1963 
ated 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 nursing facility is not re-
taliated against if the worker has 
complained, in good faith, about qual-
ity of care or services or an issue re-
lating to the quality of care or serv-
ices provided at the facility, whether 
the 
resident, 
legal 
representative, 
other responsible party, or worker 
used the form developed under sub-
section (f)(11) or some other method 
for submitting the complaint. Such 
complaint resolution process shall in-
clude— 
‘‘(i) procedures to assure accu-
rate tracking of complaints re-
ceived, including notification to 
the complainant that a complaint 
has been received; 
‘‘(ii) procedures to determine 
the likely severity of a complaint 
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1964 
and for the investigation of the 
complaint; 
‘‘(iii) deadlines for responding 
to a complaint and for notifying 
the complainant of the outcome of 
the investigation; and 
‘‘(iv) 
procedures 
to 
ensure 
that the identity of the complain-
ant will be kept confidential. 
‘‘(C) 
WHISTLEBLOWER
PROTEC-
TION.— 
‘‘(i) PROHIBITION
AGAINST
RE-
TALIATION.—No person who works 
at a nursing facility may be penal-
ized, discriminated, 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, because 
the person (or anyone acting at 
the person’s request) complained, 
in good faith, about the quality of 
care or services provided by a 
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1965 
nursing facility or about other 
issues relating to quality of care 
or services, whether using the 
form developed under subsection 
(f)(11) or some other method for 
submitting the complaint. 
‘‘(ii) 
RETALIATORY
REPORT-
ING.—A nursing facility may not 
file a complaint or a report 
against a person who works (or 
has worked at the facility with 
the 
appropriate 
State 
profes-
sional 
disciplinary 
agency 
be-
cause the person (or anyone act-
ing at the person’s request) com-
plained in good faith, as de-
scribed in clause (i). 
‘‘(iii) COMMENCEMENT
OF
AC-
TION.—Any person who believes 
the person has been penalized, 
discriminated, 
or 
retaliated 
against or had a contract for serv-
ices terminated in violation of 
clause (i) or against whom a com-
plaint has been filed in violation 
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1966 
of clause (ii) may bring an action 
at law or equity in the appro-
priate district court of the United 
States, which shall have jurisdic-
tion over such action without re-
gard 
to 
the 
amount 
in 
con-
troversy or the citizenship of the 
parties, and which shall have ju-
risdiction to grant complete re-
lief, including, but not limited to, 
injunctive relief (such as rein-
statement, compensatory damages 
(which may include reimburse-
ment of lost wages, compensation, 
and benefits), costs of litigation 
(including 
reasonable 
attorney 
and expert witness fees), exem-
plary 
damages 
where 
appro-
priate, and such other relief as 
the court deems just and proper. 
‘‘(iv) RIGHTS
NOT
WAIVABLE.— 
The rights protected by this para-
graph may not be diminished by 
contract or other agreement, and 
nothing in this paragraph shall be 
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bajohnson on DSK2BSOYB1PROD with BILLS
1967 
construed to diminish any greater 
or additional protection provided 
by Federal or State law or by con-
tract or other agreement. 
‘‘(v) REQUIREMENT TO POST NO-
TICE
OF
EMPLOYEE
RIGHTS.—Each 
nursing facility shall post con-
spicuously in an appropriate loca-
tion a sign (in a form specified by 
the 
Secretary) 
specifying 
the 
rights of persons under this para-
graph and including a statement 
that an employee may file a com-
plaint with the Secretary against 
a nursing facility that violates the 
provisions of this paragraph and 
information with respect to the 
manner of filing such a com-
plaint. 
‘‘(D) 
RULE
OF
CONSTRUCTION.— 
Nothing in this paragraph shall be 
construed as preventing a resident of 
a nursing facility (or a person acting 
on the resident’s behalf) from submit-
ting a complaint in a manner or for-
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1968 
mat other than by using the stand-
ardized complaint form developed 
under subsection (f)(11) (including 
submitting a complaint orally). 
