572 
term care ombudsman program with respect to a 
skilled nursing facility.’’. 
(2) STATE
REQUIREMENTS.—Section 1819(e) 
of the Social Security Act (42 U.S.C. 1395i–3(e)) is 
amended by adding at the end the following new 
paragraph: 
‘‘(6) COMPLAINT
PROCESSES
AND
WHISTLE- 
BLOWER PROTECTION.— 
‘‘(A) COMPLAINT FORMS.—The State must 
make the standardized complaint form devel-
oped under subsection (f)(9) available upon re-
quest to— 
‘‘(i) a resident of a skilled nursing fa-
cility; 
‘‘(ii) any person acting on the resi-
dent’s behalf; and 
‘‘(iii) any person who works at a 
skilled nursing facility or is a representa-
tive of such a worker. 
‘‘(B) COMPLAINT RESOLUTION PROCESS.— 
The State must establish a complaint resolution 
process in order to ensure that a resident, the 
legal representative of a resident of a skilled 
nursing facility, or other responsible party is 
not retaliated against if the resident, legal rep-
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jlentini on DSKJ8SOYB1PROD with BILLS
573 
resentative, or responsible party has com-
plained, in good faith, about the quality of care 
or other issues relating to the skilled nursing 
facility, that the legal representative of a resi-
dent of a skilled nursing facility or other re-
sponsible party is not denied access to such 
resident or otherwise retaliated against if such 
representative party has complained, in good 
faith, about the quality of care provided by the 
facility or other issues relating to the facility, 
and that a person who works at a skilled nurs-
ing facility is not retaliated against if the work-
er has complained, in good faith, about quality 
of care or services or an issue relating to the 
quality of care or services provided at the facil-
ity, whether the resident, legal representative, 
other responsible party, or worker used the 
form developed under subsection (f)(9) or some 
other method for submitting the complaint. 
Such complaint resolution process shall in-
clude— 
‘‘(i) procedures to assure accurate 
tracking of complaints received, including 
notification to the complainant that a com-
plaint has been received; 
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574 
‘‘(ii) procedures to determine the like-
ly severity of a complaint and for the in-
vestigation of the complaint; 
‘‘(iii) deadlines for responding to a 
complaint and for notifying the complain-
ant of the outcome of the investigation; 
and 
‘‘(iv) procedures to ensure that the 
identity of the complainant will be kept 
confidential. 
‘‘(C) WHISTLEBLOWER PROTECTION.— 
‘‘(i) PROHIBITION AGAINST RETALIA-
TION.—No person who works at a skilled 
nursing facility may be penalized, discrimi-
nated, or retaliated against with respect to 
any aspect of employment, including dis-
charge, promotion, compensation, terms, 
conditions, or privileges of employment, or 
have a contract for services terminated, be-
cause the person (or anyone acting at the 
person’s request) complained, in good 
faith, about the quality of care or services 
provided by a nursing facility or about 
other issues relating to quality of care or 
services, whether using the form developed 
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jlentini on DSKJ8SOYB1PROD with BILLS
575 
under subsection (f)(9) or some other 
method for submitting the complaint. 
‘‘(ii) RETALIATORY
REPORTING.—A 
skilled nursing facility may not file a com-
plaint or a report against a person who 
works (or has worked at the facility with 
the appropriate State professional discipli-
nary agency because the person (or anyone 
acting at the person’s request) complained 
in good faith, as described in clause (i). 
‘‘(iii) COMMENCEMENT OF ACTION.— 
Any person who believes the person has 
been penalized, discriminated, or retaliated 
against or had a contract for services ter-
minated in violation of clause (i) or against 
whom a complaint has been filed in viola-
tion of clause (ii) may bring an action at 
law or equity in the appropriate district 
court of the United States, which shall 
have jurisdiction over such action without 
regard to the amount in controversy or the 
citizenship of the parties, and which shall 
have jurisdiction to grant complete relief, 
including, but not limited to, injunctive re-
lief (such as reinstatement, compensatory 
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jlentini on DSKJ8SOYB1PROD with BILLS
576 
damages (which may include reimburse-
ment of lost wages, compensation, and 
benefits), costs of litigation (including rea-
sonable attorney and expert witness fees), 
exemplary damages where appropriate, and 
such other relief as the court deems just 
and proper. 
‘‘(iv) RIGHTS
NOT
WAIVABLE.—The 
rights protected by this paragraph may not 
be diminished by contract or other agree-
ment, and nothing in this paragraph shall 
be construed to diminish any greater or 
additional protection provided by Federal 
or State law or by contract or other agree-
ment. 
‘‘(v) REQUIREMENT TO POST NOTICE 
OF
EMPLOYEE
RIGHTS.—Each 
skilled 
nursing facility shall post conspicuously in 
an appropriate location a sign (in a form 
specified by the Secretary) specifying the 
rights of persons under this paragraph and 
including a statement that an employee 
may file a complaint with the Secretary 
against a skilled nursing facility that vio-
lates the provisions of this paragraph and 
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jlentini on DSKJ8SOYB1PROD with BILLS
577 
information with respect to the manner of 
filing such a complaint. 
‘‘(D) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as pre-
venting a resident of a skilled nursing facility 
(or a person acting on the resident’s behalf) 
from submitting a complaint in a manner or 
format other than by using the standardized 
complaint form developed under subsection 
(f)(9) (including submitting a complaint orally). 
‘‘(E) GOOD
FAITH
DEFINED.—For pur-
poses of this paragraph, an individual shall be 
deemed to be acting in good faith with respect 
to the filing of a complaint if the individual rea-
sonably believes— 
‘‘(i) the information reported or dis-
closed in the complaint is true; and 
‘‘(ii) the violation of this title has oc-
curred or may occur in relation to such in-
formation.’’. 
(b) NURSING FACILITIES.— 
(1) DEVELOPMENT BY THE SECRETARY.—Sec-
tion 1919(f) of the Social Security Act (42 U.S.C. 
1395i–3(f)), as amended by section 1413(b), is 
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jlentini on DSKJ8SOYB1PROD with BILLS
578 
amended by adding at the end the following new 
paragraph: 
‘‘(11) STANDARDIZED COMPLAINT FORM.—The 
Secretary shall develop a standardized complaint 
form for use by a resident (or a person acting on the 
resident’s behalf) in filing a complaint with a State 
survey and certification agency and a State long- 
term care ombudsman program with respect to a 
nursing facility.’’. 
(2) STATE
REQUIREMENTS.—Section 1919(e) 
of the Social Security Act (42 U.S.C. 1395i–3(e)) is 
amended by adding at the end the following new 
paragraph: 
‘‘(8) COMPLAINT
PROCESSES
AND
WHISTLE-
BLOWER PROTECTION.— 
‘‘(A) COMPLAINT FORMS.—The State must 
make the standardized complaint form devel-
oped under subsection (f)(11) available upon re-
quest to— 
‘‘(i) a resident of a nursing facility; 
‘‘(ii) any person acting on the resi-
dent’s behalf; and 
‘‘(iii) any person who works at a nurs-
ing facility or a representative of such a 
worker. 
