retary determines that there are cir-
cumstances warranting such suspension. 
‘‘(ii) 
CIRCUMSTANCES.—In 
estab-
lishing the circumstances under clause (i), 
the Secretary shall take into account— 
‘‘(I) findings from Federal sur-
veys and investigations; 
‘‘(II) findings from State surveys 
conducted under subsection (g)(2)(A); 
‘‘(III) findings from State inves-
tigations and surveys conducted under 
subsection (g)(4), including a high 
number of substantiated complaints, 
the frequency and severity of substan-
tiated complaints, and how the com-
plaints are handled by the facility; 
‘‘(IV) 
situations 
involving 
changes of ownership, administration, 
or management of a nursing facility, 
or the director of nursing; 
‘‘(V) situations involving the in-
appropriate administration of medica-
tions by a facility; 
‘‘(VI) situations involving invol-
untary discharges of residents; and 
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‘‘(VII) other factors determined 
appropriate by the Secretary. 
‘‘(iii) NO REINSTATEMENT PRIOR TO 
NEXT
STANDARD
SURVEY.—If a nursing 
facility’s designation is suspended under 
clause (i), such designation shall not be re-
instated prior to a subsequent survey as 
specified under subsection (g)(2)(A)(iii).’’. 
(B) ASSESSMENT
OF
HIGH-RATED
DES-
IGNATION
IN
SPECIAL
SURVEYS.—Section 
1919(g)(2)(A)(iii)(II) of the Social Security Act 
(42 U.S.C. 1396r(g)(2)(A)(iii)(II)) is amend-
ed— 
(i) by inserting ‘‘(or, in the case of a 
facility that is designated as a high-rated 
nursing facility under subsection (f)(12), 
shall be conducted)’’ after ‘‘may be con-
ducted’’; and 
(ii) by adding at the end the following 
new sentence: ‘‘On and after the date the 
Secretary implements the high-rated facil-
ity program under subsection (f)(12), any 
survey conducted, pursuant to the pre-
ceding sentence, of a facility that is des-
ignated as a high-rated nursing facility 
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under such subsection shall include an as-
sessment of whether such designation 
should continue or be suspended under 
subparagraph (D) of such subsection.’’. 
(2) IMPROVEMENTS
TO
THE
SPECIAL
FOCUS 
FACILITY PROGRAM.— 
(A) APPROPRIATE
PARTICIPATION.—Sec-
tion 1919(f)(10) of the Social Security Act (42 
U.S.C. 1395r(f)(10)) is amended— 
(i) in subparagraph (A), by striking 
‘‘The Secretary’’ and inserting ‘‘Subject to 
the succeeding provisions of this sub-
section, the Secretary’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(C) APPROPRIATE
PARTICIPATION.—Not 
later than 1 year after the date of enactment of 
the Nursing Home Reform Modernization Act 
of 2021, the Secretary shall ensure that the 
number of facilities participating in the special 
focus facility program is not less than 3.5 per-
cent of all nursing facilities.’’. 
(B) CONVERSION OF THE SPECIAL FOCUS 
FACILITY PROGRAM TO THE LOW-RATED FACIL-
ITY
PROGRAM
AND
ADDITIONAL
REQUIRE-
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MENTS.—Section 1919(f)(10) of the Social Se-
curity Act (42 U.S.C. 1395i–3(f)(10)), as 
amended by subparagraph (A), is amended— 
(i) in subparagraph (B), by inserting 
the following before the period at the end: 
‘‘(or, on and after the date the Secretary 
makes the conversion described in subpara-
graph (D), at a frequency determined ap-
propriate by the Secretary (but in no case 
less than once every 6 months))’’; and 
(ii) by adding at the end the following 
new subparagraphs: 
‘‘(D) CONVERSION
TO
THE
LOW-RATED 
FACILITY PROGRAM.— 
‘‘(i) IN GENERAL.—On the same date 
that the Secretary implements the high- 
rated facility program under paragraph 
(12), the Secretary shall convert the spe-
cial focus facility program under this sub-
section to the low-rated facility program. 
‘‘(ii) REGULATIONS.—The Secretary 
shall carry out the conversion under clause 
(i) through notice and comment rule-
making. 
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‘‘(iii) 
ADDITIONAL
REQUIREMENTS 
FOR
THE
LOW-RATED
FACILITY
PRO-
GRAM.—In addition to the provisions that 
apply to the low-rated facility program 
through the conversion from the special 
focus facility program, the succeeding pro-
visions of this subsection shall also apply 
to the low-rated facility program. 
‘‘(E) PARTICIPATION.—Subject to the min-
imum participation requirement under subpara-
graph (C), the Secretary shall designate the 
lowest rated nursing facilities under the 
rankings under paragraph (11)(B) for partici-
pation in the low-rated facility program. 