‘‘(E) GOOD
FAITH
DEFINED.—For 
purposes of this paragraph, an indi-
vidual shall be deemed to be acting in 
good faith with respect to the filing of 
a complaint if the individual reason-
ably believes— 
‘‘(i) the information reported 
or disclosed in the complaint is 
true; and 
‘‘(ii) the violation of this title 
has occurred or may occur in re-
lation to such information.’’. 
(c) EFFECTIVE
DATE.—The amendments 
made by this section shall take effect 1 year 
after the date of the enactment of this Act. 
SEC. 1416. ENSURING STAFFING ACCOUNTABILITY. 
(a) SKILLED NURSING FACILITIES.—Section 
1819(b)(8) of the Social Security Act (42 U.S.C. 
1395i–3(b)(8)) is amended by adding at the end 
the following new subparagraph: 
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1969 
‘‘(C) SUBMISSION
OF
STAFFING
IN-
FORMATION BASED ON PAYROLL DATA IN 
A
UNIFORM
FORMAT.—Beginning not 
later than 2 years after the date of 
the enactment of this subparagraph, 
and after consulting with State long- 
term care ombudsman programs, con-
sumer 
advocacy 
groups, 
provider 
stakeholder groups, employees and 
their representatives, and other par-
ties the Secretary deems appropriate, 
the Secretary shall require a skilled 
nursing facility to electronically sub-
mit to the Secretary direct care staff-
ing information (including informa-
tion with respect to agency and con-
tract staff) based on payroll and 
other verifiable and auditable data in 
a uniform format (according to speci-
fications established by the Secretary 
in consultation with such programs, 
groups, and parties). Such specifica-
tions shall require that the informa-
tion submitted under the preceding 
sentence— 
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bajohnson on DSK2BSOYB1PROD with BILLS
1970 
‘‘(i) specify the category of 
work a certified employee per-
forms (such as whether the em-
ployee is a registered nurse, li-
censed practical nurse, licensed 
vocational nurse, certified nurs-
ing assistant, therapist, or other 
medical personnel); 
‘‘(ii) include resident census 
data and information on resident 
case mix; 
‘‘(iii) include a regular report-
ing schedule; and 
‘‘(iv) include information on 
employee turnover and tenure 
and on the hours of care provided 
by each category of certified em-
ployees referenced in clause (i) 
per resident per day. 
Nothing in this subparagraph shall be 
construed as preventing the Sec-
retary from requiring submission of 
such information with respect to spe-
cific categories, such as nursing staff, 
before other categories of certified 
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bajohnson on DSK2BSOYB1PROD with BILLS
1971 
employees. Information 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
IN-
FORMATION BASED ON PAYROLL DATA IN 
A
UNIFORM
FORMAT.—Beginning not 
later than 2 years after the date of 
the enactment of this subparagraph, 
and after consulting with State long- 
term care ombudsman programs, con-
sumer 
advocacy 
groups, 
provider 
stakeholder groups, employees and 
their representatives, and other par-
ties the Secretary deems appropriate, 
the Secretary shall require a nursing 
facility to electronically submit to the 
Secretary direct care staffing infor-
mation (including information with 
respect to agency and contract staff) 
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1972 
based on payroll and other verifiable 
and auditable data in a uniform for-
mat (according to specifications es-
tablished by the Secretary in con-
sultation with such programs, groups, 
and parties). Such specifications shall 
require that the information sub-
mitted 
under 
the 
preceding 
sen-
tence— 
‘‘(i) specify the category of 
work a certified employee per-
forms (such as whether the em-
ployee is a registered nurse, li-
censed practical nurse, licensed 
vocational nurse, certified nurs-
ing assistant, therapist, or other 
medical personnel); 
‘‘(ii) include resident census 
data and information on resident 
case mix; 
‘‘(iii) include a regular report-
ing schedule; and 
‘‘(iv) include information on 
employee turnover and tenure 
and on the hours of care provided 
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bajohnson on DSK2BSOYB1PROD with BILLS
1973 
by each category of certified em-
ployees referenced in clause (i) 
per resident per day. 