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jlentini on DSKJ8SOYB1PROD with BILLS
579 
‘‘(B) COMPLAINT RESOLUTION PROCESS.— 
The State must establish a complaint resolution 
process in order to ensure that a resident, the 
legal representative of a resident of a nursing 
facility, or other responsible party is not retali-
ated against if the resident, legal representa-
tive, or responsible party has complained, in 
good faith, about the quality of care or other 
issues relating to the nursing facility, that the 
legal representative of a resident of a nursing 
facility or other responsible party is not denied 
access to such resident or otherwise retaliated 
against if such representative party has com-
plained, in good faith, about the quality of care 
provided by the facility or other issues relating 
to the facility, and that a person who works at 
a nursing facility is not retaliated against if the 
worker has complained, in good faith, about 
quality of care or services or an issue relating 
to the quality of care or services provided at the 
facility, whether the resident, legal representa-
tive, other responsible party, or worker used the 
form developed under subsection (f)(11) or 
some other method for submitting the com-
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jlentini on DSKJ8SOYB1PROD with BILLS
580 
plaint. Such complaint resolution process shall 
include— 
‘‘(i) procedures to assure accurate 
tracking of complaints received, including 
notification to the complainant that a com-
plaint has been received; 
‘‘(ii) procedures to determine the like-
ly severity of a complaint and for the in-
vestigation of the complaint; 
‘‘(iii) deadlines for responding to a 
complaint and for notifying the complain-
ant of the outcome of the investigation; 
and 
‘‘(iv) procedures to ensure that the 
identity of the complainant will be kept 
confidential. 
‘‘(C) WHISTLEBLOWER PROTECTION.— 
‘‘(i) PROHIBITION AGAINST RETALIA-
TION.—No person who works at a nursing 
facility may be penalized, discriminated, or 
retaliated against with respect to any as-
pect of employment, including discharge, 
promotion, compensation, terms, condi-
tions, or privileges of employment, or have 
a contract for services terminated, because 
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jlentini on DSKJ8SOYB1PROD with BILLS
581 
the person (or anyone acting at the per-
son’s request) complained, in good faith, 
about the quality of care or services pro-
vided by a nursing facility or about other 
issues relating to quality of care or serv-
ices, whether using the form developed 
under subsection (f)(11) or some other 
method for submitting the complaint. 
‘‘(ii) RETALIATORY
REPORTING.—A 
nursing facility may not file a complaint or 
a report against a person who works (or 
has worked at the facility with the appro-
priate State professional disciplinary agen-
cy because the person (or anyone acting at 
the person’s request) complained in good 
faith, as described in clause (i). 
‘‘(iii) COMMENCEMENT OF ACTION.— 
Any person who believes the person has 
been penalized, discriminated, or retaliated 
against or had a contract for services ter-
minated in violation of clause (i) or against 
whom a complaint has been filed in viola-
tion of clause (ii) may bring an action at 
law or equity in the appropriate district 
court of the United States, which shall 
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jlentini on DSKJ8SOYB1PROD with BILLS
582 
have jurisdiction over such action without 
regard to the amount in controversy or the 
citizenship of the parties, and which shall 
have jurisdiction to grant complete relief, 
including, but not limited to, injunctive re-
lief (such as reinstatement, compensatory 
damages (which may include reimburse-
ment of lost wages, compensation, and 
benefits), costs of litigation (including rea-
sonable attorney and expert witness fees), 
exemplary damages where appropriate, and 
such other relief as the court deems just 
and proper. 
‘‘(iv) RIGHTS
NOT
WAIVABLE.—The 
rights protected by this paragraph may not 
be diminished by contract or other agree-
ment, and nothing in this paragraph shall 
be construed to diminish any greater or 
additional protection provided by Federal 
or State law or by contract or other agree-
ment. 
‘‘(v) REQUIREMENT TO POST NOTICE 
OF EMPLOYEE RIGHTS.—Each nursing fa-
cility shall post conspicuously in an appro-
priate location a sign (in a form specified 
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jlentini on DSKJ8SOYB1PROD with BILLS
583 
by the Secretary) specifying the rights of 
persons under this paragraph and includ-
ing a statement that an employee may file 
a complaint with the Secretary against a 
nursing facility that violates the provisions 
of this paragraph and information with re-
spect to the manner of filing such a com-
plaint. 
‘‘(D) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as pre-
venting a resident of a nursing facility (or a 
person acting on the resident’s behalf) from 
submitting a complaint in a manner or format 
other than by using the standardized complaint 
form developed under subsection (f)(11) (in-
cluding submitting a complaint orally). 
‘‘(E) GOOD
FAITH
DEFINED.—For pur-
poses of this paragraph, an individual shall be 
deemed to be acting in good faith with respect 
to the filing of a complaint if the individual rea-
sonably believes— 
‘‘(i) the information reported or dis-
closed in the complaint is true; and 
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jlentini on DSKJ8SOYB1PROD with BILLS
584 
‘‘(ii) the violation of this title has oc-
curred or may occur in relation to such in-
formation.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of the 
enactment of this Act. 
SEC. 1416. ENSURING STAFFING ACCOUNTABILITY. 
(a) 
SKILLED
NURSING
FACILITIES.—Section 
1819(b)(8) of the Social Security Act (42 U.S.C. 1395i– 
3(b)(8)) is amended by adding at the end the following 
new subparagraph: 
‘‘(C) SUBMISSION OF STAFFING INFORMA-
TION BASED ON PAYROLL DATA IN A UNIFORM 
FORMAT.—Beginning not later than 2 years 
after the date of the enactment of this subpara-
graph, and after consulting with State long- 
term care ombudsman programs, consumer ad-
vocacy groups, provider stakeholder groups, em-
ployees and their representatives, and other 
parties the Secretary deems appropriate, the 
Secretary shall require a skilled nursing facility 
to electronically submit to the Secretary direct 
care staffing information (including information 
with respect to agency and contract staff) based 
on payroll and other verifiable and auditable 
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jlentini on DSKJ8SOYB1PROD with BILLS
585 
data in a uniform format (according to speci-
fications established by the Secretary in con-
sultation with such programs, groups, and par-
ties). Such specifications shall require that the 
information submitted under the preceding sen-
tence— 
‘‘(i) specify the category of work a 
certified employee performs (such as 
whether the employee is a registered nurse, 
licensed practical nurse, licensed vocational 
nurse, certified nursing assistant, thera-
pist, or other medical personnel); 
‘‘(ii) include resident census data and 
information on resident case mix; 
‘‘(iii) include a regular reporting 
schedule; and 
‘‘(iv) include information on employee 
turnover and tenure and on the hours of 
care provided by each category of certified 
employees referenced in clause (i) per resi-
dent per day. 
Nothing in this subparagraph shall be con-
strued as preventing the Secretary from requir-
ing submission of such information with respect 
to specific categories, such as nursing staff, be-
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jlentini on DSKJ8SOYB1PROD with BILLS
586 
fore other categories of certified employees. In-
formation under this subparagraph with respect 
to agency and contract staff shall be kept sepa-
rate from information on employee staffing.’’. 