‘‘(F) PROGRESSIVE
ENFORCEMENT
AC-
TIONS.—The Secretary, in consultation with 
States, shall utilize progressive enforcement ac-
tions, of increasing severity, to ensure facilities 
participating in the low-rated facility program 
meet the applicable requirements under this 
Act. 
‘‘(G) ENFORCEMENT
FOR
PATTERNS
OF 
DEFICIENCY.—The Secretary may utilize en-
forcement actions specified in subsection (h)(2) 
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to remedy patterns of deficiencies cited across 
multiple surveys. 
‘‘(H) 
COMPLIANCE
ASSISTANCE
PRO-
GRAMS.— 
‘‘(i) ON-SITE
CONSULTATION
AND 
EDUCATIONAL PROGRAMMING.— 
‘‘(I) IN
GENERAL.—The Sec-
retary shall establish on-site consulta-
tion and educational programming for 
nursing facilities participating in the 
low-rated facility program with re-
spect to compliance with the applica-
ble requirements under this Act. 
‘‘(II) ENTITY.—The on-site con-
sultation and educational program-
ming described in subclause (I) shall 
be carried out by quality improvement 
organizations under part B of title XI 
or other independent organizations of 
a similar type that do not have con-
flicts of interest and are deemed ap-
propriate by the Secretary. 
‘‘(III) 
REQUIRED
PARTICIPA-
TION.—A 
nursing 
facility 
partici-
pating in the low-rated facility pro-
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gram shall participate in any con-
sultations and educational program-
ming described in subclause (I) con-
ducted at the facility. 
‘‘(ii) CONSULTATION
INDEPENDENT 
OF ENFORCEMENT.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), on-site consultations 
and educational programming de-
scribed in clause (i) shall be con-
ducted independently of any enforce-
ment activity. 
‘‘(II) EXCEPTION.—Subclause (I) 
shall not apply in the case where a 
triggering event at the nursing facility 
is observed in the course of providing 
on-site consultations and educational 
programming described in clause (i). 
In establishing such on-site consulta-
tions and educational programming, 
the Secretary shall determine the trig-
gering events for which the use of 
necessary enforcement actions is per-
mitted notwithstanding the limitation 
under subclause (I). Such triggering 
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events shall include events that are re-
quired to be reported under State and 
Federal law and a pattern of defi-
ciencies or problems that the quality 
improvement organization or other or-
ganization has identified for correc-
tion but which are consistently not 
corrected. 
‘‘(I) PUBLIC AVAILABILITY.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall ensure that a nursing facility’s par-
ticipation in the low-rated facility program 
is publicly announced, including to— 
‘‘(I) resident family councils; 
‘‘(II) resident attending physi-
cians; 
‘‘(III) the State board respon-
sible for the licensing of the nursing 
facility administrator at the facility; 
‘‘(IV) State Long-Term Care 
Ombudsman programs (as described 
in section 712(a)(1) of the Older 
Americans Act of 1965); and 
‘‘(V) the community at large. 
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‘‘(ii) WRITTEN
NOTIFICATION.—The 
Secretary shall ensure that, in the case of 
a nursing facility that is participating in 
the low-rated facility program, residents of 
such facility and family or legal represent-
atives are furnished with individualized 
written notice of such participation. Such 
notice shall be provided to current resi-
dents and to new residents prior to admis-
sion. 
‘‘(J) REQUIREMENT FOR REMOVAL.—The 
Secretary shall require that a nursing facility 
show improvement prior to removal from the 
low-rated facility program.’’. 
(C) USE OF CIVIL MONEY PENALTIES.— 
Section 1919(h)(3)(C)(ii)(IV)(ff) of the Social 
Security 
Act 
(42 
U.S.C. 
1396r(h)(3)(C)(ii)(IV)(ff)) is amended— 
(i) by striking ‘‘and facility improve-
ment initiatives’’ and inserting ‘‘facility 
improvement initiatives’’; and 
(ii) by inserting the following before 
the period at the end: ‘‘, and, on and after 
the date the Secretary makes the conver-
sion described in subsection (f)(10)(D), 
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consultation, education, and other activities 
to foster improvement and remedy root 
causes contributing to deficiencies cited 
across multiple surveys among facilities in 
the low-rated facility program under sub-
section (f)(10)’’. 