Nothing in this subparagraph shall be 
construed as preventing the Sec-
retary from requiring submission of 
such information with respect to spe-
cific categories, such as nursing staff, 
before other categories of certified 
employees. Information under this 
subparagraph with respect to agency 
and contract staff shall be kept sepa-
rate from information on employee 
staffing.’’. 
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 
Sec-
retary may impose a civil 
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bajohnson on DSK2BSOYB1PROD with BILLS
1974 
money penalty in the applica-
ble per instance or per day 
amount (as defined in sub-
clause (II) and (III)) for each 
day or instance, respectively, 
of noncompliance (as deter-
mined appropriate by the Sec-
retary). 
‘‘(II) APPLICABLE
PER
IN-
STANCE
AMOUNT.—In 
this 
clause, the term ‘applicable 
per instance amount’ means— 
‘‘(aa) 
in 
the 
case 
where the deficiency is 
found to be a direct proxi-
mate cause of death of a 
resident of the facility, an 
amount 
not 
to 
exceed 
$100,000. 
‘‘(bb) in each case of a 
deficiency where the facil-
ity 
is 
cited 
for 
actual 
harm or immediate jeop-
ardy, an amount not less 
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bajohnson on DSK2BSOYB1PROD with BILLS
1975 
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 
deficiency where the facil-
ity 
is 
cited 
for 
actual 
harm or immediate jeop-
ardy, 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 
CIRCUMSTANCES.—Subject 
to 
subclauses (V) and (VI), in the 
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bajohnson on DSK2BSOYB1PROD with BILLS
1977 
amount of a penalty if the 
penalty is imposed for a 
deficiency 
described 
in 
subclause 
(II)(aa) 
or 
(III)(aa) and the actual 
harm or widespread harm 
immediately 
jeopardizes 
the health or safety of a 
resident or residents of 
the facility, or if the pen-
alty is imposed for a defi-
ciency described in sub-
clause (II)(bb). 
‘‘(VI) LIMITATION ON AGGRE-
GATE REDUCTIONS.—The aggre-
gate reduction in a penalty 
under subclause (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 regula-
tions under section 488.436 of 
title 42, Code of Federal Regu-
lations), or on the basis of 
both. 
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bajohnson on DSK2BSOYB1PROD with BILLS
1982 
quire 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 provisions apply to a 
penalty or proceeding under 
section 1128A(a).’’. 
(2) 
CONFORMING
AMENDMENT.—The 
second sentence of section 1819(h)(5) of 
the Social Security Act (42 U.S.C. 1395i– 
3(h)(5)) 
is 
amended 
by 
inserting 
‘‘(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 
striking the first sentence and in-
serting the following: ‘‘A civil 
money 
penalty 
in 
accordance 
with subparagraph (G).’’; and 
(ii) by adding at the end the 
following new subparagraph: 
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bajohnson on DSK2BSOYB1PROD with BILLS
1983 
‘‘(G) CIVIL MONEY PENALTIES.— 
‘‘(i) IN
GENERAL.—The State 
may impose a civil money penalty 
under subparagraph (A)(ii) in the 
applicable per instance or per 
day amount (as defined in sub-
clause (II) and (III)) for each day 
or instance, respectively, of non-
compliance (as determined appro-
priate by the Secretary). 
‘‘(ii) APPLICABLE PER INSTANCE 
AMOUNT.—In this subparagraph, 
the term ‘applicable per instance 
amount’ means— 
‘‘(I) in the case where the 
deficiency is found to be a di-
rect proximate cause of death 
of a resident of the facility, an 
amount 
not 
to 
exceed 
$100,000. 
‘‘(II) in each case of a defi-
ciency where the facility is 
cited for actual harm or im-
mediate jeopardy, an amount 
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bajohnson on DSK2BSOYB1PROD with BILLS
1984 
not less than $3,050 and not 
more than $25,000; and 
‘‘(III) in each case of any 
other deficiency, an amount 
not less than $250 and not to 
exceed $3050. 