(b) NURSING FACILITIES.—Section 1919(b)(8) of the 
Social Security Act (42 U.S.C. 1396r(b)(8)) is amended 
by adding at the end the following new subparagraph: 
‘‘(C) SUBMISSION OF STAFFING INFORMA-
TION BASED ON PAYROLL DATA IN A UNIFORM 
FORMAT.—Beginning not later than 2 years 
after the date of the enactment of this subpara-
graph, and after consulting with State long- 
term care ombudsman programs, consumer ad-
vocacy groups, provider stakeholder groups, em-
ployees and their representatives, and other 
parties the Secretary deems appropriate, the 
Secretary shall require a nursing facility to elec-
tronically submit to the Secretary direct care 
staffing information (including information with 
respect to agency and contract staff) based on 
payroll and other verifiable and auditable data 
in a uniform format (according to specifications 
established by the Secretary in consultation 
with such programs, groups, and parties). Such 
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jlentini on DSKJ8SOYB1PROD with BILLS
587 
specifications shall require that the information 
submitted under the preceding sentence— 
‘‘(i) specify the category of work a 
certified employee performs (such as 
whether the employee is a registered nurse, 
licensed practical nurse, licensed vocational 
nurse, certified nursing assistant, thera-
pist, or other medical personnel); 
‘‘(ii) include resident census data and 
information on resident case mix; 
‘‘(iii) include a regular reporting 
schedule; and 
‘‘(iv) include information on employee 
turnover and tenure and on the hours of 
care provided by each category of certified 
employees referenced in clause (i) per resi-
dent per day. 
Nothing in this subparagraph shall be con-
strued as preventing the Secretary from requir-
ing submission of such information with respect 
to specific categories, such as nursing staff, be-
fore other categories of certified employees. In-
formation under this subparagraph with respect 
to agency and contract staff shall be kept sepa-
rate from information on employee staffing.’’. 
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jlentini on DSKJ8SOYB1PROD with BILLS
588 
PART 2—TARGETING ENFORCEMENT 
SEC. 1421. CIVIL MONEY PENALTIES. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819(h)(2)(B)(ii) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395i– 
3(h)(2)(B)(ii)) is amended to read as follows: 
‘‘(ii) AUTHORITY WITH RESPECT TO 
CIVIL MONEY PENALTIES.— 
‘‘(I) AMOUNT.—The Secretary 
may impose a civil money penalty in 
the applicable per instance or per day 
amount (as defined in subclause (II) 
and (III)) for each day or instance, 
respectively, of noncompliance (as de-
termined appropriate by the Sec-
retary). 
‘‘(II) APPLICABLE PER INSTANCE 
AMOUNT.—In this clause, the term 
‘applicable 
per 
instance 
amount’ 
means— 
‘‘(aa) in the case where the 
deficiency is found to be a direct 
proximate cause of death of a 
resident 
of 
the 
facility, 
an 
amount not to exceed $100,000; 
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jlentini on DSKJ8SOYB1PROD with BILLS
589 
‘‘(bb) in each case of a defi-
ciency where the facility is cited 
for actual harm or immediate 
jeopardy, an amount not less 
than $3,050 and not more than 
$25,000; and 
‘‘(cc) in each case of any 
other deficiency, an amount not 
less than $250 and not to exceed 
$3050. 
‘‘(III) APPLICABLE
PER
DAY 
AMOUNT.—In this clause, the term 
‘applicable per day amount’ means— 
‘‘(aa) in each case of a defi-
ciency where the facility is cited 
for actual harm or immediate 
jeopardy, an amount not less 
than $3,050 and not more than 
$25,000; and 
‘‘(bb) in each case of any 
other deficiency, an amount not 
less than $250 and not to exceed 
$3,050. 
‘‘(IV) 
REDUCTION
OF
CIVIL 
MONEY PENALTIES IN CERTAIN CIR-
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jlentini on DSKJ8SOYB1PROD with BILLS
590 
CUMSTANCES.—Subject to subclauses 
(V) and (VI), in the case where a fa-
cility self-reports and promptly cor-
rects a deficiency for which a penalty 
was imposed under this clause not 
later than 10 calendar days after the 
date of such imposition, the Secretary 
may reduce the amount of the penalty 
imposed by not more than 50 percent. 
‘‘(V) PROHIBITION
ON
REDUC-
TION FOR CERTAIN DEFICIENCIES.— 
‘‘(aa) 
REPEAT
DEFI-
CIENCIES.—The Secretary may 
not reduce under subclause (IV) 
the amount of a penalty if the 
deficiency is a repeat deficiency. 
‘‘(bb) CERTAIN OTHER DE-
FICIENCIES.—The Secretary may 
not reduce under subclause (IV) 
the amount of a penalty if the 
penalty is imposed for a defi-
ciency described in subclause 
(II)(aa) or (III)(aa) and the ac-
tual harm or widespread harm 
immediately 
jeopardizes 
the 
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jlentini on DSKJ8SOYB1PROD with BILLS
591 
health or safety of a resident or 
residents of the facility, or if the 
penalty is imposed for a defi-
ciency described in subclause 
(II)(bb). 
‘‘(VI) LIMITATION
ON
AGGRE-
GATE
REDUCTIONS.—The aggregate 
reduction in a penalty under sub-
clause (IV) may not exceed 35 percent 
on the basis of self-reporting, on the 
basis of a waiver or an appeal (as pro-
vided for under regulations under sec-
tion 488.436 of title 42, Code of Fed-
eral Regulations), or on the basis of 
both. 
‘‘(VII) COLLECTION
OF
CIVIL 
MONEY PENALTIES.—In the case of a 
civil money penalty imposed under 
this clause, the Secretary— 
‘‘(aa) subject to item (cc), 
shall, not later than 30 days 
after the date of imposition of 
the penalty, provide the oppor-
tunity for the facility to partici-
pate in an independent informal 
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jlentini on DSKJ8SOYB1PROD with BILLS
592 
dispute resolution process which 
generates a written record prior 
to the collection of such penalty, 
but such opportunity shall not af-
fect the responsibility of the 
State survey agency for making 
final recommendations for such 
penalties; 
‘‘(bb) in the case where the 
penalty is imposed for each day 
of noncompliance, shall not im-
pose a penalty for any day during 
the period beginning on the ini-
tial day of the imposition of the 
penalty and ending on the day on 
which the informal dispute reso-
lution process under item (aa) is 
completed; 
‘‘(cc) may provide for the 
collection of such civil money 
penalty and the placement of 
such amounts collected in an es-
crow account under the direction 
of the Secretary on the earlier of 
the date on which the informal 
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jlentini on DSKJ8SOYB1PROD with BILLS
593 
dispute resolution process under 
item (aa) is completed or the 
date that is 90 days after the 
date of the imposition of the pen-
alty; 
‘‘(dd) may provide that such 
amounts collected are kept in 
such account pending the resolu-
tion of any subsequent appeals; 
‘‘(ee) in the case where the 
facility successfully appeals the 
penalty, may provide for the re-
turn of such amounts collected 
(plus interest) to the facility; and 
‘‘(ff) in the case where all 
such appeals are unsuccessful, 
may provide that some portion of 
such amounts collected may be 
used to support activities that 
benefit residents, including as-
sistance to support and protect 
residents of a facility that closes 
(voluntarily or involuntarily) or is 
decertified (including offsetting 
costs of relocating residents to 
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jlentini on DSKJ8SOYB1PROD with BILLS
594 
home and community-based set-
tings or another facility), projects 
that support resident and family 
councils and other consumer in-
volvement in assuring quality 
care in facilities, and facility im-
provement initiatives approved by 
the Secretary (including joint 
training of facility staff and sur-
veyors, technical assistance for 
facilities under quality assurance 
programs, the appointment of 
temporary 
management, 
and 
other activities approved by the 
Secretary). 