(3) INFORMATION ON HIGH-RATED AND LOW- 
RATED
FACILITIES
ON
NURSING
HOME
COMPARE 
MEDICARE WEBSITE.—Section 1919(i)(1) of the So-
cial Security Act (42 U.S.C. 1396r(i)(1)) is amend-
ed— 
(A) in subparagraph (A), by adding at the 
end the following new clause: 
‘‘(vi) On and after the date the Sec-
retary implements the high-rated facility 
program under subsection (f)(12) and 
makes the conversion under subsection 
(f)(10)(D), consistent with subparagraph 
(C)— 
‘‘(I) for each nursing facility that 
is designated as a high-rated nursing 
facility under subsection (f)(12), the 
date the facility was so designated; 
and 
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‘‘(II) for each nursing facility 
participating in the low-rated facility 
program under subsection (f)(10), the 
date the facility was identified for in-
clusion in such program.’’; and 
(B) by adding at the end the following new 
subparagraphs: 
‘‘(C) DISTINCTIONS FOR HIGH-RATED AND 
LOW-RATED
FACILITIES.—On and after the 
date the Secretary implements the high-rated 
facility program under subsection (f)(12) and 
makes 
the 
conversion 
under 
subsection 
(f)(10)(D), the Secretary shall ensure that 
graphics, including an appropriate explanation 
of such graphics, are prominently displayed on 
the website described in subparagraph (A) in 
order to distinguish each of the following: 
‘‘(i) Nursing facilities that are des-
ignated as high-rated nursing facilities 
under subsection (f)(12). 
‘‘(ii) Nursing facilities that are par-
ticipating in the low-rated facility program 
under subsection (f)(10), with information 
on facilities that have been placed in such 
program more than one time over the 
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course of the last 10 years (including the 
number of times such nursing facilities 
have been placed in the program). 
‘‘(D) FOCUS
GROUPS
AND
CONSUMER 
TESTING.—In order to help limit confusion, 
particularly among older adults, individuals 
with disabilities, and family caregivers, the Sec-
retary shall utilize focus groups and other con-
sumer testing methods prior to including the 
additional information under subparagraph 
(A)(vi) and implementing the distinctions under 
subparagraph (C).’’. 
(d) GAO STUDY AND REPORT.— 
(1) STUDY.—The Comptroller General of the 
United States (in this section referred to as the 
‘‘Comptroller General’’) shall conduct a study on the 
quality of items and services furnished by skilled 
nursing facilities under title XVIII of the Social Se-
curity Act and nursing facilities under title XIX of 
such Act, and such facilities’ compliance with the 
applicable requirements under such titles. Such 
study shall include analysis of the following: 
(A) The effectiveness of the low-rated facil-
ity program established under paragraph (8) of 
section 1819(f) of the Social Security Act (42 
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U.S.C. 1395i–3(f)), as amended by subsection 
(b)(2), and under paragraph (10) of section 
1919(f) of such Act (42 U.S.C. 1396r(f)), as 
amended by subsection (c)(2). 
(B) Other areas determined appropriate by 
the Comptroller General. 
(2) REPORT.—Not later than 6 years after the 
date of enactment of this Act, the Comptroller Gen-
eral shall submit to the appropriate Committees of 
Congress a report containing the results of the study 
conducted under paragraph (1), together with rec-
ommendations for such legislation and administra-
tive action as the Comptroller General determines 
appropriate. 
(e) RULES OF CONSTRUCTION.— 
(1) SURVEYS.—Nothing in the provisions of, or 
the amendments made by, this section shall be con-
strued to allow the Secretary to modify or deviate 
from— 
(A) a survey schedule that requires unan-
nounced and unanticipated surveying of skilled 
nursing facilities under subsection (g)(2)(A)(i) 
of section 1819 of the Social Security Act (42 
U.S.C. 
1395i–3(g)) 
or 
under 
subsection 
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(g)(2)(A)(i) of section 1919 of the Social Secu-
rity Act (42 U.S.C. 1396r(g)); 
(B) the surveying frequency specified 
under subsection (g)(2)(A)(iii) of such section 
1819 or under subsection (g)(2)(A)(iii) of such 
section 1919; or 
(C) surveys and investigations as required 
under subsection (g)(4) of such section 1819 or 
under subsection (g)(4) of such section 1919. 
(2) ACCOUNTABILITY AND STATE LAW.—Noth-
ing in the provisions of, or the amendments made 
by, this section shall be construed to impact the abil-
ity of a resident, the family of a resident, or a suc-
cessor in interest to hold a skilled nursing facility or 
nursing facility accountable or change protections 
granted under State law. 
SEC. 3. DEFINITIONS. 
In this Act: 
(1) 
APPROPRIATE
COMMITTEES
OF
CON-
GRESS.—The term ‘‘appropriate Committee of Con-
gress’’ means— 
(A) the Committee on Finance of the Sen-
ate; 
(B) the Committee on Health, Education, 
Labor, and Pensions of the Senate; 
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(C) the Special Committee on Aging of the 
Senate; 
(D) the Committee on Ways and Means of 
the House of Representatives; and 
(E) the Committee on Energy and Com-
merce of the House of Representatives. 
(2) NURSING
FACILITY.—The term ‘‘nursing 
facility’’ has the meaning given that term in section 
1919(a) of the Social Security Act (42 U.S.C. 
1396r(a)). 
(3) SKILLED
NURSING
FACILITY.—The term 
‘‘skilled nursing facility’’ has the meaning given that 
term in section 1819(a) of the Social Security Act 
(42 U.S.C. 1395i–3(a)). 
(4) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
Æ 
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