‘‘(iii) 
APPLICABLE
PER
DAY 
AMOUNT.—In this subparagraph, 
the 
term 
‘applicable 
per 
day 
amount’ means— 
‘‘(I) in each case of a defi-
ciency where the facility is 
cited for actual harm or im-
mediate jeopardy, an amount 
not less than $3,050 and not 
more than $25,000 and 
‘‘(II) in each case of any 
other deficiency, an amount 
not less than $250 and not to 
exceed $3,050. 
‘‘(iv) 
REDUCTION
OF
CIVIL 
MONEY PENALTIES IN CERTAIN CIR-
CUMSTANCES.—Subject to clauses 
(v) and (vi), in the case where a 
facility self-reports and promptly 
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1985 
corrects a deficiency for which a 
penalty was imposed under sub-
paragraph (A)(ii) not later than 10 
calendar days after the date of 
such imposition, the State may re-
duce the amount of the penalty 
imposed by not more than 50 per-
cent. 
‘‘(v) PROHIBITION
ON
REDUC-
TION FOR CERTAIN DEFICIENCIES.— 
‘‘(I) 
REPEAT
DEFI-
CIENCIES.—The State may not 
reduce under clause (iv) the 
amount of a penalty if the 
State had reduced a penalty 
imposed on the facility in the 
preceding year under such 
clause with respect to a re-
peat deficiency. 
‘‘(II) CERTAIN OTHER DEFI-
CIENCIES.—The State may not 
reduce under clause (iv) the 
amount of a penalty if the 
penalty is imposed for a defi-
ciency described in clause 
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1986 
(ii)(II) or (iii)(I) and the actual 
harm 
or 
widespread 
harm 
that immediately jeopardizes 
the health or safety of a resi-
dent or residents of the facil-
ity, or if the penalty is im-
posed for a deficiency de-
scribed in clause (ii)(I). 
‘‘(III) LIMITATION
ON
AG-
GREGATE REDUCTIONS.—The ag-
gregate reduction in a penalty 
under clause (iv) may not ex-
ceed 35 percent on the basis 
of self-reporting, on the basis 
of a waiver or an appeal (as 
provided for under regula-
tions under section 488.436 of 
title 42, Code of Federal Regu-
lations), or on the basis of 
both. 
‘‘(vi) 
COLLECTION
OF
CIVIL 
MONEY PENALTIES.—In the case of 
a civil money penalty imposed 
under subparagraph (A)(ii), the 
State— 
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1987 
‘‘(I) subject to subclause 
(III), shall, not later than 30 
days after the date of imposi-
tion of the penalty, provide 
the opportunity for the facil-
ity to participate in an inde-
pendent informal dispute res-
olution process which gen-
erates a written record prior 
to the collection of such pen-
alty, 
but 
such 
opportunity 
shall not affect the responsi-
bility of the State survey 
agency for making final rec-
ommendations for such pen-
alties; 
‘‘(II) in the case where the 
penalty is imposed for each 
day of noncompliance, shall 
not impose a penalty for any 
day during the period begin-
ning on the initial day of the 
imposition of the penalty and 
ending on the day on which 
the informal dispute resolu-
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1988 
tion process under subclause 
(I) is completed; 
‘‘(III) may provide for the 
collection of such civil money 
penalty and the placement of 
such amounts collected in an 
escrow account under the di-
rection of the State on the 
earlier of the date on which 
the informal dispute resolu-
tion process under subclause 
(I) is completed or the date 
that is 90 days after the date 
of the imposition of the pen-
alty; 
‘‘(IV) may provide that 
such amounts collected are 
kept in such account pending 
the resolution of any subse-
quent appeals; 
‘‘(V) in the case where the 
facility successfully appeals 
the penalty, may provide for 
the return of such amounts 
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1989 
collected (plus interest) to the 
facility; and 
‘‘(VI) in the case where all 
such appeals are unsuccess-
ful, may provide that such 
funds collected shall be used 
for the purposes described in 
the second sentence of sub-
paragraph (A)(ii).’’. 