‘‘(VIII) PROCEDURE.—The pro-
visions of section 1128A (other than 
subsections (a) and (b) and except to 
the extent that such provisions require 
a hearing prior to the imposition of a 
civil money penalty) shall apply to a 
civil money penalty under this clause 
in the same manner as such provi-
sions apply to a penalty or proceeding 
under section 1128A(a).’’. 
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595 
(2) CONFORMING
AMENDMENT.—The second 
sentence of section 1819(h)(5) of the Social Security 
Act (42 U.S.C. 1395i–3(h)(5)) is amended by insert-
ing ‘‘(ii),’’ after ‘‘(i),’’. 
(b) NURSING FACILITIES.— 
(1) PENALTIES IMPOSED BY THE STATE.— 
(A) IN GENERAL.—Section 1919(h)(2) of 
the Social Security Act (42 U.S.C. 1396r(h)(2)) 
is amended— 
(i) in subparagraph (A)(ii), by strik-
ing the first sentence and inserting the fol-
lowing: ‘‘A civil money penalty in accord-
ance with subparagraph (G).’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(G) CIVIL MONEY PENALTIES.— 
‘‘(i) IN
GENERAL.—The State may 
impose a civil money penalty under sub-
paragraph (A)(ii) in the applicable per in-
stance or per day amount (as defined in 
subclause (II) and (III)) for each day or 
instance, respectively, of noncompliance (as 
determined appropriate by the Secretary). 
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‘‘(ii) 
APPLICABLE
PER
INSTANCE 
AMOUNT.—In this subparagraph, the term 
‘applicable per instance amount’ means— 
‘‘(I) in the case where the defi-
ciency is found to be a direct proxi-
mate cause of death of a resident of 
the facility, an amount not to exceed 
$100,000; 
‘‘(II) in each case of a deficiency 
where the facility is cited for actual 
harm or immediate jeopardy, an 
amount not less than $3,050 and not 
more than $25,000; and 
‘‘(III) in each case of any other 
deficiency, an amount not less than 
$250 and not to exceed $3,050. 
‘‘(iii) 
APPLICABLE
PER
DAY 
AMOUNT.—In this subparagraph, the term 
‘applicable per day amount’ means— 
‘‘(I) in each case of a deficiency 
where the facility is cited for actual 
harm or immediate jeopardy, an 
amount not less than $3,050 and not 
more than $25,000; and 
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‘‘(II) in each case of any other 
deficiency, an amount not less than 
$250 and not to exceed $3,050. 
‘‘(iv) REDUCTION
OF
CIVIL
MONEY 
PENALTIES
IN
CERTAIN
CIR-
CUMSTANCES.—Subject to clauses (v) and 
(vi), in the case where a facility self-re-
ports and promptly corrects a deficiency 
for which a penalty was imposed under 
subparagraph (A)(ii) not later than 10 cal-
endar days after the date of such imposi-
tion, the State may reduce the amount of 
the penalty imposed by not more than 50 
percent. 
‘‘(v) PROHIBITION
ON
REDUCTION 
FOR CERTAIN DEFICIENCIES.— 
‘‘(I) REPEAT
DEFICIENCIES.— 
The State may not reduce under 
clause (iv) the amount of a penalty if 
the State had reduced a penalty im-
posed on the facility in the preceding 
year under such clause with respect to 
a repeat deficiency. 
‘‘(II) CERTAIN
OTHER
DEFI-
CIENCIES.—The State may not reduce 
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598 
under clause (iv) the amount of a pen-
alty if the penalty is imposed for a de-
ficiency described in clause (ii)(II) or 
(iii)(I) and the actual harm or wide-
spread harm that immediately jeop-
ardizes the health or safety of a resi-
dent or residents of the facility, or if 
the penalty is imposed for a deficiency 
described in clause (ii)(I). 
‘‘(III) LIMITATION
ON
AGGRE-
GATE
REDUCTIONS.—The aggregate 
reduction in a penalty under clause 
(iv) may not exceed 35 percent on the 
basis of self-reporting, on the basis of 
a waiver or an appeal (as provided for 
under 
regulations 
under 
section 
488.436 of title 42, Code of Federal 
Regulations), or on the basis of both. 
‘‘(iv) COLLECTION
OF
CIVIL
MONEY 
PENALTIES.—In the case of a civil money 
penalty 
imposed 
under 
subparagraph 
(A)(ii), the State— 
‘‘(I) subject to subclause (III), 
shall, not later than 30 days after the 
date of imposition of the penalty, pro-
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599 
vide the opportunity for the facility to 
participate in an independent informal 
dispute resolution process which gen-
erates a written record prior to the 
collection of such penalty, but such 
opportunity shall not affect the re-
sponsibility of the State survey agency 
for making final recommendations for 
such penalties; 
‘‘(II) in the case where the pen-
alty is imposed for each day of non-
compliance, shall not impose a penalty 
for any day during the period begin-
ning on the initial day of the imposi-
tion of the penalty and ending on the 
day on which the informal dispute res-
olution process under subclause (I) is 
completed; 
‘‘(III) may provide for the collec-
tion of such civil money penalty and 
the placement of such amounts col-
lected in an escrow account under the 
direction of the State on the earlier of 
the date on which the informal dis-
pute resolution process under sub-
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600 
clause (I) is completed or the date 
that is 90 days after the date of the 
imposition of the penalty; 
‘‘(IV) may provide that such 
amounts collected are kept in such ac-
count pending the resolution of any 
subsequent appeals; 
‘‘(V) in the case where the facil-
ity successfully appeals the penalty, 
may provide for the return of such 
amounts collected (plus interest) to 
the facility; and 
‘‘(VI) in the case where all such 
appeals are unsuccessful, may provide 
that such funds collected shall be used 
for the purposes described in the sec-
ond 
sentence 
of 
subparagraph 
(A)(ii).’’. 
(B) CONFORMING AMENDMENT.—The sec-
ond sentence of section 1919(h)(2)(A)(ii) of the 
Social 
Security 
Act 
(42 
U.S.C. 
1396r(h)(2)(A)(ii)) is amended by inserting be-
fore the period at the end the following: ‘‘, and 
some portion of such funds may be used to sup-
port activities that benefit residents, including 
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assistance to support and protect residents of a 
facility that closes (voluntarily or involuntarily) 
or is decertified (including offsetting costs of re-
locating residents to home and community- 
based settings or another facility), projects that 
support resident and family councils and other 
consumer involvement in assuring quality care 
in facilities, and facility improvement initiatives 
approved by the Secretary (including joint 
training of facility staff and surveyors, pro-
viding technical assistance to facilities under 
quality assurance programs, the appointment of 
temporary management, and other activities ap-
proved by the Secretary)’’. 
