shall preempt any provision of State 
or Federal law that provides broader rights 
with respect to written informed consent for 
residents of facilities.’’. 
(2) NURSING FACILITIES.—Section 1919(b) of 
the Social Security Act (42 U.S.C. 1396r(b)) is 
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105 
amended by adding at the end the following new 
paragraph: 
‘‘(9) STANDARDIZED PROTOCOL FOR OBTAIN-
ING INFORMED CONSENT FROM A RESIDENT PRIOR 
TO PRESCRIBING PSYCHOTROPIC DRUGS FOR A USE 
NOT APPROVED BY THE FOOD AND DRUG ADMINIS-
TRATION.— 
‘‘(A) PROTOCOL.—Not later than the date 
that is one year after the date of the enactment 
of this paragraph, the Secretary, taking into ac-
count the results of the study conducted by the 
Comptroller General of the United States under 
section 8(a)(3) of the Quality Care for Nursing 
Home Residents and Workers During COVID– 
19 and Beyond Act and in consultation with 
stakeholder groups (including residents of 
skilled nursing facilities, family members of 
such residents, advocates for such residents, 
long-term care ombudsmen, and providers), 
shall develop a standardized protocol for nurs-
ing facilities to obtain written informed consent, 
in accordance with this paragraph, from a resi-
dent (or, if applicable, the resident’s designated 
health care agent or other surrogate under 
State law or regulation) prior to prescribing a 
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106 
psychotropic drug to the resident for a use not 
approved by the Food and Drug Administra-
tion. 
‘‘(B) REQUIREMENTS.—The standardized 
protocol developed under subparagraph (A) 
shall include the following: 
‘‘(i) A requirement, with respect to a 
resident, that— 
‘‘(I) the facility, with the involve-
ment of the prescriber, inform the 
resident (or, if applicable, the resi-
dent’s designated health care agent or 
other surrogate under State law or 
regulation) of— 
‘‘(aa) possible side effects 
and risks associated with the psy-
chotropic drug, including the 
mention of any ‘black box warn-
ing’; 
‘‘(bb) treatment modalities 
that were attempted prior to the 
use of the psychotropic drug; and 
‘‘(cc) any other information 
the Secretary determines appro-
priate; 
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107 
‘‘(II) the resident (or, if applica-
ble, the resident’s designated health 
care agent or other surrogate under 
State law or regulation) provide writ-
ten informed consent to the adminis-
tration of the psychotropic drug; and 
‘‘(III) the administration of the 
psychotropic drug is in accordance 
with any plan of care that the resi-
dent has in place, including non-phar-
macological interventions as appro-
priate that can effectively address un-
derlying medical and environmental 
causes of behavioral disorders. 
‘‘(ii) An alternative protocol for ob-
taining such written informed consent— 
‘‘(I) in the case of emergencies; 
and 
‘‘(II) in the absence of a clearly 
identified designated health care agent 
or other surrogate under State law or 
regulation. 
‘‘(iii) Other items determined appro-
priate by the Secretary. 
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108 
‘‘(C) TIMING OF INFORMED CONSENT.— 
Under the standardized protocol, a nursing fa-
cility shall obtain the written informed consent 
described in subparagraph (A), with respect to 
a psychotropic drug and a resident of the facil-
ity— 
‘‘(i) prior to the initial prescribing of 
such psychotropic drug to such resident if 
such resident does not have a current pre-
scription for such psychotropic drug at the 
time such resident is admitted to the facil-
ity; and 
‘‘(ii) at least once a month to the ex-
tent that the administration of such psy-
chotropic drug to such resident is in ac-
cordance with the plan of care that the 
resident has in place. 
‘‘(D) COMPLIANCE.—Effective beginning 
on the date that is one year and 180 days after 
the date of the enactment of this paragraph, a 
nursing facility shall comply with the standard-
ized protocol developed under subparagraph 
(A). 