(B) CONFORMING AMENDMENT.—The 
second 
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 before the pe-
riod at the end the following: ‘‘, and 
some portion of such funds may be 
used to support activities that benefit 
residents, including assistance to sup-
port and protect residents of a facil-
ity that closes (voluntarily or involun-
tarily) or is decertified (including off-
setting costs of relocating residents to 
home and community-based settings 
or another facility), projects that sup-
port resident and family councils and 
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1990 
other consumer involvement in assur-
ing quality care in facilities, and fa-
cility 
improvement 
initiatives 
ap-
proved by the Secretary (including 
joint training of facility staff and sur-
veyors, providing technical assistance 
to facilities under quality assurance 
programs, the appointment of tem-
porary management, and other activi-
ties approved 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 
subclause (II), the Secretary 
may impose a civil money 
penalty in an amount not to 
exceed $10,000 for each day or 
each instance of noncompli-
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bajohnson on DSK2BSOYB1PROD with BILLS
1991 
ance (as determined appro-
priate by the Secretary). 
‘‘(II) REDUCTION
OF
CIVIL 
MONEY
PENALTIES
IN
CERTAIN 
CIRCUMSTANCES.—Subject 
to 
subclause (III), in the case 
where a facility self-reports 
and promptly corrects a defi-
ciency for which a penalty 
was 
imposed 
under 
this 
clause not later than 10 cal-
endar days after the date of 
such 
imposition, 
the 
Sec-
retary 
may 
reduce 
the 
amount of the penalty im-
posed by not more than 50 
percent. 
‘‘(III) PROHIBITION
ON
RE-
DUCTION
FOR
REPEAT
DEFI-
CIENCIES.—The Secretary may 
not reduce the amount of a 
penalty under subclause (II) if 
the Secretary had reduced a 
penalty imposed on the facil-
ity in the preceding year 
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1992 
under such subclause with re-
spect to a repeat deficiency. 
‘‘(IV) COLLECTION OF CIVIL 
MONEY PENALTIES.—In the case 
of a civil money penalty im-
posed 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 opportunity 
for the facility to partici-
pate in an independent in-
formal dispute resolution 
process which generates a 
written record prior to 
the collection of such pen-
alty; 
‘‘(bb) 
in 
the 
case 
where the penalty is im-
posed for each day of non-
compliance, shall not im-
pose a penalty for any day 
during the period begin-
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bajohnson on DSK2BSOYB1PROD with BILLS
1993 
ning on the initial day of 
the imposition of the pen-
alty and ending on the 
day on which the informal 
dispute resolution process 
under item (aa) is com-
pleted; 
‘‘(cc) may provide for 
the collection of such civil 
money penalty and the 
placement 
of 
such 
amounts collected in an 
escrow account under the 
direction of the Secretary 
on the earlier of the date 
on which the informal dis-
pute 
resolution 
process 
under item (aa) is com-
pleted 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 
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bajohnson on DSK2BSOYB1PROD with BILLS
1994 
pending the resolution of 
any subsequent appeals; 
‘‘(ee) in the case where 
the 
facility 
successfully 
appeals the penalty, may 
provide for the return of 
such 
amounts 
collected 
(plus interest) to the facil-
ity; and 
‘‘(ff) in the case where 
all such appeals are un-
successful, 
may 
provide 
that some portion of such 
amounts collected may be 
used to support activities 
that benefit residents, in-
cluding assistance to sup-
port and protect residents 
of a facility that closes 
(voluntarily 
or 
involun-
tarily) or is decertified 
(including offsetting costs 
of relocating residents to 
home 
and 
community- 
based settings or another 
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bajohnson on DSK2BSOYB1PROD with BILLS
1995 
facility), projects that sup-
port resident and family 
councils and other con-
sumer involvement in as-
suring quality care in fa-
cilities, and facility im-
provement initiatives ap-
proved by the Secretary 
(including joint training 
of facility staff and sur-
veyors, 
technical 
assist-
ance for facilities under 
quality 
assurance 
pro-
grams, the appointment of 
temporary 
management, 
and other activities ap-
proved by the Secretary). 
‘‘(V) 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 imposi-
tion of a civil money penalty) 
shall apply to a civil money 
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