(2) 
PENALTIES
IMPOSED
BY
THE
SEC-
RETARY.— 
(A) 
IN
GENERAL.—Section 
1919(h)(3)(C)(ii) of the Social Security Act (42 
U.S.C. 1396r(h)(3)(C)) is amended to read as 
follows: 
‘‘(ii) AUTHORITY WITH RESPECT TO 
CIVIL MONEY PENALTIES.— 
‘‘(I) AMOUNT.—Subject to sub-
clause (II), the Secretary may impose 
a civil money penalty in an amount 
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602 
not to exceed $10,000 for each day or 
each instance of noncompliance (as 
determined appropriate by the Sec-
retary). 
‘‘(II) 
REDUCTION
OF
CIVIL 
MONEY PENALTIES IN CERTAIN CIR-
CUMSTANCES.—Subject to subclause 
(III), in the case where a facility self- 
reports and promptly corrects a defi-
ciency for which a penalty was im-
posed under this clause not later than 
10 calendar days after the date of 
such imposition, the Secretary may 
reduce the amount of the penalty im-
posed by not more than 50 percent. 
‘‘(III) PROHIBITION ON REDUC-
TION
FOR
REPEAT
DEFICIENCIES.— 
The Secretary may not reduce the 
amount of a penalty under subclause 
(II) if the Secretary had reduced a 
penalty imposed on the facility in the 
preceding year under such subclause 
with respect to a repeat deficiency. 
‘‘(IV) COLLECTION
OF
CIVIL 
MONEY PENALTIES.—In the case of a 
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603 
civil money penalty imposed under 
this clause, the Secretary— 
‘‘(aa) subject to item (bb), 
shall, not later than 30 days 
after the date of imposition of 
the penalty, provide the oppor-
tunity for the facility to partici-
pate in an independent informal 
dispute resolution process which 
generates a written record prior 
to the collection of such penalty; 
‘‘(bb) in the case where the 
penalty is imposed for each day 
of noncompliance, shall not im-
pose a penalty for any day during 
the period beginning on the ini-
tial day of the imposition of the 
penalty and ending on the day on 
which the informal dispute reso-
lution process under item (aa) is 
completed; 
‘‘(cc) may provide for the 
collection of such civil money 
penalty and the placement of 
such amounts collected in an es-
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604 
crow account under the direction 
of the Secretary on the earlier of 
the date on which the informal 
dispute resolution process under 
item (aa) is completed or the 
date that is 90 days after the 
date of the imposition of the pen-
alty; 
‘‘(dd) may provide that such 
amounts collected are kept in 
such account pending the resolu-
tion of any subsequent appeals; 
‘‘(ee) in the case where the 
facility successfully appeals the 
penalty, may provide for the re-
turn of such amounts collected 
(plus interest) to the facility; and 
‘‘(ff) in the case where all 
such appeals are unsuccessful, 
may provide that some portion of 
such amounts collected may be 
used to support activities that 
benefit residents, including as-
sistance to support and protect 
residents of a facility that closes 
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(voluntarily or involuntarily) or is 
decertified (including offsetting 
costs of relocating residents to 
home and community-based set-
tings or another facility), projects 
that support resident and family 
councils and other consumer in-
volvement in assuring quality 
care in facilities, and facility im-
provement initiatives approved by 
the Secretary (including joint 
training of facility staff and sur-
veyors, technical assistance for 
facilities under quality assurance 
programs, the appointment of 
temporary 
management, 
and 
other activities approved by the 
Secretary). 
‘‘(V) PROCEDURE.—The provi-
sions of section 1128A (other than 
subsections (a) and (b) and except to 
the extent that such provisions require 
a hearing prior to the imposition of a 
civil money penalty) shall apply to a 
civil money penalty under this clause 
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606 
in the same manner as such provi-
sions apply to a penalty or proceeding 
under section 1128A(a).’’. 
(B) CONFORMING
AMENDMENT.—Section 
1919(h)(8) of the Social Security Act (42 
U.S.C. 1396r(h)(5)(8)) is amended by inserting 
‘‘and in paragraph (3)(C)(ii)’’ after ‘‘paragraph 
(2)(A)’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of the 
enactment of this Act. 
SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PRO-
GRAM. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—The Secretary, in consulta-
tion with the Inspector General of the Department 
of Health and Human Services, shall establish a 
pilot program (in this section referred to as the 
‘‘pilot program’’) to develop, test, and implement use 
of an independent monitor to oversee interstate and 
large intrastate chains of skilled nursing facilities 
and nursing facilities. 
(2) SELECTION.—The Secretary shall select 
chains of skilled nursing facilities and nursing facili-
ties described in paragraph (1) to participate in the 
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607 
pilot program from among those chains that submit 
an application to the Secretary at such time, in such 
manner, and containing such information as the Sec-
retary may require. 
(3) DURATION.—The Secretary shall conduct 
the pilot program for a two-year period. 
(4) IMPLEMENTATION.—The Secretary shall 
implement the pilot program not later than one year 
after the date of the enactment of this Act. 
(b) REQUIREMENTS.—The Secretary shall evaluate 
chains selected to participate in the pilot program based 
on criteria selected by the Secretary, including where evi-
dence suggests that one or more facilities of the chain are 
experiencing serious safety and quality of care problems. 
Such criteria may include the evaluation of a chain that 
includes one or more facilities participating in the ‘‘Special 
Focus Facility’’ program (or a successor program) or one 
or more facilities with a record of repeated serious safety 
and quality of care deficiencies. 
(c) RESPONSIBILITIES OF THE INDEPENDENT MON-
ITOR.—An independent monitor that enters into a con-
tract with the Secretary to participate in the conduct of 
such program shall— 
(1) conduct periodic reviews and prepare root- 
cause quality and deficiency analyses of a chain to 
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assess if facilities of the chain are in compliance 
with State and Federal laws and regulations applica-
ble to the facilities; 
(2) undertake sustained oversight of the chain, 
whether publicly or privately held, to involve the 
owners of the chain and the principal business part-
ners of such owners in facilitating compliance by fa-
cilities of the chain with State and Federal laws and 
regulations applicable to the facilities; 
(3) analyze the management structure, distribu-
tion of expenditures, and nurse staffing levels of fa-
cilities of the chain in relation to resident census, 
staff turnover rates, and tenure; 
(4) report findings and recommendations with 
respect to such reviews, analyses, and oversight to 
the chain and facilities of the chain, to the Secretary 
and to relevant States; and 
(5) publish the results of such reviews, anal-
yses, and oversight. 
(d) IMPLEMENTATION OF RECOMMENDATIONS.— 
(1) RECEIPT OF FINDING BY CHAIN.—Not later 
than 10 days after receipt of a finding of an inde-
pendent monitor under subsection (c)(4), a chain 
participating in the pilot program shall submit to 
the independent monitor a report— 
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(A) outlining corrective actions the chain 
will take to implement the recommendations in 
such report; or 
(B) indicating that the chain will not im-
plement such recommendations and why it will 
not do so. 
