shall include an examination of the ownership and 
control interests, and any affiliated parties, of the 
facilities studied (as applicable). 
(2) 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. 
(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 1 year after the date 
of enactment of this Act, the Comptroller General of the 
United States shall submit a report to Congress and the 
Secretary containing the results of the study conducted 
under subsection (a), together with recommendations for 
such legislation and administrative action as the Comp-
troller General determines appropriate. 
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SEC. 203. NATIONAL INDEPENDENT MONITOR PROGRAM. 
(a) 
SKILLED
NURSING
FACILITIES.—Section 
1819(h) of the Social Security Act (42 U.S.C. 1395i– 
3(h)(2) is amended— 
(1) by redesignating paragraphs (5) and (6) as 
paragraphs (6) and (7), respectively; and 
(2) by inserting after paragraph (4) the fol-
lowing new paragraph: 
‘‘(5) NATIONAL INDEPENDENT MONITOR PRO-
GRAM.— 
‘‘(A) IN GENERAL.—Not later than 1 year 
after the date of enactment of this paragraph, 
the Secretary, in consultation with the Inspec-
tor General of the Department of Health and 
Human Services, shall develop, test, and imple-
ment a protocol for the establishment of an 
independent monitoring program to oversee 
interstate and large intrastate chains of skilled 
nursing facilities. Such program shall be de-
signed to analyze such chains in 1 or more of 
the following instances: 
‘‘(i) Where 3 or more facilities of the 
chain were enrolled in the ‘Special Focus 
Facility program’ (or a successor program) 
established by the Centers for Medicare & 
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Medicaid Services during the preceding 3 
years. 
‘‘(ii) Where the chain has been experi-
encing financial problems that may be 
linked to serious quality deficiencies. 
‘‘(iii) Where the chain has a record of 
chronic poor performance. 
‘‘(B) 
RESPONSIBILITIES.—The 
inde-
pendent monitoring program established under 
subparagraph (A) shall include the following re-
sponsibilities: 
‘‘(i) Conducting periodic reviews and 
preparing root-cause quality and deficiency 
analyses of a chain described in such sub-
paragraph to assess compliance by the 
chain with State and Federal laws and reg-
ulations. 
‘‘(ii) Conducting oversight of efforts 
by such a chain, whether publicly or pri-
vately held, to achieve compliance with 
State and Federal laws and regulations. 
‘‘(iii) 
Analyzing 
the 
management 
structure, distribution of expenditures, and 
nurse staffing levels of facilities of such a 
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chain in relation to resident census, staff 
turnover rates, and tenure. 
‘‘(iv) Reporting findings and rec-
ommendations with respect to such re-
views, analyses, and oversight to the chain 
and facilities of the chain, to the Secretary, 
and to relevant States. 
‘‘(v) Publishing the results of such re-
views, analyses, and oversight. 
‘‘(C) IMPLEMENTATION OF RECOMMENDA-
TIONS.— 
‘‘(i) 
RECEIPT
OF
FINDING
BY 
CHAIN.—Not later than 10 days after re-
ceipt of a finding reported under subpara-
graph (B)(iv), the chain shall submit a re-
port to the independent monitor— 
‘‘(I) outlining corrective actions 
to be taken by the chain to implement 
the recommendations in such report; 
or 
‘‘(II) indicating that the chain 
will not implement such recommenda-
tions, and why it will not do so. 
‘‘(ii) RECEIPT OF REPORT BY INDE-
PENDENT
MONITOR.—Not later than 10 
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days after receipt of the report submitted 
by the chain under clause (i), the inde-
pendent monitor shall finalize its rec-
ommendations and submit a report to the 
chain and facilities of the chain, the Sec-
retary, and the State or States, as appro-
priate, containing such final recommenda-
tions. 
‘‘(iii) CIVIL
MONEY
PENALTY.—The 
Secretary may impose a civil money pen-
alty under subsection (h)(2)(B)(ii) on a 
chain that fails to respond to or to take 
corrective actions to implement the rec-
ommendations of the independent monitor 
in accordance with this subparagraph. 
‘‘(D) COST
OF
APPOINTMENT.—A chain 
shall be responsible for all costs associated with 
the appointment of independent monitors under 
the program under this paragraph. The chain 
shall pay such costs to the Secretary (in accord-
ance with procedures established by the Sec-
retary). 
‘‘(E) EVALUATION AND REPORT.— 
‘‘(i) 
EVALUATION.—The 
Inspector 
General of the Department of Health and 
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Human Services shall evaluate the inde-
pendent monitoring program under this 
paragraph. 
‘‘(ii) REPORT.—Not later than 2 
years after the implementation of such pro-
gram under subparagraph (A), the Inspec-
tor General shall submit a report to Con-
gress containing the results of the evalua-
tion conducted under clause (i), together 
with recommendations for such legislation 
and administrative action as the Inspector 
General determines appropriate. 
