858 
(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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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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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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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. 
SEC. 1433. QUALIFICATION OF DIRECTOR OF FOOD SERV-
ICES OF A SKILLED NURSING FACILITY OR 
NURSING FACILITY. 
(a) MEDICARE.—Section 1819(b)(4)(A) of the Social 
Security Act (42 U.S.C. 1395i–3(b)(4)(A)) is amended by 
adding at the end the following: ‘‘With respect to meeting 
the staffing requirement imposed by the Secretary to carry 
out clause (iv), the full-time director of food services of 
the facility, if not a qualified dietitian (as defined in sec-
tion 483.35(a)(2) of title 42, Code of Federal Regulations, 
as in effect as of the date of the enactment of this sen-
tence), shall be a Certified Dietary Manager meeting the 
requirements of the Certifying Board for Dietary Man-
agers, or a Dietetic Technician, Registered meeting the 
requirements of the Commission on Dietetic Registration 
or have equivalent military, academic, or other qualifica-
tions (as specified by the Secretary).’’. 
(b) MEDICAID.—Section 1919(b)(4)(A) of the Social 
Security Act (42 U.S.C. 1396r(b)(4)(A)) is amended by 
adding at the end the following: ‘‘With respect to meeting 
the staffing requirement imposed by the Secretary to carry 
out clause (iv), the full-time director of food services of 
the facility, if not a qualified dietitian (as defined in sec-
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tion 483.35(a)(2) of title 42, Code of Federal Regulations, 
as in effect as of the date of the enactment of this sen-
tence), shall be a Certified Dietary Manager meeting the 
requirements of the Certifying Board for Dietary Man-
agers, or a Dietetic Technician, Registered meeting the 
requirements of the Commission on Dietetic Registration 
or have equivalent military, academic, or other qualifica-
tions (as specified by the Secretary).’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on the date that is 180 days 
after the date of enactment of this Act. 
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. 
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‘‘(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— 
‘‘(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 
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‘‘(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-
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 
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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: 
‘‘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 
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‘‘(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.— 
‘‘(1) PATIENT-CENTERED
AND
POPULATION- 
BASED
MEASURES.—In entering into agreements 
under subsection (a), the Secretary shall give pri-
ority to the development of quality measures that 
allow the assessment of— 
‘‘(A) health outcomes, presence of impair-
ment, and functional status of patients; 
‘‘(B) the continuity and coordination of 
care and care transitions for patients across 
providers and health care settings, including 
end of life care; 
‘‘(C) patient experience and patient en-
gagement; 
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‘‘(D) the safety, effectiveness, and timeli-
ness of care; 
‘‘(E) health disparities including those as-
sociated with individual race, ethnicity, age, 
gender, place of residence or language; and 
‘‘(F) the efficiency and resource use in the 
provision of care. 
‘‘(2) USE OF FUNDS.—An entity that enters 
into an agreement under subsection (a) shall develop 
quality measures that— 
‘‘(A) to the extent feasible, have the ability 
to be collected through the use of health infor-
mation technologies supporting better delivery 
of health care services; and 
‘‘(B) are available free of charge to users 
for the use of such measures. 
‘‘(3) AVAILABILITY OF MEASURES.—The Sec-
retary shall make quality measures developed under 
this section available to the public. 
‘‘(4) 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. 
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‘‘(5) 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, private, or academic insti-
tution 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 
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 
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subsections (a) and (b), other than information re-
gard drug samples, with respect to the preceding 
calendar year is made available through an Internet 
website that— 
‘‘(A) is searchable and is in a format that 
is clear and understandable; 
‘‘(B) contains information that is pre-
sented by the name of the applicable manufac-
turer or distributor, the name of the covered re-
cipient, the business address of the covered re-
cipient, the specialty (if applicable) of the cov-
ered recipient, the value of the payment or 
other transfer of value, the date on which the 
payment or other transfer of value was provided 
to the covered recipient, the form of the pay-
ment or other transfer of value, indicated (as 
appropriate) under subsection (a)(1)(B)(ii), the 
nature of the payment or other transfer of 
value, indicated (as appropriate) under sub-
section (a)(1)(B)(iii), and the name of the cov-
ered drug, device, biological, or medical supply, 
as applicable; 
‘‘(C) contains information that is able to 
be easily aggregated and downloaded; 
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