(2) RECEIPT
OF
REPORT
BY
INDEPENDENT 
MONITOR.—Not later than 10 days after the date of 
receipt of a report submitted by a chain under para-
graph (1), an independent monitor shall finalize its 
recommendations and submit a report to the chain 
and facilities of the chain, the Secretary, and the 
State (or States) involved, as appropriate, containing 
such final recommendations. 
(e) COST OF APPOINTMENT.—A chain shall be re-
sponsible for a portion of the costs associated with the 
appointment of independent monitors under the pilot pro-
gram. The chain shall pay such portion to the Secretary 
(in an amount and in accordance with procedures estab-
lished by the Secretary). 
(f) WAIVER AUTHORITY.—The Secretary may waive 
such requirements of titles XVIII and XIX of the Social 
Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as 
may be necessary for the purpose of carrying out the pilot 
program. 
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(g) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as may be 
necessary to carry out this section. 
(h) DEFINITIONS.—In this section: 
(1) FACILITY.—The term ‘‘facility’’ means a 
skilled nursing facility or a nursing facility. 
(2) NURSING
FACILITY.—The term ‘‘nursing 
facility’’ has the meaning given such term in section 
1919(a) of the Social Security Act (42 U.S.C. 
1396r(a)). 
(3) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services, acting 
through the Assistant Secretary for Planning and 
Evaluation. 
(4) SKILLED
NURSING
FACILITY.—The term 
‘‘skilled nursing facility’’ has the meaning given such 
term in section 1819(a) of the Social Security Act 
(42 U.S.C. 1395(a)). 
(i) EVALUATION AND REPORT.— 
(1) EVALUATION.—The Inspector General of 
the Department of Health and Human Services shall 
evaluate the pilot program. Such evaluation shall— 
(A) determine whether the independent 
monitor program should be established on a 
permanent basis; and 
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(B) if the Inspector General determines 
that the independent monitor program should 
be established on a permanent basis, rec-
ommend appropriate procedures and mecha-
nisms for such establishment. 
(2) REPORT.—Not later than 180 days after 
the completion of the pilot program, the Inspector 
General shall submit to Congress and the Secretary 
a report containing the results of the evaluation con-
ducted under paragraph (1), together with rec-
ommendations for such legislation and administra-
tive action as the Inspector General determines ap-
propriate. 
SEC. 1423. NOTIFICATION OF FACILITY CLOSURE. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819(c) of the So-
cial Security Act (42 U.S.C. 1395i–3(c)) is amended 
by adding at the end the following new paragraph: 
‘‘(7) NOTIFICATION OF FACILITY CLOSURE.— 
‘‘(A) IN GENERAL.—Any individual who is 
the administrator of a skilled nursing facility 
must— 
‘‘(i) submit to the Secretary, the State 
long-term care ombudsman, residents of 
the facility, and the legal representatives of 
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such residents or other responsible parties, 
written notification of an impending clo-
sure— 
‘‘(I) subject to subclause (II), not 
later than the date that is 60 days 
prior to the date of such closure; and 
‘‘(II) in the case of a facility 
where the Secretary terminates the fa-
cility’s participation under this title, 
not later than the date that the Sec-
retary determines appropriate; 
‘‘(ii) ensure that the facility does not 
admit any new residents on or after the 
date on which such written notification is 
submitted; and 
‘‘(iii) include in the notice a plan for 
the transfer and adequate relocation of the 
residents of the facility by a specified date 
prior to closure that has been approved by 
the State, including assurances that the 
residents will be transferred to the most 
appropriate facility or other setting in 
terms of quality, services, and location, 
taking into consideration the needs and 
best interests of each resident. 
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‘‘(B) RELOCATION.— 
‘‘(i) IN
GENERAL.—The State shall 
ensure that, before a facility closes, all 
residents of the facility have been success-
fully relocated to another facility or an al-
ternative home and community-based set-
ting. 
‘‘(ii) CONTINUATION
OF
PAYMENTS 
UNTIL RESIDENTS RELOCATED.—The Sec-
retary may, as the Secretary determines 
appropriate, continue to make payments 
under this title with respect to residents of 
a facility that has submitted a notification 
under subparagraph (A) during the period 
beginning on the date such notification is 
submitted and ending on the date on which 
the resident is successfully relocated.’’. 
(2) 
CONFORMING
AMENDMENTS.—Section 
1819(h)(4) of the Social Security Act (42 U.S.C. 
1395i–3(h)(4)) is amended— 
(A) in the first sentence, by striking ‘‘the 
Secretary shall terminate’’ and inserting ‘‘the 
Secretary, subject to subsection (c)(7), shall 
terminate’’; and 
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(B) in the second sentence, by striking 
‘‘subsection (c)(2)’’ and inserting ‘‘paragraphs 
(2) and (7) of subsection (c)’’. 
(b) NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1919(c) of the So-
cial Security Act (42 U.S.C. 1396r(c)) is amended 
by adding at the end the following new paragraph: 
‘‘(9) NOTIFICATION OF FACILITY CLOSURE.— 
‘‘(A) IN GENERAL.—Any individual who is 
an administrator of a nursing facility must— 
‘‘(i) submit to the Secretary, the State 
long-term care ombudsman, residents of 
the facility, and the legal representatives of 
such residents or other responsible parties, 
written notification of an impending clo-
sure— 
‘‘(I) subject to subclause (II), not 
later than the date that is 60 days 
prior to the date of such closure; and 
‘‘(II) in the case of a facility 
where the Secretary terminates the fa-
cility’s participation under this title, 
not later than the date that the Sec-
retary determines appropriate; 
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‘‘(ii) ensure that the facility does not 
admit any new residents on or after the 
date on which such written notification is 
submitted; and 
‘‘(iii) include in the notice a plan for 
the transfer and adequate relocation of the 
residents of the facility by a specified date 
prior to closure that has been approved by 
the State, including assurances that the 
residents will be transferred to the most 
appropriate facility or other setting in 
terms of quality, services, and location, 
taking into consideration the needs and 
best interests of each resident. 
‘‘(B) RELOCATION.— 
‘‘(i) IN
GENERAL.—The State shall 
ensure that, before a facility closes, all 
residents of the facility have been success-
fully relocated to another facility or an al-
ternative home and community-based set-
ting. 
‘‘(ii) CONTINUATION
OF
PAYMENTS 
UNTIL RESIDENTS RELOCATED.—The Sec-
retary may, as the Secretary determines 
appropriate, continue to make payments 
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616 
under this title with respect to residents of 
a facility that has submitted a notification 
under subparagraph (A) during the period 
beginning on the date such notification is 
submitted and ending on the date on which 
the resident is successfully relocated.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of the 
enactment of this Act. 
PART 3—IMPROVING STAFF TRAINING 
SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING. 
(a) 
SKILLED
NURSING
FACILITIES.—Section 
1819(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 
1395i–3(f)(2)(A)(i)(I)) is amended by inserting ‘‘(includ-
ing, in the case of initial training and, if the Secretary 
determines appropriate, in the case of ongoing training, 
dementia management training and resident abuse preven-
tion training)’’ after ‘‘curriculum’’. 