‘‘(F) INTERMEDIATE
REMEDY.—The ap-
pointment of an independent monitor shall be 
an intermediate remedy that may be in addition 
to or in lieu of other remedies under this sub-
section.’’. 
(b) NURSING FACILITIES.—Section 1919(h) of the 
Social Security Act (42 U.S.C. 1396r(h)) is amended— 
(1) by redesignating paragraphs (8) and (9) as 
paragraphs (9) and (10), respectively; and 
(2) by inserting after paragraph (7) the fol-
lowing new paragraph: 
‘‘(8) NATIONAL INDEPENDENT MONITOR PRO-
GRAM.— 
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‘‘(A) IN GENERAL.—Not later than 1 year 
after the date of enactment of this paragraph, 
the Secretary, in consultation with the Inspec-
tor General of the Department of Health and 
Human Services, shall develop, test, and imple-
ment a protocol for the establishment of an 
independent monitoring program to oversee 
interstate and large intrastate chains of nursing 
facilities. Such program shall be designed to 
analyze such chains in 1 or more of the fol-
lowing instances: 
‘‘(i) Where 3 or more facilities of the 
chain were enrolled in the ‘Special Focus 
Facility program’ (or a successor program) 
established by the Centers for Medicare & 
Medicaid Services during the preceding 3 
years. 
‘‘(ii) Where the chain has been experi-
encing financial problems that may be 
linked to serious quality deficiencies. 
‘‘(iii) Where the chain has a record of 
chronic poor performance. 
‘‘(B) 
RESPONSIBILITIES.—The 
inde-
pendent monitoring program established under 
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subparagraph (A) shall include the following re-
sponsibilities: 
‘‘(i) Conducting periodic reviews and 
preparing root-cause quality and deficiency 
analyses of a chain described in such sub-
paragraph to assess compliance by the 
chain with State and Federal laws and reg-
ulations. 
‘‘(ii) Conducting oversight of efforts 
by such a chain, whether publicly or pri-
vately held, to achieve compliance with 
State and Federal laws and regulations. 
‘‘(iii) 
Analyzing 
the 
management 
structure, distribution of expenditures, and 
nurse staffing levels of facilities of such a 
chain in relation to resident census, staff 
turnover rates, and tenure. 
‘‘(iv) Reporting findings and rec-
ommendations with respect to such re-
views, analyses, and oversight to the chain 
and facilities of the chain, to the Secretary, 
and to relevant States. 
‘‘(v) Publishing the results of such re-
views, analyses, and oversight. 
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‘‘(C) IMPLEMENTATION OF RECOMMENDA-
TIONS.— 
‘‘(i) 
RECEIPT
OF
FINDING
BY 
CHAIN.—Not later than 10 days after re-
ceipt of a finding reported under subpara-
graph (B)(iv), the chain shall submit a re-
port to the independent monitor— 
‘‘(I) outlining corrective actions 
to be taken by the chain to implement 
the recommendations in such report; 
or 
‘‘(II) indicating that the chain 
will not implement such recommenda-
tions, and why it will not do so. 
‘‘(ii) RECEIPT OF REPORT BY INDE-
PENDENT
MONITOR.—Not later than 10 
days after receipt of the report submitted 
by the chain under clause (i), the inde-
pendent monitor shall finalize its rec-
ommendations and submit a report to the 
chain and facilities of the chain, the Sec-
retary, and the State or States, as appro-
priate, containing such final recommenda-
tions. 
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‘‘(iii) CIVIL
MONEY
PENALTY.—A 
State or the Secretary may impose a civil 
money 
penalty 
under 
subsection 
(h)(2)(A)(ii), or (h)(3)(C)(ii), respectively, 
on a chain that fails to respond to or to 
take corrective actions to implement the 
recommendations of the independent mon-
itor in accordance with this subparagraph. 
‘‘(D) COST
OF
APPOINTMENT.—A chain 
shall be responsible for all costs associated with 
the appointment of independent monitors under 
the program under this paragraph. The chain 
shall pay such costs to the Secretary (in accord-
ance with procedures established by the Sec-
retary). 
‘‘(E) EVALUATION AND REPORT.— 
‘‘(i) 
EVALUATION.—The 
Inspector 
General of the Department of Health and 
Human Services shall evaluate the inde-
pendent monitoring program under this 
paragraph. 
‘‘(ii) REPORT.—Not later than 2 
years after the implementation of such pro-
gram under subparagraph (A), the Inspec-
tor General shall submit a report to Con-
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gress containing the results of the evalua-
tion conducted under clause (i), together 
with recommendations for such legislation 
and administrative action as the Inspector 
General determines appropriate. 
‘‘(F) INTERMEDIATE
REMEDY.—The ap-
pointment of an independent monitor shall be 
an intermediate remedy that may be in addition 
to or in lieu of other remedies under this sub-
section.’’. 