‘‘(E) NO
PREEMPTION.—Nothing in this 
paragraph shall preempt any provision of State 
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109 
or Federal law that provides broader rights 
with respect to written informed consent for 
residents of facilities.’’. 
(3) GAO STUDY AND REPORT ON INFORMED 
CONSENT LAWS WITH RESPECT TO PRESCRIBING OF 
PSYCHOTROPIC DRUGS.— 
(A) STUDY.—The Comptroller General of 
the United States (in this paragraph referred to 
as the ‘‘Comptroller General’’) shall conduct a 
study of State laws and regulations concerning 
informed consent with respect to the adminis-
tration of a psychotropic drug with regard to 
the effectiveness of such laws and practices in 
changing the frequency of prescribing of psy-
chotropic drugs to older adults. The study shall 
include an analysis as to whether in the case of 
States that have not enacted such informed 
consent laws, such States have developed other 
mechanisms to guide appropriate prescribing of 
psychotropic drugs in older adults with demen-
tia. 
(B) REPORT.—Not later than 180 days 
after the date of enactment of this Act, the 
Comptroller General shall submit to the Sec-
retary of Health and Human Services, the 
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110 
Committees on Energy and Commerce and 
Ways and Means of the House of Representa-
tives, and the Committee on Finance of the 
Senate a report containing the results of the 
study conducted under subparagraph (A), to-
gether with such recommendations as the 
Comptroller General determines appropriate. 
(b) DEVELOPMENT OF MEASURE OF UTILIZATION OF 
PSYCHOTROPIC DRUGS
FOR INCLUSION
ON NURSING 
HOME COMPARE WEBSITE.— 
(1) MEDICARE.—Section 1819(i) of the Social 
Security Act (42 U.S.C. 1395i–3(i)) is amended— 
(A) by redesignating paragraph (3) as 
paragraph (4); and 
(B) by inserting after paragraph (2) the 
following new paragraph: 
‘‘(3) DEVELOPMENT OF MEASURE OF UTILIZA-
TION OF PSYCHOTROPIC DRUGS.— 
‘‘(A) IN
GENERAL.—Not later than the 
date that is one year after the date of the en-
actment of this paragraph, the Secretary shall 
include a measure of the utilization of psycho-
tropic drugs for each skilled nursing facility for 
inclusion on such website (or a successor 
website) as part of the quality measures or 
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111 
health inspections measures, or both such meas-
ures, under the Five-Star Quality Rating Sys-
tem established by the Administrator of the 
Centers for Medicare & Medicaid Services. 
‘‘(B) CONSIDERATIONS.—In developing the 
measure under subparagraph (A), the Secretary 
shall take into account special patient popu-
lations, special care units, appropriate diag-
noses, and other factors, as determined appro-
priate by the Secretary.’’. 
(2) MEDICAID.—Section 1919(i) of the Social 
Security Act (42 U.S.C. 1396r(i)) is amended— 
(A) by redesignating paragraph (3) as 
paragraph (4); and 
(B) by inserting after paragraph (2) the 
following new paragraph: 
‘‘(3) DEVELOPMENT OF MEASURE OF UTILIZA-
TION OF PSYCHOTROPIC DRUGS.— 
‘‘(A) IN
GENERAL.—Not later than the 
date that is one year after the date of the en-
actment of this paragraph, the Secretary shall 
include a measure of the utilization of psycho-
tropic drugs for each nursing facility for inclu-
sion on such website (or a successor website) as 
part of the quality measures or health inspec-
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112 
tions measures, or both such measures, under 
the Five-Star Quality Rating System estab-
lished by the Administrator of the Centers for 
Medicare & Medicaid Services. 
‘‘(B) CONSIDERATIONS.—In developing the 
measure under subparagraph (A), the Secretary 
shall take into account special patient popu-
lations, special care units, appropriate diag-
noses, and other factors, as determined appro-
priate by the Secretary.’’. 
Æ 
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