(b) 
NURSING
FACILITIES.—Section 
1919(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 
1396r(f)(2)(A)(i)(I)) is amended by inserting ‘‘(including, 
in the case of initial training and, if the Secretary deter-
mines appropriate, in the case of ongoing training, demen-
tia management training and resident abuse prevention 
training)’’ after ‘‘curriculum’’. 
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(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of the 
enactment of this Act. 
SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED 
FOR CERTIFIED NURSE AIDES AND SUPER-
VISORY STAFF. 
(a) STUDY.— 
(1) IN GENERAL.—The Secretary shall conduct 
a study on the content of training for certified nurse 
aides and supervisory staff of skilled nursing facili-
ties and nursing facilities. The study shall include an 
analysis of the following: 
(A) Whether the number of initial training 
hours for certified nurse aides required under 
sections 
1819(f)(2)(A)(i)(II) 
and 
1919(f)(2)(A)(i)(II) of the Social Security Act 
(42 
U.S.C. 
1395i–3(f)(2)(A)(i)(II); 
1396r(f)(2)(A)(i)(II)) should be increased from 
75 and, if so, what the required number of ini-
tial training hours should be, including any rec-
ommendations for the content of such training 
(including training related to dementia). 
(B) Whether requirements for ongoing 
training 
under 
such 
sections 
1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) 
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should be increased from 12 hours per year, in-
cluding any recommendations for the content of 
such training. 
(2) CONSULTATION.—In conducting the anal-
ysis under paragraph (1)(A), the Secretary shall 
consult with States that, as of the date of the enact-
ment of this Act, require more than 75 hours of 
training for certified nurse aides. 
(3) DEFINITIONS.—In this section: 
(A) NURSING FACILITY.—The term ‘‘nurs-
ing facility’’ has the meaning given such term 
in section 1919(a) of the Social Security Act 
(42 U.S.C. 1396r(a)). 
(B) SECRETARY.—The term ‘‘Secretary’’ 
means the Secretary of Health and Human 
Services, acting through the Assistant Secretary 
for Planning and Evaluation. 
(C) SKILLED
NURSING
FACILITY.—The 
term ‘‘skilled nursing facility’’ has the meaning 
given such term in section 1819(a) of the Social 
Security Act (42 U.S.C. 1395(a)). 
(b) REPORT.—Not later than 2 years after the date 
of the enactment of this Act, the Secretary shall submit 
to Congress a report containing the results of the study 
conducted under subsection (a), together with rec-
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ommendations for such legislation and administrative ac-
tion as the Secretary determines appropriate. 
Subtitle C—Quality Measurements 
SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR 
QUALITY IMPROVEMENT. 
Title XI of the Social Security Act, as amended by 
section 1401(a), is further amended by adding at the end 
the following new part: 
‘‘PART E—QUALITY IMPROVEMENT 
‘‘ESTABLISHMENT OF NATIONAL PRIORITIES FOR 
PERFORMANCE IMPROVEMENT 
‘‘SEC. 1191. (a) ESTABLISHMENT OF NATIONAL PRI-
ORITIES BY THE SECRETARY.—The Secretary shall estab-
lish and periodically update, not less frequently than tri-
ennially, national priorities for performance improvement. 
‘‘(b) RECOMMENDATIONS
FOR NATIONAL PRIOR-
ITIES.—In establishing and updating national priorities 
under subsection (a), the Secretary shall solicit and con-
sider recommendations from multiple outside stake-
holders. 
‘‘(c) CONSIDERATIONS IN SETTING NATIONAL PRI-
ORITIES.—With respect to such priorities, the Secretary 
shall ensure that priority is given to areas in the delivery 
of health care services in the United States that— 
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‘‘(1) contribute to a large burden of disease, in-
cluding those that address the health care provided 
to patients with prevalent, high-cost chronic dis-
eases; 
‘‘(2) have the greatest potential to decrease 
morbidity and mortality in this country, including 
those that are designed to eliminate harm to pa-
tients; 
‘‘(3) have the greatest potential for improving 
the 
performance, 
affordability, 
and 
patient- 
centeredness of health care, including those due to 
variations in care; 
‘‘(4) address health disparities across groups 
and areas; and 
‘‘(5) have the potential for rapid improvement 
due to existing evidence, standards of care or other 
reasons. 
‘‘(d) DEFINITIONS.—In this part: 
‘‘(1) CONSENSUS-BASED
ENTITY.—The term 
‘consensus-based entity’ means an entity with a con-
tract with the Secretary under section 1890. 
‘‘(2) QUALITY
MEASURE.—The term ‘quality 
measure’ means a national consensus standard for 
measuring the performance and improvement of pop-
ulation health, or of institutional providers of serv-
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ices, physicians, and other health care practitioners 
in the delivery of health care services. 
‘‘(e) FUNDING.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
for the transfer, from the Federal Hospital Insur-
ance Trust Fund under section 1817 and the Fed-
eral Supplementary Medical Insurance Trust Fund 
under section 1841 (in such proportion as the Sec-
retary determines appropriate), of $2,000,000, for 
the activities under this section for each of the fiscal 
years 2010 through 2014. 
‘‘(2) AUTHORIZATION
OF
APPROPRIATIONS.— 
For purposes of carrying out the provisions of this 
section, in addition to funds otherwise available, out 
of any funds in the Treasury not otherwise appro-
priated, there are appropriated to the Secretary of 
Health and Human Services $2,000,000 for each of 
the fiscal years 2010 through 2014.’’. 
SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; 
GAO EVALUATION OF DATA COLLECTION 
PROCESS FOR QUALITY MEASUREMENT. 
Part E of title XI of the Social Security Act, as added 
by section 1441, is amended by adding at the end the fol-
lowing new sections: 
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‘‘SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES. 
‘‘(a) AGREEMENTS WITH QUALIFIED ENTITIES.— 
‘‘(1) IN GENERAL.—The Secretary shall enter 
into agreements with qualified entities to develop 
quality measures for the delivery of health care serv-
ices in the United States. 
‘‘(2) FORM OF AGREEMENTS.—The Secretary 
may carry out paragraph (1) by contract, grant, or 
otherwise. 
‘‘(3) 
RECOMMENDATIONS
OF
CONSENSUS- 
BASED ENTITY.—In carrying out this section, the 
Secretary shall— 
‘‘(A) seek public input; and 
‘‘(B) take into consideration recommenda-
tions of the consensus-based entity with a con-
tract with the Secretary under section 1890(a). 
‘‘(b) DETERMINATION OF AREAS WHERE QUALITY 
MEASURES ARE REQUIRED.—Consistent with the na-
tional priorities established under this part and with the 
programs administered by the Centers for Medicare & 
Medicaid Services and in consultation with other relevant 
Federal agencies, the Secretary shall determine areas in 
which quality measures for assessing health care services 
in the United States are needed. 