SEC. 204. GAO STUDIES AND REPORTS ON TEMPORARY 
MANAGEMENT 
AND 
BARRIERS 
TO 
PUR-
CHASING FACILITIES WITH A RECORD OF 
POOR CARE. 
(a) STUDY AND REPORT ON TEMPORARY MANAGE-
MENT.— 
(1) IN GENERAL.—The Comptroller General of 
the United States (in this section referred to as the 
‘‘Comptroller General’’) shall conduct a study on— 
(A) best practices for the appointment of 
temporary 
management 
under 
sections 
1819(h)(2)(B)(iii), 
1919(h)(2)(A)(iii), 
and 
1919(h)(3)(C)(iii) of the Social Security Act 
(42 
U.S.C. 
1395i–3(h)(2)(B)(iii); 
1396r(h)(2)(A)(iii); 1396r(h)(3)(C)(iii)); and 
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(B) barriers to the appointment of such 
temporary management. 
(2) REPORT.—Not later than 1 year after the 
date of enactment of this Act, the Comptroller Gen-
eral shall submit a report to Congress containing the 
results of the study conducted under paragraph (1), 
together with recommendations for such legislation 
and administrative action as the Comptroller Gen-
eral determines appropriate. 
(3) GUIDANCE TO STATES.—The Secretary of 
Health and Human Services shall issue guidance to 
States based on the recommendations contained in 
the report submitted under paragraph (2). 
(b) STUDY AND REPORT ON BARRIERS TO PUR-
CHASING FACILITIES WITH A RECORD OF POOR CARE.— 
(1) STUDY.—The Comptroller General of the 
United States shall conduct a study on the extent 
and the nature of any barriers for new owners who 
purchase, and potential owners who wish to pur-
chase, skilled nursing facilities and nursing facilities 
with a record of poor care. 
(2) REPORT.—Not later than 1 year after the 
date of enactment of this Act, the Comptroller Gen-
eral shall submit a report to Congress containing the 
results of the study conducted under paragraph (1), 
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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 enact-
ment of this Act. 
SEC. 206. NATIONAL DEMONSTRATION PROJECTS ON CUL-
TURE CHANGE AND USE OF INFORMATION 
TECHNOLOGY IN NURSING HOMES. 
(a) IN GENERAL.—The Secretary shall conduct 2 
demonstration projects, 1 for the development of best 
practices in skilled nursing facilities and nursing facilities 
that are involved in the culture change movement (includ-
ing the development of resources for facilities to find and 
access funding in order to undertake culture change) and 
1 for the development of best practices in skilled nursing 
facilities and nursing facilities for the use of information 
technology to improve resident care. 
(b) CONDUCT OF DEMONSTRATION PROJECTS.— 
(1) GRANT AWARD.—Under each demonstration 
project conducted under this section, the Secretary 
shall award 1 or more grants to facility-based set-
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tings for the development of best practices described 
in subsection (a) with respect to the demonstration 
project involved. Such award shall be made on a 
competitive basis and may be allocated in 1 lump- 
sum payment. 
(2) CONSIDERATION
OF
SPECIAL
NEEDS
OF 
RESIDENTS.—Each demonstration project conducted 
under this section shall take into consideration the 
special needs of residents of skilled nursing facilities 
and nursing facilities who have cognitive impair-
ment, including dementia. 
(c) IMPLEMENTATION AND DURATION.— 
(1) 
IMPLEMENTATION.—The 
demonstration 
projects shall each be implemented not later than 1 
year after the date of enactment of this Act. 
(2) IN GENERAL.—The demonstration projects 
shall each be conducted for a period not to exceed 
3 years. 
(d) DEFINITIONS.—In this section: 
(1) 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)). 
(2) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
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(3) 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)). 
(e) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as are nec-
essary to carry out this section. 
(f) REPORT.—Not later than 9 months after the com-
pletion of the demonstration project, the Secretary shall 
submit a report to Congress on such project, together with 
recommendations for such legislation and administrative 
action as the Secretary determines appropriate. 
TITLE III—IMPROVING STAFF 
TRAINING 
SEC. 301. 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 patient abuse preven-
tion training’’ before ‘‘, (II)’’. 
(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, 
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in the case of initial training and, if the Secretary deter-
mines appropriate, in the case of ongoing training, demen-
tia management training, and patient abuse prevention’’ 
before ‘‘, (II)’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect 1 year after the date of enact-
ment of this Act. 
SEC. 302. 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-
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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) 
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 currently (as of the date of 
enactment 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 
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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 enactment of this Act, the Secretary shall submit a re-
port to Congress containing the results of the study con-
ducted under subsection (a), together with recommenda-
tions for such legislation and administrative action as the 
Secretary determines appropriate. 
Æ 
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