‘‘(c) DEVELOPMENT OF QUALITY MEASURES.— 
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‘‘(1) PATIENT-CENTERED
AND
POPULATION- 
BASED
MEASURES.—Quality measures developed 
under agreements under subsection (a) shall be de-
signed— 
‘‘(A) to assess outcomes and functional 
status of patients; 
‘‘(B) to assess the continuity and coordina-
tion of care and care transitions for patients 
across providers and health care settings, in-
cluding end of life care; 
‘‘(C) to assess patient experience and pa-
tient engagement; 
‘‘(D) to assess the safety, effectiveness, 
and timeliness of care; 
‘‘(E) to assess health disparities including 
those associated with individual race, ethnicity, 
age, gender, place of residence or language; 
‘‘(F) to assess the efficiency and resource 
use in the provision of care; 
‘‘(G) to the extent feasible, to be collected 
as part of health information technologies sup-
porting better delivery of health care services; 
‘‘(H) to be available free of charge to users 
for the use of such measures; and 
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‘‘(I) to assess delivery of health care serv-
ices to individuals regardless of age. 
‘‘(2) AVAILABILITY OF MEASURES.—The Sec-
retary shall make quality measures developed under 
this section available to the public. 
‘‘(3) TESTING OF PROPOSED MEASURES.—The 
Secretary may use amounts made available under 
subsection (f) to fund the testing of proposed quality 
measures by qualified entities. Testing funded under 
this paragraph shall include testing of the feasibility 
and usability of proposed measures. 
‘‘(4) UPDATING
OF
ENDORSED
MEASURES.— 
The Secretary may use amounts made available 
under subsection (f) to fund the updating (and test-
ing, if applicable) by consensus-based entities of 
quality measures that have been previously endorsed 
by such an entity as new evidence is developed, in 
a manner consistent with section 1890(b)(3). 
‘‘(d) QUALIFIED ENTITIES.—Before entering into 
agreements with a qualified entity, the Secretary shall en-
sure that the entity is a public, nonprofit or academic in-
stitution with technical expertise in the area of health 
quality measurement. 
‘‘(e) APPLICATION FOR GRANT.—A grant may be 
made under this section only if an application for the 
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grant is submitted to the Secretary and the application 
is in such form, is made in such manner, and contains 
such agreements, assurances, and information as the Sec-
retary determines to be necessary to carry out this section. 
‘‘(f) FUNDING.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
for the transfer, from the Federal Hospital Insur-
ance Trust Fund under section 1817 and the Fed-
eral Supplementary Medical Insurance Trust Fund 
under section 1841 (in such proportion as the Sec-
retary determines appropriate), of $25,000,000, to 
the Secretary for purposes of carrying out this sec-
tion for each of the fiscal years 2010 through 2014. 
‘‘(2) AUTHORIZATION
OF
APPROPRIATIONS.— 
For purposes of carrying out the provisions of this 
section, in addition to funds otherwise available, out 
of any funds in the Treasury not otherwise appro-
priated, there are appropriated to the Secretary of 
Health and Human Services $25,000,000 for each 
of the fiscal years 2010 through 2014. 
‘‘SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROC-
ESS FOR QUALITY MEASUREMENT. 
‘‘(a) GAO EVALUATIONS.—The Comptroller General 
of the United States shall conduct periodic evaluations of 
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the implementation of the data collection processes for 
quality measures used by the Secretary. 
‘‘(b) CONSIDERATIONS.—In carrying out the evalua-
tion under subsection (a), the Comptroller General shall 
determine— 
‘‘(1) whether the system for the collection of 
data for quality measures provides for validation of 
data as relevant and scientifically credible; 
‘‘(2) whether data collection efforts under the 
system use the most efficient and cost-effective 
means in a manner that minimizes administrative 
burden on persons required to collect data and that 
adequately protects the privacy of patients’ personal 
health information and provides data security; 
‘‘(3) whether standards under the system pro-
vide for an appropriate opportunity for physicians 
and other clinicians and institutional providers of 
services to review and correct findings; and 
‘‘(4) the extent to which quality measures are 
consistent with section 1192(c)(1) or result in direct 
or indirect costs to users of such measures. 
‘‘(c) REPORT.—The Comptroller General shall sub-
mit reports to Congress and to the Secretary containing 
a description of the findings and conclusions of the results 
of each such evaluation.’’. 
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SEC. 1443. MULTI-STAKEHOLDER PRE-RULEMAKING INPUT 
INTO SELECTION OF QUALITY MEASURES. 
Section 1808 of the Social Security Act (42 U.S.C. 
1395b–9) is amended by adding at the end the following 
new subsection: 
‘‘(d) MULTI-STAKEHOLDER PRE-RULEMAKING INPUT 
INTO SELECTION OF QUALITY MEASURES.— 
‘‘(1) LIST OF MEASURES.—Not later than De-
cember 1 before each year (beginning with 2011), 
the Secretary shall make public a list of measures 
being considered for selection for quality measure-
ment by the Secretary in rulemaking with respect to 
payment systems under this title beginning in the 
payment year beginning in such year and for pay-
ment systems beginning in the calendar year fol-
lowing such year, as the case may be. 
‘‘(2) CONSULTATION
ON
SELECTION
OF
EN-
DORSED
QUALITY
MEASURES.—A consensus-based 
entity that has entered into a contract under section 
1890 shall, as part of such contract, convene multi- 
stakeholder groups to provide recommendations on 
the selection of individual or composite quality meas-
ures, for use in reporting performance information 
to the public or for use in public health care pro-
grams. 
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‘‘(3) MULTI-STAKEHOLDER INPUT.—Not later 
than February 1 of each year (beginning with 
2011), the consensus-based entity described in para-
graph (2) shall transmit to the Secretary the rec-
ommendations of multi-stakeholder groups provided 
under paragraph (2). Such recommendations shall 
be included in the transmissions the consensus-based 
entity makes to the Secretary under the contract 
provided for under section 1890. 
‘‘(4) REQUIREMENT
FOR
TRANSPARENCY
IN 
PROCESS.— 
‘‘(A) IN
GENERAL.—In convening multi- 
stakeholder groups under paragraph (2) with 
respect to the selection of quality measures, the 
consensus-based entity described in such para-
graph shall provide for an open and transparent 
process for the activities conducted pursuant to 
such convening. 
‘‘(B) SELECTION OF ORGANIZATIONS PAR-
TICIPATING
IN
MULTI-STAKEHOLDER 
GROUPS.—The process under paragraph (2) 
shall ensure that the selection of representatives 
of multi-stakeholder groups includes provision 
for public nominations for, and the opportunity 
for public comment on, such selection. 
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‘‘(5) USE OF INPUT.—The respective proposed 
rule shall contain a summary of the recommenda-
tions made by the multi-stakeholder groups under 
paragraph (2), as well as other comments received 
regarding the proposed measures, and the extent to 
which such proposed rule follows such recommenda-
tions and the rationale for not following such rec-
ommendations. 
‘‘(6) MULTI-STAKEHOLDER GROUPS.—For pur-
poses of this subsection, the term ‘multi-stakeholder 
groups’ means, with respect to a quality measure, a 
voluntary collaborative of organizations representing 
persons interested in or affected by the use of such 
quality measure, such as the following: 
‘‘(A) Hospitals and other institutional pro-
viders. 
‘‘(B) Physicians. 
‘‘(C) Health care quality alliances. 
‘‘(D) Nurses and other health care practi-
tioners. 
‘‘(E) Health plans. 
‘‘(F) Patient advocates and consumer 
groups. 
‘‘(G) Employers. 
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